In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Classification of evidence levels (1++ to 4) and grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.
What Are the Possible Aetiological Factors in the Genesis of Chronic Pelvic Pain?
Endometriosis and Adenomyosis
D - Pelvic pain which varies markedly over the menstrual cycle is likely to be attributable to a hormonally driven condition such as endometriosis.
Irritable Bowel Syndrome (IBS) and Interstitial Cystitis
C - Symptoms suggestive of IBS or interstitial cystitis are often present in women with chronic pelvic pain. These conditions may be a primary cause of chronic pelvic pain, a component of chronic pelvic pain or a secondary effect caused by efferent neurological dysfunction in the presence of chronic pain (see section 3.4 in the original guideline document).
C - Musculoskeletal pain may be a primary source of pelvic pain or an additional component resulting from postural changes.
D - Nerve entrapment in scar tissue, fascia or a narrow foramen may result in pain and dysfunction in the distribution of that nerve.
Psychological and Social Issues
B - Enquiry should be made regarding psychological and social issues which commonly occur in association with chronic pelvic pain; addressing these issues may be important in resolving symptoms.
What Should Underline the Initial Assessment of Chronic Pelvic Pain?
B - The multifactorial nature of chronic pelvic pain should be discussed and explored from the start. The aim should be to develop a partnership between the clinician and the woman to plan a management programme.
B - Symptoms alone may be used to diagnose IBS positively in this group (see Appendix 1 in the original guideline document).
On taking the woman's history, special note should be taken of any "red flag" symptoms (see Appendix 2 in the original guideline document) which may need further investigation and referral to a specialist. If the situation allows, it may be helpful to ask directly about past or present sexual assault, particularly intimate partner violence. The doctor must be prepared to listen and accept these experiences as stated and know where to access specialist support.
Completing a daily pain diary for two to three menstrual cycles may help the woman and the doctor identify provoking factors or temporal associations. The information may be useful in understanding the cause of the pain.
It may be helpful to establish the woman’s level of function at the start of treatment (e.g., time off work, avoiding activities), both to monitor progress and to emphasise the value of functional goals. Asking which drugs have been used previously, and whether or not they helped, may be helpful both to aid diagnosis and to plan effective management.
What Investigations Should Be Undertaken?
Screening for Infection
D - All sexually active women with chronic pelvic pain should be offered screening for sexually transmitted infections (STIs).
A positive endocervical sample supports but does not prove the diagnosis of pelvic inflammatory disease (PID). The absence of a result positive for Chlamydia trachomatis or gonococcus does not rule out the diagnosis of PID. [Evidence level 4]
If PID is suspected clinically, this condition is best managed in conjunction with a genitourinary medicine physician in order that up-to-date microbiological advice and contact tracing can be arranged. Sexually active women with chronic pelvic pain should be offered screening for STIs. [Evidence level 4]
Transvaginal Scanning (TVS) and Magnetic Resonance Imaging (MRI)
B - Transvaginal scanning is an appropriate investigation to identify and assess adnexal masses.
B - Transvaginal scanning and magnetic resonance imaging are useful tests to diagnose adenomyosis.
D - Diagnostic laparoscopy has been regarded in the past as the 'gold standard' in the diagnosis of chronic pelvic pain. It may be better seen as a second-line investigation if other therapeutic interventions fail.
The risks and benefits of diagnostic laparoscopy and the possibility of negative findings should be discussed before the decision is made to perform a laparoscopy. Perhaps it should be performed only when the index of suspicion of adhesive disease or endometriosis requiring surgical intervention is high, or when the patient has specific concerns which could be addressed by diagnostic laparoscopy such as the existence of endometriosis or adhesions potentially affecting her fertility.
What Therapeutic Options Are Available?
B - Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3–6 months before having a diagnostic laparoscopy.
A - Women with IBS should be offered a trial with antispasmodics.
C - Women with IBS should be encouraged to amend their diet to attempt to control symptoms.
Grades of Recommendations
A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++, and directly applicable to the target population; or
A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results
B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group
Classification of Evidence Levels
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias
1– Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal
2– Case–control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal
3 Non-analytical studies, e.g., case reports, case series
4 Expert opinion