Pelvic Congestion Syndrome- another cause of chronic pelvic pain
When talking about endometriosis and chronic pelvic pain, it is important to remember that often endometriosis is not the only pelvic pain generator. Another possible contributor to chronic pelvic pain is pelvic congestion syndrome (PCS). “Pelvic congestion syndrome (PCS) accounts for up to 30% of patients presenting with chronic pelvic pain” (Reardon & Dillavou, 2021). There isn’t a significant amount of data about endometriosis and PCS, but one study found “the prevalence of ovarian varices in patients with endometriosis was 80%, whereas the control group was only 26.1%” (Pacheco & de Oliveira, 2016).
PCS is like having varicose veins in the pelvis. Blood pulls in the veins and can cause symptoms such as heaviness, pain with penetration, noncyclical pain, positional lower back pain, pelvic and upper thigh pain, prolonged postcoital discomfort, symptoms that worsen throughout the day and are exacerbated by activity or prolonged standing, and non-specific lower abdominal and pelvic pain (Durham & Machan, 2013; Mistry & le Roux, 2017). The cause of PCS is not clear, but it is associated with obstructions such as iliac vein compression (i.e., MTS) or left renal vein compression (i.e., Nutcracker syndrome) (Reardon & Dillavou, 2021).
For more information see: https://icarebetter.com/pelvic-congestion-syndrome/
References
Durham, J. D., & Machan, L. (2013, December). Pelvic congestion syndrome. In Seminars in interventional radiology (Vol. 30, No. 04, pp. 372-380). Thieme Medical Publishers. Retrieved from https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0033-1359731
LIANG, D. E., & Brown, B. (2021). Pelvic congestion syndrome: Are we missing the diagnosis?. The Medical Republic. Retrieved from https://www.sydneyfibroidclinic.com.au/app/uploads/2021/06/PCS-Medical-Republic.pdf
Mistry, P. P., & le Roux, D. A. (2017). Pelvic congestion syndrome (PCS). Practice Perspectives for Venous Disorders, 46. Retrieved from http://www.vascularsociety.co.za/wp-content/uploads/2019/02/VASSA-venous-guidelines-Practice-perspectives-for-venous-disorders-2017.pdf#page=46
Pacheco, K. G., & de Oliveira, M. R. F. (2016). The prevalence of ovarian varices in patients with endometriosis. Annals of Vascular Surgery, 34, 135-143. https://www.annalsofvascularsurgery.com/article/S0890-5096(16)30232-1/fulltext
Reardon, E. S., & Dillavou, E. D. (2021). Venous disease—What we still do not know. In Vascular Disease in Women (pp. 157-163). Academic Press. https://www.sciencedirect.com/science/article/pii/B9780128229590000031
Fibroids
We have been looking at some of the related conditions that can cause overlapping symptoms with endometriosis. This is important because, if you only treat one condition and not the others, this can lead to continued symptoms and a great deal of discouragement. Another condition with overlapping symptoms with endometriosis is uterine fibroids (leiomyomas).
Fibroids are benign tumors of the smooth muscle cells of the uterus with symptoms that can range from being asymptomatic to having “abnormal uterine bleeding, specifically in terms of heavy and prolonged bleeding” as well as pain with penetration and non-cyclic pelvic pain (Zimmermann et al., 2012). They can also affect fertility and cause urinary dysfunction (Fortin, Flyckt, & Falcone, 2018).
There has not been much research on the correlation between endometriosis and fibroids. One study reports “an incidence of concomitant fibroids and endometriosis ranging between 12 and 20%, based on 2 previously published studies” (Nezhat et al., 2016). A small study that looked at patients with abnormal uterine bleeding found that “of the 208 patients with the presenting chief concern of symptomatic leiomyoma and who underwent surgical therapy, 181 had concomitant diagnoses of leiomyoma and endometriosis” (Nezhat et al., 2016). Another study looking at those with infertility found (by using ultrasound findings) the “diagnosis of fibroids was made in 3.1% of cases, adenomyosis was found in 21.2%, and the co-existence of both uterine disorders with endometriosis was reported in 14.6% of patients” (Capezzuoli et al., 2020). Nezhat et al. (2016) states that “because of the significant overlap of symptoms, it is often difficult to discern which pathology is responsible for the patient’s complaints” and recommends “a high level of suspicion for endometriosis before and during surgery in these women, with the goal of treating both pathologies in a single surgery.”
