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Ding A, Noga H, Bouchard KN, Bedaiwy MA, Lee C, Allaire C, Orr NL, Yong PJ. Pain with orgasm in endometriosis: potential etiologic factors and clinical correlates. J Sex Med 2024:qdae084. [PMID: 39039031 DOI: 10.1093/jsxmed/qdae084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 05/05/2024] [Accepted: 07/10/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Pelvic pain worsened by orgasm is a poorly understood symptom in patients with endometriosis. AIM To assess the prevalence of pelvic pain worsened by orgasm in patients with endometriosis and explore its association with potential etiologic factors, including pelvic floor myalgia, uterine tenderness and adenomyosis, and central nervous system sensitization. METHODS An analysis was done of a prospective data registry based at a tertiary referral center for endometriosis. Eligible participants were patients aged 18 to 50 years who were referred between January 1, 2018, and December 31, 2019, diagnosed with endometriosis, and subsequently underwent surgery at the center. Clinical features were compared between participants reporting worsening pelvic pain with orgasm and those without worsening pain with orgasm, including patient-reported variables, physical examination findings, and anatomic phenotyping at the time of surgery. Pelvic floor myalgia and uterine tenderness were assessed by palpation on pelvic examination, adenomyosis by ultrasound, and central nervous system sensitization via the Central Sensitization Inventory (range, 0-100). OUTCOMES Outcomes included pelvic or lower abdominal pain in the last 3 months that worsened with orgasm (yes/no). RESULTS Among 358 participants with endometriosis, 14% (49/358) reported pain worsened by orgasm while 86% (309/358) did not. Pain with orgasm was significantly associated with pelvic floor myalgia (55% [27/49] vs 35% [109/309]; Cohen's h = 0.40, P = .01) and higher scores on the Central Sensitization Inventory (mean ± SD, 53.3 ± 17.0 vs 42.7 ± 18.2; Cohen's d = 0.60, P < .001) but not with uterine tenderness or adenomyosis. Other clinical features associated with pain with orgasm were poorer sexual health (higher scores: deep dyspareunia, Cohen's h = 0.60; superficial dyspareunia, Cohen's h = 0.34; and Female Sexual Distress Scale-Revised, Cohen's d = 0.68; all P < .05) and poorer mental health (higher scores: Patient Health Questionnaire-9, 12.9 ± 6.7 vs 9.1 ± 6.3, Cohen's d = 0.59, P < .001; Generalized Anxiety Disorder-7, 9.4 ± 5.6 vs 6.8 ± 5.5, Cohen's d = 0.48, P = .002). Anatomic findings at the time of surgery did not significantly differ between the groups. CLINICAL IMPLICATIONS Interventions targeting pelvic floor myalgia and central nervous system sensitization may help alleviate pain worsened by orgasm in patients with endometriosis. STRENGTHS AND LIMITATIONS A strength is that pain worsened by orgasm was differentiated from dyspareunia. However, pain with orgasm was assessed by only a binary question (yes/no). Also, the study is limited to a single center, and there were limited data on sexual function. CONCLUSION Pelvic pain exacerbated by orgasm in people with endometriosis may be related to concurrent pelvic floor myalgia and central sensitization.
