Potential benefits of pregnancy on endometriosis symptoms

The Burden of Pelvic Pain Associated with Endometriosis among Women in Selected European Countries and the United States: A Restricted Systematic Review

OBJECTIVE

To evaluate the burden of endometriosis-associated pelvic pain (EAPP) on health-related quality of life (HRQoL) among women living in similar socio-economic conditions.

DATA SOURCES

Searches were performed in PubMed and Embase on September 26, 2022. The review was performed in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol (PRISMA-P) and was registered on PROSPERO (ID: CRD42023370363).

METHODS OF STUDY SELECTION

Due to the high volume of eligible publications following initial review, inclusion criteria were restricted to studies undertaken in France, Germany, Italy, Spain, the United Kingdom, and the United States. This restriction was applied before screening as these countries have broad social and economic similarities, and previous studies in the literature suggest pain reporting and experience are influenced by numerous socio-cultural factors. Eligible studies were those published between 2013 and 2022 and include a sample size of ≥50 participants. The search strategy identified all relevant publications relating to the burden of illness due to EAPP. A variety of terms are used in the literature to describe pain associated with endometriosis, and this was considered in the design of the search strategy and screening procedure.

TABULATION, INTEGRATION, AND RESULTS

The database searches resulted in a total of 6139 records. After removal of duplicates, 3855 records were assessed further. A total of 27 publications were identified as eligible. Fourteen (52%) were from Italy, 5 (19%) were multinational studies, 4 (15%) were from the United States, 3 (11%) were from Spain, and 1 (4%) was from Germany. Most studies were cross-sectional (n = 15; 56%); 7 (26%) were case-control studies; 3 (11%) were cohort studies; and 2 (7%) were longitudinal studies. These publications collectively highlighted an association between EAPP and reduced HRQoL. Several studies showed that EAPP was associated with lower HRQoL when compared with endometriosis without pain and potentially with chronic pelvic pain caused by other conditions, although the evidence is limited in this case. Moreover, the studies reported detrimental effects on general HRQoL, mental health functioning, and sexual functioning, culminating in reduced work productivity and difficulties in performing everyday activities. The associations were generally similar across study populations, including adolescents, as well as younger and older women. Results were consistent across the range of different patient-reported outcome tools used to assess HRQoL.

CONCLUSION

The existing literature suggests that, among women in selected European countries and the United States, EAPP is associated with reduced HRQoL, including impaired mental and sexual functioning, as well as reduced work performance and productivity; each of which may contribute to the societal burden of endometriosis.

Measurement properties of sexual function assessment questionnaires in women with endometriosis: A systematic review following COSMIN guidelines

INTRODUCTION

Sexual function of patients with endometriosis should be assessed by patient-reported outcome measures (PROMs) that present high reliability and validity. The objective was to study the PROMs used to assess sexual function for patients with endometriosis to improve their selection for research and clinical practice.

MATERIAL AND METHODS

We performed a systematic literature review from January 2000 to September 2023. All studies including women with confirmed endometriosis and assessing sexual quality of life or sexual function or sexual distress were retrieved. Different properties of PROMs used for sexual dysfunction were assessed according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) recommendations. Properties evaluated were: structural validity, internal consistency, cross-cultural validity, reliability, measurement error, criterion validity, construct validity, and responsiveness. This literature review was registered on Prospero as 2018 CRD42018102278.

RESULTS

Seventy-four articles with evaluation of sexual function were included. Of the 25 PROMs assessing sexual function, the Female Sexual Function Index (FSFI) was the most frequently used (34/74 [45.9%] items), followed by the Female Sexual Distress Scale (9/74 [12.2%] items) and the Sexual Activity Questionnaire (SAQ) (8/74 [10.8%] items). The most commonly used measurement properties were "hypothesis testing" and "responsiveness". The PROMs with a high level of evidence for these two measurement properties were the FSFI, the SAQ, the Short Sexual Functioning Scale, the Sexual Satisfaction Scale for Women, Sexual Quality of Life-Female, the Brief Profile of Female Sexual Function, and the Sexual Health Outcomes in Women Questionnaire. The FSFI questionnaire appeared to be more relevant for evaluating medical treatment, and the SAQ for evaluating surgical treatment. Only one instrument was specific to endometriosis (the Subjective Impact of Dyspareunia Inventory [SIDI]).

CONCLUSIONS

In this systematic literature review of sexual function assessment questionnaires in endometriosis, the FSFI and the SAQ questionnaires emerged as having the best measurement properties according to the COSMIN criteria. The FSFI questionnaire appears to be suited for evaluating medical treatment, and the SAQ for surgical treatment. The SIDI is the only specific questionnaire, but its responsiveness remains to be defined.

