Fall 2003 Volume 16, Number 2	Ladies in Pain: We've Ignored You But knowing the basics of pelvic pain should change that.
	Female trouble. Lady problems. That's what they used to call the pelvic pain of often-mysterious origin that sent despondent women from doctor to doctor. Physicians were frustrated -- or skeptical -- when surgery offered no relief. And the women often withdrew socially, resigned to a lesser life.
"We'd like to say that's all past," says neurologist Ursula Wesselmann, M.D., Ph.D., but aside from the newer terminology-it's now chronic pelvic pain-the frustration, vagueness of cause and relief-searching "are still very much with us. And there's a price to pay for that." In a recent talk, Wesselmann cited figures as high as 14 percent of women having chronic pelvic pain. A British primary care study last year found it as widespread as asthma. One survey ranked it as occasionally as intense as labor pain. National outpatient costs for the problem run nearly $800 million a year. "But chronic pelvic pain is treatable!" says Wesselmann. And she's bent on demystifying the biology and on improving drug therapy. "Deep, visceral pain is difficult to localize," she explains. It's diffuse cramps and more. Patients are often struck by nausea or shifts in blood pressure as sensory nerves from pelvic organs stimulate their autonomic nerve neighbors. But, more significant, she adds, is that within the spinal cord, nerves entering from the viscera overlap the same areas as pain nerves to skin and muscles. The result is the diagnostic red herring, referred pain. "Referred pain can radiate to the legs, the back or abdominal walls," says Wesselmann. "Pain's even referred among the viscera. So women in our clinic may have right lower pelvic pain one visit, left the next. Or menstrual and GI symptoms simultaneously. If you don't realize what's going on, it's genuinely confusing." Part of the solution lies in knowing the neuroanatomy-still a dark area because the pain nerves in question splay into plexuses and ganglia. But molecular biology techniques are helping Wesselmann trace the nerves in rat spinal cords. They take on color, thanks to a marker visible only when the c-fos gene-active in stimulated neurons-turns on. And just as crucial is clarifying the physiology. Why, for example, are some women more prone to chronic pain than others? Why is it less intense at times? Wesselmann's animal model of pelvic pain could begin to answer such questions. For example, the model has suggested how pelvic pain might become chronic. Once animals have recovered from an initial pelvic insult, says Wesselmann, it only takes a tiny one later on to get a large response, even long after recovery. "We think the spinal cord gets reprogrammed. Such a thing might happen in a woman recovered from an earlier pelvic inflammation who gets, say, a low-grade yeast infection months later." Wesselmann is classifying chronic pelvic pain into subcategories, hoping there's a characteristic biology for each. That should lead to better, targeted therapies. But until that time, even if we can't find a cause, she says, "we must acknowledge these chronic pelvic problems as a true pain syndrome. Then we should treat it." For more information, call 410-614-4517.