Many women have pain in their pelvic region at some point in their lives and each woman responds to pain in her own way. Some women are bothered by pain more than others. Any pain should be discussed with your midwife or health care provider, but even more so if it disrupts your life, if it worsens over time, or if you've noticed a recent increase in pain.
Pain in the pelvic cavity and the perineum (the skin and muscles between the vagina and rectum in women and the scrotum and rectum in men) is one of the most common causes of pain in women. It is also one of the most difficult to diagnose and manage. Researchers estimate that 12 to 20 percent of women have chronic pelvic pain, and up to 33 percent of women will have pelvic pain during their lifetime. Unfortunately, 61 percent of women with chronic pelvic pain remain undiagnosed. Patients with pelvic pain may be seen by gynecologists, family physicians, nurse practitioners, internists, urologists, neurologists, and even pain specialists, physical therapists, or sexual counselors, but often do not receive relief from their pain. Diagnosing the cause of pelvic pain is often confused by the myth that most pelvic pain is due to diseases in the ovaries, fallopian tubes, or the uterus. It is also confused by the complex relationship between pelvic pain and sexual abuse in some cases.
When a woman has gynecological pain, an obstetrician/gynecologist tends to look for diseases in the uterus, fallopian tubes, or ovaries. By the same token, if she goes to a pain medicine specialist, it is highly unlikely the health care provider will perform a pelvic examination and or even be familiar with the pelvis. These stumbling blocks are compounded by the fact that patients are often embarrassed about pain in the perineal or pelvic area and frequently delay seeing a health care provider until the pain becomes intolerable.
It is not surprising that many patients with chronic pelvic and lower abdominal pain go undiagnosed. This section on pelvic pain takes a practical approach to these problems, discussing different diagnoses and various physical and psychological causes to help relieve your anxiety about previous misdiagnoses. The discussion is divided into areas where your primary care health care provider can help and where and when a specialist in chronic pelvic pain may be helpful to you.
Because pelvic pain has a number of causes, finding the cause of pelvic pain can be a long, involved, possibly stressful process resulting in frustration for you, but try not to give up trying to find out the problem. Often there are more than one reason or several reasons for the pain, and its exact source can be hard to locate.
Problems in the female reproductive organs may cause acute or chronic pain. Some pelvic pain may be caused by problems in other parts of the body.
CAUSES OF PELVIC PAIN
The type and nature of pelvic pain - whether it comes and goes or is constant, whether it is short term or long term - will help your midwife or health care provider detect the problem. Pelvic pain is often caused by a variety of factors. Some of them are described here:
Acute (sharp) pain starts over a short time (a few minutes to a few days). It often has one cause. Most often an exam and some tests can pinpoint the cause. Acute pain is a warning that something has gone wrong. The causes of acute pain need to be found and treated promptly.
INFECTION: Pelvic pain can be caused by infection or inflammation. The infection does not have to be in the reproductive organs to cause pelvic pain. The source of the pain may be the bladder, bowel, or even appendix.
Pelvic inflammatory disease is a broad term used to describe infection of the uterus, fallopian tubes, and ovaries. Most cases of PID are thought to come from sexually transmitted diseases (STDs). An STD is a disease spread through sexual contact. If an STD that affects the cervix is not treated, the infection can spread into the uterus and fallopian tubes, causing PID. Symptoms of PID include fever and pain in the lower abdomen or stomach region. The pain may range from a mild ache to severe in intensity.
MoonDragon's ObGyn Information: Pelvic Inflammatory Disease (PID)
Vaginal infection (vaginitis) can be sometimes painful, mainly during and after sexual relations. Many kinds of organisms can cause vaginal infection.
MoonDragon's ObGyn Information: Vaginitis, Bacterial
MoonDragon's ObGyn Information: Vaginitis, Candidal
MoonDragon's ObGyn Information: Vaginitis, Post-menopausal
MoonDragon's ObGyn Information: Vaginitis, Trichomonal
Infections of the urethra, bladder, kidneys (urinary tract infection - UTI) may cause pain, too. A person with a UTI will often feel pain during urination and a frequent urge to urinate even when little urine is in the bladder. When pain is felt in the back region, the infection may have spread to the kidneys.
All of these causes of pain may require a visit to your midwife or health care provider. A history will be taken, a physical exam may be performed and some laboratory and/or diagnostic tests may be done.
OVARIAN CYSTS: Sometimes a cyst may form on an ovary. A cyst is a sac filled with fluid. It is similar to a blister. Some cysts on the ovaries form as a result of the normal process of ovulation (release of the egg from the ovary). Often a cyst begins fairly quickly but goes away within a day or two. Some cysts can last a long time. These cysts are often felt as a dull ache or heaviness. Sometimes they cause pain during sexual relations. Sharp pain can occur if a cyst leaks fluid or bleeds a little. This may happen around the middle of the menstrual cycle.
MoonDragon's ObGyn Information: Ovarian Cyst
A pelvic exam often will detect a cyst. In some cases, pelvic ultrasound, also called a sonogram, which is a test in which sound waves are used to view the internal organs, is needed to be sure. Most small cysts will go away by themselves. Rarely, more severe, sharp, and constant pain happens when a large cyst twists. Large cysts and those that don't go away on their own within a few months may need to be removed by surgery.
A pelvic exam checks for anything abnormal in your reproductive organs. The exam may detect an ovarian cyst or other growth, such as a uterine tumor.
ECTOPIC PREGNANCY: A tubal or ectopic pregnancy is a pregnancy that starts outside the uterus, often in one of the fallopian tubes. This happens most often in women who have some damage to their fallopian tubes. The pain often starts on one side of the abdomen after a missed period. Vaginal bleeding or spotting may occur with the pain. This problem needs immediate urgent care and may require surgery. An ectopic pregnancy can lead to bursting of the tube and bleeding inside the abdomen. This can be life threatening.
MoonDragon's ObGyn Information: Ectopic Pregnancy
Health care providers define chronic pelvic pain as any pelvic pain that lasts for more than six months. Chronic pain differs from acute (recent) pain in that acute pain may indicate a specific injury to the body. In chronic pelvic pain, the initial injury or problem may have disappeared. The pain continues because of changes in the nervous system, tissues, or muscles. Typically, chronic pelvic pain is characterized by:
- Pain that lasts for six months or longer.
- Pain that is out of proportion to the level of tissue damage.
- Presence of depression.
- Limited physical activity.
- Limited activities of daily living and changes in roles (inability to work, inability to care for children), and the fact that conventional methods for treating the pain have failed.
Chronic pelvic pain, like most other chronic pain conditions, affects your physical and psychological well being. Your best chance of functional recovery is finding a health care provider who specializes in treating chronic pelvic pain and uses a multi-disciplinary approach to treating all aspects of pain, including the physical and psychological aspects.
Determining the cause of your chronic pelvic pain may be a process of elimination. It is important to track when your pain occurs, how long it lasts, what type of pain you are experiencing (eg, ache, sharp pain, stinging, burning), and what makes the pain better or worse. Providing this information to your health care provider will help him/her determine what tests to perform.
If you are like most people with chronic pelvic pain, you have provided this information to multiple health care providers. It may be frustrating to repeat this information again, but it is important to provide your health care provider with as much information as possible.
