Ask The Expert

June 16, 2006
David B. Toub, MD
David B. Toub, MD

I would really appreciate some advice. For the last 8 years I have experience pain during sex, from at best sore to simply excruciating. The pain is worst on entry but leaves me sore afterwards.

This month's topics

Question from Katy: Painful sex and vulval pain

I would really appreciate some advice. For the last 8 years I have experience pain during sex, from at best sore to simply excruciating. The pain is worst on entry but leaves me sore afterwards. I also often lately just feel pain in my vulval area even when I am not doing anything that would provoke it, and my vaginal opening feels tender if I put pressure on it. I have been to countless doctors and now a couple of specialists. Infection and visible physical disorders have been ruled out. The last specialist I saw thought I had vaginismus. The previous one, who was there temporarily, suggested vestibulitis. I'm not sure how these are different and how I can find out which one it is. Thanks for any help you can give me.

Answer from Dr. Toub:

Vaginismus refers to a painful constriction of the muscles in the vaginal area associated with intercourse. "Vestibulitis" is a subtype of what is referred to as "Vulvodynia," which literally means "Vulvar pain." Vulvodynia is a chronic pain condition that affects the vulvar area. It is most often misdiagnosed, in part because the symptoms may mimic other more common conditions such as a yeast infection. While I cannot be sure that this is what is going on, a lot of your symptoms are reminiscent of vulvodynia. It is important to be seen by someone with expertise in this area and sensitivity to patients with this condition. The International Society for Vulvar and Vaginal Disease (I'm not sure of their web address offhand, but it should come up easily in most search engines) maintain a referral list of providers across the US who have expertise in vulvodynia, and I would recommend consulting this list. This is the best way, I think, to be sure that you have this condition (which is important since, if this is not vulvodynia, your real condition will not be addressed). Vulvodynia treatment is still in evolution-in some cases, surgery may be recommended, but this is usually an absolute last resort since there are medications (elavil and others) that may be helpful, along with laser treatment of the affected areas (using a Candela laser that targets tiny blood vessels in the vulvar region very safely). Good luck, and thank you for your e-mail!

 

Question from Christine : Chronic Pelvic Pain and Endometriosis

I'm 27 years old and for the past 31/2 years have been dealing with chronic pelvic pain and endometriosis. I have had 2 surgeries and have been on many medications. The problem is that I have pain when I get aroused and when I have a internal exam by a gynecologist. Which means I can not have sex and have not since this all started. My question is can I get a suggestion on if you have ever heard of a case like this and if so where I can find more info on if I can get anymore help with my condition? This has been very frustrating for me because no one seems to know what to do next. Thanks if you can help.

 

Answer from Dr. Toub:

If your pain is not present at any other time except during arousal and intercourse, then this might point to something other than endometriosis, such as insufficient lubrication and other things that are not at all uncommon and usually simple to remedy. I'm assuming that this is a recent development in addition to the 3 1/2 year history of endometriosis and chronic pelvic pain.If your chronic pelvic pain otherwise is not under control and the pain you get during intercourse is the same as your chronic pain, then I'd work with your physician to intervene on behalf of your chronic pain syndrome. I can't comment on specific remedies, since this must be individualized. I am not surprised that you are frustrated-pelvic pain is a difficult entity to diagnosis and treat, and sometimes may require more than one medical specialty to be involved. Good luck, and thank you for your e-mail!

David Blair Toub, M.D.

 

Question from Stephanie: Ovary Pain

I had a laparoscope on 5/11 for pain located around my left ovary. I have been experiencing this pain for 5 or 6 years. In the beginning the pain was very intermittent. But as time went on it the period of time between these pains has gotten shorter. For a long time I have just acknowledged the pain and gone on, never complaining or letting anyone know that these pains were ocurring. They began to be daily sometime last year. Sometimes they are severe and bring tears to my eyes. I finally mentioned the pain to my doctor during my normal, yearly exam. She touched on the pain during a routine tapping on the outside of my abdomen and decided to send me for an ultrasound. It showed nothing. She sent me to a staff Ob-gyn. He sent me for a CAT scan. Again, nothing. So we did the scope just last week. I saw the pictures today. He believes that the possible source of the pain to be the vein that goes to/from my left ovary. It is distended, bulged, discolored and he said appears to be blocked. He likened it to a varicose vein. He has given me several options which I am weighing out. What I would like for you is more information on this problem. I have never heard of this. I saw the pictures to support the problem. Obviously he cannot guarantee that this is the source of the problem, but it is possible. Any information you can give me would greatly help my resolve to learn as much about this as I can.
Thank you.

