Integrated Care for Persons With Persistent Gynecologic Conditions.

Persons with persistent gynecologic conditions frequently cope with complex biopsychosocial challenges and benefit from integrated behavioral health evaluation and treatment within gynecologic practices. Integrated care refers to the provision of behavioral health services within a health care setting which contributes to improved patient, provider, and practice outcomes, however, has not been commonly provided in traditional gynecologic practices. Several models of integrated behavioral health are reviewed. Each model holds specific applications in primary and specialty gynecology settings and may enhance the gynecologic patient experience. This article reviews current research supporting integrated care and describes implementation, funding, and evaluation to improve patient outcomes.

Patterns in Vulvodynia Treatments and 6-Month Outcomes for Women Enrolled in the National Vulvodynia Registry-An Exploratory Prospective Study.

BACKGROUND: Vulvodynia is a poorly characterized condition with multiple treatment options that have been described as largely ineffective in research settings. AIM: To describe treatment patterns in women enrolled in the National Vulvodynia Registry and determine if there is an association between selected treatments and patient-reported outcomes such as pain, sexual function, and psychological distress after 6 months of treatment. METHODS: Participants completed questionnaires on general medical history and patient-reported outcomes using the short-form McGill Pain Questionnaire, the Female Sexual Function Index, the Short Form-12 quality-of-life questionnaire, the Coping Strategies Questionnaire, and the State-Trait Anxiety Inventory. The evaluation also included pain sensitivity assessment of the vaginal mucosa using a cotton-tipped applicator and the vaginal muscles using a single-digit. In this prospective cohort study, all measurements were collected at baseline and again at 6 months after treatment. OUTCOMES: Type of treatment, number of treatments, self-reported pain intensity, dyspareunia, and pain-related psychological distress measures are reported at baseline and 6 months. RESULTS: Of 344 women enrolled, 282 received treatment; 78 different treatments were identified and categorized by type (eg, topical, oral, physical therapy) and number. The most commonly used treatments were topical (85%, n = 241), physical therapy (52%, n = 147), and oral medications (45%, n = 128). Notably, 73% of participants received ≥2 treatments. There was no association between type or number of treatments and patient characteristics. At 6 months, women reported improvements in general pain (P = .001), pain during intercourse (P = .001), catastrophizing (P = .000), and anxiety (P = .000). The Short Form-12 quality-of-life questionnaire showed improvements in physical limitations (P = .024), emotional limitations (P = .003), well-being (P = .025), and social function (P = .010). However, all domains of the Female Sexual Function Index indicated worsening in sexual function (P = .000) except for pain. CLINICAL TRANSLATION: Multi-modal treatments were most commonly used in clinical practice and improvements in patient-reported outcomes such as quality of life, distress, and pain were noted; however, participants who returned at 6 months continued to report poor sexual function. CONCLUSIONS: Strengths include a prospective and long-term study design that evaluated women in clinical settings. Limitations include a high rate of loss to follow-up for certain measures and inability to evaluate efficacy of individual treatments. In a setting where women were receiving highly specialized care, we found wide variation in the type and number of treatments used to treat vulvodynia. Despite this heterogeneity in treatment selection, women reported significant improvements in all study measures except sexual function. Lamvu G, Alappattu M, Witzeman K, et al. Patterns in Vulvodynia Treatments and 6-Month Outcomes for Women Enrolled in the National Vulvodynia Registry-An Exploratory Prospective Study. J Sex Med 2018;15:705-715.

Non-opioid pain management in benign minimally invasive hysterectomy: A systematic review.

BACKGROUND: Less postoperative pain typically is associated with a minimally invasive hysterectomy compared with a laparotomy approach; however, poor pain control can still be an issue. Multiple guidelines exist for managing postoperative pain, yet most are not specialty-specific and are based on procedures that bear little relevance to a minimally invasive hysterectomy. OBJECTIVE: The purpose of this study was to determine whether there is enough quality evidence within the benign gynecology literature to make non-opioid pain control recommendations for women who undergo a benign minimally invasive hysterectomy. STUDY APPRAISAL AND SYNTHESIS METHODS: We queried PubMed, ClinicalTrials.gov, and Cochrane databases using MeSH terms: "postoperative pain," "perioperative pain," "postoperative analgesia," "pain management," "pain control," "minimally invasive gynecologic surgery," and "hysterectomy." A manual examination of references from identified studies was also performed. All PubMed published studies that involved minimally invasive hysterectomies through November 9, 2016, were included. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were restricted to benign minimally invasive hysterectomies evaluating non-opioid pharmacologic therapies. Primary outcomes included amount of postoperative analgesics consumed and postoperative pain scores. Two reviewers independently completed an in-depth evaluation of each study for characteristics and results using an established database, according to inclusion/exclusion criteria. A risk assessment was performed, and a quality rating was assigned with the use of the Cochrane Collaboration's Grades of Recommendation, Assessment, Development and Evaluation approach. RESULTS: Initially 1155 studies were identified, and 24 studies met all inclusion criteria. Based on limited data of varying quality, intravenous acetaminophen, anticonvulsants and dexamethasone demonstrate opioid-sparing benefits; ketorolac shows mixed results in laparoscopic hysterectomies. Paracervical blocks provide pain-reducing benefits in vaginal hysterectomies. CONCLUSIONS: Convincing conclusions are difficult to draw because of the heterogeneous and contradictory nature of the literature. There is a clear need for more high-quality research that will evaluate each medication type for posthysterectomy pain control.

