Pain relief for endometriosis

Treating endometriosis symptoms at home

1. Heat

Share on PinterestA hot water bottle placed on the lower abdomen often helps to relieve pain during menstruation.

Taking a warm bath, or placing a heating pad or hot water bottle on the lower abdomen can help to relax cramping pelvic muscles, which should reduce pain.

This is a common treatment for menstrual cramps that can offer immediate relief.

A study from 2001 tested the effectiveness of heating pads on 81 women with painful periods. It found that using a low-level heating pad was as effective as ibuprofen for pain relief.

2. Pelvic massage

A 2010 study found that massaging the pelvic area, including parts of the abdomen, sides, and back, was helpful in reducing menstrual pain associated with endometriosis.

Doing this type of massage shortly before the menstrual period begins may be more comfortable. It may also be useful to use massage oil.

3. Over-the-counter pain relievers

Over-the-counter (OTC) pain medications, such as acetaminophen, ibuprofen, or naproxen have been developed to fight inflammation.

Reducing inflammation will often relieve cramping and pain. A doctor can determine the best dosing levels.

4. Turmeric

Turmeric has anti-inflammatory properties. Researchers in 2013 showed that turmeric might inhibit estradiol, a form of estrogen. This may help to prevent growths.

Turmeric supplements are available as capsules. The spice is often found in teas and may be added to meals.

5. Dietary changes

Share on PinterestAvoiding dairy, processed foods, and gluten may help to reduce the severity of symptoms.

Altering the diet could reduce symptoms, though more research is needed to determine the best changes.

However, minimizing the consumption of red meat and increasing intake of fruits, vegetables, and whole grains can help to improve overall health.

Some experts recommend an elimination diet. This involves eating no foods that tend to cause inflammation, then reintroducing them slowly to determine which are problematic for the individual.

Potentially problematic foods include:

  • dairy products
  • gluten
  • processed foods
  • sugars

It is important to track symptoms so that potential triggers can be identified.

6. Light exercise

Regular exercise helps to release endorphins. These “feel good” hormones can reduce pain.

Exercise may also help to lower estrogen levels in the body and improve symptoms. Stretch before and after each workout.

7. Rest

Getting extra rest is important, especially during menstruation. Lying on the side with the knees pulled into the chest can help to relieve pain or pressure in the back.

8. Herbal supplements

Herbal or other supplements may help to reduce symptoms, though very little research has been done.

It is important to speak with a doctor before taking herbal supplements. Herbs are not monitored by the U.S. Food and Drug Administration (FDA) for quality, dose, or purity.

9. Omega-3 fatty acids

Omega-3 fatty acids may help to reduce inflammation. They are naturally found in fatty fish, such as salmon. They are also available as a daily supplement.

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SOURCES:

Endometriosis.org: “Painkillers,” “Five things that pelvic health physical therapy can do to improve your endometriosis-related pain,” “Dietary modification to alleviate endometriosis symptoms.”

Journal of Physical Therapy Science: “Efficacy of exercise on pelvic pain and posture associated with endometriosis: within subject design.”

Minerva Chirurgica: “Gluten-free diet: a new strategy for management of painful endometriosis related symptoms?”

Einstein: “Patients with endometriosis using positive coping strategies have less depression, stress and pelvic pain

Patients with endometriosis using positive coping strategies have less depression, stress and pelvic painPatients with endometriosis using positive coping strategies have less depression, stress and pelvic pain.”

Journal of Behavioral Medicine: “The association of coping to physical and psychological health outcomes: a meta-analytic review.”

Molecules: “Cannabinoid Delivery Systems for Pain and Inflammation Treatment.”

Endometriosis Foundation of America: “CBD Oil for Endometriosis Pain? Experts Warn: Buyer Beware.”

Cleveland Clinic: “Transcutaneous Electrical Nerve Stimulation (TENS).”

European Journal of Obstetrics, Gynecology and Reproductive Biology: “Effectiveness of complementary pain treatment for women with deep endometriosis through Transcutaneous Electrical Nerve Stimulation (TENS): randomized controlled trial.”

Iranian Journal of Nursing and Midwifery Research: “The effects of massage therapy on dysmenorrhea caused by endometriosis.”

Autonomic Neuroscience: “Physiological responses to touch massage in healthy volunteers.”

Mayo Clinic: “Acupuncture,” “Botox injections.”

PLOS ONE: “Effects of acupuncture for the treatment of endometriosis-related pain: A systematic review and meta-analysis.”

Pharmaceutical Biology: “Anti-inflammatory activities of essential oils and their constituents from different provenances of indigenous cinnamon (Cinnamomum osmophloeum) leaves.”

International Research Journal of Pharmacy: “Complementary and Alternative Medicine (CAM) Therapies for Management of Pain Related to Endometriosis.”

