Long-term follow-up of endometriosis surgery in Ontario: a population-based cohort study

BACKGROUND

Endometriosis is a chronic gynecological disease affecting approximately 10% of reproductive aged females and leads to decreased quality of life and productivity. Despite effective medical options, many women do require surgery for endometriosis. There is limited literature examining long term outcomes of endometriosis surgery.

OBJECTIVE

This study aimed to characterize the long-term outcomes, including recurrence of symptoms, fertility outcomes, and need for reoperation, of patients who underwent surgical management for endometriosis.

STUDY DESIGN

This was a population-based cohort study in which the universal coverage health database for the province of Ontario, Canada, was used to identify women aged 18 to 50 years who underwent surgery for endometriosis from April 1, 2002, through March 31, 2018. Surgery was classified as diagnostic laparoscopy, conservative or uterine preserving (minor or major, with and without ovarian preservation), or hysterectomy (with and without ovarian preservation). The outcomes were evaluated from 30 days after the index surgery to the end of the study period or at censoring. Cox proportional hazard regression models were used to estimate the hazard ratios between exposures and outcomes following adjustment for confounders.

RESULTS

A total of 84,885 women 2,718 (3.2%) diagnostic laparoscopy, 21,594 (25.4%) minor conservative surgery, 28,484 (33.6%); major conservative with ovarian preservation, 2,102 (2.5%) major conservative without ovarian preservation, 21,609 (25.5%) hysterectomy with ovarian preservation, and 8,378 (9.9%) hysterectomy without ovarian preservation) were included in the cohort and followed for a median of 10 years (interquartile range, 6-13 years). In the first postoperative year, women who underwent diagnostic laparoscopy were significantly more likely to require repeat surgery (adjusted hazard ratio, 1.68; 95% confidence interval, 1.51-1.87), whereas those who underwent major conservative surgery were significantly less likely to require repeat surgery (with ovarian preservation: adjusted hazard ratio, 0.44; 95% confidence interval, 0.41-0.48; without ovarian preservation: adjusted hazard ratio, 0.05; 95% confidence interval, 0.03-0.09). Among women who did not receive repeat surgery in the first year, those who underwent a diagnostic laparoscopy (adjusted hazard ratio, 0.85; 95% confidence interval, 0.76-0.95) and major conservative surgery without ovarian preservation were less likely to undergo repeat surgery (adjusted hazard ratio, 0.12; 95% confidence interval, 0.09-0.18) than those who initially had minor surgery. Compared with those who initially underwent minor surgery, patients who underwent other treatment modalities were less likely to undergo a hysterectomy (diagnostic laparoscopy: adjusted hazard ratio, 0.85; 95% confidence interval, 0.75-0.96; major surgery with ovarian preservation: adjusted hazard ratio, 0.60; 95% confidence interval, 0.57-0.64; major surgery without ovarian preservation: adjusted hazard ratio, 0.05; 95% confidence interval, 0.03-0.08). Following minor and major conservative with ovarian preservation surgery, 8,331 (38.6%) and 9,498 (33.3%) of patients sought an infertility consult within 1 year, respectively. By 5 years after the index surgery, 5,290 (29.4%) of patients who had minor conservative surgery and 4,528 (20.7%) of those who had major conservative with ovarian preservation surgery had given birth at least once.

CONCLUSION

Our study suggests that only a few endometriosis patients who undergo hysterectomy surgery require repeat surgery; however, up to 1 in 4 who undergo minor surgery and 1 in 5 who undergo major conservative surgery with ovarian preservation require additional endometriosis surgery. Up to 1 in 3 patients who had uterine sparing endometriosis surgery subsequently sought an infertility assessment. These findings may inform preoperative counseling in terms of recurrence of symptoms, fertility outcomes, and need for reoperation of women seeking surgical management for endometriosis. Future studies should consider the outcomes of patient satisfaction and quality of life based on the current practices for management of endometriosis.

Impact of Minimally Invasive Gynaecology Fellowship Training on Quality Performance Metrics for Hysterectomy

OBJECTIVE

To evaluate differences in quality metrics between hysterectomies performed by fellowship-trained surgeons and those performed by generalists.

