The American College of Obstetricians and Gynecologists Practice Bulletin

The American Col[ege of Obstetricians and Gynecologists WOMEN'S HFALTH CARE PHYSICIANS ACOG PRACTICE. BI.]LLE,TIN

NuNaarn 218

Committee on hactice Bulletins-Gyriecologr. This Practice Bulletin was developed by the American College of Obstefficians and Gynecologists' Committee on Practice Bulletins-Gynecology in collaboration with Lee A. Learman, MD, PhD, and Katherine W. McHugh, MD. Chronic Pelvic Pain Chronic pelvic pain is a cornmon, burdensome, and costly condition that disproportionately affects wornen. Diagnosis and initial managenrcnt of chronic pelvic pain in women are within the scope of practice of specialists in obstetrics and gynecology. The challenging complexity of chroruic pelvic pain care can be addressed by increased visit time using appropriate coding mndifiers, as well as identification of multidisciplinary team mer7bers within the practice or by .facilitated referral. This Practice Bulletin addresses the diagnosis and management of chronic pelvic pain that is not completely explained by identifiable pathology of the gynecologic, urologic, or gastrointestinal organ systerns. When evidence on chronic pelvic pain treatment is limited, recommendations hre extrapolated from treatment of other chronic pain conditions to help guide nxanagement. The evaluation and rnanagement of potential gynecologit etiologies of pelvic pairu (ie, endometriosis, adenomyosis, leiomyomas, adnexal pathology, vulvar disorders) are discussed in other publications of the American College of Obstetricians and Gyrccol.ogists (14).

from an inflammatory, infectious, or anoxic event or Background traumatic injury that resolves over time with treatment Definition and repair. When pain persists, a chronic stress pheno- A lack of consensus on the definition of chronic pelvic type may emerge and is charactenzed by a vicious cycle pain has impeded efforts to understand its prevalence and of physical and psychologic consequences. Prolonged the success of treatment alternatives (5). The American' activity restriction can lead to physical deconditioning. College of Obstetricians and Gynecologists and the Continued fear, anxiety, and distress can lead to long- ReVIT Alize data definitions initiative define chronic term deterioration in mood and social isolation. Although pelvic pain as "pain symptoms perceived to originate mood symptoms are ubiquitous in chronic pain syn- fiom pelvic organs/structures typically lasting more than dromes, criteria for major depression are met in approx- 6 months. It is often associated with negative cognitive, imately l2-33%o of womin across samples of women behavioral, sexual and emotional consequences as well living with or seeking care for chronic pelvic pain (7-9). as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor, myofascial, or gynecological Epidemiology dysfunction" (6). Cyclical pelvic pain is considered A systematic review of high-quality studies by the World a form of chronic pelvic pain if it has significant cogni- Health Organization in 2006 found the prevalence to range tive, behavioral, sexual, and emotional consequences (6). from approximately Z.lVo to 24Vo for noncyclical pain, 87o This Practice Bulletin does not address cyclic pain syn- to 2l.l%o for dyspareunia, and 16.87o to S lVo for dysmen- dromes (eg, dysmenorrhea, Mittelschmerz) but does dis- orrhea (10). An updated review published in 2014 used cuss dyspareunia as a component of chronic pelvic pain. a more stringent definition (noncyclical pain lasting at least o) Chronic pelvic pain differs from acute pelvic pain in 6 months) and found prevalence estimates that ranged from = oI lt several important ways. Acute pain typically arises 5.7Vo to 26.60/o (1 1). Familiarity with contributors to 5o (,)o N: C" N o N o e98 VOL. 135, NO. 3, MARCH 202A OBSTETRICS & CYNECOLOGY

e 2020 by the Arnerican College of Obstetricians and Cynecologists. Published by Wolters Kluwer Health, [nc. Unauthorized reptaduction of this article is prohibited. definition of this condition, and diagnostic criteria are variable (19).Further research is needed to establish Box l. Common Conditions Associated greater diagnosis and homogeneiry in With Chronic Pelvic Pain (continued) consistency in treatment studies. . Somatic symptom disorders , Somatic symptom disorder with pain features " Somatic symptom disorder with somatic characteristics Ctihicd,Considerations . Substance use disorder and,Recbmmendations Substance abuse " t , ., Substance dependence ,-i :,,;.{r,,,ta.,

