Nonmenstrual Pain Research Articles

Selective Progesterone Receptor Modulator Development and Use in the Treatment of Leiomyomata and Endometriosis

Selective progesterone receptor modulators (SPRMs) represent a new class of progesterone receptor ligands. SPRMs exert clinically relevant tissue-selective progesterone agonist, antagonist, or mixed agonist/antagonist effects on various progesterone target tissues in vivo. Asoprisnil (J867) is the first SPRM to reach an advanced stage of clinical development for the treatment of symptomatic uterine fibroids and endometriosis. Asoprisnil belongs to the class of 11beta-benzaldoxime-substituted estratrienes that exhibit partial progesterone agonist/antagonist effects with high progesterone receptor specificity in animals and humans. Asoprisnil has no antiglucocorticoid activity in humans at therapeutic doses. It exhibits endometrial antiproliferative effects on the endometrium and breast in primates. Unlike progesterone antagonists, asoprisnil does not induce labor in relevant models of pregnancy and parturition. It induces amenorrhea primarily by targeting the endometrium. In human subjects with uterine fibroids, asoprisnil suppressed both the duration and intensity of uterine bleeding in a dose-dependent manner and reduced tumor volume in the absence of estrogen deprivation. In subjects with endometriosis, asoprisnil was effective in reducing nonmenstrual pain and dysmenorrhea. Asoprisnil may, therefore, provide a novel, tissue-selective approach to control endometriosis-related pain. SPRMs have the potential to become a novel treatment of uterine fibroids and endometriosis.

Comparison of a Levonorgestrel-Releasing Intrauterine Device versus Expectant Management After Conservative Surgery for Symptomatic Endometriosis: A Pilot Study

Laparoscopic surgery is often carried out in women with endometriosis who experience dysmenorrhea. The results are not consistently good, and affected women often have recurrent pain. This open-label, parallel-group, randomized trial evaluated an intrauterine device (IUD) that releases levonorgestrel (a Lng-IUD), a potent 19-nortestosterone derivative progestin that can induce amenorrhea. Twenty parous women with endometriosis and moderate or severe dysmenorrhea received the Lng-IUD after operative laparoscopy, whereas 20 others had only surgery. The participants, who were 40 years of age or younger and did not want a child, were reevaluated after 12 months. Conservative surgery was performed using only mechanical instruments and electrosurgery. Adhesions were sectioned, the ovaries were mobilized, and areas of endometriosis were either excised or coagulated. The Lng-IUD that was inserted into the uterine cavity releases 20μg of levonorgestrel daily over 5 years. In one case, the Lng-IUD was displaced. After 12 months, amenorrhea was described by 28% of women given the Lng-IUD and dysmenorrhea or spotting by another 50%; 22% of these women had normal menstrual flow. Dysmenorrhea continued at a moderate or severe level in 45% of women treated by surgery alone. The absolute risk reduction of recurrent dysmenorrhea in the Lng-IUD group was 35%. Dyspareunia and nonmenstrual pain also were less frequent in the IUD group. Tolerable side effects developed in 8 of 20 women assigned to receive the IUD. At follow-up, 75% of women in the Lng-IUD group and 50% of those in the surgery-only group were satisfied or very satisfied with their treatment. This pilot study suggests that, in women with symptomatic endometriosis, inserting a Lng-IUD after conservative laparoscopic surgery reduces the chance of recurrent dysmenorrhea and provides a high level of patient satisfaction, at least over the medium term.

Laparoscopic Management of Patients with Endometriosis and Chronic Pelvic Pain

Endometriosis has been traditionally included among the most important causes of chronic pelvic pain (CPP) in women of reproductive age. The main clinical manifestations of endometriosis are dysmenorrhea, dyspareunia, and chronic nonmenstrual pain. Despite the high prevalence of endometriosis in women suffering from CPP, controversy still exists regarding the true association between the stage and extent of this peculiar disease and the severity of pain. Over the last decade, advances in endoscopic technology have enabled gynecologic surgeons to recognize many atypical appearances of the endometriotic implants not known to exist before, thus allowing their complete excision or destruction. Laparoscopic surgery may offer considerable relief in patients with endometriosis and CPP. Although cases with advanced endometriosis seem to benefit the most, we also support surgical treatment in patients with early endometriosis diagnosed using laparoscopy, as many will experience improvement in their symptoms.