METHODS

Retrospective review of 2845 consecutive hysterectomies by 75 surgeons (23 fellowship-trained, 52 generalists) at 7 hospitals in Ontario, Canada. The primary outcome was a composite of any complication or return to the emergency department (ED) within 30 days of hysterectomy. Secondary outcomes were 2 quality outcome measures (grade of complication and return to ED within 30 days) and 4 quality process measures (minimally invasive hysterectomy rate, rate of preoperative anemia, same-day discharge for laparoscopic hysterectomy [LH], and performing cystoscopy at LH).

RESULTS

Fellowship-trained surgeons were more likely to perform concurrent resection of endometriosis, bilateral ureterolysis, lysis of adhesions, uterine/internal iliac artery ligation, and morcellation (all P < 0.001). Generalists performed more vaginal procedures, including vaginal repair, vault suspension, and insertion of mid-urethral sling (all P < 0.001). After controlling for patient and surgical factors, there was no difference in the primary outcome (adjusted odds ratio [aOR] 1.07; 95% CI 0.79-1.45, P = 0.667). Fellowship-trained surgeons were more likely to perform minimally invasive hysterectomy (aOR 2.38; 95% CI 1.15-4.93, P = 0.020), had higher rates of same-day discharge for LH (aOR 2.23; 95% CI 1.31-3.81, P = 0.003), and were more likely to perform cystoscopy (unadjusted OR 2.94; 95% CI 2.30-3.85, P < 0.001). There were no differences in the rates of preoperative anemia, surgical complications, and ED visits.

CONCLUSION

Differences exist between fellowship-trained surgeons and generalists regarding case mix and process quality metrics. Postoperative complications and readmissions were comparable for both groups of surgeons.

IL-33 activates ILC2 expansion and modulates endometriosis

Introduction: Chronic inflammation drives endometriosis (EM) and its associated symptoms. Interleukin (IL)-33, has gained therapeutic interest as it is elevated in the plasma, peritoneal fluid (PF), and lesions of EM patients. However, how IL-33 contributes to EM is largely unknown. For the first time, we demonstrate, using both human samples and murine models, that IL-33 expands local group 2 innate lymphoid cells (ILC2s) and that IL-33 activated ILC2s modulate hallmark features of EM.

Methods:

We identified ILC2s (CD45+Lin−CRTH2+CD127+ST2+) in the PF of EM patients using flow cytometry. Using immunofluorescence, we determine whether IL-33 forms epithelial or stromal cell niches within the EM lesion. Then, using our well established EM model, we induced EM in female C57Bl/6 mice and treated with PBS or IL-33. Hallmark features of EM were assessed including inflammation (using multiplex cytokine analysis), immune cell profiling (using flow cytometry), and lesion architecture (using immunohistochemistry and Nanostring transcriptomic profiling). To establish cause and effect, we treated ILC2 deficient mice with PBS (n=5) or IL-33 (n=5). Unpaired t-tests and one-way ANOVAs were done when appropriate.

Results/Discussion:

In humans, ILC2s are present and elevated in EM patients (n=5) compared to healthy donors (n=3) and IL-33 colocalized with both epithelial and stromal cells within the EM lesion. Using murine models, IL-33 drove hallmark features of EM including increased inflammation, alterations in PF immune cells (including eosinophils, T cells, macrophages and ILC2s), as well as increased lesion proliferation, neurogenesis and fibrosis. Using ILC2 deficient mice, we show that IL-33 induced pathology is ILC2 dependent.

Preoperative Factors of Endometrial Carcinoma in Patients Undergoing Hysterectomy for Atypical Endometrial Hyperplasia

OBJECTIVE

To identify clinicopathological preoperative factors associated with concurrent endometrial carcinoma in patients undergoing surgical management of atypical endometrial hyperplasia.

METHODS

The records of all patients who underwent hysterectomy for preoperatively diagnosed atypical endometrial hyperplasia at a tertiary care hospital from April 2017 to April 2020 were retrospectively reviewed. Clinicopathological characteristics of patients were extracted. Patients who did not undergo hysterectomy or who had evidence of simple hyperplasia or carcinoma on initial biopsy were excluded. Univariate analysis was performed. A multivariate regression model for progression to endometrial carcinoma was developed.

