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Surgical versus medical treatment for endometriosis-associated severe deep dyspareunia: I. Effect on pain during intercourse and patient satisfaction

Vercellini P, Somigliana E, Consonni D, Frattaruolo MP, De Giorgi O, Fedele L.

Hum Reprod. 2012 Dec;27(12):3450-9.

Editor’s comment: Prof. Jim Thornton: Surgical and medical treatment are roughly equivalent for endometriosis pain
Although here is general consensus that, for patients with infertility, surgical treatment for endometriosis is better than medical, there is no agreement for patients with pain. There have been no good trials, so this non-randomised comparison is probably the best there is. In the short run (three months) surgical treatment seems to win, but by one year medical treatment is associated with better satisfaction. Even in the group where surgery might be expected to be better, those with rectovaginal endometriosis, there was no difference at one year.

Abstract

STUDY QUESTION:

Does surgical or medical treatment for endometriosis-associated severe deep dyspareunia achieve better results in terms of patients' satisfaction (main study outcome), variation of coital pain and frequency of intercourse?

SUMMARY ANSWER:

Surgery and progestin therapy were equally effective in the treatment of deep dyspareunia in women with rectovaginal endometriosis, whereas medical therapy performed significantly better than excisional treatment in those without deeply infiltrating lesions.

WHAT IS KNOWN AND WHAT THIS PAPER ADDS:

Conservative surgery and hormonal therapies have been used independently for endometriosis-associated deep dyspareunia with inconsistent results. This study reports a direct comparison between the two treatment options in women with severe pain during intercourse.

DESIGN:

Patient preference, parallel cohort study with a 12-month follow-up. The effect of conservative surgery at laparoscopy was compared with treatment with a low-dose of norethisterone acetate per os (2.5 mg/day) in women with persistent/recurrent severe deep dyspareunia after first-line surgery.

PARTICIPANTS AND SETTING:

A total of 51 patients chose repeat surgery and 103 progestin treatment. Patient satisfaction was graded according to a five-category scale. Variations in pain during intercourse were measured by means of a 100-mm visual analogue scale.

MAIN RESULTS AND THE ROLE OF CHANCE:

In the surgery group, a marked and rapid short-term dyspareunia score reduction was observed, followed by partial recurrence of pain. The pain relief effect of the progestin was more gradual, but progressive throughout the study period. At a 12-month follow-up, the frequency of intercourse per month (mean ± SD) was 4.6 ± 1.8 in the surgery group and 5.3 ± 1.5 in the norethisterone acetate group (P = 0.02). A total of 22/51 (43%) women were satisfied in the surgery group compared with 61/103 (59%) in the progestin group [adjusted odds ratios (OR), 0.36; 95% confidence interval (CI), 0.16-0.82; P = 0.015]. Corresponding figures in women with and without rectovaginal endometriotic lesions were, respectively, 13/24 (54%) versus 18/35 (51%; adjusted OR, 0.77; 95% CI, 0.22-2.67; P = 0.68), and 9/27 (33%) versus 43/68 (63%; adjusted OR, 0.23; 95% CI, 0.07-0.76, P = 0.02). BIAS, CONFOUNDING, AND OTHER REASONS FOR CAUTION: Treatments were not randomly assigned, and distribution of participants as well as of dropouts between study arms was unbalanced. However, the possibility of choosing the treatment allowed assessment of the maximum potential effect size of the interventions.

GENERALIZABILITY TO OTHER POPULATIONS:

Caucasian patients able to choose their treatment.

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