{"paper_id":"362f248c-9062-42e2-a062-62ccc37fc32f","body_text":"Management of Pelvic Pain from Dysmenorrhea or\nEndometriosis\nLaeth Nasir, MBBS, and Edward T. Bope, MD\nMany women suffer from pelvic pain, and a great many visit their family doctor for diagnosis and treat-\nment. Two common causes are primary dysmenorrhea and endometriosis. Primary dysmenorrhea is\nbest treated by prostaglandin inhibition from nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclo-\noxygenase-2 (COX-2)-specific inhibitors. Oral contraceptives can be added to improve pain control.\nEndometriosis can be treated with NSAIDs and COX-2-specific inhibitors as well but can also be treated\nwith hormonal manipulation or surgery. Empiric treatment for endometriosis in selected patients is\nnow accepted, making the disorder easier for family physicians to manage. (J Am Board Fam Pract\n2004;17:S43–7.)\nPelvic pain is one of the most common problems\naffecting women of reproductive age. The pain may\nvary from mildly irritating to incapacitating. Dys-\nmenorrhea and endometriosis are the two most\ncommon causes. Nonsteroidal anti-inflammatory\ndrugs (NSAIDs) and cyclo-oxygenase-2 (COX-2)-\nspecific inhibitors are the mainstays of therapy for\nboth disorders. Hormonal manipulation may also\nbe used in treatment. Surgical and alternative treat-\nments are also discussed.\nDefinitions\nIn the broadest sense, pelvic pain is considered any\nvisceral pain presenting below the umbilicus. This\narticle focuses on the two most common causes of\nchronic pelvic pain: dysmenorrhea and endometri-\nosis. Pain in the bowel and bladder are considered\nto be outside the pelvis, although the astute clini-\ncian also takes into account the importance of these\ncontiguous organs as causes of pain. Acute pelvic\npain is defined as recent in onset, whereas chronic\npelvic pain is that which has lasted greater than 6\nmonths and occurs not solely with menses.\nPrevalence\nA number of studies have estimated the prevalence\nof chronic pelvic pain to be similar to that reported\nfor migraine, low back pain, and asthma.\n1,2 Dys-\nmenorrhea and endometriosis are the two most\ncommon causes of pelvic pain. Primary dysmenor-\nrhea is a very common gynecologic problem in\nmenstruating women. Reported prevalence rates\nare as high as 90%; 1 in 13 sufferers are incapaci-\ntated for 1 to 3 days per month, impacting school\nand work attendance. Primary dysmenorrhea usu-\nally presents during adolescence within 3 years of\nmenses. Most women who suffer from dysmenor-\nrhea do not seek medical care.\nEndometriosis is seen in 5 to 10% of women in\nthe general population and is thought to be more\ncommon in the mature woman, but it can also\noccur in adolescents and has been reported in girls\nas young as 10.5 years of age.\n3 The peak incidence\nis between the ages of 25 and 30 years.\nManagement of Pelvic Pain\nDysmenorrhea\nAffected women experience sharp, intermittent\nspasms associated with their menstrual cycle. It is\nusually centered in the suprapubic area but may\nradiate to the back of the legs or the lower back.\nSystemic symptoms of nausea, vomiting, diarrhea,\nfatigue, fever, headache, or lightheadedness are\nfairly common. The pelvic pain of dysmenorrhea\nhas been demonstrated to be mediated through the\nFrom the Department of Family Medicine, University of\nNebraska at Omaha (LN), and Family Practice Residency\nProgram, Riverside Methodist Hospital, Columbus, OH\n(ETB). Address correspondence to: Edward T. Bope, MD,\nABFP, Riverside Family Practice Residency Program, Riv-\nerside Methodist Hospital, 697 Thomas Lane, Columbus,\nOH 43214 (e-mail: bopee@ohiohealth.com).\nThe Family Practice Pain Education Project (FP-PEP)\nacknowledges an unrestricted educational grant from Pfizer\nto Cardinal Health to produce educational materials for\nprimary care doctors about pain management. The informa-\ntion provided here is the opinions and research of the family\nphysicians who served on FP-PEP.\nThis work was presented in part at the 2003 American\nAcademy of Family Physicians (AAFP) Scientific Sympo-\nsium.\nhttp://www.jabfp.org Managing Pelvic Pain S43\ncopyright.