2020, Responses from: Dr Jeremy Meates
Endometriosis is a common cause of pelvic pain, which can be severe and debilitating.
It is caused by deposits of endometrial-like tissue in the wrong place, ie scattered around the lining of the pelvis. At the time of the period these deposits can cause bleeding and inflammation of the pelvis leading to pain and scarring. Laparoscopic surgery is often performed to both diagnose endometriosis and to treat it. Treatment involves surgically removing the inflammatory deposits and lesions and releasing adhesions caused by scar tissue. This type of surgery is associated with a significant improvement in pain for most women and it can also improve fertility.
However endometriosis is only one cause of pelvic pain and there are other common causes. When treating pelvic pain it is usually necessary to address all contributing factors.
We tend to think of factors that contribute to pain in 4 categories
- Organ related pain
- Nerve sensitivity that occurs secondary to chronic pain
- The musculoskeletal response to pain
- The psychological component of pain.
Organ related pain: Pain may originate from the abdominal or pelvic organs such as the uterus, ovaries, bladder and bowel. Uterus-related pain is very common at the time of the period. Ovary-related pain is highly variable. Some women experience quite severe ovulation pain while others may only notice slight discomfort. Bladder-related pain may lead to lower abdominal pain, frequent urination & a need to go to the bathroom urgently. It may feel like a urinary infection but often the urine samples are clear confirming it as irritation rather than infection. If you have urinary symptoms it is important of have a urine sample analysed in the laboratory to clarify the nature of the symptoms because recurrent bladder irritation, which is common, will be treated differently from recurrent infection. Bowel-related pain may be very common and patients with endometriosis often describe symptoms of variable bowel frequency, ranging from constipation to diarrhoea. They may have a diagnosis of irritable bowel syndrome and symptoms are often helped by dietary modification.
Treatments to reduce uterine pain or period pain may include pain relief medication that is taken at the time of the period, or may involve trying to suppress the period with hormone treatment. Typically this will be with progesterone or with the combined oral contraceptive pill (COCP). It is called the Combined Pill because it contains 2 hormones, estrogen and a second hormone, which is usually progesterone, but there other alternatives. The COCP can be manipulated to reduce the frequency of periods and period pain. For example skipping the sugar tablets & only having these after every third or fourth packet.
Progesterone treatment can be given as a tablet, norethisterone or provera, or a progesterone only contraceptive pill such as Noriday or Cerazette; as an injection, depo-provera; as a rod implanted under the skin, Jadelle; and it can be delivered within the uterus with a levonorgestrel intra-uterine system (L-IUS) such as a Mirena or a Jaydess.
In some cases where women have completed their family or they are sure that they have no desire to get pregnant, a hysterectomy may be performed. This will mean there is no more bleeding and no more uterine pain. This can be particularly effective in cases where adenomyosis is present (this is when endometriosis is present within the wall of the uterus).
If ovulation pain is severe then the COCP is often used to suppress ovulation. Sometimes strong medication to inhibit ovarian function is used such as GnRH analogues like Zoladex or Lucrin but these can only be used as short term measures (a few months rather than years).
Endometriosis lesions in the pelvis may be regarded as an organ-related case of pain. Treatment can include simple pain relief, or hormone treatments designed to suppress menstrual bleeding, as above, or surgery to remove the lesions.
Nerve sensitivity: Typically when there is an injury such as a twisted ankle, a broken arm or a burnt finger the pain nerve fibres in the affected tissue will be activated. When they are active minor things such as light touch or pressure will lead to pain in the area. Eventually as the injury heals the pain nerves return to their resting inactive state. However when there is repeated pain & repeated activation of the pain fibres, such as with monthly period-related pain then the pain fibres may not return to their resting state but remain activated or partially activated for months on end. This leads to a lower threshold for a pain signal, ie things such as pressure and touch that wouldn’t normally be regarded as painful start to cause pain. Quite often patients report that they can’t wear tight pants due to pain or discomfort.
As well as making the pelvic area more sensitive this nervous system sensitisation can be associated with other non-specific symptoms such as poor sleep, low mood, anxiety, nausea, sweating, dizziness and extreme fatigue.
