Chronic pelvic pain: presumptive diagnosis and therapy using GnRH agonists

Chronic pelvic pain has a prevalence of 15% to 30% of reproductive-age women. It causes a sizable minority of all gynecological visits, and is responsible for much physical and psychological suffering. Although laparoscopic inspection, plus treatment, for pelvic pain has been considered ideal, it is often unnecessary, fruitless, and even hazardous, besides being expensive. Therefore, empirical medical therapy has much to recommend it. Foremost is the fact that endometriosis is the most frequent source of chronic pelvic pain, and responds well to medical treatment. In fact, GnRH analogs (agonists) used for 6 months can reduce AFS endometriosis scores by one-half, with cure rates at 5 years of three-fourths of responders who had minimal disease and one-third of responders with severe disease. Danazol and oral contraceptives plus NSAIDs have been used, too. The latter treatment is best reserved for cases involving dysmenorrhea. The objections to empirical treatment-lack of exact knowledge of the entity being treated and the potential of overlooking cancer-are discussed here in the context of pain treatment, with an emphasis on history taking, diagnostic imaging, and careful observation.