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Is There Any Correlation Between Stages of Endometriosis and Severity of Chronic Pelvic Pain? Possibilities of Treatment

Posted on: Saturday, 8 October 2005, 03:00 CDT

By Szendei, Gyorgy; Herndi, Zsolt; Dvnyi, Nra; Csap, Zsolt

Abstract

We report herein findings on 181 patients, suffering from pelvic endometriosis confirmed by histology, whose main symptom was chronic pelvic pain (CPP). They attended the outpatient clinic at the 1st Department of Obstetrics and Gynaecology, Semmelweis University in Budapest, between 1 January 1995 and 1 January 2000. The extent of pelvic endometriosis was determined on the basis of the 1985 revised scoring system of the American Fertility Society (R-AFS). The short form of the McGiIl pain questionnaire was used for the evaluation of CPP. After the first operative intervention, therapy with a gonadotropin-releasing hormone (GnRH) analog was given for 6 months. Second-look laparoscopy was performed 8-10 weeks after the end of GnRH-analog treatment, which was followed by a non-convcntionally administered, monophasic oral contraceptive (OC) treatment. In the long term, 118 patients received the non-conventionally administered, monophasic OC treatment, which contained a third- generation progestogen, to be taken continuously for at least 6 months. The other 63 patients who did not receive OC treatment for one reason or another were evaluated as a control group. We analyzed data on CPP before the first surgical intervention, then following therapy with the GnRH analog at the second-look operation, and then after 6, 12, 18 and 24 months. We also reviewed potential causes of CPP, especially focused on endometriosis. No correlation was found between the stage of endometriosis according to R-AFS score and the severity of CPP. At the 24month follow-up after second-look laparoscopy, the non-conventionally administered monophasic OC treatment was found not only to significantly reduce pain scores, but also the required radical operative solution (hysterectomy plus bilateral adnexectomy) for CPP by OC users.

Keywords: Chronic pelvic pain, endometriosis, monophasic oral contraceptive treatment, post-treatment hysterectomy

Introduction

Chronic pelvic pain (CPP) is pain of the lower abdomen or pelvis, of at least 6 months' duration, occurring continuously or intermittently, which is not associated exclusively with menstruation or sexual intercourse [I]. The known major possible causes of CPP are pelvic inflammatory disease (PID), endometriosis, adhesions following abdominal operations, venous congestion because of varicosity of the uterine ligamentum latum, chronic intestinal and bladder-related pains, irritable colon syndrome, and changes in function of the nervous and the musculoskeletal system [2,3]. In 10% of cases an objective cause cannot be detected, therefore only detailed psychological exploration and therapy can bring relief to the patients concerned [1,4-8].

In the United Kingdom the prevalence of CPP was found to be 38/ 1000 in women aged 15-70 years, which is almost identical to that for asthma (37/1000) and spinal pain (41/1000) [6]. Because of the growing incidence of CPP it has become a problem of public health dimensions [2]. Long-lasting manifestation of CPP can severely deteriorate quality of life, and demands special attention due to attendant social and psychosocial consequences as well as healthcare costs (sick lists, hospital fees, costs of drugs, etc.).

Among the causes of CPP, pelvic endometriosis is the second most frequent after chronic pelvic inflammations [6]. Early diagnosis and appropriate therapy of endometriosis not only can ensure that the patient is free from complaints, but can also save significant healthcare costs. In 50% of patients treated because of irritable colon syndrome, laparoscopic examination verified intestinal endometriosis as the underlying cause [9,1O].

According to the literature, the incidence of endometriosis is between 2 and 50% among women of reproductive age [1,5-8,11,12]. In patients undergoing gynecological operations, endometriosis was found in 5-53% of cases by laparoscopy and in 1-50% of cases by abdominal surgery. Laparoscopic interventions for infertility revealed endometriosis in 15-80% of patients, whereas the incidence revealed during laparoscopic sterilization was only 2-4% [1,4-7,11- 13]. By laparoscopy we found endometriosis in 21.4% of infertility patients, in 51.2% of CPP patients and only in 2% of sterilization patients [8].

