Endometriosis-related Pelvic Pain Research Articles

Holistic approaches to living well with endometriosis

Endometriosis is a common chronic condition for which there is currently no cure. Those suffering from endometriosis-related pelvic pain (ERPP) may struggle with side effects and/or risks presented by conventional medical and surgical treatment strategies, or not get pain relief. Increasing numbers of endometriosis patients wish to explore holistic management with fewer side effects, however it is important that medical professionals maintain an evidence-based practice for recommended treatments. We present up-to-date evidence of holistic strategies used for managing ERPP including nutritional strategies, body and mind therapies, acupuncture, traditional Chinese medicine (TCM) and the use of adjunct devices such as phallus length reducers and transcutaneous electrical nerve stimulation (TENS). Recent findings Nutrition: Gluten-free, low-nickel and high intake of omega-3 polyunsaturated fatty acids diets improve ERPP. Low FODMAP (fermentable oligo-, di-, monosaccharides and polyols) is helpful in those with concurrent irritable bowel syndrome. Body and mind: Cognitive behaviour therapy (CBT) is particularly beneficial in postoperative pain reduction, whilst mindfulness has been shown to reduce pain scores and dyschezia. Progressive muscle relaxation therapy and regular yoga sessions improve ERPP and Quality of life. Acupuncture: 15 randomised control trials assessing acupuncture and moxibustion show improved pain scores when compared to those receiving conventional therapies alone. Adjunct devices: TENS improves deep dyspareunia and lessens the number of days pain is experienced. Conclusions Holistic management strategies for ERPP should be incorporated into routine counselling when discussing conservative, medical and or surgical treatments for endometriosis. The growing evidence presented for the use of holistic management strategies gives hope to those patients who cannot have, or don’t respond to conventional approaches and as an adjunct alongside standard treatments.

Clinical Efficacy, Pharmacokinetics, and Safety of the Available Medical Options in the Treatment of Endometriosis-Related Pelvic Pain: A Scoping Review.

In this scoping review, we sought to identify published studies evaluating the drugs currently used in the treatment of endometriosis-related pelvic pain, with reflection on their chemical properties, pharmacokinetics, safety profile, and clinical efficacy. A literature search was conducted with the use of the PubMed and EMBASE electronic databases, focusing on identifying articles published in English between January 1990 and 2023. Based on the included studies, current therapy options for the treatment of endometriosis-related pain identified and reviewed in this article were: (1) non-steroidal anti-inflammatory drugs; (2) combined oral contraceptive (COCs); (3) progestins; (4) gonadotropin-releasing hormone agonists and antagonists; (5) aromatase inhibitors (AIs); (6) selective estrogen and progesterone receptor modulators; and (7) levonorgestrel-intrauterine device. Based on the published evidence, clinicians should consider NSAIDs, COCs, and progestins as the first-line medical therapies. Compared with second-line options, such as GnRH agonists/antagonists or AIs, the abovementioned first-line options are well tolerated, efficacious, and exhibit lower overall price. Future research priorities should be to identify novel target therapies and to evaluate the effects of available drugs through different routes of administration.

Influence of interleukin-8 polymorphism on endometriosis-related pelvic pain

Endometriosis presents a pro-inflammatory microenvironment influenced by cytokines, such as interleukin (IL)-8, which expression may be influenced by genetic polymorphisms. Therefore, we aimed to investigate the role of interleukin (IL)-8 rs4073 polymorphism in endometriosis’ development and its related symptoms. A case-control study was conducted with 207 women with endometriosis and 193 healthy controls. Polymorphism was genotyped using a TaqMan validated assay. Associations were evaluated by binary logistic regression, using odds ratios (OR) and 95 % confidence intervals (CI), and P ≤ 0.05 was considered significant. Cases were younger (36 ± 6.8 versus 39 ± 8.4) and had lower body mass index (26.5 ± 5.3 versus 35.7 ± 6.3 Kg/m2) than controls (P < 0.001). Higher prevalence of symptoms and infertility was observed in cases, compared to controls (P < 0.001). Minor allele frequencies of IL-8 rs4073 (T) were 42.3 % and 39.9 % for cases and controls, respectively, and no associations were found between IL and 8 rs4073 polymorphism and endometriosis’ prevalence or staging. However, the polymorphism was associated with chronic pelvic pain among cases (OR = 0.54; 95 %CI = 0.29–0.98). The IL-8 rs4073A > T polymorphism may contribute to lower IL-8 expression and, consequently, decrease endometriosis-related pelvic pain. These findings can support the early diagnosis of endometriosis’ painful symptoms, preventing its complications, and allowing an individualized treatment.

