Endometriosis: Epidemiology, Diagnosis and Clinical Management

Is dispositional optimism associated with endometriomas and deep infiltrating endometriosis?

INTRODUCTION

Endometriosis is a chronic painful condition characterized by high prognostic uncertainty, as well as the threat of infertility and emotional symptoms that may affect many aspects of women, including psychological characteristics like dispositional optimism. Considering the impact of endometriosis on psychological health and the paucity of papers on this topic, the aim of this study is to explore optimism and associated factors in endometriosis.

METHODS

A case-control study was performed on a group of 95 women with endometriosis and 156 controls. All participants completed the Life Orientation Test-Revised (LOT-R), a self-administered tool for assessing dispositional optimism. Pain severity, medication, gynecological and socio-demographic information was also collected.

RESULTS

Low optimism was observed for women with endometriosis compared to controls even after covariate adjustment (LOT-R global scores: 14.5 vs. 15.9 points, p = .045).

CONCLUSIONS

This study provides the first evidence that a personality dimension with many prognostic implications may be altered in women with endometriosis. Our findings highlight the importance of a broader understanding of this condition, treating this disorder from a biopsychosocial perspective and suggests the need for non-medical attention within a multidisciplinary team.

Evaluation of IL-3, IL-5, and IL-6 concentration in the follicular fluid of women with endometriosis: A cross-sectional study

Background

Endometriosis is associated with abnormal immunologic responses and combined inflammatory and anti-inflammatory conditions.

Objective

This study aims to investigate follicular fluid (FF) concentration of interleukin (IL)-3, IL-5, and IL-6 in women with and without endometriosis.

Materials and Methods

In this cross-sectionalstudy 68 women who were referred to the in vitro fertilization center of Imam Reza hospital in Mashhad during 2018 were selected randomly. Leaves of cytokines in the FF samples were evaluated in the endometriosis and the control group (n = 34/each). The diagnostic accuracy of cytokines and clinical characteristics were evaluated.

Results

IL-3 and IL-6 were significantly changed in the FF of the women with endometriosis compared with the control group (p = 0.04, and p < 0.01, respectively), and the mean concentration of IL-5 in the endometriosis group was lower than in the control group (p = 0.5), but this was not significant. There were significant differences in the menstrual cycle, dyspareunia, and dysmenorrhea between the groups (p < 0.01, p = 0.04, and p = 0.02, respectively). The diagnostic accuracy of IL-3 and IL-6 in the FF was low, with the area under the curve of 0.614 and 0.645, respectively.

Conclusion

Although none of the cytokines had a predictive value for endometriosis, the decreased levels of IL-3 and increased levels of IL-6 in the FF samples of women with endometriosis, and risk factors, including irregular menstrual cycle, dyspareunia, and dysmenorrhea, could be associated with the pathogenesis of this painful disease.

Incidental appendiceal mass as the only manifestation of endometriosis

Appendiceal endometriosis is a rare condition that remains difficult to diagnose preoperatively. Herein, we present a case of appendiceal endometriosis presenting as a neuroendocrine tumor. A 34-year-old Caucasian woman was found to have an appendiceal mass with a small fluid collection on routine transvaginal ultrasound. The patient denied any symptoms. Features were consistent with those of a neuroendocrine tumour of the appendix. Laparoscopic appendectomy followed by histopathology revealed endometriosis with negative cytology for malignant cells. Preoperative characteristics of appendiceal tumours in women of childbearing age should be further investigated. Establishing clinical and surgical guidelines is the key to avoid invasive procedures and related adverse outcomes.

The Relationship of Acupuncture Use to the Endometriosis Risk in Females With Rheumatoid Arthritis: Real-World Evidence From Population-Based Health Claims

Objectives: Women affected by rheumatoid arthritis (RA) have a higher risk of endometriosis, an estrogen-dependent, chronic inflammatory disease. Though acupuncture has long been a safe and effective therapy for treating inflammatory conditions, it is unclear whether it could prevent the onset of endometriosis. This study aims to determine the effect of acupuncture on the subsequent risk of endometriosis in female RA patients.

Methods: Between 1998 and 2010, female subjects with RA were recruited from a nationwide database (5,736 patients; age ≥20 years). Enrolled patients included 2,407 acupuncture users and 2,407 nonusers randomly selected using propensity scores. The occurrence of endometriosis was recorded through the end of 2012. Cox proportional hazards regression was used to estimate the adjusted hazard ratio (HR) associated with acupuncture use.

Results: During the follow-up period, 35 acupuncture users and 94 non-users developed endometriosis, with incidence rates of 2.36 and 4.91 per 1,000 person-years, respectively. Acupuncture use was associated with a 55% lower endometriosis risk (adjusted HR, 0.45; 95% confidence interval, 0.31–0.65). Those who received high intensity acupuncture (≥15 packages) had the greatest benefit.

Conclusions: Findings suggest that adding acupuncture to conventional therapy may decrease the subsequent endometriosis risk in female RA patients. Prospective randomized trials are recommended to further clarify whether the association revealed in this study supports a causal link.

Unmasking the great masqueraders: Concurrent isolated large cecal endometrioma and solitary extra-uterine retroperitoneal cellular leiomyoma - A case report with review of literature

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Bowel involvement in endometriosis is rare. Cecal endometriosis is seen in just 3.5 % of patients with bowel involvement. Patients with bowel involvement typically also have associated ovarian &/or extra-ovarian pelvic endometriosis. This case is the rarest of rare cases in that the patient had isolated cecal endometriosis without any obvious pelvic disease.

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This is the largest reported size of a cecal endometrioma (8 × 6 cms), to the best of our knowledge.

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Extra-uterine cellular leiomyoma also known as ‘wandering fibroid’ & ‘parasitic leiomyoma’ is again an extremely rare neoplasm. There are very few reported cases of parasitic leiomyoma.

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Another rarest of rare event is the concurrent existence of the 2 above mentioned conditions in the same patient.

Introduction

Cecal endometriosis is an infrequent cause of right iliac fossa pain. The extra-uterine retroperitoneal cellular leiomyoma is a rare tumor. The concurrent existence of both these rare conditions is a unique event.

Presentation of case

We hereby report the case of a 44-year-old woman who had concurrent large isolated cecal endometrioma, which was diagnosed pre-operatively on imaging to be pelvic endometriosis/hematosalpinx and solitary retroperitoneal cellular leiomyoma, which was incidentally identified. Both the conditions were managed successfully by laparoscopy.

Discussion

Cecal endometriosis is difficult to diagnose pre-operatively as there are far commoner clinical conditions that cause similar signs and symptoms. Often it gets mistaken for these conditions and gets diagnosed incidentally ‘on table’ during surgeries being performed purportedly to treat them.

Conclusion

Although definitive diagnosis can only be obtained after histopathology, laparoscopy can be considered a standard diagnostic modality for both these conditions.

Long Noncoding RNA UCA1 Is Related to Autophagy and Apoptosis in Endometrial Stromal Cells

RESEARCH QUESTION

The expression of the long noncoding RNA (lncRNA) urothelial carcinoma-associated 1 (UCA1) in embryonic tissues is higher than that in most cancer tissues, such as bladder cancer, indicating that RNA is a carcinoembryonic antigen. However, there are no published reports on the role of UCA1 in endometriosis (EMS). Therefore, to address this gap in knowledge, we assessed the potential role of lncRNA UCA1 in the pathogenesis and progression of EMS.

DESIGN

To verify the expression of UCA1 in EMS, quantitative reverse transcription polymerase chain reaction (qRT-PCR) was used. RNA interference (siRNA) was used to study the biological function of UCA1 in EMS in vitro.

RESULTS

qRT-PCR analysis showed that the expression of lncRNA UCA1 in EMS was increased (P<0.01). Knockdown of UCA1 in vitro significantly inhibited the proliferation of endometrial stromal cells (ESCs) and induced autophagy and apoptosis.

CONCLUSION

UCA1 is highly expressed in EMS and promotes the proliferation of ESCs but suppresses autophagy and apoptosis. In EMS, UCA1 may be a prognostic marker and therapeutic target.

Long-term treatment of endometriosis with dienogest: Real-world results from the VIPOS study

Introduction:

The Visanne Post-approval Observational Study (VIPOS) was designed to assess the safety of dienogest 2 mg (DNG, Visanne) compared to other hormonal endometriosis treatments.

Methods:

Large, prospective, non-interventional, active surveillance study in six European countries (Germany, Poland, Russia, Hungary, Switzerland, and Ukraine). Women with a new hormonal therapy for endometriosis were enrolled by gynecologists and specialized centers between 2010 and 2016 and observed for up to 7 years. Self-administered questionnaires during study entry and follow-up collected information on baseline characteristics, health status and endometriosis treatment. Self-reported clinical outcomes of interest were validated by health care professionals.

