Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis

Assessment of the Pelvic Pain Experienced by Infertile Women is of Prime Importance for Diagnosing Endometriosis

OBJECTIVE

To provide evidence regarding the significance of painful symptoms among women suffering from infertility.

DESIGN

An observational retrospective cross-sectional study.

SETTINGS

University hospital-based research center.

PATIENTS

Infertile patients aged between 18 and 42 years surgically explored for benign gynecological conditions between 01-2004 and 12-2020.

INTERVENTIONS

For each patient, a standardized questionnaire was completed during a face-to-face interview conducted by the surgeon in the month preceding the surgery. Preoperative assessment the pain symptoms was recorded. Pain intensity was assessed with a 10cm visual analog scale (VAS). The pain was considered to be severe when the VAS score was ≥ 7.

MEASUREMENTS AND MAIN RESULTS

Surgery was performed in 839 infertile women. 451 women had severe pelvic pain. Infertile patients with severe pain significantly more often had endometriosis (67.4% versus 30.7% respectively; p <.001) than infertile women without severe pelvic pain, and especially deep infiltrating lesions (43.2% versus 8.5% respectively; p <.001). Moreover, these women more often had intestinal endometriosis lesions (28.4% vs 1.8%; p <.001). After multivariable regression analysis, the presence of endometriosis, irrespective of the phenotype (superficial lesions (OR1.84 [1.19-2.86] and/or ovarian endometrioma OR 2.79 [1.70-4.59] and/or deep infiltrating endometriosis OR 4.49 [2.69-7.51]), and the presence of at least one intestine endometriosis lesion (OR6.49 [2.69-7.51] were significantly associated with severe pelvic pain.

CONCLUSION

Severe pelvic pain is significantly associated with endometriosis and especially deep infiltrating lesions in a population of infertile women. These results demonstrate the importance of thorough questioning regarding pelvic pain symptoms during the initial management of infertile patients.

The clinical effect of dienogest on urinary and sexual symptoms in endometriosis patients

BACKGROUND

To evaluate the effect of dienogest on urinary symptoms and sexual functioning within a 6-month follow-up period.

METHODS

We recruited 22 women with symptoms with dysmenorrhea, deep dyspareunia, and dyschezia accompanied with irritative urinary symptoms including frequency and urgency at Kaohsiung Medical University Chung-Ho Memorial Hospital from 2017 Jan 1 to 2019 Jan 1. The diagnosis of endometriosis mainly focused on vaginal examination and transvaginal ultrasound was performed in each patient. The participating patients took a daily dose of 2 mg Dienogest and underwent outpatient visits at the beginning, 1, 2, 3, and 6 months following treatment.

RESULTS

Our data showed a significant improvement in the visual Analog Scale (VAS) score from the first month till the sixth month after DNG treatment. The Overactive Bladder Symptom Score (OABSS), Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7) were significantly improved after the DNG treatment. Besides, serum estradiol was also decreased. Our data also showed that DNG treatment for 6 months did not affect Female Sexual Function Index (FSFI) score. Some patients with heavy menstruation also improved; however, some patients with regular periods missed or skipped a period after DNG treatment, while other adverse effects were also observed.

CONCLUSION

Our study demonstrated that DNG could not only alleviate endometriosis pelvic pain but reduce urinary symptoms within the 6-month follow-up as well. DNG did not affect sexual function as measured by the FSFI score, although some adverse effects were recorded.

Distribution of endometriosis phenotypes according to patients' age in adult women with surgical evaluation

STUDY QUESTION

What is the distribution of endometriosis phenotypes according to age in adult women undergoing surgery?

SUMMARY ANSWER

The phenotype of endometriosis did not significantly vary after 24 years old.

WHAT IS KNOWN ALREADY

The phenotypic evolution of endometriosis over time remains unclear. While adolescents can exhibit any type of endometriosis lesions, ovarian endometriosis (OMA) and/or deep-infiltrating endometriosis (DIE) tend to increase with age in young adults. In adulthood, understanding the evolution of lesions is crucial for disease management, but the literature on this subject is limited. This study aims to examine the distribution of endometriosis phenotypes in relation to age among adult patients requiring surgical treatment.

STUDY DESIGN, SIZE, DURATION

This observational cohort study included patients aged between ≥18 and ≤42 years, who underwent surgery for benign gynecological conditions at our institution between January 2004 and December 2022. A standardized questionnaire was completed for each patient during a face-to-face interview conducted by the surgeon in the month preceding surgery. Women with histologically proven endometriosis were included.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The distribution of endometriosis phenotypes (isolated superficial (SUP) endometriosis, OMA ± SUP, DIE ± SUP/OMA) was compared between young adults (≤24 years) and adults (>24 years) and among adults (25-28 years, 29-33 years, 34-38 years, 39 to ≤42 years) using univariate and multivariate analysis. The distribution of different subtypes of DIE (uterosacral ligament(s), vagina, bladder, intestine, and ureter), OMA size, and intensity of pain symptoms were also examined.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1311 adult women with histologically proven endometriosis were included. In women aged 24 years or younger (n = 116), the distribution of endometriosis phenotypes differed significantly from women older than 24 years (n = 1195): The frequency of the DIE ± SUP/OMA phenotype was lower (41.4% versus 56.1%, respectively), while the rate of isolated superficial lesions was higher (from 32.0% versus 25.9%) (P = 0.001). In the group of women aged >24 years, a significantly higher proportion of vaginal DIE lesions (P = 0.012) and a lower proportion of uterosacral ligament DIE lesions (P = 0.004) were found compared to women aged ≤24 years. No significant differences were observed in terms of endometrioma size. Between the ages of 25 and 42 years, there were no significant changes in the distribution of endometriosis phenotypes after univariate and multivariate analysis. The distribution of subtype of DIE lesions did not significantly change with age between 25 and 42 years. Concerning pain symptom scores, there was a significant decrease with age for dysmenorrhea and dyspareunia.

LIMITATIONS, REASONS FOR CAUTION

Inclusion of only surgical patients may have introduced a selection bias. Women referred to our center may have suffered from particularly severe clinical forms of endometriosis.

WIDER IMPLICATIONS OF THE FINDINGS

This study highlights that endometriosis presentation did not change with age in adult women. Further research on endometriosis phenotype evolution is necessary to assist practitioners in clinical decisions and treatment strategies.

STUDY FUNDING/COMPETING INTERESTS

None declared.

TRIAL REGISTRATION NUMBER

N/A.

Urodynamic Profile and Impact of Surgery in Women Affected by Deep Infiltrating Endometriosis: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the impact of deep infiltrating endometriosis (DIE) on bladder function and the possible impact of surgical resection.

DATA SOURCES

A systematic literature research was performed using the PubMed/MEDLINE and EMBASE database (last search date: April 30, 2024).

METHODS OF STUDY SELECTION

We included studies that evaluated the urodynamics (UDS) findings in women affected by DIE before submission to surgery. Following epidemiological designs were considered suitable: randomized control trials, observational prospective or retrospective studies, and case series. Metanalysis was performed using Jamovi Software version 2.3.28 (Sydney, Australia), according to PRISMA 2020 guidelines. Nine publications were included.

TABULATION, INTEGRATION, AND RESULTS

Nine studies, including 574 women affected by DIE and submitted to urodynamic assessment, were included. In women affected by DIE, preoperative detrusor overactivity (DO) was reported in 15% (95% confidence interval [CI] 3, 26; I2 = 93.9%, p <.001), preoperative voiding dysfunction in 21% (95% CI 12, 29; I2 = 78.1%, p <.001) and preoperative low maximum cystometry capacity was shown in 18% (95% CI -2, 38; I2 = 97.2%, p <.001). An abnormal bladder sensation was recorded in 39% of patients (95% CI 18, 60; I2 = 86%, p <.001), low preoperative bladder compliance was reported in 35% of patients (95% CI 30, 40; I2 = 0%, p = .66) and preoperative painful bladder filling was showed in 37% of the evaluated population (95% CI 27, 48; I2 = 0%, p = .58). No difference between preoperative and postoperative UDS detrusor overactivity was reported (odds ratio [OR] 0.45; 95% CI -0.10, 1.0, I2 = 0%; p = .66). Moreover, no difference in preoperative and postoperative voiding dysfunction was reported (OR 0.0; 95% CI -0.76, 0.76, I2 = 49.6%; p = .12).

