Endometriosis Food List

Endometriosis Bible & Violet Protocol

The Endometriosis Bible & Violet Protocol is a comprehensive guide to understanding and treating Endometriosis and Endometriosis and Pregnancy. The author, Zoe Brown, has. suffered from Endometriosis and has also been cured of it's devestating consequences. She is dedicated to helping other women trying to cope with endometriosis and pregnancy. symptoms. In fact, this program is backed up with over 32 years of continuous trial and error and is now realized as a guaranteed roadmap for endometriosis freedom. This is a 5-step system that a large number of women used to beat their endometriosis problem. The author reveals to every user a substance which has the possibility to eradicate the clutter of dead cells that is clogging the body in endometriosis without harming their living cells. Additionally, you will know about the dangers around your own home which just wait to fire up the endometriosis lesions. Thus, you will know how to avoid them forever. More here...

Endometriosis Bible & Violet Protocol Summary


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Endometriosisassociated subfertility

Whether endometriosis causes subfertility or not is also controversial. It is generally accepted that endometriomas cause infertility because severe anatomical distortion must interfere with oocyte pick up. A causal relationship with minimal-mild disease(particularly subtlelesions) is much less certain. Numerous mechanisms have been proposed, including abnormal folliculogenesis, anovulation, luteal insufficiency, luteinized unruptured follicle syndrome, recurrent miscarriage, decreased sperm survival, altered immunity, intraperitoneal inflammation and endometrial dysfunction. However, all these functional disturbances can occur in subfertile women without endometriosis, which suggests that finding disease during investigation for subfertility may be coincidental.

Epidemiology of chronic pelvic pain

Initial reports relied on estimates from hospital series, naturally unrepresentative of the general population. Some population sample survey data are available a US study reported the responses of women interviewed by telephone 1 . The age range of respondents was 18-50. 17,927 households were contacted, 5325 women agreed to participate and of these 925 reported pelvic pain of at least 6 months' duration, including pain within the past 3 months. Having excluded those pregnant or post-menopausal and those with only cycle related pain, 773 out of 5263 (14.7 ) were identified as suffering from chronic pelvic pain (CPP). A British population survey used a postal sample of 2016 women randomly selected from the Oxfordshire Health Authority register of 141,400 women aged 18-49 2 . Chronic pelvic pain was defined as recurrent pain of at least 6 months' duration, unrelated to periods, intercourse or pregnancy. For the survey, a 'case' was defined as a woman with CPP in the previous 3 months...

Endometriosisassociated pain symptoms

Severe dysmenorrhoea, deep dyspareunia, chronic pelvic pain, ovulation pain, cyclical or perimenstrual symptoms - often bowel or bladder related, causing dyschezia or dysuria - with or without abnormal bleeding, and chronic fatigue have all been associated with endometrio-sis. However, the predictive value of any one symptom or set of symptoms is uncertain as each can have other causes, and many affected women are asymptomatic. There is little correlation between disease stage and the type, nature and severity of pain symptoms, perhaps because the current classification systems are inadequate. However, endometriomas and DIE are clearly associated with severe pain, although some affected women are pain free in the case of DIE, symptom severity is related to the depth of infiltration. Typical peritoneal lesions probably cause pain as symptoms are relieved by surgery whether this applies to subtle lesions remains unclear. The suggested causes for the pain include peritoneal inflammation,...

Peritoneal endometriosis

Peritoneal endometriosis comprises superficial lesions scattered over the peritoneal, serosal and ovarian surfaces. Pelvic pain American Society for Reproductive Medicine revised classification of endometriosis Endometriosis retrograde menstruation. Menstrual effluent containing viable cells is transported into the peritoneal cavity in a retrograde direction along the fallopian tubes and the refluxed endometrium then implants onto the surface of exposed tissues, principally the peritoneum. However, most women do not develop endometriosis even though retrograde menstruation occurs commonly, for which there are several explanations. First, the amount of menstrual effluent transported may be important as higher prevalence rates occur in women with increased menstrual exposure due to (1) obstructed outflow associated with Mullerian anomalies and (2) short menstrual cycles, increased duration of bleeding and decreased parity 1 . Second, the expression of factors such as cell adhesion...

Chronic pelvic pain

The role of endometriosis in chronic pelvic pain remains controversial and difficult to quantify. In this chapter the management protocols for chronic pelvic pain are outlined and it is extremely important that patients who have endometriosis-related chronic pelvic pain are recognized as suffering with irritable bowel syndrome. The use of the holistic approach to these patients can be extremely effective in relieving some of their pelvic pain and improving their quality of life. This relates to improved diet, fluid intake, avoidance of constipation and exercise. There is also increasing evidence that self-management courses can be very effective in helping these women cope with their long-term problems of pain.


Endometriosis is characterized by the presence of uterine endometrial tissue outside the cavity of the uterus. The common sites are the pelvic peritoneum, ovaries and rec-tovaginal septum. The prevalence of pelvic endometriosis in women with infertility has been shown to be 21 (Mahmood and Templeton, 1991). The link between endometriosis and infertility has been demonstrated in some, but not all studies on this subject. Women with endometriosis undergoing assisted reproduction face a relatively poor outcome. A systematic review suggests that pregnancy rates are halved in comparison with women with tubal infertility (Barhart et al. 2002.). Data from in vitro fertilization (IVF) programmes also suggest diminished ovarian reserve, poor oocyte and embryo quality and impaired implantation in advanced endometriosis (Brosens, 2004). Peritoneal fluid from women with endometriosis containing high levels of cytokines, growth factors and activated macrophages has been shown to be toxic to sperm...

