Georgine Lamvu

Quality of life and sexual function after hysterectomy in women with preoperative pain and depression

OBJECTIVE: We sought to examine differences in quality of life and sexual function after hysterectomy among women with preoperative pain and depression. METHODS: We analyzed data from a cohort study of 1,249 women who had hysterectomies for benign conditions. Participants were interviewed, before surgery and at 5 intervals after, regarding pelvic pain, depression, quality of life, and sexual function. We compared quality of life and sexual function at 6 and 24 months among women with preoperative pelvic pain alone, depression alone, both pelvic pain and depression, or neither. RESULTS: At 24 months, women with pain and depression had reduced prevalence of pelvic pain (96.7% decreased to 19.4%), limited physical function (66.1% to 34.3%), impaired mental health (93.3% to 38.1%), and limited social function (41.1% to 15.1%). Women with pain only improved in pelvic pain (95.1% to 9.3%) and limited activity level (74.3% to 24.2%). The group with depression only had improvement in impaired mental health (85.1% to 33.1%). Dyspareunia decreased in all groups. Compared with women who had neither pain nor depression, women with depression and pain had 3 to 5 times the odds of continued impaired quality of life: odds ratio (OR) 2.73, 95% confidence interval (CI) 1.78–4.19 for limited physical function; OR 3.41, 95% CI 2.13–5.46 for impaired mental health; OR 5.76, 95% CI 2.79–11.87 for limited social function; OR 4.91, 95% CI 2.63–9.16 for continued pelvic pain; and OR 2.41, 95% CI 1.26–4.62 for dyspareunia. CONCLUSION: Women with pelvic pain and depression fare less well 24 months after hysterectomy than women who have either disorder alone or neither. Nevertheless, these women improve substantially over their preoperative baseline in all the quality of life and sexual function areas assessed. LEVEL OF EVIDENCE: II-2

A Conceptual Model for the Pathophysiology of Vulvar Vestibulitis Syndrome

Vulvar vestibulitis syndrome (vestibulitis), the most common type of chronic vulvovaginal pain, impairs the psychologic, physical, and reproductive health of approximately 10% of women at some point in their lives. Research on the pathophysiology of vestibulitis suggests abnormalities in 3 interdependent systems: vestibular mucosa, pelvic floor muscles, and central nervous system pain regulatory pathways. To date, causes and relative contributions of these abnormalities to the development and maintenance of vestibulitis remain poorly understood. Research consistently supports the conceptualization of vestibulitis as a chronic pain disorder—akin to fibromyalgia, irritable bowel disorder, and temporomandibular disorder (TMD)—that is far more complex than vestibular hypersensitivity alone. Nevertheless, the clinical diagnosis of vestibulitis continues to rely on subjective report of pain during intercourse and vestibular sensitivity on clinical examination after exclusion of other gynecologic disorders. We propose that current diagnostic criteria, which are based on highly subjective patient and clinician measures, are not sufficient to describe and properly classify the heterogeneous clinical presentations of this disorder. To inform clinical care or research, we must be able to objectively characterize women with vestibulitis. This narrative review critically appraises current conceptualization of vestibulitis and presents a context for studying vestibulitis as a chronic pain disorder, emphasizing the need for objective assessment of clinical features. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to state that vulvar vestibulitis is common; recall that the disorder has three major pathophysiological pathways and that understanding of these pathways is important in selecting treatment options, and explain that the clinician must attempt to properly classify the clinical presentations of the disorder.

Musculoskeletal Causes of Chronic Pelvic Pain What a Gynecologist Should Know

Ten percent of all gynecologic consultations are for chronic pelvic pain, and 20% of patients require a laparoscopy. Chronic pelvic pain affects 15% of all women annually in the United States, with medical costs and loss of productivity estimated at

Association of the U.S. Food and Drug Administration Morcellation Warning With Rates of Minimally Invasive Hysterectomy and Myomectomy.

2.8 billion and

Overlap Between Orofacial Pain and Vulvar Vestibulitis Syndrome

15 billion per year, respectively. Chronic pelvic pain in women may have multifactorial etiology, but 22% have pain associated with musculoskeletal causes. Unfortunately, pelvic musculoskeletal dysfunction is not routinely evaluated as a cause of pelvic pain by gynecologists. A pelvic musculoskeletal examination is simple to perform, is not time-consuming, and is one of the most important components to investigate in all chronic pelvic pain patients. This article describes common musculoskeletal causes of chronic pelvic pain and explains how to perform a simple musculoskeletal examination that can be easily incorporated into the gynecologist physical examination.

Role of hysterectomy in the treatment of chronic pelvic pain.

OBJECTIVE: To evaluate whether there was a change in surgical practice immediately after the U.S. Food and Drug Administration (FDA) warning statement discouraging the use of power morcellation in the surgical treatment of uterine leiomyomas. METHODS: We performed a time-series analysis. Surgical case logs from the Florida Hospital operating room documentation system were used to retrospectively identify patients who underwent a hysterectomy or myomectomy between August 1, 2013, and December 31, 2014. Cases performed during the 8 months before the FDA announcement on April 17, 2014, were compared with cases performed during the 8 months after the FDA announcement. Six hospitals and 98 surgeons were included. We compared the proportion of minimally invasive surgery cases (vaginal, laparoscopic, or robotic-assisted) for each study period. RESULTS: There was a 5.8% decrease in minimally invasive hysterectomies after the FDA warning statement (85.7% [1,451/1,694] compared with 79.9% [1,350/1,690]; P<.001) and an 8.7% decrease when oncologist cases were excluded (90.2% [985/1,092] compared with 81.5% [834/1,023]; P<.001). There was a 19% decrease in minimally invasive myomectomies (62.7% [64/102] compared with 43.7% [38/87]; P=.009). Analysis by subspecialty showed a significant decrease in minimally invasive hysterectomies by obstetrician–gynecologists (ob-gyns) and minimally invasive gynecologic specialists but not urogynecologists or oncologists and a significant decrease in minimally invasive myomectomies by reproductive endocrinologists and minimally invasive gynecologic specialists but not ob-gyns. CONCLUSION: There was a significant decrease in the proportion of minimally invasive hysterectomies and myomectomies performed during the 8 months after the FDA warning statement on the use of power morcellation. LEVEL OF EVIDENCE: II

Prenatal diagnosis using fetal cells from the maternal circulation.

