Saturday, 12 December 2009

Gynaecology - Debunking Pelvic Pain

What causes pelvic pain? Nerves? without nerves, the body is numb. Pain is felt when nerves send messages to the brain. If the nerve supply is interupted or blocked, pain is blocked. Pain indicates damage. This may be damage to the nerves, muscles, ligaments, joints and organs the nerves supply. If the damage does not heal, the pain becomes chronic.

Chronic pelvic pain is relatively rare in women who have not had children or without some other cause of pelvic damage such as chronic constipation, spinal injury, back problems, or an eating disorder.

Yet when Obstetricians and Gynaecologists talk about pelvic pain, few consider the underlying damage that might be contributing to the pain, damage to the nerves, muscles and ligaments in the pelvis! Very few Gynaecologists have even seen the pelvic nerves, let alone understand their function and how easily they are damaged. This mesh of delicate nerves is lies against the side bones of the pelvis and most gynaecologists know very little about the nerves and anatomy of the pelvis

This is one of the largest networks of nerves outside the brain. It keeps the pelvis, reproduction functions, bladder, colon, rectum and lower limbs functioning properly, as doctors we interfere with it at our patients' peril. If this network is damaged, the person experiences pain in the pelvis, infertility, as well as bloating, nausea diarrhoea and any number of symptoms associated with the last part of the gut and rectum. Like all parts of the Autonomic Nervous System it also plays its part in managing blood pressure.

Click here and Click here to learn more about Pelvic anatomy

Even yesterday, a woman told me how her GP (a woman) had told her that nothing could be done about her chronic pelvic pain and that it was probably caused by stress at work.

What gynaecologists think causes Pelvic pain

Despite the existence of the massive collection of nerves within the pelvis, (called the hypogastric plexus) the idea that pelvic pain is psychological is deeply rooted within gynaecology. One paper, written in 1981 is still regularly quoted as evidence that most women with pelvic pain do not have any "organic pathology" or "real cause" for their pain. For all I know, the author has died but his work lives on!

This study is more opinion than evidence, yet is widely referred to when gynaecologists discuss pelvic pain and because of this it is worth looking at in more detail.

The author wrote of three hundred and thirty patients with longstanding pelvic pain "Sixty-five percent of them did not appear to have any underlying organic pathology" In other words, the opinion of this powerful and influential gynaecologist is that two out of three women with chronic pelvic pain do not have a physical cause for their pain!

This is ridiculous - do women make up symptoms? are they "hysterical"? or is it possible that gynaecologists do not know what to look for? or the questions to ask in order to find out what is wrong with women with pelvic pain?

Even before he did a laparoscopy (an operation to look inside the abdomen with a camera), PN Gillibrand already felt that three quarters of these women did not have a "real" cause for their pain. He felt his opinion was justified because in 80% of these women, he did not find anything wrong.

Even when he did find something wrong, he did not think it was necessarily the cause of the woman's pain. Only those 15% of women with endometriosis did he feel had a genuine cause for their pain.

The author believed that women with pelvic pain were psychologically different from women who did not have pain. These women were neurotic, emotionally unstable, with psychosexual problems and relationship difficulties.

Whatever gynaecologists think, it is no longer credible to say that three quarters of women with pelvic pain do so because they are psychologically disturbed. We know enough about psychology to know that chronic pain causes psychological damage, that chronic pain causes depression, anxiety, poor sleep and exacerbates stress. Why would a woman make it up?

Another way of interpreting this paper is to ask what does he know about pelvic anatomy? does he know what what he needed to look for when he did all those laparoscopies, which according to his view were in any case unnecessary? Did he understand the role of nerves, ligaments and muscles within a normal pelvis? When he wrote that paper, did he understand the impact of a difficult labour on the function of the pelvis? Did he even have ethical committee approval for his studies?

To an outsider, it seems impossible that dragging a baby through a muscular canal which is ill prepared for its marathon onslaught does not damage the muscles, ligaments and nerves of the pelvis. Labour is a physical event that naturally takes place in the squatting position. The squatting position widens the pelvis and allows gravity to help the delivery of the baby.

Interfering with the normal process of labour must cause damage! Such interference is likely to have long term consequences, which are likely to include pain, incontinence and prolapse. To people who are not gynaecologists this seems like common sense. By improving the management of childbirth, fewer women will have difficult labours and there will be fewer long term gynaecological complications.

As a student, one anatomist told us, "The function of the tonsils is to provide creamy coloured Rolls Royces for ENT surgeons", meaning of course that ENT surgeons operated privately on small children with rich parents in order to fund their large cars. It might equally be said, that "The purpose of a difficult labour is to provide a lucrative private practice for ageing senior gynaecologists". Without the long term consequences of difficult labours, gynaecologists would be significantly poorer, their private practice significantly smaller and women enjoying a better quality of life!

Looking to the future, once the lessons of history have been clearly learnt, how can women protect themselves during labour?

The simple common sense lessons are the best

1 Eat a healthy diet to physically prepare for labour

2 Keep fit to be ready for the marathon of labour

3 Learn all about the process of giving birth and be mentally prepared

4 Don't induce labour - close monitoring towards the end of pregnancy is a safer alternative

5 Avoid oxytocin and epidurals because they numb the body and encourage excessive pushing (in Bulgaria women are not allowed to push!)

6 Whilst labouring, walk around and Squat!

Anecdotes of childbirth

Hot towels, as used in every good Western when a woman is about to give birth, help the perineum stretch

Royalty was required to give birth publicly so that everyone could be certain that, in the days of long and full skirts, the royal baby had come out of the royal womb. Only by giving birth on her back with her legs splayed could everyone be satisfied that the baby was definitely Royal. And because every woman wants to be treated like a Queen, this practice gradually spread throughout Europe, aided and abetted by Royal Obstetricians and Gynaecologists!

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