Bailliere's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp.

403414, 2000

doi:10.1053/beog.1999.0083, available online at http://www.idealibrary.com on

2 Epidemiology of chronic pelvic pain

Krina Zondervan*
MSc, DPhil

Research Ocer Department of Public Health/Nueld Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK

David H. Barlow

MA, BSc, MD, FRCOG

Nueld Professor of Obstetrics and Gynaecology Nueld Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK

An overview is given of the current knowledge of the epidemiology of chronic pelvic pain (CPP) in terms of prevalence, incidence, and associated risk factors. However, the lack of a consensus on the denition of CPP greatly hinders epidemiological studies. Although data are limited, the prevalence of CPP in the general population appears to be high. A single study found a 3-month prevalence (pelvic pain of at least 6 months' duration) of 15% in women aged 1850 in the general US population. In the UK, an annual prevalence in primary care of 38/1000 was found in women aged 1573, a rate comparable to that of asthma (37/1000) and back pain (41/1000). The monthly incidence in primary care was 1.6/1000. No incidence gures exist for the general population. Analysis of risk factors for CPP is highly complicated owing to its multifactorial aetiology. At present, it is only of some value using women with CPP identied at community level, since those in primary, secondary or tertiary care are likely to constitute highly selected sub-groups. Key words: chronic pelvic pain; epidemiology; prevalence; incidence; risk factors.

The objective of epidemiological studies is to (1) provide information on the distribution of conditions in dierent populations (in terms of prevalence and incidence), and (2) identify risk factors associated with the condition, in an eort to shed light on potential mechanisms of causation. Such information is important for various reasons. Accurate information on the prevalence and incidence of conditions is vital for resource allocation and health care planning. In addition, epidemiological information supports a range of other research elds, for example, health economic studies, experimental studies investigating the genetic and environmental aetiology of conditions, qualitative studies assessing the relative functioning and well-being of patients, and studies aimed at the development of new treatment strategies. Here, we aim to describe the current knowledge about the prevalence, incidence, and risk factors for chronic pelvic pain (CPP). To date, the epidemiological characteristics of CPP appeared to have received little or no attention. In the UK, published
*Address for correspondence: Department of Public Health, Institute of Health Sciences, Old Road, Headington, Oxford OX3 7LF, UK. 15216934/00/030403+12 $35.00/00 c * 2000 Harcourt Publishers Ltd.

404 K. T. Zondervan and D. H. Barlow

studies appear mainly to have focused on the pathology found at laparoscopy1,2 and on possible alternative causes for the condition in those without obvious pathology.38 The focus of this chapter is therefore the epidemiological evidence from the UK, although relevant studies performed elsewhere are also discussed. LITERATURE SEARCH The papers relevant to the epidemiology of CPP were retrieved through a systematic literature search of the databases MedLine, EMBase, and PsycLit from their starting date until April 1999 (MedLine from January 1966, PsycLit from January 1974, and EMBase from January 1980). Searches were limited to papers published in the English language. UK studies were retrieved using the search terms: `inciden*', `prevalen*' and `epidemiol*' combined with the pain symptoms `pelvic near pain', `dyspareunia', `dysmen*', and `abdominal pain'. The search also included the terms `endometriosis', `adenomyosis', `pelvic inammatory disease', `pelvic adhesions', `irritable bowel syndrome', `genitourinary pain', `genitourinary symptoms', `gastrointestinal pain', `gastrointestinal symptoms', `ovarian cysts' and `pelvic congestion'. Reference lists of selected papers were hand-searched back to 1960 for additional citations. To obtain papers for non-UK studies, the search terms of the four pain symptoms only were used, and reference lists of the papers retrieved were hand-searched. DEFINITION OF CPP In epidemiological studies, the use of an objective, clear, and widely acknowledged denition for the condition of interest is of particular importance: it enables the derivation of precise results that are suitable for comparison with studies in other populations. Unfortunately, no such internationally agreed consensus yet appears to exist on the denition of CPP. The most commonly used (and most objective) denition of CPP considers only the location and duration of the pain: recurrent or constant pain in the lower abdominal region that has lasted for at least 6 months.9 Women with pelvic pain related to pregnancy or malignancy are usually excluded, as are those who experience pelvic pain only around menstruation (dysmenorrhoea) or during sexual intercourse (dyspareunia). Although the choice of 6 months' duration within this denition is arbitrary (is pain lasting for 3 months not chronic?), it does not carry the subjective anatomic or aectivebehavioural assumptions of other types of denitions used.10 For example, the International Association for the Study of Pain11 have provided a specic denition for `CPP without obvious pathology' (CPPWOP): chronic or recurrent pelvic pain that cannot be suciently explained by an apparent physical cause. This diagnostic entity has also been used in other studies, and is sometimes referred to as `the pelvic pain syndrome'12 or `pelvalgia'.13 However, there are several problems with this denition. First, it uses the simple theories of pain perception and assumes that (1) it is always possible to link pain directly with a form of tissue damage or pathology, and (2) causes of pain can be divided simply into `organic/anatomic' and `non-organic/functional'. Furthermore, it assumes that all possible pathology underlying pelvic pain is known and well established, that it can always be reliably detected through laparoscopy, and that all endoscopic surgeons irrespective of their training, skill, or clinical experience

