Differences in characteristics among 1,000 women with endometriosis based on extent of disease

Feasibility Study on Menstrual Cycles With Fitbit Device (FEMFIT): Prospective Observational Cohort Study

BACKGROUND

Despite its importance to women's reproductive health and its impact on women's daily lives, the menstrual cycle, its regulation, and its impact on health remain poorly understood. As conventional clinical trials rely on infrequent in-person assessments, digital studies with wearable devices enable the collection of longitudinal subjective and objective measures.

OBJECTIVE

The study aims to explore the technical feasibility of collecting combined wearable and digital questionnaire data and its potential for gaining biological insights into the menstrual cycle.

METHODS

This prospective observational cohort study was conducted online over 12 weeks. A total of 42 cisgender women were recruited by their local gynecologist in Berlin, Germany, and given a Fitbit Inspire 2 device and access to a study app with digital questionnaires. Statistical analysis included descriptive statistics on user behavior and retention, as well as a comparative analysis of symptoms from the digital questionnaires with metrics from the sensor devices at different phases of the menstrual cycle.

RESULTS

The average time spent in the study was 63.3 (SD 33.0) days with 9 of the 42 individuals dropping out within 2 weeks of the start of the study. We collected partial data from 114 ovulatory cycles, encompassing 33 participants, and obtained complete data from a total of 50 cycles. Participants reported a total of 2468 symptoms in the daily questionnaires administered during the luteal phase and menses. Despite difficulties with data completeness, the combined questionnaire and sensor data collection was technically feasible and provided interesting biological insights. We observed an increased heart rate in the mid and end luteal phase compared with menses and participants with severe premenstrual syndrome walked substantially fewer steps (average daily steps 10,283, SD 6277) during the luteal phase and menses compared with participants with no or low premenstrual syndrome (mean 11,694, SD 6458).

CONCLUSIONS

We demonstrate the feasibility of using an app-based approach to collect combined wearable device and questionnaire data on menstrual cycles. Dropouts in the early weeks of the study indicated that engagement efforts would need to be improved for larger studies. Despite the challenges of collecting wearable data on consecutive days, the data collected provided valuable biological insights, suggesting that the use of questionnaires in conjunction with wearable data may provide a more complete understanding of the menstrual cycle and its impact on daily life. The biological findings should motivate further research into understanding the relationship between the menstrual cycle and objective physiological measurements from sensor devices.

Is endometriosis due to evolutionary maladaptation?

Similar to diabetes and unlike many pathogen-induced diseases, endometriosis is likely a result of maladaptation to the evolutionary heritage of humans. The objective of this article is to review the literature and improve understanding of the evolutionary factors behind endometriosis, leading to more effective prevention and treatment approaches. In primates, spontaneous decidualization of the endometrium evolved to ensure optimal implantation of a limited number of early embryos, unlike many non-primates which depend on early embryos to induce decidualization and subsequent pregnancy. Spontaneous decidualization results in menstrual bleeding when embryo implantation does not occur, and endometriosis is commonly believed to be caused by retrograde menstruation. Although direct evidence is lacking, it is likely that hunter-gatherer women experienced fewer menstrual periods due to pregnancy shortly after menarche, followed by repeated pregnancies and lactation. However, the mismatch between the evolved uterine physiology and rapid societal changes has led to modern women delaying pregnancy and experiencing numerous menstrual periods, potentially increasing the incidence of endometriosis. The symptoms of endometriosis are often managed by suppressing menstruation through systemic hormonal treatments, but these may have side effects. For patients with a family history of endometriosis or in the early stages of the disease, intrauterine devices releasing progesterone locally could prevent uterine bleeding and the development of endometriosis while preserving fertility and minimizing side effects.

Patient-Reported Outcome Measures Used in Randomized Controlled Trials Following Surgical Intervention for Endometriosis: A Structured Review from the AAGL Practice Guidelines Group

OBJECTIVE

No consensus currently exists regarding patient-reported outcome measure (PROM) instruments. This structured review was conducted to identify the PROMs used by randomized controlled trials (RCTs) that evaluated surgical treatment in patients with endometriosis.

DATA SOURCES

Two parallel searches were conducted by a medical librarian using Ovid MEDLINE, Ovid Embase, and Cochrane Library for RCTs published from 2000 to July 2022. One search focused on studies reporting quality of life (QoL), and the second search focused on studies reporting pain and sexual, bowel, and bladder function.

METHOD OF STUDY SELECTION

During the title and abstract screening and reference check, 600 results were identified on PROMs relating to QoL and 465 studies on PROMs relating to pain and sexual, bowel, and/or bladder function and an evaluation of 17 and 12 studies conducted, respectively. The inclusion criteria involved selecting RCTs that focused on surgical intervention and assessing QoL, pain, and sexual, bowel, and/or bladder function using PROMs.

TABULATION, INTEGRATION, AND RESULTS

Covidence software was used to organize and identify duplicate articles through screening. We developed a data extraction form to collect key information about each included study, as well as the pertinent PROMs used in the study. Assessment of the risk of bias of each study was also performed. A total of 19 studies were identified involving 2089 participants and a total of 16 PROMs used across the studies; 9 of 19 studies (47%) were rated as having a low risk of bias. There were no high-risk studies identified in this review.

CONCLUSION

This study identified a large number of RCTs in surgical treatment of endometriosis that used various PROMs to assess QoL, pain, and bladder, bowel, and sexual function. The PROMs used by high-quality RCTs for QoL include Endometriosis Health Profile-30, Endometriosis Health Profile-5, Short-Form 36, Short-Form 12, and EQ-5D; for bowel-related symptoms Knowles-Eccersley-Scott-Symptom Questionnaire, Gastrointestinal Quality of Life Index, and Cleveland Clinic Fecal Incontinence Severity Scoring System/Wexner; for bladder-related function Bristol Female Lower Urinary Tract Symptoms, International Prostate Symptom Score, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, and Urinary Symptom Profile; and finally for sexual function Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire and Sexual Activity Questionnaire. Unlike other domains, only one tool (visual analog scale) was the dominant PROM used for the assessment of pain. In addition, the use of more than one PROM in each study to assess different aspects of patient's health and pain symptoms did not become prevalent until after 2015.

The quality, suitability, and readability of web-based resources on endometriosis-associated dyspareunia: A systematic review

People commonly and increasingly rely on the internet to search for health information, including those related to endometriosis-associated dyspareunia. Yet the content of such websites may be of variable accuracy and quality. This review aims to evaluate the quality, readability, and suitability of web-based resources on endometriosis-associated dyspareunia for patients. We searched 3 databases - Google, Bing, and Yahoo - to identify websites related to endometriosis-associated dyspareunia. Two independent reviewers screened the search results against inclusion and exclusion criteria. Another set of two reviewers evaluated the selected websites using validated measurement instruments. Out of 450 websites, 21 met the inclusion criteria and were evaluated. More than half of the websites had information on content updates, reported on authorship, or disclosed sponsorship information. The mean quality and suitability scores were 47.5 (SD = 13.3) and 65.2 (SD = 13.6) respectively, thus suggesting generally adequate quality and suitability levels. However, the mean readability scores exceeded the recommended level for health-related websites. The poor readability of the websites might limit accessibility for a significant proportion of patients with low educational levels. The findings of this review have implications for designing high-quality, readable and up-to-date web interventions for people who rely on web platforms as an alternative or complementary source of health information on dyspareunia.

Gut Microbiota and Endometriosis: Exploring the Relationship and Therapeutic Implications

Endometriosis is a common inflammatory disease affecting women of reproductive age, characterized by the growth of endometrial tissue beyond the uterus. In addition to gynecological manifestations, many endometriosis patients experience gastrointestinal symptoms, indicating a potential association between gut health and the disease. Recent studies have revealed alterations in the gut microbiota of individuals with endometriosis, including reduced diversity, microbial composition imbalances, and pathogenic bacteria. These changes can disrupt immune function, increase inflammation, and contribute to the chronic inflammatory state observed in endometriosis. Moreover, dysregulation of intestinal permeability may further exacerbate gastrointestinal symptoms in affected individuals. Understanding the role of the gut microbiota and intestinal permeability in endometriosis can provide valuable insights into disease pathogenesis, aid in non-invasive diagnostic approaches, and open new avenues for therapeutic interventions. Probiotics, in particular, have shown promise in improving endometriosis-associated pain symptoms and reducing endometriotic lesions in animal models. This review suggests that additional research and well-designed clinical trials are necessary to validate the potential diagnostic and therapeutic benefits of manipulating the gut microbiota in managing endometriosis and its gastrointestinal symptoms, thereby improving the quality of life for those affected.

