A 30-year-old female asked:
30/f endometriosis and ovarian cysts had left ovary and tube removed. had fluid drained off pelvis 6 months later. now i'm in horrible pain.
1 doctor answer • 1 doctor weighed in
Dr. Laurence Badgleyanswered
General Practice 53 years experience
You suffering sole: 30's female with endometriosis is one of a multitude of suffering persons. Doctors do not know cause. Unfortunately operative procedures of the pelvic cavity tissues can arouse adhesions. I have often wondered at incidence of bowel obstruction ; irritable bowel syndrome as function of serial operative procedures many endometriosis patients undergo.
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Dr. Laurence Badgley commented
General Practice 55 years experience
Provided original answer
ENDOMETRIOSIS ERRORS Peritoneal implants labelled as "endometriosis" are reputed to be sources of pain generation. What is the evidence for this hypothesis? One study looked at the peritoneum of women as part of a standard fertility work-up. 118 women were examined. None of these women had pelvic and abdominal pain of "endometriosis". Yet three-fourths of these patients had visually diagnosable "endometriosis". Biopsies were taken and pathology slides were prepared and examined. The visual diagnosis was confirmed by pathology 93% of the time. These finding suggest that so-called sites of supposed "endometrial implants" are not painful, but in fact are quite common (Reference 1). In another recent study, it was discovered that biopsy sites of "endometriosis" did not tissue stain nor appear as endometrial tissues under the microscope in 33-43% of women from whom tissues were taken at time of surgery for endometriosis. For a long period of time this method of tissue histopathologic evaluation has been a goal post for making the diagnosis of "endometriosis". This level of error suggests a method of pathological evaluation for endometreosis that is not dependable (Reference 2). It also suggests that the surgeon's eye cannot dependably discern "endometriosis". A most bothersome study has not received the degree of review that it deserves. In studies of women undergoing pelvic surgery, 55-100% experienced common complications including "small bowel obstruction, infertility, chronic abdominal and pelvic pain, and difficult reoperative surgery". The authors blamed peritoneal adhesions for these symptoms consequential to pelvic surgery (Reference 3). This study did not involve considerations of endometriosis, but simply catalogued tissue complications of common surgeries of the pelvic organs of women. These results suggest that the pelvic tissues of women are extraordinarily sensitive to surgical interference of peritoneal integrity, and that these kinds of tissue manipulations induce the development of adhesions. In 1999, Wellberry presented a treatise on endometriosis and proclaimed, "approximately 24% of women who complain of pelvic pain are subsequently found to have endometriosis". This observation suggests that the supposed "endometrial" wanderer implants are more a coincidental finding than a firm and direct cause of pelvic pain (Reference 4). If endometrial implants were a direct cause of "endometriosis", the incidence of finding endometrial-like tissues within women suffering with "endometriosis pain" would be closer to 90%. Wellberry proclaimed ideas that have remained a steadfast theory of "endometriosis", and which were illustrated when he put forth his various speculations as to the cause of endometriosis as follows: 1. "Peritoneal endothelium (the outer layer of peritoneal cells) can be transformed into endometrial tissue" de novo, and for unknown reasons. 2. "Chronic inflammation" (possibly STD related) causes the peritoneal lining to develop tissue changes that are like uterine endometrium. 3. "Mullerian remnants" grow into endometrial-like tissue execrences. This speculation purports that embryonic cells destined for tissue construction of the urinary tract system migrate and implant at "endometriosis" sites on the pelvic peritoneum. A final thought provided in Dr. Wellberry's dissertation was that, "most women with endometriosis have normal physical examination of their pelvises". Taken as a collection, Dr. Wellberry's statements are not affirming of proof of a theory as to the cause of "endometriosis". There is additional evidence for this quandary as to the cause of endometriosis. Dr. Ripps found an "unreliable correlation between clinical manifestation of surgical findings" (Reference 5). What this means is that what he found at surgery was unrelated to symptoms the women were having. As he stated, "even with direct visualization diagnosis of endometriosis can remain difficult". What he found was that pelvic pain these women reported, and which was aroused by pelvic examination, was not matched by signs of inflamed or endometriosis-type tissues in directly visualized pelvic peritoneum at the time of surgery. As he stated, "a patient who is asymptomatic or who has very mild symptoms may have extensive disease (he means signs of endometriosis tissue sites)...the correlation between stage and extent of disease remains controversial". In