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

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.