High rate of endometriosis recurrence in young women

Predicting disease recurrence in patients with endometriosis: an observational study

BACKGROUND

Despite surgical and pharmacological interventions, endometriosis can recur. Reliable information regarding risk of recurrence following a first diagnosis is scant. The aim of this study was to examine clinical and survey data in the setting of disease recurrence to identify predictors of risk of endometriosis recurrence.

METHODS

This observational study reviewed data from 794 patients having surgery for pelvic pain or endometriosis. Patients were stratified into two analytic groups based on self-reported or surgically confirmed recurrent endometriosis. Statistical analyses included univariate, followed by multivariate logistic regression to identify risk factors of recurrence, with least absolute shrinkage and selection operator (Lasso) regularisation. Risk-calibrated Supersparse Linear Integer Models (RiskSLIM) and survival analyses (with Lasso) were undertaken to identify predictive features of recurrence.

RESULTS

Several significant features were repeatedly identified in association with recurrence, including adhesions, high rASRM score, deep disease, bowel lesions, adenomyosis, emergency room attendance for pelvic pain, younger age at menarche, higher gravidity, high blood pressure and older age. In the surgically confirmed group, with a score of 5, the RiskSLIM method was able to predict the risk of recurrence (compared to a single diagnosis) at 95.3% and included adenomyosis and adhesions in the model. Survival analysis further highlighted bowel lesions, adhesions and adenomyosis.

CONCLUSIONS

Following an initial diagnosis of endometriosis, clinical decision-making regarding disease management should take into consideration the presence of bowel lesions, adhesions and adenomyosis, which increase the risk of endometriosis recurrence.

Ovarian endometrioma recurrence after laparoscopic surgery: First assessment of ACSAP predicting score

PURPOSE

We aimed to develop and validate a predictive score to estimate the post-operative recurrence risk after laparoscopic excision of ovarian endometrioma (OMA).

PATIENTS AND METHODS

The prediction score was developed using a training set comprising 431 patients with OMA who underwent laparoscopic surgery at our institution between January 2015 and September 2017. A follow-up period of at least 5 years was required. Clinical data were entered into least absolute shrinkage and selection operator (LASSO) regression to build a scoring system that predicted OMA recurrence. A testing set containing 185 patients from October 2017 to October 2018 was used to assess its performance.

RESULTS

Based on LASSO regression, the final score (ACSAP score) included five clinical predictors (0-15 points): Age, cyst size, previous surgery for OMA, revised American Society for Reproductive Medicine stage and post-operative pregnancy. The area under the curve values of the score were 0.741 (0.765) and 0.727 (0.795) for predicting 3-year and 5-year OMA recurrence, respectively, in the training (testing) set. The score stratified patients into three risk groups in both sets, with significant differences in the 5-year recurrence rates (low-risk, 5.3% [0%]; intermediate-risk, 20.2% [16.5%] and high-risk, 48.0% [36.5%]; P < 0.001). Moreover, patients in the intermediate- and high-risk groups exhibited a significant reduction in the 5-year cumulative recurrence following a minimum of 15-month post-operative medical treatment (both P < 0.05).

CONCLUSIONS

The ACSAP score may be a concise and useful tool for identifying patients with a higher risk of OMA recurrence after surgery who might receive long-term post-operative medical treatment.

Reproductive surgery remains an essential element of reproductive medicine

Background

Reproductive surgery has long been neglected and is perceived to be simple surgery that can be undertaken by all gynaecologists. However, given the ever-expanding knowledge in the field, reproductive surgery now comprises surgical interventions on female reproductive organs that need to be carefully planned and executed with consideration given to the individuals symptoms, function of the organ and fertility concerns.

Objectives

To discuss the different perspectives of reproductive surgeons and other gynaecological surgeons, e.g., gynaecological oncologists, and advanced minimally invasive surgeons, regarding diagnosis and management of pelvic pathology that affects reproductive potential. Furthermore, to highlight the gaps in knowledge and numerous controversies surrounding reproductive surgery, while summarising the current opinion on management.

Materials and Methods

Narrative review based on literature and the cumulative experience of the authors.

Main outcome measures

The paper does not address specific research questions.

Conclusions

Reproductive surgery encompasses all reproductive organs with the aim of alleviating symptoms whilst restoring and preserving function with careful consideration given to alternatives such as expectant management, medical treatments, and assisted reproductive techniques. It necessitates utmost technical expertise and sufficient knowledge of the female genital anatomy and physiology, together with a thorough understanding of and respect to of ovarian reserve, tubal function, and integrity of the uterine anatomy, as well as an up-to-date knowledge of alternatives, mainly assisted reproductive technology.

What is new?

A holistic approach to infertile women is only possible by focusing on the field of reproductive medicine and surgery, which is unattainable while practicing in multiple fields.

[Resolution of the national interdisciplinary council of experts "High-dose vitamin D (Devilam) in the practice of an obstetrician-gynecologist"]

On March 28, 2024, the Council of Experts "High-dose vitamin D (Devilam) in the practice of obstetrician-gynecologist, gynecologist and endocrinologist" was held in Moscow with the participation of leading experts gynecologists, endocrinologists and obstetricians-gynecologists, during which new possibilities for the use of high-dose vitamin D in patients of various ages who need correction of existing vitamin D deficiency or insufficiency.

Endometriosis: Age at diagnosis and the severity of the disease

BACKGROUND

Endometriosis is often described as a progressive disease beginning with menarche and menstrual bleeding. However, this is controversial, as the origin of the disease remains unknown. The objective of this study was to investigate the association between the severity of endometriosis and age at initial diagnosis.

MATERIAL AND METHODS

This prospective multicenter cohort study included 964 patients, newly and histologically diagnosed with endometriosis during laparoscopic treatment. The main outcome measures were diagnostic lesions with staging according to rAFS (revised American Fertility Society) scores, intensity of pain based on VAS (Visual Analog Scale) scores and quality of life from SF-36 questionnaire results. Age was treated as a categorical variable. Univariate and multivariable analyses (linear and multinomial ordinal) were conducted taking into account two by two multiple comparisons. The results were expressed with effect sizes and 95 % confidence intervals.

MAIN FINDINGS

No significant association between age and rAFS stage was found (p = 0.053). The percentage of patients with a deep nodule ≥ 2 cm was respectively 20 %, 25 %, 21 %, 18 % and 9 % for patients aged ≤ 25, 26-30, 31-35, 36-40 and >40 years respectively (p = 0.005). For dysmenorrhea, 64 %, 61 %, 54 %, 51 % and 32 % of patients aged ≤25, 26-30, 31-35, 36-40 and >40 years respectively reported a VAS score of ≥7 (p ≤ 0.001).

CONCLUSION

Prospective data obtained in patients newly diagnosed with endometriosis, revealed that the rAFS score is not related to patient age, and that the percentage of patients with a nodule ≥ 2 cm and severe dysmenorrhea did not increase with age. These percentages were significantly lower in patients aged > 40.

