by Tamer Seckin, MD
Endometriosis Excision Surgeon / Seckin Endometriosis Center (SEC)

Pelvic & Uterine Pain

Our endometriosis specialists work with patients to understand symptoms, diagnosis, and treatment options for endometriosis.

What is Pelvic Pain?

Pelvic pain originates from the layer of tissue covering organs and their connecting structures in the pelvis, mainly the peritoneum (the membrane lining the cavity of the abdomen and covering the abdominal organs). Pelvic pain can also include pain that comes with dysmenorrhea (painful cramps during menstruation), menorrhagia (excessive menstrual bleeding) and dyspareunia (pain with sex), all of which are common symptoms of endometriosis.

Classification

While there is no specific classification system for pelvic pain, there are certainly different levels of pelvic pain and cramping that women can experience.

While most women experience mild cramps, not all cramps are painful. However, for women with endometriosis, the symptoms of pelvic pain and cramping will often be more excessive, as pain during menstruation can worsen with increased menstrual flow. When pelvic pain is experienced during the initial implantation stages of endometriosis, before deep infiltrating endometriosis or invasion, the pain is nonspecific and very commonly associated with gastrointestinal symptoms such as nausea, vomiting, bloating, gas, or diarrhea.

In later stages of deep infiltrating and invading endometriosis, chronic pelvic pain can be accompanied by such severe symptoms as constipation, painful bowel movements, and painful intercourse. In fact, sometimes chronic pelvic pain can become so intense that it is referred to as "killer cramps," which causes severe cramping and heavy bleeding.

Causes

Female pelvic pain can be caused by a multitude of reasons, but it is very common for the pain to be caused by the dysfunction of abdominal and pelvic organs due to ovarian endometrioma or deeply infiltrating endometriosis. Deeply infiltrating endometrioma leave scar tissue on abdominal and pelvic organs, as well as the peritoneum. This invading uterine tissue can ultimately play a role in both pelvic pain and organ functionality.

Endometriosis pain is always pelvic in location and usually occurs with menstruation. Retrograde menstruation is the most commonly held theory as to how pelvic pain arises from endometriosis. Every month, a normal uterus sheds its lining (endometrium). The lining is then expelled out of the cervix with minimal backflow of the endometrial cavity contents. However, in some cases, it is believed that the volume of menstrual debris taken back into the uterus is excessive and can lead to endometriomas growing in and scarring either the uterus (adenomyosis) or areas outside of the uterus (endometriosis), as well as in other locations. There are many gynecological conditions that can cause pelvic pain. Nevertheless, it is widely believed that retrograde menstruation can be the main mechanism for said conditions.

Risk Factors

Having any of the following disorders, or family history of such, can increase a patient's chances of experiencing pelvic pain:

• Endometriosis

• Adenomyosis

• Fibroids

• Pelvic Inflammatory Disease (PID): An infection of the female reproductive organs, such as the uterus, fallopian tubes, or ovaries. PID often occurs due to complications of sexually transmitted diseases that harm the vagina and spread internally to the uterus and other locations. It is one of the main preventable complications that can cause infertility.

The following are personal risk factors that researchers have found can increase a patient's chances of pelvic pain:

• History of physical or sexual abuse

• History of radiation or surgical treatment to the abdomen and/or pelvis

• History of anxiety, depression, or other psychosomatic symptoms

• History of miscarriages

• Infertility

• Long duration of menstrual flow

SYMPTOMS

• Pelvic pain or cramps, especially during your period

• Pain during sex (dyspareunia)

• Pain during menstruation (dysmenorrhea)

• Painful bowel movements (dyschezia)

• Painful urination (dysuria)

• Vaginal bleeding

• Rectal bleeding

• Lower back pain

• Infertility

DIAGNOSIS

Diagnosing

• Medical History: The simplest way for a physician to gain an understanding of the severity and probable cause of your pelvic pain is by providing them with your full medical history. This includes describing the type of pain, the frequency of symptoms, and any other past medical or family history.

