Advances in the medical management of bowel endometriosis

Continued improvement to imaging diagnosis and treatment triage of endometriosis: The role of the multi-disciplinary conference

Patient-centered endometriosis management tailored to the individual patient's subset of symptoms often requires highly sensitive and specific preoperative imaging. In the setting of a present ongoing learning curve among radiologists who interpret pelvis ultrasounds and MRIs for diagnosis of endometriosis, we have found that routine feedback between minimally invasive gynecology surgeons and radiologists, based on pre-operative imaging and postoperative laparoscopic findings, is essential for the continual improvement of imaging-based staging of endometriosis and empower pre-operative imaging as an important pillar of endometriosis management. We share illustrative patient cases, which, after collaborative discussion during our routine multi-institutional, multi-disciplinary conferences (MDCs) have led to improved patient counseling, better pre-surgical planning, and therefore improved patient satisfaction. Our endometriosis MDCs will continue to improve patient management in the future by providing a forum for trainees in medical, surgical, imaging, and pathology specialties to gain expertise directly from subspecialists, and participate in the care of these patients.

The natural evolution of untreated deep endometriosis and the effect of hormonal suppression: A systematic literature review and meta-analysis

INTRODUCTION

Peritoneal infiltrating and fibrotic endometriosis, also known as deep endometriosis, is the most severe manifestation of the disease that can cause severe complications including bowel and ureteral stenosis. The natural history of these lesions and the possible effect of hormonal treatments on their progression are undefined. Therefore, we conducted a systematic review and meta-analysis to investigate whether and how frequently deep endometriosis progresses over time without or with ovarian suppression. This could inform management decisions in asymptomatic and mildly symptomatic patients.

MATERIAL AND METHODS

For this pre-registered systematic review (CRD42023463518), the PubMed and Embase databases were screened, and studies published between 2000 and 2023 that serially evaluated the size of deep endometriotic lesions without or with hormonal treatment were selected. Data on the progression, stability, or regression of deep endometriotic lesions were recorded as absolute frequencies or mean volume variations. Estimates of the overall percentage of progression and corresponding 95% confidence intervals were calculated using a random-effect model. When studies reported lesion progression as pre- and post-treatment volume means, the delta of the two-volume means was calculated and analyzed using the inverse variance method.

RESULTS

A total of 29 studies were identified, of which 19 studies with 285 untreated and 730 treated patients were ultimately selected for meta-analysis. The overall estimate of the percentage of lesion progression in untreated individuals was 21.4% (95% CI, 6.8-40.8%; I2 = 90.5%), whereas it was 12.4% during various hormonal treatments (95% CI, 9.0-16.1%; I2 = 0%). Based on the overall meta-analysis estimates, the odds ratio of progression in treated vs untreated patients was 0.52 (95% CI, 0.41-0.66). During hormonal suppression, the mean volume of deep endometriotic lesions decreased significantly by 0.87 cm3 (95% CI, 0.19-1.56 cm3; I2 = 0%), representing -28.5% of the baseline volume.

CONCLUSIONS

Untreated deep endometriotic lesions progressed in about one in five patients. Medical therapy reduced but did not eliminate this risk. Given the organ function failure potentially caused by these lesions, the decision whether to use hormonal treatments in asymptomatic or mildly symptomatic women should always be shared, carefully weighing the potential benefits and harms of the two alternatives after extensive counseling.

Endometriosis of the appendix: prevalence, associated lesions, and proposal of pathogenetic hypotheses. A retrospective cohort study with prospectively collected data

OBJECTIVE

To assess the prevalence of endometriosis of the appendix and the association with other pelvic localizations of the disease and to provide pathogenesis hypotheses.

METHODS

Monocentric, observational, retrospective, cohort study. Patients undergoing laparoscopic endometriosis surgery in our tertiary referral center were consecutively enrolled. The prevalence of the different localizations of pelvic endometriosis including appendix involvement detected during surgery was collected. Included patients were divided into two groups based on the presence of appendiceal endometriosis. Women with a history of appendectomy were excluded.