Results:

Among the >27,000 enrolled participants, 3262 women started DNG use either at study entry or during follow-up. A total of 798 study participants used DNG during follow-up continuously for 15 months or longer (DNG long-term users). When comparing the occurrence of serious adverse events (SAE) in users treated with DNG, no safety signal emerged for long-term users; the SAE incidence rate per 10,000 women-years was 367.7 (95% CI: 274.1–481.9) in DNG long-term users and 416.4 (349.1–492.5) in short-term users (treated with DNG for less than 15 months).

Conclusions:

Previous data on DNG long-term safety were derived from studies with relatively low numbers of patients and limited follow-up time. VIPOS provided valuable real-world data on the long-term use of DNG 2 mg in around 800 women treated in Europe and observed no safety signal regarding serious adverse events.

Health Information in the Era of Social Media: An Analysis of the Nature and Accuracy of Posts Made by Public Facebook Pages for Patients with Endometriosis

STUDY OBJECTIVE

To analyze the nature and accuracy of social media (Facebook) content related to endometriosis.

DESIGN

Retrospective content analysis.

SETTING

Social media platform, Facebook.

PARTICIPANTS

Social media posts on Facebook endometriosis pages.

INTERVENTIONS

A search of public Facebook pages was performed using the key word "endometriosis." Posts from the month-long study period were categorized and analyzed for accuracy. Two independent researchers used thematic evaluation to place posts into the following 11 categories: educational, emotional support, advocacy, discussion, events, humor, promotional, recipes, resources, surveys, and other. Posts categorized as educational were further subcategorized and reviewed. Each posted fact was cross-referenced in peer-reviewed scientific journals to determine whether the claim made was evidence-based. Engagement in a post was calculated by taking the sum of comments, shares, and reactions.

MEASUREMENTS AND MAIN RESULTS

A total of 53 Facebook pages meeting inclusion criteria were identified and 1464 posts from the study period were evaluated. Emotional support posts comprised the largest category of posts (48%) followed by educational posts (21%). Within the educational category, the epidemiology and pathophysiology subcategory comprised the largest group (42.0%) followed by the symptom's subcategory (19.6%). Post category had an effect on the amount of post engagement (p-value <.001) with emotional posts generating 70% of the overall engagement. The subcategories of the educational posts demonstrated a similar effect on engagement (p-value <.001). Posts were more engaging if they contained epidemiology and pathophysiology information with 44% of all engagement of educational posts occurring within this subcategory. Educational posts were found to be 93.93% accurate. There was no correlation between post engagement and post information accuracy (p-value = .312).

CONCLUSION

Facebook pages offer emotional support and education to people with endometriosis. Most information found in these Facebook pages is evidence-based. Clinicians should consider discussing the use of Facebook pages with their patients diagnosed with endometriosis.

Patients' and clinicians' perspectives on item importance, scoring, and clinically meaningful differences for the Endometriosis Symptom Diary (ESD) and Endometriosis Impact Scale (EIS)

Background

The Endometriosis Symptom Diary (ESD) and Endometriosis Impact Scale (EIS) are patient-reported outcome measures developed to evaluate efficacy in clinical trials and clinical practice. The ESD is a daily electronic diary assessing symptom severity; the EIS is a weekly electronic diary assessing symptom impact. This study explored the importance of symptoms (ESD items) and impacts (EIS domains), perspectives on scoring algorithms, and clinically important difference (CID) thresholds to inform clinical trial score interpretation.

Methods

Endometriosis patients in Germany (n = 8) and the US (n = 17), and expert clinicians (n = 4) in Germany, the US, Spain, and Finland participated in semi-structured qualitative interviews comprising structured tasks. Interview transcripts were analyzed using thematic analysis techniques.

Results

Quality and severity of endometriosis-associated pelvic pain varied considerably among patients; some experienced pelvic pain daily, others during menstrual bleeding (dysmenorrhea) only. Patients and clinicians ranked “worst pelvic pain” as the most meaningful pain concept assessed by the ESD, followed by constant and short-term pelvic pain. Preferences for summarizing daily pain scores over the 28-day menstrual cycle depended on individuals’ experience of pain: patients experiencing pain daily preferred scores summarizing data for all 28 days; patients primarily experiencing pain during selected days, and their treating clinicians preferred scores based on the most severe pain days. Initial CID exploration for the “worst pelvic pain” 0–10 numerical rating scale (0–10 NRS) revealed that, for most patients, a 2- or 3-point reduction was considered meaningful, depending on baseline severity. Patients and clinicians ranked “emotional well-being” and “limitations in physical activities” as the most important EIS domains.

Conclusions

This study informs the use of the ESD and EIS as clinically relevant measures of endometriosis symptoms and their impact. Findings from the ESD highlight the importance of individual-patient assessment of pain experience and identify “worst pelvic pain” as the most meaningful symptom assessed. Aggregating scores over the 28-day menstrual cycle may inform meaningful endpoints for clinical trials. Diverse EIS concepts (e.g. impact on emotional well-being and physical activities) are meaningful to patients and clinicians, emphasizing the importance of evaluating the impact on both to comprehensively assess treatment efficacy and decisions.

Trial registration

Not applicable. Qualitative, non-interventional study; registration not required.

Correlation of Serum Anti-Mullerian Hormone (AMH) Level on Ovarian Volume in Women with Endometrioma

Background

The correlation between endometrioma and serum Anti-mullerian hormone (AMH) level is a benchmark in determining the prognosis and management of endometrioma. Endometrioma causes a decrease in ovarian reserve due to tissue damage that affects the formation of serum AMH. Serum AMH levels in daily practice are useful as a tool to determine ovarian reserve, markers for diagnosis and prognosis in infertility and reproductive abnormalities. The purpose of this study was to determine the relationship of serum AMH level in women with endometrioma and their correlation to ovarian volume.

Methods

This research was an analytical observational study with a cross-sectional design in women of reproductive age who were diagnosed with endometrioma within the period of August 2019–March 2020 at Hasan Sadikin Hospital, Bandung. Forty-four women who met the inclusion and exclusion criteria were then divided into endometrioma (n=22) and control (n=22) groups. In both groups, transvaginal ultrasound examination was performed to measure the volume of the ovary, then a laboratory examination of serum AMH level was carried out.

Results

Serum AMH levels in the endometrioma group were significantly lower than those in the control group (P<0.001). Serum AMH level did not differ significantly based on laterality of the observation group (P=1.000). There was a negative correlation between serum AMH level and the volume of ovarian endometrioma, although not statistically significant (r=−0.332; P=0.066).

Conclusion

There was a correlation between serum AMH level and endometrioma. Serum AMH levels were significantly lower in the endometrioma group but were not influenced by their laterality. We found a negative correlation between serum AMH level and ovarian volume containing endometrioma, but not statistically significant.

MiR-182 inhibits proliferation, migration, invasion and inflammation of endometrial stromal cells through deactivation of NF-κB signaling pathway in endometriosis

Endometriosis affects about 10-15% women for reproductive age, but it is not currently curable and the underlying etiology for this disease is still not clear. In the present study, functions and mechanisms of miR-182 and RELA in endometriosis were investigated. BAY 11-7082 was used to block NF-κB pathway. qRT-PCR, ELISA and western blot assays were employed to evaluate the expressions of miR-182 and RELA, inflammatory factors and epithelial-mesenchymal transition (EMT)-related markers, and activation of NF-κB pathway. MTT, wound healing or Transwell assays were used to evaluate the cell proliferation, migration and invasion capacities. Bioinformatic and dual-luciferase reporter assays were carried out to analyze the interaction between miR-182 and RELA. MiR-182 expression was decreased, while RELA was increased as developed from normal to eutopic and ectopic status, which was accompanied by upregulated inflammatory factors and EMT-related proteins. RELA was directly targeted by miR-182 in human endometrial stromal cells. Overexpression of RELA increased inflammation-associated and EMT-related markers expression, while miR-182 upregulation decreased the expression of these genes in a dose-dependent manner, which finally attenuated the proliferation, migration and invasion capacities of endometrial stromal cells through deactivation of NF-κB signaling pathway. Moreover, co-overexpression of RELA reversed the above effects induced by miR-182. In a word, miR-182 directly targeted RELA and inhibited proliferation, migration, invasion, EMT and inflammation of endometrial stromal cells through deactivation of NF-κB signaling pathway in endometriosis. These results provide new insights into the interaction between miR-182 and NF-κB pathway and their potential as therapeutic targets for treatment of endometriosis.

