Chronic pelvic pain disorders often start with trauma, coexist with anxiety, depression and sleep disorders and require an integrated care approach.
This article is part 2 of a new series on chronic/persistent pelvic pain disorders by Dr. Witzeman, to be published in 2021. See part 1 on chronic overlapping pelvic pain disorders.
If no anatomical or pathological reason for pelvic pain is identified during an early evaluation, the sad truth is that many women have been told or led by their health care providers to believe that the pelvic pain they experience is “all in their heads.” This disturbing patient experience is one that my patients have shared with me over and over again. And sure, although all pain experiences are translated and processed in the brain and are influenced by the mind-body connections, there is nothing therapeutic about making a person believe or interpret that the very real pain experience they are having is imagined. In fact, as you might expect, this can do more harm than good.
Now let’s examine some of the evidence regarding the truly complex intersection of pelvic pain disorders and psychological health and a practical therapeutic approach to help the whole person.
Physiological underpinnings of pelvic pain
Anxiety and depressive disorders, as well as sleep disorders, are strongly associated with pelvic pain disorders in women.1-3 This increased comorbidity between persistent pelvic pain and mood disorders, as well as with other pain disorders of different body regions, may be influenced by disturbances in the hypothalamic-pituitary-adrenal (HPA) axis and the autonomic nervous system, which contribute to the regulation of stress and affect perception. of pain.
A significant proportion of patients suffering from comorbid persistent pelvic pain syndromes report a history of early life stress or trauma. Experiencing trauma, neglect, or abuse in early life can affect the functioning of the HPA axis.4.5
HPA axis dysregulation: its relationship with mental disorders (depression, anxiety, PTSD and sleep)
In healthy individuals, the stress response is an adaptive function in situations of acute challenge. However, prolonged exposure to stress can lead to permanent dysregulation of the neurobiological stress systems, leading to wear and tear on the body and brain, the so-called allostatic load.6 The respective physiological changes, particularly within the sympathetic nervous system (SNS) and hypothalamic-pituitary-adrenal (HPA) axis, have been associated with adverse health effects, including cardiovascular, metabolic, autoimmune, and mental and pain disorders.7.8
While chronic stress can undoubtedly stem from traumatic life events, the examination of extreme adversity has only taken us so far in understanding why individuals living in less demanding circumstances are also prone to stress-related disorders. One possible explanation is that allostatic load can accumulate in the presence of non-traumatic but persistent stressors.9
Which Comes First: Ongoing Stressors or Ongoing Pelvic Pain?
In general, which comes first probably depends on a person’s individual circumstances and history. For example, a person may have a very stressful childhood and upbringing that predisposes their pain-processing mechanisms to essentially be “stepped up” and upregulated when a particular condition or trigger occurs. Over time, this can lead to a predisposition to develop peripheral or even central sensitization.
Editor’s Note: See also, pain psychologist Robert Twillman discusses overlapping somatic and psychiatric disorders on our sister clinical site, Psycom Pro.
Alternatively, a person may develop a painful condition, such as secondary dysmenorrhea due to endometriosis or adenomyosis, or primary/secondary vestibulodynia, which can have very stressful implications in their life, such as lost days at work or school, sexual pain, and disagreements in the relationship, or lower self-efficacy. In fact, dyspareunia (painful sex) is a common reason to seek medical attention, especially when it has compromised an important intimate relationship.
Evidence supports a bidirectional relationship between anxiety and depression with vulvodynia and dyspareunia. Pain catastrophizing, fear of pain, hypervigilance for pain, lower self-efficacy, negative attributions about the pain, avoidance, anxiety and depression can lead to greater pain intensity.10 Childhood trauma, including but not limited to sexual trauma, may be a risk factor for the development of vulvodynia.
In a study of adolescent girls with dyspareunia, reported histories of sexual abuse and fear of physical abuse were significantly higher compared to sexually active adolescent girls from a control group. Notably, women with vulvodynia are reported to be three times more likely to report experiences of severe physical and sexual abuse and to live in fear of abuse compared to women without vulvodynia.11.12
The Sexual Response Cycle and Fear of Intercourse
Different models explain how patients become ‘trapped’ in a vicious circle of fear and pain that goes beyond obvious physical features. For example, a history of sexual pain and the resulting anticipatory anxiety leads to anxious responses that inhibit genital arousal, cause vaginal dryness, and lead to pelvic floor muscle hypertonia. The inhibition of autonomic nervous system responses due to outside awareness and fear can block sexually meaningful stimuli that can normally lead to arousal. Interestingly, reports support that some women “like” intercourse, but don’t necessarily “want” intercourse because they expect pain.13-15
Alternatively, some women will continue to have intercourse despite the pain of penetration because they want to avoid the effects of relationship disagreement more than the effects of the pain – a complex psychosexual phenomenon.14
Trauma-informed care is crucial for treating patients with a trauma history
Unfortunately, when people have experienced other forms of trauma in their lives (eg, sexual trauma at any stage of the life cycle, physical trauma, severe emotional trauma), unintended medical traumatization can easily occur, often in the care of an unconscious health care provider. Emphasizing the patient’s control over her medical care is one of the foundations of a trauma-informed care approach. Such an approach aims to prevent re-traumatization by enabling victims of gender-based violence to maintain control over their own bodies.16
When obtaining a history, it is important to discuss a patient’s trauma history only to the extent necessary for the provision of care. Avoid asking questions and requesting details that could re-traumatize the patient. It is important to ask about other forms of trauma, including previous medical trauma, as many patients have experienced multiple types of trauma and violence.17,18
When considering the physical exam – especially a gynecological exam – for pain, the approach and trust of the health care provider are very important in optimizing a person’s care.
Some important considerations when working with a trauma survivor:
- Relaxation to reduce anxiety – encourage the patient to do a relaxation or abdominal breathing exercise just before the exam
- Make sure the patient is well covered
- Have a supervisor present at the exam with the patient’s consent
- To further enhance the patient’s sense of control:
– Inform your patient about what is being examined during the evaluation
– Explain how to use the sensory assessment and pain severity scale
– Explain the difference between an exam and “what makes you feel at home”
– Offer the option to stop at any time: it may be better to split the study into two or more visits
– Provide the option to defer a speculum examination if there is no abnormal bleeding or discharge, and it is not clinical
– When a speculum examination is required, use the smallest speculum possible
Integrated Approaches to Pelvic Pain Treatment
Consider a behavioral health referral if your patient:
- Asks for a reference
- Shows avoidance and/or fear of pelvic exams/other procedures, including, for example, sustained bracing
- Can’t relax during the exam
- Has body image, sexual and other psychosocial problems associated with chronic diseases and treatments
- Will benefit from learning techniques for managing chronic pain
- Has depression, anxiety, PTSD, stress or sleeping problems
- Reports feeling overwhelmed and needs resources to cope
- Relationship Issues Reports
- Has poor adherence to treatment
- Reports that nothing else has worked
The arena of modalities that address the mind-body connection is quite broad. Choosing one or more of these modalities that can motivate your patient to participate can influence not only the emotional co-morbidities, but also the pain experience itself. Consider recommending:
Additional Clinical Resources
If you find yourself struggling with the complexity and challenging presentations of people with persistent or chronic pelvic pain disorders, check out the additional resources available through the International Pelvic Pain Society (IPPS).
Last updated: August 25, 2021
Chronic Overlapping Pelvic Pain Conditions: Differential Diagnoses and Treatment