Pelvic Pain

A variety of conditions may be associated with pelvic pain. Often, it is caused by the normal functioning of a woman’s reproductive organs. At times it may be caused by urgent conditions that require emergency care, such as appendicitis or ruptured tubal pregnancy. Other times, pelvic pain may be caused by potentially serious conditions that may require treatment. Among these causes are: pelvic inflammatory disease, endometriosis, or uterine fibroids.

 

Pelvic Inflammatory Disease (PID)

Pelvic Pain names

PID; Oophoritis; Salpingitis; Salpingo-oophoritis; Salpingo-peritonitis

 

Pelvic Pain Definition

Pelvic inflammatory disease is a general term for infection of the lining of the uterus, the fallopian tubes, or the ovaries (see also endometritis).

 

Pelvic Pain Causes, incidence, and risk factors

The same organisms responsible for bacterial sexually transmitted diseases (such as chlamydia, gonorrhea, mycoplasma, staph, strep) cause 90% to 95% of all cases of pelvic inflammatory disease (PID). Although sexual transmission is the most common cause of PID, bacteria may enter the body after gynecological events or procedures such as IUD insertion (intrauterine device used for contraception), childbirth, spontaneous abortion (miscarriage), therapeutic or elective abortion, and endometrial biopsy.

In the United States, nearly 1 million women develop PID each year. It is estimated that 1 in 8 sexually active adolescent girls will develop PID before reaching age 20. Since PID is frequently underdiagnosed, statistics are probably greatly underestimated.

Risk factors include sexual activity during adolescence, multiple sexual partners, a past history of PID, a past history of any STD (sexually transmitted disease), and the use of non-barrier type contraceptives. Use of an IUD (intrauterine device) may increase the risk of developing PID at the time of IUD insertion.

Oral contraceptives (“the pill”) are thought in some cases to enhance cervical ectropion, a condition that allows easier access to tissue where bacteria may thrive. However, oral contraceptives may in other cases have a protective role against developing PID because they stimulate the body to produce a thicker cervical mucous, which is harder for semen (which may contain bacteria) to penetrate. This makes it harder for semen to transmit bacteria to the uterus.

 

Pelvic Pain Symptoms

The most common symptoms of PID include:

  • vaginal discharge with abnormal color, consistency or odor
  • abdominal pain either localized or generalized
  • fever (not always present)
    • may range from transient to constant
    • low grade to high

Other nonspecific symptoms that may be seen with PID include:

  • chills
  • irregular menstrual bleeding or spotting
  • increased menstrual cramping
  • menstruation, absent
  • increased pain during ovulation
  • sexual intercourse, painful
  • bleeding after intercourse
  • low-back pain
  • fatigue
  • lack of appetite
  • nausea, with or without vomiting
  • frequent urination
  • pain with urination
  • point tenderness

Note: There may be no symptoms. People who experience ectopic pregnancies (pregnancies where the embryo implants in the fallopian tubes instead of the uterus) or infertility are often found to have so-called “silent” PID, which is usually caused by chlamydia infection.

 

Pelvic Pain Signs and tests

A general examination may reveal fever and abdominal tenderness. Pelvic examination may reveal cervical discharge, cervical motion tenderness (pain with movement of the cervix during a pelvic exam), a friable cervix (bleeds easily), uterine tenderness, or adnexal (ovarian) tenderness.Tests include:

  • a WBC
  • an ESR (sed rate)
  • a wet prep or wet mount microscopic examination
  • a serum HCG (pregnancy test)
  • an endocervical culture for gonorrhea, chlamydia, or other organisms
  • a laparoscopy (may be needed)
  • pelvic ultrasound or CT scan (may be needed)

 

Pelvic Pain Treatment

Early diagnosis of mild PID may be treated on an outpatient basis with antibiotics and close follow-up.

More complicated cases or those involving widespread or well-established infection may require inpatient care (hospitalization). Intravenous antibiotics are used, and usually followed with a course of oral antibiotics. Surgery may be considered for complicated, persistent cases that do not respond to adequate antibiotic treatment. Concurrent treatment of sexual partner(s) and the use of condoms throughout the course of treatment are essential.

