International Journal of Clinical Medicine, 2012, 3, 411-418 Published Online September 2012 ( 1
Biomedical Perspectives about Women with Chronic Pelvic
Pain: A Qualitative Analysis
Paula P. Souza1, Adriana P. M. S. Romão1, Ana Márcia S. Nakano2, Julio C. Rosa-e-Silva3,
Francisco J. Candido-dos-Reis3, Antonio A. Nogueira3, Omero B. Poli-Neto3*
1Department of Gynaecology and Obstetrics, School of Medicine University Hospital, University of São Paulo at Ribeirão Preto,
Ribeirão Preto, Brazil; 2Department of Public Health, School of Nursing, University of São Paulo at Ribeirão Preto, Ribeirão Preto,
Brazil; 3School of Medicine University Hospital, University of São Paulo at Ribeirão Preto, Ribeirão Preto, Brazil.
Email:,,,,,, *
Received June 18th, 2012; revised July 19th, 2012; accepted July 28th, 2012
Because the aetiology of chronic pelvic pain is complex, studies of the condition involve extensive investigation but
provide few conclusions. Numerous studies have addressed the experiences of women with chronic pelvic pain, as well
as the interaction between those women and their health care providers. Our objective was to investigate how physi-
cians at a specialized clinic perceive the medical care prov ided to such women. This was a qua litative study employing
semi-structured interviews and conten t analysis. We interv iewed seven physicians at the Chron ic Pelvic Pain Outpatient
Clinic of the University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil. Medical
training and practice constituted the central theme of the study, which was subdivided into categories addressing the
influence that the current medical training has on the type of medical care provided to women with chronic pelvic pain.
Medical practice has been characterized by a reductionist appro ach to health and illness, as well as by the fragmentation
of health care. These characteristics are, to a certain extent, the result of the biomedical model of education, which has
been predominant, ignoring social, cultural, psychological and emotional aspects. There is a need to shift the medical
paradigms toward a humanistic model of health care. We hope that we have provided a critical view of current medical
training and practice, as well as of their effects in various health care settings, particularly in the provision of care to
women with chronic pelvic pain.
Keywords: Chronic Pelvic Pain; Biomedical Model; Qualitative Research
1. Introduction
Since the days of the earliest civilizations, pain has
caused intense suffering among individuals [1]. In the
past, the understanding of pain was strongly influenced
by Christianity, which defined pain as a means of
achieving enlightenment or obtaining blessings; therefore,
studies investigating the elimination of pain were dis-
couraged, which, to a certain extent, delayed the investi-
gation of the pathophysiology of pain [2]. In mid-1979,
the International Association for the Study of Pain pro-
posed the first definition that included sensory and emo-
tional aspects, as well as being subjective in nature and
varying among individuals: pain is an unpleasant sensory
and emotional experience associated with actual or po-
tential tissue damage, or described in terms of such
damage [3]. In recent decades, the abovementioned
measures have contributed to a better understanding of
pain. However, because pain—unlike the remaining vital
signs—is subjective, there is no standard instrument that
allows an outside observer to measure pain in an objec-
tive manner, precisely because pain is an extremely
complex and individual experience. Therefore, in order
to gain a deeper understanding of pain, it is necessary to
consider the clinical correlates of pain, as well as the
emotional, cognitive, and personality characteristics of
individuals [4,5].
This context allows us to reflect on the issue of women
with chronic pelvic pain (CPP), which is a disease of
complex aetiology resulting from the interaction among
the gastrointestinal, genitourinary, musculoskeletal, nerv-
ous, psychological, and endocrine systems, as well as
being influenced by socio-cultural factors [6]. Studies of
CPP typically involve extensive investigation but pro-
vide few conclusions; this failure to understand chronic
pelvic pain leads to d issatisfaction and frustration among
patients and health pr ofessionals alike, as well as to con-
*Corresponding a uthor.
