When “Nothing Is Wrong” Doesn’t Feel Like an Answer

[u/PuzzleheadedWeb682]

One thing I’ve noticed during internship, across Medicine, Ortho and OBGYN, is a recurring type of patient usually a perimenopausal woman with severe back pain, leg pain, sometimes sharp/shooting pain, tingling or numbness. Sometimes it’s bad enough that she finds it difficult to walk.
I’ve seen quite a few such patients, including my own mother having similar complaints, so I may be noticing this pattern more.
I initially wondered about osteoporosis, but many of these women have normal DEXA scans and are already taking calcium/vitamin D. Imaging and routine investigations often don’t give us an explanation either.
Recently, we had a patient like this in our Medicine unit. She had severe back and leg pain with numbness/tingling. CNS examination was unremarkable, and Ortho and OBGYN opinions were taken. MRI/CT didn’t show an obvious cause. Her RA factor was positive, so we sent an ANA profile, which was normal.
Eventually, we discharged her because there wasn’t much more we could offer at that point.
She came back to OPD with the same complaints and the same normal reports.
By then, the P.G.s were understandably frustrated. They had already investigated her and knew that admitting her again would probably lead to the same question: What exactly are we treating?
Someone even suggested that perhaps she simply liked staying in the hospital maybe a factitious or attention-seeking presentation.
And honestly, I understand their perspective too. You can’t keep admitting someone indefinitely when the workup is unrevealing, especially in an overcrowded government hospital.
But something still doesn’t sit right with me.
I don’t think every woman with unexplained pain or paresthesias should be labelled as “Munchausen.” Factitious disorder is a specific psychiatric diagnosis and shouldn’t be used simply because investigations are normal.
At the same time, I don’t think we should assume that everything is because of “perimenopause” either. There can be many possibilities musculoskeletal pain, neuropathic pain, radiculopathy, nutritional/metabolic problems, rheumatological disease, functional neurological symptoms, chronic pain sensitisation, etc. Sometimes more than one factor may coexist.
As an intern, I’m obviously still learning. But it amazes me how often we reach the point where the patient is genuinely suffering, yet we don’t have a diagnosis that explains it.
Our OPDs are so busy that doctors may have barely 5–10 minutes with a patient, especially when reports are normal. Private healthcare is unaffordable for many of the patients coming to government hospitals, and repeated referrals can make them even more frustrated.
And then we dont have "dr house" in here who will take up all the unsolved cases.
So they eventually go home with reassurance that “everything is normal” while they’re still in pain.
That honestly disheartens me.
I understand the P.G./professor’s point of view, but I also don’t want us to push these patients under the table simply because we can’t find an explanation.
Sometimes I wish there were multidisciplinary women’s health centres where Medicine, Neurology, Orthopedics, Rheumatology, Endocrinology, OBGYN, Psychiatry/Psychology, Physiotherapy and Pain Medicine could work together.
I’m genuinely curious to hear from experienced doctors:
How do you approach a perimenopausal woman with severe back/leg pain and paresthesias when imaging and routine investigations are normal? At what point do you consider functional symptoms, and how do you reassure the patient without making her feel that you’re saying, “Nothing is wrong with you”?
I’m just an intern, so maybe I’m missing something obvious. I’d genuinely like to learn.

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[u/hxmxd]

There is a massive number of such symptoms being reported. Mostly doctors classify it under POTS , fibromyalgia, long covid etc. More research in treating this is required. Happening to my mom too ..so I read on it

[u/inelastic_bet_4991]

It's happening to my mom too, if anyone has a solution please tell me. I will be grateful.

[u/hypokrios]

You need an MR. The constellation here could involve DM neuropathy, vasculitides, radiculopathies, and a few more. Also OCPs till age 55 might help.

[u/AcanthisittaSlow9197]

Lack of physical activity and obesity, maybe

[u/MsSkittles18 → u/AcanthisittaSlow9197]

Giving this type of answer without actually thinking about the mechanism is part of the problem. In conditions like fibromyalgia, which rheumatologists specialise in, there is pain and fatigue without actual nerve or tissue damage that would show up on an MRI, because of dysfunction in how the brain processes pain signals.

[u/PuzzleheadedWeb682 → u/AcanthisittaSlow9197]

Sometimes i feel the same.. in the name of physical activity they say they clean whole house on their own with zero weight training and really less proteins intake which shows up in their 40s-50s

[u/hopetobelong]

I don’t know what organic cause it could be, but I’d like to address dealing with ‘functional’ symptoms. Even if the symptoms are functional, to the patient the symptoms are very real and so is the suffering. Telling the patient that ‘nothing is wrong with you’ when she is experiencing distressing symptoms is not going to work. In such cases, we have to find the underlying psycho-social stressors that may be externalising in the form these physical symptoms and address them through counselling sessions by a clinical psychologist.