How should OBGYNs and pain management specialists collaborate to address chronic pelvic pain?

Highlights

• A multidisciplinary team, including pelvic floor PT and other subspecialists, is critical to identify the multiple triggers of chronic pelvic pain.
• When referring to pain management, OBGYNs should clarify shared goals, the specific consult question, and the expected treatment plan.
• Pain may not be solely from a gynecologic diagnosis, as central sensitization can be a major contributor warranting specialist involvement.
• Before prescribing, providers must clarify with the pain specialist if a patient has a pain contract to avoid potential conflicts.
• Pain management specialists are an essential pathway for connecting patients with pain psychologists, who can be difficult to access otherwise.

Expert Insights

The Case for a Multidisciplinary Approach to Chronic Pelvic Pain

The management of chronic pelvic pain (CPP) demands a collaborative, multidisciplinary approach that extends beyond the traditional confines of gynecology. Experts agree that a single-specialty focus is often insufficient for this complex condition. As Dr. Deborah Bartz notes, the female abdomen contains over 29 organs in close proximity, making it difficult to definitively isolate a gynecologic etiology from genitourinary, gastrointestinal, or other sources. This anatomical complexity is compounded by the nature of conditions like endometriosis. Dr. Patricia Huguelet emphasizes that for many patients, endometriosis is merely "the tip of the iceberg," with underlying pain mechanisms that persist even after surgical diagnosis and hormonal suppression. Further complicating the clinical picture, Dr. Rachel Zigler observes that the source of pain is not always visible to the naked eye, which can lead to patients' symptoms not being taken as seriously as they should be. This underscores the need for partnerships that can address the multifaceted nature of CPP.

"In chronic pelvic pain patients with endometriosis, endometriosis is just the tip of the iceberg." Dr. Patricia Huguelet

Assembling the Collaborative Care Team

A structured, team-based strategy is crucial, particularly when initial gynecologic interventions fail to provide adequate relief. Dr. Huguelet outlines a common clinical pathway: following surgical diagnosis and initiation of hormonal suppression for endometriosis, a patient whose pain persists at the six- to eight-week post-operative visit should be referred to a multidisciplinary team. This team-based model moves beyond a singular focus on the gynecologic diagnosis to address the patient's comprehensive pain experience.

Immediate involvement of pelvic floor physical therapy is a key first step, as a specialist exam can identify pelvic floor tenderness or muscle spasm treatable with targeted therapy. The core of the pain management collaboration often involves a chronic pain specialist or an anesthesiologist, who can manage nerve-modulating medications and muscle relaxants. Dr. Huguelet also stresses the significant behavioral health component, advocating for psychosocial support and, when appropriate, mood-stabilizing medication. Depending on symptomatology, the team may expand to include a urologist to investigate conditions like interstitial cystitis or a gastroenterologist for suspected irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD).

Navigating the Referral: Practical and Logistical Considerations

Effective collaboration hinges on clear and explicit communication between the referring OBGYN and the pain management specialist. Dr. Jeannette Lager provides several key recommendations to ensure a successful partnership. First, it is essential to clarify the nature of the consultation and establish shared goals. The OBGYN should explicitly ask whether the pain service will be purely consultative or will assume management of the patient's pain medications. This prevents ambiguity in treatment plans and responsibilities. Specific therapeutic considerations, such as the potential use of a nerve block or Botox, should be communicated clearly in the consult note.

For perioperative patients already on narcotics or other pain medications, Dr. Lager advises proactive communication to solicit pain management's recommendations for a perioperative plan. A critical point of communication involves patients with existing pain contracts. The referring physician must determine if a contract is in place to avoid inadvertently prescribing medications that could violate its terms. This diligence protects both the patient and the integrity of their established pain management plan.

"If we prescribe medications while they have a pain contract, that can create issues, so make that an explicit point of communication." Dr. Jeannette Lager

Addressing Central Sensitization and Psychosocial Dimensions

A comprehensive approach must recognize that CPP is not always attributable solely to a peripheral, organ-based pathology. Dr. Lager highlights the importance of considering central sensitization and other contributing factors that warrant pain management involvement. This perspective aligns with the broader understanding that chronic pain can become a condition in and of itself, independent of the initial trigger.

Pain management specialists can also be a vital bridge to essential psychosocial support. Dr. Huguelet identifies behavioral health as a core modality in managing CPP. Echoing this, Dr. Lager notes that pain psychologists can be difficult for patients to find, and pain management teams are often well-equipped to facilitate this connection. She advises preparing the patient for the possibility that a referral to pain psychology may be part of the comprehensive treatment plan. Ultimately, as Dr. Zigler suggests, strengthening the collaboration between OBGYNs and pain specialists—working side by side—is fundamental to improving care for a condition that has historically been undertreated.