Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis

Elizabeth Ball, Khalid S. Khan, Khan KS
F1000Research · 2020 · vol. 9 , pp. 83 · doi:10.12688/f1000research.20750.1 · PMID:32089831 · PMC7001750 · W3004987819
preprint OA: gold CC0 ⤵ 39 in-corpus citations
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⚙ AI-generated summary by gemini-2.5-flash-lite, 2026-06-12 ⓘ

This review examines current concepts and innovations in understanding and managing chronic pelvic pain in women, particularly focusing on endometriosis as a common structural cause.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-12 · read from full text ⓘ

This paper reviews chronic pelvic pain (CPP) in women, including structural causes such as endometriosis and adenomyosis, alongside idiopathic and multifactorial mechanisms, and summarizes evidence for diagnosis and management, emphasizing the frequent delay to care and the limited curative value of surgery. It reports that for endometriosis, 20–28% of patients do not have reduced pain after surgery and repeat operations are common (25.5% within 2 years and 40–50% after 5 years), while a multimodal, holistic, multidisciplinary approach appears more effective than laparoscopy alone, with ongoing uncertainty around the added benefit of postoperative hormonal therapies. The review highlights limitations including the lack of robust non-invasive biomarkers/algorithms, the inability of normal ultrasound to rule out endometriosis, and that residual pain can reflect co-existing conditions (including adenomyosis, irritable bowel syndrome, bladder pain syndrome, and pain memory) rather than endometriosis recurrence alone. This paper is centrally about endometriosis—specifically reviewing chronic pelvic pain mechanisms, diagnosis challenges (including ultrasound limitations), and outcomes of surgical and medical management in endometriosis.

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Abstract

Chronic pelvic pain (CPP) in women is defined variably, but for clinical use it is cyclical or non-cyclical pain of at least 3-6 months' duration. It has major impacts on individuals and society. There are both structural and idiopathic causes. Whereas CPP is not curable in many cases, it is treatable. The most promising approach is multidisciplinary patient-centered care including cause-directed therapy, lifestyle changes, talking therapies, meditation, acupuncture, and physiotherapy (this is not a complete list). One of the most common structural causes for CPP is endometriosis. This review investigates current scientific concepts and recent innovations in this field as well as for CPP in general.
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Are

