Pelvic Pain

Pelvic Pain

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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Published by: National Women's Health Resource Center, Inc., December 2010

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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

What is it?

Overview

What Is It?
Pelvic organ prolapse (POP) occurs when one or more organs in your pelvis—your uterus, vagina, urethra, bladder or rectum—shifts downward and bulges into or even out of your vaginal canal.

Pelvic organ prolapse (POP) occurs when one or more organs in your pelvis—your uterus, vagina, urethra, bladder or rectum—shifts downward and bulges into or even out of your vaginal canal. In the United States, 24 percent of women have some sort of POP.

Just one symptom that can be associated with the condition—urinary incontinence—costs the country more than $20 billion annually in direct and indirect medical costs, while surgeries to correct POP cost more than $1 billion annually. Approximately 200,000 surgeries are done each year in the United States to correct POP.

The condition is poised to become much more common in the United States and other Western countries with the aging of the Baby Boomers (women ages 45-63). In fact, an estimated 11 to 19 percent of women will undergo surgery for POP or urinary incontinence by age 80 to 85, and 30 percent of them will require an additional surgery to correct the problem.

Many women don't have any symptoms of POP. Those who do may experience a feeling of vaginal or pelvic fullness or pressure or feel as if a tampon is falling out. They may also experience incontinence, uncomfortable intercourse, pain in the pelvic area unrelated to menstruation, lower back pain and difficulty getting stools out.. Some women also complain of not being able to fully void stools and of fecal soiling of their underwear.

Treatments include lifestyle options, such as exercises to strengthen the pelvic floor, devices designed to support the pelvic organs, physical therapy and surgery to repair damaged ligaments and reposition the prolapsed organs. For women not planning to have sex, obliterative surgeries, which close off the vaginal opening, are also an option.

Risk factors for POP include pregnancy (particularly pregnancies that have ended with a vaginal birth, especially a forceps-assisted birth), genetic predisposition, aging, obesity, estrogen deficiency, connective tissue disorders, prior pelvic surgery and chronically increased intra-abdominal pressure from strenuous physical activity, coughing or constipation. In many cases, women with POP have at least two or more risk factors.

Having been pregnant with and given birth to a child—particularly two or more children—is a significant risk factor. According to the National Association for Continence, as many as 50 percent of women who have ever given birth have some degree of POP.

While cesarean section delivery reduces the risk of POP and urinary incontinence, there is still no good evidence to support elective cesarean sections for preventing POP. Having a hysterectomy may also increase your risk of POP, depending on how the surgery was performed and how well the surgeon reattached the ligaments that typically hold up the uterus to the top of the vagina, where the cervix used to be.

Genetic factors also contribute to your risk of POP. If possible, talk to your mother, grandmother, aunts and sisters about any pelvic organ problems they've had. Also ask about urinary and fecal incontinence; although it's embarrassing to talk about, both are often associated with POP.

Diagnosis

Diagnosis

The most common symptoms associated with pelvic organ prolapse (POP) are related to urination. You may have feelings of urgency, in which you suddenly have to urinate, find yourself urinating more often than normal, experience urinary incontinence or have difficulty urinating and completely emptying your bladder.

Some women experience painful intercourse, problems reaching orgasm and reduced sexual desire or libido. Although prolapse does not directly interfere with sexuality, it may affect self-image. Data shows that women with urge incontinence have the most problems with sexuality and that POP interferes with sexuality more than any other form of incontinence. Some women avoid sex because they are embarrassed about the changes in their pelvic anatomy, and some worry that having sex will "hurt" something or cause more damage.

You may also experience problems in the rectal area. Some women with POP have pain and/or straining during bowel movements, and some experience anal incontinence, in which they inadvertently release stool.

Other symptoms include feeling as if a tampon is falling out. In fact, if the cervix has descended into the vagina, you may find you can't use a tampon at all.

However, doctors may have trouble diagnosing the condition because many symptoms can be related to situations and medical conditions unrelated to POP. The following questions can help alert your doctor to the possibility that you may have POP:

  • Do you ever have to push tissue back in the vagina to urinate?
  • Do you have to use your fingers in the vagina, on the perineum (the area between the anus and vagina) or in the rectum to have a bowel movement?
  • Do you ever feel a bulge or that something is "falling out" of your vagina? Or do you feel like you're sitting on an egg?

Let your doctor know if you answered yes to any of these questions.

Diagnosing POP begins with a complete medical history and physical examination. The doctor will carefully examine your vulva and vagina for any lesions or ulcers and will perform an internal examination to identify any prolapsed organs. The doctor will also conduct a rectal examination to test for the resting tone and contraction of the anal muscle and to look for any abnormalities in that region. The doctor may also examine you while you're standing (to see if gravity brings the organs down) and may ask you to strain as if you were urinating or having a bowel movement. A check of the nerves and reflexes in this area may be included.

POP refers to a displacement of one of the pelvic organs (uterus, vagina, bladder or rectum). These displacements are typically graded on a scale of 0 to 4, with 0 being no prolapse and 4 being total prolapse (called procidentia). Your doctor will determine which type of prolapse you have. The different types include the following:

  • Bladder prolapse (cystocele). In this form, the bladder falls toward the vagina, creating a bulge in the vaginal wall. Usually the urethra also prolapses with the bladder, called urethrocele. The two together are called cystourethrocele. Symptoms include stress incontinence (when you urinate a little when you sneeze, cough, jump, etc.) or problems urinating.
  • Rectal prolapse (rectocele). In this form, the bladder falls toward the vagina, creating a bulge in the vaginal wall. Usually the urethra also prolapses with the bladder, called urethrocele. The two together are called cystourethrocele. Symptoms include stress incontinence (when you urinate a little when you sneeze, cough, jump, etc.) or problems urinating.
  • Uterine prolapse (uterine descensus). This is a very common form of POP. It occurs when the ligaments that hold the uterus in place weaken, like a rubber band that's been stretched too often. This causes the uterus to fall, weakening the back walls of the vagina.
  • Vaginal vault prolapse. This form occurs when the vaginal supports weaken and the vagina drops into the vaginal canal after a hysterectomy. It may also occur when the front and back walls of the vagina separate, allowing the intestines to push against the vaginal wall in a form of prolapse called enterocele. Enterocele may occur with a uterus in place, but vaginal vault prolapse occurs only after hysterectomy when the uterus no longer supports the top of the vagina.

Tests

Your doctor may order several tests to confirm a diagnosis of POP. These include:

  • Urinary tract infection screening. You pee in a cup and your urine is evaluated for the presence of bacteria.
  • Postvoid residual urine volume test. This determines if any urine remains in your bladder after voiding. After urinating, the doctor or nurse inserts a catheter, or thin tube, into the urethra to measure any remaining urine or uses an ultrasound to identify any urine remaining in the bladder.
  • Urodynamic testing. This test uses special sensors placed in the bladder and rectum or vagina to measure nerve and muscle response.

If you have problems with bowel movements, your doctor will likely refer you to a gastroenterologist for a thorough evaluation, including a colonoscopy to rule out colon cancer, which can cause constipation and straining. You may also have pressure testing of the rectum known as manometry.

Treatment

Treatment

Pelvic organ prolapse (POP) is not a dangerous medical condition. Treatment options range from doing nothing and observing your condition over time to surgery to correct the prolapse. The choice of treatment typically depends on how your POP affects your quality of life, on your overall health and on your physician's expertise.

Nonsurgical options

  • Observation. If you're not having symptoms, or your symptoms are not interfering with your quality of life, you should choose a wait-and-see approach. Every year, you undergo a complete examination to evaluate your POP. Just make sure you contact your health care professional if your condition changes during the year. If you have no symptoms, treatment cannot improve your quality of life and should be avoided.

  • Addressing symptoms. Another option is to address any symptoms you have without actually "fixing" the underlying prolapse. For instance, if you're experiencing urinary or fecal incontinence, your doctor may recommend Kegel exercises (described below) or medication. If you are constipated and straining with bowel movements, then changing your diet, adding fiber supplements or taking medications such as laxatives may help.
    • Kegel exercises. These exercises strengthen your pelvic floor, which can help strengthen your organs in the pelvic region and may relieve pressure from prolapse. To make sure you know how to contract your pelvic floor muscles correctly, try to stop the flow of urine while you're going to the bathroom. If you can do this, you've found the right muscles. But do not do the actual exercises while stopping the stream of urine or you may develop a voiding dysfunction.

      To do Kegel exercises, empty your bladder and sit or lie down. Contract your pelvic floor muscles for three seconds, then relax for three seconds. Repeat 10 times. Once you've perfected the three-second contractions, try doing the exercise for four seconds at a time and then resting for four seconds, repeating 10 times. Gradually work up to keeping your pelvic floor muscles contracted for 10 seconds at a time, relaxing for 10 seconds in between. Aim to complete a set of 10 exercises, three times a day.
  • Pessaries. Pessaries are diaphragm-like devices placed in the vagina to support the pelvic organs. They are commonly used in women with POP to reduce the frequency and severity of symptoms, delay or avoid surgery and prevent the condition from worsening.