Pain Reduction with an Immersive Digital Therapeutic in Women Living with Endometriosis-Related Pelvic Pain: at-home self administered randomized controlled trial.

The management of chronic pelvic pain in women with endometriosis is complex and includes long-term use of opioids. Patients not fully responsive to drugs, or ineligible for surgical treatments need efficient alternatives to improve their quality of life and avoid long-term sequelae. This randomized controlled trial, software under test (Endocare) vs. sham, aimed to assess the effects of repeated at home administrations of a 20-minutes virtual reality (VR) solution on pain in women experiencing pelvic pain due to endometriosis. Patients were instructed to use VR headsets twice daily during at least 2 days and up to 5 days starting on their first day of painful periods. Pain perception was measured using a numerical scale (0 - 10) before and 60, 120, 180 minutes after each treatment administration. General pain, stress, fatigue, medication intake and quality of life were daily reported by patients. 102 patients were included in the final analysis (Endocare: n=51/102, 50%; Sham: n= 51/102; 50%). The mean age was 32.88 years (SD 6.96) and the mean pain intensity before treatment was 6.53 (SD 1.74) and 6.22 (SD 1.69) for the Endocare group and the control group (P=.48). Pain intensity decreased in both groups from day 1 to day 5 as well as medication use. Maximum pain intensity reduction was 51.58% (SD 35.33) at D2.T120 and 27.37% (SD 27.23) at D3.T180 for the Endocare group and the control group respectively. The Endocare was significantly superior to the sham on day 1 (T120, P=.037; T180, P=.001), day 2 (T0, P=.022; T60, T120, T180, all P<.0001) and day 3 (T60, P=.014; T120, P=.005; T180, P=.001). Similarly, the mean perceived pain relief was significantly higher with Endocare on day 1 (T120, T180) and day 2 (T60, T120, T180) compared to the control (All P<.01). No adverse event was reported. This study confirmed the effectiveness and safety of self-repeated administrations of a virtual reality immersive treatment used at home while reducing overall pain medication intake in women diagnosed with endometriosis experiencing moderate-to-severe pelvic pain and supports. Registration: Clinicaltrials.gov NCT05172492, https://clinicaltrials.gov/ct2/show/NCT05172492.

Effectiveness of a Manual Therapy Protocol in Women with Pelvic Pain Due to Endometriosis: A Randomized Clinical Trial.

A randomized controlled trial was carried out to assess the effectiveness of a manual therapy protocol in terms of the clinical characteristics, quality of life, and emotional condition of the women with endometriosis-related pelvic pain. Forty-one women (mean age of 36.10 (6.97) years) with pelvic pain due to endometriosis were randomly divided into (i) a manual therapy group (MTG) (n = 21) and (ii) a placebo group (PG) (n = 20). Both groups received an 8-week intervention. Pain, lumbar mobility, endometriosis health profile, quality of life, depression and anxiety levels, and the patient's perception of change were assessed before (T0) and after (T1) the intervention, as well as at a one-month follow-up (T2) and a six-month follow-up (T3). The MTG significantly improved pain intensity, powerlessness, lumbar mobility, and physical quality of life at T1 (p < 0.05). The results were maintained for pain intensity at T2 and T3. In addition, both the MTG and PG improved emotional wellbeing at T1 (p < 0.05). Neither group improved in terms of social support, self-image, and depression and anxiety levels after the intervention (p > 0.05). In conclusion, manual therapy may be an excellent complement to the gynecological treatment of endometriosis-related pelvic pain by alleviating pain and improving women's endometriosis health profile and physical quality of life.

Development of Provisional Acupuncture Guidelines for Pelvic Pain in Endometriosis Using an e-Delphi Consensus Process.

