Pelvic Pain: Evaluate Clinically, Treat Medically.

CHICAGO -- Patients with chronic pelvic pain should be evaluated clinically -- without the aid of a laparoscope--and if causes other than endometriosis are ruled out, medical therapy should be pursued to avoid surgery, Dr. Craig Winkel asserted at the annual meeting of the Central Association of Obstetricians and Gynecologists.

But that's not what most physicians are doing, according to Dr. Winkel. "Many physicians think that when a patient walks into the office with chronic pelvic pain, the first thing you ought to do is stick a la paroscope in her belly," the chair of the department of ob.gyn. at Georgetown University Medical Center, Washington, said in an interview.

Many physicians insist that laparoscopy is necessary to rule out ovarian cancer, but colon cancer is the only cancer that causes pelvic pain before it's widespread, Dr. Winkel said. There are no other causes of chronic pelvic pain that can be ruled out by laparoscopy, he said in an interview.

Laparoscopy also is not useful for determining whether endometrial lesions are causing the pain. Studies have shown that laparoscopy reveals endometriosis lesions up to 45% of the time in asymptomatic women. Endometriosis lesions may not always cause pain, yet when they're discovered on laparoscopy, doctors tend to focus on them as the cause of a patient's pelvic pain.

"Avoid the herd mentality," Dr. Winkel advised. "As surgeons, you learn that if you see a lesion, you should cut it out. The truth is that seeing lesions doesn't always mean that you've detected the cause of the patient's pain."

And if the cause of a patient's chronic pelvic pain truly is due to endometriosis, the upshot from years of clinical research is that, for many women, endometriosis recurrence rates are the same regardless of whether treatment is surgical or medical, he said.

The first randomized, head-to-head trial comparing surgery with medical therapy for endometrial pain is ongoing, and results are at least 2 years away. In the meantime, Dr. Winkel said that given the apparent equal effectiveness of surgery and drug therapy, patients are better off ...