iCareBetter

Category Archives: Symptoms

3 years ago Symptoms No comment

Endometriosis and Exercise

Exercise has been noted to affect levels of inflammatory markers and estrogen, which might influence endometriosis symptoms; however, chronic pelvic pain and fatigue can severely limit the ability to exercise (Buggio et al., 2017; Moradi et al., 2014). One study noted that a strength exercise program helped pain in healthy participants but not the pain in women with endometriosis (Poli-Neto et al., 2019). Physical activity is important for your overall health but can be difficult with chronic pelvic pain. Pelvic physical therapy can be a useful tool for women with endometriosis and chronic pelvic pain (Sarrel, 2019).

Studies: 

  • Poli-Neto, O. B., Oliveira, A. M. Z., Salata, M. C., Cesar Rosa-e-Silva, J., Machado, D. R. L., Candido-dos-Reis, F. J., & Nogueira, A. A. (2019). Strength Exercise Has Different Effects on Pressure Pain Thresholds in Women with Endometriosis-Related Symptoms and Healthy Controls: A Quasi-experimental Study. Pain Medicine.  Retrieved from https://academic.oup.com/painmedicine/article-abstract/doi/10.1093/pm/pnz310/5653106  

“The strength exercise regimen used in this study increased pain thresholds in healthy women but not in women with endometriosis-related painful symptoms. The maintenance or even worsening of pain perception after exercise in women with persistent pain, such as those with endometriosis, may limit their adherence to a physical training program, which in turn could prevent them from experiencing the long-term beneficial effects of exercise.” 

“Pain in particular was reported to limit their normal daily physical activity like, walking and exercise.

‘Prior to having endometriosis, I used to run every day and was very active. For the last six months while I waited for surgery to remove the cyst and endometriosis, my level of exercise was severely reduced. I could only walk about once or twice a week and it was very painful. I gained weight and felt dissatisfied with my body. It also impacted on my self-confidence. I began wearing more baggy clothes, also watched more TV and had general feelings of being lethargic and spaced out’. (P1, Group 3)

“Women who had small children mentioned that they were not able to care for them as they would like…. Fatigue and limited energy were also among reported physical impacts of endometriosis.” 

“Even post excision of endometriosis patients may continue to experience pain across multiple systems from gynecological pain to abdominal and musculoskeletal pain. Current best practices leaves women with the disease few options beyond surgery, especially for those suffering with central sensitization and nerve up-regulation due to the long term adaptations of the disease. Pelvic Physical Therapy can be a critical component to mobilize the body post operatively. An exercise prescription designed by a physical therapist may help integrate and quiet long standing nerve patterns thereby returning the woman with endometriosis back to her best possible quality of life.”

  • Buggio, L., Barbara, G., Facchin, F., Frattaruolo, M. P., Aimi, G., & Berlanda, N. (2017). Self-management and psychological-sexological interventions in patients with endometriosis: strategies, outcomes, and integration into clinical care. International Journal of Women’s Health, 9, 281. Retrieved  from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5422563/  

“With regard to endometriosis, various etiopathogenic assumptions may contribute to explain why physical activity may be a protective factor. First, exercise may reduce estrogen levels and frequency of ovulation when performed at high levels of intensity;27 second, physical activity may increase SHBG levels, which would decrease bioavailable estrogens.28–30 Moreover, regular physical activity also reduces insulin resistance and hyperinsulinemia,28 which has been hypothesized to be associated with endometriosis. In addition, regular exercise leads to an increase in the systemic levels of cytokines with anti-inflammatory properties.29,30

“Recently, Ricci et al27 performed a systematic review and meta-analysis of the literature to clarify the potential association between endometriosis and physical activity. The meta-analysis combined data from nine studies – six case-control studies and three cohort studies – involving 3,355 cases for recent physical activity and 4,600 case for past physical activity. The summary odds ratio for endometriosis for any recent versus no physical activity was 0.85 (95% confidence interval [CI] 0.67–1.07). Compared to no recent physical activity, odds ratios for low and moderate/high exercise were 1 (95% CI 0.68–1.28) and 0.75 (95% CI 0.53–1.07), respectively. The authors concluded that although physical activity may reduce the risk of the disease, the meta-analysis had not provided definitive support to this hypothesis.

“The possible anti-inflammatory effect of physical activity has also been evaluated in a rat model. Rosa-e-Silva et al31 divided 70 female rats with experimentally induced endometriosis in seven groups of ten animals each: sedentary-, light-, moderate-, and intense-exercise programs. Endometriosis was induced before physical activity in three groups and after disease induction in the other three. A reduction in levels of oxidative stress, MMP9, and proliferating cell nuclear antigen (PCNA) was identified in all the groups that practiced physical exercise, indicating a reduction in proliferation, migration, and differentiation of endometriotic tissue.

“Recently, the practice of yoga has gained worldwide spread, due to its ability to integrate the body and mind through a balanced mixture of contemplative techniques that are able to reduce stress and, at the same time, strengthen musculature.32 As stated by the World Health Organization, yoga has been classified as a mind–body practice33 that improves symptoms of various disorders, such as asthma and high blood pressure.34–36 Gonçalves et al32 evaluated the effects of yoga on 15 women with symptomatic endometriosis. All patients attended yoga practice twice a week for 8 weeks, and at the end of the program all participants reported a beneficial effect of yoga in pelvic pain management. In addition, women stated that through the practice of yoga, they developed self-control and self-awareness, with improved self-care and self-esteem. In conclusion, through the learning of specific postures and breathing and meditation techniques, yoga improved the ability of patients experiencing pain to control their symptoms. Further research is needed to confirm these promising preliminary and uncontrolled results.”

3 years ago Symptoms No comment

Adhesion Related Information

Adhesions are bands of scar-like, fibrous tissue that can form when there is any kind of tissue injury. According to Van Den Beukel et al. (2017), adhesions can cause pelvic pain. They also reports that “reformation of adhesions has been linked to relapse of pain after adhesiolysis” (Van Den Beukal et al., 2017). Hermann and Wilde (2016) note that adhesion formation is “highly prevalent in patients with a history of operations or inflammatory peritoneal processes”.

Links:

Studies:

  • Hao, M., Zhao, W. H., & Wang, Y. H. (2009). Correlation between pelvic adhesions and pain symptoms of endometriosis. Zhonghua fu chan ke za zhi, 44(5), 333. Retrieved from https://pubmed.ncbi.nlm.nih.gov/19573306/ 

“Conclusion:Pelvic adhesions are characteristic lesions of endometriosis, the site and degree pelvic adhesions are closely correlated with pain symptoms.”

  • Abd El-Kader, A. I., Gonied, A. S., Mohamed, M. L., & Mohamed, S. L. (2019). Impact of endometriosis-related adhesions on quality of life among infertile women. International Journal of Fertility & Sterility, 13(1), 72. Retrieved from https://europepmc.org/article/med/30644248

“The prevalence of adhesions resulted from endometriosis was 37.6%. Demographic characteristics of the women with endometriosis-related adhesions were not significantly different from those of women without endometriosis- related adhesions. The most common location for endometriotic adhesions was adnexal adhesion (51.2%) followed by adhesion of anterior abdominal wall (24.4%). Quality of life was significantly impacted by endometriosis related adhesions (P=0.002).”

“Preoperative blood Serum and CA 125 results were obtained and pelvic adhesion scores were calculated. The patient group with adhesion scores less than 28 points was defined as the mild adhesion group, and those with a score of 28 or more were members of the severe adhesion group. The CA 125 level was significantly higher in the severe adhesion group than in the mild adhesion group. The CA 125 level, size of the largest cyst, and WBC count were associated with the level of pelvic adhesion. Adhesion scores were significantly higher in the CA 125 ≥ 35 U/mL group than in the CA 125 < 35 U/mL group. Patients with a preoperative CA 125 level higher than 35 U/mL are at high risk for pelvic adhesion.”

“The negative impact on the tubo-ovarian unit can be directly by distorting the anatomy, indirectly by invoking inflammation or by oxidative damage with poorer-quality oocytes. Endometriosis even seems to have a negative effect on pregnancy outcome after in vitro fertilization.”

References

Herrmann, A., & De Wilde, R. L. (2016). Adhesions are the major cause of complications in operative gynecology. Best Practice & Research Clinical Obstetrics & Gynaecology, 35, 71-83. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S1521693415001935

Van Den Beukel, B. A., de Ree, R., van Leuven, S., Bakkum, E. A., Strik, C., van Goor, H., & ten Broek, R. P. (2017). Surgical treatment of adhesion-related chronic abdominal and pelvic pain after gynaecological and general surgery: a systematic review and meta-analysis. Human Reproduction Update, 23(3), 276-288. Retrieved from https://academic.oup.com/humupd/article/23/3/276/3058801

3 years ago Symptoms No comment

Immune System

Is Endometriosis an autoimmune disease?

“Experts do not classify endometriosis as an autoimmune disease. However, endometriosis may increase a person’s risk of developing an autoimmune disease, as well as other chronic conditions. The reason for the link is unclear, but it might exist because endometriosis causes inflammation, which may contribute to an imbalanced immune response.

“An autoimmune disease is one in which the body mistakenly attacks its cells, tissues, or organs. The resulting damage can cause a wide variety of symptoms, depending on which part of the body it affects. The abnormal immune response that occurs in endometriosis may be due to an existing autoimmune disorder. The evidence is not clear as to which condition causes the other.

“There is still no conclusive cause of endometriosis, and researchers do not yet know what triggers the condition. However, abnormal immune system responses and genetics may be among the factors that play a role in the development of the disorder. A person with endometriosis may also have an increased risk of comorbidities. Comorbidities are conditions that exist alongside a primary condition….

“Treatment for an autoimmune disease typically focuses on suppressing the immune system so that it stops attacking healthy cells in the body. Endometriosis does not appear to respond to any known treatments for autoimmunity.”

Links:

3 years ago Symptoms No comment

Endometriosis Systemic Effects

Endometriosis Systemic Effects

“While the most commonly seen symptoms of the disease are pelvic pain, dysmenorrhea, and infertility, endometriosis has also systemic effects in multiple organ systems. Here, we review literature describing closely associated comorbidities including cardiovascular disease, cancers, autoimmune disease, psychiatric conditions, and metabolism/body weight. We examine the pathophysiology and hypothesized mechanism by which endometriosis may lead to these systemic effects; mechanisms include cytokine and micro-RNA production as well as stem cell migration and dissemination. The broad systemic effects of endometriosis as well as correlated comorbidities are often overlooked in the treatment of patients with endometriosis. Increased awareness may lead to more effective treatment and prevention.” 

3 years ago Symptoms No comment

Urinary System (Bladder, Ureters, and Kidney)

Endometriosis close to the urinary organs, like the bladder, can cause symptoms such as pain with urinating (dysuria), blood in the urine (hematuria), urinary frequency/urgency/incontinence. However, it is important to note they may NOT cause symptoms. This is important because endometriosis around the ureters (the tubes that take your urine from your kidneys to your bladder) may not cause symptoms but can lead to kidney failure. Close follow up with your provider is important. 

Bladder:

Symptoms are similar to interstitial cystitis and may include (potentially cyclical but not necessarily so) urgency, suprapubic pain, pain with urination, blood in the urine, inflammation of the bladder lining, etc.

  • Ferrero, S., Bogliolo, S., Menada, M. V., Ragni, N., Biscaldi, E., Camerini, G., & Remorgida, V. (2009). Diagnosis and management of bladder endometriosis. Journal of Endometriosis, 1(3-4), 113-121. Retrieved from https://doi.org/10.1177/2284026509001003-401 

“Bladder endometriosis is defined as full-thickness infiltration of the detrusor; small sub-peritoneal implants and small nodules of the vesicouterine fold cannot be considered to be bladder endometriosis. In women with endometriosis, urinary tract involvement is rare (1% to 5% of cases) but the bladder is affected in 80% to 84% of these cases. Symptoms of bladder endometriosis are various and not specific: besides pain symptoms, patients may complain of urinary frequency, urgency, urge incontinence, dysuria, and hematuria. Although bladder endometriosis may be suspected at vaginal examination, the preoperative diagnosis is based on transvaginal ultrasonography and magnetic resonance imaging. Medical therapies may temporarily reduce the severity of symptoms related to the presence of vesical endometriosis; however, the symptoms may persist in cases of large bladder nodules or may recur after cessation of therapy. Surgery represents the gold standard for treatment of bladder endometriosis and laparoscopy should be preferred to laparotomy. Excision of bladder nodules may be performed either by partial-thickness resection or by partial cystectomy according to the size and depth of the infiltration of the lesions in the bladder wall. Persistent improvement of symptoms has been demonstrated at long-term follow-up, particularly when the lesions involve the vesical dome.”

“…urinary tract involvement especially the bladder endometriosis is a rare entity in women of reproductive age with clinical symptoms of cyclical urgency, hematuria and suprapubic pain. We herein present magnetic resonance imaging (MRI) findings of spontaneous bladder endometriosis case with cyclical hematuria symptoms.”

Bladder Links:

Ureter:

Ureter endometriosis, while rare, is important for a provider to assess. It does not have many specific symptoms to identify and so can be insidious with its harm. The studies below highlight endometriosis in other areas that have been shown to occur frequently with endometriosis of the ureters. 

“Little attention has been paid by the renal literature to ureteral endometriosis, a rare and silent disorder that can eventually lead to renal failure. In endometriosis, the ureteral involvement can be limited to a single ureter, more often the left one, or both ureters with consequent urine tract obstruction and ureterohydronephrosis. In most cases, the ureteral obstruction is caused by endometrial tissue surrounding the ureter (extrinsic ureteral endometriosis). In the remaining cases, endometrial cells are located within the ureter (intrinsic ureteral endometriosis). Progressive ureteral obstruction can be insidious in onset and can ultimately lead to renal failure if a correct diagnosis is missed. The true incidence of renal failure caused by endometriosis is completely unknown, although cases have been reported in the literature. The diagnosis of ureteral endometriosis is difficult since the disease may be clinically silent or associated with non-specific symptoms. Only a high index of suspicion and radiological support may help to obtain an early diagnosis. However, while renal imaging is useful in the cases of extrinsic endometriosis, the diagnosis of intrinsic endometriosis often requires ureteroscopy or laparoscopy. The prognosis of ureteral endometriosis depends on the time of diagnosis. In too many cases of bilateral obstruction, the patient is referred to the nephrologist because of an advanced, irreversible renal failure. Although some patients may benefit from progestin or anti-arotamase therapy, in most cases of ureteral endometriosis surgery is needed, laparoscopy surgery being preferred today to laparatomy.”

“Ureteral endometriosis is a serious localization of disease burden that can lead to urinary tract obstruction, with subsequent hydroureter, hydronephrosis, and potential kidney loss. Diagnosis is elusive and relies heavily on clinical suspicion as ureteral endometriosis can occur with both minimal and extensive disease. Surgical technique to treatment varies, but the goal is to salvage renal function and decrease disease burden.

“Although a relatively common gynecologic condition, localization to areas distinct from the peritoneum, ovary, and rectovaginal septum occurs in up to 12% of women with endometriosis.3 Pelvic endometriosis can infrequently involve the urinary tract system in approximately 1% of cases, which is a prevalence of 3.5 million women worldwide.4 The bladder is the most commonly involved site and the urethra the least. Of these localizations of disease, ureteral endometriosis accounts for approximately 10% of genitourinary involvement, which is 350,000 women worldwide.4,5 In endometriosis, ureteral involvement is often limited to one ureter, commonly the left, and can potentially lead to urinary tract obstruction, ureterohydronephrosis, and loss of renal function. There are estimates that 30% or nearly a 100,000 women with ureteral endometriosis will have 25% to 50% loss of nephrons at time of diagnosis of ureteral endometriosis, and an unknown number will then have loss of the kidney.6 This final insult of complete loss of renal function is exceedingly rare.

“Ureteral endometriosis is a serious localization of disease burden. Asymmetric involvement of endometriosis, with the left pelvis more commonly involved than the right, is readily explained by anatomic differences of the pelvis.12 The distal segment of the ureters and bladder are the more frequently involved locations due to the proximity of the reproductive organs.13 Additionally, ureteral endometriosis is more likely to be associated with rectosigmoid lesions as opposed to bladder involvement.14 Two major pathological types exist: extrinsic and intrinsic ureteral endometriosis. In the extrinsic type, which is the most common, endometrial glandular and stromal tissue involve only the adventitia of the ureter or surrounding connective tissues, whereas the intrinsic type involves the muscularis propria, lamina propria, or ureteral lumen.1” 

Kidney/Renal:

  • Giambelluca, D., Albano, D., Giambelluca, E., Bruno, A., Panzuto, F., Agrusa, A., … & Lagalla, R. (2017). Renal endometriosis mimicking complicated cysts of kidney: report of two cases. Il Giornale di chirurgia, 38(5), 250. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5761639/ 

“Although usually occurring in pelvic organs, endometrial lesions may involve urinary tract. Renal endometriosis is extremely rare and it has only occasionally been reported in the past. We report two cases of patients with renal cystic lesions, incidentally found at imaging techniques during oncologic follow-up for gastric sarcoma and melanoma, initially misinterpreted as complicated haemorrhagic cysts and then histologically characterized as renal localizations of extragenital endometriosis.” 

3 years ago Symptoms No comment

Ovaries and Endometriomas

Endometriomas are a type of endometriosis cyst on the ovary. Management of endometriomas can be complex as there are many schools of thought on how they should be handled. Generalists, gynecologists, or fertility experts will often suggest a wait-and-watch approach when faced with a patient who has an endometrioma. Some will suggest that surgery is only warranted for cysts above a certain size. They might even cite potential damage in the context of fertility concerns. A watch-and-wait approach is a reasonable option for many and sometimes even a skilled excision surgeon will recommend the same, depending on your circumstances. The trouble is, unlike many other kinds of cysts (the common kinds that are not related to endometriosis), no amount of waiting will change the fact that endometriomas do not resolve on their own.  There are different techniques used when surgically treating an endometrioma. Some will just drain the cyst, but that doesn’t eliminate what caused the cyst to form in the first place. Even with effective skilled excision, other endometriomas can present later on.  Accessing more advanced surgical care makes sense for two key reasons: (1) removing an endometrioma effectively is a challenging task and (2) endometriomas can be an indicator of more extensive endometriosis elsewhere that will also need to be addressed.