MEASUREMENTS AND MAIN RESULTS

Four hundred-sixty patients were included for data analysis. The prevalence of appendiceal endometriosis was 2.8%. In patients affected by endometriosis of the appendix, concomitant ovarian and/or bladder endometriosis were more frequently encountered, with prevalence of 53.9% (vs 21.0% in non-appendiceal endometriosis group, p = 0.005) and 38.4% (vs 11.4%, p = 0.003), respectively. Isolated ovarian endometriosis was significantly associated to appendiceal disease compared to isolated uterosacral ligament (USL) endometriosis or USL and ovarian endometriosis combined (46.2% vs 15.4% vs 7.7%, p < 0.001). Poisson regression analysis revealed a 4.1-fold and 4.4-fold higher risk of ovarian and bladder endometriosis, respectively, and a 0.1-fold risk of concomitant USL endometriosis in patients with appendiceal involvement.

CONCLUSION

Involvement of the appendix is not uncommon among patients undergoing endometriosis surgery. Significant association was detected between appendiceal, ovarian, and bladder endometriosis that may be explained by disease dissemination coming from endometrioma fluid shedding. Given the prevalence of appendiceal involvement, counseling regarding the potential need for appendectomy during endometriosis surgery should be considered.

Evaluating the safety of high-intensity focused ultrasound treatment for rectal endometriosis: results from a French prospective multicentre study including 60 patients

STUDY QUESTION

Is increasing the intensity of high-intensity focused ultrasound (HIFU) by 30% in the treatment of rectal endometriosis a safe procedure?

SUMMARY ANSWER

This study demonstrates the safety of a 30% increase in the intensity of HIFU in the treatment of rectal endometriosis, with no Clavien-Dindo Grade III complications overall, and namely no rectovaginal fistulae.

WHAT IS KNOWN ALREADY

A feasibility study including 20 patients with rectal endometriosis demonstrated, with no severe complications, a significant improvement in digestive disorders, dysmenorrhoea, dyspareunia, and health status, although the volume of the endometriosis nodule did not appear to be reduced.

STUDY DESIGN, SIZE, DURATION

A prospective multicentre cohort study was conducted between 2020 and 2022 with 60 patients with symptomatic rectal endometriosis. Following the failure of medical treatment, HIFU treatment was offered as an alternative to surgery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

As the main objective of this study was to examine safety, all adverse events observed during the 6 months of follow-up were analysed and graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) and Clavien-Dindo classifications. Secondary objectives included evaluating the evolution of symptoms using validated questionnaires: gynaecological and digestive pain symptoms with a visual analogue scale, health status with the Medical Outcomes Study 36-item Short Form (SF-36) questionnaire, average post-operative daily pain level, and analgesic medication required in the 10 days following treatment. MRI was also performed at Day 1 to detect early complications. Finally, we performed a blinded MRI review of the evolution of the nodule at 6 months post-treatment.

MAIN RESULTS AND THE ROLE OF CHANCE

The procedure was performed under spinal anaesthesia for 30% of the patients. The median duration of treatment was 32 min. Fifty-five patients left the hospital on Day 1. MRI scans performed on Day 1 did not highlight any early-onset post-operative complication. Using the Clavien-Dindo classification, we listed 56.7% Grade I events, 3.4% Grade II events, and no events Grade III or higher. At 1, 3, and 6 months, all gynaecologic, digestive and general symptoms, as well as health status, had significantly improved. The evolution of the nodule was also significant (P < 0.001) with a 28% decrease in volume.

LIMITATIONS, REASONS FOR CAUTION

The main objective was safety and not effectiveness. The study was not randomized and there was no control group.

WIDER IMPLICATIONS OF THE FINDINGS

HIFU treatment for rectal endometriosis results in an improvement of symptoms with low morbidity; as such, for selected patients, it could be a valuable alternative to surgical approaches following the failure of medical treatment.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the company EDAP TMS. Professors Dubernard and Rousset are consultants for EDAP TMS. Dubernard received travel support from EDAP-TMS. Dr F. Chavrier received industrial grants from EDAP-TMS. He has developed a device for generating focused ultrasonic waves with reduced treatment time. This device has been patented by EDAP-TMS. Dr Lafon received industrial grants from EDAP-TMS; he declares that EDAP-TMS provided funding directly to INSERM to support a young researcher chair in therapeutic ultrasound, which is unrelated to the current study.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier NCT04494568.

