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MRCOG PART 2 SBAs and EMQs

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Essay 236 - chronic pelvic pain

Posted by Radhika A.
The clinical assessment of this lady would begin with a detailed history along with a detrailed history of the pattern of pain and its association with bladder or bowel symptoms or psychological overlay. It should include eliciting symptoms of triple dysmenorrhea, foul discharge or dyspareunia, menorrhagia and contraceptive history.These are the common causes of dysmenrrhea which may not be responsive to simple analgesics.After a general examination it is important to note the look of cervix,look for cervical movement tenderness, mobility,size and tenderness of uterus and any adenexal mass or tenderness.In case of suspicion of pelvic inflammatory disease, suitable samples to screen for chlamydia snd gonorrhea should be obtained.The investigations required to arrive at a diagnosis may be radilogical or a diagnostic laparoscopy.A transvaginal USG is a sensitive tool for the diagnosis of adenexal mass ( TO masses, endometrioma) though it may not be of value in diagnosing peritoneal implants.The sensitivity of MRI is better in the diagnosis of adenomyosis compared to USG though it is more expensive. She should be offered diagnostic laparoscopy if the above investigations remain inconclusive. The possibility of a negative laparoscopy in about one third of patients should be discussed with the patient pre-operatively.She may be given a course of GnRh agonist or oral contraceptive pills for a period of three months before laparoscopy since ovarian suppression may relieve the symptoms in endometriosis.Till the diagnosis is established, she may be referred to a pain sopecialist to offer better options for pain relief.
Posted by Valerie T.
a)My clinical assessment would include a good history and physical examination. This is needed to obtain information about her symptoms and signs in order to make a high quality clinical assessment. This is required to determine whtehr the pain is caused by a gynaecological condiition or non gynaecological condition. the gynaecological conditions are endometriosis, pelvic inflammatory disease, adhesions, cervical stenosis.

In the history I will find out more information about the nature and pattern of dysmenorrhea; such as the type of pain, the number of days it lasts, and also whether she also has pain that starts before the onset of the menstrual period. I would find out whether she has had dyspareunia. Since dysmenorrhea, dyspareunia and chronic pelvic pain point towards endometriosis. I would find out whether she has had any vaginal discharge, since dyspareunia, vaginal discharge and dysmenorrhea points towards pelvic inflammatory diesase. I would enquire about the length and heaviness of the menstrual period, length and regularity of the menstrual cycles. This will provide me with more information about the possibilty of uterine fibroids or endometriosis. I would find out the severity of these symptoms and whether they affect her quality of life. This will help me to asess the gravity of the condition and aid in determining what type of treatment to offer. I would also ask whether she had any bloating, constipation, diarrhoea or bleeding from the back passage since these are symptoms of bowel disease. Conditions such as irritable bowel disease and inflammatory disease can be cyclical and a cause dysmenorrhea. In the history I would also ask about symptoms such as dysuria, frequency or haematuria. These are urinary symptoms and the pain may be due to a bladder condition. I would also find out whether the pain is associated with movement. This may indicate a musculoskletal origin. I would also take a sexual history, multiple partners or a past history of sexually transmitted infections would point towards pelvic inflammatory disease. I would take a past surgical history since dysmenorrhea may be due to the presence of adhesions.

In the physical examination, I would take her blood pressure and body mass index. I would perform an abdominal examination to identify any abdominal tenderness or pelvic masses. The tenderness may be indicative of pelvic inflammatory diease and the mass may be uterine fibroids. I would perform a speculum examination, to assess the cervix. Cervicitis or nabothian follicles indicate pelvic infection. I would take endocervical swabs to screen and assess for infection. I would perform a vaginal examination to measure the size of the uterus and to determine whether there was cervical excitation, adnexal tenderness or tenderness in the posterior fornix. Tenderness in the posterior fornix may indicate endometriosis. Adnexal tenderness may indicate endometriosis or pelvic infection. Cervical excitation with adnexal tenderness indicates pelvic infection

b) The first investigation is a urine dipstick test to identify the presence of protein, blood or leucocytes that may point towards a urinary tract infection. This test is good because it is simple, quick, can be done in the clinic with an immediate result. However, it is not very specific and if it does point towards a urine infection, a mid stream specimen of urine would need to be taken and a microscopy, culture and sensitivity to perfomed to identify the causative agent of the urine tract infection and the appropriate antibiotics.

