5 Pain and discomfort in women

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Contents

Objectives

When you have completed this chapter you should be able to:

Introduction to pain and discomfort in women

5-1 What is pain and discomfort?

Everyone suffers from pain at times. Pain is an unpleasant sensation which may be mild, moderate or severe. Mild pain is often called discomfort. Severe pain may be very distressing.

Pain may be localised to one part of the body or it may spread (radiate) to a number of parts. Words used to further describe the feeling of pain include sharp, stabbing, shooting, aching, burning and throbbing.

Pain is an important symptom because is suggests that “something is wrong”. Throughout this chapter pain will refer to both pain and discomfort.

Pain is an important symptom as it suggests something is wrong.

5-2 What is gynaecological pain?

Many causes of pain occur only in women and not men. This is sometimes called gynaecological pain. Gynaecological pain often occurs in women who are generally well. As a result it is often ignored or badly managed by healthcare workers.

5-3 What are the common sites of pain in women?

Common sites of pain in women are:

The pelvis, vulva and breasts are common sites of pain in women are.

Pelvic pain

5-4 What is pelvic pain?

Pelvic pain is pain in the lower abdomen (below the umbilicus). Pelvic pain may occur in women who are generally well. Most women will experience pelvic pain at some time of their lives.

5-5 What are the main categories of pelvic pain?

It is convenient to divide pelvic pain into 3 categories as this helps with making a correct diagnosis of the cause:

In this chapter pain associated with pregnancy after the first trimester will not be addressed. Please see the Bettercare Maternal Care course book for details.

5-6 What are the 3 time patterns of pelvic pain?

Most pelvic pain can be divided into 1 of 3 types or patterns:

The pattern of pain is very important as it often indicates what the likely cause of the pain is. Some conditions may also present as acute, cyclical or chronic pain.

Pelvic pain can be acute, cyclical or chronic.

5-7 What are important causes of acute pelvic pain?

A physical cause can usually be found for acute pelvic pain.

A physical cause can usually be found for acute pelvic pain.

5-8 What is acute pelvic infection?

This is usually a sexually transmitted infection which spreads from the vagina through the cervix and uterus to reach the fallopian tubes, ovaries and peritoneum. The common bacteria causing acute pelvic infection are Gonococcus and Chlamydia. Acute pelvic infection usually presents with the sudden onset of pelvic pain, fever and a vaginal discharge. Patients should be urgently referred to hospital to confirm the diagnosis and start treatment with multiple antibiotics. Failure to treat the condition early and fully may lead to chronic pelvic inflammatory disease in addition to permanent damage to the fallopian tubes.

Acute pelvic infection must be diagnosed and treated urgently.

5-9 What are ovarian cyst complications?

Ovarian cysts occur commonly and are associated with menstrual disturbances and discomfort or slight pain. They resolve spontaneously and no treatment is required. Ovarian cysts may cause acute pain of sudden onset complicated by torsion (twisting) or haemorrhage into the cyst or rupture. Ovarian torsion is often accompanied by vomiting. The diagnosis of a complicated ovarian cyst can be confirmed with ultrasonology. A woman with suspected ovarian cyst complications should be referred to a gynaecology clinic for investigation and management as surgery may be needed.

5-10 How do miscarriage and ectopic pregnancy present clinically?

If a woman in the first few months of pregnancy presents with sudden onset of severe pelvic pain and vaginal bleeding you must suspect miscarriage or ectopic pregnancy (the pregnancy is outside the uterus and in the abdominal cavity). Sometimes they may not be aware that they are pregnant. Therefore a pregnancy test is an important investigation in all women of childbearing age who present with acute pelvic pain.

A miscarriage can present with a range of different symptoms; the most common of which are cramplike lower abdominal pain and associated vaginal bleeding. An ectopic pregnancy also presents with abdominal pain and vaginal bleeding. Referral to hospital is urgent as a ruptured ectopic pregnancy can lead to severe intra-abdominal bleeding and shock. A normal temperature helps to exclude acute infections. With any sign of shock, resuscitation must begin immediately and urgent ambulance transfer arranged.

