Pelvic Pain

Good morning. I am hope you are all looking forward to this beautiful holiday season with friends and family. Unfortunately, I know many of you may be smiling and laughing in between your episodes of pelvic pain. You have become so accustomed to it and even expect it by planning your holidays around it.

Pelvic pain is located in the lowest part of your abdomen, way down about half way between your pubic bone/pubic hairline and your belly button. Any pain that is at your belly button or higher is considered abdominal pain. It can be difficult to know for sure, because pain can radiate up from the pelvis to your belly button or ribs and back pain from your spine or tailbone can wrap around to the front. And, of course, abdominal pain can radiate down from your stomach, gallbladder or kidneys into the pelvis. It can be frustrating and scary!

Depending on its source, pelvic pain may be dull or sharp; it may be constant or intermittent; and it may be mild, moderate or severe. Pelvic pain can move around to your lower back, buttocks and shoot down your vagina and thighs. Pelvic pain can occur suddenly and sharply and last for just a few minutes 3-4 times a month. You my notice that it only hurts when you have sex, go to the restroom, have your period, or ovulate (about a week to 1 ½ weeks after your period).

Pelvic pain can be so complicated that it may have nothing to do with your uterus or ovaries. It may come from the muscles and connective tissue (ligaments) in the structures of the pelvic floor. This pain may be caused by irritation of nerves in the pelvis and can hurt when you exercise or walk your dog. There is no surgery for this -- not even a Total Hysterectomy with both ovaries removed will take away this type of pain.
There are many things that can cause pelvic pain. Some are chronic (which means it is a part of how your body was made and functions and can never be cured). The occasional or acute pain will come and go and is usually caused by something curable and temporary. Most women don't have chronic pain and all women have episodes of pelvic pain during their lifetimes.

Female reproductive system related: It may be caused by female conditions like Adenomyosis, Endometriosis, Menstrual cramps (dysmenorrhea), Ectopic pregnancy (or other pregnancy-related conditions), Miscarriage (before the 20th week), intrauterine fetal death, Mittelschmerz (ovulation pain), Ovarian cysts, Pelvic inflammatory disease (PID) or Uterine fibroids.

Pain from non female related organs: Include Appendicitis, Colon cancer, Chronic constipation, Crohn's disease, Diverticulitis, Fibromyalgia, Inguinal hernia Interstitial cystitis (also called painful bladder syndrome), Irritable bowel syndrome, Kidney stones, Past physical or sexual abuse, Pelvic floor muscle spasms, Ulcerative colitis or Urinary tract infections.

If you suddenly develop severe pelvic pain, it may be a medical emergency like a ruptured ectopic (tubal) pregnancy or a ruptured cyst that is causing internal bleeding. You should seek medical attention promptly as these are life threatening.

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What Is Causing My Pain ‘Down There’?

Imagine vaginal burning and pain so severe you can’t sit comfortably, wear tight clothing or have sex. That’s the reality women with vulvodynia face, and although many of us would like to have a push-button answer to the problem, the human body does not function this way.

Why so many women suffer from pelvic pain during their cycles, during sex and some almost every day has puzzled many researchers and clinicians for years. There are a wide variety of reasons women can experience pain and problems.

Vulvodynia is a debilitating, difficult to treat, often incurable problem that causes extreme sensitivity of the vulva and vaginal labia. Possible contributors include injury to nerves in the vulva, hypersensitivity to candida (yeast) or other fungal and bacterial infections At times, the pelvic floor muscles spasm, causing throbbing and sensitivity to the slightest touch or pressure.

Some partially successful treatments have included the use of tricyclic antidepressants (to block pain receptors in the vulva), topical estrogen or lidocaine gel, and even surgery. Surgery is an extremely radical approach and requires removal of vulvar tissue in hopes the grafted tissue will cure the pain Capsaicin cream is a newer treatment that has to be specially compounded (and which contains the active ingredient in chili peppers), but has been shown to dramatically reduce symptoms.

If a woman’s condition is flared by a candida (yeast) hypersensitivity -- to which even a slight imbalance can cause itching and burning -- weekly doses of an oral antifungal medication over several weeks or months can help alleviate symptoms.

Some treatments for painful sex in women do not require medical intervention and can be treated safely at home - by using personal lubricants with intercourse, allowing injuries & surgical incisions to heal completely after surgery or childbirth, and simple patience and rest. Sometimes with vaginal pain due to menopause, excessive dryness after childbirth, or infections like yeast or bacteria, it may require a prescription from your physician. And, there are actually physical therapists that specialize in pelvic floor muscles that can help to alleviate the pain of pelvic organ prolapse.

Another condition, vaginitis, is caused from a disruption in the natural balance of bacteria that live in every healthy vagina. Vaginitis usually refers to bacterial vaginosis and yeast infections that can cause unbearable itching, burning, pain and/or odor for many women. It can re-occur several times per year.

