Chronic Pelvic Pain May Be More Than Endometriosis Alone
If you have chronic pelvic pain, endometriosis is likely- endometriosis is diagnosed in up to 80% of patients with chronic pelvic pain (Butrick, 2007). Endometriosis is bad enough, but it is frequently accompanied by other conditions that can cause chronic pelvic pain and other symptoms similar to endometriosis. It is important to consider other possibilities besides just endometriosis when trying to determine treatment for your symptoms. Some of these conditions can also be a clue that endometriosis might be present, due the higher frequency of those conditions being found together. For instance:

• Adenomyosis: Adenomyosis and endometriosis have been found together anywhere from 21.8% to 79% of the time (Antero et al., 2017; Di Donato et al., 2014; Kunz et al., 2005).
• Interstitial cystitis (IC): The so-called “evil twin” of endometriosis occurs in anywhere between 33-65% of people with endometriosis (Butrick, 2007; Chung et al., 2005). One article stated that “if [endometriosis] symptoms recur within the first 12 months after surgical therapy, IC should be considered as a possible cause” or “when therapy for the symptoms of endometriosis is unsuccessful, increasing evidence suggests that IC may be an underlying cause” (Butrick, 2007).
• Endometrial/uterine polyps: Uterine polyps have been found in 48% of people with endometriosis (Zhang et al., 2018; Zheng et al., 2015). And if you have uterine polyps, you are also more likely to have adenomyosis as well (Indraccolo & Barbieri, 2011).
• Fibroids (Leiomyomas): Both endometriosis and fibroids have been found together in 12-26% of patients, although one small study found both in 86% of the patients studied (Huang et al., 2010; Nezhat et al., 2016; Uimara et al., 2011).

These can also lead to other problems such as pelvic floor dysfunction. Other conditions not necessarily associated with endometriosis can also cause chronic pelvic pain. These might include pelvic congestion syndrome, pudendal neuralgia, or occult hernias. This is why it is so important to identify other pain/symptom generators and treat those as well. If it all gets blamed on endometriosis, you may miss a key to finding relief.

Studies:

• Sieberg, C. B., Lunde, C. E., & Borsook, D. (2020). Endometriosis and pain in the adolescent-striking early to limit suffering: A narrative review. Neuroscience & Biobehavioral Reviews, 108, 866-876. Retrieved from https://www.sciencedirect.com/science/article/pii/S0149763419307742

“Among adults, the risk of developing a comorbid condition among endometriosis patients was at least twice as large for the following comorbidities: infertility/subfertility, ovarian cyst, uterine fibroids, pelvic inflammatory disorder, interstitial cystitis, irritable bowel syndrome, constipation/dyschezia, ovarian cancer, and endometrial cancer (Surrey et al., 2018). Additionally, the incidence of developing many other comorbidities was significantly higher among endometriosis patients compared with matched women without endometriosis. Two recent and thorough reviews of the epidemiological literature described a number of factors associated with the development of endometriosis, including genetic profile, inflammation, hormonal activity, increased exposure to menstruation, immunological dysfunction, and environmental toxicants (Parazzini et al., 2017; Kvaskoff et al., 2015). Additionally, it was shown that endometriosis is associated with higher rates of a variety of conditions, including ovarian and other gynecological cancers, thyroid cancer, autoimmune diseases, asthma/atopic diseases, and cardiovascular diseases (Kvaskoff et al., 2015). Investigating comorbidities offers multiple benefits, including informing clinical surveillance, helping to develop prevention and early detection guidelines, and improving patient outcomes (Missmer, 2009). It is unknown if women with comorbid conditions experience heightened pain secondary to endometriosis; however, this should be explored when investigating comorbid conditions. Particularly, the association and degree of impact has not been studied or identified among adolescent and young women with endometriosis.”

References

Antero, M. F., O’Sullivan, D., Mandavilli, S., & Mullins, J. (2017). High prevalence of endometriosis in patients with histologically proven adenomyosis. Fertility and Sterility, 107(3), e46. Retrieved from https://doi.org/10.1016/j.fertnstert.2017.02.088
Butrick, C. W. (2007). Patients with chronic pelvic pain: endometriosis or interstitial cystitis/painful bladder syndrome?. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 11(2), 182. Retrieved from https://europepmc.org/article/med/17761077
Chung, M. K., Chung, R. P., & Gordon, D. (2005). Interstitial cystitis and endometriosis in patients with chronic pelvic pain: the “evil twins” syndrome. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 9(1), 25. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015562/
Di Donato, N., Montanari, G., Benfenati, A., Leonardi, D., Bertoldo, V., Monti, G., … & Seracchioli, R. (2014). Prevalence of adenomyosis in women undergoing surgery for endometriosis. European Journal of Obstetrics & Gynecology and Reproductive Biology, 181, 289-293. Retrieved from https://doi.org/10.1016/j.ejogrb.2014.08.016
Huang, J. Q., Lathi, R. B., Lemyre, M., Rodriguez, H. E., Nezhat, C. H., & Nezhat, C. (2010). Coexistence of endometriosis in women with symptomatic leiomyomas. Fertility and sterility, 94(2), 720-723. Retrieved from https://www.fertstert.org/article/S0015-0282(09)00620-7/pdf
Indraccolo, U., & Barbieri, F. (2011). Relationship between adenomyosis and uterine polyps. European Journal of Obstetrics & Gynecology and Reproductive Biology, 157(2), 185-189. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21470766/
Kunz, G., Beil, D., Huppert, P., Noe, M., Kissler, S., & Leyendecker, G. (2005). Adenomyosis in endometriosis—prevalence and impact on fertility. Evidence from magnetic resonance imaging. Human reproduction, 20(8), 2309-2316. Retrieved from https://doi.org/10.1093/humrep/dei021
Nezhat, C., Li, A., Abed, S., Balassiano, E., Soliemannjad, R., Nezhat, A., … & Nezhat, F. (2016). Strong association between endometriosis and symptomatic leiomyomas. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 20(3). doi: 10.4293/JSLS.2016.00053
Uimari, O., Järvelä, I., & Ryynänen, M. (2011). Do symptomatic endometriosis and uterine fibroids appear together?. Journal of human reproductive sciences, 4(1), 34. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136067/
Zhang, Y. N., Zhang, Y. S., Yu, Q., Guo, Z. Z., Ma, J. L., & Yan, L. (2018). Higher prevalence of endometrial polyps in infertile patients with endometriosis. Gynecologic and obstetric investigation, 83(6), 558-563. DOI:10.1159/000487946
Zheng, Q. M., Mao, H. L., Zhao, Y. J., Zhao, J., Wei, X., & Liu, P. S. (2015). Risk of endometrial polyps in women with endometriosis: a meta-analysis. Reproductive Biology and Endocrinology, 13(1), 1-9. Retrieved from https://doi.org/10.1186/s12958-015-0092-2