Transgender and non-binary people's perception of their healthcare in relation to endometriosis

Background

Endometriosis is described as a gynecological disease that can severely impact on people's quality of life. Much of endometriosis research and literature is focused on cis women, although gender diverse people and cis men have been diagnosed with this disease. Cis women have reported problems in their healthcare for endometriosis due to delays in diagnosis and a lack of support in their treatment. Gender diverse people have reported to experience discrimination in healthcare settings. There is a lack of research on gender diverse people's experience of living with endometriosis and little is known about their experience of healthcare for endometriosis.

Aim

Our aim in this article is to report on the healthcare experiences of transgender and non-binary people with endometriosis.

Methods

We used a phenomenological lens to explore the experiences of transgender and non-binary people with endometriosis' perceptions of healthcare. Eleven participants were recruited through social media internationally. We recruited participants that identified as transgender and/or non-binary, had suspected/diagnosed endometriosis and were 18 years old or older. Participants took part in three online semi-structured interviews and completed a diary for three months. We used Hermeneutic Analysis to analyze the data via themes. Phenomenology of embodiment was used as a theoretical point of departure in understanding the data.

Results

From the analysis, the following themes were created that captured participants' healthcare experiences: (1) Medical Gaslighting of Endometriosis and Gender Diverse Experiences, (2) Misgendering and Gendered Language, (3) Medical Discrimination, and (4) Validating Experiences with Health Care Providers (HCPs) and Recommendations by Participants. The findings revealed that medical gaslighting, misgendering and experiences of discrimination in healthcare settings had a psychological effect on participants, with reports of dysphoria, self-doubt, fear and a trauma response.

Discussion

Experiences of medical gaslighting, misgendering and discrimination in the healthcare of endometriosis may limit communication between HCPs and patients through limited treatment options being communicated, assumptions in healthcare and participants not feeling safe to disclose their gender identity for a disease that already from cis women's reports has difficulties in diagnosis and treatment. This highlights additional barriers for gender diverse people to overcome in their healthcare for endometriosis. We recommend that HCPs may benefit from further awareness and training with working with gender diverse people with endometriosis.

Large bowel perforation secondary to endometriosis

Endometriosis is described as the implantation of ectopic, viable endometrium. Among the complications associated with this phenomenon, ectopic foci that localizes to the bowel can result in many presentations. An uncommon presentation of such an occurrence is a mass effect on the colon causing an obstruction. This case report describes the progression of endometriosiscausing mass effect in the colon and resulting in perforated hollow viscous. Hence, this demonstrates the importance of maintaining endometriosis as a differential diagnosis in women of childbearing age presenting with bowel obstruction. Although the presence of endometriosis as a cause of bowel obstruction has been reported in the literature, the presentation of large bowel perforation is rare. In this case, an extremely rare presentation of sigmoid obstruction with transverse colonic perforation is observed.

Predictive Model for the Non-Invasive Diagnosis of Endometriosis Based on Clinical Parameters

OBJECTIVES

Are other pain symptoms in addition to dysmenorrhea, dyspareunia, dyschezia, dysuria, and chronic pelvic pain correlated to endometriosis and suitable for a clinical prediction model?

METHODS

We conducted a prospective study from 2016 to 2022, including a total of 269 women with numerous pain symptoms and other parameters. All women filled out two questionnaires and were examined by palpation and transvaginal ultrasound (TVUS). In cases of suspected deep endometriosis, magnetic resonance imaging (MRI) was performed. After the operation, endometriosis was diagnosed by histological examination.

RESULTS

All in all, 30 significant parameters and 6 significant numeric rating scale (NRS) scores associated with endometriosis could be identified: 7 pain adjectives, 8 endometriosis-associated pain symptoms, 5 pain localizations, 6 parameters from the PainDETECT, consumption of analgesics, and allergies. Furthermore, longer pain duration (before, during, and after menstruation) was observed in women with endometriosis compared to women without endometriosis (34.0% vs. 12.3%, respectively). Although no specific pain for endometriosis could be identified for all women, a subgroup with endometriosis reported radiating pain to the thighs/legs in contrast to a lower number of women without endometriosis (33.9% vs. 15.2%, respectively). Furthermore, a subgroup of women with endometriosis suffered from dysuria compared to patients without endometriosis (32.2% vs. 4.3%, respectively). Remarkably, the numbers of significant parameters were significantly higher in women with endometriosis compared to women without endometriosis (14.10 ± 4.2 vs. 7.75 ± 5.8, respectively). A decision tree was developed, resulting in 0.904 sensitivity, 0.750 specificity, 0.874 positive predictive values (PPV), 0.802 negative predictive values (NPV), 28.235 odds ratio (OR), and 4.423 relative risks (RR). The PPV of 0.874 is comparable to the positive prediction of endometriosis by the clinicians of 0.86 (177/205).

CONCLUSIONS

The presented predictive model will enable a non-invasive diagnosis of endometriosis and can also be used by both patients and clinicians for surveillance of the disease before and after surgery. In cases of positivety, as evaluated by the questionnaire, patients can then seek advice again. Similarly, patients without an operation but with medical therapy can be monitored with the questionnaire.

Gastroenterologist Primer: Endometriosis for Gastroenterologists

BACKGROUND AND AIM

A comprehensive understanding of endometriosis and its common gastrointestinal presentations are critical for gastroenterologists to ensure appropriate and timely screening and diagnosis. Endometriosis is a common inflammatory disease that frequently presents with gastrointestinal symptoms overlapping with irritable bowel syndrome (IBS) and other gastrointestinal disorders. Many endometriosis patients first present to a gastroenterologist or generalist, which may prolong the time to diagnosis and appropriate care.

METHOD AND RESULTS

This review describes the current literature on endometriosis presentation, overlap with gastrointestinal conditions, and standard diagnostic and treatment options for gastroenterologists to consider. For appropriate and swift treatment, gastroenterologists must consider an endometriosis diagnosis in females of menstruating age presenting with pain, bloating, altered stools, and non-gastrointestinal symptoms and refer patients for further evaluation.

Outcomes after Laparoscopic Excision of Bladder Endometriosis Using a CO2 Laser: A Review of 207 Cases in a Single Center

STUDY OBJECTIVE

Assess efficacy, safety, fertility outcomes and recurrence after laparoscopic resection of bladder endometriosis (BE) using a CO₂ laser.

DESIGN

Retrospective cohort study.

SETTINGS

University gynecologic surgery unit, referral center for endometriosis.

PATIENTS

A total of 207 women having undergone laparoscopic BE excision between January 1998 and January 2019.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Intra- and postoperative complication rates. Disease recurrence and fertility outcomes in patients with a minimum 1-year follow-up (n = 176) for "isolated" and "non-isolated" BE groups.

RESULTS

Forty-three patients presented with isolated BE. Bladder "shaving" without mucosae opening was performed in 50.7% cases. No intraoperative complications were noted. One postoperative grade 3 complication was related to BE excision: a bladder breach requiring closure by repeat laparoscopy. Mean (± SD) follow-up was 7.05 (± 4.65) years. In patients wishing to conceive (n = 132), the total pregnancy rate (PR) was 75% (48.5% spontaneous), 76.19% in the isolated BE group (56.3% spontaneous). Among the 94 patients with previous infertility, 74.5% conceived, 50% spontaneously. No statistical difference was found in PR and need for in vitro fertilization between isolated and nonisolated BE groups. BE recurrence rate was 3.4%. No difference was observed between groups with full-thickness bladder resection (4/88) and shaving (2/88) (p = .406). Age at surgery (hazard ratio 0.91 [0.84-0.98], p = .016) and postoperative pregnancy (hazard ratio 0.07 [0.01-0.91], p = .042) showed influence on disease recurrence.

CONCLUSIONS

The study demonstrates that laparoscopic BE removal is feasible with very low complications rates and was associated with high PR (both spontaneous and in vitro fertilization), even in patients with previous infertility. BE recurrence is lower than for other endometriosis locations. Bladder endometriosis; Laparoscopy; Deep infiltrating endometriosis; Fertility; Partial bladder resection.

