A Comprehensive Treatment Protocol for Endometriosis Patients Decreases Pain and Improves Function

Precision surgery for endometriosis: preventing chronic pelvic pain in patients with higher pre-operative pain scores and in patients of advanced age

OBJECTIVE

Symptom relief can be achieved for many patients with endometriosis by tailored individual treatment. However, therapy resistance is observed in some patients. This study surveyed patient-reported long-term outcomes after laparoscopic endometriosis surgery and evaluated potential pre-operative predictors for insufficient symptom control.

METHODS

This retrospective study included patients with complete surgical endometriosis resection treated between 2013-2016 at the Department of Gynaecology and Reproductive Medicine, Jena University Hospital. Our 2020 survey gathered socio-demographic, reproductive, symptom-related, and subjective general condition data from 122 patients. Overall pain intensity was assessed using a numeric rating scale (NRS) from zero (no pain) to 100 (highest imaginable pain). Clinical records provided additional information.

RESULTS

Median time between surgery and interview was 6 years. Postoperatively, the proportion of patients reporting symptoms was considerably reduced (menstrual pain 32.0% vs. 85.2%, chronic pelvic pain [CPP] 40.2% vs. 67.2%, dyspareunia 34.4% vs. 59.8%, hypermenorrhea 17.2% vs. 49.2%; p < 0.001). The majority of respondents (70%) reported improved subjective general condition. Mean NRS Score significantly decreased from 77.2 to 26.6 (p < 0.001). Among pre-operatively infertile women, 45.2% reported successful pregnancies. However, 20-30% of patients did not respond to therapy in one of the analyzed domains. Multivariate logistic regression identified CPP as a strong predictor for failure in permanent pain reduction (OR 5.544, 95% CI 1.338-22.965, p = 0.018) and risk for reoperation (OR 5.191, 95% CI 1.100-24.501, p = 0.038). Higher pre-operative NRS scores and increasing age were associated with better long-term pain relief.

CONCLUSION

Patients with higher pre-operative pain scores and patients of advanced age benefit significantly from precision surgery, experiencing sustained symptom relief and improved subjective general condition. However, younger patients with CPP and moderate pre-operative pain intensity showed a higher risk for therapy resistance and require multimodal treatment strategies.

Questionnaires for the Assessment of Central Sensitization in Endometriosis: What Is the Available Evidence? A Systematic Review with a Narrative Synthesis

It has been suggested that central sensitization (CS) may be involved in the failure of standard medical and surgical treatment to relieve endometriosis-related pain. However, there is no gold standard for the diagnosis of CS, and self-reported questionnaires are used as diagnostic surrogates. The main objective of this review was to identify all CS questionnaires used in clinical endometriosis studies. The secondary objective was to qualitatively analyze strengths and weaknesses of each questionnaire. A PubMed and EMBASE systematic literature search conducted in April 2023 using the terms "endometriosis; central pain; central sensitization; questionnaire; patient-reported outcome measure; screening tool" identified 122 publications: six articles were included in the review. The Central Sensitization Inventory (CSI) is the most frequently used questionnaire for the detection of CS in patients with endometriosis. It has been validated in patients with endometriosis, in whom it appears to have good psychometric proprieties. The Fibromyalgia Survey Questionnaire (FSQ) has also been used, although it has not been specifically validated in endometriosis patients. The debate regarding these questionnaires' construct validity is still open and will be so until a gold standard diagnostic tool for CS is found. In fact, some authors argue these questionnaires are measuring psychological vulnerability and a hypervigilant state that is associated with pain, rather than CS itself. However, their use should not be discouraged as they are able to identify chronic pain patients which warrant further attention and who may benefit from broader treatment strategies.

[Physiotherapeutic differential diagnosis of back pain associated with endometriosis]

BACKGROUND

Endometriosis (EM) is one of the most common gynecologic conditions in our society. The diagnosis takes an average of 7 to 10 years. To shorten this period, this syndrome needs more attention. The aim of this article is to show overlaps between EM and low back pain (LBP) and to describe their relevance for physiotherapeutic screening.

OBJECTIVES

What clinical signs do the syndromes EM and LBP have in common and to what extent can physiotherapeutic screening take gynecological aspects into account and be adapted accordingly?

RESULTS

To answer this question, the two syndromes were screened for overlaps. These overlaps were then related to the existing literature and case studies. The current research situation shows overlaps of the two syndromes with regard to the etiology, the pain mechanism as well as a psychosocial aspect. The literature shows that more women than men are affected by LBP and other chronic pain syndromes. EM occurs almost exclusively in women and, like LBP, is considered a chronic pain syndrome. Thus, a common pain mechanism of the two syndromes is discussed in the literature. The most frequent overlap of the two syndromes is shown by the occurrence of LBP as a frequent symptom of EM. This connection can be justified by structural causes as well as by a reflex pain presentation.

CONCLUSION

In a physiotherapeutic setting, evidence of EM can be observed in the history and physical examination. Considering these factors may help shorten the diagnosis time of endometriosis by referring for further evaluation if gynecologic involvement is suspected in LBP. A comprehensive history is important and should cover urologic, gynecologic, as well as sexual history. In this article, the term woman is used to refer to the biological female sex and is not related to individual gender identity. The clinical picture mainly affects women, which is why in the following work, as far as it concerns the people suffering from the disease, it is not used in the opposite sense.