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 40 years in clinical practice, practicing in a 400-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.
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
OCPs and Pain
Most patients complaining of intermittent, chronic pelvic pain will benefit from oral contraceptive pills. OCPs 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 OCPs to treat chronic pelvic pain, I have found multiphasic OCPs such as Ortho Novum 7/7/7, Triphasil or Tri-Norinyl have not been as effective as the stronger, monophasic OCPs 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.
Another factor in reliable suppression of ovarian function with OCPs derives from the half-life of the specific progestin used in the OCP. Some progestins (such as levonorgestrel) have very long half-lives (many days) while other progestin half-lives are measured in hours. The long half-life pills are much more ‘forgiving’ of skipping pills or taking them in any inconsistent manner and are more successful generally in keeping ovarian function suppressed.
If the OCPs do not help or if the patient continues to have pain during her menstrual flow, change the OCP schedule so the patient takes a monophasic (LoOvral, 1+35, etc.) OCP 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 OCPs 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 OCPs will usually experience spotting or breakthrough bleeding. It is not dangerous. If this becomes a nuisance, stop the OCPs for one week (she’ll have a withdrawal bleed), and then restart the OCPs continuously.