IPPS Blog

NICHD/NIH Position Available

November 10, 2020

The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) at the National Institutes of Health (NIH) is seeking a program officer with research expertise relevant to gynecologic pain syndromes. Click here to view full job description.


IPPS Call for Committee Volunteers

November 6, 2020

IPPS Call for Committee Volunteers

Enrich your IPPS experience by serving on a committee! Committee membership allows you to share your experience and expertise, but also to gain knowledge and enlarge your networking circle – all while working to fulfill the IPPS mission and expand our understanding of chronic pelvic pain.

IPPS is accepting applications for openings on the following committees:

A description of each committee is available below.

Eligibility: Membership on IPPS committees is open to all interested individuals who hold current membership in IPPS. 

Apply: To apply for a committee position, please complete the Committee Application Form by Monday, November 30, 2020.

Application Deadline: A complete application form must be submitted by Monday, November 30, 11:59pm CST, for your application to be considered. Only complete applications will be considered. 

Committee Descriptions

Ethics Professionalism and Equality Committee (EPEC)
Chair: Meryl J. Alappattu
The Ethics Professionalism and Equality Committee (EPEC) defines and establishes principles for professional behavior that govern all IPPS activities, and members, exhibitors, sponsors, contractors, volunteers and non-members participating in IPPS sponsored activities. The EPEC evaluates allegations of behavior in conflict with the IPPS Code of Conduct and ensures that this evaluative process is consistent with the standard operating procedures (SOP) outlined in the EPEC SOP policy.

Fundraising Committee
Co-chairs: Debbie Callif & Kenneth Barron
The Fundraising Committee helps expand awareness of the IPPS and raises funds for patient and physician education and general public awareness.

International Liaison Committee
Chair: Krisztina Bajzak
The International Liaison Committee works to improve relationships with international societies.

Medical Education Committee
Chair: Allyson Shrikhande
The Medical Education Committee provides resources and improves education about pelvic pain prevalence, evaluation, and management.

Membership & Marketing Committee
Chair: Mario Castellanos 
The Membership & Marketing Committee works to increase new membership and retain current members. This includes new, diverse, and current disciplines of providers involved in the treatment of pelvic pain.

Patient Education Committee
Chair: Andrea Rapkin
The Patient Education Committee aims to establish IPPS as the preeminent resource for education and support for patients with chronic pelvic pain and their families. Educational materials are delivered primarily through the IPPS website, and will be up to date, easy to follow, and reflect the multifaceted nature of chronic pelvic pain and the multidisciplinary approach to management.

Research Committee 
Chair: Georgine Lamvu 
The Research Committee promotes research focusing on pelvic pain disorders, fosters collaboration between members contributing research in pelvic pain disorders, promotes education in research and publication methodology, and educates and updates members in research focusing on pelvic pain disorders.

Social Media Committee
Chair: Heather Jeffcoat
The Social Media Committee develops and implements the social media strategies to promote the value and profile of the society.


Moving Toward Gender Inclusive Pelvic Pain Healthcare

August 21, 2020

Moving Toward Gender Inclusive Pelvic Pain Healthcare

Moving toward gender-inclusive pelvic pain healthcare.  Social Worker and IPPS member, Renee Dumaresque, provides guidance for healthcare providers on incorporating gender inclusive care into their practice. 
This blog also provides useful information for ALL pelvic pain providers.





By:
Renee Dumaresque, MSW, Ph.D. Student

You may already be dedicated to building a gender inclusive pelvic pain practice, and, perhaps, have your own ideas about how to provide safe and accessible care for transgender and gender diverse patients. This post is not meant to be exhaustive, and, of course, I am unable to speak on behalf of every transgender and gender diverse person living with pelvic pain. Hopefully, this piece can provide an entry point into learning more, or will contribute a thing or two to your existing knowledge about gender-inclusive healthcare. Based on my lived experience as a gender non-binary person with vulvodynia, and my professional experience as a social worker who is pursuing their Ph.D. in relation to queer and trans healthcare, I hope to offer some thoughts that may be helpful in making your practice more inclusive for transgender and gender diverse folks.

Chronic pelvic pain impacts people across the gender spectrum, but, for many transgender people, healthcare is not safe or accessible. Too often, this results in patients being denied appropriate care, withdrawing from care, or not engaging with healthcare at all. Healthcare holds the potential to be a transformative space of healing, support and affirmation, and there are initiatives all over the world that model dedication to gender-inclusive healthcare. What’s important, is your desire to learn, the courage to make mistakes, apologize, and try again.

Dominant understandings of health, pathology, and treatment, as well as the delivery of healthcare services, are often approached and practiced based on mainstream ideas about gender as binary and as biological. Within “women’s health”, for example, research, diagnostics, and treatment equate gender identity with biological ideas about sex. Gender does impact a person’s health and health care, but gender identity does not determine a person’s body parts or the health issues that lead a person to seek health-related support. There is no such thing as a “woman’s body” or a “man’s body”. For example, a man can have a uterus, a vulva, or breasts; and, a woman can have a prostate and testes.

A person’s gender identity relates to the way that they perceive their own experience of gender, which may or may not correlate to the sex that they were assigned at birth, for example, male and female. Mainstream ideas about gender suggest that there are only two genders and that a person must identify as a man or as a woman. However, gender exists on a spectrum, meaning that there are many ways that a person might experience gender, and for lots of people, gender is fluid throughout the course of their life.

Everyone has an experience of gender, not only transgender and gender diverse folks. For cisgender people, too, gender can shift and be extremely nuanced. When a person identifies as cisgender it means that their gender identity corresponds to gender norms associated with the sex that they were assigned at birth, for example, a person who was assigned male at birth and identifies as a man. Transgender or ‘Trans’ is an umbrella term to describe the many ways that people identify and experience gender that differs from societal norms regarding gender and gender identity.

The term ‘Trans’ does not suggest that all Trans people identity in the same way and it is not meant to erase the differences that exist between people’s unique experiences and understandings of gender. Trans includes transgender men and women, but it also includes people who don’t necessarily identify as either a man or a woman, and who may or may not identify as transgender, for example, non-binary, agender, gender fluid, and Two-Spirit folks, etc. Ideas about gender also vary within and between cultures, where people may or may not identify with Trans identity.

