Thread by @DrNicoleC

It was a hard decision on which workshop to go to this morning, but I'm in the pelvic pain workshop now! #SAHM23

Definitions
Primary dysmenorrhea: painful menses in absence of pelvic pathology

Secondary dysmenorrhea: painful menses due to pelvic pathology or medical condition (e.g. endometriosis)

Chronic pelvic pain: >6 months, intermittent or constant, not always gynecologic

#SAHM23

Evaluation:
- history (gynecologic/menstrual/FHx)
- bleeding pattern
- qualifying pain, intensity, timing
-confidential history is important

Pelvic exam is not recommended in adol patients unless STI/PID highly suspected

Same for imaging unless anatomic concern

#SAHM23

Treatment for primary dysmenorrhea:
- non-medication (hot packs, exercise)
- medication (NSAIDs, starting 1-2 days prior to bleeding if can predict, hormonal therapies)

#SAHM23

Tx cont'd:
- CHCs (pills, patch, ring), continuous vs cyclic use
- POPs: can start at lower dose and increase if needed (e.g. 5-20 mg norethindrone acetate)
- Depo 💉: 50% in 1 yr have amenorrhea
- Implants : 52mg LNG IUD have best amenorrhea rates

#SAHM23

Note: for depo shot, bone density catches up after discontinuation, and there is no difference in fracture risk in adults who previously used depo.

#SAHM23

Secondary dysmenorrhea: most common causes are endometriosis, cysts, congenital mullerian anomalies

For CMA - persistent endometriosis is higher even after surgical correction

#SAHM23

Endometriosis!
Leading cause of secondary dysmenorrhea in adolescents
- in a study of adult endo patients, 67% reporting sx before 20, 20% had sx <15
- RFs: early menarche, shorter menstrual cycles, menorrhagia, FHx, anomalies

#SAHM23

Pathogenesis: retrograde menstruation, neonatal uterine bleeding, implants from tissues outside uterus 🤷‍♀️

Pain is not always cyclic!

#SAHM23

Dx: H&P, imaging (pelvic US to r/o other etiologies), MRI if concerned for anomalies, labs (CBC/ESR, STI, UA)

ACOG recommends empiric trial of medication for 3 months. If no improvement --> consider laparoscopy with peritoneal biopsy

#SAHM23

Endometriosis dx can be staged, but important to not stage doesn't correlate with sx

Also, endo can look physically different on laparoscopy for adolescents vs adults.

#SAHM23

Management: can wax and wane in sx, is a chronic dz
- Surgical: removal/lysis of adhesions. Peritoneal stripping is NOT recommended in adolescents d/t increase risk of adhesive disease w/ growth
- Meds: continuous use or extended cycling is recommended to suppress growth
#SAHM23

GnRH agonists (leuprolide) can be considered, however leads to low estrogen (leading to decreased BMD). If on longer than 6 months, do add back therapy with norethindrone +/- conjugated estrogen. SEs post-menopausal sx

#SAHM23

GnRH antagonists (elagolix 150 mg daily, can use safely for 24 months) also an option for >18 yrs

Danazol: androgen can lead to atrophy of lesions, side effects include hirsutism, etc

Acupuncture is evidence based, but likely depends on practitioner

#SAHM23

Chronic pelvic pain:
>6 months
- Often concurrently in pts with IBS, cystitis, pelvic floor dysfx
- Differential is broad! And often multifactorial

W/up:
- IPPS has an assessment form that may be helpful
- Abd exam, Q tip test of concerned for vulvar
- STI, Pelvic US?

#SAHM23

- mass (large and sx) -->surgery
- PID - can happen in non-SA patients!
- Vulvodynia - pain for 3 months w/o clear causes. Dx of exclusion. Rule out infection, Q-tip test to identify where pain is
#SAHM23

Vulvodynia Tx:
- vulvar care (cotton underwear, loose)
- topical meds (lidocaine)
- pelvic floor PT, biofeedback

In refractory cases, consider vestibulectomy

#SAHM23

GI causes of CPP:
- IBS (Rome criteria)
- Constipation
- Fxn abd pain

Urologic causes:
- interstitial cystitis (mimic sx of UTI). Cystoscopy is gold standard for dx. Tx: dietary changes (limit caffeine, EtOH, sodas), hydrodistention, pentosanpolysulfate FDA approved

#SAHM23

If no etiology identified
- menstrual suppression
- neuromodulators (e.g. gabapentin)
- SNRIs/TCAs? no trials yet
- Ref to pain management (trigger pt injections, nerve blocks)
- Pelvic floor PT
- MH therapy/CBT

#SAHM23

Questions!
If taking medication consistently for 3 months and not having relief, would refer for lap

Vitamins - no conclusive research

Yoga - specific poses were shown to be helpful (were studied specifically)

#SAHM23

For continuous use, breakthrough bleeding usually guides decisions about when/if to have regular withdrawal bleeding.

*You don't need a withdrawal bleed!* Ask the patient, some may prefer it, some not.

#SAHM23

Imaging is not helpful for endo dx. Mostly used to rule out other things. Endometriomas aren't typically visible on US or MRI.

? about hesitancy for laparoscopy. If pt/family hesitant, can always trial a different OCP. Wouldn't use GnRH agonists without dx of endo.

#SAHM23