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Fed up with pelvic pain
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rps19 posted:
Hi Jane,

I am a 25 year old, Caucasian, generally healthy female. Been on YAZ for 5+ years. I have Hashimoto's disease, and thus far all thyroid tests have been normal. In May of this year I had chlamydia and was treated, subsequent tests were negative. In late October I was treated for H. Pylori with aggressive antibiotics. This is when the pain started. At the end of November I was treated in urgent care for an unidentified vaginal infection with PID (tested negative for gonorrhea, chlamydia, yeast, BV), again with antibiotics. My PCP seems to think it was one of these outlier STD bacteria.

My pelvic pain started before I was treated for the recent infection, but it seems to have evolved. Before it was lower, more toward my groin area, and I was having some pretty intense, constant discharge which only occurred during/after urination, when I wiped. Post-treatment, I am having pain in the sides of my lower abdomen and just under my belly button. Sometimes when I urinate I get a shooting pain along my pantyline area. I still get the discharge after urination, but much less in terms of quantity and frequency. The discharge is clear and odorless, but it still seems like a lot at one time, which alarms me a bit. It is different than any discharge I had experienced before the infection. Could this incident have changed my body chemistry somehow?

I had a pelvic and vaginal ultrasound last week and my Dr. found a 5mm fibroid tumor. She said this is far too small to be causing any symptoms but I wonder? I'm really scared now for my fertility. I really don't want a hysterectomy.

In February I have an appointment with a reputable ob/gyn who specializes in pelvic pain. I guess I'm just looking for some info/a second opinion in the meantime. Should I be worried for my fertility? Could my pain in fact be caused by the fibroid and, if so, can this be treated without a hysterectomy? If my doctor is correct and my pain is not likely caused by the fibroid, what could it be?? Could the fibroid grow between now and my appointment?

Thank you so much for your time.
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Jane Harrison Hohner, RN, RNP responded:
Dear rps: Let's take each of your questions in order, OK?

1. Future fertility---If your TSH remains within normal limits, that should not interfere with fertility. Studies have shown that between 20-40% of women with untreated Chlamydia will go on to develop scarring inside the Fallopian tubes, or bands of scar tissue ("adhesions") inside the pelvis.

It has been calculated that perhaps 1,000,000 women per year will get PID of some type. Of those, an estimated 10% will develop infertility. One landmark study (Westrom, 1996) followed almost 1,500 women, of whom about 2/3 had confirmed PID as documented by a laproscope. Among the women with a PID history 7.8% had tubal occlusion where the tube was scarred closed. By contrast, a comparison group without PID had less than 1% tubal occlusions.

It sounds like you were treated in November for "presumed" PID (cultures all negative, but pelvic pain). A woman with pelvic pain who presents in ER or urgent care often receives antibiotics for the pain as a first line treatment. Given that you received treatment last spring, and had a normal follow up culture, one would hope and expect that there was little tubal damage.

2. Pain from a 5mm fibroid--A fibroid which is about 1/4 inch in size is not a likely culprit. Some women have fibroids which are several inches, and have few symptoms. Symptoms for large fibroids are related to the exact location of the fibroid.

4. Fibroid growth--Fibroids tend to have slow growth. In my clinical experience I have seen only one which grew rapidly. This was by patient report as I had no baseline ultrasound or exam as a comparison.

3. Causes of pelvic pain---Here is a short list:
? Endometriosis (bits of uterine lining tissue growing on the bowel, bladder, ovaries, etc). This is less common among birth control pill users.
? Adhesions can also be formed if a woman has had an abdominal surgery or a serious abdominal infection (eg PID or ruptured appendix).
? Adenomyosis is endometriosis that has grown into the muscular walls of the uterus. One could have a suspicion for adenomyosis if the woman, or her family, has a history of endometriosis.
? Pelvic congestion syndrome is also more difficult condition to diagnosis. It involves varicose veins of the uterus or ovaries.
? Large uterine or ovarian masses (doubt this with your ultrasound results).

The most common non-GYN cause of pelvic pain is GI in origin:
? Irritable bowel syndrome ("IBS") can start up after eating, or during stressful events. Bloating, gas, and constipation or diarrhea may be present. Excluding GYN causes, IBS is the most common cause of chronic pelvic pain.
? Infection ("gastroenteritis") of the intestines can be caused by bacteria, viruses, or even parasites.
? Diverticulitis is a localized infection in a pouching out section of the bowel.
? Appendicitis pain may manifest with a fever, loss of appetite, and pain focused in the right lower part of the abdomen.

Bottom line, you are dong the right thing in seeing a specialist to do an evaluation.

Yours,
Jane

Lastly there can be bladder causes:
? Interstitial cystitis ("IC") can present like a urinary tract infection (UTI) with urgency, frequency, and pain with urination. Unlike a UTI there can be pain in the vagina, urethra, or pelvis; there can be pain with intercourse. Unlike a UTI pain may be less at the end of urination. Urine cultures are negative for bacteria, and antibiotics do not relieve the symptoms.
? Urethral syndrome will also have urinary urgency, frequency, pain with urination, and no evidence of bacteria in the urine. Sometimes women are given a longer than normal duration of broad spectrum antibiotics as a trial treatment. If the woman is postmenopausal she may be prescribed estrogen therapy.
? Problems with the ureters leading from the kidney to the bladder can include obstructions or diverticulum (a pouch in the walls). These are an uncommon source of pain.
 
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rps19 replied to Jane Harrison Hohner, RN, RNP's response:
I know it has been a while, but I just wanted to follow up on this. I did see the ob/gyn, and she denied my request for a laparoscopy. I think she said that she didn't see anything abnormal during my exam that would signal infertility. She said the best way to test this is to try to get pregnant, which won't be for a while for me...

I was diagnosed with vestibulodynia, which is apparently related to my issues with chronic anxiety. She said that my pelvic floor muscles on the left side felt like guitar strings. I showed her the area of my groin where I had pain - and still do quite often - and she attributed this to the connection of muscles in that area to the tense pelvic floor muscle she observed, which I am unable to relax voluntarily. She prescribed anxiety medication, lidocaine to insert into my vagina nightly, and pelvic floor physical therapy. I haven't cooperated with any of this because I wanted to see if continued hypnosis and psychotherapy would help.

At the same appointment she also tested for ureaplasma urealyticum, and I was positive. I was treated with antibiotics. Jane, I was unable to find much information about ureaplasma online. Do you have any info, and would a history of this bacteria affect my fertility at all?

Thank you again for your time.


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