Diagnostic Approach for Pelvic Pain in Reproductive-Age Patients

Initial Imaging Strategy

The American College of Radiology recommends pelvic ultrasound (transvaginal and transabdominal) with Doppler as the first-line imaging modality for evaluating reproductive-age patients with subacute/chronic pelvic pain of suspected gynecologic origin 1, 3
The ultrasound should specifically assess the retained left ovary for cysts, masses, or torsion, as well as pelvic veins for engorgement and flow patterns suggestive of pelvic congestion syndrome 1, 2

The patient's history of ovarian cyst increases the likelihood of recurrent ovarian cyst formation, according to the American College of Radiology 1
Testosterone therapy in FTM patients does not eliminate estrogen entirely, and residual ovarian function can contribute to pelvic venous congestion, as noted by Praxis Medical Insights 2
Pelvic congestion syndrome is associated with chronic/intermittent pelvic pain that worsens with standing and improves with lying down, according to Praxis Medical Insights 2

The American College of Radiology recommends MRI pelvis without and with IV contrast as the next appropriate step if ultrasound findings are equivocal or require further characterization 1, 3
MRI is superior for detecting endometriosis, characterizing complex adnexal masses, and evaluating pelvic congestion syndrome with MR venography, according to the American College of Radiology and Praxis Medical Insights 1, 2, 3

Ovarian vein embolization (with or without internal iliac vein embolization) is safe and effective for refractory pelvic congestion syndrome, as noted by Praxis Medical Insights 2
If no ovarian pathology is identified, consider non-gynecologic causes, including urologic or gastrointestinal issues, as well as musculoskeletal causes like osteitis pubis or pelvic floor dysfunction, according to Praxis Medical Insights and the American College of Radiology 2, 3, 4