Sonomorphologic Changes in Colorectal Deep Endometriosis: The Long-Term Impact of Age and Hormonal Treatment

PURPOSE

The progression of deep endometriosis (DE) in women of reproductive age is highly variable. This study aimed to analyze the sonomorphological changes of rectal endometriosis over long periods of time and the influence of hormonal treatment.

METHODS

This retrospective study included premenopausal women with rectal DE treated conservatively between 2002 and 2021. The lesion length and thickness of the nodule were evaluated at regular intervals over time. We created statistical models with mixed effects to identify potential factors influencing lesion progression and regression.

RESULTS

38 patients were monitored over a mean period of 7.2 (± 4.2) years with a mean of 3.1 (± 2.1) check-ups within the observation period. We detected a significant increase in lesion length until the end of the fourth decade of life. In addition, we found a substantial decrease in the length and thickness of the nodule depending on the length of hormonal treatment.

CONCLUSION

In conservatively managed patients with rectal endometriosis, without hormonal therapy, lesion size can exhibit a moderate increase up to the end of the fourth decade of life, after which it appears to stabilize. This increase does not follow a linear pattern. Hormonal therapy is crucial in impeding further progression, resulting in either a cessation or a regression of lesion growth.

Efficacy and safety of dienogest in the treatment of deep infiltrating endometriosis: A meta-analysis

OBJECTIVE

To systematically review and conduct a meta-analysis to assess the effectiveness of dienogest (DNG) in the prolonged conservative drug management of deep infiltrating endometriosis (DIE). The findings from this study are intended to serve as a valuable reference for clinical decision-making regarding medication in the context of DIE.

METHODS

Following the PRISMA Statement, we searched EMBASE, PubMed, The Cochrane Library, Web of Science, and Medline databases for relevant literature published in the public domain from the date of establishment of the database until October 2023. Subsequently, all English publications on clinical studies using DNG for the treatment of DIE were included. Studies involving surgical intervention or drug therapy for postoperative recurrence were excluded. All literature included in the review underwent risk assessment of bias. Two evaluators independently screened the publications, conducted a quality assessment of each article and extracted data. We used Revman 5.4 for the meta-analysis of the included literature.

RESULTS

Our final analysis consisted of five clinical studies, involving a total of 256 patients. We found that there were significant improvements in the following indicators post-medication as compared to levels before taking the medication: dysmenorrhea (MD = 4.24, 95 % CI: 2.92-5.56, P < 0.00001), non-menstrual pelvic pain (MD = 3.11, 95 % CI: 2.34-3.88, P < 0.00001), dyspareunia (MD = 1.93, 95 % CI: 1.50-2.37, P < 0.00001), dyschezia (MD = 2.48, 95 % CI: 1.83-3.12, P < 0.00001), and rectosigmoid nodule size (MD = 0.32, 95 % CI: 0.18-0.46, P < 0.00001). Compared with pre-medication levels, the following indicators were significantly worse: headache (RR = 0.03, 95 % CI: 0.00-0.23, P = 0.0006), decreased libido (RR = 0.08, 95 % CI: 0.01-0.62, P = 0.02); and there was no significant improvement in dysuria (P > 0.05).

CONCLUSION

DNG showed efficacy in relieving pain-related symptoms and significantly reducing the size of the lesions when used in the drug conservative treatment of DIE.

Towards comprehensive management of symptomatic endometriosis: beyond the dichotomy of medical versus surgical treatment

