Chronic pelvic pain: Psychological features and laparoscopic findings

RENATE H. ROSENTHAL, Ph.D. FRANK W. LING, M.D. TED L. ROSENTHAL, Ph.D. S. GENE McNEELEY, M.D.

Chronic pelvic pain: Psychological features and laparoscopic findings ABSTRACT: One hundred three consecutive patients referred for treatment of chronic pelvic pain underwent MMPI testing, and 60 had diagnostic laparoscopy. A physical cause for the pain was found in 45 (75%) of the 60. However, three fourths (34) of patients with an organic cause for the pain also had evidence of psychopathology on the MMPI. Reassurance and education as to the role of stress in causing or exacerbating pain complaints appeared helpful. Most patients improve without major surgery.

Chronic pelvic pain without obvious organic pathology handicaps many women. A century ago, the pain was blamed on the stress of piano lessons, with the pupil having to sit with the back unsupported. More recent explanations include congestion with subsequent fibrosis, I hyperreactivity of the pelvic nerves and cerebral cortex,2.J large bowel dysfunction,4 and varicosities with pelvic thrombophlebitis. s By far the most frequent clinical diagnosis, however,

is pelvic inflammatory disease (PID). The problem is that a diagnosis of PID can be confirmed only by diagnostic laparoscopy. Yet, because the pain often subsides after a few days of antibiotic therapy, laparoscopy is not usually performed. When the pain recurs, spurring repeated medical visits, a diagnosis of chronic PID is usually made. The patient may describe her pain in rather florid terms, with the symptoms varying from visit to

Dr. R. H. Rosenthal"is associate professor and Dr. T. L. Rosenthal is professor. department of psychiatry; Dr. Ling is associate professor and Dr. McNeeley is assistant professor, department of obstetrics and gynecology, all at the University of Tennessee Center for the Health Sciences. Memphis. Reprint requests to Dr. Renate H. Rosenthal at the Center. Suite 633. 66 North Pauline Street. Memphis TN 38105. NOVEMBER 1984· VOL. 25 • NO 11

visit. Sometimes the clinical findings invite suspicions of psychological complications. Certainly these women complain more than seems justified by their clinical findings, and their distress is augmented by fears of cancer or infertility, or that pain during coitus may ruin a love relationship. Physical and emotional stress have been mentioned as causes or contributing factors in pelvic pain. 6 However, despite considerable research into a psychological causation,'·13 the results have been inconclusive. Many patients with and without obvious pelvic pathology appear to have psychiatric difficulties. To investigate the various factors that may contribute to pelvic pain, we examined 103 women consecutively admitted to the Pelvic Pain Clinic of the Department of Obstetrics and Gynecology at the University of Tennessee Center for the Health Sciences. Our aims were to assess the psychological as well as physical characteristics of these patients, to follow their clinical course, and to pro833

Pelvic pain vide appropriate treatment while avoiding major surgical interventions unless these were clearly indicated by pathologic findings.

Clinical setting Public-sector gynecology patients are referred to the Pelvic Pain Clinic if they have persistent pain complaints. Because of their economic status, and their tendency to seek help at an emergency room, these patients are at high risk for being labeled as having "chronic PID. " In the present study, each of the 103 patients received a psychological evaluation consisting of the Minnesota Multiphasic Personality Inventory (MMPI) and one or more sessions with a clinical psychologist (RHR). In addition, each patient was examined by a staff gynecologist and a gynecology resident and was followed in the clinic by both the gynecologist and the psychologist. Continuity of care was ensured by the presence of at least one staff member who was familiar with all pelvic pain patients on any given clinic day. Treatment was provided as indicated by clinical findings. A diagnostic laparoscopy was performed ifthe patient's pain persisted for several weeks or months and was distressing enough for the patient to desire undergoing this procedure. Brief supportive psychotherapy was available as needed; emergency room visits were strongly discouraged, and the patients were urged to turn to the clinic staff for all of their pain complaints. Ages of the 103 women ranged from 16 to 52 years (mean of26.5), with most in their mid-twenties; 76% were black, and 24% were white. Most resided in the Memphis metropolitan area but a few

commuted from rural Shelby County. For a variety of reasons (pregnancy, surgery, relocation, or lack offaith in our approach), 45% of them came for only one visit and were lost to follow-up; 18% came only twice; the remaining 37% (38) made three visits or more. Our conclusions are based on a total of 350 patient visits.