Dienogest May Reduce Estradiol- and Inflammatory Cytokine-Induced Cell Viability and Proliferation and Inhibit the Pathogenesis of Endometriosis: A Cell Culture- and Mouse Model-Based Study

Dienogest (DNG) is a therapeutic medication used in endometriosis treatment. Limited data are available regarding its mechanism of action on endometrial cells. Using in vivo and in vitro models, we investigated whether DNG treatment causes significant biological changes in human endometrial stromal cells (ESCs). The markers related to the pathogenesis of endometriosis in ESCs were evaluated using estradiol, tumor necrosis factor alpha (TNF-α), interleukin 1β (IL-1β), and IL-32, administered alone or in combination with DNG. Implanted endometrial tissues were compared between C57BL/6 mice that did or did not receive DNG treatment by using size measurements and immunohistochemistry. A significant decrease in cell viability, protein kinase B (AKT) phosphorylation, and the expression of p21-activated kinase 4 and vascular endothelial growth factor were observed in ESCs treated with estradiol plus DNG. Cell viability, AKT phosphorylation, and proliferating cell nuclear antigen (PCNA) expression also decreased significantly after TNF-α plus DNG treatment. Treatment with IL-1β or IL-32 plus DNG significantly decreased cell viability or PCNA expression, respectively. The size of the implanted endometrial tissue significantly decreased in mice treated with DNG, accompanied by decreased PCNA expression. Thus, DNG may reduce cell viability and proliferation induced by estradiol, TNF-α, IL-1β, and IL-32, and inhibit the endometriosis pathogenesis by decreasing PCNA expression.

Histotyping and grading of endometriosis and its association with clinico-pathological parameters

Current clinical staging/grading schemes of endometriosis show poor correlation with clinical symptoms and histopathological confirmation is only in half of the clinically suspected endometriosis. In this study, done over an 8-year period, several histological features were analysed including an attempt to grade the severity of endometriosis histologically based on the number of foci per low power field. The components in each focus, the phasing of the glands and stroma, the type of glands (endometrial type or undifferentiated type), and stromal features were all analysed. This study attempts to histologically grade endometriosis while relating it to the clinical manifestations and anatomical location. Eighty cases of endometriosis were included. Most common clinical presentation was cyclical pain (n = 62) and the most common anatomical location was adnexa (n = 50). Histologically, severe endometriosis (>3 foci) was seen in 37 cases. The components were mixed in 68 cases. Well-differentiated glandular pattern was typical (n = 54), while 6 cases had undifferentiated. Proliferative phase was seen in 38 cases. Fibrosis and inflammation were present in 29 and 42 cases, respectively. Significant vascular proliferation and plasma cell infiltrate was noted (n = 35). The severe grade was significantly associated with fibrosis (p = 0.03) and inflammation (p = 0.014). Endometriotic foci, unlike eutopic endometrium, shows significant plasma cell infiltrate and vascular proliferation.IMPACT STATEMENTWhat is already known on this subject? Endometriosis, a chronic inflammatory condition in reproductive age group women. The currently used clinical staging and grading systems show poor correlation with patient symptoms and treatment outcomes. Endometriosis with classical histopathological features pose no diagnostic difficulty, however, there is poor concordance with histopathology. Atypical endometriosis is proposed as potential precursor for endometriosis related neoplasms, however, it remains as a controversial entity.What do the results of this study add? The study identifies the uncommon histological patterns which may be encountered in biopsy samples from clinically identified endometriotic lesions. The recognition of these patterns will reduce clinico-pathological discrepancies. In keeping with the other grading systems, attempts at histological grading did not show any correlation with location or patient symptoms. Atypical features were seen only in two cases and was likely to be reactive in nature.What are the implications of these findings for clinical practice and/or further research? Undifferentiated glandular pattern is often a under-recognized histological pattern. Histological grading of severity was a novel attempt to correlate with clinical parameters. Significant plasma cell infiltrate and vascular proliferation in endometriotic foci, underscores the quest for novel therapeutic targets. This study suggests that the use of non-invasive diagnostic methods like fibroscan/inflammatory markers to clinically identify severe disease should be investigated further.

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.

Deep Endometriosis: the Involvement of Multiple Pelvic Compartments Is Associated with More Severe Pain Symptoms and Infertility

Endometriosis can be classified into three phenotypes: superficial, ovarian, and deep. Deep endometriosis (DE) has been associated with more severe pain symptoms, although no large-scale studies have evaluated the association between pain intensity and infertility and the different compartments of the pelvis affected by superficial and DE. This retrospective study included 1116 women who underwent laparoscopy for endometriosis treatment at two referral centers between 2009 and 2019. For the evaluation of each symptom, patients were divided according to their visual analog scale score (< 7 and ≥ 7) and fertility status. On multiple logistic regression, severe dysmenorrhea and dyschezia were correlated with DE of the posterior compartment alone (odds ratio (OR) = 1.6, confidence interval (CI) 1.09-2.34, and p = 0.02 and OR = 2.09, CI 1.36-3.23, and p < 0.01, respectively) and in combination with other compartments. DE of the posterior and lateral compartments had the most consistent statistical power (OR = 3.55 for dysmenorrhea and OR = 4.4 for dyschezia). Infertility was associated with DE of the posterior compartment alone (OR = 1.6, CI 1.06-2.54, p = 0.04) and in combination with the anterior compartment (OR = 2.62, CI 1.29-5.29, p < 0.01), with the combination of posterior and anterior compartment having the highest OR value. Severe dyschezia and infertility were also correlated with the presence of multiple localizations of DE (p = 0.04 and p < 0.01). This study confirms the association between DE and severe pain symptoms as well as the influence of the number of DE compartments on the severity of symptoms and the chance of infertility.

Clinical characteristics and surgical management of endometriosis-associated infertility: A multicenter prospective cohort study

OBJECTIVE

To study clinical, surgical characteristics and the relationship between endometriosis lesion types and conception rate after surgery in infertile women with endometriosis.

METHODS

A prospective, multicenter cohort of 204 women (age 20-35 years) with endometriosis was followed up post-surgery between November 2017 and February 2020 at three tertiary-care hospitals.

RESULTS

Based on the severity of endometriosis lesion type, deep infiltrating endometriosis (DIE) (81/204, 39.7%) was the most common lesion; followed by ovarian endometriosis (OMA) (64/204, 31.4%), and superficial peritoneal endometriosis (SUP) (59/204, 28.9%). Endometriosis patients had a single lesion type (94/204, 46.1%), two lesion types (77/204, 37.7%), or three lesion types (33/204, 16.2%) with significant differences between regions (P < 0.001). Around 40% (37/95) of obese women had SUP (P = 0.003) whereas 78% (14/18) of underweight women had DIE (P < 0.001). Significant differences in mean Endometriosis Fertility Index scores between endometriosis lesion types and patients with one, two, and three types of lesions were observed (P < 0.001). The majority (22/32, 68.8%) of the women conceived naturally after the surgery. Half (16/32; 50%) of the women with a single lesion type conceived after the surgery; of which most (13/16, 81.2%) had SUP, followed by OMA (2/16, 12.5%), and DIE (1/16, 6.3%).

CONCLUSION

Women with SUP and only one type of endometriotic lesion were more likely to conceive post-surgery.

Primary umbilical endometriosis presenting with umbilical bleeding: A case report

Endometriosis is a condition in which endometrial tissue implants outside the uterine cavity, which can cause cyclic pain, dysmenorrhea, dyspareunia, and infertility. Endometriosis implants are typically seen on pelvic peritoneal surfaces and extra-pelvic disease is uncommon. We present an interesting case of primary umbilical endometriosis in a patient who presented with umbilical bleeding with a history of pelvic inflammatory disease complicated by bilateral tubo-ovarian abscesses. She was found to have an umbilical mass, which was resected, and the pathology was consistent with endometriosis. The objective of this case report is to detail the case and discuss diagnosis and management of umbilical endometriosis. It is important to recognize that umbilical endometriosis can occur in patients with no surgical history.

•

Primary umbilical endometriosis occurs spontaneously.

•

Diagnosis of umbilical endometriosis is clinical, but pathology confirms it.

•

Signs of umbilical endometriosis include cyclic umbilical bleeding/pain and swelling.

•

Surgical management is the primary treatment of choice.

Bowel function and quality of life following surgery for deep endometriosis

OBJECTIVE

To assess the influence of surgical approach, complications and patient characteristics and their postoperative functional outcomes on (sexual) quality of life (QoL) in patients with deep endometriosis (DE) with bowel involvement.

METHODS

Retrospective cohort study on patients surgically treated for DE in a Dutch tertiary referral hospital. Data are based on surgical records and questionnaires covering current postoperative bowel function and (sexual) QoL.

RESULTS

Postoperative functional score outcomes: constipation, fecal incontinence and Low Anterior Resection Syndrome (LARS) did not differ between patients treated with rectal shaving or segmental resection. Thirty percent of women treated with rectal shaving experienced LARS-like symptoms as well. Women who underwent segmental resection had a worse sexual QoL compared to patients managed by shaving. Patients who suffered from complications had a worse postoperative QoL. A higher postoperative constipation score was correlated with a significantly higher pain score and a lower overall and sexual QoL. LARS-score was correlated with a worsened sexual QoL.

