Publications by authors named "Frank F Tu"

44 Publications

Noninvasive bladder testing of adolescent females to assess visceral hypersensitivity.

Pain 2021 Apr 12. Epub 2021 Apr 12.

Department of Ob/Gyn, NorthShore University HealthSystem Evanston, IL, United States, Department of Ob/Gyn, University of Chicago, Pritzker School of Medicine, Chicago, IL, United States, Department of Psychology, Loyola University of Chicago, Chicago, IL, United States, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States.

Abstract: Excess pain after visceral provocation has been suggested as a marker for chronic pelvic pain risk in women. However, few noninvasive tests have been validated that could be performed readily on youth in early risk windows. Therefore, we evaluated the validity and reliability of a noninvasive bladder pain test in 124 healthy premenarchal females (median age 11, [interquartile range 11-12]), as previously studied in adult women. We explored whether psychosocial, sensory factors, and quantitative sensory test results were associated with provoked bladder pain and assessed the relation of bladder pain with abdominal pain history. Compared with findings in young adult females (age 21 [20-28]), results were similar except that adolescents had more pain at first sensation to void (P = 0.005) and lower maximum tolerance volume (P < 0.001). Anxiety, depression, somatic symptoms, and pain catastrophizing predicted provoked bladder pain (P's < 0.05). Bladder pain inversely correlated with pressure pain thresholds (r = -0.25, P < 0.05), but not with cold pressor pain or conditioned pain modulation effectiveness. Bladder pain was also associated with frequency of abdominal pain symptoms (r = 0.25, P = 0.039). We found strong retest reliability for bladder pain at standard levels of sensory urgency in 21 adolescents who attended repeat visits at 6 to 12 months (intraclass correlations = 0.88-0.90). Noninvasive bladder pain testing seems reproducible in adolescent females and may predict abdominal pain symptomatology. Confirmation of our findings and further investigation of the bladder test across menarche will help establish how visceral sensitivity contributes to the early trajectory of pelvic pain risk.
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http://dx.doi.org/10.1097/j.pain.0000000000002311DOI Listing
April 2021

Development and validation of a real-time method characterizing spontaneous pain in women with dysmenorrhea.

J Obstet Gynaecol Res 2021 Apr 15;47(4):1472-1480. Epub 2021 Feb 15.

Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois, USA.

Aim: Prior research has primarily focused on static pain assessment, largely ignoring the dynamic nature of pain over time. We used a novel assessment tool for characterizing pain duration, frequency, and amplitude in women with dysmenorrhea and evaluated how these metrics were affected by naproxen treatment.

Methods: Dysmenorrheic women (n = 25) rated their menstrual pain by squeezing a pressure bulb proportional to the magnitude of their pain. To evaluate whether bulb squeezing was affected by naproxen, we compared parameters before and after naproxen. We also analyzed the correlation between pain relief on a numerical rating scale to changes in bulb squeezing parameters. Random bulb-squeezing activity in pain-free participants (n = 14) was used as a control for nonspecific effects or bias.

Results: In dysmenorrheic women, naproxen reduced the duration of the squeezing during a painful bout, the number of painful bouts and bout intensity. Before naproxen, the correlation between these bulb squeeze parameters and self-reported pain on numeric rating scale was not significant (R = 0.12, p = 0.304); however, there was a significant correlation between changes in bulb squeeze activity and self-reported pain relief after naproxen (R = 0.55, p < 0.001).

Conclusion: Our study demonstrates a convenient technique for continuous pain assessment, capturing three different dimensions: duration, frequency, and magnitude. Naproxen may act by reducing the duration and frequency of episodic pain in addition to reducing the severity. After further validation, these methods could be used for other pain conditions for deeper phenotyping and assessing novel treatments.
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http://dx.doi.org/10.1111/jog.14663DOI Listing
April 2021

Cortical Mechanisms of Visual Hypersensitivity in Women at Risk for Chronic Pelvic Pain.

medRxiv 2021 Jan 18. Epub 2021 Jan 18.

Multisensory hypersensitivity (MSH), which refers to persistent discomfort across sensory modalities, is a risk factor for chronic pain. Developing a better understanding of the neural contributions of disparate sensory systems to MSH may clarify its role in the development of chronic pain. We recruited a cohort of women ( =147) enriched with participants with menstrual pain at risk for developing chronic pain. Visual sensitivity was measured using a periodic pattern-reversal stimulus during EEG. Self-reported visual unpleasantness ratings were also recorded. Bladder pain sensitivity was evaluated with an experimental bladder-filling task associated with early clinical symptoms of chronic pelvic pain. Visual stimulation induced unpleasantness was associated with bladder pain and evoked primary visual cortex excitation; however, the relationship between unpleasantness and cortical excitation was moderated by bladder pain. Thus, future studies aimed at reversing the progression of MSH into chronic pain should prioritize targeting of cortical mechanisms responsible for maladaptive sensory input integration.
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http://dx.doi.org/10.1101/2020.12.03.20242032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7836135PMC
January 2021

Impact of Endometriosis on Life-Course Potential: A Narrative Review.

Int J Gen Med 2021 7;14:9-25. Epub 2021 Jan 7.

Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, MI, USA.

Endometriosis may exert a profound negative influence on the lives of individuals with the disorder, adversely affecting quality of life, participation in daily and social activities, physical and sexual functioning, relationships, educational and work productivity, mental health, and well-being. Over the course of a lifetime, these daily challenges may translate into limitations in achieving life goals such as pursuing or completing educational opportunities; making career choices or advancing in a chosen career; forming stable, fulfilling relationships; or starting a family, all of which ultimately alter one's life trajectory. The potential for endometriosis to impact the life course is considerable, as symptom onset generally occurs at a time of life (menarche through menopause, adolescence through middle age) when multiple life-changing and trajectory-defining decisions are made. Using a life-course approach, we examine how the known effects of endometriosis on life-domain satisfaction may impact health and well-being across the life course of affected individuals. We provide a quasi-systematic, narrative review of the literature as well as expert opinion on recommendations for clinical management and future research directions.
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http://dx.doi.org/10.2147/IJGM.S261139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7800443PMC
January 2021

Low Serum Naproxen Concentrations Are Associated with Minimal Pain Relief: A Preliminary Study in Women with Dysmenorrhea.

Pain Med 2020 11;21(11):3102-3108

Department of Obstetrics and Gynecology, NorthShore University HealthSystem & Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA.

Objective: Incomplete pain relief after administration of nonsteroidal anti-inflammatory drugs (NSAIDs) is common, but it is unknown whether malabsorption or heightened metabolism contributes to NSAID resistance. To explain the etiology of NSAID resistance, we evaluated naproxen absorption and metabolism in relation to pain relief in a pilot study of women with dysmenorrhea.

