E26: 7 Domains of Pelvic Pain

There is a place above the knees and below the waist, that sort of rhymes, called the pelvis. And for 50% of people on the planet, those ones who are born with female parts, this is a very active place. And today, we're going to talk about pelvic pain in the "7 Domains."

This place, which is between the top of the legs and the top of the hipbones has, of course, bones and muscles. But the pelvic bones form a bowl. And inside that bowl is bowel and bladder.

And guys have those parts, but in women, there are also ovaries, and the fallopian tubes, and the uterus, and the cervix. And leading into that bowl is the vulva and the vagina.

Now, these organs are very dynamic. They are changing every day. Of course, the bowel fills up and empties, thank goodness. And the bladder fills up and empties. Also, thank goodness. But the ovaries swell with a follicle that has an egg, and it bursts. And fallopian tubes collect the eggs, and the uterus lining builds up, and then it squeezes everything out with a lot of squeezing once a month.

And the vagina has things that go on, and we'll leave that there. And the vulva has very delicate skin that's exposed to hardships daily: Lycra, and bicycle seats, and beach sand, and swimsuits, and other things we won't go into. It's amazing we don't have pain in one of these areas every day. But some women do. And today, we're going to talk about pelvic pain.

To help us understand pelvic pain, we have Dr. Howard Sharp joining us in the studio. And we're actually in the studio for the first time in a year and a half.

Dr. Howard Sharp is professor and Vice Chair for Clinical Affairs in the Department of Obstetrics and Gynecology at University of Utah Health. And he's the director of the Utah Women's Pelvic Pain Clinic.

Dr. Jones: Thanks for coming all the way into the studio, Howard.

Dr. Sharp: Well, thanks for having me. And that's a great introduction to the pelvis. Nice job. You know it so well because you've practiced it for a long, long time.

Dr. Jones: I have, and I've got one, so I'm interested. So, Howard, you are a phenomenal pelvic surgeon, and an OB. But what kind of directed you toward pelvic pain as a special interest?

Dr. Sharp: It really kind of happened partly by default, and partly by inheritance.

Dr. Jones: Oh, there you go.

Dr. Sharp: So, as you know, my father was on faculty for a number of years here, and he started the Pelvic Pain Clinic. So I have to say he is the one that started it here. And he was a little bit of a cowboy in that he would find something that he'd read about in literature, and then would do it. It's harder to just do that now, but at the time, he did that.

He went away and did a sabbatical in London with a guy named Richard Beard, and he learned how to do pelvic venography. And then he spent some time with Perry Fine and some of the other great anesthesiologists here that do the pain clinic and learned how to do trigger points.

Dr. Jones: I want to take a sidestep and say this was not early in his career. Your dad never stopped learning. He'd already had a phenomenal career as an OB-GYN in private practice. He was very sought after. He was one of the premier OBs. And when he came up to The U, he was always curious. And he took on the study of this problem that most of us just wanted to shut our eyes and plug our ears, and say, "We don't know anything about it." And he learned about it and he taught us.

Dr. Sharp: Yeah, I think he was someone who was very inquisitive. And so I think he realized it was a black box, if you will, and tried to learn about it.

So, briefly, the way I got it was when I finished my fellowship, he basically said, "You're taking over when I retire, right?" So I said, "I guess."

Dr. Jones: Yeah, right.

Dr. Sharp: That's history. That's it. That's how it started.

Dr. Jones: That's history? That's how it started? Well, we're grateful because it's a difficult field, and sometimes you have to say, "We don't know." So we're left with people who feel uncomfortable. They're in pain every day, and we don't always have the answer. We have a lot more answers than we did 15, 20 years ago, I'll tell you that, because there's a lot more known about how the brain processes information.

As we get to the physical domain . . . We're going to march through the 7 Domains. But starting with the physical domain, I don't want to ignore acute pelvic pain, because every person with women parts will probably have had pelvic pain at least once in their life. Maybe it was their first period that had cramps, or maybe it was labor, or maybe it was their first intercourse. But I'd say everybody's had an episode of pain.

