{"paper_id":"2a432dda-ce12-4d96-b043-28698a145b36","body_text":"~ 159 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2024; 8(5): 159-162 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2024; 8(5): 159-162 \nReceived: 13-07-2024 \nAccepted: 18-08-2024 \n \nDr. Sabiha Islam \nAssistant Professor, Department of \nObstetrics and Gynaecology, \nBangabandhu Sheikh Mujib \nMedical University (BSMMU), \nDhaka, Bangladesh \n \nDr Salma Akter Munmun \nAssistant Professor, Department of \nObstetrics and Gynaecology, \nBangabandhu Sheikh Mujib \nMedical University (BSMMU), \nDhaka, Bangladesh \n \nDr. Khodeza Khatun \nAssistant Professor, Department of \nObstetrics and Gynaecology, \nBangabandhu Sheikh Mujib \nMedical University (BSMMU), \nDhaka, Bangladesh \n \nDr. Shah Aziz \nMedical Officer, Department of \nObstetrics and Gynaecology, \nBangabandhu Sheikh Mujib \nMedical University (BSMMU), \nDhaka, Bangladesh \n \nDr. Walida Afrin  \nAssistant Professor, Department of \nObstetrics and Gynaecology, \nBangabandhu Sheikh Mujib \nMedical University (BSMMU), \nDhaka, Bangladesh \n \nDr Romena Afroze \nAssistant Professor, Department of \nObstetrics and Gynaecology, \nBangabandhu Sheikh Mujib \nMedical University (BSMMU), \nDhaka, Bangladesh \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr. Sabiha Islam \nAssistant Professor, Department of \nObstetrics and Gynaecology, \nBangabandhu Sheikh Mujib \nMedical University (BSMMU), \nDhaka, Bangladesh \n \nAssociation of endometriosis and pelvic pain disorders: \nA single centre experiences \n \nDr. Sabiha Islam, Dr Salma Akter Munmun, Dr. Khodeza Khatun, Dr. \nShah Aziz, Dr. Walida Afrin and Dr Romena Afroze \n \nDOI: https://doi.org/10.33545/gynae.2024.v8.i5c.1521  \n \nAbstract \nBackground: Endometriosis involves estrogen-dependent, progesterone-resistant tissue growth outside the \nuterus. The condition significantly decreases the quality  of life due to chronic pelvic pain, dysmenorrhea, \ndyspareunia, and infertility, affecting 35-50% of those with endometriosis. Management includes hormonal \ntreatments and surgery, yet chronic pelvic pain remains prevalent, impacting daily activities and we ll-\nbeing. \nAim of the study: This study aims to explore the association between endometriosis and various pelvic \npain disorders. \nMethods: This prospective observational study was conducted at the Department of Obstetrics and \nGynecology in BSMMU, Dhaka, from  June 2022 to July 2023. During the study period, 180 women who \nwere diagnosed with endometriosis were enrolled and analyzed after obtaining institutional ethical \napproval. \nResults: The study's mean age was 31.8 years. Most were married (70%), and 46.67% w ere unemployed. \nEducation levels varied: 12.78% were illiterate, 20% completed school, 38.33% attended college, and \n28.89% held a university degree. Endometriosis stages were 42.78% Stage 4, 30.56% Stage 3, 20.56% \nStage 2, and 6.11% Stage 1. Common symptom s included severe dysmenorrhea (89.44%), pelvic pain \n(78.33%), and ovulation pain (46.67%). Pelvic pain during periods and intercourse was prevalent, with \n86.11% reporting it during periods. Pain management included prescription painkillers (62.22%), and daily \nliving was affected by 64.89%. \nConclusion: The study reveals a significant link between endometriosis and severe pelvic pain, with \nadvanced stages prevalent among participants. The findings underscore the importance of timely diagnosis \nand effective management to alleviate pain and improve quality of life. \n \nKeywords: Endometriosis, pelvic pain, disorders \n \nIntroduction  \nEndometriosis is characterized by the presence of estrogen -dependent, progesterone -resistant \ntissue growths outside the uterus, leading to a persistent inflammatory response, often causing \nchronic pain and infertility  [1]. Endometriosis lesions seem to develop due to the frequent \noccurrence of retrograde menstruation, combined with neuroangiogenic factors that allow \nendometrial cells to a ttach to peritoneal surfaces, proliferate, and form endometriosis lesions  [2]. \nIt is estimated that 176 million women globally are affected by endometriosis, with 1.5% to 10% \nof them being of reproductive age  \n[3, 4] . The average age at which endometriosis is first \ndiagnosed is 28 years  [5]. Endometriosis shows no racial or socioeconomic predisposition; \nhowever, a familial link is observed in women with severe cases. It is believed to be the \ngynecological expression of a broader systemic condition, involving various health issues \nassociated with underlying hormonal and/or immune disorders\n5. Endometriosis is linked to a \ndecreased quality of life, primarily due to chronic pelvic pain, dysmenorrhea, dyspareunia, and \ninfertility. It has been reported that 35% to 50% of women with endometriosis experience pain, \ninfertility, or both  [6, 7] . Endometriosis symptoms can gradually diminish a woman's ability to \nperform daily activities, leading to a perceived decline in health status and overall well -being [8]. \nSome view the successful management of menstrual pain with hormonal treatments and over -\nthe-counter pain relievers as sufficient to support an endometriosis diagnosis, given the absence \nof a non-invasive diagnostic standard. Superficial peritoneal endometriosis is diagnosed through \nsurgical evaluation, usually reserved for those whose symptoms do not respond to empiric \ntreatment and are severe enough to warrant surgery [1]. \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 160 ~ \nFollowing surgery, hormonal treatments are continued to prevent \nfurther lesion growth and t he development of new lesions  [2]. \nChronic pelvic pain (CPP) is defined as ongoing pain in the \npelvic area that lasts for six months or more. CPP is a significant \ncause of illness, affecting an estimated 25% of menstruating \nindividuals globally  \n[9]. 40 -87% of endometriosis is observed \nwith CPP, making it the most frequently identified cause [1]. Pain \nassociated with endometriosis can persist after medical treatment \nand/or surgery, and similarly with the quality of life  [10, 11] . In \nfact, despite surgical and/or hormonal treatment, about one-third \nof women with endometriosis develop CPP  [12]. As chronic \npelvic pain is the most prevalent symptom of endometriosis, \nindividuals with this condition face prolonged negative impacts \non their well-being [13]. Accordingly, pain management should be \ninitiated at the beginning of the treatment. This study aims to \nexplore the association between endometriosis and various \npelvic pain disorders. By better understanding this association, \nwe hope to contribute to more effectiv e diagnostic and \ntherapeutic strategies for women suffering from these \ndebilitating conditions. \n \nMethodology and Materials \nThis prospective observational study conducted at the \nDepartment of Obstetrics and Gynecology in Bangabandhu \nSheikh Mujib Medical Uni versity, Dhaka from June 2022 July \n2023. During the study period a total of 180 women who were \ndiagnosed with endometriosis were enrolled and analyzed. The \ndiagnosis of endometriosis was established by history taking, \nphysical examination, visual detection of endometriotic lesions \nduring previous surgeries, ultrasound examination, or \nhistopathology. The study protocol was approved by the \ninstitutional ethics committee. \n \nInclusion criteria \n• Women aged 18-45 years. \n• Diagnosed with endometriosis and suffered from pelvic pain \nfor at least 6 months. \n \nExclusion criteria \n• Pregnant women. \n• Women with chronic pelvic pain due to diseases \n• Patients who did not give written concert from. \n \nAll participants provided verbal consent before taking part in the \nstudy. Our study use d the questionnaire for collecting data with \nthe help of interviewer. We collected and evaluated \ndemographic data including age, occupation, education, number \nof children, and other medical history. This study was designed \nto measure prevalence of symptoms and assess the impact rather \nthan test a hypothesis, therefore no sample size calculation was \nperformed. \n \nData Analysis \nAll data were presented in a suitable table or graph according to \ntheir affinity. A description of each table and graph was given to \nunderstand them clearly. Data were analyzed using SPSS v 26. \nDescriptive statistics were presented as means and standard \ndeviations (for normally distributed data), medians and \ninterquartile ranges (for non -normally distributed data), or \nnumber and percentages (for categorical data).  \n \nResults \nThe study population consisted of 180 participants with a mean \nage of 31.8 years (SD=6.1). A majority of the participants were \nmarried (70.00%), while 30.00% were single. Regarding \noccupation, 46.67% of the participants  were unemployed, \n32.78% were employed, and 20.56% were students (Table 1). \nThe level of education among participants varied, with 12.78% \nbeing illiterate, 20.00% having completed school, 38.33% \nhaving attended college, and 28.89% holding a university \ndegree. 28.89% of individuals were parents, compared to the \nmajority (71.11%) who were not at the moment (Table 1). Stage \n4 and Stage 3 endometriosis were found in 42.78% and 30.56% \nof participants, followed by 20.56% as Stage 2 and 6.11% as \nStage 1 (Figure 1). The most common symptom at disease onset \namong participants was severe dysmenorrhea, reported by \n89.44% of individuals. Other symptoms include pelvic pain \n(78.33%), ovulation pain (46.67%), deep dyspareunia (32.22%), \nchronic fatigue (38.89%), infertility  (7.78%), and cyclical or \nperi-menstrual symptoms with abnormal bleeding (17.78%), and \nwithout abnormal bleeding (20.00%) (Table 2). Table 3 shows \nthat 86.11% of participants reporting pelvic pain during periods \nin the past three months. Most of the patients (85.56%) \nexperienced pain \"always,\" with an average pain severity of 6, \npeaking at 9. To manage the pain, 62.22% used prescription \npainkillers, while 19.44% used over -the-counter medication. \nDaily living was affected for 64.89% of participants, with \n35.56% reporting that it \"often\" impacted their activities and \n30.00% saying it \"always\" affected them. Pelvic pain during \nintercourse was reported by 78.89% of participants, with 36.67% \nexperiencing it \"always.\" Additionally, 82.22% stated that pain \ninterrupted intercourse, and 88.89% avoided intercourse due to \nthe discomfort. The frequency of pelvic pain after intercourse \nwas high, with 31.67% experiencing it \"usually\" and 36.67% \n\"always.\" Pain during intercourse averaged 7 (on a scale of 5–8), \nand the same level of pain was reported 24 hours afterward \n(Table 3). \n \nTable 1: Demographic characteristics of study population (n=180). \n \nVariables Frequency (n) Percentage (%) \nAge (years), Mean (SD) 31.8±6.1 \nRelationship status \nSingle 54 30.00 \nMarried 126 70.00 \nOccupation \nUnemployed 84 46.67 \nEmployed 59 32.78 \nStudent 37 20.56 \nLevel of education \nIlliterate 23 12.78 \nSchool 36 20.00 \nCollege 69 38.33 \nUniversity 52 28.89 \nCurrently have children \nYes 52 28.89 \nNo 128 71.11 \n \n \n \nFig 1: Endometriosis stage at most recent laparoscopy (n=180). \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 161 ~ \nTable 2: Symptoms at onset of diseases among patients (n=180). \n \nSymptoms at onset Frequency (n) Percentage (%) \nSevere Dysmenorrhea 161 89.44 \nDeep Dyspareunia 58 32.22 \nPelvic Pain 141 78.33 \nOvulation pain 84 46.67 \nInfertility 14 7.78 \nChronic Fatigue 70 38.89 \nCyclical or peri-menstrual symptoms \nWith abnormal bleeding 32 17.78 \nWithout abnormal bleeding 36 20.00 \n \nTable 3: Relationship between endometriosis and pelvic pain (n=180). \n \nVariables Frequency (n) Percentage (%) \nPelvic pain with periods in last 3 months \nYes 155 86.11 \nNo 25 13.89 \nFrequency of pain \nOccasionally 6 3.33 \nOften 20 11.11 \nAlways 154 85.56 \nSeverity of period pain (average) 6 (5-7) \nSeverity of period pain (worse) 9 (8-10) \nUse of painkillers \nUses prescription 112 62.22 \nUses OTC 35 19.44 \nAffected daily living \nNever 11 6.11 \nOccasionally 51 28.33 \nOften 64 35.56 \nAlways 54 30.00 \nPelvic pain with