We women sometimes grow accustomed to a low level of discomfort each month, often prior to or during menstruation, and we delay seeking help. But chronic or recurring pain should never be ignored. It's important to visit your doctor any time you feel pelvic pain that's at all out of the ordinary for you. It could be an easily treatable problem, or could be a more serious condition that's best caught early.
The following pages describe the most common causes of women's pelvic pain: the symptoms, how they are diagnosed and treated, and stories from women who've had each condition.
"The very same hormones that make women who they are -- estrogen and progesterone -- can cause them to suffer from endometriosis," says E. Scott Sills, M.D., Clinical Instructor and fellow at the Center for Reproductive Medicine and Fertility at New York Hospital-Cornell Medical Center in New York City. "These hormones sustain it, feed it, and keep it alive."
Endometriosis is one of the most common causes of lower pelvic pain, believed to affect 5 million women, or one of every seven of childbearing age. It happens when the lining of the uterus, normally shed during the menstrual cycle, grows outside the womb, sometimes attaching to the bladder, bowel, or kidneys. The misplaced tissue can cause inflammation and pain.
"I'm almost incapacitated," says a 40-year-old registered nurse and mother of two from Fredericksburg, Virginia. "It's hard to explain to your family, and it's hard to miss work."
The week before her period starts, she's bedridden with pain so fierce it hurts to move. She's tried all medical options, even antidepressants. Exhausted by the pain after more than 20 years, she's asked her doctor to remove her uterus and ovaries. "I welcome menopause. I know I may have rest from this."
Symptoms: Endometriosis is sometimes silent, sometimes savage. The most common signs are progressively worsening menstrual cramps, pain during sex, lower backache, constipation, and painful bowel movements. Many women with endometriosis also report infertility.
Diagnosis: A careful medical history with a pelvic exam or laparoscopy can diagnose endometriosis. Laparoscopy is a procedure in which a surgeon inserts a narrow tube with a lighted microscope in the belly button to see inside the pelvis and abdomen.
Treatment: Doctors first try to control endometriosis with birth-control pills or drugs called GnRH analogs. These agents block the production of female hormones, disrupting the menstrual cycle. Danazol, a steroid that suppresses ovulation, also may be used, but its side effects -- including weight gain and facial hair -- may be permanent.
Endometrial growths can be removed with a laser during laparoscopic surgery. In severe cases, a hysterectomy is performed. If ovaries also are removed, patients are six times less likely to have pain return, says Timothy Hickman, M.D., of Wilford Hall Hospital at Lackland Airforce Base in San Antonio, Texas.
Almost always benign, these masses of muscle tissue can quietly grow in your uterus for years without causing any problems. One-fourth of white women and almost half of all African-American women will get fibroids, usually between the ages of 30 and 50. Shara Fryer, 42, had no clue she had fibroids until her menstrual cramps changed for the worse. "I'd have terrible, terrible pain before my period," says Shara, a news anchor for KTRK-TV in Houston. "With every surge of estrogen, I'd have these sharp pains in my left side."
Her gynecologist discovered two fibroids. One had wrapped itself around her bowel and was about to punch a hole in her uterus. After undergoing a 4.5-hour operation to remove the tumors, Shara is free of monthly pain.
Symptoms: Fibroids are often symptomless. In 20 to 50 percent of cases, women have heavy, prolonged, and painful menstrual bleeding, painful intercour se, intermittent spotting, frequent urination, or constipation.
Diagnosis: Doctors can generally detect fibroids through a pelvic exam and an ultrasound.
Treatment: At first, fibroids are shrunk with GnRH analogs. If pain persists, the tumors can be removed through dilation and curettage (an in-office scraping of the uterus); hysteroscopic surgery, an outpatient procedure in which a doctor inserts a slim telescopelike device through the vagina; or myomectomy, in which the tumors are removed through an incision. Fibroids regrow in about 15 percent of cases.
