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Ask The Expert

It is in your best health interest to see your gynecologist or primary care physician regarding specific medical problems or concerns

 

Chronic Pelvic Pain   Dear Dr. Toub,

I am 25 years old. When I was 16 years old, I was 15 pounds under weight and had an eating disorder. I also had swelling on my sides and my stomach would feel very hard and swell. I did not have a period on my own until now. My doctor had me on the pill to regulate me until I got up to normal weight. I've had 3 periods on my own in the past 3 months but I still have pelvic pain.

I have been on and off the pill because I have bad mood swings, bloating, night sweats and headaches. If I am not on the pill, I do not have these symptoms (except the pelvic pain). Since I have been off the pill I've had pain, bloating, my sides are hard and I have no energy. Sometimes it hurts when I have sex. This time 5 months ago I was not having all these problems. Could it be the pill I was on that caused these problems to worsen?

My last 2 paps came back inflamed. I also have a cyst on my left ovary. My doctor wants me to take the orthcyclen BC pill. He thinks I have PCO syndrome. I do not feel I have this. I do not have excessive weight gain, acne, excessive hair growth or any extra hair growth. I do have the swollen sides, pain and bloating. The last time I went to the doctor all of my hormone levels were normal.

Should I take the pill again and see what happens or seek a second opinion? My doctor wants me to take the pill, wait a month, come back and see what my pap results are. If the cyst is not gone he will take it from there and may do another laparoscopy or an ultrasound. I do not think I have polystic ovaries. I just do not know what to do.

Sincerely,

Christee

Answer from Dr. Toub: My advice would be to seek a second opinion in person. PCO syndrome is not difficult to diagnose in its classic form, which you are thinking of (aka Stein-Leventhal Syndrome). PCO can present as anovulation, which results in missed periods. The pill is an appropriate form of management of PCO in many women, but it may not be in your case. Whether or not you have classic PCO, it does sound like you have anovulation. If the pill is not a viable option for you, there are other ways to manage this, including ovulation induction. But be advised that this can lead to unintended pregnancy (5-10% risk of multiple gestation like twins as well) unless reliable birth control is used. You may want to seek out a reproductive endocrinologist for another opinion.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Teresa: Dear Dr. Toub,

I have been experiencing lower abdominal pains (right lower quadrant) since last year. When I went to consult my GP, he tested my urine and said that I had UTI. He sent my urine for further tests but no infections were found. He sent me to a urogynecologist who did an ultrasound of my kidneys. All results were normal. I also went to see a gynecologist for my routine pap smear. The results were also normal. I requested more tests from another gynecologist. An ultrasound was done on my uterus, liver, gall bladder and pancreas. All results were normal. It may be worth stating that, at times, I have difficulties with my bowel movement. After a few days, I need to move my bowels around three times within a day - it's not diarrhea. The pains are becoming more frequent and more intense. What further tests should I undergo? What kind of specialist/s should I see. What do these symptoms indicate? I hope you can give me your much sought advise, as I am really getting to get scared.

Thank you,

Teresa

Answer from Dr. Toub: Please don't be scared-your symptoms are not uncommon. Your doctor may want to consider a GI consultation to rule out a bowel source of pain (such as irritable bowel, etc.). Another option would be laparoscopy to evaluate the abdomen and pelvis for endometriosis, adhesions and other sources of pain. I'm also assuming a recent pregnancy test was negative (just to be complete).

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from RM: Dear Dr. Toub,

I'm a 26 years and have irregular periods from 5 to 7 days. Lately, my period has been coming on for two or three weeks with medium to large blood clots. After my cycle goes off, I suffer badly from cramps in my abdomen and I take advil, cramp tablets, or ibuprofen. It takes almost 8 hours before they kick in. I don't take all three pills in the same day. I have had two pap smears this year that come back normal but I have a discharge and had a yeast infection this year. Could all of this be my reason for really bad abdomen pain? What is the cause?

Thank-you in advance!

R.M.

Answer from Dr. Toub: It sounds like you have abnormal uterine bleeding accompanied by painful cramping even after the period has stopped. This does not relate to a yeast infection. I would ask your doctor about whether an ultrasound might be indicated (along with a pregnancy test for completeness sake just to be on the safe side). An evaluation is definitely indicated. If the workup is unrevealing, then attention can be directed towards providing relief of your symptoms. This is not an uncommon problem, and there are many effective ways to manage it.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from BJ: Dear Dr. Toub,

I am 28 and for as long as I can remember I have had a really sharp pain in my left side. I was diagnosed 2 years ago with moderate dysplasia while I was pregnant with my 3rd child. My doctor did laser surgery and for the next 10 months I had no pain. Now the pain is worse than ever. It starts about a week before my period and doesn't stop until a week after. I have been back to the doctor and my annual was abnormal, again. If I have dysplasia again, what would be my best path to take? Do you have any ideas as to why I have had problems all of these years? I have had sonograms and nothing ever shows up. Please help if you can.

