Evaluation and management of chronic pelvic pain

Laying the Groundwork: A Pilot Study Exploring Improved Endometriosis Management Strategies in Primary Healthcare

Objective

To evaluate if a brief educational intervention for primary health care staff regarding endometriosis gives sustainable knowledge of endometriosis symptoms and if a brief questionnaire for women seeking care for common symptoms is feasible in the Swedish primary care context.

Design

Pilot study.

Setting

3 primary care centres (PCCs) in Sweden. Exploring knowledge among staff about endometriosis at baseline and 3 months after an information workshop. Evaluation of feasibility of a brief questionnaire for women seeking care for common symptoms For PCC personnel: knowledge about endometriosis at baseline and after 3 months. For patient questionnaire: whether adequate, understandable, acceptable, and feasible.

Participants

Females in primary care centre waiting room, and staff members at participating PCCs.

Results

The knowledge level of endometriosis was improved or sustained after 3 months compared to baseline among staff at PCCs. Over 90% of the patients stated that the questionnaire was adequate, understandable, acceptable, and feasible.

Conclusion

We found that an educational programme improved the staff's knowledge about endometriosis. The programme together with the patient questionnaire could be a way to enhance knowledge about endometriosis among PCCs. This combined effort might facilitate earlier detection and treatment of women with endometriosis.

Effect of Acupuncture on Chronic Pelvic Pain Secondary to Abdominal Myofascial Syndrome Not Responsive to Local Anesthetic Block: A Pilot Study

Objective: Strong evidence shows that 85% of women with chronic pelvic pain (CPP) have musculoskeletal disorders, such as abdominal myofascial pain syndrome (AMPS). The aim of this research was to assess the efficacy of local acupuncture treatment for women with CPP secondary to AMPS unresponsive to treatment with trigger-point injection. Materials and Methods: This pilot study involved 17 women with moderate-to-severe AMPS-related CPP. Acupuncture treatments were given at abdominal-wall trigger points once per week for 10 consecutive weeks. Pain relief was assessed with a visual analogue scale (VAS), the McGill questionnaire, and pressure dynamometer. Quality of life and psychosocial function (risk for anxiety and depression) were evaluated using the Short-Form-36 questionnaire and the Hospital Anxiety and Depression scale. Assessments were performed at baseline and after 1, 3, and 6 months of treatment. Results: Both the VAS and McGill pain questionnaire showed significantly decreased pain intensity (VAS, P < 0.001; and McGill, P 0.049), and the effects were sustained even at 6 months after treatment. Conclusions: Acupuncture treatment was effective for the women who participated in this study, and the current authors believe that these preliminary results suffice to recommend performing randomized controlled trials.

Measures used to assess chronic pelvic pain in randomized controlled clinical trials: a systematic review

RATIONALE

Many types of pain assessment are available to researchers carrying out clinical trials in chronic pelvic pain (CPP), ranging from a single-item scale to multidimensional inventories.

AIM

Our objective was to investigate which assessments of pain are more commonly used in clinical trials on CPP.

METHOD

We have reviewed articles published between 1991 and 2014. A total of 74 studies out of 1299 original research articles reviewed met the selection criteria by containing at least one method of pain assessment. The selected studies were classified according to the dimensions of pain evaluated, the type of scale and the descriptors used.

RESULTS

The instruments most frequently used were single-item VAS and Biberoglu and Behrman pain score, while multidimensional inventories were used in few studies. The results of clinical studies in CPP are more frequently based on one-dimensional measurements. Valuable results from clinical studies in CPP might have been omitted because of incomplete outcome measurements.

CONCLUSION

We believe the authors of clinical studies should report their results in a comprehensive way including in the outcomes of the measurement of one-dimensional and multidimensional pain characteristics.

Measurement of pain and anthropometric parameters in women with chronic pelvic pain

RATIONALE, AIMS AND OBJECTIVES

To analyse anthropometric parameters, clinical pain and experimental pain in women with chronic pelvic pain (CPP).

