Presence of endometriosis and chronic overlapping pain conditions negatively impacts the pain experience in women with chronic pelvic-abdominal pain: A cross-sectional survey.

BACKGROUND: Evidence of overlap between endometriosis and chronic pain conditions is emerging; however, little is known about how the pain experience differs based on the presence or absence of endometriosis. OBJECTIVES: In a sample of women reporting chronic pelvic-abdominal pain (CPP), the aim of this study was to characterize differences in pain symptomatology between women with and without endometriosis and to examine the influence of chronic overlapping pain conditions (COPCs) on pain among these two groups. DESIGN: This was a cross-sectional study, based on an online survey. METHODS: Participants (aged 18+ years) completed a survey collecting pain diagnoses and symptoms assessing pelvic pain severity, pain interference, and pain impact. Independent sample t-tests, chi-square, and multiple linear regression models were employed to analyze group differences in pain symptomatology and COPCs. RESULTS: Of the 525 respondents with CPP, 25% (n = 133) reported having endometriosis. Women with endometriosis were younger at the onset of pelvic pain, relative to women without endometriosis (p = 0.04). There were no differences in age, race, ethnicity, or duration of pelvic pain between women with and without endometriosis. Women with endometriosis reported higher pelvic pain severity (+0.8, 95% CI = 0.4-1.1), pain interference (+5.9, 95% CI = 2.4-9.3), and pain impact (+1.9, 95% CI = 0.8-2.9). Endometriosis was associated with a higher number of COPCs (p = 0.003), with 25% (n = 33) of women reporting ⩾3 overlapping pain conditions compared with 12% (n = 45) of those without endometriosis. Women with endometriosis had a higher frequency of fibromyalgia (p < 0.001), chronic fatigue syndrome (p < 0.001), and temporomandibular disorder (p = 0.001). The number of COPCs was associated with higher pain severity, interference, and impact, independently of endometriosis. CONCLUSION: Women with endometriosis experienced higher levels of pain-related burden and COPCs compared with those without endometriosis. Pain intensity, interference, and impact increased with a higher number of pain conditions regardless of endometriosis presence.

Presence of endometriosis and chronic overlapping pain conditions negatively impacts the pain experience in women with chronic pelvic­abdominal pain: A cross-sectional surveyThe presence of endometriosis was associated with a higher number of chronic overlapping pain conditions (COPCs) and greater pain symptomatology, while a greater number of COPCs corresponded to increased pain burden among women with and without endometriosis. These findings underscore the need for a more comprehensive assessment of endometriosis that addresses the full experience of the disease, including its comorbidities. A greater characterization and measurement of COPCs has the potential to facilitate the development of tailored interventions for individuals with pain comorbidities, thereby contributing to improved clinical care strategies for endometriosis-related pain.

Identifying Gaps in Pelvic Pain Education: A Scoping Review and Structured Analysis of Obstetrics and Gynecology Training Milestones.

OBJECTIVE: Several clinical practice guidelines on the evaluation and management (EM) of chronic pelvic pain (CPP) have been published; however, it is not known whether obstetrics and gynecology (OBGYN) educational milestones are aligned with current practice recommendations. Therefore, this scoping review and structured analysis aims to identify gaps between clinical guidelines for the EM of CPP and OBGYN training milestones published by educational authorities like the Accreditation Council for Graduate Medical Education (ACGME) and the AAGL. DATA SOURCES: The literature search was performed in MEDLINE, PubMed Central, and Bookshelf on the PubMed interface from January 2018 to September 2022. Peer-reviewed publications were included if they were a systematic review of recent practice guidelines and focused on female CPP. Publications that focused on a single pelvic pain condition or focused on a specific treatment were excluded. METHODS OF STUDY SELECTION: Two reviewers extracted the data and appraised the study quality following the Critical Appraisal Skills Programme Checklist for systematic reviews. Four articles met inclusion criteria for thematic analysis. A reflexive thematic analysis via the inductive approach was performed to develop clinical themes common to all review articles and presumed important in the EM of CPP. Pelvic pain experts and Delphi methodology was used to assess validity and relevance of each theme in OBGYN training. Validated themes were used in a strengths weaknesses opportunities threats (SWOT) analysis of the ACGME and the AAGL Milestones used for training OBGYN residents and fellows. A SWOT analysis is an organizational tool used to analyze processes in terms of strengths, weaknesses, opportunities for improvement, and threats to implementing a potential change. TABULATION, INTEGRATION, AND RESULTS: Twelve clinical themes were conceptualized and achieved ≥ 90% consensus as being important in the EM of CPP. Clinical themes pertained to pathophysiology, biopsychosocial approach, trauma-informed care, history and physical examination, diagnostic testing, multimodal/multidisciplinary management, pain education, and medical and surgical management. SWOT analysis showed that the ACGME Milestones lacked milestones specific to CPP, while the AAGL Milestones had 6 CPP-focused competencies with multiple milestones. Milestones on trauma-informed care and application of biopsychosocial assessment were notably absent. CONCLUSION: OBGYN educational milestones published by the ACGME and the AAGL are not yet aligned with current clinical guidelines for the EM of CPP.

