Is Stress a Cause or a Consequence of Endometriosis?

Mental illness and sleep disorders among women with gynecological problems

This retrospective cohort study identifies differences between rates of selected mental illnesses and sleep disorders according to eight gynecological problems. Analyses utilize medical claims data for adult employees of a large corporation during 2017-2021. Women with a gynecological problem (most notably pain, endometriosis, pelvic inflammation and bleeding) are significantly more likely to experience mental illness. Several gynecological problems are also significantly associated with sleep disorders. Women with a gynecological problem (vs. none) are 50% more likely to have a mental health problem and 44% more likely to have a sleep disorder after adjusting for age, marital status, dependent children and year. The largest differences between higher (%) mental illness and sleep disorders appear for hyperplasia (6% vs. 45%), cancer (11% vs. 68%), pelvic inflammation (46% vs. 79%) and pain (79% vs. 43%), respectively. On the other hand, the rate of having one or more gynecological problems ranges from 7.1% for women with no mental illness or sleep disorder to 20.6% for women with schizophrenia. Understanding the association between gynecological problems, mental illness and sleep disorders can help clinicians more effectively identify and treat patients.

The impact of war situation on endometriosis patients: Evaluating physical and mental health outcomes

To investigate the impact of war situation on physical functioning, mental health status, and disease manifestations among endometriosis patients. Questionnaire-based study analyzing physical and psychosocial well-being. The study includes 50 endometriosis patients at Sheba Medical Center who completed a detailed questionnaire before and after the onset of the October 7, 2023, War in Israel. Significant deterioration in physical and mental health after the onset of war (pain score 6 vs 7; p < 0.001). Although having a first-degree relative affected by the war was associated with health deterioration (OR, 5.44; p = 0.02), similar pattern of health status aggregation was observed also in a subgroup of 19 women without family involvement, suggesting the general war situation as a likely cause. Starting new anti-anxiety or antidepressant medications and psychological therapy had a protective effect (OR, 0.21; p = 0.05). War situation exacerbates endometriosis symptoms, highlighting the importance of early psychological interventions to mitigate negative impacts.

Correlation study of NF-κB, IER3, and Recurrence of Ovarian Endometrioid Cysts

The study aimed to investigate the expression of nuclear actor-k-gene binding(NF-κB) and immediate early response 3(IER3) in ovarian endometrioid cysts and its correlation with the recurrence of the ovarian endometrioid cyst. From January 2018 to March 2019, a total of 88 patients who underwent laparoscopic ovarian cyst excision due to ovarian endometrioid cyst in Changzhou Maternity and Child Health Care Hospital were selected. Clinical data of the patients were collected. The patient's Revised American Fertility Society (R-AFS) score, least function(LF) score, and endometriosis fertility index (EFI) were calculated. Immunohistochemistry was performed to detect the expression of IER3 and NF-κB. The receiver-operating characteristic (ROC) curve was used to evaluate the predictive value of IER3 and NF-κB expression on postoperative recurrence. Cox regression was fitted to analyze the influencing factors of ovarian endometrioid cyst recurrence. The expression of NF-κB was positively correlated with IER3 (P < 0.001). ROC curve showed that NF-κB combined with IER3 had higher predictive value for disease recurrence. Multivariate Cox regression showed that the IER3 expression intensity > 4.5 (HR = 3.418,95%CI: 1.227 ~ 9.523, P = 0.019) and the NF-κB expression intensity > 4.5 (HR = 5.491,95%CI: 1.600 ~ 18.838, P = 0.007) were independent risk factors for recurrence, and EFI score (HR = 0.791,95%CI: 0.637 ~ 0.983, P = 0.035) was a protective factor for recurrence. Our results suggested that EFI score is a protective factor for recurrence. The expression levels of NF-κB and IER3 > 4.5 are correlated with the recurrence of ovarian endometrioid cysts and independent risk factors for recurrence.

Exercise and endometriosis-is there a promising future? A narrative review

BACKGROUND

Endometriosis is the leading cause of chronic pelvic pain in women of reproductive age with debilitating effects on quality of life, yet no cure exists. Exercise yields the potential in providing women with a non-invasive, non-pharmacological method of symptom control.

AIM(S)

Present up-to-date knowledge regarding how exercise may contribute to the management of endometriosis-related symptoms.

OBJECTIVE(S)

Discuss: 1. The pathophysiology surrounding exercise and endometriosis. 2. The role of exercise in endometriosis symptom control.

RATIONALE

Scientific literature has alluded to exercise being a favourable factor in the management of endometriosis-related symptoms. Moreover, current clinical guidelines for endometriosis fail to reflect the aforementioned benefits of exercise.

SEARCH STRATEGY

A search strategy using the terms 'endometriosis', 'endometriomas', 'exercise', and 'physical activity' was devised. Pubmed, Medline, Cochrane reviews, and Embase were reviewed.

