Primary care management of chronic pelvic pain in women
ABSTRACT
Chronic pelvic pain in women can arise from many causes and often results in significant declines in function and quality of life. A systematic approach for evaluating patients and initiating a management plan are recommended in the primary care setting. Comprehensive management strategies may include medication, pelvic physical therapy, and behavioral interventions.
KEY POINTS
- Diagnosing and managing chronic pelvic pain may be difficult, but patients are often best served when their primary care provider directs a team-based approach to their care.
- A detailed history, thorough abdominal and pelvic examinations, and targeted testing facilitate the diagnosis.
- As in other chronic pain syndromes, the goals of therapy should be incremental and meaningful improvements in pain, function, and overall well-being.
Diagnostic workup
Because the differential diagnosis of chronic pelvic pain is broad, the diagnostic workup and testing should be based on findings of the history and physical examination. In general, extensive laboratory testing is of limited use for evaluating women with chronic pelvic pain.3,7
Urinalysis should be obtained for symptoms suggesting bladder involvement such as interstitial cystitis.
Pelvic ultrasonography can help identify pelvic masses palpated during the physical examination, but routine use of imaging is not recommended.3,7 If pelvic congestion syndrome is suspected, starting with pelvic ultrasonography is reasonable before incurring the risk or cost of computed tomography or magnetic resonance imaging.8
GENERAL TREATMENT
Medical therapy
The main goals of medical therapy are to improve function and quality of life while minimizing adverse effects. General treatments include the following:
Analgesics. Nonsteroidal anti-inflammatory drugs and acetaminophen may provide pain relief, although there is weak evidence for their efficacy in treating chronic pelvic pain.9
Neuropathic agents. One of several available neuropathic agents commonly used in the treatment of chronic pain can be tried on patients who fail to respond to analgesics. Tricyclic antidepressants such as amitriptyline and imipramine decrease pain, reduce symptoms of depression, and improve sleep.10 The results of a small randomized controlled trial suggest that gabapentin is more effective than amitriptyline for reducing chronic pelvic pain.11,12 Published guidelines currently list both amitriptyline and gabapentin as first-line agents; nortriptyline and pregabalin are considered acceptable initial alternatives.9
Venlafaxine and duloxetine may help chronic pelvic pain, although specific evidence is lacking. Duloxetine may be an appropriate choice for women with chronic pelvic pain who also experience depression and urinary stress incontinence.9
Opioids. Opioid therapy should be considered only when all other reasonable therapies have failed.10 Patients may develop tolerance or dependence, as well as opioid-induced adverse effects such as hyperalgesia.9,10 Guidelines recommend that primary care providers consult with a pain management specialist before prescribing opioids, and that patients be thoroughly counseled about the risks and side effects.9
Nerve block and neuromodulation. There is weak evidence for the use of these modalities for treating chronic pelvic pain.9 If used, they should be part of a broader treatment plan and should be performed by providers who specialize in management of chronic pain.
DISEASE-SPECIFIC TREATMENT
Endometriosis: Hormonal therapy
Pelvic pain that significantly fluctuates with the menstrual cycle may be caused by endometriosis, the most common gynecologic cause of chronic pelvic pain. Women with cyclic chronic pelvic pain should be empirically treated with hormonal therapy for at least 3 to 6 months before diagnostic laparoscopy is performed.13
Oral contraceptives, gonadotropin-releasing hormone (GnRH) analogues, progestogens, and danazol have proven efficacy, although side-effect profiles differ significantly. In a comparative trial, patients treated with GnRH analogues had more improvement in pain scores compared with those treated with oral contraceptives, but they experienced a significant decrease in bone mineral density.11 The effects on bone mineral density associated with GnRH analogue therapy can be mitigated by “add-back” low-dose hormonal therapy (norethindrone, low-dose estrogen, or a combination of estrogen and progesterone), which may also provide symptomatic relief for associated hot flashes and vaginal symptoms.11
Interstitial cystitis often accompanies endometriosis
Recognizing that chronic pelvic pain may have more than one cause is important when developing a comprehensive care plan. Interstitial cystitis coexists with endometriosis in up to 60% of patients.14 Initial treatment is pentosan polysulfate sodium, an oral treatment approved by the US Food and Drug Administration for interstitial cystitis that works by restoring the protective glycosaminoglycan layer in the bladder.14,15 Amitriptyline may also be used to treat interstitial cystitis-associated nocturia.
Myofascial pain: Neuromuscular blockers
According to a recent systematic review of therapies for chronic pelvic pain, patients with symptoms related to myofascial pain may benefit from neuromuscular blockade.12 One randomized controlled trial of the effectiveness of botulinum toxin A vs saline for the treatment of chronic pelvic pain secondary to pelvic floor spasm found that after 6 months of observation, women who received botulinum toxin had significantly lower pain scores than those who received saline.12
