The cause of noncyclical chronic pelvic pain (CPP) in many women is unknown: 30% have no identifiable pelvic pathology, and in those who do the relationship of CPP and the pathology is often unclear. Moreover, epidemiologic studies demonstrate that the common findings of endometriosis and adhesions do not greatly increase the odds of having CPP. CPP and the functional somatic syndromes (fibromyalgia, irritable bowel syndrome, and others) share many characteristics including pain as a prominent symptom and comorbidity. For the functional somatic syndromes, the initial focus of etiologic investigations has been on local mechanisms and then on systemic pathogeneses. We believe that the research trajectories of the functional somatic syndromes and CPP are converging. Their juncture might reveal an important pathologic mechanism for CPP in some women that is primarily outside the pelvis. This observation would open up new areas of exploration and treatment of CPP.
Laparoscopy has been used for decades in diagnosis and treatment of chronic pelvic pain. As a relatively safe and effective method to diagnose and treat many pelvic pathologies, its introduction represented a great step forward in the understanding of noncyclical chronic pelvic pain (CPP) in women. However, after 4 decades of laparoscopic assessment and treatment, it now appears that in many women the cause of CPP remains unknown in spite of thorough evaluation.
In this opinion piece, we integrate existing data to suggest that the source of CPP in many women is not solely in the pelvis but rather has a systemic pathogenesis. Several observations from 3 general areas of research have been used to support this opinion. The first is from laparoscopic findings in women with CPP. The second comprises epidemiologic studies of correlates of CPP. The third is from analyses of a group of conditions known as functional somatic syndromes. A synthesis of these observations generates the hypothesis that in a substantial proportion of women with CPP, the cause of this distressing condition lies outside of the pelvic region and represents a functional somatic syndrome.
Laparoscopic studies of CPP
Laparoscopic evaluation reveals no visible pathology in about 30% of women with CPP. Most of these women continue to have CPP long after the nondiagnostic laparoscopy and in spite of further evaluations for nonlaparoscopic diagnoses.
Of those who have pelvic pathology, the most common findings are endometriosis and adhesions. On average, one or both of these findings are present in about two-thirds of CPP cases evaluated laparoscopically. Unfortunately, many of the studies reporting these findings lacked asymptomatic controls to assess whether these observations were more common in women with CPP than in those who did not have CPP. We reviewed the literature on pathologic findings in CPP patients and restricted the search to well-designed studies (ie, with controls, blinding, correlations, or in therapeutic trials, randomization). We found 4 sets of pertinent investigations.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
