A Multidisciplinary Pelvic Pain Clinic: Integrated Health Psychology in a Specialty Care Setting

Abstract

Purpose:

Chronic pelvic pain (CPP) is a relatively common health problem, impacting around 25 million women globally. This study details the development of a multidisciplinary women's CPP clinic at a major U.S. academic medical center, and examines associations between mood, pain symptoms, and trauma history.

Materials and Methods:

Data were collected from 96 subjects, including self-report measures (Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Brief Trauma Questionnaire), pain intensity ratings, psychiatric diagnoses, and relevant medical history.

Results:

Most subjects reported at least one traumatic experience. Nearly half of subjects met criteria for an anxiety disorder and/or a depressive disorder. Most subjects were diagnosed with pelvic floor dysfunction, and more than half were referred to physical therapy. Women with abdominal/pelvic surgery history reported more traumatic experiences than women without surgical history. Women with a history of sexual abuse reported trying more medications and seeking care from a greater number of providers. Many reported pain duration of >2 years.

Conclusions:

Study findings related to mental health and trauma support a multidisciplinary CPP approach that includes a clinical health psychology component. Future research may investigate the therapeutic processes that apply to this population to identify targeted efficacious interventions.

Introduction

Chronic pelvic pain (CPP) is a relatively common health problem and impacts the lives of around 25 million women globally. CPP affects all genders, although research shows that most CPP cases occur in females.¹ Worldwide incidence rates of female CPP vary considerably, ranging from 6% to 39%.^2,3 This variability stems from a lack of consensus regarding defining criteria, including location, duration, and etiology.⁴ Problems defining criteria thus create challenges in understanding the causes and in developing a comprehensive treatment model.³

CPP is broadly defined as a persistent (>6 months), noncyclic pain located in the pelvic or abdominal region.⁵ CPP often co-occurs with other medical concerns, although associations vary and tend to form syndromes rather than definitive causal pathways. In females, these comorbid conditions include irritable bowel syndrome,² bladder pain syndrome, endometriosis,⁶ pelvic adhesions, interstitial cystitis, and pelvic inflammatory disease.⁷

In addition to medical comorbidities, psychosocial factors are often linked to CPP. CPP is associated with increased workplace absenteeism and decreased productivity.^8,9 Sleep, household activities, work, and sexual relations are the most common areas of impairment.¹⁰ Many women with CPP report dyspareunia (fear of and actual pain before, during, and after intercourse).¹¹ Women of reproductive age may avoid or put off family-building efforts to prevent an exacerbation of pain, which in turn may cause long-term emotional and interpersonal repercussions.¹²

CPP patients often exhibit associated mood symptoms, including depression, anxiety, and sleep disturbances.¹³ A study of CPP patients (60.1% female) found that 95.2% of patients met criteria for at least one mental health condition, including higher rates of somatoform, depressive, and anxiety disorders than in the general population.¹⁴ In one study comparing women diagnosed with CPP and controls, the prevalence of anxiety (73% vs. 37%) and depression (40% vs. 30%) were higher among CPP patients; higher anxiety and depression were associated with lower quality of life.¹⁵

Nearly one in three women worldwide have been subjected to physical and/or sexual violence; these data were collected between 2000 and 2018 from 161 countries.¹⁶ Women in the United States report an 8.0% lifetime prevalence of post-traumatic stress disorder (PTSD).¹⁷ Higher rates of reproductive and sexual trauma, as well as other forms of abuse, are observed in higher rates among CPP patients than in the general population^18–20; furthermore, higher rates of PTSD are reported by CPP patients.²¹ One study found that almost 47% of female CPP patients reported having a sexual or physical abuse history, and ∼31% screened positive for PTSD.²¹ Similarly, in a multidisciplinary CPP clinic, ∼45% of CPP patients had a history of abuse, with the majority (73%) reporting sexual abuse.¹⁰ Adult sexual abuse has been found to increase the likelihood of severe pain-related disability and the risk of depression in women with CPP.²²

Owing to the interdependent nature of the physiological and psychosocial components of CPP, a comprehensive treatment approach, including both psychotherapy and medical treatment, is preferable. Reduction of pain alone does not improve mood symptoms in CPP patients.^23,24 In fact, previous research has suggested that multidisciplinary approaches (when compared with isolated medical treatments) are associated with better pain management, improved general health outcomes, and decreased mental health symptoms.^10,23

