This chapter focuses on three common female pelvic symptoms: CPP, vulvodynia and dyspareunia. Although we categorise presentations as ‘organic’ or ‘functional’ it is important to recognise that these overlap: many women will have both organic pathology and functional symptoms.

CPP is defined as an intermittent or constant pain in the lower abdomen or pelvis of at least 6 months’ duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy, that causes functional disability or limits daily activities

Epidemiology in primary care

CPP affects 38 per 1000 women in general practice in the UK, which makes it as common as asthma or back pain. Patients with CPP make up approximately 20% of outpatient appointments in gynaecology clinics and cost the UK National Health Service (NHS) an estimated £158 million a year.

CPP can be associated with gynaecological conditions, such as endometriosis, and non-gynaecological conditions such as IBS, interstitial cystitis/bladder pain syndrome, musculoskeletal pain and fibromyalgia In more than 50% of patients, no cause for the painful symptoms can be found.

A history of abuse (physical, sexual and/or psychological) is more common in women with CPP.

GP assessment

The aim of GP assessment in women with CPP is to exclude pathological causes of CPP and to recognise patients with functional CPP. This can usually be achieved by taking a history and performing an examination so that only selected patients are referred to secondary care.

Typical features of organic symptoms

Endometriosis is found in 35–50% women with CPP. Cyclical pelvic pain (often associated with dysmenorrhoea and dyspareunia) in women of reproductive age is the most common symptom associated with the condition and merits referral to secondary care for investigation (see Box 10.1). The gold standard for diagnosing endometriosis is laparoscopy; there are no serum or urinary biomarkers of endometriosis. However, treatment of endometriosis, using drugs that cause ovarian suppression (e.g. combined oral contraceptive pill, progestogens, gonadotrophin-releasing hormone agonists), may be started prior to laparoscopy. If these drugs successfully alleviate symptoms, a laparoscopy is not always necessary.

Adenomyosis is characterised by the same symptoms as endometriosis. It is more often diagnosed histologically following a hysterectomy but can be diagnosed by pelvic MRI. Adhesions due to previous surgery, pelvic infection or endometriosis are also associated with CPP but there is little evidence that division of adhesions reduces pelvic pain symptoms. Pelvic congestion syndrome is the association of pelvic varicosities seen on MRI with pelvic pain. Ovarian suppression has been shown to be helpful.

Typical features of functional symptoms

Patients may use emotive language or employ dramatic metaphors when describing their symptoms (e.g. ‘I feel as if I am being stabbed by a red-hot poker’).

There may be inconsistencies in the presentation or history (e.g. the patient walks to the consulting room with normal gait and no apparent discomfort yet flinches with severe pain on superficial abdominal palpation). Such inconsistencies should not be interpreted as evidence of deception, they may reflect (subconscious) variations in the extent to which the patient is attending to the pain.

Patients with functional pelvic pain often present with other medically unexplained symptoms (MUS) and are often in contact with other hospital specialties (e.g. gastroenterology for IBS, rheumatology for fibromyalgia etc).

It is important to recognise that the presence of organic pathology does not exclude functional symptoms, indeed CPP is commonly preceded by physical disease. Although a history of abuse is a risk factor for CPP it is unlikely in a generalist consultation that you will identify this.

History and examination tips

The consultation process itself can be therapeutic. So in a consultation (or over a series of consultations) with a woman with CPP you should encourage the patient to describe her symptoms and the impact they have on her, including avoidance (work, recreation, sex) and allow her to express her worries (e.g. about cancer or infertility) and concerns. Where appropriate, enquire about a history of sexual and physical assault.

Abdominal palpation and internal pelvic examination should be performed—failure to perform an examination may be interpreted as evidence that you are not taking the symptoms seriously.

Investigation and referral

Endometriosis and pelvic adhesions can only be diagnosed by direct visualisation. Referral for a laparoscopy should therefore be considered in patients in whom there is a high suspicion of these conditions or concern about associated infertility.

If the history is suggestive of underlying pathology (see Box 10.1) or any abnormalities are found during examination, the woman should be referred for specialist assessment.

Explanations of functional CPP

Give the diagnosis as a positive statement, not as an expression of negative findings (e.g. ‘You have chronic pelvic pain, this is a common condition, although we do not fully understand it’). Avoid terms such as ‘psychological’ or ‘underlying depression’ as a mechanism for pain. If patients persist in wanting a cause, consider using analogy. For example, most people will have experienced headache in their life and usually there will be no pathological explanation of this problem. Some patients may pick up on associations of headache and stress and extend this to pelvic pain inviting further discussion of psychosocial factors.

You might include the increased attention to symptoms that occurs when one is concerned or does not know what is going on. Consider framing the pain as ‘safe but a nuisance’ rather than a sign of danger. In terms of management, explain that although there is no specific treatment, you can work to reduce the symptoms and help the patient return to normal activities.