Schliep K C, Mumford S L, Peterson C M, Chen Z, Johnstone E B, Sharp H T, Stanford J B, Hammoud A O, Sun L, Buck Louis G M
Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20852, USA Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20852, USA.
Hum Reprod. 2015 Oct;30(10):2427-38. doi: 10.1093/humrep/dev147. Epub 2015 Aug 11.
What are the pain characteristics among women, with no prior endometriosis diagnosis, undergoing laparoscopy or laparotomy regardless of clinical indication?
Women with surgically visualized endometriosis reported the highest chronic/cyclic pain and significantly greater dyspareunia, dysmenorrhea, and dyschezia compared with women with other gynecologic pathology (including uterine fibroids, pelvic adhesions, benign ovarian cysts, neoplasms and congenital Müllerian anomalies) or a normal pelvis.
Prior research has shown that various treatments for pain associated with endometriosis can be effective, making identification of specific pain characteristics in relation to endometriosis necessary for informing disease diagnosis and management.
STUDY DESIGN, SIZE, DURATION: The study population for these analyses includes the ENDO Study (2007-2009) operative cohort: 473 women, ages 18-44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at one of 14 surgical centers located in Salt Lake City, UT or San Francisco, CA. Women with a history of surgically confirmed endometriosis were excluded.
PARTICIPANTS/MATERIALS, SETTING AND METHODS: Endometriosis was defined as surgically visualized disease; staging was based on revised American Society for Reproductive Medicine (rASRM) criteria. All women completed a computer-assisted personal interview at baseline specifying 17 types of pain (rating severity via 11-point visual analog scale) and identifying any of 35 perineal and 60 full-body front and 60 full-body back sites for which they experienced pain in the last 6 months.
There was a high prevalence (≥30%) of chronic and cyclic pelvic pain reported by the entire study cohort regardless of post-operative diagnosis. However, women with a post-operative endometriosis diagnosis, compared with women diagnosed with other gynecologic disorders or a normal pelvis, reported more cyclic pelvic pain (49.5% versus 31.0% and 33.1%, P < 0.001). Additionally, women with endometriosis compared with women with a normal pelvis experienced more chronic pain (44.2 versus 30.2%, P = 0.04). Deep pain with intercourse, cramping with periods, and pain with bowel elimination were much more likely reported in women with versus without endometriosis (all P < 0.002). A higher percentage of women diagnosed with endometriosis compared with women with a normal pelvis reported vaginal (22.6 versus 10.3%, P < 0.01), right labial (18.4 versus 8.1%, P < 0.05) and left labial pain (15.3 versus 3.7%, P < 0.01) along with pain in the right/left hypogastric and umbilical abdominopelvic regions (P < 0.05 for all). Among women with endometriosis, no clear and consistent patterns emerged regarding pain characteristics and endometriosis staging or anatomic location.
LIMITATIONS, REASONS FOR CAUTION: Interpretation of our findings requires caution given that we were limited in our assessment of pain characteristics by endometriosis staging and anatomic location due to the majority of women having minimal (stage I) disease (56%) and lesions in peritoneum-only location (51%). Significance tests for pain topology related to gynecologic pathology were not corrected for multiple comparisons.
Results of our research suggest that while women with endometriosis appear to have higher pelvic pain, particularly dyspareunia, dysmenorrhea, dyschezia and pain in the vaginal and abdominopelvic area than women with other gynecologic disorders or a normal pelvis, pelvic pain is commonly reported among women undergoing laparoscopy, even among women with no identified gynecologic pathology. Future research should explore causes of pelvic pain among women who seek out gynecologic care but with no apparent gynecologic pathology. Given our and other's research showing little correlation between pelvic pain and rASRM staging among women with endometriosis, further development and use of a classification system that can better predict outcomes for endometriosis patients with pelvic pain for both surgical and nonsurgical treatment is needed.
STUDY FUNDING/COMPETING INTERESTS: Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests.