Chronic pain can be either intermittent (it can come and go) or constant (it is there most of the time). Intermittent chronic pain often has a distinct cause. Constant chronic pain may be caused by more than one problem. An illness may start with intermittent pain that becomes constant.
Chronic Pelvic Pain Fast Facts:
- Researchers estimate that 12 to 20 percent of women have chronic pelvic pain.
- 10 percent of visits to gynecologists are for diagnosis and treatment of chronic pelvic pain.
- 30 percent of women with pelvic pain who have been referred to pain clinics have already had a hysterectomy.
- 20 percent of laparoscopies (lighted telescope placed into the abdominal cavity) are performed because of chronic pelvic pain.
- 25 percent of women affected by chronic pelvic pain are bed ridden for close to three days a month.
- Almost 60 percent of women with chronic pelvic pain must limit their usual activity one or more days a month.
- As many as 60 percent of women with chronic pelvic pain never receive a specific diagnosis.
DYSMENORRHEA: Dysmenorrhea (painful menstruation) is the most common cause of pelvic pain for women, and is said to be responsible for the majority of days absent from school or workplace. It is an example of long-term, intermittent chronic pain. Although some mild pain is common during a woman's menstrual period, some women have severe pain with their periods. It may be caused by prostaglandin, a hormone made by the lining of the uterus (endometrium). It causes spasms or cramping of the uterus. Most women rely on over-the-counter pain relievers (analgesics), so those who seek out medical management suffer from either very severe or repetitive dysmenorrhea that is not well controlled with over-the-counter medications.
MoonDragon's ObGyn Information: Dysmenorrhea
ENDOMETRIOSIS & ADENOMOSIS: Endometriosis is the second leading cause of pelvic pain in women. The cause of endometriosis and the reasons for pain during the menstrual cycle are not clearly known for sure. Endometriosis is a disease where the inside lining of the uterus (called endometrial tissue) grows outside of the uterus and attaches to the fallopian tubes, the bladder, intestines, and ovaries. This inside lining is the blood and tissue that is shed with menstruation. Endometriosis often makes menstrual cramps worse. It can also cause pain at times other than during the menstrual cycle. Sometimes sexual relations is painful. The intensity of the pain does not depend on the amount of endometriosis present. For some women, a small amount of endometriosis may cause a great deal of pain and for other women, a large amount of endometriosis may cause little or no pain. Researchers estimate that 90 million women in the world have endometriosis. Symptoms include dysmenorrhea (painful menses), dyspareunia (painful sex), dysfunctional uterine bleeding, and infertility. Hormonal treatment (e.g., birth control pills) or surgery can relieve some of the symptoms of endometriosis. Surgery can be an effective way to control endometriosis. Laparoscopy is a procedure during which a lighted camera is inserted into the abdomen so the surgeon can see the abdominal cavity. Laparoscopy is used to diagnose and treat endometriosis. The surgeon can remove or destroy the endometrial tissue that is outside of the uterus during this type of procedure by inserting lasers or other tools into the abdomen. Laparotomy is a more invasive procedure during which the surgeon removes the endometriosis or removes the uterus and/or the ovaries and fallopian tubes. This is a last resort treatment as it is considered major abdominal surgery.
Adenomyosis is the presence of endometrial glands and supporting tissues in the muscle of the uterus where it would not occur normally. When the gland tissue grows during the menstrual cycle and then at menses tries to slough, the old tissue and blood cannot escape the uterine muscle and flow out of the cervix as part of normal menses. This trapping of the blood and tissue causes uterine pain in the form of monthly menstrual cramps and also can cause pressure and bloating in the lower abdomen before periods and more bleeding during periods. Abnormal uterine bleeding occurs when some of the blood finally escapes the muscle resulting in prolonged spotting. It more often occurs in the posterior wall of the uterus.
Sometimes menstrual cramps can be a sign of disease. If they get worse over the years or stay strong beyond the first 1 or 2 days of flow, they can be due to a disease such as endometriosis or adenomyosis.
MoonDragon's ObGyn Information: Endometriosis
OVULATION PAIN. Pain that is felt around the time of ovulation it sometimes called mittelschmerz (German for "middle pain"). Ovulation occurs in the middle part of the menstrual cycle. Pain can range from a mild pinch or twinge to something more severe. It can occur every month in some women. It is intense only now and then, usually.
CHRONIC PAIN, CONSTANT
Some women may feel pain almost every day. This may mean that a problem has gotten worse. Or it could mean that a person has become less able to cope with the pain. The pain may then get worse even though the disease that started the problem has not changed.
Not being able to deal with pain is more likely with the pain disturbs work, physical activities, sexual relations, sleep, or family duties. Not knowing the cause of the pain can make it more stressful because the woman might fear severe illness.
When pain has been present for a long time, it affects the woman's mental and physical health. In seeking the cause for pelvic pain, your midwife or health care provider may ask you questions about the pain and its effect on your life and your emotions.
OTHER PAIN CAUSES
ADHESIONS: Adhesions or scar tissue can form as a result of the healing process. Scar tissue causes the surface of organs and structures inside the stomach to bind to each other. Endometriosis, surgery, or a severe infection such as PID can cause adhesions or scar tissue. Adhesions can involve the uterus, fallopian tubes, ovaries, and bowels. They can attach any of these structures to each other or to the sides of the pelvic area.
MoonDragon's ObGyn Information: Endometriosis
FIBROIDS:. Fibroids are the most common tumors of the uterus. Women with fibroids may not have any symptoms, but fibroids often become painful with age and deterioration. Fibroids are not fibrous tissue, but smooth muscle tumors that often have a rich blood supply. They range in size from microscopic to several inches in diameter. Although they usually occur in the body of the uterus, fibroids may also grow in the cervix and even in the round and broad ligaments surrounding the uterus. Pain can be caused by torsion or twisting and compromise of the local blood supply. Unusual pain has also been the result of fibroids that occur outside the uterus that attach to nearby organs with subsequent pain referred to the other organ (meaning the woman feels pain in the other organ). Patients usually have intermittent cramping and sharp pain. Pain may begin prior to the onset of menstruation and gradually progresses until it becomes incapacitating. Although many women get relief from over-the-counter, non-steroidal anti-inflammatory agents, progestational drugs are often prescribed to suppress the production of the prostaglandins (potent hormone-like substances) believed to be responsible for the symptoms. It is not known for certain what causes fibroids. However, estrogen is thought to play a role in their growth.
MoonDragon's ObGyn Information: Fibroid Uterus
SOME OTHER CAUSES OF LOWER ABDOMINAL & PELVIC PAIN:
- Nerve Disorders
- Diverticulitis (inflammation of a pouch bulging from the wall of the colon).
- Irritable bowel syndrome (a condition that may cause alternating bouts of diarrhea and constipation and often seems to be related to stress).
- Kidney or bladder stones.
- Muscle spasms or strain.
The pelvis itself is the area above the pelvic floor that actually constitutes the lowest portion of the abdomen. Pain in the actual perineum (between the vagina and the rectum) can be due to abnormalities of the pudendal nerve, the genital branch of the genitofemoral nerve, or the posterior femoral cutaneous nerve.
