by J. Glenn Bradley, MD,
OBGYN.net Editorial Advisor
Santa Maria Medical Clinic of Obstetrics and Gynecology
Santa Maria, California USA
Meet Marie:
"Marie"* is a 29-year-old nurse, and the mother of two children. Having her first baby proved difficult -- she was in labor for 17 hours! Not only that, but her obstetrician had to use vacuum suction during the birth of her first-born -- a 7 lb., 15 oz. baby.
Sometime after her first delivery, she gradually became aware of increasing pelvic pressure, and some discomfort with intercourse. The pelvic supports often weaken after a woman gives birth, and this is sometimes referred to as "pelvic relaxation" by doctors. It is quite likely that Marie was feeling some of the effects of this pelvic relaxation.
Her second child was even bigger than her first -- weighing in at 9 lb.4oz. After her second delivery, Marie started having even more troubling symptoms. The pressure she felt became much more bothersome; she experienced a falling out sensation ("like everything inside is going to fall on the floor"), and intercourse was becoming so painful that she avoided it as much as possible.
No wonder. When her husband would hit her cervix during love-making, she would experience miserable cramps. Additionally, she had stress incontinence (leaking urine when coughing or sneezing, laughing hard, while bending or lifting, or during exercise.)
Her periods were regular, but her menstrual cramps were becoming more intense -- often so painful that they would awaken her at night. Ibuprofen (e.g., Advil, Motrin) would reduce the pain enough to allow her to work, but she was still uncomfortable. She subsequently went on birth control pills, but even while on the pill, Marie's severe cramps persisted.
Why was she put on a contraceptive pill for menstrual cramps, you may ask. It's a fair question. The answer is that during menstruation, substances called "prostaglandins" are released from the uterine lining, and these compounds can cause severe uterine spasms. Fortunately, prostaglandins can usually be inhibited by ibuprofen, which is why many doctors advise women to take this medication when they are troubled by painful periods. Birth control pills can actually reduce the amount of prostaglandins released from the uterine lining, thereby helping many women to lessen their menstrual cramps significantly. In Marie's case, however, both the ibuprofen and the birth control pills were largely ineffective. In fact, her cramps were getting worse.
This suggested another possible cause to me -- namely, endometriosis. Endometriosis exists when the tissue that lines the uterus (i.e., endometrial tissue) is found outside the uterus, most often on pelvic organs such as the ovaries, fallopian tubes, bowel or bladder. In some cases, however, endometriosis can be totally silent. In other cases, it can produce almost incapacitating pain almost all month long. Marie's cramps seemed related to her monthly periods, which is why I initially suspected endometriosis.
But there was another possibility. There is a condition somewhat related to endometriosis called "adenomyosis." It is characterized by increasing cramps, heavier menstrual flow, perhaps some increase in uterine size, and finding the uterus to be tender on examination. It is caused by the glands that line the uterus, the same glands that grow during the reproductive cycle to provide an appropriate environment for embryonic implantation and are shed during menses as a new reproductive cycle begins. If these glands penetrate deeply into the uterine wall, then during menses there is bleeding into the uterine wall. It is similar to having a bruised thigh (i.e., a "charley horse," or a localized pain or muscle stiffness following a contusion of a muscle).
Adenomyosis is less common in women who have never had children, and is more often seen in women over 30 years of age. Unfortunately, birth control pills are even less effective in treating cramps associated with adenomyosis than they are in treating endometriosis. When I evaluated the "big picture" of Marie's medical history, I strongly suspected adenomyosis.
In the midst of everything going on with her medically, Marie went through a divorce, and continued working as a nurse while raising her two children. When the upheaval and stress in her life related to her divorce subsided, Marie went on a diet and lost 46 pounds. Aside from the many health benefits of losing excess weight, taking off the extra pounds also helped Marie overcome her stress incontinence problem. Her extra weight had been pushing down on her bladder and aggravating her leakage of urine to the point where it had become a highly embarrassing and disabling problem. When she took off the excess pounds, her stress incontinence disappeared. Unfortunately, her pelvic relaxation had gotten worse.
Now, her uterus had prolapsed, which means that it had started to descend down toward the vaginal opening. And her menstrual cramps were even worse than before!
