PELVIC PAIN Vol. 21 No. 2 | Winter 2019

a RANZCOG publication The College 5 From the President Vijay Roach Vol. 21 No. 2 Winter 2019 9 From the CEO O&G Magazine Advisory Group Vase Jovanoska Dr John Schibeci Chair and Diplomates Rep, NSW Dr Sue Belgrave Fellows Rep, New Zealand 15 Leaders in focus Dr Brett Daniels Fellows Rep, TAS Kirsten Connan Dr Jenny Dowd Fellows Rep, VIC Dr Marilla Druitt Fellows Rep, VIC Dr Fiona Langdon Young Fellows Rep, WA Pelvic Pain Dr William Milford Fellows Rep, QLD Dr Alyce Wilson Trainees Rep, VIC 19 Editorial Marilla Druitt O&G Magazine Editor Sarah Ortenzio Lisa Westhaven 20 Unlocking the aetiology of endometriosis Grant W Montgomery Layout and Production Editor Sarah Ortenzio 22 What else could it be? Causes of pelvic pain Designer Sumi Saha Shay Colley Whitehart 24 Core outcome sets for endometriosis Editorial Communications O&G Magazine Advisory Group Amanda J Poprzeczny RANZCOG 254–260 Albert Street 26 Scope of medical imaging for pelvic pain East Melbourne, VIC 3002 Australia (t) +61 3 9417 1699 Kate Stone (e) [email protected]

Advertising Sales 29 Managing pelvic pain in adolescents Bill Minnis Natalie Drever and Sarah Peek Minnis Journals (t) +61 3 9836 2808 (e) [email protected] 32 Linking subfertility with endometriosis Jennifer Pontré Printer Southern Colour 35 A pragmatic approach to surgical management (t) +61 3 8796 7000 of endometriosis O&G Magazine authorised by Ms Vase Jovanoska Jason Abbott © 2019 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). All rights reserved. No part of this 37 Interventional management options publication may be reproduced or copied in Jason Chow any form or by any means without the written permission of the publisher. The submission of articles, news items and letters is encouraged. 40 Hormonal management of endometriosis For further information about contributing to Estelle Blair-Holt, Roni Ratner, Jim Tsaltas and Luk Rombauts O&G Magazine visit: ogmagazine.org.au.

The statements and opinions expressed in articles, 43 All in their mind? The stigma of pain letters and advertisements in O&G Magazine are Christina Bryant and Arthur Stabolidis those of the authors and, unless specifically stated, are not necessarily the views of RANZCOG. 45 Physio? But I’ve got endometriosis! Although all advertising material is expected to conform to ethical and legal standards, acceptance Emma Kirkaldy does not imply endorsement by the College. 48 Multidisciplinary team management of chronic pelvic pain ISSN 1442-5319 Jessica Mills and Karen Joseph Cover photo ©photoBeard 51 Mater Mother’s Hospital: acute management of RANZCOG Regional Committees persistent pelvic pain New Zealand Dr Celia Devenish Chair Thea Bowler, Michael Wynn-Williams, Susan Evans, Jane Cumming Manager Jayne Berryman and Natalie Kiel Level 6 Featherston Tower 23 Waring Taylor Street/ PO Box 10611 Wellington 6011, New Zealand 54 Does endometriosis really cause pain? (t) +64 4 472 4608 (f) +64 4 472 4609 Thierry G Vancaillie (e) [email protected] Australian Capital Territory 56 To ‘scope or not to ‘scope, that is the question Dr John Hehir Chair Victoria Peisley Executive Officer Sonia R Grover 4/14 Napier Close, Deakin, ACT 2600 (e) [email protected] 58 The Pelvic Pain Foundation of Australia New South Wales Susan Evans A/Prof Gregory Jenkins Chair Lee Dawson Executive Officer 60 A new paradigm, science and learning opportunities Suite 2, Ground Floor, 69 Christie Street Meredith Craigie St Leonards, NSW 2065 (t) +61 2 9436 1688 (f) +61 2 9436 4166 (e) [email protected] Women’s health Queensland 62 Q&A: What should I tell my patients about Dr William Milford Chair monitoring their baby’s movements? Sylvia Williamson Executive Officer Jenny Dowd Suite 2, Level 2, 56 Little Edward Street, Spring Hill, Qld 4000 (t) +61 7 3252 3073 64 Case report: The local effects of fertility tourism (e) [email protected]

Vidhu Krishnan and Raiyomand Dalal South Australia/Northern Territory Dr Amita Singla Chair 66 An underdiagnosed cause of infertility: isthmocele Tania Back Executive Officer First floor, 213 Greenhill Road Philippa Walker and VP Singh Eastwood, SA 5063 (t) +61 8 8274 3735 (f) +61 8 8271 5886 (e) [email protected] 69 ANZJOG: From the Editor’s Desk Caroline de Costa Tasmania Dr Lindsay Edwards Chair Hayley Muir Executive Officer 72 Dr Andrew Browning: a man with a mission College House 254–260 Albert Street RANZCOG East Melbourne, Vic 3002 (t) +61 3 9412 2987 (e) [email protected] 74 A new standard: developing O&G care in the Solomon Islands Victoria Rebecca Mitchell Dr Charlotte Elder Chair Hayley Muir Executive Officer College House The College 254–260 Albert Street East Melbourne, Vic 3002 61 Notice of deceased Fellows (t) +61 3 9412 2987 (e) [email protected] 77 Letters to the Editor Western Australia Polly Weston and Rosemary Anne Jones Dr Robyn Leake Chair Carly Moorfield Executive Officer 34 Harrogate Street, 78 Provincial Fellows Practice Visits in Australia West Leederville, WA 6007 Ian Pettigrew (t) +61 8 9381 4491 (f) +61 3 9419 0672 (e) [email protected]

80 College Statements update March 2019 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists College House 254–260 Albert Street East Melbourne, Vic 3002 (t) +61 3 9417 1699 (f) +61 3 9417 0672 (e) [email protected] (w) www.ranzcog.edu.au

Vol. 21 No. 2 Winter 2019 | 3 THE COLLEGE From thePresident competent, respectful andreflective leadership. confident that, in feel very Vase, wehavestrong, advice andfeedbackfrom staff andmembers.I spend timewitheachBoardmember andhassought willing tolisten.Vase hasmadeahugeeffortto from staff andRANZCOG membersisthat Vase is hit theground runningandtheconsistentfeedback positiveimpactat theCollege.She’s made avery Your RANZCOG CEO, Vase Jovanoska,hasalready to ourdiscussions. that shewillbringafresh andinsightfulperspective Gynaecology MBSReviewCommittees.Iamsure consumer representative ontheObstetricsand expertise inthecorporate sectorandwasthe Julie Hamblin.isalawyerwithconsiderable by newlyappointedRANZCOG Boardobserver, and variedscientificprogram. We willbejoined Christchurch andlearningfrom aninteresting in NewZealand, reflecting ontheeventsin forward tospendingtimewithourcolleagues Zealand ASMinHamiltonMay. We’re looking Your RANZCOG Boardwillbeattending theNew agreed toChairthecommittee. endometriosis expert,Prof JasonAbbott,has I ampleasedthat internationally recognised and thiswillprovide ausefulreference point. Zealand hasrecently released theirguidelines, guidelines forendometriosismanagement.New Commonwealth granttodevelopcountry-specific a leadingrole inAustralia,havingreceived a of thiscomplexdisease.RANZCOG istaking clinical assessment,investigation andmanagement in patients. Infarmore modernparlance,ourauthors scientists andourassessmentmanagementof expectations andhowtheyinfluence doctorsand to reflect ontheimpact of socialmores and bear children. It’sinteresting, andimportant, biological destiny, that is,becomepregnant and was attributed toawoman’sfailure tofulfilher about women’sillnesses,thepainandsuffering or suffocation of thewomb’. pain duringmenseswasdescribedas‘strangulation enigma that isendometriosis.Inthe13thcentury, This issueof O&GMagazinediscussestheclinical President Dr VijayRoach O&G Magazinediscussthepathophysiology, 1 Like manyperceptions through variousmedia.RANZCOG isyourCollege. are endeavouringtodomore tokeep you informed are higherthaneverbefore. We recognise thisand expectations of communication from theCollege constructive criticism.Theworldischangingand to knowwhat youthinkisimportantandweinvite we wantyourfeedbackandsuggestions.We want proactively address issuesrelevant totheCollege, Finally, inlinewiththeBoard’sdetermination to group. underpin theworkof thismultidisciplinary Zealand. Collaboration andourcommonpurposewill that contributetomaternity care inAustraliaandNew Joint Committeetobringtogetherthemanyentities was warmlyreceived. TheCollegeisprogressing a of MidwivesandNewZealand Collegeof Midwives a messagefrom RANZCOG totheAustralianCollege In honourof International Dayof theMidwife,5May, from WGEA fortheirsupportandsageadvice. particularly grateful toLibbyLyons andKate Lee Workplace GenderEqualityAgency(WGEA). Iam is thefirstmedicalcollegetoengagewith in thisarea, wehavesoughtadvice,andRANZCOG discussed. Withawareness of ourlackof experience RANZCOG membershipthat willbecollated and of writing,wehavesoughtfeedbackfrom the ourselves someambitioustargets.At thetime at aleadershiplevelat RANZCOG, wehaveset Recognising theneedforbroader representation Working Group, ledbyChair, DrGillianGibson. announced ourGenderEquityandDiversity After toomanyyearsof inertia,theCollege human papillomavirusresearch. FellowshipforherpioneeringworkinHonorary Hospital Melbourne,whoreceived anACOG and Prof SuzanneGarland,from theRoyalWomen’s the prestigious ACOG DistinguishedServiceAward, Past-President Prof Steve Robson,whoreceived to hearthecitations forRANZCOG Immediate I attended theFellowshipCeremony andwasproud learned discussingtheirgovernanceandprocesses. welcoming andthere were manyinsightstobe Chalas. TheAmericanswere, asalways,warmand President Ted LAndersonandPresident-elect Lisa ASM), outgoingPresident LisaHollier, incoming FRANZCOG(to receive Honorary at theMelbourne Francesca FRANZCOG) (Honorary andTom Gelhaus on meetingformerACOG Presidents, MarkDe the WildHorseSaloon,butIalsoconcentrated The conference dinnerincludedlinedancingat Tennessee, havingattended the2019ACOG ASM. writing thisonthelongflighthomefrom Nashville, attend international scientificmeetingsandIam One of thespecialdutiesof thePresident isto 1. Reference doi.org/10.1016/j.fertnstert.2012.08.001. ancient treatments. FertilSteril. 2012;98(6Suppl):S1-62.https:// C Nezhat, FNezhat, CNezhat. Endometriosis:ancientdisease, THE COLLEGE Chief Executive Officer Vase Jovanoska From theCEO Fellows alike. environment withbothworkshops for traineesand am pleasedthat wehavecreated apositive learning of highpraiseasbeingpracticaland relevant andI The feedbackreceived ontheworkshops hasbeen their personalwellbeingandworkplaceperformance. provide practicaltechniquesandstrategies toimprove cohort toprovide supportandskillstotrainees, psychology, andinconsultation withourtrainee research evidence,includingcognitiveandpositive in theirfirstyears of medicine,are designedusing wellbeing andsupportof doctors,especiallythose Thrive workshopsthat were created topromote the been enlightening. from bothtraineesandseniorcolleaguesthat has interactivity, opennessof conversation andinsight with positivefeedbackfrom participantsaboutthe an overwhelmingresponse totheworkshops, by manyconsultantsandtrainees.There hasbeen issues of workplacebullyingandharassmentfaced Workplaces workshops,whichaimtotacklethe instrumental insettinguptheSupportingRespectful The College’sTraining SupportUnit hasbeen Respectful Workplaces andThriveWorkshops Zealand andthePacific region. the benefit of women’shealthacross Australia,New together wewillcreate meaningfuloutcomesfor of productive andmutuallybeneficial relationships, organisation, andthedevelopmentmaintenance development of anagile,sustainableandinnovative support, advocacyandeducation provisions; the stronger engagementwithmembersviabetter strategic priorities.Ibelievethat through launched inMarch thisyear, definingour The College’sStrategic Plan2019–2022was Strategic Plan women’s health. of excellencetogether indelivery andequityin privilege tobepartof theCollegeandtobeworking given meawarmwelcome.Itisanhonourand the Board,ourmembersandCollegestaff whohave like totake thisopportunitytothankthePresident, about what thefuture holdsforRANZCOG. Iwould report forO&GMagazineandIamequallyexcited I amdelightedtocontributewhat ismyfirstCEO suites andobservation rooms. simulation equipmentandhigh-fidelity medical audio recording, accesstomodern medical and to berecorded electronically in real time,videoand integrated ITsystemsthat allowexamination results centre. Someof thebenefits of thecentre include built, clinicaleducation, trainingandassessment Adelaide HealthSimulation isaworld-class,purpose- of thisexam.been adoptedasthevenuefordelivery Simulation Centre at theUniversity of Adelaidehas pilot conductedduring2018, AdelaideHealth gynaecological procedures. Followingasuccessful complex deliveriesandperformmore advanced to alevelthat willenablethemtosafely undertake through theDiplomaandwhowishtodevelopthem practitioners whohavegainedskillsinobstetrics based trainingprogram intendedformedical The AdvancedDiplomaof RANZCOG isahospital- DRANZCOG AdvancedOralExaminationApril2019 that are availabletousall. successful womenandrecognise theopportunities opportunity tocelebrate theaccomplishmentsof level from day-to-dayworkinteractions.Itwasan with co-workers andourmembersonadifferent as itgavethemthechancetopauseandconnect Staff appreciative were andinspired very bythisevent Dr ManarangiDeSilva. journey: DrBernadetteWhite,AmberMoore and female doctorsat different stagesintheirRANZCOG differentquestions of andintriguing three very along theway. We alsohadtheopportunitytoask her organisation startedandthehurdlesshefaced guest speaker of how andtoldafascinating story Day. Stephanie Woollard of SevenWomen wasour House incelebration of International Women’s In March, RANZCOG hostedaneventat College International Women’s Day 2020.Department byFebruary final version of theGuidelineistobedelivered tothe The firstprogress report isdueon30Augustandthe methodologists andhadbeenapproved bytheDoH. by RANZCOG inconsultation withtheguideline reports toDoH. AProject Planhadbeendevised we willberequired tosubmitperiodicprogress Group meetingisscheduledtobeheldinJulyand RANZCOG’s firstEndometriosisExpert Working in Australia. diagnosis andmanagementof endometriosisforuse evidence-based clinicalpracticeguidelinesforthe seven totenyears. women, withtheaveragediagnosistakingbetween 10AustralianEndometriosis affects oneinevery National ActionPlanforEndometriosis2018. Management OfEndometriosis,inlinewiththe Clinical PracticeGuidelinefortheDiagnosisand Department of Health(DoH)todevelopanAustralian College wasawardedacontractforservicesbythe As reported inprevious issuesof O&GMagazine,the Endometriosis Project 1 Currently, there are nonational THE COLLEGE 1. Reference our griefandstandwithyouinsolidarity. events of March 15inChristchurch. We are unitedin New Zealand, andallof thoseaffected bythetragic extend ourdeepestsympathies toourmembersin Finally, onbehalfof theCollege,Iwouldlike to and AdelaideHealthSimulation staff. well organisedandtheyfeltsupportedbyRANZCOG examination wasdelivered professionally, wasvery positive. Bothexaminersandcandidates feltthe candidates ontheconductof thisexamhasbeen The feedbackreceived from examinersand cases from theareas of obstetricsandgynaecology. a structured oralexamination format, including10 on Sunday7April2019. Theexamination followed The AdvancedRANZCOG OralExamination washeld endometriosis. www.health.gov.au/internet/main/publishing.nsf/Content/ Endometriosis. Commonwealthof Australia.Available from: The Departmentof Health.National ActionPlanfor THE COLLEGE interest instudents.Iwasinspired byaseniortrainee Women’s Hospitalwere passionate and tookakeen undergraduate. Ourclinicalteachers at Wellington I developedaninterest inO&G asaclinical Why didyouchooseO&Gasyour careerpathway? lecturer postat theUniversityhonorary of Auckland. the Pregnancy Termination Service,andsheholdsan Women’s Healthsince1997, istheclinicallead for Dr GibsonhasheldaVMO positionat National director andclinicianof aprivate practice. on twowomen’shealthrelated trusts,andisthe NZ Societyof Gynaecology, holdsaboardposition elected Boardmember),isthepastpresident of the federal Boardmember(currently theonlyfemale the AucklandDistrictHealthBoard,isaRANZCOG Zealand. SheholdstheClinical Director role of Dr GillianGibsonisaRANZCOG FellowinNew FRANZCOG Dr GillianGibson #CelebratingLeadership @RANZCOG @connankf Join theconversation onTwitter and inspiringread. We hopeyoufindthisan interesting in abroad rangeof leadershippositions. conversation withRANZCOG members This feature seesDrKirsten Connanin MMedEd (GenderandLeadership) MBBS(Hons), FRANZCOG, DDU Dr KirstenConnan institutional knowledgeandexperience. wonderful opportunityto‘learn theropes’ from their Board membershavebeenre-elected, soIhavea Board. Iamfortunate that most of theincumbent I hopetohaveafurthertermon RANZCOG What futureleadershipgoalsdo youhave? clearly definedboundariesincomparison. Time andresources! Clinicalworkhasmuchmore challenges/barriers toyourleadershipjourney? What doyoufeelhave beenthebiggest and networksare key. Be available,responsive andfair. Goodrelationships leader? What doyoufeelareessentialcharacteristicsasa Board member. my ServiceClinicalDirector role, andasaRANZCOG leadership roles withtheNZregional Committee, valuable. Media traininghasbeenprovided formy training, althoughacknowledgethiswouldbe to take onroles. Ihavenothadanyformalleadership both asenseof obligation aswelltheconfidence ‘shoulder tap’nominations haveprovided mewith but havebeen‘shouldertapped’formany. These I havenotbeenmentored intoleadershiproles, found me! I havenotsoughtleadershiproles; theyseemtohave How didyourleadershipjourneyoccur? and policy. privileged toholdpositionsthat influence people I wouldnotsayamanatural leader, butIam Would youdescribeyourself asaleaderandwhy? home base). (all credit tomyhusbandwhomaintainedoursolid daughter whorecently graduated withaMBChB Holding aprofessional career whileraisingour associated conference inNewZealand. to attract thelargestattendance at aRANZCOG- This ASMwasaresounding successandwasable Organising CommitteeASMinAuckland2017. Holding theChairpositionforRANZCOG O&G practiceinNewZealand. Being partof theteamthat pioneered thefirstgroup What arethehighlightsofyourprofessionalcareer? O&G role modelIclearlyidentifiedwith. and Iadmired hercapability. Shewasthefirstwoman heavily pregnant inherfinalsixmonths of training who hadreturned from trainingintheUK.Shewas

THE COLLEGE area ripeforcareer development. There isnoformalleadershipprogram, butthisisan regards toleadershiptraining? What roledoyoufeelRANZCOG shouldplaywith development. has provided theopportunityforprofessional to Melbourne!AsageneralistO&G,Collegework development, jobsatisfaction andmultipletrips Networks, friendships,collegiality, career What rolehastheCollegeplayedinyourcareer? huge institutionalknowledge. RANZCOG President, aninspirational womanwith overlapped withDrChristineTippett’stenure as New Zealand RegionalCommitteein2006–2008 Council andBoardlevel.MytimeasChairof the contributed enormouslytoCollegeworkat the There are manymenandwomenwhohave may bebarriers. are wellqualifiedtocontribute,butforwhomthere opportunities withintheCollegeforwomenwho am motivated todeveloppolicythat willmaximise My responsibility istorepresent allmembers,butI I amChairof theGenderEquityWorking Group. this term,howdoesinfluence yourrole? You aretheonlywomanonRANZCOG Board development at anational level. contributing responses tosubmissionsandpolicy meetings inWellington, weeklyteleconference, and RANZCOG NZCommitteeExecutive, withquarterly My responsibilities includeex-officio membership of Fellows ceremony.’ Meeting andtobepartof thenew the RANZCOG AnnualScientific ‘For meahighlightistoattend teleconference andemail. with asignificantamount of workundertaken by results. Supportfrom Collegestaff isoutstanding, times ayear)isquitebusy, butdoesachieve The timetableduringCouncilweek(heldthree activities bytheCouncilandarangeof committees. operations of theorganisation andissupportedinits The Boardmanagesthefinancial,legalandbusiness face tosixtimesduringtheyear. who are thedirectors of theCollegeandwemeet RANZCOG isgovernedbyaseven-memberBoard What doesbeingaRANZCOG boardmemberentail? hygiene reasons! I rarely havemycomputeronafter 8pmforsleep is notaneasyskill,butagoodonetoacquire, and routine that mustnotbecompromised. Delegating advice andwisdomof myspouse.Myexercise Strategies forcopingincludeoutstandingsupport, parents, friendships. time tospendwithwiderfamily/whānau,ageing due toworkcommitments,mainlylonghours–less Combining parenting withacareer. Lostopportunities vulnerabilities duringyourcareer? What have beenthebiggestchallenges/ Dr GillianGibson. potential willbethere formany yearstocome. it. Bereassured thecareer opportunities andearning possible, thenifyouplantohave afamily, getonwith Get through trainingasquicklyandefficiently out atthebeginningoftheircareer? What advicewouldyougivetoatraineestarting group obstetricpracticetoachieveabalance. is neededifyouare inprivate practice.Irecommend leaving allworkresponsibilities behind.Goodcover to exercise, takingholidays,gettingoutof townand toenforce boundarieswithrespect books ayear!Itry I belongtoabookclubandmanageread at least20 professional life? How doyoubalanceyourpersonaland becoming membersandhavingleadershiproles. future, thisincludesensuringthere are sufficientmen for leadershippositionstochangetheimbalance.In of medicalcollegescreating gender-based targets gender equityisneededaswell.There are examples cannot berelied uponentirely, andspecificpolicyfor pipeline effect of sheernumberscomingthrough in leadershippositionsbecomesthenorm.The Fellows willpursuearole at theCollegeifwomen I believeitismore likely traineesandyounger within O&Gleadershipandtraineeposts? How doyoufeelaboutthegenderimbalance excellence inwomen’shealthcare. has aresponsibility tomake thisaprioritytoachieve of theirsexualandreproductive health.TheCollege The womeninourcommunitiesneedtobecontrol all thesamegoalsasmen,ifgivenopportunity. give womenthevote!Ibelievecanachieve I’m proud that NewZealand wasthefirstnation to Do youseeyourself asafeminist? of addressing inequitiesinwomen’shealthcare. health committee,HeHoneWāhine, that hastheaim Zealand Committeehascreated aMāori women’s with governmentandotheragencies.TheNew by contributingtopolicydevelopment,interaction We havearesponsibility toaddress healthinequities regards toIndigenoushealth? What roledoyoufeelRANZCOG shouldplaywith THE COLLEGE Vol. 21 No. 2 Winter 2019 | 9 Vol. If you could do things differently in your career, in your career, do things differently If you could it be? what would years to three a BSc(hons) added Completing entry goal of achieving my school. It to medical a family and part, the delay for starting caused, in secondaryultimately infertility. any regrets? Do you have ahead of I put my career that I have a deep regret children. having more change during you seen workplace culture Have your career? medical school class in 1983 Our Otago University As a per cent women intake. was the first with 50 consent informed concept of medical student, the was not very evident. After Cartwright (cervical cancer enquiry were 1987–88) significant changes rights. patient to protect introduced future? What role do you see for the College in the authority for women’s the peak body and are We I envisage a in Australia and New Zealand. healthcare it easy for makes outward-facing College that more affects that women and families to get information will be easier if our Council their health. This role of the the diversity and Board membership reflects for. communities we care What three words best describe your life? Demanding, varied, rewarding. if you had What would you tell your younger self the chance to go back in time? during an adverse event will occur Sooner or later out help despite your best efforts. Seek your career and support early. for Are you willing to be contacted by trainees you career advice/mentoring, and what would bring to that relationship? I have over trainees. I would welcome contact from after perspective and experience looking 20 years of and public practice, as well as women in private familiarity with College people and processes. PELVIC PAIN are allbetter, what doeshistologyadd? for painchronicity. We needtotreat pain,butifthey in thecompensation arena isapoorprognostic sign catastrophising –andasenseof injustice,especially to diagnosethehistology?Injustice isthenew treatment? Doesitmatter that ittooksevenyears endometriosis iftheirpainisresolved withmedical Do weknowifitmatters that someonehas Controversies to treat eachpartof thecomplexhuman. organs andbodyusearrows todescribeoptions an A4pieceof papertodrawthebrain,spinalcord, brain. Nofancybusinessrequired; thebesttoolis matters; youcan’thavepainifdon’ta pain) orsleepandmooddisorders–soeverything hypersensitivity, otherpainstates (painbegets – amuscleresponse, contributionsfrom visceral proportion of theirpainisduetoendometriosis multifactorial andwehavenowayof knowingwhat Talking withthemistreatment. Explainthat painis understood; asdoesanypatient seekingcare. patients. Women needtobelistenedand and bepaineducators inyourinteractionswith you alltoconveythenewneuroscience knowledge patients cantreat it?Languagematters –Ichallenge Who wouldhavethoughtthat explainingpainto Explain pain letters todiscussandengageintheconversation. makes authorshappierthanpeoplewhowrite and lobbyists.We havecontroversies, andnothing psychologists, physiotherapists,scientists,educators We havearticlesfrom gynaecologists,anaesthetists, new languageisfilteringout. painclinicsare beingcreatedmultidisciplinary anda endometriosis research inthepoliticalarena, Momentum isbuildingforpainmanagementand up allthereferences! you think,make youwanttoknowmore andlook from around AustraliaandNewZealand tomake and great hope.We havegathered togetherauthors researchers, shiftingparadigmsof understanding In 2019theworldof painisfullof innovative University HospitalGeelong MBBS, BMedSc,FRANZCOG Dr MarillaDruitt Editorial https://painrevolution.org https://bodyinmind.org https://noijam.com/ Explain Painresources: pain-service/ co.nz/public/pain-management/counties-manukau-health-chronic- Counties ManukauHealthChronic PainService:www.healthpoint. public/pain-management/tarps-the-auckland-regional-pain-service/ TARPS AucklandRegionalPainService):www.healthpoint.co.nz/ (The Brainman onYouTube: www.youtube.com/user/HunterBrainman International PelvicPainSociety:www.pelvicpain.org/ West AustralianPainStories: https://painhealth.csse.uwa.edu.au/ New Zealand PainSociety:www.nzps.org.nz Endometriosis NewZealand: https://nzendo.org.nz/ Endometriosis Australia:www.endometriosisaustralia.org/ Pelvic PainFoundation Australia:www.pelvicpain.org.au Further reading Enough evangelising–onwiththeshow! – here are somesuggestionsbelow. (watching, reading, listening).Further yourlearning resources forpatients andknowhowtheylearnbest endeavour tobeonmessageasagroup. Knowyour not inaco-located fashion,inavirtualone–and little couldgoalongway. Gather yourteam–if disease). Ifweare allbetterat treating pain,a the left(classicallyseenwithsmokingandheart impact onapopulation asshiftingthecurveto the extreme of thespectrumwillnothaveasmuch As Geoffrey Rosesuggestedinthe1960s,targeting Gather yourteamandshiftthecurve PELVIC PAIN The University ofQueensland,Brisbane Institute forMolecularBioscience, Professorial Research Fellow Prof GrantWMontgomery of endometriosis Unlocking theaetiology at sitesoutsidetheuterus. lesions containingtissueresembling endometrium enigmatic. Thediseaseisdefinedbythepresence of The underlyingcausesforendometriosisremain glands andstroma. histological confirmation of ectopicendometrial the observation of with lesionsat thetimeof surgery sites withinthebody. Definitivediagnosis requires in theperitonealcavity, but canalsooccurinother coelomic epitheliumcoveringtheovary. into another, forexample,transformation of the or transformation of onedifferentiated celltype ducts duringdevelopmentand(iii)metaplasia unusual differentiation andmigration of Müllerian of misplacedendometrialcellsleftbehindfrom adhesion andinitiation of lesions(ii)activation through retrograde menstruation followedby viable endometrialcellsintotheperitoneum have beenproposed including(i)depositionof the diseasebetweenpatients. Severaltheories location of lesionsandvariablepresentation of for initiation of lesions,therangeintypeand must accountfortheorigin(s)of cellsresponsible Explanations fortheaetiologyof endometriosis and diseaseseverity. correlation betweendiseasesymptoms,lesiontype overlap severalotherconditionsandthere isapoor with symptomsof pelvicpainandinfertility that of lesiontypesinindividualpatients. Women present different types of lesionsanddifferent combinations cells shedat thetimeof neonatal retrograde formation, and/oractivation of stem orprogenitor or progenitor cellsincreasing the chanceof lesion include theretrograde transport of endometrialstem of retrograde menstruation couldbeextended to women before theonsetof puberty. Thetheory some casesof endometriosisare seeninyoung for allpresentations of thedisease.Forexample, provides anadequate explanationone theory 1,2 To complicate matters, there are 1,2 Lesionsmainlyoccur 3,4 No sizes associated withendometriosis. variantswithmoderate orlargeeffect modifying contributions tocomplexdiseases. have transformedourunderstandingof genetic 10 years,genome-wideassociation studies(GWAS) of somatic mutations inendometriosis lesions. in endometriosishavehighlighted thehighburden or othernon-geneticriskfactors. Recentstudies include exposures tospecific environmental insults bleeding inaproportion of babies. genomic regions associated withendometriosis. have identifiedlikely targetgenesinfour of the 14 associated withendometriosisrisk.Follow-upstudies regions andidentifiedfivenovel regionssignificantly Results replicated ninepreviously reported genomic (17 045endometriosiscasesand191596controls). Somatic mutations were identified in 79percent small effects. a largenumberof commonvariants,eachwith The results showgeneticriskismostlikely dueto and functionalchangesincreasing endometriosisrisk. studies willberequired toconfirm thespecificgenes and angiogenesis.However, extensivefunctional genes associated withcellproliferation, celladhesion Initial results suggestgeneticeffectsmostlyinfluence study architecture of thedisease.Themostrecent published risk factorsandproviding insightintothegenetic endometriosis havebeenpublisheddescribinggenetic 50 percentof riskforendometriosis. of geneticriskfactors.Thisrepresents approximately variation remaining after estimating thecontribution Environmental riskestimated from twinstudiesisthe studies are subjecttorecall bias. early stagesof developmentandquestionnaire of diagnosisare unlikely toreflect exposures during time duringdevelopment.Measurements at thetime since environmental riskfactorsmayoperate at any chemicals. factors andpossiblyexposure toendocrinedisrupting mass indexandendometriosis,specificdietary risk includeaninverseassociation betweenbody Environmental factorscontributingtoendometriosis lesions types. risk factorsinwomenwithdifferent combinations of this conclusionmustwaitaformalanalysisof genetic with different lesiontypes.However, confirmation of suggesting geneticriskfactorsare similarforwomen show goodconsistencybetweenandwithinstudies range of different lesionstypes.Overall,GWAS results and self-report of diseaseandincludewomenwitha results includewomenwithsurgicallydiagnosed heritability of approximated 50percent. and environmental factors–withanestimated The diseaseiscomplex–influenced bybothgenetic arise from different causes. exclusive anditislikely somecasesof endometriosis endometriosis inmales.Thetheoriesare notmutually explanations donotexplaintherare occurrence of 8 includeddata from 11case-controlled data sets 2 Specificfactorshavebeenhardtodefine 8 There islittleevidenceforprotein- 7 3,4 SeveralGWAS for However, these 13 6 TheGWAS Thiscan 5,6 In the last Inthelast 14-16 9-12

PELVIC PAIN Vol. 21 No. 2 Winter 2019 | 12 Vol. The New England Endometriosis. The New England Giudice. Clinical practice. LC Medicine. 2010;362(25):2389-98. Journal of Rev et al. Endometriosis. Nat K Koga, Becker, CM KT Zondervan, Dis Primers. 2018;4(1):9. deep of Pathogenesis I Brosens. S Gordts, P Koninckx, . 2017;108(6):872-85. Fertil Steril endometriosis. L Fedele. Endometriosis: P Vigano, E Somigliana, P Vercellini, Rev Endocrinol. Nat and treatment. pathogenesis 2014;10(5):261-75. of et al. Heritability R Saha, HJ Pettersson, P Svedberg, . 2015;104(4):947-52. endometriosis. Fertil Steril NG Martin. Genetic O’Connor, VM O’Connor, DT SA Treloar, in an Australian twin sample. Fertil on endometriosis influences . 1999;71(4):701-10. Steril GWAS of Q Zhang, et al. 10 Years NR Wray, PM Visscher, American Journal and Translation. Function, Discovery: Biology, Human Genetics. 2017;101(1):5-22. of AP Morris, et al. Meta-analysis V Steinthorsdottir, Y Sapkota, with endometriosis identifies five novel loci associated genes involved in hormone metabolism. Nat highlighting key . 2017;8:15539. Commun et al. Functional Y Sapkota, SJ Holdsworth-Carson, JN Fung, with endometriosis genetic variants associated of evaluation near GREB1. Hum Reprod. 2015;30(5):1263-75. HT Luong, et al. Endometrial JN Fung, SJ Holdsworth-Carson, with endometriosis risk. Hum Reprod. and its association vezatin 2016;31(5):999-1013. et al. Allelic Imbalance T Hayano, H Nakaoka, A Gurumurthy, 9p21 Interaction at Chromatin ANRIL through of in Regulation Endometriosis Risk Locus. PLoS Genet. 2016;12(4):e1005893. et al. Endometriosis risk K Shakhbazov, JE Powell, JN Fung, CDC42 and of inverse regulation act through 1p36.12 alleles at Hum Mol Genet. 2016;25(22):5046-58. LINC00339. potential et al. Analysis of I Vivo, V Steinthorsdottir, Y Sapkota, protein-modifying and patients variants in 9000 endometriosis Sci Rep. 2017;7(1):11380. ancestry. European of 150000 controls et al. Cancer-Associated MS Anglesio, N Papadopoulos, A Ayhan, The New England in Endometriosis without Cancer. Mutations Medicine. 2017;376(19):1835-48. Journal of IM Shih. Independent development TL Wang, M Noe, A Ayhan, within the same endometrial epithelium and stroma of . 2018;245(3):265-9. endometriosis. J Pathol and et al. Clonal Expansion K Suda, H Nakaoka, K Yoshihara, in Endometriosis Mutations of Cancer-Associated Diversification Rep. 2018;24(7):1777-89. and Normal Endometrium. Cell

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. References The somatic mutations mutations The somatic 14 Genetic risk factors and somatic mutations mutations Genetic risk factors and somatic 16 may both contribute to survival of endometrial cells endometrial may both contribute to survival of and and subsequent initiation during this process should define work lesions. Future of progression of the target genes and functional consequences the known genetic risk factors and overlap with in both lesions and mutations somatic spectrum of of eutopic endometrium. Armed with knowledge for fundamental genomic changes responsible we will be able to and progression, disease initiation novel and diagnosis and develop better methods of personalised treatments. more of deep infiltrating endometriosis lesions, with lesions, endometriosis infiltrating deep of known somatic lesions harbouring of 21 per cent mutations. cancer driver are DNA changes in a small number of specific cells, specific cells, of in a small number DNA changes are the and part of genetic risk factors distinct from risk. They may result or non-genetic ‘environmental’ role the (like exposures environmental specific from DNA damage in skin and causing sun exposure of and non-melanoma the risk for melanoma increasing with in DNA replication errors skin cancers) or from in the endometrium at constant tissue regeneration in rates and high proliferation each menstrual cycle specific cell types. endometriosis, have not yet solved the riddle of We genetics and genomics from discoveries but recent the about the origins of important clues provide The discovery for study. disease and new avenues seen in lesions mutations the same somatic that in endometrial glands found in cells already are support to gives strong within the endometrium endometrial tissue transported to the view that is an menstruation the peritoneum by retrograde endometriosis cells initiating of important source lesions. PELVIC PAIN persistent painformore thanfiveyears. about 30percentof patients continuetoexperience prevalence of PPPisestimated tobe15–27percent. stress disorder. have positivescreening results forposttraumatic and emotionalabuseortraumaaboutonethird of physical,sexualpatients withPPPhavehistory Canberra Health Services Division ofWomen, Youth andChildren Staff Specialist,DeptofO&G MBBS, DRANZCOG Adv, MRepMed, FRANZCOG Dr SumiSaha Causes ofpelvic pain What elsecoulditbe? and urethra. Thecoexistence of symptomsand tractconsistsof thebladder The lowerurinary Urological domaininPPP (UPOINT). infection, neurological/systemic andtenderness six domains:urinary, psychological, organspecific, clinical phenotype-basedclassification systemwith complexity, Shoskes etalwere firsttopropose a To inducereflection of thismultidimensional functional disabilityorleadtomedicalcare. or thebuttocks,andisof sufficientseveritytocause wall at orbelowtheumbilicus,lumbosacralback localises totheanatomic pelvis,anteriorabdominal noncyclical painof sixormore monthsduration that Persistent pelvicpain(PPP)hasbeendefinedas nonspecific chronic fatigue). syndrome (suchasirritablebowelsyndrome and sympathetic dystrophy) orfunctionalsomatic pain of chronic regional painsyndrome (suchasreflex psychosocial disordersharingthecharacteristics PPP hasbeenviewedasacomplexneuromuscular- women withoutPPP. times more likely toundergohysterectomy than times more gynaecologicalsurgeries,andare five PPP usethree timesmore medications, havefour investigations andsurgicalprocedures. Women with often undergoseveralexpensiveandunnecessary presentation involvingvariousorgansystems,patients the patient andphysician.Duetothevariablenature of PPP isawell-recognised, frustrating symptomforboth prostate andbladderpainsyndrome. demonstrated theclinicalapplicability of UPOINTto 6 SeeFigure 1.Severalresearchers have 5 3 Despite these interventions, Despitetheseinterventions, 5 Up to50percentof 7 4

