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Abstract |
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Key words: endometriosis/pain/site/stage
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Introduction |
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To further analyse this topic, we have conducted a multicentre cross-sectional observational study, under the framework of the Gruppo Italiano Studi Endometriosi (Tinelli et al., 2000), to assess whether the prevalence and severity of pain are related to the disease stage, site and morphological characteristics.
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Methods |
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Each patient completed a questionnaire on the presence and severity of dysmenorrhoea, deep dyspareunia and non-menstrual pelvic pain. Dysmenorrhoea and non-menstrual pain were evaluated using a modified version of Andersch and Milsom's multidimensional verbal rating scale (Andersch and Milsom, 1982), which defines pain according to the limitation of ability to work (unaffected = 0; rarely affected = 1; moderately affected = 2; clearly inhibited = 3), co-existence of systemic symptoms (absent = 0; present = 1) and need for analgesics (no = 0; rarely = 1; regularly = 2; inefficacious = 3), and ranks their simple sum in three groups (13 = mild; 4 and 5 = moderate; 6 and 7 = severe). The modifications included the definition of systemic symptoms only as present/absent, instead of `absent/few/apparent' as in the original questionnaire (Andersch and Milsom, 1982
), based on our previous experience indicating that the answer `few' was reported only by a very low proportion (<5%) of subjects (L.Fedele, personal communication). The women were also asked to rate the severity of dysmenorrhoea, non-menstrual pelvic pain and deep dyspareunia using a 10-point linear analogue scale in which 0 indicates no pain and 10 unbearable pain. The pain questionnaire was administered before diagnostic surgery during the hospital stay.
Endometriosis was staged according to the revised American Fertility Society (rAFS) classification (The American Fertility Society, 1985). Typical and atypical lesions were as defined in Vercellini et al. (Vercellini et al., 1991
).
The study started September 1998 and ended October 1999. A total of 469 women identified in 42 centres were enrolled (mean number per centre 11.2, range 534) (median age 31 years, range 1845). Tests of statistical significance for the differences in the frequency of symptoms in relation to disease stage, site and morphological characteristics were based on Pearson's 2 test. Differences in median pain scores were compared by nonparametric KruskalWallis analysis of variance by ranks. Bonferroni's test was used to investigate the differences between means.
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Results |
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Table I shows the distribution by site, frequency and severity of symptoms. Dysmenorrhoea was present in 77% of women with ovarian endometriosis, 88% of those with endometriosis of the peritoneum, 92% of those with endometriosis of ovary and peritoneum, and in all 15 with endometriosis of the rectovaginal septum. No marked difference emerged between the severity of dysmenorrhoea and site of endometriosis, but women with ovarian endometriosis tended to have lower scores; however, this finding was not significant. No association emerged between frequency and severity of non-menstrual pain, dyspareunia and site of endometriosis. Dyspareunia was reported by 80% of women with rectovaginal endometriosis, a higher proportion than reported by women with endometriosis of ovary and peritoneum, but the difference was not significant.
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Information regarding the type of endometriosis (typical/atypical) was available only for women in 24 centres, for a total of 217 cases. The relationship between type of endometriosis and pain symptoms in shown in Table II. Dyspareunia was more frequent in women with atypical than with typical mixed endometriosis, but this finding was of borderline statistical significance (
2 heterogeneity P = 0.05).
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Discussion |
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These results should not be markedly affected by bias. The pain questionnaire was filled in before laparoscopy/laparotomy, so the women and physicians were blind to the site and characteristics of endometriosis. The study population comprised of women self-referring to a network of teaching and university hospitals. Thus, they cannot be considered representative of the Italian population of women with endometriosis and pelvic pain. Nevertheless the centres were distributed in the three main areas of the country and there was no marked difference in their results (data not shown), strongly suggesting the consistency of the general results. Finally, participation during the study period was practically complete. Although we did not collect information in all centres on the ratio of women who refused the interview, an informal enquiry in a sample of six centres indicated that <5% of eligible women refused. A senior researcher in each centre supervised the staging of endometriotic lesions and the co-ordinating centre checked the staging of endometriosis and the consistency of the study forms and clinical records.
The main interest of this study is that it provides an opportunity for analysing the relationship between pain and endometriosis in a large series, in different clinical conditions, using standard methods of data collection and staging of the disease. Specific directions were given to the physicians to take care in collecting the information on endometriosis.
Our results confirm those of the majority of previous studies, which found no relationship between frequency and severity of pain symptoms and disease stage. For example, no association was reported between stage and pain symptoms in a study of 244 women with endometriosis conducted in Milan (Vercellini et al., 1996). A study of 70 women (Perper et al., 1995
) did find an association between the total number of ectopic endometrial implants, but not their location, and intensity of menstrual pain.
Attention has focused on deep retroperitoneal endometriotic foci that may penetrate the rectovaginal septum and infiltrate the posterior vaginal wall. This type of lesion may be very active, causing more severe pain than other endometriotic implants (Fedele et al., 1992; Vercellini et al., 1996
). In our study, no significant association emerged between endometriosis of the rectovaginal septum and the frequency of deep dyspareunia.
Finally, painparticularly dyspareuniawas associated only with `typical' peritoneal lesions (black nodules, stellate scars) and not with `atypical' fresh, clear implants (clear vesicles, clear or red papules, red polypoid lesions) (Vercellini, 1991). Our analysis partially confirmed this: we found a higher frequency and severity of dyspareunia, but not of dysmenorrhoea and pelvic pain, in women with active lesions, although the difference was of borderline significance. Pain at intercourse is probably related to traction and stretching of scar and inelastic tissue and mechanical pressure on endometriotic lesions, which may frequently cause pain where active. Otherwise, our data do not support the suggestion that fresh papular lesions exposed to peritoneal fluid are mainly responsible for functional pain (dysmenorrhoea or pelvic acyclic pain) due to abnormal production of prostaglandins.
