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ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 356-360

Prevalence of endometriosis in unexplained infertility and chronic pelvic pain in women attending Menoufia University Hospital


Department of Gynecology and Obstetrics, Faculty of Medicine, Menoufia University, Shebin El Kom, Egypt

Date of Submission09-Aug-2016
Date of Acceptance30-Dec-2016
Date of Web Publication25-Sep-2017

Correspondence Address:
Ahmed F Amer
Shebin El Kom, Menoufia, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_415_16

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  Abstract 

Objective
The aim of the present work was to evaluate pelvic endometriosis among women with unexplained infertility and chronic pelvic pain attending Menoufia University Hospital and subjected to diagnostic laparoscopy.
Background
Pelvic endometriosis is a common, frequently underestimated health problem in Egypt. It is correlated with patient's age less than 30years and low parity.
Patients and methods
This was a prospective clinical observational study that included 50patients with unexplained infertility and 50patients with chronic pelvic pain who underwent diagnostic laparoscopy at the gynecologic Endoscopy Units, Menoufia University Hospital, from June 2014 to December 2015 to diagnose pelvic endometriosis as an etiologic factor with correlation of the different patient characteristics and the risk for endometriosis.
Results
Endometriosis was diagnosed by means of laparoscopy in 33patients included in this study, of which 21cases were confirmed by means of histopathological examination. There was a significant association with dysmenorrhea(P<0.02), prior pelvic surgery(P<0.03), and Cancer Antigen-125 measured using mini VIDAS(P<0.001) level in positive cases.
Conclusion
Endometriosis should be suspected in infertile women and patients with pelvic pain, especially those with prior pelvic surgery. Dysmenorrhea is the most leading symptom indicating endometriosis. Laparoscopy with histopathologic examination is considered the most accurate for diagnosing endometriosis.

Keywords: chronic pelvic pain, endometriosis, laparoscopy, unexplained infertility


How to cite this article:
Gad MS, Abdel-Gayed AM, Dawoud RM, Amer AF. Prevalence of endometriosis in unexplained infertility and chronic pelvic pain in women attending Menoufia University Hospital. Menoufia Med J 2017;30:356-60

How to cite this URL:
Gad MS, Abdel-Gayed AM, Dawoud RM, Amer AF. Prevalence of endometriosis in unexplained infertility and chronic pelvic pain in women attending Menoufia University Hospital. Menoufia Med J [serial online] 2017 [cited 2019 Apr 18];30:356-60. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/356/215458


  Introduction Top


Endometriosis is defined as the presence of endometrial-like glands and stroma outside the uterine cavity. Signs and symptoms arise from cyclic bleeding into the surrounding tissues resulting in inflammation and formation of scarring and adhesions[1]. The prevalence of endometriosis is underestimated because of the need for laparoscopy, which is considered the gold standard, to confirm the diagnosis. At least 10% of all women in reproductive age are affected by the disease[2]. Women with endometriosis typically have a range of pelvic–abdominal pain symptoms, including dysmenorrhea, dyspareunia, heavy menstrual bleeding, nonmenstrual pelvic pain, pain at ovulation, dyschezia, and dysuria, as well as chronic fatigue[3]. At laparoscopy, the appearance of endometriosis is very variable; it can present as small lesions or implants in the peritoneal and/or the ovarian surface. Endometrial implants may appear in a number of different ways, including subtle red or white lesions, clear 'bubble' lesions, small hemorrhagic cysts(powder-burn, dark brown or bluish or red flame like), or white fibrotic lesions(similar to scarring). Endometriosis can present as large ovarian endometriomas[4]. Cancer antigen-125(CA125), an antigenic determinant on a glycoprotein, has been identified in several adult tissues. It is recognized by monoclonal antibody assays. Elevated CA125 levels have been shown to be positively correlated with the severity of endometriosis. Unfortunately, the assay has poor sensitivity in detecting mild endometriosis. This marker appears to be a better test in diagnosing stages III and IV endometriosis, but the test remains nonspecific and can be elevated in pregnancy, pelvic inflammatory disease(PID), fibroids, and menstruation[5]. Treatment can be medical or surgical; the aim of medical treatment is to suppress the growth and activity of endometriotic lesions. Drugs that can be used include gonadotropin-releasing hormone agonists, oral contraceptives, danazol, aromatase inhibitors, and progestins[6]. All have similar clinical efficacy in terms of reduction in pain-related symptoms and duration of relief.

Aim

The aim of this work was to identify endometriosis as an etiologic factor in patients with unexplained infertility and chronic pelvic pain.


  Patients and Methods Top


This was a prospective clinical observational study that included 50patients with unexplained infertility and 50patients with chronic pelvic pain. Cases were recruited from the outpatient clinic of the Obstetrics and Gynecology Department at Menoufia University Hospital over1.5years(duration of the study) from June 2014 to December 2015. The study was approved by the medical ethics committee of the Faculty of Medicine, Menoufia University. All women were informed about the nature of the study and they signed an informed written consent before participating in the study. The patients were subjected to the following: (a) careful history taking including age, parity, menstrual history, contraceptive history, and sexual history; (b) general examination with comment on BMI; (c) abdominal examination with stress on masses;(d) local gynecologic examination with reported nodules in the pouch of Douglas, or marked tenderness on moving the cervix.

