History of Present Illness

A 27-year-old woman returns to your office with severe pelvic pain that has persisted since her initial visit three months ago. Assessment at that time identified dysmenorrhea and pelvic floor myalgia as the leading pain generators. Screening for depression was negative. Pelvic ultrasound did not show uterine or adnexal abnormalities. The treatment plan included 84-day extended-cycle birth control pills, a referral for pelvic physiotherapy, and a high-dose regimen of a nonsteroidal anti-inflammatory drug (NSAID). The patient returned three months later with fewer bleeding days and improvement in pain, from 10 out of 10 to 8 out of 10. She had not made an appointment for physiotherapy. The patient was encouraged to continue her current regimen and urged to begin physical therapy, with follow-up planned in two to three more months.

The patient called the practice two weeks later asking for an urgent appointment and was scheduled the following day. At this visit she reported no improvement in pain since her visit one month ago. She has not had any further vaginal bleeding. She found physical therapy intolerably painful and could not get through the first session. It hurt so much that she took a 10 mg oxycodone pill left over from her partner’s postoperative prescription. The oxycodone was very effective in reducing her pain, but has worn off. She says she is “miserable” and requests a prescription for oxycodone.

Review of systems is positive for occasional bloating and constipation. The patient has smoked one pack of cigarettes per day since age 15 and drinks alcohol with friends over the weekend. She denies use of other drugs. She has no other medical problems or prior surgeries.

Physical Examination

Temperature

98.6°F (37.0°C)

Pulse

72 beats/min

Blood pressure

122/70 mmHg

Respirations

18 breaths/min

Body mass index (BMI)

24.8 kg/m²

General

Well-developed, well-nourished woman in no acute distress.

Abdomen

Soft, no masses, mild lower quadrant tenderness without rebound or guarding. Normal bowel sounds.

External genitalia

Unremarkable.

Vagina

No lesions. Scant discharge. Tight, tender bands of pelvic floor muscles bilaterally, which when palpated reproduce the patient’s pain.

Cervix

Nulliparous. No bleeding or discharge.

Bimanual exam

Limited by tenderness.

How Would You Manage This Patient?

The patient has been seen three times in the past three months for severe pelvic pain likely from dysmenorrhea and pelvic floor myalgia. Her dysmenorrhea has been adequately managed with extended-cycle birth control pills. Her pelvic floor myalgia has not been treated due to a delay, and then intolerance of physical therapy.

Rather than focusing exclusively on the patient’s request for oxycodone, the visit focused on supporting adherence to the recommended course of treatment and establishing realistic expectations for symptom improvement. The patient was counseled that severe pelvic floor myalgia may require 12 or more weeks of skilled pelvic physical therapy once or twice a week. There are no more rapid alternatives for restoring normal muscle tone and flexibility, and for correcting any contributing biomechanical issues. She was counseled that opioid medications are effective for acute pain and have potential harms when used for chronic pain, particularly constipation, nausea, somnolence, tolerance requiring higher doses over time to achieve the same analgesia, chemical dependence, and opioid addiction [1]. In light of the patient’s use of her partner’s oxycodone, she was counseled that it is not safe to use medications prescribed for other individuals.

Short-term use of opioid medication may be necessary to manage this patient’s reactive muscle pain after physical therapy visits. Screening for addiction risk is indicated in all patients, and may be particularly useful in light of this patient’s chronic tobacco use and potential nicotine addiction. The patient’s history of prior opioid use should be obtained, and her current use should be verified by performing a baseline urine drug screen (UDS) and searching available prescription monitoring registries.

If the patient is at low risk for opioid addiction, and additional analgesia is needed to make the physical therapy more tolerable, a short-term regimen can be prescribed according to evidence-based guidelines. The high-dose NSAIDs should be continued to provide baseline analgesia, and a short-acting opioid in doses up to 40 morphine milligram equivalents (MME) prescribed for pain exacerbations. The recommended starting dose of oxycodone is 5–15 mg (7.5–22.5 MME) every 4–6 hours [2]. Patients receiving opioid medications should not use other central nervous system depressants, such as benzodiazepines or alcohol, and cytochrome P450 3A4 inhibitors that impede opioid metabolism, such as amiodarone, cimetidine, fluoxetine, grapefruit juice, protease inhibitors, azoles, and macrolide antibiotics other than azithromycin. The patient should be advised that the opioid prescription is just one part of a comprehensive treatment plan. Adherence to the NSAID regimen, menstrual suppression, and physical therapy will be required for the patient’s pain to improve and should be made a condition for prescribing the opioid medication.

