Endometriosis & Pelvic Pain
Pelvic pain can be from the digestive, reproductive, urinary, musculoskeletal, or a combination of systems. Common causes of pelvic pain include endometriosis, ovarian cysts, and fibroids.
What is endometriosis?
Endometriosis is a condition in which the endometrial tissue that forms the lining of the uterus is found outside the uterus.
The most common places for endometriosis to occur include the lining of the abdomen, the ovaries, the bowel, and the uterus. It has been found in many other places in the body too.
Some women with endometriosis have few or no symptoms while others have pain or difficulty becoming pregnant.
There is no cure for endometriosis, but there are several treatment options. The best treatment depends on your individual situation.
How common is endometriosis?
Endometriosis is a condition in which the endometrial tissue that forms the lining of the uterus is found outside the uterus.
The most common places for endometriosis to occur include the lining of the abdomen, the ovaries, the bowel, and the uterus. It has been found in many other places in the body too.
Some women with endometriosis have few or no symptoms while others have pain or difficulty becoming pregnant.
There is no cure for endometriosis, but there are several treatment options. The best treatment depends on your individual situation.
What causes endometriosis?
The cause of endometriosis is not known. A common theory is that some menstrual blood and endometrium flows backwards through the fallopian tubes and into the pelvis during a period. This tissue then grows where it lands in the pelvis. This is called the retrograde menstruation theory.
How does endometriosis cause problems?
Endometriosis implants respond to changes in oestrogen. The implants may grow and bleed and the surrounding tissue can become irritated, inflamed, and swollen. The breakdown and bleeding of this tissue each month also can cause scar tissue (adhesions) to form. Sometimes adhesions can cause organs to stick together.
What are the symptoms of endometriosis?
Some women with endometriosis have no symptoms. The most common symptom is pelvic pain, especially with periods. Pain may occur:
- Just before or during your period
- Between periods, with worsened pain during the period
- During or after sex (deep penetration pain)
- With bowel movements or while urinating, especially during your period
Pelvic pain can also be caused by many other conditions, such as pelvic infections, bladder conditions and irritable bowel syndrome. Often women with endometriosis have more than one condition contributing to their pain.
What problems can I expect from endometriosis?
Apart from pain, endometriosis can cause:
Difficulty falling pregnant
Endometriosis can make it more difficult to become pregnant. This might occur because endometriosis causes scar tissue to develop, which can damage the ovaries or fallopian tubes.
However, even women with endometriosis who do not have scar tissue can have difficulty becoming pregnant.
In women who become pregnant, endometriosis does not harm the pregnancy. Symptoms of endometriosis often improve after pregnancy.
Ovarian cysts (Endometriomas)
Women with endometriosis can develop ovarian cysts containing endometriosis; this is called an endometrioma.
Endometriomas are sometimes called chocolate cysts, as they are usually filled with old blood that resembles chocolate syrup. Endometriomas are sometimes seen during a pelvic ultrasound or felt during a pelvic exam.
Most women with endometriomas will also have endometriosis elsewhere in their pelvis.
How is endometriosis treated?
Treatment for endometriosis depends on the extent of the disease, your symptoms, and whether you want to have children.
Endometriosis may be treated with medication, surgery, or both. Treatments include:
- Non-steroidal anti inflammatory drugs
- Hormonal birth control
- Other forms of hormone treatment (gonadotropin releasing hormone agonists)
- Laparoscopy
When pain is the primary problem, medication is often tried first.
If treatment does not improve your pain within three to six months, surgery is a reasonable next step.
In other cases, surgery is performed to diagnose endometriosis and remove it before you take any medicine.
The best treatment depends on your symptoms, age, future plans to become pregnant.
Medical Treatment
Non-steroidal anti inflammatory drugs (NSAIDs)
NSAIDs are a type of pain medicine that can help to relieve the pain caused by endometriosis.
The medicine works by stopping the release of prostaglandins, one of the main chemicals responsible for painful menstrual periods. NSAIDs do not shrink or prevent the growth of endometriosis.
Most NSAIDs are available over the counter including:
- Ibuprofen
- Naproxen sodium sold as Naprosyn, and store brands
NSAIDs do not always relieve endometriosis related pain. NSAIDs probably work better when combined with other treatments, like hormonal birth control.
Serious side effects from NSAIDs, although uncommon, include stomach upset, kidney problems, and worsened high blood pressure. So be sure to follow the instructions closely.
Hormonal birth control treatments
Hormonal birth control, including the combined pill, injectable, implantable and intra-uterine progestins (IUD) are often helpful in treating pain because they reduce heavy bleeding. Hormonal birth control works best in women who do not have severe pain.
Combined oral contraceptive pill (containing both oestrogen and progestins)
Women with endometriosis who are taking the pill are often advised to skip their periods and take hormone containing pills continuously for 3 or more months. This allows you to have fewer periods and have less pain and bleeding during each period.
The most common side effects of hormonal birth control are:
- Nausea
- Breast tenderness
- Irregular vaginal bleeding or spotting
These side effects usually improve after using the treatment for several months.
Progestins
Progestins are a synthetic form of a natural hormone called progesterone. This treatment might be recommended for women who do not get pain relief from, or who cannot take, hormonal birth control that contains estrogen, such as smokers. Progestins are available by prescription and usually given as a pill implant, IUD or injection.
Side effects of progestins can be bothersome for some women. The most common side effects include: bloating, weight gain, irregular vaginal bleeding, and rarely, worsened depression.
Gonadotropin releasing hormone agonists
Gonadotropin releasing hormone (GnRH) agonists are medicines that work by causing temporary menopause. They are not commonly used in endometriosis treatment because they can only be taken for a short period of time, have menopausal side-effects and they are expensive. Most endometriosis requires longer-term treatment. The treatment causes the ovaries to stop producing oestrogen, which causes the endometriosis implants to shrink.
No hormonal treatment can be used if you are trying to fall pregnant
Surgical Treatments
Surgery may be performed if you:
- Have severe pain
- Have tried medicines but still have bothersome pain
- Have a cyst or mass in the pelvic area.
- Are having trouble getting pregnant and endometriosis might be the cause.
Laparoscopy is most commonly used to diagnose and treat endometriosis. The goal of surgery is to remove endometriosis implants and scar tissue.
More than 80 percent of women who have surgery have less pain for several months after surgery. However, there is a good chance that the pain will come back unless you take some form of treatment after surgery, like hormonal birth control.
What if I still have severe pain that does not go away even after I have had endometriosis treatment?
If the pain is severe and does not go away after treatment, then you can be referred to a pain specialist.
If you do not want to become pregnant in the future, your doctor may discuss a hysterectomy and removal of your ovaries with you. It is uncommon to require this treatment.