The Hidden Problem Causing Your Chronic Pelvic Pain
We’ve been talking lately here on Women’s Health about how conditions like heart disease, rheumatoid arthritis, and sleep apnea act differently in men and women, and how important it is for women to be aware of those differences, so they can watch out for their own health.
Heart disease, for example, is just as likely to show up as unusual fatigue, nausea, and lightheadedness in women, rather than the common chest pain symptom that we’re used to hearing about in men.
Rheumatoid arthritis often affects women more severely than men, interfering with their daily lives. And women with sleep apnea are actually more at risk for mortality than men with the same condition.
But the differences don’t stop there. There is another condition that develops in such a unique way in women that doctors don’t even think to look for it, leaving patients frustrated and in pain.
Hidden Abdominal Hernias in Women
We’re talking about a hernia, a condition you may have heard about in men where an internal part of the body bulges through the surrounding tissues or muscles.
The “inguinal hernia,” for example, is the most common type and occurs when fat or part of the small intestine bulge through a weak area in the abdominal wall. Men have a lifetime risk of 27 percent, while women have a lifetime risk of only 3 percent.
That sounds like good news, until you discover that for those three percent, life can be pretty miserable. Women’s hernias, unlike most men’s, often remain hidden inside, making them much more difficult to detect. Correct diagnosis can sometimes take years, during which women are often shuttled from doctors to psychiatrists to pain specialists in their search for relief.
What Causes a Hernia, and How is it Treated?
Hernias may develop because of a weakness or defect in the abdominal wall, usually as a result of a birth defect, aging, stress and strain, heavy lifting, pregnancy, excess weight, or a previous surgery in the lower abdomen. All of these conditions can increase stress on the abdominal wall, and potentially weaken it so that it can no longer hold in the organs and tissues in place as it should.
Standard treatment for a hernia is similar in both men and women, and usually involves some sort of surgery. In a traditional procedure, the surgeon makes an incision, pushes the protruding “stuff” back in place, and then sews together the weakened muscle. He may also add surgical mesh to reinforce the repair.
Minimally invasive, or “laparoscopic” surgery, is a second option, and typically involves smaller incisions and a narrow tube through which a camera is inserted to guide the surgeon’s work. Recovery is typically faster than with traditional methods, and there is significantly less scarring. This type of procedure is available to most patients, unless they have a large hernia or have undergone a previous surgery in the same area.
Abdominal Hernias are Different in Men and Women
Treatments for hernias may be similar for both genders, but that’s where the similarities end.
The condition most often develops differently between the sexes. In men, for example, hernias often protrude outward to the point that they can be easily discovered. Often, a physical exam is all that’s needed, and the “stand and cough” method is usually enough to show the bulge in the lower abdominal area. If needed, other tests like x-rays, ultrasounds, and CT scans may be used to confirm a diagnosis.
For men, the “bulge” of the hernia is also often one of the first noticeable symptoms. It may be the only symptom, as many men don’t experience any real pain. They bulge may feel uncomfortable, but otherwise not cause a lot of problems. Other symptoms may include discomfort or pain around the area, but most men can see the bulge themselves, and thereby get an idea what’s going on.
For women, however, things are different.
Pelvic Pain Can Be a Sign of a Hidden Abdominal Hernia
First of all, the female hernia is rarely visible—thus the term “hidden” abdominal hernia. The bulges are often smaller, rarely cause a visible change, and may be more “internal,” and thus less likely to show up to the naked eye.
Imaging tests don’t always catch them, either. An ultrasound, for example, though it may be conclusive for men, may gloss right over the problem in women because their hernias are usually smaller, and may be surrounded by fat, which makes them less visible to the ultrasound.
In many cases, an MRI or even a laparoscopic (minimally invasive) exploration of the affected area is needed to pinpoint the location of the hernia.
Second of all, these hernias are often a source of pain, first and foremost, for women. Instead of noticing the bulge as the first symptom, women notice pelvic pain instead. Typically caused by nerve compression, it may be dull and achy, or debilitating and sharp, but either way, in women, hernias can cause chronic pain, and this is what usually drives them to the doctor.
