Endometriosis Chapter Notes | Gynaecology and Obstetrics - NEET PG PDF Download

Overview of Endometriosis

• Endometriosis is when tissue similar to the lining of the uterus, including glands and stroma, is found outside the uterus.
• This tissue most commonly affects the pelvic organs, peritoneum, and sometimes other parts of the body like the lungs.
• The condition can range from having a few small lesions on healthy pelvic organs to the formation of solid masses and ovarian endometriotic cysts, known as endometriomas.
• Endometriosis often comes with extensive fibrosis and the formation of adhesions, which can significantly distort pelvic anatomy.
• It is commonly suspected in women who experience subfertility, severe dysmenorrhea, deep dyspareunia, or chronic pelvic pain.
• However, these symptoms can also indicate other conditions.
• Many women with endometriosis may not have any symptoms at all, and diagnosis often occurs incidentally during pelvic examinations for unrelated reasons, such as during sterilisation procedures.

Prevalence

• The estimated prevalence of endometriosis is between 8–10% among women of reproductive age. However, the exact rate in the general population remains unknown.
• A definitive diagnosis of endometriosis can only be made through surgical inspection of the pelvis.
• In symptomatic women, reported prevalence rates can range from 2% to 100% due to various factors:
• Historical Missed Lesions: Before 1985, subtle lesions, such as small, non-coloured peritoneal lesions, were often overlooked, potentially leading to an inflated prevalence rate.
• Surgeon's Experience: The ability to recognize endometriosis can improve with a surgeon's experience and interest in the condition.
• Inspection Thoroughness: The thoroughness of pelvic inspection during laparoscopy may vary depending on the reasons for the procedure.
• Histological Confirmation: Histological confirmation rates are nearly 100% for deep lesions but only about 60% for subtle lesions, and this distinction is not always reported.
• Even if subtle endometriosis does not cause significant symptoms, it is still classified as a form of the disease.

Systems for Classifying Disease Severity

• There are various systems available to classify the severity of the disease.
• The most widely used system is from the American Society for Reproductive Medicine (ASRM). This system assigns points based on the presence of:
• Endometriotic lesions
• Periovarian adhesions
• Pouch of Douglas obliteration
• The total score obtained from these criteria categorizes the disease into four stages:
• Minimal (Stage 1)
• Mild (Stage 2)
• Moderate (Stage 3)
• Severe (Stage 4)
• This classification system is useful for predicting outcomes and managing patients undergoing surgery for subfertility.
• Deeply Infiltrating Endometriosis (DIE)
• DIE is a significant cause of pelvic pain and dyspareunia (painful intercourse).
• It usually receives a low score (Stage 1 or 2) in the classification system because only visible lesions are considered.
• This discrepancy partly explains why there is limited correlation between the total score and the severity of pain.
• There is a clear need for a better and more validated method to classify disease severity, one that can effectively differentiate between typical lesions and DIE.

Aetiology

• The presence of endometriosis may be explained by the implantation of healthy endometrial cells or metaplasia, where one type of tissue changes into another.
• However, these theories do not fully account for all aspects of the condition, suggesting that multiple mechanisms could be involved or that the theories are inadequate.
• Both theories propose that endometriotic tissue consists of 'normal' cells, yet they do not elucidate why this condition arises and progresses in only certain women.

Endometriotic Disease Theory

• This theory posits that minor lesions resulting from occasional implantation are a normal physiological occurrence.
• If these cells undergo transformation due to a genetic issue, they may give rise to typical, cystic, and deep lesions composed of 'abnormal' cells.
• Another possibility is that endometriosis is not a singular disease but a spectrum of different conditions, each with its own distinct causes.

Peritoneal Endometriosis

Peritoneal endometriosis refers to the presence of small lesions on the peritoneal, serosal, and ovarian surfaces.