The second investigation would be a transvaginal ultrasound. An ultrasound is a good and efficacious radiological intervention that can identify adnexal masses or uterine masses that may be causing the pain such as endometrial ovarian cysts and uterine fibroids. The ultrasound scan can not be used to identify peritoneal endometriosis. In some cases it may be useful in the identification of adenomyosis.

The Magnetic resonance imaging (MRI) may be considered in the investigation of dysmenorrhea. It may identify adenomyosis but has a similar detection rate as the transvaginal scan.

Diagnostic laparoscopy can also be used to investigate the cause of the dysmenorrhea. It is a common procedure but it is associuated with risks of vascular, bowel and bladder perforation. Therefore although a good method to identify pelvic endometriosis, medical treatment should be tried for 3-6 months before this investigation is done. The diagnostic laparoscopy is a much better than ultrasound in detecting endometiosis. However, it is still possible to miss cases of endometiosis with laparoscopy. This technique is also useful, because it is possible to treat the endometriosis at the same time with ablation.

c) If the diagnosis is endometriosis, then the first line treatment options are non steroidal analgesics or combined oral contraceptive pill (COCP). These have been found to be very effective. They should be used for at least 3 to 6 months. The COCP is also useful in women who need contraception. The second line treatment would be GnRH analogues or danazol. However these are associated with a lot of side effects and should not be used for long term treatment. If medical treatment is not successful, then surgical treatment should be offered and discussed. The surgical treatments available are helic ablation and total abdominal hysterectomy with bilateral salpingooophorectomy (TAH,BSO). The benefits of helica ablation are that it is effective, it avoids the risks and consequences of major surgery and it conserves fertility. The TAH, BSO is a major operation. The benefits are that by removing the uterus and ovaries, it removes the source of the pain. The disadvantages of the operation are that it is a major operation associated with morbidity and mortality. It would be inconvenient and require the patient to stay in hospital for at least 5 days and away from work for 6 weeks. Also, there is a chance that the woman may still have pain of she develops residual ovarian disease.

If the diagnosis is pelvic inflammatory disease, treatment would consists of a course of antibiotics and referral to the GUM clinic. Antibiotics are useful because they effectively treat the infection and prevent damage or further damage to the fallopian tubes. The refferal to the GUm clinic, will allow contact tracing and further spread of the disease.

If the diagnosis is pelvic adhesions, then the treatment would be non steroidal analgesics. these have been found to be effective. Second line treatment is laparoscopic adhesiolysis. This has been shown to be very effective.

If the diagnosis is musculoskeletal, non steroidal analgesics would be effective. A reffereal to the physiotherapist would also be useful.

If the diagnosis is of a gastronitestinal disorder, a referral to the gastroenterologist would be useful. However, if the diagnosis is of irritable bowel syndrome, Mebeverine and dietary change is also very effective.
Posted by Idris O.
a) History of dysmenorrhoea associated with menorrhagia may suggests uterine fibroids, adenomyosis, chronic pelvic inflammatory disease,intrauterine contraceptive device and cervical stenosis. If pelvic pain and deep dyspareunia is present it may suggest endometriosis. Previous multiple pelvic surgery like caesarean section, ovarian cystectomy may suggest pelvic adhesions. Abdominal bloating associated with altered bowel motion and painful defecation is suggestive of IBS. When there is no obvious cause, this may be idiopathic. A history of sexual abuse may be elicited in the latter. While history may be useful in suspecting some cases it is unlikely to provide a definitive diagnosis.
Additional information from a physical examination include thickened and tender uterosacrals with a fixed retoverted uterus in keeping with endometriosis. Irregularly bulky uterus suggest fibroid and if uniformly bulky and doughy may de adenomyosis.
The keeping of a pain diary and dietary habits may help in the diagnosis of IBS.
Conscious pain mapping also shown to be helpful in localising the area of pain and may distinguish pain due to adhesions from endometriosis. A physical examination may be helpful but may not be accurate.

b) Pelvic uss will confirm uterine fibroids , the number and location including the presence of ovarian cyst or adenomyosis. this depends on the expertise of the operator and the quality of the machine. MRI will confirm adenomyosis, uterosacral endometriosis and ovarian endometrioma. A diagnostic laparoscopy is the goal standard in the investigation of dysmenorrhoea, and will exclude endometriosis, pelvic inflammatory disease and suggest adenomyosis. It will also confirm ovarian endometrioma.
Laparoscopy is expensive and has to be performed under GA . It may be complicated by haemorrhage, bowel and bladder injuries. Pelvic inflammatory disease as a cause of dysmenorrhoea is difficult to diagnose from swabs from the endocervix or the vagina. This may only be useful in the diagnosis of acute infections.