INCLUSION CRITERIA

Interventional studies, within-subjects studies, randomised-control trials, systematic reviews, meta-analysis, cohort studies, publication since 2000.

EXCLUSION CRITERIA

Non-English publications, non-human studies.

RESULTS

Numerous studies have suggested positive effects for endometriosis patients who performed exercise exclusively or in conjunction with other therapies. Improvements in pain levels, quality of life, anxiety, and depression were noted.

DISCUSSION

Current research outlines promise regarding the potential benefit of exercise prescribing in patients with endometriosis as well as a synergy between exercise and hormonal therapies for the management of endometriosis-related symptoms. However, the current paucity of high-quality robust studies investigating these aspects of endometriosis management is an apparent obstacle to progression in this area.

CONCLUSION

For clinicians to incorporate exercise in managing endometriosis, clear recommendations regarding advice and benefits are needed.

The vicious cycle of chronic endometriosis and depression-an immunological and physiological perspective

Endometriosis is a chronic, estrogen-dependent, proinflammatory disease that can cause various dysfunctions. The main clinical manifestations of endometriosis include chronic pelvic pain and impaired fertility. The disease is characterized by a spectrum of dysfunctions spanning hormonal signaling, inflammation, immune dysregulation, angiogenesis, neurogenic inflammation, epigenetic alterations, and tissue remodeling. Dysregulated hormonal signaling, particularly involving estrogen and progesterone, drives abnormal growth and survival of endometrial-like tissue outside the uterus. Chronic inflammation, marked by immune cell infiltration and inflammatory mediator secretion, perpetuates tissue damage and pain. Altered immune function, impaired ectopic tissue clearance, and dysregulated cytokine production contribute to immune dysregulation. Enhanced angiogenesis promotes lesion growth and survival. Epigenetic modifications influence gene expression patterns, e.g., HSD11B1 gene, affecting disease pathogenesis. Endometriosis related changes and infertility lead to depression in diagnosed women. Depression changes lifestyle and induces physiological and immunological changes. A higher rate of depression and anxiety has been reported in women diagnosed with endometriosis, unleashing physiological, clinical and immune imbalances which further accelerate chronic endometriosis or vice versa. Thus, both endometriosis and depression are concomitantly part of a vicious cycle that enhance disease complications. A multidimensional treatment strategy is needed which can cater for both endometrial disease and depression and anxiety disorders.

Brain RFamide Neuropeptides in Stress-Related Psychopathologies

The RFamide peptide family is a group of proteins that share a common C-terminal arginine-phenylalanine-amide motif. To date, the family comprises five groups in mammals: neuropeptide FF, LPXRFamides/RFamide-related peptides, prolactin releasing peptide, QRFP, and kisspeptins. Different RFamide peptides have their own cognate receptors and are produced by different cell populations, although they all can also bind to neuropeptide FF receptors with different affinities. RFamide peptides function in the brain as neuropeptides regulating key aspects of homeostasis such as energy balance, reproduction, and cardiovascular function. Furthermore, they are involved in the organization of the stress response including modulation of pain. Considering the interaction between stress and various parameters of homeostasis, the role of RFamide peptides may be critical in the development of stress-related neuropathologies. This review will therefore focus on the role of RFamide peptides as possible key hubs in stress and stress-related psychopathologies. The neurotransmitter coexpression profile of RFamide-producing cells is also discussed, highlighting its potential functional significance. The development of novel pharmaceutical agents for the treatment of stress-related disorders is an ongoing need. Thus, the importance of RFamide research is underlined by the emergence of peptidergic and G-protein coupled receptor-based therapeutic targets in the pharmaceutical industry.

Horizons in Endometriosis: Proceedings of the Montreux Reproductive Summit, 14-15 July 2023

Endometriosis is a complex and chronic gynaecological disorder that affects millions of women worldwide, leading to significant morbidity and impacting reproductive health. This condition affects up to 10% of women of reproductive age and is characterised by the presence of endometrial-like tissue outside the uterus, potentially leading to symptoms such as chronic pelvic pain, dysmenorrhoea, dyspareunia, and infertility. The Montreux summit brought a number of experts in this field together to provide a platform for discussion and exchange of ideas. These proceedings summarise the six main topics that were discussed at this summit to shed light on future directions of endometriosis classification, diagnosis, and therapeutical management. The first question addressed the possibility of preventing endometriosis in the future by identifying risk factors, genetic predispositions, and further understanding of the pathophysiology of the condition to develop targeted interventions. The clinical presentation of endometriosis is varied, and the correlation between symptoms severity and disease extent is unclear. While there is currently no universally accepted optimal classification system for endometriosis, several attempts striving towards its optimisation - each with its own advantages and limitations - were discussed. The ideal classification should be able to reconcile disease status based on the various diagnostic tools, and prognosis to guide proper patient tailored management. Regarding diagnosis, we focused on future tools and critically discussed emerging approaches aimed at reducing diagnostic delay. Preserving fertility in endometriosis patients was another debatable aspect of management that was reviewed. Moreover, besides current treatment modalities, potential novel medical therapies that can target underlying mechanisms, provide effective symptom relief, and minimise side effects in endometriotic patients were considered, including hormonal therapies, immunomodulation, and regenerative medicine. Finally, the question of hormonal substitution therapy after radical treatment for endometriosis was debated, weighing the benefits of hormone replacement.

