Associated Pelvic Pain
Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
Consultant, Genome: The Fertility Centre, Kolkata
Managing Committee Member, Bengal Obstetric and
Gynaecological Society (BOGS)- 2018-19
Secretary, Subfertility and Reproductive Endocrinology Sub-
Committee, BOGS- 2018-19
Member, Quiz Committee, FOGSI East Zone, 2018-19
Member, Food and Drug Committee, FOGSI, 2018-19
Peer Reviewer, BMJ Case Reports
3. ENDOMETRIOSIS is a
disorder in which
endometrial tissue grows
outside the uterus.
• Most commonly involves
ovaries, fallopian tubes and
tissue lining the pelvis as
well as bladder, bowel,
vagina or rectum.
• This endometrial tissue
thickens and bleeds, just as
normal endometrium does
during menstrual cycle.
4. •Occurs in 6–10% of women of reproductive age,
with a prevalence of 38% in infertile women, and
in 71–87% of women with chronic pelvic pain
•Improved recognition of endometriotic lesions may
have led to an increase in detection rate
CONFIDENTIAL;for internal useonly
6. Complex interaction between aberrant endometrial GENESexpression & altered
PROSTAGLANDINS by anincreased
Overproduction of ESTROGEN by
increased aromatase activity
ENDOMETRIAL LESIONS proliferate release macrophages and proinflammatory cytokines in
peritoneal fluid inflammation, adhesions, fibrosis, scarring, anatomicaldistortions Pain &
7. Quality of Life
• Social functioning
• Reduced work effectiveness
• Depressive symptoms
As symptoms become more severe, quality of life isreduced further.
Endometriosis places a considerable economic
burden on families and on society. Delays in
diagnosis, high rates of hospital admission, surgical
procedures, and incidences of comorbid conditions
contribute to make endometriosis a more costly
public health problem than other chronic conditions
such as migraine and Crohn’s disease.
8. There is NO permanent cure for endometriosis
• As stated by ASRM, “Endometriosis shouldbe viewed asa chronicdisease that requiresa life-long
management plan with the goal ofmaximizing the use ofmedical treatment and avoiding repeated surgical
• No single treatment is ideal for allpatients, management chosenshould bedirected to individual needs of
• Combination therapy may be ideal; as it is a chronicdisease, we should consider not only efficacy but also
long-term safety and tolerability oftreatment options.
• Long-term treatment / repeated coursesowing to frequentrecurrenceofpain within 6-12 monthsof
completing treatment course(within 5 yearsin about half ofwomen)
9. 1. Endometriosis may be a diagnosis of exclusion
2. A significantnumber of womenwithendometriosis remainasymptomatic
Therefore, DIAGNOSIS of endometriosis in awomanwithpelvicpain is often
delayed& stretches over several years!
12. DIAGNOSIS OF ENDOMETRIOSIS
Clinicians should consider the diagnosis of
in the presence of gynecological symptoms-
non-cyclical pelvic pain
in women of reproductive age with non-
gynecological cyclical symptoms
13. Symptoms of endometriosis
•Intestinal complaints — periodic bloating, diarrhea or constipation —
are some of the unrecognized symptoms of endometriosis.
•Abdominopelvic pain, dysmenorrhea, heavy menstrual bleeding,
infertility, dyspareunia and/or postcoital bleeding, as well as diagnosis of
ovarian cyst, IBS and PID, are predictive of the diagnosis of
endometriosis among patients seeking help from general practice.
• Increasing the number of symptoms increased the chance of having
14. •Inform women with suspected or
confirmed endometriosis that keeping
a pain and symptom diary can aid
15. Clinical examination
•Clinicians may consider the diagnosis of
deep endometriosis in women with (painful) induration and/or nodules of the
rectovaginal wall found during clinical examination, or visible vaginal nodules in
the posterior vaginal fornix
ovarian endometrioma in women with adnexal masses detected during clinical
endometriosis in women suspected of the disease even if the clinical examination
•Rectovaginal digital examination may allow the detection of reduced organ mobility
and enlargement, tender nodularity in the posterior vaginal fornix, infiltration or mass
involving the rectosigmoidal colon or adnexal masses
•Reliability of the clinical examination in detecting pelvic endometriosis is improved
16. Clinical Exam vs TVS
Values for TVS were similar with regard to
• rectovaginal space endometriosis
TVS were superior to vaginal examination in cases of
• uterosacral ligament
• rectosigmoidal endometriosis.
