Differentials
Common
Primary dysmenorrhea
History
occurs 6-12 months following menarche, once ovulatory cycles have been established; pain usually lower abdominal and cramping in nature, radiates to the back and inner thigh, usually lasts from 8-72 hours and accompanies menstrual flow or precedes it by only a few hours; pain associated with systemic symptoms such as vomiting, nausea, diarrhea, fatigue, and headache
Exam
typically normal
1st investigation
- no initial test:
clinical diagnosis
Other investigations
Pelvic inflammatory disease
History
lower abdominal, often bilateral; deep dyspareunia; abnormal vaginal discharge; abnormal bleeding; may be a history of previous sexually transmitted infection/pelvic inflammatory disease or risk factors
Exam
lower abdominal tenderness; fever; mucopurulent cervical or vaginal discharge; cervicitis; cervical motion tenderness; uterine and/or adnexal tenderness or mass
1st investigation
- genital cultures or detection assays for gonorrhea, chlamydia, Mycoplasma genitalium:
positive
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Endometriosis
History
pelvic pain before and during menses or at other times in the menstrual cycle; symptoms progressively worsening over time; dyspareunia; dyschezia
Exam
cul-de-sac nodularity; uterosacral ligament thickening, tenderness or nodularity; fixed and retroverted uterus; lateral cervical deviation; adnexal masses
1st investigation
- pelvic ultrasonography:
may show presence of ovarian endometriomas
Other investigations
- diagnostic laparoscopy:
powder burn lesions due to endometriotic implants
Adenomyosis
History
usually parous; heavy menstrual flow, or abnormal bleeding pattern
Exam
diffusely enlarged, globular uterus; uterine tenderness, particularly during the menses
1st investigation
- pelvic ultrasonography (transvaginal ultrasound scan):
normal or enlarged uterus (in absence of fibroids); often asymmetrical enlargement of the anterior or posterior myometrium; lack of homogeneity/disturbed architecture within the myometrium
Other investigations
- MRI pelvis:
enlarged uterus; abnormal signal intensities within myometrium;
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Uterine leiomyoma (fibroids)
History
heavy and/or prolonged menstrual bleeding; abnormal bleeding pattern; pelvic "pressure" symptoms; urinary frequency and/or urgency; constipation; rectal pressure
Exam
enlarged uterus with smooth or irregular contour (depending on fibroid number and location)
1st investigation
- pelvic ultrasonography:
visualization of leiomyoma as solid, hypoechoic masses; provides characterization of location, size, and number of leiomyomas
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Uterine polyps
History
irregular menstrual bleeding, heavy menstrual bleeding, or intermenstrual bleeding
Exam
normal; rarely, a polyp protruding through the cervix can be seen during the speculum exam
1st investigation
- pelvic ultrasonography:
a separated mass in the inner lining of the uterus
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Other investigations
- hysteroscopy:
can be seen as a sessile or pedunculated mass arising from the lining of the uterus (can be used for both diagnosis and subsequent resection)
Uncommon
Ovarian cyst with hemorrhage
Ovarian torsion
History
lateral component to pain; acute onset of symptoms; nausea and vomiting; history of pelvic surgery
Exam
adnexal mass and/or tenderness
1st investigation
- pelvic ultrasonography:
enlarged ovary due to impaired venous and lymphatic drainage (torsion)
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Other investigations
- diagnostic laparoscopy:
torsed enlarged ovary
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Obstructive Mullerian duct anomalies
History
cyclic pain; onset of symptoms with or shortly after menarche
Exam
pelvic mass or asymmetric enlargement of uterus (due to hematometra)
1st investigation
- pelvic ultrasonography:
Mullerian duct malformation; rudimentary, noncommunicating uterine horn with entrapped blood
Other investigations
- MRI pelvis:
Mullerian duct malformation; rudimentary, noncommunicating uterine horn with entrapped blood
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Cervical stenosis
History
history of surgical procedures for cervical dysplasia e.g., large loop excision of the transformation zone (LLETZ); secondary amenorrhea; cyclic component to pain
Exam
normal or enlarged uterus (if hematometra present due to outflow obstruction)
1st investigation
- pelvic ultrasonography:
normal or fluid collection in uterus
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Other investigations
Intrauterine devices
History
presence of symptoms following copper intrauterine device insertion may be suggestive of the etiology; perforation or malposition of a device may lead to pain
Exam
absence of visible threads on speculum examination may suggest perforation
1st investigation
- pelvic ultrasonography:
echogenic device within the uterine cavity.
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Other investigations
- abdominal x-ray:
echogenic device in the abdominal cavity; subdiaphragmatic gas if perforation has occurred
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Asherman syndrome
History
pregnancy event followed by dilation and curettage leading to menstrual irregularities; less commonly leads to recurrent miscarriages and secondary infertility
Exam
normal
1st investigation
- sonohysterography (or hysterosalpingography):
abnormal distorted endometrial cavity with multiple adhesions
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Other investigations
- pelvic ultrasonography:
uterus partially enclosed by corporal adhesions
More - hysteroscopy:
distorted cavity by fibrous tissue; fallopian ostia may be occluded
Pelvic congestion syndrome
History
dull ache aggravated by standing or other physical activity; may have deep dyspareunia, postcoital tenderness, menstrual irregularities, or back ache
Exam
cervical motion tenderness, adnexal tenderness, and/or uterine tenderness on bimanual palpation
1st investigation
- laparoscopy:
dilated pelvic veins
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Other investigations
- pelvic ultrasonography:
dilated pelvic veins
More - pelvic venography:
transuterine injection of water-soluble radio-opaque contrast outlines the pelvic veins; the ovarian vein diameter, congestion of ovarian plexus, and the time taken for the disappearance of the contrast medium are considered to score the venogram; a score of 6 is diagnostic of pelvic congestion
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