How can my doctor diagnose the cause of my pelvic pain?

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:

• IBS - irritable bowel syndrome 30%
• PID - pelvic inflammatory disease.
• Endometriosis - perhaps 75% or more.⁰⁶⁰¹

Not surprisingly, these conditions may coexist.⁰⁸⁰¹

• Endometriosis and its coexistence with irritable bowel syndrome and pelvic inflammatory disease: findings from a national case-control study (2008-01)
• The prevalence of endometriosis in women with chronic pelvic pain.(2006-01)

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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