Female Pelvic Pain

Gerald J. Harkins, MD, MPT, FACOG

Pelvic pain in females is a complicated medical problem. With a myriad of causes, it also produces complex medical and mental health challenges for millions of women. The collateral impact on families and society is immense, as these women struggle to maintain a quality of life while managing their conditions.

This complexity of female pelvic pain delays and impedes diagnosis, with the time from initial complaint to correct diagnosis for women with pelvic pain and endometriosis averaging 6 to 8 years. Delays, dismissals, and misdiagnoses lead to significant patient frustration and distrust of the medical establishment. Unfortunately, these delays may also allow significant progression of the pelvic pain condition. Pelvic pain that is present for greater than 6 months is defined as chronic pelvic pain. At this point, it may become recalcitrant to treatment and, as a matter of course, a more difficult situation to manage. Chronic pain begins to develop its own neurologic complex. It becomes more resistant to simple treatments, and long-term nerve damage occurs. The effect on women and their families can be significant and lifelong.

Prompt diagnosis begins with provider education and awareness to achieve accurate and timely evaluations of women presenting with pelvic pain symptoms.

This edition of Seminars in Reproductive Medicine is intended to bring together experts in the field of female pelvic pain by providing contributions on the many varied topics that contribute to this complex and debilitating condition.

We begin with the “Evaluation of Chronic Pelvic Pain” for providers. Patients benefit from a thorough evaluation by a provider versed in the complexities and subtleties associated with the pelvic pain complaint. Sensitivity to these factors helps guide the provider on how to best structure these initial patient encounters.

Building on the theme of a thorough evaluation of a patient with female pelvic pain, the Seminar next presents the “Musculoskeletal Considerations in Female Patients with Chronic Pelvic Pain.” Providers tend to focus on the visceral contributors to pelvic pain and, as such, often overlook musculoskeletal factors. This may lead to misdiagnosis, unnecessary testing, and surgical intervention. Unraveling the root cause of this particular presentation requires a physical examination to evaluate these musculoskeletal factors. This section serves as a guide for providers who may not be well versed in such an examination.

“Pelvic Pain in Adolescents” addresses the special considerations of caring for adolescent patients with pelvic pain. Many times, the evaluation of adolescents involves both the patient and her parents. It involves consideration of her physical health, psychosocial health, and long-term implications for fertility, sexual function, and well-being. Adolescents with pelvic pain are at risk for depression and anxiety; so, special focus on helping this group of patients to identify and manage their pelvic pain symptoms has enduring implications.

Patients with pelvic pain present with a complex and varied set of symptoms. One of the most difficult set of symptoms to address is covered in the article “Interstitial Cystitis/Bladder Pain Syndrome.” This condition's presentation and etiology are variable and poorly understood. The authors summarize the two current classification systems and the theories behind the development of some of this condition's most devastating symptoms. Interstitial cystitis and bladder pain syndrome contribute to central sensitization and central neurologic changes that reinforce persistent pelvic pain and resistant pelvic pain syndromes. Research into the bladder's contribution to chronic pelvic pain is a key component to this multifactorial syndrome.

Likewise, the next article “Fibromyalgia and Irritable Bowel Syndrome in Women with Chronic Pelvic Pain” is a thorough review of the two of the most prevalent and well-studied functional somatic syndromes (FSSs). These disease states are characterized by pain, hypersensitivity, and lack of any obvious physical or laboratory findings. These syndromes predominately affect women at a greater rate than men, and there is common overlap in several these FSSs.

Endometriosis is a common and oftentimes devastating condition for women. It affects an estimated 6 to 7% of all women, with approximately 10 million women in the United States alone suffering with the condition. Yet despite being a common origin for pelvic pain in women, it may still take an upward of 6 to 8 years from the time of a first complaint of endometriosis symptoms until correct diagnosis and treatment. Article “Endometriosis and Female Pelvic Pain” reviews pathogenesis, diagnosis, and treatment options for these patients. It serves as a comprehensive review of this common disorder to bolster education and awareness for clinicians and patients.

Sexual dysfunction in women and couples is another common problem that is typically underdiagnosed, overlooked, and untreated in the care of patients with pelvic pain. It is most likely due to reluctance and embarrassment on the part of the patient to bring up the subject to their physician; however, physician awkwardness and lack of education on treatment options are also contributing factors. Sexual dysfunction may affect up to 40% of all couples, and health care providers should recognize and inquire about this issue with their patients in an open, nonjudgmental way. Article “Female Sexual Dysfunction in Women with Pelvic Pain” reviews the common causes and treatment options for women with this complex condition.

Key to the success of treatment of female pelvic pain is multidisciplinary team management. The interventional pain specialist should be an integral member of that team. Interventional pain specialists have fellowship specialty training in medical and procedural options for patients with acute and chronic pain. In the article “Interventional Pain Management and Female Pelvic Pain—Considerations for Diagnosis and Treatment,” we review interventional pain procedures that may be appropriate in the care plan for women with visceral pelvic pain.

Finally, article “Opioids and Alternatives in Female Chronic Pelvic Pain” recognizes the need to explore the medical options and alternatives for pain management for women with pelvic pain. Successful nonsurgical management typically relies on a multimodal approach, with integration of both pharmacologic and nonpharmacologic interventions.

It has been an honor to serve as an editor for this issue of Seminar in Reproductive Medicine and to both curate and learn from manuscripts on female pelvic pain. I sincerely appreciate the contribution of the authors to this Seminar and we hope these reviews serve to educate and inspire those caring for these women as we continue to focus on educating and improving the care and treatment for our patients with pelvic pain.