The direct and indirect costs associated with endometriosis: a systematic literature review

Internet-based cognitive behavioral therapy for improving health-related quality of life in patients with endometriosis: study protocol for a randomized controlled trial

BACKGROUND

The trial investigates the efficacy of internet-based cognitive behavioral therapy (iCBT) in improving health-related QoL in patients with endometriosis, which is a chronic gynecological condition affecting up to 15% of people with female-assigned reproductive organs. Endometriosis is stress-related and comes with various physical symptoms such as pelvic pain and infertility. It has a substantial impact on health-related quality of life (QoL), and mind-body interventions seem promising in reducing the psychological burden.

METHODS

This is a monocentric randomized-controlled trial recruiting 120 patients with endometriosis. The intervention consists of eight iCBT modules focusing on psychoeducation, cognitive restructuring, pacing, and emotion regulation. Participants will receive written feedback from a trained therapist weekly. The comparator is a waitlist control group. All participants will be followed up 3 months after the intervention, and the intervention group will additionally be followed up 12 months after the intervention. Trial participants will not be blinded to the allocated trial arm. Primary outcome measures are endometriosis-related QoL, pain, and pain-related disability. Secondary outcomes include coping, illness representations, and psychological flexibility. Statistical analyses will be performed following intention-to-treat principles.

DISCUSSION

This randomized-controlled trial is the first trial to test the efficacy of iCBT for improving endometriosis-related QoL. Potential predictor variables and key mechanisms in treatment will be investigated to enable further progression in medical and psychological care for patients with endometriosis.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT05098444 Registered on October 28, 2021.

Burden of Endometriosis: Infertility, Comorbidities, and Healthcare Resource Utilization

The goal of our study was to evaluate the burden of endometriosis in the community by comparing healthcare resource utilization, total direct medical costs, infertility, and comorbidity rates of women with and without a diagnosis of endometriosis. A retrospective case–control study was performed using the databases of a 2.1 million-member nationwide healthcare plan. The study population included women aged 15–55 years enrolled in the healthcare plan. Women with a diagnosis (ICD-9) of endometriosis were compared to controls without diagnosed endometriosis. Women were individually matched (1:4) on age and residence area. Patient characteristics were described, including infertility, comorbidities, and annual healthcare resource utilization. Total direct medical costs were analyzed in a generalized linear model adjusting for age. Women with endometriosis (n = 6146, mean age ± SD: 40.4 ± 8.0 y) were significantly more likely than controls (n = 24,572) to have a lower BMI and a higher socioeconomic status. After adjusting for BMI and socioeconomic status, endometriosis was significantly associated with infertility (OR = 3.3; 95% CI 3.1–3.5), chronic comorbidities, higher utilization of healthcare services (hospitalization: OR = 2.3; 95% CI 2.1–2.5), pain medications, and antidepressants. Women aged 15–19 y with endometriosis had substantially higher utilization of primary care visits (57.7% vs. 14.4%) and oral contraceptive use (76.9% vs. 9.6%). Direct medical costs associated with endometriosis were higher than those for controls (OR = 1.75; 95% CI 1.69–1.85). Endometriosis is associated with a high burden of comorbidities, increased healthcare resource utilization, and excess costs, particularly for younger patients whose healthcare needs may differ widely from the older population.

Robot-assisted laparoscopy for deep infiltrating endometriosis: a retrospective French multicentric study (2008-2019) using the Society of European Robotic Gynecological Surgery endometriosis database

OBJECTIVE

This study aimed at assessing perioperative results of robot-assisted laparoscopy (RAL) in the context of deep infiltrating endometriosis (DIE).

METHODS

This retrospective French multicentric study included all patients with DIE who underwent surgical treatment managed by RAL (Da Vinci® System). From November 2008 to June 2019, patients were included in a single European database, in Robotic Assisted Laparoscopic Gynecologic Surgery, with Society of European Robotic Gynecological Surgery collaboration. Patients had different DIE sites as follows: gynecological, urological, or digestive, or combinations of these. Surgical procedures and perioperative complications were evaluated. To assess complications, patients were divided into the following four groups according to surgical procedure and DIE site: gynecological only; gynecological and urological; gynecological and digestive; and gynecological, urological, and digestive.

RESULTS

A total of 460 patients treated at one of eight health-care facilities from November 2008 to June 2019 were included. Median operative time was 245 min (IQR 186-320), surgeon console time was 138 ± 75 min and estimated blood loss was 70.0 mL ± 107 mL. Among this patient sample, 42.1% had a multidisciplinary surgical approach with a digestive or urology surgeon in addition to gynecology surgeon (25.5% and 16.6% of cases, respectively). Among those with intraoperative complications (n = 25, 5.4%) were primarily conversion to laparotomy (n = 6, 2.0%), transfusion (n = 2, 0.6%), and organ wounds (n = 8, 1.7%). Overall, 5.6% had severe postoperative complications (Clavien-Dindo classification ≥ Grade 3).

CONCLUSION

This is among the largest published series addressing RAL for DIE. Interest in this procedure appears promising, with no observed increases in blood loss or in peri- or post-operative complications. DIE laparoscopic surgery can require complex surgical procedures performed by multidisciplinary surgical teams. Thus, it may be one of the best candidates for RAL within gynecology surgery.

'Physio-EndEA' Study: A Randomized, Parallel-Group Controlled Trial to Evaluate the Effect of a Supervised and Adapted Therapeutic Exercise Program to Improve Quality of Life in Symptomatic Women Diagnosed with Endometriosis

Aim: The ‘Physio-EndEA’ study aims to explore the potential benefits of a therapeutic exercise program (focused on lumbopelvic stabilization and tolerance to exertion) on the health-related quality of life (HRQoL) of symptomatic endometriosis women. Design: The present study will use a parallel-group randomized controlled trial design. Methods: A total of 22 symptomatic endometriosis women will be randomized 1:1 to the Physio-EndEA or usual care groups. The ‘Physio-EndEA’ program will consist of a one-week lumbopelvic stabilization learning phase followed by an eight-week phase of stretching, aerobic and resistance exercises focused on the lumbopelvic area that will be sequentially instructed and supervised by a trained physiotherapist (with volume and intensity progression) and adapted daily to the potential of each participant. The primary outcome measure is HRQoL. The secondary outcome measures included clinician-reported outcomes (pressure pain thresholds, muscle thickness and strength, flexibility, body balance and cardiorespiratory fitness) and patient-reported outcomes (pain intensity, physical fitness, chronic fatigue, sexual function, gastrointestinal function and sleep quality). Discussion: Findings of this study will help to identify cost-effective non-pharmacological options (such as this exercise-based intervention) that may contribute to the improvement of HRQoL in symptomatic endometriosis women.

Maternal-Fetal Outcomes in Women with Endometriosis and Shared Pathogenic Mechanisms

The connection between endometriosis and pregnancy outcomes is trending among the research topics. Until recently, endometriosis and its painful symptomatology were considered to be alleviated by pregnancy. However, these beliefs have shifted, as emerging literature has demonstrated the role of this condition in affecting pregnancy evolution. The underlying pathogenesis of endometriosis is still poorly understood, all the more when pregnancy complications are involved. Debatable opinions on endometriosis associated with obstetric complications exist because of the potential bias resulting from the heterogeneity of preceding evidence. This review aims to evaluate the connection between endometriosis and adverse pregnancy outcomes and their shared pathogenic mechanisms. We searched PubMed and EMBASE and focused on the studies that include placenta praevia, premature rupture of membranes, spontaneous preterm birth, gestational hypertension, preeclampsia, obstetric hemorrhages (ante- and postpartum bleeding, abruptio placentae), miscarriage, stillbirth, neonatal death, gestational diabetes mellitus, gestational cholestasis, small for gestational age, and their association with endometriosis. Not only the risks of emergence were highlighted, but also the pathogenic connections. Epigenetic alterations of some genes were found to be mirrored both in endometriosis and obstetric complications. This review issues a warning for providing increased attention to pregnant women with endometriosis and newborns as higher risks of preeclampsia, placental issues, and preterm deliveries are associated.

GnRH Antagonists with or without Add-Back Therapy: A New Alternative in the Management of Endometriosis?

To evaluate the effectiveness of a new class of medical drugs, namely oral gonadotropin-releasing hormone (GnRH) antagonists, in the management of premenopausal women with endometriosis-associated pelvic pain. We reviewed the most relevant papers (n = 27) on the efficacy of new medical alternatives (oral GnRH antagonists) as therapy for endometriosis. We first briefly summarized the concept of progesterone resistance and established that oral contraceptives and progestogens work well in two-thirds of women suffering from endometriosis. Since clinical evidence shows that estrogens play a critical role in the pathogenesis of the disease, lowering their levels with oral GnRH antagonists may well prove effective, especially in women who fail to respond to progestogens. There is a need for reliable long-term oral treatment capable of managing endometriosis symptoms, taking into consideration both the main symptoms and phenotype of the disease. Published studies reviewed and discussed here confirm the efficacy of GnRH antagonists. There is a place for GnRH antagonists in the management of symptomatic endometriosis. Novel algorithms that take into account the different phenotypes are proposed.

Stepwise Approach to the Management of Endometriosis-Related Dysmenorrhea: A Cost-Effectiveness Analysis

OBJECTIVE

To evaluate the cost effectiveness of sequential medical and surgical therapy for the treatment of endometriosis-related dysmenorrhea.

