Chapter 051. Menstrual Disorders and Pelvic Pain (Part 5)

Acute Pelvic Pain: Treatment Treatment of acute pelvic pain depends on the suspected etiology but may require surgical or gynecologic intervention. Conservative management is an important consideration for ovarian cysts, if torsion is not suspected, to avoid unnecessary pelvic surgery and the subsequent risk of infertility due to adhesions. The majority of unruptured ectopic pregnancies are now treated with methotrexate, which is effective in 84–96% of cases. However, surgical treatment may be required.Chronic Pelvic PainSomewomenexperiencediscomfortatthetimeofovulation(mittelschmerz). Pain can be quite intense but is generally of short duration. The mechanism is thought to involve rapid expansion of the dominant follicle, although...
Nội dung trích xuất từ tài liệu:
Chapter 051. Menstrual Disorders and Pelvic Pain (Part 5) Chapter 051. Menstrual Disorders and Pelvic Pain (Part 5) Acute Pelvic Pain: Treatment Treatment of acute pelvic pain depends on the suspected etiology but mayrequire surgical or gynecologic intervention. Conservative management is animportant consideration for ovarian cysts, if torsion is not suspected, to avoidunnecessary pelvic surgery and the subsequent risk of infertility due to adhesions.The majority of unruptured ectopic pregnancies are now treated withmethotrexate, which is effective in 84–96% of cases. However, surgical treatmentmay be required. Chronic Pelvic Pain Some women experience discomfort at the time of ovulation(mittelschmerz). Pain can be quite intense but is generally of short duration. Themechanism is thought to involve rapid expansion of the dominant follicle,although it may also be caused by peritoneal irritation by follicular fluid releasedat the time of ovulation. Many women experience premenstrual symptoms such asbreast discomfort, food cravings, and abdominal bloating or discomfort. Thesemoliminal symptoms are a good predictor of ovulation, although their absence isless helpful. Dysmenorrhea Dysmenorrhea refers to the crampy lower abdominal discomfort that beginswith the onset of menstrual bleeding and gradually decreases over the next 12–72h. It may be associated with nausea, diarrhea, fatigue, and headache and occurs in60–93% of adolescents, beginning with the establishment of regular ovulatorycycles. Its prevalence decreases after pregnancy and with the use of oralcontraceptives. Primary dysmenorrhea results from increased stores of prostaglandinprecursors, which are generated by sequential stimulation of the uterus by estrogenand progesterone. During menstruation these precursors are converted toprostaglandins, which cause intense uterine contractions, decreased blood flow,and increased peripheral nerve hypersensitivity, resulting in pain. Secondary dysmenorrhea is caused by underlying pelvic pathology.Endometriosis results from the presence of endometrial glands and stroma outsideof the uterus. These deposits of ectopic endometrium respond to hormonalstimulation and cause dysmenorrhea, which generally precedes menstruation byseveral days. Endometriosis may also be associated with painful intercourse,painful bowel movements, and tender nodules in the uterosacral ligament. Fibrosisand adhesions can produce lateral displacement of the cervix. The CA125 levelmay be increased, but it has low negative predictive value. Definitive diagnosisrequires laparoscopy. Symptomatology does not always predict the extent ofendometriosis. Other secondary causes of dysmenorrhea include adenomyosis, acondition caused by the presence of ectopic endometrial glands and stroma withinthe myometrium. Cervical stenosis may result from trauma, infection, or surgery. Dysmenorrhea: Treatment Local application of heat; use of vitamins B1, B6, and E and magnesium;acupuncture; yoga; and exercise are of some benefit for the treatment ofdysmenorrhea. However, nonsteroidal anti-inflammatory drugs (NSAIDs) are themost effective treatment and provide >80% sustained response rates. Ibuprofen,naproxen, ketoprofen, mefanamic acid, and nimesulide are all superior to placebo.Treatment should be started a day before expected menses and is generallycontinued for 2–3 days. Oral contraceptives also reduce symptoms ofdysmenorrhea. Failure of response to NSAIDs and oral contraceptives issuggestive of a pelvic disorder, such as endometriosis, and diagnostic laparoscopyshould be considered to guide further treatment. Further Readings Dawood MY: Primary dysmenorrhea: Advances in pathogenesis andmanagement. Obstet Gynecol 108:428, 2006 [PMID: 16880317] Genazzani AD et al: Diagnostic and therapeutic approach to hypothalamicamenorrhea. Ann NY Acad Sci 1092:103, 2006 [PMID: 17308137] Hall JE: Neuroendocrine control of the menstrual cycle, in Yen and JaffesReproductive Endocrinology, 5th ed. JF Strauss, RL Barbieri (eds). Philadelphia,Elsevier, 2004, pp 195–211 Latthe P et al: Factors predisposing women to chronic pelvic pain:Systematic review. BMJ 332(7544):749, 2006 [PMID: 16484239] Pittock ST et al: Mayer-Rokitansky-Kuster-Hauser anomaly and itsassociated malformations. Am J Med Genet A 135:314, 2005 [PMID: 15887261] Wittenberger MD et al: The FMR1 premutation and reproduction. FertilSteril 87:456, 2007 [PMID: 17074338] Bibliography Murray A: Premature ovarian failure and the FMR1 gene. Semin ReprodMed 18:59, 2000 [PMID: 11299521] Warren MP, Fried JL: Hypothalamic amenorrhea. ...