Pelvic Pain

Pelvic Pain

Pelvic Health Conditions and You

woman with her arms crossedFour of the most common pelvic health conditions women experience are menorrhagia, or heavy bleeding during menstruation defined as soaking a pad and/or tampon every hour or less; fibroids; non-cancerous tumors of the uterus; stress urinary incontinence, in which urine escapes when you sneeze, laugh, cough or engage in strenuous physical activity; and pelvic organ prolapse (POP), in which one or more pelvic organs—primarily the uterus, ure

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Fast Facts for Your Health: Pelvic Adhesions

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Author: HealthyWomen
Published by: National Women's Health Resource Center, Inc., April 2007

Pelvic adhesions are gynecologic surgery side effect that can lead to infertility, pain and more surgeries. But, your surgeon can reduce your risks for developing adhesions following surgery in a number of ways including using adhesion prevention barriers. Fast Facts for Your Health: Pelvic Adhesions explains what you should discuss with your health care team before your surgery.


All of our publications are available for free but we do charge shipping, handling and processing fees for orders of 3+ publications. Online orders are limited to a maximum quantity of 500. For requests exceeding 500 please email orders@healthywomen.org or call toll-free at 877-986-9472.

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Q:

It was discovered through an ultrasound that I have a retroverted uterus. My doctor told me that it may cause painful sex. Now I'm worried. I'm 19, a virgin and feeling depressed that sex may always be painful for me. I have always had very painful periods. What can I do to reduce the pain involved with sex?

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Tips for Talking to Your Health Care Provider

by Pamela M. Peeke, MD, MPH

woman and doctorWe've talked a lot about all the things health care professionals do wrong when it comes to communicating health information. But what about you? What is your role in the relationship? Well, as with any relationship, health communication is a two-way street. I know that I rely on my patients to tell me about any confusion they may have, or about things they don't understand, just as much as I rely on them to tell me where it hurts.

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Passport to Good Health

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Author: HealthyWomen and American Association of Nurse Practitioners
Published by: National Women's Health Resource Center, Inc., December 2010

Keep your health information organized with HealthyWomen and AANP's Passport to Good Health—a compact health record-keeping tool. Containing blood pressure and cholesterol screening ranges, preventive health screening details and schedule, vaccination schedule, personal record-keeping grids and more, it's the perfect place to keep track of personal health information and screening results.


All of our publications are available for free but we do charge shipping, handling and processing fees for orders of 3+ publications. Online orders are limited to a maximum quantity of 500. For requests exceeding 500 please email orders@healthywomen.org or call toll-free at 877-986-9472.

Didn't find what you were looking for? Visit our Health Topics A-Z area for more information.

Diagnosing and Treating Endometriosis

woman looking off into the distanceIf you've been having painful periods, possibly with pelvic pain that continues even after your period ends, you should talk to your health care provider about evaluating you for endometriosis.

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Surgical Adhesions from Gynecologic Surgery

woman reading somethingWhen you're headed for hysterectomy or other gynecologic surgery, you are probably worried about many things. Will you have any bad reactions to the anesthesia? Will the surgeon find any major problems? Will you be in much pain? Will recovery be fast?

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What is it?

Overview

What Is It?
Trichomoniasis is the most common curable sexually transmitted disease (STD) in the United States. Infected women may experience a frothy, yellow-green vaginal discharge with a strong odor, discomfort during intercourse and urination, or itching in the genital area.

Maybe you haven't heard of this infection. It is the stepchild of sexually transmitted diseases—one that is hard to pronounce, let alone find information about why it is important.

Ironically, trichomoniasis (trick-o-mon-i-a-sis or "trich") is the most common curable sexually transmitted disease (STD). In recent years, diagnosing and treating this disease has received more attention as new research has shown that it is not as harmless as was once thought.

About 3.7 million people have trichomoniasis, according to the U.S. Centers for Disease Control and Prevention (CDC). Most men infected with the parasite Trichomonas have no symptoms. When symptoms occur, men may experience irritation inside the penis, discharge or slight burning after urination or ejaculation. Most women are also asymptomatic. Some women with the infection experience a frothy, yellow-green vaginal discharge with a strong odor, discomfort during intercourse, pain during urination, itching in the genital area or spotting between periods. In rare cases, pain in the lower abdomen can occur. Women infected with Trichomonas are more at risk of acquiring human immunodeficiency virus (HIV) and other STDs.

Because trichomoniasis is so common and causes significant risks to women's health, you would expect to see more interest in its prevention. There are several reasons why this STD has received so little attention. First, its symptoms—primarily discharge and irritation of the vagina and urethra— are mild and have been seen as troubling but less serious than the side effects of other STDs. Second, the most common treatments—metronidazole and tinidazole—are highly effective in most women, though some difficulties can arise, such as drug allergies or intolerance or Trichomonas becoming resistant to this class of drugs. No other class of drugs is very effective for treatment.

The organisms that cause trichomoniasis are protozoans (the simplest, single-cell organism in the animal kingdom). These protozoans, called trichomonads, can infect other areas of the body, but Trichomonas vaginalis is responsible for genital infection and vaginitis. This parasite resides primarily in the vagina and/or bladder, where body temperature, low oxygen environment and moisture allow it to grow and multiply.

Trichomoniasis is one of the three most common types of vaginitis. The other types are bacterial vaginosis (BV), which is an overgrowth of anaerobic bacteria found in the vagina, and vulvovaginal candidiasis, more commonly known as yeast infection.

As with BV, some research suggests that trichomoniasis is associated with preterm birth. Women infected with Trichomonas during pregnancy are more likely to have low birth weight babies (less than 5.5 pounds).

Studies also link trichomoniasis with an increased risk of HIV transmission (HIV is the virus that leads to AIDS). Studies show that women infected with this STD are at higher risk of acquiring and transmitting HIV.

Trichomoniasis is transmitted through sexual intercourse. It is most common in people who are at their peak of sexual activity (teens and 20s), but it is found in higher rates among older women than other STDs. Having multiple sex partners and infection with other STDs are primary factors that increase a woman's risk of infection.

In very rare cases, trichomoniasis may be transmitted by a pregnant woman to her baby during childbirth. Pregnant women with trichomoniasis are more likely to deliver early and to give birth to a low birth-weight baby (less than 5.5 pounds). Their babies are also more likely to have conjunctivitis.

In the United States, about 3 percent of women are infected. Among women infected with other STDs, such as gonorrhea, the rate of trichomoniasis is higher. For reasons not entirely clear, African American women are 5 to 10 times more likely have trichomoniasis than Hispanic or Caucasian women.

Diagnosis

Diagnosis

A significant number of women infected with trichomoniasis have no noticeable symptoms. If symptoms develop, they usually occur within five to 28 days after exposure to an infected partner. However, in some cases, the symptoms may be delayed for longer. The most common symptoms are vaginal discharge, irritation, itching and burning during urination.

Trichomoniasis most often presents as a yellowish-green vaginal discharge with a strong odor. Itching and soreness of the vagina and vulva are common. Some women experience vague abdominal pain. Trichomoniasis can occur with other infections, particularly pelvic inflammatory disease and bacterial vaginosis.

The majority of men infected with Trichomonas do not have symptoms. The most common symptom is discharge from the penis or burning with urination. When men have symptoms, they often subside without treatment after a week or more.

For both men and women, a diagnosis based on symptoms is inadequate because many of these symptoms are shared with other inflammatory conditions of the vagina and cervix, such as bacterial vaginosis and yeast infections.

For women, the most common way to diagnose trichomoniasis is by physical examination of the pelvic area by a health care professional and by looking at a sample of vaginal fluid under a microscope (called "wet mounts") for the presence of protozoa. A pelvic examination can reveal small red ulcerations on the vaginal wall or cervix. The wet mount technique, however, is accurate only about 60 percent to 70 percent of the time, as protozoa may be hard to find or mistaken for normal cells. It can also yield false positives. There also are several rapid-diagnostic kits available that can diagnose infection in 10 to 45 minutes. These tests also come with the risk of false positives.

More reliable tests have been developed, such as the polymerase chain reaction (PCR) test, a type of nucleic acid test that uses enzymes to better detect the virus in the culture. It is very effective in identifying T. vaginalis in women and is becoming more readily available.

Treatment

Treatment

The standard drugs used for treating trichomoniasis are metronidazole (Flagyl) and tinidazole (Tindamax). In most cases, Trichomonas infection is cured in women with a single oral dose of two grams of either drug. Both of these prescription drugs are in the nitroimidazole class. Metronidazole has been found to be safe in pregnancy.

All sexual partners of an infected person should be treated. An infected person should abstain from sex during treatment and until all symptoms go away, approximately a week or two after treatment. Because of the high rate of reinfection (up to 17 percent within three months), sexually active women may want to consider getting rescreened three months after treatment. This is especially important for HIV-infected women who also have trichomoniasis, because they have an even higher rate of recurrence.

For those who fail treatment, longer courses of metronidazole or tinidazole are recommended by the Centers for Disease Control and Prevention (CDC). Patients who continue to have an infection after a single dose of metronidazole should take 500 milligrams of metronidazole orally twice a day for seven days. If this second course of medication fails, the CDC says to consider treating with two grams daily for five days of either metronidazole or tinidazole. If these therapies fail to cure the infection, further treatment should be discussed with a specialist.