Pelvic pain

Pyosalpinx Ultrasound Appearance

It is very important to take a good history of the nature and location of pelvic pain and determine by clinical examination what the likely differential diagnosis is prior to performing an ultrasound examination. There are many causes of pelvic pain and ultrasound findings taken in isolation may be misleading. For example, the majority of simple ovarian cysts are an incidental finding however, ultrasound can help determine those patients in whom surgical intervention is required. The commonest pathologies in which ultrasound may be of use are cyst accidents, pelvic infection and endometriosis. Ovarian cysts are relatively common in women during reproductive life. Ovarian cysts per se are notpainful however, a cyst accident be it haemorrhage, rupture or torsion may lead to pelvic pain. ENDOMETRIOSIS Endometriosis while sometimes asymptomatic it is often associated with chronic pelvic pain. Routine sonography is unlikely to detect peritoneal endometriotic deposits. Nodules in the pouch...

Pregnancy and Infertility

There are many causes of infertility. Abnormal semen causes the infertility problems of about 30 percent of couples seeking treatment. Tubal disease and endometriosis in the female partner account for another 30 percent. A female partner's failure to ovulate accounts for 15 percent, and the inability of sperm to penetrate the woman's cervical mucus accounts for another 10 percent. The final 15 percent of couples seeking treatment are infertile for reasons that cannot be diagnosed. endometriosis disorder of the endometrium, the lining of the uterus

Discharge And Home Healthcare Guidelines

The major cause of ectopic pregnancy is tubal damage, which can result from pelvic inflammatory disease, previous pelvic or tubal surgery, or endometriosis. Other causes may be hormonal factors that impede ovum transport and mechanically stop the forward movement of the egg in the tube, congenital anomalies of the tube, and a blighted ovum. Pelvic infections and sexually transmitted diseases (STDs), specifically chlamydia and gonorrhea, are often involved. Other risk factors include smoking, diethylbestrol exposure, T-shaped uterus, certain intrauterine devices (IUDs), and a ruptured appendix.

Gender Ethnicracial And Life Span Considerations

Endometriosis is estimated to occur in 10 to 15 of women of reproductive age in the United States the highest incidence is in nulliparous white women. It can occur at any age after puberty, although it is most commonly found in women aged 30 to 40. There is a higher incidence of endometriosis in women who marry and bear children later in their lives. The course of the disease is individual and may worsen with each repeated cycle, or the woman may remain asymptomatic throughout her reproductive years. The symptoms and progression of the disease stop after menopause. Ethnicity and race have no known effects on the risk for endometriosis. HISTORY. Elicit a complete history of the woman's menstrual, obstetric, sexual, and contraceptive practices. Endometriosis is difficult to diagnose because some of its symptoms are also manifestations of other pelvic conditions, such as pelvic inflammation, ovarian cysts, and ovarian cancers. A thorough description of the patient's symptoms becomes...

What screening tests are in use

Of the ovarian tumour markers, the most extensively studied is CA125. It is an antigenic determinant on a high-molecular-weight glycoprotein that is recognized by the mouse monoclonal antibody, OC125, developed using an ovarian cancer cell-line as an immunogen. CA125 was first discovered in 1981 (Bast et al.). Levels are raised in 50 of stage I ovarian tumours and in 90 of stage II ovarian tumours (Zurawski et al., 1988). CA125 levels may also be raised in a range of other physiological and pathological conditions, which may be gynaecological or non-gynaecological, benign or malignant (Table 14.1). This can cause particular problems in screening the high-risk population. Many of these women are premenopausal and the CA125 level may fluctuate with the menstrual cycle or maybe elevated by such conditions as endometriosis. Specificity using CA125 as a screening tool can be improved using serial determinations over time (Einhorn et al., 1992). An algorithm has been developed in...

Iatrogenic causes of amenorrhoea

Gynaecological procedures such as oophorectomy, hysterectomy and endometrial resection inevitably result in amenorrhoea. Hormone replacement should be prescribed for these patients where appropriate. Hormone therapy itself can be used to deliberately disrupt the menstrual cycle. However, iatrogenic causes of ovarian quiescence have the same consequences of oestrogen deficiency due to any other aetiology. Thus the use of GnRH analogues in the treatment of oestrogen-dependent conditions (e.g. precocious puberty, endometriosis, uterine fibroids) results in a significant decrease in bone mineral density in as little as 6 months. Although the demineralization is reversible with the cessation of therapy, especially for the treatment of benign conditions in young women who are in the process of achieving their peak bone mass, the concurrent use of an androgenic progestogen or oestrogen 'add-back' therapy may protect against bone loss.

Genetic Considerations

Elicit a detailed family history of all cancer-related illnesses, paying particular attention to the history of female relatives. The patient's descriptions of the signs and symptoms vary with the tumor's size and location symptoms usually do not occur until after tumor metastasis. The symptoms patients most commonly report are back pain, fatigue, bloating, constipation, abodomi-nal pain and urinary urgency. Most patients with ovarian cancer have at least two of these symptoms. Other symptoms include urinary frequency, abdominal distension, pelvic pressure, vaginal bleeding, leg pain, and weight loss. Pelvic discomfort and acute pelvic pain may occur, and if infection, tumor rupture, or torsion has resulted, the pain may resemble that of acute appendicitis.

