Pelvic Pain Mapping and Treatment of Endometriosis and Chronic Pelvic Pain - part 2

September 19, 2006

OBGYN.net Conference CoverageFrom IPPS - Simsbury, Connecticut - April/May, 1999

click here for RealAudio/Video version  *requires RealPlayer - free download

Barbara Nesbitt: "Hi, I'm Barbara Nesbitt, the Editor of OBGYN.net, and I have the pleasure of sitting here today with Dr. James Carter. We're at the Symposium in Connecticut for chronic pelvic pain. Dr. Carter had part I of his interview on his monograph on the diagnosis and treatment of chronic pelvic pain with Roberta in Montreal, and he's going to discuss part 2. The monograph is on OBGYN.net; it is wonderful and I have read most all of it."

Dr. Carter: "Thank you very much. As we know, diagnosing the cause or the source of chronic pelvic pain is the critical point; without the right diagnosis, you can't have the right treatment. As Roberta and I discussed on OBGYN.net - you have now provided for your clients a set of forms that they can easily complete so that they can provide a complete history to their caregiver. Their clinician can use these forms, which include a pain map and a pain diary, as a way to communicate more effectively. These forms are available on OBGYN.net thanks to your work. The patients with pain are sincerely appreciative of that."

Barbara Nesbitt: "Thank you, and the good part with the wonderful things that you are able to provide with the net is a physician, nurse, or a woman, just clicks on the form and it comes up so that she can print it out and have it."

Dr. Carter: "Yes, complete that and that gives a ready means to communicate. Now what happens when you take this in to your clinician? The key thing is - you take this in with you - you've outlined your problems that you've had and how long they've been there. What are the possible problems that you could be facing? If the pain is in the vulvar area - the pelvic area - it could be vestibulitis; it could be trigger points in the vulvar area. If it's in the vaginal area, it could be infection causes - it could again be trigger points in myofascial pain. The exam that the clinician needs to do has to concentrate very gently probing these areas to see if the pain is towards the outside or deeper. Then as you go deeper in the examination, gentle palpation on the uterosacral ligaments - looking for endometriosis. We had quite a discussion on endometriosis and the medical management of endometriosis based on the clinician's judgement, based on the work that's been done here. Dr. Ling, at the University of Tennessee, has recently published demonstrating that medical management/medical therapy can be used on patients with presumed endometriosis based on clinical judgement and get good results. We move into the issue of pelvic congestion and the role, for instance, of uterine suspension procedures or uterine positioning procedures to help relieve the pain from chronic pelvic congestion, to relieve the pain from chronic problems with menstrual cramps, but especially, and this is the one that most physicians use this for - collision dyspareunia. That's the pain that occurs when an individual complains of pain with intercourse that can be reproduced by the physician's movement of the cervix in a uterus, which is retroflexed or retroverted. The procedure, uterine suspension or uplifting of the uterus - the uplift procedure - can be used for that. Then we talk about the use of trigger point injections and biofeedback. These are combined therapies that can be used for both myofascial pain in the abdominal wall, in the abdominal musculature, as well as pain from trigger points in the musculature of the pelvic floor, the "levator ani" we call them - the large muscles in the pelvic floor - where the clinician will feel what feels like a cord of tissue, a cord like a guitar string cord. In the center of that cord will be a place where the individual patient will say, "You have hit the pain that I feel." The physician, carefully, delicately, with just one finger or even just a small Q-tip, as described by Dr. Slocumb who utilizes that as a way to probe these areas. We have to give full credit to Dr. David Simon's, whose written his new edition, which is out now - The 1999 Trigger Point Manual Myofascial Pain and Dysfunction. His colleague on that - we honor her memory - Janet Travell, was President Kennedy's personal physician. She solved his pain problems and their work has now become part of our armamentum to help women with chronic pain. Moving on from there - the laparoscopies, we've just come from the International Society of Gynecologic-Endoscopy meeting in Montreal - where your sister, Roberta, was. We had quite a discussion on all the laparoscopic approaches including: the uplift procedure, treatment of endometriosis, resection of endometriosis, and laser therapy. Dr. Chris Sutton of England, presented his preliminary work showing that, yes, laser therapy for endometriosis is effective as a treatment modality - very exciting in this front. Today we had an interview with another of our colleagues from England, Will Stones, who came over for this pelvic pain meeting all the way from London. He talked about the therapies for the pelvic congestion problem, and this is outlined in the current addition that is available. But as you get the most current materials that come from these interviews, not everything that we've talked about is in this monogram, but there's a new volume coming out from Dr. Fred Howard. He's in the process of completing an entire book on chronic pelvic pain, and it's going to be called - Care of the Woman with Chronic Pelvic Pain. I hope we have an opportunity to interview him. In addition, for those of you who are looking for an available text now, there is an excellent book on chronic pelvic pain by Dr. Debra Metzger and her colleague, Dr. John Steege, from North Carolina."

