Uncertainty of Diagnosis

When treating a female patient with abdominal pain, I sometimes don't have a clue as to what the problem is. I say this as a board-certified OB-GYN, with more than 20 years in clinical practice, practicing in a 600-bed teaching hospital, with ultrasound, MRI scans, and full lab support. Sometimes all I can say is: "This patient is sick with something."

Sometimes these patients get well before I can figure out the diagnosis. Sometimes these patients get worse and I end up performing surgery and find PID, or endometriosis, or an ovarian cyst or almost any other gynecologic, surgical or medical problem. Sometimes I do laparoscopy and find nothing abnormal, but the pain goes away.

The First Point is: In clinical gynecology, the diagnosis is often unclear. Just because you're unsure of the diagnosis doesn't mean you can't take good care of the patient. Often you must treat the patient before knowing the diagnosis.

The Second Point is: More important than knowing the correct diagnosis is doing the right thing for the patient.

If the patient has pelvic/abdominal pain or tenderness, placing her on bedrest for a few days will usually help and is never the wrong thing to do. For many of your patients, the pain will simply resolve (although you won't know why).

Pain and Fever

If the patient has a fever (in addition to her pain), I would recommend you give her antibiotics to cover PID. With mild pain and fever, oral antibiotics should work well, so long as they are effective against chlamydia (Doxycycline, tetracycline, erythromycin, Azithromycin , etc.).

If the fever is high or the pain is moderate to severe, I would recommend IV antibiotics (such as clindamycin/gentamicin or cefoxitin or cefotetan or Flagyl/gentamicin) to cover the possibility of pelvic abscess.

Chronic Pain

If there is no fever, but your patient complains of chronic pelvic pain, a course of oral Doxycycline is wise. Some of these women will  be suffering from chlamydia and you may cure them through the use of an antibiotic effective against chlamydia. Others will not improve and will need further evaluation by experienced providers in well-equipped settings.

Pregnancy Test

Any patient complaining of pelvic pain should have a pregnancy test. I am surprised at how often it is positive despite the patient saying "that's impossible."

BCPs and Pain

Most patients complaining of intermittent, chronic pelvic pain will benefit from oral contraceptive pills. BCPs reduce or eliminate most dysmenorrhea and have a favorable influence on other gynecologic problems such as endometriosis, ovarian cysts, and adenomyosis, a benign condition in which the uterine lining grows into the underlying muscle wall, causing pain and heavy periods.