Treatment of chronic pelvic pain in patients with endometriosis

Mauro Busacca

Department of Obstetrics and Gynecology, University of Milano, Via commenda 12, 20122 MIlano, Italy E-mail: mauro.busacca{at}unimi.it

Dear Sir,

We thank Dr Schattman for his interest in our article (Busacca et al., 2001Go) and his valuable comments. The use of post-operative medical therapies is an important and controversial issue in the management of patients with endometriosis. However, despite the lack of definitive scientific evidence, many physicians actually prescribe a short course of 3–6 months of GnRH analogue after surgery for advanced stages of the disease. In our study, we mainly investigated whether a routine use of this surgical/medical combined regimen in patients with symptomatic endometriosis stage III–IV may be justified. In particular, it has to be noted that only patients with moderate/severe pain complaints (dysmenorrhoea and/or deep dyspareunia and/or pelvic pain) were enrolled. We do agree with Dr Schattman that this inclusion criteria was not clearly stated in the manuscript.

Many of the interesting queries raised by Dr Schattman have been already discussed in the manuscript. We herein provide short answers to most of his comments. Pain scores of both groups were similar at baseline and, as previously stated, all patients reported moderate to severe pain symptoms. In our study, we were mostly interested in the percentage of patients who may benefit from this treatment, rather than in precisely quantifying the reduction in pain symptom score. Moreover, we think that quantifying this reduction may be clinically misleading.

With regards to other causes of pelvic pain symptoms that were excluded, they included orthopaedic, gastrointestinal and urologic diseases. Specialistic evaluations were performed when required. Finally, some patients underwent a psychological evaluation to exclude an important psychological origin of their complaints.

The surgical procedure primarily employed was the accurate excision of all endometriotic lesions, including endometriotic cysts. We did not use laser at all.

We did not think that the flare of gonadotrophin and rise of serum estradiol following the prescription of GnRH analogue during the menstrual cycle might have severely hampered the efficacy of the treatment. Nevertheless, we feel that the regimen proposed by Dr Schattman is interesting and might be suitable if physicians believe that a post-surgical course of GnRH is required.

In regard to the last point raised by Dr Schattman, the relationship between anatomic distribution and extension of endometriotic lesions on one hand and pain symptoms on the other is still a debated issue (Fedele et al., 1992Go). Moreover, the rationale of the post-surgical use of GnRH analogue is mostly to accomplish complete resection of lesions which were not visualized at surgical inspection. This situation is more likely to occur in advanced stages of the disease. Therefore, in our study, we decided to enroll only patients with endometriosis stage III–IV.

We appreciate the important comments from Dr Schattman that help the discussion regarding the important topic of the post-surgical therapy of endometriosis and we agree that this particular and controversial aspect requires further investigations.

References

Busacca, M., Somigliana, E., Bianchi, S. et al. (2001) Post-operative GnRH analogue treatment after conservative surgery for symptomatic endometriosis stage III–IV: a randomized controlled trial. Hum. Reprod., 11, 2399–2402.

Fedele, L., Bianchi, S., Bocciolone, L. et al. (1992) Pain symptoms associated with endometriosis. Obstet. Gynecol., 79, 767–769.[Abstract]





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