CONCLUSION

Women who underwent surgery for deep endometriosis rated their overall QoL as lower when a complication occurred. Segmental resection resulted in a lower sexual QoL compared to shaving. We showed that a higher LARS-score correlates with a lower sexual QOL, and postoperative constipation with more pain and a lower overall and sexual QoL. Interestingly, after using the shaving technique one-third of the patients experienced LARS-like symptoms as well.

Does Dysmenorrhea Affect Clinical Features and Long-Term Surgical Outcomes of Patients With Ovarian Endometriosis? A 12-Year Retrospective Observational Cohort Study

Background

To examine and compare the differences in clinical characteristics and long-term postoperative outcomes of ovarian endometriomas (OMA) patients with and without dysmenorrhea, including data from at least 8 years of postoperative follow-up examinations.

Methods

Retrospective analysis of 334 OMA patients, including their demographic and clinical data. Long-term follow-up record was also collected. All laparoscopic cystectomy procedures were performed by the same surgeon at Peking Union Medical College Hospital between January 2009 and April 2013. Patients were divided into the dysmenorrhea and non-dysmenorrhea groups to perform the analysis of their preoperative characteristics, relevant surgical findings, and postoperative outcomes at the follow-up.

Results

Out of 334 OMA patients, 257 (76.9%) patients were allocated to the dysmenorrhea group, while the rest 77 (23.1%) patients were included in the non-dysmenorrhea group. Compared with the dysmenorrhea group, the non-dysmenorrhea group exhibited a reduced proportion of chronic pelvic pain (CPP) (P = 0.003), dyspareunia (P < 0.001), tenesmus (P < 0.001), concurrency of deep infiltrating endometriosis (DIE) (P < 0.001), and adenomyosis (P = 0.032). Preoperative infertility was significantly higher in the dysmenorrhea group (P = 0.001). The mean operating time in the dysmenorrhea vs. the non-dysmenorrhea group was 68.0 vs. 56.0 min (P < 0.001). According to the revised American Fertility Society (rAFS) scoring system, the mean scores of the two groups were 52.1 vs. 44.6 (P = 0.033). During follow-up, the dysmenorrhea group showed a higher rate of disease relapse (P < 0.001). A minimum postoperative follow-up period of 8 years was required to evaluate the pregnancy outcomes. Successful pregnancies were identified in 97/257 (37.7%) cases in the dysmenorrhea group and 36/77(46.8%) cases in the non-dysmenorrhea group (P = 0.157), respectively. Though the dysmenorrhea group had a higher rate of postoperative infertility, differences were not significant between the two groups.

Conclusions

Compared with the dysmenorrhea group, OMA patients without dysmenorrhea exhibited lower proportions of CPP, dyspareunia, tenesmus, lower concurrency of DIE and adenomyosis, shorter mean operating time, lower mean rAFS scores, and lower infertility rates. During the long-term follow-up, a lower recurrence rate was observed in the non-dysmenorrhea group. Regarding fertility outcomes, non-dysmenorrhea patients had a higher likelihood of successful pregnancy after surgery. Postoperative management needs to be evaluated separately according to dysmenorrhea pathology.

Safety, Pharmacodynamics, and Pharmacokinetics of P2X3 Receptor Antagonist Eliapixant (BAY 1817080) in Healthy Subjects: Double-Blind Randomized Study

Background and Objective

There is no licensed treatment for refractory chronic cough; off-label therapies have limited efficacy and can produce adverse effects. Excessive adenosine triphosphate signaling via P2X3 receptors is implicated in refractory chronic cough, and selective P2X3 receptor antagonists such as eliapixant (BAY 1817080) are under investigation. The objective of the study was to investigate the safety and tolerability of ascending repeated oral doses of eliapixant in healthy volunteers.

Methods

We conducted a repeated-dose, double-blind, randomized, placebo-controlled study in 47 healthy male individuals. Subjects received repeated twice-daily ascending oral doses of eliapixant (10, 50, 200, and 750 mg) or placebo for 2 weeks. The primary outcome was frequency and severity of adverse events. Other outcomes included pharmacokinetics and evaluation of taste disturbances, which have occurred with the less selective P2X3 receptor antagonist gefapixant.

Results

Peak plasma concentrations of eliapixant were reached 3–4 h after administration of the first and subsequent doses. With multiple dosing, steady-state plasma concentrations were reached after ~ 6 days, and plasma concentrations predicted to achieve ≥ 80% P2X3 receptor occupancy (the level required for efficacy) were reached at 200 and 750 mg. Increases in plasma concentrations with increasing doses were less than dose proportional. After multiple dosing, mean plasma concentrations of eliapixant showed low peak–trough fluctuations and were similar for 200- and 750-mg doses. Eliapixant was well tolerated with a low incidence of taste-related adverse events.

Conclusions

Eliapixant (200 and 750 mg) produced plasma concentrations that cover the predicted therapeutic threshold over 24 h, with good safety and tolerability. These results enabled eliapixant to progress to clinical trials in patients with refractory chronic cough.

Clinical Trial Registration

Clinicaltrials.gov: NCT03310645 (initial registration: 16 October, 2017).

Supplementary Information

The online version contains supplementary material available at 10.1007/s40262-022-01126-1.

There are few effective treatments for patients with a long-term (chronic) cough. It is thought that chronic cough is caused by nerves becoming oversensitive, wrongly causing a cough when there is no need. We tested a new drug called eliapixant in 47 healthy men. Eliapixant reduces the excessive nerve signaling responsible for chronic cough. We looked for side effects of eliapixant and measured how it behaves in the body. In particular we looked for side effects relating to the sense of taste because gefapixant, a similar drug to eliapixant, can affect taste. Participants took one of four eliapixant doses or a placebo twice daily for 2 weeks. The highest levels of eliapixant in the blood were seen 3–4 h after taking the drug, and stable concentrations were seen after about 6 days. At the two highest doses, eliapixant reached concentrations in the body that should be high enough to work in patients with chronic cough. Side effects were generally similar between eliapixant and placebo. Taste-related side effects were mild and went away without needing treatment. The positive results of this study meant that eliapixant could be tested in patients with chronic cough.

Systematic review of patient-specific pre-operative predictors of pain improvement to endometriosis surgery

Background

Up to 28% of endometriosis patients do not get pain relief from therapeutic laparoscopy but this subgroup is not defined.

Objectives

To identify any prognostic patient-specific factors (such as but not limited to patients’ type or location of endometriosis, sociodemographics and lifestyle) associated with a clinically meaningful reduction in post-surgical pain response to operative laparoscopic surgery for endometriosis.

Search strategy

PubMed, Cochrane and Embase databases were searched from inception to 19 May 2020 without language restrictions. Backward and forward citation tracking was used.

Selection criteria, data collection and analysis:

Cohort studies reporting prognostic factors, along with scores for domains of pain associated with endometriosis before and after surgery, were included. Studies that compared surgeries, or laboratory tests, or outcomes without stratification were excluded. Results were synthesised but variation in study designs and inconsistency of outcome reporting precluded us from doing a meta-analysis.

Main results

Five studies were included. Quality assessment using the Newcastle–Ottawa scale graded three studies as high, one as moderate and one as having a low risk of bias. Four of five included studies separately reported that a relationship exists between more severe endometriosis and stronger pain relief from laparoscopic surgery.

Conclusion

Currently, there are few studies of appropriate quality to answer the research question. We recommend future studies report core outcome sets to enable meta-analysis.

Lay summary

Endometriosis is a painful condition caused by displaced cells from the lining of the womb, causing inflammation and scarring inside the body. It affects 6–10% of women and there is no permanent cure. Medical and laparoscopic surgical treatments are available, but about 28% of patients do not get the hoped-for pain relief after surgery. Currently, there is no way of predicting who gets better and who does not. We systematically searched the world literature to establish who may get better, in order to improve counselling when women choose treatment options. We identified five studies of variable quality showing: More complex disease (in specialist hands) responds better to surgery than less, but more studies needed.

Quality of Life in Japanese Patients with Dysmenorrhea or Endometriosis-Associated Pelvic Pain Treated with Extended Regimen Ethinylestradiol/Drospirenone in a Real-World Setting: A Prospective Observational Study

INTRODUCTION

Dysmenorrhea and endometriosis are common gynecologic disorders among women of reproductive age that significantly impact health-related quality of life (HRQL) as well as productivity. Although there are treatment options listed in Japanese guidelines, a gap remains in unmet medical needs for maximizing treatment outcome. The extended regimen of ethinylestradiol and drospirenone (EE/DRSP) (taken daily for up to 120 consecutive days) has been available in Japan for treating dysmenorrhea and/or endometriosis-associated pain since 2016. Yet, the effectiveness of its usage on HRQL has not been investigated elsewhere to date. Therefore, in this study, we aim to observe changes in HRQL of Japanese women treated with an extended regimen of EE/DRSP for dysmenorrhea and/or endometriosis-associated pain.

