A cross-sectional study of traditional Chinese medicine practitioner’s knowledge, treatment strategies and integration of practice of chronic pelvic pain in women

Background Chronic pelvic pain (CPP) in women is persistent, intermittent cyclical and non-cyclical lower abdominal pain, lasting for more than 6 months. Traditional Chinese Medicine (TCM) is a popular treatment option for women’s health conditions, but little is known about how treatment for CPP is delivered by TCM practitioners. The aim of this survey was to explore practitioners understanding and treatment of women with CPP, and how they integrate their management and care into the health care system. Method An online cross-sectional survey of registered TCM practitioners in Australia and New Zealand between May and October 2018. Survey domains included treatment characteristics (e.g. frequency), evaluation of treatment efficacy, referral networks, and sources of information that informed clinical decision making. Results One hundred and twenty-two registered TCM practitioners responded to this survey, 91.7% reported regular treatment of women with CPP. Treatment decisions were most-often guided by a combination of biomedical and TCM diagnosis (77.6%), and once per week was the most common treatment frequency (66.7%) for acupuncture. Meditation (63.7%) and dietary changes (57.8%) were other commonly used approaches to management. The effectiveness of treatment was assessed using multiple approaches, most commonly pain scales, (such as the numeric rating scale) and any change in use of analgesic medications. Limitations to TCM treatment were reported by over three quarters (83.7%) of practitioners, most commonly due to cost (56.5%) and inconvenience (40.2%) rather than safety or lack of efficacy. Sources informing practice were most often Integration within the wider healthcare system was common with over two thirds (67.9%) receiving referrals from health care providers. Conclusion TCM practitioners seeing women with various CPP symptoms, commonly incorporate both traditional and modern diagnostic methods to inform their treatment plan, monitor treatment progress using commonly accepted approaches and measures and often as a part of multidisciplinary healthcare for women with CPP. Supplementary Information The online version contains supplementary material available at 10.1186/s12906-021-03355-6.


Introduction
Chronic pelvic pain (CPP) in women is defined as intermittent and continuous, cyclical and non-cyclical lower abdominal pain, lasting for more than 6 months [1,2]. It is characterised by diverse pain symptoms including dysmenorrhea, dyspareunia, dyschezia and dysuria as well as considerable fatigue and negative impacts on mental health [3,4]. Women with CPP are often encumbered with a substantial, physical, psychological, emotional, social and economic burden [5][6][7][8].
CPP prevalence in women worldwide ranges between 2.1 to 81% [9,10]. In Australia, it is estimated to affect approximately 21.5% of reproductive aged women [10]. CPP represents 3.8% of primary care presentations, [11] and up to 10% of outpatient referrals to gynecologists [12]. Endometriosis and vulvodynia are two of the most commonly diagnosed causes of CPP in women of reproductive age, with estimated lifetime prevalence rates for endometriosis of approximately 11% in Australia [13] and 8-16% for vulvodynia, [14,15]. Other conditions that may cause CPP symptoms include painful bladder syndrome, fibroids, chronic urinary tract infection, irritable bowel syndrome, inflammatory bowel disease and malignancy, as well as injuries related to childbirth, neurological entrapment and psychological and psychosocial factors [1]. CPP, regardless of cause, is significantly associated with an increased risk of psychological morbidity [16] and significantly lowered quality of life [5,8]. Women may be negatively impacted in several aspects of their lives including employment, friendships, sexual and romantic relationships, academic study and social activities [5,8]. Clinical guidelines recommend specific treatments for improving women's functional ability, [17] however many treatments have limited effectiveness for reducing pain symptoms, [18] which is often a primary unmet health care need of women with diagnosed endometriosis [19]. Women with CPP due to endometriosis often report effective pain relief following surgical excision of endometriosis however surgical excision is costly and recurrence rates of pain are high with 50% of women reporting recurrence at 5 years postsurgery [18,20]. Between 50 to 75% of women with CPP report discontinuing pharmaceutical pain management due to adverse side-effects and often explore other forms of treatment including healthcare professions from outside of the dominant biomedicine system [6,21,22].
Traditional, complementary and integrative medicine (TCIM) is used by 51% of women with CPP [23,24]. Traditional Chinese Medicine (TCM) including acupuncture [24,25] and Chinese herbal medicine [25] are popular TCIM treatments for which there is preliminary, but promising evidence of effectiveness for CPP pain reduction [26,27]. However, despite women's self-directed approach to care and utilisation of TCIM, referrals between medical doctors and TCM practitioners in Australia and New Zealand are often low, [28] and impeded by limited interprofessional communication [29]. Part of this may be due to the differences between health care frameworks including the holistic view of the TCM theoretical paradigm and the connected and inseparable body, mind and emotions in contrast to the more Cartesian thinking amongst biomedicine, which tends to view the body as a collection of mechanistic interactions and emphasises mind-body duality [30]. TCM practitioners have historically identified conflict between these two theoretical frameworks, with TCM being "largely incompatible" with the mechanistic framework that underpins biomedicine [31]. Therefore, it is currently unclear what role, if any, biomedical diagnosis and outcome evaluations play when TCM practitioners are treating women with CPP, and how they integrate their treatment as part of the larger, predominantly biomedical healthcare systems in Australia and New Zealand. Given the limited evidence on this topic, this study aims to explore TCM practitioner knowledge and the clinical approach to managing women with CPP and integration of TCM clinical practice in Australia and New Zealand.

