Chronic pelvic pain (CPP) is a complex condition that affects nearly 26% of women worldwide.1–3 It is often associated with negative cognitive, behavioral, sexual, emotional consequences and presents with symptoms suggestive of lower urinary tract, sexual, bowel, myofascial, or gynecologic dysfunction and may be caused by a variety of conditions such as bladder pain syndrome (BPS), myalgia of the abdomen and pelvic floor, irritable bowel syndrome, and endometriosis.4 CPP also has profound implications in mental health and quality of life.5 In the United States (US), CPP accounts for 10% of all gynecology office visits, 40% of laparoscopies, and 10-32% of hysterectomies annually.4,6 The cost of CPP care can range from US$1,820 to US$20,898 per woman per year.7

Clinicians often fail to recognize CPP symptoms, leading to delayed diagnosis and treatment. A study of patients with BPS found that the gynecologists only recognized BPS in 1.6% of patients with symptoms.8 In regard to endometriosis, patients on average took 3.7 to 5.7 years of clinical visits with an average of 5 healthcare professionals before a diagnosis of endometriosis was established.9–12 These findings suggest that inadequate clinician training on CPP is a major obstacle to timely diagnosis and treatment.

Two studies found that graduating OBGYN residents and fellows in the US feel inadequately prepared to address CPP.13,14 A qualitative study published by Witzeman et al. found that OBGYN residents felt unprepared by their residency program to address the clinical needs of CPP patients. Similarly, Orlando et al. reported that at least 50% of fellows in minimally invasive gynecologic surgery (MIGS) had little to no experience with the EM of CPP conditions, other than endometriosis, and desired an expanded curriculum to address CPP in fellowship training.14 Although there are published clinical guidelines for the EM of CPP, these studies suggest that these guidelines may not be sufficiently incorporated into residency and fellowship training.

The Accreditation Council for Graduate Medical Education (ACGME) endorses competency-based medical education (CBME), which serves as the foundation for training program accreditation. CBME aims to achieve a standard level of proficiency for all graduates through specific competencies.15,16 Each competency is further divided into sub-competencies that list specific milestones. A milestone is defined as “a marker (or series of markers) denoting progress toward achieving competence”.17 The ACGME describes milestones as representing the “important core” of the discipline, to produce competent physicians that meet healthcare needs of the public.18 It is important to note that training programs design their curriculums to help their trainees meet these milestones to ensure competency in the discipline. EM of CPP is an important core of the discipline. Gynecologists, regardless of subspecialty, frequently encounter patients with CPP. For example, patients with endometriosis may seek consultation with an infertility specialist, while patients with pelvic floor disorders and bladder pain syndrome may seek care from a urogynecologist.

Based on recent needs assessments, there is a demand for better CPP education. In July 2022, new educational milestones were released by the ACGME and the AAGL for OBGYN residencies and subspeciality programs,18 yet it is not known if the updated Milestones documents align with current practice recommendations for the EM of CCP. Therefore, our overall goal was to determine if there are gaps between educational milestones and clinical practice guidelines. The first objective was to review current guidelines on EM of CPP and determine if there are elements (clinical themes) that are routinely and consistently recommended across guidelines. The second objective was to perform a structured analysis of ACGME and AAGL Milestones documents and determine if they are aligned with the clinical themes identified in CPP guidelines and recommendations.