Original Research
Gynecology
Multifactorial contributors to the severity of chronic pelvic pain in women

Given as an oral presentation at XXI International Federation of Gynecology and Obstetrics World Congress of Gynecology and Obstetrics, Vancouver, British Columbia, Canada, Oct. 4-9, 2015.
https://doi.org/10.1016/j.ajog.2016.07.023Get rights and content

Background

Chronic pelvic pain affects ∼15% of women, and is associated with significant societal cost and impact on women’s health. Identifying factors involved in chronic pelvic pain is challenging due to its multifactorial nature and confounding between potential factors. For example, while some women with endometriosis have chronic pelvic pain, there may be comorbid conditions that are implicated in the chronic pelvic pain rather than the endometriosis itself.

Objective

We sought to explore multifactorial variables independently associated with the severity of chronic pelvic pain in women.

Study Design

We used baseline cross-sectional data from an ongoing prospective cohort, collected from patient online questionnaires, physical examination, and physician review of medical records. Participants were recruited from a tertiary referral center for endometriosis and chronic pelvic pain in Vancouver, British Columbia, Canada, from December 2013 through April 2015. Exclusion criteria included menopausal status or age >50 years. Primary outcome was self-reported severity of chronic pelvic pain in the last 3 months (0-10 numeric rating scale). Potential associated factors ranged from known pain conditions assessed by standard diagnostic criteria, validated psychological questionnaires, musculoskeletal physical exam findings, as well as pain-related, reproductive, medical/surgical, familial, demographic, and behavioral characteristics. Mann-Whitney, Kruskal-Wallis, or Spearman test were used to identify variables with an association with the primary outcome (P < .05), followed by multivariable linear regression to control for confounding and to identify independent associations with the primary outcome (P < .05).

Results

Overall, 656 women were included (87% consent rate), of whom 55% were diagnosed with endometriosis. The following factors were independently associated with higher severity of chronic pelvic pain: abdominal wall pain (P = .005), pelvic floor tenderness (P = .004), painful bladder syndrome (P = .019), higher score on Pain Catastrophizing Scale (P < .001), adult sexual assault (P = .043), higher body mass index (P = .023), current smoking (P = .049), and family history of chronic pain (P = .038). Severity of chronic pelvic pain was similar between women with and without endometriosis.

Conclusion

Multifactorial variables independently associated with severity of chronic pelvic pain were identified, ranging from myofascial/musculoskeletal, urological, family history, and psycho-social factors. Continued research is required to validate these factors and to determine whether any are potentially modifiable for the management of chronic pelvic pain.

Introduction

Chronic pelvic pain is defined as continuous or intermittent pain in the lower abdomen or pelvis lasting for at least 3-6 months, which is differentiated from dysmenorrhea and pain during sexual intercourse.1, 2 Chronic pelvic pain affects nearly 15% of women of reproductive age worldwide.2 There are significant costs of chronic pelvic pain due to physician visits, medication use, surgical interventions, emergency visits, and hospital admissions; outpatient management alone accounts for an estimated $881.5 million in annual costs based on data from 1994 in the United States.3

A systematic review4 reported the association of noncyclical chronic pelvic pain with a variety of gynecologic, medical, and psycho-social factors. However, this review was limited by the absence of physical examination findings, since musculoskeletal contributors to chronic pelvic pain can only be assessed by clinician examination. As well, individual factors could not be assessed simultaneously to account for confounding and discern independent associations. For example, there has been greater recognition of the role of central sensitization in chronic pelvic pain, which conceptually refers to an increased sensitivity and amplification of nociceptive signaling in the central nervous system,5, 6, 7 and which could underlie a range of different conditions associated with chronic pelvic pain.

In December 2013, we initiated an ongoing prospective research cohort of women at a tertiary referral center for endometriosis and chronic pelvic pain. This cohort is highly phenotyped utilizing a multifactorial approach, to provide a simultaneous assessment of different factors potentially involved in chronic pelvic pain. The goal of the cohort is to identify factors that have an independent association with chronic pelvic pain at baseline and over the next 5 years.

In this exploratory study, we analyzed the baseline cross-sectional data from this prospective cohort to identify multifactorial variables associated with severity of chronic pelvic pain.

Section snippets

Study setting

This study involves analysis of cross-sectional baseline data from an ongoing prospective cohort of women at the Center for Pelvic Pain and Endometriosis at the BC Women’s Hospital and Health Center, a tertiary referral center for the province of British Columbia, Canada.8 After informed consent, participants in the prospective cohort were recruited from women newly referred or re-referred to the center who had a full assessment, defined as a complete history and examination, from December 2013

Results

A total of 656 women met the study criteria, with an 87% consent rate (Figure). Demographic characteristics are summarized in Table 2.

The following factors were significantly associated with increased severity of chronic pelvic pain (P < .05) (Tables 3 and 4): higher BMI, abdominal wall pain, pelvic floor tenderness, greater depression symptoms (PHQ-9), greater anxiety symptoms (GAD-7), higher PCS score, painful bladder syndrome, irritable bowel syndrome, physician impression of adhesions,

Comment

In this exploratory study of baseline cross-sectional data from an ongoing prospective cohort of women at a tertiary-level referral center, independent multifactorial variables associated with severity of chronic pelvic pain were identified. Our study is in agreement with studies showing a relationship between chronic pelvic pain and painful bladder syndrome,20 pain catastrophizing,21 and adult sexual assault.4 We also confirmed an association with myofascial/musculoskeletal conditions,5 such

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    This work was supported by a Canadian Institutes of Health Research Operating Grant Priority Announcement (Reproductive and Child Health Start-up Grant) from the Institute of Human Development, Child and Youth Health (IHD-137431) to Dr Yong, and by a Vancouver Coastal Health Research Institute Investigator Award from the Vancouver General Hospital and University of British Columbia Hospital Foundation to Dr Yong.

    This study was also supported by the Women's Health Research Institute and the British Columbia Women's Hospital Foundation.

    The authors report no conflict of interest.

    Cite this article as: Yosef A, Allaire C, Williams C, et al. Multifactorial contributors to the severity of chronic pelvic pain in women. Am J Obstet Gynecol 2016;215:760.e1-14.

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