Repetitive surgery for recurrent symptomatic endometriosis: what to do?

"The Green Peace" How ICG can prevent complications in endometriosis surgery?

This literature review summarises the investigation into using Indocyanine Green (ICG) in the surgical management of endometriosis, focusing mainly on its application in Deep Endometriosis (DE). The study reviews the development, fluorescence characteristics, and clinical usage of ICG in enhancing the precision of identifying endometrial lesions during surgery. Emphasizing the technology's contribution to improved lesion visualisation, the paper discusses how ICG facilitates increased diagnostic accuracy, potentially reducing recurrence rates and the necessity for subsequent interventions. Additionally, it explores ICG's role in minimizing the risk of iatrogenic injuries, especially in ureteral endometriosis, and its utility in surgical decision-making for rectosigmoid endometriosis by evaluating bowel perfusion. Conclusively, while acknowledging the clear benefits of ICG integration in endometriosis surgical procedures, the abstract calls for more extensive research to validate its efficacy and cost-efficiency in the broader context of endometriosis treatment.

Role of the gut microbiota in the pathogenesis of endometriosis: a review

Endometriosis is classically defined as a chronic inflammatory heterogeneous disorder occurring in any part of the body, characterized by estrogen-driven periodic bleeding, proliferation, and fibrosis of ectopic endometrial glands and stroma outside the uterus. Endometriosis can take overwhelmingly serious damage to the structure and function of multi-organ, even impair whole-body systems, resulting in severe dysmenorrhea, chronic pelvic pain, infertility, fatigue and depression in 5-10% women of reproductive age. Precisely because of a huge deficiency of cognition about underlying etiology and complex pathogenesis of the debilitating disease, early diagnosis and treatment modalities with relatively minor side effects become bottlenecks in endometriosis. Thus, endometriosis warrants deeper exploration and expanded investigation in pathogenesis. The gut microbiota plays a significant role in chronic diseases in humans by acting as an important participant and regulator in the metabolism and immunity of the body. Increasingly, studies have shown that the gut microbiota is closely related to inflammation, estrogen metabolism, and immunity resulting in the development and progression of endometriosis. In this review, we discuss the diverse mechanisms of endometriosis closely related to the gut microbiota in order to provide new approaches for deeper exploration and expanded investigation for endometriosis on prevention, early diagnosis and treatment.

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.

Oral GnRH Antagonists in Combination with Estradiol and Norethindrone Acetate for Pain Relief Associated with Endometriosis: A Review of Evidence of a Novel Class of Hormonal Agents

Current medical treatment options for endometriosis associated pains are inadequate. Evidence on effects of nonsteroidal anti-inflammatory drugs is scarce. Around one third of patients are not responsive to oral contraceptives or progestins due to progesterone resistance. Gonadotropin-releasing hormone (GnRH) agonists can only be used for a short duration because of associated side effects. Oral GnRH antagonists, including elagolix, relugolix, and linzagolix allow oral administration, induce dose dependent reduction of estradiol levels, do not cause initial flare up of endometriosis symptoms, and allow the fast return of ovarian function and menstruation after discontinuation. Elagolix at a low dose of 150 mg once daily, or the higher dose of 200 mg twice daily, significantly increased the proportion of women achieving clinically meaningful decline of dysmenorrhea, noncyclic pelvic pain, and dyspareunia. Relugolix at an oral dose of 40 mg/day results in improvement in different forms of endometriosis related pelvic pain, with an efficacy and side effect profile similar to that of GnRH agonists. Adding 1 mg of estradiol and 0.5 mg of norethindrone to 40 mg of relugolix (relugolix combination therapy) allows extension of treatment to 24 weeks with maintained efficacy and an improved side effect profile. Linzagolix, in a dose of 75 mg/day, can be used alone to treat endometriosis associated pain. For severe pelvic pain and dyspareunia, linzagolix can be used in a high dose of 200 mg/day with hormonal add-back therapy to preserve bone health.

Endometriosis: Classification, pathophysiology, and treatment options

The human endometrium is a complex hormone-target tissue consisting of two layers: the lower basalis, and the upper functionalis. The latter of the two goes through a cycle of thickening and shedding without residual scarring or loss of function. This cycle, known as the menstrual cycle, occurs on a monthly basis in most of healthy reproductive-age women. It is, however, associated with a number of reproductive diseases, endometriosis being one of them. Endometriosis is defined as the presence of endometrium at ectopic sites within the peritoneum or, more rarely, other locations outside the abdominal area. It affects around 6-10% of reproductive-age women in the world and causes debilitating pain, heavy menstrual bleeding, pain during penetrative sex, and infertility. The etiology of the disease is not yet fully understood but the generally accepted theory is that the endometriotic lesions originate from viable eutopic endometrial cells that flow back into the peritoneum through the process of retrograde menstruation. Endometriosis is usually classified into four stages: minimal, mild, moderate, and severe, though it is important to note that the presentation of symptoms does not necessarily correspond to the disease progression. The immune system plays an important role in supporting the viability and growth of ectopic endometriotic tissue, all the while promoting chronic inflammation at the lesion sites, which causes prolonged pain. There is no definitive cure for endometriosis, but there are several options for symptom management, including laparoscopy, hormonal therapy, the use of NSAIDs, dietary changes, exercise, and, in cases when all conservative treatments fail, hysterectomy.

Pain resolution and functional outcomes of total mesh excision: a case series

INTRODUCTION AND HYPOTHESIS

The objective was to assess the impact of total excision of polypropylene midurethral slings (MUS) on patient pain levels and to report on functional outcomes including recurrent/de novo stress urinary incontinence (SUI), sexual function, and quality of life measures.

METHODS

This is a retrospective analysis of patients who underwent total MUS excision from March 2017 to December 2019. The primary outcome was the impact on pain assessed by a Numeric Rating Scale (NRS). Questionnaires analyzed were: Pain Catastrophizing Scale, Pelvic Floor Distress Inventory Short Form-20, Female Sexual Function Index, and McGill Pain Index questionnaires.