Induction of autophagy by Beclin-1 in granulosa cells contributes to follicular progesterone elevation in ovarian endometriosis

Endometriosis is a common gynecological disease in which ovarian dysfunction can be an important cause of infertility. Elevated progesterone (P4) levels during the follicular phase is possibly associated with impaired oocyte quality and pregnancy outcome in endometriosis. Beclin-1 (BECN1), an essential mediator of autophagy, has been shown to be related to the development and progression of endometriosis. This study aimed to investigate the autophagic activity in ovarian granulosa cells (GCs) of patients with endometriosis and to clarify the role of BECN1 in preovulatory P4 elevation. Our results demonstrated that serum P4/estradiol (E2) ratio and P4-to-follicle index (the average P4 secretion per follicle) on the day of human chorionic gonadotropin administration were elevated in women with ovarian endometriosis. Increased expression of BECN1 and enhanced autophagy were observed in GCs of patients with ovarian endometriomas. In cultured GCs, BECN1 knockdown reduced P4 secretion and the expression of key steroidogenic enzymes; whereas overexpression of BECN1 resulted in induced P4 production with activated biosynthesis pathway. Moreover, inhibition of autophagy by BECN1 knockdown significantly attenuated low-density lipoprotein (LDL)-induced P4 synthesis. These findings provide new insights into the role of BECN1 in late follicular P4 elevation in patients with endometriosis by promoting the degradation pathway of LDL for P4 biosynthesis via lysosome activation in GCs, and have potential therapeutic implications for the improvement of oocyte quality in women affected by endometriosis.

Increased ApoE Expression in Follicular Fluid and the ApoE Genotype Are Associated With Endometriosis in Chinese Women

More than 10% of women suffer from endometriosis (EMT) during their reproductive years. EMT can cause pain and infertility and requires further study from multiple perspectives. Previous reports have indicated that an increase inapolipoprotein E (ApoE) may be associated with a lower number of retrieved mature oocytes in older women, and an association between ApoE and spontaneous pregnancy loss may exist in patients with EMT. The purpose of this study was to investigate the existence of an increase in ApoE in follicular fluid (FF) and the possible relationship between ApoE and EMT in Chinese women. In the current study, 217 Chinese women (111 control subjects and 106 EMT patients) were included. The ApoE genotypes were identified by Sanger sequencing. We found that ApoE expression in FF was higher in patients with EMT than in the control group. In addition, a significant difference in ApoE4 carriers (ϵ3/ϵ4, ϵ4/ϵ4) was found between the control subjects and the patients with EMT. Furthermore, a nonparametric test revealed significant differences in the numbers of blastocysts and high-quality blastocysts, but not the hormone levels of FSH, LH, and E2, between the two groups. We also established a multifactor (BMI, high-quality blastocysts, and ϵ4) prediction model with good sensitivity for identifying patients who may suffer from EMT. Our results demonstrate that ApoE expression in FF is increased in EMT, the ApoE-ϵ4 allele is significantly linked to EMT, and a combined analysis of three factors (BMI, high-quality blastocysts, and ϵ4) could be used as a predictor of EMT.

Surgical Trend and Volume Effect on the Choice of Hysterectomy Benign Gynecologic Conditions

With the advance of minimally invasive surgery (MIS), the surgical trends of hysterectomy changed significantly during past 2 decades. Total number (age-standardized) of all types of hysterectomy decreased, which may be due to the availability of some other alternatives, e.g. hysteroscopy, laparoscopic myomectomy. However, laparoscopic hysterectomy (LH) still remains the mainstream of surgical treatment. LH significantly increases for benign gynecologic conditions in Taiwan and worldwide. The increase of LH was accompanied with decrease of TAH; VH kept stationary, and SAH increased slightly. The increase in popularity of LH and SAH; provides evidence of surgical trends and a paradigm shift for hysterectomy. This time-frame shift suggests LH has reached a u during the later years. Older patients tend to receive AH, while middle-aged women tend to receive LH. Oder surgeons tend to perform AH, while younger surgeons tend to perform LH. However, all type hysterectomy and LH were more commonly performed by older surgeons aged over 50 years. It means both patients and surgeons became older during the time-frames. The above phenomena may also happen due to less young surgeons entered in the gynecologic practice. Most of the LHs were performed by high-volume surgeons, however, there is a shift from high-volume, to medium- and low-volume surgeons. The above scenario may be due to the wide spread of LH techniques. Surgical volume has important impacts on both complications and costs. The high-volume surgeons have lower complications, which result in lower costs. In the future, how to increase the use of LH, to improve the training and monitoring system deserves more attentions.

Massive Leiomyomata and Severe Endometriosis Resulting in a Frozen Pelvis in an Asymptomatic Patient

Leiomyomas, also known as uterine fibroids, are the most common benign uterine tumors in women. The most frequently reported symptoms are uterine bleeding and abdominal and/or pelvic pressure; however, most cases are asymptomatic and may be found incidentally. Endometriosis is a condition where the endometrium proliferates outside of the uterine cavity. Extrauterine endometrial implants are usually found in the ovaries, pelvis, and peritoneum, but can extend anywhere throughout the body. Women with endometriosis may exhibit dysmenorrhea, dyspareunia, dyschezia, and infertility. Inflammation caused by endometriosis may lead to fibrosis, scarring, and adhesions. We report a case of an asymptomatic 36-year-old African-American woman with increasing abdominal girth, consistent with a 28-week gestation, presenting to her obstetrician/gynecologist for her annual exam, who on further investigation is found to have multiple large fibroids, bilateral ovarian cysts, and widespread endometriosis with several adhesions ultimately leading to a frozen pelvis.

Brassica Bioactives Could Ameliorate the Chronic Inflammatory Condition of Endometriosis

Endometriosis is a chronic, inflammatory, hormone-dependent disease characterized by histological lesions produced by the presence of endometrial tissue outside the uterine cavity. Despite the fact that an estimated 176 million women are affected worldwide by this gynecological disorder, risk factors that cause endometriosis have not been properly defined and current treatments are not efficient. Although the interaction between diet and human health has been the focus of many studies, little information about the correlation of foods and their bioactive derivates with endometriosis is available. In this framework, Brassica crops have emerged as potential candidates for ameliorating the chronic inflammatory condition of endometriosis, due to their abundant content of health-promoting compounds such as glucosinolates and their hydrolysis products, isothiocyanates. Several inflammation-related signaling pathways have been included among the known targets of isothiocyanates, but those involving aquaporin water channels have an important role in endometriosis. Therefore, the aim of this review is to highlight the promising effects of the phytochemicals present in Brassica spp. as major candidates for inclusion in a dietary approach aiming to improve the inflammatory condition of women affected with endometriosis. This review points out the potential roles of glucosinolates and isothiocyanates from Brassicas as anti-inflammatory compounds, which might contribute to a reduction in endometriosis symptoms. In view of these promising results, further investigation of the effect of glucosinolates on chronic inflammatory diseases, either as diet coadjuvants or as therapeutic molecules, should be performed. In addition, we highlight the involvement of aquaporins in the maintenance of immune homeostasis. In brief, glucosinolates and the modulation of cellular water by aquaporins could shed light on new approaches to improve the quality of life for women with endometriosis.

Endometriosis Is Associated with a Significant Increase in hTERC and Altered Telomere/Telomerase Associated Genes in the Eutopic Endometrium, an Ex-Vivo and In Silico Study

Telomeres protect chromosomal ends and they are maintained by the specialised enzyme, telomerase. Endometriosis is a common gynaecological disease and high telomerase activity and higher hTERT levels associated with longer endometrial telomere lengths are characteristics of eutopic secretory endometrial aberrations of women with endometriosis. Our ex-vivo study examined the levels of hTERC and DKC1 RNA and dyskerin protein levels in the endometrium from healthy women and those with endometriosis (n = 117). The in silico study examined endometriosis-specific telomere- and telomerase-associated gene (TTAG) transcriptional aberrations of secretory phase eutopic endometrium utilising publicly available microarray datasets. Eutopic secretory endometrial hTERC levels were significantly increased in women with endometriosis compared to healthy endometrium, yet dyskerin mRNA and protein levels were unperturbed. Our in silico study identified 10 TTAGs (CDKN2A, PML, ZNHIT2, UBE3A, MCCC2, HSPC159, FGFR2, PIK3C2A, RALGAPA1, and HNRNPA2B1) to be altered in mid-secretory endometrium of women with endometriosis. High levels of hTERC and the identified other TTAGs might be part of the established alteration in the eutopic endometrial telomerase biology in women with endometriosis in the secretory phase of the endometrium and our data informs future research to unravel the fundamental involvement of telomerase in the pathogenesis of endometriosis.

Miscarriage on Endometriosis and Adenomyosis in Women by Assisted Reproductive Technology or with Spontaneous Conception: A Systematic Review and Meta-Analysis

Background

In the past several years, there has been an increasing concern on miscarriage caused by endometriosis or adenomyosis. However, the results reported by different studies remain controversial. The present study is aimed at assessing the impact of endometriosis and adenomyosis on miscarriage.

Materials and Methods

Searches were carried out in PubMed, Embase, and the Cochrane library for studies published from inception until February 29, 2020. The investigators included studies that evaluated miscarriage risk in pregnant women with endometriosis or adenomyosis by assisted reproductive technology (ART), or with spontaneous conception (SC). Miscarriage (<28 weeks) was the primary outcome. The secondary outcomes were antepartum hemorrhage (APH), postpartum hemorrhage (PPH), preterm birth, low birthweight, placenta praevia, placental abruption, ectopic pregnancy, stillbirth, gestational diabetes, preeclampsia, and intrauterine growth restriction (IUGR). Endnote was used for the study collection, and the data analyses were carried out by two authors using Review Manager version 5.2.

