Overview of Pelvic Pain

Pelvic and Abdominal Pain
(and endometriosis)
From Woman's Diagnostic Cyber
Frederick R. Jelovsek MD

• Intermittent lower abdominal pain
• Left-sided pelvic pain and unicornuate uterus
• Severe right-sided pain and dizziness
• Recurrent, severe right upper abdominal pain
• Abdominal bloating and ovarian cancer concern
• Can you tell me what adenomyosis is?
• Bad ovulatory pain
• Pain and bleeding with exercise
• 5 days of ovulatory pain
• Left sided pain and bicornuate uterus
• Pain after C-Section
• It hurts during sex
  

Intermittant lower abdominal pain I am 26 years old and experiencing diffuse, intermittent lower abdominal pain. No vaginal discharge. No pain on urination. Menstrual cycle has been erratic, both in frequency and duration. Also experiencing minor fatigue, though I'm not sure it's related. There is a history of breast cancer in my family. Any help would be appreciated. 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.? Nothing makes the pain worse but lying on my side seems to make lessen the pain a bit. It is not related to menstruation. My cycle varies sometimes a couple of weeks. I've had many occasions where I've missed a cycle. And lastly the pain is not associated with sexual contact and I do not use tampons. The pain is intermittent, occurring on and off from day to day. But the pain is not constant, meaning it does not occur 24 hours a day. 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 I have been on a seemingly never ending quest to find a cause for left sided pelvic pain. The most recent finding through MRI and hysterosalpingogram (HSG) is a left unicornuate uterus with a noncommunicating right horn. It seems that I have a normal right ovary as well. The MRI also checked to see that I have both kidneys and I do. My first question...as long as the MRI says I have two normal kidneys, is there any other things concerning my kidneys that I should be tested for? 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. Thanks for alerting me to this. I will ask the doctor about it!!! Secondly: is there any evidence that there are any other non- pregnancy related risks with the unicornuate uterus. I mainly ask this question because I will be having a diagnostic lap, and want to be informed of any risk that might make me consider having the uterus removed. No non-pregnancy risks that I know of except the non- communicating horn is often the site of pain. Also could this anomaly be causing the pelvic pain?...it was noted by the doctor that the noncommunicating horn could be part of the problem, although it being on the opposite side from where the pain is, seemed to be somewhat perplexing. 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 Over the past 4 months, the day I get my period I have severe pain on my right side. The pain gets so bad I have to leave work. I feel like I am going to throw up. I get dizzy and very sweaty. 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. I put a heating pad on my right side then in about 2 hours, I am fine-but cold. My flow is very heavy during this time. I am seeing a gynecologist on Thursday. I did have cysts a long time ago. Could this be the same thing? 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 I'm experiencing recurrent, severe upper right quadrant abdominal pain. This has been going on for several months now. My family practice doctor has done many sonograms and other tests for gall bladder problems but everything has been normal. Is it possible that this pain can be gynecologic in origin, with it being so high in my abdomen. Someone told me it could be in my fallopian tube. I am basically having attacks of severe pain, discomfort and tenderness in the upper right abdomen and some pain right along the midline. It doesn't seem to be related to what I eat. The attacks last anywhere from 30 minutes to six hours. They occur at anytime, sometimes I have one every night and then I'll go a week or two without one. A lot of the attacks occur at night and they just seem to be getting worse, not better. Any ideas? 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. If it's my gall bladder, do you know if it's possible for the tests to be normal? 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 I am 33 years old have 2 kids and have been having menstrual like cramps, pain in my left lower abdomen , sometimes sharp and have abdominal bloating that comes and goes during the day, also urination urgency. This has been going on for about 2 months on & off, sometimes even when I have my period. I am so scared because all the symptoms seem to be the same as ovarian cancer. Are there other things other than cancer that can cause these symptoms? Please help! I have a gyn exam for next week. 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? Thanks for your response. I feel more relaxed already. On the days that I feel the pain and bloating, I urinate 8-10 times a day & have to get up at night because I feel pressure and feel better after I urinate. When I don't have the pain and I have a bowel movement, the pains seem to start. I can only describe the pain by comparing it to when you get a piece of glass in your finger & your rub your nail over it. And it seems to be in the area of my left ovary. And the pain comes and goes -- it's not constant. About 5 years ago I had a vaginal sonogram and they told me I had 3 fibroids and one cyst on my ovary that was the kind that comes and goes. I was never told anything about it except that if I wanted to have any more children I should do so right away because sometimes fibroids get real large and prevents pregnancy. I don't plan on more children so I never really thought about it again. At my last exam 7 months ago my Dr. said he didn't feel any fibroids and that everything felt normal. I went because I was having spotting between my periods. He said sometimes that happens to women. What do you think of that? 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? Can you tell me what adenomyosis is? 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 I suffer very bad ovulatory pain, which doubles me over. I have tried every thing. Provera® worked for awhile and then the pain returned. They had me stop the Provera®. The only thing that is left is a hysterectomy, but if it would stop the pain, I will get this done. I am 35 and have 4 kids. please help me. I am sick of being in pain all the time. The Provera® I was on was 10 mg, 3 x a day. 