Dysmenorrhea and psychological distress: a meta-analysis

Dysmenorrhea is characterized by pelvic pain associated with menstruation. Similar to people with other pain conditions, females who experience dysmenorrhea report increased psychological distress. However, the pooled magnitude of this association has not been quantified across studies. Accordingly, this meta-analytic review quantifies the magnitude of the associations between dysmenorrhea severity and psychological distress. We conducted a systematic search of the literature using PsycINFO, PubMed, CINHAL, Embase, and Web of Science. Analyzed studies provided observational data on dysmenorrhea severity and anxiety symptoms, depressive symptoms, and/or global psychological distress. A total of 44 studies were included, and three random-effects meta-analyses were conducted, with average pooled effect sizes calculated using Person's r. We found significant, positive associations between measures of dysmenorrhea severity and measures of depressive symptoms (r = 0.216), anxiety symptoms (r = 0.207), and global psychological distress (r = 0.311). Our review suggests that females with greater dysmenorrhea severity experience greater psychological distress. Future directions include defining a clinically meaningful dysmenorrhea severity threshold, understanding the mechanisms and directionality underlying the dysmenorrhea-psychological distress relationship, and designing and testing interventions to jointly address dysmenorrhea and psychological distress.

Endometriosis and pregnancy: The illusion of recovery

The objective of this study was to investigate the feelings and experiences of infertile women with deep infiltrating endometriosis during and after a first pregnancy achieved by in-vitro fertilization (IVF). We conducted a qualitative monocentric study between May and November 2020. Semi-structured interviews were undertaken with infertile women with deep infiltrating endometriosis who achieved a first pregnancy by IVF and delivered at least two years prior to the interview. Data analysis was performed using an inductive approach to identify recurrent categories and themes. Fifteen interviews were conducted to reach data saturation. Pregnancy appeared to improve all components of the experience of endometriosis that were explored (psychological and physical well-being, social relationships, professional life, and sexuality). This improvement was only temporary and all symptoms and negative aspects of the women’s quality of life reappeared after a variable period.

The Underestimated Prevalence of Neglected Chronic Pelvic Pain in Women, a Nationwide Cross-Sectional Study in France

Dysmenorrhoea, dyspareunia, and non-menstrual chronic pelvic pain (NMCPP) are symptoms that are probably underreported and neglected. This study aimed to assess the prevalence and overlapping relations between these symptoms among a general population of French women of reproductive age. A cross-sectional study among the nationwide CONSTANCES cohort study recruiting a representative sample of women within different French areas was constructed. Women aged 18–49 years (n = 21,287) who reported periods in the previous three months and experienced intercourse at least once were asked about prevalence of three types of chronic pelvic pain: mild, moderate and severe dysmenorrhea; dyspareunia assessed according to its frequency; NMCPP from a binary question. Between the start of 2012 through the end of 2017, 21,287 women were enrolled, 39.8% of them (95% confidence interval (CI), 39.2–40.5) reported moderate to severe dysmenorrhea; 20.3% (95% CI, 18.7–21.9) of the youngest group (18–24 years) reported severe dysmenorrhea. Dyspareunia was reported to happen often or always by 7.9% (95% CI, 7.5–8.2) and peaked among the youngest women at 12.8% (95% CI, 11.5–14.1). NMCPP was reported by 17.0% (95% CI, 16.5–17.5). Moreover, 7.5% (95% CI, 6.4–8.6) of the women reported two or more types of severe or frequent pain. More attention should be paid to this substantial proportion (7.5%) of French women of reproductive age who experience multiple, severe and frequent pelvic pain symptoms.

Safety of in-vitro fertilization in women with endometriosis

Management of women with endometriosis in general is complex. It requires a multidisciplinary and tailored approach. The time of in-vitro fertilization (IVF) may be particularly complicated because women with the disease face peculiar additional risks. In particular, oocytes retrieval may be more difficult and women with endometriomas are exposed to a low but consistent risk of infection and ovarian abscess development. There are also concerns regarding progression of deep invasive peritoneal lesions and misdiagnosis of an occult early ovarian cancer. However, evidence on these latter points is more controversial. Taken together, this body evidence is generally reassuring and does not justify prophylactic surgery prior to IVF to shrink these risks. However, given the uncertainties, women with endometriosis must be informed in depth of these peculiar additional risks.

Endometriosis and spontaneous hemoperitoneum in pregnancy: evaluation of the magnitude of the risk in women becoming pregnant via in vitro fertilization

OBJECTIVE

To estimate the frequency of spontaneous hemoperitoneum in pregnancy (SHiP) in women with endometriosis achieving pregnancy with in vitro fertilization (IVF).

DESIGN

Retrospective case series.

