Adhesions:
Adhesions are fibrous bands of scar tissue that can
form after surgery or trauma to certain tissues. These
bands attach themselves to your organs and tissue, causing
them to stick together, so they don't move as your body
moves. This can lead to problems such as pelvic pain,
infertility and bowel obstruction. The presence of scar
tissue doesn’t automatically mean there is pain,
however, when it inhibits movement in some way, it can
be very uncomfortable. Anyone that tells you that adhesions
do not cause pain, simply does not know what he or she
is talking about. Once adhesions are present, they can
be removed surgically. Unfortunately, there is a tendency
for them to reform, at least partially as the body heals
The amount and severity of adhesions can be significantly
reduced using a variety of surgical techniques. Severe
cases may require more than one surgery to achieve the
desired progress. More
details about adhesions
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Adenomyosis:
Whereas endometriosis is defined as the presence of
endometrial tissue outside of the uterus, adenomyosis
is defined as the presence of endometrial tissue within
the middle muscular layer of the uterus. Normally, endometrial
tissue only resides within the thin innermost layer
of the uterus. The most common symptoms of adenomyosis
are increased bleeding and pain with the menstrual cycle.
The uterus is usually slightly enlarged as well. Diagnosis
of adenomyosis can be difficult. A medical history,
physical examination, surgery findings and sometimes
an MRI can be helpful in making the diagnosis. Definitive
diagnosis is accomplished by analyzing tissue obtained
from a biopsy or from a hysterectomy.
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Autoimmune
Diseases:
Population surveys have demonstrated an increased incidence
of autoimmune diseases including rheumatoid arthritis,
systemic lupus erythematosus, Sjogren’s syndrome,
multiple sclerosis, allergies, asthma and hypothyroidism.
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Bowel Problems:
There are many bowel conditions that must be considered
in a patient with pelvic pain as dysfunction of the
bowel can result in abdominal pain often with constipation.
These conditions include chronic constipation, irritable
bowel syndrome, functional outlet obstruction, redundant
colon, diverticulitis, and colonic inertia (slow transit
time).
Chronic constipation can result from local neurogenic
disorders (irritable bowel syndrome, colonic inertia)
or systemic disease (hypothyroidism, hypercalcemia,
and porphyria). Other causes include functional outlet
obstruction in the form of rectoceole or pelvic muscle
floor dysfunction.
Irritable bowel syndrome symptoms include diarrhea,
constipation, abdominal pain, bloating and nausea. Excess
mucus production is common in IBS along with visceral
hypersensitivity, which means that normal pressure associated
with bowel function can cause pain and discomfort. There
are two basic types of IBS, constipation-predominant
IBS and diarrhea-predominant IBS. Treatment varies depending
upon the symptoms.
Functional outlet obstruction is another cause of
constipation, and results when the pelvic muscle floor
(link to pelvic floor section) and the anal sphincter
(the circular muscle around the rectum) are unable to
coordinate effectively to properly evacuate the bowel.
Anorectal manometry is used to diagnose spasm of the
anal sphincter. Defecograhphy may also be helpful in
evaluating ano-rectal function. This is an unpleasant
test in which x-ray paste is placed in the rectum and
x-ray pictures are taken during defecation. Treatment
of this condition is usually with biofeedback.
Redundant or an excess amount of colon can cause constipation
and abdominal pain. Most radiologists will consider
excess colon to be a normal variant and provide a barium
enema report with normal findings. However, more aggressive
treatment may be required when other methods have failed.
In the case of redundant colon with severe incapacitating
constipation, removal of the excess colon may be required.
Opinions vary from removal of only a small portion of
bowel to removal of the entire colon. Removal of approximately
half of the colon (large bowel) is probably required
for optimal results.
Diverticulitits is caused when the small blood vessels
which supply blood to the bowel produce a small defect
through which the inner lining protrudes or herniates
out. When one of these protrusions becomes infected,
diverticulitis results and the pain and fever symptoms
which occur can be similar to appendicitis but on the
left side. This condition has the potential for thickening
of the bowel wall. Severe cases can result in perforation
of the bowel wall or stricture which can cause bowel
obstruction.
Colonic inertia refers to the inability to sense the
need to have a bowel movement. The urge to defecate
is normally in response to the stretching of the rectum
by the feces. Chronic use of laxatives which stimulate
the urge for a bowel movement chemically can decrease
and eventually eliminate the function of the stretch
receptors, creating this abnormality.
