Chronic pelvic pain (CPP) and other pain conditions related to women’s reproductive health are underdiagnosed, under-treated, and often misunderstood. For GPs, early recognition and appropriate management of these conditions are crucial, not only to alleviate pain but to improve quality of life, fertility outcomes, and long-term health.
This article explores the key pain conditions linked to women’s reproductive health, highlights evidence-based management strategies, and provides practical guidance on when and how to escalate care or refer to specialists.
The Scope of the Problem
Chronic pelvic pain affects approximately 1 in 9 Australian women, with conditions such as endometriosis, adenomyosis, and vulvodynia contributing significantly to the burden. Yet, the average diagnostic delay for endometriosis remains 6–8 years, underscoring the need for greater GP awareness and timely intervention.
Pain in women’s reproductive health is not limited to gynaecological causes – it often intersects with musculoskeletal dysfunction, gastrointestinal disorders (IBS), urinary conditions, and mental health factors, making a biopsychosocial approach essential.
Common Pain Conditions in Women’s Reproductive Health
1. Endometriosis
- Affects ~11% of women of reproductive age.
- Presents with dysmenorrhoea, chronic pelvic pain, dyspareunia, and infertility.
- Pain is often cyclical but can become non-cyclical in advanced disease.
2. Adenomyosis
- More common in women over 35.
- Features heavy menstrual bleeding, dysmenorrhoea, and diffuse pelvic pain.
3. Pelvic Floor Dysfunction
- Includes pelvic floor myalgia or hypertonicity, often presenting with dyspareunia or defecatory pain.
4. Vulvodynia/Vestibulodynia
- Chronic vulvar pain without clear pathology, frequently linked to neuropathic mechanisms.
5. Other Causes
- Ovarian cysts, pelvic inflammatory disease (PID), irritable bowel syndrome (IBS), and urinary tract disorders often overlap, compounding pain complexity.
Key Considerations in Pain Assessment
A comprehensive assessment is critical:
- Detailed history: Timing of pain (cyclical vs non-cyclical), association with menstruation, intercourse, bowel/bladder symptoms.
- Pain mapping and scoring tools: (e.g., VAS, PainDETECT for neuropathic features).
- Psychosocial screening: Depression, anxiety, sexual health, trauma history.
- Physical examination: Pelvic exam (where appropriate), musculoskeletal screen for pelvic girdle or lower back contributions.
- Imaging: Transvaginal ultrasound is first-line for endometriosis and adenomyosis; MRI may be indicated for complex or deep disease.
Management Strategies
1. Education and Validation
- Acknowledge the patient’s experience and explain pain mechanisms, especially the overlap of central sensitisation in chronic pain.
- Validate their symptoms: “Your pain is real, and it’s important we address it holistically.”
2. Pharmacological Approaches
- First-line for dysmenorrhoea/pelvic pain: NSAIDs (commence before menses).
- Hormonal therapies:
- Combined oral contraceptives (continuous or cyclic use).
- Progestins (e.g., norethisterone, dienogest).
- Levonorgestrel IUD (Mirena) for adenomyosis or endometriosis-associated pain.
- Neuropathic pain agents: Consider TCAs, SNRIs, or gabapentinoids for vulvodynia or centralised pain (often in conjunction with specialist input).
3. Non-Pharmacological Interventions
- Pelvic floor physiotherapy for hypertonicity or dyspareunia.
- Diet and bowel health support for overlapping IBS.
- Pain psychology: CBT, ACT, mindfulness for pain modulation.
4. Referral Pathways
Refer to:
- Gynaecology: For persistent pelvic pain, abnormal imaging, infertility concerns, or suspected endometriosis.
- Pelvic health physiotherapy: For musculoskeletal contributors or pelvic floor dysfunction.
- Pain specialist or multidisciplinary pain clinic: For refractory pain, neuropathic features, or functional decline.
Red Flags for Immediate Referral
Urgent referral or ED presentation is warranted for:
- Acute severe pelvic pain (e.g., ovarian torsion).
- Signs of infection/sepsis (fever, purulent discharge).
- Suspicious adnexal mass or malignancy features.
The GP’s Role in Long-Term Pain Management
- Coordinate care: Act as the central point between gynaecologists, pain specialists, physiotherapists, and psychologists.
- Regularly review treatment efficacy: Adjust pharmacological and non-pharmacological strategies.
- Address mental health and social impact: Provide referrals to counselling, sexual health services, or support groups (e.g., Endometriosis Australia).
- Promote self-management: Encourage exercise, pacing strategies, and patient education resources.
Pain in women’s reproductive health is multifactorial and often chronic, requiring a holistic, team-based approach. For GPs, early recognition, empathetic validation, and evidence-based management—including timely referrals—can dramatically improve outcomes.
By addressing reproductive health pain proactively and collaboratively, GPs can play a pivotal role in reducing diagnostic delays, improving function, and enhancing quality of life for female patients.
