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Management of Chronic Pelvic Pains
About 60% of women with endometriosis seek medical attention because of chronic pelvic pains or other pain symptoms related to their menstrual cycles. Laparoscopic diagnosis and treatment in this group of women is usually delayed by an average of 6.35 years from the beginning of symptoms, as demonstrated by one of the studies performed at our Institute for the Study and Treatment of Endometriosis (Endometriosis Institute). This is interesting considering that a comparable 'diagnostic delay' in women with endometriosis and infertility is only about half as long.
The Cause of Symptoms
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Peritoneal endometriosis |
Endometriotic implants cause a local inflammatory reaction which irritates nerve endings and sends noxious stimuli along the nerve pathways to the spinal cord and into the central nervous system (CNS) where they are interpreted as burning, dull, achy sensations or as sharp, stabbing, or crampy pains. The local inflammatory reaction is mediated by the increased production of substances, such as a variety of cytokines and prostaglandins, originating from the endometriotic implants and cells of the immune system. These substances also stimulate development of scarring and nodules around the endometriotic implants which may compress peripheral nerves compounding pain symptoms with signs of peripheral neuropathy. Pain symptoms are usually elicited when the nodules are compressed during pelvic examination or sexual intercourse. Endometriotic (chocolate) cysts may compress on other pelvic organs, causing pain and pressure during urination or bowel movements. If there is bleeding from the endometriotic lesions, as it frequently happens during the menstrual period, a woman may notice blood in the urine or stools or in secretions from other organs affected by endometriosis, e.g. blood in the sputum with endometriosis of the lungs. Because of increased systemic cytokine and prostaglandin production by the circulating immune cells, some women with endometriosis may experience generalized symptoms such as low-grade fever; crampy, generalized aches and pains; and nausea, vomiting, and diarrhea usually around the time of the menstrual period.
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Endometriotic nodule of uterosacral ligament |
Other Causes of Pelvic Pains
Pelvic organs in the female, in addition to the reproductive system, include the urinary and gastrointestinal systems, pelvic nerves, and musculoskeletal system. All of these organs are in close proximity and it is often impossible to tell which symptoms originate from which organ. Furthermore, it is not unusual that endometriotic implants are totally asymptomatic. It is therefore of primary importance to determine whether endometriosis and not a disease of another organ is actually the cause of pelvic pain symptoms. Several diagnostic tests and consultations with other specialists may be of help here. However, the patient herself may be able to observe a relationship between pain symptoms and different body functions, or physical activities which may suggest a disease of a specific organ. If the cause of the symptoms is still unclear, a trial of ovarian suppression with a drug such as Depot Lupron may help differentiate endometriosis-related pelvic pain from pelvic pains of other causes.
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Ruptured "chocolate" cyst |
Surgical Treatment
Laparoscopic surgery for chronic pelvic pains and suspected endometriosis should be performed by a surgeon with the necessary skills and expertise in the resection of such lesions and in an operating room equipped for such a surgery. Endometriotic implants should be resected, vaporized, or fulgurated and care should be taken to perform as complete as possible resection of deep infiltrating endometriotic nodules which are usually the cause of pelvic pains. To reduce pain transmission, nerve interruption procedures such as uterosacral (US) nerve ablation or presacral neurectomy should also be considered. Adhesions (scar tissues) should be completely resected and measures preventing their reformation should be applied. Endometriotic cysts should be resected with their capsule - using ovarian tissue-sparing technique - rather than be drained. The surgeon should also be prepared to resect endometriotic lesions that may involve other organs such as the bowel or bladder. Appendectomy should also be performed if there are adhesions or if endometriosis involves the appendix.
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Laser video-laparoscopy |
Pain Relief
After complete resection of endometriotic lesions, the majority of patients will have a significant improvement in pelvic pain symptoms lasting for several years. Ultimately, however, the disease recurs along with the pain symptoms, especially if there were no preventive measures taken after surgery. If resection of endometriotic implants and/or endometriomas was incomplete, the symptoms may recur earlier or there may be little, if any, symptomatic improvement after surgery.
