Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

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gynaecological pain

1st line – non-steroidal anti-inflammatory drug (NSAID) + cyclical ovarian suppression

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gynaecological pain
1st line – 

non-steroidal anti-inflammatory drug (NSAID) + cyclical ovarian suppression

For gynaecological pain caused by endometriosis, adenomyosis, or dysmenorrhoea, or of unknown aetiology, management begins with NSAIDs typically combined with some form of ovulation suppression (e.g., cyclical combined oral contraceptive).[25]​​

Continuous (not 'as required') NSAID administration is used to decrease prostaglandins, inflammation, and nociception. Most NSAIDs are well tolerated, and all have a very similar level of efficacy in equivalent doses. However, long-term use of NSAIDs can be associated with gastrointestinal (GI) adverse effects (bleeding, perforation, or ulceration), cardiovascular thrombotic events, and renal disease. Use the lowest effective dose for the shortest effective treatment duration.

A thorough history should be obtained, and Medical Eligibility Criteria for contraceptive use applied, to determine safe use of contraception for menstrual suppression.[43][44][45]​ Various formulations of cyclical combined oral contraceptives are available; consult your local drug information source for guidance on choice of formulation and dose.

It is recommended that regimens are not changed more frequently than every 3 months, because most side effects will abate during this time.

Primary options

ibuprofen: 400 mg orally every 4 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day

OR

celecoxib: 200 mg orally twice daily when required

Consider – paracetamol

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gynaecological pain
Consider – 

paracetamol

Additional treatment recommended for SOME patients in selected patient group

NSAIDs should not be used alone with the expectation of pain control but combined with paracetamol as required.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

2nd line – non-steroidal anti-inflammatory drug (NSAID) + continuous ovarian suppression

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gynaecological pain
2nd line – 

non-steroidal anti-inflammatory drug (NSAID) + continuous ovarian suppression

If cyclical ovarian suppression treatment fails, a trial of NSAIDs with continuous ovarian suppression (with the objective of eliminating menses altogether) can be tried. Options include a continuous combined oral contraceptive, injectable medroxyprogesterone, or a levonorgestrel intrauterine device.

Continuous (not 'as required') NSAID administration is to decrease prostaglandins, inflammation, and nociception. Most are well tolerated and all have a very similar level of efficacy in equivalent doses. However, long-term use of NSAIDs can be associated with GI adverse effects (bleeding, perforation, or ulceration), cardiovascular thrombotic events, and renal disease. Use the lowest effective dose for the shortest effective treatment duration.

A thorough history should be obtained, and Medical Eligibility Criteria for contraceptive use applied, to determine safe use of contraception for menstrual suppression.[43][44][45]​ Various formulations of continuous combined oral contraceptives are available; consult your local drug information source for guidance on choice of formulation and dose.​

It is recommended that regimens are not changed more frequently than every 3 months, because most side effects will abate during this time. Pregnancy must be ruled out and an appropriate start date chosen for ovarian suppression.

Medroxyprogesterone provides an injectable management option. However, an increased risk of meningioma has been reported in patients taking high doses of medroxyprogesterone for several years (including injectable formulations) in epidemiological studies and case reports, although the absolute risk appears to be small.[46]​ High doses of medroxyprogesterone may therefore be contraindicated in patients with a meningioma or a history of meningioma, and treatment should be stopped in patients who are diagnosed with meningioma during treatment.[47]​

Levonorgestrel-releasing devices provide menstrual suppression through localised delivery of a progesterone to the uterus. They may last for approximately 3-8 years depending upon the brand and indication; small devices are more suitable for nulligravidas.

Primary options

ibuprofen: 400 mg orally every 4 hours when required, maximum 2400 mg/day

or

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

or

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day

or

celecoxib: 200 mg orally twice daily when required

-- AND --

medroxyprogesterone: 150 mg intramuscularly every 3 months; 104 mg subcutaneously every 3 months

or

levonorgestrel intrauterine device: insert device as directed by manufacturer depending on the brand used

Consider – paracetamol

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gynaecological pain
Consider – 

paracetamol

Additional treatment recommended for SOME patients in selected patient group

NSAIDs should not be used alone with the expectation of pain control but combined with paracetamol as required.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

3rd line – laparoscopy

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gynaecological pain
3rd line – 

laparoscopy

For patients unresponsive to initial medical management, laparoscopy may be both diagnostic and therapeutic.[25][49]​ Even with no visible pathology, laparoscopy may provide symptom relief for some patients. Endometriosis visible on laparoscopy typically is deeply invading the underlying structure and will need to be resected rather than fulgurated to provide optimal response.