Time to move beyond surgical classification systems for endometriosis.

Endometriosis is a common condition associated with chronic pelvic pain and infertility. Its pathogenesis is poorly understood, diagnosis relies on laparoscopy, and staging is based on extent of disease. Unfortunately, the current staging systems do not correlate well with pain severity and impact, nor do they predict prognosis, i.e., treatment success and recurrence of disease. In this article, we discuss the strengths and limitations of current staging systems and propose modifications that will enable better classification systems to be developed in the future.

Transvaginal Photobiomodulation Improves Pain in Women with Pelvic Muscle Tenderness and Interstitial Cystitis/Bladder Pain Syndrome: A Preliminary Observational Study.

PURPOSE: Interstitial Cystitis/ Bladder Pain Syndrome (IC/BPS) is characterized by pelvic/bladder pain, associated with pelvic muscle tenderness, urgency, frequency, and dysuria. Prior studies show that transvaginal photobiomodulation (TV-PBM) reduces pain in women with chronic pelvic pain (CPP). Our objective was to obtain preliminary data on treatment effect and adherence, in women with IC/BPS who selected TV-PBM therapy for management of pelvic pain. MATERIALS AND METHODS: Before-and-after observational cohort study of women with IC/BPS who received TV-PBM in 17 US practices. Pain was measured using a 0-10 numeric rating scale (NRS). The primary outcome was a minimal clinical important difference (MCID); reduction of overall pelvic pain severity by ≥2 NRS points from baseline compared to after 8 treatments. Cohen d coefficient measured effect size (low effect size d<0.2, medium 0.20.8). RESULTS: Of 140 patients with IC/BPS who self-selected to start TV-PBM therapy, 89.3% (n=125) completed 4 treatments and 59.3% (n=83) completed 8. Improvement ≥1 NRS point was reported by 73.5% (n=61) and meaningful improvement (≥2 points) was reported by 63.9% (n=53) after 8 treatments. In this group, patients with severe / moderate pain decreased from 83.1% (n=44) to 38.5% (n=20); p<0.001. Pain levels decreased as follows: overall pelvic pain MCID=-2.7, d=1.07, pain with urination MCID=-2.6, d=1.0; pain with exercise MCID=-2.6, d=0.91, pain with intercourse MCID=-2.5, d=0.82. CONCLUSION: In real-world clinical settings, 2/3 women with IC/BPS who opted to undergo TV-PBM therapy reported significant decrease in pelvic pain and dysuria. These findings are promising; however, controlled studies are needed.

Vaginal laser therapy for gynecologic conditions: re-examining the controversy and where do we go from here.

Despite significant controversy, vaginal laser therapy continues to be used for treatment of many gynecologic and pelvic conditions including vaginal atrophy, vaginal dryness, dyspareunia, urinary incontinence and pelvic pain. This commentary reviews the controversy surrounding vaginal laser therapy and summarizes the important distinction between ablative and non-ablative vaginal lasers. While much research is still needed, the article describes what is important for healthcare professionals to know before making the decision to integrate this technology into their clinical practice.

Transvaginal Photobiomodulation for the Treatment of Chronic Pelvic Pain: A Pilot Study.

