Menstrual symptoms in women with pelvic endometriosis

OBJECTIVE--To investigate menstrual symptoms in relation to pelvic pathology. DESIGN--A prospective questionnaire-based study. SETTING--Aberdeen Royal Infirmary, Scotland. SUBJECTS--1250 questionnaires were sent out prior to planned admission and 1200 women (96%) brought the completed questionnaires. They comprised 598 women undergoing laparoscopic sterilization, 312 having laparoscopy because of infertility, 156 having laparoscopy because of chronic pelvic pain and 134 women undergoing abdominal hysterectomy for dysfunctional uterine bleeding. MAIN OUTCOME MEASURES--The occurrence of dysmenorrhoea, menorrhagia, menstrual regularity, premenstrual spotting, deep dyspareunia and pelvic pain in women with either endometriosis and post infective pelvic adhesions or a normal pelvis. RESULTS--Menorrhagia, menstrual irregularity and premenstrual spotting occurred with equal frequency in all groups. Deep dyspareunia, pain after intercourse and recurrent pain unrelated to menstruation or coitus was more common in women with endometriosis and those with post infective pelvic adhesions than in those with a normal pelvis. Dysmenorrhoea appears to be more prevalent among women having endometriosis. CONCLUSIONS--Menstrual symptoms, while raising a high index of suspicion for endometriosis, are not entirely reliable as indicators of disease. Dysmenorrhoea is the most common reported symptom in endometriosis sufferers. Diagnostic laparoscopy should be considered before institution of treatment in women complaining of pelvic pain and menstrual symptoms.     

Clinical and quality-of-life outcomes after fertility-sparing laparoscopic surgery with bowel resection for severe endometriosis

STUDY OBJECTIVE: To describe the effect of fertility-sparing laparoscopic excision of endometriosis and bowel resection on clinical and quality-of-life outcomes. DESIGN: Prospective observational cohort study (Canadian Task Force classification II-2). SETTING: Australian tertiary referral center for the surgical treatment of endometriosis. PATIENTS: Seven consecutive patients with known endometriosis involving the bowel. INTERVENTION: Laparoscopic resection of all endometriosis, including laparoscopic bowel resection with end-to-end anastomosis with or without temporary ileostomy. MEASUREMENTS AND MAIN RESULTS: Preoperative and 12-month postoperative data were collected by use of visual analogue scores for dysmenorrhea, nonmenstrual pelvic pain, dyspareunia, and dyschezia. Validated research tools (SF12, EuroQOL, and Sexual Activity Questionnaire) also assessed quality of life. Reduction in median pain scores at baseline was demonstrated and at 12 months after operation for dysmenorrhea 71 (interquartile range 43-85) versus 5 (0-10); p=.028, nonmenstrual pelvic pain 74 (48-85) versus 11 (0-18); p=.046, dyspareunia 66 (0-98) versus 5 (0-8); p=.080, and dyschezia 48 (20-64) versus 20 (0-40); p=.173. All measures of quality of life were improved at 12 months after surgery, although not reaching statistical significance because of the small sample size. All three women wishing to conceive after operation have been successful, resulting in three live births at term. There were few complications associated with this surgery. CONCLUSION: Fertility-sparing laparoscopic excision of endometriosis with bowel resection results in improvements in all aspects of pain and quality of life. Results appear to parallel published data for conservative resection of endometriosis not involving bowel. For women with severe endometriosis involving bowel, this surgical treatment provides a viable alternative to pelvic clearance and successfully maintains fertility.     

腹腔镜子宫骶神经切断术治疗子宫内膜异位症疼痛的多中心前瞻性对照研究

目的:研究、评价腹腔镜子宫骶神经切断术(LUNA)治疗子宫内膜异位症疼痛的安全性和有效性。方法:应用多中心随机对照的前瞻性研究方法,收集82例中、重度痛经患者的临床资料,分析比较同时行LUNA对子宫内膜异位症保守手术后各种疼痛缓解率的影响,并评价手术的安全性。结果:71例患者纳入分析,LUNA组51例,对照组20例。LUNA组术后痛经缓解率90.2%,高于对照组的60.0%(P=0.02);LUNA组性交痛术后缓解率85.7%,高于对照组的50.0%(P=0.048);LUNA组慢性盆腔痛(CPP)缓解率100%,高于对照组的71.4%(P=0.041),差异均有统计学意义。手术安全性:LUNA组患者手术时间延长,术后肛门排气时间延长,但两组术中出血量、术后体温、住院时间、总住院费用以及手术费用均无统计学差异。所有研究对象均无手术并发症发生。结论:内异症保守手术同时行LUNA手术,术后2年内能有效的缓解内异症的各种疼痛。     

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.     

