Written by Dr. Olga Ramm Urogynecologist and reconstructive pelvic surgeon. Director, Center for Urogynecology and Women's Pelvic Health at UCSF.
Chronic pain conditions affect roughly a quarter of the American population, with one in ten people reporting limited life and work activities due to pain symptoms, according to CDC statistics from 2024. Among women, one in three is affected by chronic pelvic pain symptoms, defined as continuous or intermittent pain in the pelvic area that persists for 6 months or longer. Every year in the US, chronic pelvic pain accounts for 10% of all gynecology office visits, 40% of laparoscopic surgeries,7 and 12% of hysterectomies8 even though the origin of chronic pelvic pain is not gynecologic in 80% of patients. Moreover, increasing numbers of randomized surgical trials are revealing that surgery fails to provide lasting resolution of chronic pelvic pain in a majority of people. Only recently, with increased focus on patient-reported outcomes for medical conditions, have we begun to construct a more comprehensive, outcomes-driven approach to the management of chronic pelvic pain. This has led to shifting paradigms, underscoring the importance of chronic and accumulated stress, trauma, and emotional health in the development and resolution of pain symptoms.
Through the 20th century, treatment of chronic pelvic pain syndromes has targeted pelvic end organs, such as the uterus, ovaries, or bladder, as well as the pathophysiologic mechanisms that result in pain, such as inflammation or infection. However, both animal and clinical research have indicated that many of the mechanisms for chronic pelvic pain are not organ-specific, but based within the central nervous system. Pain is triggered by crossing a threshold on a broad continuum of sensation. We register light touch, then firm touch, and ultimately painful pressure. There is biologic variation in the threshold that separates neutral sensation from pain. Animal models have demonstrated that we can lower the pain threshold through exposure to repetitive noxious stimuli, causing the central nervous system to become sensitized to even normal stimuli. Currently, we know very little about who is more susceptible to this central sensitization or how to reverse it. In the past two decades, increasing attention has turned to the impact of adversity, trauma, and chronic stress on the development of chronic pain conditions. A few measurement tools have been validated for quantifying the adversity faced by an individual. Perhaps the best known is the Adverse Childhood Experiences (ACE) questionnaire. This ten-item questionnaire, developed by Dr. Vincent Ferlitti in the 1990s, includes domains of childhood abuse, neglect, and household instability, with scores ranging from 0 to 10. High ACE scores, defined as 4 or higher, have been consistently associated with physical and mental illness, substance use, suicidality, and higher mortality. This association corroborates what all of us intuitively understand to be true: chronic stress, hardship, and anguish have a direct negative effect on physiologic and neurobiological processes. Could chronic adversity, objective or perceived, act as a repetitive noxious stimulus, resulting in central sensitization and priming us for the development of chronic pain conditions?
Several studies, most recently one that included over 7000 women, have suggested that there is a direct, dose-dependent relationship between adverse childhood experiences and the development of chronic pelvic pain diagnoses. At the same time, trauma and adversity are not limited to childhood and trauma-adversity quantification tools that encompass the entire life continuum have not yet gained widespread use in clinical practice. Undoubtedly, there are individuals with chronic pelvic pain who do not have a history of Trauma; and what is a neutral experience to many individuals may be traumatic to a few. Returning to the management of chronic pelvic pain, we know that an individual’s pain threshold can be reduced as a result of multiple or frequent pain stimuli and central nervous system priming or sensitization and that a history of trauma or chronic stress plays a role in modulating the threshold and the sensitization process. While a peripheral stimulus, for example a pelvic infection, may trigger pain in the pelvis, its symptoms may become self-perpetuating, or chronic, as a result of the central nervous system’s modulation of infection-associated pain symptoms. In addition to pain, these central mechanisms are associated with other sensory disturbances: feeling pain with normal touch, burning, or itching; with functional disturbances: urinary frequency, diarrhea, sexual dysfunction; with behavioral manifestations: catastrophizing, substance use; and psychological manifestations, most commonly anxiety and depression. So, it is not just the pain symptoms, but rather all of these phenomena collectively that form the pain syndrome diagnosis. As a result, just treating the inciting pelvic infection is unlikely to resolve a chronic pain condition once it has developed. Each one of these phenomena needs to be addressed in its own right through multidisciplinary care. In fact, although ongoing peripheral organ pathology, like infection or cancer, can produce persistent and chronic pain, the bulk of those affected by chronic pelvic pain in the developed world have no ongoing peripheral pathology.
