It has often been said, with some truth, that chronic pelvic pain in women is a common complaint but that is not well understood or treated1. Typically a young woman, often with a demanding job, and who is sexually active, presents to her general practitioner with a history of a year or more of a constant dull ache in her pelvis that nothing will relieve. The pain starts to dominate her life and interfere with daily activities such as her job, relationships and leisure. Her general practitioner goes through the usual checklist of dysmenorrhoea, pelvic inflammatory disease and endometriosis and because the pain has been so persistent a diagnosis of pelvic inflammatory disease is made and a course of antibiotics are prescribed. There is an almost immediate improvement which lasts for a few weeks, but then the pain returns and she goes back to her general practitioner who tells her that she has probably had an inadequate response to the antibiotics with a flare-up of the old infection, so a further course is prescribed. Again, there is a transitory improvement but, by this time, the woman has become anxious about her fertility and is beginning to feel that there is something more serious causing the pain, so she asks for a referral to a specialist. She will usually have some time to wait for the appointment, during which the pain becomes progressively worse. Eventually the day comes when she sees her gynaecologist who appears doubtful about the diagnosis of pelvic inflammatory disease and may give another diagnosis, such as endometriosis. A diagnostic laparoscopy is arranged at which a search is made for any pelvic pathology to account for the pain. The finding of even a single focus of endometriosis or an adhesion is given as a likely cause for the pain and ablation or division is often done at the time of the diagnostic laparoscopy. More often, no pathology is found and the result of the consultation will usually be reassurance that there is nothing to be worried about and the woman will be referred back to her general practitioner. At best, the implication of all of this management is that whatever is causing the pain will soon clear up and with it the pain should also go. If, as often happens, the pain persists, the woman will return at increasingly frequent intervals to see her doctor and, if she is lucky, she will get sympathy but little else. More often she will be left with the impression or told outright that the pain is ‘in the mind’. Many women go up this diagnostic cul-de-sac and become increasingly desperate because they cannot find someone to help them. Their quality of life deteriorates as, increasingly, they lose their self respect and self confidence.
Why have we as a profession allowed this state of affairs to continue for so long? It is not primarily because gynaecologists or general practitioners have an uncaring attitude but is more likely to be a reflection of the difficulty of treating a phantom illness whose presentation is only too familiar but whose underlying pathology is not understood. Because of this, it is pleasing to see the two papers devoted to chronic pelvic pain which are published in this edition of the Journal. Each of them, from a different point of view, characterises factors likely to be associated with chronic pelvic pain. Zondervan et al.2 from Oxford (pages 93–99) report on an exhaustive search of the literature for soundly-based epidemiological studies of chronic lower abdominal pain in the community. Collett et al.3 from Leicester (pages 87–92) have sought to determine whether childhood and adult sexual abuse is a significant feature in women with chronic pelvic pain by comparing them with two matched groups one of which is made up of women who suffer from chronic pain elsewhere in the body, and the other a control group with no pain.
One of the major problems of research into chronic pelvic pain is the lack of agreed definitions which would allow comparison between studies. Each of the three words—chronic, pelvic and pain—is open to a variety of interpretations. Reiter4, writing as guest editor of a volume of Clinical Obstetrics and Gynaecology, recognised the problem and defined chronic pelvic pain as “noncyclic pelvic pain of greater than six months duration which is not relieved by narcotic analgesics”. Immediately, one sees the problems inherent in this carefully considered definition. Does the word chronic mean continuous, unremitting pain for at least six months, or is it pain that occurs with a certain frequency with intermissions? If so, how long should the pain last on each occasion to qualify? Mathias et al.5, reporting on a telephone poll by the Gallup Organisation, comments that memory of events beyond three months becomes suspect, so is the present accepted minimum period for chronic pelvic pain of six months too long? Also, is it right to talk of ‘pelvic’ pain when many women are, in reality, complaining of lower abdominal pain? Referral patterns of visceral pain are notoriously capricious6 so it would probably be wise to include lower abdominal and pelvic pain together. One also has to question whether at this stage of our limited knowledge of the aetiology, it is wise to limit the definition of chronic pelvic pain to noncyclical pain, when the menstrual cycle plays such an important part in determining the severity of much of the pain of chronic pelvic pain7. Typically, women with pelvic congestion, who make up a large proportion of those with chronic pelvic pain start their pain history with pre-menstrual or ‘congestive’ dysmenorrhoea, which as time progresses, spreads into the luteal phase of the cycle, often with a mid-cycle exacerbation, eventually becoming unremitting pain throughout the cycle. Definitions are important if a body of reliable information is to be built up in the literature which will eventually lead to a better understanding of the pathophysiology and management of chronic pelvic pain. The time has come for clinicians and scientists to agree on definitions so that recommendations can be adopted by those interested in furthering research into the condition.