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Chronic
Appendicitis:
Sometimes, pelvic pain results from chronic low grade
appendicitis. This is a condition that is commonly missed
by many physicians, however, I was able to discover
the true source of the pain through the innovative use
of conscious pain mapping, also know as patient assisted
laparoscopy (PAL). During this procedure, a small 2mm
laparoscope and probe is used to touch the different
organs inside the pelvis and abdomen while the patient
is awake in order to precisely locate the area of pain.
Although the appendix appeared to look normal in several
patients, it evoked pain when palpated with the probe.
After the appendix was removed in these patients, the
pathologist determined that a low grade infection was
present. The patients experience resolution of the pain
after the appendix was removed. This diagnosis may not
be routine, but is very useful when appropriately used.
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Chronic
Fatigue Syndrome:
Chronic fatigue is defined as significant fatigue or
tiredness lasting more than six months, not related
to exertion, or lack of sleep and is associated with
other symptoms. Several classification systems for definition
of chronic fatigue syndrome have been proposed (Table
of CFS definitions). A majority of patients with endometriosis
experience significant fatigue which can be a significant
part of their health care problems in addition to the
pelvic pain. Treatment can be complex and long term.
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Dysfunctional
or Abnormal Uterine Bleeding:
Bleeding can be associated with pelvic pain. Abnormal
bleeding can be caused by anatomic, hormonal and abnormal
clotting mechanisms. Anatomic problems include conditions
such as adenomyosis, endometrial polyps, endometrial
hyperplasia (a precancerous condition), endometrial
cancer, uterine fibroids or problems with the cervix
that cause bleeding. Hormonal problems include a typical
imbalance in estrogen and progesterone that can cause
bleeding. Too much or too little of either hormone can
result in abnormal bleeding. In addition to these normal
female hormones hypothyroidism (low thyroid) can cause
abnormal or dysfunctional uterine bleeding. Finally
if a patient has lower than normal clotting activity,
she may have abnormal bleeding. This includes a low
activity of von
Willibrand’s factor.
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Endometriosis:
Endometriosis occurs when the tissue that lines the
uterus (tissue called the endometrium) is found outside
the uterus on areas such as the ovaries, fallopian tubes,
and ligaments that support the uterus. This misplaced
tissue develops into growths or lesions which each month,
build up blood and tissue just like the regular menstrual
cycle. However, the blood and tissue shed from these
growths has no way of leaving the body which results
in internal bleeding, breakdown of the blood and tissue
from the lesions, and inflammation -- and can cause
pain and infertility, Recently, it has become evident
that many patients with endometriosis can have overall
body symptoms including fatigue, fibromyalgia, interstitial
cystitis, and bowel problems. I believe that effective
treatment must be approached from two directions. The
first is surgical removal of all endometrial implants.
The second is treatment of the underlying causes of
the systemic symptoms, which eventually results in restoration
of health. It is important to look at the patient as
a whole rather than as individual organ systems that
in the past have had to be treated by physicians with
that specific specialty.
Learn more about Endometriosis and how to treat it Click here
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Fibroids:
The wall of the uterus is made up of smooth muscle.
Fibroids are benign smooth muscle tumors. It is very
rare for a fibroid to turn into a cancer (uterine sarcoma).
Fibroids do not usually cause pain. Depending upon the
location within the wall of the uterus (near the inside
lining of the uterus, middle of the wall of the uterus
or near the outside of the uterus), they can cause an
increased amount of bleeding with a woman’s period,
sometimes very heavy. The uterus is usually enlarged
and irregular in shape. If the fibroids grow large enough,
they can cause similar symptoms as pregnancy, pelvic
pressure, increased urinary frequency, lower back pain
and occasionally pain with intercourse. Treatment of
fibroids, if required, is usually either by myomectomy
(removal of the fibroid with preservation of the uterus)
or hysterectomy, both of which can usually be done laparoscopically.
