Painful endometriosis: If not planning a pregnancy: paracetamol and NSAID, or a combined oral contraceptive, or a levonorgestrel IUD

摘要

Endometriosis, i.e. the abnormal presence of uterine mucosal tissue outside of the uterus, is a common cause of pelvic pain occurring during menstrual periods. How is pelvic endometriosis recognised? What treatments can be offered to relieve pain related to endometriosis? To answer these questions, we carried out a review of the available evidence, using the standard Prescrire methodology. Endometriosis often presents with relatively nonspecific symptoms such as pelvic pain during menstruation or during sexual intercourse. Sometimes the site of the lesions is indicated by pain on defaecation or urinary problems during menstrual periods. Endometriosis does not seem to become worse over time. It is often observed in infertile women. In general, symptoms subside during pregnancy and after the menopause. When pelvic endometriosis is suspected, the gynaecological examination should look, first and foremost, for cervical motion tenderness, tender nodules in the posterior cul-de-sac, and bluish vaginal lesions. According to one systematic review, the lesions of endometriosis cannot be visualised by vaginal ultrasound or MRI in at least 20% of women with the condition. Ultrasound examination is nevertheless useful for excluding other diagnoses. Recourse to a specialist team from the outset is justified for women who want to become pregnant in the near future or who have gastrointestinal and urinary manifestations during menstrual periods. It is not necessary to confirm the diagnosis in a woman who does not wish to become pregnant in the near future and whose only symptoms are pain relieved by simple analgesics or hormonal contraception. According to a few double-blind randomised trials, a combined oestrogen/progestogen oral contraceptive, or an oral progestogen alone taken without interruption at high doses, are more effective than placebo for pain relief. Three randomised trials, in women who had previously undergone surgery for endometriosis, supported the analgesic efficacy of an intra-uterine device (IUD) containing levonorgestrel compared to no treatment. Among these options, those with the fewest adverse effects are: a combination of levonorgestrel or norethisterone with 30 micrograms to 40 micrograms of ethinylestradiol; or the levonorgestrel IUD. Gonadotropin-releasing hormone analogues and danazol, an androgen, are other options, with similar efficacy to that of combined oestrogen/ progestogen. Due to their adverse effects, they should only be considered after failure of first-line treatment and confirmation of the diagnosis.Treatment should not be continued beyond a few months. In practice, for women who have pelvic pain during menstrual periods, with no indication of deep-seated endometriosis and no plans for pregnancy in the short-term, a range of pain relief options can be offered, without the need to confirm the diagnosis. If pregnancy is planned, this limits the therapeutic options and in most cases, justifies seeking the opinion of a specialist team.