Some patients with pelvic pain have damage to the pudendal nerve, which is called pudendal neuropathy. The pudendal nerve transmits feelings from the external genitals, the lower rectum, and the perineum to the central nervous system. Patients with pudendal neuropathy have vaginal pain during intercourse, bladder pain during urination, rectal pain during defecation, and sitting pain. Some experts suggest the use of pudendal blocks to relieve pain in these patients.
Pelvic neuropathy. The following neuropathies are representative of some - but certainly not all - of the common conditions for which patients may consult a health care provider.
Patients may have ilio-inguinal and ilio-hypogastric nerve disturbances in the lower abdomen. These patients have past histories that often include surgical trauma in the lower abdominal wall. It is not certain of the origin of this pain but suspect it is related to the stretching or cutting of nerves located around the incision line. Pain may develop immediately after the initial trauma or gradually over time, depending on the severity of the injury and possibly the nerve fiber size.
Many patients with this type of pelvic neuropathy have undergone repeated exploratory surgeries because their original physician was convinced the initial intra-abdominal pathology had not been addressed or perhaps that recurrent pain might have been due to abdominal adhesions. This is becoming less common today due to the widespread use of laparoscopy, but the latter procedure itself may cause abdominal neuropathy due to placement of the scope or other surgical tools or because of the entrance points of the laparoscope. The classic example is the patient who has had one or more laparotomies; often the incisions are obvious and the maximal tender points are noted along the skin area marked by the incision scar.
Patients with pelvic neuropathy often benefit from repeated local anesthetic nerve blocks spaced over time. The blocks should not, however, be done too frequently because stimulating the nerve can create a new pain signal. Most patients will see improvement in pain in four to six weeks. Patients who do not respond to nerve blocks can be treated with cryotherapy (freezing) of those nerves still causing problems. When all else fails, you and your health care provider can consider a trial of spinal cord stimulation for pain relief.
Genito-femoral nerve disorders are often labeled genitofemoral neuropathies. Patients with this type of disorder have low abdominal pain or even back pain that has migrated to the front of the body and now descends into the genital area. The pain is often incapacitating when it occurs in sharp repeated attacks. Almost all patients experience significant pain relief - usually within minutes of therapy - after individual nerve blocks and maximum trigger point injections. Nerve blocks are procedures in which a surgeon positions a needle-most commonly guided by an x-ray fluoroscope-near a structure (e.g., a nerve) that the surgeon believes is the source of the pain. The surgeon then injects a local anesthetic to numb the nerve or "block" its function. He/she then monitors the effect of the block to determine if a patient achieves pain relief. For trigger point injections, a practitioner injects an anesthetic into the trigger point, which eases pain for some patients. Trigger point injections are most helpful when done in conjunction with a chronic pain management program.
There are some treatment failures, and sometimes these allow you to explore an overlooked organic disorder that may have been missed on the first pass. For most patients with pudendal neuropathy who don't respond well to pudendal blocks, however, it is because the therapy fails to deliver medication near enough to the pudendal nerve to relieve pain.
It is also possible that a pudendal block, when performed trans-vaginally via a blind approach, may miss the primary target - the ischial spinous (the bone near the bottom of the pelvis) process. In a study performed earlier, a CT scanner was used to precisely locate the ischial spinous process and, thus, allow more direct needle guidance. Twenty-six female patients with pudendal neuropathy were treated over a several month period. Over time, they received five CT-guided pudendal block treatments. All 26 patients were asked to score their pain before and after therapy based upon the classic pain scale, with 10 being the worst possible pain imaginable. Sixteen of 26 patients (62 percent) had significant pain reduction after therapy; however, 10 patients (38 percent) did not.
Gastroenterologic causes of chronic pelvic pain. Because the reproductive organs share nerves with parts of the colon and rectum, it can be difficult to determine if lower abdominal pain is related to female reproductive organs (gynecologic) or related to the stomach, intestines, and other organs of the digestive system (gastroenterologic). Irritable bowel syndrome (IBS) is a common cause of lower abdominal pain. Pain is typically intermittent cramping in the left-lower quadrant in location. Patients may experience changes in bowel function, such as diarrhea, constipation, bloating and/or flatulence. Pain is often improved after bowel movements. Symptoms may be worse after eating, during times of stress, tension, anxiety, or depression, during the pre-menstrual phase of the cycle, or with intercourse. A doctor diagnoses IBS based on the patient's history. Other conditions that can cause abdominal pain and should be ruled out include inflammatory bowel disease, polyps (benign tumors) and malignancy of the bowel. Treatment of IBS generally consists of dietary alterations, bulk forming agents, stress and anxiety reduction, anti-colonic and anti-spasmodic preparations, and low-dose tricyclic anti-depressant.
URINARY TRACT CAUSES
Urinary tract infections. Chronic pain of urologic origin may be due to recurrent steroid arthritis, urethral syndrome, urethral diverticulite, interstitial cystitis, or infiltrating bladder tumors. Ureteral causes of pelvic pain can include kidney stones, renal obstruction and endometriosis. Symptoms of urine frequency or urgency, pelvic pain and pain during intercourse with negative laboratory studies can be consistent with interstitial cystitis (IC) or urgency frequency syndrome. Symptoms of interstitial cystitis include pain on bladder filling and relief upon emptying and pain on suprapubic, pelvic, urethral, or vaginal areas. Symptoms that do not meet IC criteria may be called urgency frequency syndrome but may just represent an earlier form of interstitial cystitis or bladder hyperalgesia (over sensitivity). To diagnose IC, a doctor will insert potassium chloride in the bladder, which will be exquisitely painful in patients with this disorder. Therapy consists of increasing water intake and following a bladder diet, intravesical (inside the bladder) therapy, anti-depressants, anti-histamines, physical therapy, biofeedback or repeated anesthetic blocks to the uterine, vaginal, or nerves of the pelvis. Medications that help with IC pain include tricyclic antidepressants, membrane stabilizing agents, nonsteroidal anti-inflammatory agents, and occasionally opioids.
PELVIC JOINT INSTABILITY
Pelvic joint instability. Persistent pelvic pain and pelvic joint instability in some females has been associated with early puberty (before age 8) and the use of oral contraceptives before childbirth. Thus, patients who have pelvic pain in which all diagnostic workups have been normal and who have a history of early onset of menstruation associated with oral contraceptive use, may have pelvic joint instability.
Hematoma is another possibility to consider in women complaining of pelvic pain. A hematoma of the piriformis muscle should be considered. A hematoma is the abnormal collection of blood. The piriformis is one of the small muscles deep in the buttocks that rotate the leg outward. A hematoma of the piriformis muscle is a rare complication that can cause impingement (restriction) of the sciatic, inferior gluteal, and pudendal nerves. This may result from compression between the muscle and the iliac spine. In these cases, a CT scan should help confirm the diagnosis.
Active females who present with pubic pain and adductor pain (pain with squeezing the legs together) may be suffering from osteitis pubis. In one study of 59 patients, recovery took up to seven months among the female subjects. This disorder can be managed with a support belt and pain relievers (analgesics). There was also an associated finding of pelvic malalignment or sacroiliac dysfunction in these patients.
DIAGNOSIS OF PELVIC PAIN
Since there are so many causes of pelvic pain, your midwife or health care provider may use many tests to determine and rule out likely causes of your pain. It may seem complex, time-consuming, stressful and financially expensive if you do not have a health insurance to cover the tests, but this approach is usually the best way to find out the cause of the pain.