For more information see: https://icarebetter.com/fibroids/
References
Capezzuoli, T., Vannuccini, S., Fantappiè, G., Orlandi, G., Rizzello, F., Coccia, M. E., & Petraglia, F. (2020). Ultrasound findings in infertile women with endometriosis: evidence of concomitant uterine disorders. Gynecological Endocrinology, 36(9), 808-812. https://doi.org/10.1080/09513590.2020.1736027
Fortin, C., Flyckt, R., & Falcone, T. (2018). Alternatives to hysterectomy: the burden of fibroids and the quality of life. Best Practice & Research Clinical Obstetrics & Gynaecology, 46, 31-42. https://www.sciencedirect.com/science/article/abs/pii/S1521693417301487
Nezhat, C., Li, A., Abed, S., Balassiano, E., Soliemannjad, R., Nezhat, A., … & Nezhat, F. (2016). Strong association between endometriosis and symptomatic leiomyomas. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 20(3). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5019190/
Zimmermann, A., Bernuit, D., Gerlinger, C., Schaefers, M., & Geppert, K. (2012). Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women. BMC women’s health, 12(1), 1-11. https://link.springer.com/article/10.1186/1472-6874-12-6
Endometrial Polyps
The last couple of weeks, we have seen that adenomyosis and interstitial cystitis are found frequently in those with endometriosis and can cause similar symptoms. Another finding noted in those with endometriosis is endometrial (uterine) polyps. One meta-analysis found a significantly higher risk of endometrial polyps (EP) in those with endometriosis (Zheng et al., 2015). These polyps are overgrowths of endometrial glands and stroma (Zheng et al., 2015). While they may not cause any symptoms, they can cause abnormal menstrual bleeding, bleeding between menstrual periods, vaginal bleeding after menopause, and might affect fertility.
Zheng et al. (2015) notes that, like in endometriosis, the expression of estrogen receptors and aromatase (an enzyme that converts androgens to estrogens) is altered in endometrial polyps and can increase the local concentration of estrogen. The authors suggest that “it is important to determine whether patients with endometriosis also have EP and then remove any coexisting EP via hysteroscopy, especially for infertile patients” (Zheng et al., 2015).
For more information on endometrial polyps, see: https://icarebetter.com/endometrial_uterine-polyps/
Reference
Zheng, Q. M., Mao, H. L., Zhao, Y. J., Zhao, J., Wei, X., & Liu, P. S. (2015). Risk of endometrial polyps in women with endometriosis: a meta-analysis. Reproductive biology and endocrinology, 13(1), 1-9. https://link.springer.com/article/10.1186/s12958-015-0092-2
Interstitial cystitis- “evil twin” of endometriosis
Last week, we noted that adenomyosis can frequently coexist in people with endometriosis. Another one of those conditions that can frequently coexist with endometriosis, aptly named the “evil twin” to endometriosis, is interstitial cystitis (IC) (also called painful bladder syndrome). The walls of the bladder become inflamed or irritated, resulting in symptoms similar to a bladder infection, such as urinary urgency and/or frequency, painful urination, and pelvic pain (Al-Shaiji et al., 2021). However, in IC, there is no infection, and the symptoms can often be exacerbated during the time around menses (Al-Shaiji et al., 2021).
Endometriosis and IC can both be found in 80% of people with chronic pelvic pain (Al-Shaiji et al., 2021). Like endometriosis, it can take several years for a diagnosis of IC to be made (Al-Shaiji et al., 2021). It is important to consider this condition when looking at treatments for chronic pelvic pain. Al-Shaiji et al. (2021) reports that “up to 25%–40% of patients who undergo hysterectomy as a treatment of CPP will continue to have pain postoperatively.” Al-Shaiji et al. (2021) also cites another study that discovered that “IC was found in 79% of the patients” who had persistent pelvic pain after a hysterectomy (who were subsequently treated for IC and had improvements in their symptoms). Al-Shaiji et al. (2021) concluded that it is important to look beyond endometriosis as the only cause of a person’s pelvic pain, especially if previous treatments have been ineffective.
