Women's Health Articles - Pelvic Pain

Hysterectomy for Endometriosis in Young Women

Frederick R. Jelovsek MD

Endometriosis can be associated with a variety of pain problems such as painful menstrual cramps, pain with intercourse, painful bowel movements, painful urination, generalized pelvic pain, low back pain and even leg pain. For this reason, many women end up having a hysterectomy as treatment for endometriosis, especially if they have not responded to medical therapy and the pain is chronic, debilitating, and alters a woman's daily work or leisure activities. While most women do not undergo hysterectomy until after they are past their childbearing years, some women must "face this choice" at a young age, perhaps before childbearing is completed, because it is their only hope for a permanent pain cure. If a woman ends up having a hysterectomy for endometriosis before age 30, what can she expect?

This was looked at in a study by MacDonald SR, Klock SC, Milad MP: Long-term outcome of nonconservative surgery (hysterectomy) for endometriosis-associated pain in women <30 years old. Am J Obstet Gynecol 1999;180:1360-3, in which they reviewed their experience of women under age 30 who underwent a hysterectomy for endometriosis and compared that to women over 40 who also underwent hysterectomy for endometriosis. Because this was a long term follow-up study (average 4 years for the younger group and 9 years for the older group), there were low survey response rates in the two groups (21%, 29%). This aspect plus several other design problems with the study, led scientific discussants of this paper to strongly criticize findings and conclusions. While I somewhat agree that findings about comparison of the two groups is not totally valid, we can learn a great amount by just looking at a description of the findings in younger women. It allows us to understand what to expect if a young woman chooses to undergo hysterectomy for endometriosis-associated pelvic pain.

In this study, 80% of the women under age 30 reported that the hysterectomy completely cured their pain. On the other hand, 50% of the women still admitted to painful intercourse (dyspareunia). It is not clear if that was due to low estrogens if the ovaries were also removed at the time of hysterectomy, but it must temper the 80% report of being pain free.

While the measurement scores of depression tests were no different for younger women having hysterectomies than for older women having hysterectomies, and no difference in the proportion of women seeking psychiatric counselling (22-25%), there was a much higher rate of reporting a sensing of loss in the years following hysterectomy. This is not surprising considering only 37.5% of the younger women completed their childbearing versus 84.6% of the age over 40 who completed their childbearing. Thus there are definitely some emotional issues that come up because of the hysterectomy at a young age.

While the overall cure rate for pelvic pain was about 80-85%, younger women reported a higher rate of pain with bowel movements (18.8% vs 7.4%), more pain with sex (50% vs 17.4%), and even more pain with urination (18% vs 0%). This study cannot lead us to a reason for more pain except perhaps to suspect that the younger women might have had more severe disease that led to their early hysterectomy. The take-home point is that hysterectomy alone will not rid a woman of all endometriosis pain. Many women will still experience some vaginal, urinary and bowel pain which you would not necessarily expect to be cured with hysterectomy.

There is a good chance (37.5%) that a younger woman will regret having a hysterectomy for endometriosis. Even the older women had some regret - 18.5%. Whether this is to be expected or is a number that can be reduced through counselling or other means remains conjecture. The best that can be said is that the decision needs to be thoroughly weighed and carried out without haste after receiving the best information possible to make that decision.

Muscle Pain Presenting as Pelvic Pain

Frederick R. Jelovsek MD

Many women do not realize that pelvic pain can actually be due to muscle problems in the abdominal wall or even back problems of the spinal discs or bones that are referred or perceived as being in the pelvic area. This type of pain is broadly categorized as myofascial pain. Some doctors fail to thoroughly evaluate this possibility as a cause of chronic pelvic pain.

A recent article, Myers CA: Musculoskeletal factors of chronic pelvic pain. OBG Management 1999; Feb:10-12, gave us some information to answer questions about this uncommon cause of pelvic pain.

The spinal cord is a complex electrical connection system. The nerve roots of the spinal cord send off neurons that sense pain from skin, muscles, bones, ligaments and internal pelvic organs. The same spinal nerve roots that innervate the ovaries may also innervate abdominal wall muscles. Low back pain can arise from pain in the uterus, bladder, faloppian tubes, and cervix because the same nerves innervate those organs as well as the lumbar discs, ligaments and muscles. Conversely, abdominal wall pain, especially around an incision, may actually feel as if it is arising from the uterus or deeper in the pelvis when its origin is from the skin near an incision. Neurologists think that sometimes the spinal cord just gets confused when there are many pain impulses coming in and by the time your brain perceives the pain, it cannot tell whether the source is in the internal organs or the external muscles.