You should take metronidazole or tinidazole with food and avoid drinking alcohol for 24 to 72 hours after taking the drugs.

Prevention

Prevention

Prevention of trichomoniasis is similar to that for other sexually transmitted diseases (STDs). Protective measures include:

  • Use a latex condom every time you have sex.
  • Limit your number of sex partners.
  • Get tested if you think you have an STD and have your partner tested, too.

Facts to Know

Facts to Know

  1. Trichomoniasis is the most common curable sexually transmitted disease in the United States. According to the CDC, about 3.7 million people in the United States have trichomoniasis.

  2. Trichomoniasis is more common among African American women. The reason for this is not clear. Lack of access to medical care in economically challenged communities may play a role.

  3. Trichomoniasis increases a woman's risk of preterm birth or delivery of a low birth weight baby.

  4. It is important that sexual partners of infected women be treated. Although trichomoniasis is often asymptomatic in males, if left untreated it can cause urethral infections, particularly urethritis, and can lead to reinfection of the woman.

  5. Because a test for vaginal infection is not necessarily a part of a routine pelvic exam, you can't assume your health care professional will test you for trichomoniasis. You should request trichomoniasis screening if you have symptoms or if you have been in contact with a high-risk sexual partner.

  6. You can have more than one type of vaginitis at the same time. It is possible to have trichomoniasis and bacterial vaginosis together, each of which can be treated with metronidazole.

  7. If you visit your health care professional to see if you have a vaginal infection, you should schedule your examination when you are not having your period.

  8. It is easy to misdiagnose trichomoniasis or bacterial vaginosis as a yeast infection because yeast infection also causes an unpleasant discharge. Treatment for yeast infections is different than for trichomoniasis or BV, so an accurate diagnosis is important.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about trichomoniasis so you're prepared to discuss this important health issue with your health care professional.

  1. Do over-the-counter products work for treating and preventing trichomoniasis?

  2. Does my partner need to be treated?

  3. What difference does it make whether I have trichomoniasis or a yeast infection?

  4. If I have had trichomoniasis in the past and am pregnant, should I get tested for it even if I have no symptoms?

  5. How do I identify trichomoniasis and avoid it in the future?

  6. Do I need to refrain from sexual contact while I am being treated?

  7. Will poor hygiene increase my risk of trichomoniasis?

  8. Can trichomoniasis be passed on to my baby?

  9. Are the drugs used for treating trichomoniasis safe for pregnant women?

  10. What happens if I am infected with trichomoniasis but never get treated? Will it go away on its own?

Key Q&A

Key Q&A

  1. How do I know if I need to see my health care professional?

    Pay attention to your body. Call your health care professional if you experience any unusual symptoms, such as: a change in the color, odor or consistency of vaginal fluid; vulvar irritation; itching; and burning, frequent or painful urination.

  2. What if I am allergic to the 5-nitroimidazole drugs (metronidazole or tinidazole) or am not responding well to them?

    Up to 10 percent of women do not respond to standard treatment. For those who fail treatment, a longer course of metronidazole is recommended by the Centers for Disease Control and Prevention (CDC). If this second course of medication fails, the CDC recommends two grams daily for five days of either metronidazole or tinidazole.

    If you develop a rash in response to the 5-nitroimidazole drugs, there are other medications you can try, but they have poor cure rates. If you are allergic to tinidazole and metronidazole, your provider may suggest desensitizing you to these medications so you can undergo treatment.

  3. What are my chances of having trichomoniasis reoccur?

    Treatment is successful in most women, and once the organisms are killed they don't come back unless you are exposed again to an infected partner.

  4. What is the relationship between vaginitis and excessive douching?

    The healthy vaginal ecosystem requires just the right balance of bacteria flora. These bacteria make natural acids that keep abnormal bacteria from becoming predominant. Douching may disrupt the pH balance of the vagina and lead to bacterial vaginosis, which may increase a woman's risk of acquiring trichomoniasis.

  5. What about diagnosing and treating trichomoniasis in men?

    The organisms that cause trichomoniasis often don't cause symptoms in males. Consequently, most men never seek treatment because they don't know they are infected. Diagnosis in men is usually made with a urine culture specifically for Trichomonas. If your sexual partners are not treated, it is likely you will become reinfected.

  6. What is considered normal vaginal discharge?

    For uninfected women, vaginal discharge is usually cloudy white in appearance. Discharge often increases in the middle of your menstrual cycle, and during ovulation it changes consistency, appearing similar to egg whites. Symptomatic women with trichomoniasis experience a frothy, yellow-green vaginal discharge with a strong odor, possibly coupled with discomfort during intercourse, painful urination or genital itching.

Organizations and Support

Organizations and Support

For information and support on coping with Trichomoniasis, please see the recommended organizations, books and Spanish-language resources listed below.

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Social Health Association (ASHA)
Website: http://www.ashastd.org
Address: P.O. Box 13827
Research Triangle Park, NC 27709
Hotline: 1-800-227-8922
Phone: 919-361-8400
Email: info@ashastd.org

ASHA's STI Resource Center Hotline
Website: http://www.ashastd.org/herpes/herpes_hotline.cfm
Address: American Social Health Association
P.O. Box 13827
Research Triangle Park, NC 27709
Hotline: 1-800-227-8922
Phone: 919-361-8400

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

CDC National Prevention Information Network
Website: http://www.cdcnpin.org
Address: P.O. Box 6003
Rockville, MD 20849
Hotline: 1-800-458-5231
Phone: 404-679-3860
Email: info@cdcnpin.org

Guttmacher Institute
Website: http://www.guttmacher.org
Address: 1301 Connecticut Avenue NW, Suite 700
Washington, DC 20036
Hotline: 1-877-823-0262
Phone: 202-296-4012
Email: info@guttmacher.org

National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
Website: http://www.cdc.gov/nchhstp
Address: Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-800-CDC-INFO (1-800-232-4636)
Email: cdcinfo@cdc.gov

Sexuality Information and Education Council of the United States (SIECUS)
Website: http://www.siecus.org
Address: 90 John Street, Suite 704
New York, NY 10038
Phone: 212-819-9770

Sexual Health Questions You Have...Answers You Need
by Michael V. Reitano and Charles Ebel

Sex: What You Don't Know Can Kill You
by Joe S. McIlhaney and Marion McIlhaney

Meline Plus: Trichomoniasis
Website: http://www.nlm.nih.gov/medlineplus/spanish/trichomoniasis.html
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Centers for Disease Control and Prevention
Website: http://www.cdc.gov/std/Spanish/STDFact-Trichomoniasis-s.htm
Address: Centers for Disease Control Info
1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-800-232-4636
Email: cdcinfo@cdc.gov

Last date updated: 
Fri, 2013-02-01

What is it?

Overview

What Is It?
Premenstrual syndrome (PMS) describes a wide range of severe, recurrent symptoms that occur from several days to two weeks before your period.

Premenstrual syndrome (PMS) describes a wide range of severe, recurrent symptoms that occur from several days to two weeks before your period. PMS affects up to 75 percent of women in their childbearing years. The symptoms of PMS can appear any time between puberty and menopause, although the most common age for it to start to become a problem is during the late 20s to early 30s.

Symptoms of PMS may get worse with age and stress, although the underlying causes are not well understood. Even women who have had hysterectomies can have PMS if at least one functional ovary is left. Women who are vulnerable to depressive illness, panic disorder, other psychiatric disorders or chronic medical conditions may also be susceptible to PMS, although these conditions may occur in women without PMS as well. Heredity may also play a role: if your mother or sister suffers from PMS, you may find you experience it, too.

As many as 150 physical and behavioral symptoms have been assigned to PMS, but the number of PMS symptoms that most women experience is much more limited. The most common symptoms include irritability, bloating, mood swings, anxiety, depressed mood, fatigue, appetite changes, water retention and breast tenderness, among others.

Menstrual cramps, or dysmenorrhea, are not considered a PMS symptom, although women with PMS may experience cramps.

PMS appears to be caused by rising and falling levels of the hormones estrogen and progesterone, which may influence brain chemicals, including serotonin, a substance that has a strong affect on mood. It's not clear why some women develop PMS or PMDD and others do not, but researchers suspect that some women are more sensitive than others to changes in hormone levels.

Calcium may play a role in PMS. In one study, women who took 600 mg of calcium twice a day experienced fewer PMS symptoms than women who took a placebo.

Dietary changes and exercise may also help relieve the discomfort of PMS symptoms. When symptoms are severe, serotonergic antidepressant medication may be prescribed. It is thought that increased serotonin reduces PMS symptoms.

One of the most important strategies for coping with premenstrual discomfort is to be aware of any pattern your symptoms follow. The more aware you are of your symptoms—when they start and stop and what works best to relieve them, for example—the better you can develop strategies to recognize and cope with them—whatever they may be.

Premenstrual Dysphoric Disorder

Approximately three to eight percent of women experience premenstrual dysphoric disorder (PMDD), a condition that, like PMS, is associated with the menstrual cycle. The symptoms of PMDD are the same as PMS symptoms, although women with PMDD may experience more dysphoric (depressive) symptoms and more severe symptoms. In fact, to be diagnosed with PMDD, symptoms must be severe enough to disrupt a woman's daily function. Symptoms must also meet diagnostic criteria specific to PMDD developed by the American Psychiatric Association.