Physical and psychosocial factors are crucial for maintaining physical and mental health in endometriosis: a longitudinal analysis

OBJECTIVE

To test the associations of physical and psychosocial factors with physical and mental health in individuals living with endometriosis (EM) by means of cross-sectional and longitudinal analyses.

METHODS AND MEASURES

Data were gathered via an online survey between February and August 2021. At survey date t1, sociodemographic, EM-related and psychosocial factors as well as physical and mental health of people with EM were assessed. At survey date t2 three months later, physical and mental health was reassessed. The sample consisted of n_t1 = 723 (30.60 ± 6.31 years) and n_t2 = 216 (30.56 ± 6.47 years) cis women with EM. Statistical analyses included bivariate and partial correlation analyses and hierarchical regression analyses.

RESULTS

The participants' physical health was within the average range and their mental health was below-average at t1 and t2. Cross-sectional analyses revealed that worse health was associated with longer diagnostic delay, more surgeries, greater pelvic pain and lower sense of coherence, self-efficacy, sexual satisfaction and satisfaction with the gynecological treatment. In longitudinal analyses, pelvic pain and participants' satisfaction with the gynecological treatment remained significantly associated with health.

CONCLUSION

Treatment should address both pelvic pain and psychosocial factors to improve long-term physical and mental health in EM.

Chronic Pelvic Puzzle: Navigating Deep Endometriosis with Renal Complications

This case report delves into the intricacies of a challenging clinical scenario involving deep pelvic endometriosis, which manifested with renal complications. Endometriosis, a complex gynecological condition, is explored in this case, highlighting its multifaceted nature. The patient presented with a complex interplay of symptoms, including chronic pelvic pain, urinary tract issues, and severe deep adenomyosis. The diagnostic journey was protracted, emphasizing the need for early recognition and intervention in such cases. A thorough evaluation, including laparoscopic examination and histopathological analysis, revealed the extensive presence of endometriotic lesions in various pelvic and renal structures, ultimately leading to left hydronephrosis. The report underscores the significance of timely diagnosis and surgical intervention to prevent irreversible renal damage. This case provides valuable insights into the management of deep endometriosis with renal involvement and the importance of interdisciplinary collaboration. Understanding the complexities of this condition can aid in improving patient outcomes and enhancing the quality of care provided.

"Illness perceptions and factors of distress as mediators between trait emotional intelligence and quality of life in endometriosis"

Past findings highlighted the presence of distress symptoms and poor quality of life in people with endometriosis. Several studies showed that trait Emotional Intelligence (trait EI) is a key component of one's wellbeing, whilst Illness Perceptions may play an important role in psychological distress and perceived quality of life. The current study sought to test the hypothesis that an association between trait EI and Quality of Life in individuals with endometriosis would be mediated by Illness Perceptions, examining also the relations with General Distress (depression, anxiety, and stress). 364 women with endometriosis aged between 18 and 58 years old (M = 33.87; SD = 8.64) filled a protocol to assess Trait EI, Illness Perceptions, General Distress, and Quality of Life. Structural Equation Modelling was used to assess the relationship between the observed variables. Illness Perception was a mediator in the relationship between Trait EI, General Distress, and Quality of Life. Moreover, General Distress was a mediator between Trait EI and Quality of Life, and between Illness Perceptions and Quality of Life. Results showed that both Trait EI and Illness perceptions are key components for levels of distress and quality of life in women with endometriosis.

Understanding Psychological Symptoms of Endometriosis from a Research Domain Criteria Perspective

Endometriosis is currently the second most common gynecological disease and is associated with severe pain, vegetative impairment, and infertility. In association, there are considerable psychological symptoms that limit the quality of life of those affected. In this narrative review, the Research Domain Criteria (RDoC) framework was utilized to display the different transdiagnostic processes involved in disease progression and maintenance in regard to psychosocial functioning. Using the RDoC framework, it becomes clear that immune/endocrinological dysregulation is interlocked with (pelvic) pain chronification processes and psychological symptoms such as depressive mood, loss of control, higher vigilance toward the onset or worsening of symptoms, social isolation, and catastrophizing. This paper will discuss and identify promising treatment approaches, in addition to medical care, as well as further research implications. Endometriosis can come with substantial psychosomatic and social burden, requiring more research to understand the interdependence of different factors involved in its chronic development pathway. However, it is already clear that standard care should be extended with multifaceted treatments addressing pain, as well as the psychological and social burden, in order to halt the cycle of aggravation of symptoms and to improve quality of life for patients.

