A randomized clinical trial to compare two different approaches in women with chronic pelvic pain. A preliminary study of transcranial direct current stimulation for the treatment of refractory chronic pelvic pain. A randomized clinical trial on the benefit of adhesiolysis in patients with intraperitoneal adhesions and chronic pelvic pain. A randomized controlled trial of goserelin and medroxyprogesterone acetate in the treatment of pelvic congestion. For whom does it work? Moderators of the effects of written emotional disclosure in a randomized trial among women with chronic pelvic pain. Buserelin acetate in the treatment of pelvic pain associated with minimal and mild endometriosis: a controlled study. A randomized, double-blind crossover trial of sertraline in women with chronic pelvic pain. Postsurgical medical treatment of advanced endometriosis: results of a randomized clinical trial. The levonorgestrel-releasing intrauterine system and endometriosis staging.
One hundred six patients with chronic pelvic pain were randomly allocated to one of two treatment groups. In the standard-approach group, organic causes of pelvic pain were excluded first and diagnostic laparoscopy was routinely performed. If no somatic cause could be found, attention was given to other causes such as psychological disturbances. In the second group an integrated approach was chosen. From the beginning equal attention was devoted to somatic, psychological, dietary, environmental, and physiotherapeutic factors. In this group, laparoscopy was not routinely performed. Both groups were similar with respect to clinical characteristics of the patients and the severity of their pain as assessed by various pain parameters. Postcoital pain was reported by 27% of the patients. Twenty percent of the patients had had negative sexual experiences such as childhood sexual abuse or rape. Evaluation of the pain 1 year after the institution of treatment revealed that the integrated approach improved pelvic pain significantly more often than the standard approach for three out of four pain parameters (P less than .01). Laparoscopy played no important role in the treatment of pelvic pain. It is concluded that equal attention to both organic and other causative factors from the beginning of therapy is more likely to result in a reduction of pelvic pain than is a standard approach. The modulatory effects of transcranial direct current stimulation (tDCS) appear beneficial for different chronic pain syndromes; however, it is unclear whether this method can be used to treat refractory chronic pelvic pain.
                The objective of this preliminary study was to determine the efficacy and safety of tDCS for the management of refractory chronic pelvic pain.
                Seven patients with chronic pelvic pain having failed standard medical or surgical therapy underwent a crossover, double-blind sham controlled tDCS treatment protocol consisting of 1 mA applied for 20 minutes on two consecutive days with 2 weeks of follow-up symptom recording. Symptoms were recorded using multiple scoring systems, including visual analog scales for different pains, as well as organ-specific symptom scales. Comparison between active and sham treatment was performed by using paired t tests.
                Overall and pelvic pain scores were significantly lower after active compared with sham treatment, as were disability and traumatic stress scores. No patient discontinued the study because of side effects, which were infrequent.
                Active tDCS treatment induces a modest pain reduction in refractory chronic pelvic pain patients as compared with sham tDCS treatment. These results can guide the design and implementation of further studies investigating this method of neuromodulation for the treatment of refractory chronic pelvic pain. To see whether surgical adhesiolysis would improve pelvic pain in women with pelvic adhesions.
                Randomized clinical trial comparing surgery (adhesiolysis) with no surgery with final analysis of results after 9-12 months.
                Department of Gynecology, Leiden University Medical Center, the Netherlands.
                48 women known by laparoscopy to have stage II-IV pelvic adhesions.
                Midline laparotomy and surgical adhesiolysis.
                Pelvic pain assessed by the McGill pain score, subjective pain assessment and disturbance of daily activities.
                24 women were randomly allocated to undergo surgical adhesiolysis and 24 to a control group who did not have surgery. After 9-12 months there were no significant differences between the two groups overall with regard to pelvic pain. A subgroup of women with severe, vascularized and dense adhesions involving bowel (stage IV) had significantly less pelvic pain after adhesiolysis for two of the three methods of assessment.
                Adhesiolysis for the treatment of pelvic pain is not indicated in women with light or moderate degree pelvic adhesions. It may be beneficial in those with severe adhesions involving the intestinal tract. Following identification of the proportion of pelvic congestion among symptomatic patients complaining of chronic pelvic pain, and in a totally asymptomatic group of patients requesting tubal ligation, the efficiency of goserelin acetate versus medroxyprogesterone acetate was compared objectively using pelvic venogram scores, and subjectively by symptom resolution, improvement of psychological status and sexual functioning in a prospective randomized trial in 47 patients with pure pelvic congestion syndrome. Patients received either goserelin acetate (3.6 mg/month for 6 months) or medroxyprogesterone acetate (MPA; 30 mg/day for 6 months). Among patients with chronic pelvic pain, those with pure pelvic congestion were mostly parous, had the most severe pelvic signs and symptom scores, lowest rates of sexual functioning, and higher states of anxiety and depression as compared with others. At 1 year after treatment, goserelin remained superior to MPA in terms of pelvic venographic improvement as an objective measure. In alleviation of signs and symptomatology, improvement of sexual functioning and reduction of anxiety and depressive states as subjective measures, goserelin acetate achieved a statistically significant advantage (P = 0.0001) compared with MPA. Although written emotional disclosure has potential as a stress management intervention for people with health problems, the main (group) effects of disclosure in medical populations are limited. This study sought to identify individual difference moderators of the effects of written disclosure among women with chronic pelvic pain.