Your midwife or health care provider may ask you to keep a journal in which you describe the exact nature of the pain. What you write down can help to rule out certain causes. Bring it with you when you see your midwife or health care provider.
KEEPING A PAIN JOURNAL
Keeping a pain journal can help your health care provider pinpoint the cause and lets your provider see any patterns that may be associated with your pelvic pain. To help your health care provider diagnose the cause of your pelvic pain, it's important that you can answer a few questions:
1. When did the pain begin?
2. Is it constant pain, or does it come and go?
3. How long does the pain last?
4. How severe is the pain?
5. Is it a sharp stabbing pain or a dull ache?
6. Is the pain always in the same place?
7. When do you typically experience pelvic pain?
In your pain journal you should also note:
- The time of day when pain occurs.
- The time as it relates to your monthly cycle.
- Whether pain occurs before, during, or after:
- Bowel movements.
- Sexual intercourse.
- Physical activity.
A Personal Pain Inventory where you can record all the details of your particular pain history, including where you hurt, when the pain began, and the types of treatment you have tried. Completing the Personal Pain Inventory can help you and your health care provider design an effective pain management plan. A Personal Pain Journal is a journal where you can record your day-to-day experiences with pain and pain management. The Personal Pain Journal can help you keep track of when you hurt least and when you hurt most; what activities control your pain; and what treatments work best. By keeping a Personal Pain Journal you gain the valuable information you need to communicate with your health care provider and effectively manage your pain condition.
Your midwife or health care provider may consult with or refer you to other health care specialists. It depends on what your midwife or health care provider suspects may be the cause of the pain. The specialists may include health care providers who deal with problems of the gastrointestinal, urinary or neurologic systems.
TESTS & DIAGNOSIS
Tests that may be performed to determine the cause of your pain include:
- Pelvic & physical examination.
- Laparoscopy, cystoscopy, or sigmoidoscopy (surgical procedures during which lighted telescopes placed into different body cavities of the pelvis).
- X-ray, ultrasound, CT scan, magnetic resonance imagery or MRI.
- Tests of bladder and rectal function.
PELVIC & PHYSICAL EXAM
The evaluation begins with a physical exam. Health history, menstrual and obstetric history are reviewed. Cultures and blood tests are sometimes needed to look for infection.
A physical exam will assist your health care provider to determine your overall health and wellness. A pelvic exam helps your health care provider determine if there is an infection, abnormal growths, or tension in the pelvic floor muscles. He/she also will check for changes in sensation in your skin and any areas of tenderness or unusual abdominal or pelvic masses or growths. For cultures, your health care provider will take samples of cells from your cervix, vagina and bladder to check for infection.
Other studies are sometimes useful to find the cause of pain. They are often less helpful for evaluating chronic pain than for other gynecologic conditions. Laparoscopy, cystoscopy and sigmoidoscopy are diagnostic surgical procedures during which your health care provider looks for abnormal tissues or growths or signs of infection with lighted cameras. Imaging studies, such as ultrasound, CT scans, and MRI, may help your health care provider determine if your anatomy is normal or if there are any growths. Tests of the bladder include cystoscopy and urodynamics, while sigmoidoscopy and anal manometry are used to study bowel function. Nerve testing may also be helpful.
These Studies Include:
- Ultrasound: A test in which sound waves are reflected off the internal organs, producing an image that can be viewed on a screen.
- Computed Tomography (CT): A type of X-ray that shows internal organs and structures (also called a "CAT scan").
- Magnetic Resonance Imaging (MRI): A method of viewing internal organs and structures by using a strong magnetic field.
- Intravenous Pyelography (IVP): A type of X-ray taken after fluid is injected into a vein and excreted by the kidneys.
- Barium Enema: A solution given through the rectum that helps problems in the colon show up on X-rays.
Sometimes these tests are referred to as "imaging studies." This is because they are all used to make an image of the inside of the body, using sound waves, X-rays, or other techniques. These studies cannot always detect endometriosis or adhesions, which may be a cause of chronic pelvic pain.
Laparoscopy is the best way to assess endometriosis and some other problems. With this type of surgery, a slender device that transmits light is inserted through the navel while you are under anesthesia. This allows the health care provider to see inside the body. Sometimes, treatment can be done at the same time. A health care provider may not be certain of a diagnosis of endometriosis unless surgery is done.
MoonDragon's ObGyn Procedures: Pelvic Exam
MoonDragon's ObGyn Procedures: Pelvic Pap
MoonDragon's ObGyn Procedures: Pap Smear
MoonDragon's ObGyn Procedures: Laparoscopy
MoonDragon's ObGyn Procedures: Cystoscopy
Being in pain for any length of time can put great strain on a woman and those close to her. Women who have depression in their family or who had a difficult childhood (especially when sexual abuse was involved) are more likely to have chronic pain.
For these reasons, your midwife or health care provider may ask many questions about you and your family to see if there is a need for emotional assistance. Sometimes the midwife or health care provider may suggest that you get counseling.
Mood and pain may be chemically linked in the brain. Chemical changes may make the brain less able to cope with pain or may block out pain signals. Treatment of chronic pain can sometimes be improved by using antidepressant medications. Antidepressants alter these signals.
CHRONIC PELVIC PAIN MYTHS AND MISCONCEPTIONS
Myth: The pain is all in my head.
Fact: There are many different physical causes of pelvic pain, including nerve disturbances, pelvic neuropathy, irritable bowel syndrome, hernia, interstitial cystitis, endometriosis, fibroids, and more. Pelvic pain becomes chronic often because of changes in the nervous system, tissues, or muscles. Chronic pain of any type is complicated by psychological factors such as depression or anxiety.
Myth: Only women suffer from pelvic pain.
Fact: Chronic pelvic pain is most common in women, but men may suffer from pelvic pain related to chronic prostatitis, chronic orchalgia, or prostatodynia.
Myth: Only women who have been sexually abused suffer from pelvic pain.
Fact: 10 percent of all visits to a gynecologist are because of pelvic pain. Women who have never been sexually abused may develop chronic pelvic pain; however sexual abuse before age 15 is associated with later development of chronic pelvic pain.
Myth: There's usually only one cause of pelvic pain or one simple test to diagnose it.
Fact: Unfortunately, there are many causes of pelvic pain, and diagnosing it often is a process of elimination. Pelvic pain can result from diseases or disorders of the reproductive organs, urologic disorders, musculoskeletal disorders, gastrointestinal diseases or disorders, and neuropathy.
Myth: There is no effective treatment; just live with it.
Fact: There are many ways to treat chronic pain and improve functioning and quality of life. People with chronic pelvic pain often find that their pain is best managed by a variety of treatments, including medications, surgery, injections, cognitive behavioral therapies, and more.
TREATMENT OF PELVIC PAIN
Acute pain or intermittent chronic pain often involves treatment of one specific condition. Treatment of constant chronic pain is not like that. Your midwife or health care provider may talk to you about factors that may add to the pain, but may not know which one is the main cause. Treatment may involve a few medications at once, non-drug treatments, or surgery.
