Focal pelvic tenderness, pelvic pain and dysmenorrhea in endometriosis

Laparoscopic Appearance of Endometriosis: Color Atlas (Second Edition)

Martin DC et al., 1990

Correlation between endometriosis and pelvic pain

Porpora MG et al., 1999 · J Am Assoc Gynecol Laparosc

To evaluate the relationship between prevalence and severity of chronic pelvic pain (CPP) and stage, site, and type of endometriosis. Prospective, observational study (Canadian Task Force classification II-2). University Hospital. Of 90 consecutive women with biopsy-proved endometriosis, laparoscopy was performed in 69 for pelvic pain and in 21 for infertility or clinical and ultrasonographic suspicion of ovarian endometriosis. Preoperatively, using a 10-point visual analog scale, the severity of dysmenorrhea, CPP, and deep dyspareunia was assessed. During laparoscopy all visible endometriotic lesions were recorded and treated. MAIN Ten women (11.1%) had no pain; 72 had dysmenorrhea (mild in 13, moderate in 37, severe in 22); 55 had CPP (mild in 11, moderate in 25, severe in 19); and 39 deep dyspareunia (mild in 5, moderate in 31, severe in 3). The severity of dysmenorrhea significantly correlated with the presence and extent of pelvic adhesions (p = 0.004); the severity of CPP correlated with deep endometriosis on the uterosacral ligaments (p = 0.0001) and extent of pelvic adhesions (p = 0.02); and deep dyspareunia correlated with deep endometriosis on the uterosacral ligaments (p = 0.04). Total pain score significantly correlated with deep endometriosis on the uterosacral ligaments (p = 0.0001), peritoneal adhesions (p = 0.01), and extent of adnexal adhesions (p = 0.01). No significant correlation was found among revised American Fertility Society stage of endometriosis; presence and size of ovarian endometriomas; extent, type, and site of peritoneal lesions; and pain scores. By logistic regression analysis, the presence and intensity of total pain could be predicted simultaneously by the presence of deep endometriosis (p = 0.0001) and presence and extent of adnexal adhesions without cystic endometriosis (p = 0.01), and by the presence of ovarian endometrioma with periovarian adhesions (p = 0.03). Chronic pelvic pain was predicted by both deep endometriosis (p = 0.0001) and ovarian endometriomas with adnexal adhesions (p = 0.03). Deep dyspareunia was predicted simultaneously by deep endometriosis (p = 0.01) and an ovarian endometrioma with periovarian adhesions (p = 0. 008). Conclusion. Deep endometriosis, pelvic adhesions, and ovarian cystic endometriosis were independent predictors of pelvic pain. These data strongly suggest that it is not the size of ovarian cystic endometriosis but the association with adhesions that causes pelvic pain.

