{"paper_id":"1e7cad7e-441e-410e-9e6d-d282f3198c39","body_text":"~ 1 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2024; 8(6): 01-09 \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2024; 8(6): 01-09 \nReceived: 02-08-2024 \nAccepted: 10-09-2024 \nDr. Sneha Purankar \nSenior Resident, Department of \nObstetrics and Gynecology, KIMS \nHospital Secunderabad, \nTelangana, India \nDr. Krishna Sai Karlapudi \nSenior Resident, Department of \nObstetrics and Gynecology, KIMS \nHospital Secunderabad, \nTelangana, India \nDr. Tripura Sundari \nConsultant, Department of \nObstetrics and Gynecology, KIM’S \nHospital Secunderabad, \nTelangana, India \nCorresponding Author: \nDr. Sneha Purankar \nSenior Resident, Department of \nObstetrics and Gynecology, KIMS \nHospital Secunderabad, \nTelangana, India \nEvaluation of chronic pelvic pain in females a \nprospective observational study \nDr. Sneha Purankar, Dr.\n Krishna Sai Karlapudi and Dr. Tripura Sundari \nDOI: https://doi.org/10.33545/gynae.2024.v8.i6a.1530 \nAbstract\nIntroduction: Pain is an unpleasant sensory and emotional experience associated with actual potential \ntissue damage or described in terms of such damage . Chronic pelvic pain (CPP) is defined by the European \nAssociation of Urology (EAU) as “chronic or persistent pain perceived in structures related to pelvis.  It is \noften associated with negative cognitive, behavioral, sexual and emotional consequences and might have \nsymptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor or gynaecological dysfunction. \nAim& Objectives:  \nAim: To evaluate the causes of chronic pelvic pain in females. \nObjectives: To describe the differential diagnosis of chronic pelvic pain. To detect chronic pelvic pain \nearly and aid in its management plan further. \nMaterials and Methodology: Female patients attending department Obstetrics and Gynaecology of KIMS \nhospitals between 18-70 years age, were enrolled into study during the period from 14th September, 2020 to \n31st May 2022. \nResults: It is observed that 38% of the women were diagnosed under the category Endometriosis and 14% \nwith Adenomyosis. Hence endometriosis is the most common cause of CPP based on the study. \nIt is observed that 48% women had to undergo surgical management, 27% went for medical management. \nAlmost 9% cases were referred to other branches which included psychology and orthopaedics. \nConclusion: Women with CPP often have other associated symptoms. Most common factor was \ndysmenorrhea as per this study (51%). When past surgical history in the 100 women was taken into \nconsideration, CPP was more prevalent in those who had a history of LSCS (63%) Multidisciplinary \napproach is helpful in most of the cases. \nKeywords: Chronic pelvic, pain in females, observational study \nIntroduction  \nPain is an unpleasant sensory and emotional experience associated with actual potential tissue \ndamage or described in terms of such damage [1]. Chronic pelvic pain (CPP) is defined by the \nEuropean Association of Urology (EAU) as “chronic or persistent pain perceived in structures \nrelated to pelvis. It is often associated with negative cognitive, behavioral, sexual and emotional \nconsequences and might have symptoms suggestive of lower urinary tract, sexual, bowel, pelvic \nfloor or gynaecological dysfunction [2].  \nThe American College of Obstetricians and Gynaecologists (ACOG) define CPP as “non -cyclic \npain lasting for six or more months that localizes to anatomic pelvis, anterior abdominal wall, at \nor below umbilicus, the lumbosacral back or buttocks and has sufficient severity to cause \nfunctional disability or leading to medical care [3].  \nEAU further defines Chronic Pelvic Pain Syndrome (CPPS) as “the occurrence of CP P with no \nproven infection or other obvious local pathology which accounts for pain. \nAspects of pain may include dysmenorrhea, dyspareunia, dysuria, and dyschezia. Dysmenorrhea \nin isolation does not constitute CPP. CPP affects upto 24% of women worldwide. It has \nconsiderable effect on patient’s quality of life (QOL)  [4]. In many cases pathology is \nmultifactorial. In some, an underlying structural pelvic pathology can be identified, but often \npain is idiopathic [5]. \nAim: To evaluate the causes of chronic pelvic pain in females. \nObjectives \nTo describe the differential diagnosis of chronic pelvic pain. \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 2 ~ \nTo detect chronic pelvic pain early and aid in its management. \nTo plan further management by multidisciplinary approach \nwherever necessary.  \nTo improve quality of life. \nSpecific objectives \n1. To know the different causes of chronic pelvic pain in\nfemales\n2. To assess and highlight the importance of history,\nexamination and ultrasonography in its evaluation\n3. To reduce the burden of chronic pelvic pain on the quality\nof life\nMaterials and Methodology \nSource of data \nStudy site: Department of Obstetrics and Gynaecology at \nKrishna Institute of Medical Sciences, Secunderabad, \nTelangana, India. Krishna Institute of Medical Sciences is a \n1000 bedded tertiary care corporate hospital. \nStudy Period: 14th September 2020 to 31st May 2022. \nStudy population \nAll the female patients complaining of chronic pelvic pain and \nevaluated for further management satisfying the inclusion and \nexclusion criteria in the department of Obstetrics and \nGynaecology. \nSample Size: 100 \nStatistical Analysis \nAs per data the statistical analysis shall be calculated byN= Z 2 \n*P*Q /d2\nN= sample size Z=1.96 at 95% CI \nP= 5.2% (based on previous study, prevalence of chronic pelvic \npain in India) Q=100-P=94.8% \nd=5% (Precision/Acceptable margin of error) N= \n1.96×1.96×5.2x94.8/5×5 \nN=80 \nMaking it to near value and 20% non-response rate sample size \nconsidered is100. \nStudy Design: Prospective observational study. \nStudy Place: Department of Obstetrics & Gynaecology, KIMS \nHospital Secunderabad, Telangana. \nStudy subjects \nFemales between 18-70 years attending the department of \nObstetrics and Gynaecology KIMS hospitals Secunderabad with \ncomplaint of chronic pelvic pain. \nSample design and sample size \nFemale patients attending department Obstetrics and \nGynaecology of KIMS hospitals between 18-70 years age, were \nenrolled into study during the period from 14 th September, 2020 \nto 31 st May 2022. The average number of female patients \npresenting with chronic pelvic pain is 2 per day. 100 patients \nwere enrolled into the study. \nInclusion criteria \n1. Female patients in the age group of 18-70 years attending\noutpatient department of Obstetrics and Gynaecology,\nKIMS, Secunderabad.\n2. Reproductive / Perimenopausal/Postmenopausal women.\n3. Female patients who were willing to participate in the study\nand be in follow-up.\nExclusion criteria \nWomen not willing to participate in the study \nMethodology \nThis was a prospective observational study, all women fulfilling \nthe inclusion and exclusion criteria were enrolled in the study \nand informed consent taken. All the enrolled females were \nevaluated by detailed history taking, which includes age, history \nof present illness, family history, past medical and surgical \nhistory, obstetric history, prior treatment taken, detailed \nexamination and routine investigations were done after obtaining \napproval and consent from the ethical committee. \nComplete general physical examination and gynaecological \nexamination will be done, reports will be noted. Based on all the \nfindings, a final diagnosis of the cause of pain will be made and \npatients treated accordingly. Those requiring additional aspect of \ncare were referred to other departments. Those who were found \nto have psychological problems were referred to a psychologist. \nParameters to be studied \nIn addition to detailed history taking, clinical examination, \nroutine investigations, the following parameters will also be \nevaluated. \nDemographic and obstetric factors \n1. Age\n2. Parity\nPain and its components \n1. Aggravating and relieving factors\n2. Association with other factors (Dysmenorrhea, \nDyspareunia, white discharge)\n3. Past surgical history\n4. Examination findings\nPlan for analysis of data \nData was coded in tabular form and analyzed by using proper \nstatistical method by the statistical package for the social \nsciences (spss) version 