    Most pessaries are made from silicone, plastic or medical-grade rubber. Silicone is probably best, since it is nonallergenic, doesn't absorb odors or secretions, can be repeatedly cleaned and is pliable and soft. You typically remove the pessary at bedtime and replace it in the morning, although you can arrange to remove it less often or have it removed and cleaned at your doctor's office. Most doctors prescribe vaginal estrogen with a pessary in postmenopausal women to prevent any irritation of the vaginal walls.

Surgery

An estimated 11 to 19 percent of women will undergo surgery for POP or urinary incontinence by age 80 to 85. The goal of surgery for POP is to improve your symptoms by addressing the underlying cause. Surgery can be reconstructive, which corrects the prolapsed vagina while maintaining or improving sexual function and relieving symptoms, or obliterative, which moves the organs back into the pelvis and partially or totally closes the vaginal canal.

Surgery may involve repairs to any pelvic organs, including the various parts of the vagina, the perineum (the region between your vagina and anus), bladder neck and anal sphincter (anus). The goal of surgery is to reposition the prolapsed organs and secure them to the surrounding tissues and ligaments. Sometimes synthetic mesh is used to hold the organs in place.

Although hysterectomy is still commonly performed in women with symptomatic POP, several other surgical procedures are available. Which your doctor recommends depends on your condition and the specific type of prolapse. Surgeries can be performed through an abdominal incision, vaginally or laparoscopically, with or without robotic assistance, through small incisions in your belly.

Studies find that the vaginal or laparoscopic approach results in fewer wound complications, less postoperative pain and shorter hospital stays than with open abdominal surgery. Today, a large number of POP surgeries are performed vaginally, laparoscopically or robotically. However, all forms carry a risk of relapse.

In terms of the surgery itself, procedures vary depending on the type of prolapse. In most cases, surgery for POP is performed under general or regional anesthesia (epidural or spinal), and patients may stay in the hospital overnight.

Here's an overview of the surgical procedures used to treat the various forms of POP:

  • Rectal prolapse (rectocele). Surgery to repair a rectocele, or prolapse of the rectum, is performed through the vagina. The surgeon makes an incision in the wall of the vagina and secures the rectovaginal septum, the tissue between the rectum and the vagina, in its proper position using the patient's connective tissue. The opening of the vagina is tailored to the appropriate dimension, and extra support is reinforced between the anal opening and the vaginal opening.
  • Bladder prolapse (cystocele). Surgery to correct bladder prolapse, or cystocele, is usually performed through the vagina. The surgeon makes an incision in the vaginal wall and pushes the bladder up. He or she then uses the connective tissue between the bladder and the vagina to secure the bladder in its proper place. If urinary incontinence is also a factor, the surgeon may support the urethra with a sling made out of a special nylon like material.
  • Prolapse of the uterus (uterine descensus).In postmenopausal women or women who do not want more children, prolapse of the uterus is often corrected with a hysterectomy. In women who want more children, a procedure called uterine suspension may be an option. Some doctors now use laparoscopic surgery or vaginal surgery to repair the ligaments supporting the uterus so that hysterectomy is not necessary. This operation requires only a short hospital stay, has a quicker recovery time and involves less risk than a hysterectomy. The long-term results, however, are still being studied, so talk to your health care professional about what's right for you. If you have heavy bleeding or other uterine problems, you may want to consider hysterectomy, but if there are no other problems than prolapse, the ligament repair may be preferable. Generally, surgery for prolapse is not recommended until after you have completed childbearing because pregnancy can make it worse.
  • Vaginal vault prolapse and herniated small bowel (Enterocele). Vaginal vault prolapse and herniated small bowel often occur high in the vagina, so surgery to correct the problems may be done through the vagina or the abdomen. There are a number of surgical procedures used to treat these forms of POP. The most common involves vaginal vault suspension, in which the surgeon attaches the vagina to the sacrum. This can be done through an incision in the abdomen, by laparoscopy (belly button surgery) or via robotic surgery. Robotic surgery takes many hours but accomplishes the surgery without a big incision. In the past, these surgeries have sometimes involved the placement of nylon mesh to suspend the vagina.

    However, in July 2011, the FDA issued a warning concerning the use of vaginally placed mesh to repair POP, stating that the surgical vaginal placement of mesh may expose patients to greater risk than other surgical methods including the abdominal placement of mesh, and that there is no evidence that surgeries involving mesh lead to better outcomes. Be sure to talk with your health care professional about the best approach for you.

Prevention

Prevention

Preventing pelvic organ prolapse (POP) begins in your teens. Get in the habit of practicing Kegels or pelvic tilts as done in yoga several times a day, until doing them becomes as routine as brushing your teeth.

When you get pregnant, make sure you're aware of the risks and benefits of a forceps delivery in case one is necessary. A forceps delivery creates a very high risk for incontinence and prolapse. Talk to your health care professional about the options of a vacuum delivery or a cesarean section.

Maintaining a healthy weight and quitting smoking may also help prevent pelvic floor problems, including POP.

You should also avoid straining during bowel movements and when lifting heavy items, and if you have a chronic cough, get it checked out. Chronic coughing creates the kind of straining that can lead to POP.

Facts to Know

Facts to Know

  1. Pelvic organ prolapse (POP) occurs when one or more organs in your pelvis—your uterus, urethra, bladder urethra bladder or rectum—shifts downward and bulges into your vagina. In the United States, about 24 percent of women have some for of POP.

  2. Pelvic organ prolapse is poised to become much more common in the United States and other Western countries with the aging of the Baby Boomers.

  3. Symptoms of POP include a feeling of pelvic fullness or pressure; feeling as if a tampon were falling out; incontinence; uncomfortable intercourse; pelvic pain (not menstrually related); lower back pain; and difficulty getting stools out. However, many women don't have any symptoms.

  4. Causes of POP include pregnancy, childbirth, aging, obesity and menopause. Straining with bowel movements, lifting heavy items and chronic cough can also contribute to POP. In some cases, hysterectomy can increase the risk, while a cesarean section may reduce it. The condition also has a genetic component.

  5. Urinary symptoms are the most common symptoms associated with POP. These include feelings of urgency, frequent urination, urinary incontinence or difficulty urinating.

  6. Diagnosing POP begins with a complete medical history and physical examination, including an internal exam and an anal examination. Tests to evaluate the health of your urinary system and bladder may be performed.

  7. There are four stages of POP, ranging from 0 (no prolapse) to 4 (total prolapse).

  8. There are several types of POP, including bladder prolapse, or cystocele; rectal prolapse, or rectocele; uterine prolapse, or uterine descensus; and vaginal vault prolapse.

  9. Treatment for POP depends on the type of prolapse. Treatment options range from doing nothing and observing your condition over time to surgery to correct the prolapse.

  10. Kegel exercises help strengthen your pelvic floor and may relieve pressure from prolapse. They are an excellent way to treat and prevent POP.

Questions to Ask

Questions to Ask

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

  1. What type of POP do I have? Do I have more than one type?

  2. What treatment do you recommend to treat my prolapse?

  3. What is the success rate of the treatment you recommend? What are the benefits and potential risks?

  4. Can you treat my prolapse, or do I need a referral to a physician who regularly treats patients with my condition, such as a urogynecologist?

  5. How many patients with prolapse do you see a month?

  6. How many procedures do you perform monthly to treat prolapse?

  7. What are my treatment options if I still want to have children?

  8. Will treatment affect my sexual function?

  9. Where is this procedure usually performed and how?

  10. How soon after treatment can I return to my daily activities?

Key Q&A

Key Q&A

  1. If I have stress incontinence, does that mean I have pelvic organ prolapse (POP)?

    No, you can have stress incontinence without having POP. However, stress incontinence is usually related to some weakness in the pelvic floor. It often occurs in conjunction with POP.

  2. My doctor says I have some bladder prolapse, but I don't have any symptoms. How is that possible?

    Pelvic organ prolapse can be mild to severe and often doesn't have any symptoms. If you don't have any symptoms, you don't have to do anything if you don't want to, although incorporating pelvic floor exercises into your daily routine to strengthen your pelvic region is a good idea.

  3. I've been diagnosed with POP. Do I need surgery?

    That depends on your personal condition. If you don't have any symptoms and your condition is manageable with lifestyle changes, then you don't need surgery. Surgery is not foolproof; the prolapse could recur. So try to avoid surgery until your activities of daily living are affected. If you are scheduling your life around your prolapse symptoms, it is time to address them.

