Pelvic Congestion

September 19, 2006

OBGYN.net Conference CoverageFrom International Pelvic Pain SocietySimsbury Connecticut - April/May, 1999

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Dr. Paul Perry: "I'm Dr. Paul Perry, Chairman of the Board of the International Pelvic Pain Society, and we're here at Hartford with our annual meeting. I have with me Dr. Professor Richard Beard, from the United Kingdom. Welcome, Dr. Beard, I'd like you to introduce yourself and then we'll have some questions for you."

Professor Richard Beard: "I'm Richard Beard, and Chairman of the Department of Obstetrics and Gynecology for many years at St. Mary's Hospital in London. Now I've made the cross to a hospital nearby where I run a pelvic pain clinical unit."

Dr. Paul Perry: "Dr. Beard has been instrumental in elevating our consciousness to the condition of pelvic congestion, and for many years he's sort of been a voice in the wilderness. I'd like for you to give a little bit of history, Dr. Beard, on how you got interested in this and kind of how you see things progressing over the past few years."

Professor Richard Beard: "For many years I was stuck by the fact that many women - usually young women - came into my clinic and were complaining of severe lower abdominal pain. They'd often seen many doctors - gynecologists in particular - and they had been told that they have pelvic inflammatory disease or endometriosis and had been treated for that but with no relief of their pain. In fact, this group of women make up about 60% of all those who find their pain sufficiently severe that they come to the clinic. I felt that there was a need to start research on this group of women to try and give them some alleviation, and really that's what I've been doing over the last, probably, twenty-five years."

Dr. Paul Perry: "You know Dr. Beard, Dr. Sterns had an excellent lecture beginning our meeting on pelvic congestion, and that video of his lecture is available on our website - pelvicpain.org - if anyone would like to see the lecture in it's entirety. Could you just give us a brief summary of how you see the therapy of these women with chronic pelvic pain evolving, and specifically, the need for psychotherapy to be eminently involved in our practice of chronic pelvic pain?"

Professor Richard Beard: "Going back to Dr. Sterns, he worked with me and really had the ideal development for someone doing research in this in having done a lot of clinical work with me. He went across and did a three-year fellowship with Professor Vernstock at the University College, who's the leading expert on vascular conditions in the basic science side. That work that Dr. Sterns did, demonstrated that the pelvic circulation and particularly the ovarian circulation, is a unique one with very active control both central and local which is unique. It is an understanding of that circulation that has really helped us to move forward. We've come to recognize that the ovary plays a major part in the pelvic pain that leads to congestion. What we think happens, and there's still more work to be done on this, is that with ovarian dysfunction - and by that we mean mistiming of the release of gonadotrophins, so that you often get cystic changes in these ovaries. You get a disturbance of the control of that circulation that basically leads to veins that do not perform their function of contracting particularly when under the stimulus of gravity. And that's why these women, in particular, get such an exacerbation of their symptoms when they stand for any length of time or exercise. It's inadequate ability to all of the vessels in the pelvis to constrict and stop that flow of blood into the pelvis. It's very, I guess to finish up with that, it's analogous that sort of pain really that when a man gets a cramp in his leg, of course he can sit down and get off his leg, and the circulation soon gets going again. But a woman can't do that, the only thing she can do is lie down to get rid of the effect of gravity, and that's a long slow process."

Dr. Paul Perry: "We all appreciate your work, and owe a great debt to all of you and your colleagues in the U.K. for continuing to put the spotlight on this condition. I think that what I've seen in the past two or three years is a resurgence of the technique of pelvic venography, and that more of these patients are being picked up and being treated appropriately. What about psychotherapy, Dr. Beard, in your practice - just tell us a little bit about your feelings about that."

Professor Richard Beard: "Psychotherapy, I've always thought, was an important part of the therapy because these women have nearly always abnormal stressors in their life which fuel their stress level. They also handle stress in a inappropriate way, and then you get this vicious circle of pain and stress developing. I used to think that that took about 25% of the treatment. But I've now come to realize - particularly because we're treating young women who need their ovarian function so there's no possibility of removing their ovaries except in extreme cases - that control of both stress and pain is such a major part. As a form of therapy we do two things. One is - we give them a six-month period of ovarian down regulation with one of the GnRH analogues with addback HRT. In a major proportion of these women the pain is improved and in some cases actually transiently goes. Of course, when they come off the GnRH because they cannot continue with this forever, the pain does come back. But having made the diagnosis, women find their pain is not so severe, and having started to apply the techniques of pain and stress management which they've learned through it over that six-month period, they find that they can start to control their own pain. And that's an enormous discovery for them because they're often people who feel particularly useless, unable to help themselves and they find that they're empowered by this treatment. They start to actually order their daily lives, avoid stress, manage it in an appropriate way, and by and large that reduces the level of stress. The pain starts to fade away, and at the end of the year for most of them - that's over 75% - they will tell you, yes they do occasionally get the pain, but it's no longer a problem."

Dr. Paul Perry: "We certainly appreciate Dr. Beard being with us here at the IPPS meeting, and he's consented to be on our Advisory Board, and we're very pleased about that. Dr. Beard, we wish you all the best, and we look forward to seeing you again. Thank you for being with us on OBGYN.net."

Professor Richard Beard: "Thank you for asking me and for appointing me to your Advisory Board."