Introduction: Growing evidence suggests that acupuncture can improve pelvic pain in women with endometriosis. The treatments used in research vary considerably. It remains unclear which treatment could be recommended for clinical practice. This research project aimed at clarifying how acupuncture could be used when treating this condition. Methods: This research comprised two phases: a systematized literature review to extract acupuncture treatment details from published research, and an e-Delphi study to gain knowledge about details as used by expert acupuncturists. Review: Four databases were searched using predefined eligibility criteria. Data were extracted based on the STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) criteria. e-Delphi: Purposeful sampling from colleagues and international experts. An open first round gathered qualitative data, analyzed with the Framework method. In rounds 2 and 3, experts rated statements to build group consensus, defined as a rating of ≥5 on a 7-point Likert scale by ≥70% of the experts. The strength of agreement was graded using the median score and interquartile range. Results from the literature review and the e-Delphi were compared using the STRICTA items. Results: The literature review (n = 29 unique studies) found a wide range of treatment details with little agreement. The e-Delphi of international experts (n = 20) resulted in agreement on 94 statements (such as key factors for effectiveness); disagreement on a further 29 (such as acupressure); and absence of consensus on 55 statements (such as the number of needle insertions). A comparison of the review and e-Delphi results found little agreement. Conclusions: Details of acupuncture treatment for endometriosis-related pelvic pain were presented. In the absence of acupuncture guidelines for this condition, the researchers of this e-Delphi recommend using the treatment details on which experts agreed as guidance for good practice. The effectiveness of these guidelines should be evaluated in future research. Study registration: Deutsches Register Klinischer Studien, DRKS00022215, June 30, 2020, retrospectively registered.

Endometriosis and body image: Comparing people with and without endometriosis and exploring the relationship with pelvic pain

Qualitative studies have shown that people with endometriosis report feeling discontent with their bodies relating to the visual and functional effects of the disease. However, few studies exist which compare people with endometriosis to those without, leaving it largely unknown as to whether this discontentment differs from that regularly experienced by women. The current study therefore aimed to 1) quantitatively assess body image, namely appearance satisfaction and functionality appreciation, in people with and without endometriosis, and 2) explore the relationship between endometriosis-related pelvic pain and body image. Australians aged 18 and over were recruited for two groups: those with endometriosis (n = 312, 99 % female, Mage = 30.78, SDage = 7.40) and a control group without suspected or diagnosed endometriosis (n = 74, 100 % female, Mage = 32.38, SDage = 8.84). Participants completed an online survey consisting of measures of appearance satisfaction, functionality appreciation, and pelvic-pain impact. The endometriosis group demonstrated significantly poorer body image when compared to the control group, and endometriosis-related pelvic pain was shown to negatively correlate with body image. These findings demonstrate the likely negative effects endometriosis and pelvic pain have on body image and provide much needed insight to help develop interventions tailored to endometriosis.

The Role of Endometriosis-Specific MRI Protocol in the Diagnosis and Management of Patients with Endometriosis-Related Pain

<h3>Study Objective</h3> Preoperative MRI is helpful in the surgical planning of patients with bowel endometriosis. As yet, there is no comparative study evaluating the significance of imaging on diagnosis, patient management and surgical outcomes. The primary goal of this study was to evaluate the impact of the endometriosis-specific MRI protocol (EsMRIp) established at the Cleveland Clinic on the diagnosis and management of new patients who present with endometriosis-related pelvic pain. <h3>Design</h3> Retrospective Cohort. <h3>Setting</h3> Academic Referral Center. <h3>Patients or Participants</h3> New patients >18yoa who presented with endometriosis-related pelvic from 2015-2019 were included. Pregnant patients, with known cancer or previous endometriosis diagnosis were excluded. Patient demographics, frequency of diagnostic laparoscopies (defined as absence of preoperative imaging and a surgery performed for the primary purpose of diagnosing endometriosis), treatment modality, operative time, EBL, intra- and postoperative complications, reoperation rates, and hospital length of stay were evaluated. <h3>Interventions</h3> To evaluate the impact of EsMRIp. <h3>Measurements and Main Results</h3> A total of 1,228 new patients were identified and 361 met study criteria. There were no significant differences in patient demographics. EsMRIp has 60.7% specificity and 80% specificity. Diagnostic laparoscopies were performed more often before EsMRIp (41.9% before vs 27.0% after, p = 0.036; OR 0.51, 95% CI 0.28-0.96). After EsMRIp, patients were more likely to receive medical therapy alone (50.4% vs. 25.5%) or combined surgical/medical therapy (17.9% vs. 7.3%) and less likely to be treated with surgery alone (16.1% vs. 24.4%) (p<0.001). There were no differences in rates of intraoperative non-gynecologic consultations, postoperative complications, readmissions, or reoperations before and after EsMRIp. <h3>Conclusion</h3> Our preliminary study revealed that institutional implementation of a preoperative EsMRIp was associated with fewer diagnostic laparoscopies and treatment of patients with surgery alone. More patients received medical alone and combined medical and surgical treatments after EsMRIp use. Further prospective studies to validate the above-mentioned trends and evaluate pain and fertility outcomes would be helpful.