A Cochrane review in 2000 found evidence supporting multimodal treatments for CPP in women; the studies examined included hormonal treatments, physical therapy, psychotherapy, diet, and environmental factors.²⁵ Myofascial physical therapy is also associated with reduced pain intensity.^26,27 A 2017 article assessing the rationale for multidisciplinary treatment of CPP similarly cited pharmacology, physical therapy, psychotherapy, and interventional pain management procedures (e.g., nerve blocks, pelvic floor trigger point injections, pelvic floor botulinum toxin injections, and neuromodulation) as common elements of a successful multidisciplinary treatment program.²⁸

The purpose of this study is to (1) detail the development of a multidisciplinary women's CPP clinic at a major U.S. academic medical center, (2) characterize patient anxiety, depression, and trauma at initial appointment, and (3) examine correlations between mood, pain and pain-related medical care, and trauma history.

Materials and Methods

Participants and procedures

Data were collected from 96 women who sought care at this CPP Clinic between May 2019 and August 2020. Patients ranged in age from 18 to 83 years (mean [M] = 35.34, standard deviation [SD] = 13.91). Patient race was predominantly White (88.5% White [n = 85], 5.2% Black [n = 5], and 6.3% Other [n = 6]). Patients were primarily married or partnered (69.8% married or partnered [n = 67], 26% single or divorced [n = 25], and 4.2% unknown [n = 4]).

The CPP Clinic at (the University of Iowa Hospitals and Clinics) operates through the department of obstetrics and gynecology. Referrals originate from primary care physicians or specialists in obstetrics/gynecology, urogynecology, or gastroenterology. Women frequently wait several months for an initial consultation and travel a considerable distance to this clinic due to limited treatment options elsewhere. A clinic visit includes multiple same-day services, with OB-GYN and physical therapy examinations, as well as diagnostic testing. Treatment recommendations may include pain medications, hormonal treatments, surgical interventions, pelvic floor physical therapy, or referrals to treat underlying contributing conditions.

In May 2019, the CPP Clinic was expanded to include two health psychologists, per request from clinic physicians after noting high rates of patient depression and anxiety. They also cited treatment complexity caused by trauma history, including sexual abuse or violence. Thus, a health psychology component was developed and added as a required aspect of the initial clinic visit for all patients. This requirement was explained to patients by clinic staff at the time of appointment scheduling.

The health psychology session was scheduled for 60 minutes and included a diagnostic clinical interview (with specific focus on psychiatric and pain histories), completion of self-report measures (anxiety, depression, and trauma), and collaborative treatment planning. Although the health psychologists reviewed pain scores before and often during clinical interviews with patients, these data were previously collected by the clinic obstetrician-gynecologist as part of standard medical symptom review protocol.

Many patients presented to first clinic visit with a regimen of pain, psychiatric, or hormonal medications already in place. These data were recorded in the medical chart by either the obstetrician-gynecologist (pain and hormonal medication) or the health psychologist (psychiatric medication). Approximately 6 months after the launch of the new clinic format, sessions were decreased to 30 minutes to offer more focused patient care. The new format abbreviated the clinical interview while behavioral interventions (e.g., mindfulness exercises and cognitive reframing) were added to enhance patient coping skills.

When significant mental health concerns such as anxiety, depression, or PTSD were identified, a referral for outpatient psychotherapeutic services was suggested and could include follow-up care with the health psychologist, referral to an external mental health care provider, or continued treatment with the patient's established clinician. Patients who scheduled follow-up appointments with the CPP medical team were also offered the option to meet with the health psychologist for further treatment. Follow-up visits focused on reinforcement of cognitive-behavioral pain coping strategies. Cognitive-behavioral interventions included identification and reframing of maladaptive automatic thoughts about the pain experience, with corresponding behavioral activation and intervention (e.g., teaching of relaxation techniques). Psychoeducation regarding the role of movement in pain management was discussed in the context of behavioral activation strategies.

Patient responses from the self-report measures were recorded in the hospital's electronic medical record (EMR) system. In preparation for later data extraction and analyses, research approval for nonhuman subjects research was sought and obtained from the University Institutional Review Board. A secure database was created outside of the EMR that included demographic data, scores from the self-report measures, pain assessments, psychiatric diagnoses, and relevant medical history.