BJ   Unfortunately, it is difficult to say what exactly is going on. Laser ablation of cervical dysplasia does not cause pelvic pain in general and cervical healing is probably better with laser than with LEEP and other modalities. The only possibility that comes to mind (which is rare after laser treatment) is cervical stenosis (narrowing of the cervical canal) resulting in a backup of menstrual blood each month into the uterus (hematometra, which can be painful). But this would clearly show up on ultrasound unless the ultrasound was done when you were no longer having pain. You may want to ask your doctor about this possibility. As far as the recurrent dysplasia-this happens regardless of how the initial dysplasia was treated. Until a colposcopy is performed to examine the area and without knowing the severity of the dysplasia it is not possible to predict what, if anything, needs to be done. Follow-up with your doctor is very important.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Mel: Dear Dr. Toub,

I sometimes get pain in the pelvic region that seems to originate close to the hip bone but not in the hip bone. Sometimes it radiates as far as my thigh. Mostly this is a dull ache that may last for weeks. The pain becomes sharp enough to make me gasp and double over. This will happen several times for a day or two. I have tracked my cycle for years and am pretty familiar with the ache that I get with ovulation The pain is different than ovulation. I can not afford to go to a doctor and get tons of tests so I'm curious as to what you think.

Thank you,

Mel

Answer from Dr. Toub: Without additional evaluation, it is hard to suggest what may be going on, or even if this is a gynecologic condition. You may not require "tons of tests," but consultation with a physician really is appropriate here.

Thank you for your e-mail!

David Toub, M.D.  

Question from Tori: Dear Dr. Toub,

I am 28 years old. I have severe pain when I have my period and when I make love to my husband. We have 7 children and no medical insurance so it is very hard for me to get to the doctor. Sometimes my periods last for several months. What could this be and what should I do?

Answer from Dr.. Toub: It is not possible to say what this is other than say it can be due to a number of conditions, including endometriosis. In terms of what you should do, you really need a medical evaluation. The Internet is not a substitute for real-time, in-person medical consultation and in this case that really would be the best option.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from S: Dear Dr. Toub,

By the age of 26, I have had several pelvic surgeries. I've had 2 cesarean sections and a cesarean hysterectomy due to placenta increta. Following that, removal of fallopian tubes and right ovary. My question is, I have had chronic pelvic pain for six months. I am wondering if this could be pelvic adhesions and if so what are my options?

Answer from Dr. Toub: Any operation can be associated with adhesions and judging from your surgical history this is a possibility. It's hard to say what the options are without the benefit of additional information, but in general options range from laparoscopy to remove the adhesions to medical therapy. Your doctor can guide you best in choosing from the range of options.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Patsy: Severe Pelvic Pain Dear Dr. Toub,

I have had 8 pelvic surgeries & 1 CO2 laser surgery; in addition to multiple hormone treatments which was caused by endometriosis. I continue to have severe pelvic pain and to form graulomas. I have been offered a morphine pump but everyone whom I have spoken to about this treatment has had no success. What is your experience with this method of pain management? I had a total hysterectomy & oopherectomy in 1991.


Thank you,

Patsy

Answer from Dr. Toub: I have only used continuous IV narcotics in the setting of terminal pain such as from cancer. While this is remains a controversial issue, I am on the side of those who do not feel that narcotics are the best way to manage chronic pain. You may want to obtain another opinion from multidisciplinary pain center, as an example.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Nancy: Pelvic Pain & Vaginal Inflammation Dear Dr. Toub,

I have been experiencing lower back, hip, and frontal pain. When my husband makes love to me, I hurt for two to three days. The doctor noticed some vaginal irritation and inflammation during the exam. He doesn't want to prescribe anything until the PAP results come back. My periods are regulated by Triphasal 28. My flow starts on Wednesday nights and run as long as Sunday evening or Monday afternoon. The flow is heavy and sometimes has clots. I get severe headaches a few days before the cycle and it lasts until a few days after. My doctor gave me a different pill to try for three months called Mycette 28. (I have been taking the Triphasal 28 for almost two years.) I had my tubes cut and tied and my doctor said there was the possibility of scarring or lesions from the tubaligation. He will order an ultrasound after the PAP results come back. In the meantime...is there anything I can do to relieve the discomfort?
Thank you,

