Chronic pelvic pain and endometriosis

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.

Dr. Amelie Hofmann-Werther

Specialist in Obstetrics & Gynaecology

(Facharzt Germany)

Cervical Dysplasia & Coloscopy

Master Class in Fetal Medicine

http://www.fetalmedicine.ae/#dr-amelie