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Case History

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Image not available. A 27-year-old woman presents with an 18-month history of pelvic pain, dyspareunia and failure to conceive despite regular intercourse. Four years earlier a laparoscopy had confirmed endometriosis which was ablated and she was pain-free whilst tricycling the combined oral contraceptive (COC) pill.

What are the first-line treatments for pain associated with endometriosis?

Is a diagnostic laparoscopy necessary before commencing treatment?

How should treatment differ if pain is present and the woman is trying to conceive?

If an endometrioma was found on ultrasound scan, how should this be managed?

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Background

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Image not available. Endometriosis is defined as 'the presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction'. It is common; however, the exact prevalence is not known as not every woman has a laparoscopy in order to look for disease. There is still debate about aetiology, but it is likely to be a combination of retrograde menstruation1 and an altered immune environment which allows the ectopic tissue to implant and develop a blood and nerve supply.2 Clinical presentation can be very variable and correlates poorly with the extent of disease seen at laparoscopy.3 Treatment needs to be tailored to the woman's particular symptoms, her age and her reproductive wishes, both current and future.

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What are the first-line treatments for pain associated with endometriosis?

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Simple analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs), have traditionally been first-line treatments for endometriosis. However, a meta-analysis found that only one randomized controlled trial was considered robust enough to be included, and there was no evidence of a positive effect on pain relief when comparing naproxen to placebo in women with endometriosis.4 If women are avoiding hormonal treatment because of a desire for pregnancy, they need to be aware that NSAIDs have an antiovulatory effect when taken mid-cycle, as well as other adverse effects such as gastric ulceration.

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A variety of hormonal treatments have also been shown to be successful in reducing the pain associated with endometriosis. These include the COC pill,5 progestogens,6 danazol7 and gonadotrophin-releasing hormone agonists (GnRHa).8 These have all been shown to be equally effective at reducing pain, but have different side-effect profiles and costs. An intrauterine levonorgestrel-releasing system can also be effective.1

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Is a diagnostic laparoscopy necessary before commencing treatment?

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Current guidelines suggest that pain thought to be due to endometriosis can be treated either with simple analgesia or hormonal treatments without the need for a definitive surgical diagnosis.9,10 Laparoscopy is the gold standard for making a diagnosis, but is not without risk. Positive histology is not required to confirm the diagnosis; however, if endometriomas greater than 3 cm diameter are found, histology should be obtained.9

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How should treatment differ if pain is present and the woman is trying to conceive?

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