Ask The Expert

This month's topics

Thank-You for Hope
Thank-you for your article on Chronic Pelvic Pain, which I am a candidate of. It was very intriguing and I will discuss with my doctor.

I have chronic pelvic pain before my period begins, while I have my period and after.  All in all, I have a few good days a month!  Also with this symptom are others, such as tiredness, nausea, lower back pain, irritability, etc.  This has been going on for approximately 5 years now.  I have been told by 2 OB/GYN's that they could do nothing more for me and that it was "in my head."  I have had an ultra-sound, laparoscopy, C-125 tests, thyroid tests, etc., all to no avail.  I have been on and off the birth control pill for about 20 years, and the pain has increased. I took myself off the pill because it was not helping anymore.  My primary care physician is the only one that has any sympathy in this regard, and he and I are trying to find out the cause.  I have been researching this on my own due to his information being limited in this field.  He sent me to a second OB-GYN who, after a few months, threw her hands up in the air and said that she didn't know why I was still having the pain after the laparoscopic surgery she performed.  Needless to say, I never went back to her. These doctor's don't want to be bothered and have no idea why.  I even copied all of my files from the past 10 years, along with symptoms, etc.  She never looked through the folder, just at the summary I put together on the first page.  At that time we thought maybe it was endometriosis.  I am very frustrated with the whole OB-GYN thing. My first encounter with my original OB-GYN was that I needed a psychiatrist!  No one wants to take the time or energy to find out what is really going on and I came to the conclusion that I will have to live with it--this is just me.  Then I read your article and started researching again--Thanks for giving me hope and I will go back to my primary care doctor and talk with him again, being he is the only one who will listen.  Maybe we can try another method.

Reply:
Thank you for your kind words. I hope that your primary care doctor can provide some relief, and urge you to not give up! If you're not getting somewhere with any physician, there are others out there who would be glad to be of service. 

All the best, 

David Toub, M.D.

Chronic Pelvic Pain

Question: Chronic Pelvic Pain
I'm 23, and I have had pain in my lower abdomen for at least a year now. I've been to six different doctors and have had several surgeries with no answers. After the second surgery they told me I had endometriosis and put me on Lupron for 6 months. I was in pain the whole time, so they did exploratory surgery with uterine suspension. This time they tell me I don't have endo, the lab came back negative and they don't know why I'm in pain. I've tried a Lumbar Block; that didn't work and the pain is increasing, getting sharper, on both sides. I am in continuous, extreme pain. Nothing ever helps. What can I do? What causes pain all the time? Should I have another exploratory surgery?

Answer:
Unless there is uncertainty regarding the findings at the time of your previous operations, there may not be an obvious benefit to another operation for diagnostic purposes. That is a  decision for you and your physicians to make based on a thorough knowledge of your situation, examination, and other medical data. Assuming a thorough evaluation has been performed, including consideration of GI and urologic causes in addition to gynecologic disorders, it may be useful to consider additional options for pain management, both with your physicians and additional specialists if needed. A multidisciplinary pain center may be a useful source for consultation if desired. Please follow-up  with your doctor or other healthcare provider regarding how to proceed from here. 

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

David Toub, M.D.   

Question: Chronic Pelvic Pain
I just had laparoscopic surgery in June because my doctor was going to laser endo. When she got in, she didn't see anything but my uterus was boggy and everything was very congested and swollen. She diagnosed me with adenomyosis and has given me options of medical management. My question is, my husband and I never have sexual intercourse anymore because the pain in my lower pelvis is to severe. I also continue to have severe pain in my lower back. Is this all caused by adenomyosis or could there be something else that I should be concerned about? If I do the medical management, which is going to be Depo-Provera or Lupron Depot, should I have relief from the pain in my pelvis or is it just going to relieve it a little. All the information I find on the internet is just about the same. I am trying to find a way to have a marriage with my husband and not hurt all the time. Is there something I can request from my doctor for the pain? Please help or give your advise.

Answer:
You may want to discuss pain management with your doctor, and also ask if the diagnosis is fairly clear-cut. The reason is that adenomyosis can be difficult to diagnose without resorting to a microscopic examination of a hysterectomy specimen, although MRI and other techniques can be suggestive of adenomyosis, as can a laparoscopic exam as your doctor has performed. An enlarged, boggy uterus, however, is certainly consistent with the diagnosis, but I would also ask if other possibilities should be considered as well.

