The Journal
Of
The Egyptian Society
Of
Chronic Pelvic Pain In Women

Advisory Board

Prof. Dr. Abdel-Megeed Ismaeel
Dr. Ali Mahmoud Arafa
Dr. Therese Mikhail
Dr. Raoof El-Shamy
Dr. Nasr Said Nassar
Secretary : Heba Nassar


The Egyptian Society of Chronic Pelvic Pain in Women .
280 Terrehet El-Gabal St., El-Zaytoon, Cairo, Egypt .

Mobile Phone ( +2 ) 01014 35 991
escpp1@yahoo.com
nassarnasr@hotmail.comwww.n-w-h-f.org
( nassar women health foundation. org)

Published and Distributed for Free

Company Name:
EL-SAHOWA PUBLISHING LTD
Company Number:
05810491


Content
1 - A WELCOME MESSAGE FROM
THE FOUNDER AND THE PRESIDENT
EGYPTIAN SOCIETY OF CHRONIC PELVIC PAIN FOR WOMEN

2- TRANSVAGINAL HYDROLAPAROSCOPY:
AN ADVANCE OR A GIMMICK !!

Prof. Dr. Amr Hassan El-Shalakani,
Prof. Dr. Abdel-Megeed Ismaeel

Department of Obstetrics & Gynecology,
Ain Shams University, Cairo, Egypt.


3 – ROAD MAP OF CHRONIC PELVIC PAIN IN WOMEN
Dr. Nasr Said Nassar
Head Department Of Ob.&Gyn,
Monira General Hospital, Cairo Egypt President Of Egyptian Society Of Chronic Pelvic Pain For Women

4 – INTRAUTERINE DEVICE ( PROS AND CONS) .
AND RELATION TO CHRONIC PELVIC PAIN IN WOMEN.
Dr. Nasr Said Nassar
Head Department Of Ob.&Gyn,
Monira General Hospital, Cairo Egypt President Of Egyptian Society Of Chronic Pelvic Pain For Women


EGYPTIAN SOCIETY OF CHRONIC PELVIC PAIN FOR WOMEN

A WELCOME MESSAGE FROM
THE FOUNDER AND THE PRESIDENT
Dear colleagues,
After six years since I established and founded our society in 2003, only now, I can say that I am really delighted to declare that my society got just the first step of success.
During the last six years, I tried to raise the consciousness about chronic pelvic pain (CPP) in women among doctors with different specialties and nurses by numerous meetings, conferences, workshops and training courses in nearby society. Also, instead the patients get lost and get frustration due to rotating between different clinics of different medical specialties I established units for CPP for women in Monira General Hospital and in my own small private hospital, in both, the patients could treated for free without any fees. I started editing and publishing a nice voluble specific medical journal for (CPP) distributed for free, one of it in your hands. Also, I started large scale research for detecting the prevalence of CPP in our Egyptian society.
All of these activities were performed by struggling against many difficult situations most important of them is financially and poverty i.e. poor society, poor hospitals poor medical systems and equipments, poor patients, and also poor founder who refuses any financial support to this society. I did not accept any donation from any governmental or non- governmental organizations. We will continue, God help us.
Dr. Nasr Said Nassar
TRANSVAGINAL HYDROLAPAROSCOPY:
AN ADVANCE OR A GIMMICK !!

By

Prof. Amr Hassan El-Shalakani,
Prof. Abdel-Megeed Ismaeel

Department of Obstetrics & Gynecology, Ain Shams University, Cairo, Egypt.

Abstract:
Background: Transvaginal Hydrolaparoscopy is the recent evolution of a well known gynecological procedure culdoscopy. It is a new and modified culdoscopic technique used for exploration of the pelvic cavity that takes advantages of micro-endoscopic technology and uses aquafloatation for inspection of the tubo-ovarian structures.
Objective: This is a pilot study to evaluate the feasibility, procedure performance and complication of Transvaginal Hydrolaparoscopy.
Study design: A cross-sectional, observational study. It was conducted at "The Early Cancer Detection Unit", Department of Obstetrics & Gynecology, Ain Shams University Hospitals, between March 2004 and December 2004.
Methods: Fifteen Patients were included in this study, they were referred to our hospital for diagnostic hysteroscopy as part of their fertility investigation or admitted for performing benign hysteroscopic surgery (e.g., myomectomy, septum resection). All patients received full information about the procedure and an informed consent was obtained from each patient under study. Then, the procedure of transvaginal hydrolaparoscopy was carried out.
Results: complete evaluation of all the pelvic organs was not possible in all cases, 7 out of 15 cases (46.7%,). Various pathological conditions were estimated. Endometriosis without adhesions was found in 2 cases, endometriosis with adhesion in other 2 cases. Bilateral PCOS in 3 cases. Filmy adhesion between ovaries and peritoneum in 1 case and left tuboovarian adhesion in another case. Hydrosalpinx was discovered in 3 cases.
Conclusion: It has been shown that transvaginal hydrolaparoscopy may allow atraumatic and detailed exploration of the tubo-ovarian structure in some infertile patients. The procedure can be combined with hysteroscopy and dye hydrotubation. Visualization is restricted to the posterior part of the uterus. However, the pelvic inspection process is inferior to that achieved by conventional laparoscopy and the procedure needs a personnel who is well trained & highly skilled at both hysteroscopy and laparoscopy.

Introduction:
To expose the full ovarian surface and fossa ovarica by standard laparoscopy several steps are required such as, Trendlenburg position, distention by CO2 pneumoperitoneum with its harmful effect on the circulation and insertion of a second trocar to manipulate the bowel and adenexae, which may cause injury to blood vessels or bowels. A new technique called Transvaginal Hydrolaparoscopy (THL) has been developed as a less invasive procedure to view and explore the pelvis.1
Transvaginal Hydrolaparoscopy is the recent evolution of a well known gynecological procedure culdoscopy. It is a new and modified culdoscopic technique used for exploration of the pelvic cavity that takes advantages of micro-endoscopic technology and uses aquafloatation for inspection of the tubo-ovarian structures. Culdoscopy, in the form of THL was reintroduced in 1997 by Gordts et al., who combines a culdoscopic approach with advanced micro-endoscopic technology including the use of a small scope, high intensity light source and digital camera. In contrast to culdoscopy, the patient is in the dorsal lithotomy position and abdominal distention is obtained by instillation of saline or preferably lactated Ringer's solution. THL is likely to be more acceptable by avoiding general anesthesia.1
It was shown in earlier studies that the access from the umbilicus used in laparoscopy does not give the ideal angle for inspecting the tubo – ovarian structures. To expose the full ovarian surface and fossa ovarica several steps are required; such as Trendlenburg position, distention by CO2 pneumoperitoneum, insertion of a second trocar and manipulation of bowel and adenexa.2 THL improves the visualization of the tubo-ovarian structures because the access from the caudal pole with hydroflotation, allow inspection of the organs in their normal position without manipulation. Additionally, structures such as fimbriae, tubo-ovarian structures, and avascular adhesions are easier to inspect by hydroflotation than with a pneumoperitoneum.3,4
THL was used for investigating unexplained primary infertility in women. The procedure can be combined with hysteroscopy and dye hydrotubation and has the potential of offering the patient a complete and early exploration of the reproductive tract in a painless, safe and cost-effective way. Gordts et al, concluded that, THL is be better tolerated than hystrosalpingography, less invasive than standard laparoscopy, and can be used safely as a first line investigation of the female partner in one – stop infertility clinic.5
THL has been used as well to examine the contour of the uterus before hysteroscopic metroplasty for uterine septum. In 2002, Peter Scott and Adam Magos used THL to distinguish a septate uterus from a bicornuate one in a 22 years old woman with poor obstetric history. THL provided a detailed image of the posterior aspect of the uterus confirming a normal contour and excluding a diagnosis of a bicornuate uterus. Hysteroscopic metroplasty was then performed.6
Recently in 2003 ovarian drilling was carried out by Hirano et al, on two clomiphen citrate-resistant infertile women with PCOS by THL. Nd:YAG laser vaporization was used to ablate the portions of the ovarian cortex. No complications occurred during or after the operation on both cases. Ovulation is then induced with clomiphen citrate. The two patients recovered to have regular ovulatory cycles.7
Aim of the Work:
This is a pilot study to evaluate the feasibility, procedure performance and complication of Transvaginal Hydrolaparoscopy.
Patients & methods:
The study was conducted in "The Early Cancer Detection Unit", Department of Obstetrics & Gynecology, Ain Shams University Hospitals, between March 2004 and December 2004. Fifteen Patients were included in this study, they were referred to our hospital for diagnostic hysteroscopy as part of their fertility investigation or admitted for performing benign hysteroscopic surgery (e.g., myomectomy, septum resection). All patients received full information about the procedure and an informed consent was obtained from each patient under study.
The inclusion criteria:
- Infertility, habitual abortions and abnormal uterine bleeding.
- Uterine myoma (for hysteroscopic myomectomy).
- Uterine septum (for hysteroscopic septum resection).
The exclusion criteria:
- Upper & lower genital tract infection.
- 2nd or 3rd degree RVF uterus.
- Expected adhesions in the pouch of Douglas or masses or tumors.
- Previous pelvic surgery and previous C.S.


