Stump the gynecologist differential diagnosis of chronic pelvic pain
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Stump the Gynecologist: Differential Diagnosis of Chronic Pelvic Pain. Jennifer K. McDonald DO F.A.C.O.G. October 10, 2008. ACOG Definition.

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Stump the Gynecologist: Differential Diagnosis of Chronic Pelvic Pain

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Stump the Gynecologist: Differential Diagnosis of Chronic Pelvic Pain

Jennifer K. McDonald DO F.A.C.O.G.

October 10, 2008

ACOG Definition

“Non-cyclic pain of 6 or more months duration that localizes to the anatomic pelvis, abdominal wall at or below the umbilicus, lumbosacral back or the buttocks and is of sufficient severity to cause functional disability or lead to medical care.”


  • 10% out-patient gynecologic visits

  • 20% of laparoscopies

  • 15% of hysterectomies

  • $2.8 billion annually

15% of American women

61% of CPP will have no definitive diagnosis !!





Back Pain

Age Prevalence


  • Present for six months or more

  • Conventional treatments have yielded little or no relief

  • Degree or pain perceived seems out of proportion to the degree of tissue damage detected by conventional means

  • Physical appearance of depression is present

  • Physical activity is increasingly limited

  • Emotional roles in the family are altered


  • Acute pain

    Pain is symptom of underlying tissue damage

  • Chronic pain

    Pain itself becomes the disease

Females - Unique Design

  • Structural changes during development

  • Pelvis widens after menarche

  • Gluteal stretching

  • Internal rotation of the femurs/lateral displacement of the patella

  • Ligamentous laxity

  • Decreased muscular tone increases lumbar lordosis and exaggerated anterior pelvic tilt

  • Pelvic organs connected through shared common nerve pathways

Where do we look?

Gynecologic - extra-uterine

Gynecologic - uterine





Referred Pain

OvaryT10umbilical area

UterusT12lower abdominal wall

VaginaL1skin over groin

Most common culprits

  • Endometriosis

  • Adenomyosis

  • Interstitial cystitis

  • Irritable bowel

  • Pelvic Adhesions


  • Presence of endometrial glands and stroma outside the uterus

  • No difference among ethnic groups or socioeconomic status

  • Genetic predisposition 6-10% increased risk with history of first degree relative

DysmenorrheaAbnormal bleeding

DyspaureniaGI complaints

InfertilityUrinary complaints

Low back pain

The many faces of endometriosis

Location Location

76% ovaries

69% posterior & anterior

cul de sac

47% posterior broad ligament

36% uterosacral ligaments

11% uterus

6% fallopian tubes

4% sigmoid colon

Interstitial Cystitis

  • Prevalence of bladder origin chronic pelvic pain/interstitial cystitis is much greater than previously believed

IC is a chronic inflammatory condition of the bladder characterized by irritable voiding symptoms of urgency and frequency in the absence of objective evidence of another disease that could cause the symptoms

Pathogenesis of IC:Defective Urothelial Barrier






IC is Typically Diagnosed Late in Disease Continuum

Average Time Between Initial Development of Symptoms and Diagnosis is 5 Years

See at least

5 physicians

before diagnosis

Significant suffering

and reduced QOL

InitialDevelopment of

IC Symptoms

Diagnosis of IC

2-7 years

May have



IC Concurrent with Endometriosis

Diagnosis of Patients With CPP byCystoscopy and Hydrodistention & Laparoscopy1


IC Alone





IC and


Clinicians should consider the bladder to be the source of CPP, even when endometriosis is present

Pelvic Adhesions

  • Distort normal blood/nerve supply

  • Decreased mobility of organs/hypoxia

  • Pelvic inflammatory disease (PID)

  • Most common Chlamydia

  • Inflammatory reaction

  • Secretion of prostaglandins

Fibromyalgia Tender Points

11 or more TP sensitivity of 88% and specificity of 81%

Abdominal Wall Tenderpoints

Irritable Bowel

  • 12% US population

  • 2:1 women

  • Peak age 30-40

  • Increased GI motility and sensitivity to stimulants

Pelvic Pain Assessment Forms

Pain Diaries

Keys to Treatment

  • Pain and its perception are located in the nervous system so its treatment must encompass a Mind and Body approach

  • Multiple interactive problems are most likely with CPP so it isn’t which treatment is best but which treatments

  • It usually took time for things to get to where they are so it will be take time to get them back to normal as well

  • Chronic pain affects a family not just an individual patient

How can chiropractic help

  • Manipulation increases spinal mobility and improves blood supply by influencing the autonomic nervous system

The patient with CPP needs a multidisciplinary approach … are you ready?

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