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How hot are you on pelvic pain?

Test your knowledge for the nMRCGP with this little GEM from GP Notebook

Test your knowledge for the nMRCGP with this little GEM from GP Notebook

Chronic pelvic pain (CPP) describes chronic pain that is localised to the pelvis. It is a common problem in gynaecological clinics.

Question Approximately what is the prevalence of CPP in women?

Answer CPP is a common problem with a prevalence of about 38/1000.

Question What is the most common age group affected by CPP?

Answer Most commonly CPP affects women aged 20-50.

Question Examples of gynaecological and non-gynaecological causes of pelvic pain?

Answer The most common gynaecological diagnoses include endometriosis, pelvic inflammatory disease and adhesions. The most common gastrointestinal diagnosis is irritable bowel syndrome and genitourinary diagnoses include interstitial cystitis.

Question What is endometriosis?

Answer This is a common disorder characterised by the presence of endometrial glands and stroma outside of the endometrial cavity.

Endometriosis is a benign condition but one which is of great importance in gynaecology because of the distressing symptomatology, the association with infertility and the potential for invasion of the gastrointestinal and urinary tracts. Classically it is described in women in their 30s and 40s, particularly Caucasians. But as the use of laparoscopy has become widespread this description has become less accurate.

Question What investigations are useful in the diagnosis of endometriosis?

Answer This condition is usually confirmed by laparoscopy; changes suggestive of endometriosis may sometimes be seen on ultrasound scan: ultrasound in endometriosis:

  • transvaginal ultrasonography (TVS)
  • helpful in assessing endometriotic ovarian cysts
  • TVS is of little value in assessing the presence of adhesions and mild peritoneal deposits
  • TVS may be useful in assessing deep infiltrating disease, where endometriosis involves the Pouch of Douglas
  • often hypoechoic linear thickening, or nodules/masses with or without regular contours can be seen on TVS
  • endoanal ultrasound
  • has been evaluated for the diagnosis of deep infiltrating endometriosis

Investigation of other possible sites is dictated by symptoms, such as cystoscopy if bladder involvement is suspected.

Question What medical therapies can be used in the management of endometriosis?

Answer Medical options include non-hormonal treatment such as analgesia, eg NSAIDs.

Hormonal treatments aim to induce atrophy within ectopic endometrium either by suppressing the activity of oestrogen on the ectopic endometrium, or by suppressing ovarian production of oestrogen, either directly or indirectly via the suppression of pituitary function. Options include:

  • medroxyprogesterone
  • combined oral contraceptive pill: taken with longer cycles (such as for three months at a time) to avoid menstrual bleeding is a strategy sometimes used to control symptoms of endometriosis
  • danazol: given for six-nine months to produce a 'pseudomenopause'; it is a testosterone derivative which:

– suppresses LH surge
– inhibits ovarian steroidogenesis
– reduces plasma levels of sex hormone binding globulin
– increases free testosterone, because of reduced SHBG

  • gestrinone: a synthetic steroid derived from 19-norethisterone; this treatment has similar actions and side-effects to danazol, but it has a longer half-life than danazol and only needs to be taken twice a week
  • GnRH analogues: induce a medical oophorectomy

This fortnightly series is based on GPnotebook Educational Modules (GEMs) The full version is available via GPnotebook Plus, a service free to UK medics at GP Notebook

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