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Lower Quality of Life Among Women With Chronic Pelvic Pain After Pelvic Inflammatory Disease

From the University of Pittsburgh, Pittsburgh, Pennsylvania.

Address reprint requests to: Catherine L. Haggerty, PhD, MPH, University of Pittsburgh, Graduate School of Public Health, 130 DeSoto Street, 513C Parran Hall, Pittsburgh, PA 15261; E-mail: clcst10{at}pitt.edu.

	ABSTRACT

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION APPENDIX A REFERENCES

 
OBJECTIVE: To evaluate the morbidity from chronic pelvic pain after pelvic inflammatory disease (PID).

METHODS: A total of 547 women were studied as part of the PID Evaluation and Clinical Health (PEACH) Study. Chronic pelvic pain was defined as pelvic pain reported at two or more consecutive interviews conducted every 3 to 4 months through 32 months and was graded as mild to moderate (low pain intensity) or moderate to severe (high pain intensity). Mean Medical Outcomes Study Short Form (SF-36) scores at 32 months were compared by chronic pelvic pain categories.

RESULTS: The mean (± standard deviation) physical health composite scores and mental health composite scores from the SF-36 were progressively lower among women with increasing grade of chronic pelvic pain (physical health composite scores: no chronic pelvic pain = 87.3 ±10.7, mild to moderate chronic pelvic pain =79.1 ± 14.6, moderate to severe chronic pelvic pain = 73.6 ± 16.0, P < .01; mental health composite scores: no chronic pelvic pain =78.7 ± 13.6, mild to moderate chronic pelvic pain = 69.1 ± 15.8, moderate to severe chronic pelvic pain = 67.5 ± 17.1, P .01). Individual physical function, bodily pain, general health, vitality, social function, and mental health scores were also significantly lower among women with chronic pelvic pain and by increasing grade of pain intensity.

CONCLUSION: Chronic pelvic pain after PID is associated with reduced physical and mental health.

Chronic pelvic pain can develop after acute pelvic inflammatory disease (PID), the infection and inflammation of the reproductive organs that can follow sexually transmitted lower genital tract infections. Pelvic inflammatory disease is a common condition that affects approximately 8% of women in the United States,¹ and up to one third of women with PID could develop chronic pelvic pain.^2,3

Chronic pelvic pain is a common and disabling condition affecting 15% of women in the United States,⁴ meaning that more than 9 million American women might suffer. Women with chronic pelvic pain report poor general health,⁴ depression,^5–9 decreased energy,⁴ and a higher prevalence of sexual problems, including dyspareunia, loss of interest in sex, postcoital pain, and vaginismus.⁹ Indeed, chronic pelvic pain has also been associated with lower quality of life in the domains of health and functioning, psychological and spiritual well-being, and socioeconomic life to a greater degree than other types of pain.¹⁰

Despite the potential for PID to thus affect quality of life, there are no data on the impact of chronic pelvic pain subsequent to PID on physical and mental health. Furthermore, it is not known whether women with more intense chronic pelvic pain have lower function than women with less severe chronic pelvic pain. We investigated the relationship between chronic pelvic pain and quality of life in the PID Evaluation and Clinical Health (PEACH) Study, a multicenter, randomized, clinical trial among women with mild-to-moderate PID.

	MATERIALS AND METHODS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION APPENDIX A REFERENCES

 
The methods of participant recruitment, data collection, and follow-up have been described in detail elsewhere.^2,11 Briefly, women aged 14–37 years were recruited from emergency departments, obstetrics and gynecology clinics, sexually transmitted disease clinics, and private practices at 13 clinical sites located throughout the eastern, southern, and central regions of the United States between March 1996 and February 1999. Women with clinically suspected PID who gave informed consent were eligible for the PEACH study. Specifically, all women had 1) a history of pelvic discomfort for 30 days or less, 2) findings of pelvic organ tenderness (uterine or adnexal) on bimanual examination, and 3) leukorrhea and/or mucopurulent cervicitis and/or untreated but documented gonococcal or chlamydial cervicitis. Women were randomized to inpatient treatment of intravenous cefoxitin and doxycycline or outpatient treatment consisting of a single intramuscular injection of cefoxitin and oral doxycycline. The University of Pittsburgh Institutional Review Board approved the study.

