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The practicing gynecologist sees many patients in the office with complaints of chronic pelvic pain. The evaluation and treatment of these patients can often be daunting and evoke a visceral response of angst in the practicing physician. This can be avoided by approaching patients in a structured framework that addresses issues in a multifactorial fashion. The purpose of this chapter is to present some of the more common causes of chronic pelvic pain. This will begin with a brief overview followed by a discussion of an approach to history and physical examination, laboratory and diagnostic studies, differential diagnosis, and finally treatment options.

A discussion of contraceptive options would not be complete without reviewing the population that needs contraception. In the United States, 48% of the 6.3 million pregnancies that occur annually are unplanned. Approximately 50% of these unplanned pregnancies occur among the small percentage of women at risk for pregnancy who do not use contraception. There are approximately 60 million women in the United States who are in their reproductive years (ages 15–44). Of these women, 30% do not need contraception (they are heterosexually abstinent, pregnant, postpartum, or are attempting to get pregnant), 65% are using some sort of contraception, and 5% are not using but are still in need of contraception. Of the women who practice contraception, two-thirds use a method of reversible contraception, such as oral contraceptives or condoms. Among women who use the condom as their primary method of contraception, one-third report not using it with every act of intercourse. These women tend to mainly use the male condom; less than 1% report using the female condom as their primary method of barrier contraception. Condom use tends to decline as women age; only 16% of women aged 35–39 years used a condom at all. Twenty-eight percent of couples using contraception rely on tubal sterilization and 11% on male sterilization. As women and male partners age, they increasingly begin to rely on female methods of contraception, with over 44% of women aged 35–39 years relying on female contraceptive methods. Female sterilization is the most commonly used method in women who are over the age of 34 years, have been previously married, or have an income below 150% of the poverty level.

Coronary heart disease, traditionally considered a problem predominantly for men, is currently the leading cause of mortality in adult women in the United States, responsible for about 250,000 deaths annually. The substantial age dependency of coronary heart disease in women is important in that one of eight or nine women aged 45 to 64 years has clinical manifestations of coronary heart disease, in contrast to one of three women older than 65 years. Despite these data, until very recently, most information used to guide preventive strategies, clinical recognition, and therapy of coronary heart disease in women was extrapolated from studies conducted predominantly or exclusively in middle-aged men.

Only with proper diagnosis can an appropriate approach to therapy and discussion of prognosis occur. Dermatologic diagnosis is based on history, physical examination, and laboratory evaluation. In addition, careful and complete documentation of cutaneous abnormalities is necessary.

Diabetes mellitus is a complex of syndromes characterized by hyperglycemia and abnormal glucose metabolism. Persistent hyperglycemia leads to a variety of specific microvascular diseases involving the eye, kidney, and the peripheral nerves. In addition, diabetes mellitus is associated with an increased risk of macrovascular disease of the coronary, cerebral, and peripheral vasculature. It is estimated that approximately 6% of the U.S. population (approximately 14 million people) have been diagnosed with diabetes mellitus. An equal number of individuals probably have undiagnosed diabetes mellitus. Diabetes mellitus has a major economic and health impact. In 1992 the direct cost of treating individuals with diabetes mellitus was $85 billion, and the total cost of caring for these individuals was $105 billion. Thus, one in seven health care dollars was spent on treatment of individuals with diabetes mellitus. Individuals with diabetes mellitus are two to three times more likely to be hospitalized and two to four times more likely to have cardiovascular disease than the rest of the population. They also have the highest incidence of blindness, chronic renal failure, and nontraumatic foot amputation. Early diagnosis and appropriate management of diabetes mellitus can prevent or delay the development of complications.

Our primary focus will not be on topics such as acute disease, appendicitis, hernias, massive bleeding, or hematemesis. The diagnosis and management of these entities are either obvious or outside the scope of routine office care. We will, instead, concentrate on gallbladder disease, and conditions affecting the stomach, small and large bowel, colon, and rectum.

Headache is generally accepted as one of the 10 most common causes for visits to a physician’s office. It can be the source of disability, lost time from work and school, as well as a significant expense item as a medical workup is initiated. The obstetrician-gynecologist as a primary care provider is faced with the task of differentiating common, benign conditions from more serious causes with appropriate therapy being a natural outgrowth of this initial determination. The majority of headaches are identified as either due to muscle contractions or migraine headaches with other etiologies being less common.

In 1947, the World Health Organization stated that health is a complete state of physical, mental, and social well-being and not merely the absence of disease. Yet today, despite living 6.4 years longer than men, women suffer poorer health outcomes and greater disability from disease.

Like it or not, patients with respiratory complaints are a part of our practice. The common cold is often referred to as the most frequent illness occurring in humans: over 40% of Americans suffer from a “cold” each year, accounting for more lost productivity than any other illness. Pharyngitis affects almost 30 million patients annually, with over 10% of all school-aged children seeking medical care each year. Seventeen million patients a year are diagnosed with asthma, with more females than males among adult-onset patients. Whether it is the reason for our patient’s visit or an incidental complaint, we are involved with the diagnosis and management of these problems.

Female sexual dysfunction or dissatisfaction is a common complaint among obstetric-gynecology patients. These complaints may result from medical treatments and procedures, or may secondarily complicate the management and patient compliance of treatment for other medical issues. Therefore, it is important that clinicians treating females obtain basic information regarding human sexual function and dysfunction. This chapter presents an integration of the clinical research as well as the author’s experience regarding sexual function and the management of sexual problems often presented in an obstetricgynecology practice.