• Pelvic Exam: This thorough exam of the female pelvic organs is the simplest way for a doctor to understand the intensity and point(s) of tenderness when it comes to your pelvic pain. This will be conducted in any comprehensive physical exam if a patient is displaying any gynecological signs or symptoms.

Diagnosing the Cause

• Lab Tests: Your doctor will most likely order labs along with conducting a comprehensive physical exam. These labs can include blood work, urinalysis, and other tests to check for any infection such as PID, gonorrhea, chlamydia, etc., which all may be probable causes of pelvic pain.

• Ultrasound/Sonogram: An imaging test that provides a picture of inside the uterus. This is a useful test for pelvic pain caused by endometriosis, adenomyosis, fibroids, and other intrauterine diseases that are impossible to detect via just pelvic exam and lab work.

• MRI: This test provides more clear and precise imaging than ultrasound and is extremely useful in confirming that a patient's pelvic pain is most likely due to diseases such as endometriosis, adenomyosis, etc. However, due to its high cost and the many possible reasons behind pelvic pain, this test is recommended only after you have been advised by a physician following a comprehensive physical exam and lab work.

TREATMENT

It is crucial to determine the cause of your pelvic pain, as it will determine your treatment plan.

Non-surgical:

Drugs: There are a number of medications that can be prescribed to relieve pelvic pain:

• Painkillers: These are often prescribed to help reduce pelvic pain, but it is important to note that they will not treat the cause of your pelvic pain, especially in cases of chronic pelvic pain. Painkillers range from analgesics such as nonsteroidal anti-inflammatory drugs (aspirin or ibuprofen) to prescribed narcotics (Vicodin or Percocet).

• Birth Control: When a patient's pelvic pain occurs during specific times in their menstrual cycle (when different hormone levels are rising and falling), birth control or hormonal medications may be used to attempt to control this process. This has been shown to reduce female pelvic pain in some cases.

• Antibiotics: These prescribed medications are only given in cases of pelvic pain caused by an infection in order to treat the PID.

• Antidepressants: Studies have shown that antidepressants can reduce pelvic pain, even for patients who do not have depression. However, antidepressants primary treat depression that arises on account of pelvic pain, and do not address the pelvic pain itself.

Surgical:

When a patient wants treatment for pelvic pain caused by endometriosis, adenomyosis, fibroids, etc. (as opposed to an infection), surgery is often the most advised method. Surgeries can vary depending on a patient’s diagnosis:

• Laparoscopic deep excision surgery: If performed well, this surgical technique is the most extensive in removing all scar tissue in cases of pelvic pain caused by endometriosis and focal adenomyosis.

• Myomectomy: This surgery removes fibroids, which in turn can relieve pelvic pain.

• Hysterectomy: This procedure involves partial or complete removal of the uterus and is only necessary in cases of pelvic pain caused by severe, diffuse adenomyosis. A hysterectomy should always be a last resort, especially in cases of pelvic pain.

OUR APPROACH

Due to the myriad causes of pelvic pain, we believe that doctors must always first have a detailed discussion with their patient about their current symptoms and medical history, followed by a comprehensive pelvic exam and ultrasound. You are also advised to bring recent basic lab results and any imaging results, especially MRI. These will help us to better identify the probable cause of your pelvic pain.

When patients come to us, they are most often in need of surgical treatment. Our preferred method is laparoscopic deep excision surgery. Using this technique, we are able to remove all endometrioma, and we are often able to relieve patients of their chronic pelvic pain. However, pelvic pain can come from a variety of sources. It is important to find a surgeon who can not only operate with attention to detail, but also is patient and willing to discuss your medical history, symptoms, and complaints. By opening up to discussion, we are able to work with our patients in order to find and treat the most probable source of their pain.

PATIENT STORY

Lindsay G. was experiencing severe pelvic pain for years and was told her symptoms were "just her." After a history of ovarian cysts and surgical removal of one of her ovaries, Lindsay came to Dr. Seckin, who performed laparoscopic deep excision surgery on her in the spring of 2016. Read about Lindsay's experience leading up to her surgery with Dr. Seckin.

You can read more stories of patients with pelvic pain, at varying stages, in our testimonial section.