Pelvic pain is a common symptom of endometriosis – accurate diagnosis and effective treatment of the underlying cause can provide long term relief.
How does endometriosis cause pelvic pain?
Endometriosis causes pain (and disability) when nerve tissues are entrapped by deposits (plaques) of pelvic side walls and pain is often severe when ovaries in particular are adherent to the pelvic wall. The patient who has had corrective surgery experiences a significant reduction in pelvic pain once the initial healing phase is completed in a few short weeks.
Some patients with deep infiltrating endometriosis (DIE) have fixation of the uterus, vagina or bowel (rectum), and to a lesser degree, the bladder can also be affected. These patients will have not just cyclical pain but functional pain too, during sex, bowel or bladder function. Most often the pain can be addressed by targeted surgery.
Diagnosing pelvic pain associated with endometriosis
Pelvic pain from endometriosis is most often cyclical, significantly worse with menstruation or ovulation. Patients with DIE however often experience virtually continuous pin with at most short relief of pain symptoms immediately after a period.
Patients who can tolerate a transvaginal ultrasound scan can have a clearer picture of endometriosis (either superficial markers or DIE)
Those who cannot tolerate a vaginal scan can have an MRI scan for an equally good pre-operative assessment.
The gold standard however is planned surgery with the above information at hand, where photographs are taken at surgery before and after removing all visible evidence of pelvic endometriosis.
Treating pelvic pain from endometriosis
Treating the symptoms of pelvic pain with medication does not change the underlying pathology of endometriosis.
Locally acting pharmacological remedies (paracetamol, NSAIDs) assist by reducing the inflammatory response. Centrally acting agents (codeine, oxycodone, tramadol) work on the central nervous system. Medications such as amitriptyline, gabapentin etc are more specific modulators of nerve pain.
Occasionally patients with chronic regional pain syndrome or chronic pelvic pain require ketamine infusions to provide temporary relief until surgery can be affected.
There is good evidence that the combined oral contraceptive pill can give relief from especially ovarian related pain and the levonorgestrel IUD can relieve especially pain from co-existent adenomyosis. GnRH analogues (injection or spray) can provide temporary relief until surgery is arranged.
Many patients find symptomatic relief with non-pharmacological remedies (acupuncture, herbal and chinese medicine) generally as an adjunctive measure until definitive surgical treatment is available.