ACOG issues new practice bulletin on chronic pelvic pain in women

ACOG issues new practice bulletin on chronic pelvic pain in women
2004 MAR 22 - The American College of Obstetricians and Gynecologists (ACOG) has issued a new practice bulletin on chronic pelvic pain in women, a condition that may be far more common than previously recognised.

ACOG reviews in one document the available evidence on the different diagnoses and treatment options for chronic pelvic pain. The ACOG bulletin cautions, however, that sometimes the exact causes of a woman's pelvic pain can be hard to find and the symptoms difficult to manage.

ACOG proposes a definition of chronic pelvic pain as non-cyclical pain of at least 6 months' duration that appears in locations such as the pelvis, anterior abdominal wall, lower back, or buttocks, and that is serious enough to cause disability or lead to medical care. Approximately 15-20% of women ages 18-50 have chronic pelvic pain of more than a year's duration.

Data are limited or ambiguous on the exact physical causes of certain pelvic pain, although specific conditions like endometriosis (when tissue that normally lines the uterus grows elsewhere in the body), or interstitial cystitis (a chronic inflammatory condition of the bladder), are believed to be linked to chronic pelvic pain. Sometimes examination and testing find no physical causes, but ACOG adds that this does not preclude the possibility of physical causality and "does not negate the significance of a patient's pain."

Studies find that 40-50% of women with chronic pelvic pain have a history of physical or sexual abuse. ACOG notes that while in some cases the link between abuse and pelvic pain may be psychologic or neurologic in origin, studies also suggest that trauma or abuse may also result in biophysical changes - for example, by literally heightening a person's physical sensitivity to pain.

According to ACOG, there are different levels of evidence supporting the various treatment options. ACOG reports that good and consistent scientific evidence supports a number of options, including the following recommendations:

*Combined oral contraceptives are a treatment option for decreasing pain during menstruation (primary dysmenorrhea)

*Gonadotropin-releasing hormone (GnRH) agonists are effective in relieving pelvic pain associated with endometriosis and irritable bowel syndrome

*Nonsteroidal anti-inflammatory drugs, including COX-2 inhibitors, should be considered for moderate pain, and are particularly effective for menstrual pain

*Progestins in daily, high doses are effective in treating chronic pelvic pain associated with endometriosis and pelvic congestion syndrome

*Laparoscopic surgical destruction of endometriosis lesions should be considered to decrease pelvic pain associated with stages I-III endometriosis.

Among the recommendations based on more limited or inconsistent evidence, ACOG notes:

*Sacral nerve stimulation may decrease pain in up to 60% of women with chronic pelvic pain

*Nutritional supplements with vitamin B1 or magnesium may decrease pain of dysmenorrhea

*Injection of local anesthesia into various trigger points of the abdominal wall, vagina, and sacrum may provide temporary or prolonged relieve of chronic pelvic pain

*Magnetic field therapy, which involves applying magnets to abdominal trigger points, may improve disability and reduce pain

*Acupuncture, acupressure, and transcutaneous nerve stimulation (TENS) therapies may help decrease pain of primary dysmenorrhea.

*In women who choose hysterectomy for pain associated with reproductive tract symptoms, pain relief is found in 75-95% of cases.
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