title: Leuprolide in a 3-monthly versus a monthly depot formulation for the treatment of symptomatic endometriosis: a pilot study. Prospective Randomized Trial of Right-Sided Paracolic Adhesiolysis for Chronic Pelvic Pain Subcutaneous injection of depot medroxyprogesterone acetate compared with leuprolide acetate in the treatment of endometriosis-associated pain. Effects of 3 month therapy with danazol after laparoscopic surgery for stage III/IV endometriosis: a randomized study. Issues in planning a placebo-controlled trial of manual methods: results of a pilot study. Chronic pelvic pain treated with gabapentin and amitriptyline: A randomized controlled pilot study A randomized controlled trial of goserelin and medroxyprogesterone acetate in the treatment of pelvic congestion. Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Delayed Oral Estradiol Combined with Leuprolide Increases Endometriosis-Related Pain Comparison of contraceptive ring and patch for the treatment of symptomatic endometriosis. Anti-TNF-α treatment for deep endometriosis-associated pain: a randomized placebo-controlled trial Long-term oral contraceptive pills and postoperative pain management after laparoscopic excision of ovarian endometrioma: a randomized controlled trial. Use of a progestogen only preparation containing desogestrel in the treatment of recurrent pelvic pain after conservative surgery for endometriosis. A randomized study comparing triptorelin or expectant management following conservative laparoscopic surgery for symptomatic stage III-IV endometriosis. Dienogest is as effective as leuprolide acetate in treating the painful symptoms of endometriosis: a 24-week, randomized, multicentre, open-label trial. Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis. Effects of triptorelin versus placebo on the symptoms of endometriosis. Letrozole and norethisterone acetate versus letrozole and triptorelin in the treatment of endometriosis related pain symptoms: a randomized controlled trial Proof of concept trial of tanezumab for the treatment of symptoms associated with interstitial cystitis. Hormonal suppression treatment or dietary therapy versus placebo in the control of painful symptoms after conservative surgery for endometriosis stage III-IV. A randomized comparative trial. The efficacy of intravesical bacillus Calmette-Guerin in the treatment of interstitial cystitis: long-term followup. Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis. Safety and efficacy of the use of intravesical and oral pentosan polysulfate sodium for interstitial cystitis: a randomized double-blind clinical trial. Postoperative medical treatment of chronic pelvic pain related to severe endometriosis: levonorgestrel-releasing intrauterine system versus gonadotropin-releasing hormone analogue. Return of Chronic Pelvic Pain From Endometriosis After Raloxifene Treatment: A Randomized Controlled Trial Efficacy of static magnetic field therapy in chronic pelvic pain: a double-blind pilot study. Surgical treatment of endometriosis: a prospective randomized double-blinded trial comparing excision and ablation. The treatment with a COX-2 specific inhibitor is effective in the management of pain related to endometriosis. A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. Is acupuncture in addition to conventional medicine effective as pain treatment for endometriosis? A randomised controlled cross-over trial. A Randomized Clinical Trial to Compare Two Different Approaches in Women With Chronic Pelvic Pain Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. A randomized controlled trial of intravesical bacillus calmette-guerin for treatment refractory interstitial cystitis. Add-back therapy in the treatment of endometriosis-associated pain. Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized, controlled trial. Anastrazole and oral contraceptives: a novel treatment for endometriosis. Laparoscopic uterine nerve ablation versus vaginal uterosacral ligament resection in postmenopausal women with intractable midline chronic pelvic pain: a randomized study. For Whom Does It Work? Moderators of the Effects of Written Emotional Disclosure in a Randomized Trial Among Women With Chronic Pelvic Pain Oral estroprogestins after laparoscopic surgery to excise endometriomas: continuous or cyclic administration? Results of a multicenter randomized study. Randomized trial of leuprolide versus continuous oral contraceptives in the treatment of endometriosis-associated pelvic pain. Safety and dose flexibility clinical evaluation of intravesical liposome in patients with interstitial cystitis or painful bladder syndrome. Subcutaneous depot medroxyprogesterone acetate versus leuprolide acetate in the treatment of endometriosis-associated pain. Effectiveness of the association micronized N-Palmitoylethanolamine (PEA)-transpolydatin in the treatment of chronic pelvic pain related to endometriosis after laparoscopic assessment: a pilot study. Continuing improvement of chronic pelvic pain in women after short-term Mensendieck somatocognitive therapy: results of a 1-year follow-up study. A randomized, double-blind crossover trial of sertraline in women with chronic pelvic pain. Botulinum Toxin Type A for Chronic Pain and Pelvic Floor Spasm in Women: A Randomized Controlled Trial Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis. Long-Term Follow-Up of a Controlled Trial of Laser Laparoscopy for Pelvic Pain Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. Chronic Pelvic Pain in Women in New Zealand: Comparative Well-Being, Comorbidity, and Impact on Work and Other Activities Retreatment with nafarelin for recurrent endometriosis symptoms: efficacy, safety, and bone mineral density. Depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol for long-term treatment of pelvic pain associated with endometriosis. Randomized placebo controlled trial of lofexidine hydrochloride for chronic pelvic pain in women. Estroprogestin vs. gonadotrophin agonists plus estroprogestin in the treatment of endometriosis-related pelvic pain: a randomized trial. Gruppo Italiano per lo Studio dell'Endometriosi. Low-dose danazol after combined surgical and medical therapy reduces the incidence of pelvic pain in women with moderate and severe endometriosis. The levonorgestrel-releasing intrauterine system and endometriosis staging. Maintenance therapy with dienogest following gonadotropin-releasing hormone agonist treatment for endometriosis-associated pelvic pain. A double‐blind randomised controlled trial of laparoscopic uterine nerve ablation for women with chronic pelvic pain Changes in quality of life after hormonal treatment of endometriosis A randomized, comparative trial of triptorelin depot (D-Trp6-LHRH) and danazol in the treatment of endometriosis. Cyproterone acetate versus a continuous monophasic oral contraceptive in the treatment of recurrent pelvic pain after conservative surgery for symptomatic endometriosis. Implanon versus medroxyprogesterone acetate: effects on pain scores in patients with symptomatic endometriosis--a pilot study. Efficacy of melatonin in the treatment of endometriosis: A phase II, randomized, double-blind, placebo-controlled trial
abstract: An open-label r and omized pilot study was conducted to evaluate the efficacy and acceptability of 6 months treatment with leuprolide in a 3-monthly versus a monthly i.m . depot injection for the relief of chronic pelvic pain in women with endometriosis . A total of 30 women aged 18 - 38 years were allocated to the 3-monthly depot arm ( n = 15 ) or to the monthly depot arm ( n = 15 ) after laparoscopic diagnosis of pelvic endometriosis .  Mean ( SD ) deep dyspareunia scores according to a 0 - 3 point verbal rating scale decreased from 1.8 ( 0.9 ) at baseline to 1.3 ( 0.7 ) at the end of treatment in the 3-monthly depot group and from 2.1 ( 1.2 ) to 1.3 ( 0.7 ) in the monthly depot group . Corresponding values in non-menstrual pain scores fell from 2.1 ( 0.6 ) to 1.1 ( 0.3 ) , and from 2.1 ( 0.8 ) to 1.2 ( 0.4 ) respectively , without statistically significant differences between the groups . Serum luteinizing hormone ( LH ) and 17 beta-oestradiol concentrations were significantly suppressed at 12 and 24 weeks compared with baseline values , without differences between the groups . The monthly depot caused a slightly more marked inhibition of serum follicle stimulating hormone ( FSH ) levels with respect to the 3-monthly preparation . Mean ( SD ) endometriosis scores at baseline and at 6-month follow-up laparoscopy were respectively 32.8 ( 25.1 ) and 12.2 ( 9.3 ) in the 3-monthly depot group and 29.0 ( 22.7 ) and 13.1 ( 15.3 ) in the monthly depot group ( paired t-test , P < 0.05 ) . Mean percentage decrease in lumbar spine bone mineral density was 5.2 % in the former and 4.9 % in the latter subjects . In the 3-monthly depot group , 13 women grade d the tolerability of their treatment schedule as " good ' compared with seven in the monthly depot group ( chi 2 = 5.40 , P = 0.02 ) Background : Prior study has shown that right paracolic adhesions are found in 90 % of patients with chronic pelvic pain and less frequently in pain-free patients . We set out to determine whether paracolic adhesiolysis will reduce site-specific pain . Methods : This was a prospect i ve , r and omized trial of right paracolic adhesiolysis at the time of diagnostic and operative laparoscopy for chronic pelvic pain . Twenty-five patients with a diagnosis of chronic pelvic pain were r and omized to either undergo or withhold lysis of right paracolic adhesions at the time of operative laparoscopy . Results : Right paracolic adhesions were found in 100 % of our patients . For all subjects , there was a significant reduction of right and left lower quadrant pain ( P<0.001 ) following the operative laparoscopy . Those who underwent right paracolic adhesiolysis had significantly greater right pelvic pain reduction than those who did not ( P=0.014 ) . There was no difference in the reduction of left or mid pelvic pain between the treatment and control groups . Conclusions : Right paracolic adhesiolysis reduces short-term site-specific tenderness in patients with chronic pelvic pain . Patients who would benefit from diagnostic or operative laparoscopy are likely to benefit further from paracolic adhesiolysis OBJECTIVE To compare the efficacy and safety of SC depot medroxyprogesterone acetate ( DMPA-SC 104 ) with that of leuprolide acetate in treatment of endometriosis . DESIGN Phase 3 , multicenter , r and omized , evaluator-blinded , comparator-controlled trial . SETTING Clinical trial sites in Canada and United States . PATIENT(S ) Two hundred seventy-four women with surgically diagnosed endometriosis . INTERVENTION(S ) Intramuscular injections of DMPA-SC ( 104 mg ) or leuprolide acetate ( 11.25 mg ) , given every 3 months for 6 months , with 12 months of posttreatment follow-up . MAIN OUTCOME MEASURE(S ) Reduction in five endometriosis symptoms or signs ( dysmenorrhea , dyspareunia , pelvic pain , pelvic tenderness , pelvic in duration ) ; change in bone mineral density ( BMD ) , hypoestrogenic symptoms , bleeding , and weight . RESULT ( S ) The depot medroxyprogesterone acetate given SC was statistically equivalent to leuprolide in reducing four of five endometriosis symptoms or signs at the end of treatment ( month 6 ) and in reducing all five symptoms after 12 months ' follow-up ( month 18 ) . Patients in the  DMPA-SC 104  group showed significantly less BMD loss than did leuprolide  patients at month 6 , with scores returning to baseline at 12 months ' follow-up . No statistically significant differences in median weight changes were observed between groups . Compared with leuprolide , DMPA-SC 104 was associated with fewer hypoestrogenic symptoms but more irregular bleeding . CONCLUSION ( S ) Efficacy of DMPA-SC 104 was equivalent to that of leuprolide for reducing endometriosis-associated pain , with less impact on BMD and fewer hypoestrogenic side effects but more bleeding The effect of treatment with danazol was evaluated with respect to expectant management after laparoscopic conservative surgery . All patients conservatively operated at laparoscopy for stage III-IV endometriosis from July 1994 to October 1996 were requested to enter the study . Patients who underwent surgery for recurrent endometriosis were excluded from the study , as well as patients who had taken hormonal therapies before laparoscopy . Informed consent was obtained from 77 women who were r and omized after surgery to treatment with danazol 600 mg daily for 3 months ( n = 36 ) or to expectant management ( n = 41 ) . All patients were regularly followed up every 6 months for evaluation of fertility , recurrence of pain symptoms and disease . During the follow-up , six ( 55 % ) of the 11 infertile women allocated to danazol and eight ( 50 % ) of the 16 given no treatment became pregnant ( not significant ) . Moderate/severe pelvic pain recurred during follow-up in seven ( 23 % ) of