Semin Reprod Med 2018; 36(02): 143-151
DOI: 10.1055/s-0038-1676103
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Endometriosis and Female Pelvic Pain

Jin Hee Kim
1   Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York
Esther Han
1   Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York
› Author Affiliations
Further Information

Publication History

Publication Date:
19 December 2018 (online)


Endometriosis is a nonmalignant gynecologic disorder that can have a significant impact on a woman's quality of life with pelvic pain and possible lasting effects on one's fertility. Symptoms, when present, can be severe and affect many organ systems including the gastrointestinal and urinary systems. Other etiologies of pelvic pain must be ruled out and/or need to be addressed concurrently for optimal patient care. There are numerous medical and surgical treatment options available that have been shown to be beneficial for endometriosis-related pelvic pain. Recurrence is common when medications are discontinued and even after surgical therapy. Ultimately, the treatment approach will be dependent on the needs of the patient, taking into consideration the patient's desire for fertility, symptoms, past treatment, and patient preferences.

  • References

  • 1 Klein S, D'Hooghe T, Meuleman C, Dirksen C, Dunselman G, Simoens S. What is the societal burden of endometriosis-associated symptoms? a prospective Belgian study. Reprod Biomed Online 2014; 28 (01) 116-124
  • 2 Giudice LC, Kao LC. Endometriosis. Lancet 2004; 364 (9447): 1789-1799
  • 3 Carter JE. Combined hysteroscopic and laparoscopic findings in patients with chronic pelvic pain. J Am Assoc Gynecol Laparosc 1994; 2 (01) 43-47
  • 4 Matalliotakis IM, Arici A, Cakmak H, Goumenou AG, Koumantakis G, Mahutte NG. Familial aggregation of endometriosis in the Yale Series. Arch Gynecol Obstet 2008; 278 (06) 507-511
  • 5 Bedaiwy MA, Falcone T, Mascha EJ, Casper RF. Genetic polymorphism in the fibrinolytic system and endometriosis. Obstet Gynecol 2006; 108 (01) 162-168
  • 6 Missmer SA, Hankinson SE, Spiegelman D. , et al. Reproductive history and endometriosis among premenopausal women. Obstet Gynecol 2004; 104 (5, Pt 1): 965-974
  • 7 Sasson IE, Taylor HS. Stem cells and the pathogenesis of endometriosis. Ann N Y Acad Sci 2008; 1127: 106-115
  • 8 Bedaiwy MA, Hussein MR, Biscotti C, Falcone T. Pelvic endometriosis is rarely associated with ovarian borderline tumours, cytologic and architectural atypia: a clinicopathologic study. Pathol Oncol Res 2009; 15 (01) 81-88
  • 9 Bulun SE. Endometriosis. N Engl J Med 2009; 360 (03) 268-279
  • 10 Tokushige N, Markham R, Russell P, Fraser IS. High density of small nerve fibres in the functional layer of the endometrium in women with endometriosis. Hum Reprod 2006; 21 (03) 782-787
  • 11 Chapron C, Barakat H, Fritel X, Dubuisson JB, Bréart G, Fauconnier A. Presurgical diagnosis of posterior deep infiltrating endometriosis based on a standardized questionnaire. Hum Reprod 2005; 20 (02) 507-513
  • 12 Ballard KD, Seaman HE, de Vries CS, Wright JT. Can symptomatology help in the diagnosis of endometriosis? Findings from a national case-control study--Part 1. BJOG 2008; 115 (11) 1382-1391
  • 13 Villa G, Mabrouk M, Guerrini M. , et al. Relationship between site and size of bladder endometriotic nodules and severity of dysuria. J Minim Invasive Gynecol 2007; 14 (05) 628-632
  • 14 Seracchioli R, Mabrouk M, Guerrini M. , et al. Dyschezia and posterior deep infiltrating endometriosis: analysis of 360 cases. J Minim Invasive Gynecol 2008; 15 (06) 695-699
  • 15 Nisenblat V, Bossuyt PM, Farquhar C, Johnson N, Hull ML. Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev 2016; 2: CD009591
  • 16 Berger JP, Rhemrev J, Smeets M, Henneman O, English J, Jansen FW. Limited added value of magnetic resonance imaging after dynamic transvaginal ultrasound for preoperative staging of endometriosis in daily practice: a prospective cohort study. J Ultrasound Med 2018; 9999: 1-8
  • 17 Della Zazzera V, Benning H, Lortie K, Singh SS. Moose antler sign, a sign of deep endometriosis infiltrating bowel. J Minim Invasive Gynecol 2017; 24 (05) 706
  • 18 Rafique S, Decherney AH. Medical management of endometriosis. Clin Obstet Gynecol 2017; 60 (03) 485-496
