Successful treatment of chronic pelvic pain often requires a multidisciplinary approach, recognizing its impact on a patient’s quality of life, psychological health, relationships, and work. Health psychologists, psychiatrists, pain specialists, and physical therapists may all play important roles in helping the patient to manage her symptoms and maximize her daily functioning and well-being.
Medical therapy may be general (focused on overall management of the pain) or disease-specific (focused on specific underlying etiologies of pain). The choice of medical therapy should be influenced by side-effect profiles as well as the patient’s interest in pregnancy.
General therapies include medications that are often used for the treatment of chronic pain syndromes. Initial treatment may begin with simple analgesics, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). Some women may also benefit from neuromodulators, including tricyclic antidepressants, duloxetine, gabapentin, and pregabalin. Guidelines acknowledge the limited evidence for the effectiveness of these treatments for the management of chronic pelvic pain; the potential for side effects (such as gastrointestinal and renal side effects with NSAIDs) may limit long-term use of some treatments.
Hormonal therapies are used primarily for treating gynecologic sources of chronic pelvic pain. Women with suspected endometriosis can be empirically treated with hormonal therapy before diagnostic laparoscopy is performed. Combined oral contraceptives, progestins (oral, injectable, and intrauterine), gonadotropin-releasing hormone (GnRH) analogs, and danazol are effective for treating the dysmenorrhea associated with endometriosis, although the side effects vary. The effects on bone mineral density associated with GnRH analog therapy can be mitigated by “add-back” low-dose hormonal therapy (norethindrone, low-dose estrogen, or a combination of estrogen and progesterone), which may also provide symptomatic relief for associated hot flashes and vaginal symptoms. Danazol may be associated with severe androgenic side effects, including hirsutism, acne, and weight changes, and so typically is not used as first-line therapy. For women who have endometriosis and desire pregnancy, NSAIDs may provide symptomatic relief.
A Cochrane systematic review and meta-analysis investigated the effectiveness of noninvasive treatments for the management of chronic pelvic pain unrelated to endometriosis, primary dysmenorrhea, chronic pelvic inflammatory disease, or irritable bowel syndrome. Treatment with medroxyprogesterone, compared to placebo, was associated with a reduction in pain that was maintained up to 9 months after therapy; side effects included weight gain and bloating.
Musculoskeletal sources of chronic pelvic pain include pelvic floor myalgia, which is related to spasm of the levator ani muscles, and myofascial trigger points. Treatments include pelvic physical therapy and trigger point injections with a local anesthetic or botulinum A toxin.
Treatment of irritable bowel syndrome and interstitial cystitis are discussed in Chapters 15-05, 15-06 and 23-04.
Women with endometriosis may be offered laparoscopic surgical destruction of implants; adhesiolysis can be considered if severe and dense adhesions are also present. Uterine artery ablation has been shown to be effective for the treatment of adenomyosis, and pelvic vein embolization improves pain in patients with pelvic venous congestion.
Guidelines note that additional surgical techniques for the management of chronic pelvic pain include presacral neurectomy, laparascopic uterine nerve ablation, hysterectomy, and salpingo-oopherectomy.