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The available literature, from 2006 to 2017, on hormonal treatment has been analysed as a contribution to the HAS-CNGOF task force for the treatment of endometriosis. Available data are heterogeneous and the general level of evidence is moderate. Hormonal treatment is usually offered as the primary option to women suffering from endometriosis. It cannot be used in women willing to conceive. In women who have not been operated, the first line of hormonal treatment includes combined oral contraceptives (COC) and the levonorgestrel-releasing intra uterine system (52mg LNG-IUS). As a second line, desogestrel progestin only pills, etonogestrel implants, GnRH analogs (GnRHa) with add back therapy and dienogest can be offered. Add back therapy should include estrogens to prevent bone loss and improve quality of life, it can be introduced before the third month of treatment to prevent side effects. The literature does not support preoperative hormonal treatment for the sole purpose of reducing complications or recurrence, or facilitating surgical procedures. After surgical treatment, hormonal treatment is recommended to prevent pain recurrence and improve quality of life. COCs or LNG IUS are recommended as a first line. To prevent recurrence of endometriomas COC is advised and maintained as long as tolerance is good in the absence of pregnancy plans. In case of dysmenorrhea, postoperative COC should be used in a continuous scheme. GnRHa are not recommended in the sole purpose of reducing endometrioma recurrence risk.

Resume Objectif Etablir des recommandations de bonne pratique pour la prise en charge medicale de l’endometriose douloureuse chez les patientes sans infertilite. Methodes Revue de la litterature depuis 2006, etablissement des niveaux de preuve, relecture externe et gradation des recommandations par un groupe d’expert selon la methodologie de la HAS. Resultats Les traitements hormonaux recommandes en premiere intention pour le traitement de l’endometriose douloureuse sont la contraception par oestro-progestatifs (COP) et le systeme intra-uterin au levonorgestrel 52 mg (SIU au LNG) (grade B). Les traitements recommandes en deuxieme intention sont la contraception microprogestative au desogestrel, l’implant a l’etonogestrel, les agonistes de la GnRH (GnRHa) et le dienogest (grade C). En cas de prescription de GnRHa, il est recommande de prescrire une add-back therapie comportant un estrogene (grade B). En postoperatoire, hors desir de grossesse, il est recommande de prescrire un traitement hormonal par COP ou SIU au LNG en premiere intention (grade B). Apres chirurgie d’endometriome, la COP est recommandee pour reduire le risque de recidive (grade B) mais la prescription de GnRHa n’est pas recommandee dans ce but (grade C). La COP en prise continue est recommandee en cas de dysmenorrhee (grade B). Chez les adolescentes, la prescription de GnRHa n’est pas recommandee en premiere intention en raison des risques de demineralisation osseuse (grade B). L’endometriose est responsable de douleurs chroniques dont la prise en charge necessite une evaluation interdisciplinaire. Les therapeutiques non-medicamenteuses ameliorant la qualite de vie peuvent etre proposees (accord d’expert). D’autres therapeutiques medicamenteuses sont actuellement en cours d’evaluation.

Resume Objectif Analyser la litterature sur le traitement de l’endometriose douloureuse de l’adolescente. Methode Revue de la litterature entre janvier 2006 et decembre 2017. La recherche bibliographique etait realisee sur les bases de donnees Medline (Pubmed) et Cochrane database. Les meta-analyses, revues de la litterature, essais randomises controles, etudes de cohorte et etudes retrospectives etaient retenues. Les etudes traitant des dysmenorrhees de l’adolescente sans endometriose etaient exclues. Resultats Les etudes sont de qualite heterogene. Le dienogest et les agonistes de la GnRH (GnRHa) sont les seuls traitements evalues specifiquement pour le traitement de l’endometriose chez l’adolescente. Ils permettent une reduction des douleurs liees a l’endometriose. Les contraceptifs oestroprogestifs sont efficaces sur les dysmenorrhee de l’adolescente mais n’ont pas ete etudies dans les contextes d’endometriose. La densite minerale osseuse et la qualite de vie des patientes traitees par GnRHa est significativement meilleure sous add-back therapie comportant un œstrogene. Conclusion Le traitement medical de l’endometriose de l’adolescente comporte des specificites et des risques liees a l’âge. Le choix du traitement doit tenir compte des effets indesirables de chaque molecule.

First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas.

First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma.

First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma.