Nancy

Answer from Dr. Toub: Your doctor should be able to make specific recommendations for pain medication, regardless of the Pap smear results. Personally, it is very unlikely that a postpartum tubal ligation would result in significant adhesions (scarring), but I suppose anything is possible. An ultrasound certainly would be helpful, as is planned, although again this (in my opinion) could be performed earlier as the Pap smear really has no major bearing on your symptoms and evaluation thereof.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Lady: Dear Dr. Toub,

I had surgery on Oct. 25, 1999. The doctor said everything looked clean. I have irregular periods 36-37 days apart. I have pain in my left side, painful cramps, occasional burning and pain with urination and occasional pain with intercourse. I am unable to become pregnant even after carefully looking at ovulation charts. Symptoms seem to be endometriosis but my doctor says she didn't see anything. I am at a loss right now and am looking for any suggestions/ideas as to what the problem is.

Answer from Dr. Toub: While endometriosis can be missed even with a very careful laparoscopy, anovulation is more often a reason for fertility problems (and do not forget that male factor infertility is a major, common factor as well). You need additional evaluation from your doctor or a reproductive endocrinologist (assuming he/she is not a subspecialist).

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Tamara: Dear Dr. Toub,

I had a bladder infection, after a week I was re-tested and it was negative. I was still in pain so my OB/GYN ordered an internal ultrasound. A ruptured cyst was found. After a week, I was still in pain. My doctor suggested a laparoscopy. Over that weekend it burned and hurt to urinate. I called the doctor and had my urine checked but test was negative. I had surgery and the doctor said that my uterus and ovaries are clean. My concerns are: the irregular periods, pelvic pain, occasional burning with urination, occasional pain with intercourse, diarrhea with my periods and the ruptured cyst found on my fallopian tube. I have experienced pain in my left side for some time and was told by other doctors that it was just ovulation. I tried the pill but still had pain in my left side. I thought you didn't ovulate while on the pill so I believe it is not ovulation. I am at a loss right now and would deeply appreciate any suggestions.

Thanks,

Tamara

Answer from Dr. Toub:  If the ultrasound was negative, then except for midcycle ovulatory pain (which is not likely if you are on the pill) ovarian cysts are not a significant issue here. There are many reasons for pelvic pain, including endometriosis. The fact that you have had some relief from hormonal manipulation does raise the possibility that this may be the culprit, although other things could be going on as well. Ask your doctor about his or her thoughts on how to proceed. A second opinion is also a consideration.

Thank you for your e-mail!

David Toub, M.D.

  Ovarian Pain & Cysts Question from Mrs. D: Dear Dr. Toub,

I recently had an abdominal and pelvic ultrasound to investigate some left lower quadrant pain that I have been experiencing on and off over the last 4-5 years. The pain seems to be worse during ovulation on the left side and worse when my bowels are full. The pain is higher than where the left ovary is normally located anatomically. The results of the pelvic ultrasound showed that the left ovary was displaced into the abdominal cavity. The doctor and myself could both palpate a mass under the location of the ovary.

My medical doctor has never seen a case like this. I am now currently 9 weeks pregnant. I am not having any significant discomfort at this point. I am very concerned about the progression of my pregnancy. Will it effect my pregnancy? If the ovary is so far out of place, what happens to the fallopian tube and can anything be done to put it back? What could cause this? Should I be asking my doctor to send me to an OBGYN specialist? Is the ovary usually large enough to palpate? The size of what I can feel when it is acting up is about the size of a tennis ball and sometimes softball. If I push on my abdomen over the ovary, I can feel pain and pressure into the left side of my pelvic cavity. Intercourse is painful during this time. I am suspecting that it is an ovarian cyst because I can feel the pain and mass primarily during left sided ovulation.

Thank you in advance for your professional opinion.

Mrs. D

Answer from Dr. Toub: I think it is very appropriate to be seen by a ob/gyn specialist in this situation, if for no other reason than this is not a routine pregnancy.

Thank you for your e-mail!

David Toub, M.D.  

Question From Kathleen: Dear Dr. Toub,

I have been dealing with ovarian cysts for the past two years. The pain upon rupture is so severe that I have blacked out 3 times. The GYN I see has done ultrasounds. The cysts always dissipate eventually. For the past two months, I have spotted from ovulation to menses, severe pain and greater bleeding after sex. We have been trying to conceive for 18 months so I don't want to go on the pill.

Thanks for any suggestions.

Kathleen

Answer from Dr. Toub: Contrary to popular myth, the pill does not prevent cyst formation. Cysts are common, unfortunately, but usually do not require treatment . If you are having recurrent, severe pain, you may want to ask your doctor if laparoscopy is indicated, or at least better pain management.

Good luck, and thank you for your e-mail!

