   
Need to know what makes the pain worse and is there any thing that makes it better? Also is it related in any way to the menses even though they are irregular (and how irregular?)? How intermittent is the pain and is it associated with sexual relations, use of tampons etc.?
Assuming the pain does not get worse or better with either bowel movements or with passing your urine and you don't have an abnormally high frequency of voiding or passing stool, the next step would be to have an abdominal pelvic ultrasound to see if there are any anomalies of the ovaries or uterus.
What may be going on is very difficult to say without an exam. The only abnormality you describe except for the pain is menstrual irregularity. While this can be due to different causes, polycystic ovarian disease comes to mind. Sometimes it is associated with pain just as recurrent cysts of the ovaries. Sometimes there are endocrine problems such as Addison's disease. You have probably looked at the differential diagnosis list for chronic pelvic pain.
As you can see there are many possibilities.
Left-sided pelvic pain and unicornuate uterus
Sometimes there can also be duplicate ureters that are either connected to the kidney(s) or end blindly. MRI may miss these. They are diagnosed by a retrograde IVP in which the dye is injected into the bladder and then up the ureters. Since your pain is on the left, it may be worth having that done. They can get infected and cause pain and sometimes they just cause pain for no obvious reason.
No non-pregnancy risks that I know of except the non- communicating horn is often the site of pain.
It is more likely that there is something else such as duplicate ureter, endometriosis or adhesions causing the pain. The dilemma at surgery is whether to remove the normal horn along with the blind horn. There probably is no answer to this and the decision should be made preoperatively rather than intraoperatively about removing all uterine tissue.
Severe right-sided pain and dizziness
This sounds like a "vagal" response (vagus nerve in the abdomen), which can happen with severe pain. It is probably caused more by the pain than by whatever is causing the pain.
Could very well be endometriosis or possibly an ovarian cyst. The doctor will have you get a pelvic ultrasound to check for any abnormalities. The next step will probably be a diagnostic laparoscopy to diagnose the cause.
Recurrent, severe right upper abdominal pain
Common causes of right upper quadrant pain include acute cholecystitis (this is what your FP is looking for), duodenal ulcer, hepatitis, enlarged and congested liver, acute pancreatitis, pyelonephritis (kidney infection), renal stone, pneumonia (on the right) and tuboovarian abscess.
The sharp, crampy intermittent pain is usually more characteristic of problems with a hollow organ such as the bowel, ureter, fallopian tube or gall bladder.
In your case, I doubt that the problem is Gyn related due to the nature and location of the pain. I would put my money on a GI/Renal related problem. There are some rare causes such as hyperparathyroidism, paroxysmal nocturnal hemoglobinuria, porphyria and other rare diseases but I would look for the more common first.
Up to 5% of valid ultrasounds are falsely negative, either because the stones are too small, or because they have migrated into the duodenum by the time of the examination. In these patients, sampling the bile may provide the only clue that gallstones, or gall sand exists.
It may be worthwhile obtaining a general surgeon's opinion.
Abdominal bloating and ovarian cancer concern
Abdominal bloating can be a sign of ovarian cancer but it is always very slow in onset (over many months) and rarely causes pain and cramps until very late in the disease. Ovarian cancer is usually a disease of the 50s and 60s. I doubt you have ovarian cancer and would bet against it.
Ovarian cysts, endometriosis, fibroids, adenomyosis and infection would be possible. How frequently are you having to pass urine? Does it burn? Do you get up at night to void? Does pain get worse or better with bowel movement or voiding. Are you on anything for birth control. When was your last pelvic exam? Was it normal?
The symptoms you describe are most consistent with large fibroids or ovarian cysts, or possibly irritable bowel syndrome or interstitial cystitis.. Your doctor will check out the urine for infection just to be sure. Probably an ultrasound will be done. If the ultrasound doesn't show an abnormality, the next step would be cystoscopy to look for interstitial cystitis and a gastrointestinal consult to see about irritable bowel.
