" I have lower right abdominal pain 3 days
each month, 7-10 days before my period. I have had
an internal ultrasound which was negative. Any ideas
what might be causing this? Also the pain mostly happens
at around 1:30-2:30 in the a.m.
My last 2 periods have been 21 days apart. I am 45
years old. Normal light periods lasting around 3-5
days. Usually 24-26 days in-between cycles. No medications.
".
Laurie
Cyclical pain in a reproductive age woman almost
always has something to do with the menstrual cycle.
Any abdominal or pelvic pain occurring monthly should
be examined to see what changes of anatomy and physiology
may be responsible for causing the pain.
Many times the diagnosis of such pain is very difficult
unless diagnostic studies are used or exploratory
surgery such as laparoscopy is performed to look inside
the abdomen. The exact timing of when and how long
the pain occurs in relation to a monthly menstrual
cycle can often be a clue as to what types of pathology
to look for on the imaging studies or surgery.
What would cause pain occurring 7-10 days before
menses each month?
In the week or two prior to menses a corpus luteum
cystic gland forms on one of the ovaries at the site
where an egg was released from that ovary. This is
a hormonally functional gland that produces progesterone
primarily. The gland causes the ovary to become larger
and heavier for a while until the cystic area goes
away when menses starts.
The other main pelvic change in the week or two prior
to menses is that the veins of the pelvis often swell
(dilate) under the influence of progesterone. They
can become like varicose veins of the pelvis and sometimes
will produce a throbbing pain, but which lasts throughout
most of the last week of the cycle.
Since your pain only lasts for 3 days and it does
not start 14 days before your menses but rather 7-10
days, the best guess as to cause would be that the
pain has to do with the enlarging ovary on the right.
You would expect the pain to alternate sides if it
were due to a corpus luteum gland because ovulation
usually alters one month from one ovary and one month
from the other. However we have seen ovulation occur
pretty regularly from only one ovary even though there
appears to be no disease in the other one. Pain occurs
when the enlarging ovary "pulls" on any
adhesions of the ovary to the surrounding tissue or
simply when it stretches the ovarian capsule fairly
rapidly. Adhesions cannot be seen on ultrasound or
any xrays but if you have your pelvic ultrasound during
the 3 days you are having pain, I would expect to
see a cystic area (small) on the right ovary if that
is where you are having pain.
I cannot attach any significance to the pain occurring
in the early morning hours.
My pain occurs mostly at the time of my menstrual
flow and goes away after it is over? Does this mean
I have endometriosis?
At the time of menses, hormone levels fall and uterine
skin lining (endometrium) sloughs. This produces bloody
menstrual tissue called menses as long as the tissue
can exit the body. If there is any blockage to egress,
pain is the result. Several different conditions can
block menstrual egress and thus result in painful
menses:
primary dysmenorrhea (menstrual cramps) - the cervical
opening is not large enough for the volume of menstrual
tissue in a given unit of time so uterine pressure
builds up producing cramps until the tissue gradually
comes out
cervical stenosis - in this case the cervical opening
has some scarring due to past procedures (LEEP, cryosurgery,
conization) rather than just a tightly contracted
cervix found in primary dysmenorrhea
congenital anomalies of the reproductive tract - any
anomaly that blocks outflow of menses
endometriosis - endometrial tissue has implanted in
the peritoneal/abdominal cavity and when the tissue
is sloughed at the end of the month it has no place
to go so it just stays and irritates the pelvic lining
producing pain.
adenomyosis - instead of endometrial tissue being
in the pelvic cavity, little islands of glands have
grown down into the uterine muscle and like endometriosis,
when the tissue is sloughed, it has nowhere to go
and only produces an inflammatory response.
I get pain lasting for a day or two about 2 weeks
after my period. What would cause that?
At midcycle, 2 weeks before or 2 weeks after a menses,
the main physiologic event is ovulation. Most women
are not aware of ovulation but some are on a regular
basis. When noticeable pain happens at midcycle, physicians
often attribute the pain to a small amount of bleeding
that can occur from the site of egg ovulation. Usually
this type of pain alternates from side to side in
different months although it can present consistently
on one side if ovulation seems to favor one ovary.
I get pelvic discomfort lasting for two weeks prior
to my menstrual period. Is this PMS?
If one looks in the pelvis with a laparoscope in the
2nd half of the menstrual cycle in a woman who has
severe PMS symptoms, the most common finding is a
normal appearing pelvis. Sometimes there are large
dilated pelvic veins almost to the point of being
pelvic varicosities. There still is controversy among
physicians as to whether pelvic varicose veins cause
pain. This is also sometimes referred to as pelvic
congestion syndrome.
Newer studies using advanced imaging techniques of
MRI, CAT scans and doppler ultrasound have rekindled
treatment of these large veins to see if pelvic pain
may respond. Embolization of the veins (1, 2) and
even laparoscopic ligation (3) have been used to treat
this pain but as yet there have not been randomized
trials.
Are there other non gynecological of cyclic pelvic
pain?
The above clues as far as timing on pelvic pain and
what that pain is due to are just guidelines. Many
times gynecological conditions will have atypical
timing presentations so that you and your physician
have to always keep in mind the many possible reproductive
causes.
In addition, there can be cyclical pain presentations
from non-gynecological causes. Some of those described
include:
spinal cord disc disease or tumor (4).
irritable bowel syndrome - symptoms can be much worse
around the time of menses (5).
somatic musculoskeletal pain - different muscles and
nerves of the abdominal wall can also present cyclically
(6).
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