Table II.
Current treatments for endometriosis-associated pain.
| Analgesic efficacy | Includes both NSAIDS and opioids | |
| NSAIDS alleviate dysmenorrhea | ||
| Use and efficacy of analgesics not assessed in hormonal or surgical endometriosis studies | ||
| Hormones | Agents shown to reduce pain | Progestagens |
| Route | ||
| Oral | ||
| IUD | ||
| Depot injection | ||
| GnRH agonists | ||
| Danazol | ||
| Combined hormonal Contraceptives | ||
| Route | ||
| Oral | ||
| Transvaginal | ||
| Transcutaneous | ||
| Dosing | ||
| Cyclic use | ||
| Continuous use | ||
| Aromatase inhibitors | ||
| Only used in combination with oral contraceptives | ||
| In selected cases, appear to be effective | ||
| Antiprogestins | ||
| Effective in small studies but not tested in large populations | ||
| Agents ineffective in pain reduction | SERM—raloxifene | |
| Shortened time to return of pain after surgical removal of lesions | ||
| Other effects of hormonal agents | Known and studied effects | |
| Thins endometrium, decreases menstrual flow | ||
| Decidualizes endometrium | ||
| Prevents ovulation | ||
| Possible, as yet unstudied effects on pain | ||
| Alterations of CNS activity | ||
| Influences of estrogen and progestagens | ||
| Decreases in blood flow to the uterus or pelvis (GnRH analogues) | ||
| Surgery | Can be effective over short-term | |
| High recurrence of pain symptoms may be due to: | Remodeling of CNS (some of which occurred before surgery) | |
| Role of reproductive tract in reactivating pain | ||
| Incomplete removal (that may also increase pain) due to: | ||
| Poor technical skill because of difficult lesion locations | ||
| Lack of recognition of variable appearance of lesions | ||
| Recurrence of lesions | ||
| Surgical studies difficult to design and conduct due to: | Poor recognition of the variable appearance and location of lesions | |
| High loss to follow-up | ||
| Need to treat recurrence of pain symptoms | ||
| Underreporting of analgesic, hormonal and alternative medication | ||
| Poorly standardized approach to diagnosis | ||
| Visual inspection—but variable appearance | ||
| Histologic confirmation—but may be technically difficult to obtain or false negative | ||
| Poorly standardized approach to correlating lesions and pain | ||
| No standardized recording of pain location and lesion location | ||
| Types of lesions may not be equivalent in their role in pain | ||
| DIE most associated with pain symptoms | ||
| Location—hyperalgesia in the cul de sac | ||
| Lesion appearance may not be equivalent in the role in pain | ||
| Poorly standardized approach to treatment | ||
| Evolving technology | ||
| Many surgical tools that may not be equally effective | ||
| Excision versus ablation | ||
| Timing of surgery during the menstrual cycle | ||
| Poorly understood role of adhesions (which may be underreported) formed as a result of surgery have unknown effect on symptom recurrence | ||
| Mechanical | ||
| Engage the CNS, possibly innervated | ||
| Associated with endometriosis lesions |