Postmenopausal Subacute or Chronic Pelvic Pain
Postmenopausal Subacute or Chronic Pelvic Pain
Postmenopausal Subacute or Chronic Pelvic Pain
Variant 1: Postmenopausal subacute or chronic pelvic pain, localized to the deep pelvis. Initial imaging.
Expert Panel on Women’s Imaging: Katherine E. Maturen, MD, MSa; Esma A. Akin, MDb; Mark Dassel, MDc;
Sandeep Prakash Deshmukh, MDd; Kika M. Dudiak, MDe; Tara L. Henrichsen, MDf;
Lee A. Learman, MD, PhDg; Edward R. Oliver, MD, PhDh; Liina Poder, MDi; Elizabeth A. Sadowski, MDj;
Hebert Alberto Vargas, MDk; Therese M. Weber, MDl; Tom Winter, MDm; Phyllis Glanc, MD.n
Summary of Literature Review
Introduction/Background
Chronic pelvic pain, defined as cyclical or noncyclical pain involving the pelvis, lower abdomen, vulva, vagina,
or perineum and lasting for at least 6 months, affects as many as a quarter of women worldwide and is the single
most common presenting complaint at gynecologic office visits [1,2]. The morbidity, public health impact, and
downstream costs are substantial but poorly quantified in part due to the large variety of etiologies and lack of
definitions associated with chronic pelvic pain. For purposes of this document, the term “subacute” is added to
distinguish our target entities from diagnoses that most commonly present with acute or even emergent
symptoms. This guideline is limited to postmenopausal women, which further limits the range of potential pain
etiologies.
Subacute or chronic pelvic pain is a broad clinical presentation common to a variety of gynecologic, urinary,
gastrointestinal, and musculoskeletal disorders. There are specific ACR Appropriateness Criteria documents
pertaining to many of these diagnoses, which are detailed in Appendix 1. In particular, we emphasize the
importance of both vaginal bleeding and suspected adnexal mass in postmenopausal women because of the
prevalence of endometrial and ovarian neoplasia in this age group. These clinical features, if present, should take
precedence over the general complaint of pelvic pain in directing the management algorithm. Patients with acute
pain, suspected pelvic floor dysfunction, or urinary complaints may be managed in accordance with the respective
algorithms for those conditions. Imaging evaluation for suspected endometriosis is not considered here as
endometriosis is estrogen dependent and usually regresses after menopause [3]. If a postmenopausal woman is
experiencing pain from endometriosis, it is likely secondary to scarring or reactivation that is due to
postmenopausal hormonal therapy. In cases of persistent endometriosis-related symptoms after menopause,
readers are referred to ACR Appropriateness Criteria guidance for the premenopausal age group (see Appendix 1).
Finally, like other types of chronic pain, pelvic pain is a complex process with incompletely mapped cognitive
and neurologic contributors. As such, there is a growing body of literature regarding potential use of neurologic
imaging in patients with chronic pelvic pain [4-7]. However, central nervous system functional imaging remains
in the research domain for evaluation of chronic pelvic pain at this time, so we will not consider it formally
among the discussed imaging procedures.
When all of these aspects of subacute and chronic pelvic pain in postmenopausal women are excluded from direct
consideration, a handful of clinically significant conditions remain. We group these according to location of
clinical symptoms: pain localized to the deep or internal pelvis, with potential etiologies and associated
conditions, including pelvic venous disorders (commonly termed pelvic congestion syndrome), intraperitoneal
adhesions, hydrosalpinx, chronic inflammatory disease, or cervical stenosis versus chronic pain localized to the
perineum, vulva, or vagina that arises from suspected vaginal atrophy, vaginismus, vaginal or vulvar cysts,
vulvodynia, or pelvic myofascial pain.
Special Imaging Considerations
When there is suspected local pathology in the vulva, perineum, or vaginal wall, translabial/transperineal
ultrasound (US) or side-firing transvaginal probes may provide better visualization than end-firing transvaginal
a
Panel Chair, University of Michigan, Ann Arbor, Michigan. bGeorge Washington University Hospital, Washington, District of Columbia. cCleveland Clinic,
Cleveland, Ohio; American Congress of Obstetricians and Gynecologists. dThomas Jefferson University Hospital, Philadelphia, Pennsylvania. eMayo Clinic,
Rochester, Minnesota. fMayo Clinic, Rochester, Minnesota. gFlorida Atlantic University, Boca Raton, Florida; American Congress of Obstetricians and
Gynecologists. hChildren’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
i
University of California San Francisco, San Francisco, California. jUniversity of Wisconsin, Madison, Wisconsin. kMemorial Sloan Kettering Cancer
Center, New York, New York. lUniversity of Alabama at Birmingham, Birmingham, Alabama. mUniversity of Utah, Salt Lake City, Utah. nSpecialty Chair,
University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness
Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily
imply individual or society endorsement of the final document.
Reprint requests to: [email protected]
Endometriosis Infertility
Pelvic inflammatory disease Acute Pelvic Pain in the Reproductive Age Patient
Vaginal cancer Staging and Follow-up of Vaginal Cancer – Topic under development
Vulvar cancer Staging and Follow-up of Vulvar Cancer – Topic under development
Hematuria Hematuria