METHODS

A cost-effectiveness model was created to compare three stepwise medical and surgical treatment strategies compared with immediate surgical management for dysmenorrhea using a health care payor perspective. A theoretical study cohort was derived from the estimated number of reproductive age (18-45) women in the United States with endometriosis-related dysmenorrhea. The treatment strategies modeled were: strategy 1) nonsteroidal antiinflammatory drugs (NSAIDs) followed by surgery; strategy 2) NSAIDs, then short-acting reversible contraceptives or long-acting reversible contraceptives (LARCs) followed by surgery; strategy 3) NSAIDs, then a short-acting reversible contraceptive or LARC, then a LARC or gonadotropin-releasing hormone modulator followed by surgery; strategy 4) proceeding directly to surgery. Probabilities, utilities, and costs were derived from the literature. Outcomes included cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Univariate, bivariate, and multivariate sensitivity analyses were performed.

RESULTS

In this theoretical cohort of 4,817,894 women with endometriosis-related dysmenorrhea, all medical and surgical treatment strategies were cost effective at a standard willingness-to-pay threshold of $100,000 per QALY gained when compared with surgery alone. Strategy 2 was associated with the lowest cost per QALY gained ($1,155). Requiring a trial of a third medication before surgery would cost an additional $257 million, compared with proceeding to surgery after failing two medical treatments. The probability of improvement with surgery would need to exceed 83% for this to be the preferred first-line approach.

CONCLUSION

All sequential medical and surgical management strategies for endometriosis-related dysmenorrhea were cost effective when compared with surgery alone. A trial of hormonal management after NSAIDs, before proceeding to surgery, may provide cost savings. Delaying surgical management in an individual with pain refractory to more than three medications may decrease quality of life and increase cost.

Translational Applications of Linear and Circular Long Noncoding RNAs in Endometriosis

Endometriosis is a chronic gynecologic disease that negatively affects the quality of life of many women. Unfortunately, endometriosis does not have a cure. The current medical treatments involve hormonal manipulation with unwanted side effects and high recurrence rates after stopping the medication. Sadly, a definitive diagnosis for endometriosis requires invasive surgical procedures, with the risk of complications, additional surgeries in the future, and a high rate of recurrence. Both improved therapies and noninvasive diagnostic tests are needed. The unique molecular features of endometriosis have been studied at the coding gene level. While the molecular components of endometriosis at the small RNA level have been studied extensively, other noncoding RNAs, such as long intergenic noncoding RNAs and the more recently discovered subset of long noncoding RNAs called circular RNAs, have been studied more limitedly. This review describes the molecular formation of long noncoding and the unique circumstances of the formation of circular long noncoding RNAs, their expression and function in endometriosis, and promising preclinical studies. Continued translational research on long noncoding RNAs, including the more stable circular long noncoding RNAs, may lead to improved therapeutic and diagnostic opportunities.

AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score

STUDY OBJECTIVE

To develop a new endometriosis classification system for scoring intraoperative surgical complexity and to examine its correlation with patient-reported pain and infertility.

DESIGN

Multicenter study of patients treated at 3 recognized endometriosis centers.

SETTING

Three specialized endometriosis surgical centers in São Paulo, Brazil and Barcelona, Spain.

PATIENTS

Patients aged 15 to 45 years with histologically proven endometriosis and no history of pelvic malignancy underwent laparoscopic treatment of endometriosis.

INTERVENTIONS

Demographic data and clinical history, including dysmenorrhea, noncyclic pelvic pain, dyspareunia, dysuria and dyschezia, were prospectively recorded. All patients were staged surgically according to the new 2021 American Association of Gynecologic Laparoscopists (AAGL) and revised American Society of Reproductive Medicine (ASRM) classification systems. The staging for each system was compared against a 4-level surgical complexity scale defined by the most complex procedure performed.

MEASUREMENTS AND MAIN RESULTS

A total of 1224 patients undergoing surgery met inclusion criteria. The AAGL score discriminated between 4 stages of surgical complexity with high reproducibility (κ = 0.621), whereas the ASRM score discriminated between the complexity stages with poor reproducibility (κ = 0.317). The AAGL staging system correlated with dysmenorrhea, dyspareunia, dyschezia, total pain score, and infertility comparably with the ASRM staging system.

CONCLUSION

The AAGL 2021 Endometriosis Classification allows for identifying objective intraoperative findings that reliably discriminate surgical complexity levels better than the ASRM staging system. The AAGL severity stage correlates comparably with pain and infertility symptoms with the ASRM stage.

Awareness of Endometriosis Symptoms-A Cross Sectional Survey among Polish Women

Background: Endometriosis is a chronic inflammatory condition characterized by the presence of endometrial-like tissue outside of the uterine cavity. It affects approximately 6–12% among reproductive-age women. Laparoscopy is still the gold standard for diagnosing it. Since an average of couple of years elapses from the onset of symptoms to the definitive diagnosis, analysis of symptoms could serve as a non-invasive diagnostic tool. Methods: An anonymous survey was distributed online in November 2019. It contained 23 closed questions, which covered two areas: knowledge and awareness of endometriosis symptoms and its presence among respondents. Results: A total of 3319 women completed the survey, of which 328 were diagnosed with endometriosis (9.9%). The symptoms of endometriosis most often indicated by the general population were infertility and dysmenorrhea. In contrast, those least frequently indicated were painful defecation and dysuria. Respondents suffering from endometriosis indicated that they often or sometimes experienced dysmenorrhea (83%, n = 273), pelvic pain not related to menstruation (72%, n = 235), dyspareunia (68%, n = 223) and painful defecation or dysuria (40%, n = 132). Conclusions: Since the search for a non-invasive diagnostic endometriosis marker has been conducted for many years without success so far, it seems that awareness of the clinical presentation and reported symptoms may help to provide earlier diagnoses.

General practitioners and endometriosis: Level of knowledge and the impact of training

OBJECTIVE

To assess general practitioners' (GPs') knowledge of and practice in the diagnosis and management of endometriosis following the publication of updated French national guidelines in 2017.

MATERIALS AND METHODS

A descriptive, anonymous, epidemiological survey of 102 GPs in the Picardie region of France.

RESULTS

Only 25% of the GPs considered that they knew enough about endometriosis for their routine clinical practice. This proportion was 58.9% amongst GPs with an university diploma in gynaecology and 31.4% amongst those participating in continuing medical education courses on gynaecology. Only 19.6% of the GPs were aware of the updated French national guidelines. With regard to five main suggestive, localizing signs of endometriosis, dyspareunia, dysmenorrhoea and infertility were mentioned as being of diagnostic value by 55.9%, 37.3% and 43.1% of the GPs, respectively; in contrast, functional urinary tract disorders and painful defecation were not mentioned very often. GPs with a qualification in gynaecology and those participating in continuing medical education in gynaecology knew more about treating endometriosis.

CONCLUSION

In the Picardie region of France, GPs appear to be only moderately aware of how to manage endometriosis; this probably contributes to the diagnostic delay associated with this condition. GPs with a university diploma in gynaecology and those participating in continuing medical education in gynaecology appeared to have a better grasp of the subject. Continuing medical education on this topic should therefore be promoted and expanded.

Improving clinical care for women with endometriosis: qualitative analysis of women's and health professionals' views

PURPOSE

Endometriosis is a chronic condition where endometrial-like cells proliferate outside the uterus causing pain and disability. Limited treatments are available but symptom management is essential for social and economic participation. The aim was to compare women's and health professionals' perceptions of quality of endometriosis health care and opportunities for improvements.

METHODS

Women participated in closed moderated online discussion groups and health professionals in semi-structured telephone interviews. Discussion group text and interview transcripts were thematically analyzed using the Framework Analysis approach.

RESULTS

Forty-six women, 12 general practitioners (GPs), and 1 gynecologist participated. Endometriosis can have debilitating consequences. However, women reported that healthcare providers may dismiss symptoms, lack essential knowledge and provide inconsistent advice; treatments are seldom successful or without adverse side-effects. Health professionals acknowledged limitations in expertise, persistent myths, and challenges in achieving best practice. Enhancing collaborative care skills, individualized treatment plans, and local referral pathways to multi-disciplinary care may improve satisfaction with endometriosis care-giving and receiving.

CONCLUSIONS

This is the first comparison of patient and practitioner perceptions of endometriosis in primary healthcare. Models of multi-disciplinary, collaborative care need to be developed and evaluated against consumer-informed measures of women's wellbeing, quality of life and satisfaction with symptom management and health care.

Endometriosis-A Multifaceted Problem of a Modern Woman

Endometriosis is a chronic disease of unclear aetiology that affects millions of women around the world. It causes chronic pain, dysmenorrhea, and infertility, which significantly reduces the quality of daily life. The aim of the following study was a multivariate analysis of the functioning of women diagnosed with endometriosis, and the identification of the relationship between the level of physical activity and sexual functioning, ability to cope with stress, and the degree of anxiety and mood disorders. The prospective survey was conducted of 957 women. The research was carried out using standardised IPAQ, FSFI, HADS, and Mini-Cope questionnaires. The study showed that patients with endometriosis exhibit a higher level of depression and anxiety disorders (p = 0.01) and a lower level of sexual functions (p < 0.001). The influence of physical activity on the functioning of patients with endometriosis was demonstrated. Depending on the clinical stage of endometriosis, the influence of physical activity on individual aspects of life differed. Physical activity was shown, inter alia, to reduce anxiety (p = 0.015), and influence stress-coping strategies. Endometriosis affects the mental and physical health of women. Physical activity can reduce the severity of endometriosis symptoms and improve the daily functioning of patients.

Development of a visual, patient-reported tool for assessing the multi-dimensional burden of endometriosis

OBJECTIVE

Inadequate communication about endometriosis symptom burden between women and healthcare providers is a barrier for optimal treatment. This study describes the development of the EndoWheel, a patient-reported assessment tool that visualizes the multi-dimensional burden of endometriosis to facilitate patient-provider communication.