The pathomechanism of endometriosis has not yet been clearly elucidated. The most widely accepted theory is that proposed by Sampson, i.e., retrograde menstruation; however, the role of an imperfect immune system, which is responsible for removing menstrual detritus, is also acknowledged [7,13]. The number of diagnosed endometriosis cases shows a growing trend all over the world and could due to, on the one hand, improved diagnostic possibilities by laparoscopy, or, on the other, the recognition of microscopic changes of endometriosis [5,7,13-18]. The probable cause of endometriosis is multifactorial, emphasizing mechanical factors and possible immune processes in the development of the illness. Some etiological factors (nitrogen oxides, dioxin, pesticides, preservatives, etc.) resulting in disorders of the immune system have also been cited as possible causes of the disease; in other words, some researchers consider endometriosis as a disease of civilization [4,6,7].

In the present study, we evaluated the effect of a non- conventional oral contraceptive (OC) regime on recurrence of CPP pain scores in endometriosis patients who underwent treatment by means of a combined surgical-medical-surgical therapy. In the 2- year follow-up the severity of recurrence was lower in the patients who received the nonconventionally administered monophasic OC treatment, compared with those who did not. We found that OC usage could significantly decrease the number of post-treatment hysterectomies needed by CPP patients.

Materials and methods

At our endometriosis outpatient clinic, 511 patients were treated because of different stages of histologically verified endometriosis between 1 January 1995 and 1 January 2000. In the present article, we report on 181 patients whose main and only problem was CPP because of endometriosis. The staging of endometriosis was determined on the basis of the 1985 revised scoring system of the American Fertility Society (R-AFS) [19]. The short form of the McGiIl pain questionnaire [20] was used to evaluate pelvic pain. Pain is - as denned by the International Association for the Study of Pain - an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in those terms.

After routine laboratory, oncological, transvaginal pelvic ultrasonography and bimanual examinations, CPP patients initially received wide-spectrum antibiotic treatment (doxycycline 200 mg/day or clindamycin HCl 1200 mg/day and metronidazol 1000 mg/day) on the basis of laboratory or palpation findings for at least 12 days. If palpation findings or complaints remained unchanged, or if complaints recurred within 3 months after therapy, laparoscopy was performed. In cases where bimanual examination and ultrasonography were suggestive of endometriosis, laparoscopy or laparotomy was recommended to the patient.

Histological examination of samples taken by laparoscopy or laparotomy was performed. During surgical interventions, it was attempted to remove endometrioid tissue to the largest extent (cystectomy, ovarian resection, endocoagulation, excision, etc.). After the operation, patients received therapy with a gonadotropin- releasing hormone (GnRH) analog for 6 months. At 8-10 weeks after the end of GnRHanalog therapy a second-look laparoscopy was performed to evaluate the efficiency of the combined surgical- medical therapy. In the long term, patients received a non- conventionally administered, monophasic OC treatment, which contained a thirdgeneration progestogen, to be taken continuously for at least 6 months. If spotting appeared for > 5 days during continuous administration, the OC was taken in the way described above after a break of 7 days. Data from patients who did not receive contraceptive treatment for one reason or another were evaluated as a control group.

We evaluated data on pelvic pain obtained with the short-form McGiIl pain questionnaire before the patients had their first surgical intervention, then at the second-look laparoscopy following treatment with the GnRH analog and then after 6, 12, 18 and 24 months. We compared the numbers of patients who needed radical surgery (hysterectomy plus bilateral adnexectomy) for solution of their pain because of recurrence according to whether or not they had received the non-conventionally administered OC treatment. The data were evaluated by the χ2 test.

Results

Scores of the short-form McGiIl pain questionnaire before the first operation and at the second-look laparoscopy, performed 8-10 weeks after the 6month GnRH-analog treatment, are summarized in Table I. The best results of the combined surgicalmedical (GnRH analog) therapy were found in the evaluation of pelvic pain. The combined percentage of patients with a McGill score of '0' and '1' (i.e., less pain) changed from 39.2% before to 98.3% after therapy. Improvements were also seen in the evaluation of dysmenorrhea (patients with McGill score of '0' and '1': 72.4% before vs. 100.0% after) and dyspareunia (76.8% vs. 98.9%) (Table I).

