1. Gynaecological Causes of Acute Pelvic Pain Max Brinsmead MB BS PhD May 2015

2. In the emergency assessment of women of reproductive age it is important to exclude: – Ectopic pregnancy – Acute PID – Ovarian cyst – Endometriosis And you may be left with a diagnosis of Primary Dysmenorrhoea The Short List

3. Requires a high index of suspicion Typical History Pain (90 %) Then PV bleeding (85%) The patient at risk (prior ectopic, tubal surgery etc) Excluded by negative UCG Diagnosed by beta HCG >3000 and empty uterus on ultrasound DD includes normal pregnancy & miscarriage Ectopic Pregnancy

4. Diagnosis requires a patient at risk Usually younger patient (15 – 25 years) New partner or multiple partners Or a partner at risk e.g. one that travels It is a bilateral disease Pelvic peritoneal tenderness is a subtle sign WCC & ESR or C-reactive protein can be useful Requires careful microbiology Test for all STD’s simultaneously A role for laparoscopy in diagnosis Acute PID

5. Very common But not always the source of pain Pain can be due to: Rapid enlargement Rupture Haemorrhage - typical of the corpus luteum Torsion (rare) Ultrasound is both a boon and a bane because Paraovarian cysts Mesenetric cysts & Adhesive collections Hydrosalpinx, Bladder or even Ureter May be imaged but do not cause acute pain Ovarian Cysts

6. Not uncommon with Mirena Ignore alarming reports from the radiologist If the patient is <50 then it is usually benign Analgesia, observation and reassurance is best Repeat scan in 3 – 4 months Can use COC to suppress the ovaries and prevent confounding “cysts” appearing Laparoscopy, drainage and biopsy rarely required Management of functional cysts

7. Risk of malignancy increases with age Ultrasound assessment Look for septa and SOLID AREAS Look for Ascites Evaluate Doppler flow Tumour markers in serum essential CA125 (CA19.9, CEA, AFP, beta HCG) Dermoid cyst (Teratoma) most common ovarian neoplasm of young women And may be bilateral (15%) Evaluating an ovarian tumour

8. Pelvic clearance i.e. TAH & BSO or resection of all solid tumour Except for the very young patient With Ca of low grade malignancy Omentectomy Peritoneal washings for cytology Lymph node biopsies If you can’t do that then resist the temptation to operate and send her to someone who can! A malignant ovary requires...

9. Almost always associated with ovarian pathology Presents as “reverse renal colic” May present with acute abdomen Pulls cervix to the side of the torsion Usually requires salpingo oophorectomy Ovarian torsion

10. An enigmatic condition Common As many as 1:4 women if your diagnostic criteria are liberal The “At Risk” Individual Has delayed pregnancies Family history common Cardinal symptoms are: Dysmenorrhoea Dyspareunia Infertility Premenstrual staining Pain with defaecation during menstruation Endometriosis

11. Physical examination There may be tender nodules in the uterosacral ligaments Ultrasound Of little value unless there are endometriomas Menstrual phase Ca125 may be used But has poor sensitivity Laparoscopy required for diagnosis There is a poor correlation between findings and symptoms Debate as to the role of biopsy in diagnosis Treatment Medical for pain but surgery for infertility Endometriosis cont’d

12. Is not associated with any pelvic pathology Also called “spasmodic dysmenorrhoea” Typically a teenager but can occur in the 40's too Worse before and on the day of first flow Accompanied by pallor, prostration & diarrhoea Relieved by NSAIDs in effective doses Best managed with combined OC Which can be given for up to 3m continuously But the Mirena IUS and sometimes Depot Provera has a role Primary Dysmenorrhoea

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