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

What is HPV and what is an HPV screening test?

HPV means Human Papilloma Virus.  HPV is a group of virus types that can affect skin and mucus membranes in the body.  They are the most common skin-to-skin contact transmitted virus types worldwide.  There are numerous sub-types which have been discovered and can be detected.  Many of these sub types cause no symptoms, while others may cause genital warts.  High risk sub types are more often associated with precancerous tissue changes of the cervix (cervical dysplasia) that may lead to cervical cancer, if left untreated over years.  An HPV screening test can be performed together with a PAP smear test.  The sample is collected from the surface of the cervix just like PAP smear testing. 

Protection from HPV

The most effective way to protect oneself from HPV affection is not to get in touch with HPV. Once there is an HPV contact, depending on a person's individual immune response and local immune competence, it may lead to an infection.  HPV infection commonly does not show any symptoms or cause complaints.  In up to 90% of the cases, it is a self-limiting infection resolving within 2 years by itself.  There is still in 10% of the cases women stay chronically infected and may therefore develop abnormal intra-epithelial cervical lesions over time. The risk of an HPV affection and infection can be decreased but not 100% eliminated by protecting oneself.

HPV Vaccination

An additional option of primary prevention is an HPV vaccination against the high risk sub-types HPV type 16 and HPV type 18. About 70% of all cervical cancer lesions are caused by these two virus types. With the option of a targeted HPV vaccination, this risk can effectively be minimized. The greatest benefit of an HPV vaccination can be obtained by applying a first vaccination loading dose and its consecutive follow up boosting doses prior to onset of sexual activity in teenagers. Vaccination is recommended to both, girls and boys. The antibodies build up as an immune response to vaccination can thereafter protect from virus invasion into the skin and body mucous membranes and prevent from a chronic virus infection. 

Two vaccines are available and they do both target HPV high risk virus types HPV 16 and HPV 18. Vaccination does not cover all high risk HPV sub-types known. A yearly check up and regular PAP smear testings therefore remains crucial for women. Still, experiences with vaccinating women against HPV 16 and HPV 18 over the past years has shown, that vaccination may also be beneficial and protective against other potentially oncogenic virus types in addition. This so-called cross-protection can be explained by similarities in virus surface structure and mode of action, that allows immune response cells identify and attack several virus types.

One of the two vaccines available additionally prevents from infection with HPV low risk types HPV6 and HPV 11, known to be causing non-malignant genital warts.  A new vaccination that was recently introduced is targeting nine virus types and therefore seems to be a promising option.  All vaccines itself do not contain any oncogenic or cancerous changes causing ingredients. Risks and side effects of a vaccination are comparable with those of other well established recommended vaccinations in childhood and teenage years. Vaccination is a highly recommended option of primary prevention in teenagers, both boys and girls in the age from 9 to 15years. But also later in life vaccination is advisable. Also women in her fertile ages exceeding this main target group can profit from a boost in their local immune response and should ask their gynecologist for more information and an individualized consultation. Still, a regular check up and PAP smear remains crucial in all women.

Visit us for more information. We are happy to answer all your questions.

Dr. Amelie Hofmann-Werther

Specialist in Obstetrics & Gynaecology

(Facharzt Germany)

Cervical Dysplasia & Coloscopy

Master Class in Fetal Medicine

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

What is Tubal Patency Check (Hystero Salpingo Sonography)?

Females have a pair of fine fallopian tubes which eggs travel form the ovaries to the uterus.  To obtain a successful pregnancy, one has to have an "open" or "patent" tubes.  Women who are trying to get pregnant, but are having difficulty conceiving should get an appointment for tubal assessment.  Normal fallopian tubes cannot be seen by a regular ultrasound, hence, contrast is used. 

Tubal patency check is performed during the first half of cycle before ovulation which  means between day 8-12 of that cycle.   This test is done before ovulation to make sure there is no pregnancy even if the chance of being pregnant is low.

The pain that may be experienced varies from women to women.  Some would say they did not feel any pain at all or some would complain of cramping when the contrast is injected.  It would be safe to say that majority of women feel mild to moderate pain during the procedure.  It could be recommended that pain reliever tablets be taken an hour before the procedure.

A pelvic ultrasound is performed to assess the pelvic anatomy.  If the findings are normal then tubal assessment will proceed.   There is a special catheter  inserted through the cervix and this is where the contrast is injected while the vaginal probe is also inserted.  If the contrast is seen flowing through the fallopian tubes towards the ovary on both sides, it means that the tubes are patent.  However, if the results show that the tubes are blocked, the Physician would discuss further assessment.  It is best to always ask questions and be informed.

Dr. Afshin PourMirza, MD, PhD
Medical Director

Obstetrics & Gynaecology
Feto Maternal Medicine Specialist

www.fetalmedicine.ae

Feto Maternal and GenetYX Center