Association of adenomyosis and different endometriosis localizations to pain symptoms and their response to hormone therapy

To evaluate whether the intensity of pain symptoms in women with adenomyosis and endometriosis is associated with the specific lesion localizations or with disease extension. A retrospective investigation was performed on 234 women with sonographic diagnosis of adenomyosis and endometriosis (cases), of whom 174 (74.4%) had adenomyosis, 89 (38.0%) superficial endometriosis, 103 (44.0%) ovarian endometriosis, and 131 (56.0%) deep infiltrating endometriosis (DIE) of the utero-sacral ligaments (USL; n = 76), rectum ( n = 61), parametrium ( n = 46), and vesical-uterine folder ( n = 13); 75 control women were also enrolled. Menstrual and intermenstrual pain, deep dyspareunia, dysuria, dyschezia, and low back pain were rated on a visual analogue scale (VAS). The modification of each symptom with therapy was evaluated in the 123 women receiving progestin-only (P; n = 81) or estro-progestin (EP; n = 42) treatment, also comparing P versus EP. Concomitant lesions were more frequent (78.6%) than single localizations (21.4%). Superficial endometriosis was independently associated with more intense menstrual pain (median difference 2.62, 95% CI 1.10–4.15), deep dyspareunia (median difference 1.91, 95%CI 0.09–3.74), and low back pain (median difference 2.03, 95%CI 0.06–3.99), and with higher odds of dyschezia (OR 2.44, 95%CI 1.01–5.89). Ovarian endometriosis was associated with more intense menstrual pain (median difference1.93, 95%CI 0.63–3.24) but with less intense intermenstrual pain (median difference − 2.30, 95%CI -3.89 to -0.71) and deep dyspareunia (median difference − 3.17, 95%CI -4.97 to -1.38). DIE of the USL was associated with lower odds of dyschezia (OR 0.36, 95%CI 0.14–0.92), whereas adenomyosis and DIE of the rectum or parametrium were not independently associated with any pain symptom. The response to therapy did not differ among localizations for most symptoms: women with ovarian endometriosis had higher odds of a smaller-than-average reduction of intermenstrual pain (OR 3.04, 95%CI 1.12–8.26), and women with DIE of the parametrium of deep dyspareunia (OR 5.31, 95%CI 1.02–27.60). A poorer response of deep dyspareunia was observed in women receiving P than EP (OR 4.03, 95%CI 1.49–10.92). At baseline all symptoms were more intense in cases than in controls except dysuria; at follow-up they remained higher except for menstrual pain and dysuria. The intensity of pain and its response to hormonal therapy were associated with the specific lesion localizations, rather than with the number of concomitant lesions. Superficial endometriosis appears to be the localization associated with more intense pain symptoms.