Ask The Expert

September 17, 2006

I am a 31 year old female that has Congenital Adrenal Hyperplasia. I have been suffering from pain in the lower right abdomen for two years.

Question fromHJ : Congenital Adrenal Hyperplasia Dear Dr. Toub,
I am a 31 year old female that has Congenital Adrenal Hyperplasia. I have been suffering from pain in the lower right abdomen for two years. I also suffer from some form of infection (not yeast) as this has been ruled out. I just had a test done with the microscope and my uterus was covered in a horse shoe shape by something but the test came back normal. I am not a complainer by nature but at times all I can do is cry. Is there something the doctors are missing? Please, any advice would be helpful.
Thank-you,

H.J.

Answer from Dr. Toub: There are many possibilities, ranging from endometriosis, chronic appendicitis (always a concern with right lower quadrant pain), GI problems, ovarian cysts, fibroids, pelvic adhesions, and many others too numerous to list. There are some basic evaluations that need to be done, the most important of which, in my opinion, is a good medical history and physical examination. It is helpful to seek out physicians who are comfortable with treating chronic pain-usually they are associated with academic teaching hospitals in this country (and I'm sure it is no different in the UK). Don't give up-there is a lot that can be done, but first an extensive evaluation must be undertaken to know how to approach the problem.

Good luck, and thank you for your e-mail!

David Toub, M.D.

  Question from Sherry: Laparoscopic Surgery and Pain Dr. Toub,
In May, I had laparoscopic surgery because my gynecologist thought I had a dermoid cyst on my left ovary. I originally went in complaining of pain on my right side. They ruled out appendicitis or kidney stones. After surgery, I was a solid bruise from my navel to my leg. Since surgery, I have had pains on my left side. I tried to return to my job and found I could no longer lift and bend constantly, without pain. I even have pain when I am just sitting. I went back to the doctor numerous times. They say I have chronic pelvic pain. It has been almost three months now and I still hurt. My lowest incision is still infected and does not dry up. The doctors told me eventually it would but I think three months has been long enough. I am only 23 and I do not want to go the rest of my life in this type of pain. Can you give me any ideas on what the pain could be or something I could ask my doctor about?
Thank you for your time.

Sherry

Answer from Dr. Toub: It is not unusual for there to be significant bruising, usually along the flanks, after major laparoscopic surgery. This is typically self-limited and lasts about 1-2 weeks. I'm assuming the bruising has abated by now. As far as the pain, it is unusual to have a major wound infection after laparoscopic surgery, although not impossible. Still, it should not take 3 months to resolve. The pain on the left could also relate to pelvic adhesions from the surgery (while laparoscopy does not generally create major adhesions, some will still form in many cases), or to some other, more unusual problems such as a fluid collection in the pelvis. By definition, this is not chronic pelvic pain, since it is less than 6 months in duration.

You may want to ask your doctor more details about what was done and what was found in the OR. He/she might also consider a pelvic ultrasound, if this was not done already, Laparoscopy, while not on the same level as a liver transplant in terms of scope, can be more than minor surgery in my opinion-a hysterectomy is still a major operation whether or not it is done by laparoscopy or laparotomy, for example. For that reason, we can see many of the same complications as we occasionally see after laparotomy (surgery through a large incision).

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Germaine: Pain in Pelvic Region Dear Dr. Toub,
I am 24 years old and have been experiencing pain in the pelvic region for about 1 year. I have a fibroid in my posterior uterine wall and a cyst in my right ovary. I have been monitored every 6 months since this diagnosis, about 2 years ago. My pain comes during the middle of my menstrual cycle and sometimes 1 week before my period is due. The pain can be quite intense and it last for about 20 minutes. It comes a few times a day for about 5 days. What could be the problem?

Thank you for your assistance and kind attention.

Answer from Dr. Toub: There are several possibilities. Depending on the size and location of the fibroid, that certainly could be the reason, but there are others as well. You might have essential dysmenorrhea, which means that your periods are associated with severe cramping for unclear reasons. Usually this will respond best to some of the more potent nonsteroidal medications out there (which require your doctor's prescription and supervision). Endometriosis is also a possibility. My advice is to ask your doctor where to go from here, whether certain pain medications might be appropriate, whether or not the pain is due to the fibroid, and if a laparoscopy is indicated. Again, this is best decided by you and your doctor.

