Endometriosis and Pelvic Pain

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Endometriosis is the presence of uterine glands (the inner lining or endometrium of the uterus) located outside the uterus on other organs or surfaces of the body.
Pelvic Pain
The hallmark of symptomatic endometriosis is pelvic pain. This pain may be constant, cyclic (frequently starting before the period) or occur during intercourse. If the implants involve other organs such as the bladder or bowel, symptoms may include pain during urination or the constant sensation to defecate around the time of ones period. The degree of pain has been shown to correlate with the depth of endometriotic lesions as seen on laparoscopy and biopsy and less with the type and location of these implants.
Etiology
The cause of endometriosis remains unclear although leading theories include retrograde or “backward” menstrual flow out the tubes into the pelvis and spread via the blood and lymphatic vessels. All women are probably susceptible to this disease but many women eradicate early implants via their immune systems. There is a genetic predisposition (10 fold increase risk with a sister or mother who has disease) but interestingly, many women who have endometriosis incidentally found during surgery are completely pain free.
The diagnosis of endometriosis requires surgery and the visualization of implants and biopsy of surfaces that are questionable. The surgical experience of the gynecologist in identifying implants is very important although even in the best hands visualization alone can miss borderline implants or falsely identified endometriosis where there is none. Most surgery is performed with a laparoscope in an out-patient setting.
Treatment
Despite opposing opinions no evidence firmly establishes the superiority of medical or surgical therapy in the treatment of endometriosis related pain. There is also no evidence suggesting that surgical excision of implants is superior or inferior to vaporization (laser) or cautery (burning) of implants. Both surgical approaches have good initial outcomes but reoccurrence of pain is seen in nearly 45% of women after one year. Medical therapies include birth control pills, Depo-Provera, Danazol, anti-inflammatory drugs and GnRH agonist therapy (Lupron). These may be effective in relieving pain but some of these therapies are associated with significant side effects (menopause symptoms, hair growth, oily skin) and discontinuation of therapy is often associated with reoccurrence of symptoms. None of these therapies are curative and many are abandoned because of side effects.

SJ Wininger, MD FACOG

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