Executive Summary
Results from a study by researchers from the National Institutes of Health and the University of Utah School of Medicine, Salt Lake City, suggest a high proportion of reproductive-age women might be experiencing pelvic pain that goes untreated.
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To conduct the study, scientists surveyed 473 women ages 18-44 at 14 surgical centers in Salt Lake City and San Francisco who were scheduled to undergo laparotomy or laparoscopy for reasons such as infertility, menstrual irregularities, tubal sterilization, or pelvic pain.
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While reports of pain were highest for women diagnosed with endometriosis, data indicate one-third of those without any pelvic condition also reported a high degree of ongoing pain or pain recurring during the menstrual cycle.
Results from a study by researchers at the National Institutes of Health and the University of Utah School of Medicine, Salt Lake City suggest a high proportion of reproductive-age women might be experiencing pelvic pain that goes untreated.1
To conduct the study, scientists surveyed 473 women ages 18 to 44 at 14 surgical centers in Salt Lake City and San Francisco who were scheduled to undergo laparotomy or laparoscopy for reasons such as infertility, menstrual irregularities, tubal sterilization, or pelvic pain. While reports of pain were highest for women diagnosed with endometriosis, data indicate one-third of those without any pelvic condition also reported a high degree of ongoing pain or pain recurring during the menstrual cycle.1
“Although clinicians and women’s health researchers have long known that endometriosis is a major contributor to pelvic pain, we have very limited knowledge in regard to how pelvic pain associated with endometriosis differs in type, severity, and location from pelvic pain associated with other gynecologic conditions or among women with no gynecologic pathology,” says Karen Schliep, PhD, MSPH, a postdoctoral fellow in the Division of Intramural Population Health Research at the National Institutes of Health’s Eunice Kennedy Shriver National Institute of Child Health and Human Development in Bethesda, MD. “We need to improve our understanding of these relationships if we wish to improve care for women experiencing pelvic pain.”
What did women say?
Researchers interviewed women prior to their procedures about the kind of pain they had experienced in the past six months, along with its severity.
The women were asked if they had more than 17 specific types of pain related to sexual intercourse, their menstrual period, urination or bowel elimination, or other pain, such as muscle pain, joint pain, or migraine headaches. Scientists also asked the women to indicate, on diagrams of the pelvic area and on a standing female figure, where they experienced the pain.
More than 30% of the women reported that they were experiencing chronic pain and cyclic pain lasting six months or more. This group of women included not only those with pelvic disorders, but also those without any pelvic condition. In addition, regardless of the reason study subjects had surgery or their diagnosis after the operation, just 3% of the total study population reported having none of the 17 types of pain, while more than 60% reported six or more types of pain. Types of pain included vaginal pain with intercourse, deep pain with intercourse, burning vaginal pain after intercourse, pelvic pain lasting hours or days after intercourse, constant burning vaginal pain (regardless of intercourse), pain just before period, level of cramps with period, pain after period is over, pain at ovulation (mid-cycle), pain with urination, pain with bowel elimination, pain in groin when lifting, pain when bladder is full, abdominal pain, low back pain, muscle/joint pain, and migraine headache.
Among the study participants, about 40% were diagnosed with endometriosis, while 31% were diagnosed with other conditions, including uterine fibroids, ovarian cysts, and tumors. About 29% were not diagnosed with any pelvic condition.1
What tools to use?
Adenomyosis, pelvic adhesions, pelvic inflammatory disease, congenital anomalies of the reproductive tract, and ovarian or tubal masses can cause pelvic pain, as well as disorders in the gastrointestinal, urinary, neurologic, and musculoskeletal systems.2 However, studies indicate that endometriosis is found in 70%-90% of patients with pelvic pain symptoms.3-4
Women in the current study who were diagnosed with endometriosis experienced the most chronic pain (about 44%), compared to about 30% of women without any pelvic condition. Also, researchers note women with endometriosis were more likely to experience pain during intercourse, menstrual cramping, and pain with bowel elimination. They also were more likely to report vaginal pain and pain in the pelvic-abdominal area.1
While clinicians have looked to laparoscopy to determine the presence of endometriosis in patients with pelvic pain, three-dimensional ultrasound imaging has emerged as another imaging option for examining patients with pelvic pain associated with the condition. Three-dimensional ultrasound imaging also can be used to examine patients with embedded intrauterine devices, fibroid tumors, adenomyosis, and adnexal masses.5
Another imaging advancement, the transvaginal ultrasound transducer, allows the operator to place a probe in close proximity to target pelvic organs and to examine and image the patient at the same time. This type of ultrasound has proved accurate for evaluating deep infiltrating endometriosis.5
Beryl Benacerraf, MD, a clinical professor in obstetrics, gynecology, and reproductive biology and radiology at Harvard Medical School and radiologist at Brigham and Women’s Hospital in Boston, says, “In this era of cost concerns, it is very important to recognize that ultrasound technology now offers multiple applications such as 3D volume imaging, similar to computerized tomography and magnetic resonance imaging, real-time evaluation of pelvic organs along with the physical examination, and Doppler blood flow mapping, without contrast. Collectively, these applications make ultrasound imaging a unique imaging modality that ideally is suited to evaluate the female pelvis.”
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Schliep KC, Mumford SL, Peterson CM, et al. Pain typology and incident endometriosis. Hum Reprod 2015; doi: 10.1093/humrep/dev147.
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Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: A committee opinion. Fertil Steril 2014; 101(4):927-935.
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Spaczynski RZ, Duleba AJ. Diagnosis of endometriosis. Semin Reprod Med 2003; 21:193-208.
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Gruppo Italiano per lo Studio dell’Endometriosi. Relationship between stage, site and morphological characteristics of pelvic endometriosis and pain. Hum Reprod 2001; 16:2668-2671.
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Benacerraf BR, Abuhamad AZ, Bromley B, et al. Consider ultrasound first for imaging the female pelvis. Am J Obstet Gynecol 2015; 212(4):450-455.
