Charlotte Pickett, MD

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Pain relief can be life changing for patients with chronic pain, but ob/gyns need to be mindful of how to prescribe medication properly.

Responsible prescribing practices

Chronic pelvic pain is a common chief complaint, accounting for approximately 10% of referrals to a gynecologist, 20% of hysterectomies and 40% of diagnostic laparoscopies.

 The complex and often multifactorial nature of the disorder makes management challenging for patients and providers alike, which can frequently lead to both provider and patient dissatisfaction.

 This straightforward review of the most common etiologies, evaluation, and opioid-sparing management strategies is intended to demystify the disorder and empower providers to improve women’s quality of life through practical, evidence-based strategies.

Chronic pelvic pain has traditionally been defined as noncyclic pain of 6 months duration that localizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back or the buttocks, and is of sufficient severity to cause functional disability or lead to medical care.

 This broadly defined anatomic region necessitates an equally broad differential diagnosis, with potential sources of pain not limited to the genitourinary system. Gastrointestinal, neurological, and musculoskeletal sources of pain, with which the general ob/gyn may be less familiar, must also be considered. Adding to this complexity, chronic pain syndromes usually have a central nervous system (CNS) component: input from peripheral sources is more readily passed along through the spinal cord to higher cortical centers, leading to perceived pain that can appear disproportionate to the peripheral stimulus. This combination of multiple anatomic structures over which no individual medical specialty has comprehensive knowledge, and alterations in central pain processing belie the need for a multidisciplinary approach. 

Neuropsychobiology of chronic pelvic pain 

Historically, the severity of chronic pelvic pain was felt to be directly proportional to the extent of pathology. However, studies using diagnostic laparoscopy have shown that the extent of pelvic pain does not correlate well with the extent of endometriosis or adhesions present in the pelvis.

 This observation is consistent with current thinking about chronic pain syndromes in that, unlike acute pain, chronic pain involves both CNS and peripheral nervous system pathways. Alterations in central pathways are highly dependent on psychosocial influences, with anxiety and stress suspected to amplify the experience of pain, independent of the magnitude of the peripheral stimulus.

 In addition, there is a strong association between a history of physical or sexual abuse and development of chronic pelvic pain. This relationship could be causal, related to sensitization via alterations in central processing, or coincidental. Regardless of the relationship, concurrent treatment of these psychosocial comorbidities plays a key role in treatment success.

Given the prevalence of comorbid anxiety, depression, and sexual abuse with chronic pelvic pain, successful treatment relies heavily upon establishing a trusting, therapeutic relationship with these patients. A small qualitative study of the attitudes of patients with chronic pelvic pain toward their care revealed four main themes, which can be reframed as a useful guide for establishing a productive treatment relationship

Help the patient to feel understood and taken seriously

Emphasize potential explanation(s) for the pain, as much as “curing” it

Providing a sense of personalized care and helping patients to feel understood and taken seriously often translates to a significant amount of face-to-face time, which can be challenging to accommodate in a busy office practice. However, the additional time spent at the initial visit can often be recouped because future visits are shorter and less frequent. In fact, a patient’s favorable impression of the initial visit has been shown to be associated with a higher likelihood of complete resolution of pain.

 Helping patients suffering from chronic pain to feel they are being taken seriously requires special attention, as patients are often sensitized to even subtle messages from providers that their pain is “all in their head.” It is therefore helpful to provide tangible examples to patients of how both central and peripheral pathways are involved in our pain experience, such as the common experience of noting a laceration only long after the injury may have occurred, or times in which a stubbed toe resulted in a surprisingly intense experience of pain.

As is true with most other conditions, the etiology of chronic pelvic pain can be consistently identified through a detailed history and physical exam, provided the starting point is a reasonable list of potential diagnoses. The broad anatomic area that falls under the definition of pelvic pain requires an equally broad list of potential conditions, which can often be overwhelming. Therefore, it may be useful to organize the differential diagnosis anatomically into the uterus, cervix, fallopian tubes, ovaries, vagina, bladder, ureters, rectum, intestines, pelvic bones, pelvic musculature, and pelvic nerves. The character of a patient’s pain may help to further narrow the differential diagnosis, given the two different physiologic pathways that can be involved in pelvic pain: visceral and somatic (Table 1).