Abdominal and endovaginal ultrasound was performed for all cases with stress on the diagnostic criteria of pelvic pain. The scan result was initially reported as normal or abnormal based on conventional findings(the presence or absence of hard markers for pelvic pathology). Ahard marker was defined as a structural abnormality–for example, an endometrioma or hydrosalpinx. If one or more hard markers were present the scan was described as abnormal, and in the absence of any hard markers the scan was described as normal. The final ultrasound report placed in the patient's notes was based on these findings. The pelvis was also assessed for the presence or absence of localized pelvic tenderness, ovarian mobility, and presence of loculated peritoneal fluid in the pelvis, which could be considered as soft markers.

Localized pelvic tenderness over specific structures–for example, the uterosacral ligaments–may be associated with the presence of endometriosis. Moreover, in women with endometriosis or pelvic adhesions, limited ovarian mobility is frequently associated with adherence of the ovary to the pelvic sidewall or the uterus at the time of laparoscopy. Loculated peritoneal fluid can be identified using endovaginal ultrasound and may be an indirect marker of pelvic pathology.

The patients were divided into two groups. GroupA included patients with unexplained infertility, which refers to a diagnosis(or lack of diagnosis) made in couples in whom all standard investigations such as tests of ovulation, tubal patency, and semen analysis are normal. GroupB included patients with chronic pelvic pain for more than 6months not responding to traditional treatment. CA125 was evaluated in cases with chronic pelvic pain associated with adnexal mass.

To ensure complete evaluation of the pelvis, inspection was carried out in a systematic manner in an anticlockwise manner starting from the right adnexa and the peritoneum of the right side of the pelvic wall (including the ovarian fossa) to the peritoneum of the anterior abdominal wall and vesical peritoneum, followed by the left adnexa and the peritoneum of the left side of the pelvic wall ending with the pouch of Douglas and uterosacral ligaments.

Statistical analysis

Data were statistically described in terms of range, mean, SD, median, frequencies(number of cases), and percentages when appropriate. Comparison of quantitative variables between the study groups was made using the Mann–Whitney U-test for independent samples. For comparing categorical data, the χ2-test was performed. An exact test was used instead when the expected frequency is less than 5. APvalue less than 0.05 was considered statistically significant.


  Results Top


The current study included 100patients with unexplained infertility and chronic pelvic pain. They were divided into two groups according to laparoscopic diagnosis[(positive(groupI) and negative(groupII) for endometriosis)]. The mean age of the study population was 27.1years for positive cases and 31.1 for negative cases. There was no statistically significant difference between the two study groups as regards age, residence, occupation, and BMI, indicating homogeneity of the study groups[Table1].
Table 1: Demography of studied patients

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GroupI showed a significantly higher incidence of prior pelvic surgery and family history and a lower incidence of performing physical activity and use of oral contraceptive pills. No significance was found between the study groups as regards clinical symptoms or signs except for dysmenorrhea, which was more evident in groupI[Table2].
Table2: Risk factors of endometriosis

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Laparoscopic diagnosis of endometriosis was reported in 33patients(17cases showed typical lesions, whereas 15 showed atypical lesions) but endometriosis was confirmed by means of histological examination in 21cases only[Table3] and [Table4]. Laparoscopic diagnosis of endometriosis followed the revised American Society of Reproductive Medicine Classification(1997), as shown in [Table5]. There was no significance between the two study groups as regards laboratory findings except for CA125, which was higher in groupI[Table6].
Table3: Laparoscopic findings among the studied groups

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Table4: Laparoscopic versus histological diagnosis

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Table 5: Stages of endometriosis among diagnosed cases

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Table 6: Comparison between positive and negative cases as regards laboratory findings

