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Painful endometriosis: initial treatment options

In the absence of urinary or intestinal symptoms, and if the patient is not planning to become pregnant any time soon, first try analgesics such as NSAIDs or paracetamol. Hormonal contraception or a levonorgestrel intrauterine device are other options.

Endometriosis, i.e. the abnormal presence of clumps of uterine mucous membrane cells outside the uterus, is a frequent cause of pelvic pain during menstruation. In some women, endometriosis is very painful and debilitating. Endometriosis does not appear to get worse over time. In general, the symptoms decrease during pregnancy and after menopause.

According to a review of studies, endovaginal ultrasound or MRI do not show endometriosis lesions in at least 20% of women suffering from the condition. However, ultrasound is useful for ruling out other diagnoses.

Should the patient wish to become pregnant any time soon, this limits the therapeutic options, and advice should be sought from a specialist team.

In the absence of urinary and intestinal symptoms, it is not essential to confirm the diagnosis, in a woman who does not wish to become pregnant in the foreseeable future and whose only symptom is pain that can be relieved by simple analgesics –  paracetamol, ibuprofen or naproxen – or by hormonal contraception.

The results of high-quality clinical trials have shown that oral oestrogen-progestestogen contraception or a non-associated progestogen in high, continuous doses relieves pain more effectively than placebo. Three other trials support the analgesic efficacy of a levonorgestrel-releasing intrauterine device.

Drugs usually used in neuropathic pain, antiepileptic drugs and antidepressants have not been specifically evaluated in patients with endometriosis.

Often, the proposed analgesic medications are only partially effective. If the pain is still debilitating, the advice of a specialist team should be sought to confirm the diagnosis and consider other options. Furthermore, as with any person suffering from chronic pain, taking the psychological, sexual, family and professional impact of this pain into account is an important aspect of its management.

©Prescrire 1 March 2020

"Painful endometriosis. If not planning a pregnancy: paracetamol and NSAID, or a combined oral contraceptive, or a levonorgestrel IUD" Prescrire Int 2020; 29 (213): 75. (Pdf, subscribers only).

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