Association of endometriosis and pelvic pain disorders: A single centre experiences

Background: Endometriosis involves estrogen-dependent, progesterone-resistant tissue growth outside the uterus. The condition significantly decreases the quality of life due to chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility, affecting 35-50% of those with endometriosis. Management includes hormonal treatments and surgery, yet chronic pelvic pain remains prevalent, impacting daily activities and we ll- being. Aim of the study: This study aims to explore the association between endometriosis and various pelvic pain disorders.

This prospective observational study was conducted at the Department of Obstetrics and Gynecology in BSMMU, Dhaka, from June 2022 to July 2023. During the study period, 180 women who were diagnosed with endometriosis were enrolled and analyzed after obtaining institutional ethical approval.

The study's mean age was 31.8 years. Most were married (70%), and 46.67% w ere unemployed. Education levels varied: 12.78% were illiterate, 20% completed school, 38.33% attended college, and 28.89% held a university degree. Endometriosis stages were 42.78% Stage 4, 30.56% Stage 3, 20.56% Stage 2, and 6.11% Stage 1. Common symptom s included severe dysmenorrhea (89.44%), pelvic pain (78.33%), and ovulation pain (46.67%). Pelvic pain during periods and intercourse was prevalent, with 86.11% reporting it during periods. Pain management included prescription painkillers (62.22%), and daily living was affected by 64.89%.

The study reveals a significant link between endometriosis and severe pelvic pain, with advanced stages prevalent among participants. The findings underscore the importance of timely diagnosis and effective management to alleviate pain and improve quality of life.

Endometriosis, pelvic pain, disorders

Endometriosis is characterized by the presence of estrogen -dependent, progesterone -resistant tissue growths outside the uterus, leading to a persistent inflammatory response, often causing chronic pain and infertility [1]. Endometriosis lesions seem to develop due to the frequent occurrence of retrograde menstruation, combined with neuroangiogenic factors that allow endometrial cells to a ttach to peritoneal surfaces, proliferate, and form endometriosis lesions [2]. It is estimated that 176 million women globally are affected by endometriosis, with 1.5% to 10% of them being of reproductive age [3, 4] . The average age at which endometriosis is first diagnosed is 28 years [5]. Endometriosis shows no racial or socioeconomic predisposition; however, a familial link is observed in women with severe cases. It is believed to be the gynecological expression of a broader systemic condition, involving various health issues associated with underlying hormonal and/or immune disorders 5. Endometriosis is linked to a decreased quality of life, primarily due to chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility. It has been reported that 35% to 50% of women with endometriosis experience pain, infertility, or both [6, 7] . Endometriosis symptoms can gradually diminish a woman's ability to perform daily activities, leading to a perceived decline in health status and overall well -being [8]. Some view the successful management of menstrual pain with hormonal treatments and over - the-counter pain relievers as sufficient to support an endometriosis diagnosis, given the absence of a non-invasive diagnostic standard. Superficial peritoneal endometriosis is diagnosed through surgical evaluation, usually reserved for those whose symptoms do not respond to empiric treatment and are severe enough to warrant surgery [1]. International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 160 ~ Following surgery, hormonal treatments are continued to prevent further lesion growth and t he development of new lesions [2]. Chronic pelvic pain (CPP) is defined as ongoing pain in the pelvic area that lasts for six months or more. CPP is a significant cause of illness, affecting an estimated 25% of menstruating individuals globally [9]. 40 -87% of endometriosis is observed with CPP, making it the most frequently identified cause [1]. Pain associated with endometriosis can persist after medical treatment and/or surgery, and similarly with the quality of life [10, 11] . In fact, despite surgical and/or hormonal treatment, about one-third of women with endometriosis develop CPP [12]. As chronic pelvic pain is the most prevalent symptom of endometriosis, individuals with this condition face prolonged negative impacts on their well-being [13]. Accordingly, pain management should be initiated at the beginning of the treatment. This study aims to explore the association between endometriosis and various pelvic pain disorders. By better understanding this association, we hope to contribute to more effectiv e diagnostic and therapeutic strategies for women suffering from these debilitating conditions. Methodology and Materials This prospective observational study conducted at the Department of Obstetrics and Gynecology in Bangabandhu Sheikh Mujib Medical Uni versity, Dhaka from June 2022 July 2023. During the study period a total of 180 women who were diagnosed with endometriosis were enrolled and analyzed. The diagnosis of endometriosis was established by history taking, physical examination, visual detection of endometriotic lesions during previous surgeries, ultrasound examination, or histopathology. The study protocol was approved by the institutional ethics committee. Inclusion criteria • Women aged 18-45 years. • Diagnosed with endometriosis and suffered from pelvic pain for at least 6 months. Exclusion criteria • Pregnant women. • Women with chronic pelvic pain due to diseases • Patients who did not give written concert from. All participants provided verbal consent before taking part in the study. Our study use d the questionnaire for collecting data with the help of interviewer. We collected and evaluated demographic data including age, occupation, education, number of children, and other medical history. This study was designed to measure prevalence of symptoms and assess the impact rather than test a hypothesis, therefore no sample size calculation was performed. Data Analysis All data were presented in a suitable table or graph according to their affinity. A description of each table and graph was given to understand them clearly. Data were analyzed using SPSS v 26. Descriptive statistics were presented as means and standard deviations (for normally distributed data), medians and interquartile ranges (for non -normally distributed data), or number and percentages (for categorical data).