METHODS

Assessment questions for the tool were developed using an iterative Delphi consensus process. A consensus phase included additional practitioners and specialists to broaden perspectives and select revised statements. Semi-structured qualitative interviews were conducted with 13 women with endometriosis to assess the scoring and content of the measures.

RESULTS

Symptoms included in the tool were pelvic pain, vaginal bleeding, bowel/bladder symptoms, energy levels, fertility, impact on activities, emotional and sexual well-being, and self-perceived global health. Additional life impact areas included relationships, social and occupational activity, and self-perception. The 13 interviewees completed the tool in approximately 5-6 min (range 4.0-7.5 min). Most participants (92%) perceived that the tool would enable better patient-provider communication, including addressing symptoms and areas of impact not normally discussed during office visits.

CONCLUSION

Similar to visual circular tools used in burden assessment of other chronic diseases, the tool may facilitate improved patient dialogue with providers around endometriosis treatment goals and options.

Medical management of endometriosis

INTRODUCTION

Endometriosis is a benign gynecologic disorder that is defined as functional endometrial tissue outside of the uterine cavity. It is an estrogen-dependent, inflammatory disease that leads to symptoms of pelvic pain, dysmenorrhea, dyspareunia, and infertility, occurring in 6-10% of reproductive aged women. The severity of the disease ranges from asymptomatic to debilitating symptoms that have a major impact on women's lives. It is a chronic, recurrent disease, frequently requiring long term management until menopause and beyond. It is considered a chronic disorder that is managed with surgery, medical treatment, and oftentimes, both. Current medical therapy for endometriosis is considered suppressive of the disease, rather than curative. Fortunately, many patients do experience improvement and control of their symptoms with medical therapy. However, long-term efficacy of the medical treatments is often limited by side effects and the cost of therapy, and symptoms do tend to recur after discontinuation of these medications.

AREAS COVERED

This review summarizes our understanding of the pathogenesis of endometriosis and provides more in-depth discussion of specific medical management options used to treat endometriosis, including mechanism of action and side effects. It also provides recommendations on strategy with a forward look to novel endometriosis treatments in the future.

EXPERT OPINION

The authors emphasize that endometriosis is a chronic disorder requiring long term medical therapy. Early diagnosis of endometriosis is key in preventing severe, debilitating symptoms and progression of disease. By utilizing our current knowledge of the pathophysiology of endometriosis and by correctly implementing currently available medical and surgical therapies we can significantly reduce the physical, psychosocial and financial burden of this chronic, recurrent and indolent disease. Current available medications are suppressive therapies, but the authors are looking forward to future therapies that can effectively cure or at least control endometriosis with minimal side effects. Future research should continue to look for the genetic trigger for endometriosis which can lead us to its underlying pathogenesis and eventually a cure or prevention.

Where does the money go to? Cost analysis of gynecological patients with a benign condition

OBJECTIVES

The impact of benign gynecological conditions on life of women and on costs for the society is high. The purpose of this study is to gain knowledge and understanding of costs of the treatment of these disorders in order to be able to improve the clinical care processes, gain insight into feasible savings opportunities and to allocate funds wisely.

METHODS

The healthcare processes of 311 women attending university or community hospitals in the Helsinki and Uusimaa Hospital District between June 2012 and August 2013 due to a benign gynecological condition were followed up for two years and treatment costs analysed.

RESULTS

Total direct hospital costs averaged 689€ at six months and 2194€ at two years. The most expensive treatment was that of uterine fibroids in the short term and that of endometriosis and fibroids later on. Costs did not depend on hospital size. Surgical operations caused nearly half of hospital costs. Productivity loss caused biggest expenses outside of the hospital. LNG-IUD (levonorgestrel-releasing intrauterine device) accounted for the largest pharmaceutical costs for patients. Hospital treatment was associated with a reduced need for outpatient services during follow-up.

CONCLUSIONS

A majority of direct hospital costs arise over time. This stresses the need for prolonged healthcare management. To control costs, the need for repetitive doctors' appointments, monitoring tests, and ward treatments should be carefully evaluated. Procedures not needing an operation theatre (for example hysteroscopy for polypectomy), should be done ambulatorily.

Targeting sphingosine kinase-1 with the low MW inhibitor SKI-5C suppresses the development of endometriotic lesions in mice

BACKGROUND AND PURPOSE

Limited evidence suggests that the sphingosine-1-phosphate/sphingosine kinase 1 (S1P/SPHK1) signalling pathway is involved in the pathogenesis of endometriosis. Therefore, we analyzed in this study whether the inhibition of SPHK1 and, consequently, decreased levels of S1P affected the vascularization and growth of endometriotic lesions.

EXPERIMENTAL APPROACH

Endometriotic lesions were surgically induced in the peritoneal cavity and the dorsal skinfold chamber of female BALB/c mice. The animals received a daily dose of the SPHK1 inhibitor SKI-5C or vehicle (control). Analyses involved the determination of lesion growth, cyst formation, microvessel density and cell proliferation within peritoneal endometriotic lesions by means of high-resolution ultrasound imaging, caliper measurement, histology and immunohistochemistry. In the dorsal skinfold chamber model the development of newly formed microvascular networks and their microhemodynamic parameters within endometriotic lesions were investigated by means of intravital fluorescence microscopy.

KEY RESULTS

SKI-5C significantly inhibited the development and vascularization of peritoneal endometriotic lesions, as indicated by a reduced growth and cyst formation, a lower microvessel density and a suppressed cell proliferation, when compared to vehicle-treated controls. Endometriotic lesions in dorsal skinfold chambers of SKI-5C-treated animals exhibited a significantly smaller lesion size, lower functional microvessel density, smaller microvessel diameters and a reduced blood perfusion of the newly developing microvascular networks.

CONCLUSIONS AND IMPLICATIONS

SPHK1/S1P signalling promotes the establishment and progression of endometriotic lesions. The inhibition of this pathway suppresses the development of endometriotic lesions, suggesting SPHK1 as a potential novel target for future endometriosis therapy.

Characterizing the impact of menstrual and pelvic health disorders in a convenience sample of women in Barbados

Objective:

To describe the impact of menstrual and pelvic health disorders on a sample of Barbadian women living with one or more disorders.

Design and methods:

Responses from a survey taken online by a sample of women living in Barbados (⩾18 years) were assessed. Variables collected included, age, disorder(s) diagnosed, and symptoms. The Work Productivity and Activity Impairment (WPAI) Questionnaire: Specific Health Problem, was administered to measure impact on work and other activities. T-tests, chi- square tests, odds ratios, ANOVA, and multivariate analysis were conducted to estimate the associations between patient characterization, disorder characteristics and outcomes.

Results:

A total of 247 unique responses were received and after data were reviewed 192 responses (77.7%) from this convenience sample were analyzed. Polycystic Ovary Syndrome was the most frequently reported diagnosis (34.7%). The most frequently reported symptom was fatigue (53%). There was an OR of 2.17 (95% CI 0.54–8.74) of missing work due to menorrhagia and 2.60 (95% CI: 1.31–5.17) of missing work if diagnosed with endometriosis. The WPAI revealed endometriosis to be the condition with the most substantial impact on work in the subgroup of persons with one diagnosis, with presenteeism of 49.2%, absenteeism of 13.3% and an impact on other activities of 56.4%.

Conclusion:

Pelvic and menstrual disorders have a significant impact on productivity and other activities of Barbadian women. More research is necessary to elucidate the impacts of menstrual and pelvic disorders and treatments on patient outcomes.

Hospital care of endometriosis in Spain: a retrospective multicenter analysis of patient characteristics and costs

Background: Despite the potential serious outcomes associated with endometriosis, few data is available describing the real clinical practice and costs. The aim of this study was to evaluate the characteristics of patients diagnosed with endometriosis in Spain, to measure incidences within the hospital setting and the associated medical costs.Methods: Admission records of patients with endometriosis registered between 2009 and 2018 were obtained from a Spanish hospital discharge database and analyzed in a retrospective multicenter study.Results: Data corresponded primarily to inpatient admissions, with a median length of stay of 3 days. Length of stay correlated with patients' age. Admissions were mainly associated with surgical procedures, namely local excision or destruction of lesions. The majority of secondary diagnoses registered corresponded to inflammatory disease of female pelvic organs; 9.2% of patients presented neoplasms of uterus and only 0.9% registered ovarian neoplasms. Mean admission cost was €3566 over the study period.Conclusions: The majority of admissions reviewed in this study corresponded to the removal of ovarian lesions, although data suggested a decrease in the number of cases that were treated as hospital inpatient admissions over the study period. Older patients, surgical procedures, and lengthier admissions were associated with higher medical costs.

