19:30 - 21:00 endometriosis nz symposium north/fri_plenary_1932_fiona.pdf · 2) diagnose/ mx the...
TRANSCRIPT
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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
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Pelvic PainSome changes in management strategy
Dr Fiona Connell 2018Advanced Laparoscopic Surgeon
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• Starting with a fresh approach and deeper understanding
Huge potential for improvement by simple means
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8/06/2018 4
Pain that persists
Explain Pain , Butler & Moseley
2013
USEFUL!
NOT BIOLOGICALLY USEFUL!!
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What are we talking about?
Simple Period pain
Peripheral stimulus
Protective muscle
spasm and pain
Central sensitisation
Psychosocial effects
Pain of increasing complexity
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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
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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)
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Tight muscles are part of the
vicious cycle of persistent pain
PAIN
Anticipating pain
ANXIETYBecoming
Tense
Tightness / Spasm in PFM
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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
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Obturator internus examination
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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
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What are we talking about?
Simple Period pain
Peripheral stimulus
Protective muscle
spasm and pain
Central sensitisation
Psychosocial effects
Pain of increasing complexity
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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
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What are we talking about?
Simple Period pain
Peripheral stimulus
Protective muscle
spasm and pain
Central sensitisation
Psychosocial effects
Pain of increasing complexity
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Anxiety – in the vicious cycle
of persistent pain
PAIN
Anticipating pain
ANXIETYBecoming
Tense
Tightness / Spasm in PFM
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Psychosocial effects
• Mindfulness, yoga
• Medications
• Psychologist/ psychiatrist
• Address any underlying traumatic history
• Address SLEEP
• Manage Catastrophising
• Suggest avenues for support
• Information for partners
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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
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• 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?)
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• “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”
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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
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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