Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
Am J Obstet Gynecol. 2021 Nov;225(5):568.e1-568.e11. doi: 10.1016/j.ajog.2021.08.038. Epub 2021 Aug 28.
Chronic pelvic pain is a debilitating problem that afflicts 15% to 20% of women in the United States. Although more than 200,000 hysterectomies are performed annually for the treatment of chronic pelvic pain, previous studies indicate that 1 in 4 women undergo the discomfort and morbidity of hysterectomy without the relief of pain. The factors that predict treatment failure remain poorly characterized.
To describe the incidence of persistent pelvic pain 6 months following hysterectomy in women with chronic pelvic pain and determine whether a simple, self-reported measure of central sensitization is associated with a greater risk of persistent pelvic pain following hysterectomy.
We conducted a prospective, observational cohort study of women undergoing hysterectomy at an academic tertiary care center for a benign indication. Patients with preoperative chronic pelvic pain, defined as average pelvic pain ≥3 on a 0 to 10 numeric rating scale for >3 months before hysterectomy, were included in this analysis. The patients completed validated assessments of pain, anxiety, depression, and centralized pain (using the 2011 Fibromyalgia Survey Criteria, 0-31 points) preoperatively and 6 months after hysterectomy. The demographic information, surgical history, intraoperative findings, and surgical pathology were abstracted from the electronic medical records. Multivariate logistic regression was used to identify the independent predictors of persistent pelvic pain 6 months following hysterectomy, defined as <50% improvement in pelvic pain severity.
Among 176 participants with pelvic pain before hysterectomy, 126 (71.6%) were retained at 6 months, and 15 (11.9%) reported persistent pelvic pain. There was no difference in age (P=.46), race (P=.55), average pain severity during menses (P=.68), average overall pelvic pain (P=.10), or pain duration (P=.80) in those with and without persistent pelvic pain. Whereas intraoperative findings of endometriosis (P=.05) and uterine fibroids (P=.03) were associated with a higher incidence of persistent pain on univariate analysis, the surgical route (P=.46), pelvic adhesions (0.51), uterine weight (P=.66), and adenomyosis on histopathology (P=.27) were not related to the risk of persistent pain. Higher preoperative centralized pain scores (P=.01) but not depression (P=.64) or anxiety (P=.45) were more common in women with persistent pelvic pain. Multivariate logistic regression adjusting for age, preoperative pain severity, anxiety, depression, and operative findings of endometriosis and fibroids indicated that every 1-point increase in centralized pain before hysterectomy was associated with a 27% increase in the odds of persistent pelvic pain (odds ratio, 1.27; 95% confidence interval, 1.03-1.57) 6 months after surgery.
Although the majority of women with chronic pelvic pain report considerable improvement in pain following hysterectomy, higher degrees of centralized pain before hysterectomy is a robust predictor of persistent pelvic pain.
慢性盆腔疼痛是一种使人虚弱的问题，影响美国 15%至 20%的女性。尽管每年有超过 200,000 例子宫切除术用于治疗慢性盆腔疼痛，但先前的研究表明，1/4 的女性在没有缓解疼痛的情况下经历了子宫切除术的不适和发病率。预测治疗失败的因素仍描述不佳。
描述慢性盆腔疼痛女性子宫切除术后 6 个月持续性盆腔疼痛的发生率，并确定简单的自我报告的中枢敏化测量是否与子宫切除术后持续性盆腔疼痛的风险增加有关。
我们对在学术三级保健中心因良性指征接受子宫切除术的女性进行了前瞻性、观察性队列研究。本分析纳入了术前慢性盆腔疼痛的患者，定义为术前 3 个月内平均盆腔疼痛≥3（0 至 10 数字评分量表）。患者在术前和子宫切除术后 6 个月完成了疼痛、焦虑、抑郁和中枢化疼痛（使用 2011 年纤维肌痛调查标准，0-31 分）的验证评估。从电子病历中提取人口统计学信息、手术史、术中发现和手术病理学。多变量逻辑回归用于确定子宫切除术后 6 个月持续性盆腔疼痛的独立预测因素，定义为盆腔疼痛严重程度改善<50%。
在 176 名术前有盆腔疼痛的参与者中，126 名（71.6%）在 6 个月时保留，15 名（11.9%）报告持续盆腔疼痛。持续性盆腔疼痛患者的年龄（P=.46）、种族（P=.55）、月经期间平均疼痛严重程度（P=.68）、总体盆腔疼痛平均水平（P=.10）或疼痛持续时间（P=.80）均无差异。虽然术中发现子宫内膜异位症（P=.05）和子宫肌瘤（P=.03）与单变量分析中更高的持续性疼痛发生率相关，但手术途径（P=.46）、盆腔粘连（0.51）、子宫重量（P=.66）和组织病理学上的腺肌病（P=.27）与持续性疼痛的风险无关。术前中枢化疼痛评分较高（P=.01），但抑郁（P=.64）或焦虑（P=.45）并不常见于持续性盆腔疼痛的女性。多变量逻辑回归调整年龄、术前疼痛严重程度、焦虑、抑郁和子宫内膜异位症和肌瘤的手术发现表明，术前中枢化疼痛每增加 1 分，术后 6 个月持续性盆腔疼痛的几率增加 27%（比值比，1.27；95%置信区间，1.03-1.57）。
尽管大多数慢性盆腔疼痛女性报告子宫切除术后疼痛有明显改善，但术前中枢化疼痛程度较高是持续性盆腔疼痛的有力预测因素。
