Women's Perspectives on their Experiences of Chronic Pelvic Pain and Medical Care

"I wish I knew then what I know now" - pain science education concepts important for female persistent pelvic pain: a reflexive thematic analysis

ABSTRACT

Pain science education (PSE) provides people with an understanding of "how pain works" grounded in the biopsychosocial model of pain; it has been demonstrated to improve outcomes in musculoskeletal pain conditions. Preliminary evidence suggests PSE may be effective for female individuals with persistent pelvic pain, but how the content of PSE needs to be modified for this group remains to be determined. A reflexive thematic analysis of qualitative data was performed to identify PSE concepts that female individuals with persistent pelvic pain consider important and why. Twenty individual, semistructured interviews were conducted with adult females who had engaged with PSE and had self-identified as having "improved" pelvic pain. Most participants had been diagnosed with endometriosis (n = 16). Four themes were generated capturing PSE concepts considered important by female individuals with "improved" pelvic pain: (1) "A sensitised nervous system leads to overprotective pain" validated their pelvic pain as being real; (2) "Pain does not have to mean the body is damaged (although sometimes it does)" provided reassurance that pelvic pain does not mean their condition is worsening; (3) "How I think, feel, and 'see' my pain can make it worse" enabled participants to find optimal ways to manage their pain; and (4) "I can change my pain… slowly" provided hope that pelvic pain can improve and empowered them to pursue pain improvement as a viable goal. This study generated 4 PSE learning concepts that were important to female individuals with improved pelvic pain and may be incorporated into PSE curricula for female individuals with pelvic pain.

Health Information in the Era of Social Media: An Analysis of the Nature and Accuracy of Posts Made by Public Facebook Pages for Patients with Endometriosis

STUDY OBJECTIVE

To analyze the nature and accuracy of social media (Facebook) content related to endometriosis.

DESIGN

Retrospective content analysis.

SETTING

Social media platform, Facebook.

PARTICIPANTS

Social media posts on Facebook endometriosis pages.

INTERVENTIONS

A search of public Facebook pages was performed using the key word "endometriosis." Posts from the month-long study period were categorized and analyzed for accuracy. Two independent researchers used thematic evaluation to place posts into the following 11 categories: educational, emotional support, advocacy, discussion, events, humor, promotional, recipes, resources, surveys, and other. Posts categorized as educational were further subcategorized and reviewed. Each posted fact was cross-referenced in peer-reviewed scientific journals to determine whether the claim made was evidence-based. Engagement in a post was calculated by taking the sum of comments, shares, and reactions.

MEASUREMENTS AND MAIN RESULTS

A total of 53 Facebook pages meeting inclusion criteria were identified and 1464 posts from the study period were evaluated. Emotional support posts comprised the largest category of posts (48%) followed by educational posts (21%). Within the educational category, the epidemiology and pathophysiology subcategory comprised the largest group (42.0%) followed by the symptom's subcategory (19.6%). Post category had an effect on the amount of post engagement (p-value <.001) with emotional posts generating 70% of the overall engagement. The subcategories of the educational posts demonstrated a similar effect on engagement (p-value <.001). Posts were more engaging if they contained epidemiology and pathophysiology information with 44% of all engagement of educational posts occurring within this subcategory. Educational posts were found to be 93.93% accurate. There was no correlation between post engagement and post information accuracy (p-value = .312).

CONCLUSION

Facebook pages offer emotional support and education to people with endometriosis. Most information found in these Facebook pages is evidence-based. Clinicians should consider discussing the use of Facebook pages with their patients diagnosed with endometriosis.

'ReConnect': a model for working with persistent pain patients on improving sexual relationships

INTRODUCTION

Many individuals with persistent pain experience difficulties with sexual function which are exacerbated by avoidance and anxiety. Due to embarrassment or shame, sexual activity may not be identified as a goal for pain management programmes (PMPs). In addition, clinicians can feel that they lack skills and confidence in addressing these issues.

