1. Chronic pelvic pain Journal Club 17 th June 2011 Dr Claire Hoxley (GPST1) Dr Harpreet Rayar (GPST2)

2. Aims and Objectives  Know how to investigate and manage chronic pelvic pain in primary care and when to refer to secondary care  Research the evidence available for different management options of chronic pelvic pain  Improve evidence based practice skills  Critically appraise a systematic review

3. Case presentation  GP referral in GOPD  28 year old woman  4 year history of pelvic pain  No dysmenorrhoea or dyspareunia  Some improvement on OCP but wishes to conceive  Negative laparoscopy 2 years before (some pelvic vein congestion)  Negative triple swabs  What management options are there?

4. The Clinical Question  What are the management options for chronic pelvic pain?  What guidelines are there for investigating and managing chronic pelvic pain in primary care (non- surgical management)?

5. Chronic pelvic pain  Symptom, not a diagnosis  6 months +  Constant or intermittent pain  Not exclusively with dysmenorrhoea or dyspareunia  Not during pregnancy

6. Chronic pelvic pain  Presents to primary care as often as migraine, asthma or low back pain  Heavy economic and social burden  Limited understanding of pathophysiology  Affected by physical, social and psychological factors  Requires biopsychosocial model of management

7. Guidelines  No NICE guidelines  RCOG guidelines – Chronic pelvic pain, Initial management (Green-top 41)  No BWH Guidelines  RCOG guidelines April 2005 – outdated?  Limited guidance for primary care management (non-surgical)

8. Literature search  Search terms: chronic pelvic pain  Limits: since 2005, female, trials, reviews, case studies, guidelines  Databases searched: Cochrane and Pubmed

9. Literature search results  Cochrane results: Systematic Review 2005, updated 2010  2 protocols November 2010 Non surgical interventions for the management of chronic pelvic pain Surgical interventions for the management of chronic pelvic pain in women  Limited Pubmed evidence

10. Paper selected  Interventions for treating chronic pelvic pain in women (Review). Stones W, Cheong YC, Howard FM, Singh S The Cochrane Library 2010, Issue 11  Highest level of evidence  Reviewed 2010 (more recent than guidelines)

11. Criteria for selecting trials  Included: patients with diagnosis of pelvic congestion syndrome or adhesions. Any age  Excluded: patients with diagnosis of endometriosis, primary dysmenorrhoea, pain due to active chronic pelvic inflammatory disease or irritable bowel syndrome

12. Criteria for selecting trials  Randomised controlled trials in women with chronic pelvic pain  Any intervention including lifestyle, physical, medical, surgical, psychological  Outcome measures: pain rating scales, quality of life measures, economic analyses, adverse events

13. Data collection and analysis  2 review authors working independently  3 rd author as arbiter  Detailed search methods  Quality of trials assessed based on Cochrane guidelines

14. Results  19 trials identified  14 included (N = 6-286)  Included psychological, medical, surgical, lifestyle interventions  Excluded trials due to insufficient information re outcomes, non- comparable evaluation points, uncertainty re study design

15. Risk of bias Allocation concealment: 10 x A 3 x B 1 x C Quality of allocation concealment graded as A (adequate) B (unclear) or C (inadequate)

16. Risk of bias  13 had good follow-up rates  9 had intention-to-treat analyses  Outcome assessment blinded to treatment allocation in all 14  Participants aware of their treatment allocation

17. Combining results  2 studies on Progestogen vs. placebo Adhesiolysis vs. expectant management or diagnostic laparoscopy  Single studies for other interventions  Combined results with caution (different surgical methods)

20. Results  Ultrasound and counselling vs “wait and see”  Favours ultrasound – improvement in mood and pain scores  Large confidence intervals  Available in primary care

22. Results  Adhesiolysis vs. no surgery  No significant benefit in pain score or self-rating  Combines 2 trials (different surgical methods)

23. Limitations  Different end points/follow up  Some trials used scales influenced by menstruation – those resulting in amenorrhoea score better  Excludes many causes of chronic pelvic pain  One study had male participants  Majority of outcomes subjective

24. Implications for research  Limited range of interventions  Mainly single studies (underpowered conclusions)  Limited evidence available to base clinical practice on  High prevalence and healthcare costs  Complex causation and treatment – design of studies needs to reflect this

25. Summary and Conclusion  Limited evidence for effective management options  Some options available in primary care  Need for further research – cochrane protocols in place, separate surgical/non- surgical management  Better understanding of complex psychosocial model of chronic pelvic pain