A lifecourse approach to studying pelvic pain in women

Chronic pelvic pain (CPP) is one of the most difficult clinical problems to treat because of its multifactorial nature. Although CPP is a worldwide problem, with considerable burden on women's overall quality of life (physical, psychological and sexual), it has not been a prioritised research area, as shown by limited data on international population-based prevalence estimates and paucity of longitudinally based studies evaluating both adverse and protective factors in relation to CPP. Unlike most previous research, which relies on data from women coming in for gynaecological care, the study by Righarts et al. limits selection bias by assessing prevalence and determinants of various types of pelvic pain, including dysmenorrhoea at ages 13, 15 and 38 years. Righarts et al. reported a prevalence of pelvic pain at age 38 years that was over two-fold higher compared with other studies among women in the same age range. A 2014 international systematic review reported the CPP prevalence range to be between 5.7% (Austria) and 26.6% (Egypt) (Ahangari, Pain Physician 2014;17:E141–7). What explains this great discrepancy in prevalence between the study by Righarts et al. and the recent systematic review? The answer largely rests with chronicity rather than the description or location of pain. Chronic pelvic pain is described differently by various women's healthcare professionals. The Royal College of Obstetricians and Gynaecologists defines CPP as ‘intermittent or constant pain in the lower abdomen or pelvis of a woman of at least 6 months duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy’ and the American College of Obstetricians and Gynecologists defines CPP as ‘pain in the pelvic area that lasts for 6 months or longer… and that may occur during menstruation… or before or after eating, while urinating, or during sex.’ The common link is duration of 6 months or more. Righarts et al., however, are assessing any pelvic pain (menstrual pain, pain associated with sexual intercourse, or pain not related to menstruation or intercourse) in the past 12 months. Although the study's ability to assess within-woman changes of pelvic pain over the course of 25 years, and potential determinants of change, is highly novel and commendable, the lack of the use of a standardised questionnaire, such as the International Pelvic Pain Society's Pelvic Pain Assessment Form, limits the ability to use their data in future systematic reviews of CPP prevalence estimates. Despite this limitation in CPP assessment, the noteworthy finding in Righart et al.'s study is the sustained report of dysmenorrhoea over a woman's reproductive lifespan, with 57.6% reporting menstrual pain at age 13 years, 68.9% at age 15 years and 54.5% at age 38 years. Furthermore, among the 38-year-old women, 32.1% reported having frequent or severe pain and 36.4% reported that their pain was getting worse with age. Although Righart et al.'s reporting of the significant correlation between dysmenorrhoea and endometriosis/fibroids and between dyspareunia and rape has been previously documented; what is surprising is their finding that neither dysmenorrhoea nor dyspareunia nor other pelvic pain improved following childbirth. Thankfully, the myth that pregnancy cures gynaecological conditions most commonly linked with CPP, including endometriosis and fibroids, is slowly disappearing. However, further longitudinal studies evaluating both physical and psychological contributors to women's CPP over the lifecourse are needed if we are to make progress in relieving symptoms for women who suffer from CPP in order to improve their quality of life. None declared. The completed disclosure of interest form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.