Ask The Expert

November 17, 2006

It is in your best health interest to see your gynecologist or primary care physician regarding specific medical problems or concerns.

This month's topics

Chronic Pelvic PainVulvodynia, Vulvar Pain

 

Chronic Pelvic Pain

Question: How Can I Help My Doctor Help Me?
I have been dealing with pelvic pain for about 6 years.  I been through too many doctors who simply get frustrated and pass me along to the next.  I have hydrosalpinx and severe adhesions covering my tubes and ovaries, and blocking the tubes completely.  I have extreme difficulty walking, sleeping, and doing necessary daily functions.  I am going to yet another new doctor; how can I help this new doctor help me?  With the previous doctors I have gotten no relief, no support, and unfortunately no hope that I will ever have relief.  I am only 25, with one child.  I need help to help this new doctor help me improve my piece of mind, my pain management, and my quality of life.  Do you have any suggestion?

Answer: 
I think that you're being very understanding. Ideally, both a patient and his/her physician have responsibilities to work together to try to solve the medical issue at hand, and it is wonderful that you are looking to see what you can do to make your new doctor's job a bit easier. I think that one important step is to make sure that he/she has all your records, including operative reports and any relevant ultrasound or other imaging studies. I also think it may be helpful to establish expectations up front; is the goal to completely eliminate the pain, or can attempts at managing the pain be attempted? I would also suggest you ask your new physician how comfortable he/she is with managing chronic pelvic pain and how much experience he/she has had.

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

David Toub, M.D. 

Question:  Hot flashes and Mood Swings 
I am a 25 year old female who suffers from hot flashes, mood swings, severe cramping while menstruating, and everyday tenderness in the low back and pelvic area. I also have no sex drive. This is causing a huge strain on my marriage. I have seen numerous doctors about the pain and they say it is in my head. I have been on several anti depressants and they were of no help. Someone recently told me that I should have my hormone levels checked but when I asked my doctor they said it was not necessary and that I should start a form of The Pill. Unfortunately I don't like taking pills and have had an IUD for four years now. I am getting a second opinion, but I was wondering if you had any thoughts. Thank you.

Answer:  
 If you're having regular periods, albeit painful ones, it is unlikely  that the hot flashes are related to premature menopause. That being said, it would be a good idea to again raise the issue with your doctor in order to determine if additional evaluation is necessary. You may also want to consider a consultation with a gynecologist who has expertise in the management of chronic pelvic pain. There may be a psychologic component to your disorder, as evidenced by the lack of sex drive and mood swings, which may or may not relate to a gynecologic problem. The pain and cramping should also be evaluated by an appropriate physician, and hopefully your second opinion may be helpful.

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

David Toub, M.D.

Question: Pelvic Congestive Disorder
In July I had a Scope to find out why I was having so much pain.  I had been having pain for about 8 or 9 months.  I was on birth control pills to try to ease the pain.  Nothing was working so my OB suggested the scope.  After the scope was done I was diagnosed with Pelvic Congestion Disorder.  The doctor told me that the only cure was a hysterectomy.  He said that over time the pain would get more severe and more constant.  Since my one month check up the pain has been extremely severe and more constant.  I called the doctor  and he said that I needed to decide if I wanted another child or if I wanted to go ahead and do the hysterectomy because the pain is not getting better is just getting worse.  I wanted to know if the only cure for Pelvic Congestion Disorder is a hysterectomy?  I am currently on pain pills, but I can't take them all the time and I can't stay in bed all the time.

Answer:
You may want to check the archives, as this subject has been discussed a lot in this forum. In brief, I would suggest you discuss any and all alternatives with your doctor, as pelvic congestion syndrome remains a controversial topic. A second opinion consultation is also an option as well before any elective operation. 

Thank you for your e-mail!

David Toub, M.D. 

Question: CPP
Since I first started my period, they have been extremely painful. I'm 20 years old now, have been to 3 gynecologists, and never had an abnormal pap. My last pap was a few months ago. I was given birth control to control ovarian cysts that I was diagnosed with about 2 years ago. I am still having awful pain, more discharge than normal, no STD's and no yeast infection. I have been in to check for both. On top of that, the pill make me nauseous and difficult to function. My doctors have told me to deal with it. I am getting concerned. I don't feel this is normal, but I don't want to be a hypochondriac. Do you think I have some reason to worry? My last ultra sound was 2 years ago and had shown the cysts had gone away. I have not had one since.

Answer: 
At the present time, there is no evidence that the use of birth control pills prevents ovarian cysts, so you may want to discuss this further with your doctors. There are many women with abnormally painful menstrual periods, and there are also many potential ways to manage this. In addition to the pill (I'm not clear from your e-mail if your pain was improved at all on the pill), there are several types of medical and other treatments that can be helpful in individual women. Please speak with your doctor about your symptoms; a second opinion may be an option as well if appropriate. Good luck, and thank you for your e-mail! 

