{"paper_id":"fe1b67ce-6238-49f4-9c33-0fdba3526dfe","body_text":"Endometriosis is the most common gynecological\npathology causing cyclic or non-cyclic pelvic\npain (NCPP) accounting for 12-32% of women\nof reproductive age and for 45-70% in adolescents\n( 1 ). Endometriosis is defined as the presence\nof endometrial glands and stroma outside of\nthe endometrial cavity. Pelvic pain has long been\nrecognized as a critical concomitant of the endometriosis\nsyndrome. Up to 75% of symptomatic\nendometriosis causes cyclic pelvic pain with menstruation\n( 2 ), though it is often associated with\nseveral different pain symptoms including noncyclical,\nnonmenstrual pelvic pain ( 3 ,  4 ). Indeed,\nin Sampson’s treatise ( 5 ), 12 of the 17 symptomatic\ncases he reported presented for surgery due to\nintolerable pain. As long as 90 years, the relationship\nbetween the extent of adhesion and severity\nof pain has not been well recognized. This lack of\ncorrelation continues to confound modern era gynecologists\nin large part ( 6 ) because mediation of\npainful stimuli are inadequately understood.\nMicroscopic studies have documented nerve fibres\nin endometriotic peritoneal lesions ( 7 - 9 ), deep\ninfiltrating endometriosis ( 10 ,  11 ) and ovarian endometriomas\n( 12 ). Berkley et al. ( 13 ) described\nthe growth of efferent sympathetic and afferent\nsensory nerves into the ectopic implants of endometriosis\nin women and in a rat model of disease.\nThe studies about neurogenesis in endometriosis\ncaught the attention of gynecologists, physiologists\nand neuroscientists to evaluate the causes and\ndevelop new methods with transdisciplinary effort\nto ameliorate pain associated with endometriosis.\nOn the other hand, surgery has long been an important\npart of the management of endometriosis.\nIn 2011, Stratton and Berkley ( 14 ), described current\napproaches to surgical treatment of endometriosis\nbased on \"oncological principle\" to remove\nall visible lesions and restore normal anatomy. Endometriomas\nare not amenable to medical treatment\nand need to be removed surgically even if\nsymptoms improve with medical treatment ( 15 ),\nwhile the preferred therapeutic approach for women\nwith symptomatic endometriomas was surgery\nto relieve the patient’s pain ( 16 ). Regardless of the\nstage of endometriosis, randomized controlled trials\ncomparing the effect of surgery to conservative\nmanagement have shown that surgery and\nexcision of endometriosis results in symptomatic\nimprovement ( 17 ,  18 ). The purpose of the present\nstudy was to discuss the benefits of surgical treatment\nfor different types of pain associated with\nendometriomas.\n\nIn a prospective, observational, before-after study,\nwas conducted between March 2012 and January\n2013 in Adana Numune Training and Research\nHospital, Adana, Turkey. Twenty three cases including\n16 sexually active and 7 virgin women (mean\nage: 31.9, range: 20-43) who were sonographically\ndiagnosed and later pathologically confirmed as\nhaving unilateral endometrioma (3-8 cm in diameter)\nwithout sign and symptoms of deep infiltrative\nendometriosis (DIE), as dyschezia, hematuria,\nrectal bleeding, constipation, diarrhea and bloating,\nformed our study group. The patients whose rectal/\nrectovaginal examination, imaging studies [ultrasound\nand magnetic resonance imaging (MRI)],\nand intraoperative findings suggested DIE as well\nas the patients who had intra-abdominal adhesions,\nhistory of pelvic inflammatory disease, and pathological\ndiagnosis other than endometrioma were all\nexcluded. Women completed a preoperative questionnaire\nthat collected demographic characteristics\nand data on presenting problem as full menstrual\nhistory, medical and surgical history and characteristics\nof pain symptoms. Pain was assessed using a\nverbal scale which has good correlation with visual\nanalogue scale and higher compliance in clinical\nsettings ( 19 ). The verbal scale offered descriptors\nsuch as \"no pain, moderate pain, severe pain, and\nunbearable pain\". Women were questioned for pain\nsymptoms preoperatively and 3-6 months after the\nlaparoscopic removal of endometrioma.