Nathan Mordel, M.D. »Janet Lefkowitz, D.O. »

Chronic Pelvic Pain & Endometriosis

Chronic Pelvic Pain and EndometriosisSometimes normal uterine lining (endometrial) cells seep through the fallopian tubes and implant into and proliferate through the inner coating of the pelvis (peritoneum). This results in different degrees of irritation of the pelvic peritoneum, causing pelvic pain. Such a phenomenon is called endometriosis.

It is estimated that approximately 10% of women in their reproductive years, or nearly 90 million women world-wide, suffer from endometriosis. The fact is that there is no way to establish accurate figures because the only way to confirm a diagnosis is by performing a surgical procedure, usually via laparoscopy. Since at least 10% of women have endometriosis, it is one of the most common diseases worldwide; it is even more common than HIV/AIDS and cancer. In addition to affecting the lining of the pelvis, endometriosis may also affect one or more of the pelvic organs, including the uterus (adenomyosis), tubes, ovaries, bowel and bladder. Endometriosis may cause the formation of large ovarian “chocolate” cysts (endometriomas), pelvic adhesions/scarring, infertility, and bowel and bladder dysfunction. Sometimes, it may even invade bladder, bowel and other pelvic structures, causing severe complications.

Pain is the main symptom of endometriosis and women often experience chronic pelvic pain, painful periods, and/or painful intercourse. Pain is perceived by the brain when endometriosis invades the nerves that supply the pelvis. Prostaglandin activity in the uterus also aggravates deposits of endometriosis in the abdomen and pelvis causing significant pain. Ultimately, estrogen promotes growth and expansion of endometriosis. Therefore, the mainstay of treatment is aimed at counteracting or eliminating the effects of estrogen and prostoglandins.

Conservative treatment should be attempted first by using a hormonal agent, if no contraindications to these medications exist. First-line hormonal agents may contain either a combination of an estrogen and a progestin medication or may contain a progestin-only compound; choices include birth control pills, vaginal rings, transdermal patches, intrauterine devices (IUDs), and progesterone injections. If this is not successful, then estrogen-eliminating treatment is offered in the form of a Lupron injection (GnRH-a, gonadotropin releasing hormone agonist). Lupron treatments take several months and may produce severe side effects, especially menopause-like symptoms. Usually, the therapeutic impact lasts as long as these agents are given. Non-steroidal anti-inflammatory medications are given as well to control pain and inflammation. Rarely, narcotic pain medications are needed and patients may be referred to a pain management provider.

Surgery is the last resort after exhausting conservative options in treating severe endometriosis. A minimally invasive surgical option includes Laparoscopic Excision of Endometriosis and the pelvic adhesions it may form. Uterine and pelvic innervations travel through particular ligaments called the uterosacral ligaments, which are located adjacent to the uterus and are usually accessible during laparoscopic surgery. Sometimes LUNA (Laparoscopic uterine nerve ablation) is performed as well during laparoscopy and involves resection of the uterosacral ligaments and nerves. If pelvic adhesions are severe and involve/invade the bowel and/or bladder, additional concomitant procedures may be required. We may use the assistance of a Urologist to place illuminating ureteral stents and a Colorectal surgeon for proctosigmoidoscopy and possible bowel surgery. Laparoscopic excision of endometriosis is the recommended approach if the patient wishes to preserve her fertility/pregnancy potential. If future fertility/pregnancy is not desired, then the definitive solution is Laparoscopic Hysterectomy. Removal of solely the uterus significantly reduces prostaglandin activity, which in turn considerably diminishes aggravation of endometriosis. Thus, the ovaries can usually be preserved preventing undesirable, sometimes debilitating, menopausal symptoms.

If conservative surgery is unsuccessful and/or future pregnancy is not desired, then the definitive solution is Hysterectomy. Removal of solely the uterus significantly reduces prostaglandin activity, which in turn considerably diminishes aggravation of endometriosis. Thus, the ovaries can usually be preserved preventing undesirable, sometimes debilitating, menopausal symptoms. In severe cases, occasionally one or both of the ovaries need to be removed at a later time. There are a variety of ways a Hysterectomy procedure can be performed (in the absence of cancer) and the approach depends on the size of the uterus, patient’s history of previous abdominal surgeries, indications for the procedure, as well as the surgeon’s level of skill and comfort. Abdominal Hysterectomy and Vaginal Hysterectomy are the standard of care and involve a 1-2 night stay in the hospital. The definitive minimally-invasive solution is provided by out-patient Laparoscopic Hysterectomy or Robotic Hysterectomy. Most of our cases here at AMIGS are performed laparoscopically, even when the uterus is very large or there is a large amount of scar tissue/adhesions. The advantages of a laparoscopic procedure are many. Patients usually go home the same day, the recovery time is faster and less painful, and the cosmetic outcome is better. After May 2010 we will also have the option of performing Robotic Surgery.

Learn more about Minimally Invasive Hysterectomy.

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