Guide to Pain Management in Low-Resource Settings

How can I treat sharp, stabbing pains?
Sharp, stabbing pains are usually a form of neuropathic 
pain. Treatment includes neuropathic pain medications 
(e.g., amitriptyline 5–25 mg in the early evening, gaba-
pentin 100–1200 mg daily), regular sleep, regular exer-
cise (start with regular low-level exercise to avoid initial 
worsening of pain), and stress reduction. Start all medi-
cations at a very low dose and increase slowly. Where 
high-level surgical skills are available, excision of endo-
metriosis lesions, if present, can sometimes improve the 
pain, although frequently this type of pain continues af-
ter surgery.
How can I diagnose the cause of dyspareunia?
Dyspareunia (painful intercourse) may be the most dis-
tressing symptom for many women, as it interferes with 
the relationship they have with their husband. She may 
feel that she is letting her husband down when she is 
unable to have intercourse due to pain, and he may feel 
that she is avoiding intercourse because she no longer 
loves him. It is important to identify the cause of the 
problem:
•  Examine the vulva visually for abnormalities (in-
fection, dermatitis, lichen sclerosis).
•  Use a cotton-tipped swab to test for tenderness of 
the posterior fourchette, even if it looks normal 
(to check for vulvar vestibulitis).
•  Use one fi nger in the lower vagina to push back-
wards (to check for pelvic fl oor muscle pain or 
vaginismus). Use one fi nger to push anteriorly (to 
check for bladder or urethral pain).
•  Use one or two fi ngers to check the upper vagina 
for nodules of endometriosis, pelvic masses, or 
uterine fi xation. Push the cervix to one side to 
check for contralateral adnexal pain (to check for 
endometriosis, ovarian cysts, pelvic infection, or 
adhesions).
•  Use a speculum to look for cervicitis, vaginal in-
fection, vaginal anomaly, or endometriotic nod-
ules in the posterior vaginal fornix.

232
Susan Evans
If any part of the examination causes pain, ask the 
patient if this is the same pain she has with intercourse. 
It is important to examine the lower vagina gently with 
one fi nger before using the speculum, or pelvic fl oor/
bladder pain may be missed. Generalized dyspareunia, 
especially where sharp pains are present, may be neu-
ropathic. Include in the consultation a discussion about 
the relationship she has with her husband and whether 
he is supportive of her.
How can I help my patient                                   
with a painful vulva (vulvodynia)?
General vulval care is often helpful. Th
  e patient should 
not use soap and should avoid vulval products such 
as talc or oils. Recommend aqueous cream as a soap, 
soother, and daily vulval moisturizer. Recommend cot-
ton underwear and loose clothing.  Treat any vaginal 
infection. Prescribe amitriptyline 5–25 mg at night or 
an anticonvulsant for vulval pain if present.  For vulvar 
vestibulitis, prescribe a course of oral ketoconazole (an-
tifungal) 200 mg and betamethasone cream (0.5 mg/g) 
applied thinly daily for 3 weeks. For lichen sclerosis, 
prescribe steroid cream applied thinly daily for intermit-
tent courses only when symptoms are present.
How can I help my patient                                  
with painful pelvic muscles?
Th
  e muscles are in spasm and do not relax normally. 
Th
  is type of pain can be secondary to painful bladder 
symptoms, any type of pelvic pain, previous sexual as-
sault, or anxiety regarding sexual intercourse. Pain is se-
vere, just as pain from back spasms can be severe. Typi-
cal symptoms include dyspareunia (with pain for 1–2 
days afterwards), pain on moving, pain with insertion of 
a fi nger or a speculum, and pain with tampons. Th
 ere 
may be pain on prolonged sitting. Pelvic fl oor  muscle 
spasm is involuntary, and the patient cannot “just relax.” 
Th
  e best treatment involves pelvic fl oor physiotherapy, 
instruction in relaxation techniques, and the regular use 
of vaginal dilators in a relaxed, secure, nonpainful situ-
ation. Intercourse should be avoided until the problem 
has resolved because the problem will worsen with re-
peated painful intercourse. If intercourse continues, 
a vaginal lubricant and a slow approach to intercourse 
may help. Other treatments include:
• Resolution of initiating factors, e.g., bladder 
symptoms/pelvic pain.