Fibroids also account for 30 percent of all hysterectomies. But don't agree to the surgery until you've thoroughly researched your condition, advises one 36-year-old journalist in Dallas, who was able to postpone a hysterectomy even though her doctor told her she needed one. "I was in my early 30s and it was just too soon for me to consider a hysterectomy if it was avoidable," she says.
One of the most common bladder complaints, a bladder infection occurs when bacteria inflames the urinary tract, the bladder, and, in severe cases, the kidneys. Each year more than 7 million office visits to doctors are due to symptoms related to the bladder, says Tamara G. Bavendam, M.D., associate professor of urology and director of female urology at the University of Washington in Seattle.
Most bladder infections, often nicknamed "honeymoonitis," result from bacteria entering the urethra and bladder during sex.
"I can't count how many I've had myself," says one East Coast physician. "About the only thing you can do to prevent them is go to the bathroom after each episode of sexual intercourse."
Symptoms: Bladder infections often cause the urge to urinate frequently, and sometimes urination is accompanied by a burning sensation.
Diagnosis: A urinalysis or culture taken by a family physician generally reveals the condition.
Treatment: Antibiotics eliminate most bladder infections.
Ads on television and in magazines warn us about sexually transmitted diseases or STDs. Rarely mentioned, however, is pelvic inflammatory disease, which many women with STDs often get. The infection often is the first warning that a woman is suffering from a sexual disease such as gonorrhea or chlamydia.
The risk for pelvic inflammatory disease (PID) is low, except for women who have multiple sexual partners and who don't use condoms. Endrika Hinton, M.D., an assistant professor at Johns Hopkins University estimates that one million new cases are diagnosed each year, but only 300,000 women are hospitalized for it.
Symptoms: Though pelvic inflammatory disease sometimes has no outward signs, it often causes severe pelvic pain, fever, and other appendicitis-like symptoms, including vomiting and nausea.
Diagnosis: A pelvic exam and ultrasound reveal PID.
Treatment: Antibiotics can cure this ailment, and, in rare cases, surgery may be needed to remove the uterus, ovaries, and fallopian tubes.
Sibyl Brazil of Nacogdoches, Texas, first noticed the pain on her lower left side while shopping for groceries about 15 years ago. It came and went, starting out as a dull ache. Over a few weeks, the ache became a constant, sharp stab. "When it gets bad, really awful, you want to just die," she says.
Her misery turned out to be diverticulitis, the inflammation of abnormal pea-sized pouches protruding from her intestines. The condition, which may be the result of a low-fiber diet, often strikes older adults, says Joseph Sellin, M.D., Chief of Staff at Hermann Hospital in Houston, Texas. About half of all 50-year-olds and about 70 percent of people in their 70s get diverticulitis.
Sibyl, now 80, has been hospitalized twice in the past 10 years -- the last time after hemorrhaging. Luckily, all she needed was a dose of antibiotics. "It isn't any fun," she says. "You go along for weeks with no problem, and then all of a sudden it hits you."
Symptoms: People with diverticulitis suffer cramping abdominal pain, most commonly on the left side, or experience pain during a bowel movement. Fever and diarrhea are also signs.
Diagnosis: A physical exam, white-blood count, and barium-enema X ray generally reveal the problem.
Treatment: Antibiotics can cure diverticulitis, but in severe cases, an operation to drain and remove abscesses may be needed.
Ectopic (Latin for "out of place") pregnancies can be life threatening because the embryo plants itself outside the uterus, usually in the fallopian tubes. They also c an be incredibly painful.
Abby Parker first realized that something was wrong when pains in her right side became so excruciating that she doubled over and couldn't stand back up. "It felt like someone was stabbing a knife into me," says the 27-year-old from Eden, North Carolina. "It would make me nauseated, sweaty. I knew something was terribly wrong."
