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Endometriosis and Pelvic Pain

Source: The endometrium is the name for the cells that line your uterus (womb). These cells respond to the hormones released from the ovary.

When pregnancy does not occur each month, the tissue comes away from the body with bleeding – this is known as the menstrual period.

Endometriosis occurs when these cells move to other parts of your body. Although they can move to almost any part of the body, most commonly endometriosis occurs in the pelvis.

Even though this tissue (the endometriosis) is outside the womb, it still responds to the messages from the ovary - it gets filled, and then when you have a period it bleeds. Endometriosis is:

* common – at least 1 in 10 women have endometriosis

* chronic – because endometriosis rarely goes away without treatment before the menopause, the goals of treatment are to control the symptoms of endometriosis, not to cure it

* estrogen dependent – endometriosis is dependent on the hormone estrogen. Estrogen is produced by the ovary throughout the ‘reproductive years’; this means from the time you start having periods (puberty) to the time your ovaries shut down (menopause).

As long as you still have functioning ovaries you can still be affected by endometriosis. Once you go through menopause, your endometriosis will not be able to grow any more.

What are the signs and symptoms of endometriosis?

The symptoms of endometriosis vary from one person to another.

Some women with endometriosis have no symptoms at all.

The two main symptoms that endometriosis causes are:

1. Pain – the pain occurs in the places that the endometriosis has grown. It is mostly in the pelvis. It is mostly ‘cyclical’, which means that it happens with your period. For many women, the first thing they notice is worsening pain with periods. Women with endometriosis often have pain with sex too.

2. Trouble getting pregnant (sub-fertility or infertility) – endometriosis can make it difficult to get pregnant. Some women only have endometriosis diagnosed when they start trying to get pregnant.

What causes endometriosis?

The causes of endometriosis are not fully understood. Women with a mother or sister with endometriosis are more likely to get it.

How is endometriosis diagnosed?

There are symptoms that suggest to your doctor that you may have endometriosis - like worsening painful periods. An ultrasound can sometimes help with the diagnosis. However, the only way to know for sure if you have endometriosis is to undergo a laparoscopy. This is a surgical procedure where your gynaecologist uses a small telescope inserted through your umbilicus (belly button) to look at the organs on the inside of your pelvis. Your surgeon will take pictures and often take samples of the endometriosis to confirm the disease.

How is endometriosis treated?

The treatment of endometriosis often involves both medication (tablets and injections) and surgery (laparoscopy to remove the endometriosis). Most women who have endometriosis will require both of these treatments at different stages of their lives. The choice of treatments depends on how bad the pain is, where the pain is, and if you are trying to get pregnant.

1) Medicines:

Pain relief medication (analgesics) like naprosyn or ponstan

2) Hormone-based treatments

The oral contraceptive pill (‘the pill’)

Using an oral contraceptive to stop ovulation, the levels of estrogen in the pelvis are reduced and this can help settle the activity of endometriosis. As well, by running packets of the pill together to ‘skip’ periods, women can reduce the number of painful periods they have. It is important to realise that use of oral contraceptives will not make endometriosis go away.

Mirena

Mirena is a small device that is shaped like a T. This is placed in the uterus and releases a progesterone-like hormone. This has been shown to reduce the activity and pain of endometriosis over time for many women.

Other types of progesterone-like hormones

These medications can help settle the activity of endometriosis when used over time.

Dienogest (Vissane) is a progesterone treatment that has been shown to reduce the regrowth of endometriosis if it is taken

everyday.

GnRH-agonists

Some implants and sprays can switch off the release of reproductive hormones in women. However, this can induce a state like menopause that women may find unpleasant. It is unusual to use such medications alone for more than a few months, as there can be long-term side effects.

It is important to realise that the medications used for treatment of endometriosis are commonly contraceptive (they stop pregnancy occurring).

3) Surgery

The surgery depends on the symptoms and the location of the endometriosis. It is most often a laparoscopy. This procedure allows your surgeon to diagnose and to treat your endometriosis. The endometriosis may be cut out or burnt off.

Source: https://www.ranzcog.edu.au/Womens-Health/Patient-Information-Resources/Endometriosis

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DISCLAIMER: This information is intended to be used as a guide of general nature, having regard to general circumstances. The information presented should not be relied on as a substitute for medical advice, independent judgement or proper assessment by a doctor, with consideration of the particular circumstances of each case and individual needs. This information reflects information available at the time of its preparation, but its currency should be determined having regard to other available information. RANZCOG disclaims all liability to users of the information provided.

CHRONIC PELVIC PAIN

Chronic pain, in general, means that pain has been present continuously for more than three months, despite treatment of what was thought to be the original cause of the pain.

Chronic pelvic pain is different for every woman and may be felt anywhere below the stomach and into the pelvic area. The pain comes and goes, but remains in a certain area. Menstruation and bowel motion can aggravate the pain. Chronic pelvic pain is also often associated with feeling ill and nauseated.