                In a prospective, randomized trial, 48 women with chronic pelvic pain completed 3 individual difference measures and then wrote for 3 days about stressful consequences of their pain (disclosure) or positive events (control). Health status was assessed at baseline and 2 months after writing.
                Main effect group comparisons indicated that disclosure writing resulted in significantly lower evaluative pain intensity ratings than control writing at follow-up, but there were no main effects on other outcome variables (sensory or affective pain, disability, affect). Three baseline individual difference measures, however, significantly moderated group effects. Compared with control writing, disclosure led to less disability among women with higher baseline ambivalence over emotional expression or higher catastrophizing, and to increased positive affect among women with higher baseline negative affect. Ambivalence, but not catastrophizing, was independent of negative affect in its moderation effect.
                Although the main effects of writing about the stress of pelvic pain are limited, women with higher baseline ambivalence about emotional expression or negative affect appear to respond more positively to this intervention. To evaluate the changes of pain symptoms induced by buserelin acetate, a gonadotropin-releasing hormone agonist, in a group of patients with endometriosis.
                Thirty-five infertile patients with one or more of the following symptoms (dysmenorrhea, pelvic pain, deep dyspareunia, and endometriosis stage I or II) were allocated randomly to treatment with buserelin acetate 1,200 micrograms/d IN for 6 months (n = 19) or expectant management (n = 16). Pain symptoms were recorded by the women themselves using a questionnaire that included two scales for pain evaluation: one analogue and one multidimensional. The treated and untreated patients were followed for a minimum of 18 and 12 months from the time of randomization, respectively.
                Buserelin acetate markedly reduced dysmenorrhea, pelvic pain, and dyspareunia during the treatment and also for the 12 subsequent months. During follow-up of the expectant management group, dysmenorrhea resolved in 19% (3/16) of the cases, and pelvic pain did not recur after diagnostic laparoscopy in one of the three women affected nor did deep dyspareunia in two of the five who reported the symptom before laparoscopy.
                Buserelin acetate induced a significant improvement of pain symptoms that persisted in approximately half of the patients even after withdrawal of the drug. However, symptoms associated with endometriosis showed a spontaneous remission in approximately one fifth of the untreated patients. The efficacy of antidepressants as analgesics for a range of chronic pain problems is well documented. However, a controlled trial of an antidepressant for women with chronic pelvic pain has not yet been published. We randomized 23 women from a general gynecology clinic to either double-blind sertraline or placebo. Measures of psychological function, pain, and functional disability were taken at baseline and 6 weeks. After a 2-week washout, the groups were crossed-over and the same measures were done over the next 6 weeks. There were no significant improvements in pain or functional disability noted on sertraline compared to placebo. Studies involving larger samples of patients are needed to confirm these findings. Our purpose was to investigate the efficacy of postsurgical treatment with nafarelin in women with advanced endometriosis.
                Eligible for trial were women < or = 38 years old with unexplained infertility with or without chronic pelvic pain and stage III or IV endometriosis according to the American Fertility Society, revised, classification who underwent laparotomy as first surgical treatment for debulking or radical surgery of endometriotic lesions. Patients were assigned according to a randomization list to nasal nafarelin, 400 micrograms/day (36 subjects) or placebo nasal spray (39 subjects) for 3 months. Pelvic pain was assessed before first surgery and at the 12-month follow-up visit in women with pelvic pain by means of a multidimensional score system and a 10-point linear pain scale.
                No marked differences in pain scores emerged among women allocated to different treatments. The mean reduction of the multidimensional score was 3.6 and 4.0, respectively, in women allocated to nafarelin and placebo and of the 10-point linear scale scores was 7.0 and 6.9. These differences were not statistically significant. Within 1 year from randomization, of the 36 women allocated to nafarelin and the 39 allocated to placebo, seven (19%) and seven (18%), respectively, became pregnant.
                This study suggests that medical treatment with nafarelin does not markedly improve pelvic pain and short-term reproductive prognosis in women with stages III and IV endometriosis. This study aims to determine whether the levonorgestrel-releasing intrauterine system can influence American Society for Reproductive Medicine endometriosis staging scores, as assessed through second-look laparoscopies, and to compare the results with those obtained with a GnRH agonist. Both treatments reduced the extent of pelvic endometriotic lesions in patients with chronic pelvic pain.
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.