{"paper_id":"cd3acef4-8322-43d7-a1a2-57af4d573f9d","body_text":"Archives of Women Health and Care\nVolume 7 Issue 4Research Open\nARCH Women Health Care, Volume 7(4): 1–2, 2024 \nShort Commentary\nBeyond the Lesions: Unraveling the Multifactorial \nNature of Endometriosis and Chronic Overlapping Pain\nEmily J. Bartley, PhD*1, Meryl J. Alappattu, PhD, DPT2 and Georgine Lamvu, MD, MPH3,4\n1University of Florida, College of Dentistry, Pain Research & Intervention Center of Excellence\n2University of Florida, College of Public Health and Health Professions, Pain Research & Intervention Center of Excellence\n3University of Central Florida, College of Medicine\n4Orlando VA Healthcare System, Division of Surgery, Gynecology Section\n*Corresponding author: Emily J. Bartley, Ph.D. Assistant Professor, Pain Research & Intervention Center of Excellence, Department of Community Dentistry & Behavioral \nScience, University of Florida,1329 SW 16th St, Suite 5192, Gainesville, FL 32610, Office: 352-273-8934\nReceived: August 17, 2024; Accepted: August 20, 2024; Published: August 27, 2024\nCommentary\nEndometriosis has a long and complex history in the field of \nmedicine, with its etiology and treatment being sources of debate \nfor many years. This estrogen-dependent neuro inflammatory \ndisease is marked by the presence of endometrial-like tissue outside \nthe uterus, affecting approximately 10% of women of reproductive \nage. The disease’s symptoms are varied, with pain being a defining \ncharacteristic, including dysmenorrhea, painful intercourse, chronic \npelvic pain, and bowel and bladder pain. These symptoms can be \nprofoundly debilitating, adversely impacting quality of life and \npsychological health [1].\nCompounding these challenges is the staggering reality that \ndiagnosis can take 10 years or more, prolonging the suffering of those \naffected and underscoring the urgent need for greater awareness \nand more efficient diagnostic methods for the disease. Adding to its \nexisting burden, endometriosis remains incurable, with treatments \nbased on the suspected etiology of the pelvic pain and primarily \nfocused on symptom relief. While such treatments can benefit those \nwhose pain is driven by peripheral mechanisms, therapies that \nprimarily target the periphery are often only effective for individuals \nexperiencing anatomically localized pain. In fact, nearly 50% of \nmedical and surgical treatments are unsuccessful, leaving patients \nwith ongoing pain even after the suppression or surgical removal of \nendometriosis lesions. Moreover, there is little correlation between the \nextent of the disease and the severity of pain experienced, suggesting \nthat factors beyond the lesions themselves may play a significant role \nin the pain associated with endometriosis. Over the past two decades, \na growing body of evidence has supported this notion, indicating \nthat endometriosis is not merely a disease defined by the presence of \nendometrial lesions but one that is also mediated by central nervous \nsystem factors, including altered sensory processing as well as \nstructural and functional changes in the brain [2-7].\nIn recent years, endometriosis has increasingly been recognized \nas a heterogeneous condition that often coexists with other organic \npain disorders. Collectively referred to as chronic overlapping pain \nconditions (COPCs), these disorders frequently occur together \nand include endometriosis, vulvodynia, irritable bowel syndrome, \ntemporomandibular disorder, chronic fatigue syndrome, interstitial \ncystitis/painful bladder syndrome, fibromyalgia, tension-type and \nmigraine headaches, and chronic low back pain. COPCs predominantly \naffect females and exhibit a high degree of co-prevalence. Although \nthe underlying causes of these conditions remain poorly understood, \nthey are generally believed to share common pathophysiological \nmechanisms, with alterations in central nervous system processing \nlikely contributing to the pain experienced. Substantial evidence \nsuggests that a higher prevalence of these conditions is associated with \nmore frequent and prolonged pelvic pain episodes, increased pain \nseverity, impairments in daily activities, reduced treatment efficacy, \nand declines in psychological functioning and quality of life [8-10].