Hormonal manipulation certainly is a good option, and you have my best wishes that it will be successful. As far as the extent of pain relief you will experience, that is not possible to say with any certainty, but you should also ask your doctor for his or her opinion as well.

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

David Toub, M.D.

Question: Pelvic Floor Muscle Spasms
I have been told I have Pelvic Floor Muscle Spasms and I am currently undergoing Physical Therapy for the condition.   What can you tell me about the condition in regard to causes, treatment and prognosis?

Answer: 
I would defer to the advice and guidance of the providers currently caring for you in terms of specific and individualized details. 

Thank you for your e-mail!

David Toub, M.D.

Question: Chronic Pelvic Pain
I am 24 years old and have 3 children. A year and a half ago I had my tubes tided after my last baby was born.  Within 3 weeks I started having bad pain. I went to my doctor and he gave me pain killers but they didn't always help. He suggested I see a psychologist so l I looked for another doctor.  He did a laparoscopy and found only little cysts.  I am getting frustrated because it has caused me to lose my job twice; it affects my home life, my kids have been in and out of the emergency room a lot and nobody will give me a straight answer.  I recently went into the ER and they found a tubal pregnancy, a cyst  had burst and I had internal bleeding, so they did emergency surgery.  I'm still hurting so they did more tests and suggested I take the pill to stop the cramps. It's really bad at that time of the month but it is pretty constant. At times I can tolerate it but other times I cannot, especially while I'm working. I almost lost my job again. I'm tired of not getting answers.  He did suggest a hysterectomy but I'm so young.  I'm tired of calling to get an appointment to see him and feeling so dumb at times. There is obviously something wrong with some women, even when they have not found what it is.  I'm angry, my boyfriend is angry, and I'm tired of hurting. I am on Medicaid and at times I feel that I'm not being treated as well as I would, if I had better insurance. I don't have the money to go to a specialist but I need someone to listen and follow through with the answers they give me. What else can I do?????

Answer: 
I sympathize with your situation. You should not hesitate to seek out appropriate medical care, and I would also suggest that you ask about other methods for managing your pain besides hysterectomy. 

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

David Toub, M.D. 

Ovarian Pain & Cysts

Question: Dermoid Cysts 
I have been diagnosed with a dermoid cyst on my right side that is 5.0 cm and have been told that it must be removed because that mass should not be in my body.  I experience a little pain on my right side especially during my period but nothing I can't live with. I would like to hear your thoughts on dermoid cysts and it's removal.  I was told that it can grow teeth and hair is that true? Have you ever diagnosed a patient with this type of cysts?  I would appreciate your feedback.

Answer: 
Dermoid cysts are not at all uncommon, and are benign tumors of the ovarian germ cells. Because they are germ cells, they can develop several types of body structures, including teeth, hair, sebum, etc. In general, your provider is quite correct in recommending its removal for many reasons. First, the diagnosis needs to be confirmed since in unusual cases, the tumor may not be a benign dermoid but something more ominous. Second, the cyst can continue to grow, and if ruptured the sebaceous material can cause a significant inflammation of the abdominal lining (peritoneum) resulting in scar tissue and even infertility. Finally, on occasion the ovary containing a dermoid (or any benign or malignant growth for that matter) can twist on its blood supply, resulting in ovarian torsion and, in some cases, require removal of a gangrenous ovary.

Dermoid cysts may be managed either laparoscopically or through laparotomy, depending on the physician's preference and nature of the cyst. In addition, either the dermoid may be removed with preservation of the ovary or, in some cases, the entire ovary may need to be removed. There are many factors involved in the decision as to whether or not the ovary needs to be removed, and you should certainly discuss this with your doctor for individualized guidance. 

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

David Toub, M.D.

Hysterectomy Pain

Question: New Pain Post Hysterectomy
My wife is 48 years old and had an abdominal hysterectomy & ovaries removed 9 months ago. She had fibroids and endometriosis in her uterus. After recouping she was fine for 3 months, then a new abdominal pain came worse than anything she had before.  She just had her appendix out but that wasn't the problem because the pain is back. They found endometriosis in the appendix so she's been off hormones but the pain still comes about every 2  weeks. The doctors are completely baffled. Do you have any ideas what could possibly be causing such excruciating pain that lasts a few days every 2 weeks?