Patients with endometriosis using positive coping strategies have less depression, stress and pelvic pain Journal of Clinical and Diagnostic Research: “Comparative Effect of Cinnamon and Ibuprofen for Treatment of Primary Dysmenorrhea: A Randomized Double-Blind Clinical Trial.”

Neurology: “Botulinum Toxin Treatment of Chronic Pelvic Pain in Women with Endometriosis.”

European Journal of Nutrition: “Coffee and caffeine intake and risk of endometriosis: a meta-analysis.”

Nutrients: “Caffeinated Coffee, Decaffeinated Coffee and Endometrial Cancer Risk: A Prospective Cohort Study among US Postmenopausal Women.”

Human Reproduction: “Fatigue – a symptom in endometriosis.”

Sleep and Biological Rhythms: “Napping during the late‐luteal phase improves sleepiness, alertness, mood and cognitive performance in women with and without premenstrual symptoms.”

International Journal of Women’s Health: “Anxiety and depression in patients with endometriosis: impact and management challenges.”

Treating endometriosis

Endometriosis can be treated medically (with drugs or medicine) or with surgery. Sometimes both medicine and surgery are used. Some women also benefit from alternative therapies.

On this page:

  • Treatment to improve fertility
  • Treatment for pain
  • Alternative and complementary therapies
  • Choosing not to treat endometriosis
  • Benefits and disadvantages of different treatments

Medications range from pain relief drugs (such as paracetamol and non-steroidal anti-inflammatories) to hormonal treatments that suppress ovulation and menstruation).

Surgery can be used to remove or burn the endometrioses. The most common surgery used is laparoscopy (key-hole surgery).

If the ovaries contain cysts of endometriosis these are best treated surgically as they are unlikely to disappear on their own and they can’t be treated with medicine.

Treatment to improve fertility

Surgery has been shown to improve fertility for women with mild endometriosis. Treating more severe endometriosis with surgery, especially if there are cysts in the ovaries, also appears to improve fertility, although this hasn’t been fully proven. Medication for endometriois has not been shown to improve fertility.

Other causes of infertility should be looked for and treated.

Treatment for pain

When pain is the main problem, the treatment aims to relieve symptoms and lessen the pain.

  • Simple pain relievers (paracetamol, etc)
    Many women will experience some relief of symptoms with over-the-counter drugs such as paracetamol (Panadol) and non-steroidal anti-inflammatories (Ponstan, Nurofen, Naprogesic, etc).
  • Hormonal treatments (the Pill, etc)
    Hormone treatments are used to suppress the normal menstrual cycle, which in turn stops or slows endometriosis growth. The simplest way to achieve this is with the Pill. Other hormonal therapies that have been shown to be effective in reducing endometriosis-related pain, are also available. Some women will experience side effects with hormonal treatments.
  • Keyhole surgery or laparoscopy
    May be offered initially to help make the diagnosis. Some women are offered surgery because they don’t want to take medicine or because medicines haven’t worked. Surgery for endometriosis includes laparoscopy (key-hole surgery), which may be used to make the diagnosis and treat all visible endometriosis. This is done with laser or diathermy, which destroys the endometriosis by burning it. Alternatively the deposits of endometriosis can be cut away.
  • Hysterectomy
    In a small group of women who have severe symptoms that are not relieved by medical or other surgical treatment, more extensive surgery such as hysterectomy and removal of the ovaries may be considered.
  • Bowel surgery
    Sometimes the endometriosis affects the wall of the bowel. When this is causing significant symptoms it may be suggested that the affected piece of bowel is removed. This would require bowel surgery and is uncommon.

Alternative and complementary therapies

There are various treatments available that can either complement your medical treatment or are an alternative to medical treatment. The most popular is traditional Chinese medicine and herbal preparations. Some women experience improvement of their symptoms with these but there is no scientific evidence to support the effectiveness of Chinese medicines in reducing symptoms or improving fertility.

If you use complementary treatments it is wise to discuss their use with your doctor as they may interfere with other prescribed medications. The Pharmaceutical Benefits Scheme (PBS) does not cover the costs of alternative or complementary therapies.

Choosing not to treat endometriosis

Mild endometriosis doesn’t always need treatment. You are usually offered treatment to help relieve the symptoms rather that to cure the disease itself.

If left untreated, some endometriosis will improve, but most will stay the same. Some will become more severe without treatment.

For most women with endometriosis, the symptoms will settle once they go through the menopause. Deciding whether or not to treat endometriosis is often a matter of balancing the risks of the treatment against the effect the endometriosis is having on your life.

