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Monday, January 2, 2012

Endometriosis and Chronic Pelvic Pain

If I had to give a single disease process besides cancer in women that I would like to see abolished, it would be endometriosis.  A chronic, non-lethal disease of the female pelvis, endometriosis is a process whereby the cells that usually are confined to the uterine lining (glandular cells) somehow grow and invade tissues outside the uterus.  The result over the course of years can be debilitating pain.

Retrograde Menstrual Flow
 No one really understands the actual cause of endometriosis, but there is speculation that there is some hereditary component because mothers/daughters sometimes follow a similar path in their reproductive years.  Retrograde menstruation (bleeding backward through the fallopian tubes) potentially plays a role in this disease.  The fact is, there aren't many facts about endometriosis other than it is a very common cause of chronic pelvic pain as well as a contributor to infertility. 

 Women who ultimately are diagnosed with endometriosis often can track their symptoms back as far as their teenage years.  Their menstrual flow may have perpetually been heavy and painful.  Later, the pain dissociates from the menstrual flow days so as to be more notable just before the period and reach a crescendo during the period.  The key is that the pain is cyclic in nature in the beginning.  As the process of endometrial implants progresses within the pelvis, there is progressive scarring often found behind the uterus and around the ovaries that causes painful intercourse.  Some women even notice the same pain when inserting tampons or when moving their bowels.

Endometriosis Nodules Behind the Uterus

The diagnosis of this process if best done with a surgical procedure known as laparoscopy.  The surgeon can view the pelvic tissues with a magnifying scope and take pictures to document the extent of the scar tissue.  Ultrasound and MRI can give clues to the presence of endometriosis, but the laparoscope remains the definitive way to know for sure.

Treatment consists of suppressing the ovaries, which are integral to this whole pathway of pain.  The ovarian estrogen stimulates the growth and spread of the endometrial implants, and by keeping the ovaries quiescent, the disease process is slowed.  Pregnancy does the same thing, but no one is advocating that women pursue having a baby as a means of battling their pain!  Medications that can stop the progression of endometriosis are available for that.

Depolupron, a gonadotropin (sex hormone) releasing hormone substance is often used to put the ovaries into a temporary menopause state such that active endometriosis is arrested and healing can take place.  This therapy can be followed by continuous birth control pills, patches, rings, etc. in an effort to continue to suppression of the ovaries and the menses.  Surgery to remove active endometriosis lesions in the pelvis, especially endometriosis cysts of the ovary (chocolate cysts) is very helpful but clearly a more invasive way to treat then simply using a medication.  A new indication for the class of drugs known as aromatase inhibitors may be for those patients who fail to respond to the usual therapies for this problem, but that is still being studied at this point.

The most invasive treatment of severe endometriosis causing debilitating pelvic pain is to remove not only the uterus to relieve the bleeding but also both ovaries to eliminate the chance of ongoing pain and scarring.  If even a portion of an ovary is left in place when endometriosis is present, the disease is technically still there.  There can be reactivation of the pain/scarring cycle at any time even when the uterus is absent.  So the decision to go for major surgery for endometriosis is a big decision indeed.  If  you have cyclical pelvic pain and particularly heavy, irregular or painful menstrual flow, please consult your health care provider to find the cause and explore your options.