David Toub, M.D.  

Question: Unexplained CPP
I have been experiencing severe lower right abdominal pain after two very close laparoscopies to remove ovarian cysts a year ago.  I have complained about the pain, which is at some times debilitating, but after an ultrasound I am told that there are no new cysts, and it is probably just residual pain.  Could there be any other causes for this?

Answer: 
It is hard to say for sure, since that is something only your doctor can determine. You may want to ask if scar tissue (adhesions) might be a possibility, but it is hard to say without a detailed knowledge of your surgery and medical situation. There could be other explanations for your pain, and I would urge you to discuss this with your doctor in further detail.

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

David Toub, M.D. 

Ovarian Pain & Cysts

Question: Multiple Cyst Former
I am 29 years old with dysfunctional menses. I have a lot of pain with my period and have very heavy bleeding.  I have had 3 D&C's and a weight loss of 50 pounds. They did an ultrasound, which showed a pelvic mass.  I went to a gynecological oncologist and had another ultrasound.  That showed that I was a "multiple cyst former."  What does that mean? I don't know what to do.  I have tried the pill, but I have a heart condition and elevated blood pressure.  

Answer: 
I would recommend that you discuss this further with your gynecologic oncologist. I'm assuming that the pelvic mass has either shrunk or otherwise given evidence that suggests it is benign, but please clarify this with your doctor if there are any questions. All women form ovarian cysts from time to time, but it is possible for some women to be more prone to cysts, although this is poorly-understood. The pill does not prevent ovarian cysts, unfortunately. Again, your doctor can be  your best resource for individualized guidance on this issue. 

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

David Toub, M.D. 

Question: Cyst Pain?
I have extreme mid-month pain when I am ovulating that only subsides with 4 Advils.  This month was as bad as going into labor, and did not subside for a few days.  My doctor suggested taking the birth control pill, but I am unsure.  I am 39 with two children and want to know if I do not take the birth control pills will the pain just get worse? The doctor said this month a cyst probably burst.  Help!  I don't want to go another month with this much pain.

Answer: 
Birth control pills may be worth a try if you don't smoke (since you are over 35), but to be honest, there is no data supporting the idea that birth control pills prevent ovarian cysts. They should, in theory, but in reality they just don't. In some cases, however, birth control pills can, at least anecdotally, reduce ovarian pain in some women. We don't understand this as well as we should, but if your doctor thinks it might be appropriate, it may be worth consideration. Please discuss this further with your doctor.

Thank you for your e-mail!

David Toub, M.D.

Endometriosis & Adenomyosis

Question: Neurectomy and Labor Pains
I had a neurectomy while having a laparoscopy to treat endometriosis. Now that I am pregnant, I am wondering what to expect during labor.  I have heard that a neurectomy will either minimize or eliminate early labor pains.  To what extent should I expect "relief" of early labor pains?  I am concerned that I will not feel labor pains until I am too far along to get to the hospital.

Answer: 
I would certainly suggest you discuss this with your obstetrician or midwife, but I am not aware that presacral neurectomy would completely obliterate labor pains. PSN does reduce pain from midline structures such as the uterus and bladder, and can cause some (usually temporary) issues with bladder retention and constipation. Just as PSN does not eliminate all sensation from the bladder, I am not aware that it eliminates all sensation from the uterus. Again, individualized information should come from your doctor or other provider. 

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

David Toub, M.D. 

Vulvodynia, Vulvar Pain

Question: Pain and Pressure
Could you please give some suggestions about my problems? I feel so frustrated and a bit depressed. I am 22, been sexually active only since last December. I've seen several doctors, but still can't find the cause or solution. 

For the past four months, I been having pain in the left side in my labia majora. It moves around in different areas but on the left side. It feels like nerve pain and comes for a few weeks, then subsides for a few weeks into a tender feeling. The pain is dull and intensifies before and during my period. The problem started a few weeks after I took Alesse in the beginning of June. After that I was diagnosed with a bladder infection, a very mild bacterial infection, and a yeast infection. I have strong suspicions my problems are Pill related, which I took for 2 months and a half and stopped in August but the problem has continued. Intercourse has always been a bit painful, and has become more so. Over the past two months I have had a swelled feeling near my perinea, and on my left side. Sometimes it seems to be the lower part of my vagina and sometimes my rectum. A doctor examined me and he didn't see any swelling, hemorrhoids, and no vaginal infections. I tried all kinds of OTC pain killers but the swelled/pressured and mild dull pain just won't go away! Do you have any suggestions?