There are also internal muscles lining the pelvic bone such as the piriformis, puboccocygeus, obturator internus and externus muscles. The muscles can present with cramps and achiness and a woman perceives the pain as uterine or ovarian.

Certain questions help to categorize the pain as more likely to be musculoskeletal in origin rather than urogenital organ in origin if:

• you have a history of musculoskeletal injury to the back, hips or knees.
• your occupation is sedentary or labor intensive.
• you have repetitive musculoskeletal or postural stressors.
• physical activity worsens or lessens the pain.
• positional changes (lying to sitting, sitting to standing) worsen or relieve the pain.
• the pain changes with the time of day.
• there is noticeable muscle weakness or numbness or tingling.
• there is a history of inflammatory or collagen vascular disease such as rheumatoid arthritis or lupus.

If there is any abnormal curve in the spinal canal such as a curvature to the right or the left (scoliosis), excessive curve of the thoracic spine like a hunch-back (kyphosis) or increased arching of the small of the back (lordosis), these changes make it more likely for the pain to be musculoskeletal. The doctor will also have you lie flat on an exam table, raise your knee and will rotate the knee from side to side to see if any of the internal and external hip rotators are tight and cause pain with rotation. Next you will be asked to bring the one knee up to the chest. If the straight leg whose knee is not being raised comes up off the table or gives pain, this means the iliopsoas muscle and/or the rectus femoris (hip flexor) muscles are tight and may actually be the source of deep pelvic pain mistaken for internal organ pain. The doctor will also check for any pain in the abdominal muscles and touch the skin of the abdomen and back to see if there are places on the skin that "trigger the pain".On pelvic exam the doctor will have you try to tighten the muscles around two fingers placed in the vagina and will palpate the muscles of the interior pelvic wall to see if any of them are exquisitely tender. All of these screening exams can be checked for by you at home to see if they are abnormal.

Certain postural problems, especially kyphosis and lordosis, have been clinically correlated with pelvic pain as have other muscle weaknesses and spasms. Treatment of those problems has also been shown to help the pelvic pain. If there is any suspicion that pelvic pain has a myofascial cause, a woman should be referred to a physical therapist for a more in-depth evaluation and plan for treatment. Physical therapy and muscle exercises can significantly help these problems.

Trigger points are areas of skin on the abdominal wall that follow along one dermatome, the area of skin innervated by one specific nerve root. When touching them lightly even with a Q- tip, pain is elicited that feels as if it arises deep in the pelvic organs. When these areas are injected with a local anesthetic, there is pain relief that lasts longer than the expected duration of the specific anesthetic used. After about 5- 6 weekly injections or less, the pain totally goes away. This is thought to work somewhat like acupuncture in that the pain sensation the level of the spinal cord gets rearranged to know that the pain does not actually arise in the pelvic organ where it is perceived.

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Painful Sex and Vulvar Skin Disease

Frederick R. Jelovsek MD

Painful sexual penetration, dyspareunia, is not only an extremely aggravating medical problem, but is also a very difficult symptom for doctors to treat. Once painful sex starts, the body and emotions react physiologically to produce vaginal dryness and vulvar contraction, which in turn make pain with sex even worse. After a while, who is to say which came first - the emotional stress that causes painful sex or the medical condition that causes pain first and then increased pain with sexual penetration?

A recent journal article, Marin MG, King R, Dennerstein GJ, Sfameni S: Dyspareunia and Vulvar Disease. J Reprod Med 1998; 43:952-58, is able to answer a few questions along this line.

• unaroused sex - without adequate sexual stimulation, the normal physiologic processes such as increased vaginal lubrication, relaxation of the pelvic floor muscles, enlargement of the vaginal space, and engorgement of the labia which reveals the vaginal opening, do not take place making sexual penetration much more difficult.
• medical disease - e.g.,yeast infections.
• vulvar skin damage - e.g., frictional or chemical trauma, contact or irritant dermatitis.
• hormonal - e.g., breast feeding, menopausal estrogen deficiency status, use of DepoProvera® for contraception or ovarian or endometriosis suppression.
• emotional - distress, anxiety, anger, depression, personality style

How does painful sex develop?