RESULTS

A total of 126 patients were included. Of these patients, 19 (15.1%) had a final diagnosis of endometrial carcinoma, whereas 86 (68.2%) retained the diagnosis of atypical endometrial hyperplasia and 21 (16.7%) were found to have no residual atypical endometrial hyperplasia. The odds of a patient being diagnosed with endometrial carcinoma were 6.1 times higher (95% CI 1.32-27.68) if they had an endometrial stripe thickness >1.1 cm and 13.5 times higher (95% CI 3.56-51.1) if there was histological suspicion of carcinoma. The odds of a patient being diagnosed with endometrial carcinoma were significantly lower if the patient had an initial diagnosis of atypical endometrial hyperplasia in a polyp (OR 0.07; 95% CI 0.02-0.34).

CONCLUSION

Our results suggest that an endometrial stripe thickness >1.1 cm, a histological suspicion of carcinoma on preoperative pathology, and the absence of polyp involvement on initial diagnosis are the strongest predictors of endometrial carcinoma at the time of hysterectomy in patients with atypical endometrial hyperplasia.

Short-term outcomes of endometriosis surgery in Ontario: A population-based cohort study

INTRODUCTION

Our objective was to compare the short-term outcomes by type of surgical management of endometriosis in Ontario, Canada and to characterize the population of women undergoing surgical management of endometriosis.

MATERIAL AND METHODS

We conducted a population-based cohort study including women aged 18-50 years undergoing same-day or inpatient surgery for endometriosis from 1 April 2002 through 31 March 2018. Surgery was classified as minimally invasive hysterectomy (MIH), total abdominal hysterectomy (TAH) or minor or major conservative (uterus-preserving) surgery. Outcomes examined included length of stay, intraoperative complications, postoperative complications, emergency department visits, ambulatory care visits, and readmission. We estimated the relative risk of these outcomes in minor, major conservative surgery and TAH vs MIH adjusted for age, income quintile, parity, and comorbidities.

RESULTS

A total of 85 605 patients underwent surgery, 12.9% MIH, 22.1% TAH, 36.3% major conservative, and 28.6% minor conservative. The mean age at index surgery was 37.6 ± 7.7 years. Before surgery, 70.6% of patients had visited a physician for pain at least once (64.7% MIH, 69.5% TAH, 71.1% major conservative and 73.4% minor conservative) and 23.5% of patients had sought infertility consultation (5.7% MIH, 6.6% TAH, 29.3% major conservative and 37.1% minor conservative). The overall risk of intraoperative and postoperative complications was 1.5% and 4.7%, respectively. In adjusted models, compared with those undergoing minor conservative surgery, those having major conservative surgery were 1.77 (95% CI 1.49-2.11) times as likely to experience an intraoperative complication, those having MIH and TAH were 2.55 (95% CI 2.08-3.13) and 2.34 (95% CI 1.93-2.82) times as likely to do so, respectively. Similarly, compared with those undergoing minor conservative surgery, those having major conservative surgery were 2.60 (95% CI 2.30, 2.93) times as likely to experience any postoperative complication, and those having MIH and TAH were 4.69 (95% CI 4.11-5.36) and 5.38 (95% CI 4.76-6.09) times as likely to do so, respectively.

CONCLUSIONS

Approximately one-third of patients undergoing surgical management for endometriosis in Ontario between 2002 and 2018 had a hysterectomy. Overall, complications following surgery were low, and dependent on extent of surgery. These results should help to inform preoperative counseling for patients and health policy development for providers.

Technicity in Canada: A Nationwide Whole-Population Analysis of Temporal Trends and Variation in Minimally Invasive Hysterectomies

STUDY OBJECTIVE

The objective of our study was to provide a contemporary description of hysterectomy practice and temporal trends in Canada.

DESIGN

A national whole-population retrospective analysis of data from the Canadian Institute for Health Information.

SETTING

Canada.

PATIENTS

All women who underwent hysterectomy for benign indication from April 1, 2007, to March 31, 2017, in Canada.

INTERVENTIONS

Hysterectomy.