\nAll patients were operated using stripping method\nby the same operator. No ancillary procedures as presacral\nneurectomy, uterosacral interruptions of sensory\nnerves and uterine suspension were applied for\npain management, but if pain was present, pelvic peritoneal\nendometriotic lesions were ablated beside the\nremoval of ovarian endometriotic cysts. The diagnosis\nof endometrioma was confirmed by histological\nexamination of specimens removed at surgery.\nPain relief was analyzed by the McNemar’s test\nfor pre- and post-operative symptoms. Analyses of\npain scores were performed using the Wilcoxon signed-rank test for paired non parametric data.\nAnalyses was undertaken Statistics Package for\nthe Social Sciences (SPSS, SPSS Inc. Chicago, IL,\nUSA) version 15. A P value of <0.05 was accepted\nas statistically significant. Qualitative data are expressed\nin percentage (%) and quantitative data are\nexpressed as the means ± standard deviation (SD).\nThe study protocol was elaborated according to\nthe revised Declaration of Helsinki and was approved\nby the Local Research and Ethics Committee\nof Adana Numune Training and Research Hospital\nin Adana, Turkey. All subjects were provided\na written informed consent.\n\nAverage age of women at the time of surgery\nwas 31.9 (range 20-43). Out of 23 subjects, 43.5%\n(10/23) were nulliparous and 56.5% were parous.\nAverage endometrioma cyst diameter were 43.7\n± 21.7 mm. Twenty two women had no previous\nabdominal procedure; only one woman had a laparoscopic\nendometrioma ablation before ( Table 1 ).\nThe demographic characteristics of the patients\nmm; Millimeter.\nOut of 23 cases with unilateral endometrioma,\n91% (21/23) reported to have NCPP before the\noperation, but this ratio decreased to 60% after\nthe operation (McNemar’s test P=0.016). The\nfrequency of dysmenorrhea was also felt by 30%\nafter the operation (78 to 48%, McNemar’s test\nP=0.016,  Fig.1 ).\nAmong the sexually active cases, 31% (5/16)\nhad dyspareunia before the operation and only 1\ncase reported pain relief after the operation (Mc-\nNemar’s test P=1,  Fig.2 ).\nPercentages and %95 confidence intervals (CI) for noncyclic\npelvic pain (NCPP) and dysmenorrhea before and after the\noperation.\nPercentages and %95 confidence intervals (CI) for dyspareunia\nbefore and after the operation.\nIntensity of NCPP were reported to be none\n(8.7%), moderate (21.7%), severe (56.5%) and unbearable\n(13%) before the operation and decreased\nto none (43.5%), mild (43.5%), moderate (4.3%)\nand severe (8.7%), after the operation (Wilcoxon\nsigned-rank test P<0.001,  Fig.3 ).\nNine of 23 patients had mild lesions on peritoneal\nsurfaces and were ablated by bipolar cautery.\nNone of the patients were scheduled for long term\npain management.\nPain grades for non-cyclic pelvic pain (NCPP) before and\nafter the operation.\n\nWomen with endometriosis either may have\ndiverse and nonspecific symptoms or may be\nasymptomatic. The prevalance of endometriosis\nin asymptomatic women in general population are\nnot known, but pain is the most common symptom\nassociated with endometriosis, diagnosed\nby visulization of pelvic organs via laparoscopy.\nApproximately three quarters of symptomatic patients\nexperience nonmenstrual pelvic pain and/or\ndysmenorrhea ( 20 ). In the present study, all participants\nhad different types of pain as follows: 91%\nhad NCPP, 78% had dysmenorrhea, and 21.7%\nhad dyspareunia.\nAccording to the current guideline by European\nSociety of Human Reproduction and Embryology\n(ESHRE 2013) ( 21 ), asymptomatic endometriosis\nthat is incidentally diagnosed should not be operated.\nBoth surgical and medical treatments show improvements\nin pain scores of symptomatic cases.