Background: Chronic pelvic pain (CPP) is a common and debilitating condition that affects millions of U.S. women. Most treatments are ineffective and innovative new therapies are desperately needed. Large, controlled studies show that photobiomodulation (PBM) can reduce pain in patients with other chronic pain conditions, such as low back pain, neck pain, and fibromyalgia. The objective of this pilot study was to determine if transvaginal PBM (TV-PBM) can reduce pain in women with CPP. Methods: We conducted a before and after, observational, pilot study. Patients completed the Short Form-McGill Pain Questionnaire (SF-MPQ) at baseline, 1 week, 3 months, and 6 months after nine treatments of TV-PBM. Clinicians completed the Clinical Global Impression Scale (CGI) assessing patient illness severity at the same time. Wilcoxon rank-sum t-tests and effect size using Cohen's d coefficient (low effect size if d < 0.2, medium if 0.2 < d > 8, and high if d > 0.8) was used to measure degree of pain improvement, which was also considered clinically significant if pain reduction was >30%. Results: Thirteen women completed 9 treatments, and 10 women were successfully followed to 6 months. At baseline, the mean SF-MPQ score was 19.7 (standard deviation [SD] ± 5.9). Compared with baseline, 60% improved; the mean SF-MPQ score decreased to 10.0 (SD ±7.5, p = 0.004, d = 1.6) at 1 week after treatment, to 9.7 (SD ±7.9, p = 0.005, d = 1.7) at 3 months, and 8.2 (SD ±8.1, p = 0.002, d = 1.9) at 6 months. Conclusion: Transvaginal PBM provided significant and sustained pain relief to women with CPP up to 6 months. Further controlled studies are needed to confirm these findings, however, in this initial pilot, TV-PBM shows promise.

An observational cohort study of pelvic floor photobiomodulation for treatment of chronic pelvic pain.

Aim: This research is the first to evaluate the effectiveness of trans-vaginal photobiomodulation therapy (TV-PBMT) for chronic pelvic pain. Materials & methods: Observational analysis of 128 women, undergoing TV-PBMT for chronic pelvic pain. Minimal clinically important difference, defined as ≥2-point drop on a 0-10 numeric pain rating scale (NPRS), and effect size Cohen d coefficient, was calculated over nine treatments for overall pain, and pain with activities. Results: Compared with baseline, 64.5% of women showed improvement in overall pain, pain with bowel movement, intercourse, exercise, urination, sitting and vulvar pain (minimal clinically important difference = -2.4, -2.0, -2.4, -2.1, -2.1, -2.0, -3.1; d = 0.9, 0.7, 0.9, 0.7, 0.7, 0.7, 0.9) by treatment 9. Conclusion: In this cohort, TV-PBMT resulted in improvement of pelvic pain without serious adverse events.

Lay abstract Low-level laser is a therapy that can help pain, but this type of treatment has not been available to women with chronic pelvic pain because traditional laser devices cannot access the pelvic structures. In this research we studied a novel low-laser device that can be used in the vagina, to treat pain arising from pelvic organs and muscles. Our preliminary research shows that this approach significantly reduced pelvic pain, and pain with activities such as exercise, urination, bowel movements and intercourse, in two-thirds of women who completed the therapy.

Chronic Pelvic Pain in Women: A Review.

IMPORTANCE: Chronic pelvic pain (CPP) is a challenging condition that affects an estimated 26% of the world's female population. Chronic pelvic pain accounts for 40% of laparoscopies and 12% of hysterectomies in the US annually even though the origin of CPP is not gynecologic in 80% of patients. Both patients and clinicians are often frustrated by a perceived lack of treatments. This review summarizes the evaluation and management of CPP using recommendations from consensus guidelines to facilitate clinical evaluation, treatment, improved care, and more positive patient-clinician interactions. OBSERVATIONS: Chronic pelvic pain conditions often overlap with nonpelvic pain disorders (eg, fibromyalgia, migraines) and nonpain comorbidities (eg, sleep, mood, cognitive impairment) to contribute to pain severity and disability. Musculoskeletal pain and dysfunction are found in 50% to 90% of patients with CPP. Traumatic experiences and distress have important roles in pain modulation. Complete assessment of the biopsychosocial factors that contribute to CPP requires obtaining a thorough history, educating the patient about pain mechanisms, and extending visit times. Training in trauma-informed care and pelvic musculoskeletal examination are essential to reduce patient anxiety associated with the examination and to avoid missing the origin of myofascial pain. Recommended treatments are usually multimodal and require an interdisciplinary team of clinicians. A single-organ pathological examination should be avoided. Patient involvement, shared decision-making, functional goal setting, and a discussion of expectations for long-term care are important parts of the evaluation process. CONCLUSIONS AND RELEVANCE: Chronic pelvic pain is like other chronic pain syndromes in that biopsychosocial factors interact to contribute and influence pain. To manage this type of pain, clinicians must consider centrally mediated pain factors as well as pelvic and nonpelvic visceral and somatic structures that can generate or contribute to pain.