presents, with chronic pelvic pain? ischernia, and inflammation. The pain is typically diffuse detailed medical history and physical examination, and poorly defined without spatial discernment because A with particular attention to the abdominal and pelvic of differing densities of visceral sensory innervation and neuromusculoskeletal examination, ffie recomrnended for scattering of input in the central nervous system. the evaluation chronic pelvic pain. Physical findings Autonomic symptoffis, including diaphoresis, vital sign of increase neuromusculoskeletal abnormalities, and gastrointestinal symptoffis, often that the likelihood of contributors chronic pelvic pain include pelvic floor accompany visceral pain and can confuse the diagnosis. to muscle tendemess and abdominal wall tenderness that Patients are often focused on the vis cera as the cause of reproduce the patient's pain. pain, and so visceral etiologies should be addressed early and often, with reassurance that these diagnoses are not Perhaps the most critical portions of the evaluation of being overlooked. chronic pelvic pain ilre a detailed medical, surgical, and Neuromusculoskeletal disorders are extremely com- gynecologic history and a thorough physical examination mon and often overlooked, which prolongs patient (20, 2L). Self-administered screening forms completed by discomfort and delays appropriate treatment. No univer- patients in advance and increased visit times wittr appropriate sal consensus exists on diagnostic criteria for neuro- coding modifiers can optimize the practice effect of chronic musculoskeletal pain, but the symptoms often can be pelvic pain care. A systematic history begins with patient- a result of myofascial trigger points or neurovascular reported information completed before the visit, a detailed entrapment that is due to surgical injury or inflammation chronology of symptoms, and a review of previous treat- of tendons or ligaments. Pain is reproducible on exam- ments. Eliciting pain aggravatorc and alleviators related to ination with palpation of the aff'ected muscle groups but sexual activity and menstmation is a good starting poinl but does not typically trigger an autonomic response. The this information needs to be supplemented with an under- pathophysiology of neuromusculoskeletal pain is poorly standing of pain and other symptoms associated with phys- understood but is likely related to repeated microtrauma, ical activity and urinary and gasffointestinal function. The acute trauma, or postural misalignment, which results in Pelvic Pain Assessment Form published by ttre International hypertonicity and a myofascial pain syndrome ( I 8). Pelvic Pain Society includes many of these assessments and Psychosocial factors play a role in all types of pain is freely available for clinical use in four languages (22). and can affect symptom severity and prognosis. Pelvic The medical history should include specific chro- pain and dyspareunia are more prevalent in women with nology, triggers, and treatments of pain as well as a history of abuse, mental illness, lack of suppotr, social a review of all medical diagnoses, surgical procedures stressors, and relationship discord. These comorbidities do and findings, obstetric details, medications, and allergies. not alter the visceral or neuromusculoskeletal pain gen- Psychosocial factors are also important and may influ- erators but may worsen the associated symptom burden ence treatment choices. The success or failure of previous and psychological effects. Treating psychosocial factors as treatment attempts also may be instructive. separate but equally important pain contributors can Focusing the physical examination on the abdominal increase the woman's awareness of her conscious and and pelvic neuromusculoskeletal system, with inclusion unconscious perception of pain and facilitate her recovery. of a visceral examination, addresses most chronic pelvic Pelvic congestion syndrome is a proposed etiology pain etiologies. Attention to underlying myofascial of chronic pelvic pain related to pelvic venous insuffi- structures in addition to the viscera is highly likely to ciency. Although venous congestion appears to be yield an accurate diagnosis (20, 2l). Evaluation should associated with chronic pelvic pain, evidence is insuffi- include palpation of the lower back, sacroiliac joints, cient to conclude that there is a cause-and-effect relation- pubic symphysis, as well as the abdomen and genitalia. ship ( 19). In addition, there is no consensus on the Focal tenderness of the abdomen or the pelvic floor can

