{"paper_id":"136a031e-b889-4dcd-8789-13e8dda5fbdf","body_text":"Zusammenfassung\nHintergrund\nDie durch Endometriose bedingten Schmerzphänomene sind vielfältig. Neben nozizeptiven Schmerzen kommt es auch zu einer noziplastischen Reaktion mit zentraler Sensitivierung. Daher treten neben den klassischen zyklischen Beschwerden wie schwerer Dysmenorrhö, zyklischen Unterbauchschmerzen, Dyspareunie, Dysurie und Dyschezie auch zunehmend atypische Schmerzen wie azyklische Unterbauchschmerzen, Ausstrahlung der Schmerzen, unspezifische Blasen- und Darmbeschwerden oder Depressionen auf. Im Rahmen der diffusen Beschwerdeproblematik werden oftmals nicht nur Gynäkolog*innen von den betroffenen Patientinnen konsultiert, sondern auch Kolleg*innen anderer Disziplinen (unter anderem Innere Medizin, Gastroenterologie, Orthopädie, Schmerztherapie, Psychologie).\nFragestellung\nDarstellung der schmerzpathophysiologischen Zusammenhänge und Komplexität der Erkrankung sowie sich darauf ergebender Ansätze zu multimodalen interdisziplinären Konzepten der ganzheitlichen Therapie von Endometriose.\nMethode\nNeben hormonellen und operativen Therapien, die meist in gynäkologischer Hand liegen, sollten interdisziplinär eine optimale schmerztherapeutische Begleitung, eine Ernährungsberatung, eine psychologische Begleitung sowie physiotherapeutische Behandlung in das Behandlungskonzept aufgenommen werden. Der vorliegende Beitrag soll einen Überblick über mögliche Behandlungsstrategien bei chronisch-symptomatischer Endometriose geben.\nSchlussfolgerung\nMithilfe einer multimodalen Therapie unter Berücksichtigung der komplexen pathophysiologischen Veränderungen können die komplexen Beschwerden, die die Lebensqualität signifikant einschränken, deutlich verbessert werden.\nAbstract\nBackground\nEndometriosis is associated with various types of intense pain. In addition to nociceptive pain, there is also a nociplastic reaction with central sensitization. Atypical symptoms such as acyclic lower abdominal pain, radiating pain, non-specific bladder and intestinal complaints or even depression are frequent as are classic cyclical complaints such as severe dysmenorrhea, cyclical lower abdominal pain, dyspareunia, dysuria and dyschezia. In cases of a diverse range of symptoms, patients often consult not just gynecologists but specialists from other disciplines (e.g., internal medicine, gastroenterology, orthopedics, pain therapy, psychology).\nAims\nOverview about the pathophysiology and complexity of the disease and the resulting treatment options. A multimodal interdisciplinary concept might be able to take into consideration all aspects of the complex disease.\nMethods\nInterdisciplinary concepts should be involved in the treatment of endometriosis patients along with hormonal and surgical therapy, which are generally under the supervision of a gynecologist. Pain management, dietary changes, psychological support, as well as physiotherapy should be included. The present article is intended to provide an overview of possible treatment strategies for chronic, symptomatic endometriosis.\nConclusion\nThe use of multimodal treatment strategies regarding the complex pathophysiological aspects of this disease might be helpful in significantly improving the quality of life of endometriosis patients.\nSimilar content being viewed by others\nLiteratur\nAredo JV, Heyrana KJ, Karp BI et al (2017) Relating chronic pelvic pain and endometriosis to signs of sensitization and myofascial pain and dysfunction. Semin Reprod Med 35:88–97\nAs-Sanie S, Harris RE, Napadow V et al (2012) Changes in regional gray matter volume in women with chronic pelvic pain: a voxel-based morphometry study. Pain 153:1006–1014\nAta B, Yildiz S, Turkgeldi E et al (2019) The endobiota study: comparison of vaginal, cervical and gut Microbiota between women with stage 3/4 endometriosis and healthy controls. Sci Rep 9:2204\nBallweg ML (2004) Impact of endometriosis on women’s health: comparative historical data show that the earlier the onset, the more severe the disease. Best Pract Res Clin Obstet Gynaecol 