Pelvic Pain Acute Gynaecological – ectopic, miscarriage, acute pelvic infection, ovarian cysts, mittelschmerz Gastrointestinal – appendicitis, constipation, diverticular disease, IBS Other – UTI, calculus, MSK Chronic Pain for 3 months constantly, or 6 months intermittently. More than 1/3 cause is never found Gynaecological – endometriosis, PID (Chlamydia etc), adenomyosis, chronic pelvic infection, ovarian cysts, prolapse (low back pain) Gastrointestinal – adhesions, appendicitis, constipation, diverticular disease, IBS Others – UTI, calculus, MSK, degenerative joint disease, symphysalgia, low back pain, psychological Idiopathic –more than 1/3 of cases are! History Site – scars? Organs? Bleeding – fibroids, PID Cyclical – does it worsen with menstruation Sexual history – how many partners, STIs, contraception, ectopics, terminations, miscarriage, child birth Subfertility? – endometriosis, PID Dyspareunia – endometriosis, PID PSH – previous procedures can indicate adhesions FH – endometriosis, fibroids Any bowel or urinary symptoms? Is it linked to food? Effect on life – sleep, work, leisure, sex life Meds, Allergies Examination General – position on couch/chair, height, weight, age, anaemia, thyroid status Abdo – masses (inc bulky uterus), scars, tenderness (rebound?), striae Pelvic – tender adnexae, nodules in pouch of Douglas, cervical excitation tenderness Investigations Triple swabs during pelvic examination FBC, WCC Urine dip Laparoscopy (only if medical management unsuccessful) Premenstrual Syndrome Regular pattern of symptoms occurring before menstruation, with lessening at the start of bleeding Is severe if impairs work, relationships or usual activities Symptoms include bloatedness, breast tenderness (cyclical mastalgia), headaches, odema & mood changes Presentation No specific biochemical tests available Chart symptoms to confirm worsening in luteal phase Diagnosis Affective symptoms – depression, angry outburts, irritability, anxiety, confusion & social withdrawl Somatic symptoms – breast tenderness, bloating, headache, swelling Relief of symptoms within 4 days of onset on menses, without recurrence until day 12 Presence of symptoms in absence of pharmacological therapy, hormone ingestion or alcohol misuse Reproducible occcurance of symptoms during 2 cycles of prospective recording Identifiable dysfunction in social or economic performance (discord in relationship confirmed by partner, difficulties in parenting, poor work/school performance, increased social isolation, legal difficulties, sucidal ideation, medical attention sought for somatic symptoms Differential diagnosis If worse other than premenstrually then it is not PMS Consider alternatives for symptoms (eg IBS for bloatedness) Management Usually helped by reassurance & counselling, Improved diet, exercise, self-relaxation, reduce smoking & drinking may help, Symptomatic treatment – diuretics for oedema, analgesia for headaches