CLINICAL QUESTION

What treatments are effective for endometriosis-related pain?

BOTTOM LINE

The network meta-analysis suggests that effective pharmacologic treatments for endometriosis-related pelvic pain include leuprolide, combined oral contraceptives, leuprolide plus combined oral contraceptives, and dienogest (available only as brand name Natazia). The conclusions were limited by concerns of potential bias based on lack of masking in many of the included studies. (Level of Evidence = 1a−)

SYNOPSIS

The aim of the network meta-analysis of pharmacologic treatments for endometriosis-related pain (including dysmenorrhea, dyspareunia, and nonmenstrual pelvic pain) was to estimate their comparative efficacy despite a lack of head-to-head trials. The authors included 31 randomized controlled trials (N = 8,665 participants) that evaluated 21 therapeutic interventions. Inclusion criteria included a study population of patients with histologically confirmed endometriosis or a diagnosis via imaging (transvaginal ultrasonography or magnetic resonance imaging) plus pelvic pain (cyclic or noncyclic) for at least 6 months. The authors excluded nonrandomized controlled trials and studies with unavailable data. They assessed the methodologic quality of the included studies using the Cochrane risk-of-bias tool for randomized trials. They found that many studies had a high risk of bias based on lack of or unclear masking. For the primary composite outcome of endometriosis-related pain (16 studies with 3,336 participants), the authors found that four regimens were superior to placebo: (1) leuprolide, (2) dienogest, (3) combined oral contraceptives, and (4) leuprolide plus combined oral contraceptives. Leuprolide plus combined oral contraceptives was not significantly more effective than leuprolide alone (standardized mean difference = −0.35; 95% CI, −1.25 to 0.56) or combined oral contraceptives alone (standardized mean difference = −0.73; −1.64 to 0.18). Nonsteroidal anti-inflammatory drugs were not included in this analysis.