For more information on IC, see: https://icarebetter.com/interstitial-cystitis_bladder-pain-syndrome-by-susan-pierce-richards/
Reference
Al-Shaiji, T. F., Alshammaa, D. H., Al-Mansouri, M. M., & Al-Terki, A. E. (2021). Association of endometriosis with interstitial cystitis in chronic pelvic pain syndrome: Short narrative on prevalence, diagnostic limitations, and clinical implications. Qatar Medical Journal, 2021(3), 50. https://doi.org/10.5339/qmj.2021.50
Adenomyosis- sister to endometriosis
Endometriosis is often found along with other conditions that can cause similar symptoms (see Related Conditions). One of those conditions is called adenomyosis, where endometrial glands and stroma invade the muscular part of the uterine wall (Gracia et al., 2022). Vannuccini and Petraglia (2019) report that “adenomyosis and endometriosis share a number of features, so that for many years adenomyosis has been called endometriosis interna,” but the authors go on to point out that “nevertheless, they are considered two different entities.” Adenomyosis is found in those with endometriosis anywhere from 20-80% of the time (Vannuccini & Petraglia, 2019)!
Both conditions share similar symptoms, such as painful periods and abnormal uterine bleeding. This is important to keep in mind when looking at treatment options as it has been seen that “after surgical treatment…pelvic pain and abnormal uterine bleeding (AUB) were significantly more likely to persist with the presence of adenomyosis” (Gracia et al., 2022). Vannuccini and Petraglia (2019) also found this- noting that “on ultrasound pre-operative assessment, 47.8% of patients undergoing surgery for [deep infiltrating endometriosis] were affected by adenomyosis, and in those affected by both conditions, the surgical treatment was not as effective in treating pain as it was in those with only endometriosis.” The ability to diagnose adenomyosis with magnetic resonance imaging and/or transvaginal ultrasound (versus only after a hysterectomy) has made it easier to plan prior to surgery and adjust expectations.
When looking at treating chronic pelvic pain, it is important to note that endometriosis often coexists with several other conditions that can cause similar symptoms. These other conditions, if left untreated, can continue to cause symptoms, which can lead to a great deal of discouragement if you are not aware.
For more information on adenomyosis, see: https://icarebetter.com/adenomyosis/
References
Vannuccini, S., & Petraglia, F. (2019). Recent advances in understanding and managing adenomyosis. F1000Research, 8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6419978/
Loring, M., Chen, T. Y., & Isaacson, K. B. (2021). A Systematic review of adenomyosis: It is time to reassess what we thought we knew about the disease. Journal of minimally invasive gynecology, 28(3), 644-655. https://www.sciencedirect.com/science/article/pii/S1553465020311006
Gracia, M., de Guirior, C., Valdés-Bango, M., Rius, M., Ros, C., Matas, I., … & Carmona, F. (2022). Adenomyosis is an independent risk factor for complications in deep endometriosis laparoscopic surgery. Scientific Reports, 12(1), 1-8. https://www.nature.com/articles/s41598-022-11179-8
Teens with endometriosis
Endometriosis in adolescents was recently reviewed by Liakopoulou et al. (2022), and they report that “adolescent endometriosis is a challenging diagnosis” and that “the disease can be easily overlooked”- thus the true incidence of endometriosis in teens is not really known. The diagnosis in teens is often delayed which “can lead to suffering for several years.” The authors state that “consequently, early diagnosis appears to be of upmost importance, especially as far as adolescents and young patients are concerned, as it can optimize life quality, relief symptomatology, and decrease the negative impact of the disease on future fertility.”