What is adenomyosis?
Adenomyosis is endometriosis of the uterus rather than of the abdominopelvic cavity. In other words, endometrial glands grow down into the muscle of the uterus and become isolated pockets of functioning glands that are separate from the epithelium sloughed each month in your menses. The tissue and blood in these pockets have nowhere to go and thus produce pain from swelling.
Bad ovulatory pain
If the Provera® worked for awhile, this would indicate possible endometriosis, adenomyosis or possibly ovulatory pain. The injectable Provera®, Depoprovera®, may work better than the oral pills and give you relief.
As far as hysterectomy goes, With chronic pelvic pain, if the pain is reproduceable with palpating the uterus on a pelvic exam, about 2/3's of women get better with a hysterectomy and 1/3 continue to have pain or get worse. I would think you may need a diagnostic laparoscopy first to see what is really going on.
Pain and bleeding with exercise
Vaginal bleeding brought on by exercise or trauma is usually related to either disruption of the corpus luteum of the ovary (gland that forms after egg is ovulated each month) or anatomic abnormality inside the uterus such as a polyp or fibroid. The sudden pain and then the bleeding would go along with a ruptured corpus luteum of the ovary or even midcycle ovulation if it occurred 14 days or less from when the NEXT menses was supposed to occur. Bleeding from anatomical causes would be more likely at age greater than 35. There are other causes such as local cervical irritation, endometriosis, endocrine bleeding etc., so you are right to get an exam to put the total picture together with the other ovulatory problems you describe.
5 days of ovulatory pain
Ovulatory pain at midcycle (day 14 or 15 after start of menses in a 28 day cycle) usually does not last longer than a day or two in most cases. It is thought to be due to some bleeding that takes place at the time that the egg is ovulated from the ovary. The bleeding is usually into the abdominal/pelvic cavity internally and irritates the lining to produce pain. Bleeding could be into the substance of the ovary at that time and cause pain however.
Endometriosis usually doesn't cause pain at midcycle; it characteristically causes pain and cramps at the time of menses. In your case the pain is starting on day ten when the follicle (egg) to be ovulated is just starting to distend (swell) the ovary. It could be that you are very sensitive to any ovarian capsule swelling. I would expect your midcycle pain to vary-- sometimes on the left, sometimes on the right. Does it do this?
The cramps and heavy flow can represent endometriosis. There are two types. One affects the lining of the abdominal/pelvic cavity around the uterus and ovaries. This usually can be seen at laparoscopy, however sometimes it is missed if it is not the classic bluish/black appearing lesions. There are also red and clear looking lesions that really need to be biopsied to diagnose endometriosis. The second type of endometriosis is an internal type in which the endometrium grows down into the muscle of the uterus. It is called adenomyosis or endometriosis interna and it cannot be seen laparoscopically. It is usually diagnosed only at time of hysterectomy when the pathologist looks at the uterus microscopically.
So to specifically answer your question, yes there are some things that may not necessarily be seen at laparoscopy that could explain your symptoms. On the other hand, it would still be possible to have endometriosis that could be diagnosed at this time but not have been diagnosed two years ago at laparoscopy.
Left sided pain and bicornuate uterus
This could cause pain, but at this size it may be a physiologic cyst that goes away after another menstrual cycle or two. Your doctor will probably just "observe" it.
The inside of a bicornuate uterus is usually "heart shaped". The middle of the top indentation of the "heart" can just be a dimple or can go all the way down to the bottom (point) of the heart. The distance the septum that goes down would determine how much of the height (length on ultrasound) is divided into two cavities. The most common of the bicornuate uteri don't have much of a second cavity and then it's only at the top of the uterus.
Sometimes it is if the exterior of the uterus is divided. Usually it isn't however.
Yes, often.
Pain after C-Section
After it ends or begins? How long does your period last? In other words if you have a 5 day period, the pain is starting on day 6 or 7 after the period starts, is that correct?
