As a comprehensive chronic pelvic and sexual pain specialist (GYN), the things I hear from my physician colleagues are sometimes a little sad. For example: I once introduced myself to the head of an emergency department. I encouraged him to let his partners know that I was seeing patients nearby. About 30 minutes later he sent me a text with some of the responses from his group. “She’s not a GYN, she’s a psychiatrist.” “Someone likes the crazies.” I can’t recall the number of times I’ve told another provider my niche, and they’ve looked at me like I have two heads.
Let’s be honest. How many of us cringe when we see “pelvic pain” as the reason for the visit on our schedule or on the ER board? I would guess most of us feel it is a natural reaction to seeing a patient that may be a “frequent flier” or someone that always seems to be complaining or med-seeking. I have a three-part theory as to why most providers feel this way, and some ideas about how to change everyone’s mind about these patients.
First, I think the sinking feeling of seeing “pelvic pain” on our schedule stems from not knowing what to do with these patients. Their complaints are often confusing, and they are unable to provide usable information. We, as doctors, do not like feeling inadequate. When we are unable to figure out what is wrong, it makes seeing these patients very frustrating. We have not had sufficient training in diagnosing and treating pelvic and sexual pain issues. The medical curriculum is threadbare in addressing pelvic pain. But, instead of realizing that we are not equipped to diagnose and treat, we blame the patient for being difficult. This is a huge failure of the system, not of us as physicians.
The way to ameliorate this first issue is to provide more training in pelvic and sexual pain issues within the curriculum of specialties that are likely to interact with these patients. We need to understand why patients can’t describe their pain (it’s called viscerosomatic and viscerovisceral convergence). And we need to realize that their brains are wired to overreact to pain signalling (called wind-up, hyperalgesia, and hyperesthesia). Suffice it to say, with chronic pain, context is everything. A chronic pain patient’s brain is overreacting to normal stimuli because they have been wired to do so, and the context fits. This means they literally can’t describe their symptoms, and frankly cannot know what is causing the pain. It is our job as the physician to figure out where the pain is really coming from. There are tools out there to diagnose and treat these patients, we just need to obtain them. Spoiler alert, it’s not another diagnostic laparoscopy.
The second reason we don’t like seeing pelvic pain patients is due to a hereditary issue. The physicians before us didn’t like pelvic pain, and neither did their predecessors. So, here we are, generations down the line, dreading the pelvic pain patient on our schedule all because we were trained by people who equally dreaded it. This is something we can stop in this generation of providers. I can assure you, pelvic pain patients aren’t crazy, and for the most part, they are not med-seeking. They have real pain issues that are difficult, yes, but treatable. Let’s do a better job as providers and physicians to get the training and education needed to provide care for these patients instead of continuing to pass them on like hot potatoes.
The third reason we have difficulty with pelvic and sexual pain patients is our inability to decipher who is “real” and who isn’t. There are patients out there who are very happy with their disability checks that don’t actually want to get better. And there are patients that are only med-seeking, who are all too ready to work with us until we deny them narcotics. In my experience, these patients are actually the exception, and not the rule. Most pelvic and sexual pain patients are genuinely in pain and want to get better. Their brains may be over-processing pain, but it is real pain. Let’s give the chronic pain patients the benefit of the doubt and believe them. The patient that doesn’t want to get better will start no-showing. And the med-seeker will stop bothering if you won’t prescribe meds. The rest that are left are “real”. We need to be ready and willing to see them.
Dr. Angie Stoehr, MD, is an ABOG certified Obstetrician/Gynecologist specializing in female pelvic and intimate pain in the Dallas-Fort Worth metroplex. Her medical blog can be found at www.whenithurtsdownthere.blogspot.com. She uses a comprehensive approach to treat patients with complex pelvic pain syndromes and sexual pain issues.