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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
Endometriosis ( endometrial cells grow outside the uterus )
Longer menstrual flow
Pelvic inflammatory disease
Long term sexual abuse as child or adult
Adenomyosis ( endometrial tissue growing in uterine wall)
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
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
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
Inflammation ( Vaginitis )
Being tense prior to intercourse , not enough time for natural lubrication
Psychological factors : past sexual or physical abuse
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
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