What causes pelvic pain and how to relieve it.

Many women experience pain in their bodies. It comes and goes and can be cyclic, relating to menstrual periods and ovulation. Other pain can include migraines, breast pain, lower back pain and deep or superficial pelvic pain. It doesn't matter if it's cyclic or relatively constant - pain brings fear and disrupts our ability to enjoy life. Today we're going to focus on pelvic pain.

Pelvic pain can be dull and achy, sharp, steady, intermittent, crampy, and sometimes just feel like a deep pressure or heaviness. It can be triggered by menstrual cycles, sex, and even having a bowel movement or urinating, and it can worsen when sitting or standing for long periods of time. The pain may have obvious origins like painful periods, endometriosis or ovarian cysts. But for some women, it is not so obvious and can be so frustrating.

PCS (pelvic congestion syndrome) is one cause of pelvic pain that is common, but not well-known or talked about too much. In fact, you may never have heard of this before. There is no immediate treatment for PCS, and it can go on for years without being diagnosed. Pelvic congestion syndrome is also known as pelvic venous insufficiency. With PCS, the pelvis become swollen from the back flow of blood (similar to varicose veins in our legs). This prevents normal blood flow through the pelvis, creating congestion, and this causes pain and other symptoms. The condition is associated with ovarian and pelvic vein dilatation where the veins are stretched beyond normal dimensions. This over-stretching can cause permanent damage.

In normal veins, blood flows from the pelvis up toward the heart by way of the ovarian veins, and it is prevented from flowing backwards by valves within the vein. When the ovarian veins are damaged, the valves do not close properly, resulting in back flow of blood.

Weight gain and pregnancy can worsen this condition because increased pressure and stress on the pelvis affects the ovarian veins. This, along with the increase of estrogen in pregnancy and weight gain, causes the vessels to over-stretch and weaken.
The pain with PCS can worsen when sitting or standing, and it is relieved with lying down. It can sometimes be associated with varicose veins in the thighs, buttock regions, or vaginal area. Some women experience pain with urination and during or after sexual activity. This can worsen to the point where you may have constant pain or sharp, stabbing pain, even while laying down resting.

Problems with orgasms during sex can be a cause of PCS. This is because sexual excitement increases blood flow to the pelvis, and orgasm releases the buildup of blood, similar to what we can visibly see in a man who is excited. Increased blood flow to the pelvis will cause an erection in a man, which quickly goes away as pelvic circulation normalizes.

It is important to go see your doctor for a definite diagnosis of your pain and to rule out other causes. Abdominal and pelvic ultrasound is an important tool in the diagnosis of PCS because it can eliminate other common causes of pain and evaluate blood flow. CT Scans and MRI are helpful, but only if ultrasound is unable to see everything or to delineate an abnormality better. Pelvic venography is considered the most definitive imaging modality for diagnosing PCS because it can identify the abnormal veins and the reversal of blood flow within the affected veins.

This may seem strange, but physical therapy and relaxation techniques can be amazingly beneficial. Applications of heat and cold to your abdomen, stretching exercises and massage may help the pain because it can increase your circulation. Kegel exercises may also be helpful, but if the pain is caused from difficulty achieving an orgasm, sexual therapy and evaluation is crucial. Pain relievers that decrease inflammation like aspirin, ibuprofen (Advil, Motrin IB) or acetaminophen (Tylenol) may provide partial relief from your pelvic pain. Sometimes a prescription pain reliever may be necessary. Pain medication alone, however, rarely solves the problem of chronic pain and is not recommended long-term.

Laparoscopic surgery is an excellent way to evaluate pelvic congestion and to determine if there are other factors involved that can't be seen by any other means (i.e. extensive scarring, adhesions or endometriosis).

It is important to see your doctor and not continue to suffer with the pain. It could be easily corrected, or it may take some time and multiple treatments, but waiting may be making it worse and harder to treat as time goes on.

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Causes and Treatments for Chronic Pelvic Pain

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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