CHRONIC PELVIC PAIN ENDOMETRIOSIS RAED SAYED AHMED MBCHB, FRCSC, FACOG, MCHCH

CHRONIC PELVIC PAIN Urinary tract Gynecologic etiologies Gastrointestinal tract Endometriosis Pelvic inflammatory disease Adhesions Pelvic congestion syndrome Adenomyosis Ovarian cancer Ovarian remnant and residual ovary syndrome Leiomyoma Dysmenorrhea Urinary tract Interstitial cystitis/painful bladder syndrome Other Irritable bowel syndrome Inflammatory bowel disease Diverticular colitis Colon cancer Chronic intestinal pseudo-obstruction Chronic constipation Celiac disease

CAUSES cont’d Fibromyalgia Musculoskeletal system Mental health issues Fibromyalgia Coccydynia, piriformis/levator ani syndrome, pelvic floor tension myalgia Posture Chronic abdominal wall pain Osteitis pubis Somatization disorder Opiate dependency Physical and sexual abuse Depression Sleep disorders

ENDOMETRIOSIS A common health problem among women of reproductive age. Endometrial-like glands and stroma grow in an extrauterine site.

ETIOLOGY Various theories regarding its etiology. Menstrual flow that produces a greater volume of retrograde menstruation may increase the risk of developing the disease. Early menarche, Regular cycles (especially with an absence of amenorrhea caused by pregnancy), longer and heavier flow are also associated factors.

ETIOLOGY cont’d Endometriosis is an estrogen-dependent disease Factors that reduce estrogen levels (e.g., menstrual disorders, decreased body-fat content and smoking) are associated with a reduced risk for developing the condition.

SIGNS AND SYMPTOMS Clinical manifestations of endometriosis vary and may be unpredictable in presentation and course. Dysmenorrhea, chronic pelvic pain, Dyspareunia, Uterosacral ligament nodularity Adnexal mass. Asymptomatic in many women

Pelvic Pain Pelvic pain caused by endometriosis falls into three categories: Secondary dysmenorrhea, with pain commencing before the onset of the menstrual cycle; Deep dyspareunia that is exaggerated during menses; or Sacral backache with menses.

Pain con’d The pain associated with endometriosis has little relationship to the type of lesions seen by laparoscopy. It has been shown that the depth of endometriosis lesions correlate with severity of pain. It is thought that painful lesions are those that involve peritoneal surfaces innervated by peripheral spinal nerves, not those innervated by the autonomic nervous system.

DIAGNOSIS A histologic examination should be done to confirm the presence of endometrial lesions.

TREATMENT Current evidence suggests that pain caused by endometriosis can be managed medically. Progestins, danazol, oral contraceptives, nonsteroidal anti-inflammatory drugs and gonadotropin-releasing hormone (GnRH) agonists.

No medical therapy has been proved to eradicate the lesions.

SURGERY Surgery for women with endometrial pain is associated with significant reduction in pain during the first six months following surgery. up to 44 percent of women experience a recurrence of symptoms within one year. Data about whether surgical therapy influences long-term therapy are lacking, and there are no data to indicate whether medical or surgical therapy results in better fertility outcomes.