Chronic pelvic pain disorders often begin with trauma, co-exist with anxiety, depression, and sleep disorders, and require an integrated care approach.

This article is Part 2 of a new series on chronic/persistent pelvic pain disorders by Dr. Witzeman to be published throughout 2021. See Part 1 on chronic overlapping pelvic pain disorders.


If during early evaluation no anatomical or pathological reason for pelvic pain is identified, the sad truth is that many women have either been told or led to believe by their healthcare providers that the pelvic pain they are experiencing is “all in their head.” This disturbing patient experience is one that my patients have shared with me time and time again. And certainly, while all pain experiences are translated and processed in the brain and are impacted by the mind-body connections, there is nothing therapeutic about leading a person to believe or interpret that the very real pain experience they are having is imagined. In fact, as one might expect, this can do more harm than good.

Now, let’s explore some of the evidence regarding the truly complex intersection of pelvic pain disorders and psychological health and a practical therapeutic approach to helping the whole person.

Anxiety, depression, and sleep disorders are strongly associated with pelvic pain disorders. (Image: iStock)

Physiologic Underpinnings of Pelvic Pain

Anxiety and depressive disorders, as well as sleep disorders, are strongly associated with pelvic pain disorders in women.1-3 This increased comorbidity between persistent pelvic pain and mood disorders, as well as with other pain disorders of disparate body regions, may be influenced by disruptions in the hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system, which contribute to the regulation of stress and influence the perception of pain.

A significant proportion of patients suffering from comorbid persistent pelvic pain syndromes report a history of early life stress or trauma. Experiencing trauma, neglect, or abuse in early life can affect the functioning of the HPA axis.4,5

HPA Axis Dysregulation: The Relationship to Mental Health Disorders (Depression, Anxiety, PTSD, and Sleep)

In healthy individuals, the stress response is an adaptive function in situations of acute challenge. However, prolonged stress exposure may lead to permanent dysregulation of the neurobiological stress systems, thereby leading to wear and tear on the body and brain —termed allostatic load.6 The respective physiological changes, specifically within the sympathetic nervous system (SNS) and hypothalamic-pituitary-adrenal (HPA) axis, have been linked to detrimental health effects, including cardiovascular, metabolic, autoimmune, and mental diseases and pain disorders.7,8

While chronic stress can undoubtedly arise from traumatic life events, examining extreme adversity has taken us only so far in understanding why individuals living in less demanding conditions are also susceptible to stress-related conditions. One potential explanation is that allostatic load can accumulate in the presence of non-traumatic but persistent stressors.9

Which Comes First: Persistent Stressors or Persistent Pelvic Pain?

Generally speaking, which comes first likely depends on a person’s individual circumstances and history. For example, a person may have a highly stressful childhood and upbringing that predisposes their pain processing mechanisms to be essentially “ramped up” and upregulated when a particular condition or trigger occurs. This may lead to a predisposition to develop peripheral sensitization or even central sensitization over time.

Alternatively, a person may develop a painful condition such as secondary dysmenorrhea due to endometriosis or adenomyosis, or primary/secondary vestibulodynia, which may have very stressful implications in their life such as lost days at work or school, sexual pain and relationship discord, or lower self-efficacy. In fact, dyspareunia (painful sex) is a very common reason for seeking medical care, especially when it has endangered an important intimate relationship.

Evidence supports a bidirectional relationship between anxiety and depression with vulvodynia and dyspareunia. Pain catastrophizing, fear of pain, hypervigilance to pain, lower self-efficacy, negative attributions about the pain, avoidance, anxiety, and depression may lead to greater pain intensity.10 Childhood trauma including but not limited to sexual trauma may be a risk factor for the development of vulvodynia.

In a study of adolescent girls with dyspareunia, reported history of sexual abuse and fear of physical abuse was significantly higher compared with sexually active adolescent girls from a control group. Notably, women with vulvodynia are reported to have a 3-fold increased likelihood of reporting experiences of severe physical and sexual abuse and of living in fear of abuse compared with women without vulvodynia.11,12

The Sexual Response Cycle and Fear of Intercourse

Several models explain how patients become “trapped” in a vicious circle of fear and pain that go beyond obvious physical markers. For example, a history of sexual pain and the resulting anticipatory anxiety leads to fearful reactions that inhibit genital arousal, cause vaginal dryness, and lead to pelvic floor muscle hypertonicity. The inhibition of autonomic nervous system responses due to outside awareness and fear may block sexually meaningful stimuli that may normally lead to arousal. Interestingly, reports support that some women may “like” intercourse but not necessarily “want” to have intercourse due to anticipation of pain.13-15

Alternatively, some women will continue to have sexual intercourse despite the pain of penetration, because they want to avoid the consequences of relationship discord more than the consequences of the pain – complex psychosexual phenomenon.14

Trauma-Informed Care Is Crucial to Treating Patients with Trauma History

When people have experienced other forms of trauma in their life (eg, sexual trauma in any phase of the life cycle, physical trauma, severe emotional trauma), unfortunately, unintentional medical traumatization can easily occur, many times in the care of an unaware healthcare provider. Emphasizing the control that the patient has over her medical care is one of the foundations of a trauma-informed care approach. Such an approach aims to prevent re-traumatization by empowering survivors of gender-based violence to be in control of their own bodies.16

When obtaining a history, it is important to discuss a patient’s trauma history only to the extent that it is necessary for the provision of care. Avoid asking questions and requesting details that could retraumatize the patient. It’s important to ask about other forms of trauma, including prior medical trauma, because many patients have experienced multiple types of trauma and violence.17,18

When considering the physical exam – especially a gynecologic examination – for pain, the healthcare provider’s approach and trust are very important to optimizing a person’s care.

Some key considerations when working with a survivor of trauma:

  • Relaxation to decrease anxiety – encourage the patient to do a relaxation or belly breathing exercise just prior to the exam
  • Ensure that the patient is properly covered
  • Have a chaperone present for the exam with the patient’s consent
  • To further enable the patient’s sense of control:

     – Educate your patient on what is examined during the evaluation
     – Explain how you use the sensory exam and pain severity scale
     – Explain the difference between an exam and “what you feel at home"
     – Provide the option to stop at any point: it may be more optimal to break up the examination into two or more visits
     – Provide the option of deferring a speculum exam if there is no abnormal bleeding or discharge, and it is not clinically
     – When a speculum exam is needed, use the smallest size speculum possible

Integrated Approaches to Pelvic Pain Treatment

Consider a behavioral health referral when your patient:

  • Asks for a referral
  • Exhibits avoidance and/or distress with pelvic exams/other procedures, including, for example, persistent bracing
  • Is unable to relax during the exam
  • Has body image, sexual, and other psychosocial issues related to chronic illness and treatments
  • Will benefit from learning chronic pain management techniques
  • Has depression, anxiety, PTSD, stress, or sleep issues
  • Reports feeling overwhelmed and needs coping resources
  • Reports having relationship issues
  • Has poor treatment adherence
  • Reports nothing else has worked

The arena of modalities that address the mind-body connection is quite broad. Choosing one or more of these modalities that your patient may be motivated to engage with can impact not only the emotive comorbidities but also the pain experience itself. Consider recommending:

Additional Clinical Resources

If you find yourself struggling with the complexity and challenging presentations of people with persistent or chronic pelvic pain disorders, check out additional resources available through the International Pelvic Pain Society (IPPS).


Last updated on: May 5, 2021

Chronic Overlapping Pelvic Pain Disorders: Differential Diagnoses and Treatment

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