Postoperative desogestrel for pelvic endometriosis-related pain: a randomized controlled trial

Objective: To determine the effectiveness of desogestrel for relieving endometriosis-related pain.

Methods: A double-blinded randomized placebo-controlled trial was conducted in 40 patients who had endometriosis with moderate-to-severe dysmenorrhea or chronic pelvic pain undergoing laparoscopic conservative surgery. After surgery, patients were randomized to desogestrel or placebo group. Outcomes included changes in visual analog scale (VAS) of dysmenorrhea, pelvic pain and dyspareunia, patient satisfaction, and adverse effects.

Results: Forty patients were randomized to desogestrel group (n?=?20) and placebo group (n?=?20). At month 6, the desogestrel group had significantly lower median VAS of overall pelvic pain, dysmenorrhea and noncyclic pelvic pain. Comparing with the placebo group, the desogestrel group had greater reduction in VAS of overall pain, dysmenorrhea and pelvic pain, but comparable reduction in VAS of dyspareunia. No patient in the desogestrel group but 4 patients in the placebo group still had moderate-to-severe pelvic pain at 6?months postoperatively. The proportion of patients who rated the treatment as very satisfied was higher in the desogestrel group than in the placebo group. There was no serious adverse event during the study period.

Conclusions: Desogestrel is effective and acceptable for postoperative therapy for patients with moderate-to-severe pain related to endometriosis.     

Pain Levels of Women Diagnosed with Endometriosis: Is There a Difference in Younger Women?

Study objectiveEarly diagnosis and treatment of endometriosis affecting adolescent women are important in preventing chronic pain. Our aim was to analyze the clinical characteristics and severity of symptoms in adolescent patients with endometriosis compared with older patients.MethodsThis single-center retrospective cohort study in a tertiary referral hospital analyzed women whose first consultation at the certified endometriosis center of Bern University Hospital between January 2017 and December 2020 resulted in the clinical diagnosis of endometriosis. Patients, divided into 2 groups by age, reported visual analog scale (VAS) scores for noncyclic pelvic pain, dysmenorrhea, dyschezia, dysuria, and dyspareunia. The symptom types and severity in the 2 groups were compared. The young patients with endometriosis were analyzed in greater detail, comparing VAS scores and types of endometriosis.ResultsFrom a total of 826 patients, 144 (17.4%) patients 24 years old or younger and 682 (82.6%) patients over 24 years old were compared. The younger patients reported significantly higher pain scores for dysmenorrhea (VAS 7.3 vs 6.6; P = .015), dyspareunia (VAS 4.6 vs 3.4; P = .001), and noncyclic pelvic pain (VAS 4.3 vs 3.7; P = .032) compared with the older patient collective. Similar results were found when excluding patients with hormonal treatment.ConclusionYoung patients with clinically diagnosed endometriosis have significantly higher dysmenorrhea and dyspareunia pain levels than older patients. By acknowledging and understanding this, early diagnosis and adequate treatment can be promoted. Dyspareunia in adolescents in particular merits clinical attention.     

Effectiveness of presacral neurectomy in women with severe dysmenorrhea caused by endometriosis who were treated with laparoscopic conservative surgery: a 1-year prospective randomized double-blind controlled trial

OBJECTIVE: The purpose of this study was to assess the effectiveness of presacral neurectomy in women with severe dysmenorrhea caused by endometriosis that was treated with conservative surgical intervention. STUDY DESIGN: One hundred forty-one sexually active women of fertile age with chronic severe dysmenorrhea caused by endometriosis were treated with conservative laparoscopic surgery. Patients were assigned randomly to not receive (group A) or receive (group B) presacral neurectomy. At 6 and 12 months after the surgical procedures, the cure rate was evaluated in each patient. The frequency and severity of dysmenorrhea, dyspareunia, and chronic pelvic pain were also evaluated at the same time intervals. RESULTS: The cure rate was significantly higher in group B compared with group A at a follow-up examination at 6 months (87.3% vs 60.3%) and 12 months (85.7% vs 57.1%). At follow-up visits, the frequency and severity of dysmenorrhea, dyspareunia, and chronic pelvic pain were significantly lower in both groups compared with baseline values; in particular, significantly lower values were observed in group B versus group A for the severity. CONCLUSION: Presacral neurectomy improves the cure rate in women who are treated with conservative laparoscopic surgery for severe dysmenorrhea caused by endometriosis.     

