Effect of Trauma and Post-traumatic Stress Disorder on Chronic Pelvic Pain

Abstract & Commentary

By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.

Dr. Ling reports no financial relationship to this field of study.

Synopsis: Close to half of all women referred to a pelvic pain clinic had a physical or sexual abuse history while over 30% had a positive screen for post-traumatic stress disorder.

Source: Meltzer-Brody S, et al. Trauma and Posttraumatic Stress Disorder in Women with Chronic Pelvic Pain. Obstet Gynecol. 2007;109:902-908.

A questionnaire was administered to 713 consecutive patients referred to a pelvic pain clinic. In addition to the high frequency of a history of sexual and/or physical abuse, patients with a history of such trauma were found to have worse daily physical functioning due to poor health, more surgery, more time in bed, more medical symptoms, and more dysfunction due to pain. The importance of clinicians screening for trauma and post-traumatic stress disorder is reinforced by these findings.

Commentary

This is another in a long series of useful publications from the group of researchers at the University of North Carolina. In this case, the most disquieting and uncomfortable of the etiologies of chronic pelvic pain in women is addressed. As surgeons, gynecologists (and I certainly include myself) must constantly be reminded that not every patient fits into the category of someone who can be helped with an operation. The old adage "Don't let the abdominal wall stand between you and the diagnosis" should certainly not be universally applied. When we're operating, we can be objective and technical. We don't have to be so "touchy/feely." I would suggest, however, that our colleagues here have reminded us once again, that there is potentially so much more to women with chronic pelvic pain than initially meets the eye.

So let's look at what may well be going on in our respective offices today. First, chronic pelvic pain has a prevalence of 15% among women of reproductive age. It accounts for 10% of gynecologic consultations. In my practice, also a referral center for pelvic pain, the percentage is much higher. The fact is, many clinicians find this condition difficult to deal with, so referral to someone like myself, who actually wants to see these patients, is an option that is welcomed. While seeing these patients, who inevitably end up in the gynecologist's office, it should be remembered that posttraumatic stress disorder (PTSD) is an anxiety disorder which is initiated by serious trauma in the individual's past. Women are twice as likely to develop PTSD when compared to their male counterparts. Overall, 25% of patients with a trauma history will develop this serious condition.

What pearls of wisdom should we be taking from this article into the examination and/or consultation room? First, don't hesitate to ask the question about sexual and/or physical abuse. You'd be surprised how often a patient wants to tell someone, but is never given the opportunity. A question as straightforward as "Have you ever been touched against your will, either as an adult or child?" is enough to open the door. The patient may not walk through that door today, but she may well do so on a future visit. Second, look for evidence of abuse now. Admittedly, PTSD would not show up as recent physical abuse, but bruises now might suggest a pattern of behavior. Don't hesitate to ask how various bruises on different parts of the body got there. Third, look for signs and symptoms of anxiety. We've all seen anxious patients, but we should not simply write it off as general anxiety disorder (GAD), but should, instead, consider a PTSD diagnosis. Fourth, you might wish to contact the local abuse shelters and/or the American College of Obstetricians and Gynecologists to obtain written material that can be placed in the bathrooms in your office offering support and resources to patients who are victims of abuse. Placing the brochures or pamphlets in a private area will allow patients to pick them up without fear of being seen by others.

All of us need reminders like this article to remember that in this technology-driven profession, imaging tests and bloodwork don't necessarily always hold the answers to the tough questions. By no means am I suggesting that every patient with pelvic pain be put through an exhaustive psychiatric evaluation. That would also send the wrong message. What we can do, however, is maintain a vigilant watch for evidence that would link a patient's complex and often confusing clinical picture to their heretofore undiagnosed trauma history and/or PTSD. As the sergeant on the old television series Hill Street Blues used to tell the squad shortly before they were sent out to their daily duties, "Be careful out there."