METHODS

As part of a 2-year post-marketing surveillance study, women with dysmenorrhea or endometriosis-associated pelvic pain were prescribed extended EE/DRSP during routine clinical practice. Data were collected 1 month before and 3 and 6 months after initiating treatment. Primary outcomes were the Menstrual Distress Questionnaire (MDQ) (before, during, and after menstruation) in patients with dysmenorrhea, and the Endometriosis Impact Scale (EIS) and European Quality of Life 5-dimensions 5-level instrument (EQ-5D-5L) in patients with endometriosis.

RESULTS

The study cohort included 315 patients (mean age 28.9 years) with dysmenorrhea and 262 patients (mean age 31.3 years) with endometriosis. Mean MDQ total scores before and during menstruation decreased significantly after 6 months with extended EE/DRSP; there was no improvement in after-menstruation MDQ score. Mean EIS domain scores improved significantly by 6 months, with improvement in most EIS individual item scores. Mean EQ-5D-5L scores increased slightly during 6 months of treatment.

CONCLUSIONS

Extended EE/DRSP treatment improved HRQL outcomes in Japanese women with dysmenorrhea or endometriosis-associated pelvic pain.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov (NCT03126747) on June 2017.

Diagnostic Benefit of the Detection of Mitotic Figures in Endometriotic Lesions

Objectives Endometriosis is a chronic disease which is diagnosed by surgical intervention combined with a histological work-up. Current international and national recommendations do not require the histological determination of the proliferation rate. The diagnostic and clinical importance of the mitotic rate in endometriotic lesions still remains to be elucidated. Methods In this retrospective study, the mitotic rates and clinical data of 542 patients with histologically diagnosed endometriosis were analyzed. The mean patient age was 33.5 ± 8.0 (17 - 72) years, and the mean reproductive lifespan was 21.2 ± 7.8 (4 - 41) years. Patients were divided into two groups and patients' reproductive history and clinical endometriosis characteristics were compared between groups. The study group consisted of women with confirmed mitotic figures (n = 140, 25.83%) and the control group comprised women without proliferative activity according to their mitotic rates (n = 402, 74.27%). Results Women with endometriotic lesions and histologically confirmed mitotic figures were significantly more likely to have a higher endometriosis stage (p = 0.001), deep infiltrating endometriosis (p < 0.001), ovarian endometrioma (p = 0.012), and infertility (p = 0.049). A mitotic rate > 0 was seen significantly less often in cases with incidental findings of endometriosis (p = 0.031). The presence of symptoms and basic characteristics such as age, age at onset of menarche, reproductive lifespan and parity did not differ between the group with and the group without mitotic figures. Conclusion This study shows that a simple histological assessment of the mitotic rate offers additional diagnostic value for the detection of advanced stages of endometriosis. The possible role as a predictive marker for the recurrence of endometriosis or the development of endometriosis-associated cancer will require future study.

A potential role of Sirtuin3 and its target enzyme activities in patients with ovarian endometrioma

OBJECTIVE

Sirtuin3 (SIRT3) is a NAD⁺-dependent major mitochondrial deacetylase. In this study, we aimed to investigate SIRT3 levels and their target enzyme activities, including glutamate dehydrogenase (GDH), succinate dehydrogenase (SDH), and manganese superoxide dismutase (MnSOD), also to determine the antioxidant capacity and oxidative stress in tissue, mitochondria and serum samples in ovarian endometrioma patients.

METHODS

We collected serum and endometrioma tissue samples from 30 patients. In the control group, we collected serum and eutopic endometrial tissue samples from 26 women without endometriosis.

RESULTS

SIRT3 levels were significantly decreased in endometrioma tissue samples compared to the control group. There was no statistically significant difference in SIRT3 levels between patient and control serum samples. Furthermore, there was a decrease in GDH and SDH enzyme activities in both endometrioma tissue homogenate and mitochondria. MnSOD activity was decreased in tissue homogenate but increased in mitochondria and there was no difference in serum. While total SOD activity was decreased, CuZnSOD activity was increased in both tissue and serum samples. Besides these, total antioxidant capacity and advanced oxidation protein products (AOPP) levels were decreased in endometrioma tissue and mitochondria, but there was no difference in serum.

CONCLUSIONS

Our results suggested that decreased levels of SIRT3 in endometrioma may be an important factor in the weakening of mitochondrial energy metabolism and antioxidant defense in endometriosis. We think that SIRT3 deficiency may be an important factor underlying the pathogenesis of endometriosis. More detailed studies are needed to reveal the relationship between SIRT3 and metabolism and oxidative stress in ovarian endometrioma.

Postoperative Pain Is Driven by Preoperative Pain, Not by Endometriosis

(1) Background: The aim of this study was to evaluate the impact of endometriosis on postoperative pain following laparoscopic hysterectomy; (2) Methods: A total of 214 women who underwent a laparoscopic hysterectomy between January 2013 and October 2017 were divided into four subgroups as follows: (1) endometriosis with chronic pain before the surgery (n = 57); (2) pain-free endometriosis (n = 50); (3) pain before the surgery without endometriosis (n = 40); (4) absence of both preoperative pain and endometriosis (n = 67). Postoperative pain was compared by using Visual Analog Scale (VAS) scores and by tracking the use of painkillers during the day of surgery and the first two postoperative days; (3) Results: Women with chronic pain before the surgery reported higher VAS scores during the first postoperative days, while the use of analgesics was similar across the groups. There was no difference in the postoperative pain when comparing endometriosis patients to non-endometriosis patients; (4) Conclusions: Women with chronic pelvic pain demonstrated increased postoperative pain after laparoscopic hysterectomy, which was independent of the presence or severity of endometriosis. The increased VAS scores did not, however, translate into equally greater use of painkillers, possibly due to the standardised protocols of analgesia in the immediate postoperative period. These findings support the need for careful postsurgical pain management in patients with pain identified as an indication for hysterectomy, independent of the extent of the surgery or underlying diagnosis.

Brief Review of Endometriosis and the Role of Trace Elements

Endometriosis is a chronic, estrogen-dependent, inflammatory condition that is defined as the presence of endometrial glands and stroma outside the uterine cavity. Despite the progress in research into the mechanisms leading to the development of endometriosis, its cause has not yet been established. It seems to be possible that the formation of oxidative stress may be one of the main causes of the development of endometriosis. There is much research that studies the potential role of trace elements in the appearance of endometrial-like lesions. Most studies focus on assessing the content of selected trace elements in the blood, urine, or peritoneal fluid in women with endometriosis. Meanwhile, little is known about the content of these elements in endometrial-like implants, which may be helpful in developing the theory of endometriosis. Investigations that are more comprehensive are needed to confirm a hypothesis that some trace elements play a role in the pathomechanism of endometriosis.

Real world data on symptomology and diagnostic approaches of 27,840 women living with endometriosis

Endometriosis is a chronic disease that requires a suitable, lifelong treatment. To our knowledge, the Visanne Post-approval Observational Study (VIPOS) is to date the largest real-world, non-interventional study investigating hormonal management of endometriosis. We describe women’s experiences of endometriosis in the real world by considering their symptoms and the diagnostic process in their healthcare setting. Overall, 27,840 women were enrolled from six European countries via networks of gynecologists or specialized centers. Of these, 87.8% of women were diagnosed based on clinical symptoms; the greatest and lowest proportions of women were in Russia (94.1%) and Germany (61.9%), respectively. Most women (82.8%) experienced at least one of the triad of endometriosis-associated pain symptoms: pelvic pain, pain after/during sexual intercourse, and painful menstrual periods. The most frequently reported endometriosis-associated symptoms were painful periods (61.8%), heavy/irregular bleeding (50.8%), and pelvic pain (37.2%). Women reported that endometriosis impacted their mood; 55.6% reported feeling “down”, depressed, or hopeless, and 53.2% reported feeling like a failure or having let down family/friends. VIPOS broadens our understanding of endometriosis based on real-world data by exploring the heterogeneity of symptoms women with endometriosis experience and the differences in diagnostic approaches between European countries.

Trial registration: ClinicalTrials.gov, NCT01266421; registered 24 December 2010. Registered in the European Union electronic Register of Post-Authorisation Studies as number 1613.