c) The treatment of this patient will depend on the cause. The combined oral contraceptive pill can be used if there are no contraindications. It is very effective and has to be taken continuously.It may cause breakthrough bleeding but has the advantage of being an effective contraception. Progestogen also needs to be taking daily and is associated with acne, weight gain and irregular vaginal bleeding. The GnRH analogues are probably the most effective but are associated with menopausal symptons and this may affect tolerance. Danazol had been used in the past for the treatment of endometriosis, adenomyosis and dysmenorrhoea of unknown aetiology. It may be associated with acne, breast atrophy and weight gain which may affect compliance.
Dietary modification avoiding diary products and grains and the use of stools modifier like fybogel and clopamine may relief IBS.
Surgical options may be useful like transcervical resection of submucous fibroids or thermal ablation of the endometrium but are limited in inability to treat dysmenoorhoea but menorrhagia. This is also the same with the Mirena coil whose side effect of irregular vaginal bleeding may affect compliance. Where all the options discussed has failed, the last option would be an hysterectomy. this would be applicable if the woman has completed her family. This is a major operation and may be associated with complications of bleeding , injury to bladder, ureter, bowel and risk of thromboembolism.
Where no cause is found, the patient needs supportive care.
Posted by Sabahat S.
a) A thorough history should be taken to ascertain the severity & nature of the condition, and the degree to which it is affecting her quality of life. The nature of dysmenorrhorea- whether it is a constant heaviness in the pelvis or a feeling of cramping pain before menses ? The regularity of her cycles ? A history of unhealthy vaginal discharge, with dyspareunia and cramping dysmenorrhorea points towards a diagnosis of PID. History of multiple sexual partners, contraceptive history ( Barrier or IUCD ) previously history of STI ?
When is the pain most severe, before the menses & subsides with the starting of bleeding or persists through out most of the premenstrual & menstrual phase ?Any history of heavy bleeding during menses should be inquired (menorhagia ) ? which may indicate towards a submucuous fibroid, Adenomyosis (even PID can have menorrhagia ).
Any history of alteration in bowel habits,diarrhoea, constipation, blood in stools point towards inflammatory bowel disease. A history of alternating diarrhoea flatulence, constipation along with abdominal discomfort point towards IBS ( irritable bowel syndrome ).
A thorough abdominal examination is done to look for any evidence of mass ( ? fibroid, TO mass, enlarged uterus due to adenomyosis) any e/o distended bowel (IBD, IBS ) Pelvic examination, to look for any unhealthy vaginal discharge, a red inflamed cervix ( indicative of PID ), the size of the uterus (enlarged in adenomyosis ) tenderness over the uterus & adnexa ( PID ), any fixity of the uterus, retroverted, tender utero sacrals with nodularity (in endometriosis ) or adhesions.
b) MSU for dipstix is cheap & effective to rule out any co existent UTI.
Abdominal or preferably a vaginal ultrasound (effective, no radiological exposure ) may delineate an enlarged uterus, fibroids, (their location ) tuboovarian (adnexal ) mass . Cervical swab for ME and c/s to rule out gonorrhoea, chlamydia, PID.
Laproscopic visualization of the pelvis is the gold standard for diagnosis of endometriosis & also PID. It has the added advantage of treatment of endometriotic deposits in the same sitting ( with prior consent ). The endometriotic deposits should be sampled from one / more sites & sent for HPE.
MRI is useful in delineating endometriosis,adenomyosis and any TO mass. ( but is not cost effective & not commonly used ).
c) The treatment options will depend on the cause, severity of the condition.Patient?s choice of treatment, cost & cost effectiveness issues.
d) A course of broad spectrum antibiotics should be started ( covering aerobic & anaerobic ) for PID, awaiting results of culture sensivity. they should be given for 7 ? 14 days depending on the response.
Endometriosis could be treated with COCP, a trial of danazol or Gn RHA could be tried. Danazol & Gn RHA are associated with many unacceptable side effects (bone loss, hirsutism, acne, weight gain,masculirization ) and so are not recommended for more than 6 mths .LNG-IUS could be tried.
Laproscopic ablation of endometriotic deposits is very effective (but requires
GA ) it could be done by laser or diathermy. Laproscopic debridement &
resection of any tuboovarian mass, necrotic tissue can be carried out to
increase the efficacy of treatment of PID.
Adhesiolysis can be done laparoscopically & can result in significant improvement in pain scores.
Adenomysis can be treated with TAH which is a major surgery with all its associated risks of morbidity & mortality.
In case of an intramural or submucous fibroid, a myomectomy could be helpful, but also with all the inherent risks of a major surgery & also risk of being converted into a hysterectomy in case of emergency.
LUNA & presacral neurectomy have been tried, but have not been proven to be effective & not advocated.
In case clinical examination points to a GI cause she should be appropriately referred to gastroenterologist.
She may require referral to a pain clinic for specialist councelling and pain therapy. Written information & follow up appointments should be given .
Posted by Mohammad H.
this case of chronic pelvic pain that can be due to gynecological or non gynecological causes gynecological causes include endometriosis,pelvic inflammatory disease (PID) and fidroid
Non gyecological causes include inflammatory bowel
disease ,urinary tract conditions and psychological problems.
Menstrual history (regularity of cycle ,length of cycle ,amount of bleeding ,character of pain when pain starts & ends and the presence of intermenstrual bleeding can give clue to causes of dysmenorrhea
Histroy of vagnial discharge , dyspareunia and previous attacks of P.I.D.increases the suspecious of chronic PID.
For non gynaecological causes history of G.I.T symptams as nausea ,vomiting,loss of weightand rectal bleeding during or outside menstruation,history of urinary symptoms, dysuria, frequery ,ergencyand hematuria & PSYchological symptoms should also be considered.