Prevalence Rates at Laparoscopy for Different Indications

Prognosis

• Peritoneum: Prognosis varies based on the size of lesions.
• Superficial Lesions: Small lesions (<1 cm)="" have="" a="" better="" prognosis="" compared="" to="" larger="" lesions="" (="">3 cm).
• Ovarian Lesions: Superficial lesions on the right (R) and left (L) ovaries are noted.
• Posterior Cul-de-Sac Obliteration: Prognosis is assessed based on partial or complete obliteration.
• Adhesions: Degree of adhesions is classified as <1, 1/3-2/3,="" or="">2/3 enclosure. Filmy or dense adhesions are noted on the right (R) and left (L) sides.
• Tubal Involvement: Tubal lesions are assessed, with specific points assigned based on the extent of involvement.

Ovarian Endometriomas

• There are various theories regarding the development of ovarian endometriomas.
• One idea is that superficial lesions on the ovarian surface may become inverted, leading to the formation of endometriomas.
• Endometriomas could also originate from functional ovarian cysts or alterations in the coelomic epithelium that covers the ovary.
• Endometriomas exhibit certain features similar to cancers, such as clonal proliferation, which supports the concept of endometriosis.
• They are associated with specific types of ovarian cancer, including endometrioid and clear cell carcinoma.
• Research has found genetic alterations in endometriotic tissue, particularly related to loss of heterozygosity (LOH) in regions of chromosomes containing known or potential tumour suppressor genes (TSGs) linked to ovarian cancer.
• While endometriomas are typically regarded as benign tumours, recent studies have raised concerns about their monoclonal nature and the presence of LOH at TSG sites.

Deeply Infiltrating Disease (DIE)

• The exact cause of DIE nodules that extend more than 5 mm below the peritoneum is still debated, but they are thought to involve the uterus, vagina, bowel, bladder, and ureters.
• Donnez and colleagues suggested that these nodules might be a form of adenomyosis originating from Müllerian remnants in the rectovaginal septum.
• Koninckx and Martin classified these nodules into three main types:
• Type I. These are conical lesions with the largest area exposed to the peritoneal cavity, resulting from the infiltration of superficial disease. They are considered a distinct type of typical endometriosis.
• Type II. Infiltrating lesions characterized by bowel retraction around and over the nodule.
• Type III. Typically found in a normal pelvis, these nodules resemble adenomyosis and mainly consist of fibromuscular tissue with minimal glandular tissue.
• Type IV. Similar to Type III but specifically affecting the sigmoid colon.
• Type I lesions can occur in multiple locations, while Types II and III are usually singular. In a study of over 1000 cases, fewer than 50 women had nodules infiltrating both the rectum and sigmoid.

Disease Risk Factors

• Risk Factors:
  • Age
  • Increased peripheral body fat
  • Greater exposure to menstruation, including:
    • Short menstrual cycles
    • Long duration of menstrual flow
    • Reduced parity (fewer pregnancies)
• Protective Factors:
  • Smoking
  • Exercise
  • Use of oral contraceptives (current and recent)
• There is no evidence that controlling these factors impacts the natural history of the disease.
• Genetic Predisposition:
  • Endometriosis is 6–9 times more common in first-degree relatives of affected women compared to controls.
  • Genetic influences account for 51% of the variance in latent liability to the disease, based on an analysis of over 3000 Australian twin pairs.
• Heritability of the disease is also observed in non-human primates, which develop endometriosis spontaneously.
• Endometriosis is likely inherited as a complex genetic trait, similar to diabetes or asthma, where multiple genes interact to increase susceptibility, and environmental risk factors are necessary for the phenotype to develop.
• A recent genome-wide linkage study in 1176 affected sister-pair families has identified:
  • A significant susceptibility locus for endometriosis on chromosome 10q26
  • An area of suggestive linkage on chromosome 20p13

Symptoms of Endometriosis-Associated Pain

• Severe dysmenorrhoea (painful periods)
• Deep dyspareunia (pain during intercourse)
• Chronic pelvic pain
• Ovulation pain
• Cyclical or perimenstrual symptoms
• Symptoms related to bowel or bladder function, causing dyschezia (painful bowel movements) or dysuria (painful urination)
• Abnormal bleeding (with or without)
• Chronic fatigue

