education tutorial on the management of chronic pelvic pain in women. Target audience: medical undergraduates.

1. PELVIC PAIN IN GYNAECOLOGY Rajesh Varma MA PhD MRCOG Consultant Obstetrician and Gynaecologist Guy’s and St.Thomas’ NHS Foundation Trust

3. CHRONIC PELVIC PAIN PRE-TEST 1 A single pathology is common to most cases of chronic pelvic pain 2 Combination of clinical examination and transvaginal sonography can reliably detect ovarian endometriosis 3 Symptoms of dysmenorrhoea, dyspareunia and chronic pelvic pain are strongly predictive of finding endometriosis at laparotomy 4 Cyclical pelvic pain is usually gynaecological in nature 5 Symptoms alone may reliably diagnose irritable bowel syndrome 6 Diagnostic laparoscopy may have a beneficial role in improving women’s pain scores and changing their beliefs about her pain 7 Fibroids may become acutely painful during pregnancy 8 GnRHa is recommended prior to myomectomy & uterine artery embolisation 9 Medical treatment of mild-moderate endometriosis improves pelvic pain and fertility 10 Diagnostic laparoscopy carries a risk of death of 1 per 1000

13. Diagnostic tests Pelvic ultrasound Fibroids, ovarian cysts/endometriomas, adenomyosis Laparoscopy Diagnosis and treatment of endometriosis, adhesions risk of viscera injury (4/1000); risk of death (1/10,000) Hysteroscopy Diagnosis and resection of intrauterine fibroids MRI Pelvic adhesions; adenomyosis Pelvic and rectovaginal endometriosis Fibroids prior to UAE STI screen STI screen 6 month Therapeutic Medical trial GnRHa or COC or Mirena (6 month) Anti-spasmodic bowel treatments/diet change (6 months)

14. Treating CPP: principles OFTEN NEEED TO COMBINE TREATMENTS (e.g. IBS & endometriosis) Expectant Medical Analgesia Ovarian suppression (GnRHa, COC, POP, Mirena) Anti-spasmodic bowel UAE and MRI focused ultrasound therapy Surgical Excision or ablation endometriosis Adhesiolysis Myomectomy Hysterectomy Psychological

15. Peritoneal Endometriosis

16. Ovarian endometriosis

19. Endometriosis is surgically staged American Fertility Society (AFS)

22. MRI uterine fibroids

23. Hysteroscopic Resection of uterine fibroids Versapoint ® Resectoscope

27. CHRONIC PELVIC PAIN POST-TEST 1 A single pathology is common to most cases of chronic pelvic pain 2 Combination of clinical examination and transvaginal sonography can reliably detect ovarian endometriosis 3 Symptoms of dysmenorrhoea, dyspareunia and chronic pelvic pain are strongly predictive of finding endometriosis at laparotomy 4 Cyclical pelvic pain is usually gynaecological in nature 5 Symptoms alone may reliably diagnose irritable bowel syndrome 6 Diagnostic laparoscopy may have a beneficial role in improving women’s pain scores and changing their beliefs about her pain 7 Fibroids may become acutely painful during pregnancy 8 GnRHa is recommended prior to myomectomy & uterine artery embolisation 9 Medical treatment of mild-moderate endometriosis improves pelvic pain and fertility 10 Diagnostic laparoscopy carries a risk of death of 1 per 1000

28. CHRONIC PELVIC PAIN POST-TEST 1 A single pathology is common to most cases of chronic pelvic pain F 2 Combination of clinical examination and transvaginal sonography can reliably detect ovarian endometriosis T 3 Symptoms of dysmenorrhoea, dyspareunia and chronic pelvic pain are strongly predictive of finding endometriosis at laparotomy F 4 Cyclical pelvic pain is usually gynaecological in nature T 5 Symptoms alone may reliably diagnose irritable bowel syndrome T 6 Diagnostic laparoscopy may have a beneficial role in improving women’s pain scores and changing their beliefs about her pain T 7 Fibroids may become acutely painful during pregnancy T 8 GnRHa is recommended prior to myomectomy & uterine artery embolisation F 9 Medical treatment of mild-moderate endometriosis improves pelvic pain and fertility F 10 Diagnostic laparoscopy carries a risk of death of 1 per 1000 F