Answer: 
Even with the removal of both ovaries, it could be endometriosis, although the fact that the pain is cyclic is unusual in this circumstance. It could also be due to adhesions, or any of a number of gynecologic, GI and even urologic causes. I would certainly suggest that she pursue continued evaluation and management through her current doctors, with second opinion consultation if needed.

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

David Toub, M.D. 

Question: Post Hysterectomy Pain due to Misplaced Ovaries?
I'm 30 years old and I've had 3 pregnancies, 2 live births and one miscarriage. In 1992, I had a C-section with my son; I was 21 years old.  When I was 24 I had to have a hysterectomy due to heavy bleeding. They left my ovaries, now I'm having really bad pain in my lower stomach. I had a ultrasound in July and they found both of my ovaries are on the right side. My stomach is so tender, my clothes even hurt it to touch. Could you please explain, this I can't take the pain anymore.

Answer: 
Whether or not the position of one or both ovaries is responsible for your pain is hard to say without the benefit of a clinical evaluation in person, so your best source of guidance would be your own gynecologist or other physician. He or she would also be in the optimal position to discuss the ultrasound findings. In addition, because you are in severe pain, it is important to contact your doctor to determine how to proceed. 

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

David Toub, M.D. 

Question: Post Hysterectomy Pain 
Thank you for your website.

I am a 58 year old, married teacher, wanting to enjoy intercourse but in too much abdominal pain to do so. Things were good after my recovery from a hysterectomy I had last August. In the last four months, I have been in pain. I still have my cervix.  How is this attached or is it? Could it somehow attach itself to the rectum or colon? I am dealing with pelvic pain which worsens after walking or being on my feet for more than an hour. A recent sonogram shows varicose veins in the pelvic area, (not anal area). I have had problems with constipation which are being resolved after visit with gastroenterologist and negative sigmoidoscopy. What enlarged veins in the pelvic region and what can be done?

Answer: 
Thank you for your kind feedback. The cervix is attached by connective tissue, including the remnants of the uterosacral ligaments. If adhesions have formed, which is common after pelvic surgery, there may be some scar tissue between the cervix (the portion within the abdominal cavity) and bowel, and this might be an explanation for your pain, although this is best determined by your physician. The fact that a sigmoidoscopy was normal is good, since GI pain can also be confused with gynecologic pain. However, it may be useful to ask your gastroenterologist if he/she is certain that there is no evidence of diverticulitis or other GI disorders that can result in pain. As far as the enlarged veins, it is not clear if this is a genuine cause of pelvic pain or not, so it is not possible to say anything one way or the other with any certainty. Regardless, it is important that you consult your gynecologist and other providers to determine what is going on and how best to manage it. 

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

David Toub, M.D. 

Endometriosis & Adenomyosis

Question: Ablation for Adenomyosis
I was diagnosed with adenomyosis by 2 different MD's. The last one put me on a low dose birth control pill which he said may help. This is a well known, well thought of physician. The problem is everything I have read on the Internet says that pills make the symptoms worse. Further adding to my confusion, my sister was treated for this condition over 10 years ago with an ablation. It took away all of her pain,  yet whenever I mention this to a physician (3 gyn's and a radiologist) they look at me like this cannot be so.  They have all said that ablations do not help symptoms of adenomyosis. Obviously, this is not the case, at least not all of the time. I would very much appreciate any information you have about treatment for this very painful condition. Also, I read an ad today in a magazine about a balloon procedure for heavy periods. The company involved is mailing me information about it. I went to their web site and adenomyosis was not listed as a contraindicated condition. Do you have any information about this procedure? Once again thank you for any information you can provide.

Answer: 
Unfortunately, I would tend to agree with the three gynecologists and the one radiologist; endometrial ablation can be effective for appropriate women with excessive uterine bleeding of a benign origin. It is considered generally ineffective as a pain treatment, nor is it particularly efficacious in women with fibroids and adenomyosis. I'm not ruling out that a very rare patient with adenomyosis can benefit, but I would find this an unusual occurrence. In addition, as adenomyosis can be very difficult to diagnose clinically, even in the best of hands, it is hard to say with any certainty that your sister's situation was definitely due to adenomyosis, which further complicates any decision. I would suggest that you discuss this further with your gynecologist, as ablation is not appropriate for all women with abnormal uterine bleeding. 