17. TVS in the diagnosis of endometriosis
•Consider transvaginal ultrasound: (NICE, 2017)
• to investigate suspected endometriosis even if the pelvic and/or abdominal
examination is normal
• to identify endometriomas and deep endometriosis involving the bowel, bladder
• If a transvaginal scan is not appropriate, consider a transabdominal ultrasound
scan of the pelvis.
• In women with symptoms and signs of rectal endometriosis, TVS is useful for
identifying or ruling out rectal endometriosis, if performed by clinicians highly
experienced in TVS. (ESHRE, 2013)
18. TVS in the diagnosis of ovarian endometriosis
• Perform TVS to diagnose or to exclude an ovarian endometrioma
• clinicians should base the diagnosis of ovarian endometrioma in
premenopausal women on the following ultrasound characteristics: ground
glass echogenicity, 1-4 compartments and no papillary structures with
detectable blood flow
•Ovarian endometrioma are only rarely sole findings. This implies that if an
ovarian endometrioma is diagnosed by TVS, attention should be given to the
possible existence of deep infiltrating disease.
• One limitation is that small endometrioma could be missed.
19. 3-D US Scan
• Clinicians should be aware that the usefulness of 3D sonography to
diagnose rectovaginal endometriosis is not well established
• Do not use pelvic MRI as the primary investigation to diagnose
endometriosis in women with symptoms or signs suggestive of
endometriosis. (NICE, 2017)
• If dictated by clinical features, consider pelvic MRI (± TRUS, TVS, Ba
Enema, CT scan, Cystoscopy) to assess the extent of deep endometriosis
involving the bowel, bladder or ureter (NICE, 2017; ESHRE, 2013)
• Ensure that pelvic MRI scans are interpreted by a healthcare professional
with specialist expertise in gynaecological imaging.
• usefulness of MRI to diagnose peritoneal endometriosis is not well
established. (ESHRE, 2013)
•Do not use serum CA125 to diagnose endometriosis. (NICE, ESHRE)
•If a coincidentally reported serum CA125 level is available, be aware that:
1. a raised serum CA125 (≥35 IU/ml) may be consistent with having
2. endometriosis may be present despite a normal serum CA125 (<35 IU/ml).
The performance of serum CA-125 measurement in the diagnosis
of endometriosis grade I/II is limited, whereas its performance in
the diagnosis of endometriosis grade III/IV is better.
Clinicians are recommended not to use
•Biomarkers/ Immunological markers in endometrial tissue, menstrual or
uterine fluids, plasma, urine or serum to diagnose/ exclude endometriosis
23. NICE, 2017
• Do not exclude the possibility of endometriosis if the abdominal
or pelvic examination, ultrasound or MRI are normal. If
clinical suspicion remains or symptoms persist, consider referral
for further assessment and investigation.
24. Gold Standard
•The combination of laparoscopy and the histological verification of endometrial glands and/or
•In many cases the typical appearances of endometriotic implants in the abdominal cavity are
regarded as proof that endometriosis is present.
•Consider laparoscopy to diagnose endometriosis in women with suspected endometriosis, even if
the ultrasound was normal. (NICE, 2017)
•A negative diagnostic laparoscopy (i.e. a laparoscopy during which no endometriosis is identified)
seems to be highly accurate for excluding endometriosis and is therefore of use to the clinician in
aiding decision-making. (ESHRE, 2013)
•If a full, systematic laparoscopy is performed and is normal, explain to the woman that she does not
have endometriosis, and offer alternative management. (NICE, 2017)
25. Standard procedure
A good quality laparoscopy should include systematic checking of
•1) the uterus and adnexa,
•2) the peritoneum of ovarian fossae, vesico-uterine fold, Douglas and pararectal
•3) the rectum and sigmoid (isolated sigmoid nodules),
•4) the appendix and caecum and
•5) the diaphragm.
