What is Adenomyosis?

Adenomyosis is a condition of the uterus in which endometriotic tissue is found within the muscular walls of the uterus. Adenomyosis can be focal or diffuse. Focal adenomyosis also referred to as an adenomyoma, is when a tumorous growth of endometriotic tissue forms inside the muscular uterine walls. More commonly, however, diffuse areas of endometriotic tissue are dispersed through the uterine muscle, most often affecting the posterior (back) wall of the uterus, which can become thickened as a result.

What are the symptoms of adenomyosis?

Symptoms of AdenomyosisAdenomyosis can result in abnormal uterine bleeding (typically heavy and prolonged menstrual flows) and/or severe uterine cramping – “killer cramps.” Sometimes adenomyosis may not cause any symptoms at all. Patients who suffer from adenomyosis often report severe centralized cramping pain that worsens during the menstrual flow and may radiate up to the belly button and/or down to the lower back and into the buttocks and thighs. One reason why pain may radiate is because the uterus is innervated by nerves that run along the uterine ligaments, which lead upwards toward the umbilicus and downwards to the lower back. Some patients have such severe uterine pain that over time they develop second-degree burns over their abdominal area from the prolonged use of heating pads in an effort to sooth their debilitating cramps.

Are endometriosis and adenomyosis related?

There does appear to be a strong association between these two conditions. A subset of women who suffer from endometriosis will also, unfortunately, have adenomyosis to varying degrees and often a clinical challenge in resolving a patient’s pain is to successfully differentiate between the symptoms of endometriosis and adenomyosis. This is why it is important that your doctor assesses both the uterus and the tissue around the uterus separately in order to discern the source of your pain.

Can anything be done about adenomyosis?

Several treatments for adenomyosis are available, both conservative (organ-preserving) and radical (organ removal). Conservative treatments include pain management with non-prescription and prescription pain medications and the use of hormone therapies to suppress the menstrual cycle and either shorten or temporarily stop the menstrual flow. Sometimes a surgical procedure called a presacral neurectomy (PSN) will be performed to sever the nerves that innervate the uterus with the aim of alleviating uterine cramping. This procedure may not be especially effective in patients with adenomyosis however as the disease may result in localized inflammation that extends beyond the uterus itself, affecting surrounding extra-uterine tissues. A PSN has no effect on these surrounding tissues and therefore a portion of the patient’s pain may persist despite the procedure. A PSN also has no effect on abnormal uterine bleeding. In those patients who do not have future plans for fertility or who have completed childbearing, a hysterectomy may be considered. Hysterectomy is the only definitive (curative) treatment for diffuse adenomyosis. If a patient has an adenomyoma (focal adenomyosis) it may be possible to surgically remove the adenomyoma, rather like one might remove a fibroid, while preserving the rest of the uterus. This will depend on the size of the adenomyoma, it’s location and on the skill of the surgeon.

How is adenomyosis diagnosed?

Adenomyosis DiagnosisThe only definitive method of diagnosing adenomyosis is by obtaining a biopsy of the diseased tissue and having a pathologist inspect it under the microscope for the presence of endometriotic tissue. While this may be readily possible if a patient has an adenomyoma, in the case of diffuse adenomyosis, obtaining a biopsy of diseased tissue may not be feasible until after hysterectomy (it would be akin to searching for a needle in a haystack). Endometrial biopsies may confirm a diagnosis of adenomyosis in some cases if the biopsy is sufficiently deep but failing to confirm the diagnosis via this test does not exclude adenomyosis and this is not a routine test for adenomyosis but may be undertaken to exclude other possible causes of abnormal uterine bleeding. In most cases, the diagnosis is suspected based on the patient’s symptoms and on the findings from imaging studies (ultrasounds, CT and/or MRI). Sometimes the uterus may be found to be enlarged and have a “boggy” consistency during laparoscopy, raising a suspicion of possible adenomyosis. If diffuse adenomyosis is subtle, however, it may not be apparent on imaging nor at surgery. The absence of any telltale signs should not exclude adenomyosis as a possible source of uterine pain and the patient’s debilitating uterine symptoms still need to be addressed.

Can adenomyosis affect women of any age?

Adenomyosis is often considered to be a disease that primarily affects middle-aged and older women (30s onwards), especially women who have previously given birth. This bias could, however, be due to the fact that usually only women who have completed their families undergo hysterectomy for the treatment of their uterine pain. Given adenomyosis can almost always only be confirmed via biopsy following hysterectomy, this inevitably leads to the impression that the disease only affects women who have completed childbearing. Furthermore, the symptoms of endometriosis may often overshadow the symptoms of adenomyosis in the early course of the disease, giving the impression that its onset is later. In reality, however, both endometriosis and adenomyosis can affect women of any age, including teenagers.

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Endometriosis can cause an array of symptoms that differ from individual to individual and may worsen over time.