Does Leuprolide Acetate Predict Successful Pain Relief after Hysterectomy and BSO in Endometriosis Patients?

<h3>Study Objective</h3> Evaluate whether patients with endometriosis-associated pelvic pain who achieve pain relief with leuprolide acetate are more likely to achieve pain relief after hysterectomy and oophorectomy (BSO). <h3>Design</h3> Retrospective chart review. <h3>Setting</h3> Academic teaching hospital. <h3>Patients or Participants</h3> Patients who underwent trial of leuprolide acetate prior to hysterectomy and BSO for endometriosis. <h3>Interventions</h3> We performed a retrospective chart review of patients from 2015-2021 who had a diagnosis of endometriosis and underwent a trial of leuprolide acetate prior to hysterectomy with BSO for pelvic pain (n=31). We reviewed pre-operative records, operative notes, and postoperative records to assess whether patients achieved pain relief following ovarian suppression with leuprolide acetate or definitive surgical management with hysterectomy and oophorectomy. Patients who achieved complete pain relief with leuprolide acetate or hysterectomy with oophorectomy were considered having achieved "complete pain relief". <h3>Measurements and Main Results</h3> 31 patients underwent a trial of leuprolide acetate prior to hysterectomy and BSO for endometriosis. Fifteen patients reported "complete pain relief" with leuprolide acetate therapy and 16 did not. The groups were similar in age, ethnicity, race, BMI, parity, number of past treatments for pelvic pain, mode of hysterectomy, blood loss during surgery, presence of adhesions, and surgical complications. There was a significant difference between the two groups as to whether they achieved complete pain relief after hysterectomy with BSO. Among patients with complete pain relief after leuprolide acetate therapy, 73.7% reported complete pain relief after surgery. In patients who did not experience complete pain relief with leuprolide acetate therapy, only 37.5% reported complete pain relief after surgery (p=.045). <h3>Conclusion</h3> Patients who had complete preoperative pain relief using leuprolide acetate were more likely to achieve pain relief with hysterectomy and BSO. A trial of leuprolide acetate prior to surgery may be helpful to predict which patients will benefit from hysterectomy and BSO for endometriosis-related pelvic pain.

Pain Reduction With an Immersive Digital Therapeutic Tool in Women Living With Endometriosis-Related Pelvic Pain: Randomized Controlled Trial.

BackgroundChronic pelvic pain is a common and disabling condition in women living with endometriosis. Pharmacological and surgical treatments are not always effective at controlling pain and present important restrictions. Digital therapeutics (DTx) are emerging as major nonpharmacological alternatives that aim to extend the analgesic therapeutic arsenal of patients.ObjectiveIn this randomized controlled trial (RCT), we aimed to measure the immediate and 4-hour persisting effects of a single use 20-minute DTx (Endocare) on pain in women experiencing pelvic pain due to endometriosis.MethodsA total of 45 women with endometriosis participated in a randomized controlled study comparing the analgesic effect of a single use of a virtual reality digital treatment named Endocare (n=23, 51%) to a 2D digital control (n=22, 49%). Perceived pain and pain relief were measured before the treatment and 15, 30, 45, 60, and 240 minutes after the end of the treatment.ResultsThe clustered posttreatment pain was significantly reduced compared to the pretreatment for both Endocare and the control group (all P<.01). Endocare was significantly more effective than the control group (all P<.01). Endocare decreased the mean pain intensity from 6.0 (SD 1.31) before the treatment to 4.5 (SD 1.71) posttreatment, while the control only decreased it from 5.7 (SD 1.36) to 5.0 (SD 1.43). When comparing each posttreatment measures to the pretest, Endocare significantly reduced pain perception for all points in time up to 4 hours posttreatment. The differences did not reached significance for the control group. Moreover, Endocare was significantly superior to the control group 15, 30, and 45 minutes after the treatment (all P<.001). The mean perceived pain relief was significantly higher for Endocare at 28% (SD 2%) compared to the control, which was 15% (SD 1%) for all the posttreatment measurements (all P>.05).ConclusionsOur study aimed to test the effects of a single use of a DTx treatment on reported pain at different time points in women diagnosed with endometriosis experiencing moderate-to-severe pelvic pain. Importantly, our results support that Endocare, a virtual reality immersive treatment, significantly reduce pain perception compared to a digital control in women living with endometriosis. Interestingly, we are the first to notice that the effect persisted up to 4 hours posttreatment.Trial RegistrationClinicalTrials.gov NCT04650516; https://tinyurl.com/2a2eu9wv