RESULTS

Thirty-two women underwent total mesh excision within the inclusion period; with follow-up data available for 31 out of 32; 14 (43.8%) had previously undergone one or more partial vaginal mesh excision procedures. Types of MUS removed were: 14 (43.8%) transobturator midurethral slings, 12 (37.5%) retropubic midurethral slings, 4 (12.5%) mini-slings, and 2 (6.3%) mesh slings placed by laparotomy. Pain was the main reason for referral in 31 patients (96.9%). Mean pain NRS reduced from 6.1 pre-operatively to 3.3 post-operatively, with paired comparison showing a significant difference (p<0.01). Qualitatively, complete symptoms resolution was observed in 10 out of 31 (32.3%), another 9 out of 31 (29.0%) patients experienced clinically significant improvement, 2 out of 31 (6.5%) did not experience improvement in pain, and 10 out of 31 (32.3%) reported new/worsening pain. Post-operative complications occurred in 9 (29.0%) patients; all were Clavien-Dindo grade II. Nineteen (61.3%) reported de novo/recurrent SUI post-operatively.

CONCLUSION

Total MUS mesh excision yields high complication and SUI recurrence rates, counter-balanced by a 61.3% pain resolution/improvement rate. These data are pertinent for patient counseling.

Evaluation and management of endometriosis

The initial diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The pelvic examination should include a speculum examination and vaginal palpation. Mobility, fixation and/or tenderness of the uterus and site-specific tenderness in the pelvis should be evaluated. Transvaginal ultrasound and pelvic magnetic resonance imaging are recommended to evaluate the extent of the endometriosis and to determine whether any urinary tract or bowel procedures might also be required during surgical resection. Quality of life should be assessed by using the Endometriosis Health Profile-30, its short version EHP-5 or the generic quality of life questionnaire SF-36. Management of endometriosis is recommended when it has a functional impact (pain, infertility) or causes organ dysfunction. Many gynecological societies have published different guidelines for the evaluation and management of endometriosis. However, the complexity of this disease together with the different available treatments lead to significant discrepancies between the recommendations. Postmenopausal endometriosis should be considered when a patient has a history of symptoms before menopause including dysmenorrhea, dyspareunia, dyschezia, infertility and chronic pelvic pain. Malignant transformation of endometriosis is estimated to occur in about 0.7-1.6% of women affected by endometriosis. Endometriosis is associated with an increased risk of ovarian cancer, specifically clear cell, endometrioid and low-grade serous types.

Near-Infrared Fluorescence Imaging for the Intraoperative Detection of Endometriosis: A Pilot Study

Introduction: Endometriosis surgery is associated with a high risk of reoperation due to an insufficient recognition of endometriotic lesions. Our aim was to explore the role of near-infrared fluorescence (NIRF) imaging for the visualization and identification of endometriotic lesions next to conventional white light (WL) laparoscopy. Materials and methods: Fifteen women scheduled for diagnostic laparoscopy in whom peritoneal endometriosis was suspected were included. Peritoneal exploration was performed in WL, followed by NIRF imaging after ICG administration. Biopsies of all the suspected lesions were taken for histological examination. Subjective evaluations of the equipment and NIRF imaging were also performed. Results: Only 61% (44) of the biopsied lesions contained endometriosis. The positive predictive value (PPV) for the lesions found in WL was 64%. The PPV for the lesions found under NIRF was 69% and the PPV for the lesions found in both modes was 61%. The mean satisfaction of surgeons regarding the surgical procedure and equipment using both imaging modalities was 6.5 (p > 0.05) on a 10 item Likert scale and the mean satisfaction with the quality of the NIRF imaging was 7.4 (p > 0.05). Conclusion: In this study, the additional value of NIRF imaging, although feasible, was found to be limited for the intraoperative detection of endometriotic lesions.

Treatment of endometriosis: a review with comparison of 8 guidelines

Background

Endometriosis, the presence of endometrial-like tissue outside the uterus, is a common clinical entity between women of reproductive age, with a prevalence of about 10%. Due to the variety of endometriosis-associated symptoms, a great variety of treatments have been implemented. The aim of this review is to give an overview on therapeutical approaches of eight national and international widely used guidelines.

Methods

Six national (College National des Gynecologues et Obstetriciens Francais, National German Guideline (S2k), Society of Obstetricians and Gynaecologists of Canada, American College of Obstetricians (ACOG) and Gynecologists, American Society for Reproductive Medicine (ASRM) and National Institute for Health and Care (NICE) and two international (World Endometriosis Society, European Society of Human Reproduction and Embryology) guidelines are included in this review.

Conclusion

All the above-mentioned guidelines agree that the combined oral contraceptive pill, progestogens are therapies recommended for endometriosis associated pain. Concerning infertility, there is no clear consensus about surgical treatment. Discrepancies are also found on recommendation of the second- and third-line treatments.

Tofacitinib alters STAT3 signaling and leads to endometriosis lesion regression

Endometriosis is a widespread gynecologic condition affecting up to 15% of women of reproductive age. The Janus kinase/signal transducer and activator of transcription (JAK/STAT3) pathway is upregulated in endometriosis and is a therapeutic target. Here we sought to determine the effect of Tofacitinib, a JAK inhibitor in widespread clinical use, on JAK/STAT signaling in endometriosis and lesion growth. Endometriosis was surgically induced in C57BL/6 mice using homologous uterine horn transplantation. Lesions were allowed to form over 4 weeks followed by Tofacitinib (10 mg/kg) or vehicle administered by oral gavage over 4 weeks. Tofacitinib treatment in vivo led to endometriosis lesion regression and reduced adhesion burden compared to vehicle treatment. In vitro studies on Ishikawa cells showed that Tofacitinib reduced hypoxia-inducible factor 1α and vascular endothelial growth factor mRNA levels at 12 and 24 h. Western blot analysis showed that Tofacitinib effectively reduced STAT3 phosphorylation in Ishikawa cells and human primary stromal and epithelial cells from eutopic endometrium of patients with and without endometriosis. This study suggests that the inhibition of JAK/STAT signaling using Tofacitinib may be a viable method for the treatment of endometriosis.