What are the common symptoms of endometriosis?

  • Severe pelvic pain: The pain may be cyclical (worsening around the menstrual flow and ovulation) and/or non-cyclical in nature (constant throughout the cycle). Women describe a burning, throbbing, stabbing pain in different parts of their pelvis. This pain can be even more severe than labor pains and post-operative pain.
  • Pain with sex: Endometriosis can cause pain with deep penetration. This is because the area of tissue just beyond the end of the vagina is commonly affected by the disease, making it exquisitely tender and sore.
  • Pain with urination and bladder pain: If disease is present involving or near the bladder this may result in bladder pain/sensitivity and pain on emptying the bladder. Another common cause of bladder symptoms is interstitial cystitis, a condition that frequently co-occurs with endometriosis.
  • Pain with bowel movements: Endometriosis involving the lowest part of the colon (the rectum) may result in pain with bowel movements during menses (or during the whole month long).
  • Pain prior to bowel movements: Endometriosis involving the colon may result in pain just prior to bowel movements.
  • Cyclical rectal bleeding: If bowel disease has invaded into the bowel wall, the patient may experience cyclical rectal bleeding.
  • Bloating: Bloating may result from the inflammatory response to endometriosis involving the pelvis and bowels.
  • Nausea and vomiting: This may be a symptom of severe pain, of the effect of inflammation on the gastrointestinal tract or more specifically could be a symptom of invasive small bowel disease. Acute vomiting can be a symptom of small bowel obstruction, a rare but serious complication of endometriosis demanding emergency medical intervention.
  • Constipation and diarrhea: Endometriosis near or involving the bowel may result in IBS-like symptoms.
  • Fatigue: Severe fatigue is a non-specific symptom of endometriosis. It is a common symptom experienced by sufferers of chronic illness and pain.
  • Infertility: It has been estimated that 40% of women with endometriosis struggle with fertility problems. Around 20% of women in a healthy population will experience infertility, meaning that in those with endometriosis the risk of fertility problems is doubled. Infertility may be due to adhesions that result from the disease process or from the effect of the disease on the intrauterine environment; endometriotic tissue releases chemicals that may hinder conception and implantation.
  • Shoulder tip pain: Less commonly, if a patient has diaphragmatic endometriosis, she may present with cyclical right shoulder tip pain. Diaphragmatic endometriosis is relatively rare.

Importantly, while endometriosis is associated with a range of symptoms the most common symptom is chronic pelvic pain. You do not have to experience all of these symptoms to have endometriosis. If you are experiencing debilitating pelvic pain this is not normal. It is your body’s way of communicating that something is wrong and you should seek the help of a doctor who is familiar with treating endometriosis and pelvic pain.

How do symptoms differ between patients?

While some patients are relatively symptom-free except for certain times of their cycles (menstruation and ovulation), others are debilitated by pain each and every day of the month. Many women experience a gradual worsening of symptoms over time, both in severity and in the duration of symptoms i.e., the number of days per month they are affected. A common myth is that endometriosis only affects a woman during her period – while this may be the case for some women, for most patients the pain affects them both during and outside their period.

Is endometriosis “just” monster cramps?

Endometriosis is not “just” monster cramps. Severe cramping during the menstrual flow is, in fact, more commonly associated with another gynecological condition called adenomyosis. Adenomyosis is where endometriotic tissue is found inside the muscular walls of the uterus and can cause severe cramping and heavy menstrual bleeding. Adenomyosis often co-occurs with endometriosis and for this reason the symptoms of the two conditions are frequently confused with one another.

Endometriosis does not, however, cause uterine cramps nor abnormal bleeding; these symptoms point to a problem with the uterus whereas endometriosis affects tissue outside the uterus.

What is the impact of these symptoms on a woman’s life?

The symptoms of endometriosis can be truly devastating. They can impact upon all areas of a woman’s life rendering her unable to function.

Teenagers with endometriosis may find that they are forced to miss one or more days of school each month while those in employment may find they are struggling to hold down a job due to the need to take leave on a regular basis for severe pelvic pain. Non-prescription pain medications may fail to alleviate the pain and prescription pain medications may only offer partial relief. Maintaining a sexual relationship may be difficult if not impossible due to severe pain during sex. Pelvic pain may interfere with social events and plans and may prevent a woman from partaking in physical exercise. Understandably, over time the symptoms of endometriosis can lead to social isolation, financial difficulties, relationship breakdown and severe emotional distress. Clearly, it is a disease that needs to be taken very seriously and treated effectively as soon as possible to restore a woman’s quality of life.

If you think you may be suffering from endometriosis, don’t suffer in silence. Take your symptoms seriously by talking to your doctor.