The most important criteria for a PMDD diagnosis are mood symptoms. Physical symptoms may also be present but aren't as critical to the diagnosis. The difference between PMDD and mild PMS is like the difference between a mild tension headache and a migraine, experts say.

Women who have a history of depression are at higher risk for PMDD than other women. Treatment for PMDD includes serotonergic antidepressant medications and a particular brand of birth control pills, called Yaz. Yaz contains drospirenone (a progestin) and ethinyl estradiol (a form of estrogen) and has been shown to be clinically effective at treating the emotional and physical symptoms of PMDD, but should only be used to treat PMDD if you choose to use it for birth control because other forms of treatment don't carry the same risks as oral contraceptives. Another form of birth control pill containing drospirenone plus a daily dose of folic acid also is FDA-approved to treat PMDD. It is sold under the brand names Beyaz and Safyral.

Birth control pills containing drospirenone may cause some serious side effects in rare cases, including blood clots in the legs and lungs, so be sure and talk to your health care provider about your risks and benefits. Oral contraceptives are not recommended for women who smoke because of increased cardiovascular risks.

Diagnosis

Diagnosis

There is no specific laboratory test to determine if you suffer from PMS, and diagnosis can take some time because symptoms are so varied. But there are certain characteristics that health care professionals consider. To qualify as PMS, symptoms must follow this general pattern:

  • They tend to increase in severity as your cycle progresses.
  • They improve within a few days of your menstrual period starting.
  • They are present for at least two to three consecutive menstrual cycles.

More than 150 physical and behavioral symptoms may be associated with PMS. The most common are irritability and anxiety/tension. Other symptoms include:

  • Sudden mood swings
  • Depression
  • Headaches
  • Joint and muscle aches
  • Food cravings
  • Fluid retention
  • Forgetfulness
  • Clumsiness
  • Sleep disturbances
  • Breast swelling and tenderness

The timing and severity of these symptoms are key to a PMS diagnosis. An average menstrual cycle spans 21 to 35 days. The follicular phase extends from menses to ovulation, and the luteal phase extends from ovulation to menses. PMS occurs during the luteal phase—approximately the last 14 days of your cycle, usually during the five to seven days before you get your period.

A premenstrual symptom chart or checklist (also called a menstrual cycle diary) is the most common method used to evaluate menstrual cycle symptoms. With this tool, you and your health care professional can track the type and severity of your symptoms, as well as when they occur, to identify a pattern that may indicate PMS.

Follow these simple steps to determine if your symptoms fit the PMS pattern:

  1. Track your symptoms using the first day of menstrual flow as Day 1. (Note: Don't be surprised if you do not have any symptoms to record before day 18 or so.)

  2. Have a person close to you (your partner, roommate, friend) chart his or her impression of your symptoms, when they occur and their severity.

  3. Chart your symptoms for at least three consecutive months to help you and your health care professional identify a pattern that may indicate PMS.

  4. Record the date when/if any of the following symptoms occur over three consecutive months and note their severity (1 = mild; 2 = moderate; 3 = severe)

Physical Symptoms

  • Abdominal bloating
  • Breast tenderness
  • Constipation
  • Diarrhea
  • Dizziness
  • Fatigue
  • Headache
  • Swelling of hands/feet

Emotional Symptoms

  • Anger
  • Anxiety
  • Depressed mood
  • Irritability
  • Mood swings
  • Tension

Behavioral Symptoms

  • Crying spells and tearfulness
  • Decreased or increased appetite
  • Difficulty concentrating
  • Difficulty sleeping
  • Forgetfulness
  • Hostility

In addition to suggesting that you keep a menstrual cycle diary, your health care professional likely will ask about your personal and family medical history and will give you a physical exam.

Laboratory tests are not routine but may be obtained to rule out other conditions with similar symptoms, such as low blood sugar (hypoglycemia), mania, depression, thyroid disorders, anemia, endometriosis, allergies, fibroids, dysmenorrhea, lupus, endocrine abnormalities, neurological problems such as brain tumors and heart problems.

Menopause and PMS share some of the same symptoms, so depending on your age and health history, your health care professional may want to make sure that you are indeed ovulating and therefore experiencing PMS, not menopausal symptoms.

To do this, you will probably be asked to use an over-the-counter ovulation testing kit. This is a simple test that you can do at home. The results tell you when ovulation is likely.

If you are approaching menopause (the average age is about 51 for U.S. women, but ranges from 42 to 60 years), blood hormone tests may also be used to confirm if you are menopausal. However, a single blood test is not informative because hormone levels change often.

Treatment

Treatment

Many premenstrual syndrome (PMS) symptoms improve with treatment. Treatment options range from medication therapy to birth control pills to diet modification, including vitamin and mineral supplementation, herbal medicines and exercise.

Antidepressant drugs called selective serotonin reuptake inhibitors (SSRIs) are typically recommended to women with severe mood-related symptoms such as anxiety, depression or mood swings.

Overall, common treatment options include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications are used to relieve premenstrual headache and other menstrual-cycle related pain. A variety of NSAIDs are available including over-the-counter ibuprofen products (Motrin) and others or naproxen sodium (Aleve). They usually cost less and have fewer side effects than other treatments. Prescription NSAIDs also are available.

    Note: NSAIDS carry some risks, such as an increased risk of serious cardiovascular (CV) events, including heart attack and stroke. As a result, the FDA has issued a "black box" warning highlighting this risk, as well as the risk of potentially life-threatening stomach bleeding. If you've recently had heart surgery, you shouldn't take NSAIDS. All other women considering NSAIDS to ease PMS or any other condition should discuss these potential risks with their health care professional.

  • Contraceptive hormones. Some women with PMS or PMDD experience relief of their symptoms after they start taking birth control pills. (Other women, however, feel worse on birth control pills.) You can take the pill continuously to avoid having a menstrual period, thus preventing the hormonal changes that can lead to PMS/PMDD. The combination birth control pills Yaz (containing 3 mg of drospirenone, a progestin, and 20 mcg ethinyl estradiol, a form of estrogen) and Beyaz and Safyral (containing 3 mg of drospirenone, 20 mcg ethinyl estradiol and a daily dose of folic acid) are FDA approved for the treatment of PMDD. However, these contraceptives should only be used to treat PMDD if you choose to use them for birth control because other forms of treatment don't carry the same risks as oral contraceptives. Birth control pills containing drospirenone may cause some serious side effects in rare cases, including blood clots in the legs and lungs, so be sure and talk to your health care provider about your risks and benefits. Oral contraceptives are not recommended for women who smoke because of increased cardiovascular risks.

  • GnRH agonists (gonadotropin-releasing hormone). These medications include leuprolide (Lupron), among others. They belong to a class of hormones used to temporarily shrink fibroids and relieve endometriosis. They also may be recommended to treat PMS because they "turn off" the menstrual cycle by blocking estrogen production. Side effects may include menopausal symptoms like hot flashes, vaginal dryness and bone loss. That's why low-dose hormone therapy, a combination of estrogen and progestin hormones, is typically prescribed along with GnRH agonists. Some women may experience a return of their PMS symptoms with the additional hormone therapy. GnRH agonists are usually considered only as a short-term treatment option (given for no longer than six months) because of the increased health risks such as osteoporosis associated with low estrogen levels.

  • Antidepressant medications. Antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) are the preferred antidepressants for treating severe PMS and PMDD symptoms, including depression. SSRIs include sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac). Other types of antidepressants may also be prescribed to treat PMS and PMDD, including venlafaxine (Effexor) and clomipramine (Anafranil). The U.S. Food and Drug Administration warns that women taking antidepressants should monitor their symptoms closely, with the help of their health care professional, for signs that their condition is getting worse or that they are becoming suicidal, especially when they first start therapy or when their dose is increased or decreased.

  • Danazol. Danazol (Danocrine) is a medication that works similarly to GnRH agonists to prevent ovulation. Danocrine works to improve PMS symptoms in some women, but it has some unpleasant side effects, such as acne and facial hair growth, so it is usually only used in women who do not respond to other treatments.

  • Anti-anxiety medications such as alprazolam (Xanax) are sometimes prescribed when anxiety is the main symptom associated with PMS or PMDD. These drugs can be taken during the 14 days between ovulation and menstruation (the luteal phase) when symptoms occur (rather than daily). Dependence and serious withdrawal reactions can occur with Xanax, so its dosage and discontinuation should be carefully monitored.

  • Calcium supplements (1,200 mg daily). Additional calcium in any form may help relieve some PMS symptoms. Low-fat dairy products (milk, yogurt and cheese) are a primary source of calcium, but you can also gain calcium from the following:

    • Tofu and other soy products
    • Rice milk
    • Broccoli
    • Dark greens, like turnip greens
    • Green or red cabbage (raw)
    • Salmon and sardines
  • Taking an over-the-counter calcium supplement can also help. In one study, women who took 600 mg of calcium twice a day experienced fewer PMS symptoms than women who took a placebo. But be patient; it may take two to three months to relieve PMS symptoms with calcium supplementation. If symptoms persist, have your vitamin D levels checked or change the type of calcium supplement you're using. Low levels of vitamin D can affect how the body absorbs calcium, and some generic supplements may not have enough calcium available for absorption.

