Interventions for treating chronic pelvic pain in women

Stones, R.W., Cheong, Y.C. and Howard, F.M. (2005) Interventions for treating chronic pelvic pain in women. Cochrane Database of Systematic Reviews, 2005 (Art. No: CD0003), 1-40. (doi:10.1002/14651858.CD000387).

Abstract

Background: Chronic pelvic pain is common in women in the reproductive and older age groups and causes disability and distress. Often investigation by laparoscopy reveals no obvious cause for the pain. As the pathophysiology of chronic pelvic pain is not well understood its treatment is often unsatisfactory and limited to symptom relief. Currently the main approaches to treatment include counselling or psychotherapy, attempts to provide reassurance by using laparoscopy to exclude serious pathology, progestogen therapy such as medroxyprogesterone acetate, and surgery to interrupt nerve pathways.
Objectives: We aimed to identify and review treatments for chronic pelvic pain in women. The review included studies of patients with a diagnosis of pelvic congestion syndrome or adhesions but excluded those with pain known to be caused by i) endometriosis, ii) primary dysmenorrhoea (period pain), iii) pain due to active chronic pelvic inflammatory disease, or iv) irritable bowel syndrome.
Search strategy: We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials (searched 20th January 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005), and reference lists of articles.
Selection criteria: Randomised controlled trials (RCTs) with women who had chronic pelvic pain. The review authors were prepared to consider studies of any intervention including lifestyle, physical, medical, surgical and psychological treatments. Outcome measures were pain rating scales, quality of life measures, economic analyses and adverse events.
Data collection and analysis: For each included trial, information was collected including the method of randomisation, allocation concealment and blinding. Data were extracted independently by the two review authors using forms designed according to the Cochrane guidelines.
Main results: Nineteen studies were identified of which fourteen were of satisfactory methodological quality. Five studies were excluded. Progestogen (medroxyprogesterone acetate) was associated with a reduction of pain during treatment while goserelin gave a longer duration of benefit. Counseling supported by ultrasound scanning was associated with reduced pain and improvement in mood. A multidisciplinary approach was beneficial for some outcome measures. Benefit was not demonstrated for adhesiolysis (apart from where adhesions were severe), uterine nerve ablation, sertraline or photographic reinforcement after laparoscopy. Writing therapy and static magnetic field therapy showed some evidence of short-term benefit.
Authors' conclusions: The range of proven effective interventions for chronic pelvic pain remains limited and recommendations are based largely on single studies. Given the prevalence and healthcare costs associated with chronic pelvic pain in women, randomised controlled trials of other medical, surgical and psychological interventions are urgently required.
Chronic pelvic pain is common in women in the reproductive and older age groups and it causes disability and distress that result in significant costs to health services. The pathogenesis of chronic pelvic pain is poorly understood. Often investigation by laparoscopy reveals no obvious cause for the pain. There are several possible explanations for chronic pelvic pain including undetected irritable bowel syndrome, and central sensitisation of the nervous system. A vascular hypothesis proposes that pain arises from dilated pelvic veins in which blood flow is markedly reduced. As the pathophysiology of chronic pelvic pain is not well understood, its treatment is often unsatisfactory and limited to symptom relief. Currently the main approaches to treatment include counseling or psychotherapy, attempts to provide reassurance using laparoscopy to exclude serious pathology, progestogen therapy such as with medroxyprogesterone acetate and surgery to interrupt nerve pathways.

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