Good luck, and thank you for your e-mail!

David Toub, M.D.

  Question from Alice: Constant Itching and Burning Dr. Toub,
I have had a problem off and on for about a year. I have a constant burning and itching when I urinate. Painful intercourse occurs because I seem to tear at the opening of my vagina and afterwards there is very small amount of blood when I wipe. Urinating immediately after sex burns really bad!!

I have an OB/GYN that I've been seeing and I trust completely. He has given me creams to use for the itching and another cream when I saw him about the tearing. He explained that the tear was very small but still there, nonetheless. I can not for the life of me get this to stop!!! I've been married for 6 years and never had this problem before. I don't understand the tearing or the seemingly repeated yeast infection causing the itching. My husband is a diabetic but my doctor doesn't really think that has anything to do with it. I have been using a lubricant and still have the same burning and tearing after sex.

I am at my wits end...please any type of answer you may have will be greatly appreciated!!!


Thank-you,

Alice

Answer from Dr. Toub: A couple of thoughts come to mind-the tear is a possibility, since it is still present or may have associated scarring. Your doctor should be able to inspect the area to get more information about this as a possible cause. There is also the possibility of vulvodynia, which causes burning pain at the junction of the vagina and the vulva, which often is made worse with intercourse. While chronic yeast infections do occur, usually they can be readily diagnosed under the microscope and treated accordingly and very successfully. I would suggest you raise the possibility of vulvodynia with your doctor, and also have him investigate the vaginal tear in more detail. Pelvic rest (i.e. no intercourse for a period determined by your doctor) maybe appropriate-again, this is one of many options for your doctor to consider.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Lacey: Abnormal Pap Tests Dr. Toub,
The last 5 months I have had 2 Pap tests, which came back abnormal. I have cramping, pelvic pain, and pain during intercourse. I have been to the doctor several times and tried different prescriptions but they did not work. The doctor keeps telling me to come back in 3 months for another Pap test. Should I be worried that something is wrong and should I get a second opinion?
Thank-you,

Lacey

Answer from Dr. Toub: Without knowing the specifics of the Pap smear and one's medical history, it is hard to say, but if both Pap smears were at least "atypical" then a colposcopy is warranted in most cases. In some cases, repetitive inflammatory smears may also merit investigation. My personal philosophy is that it never hurts to get a second opinion, nor should any physician be opposed to a patient's asking for one. As far as the pelvic pain, it is more likely than not unrelated to the issues surrounding the Pap smear, but also should be evaluated.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Robin: Vulvodynia Dear Dr. Toub,
I have been diagnosed with vulvodynia for the last 3 years. I am frustrated about treatments or the lack of. I would like to know about surgical procedures that have been done for this condition. Have you had any successful treatments that have worked with your patients?
I thank you for this opportunity to ask my question.

Painfully Yours,
Robin

Answer from Dr. Toub: Surgery used to be much more in favor than it is today, so I would personally shy away from it except as a very last resort. I have seen too many women who, despite the best intentions of their gynecologists, were not helped by surgery and even hurt by it. This is not to say that there are not cases where surgery is beneficial, but it really should be a last resort. There are a lot of options-elavil and other medical regiments, Candela laser treatment (this is fairly benign treatment and has very low risk, but is not available everywhere) , etc. Personally, I have had pretty good results from medical treatment and also the Candela laser, but treatment must be individualized. It is also important to make sure that you are being evaluated by someone with expertise in this condition-not all gynecologists are experienced with vulvodynia, and either underdiagnose it or overdiagnose it. While they still do not have a web page, the International Society of Vulvar and Vaginal Disease has a pretty good referral list-they are based in Chicago and should be listed in the phone directory (the number I have on them is old and not in service the last time I called).

Good luck, and thank you for your e-mail!

David Toub, M.D.

