RAMB Novembro/Dezembro 2015

arqui

ABT

516

ssoc

ras

2015; 61(6):507-518

iscussion

This study shows that the scientific literature is vast as to

the number of scientific articles published on the preva-

lence and levels of pain in patients with endometriosis.

The painful symptoms attributed to endometriosis in-

clude CPP, dysmenorrhea, dyspareunia, dyschezia and

dysuria. Pain restricts and modifies the daily routine of

these patients, directly affecting their quality of life. De-

spite the use of instruments to measure pain, such anal-

ysis is complex due to its subjective nature and the influ-

ence of factors such as personality, psychiatric disorders

(depression) and psychosocial factors. The severity of pain

may be related to the degree of depression and anxiety,

present in 90% of women with endometriosis. Some au-

thors indicate that depression is a direct consequence of

pain, but there is no consensus on this temporal issue

when defining which condition precedes the other. How-

ever, it is possible to affirm that the two conditions coex-

ist, and that one worsens the experience of the other.

Whenever endometriosis patients exhibit depression, it is

clinically important to assess the condition and start ap-

propriate treatment as soon as possible. Depression, if

left untreated, has a negative effect on the patient’s abil-

ity to deal with the pain, daily functioning, and especial-

ly their quality of life. In addition, the impact of a chron-

ic disease, such as endometriosis, associated with persistent

painful symptoms, causes the patient to become isolated,

damaging relationships given that women with endome-

triosis are labeled as “hypochondriac” and their circle of

friends ends up getting tired of so many complaints. This

favors the emergence of depressive symptoms.

In relation to the instruments for measuring pain,

the VAS has prevailed as the most frequently applied ques-

tionnaire for analysis of endometriotic pain. It is a one-

dimensional instrument that quantifies pain according

to intensity. It consists of a line of 10 or 100 cm, which

contains the number 0 on the left and the number 10 or

100 at the other end. Patients are advised to mark the po-

sition that reflects the degree of pain, with 0 being no

pain and 10 or 100 considered the worst pain experi-

enced.

15,27

One way to reduce the painful symptoms in patients

with endometriosis is to use conventional treatment in-

cluding surgery and/or medication.

The data presented in Tables 1 and 2 show that sur-

gical treatment for endometriosis was effective in reliev-

ing dysmenorrhea, dyspareunia, pelvic pain, dyschezia

and dysuria. These studies show that laparoscopic exci-

sion reduces pain levels after surgery, ranging from 4

months,

to 6 months,

25,30

12 months

9,11,21,29

and 2-5 years.

Surgical treatment for endometriosis consists of ex-

cision of endometriotic lesions by laparoscopy. Laparot-

omy can also be used in the treatment of this disease;

however, laparoscopy is more widely employed because

it is minimally invasive compared to the first, and has the

following advantages: less blood loss, shorter postopera-

tive recovery time, less postoperative pain and early hos-

pital discharge.

A recent review addressed the surgical

treatment of endometriosis in terms of improvement in

pain and infertility. The authors conclude that surgical

treatment seems to be the definitive therapy for women

with exacerbated painful symptoms.

According to Nácul and Spritzer,

pharmacological

treatments for pain associated with endometriosis in-

clude estro-progesterone combinations (birth control),

isolated progestins (norethindrone acetate, dienogest,

medroxyprogesterone acetate – DMPA, intrauterine sys-

tems with levonorgestrel – LNG-IUS), gonadotropin re-

leasing hormone analogues (GnRHa – nafarelin acetate,

leuprolide acetate, triptorelin), danazol and gestrinone

and aromatase inhibitors (letrozole and anastrozole). The

costs and side effects of these drugs differ significantly.

Of the 17 studies that evaluated the influence of medica-

tion on decreasing pain levels, seven evaluated one drug

alone

6,13,20,26-28,32

and 10 evaluated drugs in combina-

tion.

10,12,15,17-19,22-24,31

Thus, 3 studies employed contracep-

tives;

24,26,27

10 used isolated progestins;

10,12,13,15,17,19,20,22,23,28

5 used GnRHa,

6,10,22,24,32

one used danazol

and 4 used

aromatase inhibitors.

12,15,19,22

The use of aromatase inhib-

itors for the treatment of endometriosis and its associat-

ed symptoms is justified by the fact that endometriotic

tissue over-expresses aromatase, an enzyme key for the

production of estrogen, noting that endometriosis is an

estrogen-dependent gynecological condition. However,

they exhibit poor tolerability and high costs compared

to more conventional therapies.

Among the therapeu-

tic options for treatment of endometriotic pain, estro-

gen-progestin combinations are the 1

line therapy, with

progestins as 1

or 2

line therapy, and GnRHa and da-

nazol/gestrinone as 2

and 3

line treatments, respec-

tively.

An interesting finding in relation to GnRHa (trip-

torelin) was reported by Ferrero et al.

who also

evaluated the effect of letrozole (aromatase inhibitor) and

norethisterone acetate (isolated progestin). In their study,

about 80% of patients who received letrozole and trip-

torelin reported side effects and 45% discontinued treat-

ment as a result. Side effects of GnRHa include dry vagi-

na, decreased libido, depression, irritability, fatigue and

bone mineral loss, which limits its use.

Danazol is an-

other drug that has limited use due to adverse androgen-