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Chronic Pelvic Pain in Women

david d. ortiz, md, CHRISTUS Santa Rosa Family Medicine Residency Program, San Antonio, Texas

The etiology of chronic pelvic pain in women is poorly understood.
Although a specific diagnosis is not found in the majority of cases,
some common diagnoses include endometriosis, adhesions, irrita-
ble bowel syndrome, and interstitial cystitis. The initial history and
physical examination can narrow the diagnostic possibilities, guide
any subsequent evaluation, and rule out malignancy or significant
systemic disease. If the initial evaluation does not reveal a specific
diagnosis, a limited laboratory and ultrasound evaluation can clar-
ify the diagnosis, as well as rule out serious disease and reassure the
patient. Few treatment modalities have demonstrated benefit for the
symptoms of chronic pelvic pain. The evidence supports the use of
oral medroxyprogesterone, goserelin, adhesiolysis for severe adhe-
sions, and a multidisciplinary treatment approach for patients with-
out a specific diagnosis. Less supporting evidence is available for oral
analgesics, combined oral contraceptive pills, gonadotropin-releasing

ILLUSTRATION BY Steve oh
hormone agonists, intramuscular medroxyprogesterone, trigger
point and botulinum A toxin injections, neuromodulative therapies,
and hysterectomy. (Am Fam Physician. 2008;77(11):1535-1542, 1544.
Copyright © 2008 American Academy of Family Physicians.)

C
Patient information: hronic pelvic pain is defined in a chronic pelvic pain.3 The same study esti-

A handout on chronic variety of ways. A useful clinical mated the cost of outpatient medical visits
pelvic pain, written by the
author of this article, is
definition of chronic pelvic pain associated with chronic pelvic pain to be
provided on page 1544. is noncyclic pain that lasts six $880 million per year in the United States,
months or more; is localized to the pelvis, with 15 percent of women with chronic pel-
the anterior abdominal wall at or below the vic pain reporting lost time from paid work,
umbilicus, or the buttocks; and is of suffi- and 45 percent reporting decreased produc-
cient severity to cause functional disability tivity at work.3
or require medical care.1 Other definitions
do not require that the pain be noncyclic. Etiology
Because the definition of chronic pelvic The pathophysiology of chronic pelvic pain
pain varies, it is difficult to ascertain its is not well understood.4 A definitive diag-
exact prevalence. In the United Kingdom, nosis is not made for 61 percent of women
3.8 percent of women in the primary care with chronic pelvic pain.5 Many patients
population report experiencing chronic and physicians incorrectly assume that all
pelvic pain, defined as noncyclic pain in the chronic pelvic pain results from a gyneco-
lower abdominal region lasting six months logic source. One study in the United King-
or more and without a specific disease diag- dom found that diagnoses related to the
nosis.2 This is similar to the prevalence of urinary and gastrointestinal systems were
migraine headaches, asthma, and low back more common than gynecologic diagno-
pain in the United Kingdom.2 However, in a ses.5 Table 1 lists the more commonly diag-
1996 study conducted in the United States, nosed conditions that cause chronic pelvic
15 percent of women indicated they had pain.1,6,7 The four most commonly diag-
experienced either constant or intermit- nosed etiologies are endometriosis, adhe-
tent pelvic pain during the preceding six sions, irritable bowel syndrome (IBS), and
months, which met the study’s criteria for interstitial cystitis.1,5,6,8