And there are some kinds of pains that you can't ignore. So all of a sudden, down there, you have the worst pain in your life. What could that be?

Dr. Sharp: Even acute pain is sometimes difficult to figure out. So, luckily, we have a lot of diagnostic modalities. Sometimes that ovary you were talking about, which can distend, that will undergo torsion.

Dr. Jones: A twist. Yeah.

Dr. Sharp: It will twist. And that can be very painful, and is, in fact, of course, an emergency. Endometriosis. Sometimes when there is bleeding within the structures of the pelvis, that can be very painful. Sometimes a cyst will rupture and can cause some irritation. And then, of course, there are infections, pelvic inflammatory disease. So all of those things need to be considered.

Dr. Jones: And then, of course, the one that worries us all is ectopic pregnancy, a pregnancy in a tube that starts to grow and then ruptures. And that can cause pain.

So that worst pain that you've had in your life and you're not feeling well at all, either you've got a fever or you're getting dizzy, that kind of pain takes you to the emergency room for care.

Dr. Sharp: Yes. And we absolutely want to make sure that they come to urgent care, emergency care, so we can make sure that we can get them taken care of, and it's not something that's going to be life-threatening.

Dr. Jones: Right. But there are people who may have started with one acute episode, or maybe they just started with an ache that just got worse that's now bothering them a lot of the time. So when does acute pain become chronic pain? What's the definition of chronic pelvic pain?

Dr. Sharp: Well, there's a little bit of a time course to it, and it's somewhat arbitrary. But acute pain is thought to be pain that is less than three months, and a chronic . . . The important thing about chronic pain is that it is thought to be more than three to six months, but that it's non-cyclic.

Dr. Jones: Oh, yeah. Okay.

Dr. Sharp: The cyclic stuff is going to come and go, but chronic pain is more of an almost daily or the majority of the time. And so then we have to start thinking about other things. That's where the pain processing comes in. And that's probably the biggest difference between acute and chronic pain, is the processing of pain.

Dr. Jones: Well, tell us about who's processing. You're processing it, or the computer's processing it, or the brain is processing it?

Dr. Sharp: It's the way our brain and central nervous system process it. And we'll get into this with some of the other domains. For example, stress, childhood abuse, and things like that. But all of this can affect how our central nervous system processes pain.

I liken it to a highway. So you're on a highway. Maybe you're going on I-15 and it's totally congested. You can't get through because it's just too crowded. We have to somehow fix this such that we either make more lanes or we put fewer cars on the track. And so the central nervous system is having a hard time processing all of that signal, and we have to help in that regard.

Dr. Jones: Once memories about pain are laid down, we keep reinforcing them. I think sometimes about phantom pain. People have had a limb removed, because maybe it was painful, it hurt, they had something wrong, or a cancer. And that limb came off, but it still hurts them. The brain still has memories of that.

Dr. Sharp: Absolutely. And that probably has to do with some central sensitization, which is a similar thing. We think that central sensitization has to do with either duration or just the degree of pain.

I mean, I've had a lot of patients that had, for example, a terrible kidney stone. And the stone is passed, but they have this terrible pain in their flank that has just persisted. Eventually, we can get it to go away. The stone is well gone, but the pain persists. So that's a very severe pain that causes some maybe windup in the central nervous system.

But then you've also got that person that's had pain for years and years. Maybe it started out as a little bit of endometriosis, and now it's every day.

Dr. Jones: There's a concept that was discovered . . . or not discovered, but articulated in the '70s, called the biopsychosocial model of disease. And a really smart psychiatrist from the University of Rochester, very wise man, said, "All diseases have within them, and how we cope with them, and how we heal them, the biological part, the social part, the psychological part." And recently, we've added the environmental part.

How we get better means we have to get better in all these domains. So it's kind of the 7 Domains before the "7 Domains." So we picked up after this wonderful model.

Let's talk a little bit about emotional pain, because it's always hard to know whether someone is emotionally in pain, and that makes their pain worse. Boy, if I've had a toothache for a week, I am not a happy camper. And I'm normally a happy camper.

