Period Pelvis Pain
Frederick R. Jelovsek MD
" I have lower right abdominal pain 3 days each month, 7-10 days before my period. I have had an internal ultrasound which was negative. Any ideas what might be causing this? Also the pain mostly happens at around 1:30-2:30 in the a.m.
My last 2 periods have been 21 days apart. I am 45 years old. Normal light periods lasting around 3-5 days. Usually 24-26 days in-between cycles. No medications. ". Laurie
Cyclical pain in a reproductive age woman almost always has something to do with the menstrual cycle. Any abdominal or pelvic pain occurring monthly should be examined to see what changes of anatomy and physiology may be responsible for causing the pain.
Many times the diagnosis of such pain is very difficult unless diagnostic studies are used or exploratory surgery such as laparoscopy is performed to look inside the abdomen. The exact timing of when and how long the pain occurs in relation to a monthly menstrual cycle can often be a clue as to what types of pathology to look for on the imaging studies or surgery.
What would cause pain occurring 7-10 days before menses each month?
In the week or two prior to menses a corpus luteum cystic gland forms on one of the ovaries at the site where an egg was released from that ovary. This is a hormonally functional gland that produces progesterone primarily. The gland causes the ovary to become larger and heavier for a while until the cystic area goes away when menses starts.
The other main pelvic change in the week or two prior to menses is that the veins of the pelvis often swell (dilate) under the influence of progesterone. They can become like varicose veins of the pelvis and sometimes will produce a throbbing pain, but which lasts throughout most of the last week of the cycle.
Since your pain only lasts for 3 days and it does not start 14 days before your menses but rather 7-10 days, the best guess as to cause would be that the pain has to do with the enlarging ovary on the right. You would expect the pain to alternate sides if it were due to a corpus luteum gland because ovulation usually alters one month from one ovary and one month from the other. However we have seen ovulation occur pretty regularly from only one ovary even though there appears to be no disease in the other one. Pain occurs when the enlarging ovary "pulls" on any adhesions of the ovary to the surrounding tissue or simply when it stretches the ovarian capsule fairly rapidly. Adhesions cannot be seen on ultrasound or any xrays but if you have your pelvic ultrasound during the 3 days you are having pain, I would expect to see a cystic area (small) on the right ovary if that is where you are having pain.
I cannot attach any significance to the pain occurring in the early morning hours.
My pain occurs mostly at the time of my menstrual flow and goes away after it is over? Does this mean I have endometriosis?
At the time of menses, hormone levels fall and uterine skin lining (endometrium) sloughs. This produces bloody menstrual tissue called menses as long as the tissue can exit the body. If there is any blockage to egress, pain is the result. Several different conditions can block menstrual egress and thus result in painful menses:
- primary dysmenorrhea (menstrual cramps) - the cervical opening is not large enough for the volume of menstrual tissue in a given unit of time so uterine pressure builds up producing cramps until the tissue gradually comes out
- cervical stenosis - in this case the cervical opening has some scarring due to past procedures (LEEP, cryosurgery, conization) rather than just a tightly contracted cervix found in primary dysmenorrhea
- congenital anomalies of the reproductive tract - any anomaly that blocks outflow of menses
- endometriosis - endometrial tissue has implanted in the peritoneal/abdominal cavity and when the tissue is sloughed at the end of the month it has no place to go so it just stays and irritates the pelvic lining producing pain.
- adenomyosis - instead of endometrial tissue being in the pelvic cavity, little islands of glands have grown down into the uterine muscle and like endometriosis, when the tissue is sloughed, it has nowhere to go and only produces an inflammatory response.
I get pain lasting for a day or two about 2 weeks after my period. What would cause that?
At midcycle, 2 weeks before or 2 weeks after a menses, the main physiologic event is ovulation. Most women are not aware of ovulation but some are on a regular basis. When noticeable pain happens at midcycle, physicians often attribute the pain to a small amount of bleeding that can occur from the site of egg ovulation. Usually this type of pain alternates from side to side in different months although it can present consistently on one side if ovulation seems to favor one ovary.
I get pelvic discomfort lasting for two weeks prior to my menstrual period. Is this PMS?
If one looks in the pelvis with a laparoscope in the 2nd half of the menstrual cycle in a woman who has severe PMS symptoms, the most common finding is a normal appearing pelvis. Sometimes there are large dilated pelvic veins almost to the point of being pelvic varicosities. There still is controversy among physicians as to whether pelvic varicose veins cause pain. This is also sometimes referred to as pelvic congestion syndrome.
Newer studies using advanced imaging techniques of MRI, CAT scans and doppler ultrasound have rekindled treatment of these large veins to see if pelvic pain may respond. Embolization of the veins (1, 2) and even laparoscopic ligation (3) have been used to treat this pain but as yet there have not been randomized trials.
Are there other non gynecological of cyclic pelvic pain?
The above clues as far as timing on pelvic pain and what that pain is due to are just guidelines. Many times gynecological conditions will have atypical timing presentations so that you and your physician have to always keep in mind the many possible reproductive causes.
In addition, there can be cyclical pain presentations from non-gynecological causes. Some of those described include:
- spinal cord disc disease or tumor (4).
- irritable bowel syndrome - symptoms can be much worse around the time of menses (5).
- somatic musculoskeletal pain - different muscles and nerves of the abdominal wall can also present cyclically (6).