{"paper_id":"e4b32c5c-2b84-4923-a834-708745d20224","body_text":"Interv Pain Med Neuromod. 2022 December; 2(1):e128043.\nPublished online 2022 May 31.\ndoi: 10.5812/ipmn-128043.\nLetter\nPain Management in Endometriosis\nFereshteh Sarbazi\n 1, *, Elham Akbari 1 and Behnaz Nouri\n 2\n1Department of Obstetrics and Gynecology , Farmanieh Hospital, Tehran, Iran\n2Department of Obstetrics and Gynaecology , Shahid Beheshti University of Medical Sciences, Shohadaye Tajrish Hospital, Tehran, Iran\n*Corresponding author: Department of Obstetrics and Gynecology , Farmanieh Hospital, Tehran, Iran. Email: dr.sarbazi@gmail.com\nReceived 2022 May 16; Revised 2022 May 19; Accepted 2022 May 21.\nKeywords: Pain, Endometriosis, Endometrioma, Pain Management\nDear Editor,\nEndometriosis, characterized by the presence of en-\ndometrial implants outside the endometrial cavity , is a\nchronic and incurable disease in many women of repro-\nductive age that requires lifelong management. Pain as-\nsociated with endometriosis includes dysmenorrhea, dys-\npareunia, dyschezia, dysuria, and nonmenstrual pelvic\npain. Extensive studies have been done in this field, but\noptimal management is still unclear. This article describes\nthe available medical and surgical treatment options for\npain caused by endometriosis. The choice of treatment\nis individualized and clinical symptoms, the severity of\nsymptoms, age of the patient, extent, and location of the\ndisease, tendency to fertility , drug side effects, surgical\ncomplications, and cost are considered.\nMedical Treatment Options\nAnalgesics: Nonsteroidal anti-inflammatory drugs\n(NSAIDs) are commonly used to treat primary dysmenor-\nrhea and pelvic pain, although there is very low quality\nevidence to support their use in treating endometriosis\npain (1). Patients planning for pregnancy can use NSAIDs,\nalthough, according to some studies, selective COX-2 in-\nhibitors (celecoxib, rofecoxib, and valdecoxib) can delay or\nprevent ovulation (2). Besides, NSAIDs can be used alone or\ncombined with continuous hormonal contraceptives.\nNeuromodulators: Neuromodulators (eg, anti-\ndepressants, selective serotonin uptake inhibitors, or\nanticonvulsants) are mainly used to treat chronic and\npermanent pain. They affect the central nervous system’s\nmodulation of pain. There is hope for their use in treating\nendometriosis-related pain. However, randomized clinical\ntrials of chronic pelvic pain management have not shown\ntheir significance for treating chronic pelvic pain com-\npared to placebo, especially considering their possible\nsevere side effects (3, 4).\nHormone Treatments\nHormone treatments include combined oral\ncontraceptives, progestogens, anti-progestogens,\ngonadotrophin-releasing hormone (GnRH) agonists,\nGnRH antagonists, the levonorgestrel intrauterine sys-\ntem (LNG-IUS), and danazol and aromatase inhibitors\n(eg, letrozole). All of them significantly reduce the pain\nassociated with endometriosis compared with placebo (5).\nThe side effects and efficacy of hormone treatments are\nindividual-dependent.\nEstrogen-progestin Contraceptives: Several system-\natic reviews have concluded that combined estrogen-\nprogestin contraceptives, including combined oral contra-\nceptive pills (OCP), vaginal rings, and transdermal patches,\nsignificantly reduce endometriosis-related pain (6). They\ncan be used as the first-line treatment for most patients\ndue to the possibility of long-term use and reasonable\nprice, availability , and contraceptive effects. They also re-\nduce the risk of ovarian and endometrial cancer. Both\ncontinuous and standard cyclic OCP have been effective,\nalthough some studies have found that the continuous\nmethod is more effective (7).\nProgestogens and Antiprogestogens: Progestin-\nonly therapy is used in contraindicated patients with\ncombined estrogen-progestin contraceptives or those who\nprefer not to use them. The 19-nortestosterone deriva-\ntives norethindrone acetate (5 mg dose), dienogest, and\nmedroxyprogesterone acetate are the most common pro-\ngestins used to treat endometriosis-related pain. Etono-\ngestrel implant (ENG) and levonorgestrel-releasing in-\ntrauterine system also significantly reduce endometriosis-\nrelated pain.\nDanazol: Danazol is not recommended anymore un-\nless no other medical therapy is available because of its se-\nvere androgenic side effects.\nGonadotropin-releasing Hormone Ago-\nnists/Antagonists: GnRH agonists and antagonists\nCopyright © 2022, Interventional Pain Medicine and Neuromodulation. This is an open-access article distributed under the terms of the Creative Commons\nAttribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in\nnoncommercial usages, provided the original work is properly cited.