20.0. The descriptive statistics for \ncontinuous and categorical variables have been presented as \nmean standard deviation and percentages respectively. \nSample collection \nThis study was conducted under partic ipant’s voluntary \ninformed consent after explanation of purpose, method and \ncourse. Individuals were enrolled in to study after going through \ninclusion and exclusion criteria. \nResults \nAge distribution \nA total of 100 women were included in this study. The mean age \nof our patients is 42.5 years with standard deviation of 7.7 years. \nAll women are above or equal to 18 years (as per inclusion \ncriteria), minimum age included is 27 years, and maximum is 61 \nyears. \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 3 ~ \nPie chart 1: Pie chart showing age distribution of women with CPP \nParity \nWomen of all parties were included in the study. P2 are highest \namong the study group i.e., 68% followed by P1. Nulligravida \nand nulliparous account to a total of 7%. \nPie chart 2: Pie chart showing comparision of Parity related to CPP \nPresenting complaints \nIt is observed that 94% of the women are presented with \nabdominal pain and lower backache, 5% had bowel and bladder \nsymptoms (Dysuria, Dyschezia). \nMenstrual status \nIt is observed that CPP was highest among women of \nreproductive status followed by women in perimenopausal \nstatus. \nPie chart 3: Pie chart showing menstrual status of women \nSite, type, progression of pain \nAbout 61% females with CPP had lower abdomen as the site of \npain. Lower back and abdomen accounted to 27% \nPie chart 4: Pie chart showing site of pain with CPP \nWhen type of pain was taken into consideration, dull type of \nache was most commonly seen in women with CPP (49%). \nPie chart 5: Pie chart showing type of pain with CPP \nProgression of pain was categorized; intermittent pain was felt \nby 58% of patients. 20% of women had continuous pain. \nPie chart 6: Pie chart showing Progression of pain with CPP \nAggravating and Relieving factors \nAbout 55% of women with CPP had no aggravating factors. \n30% of them had menses as aggravating factor. This suggests \nthe positive correlation of CPP and menses \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 4 ~ \n \n \nPie chart 7: Pie chart showing aggravating factors of CPP \n \nIt is found that 75% of women with CPP had no relieving \nfactors. NSAIDs and others were relieving in 11% of women. \n \n \n \nPie chart 8: Pie chart showing relieving factors of CPP \nAssociated factors: Out of all the factors associated with CPP \ntaken into the study, 51% of women had dysmenorrhea as the \nmost common factor and 16% of women had dyspareunia. \n \n \n \nPie chart 9: Pie chart showing associated factors of CPP \n \nComorbidities \nAbout 33% of women were hypothyroid and 15% were diabetic \nin women with CPP followed by hypertension and others. \n \nCategories N % \nDiabetes 15 15.0 \nHypertension 10 10.0 \nHypothyroid 33 33.0 \nPulmonary TB 1 1.0 \nEpilepsy 1 1.0 \nCholelithiasis 1 1.0 \nHBsAg 1 1.0 \n \nComorbidities in relation to CPP \nPast surgical history \nWhen past surgical history is taken into account, 63% of cases \nhad history of LSCS. \n \nCategories N % \nLSCS 63 63.0 \nTubectomy 21 21.0 \nTAH 4 4.0 \nBSO 2 2.0 \nLSO 2 2.0 \nRSO 3 3.0 \nCystectomy 1 1.0 \nMCA clipping 1 1.0 \nScar endometriosis excision 1 1.0 \nColonoscopy + cautery 1 1.0 \nNephrectomy 3 3.0 \nAppendicectomy 1 1.0 \nPolypectomy 2 2.0 \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 5 ~ \nPie chart 10: Past surgical history in women presented with CPP \nPie chart 11: Personal History \nBowel and bladder habits: \nAbout 83% of women with CPP had normal bowel and bladder \nhabits, 4% had alternating constipation and diarrhea, suggestive \nof IBS. \nPie chart 12: Pie chart showing bowel habits in patients with CPP \nBladder habits: Bladder habits were normal in 81% of women \nwith CPP and 9% had dysuria. \nPie chart 13: Pie chart showing bladder habits in patients with CPP \nPrior Medication used: About 56% of cases had not used any \nmedication before presenting to the hospital which showcases \nthe ignorance of lack of awareness of consequences of pain \namong women. 