Postmenopausal Bleeding
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Older patients commonly report pain during office visits. One study reported pain prevalence of 25% in persons older than 60 years compared with 12.5% in those less than age 60. Other studies cite the prevalence of pain in the elderly at routine office visits from 36% to 88%. Nearly one‐fifth of elderly Americans take analgesics at least several times per week and two‐thirds of these persons take prescription analgesics for more than 6 months. Among nursing home residents, 49–83% perceive uncontrolled pain as a major concern. We perceive pain when our body is threatened from either internal or external sources. Stimuli excite pain receptors in the skin, connective tissue, blood vessels, and bony surfaces, and most organs then travel via peripheral nerves and the spinal cord alerting the brain of impending injury. After exciting peripheral receptors, painful stimuli travel from nerves to the spinal cord and then to the brain. Simple processing of pain occurs within the segmental spinal cord allowing for the quick withdrawal of a limb from an adverse stimulus; for example, this is why you automatically remove your hand after you have touched a hot stove. Signals ascend within the lateral spinothalamic tract, enter the brain, and synapse within a region called the ventral posterior thalamus, where the severity of pain is realized. Pain arising from internal organs is referred to various areas on the body surface creating confusion as to the pain’s source. Referred organ pain includes left arm pain with heart attack and right shoulder blade pain from gallbladder disease. Pain also occurs when peripheral nerves are interrupted from trauma, infection or toxins, resulting in permanent sensory loss. Incessant burning and tingling called paresthesias and stabbing pain or neuralgias may arise after peripheral nerve injury, and are common expressions of neuropathic pain. Injury to nerves in the arms and legs may result in persistent pain syndromes through heightened sensitivity of an extremity’s sympathetic pathways resulting in a regional pain syndrome. Incessant burning at rest, hypersensitivity to light touch, and poor topographic discrimination are common characteristics. A common classification divides the complex regional pain syndromes into those with intact surface sensation, reflex
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Springer-Verlag Berlin Heidelberg 2008
sympathetic dystrophy, and those without, causalgia. An overactive sympathetic nervous system causes local swelling or edema, dystrophic skin changes, heightened sweating, and bony loss, along with fluctuation in temperature and blood flow in the injured limb. Understanding the cause for a person’s pain should be the first step in care. Patients with pain often have associated depression. This component must be addressed separately from the root source of the pain. Lack of clear separation of the emotional from the physical components of pain interferes with finding its origin and rendering appropriate treatment. Treatment of pain can be divided into three arenas: medical, surgical, and behaviora
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