Topics:

Ask The Expert

Ask The Expert

This month's topics

Chronic Pelvic Pain    

Question: Top Medical Centers  
How does one locate the top medical centers, (domestic or international) or pain management centers for treating chronic pelvic pain?  

Answer:  
Usually word of mouth, particularly through one's healthcare provider, is a good way to locate a chronic pelvic pain center of excellence. Another potential source (which should not preclude your discussing this with your doctor or nurse practitioner) is the International Pelvic Pain Society. (http://www.pelvicpain.org). 

Thank you for your e-mail!

David Toub, M.D.

 

Question: Sharp Monthly Pain
I don't know if this would be considered chronic pain but each month about 6 or so days from the last day of my period I get a sharp pain that switches sides each month one month its the left the next month its the right and the pain lasts for 24 hours or more and increases during urination or intercourse. My periods are normal 28-30 days apart very heavy first day and a half then slow down and last between 6-8 days. Could you tell me what this might be?

 

Answer:
Diagnosis is best handled by your personal healthcare provider, and I would suggest you contact him or her regarding your symptoms. 

Thank you for your e-mail!

David Toub, M.D.

  Question: Pain and Vaginal Dryness  
I am 22 yrs old, and have been sexually active since age 15. The first few times I had sex, everything went well, even the very first time. A couple of years ago I began having problems during intercourse. Sex is absolutely impossible without lubrication, which I use K-Y. During sex, I become sore right away, within the first few minutes, as if I had been having sex all day. I have been this way for about 5 years, and am wondering if I will ever be able to really enjoy sex again. I spoke with my doctor once, and she was not able to offer any solutions, and didn't find any physical problems. Can you offer any suggestions?  

Answer:  
Insufficient lubrication is a common reason for pain during intercourse. It may be that your partner needs to consider additional foreplay in order to allow your body to provide this on its own. The fact that you still have pain during intercourse despite lubrication with K-Y suggests that it may be possible that something else is going on, such as endometriosis, vulvodynia or another disorder. I would suggest you discuss this further with your gynecologist and see if she has any additional suggestions. If this is not helpful, perhaps a consultation with someone experienced in chronic pelvic pain might be of benefit. 

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

David Toub, M.D.

  Question: Painful Intercourse After Pregnancy  
I am 32 years old and I have had 2 children who both weighed 8 pounds and over at birth.  For the past few years when my husband and I make love, it feels as if he hits something inside me and sharp pain then ensues.  For days afterward, I have pain when I urinate, but not an infection type pain.  It feels more like a pressure type pain and it hurts right around my bladder area. I have had bad experiences talking about painful, intercourse with my former family doctor and refuse to talk face to face with another doctor about this problem.  Being told to go to an aphrodisiac shop for foods to improve my sex drive and to try sex toys to stimulate me before enjoying the companionship of my husband, I thought was a bit out of line.  All I want is an answer to the questions: Why is sex so painful for me after my children were born and what could he possibly be hitting to cause such pain. I hope these are some questions that you could help me with because this pain has put a limitation on our sex life.  

Answer:  
There are many potential reasons for your symptoms, including vulvodynia (chronic vulvar pain syndrome), endometriosis, inadequate lubrication, etc. I understand you had a bad experience in the past, but you do need to discuss this with a healthcare professional face to face, preferably someone experienced in managing chronic pelvic pain. I would suggest you consult a gynecologist to start with, since this is more often seen within this specialty. Look at it this way: you're discussing this with a gynecologist via e-mail, so I suspect you might at least consider the possibility of consulting a gynecologist in person. Truthfully, having an evaluation is the best way to arrive at the correct diagnosis and go on to treat the problem. 

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

David Toub, M.D.

  Question: Adhesion Pain?  
I am a 33 year old female who has had 12 abdominal surgeries, TAH included. I have been suffer with pelvic pain even after each surgery was preformed. I have been in pain management for 5 years and have tried every non evasive treatment there is. Finally GYN doctor sent me to a surgeon to discuss going in and removing adhesions and see what else there is going on. The surgeon said adhesions do not cause pain and took me off the estrogen stating that is was possible the endo has returned. Why do many doctors not believe adhesions cause pain, while others do?  For the patient, this leaves us in a heap of pain. Then at the same point pain management wants to leave me on the Narcotics, and GP said that I should not be managed with Narcotics. I'm so confused what do I do?  