Measures

Clinical interview

The interview included an assessment of relationship, reproductive, medical, substance use, psychiatric, and social histories, as well as a discussion of current and predicted life stressors. An extensive history of pelvic pain was also conducted, which included etiology, pain source, location, triggers, diagnoses, treatments, coping strategies, and emotional supports/resources.

Trauma

The Brief Trauma Questionnaire (BTQ) is a self-administered 10-item questionnaire.²⁹ The BTQ is sensitive to Criterion A of the PTSD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and adequate criterion validity has been demonstrated.³⁰ The BTQ not only assesses exposure to car accidents, natural disasters, and life-threatening illness, but also identifies unwanted sexual contact and physical abuse.

Depressive symptoms

The Patient Health Questionnaire-9 (PHQ-9) is a self-report measure of depression based on the diagnostic criteria. The PHQ-9 is considered a reliable and valid measure of depressive symptom severity.³¹ Categories indicate severity ranging from minimal (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), and severe (20–27) depression.³¹

Anxiety

The Generalized Anxiety Disorder-7 (GAD-7) is a self-report measure of anxiety,³² which has been used with perinatal women and CPP patients.^14,33 Categories indicate severity ranging from minimal (0–4), mild (5–9), moderate (10–14), and severe (15–21) anxiety.³²

Statistical analyses

Data were cleaned and examined for outliers, normality, skewness, and kurtosis before analyses. Descriptive characteristics of the sample are reported with frequencies, means, and SDs. Bivariate correlations indicate the associations between two continuous variables. Independent samples t-tests were used to compare between patients reporting a history of sexual abuse and those who did not in terms of pain duration, intensity, and other continuous variables of interest.

Results

Characteristics of the sample in terms of gynecological and other medical diagnoses are reported in Table 1. The average depressive and anxiety symptom scores were in the mild range. Across categories of severity, about one-quarter of the sample was experiencing minimal depression (27.4%), with the majority reporting mild or greater severity. Similar findings were observed with anxiety, with 24.2% reporting minimal anxiety, and most of the sample reporting mild or greater levels of anxiety. Most of the sample (74.2%) was diagnosed with at least one mental health condition.

Table 1.

Characteristics of the Sample

	Mean (SD)
PHQ-9, Total	8.10 (5.56)
Minimal depression, 0–4, n (%)	26 (27.4)
Mild depression, 5–9, n (%)	32 (33.7)
Moderate depression, 10–14, n (%)	16 (16.8)
Moderately severe depression, 15–19, n (%)	11 (11.6)
Severe depression, 20–27, n (%)	3 (3.2)
BTQ, Total	2.11 (2.10)
GAD-7, Total	8.29 (5.25)
Minimal anxiety, 0–4, n (%)	23 (24.2)
Mild anxiety, 5–9, n (%)	33 (34.7)
Moderate anxiety, 10–14, n (%)	20 (21.1)
Severe anxiety, 15–21, n (%)	13 (13.7)
Pain duration, months	52.24 (44.12)
Deep pain with intercourse	6.18 (3.44)
Pelvic pain after intercourse	3.86 (3.26)
Muscle/joint pain	3.83 (3.25)
Pain with urination	1.40 (2.41)
Pain with sitting	3.60 (3.20)
Medications tried	2.09 (1.96)
Treatments tried	2.17 (2.20)
Providers seen	2.43 (1.43)
	n (%)
BTQ
War-related trauma	0 (0)
Serious accident	29 (32.6)
Natural disaster	16 (18)
Life-threatening illness	6 (6.8)
Physical punishment as a child	26 (29.2)
Physical assault as an adult	18 (20.2)
Unwanted sexual contact:	34 (38.2)
Serious injury	18 (20.2)
Violent death of close other	20 (22.5)
Serious injury to close other	21 (23.6)
Reported 1+ traumas	67 (75.3)
Mental health diagnosis	69 (74.2)
Trauma stressor-related disorders	9 (9.5)
Anxiety disorders	47 (49.5)
Depressive disorders	44 (46.8)
Abdominal/pelvic surgical procedures	38 (40)
Vaginismus	4 (4.2)
Vulvovaginitis	13 (13.7)
Vulvodynia	23 (24.2)
Dysmenorrhea	12 (12.6)
Dyspareunia	59 (62.1)
Endometriosis	9 (9.5)
Constipation	21 (22.1)
Pelvic floor dysfunction	70 (73.7)
Referred for physical therapy	54 (57.4)

Six participants declined to complete the PHQ-9, BTQ, and GAD-7 measures.