Epidemiology of chronic pelvic pain 405

would interpret the pelvic ndings in the same way. It is clear from the enormous diversity of opinion in the literature as to what causes CPP reviewed in Chapter 1 that these assumptions cannot be taken for granted. Aectivebehavioural denitions of CPP have generally included a need for pain to be accompanied by `signicantly altered' physical activity or disturbance of mood, or `signicant' use of analgesics.10,14 These types of denition are highly subjective. Who can determine whether the eect that CPP has on a woman's life is signicant? Similarly, is it appropriate to classify women as CPP patients according to how well they can cope with their pelvic pain?

PREVALENCE AND INCIDENCE OF CPP The prevalence rate of a condition in a population is the proportion of the population that has the condition at a specic point in time (point prevalence) or at some point in a time period (period prevalence). The incidence rate is the number of new cases arising in a given period as a proportion of the `person-time' at risk (i.e. the aggregated time that the members of the population spend in that population over the period, before the onset of the condition). More intuitively comparable to the prevalence rate, however, is the incidence proportion (or cumulative incidence), which is the number of new cases arising in a risk period as a proportion of the population at risk at the start of the period. From these denitions, it follows that the investigation of prevalence and incidence requires dierent study designs. Whereas the prevalence is assessed in cross-sectional studies, incidence can be determined only through prospective follow-up of a group of people. The choice and size of study population is crucial for the precise estimation of prevalence and incidence, and the generalizability of the results. For example, if the objective is to derive an estimate of CPP prevalence in women aged 1850 in the general population, information should be obtained from a suciently large sample of women who are randomly selected from this population. The following sections describe the current knowledge on prevalence and incidence of CPP in the general population, and in primary care. For all relevant studies, descriptions are given of the dierent designs, which should be taken into account in the interpretation of their results. Prevalence of CPP in the general population Previously, we conducted a systematic review (based on the search of the databases MedLine, EMBase, and PsycLit described above) of data that could provide an estimate of the prevalence or incidence of CPP in the general population.15 The prevalence of abdominal pain was also investigated as there is likely to be a considerable overlap between these symptoms and those of CPP. An additional aim was to obtain information on the possible overlap between CPP and other pelvic pain symptoms (dysmenorrhoea and dyspareunia), gastrointestinal symptoms and genitourinary symptoms. For the review, CPP was broadly dened as any non-cyclical pelvic pain not related to intercourse. Studies were included (1) if they were community-based and reported the prevalence of any of the pain symptoms: CPP, dysmenorrhoea, dyspareunia, abdominal pain; or (2) if they referred to a clinical population but reported the

