Surgical versus medical treatment for endometriosis-associated severe deep dyspareunia

I. Effect on pain during intercourse and patient satisfaction

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

Research output: Contribution to journalArticle

57 Citations (Scopus)

Abstract

STUDY QUESTIONDoes 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 ANSWERSurgery 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 ADDSConservative 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. DESIGNPatient 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 SETTINGA 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 CHANCEIn 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 CAUTIONTreatments 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 POPULATIONSCaucasian patients able to choose their treatment. STUDY FUNDING/COMPETING INTEREST(S)This study was supported by a research grant from the University of Milan School of Medicine (PUR number 2009-ATE-0570). None of the authors have a conflict of interest.

Original languageEnglish
Pages (from-to)3450-3459
Number of pages10
JournalHuman Reproduction
Volume27
Issue number12
DOIs
Publication statusPublished - Dec 2012

Fingerprint

Dyspareunia
Endometriosis
Patient Satisfaction
Pain
Progestins
Therapeutics
Odds Ratio
Confidence Intervals
Conflict of Interest
Organized Financing
Coitus
Visual Analog Scale
Reoperation
Laparoscopy
Cohort Studies
Medicine

Keywords

  • deep dyspareunia
  • endometriosis
  • medical treatment
  • surgery

ASJC Scopus subject areas

  • Rehabilitation
  • Obstetrics and Gynaecology
  • Reproductive Medicine

Cite this

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title = "Surgical versus medical treatment for endometriosis-associated severe deep dyspareunia: I. Effect on pain during intercourse and patient satisfaction",
abstract = "STUDY QUESTIONDoes 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 ANSWERSurgery 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 ADDSConservative 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. DESIGNPatient 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 SETTINGA 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 CHANCEIn 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 CAUTIONTreatments 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 POPULATIONSCaucasian patients able to choose their treatment. STUDY FUNDING/COMPETING INTEREST(S)This study was supported by a research grant from the University of Milan School of Medicine (PUR number 2009-ATE-0570). None of the authors have a conflict of interest.",
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year = "2012",
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TY - JOUR

T1 - Surgical versus medical treatment for endometriosis-associated severe deep dyspareunia

T2 - I. Effect on pain during intercourse and patient satisfaction

AU - Vercellini, P.

AU - Somigliana, E.

AU - Consonni, D.

AU - Frattaruolo, M. P.

AU - De Giorgi, O.

AU - Fedele, L.

PY - 2012/12

Y1 - 2012/12

N2 - STUDY QUESTIONDoes 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 ANSWERSurgery 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 ADDSConservative 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. DESIGNPatient 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 SETTINGA 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 CHANCEIn 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 CAUTIONTreatments 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 POPULATIONSCaucasian patients able to choose their treatment. STUDY FUNDING/COMPETING INTEREST(S)This study was supported by a research grant from the University of Milan School of Medicine (PUR number 2009-ATE-0570). None of the authors have a conflict of interest.

AB - STUDY QUESTIONDoes 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 ANSWERSurgery 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 ADDSConservative 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. DESIGNPatient 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 SETTINGA 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 CHANCEIn 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 CAUTIONTreatments 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 POPULATIONSCaucasian patients able to choose their treatment. STUDY FUNDING/COMPETING INTEREST(S)This study was supported by a research grant from the University of Milan School of Medicine (PUR number 2009-ATE-0570). None of the authors have a conflict of interest.

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