Uterine size and endometrial thickness and the significance of cystic ovaries in women with pelvic pain due to congestion

Summary. In a group of 55 women with chronic pain due to pelvic congestion measurement by ultrasound revealed they had a larger uterus and thicker endometrium as compared with a group of normal women matched for age, parity and the presence of polycystic ovaries found on ultrasound scanning. Many women with pelvic congestion (56%) were found on ultrasound to have cystic changes in their ovaries which ranged from a classic polycystic pattern to the appearance of clusters of 4–6 cysts in bilaterally enlarged ovaries. It is suggested that uterine enlargement and thickening of the endometrium are caused by oestrogen, either from the effects on the target organs of an increased concentration or of hypersensitivity to oestrogen.     

Microvascular changes in the peripheral microcirculation of women with chronic pelvic pain due to congestion

Objective Pelvic venous congestion is a common finding in women with chronic pelvic pain. While the pathophysiology of this condition is poorly understood, there are clear indications that it involves vascular dysfunction. The present studies sought abnormalities in microvascular function in these patients.
Design Prospective longitudinal study.
Setting A teaching hospital tertiary referral.
Population Eighteen women with pelvic congestion and 13 nomal women.
Methods Parameters of microcirculatory function were measured in the calves of women using venous congestion plethysmography during the midfollicular and midluteal phases of the menstrual cycle. The women with pelvic congestion were studied again after treatment for the condition.
Main outcome measures Isovolumetric venous pressure, microvascular filtration capacity and limb blood flow.
Results Of the measured parameters of microvascular function, only isovolumetric venous pressure (Pvi) was significantly higher in women with congestion when compared to the controls during the same phase of the cycle. There were no menstrual cycle related differences in any of the other measured parameters in either patients or controls. Following successful treatment for the condition, values of Pvi in women with pelvic congestion were significantly reduced, achieving a level similar to that observed in the controls.
Conclusion The observed changes in Pvi suggest that this parameter is intimately associated with the pathophysiology of pelvic congestion. The increase in Pvi, without alterations in other measured microvascular parameters, may be attributable to systemic increases in postcapillary resistance secondary to neutrophil activation. These findings support the notion of systemic microvascular dysfunction in these women.     

Medroxyprogesterone acetate in the treatment of pelvic pain due to venous congestion

Ovarian function was suppressed with 30 mg of medroxyprogesterone acetate, daily for 6 months, in 22 women with lower abdominal pain due to pelvic congestion. There was reduction in pelvic congestion demonstrated by venography in 17 of the 22 women, and in 16 this was associated with induction of amenorrhoea which suggests that effective ovarian suppression is an important component of successful treatment. In the 17 women who showed a reduction in venogram score, the median change in pain score was 75% compared with only 29% in the five women with no change in venogram score (P less than 0.01). This significant association between reduction in pelvic congestion and pain indicates that pelvic congestion is likely to be the cause of pain in these women and that treatment with medroxyprogesterone acetate could be of value.     

Clinical features of women with chronic lower abdominal pain and pelvic congestion

The clinical features of 35 women with pelvic pain and demonstrable congestion on pelvic venography have been characterized by comparing their symptoms and signs with those of 22 women with pelvic pain due to classical pathology. Women with pelvic pain and congestion had a mean age of 32.4 years, were more often multiparous and had had symptoms for 6 months to 20 years. The pain was dull and aching with sharp exacerbations. In individual women it commonly occurred on one side of the abdomen but unlike the pain due to 'classical pathology', it could occur on the other side. The pain was exacerbated by postural changes, and walking. Congestive dysmenorrhoea, deep dyspareunia and postcoital ache were common findings in women with pelvic congestion and 60% had evidence of significant emotional disturbance. The combination of tenderness on abdominal palpation over the ovarian point and a history of postcoital ache was 94% sensitive and 77% specific for discriminating pelvic congestion from other causes of pelvic pain.     

Clinical features of women with chronic lower abdominal pain and pelvic congestion

Summary. The clinical features of 35 women with pelvic pain and demonstrable congestion on pelvic venography have been characterized by comparing their symptoms and signs with those of 22 women with pelvic pain due to classical pathology. Women with pelvic pain and congestion had a mean age of 32·4 years, were more often multiparous and had had symptoms for 6 months to 20 years. The pain was dull and aching with sharp exacerbations. In individual women it commonly occurred on one side of the abdomen but unlike the pain due to'classical pathology', it could occur on the other side. The pain was exacerbated by postural changes, and walking. Congestive dysmenorrhoea, deep dyspareunia and postcoital ache were common findings in women with pelvic congestion and 60% had evidence of significant emotional disturbance. The combination of tenderness on abdominal palpation over the ovarian point and a history of postcoital ache was 94% sensitive and 77% specific for discriminating pelvic congestion from other causes of pelvic pain.     

GnRH analogue in assessing chronic pelvic pain in women with residual ovaries

Objective To assess whether suppression of ovarian function by a gonadotrophin releasing hormone (GnRH) analogue could assist in the diagnosis of chronic pelvic pain in women with residual ovaries.
Design Uncontrolled, observational study.
Setting District general hospital (seven women) and teaching hospital (one woman).
Participants Eight women with residual ovaries and chronic pelvic pain.
Interventions Goserelin 3.6 mg every 28 days was used followed by surgery to remove residual ovaries.
Main outcome measures The women's response to goserelin and surgery (12 months or more post-operatively) was assessed clinically.
Results Goserelin was associated with resolution of pelvic pain in the six women who obtained relief of pain with oophorectomy. The only woman who did not respond to goserelin also failed to gain relief with surgery. One woman who responded to goserelin declined surgery.
Conclusions Suppression of ovarian function by GnRH analogues may allow differentiation of pelvic pain caused by the residual ovary syndrome from other causes. This would enable selection of cases likely to benefit from surgery, avoiding potentially difficult surgery in women who will gain little or no relief of symptoms with surgery. Only eight cases are reported and a randomised controlled trial would be required to determine the place of GnRH agonists in the treatment of the residual ovary syndrome.     

