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Recognition and treatment of irritable bowel syndrome among women with chronic pelvic pain
American Journal of Obstetrics and Gynecology (2005) 192, 761–7
www.ajog.org
GENERAL OBSTETRICS AND GYNECOLOGY: GYNECOLOGY
Recognition and treatment of irritable bowel syndrome among women with chronic pelvic pain Rachel E. Williams, PhD,a,* Katherine E. Hartmann, MD, PhD,a,b Robert S. Sandler, MD, MPH,a,c William C. Miller, MD, PhD, MPH,a,c Lucy A. Savitz, MBA, PhD,d John F. Steege, MDb Department of Epidemiology, School of Public Health,a Departments of Obstetrics and Gynecologyb and Medicine,c School of Medicine, Department of Health Policy and Administration, School of Public Health,d University of North Carolina at Chapel Hill, Chapel Hill, NC Received for publication May 15, 2004; revised October 13, 2004; accepted October 29, 2004
KEY WORDS Irritable bowel syndrome Chronic pelvic pain Treatment Epidemiology Diagnosis
Objective: We sought to describe irritable bowel syndrome (IBS) treatment among women with chronic pelvic pain. Study design: We performed a cross-sectional study of new chronic pelvic pain patients between 1993 and 2000 (n = 987). IBS was defined by Rome I criteria. IBS treatment was defined as lower gastrointestinal drugs or referral. Analyses were descriptive and multivariable. Results: IBS occurred in 35% of patients. In the highest quartile of pain, women with IBS were not more likely to have IBS treatment initiated. In the lowest three quarters of pain, women with IBS were 5.08 times more likely to have IBS treatment initiated. IBS was not diagnosed 40% of the time. IBS treatments were not recommended to 67% of patients with IBS. More than 35% of patients were prescribed narcotics. Conclusion: IBS is not consistently diagnosed and treated even in a pelvic pain clinic. Yet, treatment of IBS may reduce the overall abdominal pain of these patients. Ó 2005 Elsevier Inc. All rights reserved.
Chronic pelvic pain is a syndrome that is loosely defined by a long duration of pain in the pelvis. It may originate from any organ system or disease and may have multiple contributing factors that usually do not occur in isolation.1 Chronic pelvic pain affects 12% to
This research was supported, in part, by an unrestricted educational grant from GlaxoSmithKline and by the Sunshine Lady Foundation. * Reprint requests: Rachel E. Williams, PhD, 1200 Willow Dr, Chapel Hill, NC 27517. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.10.634
25% of women at any point in time,1-3 and 33% to 39% of women during their lifetime,1,4 with a higher prevalence found in health care settings than in the general population.1 Women with chronic pelvic pain use 3 times more medications of any type, have 4 times more nongynecologic operations, are 5 times more likely to have a hysterectomy,5 and have reduced quality of life2,6 compared with women without chronic pelvic pain. Approximately one third of women with chronic pelvic pain have irritable bowel syndrome (IBS).3 IBS is a functional gastrointestinal disorder characterized by abdominal pain and bowel symptoms such as bloating,
762 urgency, diarrhea, and constipation. Documentation shows that IBS is associated with gynecologic problems such as endometriosis, dyspareunia, and dysmenorrhea.3,7-10 IBS is most prevalent during menstruating years11-13 and is exacerbated during menstruation.14 Compared with women with only chronic pelvic pain, those with both syndromes are more likely to have screening and diagnostic procedures performed3 and are less likely to have improvement after laparoscopy.10 Few studies have been published on women with IBS and chronic pelvic pain.3,10,15,16 Both IBS and chronic pelvic pain include pain in the abdomen. Therefore, if IBS is treated and symptoms are reduced, it is possible that pelvic pain may also be reduced. Although treatment for IBS is challenging, substantial improvements in symptoms can be achieved. Lower gastrointestinal drugs can be beneficial, such as fiber, laxatives, stool softeners, anticholinergics, and antispasmodics. In addition, antidepressants can improve abdominal pain and diarrhea, as well as reduce depression17 by affecting pain control, gastrointestinal motility, and emotional behavior.18 We sought to determine whether IBS is being recognized and treated among women presenting for chronic pelvic pain. Our objectives were to evaluate whether women with IBS had greater odds of having a treatment plan with a lower gastrointestinal drug or gastroenterology referral compared with women without IBS, whether IBS is being diagnosed correctly when compared with the Rome I criteria, to describe treatment recommendations for women with and without IBS, and to evaluate whether IBS is associated with increasing complexity of treatment.
Material and methods The population of this cross-sectional study is comprised of new patients who entered the Chronic Pelvic Pain Clinic at the University of North Carolina (UNC) between June 10, 1993, and December 11, 2000 (n = 987). Typically, women are referred by their gynecologist or primary care physician within UNC Hospitals or from elsewhere in North Carolina. A few patients come from surrounding states or other countries. Most referrals occur because the patient failed previous treatments, requires additional treatment, or needs a surgical procedure. Data collection was limited to women with self-reported pelvic pain lasting 6 months or longer, although it is possible for a patient to be referred for pelvic pain lasting less than 6 months. The Institutional Review Board approved the use of these clinical data for research purposes. The clinic personnel systematically collected data to aid in patient evaluation and treatment. Patients answered self-administered questionnaires before examination at the clinic, including the Beck Depression