Each symptom can have different causes, and many women may not show any symptoms at all. The symptoms can vary based on the individual and the stage of the disease. There is often little connection between the stage of the disease and the type or severity of pain. This might be due to the current classification systems being insufficient. While endometriomas and deep infiltrating endometriosis (DIE) are linked to severe pain, some women may not experience any pain at all. In cases of DIE, the intensity of symptoms often relates to how deeply the tissue has grown into other areas. Typical peritoneal lesions likely cause pain, as surgery can relieve these symptoms; however, it’s unclear if this applies to more subtle lesions. Suggested reasons for the pain include:

• Peritoneal inflammation
• Nociceptor activation (pain-sensing nerves)
• Tissue damage
• Nerve irritation with deep infiltration

Pain Assessment in Clinical Trials

Pain symptoms in clinical studies are usually measured using a four-point Verbal Rating Scale for three symptoms:

• Dysmenorrhoea
• Dyspareunia
• Pelvic pain

Additionally, two signs are assessed:

• Pelvic tenderness
• Induration (hardening of tissue)

More recently, the focus has shifted to measuring health-related quality of life, as traditional outcomes may not fully capture what is important to patients. The only patient-generated tool specific to the disease is the Endometriosis Health Profile-30 (EHP-30), which consists of 30 questions covering five areas:

• Pain
• Control and powerlessness
• Emotional well-being
• Social support
• Self-image

Endometriosis and Its Impact on Fertility

The relationship between endometriosis and subfertility is still a topic of discussion among experts. While it is generally accepted that endometriomas, which are cysts caused by endometriosis, can interfere with egg retrieval due to significant anatomical changes, the connection between minimal to mild endometriosis, particularly subtle lesions, and fertility is not as clear.

Several potential mechanisms have been proposed to explain how endometriosis might impact fertility, including:

• Abnormal folliculogenesis: Disruptions in the normal development of ovarian follicles.
• Anovulation: The absence of ovulation, which is crucial for conception.
• Luteal insufficiency: Inadequate function of the luteal phase, which is important for implantation.
• Luteinized unruptured follicle syndrome:. condition where a follicle matures but does not release an egg.
• Recurrent miscarriage:. history of multiple miscarriages.
• Decreased sperm survival: Reduced ability of sperm to survive in the reproductive tract.
• Altered immunity: Changes in the immune response that could affect fertility.
• Intraperitoneal inflammation: Inflammation within the peritoneal cavity, which could impact reproductive organs.
• Endometrial dysfunction: Problems with the endometrium, which is crucial for implantation.

However, it is important to note that all these functional issues can also be present in women who are subfertile for reasons unrelated to endometriosis. This suggests that the presence of endometriosis during evaluations for subfertility may not be directly related to the cause of subfertility.

Diagnosis of Endometriosis

History and Clinical Examination

• Diagnosing endometriosis based only on symptoms is difficult because the symptoms can vary widely.
• Other conditions, such as irritable bowel syndrome and pelvic inflammatory disease, can have similar symptoms, leading to significant delays—sometimes several years—before a clear diagnosis is made through laparoscopy.
• Signs that may indicate endometriosis include:
  • Pelvic tenderness
  • A fixed retroverted uterus
  • Tender uterosacral ligaments
  • Enlarged ovaries
• However, these findings can also be normal in some individuals.
• The diagnosis is more likely if deeply infiltrating nodules are found on the uterosacral ligaments or in the pouch of Douglas.
• Diagnosis is confirmed when visible lesions are seen in the vagina or on the cervix, with these nodules being most reliably detected during menstruation.

