There is also a close relationship between depression and pain (73). Both give rise to similar behavior, such as behavioral and social withdrawal and decreased activity, and may be mediated by the same neurotransmitters, including norepinephrine, serotonin, and endorphins. The Beck Depression Inventory can be used as a tool for evaluation; a score over 12 suggests dysphoria and over 18, depression (133a). Antidepressants, particularly serotonin norepinephrine reuptake inhibitors (SNRIs) often relieve both depression and pain.
Childhood physical abuse has been noted to be more prevalent in women with chronic pelvic pain than in those with other types of pain (39% vs. 18.4%) (71). In a comparison of women with chronic pelvic pain, women with nonpelvic chronic pain (headache), and pain-free women, a higher lifetime prevalence of major sexual abuse and physical abuse was found in the chronic pelvic pain group. Childhood traumas may lead to an increased vulnerability to psychosocial stress and impaired coping strategies and promote chronicity of pain after an injury.
If patients are taught self-efficacy and adaptive pain coping skills through psychological treatment interventions, pain can be reduced and functioning improved. Cognitive behavioral therapy can be useful in treating chronic pelvic pain (134). Dramatizing the pain is a coping mechanism that is used by pain sufferers to generate support from others around them (135). This practice, combined with pain-related anxiety and fear, propagates pain (133).
Management of Chronic Pelvic Pain
Multidisciplinary The approach to women with chronic pain must be therapeutic, optimistic, supportive, and Approach sympathetic. The patient should be instructed to complete a daily pain ratings form after her first office visit. This form provides the clinician and patient with important information for pain management. Pain level (0–10), vaginal bleeding, and events that trigger pain such as stress, foods, and certain physical activities are recorded. The pain ratings can encourage the patient’s sense of control and decrease feelings of helplessness. Daily recording improves self-efficacy and compliance, allows for diagnosis of atypical cyclic pain (luteal as opposed to menstrual), and helps the patient to recognize the connection between pain and stressors. The ratings should be reviewed at follow-up visits.
Offering regular follow-up appointments is preferable to asking the patient to return only if pain persists because the latter reinforces pain behavior. Specific pain management skills should be taught using cognitive-behavioral approaches by a psychologist or using such techniques as mindfulness-based meditation or yoga. Patients should be taught ways to enhance opportunities for control of pain. Psychotherapy is indicated for women who have pronounced depression, sexual difficulties, or indications of past trauma. Various strategies, including relaxation techniques, stress management, sexual and marital counseling, hypnosis, and other psychotherapeutic approaches probably increase CNS descending inhibition of peripheral pain signals. Psychological group treatment is a very cost-effective approach for helping patients learn stress reduction techniques and develop coping behavioral mechanisms (136). Acupuncture can be helpful (138). Physical therapy evaluation and treatment are important.
Various studies of multidisciplinary pain management were performed. This approach incorporates the skills of the gynecologist, psychologist, and physical therapist, and may include an anesthesiologist for specialized nerve blocks. Retrospective, uncontrolled studies revealed relief of pain in 85% of the participants (137). One prospective randomized study revealed a similar response rate, which was significantly better than that of traditional therapy for pain and associated symptom reduction, improvement of daily functioning, and quality of life (138).