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O 2020 by the Americarr College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. found to have treatable musculoskeletal disorders iden- chronic pelvic pain. These medications can be prescribed tified by a physician specializing in physical medicine by obstetrician-gynecol ogists. and rehabilitation (37). Antidepressant medications are most commonly prescribed, alone or with psychotherapy, for management Cognitive Behaviorol Therapy of moderate to severe depression. Antidepressant medi- Although pelvic pain may be due to an inciting event, the cations also have been evaluated in nondepressed chronicity of pain predisposes patients to depression, patients with chronic pain syndromes. Although no anxiety, and social isolation. And, depression worsens studies have established the benefit of antidepressant the quality of Iife for women with chronic pelvic pain use for improvement in chronic pelvic pain specifically, (38). Instead of attempting to determine which order is a systematic review of 37 double-blind randomized trials prjmary, or blaming one condition for causing the other, found that SNRIs and tricyclic antidepressants were both need to be treated with equal urgency. superior to placebo for improving depressive symptoms, Cognitive behavioral therapy is a goal-oriented pain, and quality of life in palients with neuropathic pain therapy and, when used in conjunction with rnedical syndromes such as fibromyalgia and diabetic neuropathy, and physical therapies, has the advantage of addressing with a number-needed-to-treat of 24 patients for one to the effects of depression and pain on relationships and experience a clinical improvement. The analgesic effec- other aspects of well-being. The evidence that supports tiveness of SNRIs and tricyclic antidepressants was not the benefit of cognitive behavioral therapy and other evaluated separately in subgroup analyses (a5). counseling approaches for the treatment of chronic pelvic Cochrane reviews of individual antidepressants show pain comes primarily from studies in which counseling is that duloxetine (an SNRI) is superior to placebo for the a component of multidisciplinary care (39,40). Srudies management of neuropathic pain from diabetic neuropathy of patients with other chronic pain syndromes show and fibromyalgra (46), whereas rials of venlafaxine (a selec- small-to-moderate benefits of cognitive behavioral ther- tive serotonin reuptake inhibitor with weak SNRI properties) apy when compared with no therapy (41). Patients learn for neuropathic pain showed sffong placebo effects and high to modulate their thoughts and manipulate their environ- potential for selection bias (47). No published tials have ment to lessen their pain perception and improve coping established the efficacy of duloxetine or venlatzudne in the skills. ffeatrnent of chronic pelvic pain in women. Emotional well-being should be assessed at every Tricyclic antidepressants (eg, amitriptyline, nortrip- visit and professional counseling should be considered tyline, and desipramine) are commonly used to treat and offered to every patient with chronic pelvic pain. It is neuropathic pain. However, there is only weak evidence critical that the patient understands that referral does not of efficacy (48-50). A 2009 double blind randomized mean that the pain is psychosomatic or any less real. controlled trial (RCT) found that gabapentin and nortrip- Instead, counseling enableS patients to obtain support in tyline worked better in combination than either drug parallel with the other ffeatments being recommended to worked in isolation for chronic neuropathic pain (51 ). address the chronic pelvic pain generators. Based upon their effectiveness for other neuropathic pain syndromes, gabapentin and pregabalin are recom- Sex Theropy mended for the treatment of neuropathic chronic pelvic pain. These medications can be prescribed by obsteffician- Although there may be a myofascial component to gynecologists. medications have a role in the genito-pelvic pain, this condition may require the addi- Neuropathic medical management of chronic pelvic pain once under- tional expertise of individual counseling, couples ther- lying visceral etiologies have been addressed and a neu- apy, or sex therapy to overcome the specific psychosocial pain syndrome has been barriers to recovery (4, 42).Sex therapy can be a useful ropathic component of the diagnosed (52).However, many studies are not specific to adjunctive treatment to physical therapy to assist couples chronic pelvic pain and are small or retrospective in nature in the return to normal, pain-tree intercourse; female (53). Because neuropathic pain is often associated with orgasmic disorder and genito-pelvic pain have been tissue injury, it is critical to assess for and treat concurrent shown to improve with sex therapy (43, 44). myofascial dysfunction. Treatment wittr neuropathic medications may improve the effectiveness of physical the treatment of chronic pelvic pain? therapy and myofascial dysfunction by improving senso- rineural tolerance of stimuli. Based upon their effectiveness for other neuropathic pain Calcium channel alpha 2-delta ligand medications syndr omes, serotonin-norepinephrine reuptake inhibitors (gabapentin or pregabalin) are common treatments for (SNRIs) are recommended for patients with neuropathic chronic pelvic pain. Although there is a lack of evidence

