Pelvic Pain
Most women experience pelvic pain at some time during their lives. Many times pelvic pain is just the normal functioning of the reproductive or other organs. Other times pelvic pain may indicate a serious problem that needs urgent treatment. Here we look at the causes of pelvic pain, and how the cause of pelvic pain is determined.

Causes of Pelvic Pain
Many organs live in the pelvis, including the uterus, ovaries, fallopian tubes. The bladder and intestine, and appendix also live next to the reproductive organs, and sensations from these organs can feel like pain from the uterus or ovaries. To further confuse things, pain from the kidney and pain from muscles and from the abdominal wall can also seem to come from the pelvis.

I find it most helpful in explaining pain to my patients to explain my approach to finding the cause of their pelvic pain, rather than just to give a "diagnosis." I'll go into more detail after I explain my "Categories of Pelvic Pain. From my standpoint, pelvic pain falls into three classifications:

Pelvic pain that indicates a serious problem and that needs urgent surgery or hospitalization. Examples of this type of pelvic pain would be a ruptured tubal pregnancy or appendicitis.

Pelvic pain that indicates a problem that may need treatment, but not on an urgent basis. Examples of this would include pain from endometriosis, or a growing fibroid tumor. Chronic pelvic pain also falls into this category.

Pelvic pain that is caused something that is part of the normal functioning of the reproductive organs, and will probably resolve without treatment. This pain can be severe, but is self-limited. A frequent cause of this is a "functional" ovarian cyst. (More about that later.) It is easy for a doctor to fall into the trap of doing surgery for such problems because the patient wants the problem solved, and feels that surgery will offer a quick "fix."


Pelvic Pain: the True Emergencies
Pelvic pain in this category indicates a problem that if not treated urgently will cause serious harm or death. One serious cause of acute pelvic pain is a ruptured tubal (ectopic) pregnancy. Many women with a tubal pregnancy will continue to have menstrual-like bleeding, so they do not consider this possibility. One of the most serious mistakes made in evaluation of pelvic pain in women is to delay the diagnosis of ectopic pregnancy. The only way to be sure not to miss this diagnosis is to presume everyone to be pregnant until proven otherwise! Since tubal pregnancies can sometimes be present for months, be sure to have a pregnancy test if you have had intercourse within the last 6 months!!! Is this overreacting? Pregnancy tests are so easy to do. The failure to diagnose tubal pregnancy is serious. Having seen enough women who "couldn't possibly be pregnant" with a positive pregnancy test, just do the test!

What else could require urgent treatment? Most ovarian cysts do not need to be (and should not be) treated urgently. Occasionally, an ovarian cyst will twist (undergo torsion) and cut off the blood supply to the ovary. If this is not operated on quickly the ovary will die and need to be removed. Ovarian cysts can rupture, and cause internal bleeding that is serious if allowed to continue. Most of the time, however, if a cyst ruptures, no harm is done. (More about this in "ovarian cysts".) The exception to the rule is that certain types of cysts (dermoids) contain material that is very irritating, and will cause peritonitis if not treated urgently. Fortunately, only a very small percentage of ruptured cysts need any treatment at all.

Pelvic infection (Pelvic inflammatory disease, or PID) caused by chlamydia or gonorrhea need to be treated without delay. These infections often cause diffuse lower abdominal pain, and may or may not cause a fever. If an infection is suspected, treatment is usually begun without waiting for laboratory confirmation, since delay could result in serious damage to the pelvic organs. Unfortunately, the diagnosis of PID is is used to explain any pain whose cause is not obvious. Some studies have shown that up to 50% of women given this diagnosis do not have PID but instead have other conditions. Laparoscopy, a procedure in which a little telescope actually examines the tubes and ovaries, may be necessary for an accurate diagnosis.

Non-gynecologic emergencies should also be considered. Pain from appendicitis often starts out near the belly button, and then moves to the right lower side. Inflammation of the colon can cause severe pain, as can kidney stones.

If you suspect any above emergencies, you should call your physician without delay. If you don't have your own physician then you should go to an emergency room. It is a good idea to have your own gynecologist, so that that if a problem develops you can call someone who knows you, and who you know and trust.


Pelvic pain needing treatment
Pelvic pain caused by these problems may need treatment, but are rarely true emergencies.

Ovarian cysts. A cyst is anything filled with fluid. Most ovarian cysts are part of the normal functioning of the ovary. Other cysts are growths that need to be removed. Some ovarian cysts (endometriomas) are lined by the same type of tissue that lines the uterus. This can cause painful bleeding into the ovary.

Endometriosis. Endometriosis is a condition in which the type of tissue that lines the uterus implants in locations outside the uterus. This typically cause pelvic pain around the time of the menstrual period, but can cause pain at other times in the cycle.