the opinion of the author of this present report ("Endometriosis Errors") the controversy has never been settled, and additional information supports this contention. A reputed site of information is the University of Maryland website, wherein is reported the following about "endometriosis": 1. "Cause is unknown" 2. "Difficult to diagnose" 3. Severity of pain does not appear to be related to "extent of the endometriosis itself" 4. "Other causes of pelvic pain, such as celiac disease, Irritable Bowel Syndrome, and Interstitial Cystitis can mimic pain of endometriosis". Reader, are you beginning to see the clinical thread being revealed by this information? The word "endometriosis" is a word manufactured to describe a speculative and unproven biological phenomenon. Additionally, the favored phenomenon model is not well supported by clinical medical data. When it comes to endometriosis a few things need to be acknowledged. One is that the cause and syndrome described for the current disease model, wandering uterine tissues, has never been proven. In medicine worthy proof of a theory of causation is a rationally derived therapy which proves to be efficacious. Certainly, the popular therapies applied to endometriosis seem wanting. Most worrisome is the absence of relationship between laser ablation and symptom remission. I would not be surprised to find that the progressive painful nature and more widespread adhesions associated with endometriosis are directly related to the number of laparoscopic procedures a woman has undergone. My understanding of tissue pathology does not rule out that an increasing number of laser ablations of sites of supposed endometriosis "implants" instigate more widespread peritoneal inflammation, with more scarring, and increased adhesions of the peritoneum. The passage of intestinal contents, both liquid and gas, even partially obstructed is exceedingly discomforting as are all intestinal blockages. Intestinal smooth muscle is insensitive to cutting and burning, but excessive bowel dilation and intestinal wall smooth muscle stretch elicits a crampiness in the lower abdomen which is most painful. Loose stools, or occasionally chronic constipation, accompanies this Irritable Bowel Syndrome (IBS) pattern of intestinal dysfunction. To my mind the abdominal discomforts associated with endometriosis are more intestinally than ovarian or uterine derived. I suspect that women with endometriosis who develop IBS, experience gradually increasing symptoms over time; as peritoneal adhesions evolve and, like all good scars, contract over time. It is these adhesive scars that are suspected, to my mind at least, to be a major cause of the abdominal symptoms of endometriosis. The obvious explanation for symptomatic relief following hysterectomy and oophorectomy is the new absence of hormones secreted by these organs. Relaxin is one of these hormones, and which has a function of keeping ligaments looser, thereby enabling pelvic joints to sublux and cause impingements of autonomic neural tracts coursing to pelvic organs, and which impingements manifest as crampy pain, sciatica, and intestinal dysfunctions. Relaxin also loosens muscle tissue and thereby renders the entire body more flexible. Increased ligament and muscle stiffness associated with the absence of Relaxin secretion might explain diminished irritation of intestinal nerves via joint subluxations, and the onset of chronic widespread muscle spasms associated with fibromyalgia. In other words the symptoms of supposed pelvic and abdominal pain associated with "endometriosis" are real, but endometrial implants are a red herring as to the primary cause. The true cause of the endometriosis syndrome is an underlying disorder of ligament laxity. There is a known association between endometriosis, fibromyalgia, Irritable Bowel Syndrome, and Joint Hypermobility Syndrome (JHS), a condition of abnormal ligament laxity. When the inherited variety of benign Joint Hypermobility Syndrome (JHS) is factored into the endometriosis equation, the combined dynamic of ligament laxity and joint subluxation arouses an experience of greater pain intensities from worsening of pelvic organ dysfunctions. REFERENCES 1. Nicolle M. Histologic Study of Peritoneal Endometriosis in Infertile Women. Fertil Steril. 1990 June: 53 (6), 984-988, PMiD 2351237 2. McMaster-Fay R. The Clinical Utility of CD-10 Immunochemical Staining in the Diagnosis of Endometriosis. rfay.com.au/docs/cd10poster.pdf 3. Liakakos T. Peritoneal Adhesions: Etiology, Pathophysiology, and Clinical Significance. Dig. Surgery (Pub Med) 18(4); 260-273 (2001) doi:10.1159/000050149PMiD11528133 4. Wellberry, C. Diagnosis and Treatment of Endometriosis. American Family Physician (1999), Oct. 15; 60 (6): 1753-1762 5. Ripps B. Correlation of Focal Pelvic Tenderness with Implant Dimension and Stage of Endometriosis. J. Reprod. Med. (1992) 37; 620-624.
Mar 3, 2014
Dr. Laurence Badgley commented
General Practice 55 years experience
Provided original answer
I announce a study of endometriosis at Quora.com on my Pain Syndrome board.
Mar 3, 2014
Last updated Mar 3, 2014
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