David Toub, M.D.

  Question from Concerned: Dear Dr. Toub,

I am 34 years old and I have two children. Since my twenties I have had increasing pain around my left ovary. After the birth of my second child it seems like the pain is not only around my ovary but I have pain in my sacral area in my left vaginal wall and sometimes down my thigh. The pain is most severe around the time that I ovulate but I have a dull ache all the time. I even have pain after intercourse. I have seen my doctor and they did an ultrasound which showed nothing. My doctor said it was cysts that I get during ovulation but that doesn't explain the pain I get during the rest of the month. My doctor has put me on micronor and that has decreased the pain to where I only get pain in the middle of my cycle which lasts for about 1 day. Can you explain these cysts? Why do I still get pain if I'm not ovulating?

Thanks,

Concerned

Answer from Dr. Toub:  You are right-generally one does not ovulate while on the pill. The fact that the laparoscopy was negative is a good sign. I would suggest you speak to your doctor about a urology consultation to make sure interstitial cystitis is not a possibility, and focus more on treating the symptoms with appropriate pain management. Your doctor can give more individualized, specific suggestions.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Kimberly: Dear Dr. Toub:

I am 36 years old and never been pregnant. I've had two bouts of EXTREMELY painful ovarian cysts, both on the the left side in the same place and both were 2x1x1 cm.

The first time I experienced ovarian cysts, I was put on birth control pills. The pill made me sick and it aggravated my fibrocystic breast disorder.

The GYN I saw a few days ago told me the pain was "too high up" to be an ovary. He stated it could be endometriosis and recommended a laparoscopy to diagnose it but the GYN surgeon was not convinced this is endometriosis and wants to wait.

What can I do to convince my doctors that this is serious, it does hurt and that they need to do something? My mother lost her left ovary to pre-cancerous cysts at 36 and her entire reproductive system before her mid-40s; my maternal first cousin has severe endometriosis and ovarian cysts and my maternal grandmother had several pre-cancerous ovarian and uterine cysts removed in addition to breast cancer.

Kimberly

Answer from Dr. Toub:  I would tend to side with the second gynecologist, so long as it is clear from the ultrasounds that the cyst is not persistent and has no radiologic features that are of concern. Ovarian cysts are common and on occasion can be painful. Generally, they do not require surgical treatment as the risks of surgery usually outweigh any potential benefit. Also, as cysts are not uncommon and tend to recur, even if a physiologic cyst is removed, another cyst can take its place with the next menstrual cycle. While it is a common practice to place women on the pill to prevent or treat ovarian cysts, there is no evidence in the medical literature that it is of any benefit. The pill does have one added benefit, however, in that it does tend to decrease the risk of ovarian cancer with long-term use.

Whether or not laparoscopy is indicated at this point is hard to say. If you had two episodes of painful cysts that were 2 cm in diameter and went away between episodes, surgery may not be so compelling. If there is a reasonable suspicion of endometriosis or some other pathology, then that would tip the scales in favor of laparoscopy. Again, if the same cysts have persisted for more than one cycle, that might be an indication for surgery, but that is for you and your doctor to discuss. Anytime surgery can be avoided it is usually for the better, but of course it is understandable why you would prefer surgery, given the painful episodes you have experienced.

Good luck and thank you for your e-mail!

David Toub, M.D.  

Question from Martha: Dear Dr. Toub,

I am 37 and hoping to get pregnant soon. This month, my period was two days early (I'm usually pretty regular), very light and went on for 10-12 days. I have been experiencing dull ovarian pain off and on since this period began. I also have some breast tenderness. Two years ago I had a similar prolonged period but I don't remember the pain. Do you know what this could be?

Thank you,

Martha

Answer from Dr. Toub It is not appropriate or possible to render a specific diagnosis via the Internet. However, you should obtain a pregnancy test as soon as possible to make sure that is not a factor in your prolonged period. If it is a one-time occurrence, it may or may not warrant further evaluation as it may be self-limited. That is up to you and your physician.

Thank you for your e-mail!

David Toub, M.D.  

Question from Sue: Dear Dr. Toub, 

My daughter has had a pelvic ultrasound which indicated there were several small follicular cysts in the pelvic area. It goes on to say that the "preliminary report is negative". It says nothing about the ovaries. Can cysts occur in the pelvic area without involvement of the ovary?

Answer from Dr. Toub: One would assume they mean the ovaries, although there can be cysts in the pelvis from other causes, such as Nabothian cysts in the cervix. However, follicular cysts are, by implication, ovarian in origin. The report may have been termed "negative" since the finding of follicular cysts may be of no consequence. You should ask your daughter's doctor for guidance here.

Thank you for your e-mail!

