Spotlight On: Pelvic Pain

This month, we cast a spotlight on articles, SurgeryU videos, and Journal of Minimally Invasive Gynecology (JMIG) article recommendations from the AAGL Pelvic Pain (SIG) led by Chair Jessica Opoku-Anane, MD.

Access to SurgeryU and JMIG are two of the many benefits included in AAGL membership. The SurgeryU library features high-definition surgical videos by experts from around the world. JMIG presents cutting-edge, peer-reviewed research, clinical opinions, and case report articles by the brightest minds in gynecologic surgery.

SurgeryU video and JMIG article recommendations by our SIGs are accessible by AAGL members only. For full access to SurgeryU, JMIG, CME programming, and member-only discounts on meetings, join AAGL today!

SIG Recommended SurgeryU Video #1: 
Pelvic Anatomy for Chronic Pelvic Pain
By Kelly Wright, MD

Laparoscopic pelvic anatomy is reviewed using surgical footage. The author details anatomy as well as key anatomical relationships in the context of patients with chronic pelvic pain.  

Click Image to View Video

SIG Recommended SurgeryU Video #2:
Physical Exam for Chronic Pelvic Pain
By Alexandra M. Foxx, MD, Gabrielle T. Whitmore, MD, and Sara Renee Till, MD

Physical exams are one of the most important diagnostic tools available to physicians. Standardization of exams to include a trauma-informed approach helps to obtain objective information while optimizing patient comfort to establish a therapeutic relationship.  

   
Dr. Nuss is a physician in the Department of Obstetrics and Gynecology at the University of Oklahoma Tulsa School of Community Medicine in Tulsa, Oklahoma.

JMIG Article Recommendation #1:

Identifying Gaps in Pelvic Pain Education: A Scoping Review and Structured Analysis of Obstetrics and Gynecology Training Milestones
Mario E. Castellanos, MD, Jorge F. Carrillo, MD, Isabel Green, MD, MHPE, Alexandra Milspaw, PhD, Med, Georgine Lamvu, MD, MPH 

This article serves as a timely and essential resource for AAGL’s pursuit of ABOG/ACGME accreditation by identifying significant gaps in chronic pelvic pain (CPP) education within current residency and fellowship milestones. Castellanos et al. highlight that while trainees often feel inadequately prepared to manage CPP—a condition relevant across all subspecialties—current guidelines still lack specific standards for trauma-informed care and biopsychosocial evaluation. By providing evidence-based justification for these advanced training standards, the study underscores that graduate medical education curricula are critical to filling these educational voids and ensuring high-quality, patient-centered care for complex pelvic pain.

JMIG Article Recommendation #2:

The Impact of Targeted Endometriosis Treatment On Patients With Central Sensitization: Systematic Review and Meta Analysis – Journal of Minimally Invasive Gynecology
Adriana Gomez-Llerena, MD, Pallavi Shekawat, MD, Aishwarya Pradeep, MD, Victoria L. Clifton, MLIS, ELS, Sherif A. El Nashar, MBBCh, Aakriti R. Carrubba, MD

This systematic review and meta-analysis by Gomez-Llerena et al demonstrates the high incidence of central sensitization in patients with endometriosis and its negative impact on traditional treatment outcomes. Specifically, patients with central sensitization experience smaller improvements in pain scores and significantly more persistent pain after surgical treatment compared to endometriosis patients without central sensitization. The authors call for research in establishing diagnostic criteria for patients at risk for persistent pain following surgical management of endometriosis, and highlight the importance of a multimodal treatment approach to this population to address both peripheral generators and centralized pain. 

JMIG Articles Recommendations By:
Taylor Norton, MD
Adeoti Oshinowo, MD

Dr. Norton is a Board Member of the AAGL Pelvic Pain Special Interest Group and is with Intermountain Health in Murray, Utah.

Dr. Oshinowo is a member of the AAGL Pelvic Pain Special Interest Group and is with the Department of Obstetrics and Gynecology at Indiana University School of Medicine in Indianapolis, Indiana.

Diagnostic Complexity in Pelvic Pain: The Importance of Multidisciplinary Care

Our case involves a teenager with unrelenting chronic pelvic pain (CPP) and highlights the necessity of addressing the central nervous system (CNS) when traditional gynecological and pain interventions fail. 

Our patient is a 16-year-old who presented for evaluation for endometriosis and CPP. Onset of dysmenorrhea at 11 transitioning to CPP shortly thereafter. Previous laparoscopy by a fellowship-trained surgeon revealed normal peritoneum and only a minute focus of endometriosis on histologic-biopsies. She was using a progestin intrauterine device (IUD) and drosperinone, pregabalin 300mg daily along with acetaminophen, ketorolac, oxycodone, diazepam, castor oil and cannabis for flares. Extensive work-up had already been completed without other identifiable organic etiologies and symptoms were precluding ability to function and attend school. She had tried all available menstrual suppression outside of leuprolide and all oral neuromodulators at therapeutic doses in addition to physical, massage, acupuncture and TENS therapy. Pudendal and superior hypogastric nerve blocks provided no benefit. While pelvic floor exam did not fully reproduce her symptoms, hypertonicity was noted and botulinum toxin injections were scheduled. She was referred to pain management to discuss ketamine infusions and pain psychology. 

