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Chronic Pelvic Pain Question from Meryl: Chronic Pelvic Floor Pain Dear Dr. Toub, Last October, I had sex and a day and a half later had brutal pelvic pain and signs of urinary infection. A urologist told me the pain was coming from my pelvic floor muscles. I also have symptoms of Interstitial Cystitis. Sex must have triggered a host of problems, even if I have a pelvic exam, the muscles beneath the bladder flare with pain. A urologist gave me valium but I would like to do something to get these muscles into better condition. Kegels just seem to exacerbate problems. I delivered a 9.5 lb. baby with forceps and had a huge episiotomy. I am wondering if this set my body up for these problems. Having sex now is out of the question as these muscles flair up with severe pain. What can I do?? I had a pelvic/vaginal sonogram which did not show any abnormalities. How do I find a who is knowledgeable in regard to the pelvic floor muscles. Answer from Dr. Toub: Your best bet is to locate a specialist in gynecologic urology or chronic pelvic pain. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Becky: Advise for Pain Dear Toub, I have been suffering with chronic pelvic pain for some time now. I've had a hysterectomy and several laperoscopies to remove adhesions. I am still in pain! I have been to a Urinologist, internist, Ob/gyn, and bowel doctors. They have all performed many tests but can not find the cause of my pelvic pain. I am at the point where I don't mention it anymore, and try to live with the pain. Do you have any advice?? Thank you for your time. Answer from Dr. Toub: You shouldn't have to "live with the pain," but I'm not sure time is well spent at this point in determining the cause (which may be adhesive disease). Instead, attention should be directed towards relieving the pain. This can be accomplished in a number of ways, and while not always successful, many patients do receive some measurable degree of pain relief.. The higher success rates tend to come from multidisciplinary pain centers, and your doctors should be able to refer you to one for evaluation. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Angela: Birth Control and Pelvic Pain Dear Dr. Toub, I am on Norplant for birth control. When I have intercourse I get severe pain in the pelvic region and I normally hurt for one or two days. Cramps on the first day of my cycle are unbearable. Is there a correlation between the birth control and the pain I experience? Can birth control aggrivate pelvic pain? (The pain was there before I was on any type of birth control.) Answer from Dr. Toub: There is no established link between the use of the norplant (or any other form of birth control) and pelvic pain. In fact, hormonal agents often help pelvic pain. You should definitely consult your gynecologist on this matter, as it warrants evaluation. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Ann: Chronic Pelvic Pain? Dear Dr. Toub, In '97 I had a C-Section & a Tubal Ligation. Approximately 6 months ago I started having sharp pains when I would walk or sit. The pains were in the area of my scar from the c-section. Since that time I have developed a lump in the scar area. They told me this was scar tissue build up and that occasionally it may give me trouble with pain. They said it would come and go and the only thing to do was to remove it. Three weeks ago I started hurting all of the time. I went back to my doctor, who referred me to the OBGYN that performed the c-section. When the doctor did the pelvic exam I had horrible pain. I had an ultrasound and the doctor saw abnormalities on my left ovary and lower bowel area. He said he would like to do a laparoscopy. Three days before the laparoscopy was to be done I was in the hospital with severe pain. The hospital did another ultrasound and a CT scan. They told me I had several cysts on my left ovary and apparently one or more ruptured causing the severe pain. I had my laparoscopy done and I have no information from that. I have not heard from my doctor, yet. I have been reading about Chronic Pelvic Pain, adhesions, etc. and I thought I would see what your thoughts were. Answer from Dr. Toub: I think you would be better served by a second opinion, if for no other reason than there seems to be a lack of communication between you and your doctor. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Worried: Chronic Pelvic Pain Dear Dr. Toub, I have chronic pelvic pain. The pain comes on after intercourse, when I am wearing high heel shoes and being on my feet for long periods of time. The pain is located on the lower right and left sides. The right side pain is more severe. Please provide some education and insight on the topic. Answer from Dr. Toub: A discussion of chronic pelvic pain would fill a book, and then some, and I don't think anyone can do this subject justice in a brief e-mail reply. You should definitely consult with your doctor to evaluate the pain, since there are many potential reasons for your pain. For further education, you may also want to consult appropriate resources on the Web (so long as they are reputable), including OBGYN.net. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Christy: Chronic Pelvic Pain Dear Dr. Toub, I am 21 years old, and I suffer from chronic pelvic pain for the last 8 months. The pain doesn't really get worse at any time during my cycle. The results of my pap have been normal. I've had four abnormal tests, although that was about two years ago. I am going back to the doctor in about a month; they keep telling me that nothing is everything is normal but I am still in pain so much. Do you have any ideas? Answer from Dr. Toub: There are many potential reasons for chronic pelvic pain, and my best advice is to either ask your doctor about a complete and thorough evaluation, or referral to a gynecologist who has expertise in chronic pelvic pain. