Understanding endometriosis and pelvic pain starts with understanding menstrual anatomy, hormones involved in menstruation, and the neural pathways related to organs involved with endometriosis implants. Pelvic pain originates from the layer covering the organs, and their connecting structures, namely the peritoneum. Pain can also be due to the dysfunction of the organ deeply infiltrated by endometriosis. The mechanism of pain caused by endometriosis is extremely complex. Endometriosis is the most common cause of pelvic pain in women in their menstrual years, and pelvic pain is the most common symptom of endometriosis.While most women experience mild cramps, not all cramps are painful. Women with endometriosis, however, experience excessively painful cramps with menstruation that may progressively worsen in severity and duration. Cramps, or pelvic discomfort and distress, can be described as dull, sharp, stabbing, twisting, penetrating, or pulsating. In the initial implantation stages of endometriosis, before deep infiltration or invasion, the pain is nonspecific and very commonly associated with gastro-intestinal symptoms. These symptoms include nausea, vomiting, bloating, gas, fluid retention, and diarrhea. In later stages when fibrosis and nodule formation progress into invasion and infiltration, severe symptoms of constipation, painful bowel movement, and painful intercourse may begin.
Endometriosis pain is always pelvic in location and overlaps with menstruation. Every month the uterine lining (the endometrium) sheds in the absence of conception. The endometrium consists of swollen glands and blood vessels to accommodate pregnancy. The uterus must contract to expel this debris through its opening called the cervix. A deficiency in the prostaglandins may also play a role in this process. Other factors causing incomplete and ineffective emptying of the endometrial cavity are uterine anomalies such as intrauterine septum, arcuate cavity, and rudimentary horn. When the endometrial cavity and its menstrual debris is deposited into the inner peritoneal cavity through the tubal openings, the process is called the retrograde menstruation. While most women experience this normally, the volume of menstrual debris could be excessive due to factors causing heavy periods. In young girls and adolescents, coagulopathies such as Von Villa Brand disease, thrombocytopenia, factor 8 Laden must be ruled out. Endometrial polyps, fibroids submucosal, and adenomyosis develop from uterine muscle tissue and must be considered in older women with any type abnormal uterine bleeding. Heavy menstrual bleeding with pain is called menorrhagia and dysmenorrhea respectively, and point mainly to the uterus as the source of pelvic pain.
The basic mechanism explaining the foundation of endometriosis pain is peritoneal inflammation. Therefore dysmenorrhea (painful period) is mainly due to uterine cramps, and accompanying pelvic pain is due to irritation and inflammation of the peritoneum. As the implanted lesions settle down and begin to be hormonally responsive to estrogen, the so-called foci of mini periods is trapped within the thin peritoneal layer. Monthly reoccurrence of the same inflammatory process leads to thickening and disfiguring of the peritoneum due to scar formation called fibrosis. Fibrosis sets the stage for the more advanced disease including deeply infiltrating endometriosis of the bowel, bladder, ureter, and endometrioma of the ovary.
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