‘Algological bonds of endometriosis’. Features of clinical management of patients with typical and atypical symptoms of endometriosis
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Abstract:
Endometriosis remains one of the most mysterious and controversial diseases in modern gynecology. Contemporary statistical data demonstrate the extreme relevance of actively implementing effective therapeutic approaches into the clinician’s everyday practice. However, a significant challenge associated with endometriosis is the pain syndrome. The question of so-called atypical algological manifestations of endometriosis, which previously seemed unrelated to the pathogenesis of the primary disease, is increasingly raised. In this regard, the aim of this article was to propose a three-level pathogenetic concept capable of linking the primary manifestation of endometriosis (pelvic pain) with other often distant algological patterns, as well as to create an algorithm for managing these patients based on their pathogenetic staging.Keywords:
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Chronic pelvic pain and endometriosis remain two of the most perplexing problems in gynecology. In some women with both conditions, endometriosis might not be the cause of their pain. The problem is determining when the pain is caused by endometriosis. On the basis of clinical studies, I suggest three criteria that should be met before attributing chronic pelvic pain to endometriosis. First, the pelvic pain should be cyclic because endometriosis is a hormonally responsive disease. Second, endometriosis should be diagnosed surgically to avoid overdiagnosing this condition. Finally, medical or surgical treatment of endometriosis should result in prolonged pain relief. Application of these evidence-based criteria reminds us that endometriosis often can be asymptomatic, even in some women with chronic pelvic pain. These criteria might help gynecologists determine the women for whom surgical therapy will resolve the pain; however, only prospective evaluation can determine their ultimate usefulness.
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In Brief Chronic pelvic pain and endometriosis remain two of the most perplexing problems in gynecology. In some women with both conditions, endometriosis might not be the cause of their pain. The problem is determining when the pain is caused by endometriosis. On the basis of clinical studies, I suggest three criteria that should be met before attributing chronic pelvic pain to endometriosis. First, the pelvic pain should be cyclic because endometriosis is a hormonally responsive disease. Second, endometriosis should be diagnosed surgically to avoid overdiagnosing this condition. Finally, medical or surgical treatment of endometriosis should result in prolonged pain relief. Application of these evidence-based criteria reminds us that endometriosis often can be asymptomatic, even in some women with chronic pelvic pain. These criteria might help gynecologists determine the women for whom surgical therapy will resolve the pain; however, only prospective evaluation can determine their ultimate usefulness. Before attributing chronic pelvic pain to endometriosis, there should be a surgical diagnosis, and the pain should be cyclic and relieved by specific treatment.
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Endometriosis is a prevalent condition that affects millions of individuals globally, leading to various symptoms and significant disruptions to their quality of life. However, the diagnosis of endometriosis often encounters delays, emphasizing the pressing need for non-invasive screening. This retrospective cross-sectional study aimed to evaluate the utility of the Endometriosis Risk Advisor (EndoRA) mobile application in screening for endometriosis in patients with chronic pelvic pain and/or unexplained infertility. The study consisted of 293 patients who met specific criteria: they were English-speaking individuals with chronic pelvic pain and/or unexplained infertility, owned smartphones, and had no prior diagnosis of endometriosis. The results demonstrated that the EndoRA score exhibited a high sensitivity of 93.1% but a low specificity of 5.9% in detecting endometriosis. The positive predictive value was 94.1%, while the negative predictive value was 5.0%. Although the study had limitations and potential selection bias, its findings suggest that EndoRA can serve as a valuable screening tool for high-risk individuals, enabling them to identify themselves as being at an increased risk for endometriosis. EndoRA's non-invasive nature, free access, and easy accessibility have the potential to streamline evaluation and treatment processes, thereby empowering individuals to seek timely care and ultimately improving patient outcomes and overall well-being.
Unexplained infertility
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Pelvic endometriosis
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Chronic pelvic pain (CPP) affects up to 20% of reproductive aged women.1 Endometriosis is the most common reproductive system diagnosis in women who undergo investigation for CPP. Endometriosis is a chronic disease that is difficult to completely eradicate. Over the course of the reproductive years, women with endometriosis will often require several pharmacological and/or surgical treatments. This chapter will focus on the clinical diagnosis and management of endometriosis, including evidence and specific recommendations for each therapeutic option. Since menstrual pain is the most prevalent symptom of endometriosis, we will also briefly discuss primary dysmenorrhea and other causes of secondary dysmenorrhea. As is the case with most chronic pain disorders, the degree of anatomic pathology in women with endometriosis often fails to explain the severity of the pain and associated symptoms. Recent research suggests that endometriosis can alter neural processing, fostering the development and maintenance of chronic pain.2 This chapter will also summarize relevant research studies highlighting the interactions of the reproductive, immunological, and central nervous systems (CNS) in this disorder.
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In Brief OBJECTIVE: To estimate the prevalence of surgically confirmed endometriosis in women undergoing laparoscopic or abdominal hysterectomy, including those with and without preoperative indications of chronic pelvic pain or endometriosis, and to describe characteristics and operative findings associated with surgically confirmed endometriosis in women undergoing hysterectomy for chronic pelvic pain. METHODS: A retrospective cohort study was performed with 9,622 women who underwent laparoscopic or abdominal hysterectomy for benign indications in the Michigan Surgical Quality Collaborative from January 1, 2013, to July 2, 2014. The prevalence of surgically confirmed endometriosis, determined by review of the operative report and surgical pathology, was calculated for the entire cohort and for subgroups of women with and without chronic pelvic pain or endometriosis. Multivariate logistic regression models were used to identify characteristics associated with surgically confirmed endometriosis at the time of hysterectomy among women with chronic pelvic pain. RESULTS: Of the 9,622 hysterectomies available for analysis during the study period, 15.2% (n=1,465) had endometriosis at the time of hysterectomy. Among the 3,768 women with a preoperative indication of chronic pelvic pain, fewer than one in four had endometriosis (806/3,768 [21.4%]). Even among those with preoperative indication of endometriosis, many women did not actually have endometriosis at the time of hysterectomy (527/1,232 [42.8%]). The rate of unexpected endometriosis in women without a preoperative indication of chronic pelvic pain or endometriosis was 8.0% (434/5,457). Among women with a preoperative indication of chronic pelvic pain (n=3,786), multivariate analysis showed endometriosis was more common in women of younger age, white race, lower body mass index, and those who failed another treatment previously. Among those with pelvic pain, oophorectomy was more commonly performed in women with surgically confirmed endometriosis than those without (47.4% compared with 33.3%, P<.001). CONCLUSION: Fewer than 25% of women undergoing laparoscopic or abdominal hysterectomy for chronic pelvic pain have endometriosis at the time of surgery. Endometriosis is found in fewer than one fourth of women undergoing laparoscopic or abdominal hysterectomy for chronic pelvic pain.
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