Links: 

Studies

“Ovarian endometriomas are indicators for pelvic endometriosis and are rarely isolated. Particularly, left endometriomas were found to be associated with rectal DIE and left uterosacral ligament localization and bilateral endometriomas correlated with adhesions and pouch of Douglas obliteration, whereas no correlation was found between endometrioma size and DIE. Determining appropriate management, whether clinical or surgical, is critical for ovarian endometriomas and concomitant adhesions, endometriosis, and adenomyosis in patients desiring future fertility.”

“Endometriomas (ovarian endometriotic cysts) are a commonly diagnosed form of endometriosis, owing to the relative ease and accuracy of ultrasound diagnosis. They frequently present a clinical dilemma as to whether and how to treat them when found during imaging or incidentally during surgery. Previously published guidelines have provided recommendations based on the best available evidence, but without technical details on the management of endometriosis….Owing to the limited evidence available, recommendations are mostly based on clinical expertise….It is generally accepted that endometriosis presents in three different entities, which are frequently found together: peritoneal lesions, deep endometriosis and ovarian endometriotic cysts (endometriomas) (Nisolle and Donnez, 1997). Endometriomas are probably the most commonly diagnosed form of endometriosis because of the relative ease and accuracy of ultrasound diagnosis. Although their exact prevalence and incidence are not known, they have been reported in 17–44% of women with endometriosis (Busacca and Vignali, 2003). The presence of ovarian endometriomas has been reported as being a marker for deep endometriosis (Redwine, 1999) and multifocal deep vaginal, intestinal and ureteric lesions (Chapron et al., 2009).”

“The objective of this study was to evaluate the significance of severe preoperative pain for patients presenting with ovarian endometrioma (OMA)…. After multiple logistic regression analysis, uterosacral ligaments involvement was related with a high severity of chronic pelvic pain [odds ratios (OR) = 2.1; 95% confidence interval (CI): 1.1–4.3] and deep dyspareunia (OR = 2.0; 95% CI: 1.1–3.5); vaginal involvement was related with a higher intensity of lower urinary symptoms (OR = 13.4; 95% CI: 3.2–55.8); intestinal involvement was related with an increased severity of dysmenorrhoea (OR = 5.2; 95% CI: 2.7–10.3) and gastro-intestinal symptoms (OR = 7.1; 95% CI: 3.3–15.3). CONCLUSIONS: In case of OMA, severe pelvic pain is significantly associated with deeply infiltrating lesions. In this situation, the practitioner should perform an appropriate preoperative imaging work-up in order to evaluate the existence of associated deep nodules and inform the patient in order to plan the surgical intervention strategy.”

OTHER OVARIAN-RELATED ISSUES

  • Nonovarian Cystic Lesions of the Pelvis: 

Moyle, P. L., Kataoka, M. Y., Nakai, A., Takahata, A., Reinhold, C., & Sala, E. (2010). Nonovarian cystic lesions of the pelvis. Radiographics, 30(4), 921-938. Retrieved from https://pubs.rsna.org/doi/full/10.1148/rg.304095706?fbclid=IwAR0O4FKOnDt66Cbar32GNJUIWCnWOJUWgAno9F3tmtCq0Fzp_09PTSC5QQM& 

“”Not all cystic lesions in the female pelvis are ovarian. It is important to consider disease processes that may mimic those of the ovaries because they affect patient management. It also is important to be familiar with the imaging characteristics of the various pelvic cysts, their anatomic locations, and the patient’s clinical history to make an accurate diagnosis……..peritoneal inclusion cyst, paraovarian cyst, mucocele of the appendix, obstructed fallopian tube (eg, hydrosalpinx, pyosalpinx, and hematosalpinx), uterine leiomyoma, adenomyosis, spinal meningeal cyst, unicornuate uterus, lymphocele, cystic degeneration of lymph nodes, lymphangioleiomyomatosis, hematoma, and abscess. A cystic pelvic mass is nonovarian if it is separate from the normal ovaries.”

Links:

3 years ago Symptoms No comment

Comments on Thoracic Endometriosis

The term thoracic endometriosis has been used to describe the varying clinical and radiological manifestations associated with the growth of endometrial glands and stroma in the lungs or the pleural surface. Catamenial pneumothorax (CP) is defined as pneumothorax happening around the menstrual period and is the most common manifestation of thoracic endometriosis, accounting for about 80% of cases. In almost all cases, thoracic endometriosis is unilateral and right sided, although there are rare cases of left sided disease. Bilateral disease is extremely rare. The presentation of CP includes cough, chest pain, and shortness of breath. The chest pain may be similar to patients with spontaneous pneumothorax or present as shoulder, scapular or neck pain.

Some management strategies for thoracic endometriosis are as follows. For any women with a spontaneous recurring pneumothorax, a gynecologic history and evaluation of her menstrual cycle should be done. When thoracic endometriosis is suspected, Video-Assisted Thoracoscopic Surgery (VATS) is the preferred approach. The diaphragm needs to be explored thoroughly, including the visceral and parietal pleura, and if necessary, a port should be inserted at the subcostal margin to assess the posterior diaphragm. All accessible lesions and fenestrations should then be resected. Fulguration or ablation of lesions should not be used, as it is inadequate for treatment of endometriosis and will result in higher recurrence rates. Following the resection, plication is recommended to seal and strengthen the diaphragm. Simple suturing of the fenestrations does not provide tissue diagnosis and is usually followed by recurrence. Lesions close to the phrenic nerve or its main divisions are best treated by limited resection (if possible) and repair. A mechanical pleurodesis is also further recommended after all accessible lesions have been excised. 

We also propose a joint surgery by the thoracic surgeon and the gynecologist specialized in endometriosis wherever possible. Not only will this allow for an assessment of the diaphragm from both the pleural and peritoneal side concurrently, this will also allow more thorough identification of endometriotic lesion and fenestrations by both specialists. Additionally, there is a significant association between the presence of pelvic endometriosis and thoracic endometriosis and a joint surgery will further allow the treatment of any pelvic endometriosis at the same time.

Medical treatment has long been considered the first choice in patients with thoracic endometriosis. The literature contains a variety of reports on the use of oral contraceptives, progestational drugs, danazol and gonadotropin-releasing hormone (GnRH) agonists. Experience in the last three decades has been greatest with danazol and GnRH agonists. However, the results of medical treatment for CP have been disappointing. At 6 and 12 months, surgical treatment of CP resulted in far lower recurrence rate than did hormonal therapy (5% and 25% compared with 50% and 60%). Therefore, before initiating pharmacologic disruption of ovarian steroid genesis in a young woman, all surgical treatment options should have been exhausted.

3 years ago Symptoms No comment

Thoracic Endometriosis

Thoracic Endometriosis, Endometriosis of the lung 

While endometriosis of the thoracic area is rare, it can occur. Several case reports and studies that are cited below, report symptoms of coughing up blood (hemoptysis), isolated chest pain, and/or shortness of breath with menstrual cycles. At times, a collapsed lung (pneumothorax) has been reported (symptoms such as shortness of breath, chest pain, fast or shallow breathing). One study demonstrates that thoracic endometriosis has been reported since earlier than 1968! There are also links for further information as well as to a facebook group for extra pelvic endometriosis.

Studies:

 “Conclusion: The diagnosis and management of thoracic endometriosis requires a multidisciplinary approach, based upon skillful differential diagnosis, and involving careful gynecologic evaluation and assessment of the cyclicity of pulmonary symptoms. Imaging findings are non-specific, though there may be laterality towards the right lung. Since symptom recurrence is more common in those with presenting with pneumothorax, post-operative adjuvant medical therapy is recommended.

“…Thoracic endometriosis is defined as the presence of ectopic endometrial tissue inside the thoracic cavity [8]. It usually presents with pneumothorax, hemothorax, hemoptysis, lung nodules, isolated chest pain or pneumomediastinum; symptoms are synchronized with the menstrual cycle [5]. A pneumothorax occurring between 24 hours before and 72 hours after the onset of menstruation is described as “catamenial.” Although this may include primary spontaneous pneumothorax, occurring coincidently during the perimenstrual period, the majority of recurrent episodes of catamenial pneumothorax are caused by thoracic endometriosis. It is encountered in 20% to 30% of women with spontaneous pneumothorax [9].”

“Catamenial pneumothorax (CP) is generally caused by intraperitoneal air leaking from the uterus into the thoracic cavity via a defect in the endometrial tissue of the diaphragm and is usually detected in the right thorax. We report a case of left-sided CP caused by endometriosis in the visceral pleura and with no abnormal findings in the diaphragm. A 33-year-old female patient presented at the end of a course of low-dose contraceptive pills for pelvic endometriosis, with spontaneous pneumothorax in the left chest. Chest CT revealed a bulla in the left upper lung lobe.”

“Thoracic endometriosis syndrome is a rare disorder characterised by the presence of functioning endometrial tissue in pleura, lung parenchyma, airways, and/or encompasses mainly four clinical entities–catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and lung nodules. The cases were studied retrospectively by reviewing the records at Amrita Institute of Medical Sciences, for duration of five years i.e., form March 2010-2014 and analysed for the clinical presentation and management of thoracic endometriosis syndrome. Catamenial breathlessness was the main symptom. Pneumothorax and pleural effusion were the findings on investigations. Histopathology report of endometriosis was present in three cases (50%). Conditions with excess oestrogen like endometriosis, fibroid, adenomyosis were diagnosed in these patients by pelvic scan. After the initial supportive treatment with hormones, pleurodesis, hysterectomy and lung decortication were the treatment modalities. Two cases that had multiple recurrences were diagnosed as disseminated TES. They underwent combined treatment of surgery and hormones.”

“A total of 21 patients were retrieved, 15 of which were eligible for inclusion. Of these 15, 8 patients were diagnosed with thoracic endometriosis with hemoptysis as their chief complaint, and 7 patients presented with pneumothorax. The median age was 35 years (range, 23–48 years). All patients displayed some degree of catamenial symptoms, although patterns differed; some patients reported symptoms with every cycle of menstrual bleeding (n=7), whereas others showed only occasional episodes during menstruation (n=8). Patients had experienced between 1 and 7 catamenial episodes before presenting for medical advice. None of the 15 patients were smokers; 1 patient had a history of asthma, and 2 patients presenting with catamenial hemoptysis had histories of empirical tuberculosis medication-use prior to being diagnosed with thoracic endometriosis. Three patients had previously undergone video-assisted thoracoscopic surgery (VATS), undertaken at other centers, following which they had not been diagnosed with thoracic endometriosis. In 1 patient with a history of pneumothorax (P12), the episode occurred on the contralateral side to the presence of endometriotic lesions and the underlying etiology was considered equivocal.”

“A 25-yr-old Caucasian woman was referred by her GP with a 3 yr history of right shoulder pain. The shoulder pain frequently occurred at the start of menses and was responsive to ibuprofen. Clinical examination, shoulder radiographs and blood tests (CRP, rheumatoid factor) were all normal. The MRI of the shoulder and right hemi-diaphragm showed small areas of high signal on T1, T2 and STIR sequences at the lateral right hemi-diaphragm, consistent with areas of recent haemorrhage, suggestive of ectopic endometrial tissue ( Fig. 1 ). Positive identification and ablation of the endometrial tissue by laparoscopy was thought to be a low-yield procedure so the patient commenced the continuous progestogen—only pill which caused amenorrhoea and resolution of her symptoms.”

“A 54-year-old woman, born in Hungary but living in Australia during the past eight years, was found on mass miniature radiography to have a shadow in the right lung and was referred for further investigation. She gave a history of exertional dyspnoea for the past few years, during which she had gained weight….There was no history of cough, haemoptysis, or chest pain. She had had two uncomplicated pregnancies, 35 and 14 years previously, and her menopause had occurred in 1964 with no subsequent bleeding. She gave no history of any operation or serious illness. INVESTIGATION A radiograph of the chest (Fig. I) showed a thin-walled cystic lesion in the right midzone with a little irregularity of the lower wall of the cyst.”

Links:

3 years ago Symptoms No comment

Infertility links

Some have fertility questions and concerns. Out of respect for all our members, we’ve compiled this list of online resources that those who are trying to conceive, who have conceived, or who have had children may find helpful. Please note that we are not able to judge how accurate the information in these groups is; that’s beyond our scope. We’ve just tried to point you in a direction that might be helpful to you.

Links:

3 years ago Symptoms No comment

Fertility Issues

Infertility is strongly associated with endometriosis, and for some it may be the only symptom that they recognize (American Pregnancy Association, 2012). An estimated 30–50% of women with endometriosis have infertility (Macer & Taylor, 2012). Endometriosis can be “minimal” and does not have to be an advanced stage for it to affect fertility (Bloski & Pierson, 2008).

We have collected a few links and articles that address endometriosis and infertility that you can explore and better educate yourself to discuss with your providers. Infertility is a difficult journey that is highly individualized. There is no one correct answer. 

Links/Resources:

Studies:

“The association between endometriosis and infertility is well supported throughout the literature, but a definite cause-effect relationship is still controversial. The prevalence of endometriosis increases dramatically to as high as 25%–50% in women with infertility and 30–50% of women with endometriosis have infertility (2)…. Endometriosis affects gametes and embryos, the fallopian tubes and embryo transport, and the eutopic endometrium; these abnormalities likely all impact fertility. Current treatment options of endometriosis-associated infertility include surgery, superovulation with IUI, and IVF.”

“Endometriosis was associated with a greater risk of pregnancy loss (spontaneous abortion: RR 1.40, 95% CI 1.31–1.49; ectopic pregnancy: RR 1.46, 95% CI 1.19–1.80). Endometriosis was also associated with a greater risk of GDM (RR 1.35, 95% CI 1.11–1.63) and hypertensive disorders of pregnancy (RR 1.30, 95% CI 1.16–1.45).”

“Results showed that the prevalence of high uNK cells was 33.1%. Prednisolone significantly decreased the uNK cell concentration (P < 0.001), however reduction to normal limits was achieved in only 48.3% of patients. There was no difference in any of the pregnancy outcomes or complications between women who had received prednisolone and those who had not. In conclusion, this study showed a relatively high prevalence of raised uNK cells in women with recurrent reproductive failure and confirmed the effect of prednisolone on reducing uNK cell concentrations. We found however no evidence for a significant beneficial effect for prednisolone therapy on pregnancy outcomes. Until the results of an adequately powered RCT become available however, these findings should be considered preliminary.”

“Results. In the study period, 355 women underwent surgery for stage III-IV endometriosis. Follow-up data are available for 253/355 (71%) women. Postoperatively, 142/253 (56%) women attempted to conceive with a conception rate of 104/142 (73%). Confidence intervals for pregnancy for women who were attempting conception (including the nonresponders) range from 104/262 (40%) to 224/262 (85%). Median time to conception was 12 months….Conclusions. These data provide information to women with suspected severe disease preoperatively concerning their likely postoperative fertility outcomes. Ours is a population with severe endometriosis, rather than an infertile population with endometriosis, so caution needs to be applied when applying these data to women with fertility issues alone.”

  • Pantou, A., Simopoulou, M., Sfakianoudis, K., Giannelou, P., Rapani, A., Maziotis, E., … & Koutsilieris, M. (2019). The Role of Laparoscopic Investigation in Enabling Natural Conception and Avoiding in vitro Fertilization Overuse for Infertile Patients of Unidentified Aetiology and Recurrent Implantation Failure Following in vitro Fertilization. Journal of clinical medicine, 8(4), 548. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6517944/pdf/jcm-08-00548.pdf 

“In conclusion, laparoscopy appears to be a promising approach, addressing infertility, providing significant diagnostic findings, while avoiding IVF overuse regarding patients of unidentified infertility presenting with recurrent failed IVF attempts.” 

  • Young, K., Kirkman, M., Holton, S., Rowe, H., & Fisher, J. (2018). Fertility experiences in women reporting endometriosis: findings from the understanding fertility management in contemporary Australia survey. The European Journal of Contraception & Reproductive Health Care, 23(6), 434-440. Retrieved from https://pubmed.ncbi.nlm.nih.gov/30481080/ 

“Results: While individual contraceptive use did not differ by endometriosis status, avoiding pregnancy was less important to women reporting endometriosis (50.5%) than to others (68.7%; p < .001). Women reporting endometriosis were approximately three times more likely to report an infertility diagnosis-the majority (39.7%) of which were ‘unexplained female or male infertility’-(p < .001) and six times more likely to report taking longer than 12 months to conceive than those who did not report endometriosis (p < .001). Although more women reporting a diagnosis of endometriosis also reported never having been pregnant (11.9%) than those who did not report a diagnosis (6.0%), this difference was not statistically significant (p = .060). There were also no endometriosis-associated differences in women’s reports of unintended pregnancy, abortion, having been pregnant, or having had a live birth. Conclusions: Our findings counter the common assertion that women with endometriosis are unlikely to conceive, and support the need for health care and information that addresses all aspects of fertility management (not just infertility) for women with endometriosis.”

“Treatment of endometriosis may prevent a number of associated complications of pregnancy, as discussed by Zullo et al. There are numerous theories regarding the pathophysiology of adverse pregnancy outcomes associated with endometriosis. They may be due to a proinflammatory environment with high levels of cytokine production as well as changes to the inner myometrium referred to as the “junctional zone.” Complications include preterm birth, placenta previa, small for gestational age, cesarean section, and miscarriage (1). Other rarer complications of endometriosis in pregnancy also have been described: spontaneous hemoperitoneum in pregnancy, obstetrical hemorrhage, bowel perforation, and appendiceal rupture. Although many endometriomas regress during pregnancy owing to progestational effects, there have been cases of endometrioma rupture and abscess formation. These complications are associated with significant maternal and fetal morbidity and potential mortality. It is not known if endometriosis is the cause of these complications or merely a marker of an independent risk factor, and no studies have evaluated if antepartum treatment of endometriosis or endometrioma improves pregnancy outcomes. One study showed that subfertile women who conceived spontaneously were also at increased risk of pregnancy complications, such as antepartum hemorrhage, cesarean section, pregnancy-induced hypertension, preeclampsia, and very preterm birth. Further studies are needed to elucidate the true relationship between endometriosis and pregnancy complications.”

  • Dunselman, G. A. J., Vermeulen, N., Becker, C., Calhaz-Jorge, C., D’Hooghe, T., De Bie, B., … & Prentice, A. (2014). ESHRE guideline: management of women with endometriosis. Human reproduction, 29(3), 400-412. Retrieved from https://academic.oup.com/humrep/article/29/3/400/707776 

“Are hormonal therapies effective for infertility associated with endometriosis?

Suppression of ovarian function (by means of hormonal contraceptives, progestagens, GnRH analogues or danazol) to improve fertility in minimal to mild endometriosis is not effective and should not be offered for this indication alone. The published evidence does not comment on more severe disease (Hughes et al., 2007).

