Evaluation of
Abdominal and Pelvic
Pain in Women
Setul Pardanani, MD
Assistant Professor, OB/GYN & Women’s Health
Assistant Residency Program Director
Albert Einstein College of Medicine
Montefiore Medical Center
Objectives
 Review the common etiologies of
abdominal and pelvic pain
 Review the evaluation of patients
presenting with abdominal and pelvic
pain
 Review treatment options
Milestone
Abdominal/Pelvic Pain
 Level 1: Demonstrates a basic understanding of patients
presenting with abdominal/pelvic pain regarding: Risk factors
and Signs/Symptoms
 Level 2: Demonstrates the ability to formulate a differential
diagnosis and an understanding of the initial evaluation and
treatment options
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Level 3: Demonstrates the ability to utilize focused diagnostic approaches and
formulate a comprehensive management plan
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Level 4:Demonstrates an in-depth knowledge regarding patients presenting with abdominal/pelvic pain
regarding: varying presentations, treatment options, refractory pelvic pain; manage and formulate
comprehensive plans for patients with complex and atypical chronic pelvic pain and multiple
comorbidities

Level 5: Lead multidisciplinary teams for care of patients with chronic pelvic pain; apply innovative
approaches to complex and/or atypical chronic pelvic pain and implement treatment plans based on
emerging evidence
The Milestones are a product of the Obstetrics and Gynecology Milestone Project,
a Joint Initiative of the ACGME, ABOG, and ACOG
Etiology
 Gynecologic
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Infectious: PID, TOA, Endometritis, Cervicitis
Ovarian: Functional cyst, Neoplasm, Torsion
Endometriosis
Leiomyomata
Dysmenorrhea
 Obstetric
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Early Pregnancy: Ectopic Pregnancy, Spontaneous Abortion
Midtrimester/Late Pregnancy: Labor, Uterine Rupture, Abruptio Placenta, Infection
 Non Gynecologic
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Gastrointestinal: Appendicitis, Diverticulitis
Genitourinary: Cystitis, Nephrolithiasis, Pyelonephritis
Psychological: sexual abuse, depression
Musculoskeletal
Case 1
 28 yo P1 presenting for acute onset of lower abdominal
pain.
 How do you evaluate her?
Evaluation
 History
 Identify life threatening condition requiring emergent intervention
 Pain characteristics: Location, Quality, Timing, Alleviating or
Exacerbating factors, Associated symptoms
 Significant past history
 Physical
 General: Vital signs, Appearance
 Abdominal Exam
 Pelvic Exam
 Laboratory
 Pregnancy test and Type and Screen
 CBC
 Urinalysis, Urine culture
 Evaluation for Gonorrhea and Chlamydia
Evaluation
 Imaging
 Ultrasound
 CT abdomen/Pelvis
 X-ray
 MRI
 Surgical
 Laparoscopy
Endometriosis
 Definition - extra uterine endometrial tissue
“glands and stromal”
 Incidence
 7-10% women
 35% infertile women
 75% women with chronic pelvic pain
 Etiology- leading theories:
 Retrograde menstruation
 Hematogenous or lymphogenous spread
 Coelomic metaplasia
Endometriosis
 Symptoms and signs variable and unpredictable
 Common presenting complaints
 Dysmenorrhea
 Dyspareunia
 Infertility
 Physical exam findings
 Uterorsacral nodularity
 Adnexal mass
 Diagnosis
 Visualizations of lesions on laparoscopy
 Pathology of biopsy
Endometriosis
Endometriosis
Endometriosis Treatment
Depends on the symptoms complaints
 Medical
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NSAID’s
Combined oral contraceptive pills
Progestins
GnRH agonists
 Surgical
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Surgical ablation or removal of lesions
LUNA
Presacral Neurectomy
TAH/BSO
Leiomyomata
 Benign smooth muscle tumors of uterus
 Prevalence - 1/3 of women
 Evaluation
 History
 Increased bleeding
 Dysmenorrhea
 Pelvic Pain
 Pelvic pressure
 Physical exam findings
 Enlarged uterus
 Pelvic or Adnexal mass
 Diagnostic Imaging
 Ultrasound
Leiomyomata
Leiomyomata
Leiomyomata
Treatment
 Medical
 NSAIDS
 Combined Oral Contraceptive Pills
 GnRH Agonist
 Interventional
 Uterine Artery Embolization
 Ultrasound/MRI guided ablation
 Surgical
 Myomectomy
 Hysterectomy
Dysmenorrhea
 Definitions:
 Primary Dysmenorrhea-within 2-3 months of first menses
 Secondary Dysmenorrhea-usually with underlying cause
 Etiologies-Endometriosis, Infections, adnexal mass, fibroids
 Evaluation
 Assessment of underlying etiology
 Management
 NSAIDS
 Combined Oral Contraceptives
 Treatment of underlying etiology
Case 2
 37 yo P2 presenting for her well woman visit reports
pelvic pain for the past year.
 How do you evaluate her?
Chronic Pelvic Pain
 Definition - lasting > 6 months, causing functional
disability
 Incidence - 15% women
 Etiologies
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GYN
GI
GU
Neurogenic
Psychological
Musculoskeletal
Chronic Pelvic Pain
 Evaluation
 Focused on identification of underlying etiology
 History
 Focus on pain history and associated symptoms
 Physical Exam
 Laboratory
 Imaging
 Treatment
 Focused on treatment of underlying etiology
Gynecologic
 Endometriosis
 Leiomyomata
 Infections-PID, TOA
 Benign and Malignant Tumors
 Vulvar and Vestibular Pain
Non Gynecologic
 Gastrointestinal
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Irritable Bowel syndrome
Inflammatory Bowel Disease
Constipation
Diverticular Disease
 Genitourinary
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UTI-acute, recurrent, chronic
Cystitis-Infectious and interstitial
Urolithiasis
Malignancy
Non Gynecologic
 Psychological
 Abuse
 Depression
 Musculoskeletal
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Abdominal Wall and Pelvic Floor myofascial pain
Hernia
Degenerative and Herniated Disc Disease
Fibromyalgia
Summary
 Wide range of causes of pelvic pain in women
 Evaluation focused on identification of
underlying etiology
 Treatment aimed at treating pain and
underlying cause
Questions?
Good Luck!
 Welcome to the amazing world of Obstetrics and
Gynecology