  • Exercise. Regular exercise can also help relieve and possibly prevent PMS symptoms. You will get the greatest benefits if you exercise for at least 30 minutes, at least five days a week. But even taking a 20- to 30-minute walk three times a week can improve your mood.

  • Chasteberry. The extract of the fruit of the chasteberry tree is shown to be a safe and effective treatment for PMS. This therapy is used primarily outside the United States. It may be obtained over the counter, but the dose and purity may be uncertain.

In addition, there's some evidence that some nutritional supplements such as vitamin E, magnesium and vitamin B-6 may help ease symptoms of PMS. Discuss these and other strategies with your health care professional before taking any dietary supplement.

There is no single treatment that works well for every woman who experiences PMS. Typically, it's wise to try the most conservative treatment options first, which include lifestyle changes such as modifying your diet and exercising more. Discuss your symptoms with your health care professional if strategies you've tried don't work, so he or she can recommend other treatment options.

Prevention

Prevention

Can premenstrual syndrome (PMS) be prevented? Many women report benefits from a variety of lifestyle change including dietary changes, exercise and stress management. Dietary changes may include:

  • Increasing calcium intake.

  • Decreasing consumption of refined sugar.

  • Decreasing or avoiding caffeine and nicotine, which act as stimulants and can increase tension and anxiety as well as interfere with sleep patterns. For some women, the severity of PMS symptoms increases as caffeine consumption increases.

  • Decreasing alcohol consumption, which can act as a depressant. If you experience PMS, you may have an increased sensitivity to alcohol at certain points during your cycle.

  • Decreasing salt intake and increasing water consumption to avoid water retention and bloating.

  • Avoiding sodas, which may contain high levels of caffeine, salt, sugar and/or artificial sweeteners.

  • Drinking natural diuretics, such as herbal teas.

Ironically, some PMS symptoms, such as mood swings, irritability, bloating, hunger, carbohydrate cravings and fatigue, may lead you to consume foods that aggravate the condition.

Premenstrually, you may crave either refined sugar (usually combined with chocolate) or fat (combined with salt). Generally, foods high in refined sugars and fat temporarily raise energy levels. But within several hours or less, as your body metabolizes these foods, you may "crash," meaning you'll feel worse than before you ate them. Foods high in sugar content can also leave you feeling jittery.

To alleviate mood swings and fatigue, try adding more high-quality, complex carbohydrates to your diet such as:

  • Whole grain breads, pastas and cereals
  • Potatoes (white or sweet)
  • Rice (preferably brown or wild)
  • Fresh vegetables, particularly corn and peas, such as chickpeas and lentils
  • Fresh fruits

These complex carbohydrates help keep blood sugar levels even while providing your body with a long-lasting source of energy.

It's not uncommon for your appetite to increase just before your period begins. To combat the munchies and extra weight gain, try eating smaller, low-fat healthful meals using the food choices listed above.

Make sure you include adequate calcium in your diet; calcium may help prevent irritability, anxiety and other PMS symptoms. Good sources of calcium include:

  • Low-fat milk and milk products like yogurt, ice cream and cheese
  • Broccoli
  • Dark greens (like turnip greens)
  • Green or red cabbage (raw)
  • Cooked collards
  • Salmon and sardines
  • Soy products, such as tofu and soy milk
  • Calcium-fortified orange and grapefruit juices

Another good way to prevent PMS symptoms is through regular exercise in the form of aerobic activities such as brisk walking, jogging, biking or swimming. You will get the greatest benefits from exercise if you do it for at least 30 minutes, five or more days a week. But even taking a 20- to 30-minute walk three times a week can:

  • Increase endorphin and serotonin production, brain chemicals that may help decrease pain and discomfort and improve mood, respectively
  • Decrease stress and anxiety
  • Increase REM sleep

Other lifestyle changes that will help you control PMS include:

  • Sleeping consistent hours
  • Establishing a bedtime routine to help cue body and mind for sleeping
  • Keeping a PMS symptom checklist, also called a menstrual cycle diary, to identify when symptoms and which symptoms occur so you can be prepared for them

Facts to Know

Facts to Know

  1. An estimated 75 percent of women of childbearing age suffer from PMS in some form.

  2. Approximately 3 to 8 percent of women experience premenstrual symptoms severe enough to disrupt their daily function and meet criteria for premenstrual dysphoric disorder (PMDD)––a severe form of PMS.

  3. Taking additional calcium in any form may help improve or even prevent PMS symptoms. Ideally, increase daily amounts of low-fat dairy products and other calcium-containing foods to reach the 1,200 mg of calcium daily health care professionals recommend. If you have trouble reaching this goal from your diet alone, consider using over-the counter calcium supplements.

  4. Symptoms of PMS may get worse with age.

  5. If you experience PMS, you may experience an increased sensitivity to alcohol at certain points in your menstrual cycle.

  6. Some evidence suggests that women who are vulnerable to depressive illness, panic disorder or other psychiatric or chronic medical disorders may be particularly susceptible to PMS.

  7. Strategies for PMS symptom relief include medication, dietary changes, exercise and stress management.

  8. Dietary changes to relieve PMS symptoms include increasing daily amounts of dietary or supplemental calcium, drinking more water and adding more complex carbohydrates (fruits, vegetables and grains) to your meals. Decreasing foods in your diet that contain refined sugar, limiting or avoiding caffeine and nicotine, decreasing alcohol consumption, decreasing salt intake and avoiding sodas may also help.

  9. Some of the PMS symptoms you may experience, such as mood swings, irritability, bloating, hunger, carbohydrate cravings and fatigue, may lead you to consume high-fat foods and/or foods high in refined sugar, which actually aggravate these symptoms. Try to avoid them.

  10. Even women who have had hysterectomies can have symptoms of PMS if at least one functional ovary is left intact following the hysterectomy.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about premenstrual syndrome (PMS) so you're prepared to discuss this important health issue with your health care professional.

  1. What causes PMS?

  2. Are my symptoms characteristic of PMS?

  3. What other illnesses could be causing these symptoms?

  4. Which tests, if any, should I have to rule out other illnesses?

  5. How is PMS treated?

  6. What treatment may work best for me?

  7. I've heard that not getting enough calcium can cause PMS. How can I add calcium to my diet?

  8. What tests are available to determine calcium deficiency, and where can I get tested?

  9. What's premenstrual dysphoric disorder (PMDD)?

  10. How do you treat PMDD?

Key Q&A

Key Q&A

  1. What exactly is premenstrual syndrome (PMS)?

    There are more than 150 documented symptoms of PMS, but the number of symptoms seen in the vast majority of patients is much more limited. Some of the most common PMS symptoms include bloating, fatigue, sudden mood swings, irritability,anxiety, depression, weight gain, headaches, joint and muscle aches, food cravings and fluid retention. To be considered PMS symptoms, they must occur exclusively in the last 14 days of your menstrual cycle (usually about five to seven days before your period begins). True PMS symptoms tend to increase in severity as the cycle progresses, are relieved within a few days after the start of the menstrual flow and are present for at least two to three consecutive menstrual cycles. Cramps are not considered a symptom of PMS, but they can occur in women with PMS.

  2. What causes PMS?

    PMS appears to be caused by rising and falling levels of the hormones estrogen and progesterone, which may influence brain chemicals, including serotonin, a substance that has a strong affect on mood. It's not clear why some women develop PMS or PMDD and others do not, but researchers suspect that some women are more sensitive than others to changes in hormone levels.

  3. How is PMS diagnosed?

    There is no single laboratory test for PMS, but one of the most common ways to diagnosis PMS is by keeping a daily checklist, chart or "menstrual cycle diary" that tracks when your premenstrual symptoms occurs for at least three months. Your health care professional should rule out other disorders or diseases that mimic or are identical to the symptoms caused by PMS before diagnosing you with the condition. These conditions include thyroid disorders, depression, endocrine abnormalities, menopause, heart problems, allergies and low blood sugar, among other conditions. Laboratory tests, personal and family medical histories and a physical exam are also part of the diagnostic process.

  4. Is PMS treatable?

    Yes! Many women experience some relief from PMS symptoms if they make diet and lifestyle changes, particularly increasing consumption of calcium, complex carbohydrates (fruits, vegetables, grains and beans) and water, and decreasing caffeine, alcohol, salt and refined sugar intake. Regular exercise and sleep may also help relieve symptoms. Certain medications can provide relief.

  5. When does PMS typically appear?

    PMS symptoms can appear any time between puberty and menopause, though the most common age for PMS to start to become a problem is during your late 20s to mid-30s.

  6. Will my PMS symptoms get better as I age?

    Probably not until you reach menopause. In some women, symptoms of PMS worsen with age and stress. Even women who have had hysterectomies can have PMS if at least one functional ovary is left intact following the hysterectomy. Once you reach menopause, your PMS symptoms will end with the end of menstruation.

  7. If I regularly take the recommended steps to relieve my PMS symptoms, how long before I may see results?

    It may take two to three months to experience relief from PMS symptoms. If you don't see any improvements by then, check with your health care professional for a new action plan.

  8. Are menstrual cramps a symptom of PMS?

    Cramps are not considered a symptom of PMS, although they may occur in women who have PMS. Called dysmenorrhea, cramps typically begin just before (24 to 48 hours) the onset of menstruation and disappear by the end of flow.