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Biomedical Perspectives about Women with Chronic Pelvic Pain: A Qualitative Analysis
flicts between the parties involved. One of the elements
of this complexity is th e very definition of the condition,
for which there is no consensus [7]. Although there are
various definitions of CPP, most, if not all, tend to state
that the aetiology of the con dition is exclusively physical
or behavioural and are therefore inadequate. In our opin-
ion, the most appropriate definition of CPP in women is
as follows: “noncyclic pain of 6 or more months’ dura-
tion that localizes to the anatomic pelvis, anterior ab-
dominal wall at or below the umbilicus, the lumbosacral
back, or the buttocks and is of su fficient severity to cau se
functional disability or lead to medical care” [8].
The overall prevalence of CPP in women has been es-
timated at 3.8%, being similar to that of migraine, asthma,
and back pain [9,7]. The prevalence of CPP has been
estimated to be higher in developing countries [10]. For
example, its prevalence in Brazil is approximately 11%
[11]. The direct and indirect costs of CPP (including
medical costs, as well as costs related to laboratory tests
and reduced productivity) have been estimated at 39 bil-
lion dollars per year [12-14]. In addition, CPP accounts
for approximately 10% of all gynaecological appoint-
ments, 40% - 50% of all gynaecological laparoscopies
[15], and 12% of all hysterectomies [16-18].
Approximately 20% of all women with CPP do not
undergo any diagnostic investigation, and 60% do not
receive a specific diagnosis [19]. In addition, Silva et al.
[11] found that although 90% of all women with CPP
were being routinely followed at primary health care
clinics and had previously complained of their clinical
status, only a small proportion (4%) were aware of hav-
ing the disease. The above mentioned findings show
some of the reasons why women with CPP are highly
dissatisfied [20]. The resolution rates for CPP are low.
This might be at least partially attributable to the fact that
there is a disconnect between the expectations of women
with such pain and the type of medical care provided,
which does not meet their needs. We believe that the
difficulty health professionals have in managing the con-
dition is intrinsically related to the policies and philoso-
phical underpinnings that guide current medical educa-
tion and practice, which are based on scientific medicine,
the form of medicine derived from the Flexnerian reform
of medical education in the early 20th century [21].
Abraham Flexner was responsible for the most impor-
tant reform of the medical schools in the United States,
his report—informally known as the Flexner Report—
having had a major impact on medical education in nu-
merous countries, including Brazil. The Flexner report
proposed a new model of medical education and practice,
based on biological evidence, individualism, specialisa-
tion, and a technical approach to health, as well as on the
The impact of the Flexnerian model on the medical
care provided to women with CPP is not entirely p ositive,
as evidenced by the complaints of such women. Most of
the complaints are related to the lack of a holistic ap-
proach to the problem, biological aspects being priori-
tised. The most common complaints are dissatisfaction
with the doctor-patient relationship, the lack of an un-
derlying etiology for CPP, miscommunication between
doctors and patients, the lack of information regarding
the condition, and inappropriate treatment. CPP imposes
limitations to th e lives of tho se women and is responsib le
for years of suffering, including job loss and divorce.
When women with CPP seek professional help, they
have an overwhelming desire to know what is wrong
with their bodies [22]. In contrast, it seems that the bio-
medical model of medical education does not equip
medical students with the skills required in order to
manage the psychosocial aspects of CPP and its various
The quality of that relationship is one of the factors
that determine the level of patient satisfaction, having a
direct influence on patient response to treatment [23,24].
Patients who report dissatisfaction with their encounters
with physicians are more likely to show psychiatric dis-
orders, aggressive personality traits [25,26], and lower
adherence to treatment [27,28], as well as to report mul-
tiple physical symptoms that cannot be explained bio-
logically (i.e., “medically”) [25,29,30]. By context, the
principal objectives of the present study were to investi-
gate physician perception of the medical care provided to
women with CPP and identify possible determinants of
the condition for future development of continuing edu-
cation programmes.
