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When assessing and planning treatment for women with chronic pelvic pain, a condition affecting more than one million women in the UK, the key role of the central nervous system must be considered.

Chronic pelvic pain is intermittent or constant pain in the lower abdomen or pelvis of a woman for 6 months or more. Shutterstock
Chronic pelvic pain is intermittent or constant pain in the lower abdomen or pelvis of a woman for 6 months or more.

A new Scientific Impact Paper (SIP) produced on behalf of the Royal College of Obstetricians and Gynaecologists and Dr Katy Vincent (Pain Fellow and Honorary Specialist Registrar for the Nuffield Department of Obstetrics and Gynaecology) reviews the available treatments for chronic pelvic pain that target the central nervous system rather than the pelvis which is where the majority of gynaecologists currently focus their assessment and treatments. 

Chronic pelvic pain is intermittent or constant pain in the lower abdomen or pelvis of a woman for a duration of 6 months or more. It does not occur exclusively with menstruation or intercourse and is not associated with pregnancy.

Women with chronic pelvic pain may experience constant or cyclical pain, which can be unprovoked or associated with specific activities including urination, bowel opening or sexual intercourse. It can be difficult to treat, with many patients not achieving adequate relief even after many years, state the authors.

This paper highlights that chronic pelvic pain is known to occur in association with a number of gynaecological conditions, such as endometriosis, pelvic organ prolapse and chronic pelvic inflammatory disease. However, in many cases the underlying cause cannot be identified. Moreover, even when a cause is found the painful symptoms experienced may be disproportionate to the extent of disease identified or persist after optimal treatment. The experience of pain necessitates the involvement of the central nervous system and there is increasing evidence that pain, no matter where it originates from, can both be generated and perpetuated by the central nervous system, emphasise the authors.

 The paper examines the advantages and disadvantages of medical treatments including antidepressants, anticonvulsants and botox as treatment options which target the nervous system. The authors conclude that further research should be conducted around these treatments as trials have shown a positive effect and are safe.

Moreover, the paper discusses the use of non-invasive non-pharmacological treatments, which include electrical and magnetic stimulation to alter neurophysiology at the site of pain or via the brain or spinal cord to reduce pain. Additionally, some surgical options exist which may benefit a woman suffering with chronic pelvic pain.

The authors conclude that treatments targeting the central nervous system can be treated alone or combined with hormonal therapies and/or surgery. Additionally, they emphasise that the best outcomes are likely to occur when a multidisciplinary team is involved in the care of a woman suffering from chronic pelvic pain, including those with expertise in hormonal, medical, surgical and psychological therapeutic treatment methods.

While there are few data supporting the efficacy of these treatments in chronic pelvic pain specifically, there is good evidence to suggest that the underlying pain mechanisms and central changes associated with chronic pain are similar no matter where the pain is perceived to originate from and we should consider these treatment options for all women with chronic pelvic pain.

“Prompt treatment of pain symptoms may prevent or at least minimise the development of long-term changes associated with chronic pain and improve a woman’s quality of life.”

Dr Katy Vincent 
 “The condition is associated with a significant reduction in quality of life and psychological distress is frequently seen in these women. Medical options such as antidepressant and anticonvulsant medications are well tolerated and could therefore be started by a gynaecologist or GP. Other more invasive therapies are likely to require a pain management team. It is important that gynaecologists are aware that a variety of treatment options exist so that referral can be considered for patients who have shown little sign of improvement to standard treatments before performing radical or fertility-removing surgery.”
Dr Sadaf Ghaem-Maghami, Chair of the RCOG’s Scientific Advisory Committee