{"paper_id":"7ba37dec-b79c-4f3b-9a65-3cfcc2b870ae","body_text":"EMJ  ●  February 2023  ●  Creative Commons Attribution-Non Commercial 4.0\nIncidence of Chronic Pelvic Pain in Females \nAttending a Gynaecology Outpatient Department\nAbstract\nBackground and Aims: Chronic pelvic pain (CPP) is a persistent pelvic pain that \nleads to reduced work performance and impaired quality of life in females. Nearly \n15% of females report time off from paid work and around 45% report reduced \nwork productivity. There is a paucity of studies to address the issue, especially \nwith a multidisciplinary and multifactorial view. Various gynaecological disorders \nare associated with CPP such as endometriosis, adenomyosis, adhesions, chronic \npelvic inflammatory disease, and pelvic congestion syndrome. The objective is \nto determine the frequency of CPP in females attending gynaecologic outpatient \ndepartments.\nMaterials and Methods: A total of 201 patients aged 14–48 years attending the \ngynaecologic outpatient department for gynaecological disorders with complaints \nof lower abdominal pain were included in this study. Patients enrolled in the study \nwere assessed by a detailed history and pelvic examination, and a structured \nquestionnaire was filled out. Data were analysed using the statistical package for \nsocial sciences version 23.0 (International Business Machines Corporation, Armonk, \nNew York, USA). \nResults: The mean age of the patients was 32.39±6.98 years. The frequency of CPP \nin females was observed as 95.52% (95% confidence interval: 91.67–97.93%) The \nrate of CPP was significantly high in females with parity ≤5 and those who had a \nduration of pain lower than 36 months. In multivariate analysis, adjusted odds ratio \nby stepwise logistic regression model showed that parity (parity 0–1) and duration of \npain (≤36 months) were significantly associated with CPP in females.\nConclusion: The study indicates that the most common gynaecological causes of \nCPP in females attending the outpatient department were those with endometriosis \nfollowed by adenomyosis. The management of CPP needs patient-centred care with \na multidisciplinary approach. This will lead to early and effective management.\nAuthors: Sadia Shoukat,1 Maria Tasneem,2 *Tehreem Zahid,3  \nJahooran Mariyah Bibi Goolamnobee1\n1. Dr Ruth K.M. Pfau Civil Hospital, Karachi, Pakistan\n2. Jinnah Medical and Dental College, Karachi, Pakistan\n3. Shifa International Hospitals Ltd., Islamabad, Pakistan\n*Correspondence to dr.tehreemzahid@gmail.com\nDisclosure: The authors have declared no conflicts of interest.\nReceived: 07.08.22\nAccepted: 09.01.23\nKeywords: Adenomyosis, chronic pelvic pain (CPP), endometriosis.\nCitation: EMJ. 2023; DOI/10.33590/emj/10302260.  \nhttps://doi.org/10.33590/emj/10302260 \nArticle\n\nCreative Commons Attribution-Non Commercial 4.0  ●  February 2023  ●  EMJ\nINTRODUCTION\nChronic pelvic pain (CPP) affects up to 25% \nof females of reproductive age, and 15% of all \nfemales worldwide.1 It is a common complaint \nof females visiting the gynaecology outpatient \ndepartment. The annual prevalence of CPP \nwas found to be 38/1,000, a rate comparable \nto asthma (37/1,000) and back pain (41/1,000).2 \nAmong sparse population-based studies, the \nprevalence of CPP was found to be 25.4% in New \nZealand and 21.5% in Australia.3 Among South \nEast Asian countries, a 44.2% prevalence of CPP \nwas reported in Thailand.4 CPP is also one of \nthe most frequent indications for gynaecological \nlaparoscopies, accounting for approximately 40% \nof cases.5 \nCPP is defined by the Royal College of Obstetrics \n& Gynaecology (RCOG) as an intermittent or \nconstant lower abdominal pain of greater than 6 \nmonths’ duration, not occurring exclusively with \nmenstruation or intercourse and not associated \nwith pregnancy.6 It arises from structures