Endometriosis is a chronic systemic disease: clinical challenges and novel innovations

Endometriosis is a common disease affecting 5-10% of women of reproductive age globally. However, despite its prevalence, diagnosis is typically delayed by years, misdiagnosis is common, and delivery of effective therapy is prolonged. Identification and prompt treatment of endometriosis are essential and facilitated by accurate clinical diagnosis. Endometriosis is classically defined as a chronic, gynaecological disease characterised by endometrial-like tissue present outside of the uterus and is thought to arise by retrograde menstruation. However, this description is outdated and no longer reflects the true scope and manifestations of the disease. The clinical presentation is varied, the presence of pelvic lesions is heterogeneous, and the manifestations of the disease outside of the female reproductive tract remain poorly understood. Endometriosis is now considered a systemic disease rather than a disease predominantly affecting the pelvis. Endometriosis affects metabolism in liver and adipose tissue, leads to systemic inflammation, and alters gene expression in the brain that causes pain sensitisation and mood disorders. The full effect of the disease is not fully recognised and goes far beyond the pelvis. Recognition of the full scope of the disease will facilitate clinical diagnosis and allow for more comprehensive treatment than currently available. Progestins and low-dose oral contraceptives are unsuccessful in a third of symptomatic women globally, probably as a result of progesterone resistance. Oral gonadotropin-releasing hormone (GnRH) antagonists constitute an effective and tolerable therapeutic alternative when first-line medications do not work. The development of GnRH antagonists has resulted in oral drugs that have fewer side-effects than other therapies and has allowed for rapid movement between treatments to optimise and personalise endometriosis care. In this Review, we discuss the latest understanding of endometriosis as a systemic disease with multiple manifestations outside the parameters of classic gynaecological disease.

The perioperative period: a critical yet neglected time window for reducing the recurrence risk of endometriosis?

While surgery is commonly the management of symptomatic endometriosis when patients do not respond to medical or supportive therapy, recurrence after surgery poses a serious challenge, and repeat surgery increases the risk of premature ovarian failure, adhesion and organ injury. Conceivably, the recurrent endometriotic lesions could arise from minimal residual lesions (MRLs) or from de novo lesions. However, several lines of evidence suggest that the former is more likely. So far, most, if not all, efforts to combat recurrence have been focused on postoperative medication of hormonal drugs to reduce recurrence risk through lesional dormancy and possibly atrophy. However, the perioperative period may exert a disproportionally high impact on the risk of recurrence; it is likely to be amendable for possible intervention but has been generally neglected. Indeed, many perioperative factors are known to or conceivably could facilitate the recurrence of endometriosis through the suppression of cell-mediated immunity due to the activation of adrenergic signaling and the release of prostaglandins. Perioperative use of β-blockers and/or nuclear factor κB/jCycloxygenase 2 (NF-κB/COX-2) inhibitors may boost the cell-mediated immunity suppressed by surgery, resulting in the partial or even complete removal of MRLs and reduced recurrence risk. This is both biologically plausible and supported by a recent experimental study. We call for more research on possible perioperative interventions to reduce the recurrence risk of endometriosis. The potential payoff might be a substantial reduction in the risk of recurrence and cost when compared with the traditional approach of postoperative intervention.

Lack of Data-driven Treatment Guidelines and Wide Variation in Management of Chronic Pelvic Pain in Adolescents and Young Adults

STUDY OBJECTIVE

Current literature lacks data-driven guidelines for surgical treatment of adolescent and young adult (AYA) patients with chronic pelvic pain. We hypothesized that there is a significant variation in treatment of these patients, which might be an indicator of over- or undertreatment by some providers.

DESIGN AND SETTING

We completed a retrospective population-based analysis of the Nationwide Inpatient Sample from 1998 to 2016.

PARTICIPANTS

We included AYA patients aged 9-25 years whose primary diagnosis was adenomyosis, endometriosis, or chronic pelvic pain. Patients who might have undergone pelvic or abdominal procedures for other primary diagnoses were excluded.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Trends of inpatient surgical intervention were calculated. Logistic regression was performed to determine the likelihood of undergoing an intervention, adjusted for patient demographic characteristics.

RESULTS

A total of 13,111 AYA patients were analyzed. Median age at diagnosis was 22 (interquartile range, 20-24) years. The overall inpatient intervention rate was 5879/13111 (45.0%) (2445/5897 (18.6%) for excision/ablation, 2057/5897 (15.7%) for hysterectomy, 1239/5897 (9.5%) for diagnostic laparoscopy, and 156/5897 (1.2%) for biopsy). Rate of hysterectomy increased in the late 2000s while rates of all other interventions decreased. Patients in the northeast were less likely to undergo an intervention than patients in the rest of the country. Rates of intervention also differed according to race, insurance status, and type of hospital.

CONCLUSION

There is wide variation in the use of surgical treatment for chronic pelvic pain in AYA patients across the country and between types of institutions. Of concern, the rate of hysterectomy has increased over time. There is a need for data-directed treatment guidelines for the management of AYA patients with chronic pelvic pain to ensure appropriate application of surgical treatments and expand high-value surgical care.

Multidisciplinary laparoscopic management of deep infiltrating endometriosis from 2010 to 2017: A retrospective cohort study

Background

Laparoscopy has become the standard of care in the surgical management of deep infiltrating endometriosis (DIE). However, it is a challenging procedure with a high complication rate. Despite the benefits of the minimally invasive approach, DIE resection is often performed by surgeons without adequate training, especially in developing countries like Chile.

Objective

To asses our experience in the diagnosis and laparoscopic management of DIE during seven years.

Methods

A retrospective cohort study of data including 137 patients with pathology-proven DIE. Surgical and fertility outcomes were evaluated.

Results

All procedures were performed laparoscopically without conversion. Dysmenorrhea and dyspareunia were the most common symptoms in 85.4% and 56.9%, respectively. Uterosacral ligaments were the most common DIE location. Endometrioma was present in 48.9% of cases. Median operative time was 140 minutes; however, it was longer in cases requiring bowel surgery (p < 0.0001). The complication rate was 10.9%. Median follow-up was 24.5 months. The pregnancy rate was 58.1% and 90% of patients reported significant symptom relief after surgery.

Conclusion

Laparoscopic surgical management of DIE is effective and safe but it must be performed in tertiary centers with the availability of multidisciplinary teams.

Surgical treatment of endometriosis: prognostic factors for better quality of life

The present study investigated the effect of surgical treatment of endometriosis on physical and mental health. We undertook a prospective survey including 153 premenopausal women with histological diagnosis of endometriosis. The Short Form 12 (SF-12) questionnaire comprising physical and mental component scales was used. Two groups of patients were distinguished: Group A (n = 42) with SF-12 scores above the median in both physical and mental scales; Group B (n = 111) with SF-12 scores below the median in either physical or mental scale. Group A was diagnosed and operated for endometriosis for the first time at an older age (30 vs. 26 years), had undergone more frequently a single surgical intervention (64% vs. 46%), was less affected by symptom or lesion recurrence and had reported less intense current pain symptoms than Group B. Having the first endometriosis surgery at a later age was an independent predictor of better health status (adjusted odds ratio 1.146 per year, 95% confidence interval 1.058-1.242) after accounting for the potential confounding effects of reoperation, pelvic pain and time elapsed since the first surgery. In conclusion, patients with endometriosis who had a single surgery at an older age have good symptom control and better quality of life (QoL).