Stage and localization of pelvic endometriosis and pain

We analyzed the prevalence of dysmenorrhea, pelvic pain, and dyspareunia in relation to the disease stage in 160 women with endometriosis but no other associated pelvic disease who underwent their first gynecologic surgery (laparoscopy or laparotomy) at the First Obstetric and Gynecology Clinic of the University of Milan between 1985 and 1987. Dysmenorrhea was reported by 78% of the patients, pelvic pain by 39%; and deep dyspareunia by 32%. No relation was found between severity of the pain symptoms and stage of the disease or site of the endometriotic lesions.     

Presacral neurectomy for the treatment of pelvic pain associated with endometriosis: a controlled study.

OBJECTIVE: Our objective was to evaluate the efficacy of presacral neurectomy combined with conservative surgery for the treatment of pelvic pain associated with endometriosis. STUDY DESIGN: In a randomized, controlled study performed in a tertiary institution 71 patients with moderate or severe endometriosis and midline dysmenorrhea were randomly assigned to conservative surgery alone (n = 36) or conservative surgery and presacral neurectomy (n = 35). Main outcome measures were relief of dysmenorrhea, pelvic pain, and deep dyspareunia after surgery according to a multidimensional and an analog pain scale. RESULTS: Presacral neurectomy markedly reduced the midline component of menstrual pain, but no statistically significant differences were observed between the two groups in the frequency and severity of dysmenorrhea, pelvic pain, and dyspareunia in the long-term follow-up. After presacral neurectomy, constipation developed or worsened in 13 patients and urinary urgency occurred in three and a painless first stage of labor in two. CONCLUSION: Presacral neurectomy should be combined with conservative surgery for endometriosis only in selected cases.     

Existe-t-il une corrélation anatomoclinique entre endométriose minime et endométriose sévère ?: Premiers résultats du registre régional d’Auvergne de l’endométriose

OBJECTIVE: With a prospective study, to evaluate the existence of two distinct clinical diseases in the endometriosis syndrome, by comparing pain symptoms and quality of life from patients with minimal endometriosis (AFS-R<5) and data from patients with severe disease (deep infiltrating nodules and/or ovarian endometrioma). PATIENTS AND METHODS: Patients with minimal disease (group A with AFS-R<5) and severe endometriosis (group B) are selected from the Auvergne Endometriosis Registry which started in January 2004. They have never been treated before for endometriosis. A surgical laparoscopic and a pathological diagnosis are required for the subjects to be included. Pelvic pain is assessed using a standardized questionnaire, and a visual analogue scale, quality of life using SF-36. The two groups are compared for the incidence and the severity of pelvic pain and for the impairment of their quality of life. RESULTS: Forty-seven patients have a minimal disease, whereas 111 have a severe endometriosis. Demographic characteristics are similar in both groups. Quality of life (SF-36) and pelvic pains included chronic pelvic pain, dyspareunia, dysuria, and defecation disorders are as common and severe in both groups. However, dysmenorrhea is more affected in group B than in group A (p=0.03). DISCUSSION AND CONCLUSION: We find no relationship between severity of symptoms, quality of life, and the extent of endometriotic lesions at surgery. There would be no differences between minimal and severe disease. It could be explained by different painful mechanisms between minimal and severe endometriosis.     

Long-term effectiveness of presacral neurectomy for the treatment of severe dysmenorrhea due to endometriosis

STUDY OBJECTIVE: To assess the long-term effectiveness of presacral neurectomy (PSN) in women with severe dysmenorrhea due to endometriosis treated with conservative laparoscopic surgical intervention. DESIGN: Randomized, controlled trial (Canadian Task Force classification I). SETTING: University-affiliated department of obstetrics and gynecology. PATIENTS: One hundred forty-one sexually active women of reproductive age. INTERVENTION: Conservative laparoscopic surgery without (group A) or with (group B) PSN. MEASUREMENTS AND MAIN RESULTS: At entry and 24-months after surgical procedures, cure rates; frequency and severity of dysmenorrhea, dyspareunia, and chronic pelvic pain; and quality of life were evaluated. At follow-up visit, the cure rate was significantly (P<0.05) higher in group B (83.3%) than in group A (53.3%). The frequency and severity of dysmenorrhea, dyspareunia, and chronic pelvic pain were significantly (P<0.05) lower in both groups compared with baseline values, and only severity was significantly (P<0.05) lower in group B. A significant (P<0.05) improvement in quality of life was observed after surgery in both groups and was significantly (P<0.05) increased in group B compared with group A. CONCLUSION: PSN improves long-term cure rates and quality of life in women treated with conservative laparoscopic surgery for severe dysmenorrhea due to endometriosis.     

