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Chronic Pelvic Pain  

Question: Intermittent Pelvic Pain
My son was delivered by c-section after a difficult labor in September. Since then, I've had intermittent pain in my pelvis. It's a stabbing pain that starts in the middle of my pubis and radiates all through the pelvis,sometimes even through my whole torso. It feels as though the two halves of my pelvis are grinding together in the middle. This constant pain seems to be aggravated by movement and causes me to limp as I walk. I consulted my OB about it twice and she told me it should go away. This was three months ago and the pain is now getting worse, to the point where rolling over in bed can take my breath away.
Do you have any suggestions?
 

Answer: 
My best advice would be to have a thorough assessment of your pelvic pain. It may relate to adhesions (scar tissue), although in my experience a single cesarean section does not cause significant adhesions (although multiple such operations can, of course). There may be other possibilities as well, including a variety of musculoskeletal disorders and endometriosis.

Regardless, if your pain is significant, it should be evaluated thoroughly. Your gynecologist can be of greatest help to you on this issue. 

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

David Toub, M.D.  

Question:  Are there other solutions to pain besides surgery?
I am thirty-one years old and have had two surgeries in the past two years for endometriosis. I was told that I may also have adenomyosis and the endo was at Stage 2.  After surgery I was treated with Lupron Depo and felt much relief for approximately 4 months.  After that, the pain returned and I was taken off the medication.  Since that time I have been experiencing chronic pain with no luck in birth control.

I recently went to a pain clinic and was told that I needed to have additional surgery because of the results of pain mapping.  The doctor told me he felt that there may be lingering traces of endo.  Although my primary physician felt that surgery so soon would yield no results, he advised me to go ahead with it feeling that it may something else may turn up. Nothing new was found and I still have the chronic pain.

What other solutions are there to treat pain?  This is affecting my personal life and how I view myself as a woman.

 

Answer:
It is not possible to arrive at a definitive diagnosis through this forum, but it sounds as if you may want to consider a consultation at a multidisciplinary pain center (assuming that the pain center to which you were referred did not enlist multiple specialists in anesthesiology, psychiatry, gynecology, etc.).  Additional surgery may not be beneficial, and it is also possible from your symptoms that an element of vulvodynia (chronic vulvar pain syndrome) may be present.  A multidisciplinary pain center may be able to plan an appropriate course of action in consultation with your physicians.  This is never an easy situation to deal with, both from the patient's and physician's standpoint, but there are many things that can be done to enable you to manage your pain.

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

David Toub, MD

Question: Painful intercourse due to retroverted uterus or Endo?
I suffer from painful intercourse, which a  previous gynecologist told me could be caused by a retroverted uterus.  My new gynecologist told me that she thinks I may have endometriosis and perhaps cysts on an ovary.  I am really confused as to what causes the painful intercourse, only upon deep penetration.  I feel as though I do not have a diagnosis because doctor keeps reminding me that she "thinks" this is the cause of my problem. My doctor wants to try putting me on birth control and see what happens but my husband and I want to try to get pregnant and my fertility is of the utmost importance.  Would a laparoscopy diagnosis endometriosis and cysts?  Do you have any suggestions?  

Answer:
Endometriosis certainly is a consideration, and can only be reliably diagnosed through laparoscopy. The birth control pill is not the best way to treat endometriosis (which is not a confirmed diagnosis in your case) in women who desire fertility, as fertility rates tend to be lower than with other forms of medical management such as GnRH agonists. The diagnosis needs to be established first, however. There are other reasons for pelvic pain in addition to endometriosis, and all of these need to be considered and
evaluated as well. 

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

David Toub, M.D.  

Question: Chronic Lower Quadrant Pain
For the past 2 1/2 years I have been having pain in the left-lower quadrant of my abdomen.  I have had several pelvic exams and ultrasounds of the ovaries and uterus, which have all been inconclusive.  The pain is not associated with menstruation, comes on a day-to-day basis and may last from five minutes to 24 hours.  Recently when I have gotten the pain it has come with a lower-back ache as well.  Do you have any suggestions as to what this may be?  

Answer:
There are many possibilities, both gynecologic and non-gynecologic (such as irritable bowel syndrome, adhesions, etc). You may want to ask your doctor if laparoscopy is indicated as well as whether you might be well-served by a consultation with a gastroenterologist and/or urologist. 

Thank you for your e-mail!

David Toub, M.D.  