\nHowever, there is no published trials directly comparing\none againist the other; therefore, we must\nrely on other evidence to weigh up the pros and\ncons of each approach. Unlike medical treatments,\nsurgery can diagnose and remove all macroscopic\ndisease at the same procedure in the majority of\ncases. In the case of symptomatic endometrioma,\nsuggested and preffered therapeutic approach is\nsurgery. Medical therapy is unlikely to result in\ncomplete regression of endometriomas larger than\n1 cm and precludes a definitive histologic diagnosis\n( 22 ,  23 ).\nThere have been very few studies in the current\nliterature evaluating the effect of removal of endometrioma\non pain symptoms. The efficacy of\nsurgical management of endometriosis was demonstrated\nby a randomized trial, comparing the\noutcome of women after therapeutic laparoscopy\nwith the outcome of women who underwent diagnostic\nlaparoscopy alone. Laparoscopic excision\nof implants led to symptomatic improvement in\n80% of patients at six months compared to 32%\nof controls undergoing diagnostic laparoscopy ( 3 ).\nIdeally if the surgery is performed for diagnosis,\nconsent has to be obtained for surgical resection/\nablation of endometriosis at the same time ( 20 ).\nAccording to a review by Jadoul et al. ( 24 ) in\nwhich they analyzed the arguments in favour of\nand against of surgical treatments of endometriosis\nand showed that more than 50% of the patients\nreported pain relief. Also the operation technique\nused for endometrioma removal affects the pain\nrelief. Several techniques have been described to\ntreat endometriomas. In most of these techniques,\nthe procedure consists of opening and draining the\ncyst followed by either excision (stripping technique),\nfulguration, or vaporisation of the cystic\nwall (ablative technique) ( 25 - 28 ). Drainage is\nalone not recommended because of the high recurrence\nrate ( 29 ). Hart’s Cochrane systematic review\nfound that excisional surgery provides better improvement\nin pain scores and decreases chance\nof recurrence compared with ablation ( 30 ). In our\nstudy the stripping technique was used, while the\nincidence and severity of NCPP and dysmenorrhea\nwere significantly improved after the operation, as\nsimiliar to these studies. Only dyspareunia symptom\nwas remained following the surgery. Ovary is\none of the most frequent location for endometriosis,\nleading to the extensive pelvic and intestinal\ndisease. Caution must be paid not to underdiagnose\nor undertreat these women ( 31 ). Although we tried to exclude the DIE preoperatively by asking\nsymptoms and performing rectovaginal/rectal and\nimaging examinations and our operative findings\nalso excluded DIE, we still thought that the presence\nof endometriotic invisible lesions caused dyspareunia.\nMilingos et al. ( 32 ) found that symptoms\nof deep dyspareunia was correlated with the presence\nof dense pelvic adhesions and related to advanced\nendometriosis. The stripping and ablating\nof endometriotic lesions seemed to be not enough\nto improve dyspareunia. On the other hand, the\nnature of endometriotic pain was reported to be\nmemorized in the brain that might not be resolved\nby excision of endometrioma. The possible explanation\nof remaining dyspareunia after the endometrioma\nexcision could be the painful intercourse\nmemorized by the certain brain area ( 14 ).\nThere were some limitations in our study. Due\nto small number of participants, we were unable\nto categorized the subjects according to the size\nof endometriomas, although no larger study was\nconducted on this subject yet.\n\nOne hundred and fifty years after endometriosis\nwas first described, we are still debating both its\netiology and management. Although main questions\nremain unanswered, solid evidence shows\nthat laparoscopic surgery appears to be the most\nlogical approach to treatment. As a result of our\nstudy, we want to emphasize that in cases of symptomatic\nendometriosis, without sign and symptoms\nof DIE, laparoscopic removal of the cysts\nwith/without ablation of the peritoneal endometriotic\nlesions may relive NCPP and cyclic dysmenorrhea,\nbut not dyspareunia.","source_license":"CC0","license_restricted":false}