  4. I'm not sure if I'm doing Kegel exercises properly. How can I tell?

    A physical therapist or biofeedback expert is your best option when it comes to ensuring that you're doing Kegels properly. Physical therapists can give you vaginal cones that you place in your vagina. The squeezing pressure you use to keep the cone in the vagina teaches you which muscles to use for Kegels. Biofeedback can also be used to teach you which muscles to exercise. Talk to your health care practitioner about a referral to a physical therapist or a nurse practitioner with this expertise. There also are electrical stimulators that can help to identify and contract the correct muscles.

  5. I think I might have vaginal prolapse. Which doctor should I see?

    While your gynecologist can most likely manage your condition, you might also consider seeing a urogynecologist, a gynecologist who specializes in the care of women with pelvic floor dysfunction.

  6. What is the best type of surgery for POP?

    Again, that depends on the type of prolapse you have and your surgeon's comfort level with various surgical techniques.

  7. Is there any way to prevent POP?

    Maintaining a healthy weight is important, since there is evidence that being overweight significantly increases your risk of POP. Also, straining when you go to the bathroom, lifting heavy items and chronic cough can contribute to POP.

  8. What are the risks involved in not repairing POP?

    Generally, none. POP won't shorten your life or lead to other health conditions. In some situations, the prolapsed organs can irritate the vaginal wall, creating ulcers. The greatest risk is that it creates genital, urinary and rectal problems that significantly affect your quality of life. The only emergency situation is if the uterus descends to such a degree that the bladder cannot empty and acute urinary retention occurs. This is rare but requires immediate medical attention.

Organizations and Support

Organizations and Support

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

American Association of Gynecologic Laparoscopists (AAGL)
Website: 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)
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 Society for Reproductive Medicine (ASRM)
Website: http://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: asrm@asrm.org

American Urogynecologic Society
Website: 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
Website: 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)
Website: 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

Society of Interventional Radiology
Website: 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

The Incontinence Solution: Answers for Women of All Ages
by William Parker, Amy Rosenman, and Rachel Parker

Pelvic Organ Prolapse: The Silent Epidemic
by Sherrie Palm

Medline Plus: Pelvic Support Problems
Website: http://www.nlm.nih.gov/medlineplus/spanish/pelvicsupportproblems.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Last date updated: 
Tue, 2011-11-15

What is it?

Overview

What Is It?
Colon cancer is cancer of the large intestine or the rectum, and is often called colorectal cancer.

Colorectal cancer is one of the most common cancers in the United States. About one in 20 people will develop cancer of the colon or rectum in their lifetimes. It also is the second leading cause of cancer deaths when men and women are considered together and is the third leading cause of cancer death among women.

There are regional differences in colorectal cancer's incidence and mortality throughout the country, with the lowest rates occurring among those living in Western states, and survival rates lowest among African Americans.

The good news is that the disease is not only highly beatable and treatable, but also highly preventable. Regular screening and removal of polyps can reduce colorectal cancer risk by up to 90 percent. But unfortunately, fear, denial and embarrassment keep many people from being screened.

When colon cancer is caught and treated in stage I, there is a 74 percent chance of survival at five years. Once the cancer is larger and has spread to the lymph nodes, however, the five-year survival rate drops to 46 percent. If the cancer has already spread to distant parts of the body such as the liver or lungs, the five-year survival rate goes down to 6 percent.

The large intestine is the last section of the digestive tract and consists of the colon and rectum. The colon is four to six feet long, and the last seven to nine inches of it is called the rectum. After food is digested in the stomach and nutrients are absorbed in the small intestine, waste from this process moves into the colon, where it solidifies and remains for one or two days until it passes out of the body.

Sometimes the body produces too much tissue, ultimately forming a tumor. These tumors can be benign (not cancerous) or malignant (cancerous). In the large intestine, these tumors are called polyps. Polyps are found in about 30 percent to 50 percent of adults. People with polyps in their colon tend to continue producing new polyps even after existing polyps are removed.

There are several types of polyps, the most common being hyperplastic polyps, adenomatous polyps, sessile serrated polyps and malignant polyps. Hyperplastic polyps are typically not precancerous. Adenomatous polyps (also called "adenomas") and sessile serrated polyps may undergo cancerous changes, becoming adenocarcinomas. Malignant polyps are already cancerous.

Colon cancers develop from precancerous polyps that grow larger and eventually transform into cancer. It is believed to take about 10 years for a small precancerous polyp to grow into cancer. Therefore, if appropriate colorectal cancer screening is performed, most of these polyps can be removed before they turn into cancer, effectively preventing the development of colon cancer.

Besides adenocarcinomas, there are other rare types of cancers of the large intestine, including carcinoid tumors typically found in the appendix and rectum; gastrointestinal stromal tumors found in the connective tissue of the colonic or rectal wall; and lymphomas, which are malignancies of immune cells that can involve the colon, rectum and lymph nodes.

Risk Factors

The exact cause of colon cancer is unknown, but it appears to be influenced both by hereditary and environmental factors. People at an increased risk of colon cancer include those with either a personal or family history of colorectal cancer or polyps, individuals with a long-standing history of inflammatory bowel disease and people with familial colorectal cancer syndromes. Some of those at high risk may have a 100 percent chance of developing colorectal cancer.

Specific risk factors include:

  • Personal History: A personal history of colorectal cancer, benign colorectal polyps which are adenomas or sessile serrated polyps, or chronic inflammatory bowel disease (e.g., ulcerative colitis and Crohn's disease) puts you at increased risk for colorectal cancer. In fact, people who have had colorectal cancer are more likely to develop new cancers in other areas of the colon and rectum, despite previous removal of cancer.
  • Heredity: If one of your parents, siblings or children has had colorectal cancer or a benign adenoma, you have a higher risk of developing colorectal cancer. If two or more close relatives have had the disease, you also have an increased risk; approximately 20 percent of all people with colorectal cancer fall into this category. Your risk is even greater if your relatives were affected before age 60 or if more than one close relative is affected.

    Additionally, there are two genetic conditions—familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC)—that lead to colorectal cancer in about 5 percent of patients.

    • Familial adenomatous polyposis (FAP). People who have inherited the FAP syndrome may develop hundreds to thousands of polyps in their colon and rectum at a young age, usually in their teens or early adulthood. These polyps are all adenomas. By age 40, almost all patients with FAP will develop colon cancer if they don't have preventive surgery. Most people who have this syndrome begin annual colon examinations while in elementary school, and many choose to have their colon and rectum removed before cancer develops. FAP is rare, accounting for about 1 percent of all cases of colorectal cancer.
    • Hereditary non-polyposis colon cancer (HNPCC). Also known as Lynch Syndrome, HNPCC is a more common form of inherited colon cancer, accounting for about 3 percent to 5 percent of all colorectal cancer cases. While it is not associated with thousands of polyps, polyps are present and grow more quickly into cancer than in patients without HNPCC. Colon cancer in people with HNPCC also develops at a younger age than sporadic colon cancer, although not as young as in those with FAP.

      Cancers in patients with HNPCC tend to be fast growing and respond less to chemotherapy. The lifetime risk of colon cancer in people with HNPCC may be as high as 80 percent. People with HNPCC are also at an increased risk for other types of cancer, including cancer of the ovary, uterus, stomach, kidney and bladder.

    • MUTYH-associated polyposis (MAP): People with this syndrome, which is caused by mutations in the gene MUTYH, develop colon polyps that are destined to become cancerous if they are not removed. Their colonoscopy findings may be similar to FAP with hundreds to thousands of polyps or not. People with MUTYH are also at increased risk of cancers of the small intestine, skin, ovary and bladder.

There are some additional rare genetic mutations associated with colon cancer. These include Turcot syndrome, an inherited condition in which people are at an increased risk of adenomatous polyps (and thus, colon cancer) and brain tumors, and Peutz-Jeghers syndrome, a condition that leads to freckles around the mouth and sometimes on the hands and feet, as well as large polyps in the digestive tract and an increased risk of colon and other cancers at a young age.

In addition, there are several gene mutations found in Jews of Eastern European descent (Ashkenazi Jews) that increase colon cancer risk. The most common mutation, which is called the I1307K APC mutation, is found in 6 percent of American Jews.

If you have a history of adenomas or colon cancer or suspect you have a family history of the disease, you should discuss this with your health care professional because you may need to begin screening for the disease at a relatively young age. In some cases, you may wish to undergo genetic testing.