Leveraging electronic health record data for endometriosis research

Endometriosis is a chronic, complex disease for which there are vast disparities in diagnosis and treatment between sociodemographic groups. Clinical presentation of endometriosis can vary from asymptomatic disease-often identified during (in)fertility consultations-to dysmenorrhea and debilitating pelvic pain. Because of this complexity, delayed diagnosis (mean time to diagnosis is 1.7-3.6 years) and misdiagnosis is common. Early and accurate diagnosis of endometriosis remains a research priority for patient advocates and healthcare providers. Electronic health records (EHRs) have been widely adopted as a data source in biomedical research. However, they remain a largely untapped source of data for endometriosis research. EHRs capture diverse, real-world patient populations and care trajectories and can be used to learn patterns of underlying risk factors for endometriosis which, in turn, can be used to inform screening guidelines to help clinicians efficiently and effectively recognize and diagnose the disease in all patient populations reducing inequities in care. Here, we provide an overview of the advantages and limitations of using EHR data to study endometriosis. We describe the prevalence of endometriosis observed in diverse populations from multiple healthcare institutions, examples of variables that can be extracted from EHRs to enhance the accuracy of endometriosis prediction, and opportunities to leverage longitudinal EHR data to improve our understanding of long-term health consequences for all patients.

A Case Report on Endometriosis: "A Tip of Iceberg" Disease Identified and Managed Better With Imaging

Endometriosis has been more common in recent decades as a result of improved diagnosis supported by enhanced clinical concepts and greater imaging tools. A multidisciplinary care strategy that extends beyond the cellular level is required for this complicated pathophysiological condition to enable patients to live disease-free lives. This case study features a young woman who was diagnosed with endometriosis and was anxious about future fertility. The condition eventually led to a series of events that defined the intricacy of the sickness involved and the accompanying complications that were better detected, and so, therapy was comparatively simplified by imaging, which helped manage the ailment and its issues. The related complications are well established; however, with the impending use of 3D imaging technology, the disease, its extent, and associated complications can be managed in a well-planned manner.

Delta-9 tetrahydrocannabinol (THC) effects on the cortisol stress response in bovine granulosa cells

Maternal stress can result in changes in the hypothalamic-pituitary-adrenal (HPA) axis and lead to stress-related behaviours in offspring. Under physiological conditions, delta-9 tetrahydrocannabinol (THC) appears to be detrimental for fertility. However, cannabis is also commonly used for stress-relief. THC acts on the endocannabinoid receptors in granulosa cells (GCs), which affect oocyte competency. The objective of this study was to evaluate the effects of THC on in vitro bovine granulosa cell viability, apoptosis, and stress response pathway. GCs were cultured in vitro in the presence of clinically relevant therapeutic and recreational plasma doses of THC. Cortisol doses reflecting normal and elevated plasma levels were used to evaluate the effects of THC under induced stress in vitro. No effect of THC was observed on cell viability or apoptosis. High and low cortisol concentrations caused significant increases in 11β-HSD1 mRNA expression (n = 6, p < 0.0001). Interestingly, when combined with high [THC], there was a significant decrease in 11β-HSD1 expression compared to high and low cortisol treatments alone (p < 0.001, p < 0.05). GR expression was unaffected by cortisol treatments, and low [THC] treatment maintained increased expression in the presence of high and low cortisol treatments (n = 6, p < 0.01, p < 0.0001). Our findings represent a foundation to obtain useful data for evaluating THC potential therapeutic benefit.

Pelvic Pain, Mental Health and Quality of Life in Adolescents with Endometriosis after Surgery and Dienogest Treatment

BACKGROUND

Diagnostic and treatment delays have caused significant impacts on the physical and emotional well-being of adolescents with endometriosis, though such research is limited. This study aimed to assess the effects of one-year dienogest therapy on the clinical picture, pain patterns, psycho-emotional status, and quality-of-life indicators in adolescents with endometriosis after surgical treatment.

METHODS

The study enrolled 32 girls aged 13-17 with peritoneal endometriosis to analyze one-year dynamics of the Visual Analog Scale (VAS), McGill Pain Questionnaire, Beck Depression Scale (BDI), Hospital Anxiety and Depression Scale (HADS), Spielberger State-Trait Anxiety Inventory (STAI) and SF-36 quality-of-life survey scores along with clinical and laboratory indicators before surgery and after one-year dienogest therapy.

RESULTS

The therapy provided a significant alleviation of endometriosis-associated clinical symptoms, including dysmenorrhea, pelvic pain, gastrointestinal/dysuria symptoms, decreased everyday activity (<0.001), a decrease in anxiety/depression scores (BDI, HADS, STAI), and quality-of-life improvement (<0.001). These effects were accompanied by beneficial dynamics in hormone and inflammatory markers (prolactin, cortisol, testosterone, estradiol, CA-125, neutrophil/lymphocyte ratio; <0.005) within reference ranges. A low body mass index and high C-reactive protein levels were associated with higher VAS scores; a high estradiol level was a factor for anxiety/depression aggravation (<0.05).

