Management of cyclical pelvic pain

Dr. Catherine Allaire, MDCM, FRCSC (biography and disclosures)

Disclosures: Member of advisory committees for Abbvie, Actavis, and Bayer. Member of a Speaker’s Bureau for Covidien. No conflict of interest: only generic names used and evidence based recommendations and guidelines.

Mitigating Potential Bias:

• Recommendations are consistent with published guidelines
• Treatments or recommendations in this article are unrelated to products/services/treatments involved in disclosure statements

What care gaps or frequently asked questions have you noticed in the management of this condition?

Many women who come to us for treatment of chronic pelvic pain describe a long-standing history of severe dysmenorrhea, as early sometimes as the onset of menarche. Often their pain has not been addressed properly or their symptoms may have been downplayed or dismissed. Frequently their severe menstrual cramps have rendered them unable to function in their home, school or work duties, and may have been associated with nausea and vomiting and even syncope. Over time, when left untreated, the pain progressed to occur at ovulation, premenstrually, with intercourse and with bowel movements, and in some cases became a daily occurrence. These patients often have endometriosis.

Data that answers these questions or gaps

Endometriosis is a very common condition affecting an estimated 10% of women of reproductive age. Severe dysmenorrhea is the most common symptom of endometriosis and the earliest one to occur. The average delay between time of onset of symptoms and diagnosis is 11 years. At the moment, there is no cure for endometriosis but symptoms can be successfully controlled with medical and surgical management. A laparoscopy is still the gold standard for making a diagnosis of endometriosis, but there is no need to get a confirmed diagnosis prior to treating the symptoms. A thorough history, physical examination (including pelvic examination with cervical swabs in sexually active women), and pelvic ultrasound should rule out other possible causes of pelvic pain such as infections or pelvic masses(1) Laboratory investigations are of limited use, except for a urinalysis which may help identify a bladder source of pain. The clinical examination of patients with endometriosis may be normal but may also reveal uterosacral tenderness or nodularity, which is highly associated with a positive diagnosis (2, 3). The key to management of this condition and prevention of progression to chronic pain is early treatment.

What do you recommend (practice tip) in managing this problem?

If endometriosis is suspected as the cause of pelvic pain, then the current recommendations are to treat the symptoms medically first unless the patient is actively trying to conceive or has an endometrioma (discovered on ultrasound) in which case surgery may be advisable and referral to a gynecologist should be initiated.(4,5)

Medical management may be as simple as NSAIDs taken preemptively at the expected time of menses, or using combined hormonal contraceptives (CHCs) following the standard cyclical regimen. However if the menstrual symptoms persist despite these therapies, then the woman should be offered menstrual suppression. Stopping the menses is safe, completely reversible, decreases the risk of ovarian and uterine cancer and does not have any adverse effects on fertility (6). This can be achieved with the use of CHCs, following the usual contraindications and precautions. The key to successful treatment in these women is achieving complete amenorrhea, because breakthrough bleeding (BTB) can often be associated with cramping and lead to discontent and discontinuation. If prescribing an oral CHC, start with a 20ug estradiol dose monophasic regimen, administering the active pills daily for at least 3 months (21 day package, 1 tab daily for 84 days). Some CHCs are packaged to be taken continuously for 3 months, but any pill can be used continuously with proper explanation and counseling. Some factors that can increase the risk of BTB include missing a pill, smoking, taking St. John’s wort or antibtiotics, and GI upset (vomiting or diarrhea). Other causes of persistent BTB should also be considered such as fibroids, endometritis or pregnancy. If the woman has ongoing bothersome BTB without correctable factors, various strategies can be used such as taking NSAIDS like naprosyn 500 mg twice a day for 5 days, taking the pill twice a day for 3 days, or stopping the pill for 4 days and allowing a full flow to come and then restarting the pill. If BTB is still an issue after 3 months, consider switching to a CHC with a 30ug estradiol dose or a different progestin type.

Progestins alone such as medroxyprogesterone acetate (150mg IM q8-10weeks), dienogest (2mg/day), norethindrone acetate (5-15 mg /day) or the levonorgestrel-releasing IUD are also very effective menstrual suppression therapies. BTB that occurs while using progestins can often be treated with a short course (7 days) of low dose estrogen therapy.

As recently as 100 years ago, women would have an average of 150 periods in their lifetime; currently, with delaying of childbearing and decreased parity, women often have 450 lifetime periods. There is no compelling reason for women to be subjected to severe menstrual pain or other incapacitating menstrual symptoms. If the cycle is a pest, you must suppress!

References and/or Additional reading

1. Jarrell, JF, Vilos GS, Allaire C. et al. Consensus Guidelines for the Management of Chronic Pelvic Pain. J Obstet Gynecol Can. Part 1 2005;27(8) 781-801, Part 2 27(9) 869-887
   Pt 1 – Free full text   |   Pt 2 – Free full text
2. Cheewadhanaraks S, Peeyananjarassri K, Dhanaworavibul K, Liabsuetrakul T. Positive predictive value of clinical diagnosis of endometriosis. J Med Assoc Thai. 2004;87:740–744
3. Bazot M, Lafont C, Rouzier R, Roseau G, Thomassin-Naggara I, Daraï E. Diagnostic accuracy of physical examination, transvaginal sonography, rectal endoscopic sonography, and magnetic resonance imaging to diagnose deep infiltrating endometriosis. Fertil Steril. 2009;92:1825–33. (View with CPSBC or UBC)
4. Vercellini P, Crosignani P, Somigliana E, Vigano P, Frattaruolo M, Fedele L. ‘Waiting for Godot’: a commonsense approach to the medical treatment of endometriosis. Human Reproduction. 2011;26:3-13.  Free full text
5. Leyland N, Casper R, Laberge P, Singh SS, SOGC. Endometriosis: diagnosis and management. J Obstet Gynaecol Can. 2010;32:S1. Free Full Text
6. Guilbert E, Boroditsky R, Black A, et al. Canadian Consensus Guideline on Continuous and Extended Hormonal Contraception. J Obstet Gynecol Can. 2007;29:S1-32. Free Full Text

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Management of cyclical pelvic pain

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