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Affiliation(s)
- Avrilynn Ding
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver V5H 3N1, Canada
| | - Heather Noga
- Women's Health Research Institute, Vancouver V5H 3N1, Canada
- Center for Pelvic Pain and Endometriosis, BC Women's Hospital, Vancouver V5H 3N1, Canada
| | - Katrina N Bouchard
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver V5H 3N1, Canada
| | - Mohamed A Bedaiwy
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver V5H 3N1, Canada
- Center for Pelvic Pain and Endometriosis, BC Women's Hospital, Vancouver V5H 3N1, Canada
| | - Caroline Lee
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver V5H 3N1, Canada
- Center for Pelvic Pain and Endometriosis, BC Women's Hospital, Vancouver V5H 3N1, Canada
| | - Catherine Allaire
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver V5H 3N1, Canada
- Center for Pelvic Pain and Endometriosis, BC Women's Hospital, Vancouver V5H 3N1, Canada
| | - Natasha L Orr
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver V5H 3N1, Canada
- Center for Pelvic Pain and Endometriosis, BC Women's Hospital, Vancouver V5H 3N1, Canada
| | - Paul J Yong
- Women's Health Research Institute, Vancouver V5H 3N1, Canada
- Center for Pelvic Pain and Endometriosis, BC Women's Hospital, Vancouver V5H 3N1, Canada
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Liu YD, Noga H, Allaire C, Bedaiwy MA, Lee CE, Williams C, Booth A, Galea LAM, Kaida A, Ogilvie GS, Brotto LA, Yong PJ. Mental Health Outcomes of Endometriosis Patients during the COVID-19 Pandemic: Impact of Pre-pandemic Central Nervous System Sensitization. THE JOURNAL OF PAIN 2024; 25:104481. [PMID: 38246253 DOI: 10.1016/j.jpain.2024.01.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 01/23/2024]
Abstract
To correlate pain-related phenotyping for central nervous system sensitization in endometriosis-associated pain with mental health outcomes during the COVID-19 pandemic, the prospective Endometriosis and Pelvic Pain Interdisciplinary Cohort (ClinicalTrials.gov #NCT02911090) was linked to the COVID-19 Rapid Evidence Study of a Provincial Population-Based Cohort for Gender and Sex (RESPPONSE) dataset. The primary outcomes were depression (PHQ-9) and anxiety (GAD-7) scores during the pandemic. The explanatory variables of interest were the Central Sensitization Inventory (CSI) score (0-100) and endometriosis-associated chronic pain comorbidities/psychological variables before the pandemic. The explanatory and response variables were assessed for correlation, followed by multivariable regression analyses adjusting for PHQ-9 and GAD-7 scores pre-pandemic as well as age, body mass index, and parity. A higher CSI score and a greater number of chronic pain comorbidities before the pandemic were both positively correlated with PHQ-9 and GAD-7 scores during the pandemic. These associations remained significant in adjusted analyses. Increasing the CSI score by 10 was associated with an increase in pandemic PHQ-9 by .74 points (P < .0001) and GAD-7 by .73 points (P < .0001) on average. Each additional chronic pain comorbidity/psychological variable was associated with an increase in pandemic PHQ-9 by an average of .63 points (P = .0004) and GAD-7 by .53 points (P = .0002). Endometriosis patients with a history of central sensitization before the pandemic had worse mental health outcomes during the COVID-19 pandemic. As a risk factor for mental health symptoms in the face of major stressors, clinical proxies for central sensitization can be used to identify endometriosis patients who may need additional support. PERSPECTIVE: This article adds to the growing literature of the clinical importance of central sensitization in endometriosis patients, who had more symptoms of depression and anxiety during the COVID-19 pandemic. Clinical features of central sensitization may help clinicians identify endometriosis patients needing additional support when facing major stressors.