24% of women used analgesics and 13% used \nGnRH analogues \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 6 ~ \n \n \nPie chart 14: Pie chart showing prior medications used for CPP \n \nPhysical examination – P/A, P/S, P/V - Findings \nOn physical examination, P/A - 61% had soft and non -tender \nabdomen, 28% had tenderness. P/S - Cervix was healthy in 82% \ncases and hypertrophied in 4% cases  P/V- Normal sized uterus \nin 57% cases, bulky in 32%, mobile uterus in 97%, anteverted in \n87% and Retroverted in 8% \n \n \n \nPie chart 15: Pie chart showing cervix examination per speculum \n \n \n \nPie chart 16: Pie chart showing vaginal examination \n \nSize of the uterus in bimanual examination \n \nCategories N % \nVault intact 5 5.0 \nNormal 57 57.0 \nBulky size 32 32.0 \nSmall size 3 3.0 \nNo data 3 3.0 \n \nMobility of uterus in bimanual examination \n \nCategories N % \nMobile 97 97.0 \nImmobile 3 3.0 \n \nVersion of uterus in bimanual examination \n \nCategories N % \nAnteverted 87 87.0 \nRetroverted 8 8.0 \nVault intact 5 5.0 \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 7 ~ \nFornices findings in bimanual examination \nCategories N % \nFull 5 5.0 \nFree 87 87.0 \nShallow 1 1.0 \nVault intact 4 4.0 \nNot checked 3 3.0 \nInvestigations \nOvarian cyst and mass were found to be the most detected \nfindings in USG in patients with CPP followed by normal \nsonography findings, fibroid, endometriosis and Adenomyosis \nrespectively. \nPie chart 17: Pie chart showing USG findings in patients with CPP \nInvestigation Categories N % \nHB >/= 12 22 22.0 \n>/= 10 27 27.0 \n<10 15 15.0 \nNot done 36 36.0 \nTSH WNL 38 38.0 \nNot done 62 62.0 \nCUE WNL 17 17.0 \nPus cells 4 4.0 \nGlucose 2 2.0 \nRBC 1 1.0 \nNot done 76 76.0 \nUrine C/S Negative 1 1.0 \nPositive 3 3.0 \nNot done 96 96.0 \nFSH WNL 15 15.0 \nAbnormal 1 1.0 \nNot done 84 84.0 \nRBS WNL 5 5.0 \nNot done 95 95.0 \nCA-125 WNL 5 5.0 \nAbnormal 10 10.0 \nNot done 85 85.0 \nESR >/= 30 2 2.0 \nNot done 98 98.0 \nPap Smear Normal 3 3.0 \nAbnormal 2 2.0 \nNot done 89 89.0 \nDone 6 6.0 \nOther markers Done 6 6.0 \nNot done 94 94.0 \nUltrasound NAD 21 21.0 \nFibroid 17 17.0 \nCyst and mass 38 38.0 \nAdenomyosis and /or Endometriosis 16 16.0 \nUterine 2 2.0 \nOthers 6 6.0 \nMRI 1 79 79.0 \n2 6 6.0 \n3 9 9.0 \n4 3 3.0 \n5 3 3.0 \nBIOPSY Cervical biopsy 1 1.0 \nNot done 99 99.0 \nHPE Early secretory endometriosis 1 1.0 \nNot done 99 99.0 \nInvestigations done in women with CPP \nDiagnosis: It is observed that 38% of the women were \ndiagnosed under the category Endometriosis and 14% with \nAdenomyosis. Hence endometriosis is the most common cause \nof CPP based on the study. \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 8 ~ \nPie chart 18: Pie chart showing final diagnosis in 100 women \npresented with CPP \nManagement \nIt is observed that 48% women had to undergo surgical \nmanagement, 27% went for medical management. Almost 9% \ncases were referred to other branches which included \npsychology and orthopaedics \nPie chart 19: Pie chart showing management modalities for CPP in the \nstudy \nDiscussion \nChronic pelvic pain has gained significant impact on the quality \nof life in women. It is estimated to have a prevalence of 3.8% in \nwomen. Often the etiology of chronic pelvic pain is not clear, as \nthere are many disorders of the reproductive tract, \ngastrointestinal system, urological organs, musculoskeletal \nsystem, and psycho neurological system that may be associated \nwith chronic pelvic pain. The history and physical examination \nare crucial in evaluating a woman with chronic pelvic pain and \nmust address all of the possible systems potentially involved in \nchronic pelvic pain, not just the reproductive system. Laboratory \nand imaging studies should be selectively utilized, as should \nlaparoscopy. Conscious laparoscopic pain mapping has been \nproposed as a way to improve information derived from \nlaparoscopic evaluations. Treatment of chronic pelvic pain may \nconsist of two approaches. One is to treat chronic pain itself as a \ndiagnosis, and the other is to treat diseases or disorders that \nmight be a cause of or a contributor to chronic pelvic