Question: Clitoral pain
For the last couple of years, about once a month I get pain in my clitoris.  It's a shooting pain that goes up into my belly button. It's very difficult for me to urinate because of the pain.  When this happens I can barely button my pants because the pain shoots up to my belly button.  I have been to the doctor about this problem and she said it could be caused by a muscle spasm. Do you have any suggestions about what this could be?  

Answer:
The cyclic nature of the pain raises the possibility of endometriosis. While it is extremely rare on the skin surface (such as the clitoris), it is certainly possible. At the very least, a detailed examination of the external genital area is appropriate. On occasion such atypical pain syndromes may not be entirely (or adequately) explained, but pain can usually be managed so as to relieve the symptoms in the absence of an underlying cause. At this point, however, attention should be paid to trying to establish what may be going on. 

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

David Toub, M.D.  

Question: Retrograde Menstruation Causing Pain?
I have had increasing pelvic pain over the last six months.  My OB/GYN suspected endometriosis and I underwent laparoscopy. He found evidence of retrograde menstruation from a tipped uterus. He biopsied one area that was found to be inflammatory tissue. He recommends that I begin oral contraceptive therapy in hopes this will alleviate the symptoms. He did not mention UPLIFT as an option. My question is what is the most successful mode of treatment, surgical or nonsurgical?  

Answer:
First of all, a retroverted (tipped) uterus is generally not a disorder, and does not have anything to do with endometriosis. Given that the biopsy was essentially negative, there is no definitive evidence of endometriosis at this point in time. Retrograde menstruation is a common laparoscopic finding, and occurs in women with and without endometriosis. Empirically starting hormonal intervention is not an uncommon practice, but it is also important to continue an evaluation of possible reasons for the pain. These include gynecologic and nongynecologic entities. I'm assuming that you are referring to a system to suspend the uterus. I have no experience with this technique, but can say that in general, uterine suspension has few if any indications. Once a common procedure, it is hard to find reliable evidence that it is beneficial in most women, although there is anecdotal evidence of some benefit in women with significant endometriosis. At this point, however, your doctor probably is not seriously considering a retroverted uterus to be a likely reason for your pain, and I would tend to agree with him or her unless clinical evaluation suggests otherwise. It is not possible to say if nonsurgical or surgical treatment is better, since it is unclear what the diagnosis is in your situation. 

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

David Toub, M.D.  

Question: Sacrotuberous Ligament causing CPP?
In the last 3 years I have had 7 surgeries and 10 trips to the ER for pelvic pain that results in screaming out, unbearable pain. I have been diagnosed with endometriosis but was recently diagnosed with a sacrotuberous ligament problem. I can't find any information anywhere and get the feeling I am the only person ever diagnosed with this problem. It makes sense with my pain. No pain when I first get up, bad by lunch, unbearable by night. What do you know about it?        

Answer:
I'm not personally familiar with this syndrome, but it may relate to a chronic pain syndrome involving one or more of the pelvic ligaments. Whether this explains such severe pain (as opposed to your endometriosis) is hard to say, but in any event, you may want to ask about nonsurgical ways to manage a chronic pain syndrome. If seven operations in three years have not solved the problem, additional surgery is unlikely to be a remedy either. An evaluation at a multidisciplinary pain center would also be a suggestion. 

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

David Toub, M.D.    

Question: A superior hypogastric plexus blockade
I've been suffering from chronic pelvic pain for approximately seven years. I have been through several tests and surgeries.  They have eliminated endometriosis, tumors, fibroids and cysts.  I went to a pain specialist and he suggested a "superior hypogastric plexus block."  I would like to know how long it would last and what are the risks involved.  Could this surgery affect my legs or anywhere else?   Do you have another possible treatment option? The pain is unbearable and I have to make a decision soon.  Please help if you can.  

Answer:
A superior hypogastric plexus blockade (a procedure done by an interventional radiologist or anesthesiologist)  is similar to the surgical procedure known as a presacral neurectomy. In a presacral neurectomy, which can be done by laparotomy (conventional surgical incision) or laparoscopy (small incision), the superior hypogastric plexus is removed. The plexus is a series of nerves that transmit pain sensation from the middle pelvic organs, such as the bladder and uterus.