Surgical Findings of endometriosis and their correlation to pelvic pain

Objective: Endometriosis lesion characteristics have not been consistently correlated with pelvic pain location. We investigated the relationship between pain location, type, and severity with surgical findings in women with pelvic pain undergoing surgery for endometriosis excision. Design: Prospective study comparing self-reported pelvic pain characteristics with location of endometriosis lesions excised at surgery. Materials and Methods: Reproductive-aged healthy women with chronic pelvic pain were followed over one menstrual cycle. Prior to surgery, women noted menstrual, nonmenstrual and coital pain (M, NM, C), pain location, pain severity by visual analog scale (0–20), and described other pelvic symptoms on standardized questionnaires. Pelvic pain location was divided into 5 anterior and 3 posterior areas. At surgery, all lesions were excised. Endometriomas, adhesions, lesion size, depth, color, and location were recorded. Endometriosis extent was classified by ASRM stage. Multiple and logistic regression models were used to determine if endometriosis lesion location and extent predicted pain location, type, severity, and other pelvic symptoms. This study was supported by the Intramural Research Program of the National Institutes of Health. Results: Of 77 women undergoing surgery, 57 had histological verification of endometriosis. Of those women, 97% reported menstrual pain with 53% reporting more than 2 days/month lost due to pain. 97% also had non-menstrual pain with 61% suffering almost every day. Degree of debility, pelvic pain chronicity and severity was similar regardless of ASRM stage. Lesion characteristics (number, color, average size, and maximum depth) by pelvic region did not correlate with pain location. Pain type (M, NM, C) and severity did not predict the total number, average size or maximum depth of lesions, and presence of endometriomas or adhesions. Other common symptoms reported among women with histologically-diagnosed endometriosis included upper (41%) and lower (72%) GI symptoms, rectal symptoms (47%), problems with sex (52%), and urinary symptoms (30%). Women often had other pain symptoms, such as headaches (68%), back pain (83%), and leg pain (30%). Heavy periods, experienced by 66% of women, were associated with back pain and dysmenorrhea (p=0.0035 and p=0.04, respectively). Conclusion: In this study in which the location of lesions was carefully mapped, endometriosis lesion location did not correlate with pelvic pain location. Women with pelvic pain not only had menstrual pain but had high rates of nonmenstrual and coital pain as well as headaches, gastrointestinal and urinary pain. These findings raise the question of whether endometriosis lesions per se are the cause of pelvic pain in these women.

Patient satisfaction and changes in pain scores after ablative laparoscopic surgery for stage III–IV endometriosis and endometriotic cysts

Objective To document the changes in pain scores 3–12 months following ablative laparoscopic surgery. Secondary outcome measures included patient satisfaction scores. Design A prospective, cohort study. Setting A tertiary referral center for the treatment of endometriosis. Patient(s) Seventy-three consecutive women with stage III–IV endometriosis and an endometrioma >2 cm. Intervention(s) A laparoscopy was performed. The extraovarian endometriosis was ablated with a CO 2 laser, and the endometrioma capsule was fenestrated then ablated with the potassium-titanic-phosphate (KTP) laser or the Bicap™ bipolar diathermy. Main outcome measure(s) Pre- and postoperative visual analogue scores for pelvic pain were completed. Patient satisfaction was scored from 1 to 10, with a score of 10 being “most satisfied.” Result(s) A total of 73 women with stage III–IV endometriosis and 96 cysts (23 cysts were bilateral). The mean revised American Fertility Society (AFS) score was 65.5 (range 22–128). At 12 months, the mean temporal decrease in the pain score for dyspareunia was 2.14 ± 0.41; for dysmenorrhea, 1.52 ± 0.38; and for chronic nonmenstrual pain, 2.37 ± 0.43. Sixty-four (87.7%) patients were satisfied or very satisfied with the treatment. No surgical complications occurred. Conclusion(s) Laparoscopic ablative surgery for endometriomas in the presence of stage III–IV endometriosis is an effective treatment for relieving pelvic pain.

