{"paper_id":"0dacc495-8afa-4c4c-b486-7a1010c0ea88","body_text":"Editorial\nImportance of an Interdisciplinary Approach in the Treatment\nof Women with Endometriosis and Chronic Pelvic Pain\nImportância de uma abordagem interdisciplinar no tratamento de mulheres\ncom endometriose e dor pélvica crônica\nJúlia Kefalás Troncon 1 Gabrielle Barbosa Anelli 1 Omero Benedicto Poli-Neto 1\nJulio Cesar Rosa e Silva 1\n1 Departamento de Ginecologia e Obstetrícia da Faculdade de\nMedicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão\nPreto, SP, Brazil\nRev Bras Ginecol Obstet 2023;45(11):e635 –e637.\nEndometriosis, from a pathophysiological standpoint, can be\ndefined as active endometrium-like tissue outside the uter-\nus. However, to better understand and approach this com-\nplex disease, it should be addressed as a chronic\ninflammatory disease that can cause pelvic pain during a\nlong period of a women ’s reproductive lifetime. 1 Due to\nnociplasty, women affected by endometriosis can also main-\ntain pain despite adequate organic treatment, especially\nconsidering that this disease has no objective cure.\n1,2 On\nthe other hand, chronic pelvic pain(CPP) can be de fined as\npain perceived in the lower abdomen, lasting for at least six\nmonths, that has a negative impact on quality of life and that\ndemands treatment.\n2 CPP may have a gynecologic etiology\nsuch as endometriosis, but most frequently has a multifac -\ntorial nature, involving gastrointestinal, urinary, psycholog-\nical, and musculoskeletal systems.\nFurthermore, women suffering from endometriosis fre-\nquently manifest other overlapping pain conditions such as\nirritable bowel syndrome, painful bladder syndrome, fibro-\nmyalgia, migraine headaches, among others.\n3 This may be\ndue to a lower pain threshold, cross-organ sensitization, 3\nenhanced visceral pain or a common pathophysiological\norigin yet to be elucidated. Therefore, when managing pain\nin women suffering from endometriosis and/or CPP, an\nisolated gynecological approach will usually be insuf ficient.\nFor optimum care, the treatment must be patient cen-\ntered, rather than disease centered. 4 So nowadays, more\nattention has been given in studies on the bene ficial impact\nof an interdisciplinary approach toward CPP and endometri-\nosis. Preferably, a true interdisciplinary team discusses to-\ngether the best treatment for each individual patient, instead\nof a mere multidisciplinary setting where different health\ncare professionals focus only in their own speci fic interven-\ntion. Quality of life assessment and improvement should be\none of the main goals since a cure is most often unattainable.\nAn interdisciplinary team ideally would be composed by\nmedical staff with speci fic training in this area of expertise,\nand by a nurse, psychologist, physical therapist, occupational\ntherapist, nutritionist, and physical educator. The medical\nteam should be composed of not only gynecologists, but also\nurologists, gastroenterologists, psychiatrists, and pain man-\nagement specialist.\nPatients with endometriosis and CPP commonly have\nassociated mood disorders, with high levels of anxiety and\ndepression. Up to 73% of anxiety and 40% of depression was\nthe prevalence found in a cross sectional controlled study.\n5\nNotably, these women manifest a pain catastrophizing pro-\nfile\n3,6 that worsens the experiencing of the pain. So, a\npsychological approach is of upmost importance, as well as\na program in pain education,3 which will help the patient feel\nmore responsible for her own improvement. Coping strate-\ngies and constructive attitudes can positively modulate the\nwell-being of these women. A qualitative study showed that\ndaily life attitudes can in fluence the experience of pain; the\ncategories identi fied were: shaping life by pain, isolating\nfrom social contact, avoiding sexual relationship, seeking\npain relief, and seeking positive strategies.\n7\nEndometriosis can also lead to dyspareunia, which is pain\nduring sexual intercourse. This symptom can aggravate the\nnegative impact of the disease in personal and loving rela-\ntionships; up to 30% of women reported they frequently had\nto interrupt sexual intercourse because of pain, and 66% are\nAddress for correspondence\nJulio Cesar Rosa e Silva, Av.\nBandeirantes, 3900, 14040-900,\nRibeirão Preto, SP, Brazil\n(e-mail: juliocrs@usp.br).\nDOI https://doi.org/\n10.1055/s-0043-1777001.\nISSN 0100-7203.\n© 2023. Federação Brasileira de Ginecologia e Obstetrícia. All rights\nreserved.\nThis is an open access article published by Thieme under the terms of the\nCreative Commons Attribution License, permitting unrestricted use,\ndistribution, and reproduction so long as the original work is properly cited.