Recommendations fall into three categories:
- Recommendations for clinical practice (principally aimed at Fellows and Members of the Royal College of Obstetricians and Gynaecologists) based upon research evidence (where available) and the consensus view of the Group. The clinical practice recommendations have been graded from 'A' to 'C' according to the strength of evidence on which each is based. The scheme for the grading of recommendations is based on the system adopted by both the NHS Executive and the Scottish Intercollegiate Guidelines Network.
- Recommendations for future research in those clinical areas where the Group identified a need for further evidence on which to base practice.
- Recommendations relating to health education and health policy.
Recommendations for clinical practice
- There should be support for specialist obstetrics and gynaecology pain clinics and for a transdisciplinary approach with a true diversity of specialists involved (Grade C).
- The setting in which consultations for pelvic pain take place need adequately to reflect the referral pattern: patients with long-standing or disabling symptoms require extended consultation time and access to other advice and treatment resources, as in a multidisciplinary model (Grade B).
- Clinicians need to be aware of the importance of the initial medical consultation with women with chronic pelvic pain as a factor influencing the outcome from investigation and treatment. While consulting styles reflect the individual personality of the doctor, clinicians need to be aware of their own underlying attitudes and how these might enter into the dynamics of the consultation (Grade B).
- Women presenting with pelvic pain in whom no clear diagnosis is present, or where diagnoses overlap, need to be given clear explanations which do not undermine the legitimacy of their experience of pain or convey a message of dismissal (Grade B).
- Treatments need to be individualised and regularly reviewed on the basis of each patient's needs and aspirations. This takes place in some centres, which need to be identified to gynaecologists and to those in primary care. As well as offering the best available treatment for patients whose symptoms are proving difficult to manage, these would develop greater expertise in treatment and provide advanced training for the range of healthcare professionals involved in endometriosis care (Grade C).
- Patients with severe endometriosis should be referred to specialist treatment centres with experience in advanced laparoscopic surgery (Grade B).
- Laparoscopic treatment of stage I - III endometriosis is a safe procedure and has been shown in a double blind randomised controlled trial to be effective in a large proportion of patients. It requires the complete removal of disease not only from the peritoneum but also from the utero-sacral ligaments (Grade B).
- There appears to be no evidence at present that denervation procedures confer any additional benefit to the excellent results of laparoscopic ablation of ectopic endometriotic implants and deeply infiltrating disease (Grade A).
- Optimum selection of drug therapy can make a difference to treatment outcome despite the complexity of pain management and the need to take account of various other factors (Grade C).
- Collaborative working will lead to improved palliative care for cancer patients (Grade C).
- The anaesthetist should ensure individual preoperative assessment of postoperative analgesic requirements (Grade C).
- Anaesthetists (as well as other clinicians) should increase the use of simple analgesics and multimodal analgesia (Grade A).
- There should be increased involvement of acute pain teams in managing post-operative pain (Grade C).
- Education in back care and instruction in stability exercises by a physiotherapist should be available to all pregnant women (Grade B).
- Women presenting with peripartum spinopelvic pain should be referred to a specialist physiotherapist for individual examination, assessment and clinical practice treatment (Grade B).
- Consider imaging to investigate abdominal pain during pregnancy and surgical intervention as soon as appropriate (Grade C).
- Continuous caregiver support from a single individual should be available to women in labour (Grade A).
- Midwives must involve women in decisions about analgesia in labour and recognise the value of promoting personal control (Grade C).
Recommendations for future research
- It is known that physiology involves co-coordinative interactions between various internal organs, muscles and skin. However, less is understood about how pathophysiology in one structure influences those interactions and influences both the nervous system's control of bodily functions and its mechanism of pain. Recent studies show that these influences may be profound, evidencing themselves in ways that impair proper diagnosis and treatment. Therefore, dialogue between neuroscientists and researchers who study the physiology and pathophysiology of different organs is recommended. This will improve our understanding of viscero-visceral and viscero-somatic interactions in health and illness, and their influence of the nervous system.
- There should be support for research on the role of sociocultural meanings, processes and constructs involving chronic pain in obstetrics and gynaecology, with initial emphasis on sound methodology.
- Chronic pelvic pain (CPP) is common in the general population but the reasons why some women and not others seek health care need to be determined.
- Further studies are required on the relationship between consulting style and patient outcomes, perhaps using observational techniques such as video recording of consultations. Research is needed to clarify the importance of elements in the patient's experience such as continuity of care and the contribution of different members of a multidisciplinary team.
- Consensus diagnostic criteria for common painful gynaecological disorders should be established.
- Research aimed at standardising examination techniques for painful disorders, e.g. using pressure transducers to standardise palpation of the abdominal muscles, levators, should be encouraged.
- Prospective research is needed into the endocrine mechanisms of pelvic congestion as a functional disorder of the menstrual cycle.
- The development of mechanism-based classification of vulval pain is required.
- Tools for reliable and valid measures of treatment outcome in vulval and pelvic pain, including psychometric measures and measures of quantitative sensory threshold (QST) should be developed.