METHODS

We sought to develop a biopsychosocial model for helping patients return to sexual activity and manage relationships in the context of pain management, known as 'ReConnect'. The model amalgamates well-established methods from pain management and sex therapy to guide multidisciplinary team members. ReConnect comprises three components: (1) 'cognitive and myth-busting', (2) 'sensations and feelings' and (3) 'action-experimentation'. We collected self-report data from 281 women and 92 men from our specialist PMP for chronic abdomino-pelvic. pain, including questions measuring interference with and avoidance of sex due to pain, and the Multi-dimensional Sexuality Questionnaire (MSQ) to measure anxiety about sexual activity.

RESULTS

The results show statistically significant improvements for anxiety, avoidance of sex and sexual interference. Using the ReConnect model to structure clinical work, pain management clinicians reported increased confidence in addressing sexual activity goals.

CONCLUSION

By using the ReConnect model is a framework for clinicians to use to support sexual activity goals. It has demonstrated improvements in clinical outcomes such as anxiety around sex and interference of pain in sexual activity. We encourage its application in pain management services in both one-to-one and group sessions, as a method for encouraging pain patients to address this important area of life which can be adversely affected by pain.

Seeking consensus amongst UK-based interventional radiologists on the imaging diagnosis of pelvic vein incompetence in women with chronic pelvic pain: A modified Delphi study

Objectives

This modified Delphi study of vascular interventional radiologists sought to achieve consensus statements on the optimal imaging strategy and definitions of important imaging diagnostic features in women with pelvic vein incompetence.

Method

The UK-based interventional radiologists with the experience of investigating and treating pelvic vein incompetence responded to up to three rounds of online questionnaires.

Results

Three consensus statements emerged from 27 responders: (1) catheter venography is the ‘gold standard’ investigation for the diagnosis of pelvic vein incompetence; (2) pelvic vein incompetence should be defined as ‘retrograde flow along the ovarian or internal iliac veins’; (3) pelvic varices should be defined as ‘tortuous, often dilated, vulval, adnexal, para-uterine veins arising from incompetent internal iliac or ovarian veins.’

Conclusion

This study achieved consensus statements on imaging diagnosis in women with suspected pelvic vein incompetence. These can be used to minimise heterogeneity of research protocols, and represent baseline positions which can, themselves, be tested.

Is pelvic vein incompetence associated with symptoms of chronic pelvic pain in women? A pilot study

OBJECTIVE

Pelvic vein incompetence (PVI) affects 15-20% of all women, yet we know little about how it affects sufferers. The aim of this prospective pilot study was to explore symptoms experienced by women with PVI, and determine its impact on quality of life and NHS costs.

STUDY DESIGN

Case-control study at a UK University teaching hospital conducted over an eight-month period. Cases were 40 premenopausal women aged 18-49 years with PVI and varicose veins (VV). There were two age-matched controls groups: (i) 40 healthy women with no PVI but with VV, and (ii) 40 healthy women with no PVI and no VV. Subjects were asked to complete a structured questionnaire on disease specific outcomes, health status and use of healthcare resources.

RESULTS

Mean age (range) was 39.8 (24-47) years for cases, 39.1 (24-49) for VV controls and 38 (25-49) for healthy controls. Pelvic pain was reported by 38 of 40 (95%) PVI cases, compared with 25 of 40 (62%) VV controls, and 26 of 40 (65%) healthy controls (p=0.001). The median (range) EQ-5D utility score for PVI cases was 0.80 (0.29-1.0) compared with 0.80 (0.09-1.0) for VV controls and 1.0 (0.62-1.0) for healthy controls (p=0.002). Of the 40 PVI cases, 35 (88%) visited a consultant in the previous 12 months compared with 12 of 40 (30%) VV controls, and 14 of 40 (35%) healthy controls (p<0.001).

CONCLUSIONS

Women with PVI report a greater frequency of pelvic pain with reduced health status and increased use of healthcare resources compared with matched controls.