  • 19 Ling FW. ; Pelvic Pain Study Group. Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Obstet Gynecol 1999; 93 (01) 51-58
  • 20 Ferrero S, Camerini G, Venturini P. , et al. Progression of bowel endometriosis during treatment with the oral contraceptive pill. Gynecol Surg 2011; 8 (03) 311-313
  • 21 Marjoribanks J, Ayeleke RO, Farquhar C. , et al. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database of Systematic Reviews 2015; 30 (07) CD001751 . doi: 10.1002/14651858.CD001751.pub3
  • 22 Brown J, Crawford TJ, Allen C, Hopewell S, Prentice A. Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis. Cochrane Database Syst Rev 2017; 1: CD004753
  • 23 ACOG practice bulletin no. 114: management of endometriosis. Reaffirmed 2018. Obstet Gynecol 2010; 116 (01) 223-236
  • 24 Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, De Bie B, Heikinheimo O, Horne AW, Kiesel L, Nap A, Prentice A, Saridogan E, Soriano D, Nelen W. European Society of Human Reproduction and Embryology. ESHRE guideline: management of women with endometriosis. Hum Reprod 2014; 29 (03) 400-412
  • 25 Medical Eligibility Criteria. 2016–CDC. Available at: . Accessed November 1, 2018
  • 26 Brown J, Crawford TJ, Datta S, Prentice A. Oral contraceptives for pain associated with endometriosis. Cochrane Database Syst Rev 2018; 5: CD001019
  • 27 Jensen JT, Schlaff W, Gordon K. Use of combined hormonal contraceptives for the treatment of endometriosis-related pain: a systematic review of the evidence. Fertil Steril 2018; 110 (01) 137-152.e1
  • 28 Ferrero S, Evangelisti G, Barra F. Current and emerging treatment options for endometriosis. Expert Opin Pharmacother 2018; 19 (10) 1109-1125
  • 29 Barra F, Scala C, Ferrero S. Current understanding on pharmacokinetics, clinical efficacy and safety of progestins for treating pain associated to endometriosis. Expert Opin Drug Metab Toxicol 2018; 14 (04) 399-415
  • 30 Buggio L, Somigliana E, Barbara G, Frattaruolo MP, Vercellini P. Oral and depot progestin therapy for endometriosis: towards a personalized medicine. Expert Opin Pharmacother 2017; 18 (15) 1569-1581
  • 31 Ferrero S, Alessandri F, Racca A, Leone Roberti Maggiore U. Treatment of pain associated with deep endometriosis: alternatives and evidence. Fertil Steril 2015; 104 (04) 771-792
  • 32 Brown J, Kives S, Akhtar M. Progestagens and anti-progestagens for pain associated with endometriosis. Cochrane Database Syst Rev 2012; 3 (03) CD002122
  • 33 Lan S, Ling L, Jianhong Z, Xijing J, Lihui W. Analysis of the levonorgestrel-releasing intrauterine system in women with endometriosis. J Int Med Res 2013; 41 (03) 548-558
  • 34 Lockhat FB, Emembolu JO, Konje JC. The efficacy, side-effects and continuation rates in women with symptomatic endometriosis undergoing treatment with an intra-uterine administered progestogen (levonorgestrel): a 3 year follow-up. Hum Reprod 2005; 20 (03) 789-793
  • 35 Wong AY, Tang LC, Chin RK. Levonorgestrel-releasing intrauterine system (Mirena) and Depot medroxyprogesterone acetate (Depoprovera) as long-term maintenance therapy for patients with moderate and severe endometriosis: a randomised controlled trial. Aust N Z J Obstet Gynaecol 2010; 50 (03) 273-279
  • 36 Abou-Setta AM, Al-Inany HG, Farquhar CM. Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery. Cochrane Database Syst Rev 2006; (04) CD005072
  • 37 Brown J, Pan A, Hart RJ. Gonadotrophin-releasing hormone analogues for pain associated with endometriosis. Cochrane Database Syst Rev 2010; (12) CD008475
  • 38 Clemenza S, Sorbi F, Noci I. , et al. From pathogenesis to clinical practice: Emerging medical treatments for endometriosis. Best Pract Res Clin Obstet Gynaecol 2018; 51: 92-101
  • 39 Velasco I, Rueda J, Acién P. Aromatase expression in endometriotic tissues and cell cultures of patients with endometriosis. Mol Hum Reprod 2006; 12 (06) 377-381
  • 40 Słopień R, Męczekalski B. Aromatase inhibitors in the treatment of endometriosis. Przegl Menopauz 2016; 15 (01) 43-47
  • 41 Pavone ME, Bulun SE. Aromatase inhibitors for the treatment of endometriosis. Fertil Steril 2012; 98 (06) 1370-1379
  • 42 Ferrero S, Gillott DJ, Venturini PL, Remorgida V. Use of aromatase inhibitors to treat endometriosis-related pain symptoms: a systematic review. Reprod Biol Endocrinol 2011; 9: 89