The dienogest-related cystitis in women with endometriosis: a prospective, controlled, comparative study

The aim of the study was to examine the severity of clinical symptoms of acute cystitis and the level bacteriuria in female patients who underwent to laparoscopic surgery followed by a postoperative administration of dienogest 2 mg and combined oral contraceptives pills (COCP). One hundred and forty five women who had a laparoscopic surgery prospectively were enrolled. Criteria inclusions were the age from 30 to 45 years old; body mass index (BMI) absence of previous hormonal therapy at least 6 month and recent performed a laparoscopy surgery for endometriosis. The women (n = 35) who had uterine myoma, abnormal coagulation profile; concomitant neoplastic diseases; chronic pelvic inflammatory disease and chronic recurrent cystitis were excluded from study. The female patients were assigned into both groups treatment: group I (n = 54) and group II (control, n = 56) who received dienogest 2 mg once daily and COCP, respectively. During follow-up three female patients of group I were withdrawn due to prolonged genital bleedings. The final analysis included 105 women. The patients of both groups had a low level of bacteriuria <103 CFU/ml without clinical symptoms of acute cystitis before treatment. The level of bacteriuria in-group I significantly increased from 102 to 106 CFU/ml whereas in-group II did not exceed 102 CFU/ml during 4 weeks of hormonal treatment. The differences of values of acute cystitis symptom score (ACSS) for differential, typical, quality of life domains were statistically significant after 4, 8 and 12 weeks of therapy in-group I compared with group II. During 3 months of hormonal treatment with dienogest 2 mg in group I, the acute cystitis developed in 10 (18.5%), in 19 (38%) and in 34 (68%) women at 4, 8 and 12 weeks of follow-up, respectively. All cases of acute cystitis in-group I were successfully treated with fosfomycin trometamol 3 g single dose or nitrofurantoin 50 mg four times a day during 5 days. We concluded that the dienogest might increase the level bacteriuria and severity of clinical symptoms of acute cystitis during a postoperative prophylaxis of endometriosis. Impact statement What is already known on this subject? Dienogest is a 19-nortestosterone derivative progestogen that is highly selective for progesterone receptors with high efficacy for reducing endometriosis-related pelvic pain syndrome. The administration of dienogest is a standard treatment option after laparoscopic excision of endometrial heterotopic tissue with prophylactic purpose. However, there are some adverse events, which are a cause for discontinuation. What do the results of this study add? Despite the low incidence of urinary tract infection (1–5.4%) reported in different studies this study has shown that there was a significant increase of level bacteriuria and severity of clinical symptoms of cystitis in the dienogest group. What are the implications of these findings for clinical practice and/or further research? The implications of these findings are that the administration of dienogest may lead to enhancing of clinical symptoms of cystitis and increasing bacteriuria in some women after operative treatment of endometriosis.

Robot-Assisted Surgery for Endometriosis Current and Future Perspectives.

Successful resection of all visible lesions may effectively treat endometriosis-related infertility and pelvic pain. Minimally invasive surgery provides significant advantages, with lower rates of surgical complications such as surgical trauma, infection, postoperative pain, and hospital stay. Robotic surgery is shown to have similar perioperative outcomes to conventional laparoscopy; however, complex stage III and IV endometriosis, especially cases requiring significant resection such as deep infiltrating endometriosis, widespread peritoneal implants, and urologic and intestinal involvement, may benefit most from a robotic approach. There are certain aspects of endometriosis surgery where utilization of robotic technology might provide an additional benefit. These include (1) heterogeneity of lesions, and thus difficulty in identification; (2) difficulty in accurately predicting surgical complexity; and (3) prolonged operative time for complex cases. The objective of this review is to describe the current and future perspectives of robotic surgery as it pertains to endometriosis.

