International Journal of Clinical Medicine, 2013, 4, 421-427
http://dx.doi.org/10.4236/ijcm.2013.410076 Published Online October 2013 (http://www.scirp.org/journal/ijcm)
The Impact of Chronic Pelvic Pain in Women
Adriana Peterson Mariano Salata Romão1, Ricardo Gorayeb2, Gustavo Salata Romão3,
Omero Benedicto Poli-Neto1,4, Antonio Alberto Nogueira5
1Department of Gynecology and Obstetrics, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Bra -
zil; 2Department of Neurosciences and Behavioral Sciences, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão
Preto, SP, Brazil; 3Fe deral University of Sã o Carlos, SP, Bra zil; 4Department the Surgery and Anatomy, University Hospital, Faculty
of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil; 5Department of the Surgery and Anatomy, Uni-
versity Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil.
Received August 6th, 2013; revised September 3rd, 2013; accepted September 23rd, 2013
Copyright © 2013 Adriana Peterson Mariano Salata Romão et al. This is an open access article distributed under the Creative Com-
mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.
ABSTRACT
Chronic pelvic pain (CPP) is a prevalent condition with a significant impact on the personal, social, professional and
marital life of women. It is a complex condition that may have no specific causal diagnosis or may be associated with
multiple diagnoses, frequently involving treatment failure. The definition of health care strategies fundamentally de-
pends on the way women live with this con dition. Thus, the objective of the present study is to learn how women with
CPP experience their diag nosis and the meaning they attribute to it. A qualitative study was conducted by interviewing
a focus group of 11 women. The content of the interviews was recorded and fully transcribed, and the speeches were
interpreted by Bardin’s content analysis. The topics most frequently dealt with in the interview were diagnosis, begin-
ning of pain, worsening and impro v ing factor s, marital and interpersona l relationship s, interference with daily activ ities,
association with emotion al aspects, and perspectives for the future. It could be perceived how much these women need
to be better hear d and how much the asso ciation b etween psychic and ph ysical questions must be visualized by the pro-
fessionals who provide care for them. The approach used by professionals from different areas, when properly struc-
tured, can minimize the problem of the division of a sick person into separate parts. Psychological care is very impor-
tant, especially in relation to the discovery of more effective strategies for living with pain.
Keywords: Lived Experience; Chronic Pelvic Pain; Qualitative Method; Women’s Health
1. Introduction
Chronic pelvic pa in (CPP) is characterized by continuous
or intermittent pain located on the anterior abdominal
wall at the level of the navel or below, lasting at least 6
months, not exclusively related to the menstrual period or
to sexual intercourse, and sufficiently severe to cause
functional disability [1 ]. Although the prevalence of CPP
in developing countries is unknown, it is estimated to be
higher in Brazil than in developed countries, with a direct
impact on the marital, social, professional and sexu al life
of the pati e nts [2-5].
Studies have shown that, after 3 years of treatment
with different modalities such as physiotherapy, psy-
chology, pharmacology or surgery, only 20% of the
women with CPP recover [6,7]. Th is inefficiency of CPP
treatment seems to be responsible in part for the dissatis-
faction and frustration of the patients and of the health
professionals and for the conflicts between them.
In addition, even though various countries have adopted
the biopsychosocial model and the psychosomatic ap-
proach, modern medicine is still widely based on the
biomedical model [8 ], which is currently also on the basis
of medical training in Brazil. This model separates the
physical aspects of health from the psychological ones.
However, the current attitude is that the psychosocial
dimensions should be reintegrated into health care and
practice in order to construct a biop sycho social mode l [9].
The treatment of CPP is an important challenge for the
health team since it requires a combination of pharma-
cological and non-pharmacological interventions associ-
ated with several types of invasive procedures. CPP sel-
dom reflects a separate pathological process, normally
consisting of a combination of psychological [10,11],
social and biological factors, thus essentially requiring an
interdisciplinary approach involving doctors, physio-

The Impact of Chronic Pelvic Pain in Women 422
therapists and psychologists, among others, for a more
effective treatment of women with CPP [12-14].
Within the context of CPP in particular, knowing and
interpreting the meanings that women attribute to the
problems they experience can permit the professionals to
expand their understanding of the problem in order to
contribute to the promotion of more effective interven-
tions through individualized health care and an integrated
health care service [9]. Due to the co mplexity of this dis-
ease, multidisciplinary teams can make a significant con-
tribution within this context, with psychologists consid-
ering the emotional aspects and helping the patients to
deal wi th the context in which the pain is triggered and phy-
siothe rapist s deali ng wit h body aspect s and m uscle ch anges.