After three months of physical therapy the patient’s pelvic floor myalgia is greatly improved. She reports fewer flares, and only needs to take oxycodone once a week after a physically active day. A search of available prescription registries shows she has filled no other prescriptions for controlled substances. The oxycodone is refilled, adjusting the number of pills downward to accommodate her current use. She agrees with the plan to discontinue the oxycodone at her next follow-up visit and understands that a repeat urine drug screening will become necessary if opioid use becomes chronic (six months or longer) or if there is a suspicion of nonprescription drug use.

Initial Screening and Monitoring

The epidemic of prescription drug abuse in the United States has many negative effects on women’s health [3]. When a patient comes to the office asking for an opioid prescription, it can be difficult to determine the root cause of the request. Frustration and urgency to find relief are normal reactions to severe pain, but these behaviors can raise clinicians’ concerns about drug-seeking behavior. A few simple approaches can be used to rule out current use of illicit substances and misuse of prescription medication, and to stratify a patient’s risk of future addiction.

First, a patient’s current prescriptions for opioid and other controlled medications can be confirmed using searchable web-based prescription monitoring systems. Once an opioid medication is prescribed, the same monitoring systems can be checked periodically to confirm there are no other controlled substance prescriptions.

Second, a UDS can establish the absence of common drugs of abuse before an opioid is prescribed. A UDS is not commonly required before prescribing opioids for acute pain, as in the case of major surgical procedures or traumatic injuries. In contradistinction, UDS is an evidence-based recommendation before prescribing opioids for pain in the ambulatory setting and is generally repeated annually or semiannually, or when the patient’s behavior raises concern about medication misuse or substance abuse [1].

Third, risk stratification is important for preventing opioid abuse and misuse. Many screening instruments exist for opioid risk assessment [4]; however, evidence of limited reliability and validity does not support their routine use [1]. Stratification can be done instead using clinical characteristics. High-risk features include pain involving more than three regions of the body without objective signs; severe pain exacerbations and limited coping strategies; major psychological disorders; younger age (<45 years old); resistance to participation in multimodal therapy; and severe limitations in usual activities. Patients with a history of drug abuse, misuse, addiction, diversion, dependency, alcoholism, tolerance with hyperalgesia, or HIV-related pain are also at high risk [1].

Pain Medication Agreements and Best Practices

In this case, the patient was able to participate in multimodal therapy, which effectively reduced her pain and her need for opioid medication. When patients require continuation of opioid medication for chronic pelvic pain, periodic prescription monitoring and UDS testing are safeguards for detecting and preventing opioid abuse and misuse. In addition, many practices routinely use long-term opioid agreements to align treatment expectations. Examples are publicly available and include a common set of statements signed by the patient, her physician, and a witness (Box 1.1). Failure to adhere to the agreement results in discontinuation of opioid therapy [5]. One study in a primary care clinic followed patients with a variety of chronic pain syndromes who were placed on opioid contracts and reported 63 percent adherence with median follow-up of 22.5 months. Seventeen percent of the contracts were canceled for noncompliance or substance abuse, and the other 20 percent of patients discontinued the use of opioid medication [5].

The Centers for Disease Control (CDC) published guidelines for opioid prescribing for chronic pelvic pain in 2016 [6], and the CDC website provides open access to a dozen clinical tools supporting evidence-based practice (www.cdc.gov/drugoverdose/prescribing/clinical-tools.html, accessed 5/3/2017). Best practices for chronic opioid prescribing expand beyond the clinician’s role to a full-scale reengineering of the ambulatory care setting, similar to models of care for other complex chronic conditions. The Robert Wood Johnson Foundation funded a program called “Primary Care Teams: Learning from Exemplar Ambulatory Practices” (LEAP). A study of team-based approaches to improve chronic opioid therapy management in 30 LEAP clinics across the United States identified six building blocks for optimizing care. Of these components opioid contracts, registry tracking and planned visits with patients may be the most feasible to implement in Ob/Gyn practice [7].

Key Teaching Points

• 
  

  Opioids are not first-line medications for pain in the ambulatory setting, but can be used short term if around-the-clock non-opioid analgesics do not provide adequate relief during pain exacerbations.

  
  
• 
  

  Safe opioid prescribing requires baseline screening for drug abuse or misuse and appraisal of addiction risk.

  
  
• 
  

  Risk stratification relies on clinical characteristics, including a history of prior drug dependence or addiction.