Is surgery effective for infertility associated with endometriosis?

In women with minimal to mild endometriosis, the evidence, summarised in a Cochrane review, shows that operative laparoscopy is more effective than diagnostic laparoscopy in improving ongoing pregnancy rates. The comparative effectiveness of different surgical techniques is less well studied (Nowroozi et al., 1987; Chang et al., 1997; Jacobson et al., 2010). In women with ovarian endometrioma receiving surgery for infertility or pain, excision of endometrioma capsule increases the spontaneous post-operative pregnancy rate when compared with drainage and electrocoagulation of the endometrioma wall (Hart et al., 2008).”

“The incidence of endometriosis is increasing. Particularly during pregnancy and labour, clinicians should be alert to possible endometriosis-associated complications or complications of previous endometriosis treatment, despite a low relative risk. In addition to an increased rate of early miscarriage, complications such as spontaneous bowel perforation, rupture of ovarian cysts, uterine rupture and intraabdominal bleeding from decidualised endometriosis lesions or previous surgery are described in the literature. Unfavourable neonatal outcomes have also been discussed. We report on an irreducible ovarian torsion in the 16th week of pregnancy following extensive endometriosis surgery, and an intraabdominal haemorrhage due to endometriosis of the bowel in the 29th week of pregnancy.”

  • Li, X., Zeng, C., Zhou, Y. F., Yang, H. X., Shang, J., Zhu, S. N., & Xue, Q. (2017). Endometriosis fertility index for predicting pregnancy after endometriosis surgery. Chinese medical journal, 130(16), 1932. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5555127/ 

“The EFI staging system is a 10-point scale system, which considers historical factors, age and length of infertility, and surgical factors, such as the least function score and the AFS score.[5] The second aim of this study was to identify the most significant influencing factor in the EFI system. To date, in women suffering from endometriosis-related infertility, it is difficult to decide when to perform surgical excision and/or fertility treatment. Barri et al.’s study[6] indicated that the highest PRs for women with endometriosis-related infertility are often achieved using a combination of surgery and assisted reproductive technology (ART). The method of combined surgery and ART can provide significantly higher PRs compared with using either of the two treatments alone.[6] Cook and Adamson[7] claimed that it is preferable to perform surgery first, if clinically indicated, and to perform ART if spontaneous pregnancy does not occur after 9–15 months. In 2010, a study[8] by Dominique also suggested that if couples could not conceive naturally for 6–18 months after surgery, they should undergo in vitro fertilization and embryo transfer (IVF-ET). The frequent use of IVF after failure to conceive addresses the issue on the most appropriate individual therapeutic strategy, particularly for couples whose fertility prognosis is radically different. On this basis, the final aim was to investigate the optimal time for IVF-ET after endometriosis surgery. Conclusions: The EFI is a reliable staging system to predict the spontaneous PR of patients. The least function score was the most influential factor to predict the spontaneous PR. Patients with an EFI score ≥5 after 12 months from surgery are recommended to receive IVF-ET to achieve a higher PR.”

  • Barra, F., Mikhail, E., Villegas-Echeverri, J. D., & Ferrero, S. (2020). Infertility in patients with bowel endometriosis. Best Practice & Research Clinical Obstetrics & Gynaecology. https://doi.org/10.1016/j.bpobgyn.2020.05.007 

“Conclusion: In the current literature, the spontaneous fertility of women affected by colorectal endometriosis has been investigated in a few studies [21]. However, it is difficult to clearly define how intestinal endometriosis impacts per se on infertility as this is often associated with other DE lesions involving the uterosacral ligaments, torus uterine, parametrium, vagina or with endometriomas. Besides, patients with colorectal endometriosis may also be affected by focal or diffuse adenomyosis that can also negatively impact per se fertility outcomes. Lastly, multiple other factors (such as age, ovarian reserve, and tubal patency) may influence postoperative fertility outcomes.”

References

American Pregnancy Association. (2012). Endometriosis. Retrieved from https://americanpregnancy.org/womens-health/endometriosis-70984/

Bloski, T., & Pierson, R. (2008). Endometriosis and chronic pelvic pain: unraveling the mystery behind this complex condition. Nursing for women’s health, 12(5), 382-395. doi: 10.1111/j.1751-486X.2008.00362.x

3 years ago Symptoms No comment

Response to a study on prostaglandins and bacterial growth in endometriosis

Study:

“Role of prostaglandin E2 in bacterial growth in women with endometriosis

Abstract

STUDY QUESTION Can prostaglandin E2 (PGE2) in menstrual and peritoneal fluid (PF) promote bacterial growth in women with endometriosis?

SUMMARY ANSWER PGE2 promotes bacterial growth in women with endometriosis.

WHAT IS KNOWN ALREADY Menstrual blood of women with endometriosis is highly contaminated with Escherichia coli (E. coli) compared with that of non-endometriotic women: E. coli-derived lipopolysaccharide (LPS) promotes the growth of endometriosis.

STUDY DESIGN, SIZE AND DURATION Case-controlled biological research with a prospective collection of body fluids and endometrial tissues from women with and without endometriosis with retrospective evaluation.

PARTICIPANTS/MATERIALS, SETTING AND METHODS PF and sera were collected from 58 women with endometriosis and 28 women without endometriosis in an academic research laboratory. Menstrual blood was collected from a proportion of these women. Macrophages (Mφ) from PF and stromal cells from eutopic endometria were isolated in primary culture. The exogenous effect of PGE2 on the replication of E. coli was examined in a bacterial culture system. Levels of PGE2 in different body fluids and in the culture media of Mφ and stromal cells were measured by ELISA. The effect of PGE2 on the growth of peripheral blood lymphocytes (PBLs) was examined.

MAIN RESULTS AND THE ROLE OF CHANCE The PGE2 level was 2–3 times higher in the menstrual fluid (MF) than in either sera or in PF. A significantly higher level of PGE2 was found in the MF and PF of women with endometriosis than in control women (P < 0.05 for each). Exogenous treatment with PGE2 dose dependently increased E. coli colony formation when compared with non-treated bacteria. PGE2-enriched MF was able to stimulate the growth of E. coli in a dilution-dependent manner; this effect was more significantly enhanced in women with endometriosis than in control women (P < 0.05). PGE2 levels in the culture media of LPS-treated Mφ/stromal cells were significantly higher in women with endometriosis than in non-endometriosis (P < 0.05 for each). Direct application of PGE2and culture media derived from endometrial Mφ or stromal cells significantly suppressed phytohemagglutinin-stimulated growth of PBLs.

LIMITATIONS AND REASONS FOR CAUTION Further studies are needed to examine the association between PGE2-stimulated growth of E. coli and endotoxin level and to investigate the possible occurrence of sub-clinical infection within vaginal cavity.

WIDER IMPLICATIONS OF THE FINDINGS Our findings may provide some new insights to understand the physiopathology or pathogenesis of the mysterious disease endometriosis and may hold new therapeutic potential.

STUDY FUNDING/COMPETING INTEREST(S) This work was supported by grants-in-aid for Scientific Research from the Ministry of Education, Sports, Culture, Science and Technology of Japan. There is no conflict of interest related to this study.”

Dr Redwine’s Response:

“Here is my interpretation of the study: prostaglandin E2 (PGE2) is a chemical produced by the body as part of the body’s inflammatory response. Women with endometriosis have chronic inflammation due to their disease – the inflammation may wax and wane with hormonal changes throughout the month – so women with endometriosis have more PGE2 production than women without endometriosis. PGE2 can be produced wherever there is inflammation, so in women with endometriosis, it is found in increased levels in the peritoneal fluid. PGE2 can also be found in increased levels in the uterus and in the menstrual fluid. It is possible that this increased level of PGE2 in the uterus and menstrual fluid may be a result of inflammation of the uterus due to something affecting it primarily (such as occult adenomyosis) or secondarily (such as widespread pelvic inflammation due to endometriosis). e coli bacteria are a normal inhabitant of the vagina in all women. Menstrual fluid passing through the vagina picks up the e coli which is normally there, so e coli can be cultured from the menstrual fluid. Women with endometriosis have been found to have a higher level of colonization of e coli in the menstrual fluid than women without endometriosis. This study sought to figure out why this occurs. Part of the answer may relate to increased levels of PGE2 in women with endometriosis. The investigators added PGE2 to e coli in a petri dish and found that this made the e coli grow more readily. Therefore, increased levels of PGE2 which occur as a normal response to inflammation may be the explanation for heavier growths of e coli in the menstrual fluid of women with endometriosis. The study says nothing about whether women with endometriosis are more prone to pelvic infections with e coli or any other bacterium than women without endometriosis. Pelvic infection in women with endometriosis is not common. However, there are occasional case reports of an infected endometrioma cyst of the ovary turning into an abscess. It is possible that increased PGE2 production may have played a role in such cases by promoting the growth of bacteria. Keep in mind that PGE2 is only one of several inflammatory chemicals produced in response to inflammation, so there may be some contribution by other inflammatory chemicals as well. Nothing about this study suggests that women with endometriosis have decrepit immune systems.”

3 years ago Symptoms No comment

Fatigue in Endometriosis

Fatigue is a symptom of endometriosis and can be quite debilitating (Ramin-Wright et al., 2018). Taber’s Medical Dictionary (n.d.) defines fatigue as “an overwhelming sustained feeling of exhaustion and diminished capacity for physical and mental work.” Fatigue with an illness often does not improve with rest (Louati & Berenbaum, 2015). Endometriosis is an inflammatory disorder, and this inflammation can lead to fatigue. Inflammatory molecules, such as prostaglandins, cytokines, etc., contribute to fatigue as well as problems with “sleep, cognition, anxiety, and depression” (Poon et al., 2015; Zielinski, Systrom, & Rose, 2019). Chronic low-grade inflammation can cause a reduction in energy on the cellular level (Lacourt et al., 2018). Inflammation can lead to pain, sleep problems, stress, and depression….which can lead to more inflammation. In addition, hormones, “mainly estradiol,” can “promote the expression and release of pro-inflammatory factors” (García-Gómez et al., 2020). Endometriosis lesions have shown higher estrogen receptors as well as progesterone resistance. Pain can lead to sleep problems, and sleep disorders can also cause more inflammation, leading to more pain and fatigue (Lacourt et al., 2018; Zielinski, Systrom, & Rose, 2019). On a good note: “melatonin therapy has been shown to attenuate inflammatory cytokines…thus could potentially be beneficial in combating fatigue” (Zielinski, Systrom, & Rose, 2019). Stress, even good stress, can take a toll on your body and mind. Chronic stress can lead to more inflammation which can contribute to feelings of fatigue (Zielinski, Systrom, & Rose, 2019). Inflammation can affect neurotransmitters which can affect both fatigue and mood (Zielinski, Systrom, & Rose, 2019).  Lee & Giuliani (2019) report that “depression and fatigue are associated with an increased activation of the immune system which may serve as a valid target for treatment.” They also note that “antidepressants have been shown to decrease inflammation” (Lee & Giuliani, 2019). So we see that many things can contribute to fatigue. Fatigue is difficult to treat, especially if the underlying cause is not addressed. Ramin-Wright et al. (2018) states that “as fatigue is experienced by numerous women with endometriosis, it needs to be addressed in the discussion of management and treatment of the disease. In addition to treating endometriosis, it would be beneficial to reduce insomnia, depression, pain and occupational stress in order to better manage fatigue.” It is also important to remember that fatigue is a symptom of many disorders, so do not automatically assume that endometriosis is the only cause of your fatigue- it’s important to rule out other causes too. Links: Prevalence: “…it has been shown that fatigue is one of the most intense and frequent symptoms (Hansen et al., 2013; Touboul et al., 2013) as well as the symptom with highest associated distress (Lemaire, 2004). The prevalence of fatigue is significantly higher in patients with endometriosis compared to the general female population (Sinaii et al., 2002). Conversely, women with chronic fatigue syndrome often report endometriosis in their gynecological history (Boneva et al., 2011). In addition, patients with endometriosis suffer more often from stress (Hansen et al., 2013; van Aken et al., 2018). The impact of fatigue is vast as women’s educational performance is affected as well as playing sports and social activities (Gilmour et al., 2008; Moradi et al., 2014). Although chronic fatigue is mentioned as one of the most debilitating symptoms of endometriosis, it is not widely known and discussed as such (Riazi et al., 2015)…. “In our study, the prevalence of frequent fatigue is more than doubled in women diagnosed with endometriosis compared to unaffected control women. Fatigue was associated with endometriosis, pain, insomnia, depression, and occupational stress. The association between endometriosis and frequent fatigue remained significant after controlling for the confounding effects of pain, insomnia, occupational stress, depression, BMI and motherhood. This finding supports an independent effect of endometriosis which cannot be attributed to disease symptoms. Our results show that endometriosis-related fatigue is a frequent symptom which should be addressed in medical care. While the current treatment and management of the disease focuses more on classic symptoms such as pain and infertility (Bernardi and Pavone, 2013; Dunselman et al., 2014; Vercellini et al., 2014), it is important to also address fatigue when treating patients with endometriosis.”
  • Boneva, R. S., Lin, J. M. S., Wieser, F., Nater, U. M., Ditzen, B., Taylor, R. N., & Unger, E. R. (2019). Endometriosis as a Comorbid Condition in Chronic Fatigue Syndrome (CFS): Secondary Analysis of Data From a CFS Case-Control Study. Frontiers in pediatrics, 7, 195. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31179251/ 
“We found more than a third of women with CFS reported endometriosis as a comorbid condition. The endometriosis comorbidity was associated with chronic pelvic pain, earlier menopause, hysterectomy, and more CFS-related symptoms. However, endometriosis in women with CFS did not appear to further impact functioning, fatigue, inflammatory markers, or other laboratory parameters.” Inflammation as a contributing factor:
  • Louati, K., & Berenbaum, F. (2015). Fatigue in chronic inflammation-a link to pain pathways. Arthritis research & therapy, 17(1), 1-10. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4593220/
“Fatigue is a frequent symptom in several inflammatory diseases, particularly in rheumatic diseases. Elements of disease activity and cognitive and behavior aspects have been reported as causes of fatigue in patients with rheumatoid arthritis. Fatigue could be associated with activity of inflammatory rheumatism. Indeed, biologic agents targeting inflammatory cytokines are effective in fatigue. Fatigue is also associated with pain and depressive symptoms. Different pathways could be involved in fatigue and interact: the immune system with increased levels of pro-inflammatory cytokines (interleukin-1 and −6 and tumor necrosis factor alpha), dysregulation of the hypothalamic-pituitary-adrenal axis and neurological phenomena involving the central and autonomic nervous systems. A pro-inflammatory process could be involved in pain and behavioral symptoms. Inflammation could be a common link between fatigue, pain, and depression.” “Chronic pain and fatigue often occur together — as many as three in four people with chronic, widespread musculoskeletal pain report having fatigue; and as many as 94 percent of people with chronic fatigue syndromes report muscle pain. Women make up the majority of patients with these conditions…”The differences in fatigue between males and females depends on both the presence of testosterone and the activation of ASIC3 channels, which suggests that they are interacting somehow to protect against fatigue,” Sluka said. “These differences may help explain some of the underlying differences we see in chronic pain conditions that include fatigue with respect to the predominance of women over men.”  Estrogen can potentiate the action of ASICs. 
  • Qu, Z. W., Liu, T. T., Ren, C., Gan, X., Qiu, C. Y., Ren, P., … & Hu, W. P. (2015). 17β-Estradiol enhances ASIC activity in primary sensory neurons to produce sex difference in acidosis-induced nociception. Endocrinology, 156(12), 4660-4671. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26441237/ 
“E2 potentiated ASIC currents via an ERα and ERK1/2 signaling pathway. E2 also altered acidosis-evoked membrane excitability of dorsal root ganglia neurons and caused a significant increase in the amplitude of the depolarization and the number of spikes induced by acidic stimuli. E2 potentiation of the functional activity of ASICs revealed a peripheral mechanism underlying this sex difference in acetic acid-induced nociception.”   Treatment: This study, while older, measured quality of life (which included fatigue) before and after treatment with laparoscopic excision.  “Patients with endometriosis were severely ill with significant pain and impairment of quality of life and sexual activity. Four months after radical laparoscopic excision for deep endometriosis there was significant improvement in all the parameters measured including their quality of life based on EuroQOL evaluation: EQ-SD (0.595:0.729, P = 0.002) and EQ thermometer (68.9:77-7, P = 0.008); SF12 physical score (44.8:51.9, P = 0.015); sexual activity (habit P = 0.002, pleasure P = 0-002 and discomfort P IO.001).”

References

García-Gómez, E., Vázquez-Martínez, E. R., Reyes-Mayoral, C., Cruz-Orozco, O. P., Camacho-Arroyo, I., & Cerbón, M. (2020). Regulation of inflammation pathways and inflammasome by sex steroid hormones in endometriosis. Frontiers in endocrinology, 10, 935. Retrieved from https://doi.org/10.3389/fendo.2019.00935 Lacourt, T. E., Vichaya, E. G., Chiu, G. S., Dantzer, R., & Heijnen, C. J. (2018). The high costs of low-grade inflammation: persistent fatigue as a consequence of reduced cellular-energy availability and non-adaptive energy expenditure. Frontiers in behavioral neuroscience, 12, 78. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5932180/#:~:text=We%20propose%20that%20chronic%20low,rapid%20generation%20of%20cellular%20energy. Lee, C. H., & Giuliani, F. (2019). The role of inflammation in depression and fatigue. Frontiers in immunology, 10, 1696. Retrieved from https://doi.org/10.3389/fimmu.2019.01696 Louati, K., & Berenbaum, F. (2015). Fatigue in chronic inflammation-a link to pain pathways. Arthritis research & therapy, 17(1), 1-10. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4593220/ Poon, D. C. H., Ho, Y. S., Chiu, K., Wong, H. L., & Chang, R. C. C. (2015). Sickness: From the focus on cytokines, prostaglandins, and complement factors to the perspectives of neurons. Neuroscience & biobehavioral reviews, 57, 30-45. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0149763415002006 Ramin-Wright, A., Schwartz, A. S. K., Geraedts, K., Rauchfuss, M., Wölfler, M. M., Haeberlin, F., … & Leeners, B. (2018). Fatigue–a symptom in endometriosis. Human reproduction, 33(8), 1459-1465. Retrieved from https://academic.oup.com/humrep/article/33/8/1459/5040620?login=true Taber’s Medical Dictionary. (n.d.). Fatigue. Retrieved from https://www.tabers.com/tabersonline/view/Tabers-Dictionary/757231/all/fatigue Zielinski, M. R., Systrom, D. M., & Rose, N. R. (2019). Fatigue, sleep, and autoimmune and related disorders. Frontiers in immunology, 10, 1827. Retrieved from https://doi.org/10.3389/fimmu.2019.01827
3 years ago Symptoms No comment

Inflammatory markers and endometriosis (CRP and CA-125)

Endometriosis is an inflammatory disease, so a lot of people have questions about blood tests that look at inflammation. Remember, all these tests might be an indication of endometriosis, but they are very nonspecific. The only way to definitively diagnose endometriosis is through surgery. 