Dr. Sharp: Oh, you are?

Dr. Jones: I am.

Dr. Sharp: Well, it's so true. If you have a toothache, and you're driving down the road, and someone cuts you off, that toothache is going to get worse because you added stress. And that's just true. Then you add that to someone who has chronic pain all the time, that becomes pretty significant.

Dr. Jones: In terms of this emotional process, I'm thinking about people who are resilient. I've seen people with horrible problems in their pelvis. I mean, truly horrible. And when I asked them about their daily life, they talk about the work they're doing in their community, and they talk about visiting their parents, and they don't talk about the fact that their ovaries are stuck to everything and everything is scarred up. Are there some people who have an emotional construct that makes them more resilient?

Dr. Sharp: Well, I think so. And we know that there's a lot that goes into this. For example, history of abuse. A terrible thing. And particularly, there have been studies that have looked at what percentage of patients with chronic pelvic pain will admit to or . . .

Dr. Jones: Acknowledge.

Dr. Sharp: Acknowledge, yeah, that they've been sexually abused. It's almost 50%. And of those, about a third of them would score high on a post-traumatic stress disorder screen.

The earlier in childhood that that happens, it really affects the neural processing. So they may have a much harder time dealing with something with all that has happened to their central nervous system over years. So that might be a person that may be less resilient by no fault of their own.

Dr. Jones: By the time many women actually get to your clinic, because you see patients throughout the Intermountain West, kind of from the Rockies to the Sierras, they often have a long history of both emotional trauma and, of course, the pelvic pain.

They may have been given narcotics, and they may be self-medicating with alcohol. And they are anxious, and they may be self-medicating with other drugs. Those kinds of things help you for a little minute be away from your pain, but they bring back the pain doubly when you withdraw.

Dr. Sharp: Yeah. It's a tough thing because there's desperation.

Dr. Jones: Yeah. You see this every day.

Dr. Sharp: If you told somebody to go stand on their head for 10 hours a day, they would do it to get rid of it. I mean, it's that tough for them. So a lot of them are just grabbing anything that they can. Then the opioid addiction happens, and then you can even get opioid-induced pain. So it really is a destructive cycle.

And so one of the things that we try to do in the Pelvic Pain Clinic is try to understand what medications are they taking? What therapies have they used? And a lot of it is education. It is really trying to change how they think about their disease, and give them some new tools.

Dr. Jones: With respect to privacy for your patients, is there a patient or somebody who comes to mind who was successful in all those things?

Dr. Sharp: I remember a patient who came and actually could not stop crying throughout the entire interview that I met with her. And she came in with her mother. She had been recently married, but could never consummate the marriage. So intercourse was terribly painful. Had seen a number of docs, ended up getting put on lithium for bipolar disease. They actually had her marriage annulled because it just wasn't going to work for the interest of the husband. So she was pretty broken.

And we went through this. We found out what her problem was. She did not need to be on lithium at all. She got a complete fix. Needed the right diagnosis to get rid of some of the things that she was going through. But I'll never forget that patient.

Dr. Jones: And the fact that you weren't judgmental, and you took some time to learn the biopsychosocial, all the things that came around with her. And especially, to be a woman and think that your life is going to be maybe being married and then being a mother, and not be able to engage in the kinds of social and intimate acts that will create that, what a loss. What a loss.

Dr. Sharp: Yeah. Totally devastating for her, and she had no hope.

Dr. Jones: Yeah.

Dr. Sharp: So we don't always win, but most of the time, we can improve and help and get things going the right direction.

Dr. Jones: Well, Professor, we're going to do a medical mystery. We have a listener who's a 25-year-old, and she tells her story as being a woman who . . . she's never been sexually active. She has been very physically active. She's been an athlete. And she always had painful periods, but now she has pain every day. And whenever she goes and works out, she's a runner, and just running hurts her pelvis.

She's kind of stopped doing everything, and she isn't sure what it does. It's worse with her periods, but it's worse every day. And sometimes it feels like she's . . . it hurts when she has bowel movements, and then it hurts when she eats too much. And everything down there is all messed up. So what's going on?

