Journal List > J Korean Med Assoc > v.51(1) > 1042035

J Korean Med Assoc. 2008 Jan;51(1):53-64. Korean.
Published online Jan 31, 2008.
Copyright © 2008 Korean Medical Association
The Management of Chronic Pelvic Pain
Sung-Tack Oh, MD
Department of Obstetrics & Gynecology, Chonnam National University College of Medicine, Korea. Email:

Chronic pelvic pain (CPP) is defined as lower abdominal pain lasting for at least 6 months. There are two forms of CPP: cyclic or continuous. The usual cyclic pain is dysmenorrhea. Dysmenorrhea is classified into primary and secondary. The primary dysmenorrhea is painful menstruation without any other pelvic disease. It can be treated by fat-free or omega-3-rich diet, quitting of smoking, nonsteroidal antiinflammatory drugs (NSAIDs), oral contraceptive pills, and long-acting injectable progestins. The most common origin of secondary dysmenorrhea and CPP is endometriosis. The management of pain of endometriosis can be controlled with step-by-step management of the original lesion by medical and surgical treatment, postoperative medical treatment, trigger point injection, NSAIDs, and immune therapy. Other etiologies of CPP are adenomyosis, pelvic congestion syndrome, abnormalities of uterus and ovary, psychological problems, gastrointestinal diseases (e.g. irritable bowel syndrome), urinary diseases (e.g. interstitial cystitis or chronic urethral syndrome), and musculoskeletal diseases. They can be treated by the management of the underlying diseases. The special form of CPP is chronic myofacial syndrome of the abdominal wall, which can be treated by trigger point injection. The other supportive treatments for CPP are laparoscopic adhesiolysis, uterine suspension, laparoscopic uterosacral nerve ablation (LUNA), presacral neurectomy, and hysterectomy. The treatment of CPP is very difficult. Therefore the exact diagnosis of its origin is necessary, and the combination treatment in various aspects is needed.

Keywords: Dysmenorrhea; Chronic pelvic pain; Endoemetriosis

1. Chan WY, Hill JC. Determination of menstrual prostaglandin levels in nondysmenorrheic and dysmenorrheic subjects. Prostaglandins 1978;15:365–375.
2. Rees MC, Anderson AB, Demers LM, Turnbull AC. Prostaglandins in menstrual fluid in menorrhagia and dysmenorrhea. Br J Obstet Gynaecol 1984;91:673–680.
3. Lundstrom V, Green K. Endogenous levels of prostaglandin F2? and its main metabolites in plasma and endometrium of normal and dysmenorrheic women. Am J Obstet Gynecol 1978;130:640–646.
4. Rees MC, Di Marzo V, Tippins JR, Turnbull AC. Leukotriene release by endometrium and myometrium throughout the menstrual cycle in dysmenorrhea and menorrhagia. J Endocrinol 1987;113:291–295.
5. Levinson SL. Peptidoleukotriene binding in guinea pig uterine membrane preparations. Prostaglandins 1984;28:229–240.
6. Nigam S, Benedetto C, Zonca M, Leo-Rosberg I, Lubbert H. Increased concentrations of eicosanoids and platelet-activating factor in menstrual blood from women with primary dysmenorrhea. Eicosanoids 1991;4:137–141.
7. Harel Z, Lilly C, Riggs S, Drazen J. Urinary leukotriene (LT)-E4 in adolescents with dysmenorrhea. J Adolesc Health 2000;27:151–154.
8. Balbi C, Musone R, Menditto A, Di Prisco L, Cassese E, D'Ajello M, Ambrosio D, Cardonel A. Influence of menstrual factors and dietary habits on menstrual pain in adolescence age. Eur J Obstet Gynecol Reprod Biol 2000;91:143–148.
9. Deutch B. Menstrual pain in Danish women correlated with low n-3 polyunsaturated fatty acid intake. Eur J Clin Nutr 1995;49:508–516.
10. Hornsby PP, Wilcox AJ, Weinber CR. Cigarette smoking and disturbance of menstrual function. Epidemiology 1998;9:193–198.
11. Barnard ND, Scialli AR, Hurlock D, Bertron P. Diet and sex-hormone binding globulin, dysmenorrhea, and premenstrual symptoms. Obstet Gynecol 2000;95:245–250.
12. Harel Z, Biro FM, Kotenhahn RK, Rosenthal SL. Supplementation with omega-3 fatty acids in the management of dysmenorrhea in adolescents. Am J Obstet Gynecol 1996;174:1335–1338.
13. Chan WY, Dawood MY. Prostaglandin levels in menstrual fluid of nondysmenorrheic and of dysmenorrheic subjects with and without oral contraceptive or ibuprofen therapy. Adv Prostaglandin Thromboxane Res 1980;8:1443–1447.
