Guest Blog Post by Mandy Klumpkens

Endometriosis is a complicated whole body disease. Chronic pelvic pain is always present but may vary in intensity over time. Pelvic pain, including the ‘killer cramps’, may occur out of nowhere and can last for a certain period of time. On the other hand this type of pain can be so intense, that it’s presence will dominate a woman’s life. 

The way in which chronic pelvic pain is being experienced is not always an indicator to how extreme endometriosis is actually present in the pelvis. In addition, endometriosis mimics other diseases. This is why often it takes a long period of time to get diagnosed for the symptoms are being misinterpreted and maltreated. 

To understand and manage this type of pain in an optimal way, a few things need to be taken into account. Endometriosis behaves in a malignant manner. Like cancer, endometriosis cells divide without control. They attach to other tissues and will invade and damage them. Infertility and organ dysfunction might be a result of this malignancy. On top of this endometrioma has its own blood supply and is biologically active outside the uterus. Hormones play a crucial part in the level of intensity endometriosis symptoms are being experienced. Therefore when treating this disease, hormonal imbalance needs to be taken seriously for it can be the key in pain management. 

For endometriosis, estrogen levels are crucial. Estrogen is responsible for thickening the uterine lining each cycle. However women having higher levels of estrogen will have more intense thickening and symptoms may be or may become worse over time. As estrogen stimulates endometriosis, progesterone inhibits it. Progesterone treatment decreases the activity of estrogen receptors. As a result it slows estrogen action in tissues such as the endometrium. A different form of treatment includes GNRH (gonadotropin – releasing hormone) antagonists. As a result the pituitary gland will be prohibited in making FSH and LH hormones. Also it causes ovaries to stop making estrogen and progesterone. Often it is used to treat prostate cancer. As with all hormonal therapies, GNRH antagonists are commonly associated with hormonal side effects. Given the intensity in which these side effects are being experienced by most women, often this type of treatment is not favorable. 

Inflammation can be a result of hormonal alterations which can lead to changes in how the brain signals pain. Because this pain can become chronic, the way this type of pain is being perceived over and over in time will be logged in the brain in a certain way. This neural mapping will create dominant pathways in which this type of pain is being received. Because the pelvis is highly vascularized it will send its own pain impulses to the brain. The tricky part is, that because of the chronic nature and the hormonal imbalance the processing of pain can become distorted. 

When we look at how chronic pain is being perceived by the brain, central sensitization (CS) is a phenomenon that plays a prominent part in how a woman is experiencing this type of pain. CS is a condition of the nervous system associated with the development and more important the maintenance of chronic pain in time. The persistent state of heightened reactivity, is when CS occurs. This state is the reason why the brain produces a certain experience of pain that is amplified. Because of this state, the threshold that will tell us when to experience pain is lowered. In a structural way. This is why the experience of pain is still present after healing. There is a heightened sensitivity to pain and touch. When the threshold is working properly the brain should only provide a mild sensation. But when the threshold is altered this way, discomfort or even severe pain is being experienced. When this state is reached, a woman with chronic pelvic pain will be unable to engage descending inhibition pathways. Cognitive behavioral therapy will bring the threshold back to a healthy state. Also mild aerobic exercise is proven to lead to reduction in pain. Moreover behavioral interventions in combination with exercise will reduce associated pain and suffering. The central nervous system will be restructured and receptors will be retrained to interpret stimuli in a way that the pain that is being perceived is realistic. 

When treating chronic pelvic pain the best treatment will be a combination of surgery and psychotherapeutic or alternative treatment to improve quality of life. Once again treatment is personal, and the effect of a certain treatment will be different for each woman dealing with endometriosis and chronic pelvic pain. 

To learn more about the management of chronic pelvic pain, check out  Nezhat et al.’s paper on Optimal Management of Endometriosis and Pain, available for free download here.