Clinical Pearls & Morning Reports
Published March 25, 2020
Chronic pelvic pain that is unresponsive to conventional treatments develops in approximately 30% of patients with endometriosis. Read the NEJM Review Article here.
Q: Is the clinical course of endometriosis predictable?
A: Although the natural history of endometriosis is unknown, subphenotypes of lesions may vary across the life course. However, no robust evidence supports an ordered progression of endometriotic lesions. In studies of repeat surgeries, lesions progressed (in 29% of cases), regressed (in 42%), or were static (in 29%), according to revised American Society of Reproductive Medicine staging; symptom severity or recurrence was not correlated with stage.
Q: Is the pain associated with endometriosis attributable solely to the presence of endometriotic lesions?
A: As with other chronic pain conditions, pain mechanisms in endometriosis extend beyond the presence of endometriotic lesions alone. Pelvic pain in women with endometriosis, featuring enhanced anterior insula glutamatergic neurotransmission and connectivity with the medial prefrontal cortex, is associated with changes in brain chemistry and function, as compared with brain chemistry and function in age-matched, pain-free women. Women with endometriosis are also at high risk for cross-organ sensitization (pain perception from adjacent structures due to convergence of neural pathways), which may explain poor postsurgical pain relief in many affected women.
A: Endometriosis remains difficult to diagnose. Women see, on average, seven physicians before endometriosis is diagnosed. No biomarkers to detect or rule out endometriosis are available. The predominantly intraabdominal location of the lesions, plus their small size, means that laparoscopic visualization (ideally with histologic verification) remains the standard for diagnosis of the disease. Imaging is of little use for superficial peritoneal lesions. However, endometriomas can be identified reliably by transvaginal ultrasonography or magnetic resonance imaging (MRI), with more than 90% sensitivity and specificity. A skilled specialist can identify deep endometriosis and adhesions involving pelvic organs with transvaginal ultrasonography. MRI has 94% sensitivity for detecting deep endometriosis, but the specificity is only 79%.
A: In women with hormone-resistant pain associated with endometriosis, surgical treatment should be considered. Surgery is appropriate only when symptoms reach a level of severity to justify the risk. Surgery has been shown to decrease pain in some but not all women. The aim is complete destruction or removal of endometriotic tissue and adhesions, and success in achieving this aim may largely depend on the skill of the surgeon. However, the evidence supporting surgical treatment of superficial endometriosis for pain relief is sparse and currently under debate. Hysterectomy is common; endometriosis-associated pain is the leading indication for hysterectomy among women 30 to 34 years of age, accounting for 18% of all hysterectomies in the United States. However, posthysterectomy pain is three times as likely among women with preoperative pain as among those without preoperative pain, and about half of the 60% elevated risk of cardiovascular disease among women with endometriosis is attributed to the high rate of surgical menopause among such women.