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Chronic Pelvic Pain in Women: Evaluation and Treatment

Erica S. Meisenheimer, MD, MBA
Ann M. Carnevale, MD, MS

American Family Physician. 2025;111(3):218-229.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Chronic pelvic pain affects up to 26% of individuals with female anatomy and is defined as at least 6 months of pain that is perceived to originate in the pelvis. Chronic pelvic pain is highly correlated with psychosocial comorbidities, including depression, anxiety, and history of abuse. Although common causes include irritable bowel syndrome, bladder pain syndrome (interstitial cystitis), pelvic floor dysfunction, and endometriosis, chronic pelvic pain is most often the result of multiple coexisting pain conditions and central nervous system hypersensitivity. Evaluation requires a biopsychosocial approach, beginning with a complete history and physical examination to ensure an accurate and timely diagnosis. Diagnostic laboratory and imaging tests are of limited utility and should be tailored to investigate presenting symptoms and examination findings. When a single etiology is identified, treatment should follow disease-specific guidelines; otherwise, the management of undifferentiated chronic pelvic pain should follow an interdisciplinary approach to improve function and quality of life. Multimodal treatment includes pain education, self-care, behavioral therapy, physical therapy, and pharmacotherapy, with limited indications for surgical interventions. Regular follow-up to review progress is necessary. Clinicians should have a low threshold for referral to interdisciplinary pain management or other subspecialties when improvement is not seen.

Chronic pelvic pain (CPP) in individuals with female anatomy is defined as at least 6 months of pain that is perceived to originate in the pelvis. Previously, the condition included only noncyclic pain, but the current definition also includes cyclic pain when symptoms have cognitive, behavioral, sexual, or emotional effects.1 CPP has been shown to lead to decreased productivity, poor emotional well-being, and sexual and relationship dysfunction, making early recognition and prompt evaluation and treatment essential to maintain or restore quality of life.2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments
A detailed history and focused abdominal, musculoskeletal, and pelvic examination should be performed in all patients with chronic pelvic pain. History should assess for common comorbidities, including behavioral health disorders and other chronic pain conditions.1,6,8,11 CConsensus guidelines and expert opinion
In the absence of a clear etiology, chronic pelvic pain requires a biopsychosocial approach with a multimodal, interdisciplinary treatment plan.1,6,8 CConsensus guidelines and expert opinion
Patient education and cognitive behavior therapy with or without sex therapy can improve coping strategies and quality of life in patients with chronic pelvic pain.1,6,8,19–21 CConsensus guidelines and expert opinion
Pelvic floor physical therapy can improve pain, function, and mood, particularly for patients with myofascial or psychosocial elements to their chronic pelvic pain.1,22–25 BConsistent evidence of limited quantity and quality
Nonsteroidal anti-inflammatory drugs and gabapentin can be considered in the treatment of chronic pelvic pain.33–38,44 BInconsistent evidence from low- to moderate-quality studies on other pain conditions
Serotonin-norepinephrine reuptake inhibitors, such as duloxetine, and tricyclic antidepressants can be used to treat chronic pelvic pain.1,8,39–42 BModerate-quality evidence from studies on neuropathic and other types of pain

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

ERICA S. MEISENHEIMER, MD, MBA, is a faculty physician at the National Capital Consortium Family Medicine Residency at Alexander T. Augusta Military Medical Center, Fort Belvoir, Virginia, and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Maryland.

ANN M. CARNEVALE, MD, MS, is the chief resident at the National Capital Consortium Family Medicine Residency at Alexander T. Augusta Military Medical Center.

Address correspondence to Erica S. Meisenheimer, MD, MBA, at erica.sturtevant@gmail.com.

Author disclosure: No relevant financial relationships.

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