Benefits and disadvantages of different treatments

Benefits Disadvantages
Doing nothing – no treatment
  • No side effects of drugs
  • No risks of surgery
  • Most symptoms continue
  • Some symptoms may get worse
Simple pain relief
(paracetamol, ibuprofen)
  • Easy to get
  • Side effects uncommon
  • Often not effective
  • Ibuprofen use has some health risks
Progesterone-like medications
  • Reduced pain
  • Irregular or no periods
  • Stops endometriosis growth in most cases
  • Some are contraceptive
  • Side effects possible – weight gain, moodiness, acne, increased hair, cramps, breast tenderness
  • Symptoms may recur when treatment is stopped
  • May not fix pain
  • Doesn’t improve fertility
  • Shouldn’t get pregnant while on drug
  • Not all contraceptive
Menopause-causing medications
  • No periods
  • Reduced pain
  • Stops endometriosis growth in most cases
  • Side effects – hot flushes, sweats
  • Bone thinning if used for more than six months
  • Symptoms may recur when treatment is stopped
  • Shouldn’t get pregnant while on drug
  • Not a contraceptive
  • May not fix pain
The combined contraceptive pill
  • Contraceptive
  • Reduced pain
  • Can be taken to reduce or stop periods
  • Side effects – nausea, weight gain
  • Shouldn’t get pregnant while on it
  • Small risk of clots in legs or lungs
Laparoscopy
  • A definite diagnosis
  • A long-term cure in up to 70 percent of women
  • No need to use medications long-term
  • Not all endometriosis can be treated this way
  • There are risks assoicated with surgery
  • May not cure the pain
  • Recurrent endometriosis in 30 percent of women
Hysterectomy and removal of endometriosis
  • Achieve long-term cure in over 90 percent of women
  • No need to use medications
  • No more periods
  • Risks of surgery greater than laparoscopy
  • Removes fertility
  • Some women grieve for uterus loss
  • May need HRT if ovaries removed
  • May not cure pain

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Disclaimer

The Women’s does not accept any liability to any person for the information or advice (or use of such information or advice) which is provided on the Website or incorporated into it by reference. The Women’s provide this information on the understanding that all persons accessing it take responsibility for assessing its relevance and accuracy. Women are encouraged to discuss their health needs with a health practitioner. If you have concerns about your health, you should seek advice from your health care provider or if you require urgent care you should go to the nearest Emergency Dept.

Cross-Linked Hyaluronic Acid for the Management of Neuropathic Pelvic Pain

Case presentation and injection technique targets endometriosis-related pain.

Endometriosis, the presence of endometrial tissue outside of the uterus, is a frequent, estrogen-related condition, affecting approximately 176 million women in the world, or 1 in 10 women between the ages of 15 and 49.1 The condition may lead to infertility in 30 to 50% of those diagnosed,2 as well as multiple types of related pain including: dysmenorrhea, dyspareunia, intestinal and bowel pain, dysuria, and chronic low back and pelvic pain.

The management of endometriosis-related pelvic pain requires medical and, at times, surgical therapy.3 Medical modalities are directed at relieving pain through various mechanisms, including the suppression of: inflammation, cyclical ovarian hormone release, estradiol, and menses. Surgical treatment may be used as a first-line approach or after medical failure. Surgery may consist of a variety of techniques including: fulguration, excision, or ablation of endometrioma implants, as well as resection of rectovaginal nodules, lysis of adhesions and nerve pathways interruption.4 It should be noted that clinical staging of the disease often assists in the selection of treatment in a given case,5 and may include: Stage 1-Minimal, Stage 2-Mild, Stage 3-Moderate, and Stage 4-Severe. The stages are dependent upon the presence, location, extent and severity of endometrial implants, endometriomas, and adhesions.

The following case presents a woman with severe, chronic lumbosacral and pelvic neuropathic pain due to Stage 4 endometriosis-related endometrioma implants, after undergoing multiple surgical interventions that failed to improve her pain control, wherein she is then successfully treated with cross-linked hyaluronic acid (CL-HA). The diagnosis is supported by electromyography (EMG) findings of multilevel lumbosacral radiculopathy6-8 and a negative imaging workup for other causes. The use of CL-HA to treat neuropathic pain was initially presented at the 2015 annual meeting of the American Academy of Pain Medicine.9 This form of treatment is designated as Cross-Linked Neural Matrix Antinociception, or simply XL-NMA.10 CL-HA is made of chemically cross-linked hyaluronic acid – a linear, anionic proteoglycan polysaccharide composed of glucuronic acid and N-acetylglucosamine repeating units.

The Case

A 41-year-old woman, G, P, M, A: 4, 2, 2, 0, presented with persistent, worsening pelvic and low back pain that she described having for 15 years. The pain would intermittently radiate down both lower extremities, right greater than left, and up her lower back. Overall, her pain was worsening; it had persisted daily for the past six years, with localized pain over the anterior and posterior right greater trochanter.

