title: Surgical versus medical treatment for endometriosis-associated severe deep dyspareunia: I. Effect on pain during intercourse and patient satisfaction.
abstract: OBJECTIVE
  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?
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  Caucasian patients able to choose their treatment.
  
  
  BACKGROUND
  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.
authors.affiliation: Clinica Ostetrica e Ginecologica, Istituto Luigi Mangiagalli, Università Statale di Milano, 20122 Milan, Italy. paolo.vercellini@unimi.it
authors.forename: P
authors.initials: P
authors.lastname: Vercellini
authors.forename: E
authors.initials: E
authors.lastname: Somigliana
authors.forename: D
authors.initials: D
authors.lastname: Consonni
authors.forename: M P
authors.initials: MP
authors.lastname: Frattaruolo
authors.forename: O
authors.initials: O
authors.lastname: De Giorgi
authors.forename: L
authors.initials: L
authors.lastname: Fedele
mesh_terms: D000328:Adult; D015992:Body Mass Index; D015331:Cohort Studies; D003075:Coitus; D004414:Dyspareunia / Q000188:drug therapy* / Q000601:surgery*; D004715:Endometriosis / Q000150:complications / Q000473:pathology* / Q000601:surgery; D005260:Female; D006801:Humans; D016015:Logistic Models; D009640:Norethindrone / Q000031:analogs & derivatives* / Q000627:therapeutic use; D000077563:Norethindrone Acetate; D010147:Pain Measurement; D017060:Patient Satisfaction
chemical_list: D000077563:Norethindrone Acetate; D009640:Norethindrone