Non-invasive Tests for Diagnosing Endometriosis

• Trans-vaginal ultrasound is a useful tool for diagnosing and ruling out ovarian endometriomas when compared to laparoscopy. However, it is not effective for detecting peritoneal disease.
• There have been claims that MRI has over 90% sensitivity and specificity for detecting endometriomas. However, a recent systematic review did not find evidence to support this assertion.
• The measurement of CA-125 levels is not helpful for diagnosing minimal to mild endometriosis. Serum levels of CA-125 are often elevated in women with deep infiltrating endometriosis (DIE) and endometriomas. However, this test is rarely used because clinical examination and ultrasound typically provide sufficient information.

Laparoscopy

• Laparoscopy is considered the gold standard for diagnosing endometriosis unless the disease is visible in the vagina or other areas.
• Histological confirmation of at least one peritoneal lesion is ideal and necessary if deep infiltrating endometriosis (DIE) or an endometrioma larger than 3 cm is present.
• A thorough inspection of the entire pelvis during laparoscopy is essential, and it is good practice to document the type, location, and extent of all lesions and adhesions in detail.
• Ideally, the findings should be recorded on video or DVD for documentation purposes.
• Depending on the severity of the disease found during laparoscopy, it is considered best practice to remove or ablate endometriosis at the same time, provided that proper consent has been obtained from the patient.

General Treatment Issues

Involving patients in the decision-making process is essential due to the various treatment options available and the long-term nature of endometriosis. The choice of treatment depends on several factors:

Factors Influencing Choice of Treatment

• Woman's age
• Fertility status
• Nature of symptoms
• Severity of disease
• Previous treatments
• Priorities and attitudes
• Resource implications
• Costs and side-effect profile
• Risks of treatment
• Other subfertility factors
• Intended duration of treatment
• Best available evidence

Treatment Aims

• Improve natural fertility
• Enhance chances of success at ART
• Pain relief as an alternative to surgery
• Pain relief while awaiting surgery
• Adjunct to surgery
• Prophylaxis against disease occurrence
• Symptom recurrence

Summarizing the factors influencing decision-making is complex, as each patient is unique. However, some general principles can be highlighted. For example: A woman in her late 40s with severe pain and advanced disease who has completed her family may be offered a hysterectomy and bilateral salpingo-oophorectomy. A young woman who has not had children and presents similarly will want to keep as much normal tissue as possible if she chooses surgery.

The treatment aims should be agreed upon with the patient. For surgery, the intended benefits, along with the major risks and complications, should be explained and noted on the consent form. When starting medical treatment, best practice involves documenting in the notes or in a letter to the patient what options were discussed, why the treatment decision was made, as well as the aims of treatment and any side effects or risks involved.

Non-hormonal Treatment for Pain Relief

Some women find relief from their symptoms using pain relievers or alternative therapies like:

• Chinese herbal remedies
• Dietary changes
• Acupuncture
• Vitamin or mineral supplements

While these methods can improve quality of life and reduce symptoms, it's important not to recommend specific treatments without evidence of their effectiveness.

Hormonal Treatments

Hormonal treatments aim to mimic the conditions of pregnancy or menopause when endometriosis symptoms often improve. These treatments include:

• Combined oral contraceptives (COCs)
• Progestagens
• Danazol
• Gestrinone
• Gonadotrophin-releasing hormone (GnRH) agonists

These treatments have been well-studied and work by suppressing ovarian function, which reduces the size of peritoneal deposits. However, while peritoneal lesions shrink during treatment, they often return quickly after stopping. Deep infiltrating endometriosis (DIE) shows a similar pattern, with endometriomas usually not decreasing in size and adhesions remaining unchanged.

All hormonal treatments mentioned (except for dydrogesterone taken in the luteal phase) help relieve endometriosis-associated pain. However, their effects on non-menstrual pain and dyspareunia (pain during intercourse) can vary. When used for 6 months, these drugs appear to be similarly effective, but their side effects and costs differ. For instance, one randomized controlled trial (RCT) found that a COC used conventionally was less effective for dysmenorrhoea (painful periods) compared to a GnRH agonist, although there were no significant differences in relieving dyspareunia or non-menstrual pain. It's important to note that a 30% placebo effect is common in endometriosis studies, highlighting the need for placebo-controlled RCTs.

