Noncyclic Pelvic Pain Research Articles

Lasers in the surgical management of endometriosis

Endometriosis affects millions worldwide. Its symptoms include non-cyclical pelvic pain, dysmenorrhoea, dyspareunia and subfertility. The diagnosis is made by laparoscopy, and operative laparoscopic surgery for endometriosis is also possible. As well as conventional laparoscopic techniques, lasers have been used in laparoscopic surgery for the past two decades. The main advantages of lasers are that they allow surgeons to perform operative surgery via the minimally invasive approach of laparoscopy, the operation is largely bloodless, the injury to the surrounding tissue is highly controllable and postoperative adhesion formation has been shown to be no greater than with conventional methods. The CO 2 laser is the most precise laser for the division of adhesions and the accurate and safe vapourization of deposits of endometriosis. Several types of operative procedure to treat endometriosis have been carried out with the CO 2 laser laparoscope. This article provides an overview of laser physics, the effects on the tissues, the clinical use of lasers, the appearance of endometriotic lesions and the management of endometriosis of the peritoneum, ovary, rectovagina, ureter and bladder by laser laparoscopic techniques.

Symptom distribution among infertile and fertile endometriosis cases with different stages and localisations

Objective: To evaluate endometriosis patients’ symptoms and relate them to different stages and locations of endometriosis and also to fertility/infertility of the patients. Study design: Sixty-eight patients diagnosed with endometriosis constituted the population investigated in this cross-sectional observational study, 55 and 13 of whom were diagnosed from the visual findings recorded during laparoscopy and laparotomy, respectively. All cases were categorised as early- (stages I and II) or late (stages III and IV)-stage endometriosis and as fertile or infertile endometriosis. The extent of endometriosis was further divided into peritoneal, ovarian, and ovarian and peritoneal. Symptoms of dysmenorrhoea, deep dyspareunia, dyschesia and dysuria and also depressive mood state were analysed and compared among those different groups. Results: Cyclic chronic pelvic pain was more relevant in late-stage endometriosis ( P = 0.04). Deep dyspareunia, painful defecation, dysuria, infertility, and depressive state did not differ with stages of endometriosis or fertility status. Admission for pelvic pain of any duration was more prevalent among fertile patients with endometriosis ( P = 0.008). Chronic noncyclic pelvic pain was more frequently observed in patients with fertile than in those with infertile endometriosis ( P = 0.01). More cases in the fertile group experienced noncyclic pelvic pain ( P = 0.04). More patients admitted with cyclic pelvic pain had ovarian or ovarian and peritoneal endometriosis than peritoneal endometriosis only ( P = 0.03). Infertility was more prevalent among peritoneal endometriosis cases than among those with ovarian or peritoneal and ovarian involvement ( P = 0.008). Conclusion: Symptoms of endometriosis may predict the stage and localisation of the disease to some extent.

Imagerie de l'endométriose

Endometriosis is characterised by ectopic endometrial tissue, which can cause dysmenorrhoea, dyspareunia, non-cyclical pelvic pain, and sub fertility. Final diagnosis is made by laparoscopy, but can also be helped by imaging. Most endometrial deposits are found in the pelvis (ovaries, peritoneum, uterosacral ligaments, pouch of Douglas, and rectovaginal septum). Extra pelvic deposits, including those in the umbilicus and diaphragm, are rare. Endometriomas are cysts of endometriosis within the ovary. Endometrial implants are responsible of pelvic adhesions or visceral infiltration. Consequences of these disease are often severe, from pelvic chronic pain until ureteral or rectal invasion. Diagnosis is difficult. Ultrasonography is able to detect ovarian endometriomas or adenomyosis but can not detect deep posterior endometriosis. MRI. is actually the more accurate examination for diagnosis and presurgical staging for endometriosis. Nevertheless, the knowledge of MRI technical parameters, and rules of interpretation are necessary for diagnosis accuracy, due to difficulty to detect the lesions. In this review, we will successively describe endometriosis physiopathology and imaging with different locations, with a particular attention to MRI, in order to allow adequate diagnosis and staging.

