Pelvic pain. A SAFE approach

The efficacy of a multidisciplinary approach for the treatment of chronic pain has been well documented. A recent randomized prospective trial by Peters and co-workers confirmed that multidisciplinary management of chronic pelvic pain resulted in greater improvement in pain severity, increased employment, and improved functional health scores when compared with a traditional medical approach. Unfortunately, many gynecologists do not have the luxury of working in these types of settings. The SAFE approach allows the busy practitioner to evaluate the nonorganic and organic nature of pelvic pain simultaneously to manage these difficult patients better. Initially, it is important to set up regular weekly visits with a prespecified time limit. During these sessions, one should focus on compliance to treatment recommendations. Components of management that have led to pain reduction should be defined. Over time, these short visits can be spaced to bimonthly and monthly intervals; however, this strategy should not be rushed. If possible, the gynecologist should coordinate the care of difficult patients with a physical therapist and mental health provider who can work in tandem on pain reduction strategies and focused psychotherapy. The gynecologist should focus the patient's attention on improvements in pain reports and in functioning at school or work and reinforce the consistent use of medications, even if the recommended dose is low. Small improvements in health beget larger improvements in daily functioning.