•6) speculum examination and palpation of the vagina and cervix under laparoscopic
control, to check for 'buried' nodules.
•A good quality laparoscopy can only be performed by using at least one secondary port
for a suitable grasper to clear the pelvis of obstruction from bowel loops, or fluid suction to
ensure the whole pouch of Douglas is inspected.
•By a gynaecologist with training and skills in laparoscopic surgery for endometriosis
26. Stage 1: Lesions are minimal &
Stage 2: Lesions are mild - may be
several; adhesions are possible.
Stage 3: Lesions are moderate, deep
or superficial with clear adhesions
Stage 4: Lesions are multiple &
severe, both superficial & deep, with
27. Stage is based on location, amount, depth
& size of endometrial tissue
Criteria - Extent of spread of tissue; Involvement of pelvic structures in
disease; Extent of pelvic adhesions; Blockage of fallopian tubes
Limitations - not a good predictor of pregnancy, does not correlate well with
the symptoms of pain and dyspareunia or infertility.
E.g. Woman in stage 1 tremendous pain, while
Woman in stage 4 asymptomatic.
29. NICE, 2017
• Offer endometriosis treatment according to the woman's
symptoms, preferences and priorities, rather than the stage
of the endometriosis.
to confirm the diagnosis of endometriosis (be aware that a
negative histological result does not exclude endometriosis)
to exclude malignancy
1. if an endometrioma is treated but not excised
2. deep infiltrating disease
31. Drawbacks of Laparoscopy
•Evidence is lacking that a positive laparoscopy without histology proves the presence of
•Negative histology does not exclude it.
• The limited value of negative histology can also be explained partly by lack of knowledge of
the clinician and/or the quality of the procedure, resulting in bad samples, squeezed samples
or samples taken from the wrong location.
•The experience, skill and knowledge of the surgeon determine whether endometriosis will
be diagnosed if present.
•Retroperitoneally and vaginally localized endometriosis can be easily missed, especially if the
patient has not been thoroughly examined preoperatively, preferably during anaesthesia.
• For women with suspected deep endometriosis involving the bowel, bladder or ureter,
consider a pelvic ultrasound or MRI before an operative laparoscopy.
32. Is Laparoscopy is a MUST?
•Empirical treatment can be started without a definitive diagnosis-
1. if signs of deep endometriosis or ovarian endometriosis are not present in
physical examination and imaging.
2. young adolescents or in women that decide not to have a laparoscopy solely
to know if the disease is there.
•Even if peritoneal disease is found it might not be the cause of pain
•Treatment of peritoneal disease does NOT influence the natural course of
• If medical pain treatment relieves pain, many women will not be interested
whether or not their pain symptoms were due to peritoneal endometriosis.
34. Empirical treatment of pain
•Counsel women with symptoms presumed to be due to endometriosis thoroughly, and to
empirically treat them with adequate analgesia, COC or progestagens.
•Before starting empirical treatment, other causes of pelvic pain symptoms should be ruled
out, as far as possible.
•Response to hormonal therapy does NOT always predict the presence or absence of
•It has been argued that starting oral contraception in young girls because of primary
dysmenorrhea could be indicative of the diagnosis of deep endometriosis in later life.
•It has to be emphasized as well that prescribing oral contraceptives in adolescents with pelvic
pain without a definitive diagnosis of endometriosis might contribute the well known delay
in diagnosing the disease.
• Consider a short trial (for example, 3 months) of paracetamol
or a NSAID alone or in combination for first-line management
of endometriosis-related pain
• If a trial of paracetamol or an NSAID (alone or in combination) does
not provide adequate pain relief, consider other forms of pain
management and referral for further assessment.