By performing a nerve block, the interventional radiologist is essentially blocking the same set of nerves that is removed during a presacral neurectomy. Either procedure is only appropriate for midline pain; it is not effective for pain originating near the sides of the pelvis, such as ovarian pain. It is also not foolproof, and has risks. In general, presacral nerve blocks rarely can be associated with respiratory failure and other serious complications. On the other hand, the surgical presacral neurectomy can be complicated by significant bleeding and even death (fortunately this is rare). In skilled hands, however, both presacral (superior hypogastric)blockade and presacral neurectomy proceed without major problems.

Regardless of which procedure is used, there can be urinary retention and constipation, since the nerves do affect the bladder and rectum as well as the uterus. The specific risks relevant to your situation are more appropriately discussed by the physician who will perform the procedure. Success rates vary depending on the study, so it is important that your doctor discuss his or her experience with you to make sure this is an appropriate option for you. 
Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question:  Pelvic Congestion Syndrome
I was diagnosed with pelvic congestion syndrome.  My doctor, who is a pelvic pain specialist, said I need a hysterectomy and one ovary should be removed.  I don't understand why you say pelvic congestion syndrome is controversial.  

I've heard that it can come back.  Is this true?  I have been having trigger points done since last summer every four months. They would completely take away any pain I was having for that long.  I just recently had them done and two weeks later I was cramping again. My doctor said maybe she missed a spot so she went back in for another round.  I am now cramping again and it has only been a week and a half.  She mentioned that she wanted me to go see the specialist again. I am just trying to find out as much as I can.
 

Answer:  
Pelvic congestion syndrome is a controversial subject for many reasons, and it is difficult to justify major surgery in all cases for this. Dilated pelvic veins occur during pregnancy, for example, yet chronic pelvic pain is often relieved to some extent by pregnancy, making the link between "pelvic congestion" and chronic pelvic pain somewhat questionable. I am also unaware of any definitive study demonstrating benefit from the treatment of "pelvic congestion syndrome." Your doctor can provide you with additional, individualized information, and you may want to obtain a second opinion before any hysterectomy; this is good advice for most women. 

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

David Toub, M.D.  

Question: Painful Clitoris
My clitoris is painful to the touch and sometimes when walking around I will get a sharp pain. I went to the doctor for possible bladder infection but was tested negative.  What else could this be?  

Answer: 
It is hard to say with any degree of certainty, but there are  women who have painful areas around and including the clitoris. The most important thing is to first exclude a serious condition. Once tumors and infection have been ruled out, measures can be taken to try to relieve the pain. Vulvodynia (chronic vulvar pain syndrome) typically does not involve the clitoral region, but exceptions certainly can occur. It would be helpful to ask your doctor about the different possibilities and if you might be able to consult a gynecologist with particular expertise in this area (assuming your doctor does not have such clinical experience). 

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

David Toub, M.D.  

Question: Interstitial Cystitis
Four years ago, I saw a urologist due to recurring pain in my lower right quadrant. I also had problems with frequent urination. The ob-gyn and the urologist worked closely together to try to figure out where all this pain was coming from. The urologist diagnosed me with interstitial cystitis. He then performed a bladder hydration. The ob-gyn also came during my surgery and looked for evidence of endometriosis. There was no evidence of this. The pain is still there and seems to be getting worse. I would appreciate any information you have that may explain this kind of condition.

Answer: 
Interstitial cystitis is a subject that could fill a small (or medium size) hard drive. But I can say that it remains a condition that is poorly understood, although there are many helpful treatments out there that your urologist can discuss with you in more detail. Whether or not IC explains all of your pain is hard to say, and here is where your gynecologist can be of great help as well. 

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

David Toub, M.D.    

Ovarian Pain  

Question: Cystic Masses
My daughter is 14 years old and not sexually active.   She had severe pain in the lower left pelvic area.  After a long day at the E.R. she was finally diagnosed with a cystic mass.  The doctor recommended a laparoscopy. Please explain what a cystic mass is, where it comes from, how serious it is, and what it can mean for the future.     

Answer: 
Personally, the doctor who recommended laparoscopy is the most appropriate person to discuss this with you, since the indications for any proposed surgery needs to be explained to you in detail, as the patient's mother.  Nonetheless, a cystic mass is a generic term for a mass that is fluid-filled and not solid. Presumably in this case it is an ovarian cyst, although that is an assumption on my part. Whether or not surgery is indicated depends on many factors, and this is something your daughter's doctor needs to sit down and explain to the two of you. 

Thank you for your e-mail!

David Toub, M.D.   

Question: Sharp Ovarian Pain
I have sharp pain in my left ovary every other month.  I have regular exams and clear PAP tests.  I think they will prescribe a pelvic sonogram.  Is this the way to go?    