 

Pelvic Pain Expectations (prognosis)

In 15% of cases, the initial antibiotic therapy fails, and 20% experience a recurrence of PID at some time during the reproductive years.

 

Complications

The risk for ectopic pregnancy increases from 1 in 200 to 1 in 20 after having PID.

Infertility risks also increase:

  • 15% risk of infertility following the 1st episode of PID
  • 30% risk of infertility following 2 episodes of PID
  • 50% risk of infertility following 3 or more episodes of PID

 

Calling your health care provider

Call your health care provider if symptoms of PID occur. Also call if you suspect that you have been exposed to a sexually transmitted disease or if treatment of a current STD does not seem to be effective.

 

Pelvic Pain Prevention

Preventive measure include following safer sex behaviors; following the health care provider’s recommendations after gynecological events or procedures; and getting prompt treatment for sexually transmitted diseases. Sexual partners should also get adequate treatment.

The risk of PID can be reduced by getting regular STD screening exams, and by couples being tested before initiating sexual relations. Testing can detect STDs that may not be producing symptoms yet.

 

Update Date: 2007

Updated by: Bryan R. Hecht, M.D., Department of Obstetrics and Gynecology, Northeastern Ohio Universities College of Medicine, Rootstown, OH. Review provided by VeriMed Healthcare Network.

[Article from the MedLine Plus Medical Encyclopedia of the US National Library of Medicine and the National Institutes of Health.]

 

 

Endometriosis

 

Endometriosis Definition

Endometriosis is a condition in which the endometrium, tissue that normally lines the uterus, grows in other areas of the body, causing pain, irregular bleeding, and frequently infertility.

The tissue growth typically occurs in the pelvic area, outside of the uterus, on the ovaries, bowel, rectum, bladder, and the delicate lining of the pelvis, but it can occur in other areas of the body as well.

 

Endometriosis Causes, incidence, and risk factors

The cause of endometriosis is unknown. However, a number of theories have been proposed. The retrograde-menstruation theory proposes that endometrial cells (loosened during menstruation) may “back up” through the fallopian tubes into the pelvis, where they implant and grow in the pelvic and/or abdominal cavities.

The immune-system theory suggests that a deficiency in the immune system allows menstrual tissue to implant and grow in areas other than the uterine lining. Another theory suggests that the cells lining the abdominal cavity may spontaneously develop endometriosis. A genetic theory proposes that certain families may exhibit predisposing factors that lead to endometriosis.

Once the endometrial cells implant in tissue outside of the uterus, they may become a problem. Each month the ovaries produce hormones that stimulate the cells of the uterine lining to multiply and prepare for a fertilized egg (swell and thicken).

The endometrial cells outside of the uterus also respond to this signal, but they lack the ability to then separate themselves from the surrounding tissue and slough off during the next menstrual period. They sometimes bleed a little bit, but they heal and are stimulated again during the next cycle.

This ongoing process can cause scarring and adhesions in the tubes and ovaries, and around the tubal fimbriae (fingerlike projections at the end of the fallopian tubes). These adhesions can make transfer of an ovum from the ovary to the fallopian tube difficult or impossible. They can also stop passage of a fertilized egg down the fallopian tube to the uterus.

Once in a while the growing cells will penetrate the tough covering of the ovary and begin to multiply. These cells can collect large amounts of blood and form what is called, appropriately, an ovarian blood cyst (endometrioma).

Ovarian blood cysts have been known to grow to the size of a hen’s egg or even an orange, and are usually painful. Over time the collected blood darkens and, for this reason, the cysts are frequently called “chocolate cysts.”

Endometriosis is a common problem. It occurs in an estimated 10% of women during their reproductive years. The prevalence may be as high as 35% among infertile women. Although endometriosis is typically diagnosed between the ages of 25 and 35, the problem probably begins about the time that regular menstruation begins.

A woman who has a mother or sister with endometriosis has a risk of developing endometriosis that is 6 times greater than that of the general population. Other possible risk factors include early onset of menstrual periods, regular menstrual cycles, and periods lasting 7 or more days.