Except when surgery is the only option because of organ damage, the presence of suspicious lesions, or the desire to conceive, women with endometriosis-associated pain often face a choice between medical and surgical treatment. In theory, the description of the potential benefits and potential harms of the two alternatives should be standardized, unbiased, and based on strong evidence, enabling the patient to make an informed decision. However, doctor's opinion, intellectual competing interests, local availability of specific services and (mis)information obtained from social media, and online support groups can influence the type of advice given and affect patients' choices. This is compounded by the paucity of robust data from randomized controlled trials, and the anxiety of distressed women who are eager to do anything to alleviate their disabling symptoms. Vulnerable patients are more likely to accept the suggestions of their healthcare provider, which can lead to unbalanced and physician-centred decisions, whether in favour of either medical or surgical treatment. In general, treatments should be symptom-orientated rather than lesion-orientated. Medical and surgical modalities appear to be similarly effective in reducing pain symptoms, with medications generally more successful for severe dysmenorrhoea and surgery more successful for severe deep dyspareunia caused by fibrotic lesions infiltrating the posterior compartment. Oestrogen-progestogen combinations and progestogen monotherapies are generally safe and well tolerated, provided there are no major contraindications. About three-quarters of patients with superficial peritoneal and ovarian endometriosis and two-thirds of those with infiltrating fibrotic lesions are ultimately satisfied with their medical treatment although the remainder may experience side effects, which may result in non-compliance. Surgery for superficial and ovarian endometriosis is usually safe. When fibrotic infiltrating lesions are present, morbidity varies greatly depending on the skill of the individual surgeon, the need for advanced procedures, such as bowel resection and ureteral reimplantation, and the availability of expert colorectal surgeons and urologists working together in a multidisciplinary approach. The generalizability of published results is adequate for medical treatment but very limited for surgery. Moreover, on the one hand, hormonal drugs induce disease remission but do not cure endometriosis, and symptom relapse is expected when the drugs are discontinued; on the other hand, the same drugs should be used after lesion excision, which also does not cure endometriosis, to prevent an overall cumulative symptom and lesion recurrence rate of 10% per postoperative year. Therefore, the real choice may not be between medical treatment and surgery, but between medical treatment alone and surgery plus postoperative medical treatment. The experience of pain in women with endometriosis is a complex phenomenon that is not exclusively based on nociception, although the role of peripheral and central sensitization is not fully understood. In addition, trauma, and especially sexual trauma, and pelvic floor disorders can cause or contribute to symptoms in many individuals with chronic pelvic pain, and healthcare providers should never take for granted that diagnosed or suspected endometriosis is always the real, or the sole, origin of the referred complaints. Alternative treatment modalities are available that can help address most of the additional causes contributing to symptoms. Pain management in women with endometriosis may be more than a choice between medical and surgical treatment and may require comprehensive care by a multidisciplinary team including psychologists, sexologists, physiotherapists, dieticians, and pain therapists. An often missing factor in successful treatment is empathy on the part of healthcare providers. Being heard and understood, receiving simple and clear explanations and honest communication about uncertainties, being invited to share medical decisions after receiving detailed and impartial information, and being reassured that a team member will be available should a major problem arise, can greatly increase trust in doctors and transform a lonely and frustrating experience into a guided and supported journey, during which coping with this chronic disease is gradually learned and eventually accepted. Within this broader scenario, patient-centred medicine is the priority, and whether or when to resort to surgery or choose the medical option remains the prerogative of each individual woman.

"A Space Odyssey" on Laparoscopic Segmental Rectosigmoid Resection for Deep Endometriosis: A Seventeen-year Retrospective Analysis of Outcomes and Postoperative Complications among 3050 Patients Treated in a Referral Center

STUDY OBJECTIVE

To evaluate the feasibility of laparoscopic rectosigmoid resection for bowel endometriosis (RSE), reporting surgical and short-term postoperative outcomes in a consecutive large series of patients.

DESIGN

A retrospective cohort study.

SETTING

Third-level national referral center for deep endometriosis (DE).

PATIENTS

3050 patients with symptomatic RSE requiring surgical treatment.

INTERVENTIONS

Nerve-sparing laparoscopic resection for RSE perfomed by a multidisciplinary team. After collecting intraoperative surgical characteristics, postoperative complications were collected by evaluating the risk factors associated with their onset.

