Page 241 Guide to Pain Management in Low-Resource Settings

Chapter 30

Dysmenorrhea, Pelvic Pain, and Endometriosis

Susan Evans

Case report • Regular daily gentle exercise should be encour-
aged to help reduce pain levels.
A 25-year-old married woman presents with pelvic pain • Her headaches should be managed.
on most days each month, especially during the time of • Th e decision to refer her to a surgeon will depend
her period. She suff ers crampy period pain before and on whether her period pain becomes unmanage-
during her period, sharp stabbing pains that come at able or she has diffi culty becoming pregnant. It
any time and wake her at night, bladder symptoms (uri- will also depend on the surgical skills available.
nary frequency, urgency, and nocturia), headaches, and
dyspareunia (painful sexual intercourse). How frequent is pelvic pain?

What are the treatment options? Pelvic pain is underreported, undertreated, and under-
estimated throughout the world. It aff ects approximate-
Th is woman has chronic pelvic pain, with a combina- ly 15% of all women aged 18–50 years. Although it is
tion of diff erent types of pain, and she probably has en- complex to treat, the improvement in quality of life that
dometriosis. For pain control she will need treatment can be achieved is very rewarding. Most women have
for each type of pain: more than one type of pain. Th eir symptoms include
• Th e oral contraceptive pill and a nonsteroidal an- any, or all of:
ti-infl ammatory drug (NSAID) are good fi rst-line • Dysmenorrhea
options for her period pain. If the pain persists, • Dyspareunia
and high-level laparoscopic surgery to remove • Neuropathic pain
endometriosis is not available, then continuous • Bowel dysfunction
progestogen or a levonorgestrel intrauterine de- • Bladder dysfunction
vice are options. • Vulval pain
• Amitriptyline starting at 10 mg at early evening, • Bloating
daily, and increasing slowly as tolerated up to 25 • Chronic pelvic pain
mg daily could be prescribed for her sharp stab- Frequently, their pain symptoms have been present
bing pains and the bladder symptoms. for years without diagnosis or management. Th e pain
• A careful history should identify dietary triggers aff ects their education, employment, relationships, self-
for her bladder symptoms and the cause of her esteem, general wellbeing, sleep and sometimes fertility,
dyspareunia (see below). so it is important to realize that patients needs emotional
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 229
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent
verifi cation of diagnoses and drug dosages. Th e mention of specifi c pharmaceutical products and any medical procedure does not imply endorsement or
recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.