Dr. Sharp: So how long has she had painful periods?

Dr. Jones: She's had painful periods since she was maybe 15.

Dr. Sharp: It's a long time.

Dr. Jones: Yeah.

Dr. Sharp: And then it just kind of gradually became more of a constant problem?

Dr. Jones: Right. And she's seen a couple doctors and they just said, "Oh, here's some ibuprofen," or, "We'll put you on birth control pills." But that made her gain a little weight, and then she couldn't run. She stopped that, and now she just hurts all the time.

Dr. Sharp: Well, I have a guess. I wonder if she has levator tension myalgia.

Dr. Jones: Ah, yeah.

Dr. Sharp: So what often happens when you have painful menses . . . I mean, of course, that could be endometriosis, could be primary dysmenorrhea, just painful periods. But often as that happens, people kind of clench and tighten, and so the pelvic floor now is very painful. And so when you run, pelvic floor is going to have to tighten, and all those muscles are basically in spasm. So that'd be my first guess.

Dr. Jones: So in what we call differential diagnosis, it might be just dysmenorrhea. I suppose it could be endometriosis, or this condition which wraps up her running and her pain. How are you going to figure that out?

Dr. Sharp: Well, we do a pretty involved questionnaire. I have a nine-page questionnaire that goes over what's going on with her GI tract? What's going on with the GU tract? So a lot of questions about that. The physical exam is key. So history and physical. MRIs, ultrasounds, much less helpful for chronic pain. So the key thing is going to be to do that exam and see if her levator ani muscles are tender on exam.

Dr. Jones: Okay. So those are the muscles that are right in her pelvic area?

Dr. Sharp: Yes. So, as you talked about the pelvis being a bowl, that's the bottom of the bowl, and those muscles hold everything in. So it holds the bladder, the cervix, the rectum. All of that is held in with those muscles.

Dr. Jones: If you do that exam, and you push on those muscles, and she says, "Oh, that really hurts," what would you do for that?

Dr. Sharp: So couple of things. First of all, we want to know is there something going on with the pelvis? Is it out of alignment? Sometimes I'll get a leg-length discrepancy. Maybe their sacroiliac joint is out of alignment.

Then we get physical therapy to get them back in alignment. And then we also sometimes have to do pelvic floor physical therapy, where they actually work those muscles out and teach them how to do biofeedback.

Dr. Jones: That would be great because she'd like to go back to running again. She was actually hoping to be a collegiate athlete, but she had to stop running in her junior year. And so she might actually be able to get to it.

Dr. Sharp: Yeah. Let's get her back out there. Physical therapy, one of the most helpful things.

In fact, it's interesting. I got involved with this group called the International Pelvic Pain Society. And as it turns out, most are gynecologists. But over the years, many more are physical therapists. And they are the secret weapon to so much pelvic pain in terms of therapy. They do a great job.

Yeah, the history and the physical exam really are the two most valuable portions of figuring it out.

Dr. Jones: And that would be so great for her because she's already physically minded, and being able to use her body in a way that didn't hurt her, in terms of working with a physical therapist, would probably really reinforce her sense of her body's strength and autonomy again.

Dr. Sharp: Absolutely.

Dr. Jones: Yeah, it would really get her body back.

Dr. Sharp: I mean, she can actually heal herself as she learns to do her own biofeedback with someone. Absolutely.

Dr. Jones: That would be great.

I want to talk a little bit about the social domain, because anybody with chronic pain, whether it's headache, or a backache, or belly pain, but particularly pelvic pain, it affects their life at home. Certainly, it may affect their intimate life with their intimate partner, but they're also maybe not able to be the mom or the support person for all the people that women have to take care of.

Dr. Sharp: Absolutely. This is such a critical part, because you think about someone that is functionally disabled, they cannot go running anymore. They might not even be able to go out to eat anymore. So it affects everyone in their family, and it really creates a very dysfunctional social dynamic. We have to find out what they're able to do. What are they not doing now? And so, yeah, that's a critical part of that.