Barbara Nesbitt: "I have that book."

Dr. Carter: "You have that - excellent."

Barbara Nesbitt: "I read through that book; it is a wonderful book. I think if a woman that has this even has the opportunity to get that book, it would be good for her. I know it's written for the physician, but it is certainly good for the woman with the condition."

Dr. Carter: "In today's environment we have to stop looking at physicians and patients, but rather those who need care and caregivers. In fact, this is an issue and we're going to get into an issue here of self-reliance. That is, how do we in fact, approach our need for caring for ourself? Nutrition - today at this conference, we had an excellent lecture on the importance of nutrition and a whole area that's overlooked called "hyperinsulin anemia." Many of you would relate it to - I get shaky a couple of hours after I eat. It looks like just the old definition of hypoglycemia; that actually is an energy crisis. That is frequently related to the problem we have of how we use insulin in our body, and now we're finding as studying this issue as clinicians, that this relates to insulin resistance in cells; and insulin resistance in cells leads to these problems of low glucoses. Now, why would low glucose be important to a pelvic pain specialist? Because when the glucose drops low, the muscles don't have the energy that they need from the glucose, and the muscles will then have a tendency towards, what we call "trigger point activation." Dr. Simons talks about this in his new addition of his book, this issue of energy crisis in the cells. So diet becomes important to us and how we, in fact, relate to what we take into our bodies can manifest itself with something as painful as an energy crisis in the muscle that then goes into a spasm. We call it a spasm, but it's truly activation of a trigger point. So all of this ties together and we really have to treat the whole person, and to do that - the individual. This all came from Dr. Metzger's book, which was really written for the physician. Really it's for everyone and Dr. Howard's book will be the same way."

Barbara Nesbitt: "Wonderful. I had one more thing I wanted to ask you about. I had the opportunity to visit one of the exhibition booths here, and there's a new thing for - I'm going to call it pain that a woman would have on deep penetration - which would be obviously during intercourse, and it's the Carter-Thomason?"

Dr. Carter: "Yes, what you're describing is a way to perform the uterine suspension procedure. We call it the uplift uterine positioning by ligament investment, fixation, and truncation. Now what does all that stand for? The issue is for the individual who has a retroverted uterus that with penetration the cervix is struck and pain occurs. If the uterus can simply be repositioned - which we've known for a long time - then that pain can be alleviated because the cervix isn't there to be struck. The difficulty was that we knew that with the old techniques and open surgery this could be done but there wasn't an easy way to do it using the laparoscope. What this is that you're describing, is a technique which any of the laparoscopic gynecologists can perform - the uplift procedure - to simply rotate that cervix up out of the way by utilizing the round ligaments in a simplified procedure, and I have been very pleased with results in that. Patients who have reported to me pain levels on a scale of 1 to 10 would say their pain was an 8 ½ with intercourse. After the procedure, on average, there was no pain really; they would put the pain levels down to a level of a 2, which when we do the scale levels that's actually…"

Barbara Nesbitt: "It looks so to me, so simple in such a wonderful way to do this correction. Does a trocar go in and a catheter?"

Dr. Carter: "That's correct."

Barbara Nesbitt: "There's no abdominal surgery involved?"

Dr. Carter: "That's correct, there's not abdominal. It's done as a laparoscopic procedure, and the nice thing about it is it only takes about 12 to 15 minutes to do both sides because of the elegance of it. What we're doing is putting the uterus - I like to say - anatomically where it belongs, where it wants to be in terms of both menstrual flow in a slightly antiverted position. Twenty percent of women are affected by retroverted uteruses and about twenty to fifty percent of those women are, in fact, symptomatic from this condition we're talking about. They don't talk about this, I mean, you don't go up … and frequently physicians don't ask. So the important thing is, and we hear this over and over again from our pelvic pain colleagues, it's important to listen to the patient, but it's also important for the patients to tell the physician what's really bothering them. If I had a take home message, it's tell your physician what's bothering you, use those forms to help you communicate. For the physicians, clinicians, physical therapists, and nurse practitioners - become familiar with this technique as a way of communicating effectively with your patients."

Barbara Nesbitt: "Thank you, Dr. Carter."

Dr. Carter: "Thank you very much."

*The forms referred to in this interview are available here