•  Avoid straining with voiding or trying to stop 
passing urine in mid-void.
•  Regular gentle exercise (e.g., walking, stretching, 
gentle yoga), improved posture, sitting square in 
a comfortable chair with good support, keeping 
both feet fl at on the fl oor when sitting, and taking 
regular breaks.
•  Heat packs to the pelvis and a warm bath 1–2 
times daily for 3–6 weeks
•  Management of anxiety and depression, if present.
When should I refer my patient                        
with pelvic pain to a surgeon?
Surgery should be considered where nonsurgical treat-
ments have failed. Laparoscopy is preferred to laparoto-
my where it is safe and available. However, laparoscopy 
requires advanced surgical equipment and skills, and 
major surgical complications do occur. It is therefore 
important to try nonsurgical options fi rst. Endometrio-
sis surgery is frequently diffi
  cult and requires the best 
surgical skills available. Situations that suggest severe 
disease, possibly requiring a bowel surgeon as well as a 
gynecologist, include:
• Th
  e presence of ovarian endometriomas.
•  Nodules of endometriosis palpable in the recto-
vaginal septum.
•  An immobile uterus.
•  Pain opening the bowels during the menstrual 
period.
In premenopausal women, if postoperative estro-
gen replacement is unavailable, bilateral oophorec-
tomy should be avoided, if possible. Endometriomas 
in young women should be managed with cystectomy 
rather than oophorectomy in most cases. Drainage 
alone of an endometrioma is usually followed by rap-
id recurrence.
What are common barriers to 
eff ective pain management?
A long delay between the beginning of symptoms and 
the diagnosis and management of pelvic pain is com-
mon for many reasons. Th
 e patient’s family may not 
believe that her pain is real and severe, she may believe 
that severe pain with periods is normal, or her local 
doctor may believe that she is too young for endome-
triosis or underestimate how severe her pain is.
Other barriers to eff ective pain management include 
fear of gynecological examination, especially where a 
female doctor is unavailable; fear of surgery, infertility, 
and cancer; and fear of the unknown.

Dysmenorrhea, Pelvic Pain, and Endometriosis
233
It is therefore important to explain to the patient 
and her family:
• Th
  e pain is real, and the pain is not her fault.
•  She does not have cancer, and her pain is not life-
threatening.
•  Although it may not be possible to completely 
cure all her pain, she can optimistically look for-
ward to less pain and living better with what pain 
remains. It is important to be positive.
•  Resources she can contact if she needs help.
•  What extra pain relief she can use if the pain be-
comes more severe; her anxiety will decrease 
when she knows that she can manage pain if it 
occurs.
•  To ensure that she is not overworked, because 
tiredness will worsen her pain.
•  To ensure that she has activities in her life that 
she enjoys.
What should I ask                                
at follow-up visits?
Follow-up assessments are important because the pain 
will vary over time, and the patient will need continued 
support to be well. At each follow-up:
•  Ask about each of the pains she reported at her 
fi rst visit to assess progress. Pain that has been 
resolved is often forgotten. She may feel that no 
progress has been made if any pains remain.
•  Ask about any new pains. Ask about sexual func-
tion. Off er treatment for any new pains.
•  Discuss lifestyle issues again, such as regular ex-
ercise, healthy diet, stress management, relation-
ship issues, and activities that she enjoys.
•  Make sure she understands that her pain may 
change over time but that help is available if she 
needs it.
Pearls of wisdom
•  Most women with chronic pelvic pain have sever-
al diff erent pain symptoms. Each pain needs to be 
assessed, and a treatment plan made. Pelvic pain 
cannot be considered as a single entity.
•  Many common causes of pelvic pain cannot be 
seen during an operation, including bladder pain, 
neuropathic pain, uterine pain, pelvic fl oor mus-
cle pain, and bowel pain. Some women have en-
dometriosis  and all these other pains. Migraine 
headaches are also common.
•  Women with chronic pain who appear “worn 
down” emotionally or depressed often have a 
neuropathic component to their pain. Th
  is will be 
worse if the patient is stressed or overworked.
