Chapter 051. Menstrual Disorders and Pelvic Pain (Part 5) Acute Pelvic Pain: Treatment Treatment of acute pelvic pain depends on the suspected etiology but may require surgical or gynecologic intervention. Conservative management is an important consideration for ovarian cysts, if torsion is not suspected, to avoid unnecessary pelvic surgery and the subsequent risk of infertility due to adhesions. The majority of unruptured ectopic pregnancies are now treated with methotrexate, which is effective in 84–96% of cases. However, surgical treatment may be required. Chronic Pelvic Pain Some women experience discomfort at the time of ovulation (mittelschmerz). Pain can be quite intense but is generally of short duration. The mechanism is thought to involve rapid expansion of the dominant follicle, although it may also be caused by peritoneal irritation by follicular fluid released at the time of ovulation. Many women experience premenstrual symptoms such as breast discomfort, food cravings, and abdominal bloating or discomfort. These moliminal symptoms are a good predictor of ovulation, although their absence is less helpful. Dysmenorrhea Dysmenorrhea refers to the crampy lower abdominal discomfort that begins with the onset of menstrual bleeding and gradually decreases over the next 12–72 h. It may be associated with nausea, diarrhea, fatigue, and headache and occurs in 60–93% of adolescents, beginning with the establishment of regular ovulatory cycles. Its prevalence decreases after pregnancy and with the use of oral contraceptives. Primary dysmenorrhea results from increased stores of prostaglandin precursors, which are generated by sequential stimulation of the uterus by estrogen and progesterone. During menstruation these precursors are converted to prostaglandins, which cause intense uterine contractions, decreased blood flow, and increased peripheral nerve hypersensitivity, resulting in pain. Secondary dysmenorrhea is caused by underlying pelvic pathology. Endometriosis results from the presence of endometrial glands and stroma outside of the uterus. These deposits of ectopic endometrium respond to hormonal stimulation and cause dysmenorrhea, which generally precedes menstruation by several days. Endometriosis may also be associated with painful intercourse, painful bowel movements, and tender nodules in the uterosacral ligament. Fibrosis and adhesions can produce lateral displacement of the cervix. The CA125 level may be increased, but it has low negative predictive value. Definitive diagnosis requires laparoscopy. Symptomatology does not always predict the extent of endometriosis. Other secondary causes of dysmenorrhea include adenomyosis, a condition caused by the presence of ectopic endometrial glands and stroma within the myometrium. Cervical stenosis may result from trauma, infection, or surgery. Dysmenorrhea: Treatment Local application of heat; use of vitamins B 1 , B 6 , and E and magnesium; acupuncture; yoga; and exercise are of some benefit for the treatment of dysmenorrhea. However, nonsteroidal anti-inflammatory drugs (NSAIDs) are the most effective treatment and provide >80% sustained response rates. Ibuprofen, naproxen, ketoprofen, mefanamic acid, and nimesulide are all superior to placebo. Treatment should be started a day before expected menses and is generally continued for 2–3 days. Oral contraceptives also reduce symptoms of dysmenorrhea. Failure of response to NSAIDs and oral contraceptives is suggestive of a pelvic disorder, such as endometriosis, and diagnostic laparoscopy should be considered to guide further treatment. Further Readings Dawood MY: Primary dysmenorrhea: Advances in pathogenesis and management. Obstet Gynecol 108:428, 2006 [PMID: 16880317] Genazzani AD et al: Diagnostic and therapeutic approach to hypothalamic amenorrhea. Ann NY Acad Sci 1092:103, 2006 [PMID: 17308137] Hall JE: Neuroendocrine control of the menstrual cycle, in Yen and Jaffe's Reproductive Endocrinology , 5th ed. JF Strauss, RL Barbieri (eds). Philadelphia, Elsevier, 2004, pp 195–211 Latthe P et al: Factors predisp osing women to chronic pelvic pain: Systematic review. BMJ 332(7544):749, 2006 [PMID: 16484239] Pittock ST et al: Mayer-Rokitansky-Kuster- Hauser anomaly and its associated malformations. Am J Med Genet A 135:314, 2005 [PMID: 15887261] Wittenberger MD e t al: The FMR1 premutation and reproduction. Fertil Steril 87:456, 2007 [PMID: 17074338] Bibliography Murray A: Premature ovarian failure and the FMR1 gene. Semin Reprod Med 18:59, 2000 [PMID: 11299521] Warren MP, Fried JL: Hypothalamic amenorrhea. The effects of environmental stresses on the reproductive system: A central effect of the central nervous system. Endocrinol Metab Clin North Am 30:611, 2001 [PMID: 11571933] . Chapter 051. Menstrual Disorders and Pelvic Pain (Part 5) Acute Pelvic Pain: Treatment Treatment of acute pelvic pain depends on the suspected etiology. that begins with the onset of menstrual bleeding and gradually decreases over the next 12–72 h. It may be associated with nausea, diarrhea, fatigue, and headache and occurs in 60–93% of adolescents,. hypersensitivity, resulting in pain. Secondary dysmenorrhea is caused by underlying pelvic pathology. Endometriosis results from the presence of endometrial glands and stroma outside of the uterus.