CONCLUSION

Abnormal urodynamic findings before surgery are prevalent in women with DIE. Surgery seems not to affect UDS outcomes in women affected by DIE. However, heterogeneity among included studies may limit the generalizability of our findings.

Is Complete Excision Always Enough? A Quality of Sexual Life Assessment in Patients with Deep Endometriosis

Background and Objectives: The aim of this study was to find the factors associated with the severe impairment of QoSL and the factors associated with a better score in QoSL, as well as the evaluation of pain symptoms and QoSL after the complete and incomplete excision of rectovaginal nodules. Materials and methods: The present prospective study was conducted in a single tertiary center for endometriosis where 116 patients underwent laparoscopic surgery for deep endometriosis during a 3-year period. The goal of the intervention was to excise all endometriotic implants while conserving the rectum. Intraoperative findings were recorded after the intervention, and the patients were classified according to the ENZIAN classification and rASRM scores. QoSL was assessed using the EHP-30 Module C (QoSL Score). Results: When comparing the mean scores before and 2 years after the surgery, a highly significant improvement was found for QoSL and dysmenorrhea (p < 0.0001). The complete excision of rectovaginal nodules led to a significantly better QoSL and lower dyspareunia (p < 0.0001) than incomplete resection (p < 0.02). Conclusions: This prospective study proves that the complete laparoscopic excision of all endometriotic implants improved the QoSL and decreased the pain score of dyspareunia. Incomplete rectovaginal nodule excision was correlated with a poorer QoSL and a lower improvement of dysmenorrhea, dyspareunia, and chronic pelvic pain scores than complete excision.

Bladder Endometriosis: What do we know and what is left to find out? A narrative review

Bladder endometriosis accounts for 70-85% of urinary tract endometriosis cases. Urinary tract endometriosis occurs in approximately 1% of those living with endometriosis. Underlying aetiology and pathogenesis are not fully understood, but there are several plausible theories. As well as the typical pain symptoms, those with bladder endometriosis can experience several urinary tract symptoms. The manifestation of these symptoms can have complex pathways and processes. Imaging is accurate in the diagnosis of bladder endometriosis and clinicians should be mindful of the risk of silent kidney loss. Management should be guided by symptoms; both medical and surgical options are feasible. Surgical management offers potentially definitive treatment. Excisional surgery via bladder shave or partial cystectomy offers good improvement in symptoms with relatively low rates of serious complications and recurrence.

Investigating migraine phenotype and dynamics in women with endometriosis: an observational pilot study

INTRODUCTION

Migraine and endometriosis are chronic disabling pain conditions. There is evidence for a shared genetic background. Migraine phenotype and course in patients with the comorbidity are insufficient investigated. Both conditions can be treated with progestins.

METHODS

For this observational study we included women with migraine and endometriosis, visiting our clinic from 2015 to 2021. We collected available information from charts and complemented these data by a structured phone interview to collect more specific information on migraine and the course of both diseases.

RESULTS

From 344 patients fulfilling the inclusion criteria, 94 suffered from both, endometriosis and migraine. Migraine with aura was reported by 41% of the patients and was associated with earlier onset of migraine (age < 17 years (OR 6.54) and with a history of medication overuse headache (OR 9.9, CI 1.6-59.4). Present monthly migraine frequency (1.5 ± 2.6) was significantly lower than five years before the interview (2.9 ± 4.64). There was a correlation between medication overuse headache and use of analgesics more than 3 days/months for dysmenorrhoea (p < 0.03). ASRM endometriosis score was not associated with migraine characteristics.

CONCLUSIONS

We conclude that the comorbidity of endometriosis is highly linked to migraine with aura. Migraine onset in these patients was earlier. Further studies are needed to explore, if the observed decrease in migraine frequency can be attributed to recent endometriosis surgery and to understand if early diagnosis and treatment of both conditions may contribute to improve the course of both conditions. Trial registration BASEC Nr. 2021-00285.

Women's Self-Management of Dyspareunia Associated With Endometriosis: A Qualitative Study

Given the limitations of medical treatment for endometriosis, self-management is a critical component of symptom management, and providing patients with information and education is a necessary complement to medical interventions. Though 50 to 70% of people with endometriosis experience dyspareunia (painful sex), there is limited knowledge of self-management specific to painful sex. A comprehensive understanding of the self-management strategies used is foundational to developing supportive care interventions that help ease pain and related psychosocial sequelae. The objective was to describe people's experiences of navigating endometriosis-associated painful sex and developing self-management strategies. We analyzed interview data from 20 women using constant comparative and thematic analysis techniques, guided by qualitative interpretive description methodology. Participants (age range 18-44 years) all identified as women and were predominately Caucasian (90%) and heterosexual (80%). Throughout their lives, the women appeared to gradually develop self-management strategies while navigating painful sexual experiences. This complex journey encompassed four phases: 1) viewing painful sex as normal, 2) experiencing evolving thoughts and emotions, 3) coming to understand painful sex and seeking help, and 4) learning strategies to navigate painful sex, these include preparing mentally and physically for sex and communicating with intimate partner(s). Women in this study developed self-management strategies over time through engagement with others who understood their challenges. Future research is warranted regarding initiatives to counter the normalization of painful sex, develop and disseminate patient-facing information, provide education specific to dyspareunia, improve access to multidisciplinary care, facilitate social connections and support, and enhance communication with intimate partners. PERSPECTIVE: In this paper, we report on the experiences of women with endometriosis-associated painful sex and their self-management strategies. Clinicians may be interested in a qualitative exploration of endometriosis-associated painful sex as they seek to further understand their patient's experiences and what strategies can be implemented to alleviate dyspareunia. DATA AVAILABILITY: The data sets generated during and/or analyzed during the current study are not publicly available as participants did not consent to making their data publicly available but are available from the corresponding author on reasonable request.

Questionnaire-based screening of adolescents and young adult women can identify markers associated with endometriosis

STUDY QUESTION

Do adolescents and young adult women (YAW) with histologically proven endometriosis present a specific clinical history?

SUMMARY ANSWER

Questionnaire screening of adolescents and YAW can identify clinical markers associated with histologically proven endometriosis.

WHAT IS KNOWN ALREADY

Some validated questionaries can contribute to an earlier endometriosis diagnosis in adults. None of these scores, however, have been validated for adolescents or YAW.

STUDY DESIGN, SIZE, DURATION

This was an observational cross-sectional study using prospectively recorded data performed between January 2005 and January 2020 in a single university tertiary referral centre for endometriosis diagnosis and management. After a thorough surgical examination of the abdomino-pelvic cavity, women with histologically proven endometriosis were allocated to the endometriosis group, and symptomatic women without evidence of endometriosis were allocated to the endometriosis-free control group. The endometriotic patients were allocated into two sub-groups according to their age: adolescent (≤20 years) and YAW (21-24 years).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Adolescents and YAW ≤24 years of age were operated for a symptomatic benign gynaecological condition with signed informed consent. A standardized questionnaire was prospectively completed in the month before the surgery and included epidemiological data, pelvic pain scores, family history of endometriosis, and symptoms experienced during adolescence. The study searched for correlations by univariate analysis to determine clinical markers of endometriosis in adolescents and YAW compared with endometriosis-free control patients.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 262 study participants, 77 women were adolescents (≤20 years of age) and 185 patients (70.6%) were YAW. The endometriosis group included 118 patients (45.0%) and 144 (55.0%) were assigned to the control group. A family history of endometriosis, absenteeism from school during menstruation, history of fainting spells during menstruation, and prescription of oral contraceptive pills for intense dysmenorrhea were significantly more frequently observed in the endometriotic patients. The prevalence and mean pain scores for dysmenorrhea, deep dyspareunia, non-cyclic chronic pelvic pain and gastrointestinal and lower urinary tract symptoms were significantly greater in the endometriosis group, as was experienced rectal bleeding.

LIMITATIONS, REASONS FOR CAUTION

The study was performed in a single referral centre that treats patients with potentially more severe disease. This questionnaire was evaluated on a population of patients with an indication for endometriosis surgery, which can also select patients with more severe disease. Women with asymptomatic endometriosis were not considered in this study. These factors can affect the external validity of this study.