In the beginning there is an original cause of dyspareunia. Once the pain is produced, however, there is a psychological distress, and a fear of pain again with each attempt at sexual intercourse. This distress in turn causes a lack of arousal which inhibits the normal sexual lubrication and vaginal muscle relaxation and dilatation. These factors in turn reinforce the pain with sex that occurred in the first place. As you can see, after awhile the original cause may disappear but the painful sexual relations persists. Then the doctor can't find an abnormality and doesn't know how to medically treat this problem.

In this study by Marin et al., they looked at the different diagnoses in women who presented to a dermogynecology clinic and had a primary complaint of pain with sexual penetration. Of those women in whom a physical, visual change was found in the vulvar skin at the vaginal opening, the following diagnoses were assigned:

If my doctor can't find a cause for pain with sex, does that mean it can't be treated?

No. Marin et al, found no differences between groups of women with and without vulvar skin findings and pain with sex with respect to stress, anxiety or depression. In each group, about 40% of the woman perceived an increase in symptoms with stress. Women with vulvar skin conditions had more stress at the time of onset of their symptoms and women without any skin problems had less coping skills, but for the most part all the women need the same treatment regardless of whether there is a visible vulvar disturbance. Education is needed to make sure that sexual behavior changes so that the pain problem is not aggravated, i.e., stop having sexual relations if it causes pain. from 82 to 98% of women in these groups continued having sex even though there was no desire.

The stress, depression and coping skills all need to be treated whether there is a vulvar skin problem or not. If there is a chance to offer or receive these therapies early in the disease process, it needs to be taken. Once vaginismus (involuntary vaginal muscle tightening) starts, the cycle is very difficult to break.

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Does Endometriosis Always Cause Pain?

Frederick R. Jelovsek MD

Pelvic pain is estimated to be responsible for almost 25% of gynecology visits. When a laparoscopy is performed and mild or minimal endometriosis is found, doctors and patients alike may attribute the pain to the endometriosis when in fact, the endometriosis is asymptomatic and not the cause of the pain. We know that up to 15% of women may have endometriosis without having any pain symptoms. How then, do we determine when endometriosis is present, whether it is the cause of pelvic pain so we can stop looking for another cause.

In a recent clinical commentary article, Hurd WW: Criteria that indicate endometriosis is the cause of chronic pelvic pain. Obstet Gynecol 1998;92:1029-32, several conditions are identified that should be met before attributing chronic pain to endometriosis:

• the pelvic pain should be cyclical, worsening right before and during menses
• the endometriosis should be diagnosed surgically, not just by clinical history and pelvic exam alone
• appropriate treatment of endometriosis should be associated with a prolonged pain relief (not resume immediately after stopping medical therapy for example)

Cyclical pain - The nature of pain production by endometriosis is not completely known but the implants are hormonally receptive to varying levels during the normal menstrual cycle. Sometimes pain with a period can just be due to high intrauterine pressure caused by the uterine muscle cramping to expel menstrual tissue. If there is any degree of cervical narrowing (stenosis) that acts to block the quick expulsion of tissue, intrauterine pressures get extremely high and cause pain independent of any endometriosis present. While endometriosis can cause pain and painful intercourse throughout the entire menstrual cycle, if there is no worsening at the time of menses, chronic pain is very less likely to be due to endometriosis.

Diagnosis by surgery necessary - Although history and physical exam and even response to medical therapy that blocks ovulation can be suspicious for the diagnosis of endometriosis, these criteria often prove to be wrong when surgery is finally undertaken. Medical therapy that blocks ovulation will help dysmenorrhea of any cause, not just that of endometriosis. A second question that occurs, does endometriosis need to be diagnosed by biopsy at the time of surgery? If there are obvious blue or red spots (powder burns), the general consensus is that it is not cost effective to biopsy. If, however, there are just the hint of tiny clear vesicles, then a biopsy may be needed to confirm the diagnosis. Keep in mind that these clear vesicles may represent minimal endometriosis which is not actually responsible for pelvic pain compared to the blue and red forms of endometriosis.

Prolonged pain relief from adequate treatment - Whether medical or surgical resection is chosen for endometriosis treatment, the average duration of significantly decreased pain symptoms is about 10 months after cessation of medical therapy or the date of surgical therapy. Since many women have a 1-3 month period of pain reduction after laparoscopy in which no pain cause was found, recurrence of pain less than 6-8 months after surgery or discontinuance of medical therapy, should be viewed with suspicion that the pain is caused by endometriosis. Many physicians and women are mislead by temporary pain relief with ovulation suppression medications and assume that if the pain resumes immediately after therapy, that means endometriosis is recurring and causing the pain.