Dr. Andrew Cook and Libby Hopton are awarded the 2014 Carlo Romanini Award by the American Association of Gynecologic Laparoscopists (AAGL) for best video on endometriosis. The winning video was presented at the 43rd AAGL Global Congress in Vancouver, Canada, 2014. The surgery demonstrated the complete excision of full-thickness bladder endometriosis.


A letter from Andrew Cook, MD
Founder and Medical Director of Vital Health Endometriosis Center

My primary focus is helping women with endometriosis and pelvic pain regain their lives. What does this really mean? It means I spend a lot of time with patients, talking with them, helping diagnose their health care issues and performing surgery. It also means I spend quite a bit of time researching better answers to issues faced by women with complex medical issues including endometriosis and pelvic pain.

I am so lucky to have a group of dedicated people that make up Vital Health Endometriosis Center. We are an amazing team of incredibly talented people that have a shared mission to help women suffering from endometriosis. Even though I am “the boss”, I am humbled to be part of this incredible group of people. I believe women with endometriosis are so fortunate and lucky to have Vital Health Endometriosis Center available as an option to them in their medical treatment. Admittedly I am biased, just as a proud parent is of an incredibly talented child.

While I work hard to provide the correct medical care for women to regain their health, Vital Health Endometriosis Center is much more than what I alone have to offer. The combined exceptional talents of the various people at Vital Health Endometriosis Center result in a level of service that I have yet to see anywhere else on the planet. This may sound boastful or egotistical, but I hope to show this comes from a humble respect for the amazing people that make up Vital Health Endometriosis Center.

We are not just a team but more a family of like-minded individuals very determined to change the way women with this horrible disease are treated. We see so much unnecessary pain and suffering. The treatments available right now are effective for the vast majority of patients. We do not claim to have all of the answers and some cases are difficult and challenging. Regardless, we are committed and determined to work together with our patients to solve their health care issues.

I am excited to share the latest news from Vital Health Endometriosis Center. Check out my four other posts from today to read about our wonderful staff additions and accomplishments.

Latest developments at Vital Health Endometriosis Center

Libby Hopton moves to the United States and joins VHI as Director of the Department of Research and Evidence Based Medicine
Ram Gupta joins VHI providing hypnotherapy services to our patients
Dr. Nancy Lowe joins VHI providing Emotional Freedom Technique (EFT) and acupuncture

It’s a great privilege to be a part of such a dedicated team of professionals. I’m excited at the unique opportunity that Vital Health has to offer with regard to research within the field of endometriosis and chronic pelvic pain.

For those of you who know Libby, it will be easy to understand why we have been working with her since September 2013 to help her obtain a work visa here in the United States and join Vital Health Endometriosis Center. She is in the process of moving all the way from The Netherlands to beautiful Los Gatos, California. Margaret has been tirelessly working on this project for the last year, and Libby’s visa was officially approved this month.

For those of you who do not know Libby, she is a young woman who is incredibly gifted in her ability to gather and synthesize data, particularly relating to endometriosis. She is a young woman who has just completed her masters and has also suffered from endometriosis and pelvic pain. […]

Mind and body are not two separate things. Mind and body form a continuum. All emotions in the mind, effect the body and all activity in the body effect the mind. Treating one without the other is like being married without love.

Ram has had an interesting personal journey. He is a very successful Silicon Valley professional, having been in executive management roles in companies like WebMD, PeopleSoft, and Cast Iron systems, and continues to serve as director on the boards of various public and private companies.

But in 2013 life took an interesting turn for him and he came down with severe pain all over his body and specifically in the pelvis. When 9 MRIs, 300+ blood tests, and the best western medical professionals failed to help him, he sought mind medicine with Hypnotherapy, GEMT, and BioEnergy. These therapies brought Ram from the verge of dying back to being healthy.

The epiphany for Ram was that in addition to the physiological and anatomical conditions that western medicine can treat, all pain has a mind component that can only be treated with mind medicine.

Since then, Ram has dedicated himself to learning various mind medicine modalities including Hypnotherapy, GEMT, and BioEnergy from the best teachers in these disciplines. Having lived through such a traumatic experience himself, he has deep empathy for his patients. Ram does not practice mind medicine to earn a living, as he does not need to work for a living. His practice is a mission for him to help as many people as he can.

Nancy LoweDr. Nancy Lowe began her career in holistic health over 30 years ago with an interest in natural foods and nutrition. She became a certified massage therapist, and soon afterward was enrolled at Five Branches University of Traditional Chinese Medicine. She received her acupuncture license in 1987 and is now is a professor at Five Branches University.

In 2008, after two years of rigorous study with many eminent Chinese and American practitioners of Traditional Chinese Medicine [TCM], including study at Zhejiang University of Chinese Medicine in Hangzhou China, she received her Doctorate of Acupuncture and Oriental Medicine [DAOM]. She continues to study energy and herbal medicine as it applies to the body, mind and spirit.