within \nthe pelvis. The differential diagnoses of CPP \ninclude gynaecological causes (endometriosis, \nadenomyosis, adhesions, chronic pelvic \ninflammatory diseases, remnant ovary syndrome, \ntrapped ovary syndrome, or pelvic congestion \nsyndrome), gastrointestinal causes (irritable \nbowel syndrome, inflammatory bowel disease, \nor coeliac disease), urinary causes (interstitial \ncystitis or urethral syndrome), neurological \ncauses (pudendal neuralgia, trigger points, \nor nerve entrapment), and musculoskeletal \ncauses.7 The pain is caused by a single, or \noften a combination of different disorders with \noverlapping symptomatology, making it difficult \nto diagnose. \nPatients with CPP have a long history of pain, \nmarked psychiatric effects, work and physical \nimpairment, and distrust of treatment,8  leading \nto a burden on healthcare expenditure and work \nproductivity loss. Every year, 881.5 million USD \nis spent on outpatient department management \nin the USA, and an estimated 158 million EUR is \nspent on the UK National Health Service.5 In total, \n550 million USD is lost each year in the USA due \nto absence from work.8 In the United Kingdom \nin 2001, 15% of affected females reported lost \nworking days and 45% reported reduced working \ncapacity. A study showed that 43% of individuals \nwith CPP reported that their activities were \nrestricted by pain.\nWithout a medical prescription, 58.4% of females \nuse analgesics or nonsteroidal anti-inflammatory \ndrugs weekly or daily for pain relief.5 Females \nwho have had pelvic pain for longer develop \nstrong associations with disability, distress, poor \ngeneral health, low satisfaction levels, a sense of \nhelplessness, and negative coping responses.9,10 \nThe purpose of this study is to obtain insight into \nthe scope of a problem that leaves many females \ncrippled with an often misunderstood diagnosis. \nMATERIALS AND METHODS\nThis descriptive cross-sectional study was \nconducted at the Department of Obstetrics and \nGynecology Unit-2 of Dr Ruth K.M. Pfau Civil \nHospital Karachi, Pakistan, from March 2019 \nto January 2020. Data were collected from \nfemales attending the gynaecology outpatient \ndepartment who fulfilled inclusion criteria, after \ntaking their informed consent. Females aged \n14–48 years with complaints of lower abdominal \nKey Points\n1. Chronic pelvic pain (CPP) is an often ignored complaint that plagues females for years before a \ndiagnosis is made. Patients are advised of many unnecessary investigations and treatments, which \nhinder proper care. \n2. The authors’ research shows that most causes of CPP can be managed with a thorough and \ncomplete history. A multi-disciplinary approach is the best for such patients. \n3. Physicians must have an open mind when patients present with CPP. Their concerns and fears should \nbe validated and all-out efforts should be made to ease symptoms from this disregarded complaint.\nArticle\n\nEMJ  ●  February 2023  ●  Creative Commons Attribution-Non Commercial 4.0\npain greater than or equal to 6 months’ duration \nwere enrolled in the study. Menopausal females \nand those with a history of hysterectomy were \nexcluded from the study. Age, parity, duration \nof pelvic pain, history of past sexual abuse, \nfamily history of CPP, education, marital status, \nemployment status, use of pain-relieving \nmedications, diagnosed gynaecological cause, \nand pain analysis on the visual analogue scale \nwere recorded in a structured questionnaire.