Even worse than the agony was the news. Because the embryo was inside her right fallopian tube, she'd lose not only the baby, but also her tube. After surgery to remove the tube, she was back at work in six weeks. Only about 1 percent of pregnancies are ectopic, says Thomas G. Stovall, M.D., Chief of Women's Health Services at UT Medical Group, Inc., in Memphis, Tennessee. "It's virtually impossible that an ectopic pregnancy would result in a live birth."
Symptoms: At first no symptoms other than pregnancy may appear, but after awhile, abnormal bleeding or spotting occurs, followed by lower abdominal cramping and sometimes severe pelvic pain.
Diagnosis: A pregnancy test usually will detect an ectopic pregnancy, followed by blood tests for progesterone and beta HCG (human chorionic gonadotropin) -- a hormone secreted by the fetus that rises in a normal pregnancy. An ultrasound also can confirm the finding.
Treatment: Methotrexate, a chemotherapeutic agent given as a shot, may dissolve the embryo. Otherwise, an incision is made in the fallopian tube to remove the embryo, or laparoscopic surgery may be needed to remove the tube.
One of the least common causes of pelvic pain is ovarian cancer. Less than 2 percent of women get ovarian cancer, and it usually occurs after menopause. The disease became better known after the 1989 death of comedian Gilda Radner.
Still, this year alone, an estimated 26,700 women will be diagnosed with ovarian cancer and 14,800 will die from it. Many women fear the disease because it has a high mortality rate and rarely announces itself until after it has already spread.
Symptoms: Women with ovarian cancer often experience bloating, heartburn, and a dull pain in their abdomen. If you are over 40 and are having vague digestive disturbances, you may want to alert your doctor. In its advanced stage, the cancer causes cramping, fatigue, pronounced swelling, and weight loss.
Diagnosis: Early detection is key. Sixty percent of women with ovarian cancer are diagnosed at an advanced stage. Most cases are found with ultrasound, or a special blood test called a CA-125.
Treatment: Surgery, chemotherapy, and radiation are the most common treatment paths.
Christiane Northrup, M.D., a gynecologist and author of Women's Bodies, Women's Wisdom (Bantam, 1994), and Susan M. Lark, M.D., author of Fibroid Tumors and Endometriosis (Ten Speed, 1995), recommend cutting fat, caffeine, and alcohol, which can thwart the body's estrogen-releasing mechanism. Bulk up on fiber, they suggest. "Women who eat a low-fat, high-fiber diet excrete two to three times more estrogen and have as much as 50 percent lower blood levels of estrogen," says Dr. Lark. Estrogen-absorbing fiber also counters the constipation or diarrhea that often accompanies pelvic pain.
Along with traditional medicine, nondrug treatments can help you cope with the misery of endometriosis, fibroids, and other pelvic pain. Some things to consider:
Diet. What you eat has a major effect on endometriosis and fibroids, because your diet, like these ailments, can alter estrogen levels.But that doesn't mean you should rush to the grocery store and ignore your doctor when you're in pain, adds Dr. Northrup. "If you need surgery, that's what's going to heal you."
Exercise. Exercise reduces stress, which in turn can alleviate cramps, says Dr. Lark. Yoga also makes you more flexible, which can help relieve lower-back pain that many women with endometriosis and fibroids experience.
Relaxation. Put on comfortable clothes, lie down, and close your eyes. Breathe deeply, and imagine seeing inside your body. Visualize your pain by focusing on where it is in your body and then imagine a large eraser rubbing it out. You should feel a sense of calm running through your body.
Herbs. Try brewing a cup of yarrow tea, suggests Dr. Northrup. Yarrow is an anti-inflammatory herb and can soothe discomfort.
Massage. Massage can help your stomach muscles relax, lessening the abdominal pain. Chrissie Sanders, a licensed massage therapist in Houston, recommends rubbing your stomach with lotion in a smooth, clockwise motion.
Natural progesterone. To block the body's production of endometriosis- and fibroid-exacerbating estrogen, Dr. Northrup recommends asking your doctor about natural progesterone, available in a cream or doctor-prescribed pill.