Contributions such as improved quality of the profes-
sional-patient-family-institution relationship, greater ad-
hesion to the treatments proposed, the understanding of
the feelings, ideas and behaviors of the patients and their
relatives and even those of the professional health team
would be possible by attributing the proper value to the
meanings of the life experiences of the individuals in-
volved in the health-sickness process [15]. However,
despite the relevant role of this type of approach on the
health scenario, almost all studies focusing on CPP are
quantitative. Thus, in the present study, we opted for a
qualitative ap proach in order to deepen the experience of
these women and the meaning they attribute to chronic
pain.
2. Methods
Patients: Thirty-six women with a diagnosis of CPP were
invited to participate in the study. The patients had been
studied in a previous investigation and were followed up
at a Gynecology Outpatient Clinic of a University
Hospital in the interior of Brazil. Of the 36 patients
invited, 11 came to the clinic on the scheduled day. The
remaining 25 patients were not available or their tele-
phone number was wrong or they could not be contacted.
Thus, the 11 patients were divided into two groups of six
and five patients, respectively (Table 1). A meeting was
held with each group. The inclusion criteria were: a di-
agnosis of CPP and more than 18 years of age. Exclusion
criteria were: a history of psychiatric diroders (psychosis)
preceding the disease and presence of other chronic dis-
eases such as systemic arterial hypertension, diabetes
mellitus, cancer, or being pregnant.
Instrument: The instrument used for data collection
was a focus group interview held in a single session. This
technique is a particularly appropriate resource for quail-
tative investigations in which the participants will feel
more stimulated to express their opin ions than when th ey
are interviewed separately, since they also interact with
one another or with the group moderator [16].
Procedures: The group meetings were held in a room
specifically selected for the present study. The chairs
were arranged in a circle so that there would be visual
contact among all participants. Two tape recorders were
placed on two small tables on opposite sides in order to
guarantee that all speeches would be recorded. At the
beginning of the interview the researcher explained the
objectives of the study and all subjects gave written in-
formed consent to participate. The researcher used a
guiding question (how is it to live with CPP? ) that served
as the theme for conducting the group session. It was
emphasized that there would be no right or wrong replies
and that the opinion of each participant would be of fun-
damental importance. The interview lasted one hour and
thirty minutes.
Table 1. Socio-economic-relational profile.
Ident. Age Religion Profession Education Family IncomeTime of relationship No. of Children
W1 28 Catholic Seamstress Complete high school $524,701 1 and a half year 01
W2 30 Spiritualist Seller Complete high school $655,88 7 years 05
W3 28 Evangeli cal Maid Complete high school $212,62 4 years 04
W4 44 Catholic Housewife Complete high s c h o o l $655,88 22 years 02
W5 43 Evangelical Artisan Complete secondary school$524,70 27 years 03
W6 37 Spiritualist Hairdresser Incomplete secondary school$437,25 21 years 02
W7 36 Evangelical Poultry farm assistant Complete elementary school$524,70 12 years 03
W8 34 Catholic Vector control agent Complete high school $874,50 16 ye ars 03
W9 38 Catholic Housewife Complete elementary school$189,33 3 years 01 stepson
W10 31 Catholic Saleswoman Complete high school $349,80 10 years 02
W11 44 Catholic Companion of ol der people Complete elementary school$306,70 24 years 04
*
Amount regarding the current minimum (in dollars) wage at the time of interview.

The Impact of Chronic Pelvic Pain in Women 423
The interview was conducted by the researcher, who
acted as an agent facilitating and promoting group con-
versation so that opinions and ideas would emerge with-
out the pretense of reaching a consensus. This methodo-
logical resource permitted the interviewees to talk freely
about the process of falling ill and about their daily rela-
tions, values and transformations perceived after the on-
set of symptoms. During the interview, the researcher
sought to keep the group involved and managed it in
such a way as to preserve its flexibility and dyna- mism.
The objective of her interventions was to facilitate con-
versation and to provide space so that all women would
talk.
Data analysis: The option for the analysis of this stu dy
was content analysis as suggested by Bardin [17] ac-
cording to the following steps: Pre-analysis (reading of
the material/formulation of hypotheses/pre-categoriza-
tion); Exploration of the material (exhaustive reading of
the material/definition of meaning unit/classification of
the categories), and Analysis and interpretation of the
results (definition of the thematic units of the study and
treatment of the results by performing inferences and
interpreting the aggregate contents).
3. Results
Mean patient age was 35.7 years (range: 28 to 44 years).
Six women had 9 years of schooling (54.6%), two had 11
years (18.2%) and three had five years (27.3%). Regard-
ing their professio n, two had no typ e of remuner ation and
nine had remunerated activities. The mean number of
children was 2.7 and the time of relationship was 13.4
years. Monthly family income ranged from R$ 500.00 to
R$2,000.00 (U$ 226.04 to U$ 904.15).