pain. \nIn many cases, the pathology is multifactorial. Many studies \nhave shown that the surgical approach is frequently not curative. \nFor example, for endometriosis, 20 –28% of patients do not \nexperience a reduction in pain and some require another \noperation: 25.5% within 2 years and 40–50% after 5 years. \nCPP is often resistant to surgical and medical treatment and \nappears to respond better to a multimodal, holistic approach \nrather than reliance on laparoscopy alone. An evidence base is \nneeded for aspects of a multidisciplinary approach with a focus \non improving the patient’s qu ality of life, including self-\nmanagement and complementary therapies, while also taking \ninto account fertility plans. Like diabetes or hypertension, CPP \nis a chronic, idiopathic, and incurable but successfully treatable \ncondition. \nThe diagnostic and therapeutic difficulties are remarkable in \npatients with CPP. Therefore evaluation, assessment and \nObjectivation tools are often necessary to address each patient \nproperly and their clinical needs It is usually not possible to \nidentify a single etiology or definitive cure for CPP. In at least \nhalf of cases, there are one or more associated entities, such as \nirritable bowel syndrome, interstitial cystitis/painful bladder \nsyndrome, endometriosis or pelvic adhesions. \nExpert opinion says that in the absence of a single clear etiology, \nCPP can be conceptualized as a complex neuromuscular –\npsychosocial disorder consistent with chronic regional pain \nsyndrome. Certain red flag symptoms such as post coital \nbleeding, post-menopausal bleeding or onset of pain, \nunexplained weight loss, pelvic mass and hematuria may be \nsuggestive of a serious systemic disease \nThe history should include questions about aggravating and \nrelieving factors, association of pain with menses, sexual \nactivity, urination, defecation and response to any prior \ntreatment. An enquiry about patient perspectives on possible \norigins of pain and validation of concerns and anxiety is a must. \nThis study is being carried out to find out the different causes of \nchronic pelvic pain in women attending the department of \nobstetrics and gynecology of Krishna institute of medical \nsciences, Hyderabad. \nAge Distribution \nThe mean age of the women in my study was 42.5 years ranging \nfrom 18 to 70 years? \nParity \nMost of the women in my study with CPP are Para 2 i.e., 68%. \nA study on evaluation and initial management of CPP in rural \nand western UP by Shikha Seth, Neeru Goel, 160 cases has \nshown high parity to be associated with high prevalence of CPP. \nComplaints \nIn my study, it is observed that 94% of the women are presented \nwith abdominal pain and lower backache. A study on evaluation \nand initial management of CPP in rural and western UP by \nShikha Seth, Neeru Goel, 160 cases has shown that “chronic \nconstant lower abdominal pain is the most common presentation \n(64%). \nAssociated Factors \nIn my study, out of all the factors associated with CPP taken into \nthe study, 51% of women had dysmenorrhea as the most \ncommon factor and 16% of women had dyspareunia. \nIn a study by Min Hao et al, out of 480 cases of endometriosis, \n52.2% had dysmenorrhea, 23.8% had dyspareunia, and 15.4% \nhad dyschezia. \nBladder Habits \nIn my study, bladder habits were normal in 81% of women with \nCPP and 9% had dysuria. In a retrospective study on 4083 \npatients with endometriosis conducted by Pietro G et al ., with \nfocus on the symptoms showed low occurrence of urinary \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 9 ~ \ndisorders in CPP which is usually the main symptom. \nMedical History \nIn a study conducted by Pallavi Latthe and et al , heavy \nmenstrual flow, PID, pelvic athology, psychological \ncomorbidities were associated with increased risk of chronic \nnon- cyclical pain In my study about 5% of patients had \ndepression and 5% had anxiety issues associated with pelvic \npain. \nPast Surgical History \nIn a study conducted by Pallavi Latthe and et al, it was found \nthat previous caesarean section was a risk factor for chronic non-\ncyclical pelvic pain. In my study, out of 100 cases, 