One in seven women will experience pelvic pain in her lifetime, and between one- and two-thirds will have chronic pain that persists for more than three years. But although it’s common, it can be one of the most difficult and frustrating conditions physicians treat.
“As doctors we like to have a protocol: Someone comes in, you treat them, they go home. Everyone is happy,” Sarah Fox, MD, of Brown University’s Women and Infants Hospital and presenter at the American Congress of Obstetrics and Gynecology’s (ACOG) 61st Annual Clinical Meeting.
But patients with chronic pelvic pain (CPP) require ongoing treatment without a specific diagnosis, circumstances that can be challenging for physicians. Fox works primarily with women who don’t respond to traditional treatment, the people “no one else can fix.”
“You really have to have a lot of tools in your toolbox,” she said.
After ruling out serious and dangerous conditions, Fox turns to techniques to reduce pain and increase quality of life, including mind-body techniques, supplements, and creative and individualized lifestyle solutions.
Use mind-body therapy with patients
“Mind-body therapies are well-studied, and we really need to be using them,” said Fox. Both cognitive behavioral therapy (CBT) and mindfulness meditation have been shown to reduce pain and improve quality of life, and it’s possible that similar results can be achieved with classic psychotherapy, support groups, and meditative hobbies such as knitting. The key is being regimented.
For patients who aren’t interested in CBT or meditation, Fox notes that prayer modifies brain activity in the same way as meditation, and has worked with patient’s clergy to set up a prayer program, where he or she will pray with her once a week.
It’s also important to get a patient on board with treating the depression that often comes with chronic pain, and that can lead a patient to obsessing over her pain and stop exercising or doing things she enjoys. Fox recommends that this be a second visit conversation, and stresses that doctors should lead into the conversation with the pain, not the depression.
“I say, ‘Pain causes people to feel blue. When you feel blue, you have decreased norepinepherine and serotonin in the spine, so more pain signals get to the brain, then you feel more pain, and you get more blue,’” said Fox. “If you tell a patient this, you get her on board with treating her depression. If you tell her to see a psychiatrist, you’ve lost her.”
Weigh the risks and benefits compared to traditional treatment
Many physicians who feel they’ve exhausted their options turn to surgery, and many CPP patients have had multiple, and fruitless, exploratory procedures.
“Do not be the person who does the sixth, or the 11th, or God forbid, the 19th surgery on the patient. If you don’t know what to do, don’t jump to surgery.”
She also cautions against opioid therapy.
“I don’t have a patient who I’ve started on opioid therapy – or maintained on it—who I think is gotten better.”
Instead, Fox utilizes low-risk supplements when she feels they might benefit a patient.
“I’m very skeptical,” she said, but I do use them regularly.”
The key questions to ask are: Is it expensive? What are the side effects? Are there potentially dangerous side effects? If something is inexpensive and low-risk, she’ll give it a try.
“Even if it’s a placebo effect, who cares? If the patient is comfortable, it’s not too expensive, and it’s not putting them at any risk, why not? There are prescription medications that are really no better than a placebo, and we use them anyway because, for some percentage of the population, they do some good.”
It’s important, though, to be using something that you think could actually help. “You don’t just want to be giving them a sugar pill.”
For example, Fox uses fish oil in patients who don’t tolerate or respond to NSAIDs because, although there’s not robust evidence that it reduces pain, there is scientific data showing that it reduces inflammation.
Similarly, while there’s no data on the use of ginger in functional bowl disease, it has been shown to reduce nausea and vomiting in pregnancy. Both interventions are low-cost and low-risk.