Endometriosis Explained

Deep infiltrating endometriosis

2010-11-21T03:31:00.000-08:00

There was an interesting study from a French group in the on-line version of Fertility and Sterility this week. The researchers compared the clinical records of 229 women with endometriosis; 98/229 had severe or "deep infiltrating endometriosis", 131/229 had more superficial patterns. They found  that patients with DIE had: a positive family history of endometriosis (odds ratio [OR] = 3.2); more absenteeism from school during menstruation (OR = 1.7; 95% CI: 1–3), OCP treatment for dysmenorrhea (OR = 4.5). Dr Chapron, the senior author, doubted whether diagnosing endometriosis earlier will eventually lead to fewer cases of DIE and less need for surgery.

We do not have the full paper as yet. It will be interesting to see - if the information is available - (1) how many girls had severe and constant pain from the age of onset of their menstrual periods (menarche). In the denervation-reinnervation view, that implies any injury to pelvic nerves takes place before the age of 12. Pain is severe at menarche because that is when oestrogen-dependent changes in pelvic blood flow, take place. (2) What proportion of these young girls had sustained bowel problems, either in infancy associated with bottle-feeding or toilet training, or, in subsequent years ? If bowel habits do not change then the disease will simply "progress". Finally, (3) are there any other potential sources of injury to pelvic nerves in these patients ?

Stages of endometriosis (revised AFS stages I-IV)

2010-11-08T13:31:00.000-08:00

Revised American Fertility Society scores (0-5 = stage 1, 6-16 = stage 2, 16-40 = stage 4, >40 = stage 4) suggest a progression of "endometriosis" that coincides with symptoms and laparoscopic scores. Neither is true. In fact there looks like three forms of chronic pelvic pain - (1) CPP with no endometriosis (2) CPP with minor endometriosis (<15) (3) CPP with major endometriosis (>15) ...... and these are  separate entities rather than a progression of the condition.

What is absolutely clear is that symptoms such as chronic pelvic pain, bear no relationship to the extent of the endometriosis found at laparoscopy. For the most part this is predictable from a consideration of the aetiology. Advanced nulliparous endometriosis associated with persistent physical straining during defaecation results from recurrent events and score heavily (particularly since fusion of the rectum to the vagina scores 20 points, stges 3/4). Whereas significant injuries in childbirth are one-off injuries and the presence or absence of endometriosis may depend on choice of feeding; breastfeeding results in no endometriosis (yet plenty of pain, stage 0) though bottlefeeding results in early menstruation before the intrapartum injuries heal up (also plenty of pain, stage 1/2).

Net result is that scores bear no relationship to symptoms, and, stages of endometriosis do not change significantly throughout the course of the condition. Surgical removal of endometriosis without dealing with underlying abnormal nerves, may not be entirely helpful.

NGF in endometriosis

2010-11-06T05:37:00.000-07:00

A paper from Berlin in Fertility and Sterility (November 2010) "Overexpression of nerve growth factor (NGF) in peritoneal fluid from women with endometriosis promotes neurite outgrowth in endometriotic lesions" by Dr de Arellano and colleagues, finds exactly what the title says. New, abnormal nerves occur in peritoneal lesions in assoication with increased concentrations of nerve growth factor (NGF). This group have been doing a series of careful studies focussed on the neurological content of peritoneal lesions over the past few years - Sydney, Hangzhou, Leuven, Berlin, etc.

Various interpretations may be given to these observations but they add to the growing weight of evidence that injuries to pelvic nerves are the source of most clinical symptoms in clinical endometriosis.

Chronic pelvic pain in China

2010-11-05T02:57:00.001-07:00

More uterosacral injuries at laparoscopy. On this occasion a Chinese patient, delivered in Hangzhou - which is interesting because the CS rate is 60-70% and there are correspondlingly few vaginal deliveries. On this occasion there is absent of the left uterosacral ligament that is plastered against the left pelvic side wall. The right uterosacral ligament is almost intact. In this patient the features are clearly defined because of the prior procedure to remove the left ovarian endometrioma - by a second year resident. Peritoneal lavage with normal saline outlines the key anatomical features.

Levator injuries in chronic pelvic pain - BJOG, November 2010

2010-11-01T14:06:00.001-07:00

“Intrapartum risk factors for levator trauma” is the title of an Australian paper in BJOG this month (November, 2010) where the authors did MR scans four months after the first labours of 367 women. 32/367 women suffered irreversible injury to their pelvic floor muscles (levator ani). The important risk factors were forceps delivery (OR 3.83) and prolonged second stage (OR 1.01) .