  Question from MN: Vestibulitis, Gas and Cramps Hello Dr. Toub,
Seven years ago I had a two year bout with vestibulitis. Although, I don't have a problem with vestibulitis now, I do have another problem with my pelvic area. I constantly experience gas and cramping in my lower pelvic area. I have had a colonoscopy, an ultra sound, and upper and lower GI series. Nothing shows up. I am going in for a CT Scan. Have you ever heard of a correlation between vestibulitis, gas and cramping in the lower pelvic area?

Answer from Dr. Toub:  There is no relationship as far as I know. Your GI specialist should be of assistance in regard to your symptoms, and you should also run them by your gynecologist as well.

Good luck, and thank you for your e-mail!

David Toub, M.D.

  Question from Anne: Lymph Nodes & Pain Hello Dr. Toub,
Hoping you can advise me on what type of doctor I could visit to help put together my symptoms. I am 44 and at the age of 8, I had all the lymph nodes removed in my right groin. For the past two years I have been going through multiple procedures and tests. All the doctors seem to be ignoring the fact that I've had my lymph nodes removed. I have had constant pain in my lower right abdomen for about two years, usually around my ovary area. I often have a swollen stomach. I had a D&C, hysteroscopy and a laparoscopy to remove scar tissue on the right side. I had an ovarian cyst drained on the left side at the same time. I also have had a CA 125 test done with result of "8" as I currently have a cyst on my right ovary. Is it possible that some of my pain is due to the removal of my lymph nodes? I usually prop up my leg at night and I have never had leg swelling. Any suggestions as to how I should proceed?

Thank you.

Answer from Dr. Toub:  It is possible that the pain may be related to the removal of the lymph nodes, but it is not a common cause for pelvic pain, and the fact that there is no associated leg swelling is a positive sign and also argues against the lymphadenectomy (removal of lymph nodes) as the cause for your pain. Certainly there could be adhesions present on the right side, despite the previous operation to remove them-any operation can create additional adhesions, unfortunately. There are additional possible reasons for your pain as well, including the ovarian cyst. Personally, in a premenopausal woman, CA-125 levels are not terribly useful and may cause more problems than they are worth. As far as what type of doctor to consult for this, my suggestion is to find a gynecologist who is skilled in laparoscopy and the management of chronic pain. Usually such physicians will work with patients to find nonsurgical methods of pain relief, resorting to surgery when absolutely necessary. A chronic pain center, usually involving gynecologists, anesthesiologists and several other types of specialists, may also be of help to you.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from M: Chronic Pain Dear Dr. Toub,
I am so happy I have found your website. I need some advise. I am 23 years old and in 1996, I had my right ovary removed due to a cyst. When I went in for the scheduled surgery I had a temperature of 103. The surgery proceeded and it was found that my right ovary was infected and was "about to rupture". It was removed and I had a "tubal". That part was my choice as I had a very difficult first pregnancy at age 16 and decided I would not have any more children.

Previous to this surgery and since the surgery, I have had terrible pain in my lower abdominal area, especially with intercourse. When the pain occurs with intercourse it is much worse and almost unbearable. This has caused problems with my marriage and of course sexual activity with my husband.

I have seen my OBGYN many times since my surgery with these complaints. He has stated I might have endometriosis or pelvic inflammatory disease. He has given me medication or cream for both but nothing is working. It has been 3 years and I am still in terrible pain. Please help!!! I feel like I am losing my mind as my physician can not find anything wrong. I am getting to the point of having a complete hysterectomy since I don't know what else to do.

Answer from Dr. Toub: First of all, a hysterectomy is an absolute last resort for pelvic pain-it is only appropriate in certain cases and after all other alternatives have been exhausted. While I would defer to your own doctor, it is unlikely to be PID or endometriosis since you have had your tubes tied (PID and endometriosis can occur after tubal ligation but it is less likely). Regardless, an evaluation would seem to be in order. Such tests as a complete blood count, cervical and urine cultures, ultrasound and even laparoscopy may be indicated. At this time, it sounds like there is still no definitive diagnosis.