406 K. T. Zondervan and D. H. Barlow

prevalence of any of the four pain symptoms in a disease-free control group. Furthermore, the results of these studies had to relate to adult, female populations. The main result of the review was that no community-based studies were found that provided an estimate of the prevalence or incidence of CPP in the general UK population. The only study to provide a hospital-based estimate for the prevalence of CPP, dened as `recurrent pelvic pain unrelated to menstruation or coitus', was conducted by Mahmood et al1 in Aberdeen. Their estimated prevalence was 39% in 559 pathology-free women having a laparoscopy for sterilization or investigation of infertility. However, the inclusion of infertile women in this group was likely to have partly accounted for this high prevalence rate, and the estimate could not be assumed to relate to the general population. Only two studies both in the USA appeared to have been published that provided some estimate of the community prevalence (but not incidence) of CPP.16,17 In a study by Jamieson and Steege16, the prevalence of pelvic pain was assessed in 581 women aged 1845 who were approached in waiting rooms of obstetrics and gynaecology and family medicine practices. Although one-third of these women were accompanying patients, their results were pooled with those of patients, which made the results unsuitable for generalization to the population. Thirty-nine percent of women reported having some degree of pelvic pain (irrespective of duration), while 20% reported pelvic pain for more than 1 year's duration. Mathias et al17 performed the only truly community-based study of CPP. They investigated the prevalence of CPP and its relation to functioning and well-being in a telephone survey of 5263 women aged 1850 randomly selected from the general US population. CPP (of at least 6 months' duration and with pain having occurred in the past 3 months) was reported by 15% of these women (95% CI: 1317%). Prevalence rates for abdominal pain were also included in the review, but they could not easily be used as an indication for the prevalence of CPP: denitions of pain varied, and the age ranges were wider in women included in abdominal pain studies. Three community-based studies in the UK examining abdominal symptoms were found, in which prevalence rates for `abdominal pain occurring more than 6 times in the past year' ranged from 23 to 29%.1820 Not surprisingly, these rates were relatively high, because of the inclusion of upper abdominal pain, in the denition. Not one of the UK studies provided any information on the possible overlap between symptoms of CPP and dyspareunia, dysmenorrhoea, gastrointestinal symptoms and genitourinary symptoms. Similarly, this overlap has hardly been investigated at all in studies outside the UK. In the study by Mathias et al17 it was reported that of those CPP patients who were sexually active, 82% also reported dyspareunia or pain after intercourse most or all of the time in the past month, but no gures were given on the possible overlap with symptoms of dysmenorrhoea or IBS. In one hospitalbased study of 651 US women aged 18 and over, 43% of women with CPP also reported dyspareunia and 39% `excessive' dysmenorrhoea, while 79% met the diagnostic criteria of probable irritable bowel syndrome (IBS).21 It was concluded from the review that there is a great need for a community-based study in the UK, in which the prevalence of CPP and its eect upon the lives of women are assessed. Information is also warranted on the incidence of CPP in the general population, but this would be more dicult to investigate, as it would require a long-term prospective study. However, some information now exists on the prevalence and incidence of CPP in primary care, as described in the next section.

Epidemiology of chronic pelvic pain 407

Prevalence and incidence of CPP in primary care We recently estimated the prevalence and incidence of CPP in UK primary care, using data from the national general practice database MediPlus United Kingdom Primary Care Database (UKPCD).22 This database contains anonymized clinical and prescribing data from 1991 onwards on approximately 1 700 000 patients. The most common denition of CPP was used for the analysis: `constant or recurrent pain in the lower abdominal region lasting for at least 6 months, excluding pain related to pregnancy or malignancy, or pain that occurs only with menstruation or intercourse'. CPP cases were identied from a denominator of 278 509 women, on the basis of contacts for pelvic pain with the practices contributing information to the database between 1991 and 1995. The study provided the rst evidence of a high prevalence of CPP in women in the UK: an annual prevalence of 38/1000 was found in women aged 1573, which was higher than gures reported elsewhere for migraine (21/1000), and comparable to those for asthma (37/1000) and back pain (41/1000).23 The annual prevalence for women aged 1850 was similar, at 37/1000. However, CPP prevalence varied with age, from 18/1000 in 1520 year olds to 28/1000 in women older than 60. Regional variations were also found, with prevalence lowest in Scotland (16/1000) and highest in Wales (29/1000). These dierences in age and region-specic rates could have been due to underlying dierences in community-based rates, but also to dierences in health care seeking behaviour. It is certain that these results underestimated general population rates because they only provided information on women with CPP seeking health care. Mathias et al17 found that while 147/1000 of women aged 1850 had CPP in the last 3 months, only 25% had seen a health care provider in that period. In this respect, CPP appears to be similar to back pain, which was described by the UK Clinical Standards Advisory Group24 as a condition that many people cope with themselves without seeking health care. The monthly incidence of CPP found in primary care was 1.6/1000. Since the prevalence of a condition is approximated by the product of its incidence and mean duration25, the high prevalence of CPP was explained in part by a long duration of symptoms. A second study using MediPlus UKPCD investigated the duration of CPP (dened as the time between the rst and last contact for pelvic pain), as well as patterns of diagnosis and referral.26 For this purpose, a cohort of 5051 incident cases was followed for 34 years from their rst contact for pelvic pain with primary care. The study showed that women with CPP had a median symptom duration of 15 months on the database, with a third of women having persistent symptoms after 2 years. These results, however, were likely to have been inuenced not only by the actual duration of symptoms, but also by health care seeking behaviour. In turn, health care seeking behaviour was probably inuenced by many unknown factors, such as patient satisfaction with the care oered, interaction with the GP, and inclination to `put up' with symptoms. The study also revealed that, strikingly, a quarter of incident CPP cases received no diagnostic label during the 34 year follow-up, and only 40% had evidence of referral to a specialist. The majority of women received one diagnosis only, the most common being IBS and cystitis in all age groups. In addition, pelvic inammatory disease (PID) was common in women aged up to 40, and other gastrointestinal diagnoses in women above 50. The likelihood of receiving a diagnosis varied with age: women under 20 and older than 60 were less likely than others to receive a diagnosis. The referral rate

