British Journal of Obstetrics and Gynaecology June 1991, Vol. 98, pp. 558-563
ADONIS 0306S4569100146B
Menstrual symptoms in women with pelvic endometriosis T. A. MAHMOOD, A. A. TEMPLETON, L. THOMSON, C. FRASER Abstract
Objective-To investigate menstrual symptoms in relation to pelvic pathology. Design-A prospective questionnaire-based study. Setting-Aberdeen Royal Infirmary, Scotland. Subjects-1250 questionnaires were sent out prior to planned admission and 1200women (96%) brought the completed questionnaires. They comprised 598 women undergoing laparoscopic sterilization, 312 having laparoscopy because of infertility, 156 having laparoscopy because of chronic pelvic pain and 134 women undergoing abdominal hysterectomy for dysfunctional uterine bleeding. Main outcome measures-The occurrence of dysmenorrhoea, menorrhagia, menstrual regularity, premenstrual spotting, deep dyspareunia and pelvic pain in women with either endometriosis and post infective pelvic adhesions or a normal pelvis. Results-Menorrhagia, menstrual irregularity and premenstrual spotting occurred with equal frequency in all groups. Deep dyspareunia, pain after intercourse and recurrent pain unrelated to menstruation or coitus was more common in women with endometriosis and those with post infective pelvic adhesions than in those with a normal pelvis. Dysmenorrhoea appears to be more prevalent among women having endometriosis. Conclusions-Menstrual symptoms, while raising a high index of suspicion for endometriosis, are not entirely reliable as indicators of disease. Dysmenorrhoea is the most common reported symptom in endometriosis sufferers. Diagnostic laparoscopy should be considered before institution of treatment in women complaining of pelvic pain and menstrual symptoms. Endometriosis accounts for the second largest category of gynaecological publications (Kempers 1985). Despite this, our knowledge of many aspects of the disease is incomplete and this includes symptomatology. Patients who have extensive disease may have no symptoms, whereas patients with only minimal involvement Department of Obstetrics & Gynaecology, Aberdeen Maternity Hospital, Foresterhill, Aberdeen, AB9 ZZD, Seotland T. A. MAHMOOD, Senior Registrar A. A. TEMPLETON, Professor L. THOMSEN Research Sister, Infertility Clinic C. FRASER Research Assistant
Correspondence: Dr T. A. Mahmood, Forth Park Hospital, Kirkcaldy, Fife, KY2 5RA, Scotland. 558
may complain of disabling dysmenorrhoea. Associated symptoms include pelvic pain, rectal pain, dyspareunia and abnormal vaginal bleeding (Buttram 1979a, b; Puolakka et al. 1980; Ranney 1980). Pelvic pain and dyspareunia among patients with endometriosis can occur when the peritoneal lesion becomes firmly bound within a fibrotic wall and maintains its functional activity each month, so that the unyielding scar tissue causes increased tension and pain. However Roddick et al. (1960) demonstrated that hormonally responsive ectopic endometrium was not a prerequisite for painful symptoms. Other possible causes of pain include fixed uterine retroversion, tender uterosacral nodules (Hammond 8~Haney 1978) and possibly increased peritoneal fluid vol-
Menstrual symptoms and endometriosis umes and prostaglandin content (Kauppilla et al. 1984; Dinarello, 1985). However, it is also known that up to 50% of women with pelvic pain will have no demonstrable pathology (Beard et al. 1977). Abnormal uterine bleeding occurs in 11-34% of women with endometriosis and may present as oligoplenorrhoea, polymenorrhoea, menorrhagia, post-coital spotting or premenstrual spotting (Stevenson & Campbell 1960; Wentz 1980). Muse & Wilson (1982) suggested that abnormal uterine bleeding may be a reflection of ovulation dysfunction. Similarly, congestive dysmenorrhea occurs in 25-90% of women with endometriosis (Goldstein et al. 1980; Chatman & Ward 1982) and it has been suggested that retrograde menstruation may be the cause (Huffman 1981; Telinde I% Scott 1950). On the other hand, Blumen krantz et al. (1981) reported nine women undergoing peritoneal dialysis where retrograde menstruation was observed but none of these complained of dysmenorrhoea. In two studies involving laparoscopy during menstruation (Reti et al. 1983; Liu & Hitchcock 1986) the occurrence of dsymenorrhoea was not significantly different whether patients had retrograde menstruation or not. Similarly, dysmenorrhoea is a relatively common symptom in the general population ranging from 5% to 62% (Sobczyk 1980). Many of the above reports consist of retrospective studies and lack suitable controls. The purpose of this prospective questionnaire-based study was to examine menstrual symptoms in relation to a finding of endometriosis in a large group of women of reproductive age. Patients and methods