Answer: 
I'm not certain that your symptoms relate to the use of birth control pills, particularly a very low-dose pill. You may want to discuss your symptoms, however, with a doctor who has expertise in the diagnosis of vulvar pain disorders. It is not clear if you have a defined vulvar pain syndrome or not; that can only be determined by a physician who has thoroughly evaluated you in person. However, a consultation with a specialist in vulvar pain disorders could be helpful, at least as a step in determining what is going on. Please discuss this with your doctor. 

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

David Toub, M.D.

Question: Lichen Sclerosis
I was recently diagnosed with Lichen Sclerosis.  I do not have any symptoms.  No itching or pain of any kind.  The doctor that did my biopsy said treatment was dependent on symptoms.  Do I need to do anything for it?  I read that I should use steroid cream even if I do not have symptoms, that the skin could develop scar tissue.  

If you could give me your opinion it would be much appreciated. Thank You.

Answer: 
Most women with LS do have symptoms, which is usually how it is discovered. There is some suggestion in the literature that LS, which is generally considered a benign disease, could be associated with the future development of vulvar cancer, so you should discuss this further with your doctor. My opinion is neither relevant nor important-it is most appropriate to consult your doctor or a second opinion consultant who is familiar with your medical history and physical exam. 

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

David Toub, M.D.

Question: Painful, Swollen Clitoris 
I keep getting a painful, swollen clitoris. I have asked my doctor why but she doesn't know. This is very painful and affects my relationship with my husband. It's a very sharp stabbing pain. I've had it since I was a teenager. It happens fairly regularly. I used to think it was because I wore tight blue jeans. I don't anymore, but still have the same problem. I do have Herpes  and thought it might be an outbreak but I've done research and can't find anything to substantiate it.  It lasts about a week at a time, sometimes longer. Can you please help me?

Answer: 
It is hard to say what might be going on, but if your current physician has no suggestions (and to be fair, this is not a very common situation), you may want to ask her about a consultation with a gynecologist who specializes in vulvar disorders (including vulvar pain syndromes). This is not something that should be ignored, of course, and I'm sure your doctor can be very helpful in suggesting potential ideas for how to proceed. 

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

David Toub, M.D. 

Question: Vaginal Burning Pain
I am a woman 48 years old and I now suffer from constant vaginal burning. I write to you in desperation. I have been going thru this painful burning for at least 5 years. I have told countless OBGYN and they seem to ignore my complaint. I have been taking Uristat and AZO for years because this relieves the burning. Each time I go to the physician, I remind them of the painful burning I am experiencing and they simply ignore the complaint. I have had countless test for urinary tract infections and they all come back negative. When my husband and I have sex  I burn even more and sometimes I cannot even walk the pain is so bad. Is this something that I have to live with the rest of my life or is there a cure for this? Please give me some kind of answer to this.

Answer: 
I empathize with your situation, and would suggest you ask about a possible second opinion with a doctor who has expertise in vulvar pain syndromes. You are not alone; if you glance through the archives, you will see that many women have similar situations. Not every physician may be familiar with the diagnosis and management of vulvar pain, so it is important to seek out appropriate guidance. 

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

David Toub, M.D. 

Question: Interstitial Cystitis
I've been diagnosed with interstitial cystitis and Polycystic ovaries.  I experience a lot of abdominal, pelvic, and back pain. It's hard to distinguish which is causing pain at certain times.  After I eat, my bladder contracts unbearably. I can go 4 or 5 months without having a period.  My cramps are so severe, I just feel sickly most of the time.  

I have had several UTI's and a renal doctor suggested antibiotics for a year. My ob/gyn suggests a hysterectomy but I want another child. I had to take fertility pills for 3 months to have my son.  I'm so scared of all the pains I'm having and it definitely worsened after I gave birth. Any advice I would greatly appreciate.

Answer:   
I would suggest that you discuss all options with your doctor, including how to evaluate the source of your pain. Hysterectomy may or may not be indicated, and that would depend on what the diagnosis is. Polycystic ovarian syndrome generally does not require a hysterectomy. You should be aware, however, that untreated PCO is associated with an increased risk of endometrial cancer (cancer of the uterine lining) although hormonal treatment with progestins can decrease this risk. Please discuss this further with your doctor. 

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

David Toub, M.D.

Other Questions

Question: Cervical Stenosis Treatment
is it possible to treat cervical stenosis without having to undergo a hysterectomy. I've had thermal balloon ablation for heavy and painful periods. My periods now are lighter and less painful; but the pre cramping several days before the onset of the period is horrendous; worse than before. I've been offered a hysterectomy now as a last option but surely if the cervical stenosis was treated somehow?? I wouldn't have to undergo the trauma of such major surgery. Any advice would be greatly appreciated.

