Acute Pelvic Pain
• Reasons
► Complications of pregnancy (ectopic pregnancy, abortion)
► Acute infections
► Adnexal pathologies
► Cyclic pelvic pains (dysmenorrhea, mittelschmertz)
► Gastrointestinal
► Genitourinary
► Musculoscletal
In case of acute pelvic pain in women of reproductive age, pregnancy should be investigated.
Appendicitis is the most common cause of non-gynecological acute pelvic pain in women.
Primary Dysmenorrhea
► There is no pelvic pathology accompanying painful menses. The reason is the increased production of endometrial prostaglandins during menstruation.
► Primary dysmenorrhea always occurs during ovulatory cycles. Therefore, it occurs 1-2 years after menarche, after the ovulatory cycles have settled.
► The pain is colic and especially suprapubic. It starts a few hours before or with menses and lasts for 48-72 hours. It may be accompanied by back pain, nausea, vomiting, diarrhea and rarely syncope attack, There is no severe pain during cervical movements, but uterine tenderness may be present. ESR rate is normal; and it can be used in the differential diagnosis of salpingitis.
Primary Dysmenorrhea Treatment
1. Prostaglandin synthetase inhibitors or NSAIDs (mefenamic acid, naproxen)
2. Combined oral contraceptives (ovulation inhibition); Indicated when there is no response to NSAIDs
3. Progesterones (ovulation inhibition); Depot MPA, etonogestrel implant, LNG IUD
4. Diagnostic laparoscopy is performed if no result can be obtained in the patient who uses the treatment for 4-6 cycles.
Secondary Dysmenorrhea
► There is a pelvic pathology accompanying painful menses and it usually occurs in advanced ages. The most common cause is endometriosis, followed by adenomyosis and the use of copper IUDs.
► In addition to these, subacute endometritis, pelvic inflammatory disease, ovarian cyst, pelvic congestion, myoma uteri, uterine polyps, Asherman's syndrome, congenital pelvic malformations, cervical stenosis, imperforated hymen, transverse vaginal septum are seen in processes that cause obstruction such as secondary dysmenorrhea.
► The pain starts 1-2 weeks before menses and continues for a few days after the end of mens.
► Treatment is the elimination of the primary pathology.
Mittelschmerz (ovulation pain)
► It occurs due to the reaction of the follicle fluid or blood spilled into the peritoneum during ovulation. It is associated with cycle, develops acutely, is short-lived and usually has a mild course. Unilateral lower quadrant pain.
Chronic pelvic pains
• Pain in the lower abdomen and pelvis that persists in the same area for more than 6 months in women, causes functional loss or requires treatment. Its incidence is 12-20%. The most common cause of chronic pelvic pain is gynecological causes.
Reasons
► Gynecological (non-cyclic): Endometriosis (most common), pelvic adhesions (most common), pelvic congestion, salpingoooophoritis, ovarian remnant syndrome, ovarian tumors, pelvic relaxation
► Gastrointestinal: Irritable bowel syndrome (most common), ulcerative colitis, Crohn's disease, diverticulitis, carcinoma, infection, recurrent partial intestinal obstruction, hernia, abdominal angina
► Genitourinary: Cystourethritis, urethral syndrome, interstitial cystitis/painful bladder syndrome, ureteral diverticula and polyp, bladder carcinoma, ureteral obstruction
► Neurological: Femoral neuropathy, ilioinguinal neuropathy, iliohypogastric neuropathy, neuroma
► Musculoskeletal system: Myofascial syndrome and trigger points, lower-back pain syndrome (osteoporosis, scoliosis, kyphosis, spondylosis, spinal injury, tumor, anomaly)
► Systemic diseases: Fibromyalgia, acute intermittent porphyria, abdominal migraine, connective tissue diseases (SLE), lymphoma, neurofibromatosis
► Psychosocial
While endometriosis and adhesions are the most common gynecological causes; Irritable bowel syndrome is the most common non-gynecological cause.
Treatment in Chronic Pelvic Pain
► A multidisciplinary approach is required in cases of chronic pelvic pain and treatment should be performed for the underlying cause (antibiotic, SSRI).
► Laparoscopic evaluation should be performed in cases that do not respond to NSAIs. If pathology is detected during laparoscopy, there is a chance that the treatment (endometriotic focus cauterization, separation of adhesions) can be performed simultaneously. During laparoscopy, LUNA (laparoscopic uterine nerve ablation) (fibers from the inferior hypogastric plexus) or presacral neurectomy (fibers from the superior hypogastric plexus) can be performed. In some cases, hysterectomy may be performed for pain relief.
premenstrual syndrome (pms)
• It is a syndrome that presents with behavioral disorders that prevent communication and daily activities, includes physical and psychological findings, and is seen cyclically in every luteal phase.
• Premenstrual dysphoric disorder (PMDD), on the other hand, is a severe subtype of premenstrual syndrome. It is seen in 3-5% of women in reproductive life. In addition to the classic PMS picture, it shows more severe psychological findings.
Clinic
• Edema
• Weight gain
• Headache
• Breast tenderness
• Weakness
• Irritability
• Tension
• Pelvic pain
• Mood changes
• Sleep changes
• Lack of concentration
Criteria for the diagnosis of PMS
• There should be no organic cause.
• Symptoms should occur in the second half of the cycle.
• Must be completely asymptomatic for at least 7 days in the follicular phase.
• At least 2 consecutive symptoms should be observed and be severe enough to require treatment.
• Symptoms may disappear with menstruation.
• It is not seen in prepubertal, postmenopausal and pregnancy periods.
• It is not necessary to have menstruation, it can also be seen in women with hysterectomy with preserved ovaries.
etiology
• Its etiology is not clearly elucidated, but physiological ovarian function is the trigger. The disappearance of symptoms with suppression of ovarian functions strengthens this theory. However, it is reported that the decrease in the amount of serotonin plays a role.
Beta endorphins are decreased in the luteal phase in PMS. However, in the normal menstrual cycle, endorphins decrease in the follicular phase and increase in the luteal phase.
Treatment
• Treatment should be based on symptomatology. SSRIs and drugs that suppress ovulation (COC, GnRH agonists) provide effective treatment.
► Exercise
► Diet: Diet rich in carbohydrates, restriction of caffeine, alcohol, smoking and cocoa intake
► Calcium, magnesium, vitamins E and B6
► NSAID
► Combined oral contraceptive
► Spironolactone (for edema)
► Bromocriptine (for mastalgia)
► GnRH analogs
► Danazol
► Selective serotonin reuptake inhibitor {SSRI) {Fluoxetine): It is the most effective agent among medical treatment methods
► Anxiolytics: Alprozolam and buspirone
• Estrogen and corticosteroids are not used in the treatment of PMS
• Progesterone, lithium and tricyclic antiaepressants do not have significant benefits in the treatment of PMS.