A total of 1250 questionnaires were sent to patients attending Aberdeen Royal Infirmary who were to have laparoscopy for sterilization, infertility, chronic abdominal, or pelvic pain, or abdominal hysterectomy for dysfunctional uterine bleeding. All were asked to complete the questionnaire before their admission to hospital. Of these, 1200 (%Oh) patients brought completed questionnaires on arrival at hospital. Of the remaining women, 35 refused to complete the questionnaire and 15 brought incomplete questionnaires and were excluded from the analysis. None of these 50 patients had pelvic endometriosis diagnosed subsequently. The
559
study group of 1200 patients included 598 women undergoing laparoscopic sterilization, 312 having laparoscopy for infertility, 156 having laparoscopy because of pain, and 134 undergoing abdominal hysterectomy. They were asked about their age and menstrual pattern at the menarche, current menstrual history, deep dyspareunia and its effect on sexual life, and pelvic pain. All laparoscopies were performed under general anaesthesia with endotracheal intubation. A 10 mm end viewing laparoscope was introduced through an infra-umbilical incision, a modified Palmer-Jacob’s forceps introduced suprapubically for manipulation and the pelvis was inspected systemically. The uterus was held in acute retroversion and its anterior surface, utero-vesicle reflection and all the peritoneal surfaces as far as the insertion of round ligaments laterally and the anterior surface of the broad ligament were inspected. Then, with the uterus in acute anteversion, the posterior surface of the uterus, uterosacral ligaments, pouch of Douglas and rectovaginal septum were inspected, and free fluid from that area was aspirated. The posterior leaf of the broad ligament was also inspected on both sides. Both Fallopian tubes were inspected along their entire length: their mobility, presence of peritubal adhesions or tubal distortion and functional relation of fimbria to the ovaries were noted. Both ovaries were mobilized to detect endometriosis on the under surface and for periovarian adhesions. The diagnosis of endometriosis was based on the characteristic visual appearances of the disease and biopsies were not taken. All endometriotic deposits were recorded on a preprinted drawing of pelvic organs for each patient and the extent of endometriosis was scored using the revised American Fertility Society (AFS) Classification (American Fertility Society 1985). In this system a score 40 indicates severe endometriosis. Among infertile patients, tubal patency was confirmed by the transcervical injection of 0.5% methylene blue dye in isotonic saline using a Leach Wilkinson cannula. Patients undergoing laparoscopic sterilization had Filshie clips applied to the isthmic part of the tubes. Among those undergoing abdominal hysterectomy, only endometriotic deposits noted at the time of operation were recorded on the data sheet; his-
560
T. A. Mahmoodetal.
Table 1. Pelvic findings in the study groups Endometriosis Study group
Pelvic adhesions n(Y0)
Normal pelvis
37 (6) 107 (35) 24 (15)
129 (22) 78 (25) 43 (28)
432 (72) 127 (40) 89 (51)
33 (25) 201 (17)
28 (21) 278 (23)
73 (54) 721 (60)
n
Laparoscopic sterilization Infertility group Chronic abdominal pain Abdominal hysterectomy for dysfunctional uterine bleeding Total
(Yo)
tologically proven lesions (i.e., adenomyosis or other focal microscopic deposits in the histology specimen) were not considered in the data analysis. The laparoscopies were performed by six and the hysterectomies by three experienced surgeons. On each occasion, the operators performed the procedures according to the study protocol and recorded their findings on a preprinted sheet. Statistical analysis
Data were analysed using the Statistical Package for the Social Sciences (SPSS-X)on a mainframe computer (University of Aberdeen). Results
Of the 1200 women, 201 (17%) had endometriosis. In 278 (23%) there were pelvic adhesions without evidence of endometriosis and these were assumed to be post-infective. In the remaining 721 (60%)the pelvic organs appeared normal (Table 1).Most of the 201 patients with endometriosis had mild disease (n = 146, 73%) and the others had moderate (n = 46,23%) or severe (n = 9, 4%) disease. The mean age at menarche was 12-84(SD 1.53) years in the endo-
Total n
.(Yo)
598 (1 00) 312 (100) 156 (100) 134 (100) 1200 (100)
metriosis group, 13.23 (SD 1.50) in women with pelvic adhesions and 13.0 (SD 1.50) years in women with normal pelvis cf= 1.208; df 2; P
