The Ugly Step-Sister of Endometriosis

I bet you didn't know Endometriosis has a sister?!? 
And she's seriously ugly, deceptive, mean, and cruel. Let's look at who she is and how she works. Once we've given this awful gal a name and explained how she works, you can ask your GYN about her and see if there's any chance she's living in your body without your knowledge...

What is Endometriosis?
In order to talk about the step-sister, it's important to have a quick overview of what endometriosis is, so you can see how she's related. Endometriosis is when the lining of your uterus that you shed every month with your period gets out into other places, traditionally your pelvis. The tissue then finds a place to grow, steals itself a blood supply, adds some nerve endings and grows on your internal organs, like the outside of your ovaries or bladder. Sometimes it'll even grow through things like your bowel causing rectal bleeding with your periods, or through your bladder causing you to pee blood every month. It's also classic for causing severely painful and heavy periods. Sounds awful, right?  It's only definitively diagnosed with surgery, when it can be biopsied and sent to the pathologist for a look-see under the microscope. It's tough to treat and almost impossible to remove. But at least it can be easily diagnosed. Gynecologists often don't do surgery, but give what we call a "clinical diagnosis" of endometriosis. If it quacks and walks like a duck, it's probably a duck. If you have heavy painful periods that started in your teen years, it's probably endometriosis. I'm gonna leave the rest of the details for a blog on Endo sometime. So, let's get into Adenomyosis and who she is!

What is Adenomyosis?

Adenomyosis is when the lining of your uterus that you shed every month with your period starts growing into and invading the muscle of your uterus. Like a parasite. Adenomyosis causes even more painful periods than endometriosis, and heavy, heavy bleeding. I also hear complaints of severe bloating before the period starts. She's awful.

How is Adenomyosis diagnosed?
One trick about adenomyosis is she's tough to diagnose until you've taken the whole uterus out for the pathologist to see. Adeno doesn't show up on ultrasound most of the time, although some ultrasonographers will claim it looks a little "glittery". She's a diva, I tell ya. On occasion, a pelvic MRI can pick up abnormalities. On exam, the only thing I can say I've ever noticed is that the uterus feels sort of like play-doh. She also often mascarades as endometriosis, which makes it even harder to diagnose.

How is Adenomyosis treated?
This is the real kicker. Unlike endometriosis, that often responds to many hormonal treatments such as birth control pills and the shot, adenomyosis sometimes doesn't respond at all. I've seen patients treated for years with suspected endometriosis with little to no response, that finally had the hysterectomy. And lo and behold, it was adenomyosis all along. Many people with adenomyosis have some response to hormones, the levonorgestrel IUD (Mirena) being the best in studies. But definitive management is a hysterectomy.

Do I have adenomyosis?
Even your gynecologist probably can't answer this question up front, even with good testing. If you've failed other treatments for your painful and heavy periods, and you don't really need/want your uterus, it may be time to consider a hysterectomy. I avoid surgery in patients unless it's really necessary. As of yet, I haven't ever had a patient unhappy with their decision when adenomyosis was the final result on pathology.

Fertil Steril. 2018 Mar;109(3):398-405. doi: 10.1016/j.fertnstert.2018.01.013.

Gynecol Endocrinol. 2016 Sep;32(9):696-700. Epub 2016 Jul 5.

Best Pract Res Clin Obstet Gynaecol. 2006 Aug;20(4):493-502. Epub 2006 Mar 24.

Best Pract Res Clin Obstet Gynaecol. 2008 Apr;22(2):333-9. Epub 2007 Aug 30.

Gynecol Endocrinol. 2018 Aug;34(8):647-650. doi: 10.1080/09513590.2017.1397116. Epub 2018 Feb 15.

How to Make Your Own "Marijuana"

What's up with Marijuana and Pain?

I have at least a few patients per week ask my opinion on marijuana for chronic pain. It's all over the media, and certainly running around in many Facebook groups for pain sufferers. So, is there really anything to this? Actually, there is. With a quick medical literature review, one can find oodles of legitimate research about marijuana, its effects on pain, and its ability to augment the effects of opiate narcotics. The better question is "Why is it still an "investigational" drug?" Unfortunately, I don't have any power over the regulation of medical marijuana. However, I and many of my colleagues are pretty convinced that there's enough evidence for marijuana's benefit in pain management to make a good argument for a change in its drug status.

Do I recommend marijuana to my patients?

Honestly, it's a little tricky to answer this one, since marijuana itself is illegal in many states at this time. My opinion about it's effect on pain doesn't necessarily lead to recommending its use. What I mean by that is, I don't want my patients to get arrested. And there are undesirable side effects of smoking or ingesting marijuana.