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For information about the SORT evidence rating system. B = inconsistent or limited-quality patient-oriented evi- dence.org/afp Volume 77. erythrocyte sedimentation rate. to receive an explanation for their chronic pelvic pain have more than one condition (more so than a cure). colitis. such as unexplained weight loss. The Interna- tional Pelvic Pain Society has many helpful Gastrointestinal Celiac disease. inflammatory resources including history and physical bowel disease. psychosocial) can be B 4 used to improve symptoms of chronic pelvic pain. Gynecologic Adhesions.6 mg subcutaneous implant. 18 diagnosis. Therefore. Table 1. Oral medroxyprogesterone acetate (Provera). pelvicpain. or case series. chronic urinary tract infection. irritable bowel syndrome examination forms (available at http://www. Adhesiolysis improves pain. neurologic dysfunction. ecation. leiomyomata pelvic and patient education materials. herpes zoster.1.aafp. and vic pain.org/resources/handpform. Combined oral contraceptive pills improve cyclic pain. C = consensus. see http://www. and Psychiatric/ Abdominal epilepsy. myofascial pain. urolithiasis history of physical or sexual abuse is asso- Other Familial Mediterranean fever. monthly for six B 4 months can be used to reduce pain in women with chronic pelvic pain. and to be diagnosis. dysmenorrhea. peripartum pelvic pain The history should focus on characteristics syndrome. usual practice. expert opinion. 3. levator ani syndrome. can be used B 4 to reduce pain in women with chronic pelvic pain. social. abdominal migraines. depression. urination. 6 Nonsteroidal anti-inflammatory drugs should be used to treat mild to C 1. A = consistent. to be taken seri- who present to primary care practices with ously. physicians should ask questions to address these two Information from references 1. and a transvaginal pelvic ultrasound.org/afpsort. def- Urologic Bladder malignancy. porphyria ciated with chronic pelvic pain. stress fractures of the pain.aspx). sleep disturbances. chronic endometritis.6 As many as 40 percent of women care from their physicians. and diagnostic tests and their potential System Differential diagnoses significance for the patient. the initial diagnostic workup should include: a complete blood count. dietary. sexual activity. and 7.12 Therefore. 2008 . vaginal swabs for chlamydia and gonorrhea. somatization with menses. urinalysis with urine culture. 6. disease-oriented evidence. Number 11 ◆ June 1. but only when associated with severe B 4 adhesions. duration. SORT: Key Recommendations For Practice Evidence Clinical recommendation rating References If the initial history and physical examination do not reveal a specific C 4. physical examina- tion. issues and assess current safety. congestion syndrome. fibromyalgia. adenomyosis. endometriosis. good-quality patient-oriented evidence.xml Evaluating the Patient investigate all contributing factors related to When evaluating a patient with chronic pel. 6 moderate chronic pelvic pain. and radiation treatment. colon cancer.14 Red flag symptoms. as well as its association neurologic nerve entrapment. environmental. the physician should schedule several visits to complete the evalu- ation and provide appropriate counseling.9-11 tion can narrow the differential diagnosis Women with chronic pelvic pain usually and guide further laboratory and ancillary want the following: to receive personalized testing. radiation cystitis. 50 mg daily. Multidisciplinary treatment (medication.13 Because a interstitial cystitis. 1536  American Family Physician www. C 1. Selected Differential Diagnoses of Chronic Pelvic Table 2 contains a summary of selected Pain by Organ System findings on the history.aafp. the pain including psychological. the history and physical examina. gynecologic malignancies. Goserelin (Zoladex). it is important to reassured. pelvic inflammatory disease History Musculoskeletal Degenerative disk disease. modifying factors. including quality. adnexal cysts. beta human chorionic gonadotropin levels.