Setting
The study presents a cross-sectional survey of TCM practitioners within Australia and New Zealand. Participants were recruited through three professional associations; the Australian Acupuncture and Chinese Medicine Association (AACMA), the Federation of Chinese Medicine and Acupuncture (FCMA), and Acupuncture New Zealand. Registered members of the associations were emailed an invitation to participate between June and September 2018. Interested participants were provided with a participant information sheet, before recruitment commenced, that outlined the anonymity of the survey and implied consent at endsubmission. Reminder invitations were sent via the associations in June, August, and September in 2018. The survey was conducted via web-based QualtricsXM [32] and opened for data collection in May 2018 and closed in October 2018.

Participants
Participants were eligible for inclusion if they were registered with one of the above associations and selfidentified as managing women's health in their clinical practice. Additional inclusion criteria included English language skills and access to an internet connected device to complete the survey.

Survey instrument
The survey was a self-administered questionnaire uploaded into the cloud-based survey administration platform Qualtrics XM [32]. Thirty three items were designed to describe TCM practitioner's practice characteristics and their management of women with CPP (Supplementary File 1). Practice domains included practitioner's understandings and definitions of CPP, sources of clinical information, types of interventions used, treatment patterns, interdisciplinary referrals and communication, methods used to evaluate efficacy and adverse effects, and practitioner perceived barriers to care.
The first item sought information about the proportion of women with CPP attending the practice for treatment. Subsequent items sought information about the practice characteristics including signs and symptoms of women presenting with CPP, the types and frequency of treatments for CPP and associated symptoms, practitioner perceived effectiveness, frequency of adverse effects including negative interactions with pharmaceutical treatments. Frequency of practitioner's review of treatment effects was reported on an eleven-point Likert scale ranging from every week to once per year and/or every menstrual cycle to every third menstrual cycle. Number of treatments required to reduce CPP or associated symptoms was reported on a seven-point Likert scale ranging between 1 and 3 treatments up to more than 20 treatments, and with two options to report 'treatment rarely reduced pain' or 'did not reduce pain'. Further items sought information about interdisciplinary referral networks and sources of information about CPP and treatment decisions. Frequency of interprofessional referrals during the previous eight weeks were reported on a four-point Likert scale ranging from zero to seven or more. Socio demographic characteristics and geographical location of practice were also sought. Multiple response options were available for most items to capture all information. The questionnaire took 15-20 min to complete. The questionnaire was tested for logic and readability by piloting with three Chinese medicine (CM) practitioners and edited in response to their feedback to improve question clarity.

Ethics approval
The study was approved by the Western Sydney Human Research ethics Committee (EC00314) H12527 on the 24th of January 2018 and the Endeavour Human Research Ethics Committee (EC00358) #20180212 on the 12th of February 2018.

Data analyses
Data were exported from Qualtrics into Microsoft 365 Excel (version 16.0) for data cleaning and statistical analysis. Responses from participants that did not treat women but completed the survey were removed. Binary and categorical variables were generated as per the survey questions for descriptive analysis. Descriptive statistics were reported using proportions and percentages. Responses to 'other' were reported narratively.

TCM practitioner socio-demographics
Two thousand four hundred and seventy-four registered practitioners were invited to complete the survey. One hundred twenty-two participants responded and reported regularly consulting with women, of which 111 practitioners (91.7%) reported they regularly treated women with CPP in their clinical practice (overall response rate 4.9%). (Fig. 1) Twenty-one (18.9%) participants reported treating a woman with CPP at least once every day they were in clinic. Most practitioners were women aged over 40 years (n = 53, 47.7%), in clinical practice for over 15 years (n = 52, 16%) and practicing 4-5 days per week (n = 38, 34.2%). (Table 1).