14. Hanson FW, Izu A, Henzyl MR. Naproxen sodium in dysmenorrhea: its influence in allowing work/school activities. Obstet Gynecol 1978;52:583–587.
15. Budoff PW. Zomepirac sodium in the treatment of primary dysmenorrhea syndrome. N Engl J Med 1982;307:714–719.
16. Smith RP, Powell JR. Intrauterine pressure changes during dysmenorrhea therapy. Am J Obstet Gynecol 1982;143:286–292.
17. Mehlisch DR. Ketoprofen, ibuprofen, and placebo in the treatment of primary dysmenorrhea: a double-blind crossover comparison. J Clin Pharmacol 1988;28:S29–S33.
18. Mehlisch DR. Double-blind crossover comparison of ketoprofen, naproxen, and placebo in patients with primary dysmenorrhea. Clin Ther 1990;12:398–409.
19. Marchini M, Tozzi L, Bakshi R, Pistal R, Fedele L. Comparative efficacy of diclofenac dispersible 50 mg and ibuprofen 400 mg in patients with primary dysmenorrhea. A randomized, double blind, within-patient, placebo-controlled study. Int J Clin Pharmacol Ther 1995;33:491–497.
20. Owen PR. Prostaglandin synthetase inhibitors in the treatment of primary dysmenorrhea. Am J Obstet Gynecol 1984;148:96–103.
21. Roy S. A double-blind comparison of a propionic acid derivative (ibuprofen) and a fenamate (mefenamic acid) in the treatment of dysmenorrhea. Obstet Gynecol 1983;61:628–632.
22. DuRant RH, Jay MS, Shofitt T, Lider CW, Taylor W. Factors influencing adolescents' responses to regimens of naproxen for dysmenorrhea. Am J Dis Child 1985;139:489–493.
23. Harel Z, Riggs S, Vaz R, Flanagan P, Harel D. The use of the leukotriene receptor antagonist montelukast (Singulair) in the management of dysmenorrhea in adolescents. J Pediatr Adolesc Gynecol 2004;17:183–186.
24. Hauksson A, Akerlund M, Forsling ML, Kindahl H. Plasma concentrations of vasopressin and a prostaglandin F2α metabolite in women with primary dysmenorrhea before and during treatment with a combined oral contraceptive. J Endocrinol 1987;115:355–361.
25. Creatsas G, Deligeoroglou E, Zachari A, Loutradis D, Papadimitriou T, Miras K, Aravantinos D. Prostaglandins: PGFα, PGE2, 6-keto-PGF1α and TXB serum levels in dysmenorrheic adolescents before, during and after treatment with oral contraceptives. Eur J Obstet Gynecol Reprod Biol 1990;36:292–298.
26. Ekstrom P, Juchnicka E, Laudanski T, Akerlund M. Effect of an oral contraceptive in primary dysmenorrhea-changes in uterine activity and reactivity to agonists. Contraception 1989;40:39–47.
27. Ekstrom P, Akerlund M, Forsling M, Kindahl H, Laudanski T, Mrugacz G. Stimulation of vasopressin release in women with primary dysmenorrhea and after oral contraceptive treatment-effect on uterine contractility. Br J Obstet Gynaecol 1992;99:680–684.
28. Milsom I, Andersch B. Effect of various oral contraceptive combinations on dysmenorrhea. Gynecol Obstet Invest 1984;17:284–292.
29. Larsson G, Milsom I, Lindstedt G, Rybo G. The influence of a low-dose combined oral contraceptive on menstrual blood loss and iron status. Contraception 1992;46:327–334.
30. Robinson JC, Plichata S, Weisman CS, Nathanson CA, Ensminger M. Dysmenorrhea and use of oral contraceptives in adolescent women attending a family planning clinic. Am J Obstet Gynecol 1992;166:578–583.
31. Dmowski WP, Cohen MR. Treatment of endometriosis with an antigonadotrophin, danazol: a laparoscopic and histological education. Obstet Gynecol 1975;46:147–154.
32. Biberoglu KO, Behrman SJ. Dosage aspects of danazol therapy in endometriosis: short term and long term effectiveness. Am J Obstet Gynecol 1981;139:645–654.
33. Vercellini P, Bocciolone L, Vendola N, Colombo A, Rognoni MT, Fedele L. Peritoneal endomeriosis: morphologic appearance in women with chronic pelvic pain. J Reprod Med 1991;36:533–536.
34. Moghissi KS, Boyce CR. Management fo endometriosis with oral medroxyprogestrone acetate. Obstet Gynecol 1976;47:265–267.
35. Johnston WI. Dydorgesterone and endometriosis. Br J Obstet Gynecol 1976;83:77–80.
36. Telimaa S, Puolakka J, Ronuberg L, Kauppila A. Placebo controlled comparison of danazol and high dose meroxy-progestrone acetate in the treatment of endometriosis. Gynecol Endometrinol 1987;1:13–23.