  • 43 Selak V, Farquhar C, Prentice A, Singla A. Danazol for pelvic pain associated with endometriosis. Cochrane Database Syst Rev 2007; (04) CD000068
  • 44 Duffy JM, Arambage K, Correa FJ. , et al. Laparoscopic surgery for endometriosis. Cochrane Database Syst Rev 2014; (04) CD011031
  • 45 Sutton CJ, Ewen SP, Whitelaw N, Haines P. Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril 1994; 62 (04) 696-700
  • 46 Abbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R. Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril 2004; 82 (04) 878-884
  • 47 Arcoverde FVL, Andres MP, Borrelli GM, Barbosa PA, Abrão MS, Kho RM. Surgery for endometriosis improves major domains of quality of life: a systematic review and meta-analysis. J Minim Invasive 2018; . pii: S1553-4650 (18) 31244-5 . doi: 10.1016/j.jmig.2018.09.774
  • 48 Pundir J, Omanwa K, Kovoor E, Pundir V, Lancaster G, Barton-Smith P. Laparoscopic excision versus ablation for endometriosis-associated pain: an undated systematic review and meta-analysis. J Minim Invasive Gynecol 2017; 24 (05) 747-756
  • 49 Abbott JA, Hawe J, Clayton RD, Garry R. The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 2–5 year follow-up. Hum Reprod 2003; 18 (09) 1922-1927
  • 50 Shakiba K, Bena JF, McGill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery. Obstet Gynecol 2008; 111 (06) 1285-1292
  • 51 Zullo F, Palomba S, Zupi E. , et al. Effectiveness of presacral neurectomy in women with severe dysmenorrhea caused by endometriosis who were treated with laparoscopic conservative surgery: a 1-year prospective randomized double-blind controlled trial. Am J Obstet Gynecol 2003; 189 (01) 5-10
  • 52 Daniels J, Gray R, Hills RK. , et al; LUNA Trial Collaboration. Laparoscopic uterosacral nerve ablation for alleviating chronic pelvic pain: a randomized controlled trial. JAMA 2009; 302 (09) 955-961
  • 53 Goodman LR, Goldberg JM, Flyckt RL, Gupta M, Harwalker J, Falcone T. Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls. Am J Obstet Gynecol 2016; 215 (05) 589.e1-589.e6
  • 54 Coccia ME, Rizzello F, Mariani G, Bulletti C, Palagiano A, Scarselli G. Ovarian surgery for bilateral endometriomas influences age at menopause. Hum Reprod 2011; 26 (11) 3000-3007
  • 55 Busacca M, Riparini J, Somigliana E. , et al. Postsurgical ovarian failure after laparoscopic excision of bilateral endometriomas. Am J Obstet Gynecol 2006; 195 (02) 421-425
  • 56 Vercellini P, Somigliana E, Viganò P, Abbiati A, Barbara G, Crosignani PG. Surgery for endometriosis-associated infertility: a pragmatic approach. Hum Reprod 2009; 24 (02) 254-269
  • 57 Hart R, Hickey M, Maouris P, Buckett W, Garry R. Excisional surgery versus ablative surgery for ovarian endometriomata: a Cochrane Review. Hum Reprod 2005; 20 (11) 3000-3007
  • 58 Furness S, Yap C, Farquhar C, Cheong YC. Pre and post-operative medical therapy for endometriosis surgery. Cochrane Database of Systematic Reviews 2004. (03). Art. No.: CD003678. doi: 10.1002/14651858.CD003678.pub2
  • 59 Dunselman GA, Vermeulen N, Becker C. , et al; European Society of Human Reproduction and Embryology. ESHRE guideline: management of women with endometriosis. Hum Reprod 2014; 29 (03) 400-412
  • 60 Seracchioli R, Mabrouk M, Manuzzi L. , et al. Post-operative use of oral contraceptive pills for prevention of anatomical relapse or symptom-recurrence after conservative surgery for endometriosis. Hum Reprod 2009; 24 (11) 2729-2735
  • 61 Hornstein MD, Hemmings R, Yuzpe AA, Heinrichs WL. Use of nafarelin versus placebo after reductive laparoscopic surgery for endometriosis. Fertil Steril 1997; 68 (05) 860-864
  • 62 Namnoum AB, Hickman TN, Goodman SB, Gehlbach DL, Rock JA. Incidence of symptom recurrence after hysterectomy for endometriosis. Fertil Steril 1995; 64 (05) 898-902
  • 63 Espauella J, Armengol J, Bella F, Lain JM, Calaf J. Pulmonary endometriosis: conservative treatment with GnRB agonists. Obstet Gynecol 1991; 78 (3, Pt 2): 535-537
  • 64 Roman H, Bubenheim M, Huet E. , et al. Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod 2018; 33 (01) 47-57
  • 65 Mira TAA, Buen MM, Borges MG, Yela DA, Benetti-Pinto CL. Systematic review and meta-analysis of complementary treatments for women with symptomatic endometriosis. Int J Gynaecol Obstet 2018; 143 (01) 2-9