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

Associations between stigma and depression among college-attending women with endometriosis symptoms

Background: Endometriosis is a debilitating and highly stigmatized chronic condition. The relationship between stigma and depressive symptoms among college-attending women with endometriosis symptoms was examined. Method: Data were analyzed from a cross-sectional online survey of undergraduate women (N = 424). Mean anticipated, internalized, and enacted stigma values were calculated. Logistic regression assessed the relationship between stigma score and depressive symptoms. Results: Mean stigma scores were 1.98 (anticipated), 1.46 (internalized), and 1.59 (enacted) on a 5-point scale (1 being the lowest and 5 being the highest); 24.1% reported moderately severe/severe depressive symptoms. In adjusted models, stigma was associated with an increased likelihood of moderately severe/severe depressive symptoms (anticipated (aOR = 1.96, 95% CI:1.49-2.59); internalized (aOR =2.67, 95% CI: 1.88-3.85); enacted (aOR = 1.28, 95% CI: 1.16-1.42)). Conclusion: College attending-women with endometriosis symptoms experience stigma which is significantly associated with depressive symptoms. Stigma reducing interventions are warranted and may have mental health benefits.

"SO FAR AWAY" How Doctors Can Contribute to Making Endometriosis Hell on Earth. A Call for Humanistic Medicine and Empathetic Practice for Genuine Person-Centered Care. A Narrative Review

"SO FAR AWAY" * How Doctors Can Contribute to Making Endometriosis Hell on Earth [* by Knopfler M. In Dire Straits. Brothers in Arms. Vertigo Records, U.K., 1985].

Abstract

The distance physicians may create within the relationship with their patients by not having a humanistic approach to their practice may strongly influence clinical outcomes. The purpose of this paper is to convey the well-known narrative of patient dissatisfaction into pro-action by discussing the aspects of dehumanization, which may occur in the relationship between physicians and women with endometriosis. Eight dimensions of dehumanization are examined and related to everyday scenarios occurring in endometriosis care settings and the possible downstream consequences on patients' clinical outcomes are described. Objectification, which may come across as minimization of pain, may not only increase patients' perception of pain but also lead to undertreatment of unrecognized forms of endometriosis, especially among adolescents. Passivity, that is not favoring shared decision-making nor self-management, may compromise adherence to treatment, reducing patients' trust in physicians and quality of life. The same consequences may result from homogenization, that is giving for granted that all patients have the same access to care. Both isolation, ie not practicing therapeutic empathy, and loss of meaning, ie not supporting patients in the re-definition of their life plans, may affect women's psychological wellbeing and further increase pain perception. Ignoring women's personal journey by not providing clear information on the consequences endometriosis may have on their lives may favor women's self-silencing. Not promoting an un-biased communication and not setting aside scientific polarization are the main features of dislocation, which may jeopardize patient empowerment. Lastly, having a reductionist approach to the body may contribute to chronicization of pain, thus compromising quality of life. This considered, taking time to listen to women with endometriosis and tailoring decisions on the basis of their individual needs should be fostered as a moral duty. Physicians should always keep in mind that they are not only deliverers of treatment; they are a form of treatment themselves.

Polycystic ovary syndrome: Current scenario and future insights

Polycystic ovary syndrome (PCOS) prevails in approximately 33% of females of reproductive age globally. Although the root cause of the disease is unknown, attempts are made to clinically manage the disturbed hormone levels and symptoms arising due to hyperandrogenism, a hallmark of PCOS. This review presents detailed insights on the etiology, risk factors, current treatment strategies, and challenges therein. Medicinal agents currently in clinical trials and those in the development pipeline are emphasized. The significance of the inclusion of herbal supplements in PCOS and the benefits of improved lifestyle are also explained. Last, emerging therapeutic targets for treating PCOS are elaborated. The present review will assist the research fraternity working in the concerned domain to access significant knowledge associated with PCOS.

