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The Middle Years - Pelvic pain

Pelvic pain is a common symptom in adult women, and can be cyclical (related to ovulation or menstrual periods), intercourse related (this is known as dyspareunia), or generalised in nature, and at least some pelvic pain may not even be gynaecologic in origin. Around 14-24% of women at any given time will experience pain that continues for at least 6 months, making pelvic pain one of the most common conditions in gynaecology.

The causes of pelvic pain are therefore quite varied, but only a few conditions tend to be responsible for the majority of cases. These conditions include:

Endometriosis

Endometriosis can affect as many as 1 in 5 women, but may not cause symptoms in all of those women. In women with chronic pelvic pain, however, about one third will be found to have endometriosis, suggesting that for many women with pelvic pain, endometriosis would be suspected as a cause. Endometriosis is caused when the lining cells of the uterus grow in places outside the uterus, generally in the abdomen or on the ovaries and may cause painful periods, premenstrual spotting, pain with intercourse or pain with ovulation. The frequency of endometriosis which causes pain tends to increase with age. Endometriosis tends to settle or even disappear with the menopause. It can run in families. Endometriosis can sometimes be seen on ultrasound if it results in cysts on the ovaries (chocolate cysts), but in many instances, may be difficult to detect. If endometriosis is suspected, a surgical procedure called laparoscopy (also known as ‘keyhole surgery’) may be performed, and the pelvis closely examined for spots of endometriosis.

ultrasound image

An endometrioma of the left ovary.

Ovarian cysts

Ovarian cysts are extremely common, especially in women who ovulate regularly as the site of ovulation on the ovary has to heal and this often causes a cyst to form. Most ovarian cysts resolve on their own. Very few need surgery

unless they are complicated by bleeding, rupture or torsion.

Ovarian cysts can occasionally be malignant but it is extremely rare that an ovarian cancer begins with pelvic pain. If you have an ovarian cyst, ultrasound examination can give you a good indication about its risk of malignancy.

Adenomyosis

Adenomyosis is a condition in which the lining cells of the uterus (endometrial cells) grow within the muscular wall of the uterus (the myometrium), as well as within the cavity inside the uterus, where they belong. Adenomyosis may well be related to endometriosis, and the two conditions often co-exist. Adenomyosis is a very common condition, occurring in at least 20% of women, although, like endometriosis, not all women with the condition will experience symptoms. The most common symptoms of adenomyosis are heavy or prolonged menstrual bleeding (60% of women with adenomyosis), and pelvic pain, especially with the menstrual periods (25% of women). The diagnosis of adenomyosis can only truly be made with an examination of the uterus under a microscope. But there are several ultrasound features which are considered characteristic, such as uterine enlargement or patchy appearances of the uterine wall. Many women with adenomyosis also have other conditions, such as endometriosis or fibroids, which may also account for symptoms.

Adhesions

Adhesions are scars which can form within the pelvis from previous surgery, infection, or endometriosis. Pain related to adhesions may or may not be cyclical, may be solely related to intercourse, or may cause difficulties with passing urine or stool. Adhesions are sometimes visible on ultrasound. Adhesions within the uterus (Asherman Syndrome) may cause painful, light periods. The most common test used to diagnose adhesions is laparoscopy.

Other causes

There are also many other causes of pelvic pain which are not gynaecological, such as irritable bowel syndrome, diverticulitis, appendicitis and urinary tract infections.

Treatment of Pelvic pain

Many treatments are available for pelvic pain, and choice of treatment will generally depend on cause of pain. In general, treatment may range from the very simple (hormone tablets or simple pain relievers) to complex surgery if you have advanced endometriosis.