 

Endometriosis Symptoms

  • Increasingly painful periods
  • Lower abdominal pain or pelvic cramps that can by felt for a week or two before menstruation and/or during menstruation (the pain and cramps may be steady and dull or quite severe)
  • Pelvic or low-back pain that may occur at any time during the menstrual cycle
  • Pain during or following sexual intercourse
  • Pain with bowel movements
  • Premenstrual spotting
  • Infertility

Endometriosis Signs and testsNote: Frequently, symptoms may not be present. In fact, some women with severe cases of endometriosis have no pain at all, while some women with only a few small adhesions have severe discomfort.

A pelvic examination may reveal the presence of tender nodules, with a lumpy consistency. These are often found in the posterior vaginal wall or adnexa (ovary regions), and they may sometimes be felt in healed wound scars (especially those from episiotomy and C-section). There may be pain with uterine motion.

The uterus may be fixed or retroverted. A pelvic ultrasound test may detect an endometrioma on an ovary. A laparoscopy is necessary for a definite diagnosis, but most patients can start treatment without this.

 

Endometriosis Treatment

Treatment depends on the the degree of symptoms experienced, the extent of the disease (determined through laparoscopy), the woman’s desire for future childbearing, and the woman’s age.

Observation may be the appropriate treatment for younger women with minimal disease and symptoms. It is important to have the woman maintain a regular schedule of examinations (every 6 to 12 months) to note any changes or progression of the disease.

Treatment with medications may focus on several strategies. Analgesic therapy, treating the discomfort of the disease only, may be indicated for women with mild to moderate premenstrual pain, with no pelvic examination abnormalities, and with no immediate desire to become pregnant.

“Pseudopregnancy” (a state resembling pregnancy) may be achieved through hormonal drug regimens. This approach was developed in response to the observed regression of endometriosis during pregnancy.

Pseudopregnancy can be induced using oral contraceptives containing estrogen and progesterone. This takes 6 to 9 months and relieves most of the symptoms, but does not prevent scarring and adhesion left by the disease. Potential side effects, such as breakthrough spotting, may limit this treatment option.

Progesterone medications by themselves are another effective hormonal treatment for endometriosis. Progesterone pills or injections can be used. Possible side effects of these agents — including depression, weight gain, and breakthrough spotting, may be a problem for some patients.

“Pseudomenopause” (a state resembling menopause) was developed as a means of treatment because of the observation that endometriosis regresses after menopause. Danazol, a weak androgenic (male characteristic) hormonal drug may be used to reduce natural levels of estrogen and progesterone to low levels.

Some studies have shown that the use of danazol may be superior to the “pseudopregnancy” regimens in controlling symptoms and progression of the disease in women with moderate-to-severe endometriosis. However, due to possible side effects from danazol, it is now prescribed less often then some newer medications.

A new class of antigonadotropin drugs has been developed that also produces a “pseudomenopausal” state in women.

These drugs, such as Synarel and Depo Lupron (trade names), prevent stimulation of the pituitary for the production of FSH (follicle stimulating hormone) and LH (luteinizing hormone). This stops the ovary from producing estrogen. Potential side effects of these drugs include: menopausal symptoms (such as hot flashes), vaginal dryness, mood changes, and early loss of calcium from the bones.

Due to the effects on bone density, treatment of endometriosis with one of these agents is usually limited to 6 months or less.

Surgery (either laparoscopy or laparotomy) is usually reserved for women with severe endometriosis, including adhesions and infertility. Conservative surgery attempts to remove or destroy all of the outside endometriotic tissue, remove adhesions, and restore the pelvic anatomy to as close to normal as possible. Nerve removal (neurectomy) may rarely be performed during surgery as a means of relieving the pain associated with endometriosis.

Definitive surgery is appropriate for the woman with severe symptoms or disease, and no desire for future childbearing. This type of surgery involves abdominal removal of the uterus (hysterectomy), both ovaries, both fallopian tubes, and any remaining adhesions or endometriotic implants. Hormonal replacement therapy may be indicated after removal of the ovaries and should be tailored to the individual woman’s needs.