The important features of this study are that it looks at a large number of women with an expensive instrument – and finds a high rate of injury to the levator muscles. From the standpoint of women with chronic pelvic pain it is important because if you have injured the muscles of the pelvic floor it is likely that you have injured the large nerve bundles that lie closer to the baby than the muscle. There are no symptoms of pelvic pain at four months after delivery but that may well be different at five years.

Chronic Pelvic Pain and the BMJ

2010-10-08T16:08:00.000-07:00

The BMJ carried a review of chronic pelvic pain today (8th October 2010 BMJ 2010; 341:772-5) by Dr Jane Daniels and Professor Khalid Khan. It was a review of the known facts. The highlight was some research funding to study the .....
role of magnetic resonance imaging in chronic pelvic pain.

It is clear from previous studies that it is possible to study the pelvis in one millimetre slices in any plane using these techniques. Detecting significant injuries that occurred during primigravid labour and childbirth will be a significant advance. Enlarged uterosacral ligaments as a consequence of physical efforts during defaecation may also be detectable.

MR imaging won't detect every cause of chronic pelvic pain but it may mean that many women can be spared diagnostic laparoscopy and its attendant, serious risks - which would be a very good result for many women with chronic pelvic pain.

Endometriosis explained - a new website

2010-10-01T09:35:00.000-07:00

In view of the level of interest in the denervation-reinnervation view of endometriosis, a new website - www.endometriosisexplained.com - has been published.
It is largely for women with chronic pelvic pain with, or without, endometriosis to enable a better understanding of the condition.

In view of the level of interest from China and the joint research projects that have led to this new view of this important condition, some pages will be available in Chinese provided by colleagues from the University of Zhejiang,Hangzhou.

Laparoscopic surgery in China.

2010-05-30T06:09:00.000-07:00

I had the great privilege and pleasure of visiting two laparoscopic surgery units in China. The first - in Hangzhou (5 million) - had 60 gynaecological operations plus emergencies - through 10 theatres every day. Less than 10% ot the procedures were performed through the laparoscope, up to, and including radical hysterectomy with sentinel node biopsy. All consultants are highly skilled laparoscopic surgeons; all residents start laparoscopy on day one of year one. The second unit was at Fudan University, Shanghai - a teaching centre with an emphasis on gynaecological cancer - same again - with 80-100 laparoscopic radical hysterectomies in the past 9 months (no screening programmes so much early stage cervical cancer).

All equipment was reusable, including the reusable morcellator illustrated above. Technique included two 5 mm ports on the left with one 5 mm on the right, no suprapubic ports, no uterine manipulators, monopolar scissors, harmonic scalpel occasionally, and all sutures performed intracorporeally by delivering the suture through the port site incision with a conventional needle holder. There were large numbers of women with endometriomas, myomas, extensive endometriosis, etc Procedures were smooth, quick, polished, and, immediate postoperative results excellent.

These were not minimal access teams; this was a laparoscopic "army" performing to the highest possible standards.

Beijing Xiangshan Scientific Meeting, May 2010

2010-05-30T05:49:00.001-07:00

Xiangshan is a village in The Fragrant Hills, that serves the Beijing Botanical Gardens, 30k to the south of Beijing. It is also the site of a 5-star conference centre where the Chinese government holds almost-continuous, scientific conferences. Chinese colleagues arranged a 2-day, Xiangshan meeting on "Endometriosis". Forty-fifty of the most experienced researchers and clinicians attended from all around China - from Harbin in the north to Shanghai and Hangzhou in the south - to discuss endometriosis and chronic pelvic pain.

We had an excellent two day meeting where topics such as aberrant reinnervation, the role of childbirth and constipation, the contribution of multiple terminations of pregnancy to both endometriosis and adenomyosis, the aetiology of ovarian endometriomas, and, appropriate monitoring and treatment, were topics of conversation. The quality of the Chinese research and presentations was high. The quality of their laparoscopic surgery is outstanding - as good as anywhere in the West. In many ways it was a comparable meeting to an RCOG National Study Group meeting - in rather more sumptuous surroundings.

Thanks to the organisers including Xin Mei ZHANG, Sun Wei GUO, Heng CUI, Con Jian XU, Jing Lei WU and many others for some productive discussions, outstanding hospitality and a memorable meeting which will lead to many new avenues of research in Chinese gynaecology.