Management of women affected by endometriosis: Are we stepping forward?

Endometriosis is an estrogen-dependent chronic disease defined by the presence of endometrial-like tissue, glands and stroma in ectopic areas. Among all the pathogenic theories proposed to explain the origin of the disease, a pivotal role for immune, hormonal, and epigenetic disbalances have been hypothesized. Endometriosis affects up to 10%–15% of women in reproductive age and represents one of the most common gynecological causes of severe pelvic pain. The main symptoms reported by patients are dysmenorrhea and deep dyspareunia. Although the histological confirmation has been commonly considered mandatory, to date the possibility offered by the improvement in imagining techniques allows to make a proper diagnosis of the disease in most of the cases. Medical therapy represents only a symptomatic treatment and not the definitive solution. The aim of the hormonal therapy is to abolish the menstrual flow using progestin, oral contraceptives, and gonadotropin-releasing hormone agonists to reduce pelvic pain. Surgical treatment consisting of laparoscopy has the goal of abolishing pain and may be conservative or radical in nature depending on the patients’ desire of spontaneous conception in the future. Radical surgery seems to be associated with a higher percentage of pain relief as well as higher recurrence rates. Due to the worldwide acceptance and the ongoing evolution of minimally invasive surgery to treat both benign and malignant diseases, future investigations may be conducted to consider this approach to save the function of all the organs involved by the disease and to reduce post-operative discomfort and psychological impact.

Clinical evaluation and management of endometriosis: guideline for Korean patients from Korean Society of Endometriosis

Endometriosis is one of the most common diseases in reproductive ages, and it affects patients' quality of life and fertility. However, few Korean guidelines are available for the evaluation and management of endometriosis. Korean Society of Endometriosis reviewed various literatures and trials, and to provide seventy-one evidence-based recommendations. This review presents guidelines for the diagnosis and management of endometriosis with emphasis on: it's role in infertility, treatment of recurrence, asymptomatic women, endometriosis in adolescents and menopausal women, and possible association of endometriosis with cancer.

Human chorionic gonadotropin induces decidualization of ectopic human endometrium more effectively than forskolin in an in-vivo endometriosis model

Endometriosis, characterized by the presence of endometrial tissue at ectopic sites, is a leading cause of pelvic pain and subfertility in women. The stromal compartment of the endometrium is considered to play a pivotal role in the establishment and persistence of endometriotic lesions, thus impaired decidualization of these cells may result in enhanced invasion capacity at ectopic sites. Consequently, stimulation of decidualization may alleviate this disease. To analyze the effect of systemically applied compounds on decidualization of ectopic endometrial tissue, endometriosis was induced by suturing human eutopic endometrium to the peritoneum of 22 NOD/SCID mice. Each mouse received four tissue fragments from the same patient. Mice were randomly allocated either to one control and three experimental groups ( n = 4/group) which were treated with progesterone alone or in combination with forskolin or human chorionic gonadotropin for seven days or to one control and one experimental group ( n = 3/group) which was treated with progesterone and human chorionic gonadotropin for 10 days followed by 7 days without treatment. At the end of the experiments, lesions were measured and analyzed for markers of decidualization (FOXO-1, prolactin) and proliferation (Ki-67). Decidualization was induced in the ectopic lesions by systemic treatment in vivo. This induction was significantly stronger after treatment with progesterone in combination with human chorionic gonadotropin than with forskolin or with progesterone alone. Only the combination with human chorionic gonadotropin led to induction of FOXO1 protein expression and a significant physiologic transformation of the ectopic endometrial stromal cells after seven days of treatment. After termination of human chorionic gonadotropin treatment, the decidualization process continued, leading to a significant inhibition of proliferation. Thus, decidualization of human ectopic endometrial tissue can be induced in a humanized endometriosis mouse model in vivo. This model may help to decipher the signal pathways involved in this decidualization process and to develop novel therapeutical approaches to alleviate this painful disease. Impact statement Impaired decidualization of endometrial stromal cells may contribute to the development of endometriosis, and an increased decidualization reaction may prevent or alleviate this prevalent gynecological disease. Human chorionic gonadotropin (hCG) has been shown to promote decidualization in eutopic endometrium. Up to now in vitro studies mainly used cAMP for successful induction of decidualization of isolated endometrial stromal cells. Here, for the first time, decidualization of ectopic endometrial lesions is induced in an experimental endometriosis mouse model, comparing the effectiveness of hCG with that of the direct adenylyl cyclase activator Forskolin. In this 3D-organ structure in vivo, hCG proved to be more effective in the induction of decidualization than forskolin. Particularly in case of progesterone resistance, alternative pathways inducing decidualization could alleviate endometriosis, and the sophisticated hCG action could constitute a therapeutical tool to induce terminal differentiation in ectopic endometrial lesions.

Physical pain and emotion regulation as the main predictive factors of health-related quality of life in women living with endometriosis

STUDY QUESTION

To what extent are pain symptoms, psychological variables (anxiety, depression and distress) and emotion regulation associated with women's health in endometriosis?

SUMMARY ANSWER

Physical pain symptoms and emotion regulation difficulties via psychological stress negatively affect the health-related quality of life (HRQoL) of women living with endometriosis.

WHAT IS KNOWN ALREADY

There are some missing links in the definitive treatment and recovery from endometriosis. Women with chronic pain report a decrease in HRQoL and an increase in the frequency of psychological problems, but little is known about the complex relationship between these variables in the context of endometriosis.

STUDY DESIGN, SIZE, DURATION

This cross-sectional study was conducted between October 2014 and October 2015 on 193 women living with endometriosis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The sample consisted of women with a medically confirmed diagnosis of endometriosis who received treatment at the participating clinic. All participants completed the Short Form Health Survey (SF-36), the Hospital Anxiety and Depression Scale, the Perceived Stress Scale and the Difficulties in Emotion Regulation Scale. Spearman's rank correlation was used to explore the associations between the measured variables, and structural equation modeling was used to test the proposed mediation models.