David Toub, M.D.

  Hysterectomy Question from Gina: Numbness after Hysterectomy Dear Dr. Toub,

I had a total LAVH hysterectomy on 8/12/99 and on 9/15/99 I had my ovaries and tubes out. During both surgeries I had massive adhesions removed from PID and from an old abdominal surgery. Both of these recent surgeries were done laparoscopically. I did not have numbness before the surgery and the numbness I have now is intermittent. It is on the right side of my upper thigh near the pelvic crease and the crease itself. Sometimes it radiates down my entire right side and lasts for days. When I have sex with my husband my entire left leg goes numb. Do I have nerve damage or something from the surgery or from the incisions?

Thanks,

Gina

Answer from Dr. Toub: What you are describing sounds reminiscent of problems with the lateral femoral cutaneous nerve. This is much more common with a laparotomy where self-retaining retraction is used, but can happen as well after laparoscopy, particularly in thin women. This can happen with the best of surgical care, and is poorly understood. It can also resolve with time. The first thing to do is to contact your gynecologist and inquire about a referral to a neurologist. In severe cases, there is also some weakness as well, but your description does not mention any such symptoms which is a good sign. Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Valerie: Pelvic Pain after Hysterectomy Dear Dr. Toub,

Two years ago I had a hysterectomy. During this operation, my left tube and ovary were removed as well as my uterus. They were able to save my right tube and ovary. The reason for the hysterectomy was because of pelvic adhesions. My hope was that after my hysterectomy, I would not have to deal with pelvic pain. I was wrong because within six months I began to have severe pain in my left side. I have been through various tests, x-rays, nerve blockers, etc. to help alleviate the pain. Since this pain began I have been taking Talwin. Three months ago I had a sigmoidoscopy to see if the pain was coming from my bowels. I was diagnosed with active colitis. I have a new physician who is going to send me to a gastroentereologist and a gynecologist. I feel that the only way to have my pain alleviated or bearable, is to have a laparoscope to remove more pelvic adhesions or go on some medication. One of my questions to you is should I try some medication for colitis to see if that helps the pain before I have another invasive surgery. This pain has severely altered my life.

Can you please give me some advice?

Valerie

Answer from Dr. Toub: It sounds like you may have a chronic pain syndrome, although the picture is clouded by possible inflammatory bowel disease. If the problem is chronic pain syndrome, one of the most useful interventions is consultation with a multidisciplinary pain center. In such cases, surgery (other than nerve blocks, etc.) is unlikely to be of benefit, and the literature bears this out, as does clinical experience. I would suggest a second opinion from someone skilled in chronic pelvic pain, in consultation with your gastroenterologist.

Good luck, and thank you for your e-mail!

David Toub, M.D.

  Endometriosis & Adenomyosis Question from Kandi: Stage IV Endometriosis Dear Dr. Toub:

I had a complete hysterectomy in 1995 for Stage IV Endo. I had surgery again in 1997 for endometriosis and adhesions and just recently had surgery for ovarian remnant syndrome (abdominal wall cyst) and excision of an endometrioma from the recto-sigmoid. All three surgeries were laparotomies. I am still in chronic pain. I have severe bowel problems, my back and legs ache constantly. I was sent to a Colorectal Surgeon and he is considering Cul-De-Sac involvement because of the rectal pain. I have chronic constipation for several days and then it changes to running several times a day. Bowel movements are extremely painful either way. If I had rectal involvement shouldn't they have already done a bowel resection? I'm confused and very frustrated.

Thanks for your help.

Kandi

Answer from Dr. Toub: While bowel resection is an option when endometriosis involves the GI tract, it is not the only option and is best avoided unless necessary. It is not possible for me to say if it should or should not have been performed in your situation, but I'm assuming there was only a focal attachment of the endometrioma to the bowel that may not have involved the bowel lumen. As I say, this is an assumption on my part, but bowel resection may not have been necessary in your case. There are also other reasons, such as postoperative adhesions from extensive surgery, that could explain your symptoms, and in my experience the combination of a gynecologist and a gynecologic oncologist is a very powerful one in general. You may want to think about a second opinion before any additional surgery.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Lisa: Dear Dr. Toub,

I have had stage 3 1/2 endometriosis for 8 years with severe pain. I had a laparoscopy done followed by Lupron. Seven months later I had to have a hysterectomy; one ovary was left. I am having pain. Cysts are appearing and rupturing and the doctor wants to remove the last ovary.

Eight of my family members on both sides have had cancer. Since I had a hysterectomy, does this eliminate me from any cancers in the uterus area? Could I have had some form of cancer and it is in other areas now?