\n on 12 June 2026 by guest. Protected byhttp://www.jabfm.org/ J Am Board Fam Pract: first published as 10.3122/jabfm.17.suppl_1.S43 on 1 December 2004. Downloaded from \n\naction of prostaglandin factor 2x and is ischemic in\nnature; therefore, prostaglandin inhibition nearly\nalways diminishes or resolves the pain. Numerous\nstudies have documented the efficacy of standard\nNSAIDs and COX-2-specific inhibitors acting\nthrough prostaglandin synthetase inhibition to\ncontrol dysmenorrhea (SORT A*).\n4 These medica-\ntions are started 1 to 2 days before menses and\ncontinued for 2 days after menses starts. This first-\nstep treatment is effective in 80% of patients. For\nthose who fail to respond, oral contraceptive pills\nor medroxyprogesterone can be added to achieve\ncontrol. These medicines are effective in 90% of\npatients (SORT C).\n5 Figure 1 presents an algo-\nrithm for the management of primary dysmenor-\nrhea.\nSome alternative treatments for primary dys-\nmenorrhea have been studied and have shown some\nsuccess. Topical heat at 38.9°C used for 12 hours\nper day has been found to be as beneficial as\nibuprofen.\n6 Four small studies of 126 patients\n* Levels of evidence using SORT: (1) treatment of pain\ncaused by primary dysmenorrhea with NSAIDs or COX-2-\nspecific inhibitors /H11005A; (2) treatment of pain caused by\nprimary dysmenorrhea with oral contraceptive pills /H11005C;\n(3) treatment of endometriosis empirically /H11005B; and (4)\ntreatment of endometriosis pain with NSAIDs or COX-2-\nspecific inhibitors /H11005C.\nFigure 1. Primary dysmenorrhea treatment algorithm.\nS44 JABFP November–December 2004 Vol. 17 Supplement http://www.jabfp.org\ncopyright.\n on 12 June 2026 by guest. Protected byhttp://www.jabfm.org/ J Am Board Fam Pract: first published as 10.3122/jabfm.17.suppl_1.S43 on 1 December 2004. Downloaded from \n\nshowed transcutaneous electrical nerve stimulation\n(TENS) to give moderate relief in 40% to 60% of\npatients.\n7,8 Acupuncture, when studied in 43 pa -\ntients for 1 year, showed a 91% improvement in\nsymptoms and a 41% decrease in analgesic use.\n9\nDaily thiamine (100 mg) for 90 days in 556 patients\nyielded an 87% cure rate up to 2 months after\ntreatment\n10 and, in adolescents, daily intake of ma -\nrine /H9024-3 fatty acids netted significant improve-\nment.11 Nitroglycerin patches improved pain\nsymptoms in one uncontrolled trial. 12 These alter-\nnative treatments can be used alone or as adjuvants\nto standard therapy.\nIf a 3- to 4-month trial of anti-inflammatory,\nhormonal, or alternative treatments has been inef-\nfective, secondary causes of dysmenorrhea and pel-\nvic pain should be considered (Table 1). In one\nstudy of 100 women who had inadequate pain relief\nwith NSAIDs and/or oral contraceptives, almost\n80% had endometriosis on laparoscopy.\n12 Only af-\nter these secondary causes have been ruled out\nwould invasive options such as uterosacral nerve\nablation, presacral neurectomy, or nerve block pro-\ncedures, be considered. A Cochrane review did not\nfind sufficient evidence to recommend nerve inter-\nruption procedures for the treatment of pelvic pain\ncaused by dysmenorrhea.\n13\nEndometriosis\nEndometriosis typically presents with the triad of\npelvic pain, dyspareunia, and infertility. Any of\nthese 3 issues could motivate a woman to seek care;\nmost often, pain is the compelling reason for the\nvisit. Endometriosis can be investigated and treated\nby laparoscopy or can be treated empirically. The\ntraditional approach has been to perform laparos-\ncopy to visually and pathologically make the diag-\nnosis, with the advantage that any endometriosis\nfound can be surgically treated at the same time. In\none placebo-controlled, double-blind, randomized\ntrial of women with stage I, II, or III endometriosis,\n40% had alleviation of pain at 6 months that\ncould be attributed to surgical debridement.\n14 Pro-\ngestin, danazol, or gonadotropin-releasing hor-\nmone (GnRH) analogs are generally used post-\noperatively for greater duration of pain relief\n(Figure 2).