MAIN RESULTS AND THE ROLE OF CHANCE

The response rate was 46%. In this study, 54.79% of the participants presented with anxiety and 20.3% with depressive symptoms. Pain symptoms, psychological variables and difficulties in emotion regulation were negatively associated with HRQoL. Mediation models revealed that physical pain, psychological stress and difficulties in emotion regulation explained 55% of the variance in the overall HRQoL, 41% of the variation in physical and 55% of the variation in mental HRQoL. Accordingly, severe physical pain (β = -0.39, P < 0.001) was directly, and difficulties in emotion regulation (β = -0.38, P < 0.001) was indirectly related to deterioration in overall HRQoL. Physical pain had a higher direct standardized effect (β = -0.51, P < 0.001) on physical HRQoL, and had no significant direct effect on mental HRQoL. Furthermore, both physical pain (β = -0.07, P < 0.001) and difficulties in emotion regulation (β = -0.46, P < 0.001) had a significant indirect effect on mental HRQoL.

LIMITATIONS, REASONS FOR CAUTION

The data were heterogeneous with regard to the severity of endometriosis. The validity of this cross-sectional study is limited to correlations; therefore, further longitudinal studies using a more representative sample are needed to explore valid causal relationships.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study indicate that HRQoL can be improved through pain management and emotion regulation strategies. The authors believe that HRQoL would increase with concomitant application of physical treatment and psychological care.

STUDY FUNDING/COMPETING INTEREST(S)

There were no external funding sources for this study, and the authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

[Interest of hysterectomy with or without bilateral oophorectomy in the surgical treatment of endometriosis: CNGOF-HAS Endometriosis Guidelines]

OBJECTIVE

In women with symptomatic endometriosis and no desire for pregnancy, hysterectomy with or without bilateral oophorectomy is often presented as a definitive solution to their symptoms. Despite this radical treatment, it should be known that nearly 15% of these patients will have persistent pain. Thus the objective of this review was to determine the interest of total hysterectomy with or without bilateral oophorectomy for the treatment of deep endometriosis.

METHOD

The research was conducted from the US National Library of Medicine's National Institutes of Health from the following keywords: endometriosis, hysterectomy, oophorectomy, ovariectomy, radical treatment. Only articles written in English have been selected.

RESULTS AND RECOMMENDATIONS

Hysterectomy with or without bilateral oophorectomy, associated with endometriotic lesions exeresis could decrease the rate of recurrence and surgical reoperations compared to resection alone endometriosis lesions (NP4). In women with no desire for pregnancy, the benefit-risk balance of a hysterectomy, with or without bilateral oophorectomy, may be discussed in order to reduce the risk of recurrence of endometriotic disease (Expert Agreement). Taking into account the multiple adverse effects of early menopause on expectancy and quality of life (NP2), ovarian preservation should be discussed with the patient in case of hysterectomy for deep endometriosis (Expert Agreement). The use of menopausal hormone therapy (THM) does not appear to increase the symptoms of endometriosis after surgical castration (NP3). THM is not contraindicated in postmenopausal women with endometriosis (grade C).

Impact of Pelvic Pain and Endometriosis on Patient-Reported Outcomes and Experiences of Benign Hysterectomy: A Study from the Swedish National Register for Gynecological Surgery

BACKGROUND

The study objective was to analyze and compare patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs) after hysterectomy in women with and without a preoperative complaint of pelvic pain associated with and without a confirmed diagnosis of endometriosis.

METHODS

Retrospective nationwide register study. Data on 28,776 hysterectomies performed on benign indication between 2004 and 2016 were retrieved from the Swedish National Register for Gynecological Surgery. Multivariable logistic regression models were used to compare the PREMs and PROMs items. The results are presented as adjusted odds ratios (aORs) and 95% confidence intervals (CI).

RESULTS

Regardless of the occurrence of pelvic pain preoperatively and a diagnosis of endometriosis, 1 year after surgery, the women were satisfied or very satisfied (>90%) with the hysterectomy, and their medical condition was improved or much improved (>95%). The women with a preoperative complaint of pelvic pain and endometriosis more often reported excessively short hospital stays (aOR 1.45, 95% CI 1.17-1.79), more severe complications after discharge (aOR 2.02, 95% CI 1.59-2.66) at the 8-week follow-up and at the 1-year follow-up (aOR 2.31, 95% CI 1.57-3.39), and more dissatisfaction with the operation (aOR 1.83, 95% CI 1.35-2.48) than preoperative pelvic pain-free women without endometriosis at the 1-year follow-up.

CONCLUSIONS

The majority of the women were satisfied after their hysterectomy. The women with pelvic pain and endometriosis were at a higher risk of being dissatisfied. Pelvic pain per se seemed to be the main factor affecting the rating in the PREMs and PROMs, and the endometriosis was a significant contributing factor.

Treatment Patterns, Complications, and Health Care Utilization Among Endometriosis Patients Undergoing a Laparoscopy or a Hysterectomy: A Retrospective Claims Analysis

INTRODUCTION

Hysterectomy and laparoscopy are common surgical procedures used for the treatment of endometriosis. This study compares outcomes for women who received either procedure within the first year post initial surgery.

METHODS

The study used data from the Truven Health MarketScan claims databases from 2004 to 2013 to identify women aged 18-49 years who received an endometriosis-related laparoscopy or hysterectomy. Patients were excluded if they did not have continuous insurance coverage from 1 year before through 1 year after their endometriosis-related procedure, if they were diagnosed with uterine fibroids prior to or on the date of surgery (i.e., index date), or if they had a hysterectomy prior to the index date. The descriptive analyses examined differences between patients with an endometriosis-related laparoscopy or hysterectomy in regard to medications prescribed, complications, and hospitalizations during the immediate year post procedure.

RESULTS

The final sample consisted of 24,915 women who underwent a hysterectomy and 37,308 who underwent a laparoscopy. Results revealed significant differences between the cohorts, with women who received a laparoscopy more likely to be prescribed a GnRH agonist, progestin, danazol, or an opioid analgesic in the immediate year post procedure compared to women who underwent a hysterectomy. In contrast, women who underwent a hysterectomy generally had higher complication rates. Index hospitalization rates and length of stay (LOS) were higher for women who had a hysterectomy, while post-index hospitalization rates and LOS were higher for women who had a laparoscopy. For both cohorts, post-procedure complications were associated with significantly higher hospitalization rates and longer LOS.

CONCLUSION

This study indicated significantly different 1-year post-surgical outcomes for patients who underwent an endometriosis-related hysterectomy relative to a laparoscopy. Furthermore, the endometriosis patients in this analysis had a considerable risk of surgical complications, subsequent surgeries, and hospital admissions, both during and after their initial therapeutic laparoscopy or hysterectomy.

FUNDING

AbbVie.

