Letter to the Editor: Considerations beyond adenomyosis as a cause of surgical failure in treating dyspareunia in rectovaginal septum endometriosis

Juan Diego Villegas‐Echeverri, Jorge F. Carrillo
International Journal of Gynecology & Obstetrics · 2025 · vol. 169(3) , pp. 1262–1264 · doi:10.1002/ijgo.70102 · PMID:40125632 · W4408804301
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This letter argues that chronic pelvic pain, especially dyspareunia, requires a comprehensive, transdisciplinary, and biopsychosocial approach beyond solely considering endometriosis and adenomyosis.

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This letter to the editor critiques a recent study by Mercorio et al., arguing that adenomyosis should not be considered the primary cause of surgical failure for dyspareunia in patients with rectovaginal septum endometriosis. The authors highlight that chronic pelvic pain is multifactorial, involving central sensitization, overlapping pain conditions, and psychosocial factors that significantly influence postoperative outcomes. They emphasize that focusing solely on anatomical lesions like adenomyosis overlooks the complex neurobiological mechanisms underlying persistent pain in these patients. This paper is centrally about endometriosis — specifically addressing diagnostic considerations and pain management complexities in deep infiltrating endometriosis affecting the rectovaginal septum.

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Abstract

We read with interest the recent article, “Adenomyosis: A potential cause of surgical failure in treating dyspareunia in rectovaginal septum endometriosis.”1 While it is important to highlight endometriosis and adenomyosis and their contribution to chronic pelvic pain (CPP),2 focusing solely on these conditions oversimplifies the complexity of CPP and the current standard of care, which requires a detailed evaluation and a transdisciplinary, multimodal approach.3, 4 Furthermore, this approach fails to incorporate a biopsychosocial perspective, which is crucial to providing adequate care to those suffering from CPP conditions.4, 5 Our intention with this letter is to draw readers' attention to the importance of comprehensively addressing CPP, to provide patients with options that positively impact their quality of life. Access to comprehensive transdisciplinary care for CPP remains inconsistent, impacting patients both in low- and middle-income countries, where resources may be limited, and in high-income countries, where appropriate diagnostic and treatment pathways are not always readily available or accessible.6, 7 Persistent dyspareunia, both superficial and deep, is frequently a symptom of various conditions contributing to CPP, including endometriosis, adenomyosis, myofascial pain syndrome, pudendal neuralgia, and bladder pain syndrome, among others.3 Associated factors like depression, trauma, and central sensitization can exacerbate these conditions.3, 8 While endometriosis and adenomyosis are significant, they represent only part of the broader CPP spectrum.2, 3, 5 Focusing solely on these conditions can lead to misdiagnosing, underdiagnosing, and/or undertreating other contributing factors.9, 10 Multiple studies show that most patients with CPP present with multiple co-occurring and chronic overlapping pain conditions.3, 9, 10 Despite patients reporting improvement in symptoms after adequate surgery (for example for deep endometriosis and/or adenomyosis),11 the high prevalence of persistent post-surgical pain in CPP patients underscores the importance of a comprehensive evaluation.12 Currently there is no evidence suggesting that surgical intervention guarantees complete symptom relief, and its effectiveness has been reported to diminish over time.11 Reoperation rates for pain are as high as 62%13 and persistent pain, even with post-surgical hormonal therapy, is as high as 70%.14, 15 This high rate of persistent/recurrent pain and repeated surgical interventions should encourage exploration of effective postoperative therapies, both pharmacological and non-pharmacological.16 A planned multimodal approach can mitigate the risk of recurrent symptoms and improve clinical outcomes.2-4, 17, 18 While surgery can be beneficial for specific, identifiable causes of CPP like endometriosis or adenomyosis, limiting treatment to a single intervention, such as surgery, or a disease-focused approach, can have limitations.3, 16, 19 Given the complex multifactorial nature of CPP, a thorough evaluation is crucial, especially if a surgical intervention is planned. Furthermore, this detailed evaluation becomes necessary in cases of persistent postoperative symptoms.3 The three primary reasons patients experience