The cost of treating PID

The psychological and fiscal costs of pelvic inflammatory disease are substantial. The uncertainty of the diagnosis and difficulty in predicting the subsequent risk of infertility, chronic pelvic pain or ectopic pregnancy add to the anxiety associated with PID, and are in addition to the feelings of blame, guilt and isolation that the diagnosis of a sexually transmitted infection may instil. Most of the monetary costs of PID arise from surgical interventions to diagnose and treat the consequences of tubal damage, and have been estimated at between 650 and 2000 per case 4 . These costs will rise substantially with improved availability of infertility treatments in the future.

Sexual and physical abuse

Child sexual or physical abuse may be an antecedent for CPP but many individuals have suffered such abuse without this or other consequence in later life and the research literature is beset with the problem of appropriate comparison groups. Individual judgement is needed about whether to ask directly about sexual or physical abuse during a gynaecological consultation. Important considerations are the setting and plans for follow-up and support that are available to women following such disclosure. Sometimes such a history may be volunteered by the patient unprompted, especially so during a follow-up consultation when rapport has been established. Some women may even find it easier to raise the subject with an unfamiliar hospital specialist than with a general practitioner with whom they have regular consultations for other matters. It may be useful to incorporate questions on abuse into a self-completion questionnaire, such as that provided by the International Pelvic Pain Society,...

Stephen Kennedy and Philippe Koninckx

Endometriosis is usually defined as the presence of endometrial-like tissue, that is, glands and stroma, outside the uterus. The most commonly affected sites are the pelvic organs and peritoneum, although other parts of the body such as the lungs are occasionally affected. The disease varies from a few, small lesions on otherwise normal pelvic organs to solid infiltrating masses and ovarian endometriotic cysts (endometriomas) - often with extensive fibrosis and adhesion formation causing marked distortion of pelvic anatomy. Endometriosis should be suspected in women with subfertility, severe dysmenorrhoea, deep dyspareunia and chronic pelvic pain. However, many affected women are asymptomatic in which case the diagnosis is only made when the pelvis is inspected for an unrelated reason, for example sterilization.

Classification systems

In which points are allocated for endometriotic lesions, periovarian adhesions and pouch of Douglas obliteration (Fig. 44.1) 3 . The total score is then used to describe the disease as minimal (Stage 1), mild (Stage 2), moderate (Stage 3) or severe (Stage 4). This system was designed to assist in the prognosis and management of patients undergoing surgery for subfertility. Deeply infiltrating endometriosis (DIE), a major cause of pelvic pain and dys-pareunia, is typically assigned a low score (Stage 1 or 2) because only visible lesions contribute this partly explains why there is little correlation between the total score and pain severity. Clearly, a better, more validated method to classify disease severity is needed, which can differentiate between typical lesions and DIE.

Reproductive System DRG Category 336 Mean LOS 40 days Description Surgical Transurethral Prostatectomy with CC

Prostatitis, an inflammation of the prostate gland, is classified in four categories. Acute bacterial prostatitis is an acute, usually gram-negative, bacterial infection of the prostate gland, generally in conjunction with acute bacterial cystitis. Chronic bacterial prostatitis is a subclinical chronic infection of the prostate by bacteria that can be localized in prostatic secretions and is the most common recurrent urinary tract infection in men. Nonbacterial prostatitis is a chronic prostatitis for which there is no identifiable organism. Prostatodynia is a condition in which the patient experiences irritation and pelvic pain on voiding the symptoms suggest an acute inflammatory process, but there is no evidence of inflammatory cells in the prostatic secretions.

Alternative management protocols

Is it necessary to perform a laparoscopy in all cases of suspected endometriosis The recommendation in the RCOG Guideline is 'If a woman is not trying to conceive and there is no evidence of a pelvic mass on examination, there may be a role for a therapeutic trial of a COC (monthly or tricycling) or a progestagen to treat pain symptoms suggestive of endometriosis without performing a diagnostic laparoscopy first'. Although, the recommendation reflects the common practice of using a COC in this way, or even continuously, there is no evidence that one method is better than any other, or that any COCs are better than others. Fig. 44.5 Unadjusted meta-analysis of odds of pregnancy in endometriosis patients vs controls with tubal subfertility 28 . for 2 months, continuing for 6 months if successful. Both protocols acknowledge the value of continuing on maintenance therapy if adequate pain relief is achieved with one or a combination of drugs. It should be acknowledged, however, that these...

Important coexistent pathologies

Endometriosis is a common coexistent pathology in patients undergoing assisted conception. Whereas there has been no suggestion in improvement of assisted conception cycles by treating peritoneal endometriosis, there can be a benefit to treating large endometrioma prior to the IVF. It is thought this may benefit the cycle in several ways including the ovarian response itself and overall number of eggs obtained (particularly in the ovary containing the endometrioma). The second concern with ovarian endometriomas is that these can be inadvertently punctured during TVOR and there is a significant increase in ovarian abscess formation if this occurs. Pre-cycle drainage by needle aspiration can also give a significant rate of ovarian abscesses and this is generally not advised. If the ovarian endometrioma is felt to be a

Further investigations of female infertility

Male Groin Hernia Examination

Miscarriage, termination of pregnancy, ectopic pregnancy Chronic illnesses (diabetes, hypertension, renal disease) Known endocrine disorders, e.g. hypothyroidism, PCOS Previous STD's, e.g. Chlamydia Known endometriosis Galactorrhoea Cervical smear history Current medication including folate salpingostomy Ovarian surgery Pelvic surgery for endometriosis Previous laparoscopy Appendicectomy Coital frequency and timing Once preliminary investigations suggest that a woman is ovulating and semen parameters are satisfactory, the next step should be assessment of tubal status. Tubal disease implies tubal block and pelvic adhesions due to infection, endometriosis or previous surgery. Laparoscopy and chromotubation (lap and dye) is the investigation of choice as it is able to demonstrate tubal patency as well as assess the pelvis for the presence of endometriosis and adhesions. Hysterosalpingogram (HSG) which involves a pelvic X-ray following the injection of a radio opaque iodine-based dye...