Hidrox® and Endometriosis: Biochemical Evaluation of Oxidative Stress and Pain

Endometriosis is a gynecological and painful condition affecting women of reproductive age. It is characterized by dysfunctional endometrium-like implants outside of the uterine cavity. The purpose of this study was to evaluate the effects of Hidrox®, an aqueous extract of olive pulp containing hydroxytyrosol, on endometriotic lesions associated with pro-oxidative alterations and pain-like behaviors. Endometriosis was induced by intraperitoneal injection of uterine fragments, and Hidrox® was administered daily. At the end of the 14-day treatment, behavioral alterations were assessed and hippocampal tissues were collected. Laparotomy was performed, and the endometrial implants were harvested for histological and biochemical analysis. Hidrox® treatment reduced endometriotic implant area, diameter and volumes. Vehicle-treated rats showed lesional fibrosis, epithelial-mesenchymal transition and fibroblast-myofibroblast transdifferentiation, angiogenesis and pro-oxidative alterations in the peritoneal cavity. Hidrox® treatment reduced the aniline blue-stained area, α-smooth muscle actin (α-sma) and CD34 positive expressions. Moreover, it reduced mast cell recruitment into the lesions, myeloperoxidase activity and lipid peroxidation and increased superoxide dismutase (SOD) activity and glutathione levels in the endometrial explants. In the peritoneal fluid, Hidrox® treatment reduced interleukin (IL)-1β, IL2, IL6, tumor necrosis factor-α (TNF-α) and vascular endothelial grow factor (VEGF) levels increased by the disease. Hidrox® administration also reduced peripheral and visceral sensibility as shown by the behavioral tests (open field test, hot plate test, elevated plus maze test and acetic-acid-induced abdominal contractions). Animals treated with Hidrox® also showed reduced blood-brain barrier permeability and mast cell infiltration in the hippocampus, as well as astrocyte and microglia activation and brain oxidative status restoring brain-derived neurotrophic factor (BDNF) protein expression and increasing Nuclear factor erythroid 2-related factor 2 (Nfr2) nuclear translocation. In conclusion, Hidrox® displayed potential ameliorative effects on endometriotic implants and related pain-induced behaviors due to its potent antioxidative properties.

Translation and Cultural Validation of the WERF EPHect Endometriosis Patient Questionnaire into Canadian French

OBJECTIVE

To produce a culturally validated Canadian French version of the Standard EPHect Endometriosis Patient Questionnaire (EPQ-S) from the World Endometriosis Research Foundation (WERF).

METHODS

We studied 17 premenopausal women who were seen for pelvic pain symptoms or suspicion of endometriosis at the gynaecology clinic of the CHU de Québec - Université Laval (Québec City, Canada). Participants completed the French language version of the questionnaire at their first visit, and the validation took place about 1 week later.

RESULTS

All 22 of the invited women agreed to participate, of whom 17 were reached for the validation. The mean age of participants was 38.9 years, and 15 (88%) had a confirmed diagnosis of endometriosis. Fourteen participants (82%) found the questionnaire clear and relevant. The average length of time to complete the questionnaire was 36.25 ± 10.8 minutes. The validation process resulted in the addition of lines at the end of each section to allow space for specific comments and some clarifications with respect to timelines.

CONCLUSION

This study validated a Canadian French version of the EPHect questionnaire. With such validation studies, differences in language and culture will no longer be a barrier to large national and international studies on endometriosis, leading to high-quality research and breakthroughs for millions of individuals living with this disease.

Impact of symptom burden on work performance status in Spanish women diagnosed with endometriosis

OBJECTIVE

To explore work performance status in Spanish women with endometriosis and to identify those endometriosis-related symptoms that potentially contribute to the reduced work performance.

DESIGN

Cross-sectional study.

SETTING

Spain.

POPULATION

Women with endometriosis working at enrolment (n = 148).

METHODS

Work performance status was assessed through the Work Role Functioning Questionnaire (WRFQ). Endometriosis-related symptoms (pelvic pain, catastrophizing thoughts related to pain, chronic fatigue, sleep quality, mood status, gastrointestinal discomfort and social support) were also evaluated through validated scales. Statistical analyses were performed through multivariate linear regression analyses.

MAIN OUTCOME MEASURES

Work performance status.

RESULTS

Median WRFQ score was 72.0, with the lowest scores found in demands related to worker's needs to manage the workday from beginning to end and those dynamic and static physical loads required in the conduct of work duties. Severe pelvic pain, depressive mood and poorer sleep quality was inversely related to work performance status (p-values <0.020). Finally, self-perceived social support was borderline associated with better work performance (p = 0.057). Considered together, these four psychosocial factors were responsible to explain the 37.9 % of the limitations on work performance observed in our study sample.

CONCLUSIONS

Spanish women with endometriosis reported lower WRQF scores (predominantly in work scheduling and physical demands) in comparison with previous studies on Spanish healthy adults. Psychosocial factors, including pelvic pain, sleep quality and depressive mood are related with work performance status. Thus, the effectiveness of physical and psychological rehabilitation programs in work productivity in women with endometriosis should be evaluated in the close future.

How Might We Screen for Psychological Factors in People With Pelvic Pain? An e-Delphi Study

OBJECTIVE

Persistent pelvic pain (PPP) is a complex condition often influenced by psychological factors that can alter treatment outcomes. These factors are potentially modifiable; however, currently there is no instrument to screen for them. The purpose of this study was to determine: (1) which psychological factors should be screened in individuals with PPP, and (2) the most appropriate statements to represent these psychological factors.

METHODS

The study used a focus group design followed by an electronic-Delphi (e-Delphi) process. A focus group consisting of 8 experts was conducted to determine the relevant psychological factors to screen. These results informed round 1 of the e-Delphi process, consisting of a panel of 14 pain/pelvic pain experts. The e-Delphi process consisted of 3 rounds of online surveys and 2 teleconference discussions to establish consensus on the most appropriate statement to screen for each of the psychological factors.

RESULTS

The focus group identified 13 relevant psychological factors. During the e-Delphi process, relevant screening statements were assessed using a 100-point allocation system. Experts could reword and suggest new statements. Statements were assessed for consensus and stability and were eliminated as the rounds progressed if they met the exclusion criteria. At the termination of round 3, there were 15 statements remaining.

CONCLUSION

The final list of 15 statements will assist clinicians in screening for psychological factors and is an important step for clinicians in providing psychologically informed care to people with PPP. Future research should determine the psychometric properties of the statements to determine their clinical utility as a questionnaire.

IMPACT

This study has refined a list of statements to help screen for psychological factors in individuals with PPP. Developed robustly using an e-Delphi method, this list is an important first step forward for clinicians to provide psychologically informed care to these individuals.

[Endometriosis: gynecological diagnosis and treatment : What should pain management specialists know?]

BACKGROUND

Endometriosis is one of the most common diseases in women of reproductive age. Despite characteristic symptoms such as dysmenorrhea, chronic abdominal pain, dysuria, dyschezia and dyspareunia, the average latency until diagnosis is around 10 years. In addition to the individual limitations, the disease also has economic and health policy relevance. The complaints are followed by reductions in working hours, cyclically recurring short-term sick leave or presenteeism with reduced performance.

OBJECTIVE

An overview of the main recommendations of the S2k guideline on the diagnosis and treatment of endometriosis.

MATERIAL AND METHODS

For the S2k guideline "Diagnostics and therapy of endometriosis", a systematic literature search was conducted in PubMed and Cochrane according to a defined algorithm and over a period of more than 5 years, from 01.01.2014 to 31.12.2018. For the evaluation, 322 publications, including systematic reviews, meta-analyses and randomized controlled trials were considered and these were assessed by 41 mandate holders and representatives from 25 Association of the Scientific Medical Societies in Germany (AWMF) and non-AWMF professional societies, organizations, associations and working groups of the German Society for Gynecology and Obstetrics (DGGG), as well as two patient target groups.

RESULTS

In a structured consensus process, 48 recommendations and 27 statements were formulated, which are presented in extracts in this paper.

DISCUSSION

Interdisciplinary cooperation is essential in the treatment of patients with (suspected) endometriosis. This team should include all necessary disciplines in a cross-sectoral network. This is most likely to be achieved in a certified structure.

Endometriosis and Medical Therapy: From Progestogens to Progesterone Resistance to GnRH Antagonists: A Review

Background: The first objective of this review was to present, based on recent literature, the most frequently applied medical options (oral contraceptive pills (OCPs) and progestogens) for the management of symptomatic endometriosis, and evaluate their effectiveness in treating premenopausal women with endometriosis-associated pelvic pain, dysmenorrhea, non-menstrual pelvic pain and dyspareunia. The second objective was to review the concept of progesterone resistance and newly available treatment options. Methods: We reviewed the most relevant papers (n = 73) on the efficacy of OCPs and progestogens as medical therapy for endometriosis, as well as those on progesterone resistance and new medical alternatives (oral gonadotropin-releasing hormone (GnRH) antagonist). Eleven papers, essentially reviews, were selected and scrutinized from among 94 papers discussing the concept of progesterone resistance. Results: Having reviewed the most significant papers, we can confirm that OCPs and progestogens are effective in two-thirds of women suffering from endometriosis, but that other options are required in case of failure (in one-third of women due to progesterone resistance) or intolerance to these compounds. It is clear that there is a need for effective long-term oral treatment capable of managing endometriosis symptoms, while mitigating the impact of side effects. Biochemical, histological and clinical evidence show that estrogens play a critical role in the pathogenesis of endometriosis, so lowering levels of circulating estrogens should be considered an effective medical approach. The efficacy of three oral GnRH antagonists is discussed on the basis of published studies. Conclusion: There is a place for GnRH antagonists in the management of symptomatic endometriosis and clinical trials should be conducted, taking into account the different phenotypes in order to propose novel algorithms.

Endometriosis-Related Pain Reduction During Bleeding and Nonbleeding Days in Women Treated with Elagolix

Objective

In this post hoc analysis, we evaluated the impact of elagolix on dysmenorrhea and nonmenstrual pelvic pain across menstrual period (bleeding days) and nonmenstrual (nonbleeding) days.

Methods

Data from two randomized, 6-month, placebo-controlled trials (Elaris Endometriosis (EM)-I and EM-II) of elagolix (150 mg once daily (QD) and 200 mg twice daily (BID)) in premenopausal women with moderate to severe endometriosis-associated pain (N = 1686) were pooled. Women recorded the presence of menstrual period and severity of dysmenorrhea or nonmenstrual pelvic pain in a daily electronic diary.

