Ask The Expert

This month's topics

Chronic Pelvic Pain

Question: Severe Pain after Tubal
I am 32 years old and I had my tubes tied last June.  I have never had a normal menstrual cycle; it comes when it wants to.  Since I had my tubes tied, I have had very severe pain with my periods.  The pain puts me in bed and I have a lot of clots.  I will bleed heavy for the first two or three days and have the severe pain and then it will stop.  It returns within 12 to 24 hours.  The last three periods I have had, I have bled off and on for over a week and have sharp pain in my lower pelvic area.  Can you give me some kind of idea what is going on.  My doctor I went to told me I was going threw the early stages of menopause.  Please let me know something.

Answer:  
Not to disagree with your doctor, who knows your history and exam, but I'm not sure this has much, if anything, to do with menopause. Menopause does not cause menstrual pain. Your chronically irregular period may have more to do with possible anovulation and/or other potential gynecologic problems, and this is something that needs to be evaluated by your doctor to help arrive at a diagnosis. While there are anecdotal reports of menstrual problems and pelvic pain after tubal ligation, there is no definitive, reproducible evidence of a true "post-tubal ligation syndrome," so it is hard to support the tubal ligation as the reason for your current symptoms. My suggestion would be for you to again consult your doctor, and explore ways to better understand what is currently going on, such as imaging and other studies. I would not simply explain your symptoms as consistent with menopause. 

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

David Toub, M.D.  

Question: Chronic Pelvic Pain & Excessive Bleeding 
At age 43, due to chronic pelvic pain and lack of menstrual cycles, my doctor recommended going back on the birth control pills to regulate cycle.  While I had complained of pain, I was totally unprepared for the pain that would accompany the periods I now have and what I consider to be excessive bleeding.  He considers this to be normal, but I am bleeding 10-12 days and some days am unable to leave the house because it is so excessive.  The pain is extremely uncomfortable and  I am passing clots the size of 1/2 of my fist.  I labor to pass them.  Is this or does this sound normal for someone who has never had normal menstrual cycles?  According to blood work, I am not in menopause.  I guess I have 2 major questions.  Is this excessive bleeding, pain and clotting normal?  Will something happen to me if I don't have any periods until menopause? Thank you.

Answer:
Excessive bleeding, pain and clotting are never normal features of a menstrual cycle, and should be addressed by your doctor. It may be a temporary phenomenon, however, since your lack of periods may have been due to anovulation, which leads to a build up of the endometrial lining. Thus, there is more lining to be shed during a period, leading to excess bleeding. However, chronic anovulation is also a risk factor for endometrial cancer, so given your age you may want to ask your doctor if an endometrial biopsy is indicated in the office (or D+C/hysteroscopy in an OR setting).

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

David Toub, M.D.

Question: Pelvic Congestion
What is pelvic congestion and where does it come from?  What is the condition that sounds like endometriosis?

Answer:
I probably get 1-2 questions on this every month (you may want to peruse earlier posts on this issue). In a nutshell, some cases of chronic pelvic pain are ascribed to the presence of dilated pelvic veins noted at laparoscopy. There are several problems with this diagnosis, which is why there is not general agreement in the Gynecology community that this syndrome exists. First, dilated pelvic veins are common during pregnancy, yet many cases of chronic pelvic pain benefit from a current pregnancy. Second, many women have dilated veins yet do not have chronic pelvic pain. Finally, it is not clear that treatment of "pelvic congestion" yields consistent results.

Pelvic congestion syndrome may be a real entity, but there is limited data upon which to base a conclusion, and until appropriate trials are performed, I have to admit I'm still skeptical that this explains many cases of chronic pelvic pain. I suspect that when the pelvis appears otherwise normal on laparoscopy, it is easier to tell a chronic pelvic pain sufferer that there is an obvious, treatable cause of her pain, rather than stating that everything appears normal and the cause of the pain remains enigmatic. In any event, there is no definitive evidence that pelvic congestion is a reproducible cause of chronic pelvic pain, at least at this point in time.

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

David Toub, M.D.

Question: Post Menstrual Pain
I have bad pains as soon as my period is finished that lasts for a week. None of my doctors have been able to tell me what's wrong. Do you have any suggestions?

Answer:
In a general sense, I would suggest speaking with your doctors about what they recommend as the next step in evaluating your pain. If a thorough evaluation, including examination, history, imaging and lab studies are not enlightening, some physicians might recommend a trial of birth control pills and/or nonsteroidal pain medications. In some cases, a laparoscopy might be appropriate. It is not possible to make specific suggestions, since that is best discussed with your own physicians who are most familiar with your medical history. 

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

David Toub, M.D.

