Chronic Pelvic Pain

2013

Chronic pelvic pain (CPP) is defined as pelvic pain lasting more than 6 months. Some authors add the additional criteria that the pain be noncyclic. It is one of the most common presenting complaints in gynecologic practice, affecting as many as one in seven American women. Chronic pelvic pain comprises up to 10% of outpatient gynecologic visits, accounts for 20% of laparoscopies, and results in 12% (75,000 / year) of all hysterectomies performed annually in the United States. Estimated annual direct medical costs for outpatient visits for chronic pelvic pain in the United States among women 18 to 50 years old is estimated to be $881.5 million. It is often an extremely frustrating condition for both patient and care provider because in many cases an etiology cannot be identified and there is no apparent pathology. Treatment of presumed underlying conditions is frequently ineffective, and the “pain itself becomes the illness.” Because the cause often cannot be identified, chronic pelvic pain is frequently attributed to psychogenic causes. Although these may play a role in chronic pelvic pain for some women with lack of an identifiable cause, this does not necessarily equate with a psychosomatic origin for this complaint.

Common causes of chronic pelvic pain include endometriosis, pelvic inflammatory disease (PID), adhesions, ovarian remnant syndrome, pelvic congestion syndrome, and cyclic uterine pain, which may be caused by primary or secondary dysmenorrhea, uterine myomata, and adenomyosis. History of psychosexual trauma is common in women diagnosed withchronic pelvic pain. Chronic pelvic pain is frequently associated with systemic inflammation, including autoimmune diseases. Peritoneal chronic inflammation is sometimes also associated. A study of chronic pain reveals that the immune system is intimately involved in the production, conduction, and exacerbation of pain and of its clinical features, such as hyperalgesia and allodynia.

Not all pelvic pain is of gynecologic origin; other conditions must be ruled out. Genitourinary pain (e.g., due to interstitial cystitis, urethral syndrome, or overactive bladder), gastrointestinal pain (e.g., irritable bowel syndrome, bowel obstruction, or bowel neoplasm), and neu-romuscular pain are also common causes ofchronic pelvic pain. chronic pelvic pain may be intermittent or continual. Pain is affected by physical and mental fatigue, as well as stress. It may lead to depression and anxiety, dyspareunia (painful sex / intercourse), and difficulties with sleep, decreased ability to work and enjoy normal activities, and may be a contributing factor in job loss, relationship dysfunction and divorce.

Symptoms

Symptoms associated with chronic pelvic pain include:

  • • Anxiety and depression.
  • Constipation or diarrhea
  • • Dysmenorrhea
  • • Fatigue
  • • Leg pain radiating from the groin.
  • • Loss of interest in social activities
  • • Low back pain and a feeling of heaviness in the lower abdomen.
  • • Menstrual irregularity
  • • Persistent pain despite multiple treatments
  • • Reduced libido
  • • Sleep disruption
  • Spasms of the vaginal and / or pelvic floor muscles
  • • Substance use / abuse
  • • Dyspareunia (painful and difficult intercourse / vaginal penetration)
  • • Family / relationship problems

Diagnosis

Diagnosis of chronic pelvic pain is based on identifying the underlying cause(s). It also may be a diagnosis of exclusion, with no identifiable etiology. Careful attention should be paid to the history and physical examination, particularly a thorough pelvic examination to evaluate for tenderness, pelvic mass, adhesions, or prolapse. Testing may include ultrasound, laparoscopic examination, pregnancy test, CBC, vaginal and cervical cultures, Pap smear, evaluation for GI disorders, and urologic examination.

Differential Diagnosis

Differential diagnosis in chronic pelvic pain is really a matter of identifying the possible causes of pain (Table Common Causes of Chronic Pelvic Pain) and treating the etiology while addressing the pain and concomitant symptoms. In patients under 30, the most common causes of pelvic pain include endometriosis and pelvic inflammatory disease; in older women, causes most likely include uterine myoma, adenomyosis, or pelvic relaxation. It is critical to rule out any serious or life-threatening causes, as well as to assess for depression, anxiety, and serious mental health disorders.