Williams et al Inventory19 (a validated questionnaire for measuring level of depression), McGill Pain Questionnaire20 (a validated questionnaire for measuring pain level), a clinic-specific general information form and a history of abuse survey. One of the small number of physicians who specialize in chronic pelvic pain recorded diagnostic impressions and physical findings at the initial visit. Prior pathology reports were often available. All these data were available throughout the study period, except history of abuse, which was not surveyed after 1998. We completed abstraction of medical charts for 98% (n = 970) of the study population to collect information on prior surgeries, current medications, and treatments recommended after evaluation in the pelvic pain clinic (medications, surgeries, and referrals). We defined IBS by the Rome I criteria that were assessed on the self-administered general information form. IBS is defined by expert established criteria, which have evolved over time, including the Manning criteria, the Rome I criteria, and the Rome II criteria.21 Rome I criteria was used because it could be applied across the entire study period and Rome II criteria could not. According to the Rome I criteria, a positive IBS classification includes at least 3 months of continuous or recurrent symptoms of (1) abdominal pain or discomfort that is relieved with defecation, and/or associated with a change in frequency of stool, and/or associated with a change in consistency of stool; and (2) 2 or more of the following, at least one fourth of occasions or days: altered stool frequency (more than 3 bowel movements each day or less than 3 bowel movements each week), altered stool form (lumpy/hard or loose/watery stool), altered stool passage (straining, urgency, or feeling of incomplete evacuation), passage of mucus, and/or bloating or feeling of abdominal distension.21 Gynecologists recorded the diagnosis of IBS as definite, probable, possible, or none. These diagnoses were based on the physician’s judgment after asking questions about bowel symptoms and evaluating questionnaire responses. We grouped definite and probable diagnoses together to indicate a positive IBS diagnosis. We defined the outcome called ‘‘IBS treatment’’ as having a treatment plan with a recommendation for a lower gastrointestinal drug (anticholinergic/antispasmodic, cholinergic, fiber, laxative, and/or stool softener) and/or a referral to a gastroenterologist. First, we evaluated the initiation/continuation of IBS treatment among all women (n = 970) to see if it was associated with IBS status. Then, we assessed the association of IBS with the initiation of IBS treatment among women who were not taking a lower gastrointestinal drug at the start of the initial examination or were not referred from a gastroenterologist (n = 866). We performed univariate analyses to evaluate outliers for data entry errors and biologic plausibility. We used
Williams et al bivariate analyses to calculate the prevalence of recommended treatments by IBS status, unadjusted odds ratios (ORs), and 95% CIs. We also considered types of treatment recommended, which we grouped as 1 type (any pharmaceutical, any surgery, or any referral), 2 types, or all 3 types of treatment recommended. Each level was grouped as continuation/initiation of IBS treatment compared with no recommendation of IBS treatment. We described the relationship of IBS to complexity of treatment with ORs and 95% CIs calculated from bivariate analyses. We used stratified analyses to identify characteristics that potentially modified the association between IBS and IBS treatment. They were identified by a BreslowDay test of homogeneity with P ! .10 and stratumspecific ORs with greater than 100% difference or stratum-specific ORs in opposite directions of the null. We used bivariate analyses to identify characteristics that potentially confounded the relationship between IBS and IBS treatment. They were identified by calculating the magnitude of effect and strength of association of the covariate-IBS association for all women and the covariate-outcome association for women without IBS. Potential confounders were included in the full model if there was a 10% difference between the MantelHaenszel adjusted OR and the crude IBS-outcome OR. The characteristics that we evaluated as potentially modifying or confounding the association between IBS and IBS treatment included demographics, clinical diagnoses, history of abuse, depression, pain, prior abdominal surgeries, and medications being used at initial visit. Clinical diagnoses included muscular back pain, pelvic floor tension myalgia, endometriosis, pyriformis syndrome, vaginismus, pelvic congestion syndrome, myofascial syndrome, adhesions, adenomyosis, fibroids, urethral syndrome, pelvic relaxation problems, and vestibulitis syndrome. History of abuse included any sexual abuse (adult sexual abuse, child sexual abuse, or rape at any age), adult physical abuse, and physical discipline during childhood. Depression was measured with the Beck Depression Inventory. Pain measurements included number of pain sites, duration of pain, and McGill Pain Score. Prior abdominal surgeries included the prior lysis of adhesions, prior ablation/excision of endometriosis, oophorectomy (bilateral, unilateral, none), prior hysterectomy, prior diagnostic surgery (diagnostic laparoscopy or pain mapping), other prior gynecological procedures (vulvar, vaginal, uterine, ovarian, uterine suspension, laser uterosacral nerve ablation [LUNA]), prior nongynecologic abdominal procedures (bladder, bowel, appendectomy, cholecystectomy, hernia), prior surgery by laparoscopy, prior surgery by laparotomy, prior surgery through vagina, total number of prior abdominal procedures (gynecologic, bladder, bowel, appendectomy, cholecystectomy, hernia), and total number of prior surgeries for ‘‘this’’ pain. Medications
763 being taken at start of initial visit included current antidepressant, current antianxiety/sedative-hypnotic/ anticonvulsant, current hormone replacement (estrogen, hormone replacement therapy), current progestins (progesterone, norethindrone acetate [Aygestin, Wyeth, Madison, NJ], medroxyprogesterone acetate [Provera, Pfizer Inc, New York, NY]), current Lupron (TAP Pharmaceutical Products Inc, Lake Forest, Ill) current oral contraceptives, current narcotic, current nonsteroidal anti-inflammatory drug, and current upper gastrointestinal drug (antacid, antisecretory, H2 blockers). We used multivariate unconditional logistic regression to determine the estimate of effect between IBS and IBS treatment. We started with a full model of all variables identified as potential modifiers or confounders of the IBS-outcome association and used backward elimination to remove 1 variable at a time by the highest P-value until the final reduced model was determined. Characteristics that modified the IBS-outcome association were kept in the final model if the likelihood ratio test resulted in a P ! .10. Characteristics that confounded the IBS-outcome association were kept in the final model if they changed the association between IBS and IBS treatment by greater than 10%.