Laparoscopic Uterine Artery Ligation for Treatment of Symptomatic Adenomyosis

Study Objective To investigate the effect of laparoscopic uterine artery ligation on symptomatic adenomyosis. Design Prospective pilot study (Canadian Task Force classification II-2). Setting Tertiary care major teaching hospital. Patients Twenty women with symptomatic adenomyosis. Intervention Laparoscopic ligation of bilateral uterine arteries with hemoclips and electrocoagulation of bilateral uterine ovarian vessels. Measurements and Main Results Patients underwent sonographic measurement of uterine size, and recorded amount of menstruation and dysmenorrhea preoperatively and postoperatively. Six months postoperatively, mean uterine size had decreased by an amount ranging from 0.4% to 74.0%. Two of nine women achieved remission of the mass effect of an enlarged uterus. Thirteen of 16 patients achieved bleeding control and 5 returned to eumenorrhea or hypomenorrhea. Twelve of 16 patients achieved control of dysmenorrhea and 6 were analgesic free. However, nine women experienced nonmenstrual pain after surgery, three of whom underwent hysterectomy later. Treatment was rated as satisfactory by 15% of patients, but 45% were dissatisfied. Seventeen women would have refused to undergo the procedure if they could make the decision again. Conclusion Poor satisfaction in this preliminary study suggests that symptomatic adenomyosis may not be effectively treated by laparoscopic uterine artery ligation.

Does Laparoscopic Surgery for Endometriomas Really Relieve Painful Symptoms?

The objective of this study was to determine whether laparoscopic surgery for endometriomas relieves painful symptoms. A systematic literature search was carried out to identify papers relating to the laparoscopic management of endometriomas, where relief of painful symptoms was an outcome measure. Each paper was analyzed using preset criteria to identify the methodology used and how the results were reported. There is very little objective, prospective evidence to support the practice of laparoscopic surgery for endometriomas in terms of relieving pelvic pain. Only one study out of six analyzed dysmenorrhea, dyspareunia, and chronic nonmenstrual pain individually, using visual analog scores. This study demonstrated a benefit following surgery. There is an urgent need for studies with objective end points or a national system to audit results.

Levonorgestrel-releasing intrauterine device (Lng-IUD) versus expectant management after conservative surgery for symptomatic endometriosis. A pilot study

Objective: To verify if the frequency and severity of dysmenorrhea is reduced and time to symptom recurrence is prolonged in women with symptomatic endometriosis undergoing conservative surgery plus Lng-IUD insertion compared with women treated with surgery only. Dyspareunia and nonmenstrual pain were also evaluated.

Relationship between stage, site and morphological characteristics of pelvic endometriosis and pain.

The relationship between frequency and severity of pain symptoms and site, stage and morphological characteristics of endometriotic lesions was analysed in a multicentre cross-sectional observational study. A total of 469 women (median age 31 years, range 18-45) who met the following criteria were consecutively observed in the participating centres during the study period: age 18-45 years, first laparoscopic or laparotomic diagnosis of endometriosis, pain symptoms lasting > or = 6 months, pain as the main or only complaint of the condition, absence of pelvic anomalies and no previous pelvic surgery. Dysmenorrhoea and non-menstrual pain were evaluated using a multidimensional verbal rating scale. The women were requested to grade the severity of dysmenorrhoea, non-menstrual pelvic pain and deep dyspareunia using a 10-point linear analogue scale. Dysmenorrhoea was present in 77% of subjects with ovarian endometriosis, 88% of those with endometriosis of the peritoneum, 92% of subjects with endometriosis of both ovary and peritoneum and in all the subjects with endometriosis of rectovaginal septum. These differences were not statistically significant after Bonferroni's correction. No marked difference emerged between the severity of dysmenorrhoea and site of endometriosis, but women with ovarian endometriosis tended to have lower scores (not significant). No clear association emerged between frequency and severity of non-menstrual pain, dyspareunia and site of endometriosis and the presence and severity of dysmenorrhoea, non-menstrual pain and dyspareunia. Dyspareunia was more frequently reported in women with only atypical endometriosis (56.8%) versus 47.7% in women with typical endometriosis, but with borderline significance (P = 0.05). Dyspareunia occurred in 68.2% of patients with both typical and atypical lesions. The results of this study find no clear-cut association between stage, site or morphological characteristics of pelvic endometriosis and pain.