Results

At baseline, women in the placebo group and both elagolix treatment groups reported moderate or severe dysmenorrhea, on average, 81% of their menstrual period days and moderate/severe nonmenstrual pelvic pain, on average, 56% of their nonmenstrual (nonbleeding) days. Compared with placebo at month 6, elagolix-treated women had a significantly lower mean (standard deviation (SD)) percentage of menstrual period days with moderate or severe dysmenorrhea (elagolix 150 mg QD = 52.4 (38.9), p = 0.002; elagolix 200 mg BID = 38.5 (43.6), p < 0.001, placebo = 61.3 (33.7)) and a significantly lower mean (SD) percentage of nonmenstrual (nonbleeding) days with moderate or severe nonmenstrual pelvic pain (elagolix 150 mg QD = 31.1 (35.8), p < 0.001; elagolix 200 mg BID = 19.7 (29.9), p < 0.001; placebo = 35.6 (33.9)).

Conclusion

Following 6 months of elagolix treatment, women who still menstruated had a lower proportion of menstrual period days with moderate or severe dysmenorrhea compared with placebo, demonstrating pain reduction despite continued menses. Additionally, pain did not shift from dysmenorrhea to nonmenstrual pelvic pain, as the percentage of days with moderate or severe nonmenstrual pelvic pain was also reduced for elagolix-treated women compared with placebo.

Trial Registration

The Elaris EM-I study is registered with the US National Library of Medicine, www.ClinicalTrials.gov, NCT01620528. The Elaris EM-II study is registered with the US National Library of Medicine, www.ClinicalTrials.gov, NCT01931670. Both studies are registered with the EU Clinical Trial Register, www.clinicaltrialsregister.ed, 2011-004295-11.

OVARIAN ENDOMETRIOSIS: THE MODERN POSSIBILITIES OF RELAPSE PREDICTION

The article summarizes the current understanding of risk factors and mechanisms of ovarian endometriosis relapses, This article summarizes the current understanding of risk factors for relapse, mechanisms of recurrence of endometrioid ovarian cysts, as well as the potential for their prediction using genetic and molecular-biological predictors.

Demographics and Hospital Outcomes in American Women With Endometriosis and Psychiatric Comorbidities

Objectives

To explore sociodemographic differences and hospital outcomes in endometriosis patients with versus without psychiatric comorbidities.

Methods

We conducted a cross-sectional study using the Nationwide Inpatient Sample (NIS, 2012-2014), and included 63,160 females with primary diagnosis of endometriosis. We used descriptive statistics and Pearson’s chi-square test to measure the differences in demographics and utilization of gynecologic procedures by the presence of psychiatric comorbidities.

Results

Psychiatric comorbidities were present in 18.7% inpatients with endometriosis. About three-fourth of these inpatients were in reproductive age group 26-45 years (75.7%) and were whites (79.1%). Psychiatric comorbidities were seen more in females from middle-income families and from the midwest region of the US. There was no significant difference in the utilization of gynecological procedures by the presence of psychiatric comorbidities. However, inpatients with psychiatric comorbidities had a longer mean length of stay (2.5 vs. 2.3 days) and total charges ($35,489 vs. $34,673) compared to the non-psychiatric cohort. Anxiety disorders predominated at 45% in patients with endometriosis followed by depressive disorder (31.3%), psychotic disorders (12.3%), and drug abuse (6.3%).

Conclusion

Endometriosis with psychiatric comorbidities is prevalent in young white females from a middle-income family. Anxiety and depressive disorders are most prevalent and are associated with extended hospitalization stay and higher charges, thereby negatively impacting the healthcare burden compared to those without psychiatric comorbidities.

Cytokine and growth factor profile in endometriosis: a multiplex analysis of peritoneal fluid to assess diagnostic utility

We aimed to assay cytokines and growth factors in peritoneal fluid samples from women with and without endometriosis to understand the inflammatory milieu, and assess their potential diagnostic utility. This cross-sectional study conducted at a tertiary care hospital included 54 women, aged 20-45 years, with regular menstrual history and undergoing diagnostic/therapeutic laparoscopy for infertility and/or pain. Peritoneal fluid samples were collected after insertion of trocar & laparoscope but prior to other surgical intervention. A multiplex immunoassay of 27 cytokines and growth factors was performed. The concentration of FGF2 and CSF3 were significantly lower in women with endometriosis than without endometriosis (p = .043 and .003, respectively). The levels of CCL2 and IL1RN were significantly higher in moderate-severe than in minimal-mild endometriosis (p = .038 and .043, respectively). Phase-specific comparison revealed that in proliferative phase, the levels of CSF2 and CSF3 were lower in women with endometriosis than without the disease (p = .047 and .013, respectively). The ROC curve analysis provided a cutoff value 0.78 and 0.76 for FGF2 and CSF3, respectively. Cytokines and growth factors such as FGF2, CSF3, CSF2, CCL2 and IL1RN seem to contribute to the pathogenesis of endometriosis and may have a potential utility for the diagnosis of endometriosis.

Oestrogen induces epithelial-mesenchymal transition in endometriosis via circ_0004712/miR-148a-3p sponge function

Endometriosis is a common, chronic gynaecologic disease affecting up to 10% of women in their reproductive age and leading to pain and infertility. Oestrogen (E₂)‐induced epithelial‐mesenchymal transition (EMT) process has been considered as a key factor of endometriosis development. Recently, the dysregulated circular RNAs (circRNAs) have been discovered in endometriosis tissues. However, the molecular mechanism of circRNAs on the E₂‐induced EMT process in endometriosis is still unknown. Here, we demonstrated that circ_0004712 up‐regulated by E₂ treatment in endometrial epithelial cells. Knock‐down the expression of circ_0004712 significantly suppressed E₂‐induced cell migration activity. Meanwhile, we identified miR‐148a‐3p as a potential target miRNA of circ_0004712. Inhibited the expression of miR‐148a‐3p could recovered the effect of circ_0004712 knock‐down in E₂‐treated endometrial epithelial. Furthermore, Western blot assay showed that E₂ treatment could increase the expression and activity of β‐catenin, snail and N‐cadherin and reduce the expression of E‐cadherin. The expression and activity of β‐catenin pathway were recovered by circ_0004712 knock‐down or miR‐148a‐3p overexpression. Altogether, the results demonstrate that circ_0004712/miR‐148a‐3p plays an important role in E₂‐induced EMT process in the development of endometriosis, and the molecular mechanism may be associated with the β‐catenin pathway. This work highlighted the importance of circRNAs in the development of endometriosis and provide a new biomarker for diagnosis and therapies.

Predictors of Psychological Outcomes and the Effectiveness and Experience of Psychological Interventions for Adult Women with Chronic Pelvic Pain: A Scoping Review

Objective

CPP affects approximately 15% of women worldwide and has significant psychological, physical and financial impact on the lives of sufferers. Psychological interventions are often recommended as adjuncts to medical treatment for women with chronic pelvic pain (CPP). This is as women with CPP experience higher rates of mental health concerns and difficulties coping with their pain.. However, recent systematic reviews have highlighted that the efficacy of psychological interventions is not conclusive in this population. This review aimed to identify predictors of mental health outcomes and effective psychological techniques and interventions in women with CPP to inform the development of future psychological therapies.

Methods

Scoping review using the method outlined by Arskey & O'Malley (2005). Relevant databases, reference lists and grey literature were searched to identify effective mental health interventions and predictors of psychological outcomes for women with CPP.

Results

Methodological concerns made identifying predictors of mental health outcomes and effective psychological interventions difficult. However, cognitive behavioural therapy and Mensendieck therapy emerged as therapeutic interventions with the best evidence for women with CPP. A number of useful predictors of mental health outcomes and techniques included in effective interventions were identified.

Conclusion

The evidence provided in this review has the potential to inform future research directions and the development of targeted psychological interventions for women with CPP.

Upregulated Circular RNA hsa_circ_0008433 Regulates Pathogenesis in Endometriosis Via miRNA

circRNAs (circular RNAs) play important roles in the development of endometriosis. This study aimed to explore the functions of circRNAs on endometriosis. Two ectopic, two paired eutopic, and two normal endometrial tissue samples were collected for RNA-seq to obtain circRNA profiles and construct a circRNA-miRNA-mRNA network. The validation of 9 circRNAs in 15 patients was assessed by qRT-PCR. We selected hsa_circ_0008433 as the potential biomarker, followed by examining cell proliferation, colony formation, migration, angiopoiesis, cell cycle, and apoptosis. Furthermore, the expression of apoptosis-related proteins was detected using immunofluorescence (IF) and Western blotting. Bioinformatic analysis was used to select the potential target miRNA and genes of hsa_circ_0008433. A total of 209 upregulated and 117 downregulated differentially expressed circRNAs were identified from the eutopic and ectopic endometrial tissue samples. Eight circRNA levels were significantly increased in ectopic endometrial tissue sample compared with eutopic endometrial tissue. The hsa_circ_0008433 knockdown inhibited endometrial stromal cell proliferation, migration, colony formation, and angiopoiesis; promoted cell apoptosis; and downregulated Ki67 and PCNA expression levels. Moreover, the hsa_circ_0008433 knockdown increased Bax and E-CAD expression and decreased Bcl2, CDKN1B, and CyclinD1 levels. Ten potential target miRNAs of hsa_circ_0008433 were selected, and six of them occur significantly aberrant in hsa_circ_0008433-expressing cells. Increased hsa_circ_0008433 levels regulate epithelial mesenchymal transition (EMT) in endometriosis through the circRNA-miRNA-mRNA axis.

