Pelvic Pain

It is estimated that 15% of American women suffer from chronic pelvic pain. Amazingly 60% of these women report that the cause of their pain is unknown. Chronic pelvic pain occurs in women who have pain in their pelvic area that has been present for 6 months or longer and is severe enough to affect their daily functioning and relationships. Many women assume that any pelvic pain must be gynecologic in origin but there are many other causes of chronic pelvic pain. When an evaluation fails to point to a definitive cause frustration can result both for the woman and her physicians.

The traditional (or old-fashioned!) model of pain perception was that pain is proportional to the amount of damage to the involved tissues and that symptoms are either physical or mental. The modern theory of pain (called the gate theory) recognizes that perception of pain is much more complex. There are signals transmitted through the nervous system from the body to the brain (where we recognize pain) and from the brain to the affected body part. Thus painful signals are affected by emotional states (for example stress or depression). The gate refers to special cells in the nervous system that regulate how many painful signals are transmitted to the brain. Certain neurotransmitters (chemicals in the nervous system that work like hormones) such as serotonin and endorphins are the chemical messengers that regulate this process.

Pain derived from the abdomen or pelvis becomes even more complicated because the pain from internal organs (such as intestines or uterus) is caused by stretching, distension, chemical irritation or inflammation rather than a direct irritant such as a cut. The pain from internal organs is poorly localized and may be perceived as a burning or aching. The process of figuring out where the pain is coming from is made even more difficult by something called referred pain. This is when pain signals from a particular organ are felt somewhere else because of the specific nerves involved.

When evaluating possible sources of chronic pain physicians have to take a very careful history and this may have to be repeated on more than one occasion. Possible sources of pelvic pain include the reproductive organs, the urinary tract, the gastrointestinal system or the muscles and connective tissue of the abdominal wall and pelvis. Many times the initial cause can be narrowed down by other symptoms that accompany the pain, what makes it is worse and what makes it better. Because pain causes depression like symptoms and depression can worsen pain an investigation into symptoms of depression, stress or other emotional distress is usually started. Based on the history and physical exam findings other diagnostic tests may be recommended.

A list of the specific causes of chronic pelvic pain would be longer than this article! Some common causes include endometriosis, pelvic prolapse, irritable bowel syndrome, chronic constipation, interstitial cystitis (a chronic inflammation of the urinary bladder) and fibromyalgia. Life threatening disorders such as a cancer always need to be considered and excluded. Treatment of each disorder is obviously different however there are a few common treatment modalities. As the pain is chronic the treatments need to be continued indefinitely although changes in life circumstances may dictate a change in treatment. Because pain is modulated by the neurotransmitters that come from the brain and because chronic pain can result in depression the use of low doses of anti-depressant medications can be very helpful. The use of anti-depressant medications does not mean the pain is "all in your head." The medications affect the neurotransmitters that regulate pain processing. In fact it is thought that some chronic pain disorders may be the result of faulty processing of signals in the nervous system. Attention to other factors that can make any pain worse such as lack of sleep, inadequate diet or excessive stress is also important. Many women can benefit from behavioral techniques such as relaxation and behavioral modification to manage their pain.

Diagnosing and managing chronic pelvic pain can be frustrating and difficult for patients and their physicians. However with perseverance most patients can be successfully treated. For more information about pelvic pain the International pelvic pain society has an informative web site at www.pelvicpain.org.