Eliapixant is a selective P2X3 receptor antagonist for the treatment of disorders associated with hypersensitive nerve fibers

ATP-dependent P2X3 receptors play a crucial role in the sensitization of nerve fibers and pathological pain pathways. They are also involved in pathways triggering cough and may contribute to the pathophysiology of endometriosis and overactive bladder. However, despite the strong therapeutic rationale for targeting P2X3 receptors, preliminary antagonists have been hampered by off-target effects, including severe taste disturbances associated with blocking the P2X2/3 receptor heterotrimer. Here we present a P2X3 receptor antagonist, eliapixant (BAY 1817080), which is both highly potent and selective for P2X3 over other P2X subtypes in vitro, including P2X2/3. We show that eliapixant reduces inflammatory pain in relevant animal models. We also provide the first in vivo experimental evidence that P2X3 antagonism reduces neurogenic inflammation, a phenomenon hypothesised to contribute to several diseases, including endometriosis. To test whether eliapixant could help treat endometriosis, we confirmed P2X3 expression on nerve fibers innervating human endometriotic lesions. We then demonstrate that eliapixant reduces vaginal hyperalgesia in an animal model of endometriosis-associated dyspareunia, even beyond treatment cessation. Our findings indicate that P2X3 antagonism could alleviate pain, including non-menstrual pelvic pain, and modify the underlying disease pathophysiology in women with endometriosis. Eliapixant is currently under clinical development for the treatment of disorders associated with hypersensitive nerve fibers.

The role of peripheral nerve signaling in endometriosis

A hallmark of endometriosis - a chronic debilitating condition whose causes are poorly understood - is neuronal innervation of lesions. Recent evidence demonstrates that the peripheral nervous system plays an important role in the pathophysiology of this disease. Sensory nerves, which surround and innervate endometriotic lesions, not only drive the chronic and debilitating pain associated with endometriosis but also contribute to a pro-growth phenotype by secreting neurotrophic factors and interacting with surrounding immune cells. The diverse array of contributions that neurons play in endometriosis indicate that it should be considered as a nerve-centric disease. This review is focused on the emerging field of exoneural biology and how it applies to the field of endometriosis, in particular the role that peripheral nerves play in driving and maintaining endometriotic lesions. A better understanding of the mechanisms of neuronal contribution to endometriosis, as well as their interactions with accompanying stromal and immune cells, will unearth novel disease-relevant pathways and targets, providing additional, more selective therapeutic horizons.

Secondary School Girls' Experiences of Menstruation and Awareness of Endometriosis: A Cross-Sectional Study

STUDY OBJECTIVE

To characterize typical menstrual characteristics in a large sample of secondary school girls, as well as knowledge of typical (ie, normal) menstruation, endometriosis awareness, and educational needs. To establish whether self-reported atypical period symptoms indicate menstrual characteristics suggesting the need for further clinical review for a specialist opinion.

DESIGN

Cross-sectional survey.

SETTING

Secondary schools in West Midlands, England.

PARTICIPANTS

A total of 442 girls, aged 15-19 years.

INTERVENTIONS AND MAIN OUTCOME MEASURES

The questionnaire determined demographic characteristics, age at menarche, menstrual cycle patterns and experiences, awareness of endometriosis, and preferences for learning about it.

RESULTS

Period pain was common (94%), with pain reported as moderate/severe (86%). Girls reported missing school due to their menstrual periods (23%), mainly because of pain. Most believed their period was typical (63%); however, 27% were unsure, and 30% did not know whether it was regular. Self-report of atypical periods was associated with symptoms suggesting need for clinical review and with consulting a doctor [χ²(2) = 36.272, P < .001)]. Only 8% could describe endometriosis, although 86% wanted to learn more about it.

CONCLUSION

Most secondary school girls report dysmenorrhea. Although most girls reporting atypical periods had seen a doctor, more than one-fourth did not know whether their period was typical or regular. The majority do not have knowledge of endometriosis, contrasting with adolescents' familiarity with other common chronic conditions such as diabetes and epilepsy. We suggest menstrual health education (MHE) to improve knowledge of typical menstruation and pain treatment, aiding earlier identification of problematic period symptoms that might indicate underlying pathology.

Early identification of women with endometriosis by means of a simple patient-completed questionnaire screening tool: a diagnostic study

OBJECTIVES

To assess the value of a self-completed questionnaire based on patients' verbal descriptors of pelvic painful symptoms to identify women with endometriosis.

DESIGN

Prospective 1:2 nonmatched case-control study.

SETTING

Three French endometriosis referral centers.

PATIENT(S)

Endometriosis cases were women aged 18-45 years with endometriosis confirmed by histology. Controls were as follows: asymptomatic women attending a gynecologic consultation for routine examination; women without evidence of endometriosis consulting for pain/infertility; and population-based controls from the same urban locations.

INTERVENTION(S)

All women completed the 21-item yes/no questionnaire about painful symptoms.

MAIN OUTCOME MEASURE(S)

The area under the receiver operating characteristic curve of the full question set model based on binary logistic regression and the diagnostic accuracy of low- and high-risk classification rules based on selected threshold of the prediction model.

RESULT(S)

We included 105 cases and 197 controls (45 asymptomatic consultation-based controls, 66 women without endometriosis consulting for pain/infertility, and 86 population-based controls). The full question set prediction model, including age, had an area under the receiver operating characteristic curve of 0.92 (95% confidence interval, 0.87-0.95) after internal validation. The high-risk classification rule had a specificity of 98.0% and a positive likelihood ratio of 30.5. The low-risk classification rule had a sensitivity of 98.1% and a negative likelihood ratio of 0.03. For a hypothesized pretest prevalence of 10%, the high- and low-risk prediction rules ascertained endometriosis with posttest probability rates of 77.2% and 0.3%, respectively.

CONCLUSION(S)

A self-completed patient-centered questionnaire can identify women at low or high risk of endometriosis with a high diagnostic accuracy and, thus, may help early identification of women with endometriosis.

Genomics of Endometriosis: From Genome Wide Association Studies to Exome Sequencing

This review aims at better understanding the genetics of endometriosis. Endometriosis is a frequent feminine disease, affecting up to 10% of women, and characterized by pain and infertility. In the most accepted hypothesis, endometriosis is caused by the implantation of uterine tissue at ectopic abdominal places, originating from retrograde menses. Despite the obvious genetic complexity of the disease, analysis of sibs has allowed heritability estimation of endometriosis at ~50%. From 2010, large Genome Wide Association Studies (GWAS), aimed at identifying the genes and loci underlying this genetic determinism. Some of these loci were confirmed in other populations and replication studies, some new loci were also found through meta-analyses using pooled samples. For two loci on chromosomes 1 (near CCD42) and chromosome 9 (near CDKN2A), functional explanations of the SNP (Single Nucleotide Polymorphism) effects have been more thoroughly studied. While a handful of chromosome regions and genes have clearly been identified and statistically demonstrated as at-risk for the disease, only a small part of the heritability is explained (missing heritability). Some attempts of exome sequencing started to identify additional genes from families or populations, but are still scarce. The solution may reside inside a combined effort: increasing the size of the GWAS designs, better categorize the clinical forms of the disease before analyzing genome-wide polymorphisms, and generalizing exome sequencing ventures. We try here to provide a vision of what we have and what we should obtain to completely elucidate the genetics of this complex disease.

Reductions in endometriosis-associated pain among women treated with elagolix are consistent across a range of baseline characteristics reflective of real-world patients

Background

Elagolix is an oral, gonadotropin-releasing hormone (GnRH) receptor antagonist, that significantly reduces dysmenorrhea and non-menstrual pelvic pain (NMPP) in women with moderate to severe endometriosis-associated pain.

Methods

Data were pooled from two 6-month, placebo-controlled, phase 3 studies (Elaris Endometriosis [EM]-I and II) in which 2 doses of elagolix were evaluated (150 mg once daily and 200 mg twice daily). Pooled data from > 1600 women, aged 18–49, were used to evaluate the efficacy of elagolix and health-related quality of life (HRQoL) in prespecified subgroups of women with various baseline characteristics.

Results

Of the 1686 women treated, 1285 (76.2%) completed the studies. The percentages of women with clinically meaningful reductions in dysmenorrhea and NMPP were generally consistent by subgroup. Significant treatment by subgroup interaction was demonstrated for dysmenorrhea response in baseline analgesic use (p < 0.01) and previous history of pregnancy (p < 0.05) subgroups, and for NMPP response in the baseline NMPP score (p < 0.05) and history of pregnancy (p < 0.05) subgroups. Patient-reported reduction in pain at month 3 was significant across all subgroups taking elagolix 200 mg BID, and significant across most subgroups with elagolix 150 mg QD. Women across subgroups experienced improvement within each domain of the Endometriosis Health Profile-30 (EHP-30), although significant treatment by subgroup interactions were observed in several categories.

Conclusions

Elagolix was effective in reducing dysmenorrhea and NMPP, and improving HRQoL, compared with placebo across numerous subgroups of women with various baseline characteristics, covering a broad segment of the endometriosis disease and patient types.

Clinical trial registration: ClinicalTrials.gov: https://www.clinicaltrials.gov/ct2/show/NCT01620528; https://www.clinicaltrials.gov/ct2/show/NCT01931670.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01385-3.

