Non-Menstrual Pain
Understanding pelvic pain as it relates to the temporal relation of the menstrual cycle is important in reaching a diagnosis. Pain occurring unrelated to the cycle is often more perplexing, as the differential diagnosis widens outside the reproductive organs. As previously discussed, common GYN sources of non-menstrual pelvic pain are epithelial ovarian cysts, and the sequalae of endometriosis.
Though, as discussed, physiologic ovarian cysts are present in all women of reproductive age, uterine fibroids, or leiomyomas, are a common finding as well. They are a benign, monoclonal growth of cells from the fibroblasts and smooth muscle of the myometrium. They are classified as submucosal (within the uterine cavity), intramural (within the wall), or subserosal (arising at the serosal surface). They are most commonly asymptomatic55 and in most women should be seen as normal anatomic variants. The prevalence and likelihood of being symptomatic are highly associated with African-American race.56 When symptomatic, they are associated with abnormal uterine bleeding, and for bulk-related symptoms or discomfort. Bulk-related symptoms arise from an enlarged and irregularly shaped uterus, and may put pressure on the bladder, bowel, or vasculature. Though they may increase dysmenorrhea and dyspareunia, acute pain from fibroids is unlikely outside the scenario of torsion of a pedunculated fibroid, or degeneration of a large fibroid that has outgrown its blood supply. Myomas are frequently visualized on imaging and can be assumed to be benign; the incidence of leiomyosarcoma is fortunately low, and such malignancies are not believed to arise out of benign fibroids.57
A variety of complementary and alternative medicine approaches have been proposed for treating uterine fibroids, however there have not been well-constructed trials evaluating these. Traditional Chinese medicine has been modestly successful with certain herbal and acupuncture interventions but these are beyond the reach of most integrative clinicians. Chasteberry, as previously discussed, can decrease symptomatology associated with fibroids, and oral iodine therapy may decrease bulk symptoms due to its anti-estrogenic activity. Indeed, these are reasonable basic interventions, and are commonly offered within our practice. Nutritional intervention toward decreasing inflammatory markers, insulin resistance, and peripheral estrogen conversion, along with micronutrient support are also reasonable long-term interventions, though they may have a nominal effect on acute presentations.
Non-gynecologic pain commonly does present as gynecologic pain. Much as a patient may describe abdominal pain as “my stomach hurts,” pain that is localized to the pelvis is commonly presumed to be ovary or uterine pain. In fact, it may be difficult to convince a patient that their pain is non-gynecologic once they have concluded themselves that their pain is reproductive. The two most common types of pain that can masquerade as gynecologic are those of bowel and bladder.
Left-sided pelvic pain may be just as likely bowel as ovarian. While uterine pain is typically crampy in nature, so too might be the contractile forces of bowel that fills the pelvis. Sharp pain may bely the functional nature of the ovary, such as ovulation or a hemorrhagic corpus luteum, but so too might distension of the bowel be perceived as intermittently sharp. With the sigmoid colon present in the left lower quadrant and bowel occupying more space than the reproductive organs, peristaltic activity and distension are a common source of stimulation to the afferent nerves. This might be easily recognizable if history suggests relief of pain with the passage of flatus, or symptoms associated with constipation or diarrhea. A history of irritable bowel syndrome should raise clinical suspicion, as these patients often have underlying bowel motility dysfunction, and visceral hypersensitivity. Nevertheless, even without this history, sometimes the gut just causes pain. Sometimes biologically active systems cause pain without good reason.
More often than not, it is a high index of suspicion, negative imaging, and a physical examination negative for reproductive focus that leads to a diagnosis of gastrointestinal pain in the pelvis. Pelvic examination might reveal generalized discomfort in the adnexa but no focal pain when palpating the ovary, presence of hard stool in the rectum distending the vagina, palpable stool deep in the adnexa from the sigmoid, or copious spongy bowel palpable in either adnexa. Ultrasound often demonstrates distended bowel that may even obscure imaging of the ovaries.
In this author’s experience, patients are more apt to conclude their pain is gynecologic than GI, as it is more acceptable to ascribe one’s pain to the ovary than it is to flatulence.
Abdominal bloating and distension are commonly believed to be gynecologic. Patients may believe their bloating and distension are actually caused by tremendous swelling of their internal reproductive organs and are sometimes surprised to learn that their organs are of normal size. There is clearly an influence of hormones on gut distension in premenopausal women. Bloating is often cyclic, occurring in the luteal phase and associated with fluid retention. The integrative clinician can address these hormones and their dysregulation with testing. In middle-aged women, it is reasonable to image the pelvis with ultrasound to rule out pathological features associated with ovarian cancer, and sometimes CT scanning of the abdomen is needed to evaluate for partial obstruction or carcinomatosis.
Bloating and distension may be due to conditions causing excessive gas, heightened sensitivity to gaseous distension, or an exaggerated motor response to normal amounts of gas.58 Mechanisms of gut dysfunction may involve dysbiosis of the gut microbiota and interactions with mucosal surfaces, the immune system, enteric nervous system, and central nervous system.59 The integrative clinician may be uniquely qualified to evaluate and treat from this perspective. Differing types of probiotic and nutritional interventions may be of relief to the patient and are well in the purview of the integrative clinician. In fact, the functional medicine approach to nutrition, absorption, and the relative health of the microbiome brings the integrative clinician to the forefront in addressing these issues.
Bladder dysfunction can present more obviously with irritative voiding symptoms, but interstitial cystitis/bladder pain syndrome (IC/BPS) is more common in women than men and can be a source of debilitating pain with a significant impact on quality of life.60 IC/BPS is a frequent comorbidity of endometriosis in women with chronic pelvic pain,61 as well as other chronic pain syndromes such as irritable bowel syndrome, vulvodynia, and fibromyalgia 62 There are usually varying degrees of pain or discomfort with filling of the bladder, relieved by voiding. The symptoms are often gradual in onset and may have begun after a triggering event, such as a urinary tract infection, bladder catheterization, or a fall. The pathogenesis is not well-understood, but, similar to endometriosis, there is a neurologic upregulation of pain sensation. Central sensitization and increased activation of bladder sensory neurons during normal bladder filling may result in bladder pain; the increased sensitivity is present both in the bladder itself, and in increased activity and new pathways within the central nervous system.63 Again, the endocannabinoid system is emerging as integral to the processing and regulation of these pathways, and may hold a key in the management of these chronic pain syndromes.
By understanding IC/BPS as both a local and central response to afferent input, treatment by the integrative clinician can be targeted to both. However, in the absence of specialist training, the initial definitive diagnosis and treatment plan should be made in consultation with a urologist.