Catechol-O-methyltransferase gene polymorphism and vulvar pain in women with vulvodynia.

BACKGROUND: The underlying causes of vulvar pain in women with vulvodynia remain poorly understood. Catechol-O-methyltransferase, an enzyme that metabolizes catecholamines, is a neuromodulator that is involved with perception and sensitivity to pain. The catechol-O-methyltransferase gene is polymorphic, and a single nucleotide polymorphism is associated with low activity and heightened pain sensitivity. The variant allele that encodes this polymorphism commonly is called the "L allele" because of its low enzyme activity as opposed to the normal H (high activity) allele. OBJECTIVE: The methionine-containing catechol-O-methyltransferase protein coded by the L allele results in elevated catecholamine levels, reduced inactivation of the dopaminergic and adrenergic systems, and increased sensitivity to pain. This polymorphism not only may decrease the pain threshold in response to acute pain but also may facilitate the development of chronic pain. Therefore, the objective of our study was to assess whether a variation in the catechol-O-methyltransferase genotype is involved in increased pain sensitivity in women with vulvodynia. STUDY DESIGN: We conducted a prospective cohort study. METHODS: Buccal swabs were collected from 167 white women with vulvodynia and 107 control subjects; the DNA was tested for a single nucleotide polymorphism at position 158 (rs4680) in the catechol-O-methyltransferase gene. RESULTS: Women with vulvodynia had a marginally increased, yet not significant, prevalence of the catechol-O-methyltransferase genotype that is associated with high activity of the coded protein: 32.9% in the women with vulvodynia, as opposed to 21.5% in the control subjects (odds ratio, 1.80; 95% confidence interval, 1.02-3.15). Subgrouping the cases based on pain frequency revealed that the elevated occurrence of this catechol-O-methyltransferase genotype was present in 40.6% of the subset of women who experienced pain only with sexual intercourse vs only 21.5% of control subjects (odds ratio, 2.50; 95% confidence interval, 1.27-4.93). Also, women with primary vulvodynia had a significantly higher prevalence of the H allele than did the control subjects (62.9% vs 48.1%; odds ratio, 1.82; 95% confidence interval, 1.05-3.17). CONCLUSION: Increased pain sensitivity in women with vulvodynia is not due to a genetically determined low catechol-O-methyltransferase enzyme activity. Other mechanisms may account for alterations in catechol-O-methyltransferase activity in women with pain that is limited to intercourse or primary vulvodynia that contributes to pain sensitivity.

The Evidence-based Vulvodynia Assessment Project. A National Registry for the Study of Vulvodynia.

OBJECTIVE: To create a national registry for the study of vulvodynia in order to enhance classification of vulvodynia based on multiple phenotypic domains such as pain characteristics, clinical examination, sexual function, psychological functioning, and distress. STUDY DESIGN: Methodology for this prospective cohort registry was institutional review board approved and implemented at 8 enrollment sites starting in 2009. Women underwent gynecologic evaluation and pressure sensory testing for assessment of pain sensitivity in the vaginal mucosa and vaginal muscles. Psychometric questionnaires were used to assess self-described pain, distress, sexual function, and quality of life. RESULTS: More than 300 women were enrolled and 176 charts were analyzed. This cohort had a median age of 29 years and median pain duration of 25.5 months. A total of 84% of participants were previously or currently sexually active in spite of pain. The most common pain comorbidities reported by the women were migraines (34%), chronic pelvic pain (22%), and irritable bowel syndrome (20%). Anxiety affected 41% of the cohort. More than 90% presented with localized vestibular pain, and 90% had muscular examination abnormalities. CONCLUSION: A national registry for the study of vulvodynia was established with successful enrollment of participants at 8 sites. In addition to the cotton swab evaluation for vulvar allodynia, women with vulvar chronic pain should also be routinely screened for musculoskeletal dysfunction, emotional distress with specific emphasis on anxiety, and comorbid pain conditions.