Question: What Causes Pelvic Pain?
What can cause severe pelvic pain?

Answer:
The answer to this question would fill a small book or hard drive. There are many possible causes, including  fibroids, adenomyosis, chronic appendicitis, diverticulosis, levator ani syndrome, interstitial cystitis and many other disorders from the fields of gynecology, urology and gastroenterology. You should raise your concerns with your doctor, who can better trim the list of possibilities based on your individual history, symptoms and physical exam findings. 

Thank you for your e-mail! 

David Toub, M.D.

Question: Pain After Removal of Cyst and Ovary
Six  months ago, I had surgery to remove my left ovary and a cyst surrounding  it.  During the surgery, the doctor also removed a fibroid and some endometriosis. Since that time I have severe pain on my left-side between the time that my period ends and when I ovulate.  I've had two ultrasounds and they detected fluid in that area.  My OB/GYN says it's fluid from ovulation but this pain is before ovulation and located on the side from which the ovary was removed.  I'm trying to get pregnant and am concerned that this pain is a symptom of a more serious problem.  

Answer:
It's hard to say if the fluid is from ovulation since there is no ovary on that side, as you correctly state. It may be a postoperative fluid collection, which may or may not resolve on its own, or any of a number of things that can cause pelvic pain. You should also ask your excellent questions of your doctor, in order to see if additional investigation is warranted. 

Thank you for your e-mail!

David Toub, M.D.

  Question: Unexplained Chronic Pain 
I am 40 and have been having pain that comes and goes in my lower right side and sometimes into my thigh. I had a hysterectomy about 4 years ago.  They removed on ovary and my uterus. Only lying down seems to make it go away. I have had pelvic ultrasounds but my GYN has found no reason for the pain. My doctor is sending me for a colonoscopy next week. What do you think. Any help would be very appreciated. Thank you  

Answer:
It sounds like an appropriate work-up is in progress. Sometimes, the actual cause of pelvic pain remains elusive, in which case intervention should be focused on managing the pain. But it is important to first try to find out if the reason for the pain can be pinpointed. A consultation with a multidisciplinary pain center may be a reasonable idea if the colonoscopy is unenlightening. 

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

David Toub, M.D.

  Question:  Pelvic Pain
Since mid way through my second pregnancy, (he is now 11months old) I have suffered with pelvic pain.  Most often it occurs while having intercourse and, or during my period.  The best way that I can describe it is it was just like a very strong contraction.  I went to my Gyn but she could not find nothing and wants to do a Laparoscopy.  I'd appreciate any opinions or help that you can give me.  

Answer:
Depending on the level of pain, medical history and recent lab and imaging results (such as an ultrasound) a laparoscopy may be appropriate. But that is for you and your doctor to decide. You may want to consider a second opinion if you continue to have concerns or questions about whether laparoscopy is appropriate in your individual situation. 

Thank you for your e-mail!

David Toub, M.D.

  Question: Chronic Pelvic Pain
I have been experiencing pain on my left side, by my vaginal opening only after urination or even after a bowel movement for the last 2 years. It feels like it is constantly tensed up in my genital areas and when I go to the bathroom it releases or relaxes and that may be causing the pain.  I have had a pelvic/vaginal ultrasound, urine tests and thin pre pap all has come back negative. It seemed like this problem first started after I had a few drinks.  I am seeing a urologist and currently taking amitryptyline.  It seems to be better at times but it has not cured it. Your advice would be much appreciated.

Answer:
I would defer to your urologist's opinion, since he/she has had the opportunity to fully evaluate your care. There may be a component of vulvodynia as well (chronic vulvar pain syndrome), but amitryptyline is often helpful for vulvodynia as well. 

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

David Toub, M.D.

Question: Lower Right Abdominal Pain
Eight years ago my doctor discovered a cyst on my ovary, which was causing me pain on my lower right side. I would get a numbing, tingling feeling in my leg all the way down to my toes. After I went on birth control the pain went away.  I went off the pill because my husband and I wanted to have a baby and I have not been on the pill since.

Over the past several months I have been experiencing the same discomfort from before. My doctor sent me for an ultrasound, which showed nothing.  No one seems to understand this pain I am having. I'm thinking about going back on the pill to see if that will help ease the pain.  Do you have any suggestions?  

Answer:
The pill may not be a bad idea, since it sometimes alleviates many causes of pelvic pain such as endometriosis or adenomyosis. But if fertility is desired, this is not the best solution obviously.

You may want to ask your doctor if your symptoms warrant evaluation with laparoscopy or if consultation with other specialists is necessary. The numbing and tingling down your leg raises the question of whether neurological evaluation and additional imaging with a CT scan would be useful. In unusual situations, endometriosis (which would not show on an ultrasound) can involve the sciatic nerve in the leg, so this may be something you might want to raise with your doctor.

