Applied Evidence

Limited evidence guides empiric Tx of female chronic pelvic pain

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Treat patients based on experience and by applying options used for other chronic pain syndromes. Lifestyle modifications can help, but avoid opioids.


› Consider the levonorgestrel-releasing intrauterine device for relief of chronic pelvic pain (CPP) from endometriosis; it’s been found to be more effective than expectant management. B

› Prescribe a trial of depot medroxyprogesterone acetate, which was more effective than placebo for CPP for as long as 9 months. B

› Use gabapentin—with or without amitriptyline—to provide greater relief of CPP than amitriptyline alone. B

› Recommend pelvic physical therapy for CPP; the pelvic pain score can be reduced in proportion to the number of sessions. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series




Lisa G, 31 years old, gravida 0, complains of severe dysmenorrhea that began when she discontinued an oral contraceptive (OC) one year ago. Prior to stopping the OC, she had been taking an OC without interruption since she was 28, during which time she continued to have moderate symptoms of dysmenorrhea. Before taking an OC, the patient had a trial of an etonogestrel implant, which was removed because of irregular bleeding, and depot medroxyprogesterone acetate (MPA) injection, which she discontinued because of associated weight gain and fatigue.

Ms. G is not sexually active and doesn’t want to start a family at this time, but is interested in having a diagnosis. She has no other medical problems, no surgical history, and no history of sexually transmitted infection. She reports that her mother and sister had endometriosis, including pain that resolved after definitive treatment.

Ms. G reports menstrual cycles that are exquisitely painful and occur regularly (every 28 days for 4 or 5 days), with a moderate volume of bleeding that requires a regular-size tampon change every 4 to 6 hours. She reports crampy abdominal pain as 10, on a scale of one to 10; dyschezia (without hematochezia); and generalized achy abdominal pain that is continuous during menses. Pain is partially controlled by ibuprofen, 800 mg every 8 hours. Ms. G also describes gastrointestinal symptoms of bloating, constipation preceding her menstrual cycle, diarrhea during her menses, and occasionally nausea and vomiting with the severe pain.

On examination (which is not performed during menses), Ms. G appears well and is not in acute distress. Abdominal examination is benign. There is no tenderness to palpation or distension; bowel sounds are normal. Pelvic examination reveals mild tenderness upon palpation of a small and mobile uterus. Rectal examination is normal. She has no signs of hyperandrogenism (eg, male-pattern body hair, central obesity).


Rhonda M, 42 years old, gravida 3, para 3003, reports continuous pelvic pain for 7 years that is exacerbated by defecation, intercourse, and insertion of a tampon. She has a low level of dull baseline pain (3, on scale of one to 10) that occasionally spikes up to sharp, knifelike pain (10 on the pain scale), which, she says, brings her to tears. Ms. M describes the pain as “deep inside,” central in her pelvis, and radiating to the left and right, particularly during pain flares.

The patient’s 3 children were born by spontaneous vaginal delivery; however, she recalls that her youngest son was born via a traumatic vaginal delivery 8 years ago (he “got stuck coming out,” she reports). The only other component of Ms. M’s medical history is an anxiety disorder, for which she takes citalopram. She has a family history of cervical cancer.

Ms. M’s past diagnostic work-up for pelvic pain includes pelvic ultrasonography, endometrial biopsy, Pap smear, and diagnostic laparoscopy—all normal. She had a negative gastrointestinal work-up, including upper- and lower-tract endoscopy. Medical therapy, including opioids and nonsteroidal anti-inflammatory drugs (NSAIDs), did not provide significant relief of pain.

Despite the negative work-up, Ms. M is still concerned that the pain might be related to cancer. With her family history of cervical cancer, she says that she does not want to “miss anything.”

Ms. M is thin and appears anxious. The abdomen is mildly and diffusely tender to palpation with normal bowel sounds and no distension. Pelvic examination reveals some hyperesthesia upon single-digit palpation of the pelvic floor. Placement of the speculum is difficult because of discomfort.

How would you proceed with the care of these patients?

What is chronic pelvic pain? Why is management such a challenge?

Chronic pelvic pain (CPP) is defined as chronic or intermittent cyclic or noncyclic pelvic pain lasting longer than 6 months, localized to the pelvis, diminishing a woman’s quality of life, and requiring medical intervention.1 It’s estimated that CPP affects as many as 15% of women of reproductive age in the United States each year, at a cost to the health care system of approximately $2 billion annually.2,3

Chronic pelvic pain affects as many as 15% of women of reproductive age in the United States annually.

CPP can result from abnormal pain responses from multiple body systems, including gynecologic conditions such as endometriosis. Notably, a nongynecologic cause is more often the major pain generator, without significant identifiable pathology (TABLE 1). Like all chronic pain disorders, CPP can also result in central sensitization of the nervous system, altering how pain is processed at the level of the pain matrix in the brain.4

System-based causes of chronic pelvic pain image

This article reviews the limited evidence for treating CPP and offers recommendations for the primary care physician on providing symptomatic relief in the absence of diagnosed pathology (TABLE 25-13).

Quality of evidence for interventions for chronic pelvic pain image

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