Results

Thirty-nine studies, which is comprised of 697,984 women, were included in the present study. Miscarriage risk increased in women with endometriosis in SC (OR: 1.81, 95% CI: 1.44-2.28, I² = 96%) compared with those without endometriosis, while women with endometriosis who underwent ART had a similar miscarriage risk, when compared to those with tubal infertility (OR: 1.03, 95% CI: 0.92-1.14, I² = 0%). Compared with those without adenomyosis, women with adenomyosis had an augmented miscarriage risk in ART (OR: 2.81, 95% CI: 1.44-5.47, I² = 64%). Compared with those without endometriosis, women with endometriosis had higher odds of APH, PPH, preterm birth, stillbirth, and placenta praevia. No difference was observed in the incidence of ectopic pregnancy, placental abruption, pre-eclampsia, gestational diabetes, low birthweight, and IUGR.

Conclusion

Women with endometriosis had an augmented miscarriage risk in SC and a similar miscarriage risk during ART. Adenomyosis was associated with miscarriage in pregnant women using ART.

Hypothetical roadmap towards endometriosis: prenatal endocrine-disrupting chemical pollutant exposure, anogenital distance, gut-genital microbiota and subclinical infections

BACKGROUND

Endometriosis is a gynaecological hormone-dependent disorder that is defined by histological lesions generated by the growth of endometrial-like tissue out of the uterus cavity, most commonly engrafted within the peritoneal cavity, although these lesions can also be located in distant organs. Endometriosis affects ~10% of women of reproductive age, frequently producing severe and, sometimes, incapacitating symptoms, including chronic pelvic pain, dysmenorrhea and dyspareunia, among others. Furthermore, endometriosis causes infertility in ~30% of affected women. Despite intense research on the mechanisms involved in the initial development and later progression of endometriosis, many questions remain unanswered and its aetiology remains unknown. Recent studies have demonstrated the critical role played by the relationship between the microbiome and mucosal immunology in preventing sexually transmitted diseases (HIV), infertility and several gynaecologic diseases.

OBJECTIVE AND RATIONALE

In this review, we sought to respond to the main research question related to the aetiology of endometriosis. We provide a model pointing out several risk factors that could explain the development of endometriosis. The hypothesis arises from bringing together current findings from large distinct areas, linking high prenatal exposure to environmental endocrine-disrupting chemicals with a short anogenital distance, female genital tract contamination with the faecal microbiota and the active role of genital subclinical microbial infections in the development and clinical progression of endometriosis.

SEARCH METHODS

We performed a search of the scientific literature published until 2019 in the PubMed database. The search strategy included the following keywords in various combinations: endometriosis, anogenital distance, chemical pollutants, endocrine-disrupting chemicals, prenatal exposure to endocrine-disrupting chemicals, the microbiome of the female reproductive tract, microbiota and genital tract, bacterial vaginosis, endometritis, oestrogens and microbiota and microbiota-immune system interactions.

OUTCOMES

On searching the corresponding bibliography, we found frequent associations between environmental endocrine-disrupting chemicals and endometriosis risk. Likewise, recent evidence and hypotheses have suggested the active role of genital subclinical microbial infections in the development and clinical progression of endometriosis. Hence, we can envisage a direct relationship between higher prenatal exposure to oestrogens or estrogenic endocrine-disrupting compounds (phthalates, bisphenols, organochlorine pesticides and others) and a shorter anogenital distance, which could favour frequent postnatal episodes of faecal microbiota contamination of the vulva and vagina, producing cervicovaginal microbiota dysbiosis. This relationship would disrupt local antimicrobial defences, subverting the homeostasis state and inducing a subclinical inflammatory response that could evolve into a sustained immune dysregulation, closing the vicious cycle responsible for the development of endometriosis.

WIDER IMPLICATIONS

Determining the aetiology of endometriosis is a challenging issue. Posing a new hypothesis on this subject provides the initial tool necessary to design future experimental, clinical and epidemiological research that could allow for a better understanding of the origin of this disease. Furthermore, advances in the understanding of its aetiology would allow the identification of new therapeutics and preventive actions.

Polymorphisms in the 3 ′ UTR Region of ESR2 and CYP19A1 Genes and Its Influence on Allele-Specific Gene Expression in Endometriosis

Objectives. Endometriosis is supported by hormonal, immunological, and environmental factors. No specific marker for endometriosis has yet been identified. ESR2 and CYP19A1 genes play a major role in the hormonal control of endometriosis women, the development of which largely depends on steroid hormones. Aim. An analysis of ESR2 and CYP19A1 allele-specific gene expressions in the context of the risk for endometriosis occurrence. Methods. The study material included paraffin-embedded tissue specimens, collected from patients ( $n=100$ ) with endometriosis. Blood samples from age-matched, endometriosis-free women ( $n=100$ ) served as a control. the RT-PCR technique was performed to observe the expression of ESR2 and CYP19A1 genes. Moreover, Sanger’s sequencing method was applied for polymorphism analysis. Results. A set of 4 single-nucleotide polymorphisms (SNPs) was determined; all of them most significantly associated with endometriosis: rs4986938 (G>A)(chromosome 14), rs928554 (A>G) (chromosome 14), rs10046 (C>T) (chromosome 15), and rs4646 (C>A) (chromosome 15). There were no differences in the distribution of genotypes and alleles in the studied groups, taking into account ESR2 and CYP19A1 gene expressions. Conclusion. The ESR2 and CYP19A1 polymorphisms may not be correlated with endometriosis susceptibility. Further analysis is needed to specify the role of these polymorphisms in the pathogenesis of endometriosis.

Inflammation to Infertility: Panoramic View on Endometriosis

Endometriosis is a disease caused by the implantation of endometrial glands and stroma outside the uterine cavity. It affects 10% of the reproductive-age women this means that 190 million women are affected worldwide. The definitive diagnosis requires surgical exploration or a laparoscopy which is of a high expense. The pathogenesis of the disease is heterogeneous and poorly understood despite the progress in the research field. Infertility is one of the main symptoms of Endometriosis. The mechanism behind this remains unclear. Literature suggests that Endometriosis reduces implantation capacity, increases the risk of pregnancy loss, and causes anatomical obstruction imposed by endometriotic lesions. The disease has a high burden to it by decreasing the quality of women's life and imposing negative consequences for their productivity, social life, and emotional wellbeing. Since inflammation is considered the hallmark of endometriosis, it is worth looking at the mechanism of how inflammation is linked to infertility in endometriosis patients. In this study, we summarized the recent finding of how inflammation can affect oocyte, endometrium, hormones, and sperm.

Role of lncRNA FTX in invasion, metastasis, and epithelial-mesenchymal transition of endometrial stromal cells caused by endometriosis by regulating the PI3K/Akt signaling pathway

BACKGROUND

Studies have considered long non-coding RNA 5 prime to Xist (lncRNA FTX) a key lncRNA for normal uterine development, but it has not been reported whether lncRNA FTX is involved in regulating the development of endometriosis (EMs). The aim of the present study was to explore the effect and mechanism of long non-coding RNA 5 prime to Xist (lncRNA FTX) on the invasion, metastasis, and epithelial-mesenchymal transition (EMT) of endometrial stromal cells (ESCs) caused by EMs.

METHODS

Ectopic or normal endometrial tissues were collected from 38 patients with EMs, who were diagnosed and operated on at Beijing Tongren Hospital from June 2018 to December 2019, and 20 healthy volunteers with normal endometria. The expression of lncRNA FTX in both groups was detected by quantitative reverse transcription polymerase chain reaction. Ectopic endometrial stromal cells (EESC) and ESC from patients with EMs and healthy volunteers were separated and cultured, and the expression of lncRNA FTX in the cells was detected. The expression of lncRNA FTX in EESC was overexpressed or interfered. Proliferation, invasion, and migration was detected by Cell Counting Kit-8, transwell assay, and scratch assay. Apoptosis and cell cycle were detected by flow cytometry. EMT-related protein and PI3K/Akt signaling pathway-related protein expressions were detected by Western blot.

RESULTS

LncRNA FTX was underexpressed in endometrial tissues and EESC from patients with EMs. The overexpression of lncRNA FTX could significantly inhibit the proliferation, invasion, and migration of EESC, but promoted apoptosis and cell cycle arrest in the G0/G1 phase. The overexpression of lncRNA FTX significantly increased the expression of EMT-related protein, E-cadherin, and decreased the protein expression of vimentin, N-cadherin, and zinc finger E-box binding homeobox 1. In addition, the overexpression of lncRNA FTX could decrease the expression of p-PI3K/PI3K and p-Akt/Akt. Interfering with the expression of lncRNA FTX had the opposite result.