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Fibromyalgia:
Fibromyalgia is a widespread musculoskeletal pain and
fatigue disorder which causes most patients to say that
they ache all over. Characterized by widespread musculoskeletal
aches, pain and stiffness, soft tissue tenderness, general
fatigue and sleep disturbances, the most common sites
of pain include the neck, back, shoulders, pelvic girdle
and hands, but any body part can be involved. There
is a substantial overlap of symptoms with chronic fatigue
syndrome. Fibromyalgia is diagnosed when the patient
reports widespread pain in all four quadrants of the
body for a minimum duration of three months, as well
as tenderness or pain in at least 11 of 18 specified
tender points when pressure is applied. Symptoms commonly
associated with fibromyalgia include fatigue, post exertional
malaise (link to glossary) and muscle pain, morning
stiffness, cognitive or memory impairment, sleep disorder,
numbness & tingling, irritable bowel syndrome, PMS,
jaw pain, skin sensitivities, chronic headaches, and
dizziness or impaired coordination. The most commonly
used criteria for the diagnosis of fibromyalgia is the
1990 American College of Rheumatology’s guidelines.
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Food &
Hormone sensitivities:
Food and hormone sensitivities are not uncommon in patients
with endometriosis and pelvic pain. This is probably
a result of an increased tendency toward autoimmunity
(link & add to glossary) in endometriosis patients.
Evidence is mounting that patients with endometriosis
and associated conditions have an immune system dysfunction.
One common finding in this immune system dysfunction
is an imbalance in a subtype of the T
helper immune cells. The normal balance of
T-helper 1 and T-helper 2 cells is shifted to a predominace
of the T-helper 2 cells. This pattern is associated
with an increase in allergies an is probably the reason
patients with endometriosis tend to have a higher incidence
of allergies.
Food and hormone allergy (hypersensitivity) testing
can be performed utilizing several different methods.
Provocation/Neutralization (P/N) testing is the method
we employ at VitalCare Institute of Health for evaluating
food and hormone sensitivities. During this procedure,
carefully produced skin wheals are made for each food
tested. The whealing response with intradermal testing
normally correlates well with the presence or absence
of sensitivity to that food. Rather than just evaluating
wheal response, the patient’s symptoms are considered
as well during the testing. Provoking symptoms is not
required, but frequently occurs in this form of testing.
One food is tested at a time, rather than a whole group
of them at once in order to be more precise in the diagnosis
of food sensitivities.
Since the food or hormone is tested one at a time,
this type of allergy testing takes longer than scratch,
prick or previous forms of intradermal allergy testing.
This technique of allergy testing also becomes a form
of therapy. During this test procedure, a "neutralization
dose" is also determined. The neutralization dose
is the proper dose to alleviate the symptoms related
to ingestion of the allergic food. The symptoms that
are produced during testing are usually mild and rarely
severe. The accuracy and reliability of P/N testing
for food allergies has been documented with a multi-center
double blinded randomized study (1).
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Hernias:
A hernia is a defect (hole) or weak area in a structure.
Although they are not a common cause of pelvic pain,
they can be a contributing pain factor for a few patients.
Some physicians promote the belief that hernias are
often the cause of pelvic pain and routinely perform
"hernia repairs" during surgery which is not
supported by medical research studies. However, there
are several types of legitimate groin hernias that do
cause pelvic pain. The most common types are direct
and indirect inguinal hernias. Other types include femoral
hernias and obturator hernias. Repair of a hernia usually
involves removal of the hernia sac (and possibly a fat
pad that has formed) and placement of mesh to reinforce
the defective area. It is critical that the patient
not lift anything heavy for the first 6 weeks to allow
the mesh to heal into the body and gain strength. There
is a possibility with a hernia repair to have post-operative
neuropathy (nerve pain). This added risk should be weighed
against any potential gains prior to surgery. Post-operative
neuropathy can usually be treated with medications and
or nerve blocks, but on rare occasion can be permanent.
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Hormone
Imbalance (see menopausal symptoms)
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Hypothyroidism:
Hypothyroidism is usually an autoimmune disease (link
& add to glossary) where the patient’s own
body has attacked their thyroid gland, eventually resulting
in loss of thyroid function. Symptoms include constipation,
cold intolerance, heavy bleeding with periods (menorrhagia),
weight gain, thinning of hair and coarse dry skin. Diagnosis
is with blood tests looking at thyroid stimulating hormone
(TSH) levels, thyroid levels (T3 & T4) and thyroid
antibodies (anti-thyroid antibodies and anti-thyroid
peroxidase antibodies).
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Interstitial
Cystitis:
Interstitial Cystitis (IC) is a chronic inflammatory
condition of the bladder. The exact cause is unknown.