[Holistic treatment of endometriosis]

BACKGROUND

The pain phenomena caused by endometriosis are manifold. In addition to nociceptive pain there is also a nociplastic reaction with central sensitization. Atypical symptoms, such as acyclic lower abdominal pain, radiating pain, nonspecific bladder and intestinal complaints or even depression increasingly occur in addition to the classical cyclic complaints, such as severe dysmenorrhea, cyclic lower abdominal pain, dyspareunia, dysuria and dyschezia. Due to the diffuse range of symptoms, affected patients often consult not just gynecologists but also specialists from other disciplines (internal medicine, gastroenterology, orthopedics, pain therapy, psychology etc.).

OBJECTIVE

The complexity of endometriosis is presented. The resulting approaches to multimodal interdisciplinary holistic treatment are described.

RESULTS

Interdisciplinary concepts should be involved in the optimal treatment of endometriosis patients along with hormonal and surgical treatment, mostly under the supervision of a gynecologist and pain management, dietary changes, psychological support and physiotherapeutic management should also be included. This article provides an overview of possible treatment strategies for chronic symptomatic endometriosis.

CONCLUSION

Based on multimodal treatment strategies and regarding the complex pathophysiological alterations of this disease, the complex complaints that significantly impair the quality of life of endometriosis patients can be greatly improved.

Patient experiences of endometriosis diagnosis: A mixed methods approach

OBJECTIVE

To examine patient-described experiences of endometriosis diagnosis.

DESIGN

Mixed-methods study.

SETTING

Online patient-led endometriosis support groups.

POPULATION OR SAMPLE

People with endometriosis aged over 18.

METHODS

A survey with qualitative and quantitative questions was distributed through online patient-led endometriosis support groups. Descriptive statistics were used to analyse quantitative data, and thematic analysis was used for qualitative responses. Quantitative and qualitative data were triangulated to examine patient experiences of endometriosis diagnosis across age groups.

MAIN OUTCOME MEASURES

Experiences of endometriosis diagnosis among people with endometriosis.

RESULTS

A total of 2017 people with endometriosis from 63 countries responded to the questionnaire. Patients experienced an average delay of 3.7 years between symptom onset and first presentation of symptoms to a physician (the care-seeking delay) and an average delay of 5.8 years between first presentation of symptoms to a physician and diagnosis of endometriosis (the healthcare-related delay). Patients experienced an average total diagnostic delay of 9.6 years. Participants aged over 35 at the time of the study reported significantly longer times to receive an endometriosis diagnosis (mean 10.7, 95% confidence interval [CI] 10.2-11.2) compared with participants age 18-24 (6.8, 95% CI 6.1-7.5 years). The qualitative analysis identified the following themes: physicians normalised endometriosis symptoms, patients felt their symptoms were ignored by physicians because they were considered unreliable, and participant character attributes (e.g. age, appearance, weight or physical ability) led to clinician dismissal.

CONCLUSIONS

People with endometriosis of all age groups reported pervasive negative healthcare experiences during their adolescence. Patients experience delays in seeking care and in receiving a diagnosis once presenting for care.

The nano-revolution in the diagnosis and treatment of endometriosis

Endometriosis is a painful gynecological disease with a high prevalence, affecting millions of women worldwide. Innovative, non-invasive treatments, and new patient follow-up strategies are needed to deal with the harmful social and economic effects. In this scenario, considering the recent, very promising results already reported in the literature, a commitment to new research in the field of nanomedicine is urgently needed. Study findings clearly show the potential of this approach in both the diagnostic and therapeutic phases of endometriosis. Here, we offer a brief review of the recent exciting and effective applications of nanomedicine in both the diagnosis and therapy of endometriosis. Special emphasis will be placed on the emerging theranostic application of nanoproducts, and the combination of phototherapy and nanotechnology as new therapeutic modalities for endometriosis. The review will also provide interested readers with a guide to the selection process and parameters to consider when designing research into this type of approach.

Pain Levels of Women Diagnosed with Endometriosis: Is There a Difference in Younger Women?

STUDY OBJECTIVE

Early diagnosis and treatment of endometriosis affecting adolescent women are important in preventing chronic pain. Our aim was to analyze the clinical characteristics and severity of symptoms in adolescent patients with endometriosis compared with older patients.