A pregnancy test is needed in women with acute pelvic pain and no fever.

5-11 What is the clinical presentation of acute appendicitis?

The common presentation is acute onset of abdominal pain with fever, loss of appetite, nausea and vomiting. The pain typically starts around the umbilicus and later moves to the right lower abdomen which may also be tender. The symptoms are often not typical. Any woman with suspected acute appendicitis should be referred urgently to hospital for investigation and management. Treatment is usually removal of the appendix.

Note
Right lower quadrant guarding and rebound tenderness strongly suggest appendicitis. The white blood count and CRP are usually raised. Acute diverticulitis may also present with acute lower abdominal pain and fever.

Acute pain in the right lower abdomen with loss of appetite and fever suggests acute appendicitis.

5-12 What is the presentation of acute bladder infection?

Most women will experience acute bladder infection (cystitis or urinary tract infection) a number of times in their life. It is caused by bacteria and presents with dysuria (pain on passing urine), frequency and sometimes haematuria (blood in the urine). There may be lower abdominal pain and tenderness. Reagent strip testing with a urine sample is usually positive for leukocytes and nitrite.

The condition is discussed in chapter 3.

Note
Reagent strip testing of urine samples collected from women often test positive for leukocytes and nitrite due to contamination. If women are asymptomatic no treatment is required.

5-13 What is the irritable bowel syndrome?

Irritable bowel syndrome (IBS or spastic colon) is a common condition that affects the large bowel and presents with cramping abdominal pain, gaseous distension and constipation or diarrhoea. Usually there is a history of repeated episodes over many years. The pain may be acute or chronic. The diagnosis is usually made on the history as the clinical examination is normal. The cause is unknown and there is no known cure. The management is difficult. Reassurance, a change in diet and lifestyle changes to decrease stress often helps.

5-14 What are the common causes of cyclical pelvic pain?

Cyclical pelvic pain occurs at the time of the menstrual cycle each month. Therefore the causes can often be categorised by the timing of pain during the menstrual cycle:

5-15 What is ovulation pain?

Ovulation pain typically occurs in the middle of the menstrual cycle. As it is caused by ovulation it is usually only felt on 1 side of the lower abdomen. It lasts for a few hours and is not severe enough to need treatment other than paracetamol if necessary.

5-16 What is primary dysmenorrhoea?

Primary dysmenorrhoea or “period pains” is cramping lower abdominal pain which occurs for a few days during menstruation. It is common in teenagers and young adolescents and usually get better with age or after a pregnancy. Dysmenorrhoea is a common cause of missing a few days school every month.

Women with dysmenorrhoea can usually be managed at a primary care clinic. Treatment is non-steroidal anti-inflammatory (NSAID) drugs like ibrufen (Brufen) 400 mg 6 hourly orally. In severe dysmenorrhoea not responding to NSAID combined oral contraceptives (‘the pill’) are usually effective.

Primary dysmenorrhoea can usually be treated with ibrufen at a primary care clinic

Note
The cramping pain is due to uterine contractions caused by high levels of circulating prostaglandins which may also cause the associated symptoms.

5-17 What is endometriosis?

Endometriosis is a condition where endometrial tissues, which normally lines the inside of the uterus, develops and grows outside the uterus in the lower abdomen. These deposits of endometrial tissue respond to the hormonal changes during a normal menstrual cycle. This causes a local inflammatory reaction and pain.

The pain typically starts a few days before the onset of menstruation and improves once menstruation ends. However pain may continue throughout the menstrual cycle. There may be associated symptoms depending on the location of the endometrial deposits. For example:

Women with suspected endometriosis should be referred to a gynaecological clinic for diagnosis and management.

5-18 How is endometriosis diagnosed?

