https://www.apsoc.org.au/PDF/Publications/Resource_pelvic-pain-ebooklet.

pdf

Some women have pain with periods but

are otherwise completely well. They have
what doctors call ‘dysmenorrhoea’ and
often have a medical condition called
Endometriosis. The section in this ebook
on ‘period pain’ may be all you need.
•Other women have a mix of different
pains with pain of some kind almost
every day. They may also be tired,
anxious or worn down by pain. They have
what doctors call ‘chronic pelvic pain’.
There is a section in this ebook on all the
different pains you may have.

The mix of pains we have included is the

‘bigger picture’ of pelvic pain. It can include
any or all, of an irritable bowel, a painful
bladder, painful sex, pelvic muscle pain,
anxiety, low mood, fatigue, pelvic nerve pain,
headaches, or sudden pains on one side.

Period pain
Dysmenorrhoea

Period pain is the commonest cause

of pelvic pain. None of us know what
another woman’s pain is like, so it is
useful to first think about what
periods should feel like, if all is
normal.
What is normal period pain?
Have you ever wondered if your bad
period pain is really normal? Well,
your period pain should only be
considered ‘normal’ if:
• The pain is only there on the
first 1 or 2 days of your period,
and,
• It goes away if you use the
contraceptive pill or take
period pain medications
If not, it is not normal.
Severe period pain in young women
is a bigger problem now than it was
in the past. Our grandmothers often
had their first baby before they were
20 years old. After that came years
spent pregnant or breast-feeding until
menopause arrived. Even if their
periods were painful, at least they
didn’t have many of them.
Girls start their periods earlier now
and become pregnant later. They
may have 300 to 400 periods ahead
of them before menopause.
I don't think my pain is normal.
What could it be?
Painful periods can be due to:
•Pain in the uterus (womb),
especially if pain is on the first
1-2 days of a period, or,
•Pain from endometriosis,
especially if pain is there for
more than 1-2 days or doesn’t
get better with the pill
Many women with bad period pain
have both these problems, and we
know that women with endometriosis
have a more painful uterus than other
women, even if it looks normal.
Endometriosis is a medical condition
where tissue like the lining of the
uterus grows outside the uterus
where it shouldn’t be.
Am I too young to have
endometriosis?
Endometriosis used to be thought of
as an uncommon problem of women
in their 30s and 40s. We now know
that it is a common problem that
usually starts in the teens.
Endometriosis in teens often looks
different at a laparoscopy and can
easily be missed.
Teens often worry about being
different from other girls. In fact, a
study of 1000 girls aged 16-18 years
in Canberra, Australia (MDOT study)
found that 21% of the girls had
severe pain with periods and 26%
had missed school because of period
symptoms.
Endometriosis New Zealand has a
website just for teens at
www.me.school.nz
You may have been told
that your period pain is
normal, just part of being a
woman, or that you should
have a baby.
There is much more that
can be done now
Period