There is no cure for IC but there are treatments. The
classic symptoms are those of a bladder infection, frequent
urination, pain and/or burning with urination and nocturia
(getting up several times during the night to urinate).
The pain can be midline or on the side. IC can also
cause pain with intercourse. Often, IC patients have
a history of "multiple bladder infections".
On close review, this diagnosis is usually made based
upon symptoms, often without confirmation of a culture
done from an infection. Diagnosis is made during a cystoscopy
with hydrodistention. I personally do this in the operating
room under anesthesia. I have heard of it being done
in the office, but it is fairly painful. Studies have
shown up to 80% of patients with endometriosis have
IC. One reason patients continue to experience pain
after treatment of their endometriosis is that their
IC has been neither diagnosed nor treated. There are
many types of treatment for IC.
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Menopausal
Symptoms:
Menopausal symptoms are not a cause of pelvic pain,
but may be an issue in women who have undergone surgical
menopause (removal of the uterus and ovaries). The ovaries
are the primary source of female hormone production.
These hormones include estrogen, progesterone and a
small amount of testosterone. A detailed discussion
of hormone use and possible replacement is beyond the
scope of this article. This is an area that requires
a detailed understanding of the potential risks and
benefits of hormone replacement or manipulation. Estrogen
(I personally recommend the use of bio-equivalent estrogens
rather than the range of estrogens obtained from horse
urine e.g. Premarin, that has received so much attention
in the press recently) can provide relief from vasomotor
symptoms, but is not the only alternative. A variety
of other treatments are available including some herbs
such as blackcohash. The bone density should be evaluated
and if indicated should be treated either with hormonal
or non-hormonal treatment options. A cardiovascular
assessment should be performed with a lipid profile,
C-reactive protein and homecystiene level. Abnormalities
should be treated as indicated. PMS and other hormonal
induced emotional changes should be evaluated and treated
on an individual basis.
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Neuropathic
Pain:
Peripheral neuropathy is a common neurological disorder
resulting from damage to the peripheral nerves. Causes
include mechanical pressure such as compression or entrapment
to an abdominal wall nerve, which can happen following
surgery even if the surgery was completed successfully.
Common symptoms include weakness, numbness and abnormal
sensations such as burning, tickling, pricking or tingling
in the abdomen. Most often a patient with abdominal
neuropathy will experience new pain after surgery that
is in the area of one of the incisions. In other cases,
a condition known as neuroplasticity can occur where
the brain rewires itself to experience pain. The long
term sensory input of pain signals can cause an increase
in the number of nerves endings that receive this pain
information in the spinal cord. The result is that the
field of receptive nerves enlarges increasing the amount
and level of pain that the patient perceives.
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Ovarian
Vein Varicosity and Pelvic Congestion:
Pelvic congestion syndrome is a condition similar to
varicose veins in the legs where the valves in the veins
that help blood flow toward the heart do not work properly.
As a result, blood pools in the veins, which can result
in a disturbance of hormonal blood flow. The veins in
the affected body part also stretch and bulge. This
stretching of the blood vessel can result in pain, similar
to pain associated with stretching of the bowel (gas
pain). Symptoms include pelvic pressure, pelvic pain,
pain with intercourse and excessive hormonal fluctuations.
Diagnosis of ovarian vein varicosity and pelvic congestion
is confirmed at laparoscopy. More advanced cases can
be diagnosed with a pelvic ultrasound (sonogram). The
most common treatment for ovarian vein varicosity is
ligation (tying off) the ovarian vein at laparoscopy.
Since the ovary has a second blood supply via the uterine
system, tying off the ovarian vein is rarely a problem.
When all of the veins in the pelvis are involved (pelvic
congestion) then this is one situation where a hysterectomy
is indicated if a woman’s family is completed.
