The Role of Trauma and Mental Health in the Treatment of Chronic Pelvic Pain: A Systematic Review of the Intervention Literature

Towards comprehensive management of symptomatic endometriosis: beyond the dichotomy of medical versus surgical treatment

Except when surgery is the only option because of organ damage, the presence of suspicious lesions, or the desire to conceive, women with endometriosis-associated pain often face a choice between medical and surgical treatment. In theory, the description of the potential benefits and potential harms of the two alternatives should be standardized, unbiased, and based on strong evidence, enabling the patient to make an informed decision. However, doctor's opinion, intellectual competing interests, local availability of specific services and (mis)information obtained from social media, and online support groups can influence the type of advice given and affect patients' choices. This is compounded by the paucity of robust data from randomized controlled trials, and the anxiety of distressed women who are eager to do anything to alleviate their disabling symptoms. Vulnerable patients are more likely to accept the suggestions of their healthcare provider, which can lead to unbalanced and physician-centred decisions, whether in favour of either medical or surgical treatment. In general, treatments should be symptom-orientated rather than lesion-orientated. Medical and surgical modalities appear to be similarly effective in reducing pain symptoms, with medications generally more successful for severe dysmenorrhoea and surgery more successful for severe deep dyspareunia caused by fibrotic lesions infiltrating the posterior compartment. Oestrogen-progestogen combinations and progestogen monotherapies are generally safe and well tolerated, provided there are no major contraindications. About three-quarters of patients with superficial peritoneal and ovarian endometriosis and two-thirds of those with infiltrating fibrotic lesions are ultimately satisfied with their medical treatment although the remainder may experience side effects, which may result in non-compliance. Surgery for superficial and ovarian endometriosis is usually safe. When fibrotic infiltrating lesions are present, morbidity varies greatly depending on the skill of the individual surgeon, the need for advanced procedures, such as bowel resection and ureteral reimplantation, and the availability of expert colorectal surgeons and urologists working together in a multidisciplinary approach. The generalizability of published results is adequate for medical treatment but very limited for surgery. Moreover, on the one hand, hormonal drugs induce disease remission but do not cure endometriosis, and symptom relapse is expected when the drugs are discontinued; on the other hand, the same drugs should be used after lesion excision, which also does not cure endometriosis, to prevent an overall cumulative symptom and lesion recurrence rate of 10% per postoperative year. Therefore, the real choice may not be between medical treatment and surgery, but between medical treatment alone and surgery plus postoperative medical treatment. The experience of pain in women with endometriosis is a complex phenomenon that is not exclusively based on nociception, although the role of peripheral and central sensitization is not fully understood. In addition, trauma, and especially sexual trauma, and pelvic floor disorders can cause or contribute to symptoms in many individuals with chronic pelvic pain, and healthcare providers should never take for granted that diagnosed or suspected endometriosis is always the real, or the sole, origin of the referred complaints. Alternative treatment modalities are available that can help address most of the additional causes contributing to symptoms. Pain management in women with endometriosis may be more than a choice between medical and surgical treatment and may require comprehensive care by a multidisciplinary team including psychologists, sexologists, physiotherapists, dieticians, and pain therapists. An often missing factor in successful treatment is empathy on the part of healthcare providers. Being heard and understood, receiving simple and clear explanations and honest communication about uncertainties, being invited to share medical decisions after receiving detailed and impartial information, and being reassured that a team member will be available should a major problem arise, can greatly increase trust in doctors and transform a lonely and frustrating experience into a guided and supported journey, during which coping with this chronic disease is gradually learned and eventually accepted. Within this broader scenario, patient-centred medicine is the priority, and whether or when to resort to surgery or choose the medical option remains the prerogative of each individual woman.

Guideline No. 445: Management of Chronic Pelvic Pain

OBJECTIVE

To provide evidence-based recommendations for the management of chronic pelvic pain in females.

TARGET POPULATION

This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain.

BENEFITS, HARMS, AND COSTS

The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability.

EVIDENCE

Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals.

TWEETABLE ABSTRACT

Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Guideline No. 443a: Opioid Use Throughout Women's Lifespan: Fertility, Contraception, Chronic Pain, and Menopause

OBJECTIVE

To provide health care providers with the best evidence on opioid use and women's health. Areas of focus include general patterns of opioid use and safety of use; care of women who use opioids; stigma, screening, brief intervention, and referral to treatment; hormonal regulation; reproductive health, including contraception and fertility; sexual function; perimenopausal and menopausal symptoms; and chronic pelvic pain syndromes.

TARGET POPULATION

The target population includes all women currently using or contemplating using opioids.

OUTCOMES

Open, evidence-informed dialogue about opioid use will lead to improvements in patient care and overall health.