ObjectivesTo explore the prevalence of orofacial pain (OFP) among patients with vulvar vestibulitis syndrome (VVS) and to examine the relationship between signs and symptoms of OFP and clinical characteristics of women with VVS, we investigated differences in psychologic characteristics and severity of painful intercourse. MethodsIn this cross-sectional exploratory study, 137 women with VVS completed questionnaires that assessed levels of pain, anxiety, somatization, and presence of signs and symptoms suggestive of clinical and subclinical OFP. Demographic data were gathered from medical records. ResultsOFP was found to be a highly prevalent (78%) condition among women with VVS. Compared with women who had no OFP symptoms (n=30), those with symptoms (n=64) reported higher levels of anxiety (45.0 vs. 37.8, Bonferroni adjusted P=0.017), somatization (125.2 vs. 96.0, Bonferroni adjusted P<0.001), and psychologic distress (62.8 vs. 56.0, Bonferroni adjusted P=0.002). Although we observed a similar trend among women with subclinical OFP (n=43), this trend only reached statistical significance with respect to somatization. Differences were not detected for demographics, duration of pain, and severity of pain during intercourse across the 3 groups. DiscussionOFP is a common condition among women with VVS. Because severity and duration of painful intercourse did not differ by OFP classification but psychologic characteristics did, we must begin to question a unidimensional focus on vestibular mucosa as a reason for pain and persistent distress.

Effect of Lubricating Gel on Patient Comfort During Vaginal Speculum Examination A Randomized Controlled Trial

Chronic pelvic pain affects nearly 15% of women annually in the United States. It is associated with significant comorbidity, and annual costs to the health care system are estimated at approximately 2 billion dollars per year. The multifactorial nature of chronic pelvic pain makes it difficult to evaluate and treat. Therapies vary and may include surgical interventions such as hysterectomy. Although hysterectomy is an accepted treatment for chronic pelvic pain, it has important limitations that need to be discussed with the patient before surgery. Women can expect improvement in pain levels and function from their preoperative baseline. However, studies show that in the absence of any obvious pathology, 21-40% of women having a hysterectomy for chronic pelvic pain may continue to experience pain after the surgery and 5% may have new onset of pain. Women may experience improvements in mental health, physical function, social function, and dyspareunia; however, sexual frequency is not likely to change. Comorbidities such as preoperative depression may lower the chances of pain resolution after hysterectomy. Approximately 14% of women report having results worse than expected and almost 26% may have a slower recovery than expected. To maximize the chances of pain resolution, all women with chronic pelvic pain should undergo a full evaluation of the urologic, gastroenterologic, neurologic, and musculoskeletal organ systems before surgery to exclude nonreproductive causes of pain.

Racial differences among reasons for participating in research of pregnancy outcomes: The right from the start experience

Current prenatal diagnosis relies on invasive methods such as amniocentesis and chorionic villus sampling. Because these methods carry a low, but finite risk of pregnancy loss, noninvasive genetic screening techniques are the focus of intense research. Isolating fetal cells from maternal blood for genetic analysis is the least invasive method currently being investigated. We discuss the various methods that have been used to isolate these cells. Nucleated red blood cells have emerged as the ideal fetal cell type. This is because they have the DNA material necessary for genetic analysis, they are consistently present in maternal blood, they can be easily identified based on their morphology, and they have a definite gestational life span.

Vaginal apex resection: a treatment option for vaginal apex pain.

OBJECTIVE: To estimate the efficacy of lubricating gel compared with using water for pain during vaginal speculum insertion. METHODS: This study was a randomized trial of nonpregnant women aged 18–50 years who required a vaginal speculum examination between February and July 2011. Patients blinded to study assignment underwent vaginal speculum examination using a standardized technique with a medium-sized plastic speculum prepared with either 0.3 mL lubricating gel or 3 mL of water used to cover both speculum blades. Patients recorded pain using a 10-cm visual analog scale immediately after speculum insertion. A pre hoc power analysis determined that 55 patients in each arm would be required to detect a difference of 0.9 cm on a 10-cm visual analog scale. RESULTS: A total of 299 consecutive women requiring vaginal speculum examination were screened for enrollment and 120 women were randomized with 60 per group. There were no marked differences in the demographic characteristics of the gel (n=59) and water (n=60) participants available for final analysis. The gel group showed significantly lower pain scores for speculum insertion (mean±standard deviation: 1.41±1.55 compared with water 2.15±1.93, P<.01). Of patients undergoing examination with gel, 20 of 59 (33.9%) marked zero on the pain scale compared with six of 60 (10%) patients receiving water (P=.002). All 73 patients who underwent Pap screening had adequate cytology. CONCLUSION: Applying a small amount of lubricating gel significantly decreases patient pain during vaginal speculum insertion. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01289665. LEVEL OF EVIDENCE: I