While an exhaustive list of etiologies of pelvic pain is too expansive to fully itemize,

 only a handful of conditions account for the majority of chronic pelvic pain, with multiple causes often present concurrently (Table 2).

 For the general ob/gyn, the ability to diagnose and appropriately treat or refer these conditions would make a tremendous impact for most women who suffer from chronic pelvic pain. 

The aforementioned extended time at the initial visit may best be used to collect a detailed history, going back to our training roots and eliciting the seven dimensions of the symptom (Table 3) and to perform a detailed exam. In addition, it is paramount to ask the patient what she thinks her pain may represent. Patients often fear that their pain is due to malignancy or some as-yet-undiscovered and potentially lethal condition. Often, these anxieties can be readily assuaged at the initial assessment by taking the time to explain the rationale for the most likely diagnosis. Failure to identify these concerns can significantly impair further treatment.

Screening for interstitial cystitis quickly identifies a subset of patients who suffer from a non-gynecologic condition that frequently presents with chronic pelvic pain. Urinary frequency is often the first symptom. Evaluating for pain that improves with defecation or onset of symptoms associated with changes in frequency or form of stool will screen for irritable bowel syndrome. Evaluation should also include assessment of the patient’s psychosocial situation, including sexual function, presence of depression, post-traumatic stress disorder, and any history of physical or sexual abuse. The International Pelvic Pain Society (

 available for download in multiple languages.

A careful abdominal exam, which includes light and deep palpation, will identify neuralgias. Single-digit palpation with both flexion and relaxation of the rectus abdominus muscles will distinguish abdominal wall pathology from intra-abdominal sources: focal pain that worsens with engagement of the abdominal muscles is highly likely to be related to the abdominal wall, whereas pain that improves when the rectus abdominus muscles are flexed may suggest a visceral source. Evaluation of spinous processes and paraspinal muscle tenderness along with lower extremity strength, sensation, and range of motion can elucidate additional musculoskeletal sources of pain.

Before starting the pelvic exam, the providers should empower the patient to request a break or ask that the exam be concluded at any time. Provided adequate trust is established between provider and patient, in our experience, very rarely is it impossible to complete pelvic exams in patients with chronic pelvic pain, despite the high prevalence of sexual abuse and trauma in these women. 

Begin the exam with external inspection and test for provoked and unprovoked vulvodynia through light palpation with a Q-tip. A single-digit internal exam with palpation of the urethra, obturator internus, bladder base, rectum, levator ani, anterior and posterior cul-de-sac and uterosacral ligaments, in addition to palpation of the uterus and adnexa is essential to identify the many possible sources of pain. With palpation of each area, it is also important to clarify with the patient if what she is feeling is the same pain she wanted evaluated because pain produced on pelvic exam often is not experienced in daily life.

Pelvic ultrasound is not indicated for all patients but should be considered in the presence of uterine or adnexal tenderness, or if the pelvic exam is limited secondary to patient habitus. Laboratory evaluation is rarely indicated, except to address specific symptoms or exam findings. Diagnostic laparoscopy is common for evaluation of chronic pelvic pain, despite limited data supporting its use. Given the relatively poor correlation between intraabdominal findings at time of laparoscopy and the extent of symptoms, diagnostic laparoscopy should be reserved for patients with known pathology by ultrasound, or in patients in whom endometriosis is suspected, but who do not respond to or cannot tolerate a trial of hormonal therapy. 

Multiple studies have demonstrated the efficacy of a multidisciplinary approach to treatment of chronic pelvic pain.

 The decision to refer for care by another provider should be based on local resources and provider experience. While general ob/gyns are well trained to manage endometriosis, treatment of the other three most common diagnoses-interstitial cystitis/painful bladder syndrome, irritable bowel syndrome, and musculoskeletal disorders-may be outside their purview. In addition, for the subset of patients with other, less common etiologies of chronic pelvic pain, referral to a chronic pelvic pain specialist should be considered. The IPPS maintains a 

 of pelvic pain specialists, searchable by zip-code.