18:201–218\nBarcena De Arellano ML, Mechsner S (2014) The peritoneum—an important factor for pathogenesis and pain generation in endometriosis. J Mol Med 92:595–602\nBecker CM, Gattrell WT, Gude K et al (2017) Reevaluating response and failure of medical treatment of endometriosis: a systematic review. Fertil Steril 108:125–136\nBergeron S, Morin M, Lord M‑J (2010) Integrating pelvic floor rehabilitation and cognitive-behavioural therapy for sexual pain: what have we learned and were do we go from here? Sex Relatsh Ther 25:289–298\nBerman BM, Langevin HM, Witt CM et al (2010) Acupuncture for chronic low back pain. N Engl J Med 363:454–461\nBorrelli G, Carvalho K, Kallas E et al (2013) Chemokines in the pathogenesis of endometriosis and infertility. J Reprod Immunol 98:1–9\nBouaziz J, Bar OA, Seidman DS et al (2017) The clinical significance of endocannabinoids in endometriosis pain management. Cannabis Cannabinoid Res 2:72–80\nBrandes I, Neuser M, Kopf A et al (2017) Endometriosis-associated pain in patients with and without hormone therapy. J Endometr Pelvic Pain Disord 9:200–205\nCampo S, Campo V, Benagiano G (2012) Adenomyosis and infertility. Reprod Biomed Online 24:35–46\nChapron C, Marcellin L, Borghese B et al (2019) Rethinking mechanisms, diagnosis and management of endometriosis. Nat Rev Endocrinol 15:666–682\nChapron C, Pietin-Vialle C, Borghese B et al (2009) Associated ovarian endometrioma is a marker for greater severity of deeply infiltrating endometriosis. Fertil Steril 92:453–457\nCousins FL, Gargett CE (2018) Endometrial stem/progenitor cells and their role in the pathogenesis of endometriosis. Best Pract Res Clin Obstet Gynaecol 50:27–38\nDavidson MJ, Bryant A, Frawley H (2014) Perineal muscle stiffness in women with and without vulvodynia: reliability of measurement and differences in muscle stiffness. Neurourol Urodyn 33:Abstract 46\nDe Graaff A, D’hooghe T, Dunselman G et al (2013) The significant effect of endometriosis on physical, mental and social wellbeing: results from an international cross-sectional survey. Hum Reprod 28:2677–2685\nDe Ziegler D, Borghese B, Chapron C (2010) Endometriosis and infertility: pathophysiology and management. Lancet 376:730–738\nFinas D, Hüppe M, Diedrich K et al (2005) Chronischer Unterbauchschmerz am Beispiel der Endometriose – Problempatientin in der Gynäkologie? Geburtshilfe Frauenheilkd 65:156–163\nGreene R, Stratton P, Cleary SD et al (2009) Diagnostic experience among 4,334 women reporting surgically diagnosed endometriosis. Fertil Steril 91:32–39\nHäuser W (2021) Endometriose und chronische überlappende Schmerzsyndrome. Schmerz. https://doi.org/10.1007/s00482-021-00535-8\nHe W, Liu X, Zhang Y et al (2010) Generalized hyperalgesia in women with endometriosis and its resolution following a successful surgery. Reprod Sci 17:1099–1111\nHenzl MR, Buttram V, Segre EJ et al (1977) The treatment of dysmenorrhea with naproxen sodium: a report on two independent double-blind trials. Am J Obstet Gynecol 127:818–823\nHoffman D (2015) Central and peripheral pain generators in women with chronic pelvic pain: patient centered assessment and treatment. Curr Rheumatol Rev 11:146–166\nHudelist G et al (2012) Diagnostic delay for endometriosis in Austria and Germany: causes and possible consequences. Hum Reprod 27(12):3412–3416. https://doi.org/10.1093/humrep/des316\nIbrahim MG, Sillem M, Plendl J et al (2017) Myofibroblasts are evidence of chronic tissue microtrauma at the endometrial–myometrial junctional zone in uteri with adenomyosis. Reprod Sci 24:1410–1418\nJohnson NP, Hummelshoj L, Adamson GD et al (2017) World Endometriosis Society consensus on the classification of endometriosis. Hum Reprod 32:315–324\nKöhler G, Faustmann TA, Gerlinger C et al (2010) A dose-ranging study to determine the efficacy and safety of 1, 2, and 4 mg of dienogest daily for endometriosis. Int J Gynecol Obstet 108:21–25\nLasco A, Catalano A, Benvenga S (2012) Improvement of primary dysmenorrhea caused by a single oral dose of vitamin D: results of a randomized, double-blind, placebo-controlled study. Arch