37. Azadien-Boulanger G, Secchi J, Tournemine C. Hormonal activity profiles of drugs for endometriosis therapy. In: Raynoud JP, Ojassoo T, Martini L, editors. Medical Management fo Endomtriosis. 2nd ed. New York: Raven Press; 1984. pp. 125-129.
38. Couthinho EM, Husson JM, Azadieu-Boulanger G. Treatment of endometriosis with gestrinone-five year's experience. In: Raynoud JP, Ojasso T, Martini L, editors. Medical Management of Endometriosis. 2nd ed. New York: Raven Press; 1984. pp. 249-253.
39. Meldrum DR, Chang RJ, Lu J, Vale W, Rivier J, Judd HL. Medical oophorectomy using a long-acting GnRH agonsit: a possible new approach for the treatment of endotmetrisis. J Clin Endocrinol Metab 1982;54:1081–1083.
40. Reichel RP, Schweppe KW. Zoladex Endomtriosis Study Group. Goserelin (Zoladex) depot in the treatment of endometriosis. Fertil Steril 1992;57:1197–1202.
41. Hardt W, Schmidt-Gollwitzer M, Schmidt-Gollwitzer K, Genz T, Nevinny-Stickel J. Erste Ergebnisse beil der Behandlung der Endometriose mit dem LH-RH Analogen Buserelin. Geburtshilfe Frauenheikunder 1986;46:483–489.
42. Tokushige M, Suginami H, Taniguchi F, Kitaoka Y. Laparoscopic surgery for endometriosis: a long-term follow-up. J Obstet Gynecol Res 2000;26:409–416.
43. Sutton CJ, Ewen SP, Jacobs SA, Whitelaw NL. Laser laparoscopic surgery in the treatment of ovarian endometriomas. J Am Assoc Gynecol Laparosc 1997;4:319–323.
44. Daniell JF, Kurtz BR, Gurley LD. Laser laparoscopic management of large endometriomas. Fertil Steril 1991;55:692–695.
45. Donnez J, Squifflet J, Pirard C, Jadoul P, Wyns C, Smets M. The efficacy of medical and surgical treatment of endometriosis-associated infertility and pelvic pain. Gynecol Obstet Invest 2002;54:2–7.
46. Chapron C, Vercellini P, Barakat H, Vieira M, Dubuisson JB. Management of ovarian endometriomas. Hum Reprod Update 2002;8:591–597.
47. Jones KD, Sutton C. Patient satisfaction and changes in pain scores after ablative laparoscopic surgery for stage III-IV endometriosis and endometriotic cysts. Fertil Steril 2003;79:1086–1090.
48. Reiter RC. A profile of women with chronic pelvic pain. Clin Obstet Gyenecol 1990;33:130–136.
49. Fall M, Johannson SL, Aldenberg F. Chronic interstitial cystitis: A heterogeneous syndrome. J Urol 1987;137:35–38.
50. Holm-Bentzen M, Jacobsen F, Nerstrom B, Lose G, Kristensen JK, Pedersen RH, Krarup T, Feggetter J, Bates P, Barnard R. Painful bladder disease: Clinical and pathoanatomical differences in 115 patients. J Urol 1987;138:500–502.
51. Larsen S, Thompson SA, Hald T, Barnard RJ, Gilpin CJ, Dixon JS, Gosling JA. Mast cells in interstitial cystitis. Br J Urol 1982;54:283–286.
52. Travell J, Rinzler SH. The myofascial genesis of pain. Postgrad Med 1952;11:425–434.
53. Slocumb JC. Neurological factors in chronic pelvic pain: trigger point and the abdominal pelvic pain syndrome. Am J Obstet Gynecol 1984;149:536–543.
54. Carter JE. Surgical treatment for chronic pelvic pain. J Soc Laparoendosc Surg 1998;2:129–139.
55. Simons DG. Diagnostic criteria of myofascial pain caused by trigger points. J Musculoskel Pain 1999;7:111–113.
56. Chan CL, Wood C. Pelvic adhesiolysis-the assessment of symptom relief by 100 patients. Aust N Z J obstet Gynaecol 1985;25:295–298.
57. Nezhat FR, Crystal FR, Nezhat CH, Nezhat CR. Laparoscopic adhesiolysis and relief of chronic pelvic pain. JSLS 2000;4:281–285.
58. Sutton C, McDonald R. Laser laparoscopic adhesiolysis. J Gynecol Surg 1990;6:155–159.
59. Sutton C, Hill D. Laser laparoscopy in the treatment of endometriosis. Br J Obstet Gynecol 1990;97:181–185.
60. Lichten EM, Bombard J. Surgical treatment of primary dysmenorrhoea with laparoscopic uterosacral nerve ablation. J Reprod Med 1987;32:37–41.
61. Parsons LH, Stovall TG. Surgical management of chronic pelvic pain. Obstet Gynecol Clin North Am 1993;20:765–778.