METHODS

This single-center retrospective cohort study in a tertiary referral hospital analyzed women whose first consultation at the certified endometriosis center of Bern University Hospital between January 2017 and December 2020 resulted in the clinical diagnosis of endometriosis. Patients, divided into 2 groups by age, reported visual analog scale (VAS) scores for noncyclic pelvic pain, dysmenorrhea, dyschezia, dysuria, and dyspareunia. The symptom types and severity in the 2 groups were compared. The young patients with endometriosis were analyzed in greater detail, comparing VAS scores and types of endometriosis.

RESULTS

From a total of 826 patients, 144 (17.4%) patients 24 years old or younger and 682 (82.6%) patients over 24 years old were compared. The younger patients reported significantly higher pain scores for dysmenorrhea (VAS 7.3 vs 6.6; P = .015), dyspareunia (VAS 4.6 vs 3.4; P = .001), and noncyclic pelvic pain (VAS 4.3 vs 3.7; P = .032) compared with the older patient collective. Similar results were found when excluding patients with hormonal treatment.

CONCLUSION

Young patients with clinically diagnosed endometriosis have significantly higher dysmenorrhea and dyspareunia pain levels than older patients. By acknowledging and understanding this, early diagnosis and adequate treatment can be promoted. Dyspareunia in adolescents in particular merits clinical attention.

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.

Pelvic Pain, Mental Health and Quality of Life in Adolescents with Endometriosis after Surgery and Dienogest Treatment

BACKGROUND

Diagnostic and treatment delays have caused significant impacts on the physical and emotional well-being of adolescents with endometriosis, though such research is limited. This study aimed to assess the effects of one-year dienogest therapy on the clinical picture, pain patterns, psycho-emotional status, and quality-of-life indicators in adolescents with endometriosis after surgical treatment.

METHODS

The study enrolled 32 girls aged 13-17 with peritoneal endometriosis to analyze one-year dynamics of the Visual Analog Scale (VAS), McGill Pain Questionnaire, Beck Depression Scale (BDI), Hospital Anxiety and Depression Scale (HADS), Spielberger State-Trait Anxiety Inventory (STAI) and SF-36 quality-of-life survey scores along with clinical and laboratory indicators before surgery and after one-year dienogest therapy.

RESULTS

The therapy provided a significant alleviation of endometriosis-associated clinical symptoms, including dysmenorrhea, pelvic pain, gastrointestinal/dysuria symptoms, decreased everyday activity (<0.001), a decrease in anxiety/depression scores (BDI, HADS, STAI), and quality-of-life improvement (<0.001). These effects were accompanied by beneficial dynamics in hormone and inflammatory markers (prolactin, cortisol, testosterone, estradiol, CA-125, neutrophil/lymphocyte ratio; <0.005) within reference ranges. A low body mass index and high C-reactive protein levels were associated with higher VAS scores; a high estradiol level was a factor for anxiety/depression aggravation (<0.05).

CONCLUSIONS

Dienogest, after surgical treatment, significantly improved quality of life and reduced pain symptoms while showing good tolerability and compliance, and reasoning with timely hormonal therapy in adolescents with endometriosis.

Endometriosis in Adolescents: Diagnostics, Clinical and Laparoscopic Features

BACKGROUND

The early diagnosis of endometriosis in adolescents is not developed.

OBJECTIVE

We aim to conduct clinical, imaging, laparoscopic and histological analyses of peritoneal endometriosis (PE) in adolescents in order to improve early diagnosis.

METHODS

In total, 134 girls (from menarche to 17 years old) were included in a case-control study: 90 with laparoscopically (LS) confirmed PE, 44 healthy controls underwent full examination and LS was analyzed in the PE group.

RESULTS

Patients with PE were characterized with heredity for endometriosis, persistent dysmenorrhea, decreased daily activity, gastrointestinal symptoms, higher LH, estradiol, prolactin and Ca-125 (<0.05 for each). Ultrasound detected PE in 3.3% and MRI in 78.9%. The most essential MRI signs are as follows: hypointense foci, the heterogeneity of the pelvic tissue (paraovarian, parametrial and rectouterine pouch) and sacro-uterine ligaments lesions (<0.05 for each). Adolescents with PE mostly exhibit initial rASRM stages. Red implants correlated with the rASRM score, and sheer implants correlated with pain (VAS score) (<0.05). In 32.2%, foci consisted of fibrous, adipose and muscle tissue; black lesions were more likely to be histologically verified (0.001).