Unfortunately, doctors rarely connect chronic pelvic pain with hidden hernias in women. Because hernias are less common in women than men, doctors don’t think to look for them. According to Deborah A. Metzger, Ph.D., M.D., and gynecologic surgeon, “Most gynecologists and general surgeons are unaware of occult [hidden] hernias and many do not believe that they exist; and therefore, they are controversial.”
In addition, there are a number of other conditions that can cause pelvic pain in women, which is why doctors may think of these first. Endometriosis, for example, is often blamed, or ovarian cysts, or uterine fibroids, or pelvic inflammatory disease, or several other potential causes. Because of all these possibilities, women are often put through a battery of tests and procedures before the real culprit is found.
Indeed, odds are against a woman having a hernia. Men are more likely to be born with a weakness in the “inguinal canal” than women, so doctors are more likely to check for a hernia in men.
(The inguinal canal is the passage in the abdominal wall that in men, contains the spermatic cord, and in women, contains the ligament of the uterus. In men, the canal almost closes, but leaves room for the spermatic cord to pass. During fetal development, if it doesn’t close properly, it can leave behind a weakened area. In women, on the other hand, the canal is more likely to close as it should.)
Increasing the Odds of a Correct Diagnosis
How can women determine if a hernia may be causing their pelvic pain?
First, consider the type of pain. It’s often described as sharp and shooting, and occurring around the hip and back, groin, or into the flank. It may worsen when the bladder is full, during bowel movements, when lifting or bending, when exercising or during prolonged standing, when coughing, during intercourse, or during the menstrual period—whenever pressure increases on the abdominal area.
Hernia pain is often described as “deeper” in women, as well, since the bulge itself is often positioned more deeply in the body. So think deep pelvic pain that may come on fast and then linger. (This “deep” characteristic is another reason doctors often blame the pain on cysts or other gynecological issues.) Be very specific when describing your pain to your doctor, and explain as well when it occurs, and the various activities that precede it.
Second, find a doctor who is experienced in hidden abdominal hernias. Look for a gynecologist who specializes in chronic pelvic pain. If you’d prefer to stay with your doctor, suggest that he or she consider that a hernia may be causing your pain. Ask for an MRI test, a standing position examination, and even a vaginal examination to increase the odds of detection. (Pressure on the internal inguinal area, if it recreates the pain, can signal the presence of a hernia.)
A hernia may not be the cause of the pain, but if it is, requesting tests can save you years of needless suffering.
Fortunately, surgery corrects the problem in most cases, and women can return to their formerly active lives. The key is getting the correct diagnosis to start with. A 2006 study, for example, reported that laparoscopic treatment of hernia pain in women was effective at relieving chronic pain, and came with a low risk of recurrence and complications.
Jane E. Brody, “In Women, Hernias May be Hiding Agony,” New York Times, May 16, 2011, http://www.nytimes.com/2011/05/17/health/17brody.html?_r=1.
John T. Jenkins and Patrick J. O’Dwyer, “Inguinal hernias,” BMJ, February 2, 2008; 336(7638):269-272, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223000/.
“Inguinal hernia,” The National Institute of Diabetes and Digestive and Kidney Diseases, http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/inguinal-hernia/Pages/facts.aspx.
Stephanie Cary, “Hidden hernias: Painful holes in muscle are often misdiagnosed or overlooked in women,” Daily News, August 4, 2011, http://www.dailynews.com/lifestyle/20110804/hidden-hernias-painful-holes-in-muscle-are-often-misdiagnosed-or-overlooked-in-women.
Deborah A. Metzger, “Hernias in Women: Uncommon or Unrecognized?” Laparoscopy Today, January 1, 2004, http://www.laparoscopytoday.com/2004/01/hernias_in_wome.html.
- Paul Perry, et al., “Hernias as a Cause of Chronic Pelvic Pain in Women,” JSLS, April-June 2006; 10(2):212-215, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016116/.