Lifestyle Tips

Lifestyle Tips

  1. Lifestyle changes for PMS sufferers

    Some of the lifestyles changes recommended to treat premenstrual syndrome (PMS) may also be useful in preventing symptoms. Performing aerobic activity such as brisk walking, jogging, biking or swimming for a minimum of 20 to 30 minutes at least three times a week or ideally, for at least 30 minutes, five or more days a week, coupled with a balanced diet (with increased whole grains, vegetables, fruit, and decreased or no salt, sugar, alcohol and caffeine) can help. It's also important to get adequate rest; the body may have different sleep requirements at different times during the menstrual cycle.

  2. Eating right to fight PMS

    To reduce your PMS symptoms, spread your normal caloric intake over three small meals and three small snacks per day, and avoid going for long periods of time without eating. Avoid or wean yourself off caffeine. Caffeine can worsen breast tenderness, and many women report that irritability and headaches decrease when they cut their caffeine intake. Reducing salt intake can relieve fluid retention. Snack suggestions: Plain yogurt; unsalted nuts, seeds and popcorn; whole-wheat bread with peanut butter; pumpkin or banana bread; graham crackers; unsalted whole-grain crackers; bran or oatmeal muffins; raw vegetables; and raw or dried fruits.

  3. Calcium can help alleviate PMS symptoms

    If you suffer from the physical and psychological symptoms typical in premenstrual syndrome (PMS), calcium may help solve your problem. In one study, women who took 600 mg of calcium twice a day experienced fewer PMS symptoms than women who took a placebo. Calcium can be obtained through the diet or in the form of nutritional supplements or antacids. Remember to talk to your health care professional before taking calcium supplements.

  4. Medications for PMS

    If a healthy diet, regular exercise and calcium supplements fail to improve mood swings or other emotional symptoms of PMS, you may want to talk to your health care professional about a serotonin reuptake inhibitor (SSRI) antidepressant medication. Other prescription medications sometimes prescribed for severe PMS include the anti-anxiety drug alprazolam (Xanax) and gonadotropin-releasing hormone (GnRH) agonist treatments that suppress estrogen production. A type of "combination" oral contraceptive containing drospirenone, a progestin, and ethinyl estradiol, a form of estrogen, is FDA approved for both the prevention of pregnancy and for the emotional and physical symptoms associated with PMDD. However, these contraceptives (Yaz, Beyaz and Safyral) should only be used to treat PMDD if you choose to use them for birth control because other forms of treatment don't carry the same risks as oral contraceptives. Oral contraceptives are not recommended for women who smoke because of increased cardiovascular risks. Be sure to ask your health care professional about short- and long-term side effects of any medications recommended to relieve symptoms of PMS/PMDD, including the potential for dependence with the use of certain anti-anxiety medications.

  5. Is it PMS or PMDD?

    If your premenstrual symptoms are bothersome , you may have PMS. If the symptoms are primarily emotional or behavioral and are severe enough to interfere significantly with work or relationships, you may have a more serious form of PMS, premenstrual dysphoric disorder (PMDD), which affects about 3 to 8 percent of women of childbearing age. PMDD symptoms can include a markedly depressed mood, severe anxiety or tension and wild mood shifts, as well as significant physical symptoms. However, severe mood-related symptoms are key to PMDD. If you suspect you have PMDD or PMS, consult your health care professional.

Organizations and Support

Organizations and Support

For information and support on coping with Premenstrual Syndrome, please see the recommended organizations, books and Spanish-language resources listed below.

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

MGH Center for Women's Mental Health
Website: http://www.womensmentalhealth.org
Address: Perinatal and Reproductive Psychiatry Program Simches Research Builiding
185 Cambridge St Suite 2200
Boston, MA 02114
Phone: 617-724-7792

National Family Planning and Reproductive Health Association (NFPRHA)
Website: http://www.nfprha.org
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
Phone: 202-293-3114
Email: info@nfprha.org

A Gynecologist's Second Opinion
by William H. Parker and Rachel L. Parker

Bitchin' in the Kitchen: The PMS Survival Cookbook
by Jennifer Evans

Curing PMS Naturally with Chinese Medicine
by Bob Flaws

Natural Medicine for PMS
by Deborah R. Mitchell

Once a Month: Understanding and Treating PMS
by Katharina Dalton

PMS & Perimenopause Sourcebook: A Guide to the Emotional, Mental, and Physical Patterns of a Woman's Life
by Lori Futterman and John E. Jones

PMS Relief: Natural Approaches to Treating Symptoms
by J. Marshall

PMS: Women Tell Women How to Control Premenstrual Syndrome
by Stephanie Degraff Bender and Kathleen Kelleher

Self-Help for Premenstrual Syndrome
by Marla Ahlgrimm R.Ph.

SOS for PMS: Whole Food Solutions for Premenstrual Syndrome
by Lissa Deangelis and Molly Siple

Medline Plus: Premenstrual Syndrome
Website: http://www.nlm.nih.gov/medlineplus/spanish/premenstrualsyndrome.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Womenshealth.gov
Website: http://www.womenshealth.gov/espanol/preguntas/pms.cfm
Hotline: 1-800-994-9662

Last date updated: 
Tue, 2014-07-22

What is it?

Overview

What Is It?
Chronic pelvic pain (CPP) is characterized by pain in the lower abdomen and pelvic area that has been present for at least six months. Sometimes the pain may travel downward into the legs or around to the lower back. The pain may be felt all of the time or it may come and go, perhaps recurring or intensifying each month with your menstrual period.

In either case, the pain is felt internally, not externally as in another common pain disorder in women called vulvodynia. In vulvodynia (or burning vulva syndrome), the external genital area stings, itches, becomes irritated or hurts when any kind of pressure, from tight clothing to intercourse, is experienced. Chronic pelvic pain and vulvodynia sometimes occur together.

Symptoms of Chronic Pelvic Pain
Women with CPP have one or more of the following symptoms:

  • constant or intermittent pelvic pain
  • low backache for several days before menstrual period, subsiding once period starts
  • pain during intercourse (rarely, some vaginal bleeding after intercourse)
  • pain on urination and/or during bowel movements (rarely, blood in urine or stool)
  • painful menstrual periods (dysmenorrhea)
  • severe cramps or sharp pains

The course of CPP is unpredictable and different in every woman. Symptoms may stay constant, disappear without treatment or suddenly increase. They sometimes decrease during pregnancy and improve after menopause.

The severity of pain is also unpredictable. It may range—even in the same woman—from mild and tolerable to so severe it interferes with your normal activities. Your physical or mental state can also cause the level of pain to fluctuate, so you may experience fatigue, stress and depression. Moderate to severe pain generally requires medical or surgical treatment, although such therapies are sometimes unsuccessful at relieving pain entirely.

Chronic Pelvic Pain Syndrome
Unrelieved, unrelenting pelvic pain may affect your sense of well-being, as well as your work, recreation and personal relationships. You may begin to limit your physical activities and show signs of depression (including sleep problems, eating disorders and constipation), and your sex life and role in the family may change.

When pelvic pain leads to such emotional and behavioral changes, the International Pelvic Pain Society (IPPS) calls the condition "chronic pelvic pain syndrome" and says that the "pain itself has become the disease." In other words, the pain is more of a problem than the original cause. In fact, a medical examination may find nothing physically wrong with the area that hurts. Nonetheless, the nerve signals in that area continue to fire off pain messages to the brain, and you continue to hurt.

Causes of Chronic Pelvic Pain
There are two kinds of pain. Acute pain typically occurs with an injury, illness or infection. A warning signal that something is wrong, it lasts only as long as it takes for the injured tissue to recover. In contrast, chronic pain lasts long after recovery from the initial injury or infection and is often associated with a chronic disorder or underlying condition.

Endometriosis
The most common cause of pelvic pain is endometriosis, in which pieces of the lining of the uterus attach to other organs or structures within the abdomen and grow outside the uterus. In practices specializing in the treatment of endometriosis, a significant number of patients with CPP are diagnosed with endometriosis. Two disorders that sometimes accompany endometriosis and are also linked to CPP are adhesions (scar tissue resulting from previous abdominal or pelvic surgery) and fibroids (benign, smooth muscle tumors that grow inside, in the wall of, or on the surface of the uterus). Fibroids often occur in the absence of endometriosis, without any pain at all, and are not a common source of chronic pelvic pain.

Pelvic Inflammatory Disease (PID)
Another common cause of CPP is pelvic inflammatory disease (PID). PID is one of the most common gynecologic conditions, usually related to a sexually transmitted disease. However, many women recuperate fully from STD-related PID, and we don't know exactly why PID sometimes leads to CPP.

One of the most common contributors to pelvic pain is dysfunction of the pelvic floor and hip muscles. This problem often accompanies pain originating from the reproductive organs but can occur on its own or persist after other sources are successfully treated.

Other Causes of Chronic Pelvic Pain
Other causes of CPP are diagnosed more frequently by other kinds of clinical care specialists, such as urologists, gastroenterologists, neurologists, orthopedic surgeons, psychiatrists and pain management physicians. They include diseases of the urinary tract or bowel as well as hernias, slipped discs, drug abuse, fibromyalgia and psychological problems.

