Medical Tx Rivals Surgery in Chronic Pelvic Pain


ORLANDO — Women with chronic pelvic pain responded as well to medical treatment as they did to surgery, according to a prospective, observational cohort study of 370 patients that was carried out 1 year after treatment, Dr. Georgine Lamvu said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

About 15% of women report having chronic pelvic pain (CPP) in their lifetime. It is the primary indication for 12% of hysterectomies and 40% of laparoscopies and costs over $2 billion annually, said Dr. Lamvu of the University of North Carolina at Chapel Hill.

The mean pain level score, as assessed by the McGill Pain Questionnaire, was 30, or moderate to severe, in 49% of both medically and surgically treated women who were referred to the university's pelvic pain clinic for evaluation of continued CPP.

Likewise, moderate to severe depression, as measured by the Beck Depression Inventory scale, was diagnosed in 22% of both groups.

Surgical treatment ranged from diagnostic laparoscopy to hysterectomy, and medical treatment consisted of pharmacotherapy, psychotherapy, and physical therapy.

One year later, the mean McGill Pain Questionnaire score had decreased from 30 to 23 in both groups. Overall, depression scores were unchanged in 48%, improved in 32%, and worsened in 20%. However, depression did not predict worse outcome, Dr. Lamvu said. “We were surprised, but that is what we found. Outcomes were similar with both treatment types.”

Dr. Lamvu said she is planning further studies that will focus on physician-patient relationships, which may influence outcomes for pain treatment in women with CPP. “There may actually be some biological reasons for the way women respond to pain management after they have had interactions with a physician, so we will be studying that next.”

In another study on CPP presented at the meeting, Jane Leserman, Ph.D., also of the University of North Carolina, reported that breaking CPP into diagnostic subtypes may be useful in guiding therapy.

A chart review and questionnaire of 306 consecutive patients who presented to the university's pelvic pain clinic found the following most common diagnostic subtypes:

▸ Diffuse abdominal pelvic pain (43%).

▸ Vulvovaginal pain (20%).

▸ Cyclic pain (10%).

▸ Neuropathic pain (9%).

▸ Nonlocal pain (7%).

▸ Trigger point pain (6%).

▸ Palpation of the uterus (6%).

Patients who had diffuse abdominal pelvic pain had worse physical functioning and more pain than did patients with vulvovaginal, cyclic, neuropathic, and fibroid pain.

Those with vulvovaginal pain had the best physical functioning and the least pain, Dr. Leserman said.

Slightly less than half of the patients (48%) reported having been sexually or physically abused.

The women also scored at or below the 25th percentile on mental and physical health measures compared with the U.S. female population as a whole, Dr. Leserman said.

Endometriosis, which was present in 21% of the women, was not found to be significantly related to any measure of mental or physical health status, Dr. Leserman said.

“It seems like the diagnostic subtypes were better predictors of health status than was endometriosis. Perhaps the degree of diffuseness of pain and the cyclic nature of pain may help guide us in the future in terms of treatment,” she said.

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