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Chronic pelvic pain and endometriosis

Dr Amelie Hofmann-Werther

By Dr Amelie Hofmann-Werther

Dr Hofmann-Werther is a Specialist Gynaecology and Obstetrics, Fetal Medicine Sonographer, Psychosomatics and Verbal Intervention Counselor, colposcopist, CBD surgeon, Conference Organization Team, Scientific Committee and Advisory Board Member OBFEGYN.

Endometriosis defined

Endometriosis is an estrogen-dependent disease frequently resulting in substantial morbidity, severe chronic or recurrent pelvic pain, multiple surgeries, and impaired fertility. Clinically Endometriosis is defined as presence of endometrial-like tissue (Endometrium lining like cells) found outside uterus/uterine cavity, resulting in sustained inflammatory reaction. Primarily the pelvic peritoneum, ovaries, and and the lowest abdominal cavity (rectovaginal septum, Pouch of Douglas) are affected.  Affecting 6%–10% of women of reproductive age, the stigmata of endometriosis include chronic pelvic pain in menstrual bleeding (dysmenorrhea), chronic pain while intercourse (dyspareunia), irregular uterine bleeding, and/or infertility The prevalence of this condition in women experiencing pain, infertility, or both is as high as 35%–50%. Yet endometriosis is often under or non-diagnosed and associated with a six to seven year mean latency from onset of symptoms to definitive diagnosis.

Symptomology

  • Classic signs: severe dysmenorrhea, deep dyspareunia, chronic pelvic pain, Middleschmertz, cyclical or perimenstrual symptoms.
  • Typically develops on pelvic structures, i.e., bladder, bowels, intestines, ovaries, and fallopian tubes.
  • Less commonly found in distant regions, e.g., diaphragm, lungs (inducing catamenial pneumothorax), and rarely, areas far outside abdominopelvic region.
  • Ovaries among most common of locations; gastrointestinal tract, urinary tract, soft tissues, and diaphragm follow.
  • Degree of disease present has no correlation with severity of pain or symptomatic impairment.

Symptoms vary but typically reflect area of involvement and may include: 

  • Dysmenorrhea (pain in menstrual bleeding).
  • Heavy or irregular bleeding.
  • Cylical/noncylical pelvic pain.
  • Lower abdominal or back pain.
  • Bloating, nausea, and vomiting.
  • Dysuria (pain in urinating).
  • Dyspareunia (pain while sexual intercourse).

Histiopathogenesis

  • No single theory sufficiently explains pathogenesis.
  • Genetics, biomolecular aberrations in eutopic endometrium, dysfunctional immune response, anatomical distortions, and proinflammatory peritoneal environment may all ultimately be involved.
  • 5 key processes of development: adhesion, invasion, recruiting, angiogenesis, proliferation.

Epidemiology 

  • More than 176 million women globally; 775,000 in Canada and 8.5 million in North America are affected.
  • Infertility among chief clinical findings.
  • No known prevention of Endometriosis.
  • Specific menstrual characteristics may be associated; decreased risk with late age at menarche and shorter menstrual cycles with longer duration of flow.
  • Family history cannot be undervalued; near 10-fold increased risk in women with first-degree relatives who have disease endometriosis.
  • No particular demographic, personality trait, or ethnic predilection.
  • Inverse BMI relationship.
  • No definitive association with nutrition, exercise, personality traits, or other lifestyle variables.

Comorbidities  

  • Adhesions.
  • Risk of adverse pregnancy outcome and preterm birth.
  • Up to 50% of those with endometriosis may suffer from infertility.
  • Distorted pelvic anatomy/impaired oocyte release or inhibit ovum pickup and transport.
  • Endocrine and anovulatory disorders.
  • Characterized as sexual dysfunction manifesting as pain in the reproductive organs before, during, or soon after sexual intercourse.
  • Though frequently depicted as psychogenic, dyspareunia (pain while intercourse) is actually often the result of organic, multidisciplinary cause and affects as many as 80% of endometriosis patients.

 Diagnosis

  • Clinical diagnosis: pelvic examination and pain mapping, medical history.
  • Imaging studies, ultrasound, MRI.
  • Surgical diagnosis and staging.

Endometriosis Treatments

Surgical Intervention

  • Laparoscopy/Laparotomy.
  • Goals of conservative surgery include removal of disease, lysis of adhesions, symptom reduction and relief, reduced risk of recurrence, and restoration of organs to normal anatomic and physiologic condition.
  • Laparoscopic excision has been demonstrated to significantly improve deep dyspareunia as well as quality of sex life.

 Nonsurgical therapies

  • Medical treatment and combination therapy may help improve symptoms.
  • Gonadotropin-releasing hormone agonists (GnRH), oral contraceptives, Danazol®, Aromatase Inhibitors, and Progestins are mainstays.
  • Mirena® intrauterine device shown to be effective in reducing pain and may be considered alternative to hysterectomy in adenomyosis patients.
  • Alternative therapies, for example herbal medicine, physical therapy, diet and nutrition, acupuncture, specific supplements and other complementary approaches may result in reduction of pain.

Conclusion

  • Endometriosis is a chronic, costly disease requiring long-term, multidisciplinary treatment.
  • Profound personal and economic impact underscores urgent need for continued research and improvement in diagnostic and treatment modalities.
  • Timely intervention and appropriate, multifactorial treatments may restore quality of life, preserve or improve fertility, and lead to long-term effective management in absence of permanent cure.