Robert MacDermott - Consultant Gynaecologist
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  KIMS Hospital
  Kent, ME14 5FT
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Chronic Pelvic Pain

There are several gynaecological conditions that cause chronic pelvic pain eg. Endometriosis, Pelvic Inflammatory Disease, Ovarian cysts and Fibroids. Felt in the lower abdomen, the pain may radiate to the thighs and is often aggravated by intercourse. Although some women have classic features of a condition that make diagnosis easy, further investigations are often necessary to establish the correct diagnosis. In many women, the cause of lower abdominal pain is not gynaecological, but is bowel-related - often know as Irritable Bowel Syndrome.

Women may seek medical care because the pain is severe and affects their lives. Others are concerned that they may have a disease that may affect their future fertility. Some are concerned that they may have a cancer but this would be very rare in someone who has had pain for more than a year and also in women under 40 years old.

Endometriosis - Affecting around 6% of women, endometriosis is caused by deposits of glandular tissue around the pelvis. This tissue is hormonally responsive like the lining of the womb, intermittently swelling and bleeding, and thus causing pain. The pain typically gets worse on the week before a period and is particularly bad during a period. Intercourse often causes lower abdominal pain which may persist for an hour or so afterwards. Periods are sometimes heavy but are often not so. It can be a cause of infertility although the reasons for this in women with mild disease are not understood. Vaginal examination can reveal pelvic swellings and scarring, but there is usually just some tenderness on movement of the womb.

An ultrasound scan is often performed to look for endometriotic cysts in the ovaries and to exclude other causes of pain. Laparoscopy can be performed to confirm the diagnosis also to treat the condition by destroying or removing the endometriotic tissue.

Women with endometriosis usually have cyclical pain and may gain substantial improvement with hormonal treatment such as the combined pill, minipill or a Mirena coil.

Pelvic Inflammatory Disease (PID) - This is usually divided into acute and chronic types but the cause (infection) is the same. Such infections are usually (but not always) sexually transmitted, with Chlamydia being the most common. Acute PID causes severe pelvic pain with fever and even if this is treated promptly with the correct antibiotics, the scarring and tissue damage may persist - as Chronic PID. Some women get chronic PID without ever having had an episode of acute PID.

Risk factors for PID include a history of sexually transmitted infections, multiple sexual partners, sexual activity at a young age and use of a coil for contraception. However, many affected women will have none of these risk factors.

Once the disease has become chronic there is usually little benefit from giving antibiotics but it is important to take swabs from the cervix to exclude any active infection. Laparoscopy can be useful to diagnose the disease and the severity of any damage to the fallopian tubes. PID is a major cause of infertility because it often causes blockage of the fallopian tubes. Even where the tubes are not blocked, the internal lining may be damaged in a subtle way that prevents the normal passage of a fertilised egg - an ectopic pregnancy can result in these circumstances.

There is no ideal treatment for chronic PID. The removal of scarred tissue from the pelvis, eg. swollen tubes and even ovaries and the womb, sometimes helps. However, many women with chronic PID will never be able to get rid of their pain. Like suffers of arthritis, they may need to use painkillers and may find heat treatment helpful.

Ovarian cysts - There are many different types of ovarian cysts and most do not cause symptoms until they are very large. Endometriotic (chocolate) cysts are the exception in that pain can be a feature when they small. Larger cysts can be diagnosed by an abdominal and vaginal examination. Smaller cysts are diagnosed by an ultrasound scan which also gives an indication of the nature and seriousness of the cyst. Many smaller simple cysts are the result of normal ovarian function and will often disappear without any treatment.

Depending on the nature of a cyst and the associated symptoms, treatment may involve sucking the fluid out of the cyst, removing the cyst or removing the whole ovary. Sometimes it is advisable to have both ovaries and the womb removed. The fluid can be removed under ultrasound guidance but unfortunately it often returns. More effective treatments usually involve having a laparoscopy or a laparotomy.

Fibroids - One of the most common causes of heavy periods is fibroids. Fibroids are extra pieces of muscle tissue located in the womb. They are common, affecting about 20% of women, many of whom have no symptoms from them. They are more common in women of African, Caribbean or Asian origin. They are benign and the risk of them becoming cancerous is negligible. As well as causing heavy periods, larger fibroids may cause pelvic discomfort as well as bowel / urinary symptoms due to direct pressure.

The treatment of fibroids will depend on your symptoms, age, desire for future pregnancies and the size / location of the fibroids. Most women with small fibroids can be managed with any of the common simple treatments that are available. Fibroids that protrude into the cavity of the womb may be removed during an operation known as hysteroscopy. Larger fibroids may be removed by an open operation known as a myomectomy, especially if future pregnancies are desired.

Large fibroids can be treated by embolization. Embolisation is a technique where the blood vessel(s) feeding the fibroid are blocked using a narrow tube inserted into an artery in the groin. Embolisation is not a suitable treatment for all women and is available at relatively few hospitals.

Ulipristal Acetate (Esmya) is licensed for medium term treatment of heavy periods caused by moderate/large fibroids in 2016, Esmya is proving very popular with many gynaecologists. Further research will determine the long term effectiveness of this treatment.

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