Pelvic pain and Ovarian cancer

It’s Gynaecological Cancer Awareness Month (GCAM) and time to shine the spotlight on ovarian cancer. This month provides an important platform to discuss something that sadly our society still considers taboo, the area of female health.

If you still struggle to use the word vagina, you are not alone. Research suggests that most of use women find it hard to refer to their private anatomy and embarrassed to discuss aspects of their private health, which leaves many to suffer in silence and sometimes not present to the doctor until too late. There has never been a more pressing time to change this around and with common female conditions, such as endometriosis, taking on average between 7 to 10 years to diagnose, this is almost 10 years of women and girls being too afraid to speak out and living with the agony of horrendous periods, too ashamed to admit to it for fear that they will be judged or told to just get on with it because it’s “normal”. Nothing about exceedingly heavy or painful periods is normal, nor is it normal to suffer from pelvic pain, and this is why we need to discuss it. More often than not, the diagnosis is benign, but there are times when it may not be, and it’s important to understand when you need to see your doctor and also what is and isn’t normal so that you develop the self-confidence and awareness to know when something is wrong.

Pelvic pain is common and can be caused by a variety of conditions and diseases, from endometriosis or fibroids to urinary tract infections (UTIs) and irritable bowel syndrome (IBS). It can broadly be categorised into two groups: acute or sudden onset pain, and chronic or longer standing pain. The pain may be intermittent or constant and can be associated with other symptoms, such as abnormal vaginal bleeding, lower back pain, and vaginal discharge.

While it may seem obvious that pelvic pain in women can arise from reproductive organs, like your uterus or ovaries, bear in mind that it can also stem from a problem within the gastrointestinal, musculoskeletal, or urinary tract systems. Inflammation, infection, or abnormal tissue growth within any of these organs may cause pelvic pain, amongst other symptoms. Also, notice that some conditions can cause both chronic and acute pain.

Acute Causes

Ectopic Pregnancy

If you are in the early stages of a pregnancy and develop sudden onset pain, it is crucial to exclude an ectopic pregnancy, as it could become life-threatening. This is where the pregnancy embeds abnormally outside of the uterine cavity. Abnormal vaginal bleeding, change in bowel habit, and shoulder tip pain can all be associated symptoms but some women may not have any until the structure where the pregnancy is embedded, often the fallopian tube, ruptures, causing severe pain and a sudden drop in blood pressure from blood loss, which can lead to fainting and shock.

Pelvic Inflammatory Disease (both acute and chronic)

Pelvic inflammatory disease (PID) is an infection that affects the organs of a woman’s reproductive system including her uterus, ovaries, fallopian tubes, and vagina. The majority of cases are caused by a sexually transmitted infection, like gonorrhea or chlamydia. Pain may worsen during sex, and there may be other symptoms, like abnormal vaginal bleeding or discharge, as well as a temperature.

Mittelschmerz Pain

There is also a type of pain called Mittelschmerz pain, which refers to the mild, one-sided pelvic pain felt when an egg is released from an ovary each month. It may also be associated with mild mid-cycle spotting. On its own, especially if a woman’s always experienced this, it isn’t worrisome and can be perfectly normal. But sometimes the pain experienced is so severe, that women can end up hospitalised and investigated for other acute causes. Typically, the pain settles down after 24-48 hours.

Ovarian Cyst Rupture

Ovarian cyst rupture is due to an ovarian cyst that a woman may have. It may cause no symptoms or it may be associated with acute onset pain, often described as a sudden and sharp pain that can begin after sex or strenuous physical activity. If they don’t rupture, ovarian cysts can cause chronic pelvic pain.

Ovarian Torsion

Ovarian torsion occurs when the ligaments that hold your ovary in place rotate and twist, cutting off the ovary’s blood supply. The cardinal symptom is sudden and severe pelvic pain that may be sharp, dull, or crampy. Sometimes the pain radiates to the lower back or groin, and some women develop a low-grade fever, nausea, and vomiting. Interestingly, the pain may subside after a while, only to return again later. It’s a critical diagnosis to make as it’s a medical emergency that requires surgery right away to save the ovary.

Appendicitis

This can produce sudden pain that begins near the belly button and moves to the lower right part of the abdomen (which is why it may be mistaken for pelvic pain). Other potential symptoms include a loss of appetite, fever, vomiting, and pain with movement, like walking or rolling in bed. Like an ectopic pregnancy or ovarian torsion, appendicitis is serious and requires immediate medical attention.

Urinary Tract Infection

Aside from pain over the bladder region, there are often other associated symptoms such as frequency of urination, burning pain when urinating, having an urge to urinate, and blood in the urine. In older women, the symptoms of a urinary tract infection may be subtler, such as tiredness and incontinence.

Kidney Stones

These may develop when substances in the urine, like calcium, oxalate, cystine, or uric acid, build up and form crystals. A stone can cause excruciating pain if it becomes large and gets stuck in the urinary tract system.

Chronic Causes

Endometriosis

Endometriosis is a condition where the tissue that normally grows within your uterus (the endometrium) begins to grow outside it, like on the ovaries, fallopian tubes, and your intestines. Pelvic pain is a common symptom of endometriosis, especially during menstruation and sex. The pain can sometimes be felt with a bowel movement or while urinating. Besides pelvic pain, women with endometriosis may experience difficulty getting pregnant.

