There are lots of women who visit various physicians without getting any relief or even a diagnosis for chronic pelvic pain. Such situation may lead women to conclusion that their pain is unreal. Specialists know that it is real pain, and they are coming to a new understanding of this mysterious syndrome affecting 15 per cent of women in the United States aged 18 to 50, most of whom are not diagnosed.
Chronic pelvic pain comprises a set of conditions. Some of them seem to be improbable due to the fact that they do not occur in the pelvic region. The most commonly occurring conditions are endometriosis and interstitial cystitis (IC). These conditions place women at great risk for chronic pelvic pain. There are also several related conditions such as vulvodynia, pelvic inflammatory disease, irritable bowel syndrome, scarring after abdominal surgery, fibromyalgia and chronic fatigue syndrome. A lot of research has even indicated that women who have suffered physical or sexual abuse are also at high risk for chronic pelvic pain. Women suffering from chronic pelvic pain may also have a normal physical examination.
A lot of women suffering from these conditions are successfully treated and thanks to it they avoid chronic pelvic pain. According to the International Pelvic Pain Society, pelvic pain is regarded as chronic when:
* It has been present for at least six months.
* Conventional treatments bring about little relief.
* The level of pain perceived seems to be out of proportion to the level of tissue damage detected by conventional means.
* Several symptoms of depression occur. They include: sleep problems, poor appetite, constipation, and slowed body movements.
* Physical activity is enormously limited.
* Emotional roles between the family members are changed, and the patient is displaced from her habituated role, such as wife, mother, or employee. Web MD talked to several specialists in chronic pelvic pain and pain management about the latest developments in understanding and treating chronic pelvic pain.
New Understanding of Chronic Pelvic Pain
What women already know about this condition is now confirmed by medical experts. Even after physical exams women are likely to suffer strong pain. According to the tests results, their risk factor for chronic pelvic pain, such as endometriosis, has lowered or even disappeared. What’s more, it is possible that pain will become more severe over time.
"We are aware that people who have little pathology can hurt a lot," claims C. Paul Perry, MD, founder and board chairman of the International Pelvic Pain Society in Birmingham, Ala. "Issues in the last four or five years have given us the possibility to understand that there are neurophysiological processes that are not discussed in the ob-gyn literature."
He explains also that chronic pain leads to what is called CNS upregulation, or a rising sensitivity of cells that transmit pain sensation.
Perry states that the spinal cord not only transmits pain signals up to the brain but also bacsk down to other organs. "That’s how the bladder can get involved, and there is such a great connection between endometriosis and IC- the evil twins."
He tells Web MD that if chronic pelvic pain is not stopped, it will result in multiple disorders and finally become a total end-stage disease. "We are going to educate as many health care providers as possible so that patients get appropriate treatment and evade going into chronic pelvic pain syndrome."
Another specialist, Deborah A. Metzger, MD, PhD, is of a different opinion. She is convinced that inflammation leads to chronic pelvic pain. "Treat the inflammation first, and a lot of the pain disappears," she claims.
She has discovered that sugar and allergies are involved in chronic pelvic pain. "I always test patients for allergies," she claims. "For instance, vulvar pain for most women is associated with food allergies. Another component is allergies to skin fungi, such as candida."
Metzger, medical director of Harmony Women’s Health in Los Altos, California, takes an integrative approach to chronic pelvic pain. She informs Web MD it’s time for health care professionals to develop their view of women’s health. "It’s something more than menstruations, menopause, and having babies," she claims. "The true picture of women’s health includes all the problems that are predominantly female, such as IBS, chronic tiredness syndrome, fibromyalgia, depression, allergies and asthma, autoimmune disease, and thyroid disorders."
The field of pain management adds another piece to the chronic pelvic pain puzzle. Roy E. Grzesiak, PhD, is a consulting psychologist with the New Jersey Pain Institute at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School in New Brunswick, N.J.