The use of GnRH agonists is limited due to the potential for bone density loss, which can be up to 6% in the first 6 months, although this loss is nearly fully restored 2 years after stopping treatment. Symptoms from low oestrogen levels can be managed and bone loss prevented with add-back therapy using oestrogens, progestagens, or tibolone. The safe duration of this regimen is still uncertain, but some evidence suggests that bone density can be maintained over 2 years with add-back therapy. Caution is advised when using GnRH agonists with add-back therapy in women who may not have reached their peak bone density. Recent RCTs also suggest that local release of progestagens, such as through a levonorgestrel-releasing intrauterine system (IUS), may be beneficial for pain relief.

Side Effects and Complications of Danazol and GnRH Agonists

Danazol may cause a range of side effects, including:

• Weight gain (1–5 kg)
• Hot flushes
• Bloating
• Night sweats
• Increased body hair
• Headaches
• Acne and oily skin
• Vaginal dryness
• Deepening of the voice (which is irreversible)
• Irritability
• Decreased breast size
• Insomnia
• Muscle cramps
• Decreased libido
• Palpitations
• Joint stiffness
• Tingling in the limbs
• Menstrual spotting

Complications associated with danazol may include:

• Liver tumours (with long-term use)
• Bone loss
• Adverse effects on lipid levels
• 'Flare' effect (when treatment is started in the follicular phase)

Subfertility

• Hormonal treatments for subfertility associated with minimal to mild endometriosis do not improve the chances of natural conception.
• The odds ratio for achieving pregnancy after 6 months of ovulation suppression using danazol, medroxyprogesterone acetate, or GnRH agonists, compared to placebo or no treatment, is 0.74 (with a 95% confidence interval of 0.48 to 1.15).
• Such treatments may be more harmful than beneficial as they could result in missed opportunities to conceive.
• In cases of more advanced endometriosis, current evidence does not support an improvement in natural conception rates.
• Hormonal treatments may assist with conception in cases involving assisted reproductive technologies.
• Some research indicates that prolonged down-regulation with a GnRH agonist prior to in vitro fertilization (IVF) in women with moderate to severe endometriosis might enhance pregnancy rates.
• However, there are no systematic reviews available on this specific topic at present.
• It is advisable to discuss these treatment options with patients.

Surgical Treatment

The goal of surgery is to remove all visible peritoneal lesions, endometriomas, deep infiltrating endometriosis (DIE), and related adhesions while restoring normal anatomy.

Since it’s hard to assess how deeply the condition has affected tissues, excision or vaporisation is preferred for typical lesions.

Excision is the best approach for endometriomas, as recurrence rates after marsupialisation and targeted treatment are significantly higher.

Laparoscopy is recommended because it reduces complications, hospital stays, and costs compared to a larger incision (laparotomy).

Lesions can be excised surgically using scissors, ultracision, or laser techniques such as CO2 or potassium-titanyl-phosphate (KTP).

Ablation and Laparoscopic Uterine Nerve Ablation

• Ablation of lesions along with laparoscopic uterine nerve ablation (LUNA) in minimal to moderate cases reduces pain linked to endometriosis at six months compared to just diagnostic laparoscopy; patients with minimal disease see the least impact.
• LUNA is not essential, as it does not alleviate dysmenorrhea related to endometriosis on its own.
• No randomised controlled trials (RCTs) have evaluated the effectiveness of surgery for endometriomas or DIE, but ongoing research may include relevant studies.
• Retrospective studies show about 80% of women with severe symptoms are pain-free post-surgery, suggesting a significant benefit beyond placebo effects.

