What is chronic pelvic pain?
Chronic pelvic pain is defined as cyclical or non-cyclical pain below the umbilicus of duration of more than 6 months.
This article provides information only on gynaecological causes of pelvic pain, however the links for further information on other causes are provided at the end.
How common is it?
Approximately one in four patients attending gynaecology clinics presents with pelvic pain. Overall 4 women in 100 suffer from these problems. This condition is equally frequent as asthma or back pain (Kroon, Reginald, 2005).
What are the causes of gynaecological pelvic pain?
Adhesions are scarring inside the pelvis. It occurs typically after operations in the lower abdomen, but can also be a consequence of endometriosis or pelvic inflammatory disease (see below). Organs are “stuck” together and limited in free movement, which can cause pain. Treatment for this condition is very limited as any further surgery only increases this scarring.
Endometrium is the lining of the womb and undergoes cyclical shedding with small bleeding, otherwise known as periods. When this lining starts to grow outside the womb (endometriosis), i.e. inside the pelvis or in the ovary, it also undergoes those changes and bleeds regularly. This blood however does not leave the body and can cause pain.
3. Pelvic inflammatory disease (PID)
An episode of pelvic infection is in 20% followed by chronic pelvic pain and this number rises with every further episode of PID (Kroon, Reg, 2005). The mechanism is similar to adhesions as infection and pus produces scarring inside the pelvis limiting the organs in free movement.
Non-gynaecological causes of pelvic pain encompass urinary or bowel problems, such as irritable bowel syndrome (IBS). These are typically not related to the menstrual cycle.
Your doctor will take a careful history to establish the affect of your cycle and sexual life on the pain. This gives indications what next investigation would be appropriate.
Transvaginal ultrasound can identify wide range of conditions, such as chronic pelvic inflammatory disease, ovarian cysts, substantial adhesions etc. It is however only black and white image of the real structures and some subtle pathology cannot be identified.
2. Diagnostic laparoscopy
It is a keyhole surgery done to oversee the abdominal cavity and identify under direct vision any causes of pain. It is effective in the subtle problems, which cannot be identified on the ultrasound or other imaging methods. In some cases the treatment can be given at the same time (for example burning spots of endometriosis).
Depending on a condition and its presumed cause doctors use medication or surgery. Apart from painkillers medication is typically represented by pills with hormones to temper with the periods, typically when pain is related to the cycle in some way. Operation can be sometimes indicated to remove ovarian cyst or burn spots of endometriosis.
When investigations fail to show any pathology that can be treated it is often suggested that the pain is “psychological”. That is the case for approximately 60% of women with chronic pelvic pain (Cheong & Stones, 2006). Sometimes the diagnosis is known, however the treatment does not cure it and patients still suffer form a certain degree of pain. The role of human psyche in perception of pain seems to be equally important as the physical cause of the pain.
It was shown in research that the amount of pain is directly related to the patient’s beliefs about pain, her cultural and social background.
There are certain “mind sets” which are known to make the pain physically worse. Patients think about the pain all the time, they feel having no control over it and fear it will be getting only worse. This is called catastrophising. It has been shown in research that such patients describe increase levels of pain and they are less likely to recover from their chronic condition.
Trying to avoid the pain women would stop engaging with any activity that might cause the pain. Instead of facing the pain on intercourse and trying new ways of managing it in the marital life, woman would cease in sexual activities totally. Something that started as a pain ends as a life-limiting condition with all the impact on personal and professional life.
What can be done about the perception of pain?
Your role in the pain management is very important. It can be however overwhelming to try dealing with it alone.
NHS currently funds CBT (cognitive behavioral therapy) which challenges client’s thoughts and changes the pattern of the chain “thought – emotion – pain”. The referral however depends on GP and may take upto 18 months. Other option is chosing private counselling, which gives a wider range of psychotherpies to chose from. It also gives you the choice of counsellor you trust.
Within the psychosomatic medicine funded by NHS there is Royal London Hospital for Integrated Medicine in London where team of female doctors run Women’s clinics with the focus on complex psycho-medical problems, such as chronic pelvic pain. The combination of conventional medicine and complementary approaches improves the symptoms in 70% of cases referred to the clinics (info from their websites). This is again GP referral dependent.
· Royal London Hospital for Integrated Medicine
www.uclh.nhs.uk (Our Services->Our Hospitals), Tel. 0203 456 7890
· IAPT Improving Access to Psychological Therapies www.iapt.nhs.uk
· Pelvic Pain Support Network www.pelvicpain.org.uk
· Endometriosis Support Groupwww.Endometriosis.org.uk
· Adhesions Support Groupwww.adhesions.org
· IBS support group www.ibsgroup.org