MEASUREMENTS AND MAIN RESULTS

A total of 369 520 hysterectomies were performed in Canada during the 10-year period, during which the hysterectomy rate decreased from 313 to 243 per 100 000 women. The proportion of abdominal hysterectomies decreased (59.5% to 36.9%), laparoscopic hysterectomies increased (10.8% to 38.6%), and vaginal hysterectomies decreased (29.7% to 24.5%), whereas the national technicity index increased from 40.5% to 63.1% (p <.001, all trends). The median length of stay decreased from 3 (interquartile range 2-4) days to 2 (interquartile range 1-3), and the proportion of patients discharged within 24 hours increased from 2.1% to 7.2%. In year 2016-17, women aged 40 to 49 years had significantly increased risk of abdominal hysterectomy compared with women undergoing hysterectomy in other age categories (p <.001). Comparing women with menstrual bleeding disorders, women undergoing hysterectomy for endometriosis (adjusted relative risk [aRR] 1.36; 95% confidence interval [CI], 1.28-1.44) and myomas (aRR 2.01; 95% CI, 1.94-2.08) were at increased risk of abdominal hysterectomy, whereas women undergoing hysterectomy for pelvic organ prolapse and pelvic pain (aRR 1.47; 95% CI, 1.41-1.53) were at decreased risk. Using Ontario as the comparator, Nova Scotia (aRR 1.35; 95% CI, 1.27-1.43), New Brunswick (aRR 1.25; 95% CI, 1.18-1.32]), Manitoba (aRR 1.35; 95% CI, 1.28-1.43), and Newfoundland and Labrador (aRR 1.18; 95% CI, 1.10-1.27) had significantly higher risks of abdominal hysterectomy. In contrast, Saskatchewan (aRR 0.75; 95% CI, 0.74-0.77) and British Columbia (aRR 0.86; 95% CI, 0.85-0.88) had significantly lower risks, whereas Prince Edward Island, Quebec, and Alberta were not significantly different.

CONCLUSION

The proportion of minimally invasive hysterectomies for benign indication has increased significantly in Canada. The declining use of vaginal approaches and the variation among provinces are of concern and necessitate further study.

Venous Thromboembolism After Blood Transfusions in Women Undergoing Hysterectomy for Non-Malignant Indications: A Retrospective Cohort Study

OBJECTIVE

To quantify the effect of blood transfusion on the risk of venous thromboembolism (VTE) among women undergoing hysterectomy for non-malignant indications.

METHODS

A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was conducted. Women who underwent hysterectomy for non-malignant indications between 2011 and 2016 were identified using the Current Procedural Terminology and Internationally Classification of Diseases codes. The primary outcome was development of VTE. Data on patient demographics and perioperative variables were obtained. Pair-wise comparison using χ² tests were performed to compare women with and without VTE. Multivariable logistic regression was performed to adjust for potential confounders and identify independent predictors of VTE.

RESULTS

Between 2011 and 2016, 169 593 women underwent hysterectomy for non-malignant indications. The overall incidence of VTE was 0.32%. Patient characteristics associated with VTE included obesity and higher American Society of Anesthesiologists (ASA) status. Associated operative factors included abdominal surgery, blood transfusion, and prolonged operative time (P < 0.05 for all). Following adjustment for potential confounders, abdominal hysterectomy was associated with greater odds of VTE than laparoscopic or vaginal approaches (adjusted odds ratio [aOR] 1.81; 95% CI 1.48-2.21 and aOR 2.31; 95% CI 1.62-3.28, respectively). Greater odds of VTE were also observed with OR time >150 minutes (aOR 1.88; 95% CI 1.46-2.42), ASA class ≥III (aOR 1.53; 95% CI 1.05-2.26), and intra- and postoperative transfusion (aOR 2.65; 95% CI 1.78-3.95 and aOR 2.98; 95% CI 1.95-4.55, respectively).

CONCLUSION

The risk of VTE is low in women undergoing hysterectomy for non-malignant indications. Blood transfusion was associated with the highest risk of VTE.

Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis

BACKGROUND

Although surgery for endometriosis can improve pain and fertility, the risk of disease recurrence is high. There is little consensus regarding the benefit of medical therapy in preventing recurrence of endometriosis following surgery.

OBJECTIVE AND RATIONALE

We performed a review of prospective observational studies and randomised controlled trials (RCTs) to evaluate the risk of endometriosis recurrence in patients undergoing post-operative hormonal suppression, compared to placebo/expectant management.

SEARCH METHODS

The following databases were searched from inception to March 2020 for RCTs and prospective observational cohort studies: MEDLINE, Embase, Cochrane CENTRAL and Web of Science. We included English language full-text articles of pre-menopausal women undergoing conservative surgery (conserving at least one ovary) and initiating hormonal suppression within 6 weeks post-operatively with either combined hormonal contraceptives (CHC), progestins, androgens, levonorgesterel-releasing intra-uterine system (LNG-IUS) or GnRH agonist or antagonist. We excluded from the final analysis studies with <12 months of follow-up, interventions of diagnostic laparoscopy, experimental/non-hormonal treatments or combined hormonal therapy. Risk of bias was assessed using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale (NOS) for observational studies.