\n15,16\nLing17 showed empiric treatment to be effective\nin low-risk patients, including women aged 18 to 45\nyears with regular menses, no previous diagnosis of\nendometriosis, no hormonal treatment in the prior\n3 months, no evidence of gastrointestinal or urinary\ndisease, normal pelvic ultrasound, normal complete\nblood count, normal urinalysis, negative gonorrhea\nand chlamydia culture, negative human chorionic\ngonadotropin, and failure of NSAIDs and doxy-\ncycline to improve pain symptoms (SORT B). Of\npatients treated empirically, 80% experienced sig-\nnificant improvement, including patients without\ndetectable endometriosis at subsequent laparos-\ncopy. The empiric treatment group must be care-\nfully screened to be certain there is no concomitant\ndisease, such as infection or pregnancy.\nWhether identified surgically or empirically, en-\ndometriosis is treated with one or more of the\nfollowing: traditional NSAIDs, COX-2-specific in-\nhibitors (SORT C), oral contraceptive pills\n(OCPs), GnRH agonists, progestins, or danazol.\nTraditional NSAIDs or COX-2 inhibitors are used\ninitially at maximal or nearly maximal dosage.\nThere is no evidence to support switching from one\nNSAID to another to improve response, although\nthe practice is frequent.\n18 OCPs are used next if\npain relief has not been achieved, and they may be\nused alone or in combination with NSAIDs. Using\nthe “long cycle” approach with oral contraceptive\npills (3 months of pills before a week without pills)\ncan reduce the number of menses, thus improving\nthe quality of life.\n19 No evidence supports switch -\ning from one OCP to another to improve response.\nHigh-dose progestins improve endometriosis by\ndeciduation followed by pseudonecrosis and atro-\nphy of lesions. Progestins suppress gonadotropin\nrelease and ovarian function; for example, 50 mg/\nday medroxyprogesterone acetate has been shown\nto improve symptoms in up to 80% of patients with\nendometriosis.\n19 Other regimens for progesterone\nTable 1. Secondary Causes of Dysmenorrhea and\nChronic Pelvic Pain\nEndometriosis\nAdenomyosis\nEndometrial polyps\nLeiomyomata\nPelvic inflammatory disease\nPelvic organ prolapse\nAdhesions\nMusculoskeletal disorders\nGastrointestinal disorders\nUrologic disorders\nA history of sexual abuse\nhttp://www.jabfp.org Managing Pelvic Pain S45\ncopyright.\n on 12 June 2026 by guest. Protected byhttp://www.jabfm.org/ J Am Board Fam Pract: first published as 10.3122/jabfm.17.suppl_1.S43 on 1 December 2004. Downloaded from \n\ndose and delivery including intramuscular de-\npoprogesterone are effective as well. Side effects of\nprogestin therapy include weight gain, edema, de-\npression, and headache.\n20 Danazol, a testosterone\nderivative, produces a hypoestrogenic environment\nand is effective in 80% of patients; however, the\nhigh incidence of androgenic side effects, ap-\nproaching 80%, limits its use.\n20 The GnRH ago -\nnists (eg, nafarelin nasal spray and leuprolide de-\npot), suppress ovarian estrogen production causing\nestrogen deprivation. The typical course of treat-\nment is for 6 months, after which the patient must\nbe monitored for bone loss and consideration given\nto adding back estrogen or progesterone. In 50% of\ncases, there is recurrence of symptoms within 6\nmonths after GnRH agonist therapy is discontin-\nued.\n20\nIf empiric treatment or laparoscopy with local\nablation has not been successful, then more invasive\ntreatments must be considered, such as uterosacral\nnerve ablation, presacral neurectomy, or a nerve\nblock procedure. As a last resort, total abdominal\nhysterectomy and bilateral salpingo-oophorectomy\ncould be considered.\n21\nConclusion\nEvidence supports the use of traditional NSAIDs\nand the COX-2 specific inhibitors in the treatment\nof pain associated with primary dysmenorrhea and\nendometriosis. High levels of effectiveness can be\nexpected for both disorders, meaning that many\nwomen could find relief. Although endometriosis\ntreatment has traditionally followed a surgical di-\nagnosis, there is also evidence to support treating\nFigure 2. Endometriosis treatment algorithm.\nS46 JABFP November–December 2004 Vol. 17 Supplement http://www.jabfp.org\ncopyright.