Fertility Enhancement

• A recent Cochrane review found that ablation of lesions and adhesiolysis in minimal to mild endometriosis significantly improves fertility compared to diagnostic laparoscopy alone (OR 1.64, 95% CI 1.05–2.57).
• Two relevant RCTs were identified: the larger study indicated better chances of pregnancy and ongoing pregnancy rates after 20 weeks, while the smaller study did not show benefits.
• These findings are debated as patients in the larger study were not blinded regarding their treatment.
• The cumulative pregnancy rate of around 30% in the treated group is similar to rates reported in women with typical endometriosis managed expectantly.

Moderate–Severe Disease

• No RCTs have been conducted to see if surgery for moderate to severe endometriosis improves pregnancy rates.
• Three studies suggest an inverse relationship between the stage of endometriosis and the spontaneous cumulative pregnancy rate after surgery, although only one study reached statistical significance.

Laparoscopic Cystectomy

• Laparoscopic cystectomy for endometriomas is preferred over coagulation or laser vaporisation regarding recurrence of cysts, symptoms, and subsequent spontaneous pregnancy in women who were previously subfertile.
• If an endometrioma is 4 cm or larger before IVF, cystectomy is recommended to confirm the diagnosis, reduce infection risks after egg retrieval, improve access to follicles, and possibly enhance response to gonadotrophins.
• If preserving fertility is a goal, a two-step procedure (marsupialisation and rinsing followed by three months of GnRH agonist therapy, then repeat surgery) should be considered; otherwise, oophorectomy may be technically easier.
• Patients seeking fertility should be informed about the risks of reduced ovarian function post-excision and the potential loss of an ovary.

Surgical Intervention for Deep Infiltrating Endometriosis (DIE)

• When there is clear evidence of Deep Infiltrating Endometriosis (DIE), it is crucial to assess the potential involvement of the ureter, bladder, and bowel before proceeding with surgery. This evaluation helps determine the most appropriate management approach.
• Surgical procedures for DIE should be carried out by highly skilled and qualified surgeons to ensure safety, as these operations may involve the resection of parts of the bladder, ureter, or bowel wall.
• In some cases, more extensive bowel resection, including the rectum and/or sigmoid colon, may be necessary. Such complex surgeries require a team of experienced surgeons rather than relying on a single surgeon.
• A thorough pre-operative assessment is essential to accurately predict which surgical specialties need to be involved. This helps prevent leaving any disease behind and minimizes the risk of unnecessary complications.
• The ideal pre-operative work-up should include:
  • An intravenous pyelogram (IVP) to identify ureteric strictures and hydronephrosis.
  • A contrast enema to detect significant narrowing in the rectum or sigmoid colon, which may indicate the need for bowel resection.
• Pre-operative ureteric stenting is recommended for patients with bladder symptoms and a vesico-uterine nodule observed on ultrasound.
• The routine use of ultrasound, CT, or MR imaging before surgery is still debated. In less experienced medical centers, these imaging findings may influence the decision to refer patients to a tertiary care center.
• There is ongoing discussion about the best approach to radical surgery for DIE. A general principle of removing all endometriosis should guide the surgery, with consideration for bowel resection having 2 cm safety margins. This is important because small endometriotic foci can be found up to 2 cm away from a bowel lesion.
• For most patients, a conservative discoid resection is preferred, as it is associated with fewer complications. The low recurrence rate of 1% raises questions about the necessity of removing large bowel segments without further context for comparison.

Hormonal Treatment After Surgery

• Hormonal treatment after surgery does not significantly reduce pain recurrence at 12 or 24 months compared to surgery alone or surgery with placebo.
• There is no impact on disease recurrence or pregnancy rates.
• It is advisable to prescribe hormone replacement therapy (HRT) after a bilateral oophorectomy for young women, although the best regimen is unclear.
• After a hysterectomy, adding a progestagen is usually unnecessary.
• However, it may protect against the unopposed action of estrogen on any remaining disease, which could lead to reactivation or, in rare cases, malignancy.
• Clinicians should consider the theoretical benefits against the small but real risks of recurrent disease.
• There is also an increased risk of breast cancer associated with both tibolone and combined estrogen and progestagen HRT.