Stephanie

Answer from Dr. Toub:

What he is describing sounds like "pelvic congestion syndrome," in which chronic pelvic pain is ascribed to stagnant blood flow in the pelvic veins. This is a controversial subject, in my opinion, because there really isn't anything in the literature to prove such a condition exists, although many people honestly believe it is a source of chronic pelvic pain. The problem is that one can see dilated pelvic veins in women without pelvic pain, and in fact this is a very common finding during pregnancy, as the enlarging uterus partially slows the return of blood from the pelvis. Yet chronic pelvic pain is not as common during pregnancy, so something is not consistent here, in my opinion. nonetheless, pelvic congestion has been linked with chronic pelvic pain for whatever reason, even though no well-designed study has proven this link as far as I know.

Assuming that pelvic congestion syndrome is responsible for one's pelvic pain, the question is what to do about it. Treatment has ranged from supportive measures, such as pain medication, to removing the ovary (or ovaries) or interrupting the blood supply to the pelvis. If your pain is really attributable to something about that ovary (whether pelvic congestion or otherwise), removal might, in theory, be of benefit. I would caution, however, that removal of a normal ovary is rarely beneficial (I have seen one case only when I was a pelvic surgery fellow, and I think it may have been a placebo effect). Your doctor is quite correct in notifying you that treating the involved ovary may not cure your pain, so clearly he is giving you several options as is very appropriate. This is not an easy situation for either the patient or physician, since any treatment may or may not work. I cannot make any recommendation myself, other than to reserve the most radical treatments for last (which is a fairly standard, common-sense rule in medicine anyway). In any event, it sounds like you have a very thorough and caring physician looking after your care, and you should carefully weigh each option he gives you, recognizing that this is not an exact science by any means.

Sorry I cannot be of further assistance, but this is still "uncharted territory" in that there are few, if any, reliable studies on this subject so that treatment must be individualized. Good luck, and thank you for your e-mail!

David Blair Toub, M.D.

 

Question from Toni: PID? Endometriosis?

I have been suffering with chronic pelvic pain for approx. 10 yrs. I'm 35 now. After a laparoscopy and a laparotomy 7 yrs ago which included tubalplasty, It is inevitable by now that I will never have children or feel normal again. My pain has become progressively worse and I've just recently requested my post-op records to determine my next step. Apparently it's either PID or endometriosis. I'm considering a hysterectomy because I'm about ready to lose my mind in all this pain. Could I have both conditions? I have symptoms of both. Are there any other options other than hysterectomy and drug therapy? I did 6 cycles of IVF and can't bear to take any more drugs. Any input or advice will be greatly appreciated.
Thank You

Toni

Answer from Dr. Toub:

It doesn't sound like PID to me, given your history. Endometriosis is possible, but I would think that this would have been diagnosed by now, as you have had a laparoscopy and laparotomy in the past. Adhesive disease is very likely. I cannot make individual treatment recommendations, obviously, but my bias in most cases is to try to avoid additional surgery unless there is a reasonable likelihood of success. Hysterectomy for chronic pelvic pain does not have a great track record, in my opinion, so I would suggest you consider an evaluation at a multidisciplinary pain center before resorting to major surgery. Other options include a presacral neurectomy or a presacral block (the latter is done by an anaesthesiologist and does not involve surgery), if your pain is confined to the midline. If your pain is not centrally-located and may involve the ovaries, then I would try any of several medical regiments, such as Lupron, Depo-Provera, nonsteroidals, Elavil, etc. If your doctor is not comfortable or highly experienced with managing chronic pelvic pain (and many physicians are not-this is not a reflection on their overall quality, it is just that no one can be a master of everything in medicine...), he/she might refer you to someone with particular expertise in this area. Good luck, and thank you for your e-mail!

David Blair Toub, M.D.

 

Question from Maria: Would a hysterectomy help me?