To achieve earlier diagnosis, the authors suggest that “further evaluation should be considered when prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) is reported by the patient, there are relatives diagnosed with endometriosis (in cases of frequent absenteeism from everyday activities during menstruation), and estroprogestin contraceptives have been prescribed before the age of 18 years for primary dysmenorrhea treatment.” They report that “ACOG recommends laparoscopy for diagnosing endometriosis in adolescents” and that “diagnostic laparoscopy is indicated if there is no relief after 3–6 months of medical management.” The authors do report that ultrasounds and MRI’s may be utilized, but that normal imaging doesn’t rule out endometriosis. The authors state that “the benefits of laparoscopy do not only include the confirmation of diagnosis, but also the opportunity of intraoperative treatment.” But the ability to identify endometriosis is important as “during laparoscopy, endometriosis may have a variable appearance.” In adolescents, they report that “white, yellow-brown, red-pink lesions, as well as clear shiny vesicular lesions, are more frequent” and are “associated with greater levels of pain.” The authors also advise that “if suspicious lesions are not identified during laparoscopy, random biopsies of the cul-de-sac should be obtained.” The authors also remind us that “most adolescents present with stage I–II disease; however, advanced stage III–IV disease, including ovarian endometriomas, is increasingly diagnosed in adolescents” and that “the stage and location of the lesions do not directly corelate with the severity or frequency of symptoms.”
The authors note that to help with symptom relief “continuous hormonal therapy can be used to suppress menstruation and is considered safe.” But they report that the use of “gonadotropin releasing hormone (GnRH) agonist or antagonist is not recommended in adolescents with chronic pelvic pain and suspected endometriosis, due to potential impact on bone density.” If GnRH agonists are used, they state that the use “cannot exceed short periods of time, as long-term use may lead to bone density loss and potentially affect negatively cardiovascular risk.” They also caution that “GnRH agonists, when administered before surgery, change the macroscopic image of endometriotic lesions, make their visualization harder, and, thus, preclude effective surgical treatment.” They also state that “depot medroxyprogesterone acetate (DMPA) use is limited, due its association with lower bone mineral density” as well.
Reference
Liakopoulou, M. K., Tsarna, E., Eleftheriades, A., Arapaki, A., Toutoudaki, K., & Christopoulos, P. (2022). Medical and Behavioral Aspects of Adolescent Endometriosis: A Review of the Literature. Children, 9(3), 384. https://www.mdpi.com/2227-9067/9/3/384/htm
Endometriosis and early menopause
Is there an association between endometriosis and early menopause? Kulkarni et al. (2022) looked this question and found that there just might be. The authors state that early natural menopause (ENM) is the cessation of ovarian function before age 45 years. They report that endometriomas in particular (and some treatments for them) might affect ovarian reserves which could lead to earlier onset of menopause. The authors also note that the increase in inflammatory markers in the peritoneal fluid of those with endometriosis might affect follicular and ovarian function (thus leading to earlier menopause).
The authors report that “in this large, prospective cohort study, we observed that surgically confirmed endometriosis was associated with a significantly greater risk of ENM.” They noted the highest risk for ENM was among those who never used oral contraceptives (OC) or had never given birth (more ovulations throughout the lifetime that used up the number of oocytes at that were present at birth). The authors further comment that “although a meta-analysis found an association between OC use and later age at natural menopause, a recent discovery in the Nurses’ Health Study II population did not support a clear association between duration of OC use (decreasing lifetime number of ovulatory cycles) and risk for ENM.” In the study performed by Kulkarni et al (2022), they did find that “among participants who never used OCs, endometriosis was associated with a 2-fold greater risk for ENM.” The authors comment that “it is likely that OC use masks menopause, which is important to consider in this analysis particularly because women may use OCs to control endometriosis-associated symptoms.”
In the end, the researchers concluded that “endometriosis may be an important risk factor for ENM, and women with endometriosis, particularly those who are nulliparous and never-users of OCs, may be at a higher risk for a shortened reproductive duration.” Early menopause is important because it has an affect on osteoporosis, cardiovascular health, and other aspects of health.