The study population consisted of 180 participants with a mean age of 31.8 years (SD=6.1). A majority of the participants were married (70.00%), while 30.00% were single. Regarding occupation, 46.67% of the participants were unemployed, 32.78% were employed, and 20.56% were students (Table 1). The level of education among participants varied, with 12.78% being illiterate, 20.00% having completed school, 38.33% having attended college, and 28.89% holding a university degree. 28.89% of individuals were parents, compared to the majority (71.11%) who were not at the moment (Table 1). Stage 4 and Stage 3 endometriosis were found in 42.78% and 30.56% of participants, followed by 20.56% as Stage 2 and 6.11% as Stage 1 (Figure 1). The most common symptom at disease onset among participants was severe dysmenorrhea, reported by 89.44% of individuals. Other symptoms include pelvic pain (78.33%), ovulation pain (46.67%), deep dyspareunia (32.22%), chronic fatigue (38.89%), infertility (7.78%), and cyclical or peri-menstrual symptoms with abnormal bleeding (17.78%), and without abnormal bleeding (20.00%) (Table 2). Table 3 shows that 86.11% of participants reporting pelvic pain during periods in the past three months. Most of the patients (85.56%) experienced pain "always," with an average pain severity of 6, peaking at 9. To manage the pain, 62.22% used prescription painkillers, while 19.44% used over -the-counter medication. Daily living was affected for 64.89% of participants, with 35.56% reporting that it "often" impacted their activities and 30.00% saying it "always" affected them. Pelvic pain during intercourse was reported by 78.89% of participants, with 36.67% experiencing it "always." Additionally, 82.22% stated that pain interrupted intercourse, and 88.89% avoided intercourse due to the discomfort. The frequency of pelvic pain after intercourse was high, with 31.67% experiencing it "usually" and 36.67% "always." Pain during intercourse averaged 7 (on a scale of 5–8), and the same level of pain was reported 24 hours afterward (Table 3). Table 1: Demographic characteristics of study population (n=180). Variables Frequency (n) Percentage (%) Age (years), Mean (SD) 31.8±6.1 Relationship status Single 54 30.00 Married 126 70.00 Occupation Unemployed 84 46.67 Employed 59 32.78 Student 37 20.56 Level of education Illiterate 23 12.78 School 36 20.00 College 69 38.33 University 52 28.89 Currently have children Yes 52 28.89 No 128 71.11 Fig 1: Endometriosis stage at most recent laparoscopy (n=180). International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 161 ~ Table 2: Symptoms at onset of diseases among patients (n=180). Symptoms at onset Frequency (n) Percentage (%) Severe Dysmenorrhea 161 89.44 Deep Dyspareunia 58 32.22 Pelvic Pain 141 78.33 Ovulation pain 84 46.67 Infertility 14 7.78 Chronic Fatigue 70 38.89 Cyclical or peri-menstrual symptoms With abnormal bleeding 32 17.78 Without abnormal bleeding 36 20.00 Table 3: Relationship between endometriosis and pelvic pain (n=180). Variables Frequency (n) Percentage (%) Pelvic pain with periods in last 3 months Yes 155 86.11 No 25 13.89 Frequency of pain Occasionally 6 3.33 Often 20 11.11 Always 154 85.56 Severity of period pain (average) 6 (5-7) Severity of period pain (worse) 9 (8-10) Use of painkillers Uses prescription 112 62.22 Uses OTC 35 19.44 Affected daily living Never 11 6.11 Occasionally 51 28.33 Often 64 35.56 Always 54 30.00 Pelvic pain with intercourse Yes 142 78.89 No 38 21.11 Frequency of pelvic pain after intercourse Occasionally 28 15.56 Often 29 16.11 Usually 57 31.67 Always 66 36.67 Interrupt intercourse Yes 148 82.22 No 32 17.78 Avoid intercourse Yes 160 88.89 No 20 11.11 Pain during intercourse 7 (5-8) Pain 24 h after intercourse 7 (7-7)