\n on 12 June 2026 by guest. Protected byhttp://www.jabfm.org/ J Am Board Fam Pract: first published as 10.3122/jabfm.17.suppl_1.S43 on 1 December 2004. Downloaded from \n\nendometriosis empirically in carefully screened\nwomen. Beyond NSAIDs and COX-2-specific in-\nhibitors, there are several medications that may\nhelp. Invasive procedures and surgical cures should\nbe reserved for those who are not improved by the\nalgorithms presented here.\nReferences\n1. Zondervan KT, Yudkin PL, Vessey MP, Dawes MG,\nBarlow DH, Kennedy SH. Prevalence and incidence\nin primary care of chronic pelvic pain in women:\nevidence from a national general practice database.\nBJOG 1999;106:1149 –55.\n2. Beard RW. Chronic pelvic pain. BJOG 1998;108:\n8 –10.\n3. Neinstein LS. Adolescent health care: a practical\nguide, 4th ed. Baltimore: Lippincott Williams &\nWilkins; 2002.\n4. Coco AS. Primary dysmenorrhea. Am Fam Physician\n1999;60:489 –96.\n5. Lifford KL. Diagnosis and management of chronic\npelvic pain. Urol Clin North Am 2002;29:637– 47.\n6. Akin MD, Weingand KW, Hengehold DA, Goodale\nMB, Hinkle RT, Smith RP. Continuous low-level\ntopical heat in the treatment of dysmenorrhea. Ob-\nstet Gynecol 2001;97:343–9.\n7. Thomas M, Lunden T, Bjork J, Lundstrom-\nLindsbedt V. Pain and discomfort in primary dys-\nmenorrhea is reduced by pre-emptive acupuncture\nor low frequency TENS. Eur J Phys Med Rehabil\n1995;5:71– 6.\n8. Dawood MY, Ramos J. Transcutaneous electrical\nnerve stimulation (TENS) for the treatment of pri-\nmary dysmenorrhea: a randomized crossover com-\nparison with placebo TENS and ibuprofen. Obstet\nGynecol 1990;75:656 – 60.\n9. Helms JM. Acupuncture for the management of pri-\nmary dysmenorrhea. Obstet Gynecol 1987;69:51– 6.\n10. Gokhale LB. Curative treatment of primary (spas-\nmodic) dysmenorrhea. Ind J Med Res 1996;103:\n227–31.\n11. Harel Z, Biro FM, Kottenhahn RK, Rosenthal SL.\nSupplementation with omega-3 polyunsaturated\nfatty acids in the management of dysmenorrhea in\nadolescents. Am J Obstet Gynecol 1996;174:1335– 8.\n12. Transdermal nitroglycerine in the management of\npain associated with primary dysmenorrhoea: a mul-\ntinational pilot study. The Transdermal Nitroglyc-\nerine/Dysmenorrhoea Study Group. J Int Med Res\n1997;25:41– 4.\n13. Wilson ML, Farquhar CM, Sinclair OJ, Johnson\nNP. Surgical interruption of pelvic nerve pathways\nfor primary and secondary dysmenorrhoea. Co-\nchrane Database Syst Rev 2000;(2):CD001896.\n14. Sutton CJG, Ewen SP, Whitelaw N, Haines P. Pro-\nspective, randomized, double-blind trial of laser\nlaparoscopy in the treatment of pelvic pain associ-\nated with minimal, mild, and moderate endometrio-\nsis. Fertil Steril 1994;62:696 –700.\n15. Cosson M, Querleu D, Donnez J, et al. Dienogest is\nas effective as triptorelin in the treatment of endo-\nmetriosis after laparoscopic surgery: results of a pro-\nspective, multicenter, randomized study. Fertil Steril\n2002;77:684 –92.\n16. Vercellini P, Frontino G, De Giorgi O, Aimi G,\nZaina B, Crosignani PG. Comparison of a levonor-\ngestrel-releasing intrauterine device versus expectant\nmanagement after conservative surgery for asymp-\ntomatic endometriosis: a pilot study. Fertil Steril\n2003;80:305–9.\n17. Ling FW. Randomized controlled trial of depot leu-\nprolide in patients with chronic pelvic pain and clin-\nically suspected endometriosis. Pelvic Pain Study\nGroup. Obstet Gynecol 1999;93:51– 8.\n18. Barbieri RB. Endometriosis. In: Rakel RE, Bope ET,\neditors. Conn’s current therapy, 2002. 54th ed. Phil-\nadelphia: WB Saunders; 2002.\n19. Luciano AA, Turksoy RN, Carleo J. Evaluation of\noral medroxyprogesterone acetate in the treatment\nof endometriosis. Obstet Gynecol 1988;72:323–7.\n20. Wellbery C. Diagnosis and treatment of endometri-\nosis. Am Fam Physician 1999;60:1753– 68.\n21. Carlson KJ, Miller BA, Fowler FJ Jr. The Maine\nWomen’s Health Study: I. Outcomes of hysterec-\ntomy. Obstet Gynecol 1994;83:556 – 65.\nhttp://www.jabfp.org Managing Pelvic Pain S47\ncopyright.\n on 12 June 2026 by guest. Protected byhttp://www.jabfm.org/ J Am Board Fam Pract: first published as 10.3122/jabfm.17.suppl_1.S43 on 1 December 2004. Downloaded from","source_license":"CC0","license_restricted":false}