Endometriosis is probable reason for severe period pain, irregular menses

Dear Dr Mitchell,

I have some serious issues that I wonder if you could give me your expert opinion on. I am now 25 years old and have always had terrible period pains from ever since I started menstruation.

The pain is severe and last for the entire duration of the period. A few years ago my cycle change from 5 days to 7. While attending school, I had a prolonged period for about 10 days and was told by a doctor that I had hormone problems.

I did an ultrasound to see if I had fibroids or endometriosis or adenomyosis and blocked tubes two years ago, but the doctor told me that there was no indication that these were present. However, the result showed that my womb was a bit bulky.

I was with a guy for about 7 years and we tried to get pregnant for two years but nothing happened (we did not do this with a doctor’s supervision). Sometimes I have bleeding a week before my period or spotting a few days after. I also spot whenever I am ovulating with severe pain. Could you please tell me what you can make out of this situation?

The chronic pelvic pain and the prolonged menstrual periods that you experience are most likely due to endometriosis. Endometriosis is a condition in which the tissues that line the cavity of the uterus are present outside the cavity.

The endometrial tissue may be present in the abdomen or bowel, around the tubes, in the ovaries, the bladder or even in distant organs such as the lungs. The deposits may also be present in the walls of the uterus in which case the disorder is called adenomyosis.

These deposits tend to shed causing blood internally in a similiar way in which the lining of the uterus sheds resulting in menstrual period. This results in painful menstuation.

The pain classically starts before the menses, continues throughout the menses and even after the menses. The internal bleeding causes adhesions to form (the organs become bound down) and in the long run causes infertility. Endometriosis may also cause painful sexual intercourse especially on deep penetration.

The increase in the size of the uterus causing it to be bulky on examination may be as a result of adenomyosis (endometriosis in the muscle of the uterus). This may also cause painful period.

Endometriosis may be suspected on pelvic examination but the diagnosis is best confirmed by doing a diagonistic laparoscopy.

This is a minor operation which is done as an outpatient procedure. It enables the doctor to look directly at the internal organs and determine the presence of these endometriotic deposits. The presence of pelvic adhesions and the extent of damage to the fallopian tubes may also be assessed.

In some instances the endometriosis may appear to be very mild, yet the patient has very severe symptoms and is unable to conceive. Diagnostic laparoscopy is a useful procedure because it also helps to detect other causes of chronic pelvic pain such as fibroids and chronic pelvic inflammatory disease (PID). Chronic PID is usually due to sexually transmitted infection. Ultrasound is not useful in diagnosing endometriosis or blocked tubes.

If endometriosis involves the ovaries then the presence of a complex ovarian cyst may be suggestive. To diagnose blocked tubes, an x-ray called hysterosalpingogram (HSG) has to be done. In some cases the HSG may show that the tubes are not blocked but conception does not occur because endometriosis does not affect the lumen of the tubes. Instead, it causes adhesions or scarring of the ends of the tubes to become bound down, thus preventing the tubes to pick up the eggs at ovulation and preventing pregnancy.

The good news is that this condition can be treated. The treatment includes the use of medications to suppress the menstrual periods thus allowing the deposits to shrink or disappear. In severe cases, surgery has to be done, and this is best done via laparoscopy as this reduces the complications involved.

In some patients, despite adequate medical and surgical treatment, pregnancy does not occur and so in-vitro fertilisation (IVF) has to be done. The outcome with this is good especially in patients who are young and have good quality eggs.

You need to be properly evaluated and referred to an infertility specialist. The Fertility Management Unit at the University Hospital offers diagnostic and operative laparoscopy tests as well as in-vitro fertilization if this is deemed necessary.

The results are good and the cost is affordable when compared with first world countries. Consult your gynaecologist who will advise you further.

Best wishes.

Dr Sharmaine Mitchell is an Obstetrician and Gynaecologist. Send questions or comments via e-mail to allwoman@jamaicaobserver.com; fax to 968-2025; or call 511-2502 to leave a 30-second message. We regret we cannot supply personal answers.