Estroprogestin vs. gonadotrophin agonists plus estroprogestin in the treatment of endometriosis-related pelvic pain: a randomized trial

Objective: This is a randomized clinical trial comparing estroprogestin (E/P) pill given for 12 months vs. gonadotrophin releasing hormone agonist (GNRHa) given for 4 months followed by E/P pill treatment for 8 months in the relief of endometriosis-related pelvic pain. Methods: Eligible for the study were women with laparoscopically confirmed endometriosis and pelvic pain lasting 3–12 months after diagnosis. Eligible women were randomly assigned to treatment with E/P pill (gestroden 0.75 mg and ethynlestradiol 0.03 mg) for 12 months (47 patients) vs. tryptorelin 3.75 mg slow release every 28 days for 4 months followed by E/P pill for 8 months (55 patients). Results: At baseline, dysmenorrhea was reported in 46 women allocated to E/P pill only (97.9%), and in all the 55 women allocated to GNRHa+E/P pill. The corresponding value at the 12 months follow-up visit was 14 subjects (35.9%) and 16 subjects (34.8%). The baseline median values of the multidimensional and analog scale were for dysmenorrhea 4 and 6 in the EP only and 3 and 6 in the GNRHa+E/P group. The corresponding value at the 12 months follow-up visit were 2 and 6 and 0 and 5. Non-menstrual pain was reported, respectively, at baseline and 12 month visit by 46 (97.9%) and 15 (38.5%) subjects in the E/P pill group and 49 (89.1%) and 17 (37.0%) of the GNRHa+E/P pill one. The baseline median values of the multidimensional and analog scale were for non-menstrual pain 3 and 5 in the E/P only and 2 and 6 in the GNRHa+E/P group. The corresponding values at the 12 month follow-up visit were 0 and 4 and 0 and 4. These differences between the two groups were not statistically significant. Conclusions: 1 year after randomization, the two treatment schedules show similar relief of pelvic pain in women with endometriosis.

The relationship between gender and family history of pain with current pain experience and awareness of pain in others

This study aimed to evaluate the relationship between family history of pain and current pain experience in a student population. In a sample of 180 students who completed a pain history questionnaire there was a significant difference between males and females with women reporting significantly more pain models than men even when menstrual pain models were excluded from the analysis. There was also a difference on current pain symptoms, with women reporting more pain symptoms but this difference was no longer significant when menstrual pain was excluded. These results suggest that differences observed between sexes in a young student population in relation to current pain symptom reports may be accounted for by the presence of menstrual pain rather than by differences in family history of pain as it has previously been suggested. The higher incidence of pain models reported by females for menstrual as well as non-menstrual pain suggests a greater awareness of pain in others without implying a greater tendency for the young females as a group to report pain themselves.

Modern combined oral contraceptives for pain associated with endometriosis.

