I saw a patient recently. Her complaint was pelvic pain which was in the left side. This began immediately following the delivery of her last child, three years ago. She was delivered by Cesarean section and developed a wound infection following this. Her pain had got progressively worse. She had been told at the time of her Cesarean section that one ovary had a cyst on it. She is now having progressively worsening pain which is affected (worse) by changing position, but improved by lifting the abdominal wall (to relax the abdominal wall muscles). This was most recently set off by intercourse. A recent ultrasound had showed ‘cysts’ on the ovary, reportedly. Review of this report, however, showed that both ovaries were only minimally enlarged and that the left showed evidence of multiple small cysts, possibly with evidence of complex cyst, and to consider the possibility of recently ruptured cyst recommending repeat evaluation in six weeks. She was referred by a mid-level provider for consideration of a hysterectomy. This is a fairly typical referral.

I start out by telling her that hysterectomies are often not successful at treating chronic pelvic pain. Frequently, there is relief for a year or two, and then the patient returns with the same pain, often to be referred to another physician, sometimes a GI physician, other times a psychiatrist, many times with improvement but oftentimes without. I then tell her that before I make any judgments, I will have to evaluate her. She is obese. I have her to lay flat on her back and raise her legs some 6-8 inches from the flat position. She is tender at the insertion of the rectus muscles on the left at the pelvic brim (top of the pubic hair). She has tenderness of the paraspinal muscles on the left. I place both her hands on the equivalent muscles on my back and abdomen, moving so as to show how the muscles work together, contracting and relaxing in opposition to each other. I show her how both are contracted when bent at the waist. I show her when hers are in this position it produces the pain that she has. I am able to show her that this is where she has her pain and to duplicate it with her rolling off her back and lifting herself from the reclining position precipitates the pain. I show her how lifting the abdomen up (relaxing the abdominal wall muscles) relieves it.

I then tell her about the black box model that I use to demonstrate how the body controls its use of energy (see menorrhagia, biologic extended systems). I describe how this is driven by the emotional state. I also describe the analogy of the immune system and the gatecrasher concept (see immune system analogy). When I describe how cortisol is increased when one has an inappropriate major life threatened response to a minor non life threatening stimulus, she tells me that her weight fluctuates between 400 lb and 240 lb, her present weight, according to her level of stress.

Pelvic examination shows that there is tenderness, and when the cervix (mouth of the womb) is moved and when movement is in either direction, she feels pain then in both sides. I discuss the immune system and how a pelvic infection can reflect stress and how she sees her relationship with others, particularly her husband or partner. I offer to treat her with antibiotics, again reminding her of the immune gatecrasher analogy, and her need to change her perspective and her choices which create stress about events and results. I remind her that stress does not occur, but is rather chosen. I discuss how her choice of response creates stress (major life threatened response) and causes increased cortisol which is responsible for changing the glucose (recruited from glycogen in the liver and muscles for immediate response) into fat. This causes an increase in weight. This in turn alters the estrogen levels and affects the metabolism of sugar, with further insulin resistance. This is compatible with the multiple cysts on the ovary and the irregular cycles. She now tells me that she has been having irregular cycles. She is also able to understand why she has also become hypertensive, as this is all connected together. As we are ending the conversation, I can see the light bulb go on behind her eyes, as she finally understands.