In any event, the best way to get to the bottom of this is to discuss your questions with your doctor and ask where things are going from here. 

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

David Toub, M.D.

  Question: Chronic Pelvic Pain
I am 22 years old, and over the past four years, I have been dealing with chronic pelvic pain.  The pain is excruciating and feels like a stabbing pain on my lower right pelvic region as well as increased pressure. I also have severe headaches, diarrhea, loss of weight and depression due to the severity of my pain.  I have seen numerous doctors, OBGYN's, fertility experts, gastroenterologist, urologists, and holistic doctors.  I have had four laparoscopy's where they  have removed small amounts of endometriosis.  I have tried Lupron and Prozac but I am still in tremendous pain and have had no relief from any of the procedures.  I have had cat scans, blood work, and ultrasounds.   I am at loss, as to what my diagnosis is and what to do so that I can function like a normal 22 year old. Can you suggest any possible diagnosis or treatment that may help me?  

Answer:
Given that you have had multiple interventions and seen many physicians, the likelihood of any one physician (including myself) solving your chronic pelvic pain is small.

By definition, you seem to have a chronic pelvic pain syndrome which is affecting your life in numerous ways. In my experience, additional surgery is unlikely to be of benefit and may even be harmful. At some point, you may be best off being evaluated in a multidisciplinary pain center even though you may have been evaluated already by different specialties individually.  At this point, the focus should possibly be more on managing your pain than establishing a cause. While it could be endometriosis based on your description, at this point all that matters to you is getting some help with pain. While you're mentioned leuprolide and other medications, you did not say anything about pain medications, which may be more helpful at this point that other interventions have been.

You may want to ask your doctor about evaluation by a multidisciplinary pain service, as well as psychiatric evaluation. This is because anyone with a chronic pain syndrome can often benefit from some additional support such as counseling and medications as indicated. You've described depressive symptoms, which should definitely be followed up in some fashion.

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

David Toub, M.D.  

Question: Extreme Pain
I have extreme pain on my left side and pain during sex.  I have had a pelvic ultrasound, a pap, and  a colonoscopy but they found nothing.  I also have my period three times a month, heavy for about 7 or 8 days.  I was told it is from getting off the depo shot. Do you have any advise? Answer:
It's hard to say if the excessive periods are a result of coming off of depo-Provera, but it certainly if possible, especially if the ultrasound did not reveal anything abnormal within the uterus. It's also not possible to determine with limited information what is causing the pain during intercourse. Endometriosis is possible, which would not be visible on ultrasound. It might also explain the abnormal uterine bleeding as well. You should speak with your doctor about other possibilities for your symptoms and inquire what additional steps are under consideration to identify the problem and hopefully treat it.

Thank you for your e-mail!

David Toub, M.D.

Question: Chronic Pelvic Pain - Neuroma
I delivered my daughter at home 5 years ago with midwives.  I tore on my labia and was not stitched.  The back 1/4 part of my labia tuned black, fell off and has left me with continual pain that feels as though I am being constantly pinched.  I believe I have neuropathic pain.  I have been through chiropractic care, acupuncture, and bio-feedback.  I have had four perineoplasty repairs over the past three years, and have not had any relief from any of these procedures. I am wondering if you have any other suggestions and what your opinion is on the possibility of another birth helping my situation. 

I would appreciate any information you can provide.  

Answer:
Whether or not a vaginal delivery would help or hurt is hard to say with absolute certainty, but some obstetricians might be hesitant to suggest a vaginal route of delivery after perineoplasty. I can't say I would disagree-additional trauma in that area is unlikely to be helpful and may make things even worse.

It doesn't sound as though additional surgery would likely be of benefit. Your best option may be to consult a multidisciplinary pain center, which includes specialists in GYN, urology, psychiatry, anesthesiology, and even complementary alternative medicine. While only about 50% successful long-term, this is better than many other therapies for chronic pain syndrome. At the very least, an organized collaboration among several specialties is likely to have better communication among providers than seeing different physicians independently. There are no easy answers, and any future effort may be best directed towards managing the pain with nonsurgical methods. Psychological counseling should also be a part of this, since anyone with chronic pelvic pain can benefit from support. 

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

David Toub, M.D.  

Question: Pain and no Period 
I have not had my period in 3 months and there is no chance of being pregnant.  Before that time I had a very regular cycle.  I am experiencing extreme pain in my abdomen and side.  I've had an ultrasound and there is no trace of a cyst on my ovary.  What else could cause these symptoms?  She has suggested I start taking birth control pills to regulate my cycle,  however, I'm worried there may be a bigger problem.  

