Amanda Wilde (Host): Meaningful Medicine is a Novant Health Podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. I'm Amanda Wilde and Obstetrician and Gynecologist, Dr. Sarah Beebe joins me to discuss pelvic pain. Dr. Beebe, thank you so much for being here.

Dr. Sarah Beebe: Hi Amanda. Thanks for having me.

Host: I hear a lot about pelvic pain. How common is chronic pelvic pain?

Dr. Sarah Beebe: So, chronic pelvic pain specifically, so I think there's sometimes a misconception about what is chronic pelvic pain. And so technically we define chronic pelvic pain as pain that's non-cyclical, that lasts for three to six months or more. And so a lot of women will deal with cyclic pelvic pain, pelvic pain with their menses.

But if we're talking specifically about chronic pelvic pain, that's what we would be thinking about.

Host: And sometimes it's hard to know what is or isn't abnormal pain. What signs should women be alert to that could indicate that pelvic pain may be abnormal?

Dr. Sarah Beebe: So when we think about like a pathologic, chronic pelvic pain, it's going to be something that disrupts daily function. So if it's something that's causing women to miss school or work having to take long-term medications, like needing a lot of things like Ibuprofen, Motrin, Tylenol, that sort of thing.

Or really, or something that's even they're thinking about as prompting, like, this doesn't feel normal. I should talk to my doctor about it. Then it probably is something that's abnormal. Or in talking to friends, colleagues and they're like, oh, I never have anything like that, that doesn't sound normal.

Then some of those can be kind of tips and hints to say that it's probably worth at least exploring with your gynecologist.

Host: So if you're having to push through pelvic pain regularly, you need to listen to that.

Dr. Sarah Beebe: Right. Yeah. If it's something that you're kind of dealing with on a daily basis and obviously there are lots of women that will have, heavy, painful menses and that's kind of a topic for another time, that's definitely something that we talk a lot about patients with and have different ways we can help that.

But I would consider that as along with, but definitely kind of a little bit distinct from like a chronic daily pelvic pain that a woman's been dealing with for months at a time.

Host: So if pelvic pain is associated with also having irregular bleeding, not your menstrual cycle, what could that indicate?

Dr. Sarah Beebe: So, it could be a few different things. We don't always tie bleeding together with pelvic pain, though it definitely is something that can sometimes be related. Obviously the things we want to make sure it's not something concerning like a uterine or endometrial cancer. Those are going to be much less likely causes of a chronic pelvic pain and would be more in certain specific, older age ranges.

But if it's definitely atypical bleeding in between periods, that sort of thing, we'd want to keep an eye out for that. There can be various structural reasons for irregular bleeding, or most commonly it's just that women aren't ovulating normally, whether that's, that they're close to when they started their periods or menarche, or if they're approaching kind of that perimenopause menopause range, or they have some other underlying medical condition like thyroid dysfunction, something that's causing their periods to not be regular.

So I would say, definitely if you're having pain and irregular bleeding, it's worth talking to the doctor about it. Really, irregular bleeding in general is always worth bringing up at like your routine annual visit or making an appointment to talk about.

Host: Yeah. So it is important, maybe crucial to seek care and explain unexplained pelvic pain or irregular bleeding. When that happens, what kind of testing do you do to narrow down what the causes are?

Dr. Sarah Beebe: So as with any kind of doctor's visit, we're always going to talk about like history and physical exam. Those are going to be some of the most important parts. A lot of times with our exam, we can kind of elicit out whether it's going to be something that's maybe muscular. I mean, there's so many different causes of pelvic pain.

And so when we think about, I know you'd asked earlier, how common is it? I mean, it can really be anywhere up to 25% of the general population. Some men, some women. Obviously I focus with women, so that's what I can really speak to more. But there are men who have chronic pelvic pain as well because there can be non gynecologic causes for pelvic pain.

And so sometimes on either our history exam we can kind of point and direct us in either way if it's something that's more related to bowel dysfunction or nerve pain, neuropathic pain. But obviously, I kind of try to zone in and see is it something that's gynecologic. Which can also be something muscular, like the pelvic floor.

 And so that's something that can come on our exam. When we think about, imaging, really, as gynecologists our predominant imaging we like to use is a pelvic ultrasound. So I would say it's going to be pretty common for a woman who's coming in reporting pelvic pain, that we'll usually start with a pelvic ultrasound.

Amanda Wilde (Host): Dr. Beebe, what is your advice for someone who was previously told their pelvic pain is normal? Is a second opinion advisable in that case?

Dr. Sarah Beebe: I think so because I would say there's a lot of women who have kind of gone through their life and until they are able to kind of see a different gynecologist or see a gynecologist in general who are just told, oh, it's normal for women to have pain and you can kind of fight through it.

 And I think that it's important to know that it's, even though we might not always find a cause for pelvic pain, it's not that it's normal to be having daily pain, especially if it's disrupting your daily life. And so, unfortunately we might not always find a reason for pelvic pain, but we can usually find some way to help manage it in some way.

Host: Mm-hmm. Well, it seems like this topic is a good example of why it's valuable to have an annual gynecological visit. Can you talk about what happens at those visits, including cervical cancer screenings?

