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

Endometriosis and pain

Endometriosis generally causes pain that is cyclic and generally responds to medication and/or surgery. When endometriosis is found coincidentally, it may need no treatment because many women have endometriosis as a self-limited disease. In other women, the biologic behavior is much more unpredictable. Severe dysmenorrhea, focal pelvic tenderness, and deep dyspareunia are suggestive of endometriosis. Diagnosis at laparoscopy includes concerns about subtle appearance, endometriosis hidden within adhesions, retroperitoneal disease, and intra-ovarian lesions. Negative laparoscopy results do not mean that patients have no endometriosis. In contrast, a response to GnRH agonists can occur in patients with no endometriosis because conditions other than endometriosis are estrogen sensitive. Coexistent disease can confuse the picture at the time of surgery. Some coexistent diseases also can cause pain that is similar to that of endometriosis. Distinguishing those patients who need no treatment from those who need intermediate or extensive treatment can be very difficult. Care is needed to ensure that patients are neither overtreated or undertreated. An integrated approach involving a multidisciplinary team is needed in some. Other patients respond to primary care techniques.

Today's treatments: how do you choose?

OBJECTIVE

To provide a view on how the clinician can select appropriate treatment when managing individual patients with endometriosis.

METHODS

Review of randomized controlled trials and personal experience.

RESULTS

The main determinants of therapy choice are personal experience and patient acceptability. Placebo-controlled trial results support the use of naproxen, dydrogesterone, danazol and leuprolide for pain relief. Laser laparoscopy is more effective than expectant management for pain relief. In direct comparisons, oral contraceptives, Zoladex, danazol, gestrinone, nafarelin and leuprolide have similar efficacies in relieving pain, but have different side-effect profiles. In controlled trials, only laser laparoscopy was shown to improve fertility in minimal/mild disease. The physiological response of bone metabolism to GnRH agonist therapy should be seen in context and the place of add-back regimens understood. The general medical history of the patient must be considered when choosing therapy.

CONCLUSIONS

The clinician must provide the patient with appropriate information on the treatment options to allow her to make an informed choice.

The evidence for the management of endometriosis

This review article has focussed on identifying the evidence from randomized controlled trials for the medical and surgical management of endometriosis. A critical summary of the medical management has shown that there is little difference in effectiveness of various medical treatments, but there are differences in the side-effect profiles. Few randomized controlled trials have been undertaken in surgery, but these have shown that surgical management is effective in the management of both painful symptoms and subfertility.