Answer:
I'm assuming any pregnancy tests were negative and the ultrasound did not reveal fluid within the uterus. Birth control pills are a reasonable option, since your lack of periods may stem from anovulation (lack of ovulation). They pain may or may not be related, and additional investigation may be warranted should hormonal intervention (the birth control pill) not help. You should raise your concerns about a bigger problem with your doctor, since this is a very reasonable and important concern. 

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

David Toub, M.D.  

  Question: C-Section Scar is causing Pain
For 2 years I have had a sharp, tender to the touch pain, on the right side of my c-section scar (of 10 years).  The pain is at times so severe, it hurts for my children to sit on my lap or to receive hugs.  This is not a cramp but more like a sharp, dull stinging sensation.

My OB put me on oral contraceptives to possibly alleviate the pain.  This has not helped.  The pain is at its worst a week after I'm off my cycle, but then again it comes and goes at all times.  He has also done sonograms on that area that have shown nothing.  I sometimes think that it is scar tissue on my c-section scar.  But then again it's right were my right ovary would be.  Do you have any suggestions?  

Answer:
There are several things that could be going on, with a scar-related problem high on the list. Sometimes there can be a trapped nerve within the scar that can cause pain. You may want to ask your doctor if a consultation with a general surgeon might be appropriate. It is not clear if a laparoscopy would be indicated, since it is not clear that the source of pain is within the pelvic cavity. But laparoscopy is an option depending on the situation. Pain management should also be discussed with your doctor. 

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

David Toub, M.D.

  Ovarian Pain

Question: Ovarian Pain?
My wife has been complaining of pain on the lower inner quartile of her right buttock and lower left back since last August. An ultrasound detected fibroids and she had a partial hysterectomy last December but the pain has continued.  An MRI detected a 4cm follicular cyst on her left ovary but this has disappeared.  She also still has a lot of abdominal inflammation. The pain on her butt is accompanied by pressure from within the rectum. During the last three months she has noted a monthly cycle as regards the acuteness of the pain. Can her ovarian problem cause this pain?

Answer:
I hesitate to say the word "never," but an ovarian cause of pain is not at the top of my list of possible diagnoses, particularly since the cyst resolved on its own. Your wife's symptoms are more suggestive of either a GI problem, or an unusual case of endometriosis involving the GI tract (which is atypical, since there is no mention of bloody stools, for example).  Consultation with a gastroenterologist may be appropriate. Regardless, your wife's physician can discuss possible course of action with her, including what additional testing and intervention may be recommended by him or her.

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

David Toub, M.D.

Hysterectomy Pain

Question: Post Hysterectomy Pain
I am 40 years old.  I had a hysterectomy when I was 36 and left in the ovaries.  Due to constant chronic pain, I had them removed 18 months later.  Since then I have had a burning pain and constant ache on the left side.  I can not do any heavy lifting and have had trouble with my bowels ever since the last operation.  Could this pain be from adhesions; could my bowel have scar tissue forming on it?  My doctor thinks the pain is probably being caused from scar tissue.  What are my options for treatments?

Answer:
I would defer to your doctor's informed opinion, since it is certainly possible that adhesions are involved. There are many other reasons for abdominal/pelvic pain as well, and additional evaluation may be indicated depending on your doctor's perspective. Whether or not treatment is indicated depends on many factors, which your doctor can best assess. Treatment and management options would include pain medication, management by a multidisciplinary pain center, biofeedback, a TENS unit, etc. Laparoscopy with lysis of adhesions is also a viable therapeutic option, and requires surgery. Adhesions can also return, unfortunately, after any surgery, since all surgery can cause additional scar tissue to form. You should discuss all possibilities with your doctor. 

Thank you for your e-mail!

David Toub, M.D.  

Endometriosis & Adenomyosis

Question: Endometriosis / Pregnancy / Pain 
Does the degree of pain associated with endometriosis reduce during pregnancy?  Currently, I'm 6 weeks pregnant and in a lot of pain.  I have had ultrasounds showing that the pregnancy is progressing very well. 

Answer:
Because of the constant, high level of estrogen and progesterone during pregnancy, it is not uncommon for endometriosis to regress temporarily during pregnancy, although this may not happen to 100% of pregnant women. Observations of improvement in endometriosis symptoms in pregnant women gave Kistner the idea of using continuous birth control pills to treat endometriosis during the 1950's; continuous oral contraceptive use simulates pregnancy, and this treatment  is also known as the "pseudopregnancy" regimen. You may want to just double-check with your doctor that the pain is indeed due to endometriosis and not some of the other things that can occur during pregnancy. 

