FEMALE CONCERNS
| CHRONIC PELVIC PAIN— Christine M. Stabler, MD, Clinical Associate Professor of Family Medicine, Temple University
School of Medicine, Philadelphia, PA, and Deputy Director, Family and Community Medicine Residency Program,
Lancaster General Hospital, Lancaster, PA
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| Prevalence: occurs in 1 in 7 women; in 1 study, prevalence ≈39% among women 18 to 50 yr of age in primary care; accounts
for ≈10% of referrals to gynecology office; annual cost in United States >$800 million; remarks—many patients
have comorbid bowel or bladder dysfunction, sexual problems, systemic symptoms, depression, anxiety, or drug addiction
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| Definition: pain in anatomic pelvis persisting >3 mo, severe enough to cause distress and disability requiring medical
care
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| History: ask about location of pain, precipitating factors, and pain pattern (patient with chronic pelvic congestion may be
fine in morning, but develop pain as day progresses; patients with endometriosis may have pain with intercourse or on
pelvic examination); ask what makes pain better, and about quality, distribution, and severity of pain (visual analog
scale)
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 | Obstetric and gynecologic issues: history of excessive bleeding, heavy menses or clots suggestive of uterine leiomyomas
or adenomyosis; previous pelvic or abdominal surgery associated with increased risk for adhesions, leading to chronic
pelvic pain (CPP); cervical stenosis secondary to surgery may lead to incomplete or slowed evacuation of uterus during
menses (hematocolpos); patients with multiple sexual partners at increased risk for sexually ransmitted diseases
(STDs), chronic endometritis, hydrosalpinx, and adhesions
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| Other problems: women who report urgency, frequency, or burning on urination may have bladder-related problem (eg,
interstitial cystitis); patients with gastrointestinal (GI) symptoms (eg, bloating, discomfort with defecation, intermittent
constipation, gas) may have sigmoid adhesions from previous pelvic infections or pelvic surgery; women with aching
fullness of pelvis that gets worse as day progresses may have pelvic congestion, pelvic floor dysfunction, or pelvic prolapse,
related to giving birth to infant with large head, or chronic cough, ascites, or obesity; presence of constant burning
or irritation suggests pudendal neuralgia
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| Psychologic history: essential; evaluate for depression, anxiety, somatization, drug abuse or dependence, marital, social,
or family problems; women with history of sexual abuse before 15 yr of age at high risk for development of CPP or
other chronic pain syndrome
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| Review of systems: helpful in making sure nothing missed
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| Physical examination: more elaborate than routine gynecologic examination; perform in various positions to help locate
exacerbating problems; standing position helpful in evaluating for pelvic congestion or prolapse and evaluating
pouch of Douglas for enteroceles; if patient complains of painful trigger points, apply cotton-tipped swab to those areas;
if this evaluation inconclusive, evaluate tender areas and coccyx digitally (CPP can be due to coccydynia); perform
pelvic bimanual examination, looking for fixation, tenderness, or positional change of uterus; assess vaginal and
pelvic musculature and pelvic wall with Sims retractor; do rectovaginal examination
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| Other aspects: examine GI, genitourinary (GU), musculoskeletal, and neurologic systems; check gait and motor function;
do Betty maneuver for piriformis syndrome; look for obturator sign (indicates injured obturator muscles or fascia);
straight-leg raising test (may identify disc disease or radiculopathy); check for psoas and FABER (flexion in abduction
and external rotation; detects sacroiliac joint pathology) signs
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| Differential diagnosis: extrauterine gynecologic causes—endometriosis; adhesions; adnexal cyst; chronic ectopic
pregnancy; pelvic inflammatory disease (PID); salpingitis; ovarian remnant syndrome; pelvic congestion syndrome; perioperative
cysts; residual accessory ovary; uterine causes—adenomyosis; atypical dysmenorrhea; ovulatory pain; cervical
stenosis; endometrial polyps; leiomyomata; symptomatic pelvic relaxation or prolapse; intrauterine device (IUD); urologic
causes—interstitial cystitis and recurrent cystitis (most common); chronic urethral syndrome; uninhibited bladder
spasms (detrusor-sphincter dyssynergia); musculoskeletal problems—faulty or poor posture; fibromyalgia; piriformis
syndrome; hernias; GI causes—carcinoma of colon; chronic constipation; colitis; diverticular disease; inflammatory
bowel disease; irritable bowel syndrome; neurologic disorders—abdominal epilepsy; herpes zoster (postherpetic neuralgia