In fact, many women with CPP collect a different diagnosis from each specialist they see. What is going on here? It is likely that CPP represents a general abnormality in the way the nervous system processes pain signals from the pelvic nerves, producing pain that involves the genital organs, the bladder, the intestine, pelvic and hip muscles and the wall of the abdomen, as well as pain involving the back and legs.

Characteristics of Pelvic Pain Patients
Despite the number of possible causes, many women with chronic pelvic pain receive no diagnosis. These are often the women who make the rounds of various specialists seeking relief, only to be told the pain is "all in their heads." They may also be subjected to multiple tests or even unnecessary surgery. These women may feel that the pain is somehow their fault, when, in fact, the lack of a diagnosis represents the limitations of medical science.

Simply put, there is no simple answer to the question, "What causes chronic pelvic pain?" and no "typical patient." Still, a woman with pelvic pain is more likely to:

  • have been sexually or physically abused
  • have a history of drug and alcohol abuse
  • have sexual dysfunction
  • have a mother or sister with chronic pelvic pain
  • have history of pelvic inflammatory disease (PID)
  • have had abdominal or pelvic surgery or radiation therapy
  • have previous or current diagnosis of depression
  • have a structural abnormality of the uterus, cervix or vagina
  • be of reproductive age, especially aged 26 to 30 years.

Some of these, like family history, surgery and PID, are obvious risk factors; others (drug abuse, depression) may be risk factors or may result from having chronic pain.

Impact of Chronic Pelvic Pain

An estimated 4 to 25 percent of women have chronic pelvic pain, but only about a third of them seek medical care. It is also one of the most common reasons American women see a physician, accounting for 10 percent of gynecologic office visits, up to 40 percent of laparoscopies and 20 percent of hysterectomies in the United States.

The cost to the patient is also enormous. Studies and surveys show that a quarter of affected women are incapacitated by pain two to three days each month. More than twice that many are forced to curtail their normal activities one or two days each month. Many women with chronic pelvic pain have pain during intercourse, and some have significant emotional changes. For many, the pain and underlying conditions lead to fertility problems, just at the age when they want children.

Diagnosis

Diagnosis

As with many pain conditions, chronic pelvic pain (CPP) can be difficult to diagnose. For one thing there is no screening test. For another, because symptoms may be variable, it can be difficult for a woman to define and localize her pain. Finally, there are all those possible causes and associated conditions to investigate.

Conditions that can cause pelvic pain may be divided into several categories:

Gynecologic conditions

  • Endometriosis is a condition in which tissue that makes up the lining of the uterus (endometrium), exits the uterus and attaches to the ovaries, fallopian tubes, bowels or other organs in the abdomen. Because endometrial tissue responds to hormonal changes during a woman's menstrual cycle, the abnormally located tissue swells and bleeds, sometimes causing pain.

    Endometriosis pain is not always restricted to the menstrual cycle. Many women with endometriosis have pain at other times of the month. Endometriosis can also scar and bind organs together, cause tubal (ectopic) pregnancies and lead to infertility, although these outcomes are unusual.

  • Fibroids are benign (noncancerous) tumors that grow inside, in the wall of or on the outside surface of the uterus. Many women don't know they have fibroids because often they have no symptoms. However, depending on their location and size, fibroids may cause pelvic pain, backaches, heavy menstrual bleeding, pain during intercourse and such urinary problems as incontinence and frequent urination. They can interfere with fertility or pregnancy if they distort the shape of the inside of the uterus, but this is unusual. Pain with fibroids is uncommon; heavy bleeding is more common.

  • Adenomyosis, like endometriosis, involves the abnormal growth of cells from the uterine lining. In this case the cells grow into the wall of the uterus, growing into the muscle fibers there. The result is painful cramps and heavy menstrual bleeding.

  • Adhesions are fibrous bands of scar tissue that are caused by endometriosis or pelvic infection, or they may form after surgery. When these bands tie organs and tissues together inappropriately, even normal movements and sex may stretch the scar tissue and cause pain. When adhesions block the fallopian tubes or ovaries, infertility can result. If they wrap around the bowel, they may cause bowel obstruction.

  • Pelvic inflammatory disease (PID) includes any infection or inflammation of the fallopian tubes, uterine lining and ovaries. It often begins as a sexually transmitted infection, most commonly chlamydia or gonorrhea. Many women with PID have no symptoms or only mild symptoms (abnormal vaginal bleeding or discharge or pain with intercourse) and may not seek treatment. However, left untreated, PID may cause scar tissue to form that can lead to chronic pelvic pain, abscesses, tubal pregnancies and infertility.

  • Ovarian remnants can sometimes cause pelvic pain. After a hysterectomy with bilateral salpingo-oophorectomy, where the uterus, ovaries and fallopian tubes are removed, a small piece of ovary may be left behind, which can later develop a painful cyst.

Urinary Tract Disorders

  • Interstitial cystitis (IC) is an inflammatory condition in which the bladder wall becomes chronically inflamed. The lining of the bladder that protects the wall from irritation seems to break down. In its most severe form, ulcers form in the bladder lining. The resulting discomfort ranges from annoying constant sensations of bladder fullness, even immediately after voiding, to intense bladder pain with associated cramping and spasm of the pelvic floor muscles. Symptoms include frequent urination that does not relieve the sensation of bladder fullness, pain or pressure. Ninety percent of IC sufferers are women, and symptoms may flare during menstruation. IC pain often gets worse during or after intercourse. Many women with IC are treated repeatedly for bladder infections, because symptoms overlap. With IC, however, antibiotics provide no relief, and urine testing for infection is negative.

  • Chronic urethritis is inflammation and irritation of the urethra (the tube through which urine is eliminated from the bladder) caused by either an infection or noninfectious inflammation. Most urethritis occurs in men, and this rare female condition rarely responds to oral antibiotics and is often also diagnosed as bladder infection, again with negative urine infection test results and minimal or no response to oral antibiotics. Symptoms include a burning pain that may radiate into the vulva or groin, exacerbated by sex or activities that put direct pressure on the groin area, such as biking or horseback riding.

Intestinal disorders

  • Irritable bowel syndrome (IBS) symptoms include abdominal discomfort or painful cramping, bloating and gas and constipation or diarrhea (or bouts of both). Stress and depression can increase the symptoms, as can particular foods and beverages. Women are more than twice as likely to have IBS as men, and their symptoms are often worse during their periods.

  • Diverticulosis occurs when small pockets develop in the wall of the large intestine. When these pockets get plugged with undigested food, an infection can develop in the bowel wall causing diverticulitis. Usual symptoms are pain in the lower left abdomen, fever, constipation or bloody diarrhea. Diverticulosis is uncommon under the age of 50.

Musculoskeletal disorders

  • Pain and tension in the pelvic nerves, pelvic and hip bones and attached pelvic floor muscles are often the primary site of musculoskeletal chronic pelvic pain. Pain from these sources, including sciatica, pudendal neuropathy, sacroiliac inflammation, pelvic asymmetry and psoas muscle spasm, among others, may cause chronic low back, deep pelvic and lower abdominal wall pain symptoms.

  • Scoliosis (curvature of the spine), herniated disks in the lower region of the back, spinal stenosis, spine or hip arthritis and other disorders of the bones, nerves and muscles in the pelvic region can result in chronic pelvic pain.

Psychological disorders

  • Depression is a common and treatable illness; chronic pain is a common symptom of depression.

Other conditions

  • Hernias, which occur when the intestine pushes through the abdominal wall, can cause pelvic pain when the intestines become intermittently or permanently trapped in the hernia defect, effectively obstructing the small intestine. Although they are more common in men, hernias do occur in women. Hernias rarely occur more than once in any individual.

  • After abdominal surgery, nerves may get entrapped in the tissue layers of the healed wound, causing pain.

Diagnostic Tests for Pelvic Pain

When you first seek medical help for pelvic pain, you may see either your internist (primary care physician) or gynecologist. In either case, your doctor will consider every possible source of pain. Each may require different diagnostic tests and distinct treatments, including referral to specialists for evaluation of specific organ systems. If you have more than one diagnosis, each can be diagnosed and treated accordingly. Depending on the problem(s) involved, your initial doctor may recommend evaluation with other specialists.

Your doctor, nurse practitioner, midwife or physician assistant will begin by asking you specific questions about your past and present health, your menstrual cycle, sexual history, previous abdominal surgeries, accidents and injuries and your symptoms. You may be asked to describe the kind and severity of your pain (aching, burning, stabbing), where it is and how it affects your life, including activities that worsen or relieve the symptoms.

You should tell your health care professional if the pain is constant or intermittent, related to your period, or worse during urination, bowel movements or sex. Also discuss any urinary or intestinal problems you may be having. Do you have constipation or diarrhea? Can you associate the start of your pain with a bladder infection or backache? Do certain movements or physical activities affect the pain intensity or duration? All information about your pain and other symptoms can help your physician with your diagnosis. Keep a pain diary with detailed information about the pain and associated activities and symptoms.

Because pelvic pain appears to run in families, the clinician will also inquire about related illnesses and problems in your parents and siblings, especially your mother and sisters. You must be prepared to report and, if possible, provide documentation about any tests, treatments and therapies you've already undergone for the pain and what the outcomes were.