\nIt is estimated that over 95% of patients with endometriosis report \nhaving at least one overlapping pain condition. Unfortunately, these \ncomorbidities are often resistant to singular treatments and may even \nexacerbate pelvic pain severity and reduce therapeutic effectiveness. \nDespite this understanding, endometriosis has traditionally been \nclassified and treated as a peripheral disease, focusing on the removal \nor suppression of endometrial lesions—an approach that has yielded \nsuboptimal outcomes [11].\nWhy do these treatments often fall short? Given the heterogeneity \nof endometriosis and its common overlap with other pain conditions, \none possibility is that our treatment efforts are not appropriately \ntargeted, failing to address centrally mediated factors that impact \nendometriosis pain, including the multimorbidity of the disease. \nRecognizing this gap, our team recently conducted a study \nexamining the prevalence of COPCs in a sample of 525 women with \nchronic pelvic-abdominal pain (CPP), 25% of whom also reported \nendometriosis. Not surprisingly, compared to women with just CPP , \nthose with endometriosis reported more adverse pain outcomes \nincluding greater pelvic pain severity and interference, as well as a \nhigher degree of burden associated with their pelvic pain. They also \nreported a higher prevalence of COPCs, including fibromyalgia, \nchronic fatigue syndrome, and temporomandibular disorder. Even \n\nARCH Women Health Care, Volume 7(4): 2–2, 2024 \nEmily J. Bartley (2024) Beyond the Lesions: Unraveling the Multifactorial Nature of Endometriosis and Chronic Overlapping Pain\nmore striking, approximately 25% of women with endometriosis \nreported three or more COPCs, compared to only 12% of women \nwith just CPP . Interestingly, a higher prevalence of COPCs was linked \nto more adverse pain outcomes, regardless of an endometriosis \ndiagnosis. These findings align with previous data showing that as the \nnumber of pain diagnoses increases, symptoms become significantly \nmore severe. More importantly, our results underscore the substantial \nburden that multimorbidity places on patient functioning [12,13].\nGiven the impact of co-occurring pain, screening and treatment \nof COPCs in endometriosis could be crucial steps toward improving \nclinical care. However, achieving effective treatments for these \ncomorbidities is often complex, as providers frequently encounter \nchallenges stemming from limited resources and inadequate education \nabout endometriosis and chronic pelvic pain, making it difficult to \nsystematically assess and manage multiple pain conditions. Additionally, \npatients with endometriosis often endure long, fragmented care across \nmultiple medical specialties, with many providers lacking extensive \ntraining in pain management and focusing on treatment from their \nown medical lens. Unfortunately, this approach often overlooks the \nmultidimensional nature of the disease, potentially neglecting the \ncentral mechanisms driving endometriosis pain [14].\nPatients with comorbidities often face an array of challenges that \ncan significantly hinder treatment. To make meaningful strides in \ndisease management, it is crucial that we prioritize endometriosis care \nand expand the focus of treatment beyond the lesions. The presence \nof COPCs should be a key consideration in patient management, as \nthose with multiple pain comorbidities likely require a broader and \nmore comprehensive spectrum of therapeutic targets to effectively \nmanage their symptoms. Alongside pharmacological management, \nthis could include supportive counseling or psychotherapy to address \nmaladaptive beliefs and emotional distress that often accompany pain, \nintegrative and complementary therapies (e.g., yoga, mindfulness), \nself-management strategies (e.g., physical activity, stress management), \nand physical therapy to treat myofascial pain and dysfunction.