Reference
Kulkarni, M. T., Shafrir, A., Farland, L. V., Terry, K. L., Whitcomb, B. W., Eliassen, A. H., … & Missmer, S. A. (2022). Association Between Laparoscopically Confirmed Endometriosis and Risk of Early Natural Menopause. JAMA Network Open, 5(1), e2144391-e2144391. https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2788287
More updates on diet with endometriosis
A recent systemic review looked at the effect of dietary changes on pain perception in endometriosis. While the researchers went through 2185 studies, only six studies fulfilled their inclusion criteria (reproductive age; laparoscopically confirmed endometriosis; and intervention including any type of dietary change) (Sverrisdóttir, Hansen, & Rudnicki, 2022). Those six studies showed that dietary changes, such as “high intake of polyunsaturated fatty acids, a gluten-free diet and a low nickel diet,” may improve painful endometriosis (Sverrisdóttir, Hansen, & Rudnicki, 2022).
Another study created a short algorithm for dietary suggestions for those with endometriosis. They recommended overall the Mediterranean diet or an antioxidant diet- rich in vitamins, minerals, and polyunsaturated fats (Nirgianakis et al., 2021). For those who have gastrointestinal symptoms, they further recommend a gluten free, low FODMAP, or for a short time low nickel diet (Nirgianakis et al., 2021).
As far as dietary supplements go, a review by Bahat et al. (2022) reports that “magnesium, curcumin, resveratrol, and ECGC were beneficial in animal studies due to their antiangiogenic effects. ” Bahat et al. (2022) also states that “omega 3 and alpha-lipoic acid improved endometriosis-associated pain in human studies” as well as “curcumin, omega 3, NAC, vitamin C, and ECGC supplementation decreased endometriotic lesion size in animal and human studies.” The authors do caution that “low sample size and experimental study design” limits the quality of the evidence and urge that “one should keep in mind that food resources and pharmacological formulas of supplements may have different mechanisms of actions” (Bahat et al., 2022).
For more info on diet and endometriosis, see: https://icarebetter.com/diet-and-nutrition/
References
Bahat, P. Y., Ayhan, I., Ozdemir, E. U., Inceboz, Ü., & Oral, E. (2022). Dietary supplements for treatment of endometriosis: A review. Acta Bio Medica: Atenei Parmensis, 93(1). doi: 10.23750/abm.v93i1.11237
Nirgianakis, K., Egger, K., Kalaitzopoulos, D. R., Lanz, S., Bally, L., & Mueller, M. D. (2021). Effectiveness of dietary interventions in the treatment of endometriosis: a systematic review. Reproductive sciences, 1-17. https://link.springer.com/article/10.1007/s43032-020-00418-w
Sverrisdóttir, U. Á., Hansen, S., & Rudnicki, M. (2022). Impact of diet on pain perception in women with endometriosis: a systematic review. European Journal of Obstetrics & Gynecology and Reproductive Biology. https://www.sciencedirect.com/science/article/abs/pii/S0301211522000781
Endometriosis and rheumatoid arthritis
A couple of recent studies have indicated that those with endometriosis might have a higher risk of rheumatoid arthritis (RA) (Xue et al., 2021; Chen et al., 2021). One study even suggested “in the clinical management of patients with RA, rheumatologists should be especially mindful of the possibility of underlying endometriosis” (Xue et al., 2021). This is echoed by Shigesi et al. (2019) who states that “the observed associations between endometriosis and autoimmune diseases suggest that clinicians need to be aware of the potential coexistence of endometriosis and autoimmune diseases when either is diagnosed.”
Harris et al. (2016) cautions that “it remains to be understood whether and how endometriosis itself, or hysterectomy or other factors associated with endometriosis, is related to risk of…RA.” Alpízar-Rodríguez et al. (2017) found that “laparoscopically confirmed endometriosis was found to be significantly associated with subsequent RA…However, this association was attenuated after adjustment by hysterectomy and oophorectomy, suggesting a possible confounding effect by surgically induced menopause.” This effect of menopause on RA has been noted before- “the peak incidence in females coincides with menopause when the ovarian production of sex hormones drops markedly” (Islander et al., 2011). The effect of female hormones has been noted to influence RA symptoms as well. For instance, one study noted “decreased joint pain during times when estrogen and progesterone levels are high” (Costenbader et al., 2008). Estrogen can have “both stimulatory and inhibitory effects on the immune system” and it has been noted that “the rapid decline in ovarian function and in circulating oestrogens at menopause is associated with spontaneous increases in pro-inflammatory cytokines” (Alpízar-Rodríguez et al., 2017). Part of the effect may be seen in the estrogen receptors, with an increase of ER-β over ER-α receptors in RA synovial tissue (Alpízar-Rodríguez et al., 2017). This increased expression of ER-β receptors is also seen in endometriosis lesions (which can cause increased inflammation) (Bulun et al., 2012).