  
  
• 
  

  Urinary drug screens and prescription registry searches should be done before prescribing opioid medications and periodically thereafter if opioid use exceeds six months.

  
  
• 
  

  Pain medication agreements establish a shared understanding of expectations with patients requiring long-term opioid prescribing.

History of Present Illness

A 25-year-old woman, gravida 0, presents with the complaint of painful intercourse. She is sexually active with one male partner with whom she has vaginal-penile intercourse. She complains of pain with insertion of the penis and with deep thrust. She reports trying “different positions” during intercourse, but continues to experience pain. She also notes intermittent pain that she localizes to the anorectal region. She reports a history of sexual assault. She denies any domestic violence and feels safe with her current male partner. She denies a history of pelvic trauma. She denies any other bowel or bladder symptoms.

Her only medication is a combined oral contraceptive pill, which she uses for contraception. She has regular menses, occurring during placebo pills, with five days of flow, and no dysmenorrhea. She has no significant past medical or surgical history. She has no known drug allergies. She reports consistent latex condom use. She has completed college and is working full time. She lives with her male partner. She drinks two alcoholic beverages per week. She denies tobacco and illicit drug use. Her family history is noncontributory.

Physical Examination

General appearance

Well-developed, well-appearing female in no acute distress

Pulse

75 beats/min

Blood pressure

118/64 mmHg

Height

65 inches

Weight

140 pounds

BMI

23.3 kg/m²

Abdomen

Soft, non-distended, non-tender, no masses

External genitalia

Normal appearing. Pubic hair Tanner V. Normal urethral meatus.

Vagina

Normal mucosa. No atrophy, no lesions, no masses, scant clear vaginal discharge (no odor).

Cervix

Normal appearing nulliparous cervix without masses or discharge.

Bimanual exam

No urethral or bladder base tenderness. Bilateral levator ani tenderness. Uterus small, anteverted, mobile, non-tender. Cervix palpably normal and without cervical motion tenderness. No adnexal masses or tenderness bilaterally.

Rectal exam

Normal tone, no masses. Tenderness of the puborectalis musculature is present.

Gonorrhea/chlamydia/trichomonas DNA amplification probes

Negative

Urine pregnancy test

Negative

How Would You Manage This Patient?

This patient has dysmenorrhea and chronic pelvic pain, which impacts her quality of life. A complete history identified no associated gastroenterologic, urologic, or psychiatric symptoms. A urine pregnancy test was negative and sexually transmitted infection screening was negative. A pelvic exam was notable for bilateral levator ani tenderness. The absence of other causes and presence of levator ani tenderness strongly suggest levator spasm as the source of her deep dyspareunia. She was referred for pelvic physical therapy. Three months after starting pelvic floor physical therapy, she reported significant improvement in her symptoms and was able to engage in vaginal-penile intercourse without difficulty.

Levator Ani Spasm Causing Dyspareunia

Evaluation/Examination

Evaluation begins with a comprehensive patient history. Particular attention should be paid to gynecologic, sexual, gastrointestinal, and urinary symptoms. The pain should be characterized in terms of onset, location, radiation, severity, and timing. Provoking or relieving factors should be elicited. Providers should inquire about the impact of certain positions on the pain, as myofascial pain is often aggravated by specific positions and relieved by others. Menstrual history and impact of menses on the pain should be reviewed. A history of trauma such as prior pelvic surgeries, back or hip injuries, and childbirth may also be relevant. A psychosocial history is also important as patients may have other contributing conditions such as depression or post-traumatic stress disorder from history of sexual assault or interpersonal violence. Any prior treatments and their impact on symptoms should be noted.

The physical exam should include assessment of the patient’s abdomen and trunk; pelvic exam including external genitalia, internal genitalia, and pelvic floor musculature; and anorectal exam. The exam has the potential to trigger the patient’s pain and be very uncomfortable. The patient should be allowed to be in control of the exam by communicating that she may ask the examiner to stop at any time. An external genital exam should be performed. The examiner should ask the patient to contract her pelvic floor or bear down. Women with myofascial pelvic pain disorders may have weak musculature, which will be detectable by an asymmetric contraction when bearing down. An anal wink should be elicited to evaluate for other neurologic conditions. A speculum exam should be performed to assess the vaginal mucosa and cervix. Tests for gonorrhea, chlamydia, trichomonas, and yeast can be obtained if appropriate, based on risk factors or physical findings. This is particularly important in sexually active women to rule out an infectious etiology like gonorrhea, chlamydia, trichomonas, or pelvic inflammatory disease. Bimanual exam should include palpation of the urethra, bladder base, cervix, uterus, and adnexa to help rule out other etiologies of pain.