\nFemales who met the inclusion criteria were \nasked detailed questions to ascertain whether \npain was of pelvic origin or due to other causes. \nData were analysed using the statistical \npackage for social sciences (SPSS) version 23.0 \n(International Business Machines Corporation, \nArmonk, New York, USA). The quantitative \nvariables of age, parity, duration of pelvic pain, \nand pain score on visual analogue scale were \nrepresented by mean and standard deviation. \nThe qualitative variables of ethnicity, history \nof past sexual abuse, family history of CPP, \neducation, marital status, employment status, \npain-relieving medications, and diagnosed \ngynaecological cause were represented as \nfrequency and percentage.\nEffect modifiers such as ethnicity, history of past \nsexual abuse, family history of CPP, education, \nmarital status, employment status, pain relief, \nand diagnosed gynaecological cause were \naddressed through data stratification. A post-\nstratification chi-square test was applied, and a \np-value ≤0.05 was considered significant.\nRESULTS\nA total of 201 patients with lower abdominal pain \nwere included in the study. The mean age of the \npatients was 32.39±6.98 years. More than two \nthirds of these females were married (81.6%), 25 \n(12.4%) were single, 8 females were separated \nand 4 females were widows. Almost 55% of the \nfemales had multiparity. More than half (109; \n54.2%) of the females were illiterate, 62 (30.8%) \nhad attended primary education and 30 (14.9%) \nhad attended secondary education.\nOut of 201 patients, 192 (95.5%; 95% confidence \ninterval: 91.67%–97.93%) had experienced CPP. \nTen (5%) females reported sexual abuse and \n65 (32.3%) patients had a history of pelvic pain \ncomplaints in the family. There were 128 (63.7%) \nfemales who used analgesics or nonsteroidal \nanti-inflammatory drugs for relief of pain, 44 \n(21.9%) females used hormonal methods for pain \nrelief and 29 (14.4%) were taking other forms of \nmedications and therapies for symptom control. \nEndometriosis (60; 29.9%) and adenomyosis \n(56; 27.9%) were the top two most common \ndiagnoses in females.\nParity (parity ≤5) and duration of pain for less \nthan 36 months were significantly associated \nwith CPP in females, yet was not statistically \nsignificant with age groups, marital status, \neducation, employment, past sexual abuse, \nfamily history of pelvic pain, use of pain-relieving \nmedicine, and diagnosis, as shown in Table 1. \nIn a multivariate analysis, adjusted odds ratio \nby stepwise logistic regression model showed \nthat parity (parity 0–1) and duration of pain (≤36 \nmonths) were significantly associated with CPP \nin females, as shown in Table 2. \nDISCUSSION\nThe quality of life of patients with CPP is \nseverely affected, and current known therapies \nare adopted for relief from pain and an \naetiological diagnosis. This imparts a huge \nburden on the healthcare system, as patients \nexperience repeated hospital admissions, \nsurgical procedures, and emergency and \ngeneral physician visits to obtain a definitive \ndiagnosis, as well as to relieve CPP symptoms \ncausing distress, disability, and affecting daily \nactivities.11-12 This also develops a strain in \nrelationships and often requires absence \nfrom work.13,14\nCPP has a multifactorial aetiology; therefore, a \nmultidisciplinary approach is advised to reach \na diagnosis. Treating patients with medical \nand surgical therapies, as well as reassuring \nthem, gaining trust and providing psychological \nsupport for pain relief results in better cure rates \ncompared to pharmaceutical and interventional \noptions alone.15 One of the main causes of CPP \nis endometriosis, which can make management \neven more challenging. Illness imparted to the \naffected individual by pain intensity is ignored by \nmany clinicians and endometriotic foci are put \ninto consideration.16,17\nArticle\n\nCreative Commons Attribution-Non Commercial 4.0  ●  February 2023  ●  EMJ\nVariables Cut-off N Chronic Pelvic \nPain Presence\nOdds Ratio (95% \nconfidence interval) p-value\nAge Groups \n(Years)\n≤30 115 110 (95.7%) 1.07 (0.27–4.1)\n0.9180\n>30 86 82 (95.3%) Ref**\nParity\n0–1 91 89 (97.8%) 13.69 (2.27–82.36) 0.0040*\n2–5 93 90 (96.8%) 9.23 (1.85–45.99) 0.0070*\n6–7 17 13 (76.5%) Ref** N/A\nDuration of \nPain (months)\n6–36 187 183 (97.9%) 25.41 (5.81–111.1)\n0.0005*\n>36 14 9 (64.3%) Ref**\nMarital \nStatus\nSingle 25 23 (92.0%) 0.47 (0.09–2.43)\n0.3100Married/\nSeparated/\nWidow\n176 169 (96.0%) Ref**\nEducation\nPrimary 62 57 (91.9%) 0.32 (0.07–1.39) 0.1310\nSecondary 30 29 (96.7%) 0.82 (0.08–8.19)\n0.8600\nIlliterate 109 106 (97.2%) Ref**\nEmployment\nEmployed 55 53 (96.4%) 1.33 (0.27–6.63)\n0.7230\nUnemployed 146 139 (95.2%)) Ref**\nPast sexual \nabuse\nYes 10 9 (90.0%) 0.39 (0.04–3.49) 0.3740\nNo 191 183 (95.8%) Ref** N/A\nFamily history \nof chronic \npelvic pain\nYes 65 60 (92.3%) 0.36 (0.09–1.40) 0.1520\nNo 136 132 (97.1%) Ref** N/A\nUse of pain \nrelieving \nmedication\nAnalgesic/\nnonsteroidal anti-\ninflammatory drugs\n128 122 (95.3%) 0.87 (0.21–3.59) 0.9990\nHormonal/ Others 73 70 (95.9%) Ref** N/A\nDiagnosis\nEndometriosis 60 58 (96.7%) 1.28 (0.17–9.51) 0.8030\nAdenomyosis 56 53 (94.6%) 0.78 (0.13–4.91) 0.7960\nAdhesions 38 36 (94.7%) 0.80 (0.11–5.96) 0.8280\nOthers 47 45 (95.7%) Ref** N/A\nN/A: not applicable. \n* Significant <0.01\n** Reference group: comparison category equal to 1\nTable 1: Univariate analysis showing factors associated with chronic pelvic pain in females (n=201).\nArticle\n\nEMJ  ●  February 2023  ●  Creative Commons Attribution-Non Commercial 4.0\nMood disorders such as anxiety and depression \naccompanying such a diagnosis have a negative \nimpact on the perception of pain. These \nconcurrent diagnoses of CPP, endometriosis, and \nmood disorders disrupt pain inhibitory pathways, \nwhich makes the patient more sensitive to \nnociceptive stimuli.17-19 These have a profound \nimpact on the severity of pain, which is directly \nproportional to low output and absent days \nfrom work.20,21 Diagnostic delay is a significant \nfactor and fatigue is a major complaint in direct \ncorrelation with the severity of pain, leading \neventually to absenteeism from education, \nacademics, and work. Social and sexual relations \nare impaired and patients live a socially isolated \nlife.22 The miscommunication, inadequate \ntreatment for relief of pain, and negative attitude \nby doctors can further aggravate detrimental \npsychological effects.23-25 \nIn their study, Yasmin et al.26 demonstrated that \n40% of laparoscopies performed for evaluation \nof CPP aetiology remained inconclusive. In such \npatients, other factors such as childhood sexual \nabuse and non-gynaecological pathologies should \nbe considered. However, the reassuring effect of \nnegative laparoscopy improved their quality of life. \nThe authors did not perform any laparoscopies \nfor the patients, which was a limitation of the \nstudy.26 Facchin et al.27 demonstrated in their \nstudy that mood dysfunction, anxiety, depression, \nand stress all negatively influence the immune \nsystem. The resulting imbalance between \npro- and anti-inflammatory cytokines flares \ninflammatory response. A vicious cycle is started \nwith increased disease severity and increased \nmental upset and depression. Therefore, the \nauthor insists upon psychological therapy along \nwith medical and surgical treatment for better \noutcomes.27 The study conducted by Centini et \nal.28 suggests that when patients are reassured \nand made to understand their disease, they are \nfound to get positive improvement in quality of \nlife. Cognitive therapy is an integral part of CPP \ntreatment. Reduced stress, reduced mental \nanxiety, improved quality of life, and feeling \nof well-being indirectly reduce ongoing stress \nresponse within their body and inflammatory \nprocess, and therefore the disease. Centini et \nal.28 divided patients with CPP into two groups, \nwith and without endometriosis. They found that \nthose with endometriosis generally had a poorer \nVariables Cut-off Adjusted Odds Ratio  \n(95% confidence interval) p-value\nParity\n0–1 10.91 (1.42–84.13) 0.0220\n2–5 4.55 (0.69–29.75) 0.1140\n6–7 Ref* N/A\nDuration of Pain \n(months)\n6–36 22.16 (4.27–115.11)\n0.0005\n>36 Ref*\nModel Accuracy: 96.5% \nNagelkerke R Squared: 0.341\nHosmer–Lemeshow Test: p=0.951\nAge, education, marital status, employment, past sexual abuse, family history of chronic pelvic pain, use \nof pain-relieving medication, and diagnosis were excluded from the model. Stepwise Forward Wald logistic \nregression model was applied. \n*Reference group: comparison category equal to 1\nTable 2: Multivariate stepwise logistic regression model showing factors associated with chronic pelvic \npain in females.\nArticle\n\nCreative Commons Attribution-Non Commercial 4.0  ●  February 2023  ●  EMJ\nprognosis and a more severe disease overall. The \nauthors made a similar observation intheir study.28\nPetrelluzi et al.29 reported altered metabolism \nof cortisol, hypothalamic pituitary adrenal axis \nmalfunctioning, and hypocortisolism in patients \naffected with chronic fatigue syndrome.29 Tripoli \net al.30 stated that surgical and medical treatment \nfor CPP is not sufficient. Other aspects should \nalso be addressed to improve patient quality of \nlife. Patients with CPP are frustrated and socially \nisolated, with disrupted marital and sexual \nlife because of long intervals in achieving a \ndefinitive diagnosis. Sexual, social, psychological, \nemotional, and mental well-being is entirely \nneglected by physicians while treating underlying \ndisorders, which is why optimal therapeutic \nresults are not achieved.30 \nA significant amount of healthcare costs are \nborne by insurance companies and governments \ndue to the extensive workup and continuous \ndoctor's visits needed for CPP.31,32 It also requires \nmore frequent visits to the psychiatrist, and \nsometimes surgery such as a hysterectomy does \nnot improve pain.33-35\nIf the underlying cause is endometriosis, it \nresults in even more workup and reproductive \nchallenges.36 There is a complex and altered \ninterplay between the central and peripheral \nnervous systems for the generation, \ntransmission, and aggravation of pain in \nendometriosis.37,38 The pain of endometriosis \nis resolved with hormonal treatment, but can \nrecur as soon as therapy is stopped.39-42 Another \nsignificant cause of CPP is adenomyosis, which \naffects around 30% of females in their late \nreproductive years.43 Adenomyosis presents \nwith abnormal uterine bleeding and chronic \npelvic, but is not routinely diagnosed clinically or \neven radiographically. The diagnosis is mostly \nconcluded from hysterectomy specimens.44,45\nMathias et al.46 reported that females older than \n35 years of age are slightly less prone to the risk \nof developing CPP when compared to females \nof a younger age group. Females separated \nfrom their partners and widowed females were \nfound to have an increased prevalence of CPP \ncompared to single females.46 In the study \nconducted by the authors, over two thirds of \nfemales were married (81.6%). This raises the \nassociation of CPP with marital status. Mathias et \nal.46 found no significant relationship between the \neducational level of patients and CPP frequency \nin their study. \nFacchin et al.,47 when observing an association \nbetween CPP impact on the employment status \nof affected females, found a potential connection \nbetween the severity of pain of endometriosis \nand unemployment and absence from work. \nSymptomatic patients with endometriosis were \nmore likely to be unemployed compared to \nasymptomatic patients. The author concluded \nthat severe incapacitating CPP caused by \nendometriosis disrupts patients’ professional life \nand career, and renders them helpless.47 \nMackey et al.48 studied 262 participants with \nCPP. Compared to the control group, patients \naffected with CPP had lower literacy levels, \nlower monthly income due to unemployment, an \ninability to perform work, days off from work, \nand expenses on frequent physician’s visits. \nAssociated co-morbidities were also more \ncommon in disease affected group.48\nThe highest pain intensity reported in the authors’ \nstudy was a visual analogue score of 8 (4% of \npatients) leading to an inability to perform at \nwork, the feeling of helplessness about pain relief, \nand unemployment, as well as patients feeling \nunable to take care of family and to do household \nchores. Roth et al.49 studied the correlation \nbetween the level of educational achievement \nand pain perception, quality of life disruption, \nand disability. The study included a total of \n187 participants. Educational achievement was \ngrouped into five categories ranging from primary \nschool to graduation level. A direct relationship \nwas observed between higher educational levels \nand the severity of pain. The author concluded \nthat greater educational status makes patients \nsusceptible to perceiving the increased intensity \nof pain sensation, disability, and distress. The \nlevel of education was also found to be inversely \nrelated to favourable treatment outcomes. Roth \net al.49 emphasised the importance of treating \nchronic pain with a bio-psychosocial approach \nthat considers multidimensional aspects of clinical \nfactors together with socio-economic parameters, \nwhich are beyond physiological impairment.49\nDay et al.50 examined the association between \ndemographics and psychosocial variables \nwith chronic pain in 115 patients. The study \nArticle\n\nEMJ  ●  February 2023  ●  Creative Commons Attribution-Non Commercial 4.0\nillustrated that race and ethnicity could be \npotentially linked to pain severity and disability. \nPain intensity score found was far greater in \nAfrican-American patients compared to White \nAmericans. The author reported satisfaction with \nliving as a contributing factor to favourable pain \ntolerability and favourable treatment outcome \nscores in White Americans, whereas African-\nAmerican patients were living in rural areas \nwith low monthly income, poor socio-economic \nstatus, low literacy level, and poor access to \nappropriate treatment. All these factors played \npart in contributing to further aggravating \ntheir pain perception and associated illness. \nLife satisfaction plays a protective role against \nnegative mindset and affectivity.50\nThe main limitation of this study was a limited \nsample size and sample collection from a single \ncentre, which was a government-run hospital. \nThe population presenting to the hospital \nbelonged to the lower socio-economic class, \nhence some bias may be expected in the \nextrapolation of the results. \nCONCLUSION\nIn conclusion, CPP is an important but overlooked \nhealth morbidity that has been disregarded for \na long time. It has a huge impact and burden on \nhealthcare economics, patient quality of life, and \nalmost every aspect of the affected individual’s \nlife. There is a need to emphasise effective \nmanagement protocols, multidisciplinary and \nmulti-dimensional approaches, and to aim every \neffort to obtain an accurate diagnosis for pelvic \npain from the first day of presentation. This \nwould avoid unending referrals, investigations, \nand procedures, and the trial of different and \ninappropriate therapies which often do not \naddress the pathology for symptom relief. \nThere is a need to allocate healthcare resources \nand address the disease in future research for \nbetter treatment and care of females with from \ndebilitating diseases such as CPP.\nReferences\n1. Allaire C et al. Chronic pelvic pain \nin an interdisciplinary setting: \n1-year prospective cohort. Am J \nObstet Gynecol. 2018;218(1):114.