Paracervical Block or Uterosacral Ligament Infiltration for Benign Minimally Invasive Hysterectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of this study was to estimate the efficacy of preemptive paracervical block or uterosacral ligament infiltration in reducing postoperative pain and opioid consumption after benign minimally invasive hysterectomy. DATA SOURCES: We searched MEDLINE, Cochrane Library, Embase, ClinicalTrials.gov, and Google Scholar from inception until February 2020. METHODS OF STUDY SELECTION: We identified randomized placebo-controlled trials assessing the primary outcome of pain and opioid consumption after paracervical block or uterosacral infiltration in benign laparoscopic, vaginal, or robotic hysterectomy. Two investigators evaluated studies for risk of bias and quality of evidence. TABULATION, INTEGRATION, AND RESULTS: We reviewed 219 abstracts; 6 studies met the inclusion criteria: 3 using paracervical block (2 vaginal and 1 laparoscopic) and 3 using uterosacral ligament infiltration (all vaginal). Two studies were included in the meta-analysis (both vaginal hysterectomy). Because of lack of numerical data, or comparison, the other 4 studies are reported in narrative form. Three controlled trials reported a moderate benefit from paracervical block up to 8 hours after vaginal and 4 hours after laparoscopic surgery. Meta-analysis could not be performed because of the lack of numerical data for pooling results or the lack of a laparoscopic hysterectomy comparison group. Three trials reported that uterosacral infiltration decreases pain up to 6 hours after vaginal hysterectomy, and meta-analysis pooling the results of 2 of these studies demonstrated improvement in pain up to 4 hours on a 0- to 100-mm visual analog scale for pain (-19.97 mm; 95% confidence interval, -29.02 to -10.91; P < 0.000). Five trials reported a moderate reduction in cumulative opioid use within 24 hours after vaginal surgery for both paracervical block and uterosacral infiltration. Meta-analysis was not performed for paracervical block because only 1 trial provided suitable data for pooling. Meta-analysis pooling the results of 2 trials of uterosacral infiltration demonstrated opioid consumption of 20.73 morphine milligram equivalents less compared with controls (95% confidence interval, -23.54 to -17.91; P < 0.000). CONCLUSIONS: There were a total of 6 randomized placebo-controlled studies evaluated in this study. Although a meta-analysis was unable to be performed for all studies because of lack of comparison groups or numerical data, there is evidence that preemptive uterosacral ligament infiltration may reduce postoperative pain and opioid consumption after vaginal hysterectomy. Our study does not allow us to make any substantive conclusions on the use of paracervical block in vaginal hysterectomy or the use of either type of injection in laparoscopic or robotic hysterectomy.

Predictors of Mucosal and Muscle Pain in Vulvodynia: A Cross-Sectional Analysis From the National Vulvodynia Registry.

Diagnostic criteria for provoked vestibulodynia (PVD) rely on mucosal pain in the vulvar vestibule, with less emphasis on pain from pelvic floor muscles. It is unknown how psychosocial variables associated with PVD are differentially associated with mucosal versus muscle pain. Analysis of data from the National Vulvodynia Registry (n = 202) revealed several factors associated with increased mucosal pain: pain duration (P = .043), the McGill sensory subscore (P = .0086) and the Gracely pain scale (P< .001). Increased mucosal pain was also associated with decreased arousal (P = .036). On the other hand, factors significantly associated with greater muscle pain included number of comorbid pain conditions (P = .001), decreased intercourse frequency post PVD onset (P = .02) and higher scores on the McGill sensory (P = .0001) and affective (P = .0002) subscores, the Gracely pain scale (P = .0012), and state anxiety (P < .001). Sexual function was also significantly impacted by high pelvic floor muscular pain, with lower scores for arousal (P = .046), orgasm (P = .0014) and satisfaction (P = .013), and higher pain (P = .01). Significant differences in the relationship between muscle and mucosal pain for pain duration (P = .005), McGill affective score (P = .001), orgasm (P = .049), change in intercourse frequency (P = .027), and state anxiety (P = .030) suggest the possibility of mucosal or muscle pain predominant PVD subtypes. PERSPECTIVE: Patients with higher pelvic floor muscle pain scores than mucosal pain scores may represent different subgroups or characteristics of patients with provoked vestibulodynia. This research highlights the importance of assessment of the pelvic floor muscles in addition to the cotton swab test of the vestibule.

Impact of pain and nonpain co-morbidities on opioid use in women with endometriosis.

