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Presentation of the case: P.J. is a 28-year-old G0 who first visited the family medicine clinic 3 years ago to establish care after relocating to a new geographic area. She also sought consultation regarding a current diagnosis of endometriosis and chronic pelvic pain. She had a history of stage I-II endometriosis for which she had undergone 3 laparoscopies, the last one a year ago when a right ovarian cyst was drained. P.J. continued to have daily pain (6/10 on a pain scale) located in her abdomen and back that required emergency department (ED) visits. She experiences significant dyspareunia, is unable to use vaginal tampons, and is anorgasmic.

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Her current medications include oral contraceptives (for pelvic pain); hydrocodone and acetaminophen daily; gabapentin, 300 mg bid; ibuprofen, 200 mg, up to 6 times daily; venlafaxine, 75 mg hs, for insomnia; and pamelor, 75 mg hs, for depression. Her mother and 2 sisters all have histories of endometriosis. Frequent back pain radiating down her leg results from a 10year-old spinal cord injury. Depression persists. She denies a history of narcotic dependence.
Examination: Examination reveals significant mid and lower right and left quadrant myofascial restrictions, and significant pelvic spasms throughout the vaginal wall. No pelvic masses are found, but there is significant spasm of the anterior portion of the rectovaginal region. No vaginal nodularity is noted. Her uterus is small, anteverted, and nontender. Adnexa are nontender without masses.
History: The patient has had extreme dysmenorrhea since menarche at age 14. Taking conjugated estrogen and gonadotropin-releasing hormone (GnRH) agonists has not alleviated her symptoms Cervical intraepithelial neoplasia grade 1 was diagnosed 3 years ago, and follow-up cervical cytology a year ago showed low-grade intraepithelial lesion (LSIL). P.J. has no history of sexually transmitted infections or pelvic inflammatory disease.
Course of treatment: Physical therapy is recommended for the pelvic floor spasm, and acetaminophen with codeine is prescribed for pain.
When P.J. is seen for colposcopy 3 months later, her hydrocodone and acetaminophen prescription is refilled because of intolerance to acetaminophen and codeine. Colposcopy is normal, but cytology returns a LSIL. She has not initiated physical therapy, although subsequently she does so. She is referred for participation in a study of endometriosis-associated pain but does not meet inclusion criteria. During a subsequent 3-month visit, P.J. reports “excruciating pain,” and she returns to the pain clinic. At this time, she is taking trazodone, 50 mg hs; gabapentin, 2700 mg qd; oral contraceptives; and rosiglitazone, 4 mg qd. She had obtained a prescription for oxycodone, which is refilled, and acetaminophen is added.
Unable to obtain pain relief, with pain at 7/10, a fourth laparoscopy is performed, and a levonorgestrel-containing intrauterine contraceptive device (IUD) is placed. Lysis of adhesions on the posterior aspect of the uterus and of the rectosigmoid and excision of an endometriosis implant in the cul-de-sac are performed. Final histologic study reveals endometriosis. At P.J.’s first postoperative visit, her pain is 10/10, despite her pain medications. (The IUD is later removed because of irregular bleeding.)
Over the next 2 years, she is referred for pain management and narcotic withdrawal, but her chronic pain continues unabated at levels of 10/10 on pain scales. Discussion reveals that she has 4 physicians: a gynecologist who is managing pelvic pain; another gynecologist in the region; a rheumatologist, although she has no history of rheumatologic disorders; and a psychiatrist. A request is submitted to the state automated prescription system to obtain the history of her narcotic prescriptions over the past year. Presented with evidence of having filled 53 different narcotic prescriptions in 1 year, P.J. admits to addictive drug behavior. She is encouraged to go directly to rehabilitation but does not agree to this.
Discussion: This case illustrates the potential for fragmentation of care and underscores the importance of a multidisciplinary approach to the management of chronic pelvic pain. Mareta et al demonstrated that results obtained from this approach can be longer-lasting than those obtained by an individual practitioner.
The primary care practitioner to whom patients often present initially for chronic pelvic pain can introduce patients to consultants and help ensure that they not feel abandoned as “too challenging.” Within this multidisciplinary approach, the patient can understand that the objective is not cure of endometriosis or other pain-causing condition but that of control and management of pain. Clearly, for this patient, opioid management should have been monitored by 1 provider, who would be in charge of enforcing an opioid contract with the patient, see her before each prescription is refilled, and provide medications only in small quantities. Further, refills will not be given if the medication is “lost,” and the patient must agree to alternative strategies for managing her pain.