The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
The following recommendations are based on good and consistent scientific evidence (Level A):
- Combined oral contraceptives should be considered as a treatment option to decrease pain from primary dysmenorrhea.
- Gonadotropin-releasing hormone (GnRH) agonists are effective in relieving pelvic pain associated with endometriosis and irritable bowel syndrome, as well as in women with symptoms consistent with endometriosis who do not have endometriosis. Thus, empiric treatment with GnRH agonists without laparoscopy should be considered as an acceptable approach to treatment.
- Nonsteroidal antiinflammatory drugs, including cyclooxygenase isoenzyme 2 (COX-2) inhibitors, should be considered for moderate pain and are particularly effective for dysmenorrhea.
- Progestins in daily, high doses should be considered as an effective treatment of chronic pelvic pain associated with endometriosis and pelvic congestion syndrome.
- Laparoscopic surgical destruction of endometriosis lesions should be considered to decrease pelvic pain associated with stages I to III endometriosis.
- Presacral neurectomy may be considered for treatment of centrally located dysmenorrhea but has limited efficacy for chronic pelvic pain or pain that is not central in its location. Uterine nerve ablation or transection of the uterosacral ligament also can be considered for centrally located dysmenorrhea, but it appears to be less effective than presacral neurectomy. Combining uterine nerve ablation or presacral neurectomy with surgical treatment of endometriosis does not further improve overall pain relief.
- Adding psychotherapy to medical treatment of chronic pelvic pain appears to improve response over that of medical treatment alone and should be considered.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- GnRH agonists should be considered as a treatment option for chronic pelvic pain because they have been shown to relieve endometriosis-associated pelvic pain.
- Surgical adhesiolysis should be considered to decrease pain in women with dense adhesions involving the bowel, but it is unclear if lysis of other types of adhesions is effective.
- Hysterectomy is an effective treatment for chronic pelvic pain associated with reproductive tract symptoms that results in pain relief in 75 to 95% of women and should be considered.
- Sacral nerve stimulation may decrease pain in up to 60% of women with chronic pelvic pain and should be considered as a treatment option.
- Various physical therapy modalities appear to be helpful in the treatment of chronic pelvic pain and should be considered as a treatment option.
- Nutritional supplementation with vitamin B1 or magnesium may be recommended to decrease pain of dysmenorrhea.
- Injection of trigger points of the abdominal wall, vagina, and sacrum with local anesthetic may provide temporary or prolonged relief of chronic pelvic pain and should be considered.
- Treatment of abdominal trigger points by the application of magnets to the trigger points may be recommended to improve disability and reduce pain.
- Acupuncture, acupressure, and transcutaneous nerve stimulation therapies should be considered to decrease pain of primary dysmenorrhea.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- A detailed history and physical examination are the basis for differential diagnosis of chronic pelvic pain and should be used to determine appropriate diagnostic studies.
- Antidepressants may be helpful in the treatment of chronic pelvic pain.
- Opioid analgesics can be used to provide effective relief of severe pain with a low risk of addiction but do not necessarily improve functional or psychologic status and are not well studied in patients with chronic pelvic pain.
Definitions:
Grades of Evidence
I: Evidence obtained from at least one properly designed randomized controlled trial.
II-1: Evidence obtained from well-designed controlled trials without randomization.
II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.
II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Levels of Recommendations
Level A — Recommendations are based on good and consistent scientific evidence.
Level B — Recommendations are based on limited or inconsistent scientific evidence.
Level C — Recommendations are based primarily on consensus and expert opinion.