Medications such as Amitriptyline, Gabapentin, Pregabalin & Venlafaxine can be used to help with nerve sensitivity and so can lifestyle measures such as exercise (as long as it doesn’t exacerbate the pain), mindfulness, meditation, acupuncture and many other non-medication strategies.
The musculoskeletal response to pain: During times of pain such as severe period pain it is common for the muscles around the area of pain to contract and tighten. If they are contracting for a prolonged period of time they may get achy & sore. A familiar example of this would be the aches & pains you feel for a few days after doing some unfamiliar activity such as a busy weekend gardening, or going to the gym for the first time in a while, or in sport after playing the first game of the season. Patients will often describe aching type pain in the pelvis, which often radiates to the back to cause lower back pain or down the legs to the thighs.
If tightening of the muscles happens repeatedly over the course of months or years it may lead to the muscles going into spasm. This type of pain is similar what it feels like if you get a bad cramp in your leg. It’s a severe, stabbing pain. Often 8-9/10 severity. Sometimes people feel like they can’t move or can’t walk when this happens. They may lie on the floor or in bed curled up until the spasm passes. Typically this type of pain does not respond well to common pain relief medications such as paracetamol, codeine, tramadol and anti-inflammatories like ibuprofen, naproxen & diclofenac. Often heat treatment with a wheat pack, a bath or a hot shower will help.
Pelvic muscle spasm is a common reason for patients to present acutely to the Emergency Department with severe pain. Often they are given morphine or morphine derivatives such as oxycodone or sevredol, which may or may not be effective. Medications that help with muscle relaxation are often helpful.
Pelvic muscle tenderness may be diagnosed by palpating the pelvic muscles during an examination. Patients with moderate to severe pelvic muscle tenderness will often complain that it hurts to use tampons or hurts to have sex and that having a smear is painful rather than just being uncomfortable.
Gentle exercise such as going for a 10-20 minute walk followed by stretches for the pelvic muscles may be helpful (see the link below). Treatment with a pelvic health physiotherapist can be hugely beneficial. Try and avoid activities that trigger muscle spasm. This will vary with each individual but common triggers include core exercises like sit-ups, crunches & planks, and walking & running up hills or walking up a lot of steps (sometimes a problem if you live in a hilly city).
In some cases we will use Botox injections into the pelvic muscles to relive spasm. This is done in hospital, with the patient asleep under a general anaesthetic and it often causes a ‘flare up’ of pain for a week or two after the procedure. Physiotherapy treatment is particularly helpful following Botox treatment.
Hysterectomy is a very effective treatment for problematic bleeding and period pain or uterine pain associated with adenomyosis but it doesn’t specifically address pelvic muscle spasm and nerve sensitivity. Having said that, muscle tightness will often be improved for 3-6 months after surgery because patients are usually given a muscle relaxant medication as part of their general anaesthetic. Furthermore if the period pain is the cause of the muscle tightness and the nerve sensitivity in the first place then removing the cause will help in allowing these to resolve, and it usually does.
However from time to time there may be persistent pelvic pain following a hysterectomy operation and it is often associated with significant pelvic muscle tenderness. Many of these patients (although not all) respond very well to Botox treatment. However in the first instance simple treatments such as stretches, gentle exercise and physiotherapy input will be recommended before a Botox procedure.
The psychological component of pain: If you have chronic pain or recurrent severe episodes pain you may start to feel frustrated and upset. If you are unable to continue with your work or other day to day activities during times of pain you may start to feel guilty. If the pain continues to deteriorate you may experience low mood or feel despondent. If treatments have been ineffective you may feel that there is no hope. The cost of doctors visits & prescriptions adds up over time & can cause financial pressure and lead to feeling ‘stressed’. Stress and negative thought patterns tend to make the experience of pain more prominent hence it can be a vicious cycle.
All activities and strategies that help to reduce stress are helpful in day to day management of chronic pain. This can include deep breathing exercises, meditation, yoga, etc. Or may include a ‘distraction’ such as a hobby or interest. A gratitude journal can be helpful.