Chronic pelvic pain (CPP) is a complex condition that continues to be misunderstood and undertreated. It is defined as persistent pelvic pain lasting 3 to 6 months or longer, and is associated with negative emotional, cognitive, and functional outcomes.1 CPP negatively effects quality of life, including mental and functional well-being.3 There is a lack of data or consensus on the prevalence of CPP globally, but it is estimated to affect between 6 to 26% of women.4
Assessment and treatment may be complicated due to involvement of multiple systemic symptoms. There is currently a lack of research supporting use of psychological interventions in the treatment of CPP, unlike with other types of chronic pain therapies.
A study by led by Tiffany Brooks and colleagues at the University of South Australia included a cross-sectional analysis to identify mental health stressors in women with CPP. The team analyzed data gathered from questionnaires by 212 women with CPP. They utilized the Depression, Anxiety and Stress Scale(DASS-21) to assess indicators of depression, anxiety, and stress.
Their results showed that participants had higher DASS-21 scores compared to the general population. Brooks and colleagues identified seven notable predictors of pain severity correlated with DASS-21 mental health indicators.2
Higher scores were associated with stabbing pain, experiencing pain in childhood, negative prior sexual event, pain severity, younger age of menarche, never having been pregnant, and younger age.
Specifically, depression was associated with stabbing pain, heightened pain severity, pain at younger age, and a prior painful sexual experience. Studies have indicated that catastrophic thinking and coping styles may also link to depression and pain experience.Higher stress and anxiety scores were associated with younger age, stabbing pain, pain severity and negative sexual experience.
Older participants had lower DASS-21 indicators, suggesting they had developed stronger pain coping skills over time and with experience.
Two specific indicators – pain severity and stabbing pain – were higher in all three predictors of depression, anxiety, and stress. Previous studies have suggested this may be because sharp, insistent pain commands immediate attention and becomes a focus of concern leading to depression, anxiety, and stress. Brooks’ team found significant connections between pain severity and stress subscale indicator scores tied to general anxiety, but not depression and anxiety subscale scores. Prior research validates links between generalized anxiety and pain severity.
Research is unclear, however, on the prevalence of sexual trauma in women with CPP because sexual assault is often unreported. There is a lack of data on the role of mental health and trauma in women with CPP, therefore, it is difficult to determine prevalence in comparison to the general population. However, sexual abuse has been connected withnegative health outcomes, including pelvic pain, irritable bowel syndrome, and dyspareunia.
In the Australian study, indicators of sexual trauma were associated with higher DASS-21 scores. All three indicators (anxiety, depression, stress) may also occur concurrently with post-traumatic stress disorder (PTSD).
Brooks told PPM, “These results highlight that if a background of sexual trauma is present, then it is worth knowing about as it can influence pain perception, anxiety, depression and stress.”
Overall, the study provides a guide for clinicians in screening and assessment of women with CPP. The findings underscore the importance of exploring the relationship between physical and psychological aspects of chronic pain. The results further support the incorporation of mental health indicators in relation to CPP for focused treatment interventions in the future.
Relevant controlled studies on multimodal interventions that include mental health in women with chronic pelvic pain are lacking. Research supports utilizing a holistic interdisciplinary approach similar to other chronic pain management, which incorporates mental and physical well-being and improves pain and quality of life outcomes.
Brooks noted that examining “evidence based psychological interventions that target pain management, anxiety, depression, stress, trauma effectively– either with reference to mental health and/or chronic pain conditions followed by testing the effectiveness of techniques and whole therapy with women who have chronic pelvic pain” should be a focus of future research.
It is worth noting that this study was based on responses provided by women utilizing a private clinic only. The authors recommended in their paper that future research engage broader groups to incorporate the impact of socio-economic and cultural factors in pain reporting is needed to establish relevance and outcomes in larger demographics of women.