OUTCOMES

We included 17 studies (13 RCTs and 4 cohort studies), with 2137 patients (1189 receiving post-operative suppression and 948 controls), which evaluated various agents: CHC (6 studies, n = 869), progestin (3 studies, n = 183), LNG-IUS (2 studies, n = 94) and GnRH agonist (9 studies, n = 1237). The primary outcome was post-operative endometriosis recurrence, determined by imaging or recurrence of symptoms, at least 12 months post-operatively. The secondary outcome was change in endometriosis-related pain. Mean follow up of included studies ranged from 12 to 36 months, and outcomes were assessed at a median of 18 months. There was a significantly decreased risk of endometriosis recurrence in patients receiving post-operative hormonal suppression compared to expectant management/placebo (relative risk (RR) 0.41, 95% CI: 0.26 to 0.65), 14 studies, 1766 patients, I² = 68%, random effects model). Subgroup analysis on patients treated with CHC and LNG-IUS as well as sensitivity analyses limited to RCTs and high-quality studies showed a consistent decreased risk of endometriosis recurrence. Additionally, the patients receiving post-operative hormonal suppression had significantly lower pain scores compared to controls (SMD −0.49, 95% CI: −0.91 to −0.07, 7 studies, 652 patients, I² = 68%).

WIDER IMPLICATIONS

Hormonal suppression should be considered for patients not seeking pregnancy immediately after endometriosis surgery in order to reduce disease recurrence and pain. Various hormonal agents have been shown to be effective, and the exact treatment choice should be individualised according to each woman’s needs.

No. 371-Morcellation During Gynaecologic Surgery: Its Uses, Complications, and Risks of Unsuspected Malignancy

OBJECTIVE

This guideline provides guidance to gynaecologists regarding the use of tissue morcellation in gynaecologic surgery.

OUTCOMES

Morcellation may be used in gynaecologic surgery to allow removal of large uterine specimens, thus providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion.

EVIDENCE

Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyosarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, and morcellation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to July 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Gynaecologists offer women minimally invasive surgery, and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine (sarcoma, endometrial), cervical, and/or tubo-ovarian cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Tissue morcellation should be performed only after complete investigation, appropriate patient selection, and informed consent and by surgeons with appropriate training in the safe practices of tissue morcellation.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Quality of ultrasonography reporting and factors associated with selection of imaging modality for uterine fibroids in Canada: results from a prospective cohort registry

BACKGROUND

Uterine fibroids are common in women and their management is heavily influenced by information gathered through imaging. We aimed to evaluate the type and quality of imaging performed for assessment of uterine fibroids in Canada.

METHODS

Starting in July 2015, premenopausal women with symptomatic fibroids were enrolled in a prospective, noninterventional, observational registry (Canadian Women With Uterine Fibroids Registry [CAPTURE]) that included 19 Canadian sites. Clinical characteristics were extracted from the baseline visit. We evaluated the association between demographic and clinical variables of interest with regard to imaging type using unadjusted and adjusted logistic regression models.

RESULTS

Of 1493 women, 1148 had ultrasonography, 135 had magnetic resonance imaging (MRI), 80 had other types of imaging and 130 did not have imaging reported within 12 months of the baseline visit. After adjusting for demographic and clinical characteristics, patients who underwent MRI had larger fibroids (odds ratio [OR] per 1-cm increase 1.11, 95% confidence interval [CI] 1.05-1.17) and more numerous fibroids (1 v. > 1; OR 1.74, 95% CI 1.14-2.64) compared with those who underwent ultrasonography only. For ultrasonography reporting, quality criteria were met for 268 of 1148 patients (23.3%). There was a difference in the quality of reporting among the 19 sites (p < 0.001). Logistic regression model accounting for within-site variability showed that reporting results from ultrasonography in the province of Quebec were less likely to meet all quality criteria (OR 0.20, 95% CI 0.06-0.66) and those from sites in more populated cities (≥ 400 000 inhabitants) were more likely to do so (OR 6.15, 95% CI 2.20-17.18).