36. Hormonal therapies
•Clinicians are recommended to prescribe hormonal treatment [hormonal
contraceptives, progestagens, antiprogestagens, or GnRH agonists] as one
of the options, as it reduces endometriosis-associated pain
• Explain to women that hormonal treatment for endometriosis can reduce
pain and has no permanent negative effect on subsequent fertility.
•hormonal treatment for suppression of ovarian function does not
improve the chance of natural conception
•No overwhelming evidence to support particular treatments over other.
COC, vaginal contraceptive ring or a transdermal (estrogen/progestin) patch-
2. dysmenorrhea (continuous use of a CHC)
3. non-menstrual pain
• The vaginal ring reduced dysmenorrhea significantly more in patients with
RV endometriosis compared to women in the patch group.
38. Progesterone, Antiprogesterone
progestagens [medroxyprogesterone acetate (oral or depot),
norethisterone acetate, dienogest, cyproterone acetate, or danazol]
• Danazol should not be used if any other medical therapy is available.
Recent studies indicate that vaginal danazol may be better tolerated.
• LNG-IUS is particularly suited for deep RV endometriosis
Evidence is limited regarding dosage or duration of treatment
Clinicians are recommended to prescribe hormonal add-back therapy to
coincide with the start of GnRH agonist therapy, to prevent bone loss and
hypoestrogenic symptoms during treatment. This is NOT known to reduce
the effect of treatment on pain relief
careful consideration to the use of GnRH agonists in young women and
adolescents, since these women may not have reached maximum bone density.
•GnRHa is more effective than placebo but inferior to the LNG-IUS or oral
• No difference in effectiveness exists when GnRHa is administered IM/ SC/
40. Aromatase Inhibitors
In women with pain from RV endometriosis refractory to other medical or
consider prescribing aromatase inhibitors in combination with COC,
progestagens, or GnRH analogues, as they reduce endometriosis-
•The side effects are mostly hypoestrogenic in nature
•The evidence on the long-term effects is lacking.
41. Surgery for treatment
When endometriosis is identified at laparoscopy, clinicians are
recommended to surgically treat endometriosis, as this is effective for
reducing endometriosis-associated pain i.e. ‘see and treat’
• Operative laparoscopy (excision/ablation) is more effective for the
treatment of pelvic pain associated with all stages of endometriosis,
compared to diagnostic laparoscopy only
42. Surgery for Peritoneal Endometriosis
• Ablation and excision of peritoneal disease are thought to be equally
effective for treatment of endometriosis-associated pain.
• Both improves chance of spontaneous conception in ASRM stage I/II
endometriosis (CO2 laser vaporization > monopolar electrocoagulation)
• Complete surgical removal before ART- ?
•Excision of lesions could be preferred with regard to the possibility of
retrieving samples for histology.
• ablative techniques are unlikely to be suitable for advanced forms of
endometriosis with deep endometriosis component.
43. Surgery for ovarian endometrioma
• When performing surgery in women with ovarian endometrioma (≥3 cm)
• perform cystectomy instead of drainage and coagulation/ CO2 laser
vaporization- as cystectomy
1. reduces endometriosis-associated pain
2. increases spontaneous pregnancy rates
3. a lower recurrence rate of the endometrioma
• clinicians counsel regarding the risks of reduced ovarian function after
surgery and the possible loss of the ovary. The decision to proceed with
surgery should be considered carefully if the woman has had previous ovarian
44. Surgical therapies as an adjunct to ART
In infertile women with endometrioma > 3 cm
• there is no evidence that cystectomy prior to treatment with ART
improves pregnancy rates.
• only to consider cystectomy prior to ART to improve
1. endometriosis-associated pain
2. the accessibility of follicles.
45. Surgery for deep endometriosis
surgical removal of deep endometriosis, reduces endometriosis-
associated pain and improves quality of life-
in a MDT context
associated with significant complication rates, particularly when rectal
surgery is required.
In women with infertility and severe pelvic pain who are resistant to
medical treatment or severe bowel stenosis,
radical excision of endometriosis combined with bowel segmental
resection and anastomosis was associated with
a higher postoperative spontaneous pregnancy rate (Role before ART- ?)
