Primary care management of chronic pelvic pain in women
ABSTRACT
Chronic pelvic pain in women can arise from many causes and often results in significant declines in function and quality of life. A systematic approach for evaluating patients and initiating a management plan are recommended in the primary care setting. Comprehensive management strategies may include medication, pelvic physical therapy, and behavioral interventions.
KEY POINTS
- Diagnosing and managing chronic pelvic pain may be difficult, but patients are often best served when their primary care provider directs a team-based approach to their care.
- A detailed history, thorough abdominal and pelvic examinations, and targeted testing facilitate the diagnosis.
- As in other chronic pain syndromes, the goals of therapy should be incremental and meaningful improvements in pain, function, and overall well-being.
Cognitive behavioral therapy
Cognitive behavioral therapy is based on the idea that maladaptive cognitions can lead to problematic behaviors and emotional distress.24 Interventions are carried out by a provider with specialized training in its use (eg, therapist, pain psychologist, psychiatrist).
Meta-analyses of studies that investigated the efficacy of cognitive behavioral therapy for chronic pain found consistent small to medium improvement in pain-related symptoms.24 Studies that used cognitive behavioral therapy for pelvic pain found reduced overall pain severity and pain during intercourse, increased sexual satisfaction, enhanced sexual function, and less-exaggerated responses to pain.25–27
Although cognitive behavioral therapy and mindfulness-based interventions produce positive outcomes, research on these interventions typically includes treatment carried out over a span of weeks. Common barriers to such care include lack of patient motivation, financial limitations, transportation problems, and time constraints.
The following psychosocial interventions have been chosen because they can be delivered in a short amount of time and integrated into a patient’s medical care by a medical or behavioral health provider. Because of the brevity and simplicity of these interventions, more patients with pelvic pain can receive psychosocial care as part of their usual medical encounters.
Behavioral activation
People experiencing depressive symptoms tend to isolate themselves and stop participating in activities they enjoy, including spending time with family and friends. Behavioral activation interventions that address such isolating behaviors have been shown to be effective in improving depressive symptoms.28–30
A simple, brief intervention can be administered during routine medical care,28 involving the following steps:
- Determine activities that the patient might implement that would decrease depressive symptoms. Questions such as, “When do you feel less depressed?” or “What brings you some happiness in your life?” can generate possible activities.
- Ask the patient to identify people in her life who have been supportive and with whom she could engage.
- Create with the patient a list of possible activities and social interactions that may enhance well-being.
- Make a schedule for participating in activities, possibly with rewards for completing them. Patients should be encouraged to follow the prescribed schedule of activities rather than make decisions based on mood or other factors.
Relaxation strategies
Relaxation can help patients reduce stress and anxiety, and can also help reduce pain.31–33
Diaphragmatic or “belly breathing” is a deep-breathing technique in which participants are asked to take in air through the nose and fully fill the lungs and lower belly. This technique allows the body to take in more oxygen, helping to lower blood pressure and slow the heartbeat. In addition to physiologic benefits, concentrating on deep breathing can help slow down or stop intrusive thoughts and distressing physical sensations.34
Progressive muscle relaxation involves the systematic tensing and relaxing of each large muscle group in the body.35 The goal is to eliminate physical and emotional stress through focusing on the sensations of tension and relaxation.
Scripts and audio and video resources for belly breathing and progressive muscle relaxation can be found on the Internet. The techniques can be taught during the medical appointment or offered as resources for home practice.
Couple-based care
Targeting couples is more effective for improving well-being than focusing solely on a patient’s psychosocial difficulties, so each of the above interventions may be more effective if tailored to include the patient’s partner.36 If the partner is with the patient during medical visits or is included in long-term psychosocial treatment, he or she can be directly involved in learning and practicing interventions with the patient. If the partner is not present, the patient can be asked to practice newly learned well-being-enhancing strategies with her partner outside the appointment time. Couples therapy can improve psychosocial well-being for both partners.
Setting goals