MMPI results Because only 37% of the patients were seen three or more times, our

An abnormal MMPI profile seems to shed little light on the actual nature ofthe problem ofchronic pelvic pain. ability to correlate clinical findings with MMPI results was limited. There were other problems as well. Many of our patients were only marginally literate and had to struggle to complete the inventory. They also made negative comments about item content, often sharing annoyance with one another in the waiting room about the "crazy questions." For these reasons, we were unable to characterize our total group of patients with chronic pelvic pain. The observations that we did make are summarized below. On the clinical scales of the MMPI, 20 profiles (19.4%) fell entirely within normal limits, disclosing no detectable pathology. Significant elevations, consisting ofTscores above 70, were found in 19 profiles (18.4%); a depression-like symptom picture was noted in six of these patients. In the remaining profiles, two or more clinical scales

exceeded T-scores of 70. The most frequent finding was a "somatizing" pattern (13 cases with elevations on scales 1 and 3). Except as noted, clinical peak patterns varied widely on the highest and next highest elevated scales, and numerous comparisons attempting to relate subgroups to scale types proved nonsignificant. On the validity scales, 31 profiles exceeded normal limits. In 13 of these patients the F scale (indicating endorsement of numerous and inconsistent symptoms) fell at Tscores between 70 and 80, a range that generally reflects a very high level of nonspecific psychological distress. 14 For 11 other patients, whose symptoms were various and inconsistent, the F scale rose beyond a T-score of 80, placing them more than 3 standard deviations outside the normal range. Such profiles have been variously interpreted as "a cry for help" to gain the doctor's compassion, an attempt to simulate psychiatric illness, or an inattentive or random response pattern due to limited literacy. The patients in our sample probably represented all of these possibilities. For instance, some of the high F responders presented in a very demanding and dramatic fashion, but failed to return for a second appointment. Others proved to be nearly illiterate but had denied this when questioned before testing. A final subgroup (seven patients with Land/or K scores over 70) seemed unwilling to admit to even the most benign personal or psychological imperfections, and four of them never returned to the clinic, perhaps from dislike of our holistic approach. Thus, we could extract no dominant bases for grouping patient response to clinic contacts. (continued)

834

PSYCHOSOMATICS

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Indic81ions and Usage: Management of anxiety disorders orshorHerm reliel of symptoms of anxiety or anXiety assocIated with depreSSIVe symptoms. Anxiety L. or. tenSIOn assOCiated wIth stress of everyday life usually does not requIre treatment with an anxiotyttc A.... Bfectiveness In 1ong4erm use. i.e.. more than 4 months. has not CJ~ been assessed by systematic clinical studies. Reassess penodically ~ usefulness of the drug for the Individual pallent. ~

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ConI",indic81ions: Known senSl1tvrty to benzodl8zepines or acute narrow-angle

