Melanie Cole, MS (Host): The exact cause of pelvic pain for many women can be elusive despite tests and scans. And in some cases, the symptoms may be related to a problem that might be overlooked. Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field.

I'm Melanie Cole. And today, we're highlighting the AHN Pelvic Pain Program. Joining me is Dr. Radhika Patnam. She's a urogynecologist with the Allegheny Health Network. Dr. Patnam, thank you so much for joining us today. I'd like you to start by telling us about the prevalence of pelvic pain in women. What are some of the most common reasons that we know about that we can point to, and how common, how many women do you see with pelvic pain?

Dr. Radhika Patnam: Thank you for having me. Prevalence of pelvic pain is kind of a hard thing to define, mainly because we don't have the best definitions for it. When you talk about pelvic pain, it can be a lot of different things. People commonly think that anything that's kind of going on in the abdomen or into the pelvis is going to be something that has to do with female genital organs, for example, kind of thinking it must be the uterus or the ovaries. But in reality, there's so many different things that are in play here, including muscle issues, including bowel issues, that a lot of this is that we don't know how to truly define it. So, we can't really say a specific prevalence for it.

Melanie Cole, MS: Okay. That's fair. Thank you so much. So then, why is it sometimes difficult to diagnose?

Dr. Radhika Patnam: Mainly because it's hard to kind of figure out the source of it. I think a lot of times patients ignore pelvic pain until it becomes a problem. So, this could be something where there's an ongoing ache and ongoing discomfort, but until it becomes something that is in some ways taking over their life, they ignore the issue.

The other times that it can really become a problem are with pain with intercourse or dyspareunia. And a lot of women will not even be aware that they have a problem until they're attempting intercourse that they haven't for one reason or another.

Melanie Cole, MS: Is it different when you experience working with women post-pregnancy, reproductive years, pelvic pain and post-menopausal pelvic pain? Is that different for you as a physician?

Dr. Radhika Patnam: I think it really then kind of changes what I think the source of the issue is, right? Symptoms of menopause are multifactorial and complex. But a lot of women will have genitourinary symptoms of menopause. And atrophy can play a massive role in that. So, that's really what you're thinking about in that postmenopausal group.

In the premenopausal group, especially in the post delivery, we're thinking about more of the possibility of it being some sort of injury, right? What is the word I want to use? Delivery is traumatic. And because it's traumatic, it can lead to a lot of tissue damage. It can lead to a lot of pain. These are also women who are getting used to having a different body than the one they kind of started with pre-pregnancy. So, kind of thinking about what the source is in a slightly different manner.

Melanie Cole, MS: Well then, tell us about the AHN program for pelvic pain and the pelvic floor clinic that can help patients with this chronic pain and provides methods to help manage that pain.

Dr. Radhika Patnam: So, our pelvic pain clinic is run out of our urogyn office. It's me who's mainly running it. And I chose to start a pelvic pain clinic when I started working at Allegheny Health Network, mainly because I have a pretty large interest in it. I was lucky enough to go to a fellowship program that offered some real training in how to manage pelvic pain. We are looking at women who have a myriad of different problems, including vulvodynia, including pelvic floor dysfunction, including just sort of chronic pelvic pain that we don't really have an explanation for, and bladder pain syndrome.

The goal of the clinic is to get you to the right people, and whether that's me or whether that's getting you to pain management or getting you to our endometriosis specialists or even getting you to Gastroenterology. Part of the issue is kind of parsing out what is causing all the issues and whether something is causing something else. And what I mean by that is, let's say a patient has vulvodynia, vulvodynia is tenderness or pain in the vulvar area, that is more than it should be. So, you have light touch through the vulva and instead of that feeling like light touch, it feels like a burning sensation or pain. Long-term  vulvodynia can lead to having pelvic floor dysfunction. And so, you have these tight pelvic floor muscles and that causes a different kind of pain. And suddenly, instead of having one problem, you have two problems.