Proposal for targeted, neo-evolutionary-oriented secondary prevention of early-onset endometriosis and adenomyosis. Part II: medical interventions

According to consistent epidemiological data, the slope of the incidence curve of endometriosis rises rapidly and sharply around the age of 25 years. The delay in diagnosis is generally reported to be between 5 and 8 years in adult women, but it appears to be over 10 years in adolescents. If this is true, the actual onset of endometriosis in many young women would be chronologically placed in the early postmenarchal years. Ovulation and menstruation are inflammatory events that, when occurring repeatedly for years, may theoretically favour the early development of endometriosis and adenomyosis. Moreover, repeated acute dysmenorrhoea episodes after menarche may not only be an indicator of ensuing endometriosis or adenomyosis, but may also promote the transition from acute to chronic pelvic pain through central sensitization mechanisms, as well as the onset of chronic overlapping pain conditions. Therefore, secondary prevention aimed at reducing suffering, limiting lesion progression, and preserving future reproductive potential should be focused on the age group that could benefit most from the intervention, i.e. severely symptomatic adolescents. Early-onset endometriosis and adenomyosis should be promptly suspected even when physical and ultrasound findings are negative, and long-term ovulatory suppression may be established until conception seeking. As nowadays this could mean using hormonal therapies for several years, drug safety evaluation is crucial. In adolescents without recognized major contraindications to oestrogens, the use of very low-dose combined oral contraceptives is associated with a marginal increase in the individual absolute risk of thromboembolic events. Oral contraceptives containing oestradiol instead of ethinyl oestradiol may further limit such risk. Oral, subcutaneous, and intramuscular progestogens do not increase the thromboembolic risk, but may interfere with attainment of peak bone mass in young women. Levonorgestrel-releasing intra-uterine devices may be a safe alternative for adolescents, as amenorrhoea is frequently induced without suppression of the ovarian activity. With regard to oncological risk, the net effect of long-term oestrogen-progestogen combinations use is a small reduction in overall cancer risk. Whether surgery should be considered the first-line approach in young women with chronic pelvic pain symptoms seems questionable. Especially when large endometriomas or infiltrating lesions are not detected at pelvic imaging, laparoscopy should be reserved to adolescents who refuse hormonal treatments or in whom first-line medications are not effective, not tolerated, or contraindicated. Diagnostic and therapeutic algorithms, including self-reported outcome measures, for young individuals with a clinical suspicion of early-onset endometriosis or adenomyosis are proposed.

Endometriosis and Adolescence: The Impact of Dysmenorrhea

Endometriosis affects approximately 10% of premenopausal women worldwide. Despite its impact on quality of life, the delay in diagnosing this chronic disease is well known. Many patients with endometriosis report having suffered from dysmenorrhea and chronic pelvic pain in adolescence or at a young age. However, this painful symptom is often highly underestimated and considered a normal and transient symptom in young women. The real prevalence of endometriosis in adolescence remains uncertain. Some authors recently described at least one ultrasound feature of endometriosis in 13.3% of a general population of adolescent girls, which increased to 35.3% in young girls with severe dysmenorrhea. Dysmenorrhea is classified as primary dysmenorrhea or secondary dysmenorrhea. Primary dysmenorrhea is defined as a menstrual pain without organic disease, while secondary dysmenorrhea is defined as a menstrual pain associated with organic pelvic pathology. Since endometriosis represents the main cause of secondary dysmenorrhea in adolescents and young women, it is important to determine whether the patient has primary dysmenorrhea or additional suggestive symptoms related to endometriosis. Endometriosis in adolescent patients is a challenging problem with clinical and pathological differences compared with its presentation in premenopausal women. Adolescents and young women with dysmenorrhea and painful symptoms that suggest endometriosis should be referred to dedicated endometriosis centers for an early diagnosis and appropriate medical and surgical management. This paper aims to describe the role of dysmenorrhea in adolescents and the management of these young patients to confirm or exclude endometriosis.

How to Manage Endometriosis in Adolescence: The Endometriosis Treatment Italian Club Approach

The evaluation of endometriosis in an adolescent girl is a challenging topic. The initial stage of the disease and the limited diagnostic instrument appropriate for the youth age and for its typical features can reduce the ability of the gynecologist. At the same time, missing a prompt diagnosis can delay the beginning of specific and punctual management of endometriosis, which could avoid a postponed diagnosis from 6 to 12 years, typical of adolescent girls complaining of dysmenorrhea. This article aimed to answer all the potential questions around the diagnosis and management of endometriosis in adolescents starting from a clinical case looking at the possible solution that is easily reproducible in the clinical practice.

A Lifelong Impact on Endometriosis: Pathophysiology and Pharmacological Treatment

Endometriosis is a chronic inflammatory disease associated with bothersome symptoms in premenopausal women and is complicated with long-term systemic impacts in the post-menopausal stage. It is generally defined by the presence of endometrial-like tissue outside the uterine cavity, which causes menstrual disorders, chronic pelvic pain, and infertility. Endometriotic lesions can also spread and grow in extra-pelvic sites; the chronic inflammatory status can cause systemic effects, including metabolic disorder, immune dysregulation, and cardiovascular diseases. The uncertain etiologies of endometriosis and their diverse presentations limit the treatment efficacy. High recurrence risk and intolerable side effects result in poor compliance. Current studies for endometriosis have paid attention to the advances in hormonal, neurological, and immunological approaches to the pathophysiology and their potential pharmacological intervention. Here we provide an overview of the lifelong impacts of endometriosis and summarize the updated consensus on therapeutic strategies.

Adolescent endometriosis: prevalence increases with age on magnetic resonance imaging scan

OBJECTIVE

To evaluate the prevalence on magnetic resonance imaging (MRI) of ovarian endometrioma (OMA) and deep infiltrating endometriosis (DIE) in adolescents presenting with severe dysmenorrhea.

DESIGN

Prospective study.

SETTING

Clinic.

PATIENT(S)

A total of 345 adolescents aged 12-20 years referred to the radiologic MRI department unit between September 2019 and June 2020.

INTERVENTION(S)

Multiplanar pelvic MRI with cine MRI was performed. Data on the medical history with systematic questioning were collected for each patient before the scan.

MAIN OUTCOME MEASURE(S)

Data on the endometriosis phenotypes (OMA and/or DIE), distribution of anatomical lesions, and adenomyosis were evaluated and recorded using a dedicated MRI spreadsheet. Myometrial contractions were systematically reported for each case. The data were correlated with the characteristics of the patients and severity of painful symptoms evaluated using a visual analog scale.

RESULT(S)

The prevalence rates of endometriosis and adenomyosis were 39.3% (121 patients) and 11.4% (35 patients), respectively. Among the adolescents with endometriosis, 25 (20.7%) presented with OMA, and 107 (88.4%) presented with DIE. The odds ratios (confidence intervals) for each pairwise comparison between the age distributions were 2.3 (1.4-3.8) for 15-18 vs. <15 years of age and 3.3 (1.2-8.5) for 18-20 vs. <15 years of age, highlighting a predominance of cases after 18 years of age. Uterine contractions were visualized in 34.4% of cases, with no particular association with endometriosis. No clinical risk factor was identified as being particularly associated with endometriosis. Notably, the visual analog scale score was the same for cases with and without endometriosis.

CONCLUSION(S)

Severe endometriosis phenotypes (OMA and/or DIE) can be observed in adolescents with intense dysmenorrhea, with a linear increase in prevalence over time resulting in a clear predominance after 18 years of age. Endometriosis in adolescents is a challenging clinical problem with a long delay in diagnosis. Imaging can help reduce this delay in young patients with suggestive symptoms.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05153512.

Gonadotropin-Releasing Hormone Antagonists-A New Hope in Endometriosis Treatment?

Endometriosis is a chronic disease, in which endometrial-like tissue is found outside the uterine cavity. Lesions are typically located in the true pelvis but can be found, in addition to extragenital endometriosis, in the respiratory system, the diaphragm, the pleura or the pericardium. As the extrauterine endometrial lesions undergo the menstrual cycle, they cause many symptoms, including pain, and besides infertility, they all mostly affect the quality of the patient's life. Pharmacological management of endometriosis significantly increases in importance either as a first-line treatment or as a complementary therapy after surgery. Yet, current research on antagonists of the gonadotropin-releasing hormone (GnRH) has revealed their potential benefits in endometriosis treatment. Their mechanism of action is to down-regulate the hypothalamic-pituitary-gonadal axis and therefore induce a hypoestrogenic state. The resulting reduction of estrogen levels prevents disease progression and diminishes the recurrence rate after surgical removal of endometriosis. The present review summarizes recent reports of the role oral GnRH antagonists have as a significant treatment option for pain reduction in endometriosis patients.

