Differential Diagnosis for Severe Bilateral Lower Abdominal Pain

The patient's presentation of severe bilateral lower abdominal pain, nausea, dizziness, and a history of ovarian cysts, polyps, and fibroids, suggests several potential diagnoses. These can be categorized as follows:

• Single Most Likely Diagnosis

  • Ovarian Torsion: Given the patient's history of ovarian cysts and the sudden onset of severe pain, ovarian torsion is a highly plausible diagnosis. Ovarian torsion is a gynecologic emergency that requires prompt surgical intervention. The pain is often severe, acute, and may be accompanied by nausea and vomiting.

• Other Likely Diagnoses

  • Ruptured Ovarian Cyst: A history of ovarian cysts and severe abdominal pain could indicate a ruptured cyst, which can cause significant pain and potentially lead to hemoperitoneum.
  • Degenerating Uterine Fibroid: Fibroids can cause severe pain if they outgrow their blood supply and degenerate, especially during menstruation.
  • Severe Dysmenorrhea: Although the patient describes the pain as worse than her usual menstrual cramps, severe dysmenorrhea could still be a consideration, especially if she has a history of it and given the timing with her menstrual cycle.

• Do Not Miss Diagnoses

  • Ectopic Pregnancy: Although the patient does not mention abnormal vaginal discharge or missed periods, ectopic pregnancy is a life-threatening condition that must be considered in any female of reproductive age presenting with abdominal pain.
  • Appendicitis: While the pain is bilateral and lower abdominal, appendicitis can sometimes present atypically, especially in females, and is a critical diagnosis not to miss.
  • Pelvic Inflammatory Disease (PID): PID can cause severe lower abdominal pain and is a significant concern due to potential long-term consequences on fertility.

• Rare Diagnoses

  • Mittelschmerz: This refers to mid-cycle pain associated with ovulation and could be considered if the timing of the pain correlates with ovulation, though it's typically less severe.
  • Endometriosis: While endometriosis can cause severe dysmenorrhea, it's less likely to cause acute, severe pain without other chronic symptoms.

Workup

The workup for this patient should include:

• Complete Blood Count (CBC): To assess for signs of infection or anemia.
• Beta-hCG: To rule out ectopic pregnancy.
• Urinalysis: To rule out urinary tract infection or kidney stones.
• Imaging: Ultrasound is the first-line imaging modality for evaluating ovarian pathology and can help diagnose ovarian torsion, ruptured ovarian cyst, or degenerating fibroid. CT scan may be considered if appendicitis or other abdominal pathologies are suspected.
• Pelvic Exam: A thorough pelvic exam is essential to assess for tenderness, masses, or other abnormalities.

Given the severity of the patient's symptoms and the potential for gynecologic emergencies, prompt evaluation and management are crucial.