Part of what my goal in this clinic is to try to parse out what is possibly the inciting incident that led to everything and kind of pulling apart what we need to do to help to get patients better. I think one of the realities of any sort of pain care is understanding we might not get you back to where you were in the first place. Our goal is to mitigate, not cure. And that's a hard thing I think for a lot of patients to hear, but it's also, I think, really hard for providers to say, right? It's hard for a physician to look a patient in the eye and say, "I don't know how to fix you." But that's really unfortunately the reality of where we are with management of pelvic pain.

Melanie Cole, MS: Tell us a little bit about symptoms. As gynecologists, obstetricians may be the first ones to see these patients, what do they most often complain about and how is this affecting their life? Do they usually wait until it is affecting their life before they come to see a physician about it? And what are they coming to talk about?

Dr. Radhika Patnam: So, a lot of times it is definitely that they don't come in until it's gone on for a while. And I can't think of the exact number right now. But most of the quotes about something like endometriosis say that patients will see five or six doctors before they get to anyone who can even tell them what's going on.

And the complaints are a lot of different things. Some women will come in with complaints of cramping, discomfort. Others will come in with complaints of burning sensation or feeling like they always have a yeast infection or they always have a urinary tract infection. And then, others will just kind of come in with a vague abdominal discomfort they can't quite describe.

One of the problems with pelvic pain that you always want to think of is that visceral pain or having discomfort sort of in our inside organs is something that often our brain doesn't know how to interpret. And so, it'll take that pain and kind of say, "Well, what do I think it is?" Right? So, you're having right lower quadrant pain, and sometimes in your mind that becomes ovarian pain. And it becomes ovarian pain because that's your brain trying to work with pain to figure out what to do. And so, part of what we're trying to, again, figure out in the clinic is what is the pain? Where is it actually sourcing from? Can we recreate it?

Melanie Cole, MS: This is such an interesting topic. And so many women, as you say, live with it and don't think that there is possibly help. But I'd like you to speak about what you do now at the program. Tell us about some of the different treatment modalities, pain relief options that are used for these various issues.

Dr. Radhika Patnam: So, I think, first and foremost, like I said, is really listening to a patient. So much of what's going on for a lot of women is just that no one has listened to the fact that their pain is real. And I can't say that enough how important that is to kind of make women feel heard, especially when they're having pain, because a lot of people are told, "You had an ultrasound and everything's normal. It's all in your head." The thing I'm always telling patients is just because it's all in your head doesn't make it any less real. Our brain is what is interpreting the entire world around us. And so, if our brain is interpreting information incorrectly, it's still what's creating the world around us. And so, we have to kind of work within that. I'm very encouraging about patients getting to behavioral therapy to help with pain. Management of pain can be really, really difficult. And getting patients to kind of be aware of the fact that having cognitive behavioral therapy as part of their pain management is an incredibly important thing.

And I hope in the future, as this program grows, that we'll be actually able to link up with some CBT providers to make that a little bit easier for access for our patients. Typically, when I see a patient in the office, the first thing I'm going to do is kind of talk through with them how long this pain has been going on. Is this something that's been going on for 15 years versus five, to kind of break down what they've done and what they haven't, get a really clear understanding of the things that they have done for therapy in the past: if it's medications, if it's surgeries, if it's going to be sort of the more non-Western medications, acupuncture, heat therapies, cryotherapies. There's all kinds of things people try to help them when they're in pain. And I want to know what those are because they're pretty important to understand.

I do do a lot of different medications for patients. I do often work with our pelvic floor physical therapy colleagues. Patients who have really tight pelvic floor muscles, whether it's the primary source or the secondary source of their pain, in order to get them that kind of relief. Our office does do pelvic floor injections, and we do sort of the whole gamut of treatments for bladder pain syndrome as well.

Melanie Cole, MS: That leads us very well into the next question, Doctor. Tell us a little bit about the multidisciplinary approach that's important for these patients. As you mentioned, there are many different forms of modalities and many different providers that help with the team.

Dr. Radhika Patnam: And I think that's one of the things that AHN has growing right now. So, for myself, one of the things that I'm constantly working on for this clinic is trying to find other providers who want to work in this space and are interested in these kind of patients. We've been really lucky. We have a really great GI specialist right now who likes dealing with the more complex bowel disorders. And so, I do send a lot of referrals that way. We have some pretty great pain management doctors who do a myriad of different things, both medication-wise and doing more procedural-based treatments. That has been really helpful.