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Affiliation(s)
- Yang D Liu
- University of British Columbia Endometriosis and Pelvic Pain Laboratory, Vancouver, BC, Canada
| | - Heather Noga
- University of British Columbia Endometriosis and Pelvic Pain Laboratory, Vancouver, BC, Canada; Women's Health Research Institute, Vancouver, BC, Canada
| | - Catherine Allaire
- Women's Health Research Institute, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Mohamed A Bedaiwy
- Women's Health Research Institute, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Caroline E Lee
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Christina Williams
- University of British Columbia Endometriosis and Pelvic Pain Laboratory, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Amy Booth
- Women's Health Research Institute, Vancouver, BC, Canada
| | - Liisa A M Galea
- Women's Health Research Institute, Vancouver, BC, Canada; Department of Psychology, University of British Columbia, Vancouver, BC, Canada; Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Angela Kaida
- Women's Health Research Institute, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Gina S Ogilvie
- Women's Health Research Institute, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada; British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Lori A Brotto
- Women's Health Research Institute, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Paul J Yong
- University of British Columbia Endometriosis and Pelvic Pain Laboratory, Vancouver, BC, Canada; Women's Health Research Institute, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
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Cetera GE, Merli CEM, Barbara G, Caia C, Vercellini P. Questionnaires for the Assessment of Central Sensitization in Endometriosis: What Is the Available Evidence? A Systematic Review with a Narrative Synthesis. Reprod Sci 2024; 31:633-644. [PMID: 37751146 PMCID: PMC10912156 DOI: 10.1007/s43032-023-01343-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/28/2023] [Indexed: 09/27/2023]
Abstract
It has been suggested that central sensitization (CS) may be involved in the failure of standard medical and surgical treatment to relieve endometriosis-related pain. However, there is no gold standard for the diagnosis of CS, and self-reported questionnaires are used as diagnostic surrogates. The main objective of this review was to identify all CS questionnaires used in clinical endometriosis studies. The secondary objective was to qualitatively analyze strengths and weaknesses of each questionnaire. A PubMed and EMBASE systematic literature search conducted in April 2023 using the terms "endometriosis; central pain; central sensitization; questionnaire; patient-reported outcome measure; screening tool" identified 122 publications: six articles were included in the review. The Central Sensitization Inventory (CSI) is the most frequently used questionnaire for the detection of CS in patients with endometriosis. It has been validated in patients with endometriosis, in whom it appears to have good psychometric proprieties. The Fibromyalgia Survey Questionnaire (FSQ) has also been used, although it has not been specifically validated in endometriosis patients. The debate regarding these questionnaires' construct validity is still open and will be so until a gold standard diagnostic tool for CS is found. In fact, some authors argue these questionnaires are measuring psychological vulnerability and a hypervigilant state that is associated with pain, rather than CS itself. However, their use should not be discouraged as they are able to identify chronic pain patients which warrant further attention and who may benefit from broader treatment strategies.
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Affiliation(s)
- Giulia Emily Cetera
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Giussy Barbara
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
- Obstetric and Gynecological Emergency Unit and SVSeD (Service for Sexual and Domestic Violence), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Carlotta Caia
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Vercellini P, Bandini V, Viganò P, Ambruoso D, Cetera GE, Somigliana E. Proposal for targeted, neo-evolutionary-oriented secondary prevention of early-onset endometriosis and adenomyosis. Part II: medical interventions. Hum Reprod 2024; 39:18-34. [PMID: 37951241 DOI: 10.1093/humrep/dead206] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/07/2024] [Indexed: 11/13/2023] Open
Abstract
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.
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Affiliation(s)
- Paolo Vercellini
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Veronica Bandini
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
| | - Paola Viganò
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Deborah Ambruoso
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
| | - Giulia Emily Cetera
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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5
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Cetera GE, Merli CEM, Boero V, Caia C, Facchin F, Barbara G, Monti E, Vercellini P. Central Sensitization in Vulvodynia and Endometriosis: What Have We Been Overlooking So Far? Obstet Gynecol Surv 2023; 78:745-758. [PMID: 38134340 DOI: 10.1097/ogx.0000000000001183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Importance Women experience more frequent and greater pain than men, although they receive less adequate treatment and are perceived as more anxious than males. Recent clinical research has lead to hypothesize a common etiology for overlapping chronic pain conditions and mood disorders, namely, central sensitization, which originates from an alteration of pain processing pathways in the central nervous system. Objective The aim of this review was to collect all available evidence regarding the potential role of central sensitization in vulvodynia and endometriosis. Evidence Acquisition A systematic literature search was performed between July and August 2022 using the electronic database PubMed. The extracted data were summarized using a narrative approach. Results Ten articles were chosen for the review. Participants' mean age was 39.2 years (SD = 5.1). Among serum markers of central sensitization, nitric oxide levels were greater in women with endometriosis than in controls, whereas brain-derived neurotrophic factor and S100B levels differed among pain conditions with structural anomalies and those without. Functional magnetic resonance imaging showed different resting state networks between patients with endometriosis and controls. In neurophysiology studies, cases had reduced pain thresholds, compared with healthy controls. Lastly, self-reported questionnaires suggested a central component of pain in women with endometriosis-related dyspareunia and associated bladder/pelvic floor tenderness. Conclusions and Relevance The management of vulvodynia and endometriosis may benefit from a new perspective, which considers their possible central etiology. It is compelling that treatment of pain starts to be considered a therapeutic goal in its own right.