There is no single cause for vaginitis, and it is not considered sexually transmitted. Common causes may include hormonal changes due to birth control, menopause or pregnancy, as well as chronic medical conditions, such as HIV and diabetes, which weaken the immune system. Frequent sex can also be a big cause of recurrent vaginitis, due to the sugary, alkaline solution surrounding the sperm which disrupts the acidic environment of the vagina. This creates a perfect environment for bacteria and yeast to flourish. Recurrent infections can cause chronic pain in women. Treatment is painless and easy - most women simply insert a prescribed cream at night or take a prescription oral antifungal or antibacterial.

Atrophic vaginitis is thought to be a problem of menopause. The term describes the dryness, vaginal wall thinning and shrinkage, and paleness of tissue due to lack of estrogen. Urinary incontinence can go hand in hand with this. Many of you have experienced this with childbirth and breastfeeding, due to the hormone changes which are similar to menopause. This condition can feel like an infection, with burning, itching, and pain, but no active fungus or bacteria is found. Treatments such as estrogen creams or oral estrogen therapy can help.

Some women suffer from another condition called lichen dermatoses, which is a condition that can lighten and stiffen the tissue in the vulva and can cause severe itching and scar formation. A mix of topical steroids with a tiny dab of estrogen can help heal the damage to the vulvar tissue and decrease symptoms.

Vaginismus is a rare condition (affecting fewer than 2% of women in the United States) in which the muscles surrounding the vagina involuntarily spasm so tightly that you can’t have sexual intercourse or even insert a tampon. The specific cause of vaginismus is unknown, but, as with vulvodynia, physical therapy can be a successful treatment.

Physical therapists who specialize in pelvic floor disorders can correct structural abnormalities and design a manual therapy and exercise program that will retrain pelvic muscles that are too tight or too weak, depending on the condition. Their efforts can dramatically reduce symptoms without the side effects of medication. They also teach women the proper way to perform techniques at home, with dilators and their own fingers, to gently stretch and massage the muscles. If a woman’s symptoms persist despite physical therapy, a doctor can inject Botox to paralyze muscles and prevent the spasms for up to six months. Other (older) treatments that have been successful for vaginismus include sex therapy medications such as Valium and hypnotherapy.

Fibroids affect about 77% of women, but most don’t realize they have them. In some cases, there are no symptoms, but some women can develop cramping, excessive bleeding during menstruation, and painful intercourse. The growth and development of these uterine tumors are rarely cancerous, in fact less than 0.01% of the time. Fibroids may shrink naturally after menopause. Treatment options vary and usually have a lot to do with a woman's age and desire for future childbearing.

Hysterectomy is one option, but if you have a desire for future fertility, it is possible to have only the fibroids removed, leaving the uterus and ovaries intact. There is also a procedure called uterine artery embolization, which cuts off the blood supply and forces the fibroid to shrink, however this may compromise future ability to have children, as it compromises blood flow to the uterus.

Genital Herpes is a disease caused by the herpes simplex virus (HSV), of which there are two types. Type 1 (HSV-1) usually causes oral herpes, an infection of the lips and mouth. Symptoms are commonly known as cold sores or fever blisters. In the past, HSV-1 was not known to cause genital lesions, but that is changing, and we now know oral herpes can be passed to the genital area via oral sex. Genital herpes is caused by the second type of herpes virus (HSV-2) and reoccurs more often - causing more distress to the person who has it. Chronic herpes infections can be a cause of persistent pelvic pain and painful intercourse.

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Orgasms Are Causing Excruciating Pain - Why?

Sex should not be painful, right?  So why is it painful for some women and not others?  For most women it can be a shock the first time they experience it.  It usually happens during ovulation when the ovaries are swollen and tender with maturing follicles.  If one of the ovaries is bumped or tugged with deep penetration or thrusting this can cause significant sharp, stabbing pain. 

You know it's common for women to have pain like that, and now and then with sex.  But for some of you, it has become a regular thing, and every time you are intimate with your partner, it causes significant pain.  Then afterwards the pain continues long past orgasm.  In these cases, sex can really become a scary experience rather than exciting and satisfying.  This was how Kelly felt, and orgasm changed from wonderful and satisfying to painful all the time:       
                                                                                                                          

“In the past couple of months, whenever I have an orgasm, it is excruciatingly painful.  The pain is only on my outer pelvic area. It's like all the muscles from my pubic bone all the way down to the rectal area goes into painful spasms. Just like bad menstrual cramps, only external. 

The pain is awful, and the worst of it lasts for about 5 minutes (feels like an eternity), and then gradually starts to get better.  I have to sit on a heating pad to get a bit of relief, and I can still feel it the next day.  This happens even without intercourse. Just having a clitoral orgasm is enough to cause the intense pain over the whole groin area. I'm single anyway, and not married, so sex is pretty rare these days.”

There are so many reasons that women can experience pelvic pain and sexual pain, that is why it is so important to see your healthcare professional if you are concerned.

Pain at orgasm can occur because of the contractions of the uterus, and this can expose underlying problems that would normally be ignored or thought to be from something else like gas pain, IBS, constipation, bladder infection, or ovulation pain.  It's only when it happens time and time again that professional help is sought.