Fibroids. Fibroids are benign growths in the muscle of the uterus. Fibroids are very common, and usually are not painful. Some fibroids can cause pelvic pressure and pain. Click here to learn more about fibroids. (a new window will open)

Infection. Most pelvic infection is cause by Chlamydia and/or Gonorrhea. Infection can also be caused by other bacteria. Infection of the lining of the uterus (the endometrium) is called endometritis. Infection of the fallopian tubes is called salpingitis. Often pelvic infection is given the term Pelvic Inflammatory Disease, or PID. Sometimes pelvic infection can cause severe pelvic pain and a fever, but a chlamydia infection may not cause any pain at all. If pelvic infection is suspected, it is important to treat with antibiotics, since severe damage to the tubes and ovaries can result if treatment is delayed.

It is often difficult to tell for sure if pelvic infection is present. For that reason, if a woman has recurrent episodes of pelvic pain, laparoscopy may be necessary to accurately determine the cause of pain. (Laparoscopy is an examination usually done under anesthesia, which involves looking at the pelvic organs through a tiny telescoped inserted through the navel.)

Dysmenorrhea. This means pain with menstrual period. Some cramping with the menstrual period is normal, but it is not normal to have pain that interferes with a woman's normal activities. Prostaglandins are compounds in menstrual blood that cause the uterus to contract, and cause cramping. Common medicines used to treat dysmenorrhea, such as aspirin, ibuprofen, or naproxen sodium help by interfering with the production of prostaglandin. Birth control pills may also decrease cramping with periods.


Other conditions causing pain with periods are abnormal, and may require treatment.

Submucous myomas are fibroid tumors on the inside of the uterus. They can act as a foreign body, cause the uterus to contract to try to expel them. They can often be removed without major surgery using an instrument called a resectoscope.

Adenomyosis is common cause of severe menstrual pain, and is often confused with fibroids.

Pelvic adhesions. An adhesion is where two organs stick together. This is often caused by pelvic infection (PID), endometriosis, or previous surgery. Pelvic pain can occur when adhesions are stretched. For example, if an ovary is stuck to the intestine, ovulation may stretch these adhesions and cause pain. On the other hand, many adhesions cause no pain at all.

Unless adhesions cause the intestines to be blocked (a bowel obstruction) they usually cannot be diagnosed without doing laparoscopy and actually looking inside the abdomen. Most adhesions can be freed during laparoscopy, but they can reform. Freeing the adhesions may or may not relieve pain.

Pain from other organs

The colon sits next to the uterus and ovary. Pain from irritable bowel syndrome can seem like it is coming from the ovary. Usually this is a crampy pain. Constipation and inflammation of the intestine can also cause pelvic pain. As endometriosis can involve the intestines, evaluation of the intestinal tract and laparoscopy may necessary to determine whether the pain is coming from the intestine or from a gynecologic problem.

Bladder. Inflammation of the bladder is felt in the lower abdomen. A bladder infection usually also causes burning with urination and frequent urination. Interstitial cystitis is an inflammation of the bladder not caused by infection, but can cause severe symptoms. Kidney stones also can cause pelvic pain.
Abdominal wall pain. Nerves in the abdominal wall can be trapped, and cause severe pain. Often this is near a previous surgical incision. It is important to distinguish pain from the abdominal wall from problems inside the abdomen. Often this can be done by numbing areas of the abdominal wall with local anesthetics, which will eliminate pain coming from the wall, but not from internal organs.

"Annoying" Pelvic Pain
Some "normal" events can case severe pain. Pain with ovulation is called "mittleschmirz" and can at times be severe.

"Functional" ovarian cysts are fluid filled structures that if left alone will go away without any treatment. These can be caused by an egg follicle that retains fluid. It is common to have some bleeding into the area from which ovulation occurs. This can retain fluid and become a painful ovarian cyst. This type of cyst usually goes away without treatment. It is often difficult to tell which cysts in a pre-menopausal woman will go away without treatment, so most of the time a cyst is observed for 6 to 8 weeks before surgery is recommended to remove it.

Dysmenorrhea. This means pain with menstrual period. Some cramping with the menstrual period is normal, but it is not normal to have pain that interferes with a woman's normal activities. Prostaglandins are compounds in menstrual blood that cause the uterus to contract, and cause cramping. Common medicines used to treat dysmenorrhea, such as aspirin, ibuprofen, or naproxen sodium help by interfering with the production of prostaglandin. It is important to take these medicines at the first sign of the period or of cramping, to block the production of prostaglandins. If cramping is not easily relieved by these medicines the a visit to the gynecologist is recommended.

Chronic pelvic pain can be one of the most frustrating problems for women, because the pain can be debilitating. Sometimes a definite cause can be determined, such as endometriosis. At other times no cause can be found. This does not mean that the pain is psychosomatic, but rather means that science has not progressed to the point of being able to diagnose all pain.