If you have had a problem such as a urinary tract infection or vaginitis before and it has come back, your midwife or health care provider may prescribe medication or recommend treatment over the phone. Most often, antibiotics, vaginal creams or other treatments will reduce the pain of an infection within 1 or 2 days. Severe PID may require days of treatment, possibly in a hospital. With some kinds of STDs, your sexual partner must also be treated, even if there are no symptoms.
ANTI-INFLAMMATORY: For mild pain, the usual recommendation includes the use of acetaminophen or a non-steroidal anti-inflammatory agent. Drugs that reduce inflammation (anti-inflammatory), such as ibuprofen, naproxen sodium, can be used to lessen the pain of dysmenorrhea. These drugs block the making of prostaglandins, which cause the uterus to contract. Ibuprofen can be bought over the counter. If it does not work, prescription drugs may be recommended.
OPIOIDS: Opioids are reserved for patients who do not have pain relief from initial therapy. For patients with unresolved chronic pain, the use of long-acting opioids, including methadone, have proven very effective. Providing long-term opioids to patients with chronic pelvic pain is a controversial topic. For the most part, health care providers in multiple specialties in all regions of the United States have little concern about tolerance, dependence or addiction when prescribing opioids to treat chronic pain. The health care provider must be aware, however, that prior addiction and some aspect of sexual abuse are prevalent in the chronic pelvic pain population. Health care providers should use an informed consent as it allows these patients to autonomously choose to accept the risk of addiction and accept responsibility to be aware of the increased possibility of dependence. This allows for the sharing of responsibility and provides patients with self-confidence.
Most people try to use as little pain medication as they can. When treating chronic pain, it is better to use a non-narcotic pain medication as part of a routine. It is not a good idea to wait until the pain is severe before you take it. Pain medication may only take the edge off the pain. It may not get rid of it. It is best to avoid strong narcotic medication. It can lead to addiction or the need for higher doses.
HORMONES: Controlling the menstrual cycle pain through the use of hormones, such as birth control pills, continuous progestogens, or a GnRH agonist, may help IC, endometriosis, and pelvic congestion syndrome. Combination oral contraceptives (birth control pills) can be used to relieve pain from menstrual cramps. Other hormones can shrink some types of growths, such as endometriosis, fibroids, and certain types of benign tumors. Fibroids often return to their former size when treatment is stopped. Hormones are usually chosen when NSAIDS (non-steroidal anti-inflammatory drugs) have failed in decreasing discomfort. The use of GnRH agonists is an effective approach to providing relief for patients with chronic pelvic pain and may be useful in clinical diagnosis of endometriosis.
ANTI-DEPRESSANTS: Antidepressants have been used in some women with pelvic pain when other treatments have not worked. They can help break the cycle in which pain and the depression add to each other. The pain seems to be made more intense by depression.
Tricyclic antidepressants are effective as an additional therapy, especially given the high prevalence of depression in chronic pelvic pain patients. Medications that are typically used are imipramine, amytriptiline, or doxepin. These medications have been shown to improve pain tolerance, restore normal sleep, and help reduce depression. Amytriptyline has been shown to be effective in increasing the patient's activity level and reducing the intensity of pain.
Many health care providers are combining the tricyclic anti-depressants with the newer anti-depressant medications, called selective serotonin re-uptake inhibitors (SSRIs). The tricyclic medications are being used at smaller doses, helping relieve pain but limiting the side effects, while the SSRIs are helping with depression. This form of treatment has been seen to be extremely effective with patients with chronic pelvic pain and interstitial cystitis. Anti-depressants have been shown to be extremely effective in the treatment of patients who have psychogenic pain or somatoform pain disorder by reducing pain when compared with placebo.
ANTI-CONVULSANTS: Anticonvulsants have proven effective in the treatment of post-herpetic or pudendal neuralgia. Gabapentin has proven to be beneficial for the use of relieving burning or lancing pain as seen with interstitial cystitis. Pregabalin is related to gabapentin and is approved to treat neuropathic pain, specifically diabetic peripheral neuropathy and postherpetic neuralgia. It may have potential for other chronic pain disorders.
OTHER MEDICATIONS: There are many medications that are effective when they act with other medications, causing a synergistic effect. Hydroxyzine may have an additive effect with opioids. Clonidine has been shown to have a synergistic effect with morphine. It has also proven effective in treating proctalgia fugax (painful muscle spasm of the rectum).
The above medications can be used for any cause of chronic pelvic pain of unknown origin. There are some medications that are effective in the use of a particular cause of the pelvic pain.
The use of pentosan polysulfate sodium has been hypothesized to help increase the repair of the damaged bladder mucosa resulting in decreased inflammation and possible pain. It has shown a 28 to 32 percent improvement of symptoms. Pentosan polysulfate sodium has been shown to control pain and urination frequency and urgency.
MEDICATIONS FOR IRRITABLE BOWEL SYNDROME: Patients have seen improvement with tricyclic antidepressants, anti-cholinergics (dicyclomine hydrochloride, hyoscyamine sulfate) for irritable bowel syndrome. Daily use of fiber - if used religiously - is effective in significantly relieving symptoms. It is effective in increasing stool bulk, and water content and decreases transit time, decreasing pain and constipation and providing for more formed, regular bowel movements.
Trigger point injections with anesthetics (bupivacane 0.25%) have provided significant relief for patients with chronic pelvic pain. Response rates have been as high as 80 to 90 percent after repeated injections. Recently, evidence has shown that injections with Botulinum Toxin A have decreased pain scores by producing local, temporary muscle paralysis and possibly reducing mediators of neurogenic inflammation. Injecting Botulinum Toxin A into the genitofemoral and ilio-inguinal nerves or into spastic muscles with trigger points has been shown successful in patients with high tone pelvic floor dysfunction.
Of all the treatment modalities for chronic pelvic pain, surgery is the most controversial. There have been many procedures that have arisen both for the diagnosis and treatment of chronic pelvic pain that have met with limited success. Certain problems may be treated with surgery. The type of surgery depends on your exact problem.
SACRAL NEUROMODULATION: Sacral neuromodulation of the third nerve root is a FDA-approved modality for the treatment of refractory interstitial cystitis patients and urgency incontinence. Because pain is a major component of interstitial cystitis, sacral neuromodulation has proven to be effective in decreasing pain.
LAPAROSCOPY: Some surgeries, such as laparoscopy, often can be done as an outpatient procedure. Some conditions outside the uterus can be treated by laparoscopy using laser or cautery. It often can be done at the same time that the diagnosis is made. With the widespread use of laparoscopy, many procedures have been proposed for helping chronic pelvic pain including cutting (lysis) adhesions, removing endometrial lining outside the uterus either through laser or electric current (ablation or fulguration), destruction of the uterosacral nerve ablation (burning the ligaments that attach the uterus to the sacrum, which is a part of the pelvic bone), and pelvic pain mapping.
Traditionally laparoscopy has been thought of as the gold standard for evaluation and treatment of chronic pelvic pain with the improvement rates reported as high as 65 to 84 percent. There has been success in the treatment of chronic pelvic pain associated with endometriosis in the short term with laparoscopy, with symptom relief gained by 62.5 percent of the patients and those who have laser treatment of their endometriosis showing a 70 percent improvement of pain. Of these patients undergoing ablative (destruction of abnormal areas) procedures, 44 percent will recur after one year.
