Chronic Pelvic Pain in Women

Background

• Chronic pelvic pain in women refers to pain with a duration of ≥ 6 months localized to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, lumbosacral back, or buttocks.
• Though often no cause is found, common causes include endometriosis, pelvic adhesions, interstitial cystitis-painful bladder syndrome, and irritable bowel syndrome (IBS).

Evaluation

• Obtain a thorough history of the pain and perform a physical exam to determine any further diagnostic testing required (Strong recommendation).
• Confirm that pelvic pain is:
  • localized to the anatomic pelvis, anterior abdominal wall at or below umbilicus, lumbosacral back, and buttocks
  • may be noncyclic, intermittent, or constant
  • not exclusive to menstruation or intercourse, not associated with pregnancy
  • severe enough to cause functional disability or require medical care
• Consider transvaginal ultrasound for identifying and assessing pelvic masses and to determine the origin of mass as either (Weak recommendation):
  • uterine
  • adnexal
  • bladder-associated
  • gastrointestinal
• Diagnostic laparoscopy may be indicated.
  • Diagnostic laparoscopy is often considered the diagnostic test of choice for diagnosing chronic pelvic pain, however it may be better as a second-line investigation if therapeutic interventions fail (Weak recommendation).
  • Perform diagnostic laparoscopy if the patient has suspected endometriosis or pelvic adhesions requiring surgical intervention (Strong recommendation).

Management

• Medical management:
  • Offer hormonal treatments as the first-line therapy for pain due to dysmenorrhea and for cyclic pain due to endometriosis (Strong recommendation); options include:
    • combined oral contraceptives (continuous use is recommended over cyclic use due to a low side-effect profile and the ability to suppress pain associated with estrogen and progesterone withdrawal)
    • progestins, including:
      • levonorgestrel-releasing intrauterine system
      • medroxyprogesterone acetate (MPA) depot 150 mg every 3 months
    • danazol 400-800 mg/day (give for a minimum of 3 months before trying other medical options)
    • gonadotropin-releasing hormone agonists:
      • depot leuprolide acetate 3.75 mg/month for 3 months is reported to be effective for pain associated with dysmenorrhea and endometriosis
      • consider add-back therapy for long-term use (> 6 months)
  • Offer analgesics for chronic pelvic pain, options include:
    • nonsteroidal anti-inflammatory drugs (NSAIDs) for pain associated with an inflammatory process, such as dysmenorrhea
    • paracetamol (acetaminophen)
  • Consider opioids for chronic, nonmalignant pain refractory to NSAIDs:
    • may be beneficial for a small number of patients
    • requires supervision and should be used in conjunction with a management plan
• Surgical management:
  • Consider laparoscopic surgery (excision or ablation) for:
    • endometriosis lesions (Weak recommendation)
    • pelvic peritoneal defects (pockets) as they are often associated with endometriosis (Weak recommendation)
    • uterine adenomyosis
  • Consider presacral neurectomy in patients with centrally located dysmenorrhea, uterine pain, and/or endometriosis (Weak recommendation).
  • Consider hysterectomy (with or without oophorectomy) for:
    • severe symptoms refractory to other treatment when fertility is no longer desired (Weak recommendation)
    • severe endometriosis or adenomyosis (Weak recommendation)
• Offer psychotherapy as an adjunct to medical treatment as it may improve the response over medical treatment alone.
• Acupuncture, acupressure, and transcutaneous nerve stimulation therapies may decrease pain due to primary dysmenorrhea.