Answer:
Your questions are very eloquent and well-stated. Among the gynecology community, it is quite clear that adhesions can result in pain, although it is not an absolute. A classic study by Kligman demonstrated the presence of nerve fibers in some adhesions, so it is not inconsistent that adhesions can cause pain. Among general surgeons, who overall do not tend to manage patients with chronic pain, there is a general opinion that adhesions cause bowel obstruction and little else. I don't mean to insult general surgeons, since I am much more on the surgical side of things than the nonsurgical side, but the reality is that they have a different perspective. They are entitled to their perspective, as my colleagues and I are entitled to our own.

While there is a legitimate difference of opinion regarding the use of narcotics in the management of chronic pain, I am of the school that tends to avoid their chronic use for many reasons (not the least of which is the fact that after a while they really don't work very well). At the same time, I would also tend to steer clear of any additional surgery. You are at much greater risk of intraoperative complications due to adhesions (which is not uncommon after 12 abdominal operations), and the likelihood of "curing" you of all present and future adhesions is essentially zero in my opinion. Other physicians may disagree, and that is certainly appropriate, but I feel the need to provide my opinion while urging your to defer to the physicians who are most familiar with your situation.

There are many ways to manage your pain, some more likely to be effective than others. The reality is that in about half of patients with chronic pain who are managed in a multidisciplinary pain center (which offers the best overall probability of pain control), the pain may not be controllable. On the other hand, about half of such patients do find pain relief/control, so it can go either way. If you have not already explored a multidisciplinary approach, it might be appropriate to consider this at this time. I don't have any words of wisdom to help you get rid of your pain; these are extremely difficult situations to deal with both for patients and physicians. However, I would also urge you to make sure you are being managed by a multidisciplinary team of providers experienced in the management of chronic pelvic pain. Right now, it sounds like all your providers, while very well-intentioned, are offering up conflicting opinions (such is the nature of medicine). A coordinated effort as part of a multidisciplinary pain center may be the best option if it has not already been attempted. 

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

David Toub, M.D.

  Question: Hysterectomy at 19 for Endometriosis Treatment?  
I'm 19 years old and was diagnosed with endometriosis in July of 1999, a month before my 18th birthday. I was having a lot of trouble coping with it; the doctors were telling me that the best way for me to be cured of it would be to have a hysterectomy or induced menopause. At 18 years old I was not ready to deal with those options, and since then have had 2 miscarriages. The doctors are now telling me that my chances of ever having children is very slim and although I'm not having pain as much anymore, I'm still afflicted with the disease. What, if any, advice can you give me regarding this disease.  

Answer:
I'll be blunt-my best advice is to consult someone with particular expertise in the management of endometriosis, assuming that your description of events is totally accurate. First, hysterectomy does not always cure endometriosis, and is inappropriate in my opinion except as an absolute last resort. Endometriosis also does not in any way, shape or form to the best of my knowledge cause miscarriage. It can result in infertility (the inability to conceive in the first place), but that would not seem to be the issue here. You may want to investigate reasons for your two miscarriages, although they may not completely meet the definition of recurrent miscarriage. However, that is a separate issue entirely.

I would suggest you seek out a provider who can offer several options to manage your pain. I would also make sure that the diagnosis of endometriosis is definite, as this is a diagnosis that can only be diagnosed through laparoscopy or laparotomy. I am not trying to disagree with your doctors or come between you and them, but from what you have described, it may be of benefit to get additional input into your management since hysterectomy is irreversible. 

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

David Toub, M.D.

  Question: CPP  
I have been suffering from pelvic pain for three months. I went to the doctor when it first started and had a pelvic, urinalysis's and an ultrasound but nothing showed up. I have been bleeding between periods and had a bright yellow discharge last week. My pain is mostly around where my ovaries are. Lately the pain is worse, at times it feels like something is stinging or burning and my lower back hurts. I am 21 years old and have never had this type of pain before. Do you know what it could possibly be?  

