June 3, 2008 — Management of chronic pelvic pain in women is reviewed in an article published in the June 1 issue of the American Family Physician.

"A useful clinical definition of chronic pelvic pain is noncyclic pain that lasts six months or more; is localized to the pelvis, the anterior abdominal wall at or below the umbilicus, or the buttocks; and is of sufficient severity to cause functional disability or require medical care," writes David D. Ortiz, MD, from CHRISTUS Santa Rosa Family Medicine Residency Program, in San Antonio, Texas. "Other definitions do not require that the pain be noncyclic. Because the definition of chronic pelvic pain varies, it is difficult to ascertain its exact prevalence."

In women, the cause of chronic pelvic pain is poorly understood, and most cases do not result in a specific diagnosis. However, frequent causes include endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis.

Initial evaluation should include a history and physical examination to narrow the differential diagnosis, guide additional testing, and rule out a malignant neoplasm or significant systemic disease. When the results of the history and physical examination are unrevealing, limited laboratory testing and ultrasound imaging can elucidate the diagnosis, rule out serious disease, and reassure the patient.

For the symptoms of chronic pelvic pain, few treatment modalities have been proven effective. Evidence to date suggests that oral medroxyprogesterone, goserelin, and adhesiolysis for severe adhesions may be helpful. For patients in whom no specific diagnosis is reached, a multidisciplinary treatment approach is recommended.

Treatments for which less supporting evidence has been generated thus far include oral analgesics, combined oral contraceptive pills, gonadotropin-releasing hormone (GnRH) agonists, intramuscular medroxyprogesterone, trigger point and botulinum A toxin injections, neuromodulative therapies, and hysterectomy.

Medications commonly used in the management of chronic pelvic pain include combined oral contraceptives, which studies suggest may be useful in women with dysmenorrhea. However, no quality studies support the use of combined oral contraceptives in patients with chronic pelvic pain.

The only medication for which evidence shows some benefit in most patients with chronic pelvic pain is oral medroxyprogesterone acetate at 50 mg daily. However, medroxyprogesterone is typically not used in patients with endometriosis, primary dysmenorrhea, chronic active pelvic inflammatory disease, and irritable bowel syndrome.

Studies show that depot medroxyprogesterone, administered as 150 mg intramuscularly every 3 months, is helpful only in women with chronic pelvic pain related to endometriosis.

Although no evidence to date has shown specific benefit of nonsteroidal anti-inflammatory drugs for treatment of chronic pelvic pain, some expert and consensus opinions have led to recommendations for their use for this indication.

GnRH agonists, namely goserelin, is effective for pelvic congestion and has a longer duration of action vs medroxyprogesterone. However, the patient should be monitored for loss of bone density.

For a levonorgestrel intrauterine system, 1 study supports benefit in patients with chronic pelvic pain caused by endometriosis. Use of danazol should be limited to 6 months because adverse events are frequent.

Specific clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:

• When the initial history and physical examination do not allow a specific diagnosis, the subsequent workup should include complete blood count, beta human chorionic gonadotropin levels, erythrocyte sedimentation rate, vaginal swabs for chlamydia and gonorrhea, urinalysis with urine culture, and transvaginal pelvic ultrasound examination (level of evidence, C).
• Symptoms of chronic pelvic pain may respond to multidisciplinary treatment involving medication, dietary, and psychosocial modalities (level of evidence, B).
• Oral medroxyprogesterone acetate at 50 mg daily may help decrease chronic pelvic pain in women (level of evidence, B).
• Goserelin, 3.6-mg subcutaneous implant, monthly for 6 months, can be used to decrease chronic pelvic pain in women (level of evidence, B).
• Only when chronic pelvic pain in women is associated with severe adhesions, adhesiolysis relieves pain (level of evidence, B).
• Chronic pelvic pain that is cyclic is relieved with use of combined oral contraceptive pills (level of evidence, C).
• Mild to moderate chronic pelvic pain in women should be treated with nonsteroidal anti-inflammatory drugs (level of evidence, C).