Radical resection of invasive endometriosis with bowel or bladder involvement--long-term results

OBJECTIVE: With the present study we wanted to evaluate the effect of a radical resection of bowel and bladder endometriosis with respect to relief of pain symptoms and long-term effects. STUDY DESIGN: Retrospectively we analyzed 23 patients undergoing bowel or bladder resection for infiltrating endometriosis between 1995 and 2004. Chart review was performed and data were analyzed with respect to pain symptoms, fertility, type of surgery, operative morbidity and mortality. At 1, 3 and 5 years of follow-up patients were asked to evaluate their symptoms based on a visual analogue pain scale (0: no pain, 10: most severe pain). Results were compared using the Student's t-test. RESULTS: Leading symptoms were chronic pelvic pain (17/23, 73.9%), dysmenorrhea (11/23, 47.8%), dyspareunia (6/23, 26.1%), infertility (4/23, 17.4%) and dyschezia (4/23, 17.4%). Three patients (13%) had abdominal hysterectomy, 5 (21.7%) LSO (n = 2) or BSO (n = 3), 18 (78.3%) anterior rectal resection, 4 (17.4%) sigmoid resection, 2 (8.6%) segmental bladder resection and one patient (4.3%) cecal resection. Major complications requiring re-operation occurred in three patients (2x postoperative bleeding, 1x anastomosis break-down). During follow-up (mean 40.5 months) 21 of the 23 patients (91.3%) had a persistent improvement of symptoms, 8 of the 23 (34.8%) had recurrent symptoms with a mean symptom-free interval of 40.4 months after surgery (24-60 months). No patient developed dyspareunia or dyschezia during follow-up. Overall cure rate was 73.9%. Four patients became pregnant (23%). Average pain scores increased during follow-up period but still remained significantly below the initial score (p < 0.001). CONCLUSION: Radical surgery for deep endometriosis with bowel or bladder involvement leads to a reliable and persistent relief of pain symptoms. Especially deep dyspareunia and dyschezia might be eliminated by this procedure.     

Variation in practice of laparoscopic uterosacral nerve ablation: a European survey.

To examine the variation in current indications and surgical techniques for performing laparoscopic uterosacral nerve ablation (LUNA) in Europe, all consultants on the databases of the UK Royal College of Obstetricians and Gynaecologists (1569) and the European Society of Gynaecological Endoscopy (301) were surveyed. The questionnaire was returned by 719 (38% of 1870) of the gynaecologists contacted and 173 (24%) performed LUNA. Indications for LUNA, which included chronic pelvic pain (68%), dysmenorrhoea (66%), dyspareunia (39%) and endometriosis (60%), were similar across the United Kingdom and the rest of Europe. The European group were more likely to perform LUNA (62% versus 21%), completely transect the uterosacral ligaments (56% versus 36%) and at a distance of more than 2 cm from its cervical insertion (50% versus 21%) than the UK group. There is variation in the surgical techniques of performing LUNA in Europe and the techniques vary according to operator experience.     

子宫神经去除术治疗子宫腺肌症疼痛的临床观察

目的探讨子宫神经去除术（LUNA）治疗子宫腺肌症痛经及慢性盆腔痛的临床效果。方法对患有痛经、非经期盆腔痛或性交痛的子宫腺肌症患者进行LUNA手术。采用视觉模拟评分法对痛经、非经期盆腔痛及性交痛量化评分。结果对60例子宫腺肌症患者术后随访6～24个月，其痛经、非经期盆腔痛或性交痛的症状均有明显改善，手术前后三者的评分变化差异均有显著性（P〈0．01），但术后各阶段之间的比较差异无显著性（P〉0．05）。患者满意率术后3个月为76．92％，术后24个月为69．23％。结论LUNA对缓解子宫腺肌症引起的痛经及慢性盆腔痛具有一定的疗效。     

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。     

Histopathologic findings on uterosacral ligaments in women with chronic pelvic pain and visually normal pelvis at laparoscopy