WIDER IMPLICATIONS OF THE FINDINGS

Patient interviews are relevant to the diagnosis of endometriosis in adolescents and YAW. Combined with imaging and clinical examination, this approach will enable earlier diagnosis and treatment, while remaining non-invasive and rapid.

STUDY FUNDING/COMPETING INTEREST(S)

The study received no funding from external sources. There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Migraine among women with endometriosis: a hospital-based case-control study in Bangladesh

BACKGROUND

Endometriosis is a disease among women of reproductive age, which causes several health problems, such as dysmenorrhea, dyspareunia, and subfertility. In addition, it increases psychological stress and often results in marital disharmony. Similarly, migraine is more frequent among this group of women. Several studies have shown an association between endometriosis and migraine among groups of populations completely different from Bangladesh.

OBJECTIVE

This study aimed to identify the association between endometriosis and migraine among the Bangladeshi population.

STUDY DESIGN

This nonrandomized case-control study was conducted with cases of endometriosis and controls without endometriosis who were confirmed by laparoscopy or laparotomy. Among the study participants, cases of migraine in 1 group of respondents who were already diagnosed as patients of migraine were identified, and the others with complaints of headaches were further confirmed by a medicine specialist. Patients were recruited from the Department of Obstetrics and Gynecology at the Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders General Hospital and Ibrahim Medical College. The study was approved by the ethical review committee of the Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders General Hospital. Multivariate logistic regression was used to identify the association between endometriosis and migraine using odds ratios and 95% confidence intervals.

RESULTS

Of 1496 patients who underwent laparoscopy or laparotomy during the study period, the frequency of endometriosis was found to be 12.7%. A total of 190 patients with confirmed endometriosis cases and an equal number of controls without endometriosis were enrolled, maintaining the age distribution of the controls similar to that of the cases. Compared with controls, the distribution of age, body mass index, education, and marital status of the patients with endometriosis were similar. The average ages of respondents were 30.6 years in both the case and control groups. Regarding occupation, cases included more students than controls (12% vs 0%, respectively). The odds of suffering from dysmenorrhea and dyspareunia among the cases were 3.3 (95% confidence interval, 2.66-4.15; P<.001) and 9.5 (95% confidence interval, 5.3-17.9; P<.001) times higher than that of controls, respectively. In addition, the odds of menstrual irregularity was 60% lower among the cases than among controls (odds ratio, 0.4; 95% confidence interval, 0.24-0.64; P<.001). No significant difference was observed in having primary subfertility and secondary subfertility among the 2 groups of respondents. Univariate regression analysis showed that patients with endometriosis have 6.13 times higher odds (95% confidence interval, 2.50-18.40; P<.001) of having a migraine and 2.00 times higher odds (95% confidence interval, 1.2-3.2; P=.01) of having a headache than controls. Furthermore, the age- and body mass index-adjusted multivariate model showed that patients with endometriosis have 5.4 times higher odds of having migraine than patients without endometriosis (95% confidence interval, 2.11-16.4; P<.001). In addition, the higher the age of reproductive-age women, the higher the odds of having migraine. A 1-year increase in age increases the odds of having migraine by 23% (odds ratio, 1.23; 95% confidence interval, 1.13-1.16; P<.001).

CONCLUSION

Our results support the association between endometriosis and migraine among the Bangladeshi population, which is similar to relevant studies conducted in other geographic locations. The groups of physicians who treat patients suffering from the 2 diseases, endometriosis and migraine, should keep this interrelationship in mind to ensure a better quality of life for the patient.

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.

Incidence and clinical features of endometriosis in 2484 consecutive female patients undergoing appendectomy for suspected appendicitis-a retrospective analysis

INTRODUCTION

Endometriosis is a common condition affecting 5 to 10% of women of childbearing age. The true incidence of endometriosis of the appendix is currently unknown. Since symptoms often overlap with those of acute appendicitis, endometriosis of the appendix presents a diagnostic challenge in the emergency department. This large retrospective study investigates the incidence and perioperative clinical, radiologic, and laboratory findings, as well as possible differences between patients with and without endometriosis.

METHODS

Data from consecutive patients who underwent appendectomy for suspected appendicitis without a history of endometriosis were analyzed. Perioperative clinical, laboratory, perioperative, and histopathologic findings were compared between women with and without endometriosis.

RESULTS

Between January 2008 and June 2023, 2484 consecutive patients without a history of endometriosis underwent urgent appendectomy for suspected appendicitis. Endometriosis was detected on histopathologic examination in 17 (0.7%) patients. Signs of appendicitis were found less frequently on ultrasound in the endometriosis group compared to the non-endometriosis group (23.4% vs. 61.5%; p = 0.002; OR = 0.193; 95% CI 0.063-0.593). There were no differences in physical examination findings, duration of symptoms, degree of inflammation, surgical outcomes, or complication rates.

CONCLUSION

The incidence of endometriosis of the appendix in patients undergoing appendectomy for suspected appendicitis was higher than suggested by data from autopsy series and populations with biopsy-proven endometriosis. Patients with endometriosis of the appendix were less likely to have a positive ultrasound finding, but perioperative and histopathologic findings and severity of inflammation did not differ from patients without endometriosis, presenting diagnostic challenges for clinicians.

Reproducibility of #Enzian classification by transvaginal ultrasound and its correlation with symptoms

Background

The #Enzian classification represents a system to describe endometriotic lesions during surgery. Its use is well established in correlating ultrasound and surgical findings.

Objectives

To describe interobserver reproducibility of ultrasound use and symptom correlation with compartments involved using #Enzian classification.

Materials and Methods

Two experienced operators performed transvaginal sonography (TVS) in 52 patients affected by pelvic endometriosis. A rate agreement was determined. A further 200 women with endometriotic TVS signs, with no previous surgery and not taking any hormonal therapy, were staged by one of three different operators according to the #Enzian (compartments A, B, C, O, T, FA, FB, FI, FU, FO). Statistical analysis compared all the compartments, as single or associated, with single or combined symptoms (dysmenorrhea, dyspareunia, heavy menstrual bleeding - HMB, bowel symptoms).

Main outcome measures

Evaluation of the reproducibility of #Enzian classification in assessing pelvic endometriosis among different operators using TVS, and of possible associations between symptoms and specific #Enzian compartments.

Results

Excellent agreement between the two operators in evaluating almost all the compartments (k >0.8) was observed. Dysmenorrhea did not correlate with any specific compartment. We observed a significant association between dyspareunia and B compartment (p=0.02). HMB is associated with FA (p=0.02). Bowel symptoms were associated with B (p=0.02). Combining more symptoms, we observed more significant associations with different compartments.

Conclusions

#ENZIAN classification is reproducible in the evaluation of pelvic endometriosis. Some symptoms are correlated to specific ultrasound signs of the disease.

What is new?

An accurate evaluation of symptoms could guide TVS examination to detect specific endometriotic lesions and establish the best management for the patients.

Pilot study of treatment of patients with deep infiltrative endometriosis with methotrexate carried in lipid nanoparticles

OBJECTIVE

Previously, lipid nanoparticles (LDE) injected in women with endometriosis were shown to concentrate in the lesions. Here, the safety and feasibility of LDE carrying methotrexate (MTX) to treat deep infiltrating endometriosis was tested.

DESIGN

Prospective pilot study.

SETTING

Perola Byington Hospital Reference for Women's Health.

SUBJECTS

Eleven volunteers (aged 30-47 years, BMI 26.15 ± 6.50 kg/m2) with endometriosis with visual analog scale pelvic pain scores (VAS) > 7 and rectosigmoid lesions were enrolled in the study.

INTERVENTION

Three patients were treated with LDE-MTX at single intravenous 25 mg/m2 dose of MTX and eight patients with two 25 mg/m2 doses with 1-week interval.

MAIN OUTCOME MEASURES

Clinical complaints, blood count, and biochemistry were analyzed before treatment and on days 90, 120, and 180 after LDE-MTX administration. Endometriotic lesions were evaluated by pelvic and transvaginal ultrasound (TVUS) before treatment and on days 30 and 180 after LDE-MTX administration.