METHODS

Ninety-one women with a clinical diagnosis of CPP, mean age of 40.03 ± 9.97 years, submitted to anthropometric evaluation based on body mass index (BMI) and percent body fat (%BF) using bioimpedance body composition monitor; pain intensity was determined by visual analogue scale (VAS), numerical categorical scale (NCS) and McGill Pain Questionnaire; experimental pain was determined by transcutaneous electrical nerve stimulation (TENS), and anxiety and depression symptoms were determined by the Hospital Anxiety and Depression scale.

RESULTS

A total of 54.8% of the women showed %BF >32 risk of disease associated with obesity. Regarding the anthropometric data, a statistically significant difference was observed between groups for both BMI and %BF (P<0.0001). In the analysis of pain intensity by the VAS, NCS and total McGill, there was no significant difference between the groups, and experimental pain by TENS revealed significant difference only between the normal weight and overweight groups (P=0.0154). The results of anxiety symptoms were above the cut-off point in all groups, with no significant difference between them (P=0.3710). The depression symptoms were below the cut-off point in the normal weight group and above the cut-off point in the overweight and obese groups, 9.469(4.501) and 9.741(4.848), respectively, with no significant difference between them (P=0.6476).

CONCLUSION

Evaluation of anthropometric parameters and pain measurements can be applied in clinical practice, making a contribution to the diagnosis and influencing the choice of a more effective treatment for women with CPP.

Total Laparoscopic Hysterectomy: Overtreatment for Misdiagnosed Organic cause or Undertreatment for Idiopathic Chronic Pelvic Pain?

Background

Chronic pelvic pain (CPP) is considered a symptom but also a syndrome with misunderstood pathophysiology and treatment options ranging from conservative management to opioid analgesia and surgical intervention. The aim of this study was to evaluate the role of gynecological surgery in modifying presurgical pain status and reducing the postoperative analgesic use of patients suffering CPP. The second aim of the study was to analyze intraoperative and histological differences in patients who benefited from surgery versus those without benefit.

Methods

An observational study was conducted in 16 fertile women affected by CPP, treated by total laparoscopic hysterectomy (TLH) to solve their pelvic pain. In 7 cases, undetected pelvic endometriosis was found.

Results

A complete resolution of pre-operative pain symptoms (score 0) occurred in 9 patients (56.2%), an occasional pelvic discomfort (score 1) in 2 cases (12.5%), 2 patients reported minimal benefit of pelvic pain (score 2), while in 3 cases, severe pain persisted (score 3). The correlation between intraoperative/histological features and reported symptoms after surgery showed that 7 of 9 patients (77.7%) who benefited from surgery were affected by an organic cause; while 5 women with minimal or no benefits from the surgery did not have any organic disease (idiopathic CPP).

Conclusions

If conservative treatment fails to treat CPP, investigative laparoscopy represents a necessary step to discriminate patients with misdiagnosed organic from idiopathic CPP, selecting those who will potentially benefit from hysterectomy. The role of concomitant appendectomy needs to be defined in surgical treatment of idiopathic CPP.

Non-surgical interventions for the management of chronic pelvic pain

BACKGROUND

Chronic pelvic pain is a common and debilitating condition; its aetiology is multifactorial, involving social, psychological and biological factors. The management of chronic pelvic pain is challenging, as despite interventions involving surgery, many women remain in pain without a firm gynaecological diagnosis.

OBJECTIVES

To assess the effectiveness and safety of non-surgical interventions for women with chronic pelvic pain.

SEARCH METHODS

We searched the Menstrual Disorders and Subfertility Group Specialised Register. We also searched (from inception to 5 February 2014) AMED, CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS. We handsearched sources such as citation lists, trial registers and conference proceedings.

SELECTION CRITERIA

Randomised controlled trials (RCTs) on non-surgical management of chronic pelvic pain were eligible for inclusion. We included studies of women with a diagnosis of pelvic congestion syndrome or adhesions but excluded those with pain known to be caused by endometriosis, primary dysmenorrhoea (period pain), active chronic pelvic inflammatory disease or irritable bowel syndrome. We considered studies of any non-surgical intervention, including lifestyle, physical, medical and psychological treatments.