the 31 women with pelvic pain allocated to the danazol group and nine ( 31 % ) of the 29 allocated to no treatment ; the respective cumulative pain recurrence rates at 12 months were 26 and 34 % ( log rank test , not significant ) . Three women ( 8.3 % ) treated with danazol and six ( 15 % ) who received no treatment had disease recurrence as demonstrated by gynaecological examination and /or pelvic ultrasonography ( not significant ) . Our results do not demonstrate a significant advantage of 3 month danazol therapy after laparoscopic surgery for stage III-IV endometriosis with respect to postoperative expectant management OBJECTIVE There are fundamental differences between the administration of medications and the application of manual procedures , such as those used by chiropractors . The objective of this study was to gather preliminary information on how to address these differences in the design of a multisite , r and omized placebo-controlled trial of chiropractic care for women with chronic pelvic pain ( CPP ) . DESIGN Pilot study for a multisite , r and omized , placebo-controlled clinical trial . SETTING Three chiropractic research clinics in the midwest United States . SUBJECTS Thirty-nine ( 39 ) women with CPP of at least 6 months ' duration , diagnosed by board-certified gynecologists . INTERVENTIONS The active intervention consisted of the chiropractic technique , lumbar spine flexion-distraction , combined with manual Trigger Point Therapy . The placebo intervention consisted of a sham chiropractic procedure performed with an instrument combined with effleurage ( light massage ) . OUTCOME MEASURES The primary outcome measure was the change in the Pain Disability Index ( PDI ) from baseline to the end of treatment ( 6 weeks ) , assessed by group and site . If the change score was in the same direction at all sites , the results were to be combined to estimate treatment effect size . RESULTS Patient characteristics were similar to those of patients with CPP in other studies . Recruitment methods , particularly in respect to the eligibility criteria and screening protocol s , would require modification in order to recruit an adequate sample for the planned r and omized controlled trial . Clinicians followed st and ardized procedures with apparently minimal deviation , patients in both groups were satisfied with their care and blinding appeared to be successful . PDI change scores were not consistent across sites and so results were not combined and overall treatment effect sizes were not estimated . CONCLUSIONS The technical and personnel re sources required to achieve adequate st and ardization of procedures at multiple sites may make a placebo-controlled trial unfeasible , given our current lack of knowledge about the active agent in manual chiropractic procedures Summary BACKGROUND : The aim of this study was to compare the efficacy and side effects of gabapentin , amitriptyline , and their combination in women with chronic pelvic pain . METHODS : In this open-label , prospect i ve , r and omized trial , 56 women with chronic pelvic pain were investigated with a two-year follow-up at the Vienna Medical University Hospital . If pain intensity assessed by a visual analog scale ( VAS ) was 5 or more ( 0 , no pain ; 10 , maximal pain ) , despite analgesic therapy using the nonopioid drug metamizol together with weak opioids , patients were r and omized to receive gabapentin ( n = 20 ) , amitriptyline ( n = 20 ) , or a combination of both drugs ( n = 16 ) . Doses of gabapentin and amitriptyline were increased to maximum daily doses of 3600 mg and 150 mg , respectively , until sufficient pain relief or the occurrence of side effects . VAS and side effects were evaluated before treatment and at 1 , 3 , 6 , 12 and 24 months afterwards . RESULTS : All patients experienced significant pain relief during the observation period . However , after 6 , 12 and 24 months , pain relief was significantly better in patients receiving gabapentin either alone or in combination with amitriptyline than in patients receiving monotherapy with amitriptyline ( gabapentin : 0 months , 7.7 ± 1.5 ; 6 months , 1.6 ± 0.9 ; 12 months , 1.5 ± 0.9 ; 24 months , 1.9 ± 0.9 ; amitriptyline : 0 months , 7.3 ± 1.5 ; 6 months , 2.2 ± 1.6 ; 12 months , 2.2 ± 1.6 ; 24 months ; 3.4 ± 0.9 ; amitriptyline-gabapentin : 0 months , 7.6 ± 0.8 ; 6 months , 1.3 ± 0.9 ; 12 months , 1.7 ± 1.0 ; 24 months , 2.3 ± 0.9 ) . Side effects were lower in the gabapentin group than in the two other groups , the difference reaching statistical significance after three months ( P < 0.05 ) . CONCLUSION : Gabapentin alone or in combination with amitriptyline is better than amitriptyline alone in the treatment of female chronic pelvic pain . ZusammenfassungEINLEITUNG : Gegenst and der Studie war der Vergleich der Wirksamkeit und Verträglichkeit von Gabapentin bzw . Amitriptylin allein mit der Kombination der beiden Medikamente bei chronischen Unterbauchschmerzen ( chronic pelvic pain , CPP ) . METHOD EN : 56 weibliche Patientinnen mit chronischen Unterbauschmerzen wurden bei der prospektiven , r and omisierten Open-label-Studie mit einem 2-jährigem Follow-up an der Schmerzambulanz der Universitätsklinik Wien , Österreich , eingeschlossen . Wenn die Schmerzintensität trotz analgetischer Therapie mit dem Nichtopioid Metamizol und einem schwachen Opioid gemessen auf der visuellen Analogskala ( VAS ) bei 5 oder darüber lag ( 0 , kein Schmerz ; 10 , schlimmster vorstellbarer Schmerz ) , wurden die Patientinnen r and omisiert einem der drei Beh and lungsarme zugeteilt ( Gabapentin , n = 20 ; Amitriptylin , n = 20 , oder beides , n = 16 ) . Die Medikamentengaben von Gabapentin bzw . Amitriptylin wurden auf eine tägliche Dosis von 3600 mg bzw . 150 mg gesteigert , bis eine suffiziente Schmerzerleichterung erreicht war oder unerwünschte Nebenwirkungen auftraten . VAS-Werte wurde vor Beginn der Beh and lung und 1 , 3 , 6 , 12 und 24 Monate danach erhoben . ERGEBNISSE : Alle Patientinnen erfuhren während des Beobachtungszeitraumes eine signifikante Schmerzreduktion . Dennoch war die Schmerzreduktion bei Patientinnen , die Gabapentin allein oder in Kombination mit Amitriptylin erhalten hatten , signifikant höher als unter Monotherapie mit Amitriptylin ( Gabapentin : 0 , 7,7 ± 1,5 ; 6 , 1,6 ± 0,9 ; 12 , 1,5 ± 0,9 ; 24 , 1,9 ± 0,9 ; Amitriptylin : 0 , 7,3 ± 1,5 ; 6 , 2,2 ± 1,6 ; 12 , 2,2 ± 1,6 ; 24 , 3,4 ± 0,9 ; Amitriptylin-Gabapentin : 0 , 7,6 ± 0,8 ; 6 , 1,3 ± 0,9 ; 12 , 1,7 ± 1,0 ; 24 , 2,3 ± 0,9 ) . Unerwünschte Nebenwirkungen traten signifikant seltener in der Gabapentin-Gruppe auf als in den beiden and eren Gruppen ( P < 0,05 ) . KONKLUSION : Diese Ergebnisse legen nahe , dass die Pharmakotherapie mit dem Antikonvulsivum Gabapentin die Beh and lung von chronischen Unterbauchschmerzen bei ambulanten Patientinnen verbessert Following identification of the proportion of pelvic congestion among symptomatic patients complaining of chronic pelvic pain , and in a totally asymptomatic group of patients requesting tubal ligation , the efficiency of goserelin acetate versus medroxyprogesterone acetate was compared objective ly using pelvic venogram scores , and subjectively by symptom resolution , improvement of psychological status and sexual functioning in a prospect i ve r and omized trial in 47 patients with pure pelvic congestion syndrome . Patients received either goserelin acetate ( 3.6 mg/month for 6 months ) or medroxyprogesterone acetate ( MPA ; 30 mg/day for 6 months ) . Among patients with chronic pelvic pain , those with pure pelvic congestion were mostly parous , had the most severe pelvic signs and symptom scores , lowest rates of sexual functioning , and higher states of anxiety and depression as compared with others . At 1 year after treatment , goserelin remained superior to MPA in terms of pelvic venographic improvement as an objective measure . In alleviation of signs and symptomatology , improvement of sexual functioning and reduction of anxiety and depressive states as subjective measures , goserelin acetate achieved a statistically significant advantage ( P = 0.0001 ) compared with MPA OBJECTIVE To examine the effect on pain and quality of life for women with all stages of endometriosis undergoing laparoscopic surgery  compared with placebo surgery . DESIGN A r and omized , blinded , crossover study . SETTING A tertiary referral unit in a district general hospital . PATIENT(S ) Thirty-nine women with histologically proven endometriosis completed the 12-month study . INTERVENTION(S ) Women were r and omized to receive initially either a diagnostic procedure ( the delayed surgical group ) or full excisional surgery ( the immediate surgery group ) . After 6 months , repeat laparoscopy was performed , with removal of any pathology present . MAIN OUTCOME MEASURE(S ) The end points were changes from baseline values of visual analogue pain scores , vali date d quality -of-life instruments ( EQ-5D and SF-12 ) , and sexual activity question naire scores . Patients and assessors of outcomes were blinded to the treatment-group assignment . RESULT ( S ) Significantly more of the 39 women operated on according to protocol reported symptomatic improvement after excisional surgery than after placebo : 16 of 20 ( 80 % ) vs. 6 of 19 ( 32 % ) ; chi(2)(1 ) = 9.3 . Other aspects of quality of life were also significantly improved 6 months after excisional surgery but not after placebo .  Progression of disease at second surgery was demonstrated for women having only an initial diagnostic procedure in 45 % of cases , with disease remaining static in 33 % and improving in 22 % of cases . Nonresponsiveness to surgery was reported in 20 % of cases . CONCLUSION ( S ) Laparoscopic excision of endometriosis is more effective than placebo at reducing pain and improving quality of life . Surgery is associated with a 30 % placebo response rate that is not dependent on severity of disease . Approximately 20 % of women do not report an improvement after surgery for endometriosis Objectives : To determine if low-dose estrogen replacement can be added to GnRH agonist therapy after three months to reduce hypoestrogenic symptoms while allowing continued relief of pain in patients with endometriosis . Material s and Methods : Thirteen women with endometriosis and pain were treated with six months of leuprolide acetate in a prospect i ve , r and omized double-blind placebo controlled study . After three months of therapy , six subjects initiated oral estradiol 1 mg daily , and seven received an identical placebo . Results : Dysmenorrhea improved in both groups , and dyspareunia significantly improved in the GnRH agonist plus placebo group . The mean pain scores of the oral estrogen group tended to be higher than the placebo group , and hot flushes tended to be less severe with estrogen treatment . However , differences observed between the study and placebo groups did not reach statistical significance . Conclusion : In a prospect i ve , r and omized study , low-dose estrogen replacement increases endometriosis-related pain during GnRH agonist therapy . The study was terminated after the first 13 subjects due to the concerning trend toward recurrent symptoms in women who received oral estradiol during GnRH agonist therapy for endometriosis-related pain . With the trend toward increasing pain with estrogen add-back therapy , a larger study would not seem to be justifiable OBJECTIVE To evaluate the efficacy and tolerability of a contraceptive vaginal ring and transdermal patch in the treatment of  endometriosis-associated pain .  