We do have some cognitive behavioral therapy groups in the city that can be helpful depending on where you live, and I try to get patients hooked up with that. We have fantastic physical therapists. I cannot say enough good things about our physical therapy teams that we have. We are lucky in that, you know, as a urogynecologist, physical therapy is incredibly important for all of our urinary incontinence things. But our physical therapists are also really, really great with pelvic pain and helping women understand how to relax, and use their pelvic floors in ways that reduce their pain instead of increasing it.

And we're also really lucky to have a neurosurgeon who has a real interest in pain and does a lot of sort of more of the palliative pain management with procedures as well. So, AHN is really doing a great job of giving us those people so that we can all kind of interact with one another. But it is definitely also something where we're always looking to find one another to help our patients out.

Melanie Cole, MS: Dr. Patnam, are there any new innovations or technologies that can help patients with their pain? And while you're telling us that as we think about pain, which is somewhat subjective, right? So, do you also advise these patients to do any home care lifestyle changes that can help as well?

Dr. Radhika Patnam: It depends on what's going on with them and what kind of pain problems they're having. You know, bladder pain syndrome, for example, unfortunately, rests a lot on diet. And so, that's a big part of it. Understanding your own personal triggers is going to be a massive part of understanding any sort of pain. What are the things that make your pain worse, and how can we help with that to avoid those things or to mitigate those.

 In terms of sort of new innovative treatments, that's a little bit harder. I think there's always new things that are coming out. I think there are new ideas of how we can help. But I can't think of anything specifically that's sort of new and up and coming that's really going to be sort of a smoking gun. And I think that's the thing that I'm always trying to talk to patients about. There's never going to be one thing that fixes a problem. There are a lot of times where we can make women feel a lot better.

But part of what my job is as a pain physician is supporting them as they figure out how to manage their own pain and how they figure out how to live with this new thing that is now part of their life.

Melanie Cole, MS: Well, it sounds like it's a very comprehensive program for complex patients. So, speak to other providers now, Doctor. When should they refer their patients to the AHN Pelvic Pain Program?

Dr. Radhika Patnam: The first thing is that I do not typically like to manage cyclical pain. So, the patients who are having pain with their menstrual periods, that's really going to go more to our endometriosis specialists or even to the gynecologists themselves, if they're not a gynecologist to get their patient to a gynecologist. Because a lot of times, that can be done with hormones and some other things in order to get a sense of things.

I think the biggest part of making sure to get to me is if you don't have a clear answer for things. So, do the basic things. Someone's coming in with burning and itching, make sure they don't have a yeast infection. Make sure they don't have bacterial vaginosis. Make sure they don't have any other vaginal infection of any kind. If they're having recurrent urinary tract infections, kind of investigate with the basics of that. In our postmenopausal women, I can't stress enough how great vaginal estrogen is. There's very few people who are actually contraindicated to use it. You know, even patients who they themselves have had breast cancer, it's actually fairly safe in that population as well. And vaginal estrogen can make a massive difference in the post-menopausal women and even women who feel like they're kind of out of that space. They went through menopause in their 40s and they're 60 now and what's going on, but sometimes it takes that long for that tissue change to happen.

And the other thing it would be to have pretty open and honest discussions with your patients about what's going on. Understanding if they're saying there's pain with intercourse, to ask the questions, "Well, what kind of intercourse and when does it happen? Has it always happened or has it gotten worse?" Just to get a better idea of where it's coming, where it started and where it's going.

Typically, I like to see patients if they have any sort of chronic pelvic pain, and I've kind of defined that as anyone who's had it for six weeks or more. And usually, if we can improve symptoms, I'll send patients back to their primary doctor, whether that's a PCP or their gynecologist.

Melanie Cole, MS: Thank you so much, Doctor, for joining us today and telling us about the program and this complex issue that so many women face. Thank you again. And to learn more or to refer your patient to Dr. Patnam, please call 844-MD-REFER or you can visit find care.ahn.org/RadhikaPatnam. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.