Pain syndromes in endometriosis: an integrated approach to the problem management

Background. Endometriosis affects 10 % of women of reproductive age. Endometriosis is often accompanied by the following symptoms: dyspareunia, pelvic pain, and dysmenorrhea. Pain is a leading symptom of endometriosis and often persists despite treatment. Objective. To elucidate the basics of pathogenesis and treatment of pain in endometriosis. Materials and methods. Analysis of literature data on this topic; own study involving 64 women with endometriosis. Group 1 was given dienogest (2 mg per day) for 3 months, and group 2 was given dienogest in combination with Tivortin (5 intravenous infusions of 100 ml each other day with the switch to Tivortin aspartate (“Yuria-Pharm”) orally). Results and discussion. Pain in endometriosis includes several pathophysiological mechanisms: increased nociception, inflammation, and changes in the recognition of pain in the nervous system. Significant pelvic vascularization promotes the rapid transmission of pain signals from this area to the brain. The severity of pain noted by women poorly correlates with the degree of disease detected during surgery. According to the recommendations of NICE (2017), one or more of the following symptoms are sufficient for suspected endometriosis: chronic pelvic pain (>6 months), dysmenorrhea, which adversely affects quality of life and daily activity, dyspareunia, gastrointestinal disorders and urinary system symptoms associated with menstruation, and infertility in combination with one or more of the above symptoms. Endometriosis requires flexible adaptation of management and the constant choice of treatment tactics depending on the symptoms and life situation of the patient. The basic goals of treatment inlude elimination of symptoms, restoration of quality of life and fertility, prevention of recurrences and repeated surgical intervention. Analgesics, neuromodulators and hormonal agents are used for pharmacological pain management. Additional and alternative methods include reflexology, manual therapy, osteopathy, exercise, dietary changes, and sleep hygiene. Elimination of the oxidation imbalance is one of the methods to treat pain in endometriosis. The uterus is a highly vascularized organ and its cells are constantly affected by high concentrations of oxygen. In settings of hypoxia, steroidogenesis, angiogenesis, inflammation and metabolic transition occur in endometrial cells. In women with endometriosis, there is an increase in markers of oxidative stress in the blood. Intrauterine oxidative stress can be eliminated with the powerful antioxidant L-arginine (Tivortin, “Yuria-Pharm”). In our own study, it was shown that the inclusion of Tivortin into the treatment allowed to decrease the intensity of intermenstrual endometriosis-associated pelvic pain more markedly than the standard treatment. The initial pain level was 61.32±3.2 according to the visual-analog scale in group 1 and 64.2±2.8 in group 2 (Tivortin). A month later, the indicators were 36.5±2.6 and 27.2±2.2, respectively. It should be noted that the effect of Tivortin is stable. In the standard treatment group, the intensity of pain increased again after the end of therapy, and in the Tivortin group remained at a low level. Evaluation of the McGill questionnaire results showed that in Tivortin group pain decreased not only due to the actual strength of the pain, but also due to a decrease in its sensory and emotional characteristics. After treatment, in group 1 the intensity of menstrual bleeding also increased more markedly. Conclusions. 1. The goals of endometriosis treatment are to eliminate symptoms, restore quality of life and fertility, prevent recurrence and repeated surgeries. 2. The effectiveness of L-arginine (Tivortin) in the treatment of endometriosis was ensured by normalizing vascular tone in the pelvic organs, reducing oxidative stress, psychostabilizing effect, increasing the antibacterial activity of neutrophils. 3. The use of Tivortin is a promising area for the treatment of endometriosis and prevention of its recurrence.