Pain sensitivity is different for women. According to a study published in the British Journal of Anesthesia, “Sex differences in pain: a brief review of clinical and experimental findings,” women have been found to be more sensitive to pain as well as to be more likely to experience chronic pain. While researchers are still working to fully understand why, hormones, the greater nerve densities of women’s bodies, and psychological experience of pain have all been found as contributing factors.
Furthermore, women seem to be more prone to certain pain disorders than men. One of these pain disorders is pelvic pain, specifically pudendal neuralgia. In fact, according to Shalini Shah, M.D. Vice-Chair Dept. of Anesthesiology and Perioperative Care and Enterprise Director of Pain Services at the University of California – Irvine, pelvic pain in general is extremely common among women. Despite this, Dr. Shah says it has also been highly stigmatized.
To help shed light on pelvic pain, specifically pudendal neuralgia, SPR Therapeutics sat down with Dr. Shah to learn more.
SPR: Thanks for talking with us Dr. Shah! Can you tell us a bit about yourself before we dive into pelvic pain?
Dr. Shah: Of course! I completed my Anesthesiology residency at Cornell University in New York City, and then pursued a combined adult-and-pediatric pain fellowship from Harvard University where I was able to study adult pain at the Brigham and Women’s Institute and pediatric pain at Boston Children’s Hospital. I was then recruited to start a pediatric pain program by the University of California – Irvine, which is now one of the busiest pediatric pain programs in the country.
Since my time at UC Irvine, I have served as the Associate Program Director of the Pain Medicine Fellowship, and now Enterprise Director of Pain Services for UCI Health as well as Vice-Chair for the Department of Anesthesiology & Perioperative Care. I am currently President Elect of California Society of Interventional Pain Physicians—which is an organization that advocates for patients suffering in pain.
SPR: You’ve had a diverse career in pain management. It’s interesting that you have specialty focuses in both anesthesia and pain medicine.
Dr. Shah: Typically, most pain physicians have a residency in Anesthesiology. Pain medicine is a natural extension of anesthesia given that anesthesiology focuses on patient comfort and safety throughout the surgical and post-surgical arena. What I found interesting about Pain Medicine is that for the large part, it is not based on algorithms. It is patient-centered in the sense that patients are deeply involved and engaged in the treatment process. Moreover, the field is continuously evolving with newer medications and state of the art medical devices. Some patients need a very conservative treatment early on, while others may prefer a more aggressive approach earlier on. There’s no one to say one is right over the other, and that’s what I love about it. You can make that individual decision and do out of the box thinking without an algorithm, alongside the patients’ preferences. It’s a deeply engaging process.
SPR: Well pain medicine is definitely an exciting field to be in with all the innovation happening over the last few years. So, let’s dive into that a bit more. Have any innovations stood out for you?
Dr. Shah: Yes, the game-changer is peripheral nerve stimulation (PNS). Historically I used to use sacral or spinal cord stimulation on most patients. I like the fact that with the recent addition of devices specifically designed to deliver peripheral nerve stimulation, the entire field of neuromodulation has totally evolved from what it used to be. PNS Systems have become less invasive using leads constructed from wires the size of a human hair that are implanted through a small needle then removed after the treatment is complete. My patients love it, it’s patient-centric. You don’t have a device implanted for the rest of your life.
With pelvic pain, the reason PNS is such a game changer, is because we have a high population of pelvic pain patients in which we’ve either had to do repeated pudendal nerve injections or spinal cord stimulation, but this is something that they wear for 60 days. Low levels of electricity are sent to the targeted nerve to reset the signals. We’ve treated about 10 or so patients with pelvic pain using a 60-day PNS treatment approach, and in all honesty, it partly started off with the idea of “Well let’s see if this works as well as injections or as well as spinal cord stimulation.” And so far, the patients are very happy with it. They love the little easy-to-use remote control and at the end of treatment I simply withdraw the tiny lead.
SPR: Let’s talk a bit more about pudendal neuralgia. It’s probably not exactly well-known.
Dr. Shah: Sure. So, before we even start talking about pudendal neuralgia, I want to touch on something important. There is a highly stigmatized problem in the female community, which is pelvic pain in general. Pain in the pelvis – a lot of people don’t even want to use the word vagina – but whether it’s in the vagina or the rectum or the area in between, it’s painful, burning, stinging. You feel like something is inside that shouldn’t be there. So finally, after most women go to the doctor and then try different therapies, typically they receive a diagnosis from their gynecologist of pudendal neuralgia.
Pudendal neuralgia is a sensory disturbance caused by the pudendal nerve and quite honestly, it’s one of the most difficult to treat pain syndromes likely due to the sensitive area. Typically, what we recommend is a strong multi-disciplinary focus: a combination of medications, physical therapy and pain psychology. These patients seem to get the best results. Sometimes you can do a pudendal nerve injection of steroids which would assist both in the diagnosis of the issue as well as provide some therapeutic relief, but unfortunately, as the steroids wear off, typically the pain recurs sometimes back to the baseline level.
SPR: So, is it a feeling of embarrassment, perhaps from the way society has spoken about the pelvic area in the past?
Dr. Shah: That is definitely part of it. It’s something that’s really more discussed in private support groups or amongst females, in Facebook communities and things like that, but it’s not really widely discussed on TV, magazines or other more public venues.