Answer: 
An ultrasound (sonogram) is certainly reasonable, although it is a diagnostic test and not a treatment. Regardless, I would defer to the judgment of your physician in terms of your management. The pain should be evaluated, as your doctor is doing, and based on the findings appropriate treatment can be instituted. There are many ways to manage pelvic pain, but the first thing is to see if the cause can be determined. 

Thank you for your e-mail!

David Toub, M.D.  

Endometriosis & Adenomyosis  

Question:  Treatment for Adenomyosis
I have been experiencing chronic pelvic pain for nearly two years. My doctor described my uterus as boggy and she is certain that I have adenomyosis and I do have pelvic varicosities. The varicosities are mostly around my uterus and pelvic floor so I'm considering a hysterectomy but leaving the ovaries.  Does this usually treat or at least improve the symptoms?  

Answer:
There are two issues here. As far as adenomyosis, hysterectomy is both diagnostic and curative. Adenomyosis generally causes both abnormal uterine bleeding as well as cyclic uterine pain, so it is hard to say if this is what is going on in your situation. While not absolutely diagnostic, an MRI scan can often help diagnose adenomyosis, which may guide you and your physician in deciding if hysterectomy is or is not appropriate. As far as pelvic varicosities, I am skeptical that this is a significant source of chronic pelvic pain, and there is no good evidence in the literature supporting this diagnosis. It may be a real syndrome, but the data (other than anecdotal evidence) just isn't there right now. You should ask your doctor about additional steps to evaluate your pain before resorting to major surgery.

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

David Toub, M.D.

Question: Vestibulitis or Endometriosis?
My 14 year old daughter was diagnosed a 1 1/2 years ago with Endometriosis after 7 months of 20 day periods and excruciating pain with the onset of her first period.  She was diagnosed through laparoscopic surgery. She has been on continual birth control pills for over a year and then 4 months of Lupron which made everything worse including a severe depression.  She is doing pain management counseling. Her chronic and debilitating pelvic pain has not gotten better. We sought a second opinion and after a very different exam this doctor says she has vestibulitis and not Endometriosis.  He states the reason for her pelvic pain is that the glands have been causing muscle spasms for over 2 yrs and she needs pain management.  She has none of the other symptoms associated with vestibulitis except the swab test they gave her. We are totally confused and don't know what to believe.   

Answer: 
It's not possible to render a diagnosis in this forum, obviously, but given the discrepancy in diagnosis it may be best to seek out another opinion. Both endometriosis and vulvodynia (chronic vulvar pain syndrome) are unusual in a teenager, but can occur on occasion. The fact that there has been no improvement in symptoms with birth control pills or GnRH agonists is unusual for endometriosis. It would also be useful to establish or refute the diagnosis of vulvodynia with certainty, since there are interventions that can be effective for vulvodynia but such intervention would be unnecessary if the diagnosis were incorrect.

Regardless, the fact that this has so significantly interfered with her life is consistent with a chronic pain syndrome. Given that she has severe depression, however, she may need more intensive psychological/psychiatric treatment than counseling. I would suggest another opinion, as both diagnoses are unusual in this age group and the lack of response to hormonal intervention raises some questions. I would also explore psychiatric advice as well based on the depressive seizure. Any patient with chronic pain merits psychological or psychiatric evaluation since anyone with severe pain on a constant basis can benefit from some support. 

Thank you for your e-mail!

David Toub, M.D.  

Question: What doctor for severe pain?
I  was diagnosed with endometriosis.  The pain moves around the lower pelvic area, in my hip and radiates to my back. I saw a gastroenterologist and he wants to do a colonoscopy but my family doctor says it's a pulled muscle and my OBGYN says it is probably the endometriosis. What if it isn't and how do I find out? Which doctor should I see and what tests should I have?    Answer:
You may be better served by consulting a gynecologist who is skilled in the evaluation and management of endometriosis and chronic pelvic pain. At the very least, there should be an evaluation of your current situation, including whether or not the pain is due to endometriosis, adhesions, or something else. 

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

David Toub, M.D.  

Question: Chaste Tree for Endometriosis?
I am 21 years old and I have had endometriosis.  I have had laser surgery and I am currently on birth control pills.  A friend suggested chaste tree to me to relief my symptoms.  My doctor wants me to continue on birth control and she gave me permission to take chaste tree as well.  The problem is I was looking over the internet and some web pages say not to take chaste tree with the pill, some say you can but it makes the pill less effective, and some say it is ok.  What do you think?  Have you heard of it?  No one has been able to answer my question. I appreciate any information you have.  