may be pelvic); psychologic disorders—personality problems; depression; sleep disorders; sexual and/or physical
abuse
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| Laboratory studies: based on and guided by history; complete blood cell count (CBC) and erythrocyte sedimentation
rate to rule out inflammatory process; tests for various STDs as well as wet mount, vaginal pH, and cultures; urinalysis
and urine cultures if urologic problem suspected; work-up for urinary or bladder calculi or GU tumors if hematuria
present; hormone assays (if CPP patient has undergone surgery); stool guaiac testing or colonoscopy (for patients >50 yr
of age); stool specimen for ova and parasites (O and P) in selected individuals
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| Imaging studies: should be determined on basis of history and physical examination; computed tomography (CT)—
helps differentiate ovarian and uterine masses; can detect peritoneal lesions and diverticular disease; magnetic resonance
imaging (MRI)—slightly more sensitive than CT in identifying some pelvic lesions; use of intravenous (IV) contrast
helps delineate infectious, inflammatory, and malignant causes of CPP; ultrasonography (US)—can pick up pelvic
masses, adnexal cysts, pelvic varicosities, and hernias; x-rays—can detect bony problems (eg, compression fractures in
women >65 yr of age) and tumors; hysterosalpingography and hysteroscopy—may help diagnose infiltrative endometriosis,
endometrial polyps, Asherman’s syndrome, and adenomyosis; barium enema, colonoscopy, sigmoidoscopy, and upper
GI series—limited to evaluating GI sources of pain; voiding cystourethrography and cystography with
hydrodistention—used for evaluating GU system problems, including interstitial cystitis; vaginal US—useful for evaluating
patients with possible pelvic congestion syndrome; laparoscopy—often done when diagnosis cannot be ascertained
by other means
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| Other studies: urodynamic testing; nerve conduction studies; electroencephalography (for detecting rare cases of abdominal
epilepsy); cancer antigen (CA) 125 (not very helpful; low sensitivity and specificity)
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| Treatment: focused on achieving functionality of patients; may require multiple modalities, including counseling
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| Pharmacotherapy: to reduce severity of acute pain; short-term use of over-the-counter (OTC) analgesics (eg, acetaminophen,
ibuprofen, aspirin, naproxen) reasonable; some patients warrant short course of antibiotics, even if cultures negative
because chronic pelvic inflammation due to Ureaplasma urealyticum and Mycoplasma hominis not detected on
routine cultures; consider long-term use of opiates only with narcotics contract and when “everything else” has failed;
consider use of selective serotonin reuptake inhibitors (SSRIs; eg, fluoxetine, paroxetine, sertraline) and tricyclic antidepressants
(eg, amitriptyline, nortriptyline)
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| Physical modalities: useful for musculoskeletal causes of CPP; include massage, US, stretching, and exercises (including
Kegel exercise), and biofeedback
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| Psychologic therapy: includes reassurance, counseling, relaxation techniques, and stress management
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| Trigger point injections: helpful for localized pain, especially in patients with myofascial pain syndrome or localized
neuroma; usually involves injecting corticosteroid with lidocaine; comment—peripheral nerve blocks helpful for some
patients
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| Invasive techniques: neuroablation of selected nerves (can be done with radiofrequency or with chemical agent)
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| Surgery: procedures include laser laparoscopy, presacral neurectomy (“last ditch”), and hysterectomy (controversial)
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| Specific treatments: adenomyosis—short-term nonsteroidal anti-inflammatory drugs (NSAIDs), gonadotropin-releasing
hormone (GnRH) agonists, danazol (Danocrine), endometrial ablation, excision of adenomyosis, and hysterectomy;
dysmenorrhea—NSAIDS, oral contraceptives (OCs), calcium channel blockers, presacral neuroectomy; look for associated
problems; endometriosis—OCs, medroxyprogesterone (Depo-Provera), GnRH analogues, danazol, laparoscopic ablation,
and total abdominal hysterectomy and bilateral salpingo-oophorectomy; pelvic adhesions—lysis via laparoscopy,
laparotomy, or hysterectomy; chronic endometritis—doxycycline (if Chlamydia suspected); removal of IUD; surgery
(for, eg, tubo-ovarian abscess, hydrosalpinx); pelvic myofascial pain—manual myofascial release, trigger point injections,
acupuncture, muscle strengthening, and physical therapy; dyspareunia—look for psychosocial causes, eg, history
of or current abuse; treat underlying disorder, eg, vestibulitis, vaginal dryness in postmenopausal patient; biofeedback
and relaxation techniques; trigger point injections; myofascial release; interstitial cystitis—instillation of dimethyl sulfoxide