Dr. Sarah Beebe: Yeah, absolutely. So, we start PAP smears which is screening for cervical cancer at age 21. But I also have women that I see that are younger than 21 that we see for annual exams, whether it's refilling birth control, just talking about their general women's health and that sort of thing. That may or may not include a pelvic exam.

A lot of younger girls are really worried about coming to the gynecologist because they don't want to have a pelvic exam. And so I try to reassure them that a lot of times we can talk about different things without having to do a pelvic exam, talk about their periods, or talk about what they're sexually active.

Talking about things like the HPV vaccine, making sure that they've had information on that and if that's something they've either gotten or are interested in getting. And so, yeah, so 21 is when we start doing pelvic exams, to do PAP smears. And then we all, usually we'll do a breast exam as well, kind of, at least by age 20-25.

Depending on personal and family risk factors may, need mammogram screening sooner than 40, but 40 is generally when I tend to start that. Talking about. And then, later on in life range we do things like talking about bone density screening, things with the DEXA scan around age 65.

And so there's just different, you know, colon screening, those sorts of things. So just kind of talking about general overall health zoning in on women's health. Because a lot of patients will have primary care physicians that can cover a lot of those other things. But we can talk about different things like menses, what to expect as we approach perimenopause.

What timing is normal for perimenopause, different birth control options, helping with family planning, figuring out when to start prenatal vitamins, if you're going to try to conceive. Lots of those sort of things we can cover in a routine annual visit.

Host: And if you're doing an annual visit, you can really, get to know each patient and have a good patient doctor relationship so that when things come up, you already know the history.

Dr. Sarah Beebe: Right, absolutely. It's very helpful to see a patient that we've seen before and it's also just kind of fun to be able to catch up and say, oh, how's the family? And be able to kind of just check in and see where they're at from an overall wellness standpoint. And making, you know, hopefully patients feel comfortable.

I know a lot of women don't love coming to the gynecologist. But I always like to tell people we'll try to make it as enjoyable as possible. But having them be able to feel comfortable after maybe having met me a few times to be able to open up and share some of those things that they might not always want to share in the first time meeting someone.

Because I know talking about women's health can sometimes, just feel uncomfortable for a lot of women.

Host: Exactly, exactly. You touched earlier on the HPV vaccine. Just wanted to ask, what are the latest recommendations for who should receive that vaccine?

Dr. Sarah Beebe: Right. So a lot of times that initially starts with our pediatricians who are really awesome about talking with parents and families with that, because usually we really would ideally want to start that vaccine series around age 11 or 12. The goal is to have both girls and boys exposed to that vaccine or have received that vaccine before they would potentially be exposed to HPV or kind of have their onset of sexual activity. So the younger, within that age range, the better. Because the HPV vaccine basically helps kind of protect us against those higher risk strains of HPV that can cause cervical cancer.

And again, we don't start that really PAP smear testing until age 21 because we know the likelihood for cervical cancer in that young age range being usually a slow growing cancer is very low. But the more that we can do to help kind of protect, for me, obviously I see most women and girls but also for men and boys that can have HPV related cancers as well.

The great thing is that we definitely recommend catchup if we miss them in that 11 to 12 window. You can still catch up and get that vaccine and it's really strongly recommended even up to age 27 for catchup with that. However, in the US it's FDA approved up to age 45. So I definitely have women that are coming to see me maybe in their thirties with abnormal pap smears with HPV positive, may have not completed the series, got one dose but didn't finish it or just didn't get it when they were younger.

But it is something to talk about with your healthcare provider because even if you're outside of that younger age range, it's something that can potentially still be beneficial for certain women.

Host: Thank you. As we close, your enthusiasm for your work and your thoroughness in your subject are quite obvious, I'd love to know how this specialty became a passion of yours.

Dr. Sarah Beebe: Yeah. What led me into OBGYN. So in medical school, I wasn't really sure exactly kind of what field I wanted to go into. I kind of liked a little bit of everything and what I realized when I rotated through obstetrics and gynecology, is that it really is a little bit of everything.

I get to, have continuity of care with patients, like we talked about, getting to see them year after year or multiple visits. But I also get to have procedural interventions as I kind of grew up a little bit athletic. I always kind of liked a little bit of the drama and keeping my hands active.

And so, I get to perform surgeries and deliver babies, you know, do C-sections, vaginal deliveries, all of that. Procedures in the office, procedures in the operating room. And so every day feels a little bit different. And so I kind of like the diversity of that. I get to talk with a lot of women just about overall their life, overall, their health.

Get to be part of some of the greatest moments in women's lives. Get to be part of some really tough moments in women's lives and be able to kind of help them walk through that. So I just kind of fell in love with it when I rotated through it.

Host: Well, Dr. Sarah Beebe, thank you for your insights and especially on detecting and managing issues related to pelvic pain.

Dr. Sarah Beebe: I appreciate your time. Thanks for having me again.

Host: That was Obstetrician and Gynecologist Dr. Sarah Beebe. For more information, visit NH.team/Women'sHealth. To find a physician, go to novanthealth.org and for more health and wellness information from our experts, visit healthyheadlines.org. If you enjoyed this podcast, please share it on your social channels and explore our entire podcast library for more intriguing topics.

Thanks for listening to Meaningful Medicine, a Novant Health Podcast.