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Research Review - Final – Jan. 31, 2012
Noncyclic Chronic Pelvic Pain Therapies for Women: Comparative Effectiveness
Partly out of date: This report was assessed in October 2015 and some conclusions may not be current.
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The Vanderbilt Evidence-based Practice Center systematically reviewed evidence on therapies for women age 18 and over with noncyclic chronic pelvic pain (CPP). We focused on the prevalence of conditions thought to occur commonly with CPP; changes in pain, functional status, quality of life, and patient satisfaction resulting from surgical and nonsurgical treatment approaches; harms of nonsurgical approaches; evidence for differences in surgical outcomes if an etiology for CPP is identified postsurgery; and evidence for selecting one intervention over another after an approach fails.
We searched MEDLINE® via PubMed, PsycInfo®, EMBASE Drugs and Pharmacology, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases as well as the reference lists of included studies.
We included studies published in English from January 1990 to May 2011. We excluded intervention studies with fewer than 50 adult women with CPP; cross-sectional studies or case series with fewer than 100 women with CPP addressing the prevalence of comorbidities; and studies lacking relevance to CPP treatment.
Of 36 included studies, 18 were randomized controlled trials (RCTs) (2 good, 3 fair, and 13 poor quality); 3 were cohort studies (3 poor quality); and 15 were cross-sectional studies addressing the prevalence of comorbidities (quality varied by comorbidity). The most frequently reported comorbidities were dysmenorrhea, dyspareunia, and irritable bowel syndrome (IBS). Among studies addressing surgical interventions, there was no evidence that laparoscopic uterosacral nerve ablation (LUNA) is more effective than simple diagnostic laparoscopy and no evidence of benefit of lysis of adhesions. Evidence was insufficient to comment on relief of pain after hysterectomy. Nine studies of nonsurgical approaches assessed hormonal therapies for endometriosis-associated CPP and reported similar effectiveness among active agents. One exception was an RCT comparing raloxifene with placebo, which reported more rapid return of pain in the raloxifene group. Few studies assessed nonhormonal medical or nonpharmacologic management; benefits were reported in single studies of a pelvic physiotherapy approach, botulinum toxin, pelvic ultrasonography, and an integrated management approach. No studies provided evidence relating to a trajectory of care. Reporting of harms data was very limited.
Improved characterization of the targeted condition, intervention, and population in CPP research is necessary to inform treatment choices for this commonly reported entity. A uniform definition of CPP and standardized evaluation of participants are lacking across the literature. Study populations likely vary widely, and studies may be reporting effects from treating symptoms rather than a diagnosed condition. Thus our understanding of potential treatment effects is diluted. Similarly, understanding comorbidity prevalence with CPP is difficult, as conditions may be considered part of the differential diagnosis or a concomitant condition. Among studies addressing treatment effects, little evidence demonstrates the effectiveness of surgical approaches. Studies of nonsurgical approaches typically addressed hormonal management of endometriosis-related CPP and were not placebo controlled, thus limiting our ability to understand whether hormonal therapies would be beneficial for women with CPP without endometriosis and whether pain relief is due simply to the placebo effect. Some studies reported benefits of other nonsurgical approaches, but nonhormonal and nonpharmacologic management remain understudied.