Fibromyalgia Fibromyalgia is a myofascial pain syndrome, made up of the triad of diffuse pain, fatigue, and nonrestorative sleep. Women with abdominal wall or pelvic ﬂoor myofascial pain, bladder pain syndrome or interstitial cystitis and IBS often have fibromyalgia. Women are affected more commonly than men. To diagnose the syndrome, the patient must have tender points in all four quadrants. The cause is thought to be a central nervous system sensitization that results in abnormal perception of chronic pain. Fibromyalgia is closely associated with chronic fatigue syndrome, a combination of regional myofascial problems including infections and autoimmune disorders or dysautonomias. The management includes education, environmental changes (well-balanced diet, adequate time for sleep, and an environment conducive to restful sleep), exercise and stretching, and counseling or cognitive behavioral therapy for relaxation and maximizing coping mechanisms. Medications used include NSAIDs, low-dose TCAs, selective serotonin/norepinephrine reuptake inhibitors, anticonvulsants, and benzodiazepines to improve sleep (129).
Low-Back Pain Syndrome In women who experience lower-back pain without pelvic pain, gynecologic pathology rarely is the cause of their pain. However, low-back pain may accompany gynecologic pathology. Back pain may be caused by gynecologic, vascular, neurologic, psychogenic, or spondologenic (related to the axial skeleton and its structure) pathology (131).
Women with low-back pain syndrome often have pain occurring after trauma or physical exertion, in the morning on arising, or with fatigue. Nongynecologic low-back pain can intensify with the menstrual cycle.
Examination consists of inspection, evaluation with movement, and palpation. Various anatomic structures in the spine should be considered as sources of pain. Muscles, vertebral joints, and discs (including lumbosacral junction, paravertebral sacrospinal muscles, and sacroiliac joints) are common sources of spondylogenic pain that must be examined carefully (2).
Diagnostic imaging studies performed while the patient is standing, lying, and sitting with maximal ﬂexion can be helpful. An elevated ESR suggests pain of inﬂammatory or neoplastic origin. Though most patients with acute back pain do not require imaging, plain films can be obtained to evaluate for infection, fracture, malignancy, spondylolisthesis, degenerative changes, disc space narrowing, and prior surgery. For patients who require advanced imaging, MRI without contrast is considered to be the best imaging modality.
Consultation with the patient’s primary care provider should be sought before initiating management for back pain unless the source could be referred gynecologic pain. For more complex cases, an orthopaedic or neurosurgery consult may be required.
Psychological Factors From a psychological perspective, various factors may promote the chronicity of pain, including the meaning attached to the pain, anxiety, the ability to redirect attention, personality, mood state, past experience, and reinforcement contingencies that may amplify or attenuate pain (132). The Minnesota Multiphasic Personality Inventory (MMPI) studies of women with chronic pelvic pain reveal a high prevalence of a convergence “V” profile (elevated scores on the hypochondriasis, hysteria, and depression scales). Treatment that results in subjective improvement in pain severity and increased activity level produces a significant improvement in personality profile (133).