Author: Dr Helen Laycock
A 32-year-old women presented with a ten-year history of pain in her lower abdomen.
She describes experiencing constant aching pain located in her lower abdomen, just above her pubic bone, that increases in intensity during menstruation and is associated with occasional sharp stabbing pains. She has heavy bleeding during menstruation and when she gets the stabbing pain also experiencing diarrhoea and bloating.
She has a regular but heavy menstrual cycle. She has not had any children. She tells you she has seen lots of different doctors including gastroenterologists and gynaecologists. She has undergone numerous investigations including a colonoscopy, laparoscopy and numerous pelvic ultrasound scans. She describes her previous appointments have not found a cause for her pain, and that she feels no-one believes her. She says she has a low mood due to the pain, has recently started antidepressants and is awaiting a telephone call to assess her for counselling. The pain and low mood have led to her stopping work at a nursery, which she enjoyed, and this has led to her feeling stressed and anxious. She is currently in a supportive relationship but tells you she finds it hard to have sex due to this making the pain worse.
She has started Fluoxetine 20mg a month previously and has a penicillin allergy. She has tried tramadol, codeine and paracetamol for her pain but none of these helped.
On examination she has a BMI of 32 and her vital signs are within normal limits. She is apyrexial and her urine dipstick is normal. She had a normal gait and had normal upper and lower limb neurology. She had been seen by a gynaecologist for a second opinion 2 months ago and the results of that consultation and examination were available therefore a pelvic examination was not performed.