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There are a wide variety of uncommon reproductive causes for chronic pelvic pain in women. These should be kept in mind while planning diagnostic and therapeutic management.
Adenomyosis occurs when the endometrial glands or stroma that normally line the uterine cavity grow into the thick smooth muscle wall of the uterus. It is believed that a disruption in the barrier between the endometrium and the underlying myometrium (smooth muscle) promotes the incidence of adenomyosis. This disruption may be caused by a prior pregnancy (about 90% of women with adenomyosis have previously been pregnant) or uterine surgery. Symptoms typically include very heavy menstrual flows (menorrhagia) and severe midline knife like stabbing pain during the menstrual flow. The uterus is often uniformly enlarged (but not usually extending past the pelvic bone or symphysis pubis), boggy or soft in consistency, and tender. When available and affordable, the MRI provides excellent soft tissue resolution and is noninvasive. Medical management is usually not effective, estrogenic or progestagenic treatment may worsen the symptoms and GnRH agonists (like Lupron) may provide temporary relief from the symptoms but can have significant side effects. Surgical management including hysterectomy or endometrial ablation destroys future fertility.
Cervical stenosis occurs when the opening of the uterine cervix (mouth to the uterus that normally extends into the vaginal vault) is very narrow or is closed. Cervical stenosis can be congenital (a medical condition that is present at birth) or acquired. Congenital cervical stenosis is very uncommon while acquired cervical stenosis may result from a chronic cervical infection, prior surgery on the cervix, or radiation therapy involving the cervix. When there is cervical stenosis, blood and endometrium that is normally shed as the menstrual flow may have a difficult time exiting the uterus, resulting in a hematometra (uterus full of blood) that can subsequently produce very painful midline pelvic "labor like" cramps. These symptoms occur especially around the time of an expected menstrual flow. Diagnosis of an incomplete cervical stenosis can be made by an inability to pass a 2.5 mm probe or uterine sound through the cervical canal. If the cervical stenosis is complete then an ultrasound exam of the uterus should identify a fluid filled uterine cavity at the time of an expected menstrual flow. The treatment of cervical stenosis is cervical dilatation, which sometimes requires general anesthesia for the most difficult cases.
Polyps of the endocervix (within the cervical canal) or endometrium (within the uterine cavity) are localized pedunculated overgrowths of endocervical or endometrial tissue. Cervical polyps may be found in up to 5% of all routine gynecological exams and endometrial polyps may be found in up to 7% of reproductive age women. The presence of a cervical polyp is a risk factor for endometrial polyps since endometrial polyps co-exist in up to 30% of women with cervical polyps. Cervical polyps are most often associated with irregular vaginal bleeding and bleeding after intercourse. Uncommonly, cervical or endometrial polyps may be associated with painful menses (dysmenorrhea) or intermittent crampy lower abdominal pain. Treatment is removal, which can usually be performed easily via hysteroscopy.
Pelvic congestion syndrome is associated with pelvic varicosities, which are pelvic veins that are vulnerable to chronic dilatation and stasis, which then results in vascular congestion. The role of pelvic congestion in chronic pelvic pain has been controversial since there is a general lack of quality research on the topic and the defining characteristics of venous overload, valvular incompetence and vascular congestion within the pelvis are poorly agreed upon. The symptoms most often associated with pelvic congestion syndrome include a dull aching pelvic pain with intermittent episodes of sharp pain, painful intercourse especially with deep penetration, pain with menstrual flow, irregular occasionally excessive menstrual bleeding, changes in bowel habits with nausea, and burning on urination without evidence of a urinary tract infection. Pelvic venography can provide the exact location and grading of any varicosities within the pelvis but it is invasive, expensive and has greater risk than noninvasive tests. Laparoscopic identification is difficult since the pneumo-peritoneum that is established maintains an elevated intra-abdominal pressure and the Trendelenburg position enhances venous return. Radiologic procedures like ultrasound and MRI have been proposed but at present there are no uniform and accepted diagnostic criteria. All told, it is difficult to diagnose this syndrome but it makes theoretical sense that it could be an important cause for some women with chronic pelvic pain.
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