Somatization and CPP: Rosenthal

Question 1

What is somatization?

Answer 1

When the pt expresses emotional distress in terms of somatic complaints.
Very common in PC and Ob/Gyn.
Distress is out of proportion to physical findings.
Multiple, often shifting, somatic complaints at different times over the course of a pt’s life.
Pain is the most common.

Question 2

What is somatic symptom disorder?

Answer 2

Causes significant impairment with distress.

Pt is often (wrongly) suspected of drug seeking behavior or malingering. This brings about negative interactions.

Question 3

Describe the Cognitive-Behavioral mode of somatic symptom disorder.

Answer 3

Pt not only experiences symptoms, but also, anxiety and panic about the meaning of the symptoms themselves.

Question 4

Chronic pelvic pain

Answer 4

• pain in the pelvic/suprapubic region off and on every day, lasting for months
• potential causes: endometriosis, PID, leiomyomata, ovarian cysts, adhesions, others like GI/UG/MS
• fibroids won’t cause pain unless they are large and pressing on another organ; ovarian cysts normally don’t cause pain
• evaluation: H&P, pelvic US (this is often normal and enough to reassure the pt)
• there is an association between sexual abuse as a child and chronic pelvic pain (somatization); ask and she will talk

Question 5

Treatment for chronic pelvic pain

Answer 5

• team sport btw gyn, urologist, PT, pain mngmt centers, psych
• counsel them about coping and offer non-narcotic drugs
• never prescribe narcotics for chronic pelvic pain, beware of drug seekers

Question 6

What else can you do if there’s still chronic pain and no explanation and failed medical treatment?

Answer 6

Diagnostic laparoscopy; may find things you can’t find on imaging/exam like endometriosis or adhesions to bowel/pelvis.
Also, studies show that women get better when told their pelvis is “clean” following laparoscopy.
Avoid laparotomy at all costs! - this may cause adhesions, more pain, etc.

Question 7

Adenomyosis

Answer 7

• disorder of endometrial glands/stroma/blood in the wall of the uterus (so it’s like endometriosis but not ectopically)
• pts present with “boggy” enlarged, tender uterus, pelvic pain, pressure, dysmenorrhea, menorrhagia
• dx can only be made by pathology after hysterctomy

Question 8

Treatment of adenomyosis

Answer 8

• prevent ovulation with OCPs, which prevents bleeding
• NSAIDs to block PG synthesis
• if failed, do hysterectomy

Question 9

Dyspareunia

Answer 9

• pain with intercourse
• dx with H&P: how long (forever vs. recent), at what point/position, interfering with relationship
• potential causes:
  1. if on insertion: vaginitis, vulvitis, vestibular adenitis
  2. deep: cervicitis, endometriosis, adhesions, PID, mass effect of fibroids, bladder neck
  3. after sex: seminal fluid can cause contractions of uterus (via PGs) which feels like menstral-type cramps
• if no dx can be made, need to consider deeper issue and consult specialist