The association between endometriosis and pelvic pain disorders is well -documented, with significant implications for women's health. Endometriosis is characterized by the presence of endometrial-like tissue outside the uterus, leading to various symptoms, primarily chronic pelvic pain. This is a disease with extraordinary variability and the overwhelming impression from the literature is that results regarding the prevalence of pain symptoms are incredibly inconsistent. This study investigates the association between endometr iosis and pelvic pain disorders to improve diagnosis and treatment strategies. The participants had a mean age of 31.8 years, with a standard deviation of 6.1 years, indicating a relatively young adult group. This aligns with the common age range for individuals affected by endometriosis [14]. Endometriosis and disorders causing pelvic pain can affect people in a variety of relationship situations. 70.00% of the participants were married, and 30.00% were single in our study. A higher percentage of unemploye d individuals can be seen in this study. These results are comparable with the findings of Armour et al. [15]. Participants of this study had diverse levels of education: 12.78% were illiterate, 20.00% had finished school, 38.33% had attended college, and 28.89% held a university degree. Most of the subjects had attended college in the study of Williams et al . [16]. According to our study, majority of the women did not have children. Other study conducted in another country also found similar result [17]. Our observation found that most participants had advanced endometriosis, with 42.78% in Stage 4 and 30.56% in Stage 3, indicating that over 70% had severe cases likely associated with symptoms such as pelvic pain. Fewer were in earlier stages, with 20.56% i n Stage 2 and 6.11% in Stage 1. Armour also indicated similar findings [15]. The most common symptom at disease onset among participants was severe dysmenorrhea, reported by 89.44% of individuals. Pelvic pain was also prevalent, affecting 78.33%, while ovulation pain was experienced by 46.67%. Other symptoms included deep dyspareunia, chronic fatigue, infertility, cyclical or peri-menstrual symptoms with abnormal bleeding or without abnormal bleeding. Presented symptoms reported by other several studies als o similar to our findings [14-17]. Pain and the associated symptom of fatigue is commonly seen in people with endometriosis [14-18]. Fatigue is a common symptom in people with endometriosis and other types of pelvic pain with 39 -43% of respondents reporting that symptom at the onset and all clinicians should ask about this symptom when taking a history of a person presenting with pelvic pain [15]. In the last three months, 86.11% of participants reported pelvic pain with periods, with 85.56% experiencing it "always" and an average pain severity of 6, increasing to 9 at its worst. Most used prescription painkillers (62.22%), and daily life was often affected in 35.56% of cases. Pelvic pain during intercourse was reported by 78.89%, with 36.67% experiencing it "always," and 82.22% said pain interrupted intercourse. Additionally, 88.89% avoided intercourse due to pain, with an average pain score of 7 during intercourse and 24 hours afterward. Previous international surveys [7, 19] , and qualitative research have highlighted the impact of endometriosis on social activities and marital/sexual relationships [20, 21] . We also demonstrated that personal relationships, whether friendships or those of a romantic/sexual nature, were negatively impacted by endometriosis and pelvic pain. Reasons for this may include the fatigue experienced reducing social interactions and increased anxiety of experiencing heavy menstrual bleeding, nausea, gastrointestinal and bladder symptoms in public places when interacting with friends, f amily or others [18, 21, 22] . Similar to previous work, romantic and sexual relationships were commonly affected in both cohorts, with pain as a direct contributor, but fatigue, nausea, depression, and other co- morbidities also, often, contributing to rela tionship strain and potential breakdown [23, 24]. Pelvic pain may later be diagnosed as endometriosis but most importantly, our work confirms that pelvic pain causes substantive negative impact on work, education, sexual relationships, family and friendshi ps [14]. It is therefore necessary to identify and have a treatment plan for pelvic pain symptoms, regardless of the current or future diagnosis.

of the study: Some of the data, such as pain levels and the impact on daily living, were self -reported, which may introduce bias or inaccuracies in symptom reporting. The study’s sample size of 180 participants may limit the generalizability of the findings to the broader population of individuals with endometriosis. The cross-sectional nature of the study does not International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 162 ~ allow for assessment of changes over time or the long -term effects of treatment on symptoms and quality of life.

and recommendations This study highlights a strong association between endometriosis and pelvic pain disorders, with the majority of participants presenting advanced stages of endometriosis and experiencing severe pain. The most common symptoms, including dysmenorrhea, pelvic pain, and dyspareunia, significantly impacted daily life, relationships, and sexual health. Our findings emphasize the need for timely diagnosis and effective management of endometriosis to reduce the burden of chronic pain and its consequences on quality of life. Future studies should explore the long-term effects of endometriosis treatments on pain management, fertility, and overall quality of life. Funding No funding sources Conflict of interest None declared Ethical approval The study was approved by the Institutional Ethics Committee.

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