Is endometriosis really associated with pain?

To address the contrasting findings regarding how pain is related to endometriosis, the relationship between pain and stage of endometriosis was dissected differently by the chief complaint to eliminate selection biases. A total of 1,092 women with endometriosis were classified into two groups depending on their chief complaint, i.e., infertility (infertility group; n = 476) or pain (pain group; n = 616). The correlations between disease stage and various types of pain were analyzed differently in each group. The frequencies of chronic pelvic pain and dyspareunia increased with disease stage either in the infertility group, in the pain group or in the aggregate. On the other hand, no significant relation between the severity of dysmenorrhea and disease stage was observed in the aggregate. Interestingly, a parallel increase in the severity of dysmenorrhea with disease stage was observed in the infertility group, but not in the pain group. In view of selection biases involved in analyzing endometriosis associated with pain, these results could be seen to support the contention that chronic pelvic pain, dyspareunia and dysmenorrhea are in fact related to the extent of endometriosis.     

The expression and functionality of transient receptor potential vanilloid 1 in ovarian endometriomas

Pains of various kinds-dysmenorrhea, chronic pelvic pain, and dyspareunia-are the major complaints from women with endometriosis, representing the most debilitating nature of the disease. Despite extensive research, our understanding as how endometriosis causes pain is still fragmentary. In this study, we examined transient receptor potential vanilloid 1 (TRPV1)-positive nerve fibers in ectopic endometrium from women with ovarian endometriomas and in endometrium from women without endometriosis and correlated the density with the severity of dysmenorrhea in cases. We also performed an immunohistochemistry analysis of TRPV1 in ectopic and control endometrium. After finding TRPV1 immunoreactivity in ectopic endometrial cells, we further examined whether TRPV1 is functional in ectopic endometrial stromal cells (EESCs). We found that the density of TRPV1-positive nerve fibers in ectopic endometrial implants is higher than that in control endometrium and correlates positively with the severity of dysmenorrhea in women with endometriosis. In addition, TRPV1 expression was also found to be elevated significantly in EESCs when stimulated with inflammatory mediators such as prostaglandin E2 (PGE(2) ) and tumor necrosis factor-α (TNF-α). Finally, we found that TRPV1 activation can induce the release of nitric oxide (NO) and interleukin 1β (IL-1β) in EESCs. The latter finding appears to be consistent with the reports of increased TRPV1 protein expression following peripheral inflammation. Our results suggest that the increased TRPV1-positive nerve fibers may integrate various stimuli on peripheral terminals or primary sensory neurons and generate hyperalgesia in endometriosis. The expression and functionality of TRPV1 in EESCs also suggest that TRPV1 may have neurosecretory functions that are yet to be elucidated.     

Comparison of a levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study

OBJECTIVE: To determine whether the frequency and severity of dysmenorrhea are reduced in women with symptomatic endometriosis in whom a levonorgestrel-releasing intrauterine device (Lng-IUD) is inserted after operative laparoscopy compared with those treated with surgery only. DESIGN: Open-label, parallel-group, randomized, controlled trial. SETTING: A tertiary care and referral center for patients with endometriosis. PATIENTS(S): Parous women with moderate or severe dysmenorrhea undergoing first-line operative laparoscopy for symptomatic endometriosis. INTERVENTION(S): Randomization to immediate Lng-IUD insertion or expectant management after laparoscopic treatment of endometriotic lesions.Proportions of women with recurrence of moderate or severe dysmenorrhea in the two study groups 1 year after surgery and overall degree of satisfaction with treatment.Moderate or severe dysmenorrhea recurred in 2 of 20 (10%) subjects in the postoperative Lng-IUD group and 9/20 (45%) in the surgery-only group. Thus, a medicated device inserted postoperatively will prevent the recurrence of moderate or severe dysmenorrhea in one out of three patients 1 year after surgery. A total of 15/20 (75%) women in the Lng-IUD group and 10/20 (50%) in the expectant management group were satisfied or very satisfied with the treatment received. CONCLUSION(S): Insertion of an Lng-IUD after laparoscopic surgery for symptomatic endometriosis significantly reduced the medium-term risk of recurrence of moderate or severe dysmenorrhea.     