46. Colorectal involvement –
•Laparoscopy was as effective as laparotomy
•superficial shaving, discoid resection and segmental resection of the bowel to
remove the deep endometriosis nodules.
•It was impossible to make comparisons between different surgical techniques.
• excision of the lesion and primary closure of the bladder wall
• may be excised after stenting the ureter
• segmental excision with end-to-end anastomosis
consider hysterectomy with removal of the ovaries and all visible
endometriosis lesions, in women who have completed their family and
failed to respond to more conservative treatments.
Women should be informed that hysterectomy will not necessarily cure
the symptoms or the disease.
• Hysterectomy with ovarian conservation was reported to have a risk for
development of recurrent pain and a greater risk of reoperation.
48. Surgical interruption of pelvic nerve pathways
Clinicians should not perform LUNA as an additional procedure to
conservative surgery to reduce endometriosis-associated pain
Clinicians should be aware that presacral neurectomy (PSN) is effective
as an additional procedure to conservative surgery to reduce
endometriosis-associated midline pain, but it requires a high degree of
skill and is a potentially hazardous procedure -
bleeding, constipation, urinary urgency and painless first stage of
49. Adhesion prevention after surgery
oxidised regenerated cellulose (Interceed) -prevents adhesion formation
Do not use icodextrin - no benefit has been shown
carboxymethylcellulose gel - uncertainty
other anti-adhesion agents (polytetrafluoroethylene surgical membrane,
hyaluronic acid products) have been studied and proven effective for
adhesion prevention in the context of pelvic surgery, although not
specifically in women with endometriosis.
• The effect of adhesion prevention on fertility or pain is uncertain.
50. Preoperative hormonal therapies
Clinicians should not prescribe preoperative hormonal treatment to improve the outcome of
surgery for pain in women with endometriosis
•In clinical practice, surgeons prescribe preoperative medical treatment with GnRH analogues as
this can facilitate surgery due to reduced inflammation, vascularisation of endometriosis lesions
and adhesions. However, there are no controlled studies supporting this (ESHRE, 2013)
•Consider GnRH agonist x 3 cycles before surgery for deep infiltrating endometriosis
• From a patient perspective, medical treatment should be offered before surgery to women with
painful symptoms in the waiting period before the surgery can be performed, with the
purpose of reducing pain before, not after, surgery.
51. Postoperative hormonal therapies
Short Term (<6 months)
Do not prescribe
surgery, as it does
not improve the
outcome of surgery
Long term (>6 months)- Sec Prevention
role for prevention of recurrence of disease and painful
symptoms in women surgically treated for endometriosis.
there are limited data
After cystectomy for ovarian endometrioma in women not
immediately seeking conception, prescribe hormonal
Deep endometriosis- prescribe postoperative use of a LNG-IUS
or a COC (continuous/ cyclic) for at least 18–24 months, as
one of the options for the secondary prevention of endometriosis-
associated dysmenorrhea, but not for non-menstrual pelvic pain
postoperative pain recurrence is not different in women
receiving GnRH agonists, danazol or MPA or pentoxifylline,
when compared to placebo
52. Pain due to extragenital endometriosis
surgical removal is the treatment of choice for symptomatic extragenital
Diagnosis is usually made by histological confirmation, which is
important to exclude other pathology, particularly malignancy.
When surgical treatment is difficult or impossible, clinicians may
consider medical treatment of extragenital endometriosis to relieve
53. Non-medical management strategies
Do not recommend the use of nutritional supplements, complementary
or alternative medicine in the treatment of endometriosis-associated
pain, because the potential benefits and/or harms are unclear.
•Whilst high-frequency TENS was shown to be effective for primary
dysmenorrhea, there are no data to suggest that it is helpful in the control
of pain associated with endometriosis
• Evidence to support use of acupuncture for pain in endometriosis was
54. Monitoring for women with confirmed endometriosis
• Consider outpatient follow-up (with or without examination and
pelvic imaging) for women with confirmed endometriosis,
particularly women who choose not to have surgery, if they have
1. deep endometriosis involving the bowel, bladder or ureter
2. ≥1 endometrioma that is larger than 3 cm.
