Incorporating reproductive health into holistic chronic pain management: bridging a critical gap

Despite the prevalence of chronic pain within women and birthing people of childbearing age, reproductive health is often overlooked when developing a health care management plan.

Abstract

Introduction:

Not only is chronic pain more prevalent in women but also the intersection between chronic pain and reproductive health adds complexity in pain management strategies and care plan development. Despite this, it remains unclear whether reproductive health is being discussed in the context of chronic pain care.

Objectives:

The objective of this brief report was to explore the extent to which reproductive health is being addressed as a component of female chronic pain care and to identify the educational needs of women of childbearing age living with chronic pain.

Methods:

Women aged 18 to 50 years who attended a tertiary care chronic pain clinic were asked to complete a survey that investigated reproductive knowledge and discussions with a care provider.

Results:

A total of 51 participants (mean age of 33 ± 7 years) responded. More than 76% of participants had indicated that they had never discussed family planning, fertility, or pregnancy in relation to chronic pain with a health care provider. More than half of participants reported that they only “somewhat” understood the reproductive safety of their medications. Participants were interested in learning about medication and pregnancy, the impact of pain on pregnancy, the impact of pregnancy on chronic pain, and sexual health.

Conclusion:

The results from this survey raise the need to integrate reproductive health into comprehensive pain management and provide patients with information to make informed decisions around their pain care and reproductive choices.

1. Introduction

Chronic pain is a highly prevalent, debilitating condition that disproportionately affects women.^1,8,9 It is an umbrella term that includes conditions such as musculoskeletal pain, widespread pain, migraine headache, chronic pelvic pain, and others. These conditions cause substantial suffering and directly affect all aspects of life, including reproductive health. In fact, chronic pain occurs in 20% of women of reproductive age and has been recognized as a globally neglected reproductive health morbidity.^8,9 While most (>70%) chronic pain patients are female, research shaping the evidence that informs our approach to pain practice was historically conducted more often in men.¹³ Compared with men, women have higher prevalence of pain conditions, higher rates of pain-related disability, and more recurrent, severe, and long-lasting pain.¹³ They also have distinct reproductive health needs that change across the lifespan.

Chronic pain is a leading cause of female sexual dysfunction and a top reason for infertility.⁹ For example, approximately 10% of reproductive-age women suffer from endometriosis, with approximately one-third of them experiencing infertility, nearly twice the rate of those without the condition.¹⁰ Chronic pain affects more than 5% of pregnant women and negatively affect pregnancy, often reducing mental and physical health.^12,14 However, in some pain conditions such as rheumatoid arthritis and chronic headaches, women experience improvements in pain during pregnancy, followed by postpartum relapses.^5,7

Pain management often includes therapeutic approaches that have either unknown or adverse effects related to reproductive health. For example, many common pharmacological therapies such as NSAIDs, opioids, are contraindicated for pregnant individuals, while other pain medications (eg, anticonvulsants and some antidepressants) do not have sufficient evidence to definitively determine their safety profile.^3,16 The most significant effects of medication on an embryo occur during early exposure, often before many people even realize they are pregnant.⁴ As half of all pregnancies are unplanned, holistic pain care inclusive of reproductive health discussions is critical. Furthermore, the reproductive risks of long-term medication use of common chronic pain prescriptions before pregnancy and their impact on fertility are poorly understood.¹⁴ Beyond pharmacological pain management interventions, some treatment approaches, such as a hysterectomy, can prevent pregnancy altogether.

Despite the clear reciprocal impact, it is unclear whether reproductive health is being discussed in the context of chronic pain care. Therefore, the aims of this study were to explore the extent to which the reproductive health of women with chronic pain is being addressed as a component of their chronic pain care and identify educational needs related to the intersection of reproductive health and chronic pain.

2. Methods

This is a pragmatic, observational study that anonymously surveyed women aged 18 to 50 years who have a chronic pain diagnosis and who are seeking chronic pain management at a tertiary care chronic pain clinic. Participants were recruited from the Toronto Academic Pain Medicine Institute at Women's College Hospital. Participants completed a brief survey designed by the study team that queried: family planning, contraceptive use, pain with sexual intercourse, medication use, understanding of reproductive safety with medications used, discussions of chronic pain and medication use on pregnancy with a health care professional, and desired topics of education. For example, questions included “when discussing your chronic pain condition, has a pain physician ever talked to you about: the impact of chronic pain on fertility etc…” and response options included yes, no, or prefer not to answer. Demographic information was limited to the age, sex at birth, and confirmation of a chronic pain diagnosis; however, the pain diagnosis was not recorded for all participants. All results are reported through descriptive statistics. This study received approval from the Assessment Process for Quality Improvement Projects ethics board (APQIP # 2019-0167-P) at Women's College Hospital, Toronto, Canada.

