Recurrent Pelvic pain

Mittelschmerz

Mittelschmerz is midcycle abdominal pain due to leakage of prostaglandin-containing follicular fluid at the time of ovulation. It is self-limited, and a theoretical concern is treatment of pain with prostaglandin synthetase inhibitors, which could prevent ovulation.

Endometriosis

Pain associated with endometriosis may worsen premenstrually or during menses. Patients experience generalized lower abdominal tenderness, and associated complaints include dysmenorrhea, dyschezia, and dyspareunia. Endometriotic deposits in both the uterosacral ligaments and rectovaginal septum contribute to pain during intercourse. Painful defecation is due to infiltration of the bowel wall by endometriotic deposits. Importantly, remember that the pain associated with endometriosis is not correlated with the presence or amount of visible endometriotic tissue. In fact, prevalence of endometriosis is the same in women with and without pain. Rather, pain is related to the chemical mediators of inflammation and neural infiltration.

Ovulation suppression using different drugs has been tried in order to reduce the pain associated with endometriosis. Overall, no difference appears to exist in the efficacy of danazol, gestrinone, oral contraceptives, depot medroxyprogesterone acetate, and gonadotropin-releasing hormone (GnRH) analogs in placebo-controlled trials. However, dydrogesterone was found to be less effective.

In systematic reviews, laparoscopic ablation of endometriotic implants using diathermy or laser remains unproven as a treatment modality for pain or subfertility. However, results from one study indicate that a combination of ablation and laparoscopic uterine nerve ablation (LUNA) was more effective for relieving pain. During postoperative treatment, GnRH analogs resulted in significantly reduced pain scores in women who received treatment for 6 months.

Laparoscopic cystectomy of an endometrioma was found to be superior to simple drainage for treatment of recurring pain; it has recently been shown to result in lower recurrence of signs and symptoms of endometriomas and higher cumulative pregnancy rates.

GnRH agonists were used for 6 months as the only treatment in patients with documented endometriosis. At 5 years, more than half the patients were symptom-free. The best responses were obtained in patients with mild or moderate disease. Among those with persistent or recurrent pain, an increasing correlation existed with the severity of the endometriosis.

Primary dysmenorrhea

By definition, primary dysmenorrhea is menstrual pain associated with ovulatory cycles in the absence of structural pathology. It usually manifests in younger women, and a recent study on the natural course of dysmenorrhea found that most women are affected throughout the menstrual years. Improvement is more likely in women who bear children. Patients experience suprapubic cramping pain that may radiate to the anterior thigh or sacral region. Pain may be accompanied by autonomic symptoms such as nausea, vomiting, and syncope. The onset of primary dysmenorrhea is a few hours prior to the onset of menses, and pain usually lasts up to 72 hours. More than 80% of patients have an excellent response to treatment with prostaglandin synthetase inhibitors. Oral contraceptives may be used with equal effectiveness in patients who desire simultaneous fertility control.