BTQ, Brief Trauma Questionnaire; GAD-7, Generalized Anxiety Disorder-7; PHQ-9, Patient Health Questionnaire-9; SD, standard deviation.

Comparisons were conducted to examine the relationship between history of abdominal or pelvic surgery and depression, anxiety, and trauma history. Women with a history of abdominal/pelvic surgery reported more traumatic experiences (M = 2.76, SD = 2.50) than women with no such surgical history (M = 1.71, SD = 1.71), t(52.13) = −2.17, p = 0.035.

Bivariate correlations were examined between measures and are displayed in Table 2. Number of traumatic experiences was related to muscle and/or joint pain and pain with sitting. Number of traumas related to number of medications tried for pain. Depressive symptoms related to muscle and/or joint pain and pain with sitting.

Table 2.

Correlations Between Pain and Mental Health Variables

	1	2	3	4	5	6	7	8	9	10	11
1. Pain duration
2. Deep pain with intercourse	0.21
3. Pelvic pain lasting hours or days after intercourse	0.19	0.56a
4. Muscle/joint pain	0.29b	0.00	0.27b
5. Pain with urination	0.04	0.17	0.25	0.37c
6. Pain with sitting	–0.12	–0.15	0.31b	0.58a	0.31b
7. Medications tried	0.32b	0.14	0.34c	0.32b	0.01	0.31b
8. Treatments tried	0.18	0.19	0.36c	0.19	0.16	0.22	0.62a
9. Providers seen	0.17	0.17	0.43a	0.36c	0.15	0.23	0.61a	0.070a
10. GAD-7, Total	–0.03	–0.04	0.05	0.18	0.01	0.01	–0.13	–0.13	–0.00
11. PHQ-9, Total	0.11	0.00	0.25	0.51a	0.22	0.28b	0.15	0.04b	0.21	0.70a
12. Traumas, Total	0.03	0.03	0.08	0.33c	0.17	0.34c	0.32b	0.08	0.24	0.17	0.19

^a p < 0.001.

^b p < 0.05.

^c p < 0.01.

Traumas, total number of traumas, as measured by the BTQ.

Finally, mood and pain ratings were compared among women who had a history of sexual abuse and those who did not. No differences were observed in any of the pain intensity ratings (ps > 0.05) or pain duration (p > 0.05). Women with a history of sexual abuse reported trying more medications to manage pain symptoms (M = 3.05, SD = 2.01) than women without this history (M = 1.63, SD = 1.79), t(60) = −2.63, p = 0.006. Significant differences were observed in the number of treatments tried for CPP [t(60) = −2.34, p = 0.02] between women with a sexual abuse history (M = 3.0, SD = 2.37) and women without (M = 1.66, SD = 2.01). Finally, women with a sexual abuse history reported seeing more providers to treat CPP (M = 3.05, SD = 1.5) than women without (M = 2.17, SD = 1.29), and this difference was statistically significant [t(61) = −2.42, p = 0.02].

Discussion

This study describes the development of a multidisciplinary CPP specialty care clinic and details patient mental health, trauma, and pain variables. Study findings illustrate the complexities of CPP and emphasize the importance of multidisciplinary treatment to address both mental and physical health concerns.

Findings in context

Patients described pain locations and triggers (Table 1) similar to previous research linking pain to comorbid pelvic region disorders,^6,7,34 especially dyspareunia.¹¹ The most intense pain reported was deep pain during intercourse. Most women in this study were diagnosed with pelvic floor dysfunction, and more than half were referred to physical therapy (PT). Average CPP duration aligns with prior research showing pain duration of 1–5 years,¹ which supports the need for behavioral health interventions.