Factors associated with endometrial thickness and uterine size in a random sample of postmenopausal women

OBJECTIVE: The objective of this study was to investigate factors possibly associated with endometrial thickness and uterine size in a random sample of postmenopausal women. STUDY DESIGN: A random sample (n = 1000) of the total population of women 45 to 80 years of age, resident in the city of G?teborg, was invited to attend for a transvaginal sonography examination. Eight hundred twenty-seven women accepted the invitation and underwent a gynecologic and a transvaginal sonography examination with measurement of endometrial thickness and uterine size. The women's weight and height were measured and a blood sample for analysis of serum estradiol and follicle-stimulating hormone was taken. The women also provided information regarding previous medical and gynecologic history, possible medication, and smoking habits. RESULTS: Five hundred fifty-nine women were postmenopausal, and 183 (33%) of the postmenopausal women were taking some form of hormonal substitution. Factors associated with endometrial thickness and uterine size were analyzed by means of univariate and stepwise multiple regression analyses. The current use of hormone replacement therapy was the most important factor associated with both endometrial thickness and all the uterine size parameters studied. The presence of fibroids was also associated with endometrial thickness. Other factors shown to be associated with uterine size were age, parity, smoking, hypertension, and the presence of diabetes mellitus. CONCLUSIONS: Several of the known risk factors for endometrial cancer were shown to be associated with endometrial thickness and uterine size parameters.     

Increased endometrial thickness in women with hypertension

OBJECTIVE: We noticed an increase in endometrial thickness in women with hypertension who were treated with a combination of medications, including beta-blockers. The purpose of this study was to examine whether the endometrium of hypertensive women is thicker than that of healthy women and to determine whether endometrial thickening in hypertensive women is directly related to the antihypertensive beta-blocker treatment. STUDY DESIGN: We compared 3 groups of postmenopausal patients as follows: (1) women with a history of essential hypertension treated with a combination of medications, including beta-blockers; (2) women with a history of hypertension treated with a combination of medications that did not include beta-blockers; and (3) healthy women without hypertension. All patients were interviewed and examined, blood tests were performed, and endometrial thickness in the anterior-posterior diameter was measured by vaginal ultrasonography. Among the exclusion criteria were diabetes or an abnormal fasting blood glucose level, obesity, hormonal medication or replacement hormonal therapy during the previous 6 months, and a history of hormonal disturbances, infertility, or polycystic ovary syndrome. RESULTS: Of 45 hypertensive women enrolled in the study, 22 were treated with a beta-blocker combination medication and 23 were treated with other antihypertensive medications. They were compared with 25 healthy women. There was no statistically significant difference in endometrial thickness between women treated with medications, including beta-blockers, and those who were treated with other hypotensive agents. Twenty percent of women with hypertension and none of the healthy women had endometrium >5 mm thick (P <.017; odds ratio, 8.22; 95% confidence interval, 1.22-infinity). CONCLUSION: Twenty percent of hypertensive postmenopausal women were found to have increased endometrial thickness. However, we were unable to substantiate an association between the type of treatment administered, whether beta-blockers were included, and the increase in endometrial thickness.     

Bilateral oophorectomy and hysterectomy in the treatment of intractable pelvic pain associated with pelvic congestion.

OBJECTIVE--To determine whether bilateral oophorectomy combined with hysterectomy is an effective treatment for chronic pelvic pain due to congestion. DESIGN--Prospective non-randomized single centre study. SETTING--Tertiary referral centre to a specialist pelvic pain clinic in a teaching hospital. SUBJECTS--36 women, 33 of whom had failed to obtain long term relief of pain on medical therapy. MAIN OUTCOME MEASURES--Relief of pain, coital frequency, and effect on daily life. Histology of uterus and ovaries. RESULTS--Median pain score on visual analogue scale fell from a pre-operative value of 10 to 0 at one year. Twelve of the 36 women had some residual pain at one year postoperatively, but in only one woman was the pain affecting her daily life. Thirty women were noted to have pelvic tenderness pre-operatively, at one year, 26 had no tenderness and four minimal tenderness on pelvic examination. The median frequency of sexual intercourse increased from once per month preoperatively to eight times per month one year postoperatively. The uterus was histologically normal in 25 women, adenomyosis was present in eight of whom two had ovarian endometriosis. Fibroids were present in three and endometriosis was found confined to the ovaries in one woman. Multiple peripheral cysts were present in the ovaries of 25 women. CONCLUSION--Bilateral oophorectomy combined with hysterectomy and hormone replacement therapy is an effective treatment for chronic pelvic pain due to venous congestion, which has failed to respond to medical treatment and leads to restoration of normal coital function and daily life.     

Laparoscopy in 100 women with chronic pelvic pain

Laparoscopy was used to evaluate 100 women who consistently reported pelvic pain in the same location for a minimum of six months. These findings were compared with those of 50 asymptomatic women who underwent laparoscopy for tubal ligation. Overall, 83% of the group with pelvic pain had abnormal pelvic organs as compared with 29% of the asymptomatic group. Adhesions were the most common pathology accounting for 38% and pelvic endometriosis accounted for 32% of the symptomatic group. Results of this study suggest that pelvic pain reported to be in the same location for a minimum of six months, is usually associated with organic pathology.