O. B. Poli-Neto

High levels of anxiety and depression have a negative effect on quality of life of women with chronic pelvic pain

Background:u2002 Chronic pelvic pain (CPP) is a common and complex disease whose cause is often clinically inexplicable, with consequent difficulty in diagnosis and treatment. Patients with CPP have high levels of anxiety and depression, with a consequent impairment of their quality of life.

Physical therapy in the management of women with chronic pelvic pain

Objectives:u2002 Chronic pelvic pain (CPP) is defined as lower abdominal pain lasting for at least 6u2003months, which occurs continuously or intermittently and is not associated exclusively with menstruation or intercourse. CPP is a highly prevalent debilitating disease with negative impact on the quality of life and productivity of women. The dilemma regarding the management of CPP continues to frustrate the health professionals, partly because its physiopathology is poorly understood. Consequently, the treatment of this condition is often unsatisfactory and limited to temporary symptom relief. In the present review, we discuss characteristics of the clinical history and physical examination associated with musculoskeletal involvement in women with CPP and possible treatments, especially in the area of physiotherapy.

Endometriosis in postmenopausal women without previous hormonal therapy: report of three cases

Introductionu2003Endometriosis is a benign, estrogen-dependent, chronic gynecological disorder associated with pelvic pain and infertility. The disease most commonly affects women during the reproductive age, although postmenopausal patients do rarely present it. These rare occurrences are generally associated with hormonal use. Material and methodsu2003We present three cases of endometriosis in postmenopausal patients who have no history of hormone therapy and no previous history of endometriosis or infertility. Case reportsu2003In case 1, a 62-year-old woman presented with acyclic pelvic pain and a left ovarian homogeneous cystic mass. After laparoscopic salpingoophorectomy and histological analysis, an ovarian endometriotic cyst was confirmed. In case 2, a 78-year-old woman presented with a painful abdominal wall mass that was confirmed by ultrasound and tomography. Her past medical history included an abdominal hysterectomy 20 years prior to the discovery of this mass. The lesion was surgically excised and histological analysis showed areas of endometrial stroma and glands surrounded by fibrosis, compatible with endometriosis. In case 3, a 54-year-old woman presented with chronic pelvic pain and a nodule in the rectovaginal septum was noted during gynecological examination. Menopause occurred at 48 years of age. She had no previous dysmenorrhea. Ultrasound confirmed the nodule in the rectovaginal septum. The patient was submitted to a diagnostic colonoscopy that revealed a friable lesion, which was subsequently biopsied. The histological diagnosis was endometriosis. Conclusionsu2003These three cases of postmenopausal endometriosis support the celomic metaplasia theory for the genesis of this disease.

Pain pressure threshold algometry of the abdominal wall in healthy women

The objective of this study was to determine the inter- and intra-examiner reliability of pain pressure threshold algometry at various points of the abdominal wall of healthy women. Twenty-one healthy women in menacme with a mean age of 28 ± 5.4 years (range: 19-39 years) were included. All volunteers had regular menstrual cycles (27-33 days) and were right-handed and, to the best of our knowledge, none were taking medications at the time of testing. Women with a diagnosis of depression, anxiety or other mood disturbances were excluded. Women with previous abdominal surgery, any pain condition or any evidence of inflammation, hypertension, smoking, alcoholism, or inflammatory disease were also excluded. Pain perception thresholds were assessed with a pressure algometer with digital traction and compression and a measuring capacity for 5u2005kg. All points were localized by palpation and marked with a felt-tipped pen and each individual was evaluated over a period of 2 days in two consecutive sessions, each session consisting of a set of 14u2005point measurements repeated twice by two examiners in random sequence. There was no statistically significant difference in the mean pain threshold obtained by the two examiners on 2 diferent days (examiner A: P = 1.00; examiner B: P = 0.75; Wilcoxon matched pairs test). There was excellent/good agreement between examiners for all days and all points. Our results have established baseline values to which future researchers will be able to refer. They show that pressure algometry is a reliable measure for pain perception in the abdominal wall of healthy women.