DATA COLLECTION AND ANALYSIS

Study selection, quality assessment and data extraction were performed independently by two review authors. Meta-analysis was performed using the Peto odds ratio (Peto OR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs). The primary outcome measure was pain relief, and secondary outcome measures were psychological outcomes, quality of life, requirement for analgesia and adverse effects. The quality of the evidence was assessed by using GRADE methods.

MAIN RESULTS

Twenty-one RCTs were identified that involved non-surgical management of chronic pelvic pain: 13 trials were included in the review, and eight were excluded. The studies included a total of 750 women-406 women in the intervention groups and 344 in the control groups. Included studies had high attrition rates, and investigators often did not blind adequately or did not clearly describe randomisation procedures. Medical treatment versus placebo Progestogen (medroxyprogesterone acetate (MPA)) was more effective than placebo at the end of treatment in terms of the number of women achieving a greater than 50% reduction in visual analogue scale (VAS) pain score immediately after treatment (Peto OR 3.00, 95% CI 1.70 to 5.31, two studies, n = 204, I(2) = 22%, moderate-quality evidence). Evidence of benefit was maintained up to nine months after treatment (Peto OR 2.09, 95% CI 1.18 to 3.71, two studies, n = 204, I(2) = 0%, moderate-quality evidence). Women treated with progestogen reported more adverse effects (e.g. weight gain, bloatedness) than those given placebo (high-quality evidence). The estimated effect of lofexidine on pain outcomes when compared with placebo was compatible with benefit and harm (Peto OR 0.42, 95% CI 0.11 to 1.61, one study, 39 women, low-quality evidence). Women in the lofexidine group reported more adverse effects (including drowsiness and dry mouth) than women given placebo (moderate-quality evidence). Head-to-head comparisons of medical treatments Head-to-head comparisons showed that women taking goserelin had greater improvement in pelvic pain score (MD 3, 95% CI 2.08 to 3.92, one study, n = 47, moderate-quality evidence) at one year than those taking progestogen. Women taking gabapentin had a lower VAS pain score than those taking amytriptyline (MD -1.50, 95% CI -2.06 to -0.94, n = 40, low-quality evidence). Study authors reported that no statistically significant difference was observed in the rate of adverse effects among women taking gabapentin compared with women given amytriptyline. The study comparing goserelin versus progestogen did not report on adverse effects. Psychological treatment Women who underwent reassurance ultrasound scans and received counselling were more likely to report improved pain than those treated with a standard 'wait and see' policy (Peto OR 6.77, 95% CI 2.83 to 16.19, n = 90, low-quality evidence). Significantly more women who had writing therapy as a disclosure reported improvement in pain than those in the non-disclosure group (Peto OR 4.47, 95% CI 1.41 to 14.13, n = 48, very low-quality evidence). No difference between groups in pain outcomes was noted when other psychological therapies were compared with standard care or placebo (quality of evidence ranged from very low to low). Studies did not report on adverse effects. Complementary therapy Distension of painful pelvic structures was more effective for pain when compared with counselling (MD 35.8, 95% CI 23.08 to 48.52 on a zero to 100 scale, one study, n = 48, moderate-quality evidence). No difference in pain levels was observed when magnetic therapy was compared with use of a control magnet (very low-quality evidence). Studies did not report on adverse effects.The results of studies examining psychological and complementary therapies could not be combined to yield meaningful results.

AUTHORS' CONCLUSIONS

Evidence of moderate quality supports progestogen as an option for chronic pelvic pain, with efficacy reported during treatment. In practice, this option may be most acceptable among women unconcerned about progestogenic adverse effects (e.g. weight gain, bloatedness-the most common adverse effects). Although some evidence suggests possible benefit of goserelin when compared with progestogen, gabapentin as compared with amytriptyline, ultrasound versus 'wait and see' and writing therapy versus non-disclosure, the quality of evidence is generally low, and evidence is drawn from single studies.Given the prevalence and healthcare costs associated with chronic pelvic pain in women, RCTs of other medical, lifestyle and psychological interventions are urgently required.

