Endometriosis and pelvic pain: Time to treat the symptoms not the assumptions?

Abstract

The high incidence and burden of pelvic pain are increasingly recognised in both the healthcare sector and by the general public. Current approaches to management assume that the diagnosis and remediation of identified lesions will ease this burden. The evidence base and successes in other areas of medicine would suggest that this assumption requires reconsideration.

When pain is not the whole story: Presenting symptoms of women with endometriosis

“…14 The associated pain comorbidities seen in women with endometriosis, CPP and other chronic pain conditions suggest that central sensitisation to pain is the key underlying factor in the pain presentations of women with endometriosis, 15 calling into question whether clinicians should be looking for endometriotic lesions or rather focused on addressing the woman's symptoms. 16 This paper then seeks firstly, to understand how women with endometriosis initially present to the outpatient department, and secondly, whether women with severe disease present differently from those with less severe disease.…”

“…Furthermore with diverse symptomatology, there are often significant delays between first presentation and eventual diagnosis of endometriosis 14 . The associated pain comorbidities seen in women with endometriosis, CPP and other chronic pain conditions suggest that central sensitisation to pain is the key underlying factor in the pain presentations of women with endometriosis, 15 calling into question whether clinicians should be looking for endometriotic lesions or rather focused on addressing the woman’s symptoms 16 …”

Endometriosis and other causes of pelvic pain in perspective

“…These guidelines are now ratified by government and are available to all at https://ranzcog.edu.au/statements-guidelines/gynaecology/endometriosis-clinical-practice-guideline. The authors of the opinion piece 1 suggest that an evidence‐based approach to the guidelines was problematic and an ‘evidence‐informed review would conclude that a complete change in current practice is required’. Given that the guidelines build on the existing National Institute of Health and Care Excellence clinical guidelines, follow the same strict a priori methodology, and focus heavily on a patient‐centred approach, I am curious as to what the authors are referring to as a ‘complete change of practice’ – apart from their condemnation of any surgical intervention.…”

“…The authors of the opinion piece 1 suggest that surgery for endometriosis comes from ‘enthusiasm’ and not evidence. A Medline search of ‘endometriosis’ will retrieve 17 559 publications, while ‘endometriosis and surgery’ retrieves 6156 – or 35% of the total volume of all endometriosis publications.…”

“…In the opinion piece ‘Endometriosis and pelvic pain ‐ time to treat the symptoms not the assumptions’, Grover and Joseph 1 recommend that a substantive shift in management be considered. They suggest that gynaecologists are ‘surgical technicians’, unable to identify or manage chronic pain symptoms, who ignore and abandon their patients if endometriosis is not diagnosed surgically or not responsive to that surgery.…”