\n(https://creativecommons.org/licenses/by/4.0/)\nThieme Revinter Publicações Ltda., Rua do Matoso 170, Rio de\nJaneiro, RJ, CEP 20270-135, Brazil\nTHIEME\nEditorial 635\nArticle published online: 2023-11-29\n\nafraid of pain before intercourse which can lead to avoidance\nof contact. 8 The prevalence of sexual distress was of 78% in\none study, 8 and its origin multifactorial, associated with\nincreased tone of the pelvic floor muscles,9 due to a possible\nhistory of sexual, physical or moral abuse 10 or due to\nendometriosis itself.\nIn addition to a medical and psychological approach\ntoward the sexual dysfunction and distress, the evaluation\nby a physical therapist is mandatory. Besides form dyspar-\neunia, a physical therapist will also improve symptoms of\nmyofascial syndrome which are common in women suffering\nfrom endometriosis and other causes of CPP, what might\nimprove dyspareunia. Approximately 85% of women with\nCPP have musculoskeletal associated disorders; myofascial\npain syndrome can be managed, among other strategies, by\ntrigger point anesthetic injections, therapeutic ultrasound\n11\nand also by acupuncture. 12 Despite the lack of robust evi-\ndence, some studies show bene ficial effects of acupuncture\nin the treatment of these conditions. 12 Physical exercise is\nanother domain that should be addressed and encouraged.\nEven though without high-quality level of evidence, the\npractice of physical activity has almost no adverse effect, if\nthere is no medical contraindication. Supposedly, the mech-\nanism involved should be reduction of oxidative stress;\nregular practice of aerobic and other forms of physical\nactivity apparently have a positive impact in diseases with\nan in flammatory background such as endometriosis.\n13 In\nCPP in general, both aerobic and anaerobic activities seem to\nhave an analgesic effect, conditioning hypoalgesia by pain\nmodulation and effects on baroreceptors.\n14 However, wom-\nen with endometriosis apparently have altered mechanisms\nof central nociceptors, and also greater tendency to avoid the\npractice of physical activity.\n14\nRegarding the dietetic effects on endometriosis, a wide\nvariety of data are available, even though with low grade of\nevidence. Nutritional aspects in fluence hormonal and in-\nflammatory balance and as so have been implicated in the\nphysiopathology of endometriosis. 15 There appears to be a\nprotective impact on the consumption of dairy products and\ncalcium and tryptofan, 16 probably through the induction of\nanti-oxidative mechanisms and improving general well-be-\ning.15,16 Red meat and saturated fatty acids, on the other\nhand, appear to have a negative effect on the disease. 17\nConsequently, dietary interventions seem to have a posi-\ntive implication on the management of CPP and endometri-\nosis. Especially when considering other associated diseases\nsuch as irritable bowel syndrome and painful bladder, for\nexample, that could also bene fit from dietary modi fications.\nNirgianakis et al.\n18 suggest a symptom based approach in\nwhich patients with gastrointestinal related symptoms could\nmostly bene fit from low-FODMAP (fermentable oligosac -\ncharides, disaccharides, monosaccharides and polyols)\nand/or gluten-free diet, and a Mediterranean diet could be\nencouraged in general to improve global health.\n18 Most\nimportantly, nutritional changes could help patients to per-\nceive how lifestyle habits can in fluence on their perceived\npain, and how engaging in their own treatment is of great\nrelevance toward improvement.\n19\nFinally, occupational therapists could help patients devel-\nop adaptative strategies when managing the burden that CPP\nhas on almost all domains of social and professional aspects\nof their life.\n20 Not only occupational activities, but also self-\ncare, self-esteem and leisure are affected. Patients should\nbenefit from the help of an occupational therapist in reha-\nbilitation, and developing tools toward coping.\n20\nEndometriosis is a chronic disease that affects women in\nproductive age and has signi ficant economic impact. 21 CPP\noften accompanies endometriosis but also has other frequent\netiologies, for this, questionnaires that assess quality of life\nand the involvement of other organs should be incorporated\ninto the initial and ongoing evaluation of these patients as\ncurrent practice.\nTherefore, we recommend that an interdisciplinary ap-\nproach would be of bene fit in providing an optimum patient\ncentered care.\nConflicts to Interest\nNone to declare.