Results There were 987 women who entered the pelvic pain clinic between 1993 and 2000 and medical chart abstraction was completed for 98% (n = 970). The largest reason for loss was an incomplete or missing medical record. In addition, some women had missing information for specific questions. Among the women with available information, 78% of the women were younger than 40 years, 81% were white, 53% had a college or graduate education, and 37% had an annual household income of $35,000 or greater. Twenty-nine percent of the patients had pain for 4 years or more, 19% had pain in at least 6 sites, and 20% had at least 3 prior surgeries for ‘‘this’’ pain. Most of the women had at least mild depression defined by the Beck Depression Inventory (64%). Of the women we could assess for abuse, many were physically abused as adults (34%), sexually abused as adults (16%), physically disciplined as children (68%), sexually abused as children (36%), or raped at any age (27%) (Table I). Thirty-five percent of the women (n = 336) met the Rome I criteria for IBS. Medical records were not available for all the women, hence our analyses of IBS treatment is based on 970 women. Forty percent (n = 134) of the women with IBS by the Rome I criteria did not receive a diagnosis of IBS from the physician. Sixty-seven percent of the women with IBS defined by Rome I criteria (n = 225) did not have a recommendation for continuation or initiation of a lower gastrointestinal
764
Williams et al
Table I Characteristics of women with chronic pelvic pain by IBS status and recommendation for IBS treatment (lower gastrointestinal drug and/or referral to gastroenterologist)
Characteristic Demographics Age (y) !30 30-39 R40 Race White Black Other Education !High school graduate High school or GED College Income !$20,000 $20,000-$34,999 R$35,000 Pain characteristics McGill Pain score R43 Duration of pain R4 y Number of pain sites R6 Prior surgeries for pain R3 Psychologic factors Depression (BDI R10) Adult physical abuse* Adult sexual abuse* Childhood physical discipline* Child sexual abuse* Rape at any age*
IBS treatment among women with IBS (n = 336)
IBS treatment among women without IBS (n = 634)
All women (n = 970) n (%)
Continuation (n = 72) n (%)
Initiation (n = 39) n (%)
Continuation (n = 54) n (%)
Initiation (n = 33) n (%)
None (n = 547) n (%)
380 (39.4) 368 (38.1) 217 (22.5)
13 (18.1) 30 (41.7) 29 (40.3)
12 (30.8) 19 (48.7) 8 (20.5)
81 (36.0) 83 (36.9) 61 (27.1)
16 (30.2) 24 (45.3) 13 (24.5)
17 (53.1) 9 (28.1) 6 (18.8)
241 (44.3) 203 (37.3) 100 (18.4)
785 (81.5) 149 (15.5) 29 (3.0)
64 (88.9) 6 (8.3) 2 (2.8)
27 (69.2) 8 (20.5) 4 (10.3)
182 (80.9) 38 (16.9) 5 (2.2)
40 (75.5) 10 (18.9) 3 (5.7)
28 (87.5) 4 (12.5) 0 (0.0)
444 (81.8) 83 (15.3) 15 (2.8)
140 (14.5)
8 (11.1)
11 (28.2)
29 (13.0)
7 (13.2)
7 (21.9)
78 (14.4)
307 (31.9)
22 (30.6)
13 (33.3)
63 (28.1)
16 (30.2)
10 (31.3)
183 (33.7)
516 (53.6)
42 (58.3)
15 (38.5)
132 (58.9)
30 (56.6)
15 (46.9)
282 (51.9)
298 (32.9) 246 (27.1) 363 (40.0)
22 (31.4) 20 (28.6) 28 (40.0)
13 (37.1) 9 (25.7) 13 (37.1)
76 (36.0) 49 (23.2) 86 (40.8)
14 (27.5) 14 (27.5) 23 (45.1)
8 (26.7) 12 (40.0) 10 (33.3)
165 (32.4) 142 (27.8) 203 (39.8)
236 (24.5)
25 (34.7)
10 (25.6)
66 (29.3)
14 (26.9)
14 (43.8)
107 (19.7)
264 (28.5)
22 (31.4)
17 (44.7)
74 (34.3)
8 (17.0)
9 (32.1)
134 (25.4)
182 (19.0)
27 (37.5)
9 (23.1)
48 (21.4)
8 (15.4)
3 (9.4)
87 (16.2)
193 (20.2)
19 (26.4)
13 (33.3)
46 (20.8)
13 (25.0)
5 (15.6)
97 (18.0)
605 (64.4) 214 (34.3)
58 (80.6) 18 (42.9)
25 (64.1) 13 (46.4)
163 (74.4) 61 (40.9)
31 (60.8) 10 (30.3)
23 (71.9) 8 (30.8)
305 (57.9) 104 (30.1)
101 (16.4)
7 (17.5)
7 (25.0)
34 (23.3)
5 (16.1)
4 (15.4)
44 (12.7)
430 (67.8)
30 (71.4)
22 (75.9)
98 (65.3)
22 (62.9)
21 (77.8)
237 (67.5)
224 (36.0)
20 (50.0)
11 (37.9)
52 (35.6)
13 (37.1)
15 (55.6)
113 (32.8)
166 (26.6)
18 (42.9)
11 (39.3)
41 (27.9)
7 (21.2)
9 (33.3)
80 (23.1)
None (n = 225) n (%)
GED, General education diploma; BDI, Beck Depression Inventory. * Abuse questionnaire not administered after 1998 (n = 624).
drug or gastroenterology referral. Fifty-nine percent of the women with an IBS diagnosis from the gynecologists at the clinic (n = 115/282) did not have a recommendation for continuation/initiation of a lower gastrointestinal drug or gastroenterology referral. In bivariate analyses, women with IBS had greater odds of having a treatment plan that included continuation/initiation of antidepressants (OR = 1.59, 95%
CI = 1.22-2.07) anticonvulsant/sedative–hypnotic/anxiolytics (OR = 1.68, 95% CI = 1.15-2.45), hormone replacement (OR = 1.53, 95% CI = 1.07-2.18) upper gastrointestinal drugs (OR = 2.63, 95% CI = 1.724.03), lower gastrointestinal drugs (OR = 3.12, 95% CI = 2.22-4.38), or a referral to a gastroenterologist (OR = 2.54, 95% CI = 1.33-4.86). Those with IBS had lower odds of a recommendation to continue/initiate
Williams et al Table II
765
Select treatments recommended by gynecologists for continuation and/or initiation among women with chronic pelvic pain
Recommended treatment Pharmaceutical Antidepressants Narcotic Lower GI drug Hormone replacement Anticonvulsant, sedative–hypnotic, anxiolytic Upper GI drug Oral contraceptive Progestin Lupron Antipsychotic Surgery Any surgery Diagnostic surgery or pain mapping Ablate/excise endometriosis Oophorectomy Lysis of adhesions Hysterectomy Triggerpoint therapy or local block Nongynecologic surgery Other gynecologic surgery Referrals Any referral Physical therapy (referral or home) Psychology/psychiatry Gastroenterology Pain clinic, anesthesiology, or neurology
Women with IBS (n = 336) (%)
Women without IBS (n = 634) (%)
OR (95% CI)
51.5 39.0 28.9 19.4 17.3 16.0 15.8 12.2 4.5 2.1
40.1 36.3 11.5 13.6 11.0 6.8 22.1 10.3 4.9 0.8
1.59 1.12 3.12 1.53 1.68 2.63 0.66 1.22 0.91 2.68
(1.22-2.07)* (0.86-1.47) (2.22-4.38)* (1.07-2.18)* (1.15-2.45)* (1.72-4.03)* (0.47-0.94)* (0.80-1.84) (0.48-1.71) (0.84-8.49)
52.7 34.5 10.4 10.1 9.5 8.9 7.1 2.1 14.9
57.6 33.3 7.6 11.4 11.5 12.5 9.6 2.2 19.6
0.82 1.06 1.42 0.88 0.81 0.69 0.72 0.94 0.72
(0.63-1.07) (0.80-1.40) (0.90-2.24) (0.57-1.35) (0.52-1.25) (0.44-1.07) (0.44-1.18) (0.38-2.36) (0.50-1.03)
55.4 38.7 16.7 6.5 7.1
51.1 36.4 12.9 2.7 6.5
1.19 1.10 1.35 2.54 1.11
(0.91-1.55) (0.84-1.45) (0.93-1.95) (1.33-4.86)* (0.66-1.88)
* Statistically significant association.