An Interdisciplinary Approach to Endometriosis-associated Persistent Pelvic Pain

Endometriosis-associated pelvic pain is a common and often challenging problem. For certain patients, pain persists or recurs despite adequate medical or surgical therapy targeted to endometriosis. In this patient population, there is often the presence of coexisting pain conditions such as irritable bowel syndrome, painful bladder syndrome and myofascial pain as well central sensitisation. An interdisciplinary approach where both peripheral pain triggers and central sensitization are addressed is likely to lead to improved pain and quality of life. The approach to the evaluation and treatment of the patients with persistent/chronic pelvic pain and endometriosis is outlined in this article.

Research Priorities for Endometriosis

The 3rd International Consensus Workshop on Research Priorities in Endometriosis was held in São Paulo on May 4, 2014, following the 12th World Congress on Endometriosis. The workshop was attended by 60 participants from 19 countries and was divided into 5 main sessions covering pathogenesis/pathophysiology, symptoms, diagnosis/classification/prognosis, disease/symptom management, and research policy. This research priorities consensus statement builds on earlier efforts to develop research directions for endometriosis. Of the 56 research recommendations from the 2011 meeting in Montpellier, a total of 41 remained unchanged, 13 were updated, and 2 were deemed to be completed. Fifty-three new research recommendations were made at the 2014 meeting in Sao Paulo, which in addition to the 13 updated recommendations resulted in a total of 66 new recommendations for research. The research recommendations published herein, as well as those from the 2 previous papers from international consensus workshops, are an attempt to promote high-quality research in endometriosis by identifying and agreeing on key issues that require investigation. New areas included in the 2014 recommendations include infertility, patient stratification, and research in emerging nations, in addition to an increased focus on translational research. A revised and updated set of research priorities that builds on this document will be developed at the 13th World Congress on Endometriosis to be held on May 17-20, 2017, in Vancouver, British Columbia, Canada.

Local upregulation of transient receptor potential ankyrin 1 and transient receptor potential vanilloid 1 ion channels in rectosigmoid deep infiltrating endometriosis

Transient Receptor Potential Vanilloid 1 (TRPV1) and Transient Receptor Potential Ankyrin 1 (TRPA1) expressed mainly by primary sensory neurons function as major nociceptive integrators. They are also present on the rat endometrium in an oestrogen-regulated manner. TRPV1 is upregulated in peritoneal and ovarian endometriosis patients, but there is no information about TRPA1 and their pathophysiological significances. In this study, patients undergoing laparoscopic surgery were investigated: severe dysmenorrhoea due to rectosigmoid deep infiltrating endometriosis ( n = 15), uterine fibroid-induced moderate dysmenorrhoea ( n = 7) and tubal infertility with no pain ( n = 6). TRPA1 and TRPV1 mRNA and protein expressions were determined by quantitative polymerase chain reaction and semi-quantitative immunohistochemistry from the endometrium samples taken by curettage. Results were correlated with the clinical characteristics including pain intensity. TRPA1 and TRPV1 receptors were expressed in the healthy human endometrium at mRNA and protein levels. Sparse, scattered cytoplasmic TRPA1 and TRPV1 immunopositivities were found in the stroma and epithelial layers. We detected upregulated mRNA levels in deep infiltrating endometriosis lesions, and TRPV1 gene expression was also elevated in autocontrol endometrium of deep infiltrating endometriosis patients. Histological scoring revealed significant TRPA1 and TRPV1 difference between deep infiltrating endometriosis stroma and epithelium, and in deep infiltrating endometriosis epithelium compared to control samples. Besides, we measured elevated stromal TRPV1 immunopositivity in deep infiltrating endometriosis. Stromal TRPA1 and TRPV1 immunoreactivities strongly correlated with dysmenorrhoea severity, as well TRPV1 expression on ectopic epithelial cells and macrophages with dyspareunia. Epithelial TRPA1 and stromal TRPV1 immunopositivity also positively correlated with dyschezia severity. We provide the first evidence for the presence of non-neuronal TRPA1 receptor in the healthy human endometrium and confirm the expression of TRPV1 channels. Their upregulations in rectosigmoid deep infiltrating endometriosis lesions and correlations with pain intensity suggest potential roles in pathophysiological mechanisms of the disease.

Functional Connectivity is Associated With Altered Brain Chemistry in Women With Endometriosis-Associated Chronic Pelvic Pain

In contrast to women with relatively asymptomatic endometriosis, women with endometriosis-associated chronic pelvic pain (CPP) exhibit nonpelvic hyperalgesia and decreased gray matter volume in key neural pain processing regions. Although these findings suggest central pain amplification in endometriosis-associated CPP, the underlying changes in brain chemistry and function associated with central pain amplification remain unknown. We performed proton spectroscopy and seed-based resting functional connectivity magnetic resonance imaging to determine whether women with endometriosis display differences in insula excitatory neurotransmitter concentrations or intrinsic brain connectivity to other pain-related brain regions. Relative to age-matched pain-free controls, women with endometriosis-associated CPP displayed increased levels of combined glutamine-glutamate (Glx) within the anterior insula and greater anterior insula connectivity to the medial prefrontal cortex (mPFC). Increased connectivity between these regions was positively correlated with anterior insula Glx concentrations (r = .87), as well as clinical anxiety (r = .61, P = .02), depression (r = .60, P = .03), and pain intensity (r = .55, P = .05). There were no significant differences in insula metabolite levels or resting-state connectivity in endometriosis patients without CPP versus controls. We conclude that enhanced anterior insula glutamatergic neurotransmission and connectivity with the mPFC, key regions of the salience and default mode networks, may play a role in the pathophysiology of CPP independent of the presence of endometriosis.

PERSPECTIVE

Similar to other chronic pain conditions, endometriosis-associated pelvic pain is associated with altered brain chemistry and function in pain processing regions. These findings support central pain amplification as a mechanism of chronic pelvic pain, and clinicians should consider the use of adjunctive therapies that target central pain dysfunction in these women.

Surgical therapy of ovarian endometrioma: recurrence and pregnancy rates

Background and Objectives:

The study was designed to analyze preoperative clinical and surgical findings at enucleation of ovarian endometrioma with their impact on recurrence and pregnancy rates.

Methods:

This is a retrospective study of 550 histologically verified ovarian endometriomas operated on at the Department of Obstetrics and Gynecology, University Hospital Kiel, Germany, between 1995 and 2004. Preoperative data, surgical findings, and postoperative outcomes of 289 cases were analyzed. The average follow-up period was 12.9 years.