CONCLUSION

Adolescents exhibit mostly initial PE stages, which are associated with greater pain. Persistent dysmenorrhea and detected MRI parameters predict the laparoscopic confirmation of initial PE in adolescents in 84.3% (OR 15.4; <0.01), justifying the early surgical diagnostics and shortening the time delay and suffering of the young patients.

Exploring the interface between adolescent dysmenorrhoea and endometriosis: a protocol for a cohort and nested case-control study within the QResearch Database

INTRODUCTION

Dysmenorrhoea affects up to 70%-91% of adolescents who menstruate, with approximately one-third experiencing severe symptoms with impacts on education, work and leisure. Dysmenorrhoea can occur without identifiable pathology, but can indicate underlying conditions, including congenital genital tract anomalies or endometriosis. There is a need for evidence about the management and incidence of dysmenorrhoea in primary care, the impact of treatments in adolescence on long-term outcomes and when to consider the possibility of endometriosis in adolescence.

METHODS AND ANALYSIS

This study aims to improve the evidence base for adolescents presenting to primary care with dysmenorrhoea. It comprises three interlinked studies. Using the QResearch Database, the study population includes all female at birth participants aged 10-19 years any time between 1 January 2000 and 30 June 2021. We will undertake (1) a descriptive study documenting the prevalence of coded dysmenorrhoea in primary care, stratified by demographic variables, reported using descriptive statistics; (2) a prospective open cohort study following an index cohort of all adolescents recorded as attending primary care with dysmenorrhoea and a comparator cohort of five times as many who have not, to determine the HR for a diagnosis of endometriosis, adenomyosis, ongoing menstrual pain or subfertility (considered singly and in combination) anytime during the study period; and (3) a nested case-control study for adolescents diagnosed with endometriosis, using conditional logistic regression, to determine the OR for symptom(s) preceding this diagnosis.

ETHICS AND DISSEMINATION

The project has been independently peer reviewed and received ethics approval from the QResearch Scientific Board (reference OX46 under REC 18/EM/0400).In addition to publication in peer-reviewed academic journals, we will use the combined findings to generate a resource and infographic to support shared decision-making about dysmenorrhoea in community health settings. Additionally, the findings will be used to inform a subsequent qualitative study, exploring adolescents' experiences of menstrual pain.

A Comprehensive Treatment Protocol for Endometriosis Patients Decreases Pain and Improves Function

Purpose

The purpose of this paper is to evaluate the efficacy of a multimodal, outpatient neuromuscular protocol in treating remaining sensitization and myofascial pain in endometriosis patients post-surgical excision.

Patients and Methods

A retrospective longitudinal study was conducted for women aged 22 to 78 with a history of surgically excised endometriosis. 60 women with an average duration of pain of 8.63 ± 7.65 years underwent a treatment protocol consisting of ultrasound guided trigger point injections, peripheral nerve blocks, and pelvic floor physical therapy for 6 weeks. Concomitant cognitive behavioral therapy once weekly for a total of 12 weeks was also undertaken. Pain intensity and pelvic functionality were assessed at new patient consults and 3-month follow ups using Visual Analogue Scale (VAS) and Functional Pelvic Pain Scale (FPPS).

Results

At new patient consults, average VAS and FPPS were 7.45 ± 2.11 (CI 6.92-7.98) and 14.35 ± 6.62 (CI 12.68 -16.02), respectively. At 3-month follow ups, average VAS and FPPS decreased to 4.12 ± 2.44 (CI 3.50-4.73; p < 0.001) and 10.3 ± 6.55 (CI 8.64-11.96; p < 0.001), respectively. Among FPPS categories, sleeping, intercourse, and working showed the highest statistical significance.

Conclusion

Data suggests the multimodal protocol was effective in treating the remaining underlying sensitization and myofascial pain seen in Endometriosis patients post-surgical excision, particularly in decreasing pain and improving function during work and intercourse.

