Dear patients, chronic pelvic pain is a difficult process that seriously affects the quality of life of women diagnosed with endometriosis, often lasting for many years. It is possible to cope with this pain, which intensifies during menstrual periods, restricts daily activities, and even affects sexual life, through correct diagnosis and up-to-date treatment approaches. In this article, I will share modern management strategies for chronic pain related to endometriosis with you, in light of the ESHRE 2022 guideline.

What is Endometriosis and Why Does It Cause Pain?

Endometriosis is a chronic disease characterized by the growth of tissue similar to the uterine lining (endometrium) outside the uterus, usually in areas such as the ovaries, fallopian tubes, and pelvic peritoneum. This ectopic endometrial tissue responds to hormones during each menstrual cycle, bleeds, and creates chronic inflammation in its surroundings. Over time, this inflammatory process can lead to adhesions, proliferation of nerve fibers, and central sensitization, resulting in a pain picture disproportionate to the severity of the disease.

The Gold Standard in Diagnosis: Laparoscopy

The gold standard in diagnosing endometriosis is laparoscopic visualization and biopsy. Imaging methods such as ultrasound and MRI are valuable, especially in showing endometriomas (chocolate cysts) and deep endometriosis foci; however, they cannot detect superficial peritoneal endometriosis. The ESHRE 2022 guideline recommends the use of laparoscopy for both diagnostic and therapeutic purposes in cases that do not respond to empirical treatment.

Medical Treatment Options

The first step in the medical management of chronic pelvic pain involves non-steroidal anti-inflammatory drugs (NSAIDs) and hormonal treatments. Hormonal options include:

Combined oral contraceptives (COCs): Continuous or cyclic use suppresses ovarian function, reducing the activity of endometriotic foci. This is first-line treatment.
Progestins: Specific progestins such as dienogest act by causing decidualization and atrophy in endometriotic tissue. ESHRE states that dienogest is at least as effective as GnRH analogs in pain control.
GnRH Analogs: They create a hypoestrogenic environment through pituitary desensitization. Due to their negative effects on bone mineral density, they should be combined with add-back therapy.
Levonorgestrel-releasing IUD (LNG-IUD): An effective option especially in controlling dyspareunia (painful intercourse) and dysmenorrhea (painful menstruation).

When is Surgery Indicated?

In cases resistant to medical treatment, pain that significantly affects daily life, or in patients planning fertility, laparoscopic surgery comes to the forefront. The aim of surgery is the excision or ablation of all visible endometriotic lesions, release of adhesions, and restoration of pelvic anatomy. The ESHRE 2022 guideline emphasizes that surgery is effective in pain control but the recurrence risk of the disease ranges between 20-40%. Therefore, postoperative hormonal suppression therapy is important to reduce the risk of recurrence.

The Importance of a Multidisciplinary Approach

Endometriosis is not just a gynecological disease. Chronic pain causes permanent changes in the central nervous system, bringing the neuropathic pain component into play. Therefore, for effective pain management:

Pain specialist (algology) consultation
Pelvic floor physiotherapy: Release of myofascial trigger points and rehabilitation of pelvic muscles
Psychological support: Cognitive behavioral therapy due to the close relationship between chronic pain, depression, and anxiety
Nutritional counseling: Anti-inflammatory dietary approaches (Mediterranean-type nutrition)

Approach in Patients Planning Pregnancy

In the coexistence of endometriosis and infertility, the treatment strategy is different. ESHRE states that endometriosis surgery can increase the chance of natural pregnancy but carries the risk of damaging ovarian reserve. Especially in bilateral endometriomas, a significant decrease in post-surgical AMH levels can be observed. Therefore, fertility preservation approaches (egg/embryo freezing) should be evaluated before surgery. In mild-moderate endometriosis, IVF success rates may be similar to surgery, so treatment should be individualized.

Conclusion

Chronic pelvic pain due to endometriosis requires a multidisciplinary approach in addition to medical and surgical treatments. While the medical options we have today (especially dienogest and LNG-IUD) provide effective pain control in many patients, surgery significantly improves quality of life in appropriately selected cases. Remember that endometriosis is a chronic disease and requires long-term follow-up. Open communication with your physician at every step you take to manage your pain is the key to your treatment success.

Modern Management of Chronic Pelvic Pain Associated with Endometriosis