A major symptom of endometriosis is pelvic pain with a wide range of intensity, rhythm, type, and expression, without clearly established relationship between pain and the disease. Endometriosis-associated pain has physical, psychological/behavioral and social consequences with a significant impact on patient quality-of-life in relation with the biopsychosocial model of chronic pain. Pain assessment in all of its dimensions, as well as assessing the consequences of pain is therefore a crucial part of therapeutic management. Conventional analgesics are commonly used although studies demonstrating their efficacy in the treatment of endometriosis-related pelvic pain are lacking. Non-steroid anti-inflammatory drugs (NSAIDs), known to be effective in dysmenorrhea unrelated to endometriosis, have not been recently re-assessed in patients with endometriosis. Following rigorous assessment, the characterization of neuropathic components of endometriosis-related pelvic pain may lead to treatment with antiepileptic of antidepressant drugs, although gabapentin and amitriptyline have yet to be specifically assessed in the setting of endometriosis-related pain. Other pharmacologically active compounds have been tested to treat endometriosis-related pain but did not demonstrate efficacy with sufficient level of evidence. Diets, dietary supplements and herbal medicine are often proposed and/or used as adjuncts without any conclusive evidence. Although the effects on endometriosis-related pain are methodologically difficult to assess, physical adjunctive therapies such as acupuncture, transcutaneous neurostimulation, osteopathy/chiropractics, physical therapy and physical activity, the long-term therapeutic relationship they establish may potentiate beneficial effects perceived by patients. However, it remains difficult to demonstrate significant effects of cognitive and/or behavioral interventions on endometriosis-related pain.The complexity of managing endometriosis-related pain requires a holistic approach with sustained attention to the patient. Treatments, either pharmacologic or non-pharmacologic, including adjuvant therapies, associate a technical expertise to which a human approach must be added in order to bring value to these treatments. Multidisciplinary and/or inter disciplinary approaches are therefore essential to the care of patients suffering from endometriosis.

The available literature, from 2006 to 2017, on hormonal treatment has been analysed as a contribution to the HAS-CNGOF task force for the treatment of endometriosis. Available data are heterogeneous and the general level of evidence is moderate. Hormonal treatment is usually offered as the primary option to women suffering from endometriosis. It cannot be used in women willing to conceive. In women who have not been operated, the first line of hormonal treatment includes combined oral contraceptives (COC) and the levonorgestrel-releasing intra uterine system (52mg LNG-IUS). As a second line, desogestrel progestin only pills, etonogestrel implants, GnRH analogs (GnRHa) with add back therapy and dienogest can be offered. Add back therapy should include estrogens to prevent bone loss and improve quality of life, it can be introduced before the third month of treatment to prevent side effects. The literature does not support preoperative hormonal treatment for the sole purpose of reducing complications or recurrence, or facilitating surgical procedures. After surgical treatment, hormonal treatment is recommended to prevent pain recurrence and improve quality of life. COCs or LNG IUS are recommended as a first line. To prevent recurrence of endometriomas COC is advised and maintained as long as tolerance is good in the absence of pregnancy plans. In case of dysmenorrhea, postoperative COC should be used in a continuous scheme. GnRHa are not recommended in the sole purpose of reducing endometrioma recurrence risk.

To provide clinical practice guidelines for the management of painful endometriosis in women without infertility.Systematic review of the literature literature since 2006, level of evidence rating, external proofreading and grading of the recommendation grade by an expert group according to HAS methodology.Combined hormonal contraceptives (COP) and the levonorgestrel-releasing intra-uterin system (LNG-IUS) are recommended as first-line hormonal therapies for the treatment of painful endometriosis (grade B). Second-line therapy relies on oral desogestrel microprogestative, etonogestrel-releasing implant, GnRH analogs (GnRHa) and dienogest (grade C). It is recommended to use add-back therapy containing estrogen in association with GnRHa (grade B). After endometriosis surgery, hormonal treatment relying on COP or LNG-IUS is recommended to prevent pain recurrence (grade B). COP is recommended to reduce the risk of endometrioma recurrence after surgery (grade B) but the prescription of GnRHa is not recommended (grade C). Continuous COP is recommended in case of dysmenorrhea (grade B). GnRHa is not recommended as first line endometriosis treatment for adolescent girl because of the risk of bone demineralization (grade B). The management of endometriosis-induced chronic pain requires an interdisciplinary evaluation. Physical therapies improving the quality of life such as yoga, relaxation or osteopathy can be proposed (expert agreement). Promising medical alternatives are currently under preclinical and clinical evaluation.

To analyse the literature on the treatment of adolescent painful endometriosis.This work is based on a Review of the literature between January 2006 and December 2017. The Medline (Pubmed) and Cochrane database were searched for meta-analyzes, randomized trials, literature reviews, controlled, not controlled and retrospective studies published on the subject. Studies concerning adolescent's dysmenorrhea without endometriosis were excluded.Study quality is heterogeneous. Dienogest and GnRH agonists (GnRHa) are the only treatments specifically evaluated for the treatment of adolescent endometriosis. They reduce the pain associated with endometriosis. Combined oral contraceptives have not been studied in the context of endometriosis but they are effective on dysmenorrhea. Add back therapy, containing estrogens improves bone mineral density and quality of life for young women treated with GnRHa.Medical treatment of endometriosis in adolescent is associated with risks related to the young age. The therapeutic strategy should take into account the adverse effects of each treatment.