Answer:
I confess that I have no familiarity with the remedy you mention. I would also be hesitant to recommend anything for endometriosis other than proven treatments, and there are other standard treatments for endometriosis besides continuous birth control pills. Your doctor should be able to provide you with information on other potential treatment options. 

Thank you for your e-mail!

David Toub, M.D.    

Question:  HRT causing endometriosis flare-up?
I am a 24 yrs old and I had a hysterectomy in Oct '99.  I have my ovaries but my doctor put me on estrogen because of mood swings and hot flashes.  He told me that he thought I had adhesions on my bowels and microscopic endometriosis.  I am wondering if the estrogen would encourage the endometriosis to grow again?  

Answer:
Generally, postmenopausal hormone replacement does not cause endometriosis to progress, although individual results may vary. The consensus, however, is that this is not a common occurrence, and may only be a concern with high doses of estrogen. 

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

David Toub, M.D.  

Vulvodyina, Vulvar Pain  

Question: Vulvar Varicosities
I am 25 weeks pregnant and have been diagnosed with vulvar varicosities.  I have been having  pelvic bone pain for a couple months along with swelling in my vaginal area.   I was advised to try a V2 Supporter, which seems to help some but this is still very painful.  I also have a 2 1/2 year old and since he was born, sex has been painful for me and I would often swell afterwards.  Could this have been caused from these varicose veins?  Is this something that should go away after I have my baby?  Will this cause me to have problems with a vaginal delivery?  What else can I do to make this go away?  

Answer:
Like varicose veins in the leg and hemorrhoids, vulvar varicosities can also occur during pregnancy and generally are of no consequence. For the most part, they should decrease in size after delivery, and should not interfere with delivery to the best of my knowledge. There is not much that you can do as far as I know to make them go away during pregnancy. The painful intercourse you have been having between pregnancies probably is not due to the varicosities, but can be due to any of a number of things that can result in pain during intercourse. Your best bet is to have this evaluated by your gynecologist, both during pregnancy and afterwards. 

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

David Toub, M.D.  

Question: Lichen Sclerosis
What can you tell me about this?  I am not able to find relief.  I am on hormones which sometimes help a little.  I would appreciate any advice or information that you can supply.
Thank-you so much.
 

Answer: 
This could fill a small book, but in a nutshell...lichen sclerosis is a chronic, but benign vulvar condition marked by thinning of the surface epithelium and shrinkage of the labia. It is most common in postmenopausal women along with pre-pubertal patients, but can occur at any age. It is diagnosed by biopsy (this is very important, since other vulvar conditions, some of them worrisome ones, can look similar). It used to be treated with topical testosterone proprionate in petroleum and even progesterone, but both treatments have pretty much gone out of fashion for many reasons. Nowadays, LS is treated very well with highly potent topical corticosteroid creams.

Your best bet is to get a second opinion (and make sure the diagnosis has been confirmed by biopsy) and ask about topical corticosteroids. 

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

David Toub, M.D.  

PID & Other Pelvic Infections  

Question: Painful Sex
For the past 9 years sex has been very painful, more so just before my period.  I had surgery one year ago for polycystic ovaries and to remove some scar tissue.  

Since having my daughter we have never used contraceptive and would like to have another child.  I have used clomid but have not been able to get pregnant.  Recently, I began to have a fishy smell as I start to ovulate and it lasts until the period finishes.   We have been using mediation to treat it but it just comes back.  

The two problems remain: painful sex and infertility.  Any advise would be appreciated.
  Answer:
From your description, you may have a Gardnerella infection in your vagina, which is extremely common (like a yeast infection, for example) and easily treated by your doctor. Your doctor needs to do an examination, however, to see if this really is what is going on.

It does not explain your painful intercourse and infertility, which may be due to adhesions (scar tissue) in your pelvis. It sound like you need to consult with your doctor, both for the fishy odor and to see if an infertility evaluation can be commenced. Given your medical history, an assessment of your Fallopian tubes may be appropriate (to see if the tubes are open), but it is just as important to have your partner assessed as well. 

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

David Toub, M.D.    

Question: Chronic Pelvic Inflammatory Disease
I was diagnosed with chronic pelvic inflammatory disease.  Sometimes I have had no trouble for 3-4 months at a time but for the last 18 months it has hardly stopped. I am constantly in pain and very swollen.  What treatment options are available for this?  

