Chapter 051. Menstrual Disorders and Pelvic Pain (Part 4) Polycystic Ovarian Syndrome: Treatment The major abnormality in patients with PCOS is the failure of regular, predictable ovulation. Thus, these patients are at risk for the development of dysfunctional bleeding and endometrial hyperplasia associated with unopposed estrogen exposure. Endometrial protection can be achieved with the use of oral contraceptives or progestins (medroxyprogesterone acetate, 5–10 mg, or prometrium, 200 mg daily for 10–14 days of each month). Oral contraceptives are also useful for management of hyperandrogenic symptoms, as is spironolactone, which functions as a weak androgen receptor antagonist. Management of the associated metabolic syndrome may be appropriate for some patients (Chap. 236). For patients interested in fertility, weight control is a critical first step. Clomiphene citrate is highly effective as first-line treatment, with or without the addition of metformin. Exogenous gonadotropins can be used by experienced practitioners. Pelvic Pain The mechanisms causing pelvic pain are similar to those causing abdominal pain (Chap. 14) and include inflammation of the parietal peritoneum, obstruction of hollow viscera, vascular disturbances, and pain originating in the abdominal wall. Pelvic pain may reflect pelvic disease per se but may also reflect extrapelvic disorders that refer pain to the pelvis. In up to 60% of cases, pelvic pain can be attributed to gastrointestinal problems including appendicitis, cholecystitis, infections, intestinal obstruction, diverticulitis, or inflammatory bowel disease. Urinary tract and musculoskeletal disorders are also common causes of pelvic pain. Approach to the Patient: Pelvic Pain A thorough history including the type, location, radiation, and status with respect to increasing or decreasing severity can help to identify the cause of acute pelvic pain. Specific associations with vaginal bleeding, sexual activity, defecation, urination, movement, or eating should be specifically sought. A careful menstrual history is essential to assess the possibility of pregnancy. Determination of whether the pain is acute versus chronic and cyclic versus noncyclic will direct further investigation (Table 51-1). However, disorders that cause cyclic pain may occasionally cause noncyclic pain, and the converse is also true. Table 51-1 Causes of Pelvic Pain Acute Chronic Premenstrual symptoms Mittelschmerz Dysmenorrhea Cyclic pelvic pain Endometriosis Pelvic inflammatory disease Pelvic congestion syndrome Noncyclic pelvic pain Ruptured or hemorrhagic ovarian cyst or ovarian torsion Adhesions and retroversion of the uterus Ectopic pregnancy Pelvic malignancy Endometritis Vulvodynia Acute growth or degeneration of uterine myoma History of s exual abuse Acute Pelvic Pain Pelvic inflammatory disease most commonly presents with bilateral lower abdominal pain. It is generally of recent onset and is exacerbated by intercourse or jarring movements. Fever is present in about half of patients; abnormal uterine bleeding occurs in about one-third. New vaginal discharge, urethritis, and chills may be present but are less specific signs. Adnexal pathology can present acutely and may be due to rupture, bleeding or torsion of cysts, or, much less commonly, neoplasms of the ovary, fallopian tubes, or paraovarian areas. Fever may be present with ovarian torsion. Ectopic pregnancy is associated with right or left sided lower abdominal pain, vaginal bleeding and menstrual cycle abnormalities, with clinical signs generally appearing 6–8 weeks after the last normal menstrual period. Orthostatic signs and fever may be present. Risk factors include the presence of known tubal disease, previous ectopic pregnancies, or a history of infertility, DES exposure of the mother in utero, or a history of pelvic infections. Uterine pathology includes endometritis and, less frequently, degenerating leiomyomas (fibroids). Endometritis is often associated with vaginal bleeding and systemic signs of infection. It occurs in the setting of sexually transmitted infections, uterine instrumentation, or postpartum infection. A sensitive pregnancy test, complete blood count with differential, urinalysis, tests for chlamydial and gonococcal infections, and abdominal ultrasound aid in making the diagnosis and directing further management. . Chapter 051. Menstrual Disorders and Pelvic Pain (Part 4) Polycystic Ovarian Syndrome: Treatment The major abnormality. disturbances, and pain originating in the abdominal wall. Pelvic pain may reflect pelvic disease per se but may also reflect extrapelvic disorders that refer pain to the pelvis. In up to 60% of cases, pelvic. can be used by experienced practitioners. Pelvic Pain The mechanisms causing pelvic pain are similar to those causing abdominal pain (Chap. 14) and include inflammation of the parietal peritoneum,