Methods: During menses, participants completed before and after naproxen ingestion pain assessments. Analgesic effectiveness was calculated as a percent change in pain rating before and after naproxen administration. To evaluate the impact of malabsorption, the correlation between analgesic effectiveness and serum naproxen was analyzed. To identify whether hypermetabolism contributes to NSAID resistance, we also analyzed the metabolite O-desmethylnaproxen.

Results: Serum naproxen and O-desmethylnaproxen concentrations of the dysmenorrheic cohort (N = 23, 126 ± 10 µg/mL, 381 ± 56 ng/mL) and healthy controls (N = 12, 135 ± 8 µg/mL, 355 ± 58 ng/mL) were not significantly different (P > 0.05), suggesting that menstrual pain does not affect drug absorption and metabolism. However, nine dysmenorrhea participants had levels of analgesic effectiveness <30%. Among dysmenorrheic women, analgesic effectiveness was correlated with serum naproxen (r = 0.49, P = 0.019) and O-desmethylnaproxen (r = 0.45, P = 0.032) concentrations. After controlling for other gynecological diagnoses, a multivariate model analysis confirmed that lower serum naproxen concentrations were associated with reduced pain relief (P  = 0.038).

Conclusions: Our preliminary findings suggest that poor drug absorption contributes to ineffective pain relief in dysmenorrheic women. Future studies should explore whether malabsorption contributes to NSAID resistance for other pain conditions.
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http://dx.doi.org/10.1093/pm/pnaa133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7784249PMC
November 2020

Dysmenorrhea subtypes exhibit differential quantitative sensory assessment profiles.

Pain 2020 06;161(6):1227-1236

Department of Ob/Gyn, Northshore University HealthSystem, Evanston, IL, United States.

Women who develop bladder pain syndrome (BPS), irritable bowel syndrome, or dyspareunia frequently have an antecedent history of dysmenorrhea. Despite the high prevalence of menstrual pain, its role in chronic pelvic pain emergence remains understudied. We systematically characterized bladder, body, and vaginal mechanical sensitivity with quantitative sensory testing in women with dysmenorrhea (DYS, n = 147), healthy controls (HCs) (n = 37), and women with BPS (n = 25). Previously, we have shown that a noninvasive, bladder-filling task identified a subset of women with both dysmenorrhea and silent bladder pain hypersensitivity, and we repeated this to subtype dysmenorrhea sufferers in this study (DYSB; n = 49). DYS, DYSB, and BPS participants had lower vaginal mechanical thresholds and reported more pain to a cold stimulus during a conditioned pain modulation task and greater pelvic examination after-pain than HCs (P's < 0.05). DYSB participants also had reduced body mechanical thresholds and less conditioned pain modulation compared to HCs and DYS participants (P's < 0.05). Comparing quantitative sensory testing results among the DYS and HC groups only, provoked bladder pain was the only significant predictor of self-reported menstrual pain (r = 0.26), bladder pain (r = 0.57), dyspareunia (r = 0.39), and bowel pain (r = 0.45). Our findings of widespread sensory sensitivity in women with dysmenorrhea and provoked bladder pain, much like that observed in chronic pain, suggest a need to study the trajectory of altered mechanisms of pain processing in preclinical silent visceral pain phenotypes to understand which features convey inexorable vs modifiable risk.
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http://dx.doi.org/10.1097/j.pain.0000000000001826DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230023PMC
June 2020

Low Serum Oxytocin Concentrations Are Associated with Painful Menstruation.

Reprod Sci 2020 02 6;27(2):668-674. Epub 2020 Jan 6.

Department of Obstetrics and Gynecology, NorthShore University HealthSystem and The University of Chicago Pritzker School of Medicine, Evanston, IL, USA.

Oxytocin-dependent mechanisms are hypothesized to contribute to painful menses, but clinical trials of oxytocin antagonists for dysmenorrhea have had divergent outcomes. In contrast, broader studies have shown that increased systemic oxytocin concentrations are associated with increased pain tolerance and improved psychosocial function. We sought to confirm whether increased serum oxytocin concentrations are associated with menstrual pain and other psychosocial factors. Women with a history of primary dysmenorrhea (n = 19), secondary dysmenorrhea (n = 12), and healthy controls (n = 15) completed pain and psychosocial questionnaires, provided a medical history, and rated their pain during the first 48 h of menses. Serum samples were collected during menses to measure oxytocin concentrations. Oxytocin was significantly lower in participants with a history of primary (704 ± 33 pg/mL; p < 0.001) or secondary (711 ± 66 pg/mL; p < 0.01) dysmenorrhea compared to healthy controls (967 ± 53 pg/mL). Menstrual pain over the past 3 months (r = -0.58; p < 0.001) and during the study visit (r = -0.45; p = 0.002) was negatively correlated with oxytocin concentrations. Pain catastrophizing (r = -0.39), pain behavior (r = -0.32), and pain interference (r = -0.31) were also negatively correlated with oxytocin levels (p's < 0.05). Oxytocin was not significantly correlated with psychosocial factors. Contrary to our hypothesis, women with a history of primary or secondary dysmenorrhea had lower oxytocin concentrations during menses when compared to healthy controls. Lower circulating oxytocin concentrations were also associated with worse menstrual pain and pain-related behavior. When considering the existing literature, low circulating oxytocin may be a sign of dysfunctional endogenous pain modulation.
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http://dx.doi.org/10.1007/s43032-019-00071-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044072PMC
February 2020

Clinical profile of comorbid dysmenorrhea and bladder sensitivity: a cross-sectional analysis.

Am J Obstet Gynecol 2020 06 20;222(6):594.e1-594.e11. Epub 2019 Dec 20.

Department of Obstetrics and Gynecology, Northshore University HealthSystem, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL.

Background: Antecedents of chronic pelvic pain are not well characterized, but pelvic organ visceral sensitivity is a hallmark of these disorders. Recent studies have identified that some dysmenorrhea sufferers are much more likely to exhibit comorbid bladder hypersensitivity. Presumably, these otherwise healthy women may be at higher risk of developing full-blown chronic bladder pain later in life. To encourage early identification of patients harboring potential future risk of chronic pain, we describe the clinical profile of women matching this putative pain-risk phenotype.

Objective(s): The objectives of the study were to characterize demographic, menstrual, pelvic examination, and psychosocial profiles of young women with comorbid dysmenorrhea and bladder hypersensitivity, defined using a standardized experimental visceral provocation test, contrasted with healthy controls, pure dysmenorrhea sufferers, and women with existing bladder pain syndrome.