The gabapentinoids, which are a new generation of antiepileptics (AEs), have pharmacological properties that allow perioperative hyperalgesia to be reduced. They have little analgesic effect of their own, but they limit the intensity of pain and the use of analgesia postoperatively. Gabapentinoids thus reduce the incidence of chronic postsurgical pain.

Le rationnel pour l’utilisation d’antiepileptiques (AE) dans une strategie d’analgesie multimodale peri-operatoire est base sur un double constat, a la fois empirique et theorique. L’abord chirurgical provoque des lesions tissulaires et nerveuses qui conduisent a des manifestations d’hyperalgesie primaire au site lesionnel et secondaire en peripherie de celui-ci. Ces lesions sont ainsi a l’origine d’une hyperexcitabilite neuronale, en particulier au niveau de la corne dorsale de la moelle, phenomene communement appele sensibilisation. Deux hypotheses ont ete emises : 1) l’hyperexcitabilite neuronale medullaire impliquee dans les phenomenes d’hyperalgesie est liee pour une part a la transmission de l’information nociceptive au travers de synapses dont l’activite depend de l’ouverture de canaux calciques voltage-dependants, et pourrait donc etre reduite par des AE susceptibles de bloquer ces canaux ; 2) des lesions nerveuses etant induites par la chirurgie, certains AE etant des traitements des douleurs neuropathiques, leur utilisation pourrait prevenir l’apparition de douleurs post-operatoires chroniques. Tous les AE n’ont pas ete, a ce jour, utilises dans les strategies d’analgesie multimodale.

A questionnaire for self-assessment, the Amsterdam Preoperative Anxiety and Information Scale (APAIS) translated into French has been compared to a background questionnaire to validate their use as screening tool and assessment of anxiety and information needs of patients.An epidemiological study was conducted anonymously. Patients completed a questionnaire comprising a French version of APAIS and Spielberger Anxiety Inventory (STAI). A study of correlation between scores for each questionnaire was conducted. A high level of anxiety was investigated.So 1800 questionnaires were distributed, 1504 were usable. The first 100 questionnaires have confirmed the internal validity of the questionnaire APAIS. The following questionnaires in 1404 accounted 49.7% of men 55.7 ± 15.7 years old and 50.2% of women 50.8 ± 15.2 years old. The correlation coefficient (r) between STAI state and appeasement was of 0.675 (P0.001). A score higher than 10/20 by APAIS corresponded to 73% of patients with high anxiety by Spielberger's inventory. No correlation was found between the STAI state and the need for information (r=0.252; P0.001).APAIS, in its French version, assesses anxiety and information needs of patients. This questionnaire has metrological capabilities and ease of execution that make it a screening tool for use in anesthesia consultation. A score above 10 out of 20 reflects a high level of anxiety.

But du travail Alors que la douleur chronique est bien decrite apres cure de hernie inguinale, les donnees apres cure d’eventration sont rares. Le but de cette etude etait d’evaluer l’incidence, les caracteristiques et les facteurs predictifs de la douleur chronique apres cure d’eventration. Methodes Notre etude retrospective a inclus de 2005 a 2008 tous les patients operes d’une cure d’eventration avec plaque intraperitoneale biface. L’evaluation de la douleur chronique a ete realisee par un observateur independant, au moyen de 4 outils valides : (I) une echelle numerique en 11 points (score superieur a 3 : douleur chronique, superieur a 7 : douleur severe) ; (II) le questionnaire de la douleur de saint Antoine evaluant les composantes sensorielle et affective de la douleur ; (III) un questionnaire de douleur neuropathique, (iv) une echelle numerique en 5 points de satisfaction globale. Resultats Apres un suivi median de 21,1 mois, 134 patients ont ete evalues (109 ont complete les questionnaires, soit 81,3 %).Le taux de douleur chronique etait de 28,4 % (soit 31 patients) dont 6,6 % de douleur severe (7 patients). Les composantes de la douleur etaient sensorielle pour 19,3 % (6/31 patients) ou affective 45,1 % (14 /31patients). Une douleur neuropathique etait presente pour 6,4 % (7 patients). Le score de satisfaction global etait superieur ou egal a 3/4 pour 82,3 % (90 patients). En analyse multivariee, les facteurs predictifs de douleur chronique etaient la toux chronique (p = 0,001, OR 11,4), un abces parietal postoperatoire (p = 0,034, OR 4,5) et une recidive d’eventration (p = 0,05, OR 3,8). Conclusion La douleur chronique apres cure d’eventration est frequente mais rarement severe, principalement liee a la composante affective. La satisfaction globale des patients reste bonne. Une evaluation a plus long terme est necessaire.