\nReferences\n1 Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J\nMed. 2020;382(13):1244 –1256. Doi: 10.1056/NEJMra1810764\n2 Siqueira-Campos VM, de Deus MSC, Poli-Neto OB, Rosa-E-Silva JC,\nde Deus JM, Conde DM. Current challenges in the management of\nchronic pelvic pain in women: from bench to bedside. Int J\nWomens Health. 2022;14:225 –244. Doi: 10.2147/IJWH.S224891\n3 Allaire C, Long AJ, Bedaiwy MA, Yong PJ. Interdisciplinary teams\nin endometriosis care. Semin Reprod Med. 2020;38(2-03):\n227–234\n4 Chapron C, Marcellin L, Borghese B, Santulli P. Rethinking mech-\nanisms, diagnosis and management of endometriosis. Nat Rev\nEndocrinol. 2019;15(11):666 –682. Doi: 10.1038/s41574-019-\n0245-z\n5 Romão AP, Gorayeb R, Romão GS, et al. High levels of anxiety and\ndepression have a negative effect on quality of life of women with\nchronic pelvic pain. Int J Clin Pract. 2009;63(05):707 –711. Doi:\n10.1111/j.1742-1241.2009.02034.x\n6 Allaire C, Williams C, Bodmer-Roy S, et al. Chronic pelvic pain in an\ninterdisciplinary setting: 1-year prospective cohort. Am J Obstet\nGynecol. 2018;218(01):114.e1 –114.e12\n7 Mellado BH, Pilger TL, Poli Neto OB, et al. Daily life attitudes of\nwomen with moderate or severe chronic pelvic pain. A qualitative\nstudy. Eur J Obstet Gynecol Reprod Biol. 2020;254:109 –113\n8 Fritzer N, Haas D, Oppelt P, et al. More than just bad sex: sexual\ndysfunction and distress in patients with endometriosis. Eur J\nObstet Gynecol Reprod Biol. 2013;169(02):392 –396\n9 Silva AP, Montenegro ML, Gurian MB, et al. Perineal massage\nimproves the dyspareunia caused by tenderness of the pelvic floor\nmuscles. Rev Bras Ginecol Obstet. 2017;39(01):26 –30. Doi:\n10.1055/s-0036-1597651\n10 Poli-Neto OB, Tawasha KAS, Romão APMS, et al. History of\nchildhood maltreatment and symptoms of anxiety and depres-\nsion in women with chronic pelvic pain. J Psychosom Obstet\nGynaecol. 2018;39(02):83 –89. Doi: 10.1080/0167482X.2017.\n1306515\n11 Baltazar MCDV, Russo JAO, De Lucca V, et al. Therapeutic ultra-\nsound versus injection of local anesthetic in the treatment of\nwomen with chronic pelvic pain secondary to abdominal myo-\nfascial syndrome: a randomized clinical trial. BMC Womens\nHealth. 2022;22(01):325. Doi: 10.1186/s12905-022-01910-y\n12 Mitidieri AMS, Baltazar MCDV, da Silva APM, et al. Ashi acupunc -\nture versus local anesthetic trigger point injections in the\nRev Bras Ginecol Obstet Vol. 45 No. 11/2023 © 2023. Federação Brasileira de Ginecologia e Obstetrícia. All rights reserved.\nEditorial636\n\n\ntreatment of abdominal myofascial pain syndrome: a randomized\nclinical trial. Pain Physician. 2020;23(05):507 –518\n13 Bonocher CM, Montenegro ML, Rosa E Silva JC, Ferriani RA, Meola\nJ. Endometriosis and physical exercises: a systematic review.\nReprod Biol Endocrinol. 2014;12:4. Doi: 10.1186/1477-7827-\n12-4\n14 Poli-Neto OB, Oliveira AMZ, Salata MC, et al. Strength exercise has\ndifferent effects on pressure pain thresholds in women with\nendometriosis-related symptoms and healthy controls: a quasi-\nexperimental study. Pain Med. 2020;21(10):2280 –2287. Doi:\n10.1093/pm/pnz310\n15 Nodler JL, Harris HR, Chavarro JE, Frazier AL, Missmer SA. Dairy\nconsumption during adolescence and endometriosis risk. Am J\nObstet Gynecol. 2020;222(03):257.e1 –257.e16. Doi: 10.1016/j.\najog.2019.09.010\n16 da Silva JB, Gurian MB, Nonino CB, et al. Assessment of food\nconsumption in women with chronic pelvic pain secondary to\nendometriosis. Int J Reprod Med Gynecol. 2020;6(01):1 –8\n17 Arab A, Karimi E, Vingrys K, Kelishadi MR, Mehrabani S, Askari G.\nFood groups and nutrients consumption and risk of endometriosis:\na systematic review and meta-analysis of observational studies.\nNutr J. 2022;21(01):58. Doi: 10.1186/s12937-022-00812-x\n18 Nirgianakis K, Egger K, Kalaitzopoulos DR, Lanz S, Bally L, Mueller\nMD. Effectiveness of dietary interventions in the treatment of\nendometriosis: a systematic review. Reprod Sci. 2022;29(01):\n26–42. Doi: 10.1007/s43032-020-00418-w\n19 Vennberg Karlsson J, Patel H, Premberg A. Experiences of health\nafter dietary changes in endometriosis: a qualitative interview\nstudy. BMJ Open. 2020;10(02):e032321. Doi: 10.1136/bmjopen-\n2019-032321\n20 Poli-Neto OB, Bortolieiro RV, Rosa-e-Silva JC, Candido-dos-Reis FJ,\nNogueira AA. Occupational performance of women with chronic\npelvic pain and the potential of coping as an unassisted interven-\ntion. Int J Clin Med. 2018;9(09):737 –749\n21 Spigolon DN, Amaral VF, Barra CM. Endometriose: impacto eco-\nnômico e suas perspectivas. Femina. 2012;40(03):129 –134\nRev Bras Ginecol Obstet Vol. 45 No. 11/2023 © 2023. Federação Bras ileira de Ginecologia e Obstetrícia. All rights reserved.\nEditorial 637","source_license":"CC0","license_restricted":false}