The many possible causes of pain ‘down there’

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By By Dr. Judith Reichman

Q: I suffer from pain in my pelvic area. Is it “just cramps” or something worse?

A: It could be cramps, but it could be many other things. The lower third of the abdomen — the pelvis — contains several organs, and pain can start in any of them. Here are some ways to help you and your doctor identify the source and proceed to proper treatment.

Cramping pain before and during your period (dysmenorrhea) is most likely due to the production of uterine prostaglandins. These substances make the smooth muscle of the uterus contract, helping regulate menstrual bleeding.

Some women are very sensitive to these prostaglandins or produce excessive amounts, which leads to the contraction of other smooth muscles, like those in the intestinal walls. This produces diarrhea, nausea, vomiting and flu-like symptoms.

An over-the-counter anti-inflammatory drug, such as ibuprofen or naproxen, may help control the pain. Your doctor can also prescribe birth-control pills, which reduce prostaglandin production during your period.

If this doesn’t work and the pain continues, you could have endometriosis, a condition found in at least 10 percent of women. In this case, endometrial cells in the lining of the uterus grow in aberrant places, such as the outer surface of the uterus, the fallopian tubes, the ovaries and even the bowel. It’s unclear how these cells get to the wrong place, but it might be via lymph and blood vessels, or through retrograde menstruation, where blood seeps upward.

In most cases these cells are expunged by the immune system. But if they are not, the hormones that accompany ovulation can make them grow, bleed and scar the pelvic organs. Endometriosis on the bowel can cause diarrhea or constipation during menstruation.

In many cases, the only way to make a definitive diagnosis is with laparoscopy. Treatment varies. The first line of therapy is the continuous use of birth-control pills to suppress ovarian activity and prevent endometrial cell stimulation.

A more aggressive option is to completely stop ovarian function by inducing temporary menopause with drugs such as Lupron shots or Synarel (a nasal spray). These medications “silence” the pituitary gland so it can no longer cause ovarian production of estrogen and progesterone.

Other therapies include Danazol, a male-like hormone that suppresses ovulation, or Depo-Provera, an injected long-acting progestin that robs the cells of their fluctuating estrogen supply.

Past pelvic infections can also cause scarring and pelvic pain. During ovulation, tiny cysts form in the ovary. As they expand, they tug on the perineum, which is loaded with sensory nerves. Birth-control pills help, as does surgical removal of the scar tissue.

Not all pelvic pain, though, is associated with reproductive organs. You also have a bladder, ureters, a large intestine and small intestine sharing space in the pelvis. Pain can result from an inflammation or improper function of any of these.

If you suddenly develop severe pain near the navel which radiates to the right side, and you also have nausea, vomiting or fever, you may have appendicitis. This is an emergency and requires immediate surgery, lest the infection spread throughout the abdomen.

Intermittent pain and bloating — which worsens after eating or before a bowel movement — along with constipation and diarrhea, might signal irritable bowel syndrome (IBS).

To relieve symptoms, consume small and frequent meals, eat slowly and chew thoroughly, increase your fiber intake, drink plenty of water, limit alcohol and caffeine, and don’t chew gum or suck on candy, both of which stimulate gastric activity.

If these changes don’t help, your doctor may check for infections and prescribe medication for specific symptoms.

Pain during urination, or frequency and urgency of urination, usually signals a bladder infection. This should be treated with antibiotics.

Don’t wait to see what happens. A urinary infection can spread upward to the kidneys (pyelonephritis) causing high fever and severe pain, usually radiating from the pelvis to the side and back. This needs to be treated quickly, often with intravenous antibiotics, to prevent kidney damage.

If your pain is severe, spasmodic and radiating to one side of the back, accompanied by blood in the urine, you may have kidney stones (nephrolithiasis). Women who have known the pain of kidney stones say it is more severe than the pain of labor!

If this occurs, get to an emergency room; you need strong and immediate pain medication. Doctors often take a wait-and-see approach in case you pass the stone. Treatment options include a procedure whereby the stone is retrieved by a special catheter, or a method that breaks up the stone by bombarding it with sound waves (lithotripsy).

If you suffer from constant pelvic aches with periodic flare-ups of intense discomfort, and also have generalized pain and fatigue, you might have fibromyalgia. This is often associated with painful periods, insomnia, irritable bladder and vaginal pain.

Fibromyalgia is difficult and frustrating to diagnose, since standard tests and X-rays are normal. Your doctor may have to rule out other possibilities. Treatment includes sleep medications, lifestyle changes and the judicious use of painkillers, muscle relaxants and antidepressants.

There are other reasons for pelvic pain that I have not included in this already painfully long summary. But this should help you zero in on your symptoms so your doctor can determine which organ is responsible for your pain and start proper treatment.

Dr. Reichman’s Bottom Line: Pelvic pain can result from many conditions, so some detective work often is needed to figure out its cause.

Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," published by William Morrow, a division of HarperCollins.

PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.