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  #1  
Old 06-02-2012
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Psyche Persistent Pelvic Pain

A 36-year-old woman presents with a 12- to 14-month history of persistent pelvic pain. She reports no relation to dietary factors or bowel movements and denies diarrhea, constipation, melena, hematochezia, dysuria, or hematuria. She has had negative evaluations by multiple providers, with normal colonoscopy, ultrasonography and CT of the abdomen and pelvis, and cystoscopy. She underwent a hysterectomy and salpingo-oophorectomy for possible endometriosis 9 months ago, without relief of her symptoms. Her medical history is significant for chronic migraine headaches and chronic lower back pain. She is taking estrogen replacement therapy. She has two children, and has not been sexually active since her divorce from her husband more than 2 years ago. Her BMI is 30. Mild nonfocal tenderness is present on abdominal and pelvic examinations, with normal bowel sounds, no rebound, no masses, and no vaginal bleeding or discharge. Which of the following is the most appropriate management for this patient?

A Cognitive-behavioral therapy
B Naproxen
C Reassurance with follow-up at 3 to 4 weeks
D Sertraline
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  #2  
Old 06-03-2012
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A Cognitive-behavioral therapy

I think she has chronic pain disorder, history of chronic pain, mutliple evaluations by different doctors. h/o of various invasive investigations & procedures still no diagnosis.
D can also be an option.
Not sure though.
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  #3  
Old 06-03-2012
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Originally Posted by Novobiocin View Post
A 36-year-old woman presents with a 12- to 14-month history of persistent pelvic pain. She reports no relation to dietary factors or bowel movements and denies diarrhea, constipation, melena, hematochezia, dysuria, or hematuria. She has had negative evaluations by multiple providers, with normal colonoscopy, ultrasonography and CT of the abdomen and pelvis, and cystoscopy. She underwent a hysterectomy and salpingo-oophorectomy for possible endometriosis 9 months ago, without relief of her symptoms. Her medical history is significant for chronic migraine headaches and chronic lower back pain. She is taking estrogen replacement therapy. She has two children, and has not been sexually active since her divorce from her husband more than 2 years ago. Her BMI is 30. Mild nonfocal tenderness is present on abdominal and pelvic examinations, with normal bowel sounds, no rebound, no masses, and no vaginal bleeding or discharge. Which of the following is the most appropriate management for this patient?

A Cognitive-behavioral therapy
B Naproxen
C Reassurance with follow-up at 3 to 4 weeks
D Sertraline
-first idon't understand how they did hystrectomy for young pt without clear diagnosis?!!!!!.2end theris no psychological or indicaion of psychatric proplem.
-but she's on hormonal theraby,that could be the cause of her complain.so ithink (c) may be apporpriate.
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  #4  
Old 06-03-2012
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Originally Posted by um aala View Post
-first idon't understand how they did hystrectomy for young pt without clear diagnosis?!!!!!.2end theris no psychological or indicaion of psychatric proplem.
-but she's on hormonal theraby,that could be the cause of her complain.so ithink (c) may be apporpriate.
How is C going to help her as she is having this problem for years without relief?
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  #5  
Old 06-04-2012
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Originally Posted by Novobiocin View Post
How is C going to help her as she is having this problem for years without relief?
-ithink if the cause of the pain is known with reasurance that can help alot in reducing pain because the pain has somatic part and psycological part .this my wone answ ihave no referance here ,so what's the correct one?.
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  #6  
Old 06-04-2012
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Pelvic pain is considered chronic when it persists for longer than 3 to 6 months. Chronic pelvic pain is not a disease but a syndrome, thought to be a complex multifactorial entity related to neurologic, musculoskeletal, endocrine, and psychologic factors. It is a frustrating entity for both patients and clinicians, with ill-defined symptoms and, frequently, without a definitive diagnosis, but it nevertheless is treatable. Cognitive-behavioral therapy (CBT) has been shown to be effective across this spectrum of symptom syndromes. One CBT-based approach reduced pain scores in patients with chronic pelvic pain by 50% compared with usual gynecologic care, and continued improvement was seen in psychological distress, pain, and motor function 9 months after completion of therapy.

The four most common disorders associated with chronic pelvic pain are endometriosis, adhesions, interstitial cystitis, and irritable bowel syndrome. In this patient, the imaging studies and lack of response to surgery render endometriosis and adhesions improbable explanations, and the normal cystoscopy rules out interstitial cystitis. In the absence of a specific underlying etiology, pharmacotherapy has generally been unsuccessful in treating chronic pelvic pain. NSAIDs such as naproxen have utility in dysmenorrhea, but a Cochrane review found insufficient evidence to recommend them in endometriosis, and although an empiric trial has sometimes been recommended in chronic pelvic pain of undetermined etiology, there is no evidence to support this practice. Controlled trials of antidepressants such as sertraline have improved depressive symptoms in those patients for whom such symptoms are prominent, but have not been associated with significant reduction in pain.

Reassurance and follow-up would be inappropriate for this woman who has had no relief from her symptoms for more than a year.
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