Endometriosis-associated infertility: From pathophysiology to tailored treatment

Despite the clinically recognized association between endometriosis and infertility, the mechanisms implicated in endometriosis-associated infertility are not fully understood. Endometriosis is a multifactorial and systemic disease that has pleiotropic direct and indirect effects on reproduction. A complex interaction between endometriosis subtype, pain, inflammation, altered pelvic anatomy, adhesions, disrupted ovarian reserve/function, and compromised endometrial receptivity as well as systemic effects of the disease define endometriosis-associated infertility. The population of infertile women with endometriosis is heterogeneous, and diverse patients' phenotypes can be observed in the clinical setting, thus making difficult to establish a precise diagnosis and a single mechanism of endometriosis related infertility. Moreover, clinical management of infertility associated with endometriosis can be challenging due to this heterogeneity. Innovative non-invasive diagnostic tools are on the horizon that may allow us to target the specific dysfunctional alteration in the reproduction process. Currently the treatment should be individualized according to the clinical situation and to the suspected level of impairment. Here we review the etiology of endometriosis related infertility as well as current treatment options, including the roles of surgery and assisted reproductive technologies.

Height and pelvic lesion number: Do they have a positive relationship with postoperative recurrence in adolescent endometriosis?-A retrospective clinical analysis of 89 adolescent endometriosis in China

BACKGROUND

Adolescent endometriosis is a special type of endometriosis. Its diagnosis is often delayed. This study aimed to share the treatment experience of adolescent endometriosis and analyze the clinical manifestation, clinical stage, and risk factors of postoperative recurrence in China.

METHODS

Eighty-nine cases of adolescent endometriosis over 7 years in a single institution were reviewed. Demographic, clinical outcome measures were collected.

RESULT

The cumulative incidence rates of postoperative recurrence at years 1, 2, 3, 4, and 5 were 13.2%, 15.09%, 16.98%, 20.75%, and 20.75%, respectively. The risk factors associated with postoperative recurrence were disease stage, number of lesions, and height. In multivariate analysis, the independent risk factors of postoperative recurrence were height (RR: 1.132, 95% CI: 1.018-1.260) and the number of pelvic lesions (three or more, RR: 4.202, 95% CI: 1.013-17.433).

CONCLUSION

Taller patients and those who had multiple lesion sites (≥3) should receive more attention, because they have a higher possibility of relapse after surgery than their counterparts. This finding can guide the postoperative treatment of adolescent patients with endometrioma.

Cohort profile: The Endometriosis pain QUality aftEr Surgical Treatment (EndoQUEST) Study

Endometriosis affects reproductive-aged females and varies considerably in terms of symptom presentation, morphologic features, and treatment response. Most studies investigating symptom recurrence after an endometriosis-related surgery have been conducted among adults. The Endometriosis pain QUality aftEr Surgical Treatment (EndoQUEST) Study was established to assess characteristics and biomarkers that are associated with pain remediation and improved quality of life after an endometriosis-related surgery among adolescents and young adults. This paper describes the EndoQUEST methodology, summarizes baseline descriptive factors, and compares characteristics by participant retention status. We enrolled 100 surgically-confirmed endometriosis participants aged 12–23 years who provided questionnaire data on reproductive and behavioral factors, pain characteristics and quality of life at three time points; before surgery, 6 weeks to 26 weeks after surgery, and 1 year after surgery. Among these 100 participants, 88 provided blood and/or saliva at all three time points, while 12 provided blood and/or saliva samples only before surgery and 6 to 26 weeks after surgery. There was little evidence of lost to follow-up at 1 year after surgery due to pain symptoms, as pain and quality of life characteristics were similar between participants who completed the questionnaire 1 year after surgery and those who did not. Analyses utilizing these longitudinal data will advance personalized treatment decision making for adolescents and young adults with endometriosis.

ESHRE guideline: endometriosis

STUDY QUESTION

How should endometriosis be diagnosed and managed based on the best available evidence from published literature?

SUMMARY ANSWER

The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer.

WHAT IS KNOWN ALREADY

Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility.

STUDY DESIGN SIZE DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review.

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected.

LIMITATIONS REASONS FOR CAUTION

The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).

Differences in metabolic syndrome indicators by body mass index of women with endometriosis

Aim

The study aimed to identify the relationships between metabolic syndrome indicators and BMI in women with endometriosis.

Design

A retrospective observational study design was utilized to analyse secondary data from a longitudinal dataset.

Methods

A total of 281,810 women diagnosed with endometriosis and aged 15 through 49 were drawn from the National Health Insurance Service‐National Health Screening Cohort data of the Republic of Korea from the year 2009 to 2016. Body mass index (BMI) and five indicators of metabolic syndrome were extracted. Descriptive statistics, Cochran–Mantel–Haenszel test, chi‐square test and Cochran‐Armitage test were used.

Results

Yearly changes in abnormal waist circumference, elevated fasting blood sugar and abnormally low levels of high‐density lipoprotein cholesterol were statistically significant. The risk groups of these indicators all showed statistically significant differences according to BMI. The proportions of women with abnormal findings for all indicators significantly increased as BMI increased.

Clinical Aspects of Adolescent Endometriosis

Early diagnosis and long-term management of endometriosis is important in adolescent girls considering their potential for future pregnancy and need for preventing disease progression. However, symptoms and clinical findings of adolescent endometriosis may differ from those of typical adult endometriosis, making diagnosis difficult. In adolescents, menstrual pain may present as acyclic and unresponsive to commonly used medication. Typical imaging findings in adult endometriosis, such as ovarian endometriotic cysts and fibrotic scars, are less common in adolescents. Peritoneal lesions, characteristic of early-stage endometriosis, are commonly found in this age group. It should be noted that endometriosis may also be found in adolescents before menarche, because of premenarcheal endometriosis or congenital uterine anomaly and outflow obstruction; the latter requiring surgical correction. Although surgery is reported to be effective for pain, postsurgical recurrence rate is high, and the effect of hormonal treatment is controversial. The optimal timing for surgical intervention also remains to be determined. Here, we aim to identify the unique characteristics of endometriosis in adolescents to achieve early diagnosis and optimal management for this group of patients.

Risk factors for ovarian endometrioma recurrence following surgical excision: a systematic review and meta‑analysis

PURPOSE

Exploring potential risk factors for OMA recurrence, thereby contributing to the individual management of the disease and improving the patients' prognosis.

METHODS

Data sources PubMed, Embase, the Cochrane Library, CNKI, and Wanfang data were searched systematically before October 2020. We computed the pooled odd ratios or the standard mean difference with their corresponding 95% confidence interval to investigate the impact of involved risk factors on endometrioma recurrence.

RESULTS

The pooled findings of this meta-analysis demonstrated that endometrioma relapse was closely related to age at surgery [SMD (95% CI):  - 0.28 (- - 0.38 to  - 0.17), P < 0.00001], CA125 level [SMD (95% CI): 0.51 (0.14-0.88), P = 0.007], cyst size [SMD (95% CI): 0.35 (0.08-0.62), P = 0.01], dysmenorrhea [OR (95% CI): 1.47 (1.07-2.02), P = 0.02], endometriosis-related surgery history [OR (95% CI): 2.60 (1.84-3.67), P < 0.00001], pre-operative medication [OR (95% CI): 2.13 (1.41-3.22), P = 0.0003], rASRM score [SMD (95% CI): 0.33 (0.20-0.46), P < 0.00001]. Furthermore, post-operative pregnancy was indicated a protective factor for preventing the OMA recurrence after surgery [OR (95% CI): 0.22 (0.09-0.56), P = 0.001] CONCLUSION: Age at surgery, CA125 level, cyst size, dysmenorrhea, endometriosis-related surgery history, pre-operative medication, rASRM score were risk factors for endometrioma relapse. In addition, post-operative pregnancy was a protective factor for preventing recurrence after surgery. However, the effect of bilateral involvement, combination with adenomyosis, or post-operative medication on endometrioma relapse need further investigations.

