Rethinking Pain in Deep Endometriosis

A neuropathic pain component shapes pain severity and quality of life in deep endometriosis.

Key Points

Highlights: 

• Neuropathic-like pain is present in over one-third of women with deep endometriosis and chronic pelvic pain.
• This pain phenotype is associated with greater pain intensity, increased emotional burden, and poorer quality of life, independent of disease stage.

Importance:

• Recognizing neuropathic-like pain in endometriosis is critical, as it identifies patients who may benefit from systematic screening and multidisciplinary pain management, beyond conventional surgical or hormonal approaches

What’s done here:

• A retrospective monocentric cohort study was conducted in 149 women with deep endometriosis and chronic pelvic pain.
• Pain characteristics, psychological factors, and quality of life were assessed using validated questionnaires, including the DN4 interview.

Key results:

• Neuropathic-like pain was identified in 36% of patients.
• Affected patients reported significantly higher global and minimum pain intensity, greater sensory and emotional pain impact, and markedly higher catastrophizing scores.
• Quality of life was significantly reduced in the neuropathic-like pain group.
• Neuropathic-like pain was not associated with endometriosis stage, surgical complexity, or anxiety and depression scores.

From the Editor-in-Chief – EndoNews

"This study adds important granularity to the understanding of endometriosis-associated pain by demonstrating that neuropathic-like mechanisms are not exceptional but affect a substantial proportion of patients with deep endometriosis and chronic pelvic pain. The finding that more than one-third of patients exhibit neuropathic-like pain features reinforces the concept that endometriosis-related pain is frequently multidimensional, extending beyond a purely nociceptive framework.

A key strength of this work lies in its careful phenotyping of pain using validated instruments. Patients with neuropathic-like pain reported higher pain intensity, greater sensory and emotional impact, increased catastrophizing, and significantly poorer quality of life. Notably, these differences were observed independently of disease stage or surgical complexity, further challenging the long-standing assumption that anatomical severity reliably predicts pain burden.

Equally important is what the study does not show. Anxiety and depression scores did not differ significantly between patients with and without neuropathic-like pain, suggesting that the observed differences in pain experience and quality of life cannot be explained simply by global psychological distress. This distinction is clinically relevant, as it points toward pain-specific mechanisms—such as peripheral nerve involvement and central sensitization—rather than generalized mood disorders as key drivers of symptom severity.

From a clinical perspective, these findings argue strongly for a shift in pain assessment strategies. Reliance on lesion extent or surgical history alone risks overlooking patients whose dominant pain mechanism is neuropathic. Systematic screening for neuropathic-like pain, using simple validated tools, could help identify individuals who may benefit from targeted, mechanism-based interventions rather than repeated surgical or hormonal escalation.

While the retrospective design and restriction to deep endometriosis limit generalizability, the study provides a robust rationale for integrating neuropathic pain assessment into routine endometriosis care. Future prospective and interventional studies will be essential to determine whether tailored multidisciplinary approaches can meaningfully improve outcomes in this distinct pain phenotype.

In endometriosis, recognizing how pain is generated may be just as important as identifying where the disease is located."

Lay Summary

A new study published in Archives of Gynecology and Obstetrics reports that more than one-third of women with deep endometriosis and chronic pelvic pain exhibit neuropathic-like pain, a pain phenotype associated with greater symptom severity and poorer quality of life.

In this retrospective cohort study, Dolci and colleagues analyzed 149 patients treated at a tertiary pain center in Lille, France. Pain characteristics were assessed using validated instruments, including the DN4 questionnaire for neuropathic pain, the Saint-Antoine Pain Questionnaire for sensory and emotional dimensions, and the EQ-VAS for quality of life. Psychological factors such as anxiety, depression, and pain catastrophizing were also evaluated.

Neuropathic-like pain was identified in 36% of patients and was associated with significantly higher global and minimum pain intensity, greater sensory and emotional pain impact, increased catastrophizing, and markedly reduced quality of life. Importantly, neuropathic-like pain showed no association with disease stage, surgical complexity, or anxiety and depression scores, underscoring that pain severity cannot be inferred from anatomical extent alone.

The findings highlight neuropathic-like pain as a distinct and clinically meaningful pain phenotype in deep endometriosis. As the authors emphasize, systematic screening and multidisciplinary, mechanism-oriented pain management may be essential to improve outcomes for affected patients.

Research Source: https://pubmed.ncbi.nlm.nih.gov/40928523/