•  Recognize that many women have had pain for 
long periods of time, resulting in loss of confi -
dence, employment and education opportunities, 
relationships, and sometimes fertility.
•  It is important that the patient’s family value her 
health and happiness, and that she has activities 
in her life that bring her joy, relaxation, and satis-
faction. “Fit, happy people have less pain.”
•  Recognize that while surgery can be very helpful, 
it does not cure all pain. Th
  e decision whether to 
proceed to surgery or use nonsurgical treatment 
will depend on the surgical facilities available.
•  Be careful to explain the pain to the patient and 
make sure she knows that you believe in her pain. 
Most women with this type of pain have been 
told that “it is all in their head,” which lowers their 
self-esteem.
•  Make sure that the family knows that the pain is 
real. Th
  e patient will need the support of her fam-
ily to access care.
References
[1]  Evans S. Endometriosis and pelvic pain. Available from: www.drsusane-
vans.com. (An easy-to-read book for patients that explains how to diag-
nose and treat many types of pelvic pain.)
[2]  Howard FM. Pelvic pain: diagnosis and management. Lippincott Wil-
liams and Wilkins; 2000. (A textbook for doctors describing all aspects 
of pelvic pain in detail.)
[3]  Stein A. Heal pelvic pain. Available from: www.healpelvicpain.com. (A 
book for patients with all types of musculoskeletal pelvic pain.)
Websites
www.endometriosis.org (world forum for patients and doctors)
www.endometriosisnz.org.nz (for teenagers with endometriosis)
www.ic-network.com (for bladder symptom information)

235
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. All rights reserved. Th
  is material may be used for educational 
and training purposes with proper citation of the source. Not for sale or commercial use. No responsibility is assumed by IASP for any injury and/or damage to persons or property 
as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the 
medical sciences, the publisher recommends that there should be independent verifi cation of diagnoses and drug dosages. Th
  e mention of specifi c pharmaceutical products and any 
medical procedure does not imply endorsement or recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.
Guide to Pain Management in Low-Resource Settings
Chapter 31
Pain  Management  Considerations                                                             
in Pregnancy and Breastfeeding
Michael Paech
Case report 1 (analgesics in 
pregnancy)
You are visited by a woman, Shillah, and her partner, 
Alusine, from a large rural town. Th
 ey have recently 
married, and they plan to move to the regional city and 
stay with relatives because they are hoping to start a 
family. Alusine says: “Doctor, my wife has bad back and 
leg pain, and every day she takes medication prescribed 
by the local doctor. We are trying to have a baby, so I am 
worried about how those drugs might aff ect the baby. Is it 
okay for her to keep taking them?”
You ask Shillah about her pain, and learn that 
she has had it for over a year since a motor vehicle ac-
cident in which she broke some lumbar vertebrae. Th
 e 
pain has persisted and is a burning sensation that radi-
ates from the low back down through the buttock past 
the back of her knee, often occurring at night when she is 
lying quietly. She also has an area near her spine in the 
lower back that tingles and feels sore, even when it is only 
touched lightly. He doctor has tried her on several diff er-
ent analgesic drugs, and the only one that helps a little is 
a tablet she takes at night before bed, although she is also 
taking an anti-infl ammatory drug, and she takes some 
codeine when the pain is bad—but it makes her consti-
pated, so she doesn’t like to use it much. On examination 
she has no obvious spinal abnormality. You later learn 
she is taking a low dose of amitriptyline (10 mg) at night, 
regular diclofenac (100 mg twice a day), and codeine 
(30–60 mg every 6 hours as required, but only once or 
two days each fortnight).
Should you be concerned about prescribing 
pain killers in a pregnant or lactating woman?
We should be cautious about prescribing any drug to 
a pregnant woman! Nevertheless, almost 90% of wom-
en take prescribed drugs during pregnancy. Although 
the incidence of analgesic use during pregnancy varies 
across diff erent countries, it is probably 5–10% during 
the fi rst trimester and is likely to be much higher in later 
pregnancy. Th
  e incidence of perinatal use of illicit drugs 
(including opioids) also varies widely, but it ranges from 
10% to 50%. Th
 us, it is extremely common for preg-
nant women and their fetuses to be exposed to drugs 
relevant to pain management during pregnancy and 
lactation. Th
 e incidence of fetal abnormalities among 
live births is approximately 2%, so this background 
rate should be considered when comparing rates in the 
whole pregnant population with those among women 
taking specifi c drugs.