DESIGN Patient preference cohort study . SETTING Academic center . PATIENT(S ) Two-hundred and seven women with recurrent moderate or severe pelvic pain after conservative surgery for symptomatic endometriosis . INTERVENTION(S ) Continuous , 12-month treatment with a vaginal ring supplying 15 mcg of ethinyl E and 120 mcg of etonogestrel per day or a transdermal system delivering 20 mcg of ethinyl E and 150 mcg norelgestromin per day . MAIN OUTCOME MEASURE(S ) Satisfaction with treatment . RESULT ( S ) One-hundred and twenty-three women preferred the ring , and 84 preferred the patch . Forty-four ring users ( 36 % ) and 51 patch users ( 61 % ) withdrew . Thirty-six of 79 subjects ( 46 % ) in the ring group and 14 of 33 ( 42 % ) in the patch group shifted from continuous to cyclic use because of irregular bleeding . Pain symptoms were reduced by both treatments , with the ring being more effective than the patch in patients with rectovaginal lesions . According to an intention-to-treat analysis , 88 of 123 ring users ( 72 % ) and 40 of 84 patch users ( 48 % ) were satisfied with the treatment received . CONCLUSION ( S ) Patients who preferred the ring were significantly more likely to be satisfied and to comply with treatment than those who chose the patch . Both systems were associated with poor bleeding control when used continuously BACKGROUND Endometriosis is associated with an inflammatory response . Hence infliximab , an anti-TNF-α monoclonal antibody , might relieve pain . METHODS A r and omized placebo-controlled trial was design ed with 21 women with severe pain and a rectovaginal nodule of at least 1 cm . After 1 month of observation , three infusions of infliximab ( 5 mg/kg ) or placebo were given . Surgery was performed 3 months later and follow-up continued for 6 months . The primary end-point was pain ( dysmenorrhea , deep dyspareunia and non-menstrual pain ) rated at each visit by the clinician and on a daily basis by the patient who in addition scored pain by visual analog pain scale and analgesia intake . Secondary end-points included the volume of the endometriotic nodule , pelvic tenderness and the visual appearance of endometriotic lesions at laparoscopy . RESULTS Pain severity decreased during the treatment by 30 % in both the placebo ( P < 0.001 ) and infliximab groups ( P < 0.001 ) . However , no effect of infliximab was observed for any of the outcome measures . After surgery , pain scores decreased in both groups to less than 20 % of the initial value . CONCLUSIONS Infliximab appears not to affect pain associated with deep endometriosis . Treatment is associated with an important placebo effect . After surgery , pain decreases to less than 20 % . Trials registration number Clinical Trials.gov : NCT00604864 OBJECTIVE To evaluate postoperative long-term cyclic and continuous administration of combined oral contraceptive ( OC ) pills in preventing endometriosis-related pain recurrence . DESIGN Prospect i ve , r and omized , controlled trial . SETTING Tertiary care university hospital . PATIENT(S ) Three hundred eleven women who underwent laparoscopic excision for symptomatic ovarian endometrioma . INTERVENTION(S ) Patients were r and omly divided into three groups : nonuser group receiving no therapy , and cyclic user group and continuous user group receiving low-dose , monophasic OC pills for 24 months in either cyclic or continuous administration . MAIN OUTCOME MEASURE(S ) Presence and intensity of dysmenorrhea , dyspareunia , and chronic pelvic pain were assessed by a 10-point visual analogue scale ( VAS ) at 6 , 12 , 18 , and 24 months postoperatively . RESULT ( S ) A significant reduction in recurrence rate and VAS scores for dysmenorrhea was evident in the continuous users versus the other groups at 6 months , and in cyclic users versus nonusers at 18 months postoperatively . No significant differences in recurrence rate and VAS scores for dyspareunia and chronic pelvic pain were demonstrated among the groups . The increase of VAS scores from 6 - 24 months during the study period for dysmenorrhea , dyspareunia , and chronic pelvic pain was significantly higher in nonusers than in the other groups . CONCLUSION ( S ) Long-term postoperative use of OC pills can reduce the frequency and the severity of recurrent endometriosis-related dysmenorrhea OBJECTIVE To assess the effect of a new progestin progestogen only pill ( desogestrel ) versus an oral contraceptive in the treatment of recurrent endometriosis . STUDY DESIGN A r and omized prospect i ve clinical study . A group of women with endometriosis ( n=40 ) who showed recurrent dysmenorrhea and /or pelvic pain after conservative surgery , and did not desire a pregnancy . Continuous treatment for 6 months with desogestrel ( 75 microg/d ) ( n=20 ) versus a combined oral contraceptive ( ethinyl estradiol 20 microg plus desogestrel 150 microg ) ( n=20 ) was performed . RESULTS A significant improvement of both pelvic pain and dysmenorrhea was observed following each type of treatment ( P<0.001 ) . The use of desogestrel progestogen only pill was associated with a breakthrough bleeding in 20 % patients , while a significant body weight increase was observed in 15 % after oral contraceptive . CONCLUSIONS Both desogestrel and an oral estro-progestinic were effective , safe and low cost therapy of pain symptoms after endoscopic surgery for endometriosis , the former showing an impact on breakthrough bleeding , the later an incidence on body weight increase OBJECTIVE To investigate the role of adjuvant treatment with gonadotropin-releasing-hormone agonist ( GnRHa ) following conservative surgical treatment of endometriosis . STUDY DESIGN Sixty patients in the reproductive age ( mean age 28.6 years ) , with symptomatic stages III and IV endometriosis following laparoscopic surgery and without previous hormonal treatment were enrolled in a prospect i ve , r and omized , controlled trial to compare the effects of 3-month treatment with triptorelin depot-3.75 i.m . ( 30 patients ) versus expectant management using placebo injection ( 30 patients ) . RESULTS Six patients ( one in triptorelin group and five in placebo group ) were lost at follow-up , the remaining 54 were suitable for analysis . Pelvic pain persistence or recurrence , endometrioma relapses and pregnancy rate were evaluated during a 5-year follow-up . The results of 29 cases treated with triptorelin and 25 that received placebo did not show significant differences in pain recurrence ( P=1 , RR=0.94 , 95 % CI=0.57 - 1.55 ) , endometrioma relapse ( P=0.67 , RR=1.29 , 95 % CI=0.66 - 2.50 ) , and pregnancy rate in  infertile women  ( P=0.80 , RR=0.81 , 95 % CI=0.37 - 1.80 ) . Curves of time of pain recurrence and pregnancy during 5-year follow-up did not show significant differences between the two groups ( P=0.79 and P=0.51 , respectively , using Mantel-Haenzsel logrank test ) . CONCLUSION Triptorelin treatment after operative laparoscopy for stage III/IV endometriosis does not appear to be superior to expectant management in terms of prevention of symptoms recurrence and endometrioma relapse , and has no influence on pregnancy rate in endometriosis-associated infertility BACKGROUND Dienogest is a selective progestin that has been investigated in a clinical trial programme for the treatment of endometriosis . The current non-inferiority trial compared the efficacy and safety of dienogest against leuprolide acetate ( LA ) for treating the pain associated with endometriosis . METHODS Patients with confirmed endometriosis were r and omized to treatment with dienogest ( 2 mg/day , orally ) or LA ( 3.75 mg , depot i.m . injection , every 4 weeks ) for 24 weeks . The primary efficacy variable was absolute change in pelvic pain from baseline to end of treatment , assessed by visual analogue scale ( VAS ) . Safety variables included adverse event profile , laboratory parameters , bone mineral density ( BMD ) , bone markers and bleeding patterns . RESULTS A total of 252 women were r and omized to treatment with dienogest ( n = 124 ) or LA ( n = 128 ) ; 87.9 and 93.8 % of the respective groups completed the trial . Absolute reductions in VAS score from baseline to Week 24 were 47.5 mm with dienogest and 46.0 mm with LA , demonstrating the equivalence of dienogest relative to LA .  Hypoestrogenic effects ( e.g. hot flushes ) were reported less frequently in the dienogest group . As expected , bleeding episodes were suppressed less with dienogest than with LA . Changes in mean lumbar BMD between screening and final visit were + 0.25 % with dienogest and -4.04 % with LA subgroups ( P = 0.0003 ) . Markers of bone resorption increased with LA but not dienogest . CONCLUSIONS Dienogest 2 mg/day orally demonstrated equivalent efficacy to depot LA at st and ard dose in relieving the pain associated with endometriosis , although offering advantages in safety and tolerability OBJECTIVE To evaluate the effectiveness of a levonorgestrel-releasing IUD as therapy for endometriosis of the rectovaginal septum . DESIGN Prospect i ve therapeutic non-r and omized , self-controlled clinical trial analyzing changes in pain symptoms and size of lesions induced by the levonorgestrel-releasing IUD over 12 months . SETTING Tertiary referral center for treatment of deep endometriosis . PATIENT(S ) Eleven symptomatic patients with rectovaginal endometriosis . INTERVENTION(S ) A levonorgestrel-releasing IUD was inserted and maintained for 12 months . MAIN OUTCOME MEASURE(S ) Severity of dysmenorrhea , pelvic pain , and deep dyspareunia were assessed before insertion of the IUD and throughout treatment . The size of rectovaginal endometriotic lesions were evaluated by using transrectal and transvaginal ultrasonography . RESULT ( S ) Dysmenorrhea , pelvic pain , and deep dyspareunia greatly improved and the size of the endometriotic lesions was significantly reduced by treatment . CONCLUSION ( S ) Insertion of a levonorgestrel-releasing IUD alleviates pain and reduces the size of lesions in patients with endometriosis of the rectovaginal septum OBJECTIVE To compare the effect of a GnRH-agonist , triptorelin , versus placebo on the symptoms of endometriosis .  DESIGN A prospect i ve , r and omized , double-blind study of 6 months of treatment followed by 12 months of follow-up . SETTING Departments of Obstetrics and Gynecology at two universities and one general hospital . PATIENT(S ) Forty-nine women with symptoms of laparoscopically verified endometriosis . INTERVENTION(S ) Triptorelin depot or placebo was given every 4 weeks . Clinical evaluation , including the Duration Intensity Behavior Scale and Visual Analogue Scale for pain , was performed before the injections and up to 12 months after treatment . A control laparoscopy was performed 4 - 6 weeks after the last injection . MAIN OUTCOME MEASURE(S ) Quantitation of pain . RESULT ( S ) Twenty-four patients had active treatment and 25 received placebo .  Pain symptoms according to both scales were significantly more reduced after 2 months of triptorelin treatment compared to placebo . The extent of endometriotic lesions was reduced 50 % during triptorelin treatment and increased 17 % during placebo . The average area of endometriotic lesions was reduced 45 % during triptorelin treatment but was unchanged during placebo . Side effects , mainly hot flushes , were experienced by 80 % of the actively treated group but also by 33 % of patients in the placebo group . Because of recurrent symptoms , only five patients could be observed for 12 months after completion of treatment . CONCLUSION ( S ) Triptorelin reduces endometriotic lesions and pain to a significantly higher degree than placebo Background When aromatase inhibitors are used to treat premenopausal women with endometriosis , additional drugs should be used to effectively down-regulate gonadal estrogen bio synthesis . This r and omized prospect i ve open-label study compared the efficacy in treating pain symptoms and the tolerability of letrozole combined with either norethisterone acetate or triptorelin . Methods Women with pain symptoms caused by rectovaginal endometriosis were treated with letrozole  ( 2.5 mg/day ) and were r and omized to also receive either oral norethisterone acetate ( 2.5 mg/day ; group N ) or intramuscular injection of triptorelin ( 11.25 mg every 3 months ; group T ) . The scheduled length of treatment was 6 months . A visual analogue scale and a multidimensional categorical rating scale were used to assess the severity of pain symptoms . The volume of the endometriotic nodules was estimated by ultrasonography using virtual organ computer-aided analysis . Adverse effects of treatment were recorded . Results A total of 35 women were r and omized between the two treatment protocol s. Significantly more patients in group N rated their treatment as satisfactory or very satisfactory ( 64.7 % ) as compared to group T ( 22.2 % ; p = 0.028 ) . The intensity of both non-menstrual pelvic pain and deep dyspareunia significantly decreased during treatment in both study groups , though no statistically meaningful difference between the two groups was apparent . Reduction in the volume of endometriotic nodules was significantly greater in group T than in group N. Interruption of treatment due to adverse effects significantly differed between the groups , with 8 women in group T ( 44.4 % ) and 1 woman in group N ( 5.9 % ) interrupting treatment ( p = 0.018 ) . Similarly , 14 women included in group T ( 77.8 % ) and 6 women included in group N ( 35.3 % ) experienced adverse effects of treatment ( p = 0.018 ) . During treatment , mineral bone density significantly decreased in group T but not in group N. Conclusions Aromatase inhibitors reduce the intensity of endometriosis-related pain symptoms . Combining letrozole with oral norethisterone acetate was associated with a lower incidence of adverse effects and a lower discontinuation rate than combining letrozole with triptorelin PURPOSE In this r and omized , double-blind , placebo controlled phase 2 study we investigated tanezumab , a humanized monoclonal antibody that specifically inhibits nerve growth factor as a treatment for interstitial cystitis pain . MATERIAL S AND METHODS Patients with interstitial cystitis received a single intravenous dose of 200 μg/kg tanezumab or placebo . Patients recorded daily pain scores ( on an 11-point numerical rating