Answer:  
I would defer to your doctor regarding possible diagnoses, since that really requires a detailed knowledge of your medical history and physical exam findings. However, I would make sure that both your pregnancy test and recent Pap smear are negative, assuming that this is not already known to you. There are many possibilities, and your doctor is your best resource for information on diagnosis and management.

Thank you for your e-mail!

David Toub, M.D.

  Question: Leg Pain Caused by Period  
About a year ago, several days after my period, I began experiencing severe pain in my left thigh. It lasted for about 3 - 4 days. I had a cat scan, an MRI, and internal sonogram, etc. but nothing was found. My GYN said it was not connected to my period. My GP prescribed birth control pills for a few months and I had no pain. I went off the pills in December and the pain has returned. The pain is so severe that I cry from it. It is from the top of my thigh to the the top of my knee and is bone deep. It has nothing to do with the position my leg is in, whether or not I'm standing, sitting or laying down. I have another appointment with my GYN. Since this is something that is hard to diagnose, I wondered if you had heard of anything similar. Thank you for your time.  

Answer:
One thought I have relates to endometriosis involving the sciatic nerve. It is unusual, but can happen, and the fact that you responded to hormonal intervention argues that whatever is responsible also responds to hormones. You may want to discuss this possibility with your gynecologist. Again, there could be many things possibly going on here, including disorders that have no relation to gynecology, and this is something your gynecologist can help you sort out. Depending on your test results to date, endometriosis may or may not be a realistic possibility.

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

David Toub, M.D.

  Question: Pre-Menstrual Pressure  
I get severe pressure around my pubis bone during the hours before I start bleeding and through the next two days. It is on and off during that time. Sometimes, the pain is so severe I must stop whatever I'm doing and sit down. During the last few days of my period it does not bother me. Have you ever heard of this? and sit down.  

Answer:
I have not previously heard of this, but it certainly is possible. You should consider discussing this with your healthcare provider in order to attempt to find out what is causing this and how best to relieve your symptoms.

Thank you for your e-mail!

David Toub, M.D.

 

Question:  Chronic Pelvic Pain due to Cervix?
Over the past couple of months I have had severe pain in my vaginal area, specifically along the left side of my cervix and sometimes along the left vaginal wall and the bladder. When I stand up, my cervix is positioned all the way on the left vaginal wall and is only about 3/4 of an inch from the vaginal opening. The pain seems to worsen during the day as I sit or walk and gets better at night. Could the position of the cervix be the source of my pain? Why could the cervix be so off-center? I have had a sonogram and a lap, neither of which showed why the cervix is off center or why I may be having the pain.

  Answer:  
It is unlikely that cervical position, which can vary from one woman to another, is responsible for your symptoms. In some cases, the cervix may be deviated due to uterine fibroids and other abnormalities, although this does not appear to be the case given a normal laparoscopy and ultrasound. There are many potential causes of vaginal pain, and I would suggest you follow-up with your gynecologist to determine what else might be responsible, and how best to manage your pain. 

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

David Toub, M.D.

 

Question: Chronic Pelvic Pain
Please, lease help me. I had my third baby eighteen months ago and since then I have been in pain. It started with retained products followed by pelvic infections. The pain has always been in the same position, the lower right hand side of my abdomen. I had a laparoscopy which confirmed the pelvic infection and adhesion of the ovaries. After various antibiotics, which never cleared the infection, I was given the option of a hysterectomy. This I had done. The surgeon removed my ovaries at the same time, as they had adhered again.

Nine months later and the pain is still with me. I have been to a pain clinic and received a steroid injection with no relief. I note you have mentioned in previous letters about multidisciplinary pain centers are these only in the States? Any information would be much appreciated.

  Answer:  
While I cannot say for certain (since I do not know what country you hail from), I believe that multidisciplinary pain centers exist in several countries besides the US. While I cannot say with certainty why you have pain, based on your medical history it is not unreasonable to consider pelvic adhesions as a possible cause. There are many ways to manage your pain, and I would suggest you attempt to locate either a multidisciplinary pain center or a gynecologist with expertise in the management of chronic pelvic pain. 

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

David Toub, M.D.