During Marie's first office visit with me, I did find a moderate degree of uterine prolapse. But the pain she felt while being examined had more to do with her very tender retroverted uterus. About one-third of women have the body of the uterus tilted or "tipped" back ("retroverted") toward the rectum, as opposed to the most common position where the body of the uterus is tilted toward the front ("anteverted"), and lies horizontally over the bladder.
With an "anteverted" uterus, the ovaries are much higher up in the pelvis, more "out of harm's way" and less likely to be bruised during intercourse. By contrast, the so-called "tipped" (i.e., retroverted) uterus is much more prone to injury from coitus.
While not a problem for most patients, a tipped uterus can make sexual intercourse extremely painful and just about impossible for some women. Further, the trauma of vigorous intercourse can result in a tear of the supportive tissues of the uterus. A woman who has sudden, extreme pain during intercourse, feeling what is often described as "a tearing sensation" with persistently painful intercourse thereafter, should suspect damage to the supportive tissues of the uterus.
Examination by a physician will reveal a very mobile, poorly supported, exquisitely tender uterus; any motion of the cervix will be painful. This is exactly what was going on with Marie. While hysterectomy can cure this, it was not an option for Marie. Divorced, she hoped to find a new mate, and thus wanted to preserve her fertility.
The Procedure:
Marie and I discussed the options available to her. Since she was a nurse, she was already very knowledgeable about many surgical procedures, and had seen them performed on some of her own patients.
I recommended that I reposition her uterus higher in her pelvis, and change its position as well so that it would be anteverted instead of retroverted. This would have a stabilizing effect on the uterus, and restore its position to normal. Further, her ovaries would be elevated at such an angle so as to be much less prone to bruising during intercourse. I also proposed possible laser surgery for endometriosis if I found it during the procedure, and a presacral neurectomy (cutting of the presacral nerve) to alleviate the cramps and provide her with additional relief from her uterine tenderness. She agreed, and then it was just a matter of finding a mutually convenient surgery date for Marie, a busy nurse, and myself...a busy doctor!
The surgery was primarily laparoscopic, which means it was performed in a minimally-invasive manner, using a tiny camera and very small surgical instruments designed to cause less tissue trauma, reduce recovery time, and give smaller scars compared to conventional abdominal surgery. I did not see any endometriosis during my laparoscopic examination of Marie, but the appearance of her uterus was more suggestive of adenomyosis, as I had previously suspected. Marie's ovaries and tubes were normal in appearance, and there were no obvious tears in the ligaments that support the uterus.
During the operation, I lifted the uterus higher up in Marie's pelvis, then stabilized it, and also repositioned the ovaries. I also performed the nerve cutting procedure described previously. Marie was in surgery for about one hour.
Afterward, she stayed in the hospital overnight, and any post-operative pain she felt was treated with pain medication. She was back to her nursing job in a week.
Outcomes:
At her 6-week check, she had resumed all activities, had no menstrual cramps, and reported having intercourse with no pain. She remains symptom-free at this time, now six months after surgery.
Discussion:
Marie's quality (and enjoyment) of life had been hampered by severe, unrelenting menstrual cramps, and unbearable pain with intercourse. Although a hysterectomy would have definitively solved her problem, and is, in fact, the operation that many similarly-afflicted women choose for themselves each year, it was not right for Marie. She was, in effect, starting a portion of her life over again with her divorce now behind her. She wanted to remarry and have another child or children. A hysterectomy would have ended those plans.
Thus, she opted for a specialized procedure to tip the uterus and ovaries back into proper position, and a nerve surgery to stop her pain -- with a short recovery time well-suited to this busy mom and nurse. Marie's quality (and enjoyment) of life has improved since the surgery. I'm happy to report that, as the doctor in this case, I was able to tip both the scales -- and the uterus -- in my patient's favor.
For more information about how the procedures described in this case may benefit you, contact me at:
J. Glenn Bradley, M.D.
1430 East Main Street, Santa Maria, CA 93454 USA
Telephone: (805) 922-5761
Fax (805) 739-8993*(To protect patient privacy, the patient’s name and certain identifying details have been changed.)
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