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Pam: Sharp Pain after Orgasm Dear Dr. Toub, For the past few months I have been having a sharp, shooting pain in my abdomen during orgasm. It doesn't bother me during intercourse, just orgasm. It seems to come from high up in my abdomen, possibly around my belly button and shoots upward for just a split second. I have no bleeding afterward. I have been having about 1 day each month during my period of heavy bleeding and some clotting. Answer from Dr. Toub: It sounds to me like you need to see a gynecologist or primary care physician. It is not neither possible nor appropriate to diagnose over the internet. Thank you for your e-mail! David Toub, M.D. Question from Theresa: Pelvic Varicosity Dear Dr. Toub, I had a laparoscopy and I was diagnosed mild endometriosis and had several adhesions removed. The pain subsided for just over a year but has returned. I had a second laparoscopy, where he found severe varicose veins on either side of my uterus on the pelvic floor. He called this pelvic varicosity, and said most likely was the cause of my pain. What does this diagnosis mean in terms of treatment, pain relief, or future children? Does it pose any health risk? I am really not interested in hysterectomy or any further surgeries unless they are absolutely necessary. Answer from Dr. Toub: This remains a controversial issue in chronic pelvic pain management. What your doctor is describing is also known as pelvic congestion syndrome, which is pelvic pain attributed to the finding of dilated pelvic veins. The problem I have with this theory is that such dilated veins are normal in pregnancy, and I'm not aware that chronic pelvic pain is caused by pregnancy (indeed, pregnancy in many cases may help chronic pelvic pain, albeit temporarily). Treatment is also unclear-hysterectomy?, embolization?, etc. To the best of my knowledge, there is no definitive clinical study with class I evidence, linking pelvic congestion with chronic pelvic pain. It is hard to say over the Internet what the next step should be, other than a second opinion and consideration of nonsurgical management of chronic pelvic pain. You should ask your doctor about what he/she suggests be done about your chronic pelvic pain. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Ann: Pelvic Congestive Syndrome Dear Dr. Smith, Can you please explain Pelvic congestive syndrome and how common it is? Answer from Dr. Smith: Pelvic congestion syndrome is a diagnosis often made from exclusion and one that is debated in the literature. The uterus and pelvis has large veins within it, and if these veins become dilated and engorged there are some doctors who feel this can be the cause of significant pelvic pain and heaviness. An analogy can be made to that of varicose veins of the legs, when these veins become very dilated they can cause pain in the legs. Because the diagnosis is one of exclusion, its validity as well as the incidence of it is unclear. However, if the pain is from this etiology, hysterectomy usually does resolve the problem. Marshall L. Smith, Jr., M.D., Ph.D. Editor in Chief Question from Julie: Vomiting due to Pelvic Congestion Dear Dr. Smith, I have had a diagnosis of pelvic vein congestion but don't fully understand what it means. I suffer from severe pain, heavy bleeding and vomiting. The pain is so severe that I have had to have injections to ease the pain. Would a hysterectomy be a option as I don't want anymore children? Answer from Dr. Smith: Pelvic congestion syndrome is a diagnosis often made from exclusion and one that is debated in the literature. The uterus and pelvis has large veins within it, and if these veins become dilated and engorged there are some doctors who feel this can be the cause of significant pelvic pain and heaviness. An analogy can be made to that of varicose veins of the legs, when these veins become very dilated they can cause pain in the legs. Because the diagnosis is one of exclusion, its validity as well as the incidence of it is unclear. However, if the pain is from this etiology, hysterectomy usually does resolve the problem. If vomiting is a symptom also, then one should also consider the possibility of the symptoms being caused from excess prostaglandin release or sensitivity. Marshall L. Smith, Jr., M.D., Ph.D. Editor in Chief Question from Denise: Cause of Chronic Pain? Dear Dr. Toub, I have suffered from pelvic pain for just over 3 years. I have had TAH/BSO and still have pain. I did have endometriosis but am told that is not the cause of this on going pain. I am going to a pain clinic (the 2nd one in the past year) but even they say, the doctors need to find the cause of the pain and that pills are not long term answer. I have seen over 30 doctors and no one has been able to help me. I have been told that there is nothing else to be done. What can I do? Answer from Dr. Toub: It's unlikely that I will be able to improve on the work of over 30 physicians. I can say that telling you that nothing more can be done is inappropriate and incorrect, and perhaps it was a miscommunication. At this point, regardless of whether or not the reason for the pain is discovered (and it may not be discoverable) the focus should be (at