盆腔子宫内膜异位症患者的疼痛症状分析

调查１９９１年２月至１９９３年１月在我院妇科在住院的３８３例生育年龄患者的疼痛症状，其中子宫内膜异位异（异位症）患者１９２例（异位症组），其它疾病患者１９１例（对照组）。结果，痛经，非经期下腹或盆腔痛，性交痛，经期肛门坠痛的发生率，异位症组分别为６５．６％，４４．３％，３０?２％和３２．３％，对照组分别为３７．７％、３３．０％、２０．９％和２０．４％；异位症组的疼痛发生率均分别高于对照组，两者比较     

Endometriosis in patients with chronic pelvic pain: is staging predictive of the efficacy of laparoscopic surgery in pain relief?

BACKGROUND/AIMS: Endometriosis is considered an important cause of chronic pelvic pain. Despite its high prevalence, controversy still exists regarding the true association between the extent of endometriosis and the severity of symptoms. We conducted this prospective study to investigate the association between the stage of endometriosis and type and severity of pain, and to evaluate the efficacy of laparoscopic surgery in pain relief. METHODS: Ninety-five patients complaining of chronic pain were diagnosed with endometriosis and were treated with laparoscopic surgery. The severity of pain was assessed in patients with an endometriosis AFS (American Fertility Society) score less than 16 (group 1) and those with an AFS score greater than or equal to 16 (group 2), preoperatively and 6 months after surgery, using a visual pain scale. Any reduction in pain scores by 2 points or more was considered to be an improvement. RESULTS: Dysmenorrhea and deep dyspareunia, were significantly more frequent in patients of group 2. Preoperative pain scores were significantly higher for dysmenorrhea (p = 0.0022) and deep dyspareunia (p < 0.0001) but not for non-menstrual pain in group 2. Deep dyspareunia was correlated with the presence of dense pelvic adhesions. After surgery, dysmenorrhea improved in 43% of cases in group 1, vs. 66% of cases in group 2 (p = 0.0037). For deep dyspareunia, improvement was reported by 33% in group 1, vs. 67% in group 2 (p = 0.074). Improvement in non-menstrual pain was not significantly different between the two groups (67% vs. 56%). CONCLUSIONS: Advanced endometriosis is more frequently related to dysmenorrhea and deep dypareunia in comparison to early disease. Laparoscopic surgery may offer relief or improvement in the majority of patients with endometriosis and chronic pelvic pain. Cases with advanced disease seem to benefit the most.     

Presacral neurectomy for chronic pelvic pain

Over an eight-year period, 50 presacral neurectomies were performed at Madigan Army Medical Center for chronic pelvic pain failing response to medical management. Each hospital record was reviewed and 45 patients answered a questionnaire grading the severity of their pain from 0 to 10 for dysmenorrhea, dyspareunia, and other pelvic pain before and after surgery. The results showed success rates of 73% in relieving dysmenorrhea, 77% in relieving dyspareunia, and 63% in relieving other pelvic pains. The addition of a bilateral uterosacral ligament resection to the presacral neurectomy did not increase the success rate. There was an 18% lateral pelvic pain recurrence rate, and no recurrence of dysmenorrhea. Complications occurred in 4%.     