Understanding barriers to uptake of 17 alpha-hydroxyprogesterone caproate (17-OHP) in women with history of preterm birth.

Background: Premature birth is responsible for approximately 38% of infant deaths as well as a host of complications, including abnormal lung development, infection, and long-term disabilities. For women with a history of spontaneous preterm birth in a singleton pregnancy, use of 17 alpha-hydroxyprogesterone caproate (17-OHP) can reduce the risk of a recurrent preterm birth by up to 42%. However, less than half of eligible women currently receive 17-OHP.Objectives: The purpose of this study was to understand the barriers to access and acceptability of 17-OHP use from the patient perspective.Study design: A qualitative study was conducted of women with a history of a prior spontaneous, singleton preterm birth who were eligible for 17-OHP during a subsequent singleton pregnancy. Researchers recruited 118 eligible women during the Spring and Summer of 2018 from a safety-net hospital in Denver, CO, USA, a hospital that provides healthcare for individuals regardless of their insurance status or ability to pay. Responses from 35 participants were analyzed, looking at themes surrounding knowledge of and counseling received regarding 17-OHP, hesitations, and barriers toward receiving the treatment.Results: Among respondents (34.0% response rate), the mean age was 31.5 years and mean gestational age at delivery was 32.1 weeks. Major themes from interviews included reasons that encouraged women to use 17-OHP, such as the desire to do anything for the health of their baby and reasons that women felt discouraged from using 17-OHP, including unknown complications and lack of information. Other barriers to this treatment method included the time commitment, specifically the length of clinic appointments and concerns about the safety of the 17-OHP injection.Conclusions: One of the strongest reasons for women choosing to use 17-OHP was a desire to do anything possible to support their babies. Somewhat surprisingly, there was not a significant relationship with the participants between gestational age of prior preterm deliveries and subsequent use of 17-OHP. There were two important reasons women cited most frequently for choosing not to use 17-OHP. One was feeling that they lacked information or knowledge about 17-OHP to make an informed decision, which is crucial because the study also showed that all eligible women are not being appropriately counseled on the option of 17-OHP. In terms of time commitment, it was the length of individual appointments, rather than frequency that was a barrier to receiving weekly injections.

Predictors of Mucosal and Muscle Pain in Vulvodynia: A Cross-Sectional Analysis From the National Vulvodynia Registry.

Diagnostic criteria for provoked vestibulodynia (PVD) rely on mucosal pain in the vulvar vestibule, with less emphasis on pain from pelvic floor muscles. It is unknown how psychosocial variables associated with PVD are differentially associated with mucosal versus muscle pain. Analysis of data from the National Vulvodynia Registry (n = 202) revealed several factors associated with increased mucosal pain: pain duration (P = .043), the McGill sensory subscore (P = .0086) and the Gracely pain scale (P< .001). Increased mucosal pain was also associated with decreased arousal (P = .036). On the other hand, factors significantly associated with greater muscle pain included number of comorbid pain conditions (P = .001), decreased intercourse frequency post PVD onset (P = .02) and higher scores on the McGill sensory (P = .0001) and affective (P = .0002) subscores, the Gracely pain scale (P = .0012), and state anxiety (P < .001). Sexual function was also significantly impacted by high pelvic floor muscular pain, with lower scores for arousal (P = .046), orgasm (P = .0014) and satisfaction (P = .013), and higher pain (P = .01). Significant differences in the relationship between muscle and mucosal pain for pain duration (P = .005), McGill affective score (P = .001), orgasm (P = .049), change in intercourse frequency (P = .027), and state anxiety (P = .030) suggest the possibility of mucosal or muscle pain predominant PVD subtypes. PERSPECTIVE: Patients with higher pelvic floor muscle pain scores than mucosal pain scores may represent different subgroups or characteristics of patients with provoked vestibulodynia. This research highlights the importance of assessment of the pelvic floor muscles in addition to the cotton swab test of the vestibule.

Patient-Physician Interactions Regarding Dyspareunia with Endometriosis: Online Survey Results.