A meta-ethnography of patients' experiences of chronic pelvic pain: struggling to construct chronic pelvic pain as 'real'

AIM

To review systematically and integrate the findings of qualitative research to increase our understanding of patients' experiences of chronic pelvic pain.

BACKGROUND

Chronic pelvic pain is a prevalent pain condition with a high disease burden for men and women. Its multifactorial nature makes it challenging for clinicians and patients.

DESIGN

Synthesis of qualitative research using meta-ethnography.

DATA SOURCES

Five electronic bibliographic databases from inception until March 2014 supplemented by citation tracking. Of 488 papers retrieved, 32 met the review aim.

REVIEW METHODS

Central to meta-ethnography is identifying 'concepts' and developing a conceptual model through constant comparison. Concepts are the primary data of meta-ethnography. Two team members read each paper to identify and collaboratively describe the concepts. We next compared concepts across studies and organized them into categories with shared meaning. Finally, we developed a conceptual model, or line of argument, to explain the conceptual categories.

RESULTS

Our findings incorporate the following categories into a conceptual model: relentless and overwhelming pain; threat to self; unpredictability, struggle to construct pain as normal or pathological; a culture of secrecy; validation by diagnosis; ambiguous experience of health care; elevation of experiential knowledge and embodiment of knowledge through a community.

CONCLUSION

The innovation of our model is to demonstrate, for the first time, the central struggle to construct 'pathological' vs. 'normal' chronic pelvic pain, a struggle that is exacerbated by a culture of secrecy. More research is needed to explore men's experience and to compare this with women's experience.

Qualitative research as the basis for a biopsychosocial approach to women with chronic pelvic pain

Chronic pelvic pain (CPP) is a highly prevalent clinical condition and is recognized as a public health problem. Although the number of qualitative studies related to the topic is increasing, it is essential that this knowledge be presented in a synthesized manner, grounded in the context of the care provided to patients with CPP, in order to increase the clinical and research applicability of the findings. Little attention is given to CPP in undergraduate courses and in meetings for the continuing education of health professionals, the approach to CPP typically being based on the biomedical model. We believe that qualitative research can provide insights into CPP and form the basis for a biopsychosocial approach to the condition, which can in turn lead to better results, including resolution of the pain and greater patient/health professional satisfaction. Therefore, we conducted a metasynthesis of seven qualitative studies of CPP, the principal themes of which were as follows: (a) coping with CPP versus secondary gain; (b) the great importance of determining the cause of the pain; (c) expectations regarding the doctor-patient relationship; and (d) gender issues. We hope that the present study can aid in restoring the humanistic aspects of CPP treatment.

‘How do you explain a pain that can't be seen?’: The narratives of women with chronic pelvic pain and their disengagement with the diagnostic cycle

OBJECTIVES

Chronic pelvic pain (CPP) has an adverse effect on women's quality of life. Research has suggested that many women become dissatisfied with their care and withdraw from seeking help despite continuing symptoms. The aim of this study was to explore the processes which lead to disengagement and to understand the psychosocial processes that affect this group of women.

DESIGN

A qualitative narrative approach was used, guided by phenomenological-hermeneutic tradition, and informed by the philosophy of Paul Ricoeur.

METHOD

Thirty-two women with CPP were asked to write their stories about their illness trajectories. These written stories served as data which were analysed thematically according to narrative theory.

RESULTS

In the search for validation and recognition women engaged in the diagnostic cycle. Many women do not complete this cycle, become stuck at a certain point, or re-enter the cycle repeatedly. They can only opt out if the problem is resolved or by choosing to disengage with medical care.

CONCLUSIONS

While the medical consultation was a dominant theme, a complex interaction of factors was required to initiate disengagement. The dualistic nature of the diagnostic process prohibits women from telling their stories. Women were left feeling disempowered and in limbo, and they were at a loss as to how to manage their pain.

