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QUESTION: I have had what is diagnosed as 'Vulvodynia' after having an endometrial ablation back in February this year. However, I am not sure if the diagnosis is correct as the pain is not only surface but travels right through my pelvis and abdomen , round to my buttocks.  It feels very deeply internal. How can I find out what is wrong and can you advise me on any tests that would help diagnose what may have happened here.  I am very distressed by this, but do not want to take and medication until I know what the problem is for sure otherwise I feel I am masking something that could need treatment. I have had ultra sound scans which initially looked normal, but then a transvaginal scan which showed up 'something' in the womb.  Possibly a blood clot was mentioned.  What will have to happen if I do have old blood not escaping the womb?  I am keen to avoid further surgery.  Thank you, Regards,  Lou

ANSWER: Hello Lou from the U.K.,

Vulvodynia is pain on the outside (opening) to the vagina.  If your pain is deep inside, then you have pelvic pain and NOT vulvodynia.  

One of the problems with endometrial ablation is the formation of scar tissue within the uterine cavity.  If there is some endometrial tissue that was not adequately ablated within the cavity, it could continue to cycle as it did previously and if the exit is blocked by scar tissue, it would not be able to "escape the womb".  This certainly could lead to uterine cramping, as one would have in a miscarriage, as the uterus would sense that something is in there and try to force it out.  The only treatment for this would be to create an exit if this were the case.  Sometimes this can be easily done by simply dilating the cervix, but if that is not successful, then the scar tissue would need to be cut, and this procedure is called an operative hysteroscopy.  

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  I now provide personalized fee for service consultations/advice/direction via email and payable via Pay Pal.  If interested, contact me via my email at info@montereybayivf.com.  This service will allow you to have your own personal on-demand infertility expert



---------- FOLLOW-UP ----------

QUESTION: Thank you so much for your response which was really helpful. However, what do you think would cause this pelvic pain initially, as this occured staright after the ablation, and blood was escaping fine for quite a few months. The only way I can describe this pain, is if you drew a line from the right side of my pelvis, right round the vagina and inside of buttocks....this is what I feel. It is a burning, inflamed feeling, as if someone has kicked me and there is bruising .  It is restricted to this area only, and the other side feels completely normal.  What investigations would I need to find out the problem?  It did start to get better, but recently I had a transvaginal scan and after it put me right back to where I started it seems. The lady was gentle and the only discomfort I felt waas when she pulled the wand to the left side to see me ovary.  Im really worried that there is something terribly wrong that the doctors just don't seem to be 'getting' when I tell them about it.  Its really dibilitating. Can you shed any light or advice on this?  Regards,

Lou

Answer
Hello,

Without an exam I cannot give you a definitive diagnosis, however the characteristics and area of the pain sounds like a nerve in being stimulated and may have been injured at the time of ablation.  It is possible that the ablation injured some nerve in that area that supplies the vagina down to the buttocks.  Since you get the pain with vaginal pressure (from the ultrasound transducer) there must be a "trigger point" or point of maximal tenderness.  One way to test this hypothesis would be to do a vaginal exam and do a mapping point test, which is to touch each area with a probe and see if that location can be found.  If found, then some lidocaine can be injected into that point to see if that immediately resolves (anesthetizes the pain).  If found, that could lead to possible options for treatment such as permanently numbing that nerve fiber with alcohol injections, or by laparoscopic nerve ablation.  These are not the only or absolute options but possibilities only.  The findings would dictate the treatment.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  I now provide personalized fee for service consultations/advice/direction via email and payable via Pay Pal.  If interested, contact me via my email at info@montereybayivf.com.  This service will allow you to have your own personal on-demand infertility expert  

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Edward Joseph Ramirez, MD, FACOG

Expertise

I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.

Experience

I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 19 years.

Organizations
American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, Society of Assisted Reproductive Technology, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists,Resolve-National Chapter, Open Path - Northern California, Board of Directors Monterey Medical Society

Publications
American Journal of Obstetrics and Gynecology, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

Education/Credentials
Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

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