A model-based analysis to guide gonadotropin-releasing hormone receptor antagonist use for management of endometriosis.

AimsTo identify linzagolix doses, an oral GnRH receptor antagonist, that effectively lower oestradiol (E2) to relieve endometriosis‐related pelvic pain without compromising bone health.MethodsIntegrated statistical, pharmacokinetic–pharmacodynamic and systems pharmacology models were developed from Phase 1 and 2 clinical trial data in healthy volunteers and patients, receiving linzagolix 25–200 mg daily or placebo, and analysed simultaneously. The main outcome measures were pelvic pain scores for dysmenorrhoea, nonmenstrual pelvic pain (NMPP), uterine bleeding and lumbar spine bone mineral density (BMD).ResultsLinzagolix pharmacokinetics were described by a 2‐compartment model with sequential zero/first‐order absorption process (CL/F: 0.422 L/h). E2 changes over time were well described as a function of linzagolix 24‐hour AUC (AUC50: 1.68 × 105 ng h/mL). For a Caucasian reference patient, a change in E2 from 50–20 pg/mL at 24 weeks increased the odds of relief of dysmenorrhoea 1.33‐fold and NMPP 1.07‐fold (95% CI: 1.22–1.47 and 1.02–1.12, respectively) and decreased bleeding days by 1.55 (95% CI: 1.39–1.72). A previously validated quantitative systems pharmacology BMD model was adjusted to the clinical data. The mean week 24 lumbar spine BMD change from baseline ranged from −0.092% in the 50 mg dose, −1.30% in the 100 mg dose group and −2.67% in the 200 mg dose group.DiscussionThe previously‐reported E2 target range (20–50 pg/mL) to balance efficacy and safety endpoints was confirmed. Linzagolix once daily doses between 75–125 mg daily were expected to meet endometriosis‐associated pain, efficacy, and BMD loss targets in Caucasian patients.

Sleep disturbances, fatigue and psychological health in women with endometriosis: a matched pair case–control study

Research questionWhat are the associations between endometriosis, pelvic pain symptoms, fatigue and sleep? Psychological health and quality of life in endometriosis patients with good versus bad quality of sleep were also examined. DesignThis matched pair case–control study included 123 consecutive endometriosis patients and 123 women without a history of endometriosis (matched to patients for age and body mass index). Endometriosis-related pelvic pain severity was rated on a 0–10 numerical rating scale. Fatigue was measured on a 1–5 Likert scale. Women also completed a set of self-report questionnaires for assessing sleep disturbances (Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Insomnia Severity Index), psychological health (Hospital Anxiety and Depression Scale) and quality of life (Short Form-12). ResultsPainful endometriosis had an impact on fatigue (P = 0.006; η2p = 0.041) and sleep (P < 0.001; η2p = 0.051). Women with painful endometriosis reported significantly greater fatigue, poorer quality of sleep, higher daytime sleepiness and more severe insomnia than women without significant pain symptoms and controls. Poorer quality of sleep among endometriosis patients was associated with greater fatigue (P < 0.001; η2p = 0.130), poorer psychological health (P < 0.001; η2p = 0.135), and lower quality of life (P < 0.001; η2p = 0.240). ConclusionsPelvic pain (rather than endometriosis in itself) is associated with fatigue and sleep disturbances, with poor sleep having a detrimental impact on women's psychological health and quality of life.

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Endometriosis-related pelvic pain following laparoscopic surgical treatment

Introduction:Endometriosis is a common, often-debilitating disease, affecting women of reproductive age. Pain is a common symptom of the disease and is commonly treated by surgery, medical therapy,...