RESULTS

No clinical complaints related with LDE-MTX treatment were reported by the patients, and no hematologic, renal, or hepatic toxicities were observed in the laboratorial exams. FSH, LH, TSH, free T4, anti-Müllerian hormone, and prolactin levels were also within normal ranges during the observation period. Scores for deep dyspareunia (p < 0.001), chronic pelvic pain (p = 0.008), and dyschezia (p = 0.025) were improved over the 180-day observation period. There was a non-significant trend for reduction of VAS scores for dysmenorrhea. Bowel lesions by TVUS were unchanged. No clear differences between the two dose levels in therapeutic responses were observed.

CONCLUSION

Results support the safety and feasibility of using LDE-MTX in women with deep infiltrating endometriosis as a novel and promising therapy for the disease. More prolonged treatment schemes should be tested in future placebo-controlled studies aiming to establish the usefulness of this novel nanomedicine approach.

Adenomyosis and endometriosis in adolescents and young women with pelvic pain: prevalence and risk factors

BACKGROUND

The aim of this study was to evaluate the prevalence of ultrasound diagnosis of adenomyosis and endometriosis in young women complaining of pelvic pain and to find the symptoms and clinical characteristics associated with these diseases in young women.

METHODS

Cross-sectional study, including 100 young women (14-24 years) with a history of chronic pelvic pain. Women were asked detailed medical hystory and pain symptoms scores (Visual Analogue Scale) and underwent gynecological examination and ultrasound evaluation.

RESULTS

The prevalence of endometriosis and adenomyosis in young women amounted to 25.0% and 46.0%, respectively. A significant correlation was found between ovarian endometriosis and adenomyosis. Dysmenorrhea and dyspareunia were risk factors for adenomyosis. Dyschezia, dyspareunia, chronic pelvic pain, presence of sonographic soft markers suggestive of pelvic adhesions, being a worker and having a previous surgery were risk factors for endometriosis. Young women (20-24 years) had a higher incidence of both adenomyosis and endometriosis than adolescents (14-19 years).

CONCLUSIONS

Our outcomes strengthen the hypothesis of a progressive and common course of the natural history of endometriosis, which initially may manifest with symptoms, then with signs of pelvic adhesions and finally as adenomyosis, ovarian endometriomas or deep infiltrating endometriosis.

Investigating the medical journey of endometriosis-affected women: Results from a cross-sectional web-based survey (EndoVie) on 1,557 French women

OBJECTIVE

To investigate the medical journey and the quality of life of French endometriosis-affected women, from the onset of the symptoms to the therapeutic management.

STUDY DESIGN

Between January 15th 2020 and February 3rd 2020, a prospective cross-sectional web-based survey was conducted among women diagnosed with endometriosis. The questionnaire included 52 questions distributed in five sections (screening, sociodemographic characteristics, impacts on quality of life, SF36 questionnaire, management of endometriosis and proposals for care improvement).

RESULTS

One thousand five hundred fifty-seven endometriosis-affected women aged of 42±12.8 years answered the questionnaire. On average, 7 years elapsed between the first symptoms (at 23.8 ± 10.2 years) and the diagnosis (31.0 ± 8.9 years). The mean number of symptoms was 4.6 ± 2.3, with 82 % of women experiencing pain scores between 7 and 10/10. Following diagnosis, 66 % women received a medical treatment, mostly hormonal treatments (45 %), with a significant decrease in pain intensity (VAS scores after treatment = 4.9 ± 2.7, p < 0.001). Most women (62 %) had already been operated, among whom 22 % by laparotomy. Finally, patients reported numerous impacts on their daily lives, particularly on the sexual, psychological, and physical fields. The overall mean score of quality of life was 4.3 ± 2.6 /10.

CONCLUSION

This large prospective web-based survey underlines that the journey of women with endometriosis is long and difficult until diagnosis and efficient treatment. It emphasizes the urgent need to reduce the diagnostic delay and thereby the burden of endometriosis on women's lives. Moreover, the creation of referral multidisciplinary centers appears to be crucial to improve the management of the disease.

Do women with suspected endometriosis benefit from pelvic examination to improve diagnostic and management strategy?

OBJECTIVE

To analyze the literature and expose best evidence available regarding the benefit of pelvic examination for women with suspected endometriosis METHODS: the AGREE II and GRADE systems for grading scientific evidence.

RESULTS

Endometriosis is characterized by the heterogeneity in its clinical presentation with many different symptoms reported by patients. In the literature, questioning for each symptom has a high sensitivity, reaching 76-98 %, but lacks specificity (20 - 58 %). The symptom-based approach is limited by its low specificity, the absence of external validation for most of the models developed and the inability to characterize the extent of the disease, which could have major implications in the decision - making process. The latest systematic review and meta-analysis included a total of 30 studies with 4,565 participants, compared the diagnostic performance of several modalities for endometriosis. Physical examination had a pooled sensitivity of 71 % and a specificity of 69 %, with an average diagnostic accuracy of 0.76. Overall, the value of pelvic examination is conferred by its high positive likehood ratio and specificity. Besides its diagnostic value, pelvic examination improves patients' management by allowing the identification of a possible myofascial syndrome as a differential diagnosis. It also increases the quality of the preoperative workup and influences the quality of surgical excision and decreases the time to diagnosis.

CONCLUSION

Despite the lack of studies in the primary care context, pelvic examination (vaginal speculum and digital vaginal examination) increases the diagnostic value for suspected endometriosis in association with questioning for symptoms.

Assessing the role of robotic surgery versus laparoscopic surgery in patients with a diagnosis of endometriosis: A meta-analysis

BACKGROUND

Surgical management of endometriosis can be carried out with the traditional standard laparoscopic technique or the robotic surgery technique; however, it is not clear if there is a significant difference between techniques. This meta-analysis aims to evaluate and compare the impact of robotic and standard laparoscopic techniques in endometriosis regarding the clinical outcome.

METHODS

Studies comparing robotic surgery to laparoscopic surgery for endometriosis were among the studies from various languages that met the inclusion criteria. Using dichotomous and continuous random-effect models, the results of these investigations (surgery time, hospitalization time, blood loss, complications, and conversion rate) were examined, and the mean difference with 95% confidence intervals was computed.

RESULTS

Eight studies from 2013 to 2022 were selected for the current analysis including 1741 patients with endometriosis. The studied data revealed a statistically significant (P = .01) lower operation time related to laparoscopic surgery compared with the robotic technique. In addition, the hospitalization time of laparoscopic surgery is significantly (P = .03) lower than that of robotic surgery. On the other hand, blood loss, rehospitalization, postoperative and intraoperative complications, and conversion rates were not significantly different between both techniques. Heterogeneity values were variable according to the analysis factor, from 0% to 91%.

CONCLUSION

Both robotic and standard laparoscopic techniques have similar outcomes regarding blood loss, rehospitalization, conversion rate, and rate of complication. However, the substantial difference between techniques was in favor of standard laparoscopic surgery regarding operation and hospitalization time.

Deep endometriosis of ileocecum complicated by acute intestinal obstruction: a case report

Endometriosis is a frequent gynecological pathology. Digestive localization complicated by acute intestinal obstruction is exceptionally rare. We herein report a case involving a 48-year-old woman who had a long-term history of endometriosis symptoms. She was diagnosed with endometriosis by ultrasound 1 month before her admission to the emergency room with acute intestinal obstruction. The diagnosis was confirmed by histopathological examination following surgical resection. Further medical management resulted in a satisfactory outcome.

IL-8 and IL-12p70 are associated with pelvic pain among infertile women with endometriosis

OBJECTIVE

To evaluate interleukin (IL)-1β, IL-6, IL-8, and IL-12p70 levels in serum and peritoneal fluid in women related to infertility and pelvic pain.

METHODS

Eighty-seven women were diagnosed with endometriosis or cases related to infertility. IL-1β, IL-6, IL-8, and IL-12p70 levels in serum and peritoneal fluid were determined by enzyme-linked immunosorbent assay (ELISA). Pain assessment was evaluated by the Visual Analog Scale (VAS) score.

RESULTS

Serum IL-6 and IL-12p70 levels increased in women with endometriosis compared to the control group. Serum and peritoneal IL-8 and IL-12p70 levels correlated with VAS scores in infertile women. A positive correlation was also found between peritoneal IL-1β and IL-6 with VAS score. A significant difference in peritoneal IL-1β levels was associated with menstrual pelvic pain, while peritoneal IL-8 levels were related to dyspareunia, menstrual, and post-menstrual pelvic pain in infertile women.

