History

Critical to the evaluation and management of CPP is a detailed history. A pain questionnaire may assist in helping the patient express issues that she may otherwise be unable to verbally express. The history should include:

• The chronology of the pain. In what context did the pain arise? Was there an eliciting event? Has the pain changed? What does the patient think is causing the pain?

• The nature of the pain: character, intensity, location and radiation, aggravating and alleviating factors, and the effect of menses, exercise, work, stress, intercourse, and orgasm.

• The severity of pain, rated from 0 to 10 on a verbal or visual analog scale.

• Associated somatic symptoms. Specifically related to the:

- genital tract (abnormal vaginal bleeding, discharge, mittelschmerz, dysmenorrhea, dyspareunia, infertility);

- gastrointestinal tract (constipation, diarrhea, flatulence, tenesmus, alterations to pain before and after a bowel movement, blood, changes in color or caliber of stool);

- musculoskeletal system (pain distribution, radiation, association with injury, fatigue, postural changes, exercise, lifting);

- urologic tract (dysuria, urgency, frequency, nocturia, hematuria, suprapubic pain).

• Neurologic system (burning, lancinating pain, allodynia, and or numbness in the distribution of a particular peripheral nerve).

• Prior evaluations for the pain including treatment history, operative and pathology reports, as well as side effects/success or failure of prior treatments.

• Impact on family, work, daily activities. Is the degree of pain such that the pain prevents the patient from performing a family role or occupation? Is litigation or worker's compensation an issue? What is the attitude of the patient and family toward the pain and resultant behavior?

• Past medical, surgical, gynecologic, obstetric history, and medication intake including pain medication.

• Current and past psychological history. History of past or current physical, sexual, and/or emotional abuse, history of hospitalization, suicide attempts, and chemical (drug or alcohol) dependence.

• Patient's expectations. What is the goal of treatment?

Prospective daily pain ratings or calendars to note the occurrence and intensity of pain, menstrual bleeding, and mood rating (0-10) are very helpful in the evaluation of CPP. Aggravating factors should be noted in the daily rating, utilizing an analog scale from 0 (no pain) to 10 (most severe pain ever) for at least two months or two menstrual cycles, and is best continued until pain has resolved. Daily rating increases self-efficacy, demonstrates compliance, allows for diagnosis of atypical (luteal phase as opposed to just with menses) cyclic pain, demonstrates improvement with treatment, and allows the patient to recognize the connection between pain and stress or physical activities.

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