4th line – non-steroidal anti-inflammatory drug (NSAID) + induced menopause

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gynaecological pain
4th line – 

non-steroidal anti-inflammatory drug (NSAID) + induced menopause

In patients who have failed to respond to cyclical and continuous ovarian suppression treatment and laparoscopy, induction of menopause with gonadotrophin-releasing hormone (GnRH) agonists (e.g., leuprorelin) is the final medical management option. Several drugs and routes are available. For convenience and to improve compliance, some can be dosed once every 3 months. For induced menopausal symptoms, add-back therapy with oestrogen may be required, but this does not decrease the efficacy of the treatments.

Continuous (not 'as required') non-steroidal anti-inflammatory drug (NSAID) administration is appropriate to decrease prostaglandins, inflammation, and nociception. Most are well tolerated and all have a very similar level of efficacy in equivalent doses. However, long-term use of NSAIDs can be associated with GI adverse effects (bleeding, perforation, or ulceration), cardiovascular thrombotic events, and renal disease. Use the lowest effective dose for the shortest effective treatment duration.

Primary options

ibuprofen: 400 mg orally every 4 hours when required, maximum 2400 mg/day

or

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

or

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day

or

celecoxib: 200 mg orally twice daily when required

-- AND --

leuprorelin: 3.75 mg intramuscularly once monthly; or 11.25 mg intramuscularly every 3 months

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Consider – paracetamol

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gynaecological pain
Consider – 

paracetamol

Additional treatment recommended for SOME patients in selected patient group

NSAIDs should not be used alone with the expectation of pain control but combined with paracetamol as required.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

5th line – hysterectomy

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gynaecological pain
5th line – 

hysterectomy

If childbearing is complete, hysterectomy can be very effective for gynaecological-based pain. A trial of medical therapy is mandatory before undergoing the risks of surgery.

Hysterectomy alone is frequently effective, but as many as 20% of patients may return for an oophorectomy later.[53] [ Cochrane Clinical Answers logo ] ​ To completely eradicate endometriosis a concomitant oophorectomy may also be required.

interstitial cystitis (bladder pain syndrome)

1st line – avoidance of dietary triggers

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interstitial cystitis (bladder pain syndrome)
1st line – 

avoidance of dietary triggers

Many patients with interstitial cystitis (also called painful bladder syndrome) can identify dietary triggers for their pain, which may include caffeine, acidic foods, spicy foods, and a wide range of other dietary items. Some patients will get significant relief from careful dietary modification. Maintaining a food diary can help in identifying possible dietary triggers.[3][54]​​

Consider – pharmacological therapy

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interstitial cystitis (bladder pain syndrome)
Consider – 

pharmacological therapy

Additional treatment recommended for SOME patients in selected patient group

Initial therapies include antihistamines (e.g., hydroxyzine), pentosan polysulfate sodium, and mild analgesics (e.g., ibuprofen, paracetamol). Combinations of these drugs may be used.

Pentosan is effective only in about 50% of patients following 6 months of therapy.[55]​ Pentosan is related to heparin, and so should be avoided in patients taking concurrent anticoagulation or those at risk for serious consequences from bleeding. Pentosan exposure has been linked to retinal pigmentary maculopathy.[3]

Primary options

pentosan polysulfate sodium: 100 mg orally three times daily

OR

hydroxyzine: 10-75 mg orally once daily

OR

ibuprofen: 400-800 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – fulguration ± corticosteroid injection or ciclosporin

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interstitial cystitis (bladder pain syndrome)
Consider – 

fulguration ± corticosteroid injection or ciclosporin

Additional treatment recommended for SOME patients in selected patient group

Patients with Hunner ulcers require procedural management. The American Urological Association recommends fulguration (with electrocautery) and/or injection of triamcinolone. Oral ciclosporin is an option for patients with persistent or refractory symptoms.[3]

Primary options

ciclosporin: 3 mg/kg/day orally given in 2 divided doses

2nd line – bladder instillation, hydrodistension, neurostimulator implantation, or intradetrusor botulinum toxin injection

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interstitial cystitis (bladder pain syndrome)
2nd line – 

bladder instillation, hydrodistension, neurostimulator implantation, or intradetrusor botulinum toxin injection

In patients not responding to oral medical therapy, bladder instillation may be used.

Bladder instillation therapy can be done with several different drug combinations placed 2 or 3 times per week for 6 weeks.

Instillation is then repeated as needed. The overall risks are very low, but include urinary tract infection, which must be ruled out before therapy begins.

There are many individual components that have been tried in interstitial cystitis, including alkalinised lidocaine, heparin, dimethyl sulphoxide, and others. These agents may be used in combination. There is no standard approach.[3]

Relief of bladder pain symptoms at the time of alkalinised lidocaine instillation is diagnostic for pain of bladder origin (i.e., interstitial cystitis), provided infections have been excluded.

Patients who report relief of bladder pain with instillation (for any amount of time), can usually expect longer-term relief from hydrodistension.