(DMSO); pentosan polysulfate sodium (Elmiron); electronic stimulation; bladder training; ovarian remnant
syndrome—oophorectomy of remnant; pelvic congestion syndrome—can utilize progestins, SSRIs, elastic stockings,
ovarian vein ligation, embolization, or surgery; uterine leiomyomas—if large, pretreat with GnRH analogues, followed
by laparoscopic-aided or vaginal hysterectomy; other modalities include uterine artery embolization, myomectomy, and
hysterectomy
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| CONTRACEPTION —Martin A. Quan, MD, Professor of Clinical Family Medicine, the David Geffen School of Medicine
at the University of California, Los Angeles
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| Intrauterine devices (IUDs): history—decline in usage attributed to chain of events associated with Dalkon Shield,
introduced in 1970 and linked to many cases of PID in mid 1970s (resulting lawsuits led to its removal from market in
1980; eventually, all IUD manufacturers in United States [except one] withdrew their devices); in 1988, ParaGuard introduced;
current IUDs—highly effective, associated with high satisfaction rate; not associated with increased risk for PID
(aside from 3-wk window after insertion) or tubal infertility; currently available agents include ParaGuard (contains copper;
approved for 10 yr of use); and Mirena (levonorgestrel-containing device approved for 5 yr of use)
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Oral Contraceptives (OCs)
| Drospirenone-containing OC: contains 30 µg ethinyl estradiol (EE) and 3 mg drospirenone (analogue of spironolactone
[Aldactone]); has progestin, antiandrogenic, and antimineralocorticoid activities; because of antimineralocorticoid
activity, associated with reduction of cyclic fluid retention, reduction in mean body weight gain per cycle, and reduction
of symptoms related to weight gain in second half of cycle; contraindicated in patients with history of adrenal or renal insufficiency,
and in patients using medications that retain potassium (K); check serum K levels after first cycle of use
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| Extended cycles (“bicycling and tricycling”): eliminates pill-free interval for 2 to 3 cycles, using monophasic formulation;
Seasonale first extended-cycle pill approved in 2003; contains 30 µg EE and 0.15 mg levonorgestrel; patient
takes 84 active pills, followed by 7 days of placebo pills
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| Quick Start: new protocol for initiating pill in first-time users; involves taking first pill on day of office visit; enhances
compliance; precautions—do sensitive pregnancy test before starting; use emergency contraceptive method if patient had
unprotected sex within past 5 days; repeat pregnancy test 2 wk after initiating OC use; studies show no higher risk for breakthrough
bleeding; have patient use backup method for first 7 days
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| New OC formulations: norethindrone acetate, ethinyl estradiol, and ferrous fumarate (Loestrin 24 Fe)—give for 24
days, followed by 4 days of inert pills; Seasonique—essentially same as Seasonale; taken for 84 days, followed by 7 days
of low-dose estrogen pill (containing only 10 µg EE); (drosperinone and ethinyl estradiol (YAZ)—first OC approved for
premenstrual dysphoric disorder; 20 µg of EE given for 24 days, followed by 4 days of inert pill; levonorgestrel and estradiol
(Lybrel)—365-day active pill; contains 20 µg EE and 90 µg levonorgestrel; potential advantages of shortening pill-
free interval—reduced risk for follicular development (may improve efficacy in preventing pregnancy)
|
Nonoral Pill Equivalents (NOPES)
| Description: resemble pill in hormone composition and function, but have nonoral delivery; norelgestromin and ethinyl
estradiol transdermal system (Ortho Evra)—contraceptive patch; placed on torso, upper arm, or hip on weekly basis for 3
wk, followed by 1 wk patch-free interval; repeat cycle; releases 150 µg norelgestromin and 20 µg EE every 24 hr; breakthrough
bleeding comparable to OCs and compliance better; adverse reactions include mastalgia and possibly deep venous
thrombosis (DVT); although peak estrogen level 25% lower than with OC, estrogen exposure 60% greater with patch; because
of higher bioavailability of estrogen, “black box” warning issued; unknown whether increased estrogen exposure
will lead to increase in DVT; contraceptive vaginal ring (NuvaRing)—5.4 cm in diameter, transparent, and flexible; patient
inserts ring into vagina for 3 wk, then removes it for 1 wk; cycle then repeated with new ring; releases 0.015 mg EE
and 0.12 mg etonogestrel daily; efficacy similar to OCs; adverse effects generally minor; continuation rate better than 40%
rate typical for OCs; if ring accidentally comes out, advise patient to wash it in warm water and reinsert within 3 hr
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| Long-acting progestin-only agents: Norplant—introduced in 1990 and removed from market in 2000 because of difficulties
in removing; Implanon—approved for use in 2006; single implant effective for 3 yr; contains 6 to 8 mg