Study Design: This prospective cohort study acquired data on participants with moderate to severe dysmenorrhea (n = 212), healthy controls (n = 44), and bladder pain syndrome (n = 27). A subgroup of dysmenorrhea patients was found on screening with noninvasive oral water challenge to report significantly higher bladder pain during experimentally monitored spontaneous bladder filling (>15 out of 100 on visual analogue scale, based on prior validation studies) and separately defined as a group with dysmenorrhea plus bladder pain. Medical/menstrual history and pain history were evaluated with questionnaires. Psychosocial profile and impact were measured with validated self-reported health status Patient Reported Outcomes Measurement Information System short forms and a Brief Symptom Inventory for somatic sensitivity. Pelvic anatomy and sensory sensitivity were examined via a standardized physical examination and a tampon provocation test.

Results: In our largely young, single, nulliparous cohort (24 ± 1 years old), approximately a quarter (46 out of 212) of dysmenorrhea sufferers tested positive for the dysmenorrhea plus bladder pain phenotype. Dysmenorrhea-only sufferers were more likely to be African American (24%) than healthy controls (5%, post hoc χ, P = .007). Pelvic examination findings did not differ in the nonchronic pain groups, except for tampon test sensitivity, which was worse in dysmenorrhea plus bladder pain and dysmenorrhea sufferers vs healthy controls (2.6 ± 0.3 and 1.7 ± 0.2 vs 0.7 ± 0.2, P < .05). Consistent with heightened pelvic sensitivity, participants with dysmenorrhea plus bladder pain also had more nonmenstrual pain, dysuria, dyschezia, and dyspareunia (P's < .05). Participants with dysmenorrhea plus bladder pain had Patient Reported Outcomes Measurement Information System Global Physical T-scores of 47.7 ± 0.9, lower than in women with dysmenorrhea only (52.3 ± 0.5), and healthy controls 56.1 ± 0.7 (P < .001). Similarly, they had lower Patient Reported Outcomes Measurement Information System Global Mental T-score than healthy controls (47.8 ± 1.1 vs 52.8 ± 1.2, P = .017). Similar specific impairments were observed on Patient Reported Outcomes Measurement Information System scales for anxiety, depression, and sleep in participants with dysmenorrhea plus bladder pain vs healthy controls.

Conclusion: Women with dysmenorrhea who are unaware they also have bladder sensitivity exhibit broad somatic sensitivity and elevated psychological distress, suggesting combined preclinical visceral sensitivity may be a precursor to chronic pelvic pain. Defining such precursor states is essential to conceptualize and test preventative interventions for chronic pelvic pain emergence. Dysmenorrhea plus bladder pain is also associated with higher self-reported pelvic pain unrelated to menses, suggesting central nervous system changes are present in this potential precursor state.
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http://dx.doi.org/10.1016/j.ajog.2019.12.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263950PMC
June 2020

Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel.

J Vasc Interv Radiol 2019 Jun 8;30(6):781-789. Epub 2019 Mar 8.

Connecticut Image-Guided Surgery, Fairfield, Connecticut.

Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.
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http://dx.doi.org/10.1016/j.jvir.2018.10.008DOI Listing
June 2019

Persistent autonomic dysfunction and bladder sensitivity in primary dysmenorrhea.

Sci Rep 2019 02 18;9(1):2194. Epub 2019 Feb 18.

Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston IL, 60201, USA.

Menstrual pain, also known as dysmenorrhea, is a leading risk factor for bladder pain syndrome (BPS). A better understanding of the mechanisms that predispose dysmenorrheic women to BPS is needed to develop prophylactic strategies. Abnormal autonomic regulation, a key factor implicated in BPS and chronic pain, has not been adequately characterized in women with dysmenorrhea. Thus, we examined heart rate variability (HRV) in healthy (n = 34), dysmenorrheic (n = 103), and BPS participants (n = 23) in their luteal phase across a bladder-filling task. Both dysmenorrheic and BPS participants reported increased bladder pain sensitivity when compared to controls (p's < 0.001). Similarly, dysmenorrheic and BPS participants had increased heart rate (p's < 0.01), increased diastolic blood pressure (p's < 0.01), and reduced HRV (p's < 0.05) when compared to controls. Dysmenorrheic participants also exhibited little change in heart rate between maximum bladder capacity and after micturition when compared to controls (p = 0.013). Our findings demonstrate menstrual pain's association with abnormal autonomic activity and bladder sensitivity, even two weeks after menses. Our findings of autonomic dysfunction in both early episodic and chronic visceral pain states points to an urgent need to elucidate the development of such imbalance, perhaps beginning in adolescence.
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http://dx.doi.org/10.1038/s41598-019-38545-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379479PMC
February 2019

Interstitial Cystitis/Bladder Pain Syndrome.

Semin Reprod Med 2018 Mar 19;36(2):123-135. Epub 2018 Dec 19.

Department of Obstetrics and Gynecology, Pritzker School of Medicine, University of Chicago, Evanston, Illinois.

Interstitial cystitis/bladder pain syndrome is an uncommon but potentially devastating pelvic pain disorder affecting both women and men. This condition is often confusable and comorbid with other pelvic pain disorders. Although our understanding of the underlying pathophysiology is growing, the exact longitudinal course by which peripheral and central aberrations involving the bladder mucosa, peripheral inflammation, and central dysregulation of bladder sensitivity create painful bladder symptoms remains an area in need of further study. Only a limited number of drugs have been approved for treatment by the Food and Drug Administration, and overall durable efficacy of the many treatments reviewed in recent American Urological Association guidelines remains suboptimal, making awareness, early diagnosis, and use of effective treatments early in the disease course, where neural changes may still be reversible, imperative.
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http://dx.doi.org/10.1055/s-0038-1676089DOI Listing
March 2018

Abdominal skeletal muscle activity precedes spontaneous menstrual cramping pain in primary dysmenorrhea.

Am J Obstet Gynecol 2018 07 5;219(1):91.e1-91.e7. Epub 2018 May 5.

Department of Obstetrics and Gynecology, NorthShore University HealthSystem and Pritzker School of Medicine, University of Chicago, Evanston IL. Electronic address:

Background: Dysmenorrhea is a pervasive pain condition that affects 20-50% of reproductive-aged women. Distension of a visceral organ, such as the uterus, could elicit a visceromotor reflex, resulting in involuntary skeletal muscle activity and referred pain. Although referred abdominal pain mechanisms can contribute to visceral pain, the role of abdominal muscle activity has not yet been investigated within the context of menstrual pain.

Objective: The goal of this study was to determine whether involuntary abdominal muscle activity precedes spontaneous episodes of menstrual cramping pain in dysmenorrheic women and whether naproxen administration affects abdominal muscle activity.

