Chronic pelvic pain

KENNETH P. GLINTER, Trenton, Michigan

D.O.

Pelvic congestion

Chronic pelvic pain of no organic cause often is the result of the patient's prolonged, repressed anger. Diagnosis should first rule out organic pelvic disease such as endometriosis, chronic pelvic inflammatory disease, and malignancy by diagnostic gynecologic endoscopy, culdoscopy, or laparoscopy. Internal stress is expressed as a psychosomatic symptom, producing chronic pelvic vasodilatation, congestion, and pain. Most patients are or have been married. The patient is often immature, insecure, without sexual drive, and hostile toward her husband. Hysterectomy merely treats the symptom, not the cause. Psychotherapy, while releasing the woman's repressed anger, also may cure the pain.

described by Duncan and Taylor.' While Duncan and Taylor describe a syndrome, chronic pelvic pain has been the predominant complaint in our patients. In fact, it was the frequency of this symptom, which required diagnostic gynecologic endoscopy, culdoscopy, or laparoscopy at our hospital, that served as an incentive for delving further into the problem. Symptoms of pelvic congestion, such as secondary dysmenorrhea, low-back pain, dyspareunia, leukorrhea, and menstrual abnormalities are seen much less frequently. In most cases, after viewing the entire pelvis through the endoscope we were unable to find a cause for the pain. The pelvis was usually normal and no definite diagnosis could be made. Description of pain Chronic pelvic pain, as described in the literature 1,2 and by our patients, is characteristically a constant, dull, aching type of pain located in the suprapubic region or in one or both lower abdominal quadrants. Patients are unable to localize the pain and tend to indicate all or part of the lower abdomen. Occasionally, the pain is referred to the back or to the anteromedial aspects of the thighs. It is usually worse premenstrually and is aggravated by fatigue, intercourse, or prolonged standing. While many women report relief with menstruation, others complain of dysmenorrhea. The pain, which will be called psychogenic, or functional, is distinctly different from organic pelvic pain, which is usually sharp, crampy, intermittent, and radiating in a consistent, rational fashion. Organic pelvic pain frequently awakens the patient at night,3 whereas psychogenic pain is absent during sleep. Organic pain tends to be localized, and the patient usually can identify the area of

Chronic pelvic pain in women is a problem frequently encountered by the gynecologist. Its many possible causes make it difficult for the physician to arrive at a definitive diagnosis. Chronic pelvic pain as discussed here is not caused by endometriosis, chronic pelvic inflammatory disease, malignancy, or any other organic disease. After all organic causes have been ruled out, this pain still persists, challenging the physician for an explanation. I define chronic pelvic pain as a lower abdominal pain that has been present for 6 months or more with no organic pathologic findings. It appears to be identical to the pelvic pain in pelvic congestion syndrome, as

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maximal discomfort. It is usually of short duration, because organic pain quickly progresses to the point of hospitalization or subsides spontaneously .3 Functional, or psychogenic, pain may last indefinitely. Chronic pelvic pain is "real" pain. Calling it functional does not imply that it is imaginary. Pain can occur in a context of purely psychologic experiences.2
Characteristics of patients

Most patients were quite pleasant when we talked with them, but they did not appear to be very happy. Almost all were or had been married. Many were restless and complained of "nervous tension" and of conditions unrelated to the pelvis, uch as cephalgia, chronic fatigue, indigestion, or insomnia. Some authors 1,2,4,5 suggest that women with chronic pelvic pain are psychiatrically disturbed, although it is not always apparent when they first are seen by the physician. These women have been shown to be emotionally immature, extremely dependent, and unable to express hostility. Many are critical of their husbands, blaming them for their own emotional difficulty, and frequently accusing them of being the cause of their chronic pelvic pain. 4 The pain was often an excuse to avoid intercourse. These women also show a high incidence of previous gynecologic surgery, often for removal of a part or of a whole ovary or both ovaries for pelvic pain. 2 ,5 6 McCann and associates5 report frequency as high as seven times that of a control group. The surgeries were usually an earlier, unsuccessful approach to the management of chronic pelvic pain.
Stress, pelvic pain, and the autonomic nervous system The onset of chronic pelvic pain usually can