In the interim, the patient was repeatedly in the emergency room for acute on chronic flares despite attempts at outpatient management. Ultimately, she was admitted for inpatient management. A ketamine infusion initially provided excellent relief, though its efficacy waned during the admission with continued narcotic need.  Repeat superior hypogastric plexus block was performed via a higher trans-discal approach to ensure block of the entire plexus; however, this again led to no improvement and strongly suggested CNS etiology of the pain (i.e. nociplastic pain).  She was discharged home with short interval follow up with our pediatric pain management team. She was subsequently admitted to the Pediatric Pain Rehabilitation Program to increase use of adaptive pain coping skills and daily independent functioning. After completing the program, she endorsed improved coping skills and significant improvement in daily function, however, still reported daily 10/10 pain. Continued outpatient ketamine infusions have provided about 30% symptom relief. The patient continues to meet with pediatric pain psychology to support mental health and coping skills. She is now reintegrating into school. The search for a daily medication to manage her pain continues to be challenging, however the functional improvement she has made remains promising.  

While few patients are recalcitrant to this level, gynecologists must surround themselves with a multidisciplinary team who can aid with patient management while remaining captain of the ship as the patient’s advocate. When addressing “structural” peripheral pain generators such as endometriosis, pelvic floor, GI and urinary tract contributors is not successful, “non-structural” targets within the peripheral and central nervous system become the focus. Central sensitization (including nociplastic pain) can be difficult to manage but many patients can find a combination of therapies that improve their quality of life. While most gynecologists do not manage advanced neuromodulation or injections, they play a vital role in advocating for multidisciplinary care to optimize patient function. It can truly take a village to care for the patient with CPP.  

About the Authors: 
Lisa Berkowitz, MD
Ashley Gubbels, MD

Is R U MOVVING SOMe the New PALM COIEN?   

FIGO and the International Pelvic Pain Society (IPPS) have developed a new classification system for chronic pelvic pain, called “R U MOVVING SOMe” [1]. This framework, developed through collaboration with clinicians, researchers, patients, and patient advocates, aims to evolve the way that we conceptualize and communicate about chronic pelvic pain. The “R U MOVVING SOMe” system proposes 12 categories to aid in the classification of chronic pelvic pain. The first nine “R U MOVVING” categories – Reproductive, Urinary, Musculoskeletal, Other, Vulvovaginal, Vascular, Idiopathic, Neurologic, and Gastrointestinal – reflects groups of conditions arising from specific organ systems that may contribute to chronic pelvic pain. These are often the primary pain generators that may underlie this condition. Alternatively, the last three “SOMe” categories – Sensitization/Nociplastic, overlapping pain conditions and Mental health – aid in describing possible pain modifiers or intensifiers that may impact a patient’s perception of their chronic pelvic pain. 

The new FIGO-IPPS classification system is an inflexion point in global collaboration related to chronic pelvic pain. Similar to the way PALM COIEN is used to describe underlying causes of abnormal uterine bleeding, the “R U MOVVING SOMe” system allows for the classification of suspected etiologies for chronic pelvic pain [2]. On the other hand, this classification system builds upon basic underlying etiologies to also include neurocognitive and behavioral drivers of chronic pelvic pain. With this, the new FIGO-IPPS classification system is more expansive than historical gynecologic classification systems and is a great representation of the bio-psycho-social model of disease. 

It is well known that although chronic pelvic pain affects many women internationally, patients with this condition often experience delays in seeking care and receiving treatment for their symptoms [3]. This is likely related to chronic pelvic pain often being multifaceted and comorbid, leading to complexities in diagnosing, describing, and managing this condition [4].  

Given the intricate nature of this prevalent disease, it is important that the new FIGO-IPPS classification system allows for the opportunity to recognize and document multiple potential causes and factors contributing to a patient’s chronic pelvic pain. This may improve not only communication between gynecology specialists regarding patients with this condition but also improve collaboration with other healthcare professionals who play a role in the multimodal management of these patients. Among researchers, there are additional opportunities for adoption of this classification system, which can provide a more encompassing communication tool regarding chronic pelvic pain research. As we look ahead, there is also room for integrating this new classification system into electronic medical records, which can better facilitate care for patients and communication between specialties and health delivery systems. Therefore, although this classification system is not yet widely used, global adoption may allow for a more cohesive and adaptive approach to diagnosing and discussing chronic pelvic pain. 

In summary, the new FIGO-IPPS classification system offers a unique opportunity for improved diagnosis, management, and standardized research related to chronic pelvic pain. It will be interesting to see how this framework potentially advances both scientific understanding and patient-centered care moving forward. 

References: 

1. Lamvu G, Villegas-Echeverri JD, Allaire C, et al. Developing the FIGO-IPPS “R U MOVVING SOMe” classification system for female chronic pelvic pain. Int J Gynecol Obstet. 2025;171:550-565. doi:10.1002/ijgo.70522 
2. Practice Bulletin No. 128: Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women. Obstetrics & Gynecology 120(1):p 197-206, July 2012. | DOI: 10.1097/AOG.0b013e318262e320   
3. Dydyk AM, Singh C, Gupta N. Chronic Pelvic Pain. [Updated 2025 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554585/  
4. Chronic Pelvic Pain: ACOG Practice Bulletin, Number 218. Obstet Gynecol. 2020 Mar;135(3):e98-e109. doi: 10.1097/AOG.0000000000003716. PMID: 32080051

About the Authors: 
Emily Forester, DO
Adrian Balica, MD

Dr. Forester is a PGY1 OB-GYN resident at Atlantic Health MMC in New Jersey.

Dr. Balica is Chair at Atlantic Health OMC in New Jersey and an Affiliate Professor of Obstetrics and Gynecology at the USC School of Medicine in Columbia, South Carolina.