Genital tract malformations

Partial Septate Uterus

Rudimentary development of one horn may give rise to a very serious situation if a pregnancy is implanted there. Rupture of the horn with profound bleeding may occur as the pregnancy increases in size. The clinical picture will resemble that of a ruptured ectopic pregnancy with the difference that the amenorrhoea will probably be measured in months rather than weeks, and shock may be profound. A poorly developed or rudimentary horn may give rise to dysmenorrhoea and pelvic pain if there is any obstruction to communication between the horn and the main uterine cavity or the vagina. Surgical removal of this rudimentary horn is then indicated. problem. Redundant portions of the membrane may be removed but nothing more should be done at this time. Fluid will then drain naturally over some days. Examination a few weeks later is desirable to ensure that no pelvic mass remains which might also suggest haematos-alpinx. In fact, haematosalpinx is most uncommon except in cases of very long...

Synthetic LHRH Analogue in Solution

Analogue Chemical

The pivotal role that LHRH and its analogues play in the modulation of reproductive functions have attracted considerable scientific interest because of their usefulness in the treatment of endocrine-based diseases such as prostate cancer, breast cancer, endometriosis and precocious puberty. Several LHRH agonists, represented by Leuprolide ( DLeu6, desGly' -LHRH-ethylamide), are currently used in the treatment of the above conditions. The goal of this research is the synthesis and conformational analysis of a LHRH analogue, such as Aib6, desGly10 -LHRH-ethylamide in order to gain valuable insights on bioactive conformation and use these for the design of further analogues. This LHRH analogue was synthesized by the solid phase methology on a AM resin via Fmoc tBu methology. ID and 2D NMR experiments were carried out in 2-2.5mM solution of Aib6, desGly' -LHRH ethylamide in DMSO-d . The average structure of LHRH analogue was calculated from the family of the 20 models and refined using...

Mood and impact on quality of life

It is important to identify coexisting mood disturbance. While it is unlikely that depression is the cause of CPP, the presence of disturbed mood makes it difficult for patients to engage fully with pain management initiatives and tackle associated lifestyle factors. The absence of laparo-scopically visible pathology was not associated with a higher probability of depression 7,8 . In these studies no differences in mood-related symptoms were identified in women with CPP with and without endometriosis. Antidepressant therapy may be indicated to alleviate depression, but sertraline was not effective for relief of pelvic pain in a small but well-conducted randomized trial 9 .

The Injectable Bulking Agents

This product is composed of pyrolytic carbon-coated zirconium oxide beads ranging in size from 212 m to 500 m suspended in a water-based carrier gel containing beta-glucan. Pyrolytic carbon is a nonreactive product that has been used in medical devices, including heart valves, for the past 30 years. Injection requires an 18-gauge needle, and the product is radio-opaque. The beads are not biodegradable, but a urological study has shown evidence of significant migration to the local and distant lymph nodes as well as into the urethral mucosa 16 . There was also a recent report of four patients with peri-urethral mass formation 12-18 months following a Durasphere injection. The patients exhibited symptoms of irritation, pelvic pain or difficulty voiding

Ovarian endometriomas

Several variants on the implantation and metaplasia theories have been proposed to account for ovarian endometri-omas. It has been suggested that superficial lesions on the ovarian cortex become inverted and invaginated, and that endometriomas are derived from functional ovarian cysts or metaplasia of the coelomic epithelium covering the ovary. Endometriomas have features in common with neoplasia such as clonal proliferation, which is consistent with the endometriosis disease theory, and they are associated with sub-types of ovarian malignancy, such as endometrioid and clear cell carcinoma. Genetic alterations in endometriotic tissue are reported in loss of heterozy-gosity (LOH) studies, particularly involving chromosomal regions containing known or putative tumour suppressor genes (TSGs) implicated in ovarian cancer. These data suggest that endometriomas are benign tumours although recently researchers have questioned whether endometri-omas are truly monoclonal and whether they...

Deeply infiltrating disease

Rectovaginal Peritoneal Cavity

Area exposed to the peritoneal cavity) result from infiltration of superficial disease they should be considered a form of typical endometriosis (Fig. 44.2). However, Type II infiltrating lesions with bowel retracted around and over the nodule and Type III lesions, which often occur in an otherwise normal pelvis, are morphologically like ade-nomyosis with mainly fibromuscular and little glandular tissue. The same applies to infiltrating lesions of the sig-moid (Type IV). Type I lesions, like typical ones, can be multifocal, but Type II and III are invariably singular in a series of over 1000 cases, fewer than 50 women had nodules infiltrating both the rectum and sigmoid.

