Diagnosing and treating pelvic pain

Endometriosis, a disease that causes tissue that normally lines the uterus to grow outside the uterus, affects approximately 8% of young women. It is commonly associated with pelvic pain that may also manifest as abdominal and back discomfort. Affected women may also have painful menstrual cycles, painful intercourse, difficulty conceiving children or infertility. In rare cases, endometriosis patients may report blood in urine, painful urination or painful bowel movements and bloody stools. Endometriosis is driven mainly by estrogen, which fuels the production of inflammatory agents that result in pelvic adhesions and pain. This results in some organs sticking to one another in the abdomen or pelvis.

According to one of the many theories, endometriosis may happen when cells and tissue from the inner lining of the uterus bleed “backwards” through the Fallopian tubes into the pelvis during menstruation. Once there, the cells and tissue may implant on the adjacent organs, including tubes, ovaries, uterus and other associated structures. When on the ovaries, the cells and tissues can also develop into cysts that fill with thick, dark material, commonly called chocolate cysts, or formally named endometriomas. This tissue often causes cyclical pain.

Endometriosis is not so easy to diagnose. When patients have cyclic pain that seems to worsen over time or discomfort with intercourse, they may need to be evaluated by their OB/GYN doctor. The practitioner will perform a vaginal exam and may order tests, such as a transvaginal ultrasound. Sometimes direct visualization may be needed for diagnosis with what is known as laparoscopy. In laparoscopy, a small incision is made near the belly button, and a camera is inserted into the abdomen and pelvis to visualize the endometriosis implants if present. However, not all endometriosis implants are easy to identify or visualize.

The first line of treatment for en dometriosis includes anti-inflammatory medications, such as Ibuprofen, Naproxen, Diclofenac and others. Some doctors may suggest birth control pills or progesterone supplementation, which may be taken by mouth, injections, intrauterine devices or underthe-skin implants. Other treatments do exist. When there is no response to the above and fertility is not an issue, cycles can be interrupted with continuous birth control pills or a hormone called GnRH to help address the pain.

However, GnRH does lead to signs of menopause and can also cause the weakening of the bones if used longterm. Surgery is considered when these additional medical treatment options are unsuccessful, and there are masses to remove. Although this procedure may help, recurrence of the pain is still possible. Hysterectomy may be considered for those who do not plan to have children as it may specifically help with painful periods, excessive bleeding and pain with intercourse.

Researchers believe that endometriosis affects over six million women in the United States. As physicians and surgeons, OB/GYN practitioners develop a multitude of empathy for patients with endometriosis. If you are experiencing symptoms or have concerns about your reproductive health, please see a health-care professional, as many great treatment choices are available.

Nasreldin M. Ibrahim, Ph.D., M.D, FACOG, is an assistant professor of OB/GYN at LSU Health Shreveport.