在未事先诊断为子宫内膜异位症的女性中，无论临床指征如何，接受腹腔镜检查或剖腹手术的疼痛特征是什么？
与患有其他妇科疾病（包括子宫肌瘤、盆腔粘连、良性卵巢囊肿、肿瘤和先天性苗勒管异常）或盆腔正常的女性相比，手术中可视化诊断为子宫内膜异位症的女性报告的慢性/周期性疼痛最高，性交困难、痛经和排便困难也明显更严重。
先前的研究表明，各种治疗子宫内膜异位症相关疼痛的方法可能有效，因此确定与子宫内膜异位症相关的特定疼痛特征对于疾病诊断和管理至关重要。
研究设计、规模、持续时间：这些分析的研究人群包括ENDO研究（2007 - 2009年）的手术队列：473名年龄在18 - 44岁之间的女性，她们在位于犹他州盐湖城或加利福尼亚州旧金山的14个手术中心之一接受了诊断性和/或治疗性腹腔镜检查或剖腹手术。有手术确诊子宫内膜异位症病史的女性被排除在外。
参与者/材料、设置和方法：子宫内膜异位症定义为手术中可视化的疾病；分期基于修订后的美国生殖医学学会（rASRM）标准。所有女性在基线时完成了一次计算机辅助个人访谈，明确了17种疼痛类型（通过11点视觉模拟量表对严重程度进行评分），并确定了她们在过去6个月中经历疼痛的35个会阴部位、60个全身前部部位和60个全身后部部位中的任何部位。
无论术后诊断如何，整个研究队列中慢性和周期性盆腔疼痛的患病率都很高（≥30%）。然而，与诊断为其他妇科疾病或盆腔正常的女性相比，术后诊断为子宫内膜异位症的女性报告的周期性盆腔疼痛更多（49.5%对31.0%和33.1%，P < 0.001）。此外，与盆腔正常的女性相比，患有子宫内膜异位症的女性经历的慢性疼痛更多（44.2%对30.2%，P = 0.04）。与未患子宫内膜异位症的女性相比，患有子宫内膜异位症的女性更有可能报告性交时深部疼痛、经期痉挛和排便时疼痛（所有P < 0.002）。与盆腔正常的女性相比，诊断为子宫内膜异位症的女性中，报告阴道疼痛（22.6%对10.3%，P < 0.01）、右阴唇疼痛（18.4%对8.1%，P < 0.05）和左阴唇疼痛（15.3%对3.7%，P < 0.01）以及右/左下腹和脐部盆腔区域疼痛的比例更高（所有P < 0.05）。在患有子宫内膜异位症的女性中，疼痛特征与子宫内膜异位症分期或解剖位置之间没有出现明确和一致的模式。
局限性、注意事项：鉴于大多数女性患有轻度（I期）疾病（56%）且病变仅位于腹膜（51%），我们对子宫内膜异位症分期和解剖位置的疼痛特征评估有限，因此对我们的研究结果进行解释时需要谨慎。与妇科疾病相关的疼痛拓扑学的显著性检验未针对多重比较进行校正。
我们的研究结果表明，虽然与患有其他妇科疾病或盆腔正常的女性相比，患有子宫内膜异位症的女性似乎盆腔疼痛更高，尤其是性交困难、痛经、排便困难以及阴道和盆腔区域疼痛，但接受腹腔镜检查的女性中普遍报告有盆腔疼痛，即使在未发现妇科疾病的女性中也是如此。未来的研究应该探索寻求妇科护理但没有明显妇科疾病的女性盆腔疼痛的原因。鉴于我们和其他人的研究表明，子宫内膜异位症女性的盆腔疼痛与rASRM分期之间几乎没有相关性，需要进一步开发和使用一种分类系统，该系统可以更好地预测子宫内膜异位症盆腔疼痛患者手术和非手术治疗的结果。
研究资金/利益冲突：由尤妮斯·肯尼迪·施莱佛国家儿童健康与人类发展研究所的内部研究项目资助（合同编号NO1 - DK - 6 - 3428、NO1 - DK - 6 - 3427和10001406 - 02）。作者没有潜在的利益冲突。