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Affiliation(s)
- Giulia Emily Cetera
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | | | - Veronica Boero
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlotta Caia
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Federica Facchin
- Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy
| | - Giussy Barbara
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Ermelinda Monti
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Hernández Cardona MI, Ajewole C, Lewis H, Carrillo JF, Castellanos ME, Barish S, Echeverri JDV, Lamvu G. Time to move beyond surgical classification systems for endometriosis. Int J Gynaecol Obstet 2023; 163:58-62. [PMID: 37101408 DOI: 10.1002/ijgo.14786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/03/2023] [Accepted: 03/28/2023] [Indexed: 04/28/2023]
Abstract
Endometriosis is a common condition associated with chronic pelvic pain and infertility. Its pathogenesis is poorly understood, diagnosis relies on laparoscopy, and staging is based on extent of disease. Unfortunately, the current staging systems do not correlate well with pain severity and impact, nor do they predict prognosis, i.e., treatment success and recurrence of disease. In this article, we discuss the strengths and limitations of current staging systems and propose modifications that will enable better classification systems to be developed in the future.
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Affiliation(s)
| | | | - Hannah Lewis
- University of Central Florida College of Medicine/HCA Healthcare Consortium of Greater Orlando, Kissimmee, Florida, USA
| | - Jorge F Carrillo
- Orlando VA Healthcare System, Orlando, Florida, USA
- University of Central Florida College of Medicine, Orlando, Florida, USA
| | | | | | - Juan Diego Villegas Echeverri
- Unidad de Laparoscopia Ginecológica Avanzada ALGIA, Pereira, Risaralda, Colombia
- Clínica Comfamiliar, Pereira, Risaralda, Colombia
- FIGO (the International Federation of Gynecology & Obstetrics) Director of the Division of Benign Surgery, London, UK
| | - Georgine Lamvu
- Orlando VA Healthcare System, Orlando, Florida, USA
- University of Central Florida College of Medicine, Orlando, Florida, USA
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Quintas-Marquès L, Martínez-Zamora MÁ, Camacho M, Gràcia M, Rius M, Ros C, Carrión A, Carmona F. Central sensitization in patients with deep endometriosis. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1005-1007. [PMID: 36708006 DOI: 10.1093/pm/pnad002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/27/2022] [Accepted: 01/05/2023] [Indexed: 01/29/2023]
Affiliation(s)
- Lara Quintas-Marquès
- Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Maria-Ángeles Martínez-Zamora
- Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Marta Camacho
- Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Meritxell Gràcia
- Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Mariona Rius
- Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Cristina Ros
- Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ana Carrión
- Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francisco Carmona
- Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Till SR, Schrepf A, Clauw DJ, Harte SE, Williams DA, As-Sanie S. Association Between Nociplastic Pain and Pain Severity and Impact in Women With Chronic Pelvic Pain. THE JOURNAL OF PAIN 2023; 24:1406-1414. [PMID: 36958459 PMCID: PMC10511662 DOI: 10.1016/j.jpain.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/09/2023] [Accepted: 03/12/2023] [Indexed: 03/25/2023]
Abstract
Exploring the relationship between nociplastic pain and the severity and impact of pelvic pain symptoms could lend insight into the heterogeneous symptom presentation and treatment response that complicates management of chronic pelvic pain. In this prospective cross-sectional study, we sought to evaluate relationships between degree of nociplastic pain, measured by the Fibromyalgia (FM) Survey Score, and multiple aspects of the chronic pelvic pain (CPP) experience, including severity, frequency, tenderness during pelvic myofascial exam, interference with daily life, and high-impact pain. The study included 303 women who presented to a tertiary referral clinic for chronic pelvic pain and endometriosis. Multiple measures of pelvic pain, including pain severity, frequency, interference, pelvic