Dear Dr Mitchell,
I've been having painful periods from age 14. I am now 29. I got the HSG done three times and also the pelvic and abdomen. I am not sure if it is the x-ray or ultrasound. However, the first HSG (hysterosalpingogram) showed my tubes are tortuous while the other two came out normal three years later.

Last year I did a fertility test and there was a slight imbalance with my hormones. Now the pelvic and abdomen x-ray says I have several small cysts. I am writing you this in tears and pain. I just need closure where my health is concerned. I am now having my period and to ease the pain I took four Aleves. I'm dizzy and my head is shaking with eyes blurry but it helps for a while. I have a phobia about having my period. With these problems I am rather concerned about whether I'll be able to have a child.

I understand the distress that you now experience as it relates to your menstrual cycle, chronic pelvic pain and infertility. The problem that you experience is obviously long-standing since you have had significant pelvic pain since the age of 14 years. Chronic pelvic pain of this nature may be due to several factors.

These include endometriosis, pelvic adhesions secondary to pelvic inflammatory disease, ovarian cysts and uterine fibroids. In a lot of cases the pain may be due to psychogenic (mental) problems. Endometriosis is a condition in which the tissues similar to that which normally lines the inside of the uterus is present outside the cavity of the uterus. This may be in the wall or muscles of the uterus in the ovaries, on the bowel, or inside the cavity of the abdomen where it may cause adhesions around the tubes and ovaries resulting in the inability to become pregnant and chronic pelvic pain.

The long history of infertility, irregular cycles and the findings of multiple ovarian cysts on ultrasound may suggest the presence of polycystic ovarian disease. This is also associated with increased weight gain and signs of production of excessive male hormone (acne and excessive hair growth on the body). The presence of the small cysts on the other hand may be totally harmless and of no clinical significance.

Endometriosis is not usually detected on an ultrasound scan unless there are chocolate cysts in the ovaries or endometriosis in the wall of the uterus (adenomyosis). In the presence of adenomyosis, the uterus tends to be bulky and has a coarse pattern to the muscles on ultrasound. This condition causes pelvic pain that starts at least one week before the menstrual period continues throughout the period and even after the menstrual period there may still be pelvic pain. There may also be severe pain on sexual activity.

The diagnosis of endometriosis or chronic pelvic inflammatory disease is usually confirmed on laparoscopy. This is an operation which can be done as an outpatient procedure and is very useful in identifying the cause of the underlying pelvic pain.

It is also invaluable in assessing the Fallopian tubes since a special dye may be injected at the time of laparoscopy and this will determine if the tube is blocked and also detect the presence of any adhesions around the Fallopian tubes which may cause the tubes to be non-functional in picking up the egg at the time of ovulation.

The hysterosalpingogram (HSG) is a useful means of assessing whether tubes are blocked, but diagnostic laparoscopy gives a better assessment of the true function and is a better means of assessing the extent of any damage to the tubes that may be present.

You may also need to have induction of ovulation done if tests done show that you do not ovulate (release an egg) monthly.

The phobia you experience abut having your period is because of the pain that is associated with this time of your cycle and the fact that the onset of the menstrual period reminds you of the inability to conceive and thus also increases your level of anxiety and depression.

Remember too that your partner will need to be evaluated because he might be the reason for the inability to conceive over these years. He will need a physical examination and semen analysis.

You are very young at age 29, and I am sure that you will conceive eventually once both of you have had the appropriate tests done.

You should ask your family physician to refer you to a gynaecologist or an infertility specialist at the University Hospital of the West Indies if you live in Jamaica. In the meantime do not do anymore HSGs. You have definitely done far too many and this is not without its ill effects.

This will not contribute anything to your further management. In the interim you probably should go on a low-dose oral contraceptive pill and this will relieve your chronic pelvic pain.

This should be taken continuously without the seven-day break, thus preventing the menstrual period from coming. This will give significant relief until you are able to do the diagnostic laparoscopy for further evaluation.

Laparoscopic surgery may be subsequently undertaken to treat endometriosis or pelvic adhesions due to pelvic inflammatory disease, if this is detected, and this should improve your chances of becoming pregnant.
Best Wishes

Dr Sharmaine Mitchell is an obstetrician and gynaecologist. Send questions and comments via e-mail to allwoman@jamaicaobserver.com or fax to 968-2025. We regret that we cannot supply personal answers.

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