In Texas, marijuana possession is still punished pretty severely. There is a very restrictive law allowing low-THC, high-CBD in Texas, of which some people are taking advantage. A lot of states, however, have laws regarding marijuana and its derivatives making it quite legal. About half of the States allow marijuana in some form, either broadly legal for recreational use, or for specific cases such as epilepsy or cancer.

What's the difference between marijuana, CBD, and THC?

Marijuana is the whole cannabis sativa plant. It contains two active substances called tetrahydrocannabinol (THC) and cannabidiol (CBD). Both of these interact with receptors in your body and brain, but in different ways.

THC is the major psychoactive substance, meaning it's what causes the "high" you get when you smoke marijuana or ingest it. It mimics the effect of two natural chemicals that your body makes, anandamide and 2-AG. It also is the substance that is thought to be detrimental to your health. It has an addiction potential, alters brain development in teens increasing the risk for substance abuse (gateway drug theory), increases chances of psych issues like schizophrenia, reduces school grades and overall lifetime achievement, and makes it more likely for you to get in a car accident (especially if you're drinking alcohol too).

CBD oil is the non-psychoactive substance. It actually looks a lot like THC in its chemical make-up, but the bonds are a little different. This prevents it from creating the "high", and also reduces pretty significantly the undesirable side effects of THC listed above. It has been shown in clinical research to have a mostly positive effect on:
Nausea and vomiting
Appetite (increasing it in cancer patients)
Pain
Anxiety
Sleep

I can make "marijuana"; so can you!

I must admit, you and I don't really make marijuana, per se. But our bodies and brains make two substances that activate the same receptors as marijuana. Basically, if marijuana creates an effect in the brain, then it is activating a receptor. Those receptors are there because our bodies make chemicals that bind to them. The chemicals I'm talking about I listed above, anandamide and 2-AG. These are naturally made by your body and bind the endocannabinoid receptors in your body, spinal cord, and brain.

Activating endocannabinoid receptors does a few things, one of which is reducing pain sensitivity. It does this by down-regulating pain sensors, and also by augmenting the effects of natural and synthetic narcotics.

How do I make marijuana?

Again, it's not really marijuana you're making. But the best way to get your body to release the endocannabinoids anandamide and 2-AG seems to be with exercise. Have you ever heard of the "runner's high"? Literature points to the feelings of wellness and euphoria after intense exercise being linked to release of endocannabinoids. Long distance runners will tell you that it's addictive, that they feel calm and relaxed after running. In studies, patients have a higher tolerance to pain after exercising. So, exercise is kind of like smoking a doobie. It helps you relax, and alters your perception of pain. Natural weed!

Should I get CBD Oil for my Pain?

Again, I can't recommend something that is illegal in many places. I can say that if your state has legalized use of marijuana, that there is proven medical benefit of CBD oil on pain perception. Take that for what its worth. I do, however, highly recommend using exercise to create the same response. Exercise has all sorts of benefits other than activating cannabinoid receptors. Obviously, it helps with weight loss, maintaining healthy bones, and heart status. It also improves your microbiome (see You Feel What You Eat). So, get out and exercise! And maybe consider CBD oil if it's legal in your state.

References
https://www.cnn.com/2018/04/29/health/medical-marijuana-opioids/index.html
https://www.ncbi.nlm.nih.gov/pubmed/29513392
https://www.thelancet.com/action/showPdf?pii=S2468-2667%2818%2930110-5
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4302052/
https://statelaws.findlaw.com/texas-law/texas-marijuana-laws.html
https://cbdoilreview.org/cbd-cannabidiol/thc-cbd/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827335/
https://www.ncbi.nlm.nih.gov/pubmed/21175589
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724924/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724924/pdf/v038p00536.pdf

Fight Pain with Happiness

Your Mindset Matters!

In our hurried, anxious society it’s hard to be happy. It takes work and creativity to enjoy ourselves. But did you know that happiness helps reduce pain?

How is that possible? Well, pain is very context driven. The brain only perceives pain when it makes sense, under the right context. The whole purpose of pain is to alert the brain to possible tissue damage, so you’ll react - like move your hand off a hot stove. When the context is wrong, i.e. you’re happy and enjoying yourself, the pain signals don’t make sense and the brain assumes they aren’t as important.

