Chronic Pelvic Pain Syndrome In Women
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Chronic Pelvic Pain Syndrome In Women

"DOC, MY LIFE IS UNBEARABLE"

Marion and her husband were sitting patiently in the examining room when the Doctor walked in. "Hello Doctor," Marion began, "I was referred to you by Pastor Smith who told us if you couldn't figure out what was wrong with me no one could (the Doctor winced as he heard those words). Ever since I had my Hysterectomy I have had a searing pain in my pelvis. I had the surgery because of the pain...it didn't help. Doc, my life is unbearable."

Marion has what would be termed "Chronic Pelvic Pain Sydrome in Women". About 15% of all women in the U.S. suffer from this malady. Only a third of women seek medical care for this chronic pain syndrome (of which less than half ever receive a definitive diagnosis).

"WHAT IS CAUSING ALL THIS PAIN?"

Marion was understandably upset as she queried her pain Doctor, "What is causing all this pain?" The diagnosis of CPP in women is complicated. Let me put into perspective the difficulties in coming to a specific diagnosis about this condition:

The first major challenge is that women have pain, hemorrhage internally, and generally feel less well on a monthly basis...this is called menstruation. The process is actually a monthly inflammatory process with hemorrhage.

The second major challenge is that many women will have a growth that expands their uterus 400% or more, have a radical fluctuation in body chemistry, and end the process with a traumatic event to their pelvis...this is called pregnancy.

A final challenge (there are probably more) is that women have a conduit from the outside to the inside that has a tendency to "hide stuff"...this is called the Female Reproductive Tract.

It is no wonder that women have chronic pelvic pain. It's a "set-up, of sorts. In the usual course of events women are regularly "traumatized" by their normal anatomy and physiology.

The list of possible causes for chronic pelvic pain in women is enormous. Before a woman can be said to have this syndrome the pain must be present for 6 months or more (a little longer than the usual 3 months for chronic pain in other areas of the body).

As I have stated in my previous articles, a good history and physical is a starting point for any diagnostic workup. In this case, it is essential to have a very careful history taken with an emphasis on symptom fluctuations associated with menstruation.

Naturally, a thorough pelvic examination must be performed by an experienced Doctor (with the emphasis on "experienced" in performing pelvic exams).

There are a multitude of technical studies that can be done to try and secure a diagnosis. The difficulty with this is that the anatomy of the pelvis is "tight" and "shielded" by the pelvic bones.

There is no single test that completely looks at the pelvis...not even a CT scan.

"I DON'T WANT TO LIVE IF I CAN'T GET SOME RELIEF."

"I don't want live if I can't get some relief," was Marion's attitude after having her pain for so long. In her case she previously had a work-up that was very adequate. Unfortunately, it did not reveal any cause for her pain. When an adequate work-up has not yielded any specific findings the cause for the pain may be neurogenic or psychiatric in origin.

Human disease does not occur in a vacuum. There are patterns that will emerge when a person is repeatedly examined. Dr. Charles Mayo (of the Mayo Clinic) once re-examined a patient every week, for months, before he was able to see a pattern of symptoms emerge in order to make a diagnosis.

In Marion's case a pragmatic approach was taken:

1) Her pain was treated aggressively and immediately. She was given a regimen of opiates (a sure fire way to get some pain relief quickly).

2) A second medication that could reduce the nerve impulses of pain (called Lyrica) was started.

3) A third medication was also begun (to restore neurotransmitter levels to normal)... a low dose anti-depressant that "recycles" both norepinephrine and serotonin (called Cymbalta).

The opiod pain meds gave her immediate relief (and hope), while the other medications would take weeks to work.

Many doctors would have just begun the Lyrica and Cymbalta because of the risk of addiction to the opiod. It is not more righteous to leave a patient in pain because of an unwarranted fear of addiction. Many Doctors would argue otherwise.

"WHAT WOULD I HAVE DONE WITHOUT YOU, DOC?"

On multiple re-visits Marion's medications required adjustment. She was open and honest about how she was taking her opiod medications (the only way a Doctor can guard you from major side effects). She could not tolerate the Cymbalta side effects, so it was discontinued.

In about a year her pain began to diminish. She was weaned off her chronic dosing of opiods and remains on an as needed dose of opiods. On her last visit to her pain Doctor it went something like this:

"Doctor, my pain has gotten as low as a "3" at times. If you hadn't given me the relief I needed when I first met you... I think I would have taken my own life. What would I have done without you, Doc?" Her husband sat next to her and wept (click here for more articles).


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