MEASUREMENTS AND MAIN RESULTS

Clavien-Dindo IIIb postoperative complications were noted in 13.1% of patients, with anastomotic leakage and rectovaginal fistula accounting for 3.0% and 1.9%, respectively. Postoperative bladder impairment was observed in 13.9% of patients during hospital discharge but spontaneously decreased to 4.5% at the first evaluation after 30 days, alongside a statistically significant change towards global symptom improvement. Multivariate analyses were done to identify the risk factors for segmental bowel resection in terms of occurrence of postoperative major complications. Ultralow (≤5 cm from the anal verge), low rectal anastomosis (<8 cm, >5 cm), parametrectomy, vaginal resection, and previous surgeries seemed more related to anastomotic leakage, rectovaginal fistula, and bladder retention.

CONCLUSIONS

Laparoscopic rectosigmoid resection for RSE seems an effective and feasible procedure. The surgical complication rate is not negligible but could be reduced by implementing a multidisciplinary approach, an endless improvement in nerve-sparing techniques and surgical anatomy, as well as technological enhancements. Real future challenges will be to reduce the time for the first diagnosis of DE and the likelihood of surgical indications.

The 10 "Cardinal Sins" in the Clinical Diagnosis and Treatment of Endometriosis: A Bayesian Approach

Evidence-based data for endometriosis management are limited. Experiments are excluded without adequate animal models. Data are limited to symptomatic women and occasional observations. Hormonal medical therapy cannot be blinded if recognised by the patient. Randomised controlled trials are not realistic for surgery, since endometriosis is a variable disease with low numbers. Each diagnosis and treatment is an experiment with an outcome, and experience is the means by which Bayesian updating, according to the past, takes place. If the experiences of many are similar, this holds more value than an opinion. The combined experience of a group of endometriosis surgeons was used to discuss problems in managing endometriosis. Considering endometriosis as several genetically/epigenetically different diseases is important for medical therapy. Imaging cannot exclude endometriosis, and diagnostic accuracy is limited for superficial lesions, deep lesions, and cystic corpora lutea. Surgery should not be avoided for emotional reasons. Shifting infertility treatment to IVF without considering fertility surgery is questionable. The concept of complete excision should be reconsidered. Surgeons should introduce quality control, and teaching should move to explain why this occurs. The perception of information has a personal bias. These are the major problems involved in managing endometriosis, as identified by the combined experience of the authors, who are endometriosis surgeons.

Gut and reproductive tract microbiota: Insights into the pathogenesis of endometriosis (Review)

Endometriosis is characterized by the presence of endometrial-like tissue outside the uterus and is associated with an inflammatory immune response. The gut and reproductive tract microbiota constitute a protective barrier against infection by pathogens and regulate inflammatory and immune functions. This review summarizes microbiota imbalance (i.e., dysbiosis) in endometriosis and discusses how dysbiosis influences disease development. The literature was searched for studies published from inception to March 2022 in the PubMed and Google Scholar databases using a combination of specific terms. An altered gut and reproductive tract microbiome has been reported in numerous conditions, such as inflammatory bowel disease, allergies, autoimmunity, cancer and reproductive disorders (e.g., endometriosis). Furthermore, microbial dysbiosis is a hallmark of endometriosis and is characterized by a decrease in beneficial probiotics and an increase in pathogenic microbes, which leads to a series of estrobolomic and metabolomic changes. Gut or reproductive tract microbiome dysbiosis was reported in mice, nonhuman primates, and females with endometriosis. Animal models of endometriosis demonstrated the effects of the gut microbiome on lesion growth and vice versa. The immune system mediated by the microbiota-gut-reproductive tract axis triggers an inflammatory response that damages reproductive tract tissue, which possibly leads to endometriosis. However, whether the alteration of eubiosis (a balanced microbiota) to dysbiosis is a cause or a result of endometriosis is unclear. In conclusion, this review provides an overview of the relationship between the gut and reproductive tract microbiome and endometriosis, focusing on the mechanisms by which dysbiosis may increase the risk of disease.

Ultrasound-guided Aspiration Combined with Medical Treatment for an Unexpected Rectal Endometriotic Cyst: A Case Report

Most bowel endometriotic lesions are ill-defined serosal and subserosal nodules, and no case of cystic bowel endometriosis has been reported in the literature. This is the first report of an unexpected presentation of bowel endometriosis as a primary cyst located inside the posterior rectal wall. The patient was a 26-year-old nulliparous woman with progressive lower abdominal pain for 6 days and difficult defecation for 1 day. Colorectal surgeons recommended bowel resection owing to the giant rectal mass. However, the patient refused to undergo surgery. Ultrasound-guided aspiration of the rectal endometriotic cyst followed by gonadotropin-releasing hormone agonist injection was individually scheduled, which finally brought significant improvement both in symptoms and in the size of the rectal endometriotic lesion.

