Chronic pelvic pain associated with autoimmunity and systemic and peritoneal inflammation and treatment with immune modification.

OBJECTIVE: To determine the prevalence of chronic inflammation of the pelvic peritoneum, systemic inflammation and autoimmunity in chronic pelvic pain and to explore the significance of these findings and assess the response to treatment with immune modification. STUDY DESIGN: Prospective, observational clinical studies from 2 centers were performed on 3,238 women presenting with pelvic pain to determine the prevalence of chronic inflammation by biopsy when endometriosis was absent. A second study included 40 women with chronic pelvic pain not resulting from endometriosis; immunologic investigations were carried out and therapy instituted. RESULTS: Chronic inflammation of the peritoneum, while not evident in the absence of pelvic pain, was present in 15.7% of women with chronic pelvic pain. In the second group, 10% had histologic evidence of chronic inflammation, 55% demonstrated evidence of systemic inflammation, and 37.5% were found to have autoimmune disorders. Chronic inflammation of the vagina was found in 42.5% and polycystic ovary syndrome in 22% of those with systemic inflammation. Twelve of the 40 were subsequently treated, with considerable success, with immune-modifying drugs, hydroxychloroquine and methotrexate. CONCLUSION: Chronic pelvic pain is frequently associated with systemic inflammation, including autoimmune diseases. Peritoneal chronic inflammation is sometimes also associated. It is often successfully treated with immune-modifying drugs.

Chronic inflammation of the peritoneum and vagina: review of its significance, immunologic pathogenesis, investigation and rationale for treatment.

Chronic inflammation is not an infrequent histologic finding in symptomatic gynecologic patients. It is present in 14.6% of peritoneal biopsies in women with chronic pelvic pain in whom no other cause of pain is evident. It is found in almost all vaginal biopsies in noninfected women with dyspareunia and discharge of vaginal mucosal origin. It represents a local immunologically activated inflammatory disorder. When investigations are car ried out as to whether it is a local representation of a systemic disorder, numerous systemic inflammatory and autoimmune disorders are discovered. A study of chronic pain reveals that the immune system is intimately involved in the production, conduction and exacerbation of pain and of its clinicalfeatures, such as hyperalgesia and allodynia. Immune modification using local steroids and disease-modifying antirheumatic drugs, such as hydroxychloroquine, are known to inhibit inflammatory cells and cytokines, such as interleukin-1, interleukin-6 and tumor necrosis factor, which are responsible for pain and tissue damage. These drugs are found to be effective in the treatment of chronic pelvic pain when of an inflammatory nature and for symptomatic chronic inflammation of the vagina.

Chronic inflammation of the vagina: treatment and relationship to autoimmunity.

OBJECTIVE: To investigate noninfective, symptomatic, chronic inflammation (CI) of the vaginal mucosa to determine its prevalence and immunologic basis and to initiate an immunologic approach to treatment and assess the response. STUDY DESIGN: A prospective, observational, clinical study of 55 women with dyspareunia and/or discharge of vaginal mucosal origin. Vaginal biopsies and immune investigations were carried out. Treatment was instituted utilizing immune-modifying agents. RESULTS: The prevalence of CI of the vagina in symptom-free women was 0-4.3% and in the symptomatic group, 89%. Systemic immune activation was demonstrated in 43 of the 55, with 21 suffering from an autoimmune disease or a condition in which immune activation plays a part, including endometriosis in 20. Thirty-one were treated; intravaginal hydrocortisone acetate 10% foam was given in 24, giving full relief in 14 and inadequate relief in 10. Hydroxychloroquine, an immune-modifying, antirheumatic drug, was added and largely gave relief in these 10. Hydroxychloroquine alone was given in 4 and was effective in 3. Overall, immune-modifying drugs were successful in 97%. CONCLUSION: CI of the vaginal mucosa stems from local immune activation and is generally associated with evidence of other immune abnormalities, including autoimmune diseases and disorders in which immune activation play a part, including endometriosis. It can be successfully treated by immune modification.

Pelvic pain caused by intraperitoneal Enterobius vermicularis (threadworm) ova with an associated systemic autoimmune reaction.

AIM: The aim of this paper, based on a case study was two-fold; firstly to review the sites and gynecologic complications of ectopic Enterobius vermicularis and secondly study the autoimmune accompaniments of parasitic infestations. METHODS: A case of intraperitoneal ectopic Enterobius vermicularis, with accompanying autoimmune signs and symptoms, is presented and its response to surgical and medical treatment described. A medical literature search was carried out into the subject of ectopic Enterobius vermicularis, particularly from the gynecologic perspective along with a study of autoimmune activation associated with parasitic infestation. RESULTS: Pelvic pain was found to be caused by chronic inflammation from ectopic Enterobius vermicularis. This was treated both surgically and medically, with the surgical treatment proving to be inadequate but with a good response to immune modification. In the literature ectopic Enterobius vermicularis was found to be treatable surgically. CONCLUSION: Ectopic Enterobius vermicularis was found to create symptomatic inflammatory lesions that could be treated surgically and an associated autoimmune response treatable by immune modification.