myofascial pain, and high-impact pain were examined in General Linear Models with FM Survey Score as the primary predictor of interest in models controlling for endometriosis, surgical history, use of opioids, body mass index, and patient age. Higher level of nociplastic pain was associated with greater pelvic pain severity, frequency, interference, and pelvic myofascial pain (all P < .05). For all models, degree of nociplastic pain was more strongly associated with pain outcomes than the presence of endometriosis, and use of opioids was the only stronger predictor of worse pain outcomes. The likelihood of high impact pain increased 7% for each additional point on the FM Survey Score. Degree of nociplastic pain was robustly associated with severity, frequency, and impact of pelvic pain, and was independent of the presence of endometriosis, history of surgical procedures for pelvic pain, age, and BMI. Trial registration: not applicable PERSPECTIVE: This article evaluates the impact of nociplastic pain on symptoms and functional status in chronic pelvic pain. These findings raise the possibility that a simple screening tool for nociplastic pain might provide clinically actionable information without the need for deep neurobiological phenotyping and may inform development of personalized management strategies.
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Affiliation(s)
- Sara R Till
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan..
| | - Andrew Schrepf
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Daniel J Clauw
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Steven E Harte
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - David A Williams
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Sawsan As-Sanie
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Raimondo D, Raffone A, Renzulli F, Sanna G, Raspollini A, Bertoldo L, Maletta M, Lenzi J, Rovero G, Travaglino A, Mollo A, Seracchioli R, Casadio P. Prevalence and Risk Factors of Central Sensitization in Women with Endometriosis. J Minim Invasive Gynecol 2023; 30:73-80.e1. [PMID: 36441085 DOI: 10.1016/j.jmig.2022.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 11/05/2022]
Abstract
STUDY OBJECTIVE To assess prevalence of central sensitization (CS) and its association with demographic and clinical factors in patients with endometriosis. DESIGN Single-center, observational, cross-sectional study. SETTING Tertiary center. PATIENTS Consecutive patients with endometriosis referred to the center from January 15, 2022, to April 30, 2022. INTERVENTIONS For each enrolled patient, demographic and clinical data were collected, and the presence of CS was measured using the CS Inventory questionnaire (score ≥40). MEASUREMENTS AND MAIN RESULTS Primary study outcome was CS prevalence, and secondary study outcomes were the associations between demographic and clinical factors and CS. The 95% confidence intervals for CS prevalence were obtained with Bayesian-derived Jeffreys method, and the associations between CS and demographic and clinical factors were evaluated with the chi-square test and Fisher's exact test, where appropriate. The variables significantly associated with CS were then included in a multivariable logistic regression model. The significance level was set at .05 for all analyses. During the study period, 285 eligible women were enrolled. CS prevalence was 41.4% (95% confidence interval, 35.8-47.2). At univariable analysis, infertility, moderate to severe pain symptoms (except for dyschezia), altered bowel movements, posterolateral parametrium involvement, hormonal therapy failure (HTF), and most of central sensitivity syndromes were significantly associated with CS occurrence. Multivariable analysis only confirmed the significant association of CS with moderate to severe chronic pelvic pain, posterolateral parametrium involvement, HTF, migraine or tension-type headache, irritable bowel syndrome, and anxiety or panic attacks. CONCLUSION CS has a high prevalence in patients with endometriosis, especially in those with moderate to severe chronic pelvic pain, posterolateral parametrium involvement, HTF, and 3 central sensitivity syndromes (i.e. migraine or tension-type headache, irritable bowel syndrome, anxiety or panic attacks). Given the association with HTF, identifying CS through CS Inventory might be useful to counsel the patient and to choose multimodal treatment.