In 2009, Dr. Lowe added Emotional Freedom Techniques [EFT] to her practice. She realized that many of her patients’ problems had strong emotional components. She needed a way to discover and resolve the emotional roots of her patients’ suffering. When she found EFT, she understood that this was the modality she had been searching for.

Further reading

What is acupuncture and EFT?

Endometriosis excision surgery is currently the only proven treatment that reliably and effectively eradicates the disease.

Key facts summarized

  • Endometriosis excision surgery is currently the only proven treatment that reliably and effectively eradicates the disease. In the vast majority of patients, excision is a curative procedure i.e. after the procedure the disease is eradicated and does not recur. Women who undergo complete excision of their endometriosis can remain disease free for the rest of their lives.
  • No miracle pill, diet or hormone therapy exists that cures endometriosis. Hormones, dietary adjustments, supplements, and herbal remedies can at best result in a reduction in symptoms. They do not resolve the disease itself and if the therapy is discontinued the symptoms will typically return in full force in a short period of time. Non-invasive treatments are at best palliative – they help manage the symptoms of the disease but do not cure the disease.
  • Endometriosis excision surgery will treat the lesions of endometriosis and the pain associated with these lesions. It does not, however, treat other conditions that may co-occur or even result from endometriosis. Symptoms arising from these related conditions may persist despite excision surgery and may require additional treatments in order to restore a patient back to optimal health. For some of these conditions, continued care may be required.

“Endometriosis” and “cure” are rarely seen together in the same sentence. After all, endometriosis is supposed to be a chronic recurrent disease that always comes back, and for many patients, this mantra is borne out in their personal experience with the disease; they undergo repeated failed surgeries and hormone therapies without relief or at best any relief is short-lived and the same old symptoms recur within time.

To confuse matters, endometriosis and pelvic pain are often treated as being synonymous. If the pain returns following previous treatment the patient and her doctor may inadvertently assume that this is an indication of the return of the disease. Pelvic pain, however, is frequently multifactorial in nature, which means the return or persistence of pelvic pain symptoms may not necessarily point to recurrence of previously diagnosed endometriosis. Endometriosis may end up being blamed for other related gynecological conditions that often co-exist with it, such as adenomyosis, pelvic floor dysfunction, adhesion-related pain and interstitial cystitis (painful bladder syndrome).

So, as you can see, the question as to whether or not endometriosis has a cure is far from straightforward!

What do we even mean by “cure”?

In order to answer the question as to whether endometriosis has a cure, it is first necessary to provide the medical definitions of endometriosis and cure.

The medical definition of endometriosis is the presence of ectopic endometrial glands and stroma (said simply, it is the presence of endometrial-like tissue outside the uterus). This definition refers to the actual physical presence of endometriotic lesions but says nothing about the pattern of associated conditions that often co-occur with endometriosis nor of the potential further-reaching effects of the disease on other body systems, such as the gastrointestinal, immune and nervous systems. The medical definition of cure is the absence of a disease following treatment.

So, when talking of cure of endometriosis, according to these medical definitions we are in fact asking whether the endometriotic lesions can be fully eradicated without disease recurrence further along the line. As can be derived from our surgical success rates, recurrence following wide excision by a surgical specialist is uncommon. The vast majority of patients do not experience recurrence of their disease following surgery. These findings are supported by clinical data involving hundreds of patients and are in line with other surgeons around the world who are using the same technique with a similar level of skill. Essentially, endometriosis excision is a highly effective and curative procedure in most cases.

What about disease recurrence despite excision?

In a minority of patients, the disease does recur. Most cases of recurrence are not in fact true recurrence but are in fact disease persistence. It is far more common for an area of disease to be missed or only partially removed than for new disease to occur and most cases of “recurrent” endometriosis after surgery are examples of disease persistence due to incomplete removal of the disease. In such cases, thorough excision of all remaining disease will provide ongoing resolution of the disease. The problem of incomplete surgery lies at the heart of the belief that endometriosis is an incurable disease that always comes back. This is why patients who find themselves on a seemingly never-ending carousel of repeated surgeries should start questioning how complete their surgery has been and whether their surgeon is sufficiently skilled to offer them optimal surgical care.

In rare cases, however, the disease may recur despite thorough excision surgery. Clinical observations made during second look procedures reveal that recurrence following excision surgery tends to occur at the margins of previous areas of excision. It is far less common for the disease to recur in new sites. Furthermore, recurrent disease tends to be more limited in presentation than the original manifestation of the disease (women with recurrent disease typically have less disease than at the time of their first surgery and recurrent disease is superficial). One possible explanation for the patterning of recurrence at the margins of previously excised areas is that the healing process itself may trigger vulnerable tracts of tissue that contain a latent potential to become endometriosis to then transform into new areas of subtle disease in some patients. Performing excision with wide margins around the areas of visible disease can help reduce the risk of recurrence.