References
Alpízar-Rodríguez, D., Pluchino, N., Canny, G., Gabay, C., & Finckh, A. (2017). The role of female hormonal factors in the development of rheumatoid arthritis. Rheumatology, 56(8), 1254-1263. https://doi.org/10.1093/rheumatology/kew318
Bulun, S. E., Monsavais, D., Pavone, M. E., Dyson, M., Xue, Q., Attar, E., … & Su, E. J. (2012, January). Role of estrogen receptor-β in endometriosis. In Seminars in reproductive medicine (Vol. 30, No. 01, pp. 39-45). Thieme Medical Publishers. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4034571/…
Chen, S. F., Yang, Y. C., Hsu, C. Y., & Shen, Y. C. (2021). Risk of Rheumatoid Arthritis in Patients with Endometriosis: A Nationwide Population-Based Cohort Study. Journal of Women’s Health, 30(8), 1160-1164. https://doi.org/10.1089/jwh.2020.8431
Costenbader, K. H., & Manson, J. E. (2008). Do female hormones affect the onset or severity of rheumatoid arthritis?. Arthritis Care & Research, 59(3), 299-301. https://onlinelibrary.wiley.com/doi/epdf/10.1002/art.23324
Harris, H. R., Costenbader, K. H., Mu, F., Kvaskoff, M., Malspeis, S., Karlson, E. W., & Missmer, S. A. (2016). Endometriosis and the risks of systemic lupus erythematosus and rheumatoid arthritis in the Nurses’ Health Study II. Annals of the rheumatic diseases, 75(7), 1279-1284. http://dx.doi.org/10.1136/annrheumdis-2015-207704
Islander, U., Jochems, C., Lagerquist, M. K., Forsblad-d’Elia, H., & Carlsten, H. (2011). Estrogens in rheumatoid arthritis; the immune system and bone. Molecular and cellular endocrinology, 335(1), 14-29. DOI: 10.1016/j.mce.2010.05.018
Xue, Y. H., You, L. T., Ting, H. F., Chen, Y. W., Sheng, Z. Y., Xie, Y. D., … & Wei, J. C. C. (2021). Increased risk of rheumatoid arthritis among patients with endometriosis: a nationwide population-based cohort study. Rheumatology, 60(7), 3326-3333. https://doi.org/10.1093/rheumatology/keaa784
Shigesi, N., Kvaskoff, M., Kirtley, S., Feng, Q., Fang, H., Knight, J. C., … & Becker, C. M. (2019). The association between endometriosis and autoimmune diseases: a systematic review and meta-analysis. Human reproduction update, 25(4), 486-503. https://doi.org/10.1093/humupd/dmz014
Endometriosis and Constipation
Endometriosis is associated with several “digestive complaints, including abdominal pain, bloating, diarrhea, constipation, rectal bleeding, and dyschezia” (Raimondo et al., 2022). Raimondo et al. (2022) reports that “chronic constipation (CC) in women with endometriosis varies from 12% to 85%” and results from multiple causes such as inflammation, scar tissue, and damage to pelvic autonomic nerves.
Raimondo et al. (2022) reports that those “with endometriosis are more likely to have pelvic floor muscle dysfunctions” and found by using ultrasounds that hypertonic (too much muscle tone) pelvic floor muscles were found more in those with chronic constipation than those without it. While treating chronic constipation can be challenging, the study states that “specific interventions targeting the pelvic floor hypertonia, such as physiotherapy” might be beneficial.