Transgender identity is not dependant on physical transition, for example, hormones or surgery. Gender transition may or may not involve physical aspects, but it can also include emotional, spiritual, and many other shifts. Be mindful of the language that is used by your patients to describe their bodies and experiences. For some patients, labels such as “pre-operative” and “post-operative” will be problematic because of the assumption that transition must include physical change, but for others, these terms might feel right. It is important to remember, for both cisgender and transgender individuals, that the words people use to describe their experiences and their identities can mean many different things for different people. There are no generalizable rules about gender.

You cannot assume a person’s gender by looking at them. Gender expression is different than gender identity - it relates to the way that a person presents, such as masculine, feminine, androgynous, etc. Like gender identity, gender expression is often fluid, it might change day to day, and it is not dependent on gender identity.

With respect to pelvic pain healthcare, consider who is currently left out of the conversation? Which bodies and identities are not included in research, treatment, and support? What assumptions exist related to gender? Although there are many structural barriers to gender-inclusive healthcare, there is a lot that you can do to make your practice safer and more accessible to transgender and gender diverse folks. Increasing access and inclusivity does not mean implementing special practices for Trans patients that differ from the practices that you use with cisgender patients. By providing gender-inclusive care, to all patients, you will contribute to the development of new norms in mainstream healthcare. You will help to address the structural issues that result in marginalization and erasure of transgender and gender diverse patients.

Trans patients live whole lives that don’t always center their gender identity. For the most part, people want to visit their healthcare provider and be treated just like everyone else – to feel included, considered, and like their experiences and bodies are equal to other patients. Below are some ideas about how you can increase accessibility within your pelvic pain practice.

  1. Consider the advertisements, signage or other materials that you display in your clinic.

    Avoid placing material in your clinic that equates specific experiences and medical issues with a specific gender. For example, frameworks of women’s health often exclude and erase transgender and gender diverse people and their experiences. Consider displaying a sign or a poster in your clinic which communicates to patients that your clinic values transgender and gender diverse patients. Remember that signage, alone, is not helpful and must be accompanied by a thoughtful practice dedicated to gender inclusivity.

  2. Understand that building trust takes time.

    Recognize that patients are often coming into your practice having had negative experiences in healthcare. It is normal and reasonable that Trans patients might enter from a place of distrust. In fact, for a lot of people, having their guard up is a safety precaution that has been both smart and necessary. For this reason, be patient, avoid making judgments, and understand that you are in a unique position to provide a different and positive experience of healthcare. Communication and transparency is key to building trust. Always communicate what you intend to do, check in with patients about their comfort level, and ask for consent along the way.

  3. Respect patients chosen name.

    Ask patients to share their name and don’t assume that the name they provide will be the same as what you see listed on their health identification. Safety concerns, legal and financial barriers, social and family issues, and personal choice are some of the many reasons that a patient’s name might differ from their legal name or the name that appears on their health identification.  Ask patients what name appears on their health-card, and also ask patients if they prefer a different name be used in your clinic. If so, make sure to document their chosen name.

  4. Ask all patients to share their pronouns.

    Like gender identity, you cannot assume a person’s pronouns based on how they look or based on their gender identity. For example, some gender non-binary people choose to use she/her or he/him, and some people use different pronouns in different settings. By asking all patients what their pronouns are you will avoid making assumptions and it will quickly feel like your new norm. Start by introducing yourself and sharing your own pronouns, then you can ask your patient if they feel comfortable sharing theirs.

     

  5. Ask about body parts instead of assigned sex.

    Within society, gender and sex are often conflated, meaning that ideas about sex are hardly ever gender neutral in social institutions. Many people do not identify with the sex that they were assigned at birth. Instead of asking people about their assigned sex, ask people to identify the specific body parts that they have or that are relevant to their healthcare.

  6. Don’t make assumptions about sexual orientation or sexual practices.

    Sexual orientation is different than gender identity. A persons gender identity does not dictate or limit a person’s sexual orientation. Knowing a person’s sexual orientation does not tell you what sexual practices that they engage in, just as knowing what sexual practices that a person engages in does not tell you their sexual orientation. Avoid making any assumptions about a patient’s sexual orientation and their sexual practices. If having this information is necessary for providing certain aspects of health care, then, inform patients as to why having the information will be helpful and ask them if they are comfortable sharing.

     

  7. Review (and possibly revise) your patient intake form.

    Your intake form is one of the first interactions that a patient has with your practice. Thoughtful design can ensure that you share and obtain the necessary information that you need to run your business and provide quality, gender-inclusive healthcare. Review your intake form in relation to the information and the suggestions listed above. Do the questions that you ask on your intake form make assumptions about gender identity or equate gender with certain body parts? What questions might you consider adding? Are there questions that can be removed or rephrased? Reflect on the reasons that you ask each of your questions and consult with others if you need advice or if you are struggling with revisions. 

    Like any big change, moving toward gender-inclusive pelvic pain healthcare will come with lots of learning and you may have lots of questions. Changes in your practice might also come with questions from others, including patients and colleagues. Taking a few moments to explain your approach to providing care or to clarify the questions that you ask in your intake form shouldn’t take long, but it will make a big difference for Trans people who engage with your practice and who see themselves reflected in your day-to-day operations. Many people and organizations have put tons of thought into developing gender-inclusive healthcare - you do not need to reinvent the wheel! Remember that not everything that you do will work for every patient - be open to feedback, try new things, and know that you are engaging in life-saving and life-affirming work. More resources must be put into learning more about the unique ways that pelvic pain impacts Trans folks, about effective treatment, and effective support. People with pelvic pain carry huge amounts of knowledge related to health, survival, coping, healing, and resistance. Within your work, centre the knowledge of people living with pain. Continue to acknowledge that we all have something to learn from one another as we reimagine what it means to live with pelvic pain, and in some cases, how to live without it.