Operative technique:
A mild rectal laxative was done in the morning of the procedure. All THL were performed under general anesthesia with the patient in the dorsal lithotomy position. Disinfection of the cervix with povidone iodine 2%, then the central part of the posterior fornix was infiltrated with 1–2 ml of 1% lidocaine with adrenaline 1:100000, the cervix was lifted with a tenaculum placed on the posterior lip, and the Veress needle was introduced about 1.5cm below the cervix, and tested by deeper insertion for intraperitoneal location. Approximately 500 ml saline solution at 37˚C were instilled in the pouch of Douglas.
Then a stab incision was performed in the posterior fornix. A 4 mm rigid endoscope was used with an optical angle of 30˚ with a flow channel. The system was attached to a video camera. The optic was introduced 1 cm through the trocar sheath into the pouch of Douglas with the optical angle in the upward position and the posterior wall of the uterus was inspected. Subsequently, by rotation and deeper insertion of the scope, the tubo–ovarian structures were seen. Irrigation was continued during the procedure under gravity to keep the bowel and tubo – ovarian structures afloat. Tubal patency testing using a dye was performed in some cases.
At the end of the procedure, saline was left in situ, and the instrument were removed. When indicated, hysteroscopy was performed to check uterine cavity and any intrauterine procedures needed. Prophylactic broad spectrum antibiotics was prescribed and the patient was seen in a week.
Data collected was recorded and tabulated for statistical analysis.

Results:
A total of fifteen women were enrolled into our study, the mean of their age was 29.67 ± 5.58 years. The background characteristics of the patients are summarized in table (1).
Table (1): Characteristics of the studied patients.
Range Mean SD
22 42
2 17
1.5 13 29.67 ± 5.58
7.07 ± 4.39
6.43 ± 3.70 - Age (years)
- Duration of marriage (years)
- Duration of infertility (years)
Six of the patients had had previous laparoscopy as a part of their fertility workup. 3 cases underwent laparoscopy just following THL by the same surgeon. The remaining 6 either didn’t have laparoscopy performed or the results were not available.The results of previous laparoscopic finding are presented in the following figure.


All patients had diagnostic hysteroscopy prior to THL by the same surgeon, in order to check the uterine cavity in 10 (66.7%) of them or to perform benign hysteroscopic surgery in 5 (33.3%) cases. The findings are presented in table (3).
No %
- Uterine septum
- Bicornuate uterus
- Intrauterine synechea
- Submucous myomas
- Uterine polyp
- Normal 3 20
1 6.7
1 6.7
2 13.3
2 13.3
6 40
Total 15 100
Table (3): Findings of hysteroscopy.

All cases received general anesthesia, and entry into the peritoneal cavity was successful in 14 out of 15 cases. In one patient there was no successful peritoneal entry because, distension fluid was inserted extraperitoneal. The mean duration of the procedure was 15.6 ±3.2 minutes with a time range from 12 to 19 minutes. In the first 3 cases the visualization of the pelvic cavity was not satisfactory (not all the genital organs detected), for the last 4 cases visualization was excellent, with the pelvis and all its structures are completely seen.
There were no difficulties in inspecting the posterior wall of the uterus and the uterine contour in 11 (78.6%) of cases out of 14 cases. However, the posterior wall of the uterus, the uterine contour, both ovaries and both tubes with all their parts were evaluated in 7 (50%) only of the cases out of 14 cases. Poor vision with only loops of bowel was seen in 1 (7.14%) case. The ability to evaluate the pelvis and its structures by THL is presented in figure (2).
The indications of THL are shown in table (4). Ten (66.7%) of the patients had THL performed after performing diagnostic hysteroscopy, 5 (33.4%) had THL performed adjunct to hysteroscopic surgery.
Indications No %
- Diagnostic purposes:
1ry infertility
2ry infertility
- Adjunct to hysteroscopic surgery:
Resection of SM myoma
Septal resection 10 66.7
7 46.7
3 20
5 33.3
2 13.3
3 20
Total 15 100
Table (4): Indications of THL.





Various pathological conditions were estimated. Endometriosis without adhesions was found in 2 cases, endometriosis with adhesion in other 2 cases (Photo: 1). Bilateral PCOS in 3 cases. Filmy adhesion between ovaries and peritoneum in 1 case and left tuboovarian adhesion in another case (Photo: 2). Hydrosalpinx was discovered in 3 cases (Photo: 3).





Discussion:
In this study THL was performed under general anesthesia. THL could be performed under local anesthesia of the posterior fornix as reported by Gordts et al., and Waterlot et al. Performing the procedure under local anesthesia, allows the patient to explain the sensation and the intensity of pain occurring during the procedure and consequently, the procedure was gentler and more atraumatic and was tolerated by all the patients as described by Gordts et al., & Waterlot et al.1,8 Another advantage of local anesthesia described by Brosens (1999) was that the patient can follow the procedure on the video screen, and this allowed it to be explained to her and her partner.9
In this study, the THL procedure used was a modification of the technique reported by Gordts et al, on which the insertion of the veress needle was facilitated by a stab incision 1.5 cm below the cervix in the posterior fornix. We didn’t use the technique described by Waterlot et al., who used specially designed disposable balloon introducers. One was put in the uterine cavity and the second balloon introducer was inserted in the pouch of Douglas. They suggested that the role of the balloon was very important in maintaining the introducer in the pouch of Douglas during the procedure especially when the scope was pulled back to obtain a wider angle view.8
Our failure rate was low, one out of 15 cases (6.7%), failed due to extraperitoneum distention. This is comparable to a failure rate of 3.1% recorded previously by Waterlot et al., 1999, who didn’t exclude from the study women with retroverted uteus as others have done, and three failures out of 28 cases (10.7%) as were described by Gordts et al., 1998, who suggested that the failures mostly occurred at the beginning of their experience.1,8
Use of 30° optical angle system allowed detailed inspection of the posterior pelvic compartment including the tuboovarian structures, the uterosacral ligaments and the pouch of Douglas, except for the area of entrance. The anterior pelvic compartment was not accessible for inspection at this procedure. Rudi Campo et al 1999, suggested that this was not a major disadvantage for the diagnosis of endometriosis because of exclusively anterior pelvic endometriosis occurs
in < 4% of cases.10
Complete evaluation of all pelvic organs was not possible in all cases of this study (only successful in seven out of fifteen 46.7%). It was noted that without manipulation of the adenexa, it was difficult in some cases to check the ovarian surfaces from all sides. We also noted that overestimation of the size of lesions encountered because of the magnification of the scope at close distances can be troublesome. Another problem with inspection was that the visualization was not panoramic and was markedly decreased when the distention fluid became turbid or hemorrhagic. However, we suggest that increasing the experience of the surgeon can overcome these problems.

