Chronic Pelvic Pain INTRODUCTION Many women suffer for months or years from pain in their lower abdomen or pelvis. Although there are some diseases known to cause chronic pain, many women who have experienced pain for a long time and have been unable to obtain relief may not know the cause of their pain. They have often seen many different doctors, undergone multiple tests and procedures, and may have even had major surgery, all without relief. The pain continues, the cause remains unknown, and attempts at treatment are ineffective. Situations such as this are referred to as a chronic pain syndrome. You may have heard of conditions with names like "neurogenic pain syndrome," "fibromyalgia," or "myofascial pain." All of these are terms that most likely refer to different varieties of the same chronic pain condition. Chronic pain can come on suddenly, but it usually arises gradually. Because many physicians do not understand chronic pain syndromes well, patients are usually diagnosed as having other conditions. However, treatment which is usually successful for other conditions fails to relieve the chronic pain syndrome. As a result, the pain continues and patients often undergo more tests, receive more ineffective treatment, and go on to see doctor after doctor in what may seem like a wild goose chase. Meanwhile, the pain continues unabated. This leads to frustration, anger, fear, depression, and anxiety. Relationships with family, friends, and loved ones become strained and moral support from others may dwindle or disappear completely. This creates a vicious cycle that results in poor coping ability and worsened pain. CAUSES OF CHRONIC PAIN Chronic pain is a very complicated problem that medical science does not understand well. Because of this incomplete understanding, we are sometimes unable to find a cause for the pain. We know that pain is a process that depends on chemicals, which are produced by tissues in the body. These substances are called pain mediators. They stimulate nerve endings which send pain signals to the brain. Pain mediators are produced in reaction to tissue trauma, such as burns, cuts, infections, etc. We also know that the body's nervous system does not send pain signals to the brain unless the nerves are stimulated beyond a certain point. This point is called the pain threshold. When the threshold is exceeded, the nerves are stimulated and pain signals are sent to the brain. There are some cases of chronic pain that are caused by conditions that can be diagnosed and treated effectively. Some of the more common gynecologic conditions that can cause chronic pain include endometriosis, adenomyosis, uterine fibroids, and primary dysmenorrhea. Other organ systems also cause pain, especially the gastrointestinal tract. Irritable bowel syndrome, inflammatory bowel disease, and diverticulosis are a few conditions known to cause pain. Interstitial cystitis is a chronic inflammation of the bladder that causes pain. Vertebral disc misalignments, arthritis of the spine or hip, and muscle strain or spasm can also cause chronic pain. We believe that most cases of chronic pain are caused by one of two basic mechanisms. The first is excessive amounts of pain mediators present in certain areas of the body. This stimulates nerve endings past the pain threshold, and pain signals are produced. The second, and perhaps more common cause, is a lower-than-normal pain threshold. The nerves are hypersensitive and therefore send pain signals even though there is little or no stimulation for them to do so. As a result of long standing chronic pain, most patients experience tremendous stress. Frustration, anger, anxiety, and depression are all very common. These emotions usually lower the body's ability to cope with the stress of pain, leading to more severe pain, which creates more stress. Thus, the cycle of pain is established. EVALUATION OF THE PATIENT WITH CHRONIC PAIN It is important for everyone to realize that the pain of a chronic pain syndrome is real. It is not imagined. If multiple tests fail to identify a cause of the pain, many doctors, co-workers, friends, family, and even the patient herself, may begin to doubt if there is really any pain at all. However, the absence of identifiable disease, infection, trauma, or other abnormality, does not mean the pain does not exist. Likewise, just because a specific cause cannot be found, does not mean the patient is crazy, or that the pain is "all in her head." Patients with a chronic pain syndrome are often frustrated, angry, depressed, and afraid. Although it can be incapacitating, chronic pain is not life threatening, it is not cancer, and it will not cause paralysis or insanity. The search for the cause of pain starts with a thorough history. Clues can sometimes be found by determining when the pain occurs, what type of pain it is, and what makes the pain better or worse. A physical examination is performed. Various tests may be done, depending on what is found in the history and physical. The goal is to determine if there is a treatable cause for the pain. In some cases a team approach is used, where different doctors with expertise in various areas of medicine evaluate different organ systems to find the cause of the pain. In many cases a single, definite cause for the pain cannot be identified and multiple factors contribute to the pain. TREATMENT If a primary cause of the pain can be identified, then treatment is directed at that cause. Gynecologic causes of pain can be treated with medication to suppress the hormonal fluctuations of the menstrual cycle and thereby prevent ovulation, menstrual bleeding, and other consequences that can cause pain. In some cases conservative surgery can alleviate gynecologic pain. In other cases a hysterectomy (removal of the uterus) and/or oophorectomy (removal of the ovaries) may be necessary. There are many patients who suffer from chronic pelvic pain who have already had a hysterectomy, and perhaps other surgical procedures, and yet continue to have significant pain. There are also many patients who have chronic pain who have had many tests, but no abnormality can be found. These patients most likely have a chronic pain syndrome, which can be effectively treated in most cases. Treatment begins with identification of any hypersensitive areas, known as trigger points. These are tender areas that, when exposed to minimal stimulation, cause the patients typical pain. Trigger points are usually located in the wall of the lower abdomen, just beneath the skin. They may also be located in the lower back, hips, and other areas. If trigger points are present, they are injected with a small amount of local anesthetic, which blocks the pains signals from those areas. This usually results in complete pain relief that lasts for several days to one or two weeks. The trigger point injections are repeated every few weeks, and in most cases the period of pain relief lasts longer and longer as time goes on. Although not every patient responds the same way, ultimately about 90% of patients with this type of pain obtain relief with trigger point injections. Many factors are known to worsen chronic pain and cause flare-ups. Ovulation, menstruation, and sexual intercourse increase the pain in many patients. Suppression of the menstrual cycle with medication can effectively eliminate these sources of pain. Avoiding intercourse at certain times, or avoiding certain sexual positions, can be helpful. Treatment of depression, anxiety, and insomnia, and reduction of stress, will raise the pain threshold and reduce the intensity and frequency of pain. Emotional support from the patient's spouse, family, and friends is extremely beneficial, as is participation in support groups and counseling. Good nutrition, regular exercise, and a positive mental attitude will optimize the body's physiologic state and reduce pain and suffering. A very important component of the treatment of chronic pain is proper use of medication to relieve pain. Narcotic pain relievers are extremely effective when taken in adequate doses, because this type of pain medication directly raises the pain threshold. Many doctors and patients are afraid that long-term use of narcotics will lead to addiction and other problems. The fact is that studies have clearly shown that most patients suffering from significant, chronic pain can successfully use narcotics to obtain excellent pain relief, regain a normal lifestyle, and not experience addiction or other serious complications. Studies have also shown that taking pain medication at regular time intervals and maintaining a minimum level of medication in the body is more effective than waiting to take the medication only when the pain becomes severe. In other words, if pain relievers are taken before the pain becomes severe, the pain can be kept to a minimum and flare-ups can be avoided. Waiting until the pain becomes severe is much less effective, as the pain will continue to worsen until the medication takes effect, and by then more medication will be needed. Patients should take their pain relievers as often as needed to maintain comfort, but avoid excess amounts that can cause drowsiness or other side effects. CONCLUSION Chronic pain is not a completely understood entity, but some aspects of the problem are clear. Because a specific cause cannot always be found, a complete cure is not always possible. However, proper treatment with trigger point injections, pain relievers, and when necessary, antidepressants and other therapies can relieve pain and suffering, and allow patients to resume a normal, active lifestyle. Many patients who have suffered for years have obtained excellent pain relief.