Answer:
There are a number of potential options, assuming that your symptoms are due to pelvic adhesions (scar tissue) from previous PID. Laparoscopic  surgery is one approach, as is medical pain management. In some cases, evaluation in a multidisciplinary pain center can be very helpful when other options have not succeeded. 

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

David Toub, M.D.  

Hysterectomy Pain  

Question: Severe Pain, Swelling, Burning and Redness
Over the last year I have developed severe pain, redness, swelling, burning and itching.  Since most is outside the vagina my doctor seems to think it is thinning of the tissue due to  a hysterectomy.  He has increased my HRT and I am using a estrogen cream. Sex is out of the question.  Could it just be thinning of the tissue or something else?  

Answer:
It may have nothing to do with estrogen and everything to do with a condition called lichen sclerosis. This is a generally benign condition that results in a thinning of the labial tissue and associated itching. A biopsy done in the office is essential to confirming the diagnosis, as there are more worrisome conditions that can cause vulvar burning and redness. If lichen sclerosis is confirmed, treatment nowadays usually consists of topical corticosteroids (an older treatment was topical testosterone proprionate in petroleum, but this has largely been supplanted by strong steroids). The most important thing, however, is to have this area biopsied in order to determine what is really going on. 

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

David Toub, M.D.  

Other Questions  

Question: Burning Pain at the C- Section Scar
Thank you for the GREAT WEB SITE!!!!.

Why does my c-section scar on the inside burn.  It used to burn only at the on set of my period, now it seems constant. During the second one I had my tubes tied; my periods are worse then ever, more cramping, bleeding and constant burning. I am on medication for PMS but I need something for the physical part.  I am in pain and my doctor will not give me anything for pain.  What should I do?
 

Answer:
Thank you for your kind words!

In some cases, a scar can be painful due to the presence of an entrapped nerve. In others, chronic inflammation can result in pain. I am sorry that your doctor will not treat your pain; perhaps you may want to consider a second opinion. It is also possible that it isn't so much the scar that is painful as something else, such as endometriosis (which infrequently can arise in surgical scars). You should consult your doctor (or a second opinion consultant) about other possibilities. 

Thank you for your e-mail!

David Toub, M.D.    

Question: Thickened Endometrium
Two years ago, I was sent to OBGYN after an ultrasound showed a thickened endometrium.  This month I had a repeat sonogram and the endometrium is still thick even though I take Provera.  I am 53 and have menopausal symptoms. The doctors  state there is no reason to worry and since  my PAP tests are normal, just to continue my medication as prescribed.  I am beginning to wonder if I need another opinion or if I am worrying too much.  

Answer:
So long as a hysteroscopy with a D&C, or at least an office endometrial biopsy revealed benign endometrial tissue, your doctors are correct in offering reassurance. However, without a tissue sample to confirm that there is no evidence of a premalignant (or even a malignant) condition, all bets are off. Pap smears are important to get from the perspective of cervical disease, but are not  clinically useful in ruling out endometrial cancer.  Also, without a tissue diagnosis it is hard to justify the use of progesterone as it is not clear what is being treated. You should definitely ask your doctors about these issues. 

Thank you for your e-mail!

David Toub, M.D.

  Question: Treatment for Uterine Fibroids
I have fibroids that cause long periods, annoying but not very heavy.  I am taking estrogen every day now for a month now.  I am concerned about the fact that estrogen causes fibroids to get bigger.  Are there natural alternatives that could pull my period "in line".  There are so many new treatments out there, lupron, myomectomy, hysterectomy, (not an option unless life threatening ), balloon therapy.. What do you think?  

Answer: 
A short course (not long-term use) of estrogen is sometimes recommended for management of women with estrogen breakthrough bleeding. However, it is of not use for a woman with bleeding secondary to fibroids. In fact, medical management of uterine fibroids is not terribly successful, unfortunately.  There are numerous treatments available that preserve the uterus, some of which may not be an option if you are planning a future pregnancy (for example, myolysis and possibly even uterine artery embolization should not be used in women who desire fertility, although they are good procedures for women who are done with childbearing and desire to retain their uterus). You should ask your doctor about other options. In any event, estrogen would not be likely to correct your symptoms in the long term. 

Thank you for your e-mail!

David Toub, M.D.  

