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Menstrual and Uterine Disorders
The Enigma of Chronic Pelvic Pain
Ying Cheong
1
and Mary Anne Lumsden
2
1. Senior Lecturer, Consultant Gynaecologist and Subspecialist in Reproductive Medicine and Surgery,
Division of the Developmental Origins of Adult Diseases, University of Southampton; 2. Professor of Obstetrics and Gynaecology, University of Glasgow
Abstract
Chronic pelvic pain (CPP) remains a difficult gynaecological ‘headache’. Despite its prevalence in 15% of women in the general population,
there have been limited advances made in the last decade in terms of its clinical management. In this article, we review the current
evidence available in the treatment of patients with CPP and also discuss some of the important management strategies that may prove
valuable. It is important to individualise treatment based on each patient’s history, signs and symptoms. The currently available information
about the treatment of women with CPP provides some support for the use of ultrasound scanning as an aid to counselling and
reassurance, the use of progestogen (medroxyprogesterone acetate) or goserelin for pelvic congestion and (with the aim of improved
function and self-rating) the use of a multidisciplinary approach to assessment and treatment. Adhesiolysis has not been shown to be of
benefit other than in women with severe adhesions. Ablation of endometriosis may provide benefit when this is the cause of CPP. Selective
serotonin re-uptake inhibitor (SSRI) antidepressants have not been shown to be of benefit. The management of CPP remains an enigma
and much needs to be done in terms of basic science and clinical research to address this problem.
Keywords
Chronic pelvic pain, adhesions, multidisciplinary, hormones, management
Disclosure: The authors have no conflicts of interest to declare.
Received: 12 February 2009 Accepted: 16 March 2009
Correspondence: Ying Cheong, Senior Lecturer and Consultant in Obstetrics and Gynaecology, Subspecialist in Reproductive Medicine and Surgery, Division of Developmental
Origins of Adult Diseases (DOHaD), Level F, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK. E: Y.Cheong@soton.ac.uk
Chronic pelvic pain (CPP) constitutes an enigma in gynaecological perceived as painful because of alterations in the processing of spinal
practice, and while some advances have been made, it remains cord and brain stimuli. Thus, a significant number of women with CPP
a gynaecological ‘headache’. CPP is a widespread problem within will not have a definite diagnosis. Explanations for CPP without
gynaecological practice. A single study in the US found a three- organic pathology have included irritable bowel syndrome, which is
month prevalence of 15% in women 18–50 years of age in the often present but missed without appropriate history-taking in
general population, while UK data showed an annual prevalence of women referred to gynaecologists for investigation. Pelvic congestion
38/1,000 in women 15–73 years of age
1,2
– not dissimilar to the syndrome refers to dilated uterine and ovarian veins with reduced
prevalence of common conditions such as asthma (37/1,000), back venous clearance, and is present in a proportion of those in the
pain (41/1,000) and migraine (21/1,000). CPP may be associated reproductive age group with CPP.
with organic pathology, although in a significant proportion this is
not the case. It is the latter group that provides particular Naturally, in practice investigations are undertaken with a focus on a
management challenges. particular patient, following assessment of the presenting symptoms
and the clinical findings on examination. Instigating the right
Typical laparoscopic findings in women investigated for CPP are, in investigations for patients with CPP is a challenge because there is a
increasing order of frequency, endometriosis (33%), adhesions (24%) considerable overlap in symptoms in such patients. In a community
and ‘no pathology’ (35%).
3
Patterns of symptomatology and received study in 2001,
2
among all women with CPP only 34% reported that
diagnosis in the population-based studies cited above suggest a they had undergone at least one investigation for pain, but the
broad pattern of pathophysiology, with urinary (31%) and proportion of women who had undergone investigations varied from
gastrointestinal (37%) systems more commonly reported than 30 to 48% depending on their presenting symptoms. Thus, women
specifically gynaecological problems (20%).
3
Pathology such as with genito-urinary symptoms or irritable bowel symptoms tended to
adhesions or endometriosis may not correlate with the site or severity receive more investigations than women with CPP only. The reported
of pain; indeed, their resolution may not be associated with pain relief, investigations, in descending order of frequency, were
thus making causation difficult to determine. This discrepancy may be ultrasonography (21.5%), laparoscopy or laparotomy (11.2%),
explained in part by the complex neurophysiology of visceral sigmoidoscopy or colonoscopy (9.3%), radiography (7.2%) or others
sensation; in other words, sensation arising from the internal organs (4%). Among all women with CPP, 20% reported that they had never
such as the uterus and ovaries. Normal bodily sensation can be received any investigations but had received a diagnosis. Among
14 © TOUCH BRIEFINGS 2009
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