Casa et al 2002, differently stated that inspection under fluid improves the visualization of subtle, non-fibrotic lesions of endometriosis by the three dimentional effect of fluid, and allows visualization of the capillary network, which tend to be masked by pneumoperitoneum at standard laparoscopy. They also, concluded that inspection of the tuboovarian structures under fluid makes it easy to identify filmy connecting and non connecting adhesions.11
Our study didn’t evaluate the pathologies by their number and location, and didn’t compare the findings with laparoscopy as did Gordts et al 1998, Campo et al 1999, and Darai et al 2000.1,10,12 It didn’t as well compare THL with hysterosalpingeography (HSG) as did Hirano & Shibahara 2003.7 Therefore, the diagnostic accuracy of this method was not fully assessed. In this study, evaluation of uterine contour by THL was tried and was satisfactorily achieved only in eleven out of fifteen (78.6%). Also, THL was not helpful in hysteroscopic septum resection or in hysteroscopic myomectomy.
Previous studies reported the value of THL in evaluation of tubal pathology even by performing salpingoscopy.1,8 In our study, the tubal patency was tested by hydrotubation with Methylene blue in 5 cases, among these patients one had a negative chromopertubation test, the rest had normal bilateral tubal patency.
At the end of the procedure fluid was left in situ. Casa et al removed excess fluid because they suggested that fluid is not routinely used at laparoscopy.11 Then the posterior fornix was sutured. In some studies, the vaginal fornix was left to close spontaneously.1,13
Regarding complications, previous studies reported bleeding from the puncture site, inadvertent puncture of the posterior wall of the uterus, parametrium or an ovarian cyst, rectum perforation and peritonitis.1,8,12 In our study, the major contraindications were previous pelvic surgery, obstruction of the pouch of Douglas by the rectum or a prolapsed mass were routinely excluded by bimanual examination. This preoperative selection kept the rate of complications low in the form of bleeding from the puncture site in one patient. There were no complications either immediately or delayed postoperative period.

Conclusion:
It has been shown that transvaginal hydrolaparoscopy may allow atraumatic and detailed exploration of the tubo-ovarian structure in some infertile patients. The procedure can be combined with hysteroscopy and dye hydrotubation. Visualization is restricted to the posterior part of the uterus. So, it can be combined with hysteroscopy to differentiate between septate and bicornuate uterus and during septum removal. However, the pelvic inspection process is inferior to that achieved by conventional laparoscopy and the procedure needs a personnel who is well trained & skilled at both hysteroscopy and laparoscopy.

References:
1. Gordts S. Campo R. Rombauts L , Brosens I.(1998) Transvagina Hydrolaparoscopy as an outpatient procedure for infertility investigation. Hum Reprod 1998; 13:99-103.
2. Jacobi , C.A. Ordemann J. Bohm B. et al.,(1997) The influence of laparotomy and laparoscopy on tumour growth in a rat model . Surg. Endosc., 11, 618-621.
3. Nezhat ,CR. Luciano AA., Nezhat FR. Et al .(1995) , operative laparoscopy – principales and techniques . mCg RAW-Hill, New York , P. 104.
4. Brosens IA. (1996) The value of salpingoscopy in tubal infertility . Reprod Med Rev ; 5:1-11.
5. Gordts S. Rudi Campo et al., (2002): Investigation of the infertile couple , Hum Reprod Vol 17 , No 7 pp. 1684-1686.
6. Scott P. , Magos A. (2002) Culdoscopy to examine the contour of the uterus before hysteroscopic metroplasty for uterine septum , J. Obestet Gynecol; 109, pp. 591-592.
7. Hirano Y. , Shibahara H., (2003) Useflness and prognostic value of Transvaginal Hydrolaparoscopy in infertile women. Fertil Steril ; Vol 79, Jan No. 1: 186-9.
8. Waterlot A. Dreyfus JM. Andine JP (1999) . Evaluation of the performance of fertilioscopy in 160 consecutiva infertile patients with no obvious pathology . Hum. Reprod;14:707-11.
9. Brosens AI. (1999) Philosophy of endoscopic surgery in reproductive medicine . From conceptual to deductive approach ., Ref Gynecol. Obestet. 6:117-21.
10. Campo R, Gordts S , Rombauts L, Brosens I., (1999) . Diagnostic accuracy of transvaginal hydrolaparoscopy in infertility . Fertil. Steril. 1999; 6:1157-1160.
11. Casa A., Sesti F., Marziola M., Piccione E. (2002): Transvaginal Hydrolaparoscopy vs conventional laparoscopy for evaluating unexplained primary infertility women. J. Reprd. Med., 47(8); 617-620.
12. Darai E. Dessolle L. et al., (2000) Transvaginal Hydrolaparoscopy compared with laparoscopy for evaluation of infertile women : a prospective comparable blind study. Hum. Reprod., 15,2379-2382.
13. Dechaud H. Amina S. Ahmed A., et al., (2000) Does Transvaginal Hydrolaparoscopy render standard laparoscopy obsolete for unexplained infertility investigation ; J Obestet Gynecol 94 :97-102.



Road Map
Of
Chronic Pelvic Pain In Women
By
Dr. Nasr Said Nassar
Consultant Obstetrics and Gynecology
Head of Department Of Ob.&Gyn,
Monira General Hospital, Cairo Egypt
President Of Egyptian Society Of
Chronic Pelvic Pain For Women
-------------------------
What is chronic female pelvic pain?
What are possible causes of chronic pelvic pain?
What are common symptoms?
What increases the risk of chronic pelvic pain?
When to call a doctor?
How is chronic pelvic pain in women diagnosed?
** Taking complete history :
** Tests and Diagnosis
How is the prevention?
How is chronic pelvic pain treated ?
** Home Treatment
**Medication Choices
** Surgery Choices :
**Other treatment :
Alternative medicine
Lifestyle and home remedies

What is chronic female pelvic pain?
Chronic pelvic pain, refers to pain in female pelvic region, i.e. pain, below a woman’s belly button, or pain in the region between both hips, and below the belly button. In order to be considered chronic, the pain must last for at least six months or longer. The type of pain varies from woman to woman. The pain may be enough to interfere with normal daily activities, i.e. difficult to sleep, work or enjoy life.
The pain may comes in attacks and disappears or be constant. It may severe, moderate or mild.
The pain takes different forms like sharp, dull ache, heaviness, pressure, colicky or stitch pain. If the patient asked to locate pain, she might sweep her hand over that entire area rather than point to one spot.
The pain may indicate that the lesion or the pathology is in the same the site of pain, or it may be referral pain indicates that the lesion or the pathology in another place different of the site of pain..
What are possible causes of chronic pelvic pain?
The cause of chronic pelvic pain is often hard to find. Like many women, your patient never receives a specific diagnosis that explains her pain. But you have to tell your patient that doesn't mean her pain isn't real and treatable.
If the source of your chronic pelvic pain is found, treatment focuses on that cause. If no cause can be found, treatment for chronic pelvic pain focuses on managing the pain.
Some of the more common causes of chronic pelvic pain include:
 Endometriosis. This can lead to painful cysts and adhesions (fibrous bands of scar tissue).
 Tension in pelvic floor muscles. Spasms or tension of the pelvic floor muscles can lead to recurring pelvic pain.
 Chronic pelvic inflammatory disease. This can occur if a long-term infection, often sexually transmitted, causes scarring involving pelvic organs.
 Pelvic congestion syndrome. This condition may be caused by enlarged, varicose-type veins around uterus and ovaries.
 Ovarian remnant. During a complete hysterectomy — surgical removal of the uterus, ovaries and fallopian tubes (salpingo-oophorectomy) — a small piece of ovary may be left inside, which can later develop tiny, painful cysts.
 Fibroids. These non-cancerous uterine growths may cause pressure or a feeling of heaviness in lower abdomen. They rarely cause sharp (acute) pain unless they become deprived of nutrients and begin to die (degenerate).
 Irritable bowel syndrome. Symptoms associated with irritable bowel syndrome — bloating, constipation or diarrhea — can be a source of uncomfortable pelvic pain and pressure.
 Interstitial cystitis. Chronic inflammation of the bladder and a frequent need to urinate characterize interstitial cystitis. The patient may experiences pelvic pain as the bladder fills, which may improve temporarily after emptying the bladder.
 Psychological factors. If the patient is depressed, experiences chronic stress or has been sexually or physically abused, she may be more likely to experience chronic pelvic pain.
Emotional distress makes pain worse, and likewise living with chronic pain makes emotional distress worse. So chronic pelvic pain and emotional distress frequently get locked into a vicious cycle.
Detection of the cause of chronic pelvic pain in women is often very difficult, lengthy process, frustrated, and not found in many cases. Up to 61 % of chronic pelvic pain in women sufferers will never be specifically diagnosed, i.e. 61 % of these patients are with unknown etiology.
Sometimes, after a disease has been treated or an injury has healed, the affected nerves keep sending pain signals. This is called neuropathic pain. It may help explain why it can be so hard to find the cause of chronic pelvic pain.