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

 David Toub, M.D. 

Syndromes & Abnormalities

Question: Bicornuate Uterus 
What exactly is a bicornuate uterus and could it be the reason for having severe cramps?  Are there any treatment options?

Answer: 
A bicornuate uterus is a developmental abnormality in which the uterine cavity is divided into two "horns" or sections, but with a single cervix. I am not aware of any link with painful menstruation, but regardless, please discuss appropriate pain management options with your doctor or other healthcare provider. In addition, if you have been told that you do have a bicornuate uterus, it will be important for your provider to discuss what this all means, and any implications, particularly since in occasional women there can be associated urinary tract abnormalities as well. 

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

David Toub, M.D.

Question: Physical Deformity 
My daughter who is 16, informed me today of an uncomfortable gynecological condition.  We live in China where good medical help is not always easy to get, so your reply will help me to determine what I should do next.  Her condition is that she has an extra flap of skin about 1 1/2 cm in length, hanging down from one side of her outer labia.  It is painless, but bothersome.  Upon examining her, I noted that her inner labia seem to be absent, which startled me, since all her genitalia were normal at birth and through potty training.  Of course I have not seen these private parts for years, and she was unsure that anything was wrong.  Her outer labia seemed larger than normal, (though I cannot say I have much knowledge about how big is abnormal.)  They seemed large and thick, and I thought it could be that her inner labia is just small and difficult to see in light of this.  Have you ever heard of such a phenomenon, and what should I do? 

Answer: 
It may be just a normal variation in the length of the labium majus, which does occur on occasion. I'm more concerned about the apparent absence of the inner labia (labia minora), since on occasion this can be seen in lichen sclerosis. It may or may not be anything of concern (other than cosmetic appearance), but it is best to have your daughter examined, despite the difficulty in obtaining medical care. 

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

David Toub, M.D. 

PID & Other Infections

Question: Infection or Allergy?
I need help! I have had normal intercourse with my partner for 3 years. It has been almost a year now and every time we have intercourse my outer lips get red, swollen and a cut that bleeds appears on the bottom area. I have gone to numerous doctors and nothing seems to help. I do not have a yeast infection or a bacterial infection, although doctors did find I did one in the beginning and I was treated. How do I stop this from happening and where can I go to find a competent OBGYN.

Thanks for this great website!

Answer: 
Thank you for your kind words! As to where to find a competent Ob/Gyn, that is beyond the mission of this forum, and I would suggest you ask your friends/colleagues and also consult local hospitals and providers. It is not possible (nor is it appropriate) to determine what exactly is responsible for your situation, but you may want to ask if it relates to a latex allergy (assuming condoms are used) or some other allergic reaction. It would also be important to describe the details with your provider, since it may also relate to trauma, although this is not common in my experience. 

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

David Toub, M.D.

Surgery Pain & Adhesions

Question: New Adhesion Treatment??  
I had my second laparoscopy 3 years ago after 6 years of chronic pelvic pain.  In '98 my post operative diagnosis was "massive pelvic adhesions."  Laser adhesiolysis was performed and the doctor told me that he had applied a material to retard the re-growth of adhesions.  I was completely pain free for two and a half years.  In the last 6-9 months have I begun to have moderate and at times severe pain.  I have seen a new gynecologist and provided him with my op report from '98, he told me that there are new treatments for adhesions.  He could do a lap, however there is an open procedure that is very successful in retarding adhesion re-growth.  If the adhesions are very severe, he my have to do a complete a hysterectomy, possibly bilateral oophorectomy as well.  My questions are: 

• Can you tell me what you think the new open procedure is? What the material used and if in fact it could be done laparoscopically? 
• How likely is re-growth of abdominal adhesions, even after a total hysterectomy?  Bottom line is, will I need to periodically have surgery to keep me pain free?  Thanks for your advise!

Answer: 
I would suggest you clarify with your gynecologist which procedure or material he/she is referring to. Most of the ones I am intimately familiar with can be effective to some degree in appropriate situations, but not all cases are suitable. For example, one product is markedly less effective in the presence of blood, while another forms a permanent barrier that may or may not need to be removed at a later date. Regardless, no technique or material has been proven to prevent new adhesions in 100% of patients, and many former treatments that were once widely touted have been disproven (i.e. intraperitoneal antibiotics and heparin).