Common Causes of Chronic Pelvic Pain

Classification Conditions
Gynecologic Abortion

Adhesions

Adnexal torsion

Chronic salpingitis

Dysmenorrhea

Ectopic pregnancy

Endometriosis

Mittelschmerz

Pelvic congestion

Pelvic infection

Ruptured ovarian cyst

Salpingitis

Uterine fibroids

Uterine prolapse / pelvic relaxation

Gastrointestinal Appendicitis

Chronic appendicitis

Constipation

Diverticulosis

Enterocolitis

Gastroenteritis / Spastic colon

Inflammatory bowel disease

Irritable bowel syndrome

Neoplasia

Ulcerative colitis

Urologic Chronic cystitis

Detrusor hyperactivity

Interstitial cystitis

Ureteral calculus

Musculoskeletal / Neurologic Arthritis

Coccydynia

Conus medullaris lesions

Degenerative joint disease

Fibromyalgia

Fractures

Low back problems

Multiple sclerosis

Nerve entrapment syndromes

Neuromuscular disorders

Pelvic floor spasm

Poor Posture

Vertebral disk disorder

Psychogenic Abuse

Clinical depression

Hypochondriasis

Pain medication seeking

Physical or sexual abuse

Premenstrual dysphoric disorder

Psychiatric disorders

Psychosocial stress

Sleep disturbances

Substance abuse

Other Hyperparathyroidism

Calcium / magnesium deficiencies

Trauma

Conventional Treatment Approaches

The choice of medical treatment for chronic pelvic pain depends on the etiology of the pain, thus necessitating careful diagnosis. Treatment of underlying conditions is the primary treatment strategy. However, in one-third of cases, no etiology is identified. Sympathetic and supportive care is critical, with reassurance and validation of the woman’s symptoms essential, especially in the absence of an identifiable cause. The pain should be treated as a real problem. Multidisciplinary team management of chronic pelvic pain may be the most productive strategy, including the expertise of a gynecologist, a psychologist with expertise in sexual and relationship counseling, and also possibly an acupuncturist for pain management, in addition to the appropriate specialists for the underlying cause. Treatment with medication includes the use of NSAIDs, antidepressants for depression and sleep disorders, and hormonal therapies (i.e., oral contraceptives for management of cyclic pain or gonadotropin-releasing hormone analogs for pain associated with endometriosis or uterine fibroids). Trigger point injections of local anesthetics has proved helpful for prolonged pain relief in some patients, as has TENS therapy. Acupuncture has been used with good results in the treatment of dysmenorrhea, and may be beneficial in pain reduction forchronic pelvic pain. Immune modification using steroids and disease-modifying antirheumatic drugs, such as hydroxychloroquine, are known to inhibit inflammatory cells and cytokines, such as interleukin-1, interleukin-6, and tumor necrosis factor, which are responsible for pain and tissue damage. These drugs are found to be effective in the treatment of chronic pelvic pain of an inflammatory nature and for symptomatic chronic inflammation of the vagina. Surgical interventions include laparoscopy for the lysis of pelvic adhesions or removal of endometrial tissue, or hysterectomy.

Although hysterectomy without an associated pathology has not proved effective, it is nonetheless indicated as a reason for hysterectomy in 10% to 15% of those performed in the United States. According to one study 25% of hysterectomy patients reported persistent pain 1 year after surgery.

Botanical Treatment Of Chronic Pelvic Pain

Formulae For Chronic Pelvic Pain Treatment

Dietary Considerations

Dietary changes are indicated when the client suffers from digestive complaints such as constipation, bloating, flatulence, overweight, lethargy, excessive fatigue, or irritability accompanying CPP. Achieving an optimal weight and stable blood sugar may lead to improvements in digestion and mood, and increasing dietary fiber and fluids can lead to reduction in constipation and bloating. Additionally, a Mediterranean-type diet with the addition of high quality essential fatty acids can reduce the production of inflammatory mediators, and thus be beneficial in chronic pain reduction. Consider calcium and magnesium supplementation for relief of muscle spasm.