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.

Metabolomics in endometriosis: challenges and perspectives for future studies

Endometriosis is a complex disease characterized by inflammation and the growth of endometrial- like glands and stroma outside the uterine cavity. The pathophysiology of endometriosis is not entirely understood, however, with a prevalence of ~10% of women in their reproductive years, the disease symptoms significantly affect the quality of life of millions of women globally. Metabolomic studies have previously identified specific metabolites that could be a signature of endometriosis. This approach could potentially be used as a non-invasive tool for early diagnosis and provide a better understanding of endometriosis pathophysiology. This review aims to provide insight as to how endometriosis affects the metabolome by reviewing different studies that have used this approach to design follow-up studies. The search query included the term 'endometriosis' in combination with 'metabolomics', 'lipidomics', or 'sphingolipidomics' published between 2012 and 2020. We included studies in humans and animal models. Most studies reported differences in the metabolome of subjects with endometriosis in comparison to healthy controls and used samples taken from serum, endometrial tissue, follicular fluid, urine, peritoneal fluid, or endometrial fluid. Statistically significant metabolites contributed to group separation between patients and healthy controls. Reported metabolites included amino acids, lipids, organic acids, and other organic compounds. Differences in methods, analytical techniques, and the presence of confounding factors can interfere with results and interpretation of data. Metabolomics seems to be a promising tool for identifying significant metabolites in patients with endometriosis. Nonetheless, more investigation is needed in order to understand the significance of the study results.

Lay summary

Endometriosis is a chronic disease affecting the quality of life in one out of every ten women during their reproductive years, causing pain and infertility. It is characterized by inflammation and growth of tissue like the endometrium (uterus lining) outside the uterine cavity. Studies have searched for a predictor of endometriosis-associated changes by observing small molecules necessary for metabolism on a large scale (metabolomics). Metabolomics could serve to resolve one of the biggest challenges that patients with endometriosis face: a delay in diagnosis. In this review, the authors summarize identified potential biomarkers from various bodily fluids and tissues that are characteristic of metabolic processes observed in endometriosis. Biomarkers include cell growth, cell survival, high energy demand, oxidative stress, and fatty acid levels. A metabolomics approach offers promise as a non-invasive tool to identify significant metabolite changes in patients with endometriosis, potentially leading to earlier diagnoses and new opportunities for back-translational strategies.

Eutopic endometrium from women with endometriosis and chlamydial endometritis share immunological cell types and DNA repair imbalance: A transcriptome meta-analytical perspective

The aim of this study was to identify the key similarities between the eutopic endometrium of women with endometriosis and chlamydia-induced endometritis taking into account tissue microenvironment heterogeneity, transcript gene profile, and enriched pathways. A meta-analysis of whole transcriptome microarrays was performed using publicly available data, including samples containing both glandular and stromal endometrial components. Control samples were obtained from women without any reported pathological condition. Only samples obtained during the proliferative menstrual phase were included. Cellular tissue heterogeneity was predicted using a method that integrates gene set enrichment and deconvolution approaches. The batch effect was estimated by principal variant component analysis and removed using an empirical Bayes method. Differentially expressed genes were identified using an adjusted p-value < 0.05 and fold change = 1.5. The protein-protein interaction network was built using the STRING database and interaction score over 400. The Molecular Signatures Database was used to analyse the functional enrichment analysis. Both conditions showed similarities in cell types in the microenvironment, particularly CD4⁺ and CD8⁺ Tem cells, NKT cells, Th2 cells, basophils, and eosinophils. With regards to the regulation of cellular senescence and DNA integrity/damage checkpoint, which are commonly enriched pathways, 21 genes were down-regulated and directly related to DNA repair. Compared to the endometriosis samples, some chlamydial endometritis samples presented a lack of enriched immune pathways. Our results suggest that both conditions show similar distributions of microenvironment cell types, the downregulation of genes involved in DNA repair and cell cycle control, and pathways involved in immune response evasion.

The Long-Term Effect of Dienogest on Bone Mineral Density After Surgical Treatment of Endometrioma

The aim of this study was to evaluate the changing pattern of bone mineral density (BMD) levels after 3 years of dienogest use post endometrioma surgery and investigate the possible predictive factors for BMD reduction. This retrospective study included 44 reproductive-aged women who took dienogest (2 mg/day) and followed up BMD for 3 years after laparoscopic endometrioma surgery from July 2013 to December 2018. In addition, to investigate the predictive factors in the group with decreased BMD, analysis was added for patients with decreased BMD after taking dienogest for 1 year post laparoscopic endometrioma surgery. After 3 years of treatment with dienogest, BMD of both the lumbar spine (- 4.4%) and femur neck (- 3.6%) decreased significantly compared to the baseline levels. Bone loss predominantly occurred during the first year of treatment in the lumbar spine (- 2.4%) and gradually decreased with time during the treatment period. The predictive factors for BMD reduction after dienogest use were evaluated based on a 1-year change in BMD levels of 160 women, but no associated factors were found. This study demonstrated that dienogest use for 3 years was associated with a significant and gradual decrease in BMD and no predictive factors for BMD reduction during the first year of treatment with dienogest were found. These results may be useful in counseling patients regarding long-term effects of dienogest use on reducing BMD levels so that appropriate preventive measures can be taken.

Postoperative hormonal treatment for prevention of endometrioma recurrence after ovarian cystectomy: a systematic review and network meta-analysis

BACKGROUND

The efficacy of hormonal regimens for the prevention of endometrioma recurrence in women who have undergone conservative surgery is still controversial.

OBJECTIVE

To compare the efficacy of different hormonal regimens in this context and to rank them.

SEARCH STRATEGY

MEDLINE and Scopus databases were searched through January 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or cohorts, comparing the effect of any pair of interventions (i.e. cyclic oral contraceptives [OC], continuous OC, gonadotropin-releasing hormone agonist [GnRHa], dienogest [DNG], levonorgestrel-releasing intrauterine system [LNG-IUS] and expectant management) on endometrioma recurrence were selected.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two reviewers. Relative treatment effects were estimated using network meta-analysis (NMA) and ranked in descending order.

MAIN RESULTS

Six RCTs (675 patients) and 16 cohorts (3089 patients) were included. NMA of the RCTs involving expectant management, cyclic OC, continuous OC, GnRHa and GnRHa + LNG-IUS, showed that all hormonal regimens had a nonsignificant lower risk of endometrioma recurrence compared with expectant management. NMA of the cohorts involving expectant, cyclic OC, continuous OC, GnRHa, DNG, LNG-IUS, GnRHa + OC, and GnRHa + LNG-IUS indicated that LNG-IUS, DNG, continuous OC, GnRHa + OC and cyclic OC had a significantly lower risk of endometrioma recurrence than expectant management. LNG-IUS was ranked highest, followed by DNG and GnRHa + LNG-IUS. Long-term use of hormonal treatment either OC or progestin had a significantly lower risk of endometrioma recurrence than expectant treatment.

CONCLUSION

In the NMA of RCTs, there was no evidence supporting hormonal treatment for postoperative prevention of endometrioma recurrence. This was at odds with the cohort evidence, which found the protective effect of OC and progestin regimens, especially long-term treatment. Large-scale RCTs of these agents are still required.

TWEETABLE ABSTRACT

Hormonal regimens given as long-term treatment tend to reduce risk of endometrioma recurrence after conservative surgery.

Epidemiological profile of women with endometriosis: a retrospective descriptive study

Abstract Objectives: to describe the epidemiological and clinical profile of women with endometriosis and to determine the association with the prognostic characteristics of the disease. Methods: retrospective descriptive study involving 237 women attended at two referral hospitals for endometriosis, between 2011 and 2017. Associations between groups were estimated using logistic regression models. Results: most women (65.4%) were of reproductive age (29-39 years), with a body mass index in the range of 18.5-24.9 kg/m2 and a high prevalence (23-81%) of symptoms of the disease, with 49.5% being infertile. The average time of diagnosis was 5 years. Ovarian endometrioma and/or deep infiltrative endometriosis (DIE) were the most frequent type of endometriosis (87%), and 59% of patients were in the III/IV stage of the disease. Approximately 87% of women with surgical diagnosis were aged over 30, married (70%) and had lower parity. Dyspareunia was negatively associated with superficial endometriosis. Infertility was positively associated with age (30-39 years) and DIE in the uterine tubes; dysmenorrhea with DIE in the uterosacral ligament; cyclic intestinal complaints with DIE in the rectosigmoid and intestine, and with DIE classification and III/IVstage. Conclusions: knowing the epidemiological and clinical profile of Brazilian women with endometriosis can help in diagnosis and treatment planning.