Endometriosis is a major women's health-care problem. It causes pain and/or infertility, and affects millions of women worldwide. Endometriosis is defined according to histological criteria by the presence of tissue resembling endometrium in sites outside the uterus, most commonly the ovaries and peritoneum. The aim of treatment has been to remove the deposits of ectopic endometrium that are thought to be responsible for the symptoms of endometriosis. This can be achieved surgically by destroying or removing the implants; medical therapies induce atrophy within the hormonally-dependent ectopic endometrium. The duration of hormonal treatment may be limited by unwanted side effects. There is some evidence, however, from epidemiological research that current use of the combined oral contraceptive pill (OCP) is associated with a reduced incidence of endometriosis. The combined pill has the great advantage over other hormonal treatments that it can be taken indefinitely. The aim of this review was to establish the role of modern oral contraceptives in the management of painful symptoms ascribed to endometriosis. The search strategy of the Menstrual Disorders Group was utilised to identify all randomised trials of the use of oral contraceptives in the treatment of symptomatic endometriosis. In addition a search of the Cochrane Controlled Trials Register was undertaken together with approaches to pharmaceutical companies. All truly randomised controlled trials of the use of oral contraceptive pills in the treatment of women of reproductive age with symptoms ascribed to the diagnosis of endometriosis made visually at a surgical procedure, were included. Study quality assessment and data extraction was carried out independently by two reviewers. One of the assessors was an expert in the content matter. Only one study was identified which satisfied the inclusion criteria. The oral contraceptive used in a conventional manner was less effective than a GnRH analogue in the relief of dysmenorrhoea. No significant difference was noted between the effectiveness of the oral contraceptive pill and a GnRH analogue in the relief of dyspareunia or non-menstrual pain. Headaches and weight gain were more commonly associated with oral contraceptive usage than with GnRH analogue usage whereas hot flushes, insomnia and vaginal dryness were less common. There is a paucity of data relating to the use of oral contraceptive preparations in the treatment of symptomtic endometriosis. The data such as it is supports the common practice of the use of the oral contraceptive pill as a first line therapy but further research is required to fully evaluate its role in the management of endometriosis.

Gestrinone versus a gonadotropin-releasing hormone agonist for the treatment of pelvic pain associated with endometriosis: a multicenter, randomized, double-blind study

To evaluate the efficacy of gestrinone versus leuprolide acetate (LA) in improving pelvic pain in women with endometriosis and to compare their effects on bone mineral density and serum lipid profile. Multicenter, double-blind, double-dummy, randomized clinical trial. Six academic departments specialized in the study of endometriosis. Fifty-five women with moderate or severe pelvic pain and laparoscopically diagnosed endometriosis. Six-month treatment with oral gestrinone (n = 27) or IM depot LA (n = 28) followed by 6-month follow-up. Variations in severity of dysmenorrhea, deep dyspareunia, and nonmenstrual pain as shown by a visual analog scale and a verbal rating scale, modifications in bone mineral content as shown by dual-roentgenogram absorptiometry, and variations in serum cholesterol subfractions and lipoprotein(a) concentrations. Significant improvements were observed in all three symptoms considered in both treatment arms. Moderate or severe pain symptoms recurrence on both pain scales was observed in 2 of 17 (11.8%) patients given gestrinone compared with 9 of 17 (52.9%) of those given LA (odds ratio, 0.12; 95% confidence interval, 0.02 to 0.69). Lumbar bone mineral density increased slightly in the gestrinone group but decreased by 3% in the LA one. High-density-lipoprotein cholesterol fell by 25% and lipoprotein(a) decreased by approximately 40% in the gestrinone-treated women but did not vary in those receiving LA. Oral gestrinone is at least as effective as depot LA for pain relief in women with symptomatic endometriosis. A tendency to prolonged pain reduction was observed after gestrinone compared with LA treatment. Gestrinone does not negatively affect bone density but variations in serum lipids need further evaluation.