Up-regulation of DNA2 results in cell proliferation and migration in endometriosis

Accumulating evidence has suggests that women with advanced endometriosis exhibit alterations in the expression of genes in the endometrium compared to healthy controls. Furthermore, replication stress is a characteristic feature of cancer cells, which results from sustained proliferative signaling induced by either the activation of oncogenes or the loss of tumor suppressors. In the present study, we propose that DNA replication ATP-dependent helicase/nuclease 2 (DNA2) might be upregulated in endometriosis. Immunohistochemical staining results confirmed the hypothesis that DNA2 is overexpressed in the eutopic/ectopic endometrium compared to that in a control endometrium from a healthy donor. Subsequently, ectopic endometrium-derived endometrial mesenchymal stem cells (EMSCs) showed the highest level of DNA2 and checkpoint kinase 1 (CHK1), as well as the strongest proliferation and migration capabilities, followed by eutopic endometrium-derived EMSCs, and then control EMSCs. To further analyze the function of DNA2, we knocked-down DNA2 expression in KLE cells. As expected, proliferation and migration declined when cells were transfected with DNA2 small interfering RNA. Taken together, our study demonstrated the overexpression of DNA2 in human endometriosis, which might be responsible for the upregulated cell proliferation and migration. This study provides insights into the mechanisms underlying human endometriosis.

Adolescent Endometriosis

Importance

Endometriosis is a major health concern in the adolescent population and significantly impacts daily physical and psychosocial functioning. Endometriosis can have differing presentations in this population, and the diagnosis often involves long delays and multiple visits to specialists.

Objective

The aim of this review is to discuss adolescent endometriosis, factors specific to this population, accurate diagnosis, and evidence-based surgical and medical management.

Evidence Acquisition

Computerized searches on the topic of endometriosis and adolescent endometriosis were completed. References from identified sources were then searched manually to allow for a thorough review. Data from relevant sources were synthesized to create the review.

Results

The literature supports endometriosis as a frequent cause of secondary dysmenorrhea. The characteristics of adolescents with endometriosis are shown to differ from those of adults. Initial medical therapy includes nonsteroidal anti-inflammatory drugs and combined hormonal contraceptives, but laparoscopy does have a role in the adolescent population, particularly those who have inadequate response to these treatments. Adolescent endometriosis may have a different appearance and be of all stages. Medical therapies are similar to that of the adult population; however, the benefits of medical and surgical management must be tailored to the adolescent patient.

Conclusions and Relevance

Adolescent endometriosis is likely a more prevalent cause of dysmenorrhea than currently appreciated. A high index of suspicion combined with recognition of risk factors and history-based markers of endometriosis may help identify adolescent endometriosis earlier and avoid delays in diagnosis. Expert opinion supports earlier laparoscopic evaluation in patients with symptoms unresponsive to oral medications, those who have failed initial medical therapy, or those who have evidence of deeply invasive disease, such as an endometrioma. Surgeons should be familiar with the unique appearance of lesions in the adolescent and understand the evidence as it relates to surgical therapy. Postoperative medical management is generally advocated by many, although the efficacy remains unclear at present.

Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis

BACKGROUND

Although surgery for endometriosis can improve pain and fertility, the risk of disease recurrence is high. There is little consensus regarding the benefit of medical therapy in preventing recurrence of endometriosis following surgery.

OBJECTIVE AND RATIONALE

We performed a review of prospective observational studies and randomised controlled trials (RCTs) to evaluate the risk of endometriosis recurrence in patients undergoing post-operative hormonal suppression, compared to placebo/expectant management.

SEARCH METHODS

The following databases were searched from inception to March 2020 for RCTs and prospective observational cohort studies: MEDLINE, Embase, Cochrane CENTRAL and Web of Science. We included English language full-text articles of pre-menopausal women undergoing conservative surgery (conserving at least one ovary) and initiating hormonal suppression within 6 weeks post-operatively with either combined hormonal contraceptives (CHC), progestins, androgens, levonorgesterel-releasing intra-uterine system (LNG-IUS) or GnRH agonist or antagonist. We excluded from the final analysis studies with <12 months of follow-up, interventions of diagnostic laparoscopy, experimental/non-hormonal treatments or combined hormonal therapy. Risk of bias was assessed using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale (NOS) for observational studies.

OUTCOMES

We included 17 studies (13 RCTs and 4 cohort studies), with 2137 patients (1189 receiving post-operative suppression and 948 controls), which evaluated various agents: CHC (6 studies, n = 869), progestin (3 studies, n = 183), LNG-IUS (2 studies, n = 94) and GnRH agonist (9 studies, n = 1237). The primary outcome was post-operative endometriosis recurrence, determined by imaging or recurrence of symptoms, at least 12 months post-operatively. The secondary outcome was change in endometriosis-related pain. Mean follow up of included studies ranged from 12 to 36 months, and outcomes were assessed at a median of 18 months. There was a significantly decreased risk of endometriosis recurrence in patients receiving post-operative hormonal suppression compared to expectant management/placebo (relative risk (RR) 0.41, 95% CI: 0.26 to 0.65), 14 studies, 1766 patients, I² = 68%, random effects model). Subgroup analysis on patients treated with CHC and LNG-IUS as well as sensitivity analyses limited to RCTs and high-quality studies showed a consistent decreased risk of endometriosis recurrence. Additionally, the patients receiving post-operative hormonal suppression had significantly lower pain scores compared to controls (SMD −0.49, 95% CI: −0.91 to −0.07, 7 studies, 652 patients, I² = 68%).

WIDER IMPLICATIONS

Hormonal suppression should be considered for patients not seeking pregnancy immediately after endometriosis surgery in order to reduce disease recurrence and pain. Various hormonal agents have been shown to be effective, and the exact treatment choice should be individualised according to each woman’s needs.

Laparoscopic Outcomes after Normal Clinical and Ultrasound Findings in Young Women with Chronic Pelvic Pain: A Cross-Sectional Study

Chronic pelvic pain (CPP) is one of the most common chronic pain problems experienced by women, with prevalence rates comparable to asthma and back pain. However, it is poorly understood and causative pathology is only seldom found. We aimed to establish prevalence of abnormal findings at diagnostic laparoscopy in young women with CPP after normal findings at clinical examination and pelvic ultrasound scan. Information was retrospectively collected on all laparoscopies undertaken on women aged 16-30 years with normal preoperative findings over a 24-month period. One-hundred-and-fifty women (mean age 25 years and BMI 24.5) were included with laparoscopic examination revealing normal anatomy in 110 (73.3%) and pathology in 40 (27.2%). Endometriosis was detected in 30 (20%); 25 (16.7%) stage 1, 2 (1.3%) stage 2, 2 (1.3%) stage 3 and 1 (0.7%) stage 4. Most laparoscopies carried out on young women with CPP and normal clinical examination and pelvic ultrasound scan showed no significant clinical stigmata of pelvic disease. Women should be fully informed of the multifactorial nature of CPP and there should be a comprehensive management pathway for these women, as proceeding with invasive laparoscopy does not provide additional benefit when investigating CPP in the context of risk, cost and effect on long-term wellbeing.

Age at surgery and recurrence of ovarian endometrioma after conservative surgery: a meta-analysis including 3125 patients

PURPOSE

To evaluate the association between age at surgery and recurrence rate of endometrioma. Data sources PubMed, Embase, and the Cochrane Library were searched up to October 2019.

METHODS

We determined the pooled relative risk (RR) and 95% confidence intervals (CIs) to assess the relationship between age at surgery and the recurrence rate of endometrioma after surgery. Begg's funnel plot and Egger's linear regression was used to assess any publication bias.

