Let’s not normalise period pain - Medical Observer


Medical ObserverJean Hailes is proud to provide a monthly column in the medical newspaper, Medical Observer. Designed to give GPs and health professionals a short informative summary of important women's health topics and conditions, these articles provide practical information to inform and enhance clinical practice. 

In the latest 'Talking Women' article for Medical Observer, Jean Hailes gynaecologist Dr Janine Manwaring discusses endometriosis and pelvic pain.

By Janine Manwaring
MBBS (Hons), FRANZCOG. 
Gynaecologist, Jean Hailes for Women's Health

 Girl holding stomach

Endometriosis is a chronic condition that affects a woman's reproductive organs. The illness is more common than diabetes or breast cancer, yet has no known cause or cure. Around 176 million women worldwide, including adolescents, suffer from endometriosis – about 10% of the female population. It is rare before menarche or after menopause.

Up to 47% of adolescent females with pelvic pain have endometriosis. Yet alarmingly, the average delay in diagnosis of endometriosis is 7-10 years. This is due to girls and women, as well as doctors, normalising symptoms such as dysmenorrhea (painful menstruation). However, a delayed diagnosis can lead to infertility, debilitating pain and reduced quality of life.

Endometriosis affects all aspects of a woman's life. Beyond the physical suffering, there are also the heavy financial, relationship, emotional and mental health impacts. In Australia, the annual cost of medical and surgical treatments for women with endometriosis is AUS$6 billion.

Early diagnosis and treatment has the potential to reduce the long-term impact of endometriosis on not only individuals, but also the Australian economy; lost productivity is estimated to be twice the cost than the individual health care expenses associated with endometriosis.

In December 2017, federal health minister Greg Hunt formally apologised to women with endometriosis as he announced a national plan to address the condition, including an education and awareness campaign and a $160,000 research grant for the National Health and Medical Research Council.

Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, which causes a chronic, inflammatory reaction. It is primarily found on the pelvic peritoneum, uterosacral ligaments and Pouch of Douglas. More severe disease can involve the bladder and bowel. In rare cases, it can be found on abdominal surgery scars and in other organs outside the pelvic cavity. It is not fully understood how endometriosis begins. However, risk factors associated with the condition include:

  • a genetic link (if a first-degree relative has the condition, endometriosis is 10 times more likely in a patient)
  • early menarche
  • lower body weight.

Women are sometimes told that pregnancy will cure endometriosis, yet this is not the case and should not be suggested.

Signs and symptoms

Symptoms are diverse and non-specific, and do not correlate with disease severity. Endometriosis can be asymptomatic, or present but not the cause of the pelvic pain.

Possible symptoms:

  • dysmenorrhoea and pelvic pain (79%) – often 1-2 days prior to menses, can last throughout menses and for days afterwards. May not develop for years after menarche, although can be superimposed on primary dysmenorrhoea
  • dyspareunia (51%) – typically deep, may persist for hours or days after intercourse
  • bowel upset or pain – diarrhoea/constipation, bloating, cramping, dyschezia (pain when opening bowels). Can occur without endometriosis infiltrating bowel. PR bleeding rare.
  • subfertility (30%)
  • ovarian mass/cyst (29%)
  • bladder symptoms – Urinary frequency/urgency during menses; suprapubic pain with micturition; urinary retention/haematuria/flank pain from ureteric obstruction not common; and urinary tract endometriosis may be asymptomatic
  • non-specific symptoms including low back pain, pre-menstrual spotting, fatigue.

Consultation

Obtain history from patient:

  • menstrual history including menarche, cycle, timing and/or progression of dysmenorrhoea
  • bowel/bladder symptoms
  • dyspareunia
  • severity of symptoms and impact on quality of life
  • treatments: past/current including surgery and outcomes
  • mental and emotional health – patients with persistent or severe pelvic pain are at increased risk of depression or anxiety. Obtain mental health history.

Undertake the following examinations:

  • abdominal examination – check for tenderness, masses, scars
  • pelvic examination if appropriate – often normal. Most frequent abnormal finding is tenderness in posterior fornix.

Investigations:

  • no diagnostic blood tests. Ca125 can be elevated in endometriosis, but is not a sensitive marker and is not specific.
  • imaging:
    • pelvic ultrasound scan (USS) – preferably transvaginal with a well-trained provider. Standard ultrasound will not detect superficial endometriosis or adhesions.
    • specialist endometriosis USS – can identify size, location and depth of infiltrating lesions, adhesions; suspicion of superficial disease.

Management

Pelvic pain and possible endometriosis may be managed with empiric medical therapy prior to laparoscopy. Around 80-90% of women with endometriosis will have some improvement with medical therapy. Non-steroidal anti-inflammatory drugs (NSAIDs) and/or hormonal treatments are both appropriate treatment to reduce endometriosis-related pain and inflammation. Hormonal contraceptive therapy can be progestogen only or combined oestrogen/progestogen. Medical therapy will not decrease endometriomas or adhesions, or improve fertility. Pregnancy does not cure endometriosis.

When to refer to a gynaecologist:

  • failure to respond adequately to 3-6 months of medical management
  • previously diagnosed endometriosis with return of symptoms that have not responded to appropriate medical management
  • symptoms/signs suggestive of deep infiltrative endometriosis (dyschezia, deep dyspareunia, endometrioma on pelvic USS)
  • infertility.

Diagnosis

Laparoscopy is required for definitive diagnosis of endometriosis. Surgical treatment of endometriosis is associated with a reduction in pain. Symptom recurrence requiring re-operation is common and increases with time (21.5% two years; 40-50% five years). Hormonal treatment post-operation (for > 1 year) increases duration of pain relieve and delays disease recurrence.

Practice Points

  • Dysmenorrhea (painful menstruation) that impairs quality of life is not normal – first referral should be to a gynaecologist.
  • Early diagnosis and treatment reduces the long-term impacts of endometriosis and frequency of invasive treatment and fertility treatments.
  • A possible diagnosis of endometriosis should be considered in adolescents presenting with:
    • persistent pelvic pain (cyclic and/or non-cyclic)
    • severe dysmenorrhea
    • dysmenorrhea resistant to non-steroidal anti-inflammatory drugs (NSAIDs) and the oral contraceptive pill (OCP)
    • pain interfering with daily activity.
  • The combination of laparoscopy and histological verification is considered the gold standard for the diagnosis of endometriosis.
  • Seek out health professionals with endometriosis experience including: gynaecologist with advanced laparoscopic skills, psychologist/pain specialist, fertility specialist, community health nurse, pelvic floor physiotherapist, dietitian, accredited exercise physiologist, sex therapist and naturopath.

Patient resources 

Dr Janine ManwaringAbout the author

Dr Manwaring is a gynaecologist with a special interest in endometriosis and pelvic pain. She works with Jean Hailes at Epworth Freemasons, in the advanced gynaecology unit at the Women's Hospital, and also in the advanced Endosurgery and the Outpatient Hysteroscopy clinic at the Mercy Hospital.

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