oral contraception use (OR = 0.66, 95% CI = 0.470.94). IBS was not associated with recommendations of surgery (OR = 0.82, 95% CI = 0.63-1.07) (Table II). Thirty-three percent of the women with IBS had an initial treatment plan that included a lower gastrointestinal drug or gastroenterology referral. The odds of continuation/initiation of IBS treatment were 3.10 (95% CI = 2.25-4.27) times greater for women with IBS than those without IBS. Multivariable analyses had no meaningful effect on the estimate. Women with no prior IBS treatment (not taking a lower gastrointestinal drug at initial visit and not referred from a gastroenterologist) were similar to all women with respect to demographics, diagnoses, medications, and past surgeries. The odds of women with IBS having initiation of IBS treatment among women with no prior IBS treatment was 3.28 (95% CI = 2.12-5.08) times greater than women without IBS, but this estimate differed across the strata of the McGill Pain Questionnaire. Among those with high pain scores (McGill Pain Score R43, top 24%), IBS was not associated with initiation of IBS treatment (OR = 1.35, 95% CI = 0.642.86). Among those with lower pain scores (McGill
Pain Score !43), IBS was strongly associated with initiation of IBS treatment (OR = 5.08, 95% CI = 2.90-8.90). IBS was not associated with a more complex treatment plan. Ninety-one percent (n = 878) of the study population had ‘‘any pharmaceutical,’’ including drug categories not indicated for pelvic pain or IBS. Women with IBS did not have higher odds of having 1 type of treatment recommended (OR = 0.96, 95% CI = 0.681.35), 2 types of treatment recommended (OR = 0.91, 95% CI = 0.69-1.20) or 3 types of treatment recommended (OR = 1.19, 95% CI = 0.86-1.65). For women with IBS, physicians recommended that 18% of the patients receive only 1 type of treatment, 60% receive 2 types of treatment, and 22% receive all 3 types of treatment. The proportions were similar for women without IBS: 19%, 62%, and 19%, respectively.
Comment One third of the women with chronic pelvic pain have IBS, yet 40% of them are not diagnosed and 67% are
766 not recommended continuation or initiation of treatments that may alleviate IBS symptoms. This indicates that we are missing an opportunity to treat symptoms of IBS, another syndrome with chronic pain in the abdominal region. Because we do not know why these syndromes are associated, if we recognize and treat IBS, pelvic pain may also be reduced. Women with IBS and lower pain severity had higher odds of having IBS treatment recommended compared with those without IBS, yet this was untrue for those with the most pain. This finding suggests that women with IBS and high levels of pain are viewed as having more acute pelvic pain. Hence, the physician may focus on treating the pelvic pain and not the bowel symptoms. In comparison, women in lower pain categories may have treatment recommended for their IBS before initiating other treatments, because they are viewed as less acute. A cross-sectional study design was appropriate because we studied whether women with IBS had a treatment plan that included specific recommendations. Although a cross-sectional study does not allow us to make judgments about causality, we know that the information collected at initial visit was used to make recommendations for treatment and not vice versa. We defined IBS treatment as lower gastrointestinal drugs and/or referral to a gastroenterologist. This definition included drugs that would most likely be prescribed only for bowel symptoms and a referral to a specialist who may aid in IBS treatment. Although antidepressants can be prescribed for IBS symptoms, we did not include them in our IBS treatment definition because we could not determine whether they were prescribed for depression, pain, or IBS. Depression is often associated with chronic pelvic pain. In fact, 64% of our population had mild-to-severe depression according to the Beck Depression Inventory. Therefore, it is not surprising that 44% of our population were recommended continuation/initiation of antidepressants. We could not assign indication of antidepressants with confidence. Gathering information on past drug therapies and referrals is difficult in this population because they are often referred from elsewhere. We did not know if a patient was seeking care from a gastroenterologist, sought care from a gastroenterologist in the past, or previously tried lower gastrointestinal drug therapy that did not reduce symptoms. If this was the situation, these women would be classified as having no recommendation for IBS treatment in our study. This would bias the OR toward the null and reduce the percentage of women with IBS who we classified as having a recommendation for these treatments. Yet, not having information on past treatments does not explain the failure to diagnose IBS. This failure to diagnose IBS may also explain why so many women are not recommended treatments that may alleviate bowel symptoms.
Williams et al Other factors not abstracted that may be considered for future study emerging from this inquiry include: gravitity, method of delivery, family size (number of dependents), care giving burden, and insurance status. Insurance status is important as benefits and copayments vary markedly. Thus, financial and opportunity costs, such as time off from work and family obligations, may inhibit care seeking behavior. Although our population likely represents the extreme end of the spectrum of women with chronic pelvic pain, our findings highlight the need to understand the treatment of IBS in this population. We had a unique opportunity to use data that were systematically collected for 8 years by 4 gynecologists in a clinic setting with validated questionnaires and consensus-established criteria. These aspects of data collection enhance the quality of our data by reducing potential information bias and improving consistency. In addition, it makes it easier to compare our study with other studies that use these measures. We found that among women with chronic pelvic pain, those with IBS are often not diagnosed and recommended treatments that may reduce their symptoms. These findings were identified in a clinic that had a small number of highly specialized physicians who actively asked questions about bowel symptoms. The gynecologists in this tertiary pelvic pain clinic did not consistently make an IBS diagnosis and ensure treatment of IBS in women with chronic pelvic pain. In a more general gynecology office, it is likely that diagnoses and treatment of IBS are even worse. IBS and chronic pelvic pain both affect a large proportion of women and are associated with reduced quality of life2,6,22,23 and increased health care utilization,5,11,23-25 therefore clinicians need to understand what pain management plans work best for these women. Clinicians could benefit from studies of the effect of IBS on health outcomes among women with chronic pelvic pain and studies of treatment efficacy among women with IBS and chronic pelvic pain.
Acknowledgments We would like to thank Anne Shortliffe, RN, for managing the pelvic pain clinic data and Michel Ibrahim, MD, PhD, Rebecca Baker, PhD, Susan Hall, PhD, Dionne Law, PhD, Claire Newbern, PhD, Lynne Sampson, MPH, and Marlene Smurzynski, PhD, for critically reviewing this manuscript.