55. v/s placebo; 198 women aged 18–45 years
Optimaldose Leuprolide Buserelin Triptorelin ExtensionPLACEBO
59. Substantial reductions in VAS score between baseline
and Week 24
Non-inferiority of dienogest relativeto LA - Absolute
reduction in VAS score was 47.5 mm with dienogest
and 46.0 mm with LA (1.5 mmin favour of dienogest)
60. Mean levels of serum estradiol remained
stable in dienogest subgroup (256.3 to 249.9
pmol/l) and showed pronounced decrease in
LA subgroup (from 299.0 to 68.5 pmol/l)
61. In LA group, mean numberof days/week with hot flushes increased from 0.78 to 4.70.
Mean numberof days/week with hotflushes was stable in dienogest group
62. Mean lumbar BMD increasedby 0.0022 g/cm2 in dienogest subgroup and decreased by0.0415 g/cm2 in LA subgroup
• Increase in alkalinephosphatase in triptorelin group, which may reflect an increased bone
turnover; not seen with Dienogest.
• Lipid profile (particularly HDL cholesterol) & blood glucose levels were similar in both
• Dienogest isa therapeutic alternative to GnRH analogsin treatment of endometriosis.
• Postoperative treatment of endometriosis with Dienogest was asefficient as triptorelin & had
no androgenic effects.
69. No cumulative decrease in BMD up to 52 weeks of treatment.
Study on markers ofbone metabolism revealed no change in markersof bone metabolism, excepta
slight increase only in serum osteocalcin, a markerofbone formation.
70. Key clinical benefits of dienogest in
• Decreases endometriosis-associated pelvic pain
• Reduces symptoms, signs and severity of endometriosis
• As effective as GnRH agonists
• Generally well tolerated
• Not associated with clinically relevant androgenic adverse events
• Unlike GnRH agonists, not associated with clinically relevant changes in
• Efficacy and tolerability sustained with long-term (>1 year) treatment
• Significantly prevents postoperative endometrioma recurrence
• Endometriosis is a chronic disease
• Pain is very important aspect affecting QoL
• Multiple modes of therapies are usually needed
• Medical management can reduce the pain but effect is short lasting
• Surgical management can relieve pain for long term but is associated
• Needs MDT approach
Notes de l'éditeur
Pelvic pain typical of endometriosis is characteristically described as …
2o dysmenorrhea (with pain frequently commencing before onset of menses),
Deep dyspareunia (exaggerated during menses), or
Sacral backache during menses
The complex interaction between aberrant expression of endometrial genes as well as altered hormonal response will predispose patients to the development of endometrial lesions. Key components in the development of endometriosis are local overproduction
of prostaglandins by an increase in cyclooxygenase-2 (COX-2) activity and overproduction of local estrogen by increased aromatase activity. Progesterone resistance dampens the antiestrogenic effect of progesterone and amplifies the local estrogenic effect. The resulting endometrial lesions can lead to a chronic inflammatory disorder with increased numbers of activated macrophages and proinflammatory cytokines in the peritoneal fluid that may cause pain and infertility.
hypoestrogenic (GnRH agonist), hyperandrogenic (danazol, gestrinone) or hyperprogestogenic (oral contraceptives, medroxyprogesterone acetate) state that suppresses endometrial cell proliferation.
Up to 20% of women with endometriosis have concurrent chronic pain conditions, including irritable bowel syndrome, interstitial cystitis/painful bladder syndrome, fibromyalgia, and migraines
The stage of endometriosis is based on the location, amount, depth and size of the endometrial tissue. Specific criteria include:
The extent of the spread of the tissue
The involvement of pelvic structures in the disease
The extent of pelvic adhesions
The blockage of the fallopian tubes
A serum estradiol concentration of 30–50 pg/mL is considered to fulfil the requirements of estrogen threshold hypothesis, by which estrogen levels are suppressed sufficiently to inhibit endometriotic lesion growth, but are adequate to prevent hypoestrogenic side effects such as bone mineral loss.