Bridging the Pain Gap: Addressing Disparities in Chronic Pelvic Pain Care

Recognizing diagnostic delays, access barriers, and the role of CBG in advancing equitable pelvic pain care. A Collaboration between the Committee on Diversity, Equity, Inclusion and Justice for the Complex Benign Gynecology Fellowship and the Chronic Pelvic Pain Special Interest Group

Chronic Pelvic Pain Is Common—But Care Is Unequal 

Chronic pelvic pain (CPP) affects millions of individuals worldwide, estimated at 15-26%. (1) Yet despite its prevalence, disparities in diagnosis and treatment persist across racial, ethnic, and socioeconomic groups. 

Studies estimate that endometriosis alone affects about 10-15% of reproductive age individuals yet delays in diagnosis and access to subspecialty care remain widespread. (2) 

Within Complex Benign Gynecology, addressing these inequities represents an opportunity to improve both patient outcomes and the delivery of high-quality care. 

Diagnostic Delays and Barriers to Recognition 

CPP diagnoses often take years, with some conditions—such as endometriosis—requiring 5–12 years from symptom onset to diagnosis in many patients. (3) 

Racial and ethnic minority patients frequently experience longer diagnostic delays and higher rates of emergency department utilization prior to definitive evaluation. (4) Historical misconceptions—such as the belief that endometriosis is less common in Black patients—have contributed to underdiagnosis and delayed recognition. (5) Implicit bias and structural barriers may be contributors to lead to symptoms being minimized or attributed to alternative diagnoses. 

The median delay from initial presentation to surgery ranged from 13.6 months for White patients to 15.2 months for Black patients, 48.1 months for Asian patients, and 39.4 months for LatinX patients. (4) In adolescents, laparoscopy was performed at lower rates in Asian, Black, and LatinX patients, compared to White patients. (6) 

Disparities in Access to Subspecialists and Surgical Care 

Access to Pelvic Pain Specialists and Complex Benign Gynecologists is not uniform across populations. Research from large health systems demonstrates that non-White patients are referred to Pelvic Pain Specialists at lower rates than White patients, even when presenting with similar symptoms. (7) Socioeconomic factors—including insurance coverage, geographic access to subspecialty care, and healthcare literacy—may further widen these gaps. These disparities may influence both the timing and type of interventions, including access to advanced surgical evaluation and treatment. 

Structural Drivers of Inequity 

Key contributors include: 

• Lack of knowledge and normalization of pain (8) 

• Implicit bias in pain assessment and symptom attribution (9) 

• Limited access to subspecialty CBG care in underserved communities (10) 

• Historical misconceptions about disease prevalence across racial groups (5) 

• Socioeconomic barriers, including transportation, insurance, and time away from work 

Imagine this: Your patient may be the primary income provider and needs to take time off work, then may need to find childcare, and may need to take public transportation, to then navigate to a pelvic floor physical therapist. Then repeat, for the recommended 8-12 sessions. (11) 

Addressing these drivers requires a systems-level approach rather than focusing solely on individual clinical encounters. 

The Role of CBG in Advancing Equity 

Complex Benign Gynecologic surgeons are uniquely positioned to help close these gaps by: 

• Expanding access to pelvic pain specialty clinics 

• Incorporating equity-focused research  

• Prioritizing research on disparities and promoting inclusive clinical guidelines 

• Improving provider education around diagnostic bias 

Looking Forward: Equity as a Clinical Imperative 

Health equity should be viewed as a core quality metric in pelvic pain care. By recognizing disparities and actively working to address them, the CBG community can ensure that advances in diagnosis, surgical technique, and multidisciplinary care benefit all patients experiencing chronic pelvic pain. 

1. Lamvu, G. , Carrillo, J. , Ouyang, C. & Rapkin, A. (2021). Chronic Pelvic Pain in Women. JAMA, 325 (23), 2381-2391. doi: 10.1001/jama.2021.2631. 
2. Horne, A. W. & Missmer, S. A.  (2022).  BMJ,  379 , e070750.  doi: 10.1136/bmj-2022-070750. 
3. As-Sanie S, Mackenzie SC, Morrison L, et al. Endometriosis: A Review. JAMA. 2025;334(1):64–78. doi:10.1001/jama.2025.2975 
4. Li, H. J., Song, Y., & Cho, Y. K. (2021). Racial disparities in access to diagnostic laparoscopy for endometriosis: diagnostic delay, ED visits, and pre-operative indications. Journal of Minimally Invasive Gynecology, 28(11), S134. 
5. Bougie O, Healey J, Singh SS. Behind the times: revisiting endometriosis and race. Am J Obstet Gynecol. 2019 Jul;221(1):35.e1-35.e5. doi: 10.1016/j.ajog.2019.01.238. Epub 2019 Feb 6. PMID: 30738028. Capra, L., O’Brien, K.E., Woolford, S.J. et al. Racial and Ethnic Inequities in Rates of Diagnostic Laparoscopy for Evaluation of
6. Endometriosis in Adolescents with Pelvic Pain: a Retrospective Cohort Study. J. Racial and Ethnic Health Disparities (2025). https://doi.org/10.1007/s40615-025-02763-5 
7. Zaritsky EF, Tucker LY, Hen E, Childs AJ, Ritterman Weintraub ML, Wicks C. Racial Disparities in Endometriosis and Pelvic Pain Treatment Within an Integrated Health Care Delivery System. Obstet Gynecol. 2025 Dec 1;146(6):888-897. doi: 10.1097/AOG.0000000000006045. Epub 2025 Aug 21. PMID: 40839882. 
8. Davenport S, Smith D, Green DJ. Barriers to a Timely Diagnosis of Endometriosis: A Qualitative Systematic Review. Obstet Gynecol. 2023 Sep 1;142(3):571-583. doi: 10.1097/AOG.0000000000005255. Epub 2023 Jul 13. PMID: 37441792. 
9. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations. Proc Natl Acad Sci U S A. 2016;113(16):4296–4301. doi:10.1073/pnas.1516047113 
10. Apple, A. N., Mulugeta-Gordon, L., Deagostino-Kelly, M., Kinson, M. S., Farrow, M. R., Koelper, N. C., … & James, A. (2024). High-Volume Surgeons and Reducing Racial Disparities in Route of Hysterectomy. Journal of Minimally Invasive Gynecology, 31(11), 911-918. 
11. Torosis M, Carey E, Christensen K, Kaufman MR, Kenton K, Kotarinos R, Lai HH, Lee U, Lowder JL, Meister M, Spitznagle T, Wright K, Ackerman AL. A Treatment Algorithm for High-Tone Pelvic Floor Dysfunction. Obstet Gynecol. 2024 Apr 1;143(4):595-602. doi: 10.1097/AOG.0000000000005536. Epub 2024 Feb 22. PMID: 38387036; PMCID: PMC10953682.