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GENERAL OBSTETRICS AND GYNECOLOGY: GYNECOLOGY
Recognition and treatment of irritable bowel syndrome among women with chronic pelvic pain Rachel E. Williams, PhD,a,* Katherine E. Hartmann, MD, PhD,a,b Robert S. Sandler, MD, MPH,a,c William C. Miller, MD, PhD, MPH,a,c Lucy A. Savitz, MBA, PhD,d John F. Steege, MDb Department of Epidemiology, School of Public Health,a Departments of Obstetrics and Gynecologyb and Medicine,c School of Medicine, Department of Health Policy and Administration, School of Public Health,d University of North Carolina at Chapel Hill, Chapel Hill, NC Received for publication May 15, 2004; revised October 13, 2004; accepted October 29, 2004
KEY WORDS Irritable bowel syndrome Chronic pelvic pain Treatment Epidemiology Diagnosis
Objective: We sought to describe irritable bowel syndrome (IBS) treatment among women with chronic pelvic pain. Study design: We performed a cross-sectional study of new chronic pelvic pain patients between 1993 and 2000 (n = 987). IBS was defined by Rome I criteria. IBS treatment was defined as lower gastrointestinal drugs or referral. Analyses were descriptive and multivariable. Results: IBS occurred in 35% of patients. In the highest quartile of pain, women with IBS were not more likely to have IBS treatment initiated. In the lowest three quarters of pain, women with IBS were 5.08 times more likely to have IBS treatment initiated. IBS was not diagnosed 40% of the time. IBS treatments were not recommended to 67% of patients with IBS. More than 35% of patients were prescribed narcotics. Conclusion: IBS is not consistently diagnosed and treated even in a pelvic pain clinic. Yet, treatment of IBS may reduce the overall abdominal pain of these patients. Ó 2005 Elsevier Inc. All rights reserved.
Chronic pelvic pain is a syndrome that is loosely defined by a long duration of pain in the pelvis. It may originate from any organ system or disease and may have multiple contributing factors that usually do not occur in isolation.1 Chronic pelvic pain affects 12% to
This research was supported, in part, by an unrestricted educational grant from GlaxoSmithKline and by the Sunshine Lady Foundation. * Reprint requests: Rachel E. Williams, PhD, 1200 Willow Dr, Chapel Hill, NC 27517. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.10.634
25% of women at any point in time,1-3 and 33% to 39% of women during their lifetime,1,4 with a higher prevalence found in health care settings than in the general population.1 Women with chronic pelvic pain use 3 times more medications of any type, have 4 times more nongynecologic operations, are 5 times more likely to have a hysterectomy,5 and have reduced quality of life2,6 compared with women without chronic pelvic pain. Approximately one third of women with chronic pelvic pain have irritable bowel syndrome (IBS).3 IBS is a functional gastrointestinal disorder characterized by abdominal pain and bowel symptoms such as bloating,
762 urgency, diarrhea, and constipation. Documentation shows that IBS is associated with gynecologic problems such as endometriosis, dyspareunia, and dysmenorrhea.3,7-10 IBS is most prevalent during menstruating years11-13 and is exacerbated during menstruation.14 Compared with women with only chronic pelvic pain, those with both syndromes are more likely to have screening and diagnostic procedures performed3 and are less likely to have improvement after laparoscopy.10 Few studies have been published on women with IBS and chronic pelvic pain.3,10,15,16 Both IBS and chronic pelvic pain include pain in the abdomen. Therefore, if IBS is treated and symptoms are reduced, it is possible that pelvic pain may also be reduced. Although treatment for IBS is challenging, substantial improvements in symptoms can be achieved. Lower gastrointestinal drugs can be beneficial, such as fiber, laxatives, stool softeners, anticholinergics, and antispasmodics. In addition, antidepressants can improve abdominal pain and diarrhea, as well as reduce depression17 by affecting pain control, gastrointestinal motility, and emotional behavior.18 We sought to determine whether IBS is being recognized and treated among women presenting for chronic pelvic pain. Our objectives were to evaluate whether women with IBS had greater odds of having a treatment plan with a lower gastrointestinal drug or gastroenterology referral compared with women without IBS, whether IBS is being diagnosed correctly when compared with the Rome I criteria, to describe treatment recommendations for women with and without IBS, and to evaluate whether IBS is associated with increasing complexity of treatment.
Material and methods The population of this cross-sectional study is comprised of new patients who entered the Chronic Pelvic Pain Clinic at the University of North Carolina (UNC) between June 10, 1993, and December 11, 2000 (n = 987). Typically, women are referred by their gynecologist or primary care physician within UNC Hospitals or from elsewhere in North Carolina. A few patients come from surrounding states or other countries. Most referrals occur because the patient failed previous treatments, requires additional treatment, or needs a surgical procedure. Data collection was limited to women with self-reported pelvic pain lasting 6 months or longer, although it is possible for a patient to be referred for pelvic pain lasting less than 6 months. The Institutional Review Board approved the use of these clinical data for research purposes. The clinic personnel systematically collected data to aid in patient evaluation and treatment. Patients answered self-administered questionnaires before examination at the clinic, including the Beck Depression