Endometriosis and Opioid Receptors: Are Opioids a Possible/Promising Treatment for Endometriosis?

Endometriosis (EM), defined as the presence of endometrial-like tissue with surrounding smooth muscle cells outside the uterus, is a disregarded gynecological disease reported to affect 6-10% of women of reproductive age, with 30-50% of them suffering from chronic pelvic pain and infertility. Since the exact pathogenic mechanisms of EM are still unclear, no curative therapy is available. As pain is an important factor in EM, optimal analgesia should be sought, which to date has been treated primarily with non-steroidal anti-inflammatory drugs (NSAIDs), metamizole or, in extreme cases, opioids. Here, we review the pain therapy options, the mechanisms of pain development in EM, the endogenous opioid system and pain, as well as the opioid receptors and EM-associated pain. We also explore the drug abuse and addiction to opioids and the possible use of NOP receptors in terms of analgesia and improved tolerability as a target for EM-associated pain treatment. Emerging evidence has shown a promising functional profile of bifunctional NOP/MOP partial agonists as safe and nonaddictive analgesics. However, until now, the role of NOP receptors in EM has not been investigated. This review offers a thought which still needs further investigation but may provide potential options for relieving EM-associated pain.

Altered anterior insula functional connectivity in adolescent and young women with endometriosis-associated pain: Pilot resting-state fMRI study

BACKGROUND

Endometriosis is the leading cause of chronic pelvic pain. Alterations in brain functional connectivity have been reported in adult women with endometriosis-associated pain (EAP), however, it is still unknown if similar patterns of changes exist in adolescents.

METHODS

In this pilot study, resting-state fMRI scans were obtained from 11 adolescent and young women with EAP and 14 healthy female controls. Using a seed-to-voxel approach, we investigated functional connectivity between the anterior insula, medial prefrontal cortex, and the rest of the brain. Furthermore, we explored whether potential functional connectivity differences were correlated with clinical characteristics including disease duration, pain intensity, and different psychosocial factors (pain catastrophizing, fear of pain, functional disability, anxiety, and depression).

RESULTS

Our findings revealed that patients with EAP demonstrated significantly decreased connectivity between the right anterior insula and two clusters: one in the right cerebellum, and one in the left middle frontal gyrus compared to controls. Additionally, functional connectivity between the right anterior insula and the right cerebellum was positively associated with pain intensity levels. In patients with EAP, brain changes were also correlated with state anxiety and fear of pain.

CONCLUSIONS

Our results are relevant not only for understanding the brain characteristics underlying EAP at a younger age, but also in enhancing future pain treatment efforts by supporting the involvement of the central nervous system in endometriosis.

Surgically confirmed endometriosis in adolescents in Finland-A register-based cross-sectional cohort study

INTRODUCTION

Increasing awareness of endometriosis in adolescents requires data on the nature of the disease and its management. Our objective was to investigate the subtypes of surgically confirmed endometriosis in adolescents (aged <20 years) and trends in the incidence rates and endometriosis-related procedures during the study period, 1987-2012.

MATERIAL AND METHODS

In this register-based cohort study, we identified 526 adolescents receiving their initial surgical diagnosis of endometriosis between 1987 and 2012 from the Finnish Hospital Discharge Register. The age-specific incidence rate of surgically confirmed endometriosis was calculated by dividing the number of adolescents during specific periods by person-years. We calculated the relative differences in incidence rates between the periods using crude incidence ratios.

RESULTS

Adolescents were divided into three age groups, <17, 17-18, and 19 years, which comprised 8.2% (43/526), 39.7% (209/526), and 52.1% (274/526) of the study cohort, respectively. Peritoneal endometriosis and ovarian endometriosis were the most common types (379/526 [72%] and 119/526 [23%], respectively). The incidence rate of surgically confirmed endometriosis per 100 000 person-years varied from 5.63 (95% confidence interval [CI] 4.24-7.33) to 11.42 (95% CI 9.64-13.44). The incidence rate in 2001-2005 was significantly higher and was 1.6- to 2.0-fold that of the periods 1987-1990 and 2006-2012, respectively. Comparing the periods in which International Classification of Diseases, Ninth Revision (ICD-9; 1987-1995) and Tenth Revision (ICD-10; 1996-2012) codes were used, the use of laparoscopy (78.2% vs 88.9%), day surgery (10.3% vs 31.6%), and procedures for ovarian (18.8% vs 34.1%) and deep (0.6% vs 10.8%) endometriosis increased. The types of endometriosis and procedures did not differ between the age groups.

