Primary gonadotropin-releasing hormone agonist therapy for suspected endometriosis: a nonsurgical approach to the diagnosis and treatment of chronic pelvic pain.
Chronic pelvic pain is a condition that affects one in seven women of reproductive age in the United States. Direct and indirect medical costs associated with this condition are estimated to be more than $3 billion annually before factoring in the costs of diagnostic testing. At many medical centers, endometriosis is the most common single cause of chronic pelvic pain; other causes include intra-abdominal adhesions, chronic pelvic inflammatory disease, ovarian cysts, and adenomyosis. The current approach to diagnosis and treatment of chronic pelvic pain is a two-step approach, with medical history, physical examination, laboratory testing, and empiric therapy (nonsteroidal anti-inflammatory drugs, oral contraceptives, and/or antibiotics) comprising Step 1 and surgical diagnosis with laparoscopy as Step 2. At many centers, the most common diagnosis at the time of laparoscopy for chronic pelvic pain is endometriosis, typically minimal to mild disease that can be effectively treated with hormonal therapy. Therefore, a rational alternative approach is a 3-month empiric course of therapy with a gonadotropin-releasing hormone agonist before laparoscopy. The advantages of this approach are the high rate of pain relief in women, the possibility of avoiding an invasive procedure (laparoscopy), the ability to extend therapy, if pain is relieved, to the full 6-month therapeutic course of endometriosis, and a potentially lower cost relative to laparoscopy. (+info)
Hypothesis on the role of sub-clinical bacteria of the endometrium (bacteria endometrialis) in gynaecological and obstetric enigmas.
Unexplained infertility, recurrent abortion, dysfunctional uterine bleeding, pelvic pain, premenstrual syndrome, premature labour, placental insufficiency and pre-eclampsia are examples of common obstetric and gynaecological problems that frequently defy adequate explanation. Bacterial vaginosis, a non-inflammatory condition, is associated with premature labour, but antibiotics administered topically provide less effective prophylaxis than those administered orally. This would indicate that bacterial vaginosis might be a marker for significant genital tract bacteria, but some pathology is dependent on micro-organisms ascending out of reach of topical antibiotics. The author was led to consider the hypothesis that micro-organisms, possibly those associated with bacterial vaginosis, surreptitiously inhabit the uterine cavity (bacteria endometrialis) where they are culprits of some common gynaecological and obstetric enigmas. The objective of this review is to provide an initial theoretical examination of this hypothesis. Bacteria in the endometrium have been associated with infertility. Antiphospholipids have been linked to recurrent miscarriage and pre-eclampsia and with infections including Mycoplasma. Pre-eclampsia might be explained by an exaggerated host response to intrauterine micro-organisms or bacterial toxins. The hypothesis that one common factor, bacteria endometrialis, could provide a plausible explanation for a variety of obstetric and gynaecological mysteries is particularly intriguing. There is sufficient evidence to justify further investigation. (+info)
Low-dose danazol after combined surgical and medical therapy reduces the incidence of pelvic pain in women with moderate and severe endometriosis.
The most effective therapy for endometriosis is a matter for debate. The aim of the present randomized study was to evaluate the efficacy of low doses of danazol on recurrence of pelvic pain in patients with moderate or severe endometriosis, who had undergone laparoscopic surgery and 6 months of gonadotrophin-releasing hormone analogue (GnRHa) therapy. After surgery, 28 patients with moderate or severe endometriosis underwent therapy for 6 months with GnRHa i. m. every 4 weeks. They were then randomized into two groups: group A (14 subjects) was treated with 100 mg/day danazol for 6 months; group B (14 subjects, control) did not receive any type of therapy. After 12 months of treatment, group A had a significantly (P < 0.01) lower pain score than group B. There was no significant difference between the groups in oestrogen concentrations, bone mineral density or side-effects. The results suggest that low-dose danazol therapy reduces recurrence of pelvic pain in patients with moderate or severe endometriosis, treated surgically, and has few or no metabolic side-effects. (+info)
Ehlers-Danlos syndrome associated with multiple spinal meningeal cysts--case report.
A 40-year-old female with Ehlers-Danlos syndrome was admitted because of a large pelvic mass. Radiological examination revealed multiple spinal meningeal cysts. The first operation through a laminectomy revealed that the cysts originated from dilated dural sleeves containing nerve roots. Packing of dilated sleeves was inadequate. Finally the cysts were oversewed through a laparotomy. The cysts were reduced, but the postoperative course was complicated by poor wound healing and diffuse muscle atrophy. Ehlers-Danlos syndrome associated with spinal cysts may be best treated by endoscopic surgery. (+info)
Modeling of medical and surgical treatment costs of chronic pelvic pain: new paradigms for making clinical decisions.
