COMMENTARY

Chronic Pelvic Pain in Women: Common, Complex, and Real

Andrew M. Kaunitz, MD

Disclosures

March 31, 2020

This transcript has been edited for clarity.

Hello. I am Andrew Kaunitz, professor and associate chair in the Department of Obstetrics and Gynecology at the University of Florida College of Medicine in Jacksonville.

A new Practice Bulletin from the American College of Obstetricians and Gynecologists (ACOG) provides guidance on chronic pelvic pain (CPP), defined as "symptoms perceived as originating from pelvic organs or structures, and lasting more than 6 months."

A common condition in women, CPP is often associated with symptoms suggesting gynecologic, bladder, bowel, or pelvic floor dysfunction, and can result in behavioral, emotional, and sexual concerns. This guidance does not address dysmenorrhea, ovulatory pain, endometriosis, adenomyosis, leiomyoma, adnexal, or vulvar pathology.

Among patients presenting with CPP, many will be found to have nongynecologic conditions, including irritable bowel syndrome, interstitial cystitis, pelvic floor tenderness, and mood disorders.

As with other chronic pain syndromes, patients with CPP may feel pain in response to innocuous stimuli and have a heightened response to painful stimuli.

Here are ACOG's key recommendations:

  • When performing a medical history and physical exam, clinicians should focus on abdominal and pelvic neuromuscular and skeletal findings, including those involving the pelvic floor.

  • Particularly when dyspareunia is present, patients with CPP may benefit from referral for pelvic floor physical therapy, cognitive-behavioral therapy, and sex therapy.

  • Serotonin-norepinephrine reuptake inhibitors and gabapentinoids may be useful for patients with CPP.

  • The practice bulletin does not recommend initiating opioids for CPP and suggests that patients already using opioids should be slowly weaned. Referral to a pain management specialist may be useful in this latter setting.

  • Clinicians should be mindful that CPP and dyspareunia are more prevalent among women with a history of abuse, mental illness, and relationship concerns.

A final word: Many women with CPP will benefit from professional counseling. As we care for these patients, our challenge is to help them understand that recommending mental health services does not imply that their pain is psychosomatic. Rather, counseling helps support CPP patients while they pursue other needed treatments.

Thank you for the honor of your time. I am Andrew M. Kaunitz.

Dr Andrew Kaunitz is a tenured University of Florida term professor and associate chair of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine-Jacksonville. Dr Kaunitz has published more than 240 articles in peer-reviewed journals, including the New England Journal of Medicine, JAMA, and Obstetrics and Gynecology.

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