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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: [1]

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.

  • • Cervical motion tenderness is usually not a mystery. Everyone is taught that cervical motion tenderness is pathognomonic of pelvic inflammatory disease. Colloquially, this is known as the chandelier sign, where the exam evokes such pain that the patient reaches up toward the ceiling for relief.1 However, remember that the exam itself is uncomfortable. A natural response to painful stimuli is avoidance, so judge any response to pain as relative. In the best of circumstances and without pathology, aggressive motion of the uterus by manipulating the cervix can cause pain. True cervical motion tenderness is usually unmistakable.
  • • Do not fear the rectum. By the same token, ignore it if you can. Many are taught that the rectovaginal examination is a necessary part of any pelvic examination, however in most cases it does not yield additional information. In general, patients do not like it. However, it is indeed useful to evaluate the posterior pelvis when needed, as well as to rule out certain types of bowel pathology that can masquerade as gynecologic. Do the exam if you need to.

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.

  • [1] Be gentle, but do not be afraid. A gruff or inconsiderate examination of the internal orexternal genitalia must be avoided. The clinician may perform these exams with frequency,and invade the privacy of others as a matter of professional routine. Most patients will onlyrarely have to expose themselves to a clinician and will probably remember nearly everyoccasion of doing so for the rest of their lives. Meticulous attention to the patient’s comfort, dignity, and humility must be foremost in every circumstance. Gentle means morethan avoiding rough handling; it is an overall approach to the patient, acknowledging theemotional and physical discomfort that may result from a pelvic examination and activelytaking steps to assure that the experience for the patient is the least negative possible.Obviously, gentle and precise movements can limit the physical discomfort. At the sametime, however, excessive timidity in conducting the exam results in a negative experienceas well. For example, using a speculum that is too small for the vagina in an effort to avoiddiscomfort from a larger instrument results in a great deal more manipulation in order toultimately visualize the cervix. Visualization may still be compromised, and the level ofdiscomfort from moving the small speculum around is increased beyond what would haveoccurred had a properly sized speculum been used initially. The exam is designed to yieldinformation. The skillful clinician strikes the proper balance between procuring this information and keeping the experience neutral for the patient. • When possible, conduct the examination on the appropriate furniture. Circumstances arisewhen a pelvic exam must be performed with the patient’s bottom elevated on a bedpan, orthe patient in a frog-legged position. This is suboptimal for many reasons. Seek an examination table with stirrups, even if this requires moving the patient to another room. • During a bimanual examination, the majority of the information is gained from the vaginalhand. The abdominal hand is designed to move the pelvic structures into the vaginal hand,and uterine assessment is often easier than palpation of the adnexa.2 Nevertheless, careful
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