408 K. T. Zondervan and D. H. Barlow

varied similarly with age: women in the 3140 age group were twice as likely to have been referred as the youngest or oldest women in the cohort. The results of the MediPlus UKPCD analysis provided the rst evidence of a high prevalence of CPP in the UK. It also showed, however, that most women who seek medical advice are managed in primary care, and are not referred to a specialist. In any study of women seen in secondary and tertiary care, therefore, it is important to realize that they are likely to constitute highly selected sub-groups.

RISK FACTORS FOR CPP The objective of a risk-factor analysis is to elucidate potential mechanisms of causation for a condition. Dierent types of epidemiological study can be used to investigate risk factors, each having advantages and disadvantages that should be borne in mind when interpreting their results. Such studies can be prospective (cohort studies), retrospective (casecontrol studies), or cross-sectional. In cohort studies, two or more groups who are free of disease but dier with regard to levels of exposure to the risk factor are followed prospectively to investigate who develops the disease. Cohort studies are seen as the `gold standard' for risk factor analysis, mainly because they allow the collection of unbiased risk factor information. However, they are very costly, and may not be feasible when the disease of interest is rare or requires a very long followup. In addition, the careful recording of risk factor information over a long period of time usually requires a clear idea from the outset of the study which factors need to be investigated. Casecontrol studies are often chosen as an alternative, particularly if a condition is rare or if the aim is to investigate the eect of a large selection of risk factors. In such studies, a group of incident cases with the disease is identied, their risk factor information pre-dating the onset of disease is collected, and this information is compared with that provided by a carefully selected control group that is free of disease. A disadvantage of casecontrol studies, however, is that retrospectively collected risk-factor information may be incomplete (if it relies on previously recorded data) or biased (if it relies on recall). The main objective of a cross-sectional study is usually to assess the prevalence of a disease in that population, but a secondary aim can be to compare retrospective risk factor information from prevalent cases with that of non-cases in the sample. Its disadvantages are similar to those of casecontrol studies. An important additional disadvantage, however, is that the inclusion of prevalent cases means that it is often dicult to assess whether or not the exposure preceded the onset of disease. Even when detailed historical risk factor information is collected, causal relationships can almost never be inferred, thus rendering this type of study least suitable for risk factor analysis. At best, CPP presents a major challenge for the epidemiologist wishing to investigate potential risk factors. This is illustrated in Figure 1. Suppose one were to use CPP cases identied from the community for an epidemiological study. In Chapter 1, Moore and Kennedy have given an overview of the possible somatic, psychological and socioenvironmental conditions associated with CPP, following the multidimensional `biopsychosocial' model for the aetiology of CPP.27,28 The rst problem, therefore, is the fact that CPP cases may suer from various underlying somatic conditions, all of which may have dierent or even conicting risk-factors (see box I). A brief

Underlying conditions Endometriosis Recurrent PID Adhesions IBS

I Possible risk factors for underlying conditions? Endometriosis: - age - menstrual characteristics - genetic factors PID: - age - sexual contraceptive factors - IUCD use Adhesions: - history of endometriosis/ PID - history of abdominal surgery III Possible factors influencing primary health care seeking behaviour? e.g.: - age - social class/education - relationship with GP - personal factors (pressure/support from work/family; illness beliefs) IV Possible factors influencing referral to secondary/tertiary care? e.g.: - age - medical history - social class/education - diagnosis/beliefs GP

e.g.

Psychological factors CPP cases (Community)

e.g.

