Avoiding “shotgun” treatment: New thoughts on endometriosis-associated pelvic pain
An understanding of the mechanisms underlying chronic pelvic pain can help avert long-term treatment failure
In This Article
- The pain threshold and why it is important
- Types of pain and their implications
- It’s time to abandon nontargeted treatments
It’s time to abandon nontargeted treatments
Endometriosis-associated CPP remains a challenging heterogeneous and multifactorial disease state. In the past, treatments such as gonadotropin-releasing hormone agonists have been prescribed without an appropriate consideration of the disease and its mechanism of associated pain. In our CPP specialty practice, we have abandoned such nontargeted approaches. By developing an understanding of central sensitization, local neurologic responses to inflammation, and the pain threshold, clinicians are more likely to select a treatment targeted to specific mechanisms. Such an approach is superior to the traditional “shotgun” approach to treatment, which can produce harmful side effects and have high long-term failure rates. As Stratton and colleagues observed, “traditional methods of classifying endometriosis-associated pain based on disease, duration, and anatomy are inadequate and should be replaced by a mechanism-based evaluation.”19 Future clinical care and research will necessarily focus on specific disease etiologies and pain mechanisms if we are to continue to improve the care of women with CPP.
Case: Resolved
Because the history, physical examination, and imaging are strongly suggestive of endometriosis, the patient is counseled about the treatments most likely to be effective, which include medical therapies such as centrally acting agents (gabapentin, pregabalin, tricyclic antidepressants) and local treatments such as placement of a levonorgestrel-releasing intrauterine system or surgical resection. She elects to undergo total laparoscopic hysterectomy with bilateral salpingectomy and radical resection of endometriosis. Histopathology confirms adenomyosis and deep infiltrating endometriosis, including implants on the rectovaginal septum. The patient remains pain-free at her 2-year follow-up.
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