For patients with interstitial cystitis, hydrodistension is a second line treatment that may be diagnostic and therapeutic. There are many different protocols that have been summarised and reviewed.[57]

Not all patients will respond to distension. Interstitial cystitis is often a relapsing condition, so patients should expect multiple treatments, possibly as frequently as every 3 months. Optimisation of medical management decreases the need for repeat hydrodistension.

The major complication specific to distension is rupture of the bladder, which may occur as frequently as 10% in some series.

Neurostimulator implantation is used when all other efforts to control pain have failed.[59] Several different devices are available, all of which rely on placement of an electrode onto the pudendal nerve or other nerve root under anaesthesia guidance. An electrical pulse is then tonically produced to suppress nerve action. The response rate varies between 40% and 70%; however the data supporting neurostimulator use are limited.[60]

Chemical neuromodulation with botulinum toxin has become a standard treatment for patients with drug-resistant urinary urgency and frequency. There is some evidence intradetrusor injection of botulinum toxin type A also reduces pain and improves quality of life, however the effects are short term.[3] Botulinum toxin type A injected in the ambulatory setting allows for symptom relief and minimises risk for acute urinary retention requiring self-catheterisation. Small studies have shown efficacy for this treatment combined with hydrodistention.

fibromyalgia

1st line – individualised therapy

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fibromyalgia
1st line – 

individualised therapy

Fibromyalgia should be individualised and multi-modal. It may include patient education, self-management, physical activity, pharmacotherapy, and psychological therapies.

Most patients can tolerate some level of physiotherapy, particularly massage. The addition of physiotherapy can frequently improve symptoms.[26][67]​ Stretching exercises of the affected muscle groups may also be beneficial. Exercise may exacerbate muscle-based symptoms.

Pharmacological therapy includes the use of tricyclic antidepressants, gabapentinoids, or selective-noradrenaline reuptake inhibitors (SNRIs).[62][63][64][65]​ Pharmacological therapy is, at best, modestly effective in a minority of patients.[66]

If a patient is not responding to physiotherapy and/or pharmacotherapy , a second-line option is trigger-point injection. Trigger-point injection can be done using a variety of agents. Initially, precise infiltration of the tender area with local anaesthetics (such as lidocaine) can produce immediate relief and be both diagnostic and therapeutic. Patient response to trigger-point injection may include prolonged relief, minimal relief, or a short-term flare of symptoms once the anaesthetic has worn off. Repeat injection may be necessary and can also be done using botulinum toxin type A, or dry needling.

See Fibromyalgia.

levator ani syndrome

1st line – non-steroidal anti-inflammatory drug (NSAID) + physiotherapy

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levator ani syndrome
1st line – 

non-steroidal anti-inflammatory drug (NSAID) + physiotherapy

Initial management includes an NSAID (e.g., ibuprofen) and physiotherapy, often called Thiele massage. Most patients can tolerate some level of physiotherapy, particularly massage. The addition of physiotherapy can frequently improve symptoms in compliant patients.[67]​ Stretching exercises of the affected muscle groups may also be beneficial. Exercise may exacerbate muscle-based symptoms.

Primary options

ibuprofen: 400-800 mg orally every 4-6 hours when required, maximum 2400 mg/day

vulvodynia

1st line – topical local anaesthetic

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vulvodynia
1st line – 

topical local anaesthetic

A topical anaesthetic applied to the affected area prior to coitus may control vulvodynia and permit comfortable intercourse.​[68][69]​​

Another approach is to apply lidocaine jelly to the vestibule every night for several weeks in a row in an effort to induce a remission.

Consider – amitriptyline or gabapentin

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vulvodynia
Consider – 

amitriptyline or gabapentin

Additional treatment recommended for SOME patients in selected patient group

Amitriptyline or gabapentin can be used as an adjunct in a manner similar to fibromyalgia. Although, given the increasing reports of abuse and the potential risks associated with gabapentin, clinicians should consider alternative treatment options to gabapentin for managing chronic pelvic pain, particularly in patients with no identifiable pelvic pathology.[72][73]

Primary options

amitriptyline: 10-25 mg orally once daily at night

OR

gabapentin: 300 mg orally once daily on the first day, followed by 300 mg twice daily on day 2, followed by 300 mg 3 times daily on day 3, then increase dose according to response, maximum 3600 mg/day

1st line – topical gabapentin

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vulvodynia
1st line – 

topical gabapentin

Topical gabapentin is not routinely available, but is effective.[75] This formulation requires preparation by the pharmacist.

Primary options

gabapentin topical: (5% gel) apply to vulva twice daily

2nd line – excision

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vulvodynia
2nd line – 

excision

If first-line approaches fail, careful excision of the painful area can be considered.

Partial removal of the vestibule can be considered in carefully selected patients. Such patients should have clear evidence of provoked pain localised to small areas of the vestibule and have failed conservative management. Caution must be taken to avoid vaginal stenosis following excision.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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