Another study reports that digestive symptoms such as constipation are due more to the inflammation irritating the digestive tract than to lesions infiltrating the bowel itself (Roman et al., 2012). However, those “presenting with rectal endometriosis were more likely to present cyclic defecation pain (67.9%), cyclic constipation (54.7%) and a significantly longer stool evacuation time, although these complaints were also frequent in the other two groups (38.1 and 33.3% in women with Stage 1 endometriosis and 42.9 and 26.2% in women with deep endometriosis without digestive involvement, respectively)” (Roman et al., 2012). A referral to a gastroenterologist may help improve symptoms, but part of the treatment might include surgery to remove lesions that may be affecting the bowel (Meurs‐Szojda et al., 2011).
For more information on bowel symptoms: https://icarebetter.com/bowel-gi-endometriosis/
References
Meurs‐Szojda, M. M., Mijatovic, V., Felt‐Bersma, R. J. F., & Hompes, P. G. A. (2011). Irritable bowel syndrome and chronic constipation in patients with endometriosis. Colorectal Disease, 13(1), 67-71. https://doi.org/10.1111/j.1463-1318.2009.02055.x
Raimondo, D., Cocchi, L., Raffone, A., Del Forno, S., Iodice, R., Maletta, M., … & Seracchioli, R. (2022). Pelvic floor dysfunction at transperineal ultrasound and chronic constipation in women with endometriosis. International Journal of Gynecology & Obstetrics. https://doi.org/10.1002/ijgo.14088
Roman, H., Ness, J., Suciu, N., Bridoux, V., Gourcerol, G., Leroi, A. M., … & Savoye, G. (2012). Are digestive symptoms in women presenting with pelvic endometriosis specific to lesion localizations? A preliminary prospective study. Human reproduction, 27(12), 3440-3449. doi: 10.1093/humrep/des322
Endometriosis and Heart Disease
There is not much literature about endometriosis and heart disease. Marchandot et al. (2022) reports that there are some overlaps in contributors to both heart disease and endometriosis, such as “chronic inflammation, enhanced oxidative stress, endothelial dysfunction, and cellular proliferation.” Some research indicates “increased arterial stiffness and impaired flow-mediated dilation, a surrogate marker of endothelial dysfunction potentially reversible after surgical treatment, were associated with endometriosis” (Marchandot et al., 2022).
Some risk factors for heart disease have been found in those with endometriosis, including hypertension, dyslipidemia, and obesity. Research suggests that the link between hypertension and endometriosis may be because of certain treatments for endometriosis, namely from early hysterectomy/oophorectomy and from use of NSAIDs (Marchandot et al., 2022). In fact, “hysterectomy in women aged 50 years or younger has been associated with a significantly increased risk of ischaemic heart disease, with oophorectomy linked to an increased risk of both [coronary artery disease] and stroke” (Marchandot et al., 2022). Shuster et al. (2010) add that “regardless of the cause…women who experience premature menopause (before age 40 years) or early menopause (between ages 40 and 45 years) experience an increased risk of overall mortality, cardiovascular diseases, neurological diseases, psychiatric diseases, osteoporosis, and other sequelae.” High cholesterol has also been associated with endometriosis- a 25% increased risk in those with endometriosis (Marchandot et al., 2022). Marchandot et al. (2022) also reports that “the role of hormonal treatment strategies for endometriosis, including combined oral contraceptives, progestins, and gonadotrophin-releasing hormone (GnRH) analogues, has been highly questioned regarding a potentially enhanced lipid profile, cardiovascular risk profile, and weight gain.”
Marchandot et al. (2022) urge caution in interpreting results as “only small associations between endometriosis and CVD have been reported in the literature” and that current studies have been limited “by small sample sizes, observational designs, and the specific characteristics of the population from which the samples are derived (high-income countries, cohort study of hospital-based healthcare workers, primarily Caucasian Europeans, etc.).” They also state that endometriosis treatments influence cardiovascular risk factors (“the confounding influence of hormonal, non-hormonal, and pain-related interventions further complicate the cause-and-effect relationship in CV endpoints”) (Marchandot et al. 2022).