IBS. systemic illness Positive gonorrhea or chlamydia testing Pelvic inflammatory disease Transvaginal ultrasound abnormalities Adenomyosis. pelvic adhesions Nodularity or masses on abdominal. depression may be a ing the physical examination does not rule coexisting diagnosis. or malignancy (elevated/decreased white blood cell count or anemia) Elevated erythrocyte sedimentation rate Infection. malignancy. However. The physical examination can identify areas or postcoital bleeding. endometriosis. other anatomical findings that aid in the ous systemic disease. or interstitial cysti. The pelvic examination should begin of pelvic surgery. laparoscopy. interstitial cystitis. trigger points. Palpation of the outer interpreted cautiously because pain caused pelvis and back may reveal trigger points by IBS and interstitial cystitis may also fluc.   and Diagnostic Studies Finding Possible significance History Hematochezia Gastrointestinal malignancy/bleeding History of pelvic surgery. Number 11 www. trigger points Point tenderness of vagina. Table 2. Physical Examination. hormonal patterns should be tion may be painful.aafp. endometriosis/endometrioma. adhesions.11 used to elicit point tenderness in the vulva June 1.9 As with other chronic diagnosis.16 A history pain. pelvic infections. pelvic infections. postmenopausal vaginal bleeding.g. a lack of findings dur- and painful conditions. nal and pelvic components of the examina- tis. perimenopausal irregular Physical Examination bleeding. Adhesions or use of intrauterine device Nonhormonal pain fluctuation Adhesions. Selected Findings on History. A moistened cotton swab should be for pelvic adhesions.7 out intra-abdominal pathology because Historical patterns may also help direct many patients with a normal examination the work-up.1 sis or adenomyosis. Pain associated with hormonal will have pathologic findings on subsequent changes may likely result from endometrio. infection Complete blood count abnormalities Infection.. or use of with a single-digit. vulvar vestibulitis Positive Carnett’s sign Myofascial or abdominal wall cause of pain Diagnostic studies Abnormal urinalysis or urine culture Bladder malignancy. musculoskeletal causes Pain fluctuates with menstrual cycle Adenomyosis or endometriosis Perimenopausal or postmenopausal irregular Endometrial cancer vaginal bleeding Postcoital bleeding Cervical cancer or cervicitis (e. that indicate a myofascial component to the tuate based on hormone levels. irritable bowel syndrome. bimanual Adenomyosis. or bladder Adhesions. should prompt an of tenderness and the presence of masses or investigation to rule out malignancy or seri. nerve entrapment. systemic illness. 2008 ◆ Volume 77. endometriosis. malignancy hematochezia. tumors Pain on palpation of outer back and outer pelvis Abdominal/pelvic wall source of pain. hernias.org/afp American Family Physician  1537 . chlamydia or gonorrhea) Unexplained weight loss Systemic illness or malignancy Physical examination Lack of uterus mobility on bimanual examination Endometriosis. vulva. one-handed examina- an intrauterine device should raise concern tion. pelvic and/or rectal examination malignancy.15. However. while a nonhormonal The physical examination should proceed pattern of pain may signal musculoskeletal slowly and gently because both the abdomi- causes.

19 Some urologists use and having the patient raise both legs off the intravesical potassium sensitivity test the table while lying in the supine position to help diagnose interstitial cystitis. goserelin (Zoladex).aafp. adhesions.7 of the pain is within the abdominal wall (e. suspected endo- pain. Number 11 ◆ June 1.org/afp Volume 77.21.e.20 Lapa- (Figure 1). puted tomography should not be used rou- formed by placing a finger on the pain. social.17 ied the treatment of chronic pelvic pain. a multidisciplinary approach (i. tigate any pelvic masses or nodules found ness.7 A rectal examination sure the patient if no significant abnormali- may show rectal or posterior uterine masses. tender area of the patient’s abdomen found on ultrasound..18 nodularity. and vaginal swabs to test for gonorrhea and one-handed examination is completed.25 A recent Cochrane analysis of treatments for chronic pelvic pain found that only the following treatments have shown benefit: oral medroxyprogesterone acetate (Pro- vera). Treatment should be directed at the It may be appropriate to obtain a serum beta underlying cause of the pelvic pain. point tender. 2008 . The examiner places his or her finger on the tender area of the patient’s abdomen an injectable gonadotropin-releasing hor- and asks the patient to raise both legs off the table. and possibly treat.g. or point tender.18 Transvaginal ultrasound is also bimanual examination should be performed useful during the initial evaluation to inves- to check again for nodularity. plete blood count. associated risk factors should be performed.1. tinely. a urinalysis and urine ness along the bladder or other musculo. Treatment ceral pain should not worsen during the Few randomized controlled trials have stud- maneuver. cervical motion tenderness. This may also indicate that the cause metriosis. If the history and physical examination do many treatment recommendations are based not lead to a diagnosis.6. a com- for any nodules. a multidisciplinary patient’s pain during this maneuver is considered a positive test. Because different definitions of chronic pel- Laboratory/Specialized Tests vic pain were used in some of these studies. An increase in the mone (GnRH) agonist. Pelvic Pain and vagina. approach.4. Carnett’s sign for patients with pelvic pain. skeletal structures. or pelvic floor point tenderness. 50 mg daily. ties are discovered. or both.. Once the single-digit. on expert opinion or cohort/observational ings appropriate to the patient’s age and studies. environmental.4. but can help assess any abnormalities ful. or lack of during the physical examination and to reas- mobility of the uterus. Vis. fibromyalgia or trigger point). The patient should be checked (β-hCG) level to rule out pregnancy. addressing dietary.1. a chlamydia.18. culture. Figure 1.22. an erythrocyte sedimentation rate.21-23 In patients for whom a specific diagnosis is not made.24. A positive test occurs when the roscopy is often used when the diagnosis pain increases during this maneuver and remains elusive after the initial workup or to is associated with a myofascial cause of the confirm. Magnetic resonance imaging and com- Testing for Carnett’s sign should be per.6. counseling after a negative 1538  American Family Physician www. masses. then cancer screen. Figure 2 subunit of human chorionic gonadotropin shows a suggested algorithm for the evalu- ation and management of patients with chronic pelvic pain.4.4 Table 3 lists specific details and references ILLUSTRATION BY marcia hartsock regarding the most common medication treatment options. and psycho- logical factors in addition to standard med- ication therapy) has been shown to improve outcomes over medication therapy alone.