"We have to distinguish between patients who have persistent pain based on a biological disease or dysfunction and go on living and loving and parenting, and those patients whose total being gets entangled with pain, treatment, the medications, getting disability, etc. Many people of this latter group report a history of trauma, such as rape, sexual abuse, or physical abuse."
He claims that the neurobiological effects of trauma are complex and do not always make sense from a biological scientist’s point of view. Grzesiak is the author of A Psychological Vulnerability to Chronic Pain.
According to Grzesiak, "The terror and violation of the body don’t go into a person’s memory system as ‘I have been raped,’ or ‘I have been violated,’". "It goes into the non-linguistic side of brain as the experience of terror and as the feeling of being violated, not as the memory of the event."
Moreover, he claims that trauma quickens the nervous system so that any painful sensation is perceived to be severe. "These patients are not able to graduate pain, like it’s a two or three or sometimes four. The pain is either off or on, and when it’s on it is very severe."
Another result of trauma that is currently being investigated is connected with issues of a patient’s trust. "They may have difficulty trusting the physicians," says Grzesiak, who is also clinical associate professor of psychiatry at UMDMJ-New Jersey Medical School in Newark. "Invasive operations and a lot of medical procedures violate people. The healthcare provider is doing something that’s made them anxious all their lives."
Perry, medical director of the C. Paul Perry Pelvic Pain Center in Birmingham, Ala., says that certain antiepileptic medications- particularly Neurontin, but also Pregabalin, Depakote, and a few others- are effective in treating chronic pelvic pain.
It’s essential to treat depression in chronic pelvic pain, claims Perry. Some research has revealed that antidepressants can improve pain levels and pain tolerance in women who suffer from chronic pelvic pain.
"Eighty to 90 per cent of chronic pelvic pain patients have depression," Perry states.
"The medicines we’ve had the best results with for depression and neuropathic pain are Cymbalta and Effexor," he claims. "There are other SSRIs that are effective in treating depression, and you’d think they would help, but those two medications are the only ones substantiated in the literature."
From time to time Metzger combines Elavil or Neurontin with medicines such as Allegra and Singulair. Additionally, she recommends patients who have severe vulvar pain to spray Nasalcrom, an over-the-counter nasal spray, directly on the vulva.
Perry also says that for the majority of patients, opioid medications should be avoided. "That’s not an absolute, due to the fact that some patients can’t function without them. But the danger of opiods is that you can finish up with two problems: chronic pelvic pain and dependency."
Perry says that nowadays it is understood that women should try to avoid multiple surgeries due to the fact that it can bring about a cycle of pain, surgery, more pain, more surgery, etc. "We try to educate minimally invasive surgery as it helps prevent upregulation to the spinal cord," he explains.
He also says that women should avoid emergency room visits unless absolutely necessary. "A patient can get into a vicious cycle of pain crisis, ER, getting a shot, going back in the next month. We never tell them to stay out of the ER if there’s a problem, but if it’s the same-old, same-old, it can interfere with their treatment schedule. ER physicians concentrate on the pain crisis. They may not understand why somebody is hurting with so little pathology and tend to dismiss them as drug seekers, when normally they are relief seekers."
Chronic pain can take over a woman’s life, however specialists currently recommend staying active, working, and engaging in physical activity. "Low-impact aerobics might be very good," explains Grzesiak. Some research has indicated that physical therapy and exercise may be effective for chronic pain relief.
"We discourage patients from getting on disability," states Perry. "That’s a downward spiral. We strongly encourage functionality and entertainment. Young women should carry on education at school. Others should continue working, at least some."
Metzger has discovered that many patients test positive for allergies to foods, such as wheat, soy, corn, rice, and baker’s yeast. "When we get them off the food they’re allergic to, their pain disappears." She also says that vulvar pain may be connected with allergies to skin fungi. "When we desensitize patients with daily, sublingual [under the tongue] drops, the pain disappears."
She’s also seen results in patients who go on the Sugar Busters diet. "Money isn’t the root of all evil," she explains. "Sugar is."