scale ) 7 days before attending study visits and completed a urinary symptom diary for 3 of those days . Patients also completed the Interstitial Cystitis Symptom Index question naire and a global response assessment . The primary end point was change in average daily numerical rating scale pain score from baseline to week 6 . Secondary end points included global response assessment , Interstitial Cystitis Symptom Index score , micturition and urgency episode frequency per 24 hours , and mean voided volume per micturition . The incidence of adverse events was also assessed . RESULTS A total of 34 patients received tanezumab and 30 received placebo . At week 6 tanezumab produced a significant reduction from baseline in average daily pain score  vs placebo ( treatment difference [ LS mean , 90 % CI ] was -1.4 [ -2.2 , -0.5 ] ) . A significantly higher proportion of patients on tanezumab responded as improved in the global response assessment and tanezumab also significantly reduced urgency episode frequency  vs placebo . Tanezumab had no significant effect on Interstitial Cystitis Symptom Index score , micturition frequency or mean voided volume per micturition . The most common adverse events were headache  ( tanezumab 20.6 % , placebo 16.7 % ) and paresthesia  ( tanezumab 17.6 % , placebo 3.3 % ) . CONCLUSIONS Tanezumab has shown preliminary efficacy in the treatment of pain associated with interstitial cystitis OBJECTIVE To evaluate the effectiveness for the outcomes of endometriosis-related pain and quality of life of conservative surgery plus placebo compared with conservative surgery plus hormonal suppression treatment or dietary therapy . DESIGN R and omized comparative trial . SETTING University hospital . PATIENT(S ) Two hundred twenty-two consecutive women who underwent conservative pelvic surgery for symptomatic endometriosis stage III-IV ( r-AFS ) . INTERVENTION(S ) Six months of placebo ( n = 110 ) versus GnRH-a ( tryptorelin or leuprorelin , 3.75 mg every 28 days ) ( n = 39 ) or continuous estroprogestin ( ethynilestradiol , 0.03 mg plus gestoden , 0.75 mg ) ( n = 38 ) versus dietary therapy ( vitamins , minerals salts , lactic ferments , fish oil ) ( n = 35 ) . MAIN OUTCOME MEASURE(S ) Painful symptoms ( visual analogue scale score ) and quality -of-life endometriosis-related symptoms ( SF-36 score ) at 12 months ' follow-up . RESULT ( S ) Patients treated with postoperative hormonal suppression therapy showed less visual analogue scale scores for dysmenorrhoea than patients of the other groups . Hormonal suppression therapy and dietary supplementation were equally effective in reducing nonmenstrual pelvic pain . Surgery plus placebo showed significative decrease in dyspareunia scores . Postoperative medical and dietary therapy allowed a better quality of life than placebo . CONCLUSION ( S ) Postoperative hormonal suppression treatment or dietary therapy are more effective than surgery plus placebo to obtain relief of pain associated with endometriosis stage III-IV and improvement of quality of life PURPOSE Interstitial cystitis is a severe debilitating bladder disease characterized by unrelenting pelvic pain and urinary frequency . A prospect i ve , double-blind , placebo controlled study of the use of intravesical bacillus Calmette-Guerin ( BCG ) in the treatment of interstitial cystitis was recently completed with a mean followup of 8 months . Results demonstrated a 60 % BCG response rate , compared to a 27 % placebo response rate . We now report the long-term followup results of those patients who received intravesical BCG .  MATERIAL S AND METHODS Subjects r and omized to receive BCG  were followed at routine intervals with question naires and voiding diaries identical to those in the blinded study . Adverse events were closely monitored in the treatment and followup phases of the study . Subject baseline values were compared to followup data . RESULTS Of the BCG responders mean followup was 27 months ( range 24 to 33 ) , and 8 of 9 ( 89 % ) continue to have an excellent response in all parameters measured . The global interstitial cystitis survey improved 70 % , daily voids decreased 31 % , nocturia improved 54 % , mean voided volume increased 61 % , pelvic pain decreased 81 % , vaginal pain decreased 71 % , urgency decreased 71 % and dysuria decreased 82 % . Overall well-being improved 54 % and the R and -36 quality of life survey overall improved 64 % . In 86 % of the patients ( 6 of 7 ) dyspareunia resolved . Of the initial BCG nonresponders there was no significant difference in interstitial cystitis symptomatology from baseline to last followup , suggesting that BCG does not worsen interstitial cystitis symptoms . No long-term adverse events from BCG were noted . CONCLUSIONS Intravesical Tice BCG is safe , effective and durable in the treatment of interstitial cystitis . Of those patients who received only 6 weekly treatments and responded favorably 89 % continue to have an excellent response with followup ranging from 24 to 33 months BACKGROUND The objective of this multicentre r and omized , controlled clinical trial was to compare the efficacy of a levonorgestrel-releasing intrauterine system ( LNG-IUS ) and a depot-GnRH-analogue in the control of endometriosis-related pain over a period of six months . METHODS Eighty-two women , 18 to 40 years of age ( mean 30 years ) , with endometriosis , dysmenorrhoea and /or CPP , were r and omized using a computer-generated system of sealed envelopes into either LNG-IUS ( n = 39 ) or GnRH analogue ( n = 43 ) treatment groups at three university centres . Daily scores of endometriosis-associated CPP were evaluated using the Visual Analogue Scale ( VAS ) , daily bleeding score was calculated from bleeding calendars , and improvement in quality of life was evaluated using the Psychological General Well-Being Index Question naire ( PGWBI ) . The pain score diary was based on the VAS in which women recorded the occurrence and intensity of pain on a daily basis . A monthly score was calculated from the result of the sum of the daily scores divided by the number of days in each observation period . RESULTS CPP decreased significantly from the first month throughout the six months of therapy with both forms of treatment and there was no difference between the groups ( P > 0.999 ) . In both treatment groups , women with stage III and IV endometriosis showed a more rapid improvement in the VAS pain score than women with stage I and II of the disease ( P < 0.002 ) . LNG-IUS users had a higher bleeding score than GnRH-analogue users at all time points of observation with 34 % and 71 % of patients in the LNG-IUS and GnRH-analogue groups , respectively , reporting no bleeding during the first treatment month , and 70 % and 98 % reporting no bleeding during the sixth month . No difference was observed between groups with reference to improvement in quality of life . CONCLUSIONS Both , the LNG-IUS and the GnRH-analogue were effective in the treatment of CPP-associated endometriosis , although no differences were observed between the two treatments . Among the additional advantages of the LNG-IUS is the fact that it does not provoke hypoestrogenism and that it requires only one medical intervention for its introduction every 5 years . This device could therefore become the treatment of choice for CPP-associated endometriosis in women who do not wish to conceive PURPOSE We examined the safety and the efficacy of a combination of intravesical and oral pentosan polysulfate sodium in comparison to only oral pentosan polysulfate sodium in treating interstitial cystitis . MATERIAL S AND METHODS A total of 41 females diagnosed with interstitial cystitis were r and omized to receive a combination of intravesical pentosan polysulfate sodium plus oral pentosan polysulfate sodium ( 21 in treatment group ) or intravesical placebo plus oral pentosan polysulfate sodium ( 20 in placebo group ) for 6 weeks . All subjects continued to receive oral pentosan polysulfate sodium for another 12 weeks . The primary outcome was the change in the O'Leary-Sant Interstitial Cystitis Symptoms/Problem Index from baseline to week 6 , 12 , and 18 . Other outcomes included : the changes in Pelvic Pain and Urgency Frequency question naire , Health Related Quality of Life index : SF-36 , pain scale , urgency scale , voiding log , patient global assessment , and sexual function scales . RESULTS The change in the total score of O'Leary-Sant Interstitial Cystitis Symptoms/Problems Index from baseline to week 12 among the treatment group ( median -12 or approximately a 46 % reduction ) was significantly greater compared to the placebo group ( median -5.5 or approximately a 24 % reduction , p = 0.04 ) . At week 18 the treatment group showed statistically significant improvement in all Health Related Quality of Life domains compared to the baseline ( p < or = 0.01 ) , while the placebo group showed significant improvement in only 3 Health Related Quality of Life domains , ( p < or = 0.05 ) compared to the baseline . There were no significant differences within major categories of adverse events between treated and placebo groups . CONCLUSIONS The use of intravesical pentosan polysulfate sodium simultaneously with oral pentosan polysulfate sodium is a safe and effective therapeutic option . These findings will open a new option for patients with interstitial cystitis to reduce their severely devastating symptoms and to improve their quality of life and well-being OBJECTIVE To compare efficacy of the levonorgestrel-releasing intrauterine system ( LNG-IUS ; Mirena ) with depot GnRH analogue ( GnRH-a ; gosareline acetate ; Zoladex ) on endometriosis-related chronic pelvic pain ( CPP ) in patients with severe endometriosis during 12 months . DESIGN Prospect i ve , r and omized , controlled study . SETTING The reproductive endocrinology unit of a tertiary , research and education hospital . PATIENT(S ) Forty women with severe endometriosis ( revised The American Fertility Society [ AFS ] classification > 40 ) and endometriosis-related CPP and control groups were enrolled in the study . INTERVENTION(S ) The patients were treated with either LNG-IUS ( n = 20 ) or GnRH-a ( n = 20 ) . The GnRH-a dose was repeated every 4 weeks for 24 weeks . MAIN OUTCOME MEASURE(S ) Scores of CPP were evaluated using a visual analogue scale ( VAS ) and total endometriosis severity profile ( TESP ) . RESULT ( S ) The TESP score decreased in the LNG-IUS group at first , third , and sixth month follow-up visits , whereas at the 12th month follow-up visit , the TESP scores were increased to values similar to pretreatment values . Although the VAS score had no significant alteration during the follow-up period in the LNG-IUS group , the GnRH-a group showed a significant decrease in the VAS score and TESP score at the end of 1 year . The LNG-IUS treatment showed a lower patient satisfaction . CONCLUSION ( S ) Both treatment modalities showed comparable effectiveness in the treatment of CPP-related endometriosis OBJECTIVE : To evaluate whether 6 months of raloxifene was effective in treatment of  chronic pelvic pain in women with endometriosis . METHODS : Women with chronic pelvic pain and no endometriosis treatment for 6 months underwent laparoscopy for excision of all lesions . Those with biopsy-proven endometriosis were r and omly allocated to raloxifene ( 180 mg ) or placebo daily . A second laparoscopy was performed at 2 years , or earlier , if pain returned . Return of pain was defined as 2 months of pain equal to or more severe than that at study entry . Menstrual cycles and adverse events were recorded . The log rank test was used to compare the time to return of pain by drug group . Analyses were done as intent-to-treat . RESULTS : A total of 127 of 158 women underwent surgery . Of these , 93 had biopsy-confirmed endometriosis and were r and omly assigned to study treatment . Menstrual cycle length , pelvic pain severity , quality of life , bone mineral density , and adverse events did not differ between treatment groups . The Data Safety Monitoring Committee terminated the study early when the raloxifene group experienced pain ( P=.03 ) and had second surgery ( P=.016 ) significantly sooner than the placebo group . Interestingly , biopsy-proven endometriosis was not associated with return of pain ( P=.6 ) . CONCLUSION : Raloxifene significantly shortened the time to return of chronic pelvic pain . Because recurrence of endometriosis lesions did not correlate with return of pain , other factors are implicated in pelvic pain . CLINICAL TRIAL REGISTRATION : Clinical Trials.gov , www.cliicaltrials.gov , NCT00001848 LEVEL OF EVIDENCE : OBJECTIVE The aim of the study was to determine the efficacy of static magnetic field therapy for the treatment of  chronic pelvic pain ( CPP ) by measuring changes in pain relief and disability . STUDY DESIGN Thirty-two patients with CPP completed 2 weeks and 19 patients completed 4 weeks of r and omized double-blind placebo-controlled treatment at a gynecology clinic .  