1 The 2 recurrent rectal pain/pressure/burning oraching cramping, painwithdefecation, bleeding, discharge, obstructive defecation, abdominalbloating and frequently report constipation, diarrhoeaand syndrome. Patients affected intheGIdomain inducing painsymptomsbyvisceral hypersensitivity pain generator ormayplayacritical role in The gastrointestinal tract(GI)canbetheprimary Gastrointestinal domaininPPP treatment withaprolonged courseof antibiotics. to paraurethral glandinfection mayrequiresecondary been recommended. Patients withurethral syndrome pentosan polysalphate sodium)andphysiotherapyhas modification, pharmacologicalagents(suchas dietary treatment approachA multidisciplinary including women’s lives,treatment needstobeindividualised. presentation andtheimpactof theconditionon and groin. pressure sensation, radiating towardstheperineum perceived usuallywithvoidingandassociated dull tourethral syndrome, itis If thepainissecondary with filling,andsensation of incompleteemptying. hypersensitivity, pressure, discomfort, hesitancy, pain frequency (dayandnight),urgency,increased urinary For thebladderpain,patients maycomplainof European ConsensusStatement 2015 Table 1.Othercausesof PPP(adaptedfrom ISPOG urethral syndrome, coccyodynia,andperinealpain. cystitis andbladderpainsyndrome, vulvodynia, pain syndrome,’ includingsomeorallof interstitial involved haveledtothesuggestionof a‘urogenital originof thestructures the commonembryologic disorder psychological Psychiatric/ tissue and connective Musculoskeletal Gastrointestinal Urological Diseases 10 Because of the varying nature Becauseof of thevarying delusional disorders Schizophrenic, schizotypaland Adaptation disorder Somatoform disorders Hernia compressionsyndromes Nerve connective tissue musculoskeletal systemandof Malignant diseaseofthe Scar pain Dysfunction ofthepelvicfloor Neuralgia/neuropathic painsyndrome Chronic backpain Myofascial pain,triggerpoints Fibromyalgia Chronic intestinalpseudo-obstruction Stenosis ofthesmallorlargeintestine Malignant intestinaldiseases diseases intestinal Chronic-inflammatory Chronic constipation Irritable bowelsyndrome Urolithiasis tract urinary Chronic inflammatory Bladder functiondisorders Malignant urologicaldisease Urethral syndrome Interstitial cystitis Causes andfindings 8 ). 9

PELVIC PAIN 6 Vol. 21 No. 2 Winter 2019 | 14 Vol. J Steege, M Seidhoff. Chronic pelvic pain. Obstet Gynecol. Chronic M Seidhoff. J Steege, 2014;124:616-29. among women: an pelvic pain chronic of A Ahangari. Prevalence Pain Physician. 2014;17(2):e141-7. review. updated Pelvic Pain: Chronic Psychology of A Schrepf. SR Till, S As-Sanie, Clin Treatment. and Vulnerabilities, Neurobiological Prevalence, Obs and Gyn. 2019;62(1):22-36. and incidence of et al. Prevalence PL Yudkin, KT Zondervan, pelvic pain in primary a national chronic evidence from care: BJOG. 1999;106(11):1149-55. general practice database. et al. European Borovicka, AP Baranowski, J. D Engeler, Pelvic Pain. Guidelines on Chronic Urology. of Association http://uroweb.org/wp-content/uploads/EAU- from: Available Guidelines-Chronic-Pelvic-Pain-2015.pdf. to the management Phenotypic approach D Shoskes. JC Nikel, Curr Urol pelvic pain syndrome. prostatitis/chronic chronic of Rep. 2009;10:307-12. women et al. Clinical phenotyping of D Shoskes, JC Nikel, to a key bladder syndrome: with interstitial cystitis/painful management. J Urol. and potentially improved classification 2009;182:155-60. M Engman, et al. ISPOG European P Weijenborg, F Siedentopf, pelvic pain in women (short - chronic Consensus Statement version). J Psychosom Obstet Gynaecol. 2015;36(4):161-70. origin. Pain Clin Updates. urogenital Pain of U Wesselmann. 2000;8(5):1-4. pelvic chronic of et al. The fundamentals N Rana, MJ Drake, continence society pain assessment, based on international . 2018;37:S32-8. Neurology and Urodynamics recommendations. et al. Pelvic floor muscle dysfunction on D Raimondo, A Youssef, with deep infiltrating 3D/4D transperineal ultrasound in patients Obstet Gynaecol. Ultrasound endometriosis: a pilot study. 2017;50:527-32. of neuropathic and classification Diagnosis M Haanpää, R Treede. . 2010;18(7):1-6. Pain. Pain: Clinical Updates J Reid, et al. An exploratory study into objective LH Whitaker, pain in women with neuropathic characteristics of and reported pelvic pain. PLoS One. 2016;11(4):e0151950. chronic of a predictor CE Martin, E Johnson, et al. Catastrophizing: 1 year. persistent pain among women with endometriosis at Hum Reprod. 2011;26:3078-84.

UPOINT is a clinical phenotyping Figure 1. UPOINT is a clinical phenotyping based on the ‘snowflake system classification Each of pelvic pain syndrome. hypothesis’ for chronic as open to subcategorisation the six domains remains discovered. are new mechanisms and biomarkers References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. holistic and thoughtful care. Most of the patients patients the Most of holistic and thoughtful care. extensive psychotherapy (such as cognitive- require and individual behavioural therapy), physiotherapy, couples counselling along with pharmacological and social support. treatment in-depth In a nutshell, PPP management requires the multidimensional painunderstanding of mechanism by expert interdisciplinary team members. cause, the goal any treatable of Following exclusion resume to should focus on empowering the patient pathway her normal activity and function by a shared team. along with the treating

5 Features indicative of a of indicative Features The relevant nerves are sacral, nerves are The relevant 11 13 Reports of sleep disturbances, Reports of 14 Anorectal problems may result from result may problems Anorectal 10 In persistent pelvic pain, secondary sensitisation 12 musculoskeletal problem include: point tenderness, problem musculoskeletal in the muscleand alterations abnormal movement spasms, cramping,(tone, stiffness, tension, to points). PPP related and trigger fasciculation pain disorders includes myofascial musculoskeletal trigger hernia, osteitis pubis, fibromyalgia, syndrome, also have joint pain. Researchers point and sacroiliac such tissue disease, soft of an association discovered such with other comorbid conditions, as fibromyalgia, primaryas irritable bowel syndrome, dysmenorrhoea functional headache. and chronic Physiotherapy addressing pelvic floor and hip hip pelvic floor and Physiotherapy addressing for this the treatment muscle is the mainstay of proven Some other measures patients. of group pelvic floor to be helpful include self-directed muscle exercises, contraction and relaxation injections. and Botox relaxants Neurological domain in PPP domain neurological with predominantly Patients pain commonly describe burning, throbbing,related tingling, stinging and/ sensation, electric shock-like paraesthesia in the pelvis and/or perinealor painful area. episodes. of the peripheral or central nervous system canof the overall pain experience with perpetuating occur, of along with the involvement areas extending referral another organ system. pudendal, thoracolumbar, ilioinguinal, illiohypogastric, pudendal, thoracolumbar, Local anaesthetic nerve or obturator. genitofemoral for a subgroup successful treatment blocks may offer injections. In some repeated but require patients, of the of surgical decompression circumstances, rare nerve may be an option. affected Psychosocial domain in PPP Psychological factors including depression, more are and somatisation catastrophising anxiety, to common among women with PPP compared groups. control helplessness, hopelessness, difficulty concentrating helplessness, hopelessness, difficulty concentrating frequently and pain impairing daily enjoyment are women of This vulnerable group encountered. incur higher disability, health-related more reports sexual dysfunction, health costs and have associated quality invariably affecting particularly dyspareunia, by life. Many women also fear to be stigmatised of who may consider their pain is health professionals ‘in her head’. but rather not real, A formal psychological assessment by valid to evaluate has been recommended questionnaires psychological comorbidities prior the extent of Multimodal, embarking on any specific treatment. involving active personalised approaches with primary and communication providers care the basic framework pain team provide a chronic bio-psychosocial model of for comprehensive haemorrhoids, abscess, fissures, ulcers, levator aniulcers, levator abscess, fissures, haemorrhoids, bowel Functional proctalgia. chronic or syndrome syndrome, irritable bowel disorders, including may inflammatory disease and malignancy, bowel and should be flag’ symptoms similar ‘red with present and investigation. examination by thorough excluded domain in PPP Musculoskeletal system can be in the musculoskeletal Dysregulation the primary PPP or may be secondary cause of to the to the primary physical adaptation patient’s pathology problems Musculoskeletal involving other domains. other pelvic pathologymay also coexist with such as endometriosis. PELVIC PAIN Table 1.Endometriosiscore outcomesets. including preterm birth, areas of obstetricandgynaecologicalresearch, been foundwhenreviewing clinicaltrialsinother PhD Candidate,University ofAdelaide Children’s Hospital,Adelaide CMFM Subspecialty trainee,Women’s and MBBS, BMedSc(Hons),FRANZCOG Dr AmandaJPoprzeczny endometriosis Core outcomesetsfor reported. significant variabilitywith regards towhat was 119 different maternal andinfant outcomes,with interventions forpre-eclampsia, 79RCTs reported controlled trials(RCTs) addressing therapeutic In asystematic review of publishedrandomised a significantissueinobstetricsandgynaecology. Variability inreporting outcomes of clinicaltrialsis the therapeuticinterventions. studies reported anyinformation regarding harmsof that maybemade. and meta-analyses andimpactsontheconclusions the abilitytoperformmeaningfulsystematic reviews with epilepsyinpregnancy bleeding trials, • • • • • Pain Patient satisfaction withtreatment Adverse events Quality of life Improvement inmosttroublesome symptom Overall pain 1 Mostimportantly, fewer thanhalfof the 4 amongothers.Thisvariabilitylimits 2 managementof women 3 andheavymenstrual 1 Similarresults have • • • • • • • • Infertility including ANZJOG. core outcomesets.Over80journalsare involved, to therobust developmentandpromotion of journals andjournaleditorswhoare committed represents acollectiveof obstetricsandgynaecology The CROWN Initiative (www.crown-initiative.org) clinical trials.’ a minimumreporting standardfor ‘The core outcomesetsrepresent review andmeta-analysis. clinical trials,andallowformeaningfulsystematic standardise outcomecollectionandreporting in and dissemination of core outcomesetsaimsto researchers andaffected women.Thedevelopment of multiplestakeholders, includingclinicians, trial reporting. Theyare created byconsensus an attempt toreduce thisvariabilityinclinical minimum setof outcomesforclinicaltrials,in Core outcomesetsare anagreed standardised What arethecoreoutcomesets? determine aconsensus. survey methodusesmultiplerounds of surveysto core outcomesinendometriosisresearch. TheDelphi used toassesstherelative importanceof potential women withendometriosis.ADelphisurveywas input from healthcare professionals, researchers and core outcomesetforendometriosistrialsinvolved recommendations forcare. Thedevelopmentof a provide cliniciansandwomenwithevidence-based the abilitytodrawmeaningfulconclusionsand and 113outcomemeasures. review of outcomereporting revealing 164outcomes endometriosis trialsispresent, withasystematic Similar variabilityinreporting of outcomesin What arethecoreoutcomesetsforendometriosis? into trialdesignandreporting. in theirareas of research andtoincorporate them to findoutifthere are publishedcore outcomesets submitting paperstothesejournalsare encouraged Congenital abnormality Neonatal mortality Birthweight Time topregnancy leadingtolivebirth Gestational ageat delivery Livebirth Pregnancy loss(ectopic,miscarriage,stillbirth) Viable pregnancy confirmed byultrasound 5 Researchers planningtrialsand 6 Thissignificantlylimits PELVIC PAIN Vol. 21 No. 2 Winter 2019 | 16 Vol. J Duffy, M Hirsch, A Kawsar, et al. Outcome reporting across reporting across et al. Outcome Kawsar, M Hirsch, A J Duffy, therapeutic interventions evaluating trials randomised controlled BJOG. 2017;124(12):1829-39. for pre-eclampsia. of primary Choice Z Alfirevic. outcomes in randomised S Meher, interventions evaluating reviews trials and systematic BJOG. review. a systematic birth prevention: for preterm discussion 95-6. 2014;121(10):1188-94; in the et al. Variation J Troko, A Placzek, BH Al Wattar, women with epilepsy: among pregnant outcomes of reporting Biol J Obstet Gynecol Reprod . Eur review. a systematic 2015;195:193-9. primary et al. Choice of MC Herman, J Penninx, PM Geomini, for heavy menstrual bleeding. treatment outcomes evaluating BJOG. 2016;123(10):1593-8. outcomes for research of Harmonisation J Oliver Daly. Outcome Core of to practice: The role meaningful translation ANZJOG. 2018;58(1):15-6. Initiative. Sets and the CROWN in outcome Variation et al. Kusznir, JO M Hirsch, JMN Duffy, Am J review. a systematic in endometriosis trials: reporting Obstet Gynecol. 2016;214(4):452-64.

1. 2. 3. 4. 5. 6. References The final core outcome set included five core five core outcome set included The final core pain, and eight under the heading of outcomes infertility of under the heading outcomes core and presentation the table below; from (detailed in the goal is that While personal communication). clinical all future by addressed are these outcomes is not to limit the intention trials in endometriosis, and reporting and investigation outcome reporting, is encouraged. interest of additional outcomes of the FIGO at presented were outcomes These core Brazil, by Dr in Rio de Janeiro, 2018, Congress World James MN Duffy (@JamesMNDuffy),are in the and for publication. being submitted of process PELVIC PAIN to achronic paincondition. can prevent manycausesof pelvicpainprogressing Establishing trustandarrivingat atimelydiagnosis with ahealthprovider isof crucialimportance. acute andchronic pelvicpain.Theinitialconsultation There isconsiderableoverlapbetweenthecausesof conditions causing,orcontributingto,pelvicpain. is alsorelatively commonforothergynaecological Sonologist, MercyHospitalforWomen, Vic FRANZCOG, DDU, COGU Dr KateStone imaging forpelvic pain Scope ofmedical investigation. Asclinicians,youhave animportant important toallowathorough and complete information toyourmedicalimagingteam isvery and useof hormonalmedications. Providing this patient considerations suchasage,prior surgery the painisacuteorchronic, aswell asindividual medical imagingneedstotake accountof whether comorbidities. Correct useandinterpretation of the broad rangeof possibleaetiologiesand investigations forpelvicpainmustconsider gynaecologists needtomanagepain.The in providing theanswersthat patients and Medical imaginghasoften beeninadequate years. experience of symptomstoadiagnosisof seven problems, withthemediantimeintervalfrom first Delayed diagnosisandmisdiagnosisare common Pelvic painisacomplexanddiversemedicalproblem. widely publishedinrecent years. and theuterosacral ligaments,hasbeendescribedand assessment, whichincorporates thePouchof Douglas will bemissedormisdiagnosed.Amore complete endometrium andovaries,manycausesof pelvicpain ultrasound islimitedtotheassessmentof theuterus, for maximisingitsclinicalefficacy. Whenpelvic what it‘canimportant andcannotsee’isvery of pelvicpain,butithasitslimitations. Understanding valuableimagingtoolfortheassessment can beavery refrain from womensufferingpelvicpain.Ultrasound me whyIhavepain.’Sadly, thisisanall-too-common ‘I havehadlotsof ultrasounds,butnoonecanevertell 3 Thishasbeenreported forendometriosis,but 4,5 1,2 Table 1.Thingsyourimagingspecialistwantstoknow. and clinicallypertinentreport. radiologist orCOGU toprovide amore complete detailed referral orrequest formwillallowyour role inproviding thisinformation. Anappropriately identified with TV ultrasound. identified with such asinternalhaemorrhageor rupture, are readily than orequalto15mm. postmenopausal womenwillhave acystgreater have acystgreater than25mm, and7percentof cent of asymptomatic pre-menopausal womenwill rather thancausative, finding.Approximately 7per common, often transient,andmaybeanincidental, cysts ascausesof acutepelvicpainisthat theyare of torsion.Thedifficultywiththediagnosis of ovarian inflammatory disease inflammatory sonography performswellinthediagnosisof pelvic the conditionslistedinTable 2.Transvaginal (TV) Ultrasound isusefulinthediagnosisof manyof of pelvicpain. This articlewillnotcoverpregnancy-related causes ultrasound remains thefirstlineinmedicalimaging. negative betahumanchorionicgonadotropin test, complications havebeenexcluded withacurrent establishing thediagnosis.Oncepregnancy-related and generalsurgicalteams.Imagingiscentralto as adiagnosticdilemmabetweengynaecological Acute abdominalandpelvicpainoften presents Acute pelvic pain modality mayrelate tothelocalexpertiseinthisarea. images canbelimited.Thepreferred imaging dependant, andtheabilitytoreview orreassess A disadvantageof ultrasoundisthat itisoperator- assessment of tissuemobility. assessment, allowingthelocalisation of painand pelvic organsand,importantly, isadynamicreal-time from radiation. Itprovides high-resolution imagingof It isreadily available,relatively inexpensiveandfree ultrasound remains theinvestigation of firstchoice. the investigation of someformsof pelvicpain, While there isarole forMRIandCTscanningin obstetric history Gynaecology and Prior surgery medications Use of hormonal Age Comorbidities pain Nature of the Factor Mirena, Implanon,OCP, HRT age, peri-orpost-menopausal Premenarchal, reproductive may berelevant Other medicalconditionsthat location of pain Duration, cyclical/non-cyclical, What toinclude 6 , ovariancystsandsomeforms 7,8 Complications of acyst, PELVIC PAIN The 10 with 11 Vol. 21 No. 2 Winter 2019 | 18 Vol. TV ultrasound 12 Appendicitis Renal uropathy Diverticulitis Inflammatory bowel disease (IBD) Chronic pelvic pain presents pelvic pain presents Chronic IBD Diverticular disease Uropathy Interstitial cystitis Pelvic congestion Adhesive tissue 10 and is associated with significant and is associated 5 Non-gynaecological • • • • • • • • • • Non-gynaecological Musculoskeletal pain arising from the pain arising from Musculoskeletal 5 as frequently to the medical system as migraine or to the medical as frequently lower back pain performs well in identifying structural anomalies adenomyosis and such as adnexal/ovarian pathology, and not but these may be incidental findings fibroids, the pain. MRI and TVthe cause of ultrasound perform of deep well and similarly in the identification publications have been recent endometriosis. There to the ultrasound approach outlining a systematic deep endometriosis. It is an important of evaluation deep lesions of to locate investigation preoperative consent endometriosis and to adequately infiltrating the second MRI remains and plan surgery. patients owing to cost and availability. line investigation, MRI is particularly useful to use in conjunction with TV TV where or in patients ultrasound imaging the origin or ultrasound is not acceptable, where immobility is uncertain, or where pathology of nature the upper the pelvis has limited assessment of of with severe encountered wall. This is often rectal endometriosis/adhesive disease or when large or ovarian masses fill the pelvis. fibroids a non- medical imaging to provide The use of invasive diagnosis for peritoneal or superficial A Cochrane the next frontier. endometriosis remains aetiologies of chronic pain are more complex and complex more pain are chronic aetiologies of with associated frequently diverse, and it is more bowel significant comorbidities, such as, irritable 38–84 50 per cent and interstitial cystitis syndrome per cent. pelvic floor is common. of of ultrasound in the investigation The efficacy but pelvic pain has not been well evaluated, chronic patients up to 20 per cent of that it has been reported pelvic pain undergoing ultrasound for chronic will have abnormalities identified. impairment in quality of life and significant economic impairment in quality of Endometriosis alone is estimated implications. 176 million women worldwide, to affect pain accounting for approximately 20 per cent of 20 per cent of pain accounting for approximately least for benign conditions and at hysterectomies gynaecological laparoscopies. 40 per cent of is severe enough to cause functional disability or enough to cause is severe treatment. require

9 Adenomyosis Fibroids Malignant myometrial Congenital uterine anomalies Prolapse Fibroids Mal-positioned IUD Congenital uterine anomaly • • • • • Uterine Uterine • - Degeneration - Torsion • • - Haematometra - Haematocolpos In the premenarchal In the premenarchal 9 Diverticulitis presents as lower left Diverticulitis presents 6 Given the risk of adnexal necrosis, adnexal necrosis, Given the risk of 9 Ovarian pathology Hydrosalpinges Endometriosis Torsion complication Cyst Endometriosis Pelvic inflammatory disease • • • Adnexal • - Ovarian - Tubal - Adnexa • - Torsion - Haemorrhage - Rupture • • Adnexal Types of chronic pelvic pain. chronic of Types 3. Table Types of acute pelvic pain. pelvic acute of 2. Types Table a timely diagnosis is important. Torsion creates creates a timely diagnosis is important. Torsion of the adnexal structure a diffuse enlargement secondary to the oedema. It must be remembered cannot a clinical diagnosis that torsion remains that with imaging. or confirmed be completely excluded imaging findings where The most predictive adnexal surgically are torsion has been confirmed in size) than 5 cm greater enlargement (90 percent the ovaryand displacement of to a position superior Doppler can pelvis. to uterus or to the contralateral cases of be misleading, with up to 50 per cent of normal blood flow patterns. torsion demonstrating quadrant pain in adults. Ultrasound offers similar quadrant pain in adults. Ultrasound offers sensitivity and specificity to CT scanning. pain Chronic pelvic pelvic pain is a condition defined as Chronic than six months that for more pelvic pain present paediatric group, torsion often occurs in the setting torsion often group, paediatric a normal ovaryof and tube. the uterus and vagina in Congenital anomalies of acutely may present the adolescent population secondary or haematometra. to the haematocolpos These conditions can be mislabelled as ovarian masses, typically endometriomas. pelvic pain should Non-gynaecological causes of be assessed with every scan. Appendicitis is a acute right lower quadrant pain common cause of used in the less obvious clinical and imaging is often transabdominal/ The sensitivity of presentations. TV acute appendicitis ranges from ultrasound for 75–90 per cent. Torsion is a partial or complete rotation of the of or complete rotation is a partial Torsion their vascular pedicle and around adnexal structures adnexa. Torsion tube or entire can involve the ovary, approximately common, representing is relatively to emergency presentations 3 per cent of departments. This is likely secondary of to the varied degrees This is likely occlusion. Absence arterial, venous and lymphatic blood flow to the adnexa has a high positive of sign and value for torsion, but is a late predictive necrosis. of a degree indicates clinicians andpatients Providing supportto Pamphlets Patient Information RANZCOG For more information contact [email protected] website forums. avoiding thepitfallsof popularcommercial search engines and website, thepamphletspresent accurate, reliable information informed consentprocess. Publiclyavailable ontheCollege answers totheirquestions,and assistsclinicianswiththe efficient adjunctin providing patients with information and Written byexpertsintheirfields,the resource deliversan and guidelines. information that isin-date andalignedwith Collegestatements a comprehensive andrelevant source of patient-focused patients, theRANZCOG Patient Information Pamphletsare Created toprovide supportbothtocliniciansandtheir PELVIC PAIN endometriosis at laparoscopy. ligaments andpericolicfat) andpositivefindings of of change(thickened inflammatory uterosacral correlation of 79percentof ultrasoundfindings at laparoscopy. the presence of thesemarkers andpositivefindings ‘soft markers’ inultrasoundfoundaLRof 1.9 for 3. 2. 1. References doctors greater insightintothecauseof theirpain. diagnostic laparoscopy andallowpatients andtheir challenge. Thiswouldreduce thereliance on superficial forms of endometriosisisthecurrent The abilityof ultrasoundtodiagnoseperitoneal/ to replace surgery. detect pelvicendometriosiswithenoughaccuracy review concludedthat noimagingmodalitycould

International JObstandGynecol.2018;142:131-42. surgical versusclinicaldiagnosisof symptomatic endometriosis. H Taylor, etal.Anevidence-basedapproach toassessing 2009;104:156-60. infiltrating endometriosis.International JObstandGynecol. M Goncalves,etal.Transvaginal ultrasoundfordiagnosisof deep Ultrasound ObstetGynecol.2016;48:318-32. the international deependometriosisanalysis(IDEA)group. terms, definitionsandmeasurements: aconsensusopinionfrom of thepelvisinwomenwithsuspectedendometriosis,including S Guerrero, etal.Systematic approach tosonographicevaluation 12 Amore recent studyidentifieda 13 Astudyassessingtherole of 14 14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. www.ranzcog.edu.au/patient-information-pamphlets

endometriosis –are weanycloser?ANZJOG.2019;59:279-84. assess thediagnosticaccuracyof ultrasoundforsuperficial P Chowdary, KStone. Multicentre retrospective studyto Cochrane Database of Syst Rev.2016, Issue2. for thenon-invasivediagnosisof endometriosis(Review). V Nienblat, PMMBossuyt,CFarquhar, etal.Imagingmodalities BJOG. 2006,113:251-56. chronic pelvicpain–canwereduce theneedforlaparoscopy? markers’ fortheprediction of pelvicpathology inwomenwith E Okaro, GCondous,etal.Theuseof ultrasound-based‘soft edu.au/documents/pelvic_pain_report_rfs.pdf. 2011: ThePelvicPainreport. Available from: http://fpm.anzca. D Bush,SEvans. The$6BillionWoman andthe$600MillionGirl. Reproductive Medicine.2018;36:99-106. J Chandler. Evaluation of femalepelvicpain.Seminarsin Edition, Elsevier, 2016. P Callen.UltrasonographyinObstetricsandGynaecology, 6th 1998;17:369-372. detection andmanagement.Journalof Ultrasound inMedicine. C Conway. Simplecystinthepost-menopausalpatient: Gynecol. 1999;13:345-50. random samplewomen,25–40years.Ultrasound inObstand C Borgfeldt.Transvaginal sonographicovarianfindingsin Gynaecol. 2004;18:105-23. E Okaro, LValentin. BestPracticeandResearch. ClinObstand Guidelines, No.41,May2012. The initialmanagementof chronic pelvicpain.RCOG: Green Top 2018;36:97-8. G HarkinsG.Femalepelvicpain.SeminReprodMed. PELVIC PAIN

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Vol. 21 No. 2 Winter 2019 | 20 Vol. dysmenorrhoea pain ovulation floor abdominal wall/pelvic ovarian cysts vulvodynia hymen imperforate Müllerian tract anomalies pelvic inflammatory disease (PID) torsion, ectopic acute pain, such as ovarian appendicitis, PID pregnancy, inflammatory other causes, such as bladder, bowel disease, constipation On the other hand, pain throughout the month with the month On the other hand, pain throughout a perioda palpable one-sided pelvic mass worse with an an obstructed uterine horn in might represent Pain adolescent with a Müllerian tract abnormality. as cystmay also be ongoing post an acute event, such may or haemorrhagic corpus luteum. Patients rupture experiencing intermittent pain toalso transition from experiencing ongoing abdominal pelvic symptoms as examination Careful central sensitisation. of a result the abdominal the abdomen and, in particular, of any trigger are wall to ascertain whether there points will help identify cause. a musculoskeletal to lift theirThis can be done by asking the patient is, tensing the abdominal wall) the bed (that head off while examining the abdomen, known as Carnett’s sign. Bowel and bladder symptoms should also be discussed to identifyExternalfactors. contributing any should be performed withgenital examination consent, especially in girls who have not yet achieved but may have cyclical abdominal pain or anmenarche abdominal mass, to identify hymen or an imperforate a transverse vaginal septum. A sexual history should if possible, presence, without parental/carer be taken may contribute toto assess other risk factors that historypelvic pain, such as previous sexual abuse/ of assault, risk factors for PID/pregnancy. with simple If dysmenorrhoea is not well controlled anti-inflammatory analgesia, including nonsteroidal features, with atypical drugs (NSAIDs), or if associated the menses such as pain persisting beyond the end of and pain between menses, a pelvic ultrasound should be performed. Ultrasound can be useful to identify Causes of pelvic pain in adolescents: pelvic pain in Causes of • • • • • • • • • • pain in adolescentsA considered approach to pelvic with any historyA careful be taken should HEADS including questions exploring consultation, activities, (home/housing, education/employment, be sexuality/suicide). Much can drugs/depression, the of gained by understanding the context and life need young woman and her pain. Questions also secondaryto cover the development of sexual spurt, if has been a growth characteristics, if there was achieved. Getting an idea and when menarche menstrual flow and when in cycle length, duration, of help identifythe cycle she has pain will often a cause. period starts the For example, pain two days before other time at any and for the first few days, but not with nausea, vomiting and the month, associated of diarrhoea is consistent with primary dysmenorrhoea.

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1 not just for her current health and wellbeing, but not just for her current a few other are there Additionally, for her future. in typically present of pelvic pain that specific causes we will adolescence, or even during childhood, that cover in this article. Adolescents presenting with pelvic pain deserve a Adolescents presenting by Firstly, for several reasons. approach considered an early stage, we pain at and treating recognising with a lifelong battle of the likelihood can reduce or prolonged repeated that know pain. We chronic and pain lead to central sensitisation episodes of pelvic pain. to chronic/persistent predispose Dr Sarah Peek MBBS, BSci (Hons) Fellow in Paediatric and Adolescent Gynaecology, accredited IFEPAG Department of Gynaecology, Children’s Hospital, Melbourne training centre, Royal Dr Natalie Drever MBBS, BMedSci Fellow in Paediatric and Adolescent Gynaecology, accredited IFEPAG Department of Gynaecology, Children’s Hospital, Melbourne training centre, Royal in adolescents in Managing pelvic pain pain pelvic Managing Most importantly, how pain is explained and the Most importantly, is used will significantly shape how the language that she is adolescent sees and copes with the pain that adolescence itself represents experiencing. Secondly, self-discoverya time of the crucial time and growth, in which a young woman is developing her sense of self and paving the way for the adult she will become. 20–30 per cent of is Australian evidence that There missing school and women with dysmenorrhea are activities, making it an important issue to address, PELVIC PAIN menstrual bleeding, history of easy bleeding/ menstrual bleeding,history has recurrent haemorrhagiccystsand/or heavy causes of paininadolescence;however, ifapatient Blood testsare often of littlevalueto investigate might simplyappearasabicornuate uterus. such asobstructeduterinehorn/sthat at laparoscopy someunusualadolescentproblems, for identifying addition, ultrasoundcanbebetterthanlaparoscopy ovarian cystsorobstructiveMülleriananomalies.In Table 1.Managementof causes. Other causes Acute pain disease Inflammatory Pelvic anomalies Müllerian Imperforate hymen Vulvodynia Ovarian cysts pelvic pain Abdominal wall/ Ovulation pain Dysmenorrhoea management General • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Surgical, gastroenterology, adolescentmedicine,urology asappropriate pregnancy, cystrupture Pelvic ultrasoundtoruleoutacutecausesof pelvicpain,eg.torsion,ectopic Gynaecology review Counsel long-termcomplications Education aboutsafe sexualpractice,includingcontacttracing Antibiotics tocorrect if/whenappropriateSurgery Seek adviceforoptimalmanagementfrom experiencedgynaecologist Supress periodstocontrol symptomsuntilready forsurgery Specialist pelvicultrasound+/-MRI Surgical management e.g. Amitriptyline Neuromodulators that control symptoms>6monthsbefore consideration of weaning Education/emotional support Avoid irritants asrequired If complexbloods,surgery Ovulation suppression ifrecurrent simplecysts Monitoring: needrepeat scanin6–8weeks typeof cystsimplevscomplex Identify Involvement of paediatric painteam Consider role of neuromodulators Injection withsteroid andlocalanaesthetic–partlydiagnostic,treatment Physiotherapy progestogens Ovulation suppression e.g.COCP, medroxyprogesterone injection,continuous Track expectedovulation; useregular tranexamicacid andNSAIDs be considered women’s imagingultrasoundrulingoutothercausesof pain,alaparoscopy should If ongoingpaindespiteanadequate periodof menstrualsuppression andaspecialist progesterone injection,orLevonorgestrel IUS Suppression of menseswithhormonaltherapiese.g.progesterone onlypill,COCP, Tranexamic acid1gTDStoreduce bloodloss at theonsetof symptoms NSAIDs: regularly three timesaday(TDS) Involve patient inmanagementplanbasedonmaturity level of apsychologist Emotional supportforparent andchildincludingschoolsupportsinvolvement care shouldbeconsidered forallcomplexpatientsMultidisciplinary Exercise, stretching, heat, mindfulness Education likely cause Identify diarrhoea, myalgia,headaches, dizziness andfainting. symptoms that commonlyinclude nausea,vomiting, and canbeassociated with a rangeof associated dysmenorrhoeainteenagersiscommon Primary Dysmenorrhoea blood countandplatelet functionassay(PFA-100). include screening forVon Willebrand’sdisease,full a bleedingdisordershouldbeconsidered. Thiswould bruising orastrong familyhistory, investigations for PELVIC PAIN Vol. 21 No. 2 Winter 2019 | 22 Vol. ogmagazine.org.au OR Zekavat, MY Karimi, A Amanat, F Alipour. A randomised F Alipour. Karimi, A Amanat, MY OR Zekavat, for primary oral zinc sulphate trial of dysmenorrhoea controlled in adolescent females. ANZJOG. 2015;55(4):369-7. pelvic pain in Australia and New Zealand. Chronic S Evans. ANZJOG. 2012;52:499-501. and A Subasinghe, L Happo, Y Jayasinghe, et al. Prevalence dysmenorrhoea, and management options reported severity of Physician. by young Australian women. Australian Family 2016;45(11):829-34 leucocytes and L Salamonsen. Inflammation, J Evans, Rev Endocr Metab Disord. 2012;13:277. menstruation. perineal and vaginal pain in Distressing J Dennie, S Grover. . Child Health J Paediatr girls: an aetiology. pre-pubescent 2013;49:138-40. pain in paediatric Vulval S Grover. D Rampal, M Kielly, A Dunford, . 2019. Adolesc Gynecol J Pediatr and adolescent patients. 10.1016/j.jpag.2019.03.005. on hormonal contraception and AM Kaunitz. Update MM Isley, Rev Endocr Metab Disord. 2011;12(2):93-106. bone density. Hospital. Oral contraceptives – skipping periods Royal Children’s www.rch.org.au/ from: Available when taking the Pill. 2018. kidsinfo/fact_sheets/Oral_contraceptives_skipping_periods_ when_taking_the_Pill/. ant to read more ant Find similar articles when online. you explore

Medroxyprogesterone injection can be safely uses uses can be safely injection Medroxyprogesterone not suitable to are if other options in adolescence, for monitoring with consideration symptoms, control adequate is sensible to ensure It bone density. of optimal sunshine exposure/ dietary intake, calcium exercise. encourage weight-bearing and vitamin D, continuous use of becomes an issue, If bone density could be added. oestrogens oral or patch in suppressing implant can be effective Etonogestrel ovarian activity in some menses and reducing unpredictable risk of adolescents but has the wouldn’t be therefore bleeding in others and a management. It is, however, first-line considered very veryreliable contraceptive and effective and women. acceptable to many young used for 20 years in have been Levonorgestrel-IUS in Melbourne and can be the adolescent population and non-sexually active in nulliparous considered teenagers when inserted under general anaesthetic. pain or symptoms ovulation in mind that Keeping to unlikely to cyclical hormonal changes are related by this alone. be well controlled References 1. 2. 3. 4. 5. 6. 7. 8.

