Standardizing medical pain management for the endometriosis patient: A Dutch modified eDelphi procedure

OBJECTIVE: to develop a step-by-step guideline to the medical management of pain in women with endometriosis from a national modified eDELPHI process in the Netherlands. METHODS: An eDELPHI procedure was preceded by an multidisciplinary expert meeting with experts in Obstetrics and Gynaecology (OBGYN), Colorectal Surgery, Anesthesiology, Urology, and Gastro-Enterology to develop a flow diagram for endometriosis pain management. The flow diagram was tested in two rounds of an eDELPHI procedure among experts in the field of OBGYN and Anesthesiology. They were recruited through a digital newsletter. For each item, it was predefined that consensus would be reached when at least 70% of respondents agreed. RESULTS: consensus was reached on all but one item. The first two steps adhere to the WHO step-by-step approach. The third step in endometriosis management is the addition of TCAs in case of neuropathic pain. It is recommended only to use metamizol and opioids for the short term. Muscarinic receptor antagonists are accepted treatment for bladder endometriosis. The use of COX-2 inhibitors is suggested but is not an established step in pain management. It is advised to prescribe magnesium hydroxide with all types of pain management because of its positive effect on gastro-intestinal symptoms. Finally, proton pump inhibitors (PPIs) can be prescribed with use of NSAIDs. CONCLUSIONS: consensus on a step-by-step guideline on pain management between Dutch endometriosis care experts was achieved. However, the use of some medication types are based on limited scientific evidence, underlining the importance to further investigate pain management options for endometriosis.