The thematic units most frequently approached during
the focus group interview were: diagnosis, relationship,
interference of CPP with daily activities, association of
pain with emotional aspects, and perspectives for the
future. These topics will be approached in more detail in
the Discussion.
4. Discussion
4.1. Diagnosis
In the present study, the lack of explanations about the
symptoms seems to cause expectations regarding the
effec tive diagnosis.
W2: I told my mother I would prefer if there were a
pair of scissors or a piece of gauze that you could re-
move and it would get better, it would be a solution,
something you could remove, but who can remove this?
There is no way of removing it, because I don’t know if
there is a cure, is there?
The primordial wish of these women to find the cause
of their pain is a prevalent topic in the various studies on
this subject [18-22]. There is a constant search among
these women for the primary diagnosis of pain. This ne-
cessity is associated with the wish to legitimize the
symptom so as to permit treatment and the eli mination of
more serious diagnoses such as cancer [23-27]. One of
the justifications of this search is that falling ill repre-
sents a threat to the physical and psychological integrity
of an individual, with a consequent attempt to give a
meaning to the exp erience of falling ill in order to rend er
it more understandable and less threatening within the
social universe of the affected person [28].
4.2. Relationships
The women consider the participatio n of their partners to
be important, although some of them stated that they do
not have this type of help or understa n di n g.
W2: My husband doesn’t understand it, sometimes he
thinks that I am having an affair, and says he wants to
meet someone new... I told him he could believe whatever
he wants to, I am in pain and I am not doing it, I don’t
have to do anything that causes pain.
Another important condition is the feeling of oblige-
tion to have sex. Sexual difficulties are frequent in the
life of women with CPP [29-33], with their speeches
showing that they feel the obligation to have an active
sex life. Therefore, they decide “to make believe that they
have no pain”, thus actually intensifying the pain proc-
ess.
W2: I feel cornered, then I say: I will have to sleep
with him. I wait for a few minutes to see if it gets ba ck to
normal, and then it’s like I said, it comes to this. Then,
last week I said, what am I doing? I am not go ing to keep
doing this, no way. Since it is not going to get better if I
do it, I decided to change this routine, and I got into a
crisis again...
Concern with discredit and impairment of interper-
sonal relations.
W2: Sometimes you say it to yo ur partner, who is your
husband, and he think you are whining.
The conditions regard ing the social ro les of the women
are aggravated by economic, social and cultural difficult-
ties. In addition, there is the naturally accepted inequality
between men and women which permit to consider the
health problems of women to be “women’s stuff”, which
therefore do es not deserve tre a t ment.
W3: Sometimes my husband says… you’re too obnox-
ious… I bet you are i n those days...
The concepts and interpretation given by western
medicine to pains of “nonspecific” cause located in the
pelvic region affect the care provided for women who
suffer with CPP, which is based on a lot of prejudice.
These women are seen as “super-hysterical”, and “whin-

The Impact of Chronic Pelvic Pain in Women 424
ing” [34].
W2: He says my name should be Sorrowful Mary, be-
cause everything hurts, my feet, my head, my stomach,
and sometimes I think: I am really going crazy, I think I
should be ho spitalized. I am the only one in pain, so it is
uncomfortable, like she said.
4.3. Daily Activities
The changes described are not limited to physical prob-
lems, but also involve impairment of social, profession al,
marital and maternal life, limiting th e skills of women in
fulfilling their roles.
W3: I don’t work because I can’t, it’s a sort of pain
that crushes you, you can’t take it, I really don’t think I
am capabl e of working.
W2: I work because I am self-employed, but there are
days you just feel like wilting, and when you get home
you have to lie down...
Other situations such as losing a job, divorce, limita-
tion of social contacts and reduced practice of physical
activities owing to pain are common among these wom en.
The speeches of these women reveal their difficulties
in performing their household tasks and even in taking
care of their children.
W8: Because I got used to this pain, it bothers me, of
course it hurts- it hurts a lot, and it irritates me. I have
always been very patien t with my daughters, and I am no
longer patient, you know? I just warn them: “When I am
in pain you had better not talk to me, because I cannot
control myself”. It’s terrible. And if I have to go out I
can’t even dress myself properly, because I feel there is
something wrong, the pain.
4.4. Perspectives for the Future
In their speeches, the women interviewed in the present
study demonstrated distrust of care and despair regarding
the improvement of pain.
W2: There was a time when I got better, then I stopped
coming here for the medication (painkiller injections)
and the rest got worse.
W9: I received a letter saying I had to come a long
time ago. Then I said: “I am not going anymore, I am not
going to continue because it isn’t getting any better, I
went there to treat something and now it is gettin g worse,
all of this came up, I am not going back there.” My hus-
band told me today: “Go there, you are in pain.”
In general, women with CPP have a long history of
pain, marked psychic suffering, physical involvement,
difficulty to work and distrust of treatment. These condi-
tions may favor non-adhesion, prolong the pain and suf-
fering, cause impairment of physical and psychic func-
tionality, and cause deterioration of quality of life [35].