Aim: To evaluate impact of co-morbidities on opioid use in endometriosis. Patients & methods: This was a retrospective analysis of data obtained from the Symphony Health database (July 2015-June 2018), which contains medical and pharmacy claims information on 79,947 women with endometriosis. Relative risk (RR) of postdiagnosis opioid use and supply duration associated with baseline co-morbidities were determined. Results: Women with endometriosis using opioids at baseline were 61% more likely to receive opioids postdiagnosis (RR: 1.61; 95% CI: 1.59-1.63). Risk of prolonged opioid supply postdiagnosis was highest for those with prolonged supply at baseline (RR: 21.14; 20.14-22.19), and was 1.32 (1.26-1.38) for patients with ≥1 co-morbidity, 1.37 (1.31-1.43) for pain co-morbidities and 1.07 (1.04-1.11) for psychiatric co-morbidities. Conclusion: Risk of opioid use after endometriosis diagnosis was greater in patients who used opioids before diagnosis. Risk of prolonged opioid use was greater if co-morbidities existed before diagnosis.

Opioid Prescription Usage after Benign Gynecologic Surgery: A Prospective Cohort Study.

STUDY OBJECTIVE: To compare the amount of opioids (tablets and morphine milligram equivalents [MMEs]) prescribed by physicians and used by patients after benign gynecologic surgery. DESIGN: Prospective cohort study. SETTING: Tertiary center: main hospital operating room and outpatient surgery center. PATIENTS: Women undergoing benign gynecologic surgery. INTERVENTIONS: Major and minor gynecologic surgeries. MEASUREMENTS AND MAIN RESULTS: The surgery groups were minor laparoscopy (Minor), major minimally invasive (Major), and laparotomy (Laparotomy). Demographic, medical, and surgical data were abstracted from electronic medical records. On postoperative day (POD) 7, women completed a telephone survey describing pain levels, prescription use, and satisfaction with pain control. Patients who continued to use opioids for pain relief were surveyed on POD 14. If use continued, patients were surveyed again on POD 28. The primary outcome was amount of opioid prescribed compared with opioid used. Of 193 screened participants 172 were enrolled (89%), and data were analyzed for 154 (90%): 59 (38%) Major, 71 (56%) Minor, and 24 (16%) Laparotomy. The median number of tablets and MMEs prescribed was lowest for the Minor group (Minor, 24 tablets; Major, 30 tablets; Laparotomy, 30 tablets [p <.01]; Minor, 150 MMEs; Major, 225 MMEs; Laparotomy, 225 MMEs [p = .01]). We found no difference in the number of tablets (Minor, 8; Major, 8; Laparotomy, 9; p = .77) or MMEs used (Minor, 45 MMEs; Major, 45 MMEs; Laparotomy, 55 MME; p = .81) between the groups. On POD 7 there was no difference in median numerical rating scale pain scores (Minor, 3; Major, 2; Laparotomy, 2; p = .07) or satisfaction with analgesia on POD 7 (p = .44), 14 (p = .87), and 28 (p = .18). Patients with prior chronic pain used more total amounts of opioids (68 MME vs 30 MME, p <.01) and were more likely to require opioid refill (odds ratio, 10.4; 95% confidence interval, 1.3-83.6) compared with those without a similar history. CONCLUSION: In this cohort, gynecologic surgeons prescribed nearly 3 times more opioid tablets and MMEs than was used by patients despite patients reporting similar levels of pain after minor and major surgeries.

Patterns of Prescription Opioid Use in Women With Endometriosis: Evaluating Prolonged Use, Daily Dose, and Concomitant Use With Benzodiazepines.