INTRODUCTION: Dyspareunia can be a debilitating symptom of endometriosis. We performed this study to examine women's experiences with painful sexual intercourse, the impact of dyspareunia on patients' lives, and perceptions of interactions with healthcare practitioners. METHODS: An anonymous 24-question online survey was provided through the social media network MyEndometriosisTeam.com and was available internationally to women aged 19-55 years who were self-identified as having endometriosis and had painful sexual intercourse within the past 2 years. RESULTS: From June 13 to August 20, 2018, 860 women responded and 638 women completed the survey (United States, n = 361; other countries, n = 277; 74% survey completion rate). Respondents reported high pain levels (mean score, 7.4 ± 1.86; severity scale of 0 [no pain] to 10 [worst imaginable pain]), with 50% reporting severe pain [score of 8 to 10]). Nearly half (47%) reported pain lasting ≥24 hours after intercourse with the pain often leading to avoiding (34%) or stopping (29%) intercourse. Pain impacted patients' lives, causing depression (61%), anxiety (61%), low self-esteem (55%), and relationship strain. Many women feared to seek help (10%). Of those women who approached practitioners, many (36%) did not receive effective treatments. DISCUSSION: Women with dyspareunia related to endometriosis experience severe pain that can negatively impact patients' lives. Dyspareunia may be a challenging topic for discussion for both patient and practitioner, leading to a suboptimal treatment approach and management. Results suggest that practitioners need improved education and training regarding dyspareunia to evaluate and treat patients' sexual pain caused by endometriosis.

Joint Hypermobility among Female Patients Presenting with Chronic Myofascial Pelvic Pain.

BACKGROUND: Female chronic pelvic pain is estimated to affect up to 24% of adult women, many of whom have a component of myofascial pelvic pain. Although an association of joint hypermobility and pelvic pain has been hypothesized, limited data are available that estimate the prevalence of joint hypermobility in this population. OBJECTIVE: To estimate the prevalence of generalized hypermobility spectrum disorder (G-HSD) among female patients with chronic myofascial pelvic pain and examine the association between G-HSD and other frequent pelvic pain-associated complaints. STUDY DESIGN: Retrospective case control. SETTING: Tertiary referral center within a university-affiliated public health system. PATIENTS: Adult women who were diagnosed with myofascial pelvic pain during a 1-year period (n = 77 with G-HSD and n = 241 without G-HSD). METHODS: Data were abstracted via chart review of patients meeting inclusion criteria. OUTCOMES: The primary outcome of this study was the prevalence of G-HSD among patients with persistent myofascial pelvic pain. Secondary outcomes included the prevalence of dyspareunia, provoked vestibulodynia, stress urinary incontinence, irritable bowel syndrome, hip pain, low back pain, and fibromyalgia in patients with persistent myofascial pelvic pain with and without G-HSD. RESULTS: Twenty-four percent (N = 77; 95% CI: 19.6, 29.4) of myofascial pelvic pain patients also met criteria for G-HSD. After adjusting for confounders, the odds in favor of having G-HSD was 3.55 higher (95% CI: 1.50, 8.40) (P = .004) in females with dyspareunia; 7.46 higher (95% CI: 2.41, 23.1) (P < .001) with low back pain; 3.76 higher (95% CI: 1.35, 10.5) (P = .02) with stress urinary incontinence; 4.72 higher (95% CI: 2.00, 11.2) (P < .001) with irritable bowel syndrome; and 3.12 higher (95% CI: 1.36, 7.13) (P = .007) with hip pain. There was no significant association identified between provoked vestibulodynia or fibromyalgia and G-HSD. CONCLUSION: The estimated prevalence of G-HSD is higher in chronic myofascial pelvic pain patients than in the general population with statistically significant associations with several comorbid conditions. Characterizing these associations is the first step in developing effective, evidence-based screening recommendations. LEVEL OF EVIDENCE: III.

Musculoskeletal Considerations in Female Patients with Chronic Pelvic Pain.

Persistent pelvic pain conditions are common and affect nearly 25% of the female U.S. population. In a sizable proportion of pelvic pain patients, the pain is caused by musculoskeletal dysfunction; yet, healthcare providers do not routinely evaluate patients for musculoskeletal etiologies. This article provides an overview of the pathophysiology of persistent pelvic pain, as it relates to musculoskeletal disorders. The symptomatology, anatomy, evaluation, and treatment of these disorders are summarized specifically for healthcare providers (including gynecologists) who do not have pelvic musculoskeletal expertise.

Vulvodynia is not created equally: empirical classification of women with vulvodynia.