Williams et al Inventory19 (a validated questionnaire for measuring level of depression), McGill Pain Questionnaire20 (a validated questionnaire for measuring pain level), a clinic-specific general information form and a history of abuse survey. One of the small number of physicians who specialize in chronic pelvic pain recorded diagnostic impressions and physical findings at the initial visit. Prior pathology reports were often available. All these data were available throughout the study period, except history of abuse, which was not surveyed after 1998. We completed abstraction of medical charts for 98% (n = 970) of the study population to collect information on prior surgeries, current medications, and treatments recommended after evaluation in the pelvic pain clinic (medications, surgeries, and referrals). We defined IBS by the Rome I criteria that were assessed on the self-administered general information form. IBS is defined by expert established criteria, which have evolved over time, including the Manning criteria, the Rome I criteria, and the Rome II criteria.21 Rome I criteria was used because it could be applied across the entire study period and Rome II criteria could not. According to the Rome I criteria, a positive IBS classification includes at least 3 months of continuous or recurrent symptoms of (1) abdominal pain or discomfort that is relieved with defecation, and/or associated with a change in frequency of stool, and/or associated with a change in consistency of stool; and (2) 2 or more of the following, at least one fourth of occasions or days: altered stool frequency (more than 3 bowel movements each day or less than 3 bowel movements each week), altered stool form (lumpy/hard or loose/watery stool), altered stool passage (straining, urgency, or feeling of incomplete evacuation), passage of mucus, and/or bloating or feeling of abdominal distension.21 Gynecologists recorded the diagnosis of IBS as definite, probable, possible, or none. These diagnoses were based on the physician’s judgment after asking questions about bowel symptoms and evaluating questionnaire responses. We grouped definite and probable diagnoses together to indicate a positive IBS diagnosis. We defined the outcome called ‘‘IBS treatment’’ as having a treatment plan with a recommendation for a lower gastrointestinal drug (anticholinergic/antispasmodic, cholinergic, fiber, laxative, and/or stool softener) and/or a referral to a gastroenterologist. First, we evaluated the initiation/continuation of IBS treatment among all women (n = 970) to see if it was associated with IBS status. Then, we assessed the association of IBS with the initiation of IBS treatment among women who were not taking a lower gastrointestinal drug at the start of the initial examination or were not referred from a gastroenterologist (n = 866). We performed univariate analyses to evaluate outliers for data entry errors and biologic plausibility. We used
Williams et al bivariate analyses to calculate the prevalence of recommended treatments by IBS status, unadjusted odds ratios (ORs), and 95% CIs. We also considered types of treatment recommended, which we grouped as 1 type (any pharmaceutical, any surgery, or any referral), 2 types, or all 3 types of treatment recommended. Each level was grouped as continuation/initiation of IBS treatment compared with no recommendation of IBS treatment. We described the relationship of IBS to complexity of treatment with ORs and 95% CIs calculated from bivariate analyses. We used stratified analyses to identify characteristics that potentially modified the association between IBS and IBS treatment. They were identified by a BreslowDay test of homogeneity with P ! .10 and stratumspecific ORs with greater than 100% difference or stratum-specific ORs in opposite directions of the null. We used bivariate analyses to identify characteristics that potentially confounded the relationship between IBS and IBS treatment. They were identified by calculating the magnitude of effect and strength of association of the covariate-IBS association for all women and the covariate-outcome association for women without IBS. Potential confounders were included in the full model if there was a 10% difference between the MantelHaenszel adjusted OR and the crude IBS-outcome OR. The characteristics that we evaluated as potentially modifying or confounding the association between IBS and IBS treatment included demographics, clinical diagnoses, history of abuse, depression, pain, prior abdominal surgeries, and medications being used at initial visit. Clinical diagnoses included muscular back pain, pelvic floor tension myalgia, endometriosis, pyriformis syndrome, vaginismus, pelvic congestion syndrome, myofascial syndrome, adhesions, adenomyosis, fibroids, urethral syndrome, pelvic relaxation problems, and vestibulitis syndrome. History of abuse included any sexual abuse (adult sexual abuse, child sexual abuse, or rape at any age), adult physical abuse, and physical discipline during childhood. Depression was measured with the Beck Depression Inventory. Pain measurements included number of pain sites, duration of pain, and McGill Pain Score. Prior abdominal surgeries included the prior lysis of adhesions, prior ablation/excision of endometriosis, oophorectomy (bilateral, unilateral, none), prior hysterectomy, prior diagnostic surgery (diagnostic laparoscopy or pain mapping), other prior gynecological procedures (vulvar, vaginal, uterine, ovarian, uterine suspension, laser uterosacral nerve ablation [LUNA]), prior nongynecologic abdominal procedures (bladder, bowel, appendectomy, cholecystectomy, hernia), prior surgery by laparoscopy, prior surgery by laparotomy, prior surgery through vagina, total number of prior abdominal procedures (gynecologic, bladder, bowel, appendectomy, cholecystectomy, hernia), and total number of prior surgeries for ‘‘this’’ pain. Medications
763 being taken at start of initial visit included current antidepressant, current antianxiety/sedative-hypnotic/ anticonvulsant, current hormone replacement (estrogen, hormone replacement therapy), current progestins (progesterone, norethindrone acetate [Aygestin, Wyeth, Madison, NJ], medroxyprogesterone acetate [Provera, Pfizer Inc, New York, NY]), current Lupron (TAP Pharmaceutical Products Inc, Lake Forest, Ill) current oral contraceptives, current narcotic, current nonsteroidal anti-inflammatory drug, and current upper gastrointestinal drug (antacid, antisecretory, H2 blockers). We used multivariate unconditional logistic regression to determine the estimate of effect between IBS and IBS treatment. We started with a full model of all variables identified as potential modifiers or confounders of the IBS-outcome association and used backward elimination to remove 1 variable at a time by the highest P-value until the final reduced model was determined. Characteristics that modified the IBS-outcome association were kept in the final model if the likelihood ratio test resulted in a P ! .10. Characteristics that confounded the IBS-outcome association were kept in the final model if they changed the association between IBS and IBS treatment by greater than 10%.