Simple things first

Period pain medications work best when
they are taken before the pain gets bad, so
keep some with you all the time and take them
regularly during periods. The commonly used
medications include ibuprofen 200mg,
naproxen 275mg, or diclofenac 25mg.
Take two straight away then one, three times
a day with food. All these medications can
cause stomach irritation, so are best taken
with food.
The Contraceptive Pill is often helpful. Ask
your doctor for a pill with more progestogen
than estrogen for the best effect. Many
women skip periods on the pill because fewer
periods means less pain. To do this, you need
to be on a pill where all the hormone tablets
are the same colour. Plan a period only every
2-3 months or preferably not at all. Ask your
doctor or pharmacist how to do this.
A Mirena ® intrauterine device (IUCD) is
currently the most effective treatment for pain
from the uterus and lasts up to 5 years. It
slowly releases a progestogen medication to
the uterus that makes periods lighter, less
painful and it is also a contraceptive.
Remember that it is common to have irregular
bleeding and crampy pains for the first few
months, but these problems usually settle.
If you have not had children, or have a tender
pelvis you can ask to have it inserted under an
anaesthetic if you wish. Another good time to
have it inserted is at the same time as a
laparoscopy.
Complementary therapies that can help
include acupuncture, Vitex Agnus Castus
(1000mg daily) and magnesium (100-200mg
every 2 hours at period time for 2 days only).
If simple treatments for period pain don't help,
you may have endometriosis. This is where
tissue like the lining of the uterus grows in
places outside the uterus around the pelvis.
Most endometriosis can’t be seen on an
ultrasound.
When simple things don’t help
Laparoscopy. A laparoscopy is an operation
where a doctor puts a telescope through a
small cut in your umbilicus (belly button) to
look inside your pelvis. He or she can then:
• Diagnose if any endometriosis is
present, and
• Remove the endometriosis if possible
There are different types of surgery available
to treat endometriosis. Sometimes the
endometriosis is excised which means cut out
and sometimes it is cauterised (diathermied)
which means burnt.
Some laparoscopies for endometriosis are
fairly short and straight forward, while others
take much longer and are more difficult. It
depends on where the endometriosis is and
how severe it is.
We know that the amount of endometriosis
found at a laparoscopy doesn’t fit with the
amount of pain. So you may have a little bit of
endometriosis and a lot of pain, or a lot of
endometriosis and very little or no pain.
Remember that even if you have
endometriosis, that a lot of your period pain
may also be from the uterus, even if the
uterus looks normal.
This is why a good combination of treatments
to consider is a laparoscopy to remove any
endometriosis and a Mirena IUCD inserted at
the same time. The Mirena can easily be
removed later by your doctor without an
anaesthetic if it doesn’t suit you.
It is also true that even if you do have
endometriosis, a lot of your pain may be due
to other things such as a painful bladder,
painful nerves or painful pelvic muscles.
Endometriosis medications such as
progestogens, danazol, or GNRH analogues
do not remove endometriosis and do not
improve fertility, but they can be helpful for
pain relief.

An irritable or sensitive bowel is a

good example of a pain you can’t
see. It looks normal at a laparoscopy
or ultrasound but certainly doesn’t
feel normal.
Women feel bowel pain low in their
abdomen, in the same place that
they feel period pain, pelvic muscle
pain,bladderpainand
endometriosis pain, so it’s easy for
all these pains to get confused.
The most typical feature of bowel
pain is that the pain gets better once
wind or a bowel action has been
passed. There are usually other
bowel symptoms too, such as
diarrhoea, constipation or bloating.
Bloating
Doctors often think of bloating as an
inconvenience rather than a major
problem. This is because bloating
rarely means a serious illness. The
trouble is that bloating makes women
feel unattractive and uncomfortable. It
also makes any other pelvic pain
worse. Luckily, there is lots you can
do to feel better.
Before you do anything about
bloating, you should see your doctor.
Sometimes women feel bloated
because they have an ovarian cyst.
Your doctor can check this for you.
If this check is normal, then think
about what type of bloating you have.
The first type of bloating is where
the abdomen swells up and your
stomach looks big. Women often feel
like this near period time, but it is also
aggravated by certain foods. These
foods are described further below.
Cutting down on these foods often
makes a big difference to pain.
The second type of bloating is a
feeling of being bloated, when you
look normal. This is often due to a
change in the way nerves work
causing abnormal sensations such as
bloating, and sensitivity to touch. You
may find your clothes uncomfortable
or dislike anyone touching your
abdomen.
This type of problem is described
more on page 17, but other useful
treatments include:
• Peppermint oil capsules taken
3-4 times daily or peppermint
tea
• Iberogast liquid 20 drops from
a chemist, drunk in warm water
as tea 2-3 times daily
• A medication to help nerve
pain (page 18)
Many women with pelvic pain have a
mix of both types of bloating.

Which foods might be a problem?