OBJECTIVE: To examine opioid use, opioid prescribing patterns, and timing of the first opioid prescription in endometriosis patients compared with matched women in the control group without endometriosis. METHODS: We conducted a retrospective analysis of the Clinformatics Datamart database. Women diagnosed with endometriosis from January 2006 through December 2016 and aged 18-49 years were compared with women in the control group matched on age, region, race, insurance payer, and plan type. Key outcomes included: filled prescription for an opioid, multiple opioid prescriptions, number of days' supply, daily dose (morphine milligram equivalents), and concomitant opioid and benzodiazepine prescriptions. Cohorts were descriptively analyzed using t- and χ statistics and multivariable regression analyses yielded adjusted relative risk (RR) ratios and 95% CI. RESULTS: The study sample included 53,847 endometriosis patients and 107,694 patients in the control group. The mean age was 38 years, 62.4% of patients were white, and 51.6% lived in the South. Women in the endometriosis case group, compared with women in the control group, were more likely to fill an opioid prescription (42,705 [79.3%] women in the case group vs 26,106 [24.2%] women in the control group; adjusted RR ratio 2.91; 2.87-2.94), had higher likelihood of filling prescriptions with a dose of 50 morphine milligram equivalents or more (24,544 [45.6%] vs 10,463 [9.7%]; adjusted RR ratio 4.07; 3.98-4.16) or 100 morphine milligram equivalents or more (8,013 [14.9%] vs 3,582 [3.3%]; adjusted RR ratio 3.56; 3.43-3.70). Women in the case group were more likely to have concomitant opioid and benzodiazepine prescriptions (5,453 [10.1%] vs 3,711 [3.5%]; adjusted RR ratio 1.95; 1.88-2.03) and to have used these drugs concurrently for at least 30 days (1,596 [3.0%] vs 1,265 [1.2%]; adjusted RR ratio 1.43; 1.34-1.52) or at least 90 days (875 [1.6%] vs 777 [0.7%]; adjusted RR ratio 1.27; 1.17-1.37). Similar results were obtained after excluding opioid prescriptions received during a 30-day postsurgery window. CONCLUSION: Women with endometriosis had higher probabilities of prolonged use of opioids and concomitant use with benzodiazepines compared with women without this condition. FUNDING SOURCE: This study was funded by AbbVie, Inc.

Continuous vs. cyclic combined hormonal contraceptives for treatment of dysmenorrhea: a systematic review.

OBJECTIVE: This systematic review aims to evaluate the benefits of oral continuous combined hormonal contraceptives (CHCs) in managing dysmenorrhea by comparing randomized controlled trials (RCTs) evaluating the efficacy of continuous vs. cyclic CHC use for the following outcomes: (a) reducing dysmenorrhea duration and frequency, (b) severity, (c) recurrence and (d) interference with daily activity. STUDY DESIGN: Cochrane, PUBMED and Popline databases were searched from 1934 to 2018 for all relevant studies evaluating CHC for treatment of dysmenorrhea. A study was selected if it (a) compared continuous regimen vs. cyclic regimen of oral CHC, (b) measured dysmenorrhea as a primary or secondary outcome, (c) was an RCT and (d) was published in English. Due to differences in CHC used and outcome measurement, a systematic analysis of individual study results and a limited meta-analysis were conducted. RESULTS: Of 780 studies that were screened by title and abstract, 8 were included in the final analysis; 6 evaluated cyclic vs. continuous CHC, and 2 evaluated cyclic vs. extended/flexible CHC use. Quality of evidence was low for all outcome measures. Overall, compared to cyclic use, flexible/extended CHC resulted in 4 fewer days of dysmenorrhea. Studies revealed conflicting results for interference with daily activity, pain severity and pain recurrence. Side effects were few in both comparison groups. CONCLUSIONS: Continuous or extended/flexible CHC use may reduce dysmenorrhea duration compared to cyclic regimen; however, more rigorous research is needed. IMPLICATIONS: This systematic review shows that continuous CHC use may reduce dysmenorrhea duration compared to cyclic regimen, although the quality of evidence is low. Future double-blinded RCTs with more rigorous study design, consistent outcome measures and comprehensive outcome reporting are needed.

Musculoskeletal Considerations in Female Patients with Chronic Pelvic Pain.

Persistent pelvic pain conditions are common and affect nearly 25% of the female U.S. population. In a sizable proportion of pelvic pain patients, the pain is caused by musculoskeletal dysfunction; yet, healthcare providers do not routinely evaluate patients for musculoskeletal etiologies. This article provides an overview of the pathophysiology of persistent pelvic pain, as it relates to musculoskeletal disorders. The symptomatology, anatomy, evaluation, and treatment of these disorders are summarized specifically for healthcare providers (including gynecologists) who do not have pelvic musculoskeletal expertise.

Evaluation and Treatment of Female Sexual Pain: A Clinical Review.

Dyspareunia and vulvodynia are genital pain disorders that have devastating effects on women's quality of life. These disorders occur with high prevalence and place a significant financial burden on women and the health care system. Many women do not report genital pain, and most providers do not inquire about this type of pain. As a result, women also experience social isolation. Numerous treatments are thought to improve quality of life and decrease pain; however, more studies are needed. This review aims to provide an overview of clinical evaluation methods and to summarize treatment options for women suffering from dyspareunia and vulvodynia.