title: Treatment of pain associated with deep endometriosis: alternatives and evidence.
abstract: Pain is the most evident clinical manifestation of deep infiltrating endometriosis (DIE). Several hormonal and immunologic mechanisms are markedly altered in DIE compared with superficial peritoneal and ovarian endometriosis, and may explain its most aggressive behavior and the presence of severe pain symptoms. Hormonal therapies, such as combined hormonal contraceptives and progestogens, should be regarded as first-line treatment, as they are efficacious, safe, and well tolerated. Gonadotropin-releasing hormone agonists may be used in patients with symptoms persisting after the administration of first-line therapies. Scanty literature is available for danazol treatment in patients with DIE and, however, it has become less popular due to the high rates of androgenic adverse events (AEs). The partial relief of pain that often is achieved with available therapies and its recurrence after the suspension of the treatment have brought to the development of new therapies (such as aromatase inhibitors, oral GnRH antagonists) that are currently under investigation. Surgical excision of DIE should be considered in patients with pain symptoms persisting after first-line hormonal therapies. The benefits of surgery in terms of pain improvement should be always balanced with the risk of intraoperative complications and for this reason surgical cases should be referred to tertiary centers for the treatment of DIE. A multidisciplinary approach is mandatory in patients with DIE involving the bowel and/or the urinary tract.
authors.affiliation: Unit of Obstetrics and Gynecology, San Martino Hospital and National Institute for Cancer Research, University of Genoa, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy. Electronic address: simone.ferrero@unige.it.
authors.forename: Simone
authors.initials: S
authors.lastname: Ferrero
authors.affiliation: Unit of Obstetrics and Gynecology, San Martino Hospital and National Institute for Cancer Research, University of Genoa, Genoa, Italy.
authors.forename: Franco
authors.initials: F
authors.lastname: Alessandri
authors.affiliation: Unit of Obstetrics and Gynecology, San Martino Hospital and National Institute for Cancer Research, University of Genoa, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.
authors.forename: Annalisa
authors.initials: A
authors.lastname: Racca
authors.affiliation: Unit of Obstetrics and Gynecology, San Martino Hospital and National Institute for Cancer Research, University of Genoa, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.
authors.forename: Umberto
authors.initials: U
authors.lastname: Leone Roberti Maggiore
mesh_terms: D000700:Analgesics / Q000627:therapeutic use; D004715:Endometriosis / Q000150:complications* / Q000628:therapy; D005260:Female; D007987:Gonadotropin-Releasing Hormone / Q000037:antagonists & inhibitors; D006727:Hormone Antagonists / Q000627:therapeutic use; D006801:Humans; D059408:Pain Management / Q000379:methods*; D017699:Pelvic Pain / Q000209:etiology* / Q000628:therapy*; D011372:Progestins / Q000627:therapeutic use; D012720:Severity of Illness Index
chemical_list: D000700:Analgesics; D006727:Hormone Antagonists; D011372:Progestins; D007987:Gonadotropin-Releasing Hormone
keywords: Deep endometriosis; endometriosis; medical treatment; pain; surgery