GP Long case: Subacute lower back pain and loss of libido in young women

History of presenting complaint
EP is a 22-year-old female patient presenting to St. George’s Terrace Medical Centre with an 8-week history of back pain. This is the first incidence of prolonged back pain for EP. Around the same time she had been experiencing increased tiredness and fatigue.

The back pain was described as a constant 4/10 “painful tightness”, localised to the right side of her lower back. She added that she occasionally experiences paraesthesia, which radiates from this point to the anterior thigh (does not extend beyond knee). She could not think of a specific trigger, which has caused this back pain but noted that it closely followed her return to her gym, which includes exercises that strain the lower back. Exacerbating factors include movements that utilise the lumbar spine and sitting for prolonged periods of time.

EP has attempted to go to the physiotherapist who offered deep tissue massage, but explains that her symptoms show minimal improvement. She has also tried using “Deep Heat” (active ingredient methyl salicylate) and states that it helped with the pain, but experience skin changes due to overuse (peeling and redness of the skin). She is taking paracetamol, which she dulls the pain to 2/10. When asked, she stated that she has generally decreased activities that utilize the lumbar spine in hopes that she would recover faster.

She shows no infective signs such as fever, hot and cold rigors or skin changes over the vertebrae. She also has not lost weight recently and mentioned any weight loss would be welcomed.

Her secondary complaint was her current lack of libido. She attributes this to taking the oral contraceptive pill, which she has taken since the age of 13. She explained however, that her current fatigue and discomfort has further deteriorated her libido to a level that now affects her lifestyle. She also has tried changing the type of oral contraceptive pill but found the alternative that she used did not improve her libido and made her mood less stable. She is adamant to cease the oral contraceptive pill all together.

She cannot attribute the loss of libido to any other factors such as new or different sexual partners or dyspareunia. She has been in a stable relationship for the past 2 years and states she is very happy with her current partner. She however feels guilty that she is no longer interested in having intercourse with him. Prior to her loss of libido they were having intercourse 2-3 times a week, but now only have intercourse occasionally (1-2 times a month).

Finally, the combination of all these problems; back pain, fatigue and loss of libido has now begun to affect EPs mood.

Medical, Surgical and family history
No significant past medical history or surgical history.
No family history of diseases such as malignancy or osteoporosis.

Medications
2 tablets of paracetamol, 4 times daily.
Medication history: oral contraceptive pill
No known food or drug allergies.

Lifestyle history
EP is a non-smoker who drinks occasionally on the weekends (up to 4 standard drinks). She does not use any recreational drugs
She is currently trying to lose weight by eating a low-fat and low-carbohydrate diet. Prior to her back pain she was exercising and the gym regularly but has since reduced her activity in hopes of recovering from her back pain.
She is currently living with her boyfriend and is independent with her daily activities.
Significant examination findings

General inspection:
Slightly overweight young woman who appears to be comfortable and non-dyspnoeic at rest, no signs of anaemia or systemic infection
Vital signs: HR 84 bpm, BP 110/75 mm Hg, RR 20 bpm, T 36.5 ̊C,
Weight 75 kg, height 162 cm, BMI: 28.6

Lumbar Spine examination

Inspection
Slight lumbar spine scoliosis towards the right side. No other spinal deformities
Mild scarring over the 4th to 5th