Causes and Treatments for Chronic Pelvic Pain

>> Wednesday, February 20, 2013

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Why is it that so many women live with pain and have had several surgeries and treatments (or even live on pain medications) and still feel that no one has been able to give them an explanation for their suffering?

Some causes of chronic pelvic pain, like endometriosis & pelvic congestion syndrome (PCS), show up at an early age, even as soon as our first periods. Chronic pelvic pain is a common condition and reports indicate that more than 30% of women will experience it in their life time. However, for it to become a diagnosable problem, it usually will have been present for at least 6 months.

Pelvic congestion syndrome (PCS) is unique and more common than women think. It is believed that this condition is associated with varicose veins in the pelvis (lower abdomen and groin). The syndrome is associated with constant dull pelvic pain, pressure and heaviness. No one really knows why the varicose veins develop, nor how to best treat it. We know the valves in the veins that help blood flow toward the heart are either defective or damaged. The function of the valves is to prevent back flow of blood. When the valves dysfunction, pooling of the blood occurs in the veins. The veins which are engorged with blood, and as the blood pools in the veins, they get bigger and the walls are stretched. It is believed that these varicosities are located near nerves which are stimulated and cause pain. The engorged veins also occur near the uterus, fallopian tubes, vulva and even the vagina.

Pelvic Congestion Syndrome is generally seen in women between the ages of 20-45, who have had multiple pregnancies. Symptoms include, but are not limited to: swollen vulva/vagina, varicose veins (vulvar, buttocks, legs), abnormal menstrual bleeding, tenderness to touch in the lower abdomen and during intercourse, painful menstrual periods, backache, vaginal discharge, general lethargy/tiredness, and feelings of depression.

Even though the exact cause of Pelvic Congestion Syndrome is unknown, the possible causes may be:
Estrogen: It is known that estrogens can weaken the vein walls, and during pregnancy the increase in estrogens may play a role in the development of varicose veins. This may be why men do not develop this syndrome.
Anatomic: Some doctors believe that there may be some anatomical defect of the veins and other parts of the pelvis that could make them more prone to formation of varicose veins.

Pregnancy may make the veins more susceptible to damage and more prone to develop the varicosities.
Weight Gain: Just as weight gain can cause varicose veins to increase in the legs, it can also worsen Pelvic varicosities due to increased pressure.

Unlike pain with periods, women usually notice that pain worsens:
  • Just before the onset of the menstrual cycle
  • At the end of the day
  • After prolonged standing
  • During or just after intercourse, even lasting into the next day.
  • During later stages of pregnancy
  • Early treatment options include pain medication, using suppression, and alternative therapies such as acupressure and physical therapy.
Pelvic CS is a difficult diagnosis to make. All other conditions must be ruled out first. The specific diagnosis of Pelvic Congestion Syndrome is made using several tests which include:
  • Laparoscopic Surgery: It is easy to visualize the varicosities this way and ensure it is not being confused with adenomyosis or endometriosis.
  • Ultrasound: This is the first test of choice. It can assess the uterus and other organs in the pelvis. Technical advances in ultrasound can also help visualize the blood flow and asses the presence of varicosities in the pelvis. The procedure is painless and takes about 30 minutes. It is inexpensive and effective.
  • CT Scan: CT scan is frequently used in the diagnosis of Pelvic Congestion Syndrome. It can look at the entire anatomy of the lower pelvis and identify varicosity of the pelvic veins. It is associated with radiation exposure and not a recommended test in pregnant females.
  • MRI: This test does not use radiation or contrast dye and is a painless test that is the preferred test choice for many radiologists.
In the past, drugs (ergotamine) that narrowed the veins were tried. In addition, hormones were also prescribed for Pelvic Congestion Syndrome. Neither drugs nor hormones were successful, and today, drug therapy is not used in the treatment of Pelvic Congestion Syndrome. However, the pain in Pelvic Congestion Syndrome may require prescription pain medications. One class of drugs that has shown some benefit is antidepressants. These drugs are not only excellent pain relievers but also treat the depression and anxiety caused by Pelvic Congestion Syndrome.

Many women are not satisfied with conventional medical therapy because of the high failure rate. Alternative health care approaches to the treatment of Pelvic Congestion Syndrome have included physical therapy, transcutaneous electrical nerve stimulation, behavior and psychological counseling, trigger point injections, epidural and spinal nerve blocks and acupuncture.

Surgery is not the first choice therapy for Pelvic Congestion Syndrome, but potentially used after all other methods of treatment have failed. The surgical option involves stopping blood flow to the varicose veins. Noninvasive surgical techniques such as a procedure called embolization have had an 80% success rate, as measured by the amount of pain reduction experienced. But, even after the complete removal of the uterus and surrounding blood vessels, the results may not be optimum, and some women continue to have the same symptoms. So, before one jumps into surgery, she should always get a second opinion, and even then, think again – because the underlying cause of the varicosities has not been treated with the surgery. We all have friends and family who have suffered with pelvic pain and even after surgery are not better. Believe me it is NOT psychological.

Currently, embolization and antidepressant therapy are the preferred therapies.

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