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Chronic pelvic pain – Information for GPs

Definition

Intermittent or constant pain in the lower abdomen or pelvis of at least 6 months’ duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.

Red flag symptoms

  • >50 years with persistent / frequent (>12 times per month) symptoms of abdominal distension / bloating, feeling full and /or loss of appetite, pelvic or abdominal pain, increased urinary urgency and / or frequency consider serum Ca125
  • Ca125 > 35 IU/L arrange urgent pelvic USS
  • Refer urgently if suggestive of ovarian cancer

General points

  • There is frequently more than one component to chronic pelvic pain
  • Pain with a cyclical nature is more in-keeping with endometriosis or adenomyosis
  • Alternative causes include: IBS, adhesions from surgery or PID, MSK conditions and psychosomatic conditions

Management

  • Identify contributory factors; PID, endometriosis, IBS, interstitial cystitis, past surgery, abusive sexual experiences
  • Marked cyclical variation of symptoms would support endometriosis or adenomyosis diagnosis
  • Consider trial with hormonal therapy / suppression of ovulation for 3-6m - tri-cycling of COCP (three pill packs back to back, consider a 7d break if break through bleeding starts)
  • Treat any suspicion of infection (better to treat whilst awaiting swab results if in doubt, delayed treatment increases infertility risks and adhesion formation)
  • If PID is suspected, treat as per the North Yorkshire Antimicrobial Policy – PID treatment policy - An alternative regime – oral ofloxacin 400mg twice daily and oral metronidazole 400mg twice daily for 14 days - excellent CKS summary about PID and management options
  • Explore woman’s perceptions about cause of pain
  • Laparoscopy should be regarded as second line investigation, when hormonal therapy and pain management unsuccessful

Investigations prior to referral

  • Chlamydia screening
  • High Vaginal Swab
  • Pelvic USS
  • DON’T perform a cervical smear if outside the screening programme

Desirable information

  • Psycho-social factors relevant to symptoms
  • Expectations of referral and patient counselled about laparoscopy and risks

Information to include in referral letter

  • Describe problem and possible triggers
  • Current contraception / hormonal therapy
  • Details of hormonal therapy and impact on pain symptoms
  • Smear history
  • Examination findings
  • Relevant past medical / surgical history
  • Current regular medication

Patient information

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