7Ī recent study looking at complete peritoneal excision resulted in a high level of pain relief for patients with and without endometriosis. 6 Another systematic review showed significantly greater improvement in dysmenorrhea, dyschezia, and chronic pelvic pain with excision compared with ablation procedures. A Cochrane systematic review showed an unclear benefit with excision vs ablation, although studies were extremely heterogeneous. Excision vs ablationīoth excision and ablation of endometriosis as a means of surgical treatment remain debated. The vast options for the medical suppression of endometriosis and the treatment of chronic pelvic pain are outside the scope of this manuscript but are nonetheless exceedingly important in the comprehensive management of the patient. Further, a discussion should take place that the finding of no endometriosis on laparoscopy and biopsy can help the physician and patient focus on identifying and treating other pain generators. Structural abnormalities such as adenomyosis, ovarian endometriomas, and deeply infiltrating endometriosis nodules indicate advanced disease and should expedite surgical referrals.Ī comprehensive discussion regarding the limitations of surgery and continuing medical therapy and multidisciplinary treatments for pain after surgery should be had with the patient as part of preoperative counseling. For persistent pain despite a short course of medical therapy (3-6 months), surgical therapy and reevaluation of other causes of pelvic pain is indicated.Ĭareful patient assessment, physical examination findings, and imaging can help guide surgical management. However, the study authors recommend having a low threshold for surgical evaluation. Studies have shown that combined hormonal contraceptives, progestins, and gonadotropin-releasing hormone agonists are very effective at reducing pain related to endometriosis. Given that medical therapies are generally well tolerated, most national organizations recommend a trial of medical therapy to give patients a shorter time to pain relief. 4 Laparoscopy for endometriosis began in the 1970s and remains the gold standard for diagnosis and treatment of endometriosis. Although advances in imaging (eg, MRI and gel-contrast dynamic ultrasound) and the development of predictive algorithms might help with a clinical diagnosis of endometriosis, no current technology can predict all stages of the disease. However, when endometriosis is suspected, further action should be taken. Many of these can be identified using a careful history and physical to identify a “source” organ and through imaging.īecause of the range of etiologies for pelvic pain, a broader work-up should always be performed to rule out other causes. Infectious diseases as well as immunological diseases, in which the contribution to pain is more poorly understood, must also be considered. One must remember that chronic pelvic pain can be multifactorial, so a comprehensive evaluation for all causes of the disease must be undertaken, not only gynecologic causes, but also other organ systems, including musculoskeletal, gastrointestinal, genitourinary, and psychological. The average delay in diagnosis is approximately 7 years, preventing early treatment that can reduce chronic pain and stress on mental and emotional health. 1 Delays in surgical diagnosis are thought to contribute to this high cost because patients without answers seek further care and expensive testing.Įndometriosis can have serious effects on patients’ quality of life and fertility, leading to lost wages and lack of productivity. In 2008, US health care costs for endometriosis were estimated at $4000 annually per affected patient. 2 DiagnosisĪlthough expert opinion suggests that early diagnosis of endometriosis is key, diagnostic challenges in combination with the requirement for a surgical procedure for diagnosis contribute to a significant delay in treatment. 1 Patients with pelvic pain exhibit enhanced anterior insula glutamatergic neurotransmission and connectivity with the prefrontal cortex, meaning that even with full excision of disease, pain may persist. The disease affects 10% of reproductive-age women and 90% of patients with chronic pelvic pain and infertility.1 The mechanism of implantation and associated pain development is still incompletely described.1 Stage and pain do not correlate well because pelvic pain can be inflammatory and neuropathic in nature, with a component of central sensitization of the nervous system. Endometriosis is a poorly understood condition in which endometrial-like–tissue implants outside the uterus.
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