Given the portion of non-responders to surgery (reviewed by Horne 26 ) and the recurrence of pain, even if there is no recurrence of endometriosis in 23%, patients are calling for evidence-based approaches that do not require surgery or taking hormones (author’s focus group with patients from endometriosis UK, 2018). It is well known that endometriosis and CPP negatively impact mental health and quality of life, suggesting that affected women may have an increased risk of developing psychological suffering as well as of sexual problems 35 due to the presence of pain. By far the largest study on diet and endometriosis is based on the dataset of the Nurses’ Health Study (n = 3,800 with laparoscopically confirmed endometriosis) 36 . Women consuming more than two servings per day of red meat had a 56% higher risk of endometriosis (95% CI: 1.22–1.99; P <0.0001) compared to those consuming one or fewer serving per week. Intakes of poultry, fish, shellfish, and eggs were unrelated to endometriosis risk. A systematic review further reported ORs for the following foods and the presence of endometriosis: calcium intake OR: 0.99 (95% CI: 0.83–1.18), milk OR: 0.90 (95% CI: 0.65–1.23), eggs OR: 1.01 (95% CI: 0.81–1.28), bacon OR: 1.26 (95% CI: 0.60–2.65), and red meat OR: 1.26 (95% CI: 0.73–2.18) 37 . Prospective trials investigating the effectiveness of dietary interventions are needed. With endometriosis being both an inflammatory and an estrogen-dependent disease, it seems worthwhile to examine the effect of exercise, which is known to suppress both pathways. A systematic review of 3,355 women with endometriosis who had been doing recent physical activity and 4,600 cases who had been doing physical activity in the past reported that a pooled estimate of adjusted ORs for current exercise appeared to convey a significantly protective effect (OR: 0.69, CI: 0.53–0.89, Z = 2.83, P = 0.005), but the authors discuss their findings with a caveat because the overall estimates did not reach levels of significance 38 . A historic Cochrane systematic review of acupuncture in endometriosis 39 was able to include only a single study 40 with 67 participants randomized to acupuncture or Chinese herbal medicine. Dysmenorrhea scores were lower in the acupuncture group (mean difference –4.81 points, 95% CI: –6.25 to –3.37, P <0.00001) using the 15-point Chinese Medicine for Treatment of Pelvic Endometriosis scale. Since then, a systematic review 41 of two sham-controlled RCTs and a retrospective study of 121 women with all stages of endometriosis 41 – 43 suggested a decrease in pain following acupuncture, although numerical data could not be meta-analyzed owing to the way outcomes were reported. A further systematic review included two placebo-controlled RCTs 43 , 44 on acupuncture in endometriosis showing that the 56 included endometriosis patients had more pain reduction with acupuncture than placebo (RR: –1.93, 95% CI: 3.33 to 0.53, P = 0.007) 45 . A well-designed RCT protocol for a forthcoming study is underway 46 . Given the association with stress and a pro-inflammatory immune response in addition to the poorer mental health that can be associated with endometriosis, psychological approaches appear to be promising. A current systematic review of psychological and mind–body interventions for endometriosis with narrative synthesis due to the variety of study designs 47 identified three RCTs, the remaining nine being non-randomized. Psychotherapy with somatosensory stimulation 48 including a combination of Chinese medicine, hypnotherapy, cognitive behavioral therapy, and mindfulness was delivered in sessions over 3 months (n = 35) compared to waitlist controls (n = 32). The intervention group had reductions in maximal global pain (mean group difference –2.1, 95% CI: –3.4 to –0.8, P = 0.002), average global pain (–2.5, 95% CI: –3.5 to –1.4, P <0.001), pelvic pain (–1.4, 95% CI: –2.7 to –0.1, P = 0.036), and dyschezia (–3.5, 95% CI: –5.8 to –1.3, P = 0.003) and improvements in physical quality of life (3.8, 95% CI: 0.5–7.1, P = 0.026) and mental quality of life (5.9, 95% CI: 0.6–11.3, P = 0.031). In another study, 40 women were randomly divided into two groups: an intervention group of women who were allocated to hatha yoga sessions twice a week for 8 weeks (n = 28) and a control group of women who did not practice yoga (n = 12). Daily pain was significantly reduced in the yoga group compared with those who did not practice yoga ( P = 0.0007) 49 . The third study randomly assigned 100 consecutive Chinese endometriosis patients to a progressive muscle relaxation (PMR) group (n = 50) and a control group (n = 50). Over 12 weeks, both groups received one dose of depot leuprolide, and the PMR group received 12 weeks of additional PMR training. Anxiety levels and depression were measured with validated instruments. The PMR group showed significant improvement in state anxiety, trait anxiety, and depression after intervention ( P <0.05) 50 . There is growing interest in using mindfulness-based interventions, which have been shown to be effective in other types of chronic pain 51 . One of the uncontrolled studies from the previous systematic review is that of Hansen et al . 52 , who reported sustained long-term effects (6-year follow-up) of a 10-session mindfulness-based psychological intervention for a series of 10 women with endometriosis-related CPP and improved quality of life. Mindfulness meditation taught and delivered by a smartphone application has been investigated in a three-arm RCT (n = 90 women with chronic pain with and without endometriosis) compared to PMR and treatment as usual. The publication of results is awaited 53 .

