HNY Policy and Pathway Repository - York

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.

• >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 check serum CA125.
• CA125 >35 IU/L arrange urgent pelvic USS
   
• Refer urgently if suggestive of ovarian cancer
  • Please Note: CA125 can be elevated in non-malignant conditions such as:
  • Benign ovarian tumour (eg, Meigs' syndrome)
  • Endometriosis
  • Pelvic inflammatory disease/salpingitis
  • Pregnancy and menstruation (CA 125 can increase two- to three-fold during menstruation)
  • Leiomyoma, including fibroids
  • Ascites with non-malignant causes eg liver disease (cirrhosis)
  • Diverticulosis
  • Pleural and pericardial disease
  • Pancreatitis
  • Heart failure

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 experiences.
• Marked cyclical variation of symptoms would support endometriosis or adenomyosis diagnosis:
• Consider trial with hormonal therapy/ suppression of ovulation for 3-6 months.
  • Tri-cycling of COCP (three pill packs back-to-back, consider a 7 day break if breakthrough bleeding starts)
  • Mirena
  • Depo-provera
  • Implant or mini-pill (only if induces amenorrhoea)
  • GnRHa (can be started in primary care if clinician confident) +/- add back HRT.
• Treat any suspicion of infection (better to treat whilst awaiting swab results if in doubt, delayed treatment increases infertility risks and adhesion formation)
  • North Yorkshire Antimicrobial Policy: NY Antimicrobial Guidelines for PID treatment

Pelvis Inflammatory Disease:

When to Treat	Prescribing Notes and general advice	When antibiotics are needed
Refer women and contacts to GUM clinic. Exclude pregnancy.   Start empirical antibiotics as soon as a presumptive diagnosis of PID is made clinically. Do not wait for swab results. Delay of effective treatment can increase risk of tubal damage. Always culture for gonorrhoea and chlamydia. If gonorrhoea is likely use ceftriaxone regimen (28% of gonorrhoea isolates are now resistant to quinolones) or refer to GUM clinic. For further treatment options, seek specialist advice from GUM or a clinical microbiologist.	Provide pain relief with ibuprofen or paracetamol. Advise of the need to use a barrier method of contraception (such as a condom) until both the woman and her partner(s) have completed treatment.	First line: Ofloxacin 400mg BD for 14 days PLUS Metronidazole 400mg BD for 14 days   Alternative IF HIGH RISK OF GONORRHOEA: Ceftriaxone IM 500mg IM stat PLUS Metronidazole 400mg BD for 14 days PLUS Doxycycline 100mg BD for 14 days

• Excellent CKS summary about PID and management options.
• Explore women’s perceptions about cause of pain.
• Laparoscopy should be regarded as second line investigation, when hormonal therapy and pain management unsuccessful.
  • Carries risk of death 1 in 10,000 and bowel damage 2.4 in 1,000

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 if not on proforma
• Current regular medication if not on proforma
   

Investigations prior to referral

• Chlamydia screening
• High Vaginal Swab
• Pelvic USS
• Nb. DO NOT perform a cervical smear if outside the screening programme.
   

Desirable Information

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

Patient Information Leaflets/PILS

• NHS Choices information: Pelvic Pain
• Endometriosis UK 
• IBS Network
• Cystitis and Overactive Bladder foundation
• Women’s Health [www.womens-health.co.uk] or [www.womenshealth.gov]
• Pelvic Pain Support Network [www.pelvicpain.org.uk]
   

References

• RCOG Greentop Guideline No 41 May 2012 ‘The initial management of chronic pelvic pain’
• NICE Guideline April 2011 Ovarian Cancer The recognition and initial management of ovarian cancer
• https://www.nice.org.uk/Guidance/CG122
• http://patient.info/doctor/cancer-antigen-125-ca-125