Younger women that have not been pregnant are mostly effected. A thorough history and clinical examination will often suggest the diagnosis. If endometriosis is suspected the woman should be referred to a gynaecology clinic where a gynaecological ultrasound examination may strongly support the diagnosis. Further investigation is usually not needed as a good clinical response to treatment will support the clinical diagnosis of endometriosis.

Note
Laparoscopy (keyhole surgery) in severe cases laroroscopic surgery may be need to remove the endometrial deposits is the only guaranteed way of confirming the diagnosis.

5-19 What is the management of endometriosis?

A number of approaches are used:

Note
Gonadotrophin releasing hormone analogues such as Zoladex are helpful. Women with infertility should be referred to a infertility clinic. Endometriosis improves following a pregnancy.

5-20 What is adenomyosis?

This is a condition similar to endometriosis but the endometrial tissue is in the muscle of the uterus (myometrium). Unlike endometriosis the pain typically occurs during the period but may continue throughout the menstrual cycle. The diagnosis and management are as for endometriosis. Older premenopausal women that have completed their families are mostly effected. A pelvic ultrasound examination is very useful in making the diagnosis.

5-21 What are uterine fibroids?

Uterine fibroids are benign tumours which occur in the wall of the uterus. They often cause no symptoms but can present with cyclical pelvic pain and heavy periods. Large fibroids may be palpated abdominally. They can be diagnosed by ultrasonography and these women should be referred to a gynaecological clinic for management. Medical treatment is similar to that for endometriosis. Surgery with removal of the fibroma or hysterectomy may be needed.

Note
If a family planning method that contains oestrogen (the combined contraceptive pill) is used, close follow-up is necessary as oestrogen may cause an increase in size of the uterine fibroids.

5-22 What are the common causes of chronic pelvic pain?

Common causes of chronic pelvic pain include:

Chronic pelvic pain has often been present for many months and can become debilitating and lead to depression. The cause of the pain may be difficult to identify and manage.

It is often difficult to find a cause and to manage chronic pelvic pain.

5-23 What is chronic pelvic inflammatory disease?

Chronic pelvic inflammatory disease is the end result of untreated or repeated acute pelvic infections which leads to adhesions and scarring. This presents with chronic pelvic pain and can cause infertility or ectopic pregnancy. Patients often also complain of backache, dyspareunia and dysmenorrhoea. Response to treatment is often unsatisfactory and these women should be referred to a gynaecology clinic.

Note
There are often adnexal masses and tenderness on vaginal examination. Diagnosis can be confirmed by ultrasound, laparoscopy and laporotomy. Analgesics, anti-inflammatory drugs and antibiotics are used in management.

5-24 What is pelvic venous congestion?

It is caused by dilated veins (varicous veins) in the pelvis. This condition usually presents with chronic pelvic pain in women who have had children, especially after standing, at the end of the day or with sexual intercourse. The diagnosis can be confirmed by ultrasound examination. If the diagnosis is suspected the woman should be referred to a gynaecology clinic for investigation and management.

5-25 What is bladder pain syndrome?

This is a poorly understood condition which presents with symptoms similar to urinary tract infection. However it is not caused by an infection. Pelvic pain is common. Management is often not satisfactory so these women should be referred to a gynaecology clinic.

5-26 Does ovarian cancer present with pain?

Gynaecological cancers usually do not present with pain. Ovarian cancer commonly is asymptomatic until it has spread to the peritoneum when it causes vague abdominal discomfort, abdominal distension and weight loss.

5-27 Is a cause of chronic pelvic pain always found?

No. Sometimes a woman presents with chronic pelvic pain which has no obvious cause. After a careful history, clinical examination and special investigations a definite cause of the pelvic pain cannot be found. This is often a serious problem as these women may have severe pain which interferes with their lifestyle resulting in depression and desperation. There are many theories about the possible physical and emotional cause of the pain. Management at a primary care facility is difficult and these women should be referred to a gynaecological clinic.

Sometimes a cause of chronic pelvic pain cannot be found which makes management difficult and unsatisfactory.