\ne1-12.\n2. Zondervan KT et al. The \ncommunity prevalence of chronic \npelvic pain in women and \nassociated illness behaviour. Br J \nGen Pract. 2001;51(468):541-7.\n3. Ayorinde AA et al. Chronic pelvic \npain in women: an epidemiological \nperspective. Womens Health \n(Lond). 2015;11(6):851-64.\n4. Latthe P et al. WHO systematic \nreview of prevalence of chronic \npelvic pain: a neglected \nreproductive health morbidity. \nBMC Public Health. 2006;6(1):177.\n5. Kennedy S, Moore J; Royal \nCollege of Obstetricians and \nGynaecologists. The initial \nmanagement of chronic pelvic \npain. Green Top Guideline No. 41. \nAvailable at: https://rcog.org.uk/\nmedia/muab2gj2/gtg_41.pdf. Last \naccessed: 24 December 2022.\n6. Romão APMS et al. High levels \nof anxiety and depression have a \nnegative effect on quality of life of \nwomen with chronic pelvic pain. Int \nJ Clin Pract. 2009;63(5):707-11.\n7. Sewell M et al. Chronic pelvic pain-\npain catastrophizing, pelvic pain \nand quality of life. Scand J Pain. \n2018;18(3):441-8.\n8. Ayorinde AA et al. Chronic pelvic \npain in women of reproductive \nand post‐reproductive age: a \npopulation‐based study. Eur J Pain. \n2017;21(3):445-55.\n9. Till SR et al. Psychology of \nchronic pelvic pain: prevalence, \nneurobiological vulnerabilities, and \ntreatment. Clin Obstet Gynecol. \n2019;62(1):22-36.\n10. Lampe A et al. Chronic pelvic pain \nand previous sexual abuse. Obstet \nGynecol. 2000;96(6):929-33.\n11. Yosef A et al. Multifactorial \ncontributors to the severity of \nchronic pelvic pain in women. Am J \nObstet Gynecol. 2016;215(6):760.\ne1-14.\n12. Ahangari A. Prevalence of chronic \npelvic pain among women: an \nupdated review. Pain Physician. \n2014;17(2):E141-7.\n13. Miller-Matero LR et al. When \ntreating the pain is not enough: \na multidisciplinary approach for \nchronic pelvic pain. Arch Womens \nMent Health. 2016;19(2):349-54.\n14. Daniels JP, Khan KS. Chronic \npelvic pain in women. BMJ. \n2010;341:c4834.\n15. Vercellini P et al. Chronic \npelvic pain in women: etiology, \npathogenesis and diagnostic \napproach. Gynecol Endocrinol. \n2009;25(3):149-58.\n16. Stones RW et al. Psychosocial and \neconomic impact of chronic pelvic \npain. Baillieres Best Prac Res Clin \nObstet Gynaecol. 2000;14(3):415-\n31.\n17. Coxon L et al. Pathophysiology of \nendometriosis-associated pain: \na review of pelvic and central \nnervous system mechanisms. Best \nPrac Res Clin Obstet Gynaecol. \n2018;51:53-67.\n18. Vincent K. Chronic pelvic pain \nin women. Postgrad Med J. \n2009;85(999):24-9.\n19. Wesselmann U. Neurogenic \ninflammation and chronic pelvic \npain. World J Urol. 2001;19(3):180-\n5.\n20. Soliman AM et al. The effect of \nendometriosis symptoms on \nabsenteeism and presenteeism \nin the workplace and at home. \nJ Manag Care Spec Pharm. \n2017;23(7):745-54.\n21. Nnoaham KE et al. Impact of \nendometriosis on quality of life and \nwork productivity: a multicenter \nArticle\n\nCreative Commons Attribution-Non Commercial 4.0  ●  February 2023  ●  EMJ\nstudy across ten countries. Fertil \nSteril. 2011;96(2):366-73.e8.\n22. Armour M et al. The cost of \nillness and economic burden \nof endometriosis and chronic \npelvic pain in Australia: a national \nonline survey. PLoS One. \n2019;14(10):e0223316.\n23. Dalpiaz O et al. Chronic pelvic pain \nin women: still a challenge. BJU Int. \n2008;102(9):1061-5.\n24. Jones GL et al. Health-related \nquality of life measurement in \nwomen with common benign \ngynecologic conditions: a \nsystematic review. Am J Obstet \nGynecol. 2002;187(2):501-11.\n25. Vitale SG et al. Impact of \nendometriosis on quality of life \nand psychological well-being. \nJ Psychosom Obstet Gynaecol. \n2017;38(4):317-9.\n26. Yasmin H et al. What happens \nto women with chronic pelvic \npain after a negative [normal] \nlaparoscopy? J Obstet Gynaecol. \n2005;25(3):283-5.