About IPPS...

Professionals Engaged in Pain Management for People of All Gender Identities

In 1995 a group of physicians met to discuss their common interest in addressing a gap in chronic pelvic pain research, diagnostics, support and treatment. After two years, the International Pelvic Pain Society (IPPS) was incorporated to serve as a forum for professional and public education.  Since then, the IPPS has grown to include gynecologists, urologists, gastroenterologists, PM&R physicians, physical and occupational therapists, psychologists, social workers and other health professionals committed to a biopsychosocial and interdisciplinary approach to the treatment of conditions associated with chronic pelvic pain.

Chronic pelvic pain (CPP) negatively affects millions of people across the gender identity spectrum throughout the world.  CPP can impact a person’s physical, emotional, social and material well-being.  There are many biopsychosocial contributors to pelvic pain and healthcare providers need special skills in physical examination and history taking in order to better evaluate and treat patients with this type of pain.  Often, conventional medical and surgical treatments are ineffective, however, a range of new medical, surgical and mind-body therapies are available to help improve the lives of individuals living with CPP.

Please join us in our mission to provide the highest standard of care for individuals across the gender spectrum who are living with chronic pelvic pain.  With your help, we can continue to advance access to quality care and work with patients to support them with their health-related goals.

In addition to promoting excellence in care IPPS, members receive additional benefits including a quarterly newsletter, regular research updates, annual meeting discounts, access to a network of providers and other benefits designed to enhance education, practice and research.

Our primary goal is to recruit, organize and educate healthcare professionals actively involved in the treatment of patients who have chronic pelvic pain.  To achieve this goal, our society:

  • Serves as an educational resource for health care professionals and patients
  • Promotes multi-disciplinary and biopsychosocial approaches to the diagnosis and treatment of CPP
  • Promotes research and dissemination of research findings

Menopause Comes with More than Mood Swings

October 2, 2019

Menopause Comes with More than Mood Swings

...It Deserves its Place Among Chronic Pain Conditions



At this year’s PAINWeek, the International Pelvic Pain Society (IPPS) led a track of educational sessions on managing distinct types of genital, vulvar, and overall chronic pelvic region pain. Georgine Lamvu, MD, MPH, who serves as Chair of the IPPS Board and works at the Orlando VA Medical Center, provided an update on new terminology in the field and addressed the specifics of genitourinary syndrome of menopause (GSM), a relatively recent classification that has a longer lifespan than previously thought.


Updated Definitions

Vulvar pain can begin at any age, said Dr. Lamvu, and what’s important for clinicians to know now is that there is a new classification for the specific type of vulvar pain known as vulvodynia. This type of vulvar pain must last 3 months or more without a clear identifiable cause, with potential associated factors. The International Society for the Study of Vulvovaginal Disease (ISSVD) and the IPPS updated the definition in 2018 to differentiate vulvodynia from general vulvar pain. The idiopathic condition must be a diagnosis of exclusion.

Another updated definition, this one in the DSM-5, is for vaginismus. This term captures vaginal pain that lasts longer than 6 months and that is associated with intense fear or anxiety around intercourse and the tensing of pelvic and lower abdominal muscles. The prior definition was more psychogenic, noted Dr. Lamvu. We know now that vaginismus may have a musculoskeletal dysfunction component. Further, this condition cannot be attributed to PTSD, domestic violence, or other life stressors. “We are really looking at an intense psychological fear accompanied by musculoskeletal issues—anything else is not ‘vaginismus.’

Then there is GSM, which was previously known atrophic vaginismus, vulvovaginal atrophy, or urogenital atrophy. Although the disorder was described by the International Society for the Study of Women’s Health and the North American Menopause Society in 2014, and further explained by Gandhi J in an AJOG paper in 2016, many providers are still catching up with the fact that GSM is disease that progresses over time. The syndrome groupslower urogenital tract signs and symptoms associated with a low-estrogen state.

The GSM pathophysiology has to do with changes in tissue integrity and the acidity of the vagina, and thus, reduced protection against vaginitis and urinary tract infections. Symptoms may include dyspareunia, incontinence, prolapse, thin vaginal epithelium, impaired smooth muscle proliferation, loss of vascularity, dryness, and itching—all occurring in the hyposterogenism state. Risk factors may include bilateral salpingo-oophorectomy, ovarian failure, chemotherapy, smoking, and alcohol use.

“When you see someone with vaginal atrophy, you have to screen for urinary and sexual dysfunction, but now you can avoid any negative connotations associated with the term” said Dr. Lamvu. “Menopause may be identified as the cause of both vulvar andurinary symptoms with this condition.”

Genitourinary Syndrome of Menopause—On the Chronic Progression Continuum

Sharing the stats, Dr. Lamvu noted that 15% of premenopausal women experience GSM and 40 to 54% of postmenopausal women have GSM. Most of the symptoms have to do with declining estrogen levels, which change most rapidly between ages 45 and 55.