4. consider addition of opioid therapy to treat chronic pain as part of a comprehensive pain management program† *—Warning signs include: unexplained weight loss. or postcoital bleeding. and transvaginal ultrasound Normal Abnormal Address comorbid factors (psychosocial. urinalysis with Evaluate and culture. 18. or if significant underlying disease is suspected. Figure 2. NSAIDs = nonsteroidal anti-inflammatory drugs. and conduct cancer screening appropriate for patient’s age and associated risk factors Warning signs present?* No Yes History and physical examination suggestive of a Promptly evaluate specific diagnosis (i. depot medroxyprogesterone acetate (Depo-Provera). levonorgestrel intrauterine system (Mirena) Inadequate relief? Consider adding gabapentin Inadequate relief? (Neurontin) or amitriptyline Consider referral for laparoscopy or to clarify diagnosis. irritable bowel syndrome. tests for gonorrhea condition and chlamydia. . 6.g. Evaluate and environmental. the patient does not respond to treatment as expected. serum β-hCG level to rule out pregnancy.e. for malignancy or endometriosis. perimenopausal irregular or postmenopausal vaginal bleeding. (β-hCG = beta subunit of human chorionic gonadotropin.. interstitial cystitis. gonadotropin-releasing hormone (GnRH) agonists (i. Evaluation and Treatment of Chronic Pelvic Pain in Women Patient presents with chronic pelvic pain Perform history and physical examination.. and 21 through 23. goserelin [Zoladex]). hematochezia. combined oral contraceptive pills. †—Consider referral for consultation or specific testing (e. myofascial pain)? significant systemic disease No Yes Consider complete blood count. This approach is only suggested as a stepwise process and should be individualized for each patient.) Information from references 1.e. dietary) and offer reassurance treat specific abnormality Consider NSAIDs or acetaminophen Inadequate relief? Does patient have cyclic or noncyclic pain? Cyclic Noncyclic Consider adding oral medroxyprogesterone acetate (Provera). Algorithm for the evaluation and treatment of chronic pelvic pain in women presenting to primary care.. laparoscopy) at any step of evaluation or treatment if the clinical picture is unclear. treat for specific erythrocyte sedimentation rate.