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6 It is also 7 Vulvodynia Vulvodynia 5 are potent and cause potent and are 4 systemic effects. We know that by involving the by involving We know that systemic effects. and explaining the in their management patient they may feel pain, we can physiology behind why their condition better. empower them to understand the process of explanation An age-appropriate can during menstruation the body goes through that and is reassurance be therapeutic in itself of underlying reflective the pain is not necessarily adenomyosis) Endometriosis (and even pathology. diagnosis, as a differential should be considered management should but, in adolescents, first-line and strategies pain management be education, bleeding/suppression heavy menstrual of reduction menses. of and genital pain Vulval nocturnal pain, distressing of The occurrence raises the sleep, child from waking the pre-pubertal with pinworms and should be treated possibility of weeks. for three weekly mebendazole safe to recommend continuous use of the pill for continuous use of to recommend safe skipping periods. with the aim of symptom control commonly presents in childhood, but can be commonly presents can include ongoing into adolescence. Presentations urinary symptoms (80 per cent), burning sensation, or a bubbly/ticklish feeling on the perineum/vulval a triggering event, such It is also seen after area. as urinary or vulvovaginitis. In the tract infection may be inability to adolescent, the presentation history Careful use tampons or dyspareunia. and using cotton swab test subsequent examination appear can aid diagnosis. External genitalia usually sensation normal, but 94 per cent will have altered the vestibule on cotton swab test examination. at Some girls present with cyclical exacerbations of of exacerbations with cyclical present Some girls parts, epilepsy, pain in other body fatigue, chronic to their even anaphylaxis related asthma and and prostaglandins the tells us that periods. This to provoke cytokines produced pro-inflammatory known to be an shedding (which is endometrial inflammatory process) Diagnostic delay is common and can be very and family. for the patient distressing Special considerations for the use of hormonal therapies in adolescents options for dysmenorrhoea Medical treatment are essentially the same in adolescents as they are packs/ in adults. First-line options include heat NSAIDs. For simple analgesia and regular stretching, or by simple measures girls with pain uncontrolled such seeking contraception, hormonal treatments and as combined oral contraceptive pill (COCP) appropriate. are medications progesterone-only to our It is common to see adolescents referred hesitant tertiary by doctors who are centre paediatric in adolescents. This to use hormonal treatments conflicting is not surprising, given the amount of on this topic in both the medical information and the media, and it is important that literature is no evidence these concerns. There we address girls, even those in postmenarchal using COCP that in any significant results menarche, shortly after effect on height. By the time a girl achieves has been her growth the majority of menarche, have high circulating completed and she will already of the pill A clinically significant effect oestrogen. on bone mineral density has not been demonstrated health should not affect and concerns about skeletal any age. use in healthy women of COCP PELVIC PAIN cent versus55percent,respectively). years thanwomenwithunexplainedfertility(36per significantly lowerprobability of pregnancy overthree endometriosis have,overall,beenshowntohavea low as2–10percentmonth. women withuntreated endometriosismaybeas per centmonth,whiletherate of fecundityin reproduce, isestimated tobeintherangeof 15–20 normal fertilecouples,thefecundityrate, potentialto by pelvicadhesionsandfibrotic tissueformation. and stroma outsidetheuterusandischaracterised defined bythepresence of endometrialglands Endometriosis isachronic disorder inflammatory with DIEislessclear. and subfertility, althoughtheextentof thelink association betweenalltheseformsof endometriosis deeply infiltrative disease(DIE).There existsan superficial peritoneal,ovarianendometriomaand Three mainsubtypesof endometriosisexist;namely, with endometriosis Linking subfertility cent of womenpresenting withsubfertility. however, isthoughttobepresent inupto50per up to10percentof thegeneralfemalepopulation; is unknown,endometriosisestimated toaffect Box 1.Listof biologicalmechanismsidentifiedtoexplainthelink between endometriosisandsubfertility. King EdwardMemorialHospital,Perth,WA Department ofObstetricsandGynaecology MBBS(hons), MReproMed, FRANZCOG Dr JenniferPontré • • • • These include: Several biologicalmechanismshavebeenidentifiedexplainingthe linkbetweenendometriosisandsubfertility. Mechanism ofsubfertility • • • • • progesterone secretion abnormalities,includinglutealphasedefect,abnormalfollicularand Endocrine andovulatory levels of endometrialIgGandIgAantibodieslymphocytes Altered hormonalandcell-mediated function,resulting inaltered endometrialreceptivity duetoincreased cytokines Altered peritonealfluidvolumeandincreased concentrations of prostaglandins, proteases andinflammatory Distortion of pelvicanatomy byadhesions,impairingoocyterelease, capture and transport Inflammatory hydrosalpingesInflammatory in30% of cases Painful intercourse leadingtodecreased frequency follicular fluidfrom womenwithendometriosis quality.Reduced oocyteandembryo Altered progesterone andcytokineconcentrations have beenfoundin Disordered endometrialfunction,resulting inimpaired implantation Abnormal utero-tubal transportwhen compared tohealthycontrols 8,9 2 While the exact prevalence Whiletheexactprevalence 10 5,6 Women with 7

3,4 In In 1

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performed simultaneously. Inpatients withminimal Surgical excision of allvisiblediseaseshouldbe improvement inspontaneouspregnancy rate. medical treatment for before orafter surgery birth. endometriosis, intermsof clinicalpregnancy andlive contraceptive pill[COCP]) insubfertilewomenwith medroxyprogesterone andthecombinedoral suppression (GnRHagonists,danazol, gestrinone, 2007 foundnoevidenceof benefitintheuse of inhibit ovulation. ACochranereview publishedin fertility, despitethefactthat alltreatments suppressive treatment of endometriosistoimprove investigate thepotentialforuseof hormonal endometriosis, significantworkhasbeendoneto Given thedemonstrated oestrogen dependencyof natural conception Medical managementofendometriosisand insemination (IUI)andinvitro fertilisation (IVF). controlled ovarianstimulation (COS) withintrauterine including and artificial reproductive techniques(ART), which maybegivenaloneorasanadjuncttosurgery, associated subfertilityincludemedicaltreatment, Present treatment optionsforendometriosis- by afactorof uptofour. prior toARTwillincrease theclinicalpregnancy rate to sixmonthsof pre-treatment withGnRHagonists There ishigh-qualityevidencetosuggestthat three Medical managementasanadjuncttoART inflammatory state.inflammatory oestrogenic environment isthoughttoreduce the the location, extentandseverityof thedisease. for endometriosisandenablesidentification of laparoscopy isthegoldstandarddiagnostictest Direct visualisation andbiopsyat thetimeof natural conception Surgical treatmentofstageI/IIendometriosisand form of medicalsuppression, suchastheCOCP. to suggestbenefit of pre-treatment withanyother 9 13 There isalsoalackof evidenceforadjunctive 12 15 There isnoevidenceavailable 4 Thecreation of ahypo- 6

4,14 14

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33 This 28 Other benefits Other benefits 6 Vol. 21 No. 2 Winter 2019 | 24 Vol. 25-27 In the most recent 29 However, while IVF is an However, 6 Prior to commencement Prior to commencement 30 25 There is no evidence for any There Older women (over 35 years) or 31,32 6,21 Women with untreated deeply infiltrative with untreated Women 6 C Bulletti, ME Coccia, S Battistoni, et al. Endometriosis and C Bulletti, ME Coccia, S Battistoni, J Assist Reprod Genet. 2010;27(8):441-7. infertility. Endometriosis and B Borghese, C Chapron. D de Ziegler, and management. Lancet. pathophysiology infertility: 2010;376(9742):730-8. S Fieuws, et al. High prevalence C Meuleman, B Vandenabeele, and women with normal ovulation endometriosis in infertile of . 2009;92(1):68-74. normospermic partners. Fertil Steril and the The $6 Billion Woman T Vancaillie. D Bush, S Evans, from: $600 Million Girl: The Pelvic Pain Report, 2011. Available fpm.anzca.edu.au/documents/pelvic_pain_report_rfs.

may be more effective if done within six months of if done within six months effective may be more surgery for first line option and may be a reasonable younger women. those who have already undergone surgerythose who have already to improve servedfertility and failed to conceive, may be better to IVF. by earlier recourse rectovaginal endometriosis have also been foundrectovaginal delivery caesarean higher risk of andto be at namely hysterectomy, surgical complications, than controls. haemoperitoneum and bladder injury, effective treatment, the pregnancy rate in women with in women rate the pregnancy effective treatment, other women with of endometriosis is almost half that This may be because endometriosis for IVF. indications oocyte and embryoaffects quality and development, as well as endometrial receptivity. association with intrauterine growth restriction or restriction with intrauterine growth association stillbirth. References 1. 2. 3. 4. Pregnancy outcomes Although the exact mechanism for the relationship is evidence to suggest there unclear, remains in adverse obstetric outcomes inan increase women who achieve live birth with endometriosis, spontaneousincluding endometriosis-associated birth,haemoperitoneum, placenta praevia, preterm antepartum haemorrhage andpre-eclampsia, section. caesarean ART for endometriosis-associated infertility ART for endometriosis-associated the most established techniques are and IVF COS IUI, is endometriosis. There available to women with In stage I/IIoptimal approach. no consensus on the has with COS IUI infertility, endometriosis-associated by a factor the live birth rate been shown to increase to no treatment. almost six when compared of Conclusion mayEndometriosis is a common condition that ofhave significant impact on fertility via a variety it would appear fertility, mechanisms. In terms of endometriosis of plus excision a laparoscopy that the most offers normal anatomy of and restoration the spontaneous increases benefit. Surgical treatment of the success rate and improves conception rate ART in stage I/II disease, and may assist in stage III/IV. to guide good-quality research is need for more There such patients.management of ANZARD report, however, IVF cycles reporting male IVF cycles reporting however, ANZARD report, had infertility as the only cause of factor infertility per cent), followed the highest live delivery (19.7 rate and with female tubal disease by cycles reported per (19.2 infertility endometriosis as the only causes of per cent). cent and 19.2 of ART, there is no evidence that surgical treatment surgical treatment that is no evidence there ART, of and rate pregnancy will improve endometrioma of pain management of for be considered should only ovarian accessibility. or to improve counselled regarding the risks of reduced ovarian ovarian reduced of the risks regarding counselled surgery. function after include potential avoidance of contamination of of contamination avoidance of include potential content and other follicular fluid with endometrioma endometrioma, such as of potential complications or malignant transformation. rupture

25 24 15 There There 4 Should 23 There is no There 19 4 There is a paucity There 6 Prospective cohort studies Prospective however, other indications however, There are no randomised are There 21,22 20 4,20 There is a lack of prospective prospective of is a lack There 4,17 One controlled prospective study, study, prospective One controlled 4,18 laparoscopic excision or ablation of lesions of or ablation excision laparoscopic 16 adhesiolysis will increase the ongoing pregnancy pregnancy the ongoing will increase adhesiolysis to diagnostic when compared rate, and live birth alone. laparoscopy published in 2018, demonstrated a higher rate of of a higher rate demonstrated published in 2018, conception in women following surgical natural DIE. rectal of treatment have also shown that in women with infertility and in women with infertility have also shown that laparoscopy stage III/IV endometriosis, operative rates. spontaneous pregnancy may increase evidence to support the use of repeat laparoscopic laparoscopic repeat use of evidence to support the although it may be surgery fertility, to improve pain. of for treatment considered is no benefit in repeat surgery. repeat is no benefit in controlled trials comparing ablative with excisional trials comparing ablative controlled data is also a lack of There prior to ART. treatment surgery comparing laparoscopic directly to IVF for with minimal endometriosis and infertility. patients of data examining the effect of bowel resection on resection of bowel examining the effect data of and success of rate both spontaneous pregnancy study found that although one observational ART, the bowel, complete in women with DIE affecting resulted and bowel segmental resection excision of than removal in higher monthly fecundity rates endometriosis without bowel resection. All techniques carry potential risks for ovarian normal ovarian tissue of either by removal reserve, or by thermal damage to the ovarian during excision women should be Therefore, cortex during ablation. Surgical treatment of stage III/IV endometriosis Surgical treatment of stage III/IV endometriosis and natural conception endometriosis to severe with moderate In patients that demonstrates stage 3–4) the data (rASRM surgerylaparoscopic better than expectant is management. Surgical treatment of stage I/II endometriosis stage I/II endometriosis Surgical treatment of prior to ART evidence to suggest that quality is moderate There endometriosis, stage I/II in women with rASRM prior to ART may disease of treatment laparoscopic live birth rate; improve to mild endometriosis (revised American Society for Society American (revised endometriosis to mild stage classification Medicine (rASRM) Reproductive 1–2), resection of DIE be performed, there is, of course, is, of DIE be performed, there of resection over laparotomy. of laparoscopy benefit for fertility data comparing effectiveness of modalities effectiveness comparing data monopolar laser vaporisation, such as CO2 excision. and electrocoagulation for surgery may be taken into consideration. Complete into consideration. for surgery may be taken minimal to mild endometriosis of surgical excision embryo of the rate implantation,may improve as well as reduce and live birth rate rate pregnancy time to first pregnancy. Multidisciplinary review, case-by-case decision Multidisciplinary review, surgery risks of of consideration making and careful for a good outcome. essential pre-requisites are Surgical treatment of stage III/IV endometriosis prior to ART DIE as an adjunct of surgical treatment The impact of The available published studies to IVF is controversial. not large enough to allow and are observational are remains for any definitive conclusions. Thus, it of surgeryimpossible to define the absolute effect of of facilitation beyond the benefit in this group ovarian access. Management of ovarian endometrioma with ovarian endometrioma undergoing In patients the endometrioma capsule of excision surgery, spontaneous pregnancy the postoperative increases to drainage and electrocoagulation. compared rate, PELVIC PAIN 19. 18. 17. 16. 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5.

surgery forendometriosis.FertilSteril. 2009;92(4):1253-5.surgery around: reproductive performanceafter repetitive versusprimary P Vercellini, ESomigliana,RDaguati, etal.Thesecondtime classification system.HumanReprod.2006;21(10):2679-85. treatment forendometriosis:thepredictive valueof thecurrent pain recurrence anddiseaserelapse after conservative surgical P Vercellini, LFedele,GAimi,etal.Reproductive performance, endometriosis. Cochrane Database Syst Rev.2014(4):Cd011031. JM Duffy, KArambage, for FJ Correa, etal.Laparoscopic surgery of endometriosis: 1996. FertilSteril. 1997;67(5):817-21. Revised AmericanSocietyforReproductive Medicineclassification 2012;52(6):513-22. CREI ConsensusExpertPanelonTrial evidence).ANZJOG. Infertility –aconsensusstatement from ACCEPT (Australasian J Koch, KRowan,LRombauts,etal.Endometriosisand 2004(3):Cd003678. therapy forendometriosissurgery. Cochrane Database Syst Rev. C Yap, SFurness, CFarquhar. Pre andpostoperative medical endometriosis. Cochrane Database Syst Rev.2007(3):Cd000155. E Hughes,JBrown, JJCollins,etal.Ovulation suppression for 2005;112(10):1391-6. transport assessedbyhysterosalpingoscintigraphy. BJOG. rates inendometriosisduetoimpaired uterotubal S Kissler, NHamscho,SZangos,etal.Diminishedpregnancy Hum ReprodUpdate. 2000;6(1):67-74. qualityinwomenwithendometriosis. environment andembryo N Garrido,JNavarro, JRemohi,etal.Follicularhormonal 2003;20(3):117-21. patients withmild/minimalendometriosis.JAssistReprodGenet. Physiopathological aspectsof corpusluteumdefectininfertile JS Cunha-Filho, JLGross, CABastosdeSouza,etal. endometriosis. FertilSteril. 2001;75(1):1-10. DI Lebovic,MDMueller, RNTaylor. Immunobiologyof prospective controlled trial.HumReprod.2002;17(2):426-31. endometriosis withserumandperitonealfluidmarkers: a MA Bedaiwy, TFalcone, RKSharma,etal.Prediction of 2004;19(1):96-103. and infertile womenwithminorendometriosis.HumReprod. natural conceptionbetweenwomenwithunexplainedinfertility VA Akande,LPHunt,DJCahill,etal.Differences intimeto Fertil Steril. 2012;98(3):591-8. Medicine. Endometriosisandinfertility: acommitteeopinion. Practice Committeeof theAmericanSocietyforReproductive 2012;39(4):535-49. infertility. ObstetricsandGynecologyClinicsof NorthAmerica. the pathogenesis andtreatment of endometriosis-associated ML Macer, HSTaylor. Endometriosisandinfertility: areview of For more information,email: [email protected] developed by RANZCOG. onthe latestinitiatives oftopicandarticles information onavariety featuringhelpful e-newsletter, Collegiate isthe College'sfortnightly news fromRANZCOG You’ve gotmail 33. 32. 31. 30. 29. 28. 27. 26. 25. 24. 23. 22. 21. 20.

deep infiltrating endometriosis.FertilSteril. 2016;106(5):1129-35. inwomenwithuntreatedpregnancy rectovaginal anddelivery C Exacoustos,ILauriola,LLazzeri, etal.Complications during 2016;22(1):70-103. complications andoutcomes.HumReprodUpdate. on endometriosisduringpregnancy: diagnosis,misdiagnosis, U LeoneRobertiMaggiore, SFerrero, etal.Asystematic review adenomyosis. FertilSteril. 2015;104(4):802-12. postpartum complications associated withendometriosisand P Vigano,LCorti,NBerlanda.Beyondinfertility: obstetricaland South Wales Sydney. 2018. Perinatal EpidemiologyandStatistics Unit, theUniversity of New technology inAustraliaandNewZealand 2016. Sydney: National O Fitzgerald, RCPaul,KHarris,etal.Assistedreproductive on invitro fertilization. FertilSteril. 2002;77(6):1148-55. K Barnhart,RDunsmoor-Su, CCoutifaris.Effect of endometriosis with minimalormildendometriosis.FertilSteril. 1997;68(1):8-12. trial of superovulation andinsemination forinfertility associated IS Tummon, LJAsher, JSMartin,etal.Randomized controlled 2004;81(5):1194-7. fertility outcomes:amatched, case-control study. FertilSteril. endometriomas before invitro fertilization doesnotimprove JA Garcia-Velasco, NGMahutte,JCorona, etal.Removalof technology. Cochrane Database Syst. 2010(11):Cd008571. Rev for womenwithendometriomapriortoassistedreproductive L Benschop,CFarquhar, NvanderPoel,etal.Interventions Database Syst Rev.2008(2):Cd004992. forovarianendometriomata. Cochraneablative surgery RJ Hart,MHickey, PMaouris,etal.Excisional versus surgery 2011;95(6):1903-8. comparing laparoscopy withopensurgery. FertilSteril. resection forendometriosis:results of aprospective study E Darai,BLesieur, GDubernard,etal.Fertilityafter colorectal 2009;24(7):1619-25. of bowelendometriosisininfertile women.HumReprod. A Stepniewska, PPomini,FBruni,etal.Laparoscopic treatment colorectal endometriosis.HumReprod.2018;33(9):1669-76. postoperative fertilityrate followingsurgicalmanagementof H RomanH, IChanavaz-Lacheray, MBallester, etal.High Hum Reprod.2017;33(3):47-57. in deependometriosisinfiltrating the rectum: arandomized trial. versuscolorectal resectionH Roman,etal.Conservative surgery Online. 2011;23(3):389-95. of subsequentIVF/ICSItreatment. ReproductiveBiomedicine removal of minimalandmildendometriosisimproves outcome HK Opoien,PFedorcsak, TByholm,etal.Completesurgical PELVIC PAIN For For 3 Vol. 21 No. 2 Winter 2019 | 26 Vol. ) before they undertake the procedure. the procedure. they undertake ) before and, again the treatment of both the of and, again the treatment 5 4 women who do not tolerate these medications, these medications, women who do not tolerate with their use or have side effects associated despite using them, have ongoing pain symptoms surgery for management. The may be an option first question when considering surgery is ‘what is the expected outcome?’ Diagnostic procedures in modern management should not be considered the the risk to endometriosis as they increase of always benefit. The plan should woman with no real and it should be rare approach be a see-and-treat by the the gynaecological surgeon is surprised that at laparoscopy. findings important.A surgeon’s insight into their own skillset is of suspicion following a high index of Investigation endometriosis based on history taking and clinical pelvic masses and a fixed, may reveal examination uterus. This is an indication retroverted, and often be high-stage disease and the surgeon must of undertaking sidewall and cul-de-sac comfortable dissection. Based on evidence, for any endometrioma is sidewall there is a 99 per cent chance that there disease, endometrioma and the sidewall disease must be theendometrioma and the sidewall disease must this aim and the surgeon must have preoperative level 4 in their skillset (minimum RANZCOG-AGES being level 5 or 6 skills with possibility of procedure, required Even without the much-discussed deep invasive Even andendometriosis ultrasound, a good 2D scan will be able to guide direction clinical examination difficulty in most surgical situations. of for the degree endometriosis (DIE) scan a deep infiltrating Where offers outstanding this is available (and affordable), when informs the pelvic disease, often mapping of colleagues or such as colorectal additional staff, may be needed to contribute to the urologists, counselling and tailored and allows more procedure women preoperatively. consenting of not in the endometriosis are Many cases of with stage, which presents moderate–severe lesions and the involvement deeply infiltrating Peritoneal bowel, bladder or ureter. ovary, of the uterosacral disease or deep disease affecting ligaments, cul-de-sac or sidewalls is common and an has been There is required. to treatment approach versus excision over ablation considerable debate no to make it is likely and the simple fact is that which technique you use, as long as the difference (better named in toto. Ablation removed lesions are is since this is actually the effect that vapourisation, and can be carried desirable) is perfectly reasonable (such electrode out using standard electrosurgical as scissors or needlepoint) and an electrosurgical the lesion with a low-power Vapourising generator. the will remove continuous waveform current high as 50 per cent, owing to side effects. high as 50 per cent, owing It is 2 What those trials demonstrate, however, however, those trials demonstrate, What 1 early-stage disease that remains difficult to diagnose remains early-stage disease that not helpful studies are by sonography and serological in making the diagnosis. Medical options with simple analgesics and site- first line, specific symptoms should be considered to be demonstrated with hormonal treatments of the oral beneficial, although discontinuance may be as contraceptive pill and progestogens is both a placebo response of 30 per cent – common 30 per cent of is both a placebo response when they are to all medical and surgical treatments of rate studied in this manner – and a nonresponse must be 20 per cent. These figures approximately surgical treatments in mind when undertaking kept for endometriosis. with pelvic pain For any women presenting diagnoses must exclude symptoms, differential with associated conditions often life-threatening pain symptoms more with chronic pregnancy, commonest single to be endometriosis – the likely pelvic pain in women. There chronic diagnosis of clinical diagnosis to recommend data increasing are based on history pelvic examination taking, thorough and limited investigations, appropriate) (where that such as a pelvic ultrasound, with recognition sensitivity high-quality sonography has increasing small-volume disease on the discriminating at ligaments and bowel lesions, in addition uterosacral ovarian disease. of to the traditional recognition With three placebo-controlled trials for the surgical placebo-controlled With three there pain, endometriosis-associated of treatment surgeryis good evidence that pain works to relieve symptoms. Prof Jason Abbott B Med (Hons) FRCOG PhD FRANZCOG and Children’s Health School of Women’s Sydney UNSW, of endometriosis to surgical management management to surgical A pragmatic approach approach A pragmatic PELVIC PAIN in boththesurgicalandmedical managementof practice, andreferral tocentres orsurgeonsskilled with history, examination andsonography isgood not beundertaken. Evaluation asperfirstsurgery on diseaseoffers nobenefit,carriesriskandshould inthe asymptomatic womanto‘checksurgery up’ should beconsidered mandatory. Scheduled risk forcomplication andhistologyinthissetting mustbeconsidered higher Any subsequentsurgery meditation, yogaandexercise mayalloffer benefit. strategies forthewomanincludinglocalheat, appropriate, alongsidesimpleself-management involvement byaskilledphysiotherapistwhen medications, evaluation andtreatment of muscular hormonal treatments, analgesicandneuroleptic inthissituation. Considerationis mandatory of always present) andre-assessment andevaluation five years(althoughactualdisease recurrence isnot recurrence forpainisapproximately 50percentat removal of alllesionsinthepelvis,symptom Even bestsurgicaltreatments and withthevery surgical riskisincreased inthesecases. associated withrecurrent (orpersistent)diseaseand excision isdifficulttodistinguish from fibrosis fibrosis that maybeassociated withprevious surgical surgeries forendometriosisare higherrisk,sincethe respect of removing diseaseandallsubsequent be considered that ‘thefirstgoisthebestgo’with reduce theovary. Asageneralprinciple,itshould can depleteovarianfollicularreserve andvolume dissection toallowaccesssidewalldiseasethat when ovarianadhesionsnecessitate furtherovarian surgery,primary rather thansubsequentsurgery to beevaluated. Itisalsoeasiesttodothisat the does notallowforanadequate surgicalresponse the sidewalldiseaseremoved sincepersistence only istheovariandiseasetreated, butsotoois that involvestheovaries,itisimperative that not isundertaken.available wherever surgery Fordisease as laparoscopic scissors)readily andinexpensively an electrosurgical generator andanelectrode (such for excision are exactlythesameasforablation, with prevent unintendedinjury. Theinstrumentsrequired away from thelesiontopreserve theirfunctionand dissection of non-involvedanatomical structures countertraction maybereadily employedwith of thelesion.Thesurgicalprinciplesof traction- assessment of thetissuesandtogaugedepth Excisional doesallowforbothhistological surgery and, infact,mayexacerbate theproblem. maynotimprove thesituation subsequent surgery is noendometriosis,recurrence of symptomsand respond toasecondsurgicalprocedure; where there recurrence rate withendometriosis,whichmay This isimportant,sincewhilethere isadefinite considered tobeendometriosisare thisdisease. it iswelldocumentedthat notalllesionsthat are histological assessmentof theabnormaltissueand The techniqueof vapourisation doesnotallowfor and anincreased riskof unintendedthermalinjury. avoided sincethisleadstosuperficialinsulation lesion, andcarbonisation of thetissuesmustbe structures that maybeinjured inproximity tothe an understandingof thepotentialanatomical lesions isalsoperfectlyreasonable butrequires neuropathic sensitisation. Vapourisation of deep surrounding tissuethat mayinducecicatrisation and lesion withminimalthermalspread anddamageto women desiringpregnancy. should betherecommendation post-operatively for also guidewhetherexpectantmanagementorIVF implications forsubsequentpregnancy andmay and validated assessmenttoolthat hasprognostic endometriosis fertilityindex(EFI)isasurgicallybased it mayimprove counsellingandconsent.The of women,althoughthat wouldbehelpfulsince thisgroup have nowayof currently identifying It isunclearastothetriggersforthisandwe rapid(asmayrecurrence).progression maybevery cent of women.Forasmallnumberof women, progression intwoyearsisapparent for80per studies suggestingthat noprogression–minimal on surgery. Progression isusuallyquiteslow, with present, butthere isnowayof knowingthisbased Women often askhowlongtheirdiseasehasbeen surgical pelvisinthissituation. options ornotconfident intheincreasingly complex surgeonisunfamiliar withtherangeof primary endometriosis andpainisappropriate where the per centof womenlivingwiththisdiseaseglobally. contribute toimproving thequalityof lifeof some10 management of womenwithendometriosisand improve ourknowledgeinthearea of thesurgical 8. 7. 6. 5. 4. 3. 2. 1. References for endometriosis prevalence of thedisease.TheNational ActionPlan is acommonprocedure commensurate withthe surgeries,this and thesamenumberof secondary With some16,000 surgeriesforendometriosis primary with thewoman. versus newdiseaseandforprognostic discussions by photographicevidencetodeterminerecurrent pre-operative planningwillbemore readily facilitated the risksassociated withanysubsequentprocedure, and presentations, thepotentialforfurthersurgery evaluation. Furthermore, giventherangeof disease this mayalsoaidinfertilitycounsellingandEFI partof theprocedure,should beamandatory since Clinical and Scientific (NECST) network Clinical andScientific(NECST) studies viatheMRFF-funded National Endometriosis endometriosis. Large-scalenational research of clinicalcare pathways forwomenwithsuspected foundation pillarsandincludestherecommendation

org.au/necst. Trials Network. 2019. (NECST) Available from: https://jeanhailes. Jean Hailes.TheNational Endometriosis ClinicalandScientific publishing.nsf/Content/endometriosis. 2018. Available from: www.health.gov.au/internet/main/ Department of Health.National ActionPlan forEndometriosis. 2010;94:1609-15. new, validated endometriosisstagingsystem.FertilSteril. GD Adamson,DJPasta.Endometriosisfertilityindex:the pdf?ext=.pdf. endoscopic-procedures-(C-Trg-2)-Amended-November-2018. Training/Guidelines-for-performing-gynaecological- Health/Statement%20and%20guidelines/Clinical%20-%20 au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20 endoscopic procedures. 2018. Available from: www.ranzcog.edu. RANZCOG. Guidelinesforperforminggynaecological pelvic andintestinaldisease.Fertility&Sterility. 1999;72(2):310-5. Redwine DB. Ovarianendometriosis:amarker formore extensive Reviews. Cochrane Database Syst Rev.2014(3):CD009590. Brown J, Farquhar C.Endometriosis:anoverview of Cochrane Obstetrics. 2018;142(2):131-142. endometriosis. International Journalof Gynaecology& based approach toassessingclinicaldiagnosisof symptomatic Taylor HS, AdamsonGD, DiamondMP, etal.Anevidence- Publishing Ltd. 2012.p.410-18. DOI:10.1002/9781444398519. Endometriosis. Endometriosis:ScienceandPractice.Blackwell Abbott J. SurgicalTherapies:Randomized Controlled Trials in 7 hasclinicalcare asoneof itsthree 6 Photodocumentation 8 will further willfurther PELVIC PAIN 4 Vol. 21 No. 2 Winter 2019 | 28 Vol. Botulinum toxin is Botulinum toxin A minority of patients A minority of 3 6 When pain is relieved at pudendal block, at When pain is relieved 5 even temporarily, the block is considered positive. the block is considered even temporarily, a from best undertaken Pudendal blocks are under with the needle directed transgluteal route, radiological guidance to the space between the ligaments. A and sacrospinous sacrotuberous to target the likely is more transgluteal approach entrapment between these site of anatomical the pudendal ligaments and block early branching of nerve, which can occur above the ischial spine. than the vaginal proximal is more This approach which blocks the nerve in Alcock’s canal. approach, is not helpful to the steroids The addition of of the block. therapeutic effect derive therapeutic benefit from a local anaestheticderive therapeutic benefit from other agents or the useblock alone. The addition of being investigated. are pulsed radiofrequency of Pudendal block the diagnostic criteria part of Pudendal blocks are and may for pudendal nerve entrapment syndrome women with pudendal be therapeutic in a subset of pudendal neuralgia present with neuralgia. Women the nerve, which may with pain in the distribution of include the clitoris, vagina and anus. Pudendal nerve of presentation one type of entrapment syndrome, pudendal neuralgia, is defined by Nantes criteria 1). (Box endometriosis, bladder pain syndromes, vulvodynia pain syndromes, endometriosis, bladder Management is and irritable bowel syndrome. interdisciplinary education, and includes patient and pharmacotherapy psychology physical therapy, pain. for neuropathic with pain refractory may beto these measures Women Botulinum to pelvic muscles. botulinum toxin offered inhibiting engenders antidystonic effects by toxin junction. neuromuscular the at acetylcholine release signallingIt may also have actions on afferent and substance P and nociception via blockade of two to action begins to occur in Onset of glutamate. Theafter two weeks. reaches its nadir five days and months. three after action reduces of duration has long been botulinum toxin The clinical potential of Justinus when the 19th century, from recognised sausage poisoning on from studied the toxin Kerner himself. animals and, ultimately, utilised widely for spasticity, dystonia, migraine and utilised widely for spasticity, to the pelvic floor Botulinum toxin overactive bladder. non-menstrual pelvic pain dyspareunia, can reduce applied Lower doses and vaginal pelvic floor pressures. not were to select muscles, such as bulbospongiosus, found to be effective. botulinum of the application It is prudent to note that the muscle and is distinct from to is directed toxin the use of trigger point injection. It is not clear that local anaesthetic, saline or physical botulinum toxin, point superior to each other in trigger therapy are in clinical trigger points The concept of treatment. points practice has also been challenged, as trigger nociceptive central altered of may be a manifestation itself. of pain of than a generator mechanisms, rather 1 Pelvic floor myalgia arises 2 from dysfunction in muscle and the surrounding dysfunction in muscle and the surrounding from commonly in women connective tissue. It presents with with persistent pelvic pain and can be associated Gynaecologists and obstetricians have a unique their in managing pelvic pain because of role life quality of women’s broader understanding of come with experiencing outcomes and goals that pelvic pain. These include sexual health, fertility and and bladder and bowel function. pregnancy, Pain management in our specialty is not restricted 1). to caring for women with endometriosis (Table support for women A pelvic pain service should offer with our anaesthetic with any pain, collaborate colleagues, and has a unique care and palliative pain as it intersects with opportunity to address changes in a woman’s life. for indications of is a breadth there Accordingly, pelvic pain. interventions in the management of common interventions are the more Some of outlined in this article. floor to the pelvic Botulinum toxin with pelvic floor myalgia may benefit Women botulinum toxin. from Interventions are a small, but important, component Interventions are interdisciplinary pain management. Recognition of of intervention as part of management and the role is care a sociopsychobiomedical paradigm of of The necessary procedures. undertaking before pelvic pain should not be confined management of pain is practice, where to a Cartesian model of to is directed viewed as a symptom and treatment the an identified cause. Pain management targets are treatment pain and the goals of mechanisms of in life and function quality of patient to improve goals. concordance with patient-defined Dr Jason Chow FFPMANZCA BSc(Med), MBBS, FRANZCOG, Sydney Hospital for Women, Royal Institute of Australia Research Health Women’s management options management Interventional PELVIC PAIN Table 1.Typical consultations of apelvicpainservice. ligamentous dysfunction,suchas duringandafter in rheumatological diseasesorwith joint and It canbeassociated withjoint inflammation with lowbackpainorposterior pelvic pain. Pain derivedfrom thesacroiliac jointmaypresent Sacroiliac blocks management first. and womenshouldbeoffered non-interventional and somatic innervation from thesacralplexus including from coccyxtrauma,ligaments,levators Coccyx painhasmixed mechanisms,however, radiofrequency treatment totheimparganglion. Some womenwithcoccydyniamaybenefitfrom from therectum travelwithsympathetic fibres. surface of thecoccyx.Visceralafferent fibres paravertebral sympathetic chainsat theanterior The imparganglionisthecoalescenceof the alcohol orradiofrequency isundertaken. derive improvement, thenanablation withphenol, diagnostic blockwithlocalanaesthetic,andifthey hyperalgesia. Patients withcancerpainundergoa pain mechanismstendtobeinvolvedinvisceral single neuroanatomical pathway andthat central given that visceralnociceptionisnotdefinedbya Their benefitinchronic non-cancerpainisselect in thesettingof persistentpaininmalignancy. in cohortstudiesandcaseseries,particularly Superior hypogastricblockshavebeendescribed coccyx, orthrough aparavertebralapproach. junction, oranteriorandcephaladfrom thetipof the ganglion canbeaccessedthrough acoccygeal direction tolieanterolateral toL5/S1.Theimpar a longspinalneedleisdirected inaparavertebral radiological guidance.Forsuperiorhypogastricblocks, are typicallyundertaken intheprone positionunder blocks andtotheimparganglion.These Sympathetic blocksincludesuperiorhypogastric Sympathetic blocks are mostlikelysurgery toderivetherapeuticbenefit. pudendal neuralgiaafter aneventsuchasbirthor Older womenandwhohavesubacute Education Cancer pain Acute pain Obstetrics Gynaecology College health Primary Patient –individualandgroup Interventional management(includingnerveblocks,intrathecal therapy) Sexual dysfunctionandpain Management of opioid-dependentpatients Preventive analgesia Chronic painafter LSCS Obstetric traumaandpudendalneuralgia Coccydynia Pelvic girdlepain Opioid useinpregnancy including rheumatoid arthritis,SLE,Ehlers-Danlos, CRPS Chronic painconditionsinpregnancy Migraine Visceral hyperalgesia Bladder painsyndrome Chronic post-surgicalpain(includingmeshrelated pain) Peripheral neuralgias(includingpudendal,iliohypogastric) Levator myalgia Dyspareunia Persistent pelvicpain waveforms andacombination of waveforms. and organdysfunctionusingmultipleleads, Vancaillieprotocol describedbyThierry treats pain with leadsdirected totheS3nerveroot. TheSydney well-established interventionforbladderdysfunction neurostimulation isfamiliartogynaecologistsanda management forwellselectedpatients. Sacral Neuromodulation isapromising avenueof Sacral andpudendalneuromodulation despite conservative measures. for womenwithcontinueddysfunctionorlaxity ligaments isbeinginvestigated andmaybeanoption clinic. Platelet-rich plasmaappliedtothesacroiliac most presentations are forbackpainandtoa lateral sacralbrancheshasbeendescribed,but and monopolarradiofrequency ablation of the benefit from sacroiliac jointinjections.Bipolar A minorityof womenwithpersistentpainmay are mostcommonlyused. setting of pregnancy, exercise andphysicaltherapy pregnancy, orinconnectivetissuedisorders.Inthe with thedorsalroot gangliaanimportanttarget. mechanisms of pain,includingcentralmechanisms, brainstem andlimbicsystem.Thisaddresses several mechanisms andpossiblythrough effectsonthe dynamic rangeneurons through GABAergicorother ganglia involvedinnociception,inhibitionof wide altering theexcitability of cellsinthedorsalroot the pudendalnerve.Mechanismsof actioninclude foramina ormayincludeperipheralstimulation of the sacraldorsalroot ganglia,through theS3orS4 Leads are typicallyplacedviathesacralhiatus over Positive response toapudendalblock deficitfeatures No objectivesensory Pain doesnotwake at night Pain worseonsitting Pain inthedistributionof thepudendalnerve Box 1:Nantescriteria 7 PELVIC PAIN A RANZCOG R A RANZCOG Vol. 21 No. 2 Winter 2019 | 30 Vol. NT PJ Siddall, MJ Cousins. Persistent pain as a disease entity: pain as a disease entity: Siddall, MJ Cousins. Persistent PJ . clinical management. Anesth Analg for implications 2004;99:510-20. type A for et al. Botulinum toxin SD Lyons, Abbott, SK Jarvis, JA Obstetrics and pelvic floor spasm in women. pain and chronic Gynecology. 2006;108(4):915-23. botulinum toxin. Historical aspects of Ergbuth, M Naumann. FJ 1999; 53(8):1850-3. Neurology. the of A critical evaluation GM Bove, ML Cohen. JL Quintner, 2015;54(3):392-9. trigger point phenomenon. Rheumatology. criteria for T Riant, R Robert, et al. Diagnostic Labat, J-J nerve entrapment (Nantes pudendal neuralgia by pudendal 2008;27(4):306-10. critera). Neurourol Urodyn. corticosteroids T Riant, A Lassaux, et al. Adding Labat, J-J for pudendal neuralgia. BJOG. to the pudendal nerve block 2017;124(2):251-60. neuromodulation L Kite, E Howard, et al. Sacral T Vancaillie, dysfunction. ANZJOG. for pelvic pain and pelvic organ 2018;58(1):102-7.