  Ovarian Pain & Cysts  

Question: Ovarian Remnant Syndrome  
I am a 33 year old woman that has had several operations to correct several different reproductive problems. I have had a complete hysterectomy and double oophorectomy 10 years ago. Three years ago I started having severe pelvic pain, and had an ultrasound done. The ultrasound showed what appeared to be ovaries, but enlarged. The doctor wanted to operate immediately because he said that I had ovarian remnant syndrome, meaning my body made "new" ovaries after the others were removed. He said that my body did not absorb the little cells left from the surgery, and made the ovarian tissue grow. Three years later I am going to have a 3rd surgery for this. Please tell me your thoughts because my body cannot take many more surgery's. Laparoscopy is not possible because of the scar tissue from the others. Will my body ever stop making these remnants?  If it does not, what other solutions besides surgery, Lupron, or living with the pain, do I have?  

Answer:  
I'm not aware that ovarian tissue appears after complete removal. Rather, ovarian remnant syndrome can occur if (and this is something that can occur even among the best surgeons) a small amount of ovarian tissue remains after excision of the ovaries. The tissue that remains is often functional, and may be walled off by pelvic adhesions resulting in pain. Treatment generally consists of surgery (either laparotomy or, in very experienced hands, laparoscopy) to remove the ovarian remnants). So long as the remnants are completely removed (which may sometimes be extremely difficult), the syndrome should not persist. Of course, pelvic adhesions can still result from such surgery and this alone can cause pain. Whether or not this is what is going on in your situation is something you and your doctor can best judge based on your medical evaluation.

How best to proceed is something that should be discussed with your personal physician, and depends on many factors. 

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

David Toub, M.D.

  Question: Ovarian Pain Worse Post Miscarriage  
I have always had pelvic pain, especially around my left ovary, but since my miscarriage one year ago it seems to have become worse. I have also started having more severe bleeding on my period and it lasts about 6-10 days. My doctor tells me this is normal.  I have a history of ovarian and uterine cancer in my family, and this makes me worry even more. What do you suggest I do? Any advice would be very much appreciated.  

Answer:  
I'm not sure any chronic pelvic pain is normal, but that's my opinion. I would suggest you discuss your concerns with your doctor, particularly in light of your family history. A second opinion may be of use as well.

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

David Toub, M.D.

  Question: Ovarian Pain
I have pain in my right ovary around when I ovulate every other month since I stopped taking loestrin eight months ago. The pain lasts for about five days and intensifies during intercourse and bowel movements. I have been to the doctor twice and he says not to worry and sends me home without any tests. Can you tell what this pain might be and why this occurs?  

Answer:  
It may be mittelschmerz (pain associated with ovulation), but it could also be any of a number of things including endometriosis. I would suggest you approach your doctor and ask about an evaluation and also ideas on alleviating your pain. A second opinion may be helpful as well.

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

David Toub, M.D.

  Question: Mittelschmerz 
My fifteen-year-old daughter has been diagnosed with Mittelschmerz.  Does this typical run in families?  Are the symptoms likely to decrease as she gets older?  Will oral contraceptives decrease the symptoms?  

Answer:  
Mittelschmerz in my experience is usually not a chronic problem, although of course individual results can vary. I am not aware of any genetic component, although that certainly does not mean one may not exist. Oral contraceptives may help in that they prevent ovulation. They do not prevent ovarian cyst formation, however. I would certainly suggest you consult with your daughter's provider and ask if an ultrasound might be appropriate (assuming one has not already been performed). 

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

David Toub, M.D.

 

Question: What causes Nabothian cysts?
I have a Nabothian cyst of about 1.7cm that has not gone away.  Do these stay forever and what causes them?

  Answer:  
Nabothian cysts are common, normal, totally benign cysts on the cervix that contain mucus. They may disappear around the time of menopause, although that may vary. They are caused when, as part of the dynamic cellular changes that normally take place in the pre-menopausal cervix, mucus is trapped under the surface lining of the outer portion of the cervix. They cause no symptoms and again, are innocuous. Your gynecologist can provide more individualized information. 

Thank you for your e-mail!

David Toub, M.D.