Note
Once causes of chronic pelvic pain as mentioned above have been excluded, lifestyle modification should be encouraged. If depression and anxiety is present, referral to a psychiatrist may be necessary.

5-28 What are red flag symptoms for pelvic pain?

These are symptoms that suggest the possibility of a serious or even life-threatening condition which needs urgent investigation or referral to a gynaecological unit:

It is very important to look out for these red flag symptoms which may be associated with pelvic pain.

Always look out for red flag symptoms associated with pelvic pain.

5-29 What is a stepwise approach to managing a woman who presents with pelvic pain?

The important steps in management are:

Do not miss an ectopic pregnancy, chronic inflammatory disease or appendicitis in a patient with pelvic pain.

Vulvar pain

5-29 What is vulvar pain?

There are a wide variety of vulvar sensations that may warn of a problem. These range from discomfort to pain and include a burning sensation, stinging, raw feeling, crawling sensation or irritation. Itching however is regarded as a separate presenting symptom.

5-30 What are the different types of vulvar pain?

There are 2 different types of vulvar pain:

5-31 What are the most common identifiable causes of vulvar pain?

The most common identifiable vulvar conditions causing pain include:

5-32 What is a vulval fissure?

This is the most common finding in acute onset of vulvar pain. It may occur as a result of any vulvar dermatosis (skin disorder) such as allergic or irritant dermatitis, candidiasis and psoriasis. The fissure is usually located at 6 o’clock on the edge of the vulva (introitus) towards the anus. However fissures can also be found on various positions of the vulva especially if there is excessive scratching. There may be an accompanying rash.

Treatment includes management of the underlying condition and if no obvious cause is identified an oestrogen cream can be used.

A vulval fissure is the commonest cause of sudden onset of vulvar pain.

5-33 What is vulvovaginal candidiasis?

Vaginal thrush (vulvovaginal candidiasis or moniliasis) is common and usually presents with itching. However it can also present with vulval pain. It is a fungal infection which may follow a course of antibiotics and is often seen in diabetic patients. The diagnosis of vaginal thrush is often missed or inadequately treated resulting in a painful, sore and inflamed vulval area. A careful history identifies the typical post ovulatory worsening of symptoms and examination may reveal a red, inflamed appearance of the labia minora and vagina with a thick white vaginal discharge. Treat with an antifungal pessary such as clotrimazole. If the symptoms are not relieved refer to a gynaecology clinic.

Note
If needed a low vaginal swab for microscopy and fungal culture will confirm the clinical diagnosis.

5-34 What is genital herpes?

Genital herpes is a sexually transmitted disease caused by the Herpes simplex virus. The diagnosis of genital herpes is usually easily made with the very painful blisters and erosions present on the vulva. Passing urine is very painful. Diagnosis can be confirmed with a viral culture of the vesicle. Treatment is oral acyclovir (oral antiviral medication). Washing helps to reduce discomfort. Genital herpes may recur.

5-36 What is atrophic vulvovaginitis?

Older, post menopausal women or younger women during breastfeeding have a lack of estrogen that can result in vaginal dryness leading to itching, burning and pain during intercourse (dyspareunia). In postmenopausal women the vaginal skin looks pale, dry, thin and shiny with a lack of vaginal folds. Treatment includes an oestrogen cream with the addition of a topical steroid. In postmenopausal women daily application of oestrogen cream for 7 days should be followed by twice a week application.

5-37 What are vulvar varices?

Varicosities of the vulva are common in pregnancy and may persist post delivery. The patient has to be examined in the upright position to confirm the diagnosis. A dull constant ache is often present and unilateral. Treatment involves embolisation of the vessels if the varices do not resolve after the pregnancy.

5-38 What skin conditions can affect the vulva?

Lichen planus and psoriasis may cause vulvar lesions These are uncommon conditions that may involve the mucosal surfaces such as the vulva and vagina. They are typically very painful. Treat the vulval skin with a topical steroid cream.

5-39 What is vulvodynia?