\nGiven the decades of research demonstrating that endometriosis \nis not merely a disease of lesions, it is time we consider other \ncontributing biological, psychological, and social factors that affect \npatient functioning and well-being. We desperately need a paradigm \nshift in both the management of endometriosis and the way patients \nare informed about the disease and their treatment options. This \ntransformation could enhance patient care and provide a more \nholistic approach to pain management. Not only could this offer a vital \nopportunity to alleviate the profound burden of endometriosis, but \nit may also dramatically improve the overall quality of life for those \naffected.\nFunding\nResearch reported in this publication was supported by the \nNational Institutes of Health (1R21HD104957).\nReferences\n1. Shafrir AL, Farland LV , Shah DK, Harris HR, et al. (2018) Risk for and consequences \nof endometriosis: A critical epidemiologic review. Best Practice & Research Clinical \nObstetrics & Gynaecology 51: 1-15. [crossref]\n2. Vercellini P , Crosignani PG, Abbiati A, Somigliana E, et al. (2009) The effect of \nsurgery for symptomatic endometriosis: The other side of the story. Hum Reprod \nUpdate 15(2). [crossref]\n3. Guo SW (2009) Recurrence of endometriosis and its control. Hum Reprod Update  \n15(4). [crossref]\n4. Vercellini P , Fedele L, Aimi G, Pietropaolo G, et al. (2006) Association between \nendometriosis stage, lesion type, patient characteristics and severity of pelvic pain \nsymptoms: A multivariate analysis of over 1000 patients. Human Reproduction 22(1). \n[crossref]\n5. As-Sanie S, Kim J, Schmidt-Wilcke T, Sundgren PC, et al. (2016) Functional \nconnectivity is associated with altered brain chemistry in women with endometriosis-\nassociated chronic pelvic pain. J Pain 17(1). [crossref]\n6. As-Sanie S, Harris RE, Harte SE, Tu FF , et al. (2013) Increased pressure pain sensitivity \nin women with chronic pelvic pain. Obstetrics and Gynecology 122(5). [crossref]\n7. Bajaj P , Bajaj P , Madsen H, Arendt-Nielsen L (2003) Endometriosis is associated with \ncentral sensitization: A psychophysical controlled study. J Pain 4(7). [crossref]\n8. Maixner W , Fillingim RB, Williams DA, Smith SB, Slade GD (2016) Overlapping \nchronic pain conditions: Implications for diagnosis and classification. J Pain \n17(supp9). [crossref]\n9. Till SR, Nakamura R, Schrepf A, As-Sanie S (2022) Approach to diagnosis and \nmanagement of chronic pelvic pain in women: Incorporating chronic overlapping \npain conditions in assessment and management. Obstet Gynecol Clin North Am 49(2). \n[crossref]\n10. Leuenberger J, Kohl Schwartz AS, Geraedts K, Haeberlin F , et al. (2022) Living with \nendometriosis: Comorbid pain disorders, characteristics of pain and relevance for \ndaily life. Eur J Pain 26(5). [crossref]\n11. Hernández Cardona MI, Ajewole C, Lewis H, Carrillo JF , et al. (2023) Time to \nmove beyond surgical classification systems for endometriosis. Int J Gynaecol Obstet \n163(1). [crossref]\n12. Bartley EJ, Alappattu MJ, Manko K, Lewis H, et al. (2024) Presence of endometriosis \nand chronic overlapping pain conditions negatively impacts the pain experience \nin women with chronic pelvic-abdominal pain: A cross-sectional survey. Womens \nHealth V(20). [crossref]\n13. Ohrbach R, Sharma S, Fillingim RB, Greenspan JD, et al. (2020) Clinical \ncharacteristics of pain among five chronic overlapping pain conditions. J Oral Facial \nPain Headache 34(s29-s42). [crossref]\n14. Greene R, Stratton P , Cleary SD, Ballweg ML, Sinaii N (2009) Diagnostic experience \namong 4,334 women reporting surgically diagnosed endometriosis. Fertility and \nSterility 91(1). [crossref]\nCitation:\nBartley EJ (2024) Beyond the Lesions: Unraveling the Multifactorial Nature \nof Endometriosis and Chronic Overlapping Pain. ARCH Women Health Care \nVolume 7(4): 1-2.","source_license":"CC0","license_restricted":false}