Of interest, a review of 64 studies over the course of 2000 to 2014 around the world on menopause symptom prevalence found that 30 to70% of women experience GSM symptoms worldwide (see Makara-Studzinskia MT, Prz Menopauzalny, 2014). Sexual dysfunction post-menopause may go up to 92% prevalence. Women do not often mention sexual dysfunction in particular—they may mention dryness, said Dr. Lamvu, but providers need to talk to them about this symptom as well.

The median vasomotor duration in another study was 7.4 years for symptoms of menopause; symptoms may go on 4.5 years after menopause as well (see Avis NE, et al, JAMA Intern Med, 2015). “Essentially, the earlier a woman starts perimenopause, the longer her GSM symptoms may last, possibly for 11.8 years in total,” said Dr. Lamvu.

GSM is considered to be chronic, progressive, and unlikely to resolve without treatment—this, on top of its long timeframe and the fact that chronic pain may increase with age, make effective assessment and management crucial.

In fact, one VA study showed that women who had menopause had twice as high odds of also having a chronic pain syndrome and twice as high odds of having multiple pain diagnoses, even after adjusting for age, race, BMI, mental health, and so forth, noted Dr. Lamvu. “This means our screening process for these patients has to go way beyond asking patients, ‘Is your vagina dry?’”

“Pain specialists may see myalgias and neuralgias in their patients, and guess what,” continued Dr. Lamvu, “Women get those symptoms in the vagina too… Clinicians may not automatically associate these diagnoses with the vagina but they need to.”

As an example, she shared that she often sees chronic pain conditions in her GSM patients—including fibromyalgia, temporomandibular disorder, low back pain, and migraine. Anxiety and depression are also common with GSM.

Sometimes clinicians focus on vaginal atrophy and forget that other things in the pelvis can cause pain, from bladder pain syndrome to myofascial pelvic pain to neuralgia to IBS. There are commonly missed conditions associated with vaginal pain and dyspareunia. As a result, many patients go through a primary care doctor, a gynecologist, and a psychologist and are told they have vaginal atrophy, but GSM is much more than that. Evaluations of vulvovaginal pain need to go outside of a doctor’s typical comfort zone to include a biopsychosocial evaluation. Gynecological screenings must also include trauma-informed care.

How to Manage GSM

There is good news for patients with GSM—despite being a chronic condition, symptoms can be managed based on severity, said Dr. Lamvu. Education and lifestyle modifications can be very beneficial, including: 

Genitourinary Syndrome of Menopause—On the Chronic Progression Continuum

Sharing the stats, Dr. Lamvu noted that 15% of premenopausal women experience GSM and 40 to 54% of postmenopausal women have GSM. Most of the symptoms have to do with declining estrogen levels, which change most rapidly between ages 45 and 55.

Of interest, a review of 64 studies over the course of 2000 to 2014 around the world on menopause symptom prevalence found that 30 to70% of women experience GSM symptoms worldwide (see Makara-Studzinskia MT, PrzMenopauzalny, 2014). Sexual dysfunction post-menopause may go up to 92% prevalence. Women do not often mention sexual dysfunction in particular—they may mention dryness, said Dr. Lamvu, but providers need to talk to them about this symptom as well. 

The median vasomotor duration in another study was 7.4 years for symptoms of menopause; symptoms may go on 4.5 years after menopause as well (see Avis NE, et al, JAMAIntern Med, 2015). “Essentially, the earlier a woman starts perimenopause, the longer her GSM symptoms may last, possibly for 11.8 years in total,” said Dr. Lamvu. 

GSM is considered to be chronic, progressive, and unlikely to resolve without treatment—this, on top of its long timeframe and the fact that chronic pain may increase with age, make effective assessment and management crucial. 

In fact, one VA study showed that women who had menopause had twice as high odds of also having a chronic pain syndrome and twice as high odds of having multiple pain diagnoses, even after adjusting for age, race, BMI, mental health, and so forth, noted Dr. Lamvu. “This means our screening process for these patients has to go way beyond asking patients, ‘Is your vagina dry?’” 

“Pain specialists may see myalgias and neuralgias in their patients, and guess what,” continued Dr. Lamvu, “Women get those symptoms in the vagina too… Clinicians may not automatically associate these diagnoses with the vagina but they need to.”

As an example, she shared that she often sees chronic pain conditions in her GSM patients—including fibromyalgia, temporomandibular disorder, low back pain, and migraine.  Anxiety and depression are also common with GSM.

