Chronic pelvic pain can cost women productive time at work and lost opportunities with family and friends. Dr. Vadim Morozov discusses which populations are most at risk for chronic pelvic pain and the personalized treatment options that are available.
TRANSCRIPT
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We're speaking with Dr. Vadim Morozov, a gynecologic surgeon at MedStar Washington Hospital Center. Today we're discussing chronic pelvic pain which can be a symptom of a variety of gynecologic disorders. Welcome Dr. Morozov.
Dr. Morozov: Thank you. Glad to be here.
Host: What do you mean when you say chronic pelvic pain?
Dr. Morozov: So, chronic pelvic pain, by definition, a pain in your pelvis that's been there for longer than six months duration. It could be caused by multiple reasons, but most common one in the female population are things like endometriosis, fibroids, scar tissue.
Host: What symptoms might prompt a woman to seek treatment?
Dr. Morozov: So, things like very painful menstruation. Pain with intercourse for, example. Pain with going to the bathroom and just the one that doesn't go away - the one that's not getting better with just something like Motrin or Advil. Those are the conditions that I would suspect that she has something else and needs to be addressed.
Host: When we're talking pain, are you talking a burning sensation or cramping? What are...what are women complaining about?
Dr. Morozov: That's a very interesting question. So, actually women can complain about any type of pain and in the pelvis, it's highly non-specific, meaning you could have a certain condition but the pain could range from, as you mentioned, burning, pinching, to doubled over with stabbing—"I can't even take a breath."
Host: Is it always in the pelvic area or does it radiate?
Dr. Morozov: It does go to other things and other parts of the body. For example, pain with endometriosis' very commonly go down toward the back. It can go down the legs. It can shoot down toward out the stomach or in your buttocks. It's very difficult to pinpoint the location of the pain and the specific cause of the pain in a lot of cases.
Host: Who is most at risk for chronic pelvic pain?
Dr. Morozov: Obviously, uh, women are 95 percent. So, if you look at the all population of chronic pelvic pain, 95 percent of the chronic pelvic pain happens in the female population. We're still unsure why it happens. Males do too, but very unfrequently, as you can, tell from that statistic. If you had endometriosis in your family—if your mother or your sister was affected by endometriosis, you are much higher chance to have an endometriosis and pelvic pain. If you had fibroids in your family, you are at a higher risk of having a fibroid. If you're African American, for example—race plays a specific role. African Americans statistically are three times as likely to have fibroids as white women. Asians, for example, almost unheard of having fibroids on the other hand. So, very specific genetic component that plays a role.
Host: Is there any sort of genetic testing or any testing that can help determine a woman's risk?
Dr. Morozov: Unfortunately not. There are multiple companies that are trying to get commercial testing on the market. So far, we do not have anything that can predict a risk of developing endometriosis. Or even a chronic pelvic pain for the condition. The interesting thing about chronic pelvic pain and endometriosis or fibroids is that you could have endometriosis and not have pelvic pain. And almost the opposite is true. You can have the most severe pelvic pain and then, when we investigate, you will have very minimal or very mild endometriosis. So, there is no direct correlation between the cause and effect.
Host: Once a cause is defined, if a cause can be defined for chronic pelvic pain, what are some of the treatment options that are available?
Dr. Morozov: We usually start with discussing what causes the pain, as you said, right? So, if we can identify that, let's say, it's a fibroid, for example, or endometriosis or pelvic scar tissue (adhesive disease), usually we try some medical intervention in the beginning. Maybe some sort of a non-steroid anti-inflammatory, otherwise known as Advil, Motrin, and Ibuprofen. Maybe we try to have some sort of a physical therapy intervention. In my experience, in the majority of cases, that doesn't work. Very few times it actually will make women asymptomatic, meaning she's happy with that treatment and done. The next step would be the surgical intervention.
So surgical intervention, nowadays in 21st century, we truly believe it needs to be done minimally invasive, laparoscopic way, meaning small, tiny, less-than-an-inch incisions in the belly with one of them in the belly button. Go home the same day within 2-4 hours. Very quick recovery time. Almost no blood loss. Having said that, the surgery just the first step in the long way to recovery. So, identifying and treating the cause of the pelvic pain, let's say an endometriosis or whatever, will not make you pain free unfortunately. And that's a very complicated topic and people wrote books and chapters and actually I wrote some chapters and research and that. You will need to do a lot of other things on top of the surgery, meaning we will have to suppress your hormonal fluctuation one way or the other. The fewer menstrual periods you have as a woman, the shorter they are, the better your chance of not having the recurrence of endometriosis. Pelvic physical therapy would be the next step. There is a highly interesting phenomenon that's called central sensitization and to explain it in the lay terms, this is where your central nervous system gets used to the pain over many, many years. And technically speaking, no matter what we do in your pelvis, you still feel the pain. So, we'll have to address that problem. So, it's a multi-specialty approach before we can get patient to the level where she can function comfortably.