In conclusion, this study does not find any clear-cut association between stage, site and morphological characteristics of pelvic endometriosis and pain.
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Acknowledgements |
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The following clinicians collected the data: Ancona: A.Ciavattini, G.Garzetti (Clinica Ostetrica, Università di Ancona); Arzignano (VI): G.Dolcetta, M.Scollo (Ospedale Civile Arzignano); Bari: M.Vicino, G.Loverro (II Clinica Ostetrica Ginecologica, Università di Bari), S.Sabatelli (I Clinica Ostetrica e Ginecologica, Az. Osp. Consorziale Policlinico, Università di Bari); Brescia: L.Decca, L.Falsetti (Ginecologia Endocrinologica, Università di Brescia); Bologna: E.Giacomucci, C.Flamigni (Clinica Ginecologica Prima, Policlinico S. Orsola, Università di Bologna); Cagliari: V.Mais, S.Guerriero (Sezione di Clinica Ginecologica ed Ostetrica, Università di Cagliari); Carbonara: F.Boscia, G.Sangiorgio (Rep. Ginecologia Osp. Di Venere, Carbonara); Catania: P.Scollo, A.Muriana (Presidio Ospedaliero Cannizzaro, Catania), M.La Greca, C.Distefano (II U.O. Ost. Gin. Presidio S. Bambino, Azienda Vittorio Emanuele, Catania); Como: C.Belloni (Osp. Generale di Zona Valduce, Como); Feltre (BL): L.Spolaor (Unità Socio Sanitaria n. 2, Div.Ostetricia Ginecologia, Feltre); Ferrara: A.Bianchi (Clinica Ostetrica Ginecologica, Ospedale S.Anna, Università di Ferrara); Firenze: M.Aretini, M.Franchini (S. Maria Annunziata), G.L.Bracco, M.E.Coccia, G.F.Scarselli (II Clinica Gin., Ost. Università, Firenze); Foggia: F.Ciuffreda (Rep. Ginecologia Osp. Casa Sollievo della Sofferenza, San Giovanni Rotondo); Latisana: C.Fiscella (U.O. Ostetricia Ginecologia, A.S.S. n. 5, Friuli Venezia Giulia, Osp. Latisana (UD); Lecce: F.Tinelli, C.A.Demarzi (A.O. `V. Fazzi', U.O. Ostetricia Ginecologia, Lecce); Mercato San Severino (SA): B.Bianco, A.Iannelli (P.O. Curteri, Mercato San Severino (SA); Milano: U.Radaelli, N.Meroni (Istituto Clinico Humanitas, Milano), D.Federici (Div. Ost. Ginecologia, Ospedale Sacco, Milano), C.Calia, P.Vercellini (I Clinica Ostetrico Ginecologica, Università di Milano), C.Bertulessi, F.Hanozet (Clinica Ostetrico Ginecologica III, Clinica Macedonio Melloni, Università di Milano); Milano: M.Busacca (II Clinica Ostetrico Ginecologica); Montebelluna: G.Dal Pozzo, A.Pieroni (Divisione Ginecologia ed Ostetricia, Montebelluna); Padova: P.Lita, R.Bracciante (Clinica Ostetrico Ginecologica, Università di Padova); Perugia: G.Baiocchi (Az. Osp., Università, U.O. Ostetricia e Ginecologia, Policlinico Monteluce, Perugia); Roma: M.A.Congiu (Università Campus Bio-Medico, Roma), R.Fanfani (Ospedale Cristo Re, Roma), F.Sesti, S.Bonifacio (Clinica Ostetrica Ginecologica, Università Tor Vergata, Osp. S. Eugenio, Roma), M.G.Porpora (II Istituto di Clinica Ostetrica e Gineocologica, Policlinico Umberto I, Roma); San Daniele del Friuli (UD): M.Pittino, G.Del Frate (U.O. Ostetricia Ginecologia, S. Daniele del Friuli); Sassari: S.Dessole, G.Capobianco (Dipartimento di Farmacologia Ginecologica e Ostetricia, Università); Tivoli (RM): M.Montanino Oliva, M.Primilerio (Ospedale S. Giovanni Ev, Tivoli (Roma)); Torino: S.Micalef, E.Ansaldi (Divisione di Ostetricia e Ginecologia, Ospedale di Venaria Reale), M.Massobrio, D.Guidetti (Dipartimento Discipline Ginecologiche e Ostetriche, Università di Torino); Trento: M.Rosati, A.Di Dionisio (Ospedale S. Camillo, Trento); Treviso: G.Bracalente (Div. Ostetricia e Ginecologia, Ospedale Ca' Foncello, Treviso); Trieste: S.Guaschino, L.Troiano, F.De Seta (Università di Trieste); Udine: M.Santuz, F.Petraglia (Clinica Ostetrico Ginecologica, Università di Udine); Urbino: E.Canducci (Dipartimento Materno Infantile, Ospedale Civile Urbino); Varese: P.Beretta (Clinica Ostetrico Ginecologica, Università dell'Insubria Varese); Vittorio Veneto: D.De Santo (Università di Vittorio Veneto).
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Notes |
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* See Acknowledgements for details of members of the Gruppo Italiano per lo Studio dell'Endometriosi.
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References |
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Submitted on May 4, 2001; accepted on August 29, 2001.