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

David Toub, M.D.  

Question: Adenomyosis & Pregnancy  
I have just been diagnosed with adenomyosis and am undergoing IVF treatment.  My pain during my period is unbearable and my fertility doctor said I will need to have a hysterectomy due to the extent of the disease, but he wants to try and get me pregnant first. Can you even get pregnant with adenomyosis?  I don't even really know anything about this disease except that it is unbearable.

Answer:
To the best of my knowledge, adenomyosis should not interfere with pregnancy. In some cases, pregnancy may temporarily improve the symptoms associated with adenomyosis. I would also ask about the certainty of the diagnosis, since this is a condition that often is not diagnosable except after examination of the uterus at the time of hysterectomy. MRI scans can be helpful in confirming the diagnosis when suspected on clinical grounds (such as when a woman has cyclical pain, bleeding and a diffusely enlarged uterus). Because other things can cause similar symptoms, it is helpful to have a thorough evaluation before entertaining treatment such as a hysterectomy. Adenomyosis often is best treated with hysterectomy, although some women may benefit from attempts at hormonal manipulation and other interventions first. Hopefully, hysterectomy will not be necessary in your situation. 

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

David Toub, M.D.

Question: Adenomyosis and Pelvic Congestion
I have had two laparoscopy's in the past 14 months and have been diagnosed with adenomyosis and pelvic congestion.  While I do experience the heavy bleeding associated with adenomyosis, most of my pain is not during my period.  The pain I experience is always in my left hip and it radiates down my leg making it very painful to walk.  I have also had repeated cysts on my left ovary.  My doctor is recommending a complete hysterectomy, I am 40 and do not want anymore children.  I am concerned about HRT if I have my ovaries removed.  Do you think complete hysterectomy is my best option?

Answer:
Whether to remove the ovaries is again a matter for discussion with your doctor. As far as HRT, for many women any potential risks (many of which remain controversial and/or unproven) often are outweighed by the significant benefits such as osteoporosis prevention. But this is also something for your doctor to discuss at length with you. My suggestion is that you have a very thorough, detailed discussion with your physician about all of your excellent questions. 

Thank you for your e-mail!

David Toub, M.D.

Question: Medication and Endometriosis
I have had several surgery's to determine the cause of my pain.  During a laparoscopy they found endometriosis, adhesions, fibroids and scar tissue.  My back pain and pelvic pain was better for a while but returns after each laparoscopy.  My doctor feels there maybe endometriosis in places that the laparoscope can't see and has suggested vioxx  for pain.  Have you had any luck with this drug and is it possible that there could be endometriosis hiding somewhere that would affect my back? I have tried the Lupron shots without any success.  I just turned 42; will menopause cure endometriosis? I have been suffering for a long time and am beginning to get real depressed.  

Answer:
Menopause will generally "cure" endometriosis, but you may have many years to go before menopause, and on occasion endometriosis may persist after menopause. Whether or not endometriosis is responsible for your back pain is hard to say, and perhaps additional investigations might be performed to evaluate other potential causes of your symptoms. If you are not having relief with GnRH agonist drugs like Lupron, it raises the question of whether endometriosis is responsible for your current symptoms.

You may want to ask your doctor for his or her experience with the pain medication that was prescribed. Pain control, however, is certainly a reasonable intervention.

Thank you for your e-mail!

David Toub, M.D.  

Question:  Endometriosis Pain
I am 30 years old and have experienced severe menstrual cramps since age 13.  I have 2 children and have miscarried 4 times. My doctor performed exploratory surgery and confirmed that I have moderate endometriosis. He has suggested a full hysterectomy or 6 months of hormone therapy. My mother and aunt both went through the same pain, both had hormone therapies with unbearable side effects. They have both had full hysterectomies at early ages and regret it. I realize there is no cure for this condition and since I am not yet ready for hormone therapy or hysterectomy.  I want some pain control. I have been prescribed several mild pain relievers. In addition, I have exercised, meditated, prayed and tried every other form of relaxation I can think of. I have also taken Vicodin for the pain and have found this to be the only medication to alleviate my pain. My problem is that my doctor will not prescribe any pain medicine because he wants me to go on hormones. I believe this is my decision but I can't seem to get this across to him.  Your opinion would be greatly appreciated.  

Answer:
While I mean no disrespect to your doctor, it may be time to consider consulting another physician. Regardless of whether or not you are interested in hormonal treatment or surgery, pain management is absolutely essential. Also, there are many options besides hysterectomy for endometriosis, and hysterectomy should be considered a last resort for most women.

