Endometriosis and chronic pain: a multispecialty roundtable discussion.

Pelvic endometriosis is associated with significant morbidity and decreased quality of life. The diagnosis of this condition is challenging: Symptoms vary considerably often mimicking those of other medical conditions. Laparoscopic visualization is considered the primary vehicle for definitive diagnosis although use of this procedure as a diagnostic and treatment tool remains controversial. At least a third of patients with pelvic pain have completely normal pelvic anatomy at laparoscopic evaluation. For many patients the degree of disease identified at laparoscopy does not seem to correlate with the amount of pain they experience. To some extent the clinically visualized findings may represent a tip of the iceberg phenomenon in that deep infiltrating endometriosis lesions may appear on the surface as minute fibrotic implants. In these cases the extent of the disease cannot be determined by visual inspection. Additionally we must remember that laparoscopy can only tell us about structural abnormalities in the pelvis. It cannot identify pelvic floor muscular sources or functional organic sources of pain. Not surprisingly many women who have endometriotic lesions excised by laparoscopy or even by hysterectomy and bilateral salpingo-oophorectomy experience recurrence of pain. Of particular concern to health-care providers is that patients often undergo repeat surgeries for relief of symptoms and may experience surgical complications-and still not obtain long-lasting pain relief. Symptoms may in fact become worse and lead to complicated medical regimens to manage pain. Medical treatments demonstrate efficacy similar to that of laparoscopy and they are marked by similar rates of pain recurrence. It should be noted that endometriosis represents a condition that cannot be cured. Treatment must therefore involve multifaceted short- and long-term interventions to manage symptoms and patient quality of life. In this roundtable discussion gynecologic surgeons join a family physician and a nurse practitioner to discuss the challenges and the strategies for man¬aging this patient population.