ADONIS 0306S4569100146B
Menstrual symptoms in women with pelvic endometriosis T. A. MAHMOOD, A. A. TEMPLETON, L. THOMSON, C. FRASER Abstract
Objective-To investigate menstrual symptoms in relation to pelvic pathology. Design-A prospective questionnaire-based study. Setting-Aberdeen Royal Infirmary, Scotland. Subjects-1250 questionnaires were sent out prior to planned admission and 1200women (96%) brought the completed questionnaires. They comprised 598 women undergoing laparoscopic sterilization, 312 having laparoscopy because of infertility, 156 having laparoscopy because of chronic pelvic pain and 134 women undergoing abdominal hysterectomy for dysfunctional uterine bleeding. Main outcome measures-The occurrence of dysmenorrhoea, menorrhagia, menstrual regularity, premenstrual spotting, deep dyspareunia and pelvic pain in women with either endometriosis and post infective pelvic adhesions or a normal pelvis. Results-Menorrhagia, menstrual irregularity and premenstrual spotting occurred with equal frequency in all groups. Deep dyspareunia, pain after intercourse and recurrent pain unrelated to menstruation or coitus was more common in women with endometriosis and those with post infective pelvic adhesions than in those with a normal pelvis. Dysmenorrhoea appears to be more prevalent among women having endometriosis. Conclusions-Menstrual symptoms, while raising a high index of suspicion for endometriosis, are not entirely reliable as indicators of disease. Dysmenorrhoea is the most common reported symptom in endometriosis sufferers. Diagnostic laparoscopy should be considered before institution of treatment in women complaining of pelvic pain and menstrual symptoms. Endometriosis accounts for the second largest category of gynaecological publications (Kempers 1985). Despite this, our knowledge of many aspects of the disease is incomplete and this includes symptomatology. Patients who have extensive disease may have no symptoms, whereas patients with only minimal involvement Department of Obstetrics & Gynaecology, Aberdeen Maternity Hospital, Foresterhill, Aberdeen, AB9 ZZD, Seotland T. A. MAHMOOD, Senior Registrar A. A. TEMPLETON, Professor L. THOMSEN Research Sister, Infertility Clinic C. FRASER Research Assistant
Correspondence: Dr T. A. Mahmood, Forth Park Hospital, Kirkcaldy, Fife, KY2 5RA, Scotland. 558
may complain of disabling dysmenorrhoea. Associated symptoms include pelvic pain, rectal pain, dyspareunia and abnormal vaginal bleeding (Buttram 1979a, b; Puolakka et al. 1980; Ranney 1980). Pelvic pain and dyspareunia among patients with endometriosis can occur when the peritoneal lesion becomes firmly bound within a fibrotic wall and maintains its functional activity each month, so that the unyielding scar tissue causes increased tension and pain. However Roddick et al. (1960) demonstrated that hormonally responsive ectopic endometrium was not a prerequisite for painful symptoms. Other possible causes of pain include fixed uterine retroversion, tender uterosacral nodules (Hammond 8~Haney 1978) and possibly increased peritoneal fluid vol-
Menstrual symptoms and endometriosis umes and prostaglandin content (Kauppilla et al. 1984; Dinarello, 1985). However, it is also known that up to 50% of women with pelvic pain will have no demonstrable pathology (Beard et al. 1977). Abnormal uterine bleeding occurs in 11-34% of women with endometriosis and may present as oligoplenorrhoea, polymenorrhoea, menorrhagia, post-coital spotting or premenstrual spotting (Stevenson & Campbell 1960; Wentz 1980). Muse & Wilson (1982) suggested that abnormal uterine bleeding may be a reflection of ovulation dysfunction. Similarly, congestive dysmenorrhea occurs in 25-90% of women with endometriosis (Goldstein et al. 1980; Chatman & Ward 1982) and it has been suggested that retrograde menstruation may be the cause (Huffman 1981; Telinde I% Scott 1950). On the other hand, Blumen krantz et al. (1981) reported nine women undergoing peritoneal dialysis where retrograde menstruation was observed but none of these complained of dysmenorrhoea. In two studies involving laparoscopy during menstruation (Reti et al. 1983; Liu & Hitchcock 1986) the occurrence of dsymenorrhoea was not significantly different whether patients had retrograde menstruation or not. Similarly, dysmenorrhoea is a relatively common symptom in the general population ranging from 5% to 62% (Sobczyk 1980). Many of the above reports consist of retrospective studies and lack suitable controls. The purpose of this prospective questionnaire-based study was to examine menstrual symptoms in relation to a finding of endometriosis in a large group of women of reproductive age. Patients and methods