Following the medical history, your health care professional will conduct a general physical examination, including a pelvic and rectal exam to determine areas of tenderness and find such potential problems as fibroids, pain trigger points, pelvic masses and abdominal wall hernias. If you have muscle pain, skeletal problems or backache, your health care professional may check your posture and gait and look for relations between those problems and your pelvic pain.

Depending on what he or she finds, these simple, standard tests may be ordered:

  • blood tests to check for infection (complete blood count or CBC) and inflammation (sedimentation rate or ESR)

  • pregnancy test

  • urinalysis and other urinary tests

  • tests for sexually transmitted diseases

  • imaging tests, such as pelvic or abdominal sonography, MRI defecography, spinal imaging, CAT scan of the abdomen and pelvis or other imaging tests

If certain conditions are suspected, endoscopic evaluations or surgery may be recommended. These include:

  • cystoscopy (look in the bladder)

  • sigmoidoscopy or colonoscopy (partial or complete look in the colon)

  • laparoscopy (minimally invasive endoscopic look into the abdomen and pelvis)

Treatment

Treatment

A diagnosis provides a starting point for treatment. The type of treatment your health care professional recommends depends on you, your reproductive health stage (childbearing years vs. menopause, for example), your condition and your level of pain.

The goals of CPP treatment focus on creating self-management strategies that allow you to manage your pain, restore your normal activities, improve your quality of life and prevent symptoms from recurring. These goals may be difficult to achieve.

The fact is that managing any kind of chronic pain is one of the most difficult jobs in medicine. You may find that your health care professional recommends a "watchful waiting" period using nonmedical therapies such as exercise, relaxation techniques and yoga to see how your symptoms develop or whether they decrease on their own. As hard as this approach may seem at first, it may provide more information about your symptoms and prevent rushing into surgery. It is also important to see a gynecologic specialist with specific experience and training in chronic pelvic pain.

If and when you decide on a specific treatment, a team approach involving specialists in several medical fields often offers the best results. This is especially true if you've been diagnosed with several conditions, all of which may represent a single pain-processing problem.

Medications

  • Pain-relieving nonsteroidal anti-inflammatory drugs, or NSAIDs, such as ibuprofen (Motrin) and naproxen (Aleve), are available over the counter (OTC) and by prescription.

    Because they reduce the amount of the hormone prostaglandin, which is involved in producing inflammation, these drugs reduce swelling and relieve menstrual cramps and pain. Studies have shown that women with painful periods produce higher than normal levels of prostaglandin. To be most effective, NSAIDs must be taken regularly, but long-term use can lead to serious side effects, including stomach ulcers and intestinal bleeding; discuss these risks with your health care professional.

  • Hormonal therapies, like birth control pills and Depo-Provera injections, regulate ovulation and menstruation. These medications help menstrual-related pelvic pain. High-dose progestin and GnRH agonists (gonadotropin-releasing hormone drugs) completely stop menstruation. Danazol, an androgen, helps ease pelvic pain related to endometriosis. Androgenizing side effects, such as increased hair growth, clitoral enlargement, deepening of voice and weight gain are common side effects of danazol therapy, however; as a result, it is usually a therapy of last resort. These drugs all work by stabilizing or reducing the production of estrogen, which causes endometrial tissue to grow. To avoid laparoscopic surgery, which is the only secure way to diagnose endometriosis, clinicians often opt to diagnose endometriosis indirectly, based on clinical response to treatment with leuprolide (Lupron), a GnRH agonist. If leuprolide relieves the pain, a presumptive diagnosis of endometriosis may be made. This conclusion may still be incorrect because other causes for pain, such as adenomyosis or painful uterine fibroids, also tend to improve with Lupron.

  • Pain medication may be injected into abdominal or pelvic trigger points, tender areas in the abdominal wall or pelvic muscles to block pain.

  • Elmiron (pentosan polysulfate sodium) is an oral drug approved to treat interstitial cystitis. How this drug relieves interstitial cystitis is not completely understood, but it is believed to work by gradually helping repair and restore the damaged bladder lining. While some women find their symptoms improve in as little as four weeks, studies show that it usually take three months to see a significant benefit, and some women never experience a benefit.

  • Antibiotics may be prescribed for underlying infections such as PID. However, there is no substantial evidence showing that antibiotics improve residual CPP.

  • Antidepressant drugs are often prescribed for chronic pain. They seem to affect pain transmission signals to the brain as well as help relieve any underlying depression.

Surgery

Surgery may be recommended to remove endometriosis, adhesions and fibroids, correct physical abnormalities or remove a diseased or damaged uterus and ovaries that may be contributing to the pain.

  • Laparoscopy may be used for both diagnosis and treatment. During the procedure, sites of endometriosis and adhesions may be destroyed by laser beam or electric current or cut out with a specially designed laparoscopic micro-scissor. In experienced hands, even advanced stages of endometriosis can be treated laparoscopically.

  • A laparotomy is a more invasive surgical procedure that involves an abdominal incision. It's used to remove endometriosis, adhesions or ovarian cysts that can't be removed laparoscopically.

  • A hysterectomy is the surgical removal of the uterus. It may be a reasonable treatment for chronic pelvic pain after other options have been considered. Hysterectomies may be performed laparoscopically, vaginally or by laparotomy.

Other Therapies

Various other therapies may be helpful alone or in combination with medical and surgical treatment:

  • relaxation and breathing techniques to reduce stress and anxiety

  • stretching exercises, massage therapy and biofeedback to reduce muscle tension in the pelvic floor, hips and low back that can cause or enhance pelvic pain

  • physical therapy to improve posture, gait and muscle tone and to work with painful muscle groups, especially pelvic floor and hip muscles.

  • cognitive behavioral therapy that includes various pain-coping strategies

  • counseling to treat depression and associated pain symptoms

The chronic nature and complexity of pelvic pain may require multiple treatment strategies, and the right combination may take some time to discover. Often, a combination of medical, surgical and alternative therapies works best. Counseling and support groups can help you to keep a positive attitude during treatment. Meanwhile, as research continues on the possible causes of chronic pelvic pain, improved drug treatments and less invasive surgical techniques are being developed.

Prevention

Prevention

Many conditions that cause chronic pelvic pain (CPP) cannot be prevented. However, reducing your risks for developing sexually transmitted infection such as chlamydia or gonorrhea can reduce your chances of developing pelvic inflammatory disease (PID), a common cause of CPP. Regular pelvic exams—once a year after commencing sexual activity or for all women age 18 and older—are also important. Regular pelvic health checkups give you the opportunity to discuss any concerns or symptoms with your physician and help identify health conditions, such as CPP, early in their development. If you experience pelvic pain, don't wait; make an appointment to discuss your symptoms with your physician.

Facts to Know

Facts to Know

  1. Chronic pelvic pain (CPP) may be either constant or intermittent pain in the lower abdomen and pelvic area that has been present for six months or more. The exact symptoms and course of disease are unique for each woman. CPP tends to improve after menopause. According to various studies, CPP affects 4 percent to 25 percent of women.

  2. Pelvic pain symptoms may include severe menstrual cramps; pain during sex, urination or bowel movement; low backache right before your menstrual period and rectal pain.

  3. As with other chronic pain conditions, the unrelenting nature of pelvic pain and the difficulties encountered in its diagnosis and treatment may lead to depression, anxiety, fatigue, behavioral changes and impaired mobility.

  4. Common causes of pelvic pain include fibromyalgia, endometriosis, fibroids, adenomyosis, pelvic adhesions related to prior pelvic surgery, endometriosis or sexually transmitted infections, pelvic inflammatory disease, interstitial cystitis, chronic urethritis, irritable bowel syndrome, diverticulitis, spinal problems, muscular dysfunction, hernias and psychological problems.

  5. Risk factors associated with CPP include past sexual and physical abuse; sexual dysfunction; a mother or sister with chronic pelvic pain; history of pelvic inflammatory disease; abdominal or pelvic surgery; depression; and congenital structural abnormalities of the uterus, cervix or vagina.

  6. The process of diagnosing chronic pelvic pain may take time, involving various tests. The goal is to identify all underlying causes of pain. In some women, no clear diagnosis or underlying cause for chronic pain is established, which can be frustrating for both the patient and physician.

  7. The goal of treatment is to manage pain, restore normal activities, improve quality of life and prevent recurrence of symptoms.

  8. Treatment may involve a combination of medications, surgery, alternative therapies and counseling. The approach used depends on the individual's condition(s), level of pain and age.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about chronic pelvic pain (CPP) so you're prepared to discuss this important health issue with your health care professional.

  1. Why am I having pain? Do I have a condition causing the pain?

  2. I've tried over-the-counter pain relievers but they're not enough. What drugs can you prescribe that will relieve my pain? What are their side effects? Will they interact with other drugs I'm taking?

  3. Do I need surgery? What kind? What is its success rate in reducing pain or curing the condition? What will happen if I choose not to have surgery?

  4. If I have surgery, will that increase my chances of developing adhesions that can cause pelvic pain in the future? What methods do you use during surgery to reduce the chance of adhesions developing?

  5. Is there a specialist in laparoscopic surgery you could refer me to?

  6. Are there nondrug, nonsurgical therapies that can help reduce my pain and improve my condition? What can I do to cope with the pain and continue my normal activities?