What are common symptoms?
Chronic pelvic pain exhibits many different characteristics. Among the signs and symptoms are:
 Severe and steady pain, extreme and constant pain.
 Pain that comes and goes (intermittent)
 Dull aching
 Sharp pains or cramping
 Pressure or heaviness deep within the pelvis
In addition, the patient may experience:
 Pain during intercourse
 Pain while having a bowel movement
 Pain when she sit down
The discomfort may intensify after standing for long periods and may be relieved when she lies down. The pain may be mild and annoying, or it may be so severe that she miss work, can't sleep and can't exercise.
The type of pain of chronic pelvic pain can vary widely, can include:
• Pain that ranges from mild to severe.
• Pain that ranges from dull (vague) to sharp.
• Severe cramping during periods.
• Pain during sex.
• Pain when you urinate or have a bowel movement.
• Chronic pelvic pain can lead to depression.
• Depression can cause the patient to feel sad and hopeless, eat and sleep poorly, and move slowly.
Also,
• Severe menstrual cramps (dysmenorrhea).
• Low backache 1 or 2 days before the start of the menstrual period (or earlier), subsiding during the period.
• Painful urination.
• Rectal pain.
• Pain during bowel movements.
Symptoms that can accompany pelvic pain, depending on the cause, include:
• Blood in the urine or stool.
• Vaginal bleeding after intercourse.
• Heavy or irregular vaginal bleeding.
What increases the risk of chronic pelvic pain?
Factors that increase a woman's risk of developing female pelvic pain that becomes chronic include:
• Pregnancy and childbirth that have stressed the back and pelvis, including delivery of a large baby, a difficult delivery, or a forceps or vacuum delivery.
• A history of childhood or adult physical or sexual abuse. About half of women with chronic female pelvic pain report abuse in their past.
• A history of pelvic inflammatory disease (PID).
• A history of radiation therapy or surgery of the abdomen or pelvis (including some surgeries for urinary incontinence).
• Past or current diagnosis of depression. Pain sensation and depression seem to be interrelated.
• Alcohol or drug abuse.
• An abnormal structure (congenital abnormality) of the uterus, cervix, or vagina.
When to call a doctor?
General advice to all women, to call doctor if she got one of the following:
• Her periods have changed from relatively pain-free to painful.
• Pain interferes with daily activities.
• She begins to have pain during intercourse.
• She has painful urination, blood in your urine, or an inability to control the flow of urine.
• She has blood in the stool or a significant, unexplained change in her bowel movements.
• Even if she notices any minor new pelvic symptoms.
How is chronic pelvic pain in women diagnosed?
** Taking complete history :
Many helpful questions are important especially about the past and present health, and about illness or health-related problems in patient's family. She should be asked to describe the kind of pain she has, where it is and how strong it is. She should be asked about anything can causes the pain to get better or worse.
Also, some leading questions should be asked as :
• Is the pain related to her menstrual cycle?
• Is it related to bowel movements?
• Does it hurt during urination or sexual activity?
• Has she had an infection?
• Has she had surgery in your pelvic area?

More details:
• When did she first begin experiencing pelvic pain?
• Has her pain changed or spread over time?
• How often does she experience pelvic pain?
• How severe is her pain, and how long does it last?
• Where is her pain located? Does it always occur in one place?
• Would she describe herr pain as sharp or dull?
• Does her pain come in waves or is it constant?
• Can she anticipate when the pain is coming?
• Is her pain usually triggered by a specific event, such as intercourse or exercise?
• Does she feel pain during urination or a bowel movement?
• Does her menstrual cycle affect your pain?
• Does anything make herr pain better or worse?
• Does her pain limit herr ability to function? For example, has she ever had to miss school or work because of your pain?
• Is her pain causing difficulty in her marriage or other important personal relationships?
• Has she recently felt down, depressed or hopeless?
• Has she recently lost interest in things you once enjoyed?
• Has she ever had pelvic surgery?
• Has she ever been pregnant?
• Has she ever been treated for a urinary tract or vaginal infection?
• Has she ever been touched against your will?
• What does she think is causing her pain?
• What treatments has she tried so far for this condition? How have they worked?
• Is she currently being treated or has she recently been treated for any other medical conditions?
** Tests and Diagnosis
Possible tests or exams are include:
Pelvic examination,. This can reveal signs of infection, abnormal growths or tense pelvic floor muscles. Check for areas of tenderness and changes in sensation. This pelvic examination may be more extensive than what used to be during a routine gynecologic examination. It's important to know if she feels any pain during this exam, especially if the pain is similar to the discomfort the patient has been experiencing.
* A digital rectal exam may be conducted in a slower, more thorough manner than a routine pelvic exam, carefully checking for tender areas.
* Cultures. Samples can be taken from the cervix or vagina to check for infection, including sexually transmitted diseases, such as chlamydia, herpes and gonorrhea.
* A Pap test, which detects cervical cancer and cervical precancerous (dysplasia).
* A complete blood count (CBC), which can detect signs of infection, anemia, and blood cell abnormalities.
* An erythrocyte sedimentation rate (ESR), which can indicate infection if elevated.
* Urinalysis and urine culture, which can detect signs of infection and kidney stones.
* Stool analysis, to check for signs of blood.
* Abdominal ultrasound and/or transvaginal ultrasound of the pelvic area. Ultrasound plays a major role in looking for causes of pelvic pain. It is useful for detecting endometrial hyperplasia; pelvic inflammatory disease; and cancerous or noncancerous (benign) growths such as fibroids, cysts, and tumors on the ovaries, uterus, cervix, or fallopian tubes.
* Intravenous pyelogram (IVP), to check the kidneys, bladder, ureters, and urethra.
* Laparoscopy, look inside the pelvis for causes of pain, including scar tissue (adhesions), abnormal growths, cysts, tumors, and pelvic inflammatory disease.
Laparoscopy is the only way to confirm the presence of endometriosis, also, a growth or adhesion can also be removed during the procedure.
* Computed tomography (CT) scan of the pelvis, which uses X-rays to create pictures of organs and bones.
* Magnetic resonance imaging (MRI) of the pelvis, which uses a magnetic field and pulses of radio wave energy to create pictures of organs and bones.
* Cystoscopy, which uses a viewing instrument inserted through the urethra into the bladder. This allows seeing signs of inflammation, growths, or stones in the bladder.
* Urodynamic studies, which test bladder function and whether bladder spasms are causing pelvic pain.
* Evaluation for irritable bowel syndrome.
* Evaluation of abdominal wall for "trigger points."
How is the prevention?
Early diagnosis and treatment of acute pelvic pain may help prevent chronic female pelvic pain from developing.
One cause of chronic pelvic pain is pelvic inflammatory disease (PID). Protection from sexually transmitted diseases (STDs) should be emphasized.
Remember that it is quite possible to be infected with an STD without knowing it. Some STDs, such as HIV, can take up to 6 months before they can be detected in the blood.
Advice to avoid all sexual contact with anyone who has symptoms of an STD or who may have been exposed to an STD.
Advice to avoid more than one sex partner at a time. The risk for an STD increases if woman has several sex partners at the same time.
Abstaining from sexual contact is the only certain way to avoid exposure to STDs. (Practice safe sex or abstinence)
How is chronic pelvic pain treated ?
** Home Treatment
Home treatment may help ease female pelvic pain and can be used with simple medical treatment plan.
To relieve the pain:
* Try nonprescription medicine, such as ibuprofen or acetaminophen.
* Start taking the recommended dose of pain medicine as soon as the feeling of uncomfortable.
* If the patient has painful periods, she should start taking the medicine one day before menstrual period is scheduled to start.
* She should take the medicine in regularly scheduled doses to keep the pain under control. Pain medicine works better if she takes it at regularly scheduled times.
* She should not take more than the recommended dose.
* She should not take aspirin if she is younger than 20 unless doctor tells you.
* She should not take any medicine if she is or could be pregnant.
* Apply a heating pad, hot water bottle, or warm compress to the lower belly, or take a warm bath. Heat improves blood flow and may relieve pain.
* To relieve back pain, the patients lie down and elevate the legs by placing a pillow under the knees. When lying on the side, bring the knees up to the chest.
* She should try relaxation techniques, such as meditation, yoga, breathing exercises, and progressive muscle relaxation.
* She should try exercise regularly. It improves blood flow, increases pain-relieving endorphins naturally made by the body, and reduces pain.
* She should try sexual activity, which may relieve pelvic cramping and backache. If the pain is related to endometriosis, however, sex may make it worse.

