1. Pelvic Pain and Endometriosis
Dr. Jackie Hollett-Caines MD, FRCSC
Associate Professor, Western University
Department of Obstetrics and Gynecology

2. Differential Diagnosis of Pelvic Pain
Gynecologic
Urologic
Gastrointestinal
Musculoskeletal
Psychological
General

3. Gynecologic
Ovarian
Fallopian Tubes
Uterus
Vulva

4. Ovarian Mittelschmerz (ovulation pain)
Ovarian Cysts (rupture, torsion)
Ovarian Remnant Syndrome

5. Fallopian Tubes hematosalpinx (after sterilization, ablation)
endosalpingiosis
ectopic pregnancy
Pelvic Inflammatory Disease

6. Uterus
Primary Dysmenorrhea
Adenomyosis
Fibroids
Endometritis

7. Vulvar
vulvodynia

8. Urologic interstital cystitis urethral syndrome
Urinary tract infection
urinary tract calculi

9. Gastrointestinal Irritable bowel syndrome Inflammatory bowel disease
chronic constipation
chronic appendicitis

10. Musculoskeletal myofascial pain pelvic floor myalgia and spasms
nerve entrapment syndrome (neuropathic pain)
mechanical low back pain
disc disease
hernias

11. Psychological depression physical or sexual abuse sleep disturbance
psychological stress
substance abuse

12. General Gynecologic
Endometriosis
Adhesions
Pelvic Congestion

13. Endometriosis definition prevalence causes
investigations (hx, PE, investigations)
management

14. This picture shows a chocolate cyst, which can be quite common in more advanced endometriosis.

15. This is a section through an enlarnged 12 cm ovary to demonstrate a cystic cavity filled with old blood typical for endometriosis with formation of an endometriotic, or "chocolate", cyst. The hemorrhage from endometriosis into the ovary may give rise to a large "chocolate cyst" so named because the old blood in the cystic space formed by the hemorrhage is broken down to produce much hemosiderin and a brown to black color.

16. These dense adhesions are commonly associated with advanced endometriosis. They can be treated with laparoscopy techniques, but are more likely to reform after surgery.

18. Upon closer view, these five small areas of endometriosis have a reddish-brown to bluish appearance. Typical locations for endometriosis may include: ovaries, uterine ligaments, rectovaginal septum, pelvic peritoneum, and laparotomy scars. Endometriosis may even be found at more distant locations such as appendix and vagina

19. Grossly, in areas of endometriosis the blood is darker and gives the small foci of endometriosis the gross appearance of "powder burns". Small foci are seen here just under the serosa of the posterior uterus in the pouch of Douglas.

20. What is Endometriosis?
Is defined as the presence of endometrial glands and stroma occurring outside of the uterine cavity
The most common sites of involvement are:
Ovaries
Pelvic peritoneum
Cul de sac
Uterosacral ligaments

21. Prevalence overall incidence in women of reproductive age is 5-10%
In infertile women, incidence is estimated to be 25-50%

22. Risk Factors for Endometriosis
family history in a first degree relative
anomalous reproductive tracts
increased parity
nulliparity
subfertility
prolonged intervals between pregnancies

23. Etiology – Many Theories
most accepted is Retrograde Menstruation
menstrual tissue refluxes through the fallopian tubes
it then implants on pelvic structures
does not explain why most women have reflux (100%) but only 5-10% of women have endometriosis

24. Etiology of Endometriosis
Retrograde menstruation and implantation
Direct extension
Coelomic metaplasia
Induction theory
Embryonic rests/Mullerian Remnants
Lymphatic and vascular metastasis
Composite theory

25. History ask about any signs or symptoms of endometriosis
dysmenorrhea - painful menses
dyspareunia - painful intercourse
dysuria - painful urination
dyschezia - painful defecation
low back or abdominal pain
pelvic pain - suprapubic or LLQ/RLQ

26. Atypical Presentations of Endometriosis
cyclic leg pain/sciatica
cyclic rectal bleeding
cyclic hematuria
cyclic dyspnea - catamenial hemothorax
some patients may be totally asymptomatic and it is found incidentially at time of surgery

27. Physical Examination pelvic digital exam
non-mobile uterus (fixed or frozen pelvis)
adnexal masses (endometriomas)
tender nodules on the uterosacral ligaments
May even see endometriotic deposits in the vagina on speculum exam

28. Investigations if suspect endometriomas, do an ultrasound
if dyschezia - colonoscopy
if dysuria - cystoscopy

29. Diagnosis
gold standard is laparoscopy with histologically proven endometriosis on biopsy specimens
histology should show:
endometrial glands
endometrial stroma
hemosidern laden macrophages

30. Treatment laparoscopy is not required prior to treatment
overall risk of any complication with laparoscopy, minor or major, is 8.9%
injury to bowel, bladder, major blood vessel
risk of bleeding or infection
risk of anaesthetic

31. Management combined estrogen and progestin therapy
oral progestin therapy
depot progestin therapy
intrauterine progestin releasing system
danazol
GnRH agonists
aromatase inhibitors
analgesia

32. Combined Estrogen and Progestin Therapy
Oral contraceptives are considered first line treatment
Get significant relief of dysmenorrhea within 4 months
There is some data that continuous administration of OCP may be more beneficial in terms of pain relief

33. Oral Progestin Therapy
Norethindrone acetate – not available in Canada
Dienogest – Visanne
Micronor – progesterone only pill

34. Dienogest Has selective 19-nortestosterone and progesterone activity
Daily tablet of 2mg once a day
Efficacy comparable to GnRH agonist (lupron) in 6 month head to head study

35. Depot Progestin Therapy
Depot provera is injected im every 3 months
As effective as lupron
Cons to treatment:
loss of BMD
prolonged delay in resumption of menses/ovulation
Breakthrough bleeding

36. Intrauterine Progestin-Releasing System
Mirena - Contains Levonorgestrel 20 ug/day for 5 years
Results in amenorrhea in 60% of patients
5% expulsion rate and 1.5% risk of pelvic infection

37. Danazol
A weak androgen capable of suppressing gonadotropin secretion, thus leads to amenorrhea
Negative side effects include weight gain, acne, hirsutism, breast atrophy, virilization, impact on lipids

38. GnRH agonists For women who do not respond to OCP or progestins
Cannot be used longterm (> 1 year) without estrogen addback therapy (1mg estrace daily)
Induces hypoestrogenism which can result in hot flashes, insomnia, vaginal dryness, loss of libido, loss of BMD

39. Aromatase Inhibitors Still experimental
Use with either OCP or progestin therapies

40. Analgesia
Used to make patient more comfortable until the primary medical management becomes effective
NSAIDS or opiates