4.5. Emotional Aspects
Two problems are more commonly observed when
dealing with chronic pain: patients with injuries that are
not always resolved and often lead to the permancence of
symptoms, and patients who have pain symptoms but
often show no injuries that might justify the pain. These
facts often lead the professionals to consider that these
patients “have nothing”, ignoring the specificities of
chronic disease, with the possibility that a woman will
have anatomical changes which, however, do not justify
the painful signs and symptoms [36].
W9: The last time I came here I told him I felt like it
was burning around my navel, with a stinging sensation.
And he said: “Ah, but I think it is nothing”.
Emotional changes associated with pain include symp-
toms of mental and physical fatigue, periods of depress-
sion, crying episodes, sleeping problems, impatience, and
irritability. These women report that they feel unable to
plan their daily life owing to the constant imminence of
pain [19].
Women with CPP are known to have marked psychic
suffering, especially in relation to depression. Some of
the speeches of the women in the study group permitted
us to perceive the association of pain and depression.
W2: I have had depression since my adolescence. I
have the impression it was not treated well, not solved. I
started to take a lot of medications when I was still very
young, and now since my girl was born I can’t take the
medication. If I take the medication now I pass out, I
can’t understand where it came from, and the medication
can’t help either.
Other women reported that they often felt the wish to
end their own life, demonstrating the presence of despair
in addition to depressive symptoms.
W3: The other day I told my husband: if this pain goes
on for five more days I am going to put a rope a round my
neck and jump. Another day I told my son I was going to
find a hole to put my head in. And later I thought to my-
self “Oh my God, I can’t believe what I just said to my
son”.
The life conditions experienced by these women occa-
sionally lead to life styles focused pain and on failed
strategies of pain control, possibly contributing to the
persistence of the problem. In addition, the presence of
secondary gains may be another factor responsible for an
“increased pain behavior” and for ineffective coping
strategies [37,38]. In a study on women living with en-
dometriosis, Matta [39] showed that, despite the diffi-
culty of living with the disease, this group reported sec-
ondary gains due to it, i.e., mobilization of affection,
family attention and proximity of one’s mother and care-
givers.
In a speech related to this topic, M3 reports that she

The Impact of Chronic Pelvic Pain in Women 425
only feels better when she lies down and mainly when
her relatives do what she asks for. It can be seen that, in a
way, the presence of pain favors gains for her and this
can be associated with the maintenanc e of pain.
W3: Lying down is really good, it does not relieve the
pain, but makes me feel better. I say I cannot spend my
whole life in bed, but if I just give orders I am like a
queen, and I don’t feel anything, but if I do something
(laughter)... Because that’s the way it is, people do things
for me, and I even improved. They thought it was due to
the painkiller but it wasn’t, it was the resting, resting
makes it better… So I lie down.
Studies have demonstrated that women with CPP have
developed various coping strategies in order to overcome
the barriers imposed by pain, changing their routine and
reorienting their daily actions. In order to reduce pain
they rely on self-medication, on the ingestion of high
doses of the medications prescribed by the doctors and
adopt cultural practices passed on from generation to
generation such as the use of home remedies (herbs),
warm compresses, drinking wine and hot beverages,
massage, and local heat, among others. Similarly, within
the context of daily activities are distraction techniques
such as watching TV, listening to music or interacting
with children [19].
Regarding coping, although the context is directed a
priori towards depressive symptoms and difficulties in
visualizing future possibilities, some options can be dis-
cussed based on the testimony provided by the patients.
W4: Now, fifteen days before it I take a homeopathic
remedy. Some months I don’t take it, I control myself.
Sometimes he says things to me and I just take a deep
breath and keep quiet, because I know that after my pe-
riod I am going to be a different person. It took me many
years to learn that, but I learned to control myself. I
learned to control it and I take the medicine when I see I
am going to need it, and then I just keep controlling it.
5. Final Considerations
The objective of the present study was to learn in a more
profound manner the lived experience of these women
regarding CPP. The various aspects identified provide
evidence of the multiple n eeds of these women. The data
obtained can be used to propose an approach based on
the concept of multid isciplinary. Qualitativ e studies d eal-
ing with different central topics and other perspectives
are important for planning the goals of clinical services.
The present study also demonstrated the importance of
psychological care, primarily about more effective stra-
tegies for living with pain, stress and depression. Tech-
niques based on cognitive-behavioral therapy have been
extensively used to treat psychological disorders such as
stress related to health problems. These techniques intend
to change cognitive d istor tions and non-fun ctio na l be liefs
so that the patients will be better able to obtain social
support and to engage in pleasurable activities, prevent-
ing disea se s and reducing the pai n threshold.
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