"Family physicians should consider referring patients with chronic pelvic pain for diagnostic procedures (e.g., laparoscopy, colonoscopy, cystoscopy), for therapeutic options (e.g., surgery or GnRH agonist treatment) that are beyond their scope of care, or if the underlying diagnosis and best treatment option are unclear," Dr. Ortiz writes. "By performing a thorough initial work-up and knowing the local subspecialty practice scope and patterns, family physicians should be able to select the specific test or specialty (e.g., gynecology, urology, gastroenterology or pain management) in their community that would best provide the information and care that the patient requires. Because a multidisciplinary treatment approach will benefit most patients with chronic pelvic pain, the referring family physician should stay engaged in the care of the patient and coordinate the plan of care with any subspecialists involved."

Dr. Ortiz has disclosed no relevant financial relationships.

Am Fam Physician. 2008;77:1535-1542.

Clinical Context

Study Highlights

• Cause and workup
  • A definitive diagnosis is not made for 61% of women with chronic pelvic pain.
  • Among women with a specific cause of their pelvic pain, the most common causes are endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis.
  • Up to 40% of women have more than 1 potential cause of the pain, and workup should examine all contributing factors.
  • Women with this condition usually want personalized care, to be taken seriously, to receive an explanation for the condition, and to be reassured.
  • The International Pelvic Pain Society provides helpful resources including history and physical examination forms and patient education.
  • History should focus on pain characteristics, association with menses, sexual activity, urination, defecation, and radiation treatment.
  • History of sexual or physical abuse should be sought.
  • So-called red flag symptoms such as unexplained weight loss, hematochezia, perimenopausal irregular bleeding, postmenopausal vaginal bleeding, or postcoital bleeding should prompt investigation to rule out a malignant neoplasm or systemic disease.
  • A history of pelvic infection, surgery, and use of an intrauterine device should raise suspicion for pelvic adhesions.
  • Lack of physical findings does not rule out a pathologic process.
  • The pelvic examination should begin with a 1-handed, single-digit examination.
  • A cotton swab should be used to elicit tenderness in the vulva and vagina.
  • A full bimanual examination should be performed after the single-digit examination.
  • Carnett's sign should be elicited by placing a finger on the painful, tender area of the abdomen and asking the patient to raise both legs while lying in the supine position.
  • A positive test occurs when pain increases, which indicates a trigger point or fibromyalgia.
  • Visceral pain should not worsen during this procedure.
• Treatment approaches
  • Treatment should be targeted at the underlying cause.
  • A multidisciplinary approach has been found to have better outcomes than medications alone.
  • A Cochrane analysis found that only the following treatments were of benefit: oral medroxyprogesterone acetate 50 mg daily, goserelin, multidisciplinary approach, counseling after negative results on ultrasound examination, and lysis of deep adhesions in severe cases.
  • For cyclic pain, hormonal treatment may be considered.
  • Selective serotonin reuptake inhibitors have not been shown to be effective unless there is concomitant depression.
  • Oral analgesics and opiates are commonly used, but there is an absence of randomized trials to demonstrate efficacy.
  • Vitamin B₁ has been shown to be helpful for dysmenorrhea, but usefulness for noncyclic pain has not been demonstrated.
  • Gabapentin alone or in combination with amitriptyline and botulinum toxin type A injected into the muscles of the pelvic floor have shown some benefit.
  • Of surgeries, only lysis of severe adhesions has shown significant benefit.
  • No large randomized trials have examined the effects of percutaneous tibial nerve stimulation, presacral neurectomy, or sacral nerve stimulation.
  • There is less supporting evidence for the use of intramuscular medroxyprogesterone, contraceptive pills, trigger point, neuromodulative therapies, and hysterectomy.
  • Referral to specialist centers should be considered for diagnostic procedures and multidisciplinary management.

Pearls for Practice

• More than one half of women with chronic pelvic pain do not have a known diagnosis, and patients seeking medical care wish for personalized care, to receive an explanation for the condition, to be taken seriously, and to be reassured.
• A multidisciplinary approach is preferred to medications alone, and there is evidence for the efficacy of oral medroxyprogesterone acetate 50 mg daily, goserelin, a multidisciplinary approach, counseling after negative results on ultrasound examination, and lysis of deep adhesions in severe cases.

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