1. 2. 3. 4. 5. 6. 7. References DARWIN, CENTRE, 2020 CONVENTION APRIL

Other techniques and targets have been described. described. have been and targets techniques Other may be a treatment alone Pudendal neuromodulation Conus disorder. persistent genital arousal option for neuralgia has for pudendal stimulation medullaris have failed pudendal who for patients been described approach A retrograde surgery. decompression but is has also been described, to lead insertion and not widely applied. technically difficult Conclusion helpful for well- are The outlined interventions of as part be offered and may selected patients interdisciplinary with management for the woman may disengage or be Patients persistent pelvic pain. if an intervention first distress caused psychological if surgery is applied, or approach is or intervention used as the triage to interdisciplinary management. functional goals and the patient’s of An evaluation in a sociopsychobiomedical mechanisms for pain context is essential. DARWIN 15–18

www.ranzcog.edu.au/provincial-fellows SAVE THE DATE SAVE Regional Scientific Meeting Regional Provincial Fellows Provincial Fellows RANZCOG 2020 RANZCOG PELVIC PAIN involves: approach tomanagementiswelldocumented and management shouldbepersonalised. Astepwise and individualneedstheirtreatment and As diverseasthedisease,womenhavecomplex ofmanagement Overview pathophysiological processes. Hormonal managementaimstosuppress these which drivetheproliferation of endometriosis. synthesis andprogesterone resistance, bothof These alterations result inincreased oestrogen molecular andimmunologicalresponses. of endometriosisdescribesdysfunctionof Our current understandingof thepathophysiology like tissuegrowing outsideof theuterinecavity. Endometriosis ischaracterisedbyendometrial- that 700000Australianwomenhaveendometriosis. dysmenorrhea haveendometriosis.Itisestimated of severe andprimary young adultswithahistory pain. More than73percentof adolescentsand can leadtosubfertility, infertility andchronic pelvic physically, sexuallyandpsychosocially. Endometriosis with aspectrumof symptomsthat canaffect them in 10women.Women present tohealthpractitioners Endometriosis isamodernepidemic;itaffects one HMO, MonashHealth MBBS BSc, MPH, MHA, Dr EstelleBlair-Holt of endometriosis Hormonal management • Head ofReproductive Medicine,MonashHealth Group MedicalDirector, MonashIVFGroup Adjunct ClinicalProfessor, MonashUniversity MD, PhD, FRANZCOG, CREI Prof LukRombauts Melbourne IVF MonashHealth Endometriosis Surgery, Head ofGynaecologicalEndoscopyand MBBS, FRCOG, FRANZCOG Dr JimTsaltas Gynaecological EndoscopyFellow, MonashHealth MBBS, FRANZCOG Dr Roni Ratner endometriosis-related pain or NSAIDs)forfirst-linemanagement of a shorttrialof analgesics(paracetamol and/ 2 1 an anti-inflammatory andanti-angiogenican anti-inflammatory activity. Furthermore, progestins havebeenshownto and inhibitinggrowth of endometriosis lesions. of endometrium,alteringoestrogen receptors multiple pathways, including stoppingproliferation routes (orally, implantorIUD).Progestins canacton hormones, whichcanbeadministered viamultiple Progestins are syntheticprogesterone-like Progestins • Prescribe: intervention, orpost-surgicalintervention. surgical intervention,asanadjunctto process. Hormonaltreatments canbeusedtoavoid endometriosis ischronic suppression of thedisease The overarching role of hormonaltherapyin Hormonal therapy are allimportant. and decreasing diseaserecurrence followingsurgery management, side-effectprofiles, fertility treatment As achronic disease,thebalanceof symptom management inthesettingof theirdisease. Women needtobeeducated aboutpharmacological • • • (described below). post-surgery. Thirdly, as‘add back’therapy Secondly, fortheprevention of diseaserecurrence dysmenorrhea that isnotresponsive toNSAIDs. ways. Firstly, forsymptommanagementof primary for endometriosis,theCOCP canbeusedinthree venous thromboembolism. Asahormonaltherapy breast cancer, highriskof cardiovasculardiseaseor smoke, are olderthan35, havehighbloodpressure, effects. Itmaybecontraindicated inwomenwho cheap andgenerallywelltolerated withmildside pain associated withendometriosis.TheCOCP is most effectiveasmanagement of cyclicalpelvic pill (COCP) prescribed ascontinuoustherapyis suggests that lowdosecombinedoralcontraceptive peak of gonadaloestrogen production. Theevidence oestrogenic environment byinhibitingthemid-cycle The oralcontraceptivecreates arelative hypo- Combined oralcontraceptivepill treatments are outlinedbelow. about 70percentof women.Available hormonal Hormonal treatment iseffectiveandtolerated in of recurrence followingretrograde menstruation. when withdrawalbleedsare avoidedsoistherisk ectopic endometrialgrowth isthusinhibitedand hypo-oestrogenic environment iscreated and suppressing folliculargrowth andovulation, a daily oraldose(4x28, PBS: $17.44) Levonorgestrel 150μg/Ethinylestradiol 30μg treatments neuromodulators andneuropathic pain combination of medicalandsurgicaltreatment management inendometriosis Table 1 summarisesanapproach tohormonal confirmed or recurrent endometriosis. hormonal treatment forwomenwithsuspected, 3,4

3 By PELVIC PAIN

3,4 3,4 Vol. 21 No. 2 Winter 2019 | 32 Vol.

3,4 100–400 mg orally, twice daily for Danazol 100–400 mg orally, $49) months (100x100mg, PBS: three–nine Letrozole 2.5 mg daily oral dose $31.12) PBS: (1x30, Drug oestrogen/progestin Monophasic Norethisterone Medroxyprogesterone intrauterine system Levonorgestrel-releasing Dienogest Goserelin Nafarelin Danazol Letrozole Prescribe: • Newer hormonal agents Aromatase inhibitors can lead to a hypo- ovulation While inhibition of has shown that research state, oestrogenic in endometriotic is abnormally expressed aromatase converts androgens lesions. The enzyme aromatase oestrogen of and local production into oestrogen is suppressed. even when ovulation is thus likely Side effects include vaginal dryness, hot flushes, As hormonal therapy BMD. headache and decreased potent inhibitors are for endometriosis, aromatase and new agents with a poor side-effect profile used when other hormonal therapies are therefore ‘add that recommended have been ineffective. It is when commencing back’ therapy should be initiated inhibitors. aromatase Other newer and novel agents have aimed to The use of on endometriosis oestrogens the action of prevent and inhibit enzymes. The lesions, block receptors have only been these medications majority of They include selective experimentally. investigated (SERMs), selective modulators receptor oestrogen (SPRMs), anti- modulators receptor progesterone factor angiogenesis factors and tumour necrosis blockers. alpha (TNF-a) significant and poorly tolerated androgenic side androgenic significant and poorly tolerated of irreversible effects (hirsutism, acne) with some risk (voice change) as well as increased virilisation lipid derangement). metabolic risks (liver toxicity, Prescribe • antagonists GnRH state GnRH antagonists induce a hypo-oestrogenic in theby competitively blocking GnRH receptors of suppression in immediate This results pituitary. GnRHLH and FSH and does not cause an initial flare. symptomsantagonists have been showed to decrease is a lower There disease progression. and suppress which leads to a hypo-oestrogenism, of degree the than GnRHa. They have better side-effect profile and an oral form ispotential to be better tolerated now clinically available but, as yet, not in Australia.

3,4

3,4 Class combination progestin and Oestrogen Progestins GnRH agonists steroids Androgenic inhibitors Aromatase GnRH antagonists subcutaneous implant 3.6 mg every Goserelin subcutaneous implant 3.6 $264) four weeks for up to six months (PBS: 200 μg intranasal twice daily Nafarelin $121.65) (1*60 doses, PBS: 5 mg daily oral dose, for Norethisterone acetate $33.54) PBS: up to 6 months (1x30, (depot) 150 mg acetate Medroxyprogesterone intramuscular injection every 12 weeks (PBS: $25.46) Levonorgestrel-releasing intrauterine system $208) 52 mg (PBS: script Dienogest 2 mg/day (available on private as Visanne) First line Second line Third line Consider Prescribe: Prescribe: • • Androgenic steroids synthetic hormones are steroids Androgenic suppressing by directly inhibit ovulation that induce a hypo- folliculogenesis. While androgens due to less favoured these are state, oestrogenic Summary of approach to hormonal management of endometriosis. 1. Summary of management to hormonal approach of Table Side effects of progestins include irregular bleeding, include irregular of progestins Side effects tenderness and weight gain. mood changes, breast they have an intrinsic bone-sparing Importantly, ‘add-back’ therapy (see effect and can be used as but cannot be used in pregnancy, below). Progestins can be used while breastfeeding. Prescribe: • • • • Gonadotropin-releasing hormones agonists hormone agonists (GnRHa) Gonadotropin-releasing GnRH by blocking state induce a hypo-oestrogenic in this results Initially, in the pituitary. receptors but ultimately FSH and LH, a transient surge of FSH GnRH receptors. of leads to a down regulation leading subsequently reduced, and LH levels are to a ‘medical menopause’ with many undesirable side effects. The hormonal surge may briefly endometriosis symptoms while cause increased may lead to the subsequent menopausal state libido, mood swings and hot flushes, decreased bone mineral density (BMD). The current decreased GnRHa therapy should that are recommendations to counter back’ therapy be combined with ‘add protect against and to the side-effect profile if given for longer than six months. osteoporosis of prescription back’ therapy is the concurrent ‘Add of as well as the consideration a synthetic progestin the to combat and/or oestrogen bisphosphonates side effects. As hormonal therapy for endometriosis, ways, the GnRHa can be used in a variety of adjunct to including as an option to avoid surgery, post-surgery. surgery recurrence or to prevent Visit ranzcog.edu.au/pvp for more information. FRANZCOG training andselection. with anemphasisonpreparation for knowledge andskillsrelevant to the practice focuses onestablishingfoundation level in obstetrics andgynaecology. The pathway prevocational doctors interested inacareer structured learningopportunitiesto The Prevocational Pathway (PVP)provides RANZCOG Prevocational Pathway (PVP) in obstetrics &gynaecology Take thenextstep towards acareer PELVIC PAIN of dienogest). is availableonPBS)andside-effectprofile (infavour different costs(infavour of GnRHa,whichhave very symptoms associated withendometriosis;however, equally effectiveforlong-termtreatment of pain and dienogesthavebeendemonstrated tobe and daysawayfrom work.Furthermore, GnRHa assumed tobearesult of decreased visitstotheGP and lowercosttonohormonaltreatment. Thisis showed increased qualityadjustedlifeyears(QALYs) endometriosis andadenomyosisseekingfertility. used inpreparation forIVFinthosewomenwith other ways.GnRHa(withaddbacktherapy)maybe as theysuppress ovulation orare contraceptivein no fertility benefitandare generally counterproductive medications. Theoutlinedhormonaltreatments have for fertilitywiththesafetyof andside-effectprofiles prescribing conundrumisbalancingawoman’sdesire prominent duringchildbearingyears,themain Secondly, sinceendometriosisisadiseasemost endometriosis. effectiveness of hormonalmanagement of Firstly, there islimitedresearch intothecost prescribing hormonalmanagement. There are acoupleclinicalconsiderations when Clinical considerations 4 5 Preliminary modelsintotheCOCP Preliminary

medical managementof endometriosis. Overall, there are three mainissuesinthelong-term Conclusion 5. 4. 3. 2. 1. References well asbeingaffordable. pregnancy andhasafavourableside-effectprofile as medical treatment that doesnotprevent orpreclude pharmacological research shouldfocusonfinding of diseaseat individualandpopulation levels.New contribute toareduction intheimpactandburden management hasthecapacitytosynergistically desire fertility. Appropriate pharmacological intolerable sideeffects.Lastly, manywomen the medications havesignificantandsometimes following cessation of medication. Secondly, women experiencearecurrence of symptoms

2019;14(1):e0210089. endometriosis-related pain:aneconomicevaluation. PLoSONE. Oral Contraceptivescompared to‘nohormonaltreatment’ for TS Grand,HBasarir, LJJackson.TheCostEffectiveness of 2019;19(4):343-60. latest developments.ExpertOpinionof BiologicalTherapy. of hormonalandbiologicaltherapiesforendometriosis: F Barra,GGrandi,Tantari, etal.Acomprehensive review Endometriosis. ClinObstetGynecol.2017;60(3):485-96. S Rafique, AHDeCherney. MedicalManagement of 2014;29(3):400-12. management of womenwithendometriosis.HumReprod. GA Dunselman,Vermeulen N, Becker C,etal.ESHREguideline: Obstet Gynecol.2018;131(3):557-71. T Falcone, RFlyckt. ClinicalManagementof Endometriosis. 3 Firstly, PELVIC PAIN As a 4 found 5 noted, very 3 Vol. 21 No. 2 Winter 2019 | 34 Vol.

This was a randomised controlled trial (RCT) trial controlled This was a randomised 6 Secondly, as Panisch and Tam Secondly, 4 with 61 participants, most of whom were African whom were with 61 participants, most of of an RCT and example in this field American, a rare participants. a study conducted with non-Caucasian focuses on IPT is a time-limited psychotherapy that with both the onset interpersonal issues associated and for this study depression, and maintenance of content. pain-related was modified to incorporate Why are these outcomes so disappointing? a multidisciplinary that approach it is likely Firstly, effective than psychological interventions is more alone. some evidence (albeit in low- or very low-quality pain in women of reporting studies) for reduced ultrasound who had undergone reassurance counselling, and in women scans and received part in writing therapy as a form who had taken very small recent Two emotional disclosure. of some benefits for mindfulness studies have reported the better quality studies in interventions, and one of interpersonal therapy (IPT) found that the literature but not pain reducing depression, was beneficial in severity. consequence, she decides to stay home from work, consequence, she decides to stay home from the pain is indeed the belief that which reinforces she has unbearable. Meanwhile, she feels guilty that social work and misses out on the stayed away from which in this could have provided, interaction that to lower turn, lowers her mood. Lower mood leads self-worth. sense of pain tolerance, and a reduced points in this a number of CBT seeks to intervene at cycle, using interventions such as pain education, coping skills, imageryrelaxation, techniques, goal thoughts. setting, pacing, and challenging unhelpful such as mindfulness-based approaches Increasingly, or acceptance and commitment reduction stress therapy (ACT) also being used, either to are traditional CBT or as approaches supplement more the in their own right. With all these approaches, skills develops a ‘toolkit’ of the patient goal is that enable them to manage their that and strategies than fight against it, and carrypain, rather out valued effectively. activities more the supporting evidence of wealth a is there Although of musculoskeletal treatment of CBT in the efficacy works with PPP is pain, the evidence for what non- of Cochrane review limited. A 2014 more pelvic pain for chronic surgical treatments In recognition of the complexity of most pain complexity of the of In recognition a it is not surprising that PPP, conditions, including to their treatment approaches psychological range of The best evidence exists for have been suggested. (CBT).cognitive behaviour therapy The fundamental events of the interpretation CBT is that principle of and emotional reactions (the cognition) shapes Applied to persistent pain, subsequent behaviour. avoidance the cycles of this can help to understand arise; a woman may experience can that and distress pain, giving rise to the thought of an exacerbation thinking is ‘the pain is unbearable’. This kind of that and is to as ‘pain catastrophising’ sometimes referred to treatment. a poor response known to predict

3 showed that women showed that 2 Like most forms of persistent pain, PPP most forms of Like 1 Dr Arthur Stabolidis PhD MPsych (Clin) Private practice, Melbourne often feel a sense of shame and disempowerment as feel a sense of often for a satisfactorythey struggle to search diagnosis. as with other conditions with unclear Moreover, of is a high prevalence there medical aetiology, prior trauma, including childhood sexual abuse, and which add to the disorder, co-morbid psychiatric life. PPP for quality of consequences of can have a profound impact on many aspects of impact on many aspects of can have a profound a woman’s identity, life and functioning, affecting and the capacity to reproduce ability to be intimate Specific underlying causes for children. and care pelvic pain can be difficult to detect, and even of found, are lesions, scarring, or inflammation where study is difficult. In a qualitative effective treatment with women experiencing medically unexplained Malterud and disorders, Werner Persistent pelvic pain (PPP) is considered one of one of Persistent pelvic pain (PPP) is considered the most complex and difficult pain conditions to treat. A/Prof Christina Bryant PhD MA (Clin Psych) Melbourne School of Psychological Sciences, of Melbourne University The stigma of pain stigma The All in their mind? mind? in their All PELVIC PAIN interventions a therapeutic relationship is important. interventions atherapeuticrelationship is important. sessions, suggestingthat evenintechnology-based the senseof connectionwiththenarrator of the useful were thesessiononself-compassionand of theapphighlightedbywomenasparticularly and copingfrom theiruseof theapp.Otherfeatures pain, andtheyattributed gainingnewwaysof thinking the thingstheyneededtododespiteexperiencing adaptively withpain,theywere more confident doing Participants reported that bylearningtocopemore and clinicallysignificantincreases inpainself-efficacy. clinically significant reductions inpaincatastrophising that more than50percentof participantsexperienced phone appthat wecalledappEASE.Pilotdata indicate Based ontheinformation gathered, webuiltamobile was ‘all intheirmind’. others feared thedistress of beingtoldthat theirpain condition that maylimitmedicaltreatments, while concerned aboutbeinglabelledwithapsychological Meissner andcolleagues unusual approaches totreatment. Forexample, methodologically. Thisarea of research mayattract smallnumbersof participantsandare weak very Thirdly, almostallthestudieswereviewed have neglecting toaddress underlyingcausesof distress. trauma, which,arguably, willreduce theirefficacyby of few interventionsforPPPaddress thehistory treating cliniciansdon’tbelievetheirpainisreal. to them,becausetheyfeelthat thismeansthat when doctorsrecommend psychologicaltherapies We doknowthat somewomenreact negatively littleaboutwhat womenthemselvesfinduseful.very treatments haveostensiblybeendesigned.We know absence of thevoicesof thewomenforwhomthese One strikingfeature of thestudiesreviewed isthe forPPP? interventions What’s thewayforwardforpsychological stigma, costandlackof timeasreasons. were reluctant toengageinpsychotherapy, citing with theliterature, somewomenreported that they states affected theirexperience of pain.Consistent and somewere already aware of howtheirmental helpful experienceswithpsychologistsinthepast, open tousingpsychologicalstrategies. Somereported mindfulness exercises wepresented andappeared that thepatients responded positivelytotheCBTand to receiving itviatechnologicalmeans.We found receiving psychologicaltherapy, andiftheywere open groups. We wantedtounderstandhowtheyfeltabout women themselveswantbyrunningaseriesof focus to overcome ourlackof knowledgeaboutwhat help womenmanagetheirpelvicpain,wesought As partof astudyinwhichwedesignedanappto treatment sessions. mobility andfinditdifficulttoconsistently attend illness. Inaddition,manyPPPpatients suffer reduced therapy andpotentiallybeinglabelledwithamental because of thestigmaattached toundergoing Others are reluctant toattend psychologicaltherapy as acupuncture, moxibustion (heat), andcupping’. stimulation from traditionalChinesemedicinesuch together with‘techniquesof somatosensory hypnotherapy, problem-solving therapyandCBT, elements: mindfulness-basedpsychotherapy, an interventioncombiningthefollowingdisparate 7 reported ontheefficacy of 8 Others were Otherswere 2

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troubled, group of women. learned abouthowbesttohelpthisdiverse,butoften treating clinicians.Finally, muchremains tobe particularly relevant forthispopulation andtheir so anorientation towardsself-compassionmaybe exacerbated byinconclusivediagnosticprocesses, women experiencingPPPcanfeelasenseof failure, and physiotherapist.Secondly, ourstudyfoundthat care that includesagynaecologist interdisciplinary are likely tobemore effectivewhenintegrated with psychological interventionsmayhaveaplacebut should beinvolvedintheirdesign.Standalone but are opentopsychologicalinterventions,and experiencing PPPsometimesfeelmisunderstood, what theyneed.Ourowndata suggestthat women and large,neglectedtoaskwomenthemselves Firstly, ourevidencebaseispoor, andwehave,by to thetreatmentofPPP? understanding ofthepsychologicalcontributions What canthecliniciantake away fromourcurrent 8. 7. 6. 5. 4. 3. 2. 1. References

gynaecologists. for obstetriciansand T he go-toappresource 2012;2:82-92. medicine interventionsforpain.Translational Behavior Med. interventions forpain:Usingtheinternettodeliverbehavioral they are: Usingtheinternettodeliverbehavioralmedicine C RiniDWilliams,JBroderick, FJ Keefe. Meetingthemwhere 2016;128:1134–42. Pain: ARandomized Controlled Trial. ObstetGynecol. Stimulationwith Somatosensory forEndometriosis-Associated K Meissner, ASchweizer-Arau, ALimmer, etal.Psychotherapy pain. JPsychosomRes.2014;77:264–72. as usualforwomenwithco-occurringdepression andpelvic trial of interpersonalpsychotherapyversusenhancedtreatment E Poleshuck,SGamble,KBellengerK.Randomized controlled Syst Rev . 2014;(3):CD0087972014. the managementof chronic pelvicpain.Cochrane Database of Y Cheong,GSmotra,AC Williams.Non-surgicalinterventionsfor Am JObstetGynecol.2018;218:114.e1-12. setting:1-yearprospective cohort. pain inaninterdisciplinary C Allaire, CWilliams,SBodmer-Roy, etal.2018. Chronic pelvic doi.org/10.1177/1524838018821950. intervention literature. Trauma, Violence,&Abuse.2019. https:// the treatment of chronic pelvicpain:Asystematic review of the LS Panisch,LMTam. Therole of traumaandmentalhealthin doctors. SocSciMedicine.2003;57:1409-19. patient: encountersbetweenwomenwithchronic painandtheir A Werner, KMalterud.Itishardworkbehavingasacredible health morbidity. BMCPubHealth. 2006;6(1):177. prevalence of chronic pelvicpain:aneglectedreproductive P Latthe, MLatthe, LSay, etal.WHOsystematic review of RANZCOG Guidance App PELVIC PAIN

This shown to 28 27 6,23 A focus on Fortunately, Fortunately, 8,24 8,10,25 For example, For example, Vol. 21 No. 2 Winter 2019 | 36 Vol. 21 Pelvic health physios Pelvic health physios Thoughts alone may Thoughts alone may 14 8 This therapy overtly 27 Somatocognitive therapy Somatocognitive 6,8,26 15,17-19,20 5 hypertonicity and bladder and bowel 22 Amplification, viscerovisceral and viscerovisceral Amplification, 3,15,16 3,15,16 provoke inflammatory responses. inflammatory provoke pelvic health physio appointments often provide provide pelvic health physio appointments often additional time for women with complex pain seeks to build self-efficacy Treatment presentations. which has been catastrophising, and reduce with pelvic pain severity. associated women often reveal that merely contemplating contemplating merely that reveal women often system physical intimacy triggers their pain. Nervous contributions to deep dyspareunia and myofascial and may guide show interindividual variation surgery including in women requiring treatment, for endometriosis. PFM myalgia, Many women experience pain, fear and anxiety Many women experience to pelvic examinations. related event an initiating Endometriosis may be considered continues to trigger CPP. that of CPP, in addition to standardised gynaecological CPP, of pain, function and psychological improves treatment, beyond the which continue to improve distress, treatment. completion of takes time. Allowing a woman to tell her story time. Allowing a woman to may takes permitting development of be therapeutic in itself, management plans. woman-centred recognises the mind/body relationship and the the mind/body relationship recognises a positive working alliance, importance of dysfunction help identify women who may benefit to pelvic health physio. Physiotherapy referral from management is individualised and widely advocated. pain experiences the complexity of Addressing managing physiotherapeutically means assessing and context of local tissue issues within a broader from mechanisms resulting sensitised protective central nervous system (CNS) sensitivity. self-management and home-based components of self-management and home-based components of essential. management are PFMPhysiotherapy modalities may include education, (within and manual therapy and stretches relaxation, the pelvis), graded imageryaround and motor activity, neural dynamics, optimising bladder and bowel and body scanning techniques, health, breathing pacing and goal setting. This approach exercise, the understanding of sits nicely within our current pain. of neuroscience predict behavioural change and outcomes. predict do not perform intravaginal examinations to assess examinations do not perform intravaginal can, therefore, Management sinister pathology. not only approach graduated involve a staged and Subsequent itself. to therapy but also assessment colleagues may then be assessments by medical comfortable. more women CPP in that appreciation is a growing There central of with endometriosis may be a manifestation endometriosis-specific of regardless sensitisation, factors. viscerosomatic convergence, peripherally or at the at convergence, peripherally or viscerosomatic spinal cord, explain the link between gynaecological somatic pain and other visceral (such as bladder) or or One may initiate (such as PFM) structures. another. exacerbate

10 and and 7

3 13 PFMs Much

8 12 11 including 4 CPP severity 8 Poor localisation Poor localisation 5 and the most and the most 1 6 Apical breathing with Apical breathing 4 Most people with CPP or 3

7-9 Unfortunately, many women continue many women continue Unfortunately, 2 of the literature refers to myofascial trigger points, to myofascial refers the literature of debated. currently which are the existence of occur without conscious awareness. possible trauma mindful of care, Trauma-informed is important. A history sexual distressing of history, number of with an increasing events is associated pain symptoms in women with dysmenorrhoea. to experience pain, bladder, bowel and sexual bowel and sexual to experience pain, bladder, dysfunction despite optimal gynaecological a has Pelvic health physiotherapy often treatment. to treatment. approach part to play in a collaborative common and associated Comorbid symptoms are of with dysmenorrhoea (and its severity) regardless endometriosis presence. endometriosis have negative sexual effects endometriosis have negative may contract involuntarily in response to threat may contract involuntarily in response and observed in women with endometriosis. a braced abdominal wall is common. hypertonicity (non-neurogenic). Reduced flexibility, Reduced flexibility, hypertonicity (non-neurogenic). with a habitual motor control dyssynergia, altered their capacity to relax and reduced holding pattern both in voluntaryPFM may also be present and functional scenarios. severe deep dyspareunia, which is associated with which is associated deep dyspareunia, severe regardless bladder/pelvic floor muscle (PFM) myalgia endometriosis. of stage/location of of tactile input may suggest a degree of neglect or of tactile input may suggest a degree of poor motor sensory awareness. Women with endometriosis have increased with endometriosis have increased Women internus spasm PFM and obturator of prevalence Chronic pelvic pain (CPP) is a common clinical pelvic pain (CPP) is a common clinical Chronic endometriosis of manifestation Emma Kirkaldy Hospital Physiotherapist, King Edward Memorial and Bodylogic Physiotherapy WA health Post grad certs in continence and women’s and conservativeCurtin University management of South Australia University organ prolapse pelvic endometriosis! Physio? But I’ve got I’ve But Physio? Positive Carnett’s sign may suggest abdominal wall components to pelvic pain. or nerve irritation common reason for referral to women’s health to women’s health for referral common reason services. Musculoskeletal symptoms also include extrapelvic symptoms also Musculoskeletal and abdominal musculature. with abdominal wall and PFM myalgia is associated PELVIC PAIN regarding theresolution of pain. normal laparoscopy findingscanbeimportant detail theprofound impactithas ontheirperception experience notonlyintermsof physicalpainbutalso Many womenwithpelvicpaindescribe their pacing iscrucialtoachievepatient-centred goals. may behelpfulforsome. homogenised.Mirrors, imagesandvisualisation very normalise variedpresentations asmediaimagesare about anatomy, functionandvulvalcare. We needto is powerfulandpotentiallyachievedviaeducation awoman’sgenitalia their ownvulva.Demystifying have neverseenimagesof genitaliaorlooked at negatively impactonthesexualresponse cycle. experience dyspareunia. Fearandanticipation of pain avoidant, activitycanbehelpfulforwomenwho intimacy andpleasure-based, rather thanfear- mobilisation techniquescanbehelpful. may contributetopelvicpainandgentleneural iliohypogastric, femoralorobturator nerves Adverse neuraltensioninpudendal,ilioinguinal, fear-based reactions. Positive physicalexperiencescanstarttomodify PFMs, reduce hypersensitivityandstretch soft tissues. knowledge andself-awareness of thevaginaand contraction/relaxation, proprioception, confidence, intravaginal devices,toimprove awareness of techniques, withorwithoutbiofeedback and Commonly, pelvichealthphysiosutilisedigital responses allowstreatments tobeindividualised. of specifictechniquesandmonitoringindividual There ismuchwestilldon’tknowabouttheefficacy the femalesexualresponse cycle Advice andeducation around sexualactivityand treatment initself Neuroscience-based paineducation isaneffective Education mayformthemainstayof treatment. medication requirements inwomenwithCPP; Manual therapyhasthepotentialtoreduce manual therapyisusefulforsome. examinations, penetrative sexualactivity).Intrapelvic (bladder andbowelevacuation, tampons,pelvic PFMs andintegrate thisintofunctionalactivities change habitualholdingpatterns, voluntarilyrelax Ultimately, and womencanbeassistedtoidentify stretch isalsoessentialfornormalfunction. contractile activity. Theabilityof musclestorelax and Historically, muchattention hasbeenplacedonPFM contraction, holding,relaxing andstretching. full rangeof functionalcapacityof PFMs,including Physiotherapy aimstorehabilitate andretrain the guarding inresponse toperceived orreal threat. We canexplainacycleof painandprotective muscle increasing mediators. anti-inflammatory bioavailable oestrogens andinsulinresistance, while women withendometriosisincludedecreasing by whichphysicalactivitymaybeprotective for pain flare mayleadto reduced activity. Mechanisms Kinesiophobia isfrequently observedandfearof a energy, moodandinflammation. physical fitness,including regulating sleep,improving than static andbracing.Exercise hasbenefitsbeyond and movementshouldbedynamicvaried,rather by patients. downregulation of asensitisedCNShasoccurred. however, itmayneeddelayinguntilsome 31 Education andreassurance around 29,30 andcanbereadily understood 6 32 33 Manywomen withafocuson 26 37 Posture Activity 36 34,35

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requires allcomponentsof theprogram. in theliterature andinternational guidelinesand approach is widely recommendedAn interdisciplinary or cohesivemanagementplan. without anyimprovement, ameaningfulexplanation appointments at immensepersonalandfinancialcost understand whytheycontinuetoattend countless consecutive healthprofessionals. Theystruggleto describe intensefrustration withmultiplevisitsto with othersandthemselves,ascrumbling.Theyoften who rely onthem,andintimate relationships, both employment opportunities,inabilitytocare forthose of intimacy, socialwithdrawal,loneliness,limited of distress, reduced desire andarousal, avoidance of beingabletoliveameaningfullife.Theytalk likely toachievepositiveresults. after exclusion of organicpathology) maybemore with aninterprofessional approach (rather thanonly multifactorial contributorsinitiallyandconcurrently with oneanotherandourpatients. engenders open,respectful, curiousrelationships meaningful interprofessional communication that hope tohelp.We shouldtherefore seektodevelop we maytherefore continuetoservethewomenwe one anotherinasupportivemannerorderthat our minds.Equally, weneed tovalueworkingwith standard of care is,of course,at theforefront of Providing womenwiththehighestpossible optimally inatimelyfashion. plans that helpensure comorbiditiesare managed evidence-based explanations andmanagement women withconsistentmessages,multifactorial team cansupportandinspire eachother, provide presents manychallengesandjoysforclinicians.A Pain iscomplexandworkingwiththispopulation 9. 8. 7. 6. 5. 4. 3. 2. 1. References healthcare utilisation. improves pelvicpainseverity, qualityof lifeand have endometriosis,aninterprofessional setting health systemstoproviding thiscare. Forthosewho examine barriersbothwithinourselvesandour difficult formanywomentoaccess. Weneedto Unfortunately, care remains very interdisciplinary

dysfunction. NeurourolUrodynam. 2016;9999:1-24. and nonpharmacologicalmanagementof femalepelvicoor Society (ICS)jointreport onthe terminologyfortheconservative Urogynecological Association (IUGA)/International Continence K Bo,HCFrawley, BTHaylen,etal. AnInternational Endometriosis andPelvicPainDisorders.2017;9(2):77-86. to endometriosis-associated persistentpelvicpain.Journalof C Allaire, TAksoy, MBedaiwy, approach etal.Aninterdisciplinary Obstet. 2016;294(3):519-23. floor musclesinwomenwithdeependometriosis.ArchGynecol AP DosBispo,CPloger, AFLoureiro, et al.Assessmentof pelvic 2011;35(3):103-13. Therapist. Journalof Women’s Health PhysicalTherapy. Sensitization, I: PainPhysiologyandEvaluation forthePhysical Framework forBalancingTissueDysfunctionandCentral S Hilton,CVandyken. ThePuzzleof PelvicPain—A Rehabilitation 2018;15(8):1158-66. Endometriosis: Roleof theBladderand PelvicFloor. JSexMed. NL Orr, HNoga,CWilliams,etal.DeepDyspareunia in continence society. NeurourolUrodyn . 2017;36(4):984-1008. the chronic pelvicpainworkinggroup of theinternational terminology inchronic pelvicpainsyndromes: Areport from R Doggweiler, KEWhitmore, JMMeijlink, etal.Astandardfor 2018;11:3181-94. profile inwomenwithandwithoutendometriosis.JPainRes. of dysmenorrhea: aclinicalsurveycomparingsymptom SF Evans, TA Brooks, AJEsterman,etal.Thecomorbidities health morbidity. BMCPublicHealth. 2006;6:177. prevalence of chronic pelvicpain:aneglectedreproductive P Latthe, MLatthe, LSay, etal.WHOsystematic review of 2017;35(1):88-97. Pain andDysfunction.SeminarsinReproductiveMedicine. and EndometriosistoSignsof Sensitization andMyofascial J Aredo, KHeyrana,BKarp,etal.Relating Chronic PelvicPain 8 Payingequalattention to 8,41,42 38-40