Active ( 500 G ) or placebo magnets were applied to abdominal trigger points for 24 hour per day . The McGill Pain Question naire , Pain Disability Index , and Clinical Global Impressions Scale were outcome measures . RESULTS Patients receiving active magnets who completed 4 weeks of double-blind treatment had significantly lower Pain Disability Index ( P < .05 ) , Clinical Global Impressions-Severity ( P < .05 ) , and Clinical Global Impressions-Improvement ( P < .01 ) scores than those receiving placebo magnets , but were more likely to correctly identify their treatment ( P < .05 ) . CONCLUSION SMF therapy significantly improves disability and may reduce pain when active magnets are worn continuously for 4 weeks in patients with CPP , but blinding efficacy is compromised OBJECTIVE To compare reduction of pain following laparoscopy after ablation or excision of endometriosis . DESIGN A prospect i ve , r and omized , double-blind study . SETTING Endometriosis and pelvic pain clinic at a university teaching hospital . PATIENT(S ) Women of reproductive age presenting with pelvic pain and visually proved endometriosis . INTERVENTION(S ) Subjects completed a question naire rating their various pains using visual analogue scales ( VASs ) . After visual identification subjects were assigned r and omly to treatment with ablation or excision by supervised training gynecologists as primary surgeon . Follow-up question naires at 3 , 6 , 9 , and 12 months documented pain levels . MAIN OUTCOME MEASURE(S ) Change in overall pain VAS score at 12 months after operation . RESULT ( S ) There was no significant difference in reduction in overall pain VAS scores at 12 months when comparing ablation and excision . CONCLUSION ( S ) This study has not been able to demonstrate a significant difference in pain reduction between ablation and excisional treatments . Nonsignificant trends suggest that a larger study may find a difference in outcomes looking at dyspareunia or dyschezia OBJECTIVE To evaluate the efficacy and safety of a cyclooxygenase (COX)-2 specific inhibitors versus placebo in the treatment of endometriosis-associated pelvic pain . STUDY DESIGN A group of women ( n = 28 ) with pelvic pain after conservative surgery for symptomatic endometriosis ( Stage I and II ) were enrolled at the Department of Pediatric , Obstetrics and Reproductive Medicine of University of Siena . A treatment with a COX-2 specific inhibitors ( rofecoxib , 25 mg per day ) ( n = 16 ) or placebo ( n = 12 ) was given for 6 months . Pelvic pain quantification with a clinical evaluation , including Visual Analogue Scale ( VAS ) for pain , was performed before and up to 6 months after treatment . RESULTS A significant improvement of both pelvic pain and dyspareunia was observed after a 6 months persisting since the end of the treatment ( P < 0.0001 ) . The efficacy of rofecoxib was higher than placebo and no recurrence occurred , while in the placebo-treatment a 16 % ( 2/12 ) occurred . No significant side effects have been found with the use of rofecoxib . CONCLUSIONS The use of COX-2 specific inhibitors was effective , safe and low cost therapy in the management of pelvic pain associated to endometriosis and might be also proposed in early stage of endometriosis OBJECTIVE To determine the difference between two laparoscopic methods for the management of endometriomas with regard to recurrence of signs and symptoms and pregnancy rate . DESIGN Prospect i ve , r and omized clinical trial . SETTING Infertility and gynecologic endoscopy units of two medical university hospitals . PATIENT(S ) One hundred patients with endometriomas who had either infertility or pelvic pain . INTERVENTION(S ) Patients were r and omly divided into two groups ; one group underwent cystectomy ( group 1 ) , and fenestration and coagulation were performed for the other ( group 2 ) . MAIN OUTCOME MEASURE(S ) A comparison of recurrence of signs and symptoms of endometriomas and pregnancy rates in two groups . RESULT ( S ) Fifty-two patients were studied in group 1 and 48 in group 2 . The recurrence of symptoms , such as pelvic pain and dysmenorrhea , was 15.8 % in group 1 and 56.7 % in group 2 after 2 years . The rate of reoperation was 5.8 % in group 1 and 22.9 % in group 2 and these differences were statistically significant . The cumulative pregnancy rate was significantly higher in group 1 ( 59.4 % ) than in group 2 ( 23.3 % ) at 1-year follow-up . CONCLUSION ( S ) Laparoscopic cystectomy of endometriomas is a better choice than fenestration and coagulation because the former technique leads to a lower recurrence of signs and symptoms and a lower rate of reoperation and a higher cumulative pregnancy rate than the latter OBJECTIVE The aim of the study was to examine whether acupuncture is an effective additional pain treatment for endometriosis . STUDY DESIGN One hundred and one women aged 20 - 40 years participated and were r and omised into two groups , each receiving two units of 10 acupuncture treatments , twice a week over a period of five weeks . Group 1 ( n = 47 ) received verum-acupuncture during the first series , and group 2 ( n = 54 ) received non-specific acupuncture . After the first unit of 10 treatments , an observation period of at least two menstruation cycles was set , followed by a second unit , according to a cross-over design . Prior to the study ( during a two-week run-in period ) the patients ' actual  pain intensity was surveyed . Throughout the study period , participants were asked to keep a ' pain protocol ' , in which they defined and recorded their pain according to the 10-point visual analogue scale ( VAS ) . RESULTS Eighty-three out of a total of 101 patients finished the study . Group 1 showed a significant reduction of pain intensity after the first 10 treatments . In comparison , group 2 showed significant pain relief only after the cross-over . CONCLUSION Acupuncture treatment on specific acupuncture points appears to be an effective pain treatment for endometriosis , but this has to be confirmed in further study One hundred six patients with chronic pelvic pain were r and omly allocated to one of two treatment groups . In the st and ard-approach group , organic causes of pelvic pain were excluded first and diagnostic laparoscopy was routinely performed . If no somatic cause could be found , attention was given to other causes such as psychological disturbances . In the second group an integrated approach was chosen . From the beginning equal attention was devoted to somatic , psychological , dietary , environmental , and physiotherapeutic factors . In this group , laparoscopy was not routinely performed . Both groups were similar with respect to clinical characteristics of the patients and the severity of their pain as assessed by various pain parameters . Postcoital pain was reported by 27 % of the patients . Twenty percent of the patients had had negative sexual experiences such as childhood sexual abuse or rape . Evaluation of the pain 1 year after the institution of treatment revealed that the integrated approach improved pelvic pain significantly more often than the st and ard approach for three out of four pain parameters ( P<.01 ) . Laparoscopy played no important role in the treatment of pelvic pain . It is concluded that equal attention to both organic and other causative factors from the beginning of therapy is more likely to result in a reduction of pelvic pain than is a st and ard approach OBJECTIVE To assess the efficacy of two laparoscopic methods for the management of endometriomas with regard to pain relief , pregnancy rate , and disease recurrence . DESIGN Prospect i ve , r and omized clinical trial . SETTING Tertiary care hospital . PATIENT(S ) Sixty-four patients with advanced stages of endometriosis . INTERVENTION(S ) Patients were r and omly allocated at the time of laparoscopy to undergo either cystectomy of the endometrioma ( group 1 ) or drainage of the endometrioma and bipolar coagulation of the inner lining ( group 2 ) . MAIN OUTCOME MEASURE(S ) Pain relief and pregnancy rate . RESULT ( S ) Thirty-two patients were enrolled in each group . The 24-month cumulative recurrence rates of dysmenorrhea , deep dyspareunia , and nonmenstrual pelvic pain were lower in group 1 than in group 2 ( dysmenorrhea : 15.8 % versus 52.9 % ; deep dyspareunia : 20 % versus 75 % ; nonmenstrual pelvic pain : 10 % versus 52.9 % ) . The median interval between the operation and the recurrence of moderate to severe pelvic pain was longer in group 1 than in group 2 ( 19 months [ range , 13.5 - 24 months ] versus 9.5 months [ range , 3 - 20 months ] ) . The 24-month cumulative pregnancy rate was higher in group 1 than in group 2 ( 66.7 % versus 23.5 % ) . CONCLUSION ( S ) For the treatment of ovarian endometriomas , a better outcome with a similar rate of complications is achieved with laparoscopic cystectomy than with drainage and coagulation PURPOSE We compared intravesical bacillus Calmette-Guerin ( BCG ) to placebo instillations in patients with treatment refractory interstitial cystitis ( IC ) . MATERIAL S AND METHODS Subjects who met the National Institutes of Health-National Institute for Diabetes and Digestive and Kidney Diseases criteria for IC , and reported at least moderate pain and frequency for a minimum of 6 months before study entry , were r and omized to 6 weekly double-blinded intravesical instillations of either BCG or placebo , and then followed for a total of 34 weeks . The primary outcome was a patient reported global response assessment at week 34 , supplemented with medications for IC during weeks 31 to 34 . Secondary outcomes included a 24-hour voiding diary , pain , urgency , vali date d IC symptom indexes and adverse events . The target sample size was 260 participants , design ed to detect a difference in response rates between placebo and BCG of 30 % and 50 % , respectively . RESULTS A total of 265 participants were r and omized and 17 ( 6 % ) patients withdrew from study . The response rates for the primary outcome were 12 % for placebo and 21 % for BCG ( p = 0.062 ) . Small improvements were observed for all secondary outcomes , some more so with BCG , but these differences were of borderline statistical significance . Although a large number of adverse events were reported in the BCG arm , there was no statistically significant difference between the treatment arms in overall adverse event rates . CONCLUSIONS Although the BCG safety profile was acceptable , the response rate for the primary outcome was low . Effective medical treatment for patients with moderate to severe interstitial cystitis remains elusive OBJECTIVE To determine the efficacy of GnRH analogue plus add-back therapy compared with GnRH analogue alone and estroprogestin in patients with relapse of endometriosis-associated pain . DESIGN R and omized , controlled study . SETTING University hospital . PATIENT(S ) One hundred thirty-three women with relapse of endometriosis-related pain after previous endometriosis surgery . INTERVENTION(S ) Forty-six women were treated with GnRH analogue plus add-back therapy , 44 women were given GnRH analogue alone , and 43 women received estroprogestin , for 12 months . MAIN OUTCOME MEASURE(S ) Pain evaluation by a visual analogue scale , quality of life in treated patients according to the SF-36 question naire , and occurrence of adverse effects , including bone mass density loss , at pretreatment , after 6 months of treatment , at the end of treatment ( 12 months ) , and 6 months after discontinuation of treatment . RESULT ( S ) Patients treated either with GnRH analogue alone or GnRH analogue plus add-back therapy showed a higher reduction of pelvic pain , dysmenorrhea , and dyspareunia than patients treated with oral contraceptive , whereas patients treated with add-back therapy showed a better quality of life , as assessed with the SF-36 question naire , and adverse effects rate than the other two groups . CONCLUSION ( S ) Add-back therapy allows the treatment of women with relapse of endometriosis-associated pain for a longer period , with reduced bone mineral density loss , good control of pain symptoms , and better patient quality of life compared with GnRH analogue alone or oral contraceptive OBJECTIVE To evaluate the efficacy of laparoscopic resection of the uterosacral ligaments in women with endometriosis and predominantly midline dysmenorrhea . DESIGN R and omized controlled trial . SETTING Two academic departments . One hundred eighty patients undergoing operative laparoscopy as first-line therapy for stage I to IV symptomatic endometriosis . INTERVENTION(S ) Operative laparoscopy including uterosacral ligament resection or conservative surgery alone . MAIN OUTCOME MEASURE(S ) Proportion of women with recurrence of moderate or severe dysmenorrhea 1 year after surgery . RESULT ( S ) No complications occurred . Among the patients who were evaluable 1 year