A typical clinical history of pelvic pain – from a concerned mother
“My 19 year old daughter has been suffering with severe “stabbing” pelvic pain for 3 out of 4 weeks every month since the onset of her period at 12 years old. After finally being diagnosed with endometriosis, she underwent laparoscopic surgery to remove as much endo as possible. Now 1 1/2 years later, the severe pelvic pain started again in the summer months, just not as long lasting. Now the bleeding between periods has returned with the severe pelvic pain becoming more long lasting. When the severe bouts of pain occur, she becomes incapacitated and cannot attend classes. She missed many days, adding up to months of middle and high school due to the pain. It was extremely painful to sit still in a chair for long periods of time. Now she is in college and very worried that the pain is coming back so quickly and severely. Originally, the surgeon told us that it could return anywhere from 1 to 7 years. This is quick. She has taken birth control pills for years to lessen heavy bleeding during her period, as well as, to inhibit the growth of the endometriosis. Narcotics really didnt help with the pain and just put her to sleep. Anti-inflammatories have to be taken just before the onset of the bleeding and continued throughout the bleeding to inhibit cramps. That doesnt work because her pain is lasting 3 of 4 weeks per month, and her pelvic pain occurs even when she is not bleeding which is something that is often not included in write-ups on endo. If anyone can give us any new information as to pain relief ideas so that she may be able to hold off on more surgery, we would so appreciate it.”
In terms of the autonomic denervation view:
(1) it is clear that this girl has had injured pelvic nerves prior to her menarche (onset of periods). She may have had problems as an infant or during toilet training in early childhood.
(2) The pain clearly occurs in both premenstrual and perimenstrual phases. It cannot just result from bleeding during the days of menstruation. She probably has significant perivascular nerve fibre proliferation so that pain occurs as blood flow increases in weeks 3 and 4.
(3) The surgery to remove deposits of endometriosis has little effect on her symptoms as pain results from injuries to pelvic nerves rather than the deposits of endometrium.
(4) Her symptoms are so serious that she may well merit a prolonged course of GnRH agonists with add-back HRT to limit her symptoms and avoid this time off her studies. It is a serious situation though all too typical of clinical presentations of chronic pelvic pain.