Box 411 Treatment approach when endometriosis is suspected

• Trial of low-dose monophasic combination oral contraceptive pills (one pill/day for three to six months)

• If no improvement, three-month therapy with a GnRH agonist; if pain improves continue for three additional months, may consider hormonal add-back therapy

• Surgery to evaluate for pathology if no improvement with GnRH agonist:

- excision/thermal ablation/laser of endometriotic lesions;

- excision of endometriomas;

- ± presacral neurectomy (for central pain);

- ± hysterectomy and bilateral salpingo-oophorectomy;

• Endometriosis confirmed; hormonal management with one of following if pain persists/recurs following surgery:

- continuous monophasic oral contraceptive pills to induce amenorrhea;

- progestins:

• medroxyprogesterone acetate (MPA) 30 mg p.o. q.d.;

• Levonorgestrol-releasing intrauterine device:

- GnRH agonist:

• nafarelin 200-400g intranasal b.i.d.;

• leuprolide 3.75 mg i.m. q.mo. or 11.25 mg i.m. q.3mo.

• ± Add-back therapy with norethindrone 2-5 mg p.o. q.d. or conjugated/esterified estrogen 0.625 mg p.o. q.d. and MPA 2.5 mg p.o. q.d.

• Multidisciplinary pain management - may be considered early in the management.

OUTCOME WITH RESPECT TO CPP

The relationship of endometriosis to chronic pelvic pain is unclear as endometriosis is a common finding in reproductive-age women without pain, and other pathology (i.e. adhesions, interstitial cyctitis, pelvic floor muscle spasm, abdominal wall pain) may be simultaneously present.34 Classically, the severity of disease does not significantly correlate with the degree of pain.57,58 However, vaginal and uterosacral endometriosis was highly associated with complaints of deep dyspareunia58 and deeply infiltrating lesions, particularly of the uterosacral ligaments were strongly associated with pain.36 In contrast, Stovall etal.59 found at a mean follow-up of 15 years that stage of disease was associated with persistence and intensity of chronic pelvic pain. In summary, pain that is not cyclical and/or does not respond to adequate surgical and medical management of endome-triosis should be reevaluated for another source of pain and/or other contributing factors.

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