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Affiliation(s)
- Diego Raimondo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Raffone, Renzulli, Raspollini, Bertoldo, Maletta, Rovero, Seracchioli, and Casadio), Bologna, Italy
| | - Antonio Raffone
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Raffone, Renzulli, Raspollini, Bertoldo, Maletta, Rovero, Seracchioli, and Casadio), Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna (Drs. Raffone, Renzulli, Sanna, Raspollini, Bertoldo, Maletta, Rovero, and Seracchioli), Bologna, Italy.
| | - Federica Renzulli
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Raffone, Renzulli, Raspollini, Bertoldo, Maletta, Rovero, Seracchioli, and Casadio), Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna (Drs. Raffone, Renzulli, Sanna, Raspollini, Bertoldo, Maletta, Rovero, and Seracchioli), Bologna, Italy.
| | - Giada Sanna
- Department of Medical and Surgical Sciences, University of Bologna (Drs. Raffone, Renzulli, Sanna, Raspollini, Bertoldo, Maletta, Rovero, and Seracchioli), Bologna, Italy
| | - Arianna Raspollini
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Raffone, Renzulli, Raspollini, Bertoldo, Maletta, Rovero, Seracchioli, and Casadio), Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna (Drs. Raffone, Renzulli, Sanna, Raspollini, Bertoldo, Maletta, Rovero, and Seracchioli), Bologna, Italy
| | - Linda Bertoldo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Raffone, Renzulli, Raspollini, Bertoldo, Maletta, Rovero, Seracchioli, and Casadio), Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna (Drs. Raffone, Renzulli, Sanna, Raspollini, Bertoldo, Maletta, Rovero, and Seracchioli), Bologna, Italy
| | - Manuela Maletta
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Raffone, Renzulli, Raspollini, Bertoldo, Maletta, Rovero, Seracchioli, and Casadio), Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna (Drs. Raffone, Renzulli, Sanna, Raspollini, Bertoldo, Maletta, Rovero, and Seracchioli), Bologna, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna (Dr. Lenzi), Bologna, Italy
| | - Giulia Rovero
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Raffone, Renzulli, Raspollini, Bertoldo, Maletta, Rovero, Seracchioli, and Casadio), Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna (Drs. Raffone, Renzulli, Sanna, Raspollini, Bertoldo, Maletta, Rovero, and Seracchioli), Bologna, Italy
| | - Antonio Travaglino
- Gynecopathology and Breast Pathology Unit, Department of Woman and Child's Health Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS (Dr. Travaglino), Rome, Italy; Pathology Unit, Department of Advanced Biomedical Sciences, University of Naples "Federico II," Naples (Dr. Travaglino)
| | - Antonio Mollo
- Gynecology and Obstetrics Unit, Department of Medicine, Surgery and Dentistry "Schola Medica Salernitana," University of Salerno, Baronissi (Dr. Mollo), Italy
| | - Renato Seracchioli
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Raffone, Renzulli, Raspollini, Bertoldo, Maletta, Rovero, Seracchioli, and Casadio), Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna (Drs. Raffone, Renzulli, Sanna, Raspollini, Bertoldo, Maletta, Rovero, and Seracchioli), Bologna, Italy
| | - Paolo Casadio
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Raffone, Renzulli, Raspollini, Bertoldo, Maletta, Rovero, Seracchioli, and Casadio), Bologna, Italy
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10
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Persistent Pelvic Pain in Patients With Endometriosis. Clin Obstet Gynecol 2022; 65:775-785. [PMID: 35467583 DOI: 10.1097/grf.0000000000000712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
As our understanding of chronic pain conditions, including endometriosis-related pain and chronic pelvic pain evolves, the evaluation and management of patients should reflect our increasing appreciation of the role of central sensitization, comorbid conditions and biopsychosocial factors on the pain experience and treatment outcomes. This review provides a systematic approach to persistent pain in patients with endometriosis. Expanding the evaluation and treatment of endometriosis-related pain by all health care providers could limit unnecessary surgical interventions and best meet our patient's needs.