CONCLUSIONS

An association of IL-8 and IL-12p70 levels were related to pain in endometriosis, as well as a relationship between cytokine expression and VAS score. Further studies should be addressed to investigate the precise mechanism of cytokine-related pain in endometriosis.

Endometriosis and dyspareunia: Solving the enigma

Introduction

Endometriosis is a chronic oestrogen-dependent disease that affects 1 in 10 women of childbearing age. Half of these women have deep dyspareunia. The presence of this symptom has been shown to negatively affect your quality of life. There are few studies in the literature that address this issue and its pathophysiology remains poorly understood.

Materials and methods

A case-control study has been carried out in order to assess the multi-causality of dyspareunia in patients with endometriosis. All the patients were assessed in a unit specialising in endometriosis and pelvic pain and their disease was staged using high-resolution ultrasound following the criteria of the IDEA group. The patients were divided into two groups, patients with dyspareunia n = 45 (cases) and those without it n = 55 (controls).

Results

The only element that was statistically significant in explaining the dyspareunia was the presence of nodules in the retrocervical region with p = 0.000. The odds ratio of dyspareunia in the cases group was 5.3 (95 % CI 2.2-12.5).

Conclusions

Dyspareunia in patients with endometriosis is strongly dependent on the presence of nodules in the retrocervical region, although there are other factors involved that remain unknown, so more studies are still needed to understand and optimally address this symptom.

Severe pelvic pain is associated with sexual abuse experienced during childhood and/or adolescence irrespective of the presence of endometriosis

STUDY QUESTION

Is endometriosis associated with childhood and/or adolescent sexual abuse?

SUMMARY ANSWER

Endometriosis is not associated with a history of sexual abuse, unlike the presence of severe pelvic pain.

WHAT IS KNOWN ALREADY

Several studies have highlighted a link between pelvic pain and sexual abuse during childhood/adolescence. Moreover, an inflammatory state has been described in patients with a history of childhood maltreatment. Given that inflammation and pelvic pain are two entities often encountered with endometriosis, several teams have investigated whether endometriosis is associated with abuse during childhood/adolescence. However, the results are conflicting, and the link between sexual abuse and the presence of endometriosis and/or pain is hard to disentangle.

STUDY DESIGN, SIZE, DURATION

A survey nested in a cohort study of women surgically explored for benign gynecological indications at our institution between January 2013 and January 2017. For each patient, a standardized questionnaire was completed during a face-to-face interview with the surgeon in the month preceding the surgery. Pelvic pain symptoms (dysmenorrhea, deep dyspareunia, non-cyclic chronic pelvic pain, and gastrointestinal or lower urinary tract symptoms) and their intensities were assessed with a 10 cm visual analog scale (VAS). Pain was considered to be severe when the VAS score was ≥7.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A 52-question survey was sent in September of 2017 to evaluate abuses, especially sexual abuse during childhood and/or adolescence, and the psychological state during childhood and adolescence. The survey was structured to cover the following sections: (i) abuses and other life events during childhood and adolescence; (ii) puberty and body changes; (iii) onset of sexuality; and (iv) family relationships during childhood and adolescence. The patients were divided into groups according to whether or not they exhibited histologically proven endometriosis. Statistical analyses were conducted using univariate and multivariate logistic regression models.

MAIN RESULTS AND THE ROLE OF CHANCE

Two hundred and seventy-one patients answered all the questions of the survey: 168 with (endometriosis group) and 103 without endometriosis (control group). The mean ± SD overall population age was 32.2 ± 5.1 years. There were 136 (80.9%) and 48 (46.6%) women who experienced at least one severe pelvic pain symptom in the endometriosis and the control groups, respectively (P < 0.001). No differences were found between the two study groups regarding the following characteristics: (i) a history of sexual, physical, or emotional abuse; (ii) a history of abandonment or bereavement; (iii) the psychological state regarding puberty; and (iv) the family relationships. After multivariable analysis, we found no significant association between endometriosis and a history of sexual abuse during childhood and/or adolescence (P = 0.550). However, the presence of at least one severe pelvic pain symptom was independently associated with a history of sexual abuse (odds ratio = 3.6, 95% CI (1.2-10.4)).

LIMITATIONS, REASONS FOR CAUTION

Evaluation of the psychological state during childhood and/or adolescence can be subject to recall bias. In addition, selection bias is also a possibility given that some of the patients surveyed did not return the questionnaire.

WIDER IMPLICATIONS OF THE FINDINGS

Severe gynecological painful symptoms in women with or without histologically proven endometriosis may be linked to sexual abuse experienced during childhood and/or adolescence. Patient questioning about painful symptoms and abuses is important to provide comprehensive care to the patients, from a psychological to a somatic point of view.

STUDY FUNDING/COMPETING INTEREST(S)

No funding or competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Associations and gastrointestinal symptoms in women with endometriosis in comparison to women with irritable bowel syndrome: a study based on a population cohort

BACKGROUND

Endometriosis and irritable bowel syndrome (IBS) have similar symptoms, pathogenesis, and risk factors. These diagnoses often coexist and are frequently misdiagnosed leading to diagnostic delays. This study of a population-based cohort aimed to investigate associations relating to endometriosis and IBS and to compare gastrointestinal symptoms between endometriosis and IBS.

METHOD

The study cohort included women from the Malmö Offspring Study with information about endometriosis and IBS diagnoses from the National Board of Health and Welfare. The participants answered a questionnaire about lifestyle habits, medical and drug history, and self-reported IBS. The visual analog scale for IBS was used to estimate gastrointestinal symptoms the past 2 weeks. Endometriosis diagnosis and self-reported IBS were used as dependent variables to study associations with age, body mass index (BMI), education, occupation, marital status, smoking, alcohol habits, and physical activity using logistic regression. Mann-Whitney U Test or Kruskal-Wallis tests were used to calculate the differences in symptoms between groups.

RESULTS

Of the 2,200 women with information from medical records, 72 participants had endometriosis; 21 (29.2%) of these had self-reported IBS. Of the 1,915 participants who had answered the questionnaire, 436 (22.8%) had self-reported IBS. Endometriosis was associated with IBS (OR:1.86; 95%CI:1.06-3.26; p = 0.029), as well as with age 50-59 years (OR:6.92; 95%CI:1.97-24.32; p = 0.003), age ≥ 60 years (OR:6.27; 95%CI:1.56-25.17; p = 0.010), sick leave (OR:2.43; 95%CI:1.08-5.48; p = 0.033), and former smoking (OR:3.02; 95%CI:1.19-7.68; p = 0.020). There was an inverse association with BMI (OR:0.36; 95%CI:0.14-4.91; p = 0.031). IBS was associated with endometriosis (OR:1.77; 95%CI:1.02-3.07; p = 0.041) and sick leave (OR:1.77; 95%CI:1.14-2.73; p = 0.010), with a tendency to association with smoking (OR:1.30; 95%CI:0.98-1.72; p = 0.071). When excluding participants using drugs associated with IBS, the condition was associated with current smoking (OR:1.39; 95%CI:1.03-1.89; p = 0.033) and inversely with age 50-59 years (OR:0.58; 95%CI:0.38-0.90; p = 0.015). There were differences in the gastrointestinal symptoms between IBS and healthy participants, but not between endometriosis and IBS or healthy participants.

CONCLUSION

There were associations between endometriosis and IBS, without differences in gastrointestinal symptoms. Both IBS and endometriosis were associated with smoking and sick leave. Whether the associations reflect causality or depend on common risk factors and pathogenesis remains to be determined.

Acute abdominal pain in women of reproductive age: keys to suggest a complication of endometriosis

Although endometriosis is a common gynecological condition in women of reproductive age, a complication of endometriosis is rarely considered as the differential diagnosis of acute abdominal pain in that context. However, acute events in women with endometriosis can represent life-threatening conditions, which require emergent treatment and often surgical management. Mass effect of endometriotic implants can give rise to obstructive complications, specifically occurring in the bowel or in the urinary tract, while inflammatory mediators released by ectopic endometrial tissue can lead to inflammation of the surrounding tissues or to superinfection of the endometriotic implants. Magnetic resonance imaging is the best imaging modality to reach the diagnosis of endometriosis, but an accurate diagnosis is possible on computed tomography, especially in the presence of stellar, mildly enhanced, infiltrative lesions in suggestive areas. The aim of this pictorial review is to provide an image-based overview of key findings for the diagnosis of acute abdominal complications of endometriosis.