PELVIC PAIN Vol. 21 No. 2 Winter 2019 | 38 Vol. 10/08/2018 10:17:13 AM GK Haugstad, U Kirste, S Leganger, et al. Somatocognitive et al. Somatocognitive S Leganger, U Kirste, GK Haugstad, gynaecological pain. chronic management of therapy in the a current of and results background the historical of A review . 2011;2(3):124-9. Scand J Pain approach. of the et al. The influence Maher, CG AM Hall, PH Ferreira, in physical outcome on treatment relationship therapist-patient Phys Ther. 2010;90(8):1099-110. review. systematic rehabilitation: an abbreviated Use of P Mintken. EL Puentedura, A Louw, chronic of in the treatment approach education neuroscience Theory Physiother low back pain: a case report. Pract. 2012;28(1):50-62. of The effect EJ Puentedura. DS Butler, I Diener, A Louw, and stress anxiety, on pain, disability, education neuroscience pain. Arch Phys Med Rehabil. musculoskeletal in chronic 2011;92(12):2041-56. the barriers to reconceptualization Unraveling L Moseley. pain: the actual and perceived in chronic the problem of the to understand and health professionals patients ability of 2003;4(4):184-9. J Pain. neurophysiology. of pelvic benefits The psychological and physical AFF Ghaly. pelvic pain and with chronic ultrasonography in patients trial. Journal of random allocation A laparoscopy. negative 1994;14(4):269-71. Obstetrics and Gynaecology. and expanded sexual dysfunction: revised R Basson. Women’s Journal. Canadian Medical Association definitions. CMAJ: 2005;172(10):1327-33. et al. Do women with G Montanari, A Benfenati, N Di Donato, endometriosis have to worry J Obstet Gynecol about sex? Eur Reprod Biol. 2014;179:69-74. than just bad sex: sexual D Haas, P Oppelt, et al. More N Fritzer, J with endometriosis. Eur in patients dysfunction and distress Obstet Gynecol Reprod Biol. 2013;169(2):392-6. pelvic pain D Wise, et al. Chronic RH Harvey, RUAnderson, pelvic floor use after medication of reduction syndrome: trigger point wand. physical therapy with an internal myofascial . 2015;40(1):45-52. Appl Psychophysiol Biofeedback and et al. Self-Management L Buggio, G Barbara, F Facchin, with patients interventions in psychological-sexological into clinical integration outcomes, and endometriosis: strategies, . 2017;9:281-93. Health Womens Journal of International care. of an Effectiveness et al. LD Kames, AJ Rapkin, BD Naliboff, of interdisciplinary for the treatment pain management program pelvic pain. Pain. 1990;41(1):41-6. chronic et al. No. 164-Consensus GA Vilos, C Allaire, JF Jarrell, Pelvic Pain. Journal Chronic Guidelines for the Management of Obstetrics and Gynaecology Canada. 2018;40(11):e747-e87. of T Thomsen. Does evidence S Loving, J Nordling, P Jaszczak, adult female chronic support physiotherapy management of Scand J Pain. 2012;3(2):70-81. review. pelvic pain? A systematic clinical trial AA Peters, E van Dorst, B Jellis, et al. A randomized in women with chronic approaches two different to compare pelvic pain. Obstet Gynecol. 1991;77(5):740-4. C Petta, et al. Physical therapy and M Garcia, SPK Friggi, cortisol levels and improve psychological intervention normalize Psychosomatic vitality in women with endometriosis. Journal of Obstetrics and Gynecology. 2012;33(4):191-8. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. @ranzcog Follow us on social media; join the conversation A Yosef, C Allaire, C Williams, et al. Multifactorial contributors Multifactorial Williams, et al. C C Allaire, A Yosef, pain in women. Am J Obstet pelvic chronic of to the severity Gynecol. 2016;215(6):760.e1-.e14. pain in and abdominal myofascial Endometriosis J Jarrell. Reports. Pain and Headache Current adults and adolescents. 2011;15(5):368-76. of evaluation GM Bove, ML Cohen. A critical JL Quintner, (Oxford). phenomenon. Rheumatology the trigger point 2015;54(3):392-9. between relationship The W Everaerd. J van der Velde, and muscle awareness involuntary pelvic floor muscle activity, in women with and without vaginismus. experienced threat Res Ther. 2001;39(4):395-408. Behav pelvic et al. Screening A Olson, N Greer, HE Bloomfield, average-risk adult women: an in asymptomatic, examinations the American guideline from for a clinical practice evidence report . 2014;161(1):46-53. Med Physicians. Ann Intern College of et al. Central changes KT Zondervan, J Brawn, M Morotti, pelvic pain and endometriosis. Hum with chronic associated . 2014;20(5):737-47. Reprod Update chronic of et al. Association I Khachikyan, N Sinaii, P Stratton, and sensitization with signs of pelvic pain and endometriosis . 2015;125(3):719-28. pain. Obstet Gynecol myofascial and sensitization Cross-talk M Pezzone. E Ustinova, M Fraser, . nerves. Neurourology and Urodynamics bladder afferent of 2010;29(1):77-81. neural cross-talk A model of R Liang, MO Fraser. MA Pezzone, chronic for the overlap of in the pelvis: implications and irritation 2005;128(7):1953-64. pelvic pain disorders. Gastroenterology. et al. Viscero- MA Giamberardino, R Costantini, G Affaitati, clinical different in visceral hyperalgesia: characterization models. Pain. 2010;151(2):307-22. a generator Central sensitization: CJ Woolf. A Latremoliere, J Pain. pain hypersensitivity by central neural plasticity. of 2009;10(9):895-926. N Zalucki, F Birklein, et al. Thinking about GL Moseley, of motor imagerymovement hurts: the effect on pain and arm pain. Arthritis Rheum. swelling in people with chronic 2008;59(5):623-31. al. A preliminary T Mallinson, et CE Neville, CM Fitzgerald, report pelvic pain: dysfunction in female chronic musculoskeletal of findings. J Bodyw Mov Ther. examination a blinded study of 2012;16(1):50-6. of Houdenhove, RA Oostendorp. Recognition J Nijs, B Van pain: with musculoskeletal in patients central sensitization therapy practice. in manual pain neurophysiology of Application Man Ther. 2010;15(2):135-41. chronic K. The initial management of SH Kennedy. SJ Moore, Royal College of Guideline No. 41. pelvic pain. Green-top www. from: Obstetricians and Gynaecologists. 2012. Available rcog.org.uk/globalassets/documents/guidelines/gtg_41.pdf. S Khalife, et al. Provoked S Bergeron, G Desrochers, topical and of vestibulodynia: psychological predictors Res Ther. outcome. Behav cognitive-behavioral treatment 2010;48(2):106-15. Pain. Journal of Pelvic S Hilton. The Puzzle of C Vandyken, Physical Therapy. 2012;36(1):44-54. Health Women’s RAN003 FILLER ADVERT TEMPLATES HALF PAGE HORIZONTAL.indd 1

10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. PELVIC PAIN recognised asadistinct diagnosis;withclinical In practice,persistentpelvicpain isoften not Lesion-focused management Burwood PainManagementCentre,Christchurch,NZ Clinical Psychologist BMSc, DClinPsych Dr JessicaMills Christchurch Women’s Hospital,Christchurch,NZ Burwood PainManagementCentreand DipSRH, FRANZCOG, FFPMANZCA Dr KarenJoseph pelvic pain management ofchronic team Multidisciplinary of otherchronic painsyndromes. CPP shares thesamemechanismsand comorbidities An accumulating bodyof evidence demonstrates that acute pain,represents adistinctdiseasestate initself. or recurs formore thanthree months’and,unlike The ICD-11 defines chronic painas ‘Pain that persists A 2018survey of CPP, however, isoften found tobechallenging. to GPsandgynaecologists.Effective management Chronic pelvicpain(CPP)isacommonpresentation and noneas‘excellent’. rated thequalityof theirCPPassessmentas‘good’ women’s hospitalinNZfoundthat only7percent CPP, anda2016auditof gynaecologistsat atertiary per centfelttheywere unabletoadequately manage 1 of UKgynaecologistsfoundthat 45 2 3-5

symptom recurrence bytwo-yearfollow up. about halfof patients whodobenefit experiencing one-in-five experiencingnoimprovement and painrelief,results inonlypartialortemporary with oftencan bringsignificantsideeffects.Surgery of women;however, itrequires long-termuseand shown toimprove qualityof lifeinuptotwothirds long-term improvement. Medicaltherapyhasbeen with them. shown tobesuperiortheother, procedures. Neitherof theseapproaches hasbeen comprises of hormonalmanipulation orsurgical Current managementof pelvicpainusually unnecessarily exacerbates distress. there are notreatment optionsfortheirpainand same characteristics pelvic painandnodemonstrablelesionsshare the imagined; whenithasbeenshownthat thosewith suggest painissomehowthefaultof thepatient, or false dichotomy;implyingthat normalinvestigations This lesion-focusedapproach canalsocreates a on socialrelationships, workandproductivity. neurocognitive changes,andtheassociated impacts such asanxietyanddepression, chronic fatigue, are frequently experiencedalongsidechronic pain, ignoring these,andother, comorbiddifficultiesthat focus centred onthepresence of visiblelesionsrisks appropriate management forpelvicpain. laparoscopic procedures are neithersuccessful nor It isincreasingly recognised that repeated performed forthisindication findnopathology. experienced, andoverathirdof laparoscopies between stageorlaterality of lesionsandsymptoms literature, however, that there isnogoodcorrelation media forums.Itisconsistentlyreported inthe unfortunately strongly advocated forwithinmany intervention are imperative. Thisisaviewthat is with, endometriosis;thus,surgicalinvestigation and pelvic painisalwaysasignof, ordirectly synonymous There isalsooften amistaken beliefthat persisting with pelvicpainexperience. related symptomsanddistress that womenliving system inputsonpain,aswellthewiderpain- of thesurrounding structures andwidernervous organ focused.Thisapproach neglectstheinfluence pelvic painremains heavilybiomedicalandend- This meansthat themainstayof managementof recommended forotherpersistentpainconditions. approaches well-recognised multidisciplinary This lesion-focusedapproach isat oddswiththe and remediate anassumedend-organpathology. focus remaining entirely onattempting tolocate musculoskeletal ormyofascial painsyndromes. migraine, irritablebowelsyndrome andwidespread range of extra-pelvicpainsyndromes, suchas Women withpersistingpelvicpainreport awide 3,4 Thisrisksleavingthepatient feeling 9,10 andcentralchangesasthose 5,6 6-8 nortobring 7,8 However, 7-8 5,9

7,8 A PELVIC PAIN Vol. 21 No. 2 Winter 2019 | 40 Vol. Many patients are initially wary are the involvement Many patients of pain psychology or psychosocial elements of of management, as this suggests to them that experience they practitioners believe the pain that is in some way imaginary or psychological. this also seems to be the belief of Unfortunately, role many other health practitioners who see the one psychologists within pain management as of to or there tolerance, simply support or distress of patients. intervene with ‘histrionic’ or ‘psychosomatic’ psychosocial elements about the place of Education a vital part of within pain management is therefore as well as helping in treatment, engaging patients their can improve them to use all the specialities that available to them. these are experience where include approaches MDT Common themes of about pain and how pain works and what education happens in the pain system when pain becomes active persistent. Pain management promotes experiential provide that and adaptive approaches activity in a safe and painful to feared exposure aim to reduce These programs and supported way. activity tolerances, redress increase fear-avoidance, improve pain-self efficacy, functional losses, increase or decrease life, and, for some patients, quality of pain. even eliminate of the doctor within an MDT Role pain The medical specialist working within a chronic as identified in the CanMEDS has many roles, MDT framework. Specialist pain medicine physicians work pain history, and previous to understand the current balancing the history, patient and collate review flag conditions’ with iatrogenic need to rule out ‘red and act as a health over investigation, harms from and other for both patients and advocate educator members. MDT MDT management can be likened to a door management can be likened Figure 1. MDT to with many locks; unlocking one is insufficient Instead, multiple to open the door. allow patients women locks need to be targeted in order to free ongoing pain. the constraints of from

13-16 3,9,10 with 11,12 and over 30 years of evidence that multimodal MDT MDT multimodal evidence that and over 30 years of superiority over to CPP demonstrate approaches outcomes, solely biomedical ones in quality-of-life reducing risk and cost-effectiveness, iatrogenic visits. surgeries and emergency department future the supporting evidence base continuing to grow as grow the supporting evidence base continuing to increases. knowledge about pain neurobiology this model to pelvic pain has, The adoption of been lagging; despite mounting evidence however, the same mechanisms and CPP shares that pain syndromes, other chronic comorbidities of Symptom-focused approaches: treating the the Symptom-focused approaches: treating whole person pain specialist for CPP, unimodal approaches Unlike practice and have expertise both in scope of MDTs the specialist pain knowledge in order to address pain and associated multifactorial contributors of comorbidities. to address multi-pronged, are approaches MDT to both bottom-up and top-down contributors members team ongoing pain. While the scopes of may vary an individual depending on the needs of involved typically include: pain professions patient, specialist doctors, physiotherapists, psychologists, therapists, specialist nurses and social occupational pain of all with specialist understanding workers; pelvic management. For pelvic pain, in particular, floor physiotherapists and therapists with training in also included. sexual disorders are working in pain, it is not For all professionals in their scope. sufficient to simply hold a qualification some require of medicine areas Just as different experience and education, specialism, appropriate supervision pertaining to pain is essential to ensure not being unhelpful messages about pain are that by practitioners who are inadvertently reinforced schooled in the complexities and not adequately this disease. subtleties of All in their heads? ‘a sensory and emotional Pain is by IASP definition of experience’. The significant contribution psychosocial elements to the development and persistent pelvic pain is well maintenance of as an important target in the literature recognised outcomes, though largely to improve for treatment within clinical practice. The Australasian ignored element this key Pain Medicine recognises of Faculty the to managing pain and has reconceptualised to a sociopsychobiomedical one. approach required data from health insurer Southern Cross NZ places NZ places Cross Southern health insurer from data surgery top five across within the for endometriosis 21–50. the ages of for women between all surgeries Endometriosis NZ also poll by patient A 2014 these procedures the large number of demonstrated four of a mean number reporting being undertaken, 1–25. a range from with respondent, surgeries per who had respondents of Despite this, 70 per cent undergone surgery in pain. no improvement reported The benefits of multidisciplinary team managment for persistent pain, in Recommended treatments as just biomedical approaches comparison, include This allows for one component in management. a pain to be addressed; all inputs driving ongoing optimises outcomes for that multifactorial approach pain. women living with pelvic of multidisciplinaryThe benefits team (MDT) living with persisting pain management for people for over four decades, has been recognised PELVIC PAIN and psychosocialcontributorstopainwaspoor, ability toexplore underlyingnon-gynaecological majority of thesurveyedgynaecologistsfelttheir to resolve symptoms.A2016auditfoundthat the specialists whenalaparoscopy isnormalorfails ‘speciality ping-pong’referrals tootherend-organ ‘surgical technician’,andthenengaginginendless the aboveskills,rather thanactingsolelyasa work withwomenpelvicpainneedtodevelop MDT pelvicpaincentres, soallgynaecologistswho Unfortunately, there isapaucityof specialised 8. 7. 6. 5. 4. 3. 2. 1. References term benefitsforwellbeingandquality of life. have fewersideeffectsandmaygreater long- alternatives oradjunctstobiomedicaltherapiesthat message andare supportedtoseethat there are speciality sothat patients receive aconsistent gynaecology clinicsandbythewidergynaecological MDT approach tobesupportedandvalidated within MDT painclinicsare available,there isaneedforthe general publicandsomeclinicians,soevenwhen management andMDT approaches from boththe There isoften somereluctance toacceptbothself- medical training. indicating aneedforgreater attention tothisduring able toaccesstheservicestheydeserve. required before womenlivingwithpelvicpainare education, investmentandsystemicchangewillbe evidence-based guidelinesare followed.Further conditions, clinicaloutcomesare betterwhere chance forbestoutcomes,andaswithother for persistentpainconditionsoffers thegreatest As growing evidencebaseattests, anMDT approach focuses onallcontributorsandsymptoms. state that hasaspecifictreatment frameworkthat CPP needstoberecognised asadistinctdisease correlated andthisapproach often unsuccessful. relationship betweenlesionsandsymptomsispoorly in thehopesof eliminating pain,eventhoughthe pelvis focusesonlocating andremoving lesions Current managementof painperceived withinthe lives withpain Shifting focusfromthepelvis tothepersonwho related distress duringtimesof symptomflare ups. provision andhelplessnesstomanagepainpain- This alsoprevents dependenceonpassiveservice

2018;40(6):726-49. care. Journalof ObstetricsandGynaecologyCanada. endometriosis: towardvalue-based,cost-effective, affordable P Vercellini, FFacchin, LBuggio,etal.Management of Reprod Update. 2009;15(2):177-88. for symptomatic endometriosis:theothersideof thestory. Hum P Vercellini, PGCrosignani, AAbbiati, etal.Theeffect of surgery . 2012;67(7):417-25. & GynecologicalSurvey therapies for noncyclic chronic pelvic pain in women. A Yunker, NASathe, WSReynolds,etal.Systematic review of Obstetrics andGynecology.pii:S0002-9378(19)30385-0. gaps andunmetneedsinendometriosis.AmericanJournalof S As-Sanie, RBlack,LC Giudice,etal.Assessingresearch study.morphometry Pain.2012;153(5):1006-14. matter volumeinwomenwithchronic pelvicpain:avoxel-based S As-Sanie, REHarris,VNapadow, etal.Changesinregional gray Reprod Update. 2014;20(5):737-47. associated withchronic pelvicpainandendometriosis. Hum J Brawn,MMorotti, KTZondervan, etal.Centralchanges Outpatient Clinic.2016. Unpublished data. chronic pelvicpainat theChristchurch Women’s Hospital K Joseph.Unmet healthcare-needs auditof attendees with 2018;224:200-2. of ObstetricsandGynecologyReproductiveBiology think chronic pelvicpainismanagedbadly. European Journal HW Leow, WSzubert,AW Horne.45%of UKgynaecologists 5,8,16 Obstetrical . 2

140 heightx70widthp43 ATM.indd1 16. 15. 14. 13. 12. 11. 10. 9.

Journal of ObstetricsandGynecology.2018;218(1):114-e1. setting:1-yearprospective cohort.American an interdisciplinary C Allaire, CWilliams,Bodmer-Roy, etal.Chronic pelvicpainin Gynecology. 1990;33(1):205-11. approach. ClinicalObstetricsand pelvic pain:amultidisciplinary JC Gambone,RCReiter. Nonsurgicalmanagementof chronic Obstetrics &Gynecology.1991;12(sup1):109-16. hysterectomy forpelvicpain.Journalof Psychosomatic pelvicpainclinicandfrequency of multidisciplinary RC Reiter, JCGambone,SRJohnson.Availability of a pelvic pain.ObstetricsandGynecology.1991;77(5):740-4. trial tocompare twodifferent approaches inwomenwithchronic AA Peters,BJellis,JHermans,JBTrimbos. Arandomized clinical 1992;49(2):221-30. pain treatment centers:ameta-analytic review. Pain. H Flor, TFydrich,DCTurk. Efficacy ofmultidisciplinary and Rehabilitation. 1973;54(9):399-408. in thetreatment of chronic pain.Archivesof PhysicalMedicine WE Fordyce,RFowler, JFLehmann,etal.Operantconditioning Gynecologica Scandinavica. 2019;98(3):327-36. pelvic painandsuspectedendometriosis.ActaObstetriciaet thresholds andsignsof sensitization inwomenwithpersistent H Grundström, BGerdle,SAlehagen,etal.Reducedpain Research. 2018;11:3181. in womenwithandwithoutendometriosis.Journalof Pain dysmenorrhea: aclinicalsurveycomparingsymptomprofile SF Evans, TA Brooks, AJEsterman, etal.Thecomorbiditiesof 1 December2014 commenced trainingonorafter For FRANZCOG traineeswho Advanced Training Modules FRANZCOG • • • The aimsoftheATMs areto: during AdvancedTraining. procedural trainingrequirements toundertake ATMs, alltraineeswillhave thesameminimum Advanced Training Modules(ATMs). With The Collegeisintroducing compulsory ranzcog.edu.au/Specialist-Training/ATM For more information, goto

O&G consultant trainees tocommenceacareer asan Promote consistencyinpreparation of Clarify expectations for sites Clarify expectations for trainees

9/08/2018 10:30:22AM PELVIC PAIN

8 Vol. 21 No. 2 Winter 2019 | 42 Vol. In June 2017, the Mater the Mater In June 2017, 10-12 there is clearly benefit to be gained there 9 Exclude acute intra-abdominal pathology pathology acute intra-abdominal Exclude symptoms consistent with an Confirm long-term pain of exacerbation trigger for the Recognise and manage the likely of pain flare recent opioids analgesia with avoidance of Appropriate laparoscopy repeat of Avoidance and risk psychological stressors Assessment of self-harm of the Reassurance and acknowledgement of pain despite normal investigations patient’s and emphasis on self-management Education follow up Appropriate from avoiding such intervention in the previously avoiding such intervention in the previously from when clinically appropriate. PPP patient, investigated and reassurance education if adequate Additionally, in the acute setting, the patient can be provided outpatient to accept ongoing likely may be more management. a multidisciplinaryIt is well established that approach in improved PPP results to the management of outcomes. patient Mothers’ Hospital Persistent Pelvic Pain Clinic (PPPC) Mothers’ Hospital Persistent Pelvic Pain Clinic patient improving was opened with the dual aims of hospital costs associated outcomes and reducing with unnecessary The or procedures. admissions guidelines changes made include the development of in the ED, pelvic pain for the acute management of and an effective multidisciplinary to team approach management in the clinic. Management in the emergency department a consistentThe following guidelines provide of to management following exclusion approach They educate pathology. acute intra-abdominal their pain over the to improve women on strategies longer term, and support them to manage pain flares, avoiding the need for unnecessary to ED. presentation management are: The principles of • • • • • • • • • Ongoing management in the PPPC have commenced 58 patients November 2018, As of team includes advanced in the service. The core Persistent pelvic pain: the burden Persistent pelvic PPP poses a significant societal and healthcare and surgical medical burden. In Australia, the cost of over for endometriosis alone amounts to treatment in this results Globally, six billion dollars per year. week, 11 hours and $200–250 lost per woman, per an where due to absenteeism and presenteeism, productivity. employee is working with reduced Given that many ED presentations result in admission in result many ED presentations Given that which is up the cost of and diagnostic laparoscopy, to $4289 USD,

3 Flares can Flares 7 Acute 3-6 of women. It is defined by pelvic pain for of 1,2 Dr Susan Evans FFPMANZCA MBBS, FRANZCOG, of Australia Pain Foundation Pelvic Dr Jayne Berryman FFPMANZCA BSc MBBS FANZCA Specialist Pain Medicine Physician and Anaesthetist Anaesthesia and Services,Mater Health Wesley Pain Management Dr Natalie Kiel MBBS, BSc, FRACP. Queen Elizabeth II Jubilee Hospital PPP is caused by a complex combination of visceral of PPP is caused by a complex combination pain, central sensitisation and musculoskeletal often accompanied and pelvic floor hypertonicity, by evolving psychological dysfunction. more than 3–6 months that is not solely related to is not solely related than 3–6 months that more sexual activity or bowel movements. menstruation, last days to months and the patient will often have will often last days to months and the patient to escalation relating significant fear and anxiety presentation is frequent their pain. The result of to primary and the emergency providers care normal previously department (ED), where and admission repeated often are investigations undertaken. diagnostic laparoscopy) (with repeat and to both patient This scenario is frustrating hospital expenditure. in excess clinician and results developed a guideline for acute management of We unnecessaryof preventing with the aim PPP flares Management admission and surgery. investigation, of specific and treatment focuses on identification and reassurance validation, triggers while providing to the patient. education Persistent pelvic pain (PPP) affects 15–26 per Persistent pelvic pain (PPP) affects cent, persistent pelvic pain pelvic persistent Dr Thea Bowler BSc, MBBS, FRANZCOG Dr Michael Wynn-Williams MBChB, FRANZCOG Mothers Hospital Mater Eve Health, acute management of management acute Mater Mother’s Hospital: Mother’s Mater exacerbations (flares) of pelvic pain are common of pelvic pain are (flares) exacerbations constipation, by menstruation, triggered and often UTI/bladder pain or pelvic muscle spasm. PELVIC PAIN • centralsensitisation •Pregabalin 25–75mgPOmayalsobehelpfulifthere isacomponentof anxietyandpainrelated to • •Encouragepatient tobreathe toRRof 6 • • • • Management • • • all possibilitiesapproach The patients investigations shouldbeperformedtosupportclinicalfindingsandnotusedina‘scattergun’, cover Investigations • • • • experienced practitioner The patients examination shouldideallybeperformedinasafe, andcomfortable environment byan Examination • • • • • A thorough, buttimely, shouldbeobtainedthat isnotbiasedbyprevious patient admissionsordiagnosis history History • • • suchascoloxyl/senna consideration shouldbegiventoco-administration of aperientssuch asmovicol,rather thanstimulants •Opioids(SRorIR)generallyshould notbegivenfordischarge.Ifopioidsare administered intheED, •Ifpatients are onSRorIRopioidsalready, theirtreating GPmustremain thesole prescriber withdosinginopioidnaive) •Temgesic (Buprenorphine) 0.2–0.4 mgSL(thisisequivalentto10–20 mgPOmorphine,therefore care •Tapentadol IR50mgPO SSRI/SNRIs •Tramadol 50–100mgPOorslowIV, beware of riskof serotonin syndrome withconcomitantuseof • 100mgPR •Diclofenac suppository • Severe: 2microlax enemas, 3dulcolaxtabletsand8sachetsof movicolin1Lof liquidtodrinkover12hours • •Moderate: movicol2–4sachetsdaily, 2dulcolaxtabsmaneuntilbowelmovement •Mild:movicol2sachetsdaily • • For pelvicfloormusclespasm:PVorPRdiazepam 5mg Stepwise analgesia:IV/POParacetamol,PRVoltaren/IV Parecoxib ifvomitingorPOIbuprofen Non-pharmacological management:heat pack,mindfulness/deepbreathing Address reversible causes,suchasconstipation, UTI, dysmenorrhoea,hypertonicpelvicfloor demonstrated the likely triggerfortheflare where thisisknown,suchasacutepelvicmusclespasmwhere thishasbeen Reduce fearandenhancemanagementwithanexplanation of exacerbation of theirlong-termpainand Treat acutepathology asindicated If indicated, USSisthebestimagingmodalitytodefineacutepelvicpathology Consider bloodtestsandimagingonlyifclinicalevidenceof alternate pathology Urine forexclusion of pregnancy andassessmentof infection ifindicated examination. and replicate thepatient’s pain.Thisshouldonlybeundertaken byaclinicianexperiencedinpelvicfloor pubococcygeus, puborectalis, piriformisandobturator internuscanlocalisethecausative musclegroup spasm of thesemusclesthat contributessignificantlytopainflares. Directed examination ofthevulva, Pelvic floorexamination: pelvicfloorhypertonicitywillbeevidentinmostwomenwithPPP. Itisacute Vaginal examination: bimanualevaluation of theuterusandadnexaforlocalisedtendernessormasses be avoided of bleedingorvaginaldischarge, otherwisethismaySpeculum examination maybewarrantedifhistory cause Basic observations andabdominalpalpation toelicitsignsof peritonismthat mayindicate ananatomical floor physio Current engagementwithandnamesof gynaecologist,painservices,psychiatrist, psychologist,pelvic duloxetine), psychiatric medications opioidsanddoses,chronic painmedicationsMedication (eg.amitriptyline/gabapentin/pregabalin/ history: and/or anxiety, recent significantlifeevents withassessmentof riskofPsychiatric self-harmandcurrent history psychologicalsymptomsof depression andfindings priorlaparoscopic surgery Surgical history: ‘stabbing’ andmayberelated toaperiodof overactivityorstress pain worsewithmovement,referring toanteriorthigh,tenderlowerback/glutealregion, often describedas Symptoms suggestiveof pelvicmusclespasmincludepainof suddenonset,unilateral orbilateral location, Early follow up with primary healthcare provider,Early followupwithprimary gynaecologistorpersistentpelvicpainclinic (www.pelvicpain.org.au) Provide thepatient withwritten information onpelvicpain,eg.PelvicPainFoundation of Australia Encourage gentlemobilisation rather thanbedrest toreduce musclespasm acute pathology isexcluded. Optionsifrequired: Opioids increase centralsensitisation whenusedregularly andshouldbeavoidedwhere possiblewhen For dysmenorrhea: For constipation: For painful bladdersymptoms:Ural or500mLwater with1tbspbicarbsoda,increase POfluidintake. stretches-to-relax-the-pelvis-women pharmacist), refer togentlepelvicstretches availableat: www.pelvicpain.org.au/for-women/easy- 13 (inafatty base,madebyacompounding PELVIC PAIN

Vol. 21 No. 2 Winter 2019 | 44 Vol. cmeecmee cmeecmee 2011;14(1):115-23. pelvic pain et al. Chronic S, C, Williams C, Bodmer-Roy Allaire in an interdisciplinary cohort, Am J prospective setting: 1 year Obstet Gynecol. 2018;218(1):114.e1-12. Bedaiwy M, et al. An interdisciplinary approach C, Aksoy T, Allaire pain. J Endo Pelvic persistent pelvic to endometriosis-associated doi:10.5301/jeppd.5000284. Pain Disord. 2017. Multidisciplinaryand interdisciplinary Houle TT. S, Stanos pain. Phys Med Rehabil Clin N Am. chronic management of 2006;17:435-50. AR, et al. Retrospective Hoffmann S, Kellogg-Spadt Rogalski MJ, suppository vaginal diazepam use in high-tone of chart review 2010;21(7):895-9. J. Urogynecol pelvic floor dysfunction. Int Latthe P, Latthe M, Say L, et al. WHO systematic review of of review M, Say L, et al. WHO systematic Latthe P, Latthe a neglected reproductive pelvic pain: chronic of prevalence . 2006;6:177. BMC Public Health health morbidity. in New Zealand: pelvic pain K. Chronic Zondervan Grace V, the health diagnoses and use of pain severity, prevalence, . 2004;28:369-75. services. ANZ J Pub Health for the C, et al. Consensus guidelines Vilos GA, Allaire JF, Jarrell pelvic pain. J Obstet Gynaecol Can. chronic management of 2005;27:781-826. pelvic Psychological factors in chronic MD. Bishop MJ, Alappattu the fear-avoidance of and application pain in women: relevance pain. Phys Ther. 2011;91:1542-50. model of in and depression Pain, catastrophizing, JK, Chang IH. Kwon . Neurourol J Int syndrome. pelvic pain prostatitis/chronic chronic 2013;17:48-58. in women comorbidity Psychiatric Leserman J. S, Meltzer-Brody pelvic pain. CNS Spectr. 2011;16:29-35. with chronic Girls and Persistent Pelvic Pain in Management of S. Evans Phys. 2015;44:454-9. Aust Fam Women. The Pelvic Pain Report: The $6 T. Vancaillie S, Evans Bush D, billion woman and the $600 million dollar girl. 2011, Australia. et al. Surgical procedures M, Chwalisz K, Marx S, Fuldeore among women with newly and their cost estimates J Med Econ. study. diagnosed endometriosis: a US database

10. 11. 12. 13. References 1. 2. 3. 4. 5. 6. 7. 8. 9. avoiding admission and its associated problems. As problems. associated and its admission avoiding Mothers’ PPPC cycle, the Mater an auditing part of on all clinic data outcome prospective is collecting integrating of and is in the process attendances Outcomes Persistent Pain with the Electronic system. Collaboration Targeted resources aimed at aimed at resources Targeted who see women health professionals planning a pregnancy pregnant, are that or breastfeeding. Targeted resources aimed at aimed at resources Targeted who see women health professionals planning a pregnancy pregnant, who are or breastfeeding. COMPANION COMPANION RESOURCES RESOURCES Emphasis on self-management and expectation and expectation Emphasis on self-management to a level that setting: aim for pain reduction and a return functioning improved facilitates ongoing management to usual activities with planned as outpatient verbal information written and of Provision and long-term treatment regarding flares pain management of of excision Complete laparoscopic endometriosis endometriosis by experienced indicated surgeon, as clinically with hormonal Achieving amenorrhoea suppression opioid medication off Weaning using pain pathways of Modulation or (amitriptyline/duloxetine) antidepressants membrane stabilisers (gabapentin/pregabalin) with Physiotherapy for pelvic floor downtraining experienced women’s health physiotherapist input Psychology/psychiatric module Persistent Pain Education as pelvic floor botulinum toxin of Administration clinically indicated laparoscopic gynaecologist, pain specialist, gynaecologist, pain laparoscopic with referral and physiotherapist, psychologist gastroenterology functional psychiatry, to pathways comprises surgeons. The structure and colorectal and initial, three- with an program a six-month and physiotherapy visit, as well as regular six-month summary intervention. A general psychology long- of the PPPC includes: term management in • • • • • • • • • • PPP can be a frustrating of The acute exacerbation and clinician, frequently encounter for both patient in unnecessaryresulting yields intervention that By or clinical improvement. little information and diagnosing acute management at directing instituting and education triggers, providing treating multidisciplinary can up, the patient follow managed as an outpatient, potentially be adequately PELVIC PAIN Gynaecologist andPainMedicineSpecialist MD, FRANZCOG, FFPMANZCA GVancaillie Prof Thierry really causepain? Does endometriosis environment. individual’s response toatrigger, isthehormonal One importantelement,whichinfluences the neurotransmission islongandunfinished. brain. Thelistof factorsinfluencing thiscascade of pre-vertebral chain,thespinalcordandfinally is generated, multipleconnectionsoccurinthe triggered, asignalinthesympathetic nervoussystem this cantriggerpain.Peripheralreceptors are release of prostaglandins. Regardlessof location, immune responses through itsactivity, suchas and Endometrial tissuecantriggerinflammatory understood nowthanafewdecadesago. wrong place,ornot,canleadtopainisfarbetter wrong placeisstillamystery. Howthetissuein manner. Whytheendometrialtissueendsupin in mostcasesbehavesapredictable physiological The tissueis‘normal’,itbelongstothepatient and that endometriosisismerely avariation of normal. pain cascadethemore complexone.Onecanargue haemostasis, itinvolvesacascadeof events,withthe muchlikepain?’ is‘yes,itcan,but…’Painvery to thequestion‘Does endometriosisreally cause of ourcurrent understandingof pain.Theanswer pain’. That’s fundamentallywrong inthecontext will ‘lookforendometriosis’rather than‘lookfor approaching pelvicpain.Too manycolleagues outrageous; however, itsetsthestate of mindwhen It’s anoutrageousquestion,andit’smeanttobe When apatient presents withpelvic pain,itisas approach totreating thepatient withpelvic pain. the impactof oestrogens completely altersthe of thesignalat acentrallevel.Understanding endometrial tissue,butalsointhe interpretation not onlyinthedirect trophic stimulation of the 1 Oestrogen isparticularlyactive, for pelvicpain. asacurewhole personandstoppromoting surgery place itinthecontextof painmanagementof the for resection of endometriosisoff itspedestaland techniques. However, weneedtomovelaparoscopy resection of endometriosisusinglaparoscopic been madeoverthepastdecadesinapproaching not sooutrageousastatement. Great progress has We needtochangeourtreatment algorithm.That’s – andpoorer results. wrong andonlyreinforces thequestformore surgery the patient that endometriosisalwaysequalspainis endometriosis really causepain?’correctly. Telling exceedingly importanttoanswerthequestion‘does question isenoughto‘treat’ thepain.Therefore, itis finding andunderstandingtheanswertothat brings totheconsultation: whyamIhurting?Often, this questionisalsooneof themainissuesapatient quickly. dayand Thesequestionscomeupevery future? Thebrainwilldothisassessmentamazingly according tomypast,andwhat doesitmeanformy signal? What doesitmeanformenow, incontext, pain toprovide astheoutput?Howsignificantisthat interpret thesesignalsanddeterminehowmuch now thedifficultpartbegins:howdoesbrain and isdesignedtoreceive ourfullattention. And the interpretation signalbyourbrain of asensory is oneof ourhomeostatic mechanisms.Painis function of painistoprotect usfrom danger–it context of ourcurrent understandingof pain.The like anotheroutrageousstatement, butnotinthe Pain isnormal.Indaysgoneby, thiswouldseem an importantelementinthetreatment of pain. hormonal environment, therefore, isandwillremain the hormonalenvironment. Manipulation of the can indeedalsobesignificantlymodulated by perform athorough pelvicexamination. Headaches she alsosuffersheadaches,forinstance–asitisto important totake –tofindoutif afullpainhistory the generalpublic. specialists. Improved paineducation should reach Improved paineducation isneededamong surgical is neededwithinthecurriculum of medical schools. pain requires education. Improved paineducation A betterunderstandingof thepathophysiology of leads toanevenmore sensitisednervous system. greater, rather thanreduced, paintriggersand trigger threatens totipthebalanceinfavourof subsequent surgery, theweightof theintroduced itself.introduces Witheach anewone–thesurgery one elementinthecascadeof paingenesis,but for resection of endometriosis,thesurgeonremoves post-surgical neuropathy. At thefirstlaparoscopy cantriggerimportant triggerforpain,asanysurgery itselfcanturnintoanof fact,laparoscopic surgery rarely doesitactually‘cure’ thepain.Asamatter will indeedimprove thepatient’s symptoms,but can remove pain.Inmanycases,surgery surgery among physicians,aswellthepublicat large,that toward treating pelvicpainisthestubbornbelief The mainimpedimenttoachangeof attitude 2