Healthcare Resource Use and Costs Associated with Opioid Initiation Among Patients with Newly Diagnosed Endometriosis with Commercial Insurance in the USA

Introduction

To compare all-cause and endometriosis-related healthcare resource utilization (HCRU) and healthcare costs by service categories (outpatient, inpatient, emergency room [ER], pharmacy) among patients with newly diagnosed endometriosis using opioids compared to patients with endometriosis not using opioids.

Methods

A retrospective analysis of IBM® MarketScan® Commercial Claims data from 2009 to 2018 was performed for women aged 18–49 with newly diagnosed endometriosis (International Classification of Diseases (ICD)-9 code 617.xx; ICD-10 code N80.xx) over 24 months follow-up. Patients were stratified on the basis of opioid use within 12 months post first endometriosis diagnosis date. Patients with opioid use were 1:1 matched to patients without opioid use using propensity score matching.

Results

A total of 85,329 female patients with a new endometriosis diagnosis were identified and 48,470 patients (24,235 opioid and 24,235 non-opioid users) remained after inclusion–exclusion criteria and matching. Opioid patients had an estimated mean 30.33 outpatient visits, 29.59 pharmacy fills, 0.28 inpatient visits, 0.65 ER visits, and total length of stay (LOS) was 1.01 days. Non-opioid patients had an estimated mean 27.94 outpatient visits, 22.06 pharmacy fills, 0.23 inpatient visits, 0.42 ER visits, and total LOS was 0.82 days. On average, opioid patients had significantly greater all-cause HCRU compared to non-opioid patients (all p < 0.0001). Among endometriosis-related healthcare utilization, there were similar ER visits, but lower outpatient visits, inpatient visits, and total LOS and higher pharmacy fills among opioid and non-opioid patients. Estimated mean all-cause costs were higher among opioid ($26,755) vs. non-opioid ($19,302) users (p < 0.0001). A similar trend was observed for estimated mean endometriosis-related costs.

Conclusion

This analysis observed significantly higher all-cause HCRU and costs for opioid users compared to non-opioid users among patients with newly diagnosed endometriosis. While observed endometriosis-related costs were significantly higher in opioid users compared to non-opioid users during a 24-month follow-up period, endometriosis-related HCRU varied by service categories for these two populations over this time period.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-020-01361-7) contains supplementary material, which is available to authorized users.

Self-management strategies to consider to combat endometriosis symptoms during the COVID-19 pandemic

The care of patients with endometriosis has been complicated by the coronavirus disease 2019 (COVID-19) pandemic. Medical and allied healthcare appointments and surgeries are being temporarily postponed. Mandatory self-isolation has created new obstacles for individuals with endometriosis seeking pain relief and improvement in their quality of life. Anxieties may be heightened by concerns over whether endometriosis may be an underlying condition that could predispose to severe COVID-19 infection and what constitutes an appropriate indication for presentation for urgent treatment in the epidemic. Furthermore, the restrictions imposed due to COVID-19 can impose negative psychological effects, which patients with endometriosis may be more prone to already. In combination with medical therapies, or as an alternative, we encourage patients to consider self-management strategies to combat endometriosis symptoms during the COVID-19 pandemic. These self-management strategies are divided into problem-focused and emotion-focused strategies, with the former aiming to change the environment to alleviate pain, and the latter address the psychology of living with endometriosis. We put forward this guidance, which is based on evidence and expert opinion, for healthcare providers to utilize during their consultations with patients via telephone or video. Patients may also independently use this article as an educational resource. The strategies discussed are not exclusively restricted to consideration during the COVID-19 pandemic. Most have been researched before this period of time and all will continue to be a part of the biopsychological approach to endometriosis long after COVID-19 restrictions are lifted.

Contribution of Chronic Fatigue to Psychosocial Status and Quality of Life in Spanish Women Diagnosed with Endometriosis

AIM

To analyze the levels of chronic fatigue in Spanish women with endometriosis and its relationship with their psychosocial status and quality of life (QoL).

METHODS

A total of 230 Spanish women with a clinical diagnosis of endometriosis were recruited. Chronic fatigue (Piper Fatigue Scale) and pelvic pain (Numeric Rating Scale) were evaluated. An on-line battery of validated scales was used to assess psychosocial status [Hospital Anxiety and Depression Scale, Scale for Mood Assessment, Pain Catastrophizing Scale, Pittsburgh Sleep Quality Index, Gastrointestinal Quality of Life Index, Female Sexual Function Index and Medical Outcomes Study-Social Support Survey] and QoL [Endometriosis-Health Profile questionnaire-30]. Associations between fatigue and both psychosocial and QoL outcomes were explored through multivariate regression models.

RESULTS

One-third and one-half of women showed moderate and severe fatigue, respectively. Fatigue was associated with higher anxiety and depression, poorer sleep quality, poorer sexual functioning, worse gastrointestinal health, higher catastrophizing thoughts, higher anger/hostility scores and lower QoL (p-values < 0.050). Moreover, fatigue and catastrophizing thoughts showed a mediating effect on the association between pelvic pain and QoL.

CONCLUSION

This work reveals the important role of fatigue in the association between pain, psychosocial status, and QoL of Spanish women with endometriosis.

A Longitudinal Assessment of the Impact of Endometriosis on Patients' Salary Growth and Risk of Leaving the Workforce

Introduction

This retrospective cohort study evaluated the impact of endometriosis on the risks of work loss events and salary/growth over a 5-year period.

Methods

Women aged 18–49 years with ≥ 1 endometriosis diagnosis were identified in a claims database and matched 1:1 to women without endometriosis (controls). The index date was the first endometriosis diagnosis date (endometriosis cohort) or a random date during the period of continuous eligibility (controls). Baseline characteristics were compared between cohorts descriptively. Average annual salaries were compared over the 5 years post-index using generalized estimating equations accounting for matching. Time-to-event analyses assessed risk of short-term disability, long-term disability, leave of absence, early retirement, and any event of leaving the workforce (Kaplan-Meier curves with log-rank tests).

Results

A total of 6851 matched pairs (mean age at index date: 38.7 years) were included in the salary growth analysis, with a subset of 1981 pairs in the risk of leaving the workforce analysis. In year 1, the endometriosis cohort had a lower average annual salary ($61,322) than controls ($64,720); salaries were lower in years 2–5 by $3697–$6600 (all p < 0.01). The endometriosis cohort experienced smaller salary growth than controls in all years, ranging from $438 vs. $1058 in year 1 to $4906 vs. $7074 in year 5 (all p < 0.05). In the Kaplan-Meier analyses, patients with endometriosis were significantly more likely than controls to leave the workforce for any reason, take a leave of absence, and use short-term disability (all log-rank tests p < 0.001). Additionally, the median number of years to each of these events was lower for the endometriosis cohort relative to the matched controls. Sensitivity analyses among patients with moderate-to-severe endometriosis and by salary brackets confirmed the primary analyses.

Conclusions

Patients with endometriosis experienced lower annual salary and salary growth, as well as higher risks of work loss events, compared with matched controls.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-020-01280-7) contains supplementary material, which is available to authorized users.

Healthcare utilization and cost burden among women with endometriosis by opioid prescription status in the first year after diagnosis: a retrospective claims database analysis

Aims: Opioids do not represent standard therapy for endometriosis; however, women with endometriosis are frequently prescribed an opioid to manage related abdominal or pelvic pain. The aim of this study was to evaluate the impact of opioid use on endometriosis-related economic and healthcare burden in the United States.Materials and methods: We performed a retrospective, propensity-matched cohort analysis of the Truven MarketScan Commercial database from 1 January 2011 to 31 December 2016. Eligible women had at least 1 inpatient or 2 outpatient codes for endometriosis and 12 months of continuous enrollment before and after the index date (i.e. first recorded endometriosis diagnosis). The primary analysis examined healthcare costs and utilization for 12 months after the index date in women who filled at least 1 opioid prescription versus those who did not. The secondary analysis examined healthcare costs and utilization by the pattern of opioid use.Results: The primary analysis matched 43,516 women across 2 groups and the secondary analysis matched 13,230 women across 5 groups. In the primary analysis, total 12-month healthcare costs were significantly higher in the opioid group compared to the non-opioid group ($29,236.00 vs. $18,466.00, respectively; p < .001); the same pattern was observed for all healthcare utilization parameters. In the secondary analysis, higher morphine equivalent daily dose and proportion of days covered were associated with the highest healthcare costs and utilization compared to the non-opioid group.Limitations: Retrospective design and inability to confirm whether filled opioid prescriptions were actually taken.Conclusions: Filling an opioid prescription within 1 year after an endometriosis diagnosis was associated with significant excess healthcare burden. Patients prescribed an opioid may experience inadequate symptom management and benefit from the use of disease-specific, non-opioid therapies.

A two-third majority of infertile women exhibit endometriosis in pre-ART diagnostic hysteroscopy and laparoscopic chromopertubation: only one-third have a tubal obstruction

PURPOSE

This study was undertaken to evaluate the prevalence of endometriosis in infertile women of couples with non-male factor infertility.

METHODS

A retrospective validation analysis was carried out of consecutive women of infertile couples with non-male factor infertility who received combined diagnostic hysteroscopy and laparoscopy, in the period from January 2017 to August 2019 in the Department for Gynecology and Reproductive Medicine (n = 300). Type, stage and site of endometriosis were assessed and matched with the occurrence of tubal stenosis. Binary regression analysis was used to estimate the prevalence of endometriosis.

