Ms Miriama Kamo

19:30 - 21:00 Endometriosis NZ Symposium

Dr Fiona ConnellGynaecologist

North Shore and Auckland City

Hospitals

Auckland

Dr Guy GudexDirector

Repromed

Ms Deborah BushCo-founder and Chief Executive

Endometriosis New Zealand

Auckland

Professor Neil

JohnsonGynaecologist and REI Subspecialist

Auckland Gynaecology Group and

Repromed Auckland

Pelvic PainSome changes in management strategy

Dr Fiona Connell 2018Advanced Laparoscopic Surgeon

• Starting with a fresh approach and deeper understanding

Huge potential for improvement by simple means

8/06/2018 4

Pain that persists

Explain Pain , Butler & Moseley

2013

USEFUL!

NOT BIOLOGICALLY USEFUL!!

What are we talking about?

Simple Period pain

Peripheral stimulus

Protective muscle

spasm and pain

Central sensitisation

Psychosocial effects

Pain of increasing complexity

Stop the periods (trigger), treat the pain

• 6/12 of hormonal treatment

– COCP (if good contraceptive needed)]

– POP

– Norethisterone 5mg OD

• Mirena (no data regarding systemic doses outside the uterus)

• Hysterectomy if childbearing complete and very well counseled

• Simple analgesia- NOT opioids. Worse long term data, constipation

What are we talking about?

Simple Period pain

Peripheral stimulus

Protective muscle

spasm and pain

Central sensitisation

Psychosocial effects

Pain of increasing complexity

(Worsening bowel pain with menses)

Tight muscles are part of the

vicious cycle of persistent pain

PAIN

Anticipating pain

ANXIETYBecoming

Tense

Tightness / Spasm in PFM

Tense internal pelvic muscles

cause

• Sharp stabbing pain

• Painful intercourse

• Low back pain

• Low abdominal pain (stabbing ‘ovarian’)

• Difficulty emptying the bladder

• Straining to empty the bowel/ pain

• Sudden sharp pains with movement

• Aching the day after intercourse

Obturator internus examination

How many can be helped by physio?

• Stretching, yoga, relaxation, correct breathing

• Manual therapy

• Retrospective observational studies-

– 50-72% with MPPS have mod to marked improvement or complete resolution with manual techniques

What are we talking about?

Simple Period pain

Peripheral stimulus

Protective muscle

spasm and pain

Central sensitisation

Psychosocial effects

Pain of increasing complexity

Central sensitisation

• Psychological techniques- managing pain rather than curing pain

• Amitryptiline 5-20mg nocte increasing dose

• Nortryptiline 5-20mg nocte increasing dose

• Gabapentin

– 300mg OD titrated up to 1800mg divided daily

What are we talking about?

Simple Period pain

Peripheral stimulus

Protective muscle

spasm and pain

Central sensitisation

Psychosocial effects

Pain of increasing complexity

Anxiety – in the vicious cycle

of persistent pain

PAIN

Anticipating pain

ANXIETYBecoming

Tense

Tightness / Spasm in PFM

Psychosocial effects

• Mindfulness, yoga

• Medications

• Psychologist/ psychiatrist

• Address any underlying traumatic history

• Address SLEEP

• Manage Catastrophising

• Suggest avenues for support

• Information for partners

What do we need to target?

• 8-10 year delay from 1st presentation to making Dx

of endo

• 26% of 16-18y olds time off school due to

distressing menstrual symptoms

US Gallup poll

• 15% of 5263 women aged 18-50 years CPP

• Among 548 employed respondents

– 15% lost time from paid work

– 45% reported reduced work productivity

• Physiologically complex and emotionally taxing

• Pts with CP and Drs often have opposing

attitudes and goals

– Pts- “to be understood” and “legitimised”

– Drs- focus on diagnosis and treatment

Frantzve Pain med 2007

Would this result in good

patient outcomes and

satisfaction?

(or doctor satisfaction?)

• “you are not alone”

• “I can see you’ve really been suffering”

• “anxiety and sleeplessness is a normal response to pain- especially ongoing pain”

• “what you describe makes perfect sense to me”

• “being depressed if you can’t do the things you love is understandable”

• “there are many things that can help you”

• “this is not cancer”

The educated brain

Louw et al 2016

A brain in pain

Syst review of 13 RCTs- pain ed reduces pain, improves function, lowers disability, reduces psychosocial factors, enhances movement, minimises health care utilisation in chronic MS pain

What is the role of the GP?

Depends on how much secondary support you have locally

1) ID those being compromised by pelvic pain- ask about period impact

2) Diagnose/ Mx the different components of the pain- exclude cancer, avoid opioids

3) Refer on to Gynaecology early, advocate for the patient– If good use of PO hormones 6/12 doesn’t help– Simple analgesia does not allow comfortable AODL– Pain worsens following surgery

4) Explain, reassure, support self management, co-ordinate care (PT, psych, gastro, dieticians, fertility, sexual therapist)

1) ID significant changes that need re-referral