HYSTEROSCOPY: Some conditions inside the uterus can be treated with a hysteroscope (a thin telescope with a light). The hysteroscope is inserted through the cervix and into the uterus. Small growths may then be seen and removed.
NEUROBLATIVE PROCEDURES: Multiple neuroablative procedures (destroying nerves) have been used to treat chronic pelvic pain, including laparoscopic uterosacral nerve ablation and presacral neurectomy, with improvement rates as high as 75 to 95 percent when compared with diagnostic laparoscopy alone within the first year. Long-term data are not as promising with success rates seen as low as 39.5 percent four years after the procedure and even lower success rates in patients with moderate to severe endometriosis.
EMBOLIZATION: For those patients felt to have pelvic congestion syndrome with associated dyspareunia (painful intercourse), the use of embolization (clotting off abnormal blood vessels) of the ovarian veins by transcathater embolization has proven to be successful. One study showed that there was a relief of symptoms in 57.9% of patients with a complete relief in approximately 16%; however, 28% of patients had no relief.
HYSTERECTOMY: Other times, major surgery, such as a hysterectomy (removal of the uterus), is needed. Sometimes the fallopian tubes and the ovaries are removed also. Your midwife or health care provider will discuss what options you have, based on your exact problem. Risks and benefits of these procedures will also be discussed and their chance of success in relieving your problem.
Approximately 12 percent of hysterectomies in the United States (approximately 60,000 annually) are for chronic pelvic pain. Success rates, which some experts believe are exaggerated, range from 60 to 95 percent. Researchers have found that one in four women experienced some pain one year following hysterectomy. Another group of researchers demonstrated that 40 percent of patients who have had a hysterectomy will have continued chronic pain. Recurrence rates of 40 percent were also observed in women in whom hysterectomy was performed without identifiable disease. Another study showed that, in the United States, more than 60 percent of uteri removed from patients with chronic pelvic pain were pathologically normal.
Apart from traditional and herbal medications, a wide variety of treatments are available to help ease chronic pelvic pain. The positive attribute of these treatment modalities is the minimal risk the patient experiences by attempting them. These include heat therapy, muscle relaxants, nerve block, relaxation exercise, Reiki therapy, acupuncture, chiropractic care and various other Allopathic and alternative-complementary methods may be beneficial in treating various causes of pelvic pain, depending upon the cause. If disorders of the bladder, bowel or other organs are the cause of the pain, certain treatments may be suggested and may be used.
PHYSICAL THERAPY FOR PELVIC PAIN: Physical therapy has been shown to be effective in helping pelvic pain. Patients with chronic pelvic pain require intervention secondary to the myofascial (muscle) component. It has been shown that, with the use of internal manual massage, approximately 70 percent of patients will have a significant improvement of pain with physical therapy targeting the pelvic floor (pelvic floor hypertonus) specifically helpful in patients with urgency/frequency syndrome and interstitial cystitis.
In patients with levator ani syndrome (spasm of the muscles surrounding the rectum, vagina, and urethra), the use of electrical stimulation has reported success rates of 80 to 90 percent.
ACUPUNCTURE: Acupuncture - Originating in China, this age-old practice involves inserting long, extremely slender needles into specific points along the body to relieve pain and discomfort. Acupuncture also can be combined with electrical stimulation (electro-acupuncture).
Trigger point release has been shown to be effective. This can be attained by the use of manual massage and acupuncture. A number of clinical trials have demonstrated a significant reduction in pain and even resolution of the painful stimuli.
BIOFEEDBACK: Biofeedback - This involves using visual or sound cues to control the biological response to pain and stress. Learning to relax muscles and induce a state of calmness can help pelvic pain patients. Some also claim that biofeedback improves blood-flow to affected limbs, however there is no scientific evidence to support this.
For pelvic pain, 80 to 90 percent success rates have been reported with biofeedback (use of a vaginal tampon that monitors muscle tone).
HOMEOPATHY: Homeopathy - This is an alternative, non-toxic approach used to treat illness and relieve discomfort in a wide range of health conditions. Founded in Germany in the late 1860's, the practice of homeopathy is based on using the "law of similars" to stimulate a healing response - a principle that goes back to the days of Hippocrates. The law of similars states that a substance that will cause disease symptoms in a normal person can, when given in homeopathic dilutions to an ill individual, prompt the same set of symptoms to initiate a healing response.
HYPNOSIS: Hypnosis - This involves entering a state of altered consciousness, usually artificially induced, in which you focus your attention and awareness in an intense manner. It may be helpful to pelvic pain patients to learn self-hypnosis techniques to distract themselves from pain and/or improve sleep.
GUIDED IMAGERY: Guided imagery is a relaxation technique that involves sitting or lying quietly and imagining yourself in a favorite peaceful setting (e.g., beach, forest). Guided imagery, also called visualization, is more than just picturing your favorite peaceful setting-it is truly imagining yourself in that setting. Be as specific as possible. Imagine what sounds you hear, what sensations you feel (e.g., cool or warm breeze), the textures you might feel, the sights you might see. The more specific your visualization, the higher level of relaxation you'll experience as your mind truly is in the relaxing place you are picturing.
MANIPULATION THERAPY: Manipulation - Chiropractors, osteopathic physicians and manual therapists most commonly practice this intervention. Manipulation involves the movement of tissue by the laying on of hands. When performed gently, it is usually referred to as mobilization. (NOTE: Do not undergo vigorous or "thrust" - type manipulation or numbness, weakness or paralysis may follow.)
Doctors of Chiropractic and Osteopathy often perform manipulations that are called adjustments. Patients often experience temporary pain relief from this therapy and many prefer these interventions because they avoid the potential side effects or complications of medications or surgery. Patients often can learn manipulation techniques that are helpful in improving mobilization and can be performed at home in six to eight sessions. Long-term and ongoing dependence on these therapies to provide pain relief is discouraged.
NATUROPATHIC MEDICINE: Naturopathic medicine was founded on the principles of the healing power of nature, focuses on optimizing wellness and preventing disease, and has been around for centuries. Naturopathic physicians (NDs) are primary health care providers who use therapies that are generally natural and nontoxic, including clinical nutrition, homeopathy, botanical medicine, hydrotherapy, physical medicine, counseling, and sometimes acupuncture. Naturopathic physicians study at a four-year, graduate level naturopathic medical school that includes the basic sciences studied by medical doctors. They must take and pass board examinations to be licensed as primary care physicians. Naturopathic medicine can be used to complement conventional medicine and NDs may refer patients to appropriate medical specialists for certain conditions (e.g., an oncologist or surgeon).
HERBAL REMEDIES: Over-the-counter herbal remedies - There are many different herbal remedies, but there is little research about the beneficial effects of such products. Your health care provider must be informed if you are using herbal medicines. There are certain dietary supplements and other remedies that contain active biologically effective substances (eg, gingko, ginseng, vitamin E) that may cause bleeding at the time of surgery or spinal injection procedures. If taken to excess, some herbal remedies can cause cardiac irregularities. Deaths have been reported as a result of the over-use of some remedies (eg, ephedra). Key to herbal remedies is to know what you are taking and the correct use and dosages. If in doubt, consult with a Naturopathic or Herbalist Practitioner.