Endometriosis Awareness Week

2010-03-10T02:53:00.000-08:00

Many have been contributing to "Endometriosis Awareness" this week. Diana Wallis MEP and Hilary Mantel, among others, have been using some well-crafted descriptions of their personal observations of the effects of neuropathic pelvic pain to raise awareness.

Our present understanding of endometriosis as "blobs that bleed and cause pain" is partial, unsophisticated and remote from the facts. It is now clear that injuries to pelvic nerves are the source of most symptoms of pelvic pain, painful sex, painful periods and subfertility.

Normal uterus has few nerves, injured uterus has large numbers of abnormal nerves - but they also extend into the cervix, vagina and supporting (uterosacral) ligaments so that every movement is painful and any touch is exquisitely painful. Add a propensity to infection, period problems and not being able to get pregnant - and you have sufficient to cause misery and despondency throughout the female sex. Compound it with some confusion about what injury causes what symptoms and you have a recipe for personal and professional disaster.

To overcome this daily pain is a remarkable achievement for many women.

Top 10 tips for pain from injured pelvic nerves in "endometriosis"

2009-11-16T06:58:00.001-08:00

Given that chronic pelvic pain, painful periods, painful intercourse and subfertility result from injured pelvic nerves in "endometriosis" (see previous posts and pdf in the right pane of the browser), the question is what to do about them.

Fig 1 Injured pelvic nerves encasing a pelvic vein from a woman with advanced (AFS IV) "endometriosis". Any increase in pelvic blood flow e.g. before your period or during sex, will increase your pain.
First, don't make things worse. Get on a good diet (nothing with a bar code on it). Avoid prolonged physical efforts during defaecation - we know it causes injuries to pelvic nerves as does difficult vaginal delivery and surgery.

Second, simple analgesia (codeine, tylenol, aspirin, etc) can be helpful at the right time of cycle. Sometimes anti-nerve agents can be helpful e.g. amitriptyline, imipramine, etc but only on the advice of your doctor.

Third, note how your pain is relative to your menstrual cycle. For many women it crescendoes just before a period and then improves with the onset of your period. Pain improves with reductions in your pelvic blood flow i.e. OCP, GnRH, aromatase inhibitors (letrozole, anastrozole). All require prescriptions.

Fourth, sex, if possible, is easier in the first half of your cycle. Anything that touches the nerves makes pain worse. Very specific points are tender - avoid them. Climax equals increased pelvic blood flow and may cause pain afterwards.

Fifth, your symptoms arise largely from the injured nerves and not necessarily, the blobs of endometriosis. Advice to laser or remove the blobs needs careful consideration with your doctor. Selected hysterectomy can be helpful; very selective oophorectomy with add-back HRT can be helpful.

Sixth, if you are prone to thrush, treat it (and your partner) every month immediately after your period. If you have irritative bladder and bowel symptoms (going too often, having to rush) then you need some oxybutinin, tolterodine, darifenacin, solfenacin, etc. These drugs treat injured nerves in your bladder but have side effects including uncomfortable "dry eyes" and "dry mouth".

Seventh, there is often more than one point or source of pain. Map your pain during the day, during sex, during the month, and with food and bowel habit. It always stops at the menopause; sometimes the doctors can induce a pseudo-menopause if things are desperate.

Eighth, because your symptoms arise from injured autonomic nerves, acupuncture and other "alternative" treatments may be appropriate. Seek proper advice from a registered practitioner. Tell them you suffer from chronic pelvic pain and see if they can help.

Ninth, improve your posture and gait. Make sure shoulders are above hips, above knees, above ankles. Shoulders need to go back. See www.egoscue.com or any book by Peter Egoscue (Amazon). Abnormal posture may affect pelvic pain. Daily "Egoscue" menu of exercises can be very helpful.

Tenth, look after yourself and your mood. It is important that you keep your injured nerves under control. They connect directly to your mid-brain. Physical and mental health are closely connected. Change your mood with your diet, exercise, relationships, surroundings and expectations. Mood mapping at www.moodmapping.com may be helpful.

Most important thing about these symptoms associated with "endo" is to know what causes them, do not make them worse, and, look after yourself. Research groups in UK, Australia, China, Belgium, Holland and USA all record similar observations in relation to injured pelvic nerves. Full bibliography is on the front page of www.bristolanatomycourse.co.uk in the paper on "Endometriosis".