Vulvodynia presents with a sensation described most often as a chronic burning vulvar pain which occurs in the absence of any clinical signs or specific disorder. The cause is unknown and the diagnosis is made on the history and excluding other conditions. The pain is made worse by local pressure such as inserting a tampon, during intercourse, prolonged sitting or wearing tight pants. Vulvodynia is a diagnosis of exclusion.

Vulvodynia presents as marked vulval sensitivity without any clinical signs of disease.

Note
Dynia is the ancient Greek for pain.

5-40 How should a woman with vulvodynia be clinically examined?

In spite of the vulvar discomfort most patients can tolerate a gentle examination of the area. The most important information to gather from an examination is:

The gynaecological examination is normal although local gentle pressure on the vulvar can result in the typical pain.

5-41 What treatment is available for vulvodynia?

There is no single effective treatment so often multiple treatment options are explored after discussion between doctor and patient. Emotional support, education about the condition, pelvic floor exercises and lubrication during intercourse are helpful. If the woman is in a relationship, it is good practise to include her partner in the counselling and explanation of the condition. She may need to be referred to a special pain clinic for further management.

5-42 What is dyspareunia?

Dyspareunia is pain during sexual intercourse. This is a condition which has many medical and emotional causes. It is important to exclude any gynaecological causes first. A good history, including past sexual trauma, is important as the dyspareunia may reflect past traumatic or psychological events which require referral for counselling. The pain may be at the entrance to the vagina or deeper towards the cervix. The diagnosis can usually be made with a careful history and gynaecological examination. There are many conditions which may cause pain during intercourse. These include:

Some women with dyspareunia have no obvious physical reason for the pain. The cause is probably psychological with a fear or dislike of sex or a history of past sexual abuse. Referral to a psychiatry clinic could be helpful.

Breast pain

5-43 How common is breast pain?

Breast pain (mastalgia), discomfort or tenderness is very common and most women will experience breast pain at some stage of their lives.

5-44 What questions should be asked about pain in the breast?

The women should be asked:

5-45 What are common causes of breast pain?

Common causes of breast pain include:

5-46 What is cyclical mastalgia?

Many young women get painful, tender and lumpy breasts for a week or 2 before their period. It then disappears once their period is over. This is called cyclical mastalgia. These breast changes are normal and the result of fluid retention caused by hormonal changes during the menstrual cycle. The management is usually an explanation and reassurance. An anti-inflammatory medication such as ibrufen can be used. Diuretics are not helpful. Make sure that the woman is wearing a well fitted bra.

Note
Women that experience mastalgia after starting a combined oral contraceptives may need to be changed to a lower oestrogen containing tablets.

5-47 Is breast pain a symptom of cancer?

Cancer is a rare cause of pain on one breast. Almost always another cause can be found. Unless there is an associated lump, nipple discharge or skin change, the risk of cancer is small in a woman complaining of breast pain. However, all women over 40 years of age who present with any breast complaint should have a mammogram.

Breast cancer is an unlikely cause of breast pain.

Case study 1

An unmarried 23 year old woman presents at a clinic with acute abdominal pain for the past 2 days. She has a number of sexual partners and they do not use a condom during sex. She has not missed a menstrual period and her pregnancy test is negative. On examination she has a temperature of 38 °C with general abdominal tenderness and an offensive vaginal discharge.

1. What is the most likely diagnosis?

She probably has acute pelvic infection as suggested by her sexual history, fever, general abdominal pain and vaginal discharge. An ectopic pregnancy and miscarriage are excluded as she is not pregnant.

2. What is the cause of this medical condition?

It is a sexually transmitted infection usually caused by Gonocccus or Chlamydia.

3. How should she be managed?

She must be urgently referred to hospital to confirm the diagnosis and start treatment with multiple antibiotics.