Prevalence and conditions associated with chronic pelvic pain in women from São Luís, Brazil

The objective of the present study was to estimate the prevalence of chronic pelvic pain in the community of São Luís, capital of the State of Maranhão, Northeastern Brazil, and to identify independent conditions associated with it. A cross-sectional study was conducted, including a sample of 1470 women older than 14 years predominantly served by the public health system. The interviews were held in the subjects home by trained interviewers not affiliated with the public health services of the municipality. The homes were visited at random according to the city map and the prevalence of the condition was estimated. To identify the associated conditions, the significant variables (P=0.10) were selected and entered in a multivariate analysis model. Data are reported as odds ratio and 95% confidence interval, with the level of significance set at 0.05. The prevalence of chronic pelvic pain was 19.0%. The independent conditions associated with this diagnosis were: dyspareunia (OR=3.94), premenopausal status (OR=2.95), depressive symptoms (OR=2.33), dysmenorrhea (OR=1.77), smoking (OR=1.72), irregular menstrual flow (OR=1.62), and irritative bladder symptoms (OR=1.90). The prevalence of chronic pelvic pain in Sao Luís is high and is associated with the conditions cited above. Guidelines based on prevention and/or early identification of risk factors may reduce the prevalence of chronic pelvic pain in São Luís, Brazil.

Effect of intracervical anesthesia on pain associated with the insertion of the levonorgestrel-releasing intrauterine system in women without previous vaginal delivery: a RCT

STUDY QUESTIONnIs the pain associated with levonorgestrel-releasing intrauterine system (LNG-IUS) insertion reduced by intracervical anesthesia in women without previous vaginal birth?nnnSUMMARY ANSWERnIntracervical anesthesia was not associated with reduced pain in women without previous vaginal birth.nnnWHAT IS KNOWN ALREADYnThe pain associated with the insertion of intrauterine contraceptives (IUCs) is a limiting factor for the use of these contraceptives by some women. No prophylactic pharmacological intervention has proven efficacy in relieving pain during or after the insertion of IUCs. However, previous studies included women with previous vaginal delivery, and injectable intracervical anesthesia was not evaluated in any of these studies.nnnSTUDY DESIGN, SIZE, DURATIONnThis was a randomized, open, parallel-group clinical trial that evaluated 100 women without previous vaginal delivery who wished to use the LNG-IUS for the first time. These women were evaluated immediately after LNG-IUS insertion and then 2 h and 6 h later.nnnPARTICIPANTS/MATERIALS, SETTING, METHODSnThe 100 women were randomized into two groups: (i) use of a non-steroidal anti-inflammatory drug (NSAID) (ibuprofen, 400 mg) 1 h prior to LNG-IUS insertion; or (ii) 2% lidocaine intracervical injection 5 min prior to LNG-IUS insertion. The women were evaluated immediately after LNG-IUS insertion and then 2 h and 6 h after insertion. Two pain scales were used (the visual analogue scale and the facial pain scale) in addition to assessing the ease of insertion (as rated by the provider) and the level of discomfort during the procedure (as rated by the patient). Multivariate logistic regression was performed to analyze the predictors associated with moderate/severe pain.nnnMAIN RESULTS AND THE ROLE OF CHANCEnThe pain and discomfort associated with LNG-IUS insertion, and the ease of insertion of the LNG-IUS did not differ between the groups. Nulliparity was more associated with moderate/severe pain [adjusted odds ratio (OR): 3.1 (95% confidence interval (CI): 1.3-7.80]. Injectable intracervical anesthesia use reduced the risk of moderate/severe pain by 40% [adjusted OR: 0.6 (95% CI: 0.2-1.4)]. The difference between the mean pain score in the intracervical anesthesia group and the NSAID group was <10%; thus, the effect size of the intervention was not significant.nnnLIMITATIONS, REASONS FOR CAUTIONnIntracervical anesthesia was compared with an oral medication in this study. Intracervical injection of a saline solution or even a dry needling as the placebo for a double-blind study could be a more adequate control; however, this approach was not a protocol approved by the institutional review board. Considering that the majority of the insertions were easy (>80% in both groups), the results may not be extrapolated to difficult insertions with moderate/severe pain where local anesthesia may have a role.nnnWIDER IMPLICATIONS OF THE FINDINGSnThe findings can be generalized to most insertions in nulliparous women or in those without a previous vaginal delivery. There is currently no evidence to recommend the routine use of prophylactic intracervical anesthesia prior to LNG-IUS insertion; there is no evidence that this treatment reduces insertion-related pain.nnnSTUDY FUNDING/COMPETING INTERESTSnRAF and CSV give occasional lectures for Bayer Healthcare. This study received funding from the National Institute of Hormones and Womens Health, National Council for Scientific and Technological Development (CNPq).nnnTRIAL REGISTRATION NUMBERnNCT02155166.

