Interventions for treating chronic pelvic pain in women

 

Abstract

Background

Chronic pelvic pain is common in women in the reproductive and older age groups and causes disability and distress. Often investigation by laparoscopy reveals no obvious cause for the pain. As the pathophysiology of chronic pelvic pain is not well understood its treatment is often unsatisfactory and limited to symptom relief. Currently the main approaches to treatment include counselling or psychotherapy, attempts to provide reassurance by using laparoscopy to exclude serious pathology, progestogen therapy such as medroxyprogesterone acetate, and surgery to interrupt nerve pathways.

Objectives

We aimed to identify and review treatments for chronic pelvic pain in women. The review included studies of patients with a diagnosis of pelvic congestion syndrome or adhesions but excluded those with pain known to be caused by i) endometriosis, ii) primary dysmenorrhoea (period pain), iii) pain due to active chronic pelvic inflammatory disease, or iv) irritable bowel syndrome.

Search methods

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials (searched 20th January 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005), and reference lists of articles.

Selection criteria

Randomised controlled trials (RCTs) with women who had chronic pelvic pain. The review authors were prepared to consider studies of any intervention including lifestyle, physical, medical, surgical and psychological treatments. Outcome measures were pain rating scales, quality of life measures, economic analyses and adverse events.

Data collection and analysis

For each included trial, information was collected including the method of randomisation, allocation concealment and blinding. Data were extracted independently by the two review authors using forms designed according to the Cochrane guidelines.

Main results

Nineteen studies were identified of which fourteen were of satisfactory methodological quality. Five studies were excluded. Progestogen (medroxyprogesterone acetate) was associated with a reduction of pain during treatment while goserelin gave a longer duration of benefit. Counseling supported by ultrasound scanning was associated with reduced pain and improvement in mood. A multidisciplinary approach was beneficial for some outcome measures. Benefit was not demonstrated for adhesiolysis (apart from where adhesions were severe), uterine nerve ablation, sertraline or photographic reinforcement after laparoscopy. Writing therapy and static magnetic field therapy showed some evidence of short-term benefit.

Authors' conclusions

The range of proven effective interventions for chronic pelvic pain remains limited and recommendations are based largely on single studies. Given the prevalence and healthcare costs associated with chronic pelvic pain in women, randomised controlled trials of other medical, surgical and psychological interventions are urgently required.
Chronic pelvic pain is common in women in the reproductive and older age groups and it causes disability and distress that result in significant costs to health services. The pathogenesis of chronic pelvic pain is poorly understood. Often investigation by laparoscopy reveals no obvious cause for the pain. There are several possible explanations for chronic pelvic pain including undetected irritable bowel syndrome, and central sensitisation of the nervous system. A vascular hypothesis proposes that pain arises from dilated pelvic veins in which blood flow is markedly reduced. As the pathophysiology of chronic pelvic pain is not well understood, its treatment is often unsatisfactory and limited to symptom relief. Currently the main approaches to treatment include counselling or psychotherapy, attempts to provide reassurance using laparoscopy to exclude serious pathology, progestogen therapy such as with medroxyprogesterone acetate and surgery to interrupt nerve pathways.

 

Plain language summary

Limited symptom relief is available for women with chronic pelvic pain

Chronic pelvic pain in women is a common problem. Symptoms include lower abdominal pain, and pain before and during sexual intercourse. Specific causes are difficult to identify and treatment is often limited to relief of symptoms. An ultrasound or internal examination using a laparoscope is done to rule out serious conditions and to provide reassurance. The review of trials found that a multidisciplinary approach helps alleviate symptoms. A high dose of progestogen therapy using medroxyprogesterone acetate also helps but goserelin has a longer duration of benefit. There is an indication of benefit from writing therapy for some patients.

