A Functional Approach to Gynecologic Pain: Integrative Gynecology for the Non-Gynecologist
Gynecologic pain is a frustrating area of practice for many clinicians. The lack of clear understanding of anatomic considerations, inexperience with thorough and meaningful physical examination of the female reproductive system, and a natural discomfort with the intimacy associated with these syndromes lead many non-specialist clinicians to shy away from accurate diagnosis and treatment of gynecologic pain. Additionally, gynecologic pain is often multi-factorial, and a single, well- defined diagnosis may be elusive.
This chapter will seek to provide a basic template for the non-gynecologist to evaluate and treat gynecologic pain, encompassing common treatment options of both mainstream and functional medicine. It should be emphasized that a systematic approach to the accurate diagnosis of pain is critical; generalizing about sources of pain leads to incorrect diagnosis. Incorrect diagnosis both fails to treat the actual source of pain, and also leads to secondary issues. It is in our nature as clinicians to provide answers, but we must avoid the pitfalls of making uncertain diagnoses, especially in gynecologic conditions.
For example, pelvic inflammatory disease (PID) is a frequent diagnosis in emergency departments, but the diagnosis does not necessarily correlate with the actual presence of disease.1 A reproductive-age woman with pain and vaginal discharge may be diagnosed and treated for PID as a diagnosis of exclusion, for fear that the missed diagnosis would be more harmful than the wrong diagnosis. But perhaps that patient is in a mutually monogamous married relationship, and is delivered the news that she has an upper genital tract infection due to presumed sexually transmitted disease. The interpersonal outcome from the incorrect diagnosis may be just as dire as the sequalae of untreated PID.
A similarly common diagnosis in emergency departments is the “ovarian cyst” as a source of pain. The woman presents with pain, has a CT scan showing a physiologic follicle in the ovary, and perhaps without even a pelvic examination is given the diagnosis of “ovarian cyst.” In addition to “ovarian cyst” becoming a part of this patient’s medical history forevermore, her actual diagnosis might be missed entirely. Both of these examples are discussed in more detail later.
It should be stressed that this work addresses sources of non-obstetric female reproductive pain. The analysis of pregnancy-related pain exceeds the scope of this chapter, so the simple performance of a pregnancy test is a meaningful first step in the evaluation of pain in most reproductive-age women.
Examination and Imaging
The importance of the pelvic examination cannot be understated. There are certainly instances when a pelvic examination is not necessary, but visualization of the reproductive organs by imaging and palpation of the internal pelvis can provide a wealth of information in localizing and defining pain. If the discomfort is of sufficient character to warrant her bringing it to a clinician’s attention, then it is deserving of evaluation. Many times, the actual diagnosis may be nebulous or difficult to ascertain. Saying “I don’t know” seems inexcusable, but in some cases, the patient only wants the relief of knowing that she does not have a terrible diagnosis, such as cancer. Pelvic pain can be so multifactorial that sometimes “I cannot be sure” is the correct answer.
The proper way of performing a pelvic examination has been covered by other authors ad nau- seum and is beyond the scope of this text. However, this author wishes to share the following pearls on performing a meaningful exam: 
palpation of the adnexa can demonstrate or exclude the ovary as a source of pain, as well as point toward other etiologies of pain, such as the bowel.
But if you do not need to, leave it alone.
The sensitivity of the bimanual examination to diagnose ovarian cancer and to distinguish between benign and malignant lesions is notoriously poor.4 However, in a non-screening clinical setting it may be useful to localize pain. Both the sensitivity and specificity of ultrasound is much higher than that of physical examination,5 so the combination of physical examination and imaging should be considered the most reliable.
Pelvic transvaginal ultrasound is the most effective means of evaluating the female reproductive tract, and with no risk of exposure to ionizing radiation, it should be seen as the initial test of choice.6 Computed tomography (CT scan) is deemed as a secondary modality if sonography is nondiagnostic, however it exposes the patient to an equivalent radiation dose of 200 radiographs.7 The ready availability of cost-effective ultrasound in the primary care setting also makes sonography a useful diagnostic adjunct. It is able to view the pelvic structures with real-time patient feedback on discomfort, in addition to doppler interrogation of blood flow. Transabdominal ultrasound alone of the pelvic structures is of limited utility and should be avoided unless transvaginal ultrasound is not advisable.
In some acute care settings, sonography is bypassed for CT scan, as the clinician is able to search for pathology in the entire abdomen and pelvis. Ultrasound is deemed an appropriate initial test for appendicitis, for example, but a normal ultrasound does not rule it out. CT scanning has a slightly higher sensitivity for appendicitis,8 but its diagnostic efficacy is similar to ultrasound in emergency department diagnosis of nephrolithiasis.9 Many emergency clinicians turn to CT as first line, but for purposes of gynecologic pain, pelvic ultrasound should be the first, and usually the only, imaging modality required.