Chronic Pelvic Pain Guidance for GPs
Information on assessment and management of chronic pelvic pain, including endometriosis, IBS and pelvic inflammatory disease.
Chronic Pelvic Pain Referral Guidance
The multifactorial nature of Chronic Pelvic Pain makes it difficult to triage but as a general rule patients presenting for the first time in later life and those with atypical symptoms normally warrant hospital referral.
Women should be offered appropriate analgesia to control their pain even if no other therapeutic manoeuvres are yet to be initiated.
Known or Suspected Cases of Endometriosis
Pelvic pain which varies markedly over the menstrual cycle is likely to be attributable to a hormonally driven condition such as endometriosis. Options for management for suspected but unconfirmed cases while awaiting Gynaecology assessment include the following:
- Continuous course of combined oral contraceptive eg tricyling for 3/12, for patients without contraindications.
- progesterone-only pill
- oral progestogens daily
- Some patients get relief with insertion of levonorgesterol- releasing intrauterine system.
- Gonadotrophin releasing hormone (GnRH) analogues for management of severe pain despite medical treatments in conjunction with remote hospital clinic. Consider moving to a 3-month duration injection once patient tolerance of GnRH analogues has been established. Addback hormone replacement therapy (HRT) should be considered, once pain is controlled if GnRH analogue treatment is to be continued beyond 3-6 months.
Irritable Bowel Syndrome
www.bsg.org.uk provides guidance on management of IBS and may be useful in elucidating and alleviating symptoms of pelvic pain in patients with a normal gynaecologic examination.
Women with IBS should be offered a trial with antispasmodics. Women with IBS should be encouraged to amend their diet to attempt to control symptoms.
- Certain symptoms are considered ‘red flag’ and should be highlighted in referrals for CPP
- Bleeding per rectum
- New bowel symptoms over 50 years of age
- New pain after the menopause
- Pelvic mass
- Suicidal ideation
- Excessive weight loss
- Irregular vaginal bleeding over 40 years of age
- Postcoital bleeding
Suspected Pelvic Inflammatory Disease
All sexually active women with chronic pelvic pain should be offered screening for sexually transmitted infections (STIs). Suitable samples to screen for infection, particularly Chlamydia trachomatis and gonorrhoea, should be taken if there is any suspicion of PID.
If PID is suspected clinically, this condition is best managed in conjunction with a genitourinary medicine service in order that up-to-date microbiological advice and contact tracing can be arranged.