STUDY OBJECTIVE: To determine the prevalence and type of microscopic findings on laparoscopically resected uterosacral ligaments in women with chronic pelvic pain and no visible pelvic disease. The effect of this procedure on the patients' level of pain also was assessed as a secondary objective. DESIGN: Prospective follow-up (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Twenty-seven premenopausal women undergoing diagnostic laparoscopy for chronic pelvic pain had a normal pelvis on visual inspection. All patients underwent resection and histologic evaluation of the uterosacral ligaments. Pain relief was evaluated by use of a questionnaire administered before and at 3, 6, and 12 months after surgery. MEASUREMENTS AND MAIN RESULTS: Microscopic examination identified endometriosis in 2 (7.4%), endosalpingiosis in 3 (11.1%), and inflammation in 14 (51.9%) patients. Laparoscopic uterosacral ligament resection was associated with a reduction in dysmenorrhea (p < or = .001), with 14 (52%) patients reporting improved or resolved symptoms. There was a statistically significant decrease in dyspareunia (p < or = .01) and in the severity of noncyclical pain (p < or = .002). Thirty-five percent of patients no longer required medication for pain control (p < or = .005). The number of days needed off work also decreased. CONCLUSION: Despite normal laparoscopic appearance, microscopic endometriosis, endosalpingiosis, and inflammatory changes were found in uterosacral ligaments in 17 (63%) women with chronic pelvic pain. Laparoscopic resection of uterosacral ligaments improved dysmenorrhea, dyspareunia, and noncyclical pain and decreased the number of days lost from work, as well as the proportion of patients who required medication for pain control.     

Effect of palmitoylethanolamide–polydatin combination on chronic pelvic pain associated with endometriosis: Preliminary observations

Objective

Endometriosis is a chronic oestrogen-dependent gynaecological disorder, the most common symptom of which is pain. Inflammation can be considered one of the major causes of pain in endometriosis. In particular, degranulating mast cells have been found in significantly greater quantities in endometriotic lesions than in unaffected tissues. The increase in activated and degranulating mast cells is closely associated with nerve structures in painful endometriotic lesions. These observations indicate that inflammation due to mast cells may contribute to the development of pain and hyperalgesia in endometriosis. Controlling mast-cell activation may therefore relieve the pain associated with endometriotic lesions.

Study design

Four patients presenting an endometriosis-related pain intensity ≥5 (visual analogue scale for pain, or VAS) were enrolled and monitored during 3 months of the following treatment: oral palmitoylethanolamide 400 mg and polydatin 40 mg, twice daily for 90 days. Deep dyspareunia, dyschezia, dysuria, dysmenorrhoea and analgesic drug use during the 3-month follow-up period were also monitored, with the aim of demonstrating a reliable reduction in chronic pelvic pain.

Results

The preliminary results indicate that all patients enrolled experienced pain relief as early as 1 month after starting treatment. Furthermore, a reduction in the analgesic drugs usually employed for pain control was observed in all subjects treated. Additionally, some improvements in endometriotic lesions seemed to be demonstrated by imaging.

Conclusions

The palmitoylethanolamide–polydatin combination seems to be very useful in controlling chronic pelvic pain associated with endometriosis. As a result of these findings we have initiated a multi-centre pilot study to verify the effectiveness of this treatment in controlling the chronic pelvic pain associated with endometriosis.     

The prevalence of chronic pelvic pain in women in the United Kingdom: a systematic review

Objective Toobtain a prevalence estimate for chronic pelvic pain in women in the United Kingdom by analysing published data.
Design Systematic review of published papers.
Setting The general population or hospitals in the United Kingdom.
Population Women participating in relevant community surveys or control women participating in hospital-based studies.
Methods Papers were retrieved by systematically searching the databases MEDLINE, EMBASE and PsycLit, and by hand searching. Studies were included if they 1. were community-based and reported prevalence rates of chronic pelvic pain, dyspareunia, dysmenorrhoea, or abdominal pain, or 2. referred to a clinical population but reported prevalence rates in a disease-free control group.
Main outcome measures Prevalence rates for chronic pelvic pain including any overlap with dyspareunia, dysmenorrhoea and abdominal pain.
Results No community-based study has been performed that provides an estimate of the prevalence of chronic pelvic pain in the general UK population. A rate of 39% was reported in women undergoing laparoscopy for sterilisation or investigation of infertility in the single study from the United Kingdom investigating chronic pelvic pain unrelated to menstruation or intercourse. Prevalence rates for dyspareunia, dysmenorrhoea, and abdominal pain found in UK community-based studies were 8%, 45%, to 97%, and 23% to 29%, respectively, but definitions used varied greatly.
Conclusions Because chronic pelvic pain can reduce the quality of life and general wellbeing, there is a need for a community-based study into the prevalence of chronic pelvic pain and its effect upon the lives of women in the UK.     