Clitorism is a continued, painful condition in the female with recurring erection of the clitoris.  The word is also used to describe an abnormal enlargement of the clitoris. Clitorism is painful, much like its male counterpart, priapism. 

Clitoral phimosis is a condition in women, whereby the clitoral hood cannot be retracted, limiting exposure of the clitoris.  Imagine an uncircumcised man not being able to pull back his foreskin during intercourse, this is similar to this condition in women.  It is rare, but some baby girls are born this way and feel that they do not have a clitoris when they become sexually active.  

This condition is one of the reasons some women are unable to have an orgasm, due to the clitoris being 'buried' under so much tissue.  The usual treatment is surgery to unbury the clitoris so it can be normally stimulated during intercourse.  Care has to be taken not to expose too much of the clitoris by removing too much skin.  That is why it should always be done by an experienced professional. 

Some women have been found to have clitoral adhesions which can be congenital (present since birth) or acquired from recurrent infections or injury.  In this condition, the clitoris and clitoral hood are connected by little adhesions or pieces of scar tissue.  Again, this requires surgical treatment with the utmost care, as removing them can promote more adhesions. 

Endometritis refers to inflammation or infection of the endometrium, the inner lining of the uterus - which is the portion that releases during the menstrual cycle and also remains should implantation occur.

The most common cause of endometritis is an infection from compromised abortions, delivery, medical instrumentation, and retention of placental fragments. Cesarean section or prolonged rupture of membranes and long labor with multiple vaginal exams during labor are important risk factors.  

Symptoms include lower abdominal pain, fever and abnormal vaginal bleeding and discharge. Treatment is usually with broad-spectrum antibiotics.  Menstruation after acute endometritis can be excessive and scary, but should improve after a couple cycles. 

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Pelvic Pain and Sexual Intimacy

We've been talking a lot about pelvic pain and some things that could be causing it like endometriosis, polycystic ovaries (PCO), or pelvic congestion.  I hear from many of you over and over about why does sex hurt so much (dyparunea), which is definitely related to many of the pelvic pain syndromes.  In fact sometimes painful sex can be the catalyst that brings you in to see me.  

Women learn early on that sex is not always comfortable and depending on where you are at in your cycle, the pain can improve or worsen.  All women have pain now and then, but it should not be so intense that you don't want sex for fear of the pain or have to ask him to stop during intercourse because the pain is so intense you can't continue.

We know from the past blogs I wrote that becoming sexually excited and then stopping before orgasm can lead to more pain from pelvic congestion.  Pelvic congestion is when the pelvis and female organs fill with blood during sexual excitement and then release during orgasm.  We see a similar phenomenon in men when they get an erection from sexual excitement, and if they don't have an orgasm or ejaculate they will get pelvic congestion. It can produce the same pressure and pain we feel and is localized in the scrotum and testicular area (Blue balls).  This is why it is so important for an anorgasmic woman to learn what she needs to do to teach her body to have an orgasm.

This may mean using a vibrator or letting him use one on you either prior to his orgasm, or after if you did not get there with penetration and thrusting.  Most women need clitoral stimulation, which may not happen with penetration and can take practice to position yourself (and him) to accomplish this.   It is good if you can talk with your partner about this and work together.  If you still have problems then make an appointment with your gynecologist to help guide you through the next steps.

Detumescence is the flow of extra blood out of the area. So during sexual excitement blood rushes into the pelvic area and fills or engorges the vagina, uterus and clitoral area.  The contractions of orgasm put pressure on all the blood vessels in the swollen organs and tissues, and squeezes the extra blood out of them. The clitoris returns to its normal size within 10 to 20 seconds after orgasm, the vagina takes some 15 minutes to return to its previous state, and the uterus may take a little longer, between 10 and 30 minutes to become decongested and return to its previous size and position.

When there is no orgasm, the involuntary muscle contractions to put pressure on the blood vessels are absent so the excess blood pools in the female organs and tissues, which will remain swollen much longer.  Problems show up when there is continued intense sexual excitement followed by consistent lack of orgasm over a long period of time.  Pelvic congestion builds up. The sensations of this condition include vague discomfort in the pelvic area, backaches, and headaches, to intense, sharp pelvic pain that is not associated with the menstrual cycle.  This in turn can cause sex to become extremely painful and as the congestion and pain worsen we usually seek help for an explanation.  However on physical exam and ultrasound everything appears normal. 

The relationship between health and a satisfying love relationship should not be down played.  It has been shown that orgasm is a powerful muscle relaxant, and its effects can be ten times as strong as the effects of Valium and other tranquilizers. After illness, orgasm assists on the road back to health. So instead of saying, "No, I have a headache", we now know that sexual love with orgasm can actually be the best medicine for a headache or back pain. So next time give it a try. 

      Pelvic pain can be confusing and requires patients on both sides to try to figure out what may be happening.  In the end it may be a combination of different things, but if you find the right doctor to help you, it will be worth all the trouble in the end.

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