On the basis of studies of asymptomatic and symptomatic women, it is possible that some endometriosis may be a normal variant in some women. If you have endometriosis and pain, it may be wise to see if your pain meets these criteria; if not, you and your doctor may need to continue looking for causes of your pain.

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Painful Intercourse Due to Vulvar Vestibulitis

Frederick R. Jelovsek MD

Painful intercourse can be divided into two major categories:

• pain right at the entrance to the vagina -- see superficial dyspareunia
• pain deep in the pelvis -- see deep dyspareunia

Of the diagnoses associated with painful intercourse at the entrance to the vagina, one of the most difficult to diagnose is vulvar vestibulitis. Vestibulitis stands for inflammation of the vestibule of the vagina which is the moist pink skin area just in front of the hymen and goes to where the dry skin starts. It is usually less than an inch (2 cm.) wide and extends from about 3 o'clock to 9 o'clock around the vaginal opening. In vulvar vestibulitis, this area gets so sensitive that even touching it with a Q-tip (cotton-tipped applicator stick) elicits moderate to severe pain.

The diagnosis is often missed because aside from some redness of the skin and the pain, there are no signs of infection, bleeding, discharge or any lesions that can be seen or felt. If a vestibule biopsy is performed it only shows inflammatory cells and slightly increased blood vessel supply under the microscope.

In a recent article, Westrom LV and Willen R: Vestibular nerve proliferation in vulvar vestibulitis syndrome. Obstet Gynecol 1998;91:572-6, these authors did special nerve stains on the biopsy tissue of vestibule skin. They found increased numbers of nerve fibers present. These are similar findings to what investigators have found in Crohn disease (an inflammatory condition of the bowel) and interstitial cystitis (a chronic inflammatory condition of the bladder which produces pain and frequent urination without a bacterial infection present). The increased number of nerve endings may explain the increased pain that is present.

The significance of this report is that physicians may have a new way of confirming their clinical impression of vulvar vestibulitis by asking their pathologist to do a nerve stain (S-100 immunostain was the one used in this study) on the biopsy specimen in addition to the regular microscopic exam. If there appears to be increased nerve proliferation on the biopsy specimen, that would add certainty to the diagnosis. Keep in mind that the doctor can make the diagnosis on just clinical findings.

Ultrasound Diagnosis of Pelvic Endometriosis

Frederick R. Jelovsek MD

Do you need to have a surgical procedure in order to diagnose endometriosis? The answer has always been yes -- diagnostic laparoscopy. Endometriosis can be suspected from symptoms such as the new occurrence of menstrual cramps, or painful sexual relations or even on pelvic exam, but the definitive diagnosis has been surgical observation and biopsies. A recent article, Fedele L, et al. Transrectal ultrasonography in the assessment of rectovaginal endometriosis. Obstet Gynecol 1998; 91:444-8, has suggested a new imaging method to make the diagnosis in some cases.

Pelvic and/or back pain, pain with deep penetration during intercourse and rectal bleeding during menses may be signs of endometriosis that has grown deeply into the wall between the vagina and rectum. It occurs relatively infrequently, but when it does, it may be missed at surgical exploration. It can also be missed using traditional diagnostic studies such as transabdominal or transvaginal ultrasound, rectosigmoidoscopy, computerized tomography (CAT scan) or magnetic resonance imaging (MRI).

Fedele and others from the University of Verona, Italy, looked at 140 patients scheduled for surgery for possible endometriosis, using rectal ultrasound. This is a test using sound waves in which a probe about the size of a large finger is put into the rectum. The study should take less than about 5 minutes. The doctors look for areas between the rectum and the vagina and cervix that represent nodules of endometriosis. All patients had the ultrasound study within one week of their surgery. About one fourth of the patients 34/140 had surgical evidence of rectovaginal endometriosis and ultrasound had correctly diagnosed 33 of the 34 patients (sensitivity 97%). Of the other 106 patients, 15 had no evidence of endometriosis and 91 had superficial abdominal lining or ovarian endometriosis but not infiltrating into the rectovaginal septum. The rectal ultrasound was negative in 102 of those 106 patients (specificity 96.2%). As tests go this is fairly accurate.

If these studies can be repeated by other investigators, this may become a more common diagnostic test when a physician suspects endometriosis.