Dear Dr. Toub,
I know you are probably very busy but I got your address from the internet for asking questions regarding hysterectomies. I am supposed to have one and I'm not sure about it. I have terrible fainting spells, heart palpitations, dizzy spells and total anxiety resulting from all. I have been to a Cardiologist and an Electrophysiologist. My heart monitor and signal EKG showed some irregular heartbeats. I had a tilt table test which I only did for 17 minutes because I couldn't take it anymore. I had an electrophysiology study which came out normal. The only thing is that I have pretty low blood pressure (normally 94/56 area). I am beginning to think that maybe all my symptoms are menopausal. I'm 42 yrs old., I have a tendency to grow dermoid cysts. I have one ovary left right now because they both had dermoids on them and my right ovary was previously removed. It seems when I am going to get my period the palpitations are worse and so is everything else. Maybe I don't have a heart problem? Could it be all hormonal? Those are my questions to you if you can possibly answer them.
Thank you for your time.

Sincerely, Maria

Answer from Dr. Toub:

I'm not in a position to say for sure whether or not you have a cardiac condition-that is for your cardiologist to decide. So far, however, I'm not clear on what the indication is for hysterectomy. Do you currently have dermoids? If so, they certainly should be removed, but that does not require hysterectomy (even if the ovary is entirely removed). It sounds to me like you need additional information from your gynecologist, so that you can be comfortable with any decision for hysterectomy. A second opinion is also very helpful. In any event, you need to be able to make an informed choice, and I don't have enough data to say if hysterectomy is or is not warranted in your case. Good luck, and thank you for your e-mail!

David Blair Toub, M.D.

 

Another Question from Maria: Do hormones cause cardiac symptoms?

I just want to know right now if in your experience, if you've ever seen hormonal symptoms such as mine. Like the palpitations, short of breath, dizziness, etc.? I just feel like all I'm feeling is due to premature menopause, if that's possible. So I guess what I'm asking you is could it be possible? I do understand that you haven't seen any of my cardiology reports. I'm just still trying to have hope that if I have my surgery it will help with how I'm feeling.
Thanks so much,
Maria

Answer from Dr. Toub:

I have not personally seen these symptoms in association with menopause, but I can't say it isn't possible. However, menopause would be at the bottom of my list of possible diagnoses. It sounds more like a panic attack, assuming the cardiology evaluation was negative (which should also rule out mitral valve prolapse, a condition that can give similar symptoms in some individuals). I'm also not clear that this is amenable to surgery, but again, I'm basing my opinion on limited information. Thank you for your e-mail!

David Blair Toub, M.D.

 

Question from Mary: How can I get a flat stomach post- hysterectomy?

I had a hysterectomy 2 years ago. My questions are:
What can I do about my stomach? I don't seem to eat much, and I dance 3 times a week. What can I do to get it flat? Will sit ups help. It just seem to get bigger and bigger. And my waistline is bigger. I'm contemplating a liposuction. It's very depressing. Can you give me advice or direct me to someone who can?

Thank you,
Mary

Answer from Dr. Toub:

While I'm not a cosmetic surgeon, I can say that in some instances an abdominoplasty (an operation to essentially tighten the abdominal structures and remove redundant tissue) may be helpful-when I was in residency many years ago, the chief of gynecologic oncology had us do many of our hysterectomies through an abdominoplasty incision. Liposuction can also be used in appropriate patients, but like anything, it is important to make certain that your surgeon is qualified and experienced.

Sit ups can definitely help, along with a healthy diet. I don't think sit ups are able to make everyone's waistline smaller and firmer, but it can't hurt. My best advice is to speak with your primary care physician about his or her opinion (since your PCP knows you much better than I do) and ask if he/she thinks a referral to a cosmetic surgeon (for an opinion) would be appropriate. Good luck, and thank you for your e-mail!

David Blair Toub, M.D.

Question from Debbie: Can you recommend a doctor?

Could you give me a recommendation of a good doctor who specializes in fibroids and possible hysterectomy for removal in my area of Burlington Vermont?
Thank you very much,
Debbie

Answer from Dr. Toub:

It is my policy not to recommend specific hospitals/physicians, as this can lead to conflicts of interest and can be inappropriate in a public forum such as this one. Any board-certified gynecologist should be skilled in treatment of fibroids and hysterectomy-I would be more concerned about what the physician's individual philosophy is, and whether he/she is open to alternatives to hysterectomy.