RESULTS

Endometriosis was diagnosed in 67% (n = 201). Primary infertility (OR 1.76; p = 0.036), dysmenorrhea (OR 2.47; p = 0.002), and a shorter cycle length (OR 0.972; p = 0.036) were independent risk factors for detection of endometriosis in diagnostic hystero-laparoscopy. The most frequent endometriosis sites were pelvic side wall (53.2%) and uterosacral ligaments (41.8%). Patients with endometriosis showed less often a tubal occlusion (34.32% vs. 41.4%; p = 0.205) and presented a lower rate of bilateral obstruction (9.5% vs. 18.8.%, p = 0.024). Women with endometriosis of a Fallopian tube showed a higher rate of tubal occlusion on the same side (right side p = 0.002; left side p = 0.001). Patients with rASRM score III showed the highest rate of tubal obstruction.

CONCLUSIONS

The prevalence of endometriosis in infertile women was higher than expected. The indication for operative infertility diagnostics by minimal invasive techniques should be made much more generous as well as the complete clarification of the causes of female infertility.

Predictors of Depression, Anxiety and Stress Indicators in a Cohort of Women with Chronic Pelvic Pain

OBJECTIVE

Establishing predictors of mental health outcomes is a crucial precursor to the development and assessment of psychological interventions for women with chronic pelvic pain (CPP). The objective of this study was to identify predictors of depression, anxiety and stress in a cohort of women with CPP.

DESIGN

Cross-sectional analytic study.

METHODS

Pre-treatment questionnaires were collected from 212 women with CPP, who had attended a private specialist pelvic pain clinic over a period of 18 months. Multivariate linear regression with backwards elimination was used to determine the best joint predictors of depression, anxiety and stress scores on the Depression, Anxiety and Stress Scale-21 item (DASS 21).

RESULTS

Of 19 potential predictor variables, seven key predictors of depression, anxiety and stress indicators were identified. Higher depression scores were associated with higher current pain severity, a history of stabbing pains, prior experience of a sexually distressing event, having experienced pain as a child, and never having been pregnant before. Higher anxiety scores were associated with higher current pain severity, a history of stabbing pains, prior experience of a sexually distressing event, younger age of menarche, and younger age. Predictors of high-stress scores were higher current pain severity, a history of stabbing pains, prior experience of a sexually distressing event, and being younger.

CONCLUSION

We have identified several important predictors of mental health in women with CPP. Using this information, psychological assessment and treatment for these women may be better tailored to client needs.

Effects of combined GnRH receptor antagonist linzagolix and hormonal add-back therapy on vaginal bleeding-delayed add-back onset does not improve bleeding pattern

Linzagolix is a novel, oral GnRH receptor antagonist developed for the treatment of endometriosis and uterine fibroids. We assessed high-dose linzagolix safety and bleeding pattern effects in healthy women using combined versus delayed hormonal add-back therapy (ABT). This was a single-center, open-label, parallel-group study in 32 premenopausal women, who were randomized to daily linzagolix (200 mg)/ABT for 10 weeks ("Combined-ABT") or linzagolix (200 mg) for 4 weeks followed by linzagolix (200 mg)/ABT for 6 weeks ("Delayed-ABT"). Main outcome measures included bleeding records, trough estradiol (E2) concentrations and adverse events. Linzagolix alone promptly reduced bleeding, leading to amenorrhea in all women by week 5. When combined ABT was started (week 5), spotting (≤ 0.80 days/week/subject) and bleeding (≤ 0.53 days/week/subject) occurred; bleeding was markedly more frequent than after ABT start in the "Combined-ABT" group. In the "Combined-ABT" group, spotting (≤ 0.69 days/week/subject) and occasional bleeding (≤ 0.25 days/week/subject) occurred during the first half of treatment with a tendency to further decrease during the second half. Linzagolix alone rapidly reduced E2 reaching median week 4 levels of 4.1 pg/mL. Median E2 after combined linzagolix/ABT ranged between 35 and 42 pg/mL for the "Delayed-ABT" group (weeks 5-10) and between 24 and 32 pg/mL for the "Combined-ABT" group (weeks 1-10). Linzagolix was well tolerated. Most frequently reported adverse events were headache (32/156) and hot flushes (19/156). Hot flushes exclusively occurred in the "Delayed-ABT" group. In this study, treatment start with a combined linzagolix/ABT regimen resulted in better bleeding control, no hot flushes, and lower median E2 levels than a "Delayed-ABT" regimen. These results may help defining the linzagolix/ABT regimen to be adopted when treating sex-hormone-dependent diseases. Clinical Trial Registration Number-EudraCT Number: 2017-003822-34.

Path to diagnosis and women’s perspectives on the impact of endometriosis pain

Introduction:

Endometriosis is a burdensome chronic disease that can be difficult to diagnose, yet few studies examine experiences along the continuum of disease state. We sought to explore women’s journeys to an endometriosis diagnosis, experience with endometriosis pain, and interactions with healthcare practitioners.

Methods:

An anonymous 23-question online survey was distributed to women (aged >19 years) who self-identified as having a surgical or nonsurgical diagnosis of endometriosis and living in seven English-speaking countries through the social media network MyEndometriosisTeam.com .

Results:

From January through April 2018, 317 women in the United States and 134 women outside the United States completed the survey. More than 50% of the women waited 6 or more years for a diagnosis of endometriosis. Overall, 54.3% experienced endometriosis-related pain daily. Respondents (US/non-US) reported a significant impairment in quality of life that interfered with their family (45.7%/45.5%) and social life (40.1%/44.0%), education/career (42.9%/46.3%), and sexual function (68.1%/70.1%). Women reported their disease led to other conditions, including fatigue (93.6%), gastrointestinal issues (91.8%), and difficulty sleeping (87.4%). Many women were not satisfied with their practitioner’s ability to listen to concerns and felt that their practitioner’s treatment recommendations lacked consistency with their own goals/needs.

Conclusion:

Women still experience long delays and difficult journeys to an endometriosis diagnosis. Disease-associated pain is pervasive and has direct and indirect impacts on quality of life. Women are frequently not satisfied with disease-management options presented to them by their practitioners. These results suggest a need for improved medical education on disease state for both patients and practitioners.

Patterns of Prescription Opioid Use in Women With Endometriosis: Evaluating Prolonged Use, Daily Dose, and Concomitant Use With Benzodiazepines

OBJECTIVE

To examine opioid use, opioid prescribing patterns, and timing of the first opioid prescription in endometriosis patients compared with matched women in the control group without endometriosis.

METHODS

We conducted a retrospective analysis of the Clinformatics Datamart database. Women diagnosed with endometriosis from January 2006 through December 2016 and aged 18-49 years were compared with women in the control group matched on age, region, race, insurance payer, and plan type. Key outcomes included: filled prescription for an opioid, multiple opioid prescriptions, number of days' supply, daily dose (morphine milligram equivalents), and concomitant opioid and benzodiazepine prescriptions. Cohorts were descriptively analyzed using t- and χ statistics and multivariable regression analyses yielded adjusted relative risk (RR) ratios and 95% CI.

RESULTS

The study sample included 53,847 endometriosis patients and 107,694 patients in the control group. The mean age was 38 years, 62.4% of patients were white, and 51.6% lived in the South. Women in the endometriosis case group, compared with women in the control group, were more likely to fill an opioid prescription (42,705 [79.3%] women in the case group vs 26,106 [24.2%] women in the control group; adjusted RR ratio 2.91; 2.87-2.94), had higher likelihood of filling prescriptions with a dose of 50 morphine milligram equivalents or more (24,544 [45.6%] vs 10,463 [9.7%]; adjusted RR ratio 4.07; 3.98-4.16) or 100 morphine milligram equivalents or more (8,013 [14.9%] vs 3,582 [3.3%]; adjusted RR ratio 3.56; 3.43-3.70). Women in the case group were more likely to have concomitant opioid and benzodiazepine prescriptions (5,453 [10.1%] vs 3,711 [3.5%]; adjusted RR ratio 1.95; 1.88-2.03) and to have used these drugs concurrently for at least 30 days (1,596 [3.0%] vs 1,265 [1.2%]; adjusted RR ratio 1.43; 1.34-1.52) or at least 90 days (875 [1.6%] vs 777 [0.7%]; adjusted RR ratio 1.27; 1.17-1.37). Similar results were obtained after excluding opioid prescriptions received during a 30-day postsurgery window.

CONCLUSION

Women with endometriosis had higher probabilities of prolonged use of opioids and concomitant use with benzodiazepines compared with women without this condition.

FUNDING SOURCE

This study was funded by AbbVie, Inc.

Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis

Chronic pelvic pain (CPP) in women is defined variably, but for clinical use it is cyclical or non-cyclical pain of at least 3-6 months' duration. It has major impacts on individuals and society. There are both structural and idiopathic causes. Whereas CPP is not curable in many cases, it is treatable. The most promising approach is multidisciplinary patient-centered care including cause-directed therapy, lifestyle changes, talking therapies, meditation, acupuncture, and physiotherapy (this is not a complete list). One of the most common structural causes for CPP is endometriosis. This review investigates current scientific concepts and recent innovations in this field as well as for CPP in general.

Should Genetics Now Be Considered the Pre-eminent Etiologic Factor in Endometriosis?