Study Design: Abdominal electromyography activity was recorded from women with severe dysmenorrhea (n = 38) and healthy controls (n = 10) during menses. Simultaneously, pain was measured in real time using a squeeze bulb or visual analog rheostat. Ninety minutes after naproxen administration, abdominal electromyography activity and menstrual pain were reassessed. As an additional control, women were also recorded off menses, and data were analyzed in relation to random bulb squeezes. Because it is unknown whether mechanisms of menstrual cramps are different in primary or secondary dysmenorrhea/chronic pelvic pain, the relationship between medical history and abdominal muscle activity was examined. To further examine differences in nociceptive mechanisms, pressure pain thresholds were also measured to evaluate changes in widespread pain sensitivity.

Results: Abdominal muscle activity related to random-bulb squeezing was rarely observed in healthy controls on menses (0.9 ± 0.6 episodes/hour) and in dysmenorrhea participants off menses (2.3 ± 0.6 episodes/hour). In dysmenorrheic participants during menses, abdominal muscle activity frequently preceded bulb squeezing indicative of menstrual cramping pain (10.8 ± 3.0 episodes/hour; P < .004). Whereas 45% of the women with dysmenorrhea (17 of 38) had episodes of abdominal muscle activity associated pain, only 13% (5 of 38) had episodes after naproxen (P = .011). Women with the abdominal muscle activity-associated pain were less likely to have a diagnosis for secondary dysmenorrhea or chronic pelvic pain (2 of 17) than women without this pain phenotype (10 of 21; P = .034). Similarly, women with the abdominal muscle activity-associated pain phenotype had less nonmenstrual pain days per month (0.6 ± 0.5) than women without the phenotype (12.4 ± 0.3; P = .002). Women with abdominal muscle activity-associated pain had pressure pain thresholds (22.4 ± 3.0 N) comparable with healthy controls (22.2 ± 3.0 N; P = .967). In contrast, women without abdominal muscle activity-associated pain had lower pressure pain thresholds (16.1 ± 1.9 N; P = .039).

Conclusion: Abdominal muscle activity may contribute to cramping pain in primary dysmenorrhea but is resolvable with naproxen. Dysmenorrheic patients without cramp-associated abdominal muscle activity exhibit widespread pain sensitivity (lower pressure pain thresholds) and are more likely to also have a chronic pain diagnosis, suggesting their cramps are linked to changes in central pain processes. This preliminary study suggests new tools to phenotype menstrual pain and supports the hypothesis that multiple distinct mechanisms may contribute to dysmenorrhea.
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http://dx.doi.org/10.1016/j.ajog.2018.04.050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6741772PMC
July 2018

Identification of experimental bladder sensitivity among dysmenorrhea sufferers.

Am J Obstet Gynecol 2018 07 25;219(1):84.e1-84.e8. Epub 2018 Apr 25.

Department of Obstetrics/Gynecology, NorthShore University HealthSystem, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL. Electronic address: https://www.thegyrl.org.

Background: Dysmenorrhea is a common risk factor for chronic pain conditions including bladder pain syndrome. Few studies have formally evaluated asymptomatic bladder pain sensitivity in dysmenorrhea, and whether this largely reflects excess pelvic symptom reporting due to comorbid psychological dysfunction.

Objective: We sought to determine whether bladder hypersensitivity is more common among women reporting moderate or greater dysmenorrhea, without chronic pain elsewhere, after accounting for anxiety and depression. Demonstrating this would suggest that dysmenorrhea might be an early clue for visceral or widespread pain hypersensitivity and improve understanding of potential precursors to bladder pain syndrome.

Study Design: We compared cohorts of regularly menstruating women, without symptoms of chronic pain elsewhere, reporting (1) moderate-to-severe dysmenorrhea (n = 98) and (2) low levels or no menstrual pain (n = 35). Participants underwent rapid bladder filling following a standard water ingestion protocol, serially rating bladder pain and relative urgency during subsequent distension. Potential differences in bladder volumes were controlled for by sonographic measurement at standard cystometric thresholds. Bladder sensitivity was also measured with complementary measures at other times separately including a simplified rapid filling test, palpation of the bladder wall, and through ambulatory self-report. Anxiety and depression were evaluated with the National Institutes of Health Patient-Reported Outcomes Measurement Information System measures.

Results: Women with moderate-to-severe dysmenorrhea reported more urinary symptoms than controls and had a lower maximum capacity (498 ± 18 mL vs 619 ± 34 mL, P < .001) and more evoked bladder filling pain (0-100 visual analog scale: 25 ± 3 vs 12 ± 3, P < .001). The dysmenorrhea-bladder capacity relationship remained significant irrespective of menstrual pain severity, anxiety, depression, or bladder pain (R = 0.13, P = .006). Severity of menstrual pain predicted evoked bladder pain (R = 0.10, P = .008) independent of anxiety (P = .21) and depression (P = .21). Women with moderate-to-severe dysmenorrhea exhibiting provoked bladder pain (24/98, 24%) also reported higher pain during the screening rapid bladder test (P < .001), in response to transvaginal bladder palpation (P < .015), and on prospective daily diaries (P < .001) than women with dysmenorrhea without provoked bladder pain.

Conclusion: Women experiencing moderate-to-severe dysmenorrhea also harbor a higher pain response to naturally evoked bladder distension. Noninvasive bladder provocation needs to be tested further longitudinally in those with dysmenorrhea to characterize the course of visceral sensitivity and determine if it may help predict individuals at risk for developing subsequent pain in the bladder or elsewhere.
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http://dx.doi.org/10.1016/j.ajog.2018.04.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6054462PMC
July 2018

Somatic symptoms in women with dysmenorrhea and noncyclic pelvic pain.

Arch Womens Ment Health 2018 10 10;21(5):533-541. Epub 2018 Mar 10.

Pritzker School of Medicine, University of Chicago, Chicago, IL, USA.

Somatic symptoms are a robust, transdiagnostic risk factor for pain conditions. However, the extent to which somatic symptoms contribute to the manifestation of the women's pain syndromes, such as dysmenorrhea and noncyclic pelvic pain (NCPP), is unclear due to high rates of co-occurrence. Therefore, the present study investigated the primary hypothesis that somatic symptoms would be elevated in NCPP and distinctly influence the relationship between dysmenorrhea and co-occurring NCPP. A secondary analysis was performed on cross-sectional questionnaire data from 1012 nonpregnant reproductive-aged women. Eligible analyzed participants (n = 834) were categorized into four groups: healthy, dysmenorrhea, NCPP, and NCPP with co-occurring dysmenorrhea (NCPP+dysmenorrhea). A parallel mediation analysis was run to evaluate the primary hypothesis that somatic symptoms are the primary factor associated with increased NCPP accounting for dysmenorrhea. The NCPP+dysmenorrhea group had higher somatic, anxiety, and depression symptom T-scores (respectively 61, 61, 60) compared to the healthy controls (46, 51, 51; p's < .001) and the dysmenorrhea group (50, 53, 54; p's < .001). The pain and psychological symptoms were significantly correlated across the entire sample (r's = .29, - .64, p's < .01). Results from parallel mediation analysis showed that somatic symptoms were distinctly associated with NCPP+dysmenorrhea. Women with NCPP+dysmenorrhea have increased psychological and somatic symptoms compared to women with dysmenorrhea alone. Given that NCPP often co-occurs with dysmenorrhea, failure to account for comorbidity in previous studies has likely led to an overestimation of psychological symptoms in dysmenorrhea. Future studies should evaluate whether somatic sensitivity is a modifiable risk factor for NCPP.
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http://dx.doi.org/10.1007/s00737-018-0823-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6126970PMC
October 2018

Cine MRI during spontaneous cramps in women with menstrual pain.

