Dysmenorrhea and Chronic Pelvic Pain: Therapy

THERAPY

Patients with chronic pelvic pain offer a therapeutic challenge. If possible, care should be directed at a specific cause. The use of analgesics should be on a fixed time schedule that is independent of symptoms.

Suppression of ovulation may be useful as either a ther-apeutic modality or as a diagnostic tool to assist in ruling out ovarian or cyclic processes. Gonadotropin-releasing hor-mone (GnRH) agonists cause a central down-regulation of the ovarian hormones and have been used in the treatment of endometriosis. These agents may also help relieve some of the symptoms of IBS, interstitial cystitis, and pelvic congestion syndrome (in which engorged pelvic blood vessels are purported to cause pelvic aching and pain).

Patients with symptoms characteristic of IBS or infec-tion should be referred to a gastroenterologist for further evaluation. Use of a food diary to identify and eliminate foods that are associated with symptoms, combined with the nurturing physician–patient relationship to avoid “doctor shopping” and episodic care, are the mainstays of treatment. The limiting of caffeine, alcohol, fatty foods, and gas-producing vegetables is often helpful. Lactose or wheat gluten intolerance may be identified by the diary. If constipation is a major symptom, the consumption of 20 to 30 g of fiber or the use of osmotic laxatives such as lactulose is often useful. When diarrhea is a major symp-tom, antidiarrheals can be useful. Gas pain and cramping may be treated with antispasmodics such as dicyclomine and hyoscyamine.

Treatments for interstitial cystitis include dietary modification, intravesical agents, and oral agents aimed at decreasing inflammation and pain signals. As with IBS, caffeine, alcohol, artificial sweeteners, and acidic foods should be eliminated. Dimethyl sulfoxide (DMSO) is the only drug approved for direct bladder instillation to treat interstitial cystitis, although many physicians treat with a “cocktail” of anti-inflammatory and analgesic medications. Oral agents include antihistamines, tricyclic antidepres-sants, and pentosan polysulfate, a glycosaminoglycan analogue that may help reestablish the disrupted mucosa of the bladder.

Surgical therapies, such as hysterectomy, should be performed only after nongynecologic causes have been ruled out. Hysterectomy is very effective is relieving pain arising from the uterus and may also improve symptoms in women without identifiable uterine pathology. Alternate treatment modalities, such as transcutaneous electrical nerve stimulation (TENS), biofeedback, nerve blocks, laser ablation of the uterosacral ligaments, and presacral neurec-tomy may be used, as appropriate. Adding psychotherapy to medical treatment of chronic pelvic pain appears to improve response over that of medical treatment alone and should be considered. In some cases, the goal in treatment may not be a cure, that is, elimination of the chronic pain, but rather successful management of the symptoms to allow maximal function and quality of life.