Uterine Fibroids

Uterine fibroids are benign pelvic growths that can commonly cause heavy or prolonged periods. Fibroids may also cause pelvic discomfort, often described as a dull pressure or pain and if they become very large, can press on surrounding structures like the bladder or bowel, and cause additional symptoms, such as passing urine frequently or a change in bowel habit.

Irritable Bowel Syndrome

Irritable bowel syndrome typically causes crampy abdominal pain that may be worsened by stress or eating. Besides pain, other symptoms of irritable bowel syndrome include bloating and changes in bowel habit. Sometimes treating stress can help improve symptoms considerably. This condition can also be associated with endometriosis.

Muskuloskeletal

The pelvis is made up of many muscles, ligaments, and tendons. With so many elements comes the potential for several musculoskeletal problems that may cause pelvic pain. An example of this is a hernia, which is when an organ protrudes through the wall of the cavity containing it. This can also cause sudden onset acute pain and if so, it’s critical to diagnose in case the bowel is within the hernia, which could get strangulated. Also, something as straightforward as a muscle sprain after twisting or lifting can cause pelvic pain.

Let’s talk about Ovarian Cancer

The thing about ovarian cancer is that despite being one of the most common female cancers, it’s notoriously also the most difficult to diagnose. This is because the symptoms can often be slow and gradual to develop, overlap with many other conditions, and are not obvious until the cancer has almost certainly progressed. It tends to affect women who are in the menopause, but it can also affect younger women too. There is no effective screening test at the moment, though efforts are being made to develop one so that it can be as non-invasive and as accurate as possible.

Common symptoms of ovarian cancer include:

feeling constantly bloated
a swollen tummy
discomfort in your tummy or pelvic area
feeling full quickly when eating
needing to pee more often than usual

The exact cause of ovarian cancer remains unknown. But some things may increase a woman’s risk of getting it, such as:

being over the age of 50
a family history of ovarian or breast cancer – this could mean you have inherited genes that increase your cancer risk, such as the BRCA gene
hormone replacement therapy (HRT) – although any increase in cancer risk is likely to be very small
endometriosis
smoking
lack of exercise
exposure to asbestos

The treatment for ovarian cancer depends on things such as how far the cancer has spread and your general health, such as any other medical conditions that may be affecting you. Treatment will aim to cure the cancer whenever possible. If the cancer has spread too far to be cured, the aim is to relieve symptoms and control the cancer for as long as possible.

Treatment usually ranges between surgery and/ or chemotherapy:

surgery to remove as much of the cancer as possible – this will often involve removing both ovaries, the womb and the tubes connecting them to each other (fallopian tubes)
chemotherapy – This is usually used after surgery to kill any remaining cancer cells, but is occasionally used before surgery to shrink the cancer

If you have not yet completed your family but have been diagnosed with ovarian cancer, it’s really important you see a fertility specialist who can advise you on how you can preserve your fertility. It may involve doing egg or embryo freezing ahead of any cancer treatment and it’s important this is discussed and planned for in time, as the cancer treatment itself may make you infertile.

When to see your doctor

If you experience any sudden onset, severe pelvic pain, and if there are any other associated symptoms such as vomiting or a temperature or abnormal vaginal discharge, it’s vital you go into the hospital and see a doctor as this could be a medical emergency that requires intervention straight away.

If, on the other hand, your pelvic pain is longer standing, you may have had it for several weeks or months, and in particular, if there are associated symptoms, you should go and see your GP as it could be an indication of pelvic disease. If you have any of the symptoms outlined for ovarian cancer, and especially if you are feeling repetitively bloated or have a strong family history of breast or ovarian cancer, you must go and see your doctor.

Basically, if unsure or there is something that worries you, please go and speak to your doctor who can take a full detailed history, and examination and request tests if necessary, the majority of which are not interventional, and ultimately help to provide you with a diagnosis, even if it is just reassurance. If in doubt, always consult with a medical specialist, especially if you have a family history of breast or gynaecological cancer, where your risks of disease such as ovarian cancer could be increased. Being aware of what to look out for, and being mindful of what is and isn’t normal, is crucial and will help any woman as she gets older to understand and navigate her gynaecology.

As a general rule of thumb, if you notice anything different or unusual about your body, or something that is worrying you, go and see your GP. You will never waste their time but you may get a whole lot of information out of it. Ultimately, it may just save your life.

About the author

Dr Larisa Corda is an Obstetrician and Gynaecologist and Fertility Specialist MBBS BSc MRCOG. She qualified from Imperial College London and trained in the UK and Australia, gaining a wide understanding of womens’ health issues across an international population. She believes in a holistic approach to treatment that addresses many lifestyle factors as well as a combination of Eastern and Western principles, that underpin The Conception Plan she has devised, as seen on TV. Larisa is a passionate womens’ rights campaigner, with roles on a number of charities, and supports the use of natural and mild IVF techniques to assist conception where needed. She regularly appears in the media, and has several research interests including the effect of stress on fertility. To follow her advice and tips, including The Conception Plan, go to www.drlarisacorda.com and @drlarisacorda on Instagram.

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