The efficacy of combined hormonal contraception on pelvic pain in endometriosis patients

Combined hormonal contraception ineffectiveness is associated with worse chronic pelvic pain and pelvic floor myalgia.

Key Points

Highlights:

• Poorer quality-of-life is associated with a history of continuous combined hormonal contraception (CHC) discontinuation due to side-effects.

Importance:

• Tender pelvic floor may be a clinical marker of patients with endometriosis in whom hormonal suppression is inefficient.

What's done here:

• Researchers analyzed the prevalence of endometriosis patients with a history of combined hormonal contraception ineffectiveness for pain or CHC discontinuation.
• The authors also investigated the association between CHC ineffectiveness or discontinuation due to side-effects, as well as quality-of-life, psychological scores, and underlying pain conditions.
• They analyzed the data from 373 endometriosis patients of reproductive age in terms of self-reported questionnaires, physical examination findings, and validated instruments.
• The variables of this study were as the following: the history of cyclical CHC ineffectiveness (yes/no), history of cyclical CHC discontinuation due to side- effects (yes/no), history of continuous CHC ineffectiveness (yes/no) and history of continuous CHC discontinuation due to side-effects (yes/no).

Key Results:

• The ratio of participants priorly using cyclic CHC and continuous CHC was found to be 61.1% and 46.9%, respectively.
• Among 373 cases, 18–28% reported inefficacy of CHC for their pain, and 15–25% discontinued CHC due to side-effects.
• Worse CPP severity was associated with a history of continuous CHC ineffectiveness.
• The continuous CHC ineffectiveness was also associated with worse dysmenorrhea, deep dyspareunia, and dyschezia; pelvic floor myalgia, in addition to chronic pelvic pain.

Limitations:

• The present study involved some data from the patients’ retrospective recall.
• There was no data on the type of side-effects experienced by the patient, and the medication ineffectiveness was not reported using standardized criteria.
• Subgroup analysis is not possible.

Lay Summary

Chronic pelvic pain, which is experienced by more than 33% of endometriosis patients, constitutes a significant challenge for patients and physicians.

A new study that appears in the journal Human Reproduction Open has explored the prevalence of endometriosis patients with a history of combined hormonal contraception (CHC) ineffectiveness for pain or discontinuation due to side-effects. The researchers have also determined the association between CHC ineffectiveness or discontinuation due to side-effects and quality-of-life, psychological scores, and underlying pain conditions.

Yong PJ et al., from the University of British Columbia in Vancouver evaluated the data from 373 endometriosis patients who were under 50 years old and were not postmenopausal, in terms of self-reported questionnaires, physical examination findings, and validated instruments. The variables of interest included the history of cyclical CHC ineffectiveness (yes/no), history of cyclical CHC discontinuation due to side- effects (yes/no), history of continuous CHC ineffectiveness (yes/no) and history of continuous CHC discontinuation due to side-effects (yes/no).

Of all participants, 61.1% was found to report prior use of cyclic CHC, while 46.9% was found to report a history of using continuous CHC.  Among 373 cases, 18–28% reported inefficacy of CHC for their pain, and 15–25% discontinued CHC due to side-effects. The authors also cited other studies in the literature showing similar findings.

It was found that worse chronic pelvic pain severity was associated with a history of continuous CHC ineffectiveness, while poorer quality-of-life was associated with a history of continuous CHC discontinuation due to side-effects. Another observation was the association of pelvic floor tenderness with CHC ineffectiveness among the underlying conditions.

The researchers noted that the continuous CHC ineffectiveness was associated with worse dysmenorrhea, deep dyspareunia, and dyschezia. Based on these findings, they pointed out that pelvic floor myalgia may also be associated with these pain symptoms, in addition to chronic pelvic pain.

The authors acknowledge some limits to their study. First, this study involved some data from the patients’ retrospective recall. Furthermore, there was no data on the details of side-effects experienced by the patient, and the medication ineffectiveness was not reported using standardized criteria. Finally, it was impossible to perform subgroup analysis.

Based on the finding that CHC inefficacy in endometriosis patients was associated with worse chronic pelvic pain and pelvic floor myalgia, the team concluded that myofascial or nervous system contributors may be the culprit in chronic pelvic pain. They also put forward that tender pelvic floor may be a clinical marker of patients with endometriosis who don’t show an optimal response to hormonal suppression.

To help ease the side-effects of CHC for endometriosis patients reporting worse quality-of-life, the team suggests further research. Besides, to confirm that CHC is less effective in those with pelvic floor myalgia, they intend to carry out a clinical trial of CHC for pelvic pain, where patients are stratified by the presence of gynecologic and non-gynecologic pain generators.

Research Source: https://pubmed.ncbi.nlm.nih.gov/32128454/