Page 243 Guide to Pain Management in Low-Resource Settings

Dysmenorrhea, Pelvic Pain, and Endometriosis 231

10 mg daily, or depot medroxyprogesterone acetate to (start with 10 mg at night, increase slowly to 10–50 mg
achieve amenorrhea). If referral to a well-equipped hos- at night).
pital is an option, surgery, preferably laparoscopy, to di- Many women with bladder symptoms develop sec-
agnose and remove endometriosis, if medical treatments ondary pelvic fl oor dysfunction with dyspareunia and
have failed, would be indicated. Hysterectomy is only in- severe muscular pelvic pain. If pain persists, consid-
dicated if the patient is older and her family is complete. er cystoscopy with hydrodistension. All medications
Conserve the ovaries where possible in premenopausal should be avoided in pregnancy, if possible. Also note
women. Ovarian endometriomas can usually be treated that hydroxyzine is contraindicated in epileptics.
with cystectomy rather than oophorectomy.
How can I treat sharp, stabbing pains?
How can I treat ovulation pain? Sharp, stabbing pains are usually a form of neuropathic

Normal ovulation pain should only last for 1 day, oc- pain. Treatment includes neuropathic pain medications
curs 14 days before a period, and changes sides each (e.g., amitriptyline 5–25 mg in the early evening, gaba-
month. Management options include an NSAID when pentin 100–1200 mg daily), regular sleep, regular exer-
pain occurs, an oral contraceptive pill to prevent ovu- cise (start with regular low-level exercise to avoid initial
lation, or continuous norethisterone 5–10 mg daily to worsening of pain), and stress reduction. Start all medi-
induce amenorrhea. If more than the primary care lev- cations at a very low dose and increase slowly. Where
el is available, and pain is severe or always unilateral, a high-level surgical skills are available, excision of endo-
laparoscopy with division of adhesions and removal of metriosis lesions, if present, can sometimes improve the
endometriosis is indicated. An ovary should only be pain, although frequently this type of pain continues af-
removed if severely diseased, and the patient’s fertility ter surgery.
needs have been discussed and carefully considered.
How can I diagnose the cause of dyspareunia?
How can I treat a woman with pelvic Dyspareunia (painful intercourse) may be the most dis-
pain and bladder symptoms?
tressing symptom for many women, as it interferes with
Many women with pelvic pain describe frequent urina- the relationship they have with their husband. She may
tion, nocturia, pain when voiding is delayed, suprapubic feel that she is letting her husband down when she is
pain, vaginal pain, dyspareunia, or the feeling of having unable to have intercourse due to pain, and he may feel
a urinary tract infection. Th is feeling is often due to in- that she is avoiding intercourse because she no longer
terstitial cystitis of the bladder. Th ere may be a history loves him. It is important to identify the cause of the
of frequent “urinary tract infections” but with negative problem:
urine culture. First, exclude urine infection, chlamydia, • Examine the vulva visually for abnormalities (in-
and gonococcal or tuberculous urethritis. Th en ensure fection, dermatitis, lichen sclerosis).
suffi cient fl uid intake to avoid concentrated urine. Iden- • Use a cotton-tipped swab to test for tenderness of
tify and avoid dietary triggers if present. Common trig- the posterior fourchette, even if it looks normal
gers include coff ee, cola drinks, tea (including green (to check for vulvar vestibulitis).
tea), vitamins B and C, citrus fruit, cranberries, fi zzy • Use one fi nger in the lower vagina to push back-
drinks, chocolate, alcohol, artifi cial sweeteners, spicy wards (to check for pelvic fl oor muscle pain or
foods, or tomatoes. Peppermint and camomile teas are vaginismus). Use one fi nger to push anteriorly (to
usually acceptable. If food triggers are present, pain usu- check for bladder or urethral pain).
ally follows within 3 hours of food intake. Provide in- • Use one or two fi ngers to check the upper vagina
structions about how to manage symptom fl ares (drink for nodules of endometriosis, pelvic masses, or
500 mL water mixed with 1 teaspoon of bicarbonate uterine fi xation. Push the cervix to one side to
of soda. Take a paracetamol (acetaminophen) and an check for contralateral adnexal pain (to check for
NSAID if available. Th en drink 250 mL water every 20 endometriosis, ovarian cysts, pelvic infection, or
minutes for the next few hours). For symptom control, adhesions).
try amitriptyline 5–25 mg at night, oxybutynin (start • Use a speculum to look for cervicitis, vaginal in-
with 2.5 mg at night, increase slowly to 5 mg three times fection, vaginal anomaly, or endometriotic nod-
a day), or hydroxyzine, especially for those with allergies ules in the posterior vaginal fornix.