RESULTS

A total of 3125 patients from 10 studies were finally enrolled in this meta-analysis. The recurrence rate decreased with increasing age (RR = 0.93, 95% CI = 0.91-0.95, P = 0.451). Subgroup analysis demonstrated that the pooled RR was 0.926 (95% CI 0.906-0.947, P < 0.001) for a cut-off < 35, and 0.886 (95% CI 0.775-1.040, P = 0.14) for a cut-off ≥ 35. Begg's funnel plot and Egger's linear regression test showed no evidence of publication bias.

CONCLUSION

This meta-analysis suggested that younger age might be a high-risk factor for the recurrence of ovarian endometrioma after conservative surgery.

Nanoparticle-Based Platform for Activatable Fluorescence Imaging and Photothermal Ablation of Endometriosis

Endometriosis is a painful disorder where endometrium-like tissue forms lesions outside of the uterine cavity. Intraoperative identification and removal of these lesions are difficult. This study presents a nanoplatform that concurrently delineates and ablates endometriosis tissues using real-time near-infrared (NIR) fluorescence and photothermal therapy (PTT). The nanoplatform consists of a dye, silicon naphthalocyanine (SiNc), capable of both NIR fluorescence imaging and PTT, and a polymeric nanoparticle as a SiNc carrier to endometriosis tissue following systemic administration. To achieve high contrast during fluorescence imaging of endometriotic lesions, nanoparticles are constructed to be non-fluorescent prior to internalization by endometriosis cells. In vitro studies confirm that these nanoparticles activate the fluorescence signal following internalization in macaque endometrial stromal cells and ablate them by increasing cellular temperature to 53 ^° C upon interaction with NIR light. To demonstrate in vivo efficiency of the nanoparticles, biopsies of endometrium and endometriosis from rhesus macaques are transplanted into immunodeficient mice. Imaging with the intraoperative Fluobeam 800 system reveals that 24 h following intravenous injection, nanoparticles efficiently accumulate in, and demarcate, endometriotic grafts with fluorescence. Finally, the nanoparticles increase the temperature of endometriotic grafts up to 47 °C upon exposure to NIR light, completely eradicating them after a single treatment.

Endometriosis and pain in the adolescent- striking early to limit suffering: A narrative review

Endometriosis, a condition in which uterine tissue grows outside the uterus, is a debilitating disease, affecting millions of women and costing the United States approximately $78 billion annually in pain- related disability. It is also the leading cause of chronic pelvic pain (CPP), which is often unresponsive to existing treatments. Adolescent women with the disease are at particular risk as there are often significant diagnostic delays, which in turn can exacerbate pain. Research and treatment guidelines for adolescents with endometriosis are largely based on studies for adult women due to the limited number of studies focusing on adolescents. The current paper critically reviews the literature as it pertains to endometriosis pathophysiology, mechanisms contributing to CPP, and treatment implications and recommendations with a focus on gaps related to adolescents.

Recurrent endometriosis: a battle against an unknown enemy

Recurrence of endometriosis after conservative surgery is not an uncommon finding. There is no uniformity, however, on what the term 'recurrence' means. Recurrence is variously defined in the literature as the relapse of pain, clinical or instrumental detection of an endometriotic lesion, repeat rise in CA 125 levels, or evidence of recurrence found during repeat surgery. Consequently, the reported recurrence rate varies widely (0-89%) in the different series, depending on its definition and the type of study performed. As endometriosis recurrence seems to be an indeterminate enemy, we set out to examine exactly what we were fighting in our everyday battle. In this narrative review, we aimed to seek an answer to questions related to endometriosis recurrence, some of which are often asked by our patients.

Possible Role of the Posterior Compartment Peritonectomy, as a Part of the Complex Surgery, Regarding Recurrence Rate, Improvement of Symptoms and Fertility Rate in Patients with Endometriosis, Long-Term Follow-Up

STUDY OBJECTIVE

Beside the pain, there are 2 further problems in the management of endometriosis: the high recurrence rate (10% per year) and the high rate of impaired fertility. The objective of this study was to investigate the pathogenesis of these 2 factors.

DESIGN

This is a retrospective cohort study, and the aim is to evaluate the complete excision of endometriotic lesions, including the posterior compartment of the peritoneum, with regard to postoperative outcome, focusing on relieving pain, increasing fertility rate, and decreasing recurrence rate.

SETTING

Charité-University Clinic, Department of Gynaecology, Endometriosis research Centre.

PATIENTS

Fifty-four patients were enrolled in this study, with severe deep infiltrating endometriosis (scored by ENZIAN) and superficial endometriosis, as well as endometriomas (revised American Society for Reproductive Medicine [rASRM] I = 3; II = 15; III = 10; and IV = 26).

INTERVENTIONS

Posterior compartment peritonectomy (visible endometriotic lesions and inflamed altered peritoneum) was performed in all patients as part of a complex surgery: complete excision of endometriosis.

MEASUREMENTS AND MAIN RESULTS

Postoperative outcomes were evaluated, based on the postoperative follow-up (up to 5 years) of 54 investigated patients. In 36 women (66%) preoperative complaints were eliminated. Furthermore, of 28 women seeking improved fertility, pregnancy was reported in 13 cases (46%). In 7 (54%) cases pregnancy occurred spontaneously, and in the remainder with assisted fertilization. In addition, long-term follow-up demonstrated a recurrence rate in 1.8% of patients.

CONCLUSION

Overall, the number of complaints was significantly reduced. Only in the case of reproductive-aged women with ongoing postoperative complaints was it important to preserve the uterus. Although this pilot study on systematic posterior peritonectomy showed improvement in recurrence and fertility rate, the main question remains: will this surgical technique achieve better results and outcomes in the future? This has to be addressed in a prospective randomized study.

Iatrogenic endometriosis harbors somatic cancer-driver mutations

STUDY QUESTION

Does incisional endometriosis (IE) harbor somatic cancer-driver mutations?

SUMMARY ANSWER

We found that approximately one-quarter of IE cases harbor somatic-cancer mutations, which commonly affect components of the MAPK/RAS or PI3K-Akt-mTor signaling pathways.

WHAT IS KNOWN ALREADY

Despite the classification of endometriosis as a benign gynecological disease, it shares key features with cancers such as resistance to apoptosis and stimulation of angiogenesis and is well-established as the precursor of clear cell and endometrioid ovarian carcinomas. Our group has recently shown that deep infiltrating endometriosis (DE), a form of endometriosis that rarely undergoes malignant transformation, harbors recurrent somatic mutations.

STUDY DESIGN, SIZE, DURATION

In a retrospective study comparing iatrogenically induced and endogenously occurring forms of endometriosis unlikely to progress to cancer, we examined endometriosis specimens from 40 women with IE and 36 women with DE. Specimens were collected between 2004 and 2017 from five hospital sites in either Canada, Germany or the Netherlands. IE and DE cohorts were age-matched and all women presented with histologically typical endometriosis without known history of malignancy.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Archival tissue specimens containing endometriotic lesions were macrodissected and/or laser-capture microdissected to enrich endometriotic stroma and epithelium and a hypersensitive cancer hotspot sequencing panel was used to assess for presence of somatic mutations. Mutations were subsequently validated using droplet digital PCR. PTEN and ARID1A immunohistochemistry (IHC) were performed as surrogates for somatic events resulting in functional loss of respective proteins.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, we detected somatic cancer-driver events in 11 of 40 (27.5%) IE cases and 13 of 36 (36.1%) DE cases, including hotspot mutations in KRAS, ERBB2, PIK3CA and CTNNB1. Heterogeneous PTEN loss occurred at similar rates in IE and DE (7/40 vs 5/36, respectively), whereas ARID1A loss only occurred in a single case of DE. While rates of detectable somatic cancer-driver events between IE and DE are not statistically significant (P > 0.05), KRAS activating mutations were more prevalent in DE.