after operative laparoscopy , 23 of 78 ( 29 % ) women who had uterosacral ligament resection and 21 of 78 ( 27 % ) women who had conservative surgery only reported recurrent dysmenorrhea . The corresponding numbers of patients at 3 years were 21 of 59 ( 36 % ) women and 18 of 57 ( 32 % ) women , respectively . Time to recurrence was similar in the two groups . Pain was substantially reduced , and patients in both groups experienced similar and significant improvements in health-related quality of life , psychiatric profile , and sexual satisfaction . Overall , 68 of 90 ( 75 % ) patients in the uterosacral ligament resection group and 67 of 90 ( 74 % ) patients in the conservative surgery group were satisfied at 1 year . CONCLUSION ( S ) Addition of uterosacral ligament resection to conservative laparoscopic surgery for endometriosis did not reduce the medium- or long-term frequency and severity of recurrence of dysmenorrhea OBJECTIVE To establish the use of aromatase inhibitors as a therapeutic option for endometriosis . DESIGN Prospect i ve open-label Food and Drug Administration phase 2 trial with Institutional Review Board approval . SETTING Outpatient tertiary care centers . PATIENT(S ) Fifteen premenopausal patients with documented refractory endometriosis and chronic pelvic pain . INTERVENTION(S ) After a 1-month washout of endometriosis hormone therapies , women took 1 mg anastrazole ( Arimidex ; AstraZeneca , Wilmington , DE ) and one tablet of 20 microg ethinyl estradiol/0.1 mg levonorgestrel ( Alesse ; Wyeth , Madison , NJ ) daily for 6 months . MAIN OUTCOME MEASURE(S ) An analog pain scale recorded pelvic pain in daily diaries and surveys at baseline and after each treatment month . Side effects , blood counts , liver and renal function tests , cholesterol levels , and bone density were monitored . RESULT ( S ) Fourteen of 15 patients achieved significant pain reduction . Median pain scores decreased 55 % after 6 months , while mean pain scores decreased 40 % . Pain reduction comparing each treatment month to baseline achieved statistical significance . Average pain scores began dropping after only 1 treatment month and continued decreasing each additional month . No organ system experienced adverse effects . Estradiol levels were suppressed during treatment . Side effects were mild and improved over time . CONCLUSION ( S ) Fourteen of 15 patients with refractory endometriosis achieved significant pain relief using anastrazole and 20 microg ethinyl estradiol/0.1 mg levonorgestrel with minimal side effects . This treatment for endometriosis is a promising new modality that warrants further investigation OBJECTIVE To assess and compare the laparoscopic uterine nerve ablation ( LUNA ) and the vaginal uterosacral ligament resection ( VUSR ) in postmenopausal women with chronic pelvic pain ( CPP ) . STUDY DESIGN Eighty postmenopausal women with intractable and severe midline CPP were r and omized to undergo LUNA or VUSR .  Costs of two surgical procedures were assesses . Cure rate , severity of CPP , and deep dyspareunia were also evaluated after 6 and 12 months from surgery . RESULTS The mean cost of LUNA  result ed significantly higher in comparison with VURS ( 2078+/-637 versus 1497+/-297 , P<0.001 ) . The cure rate was not significantly different between the two groups at 6 ( 33/40 , 82.5 % versus 35/40 , 87.5 % for groups A and B , respectively ; P=0.530 ; RR 0.94 , 95 % CI 0.78 - 1.13 ) , and 12 months ( 27/36 , 75.0 % versus 28/38 , 73.7 % , for groups A and B , respectively ; P=0.901 ; RR 0.90 , 95 % CI 0.78 - 1.33 ) of follow-up . At same times , a significant ( P<0.01 ) decrease in severity of CPP and deep dyspareunia was observed in both groups with no difference between them . CONCLUSIONS Both LUNA and VUSR are equally effective surgical treatments in postmenopausal women with central CPP but VUNR is significantly cheaper than LUNA Objective Although written emotional disclosure has potential as a stress management intervention for people with health problems , the main ( group ) effects of disclosure in medical population s are limited . This study sought to identify individual difference moderators of the effects of written disclosure among women with chronic pelvic pain . Methods In a prospect i ve , r and omized trial , 48 women with chronic pelvic pain completed 3 individual difference measures and then wrote for 3 days about stressful consequences of their pain ( disclosure ) or positive events ( control ) .  Health status was assessed at baseline and 2 months after writing . Results Main effect group comparisons indicated that disclosure writing result ed in significantly lower evaluative pain intensity ratings than control writing at follow-up , but there were no main effects on other outcome variables ( sensory or affective pain , disability , affect ) . Three baseline individual difference measures , however , significantly moderated group effects . Compared with control writing , disclosure led to less disability among women with higher baseline ambivalence over emotional expression or higher catastrophizing , and to increased positive affect among women with higher baseline negative affect . Ambivalence , but not catastrophizing , was independent of negative affect in its moderation effect . Conclusion Although the main effects of writing about the stress of pelvic pain are limited , women with higher baseline ambivalence about emotional expression or negative affect appear to respond more positively to this intervention STUDY OBJECTIVE To evaluate continuous ( CON ) compared with cyclic ( CYC ) administration of combined oral estroprogestins for 6 months after laparoscopic excision of ovarian endometriomas associated with pain .  DESIGN Multicenter , prospect i ve , r and omized trial ( Canadian Task Force classification I ) . SETTING Tertiary care university hospitals . PATIENTS Fifty-seven women aged 18 to 40 years with ovarian endometriomas associated with moderate to severe pelvic pain who underwent laparoscopic excision of the disease . INTERVENTIONS Patients were r and omized to receive postoperative estroprogestins for 6 months , administered as either a CON or CYC regimen . MEASUREMENTS AND MAIN RESULTS At 3 , 6 , 12 , and 24 months postoperatively , patients were evaluated for recurrence of endometriomas ( defined as cysts > 3 cm in greatest diameter ) using ultrasonography , for recurrence of pain using a visual analog scale , and for patient satisfaction . After a minimum follow-up of 12 months ( mean , 22 months ) , at intent-to-treat analysis , no endometrioma recurrence was observed in the CON group , whereas there was recurrence in 1 patient ( 4 % ) in the CYC group . Pain recurred in 5 and 9 patients , respectively ( 17 % vs 32 % ; p = .23 ) . Compared with pretreatment values , pain scores improved in both groups , with no significant difference between the 2 groups . Most patients in both groups were either satisfied or very satisfied , with no significant difference between treatment groups . However , compared with the CYC group , significantly more patients in the CON group experienced moderate to severe adverse effects , and therapy was discontinued ( 41 % vs 14 % ; p = .03 ) . CONCLUSIONS Although both regimens were equally effective insofar as postoperative pain and recurrence of endometrioma , when compared with the CYC regimen , the CON regimen seems to be associated with significantly more adverse effects and discontinuation rates OBJECTIVE To compare the efficacy of leuprolide and continuous oral contraceptives in the treatment of endometriosis-associated pain . DESIGN Prospect i ve , r and omized , double-blind controlled trial . SETTING Academic medical centers in Rochester , New York , and Boston , Massachusetts . PATIENT(S ) Forty-seven women with endometriosis-associated pelvic pain . INTERVENTION(S ) Forty-eight weeks of either depot leuprolide , 11.25 mg IM every 12 weeks with hormonal add-back using norethindrone acetate 5 mg orally , daily ; or a generic monophasic oral contraceptive ( 1 mg norethindrone + 35 mg ethinyl estradiol ) given daily . MAIN OUTCOME MEASURE(S ) Biberoglu and Behrman ( B&B ) pain scores , numerical rating scores ( NRS ) , Beck Depression Inventory ( BDI ) , and Index of Sexual Satisfaction ( ISS ) . RESULT ( S ) Based on enrollment of 47 women r and omized to continuous oral contraceptives and to leuprolide , there were statistically significant declines in B&B , NRS , and BDI scores from baseline in both groups . There were no significant differences , however , in the extent of reduction in these measures between the groups . CONCLUSION ( S ) Leuprolide and continuous oral contraceptives appear to be equally effective in the treatment of endometriosis-associated pelvic pain To present single institution open-label experience with intravesical liposomes ( LPs ) , a mucosal protective agent , in patients with interstitial cystitis/painful bladder syndrome ( IC/PBS ) and to assess the safety and efficacy on IC/PBS symptoms . A total of 17 symptomatic IC/PBS patients were treated with intravesical LPs ( 80mg/40mL distilled water ) once a week for 4 weeks ( n=12 ) or twice a week treatment for 4 weeks ( n=5 ) . The primary outcome was the change in the O'Leary-Sant Symptom/Problem score and O'Leary-Sant total Score from baseline to Week 4 and Week 8 . Other outcome measurements included the changes in pain scale , urgency scale , voiding log , and patient global assessment . Both weekly and biweekly LP instillation regiments were well tolerated . The incidence of urinary incontinence , retention , or unanticipated adverse changes was not noted at any dose either during the treatment or at the 4-week follow-up . The O'Leary-Sant Symptom/Problem score , O'Leary-Sant total Score , and pain score were significantly improved from baseline at both dose regimens with added benefit with the biweekly regimen . Intravesical LPs treatment is safe and its efficacy has sustained duration . Furthermore large-scale , placebo-controlled studies are warranted to assess the efficacy for this promising new treatment for IC/PBS BACKGROUND A clinical study compared efficacy and safety of depot medroxyprogesterone acetate ( DMPA ) with leuprolide for  endometriosis-associated pain .  METHODS This multicentre , 18 month , evaluator-blinded , comparator-controlled trial r and omized 300 women with laparoscopically diagnosed endometriosis to 6 month treatment with subcutaneous injection of  104 mg/0.65 ml DMPA ( DMPA-SC 104 ) every 3 months or leuprolide ( 3.75 mg monthly or 11.25 mg every 3 months ) , with 12 months post-treatment follow-up . Endpoints included patient response to treatment in five signs/symptoms ( dysmenorrhoea , dyspareunia , pelvic pain , pelvic tenderness , in duration ) and changes in bone mineral density ( BMD ) and productivity at 6 and 18 months . RESULTS DMPA-SC 104 and leuprolide produced equivalent ( P < 0.02 ) reductions in at least four pain categories and significant ( P < 0.001 ) improvements in composite score at months 6 and 18 . At month 6 , reductions in total hip and lumbar spine BMD were significantly less ( P < 0.001 ) with DMPA-SC 104 versus leuprolide .  