The efficacy of laparoscopic uterosacral nerve ablation (LUNA) in the treatment of unexplained chronic pelvic pain: a randomized controlled trial

The aim of this work is to explore the efficacy , safety, and patients' satisfaction of laparoscopic uterosacral nerve ablation (LUNA) in relief of pain in women with chronic pelvic pain in whom diagnostic laparoscopy reveals either no pathology or mild endometriosis (AFS score ≤5). The study was a prospective, single-blind, randomized trial with 12 months follow-up. It was conducted at the endoscopy unit of the Gynecology Department of El Minia University Hospital, Egypt. One hundred ninety Egyptian women consented to participate in the study. These eligible patients were randomized using computer-generated tables and were divided into two equal groups, including the control group (diagnostic laparoscopy with no pelvic denervation) and the study group (diagnostic laparoscopy plus LUNA). Diagnostic laparoscopy with or without laparoscopic uterosacral nerve ablation was done. There were no statistically significant difference between both groups regarding the efficacy and the overall success rate (between group I and group II, it was 77.64%, 76.47%, and 74.11% versus 79.06%, 75.58%, and 73.25% at 3, 6, and 12 months, respectively) and the cumulative patients' satisfaction rate (it was 74.11%, 74.11%, and 71.76% versus 75.58%, 75.58%, and 72.09% at 3, 6, and 12 months between group I and group II, respectively; P ≤ 0.05). There was no statistically significant difference between both groups as regards the effectiveness of LUNA in the treatment of primary (spasmodic) and secondary (congestive) dysmenorrhea (P ≤ 0.05), while there was a statistically significant difference between both groups in the treatment of dyspareunia (P ≥ 0.05). LUNA can be a last alternative option in well-selected patients for control of chronic pelvic pain without endometriosis; however, its effectiveness may not extend to other indications. Also, preliminary experience in the treatment of primary deep dyspareunia presents a promising perspective on the management of deep dyspareunia, especially if it will involve a team of social, psychological, and gynecological specialists.     

Impact of endometriosis on quality of life and mental health: pelvic pain makes the difference

Abstract

Introduction: No prior study of endometriosis has investigated the psychological impact of having asymptomatic endometriosis versus endometriosis with pelvic pain in a systematic way. This study aimed at examining the impact of endometriosis on quality of life, anxiety and depression by comparing asymptomatic endometriosis, endometriosis with pelvic pain, and healthy, pain-free controls. The psychological impact of different types of endometriosis pain was also tested.

Methods: One hundred and ten patients with surgically diagnosed endometriosis (78 with pelvic pain and 32 without pain symptoms) and 61 healthy controls completed two psychometric tests assessing quality of life, anxiety and depression. Endometriosis participants indicated on a numerical rating scale the intensity of four types of pain (dysmenorrhea, dyspareunia, non-menstrual pelvic pain and dyschezia).

Results: Endometriosis patients with pelvic pain had poorer quality of life and mental health as compared with those with asymptomatic endometriosis and the healthy controls. No significant differences were found between asymptomatic endometriosis and the control group. Dysmenorrhea had significant effects only on physical quality of life; non-menstrual pelvic pain affected all the variables; no significant effects were found for dyspareunia and dyschezia.

Conclusions: Pain significantly affects women’s experience of endometriosis. The medical treatment of endometriosis with pain may not be sufficient and psychological intervention is recommended.     

Relations entre endométriose et algie pelvienne chronique : quel est le niveau de preuve ?

The relationship between chronic pelvic pain symptoms and endometriosis is unclear because painful symptoms are frequent in women without this pathology, and because asymptomatic forms of endometriosis exist. Our comprehensive review attempts to clarify the links between the characteristics of lesions and the semiology of chronic pelvic pain symptoms. Based on randomized trials against placebo, endometriosis appears to be responsible for chronic pelvic pain symptoms in more than half of confirmed cases. A causal association between severe dysmenorrhoea and endometriosis is very probable. This association is independent of the macroscopic type of the lesions or their anatomical locations and may be related to recurrent cyclic microbleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhoea. There are histological and physiopathological arguments for the responsibility of deeply infiltrating endometriosis (DIE) in severe chronic pelvic pain symptoms. DIE-related pain may be in relation with compression or infiltration of nerves in the subperitoneal pelvic space by the implants. The painful symptoms caused by DIE present particular characteristics, being specific to involvement of precise anatomical locations (severe deep dyspareunia, painful defecation) or organs (functional urinary tract signs, bowel signs). They can thus be described as “location indicating pain”. A precise semiological analysis of the chronic pelvic pain symptoms characteristics is useful for the diagnosis and therapeutic.     