CONCLUSIONS

Dienogest, after surgical treatment, significantly improved quality of life and reduced pain symptoms while showing good tolerability and compliance, and reasoning with timely hormonal therapy in adolescents with endometriosis.

How to Improve Non-Invasive Diagnosis of Endometriosis with Advanced Statistical Methods

Background and Objectives: Endometriosis is one of the most common gynecological disorders in women of reproductive age. Causing pelvic pain and infertility, it is considered one of the most serious health problems, being responsible for work absences or productivity loss. Its diagnosis is often delayed because of the need for an invasive laparoscopic approach. Despite years of studies, no single marker for endometriosis has been discovered. The aim of this research was to find an algorithm based on symptoms and laboratory tests that could diagnose endometriosis in a non-invasive way. Materials and Methods: The research group consisted of 101 women hospitalized for diagnostic laparoscopy, among which 71 had confirmed endometriosis. Data on reproductive history were collected in detail. CA125 (cancer antigen-125) level and VEGF1(vascular endothelial growth factor 1) were tested in blood samples. Among the used statistical methods, the LASSO regression-a new important statistical tool eliminating the least useful features-was the only method to have significant results. Results: Out of 19 features based on results of LASSO, 7 variables were chosen: body mass index, age of menarche, cycle length, painful periods, information about using contraception, CA125, and VEGF1. After multivariate logistic regression with a backward strategy, the three most significant features were evaluated. The strongest impact on endometriosis prediction had information about painful periods, CA125 over 15 u/mL, and the lowest BMI, with a sensitivity of 0.8800 and a specificity of 0.8000, respectively. Conclusions: Advanced statistical methods are crucial when creating non-invasive tests for endometriosis. An algorithm based on three easy features, including painful menses, BMI level, and CA125 concentration could have an important place in the non-invasive diagnosis of endometriosis. If confirmed in a prospective study, implementing such an algorithm in populations with a high risk of endometriosis will allow us to cover patients suspected of endometriosis with proper treatment.

Reproductive and sexual health effects of intimate partner violence: A longitudinal and intergenerational analysis

OBJECTIVE

To examine the prevalence, pattern and predictors of sexual and reproductive adversity among Australian women who report intimate partner violence (IPV).

METHODS

Repeat measure design employing two cohorts (born between the years of 1973-78 and 1989-95) from the National Australian Longitudinal Study on Women's Health. Logistic regression was employed to examine the effects of reported IPV exposure on sexual and reproductive outcomes. The analysis conducted throughout 2021-2022 investigated both longitudinal prevalence and outcomes, and the intergenerational differences between these cohorts.

RESULTS

IPV exposure was associated with increased odds of experiencing a range of sexual and reproductive health outcomes, including STI, endometriosis, infertility, termination and miscarriage, which increased with greater exposure to IPV. Our longitudinal results suggest a dose-dependent effect of IPV on STI outcomes. Significant intergenerational trends were also identified in the nature of IPV exposure and dependent outcomes. Sexual orientation had a significant predictive value for IPV, with women who identified as bisexual significantly more likely to report IPV (OR = 2.91, 95% CI).

CONCLUSION

Women who experience IPV are at significant risk of adverse sexual and reproductive outcomes. Healthcare professionals working with women who have diagnosed sexual and reproductive issues should inquire about IPV. Likewise, women who are exposed to IPV should undergo sexual and reproductive healthcare assessments, along with appropriate preventive measures, to assure sexual health. Future research should explore in greater detail the association between IPV and the sexual and reproductive outcomes among sexual minority women.

Characteristics, prevalence and sources of stress in individuals who discontinue assisted reproductive technology treatments: a systematic review

By considering the reasons behind discontinuing assisted reproductive technology (ART) treatment, several studies have indicated that 'stress' is an important issue, but the prevalence of stressors and stress responses, either acute or chronic, remains unclear. In this systematic review, we evaluated the characteristics, prevalence and causes of what was perceived and reported as 'stress' by couples who discontinued ART treatment. Electronic databases were systematically searched, and studies were considered eligible if they evaluated stress as a possible reason for ART discontinuation. Twelve studies were included, with 15,264 participants from eight countries. In all studies, 'stress' was assessed through generic questionnaires or medical records, not by validated stress questionnaires or biomarkers. The prevalence of 'stress' ranged from 11-53%. When the results were pooled, 'stress' was cited as a reason for ART discontinuation by 775 out of 2507 participants (30.9%). Clinical factors associated with worse prognosis, physical discomfort due to treatment procedures, family demands, time pressure and economic burden were identified as sources of 'stress' that contributed to ART discontinuation. Precisely knowing the characteristics of the stress associated with infertility is essential to devise preventive or supportive interventions to help patients to cope and endure the treatments. Further studies are necessary to investigate whether the mitigation of stress factors can reduce ART discontinuation rates.