\n27. Facchin F et al. Impact of \nendometriosis on quality of life and \nmental health: pelvic pain makes \nthe difference. J Psychosom \nObstet Gynaecol. 2015;36(4):135-\n41.\n28. Centini G et al. Chronic pelvic pain \nand quality of life in women with \nand without endometriosis. JEPPD. \n2013;5(1):27-33.\n29. Petrelluzzi KFS et al. Salivary \ncortisol concentrations, stress \nand quality of life in women with \nendometriosis and chronic pelvic \npain. Stress.  2008;11(5):390-7.\n30. Tripoli TM et al. Evaluation \nof quality of life and sexual \nsatisfaction in women suffering \nfrom chronic pelvic pain with or \nwithout endometriosis. J Sex Med. \n2011;8(2):497-503.\n31. Gao X et al. Economic burden \nof endometriosis. Fertil Steril. \n2006;86(6):1561-72.\n32. Simoens S et al. The burden of \nendometriosis: costs and quality of \nlife of women with endometriosis \nand treated in referral centres. \nHum   Reprod. 2012;27(5):1292-9.\n33. Sepulcri R de P, do Amaral VF. \nDepressive symptoms, anxiety, \nand quality of life in women \nwith pelvic endometriosis. Eur \nJ Obstet Gynecol Reprod Biol.  \n2009;142(1):53-6.\n34. Krantz TE et al. Adverse childhood \nexperiences among gynecology \npatients with chronic pelvic pain. \nObstet Gynecol. 2019;134(5):1087- \n95.\n35. Schrepf A et al.; MAPP Research \nNetwork. Adverse childhood \nexperiences and symptoms \nof urologic chronic pelvic pain \nsyndrome: a multidisciplinary \napproach to the study of \nchronic pelvic pain research \nnetwork study. Ann Behav Med. \n2018;52(10):865-77.\n36. Parasar P et al. Endometriosis: \nepidemiology, diagnosis and \nclinical management. Curr Obstet \nGynecol Rep. 2017;6(1):34-41.\n37. Morotti M et al. Mechanisms of \npain in endometriosis. Eur J Obstet \nGynecol Reprod Biol. 2017;209:8-\n13.\n38. Ball E, Khan KS. Recent advances \nin understanding and managing \nchronic pelvic pain in women \nwith special consideration \nto endometriosis. F1000Res. \n2020;9:F1000 Faculty Rev-83.\n39. Al-Jefout M et al. Prevalence of \nendometriosis and its symptoms \namong young Jordanian women \nwith chronic pelvic pain refractory \nto conventional therapy. J Obstet \nGynaecol Can. 2018;40(2):165-70.\n40. Ferrero S et al. Current and \nemerging treatment options \nfor endometriosis. Expert Opin \nPharmacother. 2018;19(10):1109-\n25.\n41. Saridogan E et al.; Working \ngroup of ESGE, ESHRE and \nWES. Recommendations for \nthe surgical treatment of \nendometriosis. Part 1: ovarian \nendometrioma. Hum Reprod Open. \n2017;2017(4):hox016.\n42. Olive DL, Pritts EA. Treatment \nof endometriosis. N Engl J Med. \n2001;345(4):266-75.\n43. Sakhel K, Abuhamad A. \nSonography of adenomyosis. J \nUltrasound Med. 2012;31(5):805-8.\n44. Genc M et al. Adenomyosis and \naccompanying gynecological \npathologies. Arch Gynecol Obstet. \n2015;291(4):877-81.\n45. Shrestha A, Sedai LB. \nUnderstanding clinical features of \nadenomyosis: a case control study. \nNepal Med Coll J. 2012;14(3):176- \n9.\n46. Mathias SD et al. Chronic pelvic \npain: prevalence, health-related \nquality of life, and economic \ncorrelates. Obstet Gynecol. \n1996;87(3):321-7.\n47. Facchin F et al. Preliminary \ninsights on the relation between \nendometriosis, pelvic pain, and \nemployment. Gynecol Obstet \nInvest. 2019;84(2):190-5.\n48. Mackey LM et al. An investigation \nof healthcare utilization and its \nassociation with levels of health \nliteracy in individuals with chronic \npain. Musculoskeletal Care. \n2019;17(2):174-82.\n49. Roth RS et al. Educational \nachievement and pain disability \namong women with chronic \npelvic pain. J Psychosom Res. \n2001;51(4):563-9.\n50. Day MA, Thorn BE. The relationship \nof demographic and psychosocial \nvariables to pain-related outcomes \nin a rural chronic pain population. \nPain. 2010;151(2):467-74.\nArticle","source_license":"CC0","license_restricted":false}