** Medication Choices
The following may help relieve symptoms:
* Prescription nonsteroidal anti-inflammatory drugs (NSAIDs), taken on a regular schedule, help relieve pain caused by inflammation or menstruation. If one type doesn't work for the patient, the doctor may recommend that the patient try at least one other before stopping NSAID therapy.
* Birth control pills (oral contraceptives) are commonly prescribed to reduce painful menstruation. Oral contraceptives are often prescribed for endometriosis-related pain, though there is little research that shows them to be effective.
* High-dose progestin is sometimes prescribed to relieve pain related to endometriosis.
* Gonadotropin-releasing hormone agonists (GnRH-As) can relieve endometriosis-related pain by stopping production of the hormones that make endometriosis worse.
GnRH-A treatment may also relieve cyclic pelvic pain not related to endometriosis, as well as pelvic pain related to irritable bowel syndrome. However, this short-term treatment induces menopause, with side effects such as hot flashes and loss of bone density, for as long as the patients take it.
* Tricyclic antidepressant medications (TCAs) are sometimes used to treat chronic pain in other areas of the body. Limited research suggests that TCA therapy decreases chronic pelvic pain intensity for some women.
* Narcotic pain medication is only recommended as a last-resort treatment for severe pelvic pain because of the risk of addiction.
* No single medication successfully treats chronic pelvic pain in all women.
* Treating chronic pelvic pain with medication is usually preferable to using a surgical option. Surgery is only recommended when a correctable cause of pain is clearly known. Even in these cases, there are no guarantees that surgery will relieve pain or that it will not cause further problems.
* Chronic pelvic pain symptoms sometimes stop naturally when menopause occurs. If the patients are close to menopausal age (usually around age 50) and the symptoms are likely related to hormones, the best option may be home treatment and medication until menopause occurs.

** Surgery Choices :
Surgery may be used in the diagnosis or treatment of chronic pelvic pain. It is most likely to be effective when it is performed for a specific condition, such as fibroids or endometriosis.
There is no evidence that surgical removal of the reproductive organs relieves chronic pelvic pain. It can even make the pain worse. When surgery, such as hysterectomy or cutting of specific pelvic-area nerves, is done for pain with no known cause, there is a risk of persistent pain or pain that is worse after surgery as well as surgery-related side effects.
Either laparoscopic surgery through a small incision or laparotomy through a larger abdominal incision can be used for procedures to treat pelvic pain.
Laparoscopy to diagnose chronic pelvic pain may be done before treatment with medications (other than birth control pills) or surgery. Sites of endometriosis (implants) or scar tissue (adhesions) may be removed or destroyed during the laparoscopy.
Hysterectomy, the surgical removal of the uterus, is sometimes used as a last-resort treatment for chronic, severe pelvic pain. Depending on the cause, hysterectomy may relieve pain for some women.
Hysterectomy is only a good treatment choice for chronic pelvic pain when a documented disease or surgically correctable condition of the pelvic organs is present.
When hysterectomy is performed solely for relief of pelvic pain, the results may be disappointing.
Studies have shown that surgery to remove scar tissue adhesions from previous surgery or from pelvic inflammatory disease does not relieve pain unless the adhesions are severe (referred to as stage IV adhesions).

Surgery may lead to complications that cause added pain, discomfort, or other problems such as infection or scar tissue.
Symptoms caused by chronic pelvic pain often go away without treatment when menopause occurs and hormone fluctuations settle down. Controlling symptoms with home treatment or medications until menopause may be an option.

**Other treatment :
Female pelvic pain treatment can be enhanced with counseling, mental skills training, relaxation, and physical therapy treatment.
Counseling and mental skills training help the patient to learn the mental and emotional tools for managing chronic pain and the stress that makes it worse.
Commonly recommended approaches include:
* Cognitive-behavioral therapy focused on changing the way patient`s think about and mentally manage pain. This approach is a proven chronic pain treatment.
( See a psychologist, licensed counselor, or clinical social worker who specializes in pain management skills.)
* Biofeedback, which is the conscious control of body function that is normally unconsciously controlled.
Biofeedback, this alternative therapy is based on the idea, confirmed by scientific studies, that the patient can use her mind to control her body. Working with a biofeedback therapist, the patient will use special monitoring equipment that beeps or flashes when her body is sending cues that pain is on the way. As she recognizes these cues, she can train her body to respond differently and decrease the sensation of pain.
* Interpersonal counseling, focused on best managing her life events, stressors, and relationships.
* Physical therapy can help the patient to learn specific exercises to stretch and strengthen certain muscle groups. Physical therapy helps her to improve posture, gait, and muscle tone.
Alternative medicine
Alternative pain treatments for chronic female pelvic pain are not well studied but are considered helpful for managing stress and building mental mastery over pain.
Several types of alternative therapies may reduce pain associated with certain medical conditions.
Acupuncture and trans-cutaneous nerve stimulation (TENS) have shown some success in relieving painful menstrual periods.
Acupuncture has also been used as a treatment for non-menstrual chronic pelvic pain but is not yet well studied.
During acupuncture treatment, a practitioner inserts tiny needles into the skin at precise points. Pain relief may come from the release of endorphins, the body's natural painkillers, but how this method works isn't known.
Trans-cutaneous electrical nerve stimulation (TENS). This approach may help improve localized or regional pain. During TENS therapy, electrodes deliver electrical impulses to nearby nerve pathways — which can help control or relieve some types of pain.
Other low-risk alternative pain treatments that many people use to help manage pain include:
Relaxation and breathing exercises, which are a proven treatment for chronic pain.
Relaxation techniques. Deep breathing and targeted stretching exercise for the pelvic region could help minimize bouts of pain when they occur.
Hypnosis.
Guided imagery.
Aromatherapy.
Meditation.
Yoga.
Massage therapy.
Chronic pelvic pain takes time to develop and can take a long time to treat. Take a time to the patients to know how to cope with pain by using one or more of the treatment choices above. Combine the treatment with the practices she prefers for keeping a positive state of mind.
Lifestyle and home remedies
One of the more frustrating aspects of chronic pain is that it can have a strong impact on the daily life. When pain strikes, the patient may have trouble sleeping, exercising or performing physical tasks, and she may withdraw from social situations because of the pain.