Traumatic events (past abuse/abortion) Depression Illness beliefs

Biopsychosocial model

CPP cases (Primary care)

CPP cases (Secondary/ tertiary care)

II

Socio-environmental factors e.g. Role of significant others Employment situation

Epidemiology of chronic pelvic pain 409

Figure 1. Complexity of investigating `risk factors' for CPP.

410 K. T. Zondervan and D. H. Barlow

description of the risk factors associated with most common diagnoses of CPP (endometriosis, PID and IBS) is given in the next section. Furthermore, psychological factors (e.g. traumatic events, depression, illness beliefs) and socio-environmental factors (e.g. the role of `signicant others') may also play a role in pain aetiology or maintenance (see box II). CPP risk may be inuenced by a variety of these factors, some of which can be dicult to measure. In addition, frequencies of underlying somatic and psychosocial conditions may vary in groups of CPP cases sampled from dierent communities, so that results from one country may not be comparable to those of another. The situation becomes even more complex when CPP cases are identied from primary (see box III) or secondary/tertiary care settings (see box IV). Associations between CPP and risk factors emerging in these settings may be very dierent compared to a community setting, because of dierences in health care seeking behaviour and referral patterns. For example, pelvic pain might be very common in young women, but if they are less likely than older women to go to their GP with their symptoms they are less likely to be identied as CPP cases. Consequently, `risk' for CPP may be seen as low in this group. Similarly, dierences in referral patterns from primary to secondary or tertiary care between, for example age and social class groups may result in an even further distorted picture of CPP risk. Descriptions of `clinical proles' of CPP patients at secondary or tertiary care level13 may therefore be of some use to an individual clinic, but are not suitable for generalization to the wider population. In summary, risk factor analysis of CPP is at present only of some value using cases identied at community level. Even at community-level, however, the unknown distribution of underlying somatic conditions and multi-causality of CPP pose serious problems, and any relationship found between a certain factor and risk of CPP should be interpreted with great caution.

Risk-factors reported in community-based studies of CPP Because only two studies both of cross-sectional design have investigated CPP at community level, the information on risk factors from such populations is very limited. The community survey in the USA by Mathias et al17 and the semi-community study of women and their companions in primary care clinics by Jamieson et al16 described the association between certain demographic factors and CPP. In a logistic regression model adjusted for age, ethnicity, education, and marital status, Mathias et al found a slightly decreased risk of CPP in women older than 35 compared to younger women (OR: 0.7, 95% CI: 0.60.8), and in women of African-American origin compared to Caucasian women (OR: 0.7, 95% CI: 0.50.95), whereas an increased risk was found in separated/widowed/divorced women compared with single women (OR: 1.5, 95% CI: 1.12.0). No association was found between CPP and educational status. Jamieson et al found that pelvic pain (dened as any current pain not associated with menstruation or intercourse) varied signicantly with age, with rates decreasing from 44% in those 1825 years old and 49% in those 2630 years old to 28% in those 3135 years old and 22% in those 3640 years old, before increasing again to 37% in those 4145 years old. Contrary to the nding of Mathias et al, a higher prevalence of CPP was observed in African-American versus Caucasian women (53 versus 35%), and no associations were found with marital status, income, education or parity. No adjustment, however, was made for other variables in signicance tests.