Am J Obstet Gynecol 2018 05 2;218(5):506.e1-506.e8. Epub 2018 Feb 2.

Department of Radiology, Northshore University HealthSystem, Evanston, IL; Department of Radiology, Pritzker School of Medicine, University of Chicago, Chicago, IL.

Background: The lack of noninvasive methods to study dysmenorrhea has resulted in poor understanding of the mechanisms underlying pain, insufficient diagnostic tests, and limited treatment options. To address this knowledge gap, we have developed a magnetic resonance imaging-based strategy for continuously monitoring the uterus in relationship to participants' spontaneous pain perception.

Objective: The study objective was to evaluate whether magnetic resonance imaging can detect real-time changes in myometrial activity during cramping episodes in women with dysmenorrhea, with a handheld squeeze bulb for pain reporting.

Study Design: Sixteen women with dysmenorrhea and 10 healthy control women both on and off their menses were evaluated with magnetic resonance imaging while not taking analgesic medication. Continuous magnetic resonance imaging was acquired using half-Fourier acquisition single-shot turbo spin echo sequence along with simultaneous reporting of pain severity with a squeeze bulb. Pearson's coefficient was used to compare results between reviewers. Proportional differences between women with dysmenorrhea and controls on/off menses were evaluated with a Fisher exact test. The temporal relationships between signal changes were evaluated with Monte Carlo simulations.

Results: Spontaneous progressive decreases in myometrial signal intensity were more frequently observed in women on their menses than in the absence of pain in the same women off their menses or participants without dysmenorrhea (P < .01). Women without reductions in myometrial signal intensity on their menses either had a history of endometriosis or were not in pain. Observations of myometrial events were consistently reported between 2 raters blinded to menstrual pain or day status (r = 0.97, P < .001). Episodes of cramping occurred either immediately before or 32-70 seconds after myometrial signal change onset (P < .05).

Conclusion: Transient decreases in myometrial uterine T2-weighted signal intensity can be reliably measured in women with menstrual pain. The directionality of signal change and temporal relationship to pain onset suggest that cramping pain may be caused by a combination of uterine pressure and hemodynamic dysfunction.
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http://dx.doi.org/10.1016/j.ajog.2018.01.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916049PMC
May 2018

Nonsteroidal antiinflammatory drug resistance in dysmenorrhea: epidemiology, causes, and treatment.

Am J Obstet Gynecol 2018 04 6;218(4):390-400. Epub 2017 Sep 6.

Department of Obstetrics and Gynecology, NorthShore University HealthSystem and Pritzker School of Medicine University of Chicago, Evanston, IL. Electronic address:

Although nonsteroidal antiinflammatory drugs can alleviate menstrual pain, about 18% of women with dysmenorrhea are unresponsive, leaving them and their physicians to pursue less well-studied strategies. The goal of this review is to provide a background for treating menstrual pain when first-line options fail. Research on menstrual pain and failure of similar drugs in the antiplatelet category suggested potential mechanisms underlying nonsteroidal antiinflammatory drug resistance. Based on these mechanisms, alternative options may be helpful for refractory cases. This review also identifies key pathways in need of further study to optimize menstrual pain treatment.
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http://dx.doi.org/10.1016/j.ajog.2017.08.108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5839921PMC
April 2018

The Effects of Platelet-Activating Factor on Uterine Contractility, Perfusion, Hypoxia, and Pain in Mice.

Reprod Sci 2018 03 20;25(3):384-394. Epub 2017 Jun 20.

1 Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, IL, USA.

It is widely hypothesized that menstrual pain is triggered by prostaglandin synthesis that evokes high-pressure uterine contractions and ischemia. However, the effects of molecules implicated in menstrual pain on uterine contractility, perfusion, and oxygenation in vivo have been rarely demonstrated. Studies in women that do not respond to nonsteroidal anti-inflammatory drugs (NSAIDs) have reported elevated levels of platelet-activating factor (PAF). To establish in vivo evidence of PAF's capability to impair uterine homeostasis and to elicit visceral pain, we examined the effects of the PAF receptor agonist (carbamyl PAF [CPAF]) in comparison to other molecules hypothesized to play a role in uterine pain in mice. Uterine pressure was increased by oxytocin, prostaglandin F2α (PGF2α), and CPAF. Even in the absence of inflammatory molecules, uterine contractions reduced uterine oxygenation by 38%. CPAF reduced uterine perfusion by 40% ± 8% and elicited further oxygen desaturation approaching hypoxia (9.4 ± 3.4 mm Hg Pao). Intraperitoneal injections of CPAF and PGF2α evoked visceral pain and pelvic hyperalgesia in awake wild-type mice. However, pain was not observed in identically injected PAF-receptor knockout mice. Thus, our model provides a demonstration that a molecule implicated in NSAID-resistant dysmenorrhea has a detrimental effect on uterine homeostasis and is capable of causing visceral pain. Our results support the general hypothesis that menstrual cramps are caused by uterine contractions, impaired perfusion, and reduced oxygenation. Since this study was limited to mice, confirmation of these results in humans would be valuable for development of novel therapeutics targeted at inflammatory precursors, contractility, perfusion, and tissue oxygenation.
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http://dx.doi.org/10.1177/1933719117715122DOI Listing
March 2018

Non-opioid pain management in benign minimally invasive hysterectomy: A systematic review.

Am J Obstet Gynecol 2017 06 30;216(6):557-567. Epub 2016 Dec 30.

Department of Obstetrics and Gynecology, University of Michigan Women's Hospital, Ann Arbor, MI.

Background: Less postoperative pain typically is associated with a minimally invasive hysterectomy compared with a laparotomy approach; however, poor pain control can still be an issue. Multiple guidelines exist for managing postoperative pain, yet most are not specialty-specific and are based on procedures that bear little relevance to a minimally invasive hysterectomy.