Self-care measures to bolster the emotional and mental health may ease the discomfort:
Emotional support: Chronic pain can trigger some intense, negative emotions, such as pain, grief and anger, which can affect the self-esteem and the relationships with others. Emotional support by patient's family members and friends , by listening , show interest and sympathy , help, advise and encourage her to follow the medical instruction, accompany the patient to doctor visits ………...etc.
Stress management: Becoming too anxious or stressed over certain situations may exacerbate chronic pain. Effective stress management techniques not only help reduce the patient's stress levels, but may also have the indirect effect of easing stress-triggered pain

References :
1. Chronic pelvic pain. American Academy of Family Physicians. http://familydoctor.org/online/famdocen/home/women/reproductive/gynecologic/033.html. Accessed Jan. 8, 2009.
2. Chronic pelvic pain. International Pain Society. http://www.pelvicpain.org/pdf/Patients/CPP_Pt_Ed_Booklet.pdf. Accessed Jan. 8, 2009.
3. Pelvic pain. American College of Obstetricians and Gynecologists. http://www.acog.org/publications/patient_education/bp099.cfm. Accessed Jan. 8, 2009.
4. Howard F. Evaluation of chronic pelvic pain in women. http://www.uptodate.com/home/index.html. Accessed Jan. 8, 2009.
5. Chronic pelvic pain. Rockville, Md.: Agency for Healthcare Research and Quality. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10940&nbr=5720&string=. Accessed Jan. 8, 2009.
6. Howard F. Treatment of chronic pelvic pain in women. http://www.uptodate.com/home/index.html. Accessed Jan. 8, 2009.
7. Gallenberg MM (expert opinion). Mayo Clinic, Rochester, Minn. Jan. 16, 2009.
American College of Obstetricians and Gynecologists (2004). Chronic pelvic pain. ACOG Practice Bulletin No. 51. Obstetrics and Gynecology, 103(3): 589–605.
8.Howard FM (2003). Chronic pelvic pain. Obstetrics and Gynecology, 101(3): 594–611.
9.Hewitt GD, Brown RT (2000). Acute and chronic pelvic pain in female adolescents. Medical Clinics of North America, 84(4): 1009–1025.
10dice LC, et al. (1998). Status of current research on endometriosis. Journal of Reproductive Medicine, 43(3): 252–262.
11.Mishell DR Jr, et al. (2001). Differential diagnosis of major gynecologic problems by age groups. In MA Stenchever et al., eds., Comprehensive Gynecology, 4th ed., pp. 155–176. St. Louis: Mosby.
12.Mishell DR Jr, et al. (2001). Endometriosis and adenomyosis. In MA Stenchever et al., eds., Comprehensive Gynecology, 4th ed., pp. 531–564. St. Louis: Mosby.
13.National Institutes of Health (1995). Integration of Behavioral and Relaxation Approaches Into the Treatment of Chronic Pain and Insomnia. NIH Technology Assessment Conference Statement (1995 October 16–18). Available online: http://consensus.nih.gov/1995/1995BehaviorRelaxPainInsomniata017html.htm.
14 WebMD.com
15 Written by familydoctor.org editorial staff. American Academy of Family Physicians
16 http://www.mayoclinic.com/health/chronic-pelvic-pain/ds00571



Intrauterine Device (Pros, Cons), And Its Relation To Chronic Pelvic Pain.
By
Dr. Nasr Said Nassar
Consultant Obstetrics and Gynecology
Head of Department Of Ob.&Gyn,
Monira General Hospital, Cairo, Egypt
President Of Egyptian Society Of
Chronic Pelvic Pain For Women

1 * What is an intrauterine device (IUD)?
2 * History of the intra-uterine device (IUD)
3 * What Types of IUDs are available?
4 * How do IUDs work ?
5 * When can an IUD be inserted.
6 * Advantages of IUDs?
7 * Disadvantages of IUDs?
8 * Chronic Pelvic Pain with IUDs.
-----------------------
1 * What is an intrauterine device?
The intrauterine device (IUD) is a form of birth control methods.
An IUD is a safe and effective method of birth control which doctors have been testing for nearly one hundred years. (8)
The IUD is a small, plastic device that is inserted and left inside the uterus to prevent pregnancy.
The IUD is the most common method of birth control all over the world. In USA, and western societies, IUD is currently the second most commonly used method following sterilization.
IUDs are the most effective form of nonpermanent birth control. They are more than 99% effective. This means that if 100 women use the copper IUD or the levonorgestrel IUDs, less than 1 woman will become pregnant in a year.(5)
The copper IUD is the most popular in Egypt.
2 * History of the intra-uterine device.
It is believed that the concept of IUDs first arose from the practice of Arabs by putting stones in the uterus of camels in order to prevent pregnancies during long journeys.
The first human intrauterine device was introduced in the 1960s and was made of inert plastic. In the late 1960s it was discovered that adding copper to the plastic IUD made it a more effective contraceptive while also reducing the risk of bleeding. (6)
- IUD introduced in the 70s known as the Dalkon shield resulted in numerous infections of the uterus giving IUDs a bad reputation which resulted in a large decline in their use. (6)
- Modern IUD is one of the safest, and most tolerated methods of birth control available and its low failure rate (1-3%) makes it one the highest contraceptive efficiency of all contraceptive methods. (6)
3 * What types of IUDs are available?
Although there have been several types of IUDs, currently only two are available:
 Copper IUD
The copper IUD consists of a polyethylene plastic frame with copper wire coiled around the stem and arms.
It also has a plastic monofilament thread attached at the end of the stem which hangs from the cervix into the vagina. This thread aims to assist in the placement and removal of the IUD.
The two main brands available are the copper T 380 and the multiload 375.
The copper IUD has been approved for use for up to 10 years and can be effective for up to 12 years.
It can be inserted at any time during the menstrual cycle as long as pregnancy has been excluded. Further, it can be inserted immediately after abortion and immediately postpartum (within 48 hours of giving birth). (6)
 Hormone releasing IUD
The more recently developed hormone releasing IUD has been available in the US since 2000 but was widely used in Europe since 1990.
This IUD is also made of plastic but contains within it a progestogen hormone called levonorgestrel. Instead of copper it contains 52mg of levonorgestrel which is released at a rate of 20 micrograms per day.
This IUD has more restrictions in its use and when it can be inserted and must be replaced after 5 years. (6)
4 * How do IUDs work?
How an IUD Works
Both types of IUDs are T-shaped, but they work in different ways. The hormonal IUD releases a small amount of the hormone progestin into the uterus. This thickens the cervical mucus, which decreases the chance that the sperm will enter the cervix. It may make the sperm less active and make the sperm and the egg less likely to be able to live in the fallopian tube. It also thins the lining of the uterus. This keeps a fertilized egg from attaching and makes menstrual periods lighter.
The copper IUD releases a small amount of copper into the uterus. This can prevent the egg from being fertilized or attaching to the wall of the uterus. The copper also prevents sperm from going through the uterus and into the fallopian tubes and reduces the sperm's ability to fertilize an egg.
As soon as the IUD is removed, it no longer protects against pregnancy. (1)
5 * When can an IUD be inserted?


We should encourage more women to use the modern IUDs; generally speaking, all women could use IUDs except at the following situations, i.e. Patients should not use an IUD if she:

• Is pregnant
• Has or has had within the past 3 months pelvic inflammatory disease
• Has a known or suspected pelvic cancer
• Has abnormal vaginal bleeding
• Have a bleeding disorder;
• Painful or heavy periods;
• Unexplained vaginal bleeding;
• Moderate to severe anaemia;
• Previous ectopic pregnancy;
• Has a risk of acquiring a sexually transmitted infection (STI)
• Has certain liver conditions, Wilson’s disease (hormonal IUD only)
• Is allergic to any part of the IUD
• Has uterine fibroids or other problems that may interfere with inserting an IUD.
• Uterine or cervix abnormality;
• Difficulties with vaginal examination and procedures.
• Cancer of uterus, cervix or endometrium;
• Copper IUDs are not suitable for women who have very painful, heavy or prolonged periods or who have iron deficiency anaemia.
• Have more than one sexual partner or a partner who has other partners;
• Vavular heart disease;
Warning Signs
These symptoms may signal there is a problem with the IUD. The patient should call her doctor if she has any of the following symptoms:
• Severe abdominal pain
• A missed period or other signs of pregnancy
• Unusual vaginal discharge
• A change in length or position of the string
• The IUD can be felt in the cervix or vagina
• Pain or bleeding when she have sexual intercourse.
• Fever or chills for no reason.
6 *Advantages of IUDs?
IUD is safe, highly effective form of long-term contraception.