While such a multidisciplinary approach sounds resource-intensive at first mention, the economic costs of chronic pelvic pain, including lost productivity, exceed $289 billion annually in the United States alone; the individual human suffering and resultant ramifications are immeasurable. The opioid epidemic has galvanized the importance of improving our approach to chronic pain, with most professional health organizations recommending a multifaceted, holistic approach. Psychological support has, in recent decades, included almost exclusively cognitive behavioral therapy (CBT or talk therapy), which helps patients understand how traumatic experience has affected them and helps them change erroneous beliefs or maladaptive ways of thinking or behaving. Armed with this insight, the patients develop a “toolbox” of coping mechanisms. Unfortunately, the efficacy of CBT in resolving trauma and its effects is well below 50%. A common account of a trauma survivor’s experience with therapy is “I’m 46 years old and I’ve been to at least eight therapists since I was sexually assaulted in college. I’ve talked about it over and over; I’m tired of talking about it. And it’s still here . . . still affecting my life. I just want to move past it… I want to feel better.” Talking alone does not make trauma and its effects go away. This is because most traditional therapies, including cognitive-behavioral therapy, depend on top-down processing in which the patient is taught to use cognitive strategies to manage or inhibit problematic feelings, thoughts, and behaviors. This approach helps patients gain insight into their way of being in the world. It helps them learn to identify stimuli that trigger them and understand their responses. They may learn to manage disturbing emotions and body sensations. But these top-down approaches do not process the episodic memories or resolve the physiological hyperarousal. Consequently, patients are still triggered by these same stimuli that their brain perceives as dangerous and they may still respond in maladaptive ways. Even with years of therapy, immediate responses to triggering stimuli tend to be physiological rather than logical. As another patient put it, “I am grateful for all the tools I now have for talking myself off the ledge, but I’m tired of still being on the ledge. I just don’t want to be on the ledge anymore”.
In contrast, biologically-informed somatic therapy, such as Emotional Resolution or EmRes, focuses on processing traumatic experiences from the bottom up. Biologically informed therapy focuses on what is going on in the body: pain, hyperarousal, the biochemical and neurobiological footprints of anguish, stress, and trauma. It enables clients to neutralize these sensations, re-calibrating the pain threshold and desensitizing the central nervous system. Undoubtedly, more investigation of bottom-up biologically informed somatic therapy modalities is needed. The first step is building collective awareness about Emotional Resolution and recognizing that historic approaches to chronic pain – surgical, pharmacologic, and psychologic – have fallen short.
About Dr. Ramm: Dr. Olga Ramm is a urogynecologist (a specialist in women's pelvic floor conditions) and a reconstructive pelvic surgeon with expertise in minimally invasive and robotic techniques. She cares for patients with pelvic organ prolapse, urinary or fecal incontinence, complex urinary or rectal fistulas, and surgical complications. Her approach focuses on collaborating with other specialists and tailoring treatment plans to patients' individual needs and preferences. She serves as director of the UCSF Center for Urogynecology and Women's Pelvic Health.
In her research, Ramm investigates topics related to urogynecology and reconstructive pelvic surgery, including surgical outcomes, birth trauma, care equity and patient consent.
Ramm earned her medical degree at the University of Kansas School of Medicine. She completed a residency in obstetrics and gynecology at Northwestern Medicine Prentice Women's Hospital, followed by a fellowship in urogynecology and reconstructive pelvic surgery at Loyola University Medical Center.
In addition to patient care, Ramm is passionate about surgical education. She has held leadership roles in undergraduate and graduate medical training, including program director for the fellowship in urogynecology and reconstructive pelvic surgery offered jointly by Kaiser Permanente East Bay and UCSF. She has also influenced education of the next generation of urogynecologic surgeons through her work with national organizations on curriculum development, clinical evaluation and certification pathways. These organizations include the Accreditation Council for Graduate Medical Education and American Board of Obstetrics and Gynecology.
Read more from Cedric Bertelli
Cedric Bertelli, Somatic Practitioner
Originally from France, Cedric Bertelli is the founder of the Emotional Health Institute, operating in the USA, France, and Japan. Cedric co-developed Emotional Resolution® (EmRes®), a groundbreaking somatic method for resolving debilitating emotional patterns. Cedric blends practical expertise with influences from neuroscience and philosophy. He trains coaches, therapists, and other professionals in the EmRes® methodology, empowering them to help clients achieve lasting emotional well-being.