Despite the prevalence of their use, there is very 
little information about the eff ects of analgesic drugs 
being taken prior to conception on fertility. Th
 ere are 
limited human epidemiological or observational data 
on the eff ects of pain-relieving drugs during early preg-
nancy. With the exception of aspirin and the nonsteroi-
dal anti-infl ammatory drugs (NSAIDs), the embryo ap-
pears protected in the fi rst 2 weeks. Th
  e fetus is most 

236
Author(s)
at risk during the period of organogenesis, between 17 
and 70 days postconception; however, the use of some 
drugs during the second and third trimesters of preg-
nancy can also cause organ abnormalities, especially 
in the central nervous and cardiovascular systems. It is 
thus important to know, in detail, the potential risks as-
sociated with analgesic drug administration at any stage 
of pregnancy.
Fortunately, we know it is likely that millions 
of women have taken some of the commonly used 
pain killers, both at the time of conception and dur-
ing early pregnancy. For a number of analgesic drugs, 
extensive clinical experience indicates a very low risk 
of problems, which is reassuring. When clinical in-
formation is combined with analysis of animal data 
about potential teratogenic or carcinogenic eff ects, 
or data about how much drug is transferred into the 
breast milk, the level of concern about a drug can be 
estimated. Consequently, regulatory bodies and edu-
cational organizations in many countries have classi-
fi ed drugs into risk categories that are used to guide 
a risk versus benefi t assessment in the pregnant and 
lactating woman. For example, there is no evidence 
that opioids are risky in early pregnancy, but they may 
cause depression of the neonate at birth, so most opi-
oids are classifi ed as drugs that have harmful but re-
versible pharmacological eff ects on the human fetus 
or neonate, without causing malformations.
It is imperative to relieve maternal suff ering, but 
at the same time, harm to the fetus should be avoided. 
Breastfeeding is also a critical imperative for optimizing 
the infant’s health, possibly with life-long benefi ts. It is 
important that we know where to look and are able to 
access information about these topics when specifi c in-
formation is required.
What would be the ideal approach to pain 
management in pregnancy and lactation?
During and immediately prior to pregnancy, nonphar-
macological pain management options should be con-
sidered and explored before analgesic drugs are used. 
Ideally, if available in the regional city, and prior to 
Shillah becoming pregnant, she should be reviewed by 
a group of health care providers, particularly those with 
an interest in pain medicine and clinical experience 
dealing with patients with diffi
  cult  pain  management 
problems. In Shillah and Alusine’s case, for example, 
this group might include an orthopedic surgeon, a reha-
bilitation physician, an obstetrician, a family doctor, an 
anesthetist or pain specialist, a physiotherapist, a chi-
ropractor, a psychologist, a pharmacist, and/or a com-
munity nurse. Th
 is multidisciplinary team approach 
will optimize her care, and regular review of her pain 
management can be organized. Shillah may well have 
physical and psychological factors contributing to 
her pain that can be treated in various ways, includ-
ing physical therapies and even invasive pain therapy 
procedures or surgery, such that her reliance on drugs 
might be reduced or even eliminated. Th
  e latter would, 
of course, solve all the issues related to the potential 
pharmacological toxicities of drugs administered dur-
ing pregnancy. Even if drug treatment remains the only 
way of controlling her pain, her response to the types 
of drugs, their doses, and the regimens prescribed will 
need to be reviewed once she becomes pregnant and 
as pregnancy advances.
What would your advice be                                   
for Shillah and Alusine?
Shillah has chronic nonmalignant pain with neuro-
pathic features, and you should refer to the chapters 
on back pain and neuropathic pain for information. 
You also need to be in a position to advise her about 
the specifi c risks of the drugs she is currently taking 
and about any risks associated with alternative drugs. 
