Persistent Pelvic Pain (women)

Overview

These guidelines have been written by Dr. Kelly Haldane (O+G registrar) and Miss Jessica Preshaw (Consultant gynaecologist, NBT)

Flow diagram for Persistent Pelvic Pain (women) care pathway.

Who to refer

Persistent or chronic pelvic pain is any type of pain in the lower abdomen, constant or intermittent, occurring for at least 6 months.

The mechanisms behind chronic pain are complex and there is often interplay between physical, psychological and social factors. It is associated with depression, anxiety, poor sleep, and reduction in mobility. It can negatively affect work and social functioning including relationships.

Please refer the following patients to a general gynaecology clinic:

• Women who feel that they have not had an adequate explanation of their pain in primary care
• Patients with uncontrolled pain despite initial treatment (trialled for 3-6 months)
• Frequent attenders to both GP and emergency services
• Patients at risk of self-harm
• Please consider referring anyone with red flag symptoms under the 2 week wait pathway (see below)

Red Flags

• Bleeding per rectum
• New bowel symptoms over 50 years of age
• New pain after the menopause
• Pelvic mass (not fibroids)
• Suicidal ideation
• Excessive weight loss
• Irregular vaginal bleeding over 40 years of age
• Postcoital bleeding

Please refer to the Gynae 2WW or Lower GI 2WW pathway as appropriate

Before referral

1. Assess for depression and/or anxiety if appropriate² 

Ask the patient:

• During the last month, have you often been bothered by feeling down, depressed or hopeless? 
• During the last month, have you often been bothered by having little interest or pleasure in doing things?

Consider completing:

Patient Healthy Questionnaire (PHQ-9)

Hospital Anxiety and Depression Scale (HAD) 

2. Ask the woman to record her symptoms  

Request that she complete a daily pain record for 2-3 menstrual cycles (or for 2-3 months if her cycle is not regular). This will be particularly helpful if she is referred and ideally be completed prior to her appointment². This may also be helpful within primary care to assess response to initial management. Suggest also documenting other major symptoms experienced like heavy bleeding, tiredness, and change in mood. There are some useful apps to help record this such as:

• Flo Period Tracker
• Clue
• Period Calendar 

3. Assess for IBS and interstitial cystitis^1,3

Use the Rome III criteria for IBS:

Continuous or recurrent abdominal pain or discomfort on at least 3 days a month in the last 3 months, with the onset at least 6 months previously, associated with at least two of the following:

• Improvement with defecation
• Onset associated with a change in frequency of stool
• Onset associated with a change in the form of stool

Consider interstitial cystitis if pelvic pain is associated with urgency, frequency and nocturia. Pain characteristically is exacerbated by bladder fullness and temporarily relieved on emptying.

4. Request a pelvic ultrasound (request routinely unless Ca125 performed and >35, see below under “Consider Ca125”) 

This may help exclude adnexal masses such as ovarian cysts or evidence of adenomyosis. 

If a Ca125 has been performed with result is >35 please request the ultrasound (pelvic and abdominal) urgently, all other ultrasounds may be requested routinely. 

5. Consider sexual health screening  

Offer sexual health screening to all women who are sexually active with chronic pelvic pain in particular to check for chlamydia and gonorrhoea.

6. Consider Ca125

Women reporting any of the following symptoms persistently or frequently (more than 12 times per month) should have a Ca125 performed.

• Bloating
• Early satiety
• Pelvic pain
• Urinary urgency or frequency

In particular, women over the age of 50 years who describe any new IBS symptoms should be offered this blood test.¹

7. Consider referral to a physiotherapist specialising in pelvic health

If the symptoms described sound musculoskeletal in origin please consider referring them to a physiotherapist that specialises in pelvic health.

Patients with pelvic health problems (specifically related to pelvic floor and bladder issues) can self refer directly to physiotherapists at Weston and St. Michael’s Hospital. Please see the Pelvic health physiotherapy page in Remedy

Management options to consider

Medical¹

• Analgesics (paracetamol or NSAID, alone or in combination)
• Hormonal treatment (combined pill or a progestogen such as the progestogen-only pill, implant (Nexplanon®), injectable (Depot-provera® or Sayana Press®), or levonorgestrel intrauterine system (Mirena®))
  • This can improve pain not just for patients with endometriosis and therefore worth trialling even if their pain is not cyclical.
• Neuropathic agents (when neuropathic pain is suspected)
• Antidepressants
• Antispasmodics or antidiarrheal medication ³ 

Non-Medical 

• Exercise referral scheme
• Mindfulness and meditation
• Social prescribing
• Amendments to diet/ nutrition e.g. trial of exclusion diet
• Talking therapies/ counselling
• Western accupuncture⁴
• Yoga⁵ 

Please note these guidelines are limited towards women. However for men with chronic pelvic pain please consider referring them to Unity. See Chronic Pelvic Pain (men)

Referral

Refer to General Gynaecology via eRS

Resources

Link to Remedy sections:

• IBS
• Endometriosis
• Pain management: this fibromyalgia page has a section on neuropathic agents

Patient information/ Leaflets:

• NHS choices
• Pelvic Pain Support Network
• The Pain Toolkit
• Action on Pain 
• Endometriosis UK
• IBS Network
• Cystitis and Overactive Bladder foundation
• Women’s Health
• RCOG patient information leaflet

Evidence:

1. RCOG Green-top Guideline No. 41 The Initial Management of Chronic Pelvic Pain
2. NICE Guidance Depression in adults: recognition and management
3. NICE Guidance Irritable Bowel Syndrome in adults: diagnsosis and management
4. Xu Y, Zhao W, Li T, Zhao Y, Bu H, Song S. Effects of acupuncture for the treatment of endometriosis-related pain: A systematic review and meta-analysis. PLoS One. 2017;12(10):e0186616. doi:10.1371/journal.pone.0186616
5. Gonçalves A, Barros N, and Bahamondes L. The Practice of Hatha Yoga for the Treatment of Pain Associated with Endometriosis. The Journal of Alternative and Complementary Medicine. 2017.45-52.http://doi.org/10.1089/acm.2015.0343

Special thanks for reviewing these guidelines before publication to:

• Oliver O’Donovan, Consultant gynaecologist at St. Michael’s Hospital, UHB
• Charlotte Steeds, Consultant in anaesthesia and pain medicine, UHB
• Rob Adams, GP Clinical Lead for the Referral Service

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.