Background
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.
Objective
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.
Study Design
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.
Results
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.
Conclusion
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.
Key words
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Article info
Publication history
Published online: August 27, 2021
Accepted:
August 24,
2021
Received in revised form:
August 12,
2021
Received:
March 16,
2021
Footnotes
S.A. is a consultant for AbbVie, Myovant, Bayer, and Eximis, and receives author royalties from UpToDate. C.M.B. is a consultant for Heron Therapeutics (San Diego, CA), Vertex Pharmaceuticals (Boston, MA), and Alosa Health (Boston, MA) and he provides expert testimony. S.A.M. is a consultant for AbbVie and Roche and currently receives grant funding from the National Institutes of Health (NIH), the Department of Defense, and AbbVie. The remaining authors report no conflict of interest.
S.A. is supported by Eunice Kennedy Shriver National Institute of Child Health and Human Development R01 HD088712. C.M.B. is supported by National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) R01AR060392, NIAMS P50 AR070600, National Institute on Drug Abuse (NIDA) R01DA038261, NIDA R01DA042859, and Common Fund UM1 NS118922. A.D.S. is supported, in part, by NIH R43 DA046981. S.R.T. is supported by Eunice Kennedy Shriver National Institute of Child Health and Human Development 1K23HD09928301A1. Additional support has been received from the Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.
Cite this article as: As-Sanie S, Till SR, Schrepf AD, et al. Incidence and predictors of persistent pelvic pain following hysterectomy in women with chronic pelvic pain. Am J Obstet Gynecol 2021;225:568.e1-11.
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© 2021 Published by Elsevier Inc.
