Answers to you questions.....

I've received some questions from readers on various subjects, so I thought I'd answer them individually.
First, a number of questions about back and leg pain with endo. All of the nerves in the pelvis eventually run into the spine before connecting with the spinal cord. Endo tends to frequently involve the uterosacral ligaments, which as the name suggests, run from the uterus to the sacrum (the base of the spine that forms the back of the pelvic girdle). Pain from the uterus as well as endo on the uterosacrals can cause pain that is perceived in the low back, although touching the skin over the area where the pain is felt doesn't usually increase the pain. This is known as "referred pain", and it is caused when internal organs are painful, but the pain is felt where the somatic nerves (from the skin or muscles) from the same nerve root as the visceral nerves (from internal organs) from the source of pain. In other words, the lumbar nerves go to the uterus as well as the low back and buttock. When the uterus hurts, your brain can't localize all of the pain to the inside of the pelvis, so it is felt in the back where the other nerves from the same spinal segment come from. This is the same reason that appendicitis initially causes pain around the umbilicus (when only the appendix is irritated), then as the inflammation involves the abdominal wall, the pain localizes to the right lower quadrant. The nerves from the intestine are felt as generalized belly pain rather than an isolated discreet spot. Likewise, some pelvic areas don't send pain impulses that are perceived as coming from the pelvis, but they're felt in the back. The uterus can also generate pain referred to the legs, most commonly the anterior and medial thigh. Referred pain is usually a deep pain that aches and throbs, sometimes it can feel hot or burning, usually it doesn't increase by pushing or rubbing the place where it is felt.
Back pain in the context of pelvic pain can also be due to muscular issues. Pelvic pain can cause muscle spasm of the levator muscles, which can cause spasm of the piriformis and obturator muscles. These little bugger muscles are both on the inside and outside of the pelvis, and line the inside of the pelvic cavity. They externally rotate the hip, and when they are in spasm, they can alter the normal curvature of the lumbar spine by pulling down on the sacrum and flattening the lumbar curve. They can also cause the tailbone to hurt (coccodynia). Similarly, the hamstrings (muscles of the posterior thigh that flex the knee) originate on the iscial tuberosity, the bones we all sit on, the ones that get sore riding a bike. When people are inactive, many times the hamstrings will tighten up (try touching your toes with straight knees - if you can't, your hamstrings are tight). This also pulls down on the posterior pelvis and flattens the lumbar curve, causing back pain.
Then next subject is fatigue after surgery - this is incredibly common after any kind of surgery. One can think of postop fatigue as nature's way of making sure we rest enough to allow the body to heal itself. This is a simplistic explanation, but usually the fatigue resolves slowly as activity increases. One study looked at healthy students who were made to stay in bed for varying numbers of days. Their cardiovascular fitness was measured before and after their forced rest. It took an average of three days of activity for every day in bed to recover to their previous level of conditioning, and that was without any illness or surgery, so extrapolating that study to surgery, it would be normal to take a while after surgery to feel as energetic as beforehand. When the body is injured, whether by surgery, infection, or disease (like endo), our response consists of mobilizing white blood cells to swarm to the area that's injured. They release all sorts of factors that eventually help promote the healing process, but sometimes cause more inflammation than they should. These factors are things like histamine, leukotrienes, prostaglandins, and cytokines that act in an incredibly complex way to effect wound healing. Along the way, they can also cause fatigue, and more nerve stimulation that rarely can eventually lead to neurogenic pain. There is also a connection between inflammation and sleep disturbances, as well as a defined restorative effect of deep sleep enhancing immune functioning. Pain in and of itself can cause fatigue, and pain that results in lack of exercise also increases fatigue. To some extent as this postop inflammation resolves, the inflammatory mediators decrease, and fatigue lessens. However, in order to get back to preop or pre-disease levels of fitness, you have to work at conditioning by exercising daily, pushing yourself somewhat in order to recondition your muscles, heart, and lungs.
The last question was about estrogen and endometriosis. Yes, estrogen alone does stimulate endometriosis, but most birth control pills are progesterone dominant, which means that the progesterone in the pill is able to suppress endometrial cells more than the estrogen stimulates them. This is why most women have lighter menstrual flows while on the pill than when they're not taking it. To the extent that endometriosis can be suppressed (some superficial endo can be suppressed quite well, while the deep lesions really can't), the more progesterone dominant pills will be better. The best way to take OCPs with regards to endo is to take them continuously, so that you don't have a period. This is facilitated by slowly increasing the interval between periods - first putting 2 packs together, then 3, then 4, and so on, while skipping only 3-4 days between active pills rather than 7.
The last question was related to weight and endo. Most of our endo patients are thin, so although I'm not aware of a study of endo patients and weight, I'd have to weigh in (pun intended) to say that endo does not cause weight gain. Abdominal bloating around the menses is usually either gas-related, muscle laxity of the abdominal wall, or fluid retention, and isn't really fat deposition, so that doesn't count.
Well, I hope this helps your inquisitive minds. Please let me know if there are any other burning questions you have, and I'll do my best to give you the straight scoop. Also, if you think you have endo and want me to review your records to see if Dr. Redwine and I can help, please check our website for instructions on how to submit this information.
Thanks for reading, and have a great week.
Dr. Mos