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ACOG Issues New Guidelines for Chronic Pelvic Pain

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Charles Vega, MD, FAAFP
  • CME Released: 3/11/2004; Reviewed and Renewed: 3/11/2005
  • Valid for credit through: 3/11/2006
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Target Audience and Goal Statement

This article is intended for primary care physicians, obstetrician-gynecologists, and other physicians who care for women with chronic pelvic pain.

The goal of this activity is to provide the latest medical news to physicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • List common etiologies for chronic pelvic pain.
  • Describe the effectiveness of various treatments for chronic pelvic pain.


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  • Laurie Barclay, MD

    Laurie Barclay is a freelance writer for Medscape.


    Disclosure: Dr. Barclay has reported no significant financial interests.


  • Gary Vogin, MD

    Senior Medical Editor, Medscape


    Disclosure: Gary Vogin, MD, has disclosed no relevant financial relationships.

CME Author(s)

  • Charles P Vega, MD

    Associate Professor, Residency Director, Department of Family Medicine, University of California, Irvine


    Disclosure: Dr. Vega has disclosed that he has received grants for educational activities from Pfizer.

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ACOG Issues New Guidelines for Chronic Pelvic Pain

Authors: News Author: Laurie Barclay, MD CME Author: Charles Vega, MD, FAAFPFaculty and Disclosures

CME Released: 3/11/2004; Reviewed and Renewed: 3/11/2005

Valid for credit through: 3/11/2006


This activity was originally released on March 11, 2004. It was reviewed and renewed in its original form on March 11, 2005.

March 11, 2004 -- The American College of Obstetricians and Gynecologists (ACOG) has developed new guidelines for the clinical management of chronic pelvic pain and published them in the March issue of Obstetrics and Gynecology.

After reviewing the available literature on chronic pelvic pain in women, the panel concludes that the condition may be far more common than previously recognized, and that specific diagnosis and effective management are often difficult.

"Many gynecologic and nongynecologic disorders appear to cause or be associated with chronic pelvic pain," write Fred Howard, MD, and colleagues from the ACOG Committee on Practice Bulletins -- Gynecology. "Treatment usually is directed to specific diseases that cause chronic pelvic pain, but sometimes there is no clear etiology for pain, and treatment must be directed to alleviating the symptoms."

The proposed definition of chronic pelvic pain is noncyclical pain of at least six months' duration involving the pelvis, anterior abdominal wall, lower back, and/or buttocks, and serious enough to cause disability or to necessitate medical care. Approximately 15% to 20% of women aged 18 to 50 years have chronic pelvic pain lasting more than one year, according to the authors.

Specific causes may include endometriosis, interstitial cystitis, or irritable bowel syndrome, but examination and testing are often nondiagnostic. Because negative workup does not rule out physical causation, ACOG notes that it "does not negate the significance of a patient's pain."

Although 40% to 50% of women with chronic pelvic pain have a history of physical or sexual abuse, which could explain psychologic or neurologic components of pain, research also suggests that trauma may heighten physical sensitivity to pain.

Treatment options supported by good, consistent scientific evidence (level A) include combined oral contraceptives for primary dysmenorrhea; gonadotropin-releasing hormone agonists for pain associated with endometriosis and irritable bowel syndrome; COX-2 inhibitors and other NSAIDs for moderate pain, especially for menstrual pain; progestins in daily, high doses for chronic pain associated with endometriosis and pelvic congestion syndrome; and laparoscopic destruction of stages I to III endometriotic lesions.

Treatment options supported by only limited or inconsistent evidence (level B) include sacral nerve stimulation, which is effective in up to 60% of women; vitamin B1 or magnesium supplements for dysmenorrhea; trigger point injections into the abdominal wall, vagina, and sacrum; magnetic field therapy of abdominal trigger points to improve disability and reduce pain; and acupuncture, acupressure and transcutaneous nerve stimulation (TENS) therapies for primary dysmenorrhea. Hysterectomy for relief of pain associated with reproductive tract symptoms is effective in 75% to 95% of women.

Obstet Gynecol. 2004;103:589-605

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