Biopsychosocial correlates of persistent postsurgical pain in women with endometriosis

Objective

To examine pain and biopsychosocial correlates over time for women with persistent postsurgical pain after surgery for endometriosis.

Methods

Cross-sectional study of women who underwent any endometriosis surgery between 2003 and 2006. Following surgery, patients completed validated questionnaires (Short-Form McGill Pain Questionnaire, 12-item Short-Form Health Survey, Beck Depression Inventory, Coping Strategies Questionnaire catastrophizing subscale). The primary outcome was pelvic pain intensity, measured by the McGill total pain score. Bivariate comparisons between each potential predictor and pain intensity were performed using the χ² and t tests, 1-way analysis of variance, and simple linear regression.

Results

In total, 79 completed the questionnaires and were included in the present analysis. The McGill affective pain score was negatively correlated with age (β-coefficient –0.12, P = 0.002) and positively correlated with catastrophization (β-coefficient 0.66, P = 0.01). Women with a history of dyspareunia scored significantly higher on the McGill total pain score (P < 0.001); there was no association between pain intensity and endometriosis severity.

Conclusion

Younger age and catastrophization are correlated with persistent pain following surgery for endometriosis. The severity of endometriosis does not predict persistent pain. Further evaluation of psychosocial factors may identify patients who are least likely to benefit from surgeries for endometriosis-associated pelvic pain.     

子宫内膜异位症患者盆腔粘连与疼痛的相关性

目的 探讨子宫内膜异位症(内异症)患者中盆腔粘连的发生率及其与疼痛症状的相关性. 方法 分析2003年1月至2007年12月间480例内异症患者盆腔粘连及痛经、慢性盆腔痛(CPP)、性交痛与排便痛的发生情况,评价内异症患者的盆腔粘连与疼痛症状之间的相关性.根据美国生育学会1985年修订的内异症分期标准(r-AFS)分为Ⅰ期155例,Ⅱ期33例,Ⅲ期108例,Ⅳ期184例. 结果 (1)480例内异症患者中,72.3%(347/480)存在盆腔粘连;Ⅰ期25.2%(39/155),Ⅱ期78.8%(26/33),Ⅲ期90.7%(98/108),Ⅳ期100.0%(184/184),且盆腔粘连程度与内异症的临床期别间呈正相关关系(rs=0.870,P<0.01);(2)480例内异症患者中,伴痛经者占61.0%(293/480),其中轻、中、重度痛经分别为52.2%(153/293)、26.6%(78/293)、21.2%(62/293);伴CPP者占23.8%(114/480),伴性交痛者占15.4%(74/480),伴排便痛者占7.1%(34/480);(3)卵巢粘连与痛经和CPP呈正相关关系(rs=0.367、0.267,P<0.01);子宫底后壁粘连与痛经和CPP呈正相关关系(rs=0.336、0.164,P<0.01);输卵管粘连与痛经、CPP和排便痛均呈显著正相关关系(rs=0.283、0.225、0.159, P<0.01);直肠粘连与痛经呈正相关关系(rs=0.101,P<0.05).除性交痛外,内异症患者的盆腔粘连程度与其痛经、CPP及排便痛均呈正相关关系(rs=0.470、0.273、0.132、P<0.01).结论 盆腔粘连是内异症的特征性病变,粘连部位及程度与疼痛症状密切相关.     

