Pain is a complex and multifaceted experience that can be influenced by various factors. Chronic pain, which is defined as pain that persists for more than three months, is a common and debilitating condition that affects millions of people worldwide. Studies have found that women are more likely than men to experience chronic pain. Women are biologically disposed to painful diseases to painful diseases, such as fibromyalgia, endometriosis, interstitial cystitis, vulvodynia, and temporomandibular disorders (TMJ).
While troubling, these statistics are a first step in addressing the systemic issue of women’s pain, for we can only begin treatment if we know there is an issue. At WHCC’s member institutes, researchers are furthering our knowledge about both the incidence of pain among women as well as its treatment.
One of these researchers is Dr. Erin Kelly, a Urogynecologist at the Lois Hole Hospital for Women at the Royal Alexandra Hospital and the Fellowship Program Director for the Female Pelvic Medicine and Reconstructive Surgery program at the University of Alberta. Dr. Kelly’s research interests in chronic pelvic pain management and surgery for pelvic floor disorders are particularly relevant to women’s health. Her work aims to improve the quality of life for women who suffer from these conditions by developing new treatments and improving existing ones.
This interview has been edited for clarity.
WHCC: Could you share the areas of your research about pain awareness?
Dr. Kelly: Shortly after I joined the Chronic Pelvic Pain program at the Lois Hole Hospital in Edmonton, we started work on a project to investigate patients’ attitudes [about] and perceptions of medical cannabis for the treatment of chronic pelvic pain. The results were fascinating. First, there was little to no research on cannabis for the treatment of chronic pelvic pain syndromes, and second, over fifty percent of the patients who participated in our survey were using cannabis as an adjunct to the medical treatment of their chronic pelvic pain. Furthermore, of those women who did not routinely use cannabis to manage their pelvic pain, fifty percent were interested in trying it.
This suggests to me that women are not getting adequate medical management of their pelvic pain through traditional medical therapies, and are having to look on their own, outside of traditional medical care. In this respect, I worry we are failing our chronic pelvic pain patients, by not exploring a broader range of therapeutic options.
This realization prompted us to write an editorial to the Journal of Obstetrics and Gynecology of Canada calling for more openness to the study of medical cannabis use for the management of chronic pelvic pain. Our hope was to bring awareness to the complexity of this pain syndrome, the struggle to find adequate therapeutic modalities to treat it, and to advocate for more studies of medical cannabis to manage chronic pelvic pain.
WHCC: What are some common misconceptions patients have about pain in urogynecological conditions?
Dr. Kelly: I think the most prominent misconception about pain in urogynecological conditions is that surgery is often curative for chronic pelvic pain. I do wish that chronic pain was this simple and that a surgery could indefinitely cure chronic pelvic pain for our patients. Then our patients could quickly move on to a better quality of life and not look back. In rare situations — for instance, with pain that is solely associated with vaginal mesh (noted by clinical findings on examination) — pelvic pain can be improved significantly with surgical excision.
Unfortunately, it is much more common that chronic pelvic pain either does not resolve completely with surgery, or is made worse by surgery. Chronic pelvic pain is complex and multifactorial, and while it can often be well-managed with a multimodal approach, it is rarely ever cured. Good management of chronic pelvic pain requires treating and seeing the whole patient. It requires recognizing the personal and social context in which the patient is suffering.
That is why taking the biopsychosocial approach to managing chronic pelvic pain is most effective. A biopsychosocial approach means involving multidisciplinary clinical teams to not only address the medical management of chronic pain but also the psychosocial aspects as well.
WHCC: What are some challenges you face in managing pain in urogynecological patients?
Dr. Kelly: In our program, our biggest challenge to managing pelvic pain is all of the barriers our patients face to getting the treatment that they need. These barriers range from the stigma surrounding pelvic health disorders to extremely long wait times to access care, to social, economic, and geographical barriers. It is heart-breaking to hear how our patients’ pain has been dismissed or diminished by other healthcare practitioners, and we try to advocate for them on both an interpersonal and societal level, to decrease the stigma and misconceptions around chronic pelvic pain syndromes.
It is frustrating to know how long they wait to see us in the Chronic Pelvic Pain Program, and we are constantly looking at ways to improve our ability to see more patients in consultation. But we only have so much capacity. Often, it is social, economic, and geographical barriers that prevent patients from accessing the healthcare they need to address the psychosocial aspects of their pain. Without addressing these aspects of pain, it is hard — if not impossible — for patients to reach levels of empowerment and self-efficacy as far as their pain.
WHCC: How do you approach educating your patients about pain and its management?
Dr. Kelly: In our Chronic Pelvic Pain Program at the Lois Hole Hospital for Women in Edmonton, we focus on dispelling misconceptions about chronic pelvic pain and providing reliable education. This ranges from individual teaching during clinical visits, to guiding patients to reliable web and social media resources, to structured pain education classes that are facilitated through our program.