The youngest patients may be at greater risk of disease recurrence although the data are mixed. A recent study found no recurrence in a small series of teenage patients following broad excision. Younger patients may present with more subtle presentations of the disease that are easier to overlook or areas of healthy appearing tissue may still harbor a latent potential to subsequently transform into endometriosis through a process of metaplasia (where one tissue type transforms into another tissue type). It is therefore important to treat endometriosis in teenagers with broad excision to minimize the risk of the patient later having to return for further surgery. Even in teenagers, most patients will experience complete and ongoing resolution of their disease following a single surgical excision procedure.

The sites in the body most likely to undergo “recurrence” following surgery are in fact the ovaries. In the case of ovarian disease deep within the ovarian tissue, it may be difficult if not impossible to detect small focal areas of disease during surgery. Ovarian endometriomas can be excised but sometimes a patient will have other small areas of disease within the ovary that are only detected if they later develop into new endometriomas. The rate of recurrence following excision of an endometrioma (cystectomy) is estimated to be around 5%. Obviously, the risk of recurrence varies depending on the skill of the surgeon.

Recurrence of deep disease is extremely rare. If an area of deep endometriosis is found following previous surgery it is highly likely that the initial surgery failed to completely remove the lesion.

Will removal of my endometriosis cure me of all my symptoms?

This is an important question. The lesions present in the pelvis may only represent half of the picture. Is endometriosis “just” about the lesions or is it more complex than that? The disease process itself (chronic pelvic pain and inflammation) and the underlying factors that determine which women ultimately develop the disease may also result in wider system dysfunction that persists even after the lesions themselves have been meticulously removed. In many cases, endometriosis may present as a multi-systemic “syndrome” of deficits extending far beyond the pelvic cavity. A comprehensive integrative approach may be required in order to restore optimal health. In short, surgery can remove the lesions but other treatments and therapies may be required to address other symptoms indirectly associated with endometriosis.

What does it mean to be “fighting for a cure”?

If endometriosis can be effectively surgically removed with little risk of recurrence, why are endometriosis advocates fighting for a cure? While surgical treatment offers curative resolution of the disease there is currently no way of preventing the development of the disease in the first place and many women experience a long and painful diagnostic delay and rounds of ineffective treatment before accessing optimal care. There is no non-invasive diagnostic test for endometriosis nor a non-invasive curative treatment. What we really should be fighting for is improved access to care, new treatment options, earlier diagnosis, and ultimately a way of stopping the disease in its tracks before it has a chance to debilitate lives. We should be fighting for a prevention.

Many women with endometriosis who suffer from pelvic pain will also have co-existing urogynecological disorders that contribute to their symptoms. Sometimes one disorder may mask other co-occurring disorders and it takes a skilled physician to correctly differentiate the many possible sources of pelvic pain.

While endometriosis is a leading cause of pelvic pain, pelvic pain is often multifactorial in origin – it can stem from multiple causes.

The following conditions commonly co-occur with endometriosis and represent additional causes of pelvic pain:


Adhesions are bands of fibrotic tissue (scar tissue) that form between adjacent organs and structures, such as between the ovaries and pelvic sidewall and between the uterus and bowel. Adhesions can be thin, cobweb-like or dense and thick like hardened glue. They arise from pelvic disease, infection or injury. Over time the inflammation associated with endometriosis can cause the formation of scarring and adhesions and the surgery to remove the disease may result in further adhesions as the body heals. Some patients are more prone to forming adhesions than others. In severe cases it is almost as if a tube of superglue has been deposited into the pelvic cavity, causing structures to fuse and distorting the pelvic anatomy. If adhesions stretch or constrict a vital structure such as the bowel this can result in pain and other symptoms, such as bowel obstruction and nausea. Surgery can be performed to remove painful adhesions. A problem, however, is in preventing the adhesions from reforming during the healing process. The use of adhesion barriers and an early second look procedure to take down newly forming adhesions before they become established can help provide ongoing relief.


Adenomyosis is a close relative of endometriosis, and is when endometriotic tissue is found within the muscular walls of the uterus. The two main symptoms of adenomyosis are severe uterine cramping that worsens with the menstrual flow and unusually heavy periods. Not all women with adenomyosis have symptoms.

Interstitial cystitis (painful bladder syndrome)

Interstitial cystitis (IC) is a chronic bladder condition that often mimics a bladder infection. The most common symptoms are pelvic pain, pelvic pressure, pain with urination, urinary frequency and urinary urgency. Women with IC typically have smaller bladder capacity and when the inside of the bladder is inspected via cystoscopy glomerulations (small capillary bleeding from the bladder wall) and Hunner’s ulcers (lesions or sores on the lining of the bladder) may be observed. Unlike endometriosis, IC cannot be surgically removed but there are treatments that can help manage symptoms, including dietary changes, bladder instillations and medications.

