Management of chronic pelvic pain in women

Abstract

Recent studies have demonstrated that 84% of women suffering from unexplained pelvic pain have dilated pelvic veins. Such appearances are generally considered to be evidence of ‘pelvic congestion’. Venographic studies of women without pain did not show these appearances. Management of pelvic congestion is considered difficult as there are few therapies currently available. Psychotherapy has been previously shown to be successful in the management of a number of painful conditions including women with chronic pelvic pain. Ovarian suppression with medroxyprogesterone acetate (MPA) has also been shown to reduce both venogram and pain scores. The first hypothesis of this thesis was that women with chronic pelvic pain in association with venographic evidence of pelvic congestion could be treated with medroxyprogesterone acetate and that longer term benefit could be obtained with the concurrent use of psychotherapy. The second hypothesis was that treatment with MPA will lower levels of pituitary gonadotrophins, the ovarian hormones, the karyopyknotic index (vaginal cytology) and reduce the dimensions of the uterus, endometrium, ovaries and pelvic veins. This thesis presents the results of a randomised controlled trial comparing two different treatment approaches; psychotherapy and ovarian suppression using MPA. One hundred and two women with pelvic congestion were randomly allocated to one of four treatment groups; MPA, MPA and psychotherapy, placebo, and placebo and psychotherapy. Women were treated for four months and thereafter followed up regularly for 9 months with pain assessments, pelvic ultrasound scanning and hormone measurements. Women treated with MPA showed a significant benefit in terms of a reduction in pain scores, with 73% of women reporting an improvement compared with 33% of those in the non-MPA groups. After 9 months therapy no clear drug effect emerged. Fifty percent of women in the placebo group were improved at the end of follow up. Those women who received MPA had significant reductions in the uterine cross-sectionnal area, endometrial thickness, oestradiol, testosterone and luteinising hormone levels. Medical therapy with MPA was shown to be a useful first line therapy for women with pain associated with demonstrable pelvic congestion.