3

PELVIC PAIN Vol. 21 No. 2 Winter 2019 | 46 Vol. K Vincent, J Moore, S Kennedy, J Tracey. Steroid hormones and Steroid J Tracey. S Kennedy, K Vincent, J Moore, connectivity in healthy brain activity and functional pain-related women. Lancet. 2014;383(1):S104. et al. Biopsychosocial CE Martin, MT Siedhoff, ET Carey, pain in women with persistent postsurgical of correlates . 2014;124:169-73. J Gynaecol Obstet endometriosis. Int vital sign: exposing Pain as the fifth DK Weiner. NE Morone, Clinical Therapeutics. the vital need for pain education. 2013;35(11):1728-32. www.ranzcog.edu.au/patient-information-pamphlets

References 1. 2. 3. government reimbursement systems. The rebate The rebate systems. reimbursement government for surgery reimbursement whereas dominates, still non-existent. is essentially for pain education in the equally important least is at education Yet, is on its way. pain. Change chronic of management was force Task Schedule Review Benefits A Medicare will be in 2018 and its recommendations convened emphasis will that is anticipated It published this year. surgical interventions towards a be shifted away from holistic approach. more Once it is understood that it’s not the location of of location it’s not the that it is understood Once its the tissue with but the interaction of the tissue, the is at that location, of regardless environment opens up a whole pain cascade, then it the origin of than Rather possibilities for treatment. of new world should the physician-surgeon feeling threatened, a greater providing opportunity of embrace this health and wellbeing. patient’s positive impact on the pain pathophysiology of understanding The lack of of physicians toward allied attitude in the is reflected or physiotherapy health. How could osteopathy the pain from remove or psychotherapy possibly it does seem way, that endometriosis? Posited will not vanish impossible: ectopic endometrium floor muscle manipulation. pelvic a session of after where pain pathophysiology, Within the context of with aberrant muscle pain triggers do correlate quite understandable, contractions, it becomes surgery false belief that The pervasive however. in the medical insurance and pain is reflected cures

For more information contact [email protected] information For more Written by experts in their fields, the resource delivers an resource by experts in their fields, the Written and information patients with providing efficient adjunct in answers to their questions, and assists clinicians with the on the College Publicly available consent process. informed information reliable accurate, website, the pamphlets present engines and search popular commercial the pitfalls of avoiding website forums. Created to provide support both to clinicians and their to provide Created Pamphlets are Information Patient the RANZCOG patients, patient-focused of source and relevant a comprehensive with College statements and aligned is in-date that information and guidelines.

clinicians and patients Providing support to Pamphlets Patient Information Patient Information RANZCOG RANZCOG PELVIC PAIN their firstperiod,andthenwith theirperiods,when severe vomitingoccurringfour-five weekly, priorto menses. Adolescentgirlshavealso beenadmittedfor severe asthma–occurringonlywith onsetof their RCH withanaphylaxisaswell ICUadmissionsfor Extending from this,adolescent girlsare seenat and prostaglandins. until day2or3, cytokines causedbyinflammatory begins afewdayspriortomensesandlastsusually dizzy. dysmenorrhoea, which Thisisclassicprimary cent haveheadaches,10perfeelfaintorare 30 percenthavevomitingand/ordiarrhoea,20 we recognised that 40percentexperiencenausea, By listeningtoadolescentswithdysmenorrhoea, understanding of acondition. that teachesussomethingorleadstoimproved has often beenanunusualpresentation of aproblem Starting withmyexperienceat RCH; remember that it development of persistentorchronic pain. associated withpain,painsensitisation andthe increasing knowledgeregarding themechanisms long-term benefit of laparoscopy forpainandthe endometriosis, thelackof RCTs demonstrating any but alsothelackof correlation betweenpainand instructive,clinicalproblems, unusual, butvery (RCH) inMelbournewhere there havebeenmany experiences of workingat RoyalChildren’s Hospital There are anumberof reasons, whichincludemy and theoralcontraceptivepill(OCP)? and pelvicpainwhohasnotresponded toNSAIDs withsignificantperiod why notlaparoscope everyone further numberwillhavesomeadhesionsfound.So will haveendometriosisfoundat laparoscopy. A pain, studiessuggestthat 30–50percentof women the painproblem. Inthesettingof periodandpelvic try and resolve pathological findingsinaneffortto of thepainand,ideally, tosurgically correct any identification of endometriosis, a laparoscopy asthe‘gold standard’forthe approach toperiodandpelvicpainisundertake The standardteachingandgynaecological Gynaecology, Royal Children’sHospital,Melbourne Director DeptPaediatricandAdolescent MBBS, FRANZCOG, MD, FFPMANZCA Prof SoniaRGrover question ‘scope, thatisthe To ‘scopeornotto 1 to identify thecause toidentify involved intheprocess of endometrialshedding and prostaglandins, whichare knowntobecritically events canbeattributed cytokines toinflammatory chronic fatigue andfibromyalgia. Most of these as domigrainesandthesymptomsassociated with irritable bowelsyndrome occurat timesof menses, they begin.Exacerbations of Crohn’s diseaseand to haveendometriosis. often, forlongerandmore heavily, are more likely have already shownthat womenwhobleed more proven endometriosis.Various epidemiologicalstudies but thisrate alsoappliestowomenwith histologically are doingmore of this. retrograde bleedingandthat thosethat bleedheavily bleeding. We knowthat 95percentof womenget different –withtheirpainoccurringondays of heavy prostaglandin-related symptoms,isactually dysmenorrhoea andheavymenses,butnotthe dysmenorrhoea, thepainpatterns of thosewith Again listeningtotheadolescentswith are clearlypretty potentsubstances. and ifyoubleedlotsare more likely todoso. don’t bleed,youdonotseemto make endometriosis, gynaecology clinicshaveamildbleedingdisorder, more than10percentof womenwithHMBinadult the teenagerandmother. Kadirhasshownthat bleedingdisordersinboth subsequently often identify also hadheavyperiods(andendometriosis),andwe realised that themothersof theadolescentswithHMB On takingahistory, includingfamilyhistory, Irapidly menstrual bleeding(HMB)havelongbeenrecognised. Bleeding disordersinadolescentswithheavy endometriosis, hasbeenreported byothers. spontaneous resolution, of evenmoderate tosevere invariably resolved bythetimeof theirsurgery. This In theseyoungwomen,theendometriosishas isundertakensurgery somemonthstoyearslater. so periodsare suppressed andthecorrective appropriate orpossibletooperate immediately, retrograde menses.Inyoungwomen,itisoften not have significantendometriosisduetosubstantial obstructed Mülleriananomaliesandmostof these contrast, Ihaveseennumerous youngwomenwith neither are theyfoundinthemedicalliterature. In (when there isnoendometrialtissuepresent), and Hauser withendometriosis?Ihaveyettoseeacase number of womenwithMayer-Rokitansky-Küster- to developendometriosis,whyaren’t there asimilar agenesis. Giventhat onein10womenare supposed the care of more than100womenwithuterovaginal Through myworkat theRCH, Ihavebeeninvolvedin different painpattern. provoking bladderandbowelsymptomstheir with theperitonealfree fluidcausingirritation a bloodclotortheyhavemore retrograde bleeding different, eitherbecausetheyare crampingtoexpel 5 3 So, at a clinical level – if you So,at aclinicallevel–ifyou Thus,thepainpattern is 2 and 4

PELVIC PAIN and offer 17 Vol. 21 No. 2 Winter 2019 | 48 Vol. SK Agarwal, C Chapron, LC Giudice, et al. Clinical diagnosis LC SK Agarwal, C Chapron, endometriosis: a call to action. Am J Obstet Gynecol. of 2019;220(4):354.e1-e12. and LA leukocytes Salamonsen. Inflammation, J Evans, Rev Endocr Metab Disord. 2012;13(4):277-88. menstruation. PR Koninckx. TM D’Hooghe, CS Bambra, BM Raeymaekers, menstruation retrograde of and recurrence prevalence Increased . in baboons with spontaneous endometriosis. Hum Reprod 1996;11(9):2022-5. inherited of C Sabin, et al. Frequency D Economides, R Kadir, bleeding disorders in women with menorrhagia. Lancet. 1998;351(9101):485-9. Endometriosis. Epidemiology of L Marcella. Eskenazi, BPaW Obstetrics and Gynecology Clinics. 1997;24(2):235-57. pain pressure RE Harris, SE Harte, et al. Increased S As-Sanie, pelvic pain. Obstet Gynecol. sensitivity in women with chronic 2013;122(5):1047-55. M Craigie. A possible link between G Hardi, S Evans, pelvic pain. chronic dysmenorrhoea and the development of ANZJOG. 2014;54(6):593-6. P Haines. Prospective, N Whitelaw, CJ Sutton, SP Ewen, laser laparoscopy trial of double-blind, controlled randomized, minimal, mild, and with pelvic pain associated of in the treatment . 1994;62(4):696-700. endometriosis. Fertil Steril moderate of excision et al. Laparoscopic J Abbott, J Hawe, D Hunter, trial. Fertil placebo-controlled endometriosis: a randomized, l. 2004;82(4):878-84. Steri and reported R Mohindra, S Ross, et al. Laparoscopy J Jarrell, with endometriosis. J Obstet Gynaecol Can. pain among patients 2005;27(5):477-85. a KD Jones, P Haines, CJ Sutton. Long-term follow-up of for pelvic pain. JSLS. laser laparoscopy trial of controlled 2001;5(2):111-5. Pain Experience Women’s R Brant, W Leung, P Taenzer. J Jarrell, Surgery With Endometriosis. for Pain Associated Future Predicts J Obstet Gynaecol Can. 2007;29(12):988-91. A Sneddon, P Arbon. The menstrual disorder of M Parker, teenagers (MDOT) study: determining typical menstrual patterns study of and menstrual disturbance in a large population-based Australian teenagers. BJOG. 2010;117(2):185-92. in the et al. Laparoscopy L Fedele, L Arcaini, P Vercellini, pelvic pain in adolescent women. J Reprod chronic diagnosis of Med. 1989;34(10):827-30. G Rose. Adolescent endometriosis: J Sanfilippo, MR Laufer, Adolesc Gynecol. J Pediatr approaches. diagnosis and treatment 2003;16(3 Suppl):S3-11. et al. Endometriosis in Dun, KA Kho, VV Morozov, EC adolescents. JSLS. 2015;19(2). Scale: M Sullivan, S Bishop, J Pivik. The Pain Catastrophizing Psychological Assessment. development and validation. 1995;7(4):524-32.

References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. patients the skills to better manage the stressors and the skills to better manage the stressors patients contributors to pain. of evidence that this is relevant), I mostly avoid is relevant), this that evidence of not know who will for pain. I admit I do laparoscopies sure and I am laparoscopy, a negative benefit from significant cohort is also a but there is a cohort, there There angrywho will be laparoscopy. about a negative a new pain – cent who will develop will be 20 per wall. point on their abdominal a trigger often their period and pelvic pain that report Women trivialised, not managed. and ignored symptoms are also others are what and I am advocating, What and pelvic pain should dysmenorrhoea saying, is that It needs to be activelynot be trivialised and ignored. to avoid the developmentmanaged to endeavour and central sensitisation, persistent pelvic pain of pain for many other chronic with the incumbent risk manage pain symptoms, The aim is to syndromes. which may some endometriosis, than excising rather heavy period. The with a subsequent well return loss (tranexamic acid or menstrual aim is to reduce menses and of suppression hormones), plus or minus and pain), provide of (a potential source ovulation and to period and pelvic pain education link patients I need physiotherapists. I know seek the assistance of interest finding psychologists with an to do better at on pain they will have an impact in pain, as I am sure and helplessness magnification rumination,

13 14-16 8-10 or at their or at 8 Adolescents who 1

12 Likewise, the study by Likewise, Additionally, repeated repeated Additionally, 11 6 Long-term follow up (mean 9 The study by Abbott demonstrated demonstrated The study by Abbott 9 But further to this, the poor correlation to this, the poor correlation But further 7 What about the risk of progression of endometriosis? endometriosis? of progression about the risk of What 4–11 years on delays of Several studies have reported endometriosis. to the diagnosis of who should be at high risk, in theory, of having of high risk, in theory, who should be at endometriosis. Their management involves suppressing menstrual loss and often reducing menses altogether to manage their symptoms. a cohort, we had performed In a retrospective only in only 8 per cent (12/150) and laparoscopy up study one had endometriosis. A long-term follow the 50 per cent of these adolescents located of with a 95 per cent young women 5–15 years later, (n=70). 25 per cent had no pain, 25 rate participation per cent had some pain, and 50 per cent had ongoing endometriosis pain. If we follow the argument that and specific treatment, without excision will progress this adolescent cohort, most, if not all, should then of have had significant endometriosis by the time they as adults. This is particularly the had a laparoscopy adolescents of that case as others have reported who fail cyclic OCP and NSAIDs, 38–100 per cent between symptoms, location and pain severity with between symptoms, location raises concerns regarding endometriosis of location to fulfil the Bradford-Hill failure endometriosis and its between pain The relationship criteria for causality. not helped by the trials relating and endometriosis is RCTs have been three There to pain and laparoscopy. with who had presented have involved women that at endometriosis was identified pain, and then when sham (diagnostic had either laparoscopy, the time of undertaken. only) or excision/laser laparoscopy The initial outcome measures for two of these studies for two of The initial outcome measures up follow six-month was endometriosis at no difference in pain scores at six or 12 months in pain scores no difference between those who had delayed or immediate surgery. excisional six years) of the former study demonstrated pain the former study demonstrated six years) of in both groups. recurrence cyclic pain is thought to predispose to persistent or to persistent is thought to predispose cyclic pain pain. chronic will have endometriosis at the time of laparoscopy. laparoscopy. the time of will have endometriosis at in the long-term follow up cohort, only 13 of Yet, under adult care, the 26 who had had a laparoscopy had endometriosis – all minimal/mild disease. So despite a long history dysmenorrhoea and never of any theoretical/potential of having had excision or was no moderate endometriosis, there spots of among the endometriosis. The fertility rate severe age than the state cohort was as good, if not better, better Maybe the outcomes were figures. matched in menstrual loss than expected due to the reduction the ongoing during adolescence. I won’t argue that no were but, there pain in 50 per cent is a problem; this cohort and I suspect the of features predictive psychological input may have contributed. lack of and you different, adolescents are may argue that You Nevertheless, in adult women, withmay be correct. ultrasounds (and ignoring commentsnormal, careful immobile and tender ovaries, due to lackregarding Jarrell with follow up to 12–14 years, demonstrated years, demonstrated with follow up to 12–14 Jarrell between those with sham surgeryno difference and endometriosis in pain score of those with excision surgery repeat and of outcomes, an equal likelihood surgery repeat being pain of with the only predictor prior to first laparoscopy. score Now add to this background the science of pain and pain science of the background add to this Now is pain that of It is the presence central sensitisation. pain sensitivity of lower thresholds with associated or not the presence sensitisation, and thus central endometriosis. absence of have been seen at RCH are likely to be in the 10 per likely RCH are have been seen at teenagers with significant dysmenorrhoea cent of repeat surgery. repeat PELVIC PAIN Pelvic PainFoundationofAustralia MBBS, FRANZCOG, FFPMANZCA Dr SusanEvans Foundation ofAustralia The Pelvic Pain outline theproblems withcurrent pelvicpainservices professionals andthoseaffected by pelvicpainto Pain Report’theyconsultedwidely withhealth Woman andthe$600MillionGirl:The Pelvic $6Billion problem. Fortheirreport entitled ‘The of PainMedicine,looked at waysof remedying this in collaboration withPainAustraliaand theFaculty Zealand), Vancaillie Prof Thierry andDrSusanEvans, In 2011,MsDeborahBush(EndometriosisNew of girlsandwomenwithpelvicpain. addressed. Noorganisation wasadvocating onbehalf the needsof womenwithpelvicpainhadnotbeen Australia’s firstNational Pain Strategy; however, with chronic pain,andledtothedevelopmentof Pain SummitwasaturningpointforAustralians held at ParliamentHouse,Canberrain2010. The was first recognised at theNational PainSummit The needforrepresenting thosewithpelvicpain Dr Meredith Craigie(painphysician). Allen (accountant),MsDonnaBenge(solicitor)and Evans (gynaecologist,painphysician),MsKathy PPFA 2014 wasco-foundedinJanuary byDrSusan The originsofPPFA of theconsultingdesk. Solutions forpelvicpainneedtoworkbothsides caring forthecomplexneedsof womenwithpain. of clinicians,includinggynaecologists,when information. Akey partof ourworkisinthesupport accessing reliable, medicallyaccurate andpractical female, withotherpelvicpainconditionshavein the difficultiesthat Australians,bothmaleand significant proportion of ourwork,wealso recognise any cause.Whiledysmenorrhea-related painisa for girls,womenandmenwithpelvicpainfrom and supportseducation, advocacyandresearch is anot-for-profit organisation that promotes The PelvicPainFoundation of Australia(PPFA) Subscribers are entitledtohave theirpracticedetails PPFA subscribersare supportedinseveralways. Health professionals whochoosetobecome Subscriber program 2019, andPPFA welcomesenquiriesfrom otherstates. PPEP-Talk program willbe provided inQueensland government andtheSAState Government.Apilot and isfundedasacollaboration betweenthefederal the National ActionPlanforEndometriosis(NAPE) endometriosis where required. PPEP-Talk ispartof care setting,andearlyreferral forconsideration of effective management of dysmenorrheainaprimary focus onpositivehealthoptionstoreduce pain,early explains pain,periodsandendometriosiswitha of neuroscience forthebenefit of allstudents.It education systemandincorporate newaspects accommodate therequirements of theAustralian Endometriosis (PPEP-Talk) Program wascreated to Society. ThePPFA-developed Periods,Painand an evaluation of theprogram totheAustralianPain in 10SAschoolswithgreat success,andpresented piloted theEndometriosisNewZealand, MEProgram to 80schoolsinSouthAustralia(SA).In2017, PPFA neuroscience-based schoolseducation program In 2019, PPFA iscontractedtoprovide an innovative, Schools program and Motivational interviewing. Musculoskeletal PelvicPain,Opioidsin Pelvic Pain,Laparoscopy forPelvicPain,Recognising Care, AvoidingBowel PaininPrimary Burnout,Male Understanding PelvicPain,TheManagementof area of expertise,inawiderangeof areas suchas professionals toupskilloutsidetheirtraditional clinicalcare. Theseminarallows to everyday are chosentoprovide maximalpracticalapplication across different professions. Thespeakers andtopics pelvic painmanagementskillsandbuildingcontacts professionals withaninterest inbroadening their seminars welcomeallAHPRAregistered health Training Seminar. Theseinexpensiveandpractical In May2019, PPFA helditsfourthHealthPractitioner Seminars of consultation. use of medications andself-care from thefirstday pelvic stretches, pelvicmusclerelaxation, better of painisemphasised.Patients canbeginlearning with theirGP. Self-care andabetterunderstanding patients canactionthemselves,orinconsultation The websitefocusesonpracticalinformation that from rural,remote andinternational locations. and education toallAustralians,includingthose The pelvicpain.org.auwebsiteprovides information Online education PPFA’s achievementssofar regardless of age,genderorpelvicpaincondition. to represent theinterests of thosewithpelvicpain in menhasalsobeenrecognised. PPFA wasformed and policies.Sincethen,theextentof pelvicpain

PELVIC PAIN Vol. 21 No. 2 Winter 2019 | 50 Vol. pain, the continuing development of a home use a home of development the continuing pain, and a large survey pelvic muscle pain, tool for male Pelvic Pain. the Language of investigating Facebook to the public that news items of provides PPFA lives in a as contributing to readers’ perceived are way. positive and collaborative doesn’t do What PPFA support, pelvic consumer does not provide PPFA to individuals with pain. pain advice or services is funded How PPFA qualified volunteer is led by a diverse and highly PPFA legal, accounting, board. The skill mix includes gynaecology education, journalism, marketing, by a part-time office and pain medicine, supported the sale of is derived from Income administrator. fees, PPFA online goods, training seminar registration A donations. subscriber subscriptions and private Health the Federal Department of 2019 grant from Government will support the PPEP- and the SA State Schools Program. Talk How you can support PPFA wishing aim is to support clinicians foremost PPFA’s women and to girls, they provide the care to improve a the lack of believe that men with pelvic pain. We is the willing to work in this area trained workforce support You services. major impediment to improved most effectively by choosing to take PPFA the aims of your own pelvic pain improving up the challenge of to help you. is ready management skills, and PPFA donations financially, If you wish to support PPFA a highly cost- are We tax-deductable. are to PPFA area close to supports an that efficient organisation subscribers who your heart: women’s health. PPFA PPFA wish to have their practice included on the training and resources website and access patient year or $200 per pay a subscriber fee of materials years. $450 for three Summary with have patients healthcare of While all areas of in no area complex pain needs, we suggest that than in pelvic apparent medicine is this need more to assist the knowledge required pain. Much of available. It crosses women with pain is already learning traditional skillsets, requiring a range of Gynaecologists zones. outside traditional comfort experts in endometriosis, menstrual already are to and hormonal issues. The upskilling required pelvic pain needs is relatively manage the majority of straightforward, and well within the ability of looks forward to helping you gynaecologists. PPFA leave your care women that the number of increase with less pain.

available for the public on the website (optional) with (optional) the website public on for the available each practitioner the specific services of a description surgery example, laparoscopic for provides, for male pelvic pain, physiotherapy for endometriosis, entitled to use and so on. They are pain specialist the including resources and teaching patient PPFA history to facilitate Pelvic Pain Questionnaire PPFA to Pelvic Pain booklet for taking, the Introduction and view consultations, before pre-reading patient their videos to improve specific pelvic pain training also supported are management skills. Subscribers difficulties when caring for they encounter where possible. where their patients, Patient resources and for girls, women products provides PPFA men through an online shop accessed via the shop accessed via the an online men through include Dr Products pelvicpain.org.au website. muscle relaxation Neumann’s pelvic Patricia Wise’s ‘This Ms Meike audio (male and female), ‘Endometriosis Endo Life’ book, Dr Susan Evans’s and Pelvic Pain’ book (paperback and ebook), for TENS machines for teens, Olive and Bee lube Dornan’s sensitive vulval skin, vaginal trainers, Peter to pelvic pain’ book, the approach ‘Musculoskeletal workbook’, and health Explain Pain ‘Protectometer sale. practitioner training videos for individual Collaboration with other groups clinician with a wide range of collaborates PPFA Pain (Queensland Persistent Pelvic organisations Pelvic Pain Network, Pelvic Pain Victoria, Tasmanian Endometriosis (QENDO, advocacy groups group), Australia, EndoActive, EndoNet, EndoSupportSA, EndoHelp, the Endometriosis Perth Sisterhood), (WHRIA, TRUE, Jean Health Organisations Womens (Robinson Research organisations Hailes), research Institute) and several universities. advocacy MBS Review has actively engaged with the MBS Review PPFA Number Item Committee, seeking a new Medicare by gynaecologists consultations for prolonged has when caring for women with pelvic pain. PPFA remunerated a timed consultation that advocated with as physicians for patients the same rate at complex conditions would allow gynaecologists to and incentivise care comprehensive more provide submission to the MBS PPFA’s upskilling in this area. this new item number was Review Board requesting followed by the opportunity to meet for a long and Bruce Robinson interview with Prof comprehensive the MBS Review), and senior members of (Chair, for continue to advocate Health. We Department of health reform. this as an essential part of NAPE has been an active participant in the advocacy PPFA and the implementation for, the preparation for, the NAPE. The NAPE is an ambitious document,of, which, if fully implemented, has enormous potential to girls and women with pelvic pain.change the lives of Federal and State of to the collaboration It is a credit Governments with the five peak advocacy bodies that for Endometriosis up the Australian Coalition make Endometriosis Australia, EndoActive, (QENDO, Canberra Endometriosis Network and PPFA). Research research has supported a wide range of PPFA either financially or with in-kind support. projects, a Pelvic Pain These include the development of into basic science research Impact Questionnaire, between endometriosis lesions and the relationship PELVIC PAIN Australian andNewZealandCollegeofAnaesthetists Dean, Faculty ofPainMedicine Dr MeredithCraigie and environmental influences, gender-specific commonly, multi-factorialaetiology. Genetic neurological systems,eitherasthe sole or, more gynaecologic, urologic, gastro-intestinal and Sources of PPPincludedisordersof the established in1998toaddress these needs. New Zealand Collegeof Anaesthetists(ANZCA) was Faculty of PainMedicine(FPM)of theAustralianand through education, trainingandpractice.The and theneedforacomprehensive medicalresponse the problem of unrelieved paininthecommunity Zealand in2012.Thisrecognised theimportanceof in 2005, andendorsedasascopeof practiceinNew medical specialtybytheAustralianMedicalCouncil disciplines. Painmedicinewasrecognised asa interactions andthesocialpsychological being explored inthescienceof neuro-immune evolving disciplinewithexciting newfrontiers now sufferers in2019. Painmedicineisarapidly However, there are glimmersof lightforPPP to chronic painingeneralandPPPparticular. poor understandingof themechanismscontributing practitioners. Thissituation hasbeenexacerbated by eventually avoidandevendistrusthealthcare treatments ornotreatment at allsothat they need. Patients haveoften hadmyriadunsuccessful comprehensive assessmentandcare thesepatients stereotypes andinadequate trainingtoprovide the disbelief byhealthcare providers basedonunhelpful pain’, blamedontheirmentalhealthorstraight dismissed, downplayedornormalisedas‘justperiod reinforced bytheirexperiencesof frequently being sexual healthovertones.Theirreluctance hasbeen their painhasembarrassinggender, fertilityand reluctant topresent tohealthcare providers as with chronic pain.Inthepast,patients havebeen above andbeyondthosesuffered byothersliving Persistent pelvicpain(PPP)presents challenges opportunities science andlearning A newparadigm, cross sensitisation betweenorgans. namely peripheralandcentralsensitisation and is expressed byadaptations intheneuronal system, persistent painresides intheglialcomponent,but Together thissuggeststhat thepathology of the pre- andpost-synapticterminalspermanently. releasing pro-inflammatory cytokinesthat modify involvement, changingtrophic supportand microcytic andglialprocesses aswellT-cell reorganisation withrecruitment of maladaptive create persistentpainstates through fundamental neuronal signallingsufficiently can amplify to glia maintainneuronal reactivity; however, they release bothpre- andpost-synaptically. Normally engulf thesynapsesandcontrol neurotransmitter brain immunesystems.Glia,particularlymicroglia, between peripheralimmune,spinalimmuneand system exhibitingbidirectional communication like cells,distributedthroughout thenervous signals. are triggered byanatomically distributedimmune involved inconductingheightenednociception to persistentpainshowthat theneuronal processes research inthecontributionof immunemechanisms noxious andinnocuousstimuli.Inaddition,recent fields whereby spinalcordneurons now respond to spontaneous activityandenlargementof receptive resulting inreduced thresholds foractivation, excitability, synapticfacilitation anddisinhibition the spinalcordcanleadtoincreased membrane tocyclical nociceptiveinputsfrom theperiphery inflammation) andneuropathic pain.Persistentor and somatic causesof nociception(including Known mechanismsof PPPincludepelvicorgan PPP phenotype. emotional responses addtothecomplexityof the somatic referral andanabilitytoprovoke strong of thelumbo-sacralnerveplexus,apredilection for contribute. Theuniqueneuroanatomical features as wellchangesrelated topregnancy mayalso mechanisms, includingtherole of sexhormones, scans suggesting altered neuronal activity at the brain scans suggesting altered neuronal activityat thebrain in regional grey matter, canbeseenonfunctional MRI alterations inbrainmorphology, commonlydecreases Changes extendtothebrainwhere characteristic other somatic andautonomicsymptoms. different sites,commonlyassociated with arange of PPP isoften describedasmultiplepains inseveral of spinalcordneurons. So,itisnotsurprisingthat convergence withexpansionof thereceptive fields as aresult of viscero-somatic orviscero-visceral response topaininothertissuesora secondary pathology generatesinvolved eitherastheprimary In PPP, multipleorgansystems appeartobe by end-organdysfunctionanywhere inthebody. These neuro-immune changescanbetriggered 1 Thesesignalsarisefrom glia,immune- 2

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Vol. 21 No. 2 Winter 2019 | 52 Vol. Dr John McNeil Campbell, Qld, Dr John McNeil Campbell, Qld, 25 December 2018 Dr Graeme Dickinson Desmond Cable, NZ, 13 February 2019 2019 Qld, 2 March Popper, Irene Dr Eva Dr Philip Vincent Moon, Qld, 8 April 2019 Fouad Shenouda, Vic, 10 May 2019 Dr Sarwat KN Dodds, EAH Beckett, SF Evans, MR Hutchinson. Spinal Glial SF Evans, KN Dodds, EAH Beckett, Occur in a Minimally Invasive Mouse Model of Adaptations and for Lesion Etiology Endometriosis: Potential Implications Persistent Pelvic Pain. Reprod Sci. 2019;26(3):357-69. the Deconstructing CJ Woolf. R Baron, Hehn, CA Von neural mechanisms. pain phenotype to reveal neuropathic Neuron. 2012;73(4):638-52. Time to flip the pain curriculum? YS Bradshaw. DB Carr, Anesthesiology. 2014;120(1):12-14. Australia. www.pelvicpain.org.au. of Pelvic Pain Foundation Pain Management Network. www.aci.health.nsw.gov.au/ chronic-pain. www.fpm.anzca.edu.au/ Better Pain Management program. resources/better-pain-management. www.fpm.anzca. Pain Medicine 2015 training program of Faculty edu.au/training/2015-training-program. The College was saddened to learn of the death the death The College was saddened to learn of Fellows: the following RANZCOG of • • • • • Notice of Deceased Fellows