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  Discussion Top


In the current study laparoscopic diagnosis of endometriosis was reported in 33(33%) patients. Typical and atypical lesions were diagnosed in 17 and 15patients, respectively. It was found that the mean age for women with endometriosis was 27 compared with 31 for those with pain. According to the recent American Society of Reproductive Medicine classification, 13cases had minimal endometriosis, six cases had mild endometriosis, seven cases had moderate endometriosis, and seven cases had severe endometriosis. Biopsy was taken from suspected patients and the diagnosis of endometriosis was confirmed in 21(21%) cases. Therefore, meticulous histopathological confirmation should still be the first step in laparoscopic diagnosis and treatment of suspected endometriosis. Positive cases of endometriosis had a statistically significant range of menstrual disturbances including dysmenorrhea, whereas there was no significance as regards menorrhagia or dyspareunia. Dysmenorrhea should direct the attention to the possibility of endometriosis, as reported by Moghissi[7]. Moreover, endometriosis was more common in patients with a history of previous surgery(e.g.cesarean section, myomectomy, and ovarian cystectomy), especially when uterine cavity was opened, which may be a predisposing factor. Another explanation is that some of these operations were originally performed to treat some endometriotic lesions but patients did not have a confirmed diagnosis of endometriosis. Laboratory findings showed marked variance as regards CA125 between positive and negative cases, which could be considered a good noninvasive test for diagnosing endometriosis. On the other hand, Mol and colleagues performed a meta-analysis to assess critically the clinical value of serum CA125 as a noninvasive diagnostic marker for endometriosis. They concluded that serum CA125 measurement has limited potential for the diagnosis of endometriosis[8]. Future studies may show a potential of this biomarker in women with endometriosis, including prognosis, disease staging, identifying subgroups of patients, and differentiation from other ovarian abnormalities. Various causes of chronic pelvic pain had been identified in different studies conducted at different places. In our study, endometriosis was the most common cause of chronic pelvic pain, which accounted for 38%, followed by pelvic congestion(14%), PID(8%), complicated ovarian cyst(8%), adhesions, and fibroid. In agreement with our study, Howard[9] found that endometriosis was present in 40% of the cases, followed by pelvic adhesions, chronic PID, and ovarian cysts. Similarly, Iftikhar[10] showed endometriosis in 56.6% of cases, followed by pelvic adhesion in 16.6%, and benign ovarian cyst and polycystic ovarian disease in 6.6% of cases. However, in a study conducted by Chhetri[11], diagnostic laparoscopy was able to detect pathology in 45(81.8%) patients. This study showed that pelvic adhesions were the most common cause of chronic pelvic pain, which was present in 16(29%) women, followed by PID (12.7%), endometriosis(9.1%), pelvic congestion (7.2%), pelvic tuberculosis(7.2%), fibroid uterus(7.2%), ovarian cysts(7.2%), and parafimbrial cyst(3.4%). Sharma etal.[12] showed that the most common finding on laparoscopy was adhesion in 40%, endometriosis in 18%, and pelvic congestion syndrome in 20% of cases.


  Conclusion Top


It is concluded that endometriosis is a common diagnosis in women with unexplained infertility and chronic pelvic pain. Laparoscopy should be indicated when diagnosis is suspected, together with tissue sampling and histopathologic examination. More research is required to find more accurate noninvasive tests and effective treatment to deal with this disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
GiudiceLC, KaoLC. Endometriosis. Lancet 2004;364:1789–1799.  Back to cited text no. 1
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2.
MaoAJ, AnastasiJK. Diagnosis and management of endometriosis: the role of the advanced practice nurse in primary care. JAm Acad Nurse Pract 2010; 22:109–116.  Back to cited text no. 2
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NnoahamKE, HummelshojL, KennedySH, JenkinsonC, ZondervanKT, World Endometriosis Research Foundation Women Health Symptom Survey. Developing symptom-based predictive models of endometriosis as a clinical screening tool: results from a multicenter study. Fertil Steril 2012; 98:692–701.  Back to cited text no. 3
    
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KennedyS, BergqvistA, ChapronC, ESHRE Special Interest Group for Endometriosis, Endometrium Guideline Development Group. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 2005; 20:2698–2704.  Back to cited text no. 4
    
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TeirneyR, PrenticeA. The medical management of endometriosis. Gynaecol Pract 2002; 2:91–98.  Back to cited text no. 5
    
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BedaiwyMA, LiuJ. Long-term management of endometriosis: medical therapy and treatment of infertility. Sex Reprod Menopause 2010; 8:10–14.  Back to cited text no. 6
    
7.
MoghissiKS. Medical treatment of endometriosis. Clin Obstet Gynecol 1991; 42:620–632.  Back to cited text no. 7
    
8.
MolBW, BayramN, LijmerJG, WiegerinckMA, BongersMY, van der VeenF, BossuytPM. The performance of CA-125 measurement in the detection of endometriosis: a meta-analysis. Fertil Steril 1998; 70:1101–1108.  Back to cited text no. 8
    
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Howard FM Chronic pelvic pain. Obstet Gynecol 2003; 101:594–611.  Back to cited text no. 9
    
10.
IftikharR. Outcome of laparoscopy in chronic pelvic pain. JSP(International) 2008; 13:155–158.  Back to cited text no. 10
    
11.
ChhetriS, KhannaS, PoonamMS, SenB. Laparoscopic evaluation of chronic pelvic pain in women. JNepal Health Res Counc 2009; 7:45–48.  Back to cited text no. 11
    
12.
SharmaD, DahiyaK, DuhanN, BansalR. Diagnostic laparoscopy in chronic pelvic pain. Arch Gynecol Obstet 2011; 283:295–297.  Back to cited text no. 12
    



 
 
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  [Table1], [Table2], [Table3], [Table4], [Table5], [Table6]



 

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