Some of the foods most likely to cause
problems are a s p e c i a l group o f
carbohydrates, sometimes called FODMAP
foods. Common FODMAP foods include
lactose, wheat products (bread, pasta, pizza
etc), onions, corn syrup, apples, and artificial
sweeteners, but there are many others.
Most people absorb these foods quite quickly
in their ‘small bowel’ (small intestine). This
means that very little of those foods reaches
the ‘large bowel’ further down.
Some people absorb these foods slowly,
which means that more of these foods reach
the large bowel undigested. In the large
bowel, the food is fermented by bacteria to
form gas and other substances that irritate the
bowel and cause pain, diarrhoea and bloating.
A small amount of these foods may be no
problem at all, but a larger amount can cause
lots of pain. If they also have a sensitive
bowel, which many women with pelvic pain
do, then they will really suffer.
This means that while your friends may be
able to eat any food and feel fine, your bowel
will be painful unless you are careful.
Should I just go ‘gluten-free’?
A gluten free diet is a special diet for people
with Coeliac Disease. Women with coeliac
disease need to be on a strict ‘gluten free’
diet for the rest of their life.
Women with an irritable bowel often feel
much better on a ‘gluten free’ diet, because
by cutting out gluten they are also cutting out
wheat, a major FODMAP food. They do not
have a problem with gluten and may be able
to tolerate small amounts of wheat.
Before you change your diet, ask your doctor
for a blood test that checks for coeliac
disease. This test isn’t reliable if you have
already cut out wheat from your diet, so it’s
much easier to get it done first.
Are there other problem foods?
Yes, definitely, but everyone is different. You
might have a problem with rich or fatty foods
(cream, takeaway, animal fats), alcohol,
coffee, fizzy drinks, and spicy food.
A low fat, low salt, high fibre diet is good for
everyone, but even more important if you
have bowel problems.
If you find it all too hard to work out, a
dietitian can help you.
Constipation
We have been brought up to think that it’s
important to have a bowel action every day.
Actually, it’s OK to have a bowel action every
couple of days or so, as long as it is soft and
easy to pass when it happens.
It is easiest to open your bowels when the
bowel motion is soft and your bowel is
contracting strongly enough to pass it easily.
You can make the bowel action softer by:
• Drinking enough water
• Increasing the fibre in your diet
• Taking a fibre supplement such as
Sterculia (normafibe ®). This
supplement is useful as it causes less
wind than most other supplements
You can increase bowel contractions by:
• Regular exercise, brisk walk every day
• Allowing unhurried time to go to the
toilet after breakfast in the morning
• Avoiding medications such as codeine
• A herbal treatment such as slippery elm
But my constipation is really bad. Nothing
works for me.
Some women have severe constipation,
even when they do everything right. It is very
unfair. They feel bloated and uncomfortable
most of the time. If so, it is time to talk to
your doctor, or maybe a gastroenterologist
(bowel physician).

Painful sex is distressing. As well

as the physical pain, there is the
emotional pain women feel when they
are unable to enjoy sex with their
partner. No one feels like sex if it
hurts, but it is easy for him to feel you
don’t care.
What causes painful sex?
There are lots of possible causes but
with some help, you and your doctor
can usually work out what the
problem is.
To make it easier, it’s a good idea to
think about where your pains are
before you go, and see if you can
help your doctor find the problem.
If you find a sore area, think about
whether this feels like the pain you
have with sex, or whether it is a
different pain. A common cause of
painful sex is painful pelvic muscles
or sore skin at the opening of the
vagina (vestibulitis).
Painful pelvic muscles
The pelvic floor muscles are the ones
you tighten when you want to stop
passing urine quickly. They can
become tight, strong and painful.
Often there is an ache in the pelvis
much of the time, sometimes with
sudden crampy spasms. Intercourse,
examinations, or using tampons are
very painful and sometimes the pain
lasts for hours or days afterwards.
There may be sudden sharp pains up
the vagina or bowel when the
muscles cramp. Pain is often worse
with exercise and isn’t helped by
normal pain medications.
You can check your pelvic muscles
yourself by inserting one finger just
inside the vagina. Push backwards
towards the bowel with your finger,
then push sideways towards your hip
on each side. Does pushing these
muscles cause the same pain you get
with intercourse?
If your pelvic muscles are painful, it is
useful to:
• Use a heat pack or a hot bath
when the pain is severe
• See a specialised women’s
physiotherapist to help the
muscles re-learn how to relax
and move normally.
• Avoid exercises that build
‘core-strength’. Your muscles
are already tight and short, and
exercises such as pilates may
aggravate the pain, even if
they help other problems.
• Explain to your partner that you
should avoid vaginal
intercourse until the muscles
improve. Sexual activity
without penetration is fine.