The effect of this chronic pain on her life should be assessed.contracetive history(IUCD and relation to onset of pain to time of insertion and use of cocp and wheather it releives pain or not)

General examination ,BMI and pallor

Abdominal examination for tenderness and abdominal masses .

speculum examination to detect vaginitis, cervicitis and cervical polyps. Local examination for cervical motion tenderness, uterine size ,adnaxal masses , uterine mobility as positive findings suggest endometriosis or P.I.D .
Investigations :

Midstream urine sample for microscoyto rule out UTI.
Ultrasound scan to detect uterine size ,presence of fibroid , ovarian cysts an dadnexal masses.
High vaginal smear, swabs for chlamydial and gonorrhea are usually negative in cases with chronic PID.
Diagnostic laparoscopy remains the gold standard investigation for chronic pelvic pain.It should be done if clinical examination is positive or after faliure to respond to medical treatment so,it is justifiable to use cocp before going to laparoscopy if clinical examination is negative.Faliure to identify a cause for this chronic pain should be discussed with the patient.If non gyneclogical cause is suspected, refeeral to o ther speciality for assessment and further investigations is appropriate.
Treatment options:

Explanation of the nature of the disease as it may be multifactorial and the probability of faliure to identify a cause for the chronic pain is important point in the management of the patient.
If a cause could be identified treatment should be directed to the cause .
As simple analgesics failed to work in this case ,a trial of cocp should be given to the patent .Cocp relieve ddddysmenorrhea , control cycle, provide reliable contraceptive beside improvement of dysmenorrhea .
Gonadotrophin releasing hormone agonists (GnRHa)can be used for 6 months .GnRHas improve dysmenorrhea,and gives a clue that this pain is due to ovarian activity.
Oopherectomy should be preserved for intractable cases that failed to respond yo medical treatmentand after GnRH a trial.
Posted by Malar R.
Assessment starts with history taking which might indicate primary or secondary dysmenorrhoea due to endometriosis, chronic pelvic inflammatory disease and pelvic masses or adhesions, bowel and bladder causes of pain. Symptoms such as timing and duration of pain with respect to the cycle, dyspareunia, heavy menstrual bleeding, dyschezia and internenstrual vaginal discharge should be asked.Bowel and bladder symptoms such as dysuria and rectal bleeding should also be assessed to rule out non gynaecological causes. Very rarely women may get endometriosis in their lungs or stomach and therefore haemoptysis and haematemesis should be asked for.
It is important to know about previous abdominal surgery including caesarean sections as adhesions can be suspected as cause for pains. Sexual history including number of partners and any recent partners must be known to screen for sexually transmitted infections if appropriate.Contraception history should be known as an IUCD might have caused pelvic infection.
The patient should be examined abdominally and vaginally to check for abnormal vaginal discharge , cervical excitation, endometriotic nodules in the uterosacral ligaments, signs of abdominal masses or pelvic masses, scars and signs of frozen non mobile pelvis.
Investigations should include high vaginal swab and endocervical swab for culture and sensitivity and endocervical swab for chlamydia to check for current infections.However the swabs might be negative despite the pain being caused by pelvic inlfammatory disease or in chronic infection.Mid stream Urine should be sent for culture to exclude urinary tract infection. An USS of her abdomen and pelvis should be done to look for pelvis masses and endometriomata.USS however can be normal in the presence of endometriosis and pelvic inflammatory disease.The patient can be listed for diagnostic laparoscopy. This will enable visualisation of her pelvis and abdomen and can show adhesions and endometriosis. This is associated with risks of infection , bleeding,bowel and bladder perforation, thromboembolism and can be negative despite the 3 year history of pain. Endometriosis , even if present , might not be visible at the time of the laparoscopy.Adhesions if present could be potentially treated at the same time with prior consent.