How to Prevent Recurrence
Recurrence of endometriotic lesions is stimulated by estrogens, the female hormones produced by the ovaries. During the normal menstrual cycle, blood levels of estradiol (the main estrogen) fluctuate between 40 and 400 pg/mL. These levels are necessary to achieve pregnancy but they also contribute to the recurrence of endometriosis. Estradiol levels between 70 and 100 pg/mL are adequate for normal body functions, do not reactivate endometriosis, and will prevent menopausal changes. There are two methods to prevent or delay recurrence of endometriosis in a woman who is not planning to conceive: 1) By changing the hormonal environment from estrogenic to strongly progestational using certain types of birth control pills, and 2) By maintaining blood estradiol levels between 70 and 100 pg/mL using GnRH analogs and add-back regimens.
Recurrent Endometriosis
In women with recurrent endometriosis and recurrent pelvic pains, several options of treatment may be considered. Clinical response to prior surgery and medical treatments as well as frequency and intensity of side effects of these treatments should be the guidelines in treatment selection. If there was a good and lasting response after surgical resection, another laparoscopic surgery may be considered. It should, however, be kept in mind that repeated surgeries cause adhesions and destruction of healthy ovarian tissue and may adversely affect fertility.
Medical Treatment
Medical treatment can suppress endometriotic lesions and decrease the size of endometriomas. Pain improvement is observed in over 80% of patients but the effect is gradual over a period of six months of typical treatment. Because all medications used in the treatment of endometriosis change the hormonal status of the patient, there may be a variety of side effects. GnRH agonists are the most commonly used hormones. They include Depot Lupron, Zoladex, and Synarel. They lower estradiol levels to less than 20 pg/mL, causing menopausal symptoms and changes. After endometriosis is suppressed, the GnRH agonist may be used for a longer period of time with estrogen add-back to control the symptoms and changes of menopause. Danocrine is an anabolic steroid that lowers the estradiol level only to 40-60 pg/mL, suppressing the menstrual cycle and endometriosis without severe menopausal symptoms. Increase in appetite and weight gain are the major side effects. Birth control pills, especially those with strongly progestational properties when given as a long-cycle regimen, may control pelvic pain symptoms but generally have only a limited effect on endometriosis. Their side effects, however, are tolerable by most patients. Progestogens alone can control pelvic pain symptoms in some women. Their effect on endometriosis and their side effects are similar to those of birth control pills.
New Treatment Methods
Several new hormonal preparations are being tested for their effectiveness in controlling endometriosis and pelvic pains. Our Endometriosis Institute has recently completed a clinical study on a new drug, Abarelix, which is a GnRH antagonist. Abarelix is more effective than GnRH agonists and seems to have fewer and less bothersome side effects. It should be approved for clinical use within the next year or two. We currently are investigating a new approach to the management of endometriosis and pelvic pains. This is based on a local intravaginal - rather than systemic - administration of the hormones such as intravaginal Danocrine. We are expecting a similar clinical effect as with oral administration but without systemic side effects. In the future, we anticipate that a new class of medications - the immunomodulators - will become available to treat endometriosis and pelvic pains more effectively.
Alternative Approaches to the Management of Pelvic Pains
As mentioned earlier, local inflammatory reaction caused by endometriosis stimulates pelvic nerves and activates neural pathways from the pelvic organs to the CNS. In some women, CNS sensitivity to these signals is increased with increased perception of pelvic pains and a vicious circle where a relatively minor irritation, associated with minimal endometriosis, results in a progressively increasing and disproportionately high perception of pelvic pains. In such patients, endometriosis may be a relatively minor health problem while pelvic pains become a chronic, overwhelming condition leading to clinical depression and other health problems. Several approaches may be tried to control pelvic pains and to break this vicious circle. Non-steroidal anti-inflammatory drugs (NSAID) are prostaglandin synthetase inhibitors which decrease the inflammatory changes associated with endometriosis and improve pain symptoms in most patients. They can be used alone or with other pain medications. Tricyclic antidepressants control depression which frequently is associated with chronic pains and, at the same time, inhibit pain transmission in the spinal cord. Other approaches to the management of chronic pain, such as peripheral nerve blocks, bio-feedback, acupuncture, reflexology, hypnosis, and visualization, may also decrease transmission and perception of pain stimuli and some patients may find them acceptable and effective.
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