Endometriosis diagnosis buffers reciprocal effects of emotional distress on pain experience

OBJECTIVES

Emotional profile is involved in the experience of chronic pain related to endometriosis. Following the Örebro Model of Behavioral Emotion Regulation of Pain, the aim of this study was to understand the processes involved in the psychological adaptation to pain experienced during menstruations in women either diagnosed or not diagnosed with endometriosis.

METHODS

The study was conducted on a sample of 545 women, either diagnosed with endometriosis or not, during their menstruations. Functional repercussions and intensity of pain, catastrophic thinking, difficulties in emotional regulation and emotional distress were assessed through an online questionnaire. Structural equation modeling (SEM) was carried out.

RESULTS

Women diagnosed with endometriosis experience more suffering than women who have not had such a diagnosis. The model we adapted from Örebro's model fits the data well. A differential effect is observed regarding the retroactive effect of depression on pain. Although emotional distress increases functional repercussions among women both with and without the diagnosis, growing pain intensity only occurs among those without.

CONCLUSIONS

A woman presenting pain during menstruation faces emotional regulation issues that make her more vulnerable to the development of emotional distress. Pain impacts emotional distress, but emotional distress does not impact pain among women for whom the origin of the pain was known (i.e., a diagnosis of endometriosis). Having a diagnosis allows women to externalize the origin of their pain, attributing it to the disease and not to their psychological state.

A systematic review and meta-analysis on alcohol consumption and risk of endometriosis: an update from 2012

Endometriosis is a complex and chronic disease, whose multifactorial nature has encouraged a deep investigation on the role of lifestyle factors. A strong association between alcohol intake and endometriosis risk has already been shown. We aimed to confirm this association, considering the updated literature. 23 eligible studies were identified through comprehensive literature search of PubMed and EMBASE (May 2012-October 2021). A borderline statistical significance was found comparing any alcohol consumption with no consumption (unadjusted OR 1.14; 95% CI: 0.99-1.31, p = 0.06), in contrast with a previous meta-analysis. However, we confirmed the significant association between moderate alcohol intake and endometriosis (unadjusted OR 1.22, 95% CI: 1.03-1.45, p = 0.02), also performing a sensitivity analysis (unadjusted OR 1.27, 95% CI: 1.04-1.54). Our partly divergent evidence reflects the tough challenge of isolating the impact of specific factors on the natural history of multifactorial diseases. Indeed, on one hand alcohol could be adopted by patients as a self-management therapy and on the other, it could favor the disease, promoting positive feedback with inflammatory mediators and oxidative stress. Our study encourages further investigation on the role of modifiable lifestyle factors and highlights the opportunity to adopt them to prevent or at least limit endometriosis progression.

Urinary Tract Endometriosis: How to Predict and Prevent Recurrence after Primary Surgical Excision

STUDY OBJECTIVE

To investigate the clinical and surgical predictors of urinary tract endometriosis (UTE) relapse.

DESIGN

Retrospective single institutional study.

SETTING

Italian multidisciplinary referral center for endometriosis.

PATIENTS

Consecutive patients affected by UTE and surgically treated between January 2016 and March 2020.

INTERVENTION

Surgical excision for UTE. Uni- and multivariate logistic regression analyses were fitted to evaluate clinical and surgical predictors of recurrence.

MEASUREMENTS AND MAIN RESULTS

A total of 105 female age-reproductive patients were enrolled. Median age was 32 years (interquartile range, 24-37). Ureteral involvement was recorded in 53 patients (50.5%), being unilateral and bilateral in 46 patients (43.8%) and 7 patients (6.7%), respectively. Bladder involvement occurred in 52 patients (49.5%). Open surgical approach was performed in 24 cases (22.9%), whereas 30 patients (28.5%) and 51 patients (48.6%) were treated with laparoscopic and robot-assisted approach, respectively. Overall, 53 patients (50.5%) received adjuvant hormonal therapy. At a median follow-up of 39 months (interquartile range, 22-51), 30 patients (28.6%) experienced disease relapse, with 14 recurrences (13.3%) recorded at the level of the urinary tract. At multivariable analysis, age at first surgery <25 years (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.10-1.84; p = .02) and the presence of a concomitant autoimmune disease (OR, 1.45; 95% CI, 1.24-2.17; p = .02) were found as predictors of deep infiltrating endometriosis recurrence, whereas adjuvant postsurgical therapy showed a protective role (OR, 0.83; 95% CI, 0.53-0.98; p = .01).

CONCLUSIONS

Young age (<25 years) and the presence of autoimmune diseases were significant predictors for the development of disease recurrence, whereas adjuvant hormonal therapy showed a protective role.

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.

Screening differentially expressed genes between endometriosis and ovarian cancer to find new biomarkers for endometriosis

AIM

Endometriosis is one of the most common reproductive system diseases, but the mechanisms of disease progression are still unclear. Due to its high recurrence rate, searching for potential therapeutic biomarkers involved in the pathogenesis of endometriosis is an urgent issue.

