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Dysmenorrhoea
Painful periods are called dysmenorrhoea and it’s very common (50% of women describe significant discomfort with their period) but when pain is severe and persistent through the entire period it is more likely to be associated with some kind of pathology within the uterus- uterine abnormalities, fibroids, adenomyosis where endometrial or uterine lining invades the muscles of the uterus and commonly endometriosis.
Endometriosis
Endometriosis is where endometrial-like tissue is located outside the uterus- most commonly within the peritoneal cavity. Since such tissue responds to normal hormonal stimulation it thickens during the menstrual cycle and bleeds as progesterone levels fall.
When period pain is accompanied by pain on intercourse and pain on going to the loo during the period there is more than a 95% chance of underlying endometriosis. Another symptom very strongly suggestive of endometriosis is late cycle spotting.
Because woman and their clinicians often regard period pain as “normal” there is often quite a delay in the diagnosis- one Australian study suggested an average of 7 years since presentation of first suggestive syndrome. The primary care physician plays an important role in picking up on these symptoms as early as possible
What is the cause?
There are several theories as to the cause of endometriosis- the most widely accepted that of retrograde menstruation. That means that instead of flowing out the cervix to the vagina and escaping, the cells of the lining of the womb actually pass up the fallopian tubes to escape into the peritoneum where the uterus ovaries and fallopian tubes, the bowel, and the bladder are situated.
Retrograde menstruation occurs in many women but only a small number will develop endometriosis and there are probably local immunological factors which allow the tissue to attach and flourish. Such theories do not however explain why the condition is sometimes seen outside the peritoneal cavity, such as in the pleura, the lining of the lungs or in the lungs. Nor do they explain how endometriosis has been documented in pre-pubescent girls or even in males.
We do know there is a familial factor involved; it runs in families since endometriosis is 6-7 times more common in first degree relatives of affected women than in the general population.
The pain is probably due to a combination of local inflammation and direct infiltration of the nerves in the pelvic floor and it is the latter which seems to be associated with the more severe pain syndromes. It is important to remember however that the degree of pain is not always correlated with the extent of the disease- women with advanced disease may have minimal discomfort while those with mild disease may describe excruciating pain. Careful examination will sometimes detect localised pelvic tenderness particularly in those women complaining of pain with intercourse.
Endometriosis is associated with infertility and the diagnosis is sometimes made only when a woman presents with difficulty falling pregnant. It would appear that the endometriosis affects both implantation and embryonic growth. The effect of endometriosis on fertility is probably overstated (it does after all run in families) and it is likely that the increasing age of women in this country attempting to fall pregnant creates a “double-whammy” situation in terms of fertility and adds to the fat that it is harder to fall pregnant as one travels through the 3rd to the 4th decade.
There are no specific lab tests for endometriosis. Transvaginal ultrasound can be very useful in the detection of the ovarian endometriomas which tend to be associated with more severe disease. Ultrasound is also useful in diagnosing adenomyosis- a condition in which ectopic endometrial tissue is seen within the uterine muscle. It is not however a particularly sensitive tool in the diagnosis of peritoneal deposits by the endometrial tissue and many women with extensive endometriosis will have a perfectly normal pelvic ultrasound. At the present time laparoscopy remains the gold standard for the diagnosis of endometriosis.
Treatment of Endometriosis
• Analgesics( pain killers) and anti-inflammatory agents such as the Non Steroidal Anti-Inflammatory Agents or NSAID, should for maximal benefit should be used regularly and not just when symptoms are at their worst.
• The Oral Contraceptive Pill and other annovulatory medications such as Implanon (an implanted rod which slowly pours out progesterone), Depo Provera (an injection of progesterone)and an estrogen and progesterone containing vaginal ring. These tend to reduce both pain and menstrual flow. Many recommend that for maximum efficacy women run cycles together to avoid regular monthly withdrawal bleeding and they need to realize there is no harm in this.
• Mirena is an intrauterine contraceptive device, the device is collated with the hormone progestin, also reduces pain and bleeding in women suitable for IUD insertion and there is growing evidence of its usefulness in the treatment of endometriosis.
Where endometriosis fails to respond to the above measures drugs such as Gestrinone, Danazol and medications which oppose the natural reproductive hormones (GnRH agonists) may prove effective though they are associated with a higher risk of side effects than any of the above agents.
A number of alternative therapies are presently under investigation but as yet there is not enough clinical evidence to recommend their use.
Surgical Treatment
Laparoscopic surgery is particularly effective at relieving the pain associated with endometriosis and also improves the chances of conception in the months immediately following treatment.
The current recommendation is for careful and complete removal or ablation of all visible endometriotic deposits rather than the more cursory procedures which many women underwent in the past at the time of their diagnostic procedure.
Unfortunately recurrence after surgical treatment is common, occurring in at least 10-20% of treated women per year. It is for this reason that most experts suggest that, unless there is an immediate desire for pregnancy; women should commence post-operative medical treatment in an attempt to prevent symptom recurrence.
In some cases of very severe disease, hysterectomy and bilateral oophorectomy
(removal of the ovaries) may be the only means of significantly relieving pelvic pain in women who have completed their family.
This is important that those women despite the hysterectomy require Combined
(estrogen plus progesterone therapy) rather than oestrogen-alone HRT as they may still have some areas of residual endometriosis which would be at risk of endometrial hyperplasia and adenocarcinoma.
Supportive treatment
Women should be given as much information as possible about the condition to enable them to make informed choices regarding treatment. Support groups and websites exist and many women find these extremely useful. Where dyspareunia or pain with intercourse is an issue there may be profound effects on relationships and enjoyment. Counselling, physiotherapy and referral to gynaecologist specializing in the treatment of pelvic pain may all be useful in such cases.
Adapted from material prepared by Dr Terri Foran - Royal Hospital for Women; Sydney; NSW. Australia. March 2009
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