be linked to a stressful event or crisis in the woman's life. 2, 5 While pregnancy is the most common, other problems include family crisis, marital conflict, or loss of a supporting figure. This correlation suggests that the syndrome is a stress disease a bodily reaction to an experience or situation that is stressful.' While there have been many hypotheses as to the nature of this disorder, Taylor s , suggested that the syndrome of pelvic congestion, of which pelvic pain is the most predominant manifestation, is a disorder of the pelvic autonomic nervous system. Circulation of the female pelvic organs is controlled primarily by the pelvic autonomic nervous system.8 Several factors may affect pelvic circulation, such as anatomic and mechanical factors and the sympathetic and parasympathetic nerve supplies to the uterus and other pelvic structures. Generally, the parasympathetic system causes vasodilatation of the vessels and inhibition of the musculature, while the sympathetic system produces the opposite effects. Chronic vasodilatation of the pelvic vessels is believed to be responsible for pelvic congestion and chronic pelvic pain, and psychic stimuli have been shown to cause this vasodilatation through profound effects on the autonomic nervous system.8 Duncan and Taylor' have shown that the pelvic vascular system is highly responsive to the mental state and that pelvic vascular changes frequently occur in psychiatrically predisposed patients. Increased pelvic blood flow occurred in women with chronic pelvic pain during periods of emotional tension, particularly those relative to resentment aroused by discussion of problems concerning their husbands and/or children. This work demonstrates the presence of a

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mechanism that is consistent with the theory of pelvic vascular change as a psychosomatic disorder. Psychosomatic illness is the development of physical symptoms whose causes are psychologic.9 It is often the result of sustained internal stresses to which the body is subjected when powerful but unacceptable emotions, such as anger, are denied awareness and expression, thereby becoming imprisoned within the physical system. The psychosomatic symptom is the ultimate expression of the repressed emotion. The pelvis and repressed emotions The prolonged repression of an emotion, specifically anger, leads to chronic internal stress which may result, through the pelvic autonomic nervous system, in chronic pelvic vasodilatation, which may then manifest itself in a variety of ways. Chronic pelvic pain is the predominant symptom produced; it is apparently due to a tendency to hyperalgesia in various areas supplied by the sensory components of the pelvic visceral nerves.6 Chronic pelvic pain is then a disturbance of the autonomic nervous system mediated through the pelvis as a result of the prolonged repression of emotions, particularly anger. Two authors 2 ,3 acknowledge the pelvis as the site chosen for the expression of repressed emotion, but they offer no explanation. Marbach 10 states:
This area is the seat of so many emotional disturbances and pleasures, satisfactions, guilts, deprivations, hostility, anxiety and fear that it seems almost logical that this area is so responsive.

and problems with children leading the list. In a group of women grossly inadequate in the spheres of sexuality and motherhood it is perhaps understandable that the reaction to such stresses should involve the reproductive tract.

I would like to suggest another explanation for selection of the pelvis to express repressed emotions. As has been noted previously, women with chronic pelvic pain are extremely dependent and are unable to adequately express anger, a basic human emotion. While some experience, express, or sublimate emotions, others repress them, and it is my feeling that chronic pelvic pain is an ultimate result of the repression and perversion of anger. Repressed emotion Branden 9 points out that parents teach their children to repress feelings early in life. A young girl may express anger at a sibling or show dislike for an older relative, only to be scolded by her parents for such "bad" feelings. Her mother or father may say, "It's terrible to feel that way. You don't really feel it." Emotionally remote and inhibited parents tend to produce the same type of offspring. The parents define acceptable and proper behavior by direct communication to the child and by example. The child may soon believe that if her behavior is not acceptable or proper her parents will not love her. In this way a child can be led to believe that her feelings, especially anger, are potentially dangerous and that sometimes it is advisable to den y them, that they must be controlled. The young, entirely dependent child may literally "sell her soul" so that she may receive the love and acceptance she needs. This effort to control emotions amounts to the child learning, as Branden 9 says, to "disown" her feelings. She ceases to experience them. She learns not to acknowledge or rec-

oped were most often ones requiring the patient to function as a woman or serving to raise serious doubts as to her capacity to do so, with pregnancy, marital conflicts,

And Duncan and Taylor' noted: ... the life situations in which pelvic congestion devel-

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ognize undesirable feelings, and she rapidly deflects her awareness from them and represses them on a subconscious level. Repression is a process very different from learning to regulate behavior in a rational manner. In repressing or disowning feelings, we censor and deny inner experience.9 The pelvis and anger Why may the anger of the young girl eventually be expressed through the pelvis of the woman? As the young girl matures, she becomes acutely aware of her femininity and sexuality. Society teaches her how to use these to advantage and educates her in "how to get a man." She is taught what roles will attract men to her. As Willard Cooke"" once said, in his presidential address to the American Association of Obstetricians and Gynecologists:
The winning of a husband is the principal occupation of the average woman. She is trained to it during adolescence, and almost all of her social life and contacts are designed with this in mind. Hence, there is intense concentration on the development of personal beauty, adornment, and attractiveness to a degree which reacts to create a dominant egocentrism.