Both papers reveal the serious disruption to the lives of women who suffer from chronic pelvic pain. Table 1 summarises the effects of chronic pelvic pain on the quality of life of women with some information on the background prevalence of symptoms in women of similar age and background who do not suffer from chronic pelvic pain. The study by Jamieson and Steege8, is community-based to the extent that a questionnaire was administered to women aged 18 to 45 years who were interviewed while waiting in a number of medical clinics and included friends who were accompanying them. The telephone survey of women between the ages of 18 and 50 of Mathias et al.5 comes closest to being a representative survey of chronic pelvic pain in a community population. Although the data from these studies are not strictly comparable, a number of epidemiological pointers do emerge. In the two community-based studies5,8, the prevalence of chronic pelvic pain (with markedly different definitions of the complaint) among populations of young women of reproductive age were found to be 39% and 14.7%. Among the women with chronic pelvic pain, limitation of home life occurred in 28% in the study of Jamieson and Steege8, compared with the 11% found in the total study population. In the same study, some limitation of sexual activity was reported in 30% of women with chronic pelvic pain as compared with 2% in the general population. It is likely that this sexual dysfunction is mainly due to the fear of post-coital ache (65%) and deep dyspareunia (71%)9. The adverse effects of post-coital ache and dyspareunia were confirmed in another study10 of 36 women with severe pelvic congestion, treated by hysterectomy and bilateral salpingo-oophorectomy who before surgery had a median frequency of intercourse of once a month which with relief of chronic pelvic pain improved to eight times a month one year later10. Other indicators of the effects of chronic pelvic pain on the quality of life shown in Table 1, such as limitation of normal exercise, loss of time at work or at home because of having to stay in bed, increased use of medication and the adverse effect on general health, all showing how damaging chronic pelvic pain can be to the quality of life. One should recall that chronic pelvic pain is experienced at an age when women should be in the healthiest and most active phase of their lives.
|Jamieson et al.8||Mathias et al.5|
|n (%)||227 (581)||773 (5263)|
|Prevalence of CPP||39*||14.7†|
|Loss of ≤ 1 day/month (home or work)||10 ||—|
|Sexual dysfunction||30 ||—|
|Regular use of medication||40 ||—|
|Limitation of normal home life||28 ||—|
A great deal of work has been done on the psychopathology of women with chronic pelvic pain, recently comprehensively reviewed by Fry et al.11,12 There still remains some doubt as to whether psychopathology is the cause or the effect of chronic pelvic pain. This uncertainty needs to be resolved, if only because so many women with chronic pelvic pain at present are labelled as being neurotic, often without good evidence. A number of facts are now emerging which suggest that psychological stressors exacerbate pelvic pain and may actually contribute to underlying causative somatic pathology13. One such stressor may be sexual abuse, particularly in childhood. The study of Collett et al.3 (pages 87–92) report a comparison of women with chronic pelvic pain, chronic pain in other sites, and women with no pain. Although matched for educational status, the chronic pelvic pain group had a high rate of pre-existing major gynaecological surgery, suggesting that their pain was greater than normal, which may make their results less general. The study showed that 12/30 women with chronic pelvic pain experienced serious sexual abuse either in childhood (n= 6) or later (n= 6), compared with only five in each of the other two groups. The women with chronic pelvic pain also had a significantly increased level of anxiety (53%), dyspareunia (73%), post-coital ache (53%) and vaginismus (40%). The 40% rate of sexual abuse among women with chronic pelvic pain is significantly higher than in the other two groups, but is similar to that reported by Fry et al.14 of 38% and 48% depending on the definition of sexual abuse. However, while these authors did not have a control group, they commented that the apparently high rate was not significantly different from the rates obtained from women's clinics and in the community. Thus, the question of whether sexual abuse is a primary cause of chronic pelvic pain remains unresolved. What seems likely is that in the 65% of women with chronic pelvic pain who have an apparently normal pelvis at laparoscopy, psychological stressors play an important part in the genesis of the pelvic pain13. It may be that women who have experienced sexual abuse at some time in their life, particularly in childhood, develop sexual dysfunction which, in itself, is known to be a potent stressor in conjunction with chronic pelvic pain.
We conclude, that chronic pelvic pain is a serious problem affecting the lives of a substantial number of women at a time when they can least afford to have such a debilitating condition. Attempts have been made to assess the cost at a national level. In the United Kingdom, Davies et al.15 analysed the cost of treating women with pelvic venous congestion. The lifetime cost of investigation for one year was estimated at £770 per woman, with a total cost to the National Health Service in 1990/1991 of £ 158.4 million or 0.6% of total expenditure. Estimates from the United States5 demonstrated that the direct cost of outpatient visits alone in women with chronic pelvic pain was US$881.5 million (£550 million) per year. These costs did not include the lost revenue from the 15% of women with chronic pelvic pain who reported time lost regularly from paid work and the 45% who reported reduced productivity.
Chronic pelvic pain is clearly a major problem seeking solutions. A concerted effort from the medical and psychological professions and finding bodies is urgently needed to establish effective research programmes that will lead to a greater understanding of the cause of chronic pelvic pain and hence to more effective treatment.