Blog roll of endometriosis blog sites

2009-11-15T09:46:00.000-08:00

A collection of endometriosis blogs listed on one page by "End to Endo" provides ease of access to many personal testimonies to the awfulness of this condition.

http://www.endtoendo.com/Endometriosis_Research_Blogroll.html

Women are beginning to receive the message that injured nerves are causing their symptoms. Colleagues in UK, Australia, Belgium, Holland, Germany, China and USA have demonstrated injuries in the uterus, cervix and Fallopian tube in women with "endometriosis". Injuries to nerves result from difficult vaginal deliveries, persistent straining during defaecation as well as some forms of surgery. Prevention is better than treatment.

Original 2005 paper
http://www.ncbi.nlm.nih.gov/pubmed/16260205

Recent 2009 review of causes of endometriosis, adenomyosis, fibroids
http://informahealthcare.com/doi/abs/10.1080/01443610903082484?journalCode=jog

Endometriosis in China

2009-10-07T08:10:00.001-07:00

Some more studies from Zheijang, China confirm the observations set out below. They are published in two papers in Fertility and Sterility (November 2009).

In the first paper the authors describe nerve fibers in the endometrium (lining of the womb) in women with all sorts of painful conditions including endometriosis, adenomyosis and fibroids.

In the second paper they suggest that these nerve fibres are the source of the pain in adenomyosis and fibroids. The methodology and the quality of the neuro-immunohistochemistry is very good throughout both papers

So women in Australia, China, Netherlands, Belgium, UK and USA all have abnormal nerve fibres in their uterus in painful pelvic conditions. The question arises as to where these nerve fibres come from .... Professor JS Fairbairn had an idea in 1931, HL Gainey set it out in 1943, Professor Sir Dugald Baird was quite clear in 1957 as well as HC Taylor, W Allen, W Masters, etc.

Why do women not know ?

Endometriosis, uterotubal dysmotility, and abnormal nerves

2009-10-01T10:45:00.000-07:00

Dr John Sampson first proposed that retrograde menstruation gave rise to endometriosis in the 1920's. Contemporary gynaecology does not give a mechanism for this "reverse" flow of menstrual debris from the uterus along the Fallopian tubes. New studies (UK, Australia, Belgium) confirm abnormal nerves in the uterus that may upset the normal pattern of menstruation. Others have shown disordered motility of the Fallopian tubes though without demonstrating abnormal nerves in the Fallopian tubes.

Image provided by Dr Gregory Brodsky.

The image, produced by Dr Gregory Brodsky, shows a cross section of the Fallopian tube as it passes through the uterine muscle (intramural Fallopian tube). Nerve fibres stain brown using an antibody named anti-S100 (standard histological technique). At 2, 6, 8 and 10 o'clock there are collections of abnormal nerves around the Fallopian tube. Nerves are important in propelling material in the correct direction. These abnormal nerves will also promote retrograde menstruation and prevent normal progress of the egg from the ovary to the uterus. Injuries in childbirth and during physical efforts during defecation may contribute to these observations - among other events.

Sir Dugald Baird on gynaecology

2009-09-11T10:05:00.001-07:00

In the preface to the sixth edition of his "Combined Textbook of Obstetrics & Gynaecology", the then Regius Professor of Obstetrics & Gynaecology at the University of Glasgow said:

"the great majority of ailments encountered in gynaecological practice are the result of infections and injuries contracted during parturition"

Sir Dugald Baird was suggesting that injuries to pelvic muscles, ligaments, blood vessels and nerves, resulted in gynaecology. We have always known that injuries to pelvic muscles, ligaments and nerves result in urinary incontinence and genital prolapse. Many now believe that injuries to pelvic nerves result in chronic pelvic pain, menstrual disorders, bladder problems, bowel problems, etc. We now know this as the denervation-reinnervation view of obstetrics and gynaecology.

There is nothing new.

Premenstrual syndrome and GnRH agonists

2009-08-31T11:54:00.000-07:00

Fig : Thousands of nerve fibres "encasing" a pelvic blood vessel. Blood flow increases in the premenstrual phase of the cycle causing these nerves to "fire". This offers a mechanism for premenstrual pelvic symptoms that may improve with GnRH treatment. Effects in the pelvis may be mirrored elsewhere (See below)

Swedish colleagues studied 28 women with "premenstrual dysphoric disorder" treated with GnRH agonists and three, rotating forms of HRT. Symptoms improved most with the lowest dose of oestrogen. The authors acknowledged the limited duration of therapy owing to potential ostopenic effects, but did not offer a mechanism of action for GnRH agonists in this setting. How do GnRH agonists improve symptoms of irritability, headache, bloating, etc. when their primary effect is suppressing the hypothalamo-pituitary axis (and reducing pelvic blood flow) ?
http://download.journals.elsevierhealth.com/pdfs/journals/0002-9378/PIIS0002937809002713.main-abr.pdf