Pain initially began in the right lower quadrant and was attributed to endometriosis in 2000. She had undergone six endometriosis surgeries (most recent was 6 months prior, excisional type, no change). She was status post-appendectomy, complete hysterectomy, with left ovary remaining, lumpectomy for right breast carcinoma (7 years prior) and self-referred to our center for evaluation. Pain interfered with sleep; weight was stable, as was bowel and bladder function. There was dyspareunia due to pain upon penetration. There was no loss of sensation or weakness, but her legs weakened when the pain became severe. She underwent trigger point injections and radiofrequency denervation, three years prior, with no relief.

Her current analgesic regime included:

Self-reported symptoms as shown on Figure 1 revealed pain over the anterior and posterior pelvis, radiating down both lower extremities, anterior and posterior aspects, to just above the knees. The patient noted the pain indicated on the left was referred or radiating from its mirror origin on the right (as shown in Figure 2). She described the pain as: aching, sharp, tight, pulling, and constant. The pain score intensity range was (lowest-average-highest): 3, to 5, to 10/10, aggravated by prolonged sitting, standing, lying, touching, stress, driving and/or riding in a vehicle, vacuuming, and pulling. The patient found some relief from “self-determination,” pain medication, rest, heat, cold, and lying down in a fetal position.

Patient’s Neuropathic Painful Dysesthesias

Right hip and anterior pelvic region:

  • The painful dysesthesias from this region proceeded downward and laterally, anteriorly, and medially.

Right sacral region:

  • The S1, S2 and S4 dysesthesias proceeded horizontally across the buttock, to the anterior pelvis.

  • The S3 dysesthesias, which were the strongest, proceeded in the same direction as the others, but felt deeper, like a level below S1, S2 and S4, and were more intense.

Initial Assessment

Examination: In examining the abdomen/pelvis, there was diffuse tenderness to the lower hemi-abdomen and pelvis, right greater than left, with mild palpation. The vaginal vault was moist, mildly reactively constricted, but admitted two digits. Upon digital pressure superiorly and to the right, right-sided abdomino-pelvic pain was evoked. In assessing the spine, percussion tenderness was noted from L2-3 to S3-4, greatest at L5-S1. The anterior and posterior loading maneuver (ALM/PLM) were both positive at L5-S1. However, the PLM was more severe, with pain noted to the right coxofemoral and greater trochanter region. Palpation over right sacral foramina and greater trochanter revealed additional hyperalgesia and hyperpathia, supporting the presence of neuropathogenicity.

Records review: X-ray of both hips from 3 years prior were noncontributory. A CT Scan of the abdomen/pelvis from two years prior noted previous swelling of the mesentery in the right lower quadrant was not seen, although there was persistent induration in the mesentery (considered: intermittent mesenteric volvulus or internal hernia).

Etiology: Given the patient history, physical assessment, and records, the following differential diagnoses were considered:

  1. Endometriosis related-lumbosacral plexopathy, secondary to radicular implants, with secondary neuropathic pain syndrome
  2. High-lumbar lesion with referred pain to hips/pelvis, with secondary radiculopathy
  3. Intermittent mesenteric volvulus and/or internal hernia, with secondary visceral pain syndrome
  4. Metastatic process due to history right breast cancer (7 years prior), lumpectomy.

New Tests Orders and Results

To refine the above differential diagnoses, several tests were ordered. See Table I for diagnostics and results. Based on the new test results, the following determinations were made:

  1. Probable: endometriosis-related lumbosacral radiculoplexopathy, as suggested by EMG plus secondary neuropathic pain syndrome, with referred pain to hips/pelvis
  2. Not found or resolved: intermittent mesenteric volvulus and/or internal hernia
  3. Not found: metastatic process.

Treatment

To localize potential sites for neuromodulation, the patient was scheduled for differential neural blockade with local anesthetic (lidocaine 2%, plain) at: right dorsal cutaneous nerve branches (see Figure 3) of T11, T12, L1, L2, L3, L4, L5, S1, S2, S3, S4. Note: The left-sided pain areas were not treated as the patient felt that the primary pain generators were on the right, and that those sites were referring pain to the left side. See the step-by-step injection technique here.

With the exception of the anterior pelvic region (see patient commentary), the patient reported good relief and began periodic injections at the same sites, with pain control maintained using an injectate of: 4 cc, 2% plain lidocaine; 7.95 cc, 0.25% plain bupivacaine; and 0.25 mg/0.05 cc, morphine sulfate-MSO4 (5 mg/cc), administering 0.5 to 1.5 cc per site. The patient related that these injections, which provided relief for about 7 days, in combination with her opioids improved substantially her ability to perform daily activities, as well as tend to her children and family, including serving as the primary caregiver of her mother who was undergoing treatment for breast cancer. The patient’s reduction in pain was significant (see Figure 4).