INTERPRETATION

We determined that imaging modality for fibroids is associated with patient characteristics. The quality of reporting results for ultrasonography of fibroids in Canada falls short of internationally endorsed guidelines and needs improvement.

STUDY REGISTRATION

ClinicalTrials.gov, no. NCT02580578.

Retrospective Comparison of PGE2 Vaginal Insert and Foley Catheter for Outpatient Cervical Ripening

OBJECTIVE

To compare the efficacy of two methods of outpatient cervical ripening (CR): an intracervical Foley catheter and a prostaglandin E₂ (PGE)₂ slow-release vaginal insert.

METHODS

All records of women receiving outpatient CR at a tertiary care hospital from January 2017 to June 2018 were retrospectively reviewed. We compared time from insertion of first CR agent until delivery between groups using a Cox proportional hazards (CPH) model. Exclusion criteria included age <18 years, multiple gestation, or contraindication to either CR method. Secondary outcomes included time from removal of agent and time from admission until delivery, additional CR used, uterine tachysystole, labour and delivery complications, type of delivery, and adverse neonatal outcomes.

RESULTS

A total of 153 patients were included (82 Foley; 71 PGE₂). Baseline characteristics were comparable except for lower dilation in the PGE₂ group (16% vs. 38% <1cm dilated; P < 0.05). In the CPH model, time from insertion to delivery was not different between PGE₂ and Foley catheter groups (median 27 vs. 33 h), controlling for parity, gestational age, initial dilation, and use of oxytocin (HR 1.13, 95% confidence interval 0.77-1.68). Patients in the PGE₂ group were more likely to experience uterine tachysystole (9% vs. 0%; P < 0.01) and require another method of CR (34% vs. 1%; P < 0.001). There were no differences in neonatal or maternal adverse outcomes between groups.

CONCLUSION

Our results suggest that outpatient Foley catheter and PGE₂ CR are comparable in time from insertion to delivery; however, PGE₂ inserts are associated with higher rates of tachysystole and the need for second CR method. A prospective study is warranted to further investigate these findings.

Dienogest and the Risk of Endometriosis Recurrence Following Surgery: A Systematic Review and Meta-analysis

STUDY OBJECTIVE

To determine whether dienogest therapy after endometriosis surgery reduces the risk of endometriosis recurrence compared with expectant management.

DATA SOURCES

Ovid MEDLINE, Ovid EMBASE, PubMed, Cochrane Central Register of Controlled Trials, Web of Science, LILACS, clinicaltrials.gov, and International Standard Randomized Controlled Trial Number Registry were searched from inception to March 2019 for observational and randomized controlled trials.

METHODS OF STUDY SELECTION

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Medical Subject Heading terms and keywords such as "dienogest," "endometriosis," and "recurrence" were used to identify relevant studies.

TABULATION, INTEGRATION, AND RESULTS

The search yielded 328 studies, 10 of which were eligible for inclusion, representing 1184 patients treated with dienogest and 846 expectantly managed controls. Among these studies, 9 looked exclusively at endometrioma recurrence, whereas 1 used reappearance of symptoms as evidence of disease recurrence. Data on both incidence of and time to recurrence of endometriosis were extracted. The incidence rate of endometriosis recurrence in patients treated with dienogest was 2 per 100 women over a mean follow-up of 29 months (95% confidence interval [CI], 1.43-3.11) versus 29 per 100 women managed expectantly over a mean follow-up of 36 months (95% CI, 25.66-31.74). The likelihood of recurrence was significantly reduced with postoperative dienogest (log odds -1.96, CI, -2.53 to -1.38, p <.001).

CONCLUSION

Patients receiving dienogest after conservative surgery for endometriosis had significantly lower risk of postoperative disease recurrence than those who were expectantly managed.

Influence of Ethnicity on Clinical Presentation and Quality of Life in Women With Uterine Fibroids: Results From a Prospective Observational Registry

OBJECTIVE

This study sought to evaluate ethnic variations in the clinical presentation of women with uterine fibroids.

METHODS

A total of 996 premenopausal women with symptomatic uterine fibroids were enrolled in a prospective, non-interventional, observational registry at 19 clinical sites across Canada (CAPTURE Registry). Patient-reported outcomes were assessed using Uterine Fibroid Symptom and Health-Related Quality of Life Symptom Severity questionnaires and the Aberdeen Menorrhagia Severity Scale (Ruta score). Linear and logistic regression models, adjusted for patient and fibroid characteristics, were used to examine differences among ethnicities for continuous and binary outcomes of interest.