least in my opinion) on improving your level of pain control. If your current medications are beneficial, that is a good thing, and if not, there are other ways to deal with chronic pain, such as biofeedback, complementary alternative medicine, TENS units, etc. If you are on continuous narcotics, that may be why you have been told that such pills are not the long term answer, and I would agree with that opinion, since (and not everyone agrees with this) chronic narcotic use is not often effective with chronic use. You may want to ask what alternatives exist for your management in addition to pain medication. Good luck, and thank you for your e-mail! David Toub, M.D. Surgery Pain & Adhesions Question from Virginia: Adhesion Treatment Options Dear Dr. Smith, I have chronic pain due to adhesions. I had my eighth surgery a year and1/2 ago for adhesions. They wrap around my intestines and bowels causing obstructions. The last two were done laprascopically and this has been cutting down on the amount of adhesions forming but now am in constant pain again. How else can adhesions be treated besides surgically? Answer from Dr. Smith: Adhesions can be an enigma to both physicians and patients. Although some precipitating factors are known, it is not totally understood why one person will develop severe adhesions after surgery, and others may not. Unfortunately, surgery itself tends to make adhesions worse, but sometimes the pain can get so bad that there is no other choice than to go in surgically and excise them. There are no known and accepted remedies outside of surgery as to how to reduce or eliminate adhesions that are already present. The only choices at this point are methods of controlling the pain, and usually pain clinics can be useful in this regard. Biofeedback and other techniques, as well as techniques of controlling bowel function, can help to make one's life more comfortable without having to resort to surgery again. Marshall L. Smith, Jr., M.D., Ph.D. Editor in Chief Question from Lorrie: What are Adhesions? Dear Dr. Toub, What are adhesions and what causes them? How can they be treated and how do they affect other pelvic organs? Answer from Dr. Toub: This could be the subject of a major tome, but here goes... Adhesions are basically scar tissue. They can occur in the abdomen and pelvis (and thorax, due to previous surgery or infection). As far as what causes them, that's controversial, but it is fairly clear that surgery (even laparoscopy), intraperitoneal infection (such as PID or a ruptured appendix) or other processes like endometriosis can all be associated with adhesion formation. Surgically, adhesions are thought to result from tissue trauma or ischemia (interference with blood supply).. How to prevent them is also a subject for debate. Many remedies have been tried, including high molecular weight dextran, installation of saline and antibiotics, etc. mainly with no proven efficacy. Some adhesion-preventing barriers have been touted, but with the exception of Gore-Tex (which is a permanent barrier unless removed surgically later on) and possibly Intercede (which is limited by the presence of any blood) I'm not aware that any of these are particularly successful. The best way to prevent surgical adhesions probably is meticulous technique and gentle handing of tissue. Treatment of adhesions is another story. Unless they result in pain, bowel obstruction or infertility, they are probably best left alone. The only way to attempt to treat adhesions is to remove them surgically. The problem with that approach is that additional surgery can cause additional adhesions, so it's kind of a Catch-22 situation. This is where consultation with your doctor is especially important, to decide if adhesions require intervention, and how to best to that. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Tina: Chronic Adhesion Syndrome Dear Dr. Toub, I am a 40 year old female with severe adhesions/scar tissue. After the removal of the ovaries, I never recovered in the eight weeks allowed. I have a full hysterectomy now, and have the same pain and worse before the surgeries. Diagnosis: Chronic Adhesion Syndrome. There is swelling, pain, and I feel as if I am carrying a 10 pound rock. Please, can you suggest some medications that will allow me to get back to a normal active life. There was a surgery suggested to remove the nerves in the abdomen area. Is that a permanent fix? Please help! Answer from Dr. Toub: Your best bet is to ask your doctor for which medications, including pain medications, would be most appropriate based on your particular situation, allergies and medical history. The surgery you're referring to sounds like a presacral neurectomy (if it isn't, please ignore my comments!). This is only appropriate for pain that is entirely in the midline (uterus and bladder) and given that you have had a hysterectomy, I'm not sure this is likely to be of benefit (based on anatomy). Also, PSN is not without its risks, particularly in someone with known adhesions. The effects of a PSN can also be accomplished without surgery by having an anaesthesiologist perform a presacral nerve block, although there are risks to this as well. Again, unless there is central pain, usually with an intact uterus, it is unlikely to be of benefit. I would try to investigate nonsurgical treatments as much as possible, since every surgery will likely cause additional adhesions. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Stephanie: "Selective Embolization" Dear Dr. Toub, I have endometriosis which grew on my bowels. I had a total hysterectomy a year and half ago. Since my hysterectomy I have had to have a lap. to remove adhesions or endometriosis (7 months ago) Now the pain is back and the doctor would like for to try Selective Embolization, he explained it in the office, but I was in so much pain it went in one ear and out the other; he also gave me OBGYN.net which has led me to you. Thank you for your help in advance. Answer from Dr. Toub: It's a mystery to me as well, unless he is suggesting uterine artery embolization, which is only indicated for abnormal uterine bleeding secondary to fibroids (and is still a work in progress in my opinion). Embolization in general is useful for the treatment of bleeding, including the GI tract (where it has an established safety and efficacy record), but I have no knowledge of it being applicable to adhesions or endometriosis. You should ask your doctor to explain it again, preferably when you are not distracted by pain (which would make it nearly impossible for any patient to understand a complex procedure). Thank you for your e-mail! David Toub, M.D. Question from A Reader: Chronic Adhesion Syndrome Dear Dr. Toub, I am a 40 year old female with severe adhesions/scar tissue. I have a full hysterectomy and have the same pain but worse prior to the surgery. I have been diagnosed with Chronic Adhesion Syndrome. There is swelling, pain and I feel as if I am carrying a 10 pound rock. Can you suggest some medications that will allow me to get back to a normal active life. There was a surgery suggested to remove the nerves in the abdomen area. Is that a permanent fix? Answer from Dr. Toub: Your best bet is to ask your doctor for which medications, including pain medications, would be most appropriate based on your particular situation, allergies and medical history. The surgery you're referring to sounds like a presacral neurectomy (if it isn't, please ignore my comments!). This is only appropriate for pain that is entirely in the midline (uterus and bladder) and given that you have had a hysterectomy, I'm not sure this is likely to be of benefit (based on anatomy). Also, PSN is not without its risks, particularly in someone with known adhesions. The effects of a PSN can also be accomplished without surgery by having an anaesthesiologist perform a presacral nerve block, although there are risks to this as well. Again, unless there is central pain, usually with an intact uterus, it is unlikely to be of benefit. I would try to investigate nonsurgical treatments as much as possible, since every surgery will likely cause additional adhesions. Good luck, and thank you for your e-mail! David Toub, M.D. Ovarian Pain & Cysts Question from Stevie: Ovary Pain Dear Dr. Toub, 14 years ago I had a large dermoid cyst on my right ovary and had it removed. 10 years ago I had a laparoscopy for cysts, scar tissue. For about a month, I have pain around my ovaries but not directly on them like before. My lower back hurts and I have more frequency in urination. I feel bloated and crampy all of the time. I would like to go to the doctor but do not know what type to go to or what symptoms to address. Answer from Dr. Toub: Your best bet is to consult with a gynecologist and relate all your symptoms to him or her. Thank you for your e-mail! David Toub, M.D. Question From Samantha: Ovarian Pain from Tubal? Dear Dr. Toub, I have been experiencing pelvic pain since my tubal ligation 2 years ago. I have been seen by 2 different doctors and have found no relief. I have tried 6 different kinds of birth control pills to try to control my cycle thinking that my pain was related to ovulation. This did not help in any way. My pain starts from 2 days after my period ends until the day it starts. I had a lap. done and everything looked clean. I think if my tubal ligation was reversed this would stop my pain, considering I went from the age of 11 to 21 with no problems. Any advice you can give will be welcomed and appreciated. Answer from Dr. Toub: There is an anecdotal "post-tubal ligation syndrome" that has been reported, but there is no definitive evidence that this exists at all. I would be personally hesitant to reverse a tubal ligation unless someone really desired fertility again. Before considering surgery, you may want to investigate ways to control the pain, since there is no guarantee that a tubal reanastomosis would be beneficial. Your gynecologist should be able to recommend some course of pain medicine, and even referral to a pain center might be appropriate, depending on the level of pain. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Sonia: IC or Chronic Pelvic Pain? Dear Dr. Toub, I have been diagnosed with IC 4 years ago. I am taking Elmiron for treatment. About one and a half year ago I started to experience a sharp pain on my right ovary. This occurs especially before my period. The ultrasound performed showed that I have had a small cyst about 3 cm on my right ovary but after the laparoscopy my gynecologist assured me that the cyst was gone and everything looks normal. The pain continues to come and go. It seems to me it is synchronized with the chronic symptoms of my interstitial cystitis. Are these two conditions related and is this a chronic ovarian inflammation? How can I treat it? Answer from Dr. Toub: There is no proven relationship between IC and chronic pelvic pain, although anyone with one chronic pain syndrome like IC certainly can have additional pain syndromes as well. The evaluation should be no different than what would be done for anyone without IC, namely a trial of pain medicines, hormonal intervention, and other pain control measures. Endometriosis is not out of the realm of possibility, even with a negative laparoscopy. A small cyst, however, is unlikely to result in chronic pain. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Stephanie: Echo-Free Cysts & Nabothian Cysts Dear Dr. Smith, "What is a dominant echo-free cyst and nabothian cysts ? Also, what is an anteverted uterus? From what I have been reading I think I may have endometriosis. Can you explain any of this to me? Thank you very much. Answer from Dr. Smith: Nabothian cysts are small cysts on the cervix, and are usually no cause for concern. They usually come and go, just as one gets acne on the face which comes and goes. A woman's uterus is usually tipped to the front or back, and this is normal in all women. An anteverted uterus is tipped to the front. Marshall L. Smith, Jr., M.D., Ph.D. Editor in Chief Question from Kathy: Ovarian Pain Dear Dr. Toub, I am assuming that the abdominal pain I have about 10 days to 2 weeks past my periods is due to ovary pain. I am 47 and the pain lasts almost a full week. The first day or two I am in constant pain with little relief from ibuprofen. The pain changes sides each month. My doctor does not seem concerned but I wonder how much longer this is going to last and if it will go away at menopause? Answer from Dr. Toub You may want to ask your doctor about evaluating your pain. It may or may not be ovarian in nature, and even could be endometriosis. It is also possible that no definitive problem may be found, but an evaluation may be appropriate depending on your physician's judgment. Good luck, and thank you for your e-mail! David Toub, M.D. Hysterectomy Question from Samantha: Should I have a Hysterectomy? Dear Dr. Toub, I am 25 yrs. old and have been in a Gyn office almost every other month for the last two years. My first problem was Class IV pap which upon biopsy was diagnosed as severe dysplasia/carcinoma-in-sutu and treated with a LEEP. My periods are heavy and full of cramping. I have abdominal pain that radiates from very low all the way around to my back. I have a 2nd degree uterine prolapse, a cyst on my right ovary, a polyp in my cervix, and a proliferative endometrium. I have taken Provera and other medications to no avail. I am tired of having pain during intercourse, bleeding afterwards, abdominal swelling and pain. I have a laparoscopy scheduled next week to check for endometriosis, if that is confirmed will that with all my other problems be indication for hysterectomy? I have family history of ovarian cancer and I do not want to continue to live in pain and fear. Answer from Dr. Toub: Whether or not a hysterectomy is appropriate is between you and your doctor. Certain forms of cancer mandate hysterectomy, and hysterectomy is an option for many women with your symptoms. But it may not be the only option, and that is something to discuss with your doctor. Good luck, and Thank you for your e-mail! David Toub, M.D. Endometriosis & Adenomyosis Question from Laurie: Thickened Endometrium? Dear Dr. Smith, I have had chronic pain in my lower left side, along with spotting in between periods,after intercourse, and my periods have changed in length and consistency also. I recently had a pelvic ultrasound, and they said I have a thickened endometrium strip. Can you please explain what this means? Answer from Dr. Smith: The inner lining of the uterus is a layer called the endometrium. This is a dynamic layer which grows each month, and then sloughs off monthly and this is the blood and tissue of the menses. So, it is thicker at some times of the month. When an ultrasound is performed, a side view of the uterus is obtained, and the thickness of this layer can be visualized. If the endometrium is thickened during the reproductive years, it may simply mean there is a little extra tissue growth that particular month and usual is no cause for concern. There are circumstances (i.e. menopause) when the lining should not be thickened and may warrant further investigation. Marshall L. Smith, Jr., M.D., Ph.D. Editor in Chief Question from a Reader: Diagnosing Endometriosis Dear Dr. Smith, By what procedure is one diagnosed with endometriosis? Would my doctor have seen signs during a hysteroscopic surgery to remove a fibroid?" Answer from Dr. Smith: Endometriosis is diagnosed only at laparoscopy, at hysteroscopy one cannot see inside the abdominal cavity where endometriosis is commonly located. Marshall L. Smith, Jr., M.D., Ph.D. Editor in Chief Question from Paul:Endometriosis on the Bowel Dear Dr. Toub, Can endometriosis. on the bowel cause diarrhea? I was on methadone for the pain but recently came off of it and have been having diarrhea for over 2 weeks. Answer from Dr. Toub: It is unlikely unless there is a current small bowel obstruction, and usually endometriosis affects the large bowel, which is not likely to produce diarrhea as I understand it. I would look to methadone withdrawal as a more likely cause, and certainly discuss this with your doctor. Good luck, and Thank you for your e-mail! David Toub, M.D. Question from Jennifer: Endometriosis vs. Adenomyosis Dear Dr. Toub, What is the difference between endometriosis and Adenomyosis? Can this spread to other organs and is a hysterectomy my only option? I have also tried hormone therapy and the birth control pill nothing seems to work. Any suggestions? Answer From Dr. Toub: Endometriosis and adenomyosis are unrelated. Endometriosis is the presence of endometrial tissue (cells from the uterine lining) on sites other than the uterus, whereas