 

Posted by IPPS Admin on February 21, 2019, 12:00AM

IPPS Responds to the Bankrupty of APS

August 21, 2020

IPPS Responds to Inquiries About the Recent American Pain Society (APS) Bankruptcy

The IPPS Board of Directors would like to express its sadness that APS has filed for dissolution via Chapter 7 Bankruptcy.




The IPPS Board of Directors would like to express its sadness that APS has filed for dissolution via Chapter 7 Bankruptcy. In light of the fact that APS was a chapter of IASP and that IASP also serves as the management company for IPPS we are taking this opportunity to clarify IPPS’ status and independence.

Regarding the relationship between APS and IASP, you can read IASP’s statement about APS here. All IASP chapters have independent governance, legal and financial structures from IASP and as a result, any chapter’s financial or legal issues have no impact on IASP.

In 2018 IPPS engaged IASP to provide management services for IPPS, however, the IPPS is an independent, autonomous organization and has independent governance, legal and financial structure from IASP.IPPS has strong reserves and is fiscally sound. Furthermore, IPPS revenue is derived from membership dues and annual conference revenue with very little support from any industry.

IPPS has always been a strong advocate for multi-modal, inter-disciplinary and integrated management of chronic pain. We advocate for pain research, for provider and patient education and for improved access to care. As long as we have support from our members we will continue this important work.

Everyone has an experience of gender, not only transgender and gender diverse folks. For cisgender people, too, gender can shift and be extremely nuanced. When a person identifies as cisgender it means that their gender identity corresponds to gender norms associated with the sex that they were assigned at birth, for example, a person who was assigned male at birth and identifies as a man. Transgender or ‘Trans’ is an umbrella term to describe the many ways that people identify and experience gender that differs from societal norms regarding gender and gender identity.


Georgine, Lamvu, MD, MPH 
IPPS, Board Chair




 

Posted by IPPS Admin on August 15, 2019, 12:00AM

Read the Covid-19 Statement from Board Chair

August 21, 2020

Read the Covid-19 Statement from Board Chair

The IPPS Board of Directors has been following the Covid-19 situation closely.




Dear Colleagues,

The COVID-19 pandemic is proving to be a serious challenge to our communities and resources. The IPPS Board of Directors has been following the situation closely and we want you to know that your safety and well-being are our top priority. At this time, the IPPS Annual Scientific Meeting, scheduled to take place in October, is being evaluated and we are developing a back-up plan in case the meeting has to be rescheduled.

Over the next 60 days we will make a decision as to whether to proceed with the annual meeting; our intent is to hold the meeting only if it is safe to do so. Currently, the IPPS is planning the following actions:

1. We are exploring various online platforms and alternate registration processes for holding an entirely virtual meeting. The goal would be to have a virtual meeting that offers the same educational and networking opportunities as the in-person meeting.

2. Registration deadlines, including early bird registration, will be extended. If the meeting is converted to a virtual meeting, the registration platform will be changed accordingly.

3. The abstract and topical seminar submission deadlines will be extended to allow investigators to overcome delays imposed by work and travel restrictions. Selected abstracts will be published in PAIN Reports.

As we are all aware, the situation surrounding COVID-19 is rapidly changing. The IPPS Board will work diligently to implement necessary changes and keep the members up to date.

Thank you for your patience and please stay safe!


Georgine, Lamvu, MD, MPH 
IPPS, Board Chair




 

Posted by IPPS Admin on April 15, 2020, 12:00AM

An interdisciplinary approach to chronic pelvic pain management is better

May 20, 2020

An INTERDISCIPLINARY approach to chronic pelvic pain management IS BETTER.

What is interdisciplinary?

An INTERDISCIPLINARY approach to chronic pelvic pain management IS BETTER.
What is interdisciplinary?

By: Jorge F. Carrillo MD, FACOG, IPPS Board Member

Chronic pelvic pain is usually a multifactorial problem that can be caused by the complex interaction of gynecological, gastrointestinal, urological, musculoskeletal, neurological and psychosocial conditions among others.1,2 Furthermore, pain in general has been described as a biopsychosocial phenomenon in which an interaction occurs between biological factors (such as physiological or anatomical alterations), psychological factors (such as beliefs, attitudes, affectivity and illness behavior) and social factors (such as culture, social interactions or work for example).3

With this model in mind the US Department of Health and Human Services (DHHS) released in 2019 a document titled “Pain management best practices inter-agency task force report. Updates, gaps, inconsistencies, and recommendations.”4 This document was released to guide federal agencies, private stakeholders, and the public at large through common gaps identified in the treatment of pain patients. The recommendations encourage providers, policymakers, legislators, regulators, and patients to adopt a biopsychosocial approach to pain management. A very important point brought up in this document was that using a multidisciplinary management approach, in a coordinated and integrated fashion, has been documented to reduce pain severity, improve mood and overall quality of life, and increase function. 4

As part of identifying treatment approaches, it is important to discuss basic concepts and definitions. Per the International Association for the Study of Pain (IASP):
1. A multimodal treatment generally refers to multiple therapies combined, these not necessarily offered by different healthcare professionals.
2. A multidisciplinary approach refers to the addition of the competencies of multiple professionals who stay within the boundaries of their fields, without necessarily communicating amongst them, and
3. An interdisciplinary treatment denotes that various disciplines are coordinated toward a common and coherent approach.5

The benefits of using a multidisciplinary approach with a shared decision-making model have been studied in patients with conditions such as chronic low back pain, TMJ, fibromyalgia, chronic headache, neck pain in the USA and other countries (England, Denmark, Canada).6–9 Furthermore, there is research suggesting that an interdisciplinary approach is clinically superior and more cost-effective than a multidisciplinary alone.10 This could be due to lack of integration of the services involved with limited communication among providers found in a multidisciplinary approach. However, is clear that for chronic pain patients a multidisciplinary approach is better than unimodal and multimodal approaches alone, so it should be encouraged. There are few studies investigating the effect of interdisciplinary and multidisciplinary approaches to chronic pelvic pain conditions, the results are promising, but we still need more research to make conclusive statements.2,11

For chronic pelvic pain patients, a comprehensive team should potentially include some or ideally all of the following healthcare providers: gynecologist, urologist, GI/colorectal specialist, physical therapist, behavioral therapist, physical medicine and rehab specialist, pharmacist, social worker, pain medicine/anesthesiologist, sex therapist, integrative medicine specialist and/or a dietician. If you are interested in expanding your network of chronic pelvic pain providers and potentially build a multidisciplinary or interdisciplinary team, a list of pelvic pain specialists members of IPPS, organized by region, can be found at our website.12 This is a free resource for both IPPS members/non-members, and healthcare providers/patients.