RESULTS

Black women were 4.9 years younger (P < 0.001), were more likely to be nulligravid (P = 0.046), had a 41% longer duration of symptoms before enrolment (P = 0.01), had a 49% larger fibroid volume (P = 0.01), and were more likely to be anemic (P < 0.001) compared with White women. Black women reported lower health-related quality of life scores (-5.19 points; 95% CI -9.90 to -0.48, P = 0.03) compared with White women. East Asian women were 2.0 years younger (P = 0.01), were more likely to be nulligravid (P < 0.001), had a 53% longer duration of symptoms (P = 0.01), had 67% larger fibroid volume (P = 0.01), and were more likely to be anemic (P = 0.003) compared with White women. East Asian women had lower symptom severity scores (-5.95 points; 95% CI -11.16 to -0.75, P = 0.02). Non-White women preferred uterine-preserving treatment options (P < 0.001).

CONCLUSION

Black and East Asian women have an increased burden of disease compared with White women and prefer uterine preservation. There is a discrepancy between disease burden and patient-reported outcomes that may reflect ethnocultural differences in disease experience.

Influence of race/ethnicity on prevalence and presentation of endometriosis: a systematic review and meta-analysis

BACKGROUND

Understanding the impact of race/ethnicity on the prevalence and presentation of endometriosis may help improve patient care.

OBJECTIVE

To review systematically the evidence for the influence of race/ethnicity on the prevalence of endometriosis.

SEARCH STRATEGY

CENTRAL, MEDLINE, PubMed, Embase, LILACS, SCIELO, and CINAHL databases, as well as the grey literature, were searched from date of inception until September 2017.

SELECTION CRITERIA

Randomised control trials and observational studies reporting on prevalence and/or clinical presentation of endometriosis.

DATA COLLECTION AND ANALYSIS

Twenty studies were included in the review and 18 studies were used to calculate odds ratio (OR) with 95% confidence interval (CI) through a random effects model. Methodological quality was assessed using the Newcastle-Ottawa risk of bias scale (NOS).

MAIN RESULTS

Compared with White women, Black woman were less likely to be diagnosed with endometriosis (OR 0.49, 95% CI 0.29-0.83), whereas Asian women were more likely to have this diagnosis (OR 1.63, 95% CI 1.03-2.58). Compared with White women, there was a statistically significant difference in likelihood of endometriosis diagnosis in Hispanic women (OR 0.46, 95% CI 0.14-1.50). Significant heterogeneity (I2  > 50%) was present in the analysis for all racial/ethnic groups but was partially reduced in subgroup analysis by clinical presentation, particularly when endometriosis was diagnosed as self-reported, CONCLUSIONS: Prevalence of endometriosis appears to be influenced by race/ethnicity. Most notably, Black women appear less likely to be diagnosed with endometriosis compared with White women. There is scarce literature exploring the influence of race/ethnicity on symptomatology, as well as treatment access, preference, and response.

TWEETABLE ABSTRACT

Prevalence of endometriosis may be influenced by race/ethnicity, but there is limited quality literature exploring this topic.

Behind the times: revisiting endometriosis and race

Endometriosis is a common gynecologic condition, affecting approximately 10% of reproductive-aged women. It commonly presents with pelvic pain, painful periods, and infertility and can significantly have an impact on one's quality of life. Early exploration into the pathophysiology of this condition identified race as a risk factor for endometriosis, with the condition predominantly identified in white women. It is still unclear whether there is a biological basis for this conviction or whether it can be explained by methodological and social bias that existed in the literature at that time. Although there is more recent literature exploring the association between endometriosis and race/ethnicity, studies have continued to focus on the prevalence of disease and have not taken into account possible variation in disease presentation among women of different ethnicities. Furthermore, information on diverse populations by race/ethnicity, other than white or black, is quite limited. This paper explores the history of how the association between endometriosis and whiteness was established and whether we still ascribe to a certain stereotype of a typical endometriosis patient today. Furthermore, we discuss the potential implications of such a racial bias on patient care and suggest areas of focus to achieve a personalized and patient focused approach in endometriosis care.