子宫内膜异位症患者疼痛与盆腔病灶解剖分布的关系

目的研究子宫内膜异位症（内异症）患者疼痛症状与盆腔病灶解剖分布特点的关系。方法详细记录130例内异症患者痛经、慢性盆腔痛（CPP）、性交痛及排便痛的发生情况。以腹腔镜检查为诊断标准。评价疼痛症状包括痛经、CPP、性交痛及排便痛与盆腔内不同部位内异症病灶的关系。结果130例内异症患者中,痛经100例（76．9％）,无痛经30例（23．1％）。轻、中度和重度痛经者分别为27例（20．8％）、41例（31．5％）、32例（24．6％）,性交痛46例（35．4％）,CPP45例（34．6％）,排便痛67例（51．5％）。痛经者深部宫骶韧带结节、阴道直肠隔结节发生率分别为45．0％、16．0％,无痛经者深部宫骶韧带结节、阴道直肠隔结节发生率为13．3％、0,两者分别比较,差异均有统计学意义（P=0．00、P=0．01）;痛经者与无痛经者比较,子宫直肠窝封闭的比例增加（分别为41．0％、10．0％,P=0．00）,深部浸润型内异症（DIE）比例增加（分别为51．0％、16．7％,P=0．00）。痛经程度与宫骶韧带结节的数目（P=0．005,r=0．302）、宫骶韧带结节浸润深度（P=0．017,r=0．227）呈线性相关。痛经伴卵巢内异症囊肿患者中,发生中、重度盆腔粘连的比例增加（分别为29．1％、8．3％,P=0．029）。与无CPP的患者比较,CPP患者深部宫骶韧带结节（分别为51．1％、30．6％,P=0．018）以及DIE（分别为57．8％、35．3％,P=0．011）比例明显升高。与无排便痛的患者比较,排便痛患者深部宫骶韧带结节（分别为46．3％、28．6％,P=0．028）、阴道直肠隔结节（分别为19．4％、4．8％,P=0．01）、子宫直肠窝封闭（分别为44．8％、22．2％,P=0．005）以及DIE（分别为53．7％、31．7％,P=0．01）的比例升高。阴道直肠隔结节是性交痛的独立危险因素（OR=3．61）。结论痛经、CPP、性交痛以及排便痛与盆腔内异症病灶的部位和浸润深度有关,位于盆腔后部的深部浸润病灶以及子宫直肠窝封闭与疼痛症状关系密切。     

不同糖耐量状态肥胖儿童血清脂联素的变化及其临床意义

目的了解不同葡萄糖耐量状态的肥胖儿童血清脂联素水平，探讨其与年 龄、体重指数(BMI)、血脂、血糖及胰岛素水平的关系。 方法选择2002~2004年于广州市儿童医院初诊并住院诊治的肥胖儿童52例，分为36例糖耐量正常(NGT)肥胖组和16例糖耐量受损(IGT)肥胖组。测定两组肥胖儿童和41例年龄、性别匹配的正常儿童空腹血清脂联素、胆固醇(CHO)、甘油三酯(TG)、低密度脂蛋白胆固醇(LDL C)、血糖和胰岛素(FINS)，计算胰岛素抵抗指数(HOMA IR)。肥胖组儿童均做口服葡萄糖耐量试验(OGTT)，测定OGTT 2h血糖和胰岛素。 结果正常对照组、NGT肥胖组及IGT肥胖组血清脂联素水平依次降低，HOMA IR依次升高，且均有统计学意义；相关性分析显示肥胖儿童血清脂联素与TG、LDL C、FINS呈显著负相关(P<005)。 结论肥胖儿童血清脂联素水平降低，并与血脂、胰岛素抵抗密切相关；与NGT肥胖组相比，IGT肥胖组儿童的血清脂联素水平进一步降低。     

The prevalence of sexual dysfunction and associated risk factors in women with chronic pelvic pain: a cross-sectional study

The aims of the study were to determine the prevalence of sexual dysfunction, its subtypes and associated risk factors in women with chronic pelvic pain (CPP) as compared to a general female population. We evaluated 112 women (mean age 34.73 ± 8.07; age range 18–50) complaining of CPP with a comprehensive history including female sexual function index (FSFI) and several general assessment questions (GAQs), a complete physical examination and routine laboratory tests. A group of 108 healthy women (mean age 33.28 ± 7.95; age range 19–52) without CPP were enrolled as cross-sectional controls. According to the general population, the incidence of female sexual dysfunction (FSD) was 67.8% in women with CPP and 32.2% in women without CPP (P < 0.0001). Among 112 CPP patients, 78 (69.6%) of them had FSD and 34 (30.4%) patients did not have FSD in the study (P < 0.0001). In that 78 patients, 42 patients (53.8%) had hypoactive sexual desire disorder, 26 patients (33.3%) had sexual arousal disorder, 17 patients (21.7%) had orgasmic disorder and finally 58 patients (74.3%) had sexual pain disorder. The FSFI scores in both groups were as follows: (patients vs. controls; median value; P value, respectively): desire: 3.31 versus 3.98 (P < 0.0001); arousal: 3.58 versus 4.35 (P < 0.0001); lubrication: 4.20 versus 4.88 (P < 0.0001); orgasm: 3.70 versus 4.48 (P < 0.0001); sexual satisfaction: 3.80 versus 4.64 (P < 0.0001); sexual pain: 2.75 versus 4.98 (P < 0.0001) and total FSFI score: 21.35 versus 27.29 (P < 0.0001). The prevalence of FSD was higher in women with CPP than in a general healthy population not complaining of CPP. Investigation of female sexuality was essential for these patients.     