intercourse \nYes 142 78.89 \nNo 38 21.11 \nFrequency of pelvic pain after intercourse \nOccasionally 28 15.56 \nOften 29 16.11 \nUsually 57 31.67 \nAlways 66 36.67 \nInterrupt intercourse \nYes 148 82.22 \nNo 32 17.78 \nAvoid intercourse \nYes 160 88.89 \nNo 20 11.11 \nPain during intercourse 7 (5-8) \nPain 24 h after intercourse 7 (7-7) \n \nDiscussion \nThe association between endometriosis and pelvic pain disorders \nis well -documented, with significant implications for women's \nhealth. Endometriosis is characterized by the presence of \nendometrial-like tissue outside the uterus, leading to various \nsymptoms, primarily chronic pelvic pain. This is a disease with \nextraordinary variability and the overwhelming impression from \nthe literature is that results regarding the prevalence of pain \nsymptoms are incredibly inconsistent. This study investigates the \nassociation between endometr iosis and pelvic pain disorders to \nimprove diagnosis and treatment strategies. The participants had \na mean age of 31.8 years, with a standard deviation of 6.1 years, \nindicating a relatively young adult group. This aligns with the \ncommon age range for individuals affected by endometriosis [14]. \nEndometriosis and disorders causing pelvic pain can affect \npeople in a variety of relationship situations. 70.00% of the \nparticipants were married, and 30.00% were single in our study. \nA higher percentage of unemploye d individuals can be seen in \nthis study. These results are comparable with the findings of \nArmour et al.\n [15]. Participants of this study had diverse levels of \neducation: 12.78% were illiterate, 20.00% had finished school, \n38.33% had attended college, and 28.89% held a university \ndegree. Most of the subjects had attended college in the study of \nWilliams et al . [16]. According to our study, majority of the \nwomen did not have children. Other study conducted in another \ncountry also found similar result  [17]. Our observation found that \nmost participants had advanced endometriosis, with 42.78% in \nStage 4 and 30.56% in Stage 3, indicating that over 70% had \nsevere cases likely associated with symptoms such as pelvic \npain. Fewer were in earlier stages, with 20.56% i n Stage 2 and \n6.11% in Stage 1. Armour also indicated similar findings  \n[15]. \nThe most common symptom at disease onset among participants \nwas severe dysmenorrhea, reported by 89.44% of individuals. \nPelvic pain was also prevalent, affecting 78.33%, while \novulation pain was experienced by 46.67%. Other symptoms \nincluded deep dyspareunia, chronic fatigue, infertility, cyclical \nor peri-menstrual symptoms with abnormal bleeding or without \nabnormal bleeding. Presented symptoms reported by other \nseveral studies als o similar to our findings  \n[14-17]. Pain and the \nassociated symptom of fatigue is commonly seen in people with \nendometriosis [14-18]. Fatigue is a common symptom in people \nwith endometriosis and other types of pelvic pain with 39 -43% \nof respondents reporting that symptom at the onset and all \nclinicians should ask about this symptom when taking a history \nof a person presenting with pelvic pain [15]. In the last three \nmonths, 86.11% of participants reported pelvic pain with \nperiods, with 85.56% experiencing it  \"always\" and an average \npain severity of 6, increasing to 9 at its worst. Most used \nprescription painkillers (62.22%), and daily life was often \naffected in 35.56% of cases. Pelvic pain during intercourse was \nreported by 78.89%, with 36.67% experiencing it  \"always,\" and \n82.22% said pain interrupted intercourse. Additionally, 88.89% \navoided intercourse due to pain, with an average pain score of 7 \nduring intercourse and 24 hours afterward. Previous \ninternational surveys  \n[7, 19] , and qualitative research have \nhighlighted the impact of endometriosis on social activities and \nmarital/sexual relationships  [20, 21] . We also demonstrated that \npersonal relationships, whether friendships or those of a \nromantic/sexual nature, were negatively impacted by \nendometriosis and