Patient preferences for elagolix and leuprolide for treating endometriosis-related pain in the United States

INTRODUCTION

We evaluated elagolix and leuprolide from the patient's perspective for the treatment of endometriosis-related pain.

AREA COVERED

Preference weights from a published discrete choice experiment were used to evaluate preferences for treatment profiles simulating elagolix (150 mg/day and 200 mg/twice-daily dosages) and leuprolide for the treatment of moderate to severe endometriosis-related pain. Sensitivity analyses were conducted by varying the range of risk for pregnancy-related problems, moderate to severe hot flashes, and bone fracture across scenarios.

EXPERT OPINION

The 200 mg twice daily dosage of elagolix is more likely to be preferred over leuprolide by patients with moderate to severe endometriosis-related pain in all scenarios explored in the evaluation and sensitivity analyses. The probability that an average respondent would select a treatment was sensitive to increases in risk of moderate to severe hot flashes for leuprolide and possible variations in the risk of pregnancy-related problems for both treatments but was not influenced by an increased risk of bone fracture.

CONCLUSIONS

Patients' preferences for treatment of endometriosis-related pain should be evaluated using the benefits and risks of each pharmacological option. Respondents were more likely to prefer the treatment profile similar to 200 mg twice daily elagolix over that of leuprolide in all scenarios.

Endometrioid Carcinoma Arising from an Endometriosis-Associated Abdominal Wall Scar

Patient: Female, 45-year-old

Final Diagnosis: Endometrial cancer

Symptoms: Abdominal discomfort • abdominal distension

Medication: —

Clinical Procedure: Hormone therapy • surgery removal

Specialty: Oncology

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

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

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

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

Adolescent Endometriosis: An Update

Endometriosis is the leading pathologic cause of dysmenorrhea and chronic pelvic pain among adolescents. The appearance of endometriosis in adolescents may be different from that in female adults, resulting in delayed recognition and intervention. This article addresses the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of endometriosis in the adolescent.

The Portuguese 35-item Survey of Pain Attitudes applied to Portuguese women with Endometriosis

Background and aims Endometriosis is a gynecologic recurring persistent condition affecting from 8% to 15% of premenopausal women worldwide. About 80% of women with endometriosis have at least one form of chronic pain - a multidimensional experience influenced by a number of psychosocial factors, including pain-related beliefs. The Survey of Pain Attitudes is the most commonly used measure of pain-related beliefs. This study aims to evaluate the psychometric properties of a Portuguese version of a brief version of the SOPA (the SOPA-35) in a sample of Portuguese women with Endometriosis. Methods A sample of 199 Portuguese women with Endometriosis provided demographic and pain history information, and completed a Portuguese version of the SOPA-35 and measures of pain intensity, disability, and psychological function. Analyses were performed to evaluate the factor structure of the Portuguese SOPA-35 items as well as the internal consistency, composite reliability, convergent validity, and concurrent validity of the scale scores. Results Confirmatory factor analysis supported a six-factor solution for a 19-item version of the Portuguese version of the Survey of Pain Attitudes (SOPA-19-P). The six scales evidenced marginal to good reliability (Cronbach's alphas: between 0.60 and 0.84; composite reliability: between 0.61 and 0.84). Four scales evidenced acceptable to good convergent validity (AVE: between 0.51 and 0.63). The findings also supported the concurrent validity of the SOPA-19-P. Conclusions The results support the use of the Portuguese SOPA-19-P for research and clinical purposes with Portuguese women in chronic pain due to endometriosis. Future research is warranted to further develop a European Portuguese version of SOPA. Implications The findings provide psychometric information about the SOPA-19-P. The results are helpful to researchers wishing to study the role of pain-related beliefs and their association with adjustment and treatment outcomes in women with chronic pain due to endometriosis.

Association of benign gynaecological diseases and risk of endometrial and ovarian cancers

Objective: Gynaecologic benign diseases such uterine fibroids share similar pathogeneses with endometrial and ovarian cancers. Whether a history of uterine fibroids increases the risk of developing endometrial or ovarian cancers is controversial, due to uterine fibroids was self-reported in those studies. Methods: In our current case-control study, 268 women with endometrial cancer and 108 women with ovarian cancer were included. In addition, 500 women without gynaecological cancers were randomly selected as a control group. Uterine fibroids in both groups were clinically diagnosed by pelvic examination and ultrasound. Data on age, parity, gravida, stages of cancers and history of uterine fibroids, endometriosis and adenomyosis were collected from hospital database. Results: After adjusted age and parity, the odds of women with history of uterine fibroids or endometriosis were lower in women with endometrial cancer than controls (odds ratio: 0.148, 95% CI: 0.097, 0.225, or 0.360, 95% CI: 0094, 1.381, respectively). The odds of women with a history of uterine fibroids or endometriosis were lower in women with ovarian cancer than controls (odds ratio: 0.141, 95% CI: 0.085, 0.235, or 1.057, 95% CI: 0.377, 2.963, respectively). However, the odds of women with a history of adenomyosis were higher in women with endometrial or ovarian cancers than controls (odd ratio: 3.757, 95% CI: 1.858, 7.599 or 2.341, 95% CI: 1.086, 5.045, respectively). Conclusion: Our observational data suggested that uterine fibroids or endometriosis may be not associated with the increased risk of developing endometrial or ovarian cancer. However, a history of adenomyosis may do.

Immunoreactivity of Kisspeptin and Kisspeptin Receptor in Eutopic and Ectopic Endometrial Tissue of Women With and Without Endometriosis

Endometriosis is characterized by the presence of ectopic endometrial tissues. Mechanisms of tissue dissemination in endometriosis may be similar to those involved in tumor metastasis. We hypothesize that dysregulation of kisspeptin (KISS1), a metastasis suppressor in endometrial carcinoma, may contribute to the pathogenesis of endometriosis. In this study, we characterized the immunoreactivity of kisspeptin and its receptor, KISS1R, in eutopic and ectopic endometrial tissue of women with and without endometriosis, in proliferative and secretory menstrual cycle phases. Immunohistochemistry was performed using KISS1 and KISS1R antibodies on samples from women with (n = 35) and without (n = 14) endometriosis. Samples from women with endometriosis included eutopic endometrium (n = 20) samples, superficial endometriotic implants (SUP, n = 10) deep infiltrating endometriotic implants (DIE, n = 15), and ovarian endometriomas (OMA, n = 15). Immunoreactivity was quantified using histoscores. KISS1 and KISS1R immunoreactivity was significantly lower in eutopic endometrial stroma of women with versus without endometriosis, regardless of the menstrual cycle phase (P = 0.001 and P = 0.015 respectively). In endometriotic implants, KISS1 levels were significantly lower in both glandular and stromal components of DIE (P < 0.01) and OMA (P < 0.01) compared to SUP. KISS1R immunoreactivity was lower in the glandular component of OMA (P = 0.035) compared to SUP. KISS1 and KISS1R levels are lower in eutopic endometrial stroma from women with versus without endometriosis, consistent with a role for decreased KISS1 expression in the pathogenesis of endometriosis. As deeply invasive lesions showed lower KISS1 levels than superficial lesions, downregulation of KISS1 levels may contribute to implant invasiveness.

Safety and Effectiveness of Dienogest (Visanne®) for Treatment of Endometriosis: A Large Prospective Cohort Study

Dienogest (DNG) is a progestin with highly selective progesterone activity and known to be effective in the treatment of endometriosis. This prospective cohort study in patients who had been treated with DNG 2 mg (Visanne^®) for endometriosis was conducted to assess the safety and effectiveness of DNG in a large Korean cohort. This study included 3356 patients with endometriosis from 73 centers in Korea. All patients were treated with DNG 2 mg daily and were followed up for at least 6 months after initial visit. Any adverse events were recorded including severity, onset/closing date, outcomes, treatments, and the causality with DNG. Effectiveness of DNG was measured by changes in visual analogue scale (VAS) from baseline at the end of follow-up. The mean age of the subjects was 34.96 years, and the mean duration of treatment was 285.44 days. Incidence of adverse drug reaction (ADR) was 13.27% (413/3113). The most frequently reported ADR were "abnormal uterine bleeding" 4.14% (129/3113), "increased weight" 2.57% (80/3113), and "headache" 1.22% (38/3113). The number of patients (%) with favorable bleeding patterns was observed to increase as the duration of treatment increases. Amenorrhea was observed in 29.63%, 41.25%, 46.26%, and 53.20% of patients at 3 months, 6 months, 12 months, and more than 12 months follow-up period, respectively. The mean (±SD) VAS change from baseline at the last follow-up visit was -28.19 ± 28.39 mm (P value < 0.0001). This large cohort study confirms, in routine clinical practice, that DNG is safe and effective for treatment of endometriosis.