Is chronic pelvic pain a comfortable diagnosis for primary care practitioners: a qualitative study

Background

Chronic pelvic pain (CPP) has a prevalence similar to asthma and chronic back pain, but little is known about how general practitioners (GPs) and practice nurses manage women with this problem. A clearer understanding of current management is necessary to develop appropriate strategies, in keeping with current health care policy, for the supported self-management of patients with long term conditions. The aim of this study was to explore GPs' and practice nurses' understanding and perspectives on the management of chronic pelvic pain.

Methods

Data were collected using semi-structured interviews with a purposive sample of 21 GPs and 20 practice nurses, in three primary care trusts in the North West of England. Data were analysed using the principles of Framework analysis.

Results

Analysis suggests that women who present with CPP pose a challenge to GPs and practice nurses. CPP is not necessarily recognized as a diagnostic label and making the diagnosis was achieved only by exclusion. This contrasts with the relative acceptability of labels such as irritable bowel syndrome (IBS). GPs expressed elements of therapeutic nihilism about the condition. Despite practice nurses taking on increasing responsibilities for the management of patients with long term conditions, respondents did not feel that CPP was an area that they were comfortable in managing.

Conclusions

The study demonstrates an educational/training need for both GPs and practice nurses. GPs described a number of skills and clinical competencies which could be harnessed to develop a more targeted management strategy. There is potential to develop facilitated self- management for use in this patient group, given that this approach has been successful in patients with similar conditions such as IBS.

A qualitative analysis of adolescents' experiences of active and sham Japanese-style acupuncture protocols administered in a clinical trial

INTRODUCTION

Acupuncture is a complex holistic intervention in which patient-practitioner relationships and healing changes occur in interactive, iterative ways. Qualitative research is one way to capture such complexity. This study sought to understand better the experiences of adolescents involved in acupuncture treatment.

MATERIALS AND METHODS

We included a qualitative substudy as part of a pilot randomized sham-controlled study of the use of Japanese acupuncture to treat chronic pelvic pain in adolescent girls. Seven (7) interviews were attained. Themes were double-coded and analyzed using qualitative analysis software.

RESULTS

Regardless of treatment arm, all subjects reported positive study-related changes, often attributed to positive qualities of the patient-practitioner relationship. Participants in both the sham and verum acupuncture treatment arms reported in the narratives that they were unsure of their study assignment. In contrast, the study's close-ended success of blinding question suggests that some participants were sure of their treatment allocation.

CONCLUSIONS

As we continue to study acupuncture using sham controls, we need a better understanding of the possible affects of sham treatments on both treatment outcomes and success of blinding. Qualitative research is one-way to explore subtle emergent changes in participants' experiences.

Clinical course of chronic pelvic pain in women

A follow-up study on a cohort of women with chronic pelvic pain (CPP) was conducted, to evaluate the clinical course and to identify factors associated with outcome. Participants were over 18 years of age and had initially visited a multidisciplinary CPP-team of a Gynaecological Department of a University Hospital. The course of chronic pelvic pain was evaluated using the Life Chart Interview (LCI) method. All participants completed questionnaires covering demographic and clinical characteristics, pain (McGill) and psychological distress (SCL-90) at baseline and follow up. The response rate was 60%. A survival analysis was conducted. After a mean follow-up period of 3.4 years, 18 women (25%) of the study sample (N=72) reported recovery from pelvic pain (i.e. pelvic pain for less than 3 months per year). Eight of these 18 women (11% of the total sample) reported no pain at all at follow up. Relapse of symptoms was not encountered. Not any demographic, clinical or pain related variable measured at baseline, nor any intervention between baseline and follow up, was associated with outcome. Our results indicate that chronic pelvic pain in women in secondary care is a longstanding condition. Further research is recommended to identify risk factors for persistence of symptoms.

Chronic Pelvic Pain in Women in New Zealand: Comparative Well-Being, Comorbidity, and Impact on Work and Other Activities

This article reports the findings of a population-based study in New Zealand that investigated comparative well-being, comorbidity, and the impact of chronic pelvic pain (CPP) on activities. Chronic pelvic pain was defined as lower abdominal pain that is associated with neither the menstrual cycle nor sexual activity. A postal questionnaire was administered to a random sample resulting in a study group of 1,160. The negative impact of CPP on women's general well-being is significant. They were more likely than women without CPP to have other long-standing illnesses, other unspecified conditions involving pain or fatigue, and sleep patterns were more seriously disturbed. Pain restricted their activities. Comparisons with the limited data available from other studies are made.