Symptom distribution among infertile and fertile endometriosis cases with different stages and localisations

OBJECTIVE: To evaluate endometriosis patients' symptoms and relate them to different stages and locations of endometriosis and also to fertility/infertility of the patients. STUDY DESIGN: Sixty-eight patients diagnosed with endometriosis constituted the population investigated in this cross-sectional observational study, 55 and 13 of whom were diagnosed from the visual findings recorded during laparoscopy and laparotomy, respectively. All cases were categorised as early- (stages I and II) or late (stages III and IV)-stage endometriosis and as fertile or infertile endometriosis. The extent of endometriosis was further divided into peritoneal, ovarian, and ovarian and peritoneal. Symptoms of dysmenorrhoea, deep dyspareunia, dyschesia and dysuria and also depressive mood state were analysed and compared among those different groups. RESULTS: Cyclic chronic pelvic pain was more relevant in late-stage endometriosis (P = 0.04). Deep dyspareunia, painful defecation, dysuria, infertility, and depressive state did not differ with stages of endometriosis or fertility status. Admission for pelvic pain of any duration was more prevalent among fertile patients with endometriosis (P = 0.008). Chronic noncyclic pelvic pain was more frequently observed in patients with fertile than in those with infertile endometriosis (P = 0.01). More cases in the fertile group experienced noncyclic pelvic pain (P = 0.04). More patients admitted with cyclic pelvic pain had ovarian or ovarian and peritoneal endometriosis than peritoneal endometriosis only (P = 0.03). Infertility was more prevalent among peritoneal endometriosis cases than among those with ovarian or peritoneal and ovarian involvement (P = 0.008). CONCLUSION: Symptoms of endometriosis may predict the stage and localisation of the disease to some extent.     

Surgical management of endometriosis.

A systematic literature review of the last two decades was performed to evaluate the effect of pelvic denervations in addition to conservative surgery on dysmenorrhoea and deep dyspareunia associated with endometriosis. Chronic pelvic pain relief after hysterectomy or adhesiolysis was also assessed. In the five non-comparative studies on the effect of pre-sacral neurectomy, the frequency of dysmenorrhoea recurrence or persistence after treatment ranged from 4 to 40%. The pooled frequency of non-responders at the end of follow-up was 23% (95% confidence interval (CI), 19 to 27%). Only two of the three comparative, non-randomized trials demonstrated a significant treatment benefit of pre-sacral neurectomy, and the results of the two identified randomized controlled trials are discordant. Significant quantitative heterogeneity among studies prevented pooling of data on dysmenorrhoea. The common odds ratio of deep dyspareunia persistence was 0.69 (95% CI, 0.31 to 1.54). In the 10 non-comparative studies on the effect of uterosacral ligament resection, the frequency of dysmenorrhoea and deep dyspareunia persistence after treatment ranged, respectively, from 0 to 50% and from 6 to 42%. The pooled frequency of non-responders at the end of follow-up was 23% (95% CI, 20 to 27%) and 13% (95% CI, 8 to 18%), respectively. Routine performance of complementary denervating procedures cannot be recommended based on the quality of the evidence available. The results of the five studies on the effect of hysterectomy on chronic pelvic pain of presumed uterine origin consistently demonstrated that 83-97% of operated women reported pain relief or improvement 1 year after surgery. There is no consensus on the outcome of adhesiolysis in patients with chronic pain, and the role of pelvic adhesions in causing symptoms is under scrutiny.     