Question: Continued Bleeding from a Hysterectomy
Last April I had a vaginal hysterectomy.  I spotted and bled for a little while following surgery.  In August, I discovered a bloody discharge. My surgeon said this was typical following a hysterectomy.  Granulation tissue will be evident and he cauterized it.  I've had had 6 treatments, the latest being in January.  Last week I was spotting again.  Is this normal?  It's been almost a year? What would you suggest?  

Answer:
In my experience, this is unusual. It also depends on whether or not the vaginal cuff was left open or closed at the time of surgery (both options are quite acceptable, and it is a matter of physician preference). Regardless, granulation should not take that long to have occurred. I would suggest you contact your physician and make sure that your Pap smear is normal, that the vaginal apex is well-healed, and ask if there is any suggestion of atrophic vaginitis. The last entity is seen generally in postmenopausal women, but if there is a significant estrogen deficiency this could occur in a premenopausal woman. 

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

David Toub, M.D.  

Question: Chronic Adhesive Pain
Two years ago started having pain after a hysterectomy.  My OBGYN found a mass on the right ovary.  He did a laparotomy but he could not find the ovary.  It had shifted with the bowel all the way to the right and was stuck to the leg muscle.  Three weeks after surgery the pain returned and he did another laparoscopy. He was unable to complete the laparoscopy because the pelvis was completely covered with adhesions.  Since then I have had several surgeries to remove adhesions.  They are talking about surgery again.  What other treatments can be done to stop or reduce the formation of adhesions?  They are attaching to my bowels, intestines, etc.  

Answer:
As mentioned in many other postings, any surgery will tend to cause adhesions, and after multiple operations adhesions are almost a given, even with the best techniques. While there are some things, such as anti adhesive barriers, that have had mixed success in some settings, the best way to minimize the risk of adhesions is to use meticulous technique or avoid surgery entirely. Given that the risk of adhesions in your situation is considerable based on your description, you may want to ask about nonsurgical ways to manage chronic pelvic pain. 

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

David Toub, M.D.  

Question: Could it be Adhesions?
I have been experiencing chronic pelvic pain for the last three years.  My doctors have been unable to determine the cause of pain.  During a Lap, my OBGYN ruled out endo but found adhesions and a small ovarian cyst.  I continue to have the pelvic pain that is worse during my period.  I also noticed that I am voiding constantly and can't hold my urine for long without an intense feeling. 

About three months before all of this happened I began exercising at a gym.  Is their any way that the adhesions were being stretched and pulling on the bowel ?
 

Answer:
It is very unlikely that exercise played any role in the adhesions or their symptoms. Regarding your pain, while it is not possible to make therapeutic recommendations, you may want to ask your doctor about whether or not a urologic evaluation is appropriate, given your bladder symptoms. In some cases, a condition called interstitial cystitis can cause similar symptoms and can be mistaken for a gynecologic cause of chronic pelvic pain. 

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

David Toub, M.D.  

Question: How to Diagnosis Pelvic Adhesions
Generally speaking, would pelvic adhesions be visible on an ultrasound?  

Answer:
Unfortunately, no. Pelvic adhesions cannot be imaged by ultrasound. Generally they can only be seen with the naked eye (as during surgery) with the possible exception of  extremely thick adhesions visible on MRI, and I suspect that detecting them on MRI is unusual. An attentive radiologist can suspect adhesions if bowel appears fixed to the abdominal wall during an MRI scan, but as far as I am aware adhesions are not detectable on an ultrasound.

Thank you for your e-mail!

David Toub, M.D.  

Question: How Long Before Adhesions Grow?
How long does it generally take for adhesions to form after surgery?  Is there anything that can prevent them or stop them from forming?  Also can they cause problems to other organs, like bladder or colon problems?  

Answer:
Adhesions have been reported to occur in as little as several days postoperatively, although in most cases they take a bit longer to form. Regardless, there is nothing you can do to prevent adhesions other than not have surgery. There are a few things a surgeon can try to do to reduce the risk of adhesions (gentle and meticulous surgical technique is probably most important and in some cases adhesion-preventing barriers may be useful), but even the best surgeon cannot absolutely prevent adhesions in all cases. Just as scars form on the skin surface no matter how careful a surgeon makes an incision, adhesions are a normal result of any operation in the abdomen and pelvis. Laparoscopy is usually associated with fewer adhesions than a laparotomy incision, but even with laparoscopy, adhesions can occur. Instilling antibiotics and different types of irrigation fluids into the abdomen have not been demonstrated to be effective, although some physicians may still use these methods in practice.