What is C-Reactive Protein (CRP)?

“C-reactive protein (CRP) is an acute inflammatory protein that increases up to 1,000-fold at sites of infection or inflammation….Having been traditionally utilized as a marker of infection and cardiovascular events, there is now growing evidence that CRP plays important roles in inflammatory processes and host responses to infection including the complement pathway, apoptosis, phagocytosis, nitric oxide (NO) release, and the production of cytokines, particularly interleukin-6 and tumor necrosis factor-α….There are many factors that can alter baseline CRP levels including age, gender, smoking status, weight, lipid levels, and blood pressure (13). The average levels of CRP in serum in a healthy Caucasian is around 0.8 mg/L, but this baseline can vary greatly in individuals due to other factors, including polymorphisms in the CRP gene (14)…. C-reactive protein levels are known to increase dramatically in response to injury, infection, and inflammation (Figure  1). CRP is mainly classed as an acute marker of inflammation, but research is starting to indicate important roles that CRP plays in inflammation.”

So what does this have to do with endometriosis?

Endometriosis is an inflammatory disease, so one might expect the markers to be high. But this does not necessarily show in blood tests:

  • Kianpour, M., Nematbakhsh, M., & Ahmadi, S. M. (2012). C-reactive protein of serum and peritoneal fluid in endometriosis. Iranian journal of nursing and midwifery research, 17(2 Suppl1), S115. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3696960/ 

“Findings: There was no significant difference between the CRP serum level in patients with endometriosis and infertile women without endometriosis. There was a significant difference in peritoneal level of CRP between case and control groups (p < 0.05). Conclusions: The findings suggested that measurement of this marker in patients’ serum or plasma cannot be used to diagnose endometriosis. It is further recommended that a combination of different markers might be helpful in this regard that could be studied in future.”

So we may not see an increase in the blood test, but there is a difference in the peritoneal (from the abdomen/pelvis) samples:

  • Kianpour, M., Nematbakhsh, M., & Ahmadi, S. M. (2012). C-reactive protein of serum and peritoneal fluid in endometriosis. Iranian journal of nursing and midwifery research, 17(2 Suppl1), S115. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3696960/

“Compared to the control group, the CRP level of the peritoneal fluid were higher in patients with endometriosis (p<0.05). Pelvic endometriosis is a chronic inflammatory disease that is in association with a general inflammatory response in the peritoneal cavity.[34,35] This disease is known to have an immunological background.[36] Macrophage constitutes 82- 99% of the all the cell population of peritoneal fluid.[37–39] Literature has repeatedly reported an increase of total peritoneal fluid cell numbers, cell concentration and macrophages in endometriosis patients in compare to the control.[40–43] The study of Dunselman et al. also confirmed that there is an increase in the number and concentration of peritoneal cells in patients with endometriosis as compared to the control group.[38]” 

What is CA-125?

It’s a test that looks at markers for certain cancers, but if your doctor orders it and it’s high, don’t let it scare you. “…many noncancerous conditions can increase the CA 125 level. Many different conditions can cause an increase in CA 125, including normal conditions, such as menstruation, and noncancerous conditions, such as uterine fibroids” (Mayo Clinic, n.d.). 

Reference

Mayo Clinic. (n.d.). CA-125 test. Retrieved from http://www.mayoclinic.org/tests-procedures/ca-125-test/basics/definition/prc-20009524 

It can also be high in people with endometriosis: 

  • May, K. E., Conduit-Hulbert, S. A., Villar, J., Kirtley, S., Kennedy, S. H., & Becker, C. M. (2010). Peripheral biomarkers of endometriosis: a systematic review. Human reproduction update, 16(6), 651-674. Retrieved from http://humupd.oxfordjournals.org/content/16/6/651.full

“Studies published since continue to demonstrate a correlation between raised CA125 levels and endometriosis (Abrao et al., 1999; Somigliana et al., 2004; Agic et al., 2008; Seeber et al., 2008), and some imply a correlation with stage of disease (Chen et al., 1998; Amaral et al., 2006; Martinez et al., 2007; Rosa e Silva et al., 2007). One study has indicated that CA125 may be more accurate at diagnosing women with later stages of disease (Maiorana et al., 2007).”  

For more on peripheral biomarkers of endometriosis see:

May, K. E., Conduit-Hulbert, S. A., Villar, J., Kirtley, S., Kennedy, S. H., & Becker, C. M. (2010). Peripheral biomarkers of endometriosis: a systematic review. Human reproduction update, 16(6), 651-674. Retrieved from http://humupd.oxfordjournals.org/content/16/6/651.full 

3 years ago Symptoms No comment

Inflammation with endometriosis

Endometriosis is an inflammatory disorder. Inflammation involves a variety of inflammatory factors, such as cytokines, prostaglandins, macrophages, and tumor necrosis factor. Inflammation is influenced by hormones; however, hormone receptors are altered in endometriosis lesions, thus changing the way endometriosis responds to hormones. Inflammation can lead to increased pain, fatigue, and general feelings of unwellness. Sometimes this inflammation can be seen in blood tests, but not always. 

Inflammatory Mediators: 

 “It has long been acknowledged by both researchers and clinicians that endometriosis is a disease associated with inflammation and elevated cytokine levels 2,3. Altered cytokine production by both cells of the immune system and the endometriotic lesion tissue has been proposed (discussed below for each of the specified cytokines) to contribute to these elevated cytokine levels. One of the driving factors for the enhanced production of endometriotic lesion cytokines is an altered progesterone responsiveness associated with the disease. Progesterone exhibits anti-inflammatory actions, and as such, progesterone analogs have been used to treat endometriosis and its associated symptoms 4. Progestin (progesterone) treatment appears to be successful in most 5, but not all 6, women, and not all progestin formulations are effective in reducing endometriosis-associated pain 7. This inconsistency could be due to the progesterone resistance typical of endometriosis which may stem from altered progesterone receptor expression 8.”

  • Monsanto, S. P., Edwards, A. K., Zhou, J., Nagarkatti, P., Nagarkatti, M., Young, S. L., … & Tayade, C. (2016). Surgical removal of endometriotic lesions alters local and systemic proinflammatory cytokines in endometriosis patients. Fertility and sterility, 105(4), 968-977. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26698677 

“Endometriotic lesion removal significantly alters the inflammatory profile both locally and systemically in women with endometriosis. Our findings indicate that ectopic lesions are the major drivers of systemic inflammation in endometriosis.”  

Mast Cells:

Mast cells are immune system cells that can stimulate inflammation (Graziottin, Skaper, & Fusco, 2014). Endometriosis is an inflammatory disease, and degranulating mast cells have been found in higher quantities in endometriosis lesions versus normal tissue (Hart, 2015; Indraccolo & Barbieri, 2010). Estrogen seems to stimulate mast cells to support the inflammatory process (Zhu et al., 2018). In fact, one study reported estrogen receptors are expressed on mast cells (although the action of estrogen on the mast cell is not described) (Hart, 2015). While many therapies for endometriosis involve lowering estrogen production by the feedback loop between the brain and the ovaries, it should be remembered that endometriosis lesions demonstrate production of estrogen themselves (and also show resistance to progesterone) (Delvoux et al., 2009). The inflammation created can lead to pain (Indraccolo & Barbieri, 2010).

*When looking at studies, it is important to keep in mind the aim of the study. Many are looking for novel drug development or therapies. However, they can still shed light on how endometriosis behaves and why it produces the symptoms and effects it does.

  • Indraccolo, U., & Barbieri, F. (2010). Effect of palmitoylethanolamide–polydatin combination on chronic pelvic pain associated with endometriosis: Preliminary observations. European Journal of Obstetrics & Gynecology and Reproductive Biology, 150(1), 76-79. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0301211510000424

“Inflammation can be considered one of the major causes of pain in endometriosis. In particular, degranulating mast cells have been found in significantly greater quantities in endometriotic lesions than in unaffected tissues. The increase in activated and degranulating mast cells is closely associated with nerve structures in painful endometriotic lesions. These observations indicate that inflammation due to mast cells may contribute to the development of pain and hyperalgesia in endometriosis.”

“A second disease/condition that also appears to involve neuroinflammation with mast cell involvement is endometriosis (EMS). EMS is clearly an estrogen-dependent chronic inflammatory disorder….Interestingly, peritoneal fluid from patients with EMS contains higher levels of some cytokines than those without this condition (e.g., MCP-1 and IL-8 [96])…. Mast cells are prominent in EMS tissue but whether their role(s) in EMS development and progression are central to the disease or peripheral with mast cells being drawn to the site of lesions is still being debated (discussed in [109])….Degranulated mast cells have been detected in EMS lesions [111] and activated mast cells implicated in the associated fibrosis [112]. Furthermore, mast cells have been reported to express estrogen receptors and thus should be responsive to the sex hormones [113]. In fact, estrogen has been reported to result in mast cell activation with release of mediators, in part due to interactions with ER-alpha [113]. Furthermore, mast cells in EMS lesions are commonly found in close approximation to neural elements in such lesions (discussed in [109, 114]). Such close approximation of these two elements in lesions is somewhat supportive of the concept of active neuroinflammation and pain in EMS [115] and is analogous to what we have observed in abnormal skin wound healing and joint contraction models previously that were responsive to mast cell stabilizer interventions [13, 16, 17].”

“Mast cells are immune cells now viewed as cellular sensors in inflammation and immunity. When stimulated, mast cells release an array of mediators to orchestrate an inflammatory response. These mediators can directly initiate tissue responses on resident cells, and may also regulate the activity of other immune cells, including central microglia. New evidence supports the involvement of peripheral and central mast cells in the development of pain processes as well as in the transition from acute, to chronic and neuropathic pain. That behavioral and endocrine states can increase the number and activation of peripheral and brain mast cells suggests that mast cells represent the immune cells that peripherally and centrally coordinate inflammatory processes in neuropsychiatric diseases such as depression and anxiety which are associated with chronic pelvic pain. Given that increasing evidence supports the activated mast cell as a director of common inflammatory pathways/mechanisms contributing to chronic and neuropathic pelvic pain and comorbid neuropsychiatric diseases, mast cells may be considered a viable target for the multifactorial management of both pain and depression.”

Chronic Inflammation causes unwell feeling and depression: This inflammation often gives rise to a general unwell feeling:

  • Elenkov, I. J., Iezzoni, D. G., Daly, A., Harris, A. G., & Chrousos, G. P. (2005). Cytokine dysregulation, inflammation and well-being. Neuroimmunomodulation, 12(5), 255-269. Retrieved from https://pubmed.ncbi.nlm.nih.gov/16166805/ 

“Complex interactions exist between cytokines, inflammation and the adaptive responses in maintaining homeostasis , health, and well-being. Like the stress response, the inflammatory reaction is crucial for survival and is meant to be tailored to the stimulus and time. A full-fledged systemic inflammatory reaction results in stimulation of four major programs: the acute phase reaction, the sickness syndrome, the pain program, and the stress response, mediated by the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. Common human diseases such as atopy/allergy, autoimmunity, chronic infections and sepsis are characterized by a dysregulation of the pro- versus anti-inflammatory and T helper (Th)1versus Th2 cytokine balance. Recent evidence also indicates the involvement of pro-inflammatory cytokines in the pathogenesis of atherosclerosis and major depression, and conditions such as visceral-type obesity, metabolic syndrome and sleep disturbances. During inflammation, the activation of the stress system, through induction of a Th2 shift, protects the organism from systemic ‘overshooting’ with Th1/pro-inflammatory cytokines. Under certain conditions, however, stress hormones may actually facilitate inflammation through induction of interleukin (IL)-1, IL-6, IL-8, IL-18, tumor necrosis factor- and C-reactive protein production and through activation of the corticotropin releasing hormone/substance P-histamine axis. Thus, a dysfunctional neuroendocrine-immune interface associate with abnormalities of the systemic anti-inflammatory feedback’ and/or ‘hyperactivity’ of the local pro-inflammatory factors may play a role in the pathogenesis of atopic/allergic and autoimmune diseases, obesity, depression, and atherosclerosis. These abnormalities and the failure of the adaptive systems to resolve inflammation affect the well-being of the individual, including behavioral parameters, quality of life and sleep, as well as indices of metabolic and cardiovascular health. These hypotheses require further investigation, but the answers should provide critical insights into mechanisms underlying a variety of common human immune-related diseases.”  

  • Dantzer, R., O’Connor, J. C., Freund, G. G., Johnson, R. W., & Kelley, K. W. (2008). From inflammation to sickness and depression: when the immune system subjugates the brain. Nature reviews neuroscience, 9(1), 46-56. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2919277/ 

“Anyone who has experienced a viral or bacterial infection knows what it means to feel sick. The behaviour of sick people changes dramatically; they often feel feverish and nauseated, ignore food and beverages, and lose interest in their physical and social environments. They tire easily and their sleep is often fragmented. In addition, they feel depressed and irritable, and can experience mild cognitive disorders ranging from impaired attention to difficulties in remembering recent events. Despite their negative impact on well-being, these symptoms of sickness are usually ignored. They are viewed as uncomfortable but banal components of infections1. Sickness is a normal response to infection, just as fear is normal in the face of a predator. It is characterized by endocrine, autonomic and behavioural changes and is triggered by soluble mediators that are produced at the site of infection by activated accessory immune cells. These mediators are known as pro-inflammatory cytokines, and include interleukin-1α and β (IL-1α and IL-1β), tumour necrosis factor-α (TNF-α) and interleukin-6 (IL-6). They coordinate the local and systemic inflammatory response to microbial pathogens. However, these peripherally produced cytokines also act on the brain to cause the aforementioned behavioural symptoms of sickness. Recently, it has been suggested that ‘sickness behaviour’2,3, a term used to describe the drastic changes in subjective experience and behaviour that occur in physically ill patients and animals, is an expression of a previously unrecognized motivational state. It is responsible for re-organizing perceptions and actions to enable ill individuals to cope better with an infection4. During the last five years, it has been established that pro-inflammatory cytokines induce not only symptoms of sickness, but also true major depressive disorders in physically ill patients with no previous history of mental disorders. Some of the mechanisms that might be responsible for inflammation-mediated sickness and depression have now been elucidated. These findings suggest that the brain–cytokine system, which is in essence a diffuse system, is the unsuspected conductor of the ensemble of neuronal circuits and neurotransmitters that organize physiological and pathological behavior….” 

References

Delvoux, B., Groothuis, P., D’Hooghe, T., Kyama, C., Dunselman, G., & Romano, A. (2009). Increased production of 17β-estradiol in endometriosis lesions is the result of impaired metabolism. The Journal of Clinical Endocrinology & Metabolism, 94(3), 876-883. Retrieved from https://academic.oup.com/jcem/article/94/3/876/2596530

Graziottin, A., Skaper, S. D., & Fusco, M. (2014). Mast cells in chronic inflammation, pelvic pain and depression in women. Gynecological Endocrinology, 30(7), 472-477. Retrieved from https://www.tandfonline.com/doi/abs/10.3109/09513590.2014.911280

Hart, D. A. (2015). Curbing inflammation in multiple sclerosis and endometriosis: should mast cells be targeted?. International journal of inflammation, 2015. Retrieved from https://www.hindawi.com/journals/iji/2015/452095/

Indraccolo, U., & Barbieri, F. (2010). Effect of palmitoylethanolamide–polydatin combination on chronic pelvic pain associated with endometriosis: Preliminary observations. European Journal of Obstetrics & Gynecology and Reproductive Biology, 150(1), 76-79. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0301211510000424

Zhu, T. H., Ding, S. J., Li, T. T., Zhu, L. B., Huang, X. F., & Zhang, X. M. (2018). Estrogen is an important mediator of mast cell activation in ovarian endometriomas. Reproduction, 155(1), 73-83. Retrieved from https://rep.bioscientifica.com/view/journals/rep/155/1/REP-17-0457.xml

3 years ago Symptoms No comment

Bowel/GI endometriosis

Gastrointestinal (GI) symptoms are common with endometriosis, anywhere from one third to up to 85% of endometriosis patients have GI symptoms, usually with a gradual onset (Aragon & Lessey, 2017; Ek et al., 2015). Of those with GI symptoms, the location of endometriosis lesions weren’t necessarily on the bowel itself (Ek et al., 2015).  Women with endometriosis are often diagnosed with irritable bowel syndrome (IBS); but one study noted that when those individuals have surgery for endometriosis, the individuals had endometriosis lesions on or near the rectum or in the pouch of Douglas (posterior cul-de-sac) and had generally minimal or mild disease (Aragon & Lessey, 2017). The symptoms are attributed to the inflammatory process from endometriosis (Aragon & Lessey, 2017)

The incidence of endometriosis on the bowel itself ranges from 5% to 12% of those with endometriosis, most often seen on the rectum and sigmoid colon  (Habib et al., 2020). Those with lesions on or close to the bowel did have more nausea and vomiting (Ek et al., 2015). Other reported symptoms include “a myriad of symptoms such as alteration in bowel habits (constipation/diarrhoea), dyschezia, dysmenorrhoea and dyspareunia in addition to infertility” (Habib et al., 2020, para. 1). Bowel endometriosis is associated with lesions on the uterosacral ligaments  and vaginal wall, which can cause painful penetration (Habib et al., 2020). Treatments for endometriosis that actually worsened GI symptoms included opioids and GnRH analogs (Ek et al., 2015). 

While hormonal medications have been shown to help relieve symptoms, it may not stop the progression of the disease which can lead, in severe cases, to bowel obstruction; therefore, it is recommended that close follow-up be utilized if you do not choose surgical treatment (Habib et al., 2020; Ferrero et al., 2011). If you think you might have bowel involvement, it is important to find the right care. The success of surgery depends on the skills and experience of the surgeon and a multidisciplinary team. It is recommended that “surgery should be performed by experienced surgeons, in centres with access to multidisciplinary care” (Habib et al., 2020, para. 1). Before committing to surgery, you want to know how they remove endometriosis; how often do they perform this surgery; does the surgeon have the advanced knowledge/surgical skills to address all disease in all locations (bowel, bladder, near ureters, culs de sac, uterine ligaments, etc.). Learning what questions to ask and choosing the right surgeon can make all the difference.