Objective: The purpose of this study was to determine whether there is enough quality evidence within the benign gynecology literature to make non-opioid pain control recommendations for women who undergo a benign minimally invasive hysterectomy.

Study Appraisal And Synthesis Methods: We queried PubMed, ClinicalTrials.gov, and Cochrane databases using MeSH terms: "postoperative pain," "perioperative pain," "postoperative analgesia," "pain management," "pain control," "minimally invasive gynecologic surgery," and "hysterectomy." A manual examination of references from identified studies was also performed. All PubMed published studies that involved minimally invasive hysterectomies through November 9, 2016, were included. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were restricted to benign minimally invasive hysterectomies evaluating non-opioid pharmacologic therapies. Primary outcomes included amount of postoperative analgesics consumed and postoperative pain scores. Two reviewers independently completed an in-depth evaluation of each study for characteristics and results using an established database, according to inclusion/exclusion criteria. A risk assessment was performed, and a quality rating was assigned with the use of the Cochrane Collaboration's Grades of Recommendation, Assessment, Development and Evaluation approach.

Results: Initially 1155 studies were identified, and 24 studies met all inclusion criteria. Based on limited data of varying quality, intravenous acetaminophen, anticonvulsants and dexamethasone demonstrate opioid-sparing benefits; ketorolac shows mixed results in laparoscopic hysterectomies. Paracervical blocks provide pain-reducing benefits in vaginal hysterectomies.

Conclusions: Convincing conclusions are difficult to draw because of the heterogeneous and contradictory nature of the literature. There is a clear need for more high-quality research that will evaluate each medication type for posthysterectomy pain control.
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http://dx.doi.org/10.1016/j.ajog.2016.12.175DOI Listing
June 2017

Reply.

Am J Obstet Gynecol 2016 07 2;215(1):132-3. Epub 2016 Mar 2.

Department of Obstetrics and Gynecology, Division of Gynecological Pain and Minimally Invasive Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, Suite 1530, Evanston, IL 60201. Electronic address:

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http://dx.doi.org/10.1016/j.ajog.2016.02.051DOI Listing
July 2016

Altered brain connectivity in dysmenorrhea: pain modulation and the motor cortex.

Pain 2016 Jan;157(1):5-6

Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, IL, USA The Pritzker School of Medicine, University of Chicago, Chicago, IL, USA.

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http://dx.doi.org/10.1097/j.pain.0000000000000364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4941100PMC
January 2016

Multimodal nociceptive mechanisms underlying chronic pelvic pain.

Am J Obstet Gynecol 2015 Dec 20;213(6):827.e1-9. Epub 2015 Aug 20.

Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, IL; Department of Obstetrics and Gynecology, Pritzker School of Medicine, University of Chicago, Chicago, IL. Electronic address:

Objective: We sought to evaluate candidate mechanisms underlying the pelvic floor dysfunction in women with chronic pelvic pain (CPP) and/or painful bladder syndrome (PBS)/interstitial cystitis. Notably, prior studies have not consistently controlled for potential confounding by psychological or anatomical factors.

Study Design: As part of a larger study on pelvic floor pain dysfunction and bladder pain sensitivity, we compared a measure of mechanical pain sensitivity, pressure pain thresholds (PPTs), between women with pelvic pain and pain-free controls. We also assessed a novel pain measure using degree and duration of postexam pain aftersensation, and conducted structural and functional assessments of the pelvic floor to account for any potential confounding. Phenotypic specificity of pelvic floor measures was assessed with receiver operator characteristic curves adjusted for prevalence.

Results: A total of 23 women with CPP, 23 women with PBS, and 42 pain-free controls completed the study. Women with CPP or PBS exhibited enhanced pain sensitivity with lower PPTs (1.18 [interquartile range, 0.87-1.41] kg/cm(2)) than pain-free participants (1.48 [1.11-1.76] kg/cm(2); P < .001) and prolonged pain aftersensation (3.5 [0-9] vs 0 [0-1] minutes; P < .001). Although genital hiatus (P < .01) was wider in women with CPP there were no consistently observed group differences in pelvic floor anatomy, muscle tone, or strength. The combination of PPTs and aftersensation duration correlated with severity of pelvic floor tenderness (R(2), 41-51; P < .01). Even after adjustment for prevalence, the combined metrics discriminated pain-free controls from women with CPP or PBS (area under the curve, 0.87).

Conclusion: Both experimental assessment of pelvic floor pain thresholds and measurement of sustained pain are independently associated with pelvic pain phenotypes. These findings suggest systematic clinical assessment of the time course of provoked pain symptoms, which occurs over seconds for mechanical pain thresholds vs minutes for aftersensation pain, would be helpful in identifying the fundamental mechanisms of pelvic floor pain. Longitudinal studies of therapies differentially targeting these discrete mechanisms are needed to confirm their clinical significance.
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http://dx.doi.org/10.1016/j.ajog.2015.08.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4711364PMC
December 2015

Power morcellators: a review of current practice and assessment of risk.

Am J Obstet Gynecol 2015 Jan 26;212(1):18-23. Epub 2014 Jul 26.

Department of Obstetrics and Gynecology, Mayo Clinic, Scottsdale, AZ.

Power morcellation has come under scrutiny because of a highly publicized case of disseminated leiomyosarcoma following a laparoscopic hysterectomy. A recent Federal and Drug Administration safety communication discouraging use of power morcellators on presumed uterine leiomyoma further highlights the need for reexamination of uterine tissue extraction. This clinical opinion aims to summarize current approaches to uterine/fibroid tissue extraction including the associated immediate and long-term potential risks of open power morcellation. The known data about risk of uterine sarcoma is reviewed followed by a discussion of acceptable risk and informed consent in the context of shared-decision making.
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http://dx.doi.org/10.1016/j.ajog.2014.07.046DOI Listing
January 2015

The influence of prior oral contraceptive use on risk of endometriosis is conditional on parity.

Fertil Steril 2014 Jun 22;101(6):1697-704. Epub 2014 Mar 22.

School of Human Movement Studies, University of Queensland, St. Lucia, Queensland, Australia.

Objective: To estimate the influence of prior oral contraceptive pill (OCP) use on future diagnosis of endometriosis in young women.

Design: Prospective cohort study, the Australian Longitudinal Study on Women's Health.

Setting: Community-based sample.

Patient(s): 9,585 women age 18-23 at study onset.

Intervention(s): None.

Main Outcome Measure(s): Risk of self-reported endometriosis estimated with Cox proportional-hazards regression with time-dependent covariates.

