Women with chronic pelvic pain frequently have psychological alterations and a life history that includes either one of the following alone or in combination: sexual abuse, family problems, divorce, or a history of violence.
12 Sexual impairment may result from chronic pain or from side effects of medication (eg, narcotics, tricyclic antidepressants (TCAs), antipsychotics)used to treat the pain.
13 Arthritis pain or somatic dysfunction may be a deterrent to participation in coitus; or altered levels of hormones and libido may contribute to decreased sexual satisfaction. Medications used to treat a woman for resultant anxiety, depression, and pain may cause disorders of desire (barbiturates, antilipid medications β-blockers); fatigue, vaginal dryness (antihistamines); impaired arousal (anticholinergics, antihypertensives, benziduazepines); or anorgasmic dysfunction (anorexic drugs—”diet pills,” TCAs, amphetamines). Over time, a woman may feel loss of attractiveness to her partner and low self-esteem. These feelings increase as some women may gain weight as a result of taking antidepressants.
14
Although the chronicity of pelvic pain becomes the focus of a gynecologic visit, some women manifest other physical signs of stress. Muscle weakness, spasm, and pain from disruption of muscle contraction and relaxation become complaints of fatigue, back pain, face pain, bruxism, headache, or fibromyalgia, or a combination of these complaints.
Because many women tend to internalize stress, repeated alternation of muscle tension and relaxation may lead to nerve entrapment or alteration of circulation to muscles or other body structures.
15 Weight changes also are modifying factors for posture, gait, and somatic complaints. Carrying extra pounds worsens spinal curves and stresses supportive structures of the pelvis, such as the extremities. When a woman loses or gains weight as a result of stress, she increases her risk for development of osteoporosis because of reduced calcium intake, altered estrogen production, and reduced bone mass (in menopause).
While dealing with the psychosocial aspects of chronic pelvic pain, many women struggle with changing moods and altered sleep cycles. These fluctuations also compromise the immune system and cause women to become fearful of other chronic diseases such as chronic fatigue syndrome, myofascial pain syndrome, and fibromyalgia.
16 Pain signals and other sensory inputs are processed at the cortical and subcortical levels, then amplified via central sensitization at the spinal cord level.
17 In chronic pelvic pain, pain is not processed normally in the dorsal horn which then allows temporal summation of pressure sensations.
16 Descending modulation from the brain-stem is impaired and contributes to excess spinal fluid levels of substance P and other neurotransmitters involved in nociception.
Lower than normal spinal fluid levels of serotonin, norepinephrine, and dopamine have also been associated with depressive syndromes.
16Sleep deprivation, depression (
Figure 3), and pain may put a woman with chronic pelvic pain at risk for serious injury. For example, she may be running late for work, preoccupied by family concerns or finances, and/or unable to focus on herself because of “medication fog.” Because of muscle pain and stress, she may become distracted and become involved in a motor vehicle accident, sustaining injuries, which lead to more pain, depression, and tension. Additionally, she may be taking one or more medications for the foregoing problems, some of which may have side effects that may alter her judgment or alertness. These factors may perpetuate the cycle.