  7. Is there a pain management specialist you could refer me to?

  8. Are there support groups for chronic pelvic pain? Where can I get more information?

Key Q&A

Key Q&A

  1. When should I consult a health care professional about pelvic pain?

    Make an appointment with your physician or alternate pelvic health clinician if your periods are painful, if you have vaginal bleeding at times other than during your normal menstrual cycle, if you have pain during intercourse, urination or bowel movements or if you have blood in your urine or stool. If severe pelvic pain suddenly appears, see a health care professional immediately. Generally, a woman with pelvic pain and symptoms will see her primary care physician or gynecologist first. Depending on his or her findings, you may be referred to other specialists such as a urologist, for example, if there is a urinary tract condition contributing to your pain syndrome. Or it may be best to undergo treatment with a gynecologist who specializes in chronic pelvic pain or a colorectal surgeon or rheumatologist, if gastrointestinal or rheumatologic conditions are contributing to your pain. In addition, you may require physical therapy.

  2. What kinds of tests will I need for a diagnosis?

    Your physician will first conduct a medical history followed by a comprehensive physical exam, including a pelvic and rectal exam, to locate your pain and find such potential contributing problems as arthritis, pelvic inflammatory disease, endometriosis, colitis, urinary tract conditions, fibroids, pelvic masses and lower abdominal hernias. The doctor may also examine the muscles of the pelvic floor and hips. Your posture and gait may be evaluated to look for relations between musculoskeletal imbalances and your pain. You may also undergo blood tests, urine tests and tests for sexually transmitted diseases. If your doctor suspects certain conditions, he or she may order an exploratory or diagnostic laparoscopy, abdominal or pelvic ultrasound, X-ray, CT scan or MRI.

  3. Why can't I get complete pain relief?

    Complete relief from chronic pain, whether from chronic pelvic pain or other chronic conditions like backache, arthritis and fibromyalgia, can be difficult to achieve. No one medication works on all women with pain symptoms. A personalized combination of therapies that may include medication, surgery, physical therapy, alternative therapies and lifestyle changes will be formulated to manage your chronic pain symptoms.

  4. Why did I get this disease? What causes it?

    Although there are risk factors that may have increased your chances for developing chronic pelvic pain, most are not things you could have prevented or controlled. The most common causes of chronic pelvic pain are endometriosis, adenomyosis, PID, muscular problems, interstitial cystitis, irritable bowel syndrome and depression.

  5. Why are my symptoms different from a friend's, who also has chronic pelvic pain?

    Because of the wide range of conditions that can cause or contribute to chronic pelvic pain, symptoms vary from woman to woman. You may find that your own symptoms vary during your monthly cycle or over time.

  6. What can I expect from medical treatments?

    Your pain symptoms may not be totally relieved by taking medications. However, by working closely with your team of health care providers and using some self-care techniques, you may be able to reduce the impact your pain symptoms have on your lifestyle.

  7. Should I have surgery? When should I consider surgery?

    The recommendation for surgery to diagnose or treat CPP varies from patient to patient, based on the evaluation test results and responses to medical therapies. In general, surgery to relieve pelvic pain succeeds when the cause of the pain is structural, for example adhesions, ovarian cysts, endometriosis or a congenital or acquired abnormality in the uterus that may be treated with surgery. For other conditions that cause chronic pelvic pain, surgery may not be an option. In either case, surgery should be carefully discussed with your physician(s) to determine whether the risks involved in surgery are outweighed by the likelihood that surgery will relieve your pain.

Lifestyle Tips

Lifestyle Tips

  1. A combination of therapies works best

    Over-the-counter (OTC) or prescription analgesics may not be adequate to relieve your pain. Complementing drug therapy with one or more alternative therapies, including physical therapy, massage and psychological counseling, may also improve pain relief.

  2. Pay attention to posture

    Bad posture, lumbar spine disorders and hip problems can all contribute to pelvic pain, as can muscle strength and length imbalances, leg length discrepancy and foot problems. If you have chronic pelvic pain, be sure to get a complete evaluation of your musculoskeletal system from a doctor or physical therapist. If such musculoskeletal problems are detected, range of motion exercises to increase flexibility of the spine, strengthening exercises for certain muscle groups or an orthotic for your shoe may be recommended.

  3. Relax to reduce stress

    Stress exacerbates many recurrent and chronic conditions, including chronic pelvic pain. Stress increases blood pressure, reduces the immune system's ability to fight infection and affects hormone production, increasing cortisone production in the adrenal glands and upsetting the balance of female hormones. Managing stress by learning to relax daily through meditation or other established therapeutic relaxation techniques is an important part of any pain relief program. Relaxation techniques include focused breathing (as women in labor are advised to do), meditation, deep breathing, progressive muscle relaxation and listening to classical music or nature relaxation recordings. Biofeedback techniques require formal instruction and training but can help you improve your ability to recognize which muscles are tense and how to relax them.

  4. Heat and hot water relaxes muscles

    Any kind of heat improves blood flow and relaxes tense muscles. A heating pad or hot water bottle applied to the lower abdomen can help relieve menstrual cramps or pain associated with trigger points; use one on your lower back if that is where your pain originates. Treat yourself to a warm bath with relaxing ingredients, such as Epsom salts, added to it.

  5. Exercise and eat right

    Regular exercise improves circulation and increases the production of natural pain-relieving substances (endorphins) in your body. By staying fit and active, you will also reduce your chances of increasing pain due to tight muscles. It may also help you to stay positive and ward off depression. Good nutrition and getting enough rest also help you manage pain.

Organizations and Support

Organizations and Support

For information and support on coping with Pelvic Pain, please see the recommended organizations, books and Spanish-language resources listed below.

American Association of Gynecologic Laparoscopists (AAGL)
Web Site: http://www.aagl.org
Address: 6757 Katella Avenue
Cypress, CA 90630
Hotline: 1-800-554-AAGL (1-800-554-2245)
Phone: 714-503-6200

American College of Obstetricians and Gynecologists (ACOG)
Web Site: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Society for Reproductive Medicine (ASRM)
Web Site: http://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: asrm@asrm.org

American Urogynecologic Society
Web Site: http://www.augs.org
Address: 2025 M Street NW, Suite 800
Washington, DC 20036
Phone: 202-367-1167
Email: info@augs.org

American Urological Association
Web Site: http://www.auanet.org
Address: 1000 Corporate Blvd.
Linthicum, MD 21090
Hotline: 1-800-RING-AUA (1-866-746-4282)
Phone: 410-689-3700
Email: aua@auanet.org

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

National Association for Continence (NAFC)
Web Site: http://www.nafc.org
Address: P.O. Box 1019
Charleston, SC 29402
Hotline: 1-800-BLADDER (1-800-252-3337)
Phone: 843-377-0900
Email: memberservices@nafc.org

National Uterine Fibroids Foundation
Web Site: http://www.nuff.org
Address: P.O. Box 9688
Colorado Springs, CO 80932
Hotline: 1-800-874-7247
Phone: 719-633-3454
Email: info@nuff.org

Society of Interventional Radiology
Web Site: http://www.sirweb.org
Address: 3975 Fair Ridge Drive, Suite 400 North
Fairfax, VA 22033
Hotline: 1-800-488-7284
Phone: 703-691-1805
Email: info@sirweb.org


A Gynecologist's Second Opinion: The Questions & Answers You Need to Take Charge of Your Health
by William H. Parker and Rachel L. Parker

A Seat on the Aisle, Please! The Essential Guide to Urinary Tract Problems in Women
by Elizabeth Kavaler

A Break in Your Cycle: The Medical and Emotional Causes and Effects of Amenorrhea
by Theresa Francis-Cheung

Coping With Endometriosis: A Practical Guide
by Robert Phillips and Glenda Motta

The Curse: Confronting the Last Unmentionable Taboo: Menstruation
by Karen Houppert

Endometriosis Sourcebook
by Mary Lou Ballweg and The Endometriosis Association

Endometriosis Survival Guide: Your Guide to the Latest Treatment Options and the Best Coping Strategies
by Margot Fromer

Endometriosis: The Complete Reference for Taking Charge of Your Health
by Mary Lou Ballweg

Honoring Menstruation: A Time of Self-Renewal
by Lara Owen

Uterine Fibroids: What Every Woman Needs to Know
by Nelson Stringer, M.D.

What Your Doctor May Not Tell You About Fibroids: New Techniques and Therapies--Including Breakthrough Alternatives to Hysterectomy
by Scott C. Goodwin, David Drum, and Michael Broder

Yale Guide to Women's Reproductive Health: From Menarche to Menopause
by Mary Jane Minkin and Carol V. Wright

Internation Association for the Study of Pain
Website: http://www.iasp-pain.org/AM/Template.cfm?Section=Fact_Sheets&Template=/CM/ContentDisplay.cfm&ContentID=4575
Address: IASP Secretariat
111 Queen Anne Ave N, Suite 501
Seattle, WA 98109
Phone: 206-283-0311

University of Maryland Medical Center: Prostatitis Chronic Overview
Website: http://www.umm.edu/esp_ency/article/000523.htm
Address: University of Maryland Medical Center
22 S. Greene St.
Baltimore, MD 21201
Hotline: 1-800-492-5538
Phone: 410-328-8667

Last date updated: 
Thu, 2012-02-09