Epidemiology of chronic pelvic pain 411

Risk-factors for endometriosis, PID and IBS The underlying conditions most commonly associated with CPP are endometriosis, PID (and related adhesion formation) and IBS. Of these, risk-factors for endometriosis and PID have been most extensively studied, but the studies have been greatly limited by the lack of a non-invasive diagnostic tool. The need for laparoscopy or laparotomy to make the diagnoses has meant that studies have inevitably included highly selected case groups identied in secondary or tertiary case. Most studies have attempted to reduce the ascertainment bias likely to result from this case denition by selecting `appropriate' control groups for comparison. These have generally consisted of either asymptomatic women undergoing laparoscopic sterilization, or women consulting for other conditions in the same care setting, who were not laparoscoped and in whom pathology therefore could not be assessed. Such study designs, however, have compromised the generalizability of the results to a wider population. The most popular hypothesis to explain the development of endometriosis is retrograde menstruation (menstrual blood owing up the fallopian tubes and into the peritoneal cavity). Studies examining the risk factors for endometriosis have therefore largely focused on dierences in menstrual characteristics, contraceptive use, and child birth between cases and controls. Mangtani and Booth29 reviewed the risk factors associated with endometriosis, highlighting the methodological problems with many of these studies. The highest prevalence rates of endometriosis have been found in women around 3040 years of age, but ascertainment bias has almost certainly played a role in these results. Similarly, the suggested higher prevalence in Caucasian women and women of higher social class (mainly observed in less recent case series) may well be explained by dierences in access to health care. Regular menses, prolonged menstrual ow, and early menarche have all been implicated as increasing the risk of endometriosis, whereas pregnancy and use of oral contraceptives (OCs) have been suggested as protective. Evidence supporting these suggestions, however, has been inconsistent.29 Vercellini et al30 reviewed the evidence on the relation between contraceptive use and endometriosis, and found that OCs and intra-uterine contraceptive devices (IUCDs) have both been associated with decreased, increased, or no eect on the risk of endometriosis. A large prospective cohort study found a protective eect of OCs in current users, but no signicant dierences in past users, suggesting that OCs only mask symptoms associated with endometriosis.31 Other factors suggested to play a role have included exercise, smoking (both decreasing risk) and alcohol use (increasing risk), potentially resulting from eects on endogenous oestrogen levels.29,32 Genetic factors are also thought to play a role in the development of endometriosis, and research investigating hereditary links is currently underway. Grodstein and Rothman33 have critically reviewed the dierent risk factors associated with the development of PID. As with endometriosis, case denition of PID is a problem in epidemiological studies, since the condition can remain asymptomatic and can by reliably diagnosed only by laparoscopy or laparotomy. The incidence of PID appears to be highest in younger women, whereas it also seems to be higher for nonCaucasian women. This may be partly due to diagnostic bias, although biological mechanisms for increased susceptibility to infection in these groups have also been proposed. As the majority of PID cases are likely to be the result of sexually transmitted diseases, young age at rst intercourse, high frequency of intercourse and a larger number of partners have all been reported to increase the risk of PID. Barrier methods of contraception and OCs have been reported to be protective.34 IUCD use

412 K. T. Zondervan and D. H. Barlow

was initially regarded as a factor strongly increasing the risk of PID, but this association was later suggested to have mainly resulted from comparison with OC and barrier users who are at decreased risk. Subsequent studies have suggested that risk may be associated with particular (non-medicated) devices or that it may only be elevated immediately after insertion of the device (possibly related to the introduction of organisms into the uterine cavity).33 Smoking and vaginal douching have also been implicated as increasing risk, but evidence for this has been weak. Although some recent epidemiological studies have estimated the prevalence of IBS, very few have addressed potential risk factors for the condition. This is not surprising, because no clear hypotheses exist about its causation and until recently it was a diagnosis made after exclusion of all others. As with CPP, psychological (e.g. depression and anxiety) and socio-environmental factors (e.g. abuse history) have been implicated in its aetiology and persistence.35 Two consecutive cross-sectional surveys of 3000 Danish men and women found (irrespective of sex) a higher prevalence and incidence of IBS in younger age groups and in those assessed as being psychologically vulnerable or experiencing problems.36 No association was found with social class, smoking, body mass index, or alcohol use. A cross-sectional survey of 1500 women in the USA found a similar decrease in prevalence of IBS with increasing age, and no association with smoking status, alcohol consumption, marital status or educational level.37

Practice points . although based on limited data, the prevalence of CPP in the community appears to be high. In the USA, a 3-month period prevalence of 15% was found in women aged 1850. In the UK, the annual prevalence in primary care was 38/1000, a rate similar to that reported for asthma or back pain . in the UK, a quarter of women consulting for CPP in primary care did not appear to receive a diagnosis despite several years of symptoms, whereas more than half are not referred to a specialist. Women seen in secondary or tertiary care for CPP are therefore likely to comprise highly selected sub-groups

Research agenda . there is a need for an international consensus on the denition of CPP. This denition should be objective, clear, and readily applicable . more information is required on the prevalence and incidence of CPP in the general population . the usefulness of risk-factor analysis for CPP is limited at present, owing to its multifactorial aetiology. The development of non-invasive diagnostic tools for some of the underlying somatic conditions that may account for CPP will be an important step forward towards unravelling some of its risk factors

Epidemiology of chronic pelvic pain 413

Acknowledgement
The study was supported by the BUPA Foundation, Registered Charity No. 277598.

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