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.