Gynaecologists face many challenges in looking Gynaecologists face many challenges in looking time and a lot of It takes women with PPP. after the remuneration Currently, emotional resilience. inadequate grossly practice are in private structures perverse incentives for are and indeed there In long consultations. gynaecologists providing high demands on are there the public sector, on surgical waiting clinics and pressures outpatient lists. Limited access to pelvic physiotherapists, pain trained psychologists and specialist pain to both sectors also contributes clinics across As individual physicians, less-than-optimal care. we may feel we cannot do much about these persistent pain is finally however, problems; as a major public health issue being recognised and federal government funding is now targeting specific pain conditions, especially endometriosis, can lobby our respective We PPP. and by association and FPM RANZCOG organisations, professional for advocate and strongly to work together ANZCA, depending on us. are change. Our patients References 1. 2. 3. 4. 5. 6. 7. gynaecologists wanting more immersive learning, learning, immersive wanting more gynaecologists the faculty’s leads to the training pathway specialist physician. of specialist pain medicine qualification the first multidisciplinaryThe FPM was medical world. The two- pain medicine in the academy in fellowship to a is an additional year fellowship primary qualification. or general practice specialist The faculty’s 2015 curriculum and training program paradigm and the sociopsychobiomedical reflects It consists structure. is based on the CanMEDs supervision with workplace-based clinical of feedback and targeted in-training progressive are resources A range of assessments. summative available on the faculty’s to e-learning platform include modules introducing support learning. They training for the core nine essential topic areas visceral pain is one. The of which stage (first year) stage (second year) provides practice development to develop expertise in an opportunity for trainees PPP is one option for their choice. of topic areas have been defined. which learning outcomes Discipline- 3 or the New South or the New South 4 5 program. Participants Participants program. 6 specific training is required to address the the to address required specific training is PPP. biomedical contributions to wide range of the Additional training in pain medicine addresses attitudes sociopsychological dimensions, changing and behaviours while enhancing the knowledge challenging to manage the more and skills required not every gynaecologist PPP conditions. However, an additional will wish to or be able to undertake steps in pain medicine. Simple training program the potential complexity of such as raised awareness PPP and altering of presentation the patient’s of considering inquirylines of when taking the history, preoperative to investigations, approaches different a can make pain relief and postoperative preparation Engaging early with a pain medicine difference. real specialist and allied health practitioners with pain training can be useful. in a prime position to set Gynaecologists are and their other for the patient expectations recovery regarding times providers healthcare and opioid analgesic tapering. The language used in history important. Not taking is critically the language used has inadvertent high infrequently, into Reframing information value for patients. threat language can help. Judicious use of less threatening adjuvant analgesics, such as low-dose amitriptyline, to the through the first night postoperatively from for reducing follow up visit can be a useful strategy opioid use. Learning about pain has been shown to effectively. to manage pain more empower patients to patients Gynaecologists can assist by directing such as the Pelvic Pain online resources reputable Australia website of Foundation For gynaecologists wishing to learn more about about For gynaecologists wishing to learn more two options; a series persistent pain, the FPM offers online learning modules and a specialist training of 12 one-hour modules in the are There program. Better Pain Management level as well as affecting the ‘top-down regulatory ‘top-down the well as affecting level as the including areas, Multiple Wager). (Tor pathways’ amygdala, thalamus, parabrachial ventro-medial somatosensory and the periaqueductal pathways prefrontal involved. The ventro-medial are grey, pain appraisal, important in cortex is particularly changes behaviours. Neuroplastic driving aversive in the appraisal of lead to changes in these areas and avoidance modulation pain, altering descending the emotional and behaviourallearning, underpinning these changes isextent of to pain. The responses brain development by genetic factors, modulated particularly adverse childhood childhood, throughout experiences. Much depends onevents, and past pain pain experiences.communicate the language used to of cultural the influence pain and The language of but very important, areas new, relatively contexts are subjective and very Pain is a pain research. personalof to others through is communicated experience that with PPP frequently Women language and behaviours. unsatisfactory with healthcarereport conversations practitioners and not surprisingly feel misunderstood. a requires with PPP therefore patients Treating the pain, the language of sound understanding of pain experience social context in which patients addition the pain in and the psychological impact of and pelvic organ pathology to knowledge of in order to develop a comprehensive neuroanatomy management plan. The most complex patients best served by a multidisciplinaryare team working in an interdisciplinary using environment a sociopsychobiomedical paradigm. Wales Agency for Clinical Innovation website, the website, the Agency for Clinical Innovation Wales Pain Management Network. may choose to do one, a few or all 12 modules. For may choose to do one, a few or all 12 modules. For WOMEN’S HEALTH of aCTG. Assessment isthenmadeof othercauses with auscultation of thefetalheart andperformance presentation beyond28weeksgestation allbegin Recommendations formanagement after immediately, nomatter what timeof theday.’ or irregular contactyourhealthcare provider with yourbump’dailyand‘ifanythingseemsdifferent distribute writtenmaterial urgingwomento‘bond Aware (stillaware.org), haveanonlinepresence and quiet. Community-basedorganisations, suchasStill side fortwohoursandthenactifthebabyisstill Top guidelinerecommending sheliesdownonher caregiver after noticingRFMandtheRCOG Green recommending awomanimmediately contacther recommended urgencyof actionvaries,withPSANZ Once theproblem hasbeenacknowledged,the movements. the pattern of herownbaby’s is nowplacedonanindividualwoman’sperception of shown toraisematernal anxietylevels.More emphasis Cardiff KickCharts)isnotadvisedasthishasbeen number of fetalmovement(asinthepreviously used taken of RFMfrom 28weeks.Actualcountingof the Fetal movementsshouldbefeltby24 weeksandnote given verbalandwritteninformation aboutsuch. about theneedtomonitorfetalmovementsbybeing to that end,allmentionwomenshouldbeeducated assume that actingonRFMwillavoidstillbirthsand, guidelines aboutRFM.Currently, theseguidelines Various bodies(RCOG, RANZCOG, PSANZ)have in AustraliaandNewZealand annually a tragicoutcome.Stillbirth affects 2500families fetuses at riskof stillbirthintimetoactandprevent become atopicof interest asawayof identifying on notingareduction infetalmovements(RFM)has of fetalactivitymaynotapplytoanother. Thefocus sensation differently andonewoman’sdescription fetal movementsisdifficultaswomenperceive the weeks insubsequentones.Thedefinition of ‘normal’ after 20weeksinafirstpregnancy orasearly16 noticed between18and20weeks,butmaybewell of alivepregnancy. Thesemovements are usually called ‘quickening’, waslikely thefirstclinicalsign Historically, maternal perception of fetalmovements, such areduction priortodiagnosis. majority of womenexperiencingastillbirthnoted their baby’smovements? patients aboutmonitoring What shouldItellmy 3 1,2 andthe FRANZCOG Dr JennyDowd and gynaecology. questions inobstetrics to thosecurly-yet-common readership, balancedanswers For thebroaderO&GMagazine in August2016. Itinvolves27hospitals, 256700births ‘My Movements’inAustralia.Thelatter began Baby’s ‘Mindfetal’ involving39000womeninSweden and Two otherclustertrialsare currently inprogress: basedonRFMalone. delivery of preterm RFMandtightenguidelinesthat lead to not encourageprograms that promote awareness on thebasisof thecurrent evidence,weshould of fetalmovementsisharmful’. Theysuggestthat, 2018. AFFIRM Trial publishedintheLancetNovember need tobereviewed inlightof theevidencefrom the The managementaspectsof theseguidelinesmay fetomaternal haemorrhage. alone seemstorecommend aKleihauertoexclude the availabilityof appropriate resources. PSANZ timing of suchascanmustobviouslydependon dopplers.Theif possible,middlecerebral artery for fetalbiometry, amnioticfluidassessment,and problems, anultrasoundscanisrecommended In thepresence of continuedRFMorotherclinical than 25, shouldbeassessed. smoking, advancedmaternal age,IVF, BMIgreater conditions, previous intrauterinegrowth restriction, Stillbirth riskfactors,suchasmaternal medical a morphologyultrasoundhasbeenperformed). methadone) orfetalmalformations (checkthat of RFM,suchasmedication (opioids,sedatives, Thornton these data inthesamejournalfrom Walker and nursery. Thisledtoapublishedcomment about on of more prolonged admissionstotheneonatal preterm birthfrom 8.1–8.6 percent,withtheflow cent, caesarean sectionfrom 25.5–28.3 percentand increase ininductionof labourfrom 35.8–40.7 per was beneficial.Otheroutcomesnotedwere an this drop wastoosmalltoprove that theintervention care to41per10000birthswiththeintervention,but stillbirth rate from 44per10000birthsafter standard stillbirth. Theresults showaslightdecrease inthe outcomewas were givenusualcare andtheprimary altered movementsafter 28weeks.Thecontrol group should refer themselvesimmediately iftheydetected changes infetalmovementsfrom 24 weeksand hospitals, inwhichwomenwere toldtomonitor 4 Thisinvolved400000pregnancies from 33 5 whoassertthat ‘encouraging awareness WOMEN’S HEALTH Vol. 20 No. 4 Summer 2018 | 54 Vol. Perinatal and Maternal Mortality Review Committee (PMMRC). Mortality Review Committee and Maternal Perinatal Mortality and Maternal the Perinatal Report of Annual Tenth Health Wellington: Mortality 2014. Review Committee: Reporting Commission, 2016 Contract No.: ISBN 978-0- Quality and Safety 908345-29-8 . Australia’s mothers Health and Welfare. Australian Institute of 2016. Canberra: AIHW, brief. and babies 2014—in perception al. Maternal JM Thompson, EA Mitchell, et T Stacey, the Auckland stillbirth risk: Findings from fetal activity and late of Birth. 2011;38:311-16. Study. Stillbirth of A Ridriguez, et al. Awareness Heazell, JE Norman, EPA fetal mortality package to reduce fetal movements and care . trial. Lancet cluster-randomised (AFFIRM): a stepped wedge, 2018:392;1629-38. fetal of JG Thornton. Encouraging awareness KF Walker, Lancet. 2018;392;1601-2. movements is harmful.

References 1. 2. 3. 4. 5. In light of the AFFIRM trial, current guidelines still guidelines current trial, the AFFIRM of In light and await better maybe we should pause stand, but action on the urgent promoting evidence regarding in order to alone, especially preterm, RFM basis of avoid unnecessaryand inductions. interventions

over three years, and is a stepped wedge cluster- wedge is a stepped years, and over three intervention involves trial. The package of randomised 28 after receive app, which women a smart phone fetal movementsasks them to log their weeks, that and them with information It also provides daily. intended to fetal activity and is about prompts about seeking care in making decisions support them been going for several monthsif RFM occurs. This has so far, Hospital, Melbourne, and the Royal Women’s at logging an interest patients those only 30 per cent of 28 App when sent a link at have started using the weeks (personal communication). to advising us with respect leave does that So where by stillbirth, either Anyone touched our patients? will be a there hopes personally or professionally, this event and many of the incidence way to reduce encourage that resources vocal in producing are all have anecdotal stories women to act. Clinicians the blue with RFM out of about women who present leads to urgent delivery and, we and a critical CTG who a saved life. The flipside is women presume, they didn’t present lose a baby feeling guilty that have blogs and websites in time. Many pregnancy advice along these lines. RANZCOG is committed to improving the health of to improving is committed RANZCOG region. women and their families, including in the Pacific O&G Magazine for The College is seeking contributions about global women’s health. Articles and opinion highlight women’s health issues or initiatives that pieces appreciated. are countries in low- to middle-income We a written contribution? Don’t have time to prepare you. can interview you and write the article for all College members. from welcome Contributions are to about contributing information For more O&G Magazine, go to: www.ogmagazine.org.au/contribute Share your story in O&G Magazine your Share Do you have experience working or volunteering volunteering or experience working have Do you middle-income countries? to in low- WOMEN’S HEALTH Western SydneyUniversity Associate Professor, Schoolof Medicine, Campbelltown andCamdenHospital Dept ofObstetrics&Gynaecology FRANZCOG, MD, DNB,FCPS,DGO, DFP, MNAMS Dr RaiyomandDalal FRANZCOG Trainee (LiverpoolHospital) MBBS, MCE Dr VidhuKrishnan fertility tourism The localeffectsof Case report obstetric team,despitetheiryears of experience. find gobsmacked notjustthemother, butalsothe crown-rump lengthwasalsoretrieved. This unusual removed manually. Surprisingly, a fetusof 50mm Initially, multiplefragmentsof adherent placentawere under anaesthesia. bleed, itwasdecidedtotake herforanexamination a further400mL.Inviewof theongoingvaginal moderate vaginalbleedoverthenext12hours,losing medically; however, shecontinuedtohaveongoing haemorrhage of 800mLthat wasmanaged wascomplicated byapostpartum The delivery and 1730g. have avaginalbirthof twinboys,weighing2230g she wentintospontaneouslabourandproceeded to spontaneously ruptured at 34weeks.Two dayslater, and, duringherinpatient stay, hermembranes Ms Nwasadmittedformanagementof hypertension preeclampsia at 33–34weeks. Her pregnancy wasfurthercomplicated byonsetof 31 weeks,furtherincreasing thefetalsurveillance. weeks anddiscordantgrowth of twinswasnotedat a high-riskclinic.MsNdevelopeddiabetesat 28 In viewof twinpregnancy, shewas managedin four fetusestocontinuewithtwin(DCDA) gestation. centre, sheunderwentreduction ofscan inatertiary reduction at 12weeksof pregnancy. Afteradetailed higher orderpregnancy andtheyoptedforfetal and herpartnerwere counselledregarding risksof and onefetaldemise.Upon return toAustralia,she dating scanthat notedpresence of sixviablefetuses became pregnant withseptuplets.Shehadanearly were transferred andMsN overseas. Fiveembryos Ms N, 35yearsoldprimigravida,underwentIVF increased successrates. transferandperceivedtreatments, multipleembryo gender selection,avoidinglongwaitinglists,cheaper known asCBRC,forvariousreasons that include Women are increasingly accessingARToverseas, risks of cross-border reproductive care (CBRC). haemorrhage. Shealsobrought toourattention the labour, discordantgrowth of twinsandpostpartum preeclampsia, preterm rupture of membranes,preterm pregnancies, whichincludedgestational diabetes, the majorcomplications associated withmultiple Our patient, unfortunately, endeduphavingall increase intheincidenceof multiplebirthrates. isthe of assistedreproductive technology(ART) A direct consequenceof increase inthepopularity Discussion remained inthenursery. was dischargedhomeonday4whilethebabies blood losswas1200mL.MsNrecovered welland Post theevacuation, thebleedingsettled.Thetotal of surrogates anddonors. gestational surrogates andcommercial exploitation concerns aboutthenature of informed consentfor that surrogacy inIndiaisa$2.5bnindustry. countries suchasIndiaandThailand.Itisestimated in developmentof commercial hubsforCBRCin Growth of CBRChasbeenexponentialandresulted terms of ‘commodification‘ of ART. ethical questions,buthasalsoraisedconcernsin The explosionof CBRChasraisednotonlylegaland with CBRC countries like Australiafacingproblems associated adherence tothesepolicieshasalsoresulted in associated withthesepregnancies. However, to ART, thereby greatly mitigating thecomplications incidence of higherorderpregnancies, secondary transfer hasresulted insignificantly reducing the Implementation of policessuchassingleembryo restriction forIVF, incaseof disabilitiesanddiseases. commercial surrogacy, transferand multipleembryo Australia hasstrictlawsforgameteselection, governing reproductive treatments. countries suchasIndiahavehighly permissivelaws same restrictions. Whencompared withAustralia, accessing servicesincountriesthat donothavethe restricted legallyorethically, coupleslookat When accesstofertilitytreatment at homeis the reproductive travellers. ranging from hotelstomaternity waitinghomesfor CBRC ‘brokers’ that facilitate theCBRCinteraction, 1,2

4 There are 3 There are RAN003 FILLERADVERTTEMPLATESHALFPAGEHORIZONTAL5 #Simulation #ObGyn involved withasimulation communityof practice.Followtopics:#FOAMObGyn #FOAMSim #SimObGyn Join acommunityof practicetofind resources and information viasocialmedia. Twitter isagreat waytobe Learn moreaboutsim Feel free tocontactusvia:[email protected] training equipmentisnowarequirement for siteaccreditation.) Members of STAG canhelpwithadviceonequipmentandsimulation trainingcurricula.(Accesstosimulation Who isontheSTAG? incorporated intotheRANZCOG trainingprogram. The STAG advisestheCollegeabouthowsimulation canbestbe Training Group(STAG)? Advisory Do youknowabouttheSimulation Doug Barclay Sarah Janssens(Chair) Bec Szabo Lenore Ellett Victoria 3002, Australia. East Melbourne, 254-260 AlbertStreet College House, AUSTRALIA Katrina Calvert www.ranzcog.com.au Email: Fax: +61394190672 Ph: +61 394171699 [email protected] facebook.com/RANZCOG SOCIAL MEDIA @RANZCOG 6/08/2018 11:52:31AM WOMEN’S HEALTH 6/08/2018 11:52:31 AM

6 @RANZCOG SOCIAL MEDIA facebook.com/RANZCOG Vol. 21 No. 2 Winter 2019 | 56 Vol. [email protected] [email protected] +61 3 9417 1699 Ph: +61 3 9419 0672 Fax: Email: www.ranzcog.com.au RANZCOG. Cross-border reproductive care. Available Available care. reproductive Cross-border RANZCOG. https://www.ranzcog.edu.au/RANZCOG_SITE/media/ from: RANZCOG-MEDIA/Women’s%20Health/Statement%20and%20 guidelines/Clinical%20-%20Gynaecology/Cross-Border- Reproductive-Care-(C-Gyn-36)-New-March-2016.pdf?ext=.pdf. cross-border of The global landscape MC Inhorn, P Patrizio. new millennium. findings for the twenty key care: reproductive Opinion in Obstetrics & Gynecology. 2012;24(3):158-63. Current families in a shrinking world: legal and Growing SL Crockin. Reproductive surrogacy. ethical challenges in cross-border BioMedicine Online. 2013;27(6):733-741. in Asia: care assisted reproduction Cross-border A Whittaker. Reproductive for access, equity and regulations. implications . 2011;19(37):107-16. Matters Health multiple RJ Hart. The contribution of JE Dickinson, KA Waller, to obstetric overseas fertility treatment from pregnancies Australian tertiary obstetric hospital. services in a Western ANZJOG. 2017;57(4):400-4. a committee opinion. Fertil care: reproductive Cross-border . 2013;100(3):645-50. Steril Katrina Calvert Katrina

References 1. 2. 3. 4. 5. 6. It is an ideal that healthcare providers all over the providers healthcare It is an ideal that responsibility The onus of world should aim for. and obstetric care with the fertility physicians rests with CBRC and the risk associated to keep providers and to a minimum by educating multiple pregnancies appropriately. counselling the woman selection of high-quality embryos, high-quality of selection embryo single genetic preimplantation selection, patient transfer, education. patient and screening cost, burdens of the added are there With CBRC, and her family the woman that travel and language ESHRE have like face. Fertility societies may have to is fair access to the ideal scenario that stressed for all patients. home at fertility treatment

5 AUSTRALIA College House, 254-260 Albert Street East Melbourne, Victoria 3002, Australia. 3

5 Lenore Ellett Lenore Bec Szabo Clinicians in Australia are obligated to to obligated are Clinicians in Australia 1 Lessons learned effects a woman’s health both Fertility treatment highlights case Our physically and psychologically. CBRC, multi embryo of complications transfer, Several strategiesfeticide and multiple pregnancies. of the complications have been suggested to reduce with multi-follicular associated multiple pregnancies development seen in ART cycles. These include CBRC also has economic implications. In Western In Western has economic implications. CBRC also of CBRC on the local the effects Australia, a study of multiple one third of that system found healthcare fertility treatment of was a result pregnancies the healthcare that overseas. The study estimated and added significantly to $1m AUD cost exceeded system. the local healthcare of the economic burden The wide variation in law between countries that that between countries in law variation The wide being in children tourism has resulted leads to fertility have There questioning their parentage. and stateless years for almost two it has taken where been cases parents. united with their IVF to be children RANZCOG has a guideline in place for management place for management has a guideline in RANZCOG CBRC. of optimise the woman’s health prior to her accessing health prior to her accessing optimise the woman’s use of make patients ART services. When the not necessarily they are fertility services overseas, and counselling in order given the same education with any associated to minimise the morbidity who coexisting medical conditions. So, women to risks seek ART overseas may be further exposed secondary diabetes, obesity, to their pre-existing further hypertension or other medical conditions, adding to the disease burden.

Sarah Janssens (Chair) Doug Barclay Who is on the STAG? The STAG advises the College about how simulation can best be advises the College about how simulation The STAG training program. into the RANZCOG incorporated Training Advisory Group (STAG)? Advisory (STAG)? Group Training Do you know about the Simulation about the Simulation Do you know Members of STAG can help with advice on equipment and simulation training curricula. (Access to simulation training curricula. (Access to simulation and simulation can help with advice on equipment STAG Members of site accreditation.) for training equipment is now a requirement to contact us via: [email protected] Feel free Learn more about sim way to be Twitter is a great via social media. and information resources practice to find Join a community of #SimObGyn #FOAMSim practice. Follow topics: #FOAMObGyn community of involved with a simulation #ObGyn #Simulation RAN003 FILLER ADVERT TEMPLATES HALF PAGE HORIZONTAL 5 WOMEN’S HEALTH the isthmocele. of symptomsisthoughttoberelated tothesize of Isthmocele canalsobeasymptomatic. Theintensity Fertility Associates,Hamilton, NewZealand Angelsea Gynaecology, Hamilton, NewZealand Waikato Hospital,NewZealand Gynaecologist andAdvancedLaparoscopicSurgeon MBBS, FRANZCOG Dr VPSingh 30–52 percentand 19.4–88 percentrespectively. Florio, Tower andFrishman reported andincidenceof ultrasound scan’. the anterioristhmusof theuterusontransvaginal has beendefinedas ‘any visiblefillingdefectin hysteroscopy. Isthmoceleorcaesarean scardefect magnetic resonance imaging(MRI),orat thetime of imaging withtransvaginalultrasoundscan(TVUS), or diagnosisforisthmocele.Itcanbeidentifiedon There isnointernational standardiseddefinition Definition anddiagnosis dysmenorrhoea, pelvicpain,and/ordyspareunia. spotting), continuousbrown discharge, menstrual disturbance(typicallypostmenstrual infertility,Isthmocele maypresent withsecondary Presentation a causeof thesesymptoms. important that weare aware that isthmocelecouldbe the incidenceof caesarean sectionincreasing, itis these symptoms,there isoften adelayindiagnosis. Morris in1995. first describedbytheobstetriciangynaecologist uterine scardeficiency, uterinenicheorpouch,was Isthmocele, alsoknownascaesarean scardefect, History infertility.pelvic painandsecondary scar defect,suchasdysfunctionaluterinebleeding, less familiarwiththeimplications from acaesarean (either antenatally orintrapartum).However, weare placenta praevia,scarectopic,anddehiscence of acaesarean sectionscarincludeplacentaacreta, increase allovertheworld.Well-known complications performed surgeriesandrates are continuingto Caesarean sectionisoneof themostcommonly Waikato Hospital,NewZealand RANZCOG Trainee andAGES Fellow BBMedsSci, MBChB Dr PipWalker of infertility: isthmocele An underdiagnosedcause per cent,Wang etalreported 6.6–69 percent. Vaate etalestimated theincidencetobetween24–84 Studies havefoundwideprevalence ranges. Bijde Prevalence than 2.5–3.0 mm. be whentheremaining myometrialthicknessisless of isthmocelerangesfrom 24–84 percent. infertility.with secondary Thereported incidence subject of attention, especiallyinthosewhopresent and describedintheliterature, andisbecominga

1 This entity is only just being identified Thisentityisonlyjustbeingidentified 1 Asotherpathology maypresent with 6 7 A‘larger’isthmoceleisthoughtto 2,3 With With 8 While While 1,2,4 8

5

Figure 1.MRIshowingisthmocele andpictorialdiagram. the resulting thicknessof themyometrium. inadequate healingof thecaesarean sectionscarand It ispossiblethat twomechanismsare at play; section when using embryos from thesamecohort, section whenusingembryos are lowerinpatients whodeliverviacaesarean There isgrowing evidencethat IVFsuccessrates (1.6 95%CI1.45-1.76, p<0.00001). odds of subfertilitywhencompared tovaginaldelivery correlation andincreased betweencaesarean delivery section scar-associated infertility showeda secondary One of thelargestsystematic reviews oncaesarean infertility.associated withsecondary Although isthmoceleisquiteprevalent, itisnotalways scar defectoccursisnotcompletelyunderstood. The exactmechanismof howisthmoceleorcaesarean Pathophysiology also beenusedtodetectisthmocele. sonohysterography andhysterosalpingography have scar contractility and abnormal myocontraction, along scar contractilityandabnormalmyocontraction,along and haematoma. and outwardprotruding of thescar, scarretraction Other key sonographicfindingstoconsiderare inward along withtheremaining myometrialwallthickness. ischemic closure. myometrium, delayedabsorbablesutures, andmore endometrial layerduringrepair, one-layerclosure of the cervicalarea, useof oxytocin, exclusion of (belowpelvicinlet),incisioninstation at delivery dilation more than5cmat timeof delivery, lower duration of labourmore thanfivehours,cervical pre-eclampsia, maternal agelessthan30years, more thanonecaesarean section,retroflexed uterus, in thedevelopmentof isthmocele.Thelistincludes A numberof riskfactorsare thoughttobeimplicated Risk factors implantation. suggesting apossibleimpactof embryo area; thetermforthisis‘niche’. triangular hypoechogeniczone intheuterinescar tool. ultrasound isusuallyconsidered asthefirstdiagnostic when investigating foristhmocele, andMRIare considered tobethegoldstandard TVUS Investigations 1 Thedepthand length of thedefectare measured 6 On TVUS, the defect is seen as a thedefectisseenasa OnTVUS, 1,6

1 Saline infusion Salineinfusion 9 7 although although 11 Reduced Reduced 8

10

WOMEN’S HEALTH

1,7 As with It is unclear 1,16 11,15 Vol. 21 No. 2 Winter 2019 | 58 Vol. A popular technique A popular 1 7 17 1

5 (See Figure 3). A Foley catheter 3). A Foley (See Figure 1 Furthermore, the laparoscopic the Furthermore, 7 This is a combined technique where This is a combined technique 1 The crucial step of laparoscopic repair is to correctly repair laparoscopic step of The crucial identify scar defect. the uterine approach has a reduced risk of incomplete removal incomplete risk of a reduced has approach bladder injury, and uterine perforation scar tissue, of resection. with hysteroscopic which is associated described in the literature is the ‘Rendezvous described in the literature technique’. the isthmocele is identified at laparoscopy with theat laparoscopy the isthmocele is identified to outline the hysteroscopy simultaneous use of The defect can be seendefect with its light source. and is known as the hysteroscope under the light of sign’ the ‘Halloween or TVUS to help can also be used during laparoscopy identify the isthmocele. of the location Future pregnancy Future Secondary for treatment, indication is an infertility endoscopic after rates pregnancy and the reported 44–92 per cent. isthmocele are of repair isthmocele and regarding is only limited data There including uterine rupture complications, pregnancy been has what However, in subsequent pregnancies. the of between the size observed is the relationship the where scar rupture, isthmocele and the risk of scar rupture. the risk of larger the defect the greater Lower uterine thickness near term could also be uterine rupture. of predictive Symptoms are generally improved after repair of of repair after generally improved are Symptoms a 97 per cent study reporting isthmocele, with one in pain. improvement caesarean section, the risk following treatment section, the risk following treatment caesarean isthmocele is scar dehiscence in subsequent of is to wait recommendation The current pregnancies. It to get pregnant. repair months after least three at delivery that is also recommended is by caesarean term, although successful vaginal section at isthmocele have of surgical repair deliveries after in the literature. been reported which type of energy source or suture material is best material or suture energy source which type of the scar defect. to repair risk of scar rupture. scar risk of The defect can be seen under the light of The defect can be seen under the light of Figure 3. sign’. ‘Halloween the hysteroscope,

11 Restoring 7,9 It is the preferred 14 7

11 2 The laparoscopic method The laparoscopic 1,2 7 This results in intermenstrual This results 2,12 1 Hormonal treatment is also not suitable for Hormonal treatment 13 has the advantage of increasing the thickness of increasing has the advantage of repair. the myometrial layer after bleeding and pelvic pain. The retained menstrual fluid is likely to impair the to impair the fluid is likely menstrual The retained disrupt cervical mucous, sperm viability and quality of sperm swim-up. Bleeding may cause the blastocyst the uterus, interfering with to be washed out of embryo implantation. surgical approach, particularly if the residualsurgical approach, myometrium is less than 3 mm thick. others would argue that medical treatment with the with medical treatment others would argue that no shows combined oral contraceptive pill or Mirena benefit. with the presence of functional endometrium leads to functional of with the presence menstrual drainage of and impaired the accumulation blood in the cavity. Isthmocele repair was first performed laparoscopicallyIsthmocele repair by Jacobson in 2003. Although some report medical therapy can help to medical therapy can help Although some report menstruation, symptoms by suppressing improve Treatment women. to symptomatic should be offered Treatment for protocol standard’ or treatment is no ‘gold There has shown a and no technique that isthmocele repair, superior outcome. statistically In addition, endometrial abnormalities around the the In addition, endometrial abnormalities around and/ scar defect, such as overhanging endometrium could endometrium within the scar, or inclusion of re-approximation lead to abnormal bleeding. Careful the endometrial layer during uterine closure of endometrial abnormalities and could reduce dysfunctional bleeding. patients who are planning a pregnancy. planning a pregnancy. who are patients resection and laparoscopic Both hysteroscopic of isthmocele have high success rates of and repair and bleeding disturbance, both infertility treating have surgical approaches different and a variety of been described. normal myometrial thickness is important in those the to help reduce planning a pregnancy patients Intra-operative laparoscopic excision and repair of isthmocele. of and repair excision laparoscopic Intra-operative Figure 4. Isthmocele seen at laparoscopy. Figure 2. Isthmocele seen at WOMEN’S HEALTH isthmocele. Figure 5. Afterlaparoscopic excision andrepair of statically superioroutcome. However, notechniquehasactuallyshowna it aimstorestore normalmyometrialthickness. preferred methodfortreatment primarilybecause approach appearstobegainingpopularityasthe infertility.present withsecondary Thelaparoscopic for symptomatic patients, includingthosewho employed. Surgicaltreatment needstobeconsidered however,TVUS; often otherimagingmodalitiesare One of thefirststepsindiagnosticworkup is time of caesarean section. sutures could allbetaken intoconsideration at the a one-layerclosure andnotusingdelayedabsorbable avoiding incisionintothecervicalarea, notperforming section. Attention tosurgicaltechnique,inparticular, the developmentof isthmocelefollowingcaesarean There are fewmodifiableriskfactorsinpreventing delay indiagnosis. this commoncomplication, wecanhelptoprevent a increasing frequency. Byincreasing awareness of is predicted that wewillencounterthisissuewith pain. Withcaesarean sectionrates risingglobally, it infertility,secondary abnormalbleedingorpelvic of caesarean sectionthata history present with Isthmocele mustbeconsidered inpatients with Conclusions give robust information toourpatients. sothat wecan techniques andoutcomesof surgery of thisconditionwithregards todiagnosis,surgical multicentre database todevelopanunderstanding and isassociated withinfertility. We needaprospective Isthmocele iscommonfollowingcaesarean section Future trends • • • • • • • • • Summary frequency. Raising awareness of thiscommoncomplication canhelp toprevent adelayindiagnosis. With caesarean sectionrates rising globally, itispredicted that wewillencounterthisissuewithincreasing shown astatically superioroutcome. primarily becauseitaimstorestore normalmyometrialthickness.However, notechniquehasactually The laparoscopic approach appears tobegainingpopularityasthepreferred method fortreatment, Reported pregnancy rates after endoscopic repair of isthmoceleare high. Surgical treatment shouldbeoffered infertility. topatients whopresent withsecondary often employed. TVUS, althoughotherimagingmodalities,suchasMRI, are One of thefirststepsindiagnosticworkup is with thesesymptoms. dyspareunia. of Isthmocelemustbeconsidered caesarean inpatients sectionthat withahistory present infertility,Isthmocele maypresent withsecondary menstrualdisturbance,dysmenorrhoea,pelvicpainor Isthmocele isanunderdiagnosedcauseof infertility. all overtheworld. Caesarean sectionisoneof themostcommonlyperformedsurgeries, andrates are continuingtoincrease and isbecomingasubjectof infertility. attention especiallyinthose whopresent withsecondary Isthmocele, alsoknownascaesarean scardefect,is onlyjustbeingidentifiedanddescribedintheliterature caesarean section at term. caesarean sectionat term. and that is therecommended modeof delivery that itdoesnoteliminate theriskof uterinerupture, months after treatment forpregnancy, before theytry Patients needtobecounselledwaitat leastthree 17. 16. 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. References

Early Pregnancy. JMinimInvasiveGynecol.2016;23:261-4. Scar IsthmoceleConnectedWiththeExtra-Amniotic Spacein DBolla,etal.Laparoscopic Ultrasound-Guided Repairof Uterine Fertil Steril. 2008;89:974-80. of wide anddeeputerinescardehiscenceafter cesarean section. O Donnez,PJadoul,JSquifflet,Donnez.Laparoscopic repair J MinimInvasiveGynecol.2018;25:21-2. Catheter DuringLaparoscopic Repairof Cesarean ScarDefect. A Akdemir, etal.Determination of IsthmoceleUsingaFoley 2017;107:17-8. cesarean sectionisthmocele:avideocasereport. FertilSteril. G Aimi,etal.Laparoscopic repair of asymptomatic post– 2016;134:336-9. used totreat cesarean scardefects.Int JGynaecolObstet. X Zhang,etal.Prospective evaluation of fivemethods Gynaecol Can.2013;35(9):779. A Murji,KGlass,NLeyland.Isthmocele.Journalof Obstet Int J.2017;7(5):00264. cesarean scardefect(isthmocele)acasereport. ObstetGyncol H Nazik,ENazik.Anewproblem arisingafter thecesarean, from thesamecohort.FertilSteril. 2016;106(3):e48.embryos lower inpatients whodeliverviacaesarean sectionwhenusing MK Hayes,etal.Repeat invitro fertilisation successrates are PLoS Med.2018;15(1):e1002494. subsequent pregnancies: Systematic review andmeta-analysis. formother,associated withcesarean delivery baby, and OE Keag, JENorman,SJStock. Long-termrisksandbenefits Women’s Health &Gynecology. 2017;3(4):1-5. an Under-Recognized Iatrogenic Infertility. Causeof Secondary F Istvan,etal.Isthmocele:SuccessfulSurgicalManagementof Gynecol. 2018;25:38-46. Defect at theSiteof aCesarean SectionScar. JMinimInvasive A Setubal,etal.Treatment forUterineIsthmocele,APouchlike Complications. JMinimInvasiveGynecol.2013;20:562-72. Cause of AbnormalUterineBleedingandOtherGynecologic AM Tower, etal.Cesarean ScarDefects:AnUnderrecognized systematic review. Ultrasound ObstetGynecol.2014;43:372-82. to thepresence of uterinenichesfollowingCesarean section: potential riskfactorsfordevelopmentandsymptomsrelated AJ BijdeVaate, LFvanderVoet, ONaji,etal.Prevalence, ‘‘Isthmocele’’. JMinimInvasiveGynecol.2016;23:857-58. B Urman, etal.Laparoscopic Repairof Cesarean ScarDefect 2011;37(1):93-9. and postmenstrualspotting.Ultrasound ObstetGynecol. evaluation of thecesarean scar:relation betweenaniche AJ BijdeVaate, HABrolmann, LFvanderVoet, etal.Ultrasound 2015;15:342. defect usingendoscopicsurgery. BMCPregnancyandChildbirth. H Masuda,etal.Successfultreatment of atypical cesarean scar 2016;23(4):227-31. case report andliterature review. ActaMedicaLituanica. defect –successfultreatment infertility: a of secondary G Bakavičiūtė,etal.Laparoscopic repair of theuterinescar WOMEN’S HEALTH These 2 and and 8 and in and in 9 10 Vol. 21 No. 2 Winter 2019 | 60 Vol. disturbingly, these show these show disturbingly, 6 McGuane and others look McGuane and others look This paper has provoked This paper has provoked 7 3 As if to emphasise the importance As if to emphasise the importance 11 4,5 Prof Caroline de Costa Caroline Prof FRANZCOG Editor-in-Chief ANZJOG some spirited discussion in the Letters to the Editor, some spirited discussion in the Letters to the Editor, the end of which can be found in the e-pages at the April issue. of this topic, Flood et al present the recent figures figures the recent this topic, Flood et al present of for primary for the state postpartum haemorrhage Victoria in 2009–2013; of the post-operative assessment of treatment of of treatment assessment of the post-operative endometriosis. at the role of early induction of labour for diabetes, labour for diabetes, early induction of of the role at in their hospital obesity and/or macrosomia authors conclude that approximately one in ten approximately authors conclude that one adverse at least suffer gynaecological inpatients events are adverse 50 per cent of event, and around is Again, further research preventable. considered needed on how adverse events may be prevented. to considerable interest should be of Both reviews clinician readers. Among the many original articles on obstetric and Yoong topics in this issue is a contribution from the techniques revisiting recommending associates abdomino-pelvic packing for intractable venous of obstetric haemorrhage. a significant increase. There are also a number of of also a number are There a significant increase. diabetes and obesity the topics of articles around to increased topics also linked in pregnancy, of Meloncelli et al discuss the role PPH rates. multidisciplinary teams, Two original articles in gynaecology look at original articles in gynaecology look at Two ultrasound, both in assisting the of the role superficial endometriosis, diagnosis of perinatal loss, congenital anomalies and mother- perinatal better and and calling for more separation’ infant outcomes, especially in rural around research a systematic et al present Tanaka Secondly, areas. adverse events, their the incidence of of review in mortality and their associated predictability gynaecogical hospital admissions in Australia. Little et al discuss the association of maternal maternal of Little et al discuss the association labour. obesity with failed induction of