persistent postoperative pain are: (1) incomplete surgical excision of the disease (e.g., for deep infiltrating endometriosis)10, 11; (2) undiagnosed coexisting chronic overlapping pain conditions9, 10; and (3) the presence of nociplastic pain and central sensitization.8, 20, 21 A detailed, comprehensive evaluation must not only encompass gynecological factors, but also include musculoskeletal, urological, gastrointestinal, neurological, and mental health factors.3, 4 A transdisciplinary, multimodal approach is crucial for effective CPP management and improved clinical outcomes.4, 5, 22 Repeated surgeries without a prior comprehensive assessment are unlikely to improve symptoms and may expose patients to unnecessary risks and disability.2-4, 18 Recent data widely indicate that a significant percentage of women with deep dyspareunia present with musculoskeletal conditions.19, 23, 24 Myofascial pain syndrome and pelvic floor dysfunction can be present in approximately 75% of patients with dyspareunia, whether or not it is associated with deep infiltrating endometriosis.3, 23 However, the musculoskeletal component is often overlooked and underdiagnosed.19, 23 Because of the fundamental contribution of musculoskeletal conditions in these patients, a failure to diagnose them leads to persistent symptoms and impaired quality of life.4, 23 Therefore, a comprehensive evaluation of dyspareunia must include a thorough musculoskeletal assessment.4, 17 Furthermore, addressing non-surgical contributors to CPP, which are often more prevalent than surgically treatable conditions alone, should be an integral part of any treatment strategy.4, 5 A trauma-informed approach, such as screening for a history of trauma and adapting communication accordingly, should also always be incorporated.3 Acknowledging the complex and multifaceted nature of CPP leads to more effective management and improved clinical outcomes, lessening its burden on patients, families, society, and healthcare systems, and ultimately empowering women and contributing to a healthier society.16, 22 All authors contributed to the conception, design, writing and review of this letter. All authors agree to be accountable for the final publication. The ideas and expressions presented in this manuscript are solely the authors' original work. The authors acknowledge the use of AI technology (www.jenni.ai) to refine the grammar, style, and translation of this manuscript into English. All changes suggested by AI were reviewed and approved by the authors. Additionally, Zotero was used for management of references. The authors have no conflicts of interest. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. This is a letter to the editor and does not include new data or original research.
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Letter to the Editor: Considerations beyond adenomyosis as a cause of surgical failure in treating dyspareunia in rectovaginal septum endometriosis Corresponding Author Juan Diego Villegas-Echeverri Division of Benign Surgery, FIGO, London, UK ALGIA Unidad de Laparoscopia Ginecológica Avanzada y Dolor Pélvico, Pereira, Colombia Clinica Comfamiliar, Pereira, Colombia Correspondence Juan Diego Villegas-Echeverri, Avenida Juan B. Gutierrez # 18-60 Suite 1104. Pereira, Colombia. Email: [email protected] Search for more papers by this authorJorge F. Carrillo University of Central Florida, Orlando VA Healthcare System, Orlando, Florida, USA Search for more papers by this authorCorresponding Author Juan Diego Villegas-Echeverri Division of Benign Surgery, FIGO, London, UK ALGIA Unidad de Laparoscopia Ginecológica Avanzada y Dolor Pélvico, Pereira, Colombia Clinica Comfamiliar, Pereira, Colombia Correspondence Juan Diego Villegas-Echeverri, Avenida Juan B. Gutierrez # 18-60 Suite 1104. Pereira, Colombia. Email: [email protected] Search for more papers by this authorJorge F. Carrillo University of Central Florida, Orlando VA Healthcare System, Orlando, Florida, USA Search for more papers by this authorDATA AVAILABILITY STATEMENT Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. This is a letter to the editor and does not include new data or original research. REFERENCES - 1Mercorio A, Della Corte L, Dell'Aquila M, Pacella D, Bifulco G, Giampaolino P. Adenomyosis: a potential cause of surgical failure in treating dyspareunia in rectovaginal septum endometriosis. Int J Gynaecol Obstet. 