Background: Chronic pelvic pain (CPP) affects up to 15% of women in the United States. The endocannabinoid system is a potential pharmacological target for pelvic pain as cannabinoid receptors are highly expressed in the uterus and other nonreproductive tissues. We hypothesize that cannabis use is common for self-management of CPP, and our primary objective was to determine the prevalence of cannabis use in this population. Materials and Methods: A cross-sectional survey of women with pelvic and perineal pain, dyspareunia, or endometriosis was performed between March and August 2019. Subjects were recruited in an outpatient gynecology office. An anonymous, confidential, electronic survey was performed using a tablet. Statistical analysis was performed using JMP (SAS, Cary, NC). Results: A total of 240 patients were approached, with 113 responses (47.1% response rate). There were 26 patients who used cannabis (23%). The majority used at least once per week (n = 18, 72%). Most users (n = 24, 96%) reported improvement in symptoms, including pain, cramping, muscle spasms, anxiety, depression, sleep disturbances, libido, and irritability. Over one-third (35%) stated that cannabis use decreased the number of phone calls or messages sent to their provider, and 39% reported decreased number of clinical visits. Side effects, including dry mouth, sleepiness, and feeling “high,” were reported by 84% (n = 21). Conclusions: Almost one-quarter of patients with CPP report regular use of cannabis as an adjunct to their prescribed therapy. Although side effects are common, most users report improvement in symptoms. Our study highlights the potential of cannabis as a therapeutic option for patients with CPP.

Introduction: Endometriosis is a condition that leads to a chronic inflammatory state, which has been associated with pelvic pain and infertility. Ovarian endometriomas are commonly treated via laparoscopic cystectomy; however, there is some debate on the degree of ovarian damage after cystectomy. The aim of this systematic review and meta-analysis is to conduct a thorough assessment of postoperative anti-Müllerian hormone levels, a marker of ovarian reserve, after laparoscopic cystectomy for endometriomas. Methods: We conducted a search of PubMed, EMBASE, Web of Science, Google Scholar, and Science Direct from inception to March 31, 2024. We included randomized and non-randomized studies that assessed pre- and postoperative anti-Müllerian hormone levels after ovarian cystectomy for endometriomas. Outcomes of interest included the differences in anti-Müllerian hormone levels assessed within 1 month prior to surgery and up to 18 months postoperatively. These outcomes were categorized as short term (up to 6 weeks), medium term (7 weeks to 6 months), and long term (6 months to 18 months). Randomized and observational studies were pooled together for analysis as only the intervention arm from the randomized trials was included in the meta-analysis. Continuous variables were extracted as means and standard deviations to produce a pooled weighted mean difference with 95% confidence intervals were calculated using a random-effects model. Results: Of the 2,396 articles identified, 30 studies were included. Primary outcomes showed a statistically significant (p < 0.001) decrease in anti-Müllerian hormone in the postoperative short-term period (−1.39 ng/mL, 95% CI: −2.01 to −0.76), medium-term period (−1.13 ng/mL [95% CI: −1.4 to −0.87]), and long-term period (−2.12 ng/mL [95% CI: −2.61 to −1.63]). There was no significant difference when comparing anti-Müllerian hormone levels in the short-term versus long-term period across all groups. There was no significant difference when comparing long-term unilateral and bilateral cystectomies on anti-Müllerian hormone levels postoperatively. Conclusions: This systematic review and meta-analysis highlights that there is a decline in serum AMH levels following laparoscopic cystectomy for endometriomas, suggesting a potential adverse impact on ovarian reserve. This outcome emphasizes the need to incorporate discussions about the implications of surgery on fertility into preoperative counseling.

The laparoscopic, or “straight-stick” approach to hysterectomy accounts for ∼30% of hysterectomies performed. Enhanced magnification and visualization, decreased blood loss, and fewer complications have made laparoscopic hysterectomy a preferred approach and the modality recommended by the American College of Obstetricians and Gynecologists and the American Association of Gynecologic Laparoscopists when vaginal hysterectomy is not possible. Laparoscopic hysterectomy is ideal for managing fibroids, adnexal masses, and endometriosis by providing excellent visualization of the pelvis while offering the benefits of minimally invasive surgery. Large pathologies, such as fibroids or adnexal masses, can be navigated safely using an angled laparoscope. In patients undergoing surgery for pelvic pain, laparoscopy allows the surgeon to inspect the abdomen fully to determine if anatomical abnormalities or pathology are present. The laparoscopic approach is useful for patients who desire supracervical hysterectomy and for those having concomitant pelvic support procedures such as sacrocolpopexy. Advantages of laparoscopic hysterectomy include the ability to allow same-day discharge with no increase in intraoperative or postoperative complications, readmission rates, or 30-day morbidity, compared with patients admitted to the hospital. Patients are able to return to normal activities sooner and experience decreased postoperative pain, compared to patients who undergo abdominal hysterectomy. Shorter hospitalization and decreased complications have also enabled the laparoscopic approach to become more cost-effective than the abdominal approach. To facilitate a safe and effective laparoscopic hysterectomy regardless of surgical complexity, the surgeon must be comfortable with adhesiolysis, retroperiteoneal dissection, and suturing. There are several limitations to laparoscopy, including numerous prior surgeries, extensive pathology, comorbidities, and concern for malignancy. In these cases, an alternative route to hysterectomy may be preferred. Many of these challenges may be overcome with alternative entry points, modifications to trocar placement, an angled lens, and appropriate instrument selection. Surgeons who perform laparoscopic hysterectomy must anticipate potential concerns and consider patient-specific characteristics carefully when choosing this route of surgery. Surgeon skillset and expertise is essential to performance of straight-stick hysterectomy. (J GYNECOL SURG 20XX:000)

Objective: The aim of this study was to highlight the safety of OnabotulinumtoxinA (BTA) injections, with or without concurrent pudendal nerve block, in treating women with myofascial pelvic pain (MFPP). Design: This was a retrospective cohort study. Setting: The review was conducted in a tertiary care academic center. Participants/Materials: We conducted a chart review of patients who were diagnosed with MFPP and treated with BTA with or without pudendal nerve block between January 2010 and February 2022. Methods: BTA was injected transvaginally into the pelvic floor muscle group. The primary outcomes were adverse events after BTA injections, and the secondary outcome was the effect of concomitant pudendal nerve block at the time of BTA injections. Results: The cohort included 182 patients; 103 (56.6%) received BTA injections with pudendal nerve block, and 79 (43.4%) received BTA alone. There were no significant demographic differences between the two groups. Post-treatment complications of BTA administration included worsening of pelvic pain (11.5%), constipation (6.6%), urinary tract infection (2.7%), urinary retention (3.8%), and fecal incontinence (2.7%). No statistical difference was noted in the number of phone calls, patient-initiated electronic messages, emergency room visits, or clinic visits for both groups within 30 days post-treatment. The mean number of total injections was 1.6 in the BTA-only group and 1.7 in the BTA with pudendal block group (p = 0.421). Median time to re-intervention with a second BTA injection was 6.0 months; 5.6 months in the BTA with pudendal block group; and 6.8 months in the BTA-only group, p = 0.46. There were 63 re-intervention events after BTA injections. Limitations: Limitations of our study include the retrospective design making it vulnerable to missing or incomplete data available for review. Conclusion: OnabotulinumtoxinA is beneficial in treating women with MFPP; with a duration of therapeutic effect of approximately 6 months. The use of a concurrent pudendal nerve block did not impact clinical outcomes.