LIMITATIONS, REASONS FOR CAUTION

Detection of somatic cancer-driver events were limited to hotspots analyzed in our panel-based sequencing assay and loss of protein expression by IHC from archival tissue. Whole genome or exome sequencing, or epigenetic analysis may uncover additional somatic alterations. Moreover, because of the descriptive nature of this study, the functional roles of identified mutations within the context of endometriosis remain unclear and causality cannot be established.

WIDER IMPLICATIONS OF THE FINDINGS

The alterations we report may be important in driving the growth and survival of endometriosis in ectopic regions of the body. Given the frequency of mutation in surgically displaced endometrium (IE), examination of similar somatic events in eutopic endometrium, as well as clinically annotated cases of other forms of endometriosis, in particular endometriomas that are most commonly linked to malignancy, is warranted.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by a Canadian Cancer Society Impact Grant [701603, PI Huntsman], Canadian Institutes of Health Research Transitional Open Operating Grant [MOP-142273, PI Yong], the Canadian Institutes of Health Research Foundation Grant [FDN-154290, PI Huntsman], the Canadian Institutes of Health Research Project Grant [PJT-156084, PIs Yong and Anglesio], and the Janet D. Cottrelle Foundation through the BC Cancer Foundation [PI Huntsman]. D.G. Huntsman is a co-founder and shareholder of Contextual Genomics Inc., a for profit company that provides clinical reporting to assist in cancer patient treatment. R. Aguirre-Hernandez, J. Khattra and L.M. Prentice have a patent MOLECULAR QUALITY ASSURANCE METHODS FOR USE IN SEQUENCING pending and are current (or former) employees of Contextual Genomics Inc. The remaining authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

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

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

Expression of MTA1 in endometriosis and its relationship to the recurrence

Metastasis-associated gene 1 (MTA1) is correlated with prognosis of many tumors. However, little is known about the role of MAT1 in endometriosis and its relationship with the recurrence of endometriosis.The expression of MTA1 in normal, eutopic and ectopic endometrium was detected by immunohistochemistry and RT-PCR, respectively. The relationship of MTA1 expression with the recurrence of endometriosis was evaluated.In the normal endometrium, eutopic endometrium and ectopic endometrium, the positive rates of MTA1 expression showed a gradually increasing trend. In addition, the MTA1 expression difference between each two groups was significant (P < .0125). However, there was no significant difference between proliferative phase and secretory phase in each group (P > .05). In the ectopic endometrium, MTA1 expression in the severe phases (III-IV) was significantly higher than that in mild phases (I-II) (P < .05), indicating the expression of MTA1 correlates with r-AFS staging (P < .05). Additionally, the MTA1 mRNA level was also closely related to the stages of r-AFS, but not to the proliferative phase or secretory phase of endometrium. Logistic regression analysis showed that r-AFS stage and MTA1 overexpression were risk factors for the recurrence of endometriosis. While, postoperative pregnancy was a protective factor for its relapse.MTA1 is closely associated with the occurrence and development of Ems. Thus, MTA1 level may be used as a new indicator to predict the progression of endometriosis.

Comparison of the efficacy of diegnogest and levonorgestrel-releasing intrauterine system after laparoscopic surgery for endometriosis

AIM

To compare the efficacy between dienogest and levonorgestrel-releasing intrauterine system (LNG-IUS) after laparoscopic surgery for endometriosis.

METHODS

A total of 285 women were diagnosed as endometriosis by laparoscopy between 2011 and 2015. Patients were grouped into no treatment (n = 83), treatment with dienogest (n =130) and treatment with LNG-IUS (n =72) after laparoscopic surgery. The changes of the pain scores were checked at 6, 12 and 24 months after the surgery, and the rates of disease recurrence and treatment discontinuation rate were determined.

RESULTS

The participants' mean age was 38.9 years (range 21-54 years). The mean age of LNG-IUS group (43.7 years) was significantly higher than the no treatment and dienogest groups (39.3 vs 33.9 years, respectively). At 6 and 12 months, the median pain scores in treatment (dienogest and LNG-IUS) groups were significantly lower than control group. Both treatment groups had significantly lower recurrence rate than control group (3.8% and 9.7%, respectively, vs 32.5%, P =0.001). No significant difference was found in the recurrence rate between the two treatment groups (P =0.461). Patients in the LNG-IUS group showed lower rate of discontinuation due to complication (27.8%) than those in dienogest group (35.6%, P =0.010).

CONCLUSION

LNG-IUS treatment in the patients with endometriosis is effective for postoperative pain control and preventing recurrence, however, the LNG-IUS group is older, it is difficult to compare the efficacy between dienogest and LNG-IUS in present study.

Progress in the diagnosis and management of adolescent endometriosis: an opinion

Increasing evidence indicates that early onset endometriosis (EOE), starting around menarche or early adolescence, may have an origin different from the adult variant, originating from neonatal uterine bleeding (NUB). This implies seeding of naïve endometrial progenitor cells into the pelvic cavity with NUB; these can then activate around thelarche. It has its own pathophysiology, symptomatology and risk factors, warranting critical management re-evaluation. It can also be progressive, endangering future reproductive capacity. This variant seems to be characterized by the presence of ovarian endometrioma. Today, the diagnosis of endometriosis in young patients is often delayed for years; if rapidly progressive, it can severely affect pelvic organs, even in the absence of serious symptoms. Given the predicament, great attention must be paid to symptomatology that is often non-specific, justifying a search for new, simple, non-invasive markers of increased risk. Better use of modern imaging techniques will aid considerably in screening for the presence of EOE. Traditional laparoscopy should be limited to cases in which imaging gives rise to suspicion of severity and a stepwise, minimally invasive approach should be used, followed by medical treatment to prevent recurrence. In conclusion, EOE represents a condition necessitating early diagnosis and stepwise management, including medical treatment.

miR-30c may serve a role in endometriosis by targeting plasminogen activator inhibitor-1

The present study aimed to investigate the role of miR-30c in endometriosis (EMs) and the underlying mechanism. The expression of miR-30c and plasminogen activator inhibitor type 1 (PAI-1) mRNA in EMs tissues was detected by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and the expression of PAI-1 protein was detected by western blot analysis. The proliferation, migration, invasion and adhesion of endometrial stromal cells (ESCs) in different groups transfected with miR-30c mimic or inhibitor were compared. It was demonstrated that miR-30c expression in ectopic and eutopic endometriosis tissues were significantly lower than in normal endometrial tissue. However, PAI-1 mRNA expression in ectopic and eutopic endometrial tissues was higher than in normal endometrial tissues. Furthermore, the expression of PAI-1 protein was higher in ectopic and eutopic endometrosis tissues than in normal tissues. RT-qPCR results indicated that miR-30c expression was significantly increased or decreased in ESCs following transfection of mimic or inhibitor of miR-30c, respectively. Overexpression of miR-30c repressed the expression of PAI-1 mRNA and protein, while inhibition of miR-30c upregulated the expression of PAI-1 in ESCs. In addition, the invasion, migration, proliferation and adhesion of ESCs was repressed following the overexpression of miR-30c, whereas they were promoted when miR-30c expression was downregulated. The results of the present study indicated that miR-30c serves an important role in the development and progression of EMs by regulating the expression of PAI-1.

Recurrence of Ovarian Endometrioma in Adolescents after Conservative, Laparoscopic Cyst Enucleation

STUDY OBJECTIVE

To evaluate the cumulative recurrence rate of endometriomas after a laparoscopic endometriotic cyst enucleation in adolescents and to find the factors associated with recurrence.

DESIGN

A multicenter retrospective cohort study.

SETTING

Three university hospitals.

PARTICIPANTS

One hundred five patients surgically treated with laparoscopic enucleation of endometriotic cysts younger than 20 years of age were selected.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Endometrioma recurrence was considered when transvaginal or transrectal sonography indicated a cystic mass with a diameter of 20 mm or greater. Recurrence rate of endometrioma and median time to recurrence were evaluated.