2. Methods
This was a qualitative study, data were collected by
means of semi-structured interviews. We interviewed
seven physicians providing medical care to women with
CPP treated at the CPP Outpatient Clinic of the Univer-
sity Hospital, Faculty of Medicine of Ribeirão Preto,
University of São Paulo, Brazil. The median age of the
physicians was 30 years (range, 27 - 58 years). Among
the seven doctors interviewed, four were men and three
women. The interviews were conducted by one inter-
viewer, with an average of 60 minutes for each partici-
pant. The analyzes were performed by three evaluators in
the portuguese language and after the material was trans-
lated into English.
The criterion used to conduct the interviews and to
determine the number of participants was the saturation
criterion in which the repetition of information during
interviews limits the ne ed to new participants. Regarding
the level of training, the participants ranged from first-
year residents to professors, and the length of experience
in providing medical care to women with chronic pelvic
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Biomedical Perspectives about Women with Chronic Pelvic Pain: A Qualitative Analysis 413
pain ranged from 1 year to 10 years. Neither the length of
experience nor the level of training of the participants
had any impact on the results obtained, meaning that
there were no significant differences among the answers
provided by the participants. Therefore, there was no
need for new thematic categories. All of the participants
gave written informed consent, and the study was con-
ducted in accordance with the regulations and guidelines
for research involving human beings established by Bra-
zilian National Health Council Resolution 196/96.
We performed content analysis in accordance with the
method proposed by Bardin (1997) [31]. According to
Minayo [32], qualitative data analysis involves a set of
operations and reflections, as well as data reorganization,
all of which are carried out in o rder to determine the sig-
nificance of the phenomenon under study [32]. Data
analysis was performed in three steps: Pre-analysis; Ex-
ploration of the material; Analysis and interpretation of
the results.
3. Results
Through means of detailed discourse analysis, we at-
tempted to understand the range of experiences of those
physicians (i.e., from medical training to clinical prac-
tice). The central theme was medical training and prac-
tice, and we subdivided it into five categories, which are
described below.
3.1. Physician Knowledge of Chronic Pelvic Pain
Physician 1: “I felt the need to know a little bit more
about those diseases, about that group of patients, be-
cause I had a lot of difficulty in dealing with them.”
Physician 5: “Instruction regarding chronic pelvic
pain is much more theoretical than practical, isnt it?
You learn what can cause the pain, but that doesnt al-
ways correlate with what the patient is telling you. Pa-
tients dont always say, ‘oh, the pain I feel is like this and
that’, and then you can think of a course of action. Its
generally not by the book’.”
The discourse of those health professionals shows their
difficulty with CPP. Physician 1 reported having diffi-
culty in reconciling theory and practice in the context of
treating patients with chronic pelvic pain. We believe
that this is due to the subjectiv e nature of the pain, which
stands in contrast with the need that those physicians
have to conceptualise the disease in physical terms. This
indicates that greater weight is given to the biological
aspects (i.e., the “concrete” aspects) of pain, an approach
that is in accordance with the Flexneriano model of
medical education and practice.
According to Lima & Trad [33] the subjectivity of
pain makes it invisible and unquantifiable, which is why
health professionals have difficulty in managing it. Al-
though the management of chronic pain has posed a ma-
jor challenge for health professionals, chronic pain has
not been given weight in the curricula of medical schools,
being strongly associated with the ideas of injury and
protection (i.e., a symptom that reveals an underlying
condition to be inv estigated and diagnosed) [34].
Physician 3: “I think that CPP is not well taught to
undergraduate students, who spend very little time within
each specialty. In medical schools today, there is a trend
toward a more general approach to medical education
rather than a focus on specialization, on specialties.”
The physician in qu estion believes that the difficulty in
managing CPP is due to the fact that undergraduate stu-
dents spend very little time within each specialty. The
great importance given to specialization has a direct im-
pact on the medical care provided, which becomes frag-
mented; a patient is seen as parts rather than as a whole.