Laparoscopy versus laparotomy in conservative surgical treatment for severe endometriosis

To determine the outcome of laparoscopy compared with laparotomy in conservative surgical treatment for severe endometriosis. Comparison of nonrandomized historical surgical series. Two teaching hospitals and referral centers specializing in reparative and reconstructive surgery. A total of 216 patients operated for severe endometriosis during a 5-year period. Conservative surgical treatment at laparoscopy (n = 67) or laparotomy (n = 149) with median follow-up of 24 months. Cumulative probability of pregnancy in previously infertile patients (22 in the laparoscopy group and 70 in the laparotomy group) and cumulative probability of pain recurrence in subjects with moderate or severe symptoms before surgery (47 in the laparoscopy group and 108 in the laparotomy group). The 24-month cumulative probability of pregnancy according to the Kaplan-Meier method was 44.9% after laparoscopy and 62.7% after laparotomy. The 24-month cumulative probability of symptoms recurrence evaluated with a 0 to 3 point verbal rating scale was, respectively, 16.4% versus 20.3% for dysmenorrhea, 33.3% versus 15.4% for deep dyspareunia, and 25.0% versus 15.9% for nonmenstrual pain. The corresponding figures obtained with a 10-point linear analogue scale were 20.3% versus 24.7%, 28.6% versus 10.4%, and 17.5% versus 20.1%. No difference is statistically significant. Laparoscopy and laparotomy seem equally effective in the treatment of infertility and chronic pelvic pain associated with severe endometriosis. However, a trend was observed toward a higher pregnancy rate and lower dyspareunia recurrence rate after surgery for severe endometriosis performed at laparotomy compared with laparoscopy.

Endometriosis and pelvic pain: relation to disease stage and localization

To determine whether prevalence and severity of pain symptoms are related to endometriosis stage and site, with particular reference to deep infiltrating vaginal lesions. Systematic assessment of chronic pelvic pain symptoms. University hospital endometriosis center. A total of 244 consecutive symptomatic patients with endometriosis diagnosed at laparoscopy or laparotomy. Assessment of dysmenorrhea and nonmenstrual pain by means of a 10-point linear analog scale, a 7-point multidimensional rating scale, and a 3-point verbal scale; evaluation of deep dyspareunia with the first and third systems only. Prevalence and severity of pain symptoms in relation to endometriosis stage and site of lesions. Correlation between revised American Fertility Society score and symptoms severity, as well as between two pain scales to assess dysmenorrhea and nonmenstrual pain. Eighty-eight women had stage I and II disease and 156 had stage III and IV disease. Only ovarian endometriosis was present in 108 patients, only peritoneal implants were present in 37, combined ovarian and peritoneal lesions were present in 57, and histologically confirmed vaginal endometriosis was present in 42. The frequency and severity of deep dyspareunia and the frequency of dysmenorrhea were less in patients with only ovarian endometriosis than in those with lesions at other sites. Patients with vaginal endometriosis had a significantly increased risk of deep dyspareunia compared with those whose lesions were at other sites (odds ratio, 2.55; 95% confidence interval, 1.21 to 5.39). Stage per se, independent of lesion site, was not correlated with frequency and severity of dysmenorrhea and nonmenstrual pain. The severity of deep dyspareunia was related inversely to the endometriosis score (Spearman correlation coefficients for linear analog and verbal rating scales, respectively, -0.22 and -0.20). Kendall test by ranks revealed a correlation between linear analog and multidimensional pain scales in the rating of both dysmenorrhea and nonmenstrual pain (respectively, tau-b, 0.59 and tau-b, 0.68). Endometriosis stage in the current classification was not related consistently to pain symptoms. The presence of vaginal lesions was associated frequently with severe deep dyspareunia. Dysmenorrhea and nonmenstrual pelvic pain were assessed with equal accuracy by a linear analog and a multidimensional scale.