Rapidly reversal, cheep and cost-effective method of contraception.
Can be removed at any time, and fertility returns quickly .
Have very small or no metabolic effects (eg on cholesterol levels and blood clotting). Do not usually interfere with normal hormonal cycle. (5)

IUD is easy to use. Once it is in place, the patient does not have to do anything else to prevent pregnancy; IUD does not interfere with sex or daily activities.
The copper IUDs are suitable for women who want long-term contraception but cannot or do not wish to use hormonal preparations.
The advantage of the copper IUD is that it is hormone-free providing a suitable option for women who experience problems with hormonal methods. (6)
IUDs are one of the most effective forms of contraception. They are more than 99% effective at preventing pregnancy with less than one pregnancy occurring per 100 women using an IUD in the first year.(6)
If her period is two weeks late she should have a pregnancy test done. If she does conceive, the IUD will have to be removed regardless of whether she planes to continue the pregnancy or not. (8)
Like the emergency pill ('morning after pill') the IUD can also be used as emergency contraceptive, i.e. it can be used to prevent a pregnancy after unprotected sexual intercourse or after the failure of another method (e.g. burst condom).
For this purpose the intrauterine device must be inserted postcoitally (after intercourse) within 5 days after the estimated date of ovulation. After emergency insertion the device can be left in the uterus for continued contraception. (11)
The copper IUD is as an emergency contraceptive. It can prevent up to 99% of pregnancies when inserted within 5 days of unprotected sex.
However, the hormone releasing IUD cannot be used for emergency contraception. (7)
** SAFE IN NULLIPARA :
Although, many health providers do not used to insert IUD for nulliparous patients, who have never, had a child.
Recent studies indicate that the modern IUD is safe.
Hubacher and colleagues recruited 1,311 nulligravid, infertile women 18 years of age and older to study the relationship between the IUD and infertility. (14) Hysterosalpingography demonstrated that 358 of the women had tubal disease and 953 did not. Among these infertile women with and without tubal disease, the odds ratio for tubal occlusion associated with prior use of a copper IUD was 1.0 (95% confidence interval, 0.5 to 1.9).
In addition, the long-term use of a copper IUD, removal of the IUD because of side effects, and a history of gynecologic symptoms during use of an IUD were not associated with an increased risk of tubal occlusion among the subjects. In contrast, the presence of antibodies to Chlamydia trachomatis among women who had not used an IUD was associated with an increased risk of tubal occlusion (odds ratio 2.4; 95% confidence interval, 1.7 to 3.2).
The Hubacher study demonstrates the safety of the IUD and suggests that C. trachomatis infection among non-IUD users is the main contributor to tubal factor infertility.(12)
** THE IUD CAN TREAT COMMON GYNECOLOGICAL PROBLEMS :
IUDs are not approved by the FDA to treat gynecologic disease. Recently published data indicate, however, that a levonorgestrel-releasing intrauterine system (IUS) is effective for treating excessive menstrual bleeding and pelvic pain caused by endometriosis.(12)
Menstrual bleeding. Randomized studies have reported that the levonorgestrel IUDs reduces heavy menstrual bleeding. In head-to-head comparison of the levonorgestrel IUS with endometrial resection and with endometrial balloon ablation, for example, patient satisfaction was similar with all treatments. (15)
In another randomized trial, treatment of heavy menstrual bleeding with the levonorgestrel-containing device was better accepted by patients than treatment with oral norethindrone.( 21)
Several trials have demonstrated that the levonorgestrel IUDs is effective for treating pelvic pain caused by endometriosis. (16 - 18)
And other evidence. Additional reported uses of the levonorgestrel IUDs include treatment of endometrial hyperplasia (19) and prevention of endometrial polyps in women who take tamoxifen. (20)
The hormone releasing IUDs (Mirena) also has many other uses apart from its role as a contraceptive. This IUD is also useful alternative to hysterectomy for the treatment of menorrhagia, dysfunctional uterine bleeding and leiomyomas .(6)
Menopausal Hormone Therapy: (Mirena) alternative delivery method for progesterone component of combined menopausal hormone replacement therapy. Good for women who cannot tolerate oral progesterone pills. Women experience similar decreases in hot flashes and night sweats when compared to women taking traditional hormone replacement regimens (estrogen and progesterone pills and patches). (7)
7 * Disadvantages of IUDs?
*** IUD gives NO protection against sexually transmitted diseases.
*** Mirena: progesterone secreting IUD. Women may experience mood changes, acne, breast tenderness and weight gain due to slight increase of progesterone levels in the circulation(7)
*** Heavy bleeding with periods and increased pain with or between periods.