Endometriosis: current therapies and new pharmacological developments

Endometriosis is a chronic inflammatory condition that is responsive to management with steroids. The establishment of a steady hormonal environment and inhibition of ovulation can temporarily suppress ectopic implants and reduce inflammation as well as associated pain symptoms. In terms of pharmacological management, the currently available agents are not curative, and treatment often needs to be continued for years or until pregnancy is desired. Similar efficacy has been observed from the various therapies that have been investigated for endometriosis. Accordingly, combined oral contraceptives and progestins, based on their favourable safety profile, tolerability and cost, should be considered as first-line options, as an alternative to surgery and for post-operative adjuvant use. In situations where progestins and oral contraceptives prove ineffective, are poorly tolerated or are contraindicated, gonadotrophin-releasing hormone analogues, danazol or gestrinone may be used. Future therapeutic options for managing endometriosis must compare favourably against existing agents before they can be considered for inclusion into current practice. Finally, as reproductive prognosis is not ameliorated by medical treatment, it is not indicated for women seeking conception.

A qualitative analysis of adolescents' experiences of active and sham Japanese-style acupuncture protocols administered in a clinical trial

INTRODUCTION

Acupuncture is a complex holistic intervention in which patient-practitioner relationships and healing changes occur in interactive, iterative ways. Qualitative research is one way to capture such complexity. This study sought to understand better the experiences of adolescents involved in acupuncture treatment.

MATERIALS AND METHODS

We included a qualitative substudy as part of a pilot randomized sham-controlled study of the use of Japanese acupuncture to treat chronic pelvic pain in adolescent girls. Seven (7) interviews were attained. Themes were double-coded and analyzed using qualitative analysis software.

RESULTS

Regardless of treatment arm, all subjects reported positive study-related changes, often attributed to positive qualities of the patient-practitioner relationship. Participants in both the sham and verum acupuncture treatment arms reported in the narratives that they were unsure of their study assignment. In contrast, the study's close-ended success of blinding question suggests that some participants were sure of their treatment allocation.

CONCLUSIONS

As we continue to study acupuncture using sham controls, we need a better understanding of the possible affects of sham treatments on both treatment outcomes and success of blinding. Qualitative research is one-way to explore subtle emergent changes in participants' experiences.

Japanese-style acupuncture for endometriosis-related pelvic pain in adolescents and young women: results of a randomized sham-controlled trial

STUDY OBJECTIVE

To assess feasibility, and collect preliminary data for a subsequent randomized, sham-controlled trial to evaluate Japanese-style acupuncture for reducing chronic pelvic pain and improving health-related quality of life (HRQOL) in adolescents with endometriosis.

DESIGN

Randomized, sham-controlled trial.

SETTINGS

Tertiary-referral hospital.

PARTICIPANTS

Eighteen young women (13-22y) with laparoscopically-diagnosed endometriosis-related chronic pelvic pain.

INTERVENTIONS

A Japanese style of acupuncture and a sham acupuncture control. Sixteen treatments were administered over 8 weeks.

MAIN OUTCOME MEASURES

Protocol feasibility, recruitment numbers, pain not associated with menses or intercourse, and multiple HRQOL instruments including Endometriosis Health Profile, Pediatric Quality of Life, Perceived Stress, and Activity Limitation.

RESULTS

Fourteen participants (out of 18 randomized) completed the study per protocol. Participants in the active acupuncture group (n = 9) experienced an average 4.8 (SD = 2.4) point reduction on a 11 point scale (62%) in pain after 4 weeks, which differed significantly from the control group's (n = 5) average reduction of 1.4 (SD = 2.1) points (P = 0.004). Reduction in pain in the active group persisted through a 6-month assessment; however, after 4 weeks, differences between the active and control group decreased and were not statistically significant. All HRQOL measures indicated greater improvements in the active acupuncture group compared to the control; however, the majority of these trends were not statistically significant. No serious adverse events were reported.