The first law of autonomic denervation states that injury to a (pelvic) autonomic nerve results in distal "irritability" (Cannon and Rosenblueth, 1949). We now know that this distal "irritability" may arise from reinnervation in the affected area. We also know that pelvic perivascular nerve fibre proliferation results from persistent efforts during childbirth and defaecation (Fig 1). We do not know in published authorities that such lesions are prominent in the PMDD-PMS spectrum ?

The second law of autonomic denervation states that if autonomic nerves are injured then this may have effects on autonomic nerves at other sites. Formal studies use the term "central sensitisation" which in this case produces symptoms of PMDD-PMS. The next question for Dr Segebladh and colleagues is what do they do after six months successful treatment with GnRH ?

Endometrial nerve fibres in Belgian "endometriosis"

2009-08-28T08:02:00.000-07:00

Now a Belgian group confirms the presence of endometrial nerve fibres in women with minimal endometriosis. Importantly they have started to characterise the nature of these nerves by using a panel of antibodies to stain for them in the lining of the womb. http://www.ncbi.nlm.nih.gov/pubmed/19690351?ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Abnormal nerve fibres are now described in isthmic myometrium, cervix, uterosacral ligaments, vagina, retroperitoneum, endometrium and endometrial deposits as well - in "endometriosis". Every anatomical structure at the junction of the uterus and vagina contains abnormal nerve fibres in these women. Potential causes include injuries at vaginal delivery, persistent physical efforts during defaecation (particularly in nulliparae) and direct injuries to autonomic nerves between the brain and pelvis. http://www.bristolanatomycourse.co.uk/
http://www.ncbi.nlm.nih.gov/pubmed/15325003?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The authors do not say where thes abnormal nerve fibres originate. Neither do they say what they believe is the source of pain in "endometriosis" - is it the endometriosis, nerve fibres or both ?

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Endometriosis and Mirena IUS

2009-08-28T07:32:00.000-07:00

Mirena (Schering Ltd), or to give it the full title; the levonorgestrel-releasing intrauterine system (LNG-IUS) is a safe, effective and acceptable form of contraception used by over 150 million women worldwide. http://www.ncbi.nlm.nih.gov/pubmed/19707273?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

It is also helpful in the treatment for menorrhagia, endometriosis (and pelvic pain), and endometrial hyperplasia. The LNG-IUS releases a very small dose of 20ug of progesterone into your system every day. The LNG-IUS is well tolerated and patient satisfaction is quite high however its use remains low in US. These authors believe this is because of the persistent negative impressions from the Dalkon Shield intrauterine experience in the 1970s. http://www.nytimes.com/1987/12/06/magazine/the-sad-legacy-of-the-dalkon-shield.html

The system can be beneficial in women with some forms of chronic pelvic pain with, or without, endometriosis, and, whether they have had children or not. It has proved popular in the UK where hysterectomy rates continue to decline as a result of this, and other, improvements in gynaecological care. http://www.ncbi.nlm.nih.gov/pubmed/15790607?ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

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Endometriosis and pregnancy

2009-08-22T05:55:00.000-07:00

Does "endometriosis" influence pregnancy outcome ? The Karolinska Epidemiology group in Stockholm asked this question in 2007 because case-control studies flagged up a potential association between "endometriosis" and preterm labor. This paper looked at 1.4 million pregnancies between 1992 and 2006 and specifically 8922 women with "endometriosis".
http://www.ncbi.nlm.nih.gov/pubmed/19690351?ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

They found that women with "endometriosis" have higher rates of preterm labour (OR 1.33), pre-eclampsia (1.13), antepartum haemorrhage (1.76) and prelabour Caesarean section (1.58). Interestingly, there were no increases in SGA or stillbirth - why ?

No precise reasons were offered for the observations. There was no analysis of differences in rates of PTL in nulliparous v multiparous women. This information may follow in a second paper. Nevertheless this is an important, and authoritative, contribution to reproductive health care.

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Nerve fibres in the endometrium in Australian "endometriosis"

2009-08-22T05:45:00.001-07:00

Do the ectopic deposits of endometrium cause pain or, is there another mechanism ?