Reduction of blood nitric oxide levels is associated with clinical improvement of the chronic pelvic pain related to endometriosis

The objective of this prospective study was to determine the plasma levels of nitric oxide (NO) in women with chronic pelvic pain secondary to endometriosis (n=24) and abdominal myofascial pain syndrome (n=16). NO levels were measured in plasma collected before and 1 month after treatment. Pretreatment NO levels (μM) were lower in healthy volunteers (47.0±12.7) than in women with myofascial pain (64.2±5.0, P=0.01) or endometriosis (99.5±12.9, P<0.0001). After treatment, plasma NO levels were reduced only in the endometriosis group (99.5±12.9 vs 61.6±5.9, P=0.002). A correlation between reduction of pain intensity and reduction of NO level was observed in the endometriosis group [correlation = 0.67 (95%CI = 0.35 to 0.85), P<0.0001]. Reduction of NO levels was associated with an increase of pain threshold in this group [correlation = -0.53 (-0.78 to -0.14), P<0.0001]. NO levels appeared elevated in women with chronic pelvic pain diagnosed as secondary to endometriosis, and were directly associated with reduction in pain intensity and increase in pain threshold after treatment. Further studies are needed to investigate the role of NO in the pathophysiology of pain in women with endometriosis and its eventual association with central sensitization.

Electromyographic characterisation of abdominal wall trigger points developed after caesarean section and response to local anaesthesia: an observational study

This study examines the electromyography pattern of abdominal trigger points developed after a caesarean section, and the association between clinical response and local anaesthetic injection.

Analysis of differential genetic expression in endometrial polyps of postmenopausal women

Abstract Objectives: To evaluate the expression of four genetic markers (PTEN, BCL2, MLH1, and CTNNB1), linked to endometrial carcinogenesis, in endometrial polyps of patients with and without postmenopausal bleeding in order to determine whether symptomatic endometrial polyps have a genetic phenotype similar to that of endometrial cancer. Methods: Samples were obtained hysteroscopically from endometrial polyps of postmenopausal patients, and the expression of genetic markers involved in the pathogenesis of endometrial cancer (PTEN, BCL2, MLH1, and CTNNB1) was analyzed. The expression of these markers was then compared between patients with and without symptoms, which was characterized as postmenopausal bleeding. Other clinical characteristics of the patients, such as duration of menopause, polyp size, presence of systemic hypertension, diabetes mellitus, and smoking habits were also analyzed. Results: Samples from a total of 60 patients were obtained, as calculated for a test power of 0.80. No statistical differences (pu2009>u20090.05) were observed between the two groups concerning the expression of the studied endometrial cancer risk factor genes, or with regard to the clinical aspects evaluated. Conclusion: The study found no evidence that symptomatic endometrial polyps have a similar phenotype to type 1 endometrial cancer; further studies are needed in order to establish whether endometrial polyps are in fact true cancer precursors, or simply raise cancer incidence due to a detection bias.