This also includes community talks, such as the recent Women’s Health Research Seminar, organized by Women’s Health Collective of Canada and Partners for Women’s Health Research, the aim of which is to raise awareness, educate, and advocate.
WHCC: Are there any recent advancements in pain management that you find promising?
Dr. Kelly: Absolutely! I think as chronic pain providers, we are well aware that chronic pain is a multidimensional, multifaceted experience that cannot only be treated with medicine and surgery. The biopsychosocial model illustrates this perfectly, and for a long time, the treatment of pain has focused on treating biology alone.
As chronic pain practitioners, we have been promoting and advocating for better management of the psychological and sociological aspects of chronic pain. This is why I am very excited about the current research work of my partners, Dr. Annick Poirier and Dr. May Sanaee. Dr. Poirier has helped to establish the Mind-Body Integration program (also known as the Hypnosis program) within our clinic. Hypnosis is a therapeutic technique that aims to create a state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestion. It has been shown to decrease pain and improve quality of life in patients with chronic pain.
Dr. Poirier is investigating the perspectives and attitudes of practitioners and patients towards this initiative using qualitative methods. I believe her results are going to clearly point out the gap in psychosocial aspects of pain that the traditional medical approach fails to address. Her results will have a significant impact on how we manage chronic pelvic pain.
Dr. Sanaee brought the Mindfulness Cognitive Behavioural Therapy course, which she learned from Dr. Lori Brotto at the University of British Columbia, to our program. Cognitive Behavioural Therapy is centered on challenging maladaptive pain-related cognitions, change-oriented psychoeducation, and behavioral interventions. Mindfulness therapy uses an acceptance-based approach. Mindfulness has been increasingly used alongside CBT for a variety of chronic pain conditions. This therapy program has been extremely well-received by our patients, and as practitioners, we are also seeing the benefits. [Dr. Sanaee] plans to study the virtual delivery of this course, with the hope that she can expand the delivery of this therapy to a broader patient group.
I am very excited to see my colleagues, among many others, studying treatments to address the psychosocial aspects of chronic pelvic pain.
WHCC: What do you think is the role of healthcare professionals in advocating for improved pain management practice?
Dr. Kelly: Stigma is the biggest barrier to better care for women with chronic pelvic pain. Women should be taught about their bodies from an early age, so they have the words to bring up their concerns confidently with their healthcare providers. Women should never be made to feel shame or guilt when discussing their pelvic health concerns.
This requires that healthcare providers routinely ask about pelvic floor health, in a supportive and non-judgmental way. Healthcare providers should also have the basic tools to support their patients through diagnosis and treatment. On a broader scale, we need to bravely speak up about our own pelvic health concerns and listen closely to those who are speaking about theirs. We need to advocate for more robust research initiatives, more education, and better access to care for women with pelvic floor disorders so that women can be empowered about their pelvic floor health.
WHCC: In your experience, how does chronic pain affect the quality of life for those with urogynecological conditions?
Dr. Kelly: Chronic pelvic pain is a debilitating condition that can affect every aspect of a woman’s life. Chronic pelvic pain often results in significant impairments in daily functioning, vocational functioning, family dynamics, and intimate relationships. This can lead to financial stress, relationship discord, and a lack of socialization and support. Chronic pelvic pain can be a very isolating and lonely experience.
WHCC: Are there specific goals you hope to achieve in your work in the coming years?
Dr. Kelly: In the coming years, my colleagues and I hope to build a more robust Chronic Pelvic Pain program here in Edmonton, where our patients not only receive medical care for their chronic pelvic pain but where the psychosocial aspects of their pain experience are addressed as well. From a research standpoint, we hope to continue to study the medical, physical, psychological, and sociological aspects of chronic pelvic pain, in the hopes of finding better approaches to treatment of this complex and multifaceted condition.
Finally, we cannot make a significant impact without advocacy. By working with local and national organizations, such as the Women’s Health Collective, we hope to reduce the stigma associated with chronic pelvic pain and to raise the voices of those suffering so that they can be seen and heard.
Earlier in the month, the Alberta Women’s Health Foundation hosted the Women’s Health Collective Canada (WHCC) National Summit in Edmonton. The Summit was presented by the Shoppers Foundation for Women’s Health™ and was the Collective’s first Summit in a post-pandemic era. A recap video can be found here, courtesy of the Royal Alexandra Hospital Foundation.
The Summit, which took place November 20th and 21st, aimed to chart a path for the work that lies ahead seeking equity in and the advancement of women’s health research. The two-day Summit brought together the three WHCC founding members and research partner institutions, the Women’s Health Research Institute, Women and Children’s Health Research Institute, Women’s College Research Institute, and IWK Health, who make up the Partnership for Women’s Health Research Canada (PWHR).
Participants celebrated the work accomplished since the Collective was formed in 2019, sharing their research and latest findings. They also looked to the future, discussing how to systemically advance women’s health research and build a strategy to engage new partners from across Canada. A clip from CTV News Edmonton live from the WHCC Summit is viewable here.