Chronic Pelvic Pain En Dome Trios Is

8/2/2019 Chronic Pelvic Pain En Dome Trios Is

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CHRONIC PELVIC PAIN--

ENDOMETRIOSIS

Chronic pelvic pain is acommon

symptom,common to anumber ofdifferent conditions/disorders/disease


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CHRONIC PELVIC PAIN--ENDOMETRIOSIS

Chronic pelvic pain is acommonsymptom,common to anumber of differentconditions/disorders/disease

SO : DO WE FOCUS ON THE PAIN or THEENDOMETRIOSIS?how can we frame the

question? How are mechanisms of chronic pelvic pain

influenced by endometriosis?


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PAIN MECHANISMS?

TRADITIONAL

Pain Pathway

Pain enters

here..


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PAIN MECHANISMS?

TRADITIONAL

Pain PathwayPain enters

here..


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Chronic Pain


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FROM : Straffon P,berkley ki.Chronic pelvic pain and endometriosis; tranlational evidence of the

relationship and implications. Human reprod update 2011 :17:327.346.

SIGNS?

LESIONS Rat model of

endometriosis

Women with

endometriosis

Refs rat Refs human

Etiology of

lesions

Surgically

induced

Endogenous origin Vemn&wil

son 1965

G/udice and

Kao 2004

bullun 2009Location of

lesions

Restricted to

abdomen

Varied, bur

predominately pelvis

Vermon &

wilson

1965

G/udice and

Kao 2004

Stegmann et al

2000

Appearance

composition

Cystic ; full

uterine horn

(endometrium,

myometrium

and stroma)

Varied appearance

(mainly

endometrium and

stroma)

Vermon &

wilson

1965

Fauconner and

chapron 2005

Stegmann et al

2009


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FROM : Straffon P,berkley ki.Chronic pelvic pain and endometriosis; tranlational evidence of the relationship and implications. Human

reprod update 2011 :17:327.346.

SYMPTOMS Rat model women Refs rat Refs human

dysmenorrhea Rats not menstruate YES Fauconnier & Chapron

05

Dyspareunia/vaginal

hyperalgesia

YES YES Cason et al 03 Anaf et al 02

Ovarian cyclicity of

dyspareunia

Correlates with estradiol

& uter.cts

UNKNOWN Cason et al 03 wray &

noble 08

Refered muscle

hyperalgesia

YES YES Nagabukuro & berkley

07

Jarrell 04

Location of reffered

muscle pain

abdomen Pelvis/ abdomen Nagabukuro & berkley

07

Jarrell 04

Ovarian cyclicity of

reffered hyperalgesia

Yrs : correlates with

estriol & uter.cts

UNKNOWN Nagabukuro & berkley

07

Wray & Noble 08

Uroogical symptoms Bladder hyperreflexia freq / urgcy Morrison et al 08 Heitkemper & jarrett 05

; Vercelini et al 09

Pain w/kidney stones & more cyclic Giamberanano et al 02 Giamberanano et al 01


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BUT : ARE THE ECTOPIC GROWTHS

INVOLVED


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BUT : ARE THE ECTOPIC GROWTHS

INVOLVED

IN WOMEN Removing lesions can alleviate pain long term in 25%


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ENDO, but not shamEndo, produces

vaginal hyperalgesia


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Surgical removal of the cysts

eliminates the hyperalgesia

McAlister SL et al, pain 2009 147 255 64


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HOW MIGHT THE CYSTS / GROWTH BE

ASSOCIATED WITH THESE EFFECTS

1. The growths must be vascularized to survive

2. Blod vessels are innerated by sensry and

sympathetic nerve fibers3. Do these nerves accompany blood vessels as

they vascularize the growths?

4. In other words , do the nerve fibers sprout toinnervate the growths?


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INNERVATION?

