How can a doctor diagnose the cause of
pelvic pain?
A full history, examination and possibly some investigations will be required (Q4.4).
The story and examination findings may allow your doctor to make a diagnosis and initiate treatment.
Although pain related to the menstrual cycle suggests a gynaecological problem, it is not always the case (Q 23.39).
Symptoms relating to the bladder or bowel may suggest that the problem is not gynaecological. Frequently, there may be a variety of symptoms and clinical skill is required to determine the more significant symptoms and prioritise investigations.
The more common conditions can often be diagnosed by your general practitioner. Specialist advice is usually sought when there is difficulty establishing a diagnosis, when there has been a poor response to initial treatment, if the pain is particularly severe or if specialist investigations such as laparoscopy (laparoscopy) may be required.
A difficult conundrum is that several conditions that may be associated with
pelvic pain are common:
Not surprisingly, these conditions may coexist.0801
Should every woman with pelvic pain be subjected to laparoscopy?
- Every case has to be evaluated carefully and management tailored
accordingly. All operations, including laparoscopy, have an element
of
risk.
- It may be reasonable to treat medically for IBS or PID and
evaluate response.
- Even if trials of medication for IBS or PID prove unsuccessful,
it may still be reasonable to treat possible endometriosis medically
before resorting to surgery.
- The Royal College of Obstetricians and Gynaecologists considers that whilst
laparoscopy is the "gold standard" for the diagnosis of endometriosis,
laparoscopy is not mandatory.RCOG-2006
"Empirical treatment for pain symptoms
presumed to be caused by endometriosis without a definitive
diagnosis includes counselling, adequate analgesia, progestogens or the combined
oral contraceptive. It
is unclear whether the combined oral contraceptives should be taken
conventionally, continuously or in
a tricycle regimen. A gonadotrophin-releasing hormone (GnRH) agonist may be
taken but this class of
drug is more expensive and associated with more adverse effects and concerns
about bone density."
The question of when to investigate pelvic pain with laparoscopy is a subject
of continued debate.
Some take the view that laparoscopy is overused to the extent that clinicians
need a tool to determine whether women wish to seek a pathology-based
explanation for chronic pelvic pain or whether they just want symptom relief.
Such an approach might reduce the number of unnecessary laparoscopies without
adversely affecting outcomes.0602
Others believe that laparoscopy is often unduly delayed.0601
The Levonorgestrel IUS - Mirena may reduce dysmenorrhoea and chronic pelvic
pain associated with endometriosis.9901,
0501,
0701 This device could
therefore become the treatment of choice for chronic pelvic pain (CPP)-associated endometriosis in
women who do not wish to conceive.0501
The
use of LNG-IUS is an alternative for the medical treatment of women suffering
from endometriosis, adenomyosis, chronic pelvic pain or dysmenorrhea, but
further long-term studies are required to reach definitive conclusions. However,
for women who do not wish to become pregnant, this device offers the possibility
of at least 5 years of treatment following one single intervention.0701

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This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London.
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