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@ 202A by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, [nc. Unauthorized reproductiorr of this article is prohibited. raises the possibility that needle insertion itself may manipulation showed weaker evidence of benefit. None of produce a sffong placebo effect or be effective on its own the studies focused on women with chronic pelvic pain (66). (60). Trigger point injections are beneficial for pelvic Preliminary evidence from a single-arm rial ttrat evaluated floor muscle spasm refractory to pelvic floor physical the success of a grcup-based therapeutic yoga program for therapy and medications (61) and may be more beneficial women wittr chronic pelvic pain showed clinically important than ischemic compression physical therapy alone for the and statistically significant improvements in baseline pain, treatment of abdominal wall trigger points in patients emotional well-being, and sexual function after 6 weeks of with chronic pelvic pain (59). Patients should be coun- yoga practice (67). seled regarding expectations and anticipated concurrent Selective cannabinoids (ie, synthetic cannabinoids that therapies before starting injections. contain only tetratrydrocannabinol ffHcl and cannabis- based exffacts that contain a combination of THC and Botulinum Toxin lnjedions cannabidiol ICBDI) for chronic neuropathic pain have been The evidence is inconclusive regarding the value of the focus of several recent systematic reviews (68, 69).A botulinum toxin injections for myofascial pain syn- systematic review of 1l randomized rials that included dromes from all sources (62).Therefore, their use should 1,,219 patients showed a statistically significant but clinically be reserved for the treatment of myofascial pelvic pain small benefit averaging less than 1 point on a 0-10-point refractory to physical therapy (63). pain scale (68). Another review included the findings from 24 twdomized rials (1,334 patients) in a rneta-analysis ttrat Other Procedures showed inconsistent improvements in pain across ffials, with There is limited evidence to suppolt laparoscopic uterosac- most showing no effect (69). Participants in the trials had ral nerve ablation and presacral neurectomy in the ffeatment heterogeneous diagnoses including multiple sclerosis, dia- of chronic pelvic pain. A large RCT found no improvement betic neuropathy, brachial plexus injury, and in pain scores or quality of life after laparoscopic uterosacral chemottrerapy-induced pain. None of the studies in either (68, nerve ablation in chronic pelvic pain (64).Most studies that review focused on women with chronic pelvic pain 69). evaluated presacral neurectomy included patients that had dysmenorrhea, and there is insufficient evidence to support nerve intemlption in the ffeatment of chronic pain (65). in the mnnagement of chronic pelvic pain?

The routine use of laparoscopic adhesiolysis is not tive, and integrative medicine therapies in the recommended for the management of chronic pelvic treatment of chronic pelvic pain? pain. Laparoscopic adhesiolysis is not helpful for the treatment of chronic pelvic pain after visceral gyneco- Data from randomized trials are needed to evaluate logic causes such as endometriosis, adenomyosis, and whether complementary and integrative therapies studied adnexal disorders have been excluded. However, intra- for other chronic pain disorders are effective for chronic operative findings may support the role of adhesiolysis in pelvic pain. However, based on evidence of benefit for specific circumstances such as bowel stricture and dense the treatment of nongynecologic chronic pain, acupunc- adhesions tethering the uterus. ture and yoga can be considered for the management of Adhesions are common in patients who have chronic pelvic pain of musculoskeletal etiology. undergone previous abdominal surgery and in patients Complementary and integrative ttrerapies have been with inflammatory conditions such as pelvic inflamma- studied in patients with chronic musculoskeletal and neuro- tory disease and endometriosis. Pelvic adhesiolysis was pattric pain syndromes of the head, neck, back, and once a common procedure in patients undergoing exffemities as well as fibromyalgia. These therapies can be laparoscopy for chronic pelvic pain (70). Early uncon- biologically based (natural compounds), min&body (such as trolled studies showed large magnitude, short-lived im- relaxation, yoga, and tai chi), manipulative (such as massage provements after lysis of adhesions, whereas later and osteopathic manipulation), and bioenergetic (acupunc- randomized trials show no benefit when compared with ture) (32,66). A systematic review of 32 snrdies of chronic diagnostic laparoscopy (71), which challenges the value pain management included six randomizd, trials of acu- of laparoscopic adhesiolysis for chronic pelvic pain and puncture that showed sffong evidence of benefit for reducing the presumption that adhesions cause chronic pelvic pain. pain and opioid use in patients with chronic musculoskeletal A systematic review of trvo RCTs and 11 cohort studies pain. One of the rials showed shoft-term benefit of auricular on laparoscopic adhesiolysis found a lack of evidence of acupuncture in pregnant women with low back and posterior benefit, an increased risk of bowel injury, and a high rate of pelvic pain.Studies of yoga relaxation,taicH, massage, and negative laparoscopies (defined in the review as no