Adhesions can in some cases affect the bowel, causing bowel obstruction. Adhesions are also associated with pelvic pain. Not everyone with adhesions (even significant ones) suffer from bowel obstruction and/or pelvic pain, fortunately. Your doctor can provide you with individualized information about this subject. 

Thank you for your e-mail!

David Toub, M.D.    

Question: Vaginal Soreness
I have been bothered by soreness in the vagina; no burning, itching or severe pain. I was diagnosed with Strep-Group D, and was treated.  The medication eased the soreness, but within a few days after finishing the medicine, the symptoms returned.  A culture taken a week ago indicated that there was no infection, but the terrible soreness persists.  I am a 66 year old woman who is in otherwise good health.    

Answer:
It may be a case of atrophic vaginitis, which is a thinning of the vaginal lining due to insufficient estrogen. While your standard postmenopausal estrogen usually prevents this, depending on individual metabolic differences it may be that you need a bit more estrogen delivered to the vagina directly in the form of estrogen cream. This may not be the reason, and you certainly need to have this evaluated by your gynecologist, but it is a thought. It is hard to explain how antibiotics were helpful if there was no documented infection, so your doctor needs to assess the situation in further detail.

Thank you for your e-mail!

David Toub, M.D.  

Question: Continual Cyst Pain
Every month at the end of my period I get pain on my right side.  It lasts about 3-4 days and has gotten worse each month.  I had an ultra sound and I do have a cyst there.  Would this be causing all the pain or does it sound like endometriosis?   I also have pain during intercourse and have heavy periods.  

Answer: 
It certainly could be the cyst or endometriosis or any of a number of potential causes of chronic pelvic pain and abnormal uterine bleeding. You should consult your gynecologist about the best way to evaluate your problem, and whether or not a laparoscopy might be appropriate. 

Thank you for your e-mail!

David Toub, M.D.  

Question: Ovulation Pain?
I have a pain in my pelvic area, usually one side only once a month about two weeks before my period.  A nurse told me that was quite normal, it was when I was ovulating, but if I'm on the pill, then I shouldn't be ovulating unless I miss understand the purpose of the pill.

Also, What is the best way to ease pelvic pain during menstruation?
 

Answer:
You are correct that you should not be ovulating while on the pill, but this is not 100% (fortunately, there are other mechanisms by which the pill prevents conception besides inhibition of ovulation). Also, your pain may not be due to ovulation per se, which would explain why you have pain while on the pill and not ovulating. I wouldn't say that having mid-cycle pain is normal, but isn't uncommon, either. In any event, it is not necessarily well-understood, but can be managed like any other recurring pelvic pain, with appropriate pain medicine as directed by your gynecologist.

The best way to reduce menstrual pain will vary from patient to patient. In general, the nonsteroidal drugs are in wide use for this, but not everyone can take them (women with ulcers should not take such medications, for example). Again, your gynecologist is in the best position to guide you in
terms of medication. 

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

David Toub, M.D.  

Question: Displaced Ovary
I have had pelvic pain and heavy periods. My doctor did an endometrial biopsy and a vaginal ultrasound.  They found my right ovary but it wasn't where it was supposed to be!  It was lying on top of my uterus.  Is this normal?   

Answer:
The ovaries are connected to the uterus by the uterovarian ligaments, which are quite pliable. Thus, the ovaries are not fixed in position, but can move around to a limited extent, so you shouldn't get too concerned! This is a normal finding as far as I'm aware. 

Thank you for your e-mail!

David Toub, M.D.  

Question: Bleeding Cervix
I had a laparoscopy and D&C to treat endometriosis and was pain free until last year. What concerns me is my cervix bleeds when touched. What are some things that could cause a cervix to bleed? My doctor put me on Amino-cerv cream.  

Now I have a yeast infection and severe itching and pain that keeps me up half the night. Can I use any yeast infection creams with this?
 

Answer:
There a number of reasons why the cervix would have a tendency to bleed when touched. In addition to cervicitis (inflammation or infection of the cervix), a major concern is the possibility of cervical dysplasia, which is a precancerous condition of the cervix that is detected usually with a Pap smear. I don't know anything about the cream your doctor prescribed, but you may want to inquire if the reason for the bleeding has been unequivocally diagnosed and if a recent Pap smear was normal. As far as a yeast infection, there should be no major issue with treating it, although you may want to consider an oral antifungal medication rather than a vaginal cream under the circumstances. 

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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