Ihe quality of pain can be characteristic of different etiologies. Visceral or splanchnic pain is colicky and caused by distention of a hollow viscus or stretching of a ligament. Examples include distention of the fallopian tube in ectopic pregnancy, uterine contractions in dysmenorrhea, and stretch of the round ligament with adhesions or in pregnancy. Peritoneal or somatic pain is sharp and localized to the region of inflamed tissue, as in salpingitis, appendicitis, and endometritis. Generalized peritonitis may be seen with larger degrees of inflammation, i.e., with spillage of blood, pus, or gastrointestinal (GI) contents into the peritoneal cavity.
Ihe onset of pain may also provide diagnostic clues. Gradual onset may occur with a slow leak of irritants, as occurs with pelvic inflammatory disease (PID). Sudden onset of pain occurs with ischemia or cyst rupture. Cyclic pain is usually related to the menstrual cycle, and timing is helpful in establishing a diagnosis. Examples include endometriosis and dysmenorrhea (Xable, „ i98z3).
PATHOPHYSIOLOGY: THE ANOVULATORY CYCLE
Anovulatory bleeding may be regular but more often is irregular due to fluctuating estrogen levels below the critical level required to maintain endometrial growth. The level of estrogen depends on the age, number, and activity of ovarian follicles. As some follicles degenerate, others resume the production of estrogen and the endometrium continues to proliferate for weeks to months, which may cause glandular hyperplasia ("Swiss cheese" hyperplasia). This estrogen steady state is insufficient to meet the growing needs of the endometrium and produces a relative estrogen insufficiency, and vaginal bleeding ensues. Alternatively, when follicle degeneration and stimulation are not balanced, absolute estrogen levels fall and withdrawal bleeding occurs. Characteristically, anovulatory cycles present as prolonged amenorrhea with periodic menorrhagia. Due to the lack of progesterone-mediated myometrial contractions and arteriolar vasospasm, anovulatory cycles are rarely associated with cramping.
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