Gonadotropin Releasing Hormone Agonists GnRHa Lupron Synarel Nafarelin Buserelin

GnRHa can also be used as treatment for painful endometriosis. Your reproductive hormones are shut down, your periods stop, and the pain associated with endo-metriosis is gone. When GnRHa is used in this way, your body is transformed into a temporary menopausal state and pregnancy cannot occur during this time. This use of GnRHa is mentioned here because many women with fertility issues suffer from endometriosis. Therefore, it is possible that this treatment may be presented to you as temporary relief to your painful endometriosis symptoms.

University of North Carolina Clinical Experience

Ing continence in 22 25 patients (88 ), significant morbidity was observed. Two patients required permanent colostomy for refractory incontinence. In terms of donor-site complications, 16 25 patients (64 ) developed a combination of posterior thigh numbness (7), dysesthesias (5), cellulitis (5), irregular contour (3), abscess (2), severe chronic pain (2), and hematoma (1), but there was no altered gait or hip dysfunction. Regarding perirectal complications, 14 25 patients (56 ) had sinus tract formation (3), flap dehiscence requiring reoperation (2), perirectal abscess requiring temporary fecal diversion (2), chronic pelvic pain (2), vaginal perforation with delayed healing (1), recurrent fistula (1), and rectal prolapse (1). Six patients required readmission for wound care, intravenous antibiotics, or operative intervention.

Tubal factor infertility

The role of intrauterine contraceptive devices (IUCDs) in the aetiology of tubal disease is controversial. In the 1980s a number of studies reported an increased risk of PID in women who used IUCDs as compared to non-users. More recent data suggest that IUCD users, who are at low risk of sexually transmitted infections, face no added risks of PID. Congenital abnormalities are uncommon causes of tubal pathology and are associated with developmental anomalies of the urinary system. Endometriosis, cornual fibroids or polyps can cause cornual block or tubal distortion. Another relatively rare cause, salpingitis isthmica nodosa, described as nodular thickening of the proximal part of the fallopian tube is of unknown aetiology.

Fsh and lhomas Pituitary Tumors Secreting Fsh Or Lh

FSH- and LH-secreting tumors are usually clinically silent. Rare cases of tumors presenting with clinical features have been reported. A 28-yr-old Finnish woman presented with oligoamenorrhea and pelvic pain. A detailed assessment revealed elevated FSH and estradiol with an appropriately suppressed LH enlarged ovaries with multiple cysts were seen on pelvic ultrasound examination. Both gonadotropins and the a-subunit exhibited a paradoxic response to TRH, and MRI revealed a pituitary macroadenoma. After removal of the pituitary tumor, all hormone values normalized, and the patient resumed normal menstrual cycles. In another report, transsphenoidal tumor resection was found in a girl who presented with precocious puberty. LH hypersecretion from a pituitary adenoma was also documented in two cases. Thus, varying degrees of hypopituitarism may occur in these patients, with decreased libido and erectile dysfunction in men and oligo- or amenorrhea in women. Alternatively, central...

Assisted reproduction

In women with minimal-mild endometriosis and patent fallopian tubes, treatment with intrauterine insemination (IUI) along with ovarian stimulation improves fertility, but it is uncertain whether unstimulated IUI is effective. In vitro fertilization (IVF) is appropriate treatment for all disease severities, especially if tubal function is compromised or there are other problems such as male factor subfertility 20 . However, a systematic review (Fig. 44.5) showed that IVF pregnancy rates are lower in patients with endometriosis than in those with tubal subfertility 28 , even though endometriosis does not appear adversely to affect pregnancy rates in some large databases (e.g.

The peritoneum

The peritoneum is a thin serous membrane which lines the inside of the pelvic and abdominal cavities. In simplistic terms it is probably best to imagine a pelvis containing the bladder, uterus and rectum (Fig. 1.4) and note that the peritoneum is a layer placed over these organs in a single sheet. This complete layer is then pierced by both the fallopian tubes and the ovaries on each side. Posteriorly the rectum also pierces the peritoneum connecting to the sigmoid colon and the area between the posterior surface of the uterus and its supporting ligaments and the rectum is called the Pouch of Douglas. This particular area is important in gynaecology as the place where gravity dependent fluid collects. As a result this is where blood is found in ectopic pregnancies, pus in infections and endometriosis which has been caused by retrograde menstruation (Sampsons theory).


The uterus is supported by the muscles of the pelvic floor together with three supporting condensations of connective tissue. The pubocervical ligaments run from the cervix anteriorly to the pubis, the cardinal ligaments pass laterally from the cervix and upper vagina to the lateral pelvic side walls and the uterosacral ligaments from the cervix and upper vagina to the sacrum. These uterosacral ligaments can be clearly seen posterior to the uterus in the Pouch of Douglas and are a common site for superficial and deep infiltrating endometriosis.


Transvaginal scanning provides much clearer images of pelvic structures in comparison to transabdominal scanning. By using the transvaginal approach it is possible to palpate pelvic organs under visual control, which enables assessment of their mobility and helps to establish the source of pelvic pain. Gentle pressure applied with the tip of the probe may be used to see whether the suspected tubal ectopic moves separately from the ovary. This 'sliding organs sign' helps to avoid false positive diagnosis of ectopic pregnancy in women with a prominent corpus luteum on ultrasound scan 21 . In experienced hands, transvaginal ultrasound will detect 75-80 of clinically significant tubal ectopic at the initial examination 22 . The remaining 20-25 can be detected on follow-up visits and ultrasound should rarely fail to visualize an ectopic pre-operatively.