Women's chronic pelvic pain symptoms
Some key symptoms related to CPP, including dysmenorrhoea (n = 58, 52.3%) and pelvic pain related low quality of life or increased absenteeism (n = 37, 33.3%) were regularly treated, however some common CPP symptoms were not often treated including dyspareunia (n = 15, 13.5%) and dyschezia (n = 12, 10.8%). (Table 2). All TCM practitioners reported that at least one in four women with CPP presented an abnormal menstrual pattern according to TCM principles which was defined as an imbalance between yin and yang, temperature irregularities and by stagnation or insufficient life energy or Qi. The severity of pain was mostly assessed by questions during the consultation (n = 72, 64.9%), and about two thirds (n = 67, 60.4%) used a scale to assess the severity of pain and over half (n = 62, 55.8%) asked about the amount of pharmaceutical analgesia frequently used. Over half (n = 62, 55.9%) assessed women presenting with CPP using traditional Chinese medicine characteristics of pulse and tongue. TCM practitioners reported potential pathological causes of CPP in women they saw in clinic as endometriosis (n = 74, 66.7%), fibroids (n = 66, 62.2%), inflammatory bowel disease (n = 63, 53.2%), polycystic ovary syndrome (n = 59, 53.2%), urinary tract infections (n = 59, 53.2%) and structural disorders of the lower back (n = 55, 49.5%). Eighteen participants (16.2%) reported other causes including interstitial cystitis, pudendal neuralgia, adhesions from surgery and due to adverse effects of medically assisted reproductive technologies (ART). Women with CPP were directly referred for biomedical pathology tests 'often' by 13.5%, (n = 15), 'sometimes' by 10.8%, (n = 12), but 'never' by 38.7% (n = 43) of TCM practitioners.

TCM approach to chronic pelvic pain case management
A combination of biomedical and TCM diagnosis most often guided treatment decisions (n = 62, 55.8%), and 17.1% (n = 19) relied only on TCM principles. Sources guiding treatment were most often text-books and lecture notes (n = 38, 34.2%), followed by peer reviewed academic articles (n = 31, 27.9%), updates published online (n = 29, 26.1%) and discussion with clinical peers (n = 25, 22.5%). Other guiding treatment sources included Facebook posts, classic texts and hair tissue analyses of heavy metal concentration reported by seven (6.3%) TCM practitioners.

TCM treatment effectiveness
Over 70% (n = 79, 71.2%) of TCM practitioners reported they perceived their treatment was effective in managing pain associated with CPP, following up to 12 treatments (n = 81, 73.0%). Various approaches for assessing treatment effectiveness were utilized as outlined in Fig. 3. Women's pain was assessed during case consultation and history note taking (n = 59, 53.2%) and measured either using patient-reported pain scales (n = 55, 49.5%) and/or through the type and quantity of analgesic medication needed to control pain (n = 53, 47.7%). TCM diagnostic techniques (including diagnosis of tongue and pulse characteristics) were used by 51 (45.9%) practitioners to evaluate the progress of treatment. Other methods of evaluating efficacy included the use of visual analogue scales and abdominal palpation. The least reported assessment tool for pain was the use of validated instruments (n = 16, 14.8%). Treatment efficacy was reviewed every menstrual cycle month by a quarter of respondents (n = 28, 25.2%).

Treatment limitations and adverse events
Practitioners' perceptions of limitations and barriers to TCM treatment of women with CPP were reported by  Limited evidence of effectiveness for treatment was cited as a barrier to treatment by 27 (24.3%) and adverse effects of treatment we reported by 12.6%, (n = 14) of practitioners. The most reported adverse effects were worsening intensity of pain, or pain occurring at additional menstrual cycle phases, such as mid-cycle. Adverse effects were most often associated with acupuncture treatment (n = 11, 9.9%), including a reported serious adverse event of bowel obstruction.