  • Age: The risk of colorectal cancer increases with age. Ninety percent of new cases of colorectal cancer in the United States are in people over 50. Clinical studies indicate that when screened for the disease, African Americans tend to be diagnosed with colorectal cancer at a younger age than Caucasians.
  • Race: African Americans are more likely to get colorectal cancer than any other ethnic group. Compared to Caucasians, African Americans are about 10 percent more likely to develop colorectal cancer. Unfortunately, they also are more likely to be diagnosed in advanced stages. As a result, African Americans are more likely to die from colon cancer than Caucasians. In 2007, the rate of death from colon cancer among African Americans was 44 percent greater than that among whites.
  • Diet: Eating a diet high in processed meats (hot dogs and some lunch meats) and red meats (lamb, beef or liver) may increase your risk of developing the disease. Avoiding red meat and eating a low-fat diet rich in vegetables, fruit and fiber (e.g., broccoli, whole grains and beans) may reduce your risk of developing colorectal cancer. Some studies suggest that boosting calcium intake helps prevent colon cancer. Until further studies are done, men should keep their intake below 1,500 milligrams because of the increased risk of prostate cancer associated with high levels of calcium. Some research has also shown that vitamin D, which you can get from foods, sun exposure or a pill, can help lower colon cancer risk, but because of the increased risk of skin cancer with sun exposure, most health care professionals don't advocate getting more sun to reduce colorectal cancer at this time. Other studies suggest that taking a multivitamin that contains folic acid may lower colon cancer risk, but more study is needed in this area. There is some research suggesting that a diet high in magnesium may decrease colon cancer risk, especially in women. More research is necessary to find out if this link exists.
  • Lifestyle: Regular exercise is a key weapon in the fight against colorectal cancer. Another significant risk factor in colorectal cancer is smoking. Get help quitting if you can't do it on your own. And keep your alcohol intake to one drink a day or less (two drinks a day or less for men).
  • Obesity: Obesity is an epidemic in the United States and has been associated with many types of cancers, including colorectal cancer. There is a strong link between higher BMI (body mass index) and waist circumference and colon cancer risk in men and a weaker association seen in women. High levels of insulin and insulin-like growth factor may play a role in development of colon cancer in obese people. Weight loss has been shown to reduce the risk of colon cancer.

Screening Tests

The American Cancer Society recommends all women and men over the age of 50 who are at average risk of colorectal cancer undergo one of the following:

  • A fecal occult blood test once a year. This test detects microscopic amounts of blood in the stool and only detects tumors that are bleeding. This must be performed on three separate bowel movements, and you should avoid nonsteroidal anti-inflammatory medications (NSAIDS) for seven days and vitamin C and red meat for three days before collecting the stool samples. Your health care professional provides the necessary materials to collect the stool specimens for simple testing at home or in the office. The stool should be collected before it is in the toilet water. A wooden stick is used to smear a small sample of stool onto the slots in the test card. You will get three test cards, which, when completed, you return to your health care professional. Your health care professional may recommend this test earlier than age 50 or more frequently if you are at high risk for colon cancer and/or polyps.
  • A flexible sigmoidoscopy every five years. This examination allows the health care professional to inspect the rectum and lining of the left colon with a thin tube with a light and camera on the end. To prepare for the test, you may be asked to follow a special diet (such as drinking only clear liquids) for a day before the exam and to use enemas or laxatives to clean out your colon. The sigmoidoscope is inserted into the rectum while you lie on your left side. Sedative medication is not usually given for this procedure. This test is both diagnostic and therapeutic. However, it can only detect polyps or cancer accurately in the last two feet of the large intestine. Unfortunately, the sigmoidoscopy visualizes less than half the colon and misses about half of cancers and polyps that are close to becoming cancer in the first two to three feet of the colon.
  • Fecal Immunochemical Test (FIT) every year. Similar to FOBT, FIT is a stool test that also detects hidden blood (occult) in the stool and must be performed every year. However, it tests for hidden blood in a different way than FOBT and has fewer false positive results. Some forms of FIT only require two stool specimens versus three for the FOBT, and neither vitamins nor foods will affect FIT results (these things can affect results of a FOBT); therefore, no dietary restrictions are necessary prior to collecting the stool samples. You perform the test in a similar manner as the FOBT. Similar to FOBT, the FIT test will not detect a tumor that is not bleeding, so a colonoscopy may be necessary for further screening or if cancer is suspected.
  • Stool DNA at an uncertain frequency (manufacturer recommends every five years). A new screening approach, this test is available but not yet certified by the FDA. This test detects abnormal DNA shed by tumor cells into the stool and requires an entire stool sample. Studies are under way to determine how often the test should be done and how to increase its accuracy.
  • A double contrast barium enema every five years. This test involves injecting barium (a liquid imaging agent that shows up during an X-ray) through the rectum into the colon, then taking X-rays of the colon. A health care professional injects the thick, chalky liquid through a small tube inserted into your anus. You may feel an urge to move your bowels, but should hold on while the X-rays are taken. After the X-rays finish, you can expel the liquid. To avoid becoming constipated afterward, you should drink plenty of fluids to flush the barium from your system. While the procedure can be uncomfortable, it is not usually painful. This test is only a diagnostic test. If abnormalities show up, a colonoscopy must be performed. The barium enema is not a very sensitive test and misses half of polyps that are larger than 1 centimeter.
  • A colonoscopy every 10 years. Similar to the flexible sigmoidoscope, the colonoscope is a longer thin black tube that allows the health care professional to examine the entire large intestine. Preparation for the procedure requires drinking a laxative the day before the colonoscopy. Adequate preparation is critically important to enable the physician to visualize the entire lining of the colon. Leftover stool obscures the view of that portion of the colon and could lead to missing lesions. The ACS recommends getting a colonoscopy starting at age 50 for the average-risk person or if a FOBT or FIT shows blood in the stool. You typically receive a mild sedative during the procedure, so you should experience minimal discomfort. The procedure itself typically lasts 20 to 30 minutes.

    This test is both diagnostic and therapeutic. It detects polyps and cancers found anywhere in the colon. Any polyps or other growths found during this examination are usually removed and sent to a laboratory for examination. Medicare now covers this procedure every 10 years for people over 50 who are considered average risk for developing colon cancer and every two years for people at high risk. Women and men over 50 should have a colonoscopy at least every 10 years. The American College of Gastroenterology recommends that African Americans, who tend to develop the disease at a younger age than other races, begin getting screening colonoscopies at age 45.

  • CT colonography (virtual colonoscopy) every five years. This is a relatively new technique that uses a CT scan to create a three-dimensional image to evaluate the colon. It does not allow for a biopsy (tissue sampling) or polyp removal if any abnormalities are found. You must take a laxative the day before this test, similar to a colonoscopy, and if any abnormalities are found, you must undergo a colonoscopy. Most insurance companies do not cover virtual colonography as screening for colorectal cancer.

Most women find sigmoidoscopies and colonoscopies much more tolerable than they expect. Worrying about the process and undergoing the necessary preparation beforehand are often more unpleasant than the exam itself. Of the above-mentioned tests, colonoscopy is the preferred screening/prevention test, and FIT is the preferred test for patients who decline invasive cancer prevention tests.

Other tests that your health care provider might perform include:

  • Digital rectal examination (DRE). Your health care professional inserts a gloved finger into the rectum to feel for any abnormalities. This simple test, which may be uncomfortable but usually is not painful, can detect many rectal cancers. However, even the longest of fingers are far too short to examine the full length of the large intestine. For this reason, other tests and examinations, such as the FOBT, flexible sigmoidoscopy and colonoscopy must be used. The rectal exam is not sufficient to screen for colon cancer.
  • Genetic testing. The few hereditary cancer syndromes mentioned here are rare but are associated with mutations in specific genes. These mutations can be passed on to other family members. Thus, if your family is affected or may be affected by one of these syndromes, you may need to undergo genetic testing. If genetic testing and counseling are done properly, lives can be changed dramatically, both in terms of preventing colon cancer and lessening the psychological impact of knowing you are predisposed to the disease.

    Genetic testing for colon cancer raises many scientific and ethical issues. Although tests are available to identify the mutations that may predispose you to colon cancer, they are not absolutely positive predictors. Additionally, some health care professionals are not yet fully educated about the tests and may misinterpret the results.

    Thus, if you have a strong family history of colon cancer, you should be seen at a genetic screening center. Talk to your health care professional about the genetic screening process and how to locate such a center.

If there is a reason to suspect that you have colorectal cancer, your health care professional will take a complete medical history and perform a physical examination as part of an initial evaluation.

Symptoms

Symptoms of colorectal cancer include:

  • Change in bowel habits (diarrhea, constipation or narrow stools for more than a few days)
  • Urgency for a bowel movement or feeling like you need to move your bowels even if you just did
  • Blood in the stool
  • Stomach pain
  • Weakness and/or fatigue

Contact your health care professional if you experience one or more of these symptoms.

Diagnosis

Diagnosis

Because the symptoms of colon cancer are vague and typically occur late in the development of the cancer, a variety of tests are used to both screen and diagnose the disease. Screening tests look for disease in those who look and feel healthy, ideally catching the disease as early as possible or, in the case of colon cancer, even before the precancerous lesion has turned into cancer. Diagnostic tests look for the cause and determine the extent of the disease in someone who has obvious symptoms.

