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

2. 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

3. 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

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

5. 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.

6. 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.

7. 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

8. 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.

9. 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.

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

11. 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.

12. No medical therapy has been proved to eradicate the lesions.

13. 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.