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Pelvic
Muscle Floor Spasm:
The bottom of the pelvis is comprised of a series of
muscles. These muscles extend from the pubic bone in
the front to the tail bone in the back. Whenever we
are in pain, the natural tendency is to tense up our
muscles. This applies to pelvic pain as well. Often,
without even realizing it, a patient is clenching the
pelvic floor muscles. Over time, months or years, these
muscles can go into spasm and become scarred and unable
to fully relax. This condition is similar to a knot
in the muscle in your back. It is not a matter of just
relaxing the muscle to make the knot go away, this is
impossible. Just as deep tissue massage is needed to
get rid of the knots (muscle spasm and muscle fibrosis)
in the back, deep tissue massage can be needed in the
pelvic area. A qualified physical therapist who deals
with pelvic pain and is experienced in transvaginal
(through the vagina) deep tissue massage of the pelvic
muscle floor is usually needed to correct pelvic muscle
floor spasms. Although muscle spasms may not seem like
a serious condition to some, anyone who has experienced
a severe spasm in the calf knows how excruciatingly
the pain can be. Imagine having this pain level constantly
in the pelvic area. This pain can require treatment
with high levels of narcotic pain medications. This
is one reason why patients can continue to experience pain after endometriosis is removed. The condition that
started the pain is gone, but this secondary condition,
which was stared because of the endometriosis, now has
a life of its own. A physical therapist with these specialized
skills can help with this last step in resolving your
pain.
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Polycystic
Ovary Syndrome (PCOS):
Polycystic Ovary Syndrome (also known as Stein-Leventhal
syndrome or functional ovarian hyperandrogenism) is
a complex endocrine disorder associated with a long-term
lack of ovulation. Recent studies have demonstrated
that PCOS is due to an underlying metabolic problem
known as insulin resistance, which drive the ovary into
producing high amounts of male hormones, creating an
unhealthy environment that causes the follicles to literally
die before mature eggs can be released. Symptoms may
include various menstrual problems, excessive body or
facial hair, endocrine abnormalities, acne, obesity,
infertility, diabetes with insulin resistance or hyperinsulinemia.
Even if specific symptoms are not causing an immediate
problem, PCOS can have significant long-term effects,
including diabetes, heart disease, and endometrial or
breast cancer, so seeking treatment is critical. PCOS
treatment decisions depend on symptoms, age and whether
or not the patient wants to become pregnant. While PCOS
usually does not cause pain directly, it does seem to
be associated with the underlying immune/endocrine dysfunction
that contributes to many of the conditions that do cause
pelvic pain.
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Primary
Dysmenorrhea:
Dysmenorrhea refers to painful periods. If a women’s
periods are painful from the start as a teenager, this
is referred to as primary dysmenorrhea. If the periods
are not painful initially but later in life become painful
then this is referred to as secondary dysmenorrhea.
Dysmenorrhea that is a result of endometriosis is usually
secondary dysmenorrhea. While endometriosis can occur
in very young women, the symptoms almost always develop
later in life, even if this is a couple of years after
the initiation of the periods while still in the teenage
years. Dysmenorrhea as a result of endometriosis is
also usually progressive in both severity and duration
of pain. A woman can have a history of primary dysmenorrheal
with progressive secondary dysmenorrheal is addition.
In this case the pain usually starts out severe and
becomes worse over time. In women who have a history
of significant primary dysmenorrhea in the midline (middle
of the body), I suggest that they consider undergoing
a prescaral
neurectomy during laparoscopic treatment
of endometriosis. Removal of the endometrial implants
will get rid of the endometriosis pain, however, it
will not remove the pain of the primary dysmenorrhea.
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Vulvodynia:
Vulvodynia is defined as chronic vulvar discomfort or
pain, characterized by burning, stinging, irritation
or rawness of the female genitalia in cases in which
there is no infection or skin disease of the vulva or
vagina causing these symptoms. Burning sensations are
the most common, but the type and severity of symptoms
are highly individualized. Pain may be constant or intermittent,
localized or diffuse. Often the vagina shows no abnormalities
or infections upon examination, and it is common for
women with vulvodynia to suffer for many years and see
many doctors before being correctly diagnosed. Vulvodynia
can be a result of chemical dermatitis (a chemical "burn")
by things that one would normally think should not be
a problem, including fabric softeners, dyes, perfume
scented products including laundry soaps and feminine
care products. In many cases the cause of vulvodynia
is not obvious and the treatment is not always effective.
A medical history and physical examination provides
the information needed to devise the course of treatment..
Vulvodynia can be associated with endometriosis, IC,
pelvic muscle floor spasm and even food sensitivities.
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Updated October 9, 2006
This page and all of the contents are
Copyright © 1996-2006 by VitalCare
Institute of Health
The information contained on this web page is considered
informational and is not intended as medical advice.
You should seek the advice and care of your local physician.
Information on this web site is subject to change without
any notice. The information on this web page may include
technical inaccuracies or typographical errors.
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