Adolescents with CPP may have a gynecologic etiology of their pain.

Inquiries about the patient’s gynecologic health should be part of the initial interview. Items should include age at menarche, menstrual pattern menstrually related symptoms, and sexual history. Some symptoms may be more suggestive of a gynecologic reason for the pain. These would include pain that is specific to a certain time in the menstrual cycle, pain that is associated with vaginal bleeding, pain which is exacerbated with menses, or pain that is worse with sexual intercourse. If the patient is sexually active or if symptoms suggest a gynecologic etiology, a pelvic examination should be included in the initial assessment. Wet mount examination, Pap smear, and cervical cultures should be obtained if indicated. Bimanual examination should include evaluation of the vagina for patency and tenderness, cervix for cervical motion tenderness, uterosacral ligaments for tenderness or nodularity, uterus for size, shape and tenderness, and adnexa for tenderness, masses, and mobility. A rectal examination, including stool guaiac, should also be performed to confirm the findings on bimanual examination and evaluate for gastroenterologic causes. Radiologic imaging studies may be indicated to further evaluate an abnormality that is identified on pelvic examination or if the clinician is unable to successfully complete the examination. A pelvic ultrasound, pelvic CT scan, or MRI of the pelvis may be necessary depending on the abnormality suspected.