Thank you,

Lisa

Answer from Dr. Toub: If you had a hysterectomy, that eliminates any risk of endometrial cancer (cancer of the uterus). It does not eliminate your risk of ovarian cancer. Ovarian cancer can occur (in the form of peritoneal mesothelioma) even after removal of both ovaries, but this is fortunately uncommon. If your remaining ovary is removed, your risk of ovarian cancer should decrease (but not to zero, unfortunately). For more detailed answers on this you may want to consult with a genetic counselor who is skilled in assessing familial ovarian and breast cancer risk. Without more information on the ages, types of cancers, etc. it is hard to say if you have a hereditary cancer syndrome going on in your family or not.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Donna: Adenomyosis Dear Dr. Toub,

I am scheduled for a TAH w/possible BOS in a couple of weeks. I am 35 years old with a history of endometriosis and ovarian cysts. I have had 4 C-Sections and 2 laparoscopies (one for endometriosis, the other for a uterine suspension). The past 6 months I have been experiencing a lot of pelvic pressure and pain. My doctor performed a transvaginal ultrasound and could not locate a fibroid but said that I could have adenomyosis. Is there any way to diagnose adenomyosis without performing a hysterectomy? My doctor said that because I already had one uterine suspension and the uterus is enlarged that a second suspension was not recommended. I did seek a second opinion by a reproductive endocrinologist who also confirmed my doctor's findings. He suggested I consider a vaginal hysterectomy, removing the specimen through a culdotomy incision. What does this mean?

Thank you in advance for your response to these questions.

Donna

Answer from Dr. Toub: It sounds like he is planning a vaginal hysterectomy, which is going to be somewhat challenging (if not very difficult) given your medical and surgical history. Adenomyosis cannot be reliably diagnosed except through exam of the hysterectomy specimen; However...MRI can be fairly good at picking it up and can be helpful in this regard (it is noninvasive, so aside from the cost there is no harm in trying it if your doctor feels it is appropriate). Personally, and this is only my opinion based on very limited information, I would be hesitant to resort to a hysterectomy in this setting unless I was very sure the benefits outweigh the risks. Having had endometriosis, 4 Cesarean sections and a uterine suspension, this will likely be very challenging surgery with an increased risk of complications. The vaginal route, to me, would be like trying to climb Mt. Everest in sneakers-it might be possible, but more likely than not it is a very dangerous way to proceed. You may want to ask for another opinion in this situation.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Syndromes and Abnormalities Question from Lady2: Vaginal Atresia Dear Dr. Toub,

I have a sister who was diagnosed with Vaginal Atresia. She was told that she does not have a uterus and has small ovary's. She had a vagina constructed at 17. She has stomach problems and is not in good health. She feels nauseated, has lumps in her stomach and pains when she pushes on it. She went to the hospital and they did a ultrasound. They told her she has tissue growth on her ovary's and to go to a GYN. In the sonogram they saw two uterus's, one on each side of her ovary's. They said that it has been functioning as a uterus and that she has endometriosis. She has never had periods. She will have laparoscopic surgery to remove the uterus. My question is why wasn't this found when she was younger and why is she feeling lumps that make her sick and give her pain. We are concerned and wonder if she could be growing cancer cells? Could you give me some information and should she get a second opinion.

Answer from Dr. Toub: It never hurts to have a second opinion, but beyond that it is not possible to comment on whether or not this should (or even could) have been detected earlier. Genital tract malformations can be very complex, and elude even the best clinicians and imaging modalities.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Peg: Cushing's syndrome Dear Dr. Toub,

I have a friend whose daughter bleeds very hard for a number of days during her period. She has been through many tests and blood tests to find out what is wrong. My friend said that they think that her daughter has cushings syndrome. Do you have any information on this? I told her I would try to find something on the internet about this and give it to her. I have found no such topic. Would you please forward it to me so that I may pass it on?

Thank you for your time.

Peg

Answer from Dr. Toub: I've never heard of it either, and I think your friend may have misunderstood. Cushing's syndrome has little if anything to do with gynecology and is a problem with excess corticosteroid production.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

PID & Other Infections Question from A: Dear Dr. Toub,

What is the newest technology in treating a woman diagnosed with PID? My co-worker is on antibiotics but she is in constant pain. What questions should she ask the doctor in controlling the pain? When does a hysterectomy help?   In general, PID is treated with antibiotics as per CDC guidelines. In general, pain should improve within a matter of days. If not, unless the diagnosis was confirmed by laparoscopy (or the patient at least had positive cultures for Chlamydia and/or gonorrhea), I would question if there might not be something else going on. PID is a clinical diagnosis and is either over diagnosed or under diagnosed depending on the situation. Hysterectomy is only appropriate for ruptured tuboovarian abscesses as this is life-threatening. My suggestion is that your friend consult her gynecologist as soon as possible for follow-up .

