NEW YORK (Reuters Health) - The American College of Obstetricians and Gynecologists has issued a new practice bulletin for chronic pelvic pain, a condition that can be difficult to diagnose and treat.

The College proposes defining chronic pelvic pain as noncyclical pain, lasting at least 6 months, localized to the anatomic pelvis, anterior abdominal wall, periumbilical area, the lumbosacral back or the buttocks, the severity of which causes functional disability or leads to medical care.

They caution in their report, published in the March issue of Obstetrics and Gynecology, that "a lack of physical findings does not negate the significance of a patient's pain, and normal examination results do not preclude the possibility of finding pelvic pathology." Currently, up to two thirds of women with chronic pelvic pain are never diagnosed or referred for specialist evaluation and do not undergo diagnostic testing.

"A fair number of women [with chronic pelvic pain] don't seek care, and when they do, they're told it's normal, that there's nothing wrong," lead author Dr. Fred Howard told Reuters Health. This is problematic, he added, because even though many of the associated conditions "can't be cure, they can be effectively treated in a large proportion of patients."

The source of pelvic pain is not limited to the reproductive tract, he noted. The genitourinary and gastrointestinal tracts or musculoskeletal disorders may be involved. Psychological disorders or neurologic diseases can also cause chronic pelvic pain.

Risk factors and conditions associated with pelvic pain include physical or sexual abuse, pelvic inflammatory disease, endometriosis, interstitial cystitis and irritable bowel syndrome. It may also be caused by trauma related to pregnancy and childbirth, abdominopelvic surgery and musculoskeletal disorders.

"Good and consistent scientific evidence" supports use of oral contraceptives and nonsteroidal anti-inflammatory drugs for dysmenorrhea. Some patients may even need opioids, Dr. Howard added. Presacral neurectomy, uterine nerve ablation or transection of the uterosacral ligament may be of benefit for treating centrally located dysmenorrhea.

Gonadotropin-releasing hormone agonists, progestins and laparoscopic treatment should be considered for endometriosis and endometriosis-like pain, the report indicates. Referral to psychotherapy may improve response to medical treatment, but physicians should avoid suggesting to the patient that the pain is "all psychological."

Other modes of treatment for which scientific evidence is more limited include surgical adhesiolysis, hysterectomy, sacral nerve stimulation, local anesthetic injections into trigger points, and physical therapy. Limited data are available on the efficacy of complementary or alternative medicine therapies, such as herbal and dietary supplements, magnetic field therapy and acupuncture.

Chronic pelvic pain is "a significant problem," Dr. Howard added. "Although it is rarely life threatening, its prevalence is similar to that of migraine, asthma and low back pain."

Obstet Gynecol 2004;108:589-605.

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