Published in IJCP
August 2018
American Family Physician
Chronic Pelvic Pain in Women
May 04, 2018 | linda m. speer, saudia mushkBar, tara erBele
Chronic pelvic pain in women is defined as persistent, non-cyclic pain perceived to be in structures related to the pelvis and
lasting more than six months. Often no specific etiology can be identified, and it can be conceptualized as a chronic regional
pain syndrome or functional somatic pain syndrome. It is typically associated with other functional somatic pain syndromes
(e.g., irritable bowel syndrome, nonspecific chronic fatigue syndrome) and mental health disorders (e.g., post-traumatic stress
disorder, depression). Diagnosis is based on findings from the history and physical examination. Pelvic ultrasonography is
indicated to rule out anatomic abnormalities. Referral for diagnostic evaluation of endometriosis by laparoscopy is usually
indicated in severe cases. Curative treatment is elusive, and evidence-based therapies are limited. Patient engagement in
a biopsychosocial approach is recommended, with treatment of any identifiable disease process such as endometriosis,
interstitial cystitis/painful bladder syndrome, and comorbid depression. Potentially beneficial medications include depot
medroxyprogesterone, gabapentin, nonsteroidal anti-inflammatory drugs, and gonadotropin-releasing hormone agonists
with add-back hormone therapy. Pelvic floor physical therapy may be helpful. Behavioral therapy is an integral part of
treatment. In select cases, neuromodulation of sacral nerves may be appropriate. Hysterectomy may be considered as a last
resort if pain seems to be of uterine origin, although significant improvement occurs in only about one-half of cases. Chronic
pelvic pain should be managed with a collaborative, patient-centered approach.
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