References
Marchandot, B., Curtiaud, A., Matsushita, K., Trimaille, A., Host, A., Faller, E., … & Morel, O. (2022). Endometriosis and cardiovascular disease. European Heart Journal Open, 2(1), oeac001. https://doi.org/10.1093/ehjopen/oeac001
Shuster, L. T., Rhodes, D. J., Gostout, B. S., Grossardt, B. R., & Rocca, W. A. (2010). Premature menopause or early menopause: long-term health consequences. Maturitas, 65(2), 161-166. doi: 10.1016/j.maturitas.2009.08.003
Fatigue, rest, and pacing
During endometriosis awareness month, the most interacted with post on our Facebook page was about fatigue- which points to how significant it impacts those with endometriosis. Fatigue and pain often go hand in hand- with one aggravating the other. One concept to help prevent flares of pain and fatigue is pacing.
Pacing is about adjusting your activities to your body’s current needs and finding the balance between activity and rest. Pacing doesn’t mean you accomplish less, rather it helps you accomplish your goals while reducing the chance of a pain/fatigue flare. We are familiar with the concept of pacing in running and other forms of exercise:
“Pacing is essentially a strategy that you use to distribute your energy throughout your entire bout of physical activity. Being cognitively aware of how much you are physically exerting yourself will keep you in touch with signs of fatigue and allow better control of performance. Properly controlling your pace during your physical activity can help you prevent working so hard that you’re unable to complete your training in the next session. Pacing allows you to avoid injury…”
(MacPherson, n.d.)
Pacing, according to one study’s participants, can include “breaking down tasks, saying ‘no’, being kind to themselves, using rest breaks, doing something each day, developing a structure and gradually building up activities” (Antcliff et al., 2021). The same study found that some of the main barriers to pacing activities were “wanting to complete tasks, or not wanting to delegate or be perceived as lazy” (Antcliff et al., 2021). Sometimes life’s demands make it difficult- especially with an illness not many people understand. The study had participants include goals such as “socialise with friends, try varying exercises, protect time for hobbies and relaxation, and gradually try activities they had been avoiding due to symptoms” (Antcliff et al., 2021). Sometimes when we feel better, we push ourselves too hard for too long to make up for when we can’t perform our usual activities. Feinberg and Feinberg (n.d.) report that with pacing “you break an activity up into active and rest periods” and that “rest periods are taken before significant increases in pain levels occur.” Pacing may mean that if you have work or an appointment scheduled, then you may need to keep your schedule clear the day before and/or after to be able to recover. It may mean only doing one load of laundry that day. It may mean protecting time for activities that feed your spirit (reading, outdoor time, time with supportive friends or family, etc.).
In the spirit of pacing and taking rest when needed, the admins of our Facebook page will be taking a week off April 2-9, 2022. During this week, our Facebook page will be on pause. This means that it will be read only during that week, so it won’t let you comment, react, post, or request to join. Don’t worry, it’ll go back to usual after that week. After 9 years of continuous volunteer work by the admins and moderators, it’s about time for a break.
See more about fatigue with endometriosis: https://icarebetter.com/fatigue-in-endometriosis/?doing_wp_cron=1594748400.8231060504913330078125
endometriosis signs and symptoms
References
Antcliff, D., Keenan, A. M., Keeley, P., Woby, S., & McGowan, L. (2021). “Pacing does help you get your life back”: The acceptability of a newly developed activity pacing framework for chronic pain/fatigue. Musculoskeletal care. https://onlinelibrary.wiley.com/doi/full/10.1002/msc.1557
Feinberg & Feinberg. (n.d.). Pacing means moving ahead. Retrieved from http://www.cfsselfhelp.org/library/pacing-means-moving-ahead-and-not-falling-behind#:~:text=Pacing%20is%20a%20tool%20that,physical%20activity%20because%20it%20hurts.
MacPherson. (n.d.). How to properly pace yourself during exercise (and why it matters) Retrieved from https://www.vitacost.com/blog/how-to-pace-yourself-to-improve-exercise/