 

Expectations (prognosis)

Fertility rates in women with mild endometriosis are very high, even without therapy. Enhanced fertility after surgery for endometriosis depends on the extent of the endometriosis.

Pregnancy rates, achieved after conservative surgery in women previously considered to be infertile, are approximately 75% for mild endometriosis, 50-60% for moderate cases, and 30-40% for severe cases.

 

Endometriosis Complications

Infertility may result from endometriosis, but not in every patient — especially if the endometriosis is mild. Endometriosis has been known to recur even after a hysterectomy. Other complications are rare. In a few cases endometriosis implants may cause obstructions of the gastrointestinal or urinary tracts.

 

Calling your health care provider

Call for an appointment with your health care provider if symptoms of endometriosis occur, or if back pain or other symptoms recur after treatment of endometriosis.

Screening for endometriosis should be considered if your mother or sister has been diagnosed with endometriosis, or if you are unable to become pregnant after 1 year of attempting to conceive.

 

Endometriosis Prevention

There is no proven prevention for endometriosis. Women with a strong family history of endometriosis may consider taking oral contraceptive pills, as this treatment may help to prevent or slow down the development of the disease.

 

Update Date: 2007

Updated by: Peter Chen, M.D., Department of Obstetrics & Gynecology, University of Pennsylvania Medical Center, Philadelphia, PA. Review provided by VeriMed Healthcare Network.

[Article from the MedLine Plus Medical Encyclopedia of the US National Library of Medicine and the National Institutes of Health.]

 

 

Uterine Fibroids

 

Uterine Fibroids Alternative names

Leiomyoma; Fibromyoma; Myoma; Fibroids

 

Uterine Fibroids Definition

Uterine fibroids are benign tumors of muscle and connective tissue that develop within, or are attached to, the uterine wall.

 

Uterine Fibroids Causes, incidence, and risk factors

The cause of fibroid tumors of the uterus is unknown. However, it is suggested that fibroids may enlarge with estrogen therapy (such as oral contraceptives) or with pregnancy.

Fibroid growth seems to depend on regular estrogen stimulation, rarely affecting women younger than 20 or postmenopausal women. As long as a woman with fibroids is menstruating, the fibroids will probably continue to grow, although growth is usually quite slow.

Fibroids can be microscopic, but they can also grow to fill the uterine cavity, and may weigh several pounds. Uterine fibroids are the most common pelvic tumor and they may be present in 15 to 20% of reproductive-age women, and 30 to 40% of women over 30.

Fibroids occur 3 to 9 times more frequently in African-American women than in Caucasian women.

Although it is possible for a single fibroid to develop, usually there are a number of them, which begin as small seedlings spread throughout the muscular walls of the uterus.

They slowly enlarge and become more nodular, frequently intruding into the cavity of the uterus or growing out beyond the normal boundary of the uterus. Rarely, a fibroid will hang from a long stalk attached to the outside of the uterus. This is called a pedunculated fibroid, and it may twist and cause the blood vessels feeding the tumor to kink. Hospitalization and surgery may be needed in this instance

 

Uterine Fibroids Symptoms

  • Sensation of fullness or pressure in lower abdomen
  • Pelvic cramping or pain with periods
  • Abdominal fullness, gas
  • Increase in urinary frequency
  • Heavy menstrual bleeding (menorrhagia), sometimes with the passage of blood clots
  • Sudden, severe pain due to a pedunculated fibroid

Note: There are often no symptoms.

 

Uterine Fibroids Signs and tests

A pelvic examination reveals an irregularly shaped, lumpy, or enlarged uterus. Frequently, this diagnosis is reliable. However, on occasion, diagnosis is difficult, especially in obese women. Fibroid tumors have been mistaken for ovarian tumors, inflammatory processes of the tubes, and pregnancy.

A transvaginal ultrasound or pelvic ultrasound may be performed to confirm the findings.

A D and C procedure or a pelvic laparoscopy may be necessary to rule out other, potentially malignant, conditions.