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11
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Orr NL, Wahl KJ, Lisonek M, Joannou A, Noga H, Albert A, Bedaiwy MA, Williams C, Allaire C, Yong PJ. Central sensitization inventory in endometriosis. Pain 2022; 163:e234-e245. [PMID: 34030173 DOI: 10.1097/j.pain.0000000000002351] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 05/17/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT A key clinical problem is identifying the patient with endometriosis whose pain is complicated by central nervous system sensitization, where conventional gynecologic treatment (eg, hormonal therapy or surgery) may not completely alleviate the pain. The Central Sensitization Inventory (CSI) is a questionnaire previously validated in the chronic pain population. The objective of this study was an exploratory proof-of-concept to identify a CSI cutoff in the endometriosis population to discriminate between individuals with significant central contributors (identified by central sensitivity syndromes [CSS]) to their pain compared to those without. We analyzed a prospective data registry at a tertiary referral center for endometriosis, and included subjects aged 18 to 50 years with endometriosis who were newly or re-referred to the center in 2018. The study sample consisted of 335 subjects with a mean age of 36.0 ± 7.0 years. An increasing number of CSS was significantly correlated with dysmenorrhea, deep dyspareunia, dyschezia, and chronic pelvic pain scores (P < 0.001), and with the CSI score (0-100) (r = 0.731, P < 0.001). Receiver operating characteristic analysis indicated that a CSI cutoff of 40 had a sensitivity of 78% (95% CI: 72.7%-84.6%) and a specificity of 80% (95% CI: 70.3%-84.5%) for identifying a patient with endometriosis with ≥3 CSS. In the group with CSI ≥ 40, 18% retrospectively self-reported pain nonresponsive to hormonal therapy and 40% self-reported daily pain, compared with 6% and 20% in the CSI < 40 group (P = 0.003 and 0.002, respectively). In conclusion, a CSI ≥ 40 may be a practical tool to help identify patients with endometriosis with pain contributors related to central nervous system sensitization.
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Affiliation(s)
- Natasha L Orr
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
- BC Women's Center for Pelvic Pain and Endometriosis Vancouver, BC, Canada
| | - Kate J Wahl
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
- BC Women's Center for Pelvic Pain and Endometriosis Vancouver, BC, Canada
| | - Michelle Lisonek
- BC Women's Center for Pelvic Pain and Endometriosis Vancouver, BC, Canada
| | - Angela Joannou
- BC Women's Center for Pelvic Pain and Endometriosis Vancouver, BC, Canada
| | - Heather Noga
- Women's Health Research Institute, Vancouver, BC, Canada
| | - Arianne Albert
- Women's Health Research Institute, Vancouver, BC, Canada
| | - Mohamed A Bedaiwy
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
- BC Women's Center for Pelvic Pain and Endometriosis Vancouver, BC, Canada
- Women's Health Research Institute, Vancouver, BC, Canada
| | - Christina Williams
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
- BC Women's Center for Pelvic Pain and Endometriosis Vancouver, BC, Canada
| | - Catherine Allaire
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
- BC Women's Center for Pelvic Pain and Endometriosis Vancouver, BC, Canada
- Women's Health Research Institute, Vancouver, BC, Canada
| | - Paul J Yong
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
- BC Women's Center for Pelvic Pain and Endometriosis Vancouver, BC, Canada
- Women's Health Research Institute, Vancouver, BC, Canada
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12