• Use the pelvic muscle relaxation CD

available from www.drsusanevans.com
• Use a small dose (5-10mg) of
amitriptyline or pregabalin (from your
doctor) early each evening
• Continue regular gentle exercise, such
as walking
• Treat other causes of pain so there is
less need to hold muscles tightly
• Think about how you hold yourself and
avoid holding tension in your pelvis
If the muscles are so painful that physio is
difficult, then a botox injection to the pelvic
floor is often helpful. The botox is injected as
day surgery under anaesthetic, lasts 4-6
months and stops the muscles cramping. It
also makes physiotherapy easier.
It is best to avoid intercourse until your
muscles have recovered, but if you do have
intercourse then:
• Use a water based vaginal lubricant
such as KY Jelly ®, a fruit based
lubricant like Sylk ®, or olive oil if you
find lubricants irritating
• Ask your partner to go slowly and wait
until you are ready. Using the
relaxation CD each day for a couple of
weeks beforehand can teach you how
to relax these muscles. Using a slow
gentle finger first allows you to get past
the initial muscle spasm, before
penetration
• Try to avoid the time around periods
when you are more sensitive
A painful bladder
If pushing the front wall of the vagina causes
pain and you have bladder troubles, then the
pain may be due to painful bladder syndrome.
Treating the bladder problems (page 10) often
helps.
The pain is deep inside and worse at
period time
Endometriosis can cause painful intercourse
deep inside, especially if it lies between the
uterus and the bowel. However, this is difficult
surgery, and you will need a gynaecologist
skilled in difficult laparoscopic surgery. A
laparoscopy will not fix pain from pelvic
muscles.
Sore vulval skin
The vulva is the area between your legs and
the labia are the folds of skin near the opening
of the vagina. If the skin is sore, good ideas
include:
• Use sorbolene and glycerine cream
instead of soap when you wash.
• Avoid waxing the hair on the labia
• Ask your doctor to check for a vaginal
or thrush infection. If you have a lot of
trouble with thrush, then a weekly tablet
of fluconazole 150mg for 6 weeks or
longer if needed often helps
• Try a low dose of amitriptyline
• See a ‘vulval dermatologist’ (skin
doctor) if you still have problems as
there are some skin conditions (not
infectious) that can make the skin sore
I was sexually abused in the past
Sexual abuse was once thought to be a major
cause of pelvic pain. We know that most
women with pelvic pain have not been
sexually abused. Even so, sexual or physical
abuse is common, is always wrong, is not
your fault and is something that can make
getting better more difficult.
‘Physical or sexual assault is always
wrong and never your fault’

You may know all about cystitis.

