Sherien Abbas, a Specialist in gynecology, obstetrics, and its surgery
“Stop being so delicate.”
“She is always complaining, and nothing is wrong with her.”
“Tell me, doctor, if we should renew, accompanied by a sneaky smile.”
I still hear these phrases in my clinic or the hospital when female patients come to see me, mostly with their husbands or moms. A provoking ridicule of women’s pain and insinuated accusations of lying, hysteria, and drawing attention. Attributing these pains to psychological reasons from the beginning and ignoring the organic diseases may worsen women’s health. Unfortunately, the paternalistic view of women’s bodies and their pains, combined with the patriarchal nature of the medical field, often leads them to late stages of diseases that could have and should have been detected early.
A 25-year-old woman came to me complaining of severe pelvic pain. After examination, tests, and an ultrasound revealed that she had a pelvic Abscess.
Doctor: Since when have you had this pain?
Woman: it’s been a while, doctor, but it used to be milder.
Doctor: did you seek medical attention?
Woman: Yes, doctor, I went to the hospital once, and they gave me medication, but then I didn’t return. I am my husband’s third wife, and he doesn’t want to spend much on medical expenses. He keeps saying these are just women’s antics and drama. So, I’ve been taking painkillers and enduring it.
Doctor: Do you know you have chronic pelvic inflammation with an Abscess on your right ovary and fluid accumulation in both fallopian tubes? This is severe and longstanding inflammation.
Unfortunately, during the surgical procedure, we diagnosed chronic pelvic inflammation with an Abscess on the right ovary and fluid accumulation in both fallopian tubes, along with severe adhesions in the pelvis that affect future fertility and quality of life due to chronic pelvic pain, a condition known as frozen pelvis.
What is chronic pelvic pain?
It is non-cyclical pain that persists for six months or more, localized in the pelvis, the lower abdominal wall below the navel, or the sacral or gluteal region. It leads to various degrees of functional impairment.[1] It is a multifactorial disorder where pain may arise from any pelvic genitourinary, gastrointestinal, musculoskeletal, or nervous system.
The problem lies in normalizing or not taking pelvic pain seriously and attributing it to psychological or neurological causes or treating it superficially without conducting the necessary investigations to determine the cause.
A 58-year-old woman came in complaining of abdominal heaviness, recurrent pelvic pain, and general fatigue and weakness. On ultrasound, there was a complex cyst with growths on the left ovary.
Doctor: how are you feeling, ma’am?
Woman: I’m not doing well, doctor. I feel pain all over my abdomen, which hasn’t gone away with painkillers.
Doctor: why did you endure this for so long?
Woman: I went to a local doctor who told me it was just colitis.
Ovarian cancer:
Ovarian cancer is the fifth most common cancer among women, and the overall prognosis for women with ovarian cancer is generally poor, with a five-year survival rate of less than 35%. Most women are diagnosed at an advanced stage. Even though the ovarian cancer rate seems slower than breast cancer, it is three times as fatal. Contrary to popular belief, there is substantial evidence that ovarian cancer has warning signs and symptoms, such as abdominal and pelvic pain, Constipation, and abdominal bloating, which are more severe and widespread among women with ovarian cancer than the general population. Additionally, some symptoms of ovarian cancer can be mistaken for those of more common benign conditions, potentially delaying timely medical visits or leading to superficial treatment.
NICE guidelines recommend that doctors measure CA-125 levels in women over the age of 50 who have continuous symptoms suggestive of ovarian cancer (such as abdominal bloating, early satiety, loss of appetite, or pelvic pain) and perform abdominal and pelvic ultrasound and are RMI to assess the risk of malignancy.
Therefore, increasing women’s and healthcare providers’ awareness of risk factors and symptoms can help reduce delays in diagnosis. Public awareness campaigns about ovarian cancer can be beneficial for early detection, and adequate knowledge of risk factors and symptoms among healthcare providers of all specialties can help women recognize signs and receive early diagnosis.
Dysmenorrhea:
Primary dysmenorrhea is menstrual pain in the absence of pelvic diseases.
Secondary dysmenorrhea is menstrual pain in the presence of pelvic diseases or due to a recognized medical condition.
Most teenagers (70-93%) experience discomfort related to menstruation. Primary dysmenorrhea is the most common reason for school and activity absenteeism, with up to 20-40% of teenagers missing school. About 40% report a negative impact on academic performance and concentration. Teenagers with severe dysmenorrhea complain of a decreased quality of life and are more prone to depression and anxiety. Healthcare practitioners should not trivialize dysmenorrhea and should provide treatment to teenagers, conducting further investigations for ongoing pain. Possible causes include primary dysmenorrhea, obstructive Müllerian anomalies, and endometriosis.