The way to interfere with pain is experience more happy emotions and less unhappy ones. Pain is processed faster when it’s linked to an unhappy emotion like fear, guilt, anger, disgust, hatred, or rejection. The brain assumes that if you are unhappy, the pain signals may be more important. Pain is processed slower when it’s linked to positive emotions like:

-Happiness
-Love
-Calmness
-Interest
-Enthusiasm
-Passion
-Gratitude

 

Mindfulness

How do you experience these emotions or more of them? Mindfulness!

Being mindful is focusing on something intently. This can be your breathing, your blessings, or any other happy thoughts and things!

Focusing on the bright side

Didn’t get a front row parking spot at the store?
Bright side: Exercise!

Raining out today?
Bright side: No need to water the plants!

Savoring

This is my favorite.
Savor a good book, a pleasant smell, or the hug and laughter of your partner and kids.

Smell the Roses

Stop and enjoy all the little things like a nice day, a helpful stranger, or a beautiful rose!

Positive Thinking

Write down and save your positive thoughts. This simple act has been shown to reduce pain. It may help change your thinking from negative to positive, which can change your whole focus.

Volunteering

Helping other people has been shown to reduce pain. Volunteer at your church, local food pantry, Big Brother/Big Sisters, or your local library. It’s all good for you!

Journal about Thankfulness

Actively writing (with a pen - not on the computer) is linked to a positive mindset and lower pain.

Acts of Kindness

Little acts of kindness can actually make a big difference in your pain. So buy a cup of coffee for the guy behind you in line, hold the door for someone, or help an elderly shopper with his/her groceries.

Laughter

It’s just like they say: Laughter is the best medicine. Watch a funny movie, go see a comedian, or swap funny stories with friends or family. Laughing actually releases natural painkillers (the good kind that don’t cause the brain’s reward systems to misbehave!).

Make a Deposit in your Positive Memory Bank

Thinking and talking about happy times in your life creates positive emotions, which helps reduce pain. Look at baby pictures, wedding photos, or talk about the good ol’ times. You get the idea. Think of what warms your heart and work to increase it. If you succeed in focusing on the positive, and stop focusing on the negative, your brain will follow suit.

For best results, you should seek help from a pelvic pain specialist. Your specialist can untangle where your pain is coming from and recommend the right treatment for you.

The Sources of Pain

The Source Makes a Difference

Why do we even have pain signals?

You'd think the whole world would be better if we just didn't have pain at all. But it's simply not that easy. Pain is actually really important. The whole purpose of pain is to alert your brain to possible tissue damage, so you move your hand off a hot stove. People who have spinal cord injuries sometimes get a cut where they can't feel it. The cut then becomes infected, and the person doesn't know until they're really sick with high fevers and possibly sepsis. It's important for our bodies to be able to feel pain to keep us safe.

Where do pain signals come from?

Pain signals related to tissue damage start with activation of something called nociceptors. These are sensory neurons all around your body that fire when there's possible tissue damage. They are easier to activate when there's inflammation and immune system activation hanging around. These two things are what help your body heal wounds and prevent infections. It makes sense that when your body is trying to fight an infection, you might want to know about it. 

 When your body is sending pain signals related to possible damage, the signals can come in different kinds of flavors:organ pain and non-organ pain. 

Pain coming from internal organs

Organ pain comes from internal organs such as your stomach, gallbladder, uterus, ovaries, intestines, and bladder.  

Pain signals from your organs mostly come from the organ being stretched (such as your stomach when you eat too much), lack of blood flow (such as your foot “going to sleep” when you sit on it), and inflammation (caused by illness or injury).

Acute pain* from an organ can be caused by appendicitis, a hot gallbladder or a heart attack. It may be accompanied by symptoms such a tightness or squeezing fullness, being pale, sweaty, or feeling a sense of impending doom. Heart attack symptoms also may include pain in the left arm, shoulder, neck, and jawline. Acute pelvic organ pain is most often felt with bladder infections or period cramps. 

Chronic pain** from an organ tends to be more like a dull ache, discomfort or nausea that won’t go away. The pain can fluctuate. When it is bad, you can have nausea and sweating. When the pain lessens, you’ll experience a more general discomfort. Perhaps you’ll feel a constant need to urinate or empty your bowels. These sensations are common.

Pain coming from other places.

Pain from skin, muscle, bones, joints, and ligaments is considered non-organ pain. These are usually a little easier for your brain to figure out. The neurons in these locations will fire with almost any unpleasant sensation; stretch, heat, cutting, inflammation etc...

In your pelvis, though, the pain signals get mixed up with the organs, making it especially hard for your brain to figure things out.