A total of 831 women were enrolled into the PEACH study. Of these, 547 women (65.8%) with at least two follow-up interviews and a complete 32-month Medical Outcomes Study Short Form survey (SF-36) were included in these analyses. These women were not found to differ by baseline pain, age, PID history, marital status, or education, compared with women who were not included. Those who were included in the analyses were more likely to be nonwhite (79.0% versus 66.6%, P <.01).

Participants were interviewed in person at baseline, 5 days, and 30 days. Study nurses conducted telephone interviews every 3 months in the first year of enrollment and every 4 months thereafter until May 2000. At that point, the rate of follow-up was 85%, with a mean follow-up time of 35 months.

We required data from at least two follow-up telephone interviews to categorize participants as having chronic pelvic pain. Chronic pelvic pain was defined as pelvic pain reported at least twice consecutively on follow-up interviews administered through 32 months. This roughly translates to a 6-month or greater duration of pain, a standard definition of chronic pain. Pelvic pain at each follow-up interview was defined as a positive response to the following question: "Since [date of last contact] have you had lower abdominal pain or discomfort?" If pain was associated with menses, participants were probed to determine whether the pain was different from their usual menstrual discomfort. Based on this definition, 202 (36.9%) participants were classified as having chronic pelvic pain.

Chronic pelvic pain was graded according to the pain scale developed by Von Korff et al.¹² Overall pain intensity scores at 6, 16, and 28 months were calculated as the mean scores for pain at worst, on average, and in the past 24 hours, measured on a Likert scale and multiplied by 10 (range 0–100). High pain intensity scores were defined as maximum scores from the 6-, 16-, and 28-month interviews greater than or equal to 50. We categorized women who reported chronic pelvic pain into those with low pain intensity (mild to moderate chronic pelvic pain) and those with high pain intensity (moderate to severe chronic pelvic pain).

Perceived health and quality of life were measured with the SF-36 at 32 months. The SF-36 is a validated^13–19 and widely used health survey that measures eight health concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, general mental health, social functioning, energy and fatigue, and general health perceptions.²⁰ Components of the SF-36 were coded as proposed by Hays et al²⁰ from the RAND Corporation, whereby responses were recoded for each variable to the same range (from 0 to 100), with higher scores defining more favorable health states. Components of the SF-36 scale were summarized into eight scales that aggregate two to ten questions each by taking the mean, and two summary measures (physical health composite and mental health composite) that aggregate the individual scales by taking the mean.²⁰ Because SF-36 scores were being compared between women with and without chronic pain, physical health composite scores excluding bodily pain were also compared.

The ² test of proportions and analysis of variance were used to compare descriptive characteristics. Mean SF-36 scores were compared among the 5-day, 9-month, 20-month, and 32-month interviews with analysis of variance and the linear test of trend. The SF-36 scores were compared in a similar manner by chronic pelvic pain and graded chronic pelvic pain. Bonferroni pairwise comparisons of the SF-36 scores were calculated between graded chronic pelvic pain groups. Comparisons of the role–physical and role–emotional scores could not be made over follow-up or among women with and without chronic pelvic pain, because all women achieved a maximum score on these domains. These SF-36 components typically exhibit a high ceiling proportion.¹⁹ Thus, comparisons of these scores will not be discussed further. Multivariate linear regressions were used to model the effect of chronic pelvic pain on physical and mental health, adjusting for age, marital status, race, education, site, history of PID, number of prior PID episodes, time to treatment, continued pelvic pain at 30 days, and respective 5-day SF-36 composite score. Mixed models were used to determine the effect of pelvic pain on physical and mental health over time.