CONCLUSIONS

The overexpression of lncRNA FTX could decrease the invasion, metastasis, and EMT of ESC caused by EMs by inhibiting the activity of the PI3K/Akt signaling pathway.

Iron-Storage Protein Ferritin Is Upregulated in Endometriosis and Iron Overload Contributes to a Migratory Phenotype

High levels of iron in the peritoneal cavity during menstruation have been implicated in the pathogenesis of endometriosis. However, whether iron directly affects the growth or migration of human endometriotic cells is poorly understood. This study demonstrated the presence of increased levels of the iron storage protein, ferritin, in the endometriotic tissues of patients with endometriosis. Furthermore, iron treatment stimulated the migration and epithelial–mesenchymal transition (EMT), but not growth, of 12Z human endometriotic cells. The expression of matrix metalloproteinase (MMP)-2/-9 was markedly increased through iron treatment in 12Z cells. Interestingly, intracellular reactive oxygen species (ROS) levels were significantly increased by iron in 12Z cells, and N-acetyl-L-cysteine significantly reduced iron-induced migration and MMP-2/-9 expression. Additionally, iron stimulated the activation of the NFκB pathway, and the activation was associated with iron-induced migration and MMP-2/-9 expression in 12Z cells. Moreover, iron markedly increased EMT and MMP-2/-9 expression in endometriotic lesions in an endometriosis mouse model. Taken together, these results suggest that iron may contribute to the migration abilities of human endometriotic cells via MMP expression through the ROS–NFκB pathway.

Cyclical Hemoptysis and Pelvic Pain in a Young Female: A Sign of Thoracic Endometriosis Syndrome

Distant autoimplantation of endometrial implants presents with signs and symptoms specific to the affected site. The constellation of cyclical hemoptysis, pleuritic chest pain, dyspnea, or cough in the right gynaecologic setting should raise concern for thoracic endometriosis syndrome (TES). Although extra-pelvic implications of endometriosis are well known, TES is exceedingly rare. We present an unusual case of aggressive TES that re-emerged after a period of latency despite suppressive therapy, making the case for future studies to establish surveillance schedules and advanced therapies. As these implants become sizable, they require a combination of medical and surgical therapies often with psychological support. This case illustrates the importance of prompt diagnosis and a multidisciplinary approach to TES.

The Diagnostic Accuracy of Combined Enolase/Cr, CA125, and CA19-9 in the Detection of Endometriosis

Background

The present study was designed to verify the accuracy of the noninvasive biomarkers enolase/Cr, CA125, and CA19-9 as a clinical diagnostic tool for the detection of endometriosis.

Methods

A cross-sectional study was performed at Rasool-e-Akram Hospital affiliated to Iran University of Medical Sciences, Tehran, Iran, from April 2015 to April 2018. Eighty-six women were scheduled to undergo laparoscopy due to chronic pelvic pain, infertility, pelvic mass, and abnormal uterine bleeding. Serum and urine samples of all patients were collected preoperatively. Serum levels of CA125 and CA19-9, and urine levels of enolase-1 were measured. Serum levels of CA125 and CA19-9 were determined by the electrochemiluminescence method (ECL). Urinary enolase-1 was measured by the ELISA method.

Result

Serum levels of CA125 and CA19-9 were significantly higher in the endometriosis group than in controls (p < 0.001, p = 0.004, respectively). Levels of enolase I and enolase/Cr were higher in patients with endometriosis, but the differences were not statistically significant. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of combined enolase/Cr, CA125, and CA19-9 were 65%, 66.6%, 71%, and 60.1%, respectively. The positive likelihood ratio (PLR) and negative likelihood ratio (NLR) of combined enolase/Cr, CA125, and CA19-9 was 1.94 and 0.52, respectively. The area under the ROC curve for enolase/Cr + CA125 + CA19 - 9 was 0.675 (95% confidence interval 0.573-0.710).

Conclusion

The present study revealed that concurrent measurement of enolase-1, CA125, and CA19-9 might be a valuable noninvasive test for the identification of endometriosis.

Laparoscopic bowel resection of deep infiltrating endometriosis. Comparative outcomes of a public teaching hospital and a referral private hospital

Purpose

To compare the operative outcomes of laparoscopic surgical treatment for bowel endometriosis in a public teaching hospital versus in a private referral hospital.

Methods

The indications for surgery, type and time of operation, length of hospital stay, need for a temporary stoma, rate of conversion to open surgery, and postoperative complications were evaluated.

Results

One hundred eighty-one patients were included (150 patients, 82.9%, in a private hospital). In the private hospital, there were more patients with infertility [56% vs. 29%; P=0.01] as an indication for surgery) and segmental resection was more common in the private hospital (48% vs. 29%, p=0.05). The average operative time (211.9±83.4 minutes vs. 128 ± 55 minutes, p<0.001) as well as the length of hospital stay (3.97±1.7 days vs. 1.56±0.85 days, p<0.001) was higher in the public hospital; the rate of conversion to open surgery was significantly lower in the private hospital (2% vs. 32.3%, p<0.001). Operations performed at the public hospital were associated with higher rates of postoperative complications (Clavien-Dindo II and II) (38.7% x 11.3%, p=0.021; OR 3.2, CI 95% 1.2-8.0).

Conclusion

Laparoscopic surgery in private centers was associated with reductions in major complications, surgical times, lengths of stay and rates of conversion to open surgery compared to that in public teaching hospitals.

The impact of endometrioma on in vitro fertilisation/intra-cytoplasmic injection IVF/ICSI reproductive outcomes: a systematic review and meta-analysis

Background

Assisted reproductive technologies (ART) such as in vitro fertilisation (IVF) and intra-cytoplasmic sperm injection (ICSI) are often used to aid fertility in women with endometrioma; however, the implications of endometrioma on ART are unresolved.

Objective

To determine the effect of endometrioma on reproductive outcomes in women undergoing IVF or ICSI.

Methods

A systematic review and meta-analysis was conducted to identify articles examining women who had endometrioma and had undergone IVF or ICSI. Electronic searches were performed in PubMed, BIOSIS and MEDLINE up to September 2019. The primary outcome was live birth rate (LBR). Secondary outcomes included clinical pregnancy rate (CPR), implantation rate (IR), number of oocytes retrieved, number of metaphase II (MII) oocytes retrieved, number of embryos and top-quality embryos and the duration of gonadotrophin stimulation and dose.

Results

Eight studies were included. Where significant heterogeneity between studies was identified, a random-effects model was used. The number of oocytes (weighted means difference; WMD-2.25; 95% CI 3.43 to − 1.06, p = 0.0002) and the number of MII oocytes retrieved (WMD-4.64; 95% CI 5.65 to − 3.63, p < 0.00001) were significantly lower in women with endometrioma versus controls. All other outcomes, including gonadotrophin dose and duration, the total number of embryos, high-quality embryos, CPR, IR and LBR were similar in women with and without endometrioma.

Conclusion

Even though women with endometriomas had a reduced number of oocytes and MII oocytes retrieved when compared to women without, no other differences in reproductive outcomes were identified. This implies that IVF/ICSI is a beneficial ART approach for women with endometrioma.

Neuroendocrine appendiceal tumor and endometriosis of the appendix: a case report

INTRODUCTION

Endometriosis of the appendix is very uncommon, accounting for only about 1% of all cases of endometriosis. However, endometriosis is found in the appendix in approximately 8-13% of patients with deep infiltrating endometriosis and is particularly common in patients with severe forms of deep infiltrating endometriosis. Neuroendocrine tumors are the most common neoplasms of the appendix and may be misdiagnosed when there are multiple endometriosis lesions in the pelvis.

CASE PRESENTATION

We describe a case of a Caucasian patient with deep infiltrating endometriosis with rectal involvement, retrocervical lesions, and a right ovarian endometrioma with no suspected lesions in the appendix. She underwent laparoscopy and, after a systematic intraoperative evaluation, suspected involvement of the appendix was observed. The patient underwent ovarian cystectomy, excision of the pelvic endometriosis lesions, appendectomy, and anterior stapler discoid resection. Histopathological analysis of the appendix revealed endometriosis and a well-differentiated neuroendocrine carcinoma at the appendix tip.

DISCUSSION

Our patient's case emphasizes the need to approach these lesions carefully and strengthens the indication for appendectomy when the appendix is affected in the setting of endometriosis. Despite the more likely diagnosis of appendiceal endometriosis, neuroendocrine tumors cannot be ruled out by imaging examinations, and both conditions can occur in the same patient.