  Question: Treatment Side Effects  
I was undergoing treatment for a small cyst in my clitoris that had developed from an earlier inflammation.  The treatment has dried out the membrane on my clitoris. My GP prescribed cream nightly to nourish the membrane.

Have you any experience with this? How long should I apply the Premarin cream? (I have been using it for 10 days now.) Do you know of any side effects I might watch out for? As the dry clitoris is the result of the initial treatment, I am particularly concerned about more side effects. I am 60 and had my last period 6 years ago. I am not on HRT.

  Answer:  
It is preferable to consult your personal healthcare provider regarding how long to continue treatment and any potential side effects, since this can vary in general from clinician to clinician. I have no personal experience with the situation you are describing, and would certainly defer to your provider's clinical expertise and judgment. 

Thank you for your e-mail!

David Toub, M.D.

  Question: Borderline Ovarian Tumor
I just had a baby in December and during my pregnancy my OB discovered a cyst on my right ovary. They left it until the baby was born and I wound up having a c-section. My Ob drained the cyst during the section and sent it to the lab.  It came back abnormal. She told me that it could be a border line ovarian tumor. What is the likelihood of that and how serious is it? What are the treatment options? She has me on birth control pills for it now but I would like to know what this could mean and how concerned I should be?  

Answer:  
A borderline ovarian tumor (also known as a tumor of low malignant potential or "LMP") is one that is not truly malignant (cancerous) but is not entirely benign either. In most women, these tumors are caught fairly early and can be treated conservatively, usually by removing the tumorous ovary or cyst itself and preserving fertility. Except in more advanced stages, in which the surgery required is more involved  and may also necessitate chemotherapy, most women do well with local removal. A simple cyst aspiration may not be adequate therapy, however, and birth control pills are not part of the treatment plan to the best of my knowledge. I am not disagreeing with your obstetrician, but you may want to ask her about the certainty of the diagnosis (based on your e-mail it sound as if the diagnosis may be in doubt). A consultation with a gynecologic oncologist would be appropriate as well. This is because careful surgical staging is necessary in order to fully establish the extent of disease. Again, most women have early stage disease and such women have about a 95% chance of cure (for Stage I tumors). Please discuss this further with your doctor and inquire about a consultation with a gynecologic oncologist. 

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

David Toub, M.D.

  Hysterectomy Pain  

Question: CPP Post Hysterectomy  
I had a cystocele, rectocoele, internal rectal sphincter repair, and a burch procedure done one year ago. Since that time I have made many visits to the Doctor that performed the surgery with complaints of vaginal pain. The pain intensified shortly after the surgery, then over 6-7 months stopped. Now I have a problem with a tearing, burning sensation upon initiation of sexual foreplay and penetration. This problem never existed before and I am perplexed. I am a health care professional and have found no answers to this problem, nor have I found others that have shared this same problem. My Doctors are totally perplexed and can't find a reason for it. I try to have intercourse with my husband but most of the time it is too painful and I just can't take it. Our relationship is good and he is patient, but I am in pain.  

Answer:  
There are several potential causes of your pain, although it is also possible that the true reason may never be known for certain (as is true of many cases of pelvic pain). It may be that your symptoms relate to suture-related irritation if permanent sutures were used during the Burch procedure (permanent sutures are often used, and usually do not cause problems), and it also may be that the symptoms are not totally related to your surgery. Regardless, you may want to ask about an evaluation at a multidisciplinary pain center. If the cause is not identified, there are many things that can be attempted to manage your symptoms. 

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

David Toub, M.D.

  Endometriosis & Adenomyosis  

Question: Long Term Lupron at 19  
I am 19 years old, and 7 months ago they diagnosed me with endometriosis. I have been on Depo Lupron for 7 months now and the Dr. said that I would have to stay on this medication until I want to have children. He decided to put me on a low level estrogen. My question is will the endometriosis feed off of the estrogen and begin growing again? If you have any advice on what I should do it would be greatly appreciated.  

Thank you so much for your time.

