Dealing with pain associated with Endometriosis and subfertility            

Dr. Anupama.R, Director and Chief consultant , PRAN fertility centre, Trivandrum

The cramps you get during your period can be tough. But if you have endometriosis, the pain can feel so intense it can affect your daily routine, and it even can stop you from doing some of the things you love. Endometriosis is a chronic and recurrent disease characterized by the presence and proliferation of endometrial tissue outside the uterine cavity, which occurs in approximately 10% of women of reproductive age.

In this estrogen-dependent disorder, lesions become inactive and gradually undergo regression during states of ovarian down-regulation, such as amenorrhea or menopause. The impact of endometriosis includes impaired fertility potential, as well as symptoms of dysmenorrhea, dyspareunia and chronic non-menstrual pain, all of which adversely affect quality of life. Concentrations of PGs are higher in the menstrual blood of women with endometriosis. It was found that frequency, amplitude and basal pressure tone of uterine contractions in women with endometriosis were higher than in those without. Thus, the severe dysmenorrhea of endometriosis patients may be the result of abnormal uterine contractions.Endometriotic lesions and adhesions may also cause the deep pelvic pain associated with endometriosis. The pain of patients with endometriosis is thus due to both uterine contraction and endometriotic lesions.

Medical management of endometriosis

Early diagnosis is essential in order to decrease pain and hopefully prevent disease progression and preserve future fertility. Lower fertilisation and implantation rates observed among women with endometriosis are likely to be due to abnormalities in oocyte quality and early embryo development, as opposed to decreased endometrial receptivity. Endometriosis-associated pain includes dysmenorrhea, dyspareunia, dysuria, dyschezia and nonmenstrual pelvic pain, but the literature searches were not restricted to these terms. In the searches, quality of life was included, although this was found as an outcome in only a limited number of studies. Treatment modality depends on age , symptoms and fertility wishes.

Early diagnosis is essential in order to decrease pain and hopefully prevent disease progression and preserve future fertility. Lower fertilisation and implantation rates observed among women with endometriosis are likely to be due to abnormalities in oocyte quality and early embryo development, as opposed to decreased endometrial receptivity. Endometriosis-associated pain includes dysmenorrhea, dyspareunia, dysuria, dyschezia and nonmenstrual pelvic pain, but the literature searches were not restricted to these terms. In the searches, quality of life was included, although this was found as an outcome in only a limited number of studies. Treatment modality depends on age , symptoms and fertility wishes.

Surgical treatment of endometriosis

Surgical treatment — elimination of endometriotic lesions, division of adhesions and interruption of nerve pathways — has long been an important part of the management of endometriosis. Operative laparoscopy (excision/ablation) is more effective for the treatment of pelvic pain associated with all stages of endometriosis. LUNA is not beneficial as an additional procedure to conservative surgery for endometriosis, as it offers no additional benefit over surgery alone (Proctor, et al., 2005). PSN is beneficial for treatment of endometriosis-associated midline pain as an adjunct to conservative laparoscopic surgery, but it should be stressed that PSN requires a high degree of skill and is associated with increased risk of adverse effects such as bleeding, constipation, urinary urgency and painless first stage of labour.

Cystectomy is superior to drainage and coagulation in women with ovarian endometrioma (? 3cm) with regard to the recurrence of endometriosis-associated pain and the recurrence of endometrioma. Cystectomy is probably more effective than CO2 laser vaporization in women with ovarian endometrioma (?3cm) with regard to recurrence of endometrioma. surgery improves pain and quality of life in women with deep endometriosis. However, surgery in women with deep endometriosis is associated with substantial intraoperative and postoperative complication rates.Postoperative adjunctive hormonal therapy within 6 months after surgery can be prescribed with the aim of improving the outcome of surgery for pain; and secondary prevention, which is defined as prevention of the recurrence of pain symptoms or the recurrence of disease in the long-term (more than 6 months after surgery). The use of nutritional supplements, complementary or alternative medicine in the treatment of endometriosis-associated pain, because the potential benefits and/or harms are unclear.

Apart from the economic burden, endometriosis has a significant effect on various aspects of womens’ lives, including their social and sexual relationships, work and study (De Graaff, et al., 2013, Nnoaham, et al., 2011, Simoens, et al., 2012). Caretakers should be aware of these issues in order to adequately assist women with endometriosis in coping with these impacts of the disease on their daily lives.