19:30 - 21:00 endometriosis nz symposium north/fri_plenary_1932_fiona.pdf · 2) diagnose/ mx the...
TRANSCRIPT
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