Maybe it’s nerves: Common pathway may explain pain

The new study by Abbott et al re-addressed the placebo effect of surgery by randomizing 39 women with pain and visible endometriosis implants to either diagnostic laparoscopy or laparoscopic excision of endometriosis. Six months after the surgery, the women had a second laparoscopic procedure during which the extent of endometriosis was reevaluated and visible disease was resected. In other words, all women had resection of endometriosis, although in half of the subjects, the resection was preceded by a sham operation.

Six months after the first operation, 80% of the resection group said they were improved, compared to 32% of the sham surgery group. Six months after the second operation, 83% of those who initially had sham surgery were improved.

This study shows that surgical resection can be effective in reducing pain associated with visible endometriosis, but there are 2 important additional findings:

• The placebo response of 32% is considerable and not to be ignored.
  
• Despite aggressive excisional surgery with its risks of major organ injury, up to 20% of subjects did not improve.
  

Is adhesiolysis helpful or not?

Hammoud A, Gago A, Diamond MP. Adhesions in patients with chronic pelvic pain: a role for adhesiolysis? Fertil Steril. 2004;82:1483–1491.

Adhesions may be blamed for chronic pelvic pain, although randomized trials have shown adhesiolysis no more effective than sham surgery.^4,5 Hammoud et al hypothesized that adhesions cause pain when they distort normal anatomy and pull on peritoneum, but stress that this idea has not been validated.

Their study found substantial evidence against the theory that adhesions cause pain, and suggests that pain and adhesions may both be due to an underlying process such as endometriosis.

They also review the evidence on the important complications that may occur with attempted surgical adhesiolysis.

Hysterectomy less helpful with preop depression

Hartmann KE, Ma C, Lamvu GM, Langenberg PW, Steege JF, Kjerulff KH. Quality of life and sexual function after hysterectomy in women with preoperative pain and depression. Obstet Gynecol. 2004;104:701–709.

Some gynecologists use removal of the uterus as the definitive treatment for chronic pain, although no controlled studies have examined the effectiveness of this operation compared to nonsurgical treatments. Hartmann et al evaluated quality of life and sexual function after hysterectomy in women who had pain, depression, or both pain and depression prior to surgery.

Results were compared between these groups and with women who had neither pain nor depression before surgery. Women with both pain and depression were more likely to have impaired quality of life after hysterectomy than were women with pain or depression alone or women with neither pain nor depression.

Two years later, pelvic pain was still troubling 19.4% of women with preoperative depression and pain, and only 9.3% of women with preoperative pain only.

Hysterectomy led to improvement in many quality of life measures and sexual function in women with pain, depression, or both. The authors concluded, “Overall we do not do harm when we perform hysterectomy for these complex patients.”

That conclusion, however, fails to consider surgical complications, time lost from work or other activities, or monetary costs, which were not evaluated.

There was no nonsurgical comparison group, and the authors point out that their study did not address the possibility that nonsurgical treatments may be as effective or more effective than hysterectomy.

REFERENCES

1. Peters AAW, van Dorst E, Jellis B, van Zuuren E, Hermans J, Trimbos JB. A randomized trial to compare 2 different approaches to women with chronic pelvic pain. Obstet Gynecol. 1991;77:740-744.

2. Jones KD, Sutton C. Patient satisfaction and changes in pain scores after ablative laparoscopic surgery for stage III–IV endometriosis and endometriotic cysts. Fertil Steril. 2003;79:1086-1090.

3. Sutton CJG, Ewen SP, Whitelaw N, Haines P. Prospective, randomized, double-blind controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild and moderate endometriosis. Fertil Steril. 1994;62:696-700.

4. Peters AAW, Trimbos-Kemper GCM, Admiral C, Trimbos JB. A randomized clinical trial on the benefit of adhesiolysis in patients with intraperitoneal adhesions and chronic pelvic pain. Br J Obstet Gynaecol. 1992;99:59-62.

5. Swank DJ, Swank-Bordewijk SC, Hop WC, et al. Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomized controlled multi-centre trial. Lancet. 2003;361:1247-1251.

MEDICAL THERAPYLetrozole for endometriosis?