And with pudendal neuralgia, there can also be a psychological stressor that’s associated with the pain; either a history of sexual trauma or sexual abuse that correlates with pelvic pain. This is another reason people may not be so open to discussing it
How do you say that you can’t sit for long periods of time at work because it hurts? How do you explain why? It’s not really something that you can easily tell your boss.
SPR: Are there any specific age groups or demographics that are more at risk or is it just based on your physical makeup?
Dr. Shah: We have seen young women in their 20s to their 30s. The biggest age demographic is usually in women from 35 to 55 years of age, although I have quite a few patients who are 65 years or older who come in and say they’ve been suffering with this for decades. The other part of what influences the ages of the patients we see is their comfort level with talking about it openly and being comfortable to discuss that it is painful to have sex and painful urination.
SPR: So how do you reach women who may be experiencing this pain?
Dr. Shah: The majority of our patients come to us by way of mouth, or referrals from gynecologists. We have created a strong reputation of building a dynamic and collaborative Pelvic Pain Program at UC Irvine Health which is rooted in the multidisciplinary method. Gynecologists and urogynecologists now understand we are able to effectively treat pelvic pain, so they typically refer to our group and work alongside us.
SPR: Do you think there are women with pelvic pain who are not seeking treatment and likely suffering?
Dr. Shah: Yes! The stigma around pelvic pain is likely keeping a lot of women from seeking treatment. So, while it’s absolutely important to start talking about more in the community, it’s important to get pain physicians more confident in talking about it as well.
SPR: In what way are pain physicians lacking confidence in this area?
Dr. Shah: Historically, treating pelvic pain was often referred to female physicians within a practice. You became the pelvic pain specialist just because you were the only female in the office. Back then, it wasn’t unheard of for a male physician to not even bother trying to understand the condition.
Thankfully things have changed, but I do think that, in general, physicians today still aren’t doing enough questioning when it comes to treating patients with pelvic pain. I think they’re reluctant to ask where in the vagina it hurts, does it hurt with sex, all these very personal questions that may be uncomfortable to ask. The reality is that times are changing, and pain physicians are leading the way in being more responsive to women’s pain. Younger generations are more and more open about health and wellness. As people become more and more confident to bring it up, to talk more openly and more publicly about it, then pelvic pain is something that’s going to show up in your practice more and more, and you’re going to need to be equipped to handle these patients when they come through the door. You’re going to have to know how to ask the right questions, know what questions you should be asking, and get used to talking about otherwise intimate topics.
SPR: It definitely sounds like pelvic pain needs to be talked about more and that there are opportunities to help more women in doing so. What advice would you give to women who may be experiencing pelvic pain?
Dr. Shah: That’s pretty simple to answer. The overarching issues that I see when we treat pelvic pain is, patients have typically given up hope and believe there’s nothing else that can be done; they may have tried several different drugs, had multiple surgeries – you name it, nothing’s helping.
‘I still have pain during urination’ ‘I still can’t sit in the office.’ ‘I still can’t drive for long drives.’
You know, they just have given up hope. I think with that in mind, I’d give two pieces of advice. First, know that there are less-invasive therapies that don’t require surgery. Second, try to talk about pelvic pain more. Stigmas will only go away if people start opening up. It’s going to be scary, but for a lot of women, talking about the pain earlier may also mean finding relief and a less-invasive treatment option faster.
SPR: That is great advice! Well Dr. Shah, thank you so much for talking with us today and sharing your knowledge about pelvic pain and treating pudendal neuralgia. Is there anything else you’d like to leave us with?
Dr. Shah: Just one last thing. Women’s health is still such a stigmatized area in some ways, that I think it’s just so important that we in the field of pain medicine just start getting the word out, start talking about and focusing on more cutting edge options like treating pudendal neuralgia with PNS that do not require any surgery. This is a promising therapy for pelvic pain, and personally, I’d like to see women’s pain discussed more in the mainstream.
SPR: Thank you so much again Dr. Shah! We look forward to seeing you continue to blaze the trail for women in pain medicine.
Dr. Shah: Absolutely! And thank you for letting me have the chance to educate people about pelvic pain. I truly hope that this helps someone come forward and find treatment sooner.
About the SPRINT® PNS System
The SPRINT Peripheral Nerve Stimulation (PNS) System is the only percutaneous PNS device that is cleared for both chronic and acute pain, including post-operative and post-traumatic pain. The SPRINT PNS System leads are implanted by a physician during an outpatient procedure without surgery, incisions, tissue destruction or anesthesia, and are connected to a wearable stimulator that delivers stimulation for up to 60 days of therapy, after which the leads are withdrawn. In multiple studies, the SPRINT system has demonstrated significant and sustained pain relief following the 60-day treatment. Physicians have used the SPRINT system to treat post-amputation pain, inoperable joint pain, lower back pain, complex regional pain syndrome (CRPS), and post-operative pain following joint replacement and surgical reconstruction (partial listing). For additional information regarding safety and efficacy visit www.sprtherapeutics.com.
About SPR Therapeutics, Inc.
SPR Therapeutics, Inc. is a privately-held medical device company headquartered in Cleveland, Ohio, focused on developing, manufacturing and commercializing non-opioid, minimally invasive, treatment options that improve quality of life. The company’s SPRINT technology is the only percutaneous Peripheral Nerve Stimulation (PNS) System cleared to treat both chronic and acute pain. More information can be found at: www.sprtherapeutics.com