Italian Study

Required to have had a hysterectomy for a nonneoplastic condition, to obviate concerns about an increased risk of endometrial carcinoma. There was no requirement that participants be at risk for BC development, and, in fact, whose who underwent premenopausal oophorectomy with hysterectomy actually had a slightly reduced risk of BC development. Women with endometriosis, cardiac disease, and OVT were excluded from the study. Although 5408 women were randomized into this study, 1422 withdrew and only 149 completed 5 yr of treatment.

How Does GnRHa WORK

When used in the treatment of endometriosis, the medication shrinks the endometriosis implants, which relieves the pain. GnRHa is sometimes used prior to surgery because it makes the endometriosis implants smaller and easier to remove. It also helps reduce the amount of scar tissue. Because of risks and side effects, GnRHa is typically only used for a short period of time, three to six months. The benefits of this treatment for endometriosis are often only a temporary solution, lasting for a few months. For others, pain relief lasts considerably longer.

How Do I Take GnRHa

If you are taking a GnRHa for treatment of endometriosis, you will likely either receive a monthly injection or need to spray the medication into your nose twice daily. This form of treatment is typically limited to three to six months. This short time period is recommended because of the potential risks and side effects associated with long-term use of GnRHa.


Before attempting to classify any fracture, it is essential that an accurate radiographic diagnosis be obtained to understand the fracture pathology and how best to manage it. It is important to remember, however, that not all complaints of pelvic pain are derived from a traumatic event. When trying to differentiate pelvic pain in elderly patients, insufficiency or stress fractures should be considered. These usually present as nondis-placed fractures, may have normal appearing X rays, and may occur not only from high-energy trauma (29) but also from low-energy trauma, such as a fall from a standing height (30,31). In addition, the diagnosis has also been made in patients who present with rheumatological disorders (32,33), Crohn's disease (30), vitamin or mineral deficiencies (34), and osteoporosis (14,15,31,35-38). These fractures can occur


There are no objective tests (physical, biochemical or endocrine) to assist in making the diagnosis. Prospectively completed specific symptom charts are required (Fig. 41.1). This is partly because the retrospective reporting of symptoms is inaccurate and because significant numbers of women who present with PMS have another underlying problem such as the perimenopause, thyroid disorder, migraine, chronic fatigue syndrome, irritable bowel syndrome, seizures, anaemia, endometriosis, drug or alcohol abuse, menstrual disorders as well as psychiatric disorders such as depression, bipolar illness, panic disorder, personality disorder and anxiety disorder.


Actinomyces israeli is occasionally detected in women with an intrauterine contraceptive device (IUCD) in situ. If there are no symptoms of vaginal discharge, intermenstrual bleeding or pelvic pain then the woman should be advised that neither treatment nor removal of the IUCD is required, but she should be reviewed in 6 months or earlier if symptoms develop. If symptoms are present then at least a 2-weeks therapy with a penicillin, tetracycline or macrolide antibiotic is indicated and the IUCD should be removed.


CHRONIC PELVIC PAIN It is generally accepted that episodes of acute PID can lead on to symptoms of chronic pelvic pain. The cause of the chronic pelvic pain, however, remains controversial. It may be that damaged tubes act as a nidus for recurrent infections orit may be due to adhesions tethering orencap-sulating the pelvic organs. It is even possible that the pain is due to altered behaviour of pelvic nerves damaged by infection. There is also little evidence as to the incidence of chronic pelvic pain resulting from single or multiple episodes of acute PID. It can be as high as 33 after recurrent episodes 16 and may have a significant effect on a patient's future quality of life 17 . The precautionary use of condoms after an episode of pelvic infection has been found to reduce the risk of chronic pelvic pain developing.

Pain history

Table 43.1 Classification of causes of chronic pelvic pain Inflammatory, infective Chronic salpingitis Inflammatory, non-infective Endometriosis, Vulvodynia A number of validated pain assessment measures are available for use in research and clinical practice, the most convenient of which are the 10 cm visual analogue scale, the Brief Pain Inventory (BPI), widely used in British pain clinics, and the McGill Short Form Pain Questionnaire. The McGill questionnaire is included in the International Pelvic Pain Society's assessment form, available for downloading at www.pelvicpain.org and the BPI may be downloaded at www.mdanderson.org where details of non-English versions may also be obtained. Patient's recall of pain symptoms over the previous month seems to be adequate and it is probably unnecessary to ask for a daily pain diary 10 cm visual analogue scales for 'usual' and 'most severe' intensity of pain recalled over the past 4 weeks correlated very well with mean and maximal diary...

Systems review

Many women with chronic abdominal or pelvic pain will turn out to have irritable bowel syndrome (IBS) as their primary problem. These patients do not have good outcomes following (inappropriate) gynaecological referral and investigation 13 . Therefore it is particularly important that a detailed history is taken of bowel symptoms. The 'Rome II' criteria for the clinical diagnosis of IBS in those with chronic pain include at least two of


Laparoscopy is commonly undertaken as the primary investigation for CPP. The aims are to give a diagnosis but also to provide 'one-stop' treatment for endometriosis and adhesions where these are identified. This approach is cost-effective for endometriosis treatment, as the expense of a second procedure or hormonal treatment is obviated 21 . The outcomes of this approach are not as good as might be expected confusion can arise from a 'negative' laparoscopy 22 and where pathology is identified it may be coincidental rather than causal, especially in the case of adhesions. There is a lack of evidence for laparoscopy as a factor improving outcome in hospital referral populations with at least 6 months' history of pain 23,24 . It is therefore sensible to consider deferring laparoscopy and focus on symptomatic treatment in the first instance.


