Static magnetic therapy

The effects of wearing small magnets as therapy for chronic pelvic pain versus placebo were assessed [61]. No difference was seen following 2 weeks' treatment but some significant differences appeared at 4 weeks as assessed by the Pain Disability Index and the Clinical Global Impression Scale but not the McGill Pain Questionnaire. Analyzed in terms of weighted mean differences, the differences were nonsignificant and there was a substantial drop-out rate. The putative mechanism of action of this modality is unclear but some data from other settings have indicated benefit, such as therapy for diabetic neuropathic foot pain. It is suggested that magnetic fields modify the abnormal discharge of damaged C-fiber afferents [62].

Issues of cost-effectiveness

The costs and benefits of different forms of endometriosis treatment have been reviewed [63]. In this condition there are choices to be made between hormonal therapy and surgery. Costs associated with surgery are heavily dependent on the capacity to undertake "one-stop" diagnostic and therapeutic laparoscopy. While appropriate for minimal to moderate disease, this approach is not feasible for complex late-stage endometriosis surgery, which requires careful planning, including bowel preparation. In recent years, the costs of medical treatments have reduced, but there is still a lack of long-term safety data relating to the use of gonadotrophin-releasing hormone (GnRH) agonists with "add-back" estrogen. Therefore, laparoscopic surgery remains the preferred option in many cases. Other forms of treatment for pelvic and vulval pain have not been analyzed systematically for cost-effectiveness.

Box 13.1 Treatment options

Interventions supported by RCT evidence

Laparoscopic surgery for endometriosis Vestibulectomy Pudendal nerve release Multidisciplinary management Counseling with ultrasound scanning Hormonal therapy for ovarian suppression

Interventions with conflicting evidence from RCTs

PSN and LUNA

Treatments supported by nonrandomized studies but shown to be noneffective in RCT

Adhesiolysis

Treatments supported by nonrandomized studies

Lignocaine ointment for vulvar vestibulitis

Tricyclic antidepressants

Gabapentin

Biofeedback

The future: strategies to improve the evidence base for the treatment of pelvic and vulval/perineal pain in women

In the clinical setting it is usually unrealistic to try to collect patients with a definitive pathologic diagnosis for treatment trials in pelvic and vulval/perineal pain. Moreover, the case mix seen in particular clinics is highly influenced by referral patterns and the specialist interest of the practitioner. Inevitably, there will be heterogeneity between units both in patients' clinical presentation and in the chronicity and severity of pain and associated functional impairment.

A practical approach to generating informative studies might involve the following elements.

• Definition of entry criteria based on pain intensity, duration and symptom impact using validated measures such as the Brief Pain Inventory.

• Grouping of participants on the basis of related constellations of symptoms. For example, it makes clinical sense to group those with mainly focal vulval vestibular symptoms separately from those with more generalized pelvic pain secondary to endometriosis. But patients often have symptoms referable to other pelvic organs, especially the bowel and bladder, and it is unrealistic to exclude them from studies of "pelvic pain." Moreover, such symptom overlap is consistent with current concepts of viscerovisceral and visceros-omatic convergence in sensory innervation.

• Where feasible, identification of a neuropathic element through sensory testing may help to strengthen understanding of treatment mechanisms as well as providing repeatable outcome measures within the same individual.

• Defining "packages" of interventions for comparison, in recognition that chronic pain management almost always involves (and indeed should involve) more than one treatment modality.

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