Lee A. Learman
History of present illness
A 32-year-old gravida 3, para 3 woman presents to your emergency department (ED) with a complaint of midline lower abdominal pain rated at 10 out of 10 on the pain scale.
She has used extended-cycle birth control pills (84 days) to suppress her menstruation for 2 years since undergoing laparoscopic treatment for endometriosis. Yesterday, on her first pill-free day, she began to have vaginal bleeding and severe cramping pain. She’s had no nausea, vomiting, dysuria, fre- quency, or urgency, and no change in her bowel habits. She is monogamous with her husband. Her other medical problems include irritable bowel syndrome, depression controlled with sertraline 50 mg daily, andfibromyalgia treated with gabapen- tin 900 mg daily.
She has had pelvic pain since menarche at age 12. At first she had pain the day before and during thefirst three days of her periods, with no pain on the lighter fourth andfifth days, and no pain between her periods. Later, during college, her pain worsened and eventually occurred during most of the month. She has undergone four laparoscopies in the last 10 years to excise or ablate endometriosis. The last procedure two years ago improved her menstrual pain for three months, but it gradually returned. Extended-cycle birth control pills have reduced her periods to just four per year, with some light days of spotting in-between. She continues to have daily pain requiring hydrocodone 10 mg/acetaminophen 325 mg, 2 pills every 6–8 hours, every day. When she has periods the pain becomes uncontrollable and she comes to the emergency room for additional medication.
Physical examination
General:Well-developed, well-nourished woman grimacing and holding her lower abdomen
Vital signs:
Temperature: 37.0°C Pulse: 90 beats/min
Blood pressure: 128/76 mmHg Respiratory rate: 18 breaths/min Oxygen saturation: 100% on room air
Abdomen:Soft, no masses, lower abdominal/suprapubic tenderness without rebound or guarding, normal bowel sounds
External genitalia:Unremarkable Vagina:No lesions; scant discharge
Cervix:Parous; scant blood
Uterus:Retroverted, tender, normal size, minimal mobility Adnexa:Nontender; without masses
Laboratory studies: Urine pregnancy test: Negative
How would you manage the patient?
The patient has an acute exacerbation of chronic pelvic pain and endometriosis, which started on her first pill-free day after completing an extended-cycle pill pack. Her baseline pain is managed with opioid medication that is not providing adequate pain relief. Because her physical examination showed only midline lower abdominal and uterine tenderness in the setting of mild vaginal bleeding, a pregnancy test was per- formed. No other tests were ordered.
The patient was given ibuprofen 800 mg PO and a heating pad was placed on her lower abdomen. After 1 hour her pain level improved to a 6 out of 10 on the pain scale. She was discharged 1 hour later with a tolerable pain level of 4 out of 10 on the pain scale. Discharge instructions were to continue using heat and ibuprofen 800 mg every 6–8 hours, start her next contraceptive pill pack immediately, and see her primary care doctor within 2 weeks to discuss a continuous active pill regimen. She was advised to continue taking her medications for chronic pelvic pain, depression, and fibromyalgia on schedule.
Acute pain management for chronic pelvic pain
An American College of Obstetricans and Gynecologists (ACOG) Committee Opinion published in 2012 highlights the burden of prescription drug misuse or abuse, which in 2009 led to over 1.2 million ED visits, a greater number than the 974 000 ED visits from illegal drug abuse [1]. It can be challenging to determine whether a patient on prescription opioids coming to the ED with pain is demonstrating signs of drug abuse or has an acute cause of pain that is refractory to their usual analgesic regimen. It is prudent to first rule out acute causes.