CONCLUSIONS

Peritoneal endometriosis was the most common type of endometriosis overall and by age group. During the 26-year period, the incidence rate of initial surgical diagnosis of endometriosis peaked in 2001-2005 and decreased thereafter. The proportion of procedures performed for ovarian and deep endometriosis increased, as did the use of laparoscopy and day surgery.

Endometriosis at all ages: diagnostic ultrasound

Endometriosis is a gynecological disease affecting about 10% of the female population. The multifactorial hormonal, inflammatory, genetic, mental and behavior pathogenesis can result in chronic pelvic pain, blooding disorders and infertility causing disruption of quality of life. Correct diagnosis of the extension and topography is substantial in defining the adequate therapeutic strategy. In an increasing proportion of the cases, endometriosis is being managed medically and para-medically; diagnostic or therapeutic surgery can often be avoided or delayed. Transvaginal sonography is considered being the first-line imaging method in the diagnosis of pelvic endometriosis. The paradigm shift from the belief that endometriosis only affects women of reproductive age has drawn attention to endometriosis in both premenarchal and postmenopausal patients. This review resumes the actually recommended ultrasound signs in the case of patients in menstrual age. Specific diagnostic approaches in adolescent and menopausal patients are highlighted.

Clinical efficacy of turtle shell decocted pills for endometriosis and their influence on cellular immunity

OBJECTIVE

To explore the therapeutic efficacy of the levonorgestrel-releasing intrauterine system combined with turtle shell decocted pills for endometriosis and their effect on cellular immune function.

METHODS

Clinical data of 118 patients with endometriosis admitted to Taizhou First People's Hospital from January 2019 to January 2020 were retrospectively analyzed. The patients were assigned into a single-drug group (n=68) and a combined traditional Chinese medicine group (n=50) according to treatment methods. The single-drug group was treated with the levonorgestrel-releasing intrauterine system, and the combined traditional Chinese medicine group was treated with additional turtle shell decocted pills for three cycles for a total of 12 weeks. Enzyme-linked immunosorbent assay was adopted to measure the concentration of Th1 cytokines (tumor necrosis factor (TNF)-α and interferon (IFN)-γ) and Th2 cytokines (interleukin (IL)-6 and IL-10), and the protein level of programmed cell death 1 (PD-1) and programmed cell death ligand 1 (PD-L1). The levels of serum luteinizing hormone (LH), follicle stimulating hormone (FSH), and estradiol (E2) were compared between the two groups. The response rate of treatment, the control rate of blood pressure and the incidence of adverse reactions were recorded in both groups.

RESULTS

The response rate of treatment in the combined traditional Chinese medicine group was higher than that in the single-drug group (P<0.05). Compared to before treatment, the TNF-α and IFN-γ increased in both groups after treatment, and the expressions were higher in the combined traditional Chinese medicine group than in the single-drug group (all P<0.05). After treatment, the levels of IL-6, IL-10, PD-1, and PD-L1 decreased, and the decreases in the combined traditional Chinese medicine group were greater than those in the single-drug group (all P<0.05). Serum LH, FSH and E2 levels before and after the treatment in the two groups were not statistically different (all P>0.05). The incidence of treatment-related adverse reactions between the two groups of patients was also not statistically different (P>0.05).

CONCLUSION

Turtle shell decocted pills can increase the clinical efficacy of levonorgestrel-releasing intrauterine system in the treatment of endometriosis, reduce levels of PD-1, and PD-L1 and improve cellular immune function. The pills do not affect the secretion of ovarian hormones or increase adverse reactions.