Endometriosis is a common, estrogen-dependent, inflammatory disorder characterized by the growth of endometrial-like tissue at extrauterine locations. Its pathogenesis and mechanisms underlying its pathophysiology are poorly understood, although genetic variation is strongly implicated in these processes. Genetic studies reveal that approximately 50% of risk for endometriosis is due to genetic factors and the other 50% likely owing to environmental factors. As with other complex diseases, genetic variants in the DNA sequence increasing endometriosis risk all have small effects, unlike most single-gene disorders. It is the combinations of these variants adding together that contribute to higher risks for individual women. In addition, recent data on disease lesions demonstrate a high frequency of somatic (likely acquired) mutations, some of which are present in the eutopic endometrium and specifically in the epithelial cell compartment, raising the possibility that abnormal epithelial progenitors in the eutopic endometrium give rise to ectopic disease. Discovery in this field is occurring at a rapid pace, and further definitions of genetic (germline) and environmental (somatic) contributions to the pathogenesis and pathophysiology of this disorder are anticipated soon. These discoveries are expected to increase diagnostic, therapeutic, and preventive strategies to minimize disease and its associated morbidities.

Extensive endometriosis surgery: rASRM and Enzian score independently relate to post-operative complication grade

PURPOSE

We aimed to assess post-operative complications based on the Clavien-Dindo classification system following routine laparoscopic treatment of all stages of endometriosis.

METHODS

A retrospective cohort study was carried out to identify women who underwent laparoscopic complete resection of newly diagnosed endometriosis between 2013 and 2016. 401 patients were identified using hospital database search software, and electronic files were reviewed. The stages of endometriosis had been classified according to the revised score of the American Society of Reproductive Medicine (rASRM) and the Enzian classification in cases of deep infiltrating endometriosis. Post-operative complications were recorded based on the Clavien-Dindo classification. Multivariate regression analysis was used to investigate the impact of the stages of endometriosis and surgical steps on complications.

RESULTS

Grade III complications requiring surgical, endoscopic, or radiological intervention occurred in only 1.7% of patients and were significantly associated with rASRM stage IV (OR 1.8). Grade II complications (blood transfusion, total parenteral nutrition) occurred in 18.7% of patients. rASRM stage IV (OR 2.0), hysterectomy (OR 3.2), conversion to laparotomy (OR 11.1), and bowel resection (OR 27.6) were significantly associated with increased risk of grade II complications. rASRM stages I-III did not show an effect on post-operative complications or hospital stay.

CONCLUSIONS

Clavien-Dindo complication grading was readily applicable to laparoscopic removal of endometriosis of all stages. Higher Clavien-Dindo grades correctly reflected clinically relevant complications and were associated with deep infiltrating endometriosis, stage IV endometriosis, bowel surgery, or hysterectomy. Clavien-Dindo classification can be recommended for evaluation of laparoscopic endometriosis surgery outcome.

Elagolix in the treatment of endometriosis: impact beyond pain symptoms

While the most common symptom associated with endometriosis is pelvic pain, the systemic manifestations of the disease and the accompanying adverse psychological, emotional, social, familial, sexual, educational and workplace effects are increasingly recognized. Elagolix is an oral gonadotropin-releasing hormone receptor antagonist that is approved for the management of moderate to severe pain associated with endometriosis. However, the benefits of elagolix extend beyond reducing pain symptoms. This article reviews the non-pain systemic manifestations associated with endometriosis and summarizes the beneficial effects of elagolix on non-pain outcomes. This includes improvements in quality of life, reductions in fatigue and improvements in workplace and household productivity. These results indicate that elagolix provides non-pain benefits in women with endometriosis and improves outcomes that are clinically meaningful to patients.

The impact of high-risk and chronic opioid use among commercially insured endometriosis patients on health care resource utilization and costs in the United States

OBJECTIVES

Evaluate all-cause and endometriosis-related health care resource utilization and costs among newly diagnosed endometriosis patients with high-risk versus low-risk opioid use or patients with chronic versus non-chronic opioid use.

METHODS

A retrospective analysis of IBM MarketScan® Commercial Claims data from 2009 to 2018 was performed for females aged 18 to 49 with newly diagnosed endometriosis (International Classification of Diseases, Ninth Edition code: 617.xx; International Classification of Diseases, Tenth Edition code: N80.xx). Two sub-cohorts were identified: high-risk (⩾1 day with ⩾90 morphine milligram equivalents per day or ⩾1-day concomitant benzodiazepine use) or chronic opioid utilization (⩾90-day supply prescribed or ⩾10 opioid prescriptions). High-risk or chronic utilization was evaluated during the 12-month assessment period after the index date. Index date was the first opioid prescription within 12 months following endometriosis diagnosis. All outcomes were assessed over 12-month post-assessment period while adjusting for demographic and clinical characteristics.

RESULTS

Out of 61,019 patients identified, 18,239 had high-risk opioid use and 5001 chronic opioid use. Health care resource utilization drivers were outpatient visits and pharmacy fills, which were higher among high-risk versus low-risk patients (outpatient visits: 17.49 vs 15.51; pharmacy fills: 19.58 vs 16.88, p < 0.0001). Chronic opioid users had a higher number of outpatient visits (19.53 vs 15.00, p < 0.0001) and pharmacy fills (23.18 vs 16.43, p < 0.0001) compared to non-chronic opioid users. High-risk opioid users had significantly higher all-cause health care costs compared to low-risk opioid users (US$16,377 vs US$13,153; p < 0.0001). Chronic opioid users also had significantly higher all-cause health care costs compared to non-chronic opioid users (US$20,930 vs US$12,272; p < 0.0001). Similar patterns were observed among endometriosis-related HCRU, except pharmacy fills among high-risk and chronic sub-cohorts.

CONCLUSION

This analysis demonstrates significantly higher all-cause and endometriosis-related health care resource utilization and total costs for high-risk opioid users compared to low-risk opioid users among newly diagnosed endometriosis patients over 1 year. Similar trends were observed for comparing chronic opioid users with non-chronic opioid users, except for endometriosis-related pharmacy fills and associated costs.

Healthcare resource utilization and costs among women diagnosed with uterine fibroids compared to women without uterine fibroids

Objective: To perform a retrospective, matched-cohort, longitudinal evaluation of annual pre- and post-diagnosis costs incurred among women with uterine fibroids (UF) (cases) compared to controls without UF. Methods: Data were derived from the IBM Watson Health MarketScan Commercial Claims and Encounters and Medicaid Multi-State databases. Women aged 18-64 years with ≥1 inpatient or outpatient medical claim with an initial UF diagnosis (index date) from 1 January 2010 to 31 December 2014 were included. Healthcare resource utilization (HCRU) data including pharmacy, outpatient and inpatient hospital claims were collected for 1 year pre-index and ≤5 years post-index. All-cause costs (adjusted to 2017 $US) were compared between cases and controls using multivariable regression models. Results: Analysis included 205,098 (Commercial) and 24,755 (Medicaid) case-control pairs. HCRU and total all-cause healthcare costs were higher for cases versus controls during the pre-index year and all years post-index. Total unadjusted mean all-cause costs were $1197 higher (p < .0001; Commercial) and $2813 higher (standardized difference 0.08; Medicaid) for cases during the pre-index year. Total adjusted mean all-cause costs in the first year post-index were $14,917 for cases versus $5717 for controls in the Commercial population, and $20,244 versus $10,544, respectively, in the Medicaid population. In Years 2-5 post-index, incremental mean adjusted total costs decreased, but remained significantly higher for cases versus controls at all time points in both populations (all p < .05). Conclusions: Costs were higher for women with UF compared to women without UF during the pre-index year and over 5 years post-index; differences were greatest in the first year post-index.

Rethinking mechanisms, diagnosis and management of endometriosis

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.

Long-Term Outcomes of Elagolix in Women With Endometriosis: Results From Two Extension Studies

OBJECTIVE

To evaluate the efficacy and safety of elagolix, an oral, nonpeptide gonadotropin-releasing hormone antagonist, over 12 months in women with endometriosis-associated pain.

METHODS

Elaris Endometriosis (EM)-III and -IV were extension studies that evaluated an additional 6 months of treatment after two 6-month, double-blind, placebo-controlled phase 3 trials (12 continuous treatment months) with two elagolix doses (150 mg once daily and 200 mg twice daily). Coprimary efficacy endpoints were the proportion of responders (clinically meaningful pain reduction and stable or decreased rescue analgesic use) based on average monthly dysmenorrhea and nonmenstrual pelvic pain scores. Safety assessments included adverse events, clinical laboratory tests, and endometrial and bone mineral density assessments. The power of Elaris EM-III and -IV was based on the comparison to placebo in Elaris EM-I and -II with an expected 25% dropout rate.

RESULTS

Between December 28, 2012, and October 31, 2014 (Elaris EM-III), and between May 27, 2014, and January 6, 2016 (Elaris EM-IV), 569 participants were enrolled. After 12 months of treatment, Elaris EM-III responder rates for dysmenorrhea were 52.1% at 150 mg once daily (Elaris EM-IV 550.8%) and 78.2% at 200 mg twice daily (Elaris EMIV 575.9%). Elaris EM-III nonmenstrual pelvic pain responder rates were 67.5% at 150 mg once daily (Elaris EM-IV 566.4%) and 69.1% at 200 mg twice daily (Elaris EM-IV 567.2%).”After 12 months of treatment, Elaris EM-III dyspareunia responder rates were 45.2% at 150 mg once daily (Elaris EM-IV=45.9%) and 60.0% at 200 mg twice daily (Elaris EM-IV=58.1%). Hot flush was the most common adverse event. Decreases from baseline in bone mineral density and increases from baseline in lipids were observed after 12 months of treatment. There were no adverse endometrial findings.

CONCLUSION

Long-term elagolix treatment provided sustained reductions in dysmenorrhea, nonmenstrual pelvic pain, and dyspareunia. The safety was consistent with reduced estrogen levels and no new safety concerns were associated with long-term elagolix use.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01760954 and NCT02143713.