Podcast Transcript: Decoding Chronic Pelvic Pain

[Dr. Mark Hoffman]
No, that's incredible. IPPS, the International Pelvic Pain Society, is, I think, all the years between AGL and SGS and I was going to APCO and ACOG, it was one meeting beyond what I could go to. It's something that I've only heard amazing things about. So many of our friends and colleagues go and are involved in the society. I keep saying one of these days I'm going to do it, but maybe Columbia will be my time to go. Again, you've talked about working with some pretty big names in pelvic pain, not just at IPPS, but also in your training and also at your current position in Orlando with some friends of mine who I know are some of the people I call and talk to about pelvic pain.

I'm trying to ask you questions for which I will understand the answer because some of the stuff you guys talk about in your pelvic pain world is just so high-level. I just sort of feel like such an idiot, but as we go through this, just, I think if you, if you say it in a way that I can understand then I think our listeners will be able to do the same, but I want to really take our audience through your evaluation for the workup, but then also basic treatments. Obviously, this is a more than just an hour conversation, but just an overview and as an intro for somebody who wants to get better at taking care of pelvic pain, what's your overall approach to evaluating patients in the clinic setting for chronic pelvic pain?

[Dr. Jorge Carillo]
I think that the very first thing and probably one of the most important things that we probably want to do, not probably, that we should be doing is acknowledge the relationship between persistent pain and persistent pelvic pain, specifically in trauma and apply what is called a trauma-informed care approach that probably a lot of people who are listening to this podcast have heard that word. Some of them are probably very familiar. Some other people are not. Applying a trauma-informed care approach, it really opens up the possibility of creating a safe environment for those patients who suffer from persistent pelvic pain because there's a very strong relationship with that.

It's a very good opportunity to really strengthen the relationship with the patients, but also to be able to open up a window for those patients to connect with us. We have to remember that a lot of these patients, which I'm sure you have that experience that you have seen them, they've seen multiple health professionals. They feel that they've been dismissed. They've gone to the emergency department several times, and they're frustrated. They come with a lot of emotional package that they really just want to be heard and they just want to feel that they're taken serious.

Trauma-informed care goes beyond just, asking about sexual trauma or physical trauma. It's something as simple as asking, how have been your prior experiences when you've had a pap smear? How well can you tolerate the pelvic exam? Feel free to stop me whenever I'm starting the exam, whenever I'm doing the exam, or if you feel that it's hurting a lot, or ask questions, or just something as simple as providing a mirror, allowing the opportunity for the patient to ask questions or to pick what they want to have examined at that appointment.

The reason why that's important is because it helps create and build up on that relationship. Trauma is something that we all have, in some form and something that really impacts, the people's health. Being able to do that is the very first and most important part of applying what is called a biopsychosocial model to treat pain. In med school and in residency, we're taught that pain is directly because of an injury or a direct cause of something that is causing harm or damaging the tissue, right?

Pain is much more complex than that. Pain is something that is individual and is something that is basically learned, that has a lot of environmental factors that will affect it. stepping away from that notion that the pain is being caused because of that lesion that you have of endometriosis or because of that peripheral thing, and that is what is going to give you the persistent pain, is still going in that vicious cycle of, oh yes, we need to remove that and cut that and that's it, the pain is going to get better. For conditions that really doesn't work that way, as we know and we have research for that.

I think that very first approach is the most important thing that you should do. Trauma-informed care starts the moment the patient walks into the office and it doesn't stop when they leave. It's something that you can carry on and even into the pre-op area and the post-op area by communicating with the anesthesiologists and the nurses who are the very first people that they see when they wake up after a surgery. It's something that really requires a teamwork. To me, it's the most important thing that it should start that way, before anything else.

[Dr. Mark Hoffman]
I've been there as well when you have a patient who tells you what's going on, you say, I'm sorry you're going through that and I believe you, and just saying I believe you. I think I've had patients break down in the office and just say for so long no one believed that I was in pain, they just didn't. I think it's hard when you don't know what is causing the patient's pain and as a physician to say I don't know is tough for some people, but oftentimes just saying I don't know what's going on right now, I believe you're in pain and we'll continue working with you. We can't promise results, we can promise effort, we can promise transparency, we can promise to apply what we know and what we think we know and to provide a safe space for our patients.

That trauma-informed care, I think, is a nice way to, I think that's something we all need to learn more about, but I think trying to imagine what it's like to be in that position. Obviously, I can't put myself in other people's shoes in that sense, but at least to be sensitive to the fact that, I don't know what these folks have gone through, but giving them the power to make the decisions in the office. I always tell folks, okay, this is your visit, I'll tell you what I think, I'll tell you a couple of things that we can do that may provide additional information.

Some of it is talking about certain things, some of it is physical exam, some of it is tests, things like imaging studies, all of that is stuff we'll recommend and you get to choose of those things which you think we should do. If you don't want to do today, then that's your choice. If you want to do it ever, that's your choice. Here's what I could learn from it. If somebody says we should do something and there's nothing we can learn from it or no benefit, then we probably shouldn't be doing it. Everything we do we'll explain why we're doing it.