Table I\. McGill pain score before the first operation and at second-look laparoscopy, performed 8-10 weeks after 6 months' therapy with a gondotropin-relcasing hormone analog: Number and percentage of patients (n = 181).

We could not find any correlation between R-AFS staging of endometriosis and McGiIl scoring system for pelvic pain, dysmenorrhea and dyspareunia symptoms.

After the second-look laparoscopy, 181 patients were followed up 6 monthly for 2 years. Of them, 118 patients received non- conventionally administered, monophasic OC containing a third- generation progestogen continuously for 6 months. If spotting appeared for > 5 days during continuous administration, OC was taken in the way described above after a break of 7 pill-free days, during which time a withdrawal bleeding occurred. The other 63 patients did not take it for some reason and their data served as a control. The characteristics of the two groups of patients are summarized in Table II. The distributions of special types of lesions were similar in both groups.

McGill scores of the two groups were compared. Results were most favorable for pelvic pain. The combined percentage of patients who scored T, '2' and '3' changed from 12.8% after the second-look laparoscopy (O months) to 15.3% at 24 months among OC users and from 12.7% to 25.4%, respectively, among non-users (Table III). Deterioration was observed for dysmenorrhea symptoms at the 2-year follow-up. The combined percentage of patients with McGill scores of T, '2' and '3' changed from 14.5% to 19.5% among OC users and from 17.5% to 36.5% among non-users at O and 24 months, respectively (Table IV). The least favorable results were seen for dyspareunia: corresponding percentages were from 21.2% to 35.6% among OC users and from 27.0% to 58.7% among non-users (Table V). The distributions of McGiIl scores for pelvic pain, dysmenorrhea and dyspareunia are shown in Figures 1, 2 and 3, respectively.

We found that non-conventionally administered monophasic OC treatment, in a 24-month follow-up after second-look laparoscopy, could significantly reduce the number of radical operative treatments (hysterectomy plus bilateral adnexectomy) required by CPP patients. Figure 4 illustrates the distribution of patients who needed radical operative treatment due to recurrence by CPP according to OC users and non-users. The differences were not significant at 6 and 12 months' follow-up, but by 18 and 24 months they were significant (p < 0.015 and p < 0.02) using the χ^sup 2^ test for evaluation of the data. Results suggest that the non- conventionally used monophasic OC in a 24-month follow-up can significantly reduce not only CPP complaints but also the required radical operative treatment. Thus this is a possible long-term treatment modality to increase quality of life for CPP patients.

Discussion

According to Nisolle and Donnez [21], the pathomechanisms of peritoneal, ovarian and retrocervical endometriosis are to be considered as three different entities. Our results with combined surgical-medical-surgical therapy suggest that they are indeed three different entities. Pelvic pain resulting from connective tissue hyperproliferation and cicatrization on the surface of the peritoneum, caused by peritoneal endometriosis, is the type most effectively treated by surgery and drug therapy. In the majority of cases ovarian endometrioma causes fewer CPP complaints, therefore it cannot be taken into consideration as a factor for CPP. On the other hand, the early diagnosis and operative treatment of endometrioma followed by medical treatment can increase the patient's chances of fertility in the future. The third entity is the retrocervical 'deep' endometriosis. Basically it is adenomyosis, where the major component of the nodular lesion is fibromuscular tissue with glandular and stromal tissue, and it can cause heavy pain (dyspareunia) to the patient. Medical therapy is less effective because of the tissue structure. In such cases, surgical therapy is more advantageous. Our results support the theory that R-AFS stages and CPP complaints caused by endometriosis are not in direct proportion with each other. We also suggest that the three entities of the illness (peritoneal, ovarian, deep endometriosis) and the CPP complaints caused by it should be treated as three separate entities according to the three presumed pathomechanisms described by Nisolle and Donnez [13,14,21-23].

