Pain relates to a neurological sensation causing emotional or physical discomfort.

The endurance of pain not only limits the individual’s capabilities, but may also alter quality of life. Therefore, the pursuit of pain relief is of the utmost importance.

Pelvic pain is commonly associated with women and is one of the common reasons for a visit to the gynaecologist.

The gynaecologist will conduct a thorough examination, order several tests as required, identify the root cause and administer appropriate treatment.

This task is carried out so that the pelvic pain is relieved and the woman is back to her pain-free lifestyle.

What if the medical examination and routine tests by the gynaecologist yield normal results?

In that case, what is the cause of the pelvic pain? Can the pain be relieved?

I am sure some women have gone through this predicament and are quite familiar with the medical term “endometriosis”. This is a condition related to pelvic pain that has been silently endured by these women.

In endometriosis, the cells of the uterus (womb) lining (endometrium) is found outside of the womb. It is often associated with cyclical period pain, and sometimes leads to long term pelvic pain.

Deposits of endometriosis can be found anywhere outside the womb, for example, on the innermost layer of the abdomen (peritoneum), ovaries, fallopian tubes, bladder and large bowel. In severe cases, it can also be found on the vaginal wall.

Endometriotic deposits cause an inflammatory reaction that leads to “injury” to the affected organ. The “injure-healing” cycle can lead to formation of adhesions or “stickiness” within the pelvis. These adhesions can lead to pain.

The actual prevalence of endometriosis is unknown, but it is estimated that between 2% and 10% of women in the general population, and up to 50% of women with infertility suffer from endometriosis.

In Malaysia, I believe the statistics are similar. This is partly due to the late diagnosis of endometriosis. Studies in Europe have shown that there is a delay in diagnosis between four and 10 years.

Among the reasons for the delay are intermittent use of contraceptive pills that cause hormonal suppression of the symptoms, misdiagnosis, and attitude towards menstruation and normalisation of pain by women.

Endometriosis cannot be reliably diagnosed based on medical history and examination alone. Special investigations in the form of a laparoscopy (keyhole surgery) is needed to confirm the diagnosis.

Early diagnosis of endometriosis is crucial as it can help the women take steps to reduce their disease burden and long-term complications of endometriosis. In fact, research reveals that the medical costs for the treatment of endometriosis is comparable to those of other chronic diseases like diabetes mellitus.

Who gets endometriosis?

Endometriosis, uterus, painful period, Star2.com

Endometriosis is the abnormal growth of cells (endometrial cells) similar to those that form the inside of the uterus, but in a location outside of the uterus. — TNS

Typically, there are two groups of women who present with symptoms of endometriosis – those who have difficulty conceiving (fertility related) and those with pain symptoms (non-fertility related).

In fertility-related cases, endometriosis causes inflammation of the pelvic organs. The chronic inflammatory process can lead to scarring of the affected organs. This can result in the blockage of the fallopian tubes (either one or both). A blocked or damaged fallopian tube makes it difficult for the egg to be picked up after an ovulation for fertilisation by the sperm.

Endometriosis is also a common cause of ovarian cyst formation. Removal of the ovarian cyst, either by laparoscopy or conventional surgery, has a risk of reducing the woman’s egg reserve (total number of eggs that she has). Multiple surgeries increases this risk. A woman’s fertility reduces with declining egg reserve.

Endometriosis can also affect egg quality. Studies conducted among women undergoing in-vitro fertilisation (IVF) treatment suggest that a woman with endometriosis tends to have “lower quality” eggs. This directly has an impact on the resulting embryos and pregnancy rate.

Endometriosis of the uterus, more commonly known as adenomyosis, may also be present in women suffering from endometriosis. Severe adenomyosis reduces pregnancy rates as it affects embryo implantation in the womb.

In non-fertility related endometriosis, many women are diagnosed when they present with severe period pain. If fertility is of no concern, period pain can be suppressed with hormonal or non-hormonal medications. Many of these treatment options are not recommended if the woman is trying to conceive.

The pain can be due to endometriosis deposits over the undersurface of the abdomen, formation of ovarian cysts, or scarring that causes adhesions of the pelvic organs. Endometriosis can also cause pain during sexual intercourse.

Treatment options

The type of medical management depends on the severity of pain and whether the woman is trying to conceive. If she is not planning for pregnancy, painkiller medications from non-steroidal anti-inflammatory drugs (NSAIDs) can control pain symptoms.

Usually, painkillers are given in combination with hormonal treatment such as a combined contraceptive pill (birth control pill that has both oestrogen and progesterone components).

If the woman cannot tolerate the side effects of oestrogen, progesterone-only hormonal medications can also be used. This form of medication can be administered orally, as three-monthly injections, a progesterone implant or a intrauterine device.

In women who have severe symptoms, monthly or three-monthly injections to temporarily “stop” her ovarian activity can be given. These injections contain gonadotrophin-releasing hormone (GnRh) analogues). They are commonly used with oral hormone supplements to prevent bone loss. This treatment is effective to alleviate pain, but the symptoms tend to recur once treatment is stopped.

The other type of “ovarian blocker” is known as GnRh antagonist. It can be given orally or as an injectable. For women who desire a pregnancy, unfortunately, many of the hormonal or ovarian blockers are not appropriate as treatment because they will prevent ovulation.

They can be given oral NSAIDs for the pain.They should also seek early advice from a fertility specialist. Many of them may need some form of assisted reproductive treatment to get them pregnant.

In terms of surgery, laparoscopy is needed in most cases of endometriosis, either as a diagnostic or therapeutic tool.

For women with ovarian endometrioma (ovarian cyst resulting form endometriosis) or with deposits of endometrial tissue outside the uterus, laparascopy can be used to remove the cyst and destroy the endometriotic spots. This intervention may help to reduce pain and is suitable for women who desire a pregnancy.

A more definitive surgical procedure is to remove a woman’s womb with or without removal of her ovaries. This can be done via laparoscopy or conventional open surgery. This is usually offered for patients who suffer from severe pain and have completed their family.

Laparoscopic nerve ablation (destroying the nerve ends) has also been offered to reduce pelvic pain. However, its efficacy has not been established.

Acupuncture and diet modifications have been advocated as possible therapies for endometriosis. Research has suggested possible therapeutic effects of acupuncture for period pain.

Research also suggests some correlation between diet and period pain but so far there are no effective dietary recommendations for prevention or treatment of endometriosis.

Many women may suffer silently from pain due to undiagnosed endometriosis. Women who suffer from period pain or have difficulty getting pregnant should consult a specialist doctor and seek appropriate advice early.

Dr Agilan Arjunan is an obstetrician and gynaecologist, and fertility specialist. For more information, e-mail starhealth@thestar.com.my.