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A 202A by the Arnerican College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. setting: l-yeer prospective coholt. Am J Obstet Gynecol 2018; tion in female c-hronic pelvig: pain: a blinded study of exam- 21 8: 1 14.e1,-12. (Irvel Il-Z) ination findings. J Bodyw Mov Ther 2012;16:5G-6. (Level 10. Latthe P, Latthe M, Say L, Gtilmezoglu M, Khan KS. rI-3) WHO systematic review of prevalence of chronic pelvic 25. Loving S, Thomsen T, Jaszczak P, Nordling J. Pelvic floor pain: a neglected reproductive health rnorbidity. BMC muscle dyst-unctions are prevalent in female chronic pelvic Public Health 2006;6:177. (Systernatic Review and Meta- pain: a cross-sectional population-based study. Eur J Pain Analysis) 2014;18: I 259-7A. (Level fI-3) 1 1. Ahangari Prevalence A. of chronic pelvic pain among 26. Carnett JB. The simulation of gall-bladder disease by inter- women: an updated review. Pain Physician 2014;17 : costal neuralgia of the abdominal wall. Ann Surg 1927;86: El 4l-7 . (Systematic Review) 147-57. (Level Il) 12. Williams RE, Hartmann KE, Sandler RS, Miller WC, Sa- 27. Yosef A, Allaire C, Williams C, Ahmed AG, Al-Hussaini vttz LA, Steege JF. Recognition and treatment of irritable T, Abdellah MS, et al. Multifactorial contributors to the bowel syndrome among women with chronic pelvic pain. severity of chronic pelvic pain in women. Am J Obstet Am J Obstet Gynecol. 2005;192:761-7. (Level II-3) Gynecol 2016;215:760.e1-1 4. (Level II-3) 13. Cheng C, Rosamilia A, Healey M. Diagnosis of interstitial cystitis/bladder pain syndrome in women with chronic pel- 28. Jurhan V. Chronic pelvic pain: an imaging approach. Diagn vic pain: a prospective observational study. Int Urogynecol Interv Imaging 2015;96:997-1007. (Level IIf I 2Ol2;23: 1361-6. (Level II-3) 29. Hirschtritt ME, Kroenke K. Screening for depression. JA- 14. Montenegro ML, Mateus-Vasconcelos EC, Rosa e Silva MA 2Ol7;318:745-6. (Level III) JC, Nogueira AA, Dos Reis FJ, Poli Neto OB. Importance 30. Humphrey L, Arbuckle R, Moldwin R, Nordling J, van de pelvic muscle tenderness evaluation wornen with of in Merwe JP, Meunier J, et al. The bladder pain/interstitial chronic pelvic pain. Pain Med 2010111:224-8. (Level II-3) cystitis symptom score: development, validation, and 15. Tirlapur SA, Kuhrt K, Chaliha C, Ball E, Meads C, Khan identification of a cut score. Eur Urol 2Al,,2;61:27 1-9. KS. The 'evil twin syndrorne' in chronic pelvic pain: a sys- (Level II-3) tematic review of prevalence studies of bladder pain syn- 31 . Engsbro AL, Begtrup LM, Kjeldsen J, Larsen PV, de drome and endometriosis. Int J Surg 2013:11:233-7. (Systematic Review) Muckaclell OS, Jarbol DE, et al. Patients suspected of irritable bowel syndrome-cross-sectional study exploring the 16. Brawn J, Morotti M, Zondervan KT, Becker CM, Vincent sensitivity of Rome III criteria in primary care. Am J Gas- K. Central changes associated with chronic pelvic pain and troenterol 201 3; t 08:972-80. (Level II-3) endometriosis. Hum Reprod Update 2014.20:73717. (Level III) 32. Skelly AC, Chou R, Dettori JR, Tumer JA, Friedly JL, Run- dell SD, et al. Noninvasive nonpharmacological treatment for 17. Aredo JV, Heyrana KJ, Karp Shah Stratton P. BI, JP, chronic pain: a systematic review. Comparative Effectiveness Relating chronic pelvic pain and endometriosis to signs Review Number 2Og. AffRQ Publication No 18-EHC0I 3-EF. of sensitization and myotascial pain and dystunction. Rockville, MD: Agency for Healthcare Research and Quality; Semin Reprod Med 2017;35:88-97. (Level IID 2018. Available at: https://effectivehealthcare.ahrq.gov/