Intern Med 172:366–367\nLeitlinie der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) (2020) „Diagnostik und Therapie der Endometriose“, https://eref.thieme.de/cockpits/0/0/coAWMF015-045/0. Zugegriffen: 10.03.2021\nLeyendecker G, Wildt L (2019) Evolutionäre Aspekte in der Pathogenese und Pathophysiologie von Adenomyose und Endometriose. J Gynäkol Endokrinol AT 29:110–121\nLund I, Lundeberg T (2016) Is acupuncture effective in the treatment of pain in endometriosis? J Pain Res 9:157–165\nMariani M, Viganò P, Gentilini D et al (2012) The selective vitamin D receptor agonist, elocalcitol, reduces endometriosis development in a mouse model by inhibiting peritoneal inflammation. Hum Reprod 27:2010–2019\nMechsner S (2016) Endometriose. Schmerz 30:477–490\nMira TA, Buen MM, Borges MG et al (2018) Systematic review and meta-analysis of complementary treatments for women with symptomatic endometriosis. Int J Gynecol Obstet 143:2–9\nMira TA, Giraldo PC, Yela DA et al (2015) Effectiveness of complementary pain treatment for women with deep endometriosis through Transcutaneous Electrical Nerve Stimulation (TENS): randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 194:1–6\nMiyashita M, Koga K, Izumi G et al (2016) Effects of 1,25-Dihydroxy vitamin D3 on endometriosis. J Clin Endocrinol Metab 101:2371–2379\nNg N, Wahl K, Orr NL et al (2020) Endometriosis and negative perception of the medical profession. J Obstet Gynaecol Can 42:248–255\nNodler JL, Divasta AD, Vitonis AF et al (2020) Supplementation with vitamin D or ω‑3 fatty acids in adolescent girls and young women with endometriosis (SAGE): a double-blind, randomized, placebo-controlled trial. Am J Clin Nutr 112:229–236\nRubin R (2019) Botulinum toxin to treat endometriosis pain. JAMA 322:716–716\nSeo J‑W, Lee D‑Y, Yoon B‑K et al (2017) Effects of long-term postoperative dienogest use for treatment of endometriosis on bone mineral density. Eur J Obstet Gynecol Reprod Biol 212:9–12\nShakiba K, Bena JF, Mcgill KM et al (2008) Surgical treatment of endometriosis: a 7‑year follow-up on the requirement for further surgery. Obstet Gynecol 111:1285–1292\nSillem M, Juhasz-Böss I, Klausmeier I et al (2016) Osteopathy for endometriosis and chronic pelvic pain—a pilot study. Geburtshilfe Frauenheilkd 76:960\nStein C, Clark JD, Oh U et al (2009) Peripheral mechanisms of pain and analgesia. Brain Res Rev 60:90–113\nStratton P, Khachikyan I, Sinaii N et al (2015) Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain. Obstet Gynecol 125:719–728\nStrowitzki T, Marr J, Gerlinger C et al (2010) Dienogest is as effective as leuprolide acetate in treating the painful symptoms of endometriosis: a 24-week, randomized, multicentre, open-label trial. Hum Reprod 25:633–641\nVercellini P, Somigliana E, Vigano P et al (2009) Surgery for endometriosis-associated infertility: a pragmatic approach. Hum Reprod 24:254–269\nWeinschenk S (2015) Neuraltherapie in der Gynäkologie. Gynäkologe 48:20–27\nWienhard J, Tinneberg H (2003) Alternative treatment possibilities of complaints due to endometriosis. Zentralbl Gynakol 125:286–289\nYaraghi M, Ghazizadeh S, Mohammadi F et al (2019) Comparing the effectiveness of functional electrical stimulation via sexual cognitive/behavioral therapy of pelvic floor muscles versus local injection of botulinum toxin on the sexual functioning of patients with primary vaginismus: a randomized clinical trial. Int Urogynecol J Pelvic Floor Dysfunct 30:1821–1828\nAuthor information\nAuthors and Affiliations\nCorresponding author\nEthics declarations\nInteressenkonflikt\nS. Mechsner gibt an, dass kein Interessenkonflikt besteht.\nFür diesen Beitrag wurden von der Autorin keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.\nRights and permissions\nAbout this article\nCite this article\nMechsner, S. Endometrioseschmerz beherrschen. Schmerz 35, 159–171 (2021). https://doi.org/10.1007/s00482-021-00543-8\nReceived:\nRevised:\nAccepted:\nPublished:\nVersion of record:\nIssue date:\nDOI: https://doi.org/10.1007/s00482-021-00543-8","source_license":"CC0","license_restricted":false}