 

Uterine Fibroids Treatment

Methods of treatment depend on the severity of symptoms, the patient’s age, her pregnancy status, her possible desire for future pregnancies, her general health, and characteristics of the fibroids. Treatment may consist of simply monitoring the rate of growth of the fibroids with periodic pelvic exams or ultrasound.

Nonsteroidal anti-inflammatory medications like ibuprofen or naprosyn may be recommended for lower abdominal cramping or pain with menses. Iron supplementation will help to prevent anemia in women with heavy periods. These methods are usually sufficient in premenopausal women.

Hormonal treatment, involving drugs such as injectable Depo Leuprolide, causes fibroids to shrink, but can also cause significant side effects. This method is sometimes used for short treatment periods before surgical procedures or when menopause is imminent.

The hormones produce an environment in the body that is very similar to that of menopause, with associated side effects like hot flashes, vaginal dryness, and loss of bone density.

The treatment lasts several months and during this time the reduction in estrogen concentration allows the fibroids to shrink. Fibroids will begin to enlarge as soon as treatment stops.

Hysteroscopic resection of fibroids (an outpatient surgical procedure) may be appropriate for women with fibroids growing within the uterine cavity. In this procedure, a small camera and instruments are inserted through the cervix into the uterus to remove the fibroid tumors.

Uterine artery embolization is a new procedure aimed at preventing the need for major surgery. Small catheters are placed through veins in the pelvis and advanced to the arteries that supply the uterus with blood.

Materials are then injected to block these arteries permanently. The decreased blood supply to the uterus may prevent further growth of the fibroids and may cause them to shrink. The long-term effects of this procedure are still unknown, and the safety of pregnancy after this procedure is questionable.

A myomectomy, which is a surgical procedure to remove just the fibroids, is frequently the chosen treatment for premenopausal women who want to bear more children, because it usually can preserve fertility.

Another advantage of a myomectomy is that it controls pain or excessive bleeding that some women with uterine fibroids experience. However, a myomectomy often cannot remove very small fibroids that may grow and cause symptoms in the future.

A total hysterectomy, which involves removal of the uterus, is a curative option that is often chosen by older women.

 

Uterine Fibroids Expectations (prognosis)

Prior to menopause, fibroids are likely to grow slowly. Women with known fibroids who choose to have children may be advised to become pregnant in early adulthood.

As a general rule, fibroids don’t interfere with fertility. However, a tumor sometimes blocks the fallopian tubes and prevents sperm from reaching and fertilizing eggs. In some cases, fibroids may prevent a fertilized egg from implanting in the uterine lining. However, proper treatment may restore fertility.

After a pregnancy is established, existing fibroids may grow due to the increased blood flow and estrogen levels. These usually return to their original size after the baby has been delivered.

Most women are able to carry their babies to term, but some of them end up delivering prematurely because there is not enough room in the uterus to sustain full term.

Cesarean section may be needed for delivery since fibroid tumors can occasionally block the birth canal or cause the baby to be positioned abnormally. After menopause, new fibroids rarely develop and those already present usually shrink.

 

Uterine Fibroids Complications

Fibroids may cause infertility because they can interfere with conception or implantation. They may cause premature delivery because of decreased area within the uterus. Severe pain or excessively heavy bleeding with fibroids may necessitate emergency surgery.

Rarely, malignant changes may occur. These usually take place in postmenopausal women. The most common warning sign is rapid enlargement of a fibroid and definitive diagnosis is usually not made until the time of surgery.

 

Calling your health care provider

Call your health care provider if gradual changes in your menstrual pattern occur (heavier flow, increased cramping, bleeding between periods), or if fullness or heaviness develops in your lower abdomen. Frequently there is associated pressure or discomfort and occasionally interference with normal urination frequency.

 

Update Date: 2007

Updated by: Robert L. Debernardo, M.D., Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA. Review provided by VeriMed Healthcare Network.

[Article from the MedLine Plus Medical Encyclopedia of the US National Library of Medicine and the National Institutes of Health.]