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If You have Chronic Pelvic Pain You may be Suffering from Endometriosis

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Endometriosis affects thousands of women

Endometriosis is a benign condition, which usually affects women of reproductive age group. It is a disease where the cells of the lining of the uterus known as the endometrium, deposit in different organs of our body. The common sites involved are the ovary (most common), the rectouterine pouch, uterosacral ligaments, fallopian tube, rectovaginal septum, bladder, etc. Besides these, it can also involve any organ of our body such as lungs, sigmoid colon, kidney, ureter, appendix, episiotomy scar, abdominal scar, and so on.

The overall incidence of endometriosis in reproductive age group women ranges from 5-10 %. Meanwhile, about one-third of the infertile women have shown endometriosis during the diagnostic laparoscopy or laparotomy.

The endometrial cells undergo cyclical changes similar to uterine changes during the menstrual cycle resulting in bleeding and breakdown of tissues at the site of origin. However, as these blood and damaged cells cannot be removed, they remain at those sites and results in chronic debilitating signs and symptoms.

What causes Endometriosis?

The exact etiology of endometriosis is not yet known however various theories have been proposed. The most accepted theory is - Sampson's theory of retrograde menstruation. Endometriosis is an estrogen-dependent tumor and its risk factors and treatment depend on conditions manipulating this hormone.

The major risk factors are early menarche, late menopause, history of endometriosis in first-degree relatives, low body mass index, prolonged menstruation, shorter lactation intervals, shorter menstrual cycle, white race, etc.

Signs and Symptoms

The classic symptom of endometriosis is severe cyclical non-colicky pelvic pain around the time of menses. It may be associated with heavy menstrual loss, chronic pelvic pain, severe fatigue, dyspareunia (pain during intercourse), or dyschezia (pain during defecation). The clinical features depend on the site of origin. For example, lung endometriosis may result in cyclical hemoptysis or hemopneumothorax, urinary tract endometriosis can result in cyclical hematuria, dysuria, flank pain, or loin pain and endometriosis of rectum can result in cyclical rectal bleeding, obstruction, and dyschezia.

Complications

Patients with endometriosis suffer from chronic pain that can hamper their day to day activities. In some cases, a patient may be bedridden for days to weeks affecting their social and psychological well-being as well.  

Endometriosis is a stubborn disease that may recur despite of treatment. The endometrial deposits may produce pressure symptoms like constipation, irritable bowel disease, rupture of the endometrial cyst, urinary retention, and infection. Moreover, these tissues may undergo degenerative and fibrotic changes resulting in infertility in patients.

Diagnosing Endometriosis

Due to the variation in progression and presentation of the disease, the diagnosis of endometriosis is often delayed, with research indicating up to 6years on average. The gold standard for diagnosis is laparoscopy and biopsy, which is a minimally invasive procedure. It shows red, puckered, black matchstick-like masses or white fibrosed lump.

Other investigations like transvaginal ultrasound, MRI, CA-125 monitoring, etc. are also helpful in diagnosis. However, these investigations can neither rule out endometriosis nor detect scanty endometriosis.

Conditions Mimicking Endometriosis

Not all the case of chronic pelvic pain or infertility point towards endometriosis. Hence a physician may consider the chronic pelvic inflammatory disease, ovarian or pelvic malignancies as their common differentials.

Treating Endometriosis

Currently, there is no definitive treatment for endometriosis. Nevertheless, medical science has equipped us with drugs and surgeries that provide symptomatic relief and improve our quality of life and fertility. Many institutions follow the staging of endometriosis given by the American fertility society based on laparoscopic findings.

Medical management includes analgesics like NSAIDS, hormonal therapy, and psychological counseling for pain and stress. Hormonal therapy is aimed to produce either pseudo menopause using drugs like Danazol, or to produce pseudopregnancy using combined oral contraceptive pills, DMPA, Mirena, etc, or may be used to produce medical castration or medical oophorectomy using GnRH analog.