Optimizing Gonadotropin-Releasing Hormone Agonist Therapy in Women with Endometriosis

Endometriosis is a highly prevalent disease among women of reproductive age. While many treatments are available, one of the most widely utilized is treatment with gonadotropin-releasing hormone (GnRH) agonists. These agents work by producing a profound suppression of gonadotropin secretion by the pituitary, resulting in a hypoestrogenic state and subsequent diminution of endometriosis lesions. The GnRH agonists on the market have been shown to work quite well in reducing all pain symptoms associated with endometriosis, including dysmenorrhea, dyspareunia, and noncyclic pelvic pain. However, there is no evidence to suggest that this treatment is of value in endometriosis-associated infertility. Conflicting data exist regarding the role of GnRH agonists in the treatment of endometriomas, but the bulk of the evidence suggests a low degree of efficacy. GnRH agonists are often initiated with the onset of menses, but a more rapid response is observed with mid-luteal administration. A limit of 6 months per treatment course is required due to loss of bone mineral density during therapy, but this can be extended via the addition of 'add-back' therapy. Such adjunctive regimens demonstrated to maintain efficacy and reduce adverse effects include progestogen alone or a low-dose combination of estrogen and progestogen. Retreatment with these drugs is supported by limited data. The use of GnRH agonists as surgical adjuncts has been studied by several investigators. Their use preoperatively has not been shown to be of value. Similarly, 3 months of postoperative administration has failed to enhance treatment. However, 6 months of postoperative GnRH agonists appear to improve the duration of relief of pain symptoms. Future studies will need to focus on the role of these agents when used for repeated courses, in young women, and in conjunction with assisted reproduction.

Uterine fibroids and gynecologic pain symptoms in a population-based study

Objective To determine the association between dyspareunia, dysmenorrhea, and noncyclic pelvic pain and the presence and characteristics of uterine fibroids. Design Population-based cross-sectional study. Setting Desio, Italy. Patient(s) Six hundred thirty-five non–care-seeking participants of the Seveso Women's Health Study with an intact uterus who underwent transvaginal ultrasound. Intervention(s) None. Main outcome measure(s) Ultrasound-detected presence of uterine fibroids and fibroid characteristics including volume, number, location, and position. Current dyspareunia, dysmenorrhea, and noncyclic pelvic pain was measured by self-report on a visual analog scale. Result(s) Uterine fibroids were detected in 96 women (15%). Women with fibroids were more likely to report moderate or severe dyspareunia (adjusted odds ratio [OR] = 2.8, 95% confidence interval [CI] = 0.9–8.3, statistically significant trend) and moderate or severe noncyclic pelvic pain (adjusted OR = 2.6, 95% CI = 0.9–7.6, statistically significant trend) than women without fibroids. Moderate or severe dysmenorrhea was not associated with the presence of fibroids (adjusted OR = 1.1, 95% CI = 0.5–2.6). Number and total volume of fibroids were not related to pain. Conclusion(s) This is the first population-based study of gynecologic pain symptoms and fibroids. Dyspareunia and noncyclic pelvic pain, but not dysmenorrhea, increased in severity with the presence of uterine fibroids. Fibroid-associated pain symptomatology in a non–care-seeking population may be different from that of a clinic population.

Validation study of nonsurgical diagnosis of endometriosis

Objective: To determine whether the surgical diagnosis of endometriosis can be predicted using symptoms, signs, and ultrasound findings. Design: Prospective study (study sample); retrospective record review (test sample). Setting: Hospital of Desio (study sample) and Mangiagalli Hospital (test sample), Italy. Patient(s): Ninety women scheduled to undergo laparoscopy or laparotomy (study sample); 120 women who underwent laparoscopy (test sample). Intervention: The study sample group was interviewed before surgery about infertility and dysmenorrhea, dyspareunia, and noncyclic pelvic pain and each member had a pelvic examination and a transvaginal ultrasound. At surgery, endometriosis was noted. For the test sample, the same information was abstracted from medical records after laparoscopy. Main Outcome Measure(s): The ability of symptoms, signs, and ultrasound to predict endometriosis at surgery. A classification tree was developed with the study sample and evaluated with the test sample. Result(s): Ovarian endometriosis, but not nonovarian endometriosis, could be reliably predicted with noninvasive tools. Ultrasound and examination best predicted ovarian endometriosis, correctly classifying 100% of cases with no false positive diagnoses in the study sample. Similar results were found in the test sample. Conclusion(s): Noninvasive tools may be used to identify women with ovarian, but not nonovarian endometriosis, with excellent agreement with surgical diagnosis.

