Endometriosis and Pelvic Pain

Symptoms

This can result in:

• Severe pain during and in between periods
• Painful intercourse
• Painful bowel movements during and around menstrual periods
• Painful urination
• Bloating
• Anxiety or depression related to the pain
• Infertility

Cause

It is oestrogen responsive, so it can start as early as the first menstrual period and last until menopause. The approximate incidence is 1 in 9 women by the age of 44, ~10% of women of reproductive age, which equates to 190 million women worldwide. The exact cause of endometriosis is still unknown. One theory is that during menstruation the endometrial tissue passes backwards through the fallopian tubes and into the pelvis where it attaches and grows (retrograde menstruation theory). However, we do not know why this results in endometriosis in some patients and not others. It appears that it is perhaps more complex than this and that there is a significant genetic, immune, and environmental component, with the exact mechanisms still under research.

Classification

Endometriosis is commonly classified into four stages depending on the location, amount of disease, and distortion of anatomy, based on the revised American Society for Reproductive Medicine (rASRM) staging system.  Stage I endometriosis is minimal disease, and it increased in severity to Stage IV endometriosis which is classified as severe disease. Interestingly, the severity of disease does not correlate with clinical features and pain, in that a woman with Stage IV endometriosis may have minimal or no pain, whereas a woman with Stage I endometriosis may have severe pain and symptoms.

Management of endometriosis and pelvic pain are multidisciplinary and include:

Medical management – this is often hormonal:

• Combined oral contraceptive pill (COCP)
• Progesterone only pill (POP) – Slinda or Visanne
• Mirena Intrauterine Contraceptive Device (IUCD)
• Anti-oestrogen medications (Zoladex, Ryeqo)

Surgical Management:

• Laparoscopic excision of endometriosis is the gold standard of surgical management and results in optimal disease management compared to ablation.
• Ablation is an older form of management of endometriosis but does not result in adequate treatment of endometriotic lesions. Dr Wetherell does not practice this form of surgery.
• Endometriosis often grows around vital structures including the ureters, bowel, pararectal spaces (spaces adjacent to the rectum), bladder and uterine arteries and veins, therefore you need a surgeon is trained and skilled to identify these structures and meticulously dissect them so that they can be preserved, whilst also excising the endometriotic nodules in their entirety. This is what Dr Lima Wetherell does in order to provide the highest chance of complete surgical excision.
• Dr Wetherell does not practice multiple laparoscopic excisions of endometriosis, as was the fashion in previous times. She believes that women should get one detailed and thorough laparoscopic excision, and then the mainstay of long term treatment is medical management via hormonal suppression.
• In general, the triggers for repeat laparoscopy for Dr Wetherell are be severe pain that is not responsive to medical and holistic multidisciplinary allied health management, and/or not achieving fertility after trying to conceive for 6 months or more, depending on individual factors such as age.

Allied health holistic management – working as a team:

• Dietician – anti-inflammatory diet, avoiding foods that trigger bloating and pain.
• Pelvic floor physiotherapy – often women have an overactive weak pelvic floor with high levels of dyspareunia, working regularly with a pelvic floor physiotherapist.
• Acupuncture – can help as an adjunct to all of the therapies above.
• Dr Wetherell has a team of preferred allied health providers that have experience in endometriosis and women’s health and we all work as a team to try to improve your health.