18. Sharp HT. Myofascial pain syndrorne of the abdominal sites/defau ltlfi les/pdf/n onpharm a-chron i c-pain -cer -209 . wall for the busy clinician. Clin Obstet Gynecol 2003,46: pdf. Retrieved September 23,2019. (Systematic Review 783-8. (Level III) and Meta-Analysis) 19. Champaneria R, Shah L, Moss J, Gupta JK, Birch J, Mid- 33. Anderson RU, Wise D, Sawyer T, Nathanson BH, Nevin dleton LJ, et al. The relationship between pelvic vein Smith J. Equal improvement in men and women in the incompetence and chronic pelvic pain in women: system- treatment of urologic chronic pelvic pain syndrome using atic reviews of diagnosis and treatment etl'ectiveness. a multi-modal protocol with an internal rnyotascial trigger Health Technol Assess 2016:20: l-108. (Systematic point wand. Appl Psychophysiol Biofeedback 2016;41: Review and Meta-Analysis) 215-24. (Level II- 1) pelvic pain: 20. Gunter J. Chronic an integrated approach to 34. Polpeta NC, Giraldo PC, Teatin Juliato CR, Gomes Do diagnosis and treatment. Obstet Gynecol Surv 2003;58: Amaral R. L., Moreno Linhares I, Romero Leal Passos 615-23. (Level III) M. Clinical and therapeutic aspects of vulvodynia: the 21. Steege JF, Siedhoff MT. Chronic pelvic pain. Obstet Gy- impofiance of physical therapy. Minerva Ginecol 2Al2; necol 2014;124:616-29. (Level III) 64:43745. (Level III) 22. International Pelvic Pain Society. Documents and fbnns: 35. Sharrna N, Rekha K, Srinivasan JK. Efficacy of transcuta- history and physical. Available at: https://www.pelvicpain. neous electrical nerve stimulation in the treatment of org/IPPS/Profes sional/Docu men ts-Form s/IPPS/C ont entl chronic pelvic pain. J Midlife Health 2017;8:36-9. h ofessional/Documents_and_Forms.aspx. Refiieved September (Level Il-2) 23,,2019. (kvel III) 36. Zoorob D, South M, Karam M, Sroga J, Maxwell R, Shah 23. Speer LM, Mushkbar S, Erbele T. Chronic pelvic pain in A, et al. A pilot randomized trial of levator injections ver- women. Fam Physician (Level Am 2016;93:380-7. III) sus physical therapy for treatment of pelvic tloor myalgia 24. Neville CE, Fitzgerald CM, Mallinson T, Badillo S, Hynes and sexual pain. Int Urogynecol J 2015:26:845-52. C, Tu F. A preliminary report of musculoskeletal dystunc- (Level I)

