Chronic Pelvic Pain: A Tricky Diagnosis

Jennifer Wider, M.D.
Society for Women’s Health Research
June 9, 2005

Women with chronic pelvic pain may suffer in silence. Roughly 60 percent of patients never receive a proper diagnosis, according to statistics gathered by the Mayo Clinic. Many women bounce around to different health practitioners without ever being treated.

“Up to 20 percent of women between the ages of 18 and 50 have chronic pelvic pain of over a year's duration,” says John M. Gibbons, M.D., director and chair of the Department of Obstetrics and Gynecology at St. Francis Hospital in Hartford, Conn. The difficulty of obtaining a proper diagnosis and adequate treatment is due in part to the fact that many doctors are not well informed about the causes of pelvic pain, Gibbons said.

Diagnosing chronic pelvic pain can be challenging. One of the reasons that making the diagnosis is tricky relates to the fact that there is no single underlying cause of chronic pelvic pain.

“There is no universally accepted definition of chronic pelvic pain,” Gibbons explained. “A working definition is non-cyclic pain of at least six months duration localized to the anatomic pelvis including the anterior abdominal wall, the lumbosacral back, and the buttocks.”

Chronic pelvic pain can be caused by a of host gynecological conditions including endometriosis, fibroids, vulvodynia (chronic vulvar discomfort), spasms in the pelvic floor muscles and pelvic inflammatory disease. Chronic pelvic pain can also result from irritable bowel syndrome, bladder infections and varicose-type veins around the ovaries. Psychological factors including depression, sexual abuse and excessive stress have also been cited as potential triggers.

Women who suffer from chronic pelvic pain usually experience pain in the area below the belly button. To be classified as chronic, the symptoms typically last for at least six months. The pain ranges from mild to severe and can vary from person to person. Some women complain of steady pain. For others, the pain comes and goes. The pain can be sharp, dull, cramping or feel like pressure or heaviness.

Most women with chronic pelvic pain realize that something is wrong. But even when the signs are there, the diagnosis may still be a challenge.

“Even when pathology is present, accurate diagnosis may be difficult because of the nature of visceral pain; it may be difficult for patients to localize, may vary under hormonal influences, and is variable from person to person,” explains Linda Porter, Ph.D., who is a neuroscience program director at the National Institutes of Health in Bethesda, Md.

Women who experience pain in the pelvic region for more than six months should see a doctor.

“There are myriad ways to arrive at a particular diagnosis,” Gibbons said. “The woman's history will establish the broad diagnosis of chronic pelvic pain. Identification of the cause entails further history, physical examination, laboratory tests, and special procedures that may range from neurophysiologic studies, to GI [gastrointestinal] endoscopy, to pelvic laparoscopy, to sophisticated imaging such as CT scans [also known as CAT scans or Computed Axial Tomography imaging] or MRIs [magnetic resonance imaging].”

Because there are many different causes of chronic pelvic pain, treatment will depend on the cause. “Medication, physical therapy, surgery, and techniques of alternative or complementary medicine such as acupuncture and massage are commonly used,” Gibbons said.

The way in which patients perceive and handle pain can vary from person to person. "Psychological concerns often arise in patients with chronic pain and should be addressed in the treatment strategies. Patients cope with, perceive, and respond to pain differently, because of many factors, including genetic, ethnic, and sex differences,” Porter explained.

© June 9, 2005 Society for Women's Health Research