My advice would be to ask your doctor about a more targeted and detailed workup for your pain. There are many possibilities, including adhesions, bowel or bladder problems, endometriosis, etc. that must be considered in the differential diagnosis. If he/she is not helpful, please consider obtaining a second opinion. This is often very helpful-I would suggest trying to locate a gynecologist who is experienced with chronic pelvic pain and its management, along with laparoscopy.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Cindy: PID, Pelvic Pain & Miscarriage Dear Dr. Toub,
First of all, thank you for your Q&A! I have been reading and I have found out that I am not all alone! I have been dealing with pelvic pain, for 14 years now. I believe it began when I had a miscarriage at 19. I had some bad advice from a County Clinic nurse. She told me to go home, set on the toilet and watch for a blood clot that would not break up when picked up. She did not encourage me to go to the hospital, therefore I did not have a D&C. Months later I received a bad pap from this county clinic and was told I had an STD. I went through that terrible embarrassment and took all the pills. A few months later I became deathly ill, I went to the emergency room and was operated on immediately because the doctors did not believe me when I told them I was not pregnant. They thought I had a tubal. I was opened and closed, given an IV for a week in the hospital and told I had PID. I read somewhere that PID can be caused by miscarriages, is that true?

I have had 3 surgeries now because of adhesions. The pain will be better for awhile but still always there. It seems to be every 3 or 4 years, I need to have laparoscopic surgery to remove some of the adhesions. Does that sound normal for adhesions to grow at that rate? Each time it involves my colon, bowel, bladder, ovaries and tubes. The last time I had surgery my doctor told me I would have to have an open hysterectomy for my next surgery. On your site, I have read that hysterectomies do not always help pelvic pain. I am just so tired of all of this. I live in an area that only has OBGYN clinics; there are no real specialist here and I don't know where to turn.

Recently I was prescribed Zoloft for major PMS symptoms. I began bleeding and continued for 57 days straight. I had terrible pain the whole time. I was given a depro. shot and the bleeding has stopped but the pain hasn't. Now my gyn. wants to do another lap. Do you think the surgeries are causing more adhesions? I have quit the Zoloft and am waiting for the shot to wear off so that I can tell what is going on without drugs.

This is just a quick review, there is more but I have already taken too much of your time. Again, my questions are:
Can a miscarriage cause PID?
Do adhesions grow back that quickly, every 3 to 4 years?
Does surgery cause more adhesions?
Is there such a thing as tubal donation and / or replacement?

I know you don't recommend specific doctors but can you lead me in a direction? The closest city is Memphis TN.

Thank you for taking the time to read, and care about women with these terrible problems.


May the Good Lord Bless You and Keep You.


Cindy

Answer from Dr. Toub: Thank you for your good wishes! Now to your excellent questions...

Miscarriage does not cause PID. The only exception would be a septic abortion (a miscarriage that got superinfected), but often times a septic miscarriage is secondary to a pelvic infection that is already present. With occasional exceptions, PID is caused principally by gonorrhea or chlamydia.

Most likely, the adhesions are a result of PID. It is not unreasonable nor unusual to treat adhesions with laparoscopic surgery, but adhesions can recur. While laparoscopy is generally less likely to form significant
adhesions than a laparotomy (surgery through a large incision), all surgery generates adhesions to some degree (even microsurgical techniques can create some adhesions, though these are usually minor). Just as all surgery on the skin will form some sort of scar, all internal surgery will form adhesions to some extent. The more abdominal surgery one has, the more likely significant adhesions will form, irrespective of the surgeon. Adhesions can reform within a week of surgery in some cases (and perhaps even earlier), so 3-4 years is
not at all unusual.