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Masciullo L, Viscardi MF, Piacenti I, Scaramuzzino S, Cavalli A, Piccioni MG, Porpora MG. A deep insight into pelvic pain and endometriosis: a review of the literature from pathophysiology to clinical expressions. Minerva Obstet Gynecol 2021; 73:511-522. [PMID: 33904687 DOI: 10.23736/s2724-606x.21.04779-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endometriosis is a chronic inflammatory disease that affects approximately 10% of women of reproductive age. Its clinical manifestations are highly heterogeneous, but pelvic pain is the most frequent, causing functional disability. Cyclic or acyclic chronic pelvic pain (CPP), dysmenorrhea and dyspareunia are frequent symptoms which often compromise all aspects of the women's quality of life (QoL). The pathophysiology of endometriosis-related pain is extremely complex and not always clear. The aim of this literature review is to focus on recent updates on the clinical presentation, the pathophysiology and the most important mechanisms involved in the pathogenesis of pelvic pain in endometriosis. A literature search in the Cochrane library, PubMed, Scopus and web of Science databases has been performed, identifying articles from January 1995 to November 2020. Several processes seem to be involved in the pathogenesis of pain, but many aspects are still unclear. Scientific evidence has shown that a correlation between pain severity and stage of endometriosis rarely occurs, whereas there is a significant correlation between pain and the presence of deep endometriosis. Onset and intensity of pain may be due to a complex process involving central sensitization and peripheral activation of nociceptive pathways as well as dysfunction of the immune system and of the hypothalamic-pituitary-adrenal (HPA) axis. A deeper understanding of these different pathogenetic mechanisms may improve future treatments in women with painful endometriosis.
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Affiliation(s)
- Luisa Masciullo
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Maria F Viscardi
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Ilaria Piacenti
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Sara Scaramuzzino
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Alessandra Cavalli
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Maria G Piccioni
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Maria G Porpora
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy -
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13
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Rossi V, Tripodi F, Simonelli C, Galizia R, Nimbi FM. Endometriosis-associated pain: a review of quality of life, sexual health and couple relationship. Minerva Obstet Gynecol 2021; 73:536-552. [PMID: 33904688 DOI: 10.23736/s2724-606x.21.04781-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Endometriosis is a chronic gynecological disease that affects women's quality of life, sexuality, and relationship. Endometriosis-associated pain plays an essential role in well-being impairment. The present review aimed to analyze literature about endometriosis-associated pain and quality of life, sexual health, and quality of the relationship, assessing the role of the biopsychosocial factors involved and the women's pain experience. EVIDENCE ACQUISITION Bibliographic research of relevant articles published from 2015 to 2020 in PubMed, Google Scholar, Web of Science, Scopus, EBSCO, and Cochrane Library. EVIDENCE SYNTHESIS Endometriosis is associated with impairing all women's quality of life domains, and pain appears to be the most influential variable. The pain mechanism is not simple and implies several biological, psychological, and social factors. Women's sexual health is also impaired, and patients report dyspareunia, sexual dysfunctions, dissatisfaction, and distress. Partners' sexual well being is compromised as well. Endometriosis negatively influences relationship quality, and the illness burden affects both couple members. CONCLUSIONS A multidisciplinary team using a couple-centered and a biopsychosocial approach is crucial to provide appropriate treatment for endometriosis-associated pain. A better comprehension of all bio-psycho-social aspects implicated in women's well-being and pain experience needs more research.
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Affiliation(s)
| | | | - Chiara Simonelli
- Department of Dynamic, Clinical and Health Psychology, Sapienza University of Rome, Rome, Italy
| | - Roberta Galizia
- Department of Dynamic, Clinical and Health Psychology, Sapienza University of Rome, Rome, Italy
| | - Filippo M Nimbi
- Department of Dynamic, Clinical and Health Psychology, Sapienza University of Rome, Rome, Italy
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