The Obstetrician and Gynaecologist. concluding that women with PPDM ‘continue women with PPDM ‘continue concluding that 1 desk editor’s editor’s From the From ANZJOG to experience excess adverse pregnancy outcomes, adverse pregnancy to experience excess birth, complicated morbidity, including maternal Welcome to the report for readers of this issue of this issue of of for readers to the report Welcome O&G Magazine. to some additions First up, I am happy to report our Editorial Board. Gynaecological oncologists have Dr Bryony Simcock and Dr Rhonda Farrell who Penny Blomfield, A/Prof joined us in place of The May. the end of the Board at from will retire likely high-quality oncology submissions number of ANZJOG to the clinicians reading interest to be of years, significantly over the past two has increased hence the decision to appoint two new Associate Editors in Penny’s place. I thank Penny for her major contribution to ANZJOG during her time with us. has also joined the Board and Dr Jason Waugh brings with him enormous experience, both as a the RCOG clinician and as the former editor of publication, Board He will be a valuable addition to current members assessing the many submissions we we saw a 10 per cent In 2018, now receiving. are submissions over the in numbers of increase on these are year and the majority of previous obstetric topics. Sarah Ortenzio I am also pleased to tell you that Periodical of as Senior Coordinator has returned and has been joined by Lindsey Publications Wiley who are at Wyatt and Foong-Ee Mathews assisting with submissions and managing many day- authors. to-day queries from The April issue is now available and will, I hope, two Within it are reading. stimulating provide et al review McCarthy Firstly, reviews. excellent outcomes for women with pre-pregnancy pregnancy diabetes (PPDM) in Australia, in both urban and rural areas, WOMEN’S HEALTH need firsttoacknowledgethat genderisnotbinary. gender equityinO&GpracticeandasaCollege,we society. Ifweare trulytoaddress thelargeissueof is receiving increasing recognition inourlarger gender,acknowledge theissueof non-binary which out thedifferences betweensexandgender poor treatment orcare.’ Theseauthorsalsospell where onesexorgenderisdisadvantageddueto mistakes wehaveseenincardiacorotherdiseases gynaecological research) weriskmakingthesame sex differences are neglected(inobstetricand in O&Gbutalsoaround research, stating that ‘when important points,notonlyoneducation andtraining collection of vaginalsamplesforHPVtesting; Māori womenare willingtoparticipate inself-taken interesting studyfrom NewZealand findsthat In thearea of sexualandreproductive healthan genetic testingforaneuploidy; discussion byHaydenHomeronpreimplantation thoughtfulandinformativeissue youwillfindavery until theJuneissue,butunderOpinioninApril The Current Controversies serieshasbeenheldover findings have relevance toAustralianpracticeaswell. et al gender equityinobstetricsandgynaecology. Carcel two of theseandbothdealwiththehottopicof I havelefttheAprileditorialsuntillast;there are Definitely good reading. indeed withoutharm’forotherpatient populations. thus ‘hasnotyetbeenshowntobeeffective,or of patients likely tohaveagoodprognosis, and only beenproven tobeof benefitforsmallgroups expensiveIVFadd-on‘hassofarthe useof this‘very 14 (includingtwoRANZCOG Fellows)make very upcoming issues. conversation andstayaheadof @anzjog or#redjournal tojointhe world of Twitter. Follow This yearANZJOGjoinedthe their field. clinicians orresearchers expertin Each articleispeerreviewed by gynaecology andrelated areas. clinical practiceof obstetrics, researchers workinginthe both establishedandemerging publishes originalresearch from and Gynaecology(ANZJOG) Zealand Journal of Obstetrics The AustralianandNew ANZJOG 13 heconcludesthat 12 Follow ANZJOGon Twitter @anzjog these The othereditorialcomesfrom Angstmannetal committee levelbefore nominating forCouncil. having themselvesgainedexperienceat state have beenelectedbytheCouncil,Councillors per centfemale.Boardmembersalmostalways Dr GillGibsonthemakeup around thetableis36 are alsopresent at meetings,sowithBoardmember Gardiner andtheRANZCOG CEO Vase Jovanoska role, theChairof theDiplomates’ group DrJudith Hamblin hasanewobservational andconsumer issues byco-optingsomemembers;lawyerJulie I understandtheBoardisaddressing thelatter men. the Boardforpastthree Boards,withfiveorsix discrepancy –there hasonlybeenonewomanon are women.Onlyat Boardlevelisthere amajor female. At Councillevel,50percentof members above 50percent,withTasmania being100percent cent femalerepresentation andmostothersare well in themajority;onlyQueenslandhaslessthan50per per cent.Across state committeesnowwomenare in 1981waslessthan5percent;2018it83 percentage of womenadmittedtotraininAustralia in 1981andstillactive,Icanassure readers that the the fewFellowswhowasactiveinCollegeaffairs are notavailablefortheearlieryearsbut,asoneof to 50percenttoday. Figures forgenderof trainees from around 5percentat thebeginningof theperiod show that thepercentage of femaleFellowshasrisen data from Collegereports across nearly40yearsto composition of Collegecommittees.We haveused over theyears1978–2018–andat theconcurrent composition of theCollege–Fellowsandtrainees I amanauthorof this.We havelooked at thegender 15 and WOMEN’S HEALTH Vol. 21 No. 2 Winter 2019 | 62 Vol. EA McCarthy, R Williamson, A Shub. Pregnancy outcomes for R Williamson, A Shub. Pregnancy EA McCarthy, diabetes mellitus in Australian women with pre-pregnancy ANZJOG. A review. rural and metropolitan: populations, 2019;59(2):183-94. adverse of Incidence A Obermair. L Eriksson, R Asher, K Tanaka, hospital and mortality in gynaecological events, preventability ANZJOG. and meta-analysis. review admissions: A systematic 2019;59(2):195-200. A Lavina, A Ali, et al. Abdomino-pelvic packing W Yoong, forgotten technique for managing intractable An often revisited: venous obstetric haemorrhage. ANZJOG. 2019;59(2):201-7. for Additional procedures R Usui, Y Sakuma. S Matsubara, packing for obstetric haemorrhage. ANZJOG. pelvic gauze 2019;59(2):E5. Response to Letter to Editor ‘Additional A Govind, W Yoong. packing for obstetric haemorrhage’. for pelvic gauze procedures ANZJOG. 2019;59(2):E6. and M Flood, SJ McDonald, W Pollock, et al. Incidence, trends primaryseverity of postpartum haemorrhage in Australia: A Collection Data study using Victorian Perinatal population-based births. ANZJOG. 2019;59(2):228-34. for 764 244 data Diagnosis and de Jersey. S N Meloncelli, A Barnett, F Pelly, diabetes mellitus in management practices for gestational the multidisciplinary survey of Australia: Cross-sectional team. ANZJOG. 2019;59(2):208-14. diabetes gestational JT McGuane, L, Grlj, MJ Peek. Obesity, early- of rates with increasing associated are and macrosomia The Canberra Hospital. ANZJOG. labour at term induction of 2019;59(2):215-20. of maternal Influence J Little, R Nugent, V Vangaveti. labour: A of and failed induction obesity on Bishop Score tertiary cohort study in a regional ANZJOG. centre. retrospective 2019;59(2):243-50. retrospective T Ma, et al. Multicentre K Stone, P Chowdary, ultrasound for superficial study to assess diagnostic accuracy of we any closer? ANZJOG. 2019;59(2):279-84 endometriosis—Are and R Seracchioli, D Raimondo, S Del Forno. Transvaginal correction laparoscopic transperineal ultrasound follow-up after in women with posterior deep uterine retrodisplacement of endometriosis. ANZJOG. 2019;59(2):288-93. infiltrating self-taken A Adcock, F Cram, B Lawton, et al. Acceptability of among an under- vaginal HPV sample for cervical screening ANZJOG. 2019;59(2):301-7. Indigenous population. screened genetic testing for aneuploidy Preimplantation HA Homer. the technology and the clinical outcomes. The biology, (PGT-A): ANZJOG. 2019;59(2):317-24. Why should the obstetrics M Hickey. A Henry, Z Wainer, C Carcel, about sex and gender issues and gynaecology community care in health? ANZJOG. 2019;59(2):181-2. CM de Costa. Gender equity in M Angstmann, C Woods, we heading? ANZJOG. are obstetrics and gynaecology – where 2019;59(2):177-80.

References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. interested junior docs who are male may decide decide male may are docs who junior interested I believe this is genuinely specialty. upon another a completely having believe that I also a barrier. as I found would be as dystopian female RANZCOG from I returned all-male College when the virtually live in a We in the early 1980s. training overseas society and this and ethnically-diverse gender- in our membership. needs to be reflected the Editor for ANZJOG onI welcome Letters to important topics, and I look these (and on other) in a participating years of forward to the next three teams both gender- has enthusiastic College that working together in the area and ethnically-diverse, healthcare. women’s reproductive of Council membership requires attendance at three three at attendance requires membership Council each each year in Melbourne, meetings sets of work in preparation. days, plus much lasting several greater considerably requires Board membership work. This of in time and unpaid commitment for women difficult be much more course can and home practice with family juggling O&G ways of innovative believe that commitments, and I essential bodies, which are running these various College and hence our our to the functioning of need to be found if independence, professional their hands up to serve to put women are more and more roles Shared roles. the College in these among the are video-conferencing tele-and use of in this direction. sensible suggestions elections, the overall Council For the past three among candidates women of percentages 25 per cent, 42 per cent and have been nominating of these elections, the two 39 per cent. In the first exactly corresponded Council membership resulting Council but in the current to these percentages, women is higher (50 per cent); of the percentage peers being elected to Council by their women are both female and male. provoke these two editorials would I had hoped that , but so ANZJOG thoughtful Letters to the Editor of been has, however, have been none. There far there has taken much comment on social media and this the College should address that two directions: is seen as a ‘leadership crisis’ in committee what is no barrier to male there membership, and that training. applicants for specialist FRANZCOG have gender we already show that In fact, figures the almost all College committees; equity across the Board level. at ‘pipeline’ is not leaking, except that and it seems This does need to be addressed will happen. is no barrier ‘there I also dispute the claim that this at to males entering specialist O&G training’ 1970s and early In the point in the 21st century. was ‘no barrier’ to women entering 1980s there then was to individual O&G training (application no College training schemes), were hospitals, there Part 1, I even though I had my MRCOG but in 1974, accepted men many saw I while job, a find not could exam. Now applicants for who had not passed that least two years training must have completed at level, have followed the house officer doing O&G at least one relevant have at pathway, pre-vocational possibly be part-way as first author, publication and post-grad degree, a relevant or fully through generally have spent four or five years preparing process. application themselves for the RANZCOG the gender composition of When they see that female, and likely is 83 per cent the trainee intake I believe 100 per cent if left unchecked, to reach WOMEN’S HEALTH RANZCOG a manwithmission Dr AndrewBrowning: rest of Africa;tobuildmore hospitals’ saysBrowning. outside Ethiopia. There isahugefistulaneedinthe health centres, butIwanted totake thisto work coordinating trainingprograms andestablishing ‘All inall,Ispentthirteen yearsinEthiopia Thinking big Hamlin’s didn’twork. establish fistulacentres around Africawhere the hospitals toprevent fistula,trainmidwivesandto May Foundation, tobuildandrunmaternity year. Hethenstartedhisowncharity, theBarbara operating onupto600–700fistulapatients per Ethiopian nurseswouldspendthenextyears first regional HamlinFistulahospital.Heandtwo to Barhidar, where hestartedanddirected the with DrCatherine Hamlin,DrBrowning moved After fiveyearsoperating, researching andteaching where hewasinvitedtowork. the HamlinFistulaHospitalinAddisAbaba,Ethiopia, desert area of Ethiopia for40years.Healsovisited Valerie Browning whohasbeenworkinginthe Wishing todomore tohelp,hethenvisitedhisaunt medicine withoutadequate resources. he wasfacedwiththestarkreality of practicing the area overnight.Itwashere that, forthefirsttime, literally tensof thousandsof refugees floodedinto at thebeginningof thegenocideinRwanda,and with Rwanda,forhismedicalelective.Itwas1993, remote missionhospitalinTanzania, ontheborder As amedicalstudentDrBrowning spenttimeina Browning because of thelackof equipment.’–DrAndrew by thegovernmentformonthsandpatients dying without water, withstaff that haven’tbeenpaid ‘My biggestchallenge?Trying torunahospital Early beginnings respected in countries where this problem is prevalent. Manual forprospective fistulasurgeonsandishighly world. Hewasaleadauthorof theWHOTraining is widelyregarded asthefinestfistulasurgeonin in Tanzania andEthiopia, DrAndrew Browning (AM) Today, withmore thanseventeenyears’experience to dowithhislife. his mind.Inthat moment,heknewwhat hewanted stories of countlesswomendyinginlabourstayed Sunday),butthe Church withhisfamily(anordinary heard aboutAfrica’smedicalmissionaries.Hewasat Andrew Browning wassixyearsoldwhenhefirst delivery at ahospitalinAfrica.’ delivery only costs$200AUD toensure awomanhassafe ‘I’d lovetotreat more patients; especiallybecauseit ostracised tohavinganormallife’ saysBrowning. someone else’slife.Itbringswomen backfrom being that youcandothat transforms completely ‘Treating obstetric fistulaisone of thefewoperations inpregnancydeath andchildbirth. andextreme injury that aimtoreduce thehighincidenceof maternal Uganda, NepalandEthiopia, at nocosttopatients, to continuerunningprojects inTanzania, SouthSudan, Foundation in2009. TheFoundation’s fundsallowhim Dr Browning decidedtoestablishtheBarbaraMay wishing toadoptaprevention-focused approach, Frustrated byacontinuouslackof resources and stretched tothelimit.’ means that thelocalmedicalandnursingstaff are isgreat, butitalso and later to200permonth.‘This month in2012at thehospitalwhere hevolunteered increased from 40amonthin2010tonear100 local communities.DrKelsey states that deliveries in amarked increase inhospitalusagebyTanzania’s Dr Browning’s preventative approach hasresulted prevention isbetterthancure.’ of under-resourced clinicswiththebeliefthat clinics toteachmidwivesandarrangingsupport way tomanagefistulasaswellbuildingmaternity local doctorsworkingonthefrontline onthebest himself ontopof travellingaround Africateaching his egoat thedoor. Hemaintainsahugeworkload since. DrBrowning isanamazingteacherthat leaves ‘I year enjoyeditsomuchthat Ihavegoneback every several fistulasurgeriesforhimtolearnmore. practice andallowedhimtoaccompanyon Browning tasked himwithgeneralgynaecology identified twofistulasurgeriesinover35years,so However, despitehisinterest, DrKelsey hadonly He waseagertolearnmore aboutobstetricfistulas. sutures, catheters andothersuppliesfrom Australia. Dr Kelsey wenttoTanzania, takingwithhimdonated me ifIwantedtojoinhim’saysDrKelsey. straight away:hewasmovingtoTanzania andasked on, soIdecidedtowritehimanemail.Hereplied one of thebestbooksonfistulaIhadlaidmyhands experience withfistulas.DrBrowning hadwritten ‘I tofindanorganisation that had wastrying same yearthat hemetDrGeoff Kelsey. dedicated fistulaclinicnearArusha.Itwasinthis the refurbishment of anotherhospitalandbuilta In 2011,DrBrowning movedtoTanzania, funded

WOMEN’S HEALTH Vol. 21 No. 2 Winter 2019 | 64 Vol. Fund for Population Activities and the International the International and Activities for Population Fund He is very Gynaecology and Obstetrics. of Federation Kelsey, Dr and doctors, like to talk to midwives keen volunteer overseas. who wish to to be exceptional. found Africa ‘I advises Kelsey. ‘Go,’ welcoming and grateful. friendly, are The people don’t want to have an agenda. you But be prepared; to sure but make terrible things are see that You’ll you start wanting before the local situation look at context; of got to be aware changes. You’ve to make by telling them they should not put people offside cannot do. Also, go for long be doing things they much in a fortnight.’ can’t do or learn enough! You or by volunteering, visit If you want to help financially www.barbaramayfoundation.com.au.

On the horizon On the last year while his to Australia relocated Dr Browning high hchool. sons finish I Tanzania, and years working in Ethiopia 17 ‘After hard really is my home. It’s been Africa now feel like everything to Australia. In Africa, for me to adjust is goes as planned. unexpected. Nothing Australia is facing a very that of barriers set different way.’ me to think another requires than to helping the more dedicated remains Andrew to be suffering with two million women estimated Africa by injuries throughout existing obstetric fistula ‘fistula camps’ in Malawi, Sierra teaching surgeons via Chad, Uganda, Congo, South Sudan, Leone, Kenya, He also consults on Togo. Somaliland, Nepal and Nations issues to United healthcare global maternal RANZCOG is committed to improving the health of to improving is committed RANZCOG region. in the Pacific women and their families, including O&G Magazine for The College is seeking contributions about global women’s health. Articles and opinion highlight women’s health issues or initiatives that pieces appreciated. are countries in low- to middle-income We a written contribution? Don’t have time to prepare you. can interview you and write the article for all College members. from welcome Contributions are to about contributing information For more O&G Magazine, go to: www.ogmagazine.org.au/contribute Share your story in O&G Magazine your Share Do you have experience working or volunteering volunteering or experience working have Do you middle-income countries? to in low- WOMEN’S HEALTH MBBS, MPH&TM,FRANZCOG Dr Rebecca Mitchell the SolomonIslands developing O&Gcarein A newstandard: of thecostof thejourney,’ shetoldtheWorld of thelackof transport,andsometimes because can take alongtimetoseekhelp,often because clinics andhealthcentres, andsometimes people ‘Many womenhavealotof difficultygetting to outstanding jobasaclinicalleader. is aninspirational SolomonIslanderwhoisdoingan 2014, shewasthesolelocalO&Gincountry. She familiar withtheseissues.From November2011until The Headof Department,DrLeeannePanisi,isalltoo equipment andstaff. Occasionally, NRHhasbeenshortonnecessary antenatal care duetopoorhealthcare access. poor outcomes.Frequently, theyhavehadlimited women andthefactorsthat contributedtotheir As agroup, wediscusstheissuesaffecting these sadness –isfamiliar. – anauseating mixof hopelessness,regret and uncommon, butfrequent enoughthat thisfeeling and, unfortunately, amaternal death. Thelatter is about severalneonatal complications, astillbirth The handoverfrom thenightshiftistelling.We hear incredibly remote. 900 islands–it’sanincredibly beautifulcountry, but Solomon Islandsare anarchipelago of approximately dispersed overalargeswathe of thePacificOcean. precious resource inacountyof 640000people, This istheonlyO&Gunitincountry. It’sa completed theirundergraduate studiesinCuba. most recently returned toSolomonIslandshaving A handfulof juniordoctorshavealsogathered, the department’sfourconsultantsandthree registrars. Honiara’s National ReferralHospital(NRH),flanked by I’m sittingonabenchinsidetheoutpatients clinicat O&G practicehere that are vastlydifferent. rounds, teachingsessions–butthere are aspectsof Some thingsare familiar–morninghandover, ward awaiting newsandupdates. Ismileandsaygood Husbands andrelatives millaround outside thedoors only bythemidwivesanddoctors. countries, theyare alonein birth suite,supported following handover. Aswith many low-income I meetthesewomenonthemorning wardround environment. It’s abeautifulmomentinanotherwisechaotic her newbornwhileamidwifedeliversplacenta. The moodislighterinbedfour. Janet*iscradling approximately 10percent. rate ismuchlowerthanAustraliaandNewZealand, at with manydevelopingsettings,thecaesarean section this isoften acauseof delayfordelivery. At NRH, as blood incasesherequires atransfusion;unfortunately, relatives are currently at thebloodbankdonating required bloodneedstobecross-matched. Her however, before gettingintotheoperating theatre, first baby. Acaesarean sectionhasbeenarranged; In bedthree, Cathy* isinobstructedlabourwithher routinely undergoultrasoundscansantenatally. the caseformultiplepregnancies aswomendonot ago that shewasexpectingtwobabies.Thisisoften deliver thesecondtwin,learningonlyfiveminutes area are occupied.Inbedone,Barbara*ispushingto Today, three outof thefourbeds inthesecond-stage one of thesecond-stagerooms. to push.At thispoint,theyare examinedandtaken to swaying inatrance-like state, untiltheyfeeltheurge allocated aprivate area; theycongregate intheroom, individually discussedat handover. Norare they per year),thewomeninfirst-stagearea are not With approximately 15birthsperday(5600 immediate postnatal area. first-stage area, thesecond-stagearea andthe birth suite,whichconsistsof three sections–the The nightteamhandoverthecare of thewomenin Obstetric careatNRH across thecountry. continue theirpursuitof improved women’shealth pleasure tovisitDrPanisiandherteamasthey sense of optimismhere at NRH, andit’sanabsolute are complexandresources are few. Butthere isa maternal mortalityrates are high.Thechallenges colleagues, it’seasytoseewhyneonatal and Despite theincredible efforts of DrPanisiand us, andweare allbasedinHoniara.’ obstetrics andgynecology–there are onlyafewof are generalpractitioners.Specialistswhodealwith many specialistdoctorsinprovincial areas; most Bank inarecent profile piece. 1 ‘And wedon’thave WOMEN’S HEALTH Vol. 21 No. 2 Winter 2019 | 66 Vol. The World Bank. Inspiring women in the Pacific: Leeane’s Bank. Inspiring women in the Pacific: Leeane’s The World www.worldbank.org/en/news/ from: Available 2018. story. feature/2018/03/05/inspiring-women-in-the-pacific-leeanne- story. * all patient names have been changed. * all patient Reference 1. Funding for this event, and associated activities, activities, this event, and associated for Funding Go Back Give Back competition. the AVI came from Group the launch, the STM Working In the week of sessions on the education a series of also facilitated delivered were Manual and its content. Workshops model) to senior clinicians (using a train-the-trainer as well as end users. Emergency management have flowcharts, based on content in the Manual, birth suite as been printed and placed on the walls of guide. a quick reference STM developing and publishing the of The process huge a work. It required took close to 18 months of local on the part of time and dedication amount of from with vigour clinicians, who pursued the project the outset. least the working (well, at is excellent The end product thinks so!), but the development processgroup positive. The STM is an examplealso extremely Australian and Pacific colleagues collaboratingof to proud women’s health, and I am towards improved have played a small part. The clinical and educational rewarding, my volunteer assignment were aspects of as the such but it is capacity development initiatives will have lasting effects. STM that A new standard? briefly the O&G team gather the day, the end of At management plans in birth suite to discuss patient a new flowchart on the wall for the night. There’s the STM on the work desk. Neither and a copy of these things guarantee good clinical outcomes, of the Manual will but my optimistic ambition is that women in this birth of positively impact on the care suite and beyond. and the morbidity and This morning’s handover, The for now. to it, is a sad reality mortality attached NRH is changing the O&G team at hard work of the and it’s been inspiring to watch however, that and midwives galvanise consultants, registrars the STM project. around hopeful ‘I’m For Dr Panisi’s part, her vision is clear. health in Solomon maternal we will improve that and helping deaths maternal Islands. Preventing is our goal.’ women with gynaecology problems morning to them as we walk into birth suite. ‘Morning suite. ‘Morning into birth as we walk to them morning manner a calm and affectionate in reply, iufela,’ they beyond the door. contrasts the struggles sharply that of care outcomes and consistency Improving as a I volunteered In 2017, I doing here? am So what the was part of role My NRH. at registrar senior O&G Internship Supervision Solomon Islands Graduate and my primary (SIGISSP), and Support Project and mentor Cuban- was to support responsibility transitioning to practice in trained junior doctors the Solomon Islands. become a that’s Honiara for a project back in I’m the pun) over the last 18 love (pardon labour of with Dr Panisi andmonths. I have been working Treatment Standard national her team to develop a and initiative It’s an exciting Manual (STM) for O&G. completion. has just reached many questions When I first arrived in Honiara, I asked and midwives. the local consultants, registrars of I provided the treatment that I wanted to be sure and consistent with local appropriate was relevant, their journey about with patients practice. I also spoke experiences. to NRH and their healthcare it became apparent After many conversations, of in quality was significant variation there that colleagues Dr Panisi and the country. across care especially workers, many healthcare explained that uncertain about best are those in the provinces, and lack access to practice women’s healthcare clinical resources. O&G a standardised we identified that Together, these some of manual could address treatment Health Organization challenges. While the World in Pregnancy Complications text ‘Managing reference available to Solomon and Childbirth’ is theoretically of many clinicians, it is not locally specific and Islands not available. options are the treatment to With much gusto, we formed a working group This was develop a STM in O&G for the country. other by Dr Panisi and included the three chaired O&G specialists, two local registrars, Islands Solomon a senior midwife and me. The Papua New Guinean STM (a document with similar objectives, but relevant (with to the PNG context) was used as a template and permission), and each chapter was reviewed My role the working group. by a member of updated was to compile the chapters, edit the content and health workers by provincial arrange external review O&G specialists. and two international is a 200-page, A6 manual – designedThe end product healthcareof Solomon Islands to fit in the pocket the Solomon It has been endorsed by workers. Islands Ministry Health & Medical Services, of designed thanks to generousand professionally RANZCOG. sponsorship from has kindly funded Health Organization The World every the manual, which means that printing of dealing with worker healthcare Islands Solomon They will be women will have a personal copy. using the pharmacy distribution disseminated during O&G outreach network and delivered visits. The content will even be available via an app by the Therapeutic Guidelines Foundation. sponsored at launched the Manual was officially On 21 May, This included a celebratory lunch and, in true NRH. music and dancing. lots of fashion, Islands Solomon Introducing the New Fellow Resource Guide

This handy guide contains everything New Fellows need to know as they take the next step in their journey. The Membership team will provide a copy to all New Fellows upon elevation.

For further information contact: [email protected]

www.ranzcog.edu.au/members THE COLLEGE Vol. 21 No. 2 Winter 2019 | 68 Vol. progesterone, but surely not testosterone! And if they if And testosterone! not surely but progesterone, measurable hormonal by the absence of thrown were then they have failed to understand fluctuations, a slipperywhat dealing with. beast they are I PMS is not an easy matter, Recognising that and evolved approach an alternative have taken I am happy to understanding’ that a ‘paradigm of with hormones. I yields well to treatment report occasions and this concept on three have presented pants have succeeded only in boring the proverbial my audience. Perhaps I should be so bold as to off as the paradigm not for publication submit a copy of and you, the Editor, such but for the amusement of see how many paragraphs you can consume before your eyelids droop. least I could identify At the criteria set out in with I would have changed the for PMDD. the DSM-V good luck with emphases perhaps. As for aetiology, And, as a bottom line, have the researchers that. breast the incidence of to relate made any attempt might the cancer with this condition; and what be in this (for any reason) hysterectomy of rates women? of population Helicopter evacuation is the usual route of transfer, transfer, of is the usual route Helicopter evacuation least is at There dependent. and this is weather per day – sometimes for one helicopter evacuation epidural, but or women requesting labouring VBACs fetal labour, or preterm for obstructed often more hours second stage over three prolonged distress, departs or postpartum haemorrhage. As the patient their partner faces a terrifying in the helicopter, arriving hours after often journey alone by road, delivery or surgery In fact, it appears has occurred. occur for all the reasons most transfers here that to avoid it. you would prefer the This isn’t a question, just demonstrates to an available resources enormous range of in obstetrician in rural practice and difference management planning according to location. Vol. 21 No. 1 Autumn 2019. O&G Magazine Vol. I was tickled pink to read the article ‘PMT, PMS and the article ‘PMT, I was tickled pink to read 20 O&G Magazine Vol. a difference?’ PMDD: is there about these psychiatrists by three No. 3 Spring 2018, ovarian dysfunction causing hormonal questions of those of I am about to suggest that upsets. Not that us who trade in hormones should seek a monopoly elements, but a balance of on these overworked convincing. expertise might have been more seemed article, there their review of In my reading some apart from to hormonal matters little reference alarming comment such as ‘Thus, hormone levels the however, and flux alone appear to be irrelevant, and physiological changes neurobiological relevant an underlying sensitivity to such may represent seemed to be no discussion of changes’. In fact, there and testosterone. oestrogen the actual levels of to ram marks to them then for attempting Full this elusive condition into a the contents of in the but sadly then to consider, box, categorisation as their holy grail. medication main, psychotropic to oestrogen was another reference In fact there no demonstrable differences are ‘…there in that hormonal levels…’, by which I in reproductive and possibly to oestrogen referring assume they are Dr Rosemary Jones Anne FRANZCOG MBChB, FRACOG, I very much enjoyed the article ‘Threatened preterm and Han-Shin Watts Jared labour out bush’ by Drs Lee, ‘in active labour, patients that with interest I read bleeding or with fetal distress, high risk of at in for transfer except should not be considered This obviously makes circumstances.’ extreme it contrasts sharply with my sense. Unfortunately, I live experience working in rural New Zealand. in Queenstown, which despite huge population has 600 births a year, and a minimum of growth almost three are only a primary birthing unit. We secondary the nearest from unit – hours by road monitoring, is analgesia, continuous CTG only there winter and obstetric assistance available. In theatre deep in snow and a large volume is often the road significantly hampers travel. tourist traffic of Letters to the Editor to the Letters Dr Polly Weston FRANZCOG MBChB (Hons), MRCOG, THE COLLEGE patient care. vulnerability that couldbeaddressed to improve about positiveaspectsof practiceand areas of The visitaimstoprovide constructive feedback are conductedwiththesupportof Fellowcolleagues. the aimof improving safety andquality of care. Visits compare themselvestoRANZCOG standards,with performance/competencies andallowsthemto opportunity togainanunderstandingof their receiving thevisit.Itprovides doctorswithan relevant tothecontextandsettingof thespecialist provide detailed,in-depthprofessional development specialist withintheirworkenvironment intendedto A PracticeVisitisacollegialpeerreview of a What isaPracticeVisit? (SRSA) program. https://ruralspecialist.org.au via theSupportforRuralSpecialistsinAustralia Currently, individualsmayapplyforfundingsupport Scientific Meetings. through profits from theProvincial FellowsAnnual with someadditionalsupportfundinggenerated continue tooperate onapartiallyself-fundedmodel, cost of avisittoanindividualis$3000. Thevisitsnow Health ContinuingEducation (RHCE)program. The Scheme forRuralSpecialists(SSRS),thenbythe Government fundingprograms; firstlytheSupport The visitswere initiallyfundedviatwoCommonwealth the ContinuingProfessional DevelopmentCommittee. supported bytheProvincial FellowsCommitteeand 2005. Theywere championedbyDrPhilipHalland Practice VisitsbeganinAustraliaasapilotproject in successfulNewZealand model, Based uponthevery favourably bytheMedicalBoardof NewZealand. commonplace there. Theyare looked upon Zealand manyyearsagoandhavebecome RANZCOG PracticeVisitscommencedinNew Background andfunding eight years. Practice VisitswillhavebeenheldinAustraliaover and audit.Bytheendof 2019, 72Provincial Fellows Practice visitsare anexcellent formof peerreview FRANZCOG A/Prof IanPettigrew Why youshouldsignupforavisitin2020 Visits inAustralia Provincial FellowsPractice • • • • • Fellows visited: is beingvisitedaswellthetwovisitingFellows. Practice Visitsare beneficialforboththeFellowwho What arethebenefits? • • After thevisit: • • • • • • • During thevisitFellowwill: • • • • • • complete: Before thevisittakes place,theFellowisrequired to What isinvolved? earn PracticeAudit&Reflection (PAR) points a reduction inprofessional isolation receive confidential reporting onperformance areas of vulnerabilityandreduce risk identify progressing gain valuablefeedbackonhow theirpracticeis suggestions onpracticeimprovement their practiceandareas of vulnerabilitywith written report outliningpositiveaspectsof the visitedFellowwillbeprovided witha confidentially bya Steering Committee the results of thevisitwillbereviewed findings receive feedbackaboutthevisitandinitial within theorganisation andsystemsissues junior staff aboutthecontext of care provided Medical Services,RANZCOG traineesandother managers, CEO, Director of Nursing, Director of interviews withrelevant personnelsuchasunit have multi-source feedbackinvolving practice settingsare reviewed where possible) OHS, record systemsinpublicandprivate (both including equipmentandprocesses suchas have theirpracticesurroundings reviewed, minor procedure intheatre outonemajorand be observedcarrying and record keeping undergo review of clinicalworkload,casemix be interviewedbythetwoFellows Fellows receive aone-daysitevisitbytwovisiting consent forthetheatre observation times withcolleaguesandobtainingpatient visit, includingthearrangementof interview compilation of theprogram forthedayof the procedures a logbookof thelastthree monthsof satisfaction questionnaires the dispersionandcollectionof 50patient a self-assessment survey a practiceprofile questionnaire to thevisit a memorandumof understandinginrelation

THE COLLEGE A RANZCOG R A RANZCOG Vol. 21 No. 2 Winter 2019 | 70 Vol. NT Commonwealth Qualified Privilege Scheme Privilege Qualified Commonwealth covered currently held in Australia are Practice Visits Privilege Scheme Qualified under the Commonwealth this activity. within communication free allowing for involved How to be visit, the visited Fellow must be be eligible for a To working in currently Fellow Provincial a RANZCOG (classification area remote rural and/or a regional, www.doctorconnect. See RA2-5) for the past year. details. for classification gov.au/locator 2020 visits, please contact regarding enquire To Ms Angie Coordinator, Fellows Provincial RANZCOG details: for further Spry, Email: [email protected] Phone: (03) 9412 2971 Visits The future of Practice expand Practice Visits will continue to It is hoped that Fellowship. to the greater and be offered DARWIN, CENTRE, 2020 CONVENTION APRIL

view how other practices operate view how other in how to and development gain training review conduct peer points (PAR) Audit & Reflection earn Practice Visiting Fellows: Visiting • • • think? What do participants all these areas to look at was a very exercise useful ‘It the actual visit and to before my practice critically of the visit.’ actual day of get organised for the ‘The a visit was having receiving best part of my solo practice and of an objective appraisal specialists.’ regional interacting with other ‘The every of practice a review aspect of visit forced list for years got done.’ – things on the ‘to do’ visitors was very from constructive and ‘Input attitude.’ with a supportive delivered stronger – my practice and I are exercise ‘Excellent for the experience.’ DARWIN 15–18

www.ranzcog.edu.au/provincial-fellows SAVE THE DATE SAVE Regional Scientific Meeting Scientific Regional Provincial Fellows Provincial Fellows RANZCOG 2020 RANZCOG THE COLLEGE • Revisions include: Termination ofPregnancy(C-Gyn 17) preferred. high incidenceof CMV aseparate statement is specific nameorprocedure and duetothe relatively felt that generally, peoplelookupastatement bya statement oninfections inpregnancy. Members alone statement onCMV asopposedtoageneral College Fellows.Thecommitteediscussedastand- should bedevelopedtoraiseawareness among the WHCfeltitisappropriate that astatement As CMV isthemostcommoncongenitalinfection, Infection (C-Obs 64)–new Prevention ofCongenitalCytomegalovirus (CMV) with anexpert. counselling todiscusstheimplications of their results so that allcarriersare giventheoptionof genetic of havingachildwithaninheritedgeneticcondition, and coupleswithinformation regarding theirchance document aimstoassistcliniciansprovide women carrier screening inAustraliaandNewZealand. This in theearlystagesof, pregnancy inrelation togenetic the counsellingof womenandcouplespriorto, guidance tohealthprofessionals regarding adviceon This statement wasdevelopedtoaddress thegapin Genetic CarrierScreening(C-Obs 63)–new • For retirement Alcohol inPregnancy(C-Obs 54) • • • • • • Revisions include: Birth after previousCaesareanSection(C-Obs 38) • Revisions include: (C-Obs 22) Use ofprostaglandinsforinductionlabour RANZCOG CouncilandBoardinMarch 2019: The followingstatements were approved by Revised CollegeStatements March 2019 College Statementsupdate Title changetoAbortion (C-Obs 55). with thestatement Substanceuseinpregnancy Rationale: thisstatement hasbeenamalgamated prostaglandins forIOLwassoftened. Recommendation 14 regarding theuseof and successrates wasadded. associated withdifferent methods of induction A tableoutliningrisksof uterinerupture manufacturer’s advice prostaglandins forinductionof labourisagainst 14) waschangedtoindicate thespecificuse of Reference to‘Off-label’ druguse(5.10.3 onpage Intrapartum Care (C-Obs 31)statement. fluids andoralintake intheCollege’sRoutine should beinlinewithrecommendations on It wasagreed that theadviceonoralintake the RCOG periodof 12monthsapplied. toconception)and pregnancy interval(delivery Inter-delivery intervalwaschangedtointer- Updated references Updated references RANZCOG Women’s HealthCommittee Chair Prof Yee Leung • • • • and are nowavailable: The followingtitleswere approved forpublication edu.au/patient-information-pamphlets. products canbeviewedandordered at www.ranzcog. pack of 18pamphlets,nowavailable.Allof these Pamphlets, includingthePregnancy andChildbirth There are 37RANZCOG Patient Information RANZCOG PatientInformation www.ranzcog.edu.au/Statements-Guidelines. A fulllistof Collegestatements canbeviewedat introduction of MyHealthRecord. many newdevelopmentsinthisarea, particularlythe out-of-dateRationale: Thisstatement dueto isvery For Retirement (PCEHR) (WPI22) The personallycontrolledelectronichealth record recruitment of staff. have theirownpoliciesandprocedures around Rationale: Itwasfeltthat mosthospitalswould For Retirement (WPI 4) medical officersandacademicstaff inAustralia Gynaecologists forvisitingmedicalofficers,salaried andselectionofObstetricians Interview • Revisions include: Combined HormonalContraceptives(C-Gyn 28) • Revisions include: procedures (C-Gyn 24) Vaginal Rejuvenation andcosmetic vaginal • • Revisions include: (C-Gyn 21) The useofmifepristoneformedicalabortion • • Revisions include: Guidelines forHPVVaccine (C-Gyn18) • • Stress Incontinence Urinary Pelvic OrganProlapse Gestational Trophoblastic Disease Pregnancy Loss Updated references Updated references Updated references Julian Hill publicity surrounding thedaughterof MP of correspondence totheCollegeandrecent VTE inlight (specifically Diane-35)andrisk of New paragraphregarding oralcontraceptives Updated references introduction of vaccine New evidencere: rates of declinesince Updated references Aligned tonewlegislation