Improvement in Fertility and Pain after Endometriosis Resection and Adhesion Prevention with 4DryField® PH: Follow-up of a Randomized Controlled Clinical Trial

BACKGROUND

Adhesions after endometriosis resection are frequent and the most common causes for chronic pain and secondary infertility. Primary results of our randomized controlled trial (RCT) on adhesion prevention after deep infiltrating endometriosis (DIE) resection using the gel barrier 4DryField^® PH showed 85% adhesion reduction in second-look surgeries. Secondary endpoint data on fertility and pain development were collected during 12-month follow-ups.

METHODS

This RCT comprised 50 patients. Preoperatively and after 1, 6 and 12 months, pain scores for cycle-independent pelvic pain, dysmenorrhea, dyspareunia, dyschezia, and dysuria, as well as the number of pregnancies, were recorded,.

RESULTS

The pregnancy rate in the intervention group was significantly higher (p < 0.05). Pain development was also improved: after 12 months, all 5 subscores were lower in the intervention group and improvements were more pronounced, most prominently concerning cycle-independent pelvic pain and dysmenorrhea, the two subcategories with the highest preoperative scores and, therefore, the highest relevance for the patients. Cycle-independent pelvic pain even recurred in the control group, while barrier application prevented this.

CONCLUSIONS

Considering the known causal link between adhesions and pain, it is apparent that the favourable outcomes in the intervention group are linked to effective adhesion prevention. The significant increase in pregnancies is remarkable.

Vascularisation in Deep Endometriosis: A Systematic Review with Narrative Outcomes

Deep endometriosis (DE) is the most severe subtype of endometriosis, with the hallmark of lesions infiltrating adjacent tissue. Abnormal vascularisation has been implicated in contributing to endometriosis lesion development in general, and how vascularisation influences the pathogenesis of DE, in particular, is of interest. This systematic review followed the PRISMA guidelines to elucidate and examine the evidence for DE-specific vascularisation. A literature search was performed using MEDLINE, Embase, PubMed, Scopus, Cochrane CENTRAL Library and Europe PubMed Central databases. The databases were searched from inception to the 13 March 2023. A total of 15 studies with 1125 patients were included in the review. The DE lesions were highly vascularised, with a higher microvessel density (MVD) than other types of endometriotic lesions, eutopic endometrium from women with endometriosis and control tissue. Vascular endothelial growth factor, its major subtype (VEGF-A) and associated receptor (VEGFR-2) were significantly increased in the DE lesions compared to superficial endometriosis, eutopic endometrium and control tissue. Progestin therapy was associated with a significant decrease in the MVD of the DE lesions, explaining their therapeutic effect. This review comprehensively summarises the available literature, reporting abnormal vascularisation to be intimately related to the pathogenesis of DE and presents potentially preferential therapeutic targets for the medical management of DE.

The relationship between pain intensity and insomnia in women with deep endometriosis, a cross-sectional study

PURPOSE

To investigate the relationship between pain intensity and insomnia frequency in women with a diagnosis of deep endometriosis. The hypothesis is that these patients with moderate or severe pain have a higher frequency of insomnia than those with mild or no pain.

METHODS

We conducted a cross-sectional study of women with deep endometriosis categorized by pelvic pain intensity based on a numerical scale. Insomnia was assessed through a self-reported questionnaire, and multiple logistic regression was used to control for confounders between pain and insomnia.

RESULTS

We included 234 women in the study, 39 (17%) without pelvic pain; 66 (29%) with mild pain; 53 (23%) moderate pain; and 76 (32%) severe pain. Twenty-nine (74%) pain-free women and 50 (75%) with mild pain had no insomnia; only 3 (8%) of the former and 3 (4%) of the latter group had severe insomnia. However, twenty-nine (55%) women with moderate pain and 37 (48%) with severe pain had insomnia. The logistic regression model showed that moderate to severe pain increased insomnia 2.8 times, twice for every 10 years of pain duration, and twice in women with low education levels.

CONCLUSIONS

Women with moderate or severe pain had a high frequency of insomnia, increasing management complexity in patients with deep endometriosis. Pain intensity, pain duration, and low education level increased the chance of insomnia in those patients.

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

STUDY OBJECTIVE

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

DESIGN

Retrospective cohort study.

SETTINGS

University gynecologic surgery unit, referral center for endometriosis.

PATIENTS

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

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Accuracy of combined physical examination, transvaginal ultrasonography, and magnetic resonance imaging to diagnose deep endometriosis

OBJECTIVES

To assess the ability of physical examination (PE), transvaginal ultrasonography (TVUS), and magnetic resonance imaging (MRI) alone and combined to diagnose deep infiltrating endometriosis (DIE).

DESIGN

We retrospectively queried our pelvic MRI database to identify women who underwent PE, TVUS, and pelvic MRI for DIE up to 12 months before surgery between January 1, 2016 and August 31, 2020. The presence of uterosacral ligaments (USL), vaginal, rectosigmoid (RS), parametrial, or sacrorectogenital septum (lateral) DIE shown by PE, TVUS, and MRI were correlated with surgical and histological findings.

SETTING

Academic hospital.

PATIENT(S)

We included 178 patients.

INTERVENTION(S)

Clinical and imaging evaluation of women who were diagnosed at surgery with deep pelvic endometriosis.

MAIN OUTCOME MEASURE(S)

The sensitivity, specificity, positive and negative predictive values, and accuracy of each technique separately and combined were assessed for each location. When the 3 techniques were combined, 2 models were tested as follows: all 3 techniques positive and concordant; and ≥2 techniques positive and concordant.

RESULT(S)

The prevalence of USL, vaginal, RS, and lateral DIE were 94.4%, 20.2%, 34.3%, and 32.6%, respectively. In addition, MRI was more sensitive than PE, TVUS or any combination to detect DIE. Moreover, MRI and model B were the most accurate for detecting USL and RS locations with an accuracy of 90.4% and 82.6%, a sensitivity of 91.1% and 50%, and a specificity of 77.8% and 90.9%, respectively. Model B was the most accurate for the vaginal location with an accuracy, sensitivity, and specificity of 82.6%, 50%, and 90.9%, respectively. Finally, MRI was more accurate than any combination for identifying a lateral location with an accuracy, sensitivity, and specificity of 75.1%, 36%, and 93.8%, respectively.

CONCLUSION(S)

A combination of PE, TVUS, and MRI was more accurate than each technique separately to diagnose DIE because of the equally high sensitivity of each, as well as the high specificity of PE and TVUS.

Physiotherapy Management in Endometriosis

Endometriosis is a disease whose underlying cause is the growth of the endometrium outside the uterine cavity. The disease is characterised by unpleasant pain in the pelvic region, irrespective of the phase of the woman's cycle. Physiotherapy in its various forms can be an excellent complement to the gynaecological treatment of endometriosis, by virtue of reducing inflammation, alleviating pain and thus significantly improving women's quality of life. Physiotherapy in endometriosis should include kinesiotherapy, manual therapy including visceral therapy, physical therapy, spa treatment including balneotherapy, and hydrotherapy. The aim of this study is to present the use of physiotherapy as an adjunct therapy in the treatment of endometriosis. A review of the available literature in the Medline, PubMed and Google Scholar databases was performed without being limited by the time frame of available publications on the forms of physiotherapy used in the treatment of endometriosis.

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

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

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

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

The Association Between Gastrointestinal Symptoms and Transvaginal Ultrasound Findings in Women Referred for Endometriosis Evaluation: A Prospective Pilot Study

PURPOSE

 To evaluate the relationship between gastrointestinal (GI) symptoms and transvaginal ultrasound (TVUS) findings suggestive of endometriosis.