Endometriosis Associated Infertility: A Critical Review and Analysis on Etiopathogenesis and Therapeutic Approaches

Endometriosis represents a frequently diagnosed gynecological affliction in the reproductive timespan of women, defined by symptoms ranging from pelvic pain to infertility. A complex interplay between the genetic profile, hormonal activity, menstrual cyclicity, inflammation status, and immunological factors define the phenotypic presentation of endometriosis. To date, imaging techniques represent the gold standard in diagnosing endometriosis, of which transvaginal ultrasonography and magnetic resonance imaging bring the most value to the diagnostic step. Current medical treatment options for endometriosis-associated infertility focus on either stimulating the follicular development and ovulation or on inhibiting the growth and development of endometriotic lesions. Techniques of assisted reproduction consisting of superovulation with in vitro fertilization or intrauterine insemination represent effective treatment alternatives that improve fertility in patients suffering from endometriosis. Emerging therapies such as the usage of antioxidant molecules and stem cells still need future research to prove the therapeutic efficacy in this pathology.

The -1195A>G polymorphism in Ciclooxygenase-2 gene is associated with lower risk of endometriosis

OBJECTIVES

This study aimed to evaluate the potential role of the PTGS2 single nucleotide polymorphisms (SNPs) -1195 A>G and +8473 T>C in endometriosis' development, and characterizing their association with the prognostic features of the disease.

STUDY DESIGN

DNA from 254 women with endometriosis and 267 controls, recruited from two reference hospitals from the Brazilian public health system, were genotyped using TaqMan allelic discrimination assays. The association between SNPs and endometriosis features was evaluated by multivariate logistic regression, using the adjusted odds ratios (OR) with their respective 95% confidence intervals (95% CI).

RESULTS AND CONCLUSION

There were significant differences between cases and controls regarding age (P < 0.001), body mass index (BMI) (P = 0.001), educational level (P < 0.001), physical activity (P = 0.003), smoking status (P < 0.001), contraception use (P = 0.02), family history of endometriosis (P = 0.002) and all symptoms (P < 0.001). The distribution of -1195 A > G was statistically different between the groups, suggesting a lower risk of developing the disease for the carriers of the -1195 GG genotype (OR = 0.19; 95% CI = 0.04 - 0.93). No differences were found for the +8473 T>C between the two groups and neither in prognostic features of the disease for both PTGS2 SNPs. In conclusion, PTGS2 -1195A>G SNP was negatively associated with development of endometriosis and the two groups were statistically different regarding age, BMI, educational level, physical activity, smoking status, contraception use, history of endometriosis and all endometriosis symptoms.

Role of Non-coding RNAs in the Pathogenesis of Endometriosis

Endometriosis is a disorder characterized by the presence of endometrial glands and stroma like lesions outside of the uterus. Although several hypothesis have tried to explain the underlying cause of endometriosis, yet the main cause remained obscure. Recent studies have shown contribution of non-coding RNAs in the pathogenesis of endometriosis. Two classes of these transcripts namely long non-coding RNAs (lncRNAs) and microRNAs (miRNAs) have mostly attracted attention of researchers. Several studies have reported aberrant expression of these transcripts in affected tissues from patients as well as animal models. Modulation of important signaling pathways such as PI3K/AKT, P38-MAPK, ERK1/2-MAPK and Wnt-β catenin by miRNAs and lncRNAs have potentiated these molecules as biomarkers or therapeutic agents in endometriosis. Single nucleotide polymorphisms with miR-126, miR-143 and miR-146b have been associated with risk of endometriosis. Moreover, miRNAs and lncRNAs control inflammatory responses, cell proliferation, angiogenesis and tissue remodeling, thus understanding the role of these transcripts in endometriosis is a possible way to develop novel diagnostic tests and therapeutic targets for this disorder.

LncRNA MEG3-210 regulates endometrial stromal cells migration, invasion and apoptosis through p38 MAPK and PKA/SERCA2 signalling via interaction with Galectin-1 in endometriosis

BACKGROUND

Endometriosis is a benign gynaecological disease with malignant characteristics that severely affects women's quality of life. Long noncoding RNA maternally expressed gene 3 (LncRNA MEG3) is a tumour suppressor that is downregulated in various cancer cells and tissues, and regulates multiple biological processes. Emerging studies have revealed that the interactions between MEG3 and proteins are involved in disease progression. Galectin-1 affects cell motility, signal transduction and vascularization, and is overexpressed in endometriosis. Our study is the first to explore the role of MEG3-210 transcript in endometriosis and to reveal the regulatory mechanism mediated by the interaction between MEG3-210 and Galectin-1.

MATERIALS AND METHODS

Endometrial tissues and sera from patients with endometriosis and controls were collected. qRT-PCR was performed to detect the expression of MEG3-210 in the endometrium and endometrial stromal cells (ESCs). The CCK-8 assay, the Transwell assay, flow cytometry and animal models were conducted to evaluate the functions of MEG3-210 in vitro and in vivo. Bioinformatic analysis, Western blot assays, RNA-pull down assays and RNA immunoprecipitation were used to explore the potential mechanism of MEG3-210 in endometriosis.

RESULTS

Our results showed that MEG3-210 expression was lower in the eutopic endometrium of women with endometriosis. MEG3-210 downregulation promoted ESCs migration, invasion, anti-apoptosis in vitro and growth of endometriotic lesions in vivo. Furthermore, MEG3-210 downregulation could activate p38 mitogen-activated protein kinase (p38 MAPK) and inhibit cAMP-dependent protein kinase A/sarcoplasmic reticulum Ca²⁺ ATPase 2 (PKA/SERCA2) signalling, which was mediated by Galectin-1. The protein levels of Galectin-1 in patients with endometriosis were elevated, and Galectin-1 siRNA could reduce the size of lesions.

CONCLUSION

MEG3-210 regulates ESCs through p38 MAPK and PKA/SERCA signalling via interaction with Galectin-1. The novel regulatory mechanism may provide new insights into drug therapy and the diagnosis of endometriosis.

Endometriosis Pain Management: a Review

PURPOSE OF REVIEW

The purpose of this review is to summarize the up-to-date pain management options and recommendations for the challenging disease, endometriosis.

RECENT FINDINGS

The mainstays of endometriosis advances of both surgical and medical management continue to evolve. Experimental pharmaceuticals include Gestirone, and aromatase inhibitors have shown promise but are still under scrutiny. Surgical techniques include laparoscopic uterosacral nerve ablation/resection and presacral neurectomy. No studies have directly compared medical versus surgical management, and as such, no one treatment modality can be recommend as superior to the other. Patients may initially be given a medical diagnosis and treated with nonsteroidal anti-inflammatory drugs, neurolepitcs, OCP, GNRH agonists/antagonists, and Danazol. Assessing the success of these regimens has proved difficult. Surgical management relies on various methods including excision/ablation of the lesions, nerve ablation, neurectomy, hysterectomy, and oophorectomy.

Expression of Membrane Progesterone Receptors in Eutopic and Ectopic Endometrium of Women with Endometriosis

Endometriosis is one of the most frequent gynecological diseases in reproductive age women, but its etiology is not completely understood. Endometriosis is characterized by progesterone resistance, which has been explained in part by a decrease in the expression of the intracellular progesterone receptor in the ectopic endometrium. Progesterone action is also mediated by nongenomic mechanisms via membrane progesterone receptors (mPRs) that belong to the class II members of the progesterone and adipoQ receptor (PAQR) family. The aim of the present study was to evaluate the expression at mRNA and protein levels of mPR members in the eutopic and ectopic endometrium of women with endometriosis. Total RNA and total protein were isolated from control endometrium (17 samples), eutopic endometrium (17 samples), and ectopic endometrium (9 samples). The expression of PAQR7 (mPRα), PAQR8 (mPRβ), and PAQR6 (mPRδ) at mRNA and protein levels was evaluated by RT-qPCR and Western blot, whereas PAQR5 (mPRγ) gene expression was evaluated by RT-qPCR. Statistical analysis between comparable groups was performed using one-way ANOVA followed by Tukey's multiple comparisons test with a confidence interval of 95 %. The analysis of gene expression showed that PAQR7 and PAQR5 expression was lower in both eutopic and ectopic endometrium as compared to the endometrium of women without endometriosis, whereas the expression of PAQR8 and PAQR6 was only reduced in eutopic endometrium. Furthermore, mPRα and mPRβ protein content was decreased in the ectopic endometrium of women with endometriosis. Our results demonstrate a decrease in the expression and protein content of mPRs in eutopic and ectopic endometrium of patients with endometriosis, which could contribute to the progesterone resistance observed in patients with this disease.

