Surgical ablative therapy has not been shown superior to medical therapy in addressing the pain of early-stage endometriosis. Medical therapy is less invasive and, as the following report illustrates, it probably treats all disease present.
In a study of 95 women with CPP in whom endometriosis was suspected after a thorough noninvasive workup yielded no diagnosis, investigators found that empiric therapy with depot leuprolide for 12 weeks provided significant pain relief compared with both the baseline and a placebo group (P ≤ .001 for both comparisons). Posttreatment diagnostic laparoscopy confirmed endometriosis in more than three quarters of both treatment groups.3
The limits of laparoscopy
Although second-line empiric therapy is controversial, laparoscopy is invasive and does not necessarily yield a definitive diagnosis. However, diagnostic laparoscopy may ultimately be indicated in patients with pain of undetermined cause. Perform laparoscopy only if no cause of pain can be identified and confirmed, and after reasonable trials of empiric medical therapy.
Up to one third of women have no pathology visualized on laparoscopy.6 This does not mean that no pathology is present. Endometriosis is missed visually during laparoscopy in up to one third of CPP patients in whom the disease is proven on biopsy.3,4
Laparoscopically identified pathology does not necessarily make the diagnosis. For example, the size and location of endometriotic implants do not always correlate with the presence of pain. Thus, endometriosis may be present but may not be the cause of CPP.1 Similarly, visualizing pelvic adhesions during laparoscopy does not necessarily mean that the adhesions are responsible for the pelvic pain, as women with extensive adhesions are sometimes asymptomatic.7
Gynecologic conditions identifiable by diagnostic laparoscopy
The following gynecologic conditions may be identified through diagnostic laparoscopy in women with cyclic and noncyclic pain:
Endometriosis is seen in at least one third to one half of women with CPP7; most sites of endometriosis are in the pelvic area. The mechanisms by which endometriosis causes pain are not fully understood, however.
Chronic pelvic inflammatory disease (PID). Laparoscopy identifies adhesions or stigmata of chronic PID in about 25% of women with CPP. Chronic PID may cause noncyclic CPP because recurrent exacerbations frequently result in hydrosalpinges and adhesions between the tubes, ovaries, and intestinal structures. Before ascribing symptoms to adhesions, however, clinicians should specifically note this pathology in the area of pain.
Ovarian causes. Ovarian cysts are frequently asymptomatic, but pain may result from rapid distention of the ovarian capsule. An ovary or ovarian remnant may enter the retroperitoneal space secondary to inflammation or previous surgery. This is known as ovarian remnant syndrome, and cyst formation in these circumstances is usually painful. Some women, for unknown reasons, may develop multiple recurrent hemorrhagic ovarian cysts that are associated with pelvic pain and dyspareunia.
Uterine origins. Adenomyosis (endometrial glands and stroma invading the myometrium) may cause dysmenorrhea and menorrhagia, but rarely causes noncyclic CPP. Uterine myomas usually do not cause pelvic pain unless they are undergoing degeneration, torsion, or are compressing pelvic nerves. (Occasionally, a submucous leiomyoma may protrude through the cervix, which has been described by women as pain not unlike childbirth.) Uterine myomas may also cause pain from rapid growth or degeneration during pregnancy.
Chronic pain itself—with or without organic pathology—produces debilitating psychological responses.
Pelvic pain is not likely to be due solely to variations in uterine position, but dyspareunia with deep penetration may occasionally be associated with uterine retroversion. A tender uterus that is in a fixed retroverted position usually signifies other intraperitoneal pathology, such as endometriosis or PID.
Pelvic congestion syndrome. As noted, this has been described in multiparous women who have pelvic vein varicosities (documented on venographic studies) resulting in “congested” pelvic organs. Many women with this condition are noted to have a uterus that is mobile, retroverted, soft, boggy, and slightly enlarged. Ovarian hormone suppression and cognitive behavioral therapy may relieve pain. If these measures fail, and if venographic studies confirm the diagnosis, then hysterectomy and oophorectomy may be beneficial. Surgery should be considered only if the diagnosis is confirmed and medical therapy fails.
If no pathology is found, is the pain psychological?
Inability to identify a pathologic diagnosis in approximately one third of patients with CPP has led to the postulation of a psychological etiology. It is appropriate to consider psychological factors early in your evaluation. However, as mentioned earlier, a suggestion of psychological etiology should not delay or preclude further investigation of somatic pathology.
Ask patients about past or present physical, sexual, or emotional abuse. History of major psychosexual trauma (molestation, incest, rape) was identified in 48% of 106 women evaluated at my institution with no pathologic diagnosis following a thorough workup and laparoscopy.2 Women with such a history should be referred for psychological evaluation.