MATERIALS AND METHODS

 A prospective design. Women referred for a diagnostic ultrasound due to suspicion of endometriosis completed a Rome III and Pelvic Floor Distress Inventory (PFDI-20) questionnaire for clinical, GI symptoms, before undergoing TVUS. Endometriosis was diagnosed in the presence of endometriomas and/or deeply infiltrative endometriotic (DIE) lesions. Association between lesion sites and GI symptoms was evaluated by univariate and multivariate analysis.

RESULTS

 The study included 241 women who presented with: dysmenorrhea (89.6 %), dyspareunia (76.3 %), chronic pelvic pain (77.2 %), dyschezia (66 %), hematochezia (15.4 %), subfertility (24.5 %). GI symptoms were present in 25.3-76.8 % and 5.4-55.6 % of Rome III and PFDI-20 questionnaire responses, respectively. TVUS findings were endometriomas (23.2 %), peritoneal adhesions (46.5 %), uterosacral ligament (26.7 %), retrocervical (11.2 %), rectosigmoid (11.2 %), intestinal (4.6 %), and bladder (0.8 %) involvement, and pouch of Douglas (POD) obliteration (15.4 %). There was a high prevalence of peritoneal adhesions, uterosacral ligament involvement, and rectosigmoid and intestinal nodules on TVUS in women with GI symptoms, up to Chi² = 9.639 (p = 0.013) on univariate and Chi2 = 8.102 (p = 0.005) on multivariate analysis.

CONCLUSION

 We observed an almost 10-fold increase in DIE lesions in women with GI symptoms. We suggest that the presence of GI symptoms should prompt a referral for endometriosis evaluation and performance of a dedicated TVUS before invasive gastrointestinal procedures.

The Role of Visceral Therapy in the Sexual Health of Women with Endometriosis during the COVID-19 Pandemic: A Literature Review

Patients with endometriosis had limited possibilities for contemporary diagnosis and treatment during the SARS-CoV-2 (COVID-19) pandemic. Surgeries that may have eliminated pain or restored fertility were postponed. Endometriosis may affect the vagina, peritoneum, bladder, or other organs outside the pelvis and impact women's sexual health, especially during pandemics. Holistic care of patients is crucial to improving their lives and sexual health. A scoping review was conducted to analyze the relevant literature in light of our experience in gynecology and physiotherapy during the COVID-19 pandemic.

Evaluation of an e-learning program for the diagnosis of rectosigmoid endometriosis with rectal water contrast transvaginal ultrasonography (rectosonography)

This study aimed to evaluate the value of an e-learning program for the diagnosis of rectosigmoid endometriosis lesions using rectal water contrast transvaginal ultrasonography (rectosonography/RSG). Theoretical RSG training using videos with a commentary was offered online to healthcare professionals involved in ultrasound screening for endometriosis. A test (without correction) with 24 RSG video loops was used to assess the participants' baseline level before the training and their improvement afterwards. If the success rate post-training was below 80 %, the participant could start over with another series of 24 videos. Between February and June 2020, thirty participants took the training course (of which 80 % were obstetrics-gynaecology residents). The e-learning program resulted in a significant performance increase in the diagnosis of rectosigmoid endometriosis lesions, with a higher test success rate after the training compared to before (74.4 % and 63.6 % respectively; +10.8 %; 95 % CI [6,6; 15]; p < 0.001). Significant improvement was also observed regarding the overall skills involved in the ultrasound diagnosis of deep infiltrating endometriosis (+9.2 %; p < 0.001), the accurate diagnosis of the height of bowel lesions (+14.7 %; p < 0.001) and uterosacral ligament lesions (+8%; p < 0.005). In conclusion, our e-learning program led to a significant improvement of the diagnostic performance of digestive endometriosis using transvaginal ultrasound with intrarectal water contrast (rectosonography). Adding feedback to the post-test video loops could further increase the efficacy of the e-learning training.

Nieuwenhuizen K, Bronsgeest K, Rhemrev J, Smeets M, English J, Jansen F, Both S, Twijnstra A. Preoperative pain measurements in correlation to deep endometriosis classification with Enzian. Deep endometriosis classification in relation to pain

Background: Deep Endometriosis (DE) classification studies with Enzian never compared solitary (A, B, C, F), and combinations of anatomical locations (A&B, A&C, B&C, A&B&C), in correlation to pain. Therefore, the results of these studies are challenging to translate to the clinical situation. Objectives: We studied pain symptoms and their correlation with the solitary and combinations of anatomical locations of deep endometriosis lesion(s) classified by the Enzian score. Materials and Methods: A prospective multi-centre study was conducted with data from university and non-university hospitals. A total of 419 surgical DE cases were collected with the web-based application called EQUSUM (www.equsum.org). Main outcome measures: Preoperative reported numeric rating scale (NRS) were collected along with the Enzian classification. Baseline characteristics, pain scores, surgical procedure and extent of the disease were also collected. Results: In general, more extensive involvement of DE does not lead to an increase in the numerical rating scale for pain measures. However, dysuria and bladder involvement do show a clear correlation AUC 0.62 (SE 0.04, CI 0.54-0.71, p< 0.01). Regarding the predictive value of dyschezia, we found a weak, but significant correlation with ureteric involvement; AUC 0.60 (SE 0.04, CI 0.53-0.67, p< 0.01). Conclusions:TPain symptoms poorly correlate with anatomical locations of deep endometriosis in almost all pain scores, with the exception of bladder involvement and dysuria which did show a correlation. Also, dyschezia seems to have predictive value for DE ureteric involvement and therefore MRI or ultrasound imaging (ureter and kidney) could be recommended in the preoperative workup of these patients. What’s new? Dyschezia might have a predictive value in detecting ureteric involvement.

Endometriosis and Infertility: A Long-Life Approach to Preserve Reproductive Integrity

Laparoscopic surgery was originally considered the gold standard in the treatment of endometriosis-related infertility. Assisted reproductive technology (ART) was indicated as second-line treatment or in the case of male factor. The combined approach of surgery followed by ART proved to offer higher chances of pregnancy in infertile women with endometriosis. However, it was highlighted how pelvic surgery for endometriosis, especially in cases of ovarian endometriomas, could cause iatrogenic damage due to ovarian reserve loss, adhesion formation (scarring), and ischemic damage. Furthermore, in the last few years, the trend to delay the first childbirth, recent technological advances in ultrasound diagnosis, and technological progress in clinical and laboratory aspects of ART have certainly influenced the approach to infertility and endometriosis with, ART assuming a more relevant role. Management of endometriosis should take into account that the disease is chronic and involves the reproductive system. Consequently, treatment and counselling should aim to preserve the chances of pregnancy for the patient, even if it is not associated with infertility. This review will analyse the evolution of the management of infertility associated with endometriosis and propose an algorithm for treatment decision-making based on the most recent acquisitions.

Diagnostic gene biomarkers for predicting immune infiltration in endometriosis

OBJECTIVE

To determine the potential diagnostic markers and extent of immune cell infiltration in endometriosis (EMS).

METHODS

Two published profiles (GSE7305 and GSE25628 datasets) were downloaded, and the candidate biomarkers were identified by support vector machine recursive feature elimination analysis and a Lasso regression model. The diagnostic value and expression levels of biomarkers in EMS were verified by quantitative reverse transcription polymerase chain reaction (qRT-PCR) and western blotting, then further validated in the GSE5108 dataset. CIBERSORT was used to estimate the composition pattern of immune cell components in EMS.

RESULTS

One hundred and fifty-three differential expression genes (DEGs) were identified between EMS and endometrial with 83 upregulated and 51 downregulated genes. Gene sets related to arachidonic acid metabolism, cytokine-cytokine receptor interactions, complement and coagulation cascades, chemokine signaling pathways, and systemic lupus erythematosus were differentially activated in EMS compared with endometrial samples. Aquaporin 1 (AQP1) and ZW10 binding protein (ZWINT) were identified as diagnostic markers of EMS, which were verified using qRT-PCR and western blotting and validated in the GSE5108 dataset. Immune cell infiltrate analysis showed that AQP1 and ZWINT were correlated with M2 macrophages, NK cells, activated dendritic cells, T follicular helper cells, regulatory T cells, memory B cells, activated mast cells, and plasma cells.

CONCLUSION

AQP1 and ZWINT could be regarded as diagnostic markers of EMS and may provide a new direction for the study of EMS pathogenesis in the future.