You can consult your local medical society to find out who the gynecologists are in your area, and both ACOG (www.acog.org) and the AMA (www.ama.org) have databases online that can be useful to obtain information about local physicians. Local word of mouth, particularly among patients, is especially useful. Thank you for your e-mail!

David Blair Toub, M.D.

 

Question from Deanna: Painful Intercourse

My daughter called tonight and said it was very, very painful when they had intercourse. Is there something tipped or has something dropped? It doesn't happen all the time.
This time it was quite painful. It takes such a long time to get an appointment. Could you tell us anything while she's waiting for her appointment.
Deanna

Answer from Dr. Toub:

While I sympathize with how long it takes to get an appointment with some physicians, I can only give some general possibilities as to why this is happening: endometriosis, insufficient lubrication (a very common problem), uterine prolapse (unusual in young women), vulvodynia (chronic vulvar pain), vaginitis (trichomonal, yeast or gardnerella infections), and a few other unusual conditions. Again, the majority of the time this can be due to inadequate lubrication, which is a situation easily remedied with KY jelly, prolonged foreplay or one of several vaginal lubricant products on the market. Hopefully, your daughter's physician will see her soon-I know how frustrating it is to have to wait several weeks for a routine office appointment. My sense is that things are only getting worse as physicians have to see more and more patients in a day just to break even. Sometimes, offices have midlevel practitioners, such as physician assistants or certified nurse practitioners, and they may not be as busy as the physicians (who have to also run back and forth to the hospital) but provide superlative, first-rate care. If your daughter's physician does have one or more midlevel practitioners on site, it may be possible to decrease her wait for an appointment. Good luck, and thank you for your e-mail!

David Blair Toub, M.D.

 

Question from Anonymous: Lower Abdominal Pain

am 32, married and just quit taking the birth control pill a week and a half ago. I have lower pain, like soreness in my lower abdominal area, around the ovary area. My Dr. said there was no reason to come in for a visit that I was ovulating and it is normal after you go off the pill.... is this true, or should I be concerned it is something other than ovulation? I also had a quarter size discharge this a.m. that was clear and sticky, but had no smell. I look forward to your response, thank you.

Answer from Dr. Toub:

Given that the pain has only been present for a short time, it may or may not be something that warrants a visit. It is possible that this is ovulatory pain, although not all women will resume ovulation that soon after stopping the pill-it depends when the pill was stopped in relation to your cycle and other factors.However, ovulatory pain ("mittelschmertz") remains a possibility. Whether or not this merits an evaluation is up to your doctor's individual perspective and judgement. For now, pain medicine would seem to be in order-speak with your doctor about what he/she recommends for this. The discharge could be mucus, or it could also be a vaginal infection (yeast, bacterial vaginosis, trichomonas are the usual culprits). If it persists you should have it checked out, in my opinion. Good luck, and thank you for your e-mail!
David Blair Toub, M.D.

 

Question from K.A.: P-A-I-N!

Dear Dr. Toub,
I am a 37 year-old female. I have very erratic periods, ranging from a period every other week, at times, to one every 4 months. When I do have periods, they are very heavy. For the past year, I have been experiencing moderate to severe pain in my extreme lower, left side. However, the pain in recent months, (particularly the past 2 months), has been disabling. It is a stabbing pain which is localized over my left ovary, and radiates down the front of my thigh, into my left hip, and into my back. I have had ultrasounds, MRI's, colonoscopies, etc., etc... I have a tangerine-sized cyst on my left ovary. I have received varied prognoses such as IBS, cyst, and "maybe" endometriosis... I simply cannot go on with a normal life with this pain occurring every day. Any suggestions??
Desperate in NC
K. A.

Answer from Dr. Toub:

Given that you have a large cyst on your left ovary, a laparoscopy to remove the cyst (which will also yield a diagnosis) would probably be the recommendation of many gynecologists. Even if there were no associated pain, the presence of a large cyst on an ovary in a woman over 35 warrants removal of the cyst (or ovary, if the cyst is suspicious or involves the entire ovary) in most cases. I would be curious as to what your gynecologist is planning to do. Good luck, and thank you for your e-mail!
David Blair Toub, M.D.