glaucoma WIlrnings: Not recommended In primary depressive disorders or psychoses. As with all OlS-acting drugs. warn patoents not to operate machinery or motor vehic\fls. and of dmlr1lshed tolerance for alcohol and other CNS depressants. Physical and Psychologocal Dependence: Withdrawal symptoms like those noted with barbiturates and alcohol have OCC>.Jrred foIlow1ng abrupt dlSCO
Pr8Cllullons: In depression accompanYIng anxtety. consider POSSlbolrty for suICide. For elderly or debolitated patients. initial daily dOsage should not exceed 2mg to avoidoversedation. Termlnale dOsage gradually since abrupt WIthdrawal of any antianxiety agent may result in symptoms like those betng treated: anXiety. agrtation. imtabolity. tensiclr1. insomnia and occasiclr1al convulSions. Observe usual precautIOnS with Impa"ed rerl8l or hepatiC functiclr1. Where gastrointestinal or cardiovascular disorders CoeXist With anxiety, note that k>razepam has not been shown of significant benefit In treating gastrolntesttnal or cardiovascular component. Esophageal dilation OCC>.Jrred in rats trealed with lorazepam for more than 1 year at 6mg,1kgJday. No effect dose was l.25mg/kgJday (about 6 tirrteS maximum human therapeutIC dose of IOmg/dlly). Effect was reversible only when treatment was WIthdrawn WIth., 2 months of lirst observation. Clinical sognificance is unknown: but use of lorazepam for prolonged periodS and ,n genatrlcs reqUires caution and frequent monitonng for symptoms of upper G.I. disease Safety and effectiveness in children under 12 years have not been established ESSENTIAl LABORATORY TESTS: Some pattents have developed Ieukopenl8: some have had elevatIons of LDH As With other benzodl8zeplnes. penodlC blood counts and liver functiclr1 tests are recornrrtended dunng lorog4erm therapy. CUNICALlY SIGNIFICANT DRUG INTERACTIONS: Benzodiazepines produce CNS depressant effects when adm",stered WIth SUCh medications as barbiturates or alcohol. CARONOGENESIS AND MUTAGENESiS: No evidence of carcM'lOgenic potential emerged in rats dunng an 18-month study. No studtes regardIng mutagenesIs have been performed. PREGNANCY: Reproductive studies were performed in mice. rats. and 2 strains of rabbits. OccaSIOnal anemalteS (reductIOn of tarsals. tibla. metatarsals. malrotated limbs. gastroschiSiS. malformed skull and mocrophthalml8) were seen ,n drug4reated rabbots wothout retaticM'lship to dOsage. AJIhough all lhese anomaltes were not present ,n the concurrent control group. they have been reported to occur randomly In hlstorical controls. At 40mg/kg and higher. there was evidence of fetal resorption and Increased letal loss In rabblts whICh was not seen allower doses. Cltntcal stgnificance of these findings IS not known. However. Increased nsk of congenttal mattormations associated with use of mnor tranquilizers (chlordiazepoxide. dl8zepam and rrteprobamatel during firSI trirrtester of pregnancy has been suggested In several studies. Because use of these drugs is rarely a maner of urgency. use of Iorazepam dunng thiS penod should almost always be avoided. POSSibility that a woman of child-beanng potential may be pregnant at instituticlr1 of therapy should be considered. Advise patients il they become pregnant to communicate with thetr phYSICian about destabolity of discontinUing the drug. In humans. blood levels from umbollCal cord blood indicate placental transfer of Iorazepam and ItS glucuronide. NURSING MOTHERS: It IS not known if oral lorazepam IS excreted In human milk like other benzodiazeplr18s. As a general rule. nursing should not be undenaken while on a drug since many

drugs afe excreted In milk.

- . . Reections. If they OCC>.Jr. are usually observed at begnning of therapy and generally disappear on conbnued medICation or on decreasng dose. In a sample of about 3.500 anxiOus patients. most frequent adverse reaction is sedatton (15.9"/0). followed by dizziness (6.9"/0). weakness (4,20/0) and unsteadiness (3.4°/0). Less frequenl are disonentaticlr1. depressiclr1. nausea. change in appetite. headache. sleep disturbance. agnation. dermatological symptoms. eye functiclr1 disturbance. vanous gastrO
o-dosllll": In management of overdosage with any drug, bear in mind munopte agents may have been taken. ManIfestations of overdosage Include somnolence. confusion and coma. Induce vomiting andjor undertake gastnc lavage followed by general supportive care. monrtOring vrtal Signs and Close observation Hypotensiclr1. though unlikely. usually may be controlled with Levanerenol Bitartrate InjectIOn U.SP Usefulness of dialys,s has not been determined.

DOSAGE: Individualize for maximum beneficial effects. Increase dose gl'lldually when needed. giving higher evening dose before increasing daytime doses. Anxiety. usually 2-3mg/day given b.i.d. or li.d~ dosage may V&r! from 1 to 10mg/d8y in divided doses. For elderly or debilitated. initially 1-2mg/day; insomnia due to anxiety or transient situational stress. 2-4mg h.s.