 

References 
1. Steege JF, Siedhoff MT. Clinical Expert Series Chronic Pelvic Pain. Obs Gynecol. 2014;124(3):616-629. doi:10.1097/AOG.0000000000000417
2. Allaire C, Williams C, Bodmer-Roy S, et al. Chronic pelvic pain in an interdisciplinary setting: 1-year prospective cohort. Am J Obstet Gynecol. 2018. doi:10.1016/j.ajog.2017.10.002
3. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The Biopsychosocial Approach to Chronic Pain: Scientific Advances and Future Directions. Psychol Bull. 2007;133(4):581-624. doi:10.1037/0033-2909.133.4.581
4. U.S. Department of Health and Human Services ITF. Executive Summary Pain Management Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations.; 2019. https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html.
5. IASP. Task Force on Multimodal Pain Treatment Defines Terms for Chronic Pain Care. https://www.iasp-pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=6981. Published 2017. Accessed April 5, 2020.
6. Choi, B, Pak A. Multidisciplinarity, inter-disciplinarity and trans-disciplinarity in health research. Clin Investig Med. 2006. doi:10.1002/eji.201090065
7. Gatchel RJ, Okifuji A. Evidence-Based Scientific Data Documenting the Treatment and Cost-Effectiveness of Comprehensive Pain Programs for Chronic Nonmalignant Pain. J Pain. 2006. doi:10.1016/j.jpain.2006.08.005
8. Giusti EM, Castelnuovo G, Molinari E. Differences in Multidisciplinary and Interdisciplinary Treatment Programs for Fibromyalgia: A Mapping Review. Pain Res Manag. 2017. doi:10.1155/2017/7261468
9. Simmons JW, Avant WS, Demski J, Parisher D. Determining successful pain clinic treatment through validation of cost effectiveness. Spine (Phila Pa 1976). 1988. doi:10.1097/00007632-198803000-00020
10. Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management. Am Psychol. 2014;69(2):119-130. doi:10.1037/a0035514
11. Brotto LA, Yong P, Smith KB, Sadownik LA. Impact of a Multidisciplinary Vulvodynia Program on Sexual Functioning and Dyspareunia. J Sex Med. 2015. doi:10.1111/jsm.12718
12. IPPS. Find the provider. https://www.pelvicpain.org/IPPS/Professional/Find_A_Provider/IPPS/Content/Professional/Find_A_Provider.aspx?hkey=d783de9c-cc3a-4655-95c6-fd9da7a3fdf8. Accessed May 8, 2020.

Menopause Comes with More than Mood Swings

October 2, 2019

Menopause Comes with More than Mood Swings

...It Deserves its Place Among Chronic Pain Conditions



At this year’s PAINWeek, the International Pelvic Pain Society (IPPS) led a track of educational sessions on managing distinct types of genital, vulvar, and overall chronic pelvic region pain. Georgine Lamvu, MD, MPH, who serves as Chair of the IPPS Board and works at the Orlando VA Medical Center, provided an update on new terminology in the field and addressed the specifics of genitourinary syndrome of menopause (GSM), a relatively recent classification that has a longer lifespan than previously thought.


Updated Definitions

Vulvar pain can begin at any age, said Dr. Lamvu, and what’s important for clinicians to know now is that there is a new classification for the specific type of vulvar pain known as vulvodynia. This type of vulvar pain must last 3 months or more without a clear identifiable cause, with potential associated factors. The International Society for the Study of Vulvovaginal Disease (ISSVD) and the IPPS updated the definition in 2018 to differentiate vulvodynia from general vulvar pain. The idiopathic condition must be a diagnosis of exclusion.

Another updated definition, this one in the DSM-5, is for vaginismus. This term captures vaginal pain that lasts longer than 6 months and that is associated with intense fear or anxiety around intercourse and the tensing of pelvic and lower abdominal muscles. The prior definition was more psychogenic, noted Dr. Lamvu. We know now that vaginismus may have a musculoskeletal dysfunction component. Further, this condition cannot be attributed to PTSD, domestic violence, or other life stressors. “We are really looking at an intense psychological fear accompanied by musculoskeletal issues—anything else is not ‘vaginismus.’

Then there is GSM, which was previously known atrophic vaginismus, vulvovaginal atrophy, or urogenital atrophy. Although the disorder was described by the International Society for the Study of Women’s Health and the North American Menopause Society in 2014, and further explained by Gandhi J in an AJOG paper in 2016, many providers are still catching up with the fact that GSM is disease that progresses over time. The syndrome groupslower urogenital tract signs and symptoms associated with a low-estrogen state.

The GSM pathophysiology has to do with changes in tissue integrity and the acidity of the vagina, and thus, reduced protection against vaginitis and urinary tract infections. Symptoms may include dyspareunia, incontinence, prolapse, thin vaginal epithelium, impaired smooth muscle proliferation, loss of vascularity, dryness, and itching—all occurring in the hyposterogenism state. Risk factors may include bilateral salpingo-oophorectomy, ovarian failure, chemotherapy, smoking, and alcohol use.

“When you see someone with vaginal atrophy, you have to screen for urinary and sexual dysfunction, but now you can avoid any negative connotations associated with the term” said Dr. Lamvu. “Menopause may be identified as the cause of both vulvar andurinary symptoms with this condition.”

Genitourinary Syndrome of Menopause—On the Chronic Progression Continuum

Sharing the stats, Dr. Lamvu noted that 15% of premenopausal women experience GSM and 40 to 54% of postmenopausal women have GSM. Most of the symptoms have to do with declining estrogen levels, which change most rapidly between ages 45 and 55.