As our patient had mild vaginal bleeding, midline lower abdominal cramping pain, and no signs of infection, periton- itis, gastrointestinal or urinary tract abnormalities, it is critical to exclude pregnancy. Additional evaluation is rarely war- ranted. Although urinalysis from a voided specimen could rule out an acute urinary tract infection, the timing of our patient’s Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
symptoms, concomitant bleeding, and pelvic examination findings favor a uterine source (dysmenorrhea). Without later- alizing signs and symptoms suggestive of an adnexal process or appendicitis, pelvic ultrasound or CT scanning would also not be warranted. These tests add cost and delay and, in the case of CT scanning, unnecessary radiation exposure.
This patient was not given parenteral opioids, which are commonly used in the ED while evaluation is underway for patients with acute pain. Because of the challenges of coping with chronic pain, patients who have a painflare may seek care in the ED for rapid control of their pain rather than relying on nonopioid medications or other approaches. Although parenteral opioids may provide immediate relief, their benefits are not long-lasting, and at best provide a bridge to specific treatments aimed at the conditions causing the pain [2]. In this case it was possible to complete the history and physical examination without acute pain relief. However, short-term parenteral opioid treatment to aide evaluation of acute pain would be appropriate if needed.
For patients with acute pain from dysmenorrhea there are many effective treatments (Table 3.1). The application of heat to the lower abdomen can be as effective as acetaminophen or ibuprofen [3]. If heat alone is ineffective, nonopioid analgesics can be added or substituted. In our case the patient’s baseline
pain regimen includes 2600 mg of acetaminophen. Although up to 4 g acetaminophen per day is safe in patients without chronic liver disease, ibuprofen’s prostaglandin inhibition makes it a better choice for dysmenorrhea [4]. Ibuprofen doses up to 3.2 g per day are safe for well-hydrated patients without renal insufficiency or a bleeding diathesis. For severe dysmen- orrhea 800 mg every 6–8 hours is appropriate. In patients taking combined estrogen–progestin birth control pills, the bleeding that occurs during the placebo or pill-free period is not physiologic. It is the result of progestin withdrawal and can be minimized by the use of continuous hormonal contracep- tion [5]. It is possible to resume active pill immediately, and even double the dose, to stabilize the endometrium and stop the bleeding. Our patient immediately received a heating pack and 800 mg of ibuprofen. Her pain improved within an hour, and was tolerable after another hour. She was discharged with instructions to start her next active pill pack immediately. Had her bleeding been heavier other interventions would have been considered, including higher doses of contraceptive pills, progestins, or antifibrinolytic agents (Table 3.1).
Prevention of future ED visits
Our patient was advised to follow-up with the doctor who prescribed her oral contraceptive pills to discuss switching from an extended cycle to a continuous regimen without pill-free periods. Other options can be discussed at that visit.
In ambulatory management of patients with chronic pelvic pain and dysmenorrhea, thefirst step is to create therapeutic amenorrhea and ovarian suppression. Continuous hormonal contraception, gonadotropin-releasing hormone agonists, and danazol are highly effective treatments. The levonorgestrel intrauterine device (IUD) is also effective despite evidence it does not consistently suppress ovulation.
Patients taking opioid medication for chronic pelvic pain may also seek care in the ED for painflares when they are not menstruating or ovulating. Avoiding these visits often requires the use by their prescriber of a treatment agreement that out- lines the details of the doses of medications, the pharmacy filling the prescriptions, and requires that no other physician prescribe opioid medications for the patient. Patients who do not accept treatments to correct the underlying causes of pain or adjunctive treatments such as physical therapy, psycho- therapy, or substance abuse counseling, can be dismissed from care. Before initiating opioid therapy, and periodically there- after, it is important to screen patients for substance abuse using validated screening tools and, if indicated, with toxicology screening. In the United States, several states have established web-based prescription monitoring programs that collect all controlled substance prescriptions filled within their jurisdic- tions. Searches should be done at each office visit and ED visit to document patient adherence to their treatment agreements.
