What are potential causes of chronic worsening abdominal pain in a woman?

Differential Diagnosis of Chronic Worsening Abdominal Pain in Women

Based on clinical presentation alone, the differential diagnosis should be systematically organized by anatomical system and patient age, with gynecologic, gastrointestinal, urologic, and musculoskeletal etiologies all considered before extensive workup.

Age-Specific Considerations

Reproductive Age Women

The most common gynecologic causes include:

• Endometriosis - estrogen-dependent condition causing chronic pain, though typically regresses after menopause 1
• Leiomyomata (fibroids) - common cause of chronic pain, can present with acute worsening if undergoing degeneration 2
• Adenomyosis - gynecologic cause of chronic pelvic pain 3
• Pelvic inflammatory disease - can present as chronic inflammatory disease with associated pain 1, 3
• Ovarian cysts - physiologic cysts, endometriomas, and cystic teratomas are most common adnexal masses in this age group 2

Postmenopausal Women

The differential shifts significantly in this population:

• Ovarian cysts - account for approximately one-third of gynecologic pain cases in postmenopausal women 1, 4
• Uterine fibroids - second most common cause, significantly more common than in premenopausal women; pain may result from torsion of pedunculated fibroids, prolapse of submucosal fibroids, or acute infarction/hemorrhage 1
• Pelvic infection - accounts for 20% of cases, including tubo-ovarian abscess, oophoritis, salpingitis, endometritis, or peritonitis 1
• Ovarian neoplasm - accounts for 8% of cases and must be considered given prevalence of ovarian malignancy in this age group 1
• Cervical stenosis - can cause pain with associated endometritis 1

System-Based Differential by Pain Location

Deep Pelvic/Internal Pain

Potential etiologies include:

• Pelvic venous disorders (pelvic congestion syndrome) - characterized by engorged periuterine and periovarian veins 1
• Intraperitoneal adhesions - though causal linkage to chronic pain remains unclear 1
• Hydrosalpinx - dilated fallopian tube visible on imaging 1
• Chronic inflammatory disease - may show pelvic fluid, pyosalpinx, inflammatory adnexal masses 1

Perineal/Vulvar/Vaginal Pain

Consider:

• Vaginal atrophy - particularly in postmenopausal women 1
• Vaginismus 1
• Vaginal or vulvar cysts 1
• Vulvodynia 1
• Pelvic myofascial pain 1, 3

Non-Gynecologic Causes

Gastrointestinal

• Irritable bowel syndrome - commonly associated with chronic pelvic pain 5, 6
• Inflammatory bowel diseases - gastrointestinal cause of chronic pelvic pain 3
• Chronic constipation 6

Urologic

• Interstitial cystitis - commonly associated condition 5, 6
• Urinary tract pathology 1

Musculoskeletal

• Pelvic girdle pain 3
• Myofascial pain 3
• Musculoskeletal disorders of the lower back or pelvis 1

Critical Red Flags Requiring Immediate Attention

In postmenopausal women, vaginal bleeding and suspected adnexal masses should take precedence over general pain complaints due to risk of endometrial and ovarian neoplasia 1, 3. These features should direct the management algorithm immediately.

Common Pitfalls

• Assuming gynecologic origin without considering other systems - chronic abdominal pain has a broad differential including gastrointestinal, urologic, and musculoskeletal causes 1, 7
• Overlooking functional disorders - after organic pathology is excluded, functional disorders like irritable bowel syndrome should be considered 7
• Missing psychosocial contributors - depression, anxiety, PTSD, and history of physical/sexual abuse are associated with chronic pelvic pain 5
• Failing to recognize age-specific patterns - the differential shifts significantly between reproductive age and postmenopausal women, with malignancy risk increasing in older patients 1, 2