Host: If a woman, say, doesn't have severe symptoms or has just gotten used to living with them, is there a risk for leaving chronic pelvic pain untreated?
Dr. Morozov: Not the pelvic pain. Now obviously, the chronic pelvic pain is, puts the huge burden on society. The estimate that it costs several billion dollars a year for economy from lost wages, lost time from work, lost...lost time from spending with your family and kids. Endometriosis, for example, left untreated, could become severe enough and could affect other organs next to it—so it could affect your bowel, it could affect a kidney. And I have dealt with cases before where the endometriosis was bad enough that the kidney almost died off because it was obscured in the outflow. So, eventually, it can get you in trouble.
Host: Have you had any women come in with chronic pelvic pain who just had a very severe condition and you were able to help them and get them back to a functional level?
Dr. Morozov: Absolutely. That's what we do. I mean, the worst endometriosis - although some expert will debate - is called a stage 4 endometriosis - was severe. And we do surgery, we restore the anatomy, we remove the endometriosis that affects the organ. And, they seem to be doing great. They're fully functional, they still have pain here and there, but at least we can get them to the point where they can function on an everyday basis and have a normal life.
Host: Do you have any one patient that stands out in particular who was maybe very severe and has done really well?
Dr. Morozov: Yeah, we have, just recently - about a month ago - I did a surgery on a patient and she's great, she feels absolutely phenomenal.
Host: Are there any environmental factors associated with the risk of endometriosis or other chronic pelvic pain?
Dr. Morozov: Absolutely. There's been a lot of research done on the environmental factors in endometriosis. One of them is well known, organa pollutants or organa phosphorus components that exist everywhere. Actually, very common product on the market is a sunscreen that has them. And I'm not abdicating, I'm not saying don't use sunscreens, but we have to be cognizant about what we buy and use. There's been studies saying that the specific components that are used in the industry actually produce both to develop an endometriosis.
Host: Are you conducting any research, you or your colleagues, regarding chronic pelvic pain that women in the community should know about?
Dr. Morozov: Not currently. I mean, I've been involved in the research for chronic pelvic pain and endometriosis. The problem with the research in this arena is that it's hard, as I mentioned before, to correlate the extent of a disease with the sensation of pain. Multiple commercial companies been in the market trying to develop some sort of the either medication or pain control, endometriosis control or fibroid control drugs and some of them are successful, majority are not. So, it's a tricky area of research.
Host: What innovations in chronic pelvic pain do you hope to see in 10 to 20 years?
Dr. Morozov: So, there is some research right now that I find very fascinating. There's a company that's testing the RNA fragments, which is a blood sample, and actually they claim they can get yours out of your saliva, so it's just a little swab out of the mouth. And they are saying that if you can analyze, sort of fragments of RNA, which is nucleic acid in your blood, they can predict whether you have an endometriosis or not. So that would be very useful diagnostic tool which we don't have right now at all. As I said, the only way to diagnose endometriosis is to perform the surgery, which, of course, carries the risk of any surgery. Bleeding, infection, you name it, damage to the surrounding organs. If we can have a test, either by blood drawing or by swabbing the mouth and sending it to the lab, tells you as a patient and me as a physician that you have a certain degree of, you know, sensitivity that that will be the endometriosis. What is more important, that test would be absolutely phenomenal to see the progression after the treatment. So, let's say we do the surgery and then we test that patient six months to a year later and see if that test becomes negative. That would be even better application.
Host: Why is MedStar Washington Hospital Center the best place for a woman to come for chronic pelvic pain care?
Dr. Morozov: Because we have the best interdisciplinary team on the East Coast. I mean, our Center for National Advanced Pelvic Surgery has multiple specialists that deal with nothing else but with chronic pelvic pain, fibroids, endometriosis. We have multiple fellowship-trained urogynecologists. We have a urologist that works with us with interest in woman health. So, this is a place where, if you have a problem, you would expect that they will be detected and solved.
Host: Thank you for joining us today, Dr. Morozov.
Dr. Morozov: Thank you for having me.
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