pelvic pain. Reasons for this may include the \nfatigue experienced reducing social interactions and increased \nanxiety of experiencing heavy menstrual bleeding, nausea, \ngastrointestinal and bladder symptoms in public places when \ninteracting with friends, f amily or others  \n[18, 21, 22] . Similar to \nprevious work, romantic and sexual relationships were \ncommonly affected in both cohorts, with pain as a direct \ncontributor, but fatigue, nausea, depression, and other co-\nmorbidities also, often, contributing to rela tionship strain and \npotential breakdown [23, 24]. Pelvic pain may later be diagnosed as \nendometriosis but most importantly, our work confirms that \npelvic pain causes substantive negative impact on work, \neducation, sexual relationships, family and friendshi ps \n[14]. It is \ntherefore necessary to identify and have a treatment plan for \npelvic pain symptoms, regardless of the current or future \ndiagnosis. \n \nLimitations of the study:  Some of the data, such as pain levels \nand the impact on daily living, were self -reported, which may \nintroduce bias or inaccuracies in symptom reporting. The study’s \nsample size of 180 participants may limit the generalizability of \nthe findings to the broader population of individuals with \nendometriosis. The cross-sectional nature of the study does not \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 162 ~ \nallow for assessment of changes over time or the long -term \neffects of treatment on symptoms and quality of life. \n \nConclusion and recommendations \nThis study highlights a strong association between endometriosis \nand pelvic pain disorders, with the majority of participants \npresenting advanced stages of endometriosis and experiencing \nsevere pain. The most common symptoms, including \ndysmenorrhea, pelvic pain, and dyspareunia, significantly \nimpacted daily life, relationships, and sexual health. Our  \nfindings emphasize the need for timely diagnosis and effective \nmanagement of endometriosis to reduce the burden of chronic \npain and its consequences on quality of life. Future studies \nshould explore the long-term effects of endometriosis treatments \non pain management, fertility, and overall quality of life. \n \nFunding \nNo funding sources \n \nConflict of interest \nNone declared \n \nEthical approval \nThe study was approved by the Institutional Ethics Committee. \n \nReferences \n1. Horne AW, Missmer SA. Pathophysiology, diagnos is, and \nmanagement of endometriosis. BMJ; c2022 .p. 379. \n2. Karp BI, Stratton P. Endometriosis -associated chronic \npelvic pain. Med. 2023 Mar 10;4(3):143-146. \n3. Johnson NP, Hummelshoj L, Adamson GD, Ke ckstein J, \nTaylor HS, Abrao MS . World Endometriosis Society \nconsensus on the classification of endometriosis. Hum \nReprod. 2017 Feb 1;32(2):315-324. \n4. Bulletti C, Coccia ME, Battistoni S, Borini A. \nEndometriosis and infertility. J Assist Reprod Genet. 2010 \nAug;27:441-447. \n5. Bloski T, Pierson R. Endometriosis and chronic pelvic pain: \nunraveling the mystery behind this complex condition. 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Hum Reprod Update. 2016 Nov 20;22(6):762-74. \n24. Culley L, Law C, Hudson N, Mitchell H, Denny E, Raine -\nFenning N. A qualitative study of t he impact of \nendometriosis on male partners. Hum Reprod. 2017 Aug \n1;32(8):1667-1673. \n \n \nHow to Cite This Article \nIslam S, Munmun SA, Khatun K, Aziz S, Afrin W, Afroze R . Association \nof endometriosis and pelvic pain disorders: A single centre experiences . \nInternational Journal of Clinical Obstetrics and Gynaecology 2024; 8(5): \n159-162.  \n \nCreative Commons (CC) License \nThis is an open access journal, and articles are distributed under the terms \nof the Creative Commons Attribution -NonCommercial-ShareAlike 4.0 \nInternational (CC BY- NC-SA 4.0) License, which allows others to remix, \ntweak, and build upon the work non- commercially, as long as appropriate \ncredit is given and the new creations are licensed under the identical terms.","source_license":"CC0","license_restricted":false}