Comment on “Evaluation and Treatment of Chronic Pelvic Pain”

An estimated 15% to 26% of women globally are affected by chronic pelvic pain (CPP). There are often cognitive, behavioral, sexual, and emotional effects that stem from CPP. CPP can present in a variety of ways, intermittent, constant, cyclical, such as ovulatory pain or dysmenorrhea, or not during menstruation (nonmenstrual pain), and it can be localized or diffuse, involving one or more specific sites, or multiple regions throughout the pelvis. Symptom burden for CPP often can result in repeated surgeries and prolonged therapy, with patients with CPP having overall higher health care utilization than patients without. This article is a clinical expert series article focusing on CPP, providing information and evidence surrounding pathophysiology, differential diagnosis by organ system and possible sources of CPP, evaluation of CPP, and treatment methods. CPP is a symptom rather than a disease, and the causes can be myriad and variable depending on the individual. Some conditions are identifiable as gynecologic in origin, such as endometriosis, and others are more broadly overlapping with pain conditions such as fibromyalgia, chronic fatigue syndrome, and others. Frequently, individuals can have chronic overlapping pain conditions that share similar pathophysiologic mechanisms; one theory is that nociplastic pain mechanisms are a common feature of chronic overlapping pain conditions. CPP can originate with any of the three mechanisms outlined by the International Association for the Study of Pain, including nociceptive pain, neuropathic pain, and nociplastic pain. Evaluation and treatment of CPP can be challenging because it is nonspecific and presentation is unique to each individual. This article recommends an organ system-based approach, meaning that many patients experience multiple sources of pain that all need treatment. Evaluation for CPP should not be delayed if a patient has not technically met the timing requirements for diagnosis. The most common non-malignant gynecologic conditions associated with CPP include endometriosis, adenomyosis, and uterine leiomyomas. The most common nongynegologic conditions associated with CPP include musculoskeletal contributors such as pelvic floor dysfunction and others, vulvodynia, interstitial cystitis/bladder pain syndrome, irritable bowel syndrome, neuropathic pain, and pelvic venous disorders. Patients with CPP often experience delayed diagnosis, dismissal, and negative clinical encounters, meaning that providers must establish a strong relationship with patients and carefully build trust to most effectively evaluate and treat this condition. Comorbid psychological conditions have a high prevalence in this population, but it is important to emphasize that patients with CPP are not imagining their pain, and it is not explained by any comorbid psychiatric conditions. Physical examination should be patient-centered and should include palpation of the back, joints, muscles, assessment of surgical scars and abdominal masses, light and deep palpation of the abdomen in all four quadrants, suprapubic and umbilical regions, and the pubic symphysis. Imaging can be used to identify potential structural causes of CPP and to rule out malignancy, with many guidelines suggesting transvaginal pelvic ultrasonography for initial diagnostic testing. Optimal treatment of CPP should include both pharmacologic and nonpharmacologic options, and patients should be educated and engaged in their care. Because presentation and response vary widely, treatment regimens are often selected through trial and error, with a focus on improving quality of life by treating contributing conditions. Pharmacologic treatment options can include analgesics, hormonal suppression, muscle relaxants, trigger point injections, neuromodulator medications, and topical medications. Nonpharmacologic treatments can include pelvic floor physical therapy, psychological and behavioral therapy, and transcutaneous electrical nerve stimulation. In some cases, surgical treatment can include the removal of endometriosis, hysterectomy, or nonextirpative surgeries. (Summarized from As-Sanie S, Ross WT, Till SR. Evaluation and treatment of chronic pelvic pain. Obstet Gynecol . 2026;147(1):21–43. doi:10.1097/AOG.0000000000006123).