[Frontiers in Bioscience E1, 455-465, June 1, 2009]

Treatment of endometriosis-related pain: options and outcomes

Edgardo Somigliana1,2, Paola Vigano2,3, Giussy Barbara1,4, Paolo Vercellini1,2,4

1Dept of Obstetrics and Gynecology, Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy, 2CROG, Center for Reseach in Obstetrics and Gynecology, Milan, Italy, 3 A.O. Sant'Anna, Como, Italy, 4 Università degli Studi di Milano, Milan, Italy


1. Abstract
1. Introduction
2. Neurobiology of pain associated with endometriosis
2.1. Direct infiltration of the nerves
2.2. Peritoneal inflammation, cell recruitment and release of pain mediators
3. Correlation of pain with the different forms of the disease
4. Effect of estrogen-progestogen combination and progestogens in women with symptomatic endometriosis
4.1. The "pill"
4.2. Progestogens
4.3. Levonorgestrel-releasing intrauterine device (IUD)
5. Long-term GnRh agonists and add back therapy
6. Effect of the surgical treatment in symptomatic endometriosis
7. Medical treatment after conservative surgery
8. Surgical interruption of pelvic nerve pathways
9. Conclusions
10. References


Endometriosis-associated pain represents a challenge for both the patient and the health care provider since it is often difficult to design treatment strategies resulting in improvement of the symptoms. The association between endometriosis stage and severity of pelvic symptoms is limited. Surgery is generally considered the first line treatment in women affected, at least in those who have not been previously operated, but there are several situations in which medical treatments are useful. Given their good tolerability, minor metabolic effects and low cost, progestogens with or without the addition of estrogens, can be considered the drugs of choice and are currently the only safe and inexpensive alternative to surgery. Progestogens are effective in controlling pain symptoms in approximately three of four women with endometriosis. There is little or no difference in the effectiveness of GnRH agonist and add-back treatment in comparison with other medical treatments for endometriosis while the surgical interruption of pelvic nerve pathways entail some clinically relevant risks.