RESULTS

In total, 105 patients were followed for 47.3 (±44.3) months (range, 3-161 months). Seventeen patients (16.2%) experienced recurrence after the first-line surgery and 8 patients (7%) underwent a second surgery. The median time to recurrence was 53.0 (±8.5) months (range, 8-111 months). Using Kaplan-Meier method, the cumulative recurrence rates of endometrioma per patient at 24, 36, 60, and 96 months after the first-line surgery were 6.4%, 10%, 19.9% and 30.9%, respectively. Surgical characteristics, such as the diameter of the cyst, revised American Society for Reproductive Medicine stage, unilateral or bilateral involvement, and coexistence of deep endometriosis were not associated with recurrence in this age group.

CONCLUSION

Although the short-term recurrence rate in adolescents after first-line surgery is relatively low, the recurrence rate appears to be higher according to the follow-up duration. Long-term and continuous follow-up is needed for patients who have undergone surgical treatment for endometriosis in the adolescent period.

The Clinical Significance of Endocannabinoids in Endometriosis Pain Management

Introduction: Patients with endometriosis often suffer from diffuse and poorly localized severe pain. The current pain management strategies include medical and hormonal therapy, as well as surgery. Medical management of pain is often insufficient and is associated with high rate of recurrence. Better pain management is therefore of urgent need. Methods: Among the various candidates, the endocannabinoid system (ECS) has recently emerged as a relevant pharmacological target for the management of endometriosis-related pain. A computerized literature search was performed to identify relevant studies combining the keywords "endometriosis," "endocannabinoid," "cannabinoid receptor," "THC," and "pain mechanisms." Conclusions: This review describes the multiple and complex pain mechanisms associated with endometriosis. Current data and theories concerning the link between the ECS and pain management for endometriosis patients are presented. Finally, we will discuss which aspects of endometriosis-associated pain can be targeted by modulation of the ECS.

Trauma and endometriosis. A review. May we explain surgical phenotypes and natural history of the disease?

OBJECTIVE

The study was performed to evaluate whether trauma is an initial event of development of endometriosis.

METHOD

Using Medline database from January 1960 up to December 2014, a systematic review was made of all published studies using the keywords trauma, healing, injury, infection, hyperperistaltism, stretch and endometriosis, adenomyosis and trauma. Studies and review articles written in French and/or in English related to the topic were included and reviewed independently by two authors.

RESULTS

The role of trauma is well-established for endometriotic lesions diagnosed in surgical scars. Various traumas including delivery, uterine curettage or incision, intraperitoneal hemorrhage, or occult pelvic inflammatory diseases could be involved to explain other localizations of the disease. Many data suggested that the healing process, particularly growth factors and the associated estrogen production, may facilitate the implantation and the growth of ectopic endometrial cells. After the initial, a traumatic event, the phenotype of the disease would depend on the tissue in which the endometriotic lesion grows.

CONCLUSIONS

The present literature review may support a potential role of a trauma as an initial event of endometriosis.

Endometrioma in Adolescents and Future Reproductive Health

There continues to be debate over the nature and progression of ovarian endometriomas in adolescence due to the possibility that they may have a different origin and to the impossibility to be able to predict progress.

The hypothesis of a different origin traces its roots in the phenomenon called “neonatal menstruation” (NUB), occurring in approximately 5% of newborn. The retrograde shedding of neonatal endometrium may contain progenitor cells and stroma that may lie dormant under the peritoneal surface until being activated when estrogens begin to rise.

In teenagers, ovarian endometriomas are often preceded by highly angiogenic implants in the fossa ovarica, with adhesion formation resulting in the invagination of the ovarian cortex and the creation of a pseudocyst.

Use of imaging techniques makes it possible to diagnose even small endometriomas. This is vital to their management, since there is evidence that the disease in an adolescent represents a severe condition, with tendency to progression. In addition, if intervention is decided, the first surgical procedure can determine the ultimate outcome of her reproductive life, because there is a significantly higher risk of inadvertently removing ovarian tissue in the presence of an endometrioma than of other ovarian pathologies. For this reason, techniques avoiding additional trauma to the ovary should be preferred and those who wish to become pregnant should attempt conception as soon as possible; if pregnancy is not sought, hormonal therapy is strongly advised.

Finally, young age at diagnosis may constitute a pivotal factor in considering fertility preservation.

Endometriosis in Adolescents: A Systematic Review

Introduction

The aim of this manuscript is to present a systematic review of characteristics and management of endometriosis in adolescents in order to gain some relevant insight into the most appropriate clinical management of the disease.

Methods

The literature review was done using electronic database PubMed focusing on the terms ‘adolescents’, ‘endometriosis’, ‘teenagers’, ‘pain’, ‘infertility’, ‘quality of life’, ‘medical’ and ‘surgical management’ from 1980 onward and was limited to articles in English. Articles were only included if they reported original relevant research.

Results

The 24 studies selected for review included 1148 adolescents with laparoscopic proven endometriosis. The diagnosis of endometriosis was histologically confirmed in 39.02% (448/1148) of cases. The results from trials have been tabulated and main results presented in a question and answer format.

Conclusions

The majority of adolescent girls with chronic pelvic pain not responding to conventional medical therapy have endometriosis (up to 80%). Laparoscopy with biopsy is the only way to diagnose endometriosis in the adolescent population, and depends on recognition of atypical manifestations of the disease. Surgical management (especially by an expert surgeon) has been shown to be beneficial in reducing pain, improving infertility, and preventing progression or recurrence of disease. Postoperative hormonal suppression helps reduce pain symptoms and recurrence of endometriomas, but it does not seem to prevent disease recurrence or progression of peritoneal endometriosis, and has not been shown to improve future fertility. Postoperative suppression until pregnancy is based on expert opinion only. There is a need for good quality properly randomized trials.

Current methods for the management of endometriosis in adolescent patients

Endometriosis is increasingly recognized as a challenging problem of both diagnosis and management in adolescent gynecology. Areas covered: This special report summarizes the current practices in the evaluation and management of endometriosis in adolescent patients. Expert commentary: We recommend prompt recognition and treatment of endometriosis whenever possible. Management should begin with empiric treatment with NSAIDS and hormonal therapy if complaints of pain interfering with daily activities are elicited. If a patient fails medical therapy after three to six months, surgical intervention is warranted by a clinician experienced in operating in this age range and familiar with the appearance of endometriosis in this age range.

Determinant factors of postoperative recurrence of endometriosis: difference between endometrioma and pain

OBJECTIVE

Although the postoperative use of hormonal treatment for endometriosis is recommended in the European Society of Human Reproduction and Embryology guidelines to prevent the recurrence of endometriosis-associated dysmenorrhoea, hormonal treatment may not be necessary for all patients who undergo surgical treatment for endometriosis. The aim of this study was to clarify the determinant factors that predict the recurrence of endometriosis after surgery in order to develop personalized hormonal treatment recommendations. Factors associated with the recurrence of endometrioma and pain were investigated independently to identify the likelihood of recurrence in each individual patient.

STUDY DESIGN

Between 2008 and 2013, 352 patients underwent surgery and were diagnosed with endometriosis based on pathological findings at the study hospital. Among these patients, 191 experienced a recurrence of endometrioma in the absence of pre- or postoperative hormonal treatment. Various clinical factors such as pre-operative pain, intra-operative findings and postoperative improvement of pain were compared between patients who experienced recurrence after surgery and those who did not.

RESULTS

The cumulative 5-year recurrence rate of endometrioma was 28.7% among the 191 patients who did not undergo pre- or postoperative hormonal treatment. Significant differences were detected in maximum tumour diameter, revised American Society for Reproductive Medicine score (r-ASRM score), operative time and operative blood loss between patients in the recurrent endometrioma group and the non-recurrent endometrioma group; only the r-ASRM score was significantly correlated with recurrence of endometrioma in the multivariate analysis. The cumulative 5-year rate of persistent/recurrent pain was 33.4%. There were significant differences in the postoperative improvement of pain between the persistent/recurrent pain group and the non-recurrent pain group according to the univariate and multivariate analyses.

