Endometriosis and chronic pelvic pain management: Between a rock (denial) and a hard place (overdiagnosis)

In their thought-provoking commentary, Hudelist et al.1 highlighted the inconsistent association between endometriosis and chronic pelvic pain. They warned that the origin of symptoms may be multifactorial and not always due to the presence of ectopic endometrium. For the inexperienced clinician, it could be easier to attribute pain to endometriosis than to delve into a challenging differential diagnosis that includes several potential causes, some of which may be unfamiliar. The authors emphasize the risk of misdiagnosis, especially in patients with noncyclic pelvic pain and with superficial peritoneal endometriosis, as well as the risk of overdiagnosis of adenomyosis. Moreira and Oliveira also argued that a lesion-centered approach in women with endometriosis can be misleading and result in unsatisfactory outcomes.2 However, few experts have enough knowledge of all pelvic pain mechanisms. Healthcare providers who feel insecure about formulating a diagnosis after reading the commentary by Hudelist et al.,1 may find it helpful to use questionnaires specifically developed to detect central sensitization. Moreover, when the cause of pain is not yet identified, a symptom-oriented approach can be considered.3 Dysmenorrhea, the most frequent cyclic complaint, can be relieved by abolishing menstruation regardless of the mechanisms involved. The same should apply to catamenial dyschezia and dysuria. Mid-cycle pain (mittelschmerz) also typically improves with ovulation inhibition. When chronic pelvic pain is noncyclical and no endometriotic lesions are identified at transvaginal ultrasound, a progestogen can be tried to assess the effect of suppressing ovulatory menstruation in case minimal peritoneal foci are present and causing the pain. Notably, conclusions cannot be drawn if amenorrhea is not achieved.3 For patients who do not respond to progestogens despite the absence of spotting and breakthrough bleeding, a GnRH analogue (GnRHa) test may be recommended. Administering a GnRH agonist or antagonist (e.g., one triptorelin 11.25 mg depot injection or linzagolix 200 mg/day orally) without add-back therapy for 3 months categorizes patients as GnRHa responders or non-responders. The post-test probability of superficial peritoneal endometriosis being the cause of chronic pelvic pain increases in GnRHa responders and, importantly, decreases greatly in GnRHa non-responders.3 A positive response is not diagnostic of endometriosis; however, these patients could benefit from prolonged use of GnRHa plus tailored add-back therapy. Additional consultations (eg, pain specialists, gastroenterologists, urologists, dietitians, physiotherapists, psychotherapists, sexologists) could be aimed at GnRHa non-responders, who appear to be at higher risk of central sensitization.3 This pragmatic stepwise approach is not etiology-based, but it allows for the targeting of multimodal management to patients who are most likely to benefit from it.3, 4 Finally, the potential downstream consequences of implementing noninvasive tests for endometriosis must be considered. Salivary tests and self-testing due to direct-to-consumer advertising and marketing5 may substantially amplify the risk of misdiagnosis, overdiagnosis, and ineffective treatments. Since Hudelist et al. doubt that endometriosis is always the source of the referred complaints,1 resorting to noninvasive testing to diagnose otherwise undetectable superficial peritoneal lesions may reveal a further scapegoat, making the already difficult navigation in the hostile sea of chronic pelvic pain of uncertain origin even more confusing. P.Ve. conceived the text and drafted the original version of the letter. N.S., V.B., P.Vi., and E.S. participated in conceiving and drafting part of the letter and critically revising it. All authors approved the final version of the letter. P.Ve. is a member of the Editorial Board of Human Reproduction Open, the Journal of Obstetrics and Gynaecology Canada, and the International Editorial Board of Acta Obstetricia et Gynecologica Scandinavica; has received royalties from Wolters Kluwer for chapters on endometriosis management in the clinical decision support resource UpToDate; and maintains both a public and private gynecological practice. P.Vi. is Co-editor-in-Chief of the Journal of Endometriosis and Uterine Disorders. E.S. is Editor-in-Chief of Human Reproduction Open; discloses payments from Ferring and Theramex for research grants and personal honoraria from Merck-Serono, Ibsa, and Gedeon-Richter; and maintains both a public and private gynecological practice. N.S. and V.B. declare they have no conflict of interest. Data sharing does not apply to this article as no datasets were generated or analyzed during the current study.