For endometriosis, continuous combined or progesterone-only oral contraceptives (OCs) remain first-line treatment. Setting clear expectations about possible side effects is important, as is counseling patients that it make take 2 to 3 months of treatment for their pain to improve. Patients whose pain doesn’t respond or responds inadequately to initial therapy should be evaluated further with laparoscopy to confirm the diagnosis and potentially relieve symptoms. Once the diagnosis is confirmed, treatment for endometriosis should be primarily medical with either ongoing continuous OCs, or one of several evidence based second-line therapies (Table 4).

Suspected interstitial cystitis should prompt a urinalysis and culture to rule out urinary tract infection and then, if feasible, the patient should be referred to a urogynecologist. These subspecialists are well-equipped to not only make this diagnosis, but also to evaluate and treat commonly related diagnoses, such as overactive bladder syndrome, urinary incontinence, and pelvic organ prolapse. Patients can be given a list of common bladder irritants and asked to sequentially eliminate each from their diet and maintain a symptom diary in preparation for their consultation. A helpful 

 is available from the American Urogynecologic Society. A treatment guide from the American Urological Association may be helpful in cases where referral to a urogynecologist is not possible.

Irritable bowel syndrome is highly likely in patients with chronic pelvic pain who have bowel symptoms. However, as with painful bladder syndrome, it is important to rule out other more serious conditions prior to settling on this diagnosis. “Red flag” symptoms (Table 5) should prompt consideration of alternative diagnoses or referral to a gastroenterologist. In the absence of these concerning symptoms, the ROME II criteria

 can be used to make the diagnosis. A practical treatment guide, including a 

, is available from the American Academy of Family Physicians.  

Musculoskeletal etiologies of pelvic pain are exceedingly common and can be readily elicited by careful exam, as described. While levator ani or obturator internus myalgia can be a primary cause of chronic pelvic pain, pelvic myalgia is more often due to chronic muscle contraction and subsequent injury in response to other painful stimuli. In addition to treating the other source(s) of pain, pelvic physical therapy is highly effective, with one study suggesting that about two-thirds of patients can expect moderate or marked improvement in pain symptoms

 and another demonstrating that patients rated the treatment efficacy as 8/10.

 The American Physical Therapy Association maintains a registry of physical therapists that is searchable by zip code and area of expertise (aptaapps.apta.org/findapt/SearchResults.aspx). 

A significant proportion of patients who report chronic pelvic pain will have physical exam findings in the abdominal wall consistent with a trigger point, which has been defined as a focus of hyperirritability in a tissue that, when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness, and sometimes to referred autonomic phenomena and distortion of proprioception.

 While much controversy continues to surround this phenomenon, a trial of self-massage to the point of moderate discomfort has been proposed as a low-risk, potentially effective intervention. For patients in whom 2 to 3 weeks of self-massage has proven to be ineffective, a trial of trigger point injections could be considered.

 There are many variations in technique, though one example can be found here: https://emedicine.medscape.com/article/1997731-technique. In our clinic, a weekly series of three to four injections of 3 to 5 mL of 0.25% bupivacaine into the area of tenderness in the abdominal wall, low back, or pelvic floor muscles often provides significant relief. If there is no response after the third or fourth injection, consider alternative treatments. 

Given the known role of psychosocial factors in modulating central pain processing, these comorbidities should be treated concurrently with evaluation and treatment of peripheral sources of pain. Delaying management of anxiety, depression, and social stressors until after a trial of treatment of peripheral sources of pain is likely to result in decreased treatment efficacy and can often lead to the patient feeling dismissed. Any plan for referral should be a shared decision with the patient, with the discussion focusing on the role of both peripheral and central pain processing in the patient’s overall pain experience. Developing a referral network of providers with expertise in pharmacologic management of depression, anxiety, and PTSD, as well as provision of counseling services will greatly bolster treatment efficacy and likely provider and patient satisfaction.   

In 2015, there were 20,101 overdose deaths related to prescription pain medications; nearly double the deaths related to heroin.