When working up symptoms of the bowel, many doctors may suggest a colonoscopy, which can rule out other problems such as colitis, polyps, diverticulosis or diverticulitis. However, in one study, a colonoscopy did not diagnose intestinal endometriosis in 92% of the patients and the authors conclude that a colonoscopy “should not be routinely performed in the diagnostic work-up of bowel endometriosis” (Milone et al., 2015, para. 4). Bowel endometriosis is treatable, without full laparotomy and without colostomy (Tarjanne, Heikinheimo, Mentula, & Härkki, 2015).

*Dyschezia- excessive straining with stools, dysmenorrhoea- pain with menstruation, dyspareunia- painful intercourse

Gastrointestinal (GI) Disease: 

Links:

Studies:

  • Rectosigmoid Endometriosis Surgery: Moawad, N. S., Guido, R., Ramanathan, R., Mansuria, S., & Lee, T. (2011). Comparison of laparoscopic anterior discoid resection and laparoscopic low anterior resection of deep infiltrating rectosigmoid endometriosis. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 15(3), 331. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183552/

“…patients often present with severe symptoms, such as dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain, along with a spectrum of bowel symptoms like diarrhea, constipation, bloating, or cyclic rectal bleeding. The triad of dysmenorrhea, dyspareunia, and bowel symptoms was found to be 80% sensitive for diagnosing bowel endometriosis.1,6–8 Multifocal bowel involvement is common, affecting 25% to 34% of patients.2,9

“Although medical and hormonal therapy have been found to be effective for improving the pain symptoms associated with rectal endometriosis, the relief is usually transient and symptoms generally recur once medical therapy is discontinued.10 Due to persistent or recurrent pain, and the marked anatomic distortion caused by deep infiltrating rectovaginal endometriosis, surgery is considered the treatment of choice for symptomatic disease.11 Moreover, surgery is mandatory in severe cases of rectovaginal nodules that result in luminal stenosis and obstructive symptoms.12

“Multiple studies suggest that complete excision of endometriotic lesions, including bowel resection when necessary, results in significant improvement in pain, as well as improvement in bowel symptoms and quality of life.9,13–15.”

“Bowel endometriosis affects between 3.8% and 37% of women with endometriosis. The evaluation of symptoms and clinical examination are inadequate for an accurate diagnosis of intestinal endometriosis. Transvaginal ultrasonography is the first line investigation in patients with suspected bowel endometriosis and allows accurate determination of the presence of the disease. Radiological techniques (such as magnetic resonance imaging and multidetector computerized tomography enteroclysis) are useful for estimating the extent of bowel endometriosis. Hormonal therapies (progestins, gonadotropin releasing hormone analogues and aromatase inhibitors) significantly improve pain and intestinal symptoms in patients with bowel stenosis less than 60% and who do not wish to conceive. However, hormonal therapies may not prevent the progression of bowel endometriosis and, therefore, patients receiving long-term treatment should be periodically monitored. Surgical excision of bowel endometriosis should be offered to symptomatic patients with bowel stenosis greater than 60%. Intestinal endometriotic nodules may be excised by nodulectomy or segmental resection. Both surgical procedures improve pain, intestinal symptoms and fertility. Nodulectomy may be associated with a lower rate of complications.”

  • Bowel Endometriosis Surgery Study: Afors, K., Centini, G., Fernandes, R., Murtada, R., Zupi, E., Akladios, C., & Wattiez, A. (2016). Segmental and discoid resection are preferential to bowel shaving for medium-term symptomatic relief in patients with bowel endometriosis. Journal of Minimally Invasive Gynecology, 23(7), 1123-1129. Retrieved from https://pubmed.ncbi.nlm.nih.gov/27544881/ 

“All 3 treatment modalities are effective in terms of immediate symptom relief with acceptable complication rates. However, significantly higher rates of symptom recurrence and reintervention were noted in the shaving group, whereas segmental resection is more likely to be indicated in cases of large nodules.”

  • Case Study of Endometriosis Causing A Small Bowel Obstruction: Slesser, A. A., Sultan, S., Kubba, F., & Sellu, D. P. (2010). Acute small bowel obstruction secondary to intestinal endometriosis, an elusive condition: a case report. World Journal of Emergency Surgery, 5(1), 27. Retrieved from https://wjes.biomedcentral.com/articles/10.1186/1749-7922-5-27 

“We present the case of a 33 year old female of Asian origin who presented with symptoms and signs of an acute small bowel obstruction. A right hemicolectomy for suspected malignancy was performed with an ileocolic anastomosis. Histological examination demonstrated extensive endometriosis of the appendix and ileocaecal junction. Conclusion: Enteric endometriosis should be considered as a differential diagnosis when assessing females of reproductive age with acute small bowel obstruction. A high index of suspicion is required to arrive at a diagnosis of this elusive condition.”

  • Extremely rare case of gastric endometriosis:

Ha, J. K., Choi, C. W., Kim, H. W., Kang, D. H., Park, S. B., Kim, S. J., & Hong, J. B. (2015). An extremely rare case of gastric subepithelial tumor: gastric endometriosis. Clinical endoscopy, 48(1), 74. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4323438/ 

“Frequent locations for endometriosis outside of the pelvic cavity include a variety of tissues and organs, such as the intestines, kidneys, lungs, skin, and pleura, with the exception of the spleen.1 Endometriosis affects the gastrointestinal tract in 5% of cases, with the sigmoid colon being the most commonly affected location, followed by the rectum.2,3 However, to the best of our knowledge, the present case is among the very few reports of gastric endometriosis. Here, we report a very rare case of gastric endometriosis that presented as a subepithelial tumor.”

  • Hepatic (liver) endometriosis a rare case and literature review:

Liu, K., Zhang, W., Liu, S., Dong, B., & Liu, Y. (2015). Hepatic endometriosis: a rare case and review of the literature. European Journal of Medical Research, 20(1), 48. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4389341/

“…endometriotic lesions have also been described in almost all other remote organs of the human body, including the omentum, gastrointestinal tract, peritoneum, operative scars, lymph nodes, umbilicus, skin, lungs, pleura, bladder, kidneys, pancreas, and even in males [3]. Hepatic endometriosis, one of the rarest forms of atypical endometriosis, was first described in 1986 [4]. To our knowledge, only 21 cases of hepatic endometriosis have been previously reported in the literature. We herein describe the 22nd case of hepatic endometriosis and evaluate the current literature addressing the diagnosis of hepatic endometriosis focusing on advances in the clinical manifestation, pathogenesis, and diagnostic workup.”

Bloating with endometriosis:

  • Ek, M., Roth, B., Ekström, P., Valentin, L., Bengtsson, M., & Ohlsson, B. (2015). Gastrointestinal symptoms among endometriosis patients—A case-cohort study. BMC women’s health, 15(1), 59. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4535676/

“Conclusions: The majority of endometriosis patients experience more severe gastrointestinal symptoms than controls. A poor association between symptoms and lesion localization was found, indicating existing comorbidity between endometriosis and irritable bowel syndrome (IBS). Treatment with opioids or GnRH analogs is associated with aggravated gastrointestinal symptoms….Gastrointestinal symptoms among patients with endometriosis described in the literature include abdominal pain, bloating, nausea, constipation, vomiting, painful bowel movements, and diarrhea [3–5]. However, reported symptoms differ between studies. Aggravated symptoms during menstruation have been reported [4, 6, 7] such as cyclic-related bloating and constipation [4]. Fauconnier et al. [7] concluded that symptoms including diarrhea, constipation, and colic rectal pain were more frequent among patients with endometriosis lesions within or close to the bowel. In contrast, Maroun et al. [3] reported gastrointestinal symptoms to be primarily independent of localization of endometriosis lesions in relation to the bowel. Different explanations concerning the occurrence of these symptoms include: endometriosis lesions cause inflammatory activity and local prostaglandin release, which can alter bowel function [8]; endometriosis lesions within the bowel cause symptoms due to mechanical obstruction or cyclic micro-hemorrhages [9]; or there is an existing comorbidity between endometriosis and irritable bowel syndrome (IBS) [8].”

  • Luscombe, G. M., Markham, R., Judio, M., Grigoriu, A., & Fraser, I. S. (2009). Abdominal bloating: an under-recognized endometriosis symptom. Journal of Obstetrics and Gynaecology Canada, 31(12), 1159-1171. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20085682 

“A significantly larger proportion of women with endometriosis than control subjects experienced abdominal bloating (96% vs. 64%). In women with abdominal bloating, the following were more common in those who had endometriosis: associated severe discomfort (30% vs. 0%), wearing loose clothes during bloating (87% vs. 38%), and simultaneous hand swelling (30% vs. 6%). The experiences of cyclically related diarrhea and constipation were more frequent with endometriosis. While there were significant changes in bloating and discomfort ratings across the menstrual cycle, there was a trend towards a difference between the control subjects and unmedicated endometriosis groups only in how the pattern of bloating severity fluctuated across the cycle. Lower abdominal girth measurements changed significantly across menstrual cycle phases. Control and unmedicated endometriosis groups differed significantly in girth changes across the menstrual cycle, controls experiencing much less variation. Compared with the unmedicated endometriosis group, women receiving hormonal treatment had higher bloating severity ratings and discomfort scores, but there was no objective difference in abdominal girth. Conclusion: Painful abdominal bloating appears to be common in women with endometriosis and causes considerable symptomatic distress.”

“Colorectal surgery for endometriosis has a significant impact on urinary function regardless of the technique. However, rectal shaving causes less postoperative voiding dysfunction than discoid excision or segmental resection.”

As pelvic floor dysfunction and other issues can contribute to bowel symptoms.

References

Aragon, M., & Lessey, B. A. (2017). Irritable Bowel Syndrome and Endometriosis: Twins in Disguise. GHS Proc, 43-50. Retrieved from https://hsc.ghs.org/wp-content/uploads/2016/11/GHS-Proc-Ibs-And-Endometriosis.pdf

Ek, M., Roth, B., Ekström, P., Valentin, L., Bengtsson, M., & Ohlsson, B. (2015). Gastrointestinal symptoms among endometriosis patients—A case-cohort study. BMC women’s health, 15(1), 59. doi: 10.1186/s12905-015-0213-2

Ferrero, S., Camerini, G., Maggiore, U. L. R., Venturini, P. L., Biscaldi, E., & Remorgida, V. (2011). Bowel endometriosis: Recent insights and unsolved problems. World journal of gastrointestinal surgery, 3(3), 31. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3069336/

Habib, N., Centini, G., Lazzeri, L., Amoruso, N., El Khoury, L., Zupi, E., & Afors, K. (2020). Bowel Endometriosis: Current Perspectives on Diagnosis and Treatment. International Journal of Women’s Health, 12, 35. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996110/

Milone, M., Mollo, A., Musella, M., Maietta, P., Fernandez, L. M. S., Shatalova, O., … & Milone, F. (2015). Role of colonoscopy in the diagnostic work-up of bowel endometriosis. World Journal of Gastroenterology: WJG, 21(16), 4997. doi: 10.3748/wjg.v21.i16.4997

Tarjanne, S., Heikinheimo, O., Mentula, M., & Härkki, P. (2015). Complications and long‐term follow‐up on colorectal resections in the treatment of deep infiltrating endometriosis extending to bowel wall. Acta Obstetricia et Gynecologica Scandinavica, 94(1), 72-79. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/aogs.12515

3 years ago Symptoms No comment

Post coital bleeding

Post coital bleeding (bleeding after sex) is common and usually benign, but it does requires thorough history and exam and perhaps additional testing. Some of the common reasons for bleeding after sex can include:

  • “cervical polyps
  • endometrial polyps
  • endometriosis
  • uterine leiomyomata
  • Cervicitis or cervical lesions
  • pregnancy
  • vaginitis
  • endometrial cancer
  • coagulopathy” (Smith, 2008)

Studies:

“Postcoital bleeding can be an annoying complaint for patients and a worrisome symptom for providers due to the risk of underlying malignancy. Despite being a common gynecologic problem, there is large diversity among gynecologists on the management of postcoital bleeding [55]. Unlike abnormal uterine bleeding or the management of abnormal cytology, there are no recommendations from governing bodies on the management of postcoital bleeding. Patients presenting with postcoital bleeding require a full history and physical examination to help in developing a differential diagnosis to guide evaluation and treatment. Although most patients with postcoital bleeding do not have underlying malignancy, providers must pay close attetion to ensure that appropriate screening tests are up-to-date. Physicians should also be aware that a large portion of women presenting with postcoital bleeding will not have an obvious source for their bleeding; however, as long as malignancy is ruled out, most of these women’s symptoms will naturally resolve in premenopausal women.?” 

Reference

  • Smith, R. (2008). Netters Obsetrics & Gynecology ( 2nd ed.). Elsevier: Philadelphia, PA.
3 years ago Symptoms No comment

Sexual functioning Pain with Penetration

Pain with any type of penetration, such as from a tampon or from a physical exam, is a symptom of endometriosis. Pain may often be felt with sexual activity. Pain can be from pulling or stretching of tissue. It can also be from pelvic floor dysfunction or other problems with the muscles and ligaments of the pelvic floor. Physical therapy can be useful for this symptom. 

“Dyspareunia is the medical term for pain during sex. It frequently occurs in people with endometriosis because penetration and other movements associated with intercourse can stretch and pull the endometrial growths…. Penetration and other movements related to intercourse can pull and stretch endometrial tissue, particularly if it has grown behind the vagina or lower uterus. Vaginal dryness can also cause this pain. Some means of addressing endometriosis, such as hormonal treatments or a hysterectomy (surgical removal of the uterus), can cause dryness…. Those who do may experience the following:

  • pain that is acute or feels like stabbing
  • pain deep in the abdomen
  • pain ranging from mild to severe

“This pain varies from person to person and may depend on the type of intercourse. Some experience pain only during deep penetration, for example, while others experience pain after sex, rather than during it.” 

Links:

Studies:

  • Melis, I., Litta, P., Nappi, L., Agus, M., Melis, G. B., & Angioni, S. (2015). Sexual function in women with deep endometriosis: correlation with quality of life, intensity of pain, depression, anxiety, and body image. International Journal of Sexual Health, 27(2), 175-185. Retrieved from https://www.tandfonline.com/doi/full/10.1080/19317611.2014.952394 

“The study evidenced that deep endometriosis has a significant impact on sexuality and body image.”

  • Williams, C., Hoang, L., Yosef, A., Alotaibi, F., Allaire, C., Brotto, L., … & Yong, P. J. (2016). Nerve bundles and deep dyspareunia in endometriosis. Reproductive Sciences, 23(7), 892-901. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26711313

“This study provides evidence that neurogenesis in the cul-de-sac/uterosacrals may be an etiological factor for deep dyspareunia in endometriosis.”

3 years ago Symptoms No comment

Nerves and endometriosis

“Endometriosis lesions are known to be hyperinnervated” (Liu, Yan, & Guo, 2019). People with endometriosis have abnormal nerve growth and nerve fibers close to endometriosis lesions (Zheng, Zhang, Leng, & Lang, 2019). Pain with endometriosis is multifactorial, including irritation of nerves in the pelvis, new nerve growth, heightened sensitivity to pain, inflammation in the pelvis, and pain producing agents in the pelvic fluid (Ferrero, Vellone, & Barra, 2019).  The interplay between nerves and inflammation is believed to play a significant role in pain. There are increased levels of multiple inflammatory factors in and around endometriosis lesions (Wei et al., 2020). Endometriosis “can also directly irritate and infiltrate pelvic nerves promoting endometriosis-associated pain” (Ferrero, Vellone, & Barra, 2019) and can lead “to corresponding neurological symptoms or deficits” (Working group of ESGE et al., 2020).

Studies:

“Endometriotic lesions are known to be hyperinnervated due to neurogenesis resulting from neutrophins secreted by endometriotic lesions and possibly platelets. These neutrophins seem to preferentially favour production of sensory neurons at the expense of sympathetic neurons….Since sensory nerves are known to be important in wound healing and fibrogenesis, our findings also give more credence to the notion that endometriotic lesions are wounds undergoing repeated tissue injury and repair.”

“…endometriosis is certainly a chronic inflammation disorder [4]. The levels and concentrations of active macrophages; interleukin (IL)-1β, IL-6, IL-8; nerve growth factor (NGF); other immune cells; and inflammatory factors are increased in peritoneal fluid (PF) and endometriotic lesions [4,5,6]. These changes are believed to contribute to serious symptoms of pain such as chronic pelvic pain, dysmenorrhea, and dyspareunia [7]. Notably in deep infiltrating endometriosis (DIE) and intestinal endometriosis, the anatomical distribution of lesions is normally more closely related to pelvic pain symptoms [2]. Abnormal innervations are observed in most endometriotic lesions: an increased number of total intact nerve fibers, increased sensory and decreased sympathetic nerve fiber density (NFD) [6], the occurrence of cholinergic and unmyelinated nerve fibers, etc. [8] In various studies, these abnormal phenomena have been correlated with endometriosis-associated pain [6, 8,9,10]. More importantly, sympathetic and parasympathetic systems have different inflammation-related effects in different stages of inflammation [10].”

“A growing body of evidence attests that patients with endometriosis endure pain associated with abnormal angiogenesis and the growth of novel nerve fibers in close proximity to ectopic lesions. Endometriotic lesions create an inflammatory environment and change the quality or quantity of inflammatory mediators or neurotransmitters, thereby stimulating peripheral nerve sensitization by remodeling the structure of peripheral synapses and accelerating conduction along nerve fibers…. Endometriosis-related pain is currently considered a form of neuropathic or neuroinflammatory pain.”

“The pathophysiology of the association between pain and endometriosis is still enigmatic. The cause of pain is likely to be multifactorial (Table 1) (9,10). In patients with severe endometriosis with large ovarian cysts and DIE, pain can be caused by the distortion of the pelvic anatomy and by the presence of extensive adhesions (involving the uterus, the ovaries and the rectosigmoid) (Figure 1) (10). However, there is a poor correlation between the degree of pain and the severity of endometriosis. Some patients with intense pain symptoms have only small endometriotic implants on the peritoneal surface while other patients with severe endometriosis are almost asymptomatic….patients with endometriosis have an inflammatory process within the peritoneal cavity. In fact, women with endometriosis have increased concentration of inflammatory cells (macrophages and T lymphocytes), chemokines (MCP1, RANTES), inflammatory cytokines (IL1β, IL6, IL8, TNFα) and inflammatory molecules in the peritoneal fluid (11). These molecules and cells can sensitize peripheral nerves promoting the generation of pain (12). In addition, some pain-inducing molecules (such as prostaglandins) have elevated concentration in peritoneal fluid of women with endometriosis. Finally, endometriotic nodule can also directly irritate and infiltrate pelvic nerves promoting endometriosis-associated pain (13).”

