From the Guidelines
The workup for left pelvic pain in a 30-year-old female should begin with a thorough history and physical examination, followed by a serum beta-human chorionic gonadotropin (b-hCG) test to rule out pregnancy, as this is a critical step in determining the appropriate imaging modality and potential causes of pain 1. The initial evaluation should include a complete menstrual, sexual, and pregnancy history, as gynecologic causes are common in this demographic.
- Order a urine pregnancy test, complete blood count, comprehensive metabolic panel, urinalysis, and tests for sexually transmitted infections including gonorrhea and chlamydia.
- Transvaginal ultrasound is the first-line imaging study to evaluate for ovarian cysts, endometriosis, fibroids, or ectopic pregnancy, given its high sensitivity and specificity for these conditions 1. If urinary symptoms are present, a urinalysis and urine culture should be performed to rule out urinary tract infection or kidney stones.
- For persistent pain without clear etiology on ultrasound, consider CT scan or MRI of the pelvis to evaluate for appendicitis, diverticulitis, inflammatory bowel disease, or musculoskeletal causes, with CT having a sensitivity of 74% to 95% and a specificity of 80% to 90% for the diagnosis of adnexal torsion 1. Laparoscopy may be necessary if endometriosis is suspected but not confirmed by imaging, as it allows for direct visualization and potential treatment of the condition 1. Pain management during the diagnostic process can include NSAIDs like ibuprofen 400-800mg every 6-8 hours or naproxen 500mg twice daily. The differential diagnosis for left pelvic pain in this age group includes ovarian cysts, endometriosis, pelvic inflammatory disease, ectopic pregnancy, urinary tract infection, kidney stones, appendicitis, diverticulitis, irritable bowel syndrome, and musculoskeletal disorders, making a systematic approach essential for accurate diagnosis and appropriate treatment 1.
From the Research
Workup for Left Pelvic Pain in a 30-year-old Female
The workup for left pelvic pain in a 30-year-old female involves a thorough evaluation to determine the underlying cause of the pain. The following steps are recommended:
- Clinical history: A careful history focusing on pain characteristics, review of systems, and gynecologic, sexual, and social history 2, 3
- Physical examination: A thorough physical examination, including a bimanual examination, to help narrow the differential diagnosis 2, 3
- Laboratory data: Laboratory tests, such as a pregnancy test, to rule out urgent life-threatening conditions 2, 4, 3
- Imaging studies: Imaging studies, such as transvaginal ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI), to confirm the diagnosis 5, 6, 2, 4, 3
Imaging Options
The choice of imaging modality depends on the suspected underlying cause of the pain. The following options are available:
- Transvaginal ultrasonography: The primary imaging modality for women with acute pelvic pain, especially when a gynecologic disorder is suspected 5, 6, 2, 4, 3
- Computed tomography (CT): May be helpful when a nongynecologic condition is suspected or when ultrasonography is nondiagnostic 5, 4, 3
- Magnetic resonance imaging (MRI): May be useful if ultrasonography and CT are nondiagnostic, especially in pregnant women when acute appendicitis is suspected 4, 3
Differential Diagnosis
The differential diagnosis for left pelvic pain in a 30-year-old female is broad and includes:
- Gynecologic conditions: Such as pelvic inflammatory disease, ruptured ovarian cyst, adnexal torsion, and ectopic pregnancy 2, 4, 3
- Nongynecologic conditions: Such as appendicitis, pyelonephritis, and musculoskeletal conditions 4, 3
- Less urgent etiologies: Such as sexually transmitted infections, pelvic floor myofascial pain, dysmenorrhea, and muscle strain 3