Although a disease is a biological, material phenome-
non, the human response to the disease cannot be meas-
ured objectively. It is evident that the curricula of medi-
cal schools have not equipped students with the skills
required in order to treat individuals humanistic. The
fragmentation of health care into specialties tends to ob-
scure physician perception of biopsychosocial aspects,
meaning that such aspects are ultimately overlooked by
physicians, who fail to co rrelate them with patient health
3.2. Stereotypical Views That Health
Professionals Hold of Chronic Pelvic Pain
and of Women with the Disease
Physician 6: “Well, you know, its too early to tell, I ha-
vent been to the outpatient clinic that often, and, I think
its a problem that is difficult to treat, the patients are
difficult, so, I suppose I still have a lot to learn about
CPP, and, well, I havent studied it, I mean, I havent
done any research on my own, but we do have the outpa-
tient clinics, where we can follow patients closely, and,
anyway, I dont think we learn that much about the sub-
ject at university.”
Physician 1: “Its difficult, isnt it? Doctors always
want to solve everything, and all of those things that
sometimes you just cant find the cause of... you see, in
the case of CPP, you cant always find a cause that is
treatable, sometimes you even think youve found some-
thing, but you cant solve the patients problem, which
sort of causes some frustration, you know, this is why I
dont like it very much.”
Some of the health professionals interviewed in the
present study emphatically stated their distaste for pro-
viding medical care to women with CPP. This is proba-
bly a reflection of their inexperience with and lack of
knowledge of the condition. That viewpoint has become
a consensus among health professionals in training and
Copyright © 2012 SciRes. IJCM
Biomedical Perspectives about Women with Chronic Pelvic Pain: A Qualitative Analysis
specialists. The setting of treating CPP has become stig-
matised, health professionals having disseminated a
negative view of the disease. According to Salmon [35],
the uncertainty regarding the aetiology and treatment of
CPP is what concerns health professionals the most,
given that it can threaten the authority on which medical
knowledge and practice are based [35]. Ponte & John-
son-Tribino36 showed that 85% of health professionals
reported frustration when treating patients with chronic
pain, a finding that is in agree ment with those of the pre-
sent study [36].
The lack of training of health professionals in manag-
ing chronic pelvic pain has had an impact not only on
how the disease is viewed (i.e., negatively) but also on
how women with the disease are stereotypically viewed,
i.e., as having multiple complaints, as being annoying,
and as being problematic.
Physician 7: “Now, it is a d ifficult type of patien t, isnt
it? We see it quite often. Thats exactly why youre con-
ducting this study, because residents, those who are
younger and inexperienced, they say, ‘listen, theres no
way you can treat that patient, she complains of every-
thing, she has multiple complaints, theres just no way,
theres no treating her, everything hurts (laughs), noth-
ing works, nothing heals, and everything hurts’.”
Physician 1: “The typical profile is, women with seri-
ous social and family prob lems; one had been left by her
husband, one had children who had been killed in acci-
dents, one had been left by her family, one had well-es-
tablished psychiatric probl e ms .”
Physician 2: “Its a patient who complains a lot, a pa-
tient who ends up having a lot of anxiety, depression...
its an ANNOYING patient.”
The stigmatisation of women with CPP by health care
providers is also related to the chronic nature of the dis-
ease, which entails difficulty in patient monitoring; be-
cause of the diagnostic and therapeutic limitations, the
resolution rates for chronic conditions are low.
3.3. Doctor-Patient Relationship
Physician 4: “You have to listen to the patients com-
plaints, you cannot underestimate them, but you cant
overestimate them, either, otherwise youll be contribut-
ing to her attributing all her problems to that pelvic
pain... You might contribute to h er somatising th e pain a
bit, if thats the case, right?”
As previously described, we believe that the doctor-
patient relationship problems in the context of CPP are
intimately related to the stereotypical view that health
professionals hold of those women. This creates a com-
munication barrier between doctors and patients, the
consequence being that the real needs of women with
CPP are not met by the type of medical care provided by
health professionals. Some of the statements clearly
show that the physicians are insecure as to what criteria
should define the threshold between believing and disbe-
lieving in the discourse of women with CPP: “you can’t
underestimate [the complaints], but you can’t overesti-
mate them, either”.
The mind-body dualism imposed by the biomedical
model is in opposition to the multifaceted nature of pain.