It is also not clear to me from your description if the endometriosis has anything to do with your symptoms. Endometriosis does not cause miscarriage nor is it the only thing that can cause severe menstrual cramps. Given that you have had menstrual cramps since age 13, your problem may be more along the lines of primary dysmenorrhea (painful menstrual periods) than anything else. Generally, nonsteroidal anti-inflammatory medications are often useful, and there are other potential treatments as well.

So to make a long story short, you might consider a second opinion, particularly from someone with expertise in the area of chronic pelvic pain and dysmenorrhea. 

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

David Toub, M.D.

  PID & Infections

Question: Endometritis
I have been battling endometritis for 7 months, have tried several different medications for anywhere from 10 days to 30 days.  I am fairly pain free as long as I am on the antibiotics but shortly after they are gone I am in severe pain and will start spotting.  Tests indicate the infection is caused by group B Strep. What is the next step? A D & C is what my doctor has suggested.  My youngest child is 4 am I safe to assume it isn't anything retained in my uterus from delivery? What could be causing this? Is my husband passing it back to me?

Thank you for your time and your expert opinion!

  Answer:
Four years is an awfully long time to pass before retained tissue causes an infection, so it likely is not due to retained tissue. However, Group B Strep endometritis (an infection of the uterus) does not commonly occur in the absence of recent childbirth or uterine instrumentation (like a D&C, etc). One thought (and again, only your doctor can provide an informed opinion as to the diagnosis) is that the group B Strep is a red herring.  Group B Strep is often found in the vaginas of asymptomatic women. It is hard to eradicate for good, which is why obstetricians do not generally treat vaginal Group B Strep (GBS) before the onset of labor, since it commonly returns after treatment. In other words, if you repeatedly culture the same woman who is prone to carrying GBS, culture results will invariably turn positive at some point. GBS usually responds well to antibiotics, so it may be that you either have a resistant strain or are just prone to re-infection (GBS can often reside in the rectum, making re-infection of the vagina more likely). Cipro is pretty broad-spectrum , so that it will usually kill many forms of sensitive bacteria.

Unless you are having fevers, abnormal uterine bleeding and/or significant uterine pain on examination, GBS endometritis is unlikely. Some women do have a chronic endometritis, but this is often due to other types of infections like tuberculosis and mycoplasma.  A D&C could be diagnostic as it would allow direct evaluation of the uterine lining for evidence of bacteria. But you may also want to ask your doctor if the GBS is causing an endometritis per se or if it's just hanging out without causing any problems.

Again, I'm not saying that it isn't endometritis, but that the diagnosis needs to be clearly made before continuing antibiotics and embarking on more invasive evaluation such as a D&C. 

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

David Toub, M.D.

  Question: Gardnerella Vaginalis
Please can you explain to me what Gardnerella Vaginalis is.  I apparently had this bacterial infection and my GP believes it may have resurfaced. I appreciate your time.

Answer:
Gardnerella vaginalis, also known as bacteroides vaginalis (or BV) is a very common vaginal infection. It causes a discharge and possibly itching, just like yeast, and is not sexually-transmitted or particularly harmful (other than the obnoxious discharge). In pregnant women, however, there is evidence that BV can increase the risk of preterm labor and other pregnancy complications.

It is common to have recurrent episodes of BV even with appropriate treatment. You should consult your doctor about any possible symptoms and the infection, once diagnosed for certain, can easily be treated with antibiotics. Good luck, and thank you for your e-mail!  

David Toub, M.D.

Adhesion Pain

Question: Chronic Pelvic Pain and Adhesions
I recently had my third surgery for adhesions and pelvic pain.  I had a hysterectomy, anterior/posterior repair, and bladder tuck.  I have been told that there is really nothing that can be done for the adhesions except for the laparoscopy.  I am at my wits end!  My medical problems helped break down my marriage.  I would love to live without all of this pain!  Please offer any suggestions!

Answer:
Personally, (and this is just my opinion, for what it's worth), I would be hesitant to suggest additional surgery. All surgery can result in additional adhesions even in the best of circumstances, and if three operations for adhesions have not been successful, I would be skeptical that additional surgery would be the solution. There are other approaches besides laparoscopy. At this point, you should ask your doctor about possible referral to a multidisciplinary pain center. This involves a team approach, with specialists in GYN, anesthesiology, urology, gastroenterology, psychiatry and even complementary alternative medical specialists in some settings. The emphasis should now be on managing your pain so that you can get on with your life. While generally only 50% successful (or less), multidisciplinary pain centers can be among the most successful management options for patients with chronic pain. So you should discuss this and other options with your doctor. 

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

David Toub, M.D.   

