Endometriosis-associated pain in women undergoing hysterectomy
Sania Latif,1 Dimitrios Mavrelos1
1) University College London Hospitals NHS Foundation Trust
25 Grafton Way
London, UK NW1 2PG
Pain is a cardinal symptom of endometriosis and its management can be
challenging. Analgesics are commonly used as first line treatment for
endometriosis-associated pain, despite there being a paucity of evidence
regarding their use for this indication. Clinicians are advised to
consider NSAIDs or other analgesics to reduced endometriosis-associated
pain due to the known benefit of NSAIDs in primary dysmenorrhea (ESHRE
guideline “Management of women with endometriosis.” Dunselman et al.,Hum Reprod. 2014; 29(3):400-12). Women who fail to respond to
conservative treatments and who have completed their family may be
offered hysterectomy with removal of the ovaries and all visible
endometriosis lesions, alongside advice that hysterectomy will not
necessarily cure the symptoms or the disease.
Brunes et al. (BJOG 2020;
https://doi.org/10.1111/1471-0528.16469) analysed data from two
Swedish population-based registers: the Swedish National Quality
Register of Gynaecological Surgery (GynOp) and the Swedish National Drug
Register. Data was collected prospectively and reported by both patient
and surgeon in this nationwide cohort study. Brunes et al. (BJOG2020) reported that women with endometriosis undergoing hysterectomy
have a higher prescription rate of analgesics. The prescription of
analgesics, psychoactive drugs and neuroactive drugs did not decrease
when they compared drug use three years pre-operatively with that 3
years post-operatively.
Hysterectomy for chronic non-specified pelvic pain associated with
endometriosis is a successful approach in many women, but some women do
not obtain any relief of pain after hysterectomy (Martin. J Minim
Invasive Gynecol, 2006; 13:566–572). It is likely that this is because
there are difficulties in evaluating hysterectomy for
endometriosis-associated pain and in establishing whether endometriosis
is the cause of pain or a co-incidental finding in a woman with chronic
pelvic pain. Other factors impacting the success of surgery and the
level of post-operative analgesic use include whether there is effective
removal of endometriotic lesions or whether the ovaries are removed.
Hysterectomy with ovarian conservation has been reported to have a
6-fold risk for development of recurrent pain, with a recurrence rate of
62% in advanced stage endometriosis (Martin. J Minim Invasive
Gynecol, 2006; 13:566–572). Surgical effort should always aim to
eradicate the endometriotic lesions completely.
Clinicians and patients should be aware that the expected benefit of
surgery is operator dependent and that the extent and duration of
therapeutic benefit of surgery are poorly defined (Vercellini et al.Hum Reprod Update. 2009;15(2):177–188). There is a need for
prospective clinical trials and long-term follow up studies in women
with endometriosis to compare treatment options including hysterectomy
for endometriosis-associated pain using defined outcome measures.
Disclosure of interests: None declared. Completed disclosure of
interest forms are available to view online as supporting information.