Treatment depends on the cause of her dysmenorrhoea and her wish for fertility, and therefore this should be established.
The combined oral contraceptive can be taken in the absence of contraindications. It can help endometriosis and primary dysmenorrhoea as well as act as contracetion if needed.
Any confirmed pelvic infections such as chlamydia should be treated. However she can continue to have pain due to chronic inflammation.
If the pain is felt to be due to menorrhagia, she can be given tranexamic acid to reduce the flow and therefore treat the pain.Tranexamic acid is effective in 80% of women in reducing blood flow and is non hormonal, cheap and easily tolerated.
A Mirena IUS can be considered if dysmenorrhoea is caused by menorrhagia. Mirenas are effective in reducing blood flow and helping dysmenorrhoea.They will also function as contraceptives if desired.
If the pain is due to adhesions, she can be managed conservatively after referral to the Pain team for consideration of analgesics such as opioids.Alternatively , she can be offered adhesiolysis.Adhesiolysis may however result in further adhesions and involve having a general anaesthetic and intraoperative risks of bleeding , infections and damage to visceral organs.

If Endometriosis is severe, she can be offered laparoscopic resection of the lesions.Again, this carries intraoperative risks of injury to bowels, bladder or ureters.
Endometriosis can also be treated with GnRH analogues. This will render her hypoestrogenic and she will have synptoms of menopause.GnRH analogues are associated with osteoporosis and thrombocytopenia and are only licensed to be used for 6 months.