Question: Is a Laparoscopy appropriate?
I have had chronic pelvic pain, off and on for several years.  The pain worsens with deep sexual intercourse.  At least 3 times it was severe enough for a trip to the ER.  A full bladder makes it worse, pressure on my lower abdomen increases it as well.  My cycles have also become much longer, 35 to 41 days.

In all cases they stated it was a ruptured ovarian cyst.  My GYN suggested a laparoscopy in order to clean out scar tissue that may have been caused by the rupturing cysts.  A 2nd opinion, said scar tissue would NOT cause pain.  An ER doctor suggested the possibility of be endometriosis.

I am 28 and can not use hormones due to hypertension.

Are there any more conservative treatments/tests in order to avoid a laparoscopy, or is that the next logical step?

Answer:
It would not be appropriate for me to recommend a particular course of treatment (only your doctors can do that!). However, I would beg to disagree with the doctor who maintained that scar tissue does not cause pain, since adhesion-related pain is well-documented in the medical literature, and is consistent with clinical experience as well.

I would be suspicious of endometriosis, and a laparoscopy would be the best way to rule this diagnosis in or out. However, medical intervention may be an appropriate preliminary step if you (understandably) wish to avoid surgery. Appropriate pain medication, hormonal intervention, etc. may be helpful, but again laparoscopy would allow diagnosis and treatment if endometriosis is present. If the laparoscopy is negative, at least you would know that your pain is not due to endometriosis or scar tissue, allowing you to focus on management of your symptoms. I would also recommend that an expert laparoscopic  surgeon be involved if laparoscopy is chosen, as small areas of endometriosis can be missed on casual inspection. Conversely, not everything that looks like endometriosis is in fact endometriosis, so biopsy of suspicious areas may be useful at the time of surgery. 

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

David Toub, M.D.

Syndromes & Abnormalities

Question: Weak Tissue Disease?
I saw my doctor for pelvic pain and painful intercourse.  I was told I had a "rip" and my doctor thought it is from a rare weak tissue disease.  I am waiting for test results and then will do a biopsy. Apparently, this disease will cause the tissues to continue reopen or rip each time.  Have heard of anything like that?  What the name is and is there treatment to where I can have a normal, non-painful sex life?  

Answer:
Without knowing the particular disease in question, it is hard to say. I would defer to the results of the test and biopsy which your doctor will be providing. 

Thank you for your e-mail!

David Toub, M.D.

  Other Questions

Question: Fibroids & Pain 
I have 3 small fibroids, the largest, 2 inches in diameter diagnosed by ultrasound.  I have chronic, gnawing lower abdominal pain.  I had colonoscopy and ultrasound and the fibroids were all that could be seen.  I am 48 and have heavy periods every 24 days.  I was also, diagnosed 20 years ago with endometriosis.  My doctor doesn't seem to think that the fibroids should be causing any pain.  Can fibroids cause pain?

Answer:
Fibroids absolutely can cause pain, but it is questionable how much pain small fibroids can cause in most cases. 2 inches is about 5 cm, which could be painful in some cases, but your doctor is appropriately skeptical since other things can cause abdominal pain in a 48 year old woman. Endometriosis can also cause pain, but it is less common in a woman your age. You will be relieved to know that fibroids and endometriosis generally regress after menopause.

However, I would be concerned about the presence of abnormal uterine bleeding at your age. While it could be due to the fibroids (besides pain, they can also cause bleeding), abnormal uterine bleeding in a woman over 35 should generally be evaluated with some form of uterine sampling. A biopsy of the uterine lining is typically performed, either in the office (endometrial biopsy) or operating room setting (e.g. D&C, hysteroscopy). If the uterine lining has not already been evaluated, you should ask your gynecologist whether he/she feels this is indicated. 

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

David Toub, M.D.  

Question: Pelvic Congestion & POCS
I have an I.U.D., heavy bleeding, and constant pain (not just during my period).  I had a laparoscopy four weeks ago where I was diagnosed with PCOS and pelvic congestion.  I want to know if there are any other possible treatments for my problems. I have taken the pill ( I think I have tried them all) and I either have break through bleeding or no menses at all, along with headaches. I was told that hysterectomy is a good option but my doctor refuses to perform the surgery because I am so young, 23 yrs. Should I seek a second opinion and are there any other treatment options?

Answer:
I would share your doctor's reticence to perform a hysterectomy, particularly when there are many other options. While I don't really subscribe to the diagnosis of pelvic congestion (this remains somewhat of an unproven and inconsistent entity), there are many ways to treat PCO, and hysterectomy is generally not indicated. While the PCO would explain the heavy bleeding, it does not have anything to do with chronic pelvic pain, so I would want to investigate other possibilities, which might involve an MRI scan, consultation with a urologist and/or gastroenterologist, etc. PCO is generally treated hormonally, but if that is not well-tolerated there are options such as ovarian drilling (a laparoscopic procedure), and treatment with ovulation induction agents. While breakthrough bleeding is problematic, it may be more acceptable to some patients than constant bleeding, or at least preferable to more radical treatment, so you need to weigh all the risks and benefits of any treatment option.

