Comprehensive evaluation of response and failure of medical treatment in patients with endometriosis-associated chronic pelvic pain.

Introduction: Endometriosis is a common gynecological condition affecting 6-10% of women of reproductive age that produces significant morbidity and constitutes a substantial burden on health care systems. Endometriosis is one of the main causes of pelvic pain as it has been estimated that 33% of patients with chronic pelvic pain have endometriosis. Several medical and surgical approaches are available for the management of endometriosis. Suppressive hormonal treatments are generally considered safe and commonly prescribed, however the desired effect of pain relief is not achieved in all patients. Less attention is paid to the reasons for discontinuation and risk factors associated with it. Identifying the proportion of patients who do not benefit from these medications and the risk factors will aid in patient counseling for pain management. In this thesis, I am evaluating patients that did not respond to the first and second line medical treatment of endometriosis. Methods: This cohort included 1440 patients of reproductive age that had confirmed or clinical suspicion of endometriosis. Through an online questionnaire, we asked these patients if they have ever used each hormonal medication to treat their pelvic pain and, if the answer was yes, if the treatment did not help or whether they discontinued due to side effects. Results: In this cohort, 58.3% (839/1440) reported prior use of cyclic hormonal contraceptives, while 42.4% (611/1440) reported prior use of continuous hormonal contraceptives. For progestins, there were 24% (344/1440) patients who used levonorgestrel intrauterine device and 20.2% (287/1440) who used dienogest. Patients who reported ineffectiveness of any hormonal treatment or discontinuation due to side-effects were younger, had higher pain severity, worse quality of life, more non-gynecological contributors to pain, and greater psychological comorbidities. Conclusion: My results highlight the importance of further studying non-responders to hormonal therapy. Prospective longitudinal studies are needed to confirm these findings and further classify the side-effects experienced by patients. Moreover, additional details on treatment inefficacy are required to identify patients that are truly non-responsive versus patients who are not adherent to mediation regimens or have financial difficulties with medication costs.Medicine, Faculty ofObstetrics and Gynaecology, Department ofGraduat