Of interest, a review of 64 studies over the course of 2000 to 2014 around the world on menopause symptom prevalence found that 30 to70% of women experience GSM symptoms worldwide (see Makara-Studzinskia MT, Prz Menopauzalny, 2014). Sexual dysfunction post-menopause may go up to 92% prevalence. Women do not often mention sexual dysfunction in particular—they may mention dryness, said Dr. Lamvu, but providers need to talk to them about this symptom as well.

The median vasomotor duration in another study was 7.4 years for symptoms of menopause; symptoms may go on 4.5 years after menopause as well (see Avis NE, et al, JAMA Intern Med, 2015). “Essentially, the earlier a woman starts perimenopause, the longer her GSM symptoms may last, possibly for 11.8 years in total,” said Dr. Lamvu.

GSM is considered to be chronic, progressive, and unlikely to resolve without treatment—this, on top of its long timeframe and the fact that chronic pain may increase with age, make effective assessment and management crucial.

In fact, one VA study showed that women who had menopause had twice as high odds of also having a chronic pain syndrome and twice as high odds of having multiple pain diagnoses, even after adjusting for age, race, BMI, mental health, and so forth, noted Dr. Lamvu. “This means our screening process for these patients has to go way beyond asking patients, ‘Is your vagina dry?’”

“Pain specialists may see myalgias and neuralgias in their patients, and guess what,” continued Dr. Lamvu, “Women get those symptoms in the vagina too… Clinicians may not automatically associate these diagnoses with the vagina but they need to.”

As an example, she shared that she often sees chronic pain conditions in her GSM patients—including fibromyalgia, temporomandibular disorder, low back pain, and migraine. Anxiety and depression are also common with GSM.

Sometimes clinicians focus on vaginal atrophy and forget that other things in the pelvis can cause pain, from bladder pain syndrome to myofascial pelvic pain to neuralgia to IBS. There are commonly missed conditions associated with vaginal pain and dyspareunia. As a result, many patients go through a primary care doctor, a gynecologist, and a psychologist and are told they have vaginal atrophy, but GSM is much more than that. Evaluations of vulvovaginal pain need to go outside of a doctor’s typical comfort zone to include a biopsychosocial evaluation. Gynecological screenings must also include trauma-informed care.

How to Manage GSM

There is good news for patients with GSM—despite being a chronic condition, symptoms can be managed based on severity, said Dr. Lamvu. Education and lifestyle modifications can be very beneficial, including: 

Genitourinary Syndrome of Menopause—On the Chronic Progression Continuum

Sharing the stats, Dr. Lamvu noted that 15% of premenopausal women experience GSM and 40 to 54% of postmenopausal women have GSM. Most of the symptoms have to do with declining estrogen levels, which change most rapidly between ages 45 and 55.

Of interest, a review of 64 studies over the course of 2000 to 2014 around the world on menopause symptom prevalence found that 30 to70% of women experience GSM symptoms worldwide (see Makara-Studzinskia MT, PrzMenopauzalny, 2014). Sexual dysfunction post-menopause may go up to 92% prevalence. Women do not often mention sexual dysfunction in particular—they may mention dryness, said Dr. Lamvu, but providers need to talk to them about this symptom as well. 

The median vasomotor duration in another study was 7.4 years for symptoms of menopause; symptoms may go on 4.5 years after menopause as well (see Avis NE, et al, JAMAIntern Med, 2015). “Essentially, the earlier a woman starts perimenopause, the longer her GSM symptoms may last, possibly for 11.8 years in total,” said Dr. Lamvu. 

GSM is considered to be chronic, progressive, and unlikely to resolve without treatment—this, on top of its long timeframe and the fact that chronic pain may increase with age, make effective assessment and management crucial. 

In fact, one VA study showed that women who had menopause had twice as high odds of also having a chronic pain syndrome and twice as high odds of having multiple pain diagnoses, even after adjusting for age, race, BMI, mental health, and so forth, noted Dr. Lamvu. “This means our screening process for these patients has to go way beyond asking patients, ‘Is your vagina dry?’” 

“Pain specialists may see myalgias and neuralgias in their patients, and guess what,” continued Dr. Lamvu, “Women get those symptoms in the vagina too… Clinicians may not automatically associate these diagnoses with the vagina but they need to.”

As an example, she shared that she often sees chronic pain conditions in her GSM patients—including fibromyalgia, temporomandibular disorder, low back pain, and migraine.  Anxiety and depression are also common with GSM.

Sometimes clinicians focus on vaginal atrophy and forget that other things in the pelvis can cause pain, from bladder pain syndrome to myofascial pelvic pain to neuralgia to IBS. There are commonly missed conditions associated with vaginal pain and dyspareunia. As a result, many patients go through a primary care doctor, a gynecologist, and a psychologist and are told they have vaginal atrophy, but GSM is much more than that. Evaluations of vulvovaginal pain need to go outside of a doctor’s typical comfort zone to include a biopsychosocial evaluation. Gynecological screenings must also include trauma-informed care.

How to Manage GSM

There is good news for patients with GSM—despite being a chronic condition, symptoms can be managed based on severity, said Dr. Lamvu. Education and lifestyle modifications can be very beneficial, including:

  • Avoid overwashing of the vagina (most patients think more washing is better; it is not)
  • Try to have regular intercourse if not painful
  • Cease smoking
  • Wear looser undergarments.

In terms of pharmacological approaches, nonhormonal lubricants may be recommended to relieve dryness and itching temporarily; these should be water or silicone based and irritant free.

Low dose vaginal estrogen is also a first-line option. The research is definitive on low dose vaginal estrogen as being effective and safer than systemic or oral hormonal therapy, said Dr. Lamvu, who noted that it typically takes 8 to 12 weeks to work. The patient may opt to use an inserted capsule, a cream, etc. Other treatment methods may involve dilators, physical therapy (PT), topical lidocaine, SERMS, vaginal DHEA, laser treatment for vascularity and collagen, oxytocin gel, and more. In cases of sexual dysfunction, Cognitive Behavioral Therapy (CBT) may be used to help with desensitization.