What is Endometriosis?
Endometriosis, also known as endometrial migration, is the presence of endometrial glands and stroma outside the uterine cavity.[2] It is the most common cause of secondary dysmenorrhea and has been identified in 62-75% of teenagers undergoing abdominal laparoscopy due to chronic pelvic pain or dysmenorrhea. It is also found in 70% of teenagers with pelvic pain that hasn’t improved with nonsteroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives (COCs). Approximately 190 million women worldwide suffer from endometriosis, and the World Health Organization estimates that it affects around 10% of women and girls worldwide.
Teenagers with endometriosis may not exhibit classic symptoms such as dysmenorrhea, Dyspareunia, dyskinesia, or infertility. Common symptoms in young women with endometriosis include general pelvic discomfort, low energy, and abdominal discomfort. Heavy menstruation, headaches, dizziness, and lower back pain are also prevalent abdominal symptoms, including bloating, Constipation, diarrhea, nausea, and pain during bowel movements.
A young woman, 17 years old, came to me unable to move and experiencing severe pain accompanying her menstrual period (dysmenorrhea)
The young woman’s mother: doctor, it’s been two days like this, and now she’s started vomiting.
Doctor: When did this pain start?
The mother: about a year ago, her periods had been causing her so much pain that she would collapse on the floor. We took her to the local doctor, and they gave her painkillers, but her aunts have similar periods; they also fall to the ground, but not to this extent.
After the ultrasound, it was revealed that there was a three-centimeter cyst (endometriomas) on the right ovary.
Severe dysmenorrhea that leads to the inability to function should raise suspicion of endometriosis among all healthcare providers. Often, endometriosis involving the uterosacral ligament and ovarian surface is the most common presentation in teenagers.
Fibromyalgia Syndrome:
A friend of mine, a rheumatologist, told me about an encounter with a couple, a comedy show he watched for the 10th time in his clinic. The husband began by looking at his wife, then smirked mockingly and said, ‘Go ahead, talk.’ He interrupted his wife before she could speak and jokingly said, ‘Tell us, doctor, do we need to change and start searching again?’
The signs of frustration were evident in the woman, who must have repeatedly heard this kind of humor. She said, ‘Doctor, my entire body is in pain. I feel exhausted, and I can’t eat wherever you touch me. It hurts my back and shoulders everywhere.’
The husband continued jokingly, ‘I took her to several doctors, and they all gave her some medications and told her to toughen up, that there’s nothing wrong with her. Her mood is low, and she keeps complaining.’
Fibromyalgia is a common rheumatic disorder with a worldwide prevalence ranging from 2% to 4%. It presents with widespread musculoskeletal pain, fatigue, numbness in the hands or feet, continuous fatigue even after rest, irregular and disturbed sleep, the potential for depression and anxiety, shortness of breath, frequent or migraine headaches, difficulty concentrating and remembering, and gastrointestinal disturbances such as bloating, Constipation, or irritable bowel syndrome.
The causes include changes in the central and peripheral nervous system functions and immune activity. It affects women ten times more than men and often occurs in midlife. It is more common in individuals with autoimmune diseases such as rheumatoid arthritis and lupus, individuals who have experienced repeated injuries, obesity, and may have a genetic component.
The diagnosis is primarily clinical based on symptoms, with tests and investigations conducted to rule out more serious diseases. Treatment is mainly the responsibility of the patient and their immediate environment, focusing on reducing psychological and physical stress. In addition to exercising, even though it can be exhausting initially, it will improve mental and physical health.
The husband returns to his famous jokes and says: ‘I have offered to marry another woman so she can help her and lighten the burden of housework.’
To the husband, it’s essential to know that this is a medical condition, not mere complaining; you should provide emotional and practical support to your wife.
Colon Cancer:
Symptoms of colon cancer become prominent in the late stages of the disease when it is diagnosed in its advanced stages. However, they are less common and less apparent in the early stages of the disease. Less common symptoms include nausea, vomiting, loss of appetite, and abdominal bloating. Although colon cancer can be accompanied by diarrhea or Constipation, late changes in bowel habits are more likely due to colon cancer rather than chronic abnormal bowel habits.
Our trivialization of women’s pain is not just a story within hospital corridors, doctors’ offices, or behind closed doors in homes; it is a deep-seated discrimination that infiltrates the fabric of our society and culture. Each woman has a complex story and real pain that we must respect and listen to. We should open our eyes and hearts to women’s daily aches and challenges. Let’s stand by them, amplify their voices, and change how we perceive their pain by not underestimating it.
[1] (William gynecology)
[2] (William gynecology)
