Mention pelvic pain, and there are few women who don’t immediately think of painful menstrual cramps, the kind that could knock you off your feet and leave you wanting to curl up in bed with a heating pad for the rest of the day. But the truth is, menstrual cramps are just one kind of pain that a woman may experience in the pelvic region and perhaps are more easily diagnosed than many of the other possible painful culprits. Pelvic pain may come from the digestive, reproductive or urinary system.
Well-Being spoke to Lori J. Fulton, M.D., OB/GYN, of the Fulton Center for Women’s Health in Jackson, MS, about some of the most common causes of chronic pelvic pain and the path to reaching a correct diagnosis.
According to Dr. Fulton, she often sees patients who come in with a broad complaint of pain in the pelvic area that warrants calls for a physical exam, followed by a series of direct questions, and diagnostic testing to confirm or disqualify a particular cause.
“There are several conditions that may be considered as ‘usual suspects’ when a woman comes to us with pelvic pain,” explains Dr. Fulton. “It is our job to get to the root of what is causing the pain by a process of elimination. Some of the most common reasons for chronic pelvic pain are endometriosis, interstitial cystitis, fibroid tumors, adhesions or scar tissue, and bowel problems. Pelvic pain may also be part of a spectrum of symptoms related to a history of sexual abuse.
Pelvic inflammatory disease strikes millions of American women each year.
Another cause of pelvic pain is pelvic inflammatory disease, but it is more often acute, rather than chronic and may be accompanied by fever. Chronic pain is pain that has persisted over a period of at least six months or more.”
Reaching a diagnosis
To get to the bottom of the problem of chronic pelvic pain, Dr. Fulton starts with a complete medical history, followed by a physical exam of both the abdominal and pelvic areas. To help identify the condition that is causing a patient to suffer pain, she may ask some of the following questions:
• Is there anything that makes it better or worse?
• Do you have pain during exercise or intercourse?
• What is your surgical history?
• Were there post-operative complications after your surgery?
• Have you had trouble getting pregnant?
• Does your pain seem to be associated with your periods?
• Have you ever been diagnosed with fibroid tumors?
“Pelvic ultrasound is an important tool that can give us more information about pelvic anatomy,” Dr. Fulton adds. “Ultrasound can tell us for instance if there are fibroid tumors, cysts, or fluid in the pelvis. However, it is not as helpful in diagnosing adhesions or endometriosis.”
“We may also order lab work such as a pregnancy test, a blood count to check for anemia or acute infections, or a test to see if there is blood in the stool,” Dr. Fulton continues.
“Other diagnostic tools include cystoscopy and laparoscopy. Cystoscopy involves the use of a scope to look inside the bladder. This procedure can be accomplished in the office. Laparoscopy is a minimally invasive surgery performed in an operating room, which allows us to look into the abdomen and pelvis with a camera. We generally would not progress to the laparoscopy until we have ruled out the other causes.”
“Thirty years ago before we had the advanced technology we have today, exploratory surgery was common,” Dr. Fulton notes. “It could leave a huge scar and required a long recovery time. With the advent of minimally invasive procedures, diagnosis and treatment of many painful conditions can now be accomplished in our office or as outpatient procedures at the hospital.”
Common causes of chronic pelvic pain
Endometriosis is a painful disorder in which tissue that normally lines the inside of the uterus grows outside the uterus. It most commonly involves the ovaries, bowel or the tissue lining the pelvis. Rarely, endometrial tissue may spread beyond the pelvic region.
Approximately 5 million women suffer with endometriosis in the U.S.
Some common symptoms of endometriosis include:
• Painful periods.
• Pain with intercourse.
• Pain with bowel movements or urination.
• Excessive bleeding.
• Other symptoms such as fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.
Interstitial cystitis, also called painful bladder syndrome – is a chronic condition in which one experiences bladder pressure, bladder pain and sometimes pelvic pain, ranging from mild discomfort to severe pain. It most often affects women and can have a long-lasting impact on quality of life. Although there’s no treatment that reliably eliminates interstitial cystitis, medications and other therapies may offer relief.
Interstitial cystitis affects roughly 3 million women with symptoms of bladder pain.
Some common symptoms of interstitial cystitis include:
• Pain in the pelvis or between the vagina and anus.
• Chronic pelvic pain.
• A persistent, urgent need to urinate.
• Frequent urination, often of small amounts, throughout the day and night, sometimes as often as 60 times a day.
• Pain or discomfort while the bladder fills and relief after urinating.
• Pain during sexual intercourse.
Often women who believe they have frequent bladder infections may actually have interstitial cystitis.
As many as 3 out of 4 women have uterine fibroids sometime during their lives.
Uterine fibroids are non-cancerous growths of the uterus that often appear during childbearing years. They generally are not associated with an increased risk of uterine cancer and almost never develop into cancer. Fibroids can range in size from smaller than the point of a pencil to as large as a grapefruit. They can be single or multiple.
Some common symptoms of uterine fibroids include:
• Heavy menstrual bleeding
• Prolonged menstrual periods – seven days or more of menstrual bleeding
• Pelvic pressure or pain
• Frequent urination
• Difficulty emptying your bladder
• Backache or leg pains
Pelvic inflammatory disease (PID) is an infection of the female reproductive organs. It usually occurs when sexually transmitted bacteria spread from the vagina to the uterus, fallopian tubes or ovaries.
Many women who have had pelvic inflammatory disease either experience no signs or symptoms or don’t seek treatment until later when they have trouble getting pregnant or if they develop chronic pelvic pain.
Some common symptoms of pelvic inflammatory disease may include:
• Pain in your lower abdomen and pelvis
• Heavy vaginal discharge with an unpleasant odor
• Irregular menstrual bleeding
• Pain during intercourse
• Painful or difficult urination
Other conditions that may be the source of pelvic pain.
• There are a number of conditions of the bowel that can cause pelvic pain, including colon cancer, chronic constipation, Crohn’s disease, diverticulitis, intestinal obstruction, irritable bowel syndrome and ulcerative colitis.
• Other urinary tract related conditions include kidney stones and kidney cysts, may also result in pelvic pain.
When should you see your doctor about pelvic pain?
Dr. Fulton encourages women to see a doctor if pelvic pain persists. “Pain is not normal,” Dr. Fulton reminds us. “It is our body’s way of letting us know that something isn’t right. As women we often try to overlook pain that isn’t keeping us from our daily activities…with the attitude of ‘I can take it, it’s no big deal, I’m too busy to worry about it.’ ”
However, Dr. Fulton warns that any type of persistent pain or discomfort can signal a serious problem that needs to be evaluated, diagnosed and treated.
“Even if you are not due yet for your annual physical, see your doctor if you are having any kind of nagging pain for several weeks or months. We have so many medications and non-invasive surgical methods for dealing with these problems today, there is really no reason to suffer or take a chance with your long-term health.”
Lori J. Fulton, M.D., is an obstetrician and gynecologist with The Fulton Center for Women’s Health in Jackson, MS. She obtained her Bachelor’s degree from Mississippi University for Women in Columbus, and her Doctor of Medicine degree from the University of Mississippi Medical Center. Dr. Fulton spent four years in residency training at Tulane and Charity Hospital in New Orleans. She is board certified in Obstetrics and Gynecology.