XL-NMA – Neural Matrix Aninociception

Approximately 20 months after the patient first presented to the clinic, she underwent an initial trial of XL-neural matrix antinociception at the same sites, using the same technique, except the volumes of the injectate were reduced to one-tenth of the lidocaine/bupivacaine/MSO4 injectate used (this varied from 0.15 cc to 0.25 cc of cross-linked hyaluronic acid, with a concentration varying from 20 mg/ml (Restylane) to 24 mg/ml (Juvederm) per site.11,12 The patient responded well, with no adverse reactions noted, and achieved a duration of relief of 3 to 4 months for the sacral sites, 4 months for the lumbar sites, and 6.5 months for the greater trochanter region. The patient rated overall improvement after the CL-HA injections at 90%. Change in pain scores was remarkable (see Figure 5).

Since that time, the frequency of injection sessions dropped from three to four times per month on the previous injectate of lidocaine/bupivacaine/morphine, to once every five to six months. There have been no adverse reactions and the patient continues on this regimen to date.

Discussion & Recommendations

While the patient’s outcome using cross-linked hyaluronic acid injections was successful, additional research is necessary to elucidate the mechanism of action of this complex substance, as well as to develop additional techniques for its use in neuropathic pain. In this case, the right anterior pelvic pain was essentially unaffected. Methods such as an intercostal T10-12, transforaminal L1, L2, lumbar sympathetic or celiac XL-NMA may be found to remedy this shortcoming.

Mechanism of Action Summary

Purported mechanisms of action are complex and no doubt, multifactorial.13 Nonetheless, it is possible that the antinociceptive effect may occur in a step-wise fashion over time (ie, immediately or in first 10 minutes after injection) and that the CL-HA acts as a physical shield, thereby forming a protective compartment and blunting spontaneous activity of C fiber and Remak bundle afferency, including aberrant nociceptive ephapse.14 In addition, contemporaneous depolarization of the action potential due to its polyanionic nature and size of its negative charge (a function of its massive molecular size, 500 million daltons to 100 GDa), blocking any transduction of signal, may occur. Its long-term effect may be due to low/high molecular weight mismatch correction resulting in TNFα-stimulated gene 6 protein modulation of the subclinical, regional inflammatory response. Dysregulation at the level of the extracellular neural matrix is stabilized, promoting a restoration of the normal immunoneural cross-talk, thereby negating what is believed to be the root cause for the development of chronic pain.15-18

Furthermore, any injury or insult to the nervous system may cause deafferentation pain (defined as “severe spontaneous pain in body parts distal to the injury despite reduced or no sensitivity to external noxious stimuli to that body part (hypoalgesia or analgesia)”19 as it represents a loss of information from the periphery to the brain. In the case presented, the nerve roots and spinal cord segments of the painful regions in question likely suffered deafferentation and neuropathic pain as a result of injury caused by the endometrial implants. It is this initial injury that likely initiated the cytokine cascade’s proinflammatory, pronociceptive state. For a complete discussion of these mechanisms of action in this regard, see the author’s previous report.13

Overall, this case provides a detailed look at the use and technique of targeted neural matrix antinociception injection of cross-linked hyaluronic acid in the successful treatment of chronic endometriosis pain of the thoraco-lumbar, sacral, and right greater trochanteric region that occurred in a 41-year woman who had previously undergone multiple endometriosis pain related surgeries with no change. The technique presented has resulted in the patient’s enduring pain relief, and proved to be a safe and effective method in this patient (see the Patient’s self-reported commentary below). Its routine use should be considered early to manage pain in similar cases.

Patient Commentary

“I was officially diagnosed with severe endometriosis when I was 26 years old. Although, I am very certain it started years before when I was in my teens. My periods where always very heavy flow and extremely painful—painful enough that I would always need a day or two off from school or work. I started taking birth control pills when I was 18 and that seemed to suppress the progression of the disease or at least the symptoms. After I had my first child, when my cycle resumed, the pain returned. My doctor did ultrasounds, MRIs, and x-rays trying to find the cause. She decided to do an exploratory laparoscopy and that’s when they discovered I had severe endometriosis.

Over the next 15 years, I had five more abdominal surgeries. My right ovary was removed, my uterus, my appendix, along with both of my tubes and my cervix because they were covered with the disease. The endometriosis continued to spread and do damage to many nerves in my pelvic area. The nerve damage caused severe pain in my right hip, low back, and my pelvic area.

The pain gradually got worse, increasing from a few days a month to everyday. I was put on countless medications. From pain meds to hormones, birth control pills, IUD and the worst was a medication that shut down my ovaries and put me into medical menopause. I used OTC pain relievers until my stomach couldn’t handle them anymore, as well as ice, heat, and local lidocaine to no avail. Another pain management doctor gave me more medications to try as well as nerve ablation—none of which helped.