Results There were 987 women who entered the pelvic pain clinic between 1993 and 2000 and medical chart abstraction was completed for 98% (n = 970). The largest reason for loss was an incomplete or missing medical record. In addition, some women had missing information for specific questions. Among the women with available information, 78% of the women were younger than 40 years, 81% were white, 53% had a college or graduate education, and 37% had an annual household income of $35,000 or greater. Twenty-nine percent of the patients had pain for 4 years or more, 19% had pain in at least 6 sites, and 20% had at least 3 prior surgeries for ‘‘this’’ pain. Most of the women had at least mild depression defined by the Beck Depression Inventory (64%). Of the women we could assess for abuse, many were physically abused as adults (34%), sexually abused as adults (16%), physically disciplined as children (68%), sexually abused as children (36%), or raped at any age (27%) (Table I). Thirty-five percent of the women (n = 336) met the Rome I criteria for IBS. Medical records were not available for all the women, hence our analyses of IBS treatment is based on 970 women. Forty percent (n = 134) of the women with IBS by the Rome I criteria did not receive a diagnosis of IBS from the physician. Sixty-seven percent of the women with IBS defined by Rome I criteria (n = 225) did not have a recommendation for continuation or initiation of a lower gastrointestinal
764
Williams et al
Table I Characteristics of women with chronic pelvic pain by IBS status and recommendation for IBS treatment (lower gastrointestinal drug and/or referral to gastroenterologist)
Characteristic Demographics Age (y) !30 30-39 R40 Race White Black Other Education !High school graduate High school or GED College Income !$20,000 $20,000-$34,999 R$35,000 Pain characteristics McGill Pain score R43 Duration of pain R4 y Number of pain sites R6 Prior surgeries for pain R3 Psychologic factors Depression (BDI R10) Adult physical abuse* Adult sexual abuse* Childhood physical discipline* Child sexual abuse* Rape at any age*
IBS treatment among women with IBS (n = 336)
IBS treatment among women without IBS (n = 634)
All women (n = 970) n (%)
Continuation (n = 72) n (%)
Initiation (n = 39) n (%)
Continuation (n = 54) n (%)
Initiation (n = 33) n (%)
None (n = 547) n (%)
380 (39.4) 368 (38.1) 217 (22.5)
13 (18.1) 30 (41.7) 29 (40.3)
12 (30.8) 19 (48.7) 8 (20.5)
81 (36.0) 83 (36.9) 61 (27.1)
16 (30.2) 24 (45.3) 13 (24.5)
17 (53.1) 9 (28.1) 6 (18.8)
241 (44.3) 203 (37.3) 100 (18.4)
785 (81.5) 149 (15.5) 29 (3.0)
64 (88.9) 6 (8.3) 2 (2.8)
27 (69.2) 8 (20.5) 4 (10.3)
182 (80.9) 38 (16.9) 5 (2.2)
40 (75.5) 10 (18.9) 3 (5.7)
28 (87.5) 4 (12.5) 0 (0.0)
444 (81.8) 83 (15.3) 15 (2.8)
140 (14.5)
8 (11.1)
11 (28.2)
29 (13.0)
7 (13.2)
7 (21.9)
78 (14.4)
307 (31.9)
22 (30.6)
13 (33.3)
63 (28.1)
16 (30.2)
10 (31.3)
183 (33.7)
516 (53.6)
42 (58.3)
15 (38.5)
132 (58.9)
30 (56.6)
15 (46.9)
282 (51.9)
298 (32.9) 246 (27.1) 363 (40.0)
22 (31.4) 20 (28.6) 28 (40.0)
13 (37.1) 9 (25.7) 13 (37.1)
76 (36.0) 49 (23.2) 86 (40.8)
14 (27.5) 14 (27.5) 23 (45.1)
8 (26.7) 12 (40.0) 10 (33.3)
165 (32.4) 142 (27.8) 203 (39.8)
236 (24.5)
25 (34.7)
10 (25.6)
66 (29.3)
14 (26.9)
14 (43.8)
107 (19.7)
264 (28.5)
22 (31.4)
17 (44.7)
74 (34.3)
8 (17.0)
9 (32.1)
134 (25.4)
182 (19.0)
27 (37.5)
9 (23.1)
48 (21.4)
8 (15.4)
3 (9.4)
87 (16.2)
193 (20.2)
19 (26.4)
13 (33.3)
46 (20.8)
13 (25.0)
5 (15.6)
97 (18.0)
605 (64.4) 214 (34.3)
58 (80.6) 18 (42.9)
25 (64.1) 13 (46.4)
163 (74.4) 61 (40.9)
31 (60.8) 10 (30.3)
23 (71.9) 8 (30.8)
305 (57.9) 104 (30.1)
101 (16.4)
7 (17.5)
7 (25.0)
34 (23.3)
5 (16.1)
4 (15.4)
44 (12.7)
430 (67.8)
30 (71.4)
22 (75.9)
98 (65.3)
22 (62.9)
21 (77.8)
237 (67.5)
224 (36.0)
20 (50.0)
11 (37.9)
52 (35.6)
13 (37.1)
15 (55.6)
113 (32.8)
166 (26.6)
18 (42.9)
11 (39.3)
41 (27.9)
7 (21.2)
9 (33.3)
80 (23.1)
None (n = 225) n (%)
GED, General education diploma; BDI, Beck Depression Inventory. * Abuse questionnaire not administered after 1998 (n = 624).
drug or gastroenterology referral. Fifty-nine percent of the women with an IBS diagnosis from the gynecologists at the clinic (n = 115/282) did not have a recommendation for continuation/initiation of a lower gastrointestinal drug or gastroenterology referral. In bivariate analyses, women with IBS had greater odds of having a treatment plan that included continuation/initiation of antidepressants (OR = 1.59, 95%
CI = 1.22-2.07) anticonvulsant/sedative–hypnotic/anxiolytics (OR = 1.68, 95% CI = 1.15-2.45), hormone replacement (OR = 1.53, 95% CI = 1.07-2.18) upper gastrointestinal drugs (OR = 2.63, 95% CI = 1.724.03), lower gastrointestinal drugs (OR = 3.12, 95% CI = 2.22-4.38), or a referral to a gastroenterologist (OR = 2.54, 95% CI = 1.33-4.86). Those with IBS had lower odds of a recommendation to continue/initiate
Williams et al Table II
765
Select treatments recommended by gynecologists for continuation and/or initiation among women with chronic pelvic pain
Recommended treatment Pharmaceutical Antidepressants Narcotic Lower GI drug Hormone replacement Anticonvulsant, sedative–hypnotic, anxiolytic Upper GI drug Oral contraceptive Progestin Lupron Antipsychotic Surgery Any surgery Diagnostic surgery or pain mapping Ablate/excise endometriosis Oophorectomy Lysis of adhesions Hysterectomy Triggerpoint therapy or local block Nongynecologic surgery Other gynecologic surgery Referrals Any referral Physical therapy (referral or home) Psychology/psychiatry Gastroenterology Pain clinic, anesthesiology, or neurology
Women with IBS (n = 336) (%)
Women without IBS (n = 634) (%)
OR (95% CI)
51.5 39.0 28.9 19.4 17.3 16.0 15.8 12.2 4.5 2.1
40.1 36.3 11.5 13.6 11.0 6.8 22.1 10.3 4.9 0.8
1.59 1.12 3.12 1.53 1.68 2.63 0.66 1.22 0.91 2.68
(1.22-2.07)* (0.86-1.47) (2.22-4.38)* (1.07-2.18)* (1.15-2.45)* (1.72-4.03)* (0.47-0.94)* (0.80-1.84) (0.48-1.71) (0.84-8.49)
52.7 34.5 10.4 10.1 9.5 8.9 7.1 2.1 14.9
57.6 33.3 7.6 11.4 11.5 12.5 9.6 2.2 19.6
0.82 1.06 1.42 0.88 0.81 0.69 0.72 0.94 0.72
(0.63-1.07) (0.80-1.40) (0.90-2.24) (0.57-1.35) (0.52-1.25) (0.44-1.07) (0.44-1.18) (0.38-2.36) (0.50-1.03)
55.4 38.7 16.7 6.5 7.1
51.1 36.4 12.9 2.7 6.5
1.19 1.10 1.35 2.54 1.11
(0.91-1.55) (0.84-1.45) (0.93-1.95) (1.33-4.86)* (0.66-1.88)
* Statistically significant association.