METHODS

Due to the similarities between endometriosis and ovarian cancer, four endometriosis datasets and one ovarian cancer dataset were downloaded from Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) were identified, followed by gene ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway and protein-protein interaction (PPI) analyses. Then, we validated gene expression and performed survival analysis with ovarian serous cystadenocarcinoma (OV) datasets in TCGA/GTEx database, and searched for potential drugs in the Drug-Gene Interaction Database. Finally, we explored the miRNAs of key genes to find biomarkers associated with the recurrence of endometriosis.

RESULTS

In total, 104 DEGs were identified in the endometriosis datasets, and the main enriched GO functions included cell adhesion, extracellular exosome and actin binding. Fifty DEGs were identified between endometriosis and ovarian cancer datasets including 11 consistently regulated genes, and nine DEGs with significant expression in TCGA/GTEx. Only IGHM had both significant expression and an association with survival, three module DEGs and two significantly expressed DEGs had drug associations, and 10 DEGs had druggability.

CONCLUSIONS

ITGA7, ITGBL1 and SORBS1 may help us understand the invasive nature of endometriosis, and IGHM might be related to recurrence; moreover, these genes all may be potential therapeutic targets.KEY MESSAGEThis manuscript used a bioinformatics approach to find target genes for the treatment of endometriosis.This manuscript used a new approach to find target genes by drawing on common characteristics between ovarian cancer and endometriosis.We screened relevant therapeutic agents for target genes in the drug database, and performed histological validation of target genes with both expression and survival analysis difference in cancer databases.

Association between severity of pain, perceived stress and vagally-mediated heart rate variability in women with endometriosis

Chronic pelvic pain is the main symptom in women with endometriosis. Evidence suggests that psychological stress and autonomic regulation contribute to symptoms and pathophysiological modulation. We investigated the relationship between endometriosis-related pain severity, perceived stress, and autonomic balance in a sample of 81 women suffering chronic pelvic pain with deep endometriosis. Perceived stress and pelvic pain symptoms were assessed using the 10-item version of the Perceived Stress Scale (PSS-10) and the Numeric Pain Rating Scale (NPRS), respectively. Autonomic nervous system regulation was evaluated using vagally mediated components of the heart rate variability (vmHRV). Our results showed that pain unpleasantness and perceived stress were positively correlated, and women with mood disorders had higher perceived stress. The women with low resting vmHRV experience more intense pelvic pain, pain unpleasantness, and a higher number of severe endometriosis-related pain descriptors. The positive association between perceived stress, mood disorder, and pain unpleasantness demonstrates the additive effect between these aversive experiences. The inverse association between parasympathetic tone and pain suggests contributions of the Descending Inhibitory Pain pathway efficiency to symptom severity in women with endometriosis.

Menstrual Distress Questionnaire (MEDI-Q): a new tool to assess menstruation-related distress

RESEARCH QUESTION

Menstruation is a physiological event often associated with subjective distress. Is there a tool that assesses and objectively evaluates the global distress experienced by women during their period?

DESIGN

An observational cross-sectional study conducted between June 2019 and May 2020 at Careggi University Hospital, Florence, Italy. A new questionnaire, The Menstrual Distress Questionnaire (MEDI-Q), was developed and administered to a group of healthy women (n = 418) of fertile age (18-50 years), without known uterine, psychiatric disorders, or both. The MEDI-Q investigated 25 items, covering the following areas: pain, discomfort, psychic or cognitive changes, gastrointestinal symptoms and changes in physiological functions. MEDI-Q Total Score and the three sub-scales, Menstrual Symptoms (MS), Menstrual Symptoms Distress (MSD) and Menstrual Specificity Index (MESI) were evaluated. The validation of MEDI-Q was achieved by testing test-retest reliability and internal consistency, convergent and concurrent validity.

RESULTS

The MEDI-Q produced reliable results with good internal consistency, convergent and concurrent validity. MEDI-Q Total Score, MS and MSD all positively correlated with general psychopathology and premenstrual symptoms. A receiver operating characteristic analysis was used to determine the cut-off value of 20 (inclusive) and to identify the women with clinically relevant menstrual distress (area under the curve 0.90, 95% CI 0.86 to 0.93; P < 0.001).

CONCLUSION

MEDI-Q is a new tool for evaluating menstruation-related distress, and provides a representative score of stress perception. MEDI-Q may be added to routine women's healthcare to help identify and adequately monitor menstruation-related disorders, and their effect on wellbeing, promptly.