Attitudes of women with chronic pelvic pain to the gynaecological consultation: a qualitative study

OBJECTIVE

To describe the attitudes that women with chronic pelvic pain (CPP) attending gynaecology clinics have to their consultations and to determine the ways in which their health care can be improved.

DESIGN

Qualitative study using semistructured individual interviews.

SETTING

UK gynaecology outpatient clinics in district general and teaching hospitals.

SAMPLE

Twenty-six women with CPP.

METHODS

Semistructured individual interviews were conducted. Data gathering and analysis followed a grounded theory approach.

MAIN OUTCOME MEASURES

Women's wishes regarding their care and their actual experiences of care.

RESULTS

Four main themes emerged. The women wanted (a) personal care, which they often did not receive; (b) to feel understood and to be taken seriously, although they often felt dismissed, which applied both to women with and without an explanation for their pain; (c) explanation as much as cure, but an adequate explanation was often not provided; and (d) to be reassured, which often they were not. Effective reassurance was complex as it included general reassurance and specific reassurance about cause and treatment.

CONCLUSIONS

Improvements are needed in the outpatient care of women presenting with CPP. Changes should focus on providing more personal care, so that presenting problems are seen to be taken seriously, findings and management are appropriately explained, and women are more effectively reassured. Interventions need to be developed that meet these needs and tested to determine if they are feasible, acceptable, and improve outcomes.

"People sometimes react funny if they're not told enough": women's views about the risks of diagnostic laparoscopy

OBJECTIVES

To explore women's views about the risks and benefits of diagnostic laparoscopy in the investigation of chronic pelvic pain, including how much information it is thought appropriate to give about three specific risks: death, major complications and the chance that the procedure would have an inconclusive result.

DESIGN

A qualitative analysis of semi-structured, audio-taped interviews with 20 women about their experiences of undergoing a diagnostic laparoscopy in a day surgery unit. Interviews were conducted 3-6 months after the procedure.

RESULTS

All the women who were interviewed were aware that diagnostic laparoscopy carried risks, including the small risk of death associated with general anaesthesia. One-third of respondents said that they had initially been reluctant to discuss the risks of the procedure in general terms. However, when specific examples of complications and risks were introduced all but one of the respondents reported that they would have liked to discuss these at the time that the decision to have the operation was made. Women maintained that the information was needed to make an informed decision about whether to have the operation, to help them understand and cope should things go wrong and in order to make appropriate plans to cover contingencies. Most were surprised to hear that the procedure is frequently inconclusive and thought that this information should be made clear to women contemplating a laparoscopy.

CONCLUSIONS

Women undergoing diagnostic laparoscopy for the investigation of chronic pelvic pain wish to be given full and accurate information about complication rates such as bowel perforation, what to expect during their recovery, and the chances of finding a cause for their pain. Although they may not want to dwell on the risk of death, they do need to be informed about the specific risks associated with the procedure in order to make a balanced decision.

Setting up a multidisciplinary clinic

Chronic pelvic pain can be a perplexing and complex problem, frustrating to both clinicians and patients. The traditional medical and surgical model does not always relieve symptoms, and many patients suffer years of pain and undergo multiple surgical procedures without long-term benefit. The biopsychosocial model for chronic pelvic pain gives clinicians the opportunity to broaden the scope for management. A multidisciplinary team can offer simultaneous assessment and management of somatic, behavioural and psychosocial components of the pain. Key members of the team are identified and their roles explored. Practical aspects of operating a multidisciplinary clinic are discussed. A multidisciplinary approach comprises many elements. Further research is needed to identify which are the essential elements to secure optimum outcome for the individual patient.