 

摘要

背景

女性慢性骨盆腔疼痛的治療方法

慢性骨盆腔疼痛在生育年齡或更年長的女性族群是很常見的，它會造成失能和痛苦。常常腹腔鏡的檢查找不出明顯會造成疼痛的原因。就因為對慢性骨盆腔疼痛的病理生理學還不是了解的很清楚，它的治療常常是不令人滿意的而局限於對症狀的緩解。目前主要的治療方法包括諮詢或精神心理療法，使用腹腔鏡排除明顯的病理問題來試圖提供安心保證，黃體激素 (progestogen) 的治療例如medroxyprogesterone acetate及截斷神經路徑的手術。

目標

我們主要的目標是要找出及評斷女性慢性骨盆腔疼痛的治療方法。這篇回顧囊括了病人診斷為骨盆充血症候群 (pelvic congestion syndrome) 或骨盆腔沾黏 (adhesions) 的研究，但排除了以下這些造成骨盆腔疼痛的原因的研究：1.子宮內膜異位症 (endometriosis) 、2.原發性經痛 (primary dysmenorrhoea) (週期性的疼痛) 、3.活動性的慢性骨盆腔發炎 (pelvic inflammatory disease) 引起的疼痛、4.大腸急躁症 (irritable bowel syndrome) 。

搜尋策略

我們搜尋了Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials (searched 20th January 2005) ，the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005) ，以及這些論文列出的參考文獻。

選擇標準

選擇標準是婦女慢性骨盆腔疼痛的隨機對照試驗 (Randomised controlled trials) 。這篇回顧的作者考慮了每一種治療的研究包括生活習慣、物理性的、內科的、手術的、心理的治療。結果的估量是根據疼痛的等級評分、生活品質的評量、經濟上的分析和不良事件。

資料收集與分析

針對每一個囊括進來的試驗，資訊的收集所採取的方法包括隨機選擇 (randomisation) 、隱藏的分配 (allocation concealment) 及矇蔽 (blinding) 。數據資料由兩位作者獨立的擷取，使用根據Cochrane guidelines設計出來的格式。

主要結論

總共找出了19篇研究，其中14篇有令人滿意的研究方法品質，有5篇研究則被排除。黃體激素 (medroxyprogesterone acetate) 在治療的過程中跟疼痛的緩解是有相關的，而goserelin的治療益處則較持久。諮詢且使用超音波掃描來支持跟疼痛的緩解及情緒的改善是有相關聯的。一個多方向的治療方法對治療結果的評分是有益處的。以下這些方法則沒有證據顯示出有治療益處，包括沾黏分離術 (adhesiolysis) (除了嚴重沾黏的個案) 、子宮神經燒灼 (uterine nerve ablation) 、sertraline (抗憂鬱劑) 的使用或腹腔鏡術後的攝影照片來加強說服力。書寫治療 (Writing therapy) 和穩定磁場治療 (static magnetic field therapy) 則有一些短期益處的證據。

作者結論

已經證實有效的慢性骨盆腔疼痛治療方法是有限的，而且一些建議大部分是基於單一的研究結果。鑒於女性慢性骨盆腔疼痛的盛行及健康照護上的花費，我們迫切的須要其他內科、外科或心理的治療方法的隨機對照試驗。慢性骨盆腔疼痛在生育年齡和更年長的族群的女性是很常見的，它會造成失能和痛苦，導致在健康照護上的顯著花費。對於慢性骨盆腔疼痛發病原因，我們的了解是不充足的。常常腹腔鏡的檢查顯現不出明顯的造成疼痛的原因。有一些可能造成慢性骨盆腔疼痛的解釋，包括未被發現的大腸急躁症和神經系統的中樞敏感化。一個血管假說認為疼痛是來自於擴張的骨盆腔靜脈，在這些靜脈中血流是顯著減少的。就因為對慢性骨盆腔疼痛的病理生理學還不是了解的很清楚，它的治療常常是不令人滿意的而局限於對症狀的緩解。目前主要的治療方法包括諮詢或精神心理療法，使用腹腔鏡排除明顯的病理問題來試圖提供安心保證，黃體激素 (progestogen) 的治療例如medroxyprogesterone acetate及截斷神經路徑的手術。

翻譯人

本摘要由高雄醫學大學附設醫院郭昱伶翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

女性慢性骨盆腔疼痛的症狀緩解是有限的女性慢性骨盆腔疼痛是很常見的問題。它的症狀包括下腹痛以及在性交前和性交時的疼痛。特定的造成疼痛的原因不容易找出，治療常常侷限於對症狀的緩解。超音波的檢查及使用腹腔鏡做內部檢查是用來排除一些需要注意的疾病狀況和提供安心保證。這篇回顧發現多方向的治療方法可以幫助緩解症狀。高劑量的黃體激素治療 (使用medroxyprogesterone acetate) 也是有幫助的，但goserelin的治療益處較持久。有跡象顯示對某些病人來說，書寫治療是有益處的。