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ie; 2020 by the ,r\rtrerican ilollege of'(.)Lrsteh'icians ancl Gynecolc-rgists. Pubiislreci b.v Vt'oitel's F,itrrr.,er I-lealth. Inc. 1*, niiutirorizeri r"epr oductim'r o l' tiris a$i *! e is pi"oiribiti,:il. 64. Daniels J, Gray R. Hills RK, Latthe P, Buckley L, Gupta J, et al. Laparoscopic uterosacral nerve ablation for alle- The MEDLINE database, the Cochrane Libr:ary, and the viating chronic pelvic pain: a randomized controlled trial. American College of Obstetricians and Gynecologists' own LUNA Trial Collaboration. JAMA 2009;302:955-61 . internal resources and documents wele used to conduct (Level I) a literature search to locate rclevant articles published 65. Proctor M, Latthe P, Farquhar C, Khan K, Johnson N. between January 200fMay 2A1.9. The search was Surgical intenuption of pelvic nerve pathways for primary rcstricted to articles published in the English Iatguage. and secondary dysmenon'hoea. Cochrane Database of Sys- Priority was given to articles reporting results of original tematic Reviews 2005, Issue 4. Art. No.: CD001896. DOI: research, although review articles and commentaries also 10. 100211465 1858.CD001 896.pub2. (Systematic Review wele consulted. Abstracts of research presented at and Meta-Analysis) symposia eurd scientitic conferences were not considered adequate for inclusion in this document. Guidelines 66. Lin YC, Wan L, Jamison RN. Using integrative medicine published by organizations or institutions such as the in pain management: an evaluation of current evidence. National Institutes of Health and the Amedcan College of Anesth Analg 2017;125:2081-93. (Level III) Obstetricians and Gynecologists were reviewed, and 67. Huang AJ, Rowen TS, Abercrombie P, Subak LL, Schembri additional studies were located by reviewing M, Plaut T, et al. Development and feasibility of a gloup- bibliographies of identitied articles. When reliable based therapeutic yoga program for women with chronic research was not available, expert opinions from pelvic pain. Pain Med 2017;18:1864-72. (Level II-3) obstetician-gynecologists were used. 68. Meng H, Johnston B, Englesakis M, Moulin DE, Bhatia A. Studies were reviewed and evaluated for quality Selective cannabinoids for chronic neuropathic pain: a sys- according to the method outlined by the U.S. tematic review and meta-analysis. Anesth Analg 2017;125: Preventive Services Task Force: 1638-52. (Systematic Review and Meta-Analysis) I Evidence obtairred from at least one properly de- 69. Aviram J, Samuelly-Leichtag G. Efficacy of cannabis- signed randomrzed controlled trial. based medicines fbr pain management: a systematic review II- I Evidence obtained from well-designed controlled and meta-analysis of randomized controlled trials. Pain trials without randomization. (Systematic Physician 2017;20:E755-96. Review and II-2. Evidence obtained from well-designed cohort or Meta-Analysis) case-control analytic studies, preterably from 70. Tu FF, Beaumont JL. Outpatient laparoscopy for more than one center or research group. abdominal and pelvic pain in the United States 1994 II-3 Evidence obtained frorn nrultiple time sedes with through 1996. Am J Obstet Gynecol 2006;194:699- or without the intervention. Dramatic results in 743. (Level II-3) uncontrolled experiments also could be regarded as this type of evidence. 7 1,. van den Beukel BA, de Ree R, van Leuven S, Bakkum EA, Strik C, van Goor H, et al. Surgical treatment of adhesion- ru Opinions of respected authorities, based on clinical related chronic abdominal and pelvic pain after gynaeco- experience, descriptive studies, or repofts of expert logical and general slrrgery: a systematic review and nreta- commrttees. analysis. Hum Reprod Update 2017;23:276-88. (System- Based on the highest level of evidence found in the data, atic Review and Meta-Analysis) recommendations are provided and graded according to 72. Molegraaf MJ, Torensma B, Lange CP, Lange JF, Jeekel J, the following categories: Swank DJ. Twelve-year outcomes of laparoscopic adhe- Level A-Recommendations are based on good and siolysis in patients with chronic abdominal pain: a random- consistent scientific evidence. ized clinical trial. Surgery 2Ol7;161:415-21 . (Level I) Level B-Recommendations are based on limited or inconsistent scientific evidence. Level C-Recommendations are based prirnarily on consensus and expert opinion.

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