Chronic Pelvic Pain: Additional Therapies

Treatment Summary For Chronic Pelvic Pain

  • • Symptomatic pain relief can be achieved with herbal analgesics and antispasmodics. Sedatives can be used if pain interferes with sleep.
  • • Anxiety and depression commonly associated with chronic pelvic pain can be treated with botanical anxiolytics and antidepressants which may be combined with herbs for pain relief and sleep promotion.
  • • Reduce inflammation with herbs, an anti-inflammatory diet, including EFA supplementation.
  • • Treat underlying or associated digestive problems such as bloating, constipation, or IBS.
  • • Treat underlying or associated gynecologic or menstrual problems, for example, ovarian cysts, dysmenor-rhea, or endometriosis.
  • • Treat underlying or associated urinary problems such as UTI or interstitial cystitis.
  • • Treat pelvic congestion syndrome with herbs that stimulate pelvic circulation.
  • • Use external treatments such as sitz baths and massage with analgesic essential oils to improve pelvic circulation and relieve pain.
  • • Employ muscle relaxation techniques, pelvic muscle re-education, biofeedback, or electrical stimulation to retrain muscle patterns and relieve pain.
  • • Mayan uterine massage may be a helpful technique for relieving pain and pelvic adhesions or uterine displacement.
  • • Achieve a healthy body weight, good posture, and adequate exercise.
  • • Supplement with calcium and magnesium for relief of muscle spasms.

Summary

A number of conditions of the reproductive organs can be treated with botanical medicine. Table Condition / Botanical Medicine Summary Table includes a summary of the herbs used to treat these conditions.

Condition / Botanical Medicine Summary Table

Benign Breast Disorder Cervical Dysplasia Chronic Pelvic Pain Endo- metriosis Uterine Fibroids
Achillea millefolium X X X
Actaea racemosa X X X
Aesculus hippocastanum X
Alchemilla vulgaris X X X
Althea officinalis X X
Ananas comosus X
Anemone pulsatilla X X
Angelica sinensis X X X
Astragalus membranaceus X
Berberis vulgaris X
Calendula officinalis X X X
Camellia chinensis X X
Cannabis indica X
Capsella bursa-pastoris X
Caulophyllum thalictroides X X X
Ceanothus spp.
Chelidonium majus X
Chionanthus virginicus X X
Cinnamomum spp and X
Erigeron
Commiphora mol mol
Curcuma long X
Cordyceps sinensis X
Corydalis ambigua X X
Dioscorea villosa X
Echinacea spp. X X
Eleutherococcus senticosus X X X X X
Eschscholzia califomica X X
Filipendula ulmaris X
Calium aparine X
Canoderma lucidum X
Geranium maculatum X
Clycyrrhiza glabra X X X X
Cossypium herbaceum
Hamamelis virginiana X
Hydrastis canadensis X X
Hypericum perforatum X X X X
Lavandula officinalis X X
Leonurus cardiaca X X X X
Linum ussitissimum X X
Lomatium dissectum X
Mahonia aquifolium X
Matricaria recutita X X
Melaleuca alternifolia X
Melilotus officinalis X
Melissa officinalis X
Mentha piperita X
Mitchella repens X X
Myrica cerifera X
Oenothera biennis X X X
Origanum vulgar X
Panax ginseng X
Panax quinquefolius X X X X X
Paeonia lactiflora X X
Phytolacca americana X
Picrorrhiza kurrhoa X
Piper methysticum X X
Piscidea piscipula X X
Rehmannia glutinosa X
Rhaponticum carthimoides X X X X X
Rhodiola rosea X X X X X
Rosmarinus officinalis X
Rubus idaeus X X
Rumex crispus
Sanguinaria canadensis X
Schisandra chinensis X X X X X
Silybum marianus X
Tanacetum parthenium X X
Taraxacum officinale X X
Thuja occidentalis X X
Thymus vulgaris X
Trifolium pratense X
Trillium erectum X
Ulmus rubra X
Usnea barbata X
Verbena officinalis X X
Viburnum opulus X X
Viburnum prunifolium
Vitex agnus-castus X X
Withania somnifera X X X X X
Zingiber officinale X X