BENEFITS, HARMS, AND COSTS

Exploring opioid use through a trauma-informed approach offers the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Therefore, health care providers and patients must understand the potential role of opioids in women's health (both positive and negative) to ensure informed decision-making.

EVIDENCE

A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, illicit drugs, fertility, pregnancy, breastfeeding, and aging.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All health care providers who care for women.

TWEETABLE ABSTRACT

Opioid use can affect female reproductive function; health care providers and patients must understand the potential role of opioids in women's health to ensure informed decision-making.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Performance and acceptability of the Stressful Life Events Screening Questionnaire in a chronic pain population: a mixed-methods study

Introduction

Pain-related fear, anxiety, and avoidance may play key roles in the chronification of pain and related disability. For practitioners, knowledge about the source or drivers of these fears, including patients' exposure to potentially traumatic events (PTEs) and related posttraumatic stress symptoms, could be particularly helpful in guiding their treatment approach.

Objectives

We aimed to investigate whether the use of a brief screening for PTEs could help inform chronic pain treatment.

Methods

The performance and acceptability of the Stressful Life Events Screening Questionnaire (SLESQ) was assessed among 567 adult patients (59% women, mean age 48.1 years) meeting at a hospital outpatient pain clinic. The sensitivity, specificity, and 20 months temporal stability of the SLESQ, assessing exposure to 14 specific trauma types followed by a 15th item capturing exposure to "other events," were assessed through digital administration and follow-up interviews with 55 participants. The qualitative responses of 158 participants reporting exposure to "other events" were reviewed and assessed based on fulfillment of the A Criterion for traumatic events in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The acceptability of the SLESQ was assessed in clinical interviews with 12 participants.

Results

The SLESQ demonstrated acceptable sensitivity (70.0%), high specificity (94.9%), and moderate temporal stability (κ = 0.66, P < 0.001). Participants' qualitative elaborations of "other events" were largely (76.3%) consistent with Criterion A events. The screening was well accepted and welcomed.

Conclusion

The results indicate that the use of a brief screening for potential trauma may be helpful to guide clinical practice in chronic pain settings.

Dissociation Among Women with Chronic Pelvic Pain: Relation to Surgical Treatment, Pelvic Pain Severity, and Health-Related Quality of Life

Chronic pelvic pain (CPP) is associated with a history of trauma and symptoms of somatoform dissociation. We aimed to describe how somatoform dissociation impacts CPP symptoms, surgical treatment, and health-related quality of life (HRQOL). Patients (N = 133) diagnosed with CPP presenting for an appointment at a women's health clinic between November, 2019 - July, 2021 were recruited to participate in a cross-sectional study and complete a survey assessing symptoms of somatoform dissociation, post-traumatic stress disorder (PTSD), pelvic pain severity, history of CPP-related surgeries, and mental and physical HRQOL. We also conducted a post-hoc analysis assessing correlations of individual symptom items on the Somatoform Dissociation Questionnaire (SDQ-20) with HRQOL outcomes. We did not find a relationship between somatoform dissociation and pelvic pain severity or surgical history. Physical HRQOL outcomes were related to somatoform dissociation, PTSD symptoms, and pelvic pain severity, while mental HRQOL outcomes were connected to somatoform dissociation and PTSD symptoms. Our study reveals preliminary evidence suggesting that among CPP patients, HRQOL outcomes are affected by unique profiles of positive and negative symptoms of somatoform dissociation, including sensory disturbances, localized genital pain, and generalized numbness and bodily analgesia. Addressing specific symptoms of somatoform dissociation may enhance HRQOL among trauma-exposed women with CPP. Replication studies are needed to validate our findings. Integrating trauma-informed approaches, including standardized evaluations of trauma exposure and symptoms of somatoform dissociation into routine care for women with CPP is encouraged.

The Experiences of Persistent Pain Among Women With a History of Intimate Partner Violence: A Systematic Review

Women experience persistent pain at higher rates than men; however, women are less likely to be provided with adequate or appropriate care and more likely to have their pain experiences dismissed. The purpose of this review is to consider the complex interaction of the biopsychosocial factors in the experience of persistent pain in order to inform improved models of care. Given persistent pain is among the most frequently reported health consequences of intimate partner violence (IPV), this review focused on studies exploring the association between persistent pain and IPV. Three reviewers independently and systematically searched seven databases. Qualitative and quantitative studies describing the association between IPV and persistent pain published between January 2000 and June 2018 were included. Twelve studies met the inclusion criteria. The included studies demonstrated that a history of IPV places an additional burden on women who experience persistent pain that cannot be explained by an underlying psychological condition. Health care practitioners should be aware of this phenomena to ensure diagnosis, assessment, and treatment plans are targeted accordingly. Future policy directives and research should account for and seek to elucidate this additional burden.