The pain was so intense that, most days, I was forced to stay home. I was unable to take care of my home or my children. I was also unable to have sex because it was too painful. When more surgery was no longer an option I began seeking someone to help me deal with the pain. At this point in my life my life quality was terrible. A friend recommended Dr. Campa . I saw him and he started a treatment plan with the injections. He gave me injections in my right hip, low back and my pelvic area.

Very early in the treatments, I began to feel improvement. The injections would bring my pain scores from a 9 or 10 down to a 2 or 3. The only drawback was that it was short relief. While they were working I was able to start participating in my family life again. I would get the injections once a week. The first three and four days were great but over the next day or two the pain would return. Although while they were working, I could be active and have intercourse that wasn’t painful. The only drawback was that the relief was so temporary.

When Dr. Campa started giving me the cross-linked injections the onset of pain relief was within 24 hours or so. The great thing about them was that they lasted for months not days! Comparing the two different injections, the cross-linked injections brought my pain scores of 9 or 10 to a 1 or 2. Only getting injections every 6 months or so compared to weekly has been so much easier and the time I saved I am able to devote to my family. The long-term pain relief has been an absolute blessing.

Before the cross-link injections, oxycodone and hydromorphone would help minimally with all the nerve pain and abdominal pain from the scar tissue and adhesions. The oral pain medication barely took the edge off of all the pain and I spent most of my time in bed or on the couch unable to move. The cross-link injections brought down my pain levels in my right hip, low back and pelvic area nerves enough that the oral pain medication made the scar tissue and adhesion pain more manageable. I continue to take oxycodone and hydromorphone to help with the severe pain that isn’t nerve related. The scar tissue and adhesion pain is a pulling pain across my whole pelvic region, but the most intense pain originates from the lower right pelvic region. This pain is controlled with opioids, which lowers the pain score from a 9 or 10/ out of 10 to about a 6 out of 10.

In the areas treated with the cross-linked injections, the pain is a least 90% better. The other areas seemed to improve some but it’s hard for me to tell if they actually improved or if they are easier to manage since the other pain is so much better.”

–Commentary provided by the author with patient permission.

Also featured in this special report on Pain Care & Research in Women

  • Case Study: Neuropathic Pelvic Pain Caused by Endometriosis
  • Challenges in Responding to Vulvodynia
  • MSK Pain and Insomnia in the Post-Menopausal Woman

  • Commentaries on the State of Pain in Women, and of Women in Pain Practice, featuring: ACOG’s Katherine W. McHugh, MD, the Society for Women’s Health Research Amy M. Miller, PhD, and Johns Hopkins Medicine’s Tina L. Doshi, MD.

View Sources

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  2. Adamson et al. Creating solutions in endometriosis: global collaboration through the World Endometriosis Research Foundation. J Endomet. 2010;2(1):3-6.
  3. ASRM. Reproductive Facts–Endometriosis: Does it cause infertility? Available at: www.reproductivefacts.org. Accessed June 25, 2018.
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  20. Campa J, Inventor. Indication and technique for the use of cross-linked hyaluronic acid in the management of pain. US 9,205,105 B2. December 8, 2015.
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Continue Reading: Step-by-Step Injection Technique to Target Endometriosis-Related Neuropathic Pelvic Pain

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Anti-inflammatory diet: Do’s

What you eat has a major effect on how you feel. Research has shown that anti-inflammatory foods can help reduce endometriosis symptoms.

Eat a diet rich in leafy greens and vegetables, omega-3 fatty acids (from foods like fish, nuts, and seeds), and green tea. Try to limit high-FODMAP foods, gluten, and dairy.

Anti-inflammatory diet: Don’ts

Trans fats cause inflammation, even for people without endometriosis, so anyone dealing with the condition should really try to really limit them. Refined carbohydrates could also inflame your gut and cause pain.

Research has shown that eating refined foods can also affect your fertility, so it’s especially important to watch your diet if you want to get pregnant.

Heating pad

When your pain is at its worst, applying heat to your abdominal area can help. This relaxes your pelvic muscles and keeps the blood flowing, which can reduce cramping.

Warm bath

Similar to a heating pad, a warm bath surrounds your body with heat, which can help you chill out and provide relief for your pain.

Throw in a bath bomb with lavender, sage, marjoram, and rose essential oils, which studies have found could reduce menstrual pain.

Castor oil

Some people swear by castor oil as a natural remedy for intense period pain. This natural vegetable oil is known for its anti-inflammatory and medicinal uses and for being a great moisturizer.

You can apply it externally to your abdominal area and combine it with a heating pad to maximize the benefits. To avoid disrupting your body’s natural pH levels, you should never apply castor oil directly to your vaginal area.

Omega-3 supplements

Omega-3 fatty acids, found mostly in fish like salmon and sardines but also in some plant sources, help strengthen your cells to fight inflammation and pain.

