Endometriosis and Pelvic Pain
Long time ago
endometriosis was though to be limited to white middle and upper class women; we know that many of these socioeconomic and racial considerations were false.
Endometriosis is the second most pathologically reported gynecological diagnosis (
regardless of the patient's background). Endometriosis can significantly affect the physical and emotional well-being of the patient.
Endometriosis occurs when endometrial tissue (
the lining of the uterine cavity) becomes implanted outside the uterus. Although endometrial tissue can be found in virtually any area of the body, it is most commonly seen in the pelvic cavity, on the surface of the ovaries, utero-sacral ligaments, uterus, fallopian tubes, and supporting broad ligaments. Like the lining of the uterus, these small ectopic patches of endometrium respond to monthly cyclic hormonal changes by bleeding at the end of each menstrual cycle. This “internal bleeding” causes inflammation and results in scarring and adhesion formation, hence, the common symptoms of severe pelvic pain and infertility.
However, as confirmed in over 1000 patients by laparoscopy, symptoms do not necessarily reflect the severity of the disease. Mild disease may cause disabling pelvic pain whereas, with extensive disease, pelvic pain is not always present. Typically, the pain and dyspareunia are worse premenstrually and may improve in the early proliferative phase, immediately after menstruation.
The most common
symptoms of endometriosis are dsymenorrhea (
painful menstruation) and dyspareunia (
painful intercourse) on deep penetration. Often the dsymenorrhea becomes progressively worse with time as the endometriotic areas increase in size. On physical examination, it is rare to palpate nodular areas of endometriosis but typical to find the uterosacral area quite tender. Definite diagnosis is possible only with visualization during laparoscopy. Classic endometriosis appears as small, raised, bluish areas that have been described as “powder burns” or “blueberry spots.” However, biopsies have confirmed that white and lighter red raised areas, filmy adhesions and peritoneal defects, as well as advanced areas of scarring and adhesions, can be due to endometrial implants.
Endometriosis can be red or yellow, raised 'bumps' or 'holes.' Any appearance that does not appear smooth and shiny is compatible with pathologic endometriosis.
The
treatment of endometriosis should be individualized according to the needs of each patient. Generally, the most common approaches are with hormonal therapy, laparoscopic surgery and major surgical management. In the past, it was thought that pregnancy would “cure” endometriosis. It is now recognized, however that the disease will persist and recur after pregnancy. Hormonal treatment, which is probably most effective when the areas of endometriosis are small, includes the use of oral contraceptives on a continuous basis. The combination of estrogen and progestin oral contraceptives may alleviate cyclic pain by suppressing the cyclic growth of endometriotic patches. However, success seems to be limited to the younger patient with milder disease. Danazol, a steroid androgen, more substantially suppresses the cyclic changes and thereafter causes atrophy of the endometriotic sites. Newer medications called GnRH agonists (
Lupron, Synarel, Zoladex) suppress the ovary by blocking the release of pituitary hormones. These agents do not have the acne and weight gain side effects of Danazol. For others, an agent containing a progesterone derivative is used. In my research, each drug offers specific benefits although all may produce osteoporosis (
bone thinning) with prolonged use. Quantitative analysis of serum hormonal levels on these drug regimens allows the evaluation of estrogen, androgen and progesterone suppression.
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