Comparative Analysis of Medical Interventions to Alleviate Endometriosis-Related Pain: A Systematic Review and Network Meta-Analysis

Abstract

Background/Objectives: Endometriosis is a chronic condition that affects 6-10% of women of reproductive age, with pain and infertility being its primary symptoms. The most common aspects of pain are overall pelvic pain, dysmenorrhea, and dyspareunia. Our aim was to compare the available medical treatments for endometriosis-related pain. Methods: A systematic search was conducted in three medical databases to assess available drug options for pain management. Randomized controlled trials (RCTs) investigating various medical treatments for endometriosis-related pain on different pain scales were included. Results were presented as p-scores and, in cases of placebo controls, as mean differences (MD) with 95% confidence intervals (CI). From the available data, a network meta-analysis was carried out. Results: The search yielded 1314 records, of which 45 were eligible for data extraction. Eight networks were created, and a total of 16 treatments were analyzed. The highest p-score, meaning greatest pain relief (p-score: 0.618), for the treatment of dysmenorrhea was achieved using gonadotropin-releasing hormone (GnRH) agonists for 3 months on a scale of 0-100. Additionally, a p-score of 0.649 was attained following a 6-month treatment with GnRH agonists combined with hormonal contraceptives (CHCs). In the case of dyspareunia on a scale of 0-100 following 3 months of treatment, CHCs (p-score: 0.805) were the most effective, and CHCs combined with aromatase inhibitors (p-score: 0.677) were the best treatment option following 6 months of treatment. In the case of overall pelvic pain, CHCs (p-score: 0.751) yielded the highest p-score on a scale of 0-100 following 3 months of treatment, and progestins combined with aromatase inhibitors (p-score: 0.873) following 6 months of treatment. Progestins (p-score: 0.901) were most effective in cases of overall pelvic pain on a scale of 0-3 following 3 months of treatment. Conclusions: Our network meta-analysis showed that in cases of dysmenorrhea, GnRH agonists supplemented with CHCs reduced pain the most following 3 months of treatment. Regarding dyspareunia CHCs were most effective, and in the case of overall pelvic pain, CHCs or progestins combined with aromatase inhibitors yielded the most desirable results.

Keywords: Biberoglu and Behrman scale; LNG-IUDs; NSAIDs; SERM; SUCRA; VAS score; danazole; opioids.

Figure 1

PRISMA flow diagram.

Figure 2

Treatment options with the possibility of being ranked from best to worst efficacy in dysmenorrhea on a scale of 0–100 after 6 months. (A) Probability chart showing likelihood in percentage of treatments being ranked from best to worst based on the SUCRA values. (B) Forest plot showing calculated mean difference (MD) with its 95% confidence interval. (C) The analysis shows the probability of all interventions to match the top rank with a numerical representation of the SUCRA. The closer to 1 the SUCRA value is, the higher the likelihood that a therapy is in the top rank; the closer to 0 it is, the more likely that a therapy is in the bottom rank. (D) Network plot of randomized controlled trials comparing different treatment options. CHC = combined hormonal pill with estrogen and progesterone.

Figure 3

Treatment options with the possibility of being ranked from best to worst efficacy in overall pelvic pain on a scale of 0–100 after 6 months. (A) Probability chart showing likelihood in percentage of treatments being ranked from best to worst based on the SUCRA values. (B) Forest plot showing calculated mean difference (MD) with its 95% confidence interval. (C) The analysis shows the probability of all interventions to match the top rank with a numerical representation of the SUCRA. The closer to 1 the SUCRA value is, the higher the likelihood that a therapy is in the top rank; the closer to 0 it is, the more likely that a therapy is in the bottom rank. (D) Network plot of randomized controlled trials comparing different treatment options. CHC = combined hormonal pill with estrogen and progesterone.