You can eat these foods, obv, but you can also take a daily fish oil supplement to ensure you’re getting a steady dose. Talk to your doctor to help find a reputable brand and decide whether supplements are right for you.

OTC pain meds

While they’re not a long-term solution, pain medicines like ibuprofen and aspirin can relieve your symptoms when they get especially bad.

Just be careful not to use them all the time, because they can cause nausea and mess with your gut microbiome if overused — which will only increase inflammation down the road.

Ginger tea

Have you ever been so overwhelmed by cramping that you literally felt nauseated? It’s super fun (JK — it sucks).

When you can’t deal, reach for a steaming cup of ginger tea to warm up your body and soothe your stomach. Research has shown that ginger can curb nausea and vomiting associated with pregnancy, and it might also help with any endo-related nausea.

Turmeric

This bright yellow spice that stars in so many ’grammable lattes contains a compound called curcumin, which has been shown to limit the growth of endometrial cells.

It’s also anti-inflammatory, so it can be helpful for pain management.

Exercise

One side effect of endometriosis in many cases is weight gain. This can happen because of a hormonal imbalance or medication use.

To help prevent your body from becoming more inflamed, combine a healthy diet with regular exercise (the American Heart Association recommends 150 minutes per week of moderate-intensity aerobic activity).

Multivitamins

A daily multivitamin can help ensure you’re getting a wide variety of vitamins and minerals. Research has shown that supplementing antioxidants such as vitamin E and C can lessen endometriosis pain.

Taking a multivitamin may also help increase your chances of getting pregnant. Talk to your doctor to find a combination of vitamins and minerals that works best for you.

Treatment


Endometriosis

Surgery

Surgery can be used to remove or destroy areas of endometriosis tissue, which can help improve symptoms and fertility.

The kind of surgery you have will depend on where the tissue is.

The main options are:

  • laparoscopy – the most commonly used technique
  • hysterectomy

Any surgical procedure carries risks. It’s important to discuss these with your surgeon before undergoing treatment.

Laparoscopy

During laparoscopy, also known as keyhole surgery, small cuts (incisions) are made in your tummy so the endometriosis tissue can be destroyed or cut out.

Large incisions are avoided because the surgeon uses an instrument called a laparoscope.

This is a small tube with a light source and a camera, which sends images of the inside of your tummy or pelvis to a television monitor.

During laparoscopy, fine instruments are used to apply heat, a laser, an electric current, or a beam of special gas to the patches of tissue to destroy or remove them.

Ovarian cysts, or endometriomas, which are formed as a result of endometriosis, can also be removed using this technique.

The procedure is carried out under general anaesthetic, so you’ll be asleep and will not feel any pain as it’s carried out.

Although this kind of surgery can relieve your symptoms and sometimes help improve fertility, problems can recur, especially if some endometriosis tissue is left behind.

You may need to take hormone treatment before and after surgery to help avoid this.

Hysterectomy

If keyhole surgery and other treatments have not worked and you have decided not to have any more children, removal of the womb (a hysterectomy) can be an option.

A hysterectomy is a major operation that will have a significant impact on your body.

Deciding to have a hysterectomy is a big decision you should discuss with your GP or gynaecologist.

Hysterectomies cannot be reversed and, though unlikely, endometriosis symptoms could return after the operation.

If the ovaries are left in place, the endometriosis is more likely to return.

If your ovaries are removed during a hysterectomy, the possibility of needing HRT afterwards should be discussed with you.

But it’s not clear what course of HRT is best for women who have endometriosis.

For example, oestrogen-only HRT may cause your symptoms to return if any endometriosis patches remain after the operation.

This risk is reduced by the use of a combined course of HRT (oestrogen and progesterone), but can increase your risk of developing breast cancer.

But the risk of breast cancer is not significantly increased until you have reached the normal age for the menopause. Talk to your doctor about the best treatment for you.

Complications of surgery

All types of surgery carry a risk of complications.

If surgery is recommended for you, speak to your surgeon about the possible risks before agreeing to treatment.

Read about the complications of endometriosis for more information about the risks of surgery.

Gonadotrophin-releasing hormone (GnRH) analogues

GnRH analogues are synthetic hormones that bring on a temporary menopause by reducing the production of oestrogen.

They’re sometimes given before surgery to help reduce the amount of endometrial tissue. You would normally take them for 3 months before your surgery.

GnRH analogues are not licensed as a form of contraception, so you should still use contraception while using them.

Painkillers

by Ros Wood and Ellen T Johnson

Most of us with endometriosis know quite a bit about having pain. Unfortunately, we know a lot less about how to manage that pain. In our attempts to deal with pain, many of us have used various medications such as aspirin, Paracetamol, Panadol, or Tylenol. These drugs alleviate pain by reducing the body’s sensitivity to pain.