Pathophysiology, diagnosis, and management of endometriosis

Endometriosis affects approximately 190 million women and people assigned female at birth worldwide. It is a chronic, inflammatory, gynecologic disease marked by the presence of endometrial-like tissue outside the uterus, which in many patients is associated with debilitating painful symptoms. Patients with endometriosis are also at greater risk of infertility, emergence of fatigue, multisite pain, and other comorbidities. Thus, endometriosis is best understood as a condition with variable presentation and effects at multiple life stages. A long diagnostic delay after symptom onset is common, and persistence and recurrence of symptoms despite treatment is common. This review discusses the potential genetic, hormonal, and immunologic factors that lead to endometriosis, with a focus on current diagnostic and management strategies for gynecologists, general practitioners, and clinicians specializing in conditions for which patients with endometriosis are at higher risk. It examines evidence supporting the different surgical, pharmacologic, and non-pharmacologic approaches to treating patients with endometriosis and presents an easy to adopt step-by-step management strategy. As endometriosis is a multisystem disease, patients with the condition should ideally be offered a personalized, multimodal, interdisciplinary treatment approach. A priority for future discovery is determining clinically informative sub-classifications of endometriosis that predict prognosis and enhance treatment prioritization.

Reconsidering evidence-based management of endometriosis

Background: Without an adequate animal model permitting experiments the pathophysiology of endometriosis remains unclear and without a non-invasive diagnosis, information is limited to symptomatic women. Lesions are macroscopically and biochemically variable. Hormonal medical therapy cannot be blinded since recognised by the patient and the evidence of extensive surgery is limited because of the combination of low numbers of interventions of variable difficulty with variable surgical skills. Experience is spread among specialists in imaging, medical therapy, infertility, pain and surgery. In addition, the limitations of traditional statistics and p-values to interpret results and the complementarity of Bayesian inference should be realised. Objectives: To review and discuss evidence in endometriosis management Materials and Methods: A PubMed search for blinded randomised controlled trials in endometriosis. Results: Good-quality evidence is limited in endometriosis. Conclusions: Clinical experience remains undervalued especially for surgery. What is new? Evidence-based medicine should integrate traditional statistical analysis and the limitations of P-values, with the complementary Bayesian inference which is predictive and sequential and more like clinical medicine. Since clinical experience is important for grading evidence, specific experience in the different disciplines of endometriosis should be used to judge trial designs and results. Finally, clinical medicine can be considered as a series of experiments controlled by the outcome. Therefore, the clinical opinion of many has more value than an opinion.

Melatonin-primed MSCs alleviate intrauterine adhesions by affecting MSC-expressed galectin-3 on macrophage polarization

Intrauterine adhesion (IUA) is characterized by the presence of fibrosis on the uterine cavity. It is mainly caused by infection or trauma to the endometrium, and it imposes a great challenge to female reproductive health. Mesenchymal stem cells (MSCs) have been used to regenerate the human endometrium in patients with IUA, but stem cell therapy is not curative in some patients. Melatonin (MT) was reported as a potential modulator of MSCs. However, it remains unclear whether MSCs pretreated with MT exert an improved therapeutic effect on IUA. In this study, an IUA model was established using our invented electric scratching tool. Our results illustrated that MT-pretreated MSCs significantly attenuated the development of IUA. Moreover, MT-pretreated MSCs highly expressed galectin-3 (Gal-3), which enhanced MSC proliferation and migration and influenced macrophage polarization. Of note, IUA mice exhibited colonic injury, and MT-pretreated MSCs alleviated this injury by normalizing colonic microbial communities and recruiting macrophages. Furthermore, inhibition of sympathetic nerves had no effect on IUA progression but delayed colonic injury, and Gal-3 combined with norepinephrine better promoted M2-like macrophage polarization and inhibited M1-like macrophage polarization. Together, these data indicated that MT-primed MSCs can ameliorate injury of both the uterus and colon in an IUA model through high Gal-3 expression to influence sympathetic nerves and in turn affect the polarization and recruitment of macrophages.

