From the Guidelines
Chronic pelvic pain suspected to be endometriosis should be treated with hormonal therapies, such as combined hormonal contraceptives, progestins, or GnRH agonists, as these have been shown to reduce the size of lesions and alleviate pain 1.
Diagnosis and Treatment Options
The diagnosis of endometriosis typically requires laparoscopy with biopsy, although imaging studies like transvaginal ultrasound or MRI may help identify endometriomas or deep infiltrating lesions.
- Treatment options include:
- Hormonal therapies, such as combined hormonal contraceptives (e.g., oral contraceptive pills containing ethinyl estradiol 20-35 mcg with progestin, taken continuously)
- Progestins (e.g., norethindrone acetate 5-15 mg daily or medroxyprogesterone acetate 30-100 mg daily)
- GnRH agonists (e.g., leuprolide 3.75 mg monthly injections for up to 6 months, with add-back therapy like norethindrone acetate 5 mg daily to prevent bone loss)
- NSAIDs like ibuprofen 400-800 mg every 6-8 hours can help manage pain
- Surgical treatment via laparoscopic excision or ablation of endometriotic lesions is effective for pain relief, particularly for advanced disease
Recommendations
According to the ACOG committee, current evidence suggests that pain caused by endometriosis can be managed medically, and treatment with a GnRH agonist for at least three months or with danazol for at least six months appears to be equally effective in most women 1.
- Therapy with a GnRH agonist is an appropriate approach to the management of the woman with chronic pelvic pain, even in the absence of surgical confirmation of endometriosis, provided that a detailed initial evaluation fails to demonstrate some other cause of pelvic pain
- For pain relief, oral contraceptives and oral or depot medroxyprogesterone acetate are effective in comparison with placebo and may be equivalent to other more costly regimens
- A multidisciplinary approach including physical therapy for pelvic floor dysfunction, psychological support, and lifestyle modifications often provides the best outcomes
Individualized Treatment
Treatment should be individualized based on symptom severity, fertility desires, side effect profiles, and patient preferences, as endometriosis is a chronic condition requiring ongoing management 1.
From the Research
Diagnosis of Endometriosis
- Endometriosis is a chronic, estrogen-dependent, inflammatory disease defined by endometrial-like tissue (lesions) outside the uterine lining 2
- A suspected clinical diagnosis can be made based on symptoms, supported by physical examination findings and imaging with transvaginal ultrasound and/or pelvic magnetic resonance imaging 2
- Definitive diagnosis requires surgical visualization of lesions 2
Treatment of Endometriosis
- Hormonal medications, such as combined oral contraceptives and progestin-only options, are first-line treatment and should be offered to symptomatic premenopausal women who do not currently desire pregnancy 2
- Hormonal treatments, including combined oral contraceptives, progestins, and gonadotropin-releasing hormone (GnRH) agonists, have been shown to lead to clinically significant pain reduction compared with placebo 2
- Surgical removal of lesions, usually with laparoscopy, should be considered if first-line hormonal therapies are ineffective or contraindicated 2
- Nonnarcotic analgesics are first-line therapy for pain relief, and hormonal therapies are beneficial if the pain has a cyclical component 3
- A multidisciplinary approach addressing environmental factors and incorporating medical management with physiotherapy, psychotherapy, and dietary modifications works best for managing chronic pelvic pain 3
Management of Chronic Pelvic Pain
- Chronic pelvic pain is defined as nonmenstrual pain lasting 6 months or more that is severe enough to cause functional disability or require medical or surgical treatment 3
- Four conditions account for most chronic pelvic pain: endometriosis, adhesions, interstitial cystitis, and irritable bowel syndrome 3
- Management involves treating the underlying condition, the pain itself, or both 3
- Nonsteroidal anti-inflammatory agents, such as naproxen and ibuprofen, have been shown to be effective in treating primary dysmenorrhea 4
Effectiveness of Oral Contraceptives
- The combined oral contraceptive pill (COCP) is widely used to treat pain occurring as a result of endometriosis, although the evidence for its efficacy is limited 5
- Treatment with the COCP was associated with an improvement in self-reported pain at the end of treatment compared with placebo 5
- However, the quality of the evidence is very low, and further research is needed to fully evaluate the role of COCPs in managing pain-related symptoms associated with endometriosis 5