Endometriosis-related pelvic pain following laparoscopic surgical treatment

Introduction: Endometriosis is a common, often-debilitating disease, affecting women of reproductive age. Pain is a common symptom of the disease and is commonly treated by surgery, medical therapy, or a combination of the two. This study aimed to evaluate the rates of ongoing pain post laparoscopic excision and the risk factors for ongoing pain symptoms. Methods: This retrospective cohort study analyzed the medical records of all patients who underwent laparoscopic surgery for endometriosis in a large tertiary healthcare service in Australia between January 2009 and September 2016. Results were analyzed using SPSS statistics version 11. Results: A total of 972 patients met the inclusion criteria; of these, 398 had follow-up at our hospital network and were included in the final analysis. The median age was 34.5 years, 69.6% were of Caucasian ethnicity, and the median body mass index was 25.9; 70.6% of our patients reported decreased pain after surgery. Patients who suffered from chronic pain were twice as likely to experience ongoing pain, while patients with stage 3–4 endometriosis were found to have 65% reduced odds of pain at follow-up (95% confidence interval = 0.22–0.61, p &lt; 0.001). In univariate analysis of non-Caucasian patients, those who had a specialist endometriosis surgeon perform the surgery had significantly higher incidence of symptom improvement (58% reduced odds of recurrent pain and 40% reduced odds, p &lt; 0.05, accordingly). Conclusion: The prevalence and severity of pain associated with endometriosis mandates a thorough understanding of the effectiveness of current management. Our article highlights the utility of laparoscopic surgery in treating endometriosis-associated pain.

Patient-Reported Use of Medical Cannabis for Management of Chronic Pelvic Pain [12H

INTRODUCTION: Chronic pelvic pain (CPP) affects up to 15% of women in the United States. The endocannabinoid system can be a pharmacological target for endometriosis-related pelvic pain, as cannabis receptors are highly expressed in the uterus and other non-reproductive tissues. We hypothesize that many patients with CPP use cannabis and report improvement in symptoms. METHODS: An anonymous, confidential, electronic survey was performed from March through August 2019. Patients aged 18 through 89 were included if they had a diagnosis of pelvic/perineal pain, dyspareunia, or endometriosis. Subjects were approached during outpatient appointments. Study approval was obtained from the Institutional Review Board. RESULTS: A total of 122 of 240 (50.8%) patients responded. Of these, 113 self-reported a diagnosis of CPP (92.6%). Twenty-six patients reported cannabis use (23%). Six (24%) used Cannabidiol (CBD), 3 (12%) used tetrahydrocannabinol (THC), and 15 (60%) used a combination of CBD and THC. Frequency of use varied, with the majority using at least once per week (n=18, 69.2%). Only 5 (19.2%) utilized a State Medical Cannabis Program to obtain a certification. Of users, 24 (92.3%) reported improvement in symptoms, including pain, cramping, muscle spasms, anxiety, depression, sleep disturbances, libido, and irritability. However, 21 (80.7%) reported side effects; the most common were dry mouth, sleepiness, and feeling “high.” CONCLUSION: Up to 23% of patients with CPP report use of cannabis as an adjunct to their prescribed therapy, and they use a variety of formulations and doses. Most report daily or weekly use. Although side effects are common, most users report improvement in symptoms.

Clinical Utility of Presacral Neurectomy as an Adjunct to Conservative Endometriosis Surgery: Systematic Review and Meta-Analysis of Controlled Studies

The objective of this review was to compare the efficacy and safety of conservative surgery with or without adjunctive presacral neurectomy (PN) for chronic endometriosis-related pelvic pain. In a systematic review with meta-analysis, randomized or nonrandomized controlled studies of conservative endometriosis surgery with or without adjunctive PN were included. Main outcomes were treatment failure (the proportion of women in which surgery failed to adequately resolve midline pain) and the frequency of operative and postoperative complications. A total of 7 studies with 8 group comparisons (3 randomized) representing 503 women (250 PN; 253 Control) were included. Over 34 months median follow-up, crude rates of treatment failure were 15.0% with PN and 40.9% with Controls (risk ratio = 0.43, 95% CI = 0.30 to 0.60, p < 0.001). The risk of postoperative constipation was higher with PN vs. Controls (12.5% vs. 0%, p = 0.024). No treatment group differences were observed for the risk of operative complications (0.6% vs. 0%, p = 0.498), reoperation (4.1% vs. 3.0%, p = 0.758) or urinary incontinence (5.0% vs. 0%, p = 0.195). Overall, in well-selected patients, conservative surgery with adjunctive PN may provide greater relief from midline pain and a similarly low rate of operative complications relative to conservative surgery alone but may increase the risk of constipation postoperatively. However, results were derived from mainly older and lower quality studies. Since then, surgical techniques to treat endometriosis have been improved and the effect of PN observed in prior studies should be confirmed in future studies in women in whom radical excision of deep infiltrating lesions is obtained.