A good example of this concentration is seen in the advertising media, which exploit the female's conditioned need for more physical attractiveness. The adolescent woman is taught by society: The more sexually appealing you are, the more attractive you will be to men and consequently, the more approval and love you will have. She soon learns the tremendous importance placed on her femininity and sexuality and realizes that the seat of characteristics that make her distinctly feminine are her genitalia and pelvic organs. Through subtle conditioning and pressure, she begins to believe that her physical appearance and sex appeal are her most important aspects. She is faced with a con-

flict between society's values and her personal feelings of self-worth. She may feel, "I'm more than just a pelvis or vagina. I have a lot more to offer." But all around her she sees primary importance placed on her physical appearance and sex appeal. Often women with chronic pelvic pain complain bitterly about being abused as sex objects, but their frequently seductive manner of dress suggest internal conflict 3 ,5 They often relate poorly sexually". Intellectually, they do not accept themselves as sexual objects, but societal pressures have shortcircuited emotional growth, and struggle ensues. The conditions are now set for the expression of emotions, particularly anger, through chronic pelvic pain. Thus the patient with chronic pelvic pain is seen to be a dependent woman who has learned when very young that the expression of her anger is unacceptable and should be controlled if she wants to be loved. She has been taught by society that her physical attractiveness and sex appeal are the most important things about herself. It has been shown that most of these women marry early; in one study 17 was the average age at first marriage. 2 Instead of establishing a close relationship with another person, and encouraging free expression of emotions as a sign of mutual concern, marriage for this woman usually perpetuates repressed anger, abetted by her still strong dependency and fear of rejection. She fears her husband's withdrawal of love just as she feared her parents'. Anger can be repressed within the body only so long before it demands expression. Internal stresses build up and the body must have a release. Finally, the anger may be expressed as a psychosomatic symptom chronic pelvic pain. In using this method of

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expression, these women are employing what they have been taught is the most important part of themselves the pelvis. The pelvis serves well as a mode for the expression of anger, because pelvic pain can be and often is used as an excuse for avoiding sex. If societal indoctrination has taught a woman that her pelvis and genitalia are her most important parts, quite likely her husband believes the same thing. What better way to express her repressed anger toward him than by denying him the most important thing he wants from her sex? Chronic pelvic pain is a more socially acceptable expression of the woman's anger than verbal rage, which brings the possibility of rejection by her husband. When troubled by pelvic pain, however, she may receive sympathy and understanding from him. Repressing her anger is more comfortable and less threatening to the marital relationship. It is unfortunate that these women handle the situation in this way, for, as Rubin 12 says, "If a relationship is destroyed by a show of anger, then there's an excellent chance that it was a sick, destructive affair and that all parties are better off for its termination." But it should be understood that, as Branden 9 has shown, the whole process of repressing anger is done on a subconscious level and the choice of the pelvis for the expression of anger is also subconscious.
Treatment

Before beginning a discussion on therapy, it is essential to point out that in the workup of chronic pelvic pain, extensive investigation and numerous consultations may be required to rule out an organic lesion. 3 Intravenous programs, upper gastrointestinal and gallbladder x-rays, barium enema, urine cultures, sigmoidoscopy, x-rays of the dorsal

and lumbar spine, and repeated pelvic examinations are sometimes necessary in the diagnostic workup. Gynecologic endoscopy, laparoscopy, or culdoscopy also should be performed. Occult pelvic disease, such as endometriosis, and chronic pelvic inflammatory disease should be ruled out. The first step in treatment of chronic pelvic pain without organic disease is to reassure the patient that her condition, although troublesome, is not serious or progressive. 6 Reassurance that there is no pelvic pathologic condition, as confirmed by gynecologic endoscopy, may alleviate a fear of cancer, which could add more anxiety to an already distressed patient. Factors of fatigue, situations of stress, and more specific problems of her marital relationship should be discussed with the patient. The physician must accept the fact that the patient really is troubled and in pain. She must be respected as a person and allowed to express her anger and she should be encouraged to continue to express her anger and other emotions while she becomes independent.2 Contact with the husband is very important, to familiarize the patient's husband with the problem and to discuss his role in the conflict. Often it is necessary to reassure him as well, because he may become threatened by the sudden change in the marital relationship. Seeing the husband and wife together may help to bring her anger to the foreground. Mild cases, or those of short duration, usually improve without psychiatric consultation, but psychiatric therapy will have to be considered at some point in the treatment of severe cases.2,6 Taylors reports that hysterectomy seems justified in the small percentage of patients who are 35 years of age or older, desire no

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additional children, and who have had severe symptoms for a number of years. He feels that surgery becomes more justifiable if there is complicating menorrhagia or organic disease in the pelvis. In the presence of pain alone, psychiatric consultation is indicated before hysterectomy is undertaken. Hysterectomy may cure chronic pelvic pain, but it treats the symptom, not the problem. The patient may simply transfer her symptoms to another organ. Chapman 13 points out that functional pelvic pain and pelvic congestion syndrome are responsible for a great deal of needless surgery in our hospitals today. He believes that the physician, out of frustration in treating the symptoms, resolves the problem with a hysterectomy, only to be amazed and disappointed later because the patient does not get better and often, in fact, gets worse. Until physicians can accept the concept of psychotherapy for this problem, they will continue to treat chronic pelvic pain by medical and surgical methods. Even after acceptance of this concept by physicians, there will be resistance to therapy because they will not believe that emotional problems can cause so much physical distress. Chapman" states:
Our culture must some day come to realize that pain can be caused by emotional short circuiting of the nervous system, that this pain is real and intense, and that it can only be relieved by proper emotional treatment, not by the knife ..