We know that endometriosis is common - 10% of women aged 15-45 years. It is alleged that small deposits of ectopic endometrium cause pain at different times of the month. Yet many women experience the same pain without a diagnosis of endometriosis. The Sydney group (Al-Jefout et al. Human Reproduction, 18th August 2009) now report nerve fibres in endometrial samples taken in the outpatient department with a suction curette. They say this is a "new, non-invasive test" for endometriosis but what are the nerve fibres doing there ? And where have they come from ? http://www.ncbi.nlm.nih.gov/pubmed/19690352?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Nerve fibre proliferation occurs in isthmic myometrium, cervix, vagina, vulva and uterosacral ligaments as well as bladder and bowel. So there are abnormal nerve fibres all over the pelvis in women with gynaecological symptoms; those symptoms frequently occur with one another (Zondervan, 2000) and are more common in parous women. Is it possible that nerve fibre proliferation takes place following injury to pelvic nerves during childbirth ?
http://www.ncbi.nlm.nih.gov/pubmed/15325003?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

But ..... many women without children have similar symptoms. Yes, some injure their pelvic nerves by direct trauma, some injure their pelvic nerves through persistent straining during defaecation and some injure the nerves between brain and pelvis. Each results in similar clinical presentations.
http://www.ncbi.nlm.nih.gov/pubmed/17454472?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
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Premenstrual syndrome and constipation ?

2009-08-15T08:08:00.000-07:00

Large pelvic nerves converge on the junction of the uterus and vagina (Spackman, 2006). Big babies, forceps deliveries, malpresentations (the baby lying back to back) can result in injuries but these may be much worse if prolonged maternal pushing precedes the delivery. Prolonged pushing results in swelling and friability of soft tissues, making them much more vulnerable to injury as the baby emerges. Caesarean sections injures them in other ways.

It is therefore not to difficult to understand how persistent straining during defaecation causes problems ?

One per cent of women manage successful defaecation once per week; 0.05% manage it once per month (Heaton, 1992) 20-30% of Western bowel movements are complicated by persistent straining. Many young women visit the bathroom every day to make an attempt. The trouble is these problems are wrapped up in the word "constipation". When we look at the results under the microscope, the pelvic nerves are torn and then they re-grow along, and around, pelvic blood vessels (Fig 1, Quinn, 2006).

That tells you that any increase in pelvic blood flow results in pain. Pelvic blood flow increases in the second half of the menstrual cycle before the start of your period. So premenstrual discomfort or pain may have a "real" explanation in these patterns of nerve injury. Injuries in one part of the nervous system may have effects at another.

Pelvic pain and injured pelvic nerves

2009-08-13T06:56:00.001-07:00

Chronic pelvic pain (CPP) affects 10% of women aged 15-45 years. There is a gathering pandemic in Western countries.

Most of the time doctors do not find the cause. They often talk about the "possibility of endometriosis" where the lining of your womb sticks to the surfaces of your pelvic organs. Many women have a diagnostic laparoscopy where a telescope is put through the umbilicus under general anaesthetic to look into your pelvis. If it is "endo" then you get treatment; if it is not "endo" then you may, or you may not. Many women complain they have been "fobbed off".

CPP from "endo" is said to result from bleeding into the pelvis at the same time as your period. But, most women with "endo" experience pain at other times of the month. The question arises as to whether "endo" is the source of your pain or not ?

New research confirms that many women with "endo" have injuries to their pelvic nerves from childbirth and/or constipation and/or surgery and/or miscellaneous injuries. Injuries to pelvic nerves result in their chaotic and proliferative regrowth (Fig 1). Imagine your lower uterus, upper vagina and their suspending ligaments being infiltrated with these new nerves. They will cause pain at different times of the month, with movement, with changes in blood flow, etc. They will require different patterns of treatment to "endometriosis", They place the condition in a new framework.

All pelvic pain needs appropriate advice whether "endo" is present, or not.

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Endometriosis Explained

2009-07-30T14:07:00.000-07:00

Endometriosis Explained sets out a new explanation of the condition based on injuries to pelvic nerves. It also considers other patterns and forms of chronic pelvic pain in women.

On the right hand side of the browser at the top of the column there are four different versions of the new view. Please note that these accounts contain pictures of human cadaveric and surgical anatomy. If you do not wish to see this material then do not use the link.

Most of the information describes material published in peer review medical journals over the past three years that supports this view. The explanation describes the aetiology of endometriosis, adenomyosis, fibroids, and, why these conditions frequently coexist.

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