Sometimes clinicians focus on vaginal atrophy and forget that other things in the pelvis can cause pain, from bladder pain syndrome to myofascial pelvic pain to neuralgia to IBS. There are commonly missed conditions associated with vaginal pain and dyspareunia. As a result, many patients go through a primary care doctor, a gynecologist, and a psychologist and are told they have vaginal atrophy, but GSM is much more than that. Evaluations of vulvovaginal pain need to go outside of a doctor’s typical comfort zone to include a biopsychosocial evaluation. Gynecological screenings must also include trauma-informed care.

How to Manage GSM

There is good news for patients with GSM—despite being a chronic condition, symptoms can be managed based on severity, said Dr. Lamvu. Education and lifestyle modifications can be very beneficial, including:

  • Avoid overwashing of the vagina (most patients think more washing is better; it is not)
  • Try to have regular intercourse if not painful
  • Cease smoking
  • Wear looser undergarments.

In terms of pharmacological approaches, nonhormonal lubricants may be recommended to relieve dryness and itching temporarily; these should be water or silicone based and irritant free.

Low dose vaginal estrogen is also a first-line option. The research is definitive on low dose vaginal estrogen as being effective and safer than systemic or oral hormonal therapy, said Dr. Lamvu, who noted that it typically takes 8 to 12 weeks to work. The patient may opt to use an inserted capsule, a cream, etc. Other treatment methods may involve dilators, physical therapy (PT), topical lidocaine, SERMS, vaginal DHEA, laser treatment for vascularity and collagen, oxytocin gel, and more. In cases of sexual dysfunction, Cognitive Behavioral Therapy (CBT) may be used to help with desensitization.

In those patients with GSM and other chronic pain syndromes, multimodal treatment is necessary. For instance, a vaginal estrogen, with perhaps a lidocaine ointment, with perhaps PT and CBT, as well as treatment of sleep,  mood or fatigue disorders may be warranted. Sometimes, a patient assumes that insomnia or mood changes are just symptoms of menopause, but they should be screened for a true sleep or mood disorder on top of menopause.

Practically speaking, Dr. Lamvu shared that the number one obstacle she sees in GSM management is patient compliance. Patients do not like to use the creams or fail to finish the full therapy. For this reason, patient education and involvement in the decision-making process is key. Remind patients that while 8 to 12 weeks is a typical time for noticeable improvement, a return to normal sexual function may take longer than 3 months.

Overall, emphasized Dr. Lamvu, the percentage of women experiencing and living with GSM is staggering. “We cannot focus on what we don’t know—we cannot ignore the vagina,” she said. “We have to put her in the same chronic conundrum as the other chronic pain conditions.”

Avoid overwashing of the vagina (most patients think more washing is better; it is not)
Try to have regular intercourse if not painful
Cease smoking
Wear looser undergarments

In terms of pharmacological approaches, nonhormonal lubricants may be recommended to relieve dryness and itching temporarily; these should be water or silicone based and irritant free.

Low dose vaginal estrogen is also a first-line option. The research is definitive on low dose vaginal estrogen as being effective and safer than systemic or oral hormonal therapy, said Dr. Lamvu, who noted that it typically takes 8 to 12 weeks to work. The patient may opt to use an inserted capsule, a cream, etc. Other treatment methods may involve dilators, physical therapy (PT), topical lidocaine, SERMS, vaginal DHEA, laser treatment for vascularity and collagen, oxytocin gel, and more. In cases of sexual dysfunction, Cognitive Behavioral Therapy (CBT) may be used to help with desensitization.

In those patients with GSM and other chronic pain syndromes, multimodal treatment is necessary. For instance, a vaginal estrogen, with perhaps a lidocaine ointment, with perhaps PT and CBT, as well as treatment of sleep, mood or fatigue disorders may be warranted. Sometimes, a patient assumes that insomnia or mood changes are just symptoms of menopause, but they should be screened for a true sleep or mood disorder on top of menopause.

Practically speaking, Dr. Lamvu shared that the number one obstacle she sees in GSM management is patient compliance. Patients do not like to use the creams or fail to finish the full therapy. For this reason, patient education and involvement in the decision-making process is key. Remind patients that while 8 to 12 weeks is a typical time for noticeable improvement, a return to normal sexual function may take longer than 3 months.

Overall, emphasized Dr. Lamvu, the percentage of women experiencing and living with GSM is staggering. “We cannot focus on what we don’t know—we cannot ignore the vagina,” she said. “We have to put her in the same chronic conundrum as the other chronic pain conditions.”







 

Posted by IPPS Admin on October 2, 2019, 12:00AM

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2019 Recipients

Alexander Wang, MD
IPPS Resident Scholarship (300)

2017 Recipients

Sara R Till, MD, MPH
IPPS Research Development Grant (10,000)
Chensi Ouyang, MD
Fred Howard Early Investigator Award (2,000)
Charlotte Pham, DO
IPPS Resident Scholarship in Pelvic Pain Education
Jorge F. Carrillo, MD
IPPS ASPE Education Award

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