Pelvic floor muscle spasm

Chronic pelvic pain can result in a tightening of the pelvic floor muscles. When the pelvic floor muscles become overly tight or overly relaxed or loose (such as following childbirth) the patient is said to have Pelvic Floor Dysfunction (PFD). Some patients with endometriosis or other forms of chronic pelvic pain will go on to develop pelvic floor muscle spasms due to a tightening of the pelvic floor muscles in response to ongoing severe pelvic pain. Pelvic floor muscle spasms are excruciatingly painful and can occur spontaneously or become triggered by activity, such as sexual intercourse. Pelvic physical therapy can help alleviate the painful and debilitating symptoms of PFD and pelvic floor muscle spasm.


Fibroid tumors are accumulations of smooth muscle tissue that form within the muscular walls of the uterus. A woman may develop multiple fibroids and the tumors can vary in size from smaller than a marble to larger than a grapefruit. Fibroids if symptomatic can cause heavy periods and uterine cramping that worsens with menstruation.

Uterine retroversion

Normally the uterus is anteverted; it is tilted forward slightly, toward the bladder. In approximately 1 in 5 women the uterus is retroverted; it is tilted backward toward the bowel. While retroversion of the uterus is considered a normal phenomenon it can be associated with lower back pain, painful sex and painful bowel movements. Retroversion may be more symptomatic in women who have co-occurring uterine pathology, such as fibroids and adenomyosis.

Uterine prolapse

Uterine prolapse is when the uterus drops down into and sometimes out of the vagina. It is more common in patients who have had previous vaginal deliveries, as the process of childbirth can loosen the pelvic support structures that support the uterus. Prolapse is also more common in women post-menopause as the drop in estrogen levels can also reduce the tone of the support structures in the pelvis. Patients suffering from prolapse may complain of a bearing down sensation and lower back pain. Prolapse may also be associated with stress incontinence (where lifting, coughing, sneezing and/or exercise result in loss of urine).

Pelvic congestion

Pelvic congestion, uterine varicosities and ovarian vein varicosities (varicose veins) are all variations of enlarged pelvic blood vessels and may present as a source of pelvic pain. Pelvic congestion may be manageable conservatively or via radical organ removal (hysterectomy) depending on the site of the varicosities.

Ovarian cysts

The most common non-endometriotic ovarian cysts are functional cysts (follicular cysts and corpus luteal cysts). Functional cysts form and resolve as a normal part of the menstrual cycle. Sometimes functional cysts may persist longer than normal and cause pain. Even the presence of one or more small to medium-sized cysts can stretch the ovary causing pain. If the ovary is also involved by scar tissue or adhesions, the presence of a functional cyst during the cycle can cause a cyclical stretching of the scar tissue producing a painful pulling sensation. If a cyst ruptures, this may result in acute pain. Not all cysts are symptomatic. Sometimes a patient will have large ovarian cysts without any symptoms at all. Non-functional cysts include endometriomas, hemorrhagic corpus lutea and dermoid cysts. Imaging can help differentiate between functional and non-functional cysts. Endometriomas and dermoid cysts do not resolve on their own without surgery.

Ovarian torsion

Ovarian torsion is when an ovary twists on itself. Torsion is associated with acute lower abdominal pain and represents a medical emergency. If the torsion is not resolved quickly the blood supply to the ovary may be compromised and the ovary may cease to function, resulting in loss of the ovary.

Abdominal wall neuropathy

The ilio-inguinal, ilio-hypogastric, and genital femoral nerves are found in the lower abdominal wall between the belly button and hipbone, down to the groin and upper leg. When these nerves are damaged, a nerve block or trigger-point injection can be helpful; often, a series of nerve blocks can ease the pain. In some cases, a technique called radiofrequency nerve ablation is used to provide longer lasting relief.

Pudendal neuropathy and pudendal nerve entrapment (PNE)

The pudendal nerve is located along the side of the vagina. This nerve has three basic branches: an anterior branch, to the clitoris; a middle branch, to the vaginal and vulvar area; and a posterior branch, to the anus. Pain can be present in any portion of the nerve if it becomes damaged or entrapped. The pain is often worse when the patient is sitting. Pudendal neuropathy can be treated with pudendal nerve blocks and pelvic physical therapy. In some cases radiofrequency ablation of the pudendal nerve may be helpful.

Ovarian remnant syndrome

An ovarian remnant is when a small piece of ovarian tissue is left behind following removal of an ovary. This can occur if the ovary is fused by adhesions to the adjacent pelvic sidewall prior to removal. In such cases, the ovary must first be carefully peeled away from the adherent structures without leaving a remnant behind. Ovarian remnant syndrome is when a patient experiences pain as a result of the ovarian remnant. Sometimes a remnant will be identified by the presence of a cyst in the ovarian tissue on ultrasound or by persistently elevated estrogen levels (in the case of removal of both ovaries). Ovarian remnant syndrome can be resolved by surgically removing the remaining remnant of ovarian tissue.