Very low dose danazol for relief of endometriosis-associated pelvic pain: a pilot study

To evaluate the efficacy and safety of very low dose danazol in improving pelvic pain in women with endometriosis, the benefit of preceding the treatment by a short course of a GnRH agonist, symptoms recurrence after drug withdrawal, and variations in menstrual pattern. Open-label, randomized study. University hospital endometriosis center. Forty-two women with moderate or severe pelvic pain and laparoscopically diagnosed endometriosis. Treatment with oral danazol, 50 mg/d, for 9 months (group I, n = 21) or leuprolide depot for 3 months followed by oral danazol, 50 mg/d, for 6 months (group II, n = 21), and a 6-month follow-up. Variations in severity of symptoms during treatment and at the end of follow-up as shown by a linear analog scale and a verbal rating scale; menstrual blood loss as assessed by a pictorial chart. Four patients withdrew from the study, one in each group at the fifth month of treatment (for persistent pain) and one in each group during follow-up (they requested additional therapy); one woman in group I was lost to follow-up. Significant improvements were obtained in dysmenorrhea, deep dyspareunia, and nonmenstrual pain in both treatment schedules without differences between the groups. Also menstrual blood loss was significantly reduced in both groups. A temporary fall in high and rise in low density lipoprotein cholesterol was observed in the study population. At the end of follow-up symptoms recurred without significant differences in median pain scores with respect to baseline. Very low dose danazol may be an alternative for temporary relief of endometriosis-associated pain. Ovulation is not always inhibited and barrier contraception is needed. Side effects occur but are rarely severe. Further data are required to evaluate the influence of long-term administration on the lipid profile.

A gonadotropin-releasing hormone agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis

To evaluate the efficacy of goserelin versus a low-dose cyclic oral contraceptive (OC) in improving pelvic pain in women with endometriosis and to compare recurrence of symptoms during follow-up. Open-label, randomized trial. University hospital endometriosis center. Fifty-seven women with moderate or severe pelvic pain and laparoscopically diagnosed endometriosis. Six-month treatment with goserelin depot (n = 29) or a low-dose cyclic OC (n = 28) followed by 6-month follow-up. Variation in severity of symptoms during treatment and at the end of follow-up as shown by a linear analog scale and a verbal rating scale. At 6 months of treatment, a significant reduction in deep dyspareunia was observed in both groups, with goserelin superior to the OC at linear analog scale assessment. Nonmenstrual pain was diminished on both scales without differences between treatments. Women taking the OC experienced a significant reduction in dysmenorrhea. At the end of follow-up, symptoms reappeared without differences in severity between the groups. Low-dose cyclic OCs may be a valuable alternative for the treatment of dysmenorrhea and nonmenstrual pain associated with endometriosis. Symptoms recurred in most subjects 6 months after drug withdrawal.

The role of laparoscopy in chronic pelvic pain: promise and pitfalls.

Published studies relating to the usefulness of diagnostic and operative laparoscopy in women with chronic pelvic pain (CPP) were reviewed. This revealed that approximately 40 per cent of all laparoscopies were done for CPP. However, the definition of CPP was found to be nebulous and inconsistent, and that muddled definitive conclusions about patient diagnoses and treatments. The following definition of CPP was proposed: nonmenstrual pain of 3 or more months duration that localizes to the anatomic pelvis and is severe enough to cause functional disability and require medical or surgical treatment. A survey of published reports showed laparoscopically diagnosable abnormalities in 61 per cent of patients, compared with abnormalities in 28 per cent of women without CPP. Studies in adolescents were also reviewed and showed that adolescents with CPP also had significant laparoscopically diagnosed abnormalities, with 78 per cent showing some pathology, especially endometriosis (40 per cent). Endometriosis, pelvic adhesions, chronic pelvic inflammatory disease, and ovarian cysts were the diagnoses most commonly made via laparoscopy in CPP patients. The potential roles of each of these abnormalities in CPP were discussed, as well as the results of laparoscopic treatment of each disease. Laparoscopy was also found to have a limited role in women with CPP after hysterectomy or bilateral salpingo-oophorectomy, with usefulness in diagnosing and treating adhesions and residual ovary syndrome, although its role in ovarian remnant syndrome was uncertain. Overall, the data showed that less than 50 per cent of women with CPP were helped by diagnostic and operative laparoscopy, stressing the need for both physicians and patients to recognize that laparoscopy is neither the ultimate evaluation nor the panacea for CPP.