Self-Advocacy for pelvic pain: Identifying pelvic pain red flags

Your period is a barometer of health, a vital sign. Yet, throughout our reproductive years, we try to control and even eliminate menstruation. Rather than being taught to cultivate harmony with our menstrual cycle we try to tame it, hide it, and avoid it altogether. Women talk about their period with disdain and commiserate over a shared experience of pain, fatigue and mood swings as though it is a mantle of womanhood.

Mid-cycle pain, and pain during your period (dysmenorrhea), are warning signs that require further evaluation by your gynecologist.

Let’s explore the common causes of pelvic pain as outlined by the American Family Physician.

 

 

Why you may be experiencing pelvic pain

PRIMARY DYSMENORRHEA 

Primary dysmenorrhea is menstrual pain that occurs in the absence of an underlying disease (pathology) to the reproductive organs and pelvic cavity.

Symptoms:

• cramping pain in your lower abdomen just above your pubic bone that may start a few days before your period and continue through cycle days 1-3. This pain may radiate to your lower back and thighs.
• You may also experience nausea, bloating, bowel changes, and fatigue.

Assessment: A pelvic exam would be a normal part of assessment and your doctor should order a urine test to rule out pregnancy or pelvic infection.

ENDOMETRIOSIS

Endometriosis is an estrogen-driven disease of the reproductive system that affects approximately 10-15% of reproductive age women and can have significant consequences for a woman’s quality of life and fertility. In fact, some research suggests that endometriosis may be the cause of 20-50% of infertility cases.

Endometriosis is caused when endometrial tissue, the inner lining of your uterus, begins to grow abnormally outside the uterus. Endometrial tissue forms adhesions throughout the pelvic cavity causing pain, heavy bleeding, and inflammation.This misplaced tissue bleeds during menstruation but it becomes trapped and cannot shed through normal menstrual bleeding.

Symptoms:

• pain randomly throughout your cycle, or just during your period
• Pain can also be present during sex, urination, and bowel movements
• Endometriosis is a common reason for infertility due to adhesions that form in the uterine cavity and subsequent scarring. For some women, difficulty conceiving may be the only symptom of endometriosis

Assessment: Your doctor may perform a recto-vaginal examination to assess whether you have a retroverted uterus, diminished uterine mobility, or adhered masses. The gold standard for diagnosing endometriosis is laparoscopy and biopsy. Less invasive procedures may include the use of transvaginal ultrasound or an MRI.

ADENOMYOSIS

Adenomyosis occurs when the uterine lining begins to grow into the muscular wall of the uterus as opposed to endometriosis which grows outside the uterine cavity.

Symptoms:

• midcycle and/or heavy menstrual bleeding
• severe cramping
• bloating
• abdominal pressure

Assessment: Diagnosis is typically made by a transvaginal ultrasound to examine the endometrial tissue within the uterus.

FIBROIDS (LEIOMYOMATA)

Fibroids are non-cancerous tumors that vary in size and location in the pelvic cavity; they may be within the endometrial lining (sub-mucosal), within the uterine muscle layer (myometrial), or attached to the outside of the uterus (sub-serous).

Symptoms:

• menstrual and pelvic pain accompanied with heavy bleeding and possibly painful urination and lower abdominal pressure
• Some women have fibroids that are small enough not to cause any symptoms

Assessment: Fibroids can be detected by trans-vaginal ultrasound.

PELVIC INFLAMMATORY DISEASE 

Pelvic inflammatory disease (PID) is an infection occurring in sexually active women. If left untreated PID can lead to chronic pelvic pain, infertility, ectopic pregnancy, and further infection.

Symptoms:

• Pain in your lower abdomen that may be mild or severe
• painful sex
• abnormal cervical discharge
• possibly a fever
• abnormal uterine bleeding

Assessment: Your doctor will order blood work to detect known inflammatory markers and labs for gonorrhoeae or chlamydia. Ultrasound may show thickened fallopian tubes and pelvic fluid.

INTERSTITIAL CYSTITIS 

Interstitial cystitis causes chronic pelvic and bladder pain. It is often a diagnosis arrived at via elimination when no other causes for pain can be found. Endometriosis and IC share some common symptoms and this can delay a correct diagnosis. IC be more severe before your period and is most commonly associated with pelvic pain.

Symptoms:

• 6 months or more of chronic pelvic pain
• bladder pressure and pain accompanied by urinary urgency and frequency
• You may also experience pain that radiates from your bladder into the groin or rectum

Assessment: referral to a urologist who will perform a cystoscopy and biopsy

Chronic pain pervades all areas of one’s life. Experts in pain medicine have raised the question that perhaps because menstrual pain is a highly common experience among women worldwide it has historically been dismissed in pain management.

ECTOPIC PREGNANCY 

An ectopic pregnancy occurs when the embryo grows in the fallopian tube instead of the uterus. This a medical emergency as it can cause your fallopian tube to rupture. You should seek medical care if you suspect you have an ectopic pregnancy. Pain and bleeding should not be ignored.

Symptoms:

• Pelvic pain, often pinpointed/sharp/intense
• bleeding
• feeling faint, and other early pregnancy symptoms such as nausea, fatigue, and breast-tenderness.

Assessment:

Your doctor will confirm an ectopic pregnancy with a pelvic or trans-vaginal ultrasound to locate the gestational sac. 

Self-advocacy for pain relief 

You don’t have to suffer month to month with killer menstrual cramps, pain during ovulation, or generalized pelvic pain.

Instead, become a pain detective and start keeping a record of when your pain occurs, the location and nature of the pain (sharp, dull, intermittent, throbbing, radiating etc.), and rank your pain level on a scale of 0-10 (0 = no pain, 10= severe pain). Consider, also, how your pain affects your daily life. With this evidence in hand, schedule an office visit with your doctor so you can discuss your pain experience in detail. Your doctor should be your partner, a co-collaborator, in your healthcare, supporting you to make the best decision for your healing process. If you don’t feel this way about your current provider, then it’s time to find a doctor who you can trust!

You can use this symptom checklist to document your symptoms for quick reference when you consult your doctor.

If you would like deeper support please contact me, I’d love to hear from you!