adenomyosis is the presence of endometrial cells within the muscle layer of the uterus, resulting in abnormal uterine bleeding and pelvic pain. There are many treatments for endometriosis, but the only time-proven treatment for adenomyosis in most patients is hysterectomy. However, localized areas of adenomyosis, particularly if encapsulated with fibrous tissue, may be removed surgically just as fibroids can be locally removed. But this is not always feasible, unfortunately, since adenomyosis in many cases is widespread in the uterus. Medical therapy with hormonal agents are sometimes effective, although likely only in the short term. Adenomyosis is not always easy to diagnose short of doing a hysterectomy and reading the pathology report, although MRI and in some cases ultrasound can aid in diagnosis. Whether or not hysterectomy is necessary depends on the level of certainty of the diagnosis, severity of symptoms, and your own preferences. Good luck, and thank you for your e-mail! David Toub, M.D. Syndromes and Abnormalities Question from Susan: Ovarian Remnant Syndrome? Dear Dr. Toub, I had Total Abdominal Hysterectomy, BSO and appendectomy in May '99. I had a lot of adhesions. I have heard it is possible to leave piece of ovary due to many adhesions, Ovarian Remnant Syndrome. To the right of my navel about 6 inches I have pain. ERT made it worse so I stopped it. Could part of an ovary be left and how far can it migrate? According to my doctor and pathology report, there is no Endometriosis. What do I do now? Can adhesions hurt this soon? If part of ovary is left wouldn't that set up chance for ovarian cancer? Answer from Dr. Toub: I would not jump to the diagnosis of ovarian remnant syndrome without additional evidence, such as a detailed MRI revealing an ovarian remnant. More likely, given your history, this pain relates to adhesive disease or undiscovered endometriosis. Certainly, ovarian remnant syndrome can occur in women who have had extensive adhesions, but it is fortunately uncommon. Assuming a woman has an ovarian remnant left behind, it may cause no symptoms, or recurrent pain. It does not increase one's ovarian cancer risk (1 in 70 over an average lifetime), but it does not reduce the risk either compared with women who have had their ovaries removed (the risk here is not zero, either). You may want to consider a second opinion as well. Good luck, and thank you for your e-mail! David Toub, M.D. PID & Other Infections Question from A Reader: What physician should I see? Dear Dr. Smith, For years now I have been experiencing chronic pelvic pains. I have been diagnosed with PID a few times. A physician told me that once you have had PID, you will have chronic pain off and on for the rest of your life. After intercourse I have strong cramps that will not go away and sometimes a burning in my lower adominal area. I would appreciate it if you could give me some advice in this matter. What type of physician should I see that can help me begin to resolve this matter. Answer From Dr. Smith: PID, or pelvic inflammatory disease, is an inflammation of the uterus, tubes and ovaries. Unfortunately, it can be a very difficult diagnosis to make, and in the past has been used as a wastebasket diagnosis for nearly any type of pelvic pain. Without a laparoscopy or surgery to actually see inside the abdomen, this diagnosis should always be re-evaluated. The best person to do this is a gynecologist to evaluate pelvic pain, and they probably would eventually recommend a laparoscopy to complete the evaluation. Marshall L. Smith, Jr., M.D., Ph.D. Editor in Chief Question from Lucy: Vestibulitis Dear Dr. Toub, I was diagnosed with endometriosis. in 1980. I have had a hysterectomy. I know a lot of women with endometriosis have chronic yeast infections, as do I. I have been treated with Diflucan and Nystatin a few times. The yeast causes vestibulitis and when I take antifungals, I sometimes get an overgrowth of lactobacilli, which can be irritating. I have tried a yeast free diet, no sugar and no simple carbohydrates. As long as I take the antifungal I am okay. Diflucan once a week helped for several months. When my doctor took me off, it came right back. The infections are definitely cyclical. What can I do to stop them? Answer from Dr. Toub: There are several additional ways to manage chronic yeast infections, including suppressive therapy and boric acid. Your doctor should be able to give you some guidance here, and it is important that this be done only under supervision since there are potential side effects depending on the medication. I would also be concerned about the possibility of undiagnosed diabetes, which can cause recurrent yeast infections. You should definitely ask your doctor about this. Yogurt can also be helpful, and even if not, it has calcium which may be beneficial. Good luck, and thank you for your e-mail! David Toub, M.D. Other Questions Question from James: Burning Sensation Dear Dr. Smith, My wife and I have had this problem for the duration of our marriage, about two years. We have seen several different OBGYN professionals and have been told effectively nothing and have no chance to fix the situation. The problem is during sex when I ejaculate inside of my wife it causes an incredibly painful burning sensation for my wife. Do you have any suggestions as what causes this? I would be extremely appreciative. Answer from Dr. Smith: If infections have been effectively ruled out and the burning persists, then the possibility of the woman being sensitive to the semen must be considered. Occasionally a