Assisted Reproduction

• For women with minimal to mild endometriosis and open fallopian tubes, intrauterine insemination (IUI) combined with ovarian stimulation can improve fertility.
• The effectiveness of unstimulated IUI is uncertain.
• In vitro fertilisation (IVF) is appropriate for all levels of endometriosis, especially if tubal function is compromised or if there are other factors like male infertility.
• A systematic review found that pregnancy rates with IVF are lower in patients with endometriosis compared to those with tubal infertility.
• The impact of endometriosis on pregnancy rates can vary between studies and populations, as seen in reports from the Society of Assisted Reproductive Technologies (SART) and the Human Fertilisation and Embryo Authority (HFEA).
• A key consideration is whether to perform surgery before IVF in women with endometriomas to prevent complications.
• In cases of deep infiltrating endometriosis (DIE), surgery before IVF is advisable because oocyte retrieval can be extremely painful, and there is an increased risk of bowel perforation due to associated adhesions.

Alternative Management Protocols for Endometriosis

Laparoscopy Not Always Necessary

• The RCOG Guideline suggests that in cases of suspected endometriosis, a laparoscopy may not be necessary in all situations.
• If a woman is not trying to conceive and there is no evidence of a pelvic mass on examination, a therapeutic trial with a Combined Oral Contraceptive (COC) or a progestagen could be considered to treat pain symptoms indicative of endometriosis without immediate diagnostic surgery.
• However, it is important to note that there is no strong evidence supporting one method of COC administration over another or that different COCs have varying levels of effectiveness.

Management Protocols for Endometriosis

• Two management protocols have been proposed by North American authors for the treatment of endometriosis.
• Olive and Pritts suggest starting with a non-steroidal anti-inflammatory drug (NSAID) or a Combined Oral Contraceptive (COC). If these do not alleviate symptoms, options include operative laparoscopy or a therapeutic trial of a GnRH agonist with add-back therapy.
• Operative laparoscopy may also be considered if the GnRH agonist does not provide relief.
• Gambone et al. offer similar recommendations, advocating for first-line treatment with an NSAID or COC, or both, depending on the type of pain, contraindications, and contraceptive needs.
• If initial treatments fail, alternatives include operative laparoscopy or a therapeutic trial of danazol, a progestagen, or a GnRH agonist with add-back therapy.

Study Findings

• Mahadevan et al. (1983) conducted a study on the odds ratio (95% CI) with various results ranging from 0.1 to 18.1.
• Other studies by Wardle et al. (1985), Matson et al. (1986), Frydman et al. (1987), Inoue et al. (1992), Mills et al. (1992), Simon et al. (1994), Dmowski et al. (1995), Gerber et al. (1995), Olivennes et al. (1995), Tanbo et al. (1995), Arici et al. (1996), Padigas et al. (1996), Huang et al. (1997) contributed to the overall odds ratio.

Unadjusted Meta-Analysis

• The unadjusted meta-analysis compared the odds of pregnancy in endometriosis patients versus controls with tubal subfertility.
• The analysis considered the continuation of treatment for 2 months, extending to 6 months if successful.
• Both protocols recognized the importance of maintaining therapy if sufficient pain relief is achieved.
• It is essential to understand that these protocols might have been shaped by cost factors and the reality that not all women with endometriosis-related pain have access to appropriate surgical interventions.

Management of Chronic Pelvic Pain

• There is an ongoing debate about the connection between endometriosis and chronic pelvic pain, making it difficult to measure.
• This chapter outlines management protocols for individuals suffering from chronic pelvic pain.
• It is crucial to recognize that patients with endometriosis-related chronic pelvic pain often also experience irritable bowel syndrome.
• A holistic approach can significantly reduce pelvic pain and improve the quality of life for these patients.
• Key elements of this approach include:
  • Enhanced diet
  • Increased fluid consumption
  • Prevention of constipation
  • Regular physical activity
• There is increasing evidence that self-management courses can effectively help women manage their long-term pain issues.