Foreign body

Pelvic pain may result from foreign materials left in the body after a previous procedure, such as surgical staples and mesh. Sometimes a foreign body may result in a chronic inflammatory reaction called a foreign body giant cell reaction. Foreign body reactions can be resolved by removing the source of the reaction. Avoiding the use of foreign non-biodegradable materials in the body can prevent these reactions from occurring in the first place.


Groin hernias include inguinal, obturator and femoral hernias. Inguinal hernias are the most common. Inguinal hernias are actually an uncommon source of pelvic pain and are often over-diagnosed and treated with mesh, which can then become a new source of pelvic pain. For this reason, inguinal hernias should be treated without mesh. Sometimes a patient may develop a painful abdominal wall hernia, including umbilical hernias, incisional hernia and ventral hernias. Surgical correction can resolve the hernia and any associated pain.


Appendicitis is a condition in which the appendix becomes inflamed. In the case of acute appendicitis, the onset of inflammation is sudden and is accompanied by severe right-sided pelvic pain that brings the patient to the ER and the appendix is removed during emergency surgery. Occasionally a patient will present with chronic appendicitis or her acute pain will be passed off as endometriosis pain, potentially leading to a life-threatening situation if the appendix then ruptures.

Food sensitivities and food allergies

While technically different, food allergies and food sensitivities can result in similar types of problems. A food allergy, such as to seafood, is mediated by the immune system: the patient may break out in a rash and/or may experience difficulty breathing. A food sensitivity, such as lactose intolerance, has an end-organ response: the patient reacts to the food with, for example, a spasm of the bowel.

Gluten is a protein found in wheat, rye, barley, oat bran, and wheat germ. While it can cause celiac disease, gluten is also a leading cause of food sensitivity. The symptoms are very similar. With celiac disease, the lining of the gastrointestinal tract becomes damaged, but the pain with gluten sensitivity – such as severe bowel pain, up to a level of 10/10 – can be just as severe. Other symptoms include bloating, diarrhea, skin problems, headaches, even neurologic symptoms, such as irritation and anxiety. Food sensitivities can also contribute to or cause pain in the vulvar area and make interstitial cystitis symptoms worse.

Gastrointestinal problems

Bowel problems are common in pelvic pain patients. Many patients report bloating, cramping, gassiness, and alternating bouts of constipation and diarrhea. One cause of gastrointestinal problems includes food allergies and sensitivities. Other causes of gastric symptoms include bowel motility problems or spastic bowel, bowel obstructions due to adhesions, redundant colon (an extra length of colon), diverticulitis (when a small pouch forms in the colon and becomes infected) and anal fissures, a crack in the lining of the anus, often resulting from constipation.

Generalized visceral hypersensitivity

Visceral refers to the internal organs and hypersensitivity refers to abnormally increased sensitivity. With generalized visceral hypersensitivity, the entire inside of the body hurts. This is usually because inappropriate signals are being sent by the nervous system, creating types of neuropathic pain or centralized pain.


The vulva is the area surrounding the outside of the vagina. Vulvodynia means “pain of the vulva.” There are two general types of vulvodynia. Patients with generalized vulvodynia can experience pain anywhere on the vulva between the thighs. It can involve the entire area or specific, isolated areas. The pain can be intermittent or constant. Vulvar vestibulitis involves pain of the vestibule, the small area around the opening of the vagina inside the labia minora, or inner lips. Pain is only present with pressure on the area, such as with intercourse or tampon insertion.


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Cold and flu season is upon us.  In addition to being inside more, we also tend to be under more stress with the New Year upon us.  This is the perfect recipe for catching a cold or flu!  A mounting amount of evidence has shown that stress lowers our immune system.  To help you to stay well this cold and flu season, I have put together a little survival recipe for avoiding the cold and flu.  I have also included some natural remedies for helping to shorten the duration and lessen the severity of a cold or flu if you become sick.  In addition, we have provided a few supplement suggestions to help you prevent or fight a cold or flu.  Feel free to contact us with any questions.  Be well!