 We cannot take the opioid epidemic lightly. However, we should not overlook careful prescription of opioids as an option for pain management. Multiple studies have demonstrated that opioids decrease acute pain by about 30%.

 Their lasting effect on chronic pain is much more controversial. Because most placebo-controlled randomized clinical trials evaluating opioids for pain management are ≤6 weeks in duration, there is insufficient evidence to guide opioid prescribing for chronic pain.

Chronic pelvic pain is a complex, often multifactorial condition that afflicts many women and poses a significant challenge to our healthcare system. Evaluation should include a comprehensive history and physical with consideration for gynecologic and non-gynecologic sources of pain. Practical, non-opioid-based treatments exist for the most common causes of chronic pelvic pain, which should be provided in concert with therapy for any co-existing psychosocial stressors. Opioids should be prescribed only after careful consideration and with patient safety in mind. While challenging, treatment of chronic pelvic pain can be rewarding and have a lasting impact on our patients’ quality of life. 

The authors report no potential conflicts of interest with regard to this article.

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Articles

This review discusses the etiologies, evaluations and management strategies for what can often be a frustrating condition for patients.

Making chronic pelvic pain a little less painful

As practicing obstetrician-gynecologists in a safety-net hospital, we strongly support Title X and are dismayed by a proposed federal rule change

threatening to severely compromise it. We are privileged to serve beneficiaries of Title X, the only federal grant program that guarantees contraceptive access for low-income women, and we see the positive impact the program has on their lives and health. In New Mexico, where we practice, a large percentage of women receive services through Title X.

With one of the country’s highest adolescent pregnancy rates and a high rate of medically complex patients, Title X allows New Mexican women of all ages to make positive health choices. 

Enacted in 1970 during the Nixon administration, Title X drew bipartisan support with no dissenting votes in the Senate and only 32 dissenting votes in the House, demonstrating the overwhelming support for family planning as an integral component of preventive health care. The broad base of support came from a shared understanding that greater access to birth control would lead to fewer abortions by reducing unintended pregnancies. 

Since enactment, Title X has become a critical safety net providing comprehensive contraceptive services to underserved women. Providers are required to follow quality guidelines mandating evidence-based practices, including the provision of the full range of FDA-approved methods. Research confirms that Title X centers are more likely than others to provide a broad array of contraceptives, including highly effective long-acting reversible contraceptives (LARC) and to employ protocols that facilitate the initial and continued use of contraception by patients.

The proposed regulatory changes to Title X would severely undermine the program’s success. At risk is care that complies with the Institute of Medicine’s six dimensions of quality: care that is safe, timely, patient-centered, effective, efficient and equitable. The proposed binding rule restricts providers’ ability to offer the evidence-based contraceptive care and reproductive health counseling known to result in improved health outcomes.

Although evidence is clear that abortion rates are lowest in regions that invest in family planning services, this ill-conceived rule change promotes less effective contraceptive methods and reduces access to abortion. We explain only a few of the many damaging components of the rule: 

The rule undermines access to comprehensive contraception through several mechanisms. One is the removal of the requirement for provision of “medically approved” family planning methods. In contrast to the current requirement, it would allow for exclusion of contraceptive methods based on grantee bias, limiting methods provided. Another is the provision of funds to faith-based entities that promote fertility awareness and abstinence. The rule change would open the door for ideologically-driven entities that oppose abortion and most forms of contraception-for example, so called “crisis pregnancy centers”-to become Title X grantees, offering medically inaccurate information and a single form of contraception, i.e., natural family planning. The rule elevates natural family planning and abstinence counseling to a program priority and excludes reference to evidence-based contraception guidelines.

The rule creates burdensome requirements intended to block federal funds to Planned Parenthood. It requires Title X grantees to create additional financial and physical separation of contraception and abortion services. The rule targets centers that provide both Title X family planning services and non-federally funded abortion services, forcing clinics to stop providing abortion care or to shutter their Title X family planning component. In a similar change, when Texas excluded abortion providers from its family planning program in 2013, the number of contraceptive prescriptions, provision of LARC and number of women served by the program dropped dramatically. 