psychiatrists fear, there is a transfer of symptoms to another part of the body following surgery.
Summary

While Taylors reports good results in his small series of women who had hysterectomies for unexplained chronic pelvic pain, the longest follow-up was for 2 years. It would indeed be interesting to see a longterm follow-up on these women, for at least 5 to 10 years, to see if there is definite improvement following hysterectomy, or if, as

Chronic pelvic pain is a problem frequently encountered by the gynecologist. After ruling out organic pelvic disease, such as endometriosis, chronic pelvic inflammatory disease, and malignancy, it is difficult to make a definite diagnosis. This problem is frequently associated with nervous tension and other vague complaints unrelated to the pelvis, such as cephalgia, chronic fatigue, indigestion, or insomnia. While,it is not always apparent initially, most of these patients have a psychologie disturbance. The onset of chronic pelvic pain can usually be linked to stress in the woman's life. Psychic stimuli have been shown to have profound effects on the pelvis, mediated through the autonomic nervous system. These psychic stimuli are the result of repressed emotions, usually anger, which subjects the body to sustained internal stress. When the internal stress becomes too much for the body to contain, it is ultimately expressed as a psychosomatic symptom, in this case chronic pelvic pain. The process of repressing emotions begins very early in the young girl's life as her parents, because of their own emotional problems, do not allow her to express her feelings. She needs their love and acceptance, but she feels she will not get them if she expresses anger. She then grows up believing that love will be withdrawn when she shows anger, and she carries this belief into marriage. Ultimately this prolonged repression of anger results in psychosomatic expression through chronic pelvic pain. Therapy is based on acceptance of the theory of psychosomatic ill-

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ness and helping the patient to express her anger and other emotions. Many cases improve spontaneously, while others require psychiatric consultation.
1. Duncan, C. H, and Taylor, H. C., Jr.: A psychosomatic study of pelvic congestion. Am J Obstet Gynecol 64:1-12, Jul 52 2. Benson, R.C., Hanson, K.H., and Matarazzo, J.D.: A typical pelvic pain in women: Gynecologic-psychiatric considerations. Am J Obstet Gynecol 77:806-25, 25 Apr 59 3. Page E.W.: Psychiatric problems in obstetrics and gynecology. Psychosomatics 8:251-4, Sept-Oct 67 4. Gidro-Frank, L., Gordon, T., and Taylor, H.C., Jr.: Pelvic pain and female identity: A survey of emotional factors in 40 patients. Am J Obstet Gynecol 79:1184-1200, Jun 60 6. McCann, E.C., Morrison, R.M., and Miller, B.A.: Panel on pelvic congestion syndrome. Trans New Eng Obstet Gynecol Soc, 21:71-88, 1 Nov 67 6. Taylor, H.C., Jr.: Pelvic pain based on a vascular and autonomic nervous system disorder. Am J Obstet Gynecol 67:1177-96, Jun 54 7. Taylor, H.C., Jr.: Vascular congestion and hyperemia; their effect on function and structure in the female reproductive organs. Am J Obstet Gvnecol 57:654-8, Apr 49 8. Taylor, H. C., Jr.: Vascular congestion and hyperemia; their effect on function and structure in the female reproductive organs. Am J Obstet Gynecol 57:211-30, Feb 49 3. Branden, N.B.: The disowned self. Nash Publishing Corp., Los Angeles, 1971 10. Marbach, A. H.: Psychiatric problems in obstetrics and gynecology. Int Surg 48:524-32, Dec 67 11. Mengert, W.F.: Practical Ob. Gyn.-The Open Line. Ob Gyn News 7:38-41, 15 Jun 72 12. Rubin, T.I.: The angry book. Collier-MacMillan Limited, London, 1969, p 169 13. Chapman, J.D.: The feminine mind and body. Philosophical Library, New York, 1967, p 204

Submitted for publication in November 1972. Updating, as necessary, has been done by the author. This paper, an entry in the 1972 PhilipsRoxane writing award program sponsored by the American College of Osteopathic Obstetricians and Gynecologists, was written during Dr. Glinter's residency in the Department of Obstetrics and Gynecological surgery at Riverside Osteopathic Hospital, Trenton, Michigan. Dr. Robert J. Nelson is chairman of that department. Dr. Glinter, Suite C. 2865 West Rd., Trenton, Michigan 48183.

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