The pelvis is a tight area, with lots of stuff in it, including your bladder, uterus, tubes, ovaries, bowel, muscles, nerves, and fascial tissue. The body has to transmit information from all these things to the brain for processing. Because it's such a tight area, there's only a few spots in the spinal cord that are available to transmit ALL of this information. Once the information gets to the spine, the pain signals all get thrown in together. What your brain reads is "there's pain somewhere in my pelvis". Every body feels that different. Some people feel it as bladder pain or bowel pain, some feel it as ovary pain.

What is pelvic and intimate pain, and what can be done about it?

Pain specialists define pelvic pain as anything that hurts between your belly button and mid thighs, front and back. (See What’s in the Pelvis?). Intimate pain is anything that hurts in your genital region, including pain with sexual intercourse.

You may have been told at one time that your pain is “all in your head,” or you’re “blowing things out of proportion.” But rest assured, chronic pelvic and sexual pain are medical problems.

Seeking help from a pelvic pain specialist is the best approach to help diagnosis and manage pelvic pain. S/he can teach you how to get your brain and body to stop making your pain worse than it needs to be.

* Acute pain is defined as a one-time or brief event

**Chronic pain is defined as lasting from a few weeks to more than six months

References:

1. Aredo J, Heyrana K, Karp B, Shah J, Stratton P. Relating chronic pelvic pain and endometriosis to signs of sensitization and myofascial pain and dysfunction. Seminars in Reproductive Medicine. 2017;35(1):88-97.
2. Huang L, Kutch JJ, Ellingson BM, Martucci KT, Harris RE, Clauw DJ, Mackey S, Mayer EA, Schaeffer AJ, Apkarian AV, Farmer MA, MAPP. Brain white matter changes associated with urological chronic pelvic pain syndrome: multisite neuroimaging from a MAPP case-control study. Pain. 2016;157:2782-2791.

How Your Body and Brain Process Pain

How Your Body and Brain Process Pain

Pain is processed differently, depending on its source.

When pain is generated in your body, it is transmitted as a signal to the spinal cord, past several gateways, and then to the brain where it is finally processed. Once the brain decides the signal warrants a response, and what kind of response, it sends a signal back down to the body for a reaction.

Here’s a simple diagram:



Copyrighted 2018 When It Hurts Down There

One time, brief pain

When the pain is a one-time or brief event (also called “acute”), the signals follow a path like the one pictured here. For instance, if you burn your left hand with a curling iron, the cell damage in your skin is the instigator of the pain signal. The signal goes to your spinal cord, which sends the signal up to your brain.

If your lower midbrain decides the signal is important, the signal gets passed on to the midbrain. These gateways decide how bad the pain is and relies on the upper brain to confirm: it’s your left hand; the pain is moderately intense; and that it’s a burn and not a cut. The brain then sends a signal to your right hand to move the curling iron away from the skin and to put your left hand under cold water. This all happens in a split second.

Chronic, lasting pain

With chronic (constant) pain, weird things happen with the pain signals in the body. When the same nerves in the body have to fire over and over again, they’ll yell for help by releasing nerve-recruiting chemicals.

When you get the experience of pain over and over again, the brain can’t tell if it’s dangerous, and the nerves in the brain can start overreacting.

For example, the body may think there’s damage, such as inflammation, immune system activation, or an abnormal nerve signal. So the pain-processing nerves in the brain think that they too need more help. They start recruiting their brain neighbors to help process the pain, and make more connections and branches. This “neighboring help” may partly be driven by inflammation and stress that can result in high levels of inflammation chemicals and stress hormones. All this activity from the constant pain can make the brain more sensitive to pain.

With pelvic pain, the brain doesn’t know exactly where the pain signals are coming from. When you have chronic pain in your pelvis, your body may not have to send a signal to the brain to get a reaction. It can just start reacting on its own! And the brain can also get mixed signals from the “neighboring help” and link things like your daily bodily functions, touch, and movement to the pain.

Think of the pain signal in your body acting like a fire alarm.

Normally a fire alarm goes off only if there's smoke or a fire. You wouldn’t expect the alarm to sound when you simply light a match or turn on the stove. Normally you wouldn’t expect pain because of average bodily functions, such as having a bowel movement or coughing, or when you have sex. But when your body and brain get overly sensitized to the pain, bodily functions, normal touch, and movement will now cause pain too.

As a result, your “alarm” will go off randomly, even when there’s nothing happening!

Seeking help from a pelvic pain specialist is the best approach to help diagnosis and manage pelvic pain. And given the complexity of the pelvic area (See What’s in the Pelvis?), pain is often in more than one site. Your specialist can untangle where your pain is coming from and recommend a course of treatment.