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 Today I was at the gym running on the treadmill, and I felt this sharp pain in my lower abdomen as I ran. When I got home and used the restroom, there was some blood in my underwear. My period didn't start. This isn't the first time I have felt that pain but I thought it was just a side stitch. I am having other problems with my menstrual cycle, like breakthrough bleeding, and some cramping. I have an appointment with my gyn, but I'm really starting to get concerned. Any ideas? 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 I suffer every month for at least five days during ovulation. My period is like clock work, every 28 days, and my pain too is right on track, 10 days after the first day of my period and has become increasingly painful. I am 31 years old and have been dealing with this for 3 years. I had laparoscopic surgery two years ago to determine if it was endometriosis and was told it was not. The pain is getting so much worse as are my periods. I have very heavy bleeding the first three days, during these days too, I am passing quarter size clots regularly with bad cramping. I am really hurting and am afraid my doctor will think I am whining if I go back again. Is there a different problem this could be that would not be seen by laparoscopy while looking for endometriosis? 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 I recently had an ultrasound because of left sided pelvic pain. Of course during the ultrasound they found all kinds of interesting little things, including a cyst (only 2.6 cm) on my left side. 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. Also the report said "the uterine myometrial thickness appears more prominent on the right than the left although no second endometrial stipe is seen to suggest a bicornuate uterus. This could, however, represent a developmental anomaly only partially formed." Several years ago (11) I had a hysterosalpingogram (HSG) as a part of an infertility work up, and " possible bicornuate uterus" was listed on that as well. My doctor at the time dismissed it because I had one child born at 37 weeks. From what I know of a bicornuate uterus...why would it have a second endometrial stripe? 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. Also if I did have this would it be visible during a laparoscopy. I had a lap 11 yrs ago as well. Sometimes it is if the exterior of the uterus is divided. Usually it isn't however. Anyway I have since found out that you can indeed carry a baby to term with a bicornuate uterus. Yes, often. Pain after C-Section I had a c-section last June, and in December of last year I began to experience pain in the lower left side of my abdomen. The pain usually begins a day or two after my period ends, 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? The pain is the worst after my period is over with, but I do have pain throughout my period also. My period usually lasts 5-6 days. The pain increases in severity the 3rd and 4th day and is gone by the 5th or 6th day. I went to the ER last year, and after HOURS of tests and waiting, the doctor said I was ovulating, and that was causing the problem. He also said that the ultrasound showed some kind of cysts on my ovaries, but said it was normal to have them, and nothing to worry about. "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. I was not comfortable with this diagnosis, so I saw my gyn in January, who said it wasn't ovulation - I am on BC pills, so shouldn't even ovulate. 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". I am on Trilevlen- 21 active, 7 "reminder" pills. Does this affect 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. She did an exam, and decided it was either scar tissue from c- section, or endometriosis. This is possible. She also had an ultrasound done, but said it showed no cysts - WHERE DID THEY GO? They probably were not "cysts" in the first place, but rather follicle development that had gone away (that's normal). She acted unconcerned, and prescribed pain pills to last until my next check-up. I am still having the pain, and it has been a year since the C-section. Is this 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. The gyn did suggest scar tissue causing the pain. If so, how long can this go on? For many years if it is due to scar tissue. Or could it be beginning stages of endometriosis? 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. When I asked about endometriosis, my gyn said the only way to diagnose it is a surgical procedure, and she wanted to avoid doing that until I had all the children that I wanted to have. WHY??? is it dangerous? 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. But she acted like she didn't really want to do laparoscopy to check. Endometriosis runs in my family, and I am concerned about the pain I am having, but no one else seems to be concerned. Am I overreacting? Is it that they are not concerned or is it that they cannot easily solve your pain problem? It seems to me to be lack of concern, but that is just my opinion. My husband thinks my C-section was botched some way, and the gyn, who is also the ob who did the C-section, is trying to cover it up! 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. Please help me in any way that you can. Do I need to see another gyn for a second opinion? 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 I feel pain when having intercourse, I also feel pain, just before and during orgasm, can you please tell me what is causing this. Sometimes it is so sore that I lose the desire to have sex. Sometimes it is also difficult for me to reach orgasm, please let me know if you can help me. I am 21 years old, and I also suffer from constant bleeding, I've been on the Depo for nearly 5 or 6 years and I still have spotting all the time, the doctors can't help me. 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 congenital abnormalities of the hymen post traumatic scarring of the entrance episiotomy scarring or delivery lacerations post laser treatment of condyloma vulvar hypersensitivity or allergic reactions periorificial (irritant) dermatitis cyclic/recurrent yeast vulvovaginitis cyclic/recurrent bacterial vulvovaginitis vulvar vestibulitis dysesthetic vulvodynia vulvar dermatoses Vaginal lack of estrogen breast feeding menopausal estrogen deficiency use of DepoProvera (R) use of progestin only birth control or ovarian suppression vaginismus (involuntary pelvic muscle contraction) vaginal foreign body Deep endometriosis adenomyosis interstitial cystitis of bladder ovarian neoplasm ovary adhered to uterus/vaginal apex prolapse of fallopian tube pelvic adhesions uterine prolapse/descensus uterine retroversion posterior uterine fibroid other uterine neoplasms 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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