CONCLUSION

Preliminary estimates indicate that Japanese-style acupuncture may be an effective, safe, and well-tolerated adjunct therapy for endometriosis-related pelvic pain in adolescents. A more definitive trial evaluating Japanese-style acupuncture in this population is both feasible and warranted.

Adolescent endometriosis-related pelvic pain treated with acupuncture: two case reports

BACKGROUND

Chronic pelvic pain in adolescents accounts for 10% of outpatient gynecology visits, and 70% of adolescent patients whose pelvic pain is unresponsive to initial therapy have endometriosis. To date, there has been no published research investigating the use of acupuncture for adolescents with chronic pelvic pain and/or endometriosis.

METHODS

This paper presents two case reports describing the impact of a course of acupuncture on adolescent girls with endometriosis-related chronic pelvic pain of more than 1 year.

RESULTS

Both patients, undergoing between 9 and 15 treatments over a 7- to 12-week period, experienced modest improvement in pain as measured by oral self-reports of pain on a scale from 1 to 10, as well as self or family-reported improvement in headaches, nausea and fatigue. No adverse effects were reported.

CONCLUSIONS

These case reports provide preliminary evidence that acupuncture may be an acceptable and safe adjunct treatment therapy for some adolescents with endometriosis-related pelvic pain refractory to standard antiendometriosis therapies. These observations suggest that a prospective, randomized controlled trial of the safety and efficacy of acupuncture for this population may be warranted.

Cyproterone acetate versus a continuous monophasic oral contraceptive in the treatment of recurrent pelvic pain after conservative surgery for symptomatic endometriosis

OBJECTIVE

To evaluate the efficacy and safety of cyproterone acetate versus an oral contraceptive in the treatment of endometriosis-associated recurrent pelvic pain.

DESIGN

Randomized controlled trial.

SETTING

Academic center.

PATIENT(S)

Ninety women with recurrent moderate or severe pelvic pain after conservative surgery for symptomatic endometriosis.

INTERVENTION(S)

Six months of continuous treatment with oral cyproterone acetate, 12.5 mg/d, or an oral contraceptive containing ethinyl estradiol, 0.02 mg, and desogestrel, 0.15 mg.

MAIN OUTCOME MEASURE(S)

Degree of satisfaction with therapy.

RESULT(S)

Six patients in the cyproterone acetate arm and nine in the oral contraceptive arm withdrew because of side effects (n = 9), treatment inefficacy (n = 4), or loss to follow-up (n = 2). At 6 months, dysmenorrhea, deep dyspareunia, and nonmenstrual pelvic pain scores were substantially reduced, and significant improvements were observed in health-related quality-of-life, psychiatric profile, and sexual satisfaction; no major between-group differences were seen. Subjective and metabolic side effects were limited. According to an intention-to-treat analysis, 33 of 45 (73%) of patients in the cyproterone acetate group and 30 of 45 (67%) in the oral contraceptive group were satisfied with the treatment received.

CONCLUSIONS

Both cyproterone acetate and a continuous monophasic oral contraceptive were effective, safe, and inexpensive therapy for recurrent pain after conservative surgery for endometriosis.

Pitfalls of the medical paradigm in chronic pelvic pain

This article reviews specific clinical and philosophical problems in the medical and psychiatric literature on chronic pelvic pain since 1993. The problem of the dichotomy of 'organic' and 'psychogenic' pain has been well established in previous literature. The aim here is to consider recent developments purporting to respond to the impasse presented by this dichotomy. An evaluation of emergent trends towards multi-disciplinarity, and the 'biopsychosocial model' is developed. The resulting pitfalls discussed include the failure to develop understandings of the 'subjective' aspects of pain, the tendency to reduce causal processes to 'mechanisms', and the tendency to consider the psychosocial as purely reactive to the biological, inevitably positioned as prior. It is argued that these trends are only partial solutions to the problems and do not fully address the issues at stake. A greater diversity of theoretical and empirical perspectives needs to be introduced into medical research on chronic pelvic pain.