Pain at Midlife

Gynecologic Sources of Pain

Chronic pelvic pain in perimenopausal and postmenopausal women can be due to a variety of gynecologic disorders, including benign or malignant tumors, interstitial cystitis, pelvic adhesions, or vulvodynia. Nongynecologic conditions, such as colorectal tumors, colitis, irritable bowel syndrome, and diverticular disease, may also be causes of pelvic pain. Two of the most common causes of pelvic and vulvar/vaginal pain among midlife women are fibroids and vulvodynia/dyspareunia.

Leiomyomas, commonly referred to as fibroids, are common, benign pelvic tumors that are present in both premenopausal and postmenopausal women. These are the most frequent cause of gynecologic surgery in the United States, accounting for one third of hysterectomies each year.^[27] Fibroids are a common finding in women undergoing surgery for pelvic pain.^[28] Cramer and Patel found fibroids in 74% of premenopausal women and 84% of postmenopausal women undergoing hysterectomy not specifically for fibroids.^[29] Although this is a biased sample, it suggests the prevalence of fibroids is higher than previously appreciated, because symptoms are experienced by only 20% to 50% of women with one known fibroid.^[30] When fibroids are symptomatic, the most common symptoms reported include abnormal uterine bleeding, pelvic pain or pressure, decreased capacity of the urinary bladder, constipation, back pain, and reproductive dysfunction.

Fibroid tumors have both estrogen and progesterone receptors and respond to hormonal stimulation. Enlargement during the reproductive years may cause increases in severity and frequency of symptoms. Because fibroids are slow growing, significant changes in size may take months or years, and some may remain stable for long periods of time. After menopause, fibroids commonly regress because of the reduced levels of estrogen and progesterone. In a recent population study on fibroid-associated symptomatology, the question about the generalizability of pain symptoms and presence of fibroids has raised questions about data collected in the past, which was primarily derived from self-selected populations of women seeking gynecologic care.^[31]

The pain associated with fibroids is related to their location and size. Posterior fibroids can cause lower back pain, and those found in the broad ligament may cause unilateral lower abdominal pain or may compress the sciatic nerve. Anterior fibroids may cause bladder compression and may be felt by the woman as painful, especially during a bimanual examination. Very large fibroids can cause dyspareunia, difficulty with urination, and/or defecation.

Theoretically, women taking HT may be at more risk for postmenopausal pain if they have fibroids because HT can potentially stimulate fibroid growth. However, there are no data to indicate whether postmenopausal women note clinical changes in pain level. Generally, no treatment is necessary for fibroids after the menopause. If the patient is experiencing pain or postmenopausal bleeding, a workup for other possible causes, including neoplasm, is necessary.

Cite this: Pain at Midlife - Medscape - Nov 01, 2004.

Table 1. Medications for Prophylaxis Against Migraines
Category	Drug	Brand Name	Dose/Day
Beta blockers*	Atenolol	Tenormin	50-150 mg
	Metoprolol	Lopressor	50-300 mg
	Nadolol	Corzide, Corgard	20-160 mg
	Propranolol	Inderal, Inderide	40-240 mg
	Timolol	Blocadren	10-60 mg
Calcium channel blockers	Verapamil	Calan	120-480 mg
		Calan SR
		Covera-HS
		Isoptin SR
		Tarka
		Verelan PM
	Diltiazem	Cardizem	90-180 mg
	Nifedipine	Procardia	30-120 mg
Serotonin antagonists/agonists antidepressants (tricyclics)	Cyproheptadine	Periactin	4-12 mg
	Amitriptyline	Elavil	10-150 mg
	Nortriptyline	Pamelor	10-150 mg
	Doxepin	Sinequan	10-150 mg
	Imipramine	Tofranil	10-150 mg
Antidepressants (selective serotonin-reuptake inhibitors)	Fluoxetine	Prozac	10-80 mg
Antidepressants (selective serotonin-reuptake inhibitors)	Trazodone	Desyrel	50-300 mg
Anticonvulsants	Divalproex sodium	Depakote	250-1500 mg
Anticonvulsants	Gabapentin	Neurontin	300-2700 mg

* Noncardioselective beta blockers may take up to 3 months for effectiveness; always taper the dose when discontinuing.

Table 2. Medications Prescribed for Abortive Treatment of Migraine Headaches
Category	Drug	Brand Name	Dose/Day
"Triptans" 5HT₁ serotonin receptor agonists*	Sumatriptan	Imitrex	SQ: 6 mg SQ, one time dose; maximum is 12 mg/day SQ PO: 25-50 mg PO; maximum 100 mg per dose or repeat q 2 h for maximum 300 mg/24 h Nasal: 5-20 mg nasal, q 2 h; maximum of 40 mg/24 h
	Rizatriptan	Maxalt	5-10 mg PO, repeat q 2 h; maximum 30 mg/24 h
	Zolmitriptan	Zomig, Zomig ZMT	2.5-5 mg PO, repeat q 2 h; maximum 10 mg/24 h Orally disintegrating tablet (ZMT) 2.5 mg q 2 h; maximum 10 mg/day
	Naratriptan	Amerge	1-2.5 mg PO, repeat after 4 h; maximum 5 mg/24 h
	Almotriptan	Axert	6.25-12.5 mg PO; repeat q 2 h maximum 12.5/24 h
	Frovatriptan	Frova	2.5 mg PO; repeat after 2 h; maximum 7.5 in 24 h
	Eletripan	Relpax	20-40 mg PO; repeat after 2 h, maximum 80 mg/24 h
"Ergot" derivatives alpha adrenergic blockers^‡	Ergot	Migranal nasal spray	1 spray q nostril repeat 15 min; maximum 6 sprays/24 h and 8 sprays/wk
	Ergot alkaloid with caffeine	Cafergot	Oral dose: 1 mg ergotamine/100 mg caffeine; 2 tabs PO at onset followed by 1 tab q 30 min up to maximum of 6 tabs/24 h; maximum dose is 6 tabs per attack and 10 tabs/wk
	Ergot alkaloid with caffeine	Cafergot suppositories	Suppositories 2 mg ergotamine/100 mg caffeine. 2 per attack or maximum of 5 supp/wk
Others	Butabarbital + acetaminophen + caffeine	Fioricet, Esgic	50 mg/325 or 500 mg/40 mg; 1-2 tab PO q 4 h; maximum 6 daily
	Acetaminophen + aspirin + caffeine	Excedrin Migraine	250 mg/250 mg/65 mg; 2 tabs PO q 6 h; maximum 8 tabs/24 h for 2 days
	Isometheptene mucate/dichloralphenazone/acetaminophen	Midrin	65 mg/100 mg/325 mg; 1-2 caps PO q 4 h max 8 caps/24 h
	Ibuprofen	Motrin, Advil	200 mg-800 mg q 6 h

* Serotonin receptor agonists are selective for a 5-hydroxtryptamine receptor subtype that mediates vasoconstriction and are present on cranial arteries, basilar artery, and the vasculature of dura mater.
Alpha adrenergic antagonists stimulate the smooth muscle of peripheral and cranial blood vessels, cause depression of central vasomotor and inflammatory centers, and antagonize serotonin.
^‡ Ergot alkaloids interact with 5HT₁ agonists and should not be given concomitantly. Ergots are contraindicated in pregnancy.

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