Chronic pelvic pain can have many causes, both gynecological and non-gynecological. Endometriosis, where endometrial-like tissue grows outside the uterus, is a common cause of pelvic pain among women. Theories about the etiology of endometriosis include retrograde menstruation and factors related to estrogen levels. Symptoms include dysmenorrhea, chronic pelvic pain, and dyspareunia. Diagnosis requires a histologic examination. Treatment options include medications and surgery, though medical therapy does not eradicate lesions and recurrence after surgery is common.

1. CHRONIC PELVIC PAIN
ENDOMETRIOSIS
RAED SAYED AHMED
MBCHB, FRCSC, FACOG, MCHCH

2. CHRONIC PELVIC PAIN
Gynecologic etiologies Gastrointestinal tract
 Endometriosis  Irritable bowel syndrome
 Pelvic inflammatory disease  Inflammatory bowel disease
 Adhesions  Diverticular colitis
 Colon cancer
 Pelvic congestion syndrome
 Chronic intestinal pseudo-obstruction
 Adenomyosis
 Chronic constipation
 Ovarian cancer  Celiac disease
 Ovarian remnant and residual ovary
syndrome
 Leiomyoma
 Dysmenorrhea
Urinary tract
 Interstitial cystitis/painful bladder
syndrome

3. CAUSES cont’d
Musculoskeletal system Mental health issues
 Fibromyalgia  Somatization disorder
 Coccydynia, piriformis/  Opiate dependency
levator ani syndrome,  Physical and sexual
pelvic floor tension
myalgia abuse
 Posture  Depression
 Chronic abdominal wall  Sleep disorders
pain
 Osteitis pubis

4. ENDOMETRIOSIS
 A common health problem among women of
reproductive age.
 Endometrial-like glands and stroma grow in an
extrauterine site.

5. ETIOLOGY
 Various theories regarding its etiology.
 Menstrual flow that produces a greater volume of
retrograde menstruation may increase the risk of
developing the disease.
 Early menarche,
 Regular cycles (especially with an absence of
amenorrhea caused by pregnancy),
 longer and heavier flow are also associated factors.

6. ETIOLOGY cont’d
 Endometriosis is an estrogen-dependent disease
 Factors that reduce estrogen levels (e.g., menstrual
disorders, decreased body-fat content and smoking)
are associated with a reduced risk for developing the
condition.

7. SIGNS AND SYMPTOMS
 Clinical manifestations of endometriosis vary and
may be unpredictable in presentation and course.
 Dysmenorrhea,
 chronic pelvic pain,
 Dyspareunia,
 Uterosacral ligament nodularity
 Adnexal mass.
 Asymptomatic in many women

8. Pelvic Pain
 Pelvic pain caused by endometriosis falls into three
categories:
1. Secondary dysmenorrhea, with pain commencing
before the onset of the menstrual cycle;
2. Deep dyspareunia that is exaggerated during
menses; or
3. Sacral backache with menses.

9. Pain con’d
 The pain associated with endometriosis has little
relationship to the type of lesions seen by
laparoscopy.
 It has been shown that the depth of endometriosis
lesions correlate with severity of pain.
 It is thought that painful lesions are those that
involve peritoneal surfaces innervated by peripheral
spinal nerves, not those innervated by the autonomic
nervous system.

10. DIAGNOSIS
 A histologic examination should be done to confirm
the presence of endometrial lesions.

11. TREATMENT
 Current evidence suggests that pain caused by
endometriosis can be managed medically. Progestins,
danazol, oral contraceptives, nonsteroidal anti-
inflammatory drugs and gonadotropin-releasing
hormone (GnRH) agonists.

12.  No medical therapy has been proved to eradicate the
lesions.

13. SURGERY
 Surgery for women with endometrial pain is
associated with significant reduction in pain during
the first six months following surgery.
 up to 44 percent of women experience a recurrence of
symptoms within one year.
 Data about whether surgical therapy influences long-
term therapy are lacking, and there are no data to
indicate whether medical or surgical therapy results
in better fertility outcomes.