etonogestrel; Depo-Provera—extremely effective; mechanism of action similar to OCs; adverse reactions include breakthrough
bleeding, amenorrhea, and reduction in bone mineral density (BMD), possibly increasing risk for osteoporosis;
black box warning issued in 2004 stating Depo-Provera should not be used for >2 yr unless other forms of birth control inadequate;
strategies to increase BMD—1) calcium intake (1000 mg daily); 2) daily weight-bearing exercises; 3) smoking
cessation; 4) avoid use in women >35 yr of age, especially those with risk factors for osteoporosis; 5) limit use to 2 yr; 6)
consider regular measurement of BMD for long-term users; 7) consider adding back estrogen; physiologic effect—
pituitary-adrenal axis so profoundly affected that estrogen production decreased; in some women, this results in estrogen
levels equivalent to those in postmenopausal women
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Other Methods
| Emergency or postcoital contraception: Preven—first agent approved, later discontinued; same action achieved
by giving equivalent doses of EE and levonorgestrel; Plan B—progestin-only method; available OTC for women >18 yr
of age; give one tablet immediately, with repeat dose at 12 hr within 72 hr of unprotected intercourse; Ovrette—
norgestrin-containing mini pills; alternative to Plan B; 20 tablets equivalent to one Plan B tablet
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| Barrier methods: polyurethane sponge—impregnated with spermicide; placed on cervix; condoms—use increasing;
protection from STDs; patients require instructions on purchase, use, removal, and what to say to partners reluctant
to use
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Suggested Reading
Burkman RT: The transdermal contraceptive system. Am J Obstet Gynecol 190(4 Suppl):S49, 2004; Butrick CS: Patient
with chronic pelvic pain: endometriosis or interstitial cystitis/painful bladder syndrome? JSLS 11:182, 2007; Cole JA
et al: Venous thromboembolism, myocardial infarction, and stroke among transdermal contraceptive users. Obstet Gynecol
109(2 Pt 1):339, 2007; Dunn S et al: Emergency contraception. J Obstet Gynaecol Can 25:673, 2003; Gupta N: Advances
in hormonal contraception. Adolesc Med Clin 17:653, 2006; Hubacher D, Grimes DA: Noncontraceptive health
benefits of intrauterine devices: a systematic review. Obstet Gynecol Surv 57:120, 2002; Latthe P et al: Factors predisposing
women to chronic pelvic pain: systematic review. BMJ 332:749, 2006; Martinez F, Avecilla A: Combined hormonal
contraception and venous thromboembolism Eur J Contracept Reprod Health Care 12:97, 2007; Seeger JD et al:
Risks of thromboembolism in women taking ethinyl estradiol/drospirenone and other oral contraceptives. Obstet Gynecol
110:587, 2007; Stratton P et al: Return of chronic pelvic pain from endometriosis after raloxifene treatment: a randomized
controlled trial. Obstet Gynecol 11:88, 2008; Szarewski A: Hormonal contraception: recent advances. J Fam Health
Care 16:35, 2006; Thonneau P et al: Risk factors for intrauterine device failure: a review. Contraception 64:33, 2001;
Thurman AR et al: Preventing repeat teen pregnancy: postpartum depot medroxyprogesterone acetate, oral contraceptive
pills, or the patch? J Pediatr Adolesc Gynecol 20:61, 2007; Tu FF et al: Comparative measurement of pelvic floor
pain sensitivity in chronic pelvic pain. Obstet Gynecol 110:1244, 2007; Westhoff C et al: Initiation of oral contraceptives
using a quick start compared with a conventional start: a randomized trial. Obstet Gynecol 109:1270, 2007; Zurawin RK,
Ayensu-Coker L: Innovations in contraception: a review. Clin Obstet Gynecol 50:425, 2007.
Educational Objectives
| The goal of this program is to improve the management of chronic pelvic pain (CPP) and evaluate newer developments
in contraception. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Diagnostically work up women complaining of CPP.
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| 2. Treat patients with CPP, utilizing measures such as drugs, trigger point injections, various physical modalities,
counseling, and surgery.
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| 3. Manage specific causes of CPP.
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| 4. Prescribe or recommend the use of various contraceptive modalities, including intrauterine devices (IUDs),
oral contraceptives, contraceptive patches, vaginal rings, long-acting progestin agents, and barrier methods.
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| 5. Provide emergency postcoital contraception.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgements
Dr. Stabler was recorded March 27, 2007, at the 31st semi-annual Family Practice Review, sponsored by Temple University
School of Medicine, and Lancaster General Hospital, and was held in Lancaster, PA. Dr. Quan spoke on May 30, 2007, at
the 34th annual UCLA Family Practice Refresher Course, sponsored by the David Geffen School of Medicine at the University
of California, Los Angeles. The Audio-Digest Foundation thanks the speakers and sponsors for their cooperation in the
production of this program.
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