Tuesday 3 May 2005
Guidance on chronic pelvic pain
Issue 09: 2 May 2005
Source: RCOG report The Initial Management of Chronic Pelvic Pain
New guidance on investigating and treating chronic pelvic pain has been issued by the UK’s Royal College of Obstetricians and Gynaecologists (RCOG).
The guideline report The Initial Management of Chronic Pelvic Pain defines chronic pelvic pain as “intermittent or constant pain in the lower abdomen or pelvis, of at least 6 months’ duration, not occurring exclusively with menstruation or intercourse, and not associated with pregnancy.”
Past research has suggested that as many as one in six adult women may have chronic pelvic pain, and that it presents in primary care as frequently as migraine or low back pain.
The new report’s recommendations are based on published evidence where possible. But the authors emphasize the fact that “little good-quality evidence exists” and that the advice is likely to require modification in the near future as new evidence comes along.
The recommendations, each of which is discussed in detail in the full report, include:
“There is frequently more than one component to chronic pelvic pain. Assessment should aim to identify contributory factors rather than assign causality to a single pathology.”
“The initial history should include questions about the pattern of the pain and its association with other problems, such as psychological, bladder, and bowel symptoms, and the effect of movement and posture on the pain.”
“Suitable samples to screen for infection, particularly chlamydia and gonorrhoea, should be taken if there is any suspicion of pelvic inflammatory disease (PID). Ideally, all sexually active women below the age of 25 years who are being examined should be offered opportunistic screening for chlamydia.”
“Diagnostic laparoscopy has been regarded in the past as the ‘gold standard’ in the diagnosis of chronic pelvic pain. It may be better seen as a second line of investigation if other therapeutic interventions fail.”
“Women with cyclical pain should be offered a therapeutic trial using the combined oral contraceptive pill or a gonadotrophin-releasing hormone (GnRH) agonist for a period of 3-6 months before having a diagnostic laparoscopy. The levonorgestrel-releasing intrauterine system could also be considered.”
“Women should be offered appropriate analgesia to control their pain, even if no other therapeutic manoeuvres are yet to be initiated. If pain is not adequately controlled, consideration should be given to referral to a pain management team or a specialist pelvic pain clinic.”
The guidelines also include discussion of the complex relationship between chronic pelvic pain and sexual or physical abuse, and the importance of determining, and dealing with, a woman’s beliefs about her pain.
To view the report, visit the RCOG’s website at
http://www.rcog.org.uk .
Guidance on chronic pelvic pain 
