Clinical & Expertise Section · June-July 2026

7 hours ago
4 min read

Beyond Lesions: Rethinking Pain Management in Endometriosis

Dr. Aurore Maire, general practitioner specializing in pain management, IFEM Endo France.

"The invisible is not non-existent."

It can be disconcerting to face a patient in the clinic who, despite a perfectly performed surgery or amenorrhea achieved through hormonal treatment, presents with persistent and often debilitating pain.

When faced with this situation, "classical" treatments (hormones and surgery) show their limits. To eliminate the pain, an advanced semiological analysis becomes indispensable to identify and treat the complex, intertwined mechanisms at play.

1. Semiological Analysis: Identifying the mechanisms of pain

To tailor patient management, it is crucial to distinguish nociceptive pain linked to active lesions from other chronic pain phenomena.

How to identify neuropathic pain?

Using an internationally validated questionnaire like the DN4 score is particularly useful in daily practice. During history-taking, look for key descriptors used by patients that evoke neuropathic characteristics:

Painful symptoms: Electrical shocks, burning, vise-like squeezing, painful cold sensation.
Associated symptoms: Paresthesia (tingling), dysesthesia (pins and needles), pruritus (itching), and numbness.

During the clinical examination, objective signs can confirm this direction: hypoesthesia to touch and/or pinprick, as well as mechanical allodynia (pain triggered by a normally painless stimulus, such as a simple touch or light brushing).

What signs point toward pelvic or central sensitization?

When a patient presents with severe pain despite the absence of visible endometriosis lesions on reference imaging (transvaginal pelvic ultrasound or pelvic MRI performed by a reference radiologist), or when facing continuous, non-cyclic pain despite amenorrhea achieved through hormonal therapy, a pelvic or central sensitization phenomenon must be systematically suspected.

To refine the diagnosis, two complementary clinical tools should be used:

The PP (Pelvi-Perineal) Convergence Score:

It evaluates three key clinical markers: a global lowering of the pain threshold (hyperalgesia), a temporal diffusion of pain, and a high variability of symptoms. A score greater than 4 confirms the orientation toward pelvic sensitization.

The CSI (Central Sensitization Inventory) Score:

This questionnaire, which is not specific to pelvic pain, applies to all types of chronic pain. Clinicians preferentially use Part A (25 somatic and emotional symptoms scored from 0 to 4 on a Likert scale, for a total score out of 100). Part B (history of psychiatric/somatic diagnoses) is generally excluded from clinimetric analyses.

Subclinical: 0 to 29
Mild: 30 to 39
Moderate: 40 to 49
Severe: 50 to 59
Extreme: 60 to 100

Management strategy in case of confirmed sensitization:

Educate the patient about the clinical phenomenon in an pedagogical manner to defuse misunderstanding.
Initiate specific treatments, as conventional analgesics (NSAIDs, opioids) prove structurally ineffective in this context. Neurostimulation (TENS), antiepileptics (Gabapentin, Pregabalin), or tricyclic antidepressants and SNRIs (Amitriptyline, Duloxetine, Venlafaxine) are preferred.

⚠️ Preoperative Alert: A pelvic or central sensitization phenomenon constitutes a major risk factor in the event of surgery. It is predictive of increased postoperative pain and insufficient relief of the initial pain symptoms. Therefore, it is formally recommended to implement these specific treatments prior to any surgical intervention.

The machinery of chronicity and its vicious cycles

When pain settles in, deleterious vicious cycles develop: the direct impact of pain on muscle tension, progressive physical deconditioning, and alteration of the thymic state (impact on mood and the emotional system) form a mechanism that enhances and perpetuates pain intensity. Breaking this cycle requires a comprehensive management approach, imperatively combining specialized physiotherapy and psychological support.

2. Differential diagnoses and clinical pitfalls to avoid

The primary pitfall in consultation: Minimizing the patient's pain, or worse, not believing her because her test results are reassuring.

The invisible is not non-existent. In chronic pain phenomena, imaging exams (such as MRIs) are frequently normal, and periods can be perfectly blocked. Other mechanisms are at play, and these can only be explored through history-taking and clinical examination.

A rigorous investigation is also necessary to look for differential diagnoses that can mimic or worsen the clinical picture:

Pelvic congestion syndrome.
Inflammatory bowel/digestive diseases.
Maigne's syndrome, etc.

3. The First-Line therapeutic arsenal

Treatment must be targeted and strictly adapted to each identified mechanism:

Type of Pain	First-Line Therapeutic Options
Neuropathic Pain & Sensitization (Pelvic / Central)	• Medicinal treatments: Anti-epileptics or antidepressants (Laroxyl, Duloxetine, Venlafaxine, Gabapentin, Lyrica). • Neurostimulation: Devices such as Urostim, Livia, Bluetens, Urgogyn. (Regulatory note: specific devices like the TENS eco 2 or Ecomodyn are restricted to prescription by a pain specialist/algologist or a physician holding an advanced degree in chronic pain).
Myofascial Pain	• Specialized pelvic physiotherapy. • Adapted Physical Activity (APA). • Local heat application and relaxation techniques.
Myometrial Hypercontractility	• Prescription of salbutamol (Ventolin or Airomir).
Inflammatory Pain	• Non-steroidal anti-inflammatory drugs (NSAIDs). • Nefopam. • Weak opioids (Tramadol, Codeine, Lamaline, Izalgi).

4. Lifestyle and nervous system regulation

Medical management benefits from being supported by holistic management measures, which have a direct and measurable impact on the inflammatory terrain and the patient's nervous system:

Diet: Adoption of an anti-inflammatory diet such as the Mediterranean diet, with strict avoidance of ultra-processed foods.
Stress Management: Integration of techniques to regulate the stress axis (heart coherence, meditation, hypnosis, relaxation) and psychological follow-up if necessary.
Overall Hygiene: Maintaining good hydration, regulating sleep, and practicing adapted physical activity.

5. When to Refer to a Specialized Pain Consultation?

Certain criteria, or "red flags", should prompt the primary care physician to refer the patient to a pain specialist within our network:

The clear identification of a pelvic or central sensitization phenomenon.
A major impact of pain on the patient's quality of life (repeated sick leave, cessation of leisure activities, impairment of social and family relationships).
The failure of well-managed first-line therapies.
The need to initiate a prescription for a specific restricted TENS device.

In Conclusion: The key take-home message

The earlier the pain is managed, the less chance it has of becoming chronic. Early screening and directed referral are essential. Adapted treatments exist for every pain mechanism: let us no longer leave patients in a therapeutic impasse.

Promising new options and therapeutic avenues are currently under study, paving the way forward:

Intramuscular botulinum toxin injections (targeting the muscles of the pelvi-perineal sphere).
Intramyometrial botulinum toxin injections.
Photobiomodulation sessions.
New perioperative analgesia protocols.
New vagus nerve stimulation techniques.

Research is advancing rapidly: let us no longer leave patients in a therapeutic impasse.

Dr. Aurore Maire, general practitioner specializing in pain management, IFEM Endo France.