Pelvic Pain and Endometriosis Dr. Jackie Hollett-Caines MD, FRCSC Associate Professor, Western University Department of Obstetrics and Gynecology

Differential Diagnosis of Pelvic Pain Gynecologic Urologic Gastrointestinal Musculoskeletal Psychological General

Gynecologic Ovarian Fallopian Tubes Uterus Vulva

Ovarian Mittelschmerz (ovulation pain) Ovarian Cysts (rupture, torsion) Ovarian Remnant Syndrome

Fallopian Tubes hematosalpinx (after sterilization, ablation) endosalpingiosis ectopic pregnancy Pelvic Inflammatory Disease

Uterus Primary Dysmenorrhea Adenomyosis Fibroids Endometritis

Vulvar vulvodynia

Urologic interstital cystitis urethral syndrome Urinary tract infection urinary tract calculi

Gastrointestinal Irritable bowel syndrome Inflammatory bowel disease chronic constipation chronic appendicitis

Musculoskeletal myofascial pain pelvic floor myalgia and spasms nerve entrapment syndrome (neuropathic pain) mechanical low back pain disc disease hernias

Psychological depression physical or sexual abuse sleep disturbance psychological stress substance abuse

General Gynecologic Endometriosis Adhesions Pelvic Congestion

Endometriosis definition prevalence causes investigations (hx, PE, investigations) management

This picture shows a chocolate cyst, which can be quite common in more advanced endometriosis.

This is a section through an enlarnged 12 cm ovary to demonstrate a cystic cavity filled with old blood typical for endometriosis with formation of an endometriotic, or "chocolate", cyst. The hemorrhage from endometriosis into the ovary may give rise to a large "chocolate cyst" so named because the old blood in the cystic space formed by the hemorrhage is broken down to produce much hemosiderin and a brown to black color.

These dense adhesions are commonly associated with advanced endometriosis. They can be treated with laparoscopy techniques, but are more likely to reform after surgery.

Upon closer view, these five small areas of endometriosis have a reddish-brown to bluish appearance. Typical locations for endometriosis may include: ovaries, uterine ligaments, rectovaginal septum, pelvic peritoneum, and laparotomy scars. Endometriosis may even be found at more distant locations such as appendix and vagina

Grossly, in areas of endometriosis the blood is darker and gives the small foci of endometriosis the gross appearance of "powder burns". Small foci are seen here just under the serosa of the posterior uterus in the pouch of Douglas.

What is Endometriosis? Is defined as the presence of endometrial glands and stroma occurring outside of the uterine cavity The most common sites of involvement are: Ovaries Pelvic peritoneum Cul de sac Uterosacral ligaments

Prevalence overall incidence in women of reproductive age is 5-10% In infertile women, incidence is estimated to be 25-50%

Risk Factors for Endometriosis family history in a first degree relative anomalous reproductive tracts increased parity nulliparity subfertility prolonged intervals between pregnancies

Etiology – Many Theories most accepted is Retrograde Menstruation menstrual tissue refluxes through the fallopian tubes it then implants on pelvic structures does not explain why most women have reflux (100%) but only 5-10% of women have endometriosis

Etiology of Endometriosis Retrograde menstruation and implantation Direct extension Coelomic metaplasia Induction theory Embryonic rests/Mullerian Remnants Lymphatic and vascular metastasis Composite theory

History ask about any signs or symptoms of endometriosis dysmenorrhea - painful menses dyspareunia - painful intercourse dysuria - painful urination dyschezia - painful defecation low back or abdominal pain pelvic pain - suprapubic or LLQ/RLQ

Atypical Presentations of Endometriosis cyclic leg pain/sciatica cyclic rectal bleeding cyclic hematuria cyclic dyspnea - catamenial hemothorax some patients may be totally asymptomatic and it is found incidentially at time of surgery

Physical Examination pelvic digital exam non-mobile uterus (fixed or frozen pelvis) adnexal masses (endometriomas) tender nodules on the uterosacral ligaments May even see endometriotic deposits in the vagina on speculum exam

Investigations if suspect endometriomas, do an ultrasound if dyschezia - colonoscopy if dysuria - cystoscopy

Diagnosis gold standard is laparoscopy with histologically proven endometriosis on biopsy specimens histology should show: endometrial glands endometrial stroma hemosidern laden macrophages

Treatment laparoscopy is not required prior to treatment overall risk of any complication with laparoscopy, minor or major, is 8.9% injury to bowel, bladder, major blood vessel risk of bleeding or infection risk of anaesthetic

Management combined estrogen and progestin therapy oral progestin therapy depot progestin therapy intrauterine progestin releasing system danazol GnRH agonists aromatase inhibitors analgesia

Combined Estrogen and Progestin Therapy Oral contraceptives are considered first line treatment Get significant relief of dysmenorrhea within 4 months There is some data that continuous administration of OCP may be more beneficial in terms of pain relief

Oral Progestin Therapy Norethindrone acetate – not available in Canada Dienogest – Visanne Micronor – progesterone only pill

Dienogest Has selective 19-nortestosterone and progesterone activity Daily tablet of 2mg once a day Efficacy comparable to GnRH agonist (lupron) in 6 month head to head study

Depot Progestin Therapy Depot provera is injected im every 3 months As effective as lupron Cons to treatment: loss of BMD prolonged delay in resumption of menses/ovulation Breakthrough bleeding

Intrauterine Progestin-Releasing System Mirena - Contains Levonorgestrel 20 ug/day for 5 years Results in amenorrhea in 60% of patients 5% expulsion rate and 1.5% risk of pelvic infection

Danazol A weak androgen capable of suppressing gonadotropin secretion, thus leads to amenorrhea Negative side effects include weight gain, acne, hirsutism, breast atrophy, virilization, impact on lipids

GnRH agonists For women who do not respond to OCP or progestins Cannot be used longterm (> 1 year) without estrogen addback therapy (1mg estrace daily) Induces hypoestrogenism which can result in hot flashes, insomnia, vaginal dryness, loss of libido, loss of BMD

Aromatase Inhibitors Still experimental Use with either OCP or progestin therapies

Analgesia Used to make patient more comfortable until the primary medical management becomes effective NSAIDS or opiates