woman is very sensitive to some of the components in a particular man's semen, and it may cause this burning sensation. If this turns out to be the case, then use of a condom is usually the best alternative in order to prevent exposure of the semen to the woman's tissues. Marshall L. Smith, Jr., M.D., Ph.D. Editor in Chief Question from DL: Pain During Penetration Dear Dr. Toub, When my girlfriend and I attempted intercourse, she experienced a strong pain that she described as a "pinching" feeling at the SLIGHTEST penetration. She said that she has always had this problem and fears intercourse due to this. I know that it is not due to my size. I know you can't make a direct diagnosis here, but can you suggest some possibilities as to what might be causing this situation? I hope to gently convince her to have a doctor address the issue... it does bother her a great deal! Answer from Dr. Toub: There are a number of possibilities, ranging from medical (e.g. vulvodynia) to social (e.g. history of abuse in the past) to psychological (e.g. anxiety disorders). It is not a function of penile size, as you correctly point out, nor is it anyone's fault. I would also recommend a medical consultation, preferably with a gynecologist, and from there a determination can be made as to how to proceed. Good luck, and thank you for your e-mail! David Toub, M.D. Question from LJSWOF: "Keratin in the Uterus?" Dear Dr. Toub, I am 61, post menopausal. I have had brown spotting for 4-5 months and I am scheduled for a vaginal hysterectomy in January. I had a repeat PAP which indicated abnormal cells. I've had two colpolscopies. The first one negative; the second one looked fine but a Biopsy revealed Keratin. A hysterosonogram showed a possible fibroid. (I had my ovary removed 2 years ago because I had an egg-sized Dermoid Cyst.) I can not find information on Keratin in the uterus. My question is, how did keratin get in my uterus? I have no hyperkeratosis any where else. Answer from Dr. Toub: I have no idea what this is referring to, except possibly a Pap smear result of hyperkeratosis, which indicates a possible thickening of the cellular lining of the cervix. As with the uterus proper, the cervix does not produce keratin. However, as the major cell type within any epithelial structure is termed a keratinocyte, hyperkeratosis implies an increase in the number of these cells. It does not in and of itself imply keratin production, however. Good luck, and Thank you for your e-mail! David Toub, M.D. Question from Staci: Fear of Pain Dear Dr. Toub, I been diagnosed with severe endometriosis. I had a laparoscopy in September and started Lupron shots in October. I've also had several bladder infections. My problem is, I don't ever want to have intercourse because every experience I have had has been really painful. My husband it getting very upset and I see him drifting farther and farther away from me. I have talked to me doctor about it and he prescribed methyltestosterone and also put a estraring inside of me. But now I just don't dare try. Can you give me any suggestions? Answer from Dr. Toub: While well-intentioned, I'm not sure I understand the rationale for the hormonal intervention in this case. Testosterone does play a role in libido, but I'm not sure that sexual drive is the issue here, but rather anxiety and fear of pain due to endometriosis. In cases like this, counseling may be of benefit. Also, if pelvic pain is still a problem, then other treatments for endometriosis and its associated pelvic pain may be considered by you and your gynecologist. Good luck, and thank you for your e-mail! David Toub, M.D. Question from a Reader: Genital Warts Dear Dr. Toub, What are genital warts and what are the symptoms? Answer from Dr. Toub: They're usually small raised lesions, often on a stalk and are also known as condylomata acuminata. They're very common and usually have no symptoms. They are caused by the human papillomavirus and look like warts anywhere else for the most part. Most often they occur around the labial areas but also within the vagina and on the cervix. They're not at all dangerous, but can also be easily treated. They do tend to recur (like most viral diseases) but cure rates with primary therapy are excellent. Thank you for your e-mail! David Toub, M.D. Question from Concerned: Fibroids Dear Dr. Toub, I have been experiencing chronic pain for the past year. It is located across low back region below sacrum. It is most painful when sitting. I know I have fibroids; could this pain be caused by them? Answer from Dr. Toub: It would depend on the size and location of the fibroids. If the fibroids are small and/or not impinging on the sacrum, it is unlikely that they are the cause of your symptoms. A large enough fibroid (and it's debatable what "large enough" means) that is located posteriorly could cause back pain, particularly if the uterus were retroflexed (tipped backwards). Your best bet is to consult with your gynecologist and review any previous imaging studies. It may also be useful to run this past your primary care provider, as there are many causes of lower back pain, most of which are not gynecologic in origin. Good luck and Thank you for your e-mail! David Toub, M.D. Question from Carrie: Genital Problems Dear Dr. Toub, My vagina has been causing me problems lately. I'm only 14 and I have never had sex or been to an OBGYN. My vagina sometimes burns and gives off a discharge. I know it is normal to give off discharge, but is my discharge normal? It is clear and kind of like mucus and sometimes it is white. I have lots of little whitish bumps on my vagina and it is fire red. Also, it gets very dry and smelly. Especially around my period when it is fishy smelling. A couple of weeks ago I saw a rather large bump on my vagina and put cortisone cream on it and it went away. But as it went it away, the cortisone made it burn really badly. Is this weird? Am I just being paranoid? Answer from Dr. Toub: The most appropriate thing to do in this situation is see your regular doctor or an adolescent gynecologist ( a doctor who treats teenage women, NOT a teenager who happens to be a gynecologist 8-) ). There are many reasons why you could have had these symptoms, many of which are not serious. But it's best to get it checked out rather than give yourself medications that may or may not work. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Lisa: Clitoral Nerve Damage? Dear Dr. Toub, Is it possible to damage the nerves in the clitoris during intercourse? I have had horrendous problems with urinary frequency, feelings of pressure and sharp pain in the clitoris, and irritation of my urethra following intercourse in mid November. Have seen the gynecologist and two urologists. None of them can find anything wrong, but intercourse sets off bladder spasms (no UTI) and an achy feeling in the clitoris. Also, the clitoris does not respond to stimulation anymore. I can achieve orgasm but the sensation is not what it was prior to the onset of the other symptoms. Have you ever heard of injury to the clitoris before? I am very concerned and my husband feels like he has harmed me. Any response would be appreciated. Answer from Dr. Toub: To the best of my knowledge, intercourse cannot damage the nerves supplying the clitoris, so your husband can be reassured! I'm not sure how to explain your symptoms in relation to intercourse, and the fact that two other gynecologists and two urologists in addition are stumped supports the idea that this is an extremely unusual situation. Even after vulvar surgery (so long as the clitoris is not removed entirely), clitoral sensation generally remains intact. Hopefully your doctors, who are even more familiar with the specifics of your situation, can provide some guidance in terms of where to go from here. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Jeff: Painful Ejaculation Dear Dr. Toub, My wife I and have always used condoms but recently we decided to try intercourse normally during her "safe period". Following ejaculation she immediately felt a burning sensation. This is the first time I have ejaculated in her. She is taking a medication for hemorrhoids called hydrocortisone acetate and had inserted rectally before bed. I don't think my penis had come in contact with it in her rectal area but wondered if it could have something to do with the burning. Or is it possible allergic reaction? Could you recommend some good research or articles. Also, we read the precautions for the medicine and found that, at least among lab animals some, indications about medical abnormalities in the fetus while using the medication so we both feel stressed about the repercussions of that. Answer from Dr. Toub: Medically speaking, there is no guarantee that any time during a woman's menstrual cycle is "safe.' It is really more a matter of probabilities for ovulation and conception. It is unlikely that the hemorrhoid medication had anything to do with the reaction. It is also hard to say what did cause the burning sensation, especially as a one-time occurrence, nor is there any research on this that I am aware of. While I appreciate your concern about the package labeling, if the medication is just a steroid, it is not generally considered harmful to an embryo or fetus (steroids are often prescribed during pregnancy to accelerate fetal lung maturity, although not at the embryo stage of course). I would recommend that you consult with your wife's doctor to make sure there is no significant basis for concern on that front. My best advice is to use condoms or some other reliable form of birth control rather than relying on the rhythm method, which is much less reliable as a means of contraception. Good luck, and thank you for your e-mail! David Toub, M.D. Question from Bird: Ovulation Dear Dr. Smith, How many days after the first day of you last period would a woman start ovulation? Answer from Dr. Smith: The confusing part to most people is the fact that this length is the variable part of the cycle, and that the consistent part of the cycle is the time FROM ovulation to the beginning of the next menses. This time is always approximately 14 days in a menstrual cycle. The time period which is variable is the time from the first day of the menses until ovulation, and unfortunately this is the time most people are watching to time ovulation. It will vary according to the length of that particular cycle. If a woman goes 30 days between menses, then it is 16 days from menses until ovulation and 14 days from ovulation until the next menses (ALWAYS 14 days). A 32 day cycle, 18 days from menses until ovulation, and 14 from ovulation until menses, and so on. The confusion usually arises when a woman has a 28 day cycle, then both time periods are 14 days. Remember, the time from ovulation UNTIL the next menses is always 14 days, and the time from menses until the next ovulation is the varying time period. The easiest way is to predict which day the next menses will start on, and then ovulation will occur two weeks before that date. Marshall L. Smith, Jr., M.D., Ph.D. Editor in Chief 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.