Mary Ellen Rousseau, CNM, MS; Sarabeth F. Gottlieb, CNM, MSN


J Midwifery Womens Health. 2004;49(6) 

In This Article

Gynecologic Sources of Pain

Chronic pelvic pain in perimenopausal and postmenopausal women can be due to a variety of gynecologic disorders, including benign or malignant tumors, interstitial cystitis, pelvic adhesions, or vulvodynia. Nongynecologic conditions, such as colorectal tumors, colitis, irritable bowel syndrome, and diverticular disease, may also be causes of pelvic pain. Two of the most common causes of pelvic and vulvar/vaginal pain among midlife women are fibroids and vulvodynia/dyspareunia.

Leiomyomas, commonly referred to as fibroids, are common, benign pelvic tumors that are present in both premenopausal and postmenopausal women. These are the most frequent cause of gynecologic surgery in the United States, accounting for one third of hysterectomies each year.[27] Fibroids are a common finding in women undergoing surgery for pelvic pain.[28] Cramer and Patel found fibroids in 74% of premenopausal women and 84% of postmenopausal women undergoing hysterectomy not specifically for fibroids.[29] Although this is a biased sample, it suggests the prevalence of fibroids is higher than previously appreciated, because symptoms are experienced by only 20% to 50% of women with one known fibroid.[30] When fibroids are symptomatic, the most common symptoms reported include abnormal uterine bleeding, pelvic pain or pressure, decreased capacity of the urinary bladder, constipation, back pain, and reproductive dysfunction.

Fibroid tumors have both estrogen and progesterone receptors and respond to hormonal stimulation. Enlargement during the reproductive years may cause increases in severity and frequency of symptoms. Because fibroids are slow growing, significant changes in size may take months or years, and some may remain stable for long periods of time. After menopause, fibroids commonly regress because of the reduced levels of estrogen and progesterone. In a recent population study on fibroid-associated symptomatology, the question about the generalizability of pain symptoms and presence of fibroids has raised questions about data collected in the past, which was primarily derived from self-selected populations of women seeking gynecologic care.[31]

The pain associated with fibroids is related to their location and size. Posterior fibroids can cause lower back pain, and those found in the broad ligament may cause unilateral lower abdominal pain or may compress the sciatic nerve. Anterior fibroids may cause bladder compression and may be felt by the woman as painful, especially during a bimanual examination. Very large fibroids can cause dyspareunia, difficulty with urination, and/or defecation.

Theoretically, women taking HT may be at more risk for postmenopausal pain if they have fibroids because HT can potentially stimulate fibroid growth. However, there are no data to indicate whether postmenopausal women note clinical changes in pain level. Generally, no treatment is necessary for fibroids after the menopause. If the patient is experiencing pain or postmenopausal bleeding, a workup for other possible causes, including neoplasm, is necessary.


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