  Answer:  
What your doctor is doing is something called "add-back therapy." The rationale for using a GnRH-agonist medication like leuprolide is to decrease estrogen levels which in turn should inhibit the activity of your endometriosis. The problem with GnRH-agonists is that they temporarily create a menopausal state, and if given for more than 6 months this can result in osteoporosis. In general, then, such medications should NOT be administered for more than 6 months. However, there is a theory that by adding back low levels of estrogen, the estrogen levels are too low to activate endometriosis but high enough that osteoporosis should not result. There is clinical evidence that supports this, but my recollection is that the most reliable data was for only one year of add-back therapy; we do not necessarily know that this is a safe practice for longer periods of time. At the very least, you and your doctor should discuss this regimen, and whether or not it is appropriate in your individual situation. Also, I would ask if a progestin hormone should also be added, which is the practice in some add-back regimens. Finally, you should ask about bone densitometry measurements, which may need to be done periodically to make sure that you are not losing bone mineral (which would result in osteoporosis). It's very important that you discuss this fully with your doctor. 

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

David Toub, M.D.

  Question: Eleven Surgery's for CPP, Endometriosis, Cysts & Adhesions 
I am 19 years old and have had 11 surgeries. The doctors found endometriosis, cysts, and adhesions, I had to have my left tube and ovary removed last year. My former doctor passed away and I am requesting a hysterectomy from my new doctor who is very reluctant. I understand because of my age but I have tried all kinds of different pills, even 6 months of lupron injections. I have had severe pelvic pain and very bad periods that are not regular. To top it all off, because of the pain and surgeries, I had a dependency to pain medicine. Are there any other options, or am I right in asking for a hysterectomy?  

Answer:  
Whether or not hysterectomy is "right" is a decision best made by you and your doctor. However, I certainly understand your doctor's hesitation in considering hysterectomy. What I would recommend is that you investigate additional options for pain management, including evaluation by a multidisciplinary pain center. It sounds like you are currently taking narcotics for pain, whereas other options for pain control may be more useful to you depending on your doctor's judgment. My other recommendation is to avoid additional surgery if at all possible, which is a good rule of thumb. Anyone with a history of eleven surgeries is at higher risk for complications from additional operations, and if all those surgeries failed to correct the problem, additional surgery is perhaps unlikely as well. Again, all this needs to be carefully weighed by you and your doctor, and obtaining additional opinions is something that generally does not hurt.

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

David Toub, M.D.

 

Question: 20 Years Old with Endometriosis
I am 20 years old and have just been diagnosed with endometriosis. I have had severe right flank pain for the last three years that has only been controlled with pain meds. (I had a laparoscopy about 3 weeks ago.) I am starting on lupron shots tomorrow and am worried about this affecting my young body. Could this treatment affect my ability to have children? If the pain persists after my treatment, what are the options besides going back on the lupron?  I going to have to deal with the pain for the rest of my life unless I have a hysterectomy? I am worried about being so young and dealing with this. Please let me know any advice that you have.

 

Answer:  
I think it is best if you present your excellent questions to your doctor, since he/she is most familiar with your situation. I can say that GnRH-agonists like Lupron are not known to have long-term effects on fertility, and in fact they are not contraceptive agents either (in other words, while a woman may be less likely to conceive while on Lupron, it can happen, and you should discuss any needs for contraception with your doctor). 

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

David Toub, M.D.

  Question: Endo and Adenomyosis--diagnosis?  
I have had endometriosis for over 20 years, diagnosed during a laparoscopy in 1996 with successful.  I have been nearly pain free until a few months ago when the pain and cramps returned at age 43.  I have never had children.  Am on daily BC pills to prevent periods.  A second laparoscopy done in January but no lesions were seen. My pain (very similar or same as endo pain) continues daily, along with fatigue, headache, and lately extreme nausea. I take medication for the pain. My doctor suspects possible adenomyosis but wants to try Synarel to see if it is gynecological. I am very wary of Synarel's side effects on top of the pain. He has mentioned hysterectomy as a last resort: my hope is that it would be partial only. (I do not want a hysterectomy, but am getting desperate.) I am getting married in June; I need a solution before then, as well as for the pain.  Would an MRI be helpful?  What is a good course of action?  

