The following groups of patients should be considered for multidisciplinary therapy early in the management process: (i) no obvious pathology, (ii) pathology that has an equivocal role in pain production, (iii) poor response to traditionally effective medical or surgical management, (iv) more than one visceral or somatic structure involved in the production of pain (i.e., more than one “pain generator”), (v) significant stress, anxiety, posttraumatic stress disorder, or depression, (vi) history of past or current physical, emotional, or sexual trauma.
Any patients with dysmenorrhea or pain that worsens in the luteal or menstrual phase should be given hormonal agents to suppress ovulation and/or menses, as discussed above.
Patients with neuropathic pain or those with evidence of central sensitization or myofascial pain benefit from agents that alter neural processing. A low dose of a tricyclic antidepressant, various anticonvulsants, or selective serotonin/norepinephrine reuptake inhibitors are often effective, especially if combined with cognitive behavioral therapy. These pharmacologic agents lower the threshold for nerve firing and can help reduce reliance on narcotic pain medication, increasing activity and relieving the impact the pain has on the women’s overall lifestyle (11). Only one small, randomized controlled trial looked at the effect of selective serotonin reuptake inhibitors on pelvic pain, and failed to show a significant difference in pain or functional ability in a short follow-up period (138).
Anticonvulsants such as gabapentin or pregabalin are useful for treatment of chronic pelvic pain. Gabapentin plus amitriptyline was more efficacious than amitriptyline alone (139).
Local anesthetics are sodium channel blockers and they downgrade nerve firing. Ilioinguinal iliohypogastric, pudendal, nerve blocks and trigger point injections can be easily learned by the gynecologist and used liberally where appropriate to down-regulate neural signaling (11).
Women with depression should be treated with an appropriate therapeutic dose of antidepressant medication. Psychiatry can be consulted in this setting.
The role of opioid therapy in chronic pain is controversial and randomized controlled trials are lacking. Long-term management of chronic pelvic pain with narcotic medications is considered a last resort after failure of all other treatment modalities. Opioids should be given on a scheduled basis, and patients should have consistent follow-up with evaluation of the extent of pain relief, level of function, and quality of life. Physicians should carefully document failure of other treatment options and patient counseling. Narcotics should be prescribed only with a narcotic contract. The patient should sign a written contract agreeing to obtain pain medications from only one provider and describing other expectations with respect to treatment. Some other points that the patient should agree to include no early refills or increasing dosage of medication without discussion with the doctor, no alcohol or illegal drugs, random blood or urine drug screens if needed, and psychiatric or psychological evaluation if needed (140).
Physical Therapy Physical therapy (PT) procedures restore tissue and joint ﬂexibility, improve posture and body mechanics, restore strength and coordination, reduce nervous system irritability, and restore function. PT is an important component of the management of patients with myofascial pain in the abdominal wall, pelvic ﬂoor, or lower back (141).