SETTING

Referral academic assisted reproductive technology (ART) center.

PATIENT(S)

Three hundred and forty-eight women with a history of surgery for endometriosis and women with ovarian endometriomas or deep endometriotic nodules detected at basal transvaginal ultrasound performed before IVF cycle.

INTERVENTION(S)

Information obtained from patients' charts on basal characteristics, IVF cycle, and pregnancy outcomes, and binomial distribution model created to determine the 95% confidence interval (CI) of the proportion of SHiP.

MAIN OUTCOME MEASURE(S)

Rate of SHiP.

RESULT(S)

Overall, 362 pregnancies were included, among which 238 (66%) had a history of previous surgery for endometriosis and 231 (64%) had endometriosis detected at ultrasound (107 women, 30%, had both). Pregnancies were achieved after fresh and frozen cycles in 244 (67%) and 118 (33%) women, respectively. One case of SHiP was recorded, corresponding to a rate of 0.3%.

CONCLUSION(S)

In the general population of women with endometriosis undergoing IVF, SHiP is uncommon. Future studies should better identify the risk factors for SHiP to disentangle the subgroups of women at higher risk.

Pregnancy outcomes in women with history of surgery for endometriosis

OBJECTIVE

To assess the relationship between history of surgery for endometriosis and adverse obstetrical outcomes.

DESIGN

Retrospective study using prospectively recorded data.

SETTING

Referral center.

PATIENT(S)

Total of 569 women with history of surgery for endometriosis, postoperative conception, and pregnancy evolution over 22 weeks of gestation.

INTERVENTIONS(S)

Surgery for endometriosis.

MAIN OUTCOME MEASURE(S)

Small for gestational age (SGA) status of the newborn, spontaneous preterm birth (PT, before 37 weeks' gestation), and placenta previa.

RESULTS

Among 733 pregnancies included in the study, 566 deliveries were recorded (77.2%), of which 535 were singleton (72.9% of pregnancies) and 31 twins (4.2%). SGA was observed in 81 of 535 (15.1%) singleton pregnancies and in 9 of 31 (29%) twin pregnancies. PT occurred in 53 of 535 (9.9%) singleton pregnancies and in 19 of 31 (61.2%) twin pregnancies. The number of singleton and multiple pregnancies complicated by placenta previa were, respectively, 9 of 535 (1.7%) and 0 of 31. The independent factor found to relate to SGA was the absence of endometriomas; conception with the use of assisted reproductive technologies (ART) only tended toward statistical significance. Independent factors found to increase risk of PT were conception with the use of ART, body mass index >30 kg/m², and surgery of deep endometriosis infiltrating the rectum and the bladder. Independent factors associated with placenta previa were conception with the use of ART and history of stage III or IV endometriosis.

CONCLUSION(S)

The risk of SGA and PT is increased in women with a history of surgery for endometriosis, and a high rate of conception with the use of ART may jeopardize outcomes.

Rethinking mechanisms, diagnosis and management of endometriosis

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

Magnetic resonance imaging presentation of deep infiltrating endometriosis nodules before and after pregnancy: A case series

OBJECTIVE

To compare the magnetic resonance imaging (MRI) features of deep infiltrating endometriosis (DIE) lesions before and after pregnancy.

DESIGN

Retrospective study.

SETTING

A single French university tertiary referral hospital.

PATIENTS

Twenty-one women without a prior history of surgery for endometriosis with a radiological diagnosis by MRI with two sets of examinations performed before and after pregnancy.

INTERVENTIONS

The volumes of the lesions were compared using the same protocol before and after pregnancy based on MRI (1.5 T) examinations by a single experienced radiologist who is a referring practitioner for image-based diagnosis of endometriosis.

MAIN OUTCOME MEASURE(S)

The DIE lesion volume.

MEASUREMENTS AND MAIN RESULTS

Between October 2012 and December 2016, a total of 21 patients (67 lesions) were included and compared before and after pregnancy. The mean time interval between the MRI before pregnancy and delivery was 19.6 ± 8.5 months (median: 17.6, IQR 13.5-25.2 months). The mean time interval between delivery and the MRI after pregnancy was 11.0 ± 6.4 months (median: 8.3, IQR 6-15.2 months). The mean overall DIE lesion volume by MRI was significantly higher before pregnancy compared to after pregnancy (2,552 ± 3,315 mm3 vs. 1,708 ± 3,266 mm3, respectively, p < 0.01). The mean volume by MRI of the largest lesion of each patient was significantly higher before pregnancy compared to after pregnancy (4,728 ± 4,776 mm3 vs. 3165 ± 5299 mm3; p < 0.01).

CONCLUSION

Our data indicate a favorable impact of pregnancy on DIE lesion volumes as measured by MRI.