Answer:  
While there is no absolute way to diagnose adenomyosis apart from a hysterectomy (in other words, it is usually conclusively diagnosed only after the fact, although it may be suspected on clinical grounds), MR imaging of the uterus can be fairly helpful in many cases, although a negative study may not rule out adenomyosis. There are a number of ways to manage endometriosis if that is what is going on, and a GnRH-agonist like nafarelin (Synarel) may be an appropriate option. It cannot distinguish between endometriosis and adenomyosis, however.

You may want to discuss additional options besides hysterectomy with your doctor, to see if any are appropriate for you.

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

David Toub, M.D.

  Vulvodynia, Vulvar Pain  

Question: Vulvodynia  
I just came across an article about Vulvodynia.  I think this is what is wrong with me.  I have had this problem for about 4 years. The physicians, I have seen have never mentioned Vulvodynia, although they didn't offer any diagnosis or solution this particular problem at all. In fact one scared me out of wanting any treatment by saying he could cut all the skin away but I would be deformed, (not that I'm not already)!

My question to you is, do many people have discoloration and a thickening of the skin there from this problem and if I were treated for this, is it possible for my skin to appear normal again?  What kind of doctor should I see, Dermatologist or OBGYN?

I am 35, single and need to have a normal life again. It has been years for me, out of fear of spreading this, if that's possible (if bacterial couldn't it be?). Mainly I just do not want to be seen there. As silly as this may sound, I am embarrassed to have even a doctor see me there. I would consider it if someone could actually help with this problem. I look forward to your response. I don't care how far I have to travel to get help with this.

  Answer:  
It is my policy to not issue referrals through this or any other forum, nor do I know of a specialist in vulvodynia in your area. That being said, I would suggest you find a gynecologist with expertise in vulvar pain disorders. Not every ob/gyn has clinical experience with the diagnosis and management of vulvodynia, and there is a lot of misinformation and misunderstanding out there, even among very well-intentioned physicians. Generally there are no significant discolorations associated with vulvodynia, apart from some mild increased redness on careful examination. There are many appropriate treatments, including medical therapy, but these need to be individualized so it is important that you are seen by someone who has experience. Your local gynecologist may be in a position to refer you if he or she does not have the requisite clinical experience. 

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

David Toub, M.D.

  Click here for OBGYN.net's Physician Locator
Click here for Vulvodynia.com  

Other Questions  

Question: IUD's & Lower Back Pain  
Has any connection been found between the use of IUDs and lower back pain?  

Answer: 
I am unaware of any association. I would suggest, however, that you contact your gynecologist for an individualized perspective. 

Thank you for your e-mail!

David Toub, M.D.

  Question: Non-stop Bleeding in 12 Year Old  
My 12 yr. old daughter began her first menstrual period on 12-5-2000 and to this date she has not stopped, except for maybe 10 days on and off. She has  been under a doctors care this whole time and has been given a series of medications. My question is, have you ever come across or have ever heard about this happening before? Anything  would help at this point.  

Answer:
Abnormal uterine bleeding is not uncommon in young women, but if severe may require hormonal intervention including intravenous estrogen (there is evidence, however, that oral medications may be as effective as the traditional IV approach). You may want to ask your daughter's doctor if anything is going on other than the abnormal uterine bleeding often associated with anovulation (also referred to as dysfunctional uterine bleeding or "DUB"). Additional evaluation may be appropriate depending on the circumstances and her doctor's clinical judgment.

Thank you for your e-mail!

David Toub, M.D.

  Question: Painful Sex  
Please help me.  I can't take it anymore. I have pain all the time.  It's in my right side! I have had ultra sounds and they show nothing. When my & I have sex he hits something that hurts terrible. He is frustrated and so am I. I am not only hurting when we have sex, although this is the way it started. It hurts when I walk or move. I have had 2 abortions. Could I have scar tissue?  

Answer: 
I would suggest you have a frank discussion with your gynecologist or other healthcare provider regarding your symptoms and how best to evaluate them. It is unlikely that your previous abortions are responsible for these symptoms, since abortion is generally not associated with chronic pelvic pain or other long-term physical consequences. Your doctor is in the best position to evaluate your pain, or refer you to a specialist who can provide additional assistance. 

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

David Toub, M.D.

