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Menstrual and Uterine Disorders
of treatment examining multidisciplinary care, mainly because is currently no evidence to support the routine use of PSN and LUNA
individual treatment effects would be difficult to dissect; thus, in in women with CPP.
general, the aim of trials for the treatment of pelvic pain is the
examination of an individual medical or surgical treatment. The Other Therapies
core elements of a multidisciplinary team will include a Static Magnetic Therapy
gynaecologist and a physician with a special interest in pain There were no significant differences in the outcomes with regard to
management, a psychologist, a pain clinic nurse and a the effects of static magnetic therapy versus placebo. Similarly,
physiotherapist. Figure 1 shows a typical referral and management photographic reinforcement after surgery does not appear to have
flow chart for patients referred to the Southampton pain team. The any beneficial effect.
5
multidisciplinary ‘package’ in the UK – when available – is quite
varied, but may include cognitive behavioural psychotherapy, Writing Therapy
nursing support (such as between clinic times where medications The aim of this intervention was to allow patients to identify and
need readjusting) and the use of complementary therapies, express the thoughts and feelings associated with their pain as a
including acupuncture. means of reducing their impact. Women with higher baseline
ambivalence about emotional expression appear to respond more
The main evidence to show that a multidisciplinary team approach positively to this intervention, thus showing a sub-group who may
works comes from Leiden in The Netherlands.
11
This randomised benefit specifically from this type of psychological approach.
5
controlled trial showed that the multidisciplinary approach is
beneficial compared with a conventional approach in terms of Conclusion
improvement of quality of life scores, although the McGill pain The currently available information about the treatment of
scores were not different in the two approaches. However, the study women with CPP provides some support for the use of ultrasound
also suggested a strong ‘functional’ component in many women scanning as an aid to counselling and reassurance, progestogen
with CPP, and also suggested that this group of women benefited (medroxyprogesterone acetate) or goserelin for pelvic congestion and
from the ‘integrated’ multidisciplinary treatment including (with the aim of improved function and self-rating) a multidisciplinary
psychotherapy. Indeed, counselling supported by ultrasound approach to assessment and treatment. Adhesiolysis has not been
scanning
12
was effective in terms of both pain scores and mood. shown to be of benefit other than in women with severe adhesions.
There are important questions about the optimal use of this Ablation of endometriosis may provide benefit when this is the cause of
approach, as it is time-consuming and expensive. Realistically, many CPP. SSRI antidepressants have not been shown to be of benefit. The
cases will continue to be seen by a single specialist, emphasising management of CPP remains an enigma and much needs to be done in
the need for skills relevant to CPP to be embedded in specialist terms of basic science and clinical research to address this problem. ■
gynaecological training.
Ying Cheong is a Senior Lecturer, Consultant Gynaecologist and Subspecialist in
Surgical Treatment
Reproductive Medicine and Surgery in the Division of the Developmental Origins of
Adhesions Adult Diseases at the University of Southampton. She has a long-standing interest
Whether adhesions are a cause of pelvic pain or not remains
in the management of chronic pelvic pain and has written extensively in this area.
She is the co-author of the Cochrane review on ‘Interventions on chronic pelvic
controversial. However, the results in all outcome measures in
pain’. Her other research interests include systematic reviews, subfertility-related
women undergoing adhesiolysis via laparotomy
13
were not different pathologies such as adhesions, endometriosis and polycystic ovaries and the
from those seen in women who did not undergo surgery. However,
impact of nutrition on early embryo environment.
the small subgroup with severe adhesions did show a significant Mary Ann Lumsden is a Professor of Medical Education and Gynaecology and
benefit after surgery.
Head of the Section of Reproductive and Maternal Medicine in the Division of
Developmental Medicine at the University of Glasgow. She is an Honorary
Consultant Obstetrician and Gynaecologist at the Greater Glasgow Hospitals NHS
Disruption of Sensory Pathways Trust. Professor Lumsden’s past appointments at the University of Glasgow include
Pre-sacral neurectomy (PSN) and laparoscopic uterine nerve ablation
Senior Lecturer and Reader; since then, she has been awarded a personal chair.
Professor Lumsden graduated in medicine from St Mary’s Hospital Medical School
(LUNA) are both surgical procedures that involve the disruption of
at the University of London in 1977. Her MD was awarded in 1985.
sensory nerve afferents that carry pain stimuli from the pelvis. There
1. Mathias SD, Kuppermann M, Liberman RF, et al., treating chronic pelvic pain in women, Cochrane Database 10. Peters A, van Dorst E, Jellis B, et al., A randomized
Chronic pelvic pain: prevalence, health related quality Syst Rev, 2005;(4). clinical trial to compare two different approaches in
of life, and economic correlates, Obstet Gynecol, 1996;87: 6. Soysal ME, Soysal S, Vicdan K, Ozer S, A randomized women with chronic pelvic pain, Obstet Gynecol,
321–7. controlled trial of goserelin and medroxyprogesterone 1991;77(5):740–44.
2. Zondervan KT, Yudkin PL, Vessey MP, et al., The acetate in the treatment of pelvic congestion, Hum 11. Ghaly A, The psychological and physical benefits of
community prevalence of chronic pelvic pain in women Reprod, 2001;16:931–9. pelvic ultrasonography in patients with chronic pelvic
with associated illness behaviour, Br J Gen Pract, 7. Farquhar CM, Rogers V, Franks S, et al., A randomized pain and negative laparoscopy. A random allocation
2001;51:541–7. controlled trial of medroxyprogesterone acetate and trial, J Obstet Gynaecol, 1994;14:269–71.
3. Howard FM, The role of laparoscopy in chronic pelvic psychotherapy for the treatment of pelvic congestion, 12. Peters A, van Dorst E, Jellis B, et al., A randomized
pain: promise and pitfalls, Obstet Gynecol Surv, Br J Obstet Gynaecol, 1989;96:1153–62. clinical trial to compare two different approaches in
1993;48:357–87. 8. Walton SM, Batra HK, The use of medroxyprogesterone women with chronic pelvic pain, Obstet Gynecol,
4. Sutton CJ, Ewen SP, Whitelaw N, et al., Prospective, acetate 50mg in the treatment of painful pelvic 1991;77(5):740–44.
randomized, double-blind, controlled trial of laser conditions: preliminary results from a multicentre trial, 13. Swank DJ, Swank-Bordewijk SC, Hop WC, et al.,
laparoscopy in the treatment of pelvic pain associated J Obstet Gynaecol, 1992;12(Suppl. 2):s50–53. Laparoscopic adhesiolysis in patients with chronic
with minimal, mild, and moderate endometriosis, Fertil 9. Reginald P, Beard R, Kooner J, et al. Intravenous abdominal pain: a blinded randomised controlled multi-
Steril, 1994;62:696–700. dihydroergotamine to relieve pelvic congestion with centre trial, Lancet, 2003;361(9365):1247–51.
5. Stones RW, Cheong Y, Howard F, Interventions for pain in young women, Lancet, 1987;ii:351–3.
16 EUROPEAN OBSTETRICS & GYNAECOLOGY
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