*** Irregular bleeding and/or spotting for the first few months after insertion (more common with Mirena)


*** Pelvic infections associated with STDs (The IUD does not protect against STDs.)
*** Serious complications from use of an IUD are rare. However, some women do have problems. These problems usually happen during, or soon after, insertion:
Expulsion: The IUD is pushed out of the uterus into the vagina. It happens within the first year of use in about 5% of users. This rate decreases with length of use. It is more likely to occur in women who have not had children. If the IUD is partly or fully expelled, it is no longer effective.
Perforation: The IUD can perforate (or pierce) the wall of the uterus during insertion. This is very rare and occurs in only about 1 out of every 1,000 insertions.
Infections: Infections in the uterus or fallopian tubes can occur. This may cause adhesions in the reproductive organs, causes chronic pelvic pain and infertility. In women at low risk for STDs, this occurs in as few as 1 out of every 1,000 women using an IUD.
Pregnancy: Rarely, pregnancy may occur while a woman is using an IUD. If the string is visible, the IUD should be removed. If the IUD is removed soon after conception, the risks caused by having the IUD in place are decreased. If the IUD remains in place, there are increased risks to the mother and fetus, including increased risk of miscarriage, infection, or preterm birth. If pregnancy occurs, there is also an increased risk that it will be an ectopic pregnancy. However, pregnancy may go to term with an IUD in place.(1)
8 * Chronic Pelvic Pain with IUDs :
Types of pain usually occurred with IUD insertion, and considered as side effects of a correctly placed IUD are :
- Cramp-like pain similar to spasmodic dysmenorrhea
- Dull aching low abdomen
- Deep seated pelvic pain
- Dyspareunia
- Dysmenorrhea
- low backache pain
- Chronic pelvic pain (CPP)
The chronic pelvic pain with IUDs, mainly attributed to the presence of:
- * Pelvic varicosities and/or venous stasis {diagnosed by laparoscopy (52%), and venography (95%),}.
- * Chronic pelvic inflammatory disease (28%).
- * Pelvic adhesions (8%).
- * Pain was associated with Menorrhagia in one-third of the IUD cases and was explained on the basis of increased pelvic vascularity, chronic pelvic inflammatory disease, and cystic changes in the ovaries.(2)
After insertion of the IUD the women may initially experience pelvic pain but this usually subsides after a short time.
Persistent pain and heavier bleeding can be a sign that the IUD has not been inserted properly.
The differential diagnosis of pain directly attributable to the IUD is discussed. In a series involving 1250 IUD insertions.(9)
- 1.7% incidence of faintness, bradycardia or syncope (0.8% in parous patients and 3.2% in nulliparous patients).
- Insertional pain, there is a 5.7% incidence of moderate-severe insertional pain (2.2% in parous patients and 11.7% in nulliparous patients).
- A pain and/or bleeding removal rate of 11.1/100 woman-years.
- Pelvic pain, which includes insertional pain, intermenstrual cramps dyspareunia, and increased dysmenorrhea, is the most important factors necessitating IUD removal.
- The larger and stiffer IUDs and those whose shape does not conform to that of the endometrial cavity produce localized endometrial ulceration and inflammation which contribute to the pelvic pain.
- Endometrial prostaglandin release secondary to the presence of the IUD may also play an important part of the chronic pelvic pain. (9)
At the end of each monthly menstrual period and any time patient will feel strange cramping during her period, she should check for the string inside of her vagina.
It is important to rule out source of the chronic pelvic pain:
- Pelvic infection mainly sexually transmitted diseases, and particular concern for actinomyces.
- Pelvic congestion.
- An ultrasound may be helpful in documenting correct placement of the IUD and in checking for fibroids as a potential cause of these symptoms. (4)
In a retrospective IUD study of 8,536 first and repeated insertions of an IUD, spanning the years 1972-1978, shows :
- (8.1%) of women with IUDs are complaining of lower abdominal/pelvic pain.
- At the pelvic examination 65 % of these women had tenderness at palpation (i.e. 65 % are patients with tenderness at palpation).
- 44.7% of these patients, the most frequent alteration was tenderness of the uterus surroundings and the next one was tenderness of both the uterus and its surrounding at palpation (15.4%), only uterus tenderness without involvement of the surroundings was noted at 8.6% of the patients.
- Enlargement at one side only without fluctuation was 7.5%, and enlargement at both sides without fluctuation was 0.4%. Enlargement at one side or both with fluctuation was found to be 2.6% of the patients.
- Abscess formation was registered in 0.4% women of the insertions. (10)
PELVIC INFLAMMATORY DISEASE (PID)
The use of intrauterine devices is one of the causes of pelvic inflammatory disease (PID), which occurs more than four times higher in IUD users.
Pelvic inflammatory disease (PID) is an infection of the female pelvic organs, and occurs most often among sexually active women between the ages of 15 and 25 ( in western societies) , 25 and 35 (in our Egyptian society).
PID can cause adhestions inside the reproductive organs, which can later cause serious complications, including chronic pelvic pain, infertility, ectopic pregnancy. Occasionally, the infection can spread to in the peritoneum causing inflammation and the formation of scar tissue on the external surface of the liver (Fitz-Hugh-Curtis syndrome).
Douching is also a cause of pelvic inflammatory disease (PID). It appears that women know that the IUD is a source of pelvic infection and trying to clean the area by doing regular vaginal douching, but the reality is increasing the possibility of occurrence of PID , by flushing of bacteria up from inside the uterus CHRONIC METRITIS, then to tubes SALPINGITIS, and ovaries OOPHORITIS, PERIOOPHRITIS, also bacteria reaches the pelvic cavity and peritoneum. PID may be acute then turned to chronic.
The fallopian tubes and ovaries are normally protected by the acidic vagina, the mucous plug of the cervix, and cilia in the uterus and fallopian tubes. But there are seven situations, during which infection can more easily penetrate those delicate organs:
- During menstruation,
- The vagina is alkaline,
- The cervical plug is gone,
- A healthy menstrual flow protects the fallopian tubes and ovaries from infection.
- Sexual activity, during a period, can introduce bacteria.
- Use of an IUD is also a significant cause of infection.
- Vaginal douching
SYMPTOMS 0f (PID)
Lack of appetite, nausea, fever, chills, generalized aching, fast heartbeat, and occasionally vaginal bleeding.
There is aching (pain) of both sides of the abdomen. Bowel movements may intensify the pain , frequently pelvic inflammatory disease can result in both chronic pelvic pain and infertility. A single attack of this disease (PID) produces infertility about 15% of the time. Once salpingitis or oophoritis occurs, there is a 70% likelihood of infertility.
Conclusions
The intrauterine device (IUD) is a form of birth control methods.
An IUD is a safe and effective method of birth control. Rapidly reversal, cheep and cost-effective method of contraception.
IUD is safe for nulliparous patients, also the IUD can treat common gynecological problems beside its contraceptive effect.
The IUD is a small, plastic device that is inserted and left inside the uterus. Only two are available Copper IUD can be effective for up to 12 years and Hormone releasing IUD must be replaced after 5 years.
The copper IUD is the most popular in Egypt.
We should encourage more women to use the modern IUD.
Disadvantages of IUDs may be gives NO protection against sexually transmitted diseases, heavy and irregular bleeding also pelvic infections and pelvic varicosities and/or venous stasis, finally chronic pelvic pain.
Pelvic Pain with IUDs, has many types like :
• Cramp-like pain similar to spasmodic dysmenorrhea
• Dull aching low abdomen
• Deep seated pelvic pain
• Dyspareunia
• Dysmenorrhea
• low backache
• Chronic pelvic pain (CPP)
The chronic pelvic pain with IUDs, mainly attributed to the presence of:
* Pelvic varicosities and/or venous stasis {diagnosed by laparoscopy (52%), and venography (95%),}.
* Chronic pelvic inflammatory disease (28%).
* Pelvic adhesions (8%).
Pain was associated with Menorrhagia in one-third of the IUD cases and was explained on the basis of increased pelvic vascularity, chronic pelvic inflammatory disease, and cystic changes in the ovaries.


REFERENCES
1 - The American College of Obstetricians and Gynecologists April 2007
2 - Chronic pelvic pain in Lippes IUD users. Laparoscopic and venographic evaluation. Contraceptive Delivery Systems, 1981 Jan;2(1):41-51.
3 - Pelvic inflammatory disease From Wikipedia, the free encyclopedia
4 - IUD, spotting & pelvic pain
From: Verena Boylan MD anonymous@obgyn.net
Fri, 14 Apr 2000 08:42:29 -0500 (CDT)
5 - Written by the Center for Young Women's Health Staff Updated 5/12/2005
6 - BigPond Created: 27/9/2008 Modified: 6/2/2009
7 – The view from the bay. The many uses of the IUD
From Dr. Leah MillheiserHome > Student information > Student Health Service
8 – McGill University Women's > Health Matters > Health Matter > Health Service >Contraception> the Intrauterine Device (IUD), Page last update: Aug. 22, 2006
9 – TROBOUGH GE ,Pelvic pain and IUD, Journal of Reproductive Medicine, March 1978 ; 20 (3) : 167-174
10 – Lampe L, BatarI, Hafez ES, Van Os WAeds. Medicated IUDs polymeric delivery systems and IUD-related pelvic inflammatory diseases. Proceedings of the International Symposium. Amsterdam, Holland, June 27-30, 1979. Detroit, Michigan, Hafez and Van Os, 1979. :32A-B.
11 - Bayer HealthCare, Bayer Schering Pharma, Intra uterine device.
12- Robert L. Barbieri, MD, We should encourage more women to use the modern IUD April 2007 • Vol. 19, No. 04
13 - FPWA Sexual Health Services (Formerly Family Planning WA) Page last updated Mon, 12 Jan 2009
14 - Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F, Guzman-Rodriguez R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med. 2001; 345: 561 –567.
15 - Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2005 Oct 19; (4): CD002126.
16 - Clinical trial of a levonorgestrel releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis. Hum Reprod. 2005; 20: 1993 –1998.
17. Lockhat FB, Emembolu JO, Konje JC. The efficacy, side-effects and continuation rates in women with symptomatic endometriosis undergoing treatment with an intrauterine administered progestogen: a 3 year follow-up. Hum Reprod. 2005; 20: 789 –793.
18. Vercellini P, Frontino G, De Giorgi O, Aimi G, Zaina B, Crosignani PG. Comparison of a levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study. Fertil Steril. 2003; 80: 305 –309.
19- Vereide AB, Kaino T, Sager G, Arnes M, Orbo A. Effect of levonorgestrel IUD and oral medroxyprogesterone acetate on glandular and stromal progesterone receptors and estrogen receptors in human endometrial hyperplasia. Gynecol Oncol. 2006; 101: 214 –223.
20- FPWA Sexual Health Services (Formerly Family Planning WA) Page last updated Mon, 12 Jan 2009
21 - Irvine GA, Campbell-Brown MB, Lumsden MA, Heikkila A, Walker JJ, Cameron IT. Randomized comparative trial of the levonorgestrel intrauterine system and norethisterone for the treatment of idiopathic menorrhagia. Br J Obstet Gynecol. 1997; 104: 614 –616.
22. Vereide AB, Kaino T, Sager G, Arnes M, Orbo A. Effect of levonorgestrel IUD and oral medroxyprogesterone acetate on glandular and stromal progesterone receptors and estrogen receptors in human endometrial hyperplasia. Gynecol Oncol. 2006; 101: 214 –223.
23. Gardner FJE, Konje JC, Abrams KR , et al. Endometrial protection from tamoxifen-stimulated changes by a levonorgestrel releasing intrauterine system: a randomized controlled trial. Lancet. 2000; 356: 1711 –1717.
24. Mosher WD, Martinez G, Chandra A, Abma J, Willson S. Use of contraception and use of family planning services in the United States, 1982–2002. Hyattsville, MD: National Center for Health Statistics; 2004.