  • Working group of ESGE, ESHRE, and WES, Keckstein, J., Becker, C. M., Canis, M., Feki, A., Grimbizis, G. F., … & Tanos, V. (2020). Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. Human Reproduction Open, 2020(1), hoaa002. Retrieved from https://academic.oup.com/hropen/article/2020/1/hoaa002/5733057

“Endometriosis close to the sympathetic and parasympathetic nerve fibres (hypogastric plexus and splanchnic nerves) can lead to a dysfunction of pelvic organs (e.g. dysfunction of the bladder as well as disturbance of vaginal lubrication and intestinal dysfunction) (Possover, 2014). Involvement of somatic nerves, such as the sacral plexus and the sciatic nerve, leads to corresponding neurological symptoms or deficits.”

References

Ferrero, S., Vellone, V. G., & Barra, F. (2019). Pathophysiology of pain in patients with peritoneal endometriosis. Annals of translational medicine, 7(Suppl 1). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6462618/

Liu, X., Yan, D., & Guo, S. W. (2019). Sensory nerve-derived neuropeptides accelerate the development and fibrogenesis of endometriosis. Human Reproduction, 34(3), 452-468. Retrieved from https://academic.oup.com/humrep/article-abstract/34/3/452/5303712

Wei, Y., Liang, Y., Lin, H., Dai, Y., & Yao, S. (2020). Autonomic nervous system and inflammation interaction in endometriosis-associated pain. Journal of Neuroinflammation, 17(1), 1-24. Retrieved from https://link.springer.com/article/10.1186/s12974-020-01752-1

Working group of ESGE, ESHRE, and WES, Keckstein, J., Becker, C. M., Canis, M., Feki, A., Grimbizis, G. F., … & Tanos, V. (2020). Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. Human Reproduction Open, 2020(1), hoaa002. Retrieved from https://academic.oup.com/hropen/article/2020/1/hoaa002/5733057

Zheng, P., Zhang, W., Leng, J., & Lang, J. (2019). Research on central sensitization of endometriosis-associated pain: a systematic review of the literature. Journal of pain research, 12, 1447. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6514255/

3 years ago Symptoms No comment

Sciatic Pain and Endometriosis

While endometriosis may not necessarily have to be on the sciatic nerve to cause similar symptoms, there have been some cases documented of that happening. Some symptoms could be: cyclical pain along the sciatic nerve (sciatica), back pain, gluteal pain radiating to the front of the thigh and outside the lower leg, positive straight leg raise test (seen in low back disc injuries as well), sensory loss, changes in reflexes, and muscle weakness (Foti et al., 2018). There are multiple case studies demonstrating endometriosis affecting the sciatic nerve region. However, symptoms can occur from lesions near that region (like the side posterior pelvic area) (Vilos, Vilos, & Haebe, 2002). Pelvic floor dysfunction and other myofascial disorders (such as piriformis syndrome) can also cause similar symptoms (Cass, 2015; Weiss, Rich, & Swisher, 2012). As is often seen with endometriosis, there may be more than one pain/symptom generator present. This might mean utilizing different providers, such as a pelvic physical therapist as well as a surgeon, in order to address all the underlying issues.

Read more about Endometriosis symptoms and Types of Endometriosis Pain (endometriosis back pain & endometriosis Leg Pain )

Studies:

“Cyclic leg signs and symptoms were associated with pelvic peritoneal pockets, endometriosis nodules, or surface endometriosis of the posterolateral pelvic peritoneum. We hypothesize that the pain associated with these lesions is more likely referred pain originating from pelvic peritoneum than direct irritation of the lumbosacral plexus of the sciatic nerve.” “Endometriosis is a common gynecological disorder that can cause musculoskeletal symptoms and manifest as nonspecific low back pain. The patient was a 25-year-old woman who reported the sudden onset of severe left-sided lumbosacral, lower quadrant, buttock, and thigh pain. The physical therapist examination revealed findings suggestive of a pelvic visceral disorder during the diagnostic process. The physical therapist referred the patient for medical consultation, and she was later diagnosed by a gynecologist with endometriosis and a left ovarian cyst.” “Radiating leg pain related to the menstrual cycle has been reported as a complication of endometriosis in a number of case studies (Baker et al., 1966; Bjornsson, 1976; Denton & Sherrill, 1955; Floyd et al., 2011; Forrest & Brooks, 1972; Head et al., 1962; Motamedi et al., 2015; Pacchiarotti et al., 2013), and in two surveys (Missmer & Bove, 2011; Walch et al., 2014). A consistent and thus perhaps key diagnostic feature seems to be the cyclical or catamenial nature of the symptom, especially earlier in the progression of the endometriosis (Capek et al., 2016; Dhote et al., 1996; Moeser et al., 1990; Takata & Takahashi, 1994; Zager et al., 1998). However, the symptom duration usually expands with endometriosis progression, developing into constant pain if left untreated. “Examination findings in women with leg pain due to endometriosis are typical of sciatica due to other causes (Torkelson et al., 1988), including painful straight leg raising testing, and may also include a diminished Achilles tendon reflex, mild muscular atrophy, and tenderness of the sciatic nerve at the sciatic notch. Lumbar spinal investigations (myelogram, CSF analysis) are usually unremarkable, but magnetic resonance imaging can demonstrate larger lesions (Binkovitz et al., 1991; Cottier et al., 1995; Yekeler et al., 2004). “Surgical descriptions of sciatic endometriosis describe inflammatory lesions that involve surrounding structures that are not necessarily otherwise diseased (Descamps et al., 1995; Yekeler et al., 2004). In an animal model, it has been shown that a focal inflammation of the sciatic nerve (called sciatic neuritis) evokes mechanical sensitivity in the axons of a subset of nociceptive (potentially pain-evoking) neurons without causing overt nerve damage (Bove et al., 2003; Dilley & Bove, 2008; Dilley et al., 2005). Furthermore, the sheaths of nerve trunks are innervated by mechanically and chemically-sensitive nociceptors (Bove & Light, 1995a, b, 1997), which also participate in maintaining the local environment of the nerve (Sauer et al., 1999). These findings suggest that inflamed nerves are a source of pain perceived as coming from the nerve and as coming from the structure(s) that the nerve innervates.” “Endometriosis (EN) is a common gynecological condition characterized by the presence of functional endometrium located outside the uterine cavity. Sciatic nerve (SN) is rarely affected by EN. Magnetic resonance imaging allows a direct visualization of the spinal and SN, and it is the modality of choice for the study of SN involvement in extrapelvic EN. We report a case of an endometrioma located in the right SN with a systematic review of the literature.” “The patient is a 49-year-old perimenopausal woman with dysmenorrhea and a left ovarian cyst who presented for evaluation of new onset left hip and leg pain. The left ovarian cyst was first noted 4 years ago and the patient declined surgery at that time, instead opting for surveillance with repeat imaging which now demonstrated an interval increase in the cyst size. The patient had an extensive evaluation for her leg pain including MRI and nerve conduction studies which were all unremarkable. The patient declined medical management or definitive surgical treatment of the suspected endometriosis. She opted for a diagnostic laparoscopy and left ovarian cystectomy.” “A 35-year-old female patient consulted for right low back pain extending along her posterior thigh, calf and foot since 2 years. The pain was recurrent, acute in onset, lasted several days and gradually diminished until disappearing. It was refractory to common analgesics and during the crisis she had difficulties to walk. Neurologist requested a calendar of pain in which the relationship between the menstrual cycle and the pain became evidenced. We performed MRN of the lumbo sacral plexus that showed multiple endometriotic implants in ovaries, L5-S1 roots and a huge one on the sciatic nerve (intra and extrapelvic segment). The patient started oral contraceptives but presented progressive worsening of pain until it became constant and developed step page. Electromyogram showed acute and chronic axonal damage in the sciatic nerve distribution. Medical treatment was changed to leuprolide acetate. The patient evolved with improvement of ovarian endometriosis but persistence of sciatic nerve lesions, leg pain and weakness up to now. Surgical option was considered.” “A 25-year-old woman presented to her general practitioner with a two-month history of constant pain in her thigh. There was no history of trauma and the onset was insidious. A diagnosis of a soft-tissue injury was made. However, despite anti-inflammatory medication and physiotherapy she developed increasing pain, typically sciatic in nature, from the left buttock, radiating down the posterolateral aspect of the leg and heel. This would escalate to a severe left-sided sciatic pain during menstruation. Two years later she had developed a limp and was referred to an orthopaedic surgeon. At the time of clinical assessment she had marked pain (Visual Analogue Scale (VAS)2 7 and Peripheral Nerve Injury (PNI) scale3 2) and required either two crutches or a wheelchair. On examination, she had an antalgic gait and was unable to bear weight fully on her left leg because of the pain in her buttock and leg. The pain was exacerbated by hip flexion and knee extension. There was no apparent muscle wasting or sympathetic changes in the leg and foot. Palpation of the left gluteal region, especially over the sciatic notch, was painful. Motor power was preserved throughout the leg, except for some weakness in the biceps femoris. Straight-leg raising was to 30° only. Reflexes were present, but the ankle jerk only with reinforcement. Sensation to pin-prick, temperature and light touch was reduced in the heel and sole of the foot. “The diagnosis of sciatic endometriosis was considered…Histopathological examination confirmed endometriosis of the sciatic nerve with no evidence of malignancy (Figs 4 and 5). Post-operatively and at 12 months follow-up her pain was considerably relieved (VAS2 2, PNI3 1). She was able to walk without crutches and could straighten the leg. There was an improvement in sensation over the heel and sole of the foot to pin-prick, temperature and light touch. She was referred to a gynaecologist, who performed a laparoscopy which now showed no evidence of intra-pelvic endometriosis.” “A 20-year-old woman presented with complaints of severe dysmenorrhea lasting for more than 6 years and dysfunction of her left lower limb lasting for approximately 4 months. Both CT and MRI demonstrated a suspected intrapelvic and extrapelvic endometriotic cyst (7.3 cm × 8.1 cm × 6.5 cm) passing through the left greater sciatic foramen. Laparoscopic exploration showed a cyst full of dark fluid occupying the left obturator fossa and extending outside the pelvis. A novel combination of transgluteal laparoscopy was performed for complete resection of the cyst and decompression of the sciatic nerve. Postoperative pathology confirmed the diagnosis of endometriosis. Long-term follow-up observation showed persistent pain relief and lower limb function recovery in the patient.” “We report a case of a 32-year-old patient who presented with cyclic leg pain in the inner right thigh radiating to the knee caused by a cystic endometriotic mass in the obturator internus muscle with nerve retraction…. Surgical removal of the mass was performed using the laparoscopic approach… A mass located within the right obturator internus muscle, below the right iliac external vein, behind the corona mortis vein, and lateral to the right obturator nerve was identified. The whole region was inflamed, and the nerve was partially involved. Dissection was performed carefully with rupture of the tumor, releasing a chocolate like fluid (Fig. 2), and the cyst was removed. Pathology examination was consistent with endometriosis. Patient improvement was observed, with pain relief and improved ability for right limb mobilization.” “The signs suggestive of intrapelvic nerve involvement include perineal pain or pain irradiating to the lower limbs, lower urinary tract symptoms, tenesmus or dyschezia associated with gluteal pain. Whenever deeply infiltrating lesions are present, the patient must be asked about those symptoms and specific MRI sequences for the sacral plexus must be taken, so that the equipment and team can be arranged and proper treatment performed.” “Before surgery, more women were affected by leg pain in the endometriosis group, compared to the control group (45.5% and 25.9%, respectively). Preoperative VAS scores for leg pain, however, were not significantly different between the two groups. A moderate correlation in the preoperative VAS scores between leg pain and dysmenorrhea was observed. After laparoscopy, we found a significant improvement in leg pain intensity in both groups. Conclusions: The prevalence of leg pain is increased in endometriosis, while leg pain intensity is not, compared to women without endometriosis. Laparoscopic surgery—even without preparation and decompression of nerve tissue—is associated with an improvement in pain intensity in women with endometriosis, as well as in the group without endometriosis.” “Pelvic floor dysfunction can also arise in response to other common chronic pain syndromes, such as endometriosis, irritable bowel disease, vulvodynia, and interstitial cystitis. A prospective evaluation of patients with chronic pelvic pain of various etiologies found abnormal musculoskeletal findings in 37%, versus 5% of controls.7 For this reason, the pelvic floor should be included in any evaluation regardless of the suspected source of pelvic pain.”

References Foti, P. V., Farina, R., Palmucci, S., Vizzini, I. A. A., Libertini, N., Coronella, M., … & Milone, P. (2018). Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights into imaging, 9(2), 149-172. Retrieved from https://link.springer.com/article/10.1007/s13244-017-0591-0 Vilos, G. A., Vilos, A. W., & Haebe, J. J. (2002). Laparoscopic findings, management, histopathology, and outcomes in 25 women with cyclic leg pain. The Journal of the American Association of Gynecologic Laparoscopists, 9(2), 145-151. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S1074380405601223

3 years ago Symptoms No comment

Pain with Penetration

Pain with any type of penetration, such as from a tampon or from a physical exam, is a symptom of endometriosis. Pain may often be felt with sexual activity. Pain can be from pulling or stretching of tissue. It can also be from pelvic floor dysfunction or other problems with the muscles and ligaments of the pelvic floor. Physical therapy can be useful for this symptom. 

“Dyspareunia is the medical term for pain during sex. It frequently occurs in people with endometriosis because penetration and other movements associated with intercourse can stretch and pull the endometrial growths…. Penetration and other movements related to intercourse can pull and stretch endometrial tissue, particularly if it has grown behind the vagina or lower uterus. Vaginal dryness can also cause this pain. Some means of addressing endometriosis, such as hormonal treatments or a hysterectomy (surgical removal of the uterus), can cause dryness…. Those who do may experience the following:

  • pain that is acute or feels like stabbing
  • pain deep in the abdomen
  • pain ranging from mild to severe

“This pain varies from person to person and may depend on the type of intercourse. Some experience pain only during deep penetration, for example, while others experience pain after sex, rather than during it.” 

Links:

Studies:

  • Melis, I., Litta, P., Nappi, L., Agus, M., Melis, G. B., & Angioni, S. (2015). Sexual function in women with deep endometriosis: correlation with quality of life, intensity of pain, depression, anxiety, and body image. International Journal of Sexual Health, 27(2), 175-185. Retrieved from https://www.tandfonline.com/doi/full/10.1080/19317611.2014.952394 

“The study evidenced that deep endometriosis has a significant impact on sexuality and body image.”

  • Williams, C., Hoang, L., Yosef, A., Alotaibi, F., Allaire, C., Brotto, L., … & Yong, P. J. (2016). Nerve bundles and deep dyspareunia in endometriosis. Reproductive Sciences, 23(7), 892-901. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26711313

“This study provides evidence that neurogenesis in the cul-de-sac/uterosacrals may be an etiological factor for deep dyspareunia in endometriosis.”

3 years ago Symptoms No comment

Pelvic Floor Dysfunction links

Studies:

“Unlike in pelvic floor disorders caused by relaxed muscles (eg, pelvic organ prolapse or urinary incontinence, both of which often are identified readily), women affected by nonrelaxing pelvic floor dysfunction may present with a broad range of nonspecific symptoms. These may include pain and problems with defecation, urination, and sexual function, which require relaxation and coordination of pelvic floor muscles and urinary and anal sphincters.”

Links to Pelvic Floor Dysfunction Resources:

3 years ago Symptoms No comment

Location of lesions and where pain is felt

Endometriosis lesions in different locations may cause different symptoms. Often the symptoms are referred pain (pain in a different place than where the endometriosis lesion is located). There is also some information about central sensitization. 

Overview

  “Clinical manifestations depend on the anatomic locations of the disease.

  • Bladder: dysuria, gross hematuria during menses, irritative voiding symptoms, urgency, frequent urination, urinary storage symptoms, tenesmus, burning sensation, suprapubic discomfort and pain, urinary incontinence [2, 3, 15].
  • Ureters: dysmenorrhea, dyspareunia, urinary symptoms, hydronephrosis, flank pain, decline of renal function [2, 3].
  • Round ligaments: painful, palpable inguinal mass (extra-pelvic portion of the ligaments); nonspecific pelvic pain (intra-pelvic portion) [11].
  • Retrocervical region and uterosacral ligaments: severe and painful symptoms, dyspareunia [3].
  • Vagina: dysmenorrhea, dyspareunia, postcoital spotting, prolonged menstruation not responding to medical therapy leading to anaemia [3, 16].
  • Rectosigmoid colon: cyclic pain during defecation, dyschezia, cyclic hematochezia, bloating, constipation, bowel cramping, catamenial diarrhoea, pencil-like stools, bowel obstruction [2, 3, 12, 17].
  • When unusual locations outside the pelvis occur, the pain may be site specific.
  • Thoracic-diaphragmatic endometriosis: chest pain (diffuse or basithoracic) with right-sided predominance, scapular or cervical pain associated with menses, sometimes radiating to the arm, pneumothorax, dyspnea, hemoptysis [18–20].
  • Sciatic nerve: cyclic sciatica, back pain, gluteal pain radiating to the dorsal thigh and lateral lower leg, positive Lasègue’s sign, sensory loss, reflex alterations, muscle weakness, paresis [2, 21–23].”
  • Riazi, H., Tehranian, N., Ziaei, S., Mohammadi, E., Hajizadeh, E., & Montazeri, A. (2015). Clinical diagnosis of pelvic endometriosis: a scoping review. BMC women’s health, 15(1), 39. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450847/pdf/12905_2015_Article_196.pdf 

“Clinical diagnosis by signs obtained from physical examination: Clinical signs of the disease that identified by physical examination (pelvic examination by inspection and palpation) included a broad range of signs. External genitalia and the vaginal surface were usually unremarkable [15]. Findings of physical examination are listed as follows:

  • External genitalia: Visible red, blue, or hemorrhagic nodules on the external genitalia [21].
  • Vagina: Visible red, blue, or hemorrhagic nodules on the vagina, and tender masses, nodules, and fibrosis on palpation of the upper vagina [8,15-17,21].
  • Cervix: Visible lesions on the cervix, tenderness on cervical movement, lateral cervical displacement, and cervical stenosis [15,16,19,21,37].
  • Uterus: A fixed (decreased or absent mobility) and retroverted uterus, and uterine motion tenderness in pelvic examination [8,15-17,19,21,24].
  • Adnexa: Tender or fixed adnexal masses resulting from endometriomas, adnexal enlargement, and pelvic masses [8,14,17,19,21].
  • Posterior vaginal fornix: Tender nodules in the posterior vaginal fornix, bluish implants typical of endometriosis or red, hypertrophic lesions bleeding on contact [15,17].
  • Pouch of Douglas: Fullness or mass or nodularity or pain in the pouch of Douglas, local tenderness or palpable tender nodules in cul de sac [8,14,16,19,30].
  • Rectovaginal septum: Tender masses, nodules, and fibrosis of the rectovaginal septum [15,19-21,37].
  • Uterosacral ligament: Thickening, pain or tenderness or nodularity in uterosacral ligament [8,14-16,19,21,24,30].”
  • Demco, L. (2000). Review of pain associated with minimal endometriosis. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 4(1), 5. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015350/ 

“What is most interesting is that right-left orientation of the pelvis does not exist in some patients. That is to say, palpation of a lesion of endometriosis on the left side of the pelvis may produce pain that the patient perceives as being on the right side of the abdomen, and the opposite is also true.”   