13. provided 1540  American Family Physician www. NSAIDs = nonsteroidal anti-inflammatory drugs. primary dysmenorrhea. 2008 . IBS. 24. but there are no trials been described elsewhere.4.4 they that gabapentin (Neurontin). and irritable bowel syndrome) 4 Depot medroxyprogesterone Studies only show benefit in patients with chronic pelvic pain (Depo-Provera). nonsteroidal anti-inflammatory drugs peutic options than the larger population of (NSAIDs). open-label study showed tive for treating chronic pelvic pain. goserelin Goserelin effective for pelvic congestion and has longer duration [Zoladex]) of effect than medroxyprogesterone. and lysis of deep adhesions.e. This Cochrane review excluded pain have also shown some benefit. sium have been shown to benefit patients endometriosis. and opioid analgesics. 21. or GnRH agonists) should be to control pain. monitor patient for bone density loss1. conditions. ized. are com- patients with chronic pelvic pain. recommendation from expert/consensus opinions only1.28.21.aafp.6 Vitamin B1 and oral magne- ments.22 Specific management of IBS. 22.27 that evaluated their effectiveness for non– Although selective serotonin reuptake menstrual-related pain. 50 mg daily most patients with chronic pelvic pain (excluding those with endometriosis.1 If opioid analgesics are necessary progestins. IM = intramuscularly.26.30 A recent random- inhibitors have not been shown to be effec. long-acting opioids with considered.29 patients with known endometriosis.4 monly used to treat moderate pain. Common Medications for Treatment of Chronic Pelvic Pain Treatment Comment Combined oral contraceptives Evidence supports use in patients with dysmenorrhea.4 Trigger point injections of the abdominal Lysis of adhesions is only beneficial for more wall for myofascial causes of chronic pelvic severe cases. hormonal treatments (continuous that show a specific benefit in chronic pel- or cyclic low-dose oral contraceptive pills. such as acetaminophen.. Information from references 1. ultrasound.21 no quality studies show benefit in patients with chronic pelvic pain Oral medroxyprogesterone Only medication with evidence showing some benefit in acetate (Provera).org/afp Volume 77. alone or in may be used to treat concomitant depression.Pelvic Pain Table 3. chronic active pelvic inflammatory disease. Number 11 ◆ June 1. because these con. and interstitial cystitis has with dysmenorrhea.1.6 GnRH agonists (i. combination with amitriptyline. or pelvic tion with a treatment plan similar to that congestion syndrome. 6. however. associated with a high incidence of side effects25 GnRH = gonadotropin-releasing hormone. Analgesics primary dysmenorrhea. as these disease Oral analgesics. For pain that appears to be cyclic in there are no prospective controlled studies nature.4. 150 mg IM related to endometriosis22 every three months NSAIDs No studies show benefit specifically for treatment of chronic pelvic pain. used when treating other chronic. even if the cause is thought scheduled dosing may be used in conjunc- to be IBS. 4. interstitial cystitis. vic pain.6 Levonorgestrel intrauterine One study supports benefit in patients with chronic pelvic pain system (Mirena) related to endometriosis24 Danazol Use for six months only. and 25. controlled. and chronic. painful ditions may also respond to hormone treat. populations have slightly different thera. active pelvic inflammatory disease.

