The most common ovarian mass in adolescents is the functional ovarian cyst that will spontaneously regress over 6 - 8 weeks and that typically does not cause significant symptoms. Typical appearance on ultrasound is that of a unilocular fluid filled mass typically up to 4 - 5 cm in size. Functional cysts may cause pain if they are persistent in nature, if they rupture, or if they undergo torsion. Other ovarian masses that are less common than functional cysts but that are more likely to be a source of CPP include hemorrhagic corpus luteal cysts, mature cystic teratomas, serous or mucinous cystadenomas, and endometriomas.

As previously mentioned, functional ovarian cysts typically regress spontaneously and do not require any further interventions. Persistent functional cysts or other ovarian masses that require surgical intervention should be treated with ovarian cystectomy with preservation of normal ovary for future fertility. Some patients experience lower abdominal pain associated with ovulation. The pain typically lasts for up to 48 h in mid-cycle and can be relieved either with NSAIDS or ovulation suppression with OCPs. Because the symptoms occur monthly, patients may report their symptoms as chronic in nature.

Before leaving gynecologic causes of chronic pain, we should mention two etiologies that are not truly gynecologic but that are frequently encountered in a gynecologic work-up. These include musculoskeletal pain and urinary tract infection (UTI). To screen for musculoskeletal pain, posture should be assessed looking for excessive lordosis, habitual one-legged standing, and leg length discrepancy. The upper and lower back should be palpated as well as the abdominal wall during leg flexion and head and leg raises. Asking the patient to point to the area where the pain hurts the most can be enlightening.

UTI as a cause of chronic abdominal pain is not very common, but it is a good idea to obtain a urine analysis when evaluating a young woman for CPP/RAP. If there are findings that suggest a possible UTI, cultures and sensitivities should be obtained.