If so, you probably mean bacterial
cystitis, which is the medical word
for a bladder infection (urine
infection). The word ‘cystitis’ really
only means an irritated bladder. It
does not say what caused the
irritation.
Women with pelvic pain often have
another type of bladder irritation
called either Interstitial cystitis (IC)
or Painful Bladder Syndrome
(PBS). This type of cystitis is
different from a urine infection.
There is irritation of the bladder wall
but no infection. It is another pain
you can’t see at a laparoscopy.
If you have endometriosis, bladder
troubles and pain on most days,
then it is quite possible that you
have PBS. Sometimes it is the
bladder which causes most of the
pain.
What problems does painful
bladder syndrome cause?
The common symptoms include:
• Frequency. (Needing to go to
the toilet a lot)
• Nocturia. (Needing to get up
to the toilet at night)
• Urgency. (Needing to rush to
the toilet and finding it difficult
to ‘hold on’)
• Pain which gets worse as the
bladder fills, and improves
once the bladder empties
• Pain with intercourse.
Especially in positions that put
pressure on the front wall of
the vagina (near the bladder)
Many women with a painful bladder
describe having ‘frequent urine
infections’. Sometimes there is a
bladder infection, but often it is a flare
up of their painful bladder that feels
like a urine infection. If urine is sent to
a laboratory, it often shows some
blood but no infection.
Simple things first
A urine test with your doctor to check
for infection or other problems is a
good idea. They can also check for a
chlamydia infection of the urethra if a
sexual infection is possible.
Make sure you are drinking enough
(but not too much) fluid each day. For
most women, this will be around one
and a half, to two litres of mostly
water daily. If you drink a lot more
than this, that may be part of the
problem.
If you still have problems, think about
whether any of the foods or drinks on
the next page trigger your bladder
problems. Use the ‘bladder first aid’
treatment if your pain flares up, and
try a bladder medication such as
amitriptyline from your doctor.
Dietary changes. There are many foods that
can make bladder pain worse, but most
women only have problems with some of
these. They include:
• Foods high in acid such as citrus fruit,
cranberry juice, vitamin C, some herbal
or green teas or tomatoes. A plain mint/
chamomile tea or just water is best
• Foods that stimulate nerves such as
caffeine, chocolate or cola drinks
• Foods high in sodium or potassium
such as bananas
• Artificial Sweeteners
• Fizzy drinks (including mineral water)
Diet cola drinks are probably the worst as they
contain acid, caffeine and artificial
sweeteners. Cigarettes can also affect the
bladder.
If you eat these foods, remember how you feel
afterwards. If you feel worse, this may be a
trigger food for you. You may also find trigger
foods of your own.
Medications are really useful but you may
need to try a few different ones with your
doctor to find the right one for you:
• Low dose amitriptyline from your
doctor. This is a good first choice as it
helps frequency, urgency, pain and the
number of times you pass urine at
night. It can also sleep, bloating and
headaches. A dose starting at 5mg
taken in the early evening and
increasing slowly to between 5 and 25g
early in the evening suits around half
the women who try it. Sleepiness in the
mornings usually wears off in a week or
so, but start with a small dose.
• If amitriptyline makes you feel too
sleepy, then you can try tolterodine
1-2mg daily, oxybutinin 5-15mg daily or
solifenacin 5-10mg daily.
• Hydroxyzine 10-50mg at night is often
helpful but not available in all
countries.This is an anti-histamine so
especially useful for women with
allergies.
• Pentosan polysulphate sodium
(Elmiron®) 100mg three times daily.
This is the only medication specifically
used for painful bladder syndrome. It
helps about half the women who take it
but is expensive and may take six
months to work.
Bladder First Aid
If there are times when your pain or urgency
comes on suddenly, you may be able to help it
quickly by:
• Drinking 500ml of water mixed with
o 1 teaspoon of bicarbonate of
soda, or
o a sachet of Ural ® or
Citravescent ®
• Then take 2 paracetamol tablets (1g)
and drink 250ml water every 20 min for
the next few hours
• If you are no better, have a urine test
for infection. Only take antibiotics if an
infection is found.
Remember that if your bladder problems
continue, you should discuss this with your
doctor.

