Page 242 Guide to Pain Management in Low-Resource Settings

230 Susan Evans

as well as physical support. Th is chapter will provide an problems to allow patients more energy to cope with
overview of pharmacological and non-pharmacological their pain:
interventions for eff ective pelvic pain control. • Premenstrual syndrome (PMS), depression, anxi-
ety
How can I assess the cause of pain • Menorrhagia
in a woman with pelvic pain? • Acne
• Constipation
Pelvic pain is assessed with a history, an examination, • Poor nutrition, poor posture, lack of exercise
and special investigations. • Other pain conditions, including migraine

History How can I treat dysmenorrhea
on day 1–2 of the menstrual cycle?
Ask about the date of the last period in case of pregnan-
cy, and make a list of each pain or symptom the patient Pain at this stage of the cycle is usually uterine pain.
has. For each pain, ask her to describe what it feels like, Management options at the primary care level include
where it is, when it occurs, how many days she has it monophasic oral contraceptive pills, such as 20–35 μg
per cycle, and what aggravates or relieves it. Ask about ethinyl estradiol with 500–1,000 μg norethisterone or
bladder symptoms (nocturia, frequency, urine infec- 150 mg levonorgestrel, as well as pain medication. Th e
tions, urgency), ask about bowel function (constipation, pain medication of fi rst choice should be an NSAID tak-
diarrhea or bloating, pain opening her bowels during en early on in the episode of pain, such as ibuprofen at
her period), ask about pain with movement and pain in a dose of 400 mg initially and then 200 mg three times
other areas of the body (e.g., migraine or muscle tender daily with food. For moderate or severe pain, opioids
points), ask whether intercourse is painful, and ask how should be off ered. Nonpharmacological options include
many days a month she feels completely well. hot or cold packs over the lower abdomen, Vitex agnus
castus (chasteberry) 1 g daily (avoid if pregnant; ineff ec-
Examination tive if on oral contraceptive pills), vitamin E (400–500
Assess the patient’s general well-being (depression, pos- IU natural vitamin E from 2 days before period until day
ture, and nutrition), the abdomen (for sites of pain, ten- 3) and zinc 20 mg (as chelate) twice a day. Traditional
derness, peritonism, or masses), the vulva (for tender- Chinese Medicine (acupuncture and herbal therapies)
ness, skin lesions, or vulval infection), the pelvic fl oor are also popular, but they should only be recommended
muscles (for tenderness and spasm), the vagina (for if aff ordable and if the patient has a positive attitude.
nodules of endometriosis posterior to the cervix or in Many women with severe dysmenorrhea become
the rectovaginal septum, or congenital anomalies), and fearful as their period approaches. Th ey fear pain that
the pelvis (for uterine or adnexal masses, pregnancy). they cannot control. By providing them with strong an-
Vaginal examination is rarely necessary in virgins. algesics to control severe pain if it occurs, this anticipa-
tion of pain can be reduced and they can regain control
Investigation of the pain. Th erefore, “on-demand” doses of analgesics

Exclude pregnancy, including ectopic pregnancy, screen should be provided.
for sexually transmitted diseases if appropriate, and take
a cervical smear if available (unnecessary for virgins). How can I treat prolonged dysmenorrhea?
Could the patient have endometriosis?
Ultrasound may show an endometrioma, but it is often
normal, even with severe endometriosis. Dysmenorrhea (painful cramps) for more than 1–2
days is often due to endometriosis, even in teenagers.
How can I plan treatment A woman with endometriosis also has a more painful
for pelvic pain? uterus than other women. She thus has two causes for
her pain. Management options include on the prima-
Th e treatment recommended depends on the symp- ry care level all the treatments used for dysmenorrhea
toms present. Most women will have more than one above, a levonorgestrel intrauterine device, continuous
pain symptom. Plan a treatment for each separate pain progestogen (norethisterone 5–10 mg daily, dydroges-
symptom. Remember to treat any coexisting health terone (a synthetic hormone similar to progesterone)