- Additional studies on the prevalence of various vulval pain disorders are required. Only one study is known to be under way that is population-based.
- Establish multicentre, multidisciplinary groups to run randomised clinical trials in the treatment of vulval pain.
- Collect evidence about the efficiency of existing and new treatment modalities to prevent peritoneal formation.
- Epidemiological studies are needed on the incidence and morbidity of chronic gynaecological diseases and cost/benefit analysis.
- The precise healthcare, and the indirect, costs (e.g. effect on quality of life, ability to work) of CCP need to be estimated.
- Collaborative multidisciplinary research projects into the causes and management of peripartum spinopelvic pain should be undertaken with the obstetric team.
- Maternity services should be encouraged to research the 'working with pain' framework suggested by Leap.1
- Further research is required into the most appropriate drug for labour use and most appropriate method of administration.
- More collaborative research (and audit) into pain and analgesia is needed among all members of the perinatal management team.
Recommendations for health education and policy
- There should be greater awareness of the necessity to provide pain relief in acute and chronic situations in obstetrics and gynaecology.
- The role of establishing whether pain is 'real' or not should be rejected, as chronic pain may be a diagnosis as well as a symptom.
- Health professionals should discard dualistic notions of pain being either physical or psychological, and adopt a biopsychosocial model of pain instead. The biopsychosocial model of pain is especially important with regard to chronic pain in women, where there is been a greater tendency to label unexplained pains as manifestations of psychiatric illness.
- Referral patterns from primary to secondary care must be understood better to plan resource allocation and develop evidence-based protocols.
- Tertiary referral clinics in which gynaecologists and psychologists work together are necessary to treat effectively some of the more complex cases of pelvic pain in women. These clinics should be supported by the NHS regionally.
- Gynaecology departments with interests in pain management need to employ a psychologist as part of the treatment team. Ideally, the psychologist should be also a member of the clinical psychology department. The International Association for the Study of Pain recommends that medically and psychologically trained professionals should treat chronic pain.
- There is an apparent disparity between the existence of physiological and symptom 'cross talk' between organs (viscero-visceral or viscero-somatic interactions). To understand this disparity we need to convene multi-specialist discussion groups, i.e. obstetricians-gynaecologists, urologists, gastroenterologists, cardiologists, neurologists, rheumatologists, anaesthetists, pain nurses, physiotherapists, psychologists, psychotherapists and psychiatrists.
- The variety, the intensity and the destructive effects of chronic pelvic pain need to be recognised. Treatment strategies that directly address this problem are urgently needed. These should be disseminated to clinicians and patients alike. Patients must participate in the control of symptoms and not be regarded as unfeeling recipients of prescription.
- All prescribers, especially for pain relief, should understand the pharmacological basis of the drugs they prescribe.
- The final selection of drugs should take account of the fact that drug therapy is only one option in pain management.
- The continuing pain that endometriosis can produce is a strong indication of the need for radical review of the current understanding and treatment of this disease. In order to develop treatments that are not exclusively based on the clinical model of medicine, psychologists need to be involved (at every level) in the design and implementation of research projects as well as the design and delivery of patient care and clinical training.
- Effective teamwork should be taught as a keystone for pain control in palliative care.
- There is a need to increase awareness of the breadth of conditions during pregnancy that require surgery.
- Maternity services should make sure that women have access to written and verbal information on pain relief and should support women in their choices of pain relief.
- Maternity services should respect women's wishes to remain in control in labour and to have some control over their pain relief.
- Improve public information and data on pain and analgesia with professional, collaborative websites.
- NHS Trusts should review and improve the integration of obstetric anaesthesia and support services into women's health.
- Gynaecologists should be taught psychological pain management theory and skills as part of their training and should take more time for in-depth assessment.
- There should be dissemination of existing information from psychology sources to both clinicians and patients.
- The RCOG and the British Psychological Society should set up a joint education committee to develop the content of a training programme in psychogynaecology, for trainees and staff, in obstetrics, gynaecology and psychology.
- Study guides need to emphasise the importance of attention to the patient's needs for treatment objectives and explanation, rather than an exclusive pursuit of a pathological diagnosis. Consulting styles that address these needs can be taught in role-play and evaluated in OSCE formats, as can the communication skills required to convey diagnostic uncertainty or negative findings without undermining the patient's confidence.
- The RCOG should create a subspecialty of benign gynaecological surgery and funding should be available to ensure an adequate number of such centres throughout the UK.
- Educational programmes in vulval disorders, vulval pain and chronic pelvic pain should be promoted.
- Gynaecologists need to be educated to take a full history, including a full gastroenterological history.
- There should be an awareness of the ethical issues in the management of pain.
Leap N. Pain in labour: towards a midwifery perspective. MIDIRS Midwifery Digest 2000;March:49-53.
Table 32.1 Grading of recommendations
|A||Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation.|
|B||Requires availability of well-conducted clinical studies but no randomised clinical trials on the topic of recommendation.|
|C||Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality.|