	RESULTS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION APPENDIX A REFERENCES

 
The mean age of the PEACH cohort at baseline was 23.4 years. Almost one third of the women (30.2%) had a prior history of PID. The majority of PEACH participants were never married (77.9%), nonwhite (74.7%), and had less than a high school education (38.5%). Of the 202 (36.9%) women with chronic pelvic pain, more than half (60.9%) reported pain that was highly intensive. Women with chronic pelvic pain were less likely to be black and were more likely to report a history of PID, a greater number of prior PID episodes, and continued pelvic pain at 30 days (Table 1). Chronic pelvic pain was associated with older age, marital status, less education, and 3 or more days between PID symptom onset and treatment, although results were nonsignificant. Women with chronic pelvic pain were more likely to live in Providence and less likely to live in Pittsburgh. Chronic pelvic pain was associated with lower physical health composite and mental health composite scores at 5 days postenrollment.

View larger version (16K): [in this window] [in a new window]   Figure 1. Physical and mental health among women with and without chronic pelvic pain (means ± standard deviation are presented). All differences are significant (P = .001). CPP = chronic pelvic pain. Haggerty. Chronic Pelvic Pain Morbidity. Obstet Gynecol 2003.

View larger version (20K): [in this window] [in a new window]   Figure 2. Effect of chronic pelvic pain (CPP) intensity on physical and mental health (means ± standard deviation are presented). All overall and trend comparisons are significant (P = .001). Significant pairwise comparisons: physical function: no chronic pelvic pain vs mild to moderate chronic pelvic pain; no chronic pelvic pain vs moderate to severe chronic pelvic pain; mild to moderate chronic pelvic pain vs moderate to severe chronic pelvic pain. Bodily pain: no chronic pelvic pain vs mild to moderate chronic pelvic pain; no chronic pelvic pain vs moderate to severe chronic pelvic pain; mild to moderate chronic pelvic pain vs moderate to severe chronic pelvic pain. General health: no chronic pelvic pain vs mild to moderate chronic pelvic pain; no chronic pelvic pain vs moderate to severe chronic pelvic pain. Physical health composite: no chronic pelvic pain vs mild to moderate chronic pelvic pain; no chronic pelvic pain vs moderate to severe chronic pelvic pain; mild to moderate chronic pelvic pain vs moderate to severe chronic pelvic pain. Vitality: no chronic pelvic pain vs mild to moderate chronic pelvic pain; no chronic pelvic pain vs moderate to severe chronic pelvic pain. Social function: no chronic pelvic pain vs mild to moderate chronic pelvic pain; no chronic pelvic pain vs moderate to severe chronic pelvic pain. Mental health: no chronic pelvic pain vs mild to moderate chronic pelvic pain; no chronic pelvic pain vs moderate to severe chronic pelvic pain. Mental health composite: no chronic pelvic pain vs mild to moderate chronic pelvic pain; no chronic pelvic pain vs moderate to severe chronic pelvic pain. Haggerty. Chronic Pelvic Pain Morbidity. Obstet Gynecol 2003.

	DISCUSSION

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION APPENDIX A REFERENCES

Among the entire PEACH cohort, SF-36 scores were much lower than those in the general population of women at 5 days but were more similar to population norms at 32 months.^14,19 Women with chronic pelvic pain in the PEACH Study had lower scores for physical functioning, bodily pain, general health, vitality, social functioning, and mental health as compared with women without chronic pelvic pain in the PEACH Study or women of the same age in the general population.¹⁴ Further declines were evident with increasing grade of pain intensity. Women with moderate to severe chronic pelvic pain had 32-month physical functioning scores more comparable to woman aged 55–64 in the general population and had mental health, bodily pain, vitality, and social functioning scores even lower than women aged 55–64 in the general population.¹⁴ Thus, chronic pelvic pain had a dramatic impact on physical and mental health among these young women.