A bowel preparation is often required before many of these tests, especially a colonoscopy. This involves cleaning out your bowel the night before the test with a laxative solution. It is important that the bowel be clean so the physician performing the colonoscopy gets the best look at your colon. Since some preparations can affect your blood level for certain electrolytes, your health care professional will tell you which preparation to use for your procedure.

Diagnostic Tests

  • Flexible sigmoidoscopy or colonoscopy. Sigmoidoscopy is a procedure that allows a physician to view the lining of the rectum and the lower part of the colon. This area accounts for less than one-half the total area of the rectum and colon. If a mass or any other types of abnormalities are seen through the flexible sigmoidoscope or colonoscope, a sample (biopsy) is taken for further examination by a pathologist to determine if it is cancerous or benign.

  • Complete blood count (CBC) and blood chemistry. The CBC determines whether you are anemic because many people with colorectal cancer become anemic due to prolonged bleeding from the tumor.

  • Computed tomography (CT). In this test, a rotating X-ray beam creates a series of pictures of the body from many angles, helping visualize any masses that may indicate that the colon cancer has spread to your liver or other organs.

  • Magnetic resonance imaging (MRI): Like CT, magnetic resonance imaging displays a cross-section of the body. However, MRI uses powerful magnetic fields and radio waves instead of radiation.

  • Chest x-ray. This familiar imaging test detects if colorectal cancer has spread to the lungs.

  • PET scanning: This test can determine if certain cells are using glucose more than other cells. Cancer cells, which are actively dividing, use more glucose so they light up on a PET scan. This test is used to follow cancer and can be combined with a CT scan to better localize a possible recurrence. It is important to remember that not all tumors will be responsive to PET/CT imaging.

Colorectal Cancer Stages

As with all cancers, there are various stages of colon cancer:

  • Stage 0: Abnormal (dysplastic) cells have been found in the innermost lining (mucosa) of the colon. This stage is also known as carcinoma in situ or intramucosal carcinoma, and there is a very small chance these cells have spread, so this stage is not considered to be invasive cancer.

  • Stage I: Cancer has spread to the inside lining of the colon but hasn't spread beyond the colon wall or rectum.

  • Stage II: Cancer has spread through the colon or rectum and may invade surrounding tissue, but no lymph nodes are involved.

  • Stage III: Cancer has spread to the lymph nodes, but not to distant sites.

  • Stage IV: Cancer has spread to other distant parts of the body, such as the liver or the lung.

Treatment

Treatment

Surgery is often required to treat colorectal cancer. The surgical procedure used depends on where the cancer is located. Most patients who undergo surgery for colon cancer have an open abdominal operation, where the surgeon makes an incision in the abdomen and removes the tumor and any affected lymph nodes. In some cases, however, a procedure called laparoscopic colon cancer resection may be used. Like open abdominal surgery, laparoscopic surgery is performed under general anesthesia, but multiple, much smaller incisions are made, which leads to a shorter recovery time. Studies have shown similar results when open abdominal and laparoscopic techniques are used to remove colon cancer. A surgeon experienced at laparoscopic surgery should perform these surgeries.

Occasionally, early cancerous changes may be limited to a portion of an otherwise noncancerous polyp. In these cases, it is sometimes possible to remove some very early colon cancers during a colonoscopy.

If part of the colon needs to be removed due to a larger cancerous tumor, the surgeon will remove the affected portion and leave as much of the healthy colon behind as possible. In rectal cancer, the rectum is removed.

In many cases, the surgeon will be able to reconnect the healthy portions of the colon and rectum, which allows waste to flow through the colon to the rectum. If this is not possible, you may need to have a colostomy. A colostomy (stoma) involves creating a hole in the wall of abdomen to which an end of your colon is attached so you can eliminate waste into a special bag. Depending on the situation, a colostomy may be temporary or permanent.

You may be referred to an enterostomal therapist (a health care professional, often a nurse, trained to help people with their colostomies) as part of your initial workup. The enterostomal therapist can address concerns about how a colostomy might affect your daily activities.

Even after colon cancer has been completely removed with surgery, cancer cells can remain in the body and cause relapse. To kill these cells and decrease the chances of a relapse, health care professionals use chemotherapy. Not all people need chemotherapy after surgery. Those most likely to receive chemotherapy are people at risk for recurrence, namely, those with stage III colon cancer or high risk stage II.

For some rectal cancers, chemotherapy is given along with radiation therapy in an attempt to shrink the tumor before surgery. This is called neoadjuvant chemotherapy.

Several chemotherapy drugs are used to treat colon cancer. In many cases, two or more of these drugs are combined for more effective treatment:

  • 5-Fluorouracil (5-FU): 5-FU is part of most chemotherapy treatments for colorectal cancer, and it is often given together with another chemotherapy drug called leucovorin (folinic acid). 5-FU may be given through a vein over two hours or as a quick injection followed by continuous infusion via a battery-operated pump over the following one or two days. In most cases, patients get 5-FU every two weeks for six months to a year. Side effects include nausea, loss of appetite, diarrhea, low blood cell counts and sensitivity to sunlight.
  • Capecitabine (Xeloda): A chemotherapy drug in pill form, Xeloda changes to 5-FU once it reaches the tumor and is about as effective as continuous intravenous 5-FU. Patients taking capecitabine usually get it twice a day for two weeks, followed by a week off. Capecitabine is a convenient option to 5-FU because it can be taken at home, but it still has similar side effects.
  • Irinotecan (Camptosar): This drug is often combined with 5-FU and leucovorin in a regimen called FOLFIRI. Irinotecan may also be used by itself as a second-line therapy if other chemotherapy drugs are not effective. It is given intravenously over 30 minutes to two hours. Some people cannot break down irinotecan, which leads to severe side effects like diarrhea and low blood counts. This inability to break down the drug is due to an inherited gene variation that can be tested for, so it is possible to predict how you will react. If you are taking irinotecan and experience severe side effects, call your doctor right away.
  • Oxaliplatin (Eloxatin): For the treatment of advanced colorectal cancer, oxaliplatin is usually given together with 5-FU and leucovorin (known as the FOLFOX regimen) or with capecitabine (known as the CapeOX regimen) as a first- or second-line treatment. It may also be used as adjuvant therapy after surgery for colorectal cancers at earlier stages. Patients take oxaliplatin intravenously over two hours, usually once every two or three weeks. Oxaliplatin may affect peripheral nerves, leading to numbness, tingling and heightened sensitivity to temperature, especially in the hands and feet. In most cases, these side effects go away once patients stop taking the medication, but they can persist. Talk to your doctor about potential side effects before you start taking oxaliplatin.

Individuals with advanced colon cancer may receive targeted drugs that help stop cancerous tumors from growing. These drugs include bevacizumab (Avastin), cetuximab (Erbitux) and panitumumab (Vectibix). They may be given alone or together with chemotherapy.

Not all people benefit from targeted medications. Researchers are currently examining who are most likely to respond. Until then, health care professionals will continue to weigh the risks and benefits of targeted drugs before they prescribe them for people with advanced disease.

Radiation therapy may benefit some people with rectal cancer, but it is not usually used in the treatment of early stage colon cancer. Like chemotherapy, radiation may be helpful for patients who are at high risk of cancer recurrence, for instance if the cancer has spread to nearby organs. In general, the goal of radiation is to reduce chances of colon cancer recurrence rather than to improve survival.

For those whose colorectal cancer has metastasized to a few areas in the liver, lungs or elsewhere in the abdomen, surgically removing or destroying these metastases can increase survival.

If the cancer comes back in only one part of the body, you may need surgery again. If it has spread to several parts of the body, you may receive chemotherapy and/or radiation therapy.

Prevention

Prevention

The most important line of defense against colorectal cancer is screening for colorectal cancer. You should follow the established guidelines for screening procedures so that any precancerous polyps can be removed before they turn into cancer and, if cancer exists, it can be detected at the earliest possible stage. If you are at average risk of colorectal cancer, the American Cancer Society recommends that all women and men over the age of 50 undergo one of the following:

  • annual fecal occult blood test
  • flexible sigmoidoscopy every five years
  • double contrast barium enema every five years
  • colonoscopy every 10 years unless you are African American, in which case your screening can begin at age 45
  • virtual colonoscopy (CT colonography) every five years
  • stool DNA testing, interval uncertain (a new screening approach, this test is available but not yet certified by the FDA)

Any positive screening test should be followed by an appropriate and complete diagnostic evaluation of the colon including a colonoscopy with biopsies, if necessary.

If you are at an increased risk of colorectal cancer or adenomas because of a family history of cancer or polyps, you should follow the above recommendations and also:

  • Begin colorectal screening at age 40, or 10 years before the youngest case of colon cancer in the immediate family.

  • Discuss genetic counseling and/or testing with your health care professional.