Chronic pelvic pain develops over several years. The most common early complaint is a feeling of period pain or cramping that persists long after the period has finished. Eventually pain is present every day and associated with natural events, such as ovulation, bowel motion, urinating and intercourse.

Chronic pelvic pain can be associated with other chronic conditions, such as irritable bowel syndrome, premenstrual mood disorder and migraine headaches.  

How is Chronic Pelvic Pain diagnosed?

History and physical examination

Women with chronic pelvic pain may have seen multiple doctors and undergone several surgeries such as laparoscopy (keyhole surgery), cystoscopy (bladder examination) and so on. You may feel as though you have seen lots of people and no one has been able to help.

The diagnosis of chronic pelvic pain is a ‘diagnosis by exclusion’, meaning that no known obvious cause for the pelvic pain has been found. The physical examination and investigations aim to make sure that there is no obvious cause that needs to be specifically treated.

Sonography scans

Ultrasound is the best imaging technique for the pelvic organs. In rare circumstances, other tests may be requested to look at other abdominal and pelvic structures, such as the spine.

How is Chronic Pelvic Pain Treated?

We do not use the term ‘cure’ for treatment of chronic pelvic pain. There is also little place for surgery in the management of chronic pelvic pain.

Rather, pelvic pain, as with any chronic pain condition, is ‘managed’ through a variety of measures involving everyday life, from work to leisure activity adjustments, as well as medical and non-medical interventions.

The crucial element in the process is that you, the patient, are the driver of this management plan.

Prevention, understanding and acceptance

To some degree, chronic pain can be minimised by making sure that episodes of acute pain are treated early on. This means, for instance, that painful periods in young girls should be taken seriously. As menstruation is often predictable, it is advisable to take simple over-the-counter medication as soon as possible.

For those who want to avoid medication, there are other means, such as heat packs, herbs or acupuncture, to ease the pain.

Pain that persists despite treatment of underlying conditions, (such as endometriosis) may be linked to a fault in the way the brain processes and interprets the pain sensation. There are several wellwritten books that go into great detail to explain the process of how chronic pelvic pain comes about without an apparent ‘cause’.

Understanding that pain can be perceived without an underlying condition, such as endometriosis, is an important step in the management of chronic pain. The most important step then is the acceptance that treatment of chronic pain no longer involves the search for a ‘removable cause’ and a ‘cure’.

Hormonal therapies

Treatment of chronic pain consists in part in the identification of ‘triggers’ of pain. In the case of chronic pelvic pain, ovulation (the development and release of an egg during the fertile time of a woman’s monthly cycle) is an important trigger, as is your monthly menstrual period. Therefore, changing your hormone levels by taking ‘the Pill’ to suppress ovulation and menstruation may have a positive impact on chronic pelvic pain.

Lifestyle adjustments

‘Pacing’ is the magic word in the treatment of chronic pain. Pacing means avoiding excess physical activity that may lead to days when your level of pain is higher and will result in severely reduced activity

.In view of the common association between irritable bowel syndrome and chronic pelvic pain, it is important to maintain an appropriate diet, predominantly aimed at reducing the formation of intestinal gas. A low-inflammation diet can also be helpful.

Psychotherapy

The mind is our most potent weapon against chronic pain. You can learn how to use your brain to reduce pain perception with simple, daily techniques. Psychologists can be very helpful in preparing your mindset to tackle this problem.

Physiotherapy and osteopathy

Chronic pelvic pain can lead to changes in posture and cause other muscle disorders. Physiotherapy and osteopathy are aimed at identifying muscular issues and providing a framework of exercises to assist with change.

Other medication

Medication is often required to treat chronic pain. Pelvic pain may respond to non-steroidal medications, such as naproxen and ibuprofen, as well as some low-dose antidepressants. It is unfortunate that some of the medications are called ‘antidepressants’ as this classification can often deter women from taking medication that may help. You do not have to be depressed to gain benefit from the use of these drugs. Opioids (strong pain-killing drugs) are rarely recommended, as they can worsen chronic pain in the long term and bring along other problems. It is best to stay away from opioids, even weak ones such as codeine, wherever possible.

Mindfulness, yoga and acupuncture

Yoga and other ‘mind-body’ programs are a useful tool in the management of chronic pain in general. Acupuncture may also play a role, especially in the management of painful periods. The use of so-called ‘soft tissue’ lasers for management of chronic pelvic pain is yet to be evaluated.

Source: https://www.ranzcog.edu.au/Womens-Health/Patient-Information-Resources/Chronic-Pelvic-Pain

DISCLAIMER: This information is intended to be used as a guide of general nature, having regard to general circumstances. The information presented should not be relied on as a substitute for medical advice, independent judgement or proper assessment by a doctor, with consideration of the particular circumstances of each case and individual needs. This information reflects information available at the time of its preparation, but its currency should be determined having regard to other available information. RANZCOG disclaims all liability to users of the information provided.

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