BACKGROUND: Vulvodynia classification is based on the sensory dimensions of pain and does not include psychological factors associated with the pain experience and treatment outcomes. Previous work has shown that individuals with chronic pain can be classified into subgroups based on pain sensitivity, psychological distress, mood, and symptom severity. OBJECTIVE: The aim of this study was to identify distinct subgroups of women with vulvodynia enrolled in the National Vulvodynia Registry. We hypothesized that women with vulvodynia can be clustered into subgroups based on distress and pain sensitivity. DESIGN: A cross-sectional study. METHODS: We conducted an exploratory hierarchical agglomerative cluster analysis using Ward's cluster method and squared Euclidean distances to identify unique subgroups based on baseline psychological distress and pain sensitivity. The variables included the catastrophizing subscale of the Coping Strategies Questionnaire, the Beck Depression Inventory, the State Trait Anxiety Index-Trait scale, McGill Pain Questionnaire-Affective subscale, and vulvar and pelvic muscle pressure pain sensitivity. SUBJECTS: Eight sites enrolled women who presented with vaginal or vulval pain of at least 3-month duration. RESULTS: Two distinct subgroups, high pain sensitivity with high distress (n=27) and low pain sensitivity with low distress (n=100), emerged from the cluster analysis. Validation indicated that subgroups differed in terms of clinical pain intensity, sensory aspects of pain, and intercourse pain. CONCLUSION: Empirical classification indicates that unique subgroups exist in women with vulvodynia. Providers should be aware of the heterogeneity of this condition with respect to pain-related distress and pain sensitivity.

Mucosal versus muscle pain sensitivity in provoked vestibulodynia.

BACKGROUND: An estimated 8.3%-16% of women experience vulvovaginal discomfort during their lifetime. Frequently these patients report provoked pain on contact or with attempted intercourse, commonly referred to as provoked vestibulodynia (PVD). Despite the burden of this condition, little is known about its potential etiologies including pelvic floor muscular dysfunction and mucosal components. This knowledge would be beneficial in developing targeted therapies including physical therapy. OBJECTIVE: To explore the relative contribution of mucosal versus muscle pain sensitivity on pain report from intercourse among women with PVD. DESIGN: In this proof of concept study, 54 women with PVD underwent a structured examination assessing mucosal and pelvic muscle sensitivity. METHODS: We examined three mucosal sites in the upper and lower vestibule. Patients were asked to rate their pain on cotton swab palpation of the mucosa using a 10-point visual analog scale. Muscle pain was assessed using transvaginal application of pressure on right and left puborectalis, and the perineal muscle complex. The Gracely pain scale (0-100) was used to assess the severity of pain with intercourse, with women rating the lowest, average, and highest pain levels; a 100 rating the highest level of pain. RESULTS: The lower vestibule's mucosa 5.81 (standard deviation =2.83) was significantly more sensitive than the upper vestibule 2.52 (standard deviation =2.6) (P<0.01) on exam. However, mucosal sensitivity was not associated with intercourse pain, while muscle sensitivity was moderately associated with both average and highest intensity of intercourse pain (r=-0.46, P=0.01 and r=-0.42, P=0.02), respectively. CONCLUSION: This preliminary study suggests that mucosal measures alone may not sufficiently capture the spectrum of clinical pain report in women with PVD, which is consistent with the empirical success of physical therapy in this population.

Obstetrics-gynecology resident attitudes and perceptions about chronic pelvic pain: a targeted needs assessment to aid curriculum development.

BACKGROUND: Chronic pelvic pain (CPP) accounts for 10% of gynecologic visits and is a common complaint in university-based and community resident clinics. Resident education about CPP has been inconsistent, and review of the limited literature shows predominantly negative perceptions of patients with CPP. Current literature lacks information regarding obstetrics-gynecology residents' attitudes and acquired knowledge regarding CPP. OBJECTIVE: This targeted needs assessment aims to identify regional obstetrics-gynecology resident attitudes and self-perceived knowledge regarding chronic pelvic pain in order to better address potential educational barriers and look toward placing a greater emphasis on this area in resident training. METHODS: We conducted a focus group of obstetrics-gynecology residents to identify major themes regarding attitudes about CPP. This informed the development of a survey administered to university-based and community-based obstetrics-gynecology residents (N  =  57) in the Colorado part of the Western Mountain Region. Cronbach α was calculated to determine reliability for each theme, and descriptive statistics were calculated for each theme. Independent samples t tests assessed differences between training levels and between university and community training sites. RESULTS: Survey response rate was 72% (41 of 57). Residents consistently reported feeling overwhelmed by CPP patients, perceived a lack of time to see these patients, and indicated a desire to learn more in this area, but they varied in chosen learning methods. No significant differences were found between levels of training or training sites. CONCLUSIONS: Most obstetrics-gynecology residents surveyed believe they are inadequately prepared to address the needs of women presenting with CPP.