Low back pain and Sciatic nerve pain (sciatica)

  • Case Study of Sciatic Endometriosis:

Possover, M. (2017). Five-year follow-up after laparoscopic large nerve resection for deep infiltrating sciatic nerve endometriosis. Journal of minimally invasive gynecology, 24(5), 822-826. Retrieved from https://www.jmig.org/article/S1553-4650(17)30260-1/fulltext?fbclid=IwAR1OzlK62hXEY-TFBIx9flq10cgSjxLLyTOUAMqp0zyo3FBW3v2fgqE3dGA 

“In deep infiltrating intraneural endometriosis of the sciatic nerve, patients present with motor disorders before and after surgical resection. The average VAS score was reduced from 9.33 preoperatively to 1.25 at a 3-year follow-up. When full resection of endometriosis including nerve resection is completed, sciatic nerve function recover, but recovery of a normal gait may take at least 3 years and intensive physiotherapy.”

  • Case study of Sciatica and Back pain due to endometriosis:

Uppal, J., Sobotka, S., & Jenkins III, A. L. (2017). Cyclic sciatica and back pain responds to treatment of underlying endometriosis: case illustration. World Neurosurgery, 97, 760-e1. Retrieved from https://doi.org/10.1016/j.wneu.2016.09.111 

“We report on a 39-year-old gymnast with cyclic sciatica and back pain, whose initial presentation initially led to a spinal fusion at L4/5 and L5/S1, but that procedure did not change her symptoms. Her diagnosis of endometriosis was not made until 2 years after her spinal fusion. Ultimately, once diagnosed with endometriosis of the retroperitoneal spinal and neural elements, her back and leg pain responded completely to hormonal therapy and then to a hysterectomy and a bilateral salpingo-oophorectomy. Because her true diagnosis of endometriosis was unknown and she had some degenerative changes in her spine, she underwent a spinal fusion that would probably not have been done if the diagnosis of endometriosis had been suggested.”

  • Case Study Low Back Pain due to spinal endometriosis:

Dongxu, Z., Fei, Y., Xing, X., Bo-Yin, Z., & Qingsan, Z. (2014). Low back pain tied to spinal endometriosis. European Spine Journal, 23(2), 214-217. Retrieved from https://pubmed.ncbi.nlm.nih.gov/24531988/ 

“A 33-year-old woman presented with severe low back pain. She had the low back pain periodically for 3 years, and the pain was associated with menstruation. Radiographs showed a lesion in the posterior L3 body. After surgery, tissue biopsy indicated the presence of endometrial tissue in the lesion and thus confirmed endometriosis.”

Links:

3 years ago Symptoms No comment

Pain Associated with Minimal Endometriosis

“Minimal” endometriosis does not mean minimal pain. In fact, the opposite may be true- “minimal”, smaller lesions can produce a large number of prostaglandins that can lead to major pain. While this is an older study and “microscopic” endometriosis is debated, it is an interesting study demonstrating the appearance of lesions and the related pain felt. The research was done using laparoscopy under IV conscious sedation. Researchers identified that more pain was felt by the patient for some colors of lesions versus other colors. They also discovered that palpation of the endometriosis lesions produced the pain of cramps, not the uterus. Location of the endometriosis lesions in certain areas reproduced pain in other areas of the body, such as lesions on the utero-sacral ligaments lead to cramps in the back or those on the side wall of the pelvis led to pain radiating down the leg.

Links:

Study:

“A simple analogy that is often used to explain endometriosis to the patient is the example of the eyelash and the eye. The eyelash is a “normal” part of the eye and quite separate from the eyeball. Should a “normal eyelash” be placed on a “normal” eyeball, the eye becomes red with dilated corkscrew vessels. The eye becomes painful but continues to function, though not optimally. The eyeball returns to its normal state once the eyelash is removed. The body reacts in a similar manner when the “normal peritoneum” is exposed to the “normal endometrial tissue.” The peritoneal lining develops red lesions with dilated corkscrew vessels and becomes painful. The pelvic organs continue to function but not optimally, which can lead to infertility. The way to cure the problem is to find and remove the “normal endometrial tissue.” Although this analogy is not perfect, the patients seem to grasp the concept, since they have all experienced an eyelash in the eye scenario….

“Initial work on mapping of pain associated with the endometriosis lesions resulted in some thought-provoking findings. The classic black lesions were found to be painful in only 11% of patients when the lesion was touched. Similarly, white lesions were painful in 20% of patients with red lesions at 37%, and clear lesions at 32% were the most painful (Table 1). These results added further reason as to why initial therapy had such poor results. Surgeons would only “see” the black lesions and removed them, but these were the least painful lesions. The most painful clear lesions were not “seen” at laparotomy and therefore remained, as did the pain. What became apparent next, while mapping the patient, was the fact that the pain extended 28 mm beyond the visible border of the lesion onto what looked like “normal” peritoneum… 

“…Palpation of the lesions of endometriosis produced the cramps, not the uterus. Patients, postoperatively, reported that once they identified the cramps of endometriosis, they noticed that they were different than menstrual cramps. Furthermore, palpation of the endometriosis lesions on patients without a uterus and both ovaries removed reproduced the cramps of endometriosis. This confirmed the findings of other researchers who have concluded that a hysterectomy often does not change the course of the pain of endometriosis since it is the lesions, not the uterus, which are responsible for the cramp-like pain. The location of the lesion in relationship to the pelvis can, in most instances, reproduce the symptoms the patient experiences. Lesions on the utero-sacral ligament, when palpated, cause pain or cramps in the back. Palpation of lesions on the side wall of the pelvis result in pain or cramps radiating down the leg.

“What is most interesting is that right-left orientation of the pelvis does not exist in some patients.12 That is to say, palpation of a lesion of endometriosis on the left side of the pelvis may produce pain that the patient perceives as being on the right side of the abdomen, and the opposite is also true. How many times has a laparoscopy under general anesthesia been done on a patient complaining of right-sided pain where the surgeon saw a normal looking pelvis on the right—only to wake up the patient and tell her, “I saw nothing on the right side of your pelvis that would cause your pain.”

“The data revealing the failure of the approach of “treat and see,” based on what the surgeon observed at laparoscopy under general anesthetic, is strong and reveals that a new approach is needed. An approach based on patient confirmed diagnosis and patient-based analysis of the results of therapy needs to be looked at in greater detail. The only person who knows where the pain starts and ends is the patient herself. She is also the only one who can confirm when the pain is no longer present.”                     

3 years ago Symptoms No comment

What influences pain levels?

Some women might experience minimal pain with endometriosis, while many experience may experience severe pain. Bloski and Pierson (2008) state that “women with minimal or mild endometriosis have been found to have high degrees of pain and infertility, while asymptomatic women have been diagnosed with Stage IV on laparoscopy for tubal ligation. The variability in clinical presentation and stage of disease likely reflects of our lack of understanding of the pathophysiology of endometriosis.” Pain is influenced by several factors- the location of the endometriosis, the “type” or “stage” (clear, black, red, etc) of lesions, how much innervation is there, how much inflammatory chemicals are being released, if adhesions are pulling on anatomy, if other conditions such as pelvic floor dysfunction, interstitial cystitis, or adenomyosis is present. Pain with endometriosis is multifactorial, including irritation of nerves in the pelvis, new nerve growth, heightened sensitivity to pain, inflammation in the pelvis, and pain producing agents in the pelvic fluid (Ferrero, Vellone, & Barra, 2019). Interesting is that one study, from 1986, demonstrates evidence from many years ago, yet misinformation and misconceptions still exist! Differences that could influence pain levels:

“The three most commonly suggested mechanisms for pain production in endometriosis are [1] production of substances such as growth factors and cytokines by activated macrophages and other cells associated with functioning endometriotic implants (7, 8); [2] the direct and indirect effects of active bleeding from endometriotic implants; and [3] irritation of pelvic floor nerves or direct invasion of those nerves by infiltrating endometriotic implants, especially in the cul-de-sac (8, 9). It remains plausible that in any individual more than one or all of these mechanisms may be in operation. The neural irritation or invasion hypothesis has gathered much support in the past decade. Tender nodularity in the region of the cul-de-sac and the areas of the uterosacral ligaments has approximately 85% sensitivity and 50% specificity for the diagnosis of infiltrative endometriosis (10). Women with such findings on pelvic examination may have deep dyspareunia and more severe dysmenorrhea. Those with infiltration of the uterosacral ligaments and/or diseases directly adjacent to or invading the rectal wall may have dyschezia (9). The intensity of pain associated with infiltrative disease has been correlated with the depth of penetration of the lesion. The most severe pain is seen when the disease extends ≥6 mm below the peritoneal surface (10). Both perineural inflammation and direct infiltration of nerves by endometriosis have been observed (11). However, these kinds of perineural changes have been observed most commonly in women with central pelvic disease (i.e., around the uterosacral ligaments and in the cul-de-sac and not in those with lateral peritoneal or ovarian endometriosis).”

*Dyspareunia- pain with intercourse, dysmenorrhea- pain with menstruation, dyschezia- pain or straining with defecation

  • Vernon, M. W., Beard, J. S., Graves, K., & Wilson, E. A. (1986). Classification of endometriotic implants by morphologic appearance and capacity to synthesize prostaglandin F. Fertility and sterility, 46(5), 801-806. Retrieved from https://www.fertstert.org/article/S0015-0282(16)49814-6/pdf 

“The severity of the symptoms of endometriosis has not always correlated well with the anatomic severity of the disease. This lack of correlation may be due to variations in the metabolic activity of the endometriotic implants present at different stages of the disease. Because prostaglandin F (PGF) has been implicated as a hormonal mediator of the clinical symptoms of endometriosis, PGF synthesis and content was measured in implants from 14 patients with mild, moderate, severe, or extensive disease. To assess whether PGF production was related to the status of implants, the authors classified implants, based on gross and histologic criteria, as (1) petechial or reddish; (2) intermediate or brown; or (3) powder-burn or black. PGF production of implants from patients with mild or moderate disease was greater than that of implants from patients with severe or extensive disease (P < 0.05), and PGF content was similar for all stages of endometriosis. Petechial implants produced twice the amount of PGF than intermediate implants (P < 0.05), which in turn produced more PGF than powder-burn implants (P < 0.05). Powder-burn implants did not have the in vitro capacity to produce PGF, and the amount of PGF contained in implants of all classes was similar. Therefore, endometriotic implant PGF production and possibly other biochemical activities are dependent on the physical status of the implant. The classification of implants by morphologic appearance may afford additional assistance in determining the prognosis of the disease and in the examination of the subtle effects of the disease on symptoms.”

  • Wang, Y. Y., Leng, J. H., Shi, J. H., Li, X. Y., & Lang, J. H. (2010). Relationship between pain and nerve fibers distribution in multiple endometriosis lesions. Zhonghua fu chan ke za zhi, 45(4), 260. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20646536 

“There was significantly different distribution of nerve fibers in multiple endometriosis lesions, which was correlated with dysmenorrhea, anus pain, dyspareunia and chronic pelvic pain, not with clinical staging.”

  • McKinnon, B., Bersinger, N. A., Wotzkow, C., & Mueller, M. D. (2012). Endometriosis-associated nerve fibers, peritoneal fluid cytokine concentrations, and pain in endometriotic lesions from different locations. Fertility and sterility, 97(2), 373-380. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22154765 

“The presence of endometriosis-associated nerve fibers appear to be related to both the pain experienced by women with endometriosis and the concentration of PF cytokines; however, this association varies with the lesion location.”

  • Wang, G., Tokushige, N., & Fraser, I. S. (2011). Nerve fibers and menstrual cycle in peritoneal endometriosis. Fertility and sterility, 95(8), 2772-2774. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21334610/ 

“There was no difference in the density of nerve fibers across the menstrual cycle in peritoneal endometriotic lesions. These findings may explain why patients with peritoneal endometriosis often have painful symptoms throughout the menstrual cycle.” 

“Position and depth of invasion of endometriotic implants greatly impacts the procedure performed. Deeply infiltrating endometriosis (DIE) consists of endometriotic nodules that invade greater than 5mm into the peritoneal or organ surface. The type of pelvic pain is correlated to the location of the DIE implants and can aid in pre-operative assessment of each patients individualized symptoms (1). Patients with DIE are more likely to have noncyclic CPP, most likely related to the infiltration of subperitoneal or visceral nerves by the implant. This is facilitated by activation of prostaglandins and chemokines associated with local angiogenic and neurogenic environments. This is thought to increase C-type nerve fibers and increase sensation of CPP due to the constant inflammatory state that endometriosis creates (15). The stroma of these lesions expresses receptors for nerve growth factor (NGF), which aids in recruitment of sensory nerve fibers (16). This increase in innervations allows for further pain perception in affected individuals. The increase in these nociceptors is further enhanced by sensitization with estrogen, which is found in abundance due to local implant estradiol (E2) production.”

*angiogenic- forms new blood vessels, neurogenic- forms new nerves, nociceptors-pain receptors

“The pelvis is highly vascularized and enervated, which is why pain impulses from this region are processed and sent to the brain. This, along with multiple other factors, contributes to the pain syndrome that is associated with endometriosis. Peritoneal fluid in women with endometriosis contains high levels of nerve growth factors that promote neurogenesis, the ratio of sympathetic and sensory nerve fibers is significantly altered within endometriotic tissue, and the nerve density within endometriotic nodules is increased.7,8 Also, the cytokines and prostaglandins produced by mast cells and other inflammatory cells attracted to ectopic endometrial-like tissue can activate nerve fibers and can trigger nearby cells to release inflammatory molecules.5,6,8,9

“Another source of pain is nerve fiber entrapment within endometriotic implants.4 The cyclical sciatic pain, weakness, and sensory loss can all stem from endometriotic entrapment of the sciatic, femoral, or lumbosacral nerve roots.9 There are numerous descriptions of sacral radiculopathy occurring in patients with endometriosis, and there are even descriptions of wheelchair-bound patients becoming fully ambulatory after treatment of infiltrative endometriosis.9

“Central sensitization is another mechanism that promotes endometriosis-associated pain. Patients become highly sensitive to subsequent painful stimuli because of endometriosis-induced neuroplastic changes in descending pathways that modulate pain perception.10 In response to a subsequent insult (ie, nephrolithiasis or peritoneal organ injury), women can experience pain from endometriosis as a result of inability to engage descending inhibition pathways.”

“Initial work on mapping of pain associated with the endometriosis lesions resulted in some thought-provoking findings. The classic black lesions were found to be painful in only 11% of patients when the lesion was touched. Similarly, white lesions were painful in 20% of patients with red lesions at 37%, and clear lesions at 32% were the most painful (Table 1). These results added further reason as to why initial therapy had such poor results. Surgeons would only “see” the black lesions and removed them, but these were the least painful lesions. The most painful clear lesions were not “seen” at laparotomy and therefore remained, as did the pain. What became apparent next, while mapping the patient, was the fact that the pain extended 28 mm beyond the visible border of the lesion onto what looked like “normal” peritoneum ((Figure 1). Therefore, if the surgeon only removed the lesion at its border, the microscopic disease in the previously identified normal looking peritoneum was left, and persistence or recurrence of the symptoms was encountered.” 

  • Fraser, I. S. (2010). Mysteries of endometriosis pain: Chien‐Tien Hsu Memorial Lecture 2009.Journal of Obstetrics and Gynaecology Research, 36(1), 1-10. Retrieved from https://pubmed.ncbi.nlm.nih.gov/20178521/  “The more that one looks at the condition endometriosis, the more one realises that it is a unique and complex condition exhibiting a bizarre range of deviations from normal endometrial and myometrial physiology, and presenting with a challenging range of pain‐related symptoms. The changing nature of the pain is not well defined, and the molecular mechanisms leading to pain generation are far from clear. Recent research has begun to reveal some of these links between expression of unusual molecules in the eutopic endometrium and ectopic lesions, microanatomical changes in the pelvic nervous sytem, neuronal dysfunction and the later development of neuropathic pain.” 
  • Miller, E. J., & Fraser, I. S. (2015). The importance of pelvic nerve fibers in endometriosis. Women’s health, 11(5), 611-618. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26314611/

“Several lines of recent evidence suggest that pelvic innervation is altered in endometriosis-affected women, and there is a strong presumption that nerve fibers demonstrated in eutopic endometrium (of women with endometriosis) and in endometriotic lesions play roles in the generation of chronic pelvic pain. The recent observation of sensory C, sensory A-delta, sympathetic and parasympathetic nerve fibers in the functional layer of endometrium of most women affected by endometriosis, but not demonstrated in most women who do not have endometriosis, was a surprise. Nerve fiber densities were also greatly increased in myometrium of women with endometriosis and in endometriotic lesions compared with normal peritoneum. Chronic pelvic pain is complex, and endometriosis is only one condition which contributes to this pain. The relationship between the presence of certain nerve fibers and the potential for local pain generation requires much future research.” 

“Our group discovered that ectopic growths harvested from ENDO rats and women with established endometriosis develop their own C-fiber (sensory afferent) and sympathetic (autonomic efferent) nerve supply. The supply is derived from nerve fibers innervating nearby territories that sprout branches into the growths [10], [11]. This discovery suggests that, rather than the growths alone, it is the ectopic growth’s own innervation that is a major contributor to the maintenance and modulation of pain in established endometriosis.” 