Results:

Ovarian endometriomas recurred in 23.9% of patients. Risk factors identified for recurrence of endometriomas were preoperative pain (P = .013), dysmenorrhea (P = .013), larger cyst size (>8 cm), younger age (<25 years), and preoperative cyst rupture. Factors associated with postoperative dysmenorrhea were younger age <25 years (P < .001), nulliparity (P = .020), and lager cyst size >8 cm (P = .048). Recurrence of pain was influenced by previous surgery of endometrioma (P < .05). Laparoscopy had a higher percentage of symptom-free patients than laparotomy did (49.0% vs 33.3%). Additional postoperative hormonal treatment resulted in a higher spontaneous pregnancy rate (41.4% vs 12.6%; P < .001) but a lower recurrence-free interval rate (70.5% vs 82.6%; P = .050) when compared with surgery only.

Conclusions:

We identified preoperative and intraoperative findings associated with higher risk of recurrence of endometrioma, pain, and dysmenorrhea. Patients desiring pregnancy benefited from postoperative hormone treatment, but no favorable results from combined therapy were observed with regard to recurrence rate.

Development of pro-apoptotic peptides as potential therapy for peritoneal endometriosis

Endometriosis is a common gynaecological disease associated with pelvic pain and infertility. Current treatments include oral contraceptives combined with nonsteroidal anti-inflammatory drugs or surgery to remove lesions, all of which provide a temporary but not complete cure. Here we identify an endometriosis-targeting peptide that is internalized by cells, designated z13, using phage display. As most endometriosis occurs on organ surfaces facing the peritoneum, we subtracted a phage display library with female mouse peritoneum tissue and selected phage clones by binding to human endometrial epithelial cells. Proteomics analysis revealed the z13 receptor as the cyclic nucleotide-gated channel β3, a sorting pathway protein. We then linked z13 with an apoptosis-inducing peptide and with an endosome-escaping peptide. When these peptides were co-administered into the peritoneum of baboons with endometriosis, cells in lesions selectively underwent apoptosis with no effect on neighbouring organs. Thus, this study presents a strategy that could be useful to treat peritoneal endometriosis in humans.

Impact of surgical excision of lesions on pain in a rat model of endometriosis

BACKGROUND

Chronic pain is the most common and disabling feature of endometriosis. Surgical excision of endometriosis lesions provides relief but pain relapse is common. Studies in a preclinical model of endometriosis might help to unravel the role of the ectopic lesions as the source of pain. Thus, we evaluated the impact of lesion excision on mechanical hyperalgesia in a preclinical model of endometriosis pain.

METHODS

Endometriosis was induced by implanting autologous uterine tissue onto the gastrocnemius muscle. Surgical excision or aspiration drainage of the cystic lesion was performed at different times post-implant and mechanical nociceptive thresholds were assessed at the site of the lesion.

RESULTS

Lesions at 2, 8 and 16 weeks post-implant produced mechanical hyperalgesia of similar magnitude (n = 6/group). Excision of lesions (n = 6/group) produced a longer inhibition, with a magnitude and time course depending upon the timing of excision. Excision at 2 and 8 weeks produced a rapid onset marked attenuation of hyperalgesia, which returned to pre-excision values by post-surgical week 3. In contrast, excision of the lesion at 16 weeks produced a peak of inhibition of hyperalgesia 2 weeks post-excision, but then the inhibition was sustained. Aspiration of fluid from cysts in the lesions briefly attenuated mechanical hyperalgesia (n = 6/group).

CONCLUSIONS

In this preclinical model, we demonstrate that endometriosis pain is alleviated by surgical excision of the ectopic lesion or drainage of its cysts, providing support for the clinical observation that endometriosis pain is dependent upon the ongoing presence of the lesions.

Endometriosis: pathogenesis and treatment

Endometriosis is defined as the presence of endometrial-type mucosa outside the uterine cavity. Of the proposed pathogenic theories (retrograde menstruation, coelomic metaplasia and Müllerian remnants), none explain all the different types of endometriosis. According to the most convincing model, the retrograde menstruation hypothesis, endometrial fragments reaching the pelvis via transtubal retrograde flow, implant onto the peritoneum and abdominal organs, proliferate and cause chronic inflammation with formation of adhesions. The number and amount of menstrual flows together with genetic and environmental factors determines the degree of phenotypic expression of the disease. Endometriosis is estrogen-dependent, manifests during reproductive years and is associated with pain and infertility. Dysmenorrhoea, deep dyspareunia, dyschezia and dysuria are the most frequently reported symptoms. Standard diagnosis is carried out by direct visualization and histologic examination of lesions. Pain can be treated by excising peritoneal implants, deep nodules and ovarian cysts, or inducing lesion suppression by abolishing ovulation and menstruation through hormonal manipulation with progestins, oral contraceptives and gonadotropin-releasing hormone agonists. Medical therapy is symptomatic, not cytoreductive; surgery is associated with high recurrence rates. Although lesion eradication is considered a fertility-enhancing procedure, the benefit on reproductive performance is moderate. Assisted reproductive technologies constitute a valid alternative. Endometriosis is associated with a 50% increase in the risk of epithelial ovarian cancer, but preventive interventions are feasible.

Increased pressure pain sensitivity in women with chronic pelvic pain

OBJECTIVE

To determine whether women with chronic pelvic pain and variable degrees of endometriosis demonstrate altered pain sensitivity relative to pain-free healthy women in a control group and whether such differences are related to the presence or severity of endometriosis or comorbid pain syndromes.

METHODS

Four patient subgroups (endometriosis with chronic pelvic pain [n=42], endometriosis with dysmenorrhea [n=15], pain-free endometriosis [n=35], and chronic pelvic pain without endometriosis [n=22]) were each compared with 30 healthy women in a control group in this cross-sectional study. All patients completed validated questionnaires regarding pain symptoms and underwent screening for comorbid pain disorders. Pain sensitivity was assessed by applying discrete pressure stimuli to the thumbnail using a previously validated protocol.

RESULTS

While adjusting for age and education, pain thresholds were lower in all subgroups of women with pelvic pain relative to healthy women in the control group (all P values <.01). There was no difference in pain thresholds when comparing patients with endometriosis without pelvic pain with healthy women in the control group (mean difference 0.02 kg/m2, 95% confidence interval -0.43 to 0.47). The presence and severity of endometriosis and number of comorbid pain syndromes were not associated with a difference in pain thresholds.