\n\nSarbazi F et al.\neffectively reduce the pain associated with endometrio-\nsis, but due to their side effects, they are recommended\nas second-line treatment in cases where hormonal con-\ntraceptives or progestogens are not effective. There is\nlimited evidence regarding the dosage and duration of\ntreatment. It is recommended to use add-back treatment\nwith GnRH agonist therapy to prevent osteoporosis and\nhypoestrogenic symptoms (8).\nAromatase Inhibitors: Due to severe side effects, aro-\nmatase inhibitors are used only in cases where the pain\nassociated with endometriosis is resistant to other medi-\ncal treatments or surgical treatment. Aromatase inhibitors\nmay be combined with oral estrogen-progestin contracep-\ntives, progestogens, and GnRH agonists or antagonists.\nSurgical Treatment\nDue to the risks of surgery , its high cost, the lengthy re-\ncovery period, and the possibility of recurrence, medical\ntreatments have priority , and surgical treatment is consid-\nered when the patient is resistant to medical treatments or\ncannot use them for any reason. Disadvantages of surgical\nprocedures are related to the usual surgical risks, includ-\ning the risk of injury , especially to the bowel and bladder,\nand the possibility of reduced ovarian reserve and adhe-\nsions.\nConservative Surgery: In conservative surgery , all en-\ndometriosis lesions are removed, and adhesions are re-\nleased while the uterus and ovaries are preserved. This sur-\ngical procedure is considered the first-line treatment for\nmost women planning for surgical treatment because it\npreserves hormone production and fertility and is less in-\nvasive and morbid than definitive surgery . However, recur-\nrence is more likely with this method than with definitive\nsurgery .\nDefinitive Surgery: Definitive surgery includes hys-\nterectomy (total hysterectomy is preferred) with or with-\nout oophorectomy . Definitive surgery is recommended for\npatients with debilitating pain or completed childbearing\nor when other medical and surgical treatments have failed.\nLaparoscopy is preferred to laparotomy due to better sur-\ngical visualization, shorter hospital stay , less pain, shorter\nrecovery period, and better cosmetic results.\nFootnotes\nAuthors’ Contribution: All authors contributed equally\nto this article.\nConflict of Interests: There are no personal/financial in-\nterests.\nFunding/Support: The authors did not declare it.\nReferences\n1. Brown J, Crawford TJ, Allen C, Hopewell S, Prentice A. Nons-\nteroidal anti-inflammatory drugs for pain in women with en-\ndometriosis. Cochrane Database Syst Rev . 2017; 1. CD004753. doi:\n10.1002/14651858.CD004753.pub4. [PubMed: 28114727]. [PubMed\nCentral: PMC6464974].\n2. Duffy DM, VandeVoort CA. Maturation and fertilization of non-\nhuman primate oocytes are compromised by oral administration\nof a cyclooxygenase-2 inhibitor. Fertil Steril . 2011; 95(4):1256–60. doi:\n10.1016/j.fertnstert.2010.12.048. [PubMed: 21236424]. [PubMed Cen-\ntral: PMC3053529].\n3. Horne AW, Vincent K, Hewitt CA, Middleton LJ, Koscielniak M, Szubert\nW, et al. Gabapentin for chronic pelvic pain in women (GaPP2): a mul-\nticentre, randomised, double-blind, placebo-controlled trial. Lancet.\n2020;396(10255):909–17.\n4. Rayegani SM. Pain and Neuromodulation. Int Pain Med Neuromod .\n2021;1(1). doi: 10.5812/ipmn.118842.\n5. National Institute for Health and Care Excellence. Endometriosis: di-\nagnosis and management. NICE guideline NG73 . National Institute for\nHealth and Care Excellence; 2017. Available from: https://www.nice.\norg.uk/guidance/ng73.\n6. Grandi G, Barra F, Ferrero S, Sileo FG, Bertucci E, Napolitano A, et al.\nHormonal contraception in women with endometriosis: a system-\natic review .Eur J Contracept Reprod Health Care . 2019;24(1):61–70. doi:\n10.1080/13625187.2018.1550576. [PubMed: 30664383].\n7. Muzii L, Di Tucci C, Achilli C, Di Donato V, Musella A, Palaia I, et al. Con-\ntinuous versus cyclic oral contraceptives after laparoscopic excision\nof ovarian endometriomas: a systematic review and metaanalysis.\nAm J Obstet Gynecol. 2016;214(2):203–11. doi: 10.1016/j.ajog.2015.08.074.\n[PubMed: 26364832].\n8. Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel\nL, et al. ESHRE guideline: endometriosis. Hum Reprod Open .\n2022;2022(2):hoac009.\n2 Interv Pain Med Neuromod. 2022; 2(1):e128043.","source_license":"CC0","license_restricted":false}