  Question: Removal of Scar Tissue or Not? 
I had my tubes tied last year. During the surgery my right ovary was removed due to a cyst. Since this surgery I have noticed that right side before and after my period hurts. I asked my obgyn and he told me that there may be some scar tissue that had formed or I maybe ovulating. He said we could go back in and remove scar tissue to relieve the pain but he didn't recommend it. He said that if I could live with the pain to do so and just take advil. Since this last conversation with my doctor I have noticed the pain becoming more intense. Often my mood is unbearable. Do you recommend going back in and removing the scar tissue? I have a high tolerance for pain but this is becoming hard to live with.  

Answer:  
I would respectfully disagree with your doctor as far as suggesting that you "live with the pain." Otherwise, his assessment is quite accurate based on the limited information provided. It would not be appropriate for me to make any sort of recommendation, since only your doctor can do that. What you need to decide with his assistance is decide how to best manage your pain, either surgically or medically. This requires some consideration about the relative risks and benefits involved.

Thank you for your e-mail!

David Toub, M.D.

  Question: When Does Dysplasia Become Cancer?  
I am 23 years old and was diagnosed with cervical dysplasia. I had the LEEP procedure done to get rid of the bad cells and my last 2 pap tests have come back negative. My question is, what are the chances that bad cells will come back and if so how quickly do they turn in to cancer?  

Answer:  
It is not possible to give a prognosis, since it depends in part on the degree of dysplasia. Regardless, LEEP and CO2 laser procedures both provide excellent cure rates overall. I would suggest you raise your questions with your gynecologist, who is in a better position to provide useful answers to your questions.

Thank you for your e-mail!

David Toub, M.D.

  Question: Bartholin Cyst Removal 
I have been suffering with repeated Bartholin abscesses and Bartholin cysts and am now investigating the gland removal procedures. No information seems to available on the laser method - is this considered the best method and what does it involve? Is it only done in certain hospitals?

The surgical removal sounds quite drastic, described on one website as painful, disfiguring and seldom done, as well as making sex painful. I am a young healthy 28 year old, would I necessarily have such negative results?

Is the best procedure to not have anything done? I have a Marsupialization done every 6-8 weeks when I have an abscess and live with a constant cyst on each side. Will I ever have sex again? will it ever not be painful?

  Answer:  
I would concur that gland excision is a fairly involved procedure that has an increased risk of bleeding (which occasionally can be quite significant and even catastrophic regardless of how expert the surgeon is). Marsupialization is usually pretty much definitive, and I cannot easily understand why multiple Marsupialization procedures are necessary unless they are becoming obstructed each time for unclear reasons.

I would first want to determine if you are diabetic, since these infections may be more common (or at least more problematic) among diabetics. In some cases, a very severe infection (necrotizing fasciitis) can occur in diabetics with Bartholin's abscesses which is often difficult to diagnose.

I am not aware that laser excision, if excision is the plan chosen by you and your physician, holds any proven advantages to more standard methods, but I don't know that it doesn't, either. In any case, a second opinion may be appropriate. Only a doctor who is familiar (in person) with your examination and medical history can make a determination as to how to proceed.

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

David Toub, M.D.

  Question: Hormonal Imbalance?
I am 39 and in general good health. My periods have been occurring every 2 wks for several months. My Dr. did a pelvic exam. He said I don't have fibroids and that I have a hormonal imbalance and should go on the Pill or have a D&C. He ran tests and they were normal. I have two questions.

1. Is it recommended to do saliva tests for hormonal imbalances?

2. What advantage is a hysteroscope over a D&C?

  Answer:  
I am not familiar with saliva tests for hormonal disorders; standard blood tests are what are generally done. As far as hysteroscopy, in many people's view a D&C should rarely if ever be done without it. That is because a D&C is a blind procedure, and even with the most careful D&C only about half of the uterine cavity is sampled. Hysteroscopy allows the clinician to see the endometrial cavity (the inside of the uterus) so that things like polyps and premalignant disorders may be picked up more readily. D&C is not a curative procedure, but is used for diagnostic purposes.

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.

 
Loading comments...
Please Wait 20 seconds or click here to close