Thank you for your e-mail!

David Toub, M.D.  

Question from D: Hello Dr. Toub,

I have been diagnosed with a pelvic infection. I have been having pains in the lower pelvic area for about 9 years. Last month I experienced excruciating pain. They usually come off and on but never so intense. I was admitted to the hospital and had a vaginal exam and an ultrasound. Everything appeared to be okay but I was placed on medication before I had the ultrasound. The doctors who examined thought it could have been PID. I remember having these pains before I became sexually active. I am confused and would like to receive some real insight as to what my problem could. Can you provide me with any information?

Answer from Dr. Toub: Depending on the situation, PID is either underdiagnosed or overdiagnosed. In many cases, treatment is instituted for PID before the diagnosis is clear, to be on the safe side, and this may have been what happened in your case. This is appropriate management, based on the limited information I have from you. As far as what is really going on, assuming it is not PID, would depend on additional information such as an ultrasound and physical exam findings.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Becki: Foul Smell and Odd Color Dear Dr. Toub,

I used to have normal 28 day cycle periods; for 9 months I have been having irregular periods. They range from 13 to 19 day cycles. When I bleed, the color is not like it used to be, the red, bright red and tapering off to the dark brownish red. Now I flow just the dark brown red stuff. It smells terrible and it looks like a heavy lochia. I hope you answer my question here as I have not had a pap or exam for almost 2 years due to panic disorder/agoraphobia. I am a registered nurse and my specialty is cardiac care. This GYN stuff confuses me.

Thank you,

Becki

Answer from Dr. Toub: Sometimes the GYN stuff can be confusing for all of us! Regardless, given your age and symptoms, I would suggest you see your gynecologist somehow for an evaluation, perhaps to include an endometrial biopsy (to be certain there are no precancerous conditions within the uterine lining). Difficult though it may be in your situation, this really is the best course of action.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Other Questions Question from Meg: Cystocele and Rectocele Dear Dr. Toub,

I was told by my doctor that my uterus and bladder had dropped and that I would have to have a vaginal hysterectomy, cystocele and rectocele. My periods have been infrequent so he prescribed provera for me to take for 7 days to start my period so that on the 4th to 6th day of my period I would have a hysterosonogram. I took the medication but it did not work.

I went to another doctor and she said my uterus had dropped, my bladder droppage was mild and that I did not need the rectocele. She suggested that I wear a pessary and I was fitted for that. I wore the pessary for a couple days and had some problems. I could not have a bowel movement without removing the pessary first and I felt uncomfortable wearing it. The doctor also recommended that I keep a urine chart for 3 days. She feels I could have other problems with my bladder because I have urgency/frequency problems and would like to take nonsurgical measures first before surgery. I feel surgery would greatly help but am now confused with the different options about the rectocele. When I see my local doctor I would like to ask him why he feels I need the rectocele and would like help asking the proper questions. Are there other questions I should be asking both doctors? Are there other procedures I should know about?

Thanks!

Meg

Answer from Dr. Toub: You should mention your current symptoms, such as difficulty with bowel movements. Some women with severe rectocele must actually place a finger in their vaginas to depress the rectocele and allow for a bowel movement (rectal splinting)-whether or not this is necessary for you should be discussed.

Thank you for your e-mail!

David Toub, M.D.  

Question from Michelle: Dear Dr. Toub,

I'm 38 years old and I have had a couple of UTI's and a yeast infection due to a forgotten tampon. I have not had a Pap since 1995, on the assumption that I was healthy. My last pap was inconclusive. I shrugged it off since they had always been negative. About 6 months ago I noticed 2 or 3 little "growth-like" blisters on the inner surface of my vagina. I did research and it was described as Polyps. Then I also noticed a thick mass growth. Can you please tell me what is going on? I'm praying that it is not our worst fear as women. Thanks for making yourself available to us on-line.

Michelle

Answer from Dr. Toub: There are many possibilities, including benign vaginal warts, but unfortunately a definitive diagnosis will have to await your doctor visit. A Pap smear should of course be done at that visit as well.

Good luck and Thank you for your e-mail!

David Toub, M.D.  

Question from Andria : Pool of blood after surgery Dear Dr. Toub,

I had a full vaginal/laparoscopic hysterectomy 2 1/2 weeks ago. A week after I had my hysterectomy I had pain in my belly. My doctor said I have a pool of blood in my belly and it is draining vaginally. He wanted to see me in a week. It's been a week and I'm still bleeding and hurt. What going to happen now?