63% had \nprior history of caesarean section. \nInvestigations \nA study conducted by Damyanti Sharma and et.al, showed that \nclinical examination and ultrasonography has a sensitivity of 8.1 \nand 2%, respectively. Laparoscopy helps in detecting many \ncauses of CPP which clinical methods and ultrasonography fail \nto identify. This enforces the position of laparoscopy as a gold \nstandard in evaluation of this condition. \nIn my study, out of 100 cases, USG was more helpful in the \novarian causes of chronic pelvic pain i.e. 38% cases followed by \ndiagnosis of fibroid uterus \nDiagnosis \nIt is observed that 38% of the women were diagnosed under the \ncategory Endometriosis and 14% with Adenomyosis. Hence \nendometriosis is the most common cause of CPP based on the \nstudy. Of the other causes diagnosed, pelvic adhesions are also \none of the major one. In a study of 480 cases of endometriosis \nperformed by Hao M et al., 72%, i.e., 347/480 cases had pelvic \nadhesions this shows a positive correlation between degree of \npelvic adhesions and endometriosis. \nManagement \nIn my study, out of 100 cases, 48% had undergone surgical \nmanagement which include open and laparoscopic procedures. \n27% had relief with medical management. 9% were referred to \nother departments for further management which included \northopaedics, psychiatry and psychology. \nConclusion & Recommendations \nProper history taking and clinical examination should be done. \nAll required investigations such as ultrasonography, MRI pelvis \nif required can be advised a final diagnosis is to be made out \nbased on the findings and treated accordingly Psychologist and \nphysiotherapist help should be sorted out whenever required. \nLimitations \nNot all causes of chronic pelvic pain are curable, but treatable. \nHence proper evaluation is a must. Multidisciplinary approach is \nrequired in most of the cases, which may not be available at all \nhealth care centers. \nConflict of interest: There is no conflict of interest. \nConclusion \nIn my study mean age of the patients was 42.5 years. The \npercentage of women with endometriosis was 38%, thereby \nendometriosis is the most common cause of chronic pelvic pain \naccording to this study. \nWomen with CPP often have other associated symptoms. Most \ncommon factor was dysmenorrhea as per this study (51%). \nWhen past surgical history in the 100 women was taken into \nconsideration, CPP was more prevalent in those who had a \nhistory of LSCS (63%) Multidisciplinary approach is helpful i n \nmost of the cases. \nReferences \n1. Passavanti MB, Pota V, Sansone P, Aurilio C, De Nardis L,\nPace MC. Chronic pelvic pain: assessment, evaluation, and\nobjectivation. Pain research and treatment; 2017.\n2. Engeler DS, Baranowski AP, Dinis-Oliveira P, Elneil S,\nHughes J, Messelink EJ, van Ophoven A, Williams AC. The\n2013 EAU guidelines on chronic pelvic pain: Is\nmanagement of chronic pelvic pain a habit, a philosophy, or\na science? 10 years of development. European urology.\n2013 Sep 1;64(3):431-439.\n3. Howard FM. ACOG practice bulletin no. 51. Chronic pelvic\npain. Obstet Gynecol. 2004 Mar;103(3):589-605.\n4. Latthe P, Latthe M, Say L, Gülmezoglu M, Khan KS. WHO\nsystematic review of prevalence of chronic pelvic pain: A\nneglected reproductive health morbidity. BMC public\nhealth. 2006 Dec;6(1):1-7.\n5. Ayorinde AA, Macfarlane GJ, Saraswat L, Bhattacharya S.\nChronic pelvic pain in women: an epidemiological\nperspective. Women’s Health. 2015 Nov;11(6):851-64.\nHow to Cite This Article \nPurankar S, Karlapudi KS, Sundari T. Evaluation of chron ic pelvic pain in \nfemales a prospective observational study.  International Journal of Clinical \nObstetrics and Gynaecology 2024; 8(6): 01-09.  \nCreative Commons (CC) License \nThis is an open access journal, and articles are distributed under the terms \nof the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 \nInternational (CC BY- NC-SA 4.0) License, which allows others to remix, \ntweak, and build upon the work non-commercially, as long as appropriate \ncredit is given and the new creations are licensed under the identical terms.","source_license":"CC0","license_restricted":false}