Chronic Pelvic Pain

Chronic Pelvic Pain

What is chronic pelvic pain?

Chronic pelvic pain is chronic or persistent pain in the pelvic region lasting for at least six months that can be cyclical or non-cyclical in nature. Chronic pelvic pain (CPP) is relatively common, with 4-16% of women being diagnosed with CPP over their lifetime. However, many women have symptoms of CPP for over two years before seeking medical care.

What causes chronic pelvic pain?

There are many potential causes of chronic pelvic pain, but typically patients have a combination of psychological and physical factors that contribute to their chronic pain. Pelvic floor dysfunction, which is impaired relaxation of the muscles in the pelvic area that provide support to the pelvic organs, is a very common cause of pain in CPP. Along with pelvic floor dysfunction, causes of CPP can include endometriosis, chronic bladder infection, pelvic adhesions, and musculoskeletal injury. Over time, pain caused by these conditions causes the body to experience constant high levels of pain, and can make the brain react to normal stimuli as though it were painful, increasing the amount of pain experienced. These physical factors are often coupled with psychological conditions that can predispose a patient to CPP, including generalized anxiety disorder, major depressive disorder, and posttraumatic stress disorder.

What other conditions can be associated with chronic pelvic pain?

  • Chronic Fatigue Syndrome
  • Fibromyalgia
  • Sjogren’s Syndrome
  • Interstitial cystitis
  • Chronic prostatitis
  • Irritable Bowel Syndrome
  • Pelvic Floor Muscle Pain Syndrome
  • Endometriosis
  • Pelvic adhesions
  • Mood disorders

What are treatment options for chronic pelvic pain?

Medical Therapies for Chronic Pelvic Pain

Indication Medication
First Line Options

Non-steroidal anti-inflammatory drugs (NSAIDS)

  • Ibuprofen
  • Naproxen
Cyclical pain

Hormone-replacement therapy

  • Oral contraceptives
  • Depot medroxyprogesterone
  • Intrauterine device (IUD)

Non-cyclical pain or neuropathic pain

  • Diagnosed underlying mood disorder
  • No diagnosed underlying mood disorder
Selective serotonin reuptake inhibitors (SSRIs)
Tricyclic antidepressants (TCAs), pregabalin, gabapentin, serotonin-norepinephrine reuptake inhibitors (SNRIs)
Pelvic floor muscle spasm Cyclobenzaprine
Compounded diazepam and/or baclofen vaginal suppositories or creams
Non-cyclical pelvic pain Botulinum toxin injection
Suspected sacral nerve injury

Local corticosteroid injection
Peripheral nerve blocks, radiofrequency ablation, neuromodulation

Severe uncontrolled pelvic pain Referral to pain medicine specialist, consider opioids

Non-Pharmacologic Therapies for Chronic Pelvic Pain

  • Pelvic floor physical therapy
  • Cognitive behavioral therapy
  • Mindfulness
  • Hysterectomy
    • Generally considered to be a last option
  • Trigger point injections for short-term pain relief as an adjunctive treatment only

Compounded Medications for Chronic Pelvic Pain

Diazepam Vaginal suppository

In a prospective study of 21 women with pain due to pelvic floor dysfunction, 62% of women had moderately or markedly reduced pain with intravaginal diazepam use

In a retrospective study of 26 women with pelvic floor dysfunction and sexual pain, 25 women reported subjective improvement with intravaginal diazepam use

Topical gabapentin use has shown effectiveness in treating pain with reduced side effects compared with oral forms

In a prospective study of 118 patients with neuralgia, about 50% of patients reported improved pain relief with the use of a combination of amitriptyline and ketamine cream

In a retrospective study of 38 patients with provoked vestibulodynia, improved pain relief was noted in over 50% of patients with the use of a combination of amitriptyline and baclofen cream

In a retrospective study of 61 women with vulvodynia, 5% lidocaine ointment was associated with a significant decrease in intercourse-related pain

Baclofen / diazepam Vaginal suppository or cream
Baclofen / diazepam / gabapentin Vaginal suppository or cream
Baclofen / gabapentin Vaginal cream
Amitriptyline / ketamine Vaginal cream
Amitriptyline / baclofen Vaginal cream
Lidocaine Vaginal ointment

Compounded medications can be great options for patients who have specific medical needs unmet by commercial medications. All of the medications in the table above are not available at traditional pharmacies, and would need to be compounded to a patient’s specifications. Contact your healthcare provider for more information about specially compounded medications and to see if they may be right for you.


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