"Normal" cysts on the ovaries are almost always follicles in the ovary and not "cysts" that are abnormal physiological events or "cysts" that are benign growths. They are usually less than 2.0- 2.5 cm in size and there can be several. They can occur on BC pills, especially with the lower dose pills. Most doctors appropriately under play their significance. Radiologists and Ob- Gyns should never call them "cysts" in the first place.
That's not correct. Ovulation is decreased but it certainly happens. On the other hand, I would agree that the pain was unlikely to be due to "ovulation".
Triphasic pills often block ovulation but not always. They work in many different ways though so even if ovulation isn't blocked, pregnancy still doesn't occur.
This is possible.
They probably were not "cysts" in the first place, but rather follicle development that had gone away (that's normal).
Pain for 6 months is not normal. It may not be related to the C- Section. If it is related to the C-Section it would be due to some scarring which can develop later.
For many years if it is due to scar tissue.
Yes, but that's why I asked about the pain. Endometriosis almost always produces it pain DURING the time of the menses, not after it.
The surgical treatment of endometriosis often involves resection of tissue, sometimes removal of the ovaries and/or uterus. Even if those organs are not removed, the resection of endometriosis can cause scarring that affects your fertility.
Is it that they are not concerned or is it that they cannot easily solve your pain problem?
Poorly performed surgery (at C-Section) almost always would cause pain or problems from day one after the surgery, not 6 months later. We do live in a skeptical society and I can see how he would think that. Maybe he just wants to deny that you could have a chronic disease.
This can often help. Another doctor may suggest a trial with some anti-endometriosis medicines to see if the pain gets better. That would point to endometriosis as a cause. Another approach may be to consider a diagnostic laparoscopy to see if there is any scarring that can be removed or released to improve the pain. That is usually an outpatient surgery procedure.
It hurts during sex
In order to help you, we first need to determine the original cause of the pain. Then, we need to know to what degree you are having an involuntary reaction to fear of having pain each time you have sex. We want to first make sure the original cause of the pain is treated as best as possible. What pain remains is the body's reaction to the fear of pain which in turn causes vaginal muscle spasms that cause a secondary pain. This fear of pain may be conscious or subconscious but is also decreases the ability to have orgasm.
First we need to know how the painful intercourse started. Did the pain start originally at the opening of the vagina (vulva, introitus), the inside of the vagina or only deep inside the pelvis when thrusting moves the pelvic contents such as the cervix, uterus or ovaries? It should be easy for you to tell if the entrance to the vagina (introitus) was the original painful part. It would have hurt just with touching the area with your fingers or a pad rubbing against it.
Vaginal pain is a little harder to tell. The pain would be present mostly upon your partner entering the vagina and with the movement back and forth without deep penetration. You probably have some degree of this pain now even though you may not have had it originally. This is because the vaginal muscles now involuntarily contract because of fear of being hurt and the contraction makes the vagina and opening smaller instead of larger which is the normal response. Since you are on DepoProvera (R) which is known to cause vaginal dryness, this could have been or can still be your main problem.
Deep pelvic pain is much worse when you are having intercourse and you are on the "top" position. This results in the deepest penile penetration and often moves the pelvic organs. Any pathology such as endometriosis, an ovarian cyst or uterine abnormalities can be painful with deep penetration. If that is your original pain problem then a pelvic exam and possibly a pelvic ultrasound will help clarify the cause.
Here are some of the possible causes of painful sex (dyspareunia)
Vulvar entrance
Vaginal
Deep
As you can see the list of possibilities is extensive and treatment must be directed toward the initial cause. Once the initial cause of pain has been treated, any secondary vaginismus (vaginal or pelvic muscle spasm) due to a learned fear of pain must be treated. This is a slow process and will involve your partner's help in getting the pelvic muscles to relax rather than contract. You will need you doctor's help or that of a professional sex therapist for instructions on manual massage of the vaginal muscles to induce relaxation.
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