Abdominal Pain General Guidance
Uncertainty of Diagnosis
When treating a female patient with abdominal pain, I sometimes don't
have a clue as to what the problem is. I say this as a board-certified OB-GYN, with more
than 20 years in clinical practice, practicing in a 600-bed teaching hospital, with
ultrasound, MRI scans, and full lab support. Sometimes all I can say is: "This
patient is sick with something."
Sometimes these patients get well before I can figure out the diagnosis.
Sometimes these patients get worse and I end up performing surgery and find PID, or endometriosis, or an ovarian cyst or almost any other gynecologic, surgical or medical
problem. Sometimes I do laparoscopy and find nothing abnormal, but the pain goes away.
The First Point is: In clinical gynecology, the diagnosis is often
unclear. Just because you're unsure of the diagnosis doesn't mean you can't take good
care of the patient. Often you must treat the patient before knowing the diagnosis.
The Second Point is: More important than knowing the correct
diagnosis is doing the right thing for the patient.
Pain and Bedrest
If the patient has pelvic/abdominal pain or tenderness, bedrest will usually help and is never the wrong thing to do. For many of
your patients, the pain will simply resolve (although you won't know why).
Pain and Fever
If the patient has a fever and pain (without an innocent explanation
for the fever), I would recommend
you give her antibiotics to cover PID. With mild pain and fever, oral antibiotics should
work well, so long as they are effective against chlamydia (Doxycycline, tetracycline,
erythromycin, azithromycin , etc.).
If the fever is high or the pain is moderate to severe, I would
recommend IV antibiotics (such as clindamycin/gentamicin or cefoxitin or cefotetan or
Flagyl/gentamicin) to cover the possibility of pelvic abscess.
CDC Protocols for
PID
Chronic Pain
If there is no fever, but your patient complains of chronic pelvic pain,
a course of oral Doxycycline is wise. Some of these women will be suffering from
chlamydia and you may cure them through the use of an antibiotic effective against
chlamydia. Others will not improve and will need further evaluation by experienced
providers in well-equipped settings.
Pregnancy Test
Any patient complaining of pelvic pain should have a pregnancy test. I
am surprised at how often it is positive despite the patient saying "that's
impossible."
Read more about
Pregnancy Tests
BCPs and Pain
Most patients complaining of intermittent, chronic pelvic pain will
benefit from oral contraceptive pills. BCPs reduce or eliminate most dysmenorrhea and have
a favorable influence on other gynecologic problems such as endometriosis, ovarian cysts,
and adenomyosis, a benign condition in which the uterine lining grows into the underlying
muscle wall, causing pain and heavy periods.
When using BCPs to treat chronic pelvic pain, I have
found multiphasic BCPs such as
Ortho Novum 7/7/7, Triphasil or Tri-Norinyl have not been as effective as the stronger,
monophasic BCPs such as LoOvral, Ortho Novum 1+35 or Demulen 1/35 (in my experience). I
believe the reason is that the multiphasic pills, by virtue of their lower dose and
changing dosage, do not suppress ovulation as consistently as the higher-dose pills.
If the BCPs do not help or if the patient continues to have pain during
her menstrual flow, change the BCP schedule so the patient takes a monophasic (LoOvral,
1+35, etc.) BCP every day. She will:
-
not stop at the end of a pack.
-
not wait one week before restarting.
-
not have a menstrual flow.
If she doesn't have a menstrual flow, she can't get dysmenorrhea. Taken
continuously, BCPs are effective and safe. The only important drawback is that she will
not have a monthly menstrual flow to reassure her that she is not pregnant.
Because the birth control pills are so very effective in treating
dysmenorrhea, the emergence of cyclic pelvic pain while taking BCPs is a
worrisome symptom. Endometriosis can cause these symptoms. Happily, birth control pills, particularly if
taken continuously, are a very effective treatment for endometriosis.
After a number of months, women on continuous BCPs will usually
experience spotting or breakthrough bleeding. It is not dangerous. If this becomes a
nuisance, stop the BCPs for one week (she'll have a withdrawal bleed), and then restart
the BCPs continuously.
Read more about Birth Control Pills |