BMD returned to pre-treatment levels 12 months post-treatment in the DMPA-SC 104 but not the leuprolide group . Total productivity also significantly ( P < or = 0.05 ) improved in both groups at 6 and 18 months . CONCLUSIONS DMPA-SC 104 reduces endometriosis-associated pain as effectively as leuprolide and improves productivity with significantly less BMD decline OBJECTIVE Aim of our study was to evaluate the effectiveness of the association between N-Palmitoylethanolamine and transpolydatin in the management of  chronic pelvic pain related to EMS . STUDY DESIGN This was a r and omized , double-blind , parallel-group , placebo-controlled clinical trial involving 61 subjects , su bmi tted to a first line laparoscopic conservative surgery , who were r and omized into 3 groups receiving : group A ( n=21 ) the association N-Palmitoylethanolamine-transpolydatin 400 mg + 40 mg twice a day for 3 months ; group B ( n=20 ) the placebo for 3 months ; group C ( n=20 ) a single course of Celecoxib 200 mg twice a day for 7 consecutive days . Assessment s of the severity of pelvic endometriosis ( pelvic pain , dysmenorrhoea and dyspareunia ) were recorded before and after treatment on a question naire and a 10-point VAS . Differences between groups were verified with Kruskal-Wallis ANOVA for non-parametric multiple comparisons . RESULTS A marked decrease in dysmenorrhoea , dyspareunia and pelvic pain was observed in all groups , and the association between N-Palmitoylethanolamine and transpolydatin result ed to be more effective than placebo ( P<.001 ) . Additionally , the treatment with Celecoxib result ed in a decrease in pelvic pain more effective either than the association N-Palmitoylethanolamine and transpolydatin or placebo . CONCLUSION These preliminary results show that the association between micronized N-Palmitoylethanolamine and transpolydatin is effective in the management of pelvic pain related to endometriosis after laparoscopy . Additionally , this association seems to be safe , shows an optimal control of pain and can be used in patients who are unable to receive other therapies OBJECTIVES Chronic pelvic pain is a common source of disability among women in the western world . Here we report that 3 months of Mensendieck somatocognitive intervention in chronic pelvic pain patients was followed by continued improvements of outcomes at 1-year follow-up in a r and omized , controlled study design . METHODS Forty women with chronic pelvic pain unexplained by pelvic pathology were r and omly assigned to 2 groups : ( 1 ) st and ard gynecologic treatment and ( 2 ) gynecologic treatment plus somatocognitive therapy aim ed at reducing physical pain by changing posture , movement , and respiration patterns . A st and ardized Mensendieck test ( SMT ) of motor function ( assessing posture , movement , gait , sitting posture , and respiration ) , a self-rating question naire assessing psychologic distress and general well-being ( GHQ-30 ) and a visual analog score of pain ( VAS ) were obtained before , after 90 days of treatment and 1 year after inclusion . RESULTS Patients treated by st and ard gynecologic treatment/supervision did not improve significantly at 1-year follow-up in any of the test modalities . By contrast , those who in addition received somatocognitive therapy had improved scores for all motor functions and pain , as well as GHQ-30 scores for coping , and anxiety-insomnia-distress . CONCLUSION Mensendieck somatocognitive therapy combined with st and ard gynecologic care improves psychologic distress , pain experience , and motor functions of women with chronic pelvic pain better than gynecologic treatment alone . The effect lasted and even further improvement occurred 9 months after treatment The efficacy of antidepressants as analgesics for a range of chronic pain problems is well documented . However , a controlled trial of an antidepressant for women with chronic pelvic pain  has not yet been published . We r and omized 23 women from a general gynecology clinic to either double-blind sertraline or placebo . Measures of psychological function , pain , and functional disability were taken at baseline and 6 weeks . After a 2-week washout , the groups were crossed-over and the same measures were done over the next 6 weeks . There were no significant improvements in pain or functional disability noted on sertraline compared to placebo . Studies involving larger sample s of patients are needed to confirm these findings OBJECTIVE : To estimate whether botulinum toxin type A is more effective than placebo at reducing pain and pelvic floor pressure in women with chronic pelvic pain and pelvic floor muscle spasm . METHODS : This study was a double-blinded , r and omized , placebo-controlled trial . All participants presented with chronic pelvic pain of more than 2 years duration and evidence of pelvic floor muscle spasm . Thirty women had 80 units of botulinum toxin type A injected into the pelvic floor muscles , and 30 women received saline .  Dysmenorrhea , dyspareunia , dyschezia , and nonmenstrual pelvic pain were assessed by visual analog scale ( VAS ) at baseline and then monthly for 6 months . Pelvic floor pressures were measured by vaginal manometry . RESULTS : There was significant change from baseline in the botulinum toxin type A group for dyspareunia ( VAS score 66 versus 12 ; χ2=25.78 , P<.001 ) and nonmenstrual pelvic pain ( VAS score 51 versus 22 ; χ2=16.98 , P=.009 ) . In the placebo group only dyspareunia was significantly reduced from baseline ( 64 versus 27 ; χ2=2.98 , P=.043 ) . There was a significant reduction in pelvic floor pressure ( centimeters of H2O ) in the botulinum toxin type A group from baseline ( 49 versus 32 ; χ2=39.53 , P<.001 ) , with the placebo group also having lower pelvic floor muscle pressures ( 44 versus 39 ; χ2=19.85 , P=.003 ) . CONCLUSION : Objective reduction of pelvic floor spasm reduces some types of pelvic pain . Botulinum toxin type A reduces pressure in the pelvic floor muscles more than placebo . Botulinum toxin type A may be a useful agent in women with pelvic floor muscle spasm and chronic pelvic pain who do not respond to conservative physical therapy . Clinical Trial Registration : Australian Clinical Trials Registry , http://www.actr.org.au/ , ACTRN012605000515695 LEVEL OF EVIDENCE : OBJECTIVE To assess the longer term efficacy of laparoscopic laser surgery in the treatment of painful pelvic endometriosis and to observe the natural history of the disease at second-look laparoscopy in a control group . DESIGN One-year follow-up of a prospect i ve , r and omized , double-blind controlled trial . SETTING A referral center for the laparoscopic laser treatment of endometriosis . PATIENT(S ) Sixty-three patients with pelvic pain and minimal to moderate endometriosis . INTERVENTION(S ) After the 6-month follow-up visit , the r and omization code was broken , and follow-up was continued to 1 year . Symptomatic patients were offered second-look laser laparoscopy . MAIN OUTCOME MEASURE(S ) Continued symptom relief at 1 year after treatment and findings at second-look laparoscopy in symptomatic controls . RESULT ( S ) Symptom relief continued at 1 year in 90 % of those who initially responded . All symptomatic controls had a second-look procedure , with 7 ( 29 % ) showing disease progression , 7 ( 29 % ) showing disease regression , and 10 ( 42 % ) having static disease . CONCLUSION ( S ) The benefits of laser laparoscopy for painful pelvic endometriosis are continued in the majority of patients at 1 year . Untreated painful endometriosis will progress or remain static in the majority of patients but will spontaneously improve in others Background and Objectives : The purpose of this study was to assess the long-term efficacy of laparoscopic laser surgery in the treatment of  painful pelvic endometriosis .  Methods : We conducted a long-term follow-up of 56 patients who had participated in a r and omized , double-blind controlled study at a tertiary referral center for the laparoscopic treatment of endometriosis . The patients had pelvic pain , minimal-to-moderate endometriosis , and underwent laser laparoscopy .  We asked patients whether they had now achieved satisfactory symptom relief or whether they had received any further medical intervention for their endometriosis . The main outcome measure was continued symptom relief after treatment and subsequent medical history . Results : Of the original 56 patients , we were able to contact 38 ( 67.9 % ) . The mean ( range ) time since operation was 73 months . Painful symptoms had recurred in 28/38 ( 73.7 % ) patients at some point since their operation . The median ( range ) time for recurrence was 19.7 ( 5 - 60 ) months . At the time of follow-up , satisfactory symptom relief was reported in 21/38 ( 55.3 % ) patients . The remaining 17/38 ( 44.7 % ) patients continued to experience painful symptoms , and eight eventually had a hysterectomy . Conclusions : This study suggests that operative laparoscopy can have long-term benefits for the majority of women with pelvic pain due to endometriosis , but because of the small numbers , this study lacks the power to demonstrate this conclusively OBJECTIVE To evaluate whether persistence of pelvic pain after excision of endometriosis was associated with adenomyosis as defined by a thickened uterine junctional zone ( JZ ) on magnetic resonance ( MR ) imaging . DESIGN Prospect i ve clinical trial . SETTING Government research hospital . PATIENT(S ) Fifty-three women with chronic pelvic pain . INTERVENTION(S ) Preoperative MR imaging to measure uterine JZ thickness , surgical excision , and pathologic diagnosis of endometriosis . Those with biopsy-proven endometriosis were r and omized to raloxifene or placebo .  Visual analog scale ( VAS ) was used to rate dysmenorrhea and nonmenstrual pain severity before surgery and 3 months later . MAIN OUTCOME MEASURE(S ) Comparison of JZ thickness and pain severity before and 3 months after surgery in women with endometriosis controlling for medical treatment . RESULT ( S ) Forty of the 53 patients had biopsy-proven endometriosis , and 6 of these 40 women with endometriosis had a thickened JZ . Overall , dysmenorrhea at 3 months was positively correlated with preoperative JZ thickness ( r = 0.47 , P=.01 ) . Dysmenorrhea pain severity showed no significant decrease in those patients whose JZ measured > or=11 mm compared with those with JZ < 8 mm ( P<.0001 ; VAS decreased 4.3 + /- 0.6 ) , or > or=8 and < 11 mm ( P<.02 ; VAS decreased 4.8 + /- 1.3 ) . Nonmenstrual pain severity was correlated with JZ thickness ( r = 0.51 , P=.004 ) at 3 months with a significant decrease in nonmenstrual pain only in women with a JZ < 8 mm ( VAS decreased 4.0 + /- 0.7 , P<.0001 ) . The association between dysmenorrhea and nonmenstrual pain reduction and thinner JZ remained after controlling for medical treatment . CONCLUSION ( S ) Following surgical excision of endometriosis , chronic pelvic pain was significantly more likely to persist with JZ thickness > 11 mm on preoperative MR imaging . This suggests that myometrial JZ abnormalities or adenomyosis may contribute to chronic pelvic pain in women with endometriosis This article reports the findings of a population -based study in New Zeal and that investigated comparative well-being , comorbidity , and the impact of chronic pelvic pain ( CPP ) on activities . Chronic pelvic pain was defined as lower abdominal pain that is associated with neither the menstrual cycle nor sexual activity . A postal question naire was administered to a r and om sample result ing in a study group of 1,160 . The negative impact of CPP on women 's general well-being is significant . They were more likely than women without CPP to have other long-st and ing illnesses , other unspecified conditions involving pain or fatigue , and sleep patterns were more seriously disturbed . Pain restricted their activities . Comparisons with the limited data available from other studies are made OBJECTIVE To assess the efficacy , safety , and effect on bone mineral density of a 3-month course of retreatment with intranasal nafarelin acetate for recurrent symptoms of endometriosis . DESIGN Multicenter , open-label , nonr and omized clinical trial . SETTING Eleven hospital-based and private practice s. PATIENT(S ) Thirty-six women with endometriosis symptoms recurring after 3 or 6 months of treatment with nafarelin .  INTERVENTION(S ) Nasal nafarelin 200 micrograms twice daily for 3 months . MAIN OUTCOME MEASURE(S ) Assessment s for dysmenorrhea , dyspareunia , pelvic pain , tenderness , and in duration . Measurement of bone mineral density of the lumbar spine . RESULT ( S ) Improvements from admission to the end of retreatment were significant for dysmenorrhea , pelvic pain , tenderness , in duration , and dyspareunia . Three months after retreatment ended , mean symptom scores for dysmenorrhea and pelvic tenderness , although worse than at the end of retreatment , were still significantly better than scores at admission . Mean bone mineral density 3 months after retreatment was 0.56 % lower than before retreatment and 1.94 % lower than before initial treatment . CONCLUSION ( S ) Three-month nafarelin retreatment for recurrent endometriosis symptoms was effective and safe OBJECTIVE Our purpose was to evaluate the efficacy and safety of depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol in the long-term treatment of pelvic pain in women with endometriosis . STUDY DESIGN Eighty patients with endometriosis and moderate or severe pelvic pain were r and omized to treatment for 1 year with intramuscular depot medroxyprogesterone acetate 150 mg every 3 months or a cyclic monophasic oral contraceptive ( ethinyl estradiol 0.02 mg , desogestrel 0.15 mg ) combined with oral danazol 50 mg a day for 21 days of each 28-day cycle . The women were asked to grade the degree of their satisfaction at the end of therapy . Variations in severity of symptoms during treatment were determined by a 10 cm visual analog and a 0- to 3-point verbal rating scale . RESULTS Twenty nine of 40 subjects ( 72.5 % ) in the depot medroxyprogesterone acetate group were satisfied after 1 year of therapy compared with 23 of 40 ( 57.5 % ) in the oral contraceptive plus danazol group ( chi 2(1 ) = 1.37 , p = 0.24 , odds ratio 1.95 , 95 % confidence interval 0.76 to 4.97 ) . A significant decrease was observed in all symptom scores in both study groups . At 1-year assessment dysmenorrhea was significantly greater in women allocated to oral contraceptive plus danazol . CONCLUSION Depot medroxyprogesterone acetate seems to be an effective , safe , and convenient low-cost treatment for pelvic pain associated with endometriosis . However , women should be carefully