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.

3 Oct 2018

Chronic pelvic pain and endometriosis

Chronic pelvic pain and endometriosis - woman holding pelvic area

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.


  • 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).


  • 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.


  • 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.


  • 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.


  • 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.


  • 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.

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