oral contraception use (OR = 0.66, 95% CI = 0.470.94). IBS was not associated with recommendations of surgery (OR = 0.82, 95% CI = 0.63-1.07) (Table II). Thirty-three percent of the women with IBS had an initial treatment plan that included a lower gastrointestinal drug or gastroenterology referral. The odds of continuation/initiation of IBS treatment were 3.10 (95% CI = 2.25-4.27) times greater for women with IBS than those without IBS. Multivariable analyses had no meaningful effect on the estimate. Women with no prior IBS treatment (not taking a lower gastrointestinal drug at initial visit and not referred from a gastroenterologist) were similar to all women with respect to demographics, diagnoses, medications, and past surgeries. The odds of women with IBS having initiation of IBS treatment among women with no prior IBS treatment was 3.28 (95% CI = 2.12-5.08) times greater than women without IBS, but this estimate differed across the strata of the McGill Pain Questionnaire. Among those with high pain scores (McGill Pain Score R43, top 24%), IBS was not associated with initiation of IBS treatment (OR = 1.35, 95% CI = 0.642.86). Among those with lower pain scores (McGill
Pain Score !43), IBS was strongly associated with initiation of IBS treatment (OR = 5.08, 95% CI = 2.90-8.90). IBS was not associated with a more complex treatment plan. Ninety-one percent (n = 878) of the study population had ‘‘any pharmaceutical,’’ including drug categories not indicated for pelvic pain or IBS. Women with IBS did not have higher odds of having 1 type of treatment recommended (OR = 0.96, 95% CI = 0.681.35), 2 types of treatment recommended (OR = 0.91, 95% CI = 0.69-1.20) or 3 types of treatment recommended (OR = 1.19, 95% CI = 0.86-1.65). For women with IBS, physicians recommended that 18% of the patients receive only 1 type of treatment, 60% receive 2 types of treatment, and 22% receive all 3 types of treatment. The proportions were similar for women without IBS: 19%, 62%, and 19%, respectively.
Comment One third of the women with chronic pelvic pain have IBS, yet 40% of them are not diagnosed and 67% are
766 not recommended continuation or initiation of treatments that may alleviate IBS symptoms. This indicates that we are missing an opportunity to treat symptoms of IBS, another syndrome with chronic pain in the abdominal region. Because we do not know why these syndromes are associated, if we recognize and treat IBS, pelvic pain may also be reduced. Women with IBS and lower pain severity had higher odds of having IBS treatment recommended compared with those without IBS, yet this was untrue for those with the most pain. This finding suggests that women with IBS and high levels of pain are viewed as having more acute pelvic pain. Hence, the physician may focus on treating the pelvic pain and not the bowel symptoms. In comparison, women in lower pain categories may have treatment recommended for their IBS before initiating other treatments, because they are viewed as less acute. A cross-sectional study design was appropriate because we studied whether women with IBS had a treatment plan that included specific recommendations. Although a cross-sectional study does not allow us to make judgments about causality, we know that the information collected at initial visit was used to make recommendations for treatment and not vice versa. We defined IBS treatment as lower gastrointestinal drugs and/or referral to a gastroenterologist. This definition included drugs that would most likely be prescribed only for bowel symptoms and a referral to a specialist who may aid in IBS treatment. Although antidepressants can be prescribed for IBS symptoms, we did not include them in our IBS treatment definition because we could not determine whether they were prescribed for depression, pain, or IBS. Depression is often associated with chronic pelvic pain. In fact, 64% of our population had mild-to-severe depression according to the Beck Depression Inventory. Therefore, it is not surprising that 44% of our population were recommended continuation/initiation of antidepressants. We could not assign indication of antidepressants with confidence. Gathering information on past drug therapies and referrals is difficult in this population because they are often referred from elsewhere. We did not know if a patient was seeking care from a gastroenterologist, sought care from a gastroenterologist in the past, or previously tried lower gastrointestinal drug therapy that did not reduce symptoms. If this was the situation, these women would be classified as having no recommendation for IBS treatment in our study. This would bias the OR toward the null and reduce the percentage of women with IBS who we classified as having a recommendation for these treatments. Yet, not having information on past treatments does not explain the failure to diagnose IBS. This failure to diagnose IBS may also explain why so many women are not recommended treatments that may alleviate bowel symptoms.
Williams et al Other factors not abstracted that may be considered for future study emerging from this inquiry include: gravitity, method of delivery, family size (number of dependents), care giving burden, and insurance status. Insurance status is important as benefits and copayments vary markedly. Thus, financial and opportunity costs, such as time off from work and family obligations, may inhibit care seeking behavior. Although our population likely represents the extreme end of the spectrum of women with chronic pelvic pain, our findings highlight the need to understand the treatment of IBS in this population. We had a unique opportunity to use data that were systematically collected for 8 years by 4 gynecologists in a clinic setting with validated questionnaires and consensus-established criteria. These aspects of data collection enhance the quality of our data by reducing potential information bias and improving consistency. In addition, it makes it easier to compare our study with other studies that use these measures. We found that among women with chronic pelvic pain, those with IBS are often not diagnosed and recommended treatments that may reduce their symptoms. These findings were identified in a clinic that had a small number of highly specialized physicians who actively asked questions about bowel symptoms. The gynecologists in this tertiary pelvic pain clinic did not consistently make an IBS diagnosis and ensure treatment of IBS in women with chronic pelvic pain. In a more general gynecology office, it is likely that diagnoses and treatment of IBS are even worse. IBS and chronic pelvic pain both affect a large proportion of women and are associated with reduced quality of life2,6,22,23 and increased health care utilization,5,11,23-25 therefore clinicians need to understand what pain management plans work best for these women. Clinicians could benefit from studies of the effect of IBS on health outcomes among women with chronic pelvic pain and studies of treatment efficacy among women with IBS and chronic pelvic pain.
Acknowledgments We would like to thank Anne Shortliffe, RN, for managing the pelvic pain clinic data and Michel Ibrahim, MD, PhD, Rebecca Baker, PhD, Susan Hall, PhD, Dionne Law, PhD, Claire Newbern, PhD, Lynne Sampson, MPH, and Marlene Smurzynski, PhD, for critically reviewing this manuscript.
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