Additional complexity has been added to the healthcare decision-making process by the socioeconomic constraints of the industry and a population that is increasingly educated about healthcare. As a result, decisions balanced on the basis of outcomes and economic realities are needed. This modeling of surgical versus medical treatment costs for chronic pelvic pain and endometriosis factors in the large number of women with chronic pelvic pain, direct and indirect costs of the condition, and clinical benefits, projected costs, and savings of the therapies. This process of calculation becomes an aid for decision making in the current healthcare system. (+info)
Evaluation of Lovelace Health Systems chronic pelvic pain protocol.
Although laparoscopy has been considered the gold standard for the diagnosis of endometriosis, it often fails to detect the disease and provide lasting pain relief. Motivated by concerns for patient well-being, treatment efficacy, and cost containment, Lovelace Health Systems of Albuquerque, New Mexico, turned to the Lovelace Chronic Pelvic Pain Protocol, based on a chronic pelvic pain algorithm used to identify potential candidates for therapy with gonadotropin-releasing hormone agonist (GnRH agonist). Since the protocol's introduction in January 1997, empiric therapy with GnRH agonist has proved beneficial to patients, physicians, and healthcare system budgets. (+info)
The active straight leg raising test and mobility of the pelvic joints.
Objective signs to assess impairment in patients who are disabled by peripartum pelvic girdle pain hardly exist. The purpose of this study was to develop a clinical test to quantify and qualify disability in these patients. The study examined the relationship between impaired active straight leg raising (ASLR) and mobility of pelvic joints in patients with peripartum pelvic girdle pain, focusing on (1) the reduction of impairment of ASLR when the patient was wearing a pelvic belt, and (2) motions between the pubic bones measured by X-ray examination when the patient was standing on one leg, alternating left and right. Twenty-one non-pregnant patients with peripartum pelvic girdle pain in whom pain and impairment of ASLR were mainly located on one side were selected. ASLR was performed in the supine position, first without a pelvic belt and then with a belt. The influence of the belt on the ability to actively raise the leg was assessed by the patient. Mobility of the pelvic joints was radiographically visualized by means of the Chamberlain method. Assessment was blinded. Ability to perform ASLR was improved by a pelvic belt in 20 of the 21 patients (binomial two-tailed P = 0.0000). When the patient was standing on one leg, alternating the symptomatic side and the reference side, a significant difference between the two sides was observed with respect to the size of the radiographically visualized steps between the pubic bones (binomial two-tailed P = 0.01). The step at the symptomatic side was on average larger when the leg at that side was hanging down than when the patient was standing on the leg at that side. Impairment of ASLR correlates strongly with mobility of the pelvic joints in patients with peripartum pelvic girdle pain. The ASLR test could be a suitable instrument to quantify and qualify disability in diseases related to mobility of the pelvic joints. Further studies are needed to assess the relationship with clinical parameters, sensitivity, specificity and responsiveness in various categories of patients. In contrast with the opinion of Chamberlain, that a radiographically visualized step between the pubic bones is caused by cranial shift of the pubic bone at the side of the standing leg, it is concluded that the step is caused by caudal shift of the pubic bone at the side of the leg hanging down. The caudal shift is caused by an anterior rotation of the hip bone about a horizontal axis near the sacroiliac joint. (+info)
A systematic history for the patient with chronic pelvic pain.
Chronic pelvic pain is a source of frustration to both the physician and the patient. Physicians have been ill equipped by their training to confront the multifaceted nature of the complaints of patients with chronic pelvic pain. Patients have experienced a repetitive dismissal of their complaints by physicians too busy in their practices to address their problems comprehensively. The approach to the patient with chronic pelvic pain must take into account six major sources of the origin of this pain: 1) gynecological, 2) psychological, 3) myofascial, 4) musculoskeletal, 5) urological, and 6) gastrointestinal. Only by addressing and evaluating each of these components by a very careful history and physical examination and by approaching the patient in a comprehensive manner can the source of the pain be determined and appropriate therapy be administered. This article was developed to provide the clinician with a set of tools and a methodology by which the patient with this complaint can be approached. (+info)