Result(s): Compared with never users, endometriosis hazard ratios in nulliparous women with <5 years and ≥ 5 years of OCP use (preceding diagnosis) were 1.8 (95% CI, 1.30-2.53) and 2.3 (95% CI, 1.59-3.40), respectively. Similar risk was seen in both women reporting infertility and unsure fertility. In parous women with <5 years of use, the hazard ratio for endometriosis was 0.41 (95% CI, 0.15-0.56) and for ≥ 5 years of use was 0.45 (95% CI, 0.16-1.23). Women reporting early noncontraceptive OCP use had a twofold higher risk (odds ratio 2.07; 95% CI, 1.72-2.51).

Conclusion(s): Prior OCP exposure reduces the risk of diagnosis of endometriosis in parous women but increases it among nulliparous women; these associations appear unaffected by fertility status. An increased risk of endometriosis diagnosis seen in women reporting early noncontraceptive OCP use may explain some of the positive OCP risk seen in nulliparous women.
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http://dx.doi.org/10.1016/j.fertnstert.2014.02.014DOI Listing
June 2014

Increased pressure pain sensitivity in women with chronic pelvic pain.

Obstet Gynecol 2013 Nov;122(5):1047-1055

Departments of Obstetrics and Gynecology, Anesthesiology, and Internal Medicine (Rheumatology), University of Michigan Health Center, Ann Arbor, Michigan; and the Department of Obstetrics and Gynecology, Northshore University Health System, Chicago, Illinois.

Objective: To determine whether women with chronic pelvic pain and variable degrees of endometriosis demonstrate altered pain sensitivity relative to pain-free healthy women in a control group and whether such differences are related to the presence or severity of endometriosis or comorbid pain syndromes.

Methods: Four patient subgroups (endometriosis with chronic pelvic pain [n=42], endometriosis with dysmenorrhea [n=15], pain-free endometriosis [n=35], and chronic pelvic pain without endometriosis [n=22]) were each compared with 30 healthy women in a control group in this cross-sectional study. All patients completed validated questionnaires regarding pain symptoms and underwent screening for comorbid pain disorders. Pain sensitivity was assessed by applying discrete pressure stimuli to the thumbnail using a previously validated protocol.

Results: While adjusting for age and education, pain thresholds were lower in all subgroups of women with pelvic pain relative to healthy women in the control group (all P values <.01). There was no difference in pain thresholds when comparing patients with endometriosis without pelvic pain with healthy women in the control group (mean difference 0.02 kg/m2, 95% confidence interval -0.43 to 0.47). The presence and severity of endometriosis and number of comorbid pain syndromes were not associated with a difference in pain thresholds.

Conclusion: Women with chronic pelvic pain demonstrate increased pain sensitivity at a nonpelvic site compared with healthy women in a control group, which is independent of the presence or severity of endometriosis or comorbid pain syndromes. These findings support the notion that central pain amplification may play a role in the development of pelvic pain and may explain why some women with pelvic pain do not respond to therapies aimed at eliminating endometriosis lesions.

Level Of Evidence: II.
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http://dx.doi.org/10.1097/AOG.0b013e3182a7e1f5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3897295PMC
November 2013

Deliberate practice improves obstetrics and gynecology residents' hysteroscopy skills.

J Grad Med Educ 2012 Sep;4(3):329-34

Introduction: Development of surgical skills is an integral component of residency education in obstetrics and gynecology.

Objective: We report data from a supervised, deliberate, dry lab practice in hysteroscopy for junior obstetrics-gynecology residents, undertaken to evaluate whether simulation training improved hysteroscopy performance to a skill level similar to that of senior residents.

Methods: A prospective, comparative, multicenter trial compared Objective Structured Assessment Of Technical Skills (OSATS) performance of 2 groups: 19 postgraduate year (PGY)-1 and PGY-2 and 18 PGY-3 and PGY-4 Ob-Gyn residents. PGY-1 and PGY-2 participants underwent 4 sessions of brief, deliberate, focused training in hysteroscope assembly and operative hysteroscopic polypectomy using uterine models. Subsequently, all participants completed a simulated hysteroscopic polypectomy OSATS, and procedure times and structured assessment scores were compared among groups.

Results: PGY-1 and PGY-2 residents who had completed OSATS training performed at or above the level of untrained PGY-3 and PGY-4 residents. Junior residents had better assembly times and scores, resection scores, and global skills scores (P < .05). Resection times did not differ between groups but differed among institutions.

Discussion: Brief, hands-on training sessions, which were task-specific and repetitive facilitated short-term gains in learning operative hysteroscopy and increased the dry lab skill level of junior residents compared to that of senior residents. This curriculum was effectively implemented at 3 institutions and generated comparable results, suggesting generalizability.
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http://dx.doi.org/10.4300/JGME-D-11-00077.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444186PMC
September 2012

The association of dysmenorrhea with noncyclic pelvic pain accounting for psychological factors.

Am J Obstet Gynecol 2013 Nov 22;209(5):422.e1-422.e10. Epub 2013 Aug 22.

Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, IL.

Objective: The factors that underlie pelvic pain are poorly understood. Specifically, the relative influence of dysmenorrhea and psychological factors in the etiology of noncyclic pelvic pain conditions, such as interstitial cystitis and irritable bowel syndrome, is unknown. To further characterize pelvic pain, we compared the frequency of menstrual, somatosensory, and psychological risk factors between women with and without severe noncyclic pelvic pain symptoms.

Study Design: A total of 1012 reproductive-aged women completed a 112-item questionnaire with domains including mood, fatigue, physical activity, somatic complaint, and pain. Questionnaire items included existing items for menstrual distress and newly written items derived from qualitative interviews. The relationship of dysmenorrhea and noncyclic pelvic pain complaints (dyspareunia, dyschezia, or dysuria) was modeled using quantile regression.

Results: Among women who menstruate regularly, those with dysmenorrhea had disproportionally more severe noncyclic pelvic pain (54/402, 13%) than women without dysmenorrhea (5/432, 1%; odds ratio, 13; 95% confidence interval, 5-33). In a multivariate-adjusted model, dysmenorrhea (β = .17), activity capability (β = .17), somatic complaint (β = .17), and bodily pain (β = .12) were the primary predictors of noncyclic pelvic pain. Depression (β = .03) and anxiety (β = .01) were not significantly predictive. The presence of dysmenorrhea, somatic complaint, and low activity capability predicted 90% of the cases of women with noncyclic pelvic pain.

Conclusion: The association between dysmenorrhea and noncyclic pelvic pain suggests that menstrual pain is an etiological factor in noncyclic pelvic pain, whereas depression and anxiety may be secondary effects. Longitudinal studies are needed to determine whether dysmenorrhea causally influences development of noncyclic pelvic pain or shares common underlying neural mechanisms.
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http://dx.doi.org/10.1016/j.ajog.2013.08.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4191839PMC
November 2013

A noninvasive bladder sensory test supports a role for dysmenorrhea increasing bladder noxious mechanosensitivity.

