#38. Women and pelvic pain: A big pain problem below the waist

Chronic or cyclical pelvic pain in women is a very big health issue. Most data come from large studies in the USA. It is estimated (Wesselman, U., “Management of chronic pelvic pain”, in: Aronoff, G.M. (ed), Evaluation and treatment of chronic pain, Williams & Wilkins, 3rd edition, 1998:269-279) that this type of pain accounts for 40% all laparoscopies (a procedure during which a doctor puts a little tube inside the abdomen to visualize the female internal organs) and 12-16% of hysterectomies done yearly (80,000 surgeries per year in the USA alone). Of the 45 million women in the USA of childbearing age, 30-50% suffer from painful periods (cyclical pain), while 15% of those with chronic pelvic pain lose time from work and 45% report reduced productivity.

Chronic pelvic pain costs a lot. In terms of money, 10 years ago the yearly cost was estimated to be close to 882 million dollars in the USA (imagine what happens in today’s dollars coupled by the significant yearly increase of health care expenditures). But as in the case of every kind of chronic pain, the personal cost are immense and cannot be measured in dollar values (suffering, inability work or enjoy life, marital problems, ineffective treatments and the list goes on and on).

Chronic pelvic pain is very difficult to treat. At least one third of all sufferers do not have an obvious pathology that the doctors can find and treat. Additionally, pain may originate in other structures within the pelvis, which houses many more than just the reproductive organs for women (a term used to indicate the uterus, ovaries and tubes). Such pelvic structures are the bladder that collects the urine, the ureters (tubes connecting the kidneys to the bladder) and parts of the gut. Even pain from muscles and joints or neurological problems may give rise to pain felt in the pelvis and lower abdomen.

Beyond physical structures that may give origin to chronic pelvic pain, research over the past years has shown that depression can be related to pelvic pain (but here we have again the chicken and egg dilemma: How much of the pain causes the depression and how much of the depression causes the pain). There is also evidence from research that sexual abuse may play a role in chronic pelvic pain. In one study 58 per cent of women with chronic pelvic pain had history of childhood sexual abuse as compared to 30% of gynecological patients without pain or even patients with other kinds of pain. Let’s look at two very different examples (taken from my book BEYOND PAIN) in order to understand this very complex type of pain. Christina was 26 when she came to me. Her chronic pelvic pain appeared in cycles with her periods at age 14 but by 19 it became constant. At 21 she had a laparoscopy and was told they found a “little bit of endometriosis”, a condition in which parts of the lining of the uterus migrate into the abdominal cavity and produce inflammation and scar tissue. She was given medications which did not help and one more laparoscopy followed a year later but it did not help either. Very soon, she was hooked on strong pain medications and had to be admitted to a detoxification centre. Christina’s personal history was of great importance to myself and my team. She came from a strict Italian family and was a devout Catholic, “saving herself” for marriage. She fell in love in her mid teens with a boy but resisted his sexual advances for many months. Finally, she gave in to her boyfriend’s pressure. A month later, her boyfriend abandoned her for another woman. She was absolutely devastated… She ended up been involved in other unhappy and abusive relationships, became terribly depressed and fell back on consuming large doses of strong analgesics (opioids), few of them prescribed by her doctor, most of them bought in the street. Investigations in my inpatient unit showed that there were little physical problems with her pelvic organs, while serious stress and interpersonal difficulties were the primary contributors to her pain.