Laparoscopic findings With the concurrence of the clinic staff, 60 of the 103 patients underwent diagnostic laparoscopy (Table 1). These laparoscopies were performed on the basis of clinical indications, and 45 (75%) of the 60 patients did have significant pelvic abnormalities. The findings included 24 patients (40%) with adhesions only; another ten (17%) had endometriosis, and three of the ten also had adhesions; the remaining 11 (18%) had conditions such as ovarian cysts, polycystic ovarian disease, hydrosalpinx, and venous congestion, and six of these 11 women also had adhesions. Thus, adhesions were found in 33 (73%) of the 45 patients with abnormallaparoscopies. An attempt was made to correlate psychological findings with the organic pathology. The patients who were laparoscoped proved closely comparable in MMPI characteristics to those who did not need or desire laparoscopy, showing no more or less maladjustment in their profiles than did the remaining patients (P= 1.067, NS). The relationship of MMPI status to gynecologic pathology is summarized in Table 2. Fourteen patients with normal laparoscopy showed some psychopathology on the MMPI. Of these, four were classic somatizers with hysterical features and somatic preoccupations, two were very defensive and rigid, and the others showed a variety of scale elevations. As a group, though, they did not display significantly more psychopathology than did the patients with actual pelvic pathology (P=O.2587, NS). Discussion Psychologically, women with chronic pelvic pain range from en836

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PSYCHOSOMATICS

Table 1-Laparoscopy Results (N =60)

I

l

Patients findings

N

%

Normal

15 24

25 40

Other pathology

10 11

18

Total

60

100

Adhesions only Endometriosis (with or without adhesions)

17

-

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-

Table 2-Relatlonshlp of Laparoscopy and MMPI Results (N =60)

MMPI

Normal laparoscopy

Normal results

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I

j

Abnormal laparoscopy

11

Deviant findings

14

34

Total

15

45

tirely normal to severely disturbed. Data on our present sample suggest that psychological distress is common, but no control group is available to verify whether the low percentage of normal MMPI profiles reflects a characteristic of poor, marginally educated women in social and economic misery, or whether the pelvic pain group is a particularly distraught subset of this population. Clinically, the presence of abnormal MMPI findings appears to be a very poor predictor of pelvic pathology: the majority of patients with documented pelvic pathology also displayed psychopathology on

-

the MMPI. Then again, because their complaints appeared to correlate with actual pelvic pathology, patients with normal MMPI profiles rarely presented diagnostic problems. By itself, then. an abnormal MMPI profile seems to shed little light on the actual nature of the problem of chronic pelvic pain. The patient mayor may not have pelvic pathology; only a careful gynecologic assessment, often including laparoscopy, can clarify the diagnosis and lead to successful treatment. Our findings seem to confirm other reports l5 . 17 that cast doubt on the usefulness of the MMPI to distinguish organic from

functional pain complaints. Although the MMPI can be used to confirm or refute the clinical impression of a patient's psychological make-up, 1M we believe that it should not be used as a diagnostic tool in the evaluation of pain complaints. A sensitive clinical assessment that includes a psychosocial history and behavioral observations may yield at least as much information as the MMPI profile. Observations of the patient's pain behavior in the office and waiting room, along with information about her living conditions, about the demands on her at home and at work, and about the relationship of the pain to life stresses should be included in the assessment. Sexual problems need to be addressed, as do questions from the patient about fertility, female anatomy, and physiology. Cancer fear is a prominent problem for these women, and the fear itself and its relation to the pain must be dealt with openly. The patient may have other fears about the meaning of the pain. and these greatly affect the intensity of her complaints. In fact, psychological distress tends to be a complicating factor in the majority of these patients; often, clinic visits may provide a welcome escape from domestic turmoil. Most patients seem initially reluctant to reveal personal information,1J fearing that the physician will dismiss their complaints as emotional in origin. We have found it advantageous to address this fear openly. The gynecologist and the psychologist jointly interview each patient. We explain to each patient that we in no way question her pain, but that training and experience have taught us that pain of any origin can be made (continued)