Table II. Patient characteristics according to use or non-use of the non-convennonally administered, monophasic oral contraceptive (OC) treatment: Number and percentage of patients.

Table III. McGiIl pain score for pelvic pain according to use or non-use of the non-conventionally administered, monophasic oral contraceptive (OC) treatment: Number of patients at different study time points.

Table IV. McGill pain score for dysmenorrhea according to use or non-use of the non-conventionally administered, monophasic oral contraceptive (OC) treatment: Number of patients at different study time points.

Table V. McGill pain score for dyspareunia according to use or non-use of the non-convcntionally administered, monophasic oral contraceptive (OC) treatment: Number of patients at different study time points.

Figure 1. Distribution of McGiIl pain scores for pelvic pain at different study time points according to use or non-use of the nonconvcntionally administered, monophasic oral contraceptive (OC) treatment

On the basis of our results, the best results can be observed in the pelvic pain symptom after surgical and medical therapy. This could be related to the fact that pelvic cicatrization and adhesions due to endometriosis is the major source of CPP. Their microsurgical (coagulation, adhesiolysis, etc.) and medical loosening have proved to be effective [5,7,12,24-26].

According to Ludwig, the most frequent cause of secondary dysmenorrhea is endometriosis or adenomyosis [27]. The opinion of Schweppe is that adenomyosis must be the diagnosis if dysmenorrheic complaints disappear or decrease after administration of OCs for 6 months or more [28]. Our results concerning dysmenorrhea are rather modest. During the first or second spontaneous menstruation after GnRH-analog treatment the endometrial and endornetrioid tissue are incomplete, which is why dysmenorrheic complaints are diminished in the short term; however, they recur without further medication. Apparently, dysmenorrhea can be treated successfully with non- conventionally administered OCs. The aim of this treatment is hormone replacement therapy where the long-term use of monophasic drugs is leading to endometrial 'hypotrophy-atrophy, which it seems generally to be true for long-term use of monophasic OCs in the reproductive age [7,29-31].

Figure 2. Distribution of McGill pain scores for dysmenorrhea at different study time points according to use or non-use of the non- conventionally administered, monophasic oral contraceptive (OC) treatment

Figure 3. Distribution of McGill pain scores for dyspareunia at different study time points according to use or non-use of the non- conventionally administered, monophasic oral contraceptive (OC) treatment

Dyspareunia is caused by endometrioid tissue mass that penetrates deeply into the retrocervically located rectovaginal space. According to the pathomechanisms of Nisolle and Donnez [14,21,32], rectovaginal or 'deep* endometriosis reacts to a lesser degree to hormonal treatment because of its small glandular and stroma substance; thus the elimination of the illness and its complaints is a primarily a surgical or microsurgical task [12,17,32]. Endoscopy plays a vital role in the diagnosis; however, the diagnosis alone is not enough - the surgeon who is performing the intervention must be in possession of the appropriate surgical possibilities and experience [15,18,25,33,34]. Diagnostic and operative endoscopy is becoming more and more a routine intervention in Hungary. Diagnostic laparoscopy offers therapeutic possibilities also (adhesiolysis, endocoagulation, ovary resection, laser vaporization, etc.). The sooner the diagnosis is made and the appropriate surgical intervention is performed, the more efficiently complaints can be diminished.

Figure 4. Percentage of patients ( =181) requiring a radical operative solution (hysterectomy plus bilateral adnexectomy) owing to recurrence of chronic pelvic pain in the 24-month follow-up period according to use or non-use of the non-conventionally administered, monophasic oral contraceptive (OC) treatment

Postoperative administration of a GnRH analog promotes recovery due to its reversible endocrine effects; however, it does not represent a radical solution [35,36]. Reversible menopause is a sideeffect of GnRH-analog therapy. Others include anxiety, depression and sleeping disorders, which can be prevented with monophasic drugs used in the menopause - the so-called 'add-back therapy' without decreasing the chances of recovery from endometriosis [24]. However, the optimally chosen long-term drug therapy can reduce the number of cases requiring a radical operative solution by twothirds. Results with non-conventionally administered, monophasic low-dose OCs are better than with pills containing the progesterone only [30,31,36,37]. Our data also support this: the number of cases requiring a radical solution (hysterectomy and bilateral adnexectomy) because of CPP was reduced from 17.5% of non- users to 5.9% of patients using non-conventionally administered, third-generation monophasic OCs.

