1. Evaluation of Abdominal and Pelvic Pain in Women
Setul Pardanani, MD
Assistant Professor, OB/GYN & Women’s Health
Assistant Residency Program Director
Albert Einstein College of Medicine
Montefiore Medical Center

2. Objectives Review the common etiologies of abdominal and pelvic pain
Review the evaluation of patients presenting with abdominal and pelvic pain
Review treatment options

3. Milestone Abdominal/Pelvic Pain
Level 1: Demonstrates a basic understanding of patients presenting with abdominal/pelvic pain regarding: Risk factors and Signs/Symptoms
Level 2: Demonstrates the ability to formulate a differential diagnosis and an understanding of the initial evaluation and treatment options
Level 3: Demonstrates the ability to utilize focused diagnostic approaches and formulate a comprehensive management plan
Level 4:Demonstrates an in-depth knowledge regarding patients presenting with abdominal/pelvic pain regarding: varying presentations, treatment options, refractory pelvic pain; manage and formulate comprehensive plans for patients with complex and atypical chronic pelvic pain and multiple comorbidities
Level 5: Lead multidisciplinary teams for care of patients with chronic pelvic pain; apply innovative approaches to complex and/or atypical chronic pelvic pain and implement treatment plans based on emerging evidence
The Milestones are a product of the Obstetrics and Gynecology Milestone Project, a Joint Initiative of the ACGME, ABOG, and ACOG

4. Etiology Gynecologic Obstetric Non Gynecologic
Infectious: PID, TOA, Endometritis, Cervicitis
Ovarian: Functional cyst, Neoplasm, Torsion
Endometriosis
Leiomyomata
Dysmenorrhea
Obstetric
Early Pregnancy: Ectopic Pregnancy, Spontaneous Abortion
Midtrimester/Late Pregnancy: Labor, Uterine Rupture, Abruptio Placenta, Infection
Non Gynecologic
Gastrointestinal: Appendicitis, Diverticulitis
Genitourinary: Cystitis, Nephrolithiasis, Pyelonephritis
Psychological: sexual abuse, depression
Musculoskeletal

5. Case 1 28 yo P1 presenting for acute onset of lower abdominal pain.
How do you evaluate her?

6. Evaluation
History
Identify life threatening condition requiring emergent intervention
Pain characteristics: Location, Quality, Timing, Alleviating or Exacerbating factors, Associated symptoms
Significant past history
Physical
General: Vital signs, Appearance
Abdominal Exam
Pelvic Exam
Laboratory
Pregnancy test and Type and Screen
CBC
Urinalysis, Urine culture
Evaluation for Gonorrhea and Chlamydia
Initiate the evaluation with a thorough history, first and foremost to identify life threatening conditions requiring emergent interventions. Then, establishing characteristics of the pain including location, quality, timing, associated factors and symptoms to help focus your differential diagnosis. A patients past history can also help to identify risk such as a infections, previous surgeries, abuse.
The next step is to perform a physical exam. The vital signs can help to identify acute issues. Once noted to be stable, an assessment of the general appearance of the patient can be helpful. Is she lying comfortably or appears in distress. A focused abdominal exam to localize the pain and assess for guarding and rebound to identify signs of peritoneal irritation. The pelvic exam can help to assess for discharge, bleeding, masses and localization of the pain.

7. Evaluation Imaging Ultrasound CT abdomen/Pelvis X-ray MRI Surgical
Laparoscopy
In regards to imaging, ultrasound is considered first line due to absence of radiation exposure and low cost. It is also is usually readiliy available and easy to utilize.

8. Endometriosis
Definition - extra uterine endometrial tissue “glands and stromal”
Incidence
7-10% women
35% infertile women
75% women with chronic pelvic pain
Etiology- leading theories:
Retrograde menstruation
Hematogenous or lymphogenous spread
Coelomic metaplasia

9. Endometriosis Symptoms and signs variable and unpredictable
Common presenting complaints
Dysmenorrhea
Dyspareunia
Infertility
Physical exam findings
Uterorsacral nodularity
Adnexal mass
Diagnosis
Visualizations of lesions on laparoscopy
Pathology of biopsy

10. Endometriosis

11. Endometriosis

12. Endometriosis Treatment
Depends on the symptoms complaints
Medical
NSAID’s
Combined oral contraceptive pills
Progestins
GnRH agonists
Surgical
Surgical ablation or removal of lesions
LUNA
Presacral Neurectomy
TAH/BSO

13. Leiomyomata Benign smooth muscle tumors of uterus
Prevalence - 1/3 of women
Evaluation
History
Increased bleeding
Dysmenorrhea
Pelvic Pain
Pelvic pressure
Physical exam findings
Enlarged uterus
Pelvic or Adnexal mass
Diagnostic Imaging
Ultrasound

14. Leiomyomata

15. Leiomyomata

16. Leiomyomata Treatment Medical Interventional Surgical NSAIDS
Combined Oral Contraceptive Pills
GnRH Agonist
Interventional
Uterine Artery Embolization
Ultrasound/MRI guided ablation
Surgical
Myomectomy
Hysterectomy

17. Dysmenorrhea Definitions:
Primary Dysmenorrhea-within 2-3 months of first menses
Secondary Dysmenorrhea-usually with underlying cause
Etiologies-Endometriosis, Infections, adnexal mass, fibroids
Evaluation
Assessment of underlying etiology
Management
NSAIDS
Combined Oral Contraceptives
Treatment of underlying etiology

18. Case 2
37 yo P2 presenting for her well woman visit reports pelvic pain for the past year.
How do you evaluate her?

19. Chronic Pelvic Pain
Definition - lasting > 6 months, causing functional disability
Incidence - 15% women
Etiologies
GYN GI GU
Neurogenic
Psychological
Musculoskeletal

20. Chronic Pelvic Pain Evaluation Treatment
Focused on identification of underlying etiology
History
Focus on pain history and associated symptoms
Physical Exam
Laboratory
Imaging
Treatment
Focused on treatment of underlying etiology

21. Gynecologic Endometriosis Leiomyomata Infections-PID, TOA
Benign and Malignant Tumors
Vulvar and Vestibular Pain

22. Non Gynecologic Gastrointestinal Genitourinary
Irritable Bowel syndrome
Inflammatory Bowel Disease
Constipation
Diverticular Disease
Genitourinary
UTI-acute, recurrent, chronic
Cystitis-Infectious and interstitial
Urolithiasis
Malignancy

23. Non Gynecologic Psychological Musculoskeletal Abuse Depression
Abdominal Wall and Pelvic Floor myofascial pain
Hernia
Degenerative and Herniated Disc Disease
Fibromyalgia

24. Summary Wide range of causes of pelvic pain in women
Evaluation focused on identification of underlying etiology
Treatment aimed at treating pain and underlying cause

25. Questions?

26. Welcome to the amazing world of Obstetrics and Gynecology
Good Luck!
Welcome to the amazing world of Obstetrics and Gynecology