Laparoscopic treatment of pelvic pain associated with minimal and mild endometriosis with use of the Helica Thermal Coagulator

OBJECTIVE: To investigate the clinical efficacy and safety of Helica Thermal Coagulator (TC) in the treatment of pelvic pain associated with minimal (stage I) and mild (stage II) endometriosis. DESIGN: A clinical observational study. SETTING: A referral center for laparoscopic treatment of endometriosis. PATIENT(S): Eighty-one women with pelvic pain symptoms associated with minimal and mild endometriosis diagnosed at laparoscopy. INTERVENTION(S): Helica TC to treat endometriotic lesions. The revised American Fertility Society (rAFS) classification was used to stage endometriosis. Pain symptoms and patient satisfaction were assessed subjectively at 3 and 6 months follow-up. MAIN OUTCOME MEASURE(S): Improvement or relief of pelvic pain symptoms, and intra- or postoperative complications. RESULT(S): A total of 79 women completed the study to 6 months follow-up. At 3 months, 59 (74.7%) women reported resolution and satisfactory improvement of symptoms, whereas 20 (25.3%) women continued to experience painful symptoms. At 6 months, 69 (87.4%) women reported resolution and satisfactory improvement of symptoms, whereas 9 (11.4%) women reported no changes and 1 (1.2%) woman experienced worsening symptoms. No significant differences were found between minimal and mild disease. No side effects or surgical complications occurred. CONCLUSION(S): Meaningful improvements and relief in clinical symptoms can be obtained with conservative laparoscopic surgery. Helica TC is a simple, effective, and safe device for the treatment of pelvic pain in women with stages I and II endometriosis. This approach requires further evaluation as part of randomized controlled trials.     

Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis

Objective: To assess the longer term efficacy of laparoscopic laser surgery in the treatment of painful pelvic endometriosis and to observe the natural history of the disease at second-look laparoscopy in a control group.

Design: One-year follow-up of a prospective, randomized, double-blind controlled trial.

Setting: A referral center for the laparoscopic laser treatment of endometriosis.

Patient(s): Sixty-three patients with pelvic pain and minimal to moderate endometriosis.

Intervention(s): After the 6-month follow-up visit, the randomization code was broken, and follow-up was continued to 1 year. Symptomatic patients were offered second-look laser laparoscopy.

Main Outcome Measure(s): Continued symptom relief at 1 year after treatment and findings at second-look laparoscopy in symptomatic controls.

Result(s): Symptom relief continued at 1 year in 90% of those who initially responded. All symptomatic controls had a second-look procedure, with 7 (29%) showing disease progression, 7 (29%) showing disease regression, and 10 (42%) having static disease.

Conclusion(s): The benefits of laser laparoscopy for painful pelvic endometriosis are continued in the majority of patients at 1 year. Untreated painful endometriosis will progress or remain static in the majority of patients but will spontaneously improve in others.     

Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain: a prospective cohort study

OBJECTIVE: To assess the efficacy of conscious pain mapping in diagnosing and treating chronic pelvic pain (CPP). DESIGN: Prospective cohort study. Setting Gynaecology Department, UK District General Hospital. POPULATION: Forty-three women diagnosed with CPP. METHODS: The cohort was followed up for 18-24 months after diagnosis and treatment based on conscious pain mapping. MAIN OUTCOME MEASURES: Improvement of pain assessed by using visual analogue scale (VAS) pain scores at 6-month follow up. RESULTS: Thirty-nine women had successful conscious pain mapping. Pelvic pathology was identified in 18, pelvic congestion in 13 and 8 women had normal pelvic organs. In 35 women (90%), conscious pain mapping identified the cause of pain. Five out of eight women (63%) who were judged to have a normal pelvis had positive findings at pain mapping. VAS scores fell significantly from pre-treatment to post-treatment values at 6-month follow up (P < 0.01). Overall, 26 women (74%) felt that their symptoms had improved after treatment based on findings at pain mapping. However, we concluded that pain mapping only contributed to the diagnosis and treatment in seven women (27%), who may not have received appropriate diagnosis and treatment if they had a laparoscopy under general anaesthetic. Conclusions CONSCIOUS: pain mapping is a useful additional investigation in the management of women with CPP. It can be employed in women with a negative laparoscopy or with visible pathology where the conventional treatment has failed.     

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.     

Long-term follow-up after laparoscopic treatment for endometriosis: multivariate analysis of predictive factors for recurrence of endometriotic lesions and pain

Objective

To investigate factors that might influence the recurrence of both painful symptoms and endometriotic lesions following laparoscopic treatment of endometriosis.