腹腔镜下单极电消融术治疗子宫腺肌病术后痛经缓解程度的分析

目的 探讨腹腔镜下单极电消融术治疗子宫腺肌病痛经缓解的疗效。方法 对20例子宫腺肌病患者行腹腔镜下单极电消融术，观察其痛经缓解情况，并将治疗前后痛经程度的各项指标根据慢性疼痛分级问卷法进行评分和统计学分析。结果 35％的患者术后第1个月痛经即消失；45％的患者术后3个月痛经消失；20％的患者术后随着月经周期的推移而逐渐缓解。平均观察4～8个月经周期，17例（85％）完全缓解，3例（15％）明显缓解，无部分缓解和无效病例。结论 腹腔镜下单极电消融术治疗子宫腺肌病，痛经缓解明显。     

Cyclooxygenase-2 expression in deep endometriosis and matched eutopic endometrium

OBJECTIVE: To identify any relationship between cyclooxygenase-2 expression and the intensity of severe, endometriosis-related dysmenorrhea. DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): Patients with deep endometriosis. INTERVENTION(S): During surgery, paired samples of tissue representing deep endometriosis and eutopic endometrium were obtained from 46 patients. Control endometrial tissue samples were obtained from 34 fertile women who underwent laparoscopic tubal ligation or reversal of tubal sterilization. Pain assessment for dysmenorrhea was done with a 10-point linear analogue scale. MAIN OUTCOME MEASURE(S): The percentage of surface immunostained for Cox-2 was determined by an immunohistochemical technique. Relationships between pain score for dysmenorrhea and Cox-2 expression were analyzed. RESULT(S): Cox-2 expression was significantly higher in eutopic endometrial stromal cells from patients with deep endometriosis than in stroma from controls during the early, mid, and late secretory phases. In endometriosis patients, Cox-2 expression in eutopic endometrial stromal cells was significantly higher in women with more severe dysmenorrhea (pain score > or =7 vs. <7) during early and mid secretory phases. CONCLUSION(S): Elevated Cox-2 expression in stromal cells in eutopic endometrium from patients with deep endometriosis may play a role in severe, endometriosis-related dysmenorrhea.     

左炔诺孕酮宫内缓释系统治疗阴道直肠隔子宫内膜异位症的临床观察

目的:探讨左炔诺孕酮宫内缓释系统(LNG-IUS)治疗阴道直肠隔子宫内膜异位症(RVEM)疼痛的有效性。方法:回顾分析2006年1月至2009年4月就诊于北京协和医院19例有中、重度痛经的RVEM患者应用LNG-IUS的治疗效果,所有RVEM患者的诊断均经活检病理证实。应用LNG-IUS后随访6个月、1年、2年、3年,妇科查体结节大小、CA125、各种疼痛症状、月经情况以及副作用。结果:放置LNG-IUS后3年后,痛经评分由原来的8.42±1.34下降为2.36±2.73(P=0.003)。血清CA125从放置6个月时开始显著下降(P0.0001)。6个月时痛经、性交痛缓解率可达100%,经期大便痛缓解率89.47%。36个月时3者缓解率分别为84.62%、76.92%、69.23%。放置LNG-IUS后复发率较术后期待治疗明显下降,1年复发率为0,2年复发率6.7%(1/15),3年复发率23.1%(3/13)。放置LNG-IUS后1年内经期延长和不规则出血是常见现象,随着放置时间延长,情况有所缓解。结论:深部侵润型子宫内膜异位症不愿手术者,应用LNG-IUS在短期内可有效地缓解疼痛,但随着放置时间的延长,疼痛的复发几率增加。     

Vascular endothelial growth factor (VEGF) and ovarian endometriosis: correlation between VEGF serum levels, VEGF cellular expression, and pelvic pain

Vascular endothelial growth factor (VEGF) serum levels and VEGF and cellular expression were prospectively analyzed in 60 patients (group A consisted of asymptomatic patients or patients presenting mild dysmenorrhea; 30 women comprised group B severe dysmenorrhea and/or chronic pelvic pain and/or dyspareunia) who underwent surgery for cystic ovarian endometriosis to asses whether a correlation exists among VEGF serum levels, VEGF cellular expression, and pelvic pain. No differences were found in VEGF serum levels and VEGF cellular expression between both groups. Therefore, we conclude that pain symptoms in ovarian endometriosis are not correlated with VEGF serum levels and VEGF cellular expression.     

Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized,controlled trial

OBJECTIVE: To evaluate the efficacy of laparoscopic resection of the uterosacral ligaments in women with endometriosis and predominantly midline dysmenorrhea. DESIGN: Randomized controlled trial. SETTING: Two academic departments.One hundred eighty patients undergoing operative laparoscopy as first-line therapy for stage I to IV symptomatic endometriosis. INTERVENTION(S): Operative laparoscopy including uterosacral ligament resection or conservative surgery alone. MAIN OUTCOME MEASURE(S): Proportion of women with recurrence of moderate or severe dysmenorrhea 1 year after surgery. RESULT(S): No complications occurred. Among the patients who were evaluable 1 year after operative laparoscopy, 23 of 78 (29%) women who had uterosacral ligament resection and 21 of 78 (27%) women who had conservative surgery only reported recurrent dysmenorrhea. The corresponding numbers of patients at 3 years were 21 of 59 (36%) women and 18 of 57 (32%) women, respectively. Time to recurrence was similar in the two groups. Pain was substantially reduced, and patients in both groups experienced similar and significant improvements in health-related quality of life, psychiatric profile, and sexual satisfaction. Overall, 68 of 90 (75%) patients in the uterosacral ligament resection group and 67 of 90 (74%) patients in the conservative surgery group were satisfied at 1 year. CONCLUSION(S): Addition of uterosacral ligament resection to conservative laparoscopic surgery for endometriosis did not reduce the medium- or long-term frequency and severity of recurrence of dysmenorrhea.     

A randomized pilot study of acupuncture treatment for primary dysmenorrhea

Objective

To compare the therapeutic effect of acupuncture and non-steroidal anti-inflammatory drug (NSAID) therapy in primary dysmenorrhea patients.

Study design

Thirty-five young women with a diagnosis of primary dysmenorrhea were recruited for the study. Their dysmenorrhea severity was rated by visual analog scale (VAS) immediately prior to entry into the study. They were randomly divided into two groups; and the following month they were given NSAID (group 1, n = 24) or acupuncture treatment (group 2, n = 11). Pain was rated again using VAS during menstruation in both groups.

Results

After one month's treatment, pain scores were significantly lower in both groups (p < 0.05). Mean pain scores decreased by 52.2% and 69.5% in the NSAID and acupuncture groups, respectively.

Conclusion

Acupuncture was as effective as NSAID therapy for patients with primary dysmenorrhea. Since this was a pilot study with a small sample size and short follow-up period, larger studies are needed to clarify the effect of acupuncture in the treatment of primary dysmenorrhea.     

Identifying Preoperative Factors Associated with Nonresponders in Women Undergoing Comprehensive Surgical Treatment for Endometriosis

Study ObjectiveTo examine whether existing quality of health outcome measures can be used to predict or have an association with nonresponse surgery for endometriosis.DesignRetrospective cohort study.SettingsSingle endometriosis referral center.PatientsWomen (n = 198) undergoing surgery for endometriosis.InterventionsValidated health questionnaires and visual analogue scales.Measurements and Main ResultsPatients were given validated health questionnaires, including Endometriosis Health Profile 30, Gastrointestinal Quality of Life Index, EuroQol-5, Hospital Anxiety and Depression Scale, preoperatively and at 12 months after full surgical excision of endometriosis. Visual analogue scales were also used that measured dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain. Surgical management was dependent on severity of disease. Superficial disease was treated by laparoscopic peritoneal excision or laser ablation. Deep infiltrating disease involving the bowel was excised completely together with laparoscopic bowel surgery (shave, disc, or segmental resection) with/without concomitant total hysterectomy and bilateral salpingo-oophorectomy. Nonresponders were defined as women who failed to demonstrate an improvement in pain scores 12 months postoperatively. We examined preoperative and postoperative questionnaires, visual analogue scores, and other variables such as age at onset of symptoms, type of surgery, and the presence of postoperative complications comparing responder and nonresponder women to identify the factors associated with nonresponse. Of 102 women treated for superficial endometriosis, 25 (24.51%) were nonresponders. No factors were associated with nonresponse at 12 months. Of 96 women treated for severe endometriosis involving the bowel, 10 (10.41%) were nonresponders. Nonresponders had significantly less preoperative pain (p = .031) and feeling of control (p = .015) than responders. There was no association between nonresponders and women who underwent a hysterectomy with bilateral salpingo-oophorectomy or those with complications. Radical bowel surgery (resection) was associated with nonresponders.ConclusionMinimal preoperative factors are associated with nonresponse for women having surgery for endometriosis. The severity of pain experienced by women with endometriosis may be used to predict their response to surgery.