Anaf V, Simon P,el Nakadi I, Fayt I, Simonart T,Peny MO and Noel JC (2000) relationshipbetween endometriotic foci and nerves inrectovaginal endometriotic nodules. Hum reprod15 : 1744-1750

Anaf V, Simon P,el Nakadi I, Fayt I, Simonart T,Peny MO and Noel JC (2002) Hyperalgesia, nerveinfiltration and nerve growth factor expression in

deep adenomyotic nodules, peritoneal andovarian endometriosis. Hum reprod 17.1895-1900


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INNERVATION?

INNERVATION

OF LESIONS

Rat model of

endo metriosis

Women with

endometriosis

Refs rat Refs human

Sensory YES YES Berkley et al 04 Berkley et al 05

tokushige et al

06

Sympathetic YES YES Berkley et al 04 Berkley et al 05

Tokushige at al

06

Hormonal

influences

Correlates with

estradiol,Dyspareunia,&

uterine

contract

Innervation

byprogestogens

or combined

oral

contraceptives

Wray & Noble

08: Zhang et al08

Tokushige at al

06


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How are mechanisms of chronic pain

influenced by endometriosis

Fibers that sprout from existing nerves into lesions

FROM : Dmitrieva N,Nagabukuro H,Reseuhr D,Zhang GH,Mc Allister SM, McGinty KA,

Berkley KJ. Endocannabinoid involvment in endometriosis pain 2010 ; 161 : 703-10


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How are mcehanisms of chronic pain

influenced by endometriosis




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Clearly multiple intercting factors can contribute

to chronic pain in the context of endometriosis

Peripheral nerve sprouting(sensory/symphatetic)sensitization

Central sensitization (initiation &maintenance)

-----------------------------

Hormonal status

Local inflammation

Peritoneal fluid components

Gene expression

Stress

Eutropic uterus

1 A.As-Sanie.R Harris G, Neshewat,AKairys,D Williams,D Clauw, TSchmidt Wicke

Altered regional brain morphology inwomen with endometriosis andchronic pain

2. X Mao Y Zheng,Q MA S-W guo

Oxytocin receptor expression and itsrelationship with uterine contraction

3.N Santanam, c kocher C Cook B DawleyPain sensitive micro RNAs in womenwith endo metriosis

4.M.L barcena de arellanoJ.arnold,Vercelino,V Chiantera,Aschneider,S Mechsner Evidence of

neutrophic events due toperitonealendometriotic lesions

5.J.Arnold M.I barcena de Arellano C Ruster,S Mechsner Imbalance of symphateticand sensory innervation in peritonealendometriotic lesions


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Peripheral nerve

sprouting

(sensory/symphatetic)

sensitization

Central sensitization(initiation &

maintenance)

-----------------------------

Hormonal status

Local inflammation

Peritoneal fluidcomponents

Gene expression

Stress

Eutropic uterus

1 A.As-Sanie.R Harris G, Neshewat,A Kairys,D

Williams,D Clauw, T Schmidt Wicke

Altered regional brain morphology in women

with endometriosis and chronic pain

2. X Mao Y Zheng,Q MA S-W guo

Oxytocin receptor expression and its

relationship with uterine contraction

3.N Santanam, c kocher C Cook B Dawley Pain

sensitive micro RNAs in women with endo

metriosis

4.M.L barcena de arellano J.arnold,Vercelino,V

Chiantera,A schneider,S Mechsner

Evidence of neutrophic events duetoperitoneal endometriotic lesions

5.J.Arnold M.I barcena de Arellano C Ruster, S

Mechsner Imbalance of symphatetic and

sensory innervation in peritoneal

endometriotic lesions

Clearly multiple intercting factors can contribute to

chronic pain in the context of endometriosis


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Nociceptive pain :

Pain Perception

(Trauma,inflammation,etc)Pain

Stimulus


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Spesifik aims

To use VBM to determinne if women with CPP,

with and witahout endometriosis, display

changes brain morpholgy,especially in regions

knw to be involved in pain processing, in

cmparison to age matched healthy controls

To examine if cuch changes are prsent an all

women with endometriosis or just those withchronic pain symptoms.


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Participants


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Chronic Pelvic Pain En Dome Trios Is

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