Stress can aggravate pain, but can also be caused by pain. Management of chronic pain requires evaluation of all possible organ systems that could be causing the pain, and should also include an assessment of lifestyle and stress. If you have chronic pain you should seek out a physician who is both an expert in gynecology and who is willing to see you regularly to help you with your problem.

Diagnosis of Pelvic Pain:
Pelvic pain must be diagnosed accurately if the pelvic pain is to appropriately treated. In order to determine the cause of pelvic pain obtain the history of the pelvic pain. An examination is done. It is common to find a cause of pain that would otherwise go undetected by doing a vaginal probe ultrasound scan during the initial visit. I will describe the steps that I go through to determine the cause of pelvic pain.

Some questions that I ask:

• When did pelvic pain start? Has it been present for hours, days, weeks, or months?
• Is the pelvic pain better or worse during the menstrual period?
• Does intercourse effect the pelvic pain?
• Is the pelvic pain annoying, just worrisome, or severe enough to interfere with activities?
• Are there any risk factors for sexually transmitted diseases?
• What is the possibility of pregnancy?
• What else effects the pelvic pain? Eating? Having a bowel movement? Any history of kidney or bladder problems?
• Have any studies or surgery been done?

It is very helpful to bring in any records of surgery (the operative report) or other major examinations with her.


What I look for during an examination:
When someone is having pelvic pain, I try to do the exam a gently as possible. Since I will be using the ultrasound, there is no need to press hard during the exam, and usually it can be done with very little discomfort in spite of the pain.

• I make a general assessment of my patient to determine her overall health and degree of pain.
• I look for tender areas in the abdominal wall, as well as deep in the abdomen.
• In doing the pelvic exam I look for signs of infection, and may do tests for chlamydia and gonorrhea. I feel the size of the uterus and ovaries, and look for tender areas. (I don't need to press hard if I am going to do an ultrasound exam.) Often endometriosis implants behind the uterus between the vagina and rectum. This area can only be felt by placing one of the examining fingers in the vagina and another in the rectum. An examination for pain is not complete unless a "recto-vaginal" exam is done.
• It is essential to be sure that any woman with pelvic pain is not pregnant. If there is even the most remote possibility of pregnancy a pregnancy test should be done.

Vaginal Probe ultrasound exam by the gynecologist:
A small probe placed inside the vagina makes pictures of the pelvic organs by using sound waves. This is not uncomfortable, and take only a few minutes. Many times the ultrasound will show cysts, fibroids, or other problems that cannot be felt on exam.

I feel that the gynecologist should do the ultrasound him or herself at the time of the initial evaluation. Much information on the source of the pain is obtained that lost if someone else does the scan. In addition, it is far less convenient to send a women elsewhere for a scan and then have to wait for the results, when the results are immediately available if the gynecologist does the ultrasound. It is also usually much less expensive for the ultrasound to be done by the gynecologist as compared to a hospital or other facility.


Laparoscopy:
Laparoscopy is a procedure in which a little telescope is used to examine the tubes and ovaries, and may be necessary to determine a diagnosis. Laparoscopy may just be diagnostic, in which case the gynecologist just looks at the pelvis. Whenever I do diagnostic laparoscopy I am always prepared to do operative laparoscopy. During operative laparoscopy the problem encountered is treated by using lasers and/or other instruments. Examples of operative laparoscopy include the freeing of adhesions, removal of endometriosis, or removal of ovarian cysts.

If you need a laparoscopy, it is important to have it done by a gynecologist who is an expert in both operative and diagnostic laparoscopy. There have been too many times where I have had to perform a second laparoscopy because disease was either not treated at all, or was inadequately treated during a laparoscopy in which the surgeon was not prepared to treat the problem that was found.

Other studies:

• If a problem inside the uterus, such as a submucous fibroid is suspected, hysteroscopy can be done to look directly inside the uterus. This is usually a simple office procedure. Hysteroscopy may also show adenomyosis, which can cause severe pain with menstruation or even all month long.
• If there are strong bladder symptoms, but urine cultures show no infection, than interstitial cystitis should be suspected. Cystoscopy (looking inside the bladder) is a simple procedure, but usually requires general anesthesia to test for interstitial cystitis. At times I will do cystoscopy at the same time as a laparoscopy if I suspect interstitial cystitis.
• If the pain is suspected of coming from the intestine or stomach, I may refer a woman to a specialist in these areas for evaluation. This usually would be done prior to laparoscopy, even though endometriosis can cause intestinal problems.

What if no definite cause can be found?
I feel that it is important to develop a relationship with my patients so they understand that we may not be able to identify a cause for the pelvic pain. The fact that a cause cannot be found does not make the pain any less real. It is important to continue to work on ways to minimize the effect of the pain on her life.


Copyright © 1998 Paul D. Indman, M.D.

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