CONCLUSION

This study suggests that the risk factors for recurrence of endometrioma differ from the risk factors for recurrence of pain. The use of postoperative hormonal treatment should be considered based on the dominant risk factors and needs of each patient.

Analysis of Adherence, Persistence, and Surgery Among Endometriosis Patients Treated with Leuprolide Acetate Plus Norethindrone Acetate Add-Back Therapy

BACKGROUND

Endometriosis affects over 10 million women in the United States. Depot leuprolide acetate (LA), a gonadotropin-releasing hormone agonist, has been used extensively for the treatment of women with endometriosis but is associated with hypoestrogenic symptoms and bone mineral density loss. The concomitant use of add-back therapies, specifically norethindrone acetate (NETA), can alleviate these adverse effects.

OBJECTIVE

To compare adherence to and persistence with LA treatment and time to endometriosis-related surgery among women treated with NETA and women treated with LA plus other add-back therapies or LA only.

METHODS

This retrospective analysis was conducted using Truven Health MarketScan Commercial Claims and Encounters Database. Women with a diagnosis of endometriosis (ICD-9-CM code 617.xx) who initiated LA (index date) in 2005-2011 were selected for inclusion. Additional requirements were 12 months of continuous enrollment pre- and post-index and no evidence of endometriosis-related surgeries pre-index or up to 30 days post-index; no pre-index use of estrogen or noncontraceptive hormones; and no diagnoses of uterine fibroids, malignant neoplasms, infertility, or pregnancy. Patients were characterized as using NETA; other add-back therapies (estrogens, progestins, or estrogen-progestin combinations); or no add-back therapy. Adherence to and persistence with LA were measured over the 6 months following the index date using outpatient medical and pharmacy claims. Patients were considered adherent if their proportion of days covered was greater than or equal to 0.80. Persistence was operationalized as time to discontinuation, defined as a continuous gap of > 60 days without LA on hand. Time to endometriosis-related surgery (laparotomy, laparoscopy, excision/ablation/fulguration, oophorectomy, and hysterectomy) was measured over the 12 months following the index date. Surgeries were identified from inpatient and outpatient medical claims using procedure codes. Outcomes were compared among cohorts using multivariable logistic and Cox proportional hazards regression models controlling for demographics and baseline clinical characteristics.

RESULTS

The final sample included 3,114 women, with a mean age of 36.9 years. The majority of women used LA only with no add-back therapy (n = 1,963, 63.0%), while 15.1% (n = 470) used NETA, and 21.9% (N = 681) used other add-back therapies. During the 6-month follow-up, more patients in the LA plus NETA cohort were adherent to LA therapy compared with LA only (47.2% vs. 31.5%, P < 0.001), and fewer patients discontinued (37.9% vs. 59.6%, P < 0.001). Additionally, fewer patients underwent endometriosis-related surgery in the 12 months after LA initiation in the LA plus NETA cohort (12.6% vs. 16.9%, P = 0.021). In multivariable models, women who initiated LA plus NETA or LA plus other add-back therapies had a higher likelihood of being adherent to LA than LA only patients (OR = 1.91, 95% CI = 1.55-2.36 and OR = 1.95, 95% CI = 1.63-2.34) and lower likelihood of LA discontinuation (HR = 0.54, 95% CI = 0.46-0.63 and HR = 0.59, 95% CI = 0.52-0.68). NETA patients had a lower surgery rate in the 12-month post-index period compared with other add-back patients (HR = 0.68, 95% CI = 0.50-0.93) or LA only patients (HR = 0.69, 95% CI = 0.52-0.92).

CONCLUSIONS

For women with endometriosis, treatment with LA and concomitant add-back therapies was associated with better adherence to and persistence with LA over the 6 months following initiation, compared with treatment with LA only. The increased adherence and persistence to LA may translate into decreased need for surgical intervention, although fewer endometriosis-related surgeries were only observed in the 12 months following LA initiation for patients using concomitant NETA add-back therapy. These results support an increased and earlier use of NETA add-back therapy among women who initiate LA.

DISCLOSURES

This study was funded by AbbVie, which also markets the endometriosis drugs Lupron and Lupaneta Pack. AbbVie participated in the study design, research, data collection, analysis and interpretation, writing, review, and approval of this publication. Soliman and Castelli-Haley are employees of AbbVie and may own AbbVie stock or stock options. Bonafede and Farr are employees of Truven Health Analytics, which received a research contract to conduct this study with and on behalf of AbbVie. Winkel is a clinical professor in the Department of Obstetrics and Gynecology at Georgetown University in Washington, DC, and has served in a consulting role on research to AbbVie for this project. An earlier version of the current research was presented at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 20th Annual International Meeting; Philadelphia, PA; May 2015. All authors participated in data analysis and interpretation and contributed to the development of the manuscript.

Epidemiology of Endometriosis in France: A Large, Nation-Wide Study Based on Hospital Discharge Data

We aimed to assess the prevalence of hospitalization for endometriosis in the general population in France and in each French region and to describe temporal trends, rehospitalization rates, and prevalence of the different types of endometriosis. The analyses were carried out on French hospital discharge data and covered the period 2008–2012 and a population of 14,239,197 women of childbearing age. In this population, the prevalence of hospitalization for endometriosis was 0.9%, ranging from 0.4% to 1.6% between regions. Endometriosis affected 1.5% of hospitalized women of childbearing age, ranging from 1.0% to 2.4% between regions. The number of patients hospitalized for endometriosis significantly increased over the study period (p < 0.01). Of these, 4.2% were rehospitalized at least once at one year: ranging from 2.7% to 6.3% between regions. The cumulative rehospitalization rate at 3 years was 6.9%. The types of endometriosis according to the procedures performed were as follows: ovarian (40–50%), peritoneal (20–30%), intestinal (10–20%), and ureteral or bladder (<10%), with significant differences between regions. This is the first detailed epidemiological study of endometriosis in France. Further studies are needed to assess the reasons for the increasing prevalence of endometriosis and for the significant differences in regional prevalence of this disease.

Endometriosis in adolescents

Background and Objectives:

Women with endometriosis often report onset of symptoms during adolescence; however, the diagnosis of endometriosis is often delayed. The aim of this study was to describe the experience of adolescents who underwent laparoscopy for pelvic pain and were diagnosed with endometriosis: specifically, the symptoms, time from onset of symptoms to correct diagnosis, number and type of medical professionals seen, diagnosis, treatment, and postoperative outcomes.

Methods:

We reviewed a series of 25 females ≤21 years of age with endometriosis diagnosed during laparoscopy for pelvic pain over an 8-year period. These patients were followed up for 1 year after surgery.

Results:

The mean age at the time of surgery was 17.2 (2.4) years (range, 10–21). The most common complaints were dysmenorrhea (64%), menorrhagia (44%), abnormal/irregular uterine bleeding (60%), ≥1 gastrointestinal symptoms (56%), and ≥1 genitourinary symptoms (52%). The mean time from the onset of symptoms until diagnosis was 22.8 (31.0) months (range, 1–132). The median number of physicians who evaluated their pain was 3 (2.3) (range, 1–12). The adolescents had stage I (68%), stage II (20%), and stage III (12%) disease. Atypical endometriosis lesions were most commonly observed during laparoscopy. At 1 year, 64% reported resolved pain, 16% improved pain, 12% continued pain, and 8% recurrent pain.

Conclusions:

Timely referral to a gynecologist experienced with laparoscopic diagnosis and treatment of endometriosis is critical to expedite care for adolescents with pelvic pain. Once the disease is diagnosed and treated, these patients have favorable outcomes with hormonal and nonhormonal therapy.