I am not aware of anything along the lines of tubal transplants, and the fertilized oocyte would require a uterine environment to continue to grow anyway. You are quite correct in wondering if hysterectomy cures pelvic pain; while there are many cases where it is of benefit, at least 75% of the time it is not beneficial, and in my opinion it rarely helps unless the uterus is itself the source of chronic pain. My best advice would be to investigate nonsurgical methods of pain relief. After so many surgeries, additional surgery is unlikely to cure your pain, and so long as the adhesions have not resulted in a bowel obstruction or other major emergency, they might be best left alone. If the adhesions are significant, a hysterectomy is more risky than in a woman without major adhesions. A multidisciplinary pain center may be of benefit-while my policy is to not refer people to hospitals or physicians via e-mail, I can say that there is at least one chronic pelvic pain center at an academic medical center in the south, namely the University of North Carolina. In addition, there are a number of excellent gynecologists at UT Memphis who would also serve your interests. Your doctor should be able and willing to refer you for a second opinion.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Joann: Endometriosis Pain Dear Dr. Toub,

I have a a ten year history of endometriosis. I've had three laparoscopies and I have been on depo lupron, depo provera and syneral. My last laparoscopy showed no endometriosis, but my gyn put incisions in both
ligaments of my ovaries, which provided relief (in addition to the depo provera) for about two years. The pain is back and the ultrasounds are negative. My gyn doesn't want to do another laparoscopy. She said that the endometriosis may not be able to be seen or lasered where it is. She also said that the pain could be from scar tissue from past procedures and that lasering it will only provide temporary relief, as it will probably grow back. Meanwhile, my primary care doctor wanted to check into other possible causes of abdominal pain, and although I didn't have any signs of irritable bowel syndrome that is what I am being treated for. Fiber was added to my diet along with 20 mg of dicyclomine twice a day. I've been on motrin, anaprox, propoxy and naproxen. They all seem to now aggravate my stomach and the dicyclomine is not doing anything for the pelvic pain. I am considering checking out a pain management center because I am at my wits end. I am still on the depo provera and in pain almost everyday. Do you have any suggestions?

Answer from Dr. Toub: It sounds like your doctor did a laparoscopic uterosacral ligament ablation. It is not a difficult procedure and is relatively safe, but unfortunately provides long-term pain relief for less than 50% of patients. It is also not
suited to treat anything other than midline pelvic pain (it will not affect ovarian pain, for example). While it is true that endometriosis can elude detection, your doctor is wise to consider other sources of chronic pelvic
pain, including potential GI sources. That does not mean that this is what is going on in your case, but it is very appropriate nonetheless. As far as lasering endometriosis, it is less effective in my opinion than excising the endometriosis, although laser ablation is very common and in many cases will suffice. Your idea of a pain management center is right on the mark, and would have been my suggestion as well. Unless there is a reasonable likelihood of successful pain relief, additional surgery is often unwise. If three operative laparoscopies have not accomplished their goal, why would a fourth laparoscopic procedure succeed? A multidisciplinary pain center can be useful in many cases and can avoid additional surgery and trauma. Your doctor should be helpful in directing you to one with expertise in chronic pelvic pain.


Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from JY: Severe Pelvic Pain For the past 6-8 months I have been experiencing severe pelvic pain that lasts during the entire month. I have also had 4 c-sections. My Dr. has recommended a hysterectomy, stating that I have adhesions, adenomyosis and scarring from the surgeries. When we submitted this to my insurance company, they denied it on the fact that I had not had a D & C, hysteroscopy and laparoscopy. I had these procedures done approximately 1 week ago and I am still having the same severe pelvic pain as in the past. What is your recommendation?

Thanks,

JY

Answer from Dr. Toub: Obviously without the complete details it is difficult to come to a recommendation, nor is it appropriate to make more than general recommendation via e-mail in my opinion. I can say that hysterectomy is usually not the first method used to treat chronic pelvic pain, so I understand your HMO's reservations. Adenomyosis is not often diagnosed without a hysterectomy specimen, although it can be suspected based on symptoms like heavy bleeding, pain and a globular, enlarged uterus. Sometimes it can also be suggested by an MRI scan of the pelvis. I would also, if I were the HMO, want to know what was found at the time of your laparoscopy one week ago, and why hysterectomy is the preferred treatment. This is not just from utilization and financial concerns, but also from a quality of care point of view. You may want to discuss these issues with your doctor, including possible medical approaches to treating your pain.

Good luck, and thank you for your e-mail!

David Toub, M.D.  

 

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