Peripheral Blood Leukocyte Telomere Length and Endometriosis

Endometriosis is a common gynecologic disease defined by the presence of endometrial-like tissue outside the uterine cavity. While its etiology is largely unknown, accumulating evidence suggests that inflammation plays a major role. Our objective was to investigate the association between peripheral blood leukocyte telomere length (LTL) and endometriosis using data from two large population-based studies, the New England Case-Control Study (NEC; n = 877) and the National Health and Nutrition Examination Survey (NHANES; n = 2268). NEC control participants were identified through a combination of random digit dialing, drivers' license lists, and town resident lists. In NHANES, selection algorithms were used to identify a nationally representative sample. Blood samples and demographic, reproductive, and health-related information were available from both data sources. Endometriosis was defined as self-reported of physician-diagnosed endometriosis. LTL was measured using quantitative polymerase chain reaction. Multivariable logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for the association between LTL and endometriosis. Shorter LTL was associated with greater odds of history of endometriosis. In NEC, women with the shortest LTL tertile compared with the longest had a 2.5-fold greater odds of endometriosis (OR_T3/T1 = 2.56, 95% CI = 1.16-5.63; p value, test for linear trend = 0.02). The association was stronger among women who usually experienced moderate or severe menstrual pain (OR _T3/T1 = 3.50, 95% CI = 1.12-10.97). In NHANES, the data suggested a similar but attenuated association (OR_T3/T1 = 1.29, 95% CI = 0.85-1.96). The observed associations in NEC suggest that shorter LTL may be associated with greater odds of endometriosis. A better understanding of how LTL influences endometriosis risk could elucidate novel disease pathophysiology.

Risk of depression and anemia in users of hormonal endometriosis treatments: Results from the VIPOS study

OBJECTIVE

Dienogest (DNG) 2 mg (Visanne) was launched for endometriosis treatment in Europe in 2010. The Visanne Post-approval Observational Study (VIPOS) was designed to assess the safety of DNG 2 mg/day compared to other hormonal endometriosis treatments, focusing especially on clinically relevant depression and anemia.

STUDY DESIGN

Large, prospective, non-interventional, active surveillance study in six European countries. Participants were recruited via gynecologists or specialized centers routinely prescribing endometriosis medication. Self-administered questionnaires during study entry and follow-up collected information on baseline characteristics, health status and endometriosis treatment. Patient-reported anemia and depression cases were validated by health care professionals. Inferential statistics were based on Cox proportional hazards models and crude and adjusted hazard ratios (HR) between cohorts were calculated (including 95% confidence intervals [CI]). Adjustment for potential confounding was performed by including predefined prognostic factors as covariates in the Cox models.

RESULTS

Out of 26,430 participants, 11.4% used DNG, 12.8% used other approved endometriosis medications (OAED) and 75.7% used hormonal treatments not approved but frequently used for endometriosis treatment (NAED). At baseline, DNG users more frequently reported a surgically confirmed endometriosis diagnosis, severe endometriosis-associated pain and a history of depression, compared to the other cohorts. Baseline characteristics showed large inter-country variability. Overall, the number of confirmed anemia and depression events were substantially lower than expected. The adjusted HRs for anemia were 1.1 (95% CI, 0.4-2.6) for DNG vs OAED and 1.3 (95% CI, 0.7-2.4) for DNG vs NAED. The adjusted HRs for new or worsening depression were 1.8 (95% CI, 0.3-9.4) for DNG vs OAED and 1.5 (95% CI, 0.8-2.8) for DNG vs NAED.

CONCLUSION

The main limitations encountered (low number of confirmed events and considerable inter-country variability) made a robust statistical analysis and a solid interpretation of the results challenging. However, no safety signal regarding anemia for DNG users could be detected, whereas a slight increase in depression risk cannot be excluded but might be explained by baseline severity of endometriosis or unknown country-specific confounding variables. VIPOS reflected routine use of hormonal endometriosis medications and provided real-world insights into endometriosis management in Europe.

Multifocal abdominal endometriosis, a case report

Multifocal endometriosis found outside of the pelvis is very rare. We present here a case of endometriosis found in the pelvis, appendix and umbilicus. A 52-year-old female had a previous umbilical hernia repair, and years later started to develop a recurrent umbilical mass. After a full work-up, it was decided the patient have a diagnostic laparoscopy with wide local excision of umbilical mass to rule out any underlying malignancy. Findings during the procedure included an umbilical mass, dilated appendix and ovoid mass abutting the appendix. Pathology of the umbilical mass was found to be consistent with endometriosis. Umbilical and pelvic endometriosis is a rare condition. Options for diagnosis prior to surgical interventions are limited in endometriosis. In this case, ruling out underlying malignancy took priority, and the mass was removed and she will have less chance of recurrence.

Pathophysiological Basis of Endometriosis-Linked Stress Associated with Pain and Infertility: A Conceptual Review

Women with endometriosis are often under stress due to the associated pain, infertility, inflammation-related and other comorbidities including cancer. Additionally, these women are also under stress due to taboos, myths, inter-personal troubles surrounding infertility and pain of the disease as well as due to frequent incidences of missed diagnosis and treatment recurrence. Often these women suffer from frustration and loss of valuable time in the prime phase of life. All these complexities integral to endometriosis posit a hyperstructure of integrative stress physiology with overt differentials in effective allostatic state in women with disease compared with disease-free women. In the present review, we aim to critically examine various aspects of pathophysiological basis of stress surrounding endometriosis with special emphasis on pain and subfertility that are known to affect the overall health and quality of life of women with the disease and promising pathophysiological basis for its effective management.

Pelvic MRI in the diagnosis and staging of pelvic endometriosis: added value of structured reporting and expertise

PURPOSE

To compare the diagnostic characteristics of routine-read (RR), structured-reported read (SR), and structured expert-read pelvic (SER) MRI for staging of pelvic endometriosis in a tertiary care academic center.

METHODS

Of 530 patients with endometriosis (2013-2018), 59/530 (11.1%) were staged surgically and underwent pelvic MRI. Radiology reports were considered RR; MRI studies were independently reassessed by SR and SER. Involvement was recorded by compartment [anterior (AC), middle (MC), posterior (PC), adnexal (AX), and other (OC)]. Diagnostic discrepancy between review methods was assessed with McNemar's test. Interobserver agreement was assessed using Cohen's unweighted kappa.

RESULTS

Of 295 compartments in 59 women (mean age = 38.8 years; range 20-69), 147/295 (49.8%) had confirmed endometriosis. Overall sensitivity: RR = 42.9%; SR = 86.4%; SER = 74.2%. SR's increased sensitivity was significant for PC (p < 0.001), MC (p < 0.001), AC (p = 0.001), AX (p = 0.038). Higher sensitivity by SER was significant for PC (p < 0.001), MC (p = 0.004) and AC (p < 0.001), but not AX (p > 0.05). Overall specificity: RR = 95.3%; SR = 45.9%; SER = 81.8%. SER specificity was no different than RR for PC or AX (p > 0.5). RR sensitivity relied heavily on detection of AX involvement, whereas SR and SER showed additional sites of disease while maintaining comparable specificity for SER. Overall agreement between SR and SER was fair [k = 0.342 (95% CI 0.25, 0.44)].

CONCLUSIONS

Even at a tertiary care academic center, SER outperforms both SR and RR in the assessment of pelvic endometriosis. Although lack of expertise may negatively impact specificity, use of structured reporting is significantly more sensitive than RR. Therefore, its use can be of assistance in surgical planning and patient counseling.

What abdominal radiologists should know about extragenital endometriosis-associated neuropathy

PURPOSE

The aim of this study is to provide an overview of endometriosis-associated neuropathy and to review main anatomical concepts of intrapelvic peripheral nerves.

METHODS

In this pictorial essay, we review the anatomy of pelvic nerves and imaging features of endometriosis-associated neuropathy. We also evaluate clinical findings, imaging features, and outcome of seven patients with endometriosis-associated neuropathy.

RESULTS

Nerve involvement by endometriosis is rare and may manifest with neurological symptoms, including pain, muscle weakness, bowel and bladder incontinence, and paraplegia. The neural involvement may be isolated or caused by a direct extension of a deep infiltrating endometriosis of the pelvic structure. Magnetic resonance imaging (MRI) is a reliable imaging modality for detecting neural involvement of endometriosis. On MRI, the main imaging features are retractile fibrous tissue and endometriomas. The signal intensity of the endometriotic tissue may vary depending on the age of the hemorrhage and the proportion of endometrial cells and stroma. Early diagnosis and treatment may avoid permanent neural damage.

CONCLUSION

Considering that patients with endometriosis usually undergo pelvic MRI, which is generally reported by a non-musculoskeletal-trained radiologist, abdominal radiologists need to be familiar with the pelvic nerve anatomy and the possible patterns of presentation of neural endometriosis. Early diagnosis may obviate permanent nerve damage and MRI is a reliable tool for the diagnosis.

GenomeForest: An Ensemble Machine Learning Classifier for Endometriosis

Endometriosis is a complex and high impact disease affecting 176 million women worldwide with diagnostic latency between 4 to 11 years due to lack of a definitive clinical symptom or a minimally invasive diagnostic method. In this study, we developed a new ensemble machine learning classifier based on chromosomal partitioning, named GenomeForest and applied it in classifying the endometriosis vs. the control patients using 38 RNA-seq and 80 enrichment-based DNA-methylation (MBD-seq) datasets, and computed performance assessment with six different experiments. The ensemble machine learning models provided an avenue for identifying several candidate biomarker genes with a very high F1 score; a near perfect F1 score (0.968) for the transcriptomics dataset and a very high F1 score (0.918) for the methylomics dataset. We hope in the future a less invasive biopsy can be used to diagnose endometriosis using the findings from such ensemble machine learning classifiers, as demonstrated in this study.

