Clinical Review

Endometriosis and pain: Expert answers to 6 questions targeting your management options

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6. Can the risk of postoperative recurrence be reduced?
“The main problem with surgery is the ­recurrence rate,” Dr. Falcone says. “Studies have shown that the recurrence rate of pain at 7 years may be as high as 50%.”17 Furthermore, “the recurrence of pain may not be associated with visualized endometriosis at laparoscopy.”

“Incomplete removal of lesions may be associated with an increase in pain after surgery,” says Dr. Stratton.18 “Incomplete removal of lesions may occur because of varying technical skill or specific lesion characteristics. The lesions may be difficult to remove because of their location. Lesions may not be recognized because their appearance can vary from subtle (red or clear or white) to classic (blue-black). The depth of the lesion may not be appreciated until surgery is under way and a surgeon may not be adequately prepared to treat deep lesions when they are identified.”

Another reason pain may persist or recur after surgery for endometriosis: Adenomyosis.19 “Adenomyosis appears as either diffuse or focal thickening of the junctional zone between the endometrium and myometrium of the uterus on T2 weighted magnetic resonance imaging (MRI),” says Dr. Stratton. “After excision of endometriosis, chronic pelvic pain is significantly more likely to persist in women who have a junctional zone thickness of more than 11 mm on MRI,” she says.

The frequent recurrence of pain after surgery for endometriosis means that the disease is a long-term challenge.

“Pelvic pain caused by endometriosis is a chronic problem that requires a multiyear management plan, involving both surgery and hormonal therapy,” says Robert L. ­Barbieri, MD. “To reduce the number of surgical procedures in the lifetime of a woman with endometriosis and pain, I suggest hormonal medical therapy following conservative surgery for endometriosis.”

“Definitive surgery, such as hysterectomy or hysterectomy plus bilateral ­ salpingo-oophorectomy (BSO) typicallyresults in prolonged symptom relief,” Dr. ­Barbieri says. “Following hysterectomy, hormonal therapy may not be needed. Following BSO, low-dose hormonal therapy is often needed to reduce the severity of menopausal symptoms.”

Dr. Barbieri is Editor in Chief of OBG Management; Chair of Obstetrics and Gynecology at Brigham and Women’s Hospital in Boston, Massachusetts; and the Kate Macy Ladd Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School in Boston.

After surgical treatment of endometriosis associated with pain, Dr. Barbieri presents the patient with the following menu of hormonal options:

  • no hormonal therapy
  • estrogen-progestin contraceptives, either cyclic or continuous
  • the LNG-IUS
  • norethindrone acetate 5 mg daily
  • DMPA 150 mg every 3 months
  • leuprolide acetate depot 3.75 mg intra­muscularly monthly
  • nafarelin nasal spray 200 µg twice a day
  • danazol 200 mg twice a day.

“I explain the side effects common with each approach and have the patient select what she determines to be her best option,” says Dr. Barbieri. “In my experience, conservative surgery followed by hormonal therapy is effective in more than 75% of women.”

“The evidence to support postoperative hormonal therapy is modest,” Dr. Barbieri notes. “The best evidence is available for use of the LNG-IUS, estrogen-progestin contraceptives, and GnRH agonists.”20–22

In addition, “major professional societies have highlighted the option of postoperative hormonal therapy to reduce the risk of recurrent pain and repetitive surgical procedures in the future,” Dr. Barbieri says.23,24

When pain recurs after surgery for endometriosis, it pays to consider what type of pain it is, says Dr. Barbieri.

“There are 2 major types of pain—nociceptive and neuropathic,” he says. “Nociceptive pain is caused by an injury, acute or chronic. Neuropathic pain is caused by ­‘activation’ of neural circuits, sometimes in the absence of an ongoing injury. Many women with endometriosis and chronic pain have both nociceptive and neuropathic pain. Consequently, it is important to consider the use of a multidisciplinary pain practice in the management of chronic pain syndromes. Multidisciplinary pain practices have special expertise in the management of neuropathic pain. Standard conservative surgical intervention is unlikely to improve pain caused by neuropathic mechanisms. Likewise, opioid analgesics are not recommended for the treatment of neuropathic pain.”

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