CPP can be cyclic or continuous. Causes leading to CPP can include gastrointestinal, urogenital, musculoskcletal, neurological and other factors. Endometriosis and PID arc the two major causes of CPP. In the differential diagnostic procedure laparoscopy plays an important role. A delay in the early diagnosis of endometriosis can lead to its progression, reduce fertility capacity (owing to adhesions, tube damag\e, decrease of follicle number) and increase CPP complaints of patients, increasing the need for expensive assisted reproduction techniques and other medical therapies. By using adequate early diagnostic and operative techniques combined with short- and long-term medical therapies, we can provide a longer complaint-free period for the patient suffering with endometriosis [8,15,18,25,31,38].

References

1. Prentice A. Medical management of chronic pelvic pain. Baillicrcs Best Pract Res Clin Obstet Gynaecol 2000;14:495499.

2. Mathias SD, Kuppcrmann M, Licberman RFR. CPP prevalence, health-related quality of life and economic correlates. Obstet Gynecol 1996;87:321-327.

3. McGurgan P, O'Donovan P. CPP: presentation, investigation and management. Oxfordshire: TMG Healthcare Communication Ltd; 1999.

4. Ballweg ML, the Endometriosis Association. The endometriosis sourcebook. Chicago: Contemporary Books; 1995.

5. Brosens I (guest editor). Endometriosis. Baillicres Best Pract Res Clin Obstet Gynaecol 1993;?.

6. Moore J, Kennedy S. Causes of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol 2000;14:389-403.

7. Shaw RW. Endometriosis. Current understanding and management. Oxford: Blackwell Science; 1995.

8. Szendei G. Endometriosis. In: Urbancsek J, Papp Z, editors. Ngygyszati endokrinolgia. Budapest: Springer Hungaria Kiad Kft; 1997. pp 437-477.

9. Anaf V, El Nakadi I, Englcrt Y. Large bowel endometriosis and ovarian stimulation. Hum Rcprod 2000; 15:790-794.

10. Shah M, Tager D, Feller E. Intestinal endometriosis masquerading as common digestive disorders. Arch Intern Med 1995; 155:977-980.

11. Gruppo Italiano per Io Studio dell' Endometriosi. Relationship between stage, site and morphological characteristics of pelvic endometriosis and pain. Hum Reprod 2001;16:26682671.

12. Vercellini P, Trespidi L, Dc Giorgi O. Endometriosis and pelvic pain: relation to disease stage and localization. Fcrtil Steril 1996;65:299-304.

13. Brosens IA. Endometriosis - a disease because it is characterized by bleeding. Am J Obstet Gynecol 1997; 176:263-267.

14. Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis, and adcnomyoric nodules of the rectovaginal septum are three different entites. Fertil Steril 1997;68:585596.

15. Porpora M, Gomel V. The role of laparoscopy in the management of pelvic pain in women of reproductive age. Fertil Steril 1997;68:765-779.

16. Sutton CJG, Ewen SP, Whitelaw N, Haines P. Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril 1994;62:696-700.

17. Walter JA, Hentz JG, Magdibay PM, Cornelia JL, Magrina JF. Endometriosis: correlation between histologie and visual findings at laparoscopy. Am J Obstet Gynecol 2001; 184: 1407-1413.

18. Winkel CA. A cost-effective approach to the management of endometriosis. Curr Opin Obstet Gynecol 2000; 12:317-320.

19. American Fertility Society. Revised American Fertility Society classification of endometriosis. Fertil Steril 1985;43:351- 352.

