What is the appropriate referral and initial work‑up for a woman with chronic pelvic pain lasting more than six months, unrelated to menstrual cycles, pregnancy, or acute infection?

Chronic Pelvic Pain: Referral and Initial Work-Up

Direct Recommendation

For women with chronic pelvic pain lasting more than six months (unrelated to menstrual cycles, pregnancy, or acute infection), begin with combined transabdominal and transvaginal ultrasound as the initial imaging study, and refer to gynecology when imaging reveals structural abnormalities, when pain is refractory to initial management, or when endometriosis is suspected based on clinical features. 1

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Initial Diagnostic Approach

Essential Clinical History Elements

The evaluation must systematically assess pain characteristics by anatomical location to narrow the differential diagnosis:

• Deep or internal pelvic pain suggests pelvic venous disorders (pelvic congestion syndrome), intraperitoneal adhesions, hydrosalpinx, chronic inflammatory disease, or cervical stenosis 1
• Perineal, vulvar, or vaginal pain points toward vaginal atrophy, vaginismus, vaginal or vulvar cysts, vulvodynia, or pelvic myofascial pain 1
• Lower abdominal pain may indicate gastrointestinal causes (irritable bowel syndrome, inflammatory bowel disease) or musculoskeletal etiologies (pelvic girdle pain, myofascial pain) 2

Critical Screening Components

• Screen for depression, anxiety, posttraumatic stress disorder, and history of physical or sexual abuse, as these are strongly associated with chronic pelvic pain and influence treatment outcomes 3
• Document gynecologic history specifically for endometriosis and adenomyosis, which are primary gynecological causes 1
• Assess for dyspareunia, dysuria, and dyschezia to identify organ system involvement 4

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Initial Imaging Algorithm

First-Line Imaging

Combined transabdominal and transvaginal ultrasound is the initial imaging study of choice for women with chronic pelvic pain 1. This approach provides:

• Anatomic overview of pelvic structures 1
• High-resolution detail of uterine size, endometrial canal distension, fallopian tube dilation, ovaries, and adnexal masses 1
• Ability to identify structural abnormalities requiring specialist referral 1

Plain radiography has no role in evaluating chronic pelvic pain and should not be ordered 1

Advanced Imaging Considerations

For postmenopausal women or when initial ultrasound is equivocal:

• CT abdomen and pelvis with IV contrast is appropriate when there is poorly localized pain, concern for non-gynecologic etiologies, or broad differential diagnosis requiring evaluation of multiple organ systems 5
• MRI pelvis is the preferred modality when deep pelvic endometriosis is suspected, with 90.3% sensitivity, 91% specificity, and 90.8% accuracy 6

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Referral Indications

Gynecology Referral

Refer to gynecology when:

• Structural abnormalities are identified on ultrasound (adnexal masses, hydrosalpinx, significant adenomyosis, fibroids) 1, 2
• Endometriosis is suspected based on clinical features (pain with deep penetration, dyschezia, cyclical worsening) requiring laparoscopic evaluation 3, 7
• Vaginal bleeding or suspected adnexal mass in postmenopausal women, as these take precedence due to risk of endometrial and ovarian neoplasia 5, 2
• Pain is refractory to initial conservative management after 3-6 months 7

Multidisciplinary Referrals

Based on clinical presentation and examination findings:

• Urology referral for symptoms suggesting interstitial cystitis/painful bladder syndrome (urinary frequency, urgency, suprapubic pain with bladder filling) 3, 7
• Gastroenterology referral for features of inflammatory bowel disease or when irritable bowel syndrome requires specialized management 2, 3
• Physical therapy referral for pelvic floor dysfunction, myofascial pain, or musculoskeletal findings on examination 3, 7
• Pain management or psychiatry referral for comorbid depression, anxiety, or when pain is refractory to standard approaches 3, 7

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Common Pitfalls to Avoid

Diagnostic Errors

• Do not assume pain is purely gynecologic without systematic evaluation of gastrointestinal, urologic, and musculoskeletal systems, as 15% of chronic pelvic pain cases are associated with abdominal myofascial pain syndrome alone 8
• Do not overlook musculoskeletal examination, as the musculoskeletal system is compromised in most women with chronic pelvic pain 9, 8
• In postmenopausal women, do not pursue endometriosis workup unless there is history of hormonal therapy, as endometriosis is estrogen-dependent and typically regresses after menopause 5

Management Errors

• Do not delay referral when red flags are present: postmenopausal bleeding, palpable masses, or progressive symptoms warrant urgent gynecologic evaluation 5, 2
• Do not order CT as first-line imaging when ultrasound is more appropriate and avoids radiation exposure 1
• Do not pursue hysterectomy early in the treatment algorithm, as significant improvement occurs in only about 50% of cases and should be considered only as a last resort when pain is clearly of uterine origin 7