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Chronic Pelvic Pain

The other day, AG, a 28-year-old accountant, came to see me about her menstrual

cramps. She has been suffering from it since puberty.

“ I had my first period at 12. The pain wasn’t too bad, and it was relieved

after a hot shower. But by my late teens, it was getting more severe and I had to

take Panadol regularly,” she recalled.

When she was in university, Panadol and other pain killers were not

effective anymore. Her family physician suggested oral contraceptives pills.

“My mum was not convinced so she took me to her gynaecologist. I was

just 20.I remember the gynae saying that I had primary dysmenorrhoea and that it

would disappear after I had given birth,” she continued.

“Do you have the pain on the first day or throughout your period,” I

interrupted, as primary dysmenorrhoea refers to menstrual cramps which occur

only on the first day and usually last for a few hours.

“I cannot recall,” she replied.

“Anyway, I was prescribed oral pills. I took them for a few months but

stopped because of the side effects. The cramps became worse and I was

completely incapacitated. On one occasion, I almost passed out.”

“Any investigation done?” I asked.

“Yes. An ultrasound scan and the result was normal. The gynae then

suggested an operation where a telescope was inserted through my belly button to

check my womb (laparoscopy). I reluctantly agreed as the pain was getting


“What were the findings?” I asked.

“My gynae found small chocolate-coloured spots of menstrual blood at the

back of the uterus and ovaries which she removed during the operation. My pain

went away and I was symptom-free for the next few years until recently when I

experienced pain during sexual intercourse. The backache and menstrual pain

returned and I had pain when I passed motion during menses.”

When I examined AG, her uterus was tender to the touch and relatively

immobile. An ultrasound scan showed an ovrian cyst about the size of a tennis ball

on her left side. It was subsequently removed through key-hole surgery and was

confirmed to be an endometriotic cyst or “blood cyst”.

Endometriosis is a common and troublesome disease affecting about one

in 10 women of reproductive age. In women with fertility problems, the number

may be as high as 50 per cent.

It is also a progressive disease, as is the case for AG. The lining of the

womb (endometrial tissues) is spilled into other parts of the reproductive organs

including the fallopian tubes, ovaries and the back of the womb.

These abnormal and wayward tissues bleed every month during

menstruation. The surrounding areas become inflamed and form scars which pull

on the nerve endings and cause pain. But some women will have little or no pain

despite having extensive disease while others may have severe pain with only a

few small affected areas.

The endometrial tissues trapped in the ovary will bleed and lead to the

formation of the dark, thick and chocolate- coloured cyst known as “chocolate

cyst” or “blood cyst”.

It may leak and form adhensions (abnormal tissues that bind organs

together). The adhensions can block the fallopian tube and interfere with

ovulation, causing infertility.

The exact cause of endometriosis is not well understood. A familiar

association exists as it can affect many siblings in a family. Past pelvic infection

can also be a cause.

Common symptoms of endometriosis include menstrual cramps, backache

and pain during sexual intercourse. Menstruation may be irregular, with staining

before or after menstruations. There may also be clots in the menses.

An ultrasound scan may be misleading in the diagnosis of endometriosis.

It is usually normal if there is no cyst formation as in the case of AG when she

consulted the first gynaecologist. The diagnosis is based on clinical suspicion and

confirmed by laparoscopy.

A blood tumour marker test (CA125) is also not very helpful as the level

may be normal or raised. When a cyst is present, surgical removal and

microscopic examination is the only way to confirm the diagnosis as in AG’s case.

The recurrence of endometriosis is very common. It will only dry up after

menopause when the lesion is no more stimulated by ovarian hormones.

Pregnancy has a beneficial effect on endometriosis. Hormonal changes

cause the diseased areas to become inactive. As infertility may be a consequence

of endometriosis, I discussed with AG and her husband the possibility of their

conceiving a baby. They heeded my advice and AG is now pregnant.

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