ACOG Committee on Practice Bulletins–Gynecology.23 Botulinum toxin type A injec. health- related quality of life. pain have shown some benefit. Obstet Gynecol. Chronic pelvic pain. Liberman RF. Price J. of the patient and coordinate the plan of care 12.87(3):321-327. Gynecologic presentation of interstitial cystitis as family physicians should be able to select the detected by intravesical potassium sensitivity.4 Total abdominal Address correspondence to David D. laparoscopy. cystoscopy). Several other therapies using the neuro- modulation theory of treating pain have REFERENCES been evaluated in patients with chronic pel- 1. Yudkin PL. Lipschutz these findings. Howard FM. TUS Santa Rosa Family Medicine Residency Program. 1999. treatment of dysmenorrhea that is centrally Author disclosure: Nothing to disclose. Hope T. gastroenterology or pain manage.g. Ortiz. 2008 ◆ Volume 77.39 although there are no large.4 the referring fam- 11. located in the pelvis. RC.106(11):1156-1161. Tu FF. Mountfield J.org/afp American Family Physician  1541 .37 Two trials 2.52(12):1556-1562. BSE. U. 41: The initial management of chronic pelvic pain. Ortiz. colo.32 TUS Santa Rosa Family Medicine Residency Program in San Antonio. Florida. MD.. chronic pelvic pain: a systematic review of diagnosis: ough initial work-up and knowing the local part 1. Chronic pelvic pain.98(1):127-132. 2001. Kennedy S. 2003. Suite F4703. San Antonio. has shown benefit in the not available from the author. Bullen M.36. Kennedy SH. Mayou with any subspecialists involved. vic pain. col.60(6):379-385. for therapeutic options women consulting for chronic pelvic pain in UK primary (e. Obstet Gynecol Surv. Eglin Air Force Base. DH. gynecology. 9. stimulation in women with chronic pelvic Obstet Gynecol..31.184(6):1149-1155.aafp. Reprints are for endometriosis. 2004. Gynecol. 1999. Dawes MG. Vessey MP. Parsons CL. Farmer G.35 but this finding can. Uncontrolled studies of sacral nerve ACOG Practice Bulletin No. Interventions for treating Family physicians should consider referring chronic pelvic pain in women. or if the 6. Harris J. inves- treatment approach will benefit most patients tigations. 8. along with ablative therapy (e-mail: david.33. Chronic patient requires. TX 78207 neurectomy. Steege JF. not be generalized to chronic pelvic pain. have shown some benefit in using percutane. Kuppermann M. Number 11 www. Zondervan KT. Obstet Gynecol. CHRIS- hysterectomy showed some benefit in obser.org). 2006. and a clinical assistant professor in the Surgical and Nerve   Department of Family and Community Medicine at the University of Texas Health Science Center at San Antonio. underlying diagnosis and best treatment 7. patients with chronic pelvic pain for diag- 5. Br J Obstet Gynae- pelvic pain.K. is a faculty member at the CHRIS- shown benefit. Barlow nostic procedures (e. Zondervan KT. Patterns of diagnosis and referral in noscopy. that are beyond their scope of care. Mathias SD.34 Presacral N.:RCOG. Dawes MG. Stones RW.106(11):1149-1155. Musculoskeletal causes of option are unclear. Yudkin PL. with chronic pelvic pain. Pelvic Pain significant pain relief in women with chronic pelvic pain. ment) in their community that would best Guideline No. 2000.. Yudkin PL.. Attitudes of women with chronic pelvic pain to the June 1.101(3):594-611. By performing a thor.38. Jackson B. Bordman R. Cochrane Database Syst Rev. Prevalence and incidence of chronic pelvic pain in primary care: evidence from a ous tibial nerve stimulation to treat chronic national general practice database. Referral 4. Kahn BS. and economic correlates. Obstet specific test or specialty (e. for their assistance in preparing the manuscript.g. provide the information and care that the 10. Tex. urology.. Chronic pelvic pain: prevalence.103(3):589-605. 51. Steege JF. MD. 2005. Royal College of Obstetricians and Gynaecologists. Below the belt: approach to chronic ily physician should stay engaged in the care pelvic pain. London. 1996.ortiz@christushealth. surgery or GnRH agonist treatment) care. Stanford EJ. subspecialty practice scope and patterns. and diagnoses. Santa Rose St.g. Zondervan KT. 2001. Because a multidisciplinary pelvic pain in the community-symptoms. Kennedy SH. Vessey MP. et al. only lysis of severe Arkansas for Medical Sciences in Little Rock and completed a family medicine residency at the Eglin Family Medicine adhesions has been shown to benefit patients Residency Program. PhD. Can Fam Physician. As-Sanie S.(4):CD000387. and Rebecca Ortiz. Willems JJ. Am J Obstet Gynecol. The author thanks James Tysinger. with chronic pelvic pain.2005. The Author tions into the pelvic floor muscles have also David D. R. Barlow DH. Stimulation Therapies He received his medical degree from the University of Among surgical therapies. placebo-controlled studies that confirm 3. Br J Obstet Gynaecol. 333 vational and cohort studies. Vessey MP.

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