PELVIC PAIN PSYCHOLOGY OF PAIN
Psychological factors may increase the likelihood that pain will become chronic; however, chronic pelvic pain and vulvar pain rarely result from a psychological disorder. Most women with pain will have a significant degree of anxiety, depression, sexual dysfunction and social withdrawal. There also is higher prevalence of major depression, affective disorder, panic disorder, somatization disorder (the brain assigns pain to a specific area that appears normal), and sexual abuse as well as physical abuse in women with chronic pelvic pain. Therefore, the majority of patients with chronic pelvic pain have abnormal psychological profiles; however, the patients without obvious causes for their pain do not appear to be psychologically different from those who have diagnosed disease. Trigger points, nerve entrapments, pelvic congestion syndrome, interstitial cystitis, irritable bowel syndrome, excessive pain with endometriosis and adhesions are all common sources of pelvic pain which can create changes in the central processing of signals entering the spinal cord and brain from the more distant structures. The psychological state can certainly play a role in sensitizing "the nervous system" - either by increasing transmission of ascending impulses or decreasing signals - and inhibit normal pain processes that can contribute to long-term pain.
You hope to find a health care provider who respects and believes in you and the pain and suffering that you have experienced so far. But this validation of you and your experience can only go so far in helping you.
What you need more is a logical, systematic, coordinated, and comprehensive strategic plan to help you get better. This plan includes the involvement of several other approaches, disciplines and colleagues including the following:
- A medication regimen to help allay the pain experience.
- Local anesthetic nerve blocks to decrease the pain signal where it originates.
- Physical therapy to give relaxation and strength of adjoining muscles, ligaments and tendons.
- Psychology to assist with the mental anguish that accompanies pain, and personal empowerment or development of inner strength.
What about depression then? What is the cause? Who is at risk? How can it be identified? Can it be treated? Patients with pain have enough problems to attend to without the added burden of depression. This brief descriptive about depression is to acquaint you with some of the signposts so you can identify it yourself and report it early on before it takes a heavy toll in regard to happiness and eventual recovery.
There is no single cause of depression. It can occur anytime and can last a variable time period. Sometimes a combination of biological, psychological, and environmental factors may generate a risk for depression when before there was none. These factors include hormonal fluctuations, sleep deprivation, mood swings, and feelings of loss, shame, or even guilt.
For some, there may be uncontrollable crying, sadness, even loss of self-assurance. In others, there may be mood swings. Some may develop feelings of hopelessness and despair. Many women who suffer from clinical depression have feelings of confusion, irritability, anxiety and psychosis. Symptoms of clinical psychosis include feelings of inadequacy, mood swings, hallucinations or delusions. It should be noted that some women get better on their own, but many others do not. These women can end up much worse over time and sometimes their recovery can be delayed substantially. The pathway to successful recovery is based upon detection and immediate treatment, not delay and isolation.
Where can you go for help? Can clinical depression be prevented? What are logical first steps in recognizing you may have clinical depression? One of the first steps should be a medical evaluation that includes a comprehensive thyroid screening. It is interesting that about 10 percent of women who develop depression have a history of thyroid illness. Often, women who suffer clinical depression in silence know something is wrong, but due to feelings of guilt or shame, will not ask for help. Try to talk about feelings. Do not hide them from those who can help you. The sooner you get help, the better off you will be.
You may be surprised or hurt when the health care provider you trust refers you for a psychological evaluation, especially if your health care provider says he/she believes you and that your pain is not in your head. If this is the case, why then is a referral to a psychologist necessary?
Your current pain and physical distress are considered real and valid. Unfortunately, the misunderstandings about where the pain is coming from are confusing and often the reason your pain may not be identified for some time. Actually, a psychological evaluation during a pain work-up is becoming more and more common. In time, it may even become a routine procedure, used to help your health care provider in developing the best plan possible for you. We know that pain and suffering create emotional and social stresses that eventually affect the way you respond to all sorts of stimuli, including medical therapy. This can significantly affect your recovery even if your health care provider has the correct diagnosis and has initiated the correct therapy.
Findings from this psychological evaluation can help your health care provider to help you with development of a better plan for getting you well again. Completion of this type of evaluation can also help to identify and uncover some concerns that were not even considered. This type of complete understanding of your psychological status can help you personally to become stronger and give you an opportunity to resolve many "unrecognized problems" and thus enhance your ability to heal and become strong again.
You should meet with a qualified, experienced psychologist. Typically such meetings consist of an interview and then testing as decided for your particular case. Psychologists play an important role in helping doctors to help you for the following reasons noted below:
- People with illness or injury undergo great turmoil and stressful times that they often do not even realize. When pain or stress build up, other problems can arise. This can cause certain personality changes that may include family discord and disharmony and also problems in the workplace. Some patients also have difficulty sleeping.
- The above may trigger other alterations regarding work that include the stress of losing one's job or getting less pay for a period of time.
- Conflicts in the workplace also may cause more stress and affect our feelings of self-worth. Happiness may disappear and be replaced with loneliness, despair and depression.
- Certain medications may be necessary to help you on the road to recovery and may in fact, speed up your return to good health.
- Some of the alternative treatment methods may be indicated and may be recommended by the psychologist. Also some of the pain conditions have been found to be responsive to treatments that are administered by psychologists themselves, including biofeedback and psychotherapy sessions.
COGNITIVE BEHAVIORAL THERAPY
Cognitive behavioral therapy is a treatment modality useful in teaching and promoting coping skills, allowing the patient the ability to deal with contributing stresses and reverse the adverse outcomes of chronic pain. The treatment includes phases of education, skills acquisition, behavioral modification, and maintenance. Examples of such treatment include muscle relaxation, deep breathing, distraction techniques and imagery, which decrease generalized muscle spasm and arousal. An important goal of this type of therapy is to succeed in overcoming the fears of daily life activities, including returning to work.
Progressive activity programs are useful in increasing physical activity and decreasing disability behaviors, thus helping to decrease the effects of chronic pelvic pain. Stress management is essential to any effective cognitive behavioral therapy. This can be attained by learning to identify and attempt to alter these stresses in conjunction with providing support in avoiding stresses. These goals are coordinated with education and understanding of the importance of nutrition, exercise, sleep, relaxation and avoidance of substance abuse and are attainable in most cases. As is seen with both interstitial cystitis and irritable bowel syndrome, dietary modifications, such as a decrease in acidity, and avoidance of stimulants, such as alcohol and caffeine, will help control symptoms and allow patients a better quality of life.
CHRONIC PELVIC PAIN - GETTING HELP
While pelvic pain is difficult to diagnose, there are health care providers who understand and know how to treat it. Ideally, the health care provider should have expertise in pain and gynecology, but such individuals can be difficult to find. Be aware that many health care providers and other health-care practitioners call themselves pain specialists, but may not be as well trained or experienced in treating chronic pain conditions.
Here are some places and people that can help manage pelvic pain:
- Comprehensive Pain Centers: Such centers provide multi-modal, interdisciplinary treatment, but may not have pelvic programs or specialists. Be sure to check first.