Adverse childhood events and substance use history or recent opioid use among women with chronic pelvic pain

Introduction:

We aimed describe the association of adverse childhood events (ACEs) with a history of substance use disorder and recent opioid use among women with chronic pelvic pain (CPP).

Methods:

This cohort study investigated two data sets of women presenting to subspecialty gynecologic and pelvic floor disorder clinics where questionnaires querying substance use disorder, opioid use in the last 3 months, and ACEs (BRFSS-ACE questionnaire) were obtained. We compared the recent opioid use, morphine milligram equivalents (MMEs) per dose, pills used per month, and minimum MMEs reported per month between women with high (⩾4) or low (<4) reported ACEs.

Results:

Patients completing the BRFSS-ACE ( n = 113) were older, more likely to be Hispanic/Latina, had higher levels of education, a higher prevalence of pain syndromes, and a greater degree of bother from pelvic floor disorders than those not completing the BRFSS-ACE. Women reporting a high number of (⩾4) ACEs ( n = 56) were younger, less likely to identify as Hispanic, had higher co-occurrence of fibromyalgia and IBS, and a higher prevalence of a history of substance use disorder (18% vs 2%, p < 0.01) than women with low (<4) ACEs ( n = 57). High ACEs were not significantly associated with recent opioid use (43% vs 39%, p = 0.83), opioid pills used per month, MMEs per dose, or the minimum MMEs used per month.

Conclusion:

Women with CPP reporting higher numbers of ACEs are more likely to report a history of substance use disorder but were not more likely to have used opioids in the last 3 months.

Depression Partially Mediates the Association of Adverse Childhood Experiences with Pain Intensity in Patients with Chronic Pelvic Pain Syndrome: Results from a Cross-Sectional Patient Survey

OBJECTIVE

Adverse childhood experiences (ACEs), such as emotional and physical maltreatment, are linked to chronic pelvic pain syndrome (CPPS) in adults. Psychological factors are important in understanding CPPS. We aimed to determine the nature and frequency of ACEs in male and female patients with CPPS and to investigate whether somatic symptoms and psychological comorbidities mediate the relationship of ACE severity with pain intensity.

DESIGN

Cross-sectional study.

SETTING

Interdisciplinary outpatient clinic for CPPS in Hamburg, Germany.

SUBJECTS

Individuals with CPPS (n = 234) who were 18 to 84 years of age.

METHODS

Using a self-administered questionnaire, we assessed the history of ACEs (ACE Scale), pain intensity (McGill Pain Questionnaire), somatic symptoms (Patient Health Questionnaire-15]), depression (Patient Health Questionnaire-9), and anxiety (Generalized Anxiety Disorder Scale). Parallel mediation analysis was conducted to examine whether the association of ACE severity with pain intensity is mediated by somatic symptoms, depression, and anxiety.

RESULTS

Emotional abuse and neglect were reported more than twice as often as physical abuse and neglect (37.2% vs 17.1%). Depression partially mediated the association of ACE severity with pain intensity in the whole study population. In sex-stratified analyses, different patterns of associations were observed, but somatic symptoms predicted pain intensity in both sexes.

CONCLUSIONS

Emotional maltreatment was highly prevalent, supporting an increased consideration of psychological factors in CPPS and indicating the need to screen for ACEs in patients with CPPS. Findings further suggest that depression and somatic symptoms may be important targets for therapeutic interventions in patients with CPPS who have a history of childhood adversity.

Sexual abuse and chronic pelvic pain in a gynecology outpatient clinic. A pilot study

INTRODUCTION AND HYPOTHESIS

Almost 20% of women will suffer from sexual abuse at some point in their lives. This is a known risk factor for developing chronic pelvic pain (CPP), which is a major health problem worldwide. We conducted a pilot study in a Gynecology Outpatient Clinic to find the correlation between these two clinical entities and provide better evidence for their diagnosis and treatment.

METHODS

A semi-structured interview for the evaluation of sexual violence in women (EVS) was used as a screening tool and a complement to routine gynecological examination to identify patients suffering from sexual abuse. Patients included were also assessed for comorbidities, including CPP, and other coexisting mental health problems.

RESULTS

Of the 61 patients screened, 33 (54.1%) had pelvic pain. Also, 11 patients (18%) had suffered sexual abuse at some point in their lives, which was only disclosed when the specific interview was performed. Ten patients (90.8%) out of 11 that had been sexually abused also had pelvic pain. This was found to be statistically significant in this sample (p = 0.008) with a more than 11-fold greater risk of having pelvic pain (OR, 11.7; 95% CI, 1.4-98.7). Most patients did not have psychological violence (77%) but those that did (23%) had a seven-fold greater risk of having pelvic pain (OR, 7.4; 95% CI, 1.5-36.9).

CONCLUSION

Specific tools should intentionally be used for evaluating sexual abuse and chronic pelvic pain, since a strong correlation exists between these two entities and they are seldom reported by patients.