First, what about a tricyclic antidepressant such as am-
itriptyline, an NSAID such as diclofenac, and an opioid 
such as codeine?
It is important to be honest and transpar-
ent in all communication. Although there can be no 
guarantees of complete safety with any drug, and be-
cause controlling neuropathic pain can be challenging, 
it is not necessary for her to abandon all pain killers. 
Indeed, there is no evidence that continuing amitrip-
tyline in early pregnancy signifi cantly increases the 
risk of malformations. Th
  is is a drug many pregnant 
women have used, so the couple can be reassured of its 
relative safety, and it could be continued. Th
 e NSAIDs 
such as diclofenac and indomethacin (and a similar 
drug, aspirin) are not eff ective against neuropathic 
pain but may be very helpful for a few days for mus-
culoskeletal or postoperative wound pain. However, 
unless there is active infl ammation, which is unlikely 
in Shillah’s case, they should not be continued long-
term. Although these drugs do not cause fetal mal-
formations, they adversely infl uence fertility, increase 
the risk of miscarriage by interfering with blastocyst 
implantation, and can cause serious problems in late 

Chapter Title
237
pregnancy (see below). You should advise Shillah to 
stop the diclofenac, and if available to try paracetamol 
(acetaminophen) instead, this being a much safer op-
tion. Although it is not ideal, there is no reason why 
Shillah should not continue to take codeine when she 
needs it (at a maximum dose of 240 mg per day), es-
pecially if you check her diet and advise her as to how 
to reduce her risk of constipation. Codeine has been 
used by many pregnant women and is considered safe 
for the fetus in early pregnancy. Th
 e main problem 
with codeine is that some people lack the liver enzyme 
required to demethylate it to its active metabolite, 
morphine, rendering it completely ineff ective.  Other 
people are ultrarapid codeine metabolizers and will ex-
perience higher plasma concentrations and more side 
eff ects (sedation, dysphoria, constipation, and neonatal 
depression), even after small to modest doses.
Are there any other analgesics that 
might  be  available  when  Shillah  attends                              
the large city hospital?
Th
  ere are some other pain killers that might prove more 
eff ective or cause fewer side eff ects. Instead of codeine, 
oxycodone (5–15 mg repeated as required) is an ex-
ample of an oral opioid, eff ective against moderate to 
severe pain, which causes less constipation. Long-term 
opioid administration continued until delivery of the 
baby has some signifi cant disadvantages, however (see 
case 3 below), so it would be essential to confi rm  that 
Shillah’s pain is opioid-sensitive. She could be admitted 
to hospital, her pain evaluated (pain scores, functional 
disability, and opioid-related side eff ects) and docu-
mented, and then the opioid introduced at a low dose, 
escalating the dose over a few days until the drug is ef-
fective with acceptable side eff ects, or until failure (lack 
of eff ect, or benefi t limited by excessive side eff ects).
Another possibility is tramadol, which has oral 
and intravenous formulations. Doses of 400–600 mg 
per day are eff ective against both acute pain and neu-
ropathic pain. Tramadol has several antinociceptive ac-
tions (serotoninergic, noradrenergic, and weak mu-opi-
oid activity from its principal metabolite), is useful for 
moderate to severe pain, and does not cause respiratory 
depression. Tramadol should be avoided in women who 
are at increased risk for seizures, such as those with 
preeclampsia or eclampsia, or those taking other drugs 
that increase central nervous system levels of serotonin. 
Common side eff ects are nausea and dizziness. Animal 
studies indicate that tramadol is a low-risk drug for fetal 
abnormalities, but experience in early pregnancy is very 
limited, so it would be preferable to use an opioid in-
stead for Shillah. After the period of organogenesis, lim-
ited data suggest that tramadol is probably of low risk to 
the fetus, although high dosing near delivery should be 
avoided (see case 3 below).
In some countries, transdermal clonidine patch-
es (100 μg/day) are available, but clonidine is of ques-
tionable eff ectiveness, and despite extensive clinical use 
during pregnancy without evidence of causing congeni-
tal abnormalities, data on its safety in the fi rst trimester 
are very limited. Th
  erefore, the use of clonidine is not 
recommended.