A strength of this study is the generalizability of the results. Women who met generally accepted clinical criteria for mild to moderate PID were enrolled. The primary limitation of the study is the assessment of chronic pelvic pain. Data on endometriosis, dysmenorrhea, or preexisting chronic pelvic pain were not collected. However, the exclusion of women with more than 30 days of pelvic pain reduced the potential for enrollment of women with chronic pelvic pain at baseline. Also, chronic pelvic pain was based on the frequency of interviews at which women reported pain. Most prospective studies of pain evaluate chronicity with self-report at one follow-up interview, disregarding the intermittent nature of chronic pain. To include women with both intermittent and continuous chronic pelvic pain, consistent but not constant pain reports were used to classify chronic pain. No data was available on the intermittency of pain between follow-up interviews. The inclusion of women with less frequent pain in the group with chronic pelvic pain might have biased our results and narrowed differences between groups. Thus, differences in mental and physical health between women with and without chronic pelvic pain might be even larger than those reported.

Although chronic pelvic pain was assessed prospectively, physical and mental health comparisons were cross-sectional. Therefore, we cannot make causal inferences as to the association between chronic pelvic pain and physical and mental health. A cross-sectional analysis was chosen to measure physical and mental health in tandem with chronic pain. Our findings suggest that in addition to bodily pain, women who suffer from chronic pelvic pain concurrently experience reduced physical function, general health, vitality, social functioning, and mental health.

Chronic pelvic pain after an acute episode of PID is common and causes considerable physical and mental anguish. All PEACH Study participants had similar rates of infertility, chronic pelvic pain, recurrent PID, and ectopic pregnancy, whether treated as inpatients or out-patients.² Therefore, treatment was maximized in these women. Additionally, rates of pregnancy were no lower than in the general population.²¹ Thus, in an excellent treatment setting, chronic pelvic pain might be the most morbid and costly sequelae of modern-day PID.

The prevention of chronic pelvic pain after PID would greatly reduce future morbidity. Studies examining the risk factors for chronic pelvic pain after PID are needed. Such investigations could direct intervention studies aimed at chronic pelvic pain prevention among women treated for PID.

	APPENDIX A

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION APPENDIX A REFERENCES

 
The PEACH Study principal investigators include: Susan L. Hendrix, DO, Robert L. Holley, MD, Roberta B. Ness, MD, MPH, John Nichols, Jr, MD, Jeffrey Peipert, MD, Hugh Randall, MD, Diane Schubeck, MD, Steven J. Sondheimer, MD, David E. Soper, MD., Richard L. Sweet, MD, Wayne Trout, MD, and Tamer Yalcinkaya, MD. The authors thank the interviewers who recruited and interviewed study participants: Susan Allen, Audrey Baum, Corina Becker, Debbie Carr, Hope CohenWebb, Amy Cooper, Peg Crowner, Leslie Curll, Jackie Faas, Amanda Farmer, Emily Hoffman, Anne Holdredge, Alice Howell, Susan Kay, Faye Leboeuf, Ingrid Macio, Kathy Martin, Katherine McMahon, Margaret McNamee, Ann Meers, Kim Miller, Andrea Montagno, Joy Mowery, Jan Mitton, Cheryl Myers, Deborah Nelson, Brenda Nobels, Tara Pealer, Emily Pereira, Anne Rideout, Georgia Rothstein, Carol Sams, Tara Schuda, Buffie Schiavoni, Marsha Scott, Jennifer Seckman, Kelly Timbers, Sam Whitaker, Lisa Williams, and Mirza Vincetic.

	Footnotes

 
^* For other members of the PEACH Study, see Appendix A.

Supported by grant HS08358-05 from the Agency for Healthcare Research; and Quality and National Research Service Award 1 F32 HD41294-01 from the National Institute of Child Health and Human Development.

doi:10.1016/S0029-7844(03)00695-1

Received January 7, 2003. Received in revised form April 22, 2003. Accepted June 5, 2003.

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TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION APPENDIX A REFERENCES

 
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