Medical therapy options for endometriosis related pain, which is better? A systematic review and network meta-analysis of randomized controlled trials

Our objective was to assess and rank different pharmacological interventions for relieving endometriosis-related pain. We conducted an online bibliographic search in different databases from their inception until March 2019. We included randomized controlled trials (RCTs) that assessed different medical therapies in the management of endometriosis-related pain. We applied this network meta-analysis (NMA) based on the frequentist approach using statistical package "netmeta" (version 1.0-1) in R software. Our main outcomes were the change in severity of pelvic pain, dysmenorrhea score, non-menstrual pelvic pain score, and dyspareunia score. Overall, 36 RCTs were included in this study (patients no. = 7942). Dienogest (0.94), combined hormonal contraceptives (CHCs) (0.782), and elagolix (0.38) were the highest-ranked interventions for reducing the severity of pelvic pain at three months, while at six months, gonadotropin-releasing hormone (GnRH) analogues (0.75), levonorgestrel-releasing intrauterine system (LNG-IUS) (0.73), and dienogest (0.65) were linked to more reduction in pelvic pain. The ranking p-score showed that GnRH analogues was the highest-ranked treatment for reducing dysmenorrhea at 3 months (1.00), while CHCs were the highest-ranked treatment at 6 months (0.97), followed by GnRH analogues (0.89). GnRH analogues (0.63) and elagolix (0.54) at three months while desogestrel (0.94) and CHCs (0.91) at six months were the highest-ranked treatment to reduce non-menstrual pelvic pain. GnRH analogues and elagolix were the highest-ranked pharmacologic therapies for reducing dyspareunia. In conclusion, CHCs, GnRH analogues, progesterone, and elagolix were the best approaches in reducing the pain of endometriosis.

Polymorphisms in the 3'UTR Region of ESR2 and CYP19A1 Genes in Women With Endometriosis

OBJECTIVE

ESR2 and CYP19A1 genes play a major role in the hormonal control of women with endometriosis. The aim of the study was to analyze single nucleotide polymorphisms (SNPs) in the 3'UTR region of ESR2 and CYP19A1 genes. The study aimed at localisation of new polymorphisms, the nucleotide variants of which determine the level of susceptibility to endometriosis.

STUDY DESIGN

The study included n = 200 patients: 100 with endometriosis and 100 healthy controls. The Sanger's sequencing method was applied for polymorphism analysis.

RESULTS

Statistically significant correlations were identified between new, not previously described, two SNPs of ESR2 gene and endometriosis: rs4986938 (G>A) and rs928554 (A>G). In the case of rs4986938 polymorphism, the genotype AA was found to decrease the risk of endometriosis (OR = 0.24 95 % PU 0.05-1.22, p = 0.04). Analysis of the rs928554 polymorphism revealed that the occurrence of the AG genotype reduced the risk of endometriosis (OR = 0.38 95 % PU 0.21-0.71, p = 0.002). There were no differences in the distribution of genotypes of the polymorphisms rs10046 (C>T) and rs4646 (C>A) of CYP19A1 gene between patients and control.

CONCLUSIONS

Further studies are necessary in groups with higher numbers of patients to explain whether the above-mentioned polymorphisms may be the risk factors for endometriosis.

Vitamin D-Binding Protein in Pregnancy and Reproductive Health

Vitamin D-binding protein (VDBP), the main carrier of vitamin D, has recently been implicated in reproductive health and pregnancy outcomes including endometriosis, polycystic ovary syndrome (PCOS), pre-eclampsia, and gestational diabetes mellitus (GDM). Improved methods for measuring VDBP and an increased understanding of its role in biological processes have led to a number of newly published studies exploring VDBP in the context of pregnancy. Here, we synthesize the available evidence regarding the role of VDBP in reproductive health and pregnancy, and we highlight areas requiring further study. Overall, low levels of maternal serum VDBP concentrations have been associated with infertility, endometriosis, PCOS and spontaneous miscarriage, as well as adverse pregnancy outcomes including GDM, pre-eclampsia, preterm birth and fetal growth restriction. However, increased VDBP concentration in cervicovaginal fluid has been linked to unexplained recurrent pregnancy loss and premature rupture of membranes. Some genetic variants of VDBP have also been associated with these adverse outcomes. Further studies using more accurate VDBP assays and accounting for ethnic variation and potential confounders are needed to clarify whether VDBP is associated with reproductive health and pregnancy outcomes, and the mechanisms underlying these relationships.

Use of dienogest in endometriosis: a narrative literature review and expert commentary

Objective: Endometriosis affects up to 10% of women of reproductive age, and the main goal of treatment is to relieve symptoms. Progestins have been the mainstay of endometriosis suppression, of which dienogest has become an important option in many parts of the world. This is an expert literature review, with recommendations on the use of dienogest in the context of various clinical considerations when treating endometriosis.Methods: A search of PubMed was conducted for papers published between 2007 and 2019 on the use of dienogest in endometriosis. Experts reviewed these and included those they considered most relevant in clinical practice, according to their own clinical experience.Results: Evidence regarding the long-term use (>15 months) of dienogest for the management of endometriosis is presented, with experts concluding that the efficacy of dienogest should be assessed primarily on its impact on pain and quality of life. Fertility preservation, the option to avoid or delay surgery, and managing bleeding irregularities that can occur with this treatment are also considered. Counseling women on potential bleeding risks before starting treatment may be helpful, and evidence suggests that few women discontinue treatment for this reason, with the benefits of treatment outweighing any impact of bleeding irregularities.Conclusions: Overall, the evidence demonstrates that dienogest offers an effective and tolerable alternative or adjunct to surgery and provides many advantages over combined hormonal contraceptives for the treatment of endometriosis. It is important that treatment guidelines are followed and care is tailored to the woman's individual needs and desires.

Detection of endometriosis using immunocytochemistry of P450 Aromatase expressions in eutopic endometrial cells obtained from menstrual sloughing: a diagnostic study

Objective

To explore the possibility of a new diagnostic approach of endometriosis based on immunocytochemistry scoring of Aromatase P450 expressions in endometrial cells collected from menstrual sloughing. This is a case control study. Immuncytochemistry scores vs. histopathological examination in one tertiary- and secondary-level hospital in Bandung; two secondary level hospital in Garut and Sumedang, West Java, Indonesia. Thirty-five patients with and without endometriosis were enrolled. All subjects had diagnostic procedures for endometriosis suspicion, with addition menstrual blood samples for cytopathological examination. The specimens were sent for immunocytochemistry assessment of P450 Aromatase expressions (ICAPEC). The previous procedure resulted in cut-off point of histo score (H-score), sensitivity, specificity, (+) and (−) ICAPEC predictive value.

Results

The P450 Aromatase expression in endometrial cells of women with endometriosis was significantly stronger than without one. The cut-off point of H-scores to detect endometriosis was > 4. By this criteria, H-score had 94.6% sensitivity, 90.9% specificity, 92% positive predictive value and 93% negative predictive value. Immunocytochemistry scoring of Aromatase P450 expression in endometrial cells (ICAPEC) derived from menstrual blood specimen was a good candidate as alternatives approach in diagnostic procedure of endometriosis. Application and evaluation in clinical practice would provide the economically benefit in diagnostic procedure.

Concurrent Escherichia coli tubo-ovarian abscess and Campylobacter jejuni gastroenteritis: A case report

Haematogenous or direct spread of bacterial infection causing pelvic inflammatory disease of the upper female reproductive tract is uncommon. We report a diagnostically challenging case of a 41-year-old woman with a background of Stage 4 endometriosis presenting with fever, diarrhoea and abdominal pain with recent history of pyelonephritis. Initially managed for undifferentiated abdominal pain with unclear focus of infection, a broad range of investigations were undertaken. Laboratory samples confirmed the presence of Campylobacter jejuni and appropriate treatment for Campylobacteriosis was commenced. Despite treatment, her condition deteriorated and repeat radiological imaging revealed bilateral tubo-ovarian abscess requiring surgical drainage for control of severe sepsis. Sterile surgical samples of the abscess revealed Escherichia coli. This case adds to the growing body of evidence of the association between pelvic inflammatory disease, severe endometriosis and development of tubo-ovarian abscess. Sepsis associated with tubo-ovarian abscess has a mortality rate of up to 10%. Hence, we present this case to highlight severe endometriosis as a risk factor for disease and the need for prompt reassessment of the deteriorating woman with sepsis and pelvic pain to direct efforts to minimise morbidity and mortality.

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Few cases of tubo-ovarian abscess caused by haematogenous or direct spread of bacterial infection have been reported.

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Tubo-ovarian abscess in women with known endometriosis are 8 times more likely to require surgical intervention than women without endometriosis.

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Prompt recognition of the patients deterioration in the case reported led to additional investigations, prompt multidisciplinary management and a favourable outcome.