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Chronic Pelvic Pain:Non-Surgical Treatments are Best

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Ob-gyns recommend conservative nonsurgical treatment approaches for treating women with endometriosis-associated pain followed by more invasive procedures if these fail to alleviate pain, according to a newly updated Practice Bulletin published in the July issue of The American College of Obstetricians and Gynecologists’ journal, Obstetrics & Gynecology. The Practice Bulletin “Management of Endometriosis” includes the latest recommendations on the incidence, diagnosis, and treatment of this common gynecologic health condition.

Endometriosis is a chronic condition in which endometrial tissue that lines the inside of the uterus migrates outside of the uterus and attaches to the lining of the abdominal cavity and to internal organs inside the pelvis, including the ovaries, fallopian tubes, bladder, and bowel. The condition occurs in 6-10% of reproductive-age women. Endometriosis is a leading cause of chronic pelvic pain and a common cause of infertility, the two main symptoms. Some women with endometriosis have no symptoms, but for those that do, pain can range from mild to severe.

“We recommend starting with conservative approaches to treating women with endometriosis-associated pain,” says Tommaso Falcone, MD, who led the document update. “For instance, continuous oral contraceptives and nonsteroidal anti-inflammatory drugs are effective. If these fail and further medical management is needed, then gonadotropin-releasing hormone agonists or progestins can help by suppressing the disease.” Medical therapy, however, will not improve fertility for women trying to get pregnant since most of these drugs suppress ovulation. Medical therapy is effective while using it, but recurrence of pain symptoms is common after discontinuing the drugs. Surgery to remove endometriosis tissue helps improve pregnancy rates among infertile women, but it is difficult to predict by how much, said Dr. Falcone.

According to the College vaginal ultrasound is the best way to investigate the presence of endometriosis. The only definitive way to diagnose endometriosis is with laparoscopic surgery. Laparoscopy also can remove visible endometriosis lesions, but it is not 100% effective in helping pain. As with medical therapy, there is a high recurrence of symptoms in patients after laparoscopic surgery. Both laparoscopic surgery and long-term hormone suppression—typically with an oral contraceptive—will likely be needed to control pain.

The treatment of last resort for women with severe endometriosis is hysterectomy. “If a woman has completed having children and all other conservative treatments haven’t worked to stop the pain, she may consider having her uterus removed,” said Dr. Falcone. “If both ovaries are normal and all of the visible endometriosis is removed, then consideration should be given to conserving them.” This way, Dr. Falcone noted, women won’t suffer the consequences of a surgical menopause.

Even when both ovaries are removed, endometriosis symptoms can recur in some women, likely due to lesions that remain attached to the bowel. The Practice Bulletin notes that estrogen therapy after ovary removal does not appear to affect the risk of recurrence of endometriosis and can be safely considered to avoid an immediate surgical menopause.

Practice Bulletin #114, “Management of Endometriosis,” is published in the July 2010 issue of Obstetrics & Gynecology.

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