  • Vitamin D: Low vitamin D levels have been linked to increasing your susceptibility to colds and other infections. 2,000-5000 IU per day in winter is safe and reasonable.
  • 1-3, 1-6 Beta Glucans: Research has shown that these compounds strengthen the immune system and protect you against viruses and bacteria. These compounds are found in certain types of mushrooms.  They help your white blood cells bind to and kill viruses and bacteria.
  • Probiotics: Whatever your age, research suggests that the preventive use of probiotics can reduce the duration and severity of common colds. Health bacteria is also critical to a healthy immune response and reducing inflammation.
  • Stress reduction:  Practice a stress-reduction technique. Stress weakens our defenses and makes us more susceptible to becoming ill.
  • Exercise:  Get regular exercise. Exercise helps keep the immune system strong; however, don’t overdo your exercise, as this can weaken your immune system.
  • Sleep:  Get plenty of rest. Adequate sleep is necessary for the body to repair, heal, and fight infection (8+ hours nightly).  Interesting side note – a new study from Stanford shows that women need more sleep than men, because we use our brains more with multi-tasking throughout the day. We need additional hours to “recharge” our brains.
  • Diet:  Nourish your body with whole foods and lots of colors (from fruits and vegetables). Stay away from sugar, which can weaken immune cells fighting ability.
  • Hydration:  Use water as preventive medicine. A quick cold rinse after every hot shower is a good way to stimulate immune cell activity. In addition, gargling with plain water a few times per day has been shown to prevent colds.
  • Adequate protein:  Eat protein at every meal.  Protein provides the building blocks for your entire body.  This includes strengthening and repairing your immune system.
  • Attitude:  Laugh a lot!  Laughter can strengthen lower stress and strengthen your immune system.
  • Reduce your exposure to infection:  Wash your hands!!!

When you are sick:

  • Drink plenty of fluids in order to maintain water balance and to thin secretions.
  • Eat raw garlic, which kills bacteria and viruses. Crush a clove or two and add to foods like soups and grains just before serving.
  • Gargling with plain water 3 x’s daily removes mucus and keeps bacteria and viruses from sticking around.
  • A warm, humid environment created by a humidifier may provide some comfort while fighting off a cold.
  • Saline nasal rinses (3-6 x’s daily) (a standard 0.9% saline (sodium chloride) solution with trace elements and minerals in concentrations similar to those in seawater). Neti pots (small pots for nasal rinsing) and mineral salts to use with them are now widely available.  We have a few of these at the office or you can purchase one at a health food store or pharmacy.
  • Try a small amount (a few Tbsp daily) of some raw honey.  It kills bacteria and can soothe irritated mucous membranes. It should not be given to children younger than 12 months old.
  • Eat healthfully.  Opt for fresh fruits and vegetables and whole grains, and lean proteins, as excessive sugar, dietary fat, and alcohol have been reported to impair immune function.  Pass on the OJ – it is very high in sugar.  Look for a lower sugar source of vitamin C such as eating an orange and drinking a glass of water.
  • 8+ hours of sleep nightly.

Helpful Supplements:

  • High Quality Multivitamin:  This is the foundation for a healthy immune system.  It provides all the vitamins and minerals you need for building blocks.
    • Example: Metagenics formulaPhytogenics without Iron
    • Dosage:  Take 1-2 daily with meals
  • 1-3, 1-6 Beta Glucans:
    • Dosage:  250 mg daily
    • Andrographis:  Andrographis contains bitter constituents that have been shown to stimulate the immune system, decrease inflammation, and fight infection.
      • Dosage:  400-2000 mg 3 x’s daily
      • Precautions:
        • Careful with gallbladder disease, autoimmune disease, kidney disease
        • Safety not known with pregnancy
        • Cytochrome P450 1A2, 2C9, 3A4
          Andrographis extract may alter how these drugs are metabolized.
        • Anticoagulants and antiplatelet drugs
          Animal lab studies have demonstrated inhibition of platelet aggregation.  Use caution and talk to your doctor if you are taking anticoagulant or antiplatelet medications.
        • Chemotherapy drugs
          Andrographolide may have antioxidant effects. This may interfere with the actions of some chemotherapy drugs.
        • Blood pressure lowering drugs
          Andrographis may lower your blood pressure.


  • Vitamin C: Studies have shown that taking vitamin C may make your cold shorter and less severe.
    • Dosage:  1-4 g daily
  • Zinc Lozenges: Zinc lozenges used at the first sign of a cold have been shown to help stop the virus and shorten the illness.
    • Dosage: 1 tablet (20-30 mg) every 2 hours for 1st 1-2 days of FIRST SIGN OF cold or flu.
    • Do not take long-term.  May cause a copper deficiency.
  • Probiotic:
    • Dosage 10-200 billlion CFU daily
    • Efficacy of formula varies depending on bacterial strains and delivery system used
  • Vitamin D:
    • 2000-5000 IU daily
    • Best to have levels checked with a goal of 60-80 ng/mL
  • Olive Leaf: antiviral, antibacterial, antiparasitic
    • 1000 mg 4 x’s daily
    • Precautions:
      • Caution with Coumadin
      • Not to be used with pregnancy – safety not known
      • May have a die off reaction – start with lower dose
      • Separate dose 1 hr before or 2 hours after probiotics

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