GnRH analogue in everyday gynecology, Is it possible to rationalize its use?

The study was an audit of patients who attended the Menstrual Disorders Clinic at Glasgow Royal Infirmary over a five year period, and received gonadotrophin-releasing hormone analog (GnRHa). We aimed to identify the clinical indications for the use of GnRHa, and the effect of the latter in terms of symptom resolution and ultimate outcome. We aim to use this information to formulate a strategy for the use of GnRHa by targeting this expensive therapy to those situations where maximum benefit will be achieved. A retrospective case review analysis of 201 patients. Thirty-eight percent of women presented with pelvic pain, 33% with disordered menstruation and 26% with premenstrual symptomatology. Overall, 74% of patients reported a beneficial effect of GnRHa. In the non-cyclical pelvic pain group, those patients with adhesions constituted a much greater proportion of those who did not derive benefit from GnRHa than those who did (43% vs. 16%; p<0.05; data not shown). In those patients with disordered menses, there was no difference between the diagnosis in those who did or did not derive benefit from GnRHa. Also with the exception of endometrial preparation prior to ablation and in the correction of anemia, the ultimate outcome was no different in the two groups. Of the patients with premenstrual symptomatology, the greatest proportion of those deriving benefit from GnRHa (41%) ultimately had an operative resolution. Our results enable us to use GnRHa as a first line in those clinical situations where maximum benefit will be achieved, either in terms of symptom resolution or as a tool to identify the most appropriate therapeutic option. We can therefore rationalize our prescribing both to the benefit of the patient and to our budget.

Menstrual disorders and pelvic pain after sterilization

Changes in menstrual cycle length, menstrual duration, number of pads, dysmenorrhea and non-cyclic pelvic pain were studied in 43 women following tubal sterilization with three different techniques. One group consisted of 17 women undergoing laparotomy by Pomeroy technique; the second group consisted of 11 women undergoing laparoscopy by Fallope rings; and the third group consisted of 15 women undergoing colpotomy by fimbriectomy. The differences before and after sterilization in cycle length were non-significant in all groups (p > 0.05). After sterilization, menstrual duration and number of pads were significantly increased in the laparotomy (p < 0.001) and laparoscopy (p < 0.01) groups but non-significantly in the colpotomy group (p > 0.05). Comparison of these parameters between the groups did not show any significant differences (p > 0.05). After sterilization, increases in the severity of dysmenorrhea and non-cyclic pelvic pain were non-significant in all groups (p > 0.05). We concluded that there were no significant differences in menstrual disorders after sterilization among these three different techniques.

"Changes in Menstrual Symptoms among Sterilized and Comparison Women: A Prospective Study."

Changes in menstrual parameters after tubal sterilization were analyzed in ethnically diverse, poor women from three geographic areas in the United States. Two large suitable comparison groups were similarly studied. Menstrual cycles, duration of menstrual flow, and bleeding between periods were unchanged in the sterilization and comparison groups. The prevalence of dysmenorrhea increased in 10.8% of sterilized women, compared with 2.1% in the comparison groups. This difference was even more significant--16.4 and -0.5%--when usage of oral contraceptives and intrauterine devices was discounted. There was a nonsignificant increase in noncyclic pelvic pain.

Post-tubal sterilization syndrome—A misnomer

Menstrual parameters and gynecologic symptoms of 389 women who underwent laparoscopic tubal banding were studied prospectively and longitudinally. Previous oral contraceptive users exhibited an immediate increase in menstrual flow and dysmenorrhea, which declined slightly with time. No such changes occurred in women who used other methods of temporary contraception. A significant increase in noncyclic pelvic pain, independent of previous contraceptive usage, developed only in women >38 years of age. Menstrual cycles and dyspareunia were not affected. A small control group of women whose husbands underwent vasectomy showed no significant changes in any of these parameters.