Pain typology and incident endometriosis

Mumford SL et al., 2015 · Hum Reprod · Free full text on PubMed Central

What are the pain characteristics among women, with no prior endometriosis diagnosis, undergoing laparoscopy or laparotomy regardless of clinical indication? Women with surgically visualized endometriosis reported the highest chronic/cyclic pain and significantly greater dyspareunia, dysmenorrhea, and dyschezia compared with women with other gynecologic pathology (including uterine fibroids, pelvic adhesions, benign ovarian cysts, neoplasms and congenital Müllerian anomalies) or a normal pelvis. Prior research has shown that various treatments for pain associated with endometriosis can be effective, making identification of specific pain characteristics in relation to endometriosis necessary for informing disease diagnosis and management. STUDY DESIGN, SIZE, The study population for these analyses includes the ENDO Study (2007-2009) operative cohort: 473 women, ages 18-44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at one of 14 surgical centers located in Salt Lake City, UT or San Francisco, CA. Women with a history of surgically confirmed endometriosis were excluded. PARTICIPANTS/MATERIALS, Endometriosis was defined as surgically visualized disease; staging was based on revised American Society for Reproductive Medicine (rASRM) criteria. All women completed a computer-assisted personal interview at baseline specifying 17 types of pain (rating severity via 11-point visual analog scale) and identifying any of 35 perineal and 60 full-body front and 60 full-body back sites for which they experienced pain in the last 6 months. MAIN There was a high prevalence (≥30%) of chronic and cyclic pelvic pain reported by the entire study cohort regardless of post-operative diagnosis. However, women with a post-operative endometriosis diagnosis, compared with women diagnosed with other gynecologic disorders or a normal pelvis, reported more cyclic pelvic pain (49.5% versus 31.0% and 33.1%, P < 0.001). Additionally, women with endometriosis compared with women with a normal pelvis experienced more chronic pain (44.2 versus 30.2%, P = 0.04). Deep pain with intercourse, cramping with periods, and pain with bowel elimination were much more likely reported in women with versus without endometriosis (all P < 0.002). A higher percentage of women diagnosed with endometriosis compared with women with a normal pelvis reported vaginal (22.6 versus 10.3%, P < 0.01), right labial (18.4 versus 8.1%, P < 0.05) and left labial pain (15.3 versus 3.7%, P < 0.01) along with pain in the right/left hypogastric and umbilical abdominopelvic regions (P < 0.05 for all). Among women with endometriosis, no clear and consistent patterns emerged regarding pain characteristics and endometriosis staging or anatomic location. LIMITATIONS, Interpretation of our findings requires caution given that we were limited in our assessment of pain characteristics by endometriosis staging and anatomic location due to the majority of women having minimal (stage I) disease (56%) and lesions in peritoneum-only location (51%). Significance tests for pain topology related to gynecologic pathology were not corrected for multiple comparisons. Results of our research suggest that while women with endometriosis appear to have higher pelvic pain, particularly dyspareunia, dysmenorrhea, dyschezia and pain in the vaginal and abdominopelvic area than women with other gynecologic disorders or a normal pelvis, pelvic pain is commonly reported among women undergoing laparoscopy, even among women with no identified gynecologic pathology. Future research should explore causes of pelvic pain among women who seek out gynecologic care but with no apparent gynecologic pathology. Given our and other's research showing little correlation between pelvic pain and rASRM staging among women with endometriosis, further development and use of a classification system that can better predict outcomes for endometriosis patients with pelvic pain for both surgical and nonsurgical treatment is needed. Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests.

Pain symptoms associated with endometriosis

Fedele L et al., 1992 · Obstet Gynecol

We evaluated the prevalence and severity of dysmenorrhea, pelvic pain, and deep dyspareunia and their relation to disease stage and site in 124 infertile women with endometriosis and 67 infertile women with normal findings. Seventy-eight endometriosis patients had stages I-II disease and 46 had stages III-IV. The frequency of dysmenorrhea was similar in patients and controls; pelvic pain was more frequent only in patients with stages III-IV, whereas deep dyspareunia was more prevalent regardless of disease stage. Dysmenorrhea was significantly more severe in stages III-IV patients than in either stages I-II patients or controls. Pelvic pain was more severe in stages III-IV, but we observed a statistically significant difference only in comparison with stages I-II. An association of two or more pain symptoms was more frequent in women with endometriosis than in those with normal pelves (relative risk = 3.1, 95% confidence interval 1.52-6.46). Ovarian endometriomas were the only lesions significantly associated with severe dysmenorrhea and pelvic pain. We conclude that endometriosis in infertile women causes pelvic pain, the severity of which is related to the extent of the disease.

Combined hysteroscopic and laparoscopic findings in patients with chronic pelvic pain

Carter JE, 1994 · J Am Assoc Gynecol Laparosc

To document the abnormal findings at hysteroscopy and laparoscopy in patients with chromic pelvic pain. Prospective evaluation at surgery of women treated consecutively between January 1, 1991, and December 30, 1992. A private practice. One hundred forty-one women with pelvic pain (average age 35 yrs). Laparoscopy was performed in all patients, and hysteroscopy in all but one, who had had a hysterectomy. Endometrial and endocervical biopsies were performed. MAIN In 42 (30%) of 140 patients with a primary diagnosis of chronic pelvic pain hysteroscopic evaluation with endometrial and endocervical biopsies revealed an abnormality. Findings at hysteroscopy included leiomyomas in 25 patients (18%), intrauterine polyps in 9 (6.4%), and cervical stenosis in 4 (2.9%). Three women (2.1%) had intrauterine scarring and one (0.7%) had a bicornuate uterus. Endometrial biopsies showed adenomatous hyperplasia with atypia, and cystic hyperplasia in one patient each. Endocervical biopsies revealed cervical dysplasia in four women (2. 89%). An abnormal finding was documented on laparoscopic examination in all 141 patients. These included endometriosis in 113 patients (80%), adhesions in 67 (48%), leiomyomas in 59 (42%), and enlarged globular uterus in 34 (24%). In addition, appendiceal abnormalities were present in three women (2.1%) and hernia in two (1.4%). Hysteroscopic abnormalities were found in 30% and laparoscopic abnormalities in 100% of patients who had a primary diagnosis of chronic pelvic pain.