Chronic Pelvic Pain Management in Women: An Integrative Approach

The following article features coverage from PAINWeek 2017 in Las Vegas, Nevada. Click here to read more of Clinical Pain Advisor‘s conference coverage.

LAS VEGAS – A Pain Week 2017 presentation by Kathryn Witzeman, MD, FACOG, associate professor at the University of Colorado in Denver and director of the Women’s Integrated Pelvic Health Program at Denver Health Medical Center, focused on integrative modalities for the treatment of female chronic pelvic pain (CPP).¹

Dr Witzeman began the program by noting that CPP is a symptom, not a diagnosis. “The term ‘chronic pelvic pain’ does little to guide a clinician in selecting treatment modalities that focus on contributors to the symptom of pelvic pain,” Dr Witzeman told Clinical Pain Advisor. “It also focuses the patient on ‘pain’ and the treatment of pain, instead of what is actually contributing to their experience and how they can be engaged and impactful in feeling better.”

Rather than addressing the presenting symptom or specific disease separately, clinicians should aim to identify underlying factors that commonly contribute to chronic pain, such as stress, poor nutrition, and inflammation. Potential contributing factors to CPP in particular include gastrointestinal, urinary, reproductive, and neurosensory issues, as well as psychiatric conditions such as anxiety, depression, and post-traumatic stress disorder.

Dr Witzeman discussed a wide range of integrative modalities, including the following: 

• Cognitive behavioral therapy has been associated with reduced pain, increased activity, and improved sexual response in women with provoked vestibulodynia²
• Mindfulness-based stress reduction was found to reduce pain and promote modulation of pro-inflammatory cytokines in a 2016 feasibility study of women with CPP³
• Clinical hypnosis has consistently been shown to reduce pain in a variety of chronic pain conditions; it has demonstrated efficacy in treating irritable bowel syndrome (IBS) and improving quality of life in patients with dysmenorrhea⁴
• Breathing techniques have been linked with increased heart rate variability, considered an indicator of autonomic nervous system functioning – specifically, the balance between the sympathetic and parasympathetic systems.⁵ Low heart rate variability is associated with cognitive and psychological issues as well as heart disease, cancer, and other physical illnesses.
• Yoga may lead to reductions in chronic pelvic pain and quality of life, and trauma-informed yoga has been shown to alleviate posttraumatic stress disorder symptoms⁶
• Manual techniques such as pelvic physical therapy, osteopathic manipulation, chiropractic care, and massage have shown promising but limited results indicating their efficacy in CPP
• Acupuncture may be effective in treating primary dysmenorrhea, according to randomized controlled trials⁷
• Plant-based medicine such as aromatherapy may reduce pain and anxiety

In addition, nutritional interventions to improve IBS, a common CPP comorbidity, were discussed, including food sensitivities and allergies, probiotics, and foods known to support gut health and reduce inflammation.

Dr Witzeman also reviewed traditional medical and surgical treatments for CPP and dysmenorrhea, which may exacerbate symptoms. For example, opioids may result in sleep dysfunction, one of the contributing factors to chronic pain, and hormonal treatments may influence pain processing.

Dr Witzeman suggested that clinicians interested in incorporating integrative modalities into their practices could start by learning 1 approach from the different areas covered: mind-body, manual medicine, nutrition, and plant based medicines. “It can be less overwhelming to choose one modality in each area and become familiar with its use for pelvic pain problems — or other areas of chronic pain for that matter — that a clinician commonly sees in their practice,” she concluded.    

Dr Witzeman suggested the following resources:

• Clinical hypnosis: www.asch.net
• Pain psychologists: https://societyforhealthpsychology.org/pain-psychology
• Women’s health physical therapists: http://www.womenshealthapta.org/pt-locator
• Acupuncture: http://www.ccaom.org
• Free apps: Headspace; Insight Timer
• Commercial products: www.healthjourneys.com

Read more of Clinical Pain Advisor’s coverage of PAINWeek 2017 by visiting the conference page.

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References

1. Tennant F. Beyond pharmacotherapy: an integrative approach to the management of female chronic pelvic pain. Presented at Pain Week 2017; September 5-9, 2017; Las Vegas, Nevada.
2. Goldfinger C, Pukall CF, Thibault-Gagnon S, et al. Effectiveness of cognitive-behavioral therapy and physical therapy for provoked vestibulodynia: a randomized pilot study. J Sex Med. 2016; 13(1):88-94. doi:10.1016/j.jsxm.2015.12.003
3. Crisp CD, Hastings-Tolsma M, Jonscher KR. Mindfulness-based stress reduction for military women with chronic pelvic pain: a feasibility study. Mil Med. 2016;181(9):982-989. doi:10.7205/MILMED-D-15-00354
4. Shah M, Monga A, Patel S, Shah M, Bakshi H. The effect of hypnosis on dysmenorrhea. Int J Clin Exp Hypn. 2014; 62(2):164-178. doi:10.1080/00207144.2014.869128
5. Lehrer PM, Gevirtz R. Heart rate variability biofeedback: how and why does it work? Front Psychol. 2014; 5:756. 2014. doi:10.3389/fpsyg.2014.00756
6. van der Kolk BA, Stone L, West J, et al. Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. J Clin Psychiatry. 2014; 75(6):e559-65. doi:10.4088/JCP.13m08561
7. Cho S-H, Hwang E-W. Acupuncture for primary dysmenorrhoea: a systematic review. BJOG. 2010; 117(5):509–21.  doi:10.1111/j.1471-0528.2010.02489.x