Dr. Jones: Right. And it's part of that biopsychosocial part.

Well, I also think about the financial domain, because if these are women who provide . . . either they're working for their own income because they're single, or they are providing for their family, when you're either taking drugs which keep you from being able to function, or you can't work several days out of the month, or you lost your job because you just didn't come in enough days, it affects your financial life as well.

Dr. Sharp: Yeah. And you're also spending a lot of money on healthcare.

Dr. Jones: Oh, yeah.

Dr. Sharp: So many appointments. Yeah, the financial piece is pretty significant, so it behooves us to try to do more with the history and the physical rather than getting MRIs on everybody.

Dr. Jones: Well, I've been thinking a little bit about the environmental domain just because we did some research here in Utah with the reproductive endocrine division, looking at people who are going to have laparoscopies for any one of a number of reasons, and measuring to see if they had levels of toxic chemicals in their blood.

And they found that women who had higher levels of DDT and PCB . . . and both of these chemicals have been banned, but they were banned some years ago. Women now are reaping the persistence of these drugs in their bodies, and they had a higher incidence of endometriosis than women who didn't have high levels.

So we know the environment can actually change the way our pelvis reads estrogen. It may proliferate things like endometriosis, maybe even fibroids. So the environment fits into pelvic pain as it changes the pelvis in ways that we weren't really expecting.

You mentioned that helping people learn more is really a good one. But I think that there's been so much in the pain domain in terms of cognitive and behavioral therapy. You have worked with therapists. Is there someone that you work with there?

Dr. Sharp: I don't have one in my clinic. There is one at the Pain Management Center, and then there are experts that work with this in the Valley. But it is really important. In the past, I think, a lot of times, if we haven't found the answer, we've said, "Go see a psychiatrist." And that is not helpful. It is much more helpful to say, "There are some psychological aspects of this that we need some help with."

And actually, I usually start with mindfulness and some of that. You can do some self-help. And then we will often get the pain psychologists involved, which are very helpful.

The reason for this is not because they're "crazy." The reason is that . . . Remember we were talking about the headache and driving down the street and someone cuts you off? It's recognizing when you get stressed or irritated, and then saying, "Oh, yeah. What can I do? I'm now mindful enough. I'm now realizing that I'm getting stressed. What techniques can I use?"

And that's where pain psychologists come in so well, is to teach how to deal with that. We're not necessarily going to cure someone by sending them to the pain psychologist. We're going to help. And I think that's the mindset that I try to explain to patients, rather than just handing them off.

Dr. Jones: Right. Help them be more resilient.

Dr. Sharp: Yes.

Dr. Jones: In other words, they know that some days are good days, and some days are bad days, even though their pelvis is the same both days. So how is their brain different on the bad day? And what things can they do to make more bad days into okay days?

Dr. Sharp: For sure. Well, here's a stocking stuffer for you.

Dr. Jones: Okay. I'll take it.

Dr. Sharp: Go get everyone in your house "Full Catastrophe Living" by Jon Kabat-Zinn. So he started the mindfulness program at University of Massachusetts a long time ago.

Dr. Jones: Very famous guy.

Dr. Sharp: Yes. He's now retired, but does a TED Talk. He's just brilliant. I actually recommend that book to my patients. And the reason for that is there's a lot in there that really teaches how to be resilient. And it's kind of the blueprint on this. Now, there are a lot of other books, and that's an older one, but they change it.

Dr. Jones: Everybody refers to him, though. Everybody refers to him, because he did the very first work to show that you could lower blood pressure, that you could lengthen people's lives who had cancer.

Dr. Sharp: Yes. And there are actually decent studies on this.

Dr. Jones: Yeah.

Dr. Sharp: Cancer, blood pressure, all that, yeah. So I think it's critical that we have some kind of a psychological domain that is addressed with chronic pain.

Dr. Jones: Well, that's where having people . . . You have to listen enough that they trust you, that when you say, "I think we're going to need to help your brain be more resilient," they're not going to turn that volume down on you, because you have to listen long enough that they'll leave you.