  • Anaf, V., Chapron, C., El Nakadi, I., De Moor, V., Simonart, T., & Noël, J. C. (2006). Pain, mast cells, and nerves in peritoneal, ovarian, and deep infiltrating endometriosis. Fertility and sterility, 86(5), 1336-1343. Retrieved from https://doi.org/10.1016/j.fertnstert.2006.03.057 

“The presence of increased activated and degranulating mast cells in deeply infiltrating endometriosis, which are the most painful lesions, and the close histological relationship between mast cells and nerves strongly suggest that mast cells could contribute to the development of pain and hyperalgesia in endometriosis, possibly by a direct effect on nerve structures.” 

“The objective of this study was to evaluate the significance of severe preoperative pain for patients presenting with ovarian endometrioma (OMA)…. After multiple logistic regression analysis, uterosacral ligaments involvement was related with a high severity of chronic pelvic pain [odds ratios (OR) = 2.1; 95% confidence interval (CI): 1.1–4.3] and deep dyspareunia (OR = 2.0; 95% CI: 1.1–3.5); vaginal involvement was related with a higher intensity of lower urinary symptoms (OR = 13.4; 95% CI: 3.2–55.8); intestinal involvement was related with an increased severity of dysmenorrhoea (OR = 5.2; 95% CI: 2.7–10.3) and gastro-intestinal symptoms (OR = 7.1; 95% CI: 3.3–15.3). CONCLUSIONS: In case of OMA, severe pelvic pain is significantly associated with deeply infiltrating lesions. In this situation, the practitioner should perform an appropriate preoperative imaging work-up in order to evaluate the existence of associated deep nodules and inform the patient in order to plan the surgical intervention strategy.”

“In the brain stem, the neurotransmitters serotonin and norepinephrine modulate pain transmission through ascending and descending neural pathways. Both serotonin and norepinephrine are also key neurotransmitters involved with the pathophysiology of depression. Tricyclic antidepressants are effective treatments for pain and depression; selective serotonin reuptake inhibitors provide less benefit. Duloxetine and venlafaxine, which are serotonin and norepinephrine reuptake inhibitors, were shown in clinical trials to alleviate pain and depressive symptoms. Diabetic neuropathy and other chronic pain syndromes were also shown to benefit from duloxetine and venlafaxine. Antidepressants remain fundamental therapeutic agents for depression and anxiety disorders. Their extended use into chronic pain, depression with physical pain, physical pain with or without depression, and other potential medical conditions should be recognized.”

  • Grundström, H., Gerdle, B., Alehagen, S., Berterö, C., Arendt‐Nielsen, L., & Kjølhede, P. (2019). Reduced pain thresholds and signs of sensitization in women with persistent pelvic pain and suspected endometriosis. Acta obstetricia et gynecologica Scandinavica, 98(3), 327-336. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/aogs.13508

“Women with pelvic pain and suspicion of endometriosis should probably be treated more thoroughly to prevent or at least minimize the concomitant development of central sensitization.”

Links:

  • “Hormones and chemicals released by endometriosis tissue also may irritate nearby tissue and cause the release of other chemicals known to cause pain….Some endometriosis lesions have nerves in them, tying the patches directly into the central nervous system. These nerves may be more sensitive to pain-causing chemicals released in the lesions and surrounding areas. Over time, they may be more easily activated by the chemicals than normal nerve cells are. Patches of endometriosis might also press against nearby nerve cells to cause pain.” https://www.nichd.nih.gov/health/topics/endometri/conditioninfo/Pages/symptoms.aspx

Reference

Bloski, T., & Pierson, R. (2008). Endometriosis and chronic pelvic pain: unraveling the mystery behind this complex condition. Nursing for women’s health, 12(5), 382-395. doi: 10.1111/j.1751-486X.2008.00362.x

Ferrero, S., Vellone, V. G., & Barra, F. (2019). Pathophysiology of pain in patients with peritoneal endometriosis. Annals of translational medicine, 7(Suppl 1). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6462618/

3 years ago Symptoms No comment

Introduction: Pain

What a Pain!

  • Pain can be experienced as mild to severe.
  • Pain can occur at any time during the menstrual cycle. 
  • Pain may not be confined to the pelvic area. 
  • Pain can be experienced as inflammatory (due to inflammation), peritoneal quality (irritation of surrounding tissue in the abdomen), musculoskeletal (muscles and ligaments affected), and/or neuropathic (irritated nerves).

Pain greatly affects quality of life, sleep patterns, fatigue, ability to work or go to school, and the ability to perform normal daily tasks. It is important to identify what it causing pain. Other related conditions can contribute to pain. Removing endometriosis is a significant step in pain relief, but it is often not the only step. Identifying other conditions, such adenomyosis or interstitial cystitis, which may be contributing to symptoms is important as well. In addition, pain and other conditions can have an effect on muscles, ligaments, and nerves. Years of pain and untreated disease cannot be undone in a day. Medications, physical therapy, and other therapies can help (see “Treatments“). 

3 years ago Symptoms No comment

Symptoms Based on Endometriosis Locations

Symptoms based on location of endometriosis lesions:

  • Foti, P. V., Farina, R., Palmucci, S., Vizzini, I. A. A., Libertini, N., Coronella, M., … & Milone, P. (2018). Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights into imaging, 9(2), 149-172.

           “Clinical manifestations depend on the anatomic locations of the disease.

  • Bladder: dysuria, gross hematuria during menses, irritative voiding symptoms, urgency, frequent urination, urinary storage symptoms, tenesmus, burning sensation, suprapubic discomfort and pain, urinary incontinence [2, 3, 15].
  • Ureters: dysmenorrhea, dyspareunia, urinary symptoms, hydronephrosis, flank pain, decline of renal function [2, 3].
  • Round ligaments: painful, palpable inguinal mass (extra-pelvic portion of the ligaments); nonspecific pelvic pain (intra-pelvic portion) [11].
  • Retrocervical region and uterosacral ligaments: severe and painful symptoms, dyspareunia [3].
  • Vagina: dysmenorrhea, dyspareunia, postcoital spotting, prolonged menstruation not responding to medical therapy leading to anaemia [3, 16].
  • Rectosigmoid colon: cyclic pain during defecation, dyschezia, cyclic hematochezia, bloating, constipation, bowel cramping, catamenial diarrhoea, pencil-like stools, bowel obstruction [2, 3, 12, 17].
  • When unusual locations outside the pelvis occur, the pain may be site specific.
  • Thoracic-diaphragmatic endometriosis: chest pain (diffuse or basithoracic) with right-sided predominance, scapular or cervical pain associated with menses, sometimes radiating to the arm, pneumothorax, dyspnea, hemoptysis [18,19,20].
  • Sciatic nerve: cyclic sciatica, back pain, gluteal pain radiating to the dorsal thigh and lateral lower leg, positive Lasègue’s sign, sensory loss, reflex alterations, muscle weakness, paresis [2, 21,22,23].”
3 years ago Symptoms No comment

Endometriosis symptoms

Endometriosis symptoms

Endometriosis symptoms can vary widely in both presentation and severity. While endometriosis can present with “typical” symptoms such as chronic pelvic pain during menstruation, it can also present with symptoms not readily attributed to endometriosis. One example is sciatica type symptoms- pain running along the lines of the sciatic nerve (from the low back down the back of the leg). For some, infertility rather than pain is the first sign that they note.

Pelvic Endometriosis:

The following study performed a literature review on pelvic endometriosis in order to identify signs and symptoms (hoping to lead to more timely investigation into the possibility of endometriosis).

Riazi, H., Tehranian, N., Ziaei, S., Mohammadi, E., Hajizadeh, E., & Montazeri, A. (2015). Clinical diagnosis of pelvic endometriosis: a scoping review. BMC women’s health, 15(1), 39. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450847/pdf/12905_2015_Article_196.pdf

  • Pain:
    • Pain with periods (dysmenorrhea)- during and at the end of menstruation
    • Pelvic pain before and during menstruation
    • Pain during sexual intercourse or after sex (dyspareunia)
    • Lower abdominal pain or suprapubic pain
    • Lower back pain and loin pain
    • Chronic pelvic pain (lasting ≥6 months)
    • Pain between periods (intermenstrual pain)
    • Ovulation pain
    • Rectal pain (throbbing, dull or sharp, exacerbated by physical activity)
    • Pain often worsened over time and changed in character
  • Menstrual symptoms:
    • Heavy or prolonged periods (hypermenorrhea or menorrhagia)
    • Premenstrual spotting for 2–4 days
    • Mid cycle bleeding
    • Irregular bleeding
    • Irregular periods
  • Urinary problems:
    • Pain with urination (dysuria)
    • Blood in urine (hematuria)
    • Urinary frequency
    • Urinary tract infection
    • Inflammation of the bladder (cystitis)
  • Digestive symptoms:
    • Abdominal bloating
    • Diarrhea with period
    • Painful bowel movements
    • Painful defecation (dyschezia) during periods
    • Blood in stool (hematochezia)
    • Nausea and stomach upset around periods
    • Constipation
    • Irritable bowel syndrome (IBS)
    • Early satiety
  • Gynecologic comorbidities:
    • Gynecological infections and low resistance to infection
    • Candidiasis
    • Infertility
    • Pelvic inflammatory disease
    • Ovarian cysts
    • Bleeding after sex (postcoital bleeding)
  • Comorbidities:
    • wide range of allergies and allergic disease
    • dizziness
    • migraines and headaches at the time of period or before
    • mitral valve prolapse
  • Social life symptoms:
    • Inability to carry on normal activities including work or school
    • Depressed and anxious feelings
    • Irritability or premenstrual tension syndrome
    • Psychoemotional distress
  • Musculoskeletal symptoms:
    • muscle/bone pain
    • joint pain
    • leg pain
  • Other symptoms:
    • Chronic fatigue, exhaustion, low energy
    • Low-grade fever
    • Burning or hypersensitivity- suggestive of a neuropathic component
    • Mictalgia (pain with urination)

Some signs of endometriosis in other places/specific places might include:

  • Bowel:
    • Abdominal pain
    • Disordered defecation (dyschezia)
    • Having to strain harder to have a bowel movement or having cramp like pain in the rectum (tenesmus)
    • Bloating, abdominal discomfort (meteorism)
    • Constipation
    • Diarrhea
    • Alternating constipation/diarrhea
    • Painful defecation
    • Dark feces containing blood (melena) or fresh blood with bowel movements (hematochezia) (Charatsi et al., 2018)
    • “The gastrointestinal tract is the most common location of extrapelvic endometriosis (and extragenital pelvic endometriosis when referring to rectum, sigmoid, and bladder)… Symptoms, in general, include crampy abdominal pain, dyschezia, tenesmus, meteorism, constipation, melena, diarrhea, vomiting, hematochezia, pain on defecation, and after meals. The traditional cyclical pattern of symptomatology has not been confirmed by recent studies which postulate a rather noncyclical chronic pelvic pain as a more persistent symptom [32]. Cyclical symptoms that aggravate during menses, however, have also been reported in a small number of patients [33, 34]. Since intestinal mucosa is rarely affected, rectal bleeding is also an unusual symptom, reported in 0 to 15% to 30% of patients [15, 35, 36]. Bleeding can also occur due to severe bowel obstruction and ischemia [32, 37]. Acute bowel obstruction due to stenosis is a scarce complication reported only in cases when severe small bowel involvement is present or in the presence of dense pelvic adhesions.” (Charatsi et al., 2018)
  • Bladder and Ureters:
    • “feeling the need to urinate urgently,
    • frequent urination,
    • pain when the bladder is full,
    • burning or painful sensations when passing urine,
    • blood in the urine,
    • pelvic pain,
    • lower back pain (on one side)” (Medical News Today, 2018)
    • None (if endometriosis is close to the ureters there may be no presenting symptoms)
    • “Vesical endometriosis is usually presented with suprapubic and back pain or with irritative voiding symptoms [96]. These symptoms generally occur on a cyclic basis and are exaggerated during menstruation. Less than 20% of patients however report cyclical menstrual hematuria, which is considered a pathognomic sign for bladder endometriosis [97–99]. Bladder detrusor endometriosis symptoms may cause symptoms similar to painful bladder syndrome; therefore, diagnosis of bladder endometriosis should be considered in patients with recurrent dysuria and suprapubic pain [100]. Clinical symptoms of ureteral endometriosis are often silent [76, 101, 102]. Since the extrinsic form of the disease is more common resulting from endometriosis affecting the rectovaginal septum or uterosacral ligaments and surrounding tissues, patients present with dyspareunia, dysmenorrhea, and pelvic pain [103]. Abdominal pain is the predominant symptom, occurring in 45% of symptomatic patients [93, 104–106]. Symptoms are often cyclical when the ureter is involved, and cyclic microscopic hematuria is a hallmark of intrinsic ureteral disease [95, 107, 108]. There is a limited correlation between severity of symptoms and the degree of obstruction of the ureter. High degree of obstruction may proceed for a long time without symptoms, leading to deterioration of renal function [76]. Unfortunately, ureteral endometriosis is often asymptomatic leading to silent obstructive uropathy and renal failure [109].” (Charatsi et al., 2018)
  • Thoracic (Diaphragm and Lung):
    • “…many patients being asymptomatic. Symptomatic patients often experience a constellation of temporal symptoms and radiologic findings with menstruation, including catamenial pneumothorax (80%), catamenial hemothorax (14%), catamenial hemoptysis (5%), and, rarely, pulmonary nodules.However, symptoms have been reported before menstruation, during the periovulatory period, and following intercourse.Symptoms of thoracic endometriosis are largely related to the anatomic location of the lesions. Pleural TES typically presents with symptoms of catamenial pneumothorax and chest or shoulder pain. Catamenial pneumothorax is defined as recurrent pneumothorax occurring within 72 h of the onset of menstruation. The symptoms experienced by patients are comparable to those of spontaneous pneumothorax and include pleuritic chest pain, cough, and shortness of breath. Furthermore, diaphragmatic irritation may produce referred pain to the periscapular region or radiation to the neck (most often right-sided). The right hemithorax is involved in up to 92% of cases, with 5% of cases involving the left hemithorax and 3% experiencing bilateral involvement. Catamenial hemothorax is a less common manifestation of pleural TES. Similar to catamenial pneumothorax, it presents with nonspecific symptoms of cough, shortness of breath, and pleuritic chest pain. It is predominantly right-sided, although rare cases of left-sided hemothorax have been reported.Less common bronchopulmonary TES presents as mild to moderate catamenial hemoptysis or as rare lung nodules identified on imaging. Massive, life-threatening hemoptysis is rare. Pulmonary nodules can be an incidental finding at the time of imaging or can occur in symptomatic patients. They can vary in size from 0.5 to 3 cm. Outside of the well-established clinical manifestations of TES, cases of isolated diaphragmatic endometriosis are typically asymptomatic but can result in irritation of the phrenic nerve. This can produce a syndrome of only catamenial pain, presenting as cyclic neck, shoulder, right upper quadrant, or epigastric pain.” (Nezhat et al., 2019)

(catamenial refers to menstruation; pneumothorax is air leaking into the space between the lung lining; hemothorax is blood leaking into the space between the lung lining; hemoptysis is coughing up blood)

  • Sciatic: pain in the buttock or hip area; pain, numbness, and/or weakness going down the leg; symptoms may initially occur with ovulation or menses (Sarr  et al., 2018)
  • Scar: “Symptoms at presentation included the presence of a palpable mass at the level of the scar (78.57%), non-cyclic and cyclic abdominal pain (50%, 42.85% respectively), bleeding form mass (7.14%) and swelling of the affected area (7.14%).” (Malutan et al., 2017)

This qualitative study describes symptoms as experienced by individuals with endometriosis:

“All women had suffered severe and progressive pain during menstrual and non-menstrual phases in different areas such as the lower abdomen, bowel, bladder, lower back and legs that significantly affected their lives. Other symptoms were fatigue, tiredness, bloating, bladder urgency, bowel symptoms (diarrhoea), bladder symptoms and sleep disturbances due to pain….

“The women described the pain as ‘sharp’, ‘stabbing’, ‘horrendous’, ‘tearing’, ‘debilitating’ and ‘breath-catching’. Severe pain was accompanied by vomiting and nausea and was made worse by moving or going to the toilet. The frequency of pain differed between the women with some reporting pain every day, some lasting for three weeks out of each menstrual cycle, and another for one year…

“Most of the women complained of dyspareunia during and/or after sex….

“Heavy and/or irregular bleeding was another symptom experienced but in some women, it was a side effect of endometriosis treatment. Bleeding when exercising and after sex were experienced by only a few women. Women and their partners were particularly worried when bleeding occurred after sex….

“Most women reported that endometriosis had significant impacts as they lived through it every day of their lives…. The physical impact was associated with symptoms, treatment side-effects and changes in physical appearance. Pain in particular was reported to limit their normal daily physical activity like, walking and exercise. Women who had small children mentioned that they were not able to care for them as they would like…Fatigue and limited energy were also among reported physical impacts of endometriosis. Although infertility was primarily a physical impact of endometriosis, it had a negative impact on the psychological health, relationship, and financial status of the women….

“Most women reported a reduction in social activity, and opted to stay home, and missed events because of severe symptoms especially pain, bleeding and fatigue. They resorted to using up their annual leave after exhausting their sick leave because of their disease. Some women also decreased their sport or leisure activities and some gave up their routine sport including water ski, horse-riding, swimming and snow skiing….”

References

Charatsi, D., Koukoura, O., Ntavela, I. G., Chintziou, F., Gkorila, G., Tsagkoulis, M., … & Daponte, A. (2018). Gastrointestinal and urinary tract endometriosis: a review on the commonest locations of extrapelvic endometriosis. Advances in medicine, 2018. Retrieved from https://www.hindawi.com/journals/amed/2018/3461209/

Malutan, A. M., Simon, I., Ciortea, R., Mocan-Hognogi, R. F., Dudea, M., & Mihu, D. (2017). Surgical scar endometriosis: a series of 14 patients and brief review of literature. Clujul Medical, 90(4), 411. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683831/

Medical News Today. (2018). Can endometriosis cause bladder pain?. Retrieved from https://www.medicalnewstoday.com/articles/321439

Nezhat, C., Lindheim, S. R., Backhus, L., Vu, M., Vang, N., Nezhat, A., & Nezhat, C. (2019). Thoracic endometriosis syndrome: a review of diagnosis and management. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 23(3). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684338/

Saar, T. D., Pacquée, S., Conrad, D. H., Sarofim, M., De Rosnay, P., Rosen, D., … & Chou, D. (2018). Endometriosis involving the sciatic nerve: a case report of isolated endometriosis of the sciatic nerve and review of the literature. Gynecology and minimally invasive therapy, 7(2), 81. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6113996/

iCareBetter