Pelvic pain can affect your life

dramatically, and it’s understandable if
you are just ‘sick and tired of feeling
sick and tired’.
You may have had pain for a long
time, been told that everything was
normal, or not been taken seriously.
You may have had treatments which
haven’t really helped and been
disappointed.
It’s hard to feel positive when this
happens, but even so, keeping a
positive attitude is one of your best
defences against pain.
You have lots to look forward to.
What is your coping style?
Everyone copes with pain a little
differently. Maybe you put on a brave
face at work or with friends, when
inside you feel far from well. Maybe
you have struggled on, trying to cope
alone.
You might recognise some of your
own feelings and behaviours in the
Pain Cycle chart below.
These coping strategies are
common, but maybe it’s time to review
how you manage your pain, and work
towards being the woman you’d like to
be.
Best practice treatment is not just
about what your doctors and health
care team can do for you. It’s also
about self-help, and what you can do
for yourself.
Doing things for yourself can help you
feel ‘back in control’. This can be
daunting in the beginning, but the
more you do things for yourself, the
more you will build confidence and the
easier it will become. Remember,
setbacks are normal and not a reason
to give up.
‘Fit, happy people have less
pain’
‘Choosing to live well with pelvic
pain doesn’t mean you have to
be a superwoman,
but it does mean choosing not to
be a victim’

Simple things first

•Take some time to think about what it is
that worries you most about the pain and
ask your doctor about your concerns
•Think about the things that trigger your
stress, and problem-solve them one at a
time
•Accept that you might need help. Others
will be glad to help, especially when they
see you making positive steps for your
own well-being
•Prepare for visits with your doctor by
writing down your symptoms and the
questions you’d like to ask. Short term
treatments, like pain medications, may
give you time to consider all your options
• Plan time for fun and leisure. Being
outdoors is a great way to manage pain
and stress. Do things you like which take
your mind off the pain and keep you busy.
Singing and music are a great start.
•Look after your body. Smoking, alcohol,
drugs and being overweight make people
feel sluggish and tired. You don’t need it.
• Start regular gentle exercise, which tones
the body and releases ‘feel good’
hormones. Walking is wonderful. If
exercise causes you pain, read pages 8
and 14. It’s OK to start small and build up
•Get regular sleep. Simple remedies
include lavender oil on your pillow,
chamomile tea before going to bed and
regular, calm bedtime routines.
•Consider relaxation or meditation to send
positive energy to the mind.
•Learn to love your body. Replace
unhelpful thoughts with helpful ones.
When simple things don’t work
If you still feel low, it’s really important to seek
help. Depression and anxiety are common if
you have had a lot to cope with.
These problems didn’t cause your pain, but
they do make it harder to get better and you
deserve to be well. Keep up with the things on
the ‘simple things first’ list and get help. It’s
really important. There are lots of services to
help you.
Useful services include:
•Your doctor or a psychologist. Explain
how you feel and ask if you could be
depressed. There is no need to feel
uncomfortable talking with your doctor
about this
•online information on depression at
www.beyondblue.org.au,
and
www.depression.org.nz
• free online self-help programs at
www.facebook.com/ehub.selfhelp
• a telephone information line at
1300 22 4636 (Australia)
‘I can be well, and this is my plan’

Everyone knows that muscle

cramp is painful, but imagine what a
muscle cramp on the inside of your
hip bones might feel like.
Many women with pelvic pain
describe a sudden pain that can come
on at any time, sometimes wakes
them at night, makes them want to
curl up in a ball, may go down into the
legs and isn’t helped much by normal
pain medications. They may have
trouble walking when they have the
pain and exercise often makes it
worse.
Women with this type of pain often
find getting the help they need very
frustrating. Nothing shows at a
laparoscopy, or on an ultrasound scan
but they are right. It is bad pain.
A careful examination with 1 finger
in the vagina, feeling high on the
inside of the hip bones can find the
muscle. Usually it is a muscle called
Obturator Internus but often the pelvic
floor muscles are tight and painful too.
All the treatments for painful pelvic
muscles on page 8-9 help this type of
pain too, but botox is especially useful
if the pain continues.
What else could cause sudden pain
on one side?
Other common causes of pain on one
side include:
•Appendicitis (right side. Not
usually a long term pain)
•Ovulation pain (2 weeks before a
period starts when not on the pill,
and only once each month)
•A ruptured ovarian cyst (less
common if you are on the pill)
•An ectopic pregnancy (a
pregnancy test will be positive)
•Bowel pain
•A kidney stone (there will be
blood in your urine. Not usually a
long term pain)