The pelvic floor muscles should be systematically palpated to identify trigger points or contracted muscle bands. Examiners should first insert one finger into the introitus and palpate the bulbocavernosus muscle, located just lateral to the introitus. Next, the superficial transverse perineal muscles should be palpated by moving the finger inferiorly. Last, the levator ani muscle complex should be examined. The levators are the “pelvic floor” surrounding the rectum. Moving medial to lateral, the complex is composed of the pubococcygeus, puborectalis, and iliococcygeus muscles. The examiner may picture the vagina as a face of a clock with the pubococcygeus muscle from 7 to 11 o’clock and 1 to 5 o’clock. The puborectalis is slightly more lateral within the distal vagina (Figure 2.1) and the iliococcygeus is from 4 to 8 o’clock [7]. Each muscle group should be palpated and note taken of whether palpation elicits pain. Trigger points are tender to palpation, and palpation may cause involuntary spasm. With levator ani spasm, palpation of the levators will elicit pain. Unilateral or bilateral tenderness may be present. The patient should be asked to rate the pain throughout the exam and whether palpation of the trigger points reproduces her presenting symptoms. A rectovaginal exam should be performed, noting any decreased tone, masses, tenderness, rectovaginal septum nodularity, or trigger points involving the pubococcygeus and puborectalis muscles.

Figure 2.1 Pelvic bones and muscles of pelvic floor. Anatomic structures are indicated.

(illustration by Joseph Werkmeister)

Pelvic ultrasound is not usually required for the diagnosis of levator ani spasm, but can be useful when ruling out other underlying structural causes of pain such as ovarian cysts or masses and uterine masses. Diagnostic gastrointestinal procedures such as colonoscopy or upper GI endoscopy may be useful if the patient’s history or physical exam suggests a functional or structural gastrointestinal condition.

Key Teaching Points

1. 
   

   ▪ Levator ani spasm is a form of myofascial pelvic pain that may lead to dyspareunia.

   
   
2. 
   

   ▪ Evaluation involves identification of trigger points, tender or taut muscle foci within the levator ani muscle complex, which are signs of levator ani spasm.

   
   
3. 
   

   ▪ Treatment is multifactorial.

   
   
4. 
   

   ▪ First-line therapies include pelvic floor physical therapy, heat, massage, and cognitive-behavioral therapy with vaginal dilator use.

   
   
5. 
   

   ▪ Second-line therapies include pharmacologic therapies such as nonsteroidal anti-inflammatory drugs and muscle relaxants.

History of Present Illness

A 16-year-old adolescent, gravida 0, presents with ongoing lower abdominal cramping pain that worsens with vaginal bleeding. She underwent menarche at age 14 and within six months began having regular monthly cycles with dysmenorrhea. Her pediatrician prescribed nonsteroidal anti-inflammatory drugs (NSAIDs), which initially provided some improvement in her symptoms. Six months later, the patient reported worsening dysmenorrhea and the patient was started on low-dose combination hormonal oral contraceptive pills. After three months, the patient still reported dysmenorrhea, and her pediatrician switched her to extended cycle combined hormonal contraception pills. The patient reports good compliance over the last three months on the new regimen, but reports still experiencing lower abdominal crampy pelvic pain, which worsens with unscheduled bleeding. At times, her pain is so significant that despite taking NSAIDs she has had to leave school early or miss sports practices. She denies dysuria, constipation, nausea, vomiting, fever, and ever being sexually active.

She has no medical problems and has never had surgery. She has no known drug allergies, and her only medications are her combined hormonal contraceptive pill and NSAIDs. She does well academically in school, lives with both parents and two siblings, and denies alcohol, tobacco, or marijuana use. Her family history is significant for endometriosis in her mother, which required infertility treatment to achieve conception.

Physical Examination

General appearance

Well-developed, well-nourished teen who is engaged, is communicative, and appears to be in no acute distress

Pulse

78 beats/min

Blood pressure

108/62 mmHg

Height

65 inches

Weight

130 pounds

BMI

21.6 kg/m²

Abdomen

Soft and non-tender, no masses

How Would You Manage This Patient?