counseled regarding menstrual changes and the potential prolonged delay in the return of ovulation BACKGROUND We hypothesised that the orally-active alpha(2)-adrenoceptor agonist lofexidine hydrochloride would ameliorate  chronic pelvic pain in women . METHODS A r and omized placebo-controlled parallel group trial was undertaken in the University Hospital Gynaecology Clinic . Women with pelvic pain of at least 6 months duration were eligible , and were r and omized using a sealed envelope system to receive up to 600 mg lofexidine hydrochloride twice daily over 8 weeks or placebo . Outcome measures were summary and daily diary visual analog scales for pain ( VAS ) and a 5 point self rating scale . RESULTS 9/19 women r and omized to lofexidine completed the study compared to 14/20 of those r and omized to placebo . Intention-to-treat analysis showed that 4/19 in the lofexidine group achieved 50 % or greater reduction in VAS compared with 8/20 in the placebo group ( OR 2.5 , 95 % CI 0.6 - -10.3 ) . Summary and diary VAS were closely correlated . CONCLUSIONS Within the limits of a small study with power to detect only a substantial effect , we conclude that lofexidine hydrochloride is not effective for the treatment of chronic pelvic pain OBJECTIVE This is a r and omized clinical trial comparing estroprogestin ( E/P ) pill given for 12 months vs. gonadotrophin releasing hormone agonist ( GNRHa ) given for 4 months followed by E/P pill treatment for 8 months in the relief of  endometriosis-related pelvic pain . METHODS Eligible for the study were women with laparoscopically confirmed endometriosis and pelvic pain lasting 3 - 12 months after diagnosis . Eligible women were r and omly assigned to treatment with E/P pill ( gestroden 0.75 mg and ethynlestradiol 0.03 mg ) for 12 months ( 47 patients ) vs. tryptorelin 3.75 mg slow release every 28 days for 4 months followed by E/P pill for 8 months ( 55 patients ) . RESULTS At baseline , dysmenorrhea was reported in 46 women allocated to E/P pill only ( 97.9 % ) , and in all the 55 women allocated to GNRHa+E/P pill . The corresponding value at the 12 months follow-up visit was 14 subjects ( 35.9 % ) and 16 subjects ( 34.8 % ) . The baseline median values of the multidimensional and analog scale were for dysmenorrhea 4 and 6 in the EP only and 3 and 6 in the GNRHa+E/P group . The corresponding value at the 12 months follow-up visit were 2 and 6 and 0 and 5 . Non-menstrual pain was reported , respectively , at baseline and 12 month visit by 46 ( 97.9 % ) and 15 ( 38.5 % ) subjects in the E/P pill group and 49 ( 89.1 % ) and 17 ( 37.0 % ) of the GNRHa+E/P pill one . The baseline median values of the multidimensional and analog scale were for non-menstrual pain 3 and 5 in the E/P only and 2 and 6 in the GNRHa+E/P group . The corresponding values at the 12 month follow-up visit were 0 and 4 and 0 and 4 . These differences between the two groups were not statistically significant . CONCLUSIONS 1 year after r and omization , the two treatment schedules show similar relief of pelvic pain in women with endometriosis The most effective therapy for endometriosis is a matter for debate . The aim of the present r and omized study was to evaluate the efficacy of low doses of danazol on recurrence of pelvic pain in patients with moderate or severe endometriosis , who had undergone laparoscopic surgery and 6 months of gonadotrophin-releasing hormone analogue ( GnRHa ) therapy .  After surgery , 28 patients with moderate or severe endometriosis underwent therapy for 6 months with GnRHa i. m. every 4 weeks . They were then r and omized into two groups : group A ( 14 subjects ) was treated with 100 mg/day danazol for 6 months ; group B ( 14 subjects , control )  did not receive any type of therapy . After 12 months of treatment , group A had a significantly ( P < 0.01 ) lower pain score than group B. There was no significant difference between the groups in oestrogen concentrations , bone mineral density or side-effects . The results suggest that low-dose danazol therapy reduces recurrence of pelvic pain in patients with moderate or severe endometriosis , treated surgically , and has few or no metabolic side-effects This study aims to determine whether the levonorgestrel-releasing intrauterine system can influence American Society for Reproductive Medicine endometriosis staging scores , as assessed through second-look laparoscopies , and to compare the results with those obtained with a GnRH agonist . Both treatments reduced the extent of pelvic endometriotic lesions in patients with chronic pelvic pain OBJECTIVE To examine whether long-term administration of dienogest following gonadotropin-releasing hormone agonist ( GnRH-a ) therapy would prolong the relief of pelvic pain while reducing the amount of irregular uterine bleeding . STUDY DESIGN This was a prospect i ve , non-r and omized clinical trial . Among the patients suffering from chronic pelvic pain associated with recurrent endometriosis , Group G ( n=38 ) received GnRH-a for 4 - 6 months and then dienogest ( 1 mg/day ) for 12 months . The dose of dienogest was increased to 1.5 or 2 mg/day when a patient had uncontrollable uterine bleeding { n=15 (39%)}. Group D ( n=33 ) received only dienogest ( 2 mg/day ) for 12 months . Pelvic pain was assessed using a visual analog scale ( VAS ) . Uterine bleeding was semi-quantified using a pictorial blood loss assessment chart ( PBAC ) . RESULTS In Group G , GnRH-a significantly reduced the VAS score for pelvic pain , and alleviation was maintained during the 12-month therapy with dienogest . There was no significant difference in pain reduction between Group G and Group D. The PBAC score during the first 6 months on dienogest was significantly smaller in Group G than in Group D. CONCLUSION Treatment with a GnRH-a followed by long-term dienogest therapy maintains the relief of endometriosis-associated pelvic pain achieved with GnRH-a therapy for at least 12 months . This regimen reduces the amount of irregular uterine bleeding that often occurs during the early phase of dienogest therapy Objective To determine the effectiveness of laparoscopic uterine nerve ablation ( LUNA ) for chronic pelvic pain in women with endometriosis and women with no laparoscopic evidence of endometriosis Background . To assess whether hormonal treatment of endometriosis improves quality of life for women with endometriosis To compare treatment efficacy and safety parameters  a total of 55 premenopausal women with histologically proven endometriosis ( stage II-IV ) were r and omized to receive the LHRH-analogue depot triptorelin ( n = 30 ) or the steroid danazol ( n = 25 ) for a total of 24 weeks . Immediately after cessation of the endocrine therapy a second-look operation was performed . Four as well as 24 weeks after the end of treatment patients were seen for re-evaluation of clinical symptoms and safety parameters . Estradiol suppression was significantly more pronounced with triptorelin , while the free and rogenic index rose with danazol . Both substances were equally effective in reducing endometriotic implants ( 58 % and 51 % , respectively ) . Dysmenorrhea was absent at the end of medical therapy in both treatment groups . Dyspareunia and pelvic pain decreased at least by 50 % . Red blood count , thrombocytes , liver enzymes and the atherogenic index rose with danazol , while the urinary calcium/creatinine ratio showed a marked elevation with triptorelin .  Adverse effects were mainly due to the hypoestrogenism of the LHRH analogue and the and rogenic/anabolic properties of the steroid . Triptorelin  and  danazol are equally effective in treating endometriosis . Therefore , choice of treatment should be based on the patient 's medical history and the pharmacological profile of each substance OBJECTIVE To evaluate the efficacy and safety of cyproterone acetate versus an oral contraceptive in the treatment of endometriosis-associated recurrent pelvic pain . DESIGN R and omized controlled trial . SETTING Academic center . PATIENT(S ) Ninety women with recurrent moderate or severe pelvic pain after conservative surgery for symptomatic endometriosis . INTERVENTION(S ) Six months of continuous treatment with oral cyproterone acetate , 12.5 mg/d , or an oral contraceptive containing ethinyl estradiol , 0.02 mg , and desogestrel , 0.15 mg . MAIN OUTCOME MEASURE(S ) Degree of satisfaction with therapy . RESULT ( S ) Six patients in the cyproterone acetate arm and nine in the oral contraceptive arm withdrew because of side effects ( n = 9 ) , treatment inefficacy ( n = 4 ) , or loss to follow-up ( n = 2 ) . At 6 months , dysmenorrhea , deep dyspareunia , and nonmenstrual pelvic pain scores were substantially reduced , and significant improvements were observed in health-related quality -of-life , psychiatric profile , and sexual satisfaction ; no major between-group differences were seen . Subjective and metabolic side effects were limited . According to an intention-to-treat analysis , 33 of 45 ( 73 % ) of patients in the cyproterone acetate group and 30 of 45 ( 67 % ) in the oral contraceptive group were satisfied with the treatment received . CONCLUSIONS Both cyproterone acetate and a continuous monophasic oral contraceptive were effective , safe , and inexpensive therapy for recurrent pain after conservative surgery for endometriosis BACKGROUND Implanon has been reported to be effective in the treatment of dysmenorrhea . We compared the therapeutic efficacies of depot medroxyprogesterone acetate ( DMPA ) and Implanon with regard to pain relief in women with endometriosis . STUDY DESIGN In a clinical research center at a university hospital , 41 patients with dysmenorrhea , nonmenstrual pelvic pain and dyspareunia associated with histologically proven endometriosis were included in an open , prospect i ve , r and omized , controlled clinical trial . Twenty-one women were assigned by computer-generated r and omization to receive  Implanon , and 20 women to receive DMPA . As main outcome measures of this pilot study , we evaluated pain improvement quantified according to visual analog scale score , side effects , vaginal bleeding patterns , withdrawal rate and overall degree of satisfaction . RESULTS During a follow-up period of 1 year , we ascertained a clear improvement in pain intensity for both treatment options . After 6 months , the average decrease in pain was 68 % in the Implanon group and 53 % in the DMPA group . The side-effects profile and the overall degree of satisfaction after study termination were comparable for both treatment options . CONCLUSION Concerning pain relief , the therapeutic efficacy of the contraceptive implant Implanon is not inferior to that of DMPA in symptomatic endometriosis & NA ; Melatonin reduced pain scores and analgesic use , and improved sleep quality in endometriosis‐associated chronic pelvic pain . Melatonin modulates the secretion of brain‐derived neurotrophic factor independently of its analgesic effect in endometriosis . & NA ; Endometriosis‐associated chronic pelvic pain ( EACPP ) presents with an intense inflammatory reaction . Melatonin has emerged as an important analgesic , antioxidant , and antiinflammatory agent . This trial investigates the effects of melatonin compared with a placebo on EACPP , brain‐derived neurotrophic factor ( BDNF ) level , and sleep quality . Forty females , aged 18 to 45 years , were r and omized into the placebo ( n = 20 ) or melatonin ( 10 mg ) ( n = 20 ) treatment groups for a period of 8 weeks . There was a significant interaction ( time vs group ) regarding the main outcomes of the pain scores as indexed by the visual analogue scale on daily pain , dysmenorrhea , dysuria , and dyschezia ( analysis of variance , P < 0.01 for all analyses ) . Post hoc analysis showed that compared with placebo , the treatment reduced daily pain scores by 39.80 % ( 95 % confidence interval [ CI ] 12.88–43.01 % ) and dysmenorrhea by 38.01 % ( 95 % CI 15.96–49.15 % ) . Melatonin  improved sleep quality , reduced the risk of using an analgesic by 80 % , and reduced BNDF levels independently of its effect on pain . This study provides additional evidence regarding the analgesic effects of melatonin on EACPP and melatonin ’s ability to improve sleep quality . Additionally , the study revealed that melatonin modulates the secretion of BDNF and pain through distinct mechanisms
target: RESULTS The instruments most frequently used were single-item VAS and Biberoglu and Behrman pain score , while multidimensional inventories were used in few studies .
  The results of clinical studies in CPP are more frequently based on one-dimensional measurements .
background: RATIONALE Many types of  pain assessment are available to research ers carrying out clinical trials in chronic pelvic pain ( CPP ) , ranging from a single-item scale to multidimensional inventories .
  AIM Our objective was to investigate which assessment s of pain are more commonly used in clinical trials on CPP .