Study design

Retrospective cohort study in a University teaching hospital. We reviewed data from patients referred for laparoscopy between March 1993 and November 2007. We selected women who were followed up throughout Transvaginal-ultrasound (TV-US) after a first conservative laparoscopy for endometriosis. After laparoscopy, all patients were followed up according to an internal protocol: a standard gynaecologic examination, the assessment of painful symptoms and a TV-US scan that were repeated at 3, 6, and 12 months, and subsequently on a yearly basis. Sixteen factors were assessed by univariable and multivariable Cox proportional hazards models to evaluate their associations with recurrence of endometriotic lesions and pain related-endometriosis.

Results

401 women were enrolled. A total of 154 (38.4%) experienced moderate or severe pain after laparoscopy; endometriotic lesions were observed by TV-US in 74 (18.4%) patients. In the multivariable model, age at menarche, severity of chronic pelvic pain (CPP) and dysmenorrhoea prior to surgery were significant risk factors for recurrence/occurrence of pain. Age at the first laparoscopy, stage of disease, pre-operative severity of CPP, and pregnancy were predictive factors of the recurrence for such lesions.

Conclusion

The severity of CPP prior to the first laparoscopy showed the only significant factor in the overall prediction of recurrence of pain and endometriotic lesions. Patients with severe CPP at the time of their first surgery might represent a sub-group of women with a more aggressive form of endometriosis.     

Correlation between symptoms of pain and peritoneal fluid inflammatory cytokine concentrations in endometriosis

Endometriosis affects 10–20% of women during reproductive age and is a common cause of infertility and pain leading to work absenteeism and reduced quality of life.The objective of this study was to investigate the association between the presence and concentration of interleukin-8 (IL-8), RANTES, osteoprotegerin (OPG), pregnancy-associated plasma protein A (PAPP-A), tumour necrosis factor-α (TNF-α), midkine and glycodelin in the peritoneal fluid (PF) and the intensity of pain reported by patients undergoing laparoscopy in our clinic. They rated their pain during menstruation, intercourse and lower abdominal using a visual analogue scale. During laparoscopy, PF was aspirated. Pain scores were correlated to the concentration of the above substances in the PF and to the stage of endometriosis. Endometriosis was histologically confirmed in 41 of 68 participating women; 27 without such evidence were considered as controls. TNF-α and glycodelin correlated positively with the level of menstrual pain. For IL-8, RANTES, OPG and PAPP-A no correlation between their PF concentration and the menstrual pain scores was observed. Patients with severe dysmenorrhoea had increased PF cytokine and marker levels; the difference was significant for TNF-α and glycodelin when compared with the other patients (no or moderate pain). TNF-α and glycodelin may thus play a role in endometriosis and the severity of menstrual pain.     

Incidence and characterization of diagnosed endometriosis in a geographically defined population

OBJECTIVE: We examined whether widespread use of laparoscopy was accompanied by increased diagnosis of asymptomatic endometriosis, inflated rates of diagnosis, or changes in the clinical spectrum of disease. DESIGN: Population-based cohort. SETTING: Olmsted County, Minnesota. PATIENT(S): All participants were women residents, aged > or =15 years. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): We estimated the likelihood that women with a surgical procedure during which endometriosis could be visualized would receive a surgical diagnosis, as well as the proportions of all diagnoses, regardless of setting, that were [1] assigned without surgery, [2] refuted by surgery, [3] surgically confirmed, and [4] asymptomatic. The incidence of diagnosed endometriosis for 1987 to 1999 was compared with published rates for 1970 to 1979. RESULT(S): Of 8,229 women aged > or =15 years with > or =1 surgery during which endometriosis could be visualized, 11.5% received a surgical diagnosis of endometriosis. The incidence of diagnosed endometriosis, regardless of setting, was 1.9 per 1,000 person-years (10% were without relevant surgery, 6% had surgery but no surgical evidence, 85% had surgical evidence); 85% of surgically confirmed diagnoses had presenting symptoms. Using definitions comparable with those in the 1970 to 1979 study, the 1987 to 1999 incidence was 2.46 per 1,000 versus 2.49 per 1,000 for 1970 to 1979; 88% of symptomatic incident diagnoses were surgically confirmed versus 65% for 1970 to 1979. CONCLUSION(S): Widespread use of laparoscopy does not appear to have contributed to dramatically increased rates of endometriosis diagnoses but rather to a smaller proportion of diagnoses being assigned without surgical confirmation.