Endo & Pain Management
Endometriosis is a common instigator of chronic pelvic pain in women, causing significant negative impacts on quality of life. It is difficult to diagnose and treat benign gynecological affliction that is involved in more than 25% of infertility cases and in more than 75% of pelvic pain cases. Dysmenorrhea and dyspareunia are often associated with endometriosis. While surgical and drug treatment is the standard therapy, a high relapse of symptoms is observed. The etiology of endometriosis is not fully understood, but theories include transplantation, epithelium metaplasia, and induction. This paper reviews the existing literature on treatment of pelvic pain caused by endometriosis.
The mechanisms behind endometriosis-induced pain have mainly focused on endometrial lesions and adhesions. However, 30% of patients still present pain after surgery, suggesting additional mechanisms. Inflammation from cyclical bleeding and the created inflammatory environment alters activation of nociceptive pathways, contributing to pain generation. As the mechanisms behind chronic pain associated with endometriosis are complex, so is the management approach. The therapeutic plan should be individualized for each patient based on considerations including age, desire to preserve fertility, lesion's anatomical location, lesion extension, symptoms, risks, and adverse reactions of treatment methods.
Treatment ranges from a medical approach based on hormonal medications to laparoscopy for removing endometriotic implants. Treatment methods include NSAIDs, hormonal contraceptives, GnRH analogues, and aromatase inhibitors. Both treatment methods, medical or surgical, are effective in reducing pelvic pain but have different risk profiles. In most cases, better results are achieved using both surgical and drug treatment. The American Society of Reproductive Medicine Practice Committee states that "endometriosis should be viewed as a chronic condition requiring a long-term therapeutic management plan, with the predominant use of drug treatment, avoiding repeated surgery as much as possible". Before starting treatment, patients should have a thorough anamnestic, clinical, and paraclinical documentation of the disease, excluding other causes of pelvic pain.
For patients with mild or moderate painful symptoms, and without ultrasound evidence of endometrioma, non-steroidal anti-inflammatory drugs (NSAIDs) or hormonal therapy with combined oral contraceptives (COCs) are recommended as a first-line treatment. Women who wish to become pregnant can safely use non-steroidal anti-inflammatory drugs but should avoid COX-2 inhibitors (coxibs) as these can interfere with ovulation. There is no evidence of greater efficacy of non-steroidal anti-inflammatories over oral contraceptives or vice versa. The choice of the therapeutic plan is based both on the efficacy of the method and on the patient's tolerance and goals. Overall, the goal is to manage the chronic condition and relieve pain in a manner that improves the patient's quality of life.
Balalau, D. O.; Ciupitu, I. A.; Bogheanu, D.-M.; Ghiocel-Zariosu, A.-I.; Balalau, C.; Ples, L.; Bălan, D. G.; Paunica, I.; Sima, M.-R. Management of Pelvic Pain Caused by Endometriosis. J. Mind Med. Sci. 2023, 10 (1), Article 9. https://doi.org/10.22543/2392-7674.1390.
