27th June 2023

Pelvic pain and dyspareunia

Pelvic Pain

Chronic pelvic pain is defined by the Green-Top Guidelines produced by the Royal College of Obstetricians and Gynaecologists as “Intermittent or constant pain in the lower abdomen or pelvis of a woman of at least six months in duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy. It is a symptom not a diagnosis.” Pain is a sensory experience affected by physical, emotional, and social factors. In unpicking the pain, it is key to consider pelvic pain as multifactorial and not suggest that it is purely one contributing factor when there are likely several.

Endometriosis and adenomyosis

Characteristic symptoms are dysmenorrhea, dyspareunia and chronic pelvic pain varying markedly over the menstrual cycle. Endometriosis is a condition where tissue similar to endometrium is found growing outside the uterus; adenomyosis is the growth of endometrial tissue in the muscular walls of the uterus. Ovarian suppression with ‘the Pill’ or Goserelin (injectable gonadotrophin releasing hormone agonist) may be effective in these cyclical pain conditions.

Adhesions

Adhesions may be caused by previous surgery, previous infection (such as Pelvic Inflammatory Disease) and endometriosis. Pelvic pain may be made worse by stretching or movement, but not all adhesions are symptomatic. Adhesiolysis (the surgical cutting of adhesions) is of limited benefit to improve pain in all but the densest of vascular adhesions.

Alternative Causes of Pelvic Pain

It is important when considering pelvic pain to assess the relationship of the pain to bowel movements (irritable bowel syndrome), urinary frequency or association with urination (cystitis) or possible relationship to past or ongoing psychological trauma, such as past sexual abuse. Pelvic joints can be involved in musculoskeletal pain, and nerve entrapment in the pelvic region can also cause pelvic pain.

One distinct cause of transitory pelvic pain is Mittelschmerz – this is mid-cycle menstrual pain associated with ovulation; it is most common in teenagers and older women.

Dyspareunia

Dyspareunia is pain during or after activity over a period of at least six months; it is more common in women. Pain may be superficial – felt in the vulva or around the entrance to the vagina or deeper where it is felt on deeper penetration. Primary dyspareunia has been present since first intercourse, while secondary dyspareunia develops later. Risk factors include younger age, operative (as opposed to vaginal) delivery, stress, and pelvic infections. Pain should be investigated, including ruling out infection and malignant causes, and a detailed history should be taken. Once physical causes have been fully treated, it is appropriate for the management to involve both partners and should take a multidisciplinary approach.