As far as the pain, hysterectomy may not be curative or even indicated, at least not without trying many other things and getting a better idea of what is causing the pain. Again, pelvic congestion syndrome is a nebulous diagnosis and one that has variable support in the medical literature. You should consult your doctor about the possible need for additional evaluation and treatment. A second opinion is also a potential option as well.

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

David Toub, M.D.  

Question: Pelvic Pain caused by Scarring
I am 19 years old  and I have pelvic pain that is caused by scarring.  I have also had cysts on my ovaries and tubes, could this have something to do with the scarring?  What would have caused scar tissue to form in the first place and what are my treatment options?  

Answer:
For a more definitive and individualized answer, I would refer you to your gynecologist. In general, scar tissue at your age could be due to endometriosis or a previous pelvic infection which may have been silent. Without knowing more about the laparoscopic  findings, it is hard to say if the cysts are related. By the same token, your doctor is in the best position to give you potential treatment options, and he/she is the most appropriate person for this task as well.

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

David Toub, M.D.

  Question: Retroverted Uterus
Is it possible that a tilted uterus could press on a rectum causing difficult elimination and back pain?  If so, what type of treatment would help to minimize the problem?

Answer: 
Retroverted (tipped backwards) uteri rarely cause major problems and generally do not require treatment; this is a normal variation. However, in occasional women a retroverted uterus can cause pain in the sacral region and even affect bowel movements, particularly if the uterus is enlarged due to fibroids or some other disorder. Treatment can vary-if the problem is due to a fibroid, removal of the fibroid may be helpful. A pessary, which is a vaginal device that can be inserted in the office by your gynecologist, can also be beneficial, but intercourse may not be feasible. The uterus can be suspended surgically, either through laparoscopy or a larger incision. Finally, hysterectomy is a last resort but can eliminate the problems associated with a retroverted uterus.

I would offer some words of caution, however, at this point. There are other things that can cause constipation and back pain, and unless the uterus is enlarged it would be unusual in my experience for a retroverted uterus to cause symptoms. Too many uterine suspensions and hysterectomies are performed for borderline indications in my opinion, and often without any measurable benefit to women. So you should consider asking your doctor about other reasons for your symptoms, and which intervention is appropriate for your individual situation. 

Thank you for your e-mail!

David Toub, M.D.

Question: Tilted Pelvic?
I am 28 and I had a tubal ligation 4 years ago.  Last year I began to have severe pain during my menstrual cycle and was bleeding every other week.  On the first day of my cycle I use at least 10 pads and change them hourly.  The doctor there said I had a hormonal imbalance and that I have a "tilted pelvic."  What does that mean and would it cause severe pain and very heavy bleeding?  

Answer:
I have no idea what this means either. He/she may be referring to a "retroverted uterus" which simply means that your uterus is tipped back rather than tipped upwards. Women normally have one or the other, just as some people have blue eyes and others have brown eyes. A retroverted uterus is not abnormal in most cases. It would not cause heavy bleeding, and generally has nothing to do with pain unless there is something else going on such as endometriosis. While women with endometriosis may have a higher incidence of a retroverted uterus (and I'm not sure this is absolutely proven), the position of the uterus per se has nothing to do with pelvic pain. Endometriosis can cause abnormal bleeding and pelvic pain, although it is less likely in a woman after a tubal ligation. In any event, additional evaluation is necessary. Also, "hormone imbalances" do not cause pelvic pain, so I'd consider other possibilities first. 

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

David Toub, M.D.  

  Question: Bleeding After Intercourse & Pelvic Pain
For the past 5 months I have been getting a sharp pain in my lower abdominal area.  I also have started to bleed after intercourse.  I went to my regular doctor and he diagnosed it as IBS, however, I have no other symptoms to indicate that.  Should I get a second opinion? Your help is greatly appreciated.  

Answer:
While lower abdominal pain can be due to many things including irritable bowel syndrome, postcoital bleeding has nothing to do with IBS. It would be a good idea to consult your gynecologist, and particularly make sure your Pap smears are up to date and normal. A second opinion never hurts, and does not mean that the original opinion is incorrect. Most doctors know this, and should not have any hesitation about their patients asking for second opinions, as I'm sure is the case with your regular doctor. Good luck, and thank you for your e-mail!  

David Toub, M.D.    

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