Obstacles and pitfalls of endometriosis-related chronic pelvic pain management: trying to alleviate the burden.

Chronic Pelvic Pain (CPP) could be defined as the presence of non-cyclic pain of 6 months duration or longer that localizes to the pelvis and is severe enough to cause functional disability and require medical or surgical treatment. Among women who undergo laparoscopy for CPP, endometriosis results in approximately 1/3 of the cases; conversely, among women who do not have CPP, endometriosis is present in only 5% of cases. Moreover, accumulating evidences support the opinion for which CPP has poor correlation with endometriosis stage, moderate correlation with isolated presence of ovarian endometrioma, strong correlation with Deep Infiltrating Endometriosis (especially if it affects bowel or urinary tract) and/or adhesion. Endometriosis-related CPP could arise through different pathways: one of the clearest reason is that endometriotic lesion could provoke a compression or infiltration of nerves; another possible causes of arising CPP could be represented by the increase of Nerve Growth Factor (NGF) in the endometriotic lesion area; last but not least, CPP could arise and be exacerbated also by inflammation of the peritoneal microenvironment. The hormonal therapies do not eliminate the endometriotic implants and, for this reason, stopping the treatment pelvic pain and other typical symptoms of endometriosis may recur and exacerbate the pre-treatment condition. The surgical treatment of endometriosis-related CPP is still not perfectly encoded, due to the unclear etiology and the different response to therapies. For these reasons, there is necessity of more efforts to create new non-invasive strategies that set a more accurate diagnosis and treatment of the causes of endometriosis-related CPP.