Any surgery can (and usually does) create new adhesions, even laparoscopy. While laparoscopy in general has a lower probability of adhesions, pretty much any time the peritoneal cavity is entered adhesions can result. What you will need to weigh with your provider's expert input is whether the potential benefits (both short-term and long-term) outweigh the potential short-term and long-term risks. Please discuss this further with your doctor or other healthcare provider, as his or her guidance is essential.

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

David Toub, M.D.

"For more information about adhesions and their treatment, please visit the International Adhesions Society" 

Question: Adhesions Do Cause Pain! 
I had surgery in 1990 for adhesions around my bowel, and again in 1991 for adhesions around the bowel and my right ovary. My doctor at that time told me I might get them back. I now have a lot of pain on my right side going into the hip area. The pain is getting worse and covering more area. I need to know what to do. My family doctor sent me to a surgeon and he told me that you don't have pain with adhesions and wanted me to have a nerve block, which I refused. I know the pain I have, is the same as before.  Please help me, this is getting worse.  What should I do? 

Answer:  
Unfortunately, some general surgeons may not realize that adhesions (scar tissue) can cause pain, and this is not the first time I have heard of this situation. This arises, in part, because surgeons tend to associate adhesions with bowel obstruction, not pain, since from a practical standpoint, that is what they typically see with their patients. Regardless, there have been studies demonstrating the presence of nerve fibers within adhesions, and clinically they also can be associated with pain (although not always). Whether or not a nerve block is appropriate here is a matter of your personal physician's clinical judgment, but it may also be useful to consult a provider with particular expertise in pain management. In addition, depending on how quickly your pain is worsening, it may be prudent to seek appropriate medical attention fairly soon. 

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

David Toub, M.D. 

Vulvodynia, Vulvar Pain

Question: Vulvar Vestibulitis and Pregnancy
After the birth of my first child in 1997, I suffered from vulvar vestibulitis.  It was pretty bad for quite awhile, and I tried various creams before undergoing a minor surgical procedure to excise the affected area. Since then I have been much better. I am wondering if there is any information on what is likely to happen if I deliver vaginally, which I am planning to do.  I haven't been able to find any articles on the subject.  Any information at all would be helpful.

Answer:  
Depending on the extent of the surgery, vaginal delivery may or may not be advisable, and you need to discuss this in more detail with your obstetrician or midwife. You may also want to consult the website of the National Vulvodynia Association (www.nva.org) for more information. 

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

David Toub, M.D.

Question: Vulvar Vestibulitis
I have been diagnosed with vulvar vestibulitis, and I have been looking for treatment options.  My doctor has sent me to a specialist, but I can't get in for another month and a half.  I don't even know if this specialist will be able to help me.  I have tried pain relievers, creams, and just about anything else the doctor thought of, but none of it really helped.  Intercourse is extremely painful, and my husband and I are at a loss.  Do you have any further information?  I have been to all the websites I could find, and none of them have any further information.

Answer:  
Unfortunately, the best way to determine the best treatment options for you as an individual is to consult with your doctor. You may want to ask if an earlier appointment can be made. There are several treatment options for vulvar vestibulitis, including medical approaches. There is also a National Vulvodynia Association (www.nva.org), which may be of help. 

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

David Toub, M.D. 

Other Questions

Question: Incompatible Fluids?
I need some advice.  I am dating a guy who I am very much in love with and each time we have intercourse, he complaints that there is a sticky feeling on his penis and a painful feeling.  This happens both internally and externally directly after the intercourse.  I stopped shaving the vaginal area, thinking it was the pubic hairs, however, it is still painful to him when he is inside of me.  I am not experiencing any discharge, painful, burning myself. He feels our chemical fluids are not compatible.  I am worried about losing him because of this.  Could this be true, we are not compatible?

Answer:  
Compatibility is determined largely by behavior and personality, not anatomy. What I would suggest is that he consult his primary care physician or a urologist to be on the safe side. From a gynecologic perspective, I am not aware of anything that should normally cause him to have these sensations. 

Thank you for your e-mail!

David Toub, M.D. 

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