527: A randomised nested cohort study on women with persistent pelvic pain: a real world study

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Chronic primary visceral / pelvic pain, Treatment/management

Background and Aims: Persistent pelvic pain(PPP), defined as pain in the lower abdomen or pelvis, for at least 6months.[1] PPP can adversely impact quality of life, productivity, mental health, sexual function.[2] It is commonly attributed to endometriosis, but only 50% of women with PPP have endometriosis.[3,4] PPP, like other persistent pain conditions, has biopsychosocial contributors.[5]

Laparoscopy is often undertaken to identify and remove endometriosis. However, long-term effectiveness of this surgery is limited[1]. In contrast, medical treatments are effective for long term management of both PPP and endometriosis.[6] We undertook a real world study to compare these approaches

Methods: Within the PPP Cohort study, a nested pragmatic RCT was conducted. Women were randomised to either gynaecology clinic A or B. Clinic A had gynaecologists with advanced laparoscopic skills, Clinical B had general gynaecologist with more expertise in hormonal and pain management. Baseline demographics and medical history were collected. Quality of life and pain were assessed using the WHO Quality of Life-Brief(WHO-QOL-BS), Pain Catastrophisation Scale(PCS), and visual analogue scores(VAS) for dysmenorrhoea, dyschezia, dysuria, dyspareunia, and non-cyclical pain. Follow-up was completed every 6 months for 36 months. Data were analysed using STATA 16.1

Results: 358 women were randomised(180 to Clinic A, 178 to Clinic B). Baseline demographics were comparable. Laparoscopy was performed in 40%(Clinic A) vs 12%(Clinic B) (p<0.0001), with similar endometriosis rates of 50%. No significant differences were found between clinics across PCS or WHO-QOL-BS scores over time. Bladder symptoms did not correlate with finding endometriosis, and those in Clinic B had reduced symptoms at 36 months. Dyspareunia, reported in 71% at baseline (31% reporting severe symptoms), did not correlate with having a laparoscopy or endometriosis severity, with more favourable outcomes in clinic B. Other pain scores including dyschezia were not significant.

Conclusions: This “real world” study of patients presenting with persistent pelvic pain, provides evidence to support non-inferiority of a clinic model with low recourse to surgical management compared to a clinic model who favoured surgical management. The PPP Study design avoids the small patient cohorts as well as the challenges of patient selection that have occurred in previous RCTs undertaken in women with pelvic pain attributed to endometriosis.

References: 1. RCOG. The initial management of chronic pelvic pain Green-top guidelines.
2. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. 1996;87:321–7.
3. Evans SF, Brooks TA, Esterman AJ et al The comorbidities of dysmenorrhoea: a clinical survey comparingsymptom profile in women with and without endometriosis. J Pain Res.2018;11:3181
4. Yosef A, Allaire C, Williams C, et al. Multifactorial contributors to the severity of chronic pelvic pain in women. Am J Obstet Gynecol 2016; 215(6): 760-e1
5. Grinberg K, Sela Y, Nissanholtz-Gannot R. New insights about Chronic Pelvic Pain Syndrome (CPPS). Int J Environ Res Public Health. 2020;17:3005.
6. Wong WSF, Lim CED. Hormonal treatment for endometriosis associated pelvic pain. Iran J Reprod Med. 2011;9:163–70.

Presenting Author: Prof Sonia Grover
Submitting Author: Sonia Grover

Senior Author: Prof Sonia Grover

IASP 2026 Global Year theme of Neuropathic Pain: No

• Alaina R Francis: MBBS - Mercy Hospital for Women, Heidleberg, Melbourne, Australia
• Isabelle C Conroy: MD BBioMed Sci - University of melbourne
• Christopher Stevenson: BSc (hons) MSc PhD GCertHE - Deakin University, Melbourne, Australia
• Shane Kavanagh: MPH, PhD - Deakin University
• Samantha S Mooney: MBBS, M Reprod M, FRANZCOG - Mercy Hospital for Women, University of Melbourne