Pelvic Pain and Endometriosis

There are many reasons for pelvic pain. Gynaecological causes of pelvic pain mainly include endometriosis, denomyosis, ovarian cysts, pelvic congestion, pelvic inflammatory diseases and sometimes adhesions to name a few. In some patients the source of pain is the bowel and in about a third of patients no particular cause is found.

Endometriosis

Endometriosis is a common condition where tissue that behaves like the lining of the womb (the endometrium) is found outside the womb usually in the surrounding organs like ovaries and fallopian tubes, the lining of the inside of the abdomen ( peritoneum), bowel or bladder.

These tissues respond to hormones just like the lining of the womb. They become inflamed and bleed during periods. If untreated this can lead to scarring and constriction of organs like the bowel, ureters and fallopian tubes with significant sequelae. Most patients can be treated medically with hormonal contraceptives and surgery is usually offered as second line treatment or if there is compromise of function of any organs.

The condition is estimated to affect around 2 million women in the UK. Most of them are diagnosed between the ages of 25 and 40.

Endometriosis is rare in women who have been through the menopause.

Symptoms of endometriosis

Endometriosis is a long-term (chronic) condition. Symptoms can vary significantly from person to person, and some women have no symptoms at all.

The most common symptoms include:

painful periods or heavy periods
pain in the lower abdomen (tummy), pelvis or lower back
pain during and after sex
difficulty getting pregnant
discomfort when going to the toilet
bleeding from your back passage (rectum) or blood in your faeces

What causes endometriosis?

The causes of endometriosis aren’t fully known, but there are several theories.
One such theory is that such cells were present in these areas during development of pelvic organs. Another theory is related to related to retrograde menstruation.

Diagnosing endometriosis

Symptoms and examination findings often provide the diagnosis. Imaging modalities include ultrasound and MRI. Often endometriosis can cause ovarian cysts which are easily seen on ultrasound scans. MRI scans are particularly useful in detecting endometriosis of bowel/ kindneys and ureters.
Laparoscopy is often offered to diagnose and treat endometriosis.

Types of endometriosis

There are different classifications- mild, moderate or severe is one. Another one is superficial or deep. Often clinicians use a combination of the two while describing the disease. In general if you have bowel endometriosis, of if any organ is compromised or if you have bilateral ovarian disease it is considered as severe disease.

What is the role of Hysterectomy in endometriosis?

This is a common question. Hysterectomy only helps with pain if the source of pain is the uterus. It is important that any extra uterine endometriosis is removed at the same time. Hysterectomy can be performed with or without removal of ovaries depending on the age of the patient and the severity of the disease. if the ovaries are removed at the same time, combined HRT rather than Oestrogen only HRT is recommended.

Medical treatment for endometriosis

The symptoms of endometriosis can often be managed with painkillers and hormone medication, which help prevent the condition interfering with your daily life.

Laparoscopic surgery

This is offered to patients with pelvic pain that is not responding to hormonal medication, subfertility, evidence of ovarian cysts or organ compromise on scans

Laparoscopic surgery is often offered as a day case procedure. The surgery involves either diathermy ( cauterisation) or excising the endometriosis. In patients with severe disease or those undergoing hysterectomy it will be an inpatient procedure. In some patients especially where the bowel is thought to be involved, a bowel prep may be advised prior to surgery. Following surgery, hormonal treatment is usually recommended to prevent recurrence. In some patients with severe disease, a two staged procedure may be needed. This may also be offered if you have a large ovarian cyst to reduce risk of losing ovary.

Please check this link for more information on laparoscopy

Endometriosis centres

In some cases endometriosis can be severe and may require complex multidisciplinary input. The British Society of Gynaecological endoscopists ( BSGE) has identified specialist centres to provide this specialist service. Dartford and Gravesham NHS trust is a BSGE accredited endometriosis centre which provides specialist endometriosis surgery. Mr Kovoor is the lead for this service.
Please click here for more information.

Endometriosis and pregnancy

One of the main complications of endometriosis is difficulty getting pregnant
Although surgery can’t guarantee you’ll be able to get pregnant, there’s good evidence that treating endometriosis tissue during keyhole (laparoscopic) surgery can improve your chances of having a successful pregnancy.