If you are at an increased risk for colorectal cancer for a reason other than family history, such as a personal history of inflammatory bowel disease, you may also need to begin screening before age 50. Screening recommendations vary based on your particular risk factors; discuss your individual screening schedule with your health care professional.

Modifying your diet and exercise may help decrease your risk of forming colon polyps and/or colon cancer. A diet rich in vegetables, fruit and fiber and low in fat may reduce the risk of developing colon cancer. Some suggest that increasing intakes of calcium and vitamin D can help prevent colon cancer. (Men should keep their intake below 1,500 milligrams because of the increased risk of prostate cancer associated with high levels of calcium.) Calcium can be found in dairy products, calcium-fortified products such as orange juice, soy and dark green vegetables. Other research has shown that taking a multivitamin containing folic acid (a B complex vitamin) decreases the risk of colon cancer, but more study is needed. There is some research suggesting that a diet high in magnesium may decrease colon cancer risk, especially in women. More research is necessary to find out if this link exists.

Regular exercise is important in preventing colon cancer. Experts say that vigorous exercise is not necessary. Instead, just incorporate more activity into your daily routine, such as taking the steps instead of the elevator or parking your car farther from the building you are entering. Overall, the American Cancer Society recommends 30 minutes of physical activity at least five days per week and says that 45 minutes or more of moderate to vigorous activity five or more days a week may further reduce the risk of colon, breast, uterine and prostate cancers.

It is also advisable to drink alcohol only in moderation (no more than one alcoholic beverage per day for women, for a total of less than seven drinks per week, and no more than two alcoholic beverages for men, for a total of less than 14 drinks per week) and abstain from tobacco use.

Results from multiple studies show that people who regularly take aspirin and other non-steroidal anti-inflammatory medications (NSAIDS) have a lower risk of colorectal cancer and adenomatous polyps. An August 2009 study published in the Journal of the American Medical Association found that aspirin can help prevent colorectal cancer deaths as well. The study looked at 1,279 men and women with colon cancer and found that those who took aspirin regularly after their diagnoses were 30 percent less likely to die from the disease than people who didn't take aspirin. However, the risk of stomach ulcers and other side effects associated with aspirin and NSAIDS may outweigh the benefits. Therefore, experts do not recommend people at average risk of colorectal cancer take NSAIDS as a prevention strategy. Discuss the potential risks and benefits of taking NSAIDS with your health care professional.

Facts to Know

Facts to Know

  1. The American Cancer Society estimates that about 103,170 new cases of colon cancer and 40,290 new cases of rectal cancer will be diagnosed in 2012. Combined, these cancers are predicted to cause about 51,690 deaths during 2012.

  2. While colorectal cancer is the second leading cause of cancer deaths when men and women are considered together and is the third leading cause of cancer death among women, incidence among Caucasians in the United States has been decreasing, perhaps due to improved screening methods. Among African Americans, however, incidence rates have remained relatively stable.

  3. The risk of developing colorectal cancer is highest among those with a family history of colorectal cancer or adenomatous polyps and those who have inflammatory bowel disease.

  4. Except for those with hereditary conditions that may predispose them to developing colorectal cancer relatively early in life, 90 percent of all cases occur after the age of 50.

  5. Tumors that grow in the large intestine are called polyps. A biopsy determines if the polyp is benign (not cancerous) or malignant. Benign polyps can be precancerous (adenomatous and sessile serrated) or not precancerous (hyperplastic). Thirty percent to 50 percent of the population has polyps. Over the course of about 10 years, adenomatous polyps can become cancerous if they are not removed.

  6. Undergoing appropriate screening for colorectal cancer can decrease death rates from this cancer by up to 90 percent. Colorectal cancer screening is designed to detect and remove precancerous polyps (adenomas and sessile serrated polyps) before they turn into cancer and to diagnose cancer at the earliest stages.

  7. If you or a close relative were diagnosed with colon cancer at age 45, then other members of your family should begin screening around age 35. If you have a close relative with colorectal cancer, you should begin screening at the age of 40 or 10 years before the age at which the youngest relative was diagnosed with cancer.

  8. Cancer specialists are using more aggressive strategies to make sure cancer does not return after surgery. You may receive both chemotherapy and radiation therapy to increase your chances of a complete cure. These treatments destroy microscopic accumulations of cancer cells that cannot be seen or removed during surgery.

  9. When colon cancer is caught and treated in stage I, there is a 74 percent chance of survival at five years. Once the cancer is larger and has spread to lymph nodes, the five-year survival rate drops to 46 percent. If the cancer has already spread to distant parts of the body such as the liver or lungs, the five-year survival rate goes down to 6 percent.

  10. You may be able to reduce your risk for colorectal cancer by eating a diet high in fiber and low in fat, getting plenty of exercise, limiting your alcohol intake to one drink or less a day, losing weight if you are obese, taking calcium and having regular colorectal cancer screenings.

Questions to Ask

Questions to Ask

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

  1. What causes colorectal cancer?

  2. How can I reduce my risk for colorectal cancer?

  3. What are the signs and symptoms of colorectal cancer?

  4. What exams or tests will you do during my regular physical to screen for colorectal cancer?

  5. What is the "stage" of my cancer? What does that mean? What does it tell me about how severe my cancer is?

  6. Will treatment be needed before I have surgery?

  7. How long will I be in the hospital?

  8. If I'm in pain, what medication will you give me to make me feel better?

  9. Will I need more treatment after surgery?

  10. If I need chemotherapy after surgery, how soon after my surgery would I start?

  11. What kind of chemotherapy is used for colon cancer?

  12. When is radiation therapy used for colon cancer?

Key Q&A

Key Q&A

  1. My health care professional told me I have polyps. What are these and how will they be treated?

    Colorectal polyps are excess growths of tissue in the lining of your colon or rectum. They can be noncancerous (hyperplastic), precancerous (adenomas or sessile serrated polyps) or malignant (cancerous). All colorectal cancers develop from precancerous polyps. Therefore, if these precancerous polyps are removed during colonoscopy or sigmoidoscopy, they will no longer be able to grow into cancer. Most colorectal polyps are easily removed during colonoscopy without the need for surgery. Once you have polyps, you are at increased risk for developing more polyps in the future and need repeated screening to detect and remove them.

  2. My father and grandmother both had colon cancer. What are my risks and what should I do?

    First, realize the disease is highly curable when diagnosed early. When the cancer spreads to other distant places like the lung or liver, however, the survival rate is less than 10 percent. A family history of colon cancer or adenomatous polyps significantly increases your chances of developing the disease, and the more family members you have with colon cancer, the higher your risk. Make an appointment with your health care professional now to discuss your personal and family health history and to determine the next steps you should take. You will need to have colorectal cancer screening starting at the age of 40 or 10 years before the age at which the youngest relative was diagnosed with cancer. You will probably have regular surveillance of your colon by colonoscopy.

  3. Is there any way to reduce my risks for colon cancer?

    Most important is to ask your health care professional about colorectal cancer screening beginning at age 50 (45 for African Americans) if you are at average risk or earlier if you have family members (such as your father, mother, sister or brother) who had colorectal polyps or cancer. If you undergo appropriate screening for colorectal cancer, you may decrease your risk of death from colorectal cancer by 90 percent. This is because physicians can detect and remove precancerous polyps before they turn into cancer, most effectively by colonoscopy. Research increasingly suggests that a diet high in fiber, fruits and vegetables and low in fat may help reduce your risk for colon cancer. Losing weight if you are obese may decrease your risk of colorectal cancer. Taking calcium and vitamin D may prevent formation of precancerous polyps and colon cancer. And getting regular exercise may help, too.

  4. My health care professional told me my cancer had metastasized and that I had a "met" in another place besides the colon. What does that mean?

    "Met" is short for metastasis, which means the cancer has spread to other parts of the body. Any time your health care professional uses a word you don't understand, stop him or her right there and ask what that word means.

  5. What are my chances of a cure?

    No one really knows if cancer is totally cured. But it is sometimes pushed back so far it never grows again, which is called achieving remission or long-term survival. Your chances of surviving for a long time largely depend on the stage of your cancer at the time of diagnosis and the success of treatments you receive. The earlier the cancer is detected, the higher your chances for long-term survival.

  6. My cancer is pretty advanced. How long have I got?

    Any number that a health care professional gives you is based on estimates derived from experiences with other patients. No one can tell you what your specific chances are. Survival averages are just that: averages.

  7. What can I do about this ongoing pain?

    One of the worst things that cancer patients do is to suffer pain when they do not have to! Discuss your pain with your health care professional so that you can get the relief you need. It might be necessary to see a pain specialist. Most health care professionals can refer you to someone who specifically handles chronic pain problems. If you have severe pain, narcotics may be the best type of medicine.