In those patients with GSM and other chronic pain syndromes, multimodal treatment is necessary. For instance, a vaginal estrogen, with perhaps a lidocaine ointment, with perhaps PT and CBT, as well as treatment of sleep,  mood or fatigue disorders may be warranted. Sometimes, a patient assumes that insomnia or mood changes are just symptoms of menopause, but they should be screened for a true sleep or mood disorder on top of menopause.

Practically speaking, Dr. Lamvu shared that the number one obstacle she sees in GSM management is patient compliance. Patients do not like to use the creams or fail to finish the full therapy. For this reason, patient education and involvement in the decision-making process is key. Remind patients that while 8 to 12 weeks is a typical time for noticeable improvement, a return to normal sexual function may take longer than 3 months.

Overall, emphasized Dr. Lamvu, the percentage of women experiencing and living with GSM is staggering. “We cannot focus on what we don’t know—we cannot ignore the vagina,” she said. “We have to put her in the same chronic conundrum as the other chronic pain conditions.”

Avoid overwashing of the vagina (most patients think more washing is better; it is not)
Try to have regular intercourse if not painful
Cease smoking
Wear looser undergarments

In terms of pharmacological approaches, nonhormonal lubricants may be recommended to relieve dryness and itching temporarily; these should be water or silicone based and irritant free.

Low dose vaginal estrogen is also a first-line option. The research is definitive on low dose vaginal estrogen as being effective and safer than systemic or oral hormonal therapy, said Dr. Lamvu, who noted that it typically takes 8 to 12 weeks to work. The patient may opt to use an inserted capsule, a cream, etc. Other treatment methods may involve dilators, physical therapy (PT), topical lidocaine, SERMS, vaginal DHEA, laser treatment for vascularity and collagen, oxytocin gel, and more. In cases of sexual dysfunction, Cognitive Behavioral Therapy (CBT) may be used to help with desensitization.

In those patients with GSM and other chronic pain syndromes, multimodal treatment is necessary. For instance, a vaginal estrogen, with perhaps a lidocaine ointment, with perhaps PT and CBT, as well as treatment of sleep, mood or fatigue disorders may be warranted. Sometimes, a patient assumes that insomnia or mood changes are just symptoms of menopause, but they should be screened for a true sleep or mood disorder on top of menopause.

Practically speaking, Dr. Lamvu shared that the number one obstacle she sees in GSM management is patient compliance. Patients do not like to use the creams or fail to finish the full therapy. For this reason, patient education and involvement in the decision-making process is key. Remind patients that while 8 to 12 weeks is a typical time for noticeable improvement, a return to normal sexual function may take longer than 3 months.

Overall, emphasized Dr. Lamvu, the percentage of women experiencing and living with GSM is staggering. “We cannot focus on what we don’t know—we cannot ignore the vagina,” she said. “We have to put her in the same chronic conundrum as the other chronic pain conditions.”







 

Posted by IPPS Admin on October 2, 2019, 12:00AM

Shop AmazonSmile to Support IPPS

November 20, 2018

Shop AmazonSmile to Support IPPS

With gratitude we would like to thank you for your support and dedication to the treatment of men, women and children with pelvic and abdomino-pelvic pain.

When doing your holiday shopping on Amazon.com, it is easy to support IPPS at the same time. Through AmazonSmile, a portion of your purchases can be donated to IPPS.

Follow this link and designate IPPS as the charity to receive a portion of the total price of every purchase you make on Amazon.com. Please encourage your family, friends and patients to do the same!


May Is Pelvic Pain Awareness Month!

April 27, 2018

May Is Pelvic Pain Awareness Month!

While there are many causes to be aware of and advocate for, one close to our hearts at the International Pain Society is abdomino-pelvic pain, and we are excited to report that May is Pelvic Pain Awareness Month! This designation for May was created by the International Pelvic Pain Society last year. So let’s talk a few moments about what is pelvic pain, how impactful the diagnosis can be, and what we can do!

By: Kaitlyn Parrotte, PT, DPT, OCS, CFMT
Edited by: Amy Stein, DPT, BCB-PMD

According to the American College of Obstetricians and Gynecologists, chronic pelvic pain is described as a “noncyclical pain of at least 6 months’ duration that appears in locations such as the pelvis, anterior abdominal wall, lower back, or buttocks, and that is serious enough to cause disability or lead to medical care.”1 While the incidence and prevalence of chronic pelvic pain in men and women are reported in an inconsistent manner,2 some estimates compare its global prevalence to asthma (4.3%-8.6%), and one to the prevalence of low back pain (23.2 +/- 2.9%).3 Individuals who suffer from chronic pelvic ad abdominal pain also often present with other complicating factors such as depression, anxiety, poor sleep, difficulty with work, and/or relationship issues. Also, many people with chronic pain are commonly disabled by fear that activity will make things worse.2 Furthermore, pelvic pain is puzzling as it is a multisystem disorder, which includes sexual, bowel, urinary, gynecological, and musculoskeletal symptoms. It is challenging to determine a clear mechanism of pain with this diagnosis, and the term “pelvic pain” does not take into account the many signs and symptoms that may be occurring outside of the anatomical pelvis.2  

Due to the complicated nature of this condition, there is a significant economic burden associated with management of it. In the United States, approximately $881.5 million was spent on chronic pelvic pain to cover the costs of direct healthcare. Additionally, approximately $2 billion was spent as an overall cost, which includes direct medical costs and indirect costs, such as those related to absenteeism from work.3 Besides economic burdens on individuals suffering from chronic abdominal and pelvic pain, there are also many challenges for the healthcare system to deal with. For instance, while a diagnosis of chronic pain in the United States typically yields more than 80% of physician referrals, it is estimated that only about 15% of individuals with chronic pelvic pain consult primary care providers, and only 40% of this group are referred to specialists for further investigation.3 Furthermore, if specialist care is involved in the management of chronic pelvic pain, it is often spread between multiple specialties, such as urology, gynecology, urogynecology, colorectal services, pain medicine, and even occasionally spinal services, rheumatology, and neurology. Thus, there is a risk that patients may be passed back and forth between different teams of the same speciality, or between different specialties, and may not receive consistent or effective care.2  In a nutshell: chronic abdomino-pelvic pain can be a debilitating condition that can have significant consequences on an individual’s physical, mental, economic, and social well-being.