Surgical management is considered basically when there is no improvement despite 3 to 6 months of medical management or if there is severe and deeply infiltrated endometriosis having severe symptoms. Treatment should be personalized based on the age, symptoms, extent of disease, and desire to have children. Fertility sparing surgeries like laparoscopic resection are available for those who want to conceive in the future. But it has chances of recurrences. Hysterectomy and oophorectomy can be planned ideally for a menopausal patient or those who have completed their family or for those having severe symptoms.

Endometriosis-Related Infertility

Even despite medical and surgical management, the patient develops infertility then the couple should be advised for artificial reproductive techniques. This includes ovarian hyperstimulation with clomiphene citrate followed by IVF, GIFT, ZIFT, ICSI, etc.

Endometriosis at Special Sites

If endometriosis develops at nonreproductive organs then depending on its size and depth, it can be excised or medically managed. Lung, pleural, and brain are rare sites and in these areas, hormonal therapy may be effective.

Ongoing Clinical Trials and Future of Endometriosis

Recent clinical trials are being done about the effectiveness of HIFU (High intensity focused ultrasound) and transcutaneous auricular vagus nerve stimulation.

Various routes of administration of drugs to provide localized hormonal therapy are under study such as the intracystic method of administration of hormones.

Newer medications under study include mifepristone and aromatase inhibitors (letrozole, anastrozole, and exemestane).

Besides these, ethanol sclerotherapy, Chinese herbal medications; gestrinone (antiprogestational and antiestrogenic properties); immunomodulators (pentoxifylline and interferon); and selective estrogen receptor modulators are also being studied.

Acupuncture and yoga have also been proposed as effective modalities for the treatment of pain.

To provide psychological support for patients thriving with endometriosis and infertility, cognitive behavior therapy has also been applied, in cases where depression is seen. Peer groups are formed and various small organizations are also working to provide moral support and guidance to these patients. Proper counseling and patient education help reduce the stress and anxiety due to the disease to a certain extent.

To summarize, the combined medical and surgical approach should be considered and discussed with the concerned gynecologist to obtain individualized treatment and better outcomes against endometriosis.

Prognosis

The overall rate of recurrences is about 40 percent after 5 years. The cumulative probability of pregnancy at 3 years after laparoscopic treatment was around 47 percent. Hence endometriosis is still regarded as a gynecological challenge considering different aspects together such as pain management, recurrences rate, cost, side effect, chances of pregnancy, etc.

 

 

References

  • Endometriosis: diagnosis and management, NICE Guideline, No. 73

  • G Schultes, Classification of endometriosis. ,[Pub Med], PMID: 10568017

  • Acién, P., Quereda, F.J., Gómez-Torres, M.J., Bermejo, R., Gutierrez, M., 2003. GnRH analogues, transvaginal ultrasound-guided drainage, and intracystic injection of recombinant interleukin-2 in the treatment of endometriosis. Gynecol. Obstet. Invest. 55, 96–104.

  • Giuseppe Benagiano, Felice Petraglia, Stephan Gordts, Ivo Brosens,2016."A new approach to the management of ovarian endometrioma to prevent tissue damage and recurrence"

  • Soto E, Luu TH, Liu X, Magrina JF, Wasson MN, Einarsson JI, Cohen SL, Falcone T. Laparoscopy vs. Robotic Surgery for Endometriosis (LAROSE): a multicenter, randomized, controlled trial. Fertil Steril. 2017 Apr;107(4):996-1002.e3. doi: 10.1016/j.fertnstert.2016.12.033. Epub 2017 Feb 24.

  • DiVasta AD, Feldman HA, Sadler Gallagher J, Stokes NA, Laufer MR, Hornstein MD, Gordon CM. Hormonal Add-Back Therapy for Females Treated With Gonadotropin-Releasing Hormone Agonist for Endometriosis: A Randomized Controlled Trial. Obstet Gynecol. 2015 Sep;126(3):617-27. doi: 10.1097/AOG.0000000000000964.

  •  Hammerschlag Richard, Burry Kenneth, 2008.Endometriosis: Traditional Medicine vs Hormone Therapy. ClinicalTrials.gov Identifier: NCT00034047

  • Hummelshoj L, Prentice A, Groothuis P. Update on endometriosis. Women's Health (Lond Engl) 2006;2:53–56. doi: 10.2217/17455057.2.1.53. [PubMed]


     

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