Fewer of us are familiar with the use of the non-steroidal anti-inflammatory drugs (NSAIDs) for managing pain. Some of the more common NSAIDs include ibuprofen (ACT-3, Advil, Brufen, Motrin, Nurofen), naproxen sodium (Aleve, Naprogesic, Naprosyn, Naproxen), ketoprofen (Orudis KT), and mefenamic acid (Ponstan). These drugs can be effective in alleviating pain and inflammation, but to do so, they must be used correctly. Too often, women are prescribed NSAIDs without clear instructions about their use, so they use them the same way they use analgesic drugs. However, when used incorrectly, NSAIDs don’t work.

It is thought that much of the pain of endometriosis, especially menstrual pain, is due to inflammation that may be caused in part by high levels of “bad prostaglandins.” Prostaglandins are hormone-like chemicals that can be found in every cell of the body. Prostaglandins have beneficial effects (enhance immune function, block inflammation, relax muscles, maintain the integrity of the stomach lining, dilate blood vessels, etc.), as well as detrimental effects (produce inflammation, decrease oxygen flow, contract muscles, induce pain, etc.). The bad news is that women with endometriosis have been shown to produce an excess of a prostaglandin called PGE2, which causes inflammation, pain, and uterine contractions.

Theoretically, NSAIDs would seem to be a good choice for relieving menstrual pain because most of them work by blocking the production of all prostaglandins. The result is less pain, swelling, and inflammation. However, since NSAIDs work by stopping the production of the pain-causing prostaglandins, they must be taken before any of these chemicals are produced. In other words, you must start taking NSAIDs at least 24 hours before you expect to experience pain. If you delay taking them until after you feel pain, the medication cannot block the pain-producing chemicals that have already been released, so they will not alleviate pain.

If you are using NSAIDs for ovulation pain or menstrual pain, it is recommended that you start taking them as directed at least 24 hours before you expect to ovulate or 24 hours before you expect to start bleeding. If you have an unpredictable menstrual cycle, you may want to take them for a week or more before you expect menstruation to begin. To be effective, it is important to take NSAIDs regularly every six hours so that no pain-producing chemicals are produced during ovulation or menstruation. Another advantage of taking certain NSAIDs is that they decrease the amount of menstrual bleeding (1, 2).

There are many different brands of the NSAIDs available. Some are available over-the-counter at your local pharmacy, while some are available by prescription only. It is difficult to predict which type of NSAID will be effective for a particular individual, so you may need to try two or three brands before finding one that relieves your pain. Talk to your pharmacist or doctor about suitable brands to try. If you’ve already tried an NSAID without success, you may want to try again. If you were using them incorrectly before, try starting them well in advance of your pain so that no pain-producing prostaglandins are produced.

The most important thing to remember is that unlike analgesics, NSAIDs do not block existing pain. Instead, they block the production of prostaglandins that produce the pain. Therefore, they must be taken before you feel any pain. And they must be taken every six hours around the clock if they are to work effectively.

Like many drugs, NSAIDs can have side effects – some quite serious. Because NSAIDs block all prostaglandin production, they also block the good prostaglandins responsible for maintaining the integrity of the stomach lining. That’s why the most common side effects of NSAIDs include nausea, vomiting, diarrhoea, irritation of the stomach, and stomach ulcers. To help reduce stomach irritation, NSAIDs should be taken with food. Newer NSAIDs called selective COX-2 inhibitors (Vioxx, Celebrex, Bextra) were originally thought to cause less bleeding and fewer ulcers than traditional NSAIDs. However, follow-up studies on these drugs have shown there is no clinically meaningful safety advantage over traditional NSAIDs. Therefore, COX-2 inhibitors should be used with the same caution as any other NSAID. If you are considering taking any type of NSAID, be sure to ask for a complete list of potential side effects, warnings, and possible drug interactions from your pharmacist or healthcare practitioner. Also be sure to inquire about the types of side effects that should be reported to your doctor immediately.

Finally, it’s important for you to know that the effects of “bad prostaglandins” can also be moderated in part by diet and supplements. As we’ve discussed in prior articles and interviews with Dian Shepperson Mills, reducing animal fats, caffeine, and alcohol, and adding flax oil, fish oil, and olive oil to your diet can increase the production of “good prostaglandins” and decrease the production of “bad prostaglandins.” If you cannot take NSAIDs (or choose not to), dietary changes may be a good option to try.

  1. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev 2000;(2):CD000400, ISSN: 1469-493X, Lethaby A; Augood C; Duckitt K; Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
  2. Medical management of dysfunctional uterine bleeding, Baillieres Best Pract Res Clin Obstet Gynaecol 1999 Jun;13(2):189-202, ISSN: 1521-6934, Irvine GA; Cameron IT Ayshire Central Hospital, Irvine, UK

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