Sincerely,

Andria

Answer from Dr. Toub: It really is not possible (nor appropriate) to give individualized predictions via e-mail, but it sounds like your doctor drained the hematoma (collection of blood) vaginally. This is not an uncommon complication and it can take some time to resolve fully. Your best bet is to go ahead with your visit to the doctor as scheduled.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Surgery Pain & Adhesions Question from TK: Dear Dr. Toub,

I am 46 years old and had an IUD inserted 20 months ago, following an unplanned pregnancy that ended in miscarriage. As soon as the IUD (copper T) was put in, I experienced significant pain in my lower right abdomen, on a line from the pubic bone to the outer edge of my pelvis. As expected, this pain diminished following my period and only continued intermittently and in a fairly mild form, although always in the same location. Four months ago I started experiencing significant pain in the same location. My OB-GYN performed an ultrasound and found the IUD in place and nothing suspicious relating to my ovaries. I followed his advice to take NSAID's and wait to see if the pain became better of worse. The pain continued about the same until a month ago, when I experienced incapacitating pain. My doctor found the IUD had been partially expelled and he removed it. This produced some pain relief. Three weeks later I am experiencing the same sharp pain from groin to pelvis that started at the time the IUD was put in. A thorough pelvic exam and ultrasound were negative. At no time have I had any signs or symptoms of infection.

The only abdominal surgery I have ever had was an appendectomy 35 years ago. The pain does basically follow the line of my scar.

Do you have any ideas about what the IUD could have done to cause this pain, and what, beyond medication, could be done to stop it?

Thank-you for your help.

TK

Answer from Dr. Toub: The Cu-T380A IUD has a long history of safe and effective use in this country, and if anything is underutilized. It is not generally associated with pelvic pain. Short of a rare uterine perforation (which would have been detected on exam and ultrasound), it is hard to explain your symptoms in relation to the IUD. The fact that removal of the device has not improved your symptoms suggests that it may not be related. The appendectomy scar, however, may be related, particularly if the pain tracks along the area of the scar. This could either be from adhesions or nerve entrapment within the scar. Why this would start only after insertion of the IUD is unclear. Assuming that there is no evidence of an infection, such as PID, you may want to ask your doctor to investigate the scar as a potential pain source. In some cases, referral to a multidisciplinary pain center may be helpful.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Marge: Dear Dr. Toub,

I am 35 and suffering from lower right abdominal pain since May of '98. The first diagnosis of 3 fibroids was made following a laparoscopy. The suggestion was made for a myomectomy, which I had in November. The surgery uncovered 5 fibroids, 4 were removed. The last was not removed because the doctor did not want to chance too much bleeding, resulting in a hysterectomy. The fibroid is located on the back of the uterus on a major blood vessel. The pain was gone for about 3 months but by June, I was in constant pain. An ultrasound showed another possible fibroid. During this time, I also developed a motility problem with my gall bladder and surgery was planned. My ob/gyn suggested that he take part in the surgery so that he could look around. I ended up having my gall bladder, appendix and a 5 cm ovarian cyst removed. In addition, I had extensive adhesions from the myomectomy. I felt great for 2 months but now the pain is back.

Is it possible to develop another cyst in a short amount of time or could it be adhesions? If it could be a cyst, is there any reason that I can not just leave it alone? I realize that I would have to live with the pain, but is there any other danger involved? As far as the adhesions go, I have been trying to get pregnant since January with no luck. Can the adhesions be preventing it?

Thank you,

Marge

Answer from Dr. Toub: Without an ultrasound, it is hard to say if this is a cyst or adhesions. Assuming it is a cyst for hypothetical purposes, whether or not to intervene depends on many factors. These include the ultrasound appearance of the cyst, size, family history, persistence over several weeks, growth and others. Cysts are very common and do not warrant intervention unless there is a suspicion of the cyst being a benign or malignant tumor.

Adhesions can result in infertility, so if this is a concern you may want to consult your doctor or a reproductive endocrinologist about whether an evaluation is indicated at this time. As far as the pain, you should not have to "live with it." There are many ways to manage chronic pelvic pain to allow a more pain-free life and your doctor should be of assistance in this regard, or else be willing to refer you for a consultation.

Good luck and Thank you for your e-mail!

David Toub, M.D.  

 

DISCLAIMER: The above represents material for educational and discussion purposes only. The material provided should NOT be used for diagnosing or treating any health problem or condition. It is NOT a substitute for consultation with and advice from qualified healthcare providers. If you have or suspect you have a health problem, consult a qualified healthcare provider. The author and any other party involved in the preparation or dissemination of the material presented are not responsible for any errors or omissions in the material provided above, or any results obtained from the use of such material.

 
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