3. Results

Participants (N = 51, mean age of 33 ± 7 years) included women with a diagnosed chronic pain condition (eg, fibromyalgia, endometriosis, chronic pelvic pain, chronic migraine, chronic back pain). Participants reporting taking a variety of classes of medications including opioids, NSAIDS, antiepileptic, antidepressants, ketamine, and cannabis for their pain management.

The findings from the survey indicated that most participants (78%) have never discussed family planning in the context of their pain care (14% have and 8% prefer not to answer). Furthermore, most (84%–86%) patients surveyed indicated that they had never spoken to a pain care provider about the impact of chronic pain on fertility, or the impact of chronic pain on pregnancy, or the impact of pregnancy on chronic pain conditions (4%–6% have and 10% prefer not to answer). More than 76% of the participants reported that their physician had not discussed the risks of pain medications on an unborn fetus (12% have and 12% prefer not to answer) and 59% had not discussed contraceptives (31% have and 10% prefer not to answer). More than half of the participants (67%) reported that they did not understand or only “somewhat” understood the reproductive safety of the medications they are taking. Importantly, 66% of these patients indicated that they potentially wanted to have children in the future (35% indicated yes and 31% indicated they were unsure). Participants also indicated that they would be interested having additional educational resources (Table 1).

Table 1.

Participants' interests in reproductive health topics.

Reproductive health topic	Interest N (%)
Medication and pregnancy	15 (29.4)
Impact of pregnancy on chronic pain	18 (35.2)
Impact of pregnancy on chronic pain	18 (35.2)
Sexual health and intimacy	18 (35.2)
Menopause and pain	1 (2.0)

4. Discussion

The results of our study indicate that women of reproductive age have gaps in their care around the impact of chronic pain on reproductive health. These data highlight the importance of discussing reproductive intentions and ensuring awareness of the connection between reproduction and chronic pain.

It has been suggested that “we have forgotten…women's reproductive health is intimately linked with their overall physical and mental health.”¹⁵ Chronic pain management is complex and involves addressing biopsychosocial–spiritual components that reciprocally influence one another and vary across the lifespan.¹¹ Failing to address reproductive health may adversely affect drivers of pain, such as anxiety or depression, and have a negative impact on chronic pain outcomes. As evident in other chronic disease care models, providing effective reproductive care for people with chronic pain can be difficult due to fragmented health care, unclear responsibilities in managing the overlap between chronic health conditions, and reproductive needs. Despite these challenges, a recent qualitative study indicated that both providers and patients with chronic diseases were receptive to reproductive goal assessment.⁶ For women in this study, 35% indicated that they would like to get pregnant, which indicates that a discussion around reproductive health is warranted. Moreover, approximately 40% of pregnancies are unplanned, which further supports the need for education on these topics whether a person is planning or not to get pregnant.² Thus, pain management aligned with patient-centered value-based goals should include integration of reproductive goal assessment into chronic pain service provision.^17,18

Chronic pain conditions and management approaches have implications for reproductive health. Growing evidence suggests that certain chronic pain conditions, such as chronic pelvic pain, increase the risk of infertility.¹⁸ Therapeutic approaches for managing chronic pelvic pain are often hormonal in nature and block ovulation. However, the impact and management of other chronic pain conditions on fertility are less known. Health care providers are further challenged with the complexity of balancing maternal benefits of treatment with the risk of fetal exposures with, for example, different medications. For women of reproductive age, special consideration must be paid to the treatment of chronic pain because of risks associated with chronic pain and/or medication use on a fetus.^3,14 The results from this study indicate a gap in care for women of reproductive age regarding the interaction of chronic pain, medications, and pregnancy; with most women reporting that they did not get counselled on reproductive-related pain medication risks. Thus, while research is warranted for this area, a discussion about known risks, as well as risk mitigation strategies such as nonpharmacological pain management approaches, remains important. Participants in this study indicated that education on medication and pregnancy, the impact of pain on pregnancy, the impact of pregnancy on chronic pain, and sexual health would be of interest.

The results of this study warrant replication in a larger sample size; however, it is clear that women would benefit from, and are requesting, more reproductive health education from health care providers. Furthermore, specific pain diagnosis (eg, pelvic pain), years lived with pain, and gender identity were not reported by all participants. Future studies should include detailed analyses on sex, additional pain characteristics (eg, condition or years lived with pain), medication, and provider perspectives.

Our results clearly indicate that reproductive health is not being discussed in the context of chronic pain care. Patients are not being asked about their reproductive health goals or concerns while being offered chronic pain interventions that could be misaligned with these goals. These findings identify a gap in care and present an opportunity to integrate reproductive health in holistic pain care and lead the next era of sex and gender in health. Through therapeutic alliance, open dialogue, and ongoing questioning around goals, reproductive health discussions can be integrated during history taking, medication review, care planning, and follow-up visits.

Disclosures

The authors have no conflict of interest to declare.