Implantation of viable endometrial cells and metaplasia of one tissue type into another are both reasonable explanations for the occurrence of endometriosis. However, neither theory can account for all aspects of the disease, which could mean that several mechanisms are involved or simply that the theories are inadequate. Both assume that endometriotic tissue consists of 'normal' cells but they fail to explain why development and progression occur only in some women. In contrast, the endometriotic disease theory 4 considers subtle lesions due to intermittent implantation to be a normal, physiological event. If these cells are transformed because of a genetic insult, they progress to typical, cystic and deep lesions, consisting of 'abnormal' cells. An alternative explanation is that endometriosis is a heterogeneous not a single disease and the different types, which are considered here, result from different disease processes each with their own aetiology 5 .

Disease risk factors

Risk factors include age, increased peripheral body fat, and greater exposure to menstruation (i.e. short cycles, long duration of flow and reduced parity), whereas smoking, exercise, and oral contraceptive use (current and recent) may be protective 1 . There is no evidence, however, that the natural history of the disease can be influenced by controlling these factors. Genetic predisposition is likely as endometriosis occurs 6-9 times more commonly in the 1st degree relatives of affected women than in controls, and in an analysis of > 3000 Australian twin pairs, 51 of the variance of the latent liability to the disease was attributable to additive genetic influences 8 . Disease her-itability is also apparent in non-human primates, which develop the disease spontaneously. These data imply that endometriosis is inherited as a complex genetic trait like diabetes or asthma, which means that a number of genes interact with each other to confer disease susceptibility but the phenotype...


Laparoscopy is the gold standard for diagnostic purposes, unless disease is visible in the vagina or elsewhere. His-tological confirmation of at least one peritoneal lesion is ideal, and mandatory if DIE or a > 3 cm diameter endometrioma is present. The entire pelvis should be inspected systematically, and good practice is to document in detail the type, location and extent of all lesions and adhesions. Ideally, the findings should be recorded on video or DVD. Depending upon the severity of disease found, best practice is to remove ablate endometriosis at the same time, provided that adequate consent has been obtained.

Pain relief

All the hormonal treatments above (with the exception of dydrogesterone given in the luteal phase) relieve endometriosis-associated pain. However, using the total amount of pain (dysmenorrhoea, non-menstrual pain and dyspareunia) as the primary outcome measure inevitably produces a favourable result as all hormonal treatments abolish menstruation the effects on non-menstrual pain and dyspareunia are variable. When taken for 6 months, the drugs are equally effective 14-17 , but their side effect (Table 44.4) and cost profiles differ. These analyses include one RCT comparing a COC taken conventionally against a GnRH agonist the COC was less effective in relieving dysmenorrhoea but there were no significant differences between the treatments in the relief of dyspareunia or non-menstrual pain 18 . It is important to emphasize that a 30 placebo effect is common in endometriosis studies hence the need for placebo-controlled randomized controlled trials (RCTs). loss of efficacy, by using...


Hormonal treatment for subfertility associated with minimal-mild endometriosis does not improve the chances of natural conception 22 . The odds ratio for pregnancy following ovulation suppression for 6 months with danazol, medroxyprogesterone acetate, or GnRH agonists versus placebo or no treatment was 0.74 (95 CI 0.48-1.15) (Fig. 44.3). Clearly treatment can do more harm than good because of the lost opportunity to conceive. In more advanced disease, there is no evidence of an effect on natural conception, but there may be a role for hormonal treatment as an adjunct to assisted conception. There are a few studies suggesting that prolonged down-regulation with a GnRH agonist prior to IVF in women with moderate-severe disease might improve pregnancy rates. There are no systematic reviews on this topic, but

When to investigate

Couples should be seen when a fertility problem is perceived to exist. This first consultation can be in primary care and does not necessarily require referral to a specialist clinic. Exclusion of any obvious medical factors, explanation about normal patterns of conception and advice about lifestyle measures may be sufficient in many cases. Referral to a fertility clinic should takeinto account theageof the female partner and duration of infertility. In the absence of any known reproductive pathology, couples who have been trying for 1-2 years should be investigated and seen in a dedicated fertility clinic. Earlier intervention is indicated in the presence of specific high-risk factors in either partner. In the male, this could be a history of azoospermia, testicular surgery, vasectomy or coital failure. Reasons for early referral in a woman include oligoamenorrhoea, known endocrine conditions affecting ovulation, history of tubal disease, endometriosis or salpingectomy. Accessing...


Virtually all ultrasound scanning in assisted conception is performed transvaginally. The initial scan assesses several areas (1) The ovarian morphology if there are underlying polycystic ovaries, they may be hyper-responsive to stimulation with gonadotrophins (see p.461) (2) The presence of ovarian cysts and if present suitable treatment arranged (3) Many centres now also measure the ovarian volumes as well as the antral follicle count as these are also used in the dose calculation of FSH for the stimulation phase of IVF (4) The ovaries are assessed for accessibility, not just for the monitoring itself but also if transvaginal oocyte retrieval (TVOR) is planned, to ensure that this can be performed without undue difficulty. Sometimes in patients who have abdominal adhesions (either from iatrogenic causes, previous pelvic inflammatory disease (PID) or endometriosis) then gentle abdominal pressure can be applied during the screening ultrasound to ensure that the ovary can be moved down...