I think that was something certainly I saw and, I'm trying to model after some of the people that taught me, like Suzie As-Sanie, who, again, her approach to pelvic pain was, I'd never seen anything like it. There's no one, and I went to a residency program where I'm very proud of it and proud of the training I had and proud of the experience and very grateful for the great training I got there. I had not seen anything like that before. I think I had a similar experience where I was like, wait, did I go to the residency program because, did I graduate from residency because this is all brand new.

This is just so different than what I was taught. It's just a whole other world. It felt very, almost like if someone had kept it a secret a little bit and that was a shame because it's something that a lot of our patients deal with. That trauma-informed care is something that, yes, I do think it's important. It takes time, in this healthcare environment. We don't always get as much time with our patients as we need. Say, listen, we don't have time today. Let's come back another time. We'll continue the conversation. Yes, I think that's important. I also want to touch on the other thing you said was the biopsychosocial aspect of chronic pelvic pain.

Can you elaborate a little bit on what the definition of that is and what you mean by that? Because I think we could talk for days and days about endometriosis surgery and the value and treating what I believe is not necessarily a surgical problem only with surgery. Obviously, we do a lot of surgery. Yes, biopsychosocial model, what does that mean?

(2) Applying the Biopsychosocial Model to Pelvic Pain

[Dr. Jorge Carillo]
That's a concept that is not new. It's an old concept and it's been applied to many things that are related to health. When it comes to pain, basically, what it tells is that it's acknowledging that pain usually, most of the times, has a biological component. There's something biological or physiologically speaking that is leading to that painful experience. The cycle and the social aspect of it are key when it comes to pain because a lot of it, of the pain experience, comes from the cognitive part and the cognition. That's something that is learned. It goes along with the behavior that the patient has or that the person has in response to a painful stimulus. That's really what makes the pain experience different among individuals.

Probably the way how I interpret pain is most likely very different compared to the way how you interpret pain because we both have different experiences of pain. That pertains to the psychological aspect, that cognitive part, the part of the behavioral part. The emotional part. We know there's a very strong association between persistent pain and anxiety and persistent pain and depression and, this other word, catastrophization as well. Again, those are cognitive processes and behavioral processes that will impact that psychological part. Then you have the social aspect of it, which also plays a very important role.

If we're in a society where pain, especially pain in women, is totally normalized, it's something that, well, you have painful periods, well, just take ibuprofen, Tylenol, and try to deal with it. Just keep going. Keep moving. Someone calls in sick because they're having very bad periods and they're afraid of doing so because they perceive that they're going to be looked at as weak so they don't speak up. In that aspect, the care is delayed. Because there's actually studies that we all know, we always talk about the delay in diagnosis and, especially with endometriosis 7 to 10 years and all that.

There's actually studies looking at why that could happen and what factors happen. There are factors that come from the patient side, the society side, and there are factors that come from the medical aspect, the health professionals aspect. The part that comes from the society part is basically normalization and lack of education, the lack of talking more about how it's not normal to experience pain with intercourse. It's not normal to have periods that are debilitating, that don't allow people to actually carry normal functions. Those studies are out there and that's information that we know.

[Dr. Mark Hoffman]
The number of people who were just told, well, this is just what it's like to have a period, sometimes it's not even intentional. Their parents, their mom might've gone through very similar things. They had endometriosis as well or had a long history of painful menstrual cycles. It wasn't until they got the hysterectomy that they felt better. There's this sort of familial or in a sense, cultural understanding of this is the way it's going to be for me. I hear that a lot. This, I know I'm going to get my hysterectomy too, because my mom and my aunts and my grandma all had theirs. It's like this is the path.

Understanding people's social and cultural backgrounds enough, just again, that's part of getting to know a patient, which in healthcare these days, as I said a minute ago, can be challenging. That relationship with these patients who are dealing with such complex chronic things, establishing that trust is huge because they've oftentimes been, I don't think it's because of doctors who didn't care or didn't try. It was that they are dealing with really complex things that haven't been managed in a way that has provided the results that these folks deserve.

Yes, I think it's clearly tough. I think it's one of the toughest things that we do, but I also think it's not something that is taught as uniformly and as consistently as some of the other things in our specialty. This is what excites me about AGL, about IPPS, about MIGS in general, is there is this huge field with endometriosis, fibroids, pelvic pain, that is not necessarily as well understood and taught over four years of residency. It's something that huge opportunity for our patients and for those of us who do this to learn more about it. When you meet a patient in clinic, you establish that rapport.

Again, before they walk in the office, let alone your clinic room, the staff, how they communicate, I'm sure you have all of that stuff that you've addressed in your clinic. When you're meeting them for the first time, again, so history, you've talked about the pain survey. Talk to me a little bit about history, about what you guys do pregame. Do you send your patients surveys? I know Suzie would do that and get these 30-page surveys back. We don't do that. It's not something I can ask my staff to do or I haven't asked my staff to do, but do you guys do anything to send out pregame surveys and things to your patients?

(3) Strategies to Optimize Pelvic Pain Assessment