  8. What caused this? Was it something I did? How long did it take to grow?

    No one is really sure what causes colorectal cancer. It's very unlikely that it was something you did. The tendency to get the disease may be hereditary, that is, it may run in families. A polyp in your colon can take as many as 10 years to become cancerous. Colorectal cancer is difficult to find without regular screening and often does not cause symptoms until it's already well developed. So don't beat yourself up that you didn't "catch" it a few months ago.

Organizations and Support

Organizations and Support

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

American Cancer Society (ACS)
Website: http://www.cancer.org
Address: 250 Williams Street
Atlanta, GA 30303
Hotline: 1-800-ACS-2345 (1-800-227-2345)
Phone: 404-315-1123

American College of Gastroenterology
Website: http://www.acg.gi.org
Address: P.O. Box 342260
Bethesda, MD 20827
Phone: 301-263-9000

American Institute for Cancer Research
Website: http://www.aicr.org
Address: 1759 R Street, NW
Washington, DC 20009
Hotline: 1-800-843-8114
Phone: 202-328-7744
Email: aicrweb@aicr.org

Association of Cancer Online Resources, Inc.
Website: http://www.acor.org
Address: 173 Duane Street, Suite 3A
New York, NY 10013-3334
Phone: 212-226-5525

Cancer Care, Inc.
Website: http://www.cancercare.org
Address: 275 Seventh Ave., Floor 22
New York, NY 10001
Hotline: 1-800-813-HOPE (1-800-813-4673)
Phone: 212-712-8400
Email: info@cancercare.org

Cancer Information and Counseling Line (CICL)
Address: AMC Cancer Research Center
1600 Pierce Street
Denver, CO 80214
Hotline: 1-800-525-3777
Email: contactus@amc.org

Cancer Support Community
Website: http://www.gildasclub.org/
Address: Gilda's Club Worldwide
48 Wall Street, 11th Floor
New York, NY 10005
Phone: 888-GILDA-4-U
Email: info@gildasclub.org

Corporate Angel Network
Website: http://www.corpangelnetwork.org
Address: Westchester County Airport
One Loop Road
White Plains, NY 10604-1215
Hotline: 1-866-328-1313
Phone: 914-328-1313
Email: info@corpangelnetwork.org

Gathering Place
Website: http://www.touchedbycancer.org
Address: The Arnold & Sydell Miller Family Campus 23300 Commerce Park
Beachwood, OH 44122
Phone: 216-595-9546
Email: info@touchedbycancer.org

Mautner Project - The National Lesbian Health Organization
Website: http://www.mautnerproject.org
Address: 1875 Connecticut Ave., NW Suite 710
Washington, DC 20009
Hotline: 1-866-MAUTNER (1-866-628-8637)
Phone: 202-332-5536
Email: info@mautnerproject.org

Memorial Sloan-Kettering Cancer Center, New York
Website: http://www.mskcc.org
Address: 1275 York Ave
New York, NY 10065
Phone: 212-639-2000
Email: publicaffairs@mskcc.org

National Cancer Institute (NCI)
Website: http://www.nci.nih.gov
Address: NCI Public Inquiries Office
6116 Executive Boulevard, Room 3036A
Bethesda, MD 20892
Hotline: 1-800-4-CANCER (1-800-422-6237)
Phone: TTY: 1-800-332-8615

National Coalition for Cancer Survivorship (NCCS)
Website: http://www.canceradvocacy.org
Address: 1010 Wayne Ave., Suite 770
Silver Spring, MD 20910
Hotline: 1-877-NCCS-YES (1-877-622-7937)
Phone: 301-650-9127
Email: info@canceradvocacy.org

National Comprehensive Cancer Network
Website: http://www.nccn.org
Address: 275 Commerce Dr, Suite 300
Fort Washington, PA 19034
Phone: 215-690-0300

Native American Cancer Research
Website: http://www.natamcancer.org
Address: 3022 South Nova Rd.
Pine, CO 80470
Phone: 303-838-9359
Email: info@natamcancer.net

Prevent Cancer Foundation
Website: http://www.preventcancer.org
Address: 1600 Duke Street, Suite 500
Alexandria, VA 22314
Hotline: 1-800-227-2732
Phone: 703-836-4412

Women's Cancer Resource Center
Website: http://www.wcrc.org
Address: 5741 Telegraph Avenue
Oakland, CA 94609
Hotline: 1-888-421-7900
Phone: 510-420-7900
Email: info@wcrc.org

The Colon Cancer Survivors' Guide, Second Edition: Living Stronger, Longer
by Curtis Pesmen

Understanding Colon Cancer
by A. Richard M.D. F.A.C.P. Adrouny

Living With Colon Cancer: Beating the Odds
by Eliza Wood Livingston, David, M.D. Spiegel

Intimacy After Cancer: A Woman's Guide
by Dr. Sally Kydd, Dana Rowett

What to Do If You Get Colon Cancer: A Colon Cancer Specialist Helps You Take Charge and Make Informed Choices
by Paul Miskovitz, Marian Betancourt

National Cancer Institute
Website: http://www.cancer.gov/espanol/pdq/tratamiento/colon/patient
Hotline: 1-800-422-6237
Emails: nciespanol@mail.nih.gov

Medline Plus: Colon Cancer
Website: http://www.nlm.nih.gov/medlineplus/spanish/ency/article/000262.htm
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Family Doctor
Website: http://familydoctor.org/online/famdoces/home/common/cancer/treatment/026.html

Last date updated: 
Tue, 2012-05-15

What is it?

Overview

What Is It?
Bacterial vaginosis (BV) is a condition in which the normal balance of bacteria in the vagina is disrupted and replaced by an overgrowth of certain bacteria. Symptoms may include discharge, odor, itching or irritation, but often there are no symptoms.

Bacterial vaginosis (BV) is the most common of three vaginal infections that fall under the category known as vaginitis. The other two infections are trichomoniasis, a sexually transmitted disease, and the fungal infection commonly known as a yeast infection.

BV is the least understood and most often ignored or misdiagnosed of these conditions. However, it is gaining more attention as more research shows that untreated BV can lead to significant health complications, including premature delivery, postpartum infections, clinically apparent and subclinical pelvic inflammatory disease (PID), postsurgical complications (after abortion, hysterectomy, cesarean section and other reproductive procedures), increased vulnerability to HIV infection and, possibly, infertility. As many as one-third of women in the United States have BV.

BV is now considered a sexually transmitted disease. Women who have a new sex partner or multiple sex partners are at an increased risk for getting BV, although it is occasionally diagnosed in women who have never had sex. Douching also appears to increase the risk of developing BV.

BV has gone by different names in the past, including nonspecific vaginitis and Gardnerella vaginalis vaginitis. BV is simpler to remember, but there is nothing simple about this condition, and it is not harmless, as was once believed.

BV is actually a syndrome resulting from an imbalance in the different types of bacteria in the vagina (also called vaginal "flora"). A healthy vagina has numerous organisms that naturally live there. The vast majority—about 95 percent—belong to a type of bacteria called lactobacillus.

There are several kinds of lactobacillus, at least one of which is responsible for keeping the vagina's pH at normal levels. When these levels become unbalanced, certain microorganisms may overtake the normal flora leading to a low-grade infection that often produces an abnormal vaginal discharge.

Diagnosis

Diagnosis

With many negative outcomes now linked to bacterial vaginosis (BV), it is important that women get tested and treated. But surveys find that the majority of health care professionals don't routinely test for or treat BV. And yet an estimated 29 percent of women aged 14 to 49 and 50 percent of African American women have BV.

The most common symptoms include a discharge and an unpleasant vaginal odor. Women may easily mistake BV for a yeast infection, which is caused by the overgrowth of fungi called Candida albicans. However, BV requires a different treatment, so it is important you get an accurate diagnosis. Additionally, you may have more than one type of vaginitis at the same time, so having a yeast infection doesn't mean you can't also have BV.

Fortunately, a trained health care professional can easily diagnose BV. All it takes is a test to check the level of acidity, or pH, in the vagina. A vaginal pH greater than 4.5 is one sign you may have BV.

Your health care professional will also take a vaginal discharge specimen for examination under a microscope to look for "clue cells"—cells from the vaginal lining that are covered with bacteria. It is important not to douche or use deodorant sprays before a medical exam because these products can make it more difficult to diagnose BV.

In addition to checking the vaginal pH and checking for clue cells, your health care professional may place a drop of 10 percent potassium hydroxide on a vaginal fluid specimen and check the odor. Several commercial tests also are available to diagnose BV. Cultures for Gardnerella vaginalis alone and cervical Pap tests are not accurate methods for diagnosing BV.

The most common symptom of BV is a vaginal discharge similar in consistency and appearance to skim milk. The discharge caused by the infection often has a strong "fishy" odor that may become worse after sex because semen changes the acidic level of vaginal fluids. BV also may cause vaginal itching and irritation. About 50 percent to 75 percent of all women with BV experience no symptoms.