Discussion
This study provides insight into how TCM practitioners manage women presenting to them with CPP. Pelvic pain symptoms such as dyspareunia was an uncommon presenting symptom despite affecting almost three quarters of women with CPP [33] and may reflect the normalization of pelvic pain associated with the menstrual cycle [34] and/or TCM practitioners overlooking signs and symptoms associated with CPP. Just under two thirds of Australian women with CPP do not exclusively pursue or continue with medical care [10,35]. They are motivated to use self-help measures and (self-perceived) low risk, natural interventions including TCIM practitioners, whose practices are often based on holistic philosophies, and may provide whole person alternatives and adjuncts to Western biomedical management, which is an expressed need of women with CPP [36]. The majority of TCM practitioners provided treatment informed by both biomedical and TCM sources. Most practitioners in this study perceived their treatments were effective however few reported evaluating the efficacy of treatments using validated methods. TCM practitioners in our sample did not commonly use peer reviewed academic articles as part of their clinical practice, similar to previous research showing that clinical trial results do not always change practice for acupuncture practitioners [37,38]. This may be due to practitioners' perceptions that randomised clinical trials are not relevant to acupuncture practice, [39,40]. However, negative attitudes towards acupuncture cited in clinical practice guidelines for CPP, may also distort TCM practitioners' attitudes towards evidence-based practice. Derogatory reference to female users of acupuncture as 'desperate', [1] not only diminishes women with CPP using TCM, it describes a negative prejudice as the quality of evidence was similarly low for some medical treatments as it was for acupuncture, and yet medical users were not described as desperate. A negative prejudice in clinical guidelines may devalue TCM practitioners perceptions of evidence based clinical practice. There are a number of other factors that can impede translation of clinical trial results into community health practices, including financial and time barriers [41], similar to that reported by practitioners in this survey. This is a concern as the total number of treatments given might be an important factor in achievement of therapeutic outcomes [42][43][44], as practitioners may be prevented from delivering optimal 'doses' of acupuncture treatment [45].
Efficacy and safety has been previously demonstrated for acupuncture in the reducing pain associated with endometriosis [46,47] and improving quality of life, [48,49] with these pain improvements being clinically relevant as they exceed the minimally important difference for treatment of pain in women with endometriosis (at least 10 mm on a 100 mm visual analogue scale, or a 20% in absolute pain reduction) [50][51][52]. Whilst over two thirds of practitioners were using scales to assess the severity of women pain on presentation, none reported knowledge of how much reduction constitutes a minimal important clinical effect. The absence of a validated measure of treatment efficacy may reflect TCM lower value of research based knowledge and information over traditional techniques, [53] which is not unique to TCM but is critical in the integration of health services and interprofessional communication of referral networks.
Many practitioners reported non-integration through referral pathways into health care settings. Barriers to interprofessional referrals have been cited as being due to biomedical dominance and a lack of clarity about each other's roles [54][55][56]. Cross-professional education and training about practices, mutual understanding of responsibilities and limitations, and processes including formal correspondence may assist overcoming these barriers, which is important because failures in interprofessional communication are a leading cause of patient harm [29,54,56]. As TCM represents 11% of primary care capability in rural areas of Australia [57] and acupuncturists up to 8.8% of services for women with other reproductive needs, [58] improved integration and shared care could improve safety as well as continuity of care and the healthcare experiences of women with CPP. TCM as part of multidisciplinary clinical care for women with CPP due to endometriosis, has been shown to improve women's self-efficacy by cultivating confidence and resilience, relieving social isolation and improving quality of life [59].

Limitations
Limitations of this research included low response and completion rates which reduce the validity and generalizability of the findings. Reliance on professional associations distribution of the survey limited the opportunity for reminder emails and there were no financial incentives for participants. Women's health is not a recognized specialization for TCM practitioners in Australia or New Zealand, in contrast to other therapies such as physiotherapy, and therefore there is no way of targeting this particular cohort or ascertaining an accurate response rate given the number of eligible practitioners is unknown. Surveys of health practitioners have notoriously low response rates [60] and the response rate, and total number of responses in this survey are in line with previous data collected in the Australian and New Zealand setting [25]. Given these factors the findings are generalizable to the specific sub-group/sub-specialization of TCM practitioners who regularly treat women with CPP. The survey instrument was cross-sectional and designed to explore the subjective, self-reported opinions of TCM practitioners in their clinical approach to women presenting with CPP, and cannot be used to determine trends or changes in practice over time. Additionally, participant recall bias may have limited the accuracy of findings in this survey, however the limited recall period used (previous eight weeks to three months depending on the question) should have minimized the impact of this.

Future research
While there are limitations to this study, future research within this topic is warranted. Further research into the perceived effectiveness of TCM treatment from the perspective of women with CPP requires exploration to identify areas relating to women's self-motivated reasons for TCM use, cost effectiveness, and the experience of care these women encounter. Additionally, investigations into how TCM including acupuncture can fit within the current model of care for women with CPP requires exploration to identify barriers and benefits to interdisciplinary practices including TCM and biomedicine.

Conclusion
Traditional Chinese Medicine practitioners provide treatments within a biomedical framework, informed by traditional practices and perspectives, and form an important part of a multidisciplinary healthcare team when treating women with CPP. The usage of research to guide clinical treatments was uncommon and may represent barriers in translating clinical trials into clinical practice. Continuity of care and safety could be improved by further integration of TCM into mainstream healthcare services which may be facilitated through improved interprofessional communication.
Additional file 1. Survey Tool. edited the tables and figures. All authors read, edited and approved the final manuscript.
Authors' information SA is an adjunct research fellow at NICM Health Research Institute, Western Sydney University and in clinical practice.

Funding
The authors declare funding from the Endeavour College of Natural Health Research Grant Program for funding aspects of this study.

Availability of data and materials
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Declarations
Ethics approval and consent to participate This study was designed according to the Declaration of Helsinki principles and the study was approved by the Western Sydney Human Research ethics Committee (EC00314) H12527 on the 24th of January 2018 and the Endeavour Human Research Ethics Committee (EC00358) #20180212 on the 12th of February 2018. The participant information form informed of potential risks from participation in the survey and that consent was implied through participation and that responses could not be withdrawn due to anonymity of survey.

Consent for publication
Not applicable.