Intro

Chronic pelvic pain (CPP) is defined as cyclical or non-cyclical pain of at least 6 months’ duration. Aspects of pain may include dysmenorrhea, dyspareunia, dysuria and dyschezia. Dysmenorrhea in isolation does not constitute CPP. CPP affects up to 24% of women worldwide 1 . It accounts for 20% of gynecological clinic referrals 2 , 3 . It has a considerable impact on patients’ quality of life and their income, and annual costs to the NHS have been estimated at approximately £326 million 4 in addition to the costs to the public due to sick leave. One of the challenging issues is the long delay in women getting a diagnosis and accessing adequate care 5 . In some patients, an underlying structural pelvic pathology can be identified (e.g. endometriosis, adenomyosis, or chronic pelvic inflammatory disease with adhesions or hydrosalpinx), but often pain is idiopathic 6 , meaning it is not due to a visible structural cause (e.g. bladder pain syndrome, irritable bowel syndrome, and pain memory), which describes the process of constant activation of the body’s pain perception system and applies to women with or without a structural disease such as endometriosis. It often occurs after an episode of acute pain, even if the painful stimulus has already been removed; mechanisms have been reviewed by Flor et al . 7 . In fact, changes in the brain have been reported in endometriosis patients with CPP but not in asymptomatic women with endometriosis 8 . In many cases, the pathology is multifactorial 9 . Follow up studies have shown that the surgical approach is frequently not curative. For instance, for endometriosis, 20–28% of patients do not experience a reduction in pain 10 , 11 and some require another operation: 25.5% within 2 years and 40–50% after 5 years 12 . CPP is often resistant to surgical and medical treatment and appears to respond better to a multimodal, holistic approach rather than reliance on laparoscopy alone 13 , 14 . What is therefore required is an evidence base for aspects of a multidisciplinary approach with a focus on improving the patient’s quality of life, including self-management and complementary therapies, while also taking into account fertility plans. Like diabetes or hypertension, CPP is a chronic, idiopathic, and incurable but successfully treatable condition.

Recent

Laparoscopy is a costly and invasive “gold standard’ to diagnose causes of CPP. The recently completed MEDAL study 54 on 291 women with CPP aimed to determine the proportion of women with CPP for whom MRI is accurate enough to replace laparoscopy following evaluation of their symptoms. The authors concluded that MRI scans are not sufficiently accurate to find the cause of CPP in women and should not replace laparoscopy. A Cochrane review from 2014 55 , which included 13 publications of non-surgical interventions for the management of CPP, reported moderate-quality evidence to support progestogen as an option for CPP at the cost of side effects such as weight gain and bloating. Other interventions such as a comparison of goserelin with progestogen, gabapentin with amitriptyline, “reassurance ultrasound” versus “wait and see”, and writing therapy versus non-disclosure provided too low-quality evidence or was drawn from a single study only. Thus, no recommendations could be made, and the authors called for RCTs of other medical, lifestyle, and psychological interventions. Similarly, another Cochrane review on oral contraception for the treatment of endometriosis-related pain 56 concluded that the limited evidence from two trials at high risk of bias provided insufficient evidence to make a judgement on the effectiveness of the combined oral contraceptive pill (COCP) compared with placebo. To provide an effective oral treatment to alleviate pain in women with CPP in the absence of any obvious pelvic pathology, a double-blind placebo-controlled randomized multicenter clinical trial called GAPP is underway. A total of 300 women with CPP and a normal laparoscopy will be randomized to gabapentin or placebo and their treatment will be titrated over a 4-week period to a maximum of 2,700 mg or placebo equivalent and maintained at that dose for 12 weeks. Average and worst pain scores will be measured by validated questionnaires. The results are expected soon 57 . A review on CPP management would not be complete without the mention of the role of physiotherapy, including treatment of myofascial trigger points, pelvic floor relaxation, and biofeedback. However, it is difficult to examine these treatments as stand-alone interventions, and a recent systematic review called for well-conducted, larger trials 58 . Future research should be directed at helping to shorten the delay in making the diagnosis of endometriosis, involving primary and secondary care. Women who benefit most from surgery should be identified through systematic review of evidence, new RCTs, or analysis of existing data (such as CRESCENDO NIHR PB-PG-0317-20018). Lifestyle measures such as diet and exercise for CPP need to be prospectively examined in RCTs. In conclusion, progress is being made in creating better awareness of endometriosis, identifying approaches to diagnose endometriosis earlier, and enabling women to access effective treatment. However, not all women with CPP with or without endometriosis will benefit from surgery, and a multidisciplinary patient-centered approach is needed. Whereas evidence for non-surgical approaches is increasing, more RCTs on which to base recommendations are needed.

Abbreviations

CI, confidence interval; CPP, chronic pelvic pain; OR, odds ratio; PMR, progressive muscle relaxation; RCT, randomized controlled trial.

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Condition tags

endometriosischronic_pelvic_pain

MeSH descriptors

Chronic Pain Endometriosis Pelvic Pain Chronic Pain Endometriosis Female Humans Pelvic Pain

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