2025; 168(3): 1298-1304. - 2Becker CM, Bokor A, Heikinheimo O, et al. ESHRE guideline: endometriosis. Hum Reprod Open. 2022; 2022(2): hoac009. - 3Lamvu G, Carrillo J, Ouyang C, Rapkin A. Chronic pelvic pain in women: a review. JAMA. 2021; 325(23): 2381-2391. - 4Allaire C, Yong PJ, Bajzak K, et al. Guideline No. 445: management of chronic pelvic pain. J Obstet Gynaecol Can. 2024; 46(1):102283. - 5Chen I, Money D, Yong P, Williams C, Allaire C. An evaluation model for a multidisciplinary chronic pelvic pain clinic: application of the RE-AIM framework. J Obstet Gynaecol Can. 2015; 37(9): 804-809. - 6Westwood S, Fannin M, Ali F, et al. Disparities in women with endometriosis regarding access to care, diagnosis, treatment, and management in the United States: a scoping review. Cureus. 2023; 15(5):e38765. - 7Fourquet J, Zavala DE, Missmer S, Bracero N, Romaguera J, Flores I. Disparities in healthcare services in women with endometriosis with public vs private health insurance. Am J Obstet Gynecol. 2019; 221(6): 623.e1-623.e11. - 8Orr NL, Huang AJ, Liu YD, et al. Association of central sensitization inventory scores with pain outcomes after endometriosis surgery. JAMA Netw Open. 2023; 6(2):e230780. - 9Maixner W, Fillingim RB, Williams DA, Smith SB, Slade GD. Overlapping chronic pain conditions: implications for diagnosis and classification. J Pain. 2016; 17(9): T93-T107. - 10Bartley EJ, Alappattu MJ, Manko K, Lewis H, Vasilopoulos T, Lamvu G. Presence of endometriosis and chronic overlapping pain conditions negatively impacts the pain experience in women with chronic pelvic-abdominal pain: a cross-sectional survey. Womens Health (Lond). 2024; 20:17455057241248017. - 11Maguire B, DeMaio A, O'Neill A, Clancy C. A quality-of-life meta-analysis comparing pre- and post-operative symptoms in women undergoing colorectal resection for deep infiltrating endometriosis. Color Dis. 2025; 27(2):e70036. - 12Yosef A, Allaire C, Williams C, et al. Multifactorial contributors to the severity of chronic pelvic pain in women. Am J Obstet Gynecol. 2016; 215(6): 760.e1-760.e14. - 13Cooper KG, Bhattacharya S, Daniels JP, et al. Preventing recurrence of endometriosis-related pain by means of long-acting progestogen therapy: the PRE-EMPT RCT. Health Technol Assess. 2024; 28(55): 1-77. - 14Cooper KG, Bhattacharya S, Daniels JP, et al. Long acting progestogens versus combined oral contraceptive pill for preventing recurrence of endometriosis related pain: the PRE-EMPT pragmatic, parallel group, open label, randomised controlled trial. BMJ. 2024; 385:e079006. - 15As-Sanie S, Till SR, Schrepf AD, et al. Incidence and predictors of persistent pelvic pain following hysterectomy in women with chronic pelvic pain. Am J Obstet Gynecol. 2021; 225(5): 568.e1-568.e11. - 16Mijatovic V, Vercellini P. Towards comprehensive management of symptomatic endometriosis: beyond the dichotomy of medical versus surgical treatment. Hum Reprod. 2024; 39(3): 464-477. - 17 Chronic Pelvic Pain. ACOG practice bulletin, number 218. Obstet Gynecol. 2020; 135(3): e98-e109. - 18Roman H, Chanavaz-Lacheray I, Hennetier C, et al. Long-term risk of repeated surgeries in women managed for endometriosis: a 1,092 patient-series. Fertil Steril. 2023; 120(4): 870-879. - 19Yong PJ, Williams C, Bodmer-Roy S, et al. Prospective cohort of deep dyspareunia in an interdisciplinary setting. J Sex Med. 2018; 15(12): 1765-1775. - 20As-Sanie S, Kim J, Schmidt-Wilcke T, et al. Functional connectivity is associated with altered brain chemistry in women with endometriosis-associated chronic pelvic pain. J Pain. 2016; 17(1): 1-13. - 21Till SR, Schrepf A, Clauw DJ, Harte SE, Williams DA, As-Sanie S. Association between nociplastic pain and pain severity and impact in women with chronic pelvic pain. J Pain. 2023; 24(8): 1406-1414. - 22Panisch LS, Rogers RG, Breen MT, Nutt S, Dahud S, Salazar CA. Dissociation among women with chronic pelvic pain: relation to surgical treatment, pelvic pain severity, and health-related quality of life. J Trauma Dissociation. 2023; 24(2): 296-311. - 23Lamvu G, Carrillo J, Witzeman K, Alappattu M. Musculoskeletal considerations in female patients with chronic pelvic pain. Semin Reprod Med. 2018; 36(2): 107-115. doi:10.1055/s-0038-1676085 - 24Yong PJ. Deep dyspareunia in endometriosis: a proposed framework based on pain mechanisms and Genito-pelvic pain penetration disorder. Sex Med Rev. 2017; 5(4): 495-507. Article Metrics Total unique accesses to an article’s full text in HTML or PDF/ePDF format.More metric information Scite metrics Explore this article's citation statements on scite.ai Share QR Code Generating QR code QR code copied to clipboard! Something went wrong while generating your QR code. Please try again in a moment. If the issue persists, refresh the page or contact support. Export citation Unable to load citation data. Please try again in a moment. How to cite Elkins, L. J., & Spiegelman, M. (2021). pyUserCalc: A revised Jupyter notebook calculator for uranium-series disequilibria in basalts. 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