This patient has dysmenorrhea and chronic pelvic pain, which is impacting her quality of life and ability to function despite six months of combined hormonal contraceptives and NSAIDs and therefore needs additional evaluation. A focused history identified no associated gastrointestinal (GI), urologic, musculoskeletal, or psychological symptoms. A urine specimen was collected for pregnancy testing and sexually transmitted infection (STI) screening. Both were negative. After pelvic examination education, consent was obtained from both the patient and her mother, and a pelvic examination was performed. No abnormalities were noted. A pelvic ultrasound identified no anatomic abnormalities.

The patient underwent diagnostic laparoscopy with peritoneal biopsies, coagulation of possible endometriotic implants, and insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS). Pathologic examination of the peritoneal biopsies confirmed endometriosis. Three months after surgery, she reported her symptoms have improved. She is using less NSAIDs and no longer experiencing disruption in school or sports practices.

Adolescent Endometriosis

Dysmenorrhea is the most common gynecologic complaint and the leading cause of school absenteeism among adolescents and young adult women [1]. In epidemiologic studies, 60 to 70 percent of adolescents reported experiencing painful periods and 15 percent reported interruption of their daily activities due to severe menstrual pain [2]. Up to 90 percent of adolescents experiencing dysmenorrhea have primary dysmenorrhea or painful menses without an identifiable etiology [2]. Primary dysmenorrhea may be caused by an overproduction of prostaglandins within the endometrium. Both prostaglandins and leukotrienes are biochemical by-products of ovulation and inflammatory modulators known to cause myometrial contractions and vasoconstriction leading to local tissue ischemia and crampy pain [2]. Secondary dysmenorrhea is painful menses due to an identifiable abnormality, most commonly endometriosis, and the next most common, outflow tract obstructions (Box 3.1) [2]. Types of outflow tract obstructions that present with pain at the time of or shortly after menarche include imperforate hymen, transverse vaginal septum, obstructed hemivagina and ipsilateral renal anomaly syndrome, lower vaginal atresia, cervicovaginal agenesis/dysgenesis, and obstructed uterine horn [3].

The initial evaluation of dysmenorrhea focuses on menstrual history and associated symptoms. A family history of endometriosis should be elicited, particularly in first-degree relatives, and if present should raise clinical suspicion [4]. A pelvic examination is not necessary in patients who have never been sexually active and have a history compatible with primary dysmenorrhea [1]. A trial of empiric therapy is a reasonable first step. NSAIDs are the initial pharmacologic intervention in patients with primary dysmenorrhea not needing contraception. NSAIDs lead to a reduction in prostaglandin production and improvement in symptoms [1]. In patients who need contraception, do not tolerate or cannot take NSAIDs, or need additional symptom relief, hormonal therapies including combined hormonal contraceptives, progestin-only contraceptive pills, transdermal patch and vaginal ring, depot medroxyprogesterone intramuscular injection, etonogestrel subdermal implant, and LNG-IUS are all effective in treating primary dysmenorrhea [1]. While safe and effective strategies for treating primary dysmenorrhea are available, many symptomatic teens do not seek treatment and rely on less effective over-the-counter or non-pharmacologic interventions [5].

Patients who do not respond to standard therapy for primary dysmenorrhea, have onset of severe symptoms with onset of menarche or shortly thereafter, or experience atypical symptoms such as heavy or abnormal menstrual bleeding, mid-cycle pain, or dyspareunia require further evaluation (Table 3.1) [5]. Patient history should review symptoms related to GI, urologic, musculoskeletal, and psychosocial etiologies, which may contribute to the pain. Evaluation for other causes of dysmenorrhea should include a pelvic examination, particularly if the patient is sexually active. Many adolescents who are not sexually active are able to tolerate a pelvic examination with education and support. The pelvic examination can identify signs of pelvic inflammatory disease, outflow track obstruction, and adnexal masses, and allow for assessment of tenderness and uterosacral nodularity. Pelvic imaging should be ordered regardless of the findings on pelvic examination. Ultrasound is the preferred initial imaging modality. There is no evidence that MRI is more advantageous as the initial study. Although a normal pelvic ultrasound does not eliminate the possibility of endometriosis, it can identify mullerian abnormalities and ovarian masses including endometriomas.

Table 3.1 Diagnostic and therapeutic considerations in adolescents with dysmenorrhea

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Related

Related posts:

1. Section II – Vaginal Discharge and Sexually Transmitted Infections
2. Section VIII – Infertility
3. Section XI – Pelvic Masses and Cysts
4. Section XII – Incontinence and Prolapse

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