CONCLUSION

Women with chronic pelvic pain demonstrate increased pain sensitivity at a nonpelvic site compared with healthy women in a control group, which is independent of the presence or severity of endometriosis or comorbid pain syndromes. These findings support the notion that central pain amplification may play a role in the development of pelvic pain and may explain why some women with pelvic pain do not respond to therapies aimed at eliminating endometriosis lesions.

LEVEL OF EVIDENCE

II.

Postoperative medical therapy after surgical treatment of endometriosis: from adjuvant therapy to tertiary prevention

The high rate of disease recurrence after surgery is critical and frustrating for women with endometriosis. Adjuvant treatments using a 3- to 6-months course of hormone therapy after surgery have been extensively investigated during the last 2 decades; however, results have been unsatisfactory, primarily because the benefits of hormone therapy rapidly vanish once treatment is discontinued. The protective effect is limited to the period of use. Accordingly, it is recognized that suppressive hormone therapy after surgery markedly prevents recurrent episodes only if given over the long term. The emerging view is that estroprogestins do not ameliorate the effects of surgery but demonstrate tertiary prevention of the disease. They prevent ovulation and reduce retrograde menstrual flow, two crucial events in the pathogenesis of endometriosis. The available literature strongly supports the benefits of prolonged administration of estroprogestins after surgery in preventing recurrence of endometriomas and dysmenorrhea. In contrast, data on dyspareunia and nonmenstrual pelvic pain remain scanty and unconvincing, and there is no information about recurrence of other forms of endometriosis such as peritoneal implants and adhesions. Overall, estroprogestin therapy after surgery to treat endometriosis should be recommended in women who do not seek to become pregnant. Further evidence is warranted to better delineate the beneficial effects of this emerging but convincing strategy.

Surgical Therapy of Endometriosis: Challenges and Controversies

Endometriosis is one of the most common disorders encountered in surgical gynaecology. The laparoscopic technique, the planning of the surgical intervention, the extent of information provided to patients and the interdisciplinary coordination make it a challenging intervention. Complete resection of all visible foci of disease offers the best control of symptoms. However, the possibility of achieving this goal is limited by the difficulty of detecting all foci and the risks associated with radical surgical strategies. Thus, the excision of ovarian endometrioma can result in a significant impairment of ovarian function, while damage to nerve structures during resection of the uterosacral ligaments, the parametrium, the rectovaginal septum or the vaginal cuff to treat deep infiltrating endometriosis can lead to serious functional impairments such as voiding disorders. A detailed risk-benefit analysis is therefore necessary, and patients must be treated using an individual approach.

The influence of endometriosis-related symptoms on work life and work ability: a study of Danish endometriosis patients in employment

OBJECTIVE

Little is known about the implications of endometriosis on women's work life. This study aimed at examining the relation between endometriosis-related symptoms and work ability in employed women with endometriosis.

STUDY DESIGN

In a cohort study, 610 patients with diagnosed endometriosis and 751 reference women completed an electronic survey based on the Endometriosis Health Profile 30-questionnaire and the Work Ability Index (short form). Percentages were reported for all data. Binary and multivariate logistic regression analyses were used to assess risk factors for low work ability. The level of statistical significance was set at p<0.025 in all analyses.

RESULTS

In binary analyses a diagnosis of endometriosis was associated with more sick days, work disturbances due to symptoms, lower work ability and a wide number of other implications on work life in employed women. Moreover, a higher pain level and degree of symptoms were associated with low work ability. Full regression analysis indicated that tiredness, frequent pain, a higher daily pain level, a higher number of sick days and feeling depressed at work were associated with low work ability. A long delay from symptom onset to diagnosis was associated with low work ability.

CONCLUSIONS

These data indicate a severe impact of endometriosis on the work ability of employed women with endometriosis and add to the evidence that this disease represents a significant socio-economic burden.

The adjuvant use of N-palmitoylethanolamine and transpolydatin in the treatment of endometriotic pain

OBJECTIVE

To test the adjuvant use of the combination of N-palmitoylethanolamine and transpolydatin in the medical treatment of endometriotic pain.

STUDY DESIGN

We enrolled 47 patients admitted to the Outpatient Endometriosis Care Unit of Ferrara University from January 2011 to December 2011. They were divided into two groups according to the endometriosis site (group A: recto-vaginal septum; group B: ovary). One tablet, containing 400 mg of micronized N-palmitoylethanolamine plus 40 mg transpolydatin, was administered twice daily on a full stomach for 90 days. Each patient was requested to grade the severity of dysmenorrhea, chronic pelvic pain, dyspareunia and dyschezia using a 0-10 cm visual analogic scale prior to beginning treatment (T0), after 30 days (T1), 60 days (T2) and 90 days (T3). The continuous and categorical variables were compared, respectively, using Student's t-test and the chi-square test. Analysis of variance for repeated measures was used to verify the reduction of endometriotic pain.

RESULTS

The intensity of endometriotic pain decreased significantly for both groups (p<0.0001). The efficacy of drug treatment was significant after 30 days. Pain intensity decreased equally in the two groups except for dysmenorrhea, which was reduced more rapidly in group B.

CONCLUSIONS

The combination of N-palmitoylethanolamine and transpolydatin reduced pain related to endometriosis irrespective of lesion site. It had a marked effect on chronic pelvic pain determined by deep endometriosis and on dysmenorrhea correlated to ovarian endometriosis.

[Recurrence of pain after surgery for deeply infiltrating endometriosis: How does it happen? How to manage?]

Recurrence of deep endometriosis remains a major issue in the management of endometriosis. The main cause for recurrence appears to be an incomplete excisional surgery. Therefore, the goal of the primary surgery should be the complete resection of all endometriotic lesions. If surgical skills cannot meet this objective it seems preferable to refer the patient to a center with a recognized expertise in this field rather than performing an incomplete surgery. It seems also possible to tailor the indications according to the symptoms, especially when endometriosis affects the bladder in association with an asymptomatic vaginal and/or rectal involvement. This strategy does not increase the rate of recurrence. Postoperative medical treatment based on ovarian function suppression is attractive as it diminishes the recurrence rate. Facing the recurrence, appropriate assessment of the benefit risk balance must be performed. Medical treatment is an option. When surgery is chosen, it seems interesting to discuss carefully the indication of hysterectomy with bilateral oophorectomy, especially for women over 40 years old with no desire for pregnancy and/or symptomatic adenomyosis. Risks of induced ovarian castration must be taken into account.