Power point cardiovascular disease


Presentation : Chronic Pelvic pain , Dysmenorrhea, Dyspareunia

Suzelle L. Costales

Advanced Primary care of family II

Florida National University

What is Chronic Pelvic Pain and what are s/s ?

Chronic pelvic pain is pain below the umbilicus mainly at and around the pelvic area of the body , pain associated with CPP is pain that lasts more than six months and is not associated with menstrual period symptoms.

Incomplete relief with OTC treatments

Significantly impaired function at work or home/ sex life

Altered family roles

Signs of depression , weight loss /gain and anxiety.

Chronic pelvic pain can be associated with other disease process and usually arises from gynecological causes

Chronic Pelvic Pain epidemiology / Pathophysiology

CPP is a common reason for office visit in the US. According statistics 1 out of 7 women in the USA visit a medical office with chief complaint of chronic pelvic pain.

Of all references to a gyn specialist 10 % are for pelvic pain and prevalence for CPP in reproductive aged women is aprox 39 %.

CPP is considered a symptom of an underlying problem that can be gynecological , gastrointestinal and neuro-muscular in origin. CPP can be very complex to treat due to the many factors that can be contributing and causing CPP. Each provider takes a personalized approach for each patient in order to find the root cause of CPP.

Risk Factors of Chronic Pelvic Pain

C- section

Endometriosis ( endometrial cells grow outside the uterus )


Longer menstrual flow

Ovarian cysts

Uterine fibroids


Pelvic inflammatory disease

Long term sexual abuse as child or adult

Adenomyosis ( endometrial tissue growing in uterine wall)


Chronic UTI

Bladder Stones

Guidelines for screening : CPP

Accurate and complete Health history: important to get chronological history of pain.

Physical examination : gynecological, urologic , gastroenterological , and psychologic examination , musculoskeletal exam

Assess pain each visit / detailed

Vaginal examination , pap smear, pelvic examination: single digit and bimanual

Labs: CBC, Urinalysis, pregnancy test , STD test,

Transvaginal ultrasound , CT scan , MRI, laparoscopy


“Menstrual cramps” or pain that is associated with the menstrual cycle each month.

Lasts 3-5 days , starts before menstruation begins can last during and after menstruation

Pain is mainly in the pelvis and lower abdomen

More than 50 % of women experience some level of dysmenorrhea each month right before and or/ during their menstrual cycle.


Dysmenorrhea occurs due to “ Prostaglandins “ ( hormone found in uterus) the inflammatory trigger which leads to uterine muscle contractions that help to released or expel the lining.

Prostaglandins are hormones in the body responsible for muscle contraction and relaxation mainly of smooth muscle tissue in the body.

Some women have higher levels of prostaglandin hormone in the body leading to more severe pain , nausea , bloating and discomfort during their menstruation.

Dysmenorrhea can begin as early as 2 – 3 years after menarche and varies in severity from woman to woman

Risk factors for Dysmenorrhea

Heavy menstrual flow

Age < 20 years

Early menarche < 12 y rs



High stress


Family history



Primary Dysmenorrhea

Usually pain is moderate although can be severe at times but not for long periods , lasts 2-3 days at start of period

Responds well to OTC medication and home remedies

Not caused by underlying disease of the uterus or pelvis

Occurs before and during period

Secondary dysmenorrhea

Dysmenorrhea occurring during menstruation when underlying disease is present such as endometriosis.

More prevalent in women in their late 30 s and 40 s

Pain becomes stronger or begins suddenly later in life. Patient will have sudden new onset pain during menstruation.

Secondary dysmenorrhea should be investigated further

Secondary Dysmenorrhea Causes

Extrauterine causes : endometriosis , PID, Adhesions, structural abnormalities of genital tract

Intramural ( in the muscle layer of Uterus) : adenomyosis , fibroid

Intrauterine : infection , polyps, cervical stenosis , intrauterine contraception

Dysmenorrhea : Assessing and TX

When assessing a female for the first time its important to always ask when was the last menstrual period , age of menarche and any unusual bleeding, or changes in mood/ behavior. A though history and physical assessment should be done : time and pattern? heaviness of menstruation? , what self treatments have you tried? Other symptoms ?

Dysmenorrhea is usually managed in the home with OTC remedies , without the need for a prescription

Can be managed with OTC pain relievers such as NSAIDS and sometimes if severe hormonal options such as birth control or IUD an be prescribed as well if pain is severe. Home remedies such as Hot compresses , exercise, taking vitamins: Fish oil omega 3 , magnesium, B1 B6 vitamin C, vitamin E,

Abdominal / transvaginal US , laparoscopy, blood test and culture ( rule out std )


What is Dyspareunia ? S/S?

Painful intercourse in female or males , more frequently occur in women

Pain can be moderate to severe and occurs during penetration.

Can be due to physiological and or psychological factors.

Can be felt deep in the vaginal canal or outer genitals , can occur with tampon use .

Signs include cramping , sharp / burning pain, and during intercourse

Causes of Dyspareunia in Females

Abnormalities in the Uterus such as ulcers/ cysts ( bartholins cyst )

Injury to the Uterus / vagina

Infection ( uti , yeast infection)

Vaginal dryness/ vaginal atrophy ( after menopause )

Poorly fitted diaphragm / cervical cap

Past surgery

Inflammation ( Vaginitis )



Being tense prior to intercourse , not enough time for natural lubrication

Psychological factors : past sexual or physical abuse

Retroverted uterus

Dyspareunia in Males

Peyronies Disease : scar tissue formation that can cause painful erection and cause penis to bend – resolves on its own or may require surgery .

Begins with pain and swelling can lead to plaque formation

Infection can cause painful intercourse in men UTI, Yeast infection and STD

Assessment /Treatment for Dyspareunia

Assessment: thorough history and physical of CC and HPI. Level of pain ? Onset ? Characteristics ? Contributing actors ? Alleviating factor? Other symptoms? Treatment depends on the cause

Tx: Antibiotics if infection is present , in post menopausal women cause may be vaginal dryness from low estrogen levels and topical options can be prescribed ( osphena )

Desensitization : Kegel exercise

Counseling or sex therapy if cause in psychological

lubrication use during intercourse

Diagnostic test

Pelvic exam



Pelvic Ultrasound


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