Treatment

Treatment

As with other vaginal infections, the primary goal in treating bacterial vaginosis (BV) is to relieve signs and symptoms of infection. All women with symptoms should be treated.

BV is treated with antibiotics. The most common therapies are metronidazole (Flagyl), and clindamycin (Cleocin). Both metronidazole and clindamycin are available by prescription in oral (pill) form, and metronidazole is available in a gel (MetroGel-Vaginal), and clindamycin is available in a cream (Clindesse) that you insert into the vagina. Generic versions of these antibiotics also are available and effective.

If your symptoms disappear with treatment, you don't have to see your health care professional again. One round of treatment usually works in about 75 percent of cases. However, BV frequently recurs and can be chronic in some women.

Don't drink any alcohol while using metronidazole (either oral or vaginal) because it may make you nauseous and/or lead to severe vomiting. Also, if you're using intravaginal forms of clindamycin, the oil-based medication may weaken latex condoms or diaphragms. Clindamycin may also cause colitis, a potentially life-threatening infection of the colon.

Talk to your health care professional about this risk and be sure to alert him or her if you experience severe diarrhea, stomach cramping or blood in your stool while taking clindamycin or within a few weeks of stopping it. Over-the-counter treatments available for some vaginal infections (Candidiasis, or "yeast" infections) are NOT effective for BV.

While you're being treated for BV, you may be advised not to have sex; if you do have sex, your partner should wear condoms. Treating your male partner isn't necessary, however, since studies find it doesn't help prevent another infection. Female partners may need treatment, however.

Treatment is more complicated for pregnant women. If you've previously delivered a premature infant, you may be tested for BV during your first prenatal visit. If you have the infection, you'll be treated in the earliest part of your second trimester of pregnancy.

Regardless of other risk factors for preterm delivery, all symptomatic pregnant women should be tested and treated. However, most studies show no difference in risk of preterm delivery in asymptomatic women who don't get treated versus those who get treated. Thus, pregnant women with asymptomatic BV don't require treatment.

In any case, pregnant women who are going to be screened should have this done during the first prenatal visit. Pregnant women are usually treated with oral rather than topical (intravaginal) medications.

Prevention

Prevention

Numerous factors may be associated with vaginal infections. Although no single factor has emerged as a primary cause, experts say healthy diets and behavior are the best medicine.

One of the more disturbing aspects of bacterial vaginosis (BV) is that the infection frequently returns after treatment. About 30 percent of women have a recurrence within three months of treatment. While the reasons for recurrent BV are not well understood, long-term maintenance treatment may be recommended for women with frequent recurrences of BV.

However, you should take all prescribed medicines as recommended to decrease the likelihood of recurrence. Continue taking the medicine as you've been directed even if your symptoms disappear.

One cause of recurrent BV may be that even after the harmful bacteria that replaced the "good" bacteria is gone, the "good" bacteria have trouble growing back in the vagina.

Most women with recurrent BV infection respond well to therapies that help maintain the ratio of "good" to "bad" bacteria in the vagina. One such therapy is metronidazole gel (0.75 percent) for seven to 10 days followed by an application twice a week for four to six months.

Here are some tips that may decrease the risk of BV or recurrent BV:

  • Don't douche. Douching upsets the normal pH balance of the vagina.
  • Avoid sexual contact with someone who has a sexually transmitted disease; use condoms if you're uncertain.
  • Avoid local irritants such as bubble baths, harsh soaps, feminine hygiene sprays and deodorant tampons, all of which can affect the normal pH of the vagina.
  • Reduce semen exposure (which can affect the vaginal bacteria balance) by using condoms.
  • Don't smoke.
  • If you develop BV three or more times in a year, talk to your health care professional about alternating medications or using intravaginal metronidazole as a prophylactic for three to six months.

Facts to Know

Facts to Know

1. Half of all African-American women aged 14 to 49 in the United States have BV. This may help explain why African-American women have higher rates of problem pregnancies. The reason for increased BV in this population is not clear.

2. BV is widespread but its prevalence varies widely. BV is the most common cause of vaginitis in women of childbearing age—an estimated 29 percent of women aged 14 to 49 and 50 percent of African American women in that age bracket have BV.

3. BV increases a woman's risk of delivering prematurely or delivering a baby with low birthweight. A National Institutes of Health study found that pregnant women with BV were more likely to deliver a baby with low birthweight than those without the infection. The most common cause of premature birth from BV is premature rupture of membranes.

4. A woman with BV may be more likely to become infected with HIV, the sexually transmitted virus that causes AIDS (acquired immunodeficiency syndrome). Recent studies have shown a relationship between BV and HIV, so health officials now consider BV a risk factor for HIV acquisition, particularly in developing countries where BV is often untreated.

5. Bacterial vaginosis infection disrupts the vaginal ecosystem. Some women infected with BV may have up to 1,000 times more anaerobic bacteria (bacteria that require no oxygen to live) than uninfected women. Once this imbalance occurs, the body has difficulty getting back to normal. Consequently, researchers are looking at natural ways to supplement the "good" bacteria needed to protect the genital tract from infection, and thereby reduce recurrences.

6. Because its symptoms mimic other vaginal infections, BV is often mistaken for a common yeast infection.

7. About 50 percent to 75 percent of women with BV have no symptoms. And yet studies find that as many as one-third of women entering obstetric clinics have a BV infection.

8. Despite adequate treatment, BV recurs in 30 percent of women within three months. Researchers are not sure what makes some women more prone to recurrent BV.

9. The greatest risk factors for BV are having a new sex partner or having multiple sex partners.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about bacterial vaginosis (BV) 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 BV?

  2. Does my male partner need to be treated?

  3. What if I have a female partner? Will she need to be treated?

  4. What difference does it make whether I have BV or a yeast infection?

  5. If I have had BV in the past and am pregnant, should I get tested for BV even if I don't have any symptoms?

  6. How do I identify BV and avoid it in the future?

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

  8. How much douching is excessive?

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

  10. Is BV considered a sexually transmitted infection?

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. If you experience symptoms, such as a change in the color and consistency of vaginal fluid, genital itching or burning, you may have a vaginal infection, which, if left untreated, can lead to health complications.

2. What makes bacterial vaginosis (BV) serious for women who are pregnant?

Studies have shown that women with untreated BV are at higher risk of delivering prematurely or giving birth to a low-weight baby. Not all vaginal infections cause pregnancy problems, but BV is potentially serious and requires attention. Screening and treatment is appropriate for pregnant women with symptomatic BV. Follow-up may be needed during the pregnancy.

3. Are all pregnant women treated for BV?

No. Regardless of other risk factors for preterm delivery, all pregnant women with BV who have symptoms should be treated. However, treating pregnant women who test positive for BV but who don't have symptoms (asymptomatic) is controversial. Generally, pregnant woman with asymptomatic BV don't require treatment.

4. What are my chances of having BV come back?

As many as 30 percent of women who have been treated for BV experience recurrences within 90 days of treatment. Not finishing your prescribed medicine can lead to a recurrence.

5. Why does excessive douching increase the risk of developing BV?

The healthy vaginal ecosystem requires the right balance of bacteria flora. Nearly 95 percent of the vaginal mucous membrane, which protects against bacteria and other pathogens, is made up of healthy bacteria called lactobacilli. These bacteria make natural acids that keep unhealthy bacteria from getting out of hand. Too much douching can disrupt the bacterial balance and lead to infection.

6. Can I treat BV with over-the-counter yeast infection medications?

No. Vaginal creams and suppositories for treatment of "yeast" (Candida) infections do not treat BV.

7. Why is it important to determine what type of vaginitis I have?

BV, trichomoniasis and candidiasis (yeast infection) are caused by different pathogens and must be treated differently. Each type of infection requires a specific treatment, and some infections have more than one cause.

8. What about diagnosing and treating BV in men?

The organisms that cause BV in women can exist in the male urethra. Clinical studies have shown, however, that treating male partners with antibiotics doesn't affect a woman's risk of recurrence or her response to treatment.

Organizations and Support

Organizations and Support

For information and support on coping with Bacterial Vaginosis, please see the recommended organizations 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

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

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

Planned Parenthood Federation of America
Website: http://www.plannedparenthood.org
Address: 434 West 33rd Street
New York, NY 10001
Hotline: 1-800-230-PLAN (1-800-230-7526)
Phone: 212-541-7800

Family Doctor
Website: http://familydoctor.org/online/famdoces/home/women/reproductive/vaginal/234.html

Centers for Disease Control and Prevention
Website: http://www.cdc.gov/std/Spanish/STDFact-Bacterial-Vaginosis-s.htm
Address: Centros para el Control y la Prevención de Enfermedades
P.O. Box 6003
Rockville, MD 20849
Hotline: 1-800-458-5231
Phone: 1-800-232-4636
Email: cdinfo@cdc.gov

Last date updated: 
Wed, 2009-10-28