Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

12. Chronic Pelvic Pain in Women
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reporting significant improvement in pain symptoms [ 17 ].
Notwithstanding adequate trial design, these studies documented a 30 %
placebo effect; the difference, however, was that the therapeutic benefit
was much longer- lasting for those in the treatment arms [ 18 ].
DIE is not consistently recognizable by the unfamiliar surgeon, and
since depth of infiltration correlates with pain symptoms, excising these
lesions seems more logical [ 19 ]. Ovarian endometrioma, often associated
with DIE, are better managed by enucleating the cyst rather than
ablation [ 20 , 21 ]. Data to support postoperative suppression are limited,
although the benefits of surgery may be extended with combined oral
contraceptives (COCs), progestins, or gonadotropin- releasing hormone
agonists (GnRH-a).
Adenomyosis
Adenomyosis is an enigmatic disorder characterized anatomically as
endometrial glands and stroma existing within the myometrium diffusely.
Focal lesions are referred to as an adenomyoma . Although traditionally
gynecologists have considered adenomyosis a cause of heavy,
prolonged, and/or painful menses, it is apparent from studies of hysterectomy
specimens for a spectrum of benign disorders that adenomyosis
is an extremely common entity, found in approximately 25–65 % of
hysterectomy specimens.
Until relatively recently, adenomyosis was something diagnosed
based on clinical suspicion and confirmed only at the time of hysterectomy.
Advances in uterine imaging have provided the clinician with the
opportunity to diagnose this entity with reasonable accuracy. In the relatively
small uterus, TVUS is an effective means of identifying adenomyosis,
assuming adequate sonographer skill and real-time evaluation
of the study, as opposed to review of still images [ 21 ]. Magnetic resonance
imaging (MRI) may be an effective secondary tool used to confirm
adenomyosis, especially when the uterus is large or associated with
concomitant uterine myoma.
The relationship between adenomyosis and abnormal uterine bleeding
(AUB) or CPP remains unclear, in particular because many trials
were performed to evaluate symptom reduction without performing a
hysterectomy. The levonorgestrel intrauterine system (LNG-IUS) has
proved to be more effective than other modalities in quality of life measures
when compared to hysterectomy in a randomized trial [ 22 ].