4. What other conditions may present with acute pelvic pain and fever?

Acute appendicitis and acute urinary infection may also present with acute abdominal pain. With acute appendicitis the pain and tenderness is usually in the lower right side of the abdomen while women with acute urinary infection have frequency and dysuria. Patients with acute appendicitis often have loss of appetite, nausea and vomiting while reagent strip testing with a urine sample is usually positive for leukocytes and nitrite with acute urinary infection.

5. What is an important complication of acute pelvic infection?

If not correctly treated early and fully with antibiotics it may lead to chronic pelvic inflammatory disease. This presents with chronic pelvic pain and may cause infertility and ectopic pregnancy.

6. What are red flag symptoms for pelvic pain?

These are symptoms that suggest the possibility of a serious or life-threatening condition which needs urgent investigation or referral to a gynaecological unit. Fever with abnormal vaginal discharge are red flag symptoms and suggest acute pelvic infection.

Case study 2

A teenager complains of cramping abdominal pain which occurs for the first few days during her menstrual period. She feels nauseous with the pain and often misses a few days school. On examination she is generally well, has no abdominal tenderness and no fever or vaginal discharge.

1. What is the most likely diagnosis?

Primary dysmenorrhoea. Also called period pains. She has the typical symptoms of cyclical pelvic pain that occurs during menstruation. If she is sexually active she need a gynaecological examination to rule out chronic pelvic infection.

2. How should he be managed?

She can be managed at a primary care clinic with ibrufen 400 mg orally every 6 hours. If she does not respond adequately to treatment, she should be referred to a gynaecology clinic.

3. What causes cyclical pelvic pain during the middle of the menstrual cycle?

Ovulation.

4. What condition typically causes cyclical pelvic pain that starts a few days before the start of the menstrual period and improves once menstruation begins?

Endometriosis.

5. What is endometriosis?

Deposits of endometrial tissue outside the uterus which cause pain during menstruation.

6. What is the management of a women if you suspect endometriosis?

Refer her to a gynaecological clinic for investigation and treatment. A gynaecological and rectal examination should be done. Ultrasonology may strongly support the diagnosis but laparoscopy may be needed to confirm the diagnosis of endometriosis. Lifestyle change and simple analgesics are helpful while a combined family planning pill or family planning injection is usually effective in preventing the symptoms.

Case study 3

A married woman complains of vulvar pain for the past few days. The pain is worse during sexual intercourse. She is generally well and has no vaginal discharge. On examination there is no painful vulvar blisters or rashes but a small cut is seen on the edge of the vulva closest to the anus.

1. What is the diagnosis?

A vulvar tear. This is a common cause of acute vulvar pain.

2. What are other common causes?

There may be an obvious cause such as herpes infection, candida vulvovaginitis or atrophic vulvovaginitis. However there may be no obvious cause.

3. Does this woman have herpes infection?

No as there are no painful blisters.

4. What should be the management?

As there is no obvious cause estrogen cream should be used. If there was an obvious cause, the cause should be treated.

5. What is vulvodynia?

Marked sensitivity of the vulva without any clinical signs such as a vulvar tear. The cause is unknown. Management is difficult and consists of educational support, pelvic floor exercises and use of a lubricant during intercourse. Referral to a gynaecological clinic may be needed.

6. What is dyspareunia?

Pain during intercourse. There are many causes including infections, atrophic vulvovaginitis, vulvar tears and vulvodynia. Management consists of looking for and then treating the cause.

Case study 4

A young woman presents with painful breasts. On taking a history she says the pain starts towards the end of her menstrual cycle and stops once her period begins. Her breasts are normal on inspection and palpation. There are no breast lumps or nipple changes. She is anxious that she has breast cancer.

1. What is the likely diagnosis?

Cyclical mastalgia. This condition is common in young women and caused by the normal hormonal changes during the menstrual cycle. Both breast are affected.

2. Is pain a common symptom of breast cancer?

No. Most breast cancers are not painful.

3. How should this woman be managed?

Explain the cause of the condition and reassure her that it is not breast cancer. Ibrufen can be taken for pain. She should make sure that she wears a well fitting bra.