Hopefully, if you were not already passionate about raising awareness of pelvic pain, you now have some insight as to why this cause is so important! Now the question lies, what can you do? How can you get involved?

One thing that you can take action is by hosting a local event to raise awareness and/or funds for research and educational programs that will promote more effective diagnosis and treatment for those suffering from abdomino-pelvic pain; these funds can be directly donated to IPPS! While hosting an event may seem overwhelming, it is actually easier than you think! Here is a guide to help you plan one:

How to plan and host a Pelvic Pain Awareness Event

Step One: decide what type of event and where

Some ideas are to host a bar night, a get together at a coffee shop with a musician, a lecture in the form of grand rounds or a community education event in the name of pelvic pain awareness.

*bar night: easiest option: no planning other than location, an agreement from the bar to donate a portion of the proceeds, and getting people to come.

*more involved: plan a speaker night for pelvic pain awareness--could be yourself and/or other speakers. Location could be your office, coffee shop, hospital, or restaurant/bar.

Examples of previous events:

1. Coffee shop example: Milwaukee’s 2017 event was held at a coffee shop.   Healthcare providers were invited. When response was low, the event was opened up to patients, friends and family. There was a flyer posted in the clinic. Attendees ordered from the menu and the coffee shop donated 20% of what was ordered. Several patients wrote checks to IPPS who could not attend.

2. Speaker event example: “Girls Night Out” style event in Los Angeles: This event was held in a Speakeasy. Cocktails and hors d’ouvers were served. Entry fee was required, but the fee was offset quite a bit by corporate sponsors. There were approximately 50 people (due to room size) and we sold out.  There were 4 speakers- 2 urogyns, 1 PT, and 1 sex therapist.  It was designed as a community event, but other providers did purchase tickets to attend, too.

3. Bar night example: “Asked a friend to use part of his bar for non-profit event.”  The bar gave reduced food prices and first drink free.  2 PT’s and 1 MD collected an entrance fee for food and drink tickets on the event planning website Eventbrite and at the door. All proceeds went to IPPS.

The to do list:

  1. Choose a date in May.
  2. Speak with venue. Many bars are willing to donate up to 20% of proceeds to a charity for 1-2 hours: it brings people into the bar/restaurant, it shows support for the community and they write it off as a donation: (Provide them with www.pelvicpain.org and let them know we are a non-profit 501c3).
  3. Arrange speakers if planned.
  4. Make flyer with template provided (See attached).
  5. Entrance fee: Suggested donation (i.e., $25 food/drink value, charge $45) vs. donation from venue proceeds.
  6. Raffle option: Reach out to local and pelvic pain vendors for prizes (i.e., hot packs, massages, free spin class, restaurant gift certificate, etc.). Can have raffle tickets sold at the bar. (e.g. $6=1 ticket, $1=2 tickets, $20=5 tickets)
  7. If you have industry connections, you could ask for support for the event as well.

Getting the word out:

· Display the flyer in your clinic (see attached template)

·        Contact Heather: heather@fusionwellnesspt.com  to get posted on IPPS Twitter, website, and Facebook accounts.

· Post on your social media. Let them know this is happening across the country.

· Do a press release with a local paper.

Getting funds to IPPS:

Send checks to IPPS Business office.

Questions:  Contact Debbie Callif: debbie@callif.org   262-240-1202 or Amy Stein: amy@beyondbasicspt.com  212-354-2622

If hosting an event is not a possibility, you can still contribute in many ways:

  1. Meet with practitioners in your area to educate them on chronic pelvic pain and build a referral network for patients.
  2. Host a community outreach program at your clinic, at a local gym, at a workout studio, or at a community center, to help make the general public more aware of what pelvic pain is, and what can be done about it. This way, you are better equipping patients to be able to advocate for themselves!
  3. Donate funds for research and educational programs at the International Pelvic Pain Society website (https://wjweis.association-service.org/securesite/ipps/donations.aspx).

There are many ways to contribute! So circle the month of May in your calendars and consider how you can participate. Together, we can help bring chronic pelvic pain into the forefront of healthcare, to ensure individuals dealing with this condition are receiving consistent and effective care.

Sources:

  1. Andrews J, Yunker A, Reynolds WS, Likis FE, et al. Noncyclic chronic pelvic pain therapies for women: comparative effectiveness. AHRQ Comparative Effectiveness Reviews, Rockville (MD), 2012.
  2. Baranowski AP, Lee J, Price C, Hughes J. Pelvic pain: a pathway for care developed for both men and women by the British Pain Society. Br J Anaesth. 2014;112(3):452–9.  
  3. Ahangari A. Prevalence of chronic pelvic pain among women: an updated review. Pain Physician. 2014;17(2):E141–7.

The Twisted Trunk: Implications for Abdominal and Pelvic Pain

March 26, 2018

The Twisted Trunk: Implications for Abdominal and Pelvic Pain

While attending the 3rd World Congress of Abdominal and Pelvic Pain Conference last October in Washington, DC, I had the pleasure of listening to the lecture of Dr. Diane Lee, BSR, FCAMPT, CGIMS. Dr. Lee discussed the impact that altered pelvic biomechanics and non-optimal function in the abdominal wall and pelvic floor have on pelvic pain. Dr. Lee is a practicing Physiotherapist and Women’s Health clinical specialist in Canada. As an author, instructor, fellow and the owner and director of her own therapy clinic, Dr. Lee has made a significant contribution to this field. Her lecture, The Twisted Trunk: Implications for Abdominal and Pelvic Impairment and Pain is summarized below.