This is a pain you may not have

heard of before, and it’s a pain that
men can get too especially if they
spend a lot of time cycling.
The pudendal nerve is the nerve
that goes to the muscles and skin
between our legs where we sit.
The nerve travels through tight
places around the inside of the pelvis,
where it can get irritated or put under
pressure causing pudendal neuralgia.
What causes pudendal neuralgia?
Common causes include vaginal
birth of a baby, injuries like a bad fall on
your bottom, cycling, constipation and
overly tight pelvic muscles. These
muscles include obturator internus
(often also with pain on one side and
difficulty walking) and piriformis (often
with pain in a buttock, difficulty walking
or pain down the back of the leg).
Sometimes no cause is found.
What are the symptoms of pudendal
neuralgia?
There are many different symptoms
including:
•a burning or sharp ‘electric’
pain in the area of the pudendal
nerve anywhere from the clitoris or
penis back to the anal area,
especially on sitting. It may be on
one side or both sides, near the
front, or further back, and is
usually worse during the day.
•sexual changes with either less
feeling in the penis or clitoris or
unusual sexual arousal.
What can I do to help the problem?
To help the nerve recover:
•avoid activities that put
pressure on the nerve, such as
prolonged sitting, or cycling
•when you sit, use a ‘U-shaped’
foam cushion with the front and
centre area cut out, or a towel
rolled up under each buttock to
avoid pressure on the nerve
•see a pelvic physiotherapist to
learn how to relax and lengthen
your pelvic muscles, to take
pressure off the nerve
•avoid straining when you pass
urine or open your bowels, and
avoid overly strengthening your
pelvic muscles
•some centres offer botox to the
pelvic floor muscles, pudendal
nerve blocks or, occasionally if
necessary, surgery to release the
pudendal nerve.

You may be surprised that we

have included headaches in this
book, but they are really common in
women with pelvic pain, especially at
period time.
It’s always best to talk about your
headaches with your doctor first, but
once they are happy that there is no
serious illness present, we suggest
you try one of these treatments.
None of these treatments suit
everyone, so you may need to try
more than one to find something that
suits you best. It is worth the effort.
Your headaches are unlikely to go
away by themselves and life is better
without headaches.
Headaches with periods
A headache that comes each month
with a period often improves with one
of these options:
•A mirena iucd in the uterus
•A diclofenac 100mg suppository
•A ‘triptan’ nasal spray available
from your doctor, or,
•An estrogen hormone patch used
at period time
A low grade headache for several
days each month
Sometimes they may be severe,
while at other times just a nuisance.
It is definitely worthwhile trying one of
these preventer medications taken
every day:
•Amitriptyline 5-25mg early each
evening
•Cyproheptadine, 2-4mg at night
•Other medications from your
doctor, or explained in our book
Try each one for 2-3 months and
keep a headache diary, so you can
decide if it has helped. Also ask your
dentist if tightness in your jaw may be
causing your headaches.
Migraines at other times
Make a plan with your doctor and
ask about a ‘triptan’ nasal spray.
There is much more information on
headaches in our book, and at
www.migraineclinic.org.uk

