Pain management

Pain management

Pain is a common symptom of endometriosis. The type of pain and degree of pain differs from person to person.

There are different types of pain and they all require a different approach, whether or not combined.

Types of pain

Visceral pain
Visceral pain is pain that arises from activation of a pain receptor that is connected to an organ in the chest, abdominal, or pelvic cavity. The nerve supply to the organs comes from different places along the spinal cord. As a result, the painful area is often difficult to identify. It is usually a scattered, dull and nagging pain with a feeling of discomfort. Sometimes there are other complaints such as nausea, vomiting, sweating, intestinal complaints and emotional reactions such as fear. This is because the nerve pathways that are connected to the organs not only conduct pain stimuli, but also the stimuli that ensure the function of these organs.

Neuropathic pain
Neuropathic pain (also called nerve pain or neuralgia) specifically refers to pain resulting from damage to the nervous system. This creates pain stimuli that have no function. It can arise from damage to one nerve or to a bundle of nerves. With endometriosis, the disease may grow around and sometimes even into to nerves of the sacral plexus which can result in severe buttock and sciatic type pain.

Neuropathic pain is described as stabbing, burning, painful, or like an electric shock; it is often accompanied by tingling or numbness. The painful area does not always have to be the same as where the nerve damage is located. Neuropathic pain does not respond well to common painkillers (paracetamol, NSAIDs or opioids). For neuropathic pain, medications are prescribed that work specifically on the overstimulation of nerves or brain.

Chronic pain
Chronic pain occurs when pain is experienced daily for 3 months or more. Sometimes there is a clear cause for this, but usually no physical cause can be found. This form of pain can be caused by sensitisation of the autonomic nervous system. This means that the brain is so used to sending a pain signal that it cannot stop it, even though pain is no longer present. You can compare this to “phantom pain”, when people still feel pain in a leg that has already been amputated.

Finally my complaints were listened to. At Endometriose in Balans, my problem was well managed and the gynaecologists have a real knowledge”. Lydia (aged 23)

Pain treatments

The treatment of pain is often complex. When there is a clear cause, the underlying problem can be addressed with medication or surgery. In the case of endometriosis or adenomyosis we then speak of hormonal therapy or, for example, the removal of the areas affected by endometriosis. When these treatments are not possible, or when they have taken place but have been insufficiently effective or when no good cause for pain can be found, pain treatment can offer a solution.

There is often a complex interaction between pain, behaviour, thoughts, emotions and social context. That means that the main treatment is actually multidimensional. The treatment consists of a combination of physiotherapy (sometimes specifically aimed at the problem area, such as with pelvic floor therapy), guidance by a psychologist (such as with cognitive behaviour therapy) and support with medication.

In addition to paracetamol and NSAIDs (diclofenac, naproxen, ibuprofen), other forms of pain relief are also possible. This depends on the type of pain you are experiencing. This, for example, may involve the use of pregabalin or amitriptyline. These are medications that can be effective when there is neuropathic or chronic pain. It should be used daily to build up a “medication level”. These medicines also have side effects that you should be informed about if prescribed.

Opiates (morphine-like medication) very rarely have a place in the treatment of endometriosis. This is because this type of analgesic treats a different type of pain than that which is caused by endometriosis. However, opiates do play a role in the management of post-operative pain.

TENS device
TENS stands for Transcutaneous Electrical Neuro Stimulation. With this treatment, the pain is reduced by means of weak electrical currents. It is important to note that TENS cannot eliminate the cause of the pain; it can reduce the pain by disrupting nerve conduction that makes you feel pain, by stimulating the release of pain-relieving substances by the body and by its muscle relaxant effect.

The TENS device is a handy device, with two cables to which you have to attach the electrodes. You stick these self-adhesive electrodes on the skin. The TENS device applies the electrical currents through the skin via the electrodes. The placement of the electrodes is specifically tailored to your situation. One can use TENS therapy three to four times a day. Depending on the type of TENS therapy, a treatment takes a minimum of 20 and a maximum of 60 minutes.

Ganglion IMPAR Infiltration
Ganglion Impar is a nerve node that is part of the autonomic or involuntary nervous system. It is located at the front at the junction of the sacrum and the tailbone. This nervous system is partly responsible for the pain sensation in the tailbone and the area around the anus. During the treatment one lies on one’s stomach and the correct position for the needle is determined under X-ray scanning at the buttock seam. After the skin has been disinfected, it is made numb with local anaesthetic. The needle is then inserted near the Impar ganglion. The doctor checks whether the needle is in the correct position with contrast fluid. Subsequently, local anaesthetic, with or without anti-inflammatory drugs (therapeutic block), is injected with the aim of treating the Impar ganglion.

Depending on the success of a trial block, it is decided to proceed to a long-acting block. With a long-acting (therapeutic) blockade, the effect can occur within 2 days, but it should be taken into account that the effect of the treatment can only occur after 6 weeks in many cases. Therefore, the effect of the treatment is evaluated only after 6-8 weeks.

Local / neuraxial nerve block
Between the vertebrae there are openings through which nerves run from the spinal cord to the trunk or limbs. The beginning of such a nerve is called nerve root. If the nerve root is irritated, radiating pain may develop in the trunk or limb that is supplied with sensation by this nerve root. In a nerve root block (sometimes called nerve node block), an attempt is made to influence the nerve root in such a way that the sensation of pain is no longer passed on to the brain. The specialist first tries to determine which nerve root is involved in the pain. This is done by one or more test blocks with an anesthetic fluid. However, it is not possible to run multiple trial blocks on the same day. If the test block is successful, the pain will in any case decrease by more than 50% compared to your original pain. This anesthetic effect is temporary and usually lasts for several hours. Once it has become clear which nerve root is involved in the pain, the pain specialist can try to treat the nerve root with current (PRF) or with an anti-inflammatory (corticosteroid). If necessary, the treatment can be repeated up to 2-3 times a year. The trial block or long-term nerve block lasts fifteen minutes to three quarters of an hour.

Pain treatment takes place in the pain clinic by specialised pain specialists. In consultation with you, we seek the optimal treatment.

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