NOVEMBER 1984· VOL. 25 • NO II

837

Pelvic pain worse by fear, stress, and depression. Chronic pain, we explain, tends to evoke the very emotions that, in turn, can exacerbate the pain. It is essential for the p~tient to understand that we must know her as a person, learn about her life, worries, and problems. Often it takes several visits before we have a clear picture of the patient's psychosocial status, because some patients steadfastly deny any stresses or problems besides the pain. As trust is established, however, the opportunity to discuss problems, often with the psychologist alone, tends to be welcomed and may become the main part of a clinic visit. Three fourths of the women who were laparoscoped had significant pelvic pathology. Almost all had been told on one or more occasions that they had chronic PIO, and had been treated accordingly, but this diagnosis had rarely been substan-

tiated_ We believe that this stigmatizing and self-perpetuating diagnosis is made too hastily in many emergency rooms frequented by indigent women. Another finding worth emphasis is that most patients improved

Overreaction to minor discomfort appeared to be a very common problem among the women studied by us. without major surgery. In patients who came for return visits, it often emerged that the painful days followed a pattern suggestive of menstrual or intermenstrual pain, emotional stress, or pain due to physical exertion. A pain diary proved helpful in making these diagnoses. Reassurance, education, and the knowledge that the clinic staff were available if a crisis arose were

responsible for improvement in many patients. Encouragement to increase physical activity was also important in pain relief. Overreaction to minor discomfort appeared to be a very common problem among the women studied by us. In fact, psychological overreaction to pain sensations may play a role in their symptomatology. As time went by, many patients learned to notice an exacerbation of pain due to stress, and were thus able to hold in check their impulse to blame everything on the pain or to seek emergency room care. Clinic visits at stich times can be used for brief supportive psychotherapy, crisis intervention, and education about the connection between psychological and physical well-being. 0 The authors thank Florence Jackson, LPN, and the Gynecology Outpatient Clinic staff.

REFERENCES 1. Taylor HC: Vascular congestion and hyperemia. Am J Obstet Gynecol 57:211-268. 1949. 2. Theobald GW: Pelvic sympathetic syndrome J Obstet Gynecol Br Emp 58:733761. 1951 3. Theobald GW: Cortical pain image or painsensitivity panel. Br Med J 2:330-333. 1965. 4. Jeffcoate TNA: Pelvic pain. Br Med J 3:431435.1969. 5. Hobbs JT: The pelvic congestion syndrome. Practitioner 216:529-540. 1976. 6. Renaer M: Chronic pelvic pain without obvious pathology in women. Eur J Obstet Gynaecol Repro BioI 10:415-463. 1980. 7. Eicher W. Heep J: Psychogene Schmerzzusliinde im kleinen Becken. FOr/schr Med 90:930-932. 1972.

NOVEMBER 1984· VOL. 25· NO 11

8. Hackl H. Lindstrom B. Orstam S. et al: Uber den Beckenschmerz bei der Frau-eine psychiatrische-gynaekologische Studie. Wien Klin Wochenschr 92:252-255. 1980. 9. Renaer M. Guzinski GM: Pain in gynecologic practice. Pain 5:305-331. 1978 10. Castelnuovo-Tedesco P. Krout BM: Psychosomatic aspects of chronic pelvic pain. Int J Psychiatry Med 1: 109-126. 1970. 11. Gidro-Frank L. Gordon T. Taylor HC: Pelvic pain and female identity. Am J Obstet Gynecol 79: 1184-1202. 1960. 12. Gross RJ. Doerr H. Caldirola D. et al: Borderline syndrome and incest in chronic pelvic pain patients. Int J Psychiatry Med 10:79-96. 1980. 13. Markel SN. Rigberg CC. Strusz IK: Chronic pelvic pain of obscure origin: A clinical

study J Psychosom Obstet Gynecol 2:8085.1983 14 Lachar D: The MMPI Clinical Assessment and Automated Interpretation. Los Angeles. Western PsychOlogical Services. 1974. 15. Pearce S. Knight C. Beard RW: Pelvic painA common gyneCOlogical prOblem. J Psychosom Obstet Gyneco/l 12-17. 1962. 16 Rook JD. Pesch RN. Keeler EC Chronic pain and the questionable use of the Min· nesota MUltiphasic Personality Inventory. Arch Phys Med Rehabi/62:373-376. 1981

17. Cox GB. Chapman CR, Black RG The MMPI and chronic pain. J Behav Med 4:437 -443. 1976 18 Cohen CA, Foster HM. Peck EA MMPI evaluation of patients with chronic pain South Med J 76:316-321. 1963

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