A Two-Pronged Approach

Pain-Specific Therapy

Here we have many different treatments— pharmacologic, psychological, and neuroablative—that rest, to some extent, on acceptance of the notions that pain may not necessarily be cured but can be managed, and that patients can progress toward more normal lives that are not dominated by pain.

It is important that we not use psychological treatment as a last resort. If we do everything else, and then tell a patient that everything else has failed and we are recommending psychological treatment, we are in essence sending her the message that we think her pain is not real. There are two errors here that warrant correction: First, psychological pain is indeed real. Second, most of the time, the etiology of chronic pelvic pain is not psychological.

What we should do right away, with all of our patients, is explain that cognitive-behavioral therapy, relaxation therapy, and other psychological techniques are extremely useful in helping patients decrease and cope with pain.

I sometimes use the analogy of how our emotions and mind can cause us to turn beet red and make us sweat and become tachycardic when we are embarrassed about something we have said or done. If our emotions can cause that kind of physical reaction, might not relaxation therapy, for instance, cause physiologic changes that help decrease our pain? More often than not, it is financial issues and the relatively poor coverage of mental health care in this country—and not patient acceptance—that is the major impediment to including psychotherapy in the treatment of chronic pelvic pain.

In the neuroablative arena, there is some evidence that adding presacral neurectomy (excision of the superior hypogastric plexus, or presacral nerve) to other treatments for endometriosis is sometimes indicated, although it's not perfectly clear what those indications are. I tend to use the therapy in patients who have previously failed medical or surgical therapy. It is one of the neurolytic therapies that may be useful in decreasing pain centrally even when there is no specific nerve dysfunction.

Tricyclic antidepressants, particularly amitriptyline, have been shown to be effective in treating chronic pelvic pain and other chronic pain syndromes, and therefore are a part of the pharmacologic arm of pain-specific therapy. In addition to reducing depressive symptoms—which is often an aim anyway in patients with chronic pelvic pain, as depression occurs with increased frequency in these women—it is generally thought that the tricyclic antidepressants improve pain tolerance.

Analgesics, of course, are a mainstay of pharmacologic pain-specific treatment of chronic pelvic pain, and there is little controversy about the use of analgesics like acetaminophen, NSAIDs, tricyclic antidepressants, and other neuropathic medications, such as gabapentin and other anticonvulsants used for chronic pain.

The use of opioids in the treatment of chronic pain remains controversial, however. Several studies, as well as clinical experience in pain centers, suggest that opioids are effective for chronic—and not only acute—pain: that the analgesics improve function and quality of life in patients who have failed other treatments. There is, however, the well-known risk of addiction, which is estimated to occur in anywhere from 3% to 15% of chronic pain patients.

As gynecologists, we can consider providing opioid treatment ourselves, but only if we are attuned to looking for addictive behaviors and only if we are familiar with state regulations that address chronic opioid use. Federal codes are quite clear in stating that the federal government has no intention of preventing physicians from treating chronic pain with opioids if such treatment is indicated, but state regulations vary.

Treatment of Chronic Pelvic Pain

This is the second installment of the Master Class in Gynecologic Surgery on pelvic pain. In part 1, I drafted Dr. Fred Howard, who serves as associate chair for academic affairs, director of the division of gynecologic specialists, and professor of obstetrics and gynecology at the University of Rochester (N.Y.), to discuss the differential diagnosis and work-up of chronic pelvic pain. In part 2, he will turn from the diagnosis to the treatment of chronic pelvic pain.

I am certain that the reader will be immediately drawn to Dr. Howard's double-armed treatment regimen of both disease-specific therapy and pain-specific therapy. Although he recognizes the importance of surgical treatment—especially in cases of endometriosis, uterine fibroids, ovarian cysts, and other reproductive tract disorders—he is quick to point out that medical, psychological, or physical therapy will suffice in most women's cases. Moreover, as Dr. Howard recognizes, physicians as well as their patients must realize and accept that although a cure is the ultimate goal of treatment, pain management may be the reality.