Beyond the Binary: Sexual and Reproductive Health Considerations for Transgender and Gender Expansive Adolescents

Awareness and visibility of transgender individuals have grown exponentially. However, conceptualizing sexual and reproductive health (SRH) as “women's” or “men's” health services further marginalizes transgender and gender-expansive (TGE) youth. Multiple reviews and commentaries have been published on the topic of SRH care for adults under the umbrella term of sexual and gender minorities, all with a call to action for more inclusive care and the need for more clinical research involving TGE individuals, and notably, TGE youth. Results from adult TGE studies are often translated to describe adolescent models. However, models specific to adolescent TGE populations are needed to understand their unique SRH needs. This review will describe the current literature relating to SRH needs of TGE youth and adults, highlighting key areas with significant disparities in need of further research. This comprehensive summary will also provide recommendations for clinicians and researchers with the goal of improving SRH care and obtaining wider representation in both clinical settings and research directed toward TGE youth.

Impact of Endometriosis in Women of Arab Ancestry on: Health-Related Quality of Life, Work Productivity, and Diagnostic Delay

Introduction: Endometriosis has a negative effect on health-related quality of life (HRQoL), wellbeing and daily functioning. Endometriosis is an under-researched condition within non-western populations. Cultural representations are needed to understand the relative roles of societal norms, traditional factors, and religious sensitivities on the impact of endometriosis on HRQoL in various populations. In particular, there is a lack of emphasis placed in understanding the association of HRQoL on endometriosis in Arab women. Method: In this prospective case-control study, 2,610 Arab ancestry women in the United Arab Emirates were recruited to investigate the impact of endometriosis on HRQoL, diagnostic delay, psychological co-morbidities, work productivity, and physical activity. Participants completed the following standardized, validated questionnaires: Short Form-36 version 2 questionnaire, the World Endometriosis Research Foundation EPHect minimum clinical questionnaire version, and Work Productivity and Activity Impairment questionnaire. Translations to the Arabic language, validated using the forward-backward translation method, of the questionnaires were utilized. Results: HRQoL scores were significantly impaired in women with endometriosis, as demonstrated in the Physical Composite Scores and Mental Composite Scores in the symptomatic control group (p = 0.001; p = 0.003, respectively) and the asymptomatic control group (p < 0.001; p < 0.001, respectively). Susceptibility and severity of multiple pain syndromes and infertility in women with endometriosis was the main indicator of lower HRQoL. Anxiety (p = 0.007) and depression (p = 0.005) were significantly associated with endometriosis, in comparison to symptomatic controls. The average diagnostic delay was 11.61 years, however single women experience 15.81 years of diagnosis delay, with approximately 18% (n = 15) of the single women experiencing more than a 20-year delay in diagnosis. The intensity of physical activity was not associated with endometriosis, when compared to symptomatic (p = 0.405) or asymptomatic controls (p = 0.144). Conclusion: For the first time, we provide evidence from a combined hospital, clinic, and population-based study that Arab women with endometriosis experience significant impacts on HRQoL, substantial diagnostic delay after the onset of symptoms, significant association to psychological disorders (anxiety and depression), and a negative impact on work productivity. Future research must focus on understanding the personal and culturally centered beliefs of Arab women to ensure a positive HRQoL trajectory by improving diagnosis and management strategies.

Combating Diagnostic Delay of Endometriosis in Adolescents via Educational Awareness: A Systematic Review

Endometriosis occurs in approximately 10% of adult women worldwide; however, it is commonly under- or misdiagnosed in adolescents. The purpose of this study was to analyze existing scientific literature for reasons for diagnostic delay of endometriosis and to determine how education regarding endometriosis could be improved. An integrative review was conducted based on articles published between December 1980 and December 2020. Suitable articles were identified from the MEDLINE/PubMed databases, using relevant terms. Eligible studies included discussion on potential causes of diagnostic delay of endometriosis in the adolescent population. Data were extracted from eligible publications and qualitative synthesis was used. The 27 articles included in the study revealed several primary reasons for the delay, such as a physician and/or patient knowledge gap, normalization by physician and patient, lack of research, and physician resistance. Strategies to lessen diagnostic delay of endometriosis in adolescents must include integrated actions by educators and healthcare providers to improve health literacy and awareness of common causes of pelvic pain in this age group.