- Pain Medicine Practitioners: Pain medicine has become a medical specialty in recent years. Pain medicine practitioners specialize in treating many different pain conditions. Depending on background and interest, many treat pelvic pain; however, inquire about their experience and interest in treating pelvic pain and whether they incorporate a variety of therapeutic (multi-modality) approaches.
- Pelvic Specialists/Obstetricians/Gynecologists/Urologists/Physical therapists/Colorectal specialists/Sex and Pain Counselors: These health care providers have special skills, training, and education in women's health care, but they may not be well versed in chronic pain. Be sure to ask about their experience with treating chronic pelvic pain.
Following are professional societies that may be able to help you locate health care professionals or facilities that are knowledgeable about managing and treating chronic pelvic pain.
PELVIC PAIN-RELATED INFORMATION RESOURCES
International Pelvic Pain Society
Suite 402, Women's Medical Plaza
2006 Brookwood Medical Center Drive
Birmingham, AL 35203
(205) 877-2950 (outside the US)
Interstitial Cystitis Association
110 North Washington Street - Suite 340
Rockville, Maryland 20850
Fax: (301) 610-5308
Irritable Bowel Syndrome Association
1440 Whalley Ave. #145
New Haven, CT 06515
American College of Obstetricians and Gynecologists
409 12th Street, S.W.
Washington, D.C., 20090-6920
National Vulvodynia Association
PO Box 4491
Silver Spring, MD 20914-4491
Fax: (301) 299-3999
North American Society for Pediatric and Adolescent Gynecology
1015 Chestnut Street, Suite 1225
Philadelphia, PA 19107-4302
Fax: (215) 923-3474
International Adhesions Society
PAIN-RELATED INFORMATION RESOURCES
American Academy of Pain Medicine
4700 West Lake Avenue
Glenview, IL 60025
American Board of Pain Medicine
4700 West Lake Avenue
Glenview, IL 60025
American Chronic Pain Association
Post Office Box 850
Rocklin, CA 95677
American Society of Pain Management Nurses
7794 Grow Drive
Pensacola, FL 32514
(888) 34-ASPMN (342-7766)
Fax: (850) 484-8762
American Pain Society
4700 W. Lake Avenue
Glenview, IL 60025
Fax: (877) 734-8758
OTHER HEALTH CARE-RELATED INFORMATION RESOURCES
American Academy of Family Physicians
P.O. Box 11210
Shawnee Mission, KS 66207-1210
The National Women's Health Information Center
8550 Arlington Blvd., Suite 300
Fairfax, VA 22031
(800) 994-WOMAN (800-994-9662)
For a full list of available products from Mountain Rose Herbs, click on banner below:
HELPFUL PRODUCTS & FURTHER EDUCATION
Prescription for Nutritional Healing: The A-To-Z Guide To Supplements
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
Prescription for Nutritional Healing: The A-To-Z Guide To Supplements
-- by Phyllis A. Balch, James F. Balch - 4th Edition
Prescription for Herbal Healing: The A-To-Z Reference To Common Disorders
-- by Phyllis A. Balch
The Complete Guide to Natural Healing
If you see a suggested Amazon product "not there" as indicated by an orange box with the Amazon logo, this only means the specific product link has been changed by Amazon.com. Use the "click here" icon on the orange box and it will bring you to Amazon.com and you can do a search for a specific product using keywords and a new list of available products and prices will show. Their product and resource links are constantly changing and being upgraded. Many times there are more than one link to a specific product. Prices will vary between product distributors so it pays to shop around and do price comparisons.
Educational materials and health products are available through Amazon.com. Use the search box provided below to search for a particular item.
HERBS, OILS, & SUPPLIES
MoonDragon's Health & Wellness: Manufacturers & Distributors
Mountain Rose Bulk Herbs
Mountain Rose Herbs, Bulk Herbs A
Mountain Rose Herbs, Bulk Herbs B
Mountain Rose Herbs, Bulk Herbs C
Mountain Rose Herbs, Bulk Herbs D
Mountain Rose Herbs, Bulk Herbs E
Mountain Rose Herbs, Bulk Herbs F
Mountain Rose Herbs, Bulk Herbs G
Mountain Rose Herbs, Bulk Herbs H
Mountain Rose Herbs, Bulk Herbs I
Mountain Rose Herbs, Bulk Herbs J
Mountain Rose Herbs, Bulk Herbs K
Mountain Rose Herbs, Bulk Herbs L
Mountain Rose Herbs, Bulk Herbs M
Mountain Rose Herbs, Bulk Herbs N
Mountain Rose Herbs, Bulk Herbs O
Mountain Rose Herbs, Bulk Herbs P
Mountain Rose Herbs, Bulk Herbs R
Mountain Rose Herbs, Bulk Herbs S
Mountain Rose Herbs, Bulk Herbs T
Mountain Rose Herbs, Bulk Herbs U
Mountain Rose Herbs, Bulk Herbs V
Mountain Rose Herbs, Bulk Herbs W
Mountain Rose Herbs, Bulk Herbs Y
Mountain Rose Aromatherapy Oils
Mountain Rose Herbs, Aromatherapy Oils A-B
Mountain Rose Herbs, Aromatherapy Oils C-E
Mountain Rose Herbs, Aromatherapy Oils F-L
Mountain Rose Herbs, Aromatherapy Oils M-P
Mountain Rose Herbs, Aromatherapy Oils Q-Z
Mountain Rose Herbs, Aromatherapy Oils: Oil Blends & Resins
Mountain Rose Herbs, Aromatherapy Oils: Diffusers, Nebulizers, & Burners
Mountain Rose Herbs, Aromatherapy Oils: Oil Kits
Mountain Rose Herbs.com: Order Online
Accessories & Tools
Aroma Sprays and Flower Waters
Body and Bath
Bottles, Jars & Containers
Green & Black Teas
Herbal Salves & Balms
Herbs for Pets
Incense, Resins and Candles
Medicinal Herb Seeds
Tea Brewing Supplies
Click Here To Visit Herbal Remedies Product Page
A Source For Medicinal & Ritual Herbs & Supplies
Aphrodisiacs Aromatherapy Bath & Body Care Bulk Herbs By The Pound Capsules, Tablets & Extracts Chinese Herbals Electronics Extracts First Aid Products Food Products, Mixes, Seeds, Snacks & More! Hair Care Products & Supplies Herbs & Oils, Kilo & Ton Hydroponics & Gardening Kava Products Kitchen & Housewares Mushrooms Musical Instruments Oral Care & Dental Products PC & IT - Computer Supplies & Assessories Skin Care, Cosmetics, & Gift Sets Smokes, Seeds, Cacti Spices, Salts, Sweeteners, & Seasonings Sports, Toys & Games Sweets, Candy, Chips & Snacks Stimulants Sedatives Teas & Coffees
Shaman Shop Home Page
MoonDragon's Nutrition Information Index
MoonDragon's Health & Wellness: Nutrition Basics Index
MoonDragon's Health & Wellness: Therapy Index
MoonDragon's Nutrition Therapy Index
MoonDragon's Alternative Health Information Index
MoonDragon's Aromatherapy Information Index
MoonDragon's Health & Wellness Index
MoonDragon's ObGyn Information Index by Subject Order
MoonDragon's ObGyn Information Index by Alphabetical Order
MoonDragon's Main Indexlisting
MoonDragon's Home Page