Chapter 051. Menstrual Disorders and Pelvic Pain (Part 4)

Polycystic Ovarian Syndrome: Treatment The major abnormality in patients with PCOS is the failure of regular, predictable ovulation. Thus, these patients are at risk for the development of dysfunctional bleeding and endometrial hyperplasia associated with unopposed estrogen exposure. Endometrial protection can be achieved with the use of oral contraceptives or progestins (medroxyprogesterone acetate, 5–10 mg, or prometrium, 200 mg daily for 10–14 days of each month). Oral contraceptives are also useful for management of hyperandrogenic symptoms, as is spironolactone, which functions as a weak androgen receptor antagonist. Management of the associated metabolic syndrome may be appropriate for some patients...
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Chapter 051. Menstrual Disorders and Pelvic Pain (Part 4) Chapter 051. Menstrual Disorders and Pelvic Pain (Part 4) Polycystic Ovarian Syndrome: Treatment The major abnormality in patients with PCOS is the failure of regular,predictable ovulation. Thus, these patients are at risk for the development ofdysfunctional bleeding and endometrial hyperplasia associated with unopposedestrogen exposure. Endometrial protection can be achieved with the use of oralcontraceptives or progestins (medroxyprogesterone acetate, 5–10 mg, orprometrium, 200 mg daily for 10–14 days of each month). Oral contraceptives arealso useful for management of hyperandrogenic symptoms, as is spironolactone,which functions as a weak androgen receptor antagonist. Management of theassociated metabolic syndrome may be appropriate for some patients (Chap. 236).For patients interested in fertility, weight control is a critical first step. Clomiphenecitrate is highly effective as first-line treatment, with or without the addition ofmetformin. Exogenous gonadotropins can be used by experienced practitioners. Pelvic Pain The mechanisms causing pelvic pain are similar to those causing abdominalpain (Chap. 14) and include inflammation of the parietal peritoneum, obstructionof hollow viscera, vascular disturbances, and pain originating in the abdominalwall. Pelvic pain may reflect pelvic disease per se but may also reflect extrapelvicdisorders that refer pain to the pelvis. In up to 60% of cases, pelvic pain can beattributed to gastrointestinal problems including appendicitis, cholecystitis,infections, intestinal obstruction, diverticulitis, or inflammatory bowel disease.Urinary tract and musculoskeletal disorders are also common causes of pelvicpain. Approach to the Patient: Pelvic Pain A thorough history including the type, location, radiation, and status withrespect to increasing or decreasing severity can help to identify the cause of acutepelvic pain. Specific associations with vaginal bleeding, sexual activity,defecation, urination, movement, or eating should be specifically sought. A carefulmenstrual history is essential to assess the possibility of pregnancy. Determinationof whether the pain is acute versus chronic and cyclic versus noncyclic will directfurther investigation (Table 51-1). However, disorders that cause cyclic pain mayoccasionally cause noncyclic pain, and the converse is also true. Table 51-1 Causes of Pelvic Pain Acute Chronic Cyclic pelvic Premenstrualpain symptoms Mittelschmerz Dysmenorrhea Endometriosis Noncyclic Pelvic inflammatory Pelvic congestionpelvic pain disease syndrome Ruptured or hemorrhagic Adhesions and ovarian cyst or ovarian torsion retroversion of the uterus Ectopic pregnancy Pelvic malignancy Endometritis Vulvodynia Acute growth or History of sexual degeneration of uterine myoma abuse Acute Pelvic Pain Pelvic inflammatory disease most commonly presents with bilateral lowerabdominal pain. It is generally of recent onset and is exacerbated by intercourse orjarring movements. Fever is present in about half of patients; abnormal uterinebleeding occurs in about one-third. New vaginal discharge, urethritis, and chillsmay be present but are less specific signs. Adnexal pathology can present acutelyand may be due to rupture, bleeding or torsion of cysts, or, much less commonly,neoplasms of the ovary, fallopian tubes, or paraovarian areas. Fever may bepresent with ovarian torsion. Ectopic pregnancy is associated with right or leftsided lower abdominal pain, vaginal bleeding and menstrual cycle abnormalities,with clinical signs generally appearing 6–8 weeks after the last normal menstrualperiod. Orthostatic signs and fever may be present. Risk factors include thepresence of known tubal disease, previous ectopic pregnancies, or a history ofinfertility, DES exposure of the mother in utero, or a history of pelvic infections.Uterine pathology includes endometritis and, less frequently, degeneratingleiomyomas (fibroids). Endometritis is often associated with vaginal bleeding and ...