Putting patients at the centre of pain management
Pelvic pain affects 15% of women yet we still have limited
understanding of the underlying mechanisms resulting in a dearth of
effective treatments. Chronic pain represents an increasing burden on
both individuals and societies negatively influencing finances,
productivity, and psychological wellbeing (Mathias et al, Obstet
Gynecol. 1996 Mar;87(3):321-7). Establishing the association between
pelvic and other pain syndromes is important but commonly hindered by a
lack of non-invasive diagnostic strategies to exclude nociceptive
pathologies causes such as endometriosis, adenomyosis, adhesions, or
infection.
In this study, Beales et al explore the association between pelvic pain
bothersomeness and women’s sensitivity to pressure or cold on various
skin sites in a community-based cross-sectional study of adult females
based on data from the Raine Study (Beales et al, BJOG, 2022). The
results demonstrated that pelvic pain bothersomeness was associated with
higher pressure and cold pain sensitivity and the authors hypothesise
that higher pain sensitivity may be the underlying mechanism for high
levels of non-cyclical pelvic pain bothersomeness, independent of
musculoskeletal pain presence.
The clinical applicability of these important findings must be
considered alongside the study’s limitations: the response rate of this
questionnaire-based study was low (34%) introducing the possibility of
selective response bias affecting statistical analysis; a small sample
size of women reporting high pelvic bothersomeness (39, 8.2%); and the
narrow age range (20.7 to 24.4 years old) limit the generalisability of
the findings. It was unclear where participants were in their menstrual
cycle when sensitivity testing was performed as increased pressure and
cold sensitivity has been associated with severe dysmenorrhoea (Hapidou
et al, Pain. 1988 Sep;34(3):277-283). The analysis of non-cyclical
pelvic pain further limits the conclusions and applicability of the
study as the authors provide no distinction between the underlying
causes of pain (gynaecological, urinary, digestive, or musculoskeletal).
Menstrual pain was noted to be a highly prevalent in this population of
young women, but interestingly it was those women experiencing
non-cyclical pain that were found to have significantly increased
pressure and cold pain sensitivities, with the authors hypothesising an
augmentation in nociception as a possible symptom mechanism.
The findings of heightened sensitivity in the upper extremity rather
than being exclusively limited to the area of the pelvis are in keeping
with our current understanding of pain centralisation. Should these
findings be oversimplified, healthcare professionals risk minimising
patients’ pain symptoms as intrinsic non-modifiable factors. We must
appreciate that centralised pain may result from prolonged repeated
nociceptive stimulation from genitourinary pathologies such as
endometriosis that can be difficult to diagnose. Collectively we must
seek to understand whether early diagnosis and treatment of conditions
such as endometriosis can prevent centralisation of pain.
As highlighted by this study, it is possible that women with high pelvic
bothersomeness have increased sensitivity to pain. Although these
findings do not yet yield direct clinical implication, they identify an
important target for future research and treatment. It is essential
clinicians approach patient care according to the bio-psycho-social
model, considering treatable pathologies while optimising modifiable
lifestyle factors, psychological interventions, and appropriate
pharmacological management.
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