New Understanding of Diagnosis, Treatment and Prevention of Endometriosis

For 100 years, pelvic endometriosis has been considered to originate from the implantation of endometrial cells following retrograde menstruation or metaplasia. Since some observations, such as the clonal aspect, the biochemical variability of lesions and endometriosis in women without endometrium, the genetic-epigenetic (G-E) theory describes that endometriosis only begins after a series of cumulative G-E cellular changes. This explains that the endometriotic may originate from any pluripotent cell apart from the endometrium, that 'endometrium-like cells' can harbour important G-E differences, and that the risk is higher in predisposed women with more inherited incidents. A consequence is a high risk after puberty which decreases progressively thereafter. Considering a 10-year delay between initiation and performing a laparoscopy, this was observed in the United Arab Emirates, Belgium, France and USA. The subsequent growth varies with the G-E changes and the environment but is self-limiting probably because of the immunologic reaction and fibrosis. That each lesion has a different set of G-E incidents explains the variability of pain and the response to hormonal treatment. New lesions may develop, but recurrences after surgical excision are rare. The fibrosis around endometriosis belongs to the body and does not need to be removed. This suggests conservative excision or minimal bowel without safety margins and superficial treatment of ovarian endometriosis. This G-E concept also suggests prevention by decreasing oxidative stress from retrograde menstruation or the peritoneal microbiome. This suggests the prevention of vaginal infections and changes in the gastrointestinal microbiota through food intake and exercise. In conclusion, a higher risk of initiating endometriosis during adolescence was observed in UAE, France, Belgium and USA. This new understanding and the limited growth opens perspectives for earlier diagnosis and better treatment.

Current Challenges in the Management of Chronic Pelvic Pain in Women: From Bench to Bedside

Chronic pelvic pain (CPP) affects a significant proportion of women worldwide And has a negative impact on several aspects of these women’s lives including mental health, work, relationships and sexual function, among others. This set of factors ultimately reflects negatively on quality Of life. The physiopathology of CPP is complex and remains to be fully clarified; however, recent advances have increased understanding of the mechanisms involved in chronic pain in general, and more specifically, CPP. Nonetheless, even when a detailed clinical history is obtained, meticulous physical examination is performed and imaging resources are appropriately used, the organic cause of the pain may still fail to be identified in a substantial number of women with CPP. Management of CPP may therefore be challenging. This narrative review was aimed at adding to the available literature on the subject, presenting and discussing the principal characteristics of CPP in women. The paper highlights gaps in the literature while providing the most up-to-date evidence associated with the physiopathology and classification of pain, its diagnosis and treatment. In addition, current challenges in the management of women with CPP are discussed.

Conservative Management of Rectovaginal Deep Endometriosis: Shaving Should Be Considered as the Primary Surgical Approach in a High Majority of Cases

Deep endometriosis infiltrating the rectum remains a challenging situation to manage, and it is even more important when ureters and pelvic nerves are also infiltrated. Removal of deep rectovaginal endometriosis is mandatory in case of symptoms strongly impairing quality of life, alteration of digestive, urinary, sexual and reproductive functions, or in case of growing. Extensive preoperative imaging is required to choose the right technique between laparoscopic shaving, disc excision, or rectal resection. When performed by skilled surgeons and well-trained teams, a very high majority of cases of deep endometriosis nodule (>95%) is feasible by the shaving technique, and this is associated with lower complication rates regarding rectal resection. In most cases, removing a part of the rectum is questionable according to the risk of complications, and the rectum should be preserved as far as possible. Shaving and rectal resection are comparable in terms of recurrence rates. As shaving is manageable whatever the size of the lesions, surgeons should consider rectal shaving as first-line surgery to remove rectal deep endometriosis. Rectal stenosis of more than 80% of the lumen, multiple bowel deep endometriosis nodules, and stenotic sigmoid colon lesions should be considered as indication for rectal resection, but this represents a minority of cases.