Emergency Surgery

Erectile Fracture

Figure 2 Late problems in stable rotational type B1 injuries. Anteroposterior plain radiograph (A) and inlet view (B) of the pelvis of a male patient who sustained this apparently stable AP compression (type B1) injury in a fall from a height. Once the pain from associated rib fractures settled, he mobilized well on crutches and was discharged. Over the following months, he experienced worsening anterior and posterior pelvic pain. Open reduction of the diastasis with sacroiliac joint bone grafting and plating achieved sound fusion and relieved his pain. Figure 2 Late problems in stable rotational type B1 injuries. Anteroposterior plain radiograph (A) and inlet view (B) of the pelvis of a male patient who sustained this apparently stable AP compression (type B1) injury in a fall from a height. Once the pain from associated rib fractures settled, he mobilized well on crutches and was discharged. Over the following months, he experienced worsening anterior and posterior pelvic pain. Open...


The prevalence is estimated to be 8-10 in women in the reproductive years 1 , although the precise rate in the general population is unknown because the pelvis has to be inspected at surgery to make a definitive diagnosis. In symptomatic women, the reported rates vary from 2 to 100 (Table 44.1) for which several explanations exist (1) 'subtle' (e.g. small, non-coloured) peritoneal lesions were not recognized before 1985, leading to an apparent increased prevalence since then (2) recognition increases with the surgeon's experience and interest in endometrio-sis (3) the indication for laparoscopy influences how meticulously the pelvis is inspected, and (4) histological confirmation (close to 100 for deep lesions and at best 60 for subtle lesions) is not always obtained or reported. Whatever the true prevalence, it remains possible that the most common manifestation - subtle endometriosis - may not be a disease entity at all 2 .

Physical examination

Agentle one finger digital examination commences with palpation of the pelvic floor muscles. Focal tenderness may be present, indicating a primary musculoskeletal problem that should prompt referral to a pelvic floor physiotherapist for further assessment. As with vestibu-lodynia pelvic muscle tenderness may be a residual secondary response to pain from other parts of the pelvis, for example, a previous episode of pelvic infection. Further digital examination may reveal nodularity in the pouch of Douglas or restricted uterine mobility suggestive of endometriosis. Adenomyosis may be suggested by a bulky tender uterus. Uterine retroversion should be noted although its relevance to dyspareunia is debatable. Adnexal rather than uterine tenderness may point to pelvic congestion syndrome. In the UK clinic setting pelvic tenderness alone is unlikely to be specific for chronic pelvic inflammatory disease although this diagnosis will be part of the differential among populations where early...


Endometriosis Endometriosis the female partner is aged 28 years can expect a cumulative live-birth rate of 36 over the next 12 months (Collins et al. 1995). Previous pregnancy, shorter duration of infertility and age below 30 years all enhance a woman's chances of live birth, while male factor problems, tubal disease and endometriosis halve them.

Surgery for DIE

If there is clinical evidence of DIE, the possibility of ureteric, bladder and bowel involvement should be considered pre-operatively to determine the best management. Surgery needs to be performed as safely as possible and by the most appropriate surgeons because it may be necessary to resect part of the bladder or ureter, as well as bowel wall. Occasionally, more extensive bowel resection (e.g. the rectum and or sigmoid) is needed. Such operations require a team of experienced surgeons rather than a single surgeon. Therefore, pre-operative assessment is important as it aims to predict as accurately as possible which specialities should be available to avoid leaving disease behind and unnecessary complications. The ideal work-up should comprise an intravenous pyelogram (IVP) to detect ureteric strictures and hydronephro-sis and a contrast enema to diagnose extensive narrowing at the level of the rectum or sigmoid (an indication for bowel resection). Pre-operative ureteric stenting is...

Surgical treatment

The goal of surgery is to eliminate all visible peritoneal lesions, endometriomas, DIE and associated adhesions and to restore normal anatomy. Since depth of infiltration is difficult to judge, excision or vaporization is preferable for typical lesions. Excision is the preferred method for endometriomas since recurrence rates following marsu-pialization and focal treatment are much higher. It is controversial whether conservative discoid resection or resection anastamosis of larger DIE lesions should be offered. Laparoscopy should be used as it decreases morbidity and the duration of hospitalization, and therefore cost, compared to laparotomy. Whether laparoscopy also reduces post-operative adhesions is less clear. If local expertise is lacking, then referral to a specialized centre with the necessary expertise to offer all available treatments in a multidisciplinary context, including advanced laparo-scopic surgery and laparotomy, is strongly recommended. This particularly applies if...

Noninvasive tests

Compared to laparoscopy, trans-vaginal ultrasound is a useful tool to diagnose and exclude ovarian endometri-omas but it has no value for peritoneal disease 12 . Although, it has been claimed that MRI has > 90 sensitivity and specificity for endometriomas, a recent systematic review failed to find the supporting evidence (unpublished data). CA-125 measurement has no value as a diagnostic tool for minimal-mild endometriosis 13 . Serum levels are generally elevated in women with DIE and endometriomas but the test is rarely used in practice because clinical examination and ultrasound usually suffice.

51 Tips for Dealing with Endometriosis

51 Tips for Dealing with Endometriosis

Do you have Endometriosis? Do you think you do, but aren’t sure? Are you having a hard time learning to cope? 51 Tips for Dealing with Endometriosis can help.

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