Surgical management of endometriosis-associated pain

Endometriosis and pelvic pain are associated. However, only half of the subtle and typical, and not all cystic and deep lesions are painful. The mechanism of the pain is explained by cyclical trauma and repair, an inflammatory reaction, activation of nociceptors up to 2.7 cm distance, painful adhesions and neural infiltration. The relationship between the severity of lesions and pain is variable. Diagnosis of the many causes requires laparoscopy and expertise. Imaging cannot exclude endometriosis. Surgical removal is the treatment of choice. Medical therapy without a diagnosis risks missing pathology and chronification of pain if not 100% effective. Indications and techniques of surgery are described as expert opinion since randomised controlled trials were not performed for ethical reasons, since not suited for multimorbidity while a control group is poorly accepted. Subtle endometriosis needs destruction since some cause pain or progress to more severe disease. Typical lesions need excision or vaporisation since depth can be misjudged by inspection. Painful cystic ovarian endometriosis needs adhesiolysis and either destruction of the lining or excision of the cyst wall, taking care to avoid ovarian damage. Cysts larger than 6cm need a 2 step technique or an ovariectomy. Excision of deep endometriosis is difficult and complication prone surgery involving bladder, ureter, and bowel surgery varying from excision and suturing, disc excision with a circular stapler and resection anastomosis. Completeness of excision, prevention of postoperative adhesions and recurrences of endometriosis, and the indication to explore large somatic nerves will be discussed.

The Importance of a Multi-Disciplinary Approach to the Endometriotic Patients: The Relationship between Endometriosis and Psychic Vulnerability

Endometriosis is a chronic inflammatory condition, which is distinguished by the presence of the endometrial-like glands and stroma outside the uterine cavity. Pain and infertility are the most commonly expressed symptoms, occurring in 60% and 40% of cases, respectively. Women with endometriosis, especially those with pelvic pain, also have a greater vulnerability to several psychiatric disorders. There is, in particular, a tendency to contract affective or anxiety disorders as well as panic-agoraphobic and substance use disorders. Endometriosis with pelvic pain, infertility and psychic vulnerability usually leads to disability and a markedly lower quality of life for women of reproductive age. Thus, the burden of endometriosis is not limited to the symptoms and dysfunctions of the disease; it extends to the social, working and emotional spheres, leading to a severe impairment of global functioning. An analysis of scientific literature revealed a close relationship between specific temperamental traits, the expression of several psychiatric symptoms, chronicity of pain, risk of substance use and lower probability of a positive outcome. Endometriosis symptoms and the impact of related psychological consequences, increased vulnerability and the possible onset of psychiatric symptoms may influence coping strategies and weaken resilience, so triggering a vicious cycle leading to a marked deterioration in the quality of life. A multidisciplinary approach consisting of a medical team composed of gynecologists, psychologists, psychiatrists, experts in Dual Disorder, algologists and sexologists, would guarantee the setting of a target and taking the best decision on a personalized treatment plan. That approach would allow the prompt detection of any psychopathological symptoms and improve the endometriosis-related physical symptoms, bringing a healthier quality of life and a greater likelihood of a positive outcome.

Commentary: Novel Use of Offset Analgesia to Assess Adolescents and Adults with Treatment Resistant Endometriosis-Associated Pain

Background and Objective

Endometriosis, affecting approximately 176 million adults and adolescents worldwide, is a debilitating condition in which uterine tissue grows outside the uterus. The condition costs the US economy approximately $78 billion annually in pain-related disability. By understanding the neural underpinnings of endometriosis-associated pain (EAP) and risk factors for chronification, translational research methods could lessen diagnostic delays and maximize successful pain remediation. This can be accomplished by the novel use of a known method, offset analgesia (OA), to better elucidate the neural mechanisms that may contribute to and maintain EAP. This commentary will provide justification and rationale for the use of OA in the study of EAP.

Conclusion

Utilizing an OA paradigm in patients with endometriosis, especially adolescents, may (1) provide insight into neural mechanisms contributing to pain maintenance, which could capture those at-risk for the transition to chronic pelvic pain, (2) provide a metric for the development of future centrally mediated treatment options for this population, and (3) elucidate the brain changes that result in resistance to treatment and pain chronification.