Dr. Sharp: So true. And I still struggle with that, because sometimes I'll come out of a patient interaction and I think, "Did I think they listened to me, and did I listen to them? Did we communicate? Did we connect?" And I think that trust . . .

A lot of times, people come in, and they've been told that they have adhesions or endometriosis. And they may have that, but it may be a "true, true, unrelated." They have endo, they have pain, but they've got this chronic pain, and we have to reeducate them. And sometimes that's a bitter pill to swallow when they've been told something different for years and years.

Dr. Jones: Oh, and they've had five operations already and they want you to do their sixth, or seventh, or eighth.

Dr. Sharp: Yes. So it's hard to gain that trust often in one visit. But when you get that connection, and you both know it, you and the patient . . . I mean, you've known that over the years.

Dr. Jones: Of course.

Dr. Sharp: There is nothing so great.

Dr. Jones: I completely agree.

I always want to focus a little bit on the spiritual domain, because we don't always know what people's spiritual foundations are when they come to see us. And sometimes when they are crying the whole time, you get a feeling they've got nothing to hang their hanger on spiritually.

But there have been several studies on chronic pain that suggest that people who have a stronger spiritual foundation . . . It doesn't have to be religious, although it can be helpful if the religious foundation is a positive one. Some religious foundations are not always positive.

But people who have a positive religious or spiritual foundation have somewhere to go when they feel like they're adrift. They have somewhere to go. And practicing that foundation can make people feel better.

And so there's a study where they took patients with pain, and some had pelvic pain, some had chronic headache, some of them had arthritis pain. They were mostly women.

And they randomized them to just being restful, taking a restful time, doing mindfulness training, or doing some spiritual-based mindfulness training where they were trying to connect to something bigger, or feeling that they were part of something important, that they were important because they were a part of it.

So they would practice this 20 minutes a day, and then they would come into the lab and take their hand, and put it in icy cold water. How long could they hold their hand in the water?

You know I've told you this. It turns out that people who had the spiritual-based training, they had the same amount of pain, but they could hold their hand in the water for twice as long. So it's as if they were little bit more resilient to the input from the icy water on their hand.

Now, I'm not saying that it fixes everything. But when we think about how we go from bad days to okay days, how we feel like we're part of something bigger instead of something that's so tiny, and focused, and small in our pelvis, those are things that it's not something . . . For us in the office, we don't always have those tools. But if we don't find out what tools people actually have, and encourage them to build on those, then we forget that whole domain.

Dr. Sharp: Yeah. I think it's part of the network. Everyone needs a network. And if it's a spiritual mentor or a religion, great. That's one more part of the network. So, yeah, I think that's a great point.

Dr. Jones: Okay. Before we go, I want to ask . . . We often ask questions at the "7 Domains" about whether you're normal. Women want to know, "Am I normal? I have this. My breasts aren't the same size, or I sneeze all the time. Am I normal?"

So you've taken care of thousands of women, and they come to you maybe for their annual exam, or come to you and they say, "I have an ache somewhere. And it seems to come a couple days a month, and then it gets better. I hadn't really called you up to complain about it, but it just is there sometimes, but then it goes away. Am I normal? Is this normal?"

Dr. Sharp: Well, hopefully.

Dr. Jones: I like that.

Dr. Sharp: I'm going to use part of the definition of chronic pelvic pain, and that is pain that also leads to dysfunction, worry, or a visit to the doc. So if it's something that is really worrying you, it's worth getting it checked out. And there might be some things that is a very transient pain that's probably not a big problem. But recurrent things, if it keeps coming back, or if it's persisting, that would be abnormal. And I want to see that patient.

Dr. Jones: Okay, good. So little bit is okay. Most things are fixable. But you want to rule out the bad things.

Dr. Sharp: Yes.

Dr. Jones: Yeah. Well, thanks for joining us.

And remember, for those of you who are listening, thank you for joining us. You can get our podcast wherever you get your podcasts. We have other great shows here on The Scope.

But I'm going to finish with my "7 Domains of Pain" haiku.

It hurts every day
But some days are brighter now
There's a path ahead