Clin J Pain 2013 Oct;29(10):883-90

*Department of Obstetrics and Gynecology, NorthShore University HealthSystem †Department of Obstetrics and Gynecology, Pritzker School of Medicine, University of Chicago, Chicago, IL.

Objective: Catheterization to measure bladder sensitivity is aversive and hinders human participation in visceral sensory research. Therefore, we sought to characterize the reliability of sonographically estimated female bladder sensory thresholds. To demonstrate this technique's usefulness, we examined the effects of self-reported dysmenorrhea on bladder pain thresholds.

Methods: Bladder sensory threshold volumes were determined during provoked natural diuresis in 49 healthy women (mean age, 24±8 y) using 3-dimensional ultrasound. Cystometric thresholds (Vfs, first sensation; Vfu, first urge; Vmt, maximum tolerance) were quantified and related to bladder urgency and pain. We estimated the reliability (1-wk retest and interrater). Self-reported menstrual pain was examined in relationship to bladder pain, urgency, and volume thresholds.

Results: Average bladder sensory thresholds (mL) were Vfs (160±100), Vfu (310±130), and Vmt (500±180). Interrater reliability ranged from 0.97 to 0.99. One-week retest reliability was Vmt=0.76 (95% CI, 0.64-0.88), Vfs=0.62 (95% CI, 0.44-0.80), and Vfu=0.63 (95% CI, 0.47-0.80). Bladder filling rate correlated with all thresholds (r=0.53 to 0.64, P<0.0001). Women with moderate to severe dysmenorrhea pain had increased bladder pain and urgency at Vfs and increased pain at Vfu (P's<0.05). In contrast, dysmenorrhea pain was unrelated to bladder capacity.

Discussion: Sonographic estimates of bladder sensory thresholds were reproducible and reliable. In these healthy volunteers, dysmenorrhea was associated with increased bladder pain and urgency during filling but unrelated to capacity. Plausibly, women with dysmenorrhea may exhibit enhanced visceral mechanosensitivity, increasing their risk to develop chronic bladder pain syndromes.
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http://dx.doi.org/10.1097/AJP.0b013e31827a71a3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644544PMC
October 2013

Gynecologic management of neuropathic pain.

Am J Obstet Gynecol 2011 Nov 12;205(5):435-43. Epub 2011 May 12.

Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, IL, USA.

Obstetrician/gynecologists often are the initial management clinicians for pelvic neuropathic pain. Although treatment may require comprehensive team management and consultation with other specialists, there are a few critical and basic steps that can be performed during an office visit that offer the opportunity to improve quality of life significantly in this patient population. A key first step is a thorough clinical examination to map the pain site physically and to identify potentially involved nerves. Only limited evidence exists about how best to manage neuropathic pain; generally, a combination of surgical, manipulative, or pharmacologic methods should be considered. Experimental methods to characterize more precisely the nature of the nerve dysfunction exist to diagnose and treat neuropathic pain; however, additional scientific evidence is needed to recommend these options unanimously. In the meantime, an approach that was adopted from guidelines of the International Association for the Study of Pain has been tailored for gynecologic pain.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3205239PMC
http://dx.doi.org/10.1016/j.ajog.2011.05.011DOI Listing
November 2011

Pelvic floor muscle examination in female chronic pelvic pain.

J Reprod Med 2011 Mar-Apr;56(3-4):117-22

Rehabilitation Institute of Chicago, Chicago, Illinois 60611, USA.

Objective: To determine if women with self-reported chronic pelvic pain (CPP) were more likely to have positive findings on two vaginal pelvic floor muscle (PFM) tests compared to women without CPP when the examiner was blinded to pain status.

Study Design: This was a prospective, cross-sectional study. Blinded examiners performed two vaginal pelvic floor tests (tenderness and strength) on 48 participants: 19 with self-reported CPP and 29 who were pain-free. Relative frequency of positive findings between groups and the total number of positive physical examination findings were calculated.

Results: Women with self-reported CPP were more likely to have PFM tenderness (63.2% with physician [M.D.] examiners [board certified in physical medicine and rehabilitation] and 73.7% with physical therapist [P.T.] examiners) as compared to pain-free participants (Fisher's exact test [FET]), 48 p < 0.001 with M.D., p < 0.001 with P.T.). PFM weakness was not more likely in women with CPP (31.6% with M.D., 42.1% with P.T.) as compared with pain-free participants (48.3% with M.D., 17.2% with P.T.) (FET, 48 p = 0.37 with M.D., p = 0.096 with P.T.).

Conclusion: PFM tenderness is found more frequently in women with self-reported CPP than in pain-free women. PFM strength did not differentiate CPP from pain-free participants. Improved standardization of the PFM examination across disciplines may be helpful in distinguishing subgroups and treating women with CPP.
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May 2011

Promises and pitfalls of the AAGL LISTSERV: a descriptive analysis.

J Minim Invasive Gynecol 2010 Jul-Aug;17(4):407-10

Washington Hospital Center, Washington, DC, USA.

The objectives of this retrospective database review were to describe and quantify the information contained in the Issues in Endoscopy LISTSERV database and to determine the sensitivity and specificity of the LISTSERV search engine for common topics in minimally invasive gynecology. All LISTSERV entries from January 1 to December 31, 2008, were reviewed for 30 commonly discussed minimally invasive gynecology topics. Each entry was categorized by primary topic(s), and the database was used to search for terms related to total laparoscopic hysterectomy and endometrial ablation. The search engine sensitivity and specificity were calculated for both topics. In 2008, 812 entries were recorded from at least 27 countries. The most frequently discussed topics were hysterectomy and endometrial ablation. Approximately 10% of posts cited literature. The term "TLH" had 69.2% sensitivity and 97.2% specificity for identifying posts in which the subject was total laparoscopic hysterectomy. The addition of the term "total lap hysterectomy" increased the sensitivity to 90.4%. Additional terms led to minimal improvements in sensitivity. A second search using the term "endometrial ablation" yielded sensitivity and specificity of 68.1% and 96.7%, respectively. The addition of the search terms "NovaSure" and "ThermaChoice" changed the sensitivity to 90.4%, and specificity to 95.7%. Although the sensitivity and specificity of the search engine is reasonable for commonly used terms, the use of nontraditional medical terms and abbreviations limits the utility of the LISTSERV database for research. The presence of more than 800 posts in 2008 suggests that surgeons worldwide frequent the forum to discuss various topics. However, minor changes such as the addition of a topic selection menu for entry submission may improve the accuracy of the database search engine. Standardized post hoc filtering of the database at regular intervals may be preferable to substantially altering the current user-friendly entry format.
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http://dx.doi.org/10.1016/j.jmig.2010.03.008DOI Listing
September 2010
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