A total of 1250 questionnaires were sent to patients attending Aberdeen Royal Infirmary who were to have laparoscopy for sterilization, infertility, chronic abdominal, or pelvic pain, or abdominal hysterectomy for dysfunctional uterine bleeding. All were asked to complete the questionnaire before their admission to hospital. Of these, 1200 (%Oh) patients brought completed questionnaires on arrival at hospital. Of the remaining women, 35 refused to complete the questionnaire and 15 brought incomplete questionnaires and were excluded from the analysis. None of these 50 patients had pelvic endometriosis diagnosed subsequently. The
559
study group of 1200 patients included 598 women undergoing laparoscopic sterilization, 312 having laparoscopy for infertility, 156 having laparoscopy because of pain, and 134 undergoing abdominal hysterectomy. They were asked about their age and menstrual pattern at the menarche, current menstrual history, deep dyspareunia and its effect on sexual life, and pelvic pain. All laparoscopies were performed under general anaesthesia with endotracheal intubation. A 10 mm end viewing laparoscope was introduced through an infra-umbilical incision, a modified Palmer-Jacob’s forceps introduced suprapubically for manipulation and the pelvis was inspected systemically. The uterus was held in acute retroversion and its anterior surface, utero-vesicle reflection and all the peritoneal surfaces as far as the insertion of round ligaments laterally and the anterior surface of the broad ligament were inspected. Then, with the uterus in acute anteversion, the posterior surface of the uterus, uterosacral ligaments, pouch of Douglas and rectovaginal septum were inspected, and free fluid from that area was aspirated. The posterior leaf of the broad ligament was also inspected on both sides. Both Fallopian tubes were inspected along their entire length: their mobility, presence of peritubal adhesions or tubal distortion and functional relation of fimbria to the ovaries were noted. Both ovaries were mobilized to detect endometriosis on the under surface and for periovarian adhesions. The diagnosis of endometriosis was based on the characteristic visual appearances of the disease and biopsies were not taken. All endometriotic deposits were recorded on a preprinted drawing of pelvic organs for each patient and the extent of endometriosis was scored using the revised American Fertility Society (AFS) Classification (American Fertility Society 1985). In this system a score 40 indicates severe endometriosis. Among infertile patients, tubal patency was confirmed by the transcervical injection of 0.5% methylene blue dye in isotonic saline using a Leach Wilkinson cannula. Patients undergoing laparoscopic sterilization had Filshie clips applied to the isthmic part of the tubes. Among those undergoing abdominal hysterectomy, only endometriotic deposits noted at the time of operation were recorded on the data sheet; his-
560
T. A. Mahmoodetal.
Table 1. Pelvic findings in the study groups Endometriosis Study group
Pelvic adhesions n(Y0)
Normal pelvis
37 (6) 107 (35) 24 (15)
129 (22) 78 (25) 43 (28)
432 (72) 127 (40) 89 (51)
33 (25) 201 (17)
28 (21) 278 (23)
73 (54) 721 (60)
n
Laparoscopic sterilization Infertility group Chronic abdominal pain Abdominal hysterectomy for dysfunctional uterine bleeding Total
(Yo)
tologically proven lesions (i.e., adenomyosis or other focal microscopic deposits in the histology specimen) were not considered in the data analysis. The laparoscopies were performed by six and the hysterectomies by three experienced surgeons. On each occasion, the operators performed the procedures according to the study protocol and recorded their findings on a preprinted sheet. Statistical analysis
Data were analysed using the Statistical Package for the Social Sciences (SPSS-X)on a mainframe computer (University of Aberdeen). Results
Of the 1200 women, 201 (17%) had endometriosis. In 278 (23%) there were pelvic adhesions without evidence of endometriosis and these were assumed to be post-infective. In the remaining 721 (60%)the pelvic organs appeared normal (Table 1).Most of the 201 patients with endometriosis had mild disease (n = 146, 73%) and the others had moderate (n = 46,23%) or severe (n = 9, 4%) disease. The mean age at menarche was 12-84(SD 1.53) years in the endo-
Total n
.(Yo)
598 (1 00) 312 (100) 156 (100) 134 (100) 1200 (100)
metriosis group, 13.23 (SD 1.50) in women with pelvic adhesions and 13.0 (SD 1.50) years in women with normal pelvis cf= 1.208; df 2; P
