Assess psychological factors in chronic pelvic pain cases.

FORT LAUDERDALE, FLA. -- About 75% of premenopausal women with chronic pelvic pain gain significant relief from hysterectomy, even when no apparent physiologic cause is found. But what about the other 25%?

"We tend to look at fibroids and endometriosis. It behooves us to look at interstitial cystitis and muscle problems of the pelvic floor." It is important to avoid getting this 20%-25% of patients to hysterectomy, Dr. Charles E. Miller said at a meeting on hysterectomy sponsored by the Cleveland Clinic.

Do not stop at a diagnosis of endometriosis if symptoms suggest otherwise. Consider other etiologies, including irritable bowel disease, interstitial cystitis, and psychological factors, said Dr. Miller, director of minimally invasive gynecologic surgery at Lutheran General Hospital in Park Ridge, Ill.

Each year, about 75,000 of the more than 600,000 hysterectomies performed for benign disease are for relief of chronic pelvic pain. In a study of 99 women who reported persistent pelvic pain for 6 months who reported persistent pelvic pain for 6 months or more, 78% showed improvement a mean 22 months after laparoscopic hysterectomy (Obstet. Gynecol. 1990;75:676-9).

"You will see this number as we go through these slides. About three out of four women are going to gain significant relief with hysterectomy," said Dr. Miller, who is also on the obstetrics and gynecology faculty at the University of Illinois at Chicago. Other researchers confirmed this figure in subsequent studies (Obstet. Gynecol. Surv. 1993;48:357-87; Obstet. Gynecol. 1995;86:941-5).

"We must be able to do more. That is why we look for alternative diagnoses," Dr. Miller said. "Interestingly enough, there are a lot of studies that relate endometriosis and interstitial cystitis, and endometriosis and irritable bowel. So it's not enough to stop at endometriosis if symptoms suggest something else."

Researchers have linked pelvic pain with depression, so psychological factors should be assessed as well, Dr. Miller said. "The psychological aspects of chronic pelvic pain ... are real, and if we do it right, we can help our patients." For example, women reported a "marked reduction" in symptoms 24 months after hysterectomy if they had pain but no depression in one study (Obstet. Gynecol. 2004;104:701-9). Although pain improved among the group with depression, it was to a lesser extent. Also, the comorbid group was more likely to experience impaired quality of life (odds ratio 3.5) and limited social (OR 5.8) and physical function (OR 2.7).

The bottom line is that obstetricians and gynecologists need to sit down and spend time counseling patients with chronic pelvic pain, Dr. Miller said.

"The psychological issues "are hard to bring it up, and I realize that. You can see the body language that happens," Dr. Miller said. "Her head goes back, her arms go up, and she looks at you and says: 'You think I'm crazy.' She is already signing the form in her head to leave our practice."

One anecdotal caveat, Dr. Miller said, is a randomized trial by Dr. Chris Sutton in England that assessed endometriosis, pelvic pain, and laparoscopy. "He took 100 patients with endometriosis for supracervical laparoscopy. Would you believe that 50% came back for further surgery?" The lesson here might be that select patients with endometriosis around the rectal-vaginal septum are candidates for total hysterectomy.

"Hysterectomy appears to still be a worthwhile treatment for pelvic pain, even in patients where we lack pathology," Dr. Miller said. "But there are variables we need to explore."

BY DAMIAN McNAMARA

Miami Bureau