As this patient is 30 years old, treatment of her dysmenorrhoea with hysterectomy and bilateral salpingoophorectomy should not be offered as first line options. Equally , if menorrhagia is the cause of her pain, endometrial ablation should only be offered after establishing fertility wishes.
Posted by Saad A.
The causes of dysmenorrhea are chronic PID, endometriosis, adenomyosis, fibroids, IUCD, cervical stenosis. Detailed history is obtained from the patient to know about the pain its onset , duration, character whether colicky or constant, aggravating factors whether increased in severity on movement, menstrual irregularities, contraceptive history especially IUCD placement, previous history of PID, treatment taken previously other than analgesia. Previous medical or surgical history (cone biopsy to rule out cervical stenosis) .After her general examination abdominal examination is carried out to rule out any uterine/ovarian masses, abdominal tenderness, pelvic examination for uterine tenderness, fixity, nodularity and adenaxal masses and size of uterus. Investigations are needed to to confirm diagnosis. Blood for CRP & ESR may indicate chronic inflammatory disease. Endocervical swabs for Chlamydia and gonorrhoea.
Laproscopy is the most useful diagnostic modality for this patient. Not only diagnostic but treatment can take place; help to identify endometriosis, chronic PID. If endometriosis present then its grading should be done, by identifying the extent of the lesion in the pelvis. MRI more sensitive than ultrasound in case of adenomyosis and endometriosis and is non invasive.
The treatment is according to the case. The endometriosis is treated by laproscopic diathermy/Laser by excision /ablation techniques. Though adhesiolysis is not very effective in pain relief. Antibiotic is not effective in chronic PID.Medical hormone therapy like COCP progesterone can be advised .Side effects like acne. Headache nausea, vomiting.Contraindication like history of VTE and history of breast cancer should be asked before prescription.GnRh analogue,danazole,gastrinone are expensive.Androgenic side effects like acne,hirsuitism, oily skin can occur and risk of osteoprosis with GnRH but effective with addback therapy.If no relief TAH and BSO will be advised if patient has completed her therapy.Risl of anaesthesia and operation should be discussed with the patient.
Posted by AMNA  K.
a)Clinical assessment of patient with dysmenorrhoea is based on detailed history and examination and includes onset of pain in relation to menstrual cycle as pain around the onset of menses and of increasing in severity as flow progresses suggests endometriosis,severe2to3 days before and eases off with menses favors pelvic inflammatory disease. Nature of pain as spasmodic pain is more likely with IUCD in situ or endometrial polyp.
Severity of pain is judged by impact on functional ability of women (frequent day off and social restriction). Other associated features like prolonged and heavy menstrual flow (fibroids and IUCD in situ), vaginal discharge( may favor PID), dysperunia with dysmenorrhea ( endometriosis and PID) , inter menstrual bleeding( cervical polyp).
History of sexually transmitted disease(to suggest PID) and contraceptive practices ( IUCD, OCP) is also important as IUCD is a cause and COCP is treatment. Symptoms related to other systems including gestro intestinal tract to exclude irritable bowl syndrome(IBS) by Rome?s criteria (relieved with defecation, change in the frequency of stool and change in the appearance and form of stool) and urinary tract for interstitial cystitis (dysuria, frequency, haematuria) should also be enquired, as these disorders may cause intermittent or cyclical pain which may coincides with onset of menses.Family history is important if endometriosis is suspected and history of previous suregeries may suggest adhesions as a cause odysmenorrhea Reproductive wishes of the patient should also be explored to plan treatment.
Examinations include abdominal palpation for abdomino pelvic masses (fibroid) and pelvic examination including speculum examination for vaginal discharge and polyps(cervical) bimanual for findings like enlarged (fibroid) and bulky uterus(adenomyosis) and fixed retroverted fendometriosis. .Complete normal examination is suggestive of IBS.
b)Regading investigations a raised white cell count suggests infection and may be associated with raised erythrocyte sedimentation rate(ESR) along with raised Creactive protein(CRP) in patients with chronic PID. Ca-125 although non specific but may be raised in some cases of endometriosis. Urethral and endocervical swabs for culture and Chlamydia ELISA/PCR. A negative swab for Chlamydia and gonorrhoea does not exclude PID.
Pelvic ultrasound (preferably trans vaginal) will demonstrate fibroids, IUCD and ovarian cysts including endometriomas,but less sensitive and specific in the detection of endometriosis and adhesions. MRI scan may identify endometriosis and adenomyosis. Hysteroscopy may be indicated to evaluate intrauterine pathology suggested by imaging. Gold standard is diagnostic leproscopy to clarify the diagnosis and can demonstrate PID, ovarian cysts and endometriosis.If history and examination suggest involvement of GIT tract and urinary tract then endoscopy and cystoscopy respectively.
c)Treatment options in this case depend upon identified cause and patient wishes . If she is not willing for further pregnancy and there are no contraindication then COCP are very effective and provide symptoms relief in >80% particularly in endometriosis. Levonorgestrel intrauterine device(Mirena) is also very effective especially if there is co existent menorrhagia and patient needs long term contraception, although Mirena is not licensed for dysmenorrhoea. Danazole ,GnRH analogues, gastrinone all are effective but side effects(breast atrophy, weight gain ,and viralization with danazole and hot flushes, decreased bone mineral density with GnRH analogues) limit their use fullness.
Surgical options in this case also depends upon the etiology and may necessitate conservative leproscopic or open surgery with adhesiolysis,salpingectomy and ablation or excision of endometriotic deposits. Hysteroscopic resections of endometrial polyps , intrauterine adhesions and submucosal fibroids can also be planned if conservative surgery is decided.In severe cases resistant to medical therapy hystrectomy with or without bilateral oophrectomy may be required more likely in patients with moderate to severe endometriosis or with significant PID. Surgery whether conservative or redical must be planned after through discussion with patient and after obtaining an informed consent.
Regarding leproscopic uterin nerve ablation , there is a place in refractory cases of dysmenorrhoea but at present there is insufficient evidence to recommend it.
If cause of dysmenorrhoea is because of involvement of other systems like GIT(IBS), and UT(interstitial cystitis) then collegues from same disciplines should be consulted. If examination and investigations are normal then patient should be reassured and no treatment is needed.
Posted by Sabahat S.
Please check my answer
Posted by Sabahat S.
Please check my answer