References:



Hampson JP, Reed BD, Clauw DJ, Bhavsar R, Gracely RH, Haefner HK, Harris, RE. Augmented central pain processing in vulvodynia. J Pain. 2013;14(6):579-589.

Janicki T. Chronic pelvic pain as a form of complex regional pain syndrome. Clinical Obstetrics and Gynecology. 2003;46(4):797-803.

Mercier C, Léonard G. Interactions between pain and the motor cortex: Insights from research on phantom limb pain and complex regional pain syndrome. Physiother Can. 2011;63(3):305-314.

Kim W, Kim SK. Neural circuitry remodeling and structural plasticity in the cortex during chronic pain. Korean J Physiol Pharmacol. 2016;20(1):1-8.

Aredo J, Heyrana K, Karp B, Shah J, Stratton P. Relating chronic pelvic pain and endometriosis to signs of sensitization and myofascial pain and dysfunction. Seminars in Reproductive Medicine. 2017;35(1):88-97.

Lee Y, Park K. Irritable bowel syndrome: Emerging paradigm in pathophysiology. World J Gastroenterology. 2014;20(10):2456-2469.

Schrepf A, O’Donnell MA, Luo Y, Bradley CS, Kreder KJ, Lutgendorf S, MAPP Network. Inflammation and inflammatory control in interstitial cystitis/bladder pain syndrome: associations with painful symptoms. Pain. 2014;155(9):1755-1761.

what's in the Pelvis

What’s in the Pelvis?

Understanding the complexity of the pelvis goes a long way in understanding why it may be difficult to pinpoint and treat the exact source of your pain and discomfort.

The pelvis is a tight area with many organs and structures. It includes your bladder, uterus, Fallopian tubes, ovaries, bowels, muscles, nerves, skin, and more!



Copyrighted 2018 When It Hurts Down There



The body transmits information from all these parts and places to the spinal cord, which sends the signal to the brain for processing. The problem lies in the fact there are only a few spots in the spinal cord available to transmit all of this information.

From the picture you can see in the picture how complex and interwoven the parts of the pelvis are, and how a pain signal might get confused on its way to the spinal column and brain.

As a result, what your brain receives is "there's pain somewhere in my pelvis." Because the brain is not sure of the origin of the pain or the severity, it has to guess. And on top of that, the brain can become so confused that the organ and skin pain signals get mixed up. So, while it may be that your bladder needs attention, you feel it in the muscles and skin of your buttocks.

Without knowing the source of the pain, getting a firm diagnosis is a challenge. Which is why a pelvic pain specialist can help. S/he can untangle where your pain is coming from, which is often more than one site, and develop a course of treatment.

1. Aredo J, Heyrana K, Karp B, Shah J, Stratton P. Relating chronic pelvic pain and endometriosis to signs of sensitization and myofascial pain and dysfunction. Seminars in Reproductive Medicine. 2017;35(1):88-97.

How Pain Works

How Pain Works

All pelvic pain patients have several things in common. Pain starts in the body, gets sent up the spinal cord, and gets processed in the brain. This happens in every single person. It's kind of like a relay race. If the baton doesn't get passed, or if someone poops out and stops running, the baton never makes it to the finish line. Without a pain signal or the ability to relay and process it, you wouldn’t have pain.  Think about people with spinal cord injuries and paralysis. Paralyzed people can’t feel pain below their injury. The pain signals are still there, but they can’t get to the brain. The pain doesn’t get past the injury in the spine. No relay, no pain.

Pain Tolerance

Once the pain makes it all the way to the brain, it has to be processed. This is where things get even more interesting. There are multiple studies that show that patients with chronic pain have a different tolerance for pain. If you took a person without a pain condition and laid them down in an MRI machine, it would take something pretty noxious, like poking them with a sharp object to see a lighting up of the pain centers in the brain. In pelvic pain patients, the MRI shows the pain centers lighting up much easier, like with normal touch, or sometimes even just light touch with a cotton swab! Everyone’s tolerance for lighting up the pain centers is a little different.
 

Pain Processing Centers

All pain is processed in the same areas of the brain. Science doesn’t have this completely figured out yet, but we do know that pain signals go through certain pathways, hitting certain areas for processing. As the pain is processed, it’s localized and given meaning and context. The same mixture of chemicals are released when you’re riding a rollercoaster and when you’re being chased by a bear. How does the brain know which one is fun and which one is scary?

By knowing which areas are being used for processing, we can figure out what to do to interfere with that part of the process and make more pleasure and less pain. All pain is also modifiable by changing the circumstances of the pain and its surroundings.