20. Melzack R. The short-form McGiIl pain questionnaire. Pain 1987;30:191-197.

21. Nisolle M, Donnez J. Peritoneal, ovarian and recto-vaginal endometriosis. The identification of three separate diseases. London: Parthenon Publishing; 1997.

22. Anaf V, Simon P, Fayt I, Noel J-C. Smooth muscles are frequent components of endometriotic lesions. Hum Reprod 2000; 15:767-771.

23. Donnez J, Spada F, Squifflet J, Nisolle M. Bladder endometriosis must be considered as bladder adcnomyosis. Fertil Steril 2000;74:1175-1181.

24. Bcrgqvist A, Theorell T. Changes in quality of life after hormonal treatment of endometriosis. Acta Obstet Gynecol Scand 2001;80:628-637.

25. Jones KD, Sutton CJG. Laparoscopic management of ovarian endometriosis: a critical review of current practice. Curr Opin Obstet Gynecol 2000;12:309-315.

26. Magtibay PM, Heppell J, Leslie KO. Endometriosis-associatcd invasive adenocarcinoma involving the rectum in postmenopausal female: report of a case. Dis Colon Rectum 2001;44:1530-1533.

27. Ludwig H. Dysmenorrhoea. Ther Umsch 1996;53:431-441.

28. Schweppe KW. Should we treat endometriosis in teenagers? In: Ben Rafal Z, et al., editors. Controversies in obstetrics, gynecology and infertility. Israel: E Oren Publisher Ltd, International Proceedings Division; 2003.

29. Parazzini F, Di Cintio E, Chatenoud L, Moroni S, Mezzanotte C, Crosignani PG. Oral contraceptive use and risk of endometriosis. Italian Endometriosis Study Group. Br J Obstet Gynaecol 1999;106:695- 699.

30. Venturini PL, Fasce V, Gorlero F, Ginocchio G. CPP: oral contraceptives and non-steroidal anti-inflammatory compounds. Cephalgia 1997;Suppl 20:29-31.

31. Vercellini P, Cortesi I, Crosigani PG. Progcstins for symptomatic endometriosis: a critical analysis of the evidence. Fertil Steril 1997;68:393-401.

32. Wright JT. The diagnosis and management of infiltrating nodular recto-vaginal endometriosis. Curr Opin Obstet Gynecol 2000;12:283-287.

33. Szendei G, Inovay J, Hidvgi J, Konrd S, Papp Z. Laparoscopia utjan vegzett adhaesiolysis. Magy Norv L 1997;60:281-287.

34. Szendei G, Inovay J, Somos P, Sziller I. Place of laparascopy in infertility - judgement of the pelvic organs and functional states. Med Sci Monit 1998;4:945-950.

35. Evcrs JLH. The second-look laparoscopy for evaluation of the result of medical treatment of endometriosis should be performed during ovarian suppression. Fertil Steril 1987;47:502-504.

36. Muzzi L, Marana R, Caruana P, Catalano GF, Margutt F, Panici PB. Postoperative administration of monophasic combined oral contraceptives after laparoscopic treatment of ovarian endometriosis: a prospective, randomized trial. Am J Obstet Gynecol 2000;183:588-592.

37. Jensen JT, Speroff L. Health benefits of oral contraceptives. Obstet Gynecol CUn North Am 2000;27:705-721.

38. Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis P. Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril 1998;70:1176-1180.

GYORGY SZENDEI, ZSOLT HERNDI, NRA DEVENYI, & ZSOLT CSAP

1st Department of Obstetrics and Gynaecology, Faculty of Medicine, Semmeltueis University Budapest, Budapest, Hungary

(Received 24 January 2005; revised IS March 2005; accepted 18 March 2005)

Correspondence: G. Szendei, Semmclwcis University Budapest, Faculty of Medicine, 1st Department of Obstetrics and Gynaecology, Division of Endocrinology, H-1088 Budapest, Baross u. 27, Hungary. Tel: 36 309705613. Fax: 36 1317 6174. E-mail: szendei@noil.sote.hu

Copyright CRC Press Aug 2005

Source: Gynecological Endocrinology

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