Answer: 
In general, most cases of cervical stenosis can be managed by one or more dilation treatments, even in an office setting. If the cramping is not due to cervical stenosis, that is an entirely different matter. In the absence of significant trapping of blood within the uterus, I would wonder if the cramping might be due to something other than blocked flow (as can occur with significant stenosis). Please discuss this further with your doctor, and you may also want to discuss ways to manage such uterine pain in addition to hysterectomy. 

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

David Toub, M.D.

Question: Painful Intercourse
My boyfriend and I had complete STD screenings before we engaged in sexual activities. That was 8 months ago. For the first two months of our sexual relationship, we were having sex on the weekends and there were no problems. We have been living together for 6 months and making love on the average of 12 times a week. About 5 months ago I started experiencing a burning sensation a few hours after sex and painful urination. I have been to the doctor almost every month for the last 5 months complaining about the pain. They suggested K-Y. We use it. They have also given me several antibiotics and nothing helps. Most times I do not have a UTI but twice I did. 

I know it's directly related to my boyfriend because several times I have gone away and after a few days the pain leaves and doesn't return until the next time we have sex. Can you suggest something we may have over looked. We are planning on a life time together and I need to know why making love to him hurts so much.

Answer: 
I would suggest you ask your doctor about the possibility of a latex allergy (if you are using condoms) or a vulvar pain syndrome. It is hard to say what is going on without a full evaluation from your doctor or a second opinion consultant.  

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

David Toub, M.D. 

Question: Uterine Fibroid
I was told at an exam yesterday that my uterus is tipped far back and has a 5 cm. fibroid that is also resting on my rectum. I'm 45 and have had rectal pain and bleeding in the rectum for about 9 months during my periods.  I have very annoying back pain, longer periods, and other symptoms at the time of my period.  He recommended either a supracervical hysterectomy or removal of the fibroid and  uterine support.  He also mentioned fluid that he could see during the ultrasound.   Is this good advice at my age?

Answer:   
Whether or not this is good advice is for you and your doctor to discuss, since it requires a detailed knowledge of your individual medical situation. I would, however, suggest that you ask if there is any need to sample the uterine lining beforehand (such as with a D&C/hysteroscopy or an office endometrial biopsy) due to the findings of fluid (which I assume is within the uterus) during ultrasound. Again, a decision as to whether there is any need for additional testing, such as a biopsy, would require your doctor's clinical judgment. 

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

David Toub, M.D. 

Question: Ovarian Remnant Syndrome
Is it possible for a woman with Ovarian Remnant Syndrome to produce viable eggs from the remaining ovarian tissue?  Is it possible for a woman, following removal of her ovaries, but not her fallopian tubes, to became pregnant 9 months after her ovaries were removed? 

Answer: 
First question: I suppose that it might be possible, since as far as I am aware residual ovarian tissue can ovulate and otherwise behaves as any other ovary. Retrieving any ova could, however, prove difficult due to scar tissue, but I would defer to a reproductive endocrinologist for additional insight into this. In addition, I would speculate that the use of ovulation induction agents could cause significant pain, since typically women with ovarian remnant syndrome note cyclical pain in the retained ovaries that are often encased in scar tissue.

As far as the second question, successful pregnancy would require the following conditions at minimum:

* Conception (and preferably implantation into the uterus) took place before removal of the ovaries
* A normal uterus is present (i.e. a hysterectomy was not performed at any time)
* After removal of both ovaries, hormonal therapy was started at levels to support a pregnancy

I'll be honest-it is extremely unlikely for many reasons that a woman could continue a pregnancy after removal of both ovaries. In addition, conception could not occur after both ovaries had been removed. Please discuss this further with your gynecologist or other healthcare provider.

Thank you for your e-mail!

David Toub, M.D. 

Question: Pain During Intercourse
I'm 24 years old.  I have had lower abdominal pain, mainly on the right side for about two years.  I have gone to several different specialists, including a urologist, gastrointestinal specialist and a gynecologist. I've had a cat scan and an ultrasound done. The tests did not show anything.  For the past 2-3 months I've also have had severe pain with intercourse, mostly on penetration.  Do you have any suggestions?

Answer: 
My first question would be whether this has been evaluated with laparoscopy. If not, you may want to ask if it would be an appropriate next step for you personally; that is something that only you and your doctor can decide. 

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

David Toub, M.D.  

DISCLAIMER: The above represents material for educational and discussion purposes only. The material provided should NOT be used for diagnosing or treating any health problem or condition. It is NOT a substitute for consultation with and advice from qualified healthcare providers. If you have or suspect you have a health problem, consult a qualified healthcare provider. The author and any other party involved in the preparation or dissemination of the material presented are not responsible for any errors or omissions in the material provided above, or any results obtained from the use of such material.