The rule restricts non-directive pregnancy options counseling and abortion referral: The most explicit anti-abortion components of the rule egregiously violate the patient-provider relationship and limit access to reproductive health care. Title X providers could not encourage, promote or “present” the option of abortion unless the patient had already chosen to terminate the pregnancy and explicitly requested a referral. In that case, a physician may, but is not required, to give her a list of providers, all of whom must offer prenatal care but only some of whom may also provide abortion. The physician may not tell the patient which providers on the list provide both abortion and prenatal care, even if she explicitly asks. If the patient has not made up her mind but requests information regarding abortion referral, the provider may only give her a list of providers who offer prenatal care. This “gag” component violates providers’ ethical duty to impart complete, unbiased, and accurate information and is counter to the quality-care principles of the Institute of Medicine.

The rule undermines adolescents’ confidentiality: Under current rules, Title X providers must offer confidential services to adolescents. The proposed rule requires providers to certify that they encourage family participation in minors’ decisions to seek family-planning services, including required documentation of specific actions taken to encourage family involvement. Because this requirement would undoubtedly deter many minors from seeking care, it runs counter to our national goal of reducing the high rate of teen pregnancy and sexually transmitted infections.

In addition, the dense 31-page document outlining the proposed rule contains vague and confusing language. Struggling to understand what is and is not permissible, providers are apt to err on the side of a more conservative interpretation, lest they inadvertently violate the rule. If authorized, this rule would make effective birth control far less accessible to low income women-including women of color-and would therefore exacerbate the socioeconomic and racial health inequities tarnishing American society. 

Title X has had an enormous positive impact on women’s health. Twenty percent of women in the United States who receive contraceptive services obtain them from a Title X-supported clinic. Consequently, in the past two decades Title X has averted nearly 20 million unintended pregnancies and 9 million abortions. The program has saved three tax-payer dollars for every dollar invested.

The Centers for Disease Control and Prevention heralded family planning as one of the top 10 public health achievements of the 20

century. Family planning has led to improved health outcomes for infants, children, and adult women and has provided new social and economic opportunities for women.

The comment period for the rule changes ended on July 31, 2018. The American College of Obstetricians and Gynecologists, along with 40 of its state Sections-including New Mexico ACOG-submitted formal comments to the Department of Health and Human Services detailing all these concerns on behalf of women’s health care providers. Many other leading medical organizations also lent their expertise to oppose the rule, and we’re hopeful the Administration will take heed. In the meantime, while we wait to hear the decision on final rule language, as ob/gyns, we must take our place in the vanguard, continuing to honor our human-rights charge of empowering women, families and societies through access to family planning.

Disclaimer: This guest editorial does not necessarily reflect the views of all members of the editorial staff or the board of 

1. Compliance with Statutory Program Integrity Requirements, 83 Fed. Reg. 25502 (June 1, 2018) (to be codified at 42 CFR Part 59).  Accessed at 

https://www.gpo.gov/fdsys/pkg/FR-2018-06-01/pdf/2018-11673.pdf

2. The Title X Family Planning Program in New Mexico.  National Family Planning and Reproductive Health Foundation.  Accessed 8-19-18 at 

https://www.nationalfamilyplanning.org/file/impact-maps-2017/NM.pdf

3. Mia R. Zolna & Jennifer J. Frost, Guttmacher Inst., 

Publicly Funded Family Planning Clinics in 2015: Patterns and Trends in Service Delivery Practices and Protocols

 at 30, 35 (2016).  Accessed 8-19-18 at 

4. Gavin L, Moskosky S, Carter M, et al.  Providing Qualify Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs, MMWR 2014;63(4)1-54.  Accessed 8-19-18 at 

5. Title X: Three Decades of Accomplishment. The Guttmacher Report on Public Policy (2001). Accessed 8-19-18 at 

6. CDC:  Achievements in Public Health, 1900-1999:  Family Planning  

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4847a1.htm

Proposed changes to the regulations threaten the preventive health care benefits for women and families that the program was originally created to provide.

Author | Charlotte Pickett, MD

Articles

Responsible prescribing practices

Making chronic pelvic pain a little less painful

Don’t mess with Title X, vital for women’s health