Pain and pathologyBMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c5995 (Published 26 October 2010) Cite this as: BMJ 2010;341:c5995
- G R Harrison, consultant in pain management1
My main concern with Daniels and Khan’s article is the Royal College of Obstetrics and Gynaecology’s algorithm, which states that “if no pathology is seen at laparoscopy, a letter of reassurance should be offered and the woman contacted for review a year later.”1 This ignores the fact that the woman is in pain. Many women with chronic pelvic pain never have a diagnosis, despite multiple laparoscopies. In many cases the underlying problem is visceral hyperalgesia,2 which cannot be detected with standard radiological or surgical techniques.
Offering reassurance is not helpful to a woman with severe pain that interferes with her life and may prevent her from working. All women with chronic pelvic pain should be referred to a pain management unit. It is unfortunate that few specialist pelvic pain units in the UK offer a multidisciplinary approach to pain management.
Endometriosis is another problem. Some women with no abdominal symptoms present for assessment of infertility and are found at laparoscopy to have grade IV endometriosis, whereas others with severe pain have extremely small endometrial deposits at laparoscopy (which are thought to cause the pain). Why is there such disparity between the pain and the degree of pathology? Could it be that endometriosis is painless but other conditions that we cannot assess or diagnose cause the pain?
Chronic pelvic pain is still an area of considerable ignorance. A great deal of research is needed before we can start to understand the pathophysiology of this multidimensional problem.
Cite this as: BMJ 2010;341:c5995
Competing interests: None declared.