Chronic Pelvic Pain: The Need for Earlier Diagnosis and Diverse Treatment

Commentary

Chronic pelvic pain affects approximately 15% of women and costs more than $3 billion annually.1 The full differential diagnosis for chronic pelvic pain (CPP) in women is extensive and beyond the scope of this article, but chronic pain can be broadly categorized as visceral, neuromyofascial, psychosocial, or a combination thereof. 

The Three Least Understood CPP Etiologies

Some of the most common and yet, least understood, etiologies of CPP in women are endometriosis, dyspareunia, and localized provoked vulvodynia.

Endometriosis is a complex, poorly understood disorder of aberrant endometrial glands and hormonal dysregulation which can result in chronic inflammation, pain with both intercourse and menstruation, and infertility. Symptoms may also include backaches, pain with defecation and urination, and blood in the urine or stool, depending on the location of the lesions. Women suffer pain for an average of 3 to 11 years before diagnosis2 due to the difficulty in diagnosing endometriosis, which requires surgical biopsy to confirm the condition.3 Treatment is largely focused on either medical suppression of the ectopic glandular tissue or surgical exploration and excision. There is a significant effect on fertility, which can require costly and difficult treatment or loss of desired parenting. Further investigation into the cause of endometriosis, risk factors for severe disease, and improved treatment strategies are needed.

Dyspareunia, or pain with intercourse, may be related to endometriosis, but is also commonly diagnosed in women with neuromyofascial disorders, anxiety, and a history of sexual, physical, or emotional abuse. Pain may be experienced at the vaginal introitus, deep inside the pelvis, or radiating through the pelvis/down the legs, or present as throbbing or sharp pain for hours or days after intercourse. Rarely is the physical exam able to reproduce the pain, so it is important for the provider to trust the patient’s description. This condition profoundly affects the woman physically and emotionally, and also affects her relationships. Treatment often requires extensive physical therapy, polypharmacy, and mental health therapy for the patient and/or the couple.4

Localized provoked vulvodynia is an extreme sensitivity to any vulvar stimulation or touch. Often, there is no identifiable cause or provocation, but the condition may result in a devastating impact on the woman’s life and functional status. Physical exams are typically limited to any stimulus of the vulva (best elicited with a cotton-tipped swab), producing burning and pain, which persists after the stimulus is withdrawn. The condition is difficult to treat, requires significant lifestyle adjustments, and ongoing care to manage the disease. Women must adjust nearly every part of their lives to address the symptoms, including diet, wardrobe, activity, type of exercise, and sexual practices.5 Oral and topical medications may be used as a part of a treatment plan for vulvodynia.

Challenges in Treating CPP

In treating chronic pelvic pain, multidisciplinary teams may include primary care, gynecology, gastroenterology, urology, as well as physical therapy, mental health counseling, sex therapy, osteopathic manipulation therapy, and nutrition counseling. These collaborative teams are useful for the holistic care of women suffering from CPP. In resource poor areas, the complex, multidisciplinary care required is rarely possible and contributes to social isolation, prolonged dysfunction, and delayed diagnosis.

Healthcare providers face challenges with these complex conditions, often caused by a combination of disorders, due to the need for extended and frequent appointments, including follow-ups, as well as multiple medications, and referrals to specialists. These challenges are even more significant in low resource areas. The most important service a clinician can provide, therefore, is one of care coordination and patient support. Listening to and validating the patient’s experience, making appropriate referrals, and remaining part of the therapeutic team is crucial in the care of a woman with CPP.

In the current environment of an opioid epidemic and ongoing legislative reactions, it is also important to emphasize that opioids are not an appropriate first-line treatment for CPP. Patients already on opioid therapy for this indication should be weaned. The Centers for Disease Control (CDC) and Prevention guidelines on opioid use for chronic pain apply to these conditions and are endorsed by the American College of Gynecology (ACOG).

Expectations of intervention must be honest, reasonable, and openly discussed. Pain relief and resumption of normal activities are the core goals, but preparing the patient for a possible reduction (not elimination) of pain and/or relapse is also key. Overall, further research is needed to diagnose disease states earlier in the pain continuum and to make available more treatment options.

Also featured in this special report on Pain Care & Research in Women

• Case Study: Neuropathic Pelvic Pain Caused by Endometriosis
• Challenges in Responding to Vulvodynia
• MSK Pain and Insomnia in the Post-Menopausal Woman

• Commentaries on the State of Pain in Women, and of Women in Pain Practice, featuring: ACOG’s Katherine W. McHugh, MD, the Society for Women’s Health Research Amy M. Miller, PhD, and Johns Hopkins Medicine’s Tina L. Doshi, MD.