Previous research indicates a relation between CPP and sexual trauma.^10,20 This study did not observe a significant relation between history of sexual trauma and either pain intensity or duration, aligning with some prior work,^35,36 but not others.³⁷ Women with a history of abdominal or pelvic surgeries reported more traumatic experiences than women without surgical history, a finding that is deserving of further investigation. The correlation between trauma and general poor health outcomes has been repeatedly demonstrated in the literature.^7,22,34

Furthermore, one study identified that women with a history of childhood abuse reported more chronic physical symptoms, medical visits, emergency room visits, prescriptions, and PTSD symptoms than those without a history of childhood abuse.³⁸ However, there are no identified factors in the literature that more thoroughly describe the etiology of the relationship between CPP, trauma, and health care utilization. It has been hypothesized that development of PTSD may impede individuals' ability to utilize health care effectively, with challenges related to avoidance of trauma-related stimuli and hypervigilance symptoms that may impede individuals' ability to access or utilize health care in an effective way,¹⁹ although this has not been demonstrated empirically.

Findings correspond with previously shown high rates of comorbidity between CPP and psychiatric disorders.^13,14,39,40 Most (74.2%) patients had a documented mental health diagnosis, including approximately half with an anxiety and/or depressive disorder. Symptoms were in the mild range. Depressive symptoms related to higher muscle/joint pain and pain with sitting, whereas anxiety was not related to pain intensity. Given years of CPP, it may be the case that coping is initially characterized by future-oriented anxiety but later evolves into depression due to lack of adequate treatment, pain relief, and hope for a cure.

Clinical lessons learned/future directions

The clinical response to this multidisciplinary model was positive, although suggestions for improvement may be made. The health psychology session was originally scheduled for 60 minutes to allow for diagnostic assessment, but the reduced 30-minute session, with its emphasis on coping skills and provision of resources, proved to be a better fit.

An adjustment of clinic flow may be warranted, wherein consultation between providers may be lengthened to increase information-sharing and improve treatment planning. Because PT assessment and treatment can be physically uncomfortable and triggering for women with sexual trauma history, meeting with the health psychologist before PT might increase the use of in vivo coping strategies.

It was expected that CPP clinic patients would request follow-up health psychology care, but this prediction did not prove accurate. Many patients traveled to this clinic from quite a distance, making regularly scheduled on-site psychotherapeutic care less convenient. Telehealth for return visits may address this concern, however. Many patients had established treatment before visiting the CPP clinic. Although this care model required that all new patients meet with a psychologist, assessment of patient needs before the clinic visit might allow better flexibility and choice.

Both the existing literature and this project support a multidisciplinary treatment approach from the clinician perspective. Assessment of the patient perspective and implementation outcomes are warranted in future research. Further research examining the role of psychological factors and utilization of health care services would likely refine the care model. In addition, research examining the impact of a brief session with a health psychologist may provide insights on the treatment outcomes related to brief integrated care interventions. Determining the impact of catastrophizing, perceived disability, cognitive flexibility, and emotional resilience on the utilization and response to treatment could enhance the interventions employed. Distinguishing between sexual and nonsexual traumas could also prove useful in assessing the impact of psychological factors on CPP (e.g., duration, intensity, and functional impairment).

Conclusions

The present findings introduce the development of a multidisciplinary CPP clinic in an academic medical center. Data indicate that there was a high prevalence of mental health diagnoses, suggesting a need for clinical health psychology. Most women reported at least one past trauma, which related to health care utilization and pain severity. The importance of trauma among women with CPP has been underscored in prior literature, with particular emphasis on sexual trauma. Future research may investigate the therapeutic processes that apply to this population to identify targeted efficacious interventions. Pain reported with intercourse has important implications for sexual functioning and intimate relationships, which can be addressed by health psychologists.

This study points to the importance of integrating across health care disciplines to improve patient care, particularly among populations with chronic and unmanaged pain. Providing psychoeducation about the potential benefits of multidisciplinary care can be viewed as an important part of the health psychologist's role. In summary, this study identifies trauma and mental health variables as key measurable components affecting women with CPP, underscoring the importance of integrated psychological care within specialty clinics.

Authors' Contributions

S.A.P. and K.E.F. conducted all psychological evaluations and extracted the data from the EMR. E.B.K.T. and M.S.S. prepared data for analyses and conducted data analyses. E.B.K.T., M.S.S., K.E.F., and S.A.P. prepared the article. All authors reviewed, edited, and approved the final version of this article.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was used to conduct this research. Publication fee will be paid using internal discretionary funds.