According to that fragmented view, the aetiology of the
condition is exclusively physical or psychological,
meaning that the pain is either “real” or “imaginary”. In
this sense, health professionals and patients grow in-
creasingly apart in the setting of providing/obtaining
treatment for CPP, the therapeutic relationship being
often replaced by a relationship of distrust.
The benefits of a doctor-patient relationship that is
based on an effective communication process include
higher diagnostic accuracy, reduced number of lawsuits,
increased treatment adherence, optimization of health
resources, increased satisfaction, and better results in
treating various conditions [37,38]. According to Morris
[39], communication does not replace medical technol-
ogy; rather, it aids in understanding the emotional and
social factors that aggravate the condition. Neither ex-
treme is ideal; there is a need to strike a balance between
the two [39].
3.4. Technical/Interventional Model
Physician 4: “I think that, because the symptoms are ex-
tremely vague, sometimes clinical examination alone,
sometimes the patient is unable to give you correct in-
formation, so you end up having to adopt a more invasive
Physician 1: “The diagnosis of chronic pelvic pain is
problematic, I think we still have a long way to go, I
think certain mechanisms are missing, I mean, not that
our facility lacks anything, but the fact is that CPP is a
clinical diagnosis and is often secondary to a disease
that requires an imaging test, blood tests, something that
explains the pelvic pa in.”
The discourse of the participants reveals an over-reli-
ance on the use of technology in the treatment of indi-
viduals, an approach that is consistent with the bio-
medical model of medical education and practice. The
principal objective of the medical care provided to
women with CPP has been to diagnose and treat the con-
dition, other needs related to the h ealth-illness contin uum
being put aside. That leads us to ask, “What are the real
health care needs of women with CPP?” This excessive
interventionism—characterised by the tyranny of ancil-
lary tests; excessive fragmentation of patients into organs
and functions; and inattention to emotional and psycho-
social aspects—originates from the increasing techno-
logical sophistication of modern medicine and its sci
ence-based approach [40].
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Biomedical Perspectives about Women with Chronic Pelvic Pain: A Qualitative Analysis 415
Initially, this over-reliance on technology might be re-
lated to the need to visualise (i.e. , biologically conceptu-
alise) the pain. Subsequently, it is related to the need to
establish an accurate and definitive d iagnosis, which will
in turn lead to the desired resolution of the symptom.
However, the participants also attributed their overreli-
ance on technology to their difficulty in understanding
the complaints of women with CPP. According to the
participants, because the complaints are subjective, inva-
sive methods are needed in order to establish an accurate
Grace [41] and Price et al. [42] conducted qualitative
studies investigating the perception that women with
CPP have of the type of medical care received. The find-
ings of those studies constitute evidence of the technical
approach to health and show that health professionals
reject and underestimate the complaints of those women,
defining the symptoms on the basis of test results. In ad-
dition, women with CPP have reported that their anxie-
ties are not allayed during medical appointments [41,42].
Some of the consequences of the over-reliance on tech-
nology in the health care setting include a strain on the
doctor-patient relationship, the risk of iatrogenic compli-
cations, excessive specialization; institutionalization of
medical care, and increased health care costs.
3.5. Need for a Multidisciplinary Team
Physician 6: “I think it should be a bit more integrated,
especially in those patients in whom you cant find a
specific cause. Oh, [integrated] with psychology, physic-
cal therapy.”
Physician 6: “I believe that patients with chronic pel-
vic pain need a multidisciplinary approach.”
Physician 5: “In my opin ion, it is very difficult to treat
women with chronic pelvic pain because there is a very
strong psychological component; you have to address
The abovementioned statements show that the respon-
dents recognise the importance of a multidisciplinary ap-
proach. However, their belief in the importance of a mul-
tidisciplinary approach is related to the difficulty that
they have in managing aspects that are outside the realm
of the technical and experimental. Therefore, the respon-
sibility of addressing issues oth er than those o f biological
nature is handed over to other health professionals, which
contributes to the fragmentation of health care.
