Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

12. Chronic Pelvic Pain in Women
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While theories of pain perception evolved, gynecologists began
incorporating laparoscopy into their diagnostic armamentarium.
Endometriosis, for example, had long been understood as a cause of
pelvic pain, but the presence of milder disease could now be investigated
without the morbidity of a laparotomy. This led to great attention
paid to endometriosis, adhesions, simple ovarian cysts, hernias, and
other variations as pain etiologies. However, it became apparent over
time that these findings could be completely incidental in some cases.
On the other hand, patients with pristine pelvic anatomy could have
the same constellation of symptoms that were thought to be caused by
laparoscopic findings in others. Over time, enthusiasm about endometriosis
and adhesions as concrete “causes” of pelvic pain has waned,
but the remnants of these impressions left us with three significant
problems [ 7 ]:
1. The significance of laparoscopic findings is exaggerated, either by
well-intentioned physicians or in the desperate patient’s interpretation.
The result can be that every twinge of pain can be translated
as the development or rupture of a follicular cyst or the spread of
endometriosis throughout the abdomen and pelvis like metastatic
cancer.
2. These diagnoses are flogged with unhelpful repeated laparoscopic
lysis of adhesions, excision or ablation of endometriosis, or ovarian
cystectomies. In the worst case, belief that the root of pain is
housed in gynecologic organs (“Doctor, I feel like I want to just rip
it all out of me”) results in serial removal of the uterus and ovaries
at a young age and leaves the patient with an unaddressed chronic
pain syndrome.
3. When minimal or no abnormalities are detected on laparoscopy,
the patient is made to feel “crazy” or that her pain is “all in her
head.”
This chapter outlines some of the more common contributors to
gynecologic pain syndromes (Table 12.1 ). Put in the context of central
sensitization, where the patient’s pain response can be globally abnormal
no matter the stimulus, these contributors can be understood as
peripheral pain generators . The aim of treatment is thus to (1) turn
down the overall “master volume dial” through an individualized
regimen of medication (e.g., antidepressants, neuroleptics, etc.),
psychotherapy, and/or alternative strategies (e.g., mindfulness- based