By Sigourney Cross
Pelvic Health and Rehabilitation Center, Berkeley, CA
www.pelvicpainrehab.com

The Integrated Systems Model

Dr. Lee poses the question, “Would you race a car that had its wheels out of alignment around a racetrack?” Most people would answer no. Many people who are seeking relief from their pelvic floor symptoms have comorbidities or other conditions that can be contributing factors. When clinicians are deciding whether to start treatment at the pelvic floor or to look elsewhere first and see how the pelvic floor responds, Dr. Lee suggests using the Integrated Systems Model (ISM). Learn more about the ISM approach on Dr. Lee’s website here. The ISM is an “evidence informed clinical reasoning framework to optimize strategies for function and performance.”4 This approach helps clinicians in their clinical decision making in the assessment and treatment of patients. It helps identify which patients need specific training of the muscles of the trunk and pelvic floor and those who do not by assessing motor control.

The ISM and Motor Control

Motor control is the process of how humans and animals use their brain to activate and coordinate muscles to perform a task or skill. The motor control response to pain varies from person to person because the following three dimensions influence it.

  1. Sensorial Dimension-Location and behavior of primary complaint
  2. Cognitive Dimension-Beliefs and attitudes about their experiences
  3. Emotional Dimension-Feelings associated with experiences

Because motor control varies based on an individual’s thoughts, beliefs, and experiences surrounding that task, this makes it challenging for clinicians to assess. There is not one universal strategy of muscle activation for control. Each strategy is unique to not only the individual but also to the task itself. Some people may brace and stiffen during pain while others can loosen and destabilize. The goal of rehabilitation or using motor learning strategies is to remove, modify or enhance an individual’s adaptation based on the unique solution adopted from the patient.3 Physical Therapists must take a thorough history to understand which of the above dimensions is creating the largest barrier to changing their motor control strategy. We can then implement this change through patient education, building trust, movement, and touch to change the sensory input in order to change the motor output.

Before focusing on the pelvic floor in isolation, it’s important look at the patient’s overall alignment and motor control. Some patients may only need motor control training strategies to re organize their muscle recruitment dys-synergies. These dys-synergies can come from the pelvic floor reacting to varying processes in the body including the following:

  1. Excessive intra-abdominal pressure–This can be caused by varying factors whether it be an abdominal trauma, an acute syndrome such a pancreatitis or different exercises.
  2. Poor foot control creating an ascending force up the lower extremities-This causes internal rotation of the leg, which put forces on the obturators’, which are connected to the pelvic floor.
  3. A descending force from the thorax-This can cause a rotation within the thorax.
  4. Pulls from the coccyx on the dura-This can come from an old spinal concussion or disc protrusion.
  5. Twists in the trunk
What is a twist in the trunk?

A twist in the trunk occurs when there is an incongruent rotation between the thorax and the pelvis or to put it simply, when the pelvis and thorax are going in opposite directions. This is a significant finding because all of the multi segmental muscles of the trunk are important in motor control and movement.2

There is a significant correlation between the presence of pelvic floor diagnoses and movement diagnoses of the spine and hip. In a study by Wente & Spitznagle, 2017, they found that out of 225 patients with urinary urgency and frequency almost 50% of them had hip or spine impairments and 18% had either thoracic or pelvic girdle impairments.

Consider a very common case. A 31-year-old mother, five months postpartum, feels persistent pelvic girdle pain that increases with large steps. Using the ISM approach, you would start by picking a meaningful task. This could be a task that causes pain, a movement the patient finds difficult, or a task the patient avoids altogether. Once the task is picked you then analyze the task and identify areas of the body with suboptimal alignment and poor biomechanics. The goal with this type of analysis is to find the driver or the patient’s sub optimal movement strategy. The driver is what is going to be the most impactful impairment you can change. While analyzing this new mom’s posture (Learn more about posture here), thorax rotation, single leg stance and active bent SLR a common suboptimal strategy was found. As shown in the picture above, this is an over-activation of the iliocostalis (one of the deep muscles of the back that connects from your ribs to your hip) and an under activation of the deep abdominals.5 This imbalance of your muscles pulling your ribs one direction and your pelvis the other causes twists in the trunk. Physical therapists can correct misalignments with varying techniques including manual therapy techniques and therapeutic exercise. Correcting this patients alignment and getting the “twists” out of her trunk, allowed her to restore control at her thorax and use a more optimal movement pattern. It changed her motor control strategy, therefore allowing her to perform her meaningful tasks without pelvic girdle pain.

What do we do with this information?

This lecture has been very meaningful to my clinical practice in the sense that it helps explain why some patients may still feel lingering pelvic floor symptoms when there is no longer impairment at the tissue level. I think it is important to understand that examining the pelvic floor in isolation may not reveal all the contributing factors causing patients symptoms. Although there are many individuals who require specific isolated pelvic floor muscle training, It’s important to be cognizant of identifying the individuals who do not, and who would benefit more from treating misalignment of the trunk and creating more optimal biomechanics, motor control and recruitment strategies. If you are struggling with pelvic floor symptoms the physical therapists at the Pelvic Health and Rehabilitation Center can help!

We thank Dr. Diane Lee for a fantastic lecture. To view the presentation in its entirety please start on page 185 here.

~~~

References:

1Hodges & Smeets. Contemporary theory of motor adaptation in pain. Clin J pain. 2015
2Hodges, P W. Pain and motor control: From the laboratory to rehabilitation. Journal of Electromyography and Kinesiology: Official Journal of the International Society of Electrophysiological Kinesiology. 2011;21(2): 220–228
3Hodges, Van Dillen, McGill, Brumagne, Hides, Moseley. Consensus from the Evidence. Pain and motor control. Journal of electromyography and Kinesiology. 2013; 21.
4Lee D, Lee LJ. The Pelvic Girdle. An integration of Clinical Expertise and Research. 2007-2013.
5Macintosh JE, Bogduk N. The attachments of the lumbar erector spinae. Spine Phila Pa. 1991;(7):783-92.
6Wente KR, Spitznagle TM. Movement-Related Urinary Urgency: A Theoretical Framework and Retrospective, Cross-sectional Study. Journal of Women’s Health Physical Therapy: May 2017; 41(2) 83–90.

Posted by IPPS Admin on March 26, 2018, 12:00AM

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  • 24th Annual Scientific Meeting on Pelvic Pain - October 20-24, 2021 - Baltimore, MD