Endometriosis and related pelvic pain: association with stress, anxiety and depressive symptoms

Endometriosis is a chronic inflammatory disease affecting 10% of women in reproductive age and manifested as infertility and pelvic pain, which may be severe and incapacitating. This review aims to address the latest evidence on the association of endometriosis with chronic stress, anxiety and depression, and to find out whether the effective treatment of endometriosis has the additional benefit of attenuating these psychological comorbidities. Studies have found that women with endometriosis, especially those with painful symptoms, have higher levels of stress and a decreased quality of life compared to healthy women. Importantly, depression and anxiety are more prevalent in women with endometriosis, and the presence of psychiatric disorders correlates more to the severity of the endometriosis-related pain than to other disease characteristics. Considering therapeutic implications, controlled clinical trials found that medical and surgical treatments of endometriosis also ameliorated perceived stress, anxiety and depressive symptoms. In conclusion, current evidence indicates that women with endometriosis have an increased prevalence of psychological disorders which correlate more with pain itself than with endometriosis per se. In addition, the effective treatment of endometriosis may reduce the psychological burden of the disease.

Comorbidities and Quality of Life in Women Undergoing First Surgery for Endometriosis: Differences Between Chinese and Italian Population

An observational cross-sectional study was conducted in a group (n = 371) of fertile age women with endometriosis, by administering a structured questionnaire, in order to evaluate the incidence of gynecological and systemic comorbidities and the impact on quality of life (QoL) in two different groups of Italian and Chinese patients affected by endometriosis. Chinese (n = 175) and Italian (n = 196) women were compared regarding systemic (inflammatory, autoimmune, and mental) and gynecological comorbidities, pain symptoms, and QoL, by using the Short Form 12 (SF-12). Italian patients resulted younger at the diagnosis and suffered more frequently from severe pain than Chinese ones. Deep infiltrating endometriosis (DIE) and mixed phenotypes were more frequent in Italian patients, whereas ovarian (OMA) and superficial endometriosis (SUP) were more common in the Chinese. The Italian group showed more systemic comorbidities, and those disorder were already present before the diagnosis of endometriosis. Furthermore, the Italian group showed lower SF-12 physical and mental scores, suggesting a worse health-related QoL in Italian endometriotic patients. A number of differences has been observed between Italian and Chinese women with endometriosis in terms of comorbidities and QoL, which may be related to the ethnicity, the different health system organization and the social and cultural background.

Reduced vagal tone in women with endometriosis and auricular vagus nerve stimulation as a potential therapeutic approach

Sensory and sympathetic nerves have been shown to promote the progression of endometriosis through the release of neuromediators and the lesional activation of respective receptors. The role of vagus nerves (VN) in lesional progression, however, is completely unclear, despite the signs suggestive of increased sympathetic tone in women with endometriosis. This study was undertaken to investigate whether VN plays any role in the progression of endometriosis. We recruited 45 patients with endometriosis and 42 healthy women, who were given electrocardiogram test and their heart rate variability was evaluated. In addition, three prospective, and randomized mouse experiments were conducted that evaluated, respectively, the effect of vagotomy, the effect of VN stimulation (VNS), and the therapeutic potential of VNS after the endometriosis was well established. All lesions were excised, weighed, and processed for immunohistochemistry and histochemistry analysis of select markers for lesional progression and fibrosis. We found that endometriosis patients exhibited reduced vagal activity as compared with controls, indicative of disrupted autonomic balance. Vagotomy increased while VNS decreased the lesion weight as compared with control mice, concomitant with more progressive and retarded lesion development and fibrogenesis, respectively. In addition, VNS demonstrated promising therapeutic effect, as evidenced by significantly reduced lesion weight, more attenuated lesional progression concomitant with improved hyperalgesia. Taken together, our data indicate that VN activity may play a dampening role in the progression of endometriosis. Consequently, boosting the VN activity may have therapeutic potentials for patients with endometriosis.

Long-term hormonal treatment reduces repetitive surgery for endometriosis recurrence

RESEARCH QUESTION

How effective is medical hormonal treatment in preventing endometriosis recurrence and in improving women's clinical symptoms and quality of life?

DESIGN

This observational cross-sectional study evaluated the effects of hormonal medical treatment (progestins, gonadotrophin-releasing hormone analogues or continuous oral contraceptives) on endometriosis recurrence, current clinical symptoms and quality of life in three groups of patients: Group A (n = 34), no hormonal treatment either before or after the first endometriosis surgery; Group B (n = 76), on hormonal treatment after the first endometriosis surgery; and Group C (n = 75), on hormonal treatment both before and after the first endometriosis surgery.

RESULTS

Group C patients were characterized by a lower rate of endometriosis reoperation (P = 0.011) and a lower rate of dysmenorrhoea (P = 0.006). Women who experienced repetitive endometriosis surgery showed worse physical (P = 0.004) and mental (P = 0.012) status than those who received a single surgery, independent of the treatment.

CONCLUSION

Hormonal treatments represent a valid cornerstone of endometriosis management and may be useful as an alternative to surgery, but also before surgery, to plan better, and after surgery in order to reduce the risk of recurrence. Medical counselling is very helpful in choosing the correct and individualized endometriosis treatment. In fact, the gold standard for modern endometriosis management is the individualized approach and surgery should be considered, depending on the clinical situation and a patient's symptoms.