May Is Pelvic Pain Awareness Month!

While there are many causes to be aware of and advocate for, one close to our hearts at the International Pain Society is abdomino-pelvic pain, and we are excited to report that May is Pelvic Pain Awareness Month! This designation for May was created by the International Pelvic Pain Society last year. So let’s talk a few moments about what is pelvic pain, how impactful the diagnosis can be, and what we can do!

By: Kaitlyn Parrotte, PT, DPT, OCS, CFMT
Edited by: Amy Stein, DPT, BCB-PMD

According to the American College of Obstetricians and Gynecologists, chronic pelvic pain is described as a “noncyclical pain of at least 6 months’ duration that appears in locations such as the pelvis, anterior abdominal wall, lower back, or buttocks, and that is serious enough to cause disability or lead to medical care.”1 While the incidence and prevalence of chronic pelvic pain in men and women are reported in an inconsistent manner,2 some estimates compare its global prevalence to asthma (4.3%-8.6%), and one to the prevalence of low back pain (23.2 +/- 2.9%).3 Individuals who suffer from chronic pelvic ad abdominal pain also often present with other complicating factors such as depression, anxiety, poor sleep, difficulty with work, and/or relationship issues. Also, many people with chronic pain are commonly disabled by fear that activity will make things worse.2 Furthermore, pelvic pain is puzzling as it is a multisystem disorder, which includes sexual, bowel, urinary, gynecological, and musculoskeletal symptoms. It is challenging to determine a clear mechanism of pain with this diagnosis, and the term “pelvic pain” does not take into account the many signs and symptoms that may be occurring outside of the anatomical pelvis.2  

Due to the complicated nature of this condition, there is a significant economic burden associated with management of it. In the United States, approximately $881.5 million was spent on chronic pelvic pain to cover the costs of direct healthcare. Additionally, approximately $2 billion was spent as an overall cost, which includes direct medical costs and indirect costs, such as those related to absenteeism from work.3 Besides economic burdens on individuals suffering from chronic abdominal and pelvic pain, there are also many challenges for the healthcare system to deal with. For instance, while a diagnosis of chronic pain in the United States typically yields more than 80% of physician referrals, it is estimated that only about 15% of individuals with chronic pelvic pain consult primary care providers, and only 40% of this group are referred to specialists for further investigation.3 Furthermore, if specialist care is involved in the management of chronic pelvic pain, it is often spread between multiple specialties, such as urology, gynecology, urogynecology, colorectal services, pain medicine, and even occasionally spinal services, rheumatology, and neurology. Thus, there is a risk that patients may be passed back and forth between different teams of the same speciality, or between different specialties, and may not receive consistent or effective care.2  In a nutshell: chronic abdomino-pelvic pain can be a debilitating condition that can have significant consequences on an individual’s physical, mental, economic, and social well-being.

Hopefully, if you were not already passionate about raising awareness of pelvic pain, you now have some insight as to why this cause is so important! Now the question lies, what can you do? How can you get involved?

One thing that you can take action is by hosting a local event to raise awareness and/or funds for research and educational programs that will promote more effective diagnosis and treatment for those suffering from abdomino-pelvic pain; these funds can be directly donated to IPPS! While hosting an event may seem overwhelming, it is actually easier than you think! Here is a guide to help you plan one:

How to plan and host a Pelvic Pain Awareness Event

Step One: decide what type of event and where

Some ideas are to host a bar night, a get together at a coffee shop with a musician, a lecture in the form of grand rounds or a community education event in the name of pelvic pain awareness.

*bar night: easiest option: no planning other than location, an agreement from the bar to donate a portion of the proceeds, and getting people to come.

*more involved: plan a speaker night for pelvic pain awareness--could be yourself and/or other speakers. Location could be your office, coffee shop, hospital, or restaurant/bar.

Examples of previous events:

1. Coffee shop example: Milwaukee’s 2017 event was held at a coffee shop.   Healthcare providers were invited. When response was low, the event was opened up to patients, friends and family. There was a flyer posted in the clinic. Attendees ordered from the menu and the coffee shop donated 20% of what was ordered. Several patients wrote checks to IPPS who could not attend.

2. Speaker event example: “Girls Night Out” style event in Los Angeles: This event was held in a Speakeasy. Cocktails and hors d’ouvers were served. Entry fee was required, but the fee was offset quite a bit by corporate sponsors. There were approximately 50 people (due to room size) and we sold out.  There were 4 speakers- 2 urogyns, 1 PT, and 1 sex therapist.  It was designed as a community event, but other providers did purchase tickets to attend, too.

3. Bar night example: “Asked a friend to use part of his bar for non-profit event.”  The bar gave reduced food prices and first drink free.  2 PT’s and 1 MD collected an entrance fee for food and drink tickets on the event planning website Eventbrite and at the door. All proceeds went to IPPS.

The to do list:

  1. Choose a date in May.
  2. Speak with venue. Many bars are willing to donate up to 20% of proceeds to a charity for 1-2 hours: it brings people into the bar/restaurant, it shows support for the community and they write it off as a donation: (Provide them with www.pelvicpain.org and let them know we are a non-profit 501c3).
  3. Arrange speakers if planned.
  4. Make flyer with template provided (See attached).
  5. Entrance fee: Suggested donation (i.e., $25 food/drink value, charge $45) vs. donation from venue proceeds.
  6. Raffle option: Reach out to local and pelvic pain vendors for prizes (i.e., hot packs, massages, free spin class, restaurant gift certificate, etc.). Can have raffle tickets sold at the bar. (e.g. $6=1 ticket, $1=2 tickets, $20=5 tickets)
  7. If you have industry connections, you could ask for support for the event as well.

Getting the word out:

· Display the flyer in your clinic (see attached template)

·        Contact Heather: heather@fusionwellnesspt.com  to get posted on IPPS Twitter, website, and Facebook accounts.

· Post on your social media. Let them know this is happening across the country.

· Do a press release with a local paper.

Getting funds to IPPS:

Send checks to IPPS Business office.

Questions:  Contact Debbie Callif: debbie@callif.org   262-240-1202 or Amy Stein: amy@beyondbasicspt.com  212-354-2622

If hosting an event is not a possibility, you can still contribute in many ways:

  1. Meet with practitioners in your area to educate them on chronic pelvic pain and build a referral network for patients.
  2. Host a community outreach program at your clinic, at a local gym, at a workout studio, or at a community center, to help make the general public more aware of what pelvic pain is, and what can be done about it. This way, you are better equipping patients to be able to advocate for themselves!
  3. Donate funds for research and educational programs at the International Pelvic Pain Society website (https://wjweis.association-service.org/securesite/ipps/donations.aspx).

There are many ways to contribute! So circle the month of May in your calendars and consider how you can participate. Together, we can help bring chronic pelvic pain into the forefront of healthcare, to ensure individuals dealing with this condition are receiving consistent and effective care.

Sources:

  1. Andrews J, Yunker A, Reynolds WS, Likis FE, et al. Noncyclic chronic pelvic pain therapies for women: comparative effectiveness. AHRQ Comparative Effectiveness Reviews, Rockville (MD), 2012.
  2. Baranowski AP, Lee J, Price C, Hughes J. Pelvic pain: a pathway for care developed for both men and women by the British Pain Society. Br J Anaesth. 2014;112(3):452–9.  
  3. Ahangari A. Prevalence of chronic pelvic pain among women: an updated review. Pain Physician. 2014;17(2):E141–7.

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