According to the US Centers for Disease Control and Prevention, between 2004 and 2008 the number of ED visits for nonmedical opioid procurement more than doubled. To
Table 3.1 Selected treatment options for acute dysmenorrhea
Treatment Regimen
Continuous low-
level topical heat Apply heated patch to lower abdomen
NSAIDS:
Ibuprofen
Mefenamic acid Up to 2400 mg daily in divided doses 500 mg initial dose and then 250 mg every 6 h
If dysmenorrhea is accompanied by heavy menstrual bleeding
Oral contraceptives OCs containing 35μg ethinyl estradiol (and any progestin) taken 2–4 times daily will usually stop bleeding within 48 h, and then taper to 1 pill daily. To avoid nausea use an anti-emetic such as promethazine 12.5–25.0 mg PR
Progestins:
MPA
NET MPA 10–20 mg BID
NET 5 mg 1–2 times daily Transexamic acid
(antifibrinolytic) 1300 mg TID (3900 mg daily) for up to 5 days until bleeding stops. Use if other treatments ineffective and patient not at increased risk for thrombosis
BID, two times daily; MPA, medroxyprogesterone acetate; NET, norethindrone; NSAIDs; non-steroidal anti-inflammatory drugs; OCs, oral contraceptives; PR, by rectum; TID, three times daily.
decrease the numbers of patients making repeated ED visits for pain, several hospitals have established case management programs. One such program included narcotic restriction, nonnarcotic treatment regimens, medication restriction to one pharmacy and one provider, and referral to primary care providers and addiction specialists. To be eligible, patients needed to demonstrate ED overuse or other signs of drug- seeking or drug addiction. ED overuse was defined as three or more visits per month, two or more visits per month for two consecutive months, or greater than six per year. Comparing the year prior to enrollment to the year after enrolment, ED visits dropped by 77%, from 3689 to 852 [6].
Key teaching points
Women with chronic pelvic pain who have acute pain should be evaluated for specific causes and not dismissed as medication-seeking.
Diagnostic evaluation should be tailored to the patient’s risk factors, history, and physical examinationfindings.
Pain and bleeding during the placebo or pill-free segment of a birth control pill cycle are caused by progestin withdrawal and can be prevented using continuous hormonal contraception.
Women with acute pain from dysmenorrhea should be treated acutely with heat, nonsteroidal anti-inflammatory medications (ibuprofen or mefenamic acid), and progestins or combined oral contraceptive pills to address the underlying cause of the pain.
Frequent emergency department visits for pain can be reduced by use of case managers, narcotic restriction, nonnarcotic treatment regimens,“one pharmacy/one provider”restrictions, and appropriate referral to primary care providers and addiction specialists.
References
1. American Congress of Obstetricians and Gynecologists. Nonmedical use of prescription drugs. Committee Opinion No. 538.Obstet Gynecol2012;120:
977–82.
2. Manterola C, Vial M, Moraga J, Astudillo P. Analgesia in patients with acute abdominal pain.Cochrane Database Syst Rev2011, Issue 1.
Art. No.: CD005660. DOI: 10.1002/
14651858.CD005660.pub3.
3. Akin MD, Weingand KW, Hengehold DA, et al. Continuous low-level topical heat in the treatment of dysmenorrhea.
Obstet Gynecol2001;97(3):343.
4. Marjoribanks J, Proctor M, Farquhar C, Derks RS. Nonsteroidal anti-
inflammatory drugs for dysmenorrhoea.
Cochrane Database Syst Rev2010, Issue 1. Art. No.: CD001751. DOI: 10.1002/
14651858.CD001751.pub2.
5. Edelman A, Gallo MF, Jensen JT, Nichols MD, Grimes DA. Continuous
or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception.Cochrane Database Syst Rev2005, Issue 3. Art. No.: CD004695.
DOI: 10.1002/14651858.CD004695.
pub.
6. Masterson B, Wilson M. Pain care management in the emergency department: a retrospective study to examine one program’s effectiveness.J Emerg Nurs2012;
38(5):429–34.
Case 3: Acute exacerbation of chronic pelvic pain in a 32-year-old woman