If you have pain on most days, or

several different pains, you may have
wondered why your body is so
sensitive. Someone may have told
you ‘it’s all in your head’. You don’t
need to worry that you are weak, or
that the pain is imaginary. It’s real, but
it may be something you haven’t
thought of.
Often it is a change in the way the
nerves, spinal cord and brain work
called neuropathic pain or central
sensitisation. Pain from nerves is yet
another pain you can’t see at a
laparoscopy, and part of what doctors
call the “Chronic Pain Condition’
How did it happen?
When something painful happens to
us, the nerves in that area send pain
signals to the spinal cord and then up
to our brain. It is when the brain
notices the pain that we feel it.
Sometimes, after bad pain, or if there
has been pain for a long time, the
pain pathways from the pelvis to the
brain change. The structure of the
nerves change and they start sending
pain impulses to the brain at any time,
not just when something painful is
happening. The brain changes too,
and starts to feel pain when it
shouldn’t, even with normal
sensations like touch or normal bowel
function.
Central sensitisation is very common
in women with pelvic pain, but it is
also common after back injuries, or
shingles. The pain that is felt long
after a badly injured leg is amputated
(Phantom Limb Pain) is another
example of neuropathic pain.
Do I have neuropathic pain?
There are no scans or blood tests that
show neuropathic pain, but once you
understand it, neuropathic pain is
quite easy to understand:
• It can come on at any time, and
is usually present on most days
•The pain may be burning, sharp,
or aching
• It is common to feel bloated,
even if you look normal
• It is common to sleep badly
•Things that would not normally
be painful, are painful. Some
women feel pain just with
touching their abdomen. This is
called ‘Allodynia’
•Things that are painful become
more painful. For example,
periods may have always been
painful, but are now very painful.
This is called ‘Hyperalgesia’
•When the pain is really bad, you
may feel it over a bigger area.
This is called ‘Wind-up pain’

Things have just become too much for me

Neuropathic pain affects our mood too.
Women who have managed their pain well for
years, may start to feel ‘worn down’ by their
pain or anxious about things they don’t need
to be anxious about.
We know that some of the same chemicals
involved in neuropathic pain are also involved
in anxiety and depression, so once again, you
are certainly not imagining it. These problems
often improve once the pain is treated.
What is the ‘Chronic Pain Condition’?
Chronic pain is a medical condition, just as
asthma, diabetes and endometriosis are
medical conditions, but it involves the way
nerves work.
Around 1 in 5 people (men and women) seem
to be at risk of developing neuropathic pain
problems after injury or pain. Often there are a
mix of different pains. For example, a woman
with pelvic pain might also have tender points
in the muscles around her shoulders,
headaches on most days, long term pain after
an injury or an irritable bowel.
Brain scans show that in someone with
neuropathic pain, even small things are seen
by the brain as pain.
What will help me get better?
Once chronic pain becomes established, it
may not be possible to eliminate it completely,
but the good news is that you can expect a big
improvement with management of your pain.
All of the treatments aim to help your brain
and nerves work normally again.
Lifestyle issues: You may have worked out
already that your pain is worse if you are
stressed or over-tired. More than ever, you
need to be kind to yourself. This doesn’t mean
lying on a couch all day. It means regular
gentle exercise, a good diet, a positive
attitude, regular sleep, and resolving stressful
issues. Neuropathic pain is not dangerous, but
it is painful. Even so, there are still lots of
things in life you can enjoy and a positive
attitude really helps.
Medications every day to help the nerves
work normally. These medications are not
painkillers, but help the nerves work normally
when taken regularly.
It is true that no one wants to take a regular
medication, but we recommend you see your
doctor and try them at least for a couple of
months. Then think about the problems you
had before and decide if they have been
helpful:
•amitriptyline is an old-fashioned
medication that used to be used in big
doses to treat depression. Small doses
won’t treat depression but often help
nerve pain, sleep, headaches, a bloated
feeling, an overactive bladder and muscle
pains. It suits around half the women who
try it. Start with just 5mg (half a blue
tablet) early in the evening. If you are not
too sleepy the next day, go up to 10mg,
then slowly to between 10 and 25mg if all
goes well. If you are sleepy, stay on 5mg
and wait for this to pass.
•pregabalin or gabapentin. These are
different medications you can discuss
with your doctor. Start on a small dose
and work up. There is no hurry.
•other medications for this type of pain
Preparing for an operation
If you have this type of pain and need an
operation, it is a good idea to talk to your
doctor about using a neuropathic medication
before and after your surgery. This hasn’t
been commonly used for pelvic pain surgery
in the past, but we believe it helps recovery.
If you are already on amitriptyline then this
should be continued until you are fully
recovered.
Alternatively, you can ask your anaesthetist
whether a dose of gabapentin or pregabalin
just before your operation might help with pain
after the operation.