By: Julianna Cervino, MD
Editor’s Note: This is a review of research published in 2015 in Human Reproduction titled, “Pain typology and incident endometriosis.” Schliep et al aimed to define the different types of pain experienced by patients undergoing laparoscopy or laparotomy for a variety of indications and with no previous diagnosis of endometriosis. Dr. Julianna Cervino summarized the research below and concluded by highlighting important points of convergence between study findings, fertility awareness-based methods (FABMs), and a woman’s charting of the menstrual cycle.
Introduction
Endometriosis is a gynecological condition defined by the presence of endometrial glands and stroma outside of the uterine cavity. Approximately ten percent of women of reproductive age have endometriosis. However, this could be an underestimation, given that women may be asymptomatic or have atypical symptoms. Although patients with endometriosis commonly present with pelvic pain, clinical manifestations may also include dysmenorrhea, dyspareunia, dysuria, dyschezia, and chronic pelvic pain.
Among different patients with endometriosis, pain can range from very minimal to debilitating. These pain syndromes are well known, but a clear depiction of pain type and topology of endometriosis versus other gynecologic conditions is needed. The objective of this study was to describe pain type, severity, and location among all women undergoing a diagnostic laparoscopy or laparotomy for any gynecological condition, including endometriosis.
Methodology
This study had an operative cohort of 473 women ages 18 to 44 who were undergoing laparotomy or laparotomy at one of fourteen surgical centers in Salt Lake City, Utah or in San Francisco, CA. All women completed a comprehensive questionnaire about their pre-operative pain. Following surgery, the surgeons completed a standardized operative report. Endometriosis was diagnosed during surgery in appropriate patients using the revised American Society for Reproductive Medicine’s (rASRM) staging criteria. The researchers utilized descriptive statistical techniques to examine the information from the questionnaires and operative reports.
Results
The study found that women with endometriosis were more likely to report cyclic pelvic and chronic pelvic pain compared to women with any other gynecologic condition or a normal pelvis.
According to the survey, women with surgically diagnosed endometriosis were also more likely to report dysmenorrhea and dyspareunia. Interestingly, there was no clear pattern between severity of symptoms and staging of endometriosis based on the rASRM criteria. In terms of location, women with endometriosis reported more vaginal pain, right and left sided labial pain, and more pain in the hypogastric/umbilical abdominopelvic regions. No association was found between stage of endometriosis and location of pain.
Discussion
This study provided the first empirical evidence reflecting a higher prevalence of (1) chronic and cyclic pelvic pain, (2) dyspareunia, (3) dysmenorrhea and dyschezia, and (4) pain in the perivaginal and abdominopelvic regions among women with a surgical diagnosis of endometriosis as compared to women with other gynecological pathology or a post-operative normal pelvis. Unlike prior research, this study found no association between pain type and stage of disease. This is interesting and may point to the need for a revised staging system that takes symptomatology into account. This study is not only helpful in giving us an evidence-based approach to assessing endometriosis pain but also highlights areas for future study. For example, it was found that women with endometriosis report more hypogastric/umbilical abdominopelvic pain. It is worth investigating this pain type further, as these women may also have pain generated by a comorbid condition like irritable bowel syndrome that can make diagnosing these distinct diseases difficult.
This research by Schliep et al is extremely relevant for medical professionals in women’s health and provides evidence of pain typology in women suffering from endometriosis. The study findings should be used to educate patients on what their endometriosis diagnosis means and what pain syndromes they may have. The study can also be validating and reassure these patients that they are not alone, and that others recognize and seek to understand their pain.
Strengths and Limitations
Some strengths of this study include the large sample size and the variety of surgical indications represented, including pelvic pain, pelvic mass, irregular menses, fibroids, tubal ligation, and infertility. This variety in indication may reflect a pathologically diverse population. Another strength of this research is the pain assessment tool, which asked women about 17 different sources or timing of pain. They then could specify pain location by clicking on thirty-five locations in the perineal/upper thigh region and on sixty front and back body sites.
The main limitation of the study was the participant population: 74.8% non-Hispanic white, 94.7% married, and 80.2% college educated. This is not a diverse population and does not reflect the diversity of women who have endometriosis. A more inclusive study population would add strength to future research.
Fertility Awareness and Endometriosis
Fertility awareness-based methods (FABMs) serve as powerful tools to understand a woman’s cycle and diagnose and treat a variety of gynecologic conditions, including endometriosis. Women who have chronic or cyclic pelvic pain or who already have a diagnosis of endometriosis could incorporate charting their pain along with cervical mucus and/or other biomarkers tracked with their FABM. Such a practice could lead to quicker diagnosis and treatment of endometriosis as well as other gynecologic conditions.
Editor’s Note: Follow the links below to learn more about clinical applications of fertility awareness-based methods in endometriosis.
Empowered Through Fertility Awareness: A Patient Interview
The Truth about Diet and Endometriosis: A Research Review
The Creighton Model: From Skepticism to Pregnancy
Endometriosis in Adolescents: A Review of Research
Omega-3 Polyunsaturated Fatty Acids for Endometriosis-Related Pain: A Research Review
References
[1] Schliep KC, Mumford SL, Peterson CM, et al. Pain typology and incident endometriosis. Hum Reprod. 2015;30(10):2427-2438. doi:10.1093/humrep/dev147.
[2] Schenken, Robert. “Endometriosis: Pathogenesis, Clinical Features, and Diagnosis.” UpToDate, www.uptodate.com/contents/endometriosis-pathogenesis-clinical-features-and-diagnosis.
ABOUT THE AUTHOR
Julianna Cervino, MD
Julianna Cervino, MD wrote this review as a fourth-year medical student during the FACTS elective in fertility awareness. She completed medical school at Drexel University College of Medicine and is an obstetrics and gynecology resident at Brown University. She plans to be a general obstetrician gynecologist and looks forward to providing comprehensive women’s healthcare. The FACTS course introduced her to fertility awareness-based methods and she is excited to offer them as an option to her patients.
