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Years of unjustified hypoestrogenism, fear, and stress will not improve the management of chronic pelvic pain!

      To the Editors:
      Agarwal et al
      • Agarwal S.K.
      • Chapron C.
      • Giudice L.C.
      • et al.
      Clinical diagnosis of endometriosis: a call to action.
      should be congratulated for emphasizing that patients with severe chronic pelvic pain should be managed actively. Indeed, years of inadequate treatment, with the assumption that this pain is normal, is deeply frustrating for these patients. Chronic pain may have significant negative impact on a patient’s quality of life, resulting in central sensitization, loss of self-confidence and trust in physicians, and making long-term management more difficult.
      Some of these women have severe or deep endometriosis that may be identified clinically or with imaging techniques. Others may have superficial disease, which could be confirmed at laparoscopy, although this should not be the first option in teenagers. Even minimally invasive surgery is too invasive to manage minimal endometriosis, which is not always progressive and may heal during medical treatment or even spontaneously.
      • Evers J.L.
      Is adolescent endometriosis a progressive disease that needs to be diagnosed and treated?.
      The presumption of endometriosis should not be mandatory for the physician to propose adequate treatment of severe chronic pelvic pain in young patients without obvious or confirmed endometriotic lesions. Many of these patients do not have and will never have endometriosis. The menstrual disorder of teenagers (MDOT) study reported that almost 30% of teenagers thought that something was wrong with their period, and 21% reported severe pain and 47% moderate pain.
      • Parker M.A.
      • Sneddon A.E.
      • Arbon P.
      The menstrual disorder of teenagers (MDOT) study: determining typical menstrual patterns and menstrual disturbance in a large population-based study of Australian teenagers.
      However, the prevalence of endometriosis is about 10% among women of reproductive age.
      Overdiagnosing the disease using clinical criteria because a noninvasive diagnosis test is not available will have severe consequences. Treatment of “a supposed endometriosis” with high-dosage progestins or gonadotropin-releasing hormone agonist will likely result in years of unnecessary hypoestrogenism. Young patients will experience years of unjustified fear and anxiety about probable infertility induced by a “possible mysterious chronic disease” that cannot be cured. Fear will likely worsen the symptoms of these young patients as adolescents’ pain involves a significant psychosomatic component.
      Careful management of severe dysmenorrhea, using analgesics and amenorrhea obtained with continuous low-dosage contraceptive pills, is possible. If the goal is to prevent a spontaneous worsening of the disease, prevention of menstruation is enough.
      • Brosens I.A.
      Endometriosis—a disease because it is characterized by bleeding.
      Finally, the absence of a noninvasive diagnostic test does not demonstrate that the cause of endometriosis is permanent, that the number of lesions is constantly increasing, or that recurrences are unavoidable thus implying that deep hypoestrogenism may be indicated when endometriosis is “suspected” on clinical symptoms.

      References

        • Agarwal S.K.
        • Chapron C.
        • Giudice L.C.
        • et al.
        Clinical diagnosis of endometriosis: a call to action.
        Am J Obstet Gynecol. 2019; 220: 354-364
        • Evers J.L.
        Is adolescent endometriosis a progressive disease that needs to be diagnosed and treated?.
        Hum Reprod. 2013; 28: 2023
        • Parker M.A.
        • Sneddon A.E.
        • Arbon P.
        The menstrual disorder of teenagers (MDOT) study: determining typical menstrual patterns and menstrual disturbance in a large population-based study of Australian teenagers.
        BJOG. 2010; 117: 185-192
        • Brosens I.A.
        Endometriosis—a disease because it is characterized by bleeding.
        Am J Obstet Gynecol. 1997; 176: 263-267

      Linked Article

      • Clinical diagnosis of endometriosis: a call to action
        American Journal of Obstetrics & GynecologyVol. 220Issue 4
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          Endometriosis can have a profound impact on women’s lives, including associated pain, infertility, decreased quality of life, and interference with daily life, relationships, and livelihood. The first step in alleviating these adverse sequelae is to diagnose the underlying condition. For many women, the journey to endometriosis diagnosis is long and fraught with barriers and misdiagnoses. Inherent challenges include a gold standard based on an invasive surgical procedure (laparoscopy) and diverse symptomatology, contributing to the well-established delay of 4–11 years from first symptom onset to surgical diagnosis.
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      • Reply
        American Journal of Obstetrics & GynecologyVol. 221Issue 2
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          Thank you for your letter entitled “Years of unjustified hypoestrogenism, fear, and stress will not improve the management of chronic pelvic pain!” The goal of our manuscript entitled “Clinical diagnosis of endometriosis: a call to action” 1 was to highlight the current unacceptable delay in diagnosis and to encourage a focus on pain, functioning, and quality of life, with or without a previous surgical diagnosis endometriosis. We agree with your statement “Even minimally invasive surgery is too invasive to manage minimal endometriosis, which is not always progressive and may heal during medical treatment or even spontaneously.”
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