Patient satisfaction and changes in pain scores after ablative laparoscopic surgery for stage III-IV endometriosis and endometriotic cysts

OBJECTIVE: To document the changes in pain scores 3-12 months following ablative laparoscopic surgery. Secondary outcome measures included patient satisfaction scores. DESIGN: A prospective, cohort study. SETTING: A tertiary referral center for the treatment of endometriosis. PATIENT(S): Seventy-three consecutive women with stage III-IV endometriosis and an endometrioma >2 cm. INTERVENTION(S): A laparoscopy was performed. The extraovarian endometriosis was ablated with a CO(2) laser, and the endometrioma capsule was fenestrated then ablated with the potassium-titanic-phosphate (KTP) laser or the Bicap bipolar diathermy. MAIN OUTCOME MEASURE(S): Pre- and postoperative visual analogue scores for pelvic pain were completed. Patient satisfaction was scored from 1 to 10, with a score of 10 being "most satisfied." RESULT(S): A total of 73 women with stage III-IV endometriosis and 96 cysts (23 cysts were bilateral). The mean revised American Fertility Society (AFS) score was 65.5 (range 22-128). At 12 months, the mean temporal decrease in the pain score for dyspareunia was 2.14 +/- 0.41; for dysmenorrhea, 1.52 +/- 0.38; and for chronic nonmenstrual pain, 2.37 +/- 0.43. Sixty-four (87.7%) patients were satisfied or very satisfied with the treatment. No surgical complications occurred. CONCLUSION(S): Laparoscopic ablative surgery for endometriomas in the presence of stage III-IV endometriosis is an effective treatment for relieving pelvic pain.     

The influence of peritoneal endometriotic lesions on the generation of endometriosis-related pain and pain reduction after surgical excision

Purpose  To investigate the influence of different kinds of endometriotic lesions, especially peritoneal endometriotic implants in pain generation and the pain reduction after surgical excision in a prospective study. Methods  Fifty-one pre-menopausal patients underwent surgical laparoscopy due to chronic pelvic pain, dysmenorrhoea and/or for ovarian cysts. In 44 patients, endometriosis was diagnosed. The pre- and post-operative pain score was determined using a standardized questionnaire with a visual analogue scale. Patients with peritoneal endometriosis were divided into two different groups depending on their pre-operative pain score: group A had a pain score of 3 or more, while group B a pain score of 2 or less. Patients without peritoneal endometriosis were classified as group C, and patients without endometriosis were classified as group D. The pre- and post-operative pelvic pain and/or dysmenorrhoea was analysed according to the different types of endometriotic lesions. Results  In groups A and C, the post-operative pain score decreased by at least 2 grades or more (p < 0.0). In group D, the post-operative pain score showed no significant reduction. Conclusion  The present study suggests that the surgical excision of endometriotic lesions—including peritoneal implants—is an effective treatment of endometriosis-associated pelvic pain and/or dysmenorrhoea.     

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.     

Long-term follow-up of pain and quality-of-life scores after laparoscopic adhesiolysis

There is increasing evidence that laparoscopic adhesiolysis improves chronic pelvic pain. We performed a long-term review of women after laparoscopic adhesiolysis over the past 4 years. Patients were excluded from the study if they had additional pathology such as endometriosis or required additional procedures other than adhesiolysis. Umbilical insertion of Verress needle and primary trocar was used except when the patient had had a previous midline laparotomy, in which case Palmers point was used for entry. Adhesions were divided using Metzenbaum scissors with haemostasis using suction irrigation achieved with a Surgiflex R Wave suction irrigation system with BICAP bipolar diathermy probe (ACMI, USA). Hydroflotation with heparinised saline or 4% icodextrin was used to reduce adhesion recurrence. Patients were sent a postal questionnaire and contacted by telephone. Visual analogue scales were used to record pain scores for dysmenorrhoea (in those women who still had a uterus), dyspareunia, dyschezia and chronic daily pain. An EQ-5D questionnaire was also enclosed to assess quality of life. One hundred and forty-three procedures were identified between September 1998 and July 2002. Having excluded those with additional pathology that required treatment, 90 were eligible for the study. Seventy-six replies were obtained; seven patients had moved away. Sixty-nine replies were analysed. Fifty-one (74%) reported some improvement in their symptoms [12 (17%) pain completely gone, 26 (38%) greatly improved, 13 (19%) a little better]. Patients still had significant pain [scores out of 100 for dysmenorrhoea (45), dyspareunia (28), dyschezia (28) and daily pain (29)]. Overall, quality of life was still lower than national averages (self-rated health status mean =67.0 vs. 82.34, P< 0.05, weighted health state index =0.67 vs. 0.85, P< 0.05), except in the good responders (pain gone or greatly improved, for whom quality of life returned to normal). There was no difference in pain scores, response and quality of life between women who had had their surgery more than 24 months earlier and those who had had surgery more recently. We have found a good response to adhesiolysis, which is comparable with other studies. A good response is associated with a normal quality of life and appears to be long standing.