Assessment of dysmenorrhoea

In women with symptoms of lower abdominal or pelvic pain where there is a suspicion of pregnancy, its exclusion is mandatory with a serum or urine pregnancy test. Pregnancy complications such as ectopic pregnancy require urgent sonographic evaluation and treatment by a gynaecologist.[36]National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Aug 2023 [internet publication]. https://www.nice.org.uk/guidance/ng126 The pain is unlikely to affect sequential menses and should be easily distinguished from dysmenorrhoea.

Appendicitis is a serious non-gynaecological condition that should be considered in the differential diagnosis for women who present with lower abdominal pain and associated symptoms such as anorexia, fever, nausea, and vomiting. A relationship with menses would be very unusual. Antiemetics and analgesics increase patient comfort and do not adversely affect the accuracy of physical examination. Appropriate diagnostic studies, including a WBC count and a CT scan of the abdomen, help to confirm this diagnosis if clinical suspicion is high. In consultation with a general surgeon, preoperative antibiotics should be chosen that provide broad-spectrum gram-negative and anaerobic coverage.[37]Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD001439. https://www.doi.org/10.1002/14651858.CD001439.pub2 http://www.ncbi.nlm.nih.gov/pubmed/16034862?tool=bestpractice.com

Ovarian torsion

Ovarian torsion is typically characterised by acute-onset lower abdominal pain with associated nausea and vomiting. Although ovarian torsion remains a clinically diagnosed entity, pelvic ultrasound may be a useful diagnostic tool in less clear-cut cases. In addition to pain management, urgent surgical evaluation is recommended to preserve ovarian function and future fertility.

Acute pelvic inflammatory disease (PID)

Tests for sexually transmitted infections should be considered in the initial evaluation if risk factors are present. However, these may be negative, even in cases of confirmed PID. Immediate antibiotic treatment for women with acute PID is recommended to minimise short-term and long-term morbidity such as infertility, ectopic pregnancy, and chronic pelvic pain. Ultrasound scan can aid in the diagnosis of associated pathology, such as tubo-ovarian abscess, which may require surgical intervention.