Chronic uncertainty about chronic pain

Perinatal postmortetns give tangible information about organic disease, but much of the practice of obstetrics and gynaecology involves the treatment of psychosomatic illness which is poorly understood. The psychological antecedents of chronic pelvic pain are complex, and may include sexual abuse in childhood or adult life, marital dysharinony, sexual dysfunction and fear of cancer. Chronic pelvic pain is a demoralising condition which causes much distress, social disruption and economic loss to women and to the community. Richard Beard (pages 8–10) gives a graphic account of the vicissitudes of a woman suffering from chronic pelvic pain, who initially may be thought to have pelvic inflammatory disease, endometriosis, adhesions or ovarian cysts, before it is realised that she has the chronic pelvic pain syndrome; she may then be given other labels-dysmenorrhoea, dyspareunia, the pelvic congestion syndrome, or the irritable bowel syndrome. Krina Zondervan and her colleagues (pages 93–99) carried out a systematic review of published studies of chronic pelvic pain to ascertain its prevalence in the United Kingdom. The study was very thorough, involving a search of three electronic databases, using twelve search terms, and supplemented by a hand search of the reference list of selected papers as far back as 1960. One strength of this review is that the authors resisted the temptation to perform a formal meta-analysis, recognising the heterogeneity of the clinical conditions in the search terms; the study is therefore purely descriptive. The authors found that there was no study in the community of the prevalence of chronic pelvic pain in the United Kingdom. Their analysis was confounded by differences in the definition of the syndromes constituting chronic pelvic pain, in the selection of the women participating in the studies, and in the perceptions of the severity of the pain in different cultures. A specific factor which may be associated with chronic pelvic pain is sexual abuse in childhood or adult life, and B. J. Collett and colleagues have investigated this possibility (pages 87–92). The authors carried out a prospective observational study to compare the occurrence sexual abuse in groups of women with chronic pelvic pain, chronic pain not in the pelvis, and no pain. Women with chronic pelvic pain had a greater frequency of painful periods, previous gynaecological surgery, loss of interest in sex, and painful sexual intercourse, and were more anxious than the controls; they had more often been sexually abused, and more frequently this abuse had been penetrative intercourse. The limitations of this study are its small size and unknown confounding factors which may have influenced the results. The strength of this study is that it was rigorously performed, the interviews being undertaken by a single researcher who visited all ninety women in their homes and administered three questionnaires to each woman. The value of this study is that it supports the association of sexual abuse and chronic pelvic pain, such that gynaecologists should seek this information when taking a woman's medical history. We should therefore perform much more basic research into chronic pelvic pain. As Richard Beard and Krina Zondervan advocate, clinicians and scientists must agree on the definitions of the chronic pelvic pain syndromes; we should carry out studies in the community of the prevalence of chronic pelvic pain; and we need to undertake smaller studies of the factors associated with chronic pelvic pain and randomised trials of its treatment. Only then will our uncertainty diminish, and our irrational investigations and treatments of this debilitating condition disappear.