According to Ferreira et al. [43], the treatment of
chronic pain requires the involvement of an interdisci-
plinary team including physicians, nurses, physical
therapists, and psychologists. The teams should provide
information regarding the disease, as well as explore is-
sues such as self-perception, attitude, and self-care in
order to help those women develop better strategies to
control the behaviours and experiences related to the
disease [43].
4. Discussion
The limitations of the biomedical model become evident
in the chronic pelvic pain care setting. The canons of
biomedicine require that individuals be “pigeonholed”
into pre-established disease categories often ignoring the
multifaceted nature of the CPP. In recent decades, how-
ever, there has been an increasing concern over the
training of future health professionals. The curriculum
guidelines for undergraduate medical courses recom-
mend the inclusion of ethical and humanistic dimensions
that allow students to develop attitudes and values to-
ward citizenship, in an attempt to combine technical ex-
cellence with humanistic traits.
In clinical practice, there has been a search for alterna-
tive methods of care (such as psychotherapy, acupunc-
ture, and support groups) that permeate an ethical and
humanistic model. Such methods allow us to achieve an
integrated view of individuals, thereby making subjective
expression, meanings, and worldviews central to the un-
derstanding of illness.
For some decades, the humanization of care has been
on the agenda of certain entities supported by the World
Health Organization. In recent years, the Brazilian Na-
tional Ministry of Health has invested in improving hos-
pital management and the medical care provided to the
population, in an attempt to build a culture of humanistic
care. The concept of humanization of care is based on the
idea of a model that is focused on the possibility of
communication and dialogue between users and health
professionals. One of the gr eatest challeng es in provid ing
humanistic health care lies in reconciling quality health
care—anchored in a well-established body of knowledge
and based on the regularities of the health-illness contin-
uum—with the subjective dimension and the sociocul-
tural background of patients. However, in order to
achieve a health care model that is based on such prince-
ples, we need to go beyond the standard application of
norms and rules of scientific medicine [40]. On the other
hand, there are some important analogies to be made
within the context o f the CPP to emphasize the complex-
ity of the condition. For example in the appropriate use
of terms such as “disease and illness”, where the latter
term, which is more appropriate for the condition in
question, is considered a complex interaction of psycho-
logical, social, medical or even the subject of the experi-
ence and self-attribution sometimes. This analogy leads
us also to reflect about the concepts of nociception and
pain. Studies have shown that brain regional changes,
which occur only after input of the nociceptive CPP, play
an important role in chronic pain. These changes, since it
occurred, may contribute to a perception of pain contin-
ues even after the disappearance/removal of the initial
Copyright © 2012 SciRes. IJCM
Biomedical Perspectives about Women with Chronic Pelvic Pain: A Qualitative Analysis
nociceptive stimulus. Additionally, whether pain be-
comes chronic depends on the interaction of various fac-
tors, namely the persistence of the peripheral pain gen-
erator, the antinociceptive capacity, and (maladaptive)
neuroplasticity of the pain system [44]. Accordingly, the
problem involving the CPP must not be limited of the
biomedical model or quality of care.
5. Final Consideration
In the present study, we investigated the perception that
health professionals have of the problems related to the
treatment of chronic pelvic pain. Although the present
study is by no means definitive, we believe that it pro-
vides the basis for further discussion of the model on
which medical education and practice are currently based,
as well as of the possibility of adjusting or even restruc-
turing that model.
Through these considerations we propose that the
theme be included in the curricula of undergraduate
medical schools as soon as possible; that our findings be
directly applied to clinical practice; and that chronic pel-
vic pain treatment protocols emphasizing the biopsycho-
social aspects of the disease be established. Qualitative
studies of chronic pelvic pain have contributed to impor-
tant changes in our facility, including changes in the
physical structure in order to improve the quality of the
medical care provided to patients; adoption of a more
humane approach to patients; interaction among the
members of the multidisciplinary health care team, psy-
chologists actively participating in the medical care pro-
vided; and association between teaching and research,
which allows the discussion of research topics that can
aid in gaining a deeper understanding of chronic pelvic
pain [22].
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