Living with endometriosis: Comorbid pain disorders, characteristics of pain and relevance for daily life

BACKGROUND

Pain plays a central role in endometriosis. The complex relationship among pain characteristics, comorbid pain disorders and daily life represents a challenge for medical support. This multicentre cross-sectional case-control study analysed the association between endometriosis-related chronic pain and functions of daily life in 510 women with endometriosis, 265 (52%) who experienced chronic pain, either from endometriosis alone (N = 134, 26.3%) or in association with additional pain disorders (N = 131, 25.7%).

METHODS

Self-administered questionnaires from the Brief Pain Inventory and the Pain Disability Index were used to investigate associations between pain characteristics (frequency, duration, intensity) and daily life. Also, associations between different endometriosis characteristics (rASRM stage, presence of adhesions, localisation of lesions) and pain were evaluated.

RESULTS

Chronic pain is negatively associated with almost all (12/14) aspects of daily life investigated, including standing, walking, sitting, defaecation, sleep, sports activities, family and domestic responsibilities, sexuality, social functioning, professional life, mood, and joy of life. Altogether, 33.7% of women with chronic pain reported moderate and 27.5% severe limitations. Comorbid pain disorders resulted in significantly more limitations. The length of pain episodes showed a particularly important influence, especially for family/domestic responsibilities (OR 22.94, p < 0.001), professional life (OR 16.56, p < 0.001) and social functioning (OR 41.03, p < 0.001).

CONCLUSIONS

Our data confirm that despite treatment, about 50% of women experience pain. Pain was associated with at least moderate negative effects on almost all areas of daily life; additional pain comorbidities increased limitations. Improving pain management is essential for improving quality of life in women with endometriosis.

SIGNIFICANCE

The study provides an accurate overview of the impact of endometriosis-associated pain on daily life. This is important because pain plays a central role in women living with endometriosis, and despite modern therapies, many women continue to suffer from chronic pain. The detailed analysis of its impact with a comprehensive survey of all aspects of daily life in a very large study population is unique. We expect an improved understanding of consequences of pain to significantly advance medical support in these patients.

Gastrointestinal symptoms as a predictor of deep endometriosis of the pelvic posterior compartment on magnetic resonance imaging

Objective:

To determine if gastrointestinal (GI) symptoms can predict deep endometriosis (DE) of the posterior pelvic compartment on magnetic resonance imaging (MRI).

Methods:

Patients with suspected endometriosis undergoing endometriosis protocol MRI at an academic center between 9/1/2015 and 7/31/2018 were identified. Presenting GI symptoms were collected via a standardized survey instrument prospectively at initial presentation. MRI and interdisciplinary conference notes were reviewed to identify posterior compartment DE (rectosigmoid, uterosacral ligaments, posterior cul de sac, and pelvic side walls). Associations between symptoms and DE were evaluated.

Results:

A total of 104 patients met inclusion criteria, and 89 (85.6%) presented with at least one GI symptom. Posterior compartment DE was identified on MRI in 47 patients (45.2%). The GI symptom that most strongly predicted DE was a bowel movement resulting in pain relief (OR 3.36, 95% CI 1.31–8.61, p = 0.012), with sensitivity, specificity, positive and negative predictive values 0.42, 0.82, 0.67, and 0.63, respectively. Other GI symptoms such as nausea, vomiting, rectal bleeding, change in frequency of bowel movements, and pain exacerbation by bowel movements did not significantly correlate to having DE. Of the 15 patients with no GI symptoms, 5 were found to have posterior compartment DE.

Conclusion:

In patients with suspected endometriosis, those who noted that bowel movements relieved their pain had more than three times the odds of having DE of the posterior compartment on MRI. Preoperative evaluation with MRI may be of value in these patients; however, lack of gastrointestinal symptoms does not exclude the possibility of posterior compartment DE.

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

Background

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

Objectives

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

Search strategy

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

Selection criteria, data collection and analysis:

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

Main results

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

Conclusion

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

Lay summary

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

MRI in the Diagnosis of Endometriosis and Related Diseases

Endometriosis, a common chronic inflammatory disease in female of reproductive age, is closely related to patient symptoms and fertility. Because of its high contrast resolution and objectivity, MRI can contribute to the early and accurate diagnosis of ovarian endometriotic cysts and deeply infiltrating endometriosis without the need for any invasive procedure or radiation exposure. The ovaries, which are the most frequent site of endometriosis, can be afflicted by multiple related conditions and diseases. For the diagnosis of deeply infiltrating endometriosis and secondary adhesions among pelvic organs, fibrosis around the ectopic endometrial gland is usually found as a T2 hypointense lesion. This review summarizes the MRI findings obtained for ovarian endometriotic cysts and their physiologically and pathologically related conditions. This article also includes the key imaging findings of deeply infiltrating endometriosis.

Diagnostic Benefit of the Detection of Mitotic Figures in Endometriotic Lesions

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

Evolution of bowel complaints after laparoscopy endometriosis surgery: a 1497 women comparative study

STUDY OBJECTIVE

To assess what degree can digestive symptoms improve after endometriosis surgery for different localisations?

DESIGN

A comparative retrospective study employing data prospectively recorded in The North-West Inter-Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to November 2018.

SETTING

Two referral centres Patients: 1,497 women undergoing surgery due to pelvic endometriosis were divided into three groups: superficial endometriosis (Group 1, n=396), deep endometriosis sparing the bowel (Group 2, n=337), and deep endometriosis involving the bowel (Group 3, n=764).

INTERVENTIONS

Surgery for endometriosis.

MEASUREMENTS AND MAIN RESULTS

Preoperative and postoperative gastrointestinal symptoms were evaluated with standardised questionnaires, including the Gastrointestinal Quality of Life Index (GIQLI) and Knowles-Eccersley-Scott-Symptom questionnaire (KESS). The degree of postoperative improvement in digestive symptoms was compared between the groups. The women in Group 3 were significantly symptomatic in terms of cycle-related gastrointestinal symptoms and scores of standardised questionnaires GIQLI, KESS. According to the 1-year postoperative evaluation, women in Group 3 experienced the most significant improvement in their gastrointestinal symptoms.

CONCLUSION

Women with severe bowel symptoms and deep endometriosis infiltrating the bowel should be informed about the high probability of symptom improvement after the removal of bowel nodules. Conversely, in women without deep endometriosis, postoperatively, there is less improvement in baseline digestive complaints.

The role of gut and genital microbiota and the estrobolome in endometriosis, infertility and chronic pelvic pain

BACKGROUND

Endometriosis is a chronic, burdensome condition that is historically understudied. Consequently, there is a lack of understanding of the etiology of the disease and its associated symptoms, including infertility and chronic pelvic pain (CPP). Endometriosis development is influenced by estrogen metabolism and inflammation, which are modulated by several factors including the microbiome and the estrobolome (the collection of genes encoding estrogen-metabolizing enzymes in the gut microbiome). Therefore, there is increasing interest in understanding the role of microbiota in endometriosis etiology.

OBJECTIVE AND RATIONALE

To date, there is no cure for endometriosis and treatment options often are ineffective. This manuscript will review the potential relationship between the microbiome and endometriosis, infertility and CPP and highlight the available data on the microbiome in relation to endometriosis and its related symptoms. The overarching goal of this manuscript is to inform future microbiome research that will lead to a deeper understanding of the etiology of the disease and possible diagnostic modalities and treatments. The potential impact of the microbiome on estrogen regulation modulated by the estrobolome, as well as inflammation and other endometriosis-promoting mechanisms within the genital tract, will be reviewed. The methodological limitations of microbiome-related studies will be critically assessed to provide improved guidelines for future microbiome and clinical studies.

SEARCH METHODS

PubMed databases were searched using the following keywords: endometriosis AND microbiome, infertility AND microbiome, pelvic pain AND microbiome, IVF (in-vitro fertilization) AND microbiome, endometriosis AND infertility. Clinical and preclinical animal trials that were eligible for review, and related to microbiome and endometriosis, infertility or CPP were included. All available manuscripts were published in 2002-2021.

OUTCOMES

In total, 28 clinical and 6 animal studies were included in the review. In both human and animal studies, bacteria were enriched in endometriosis groups, although there was no clear consensus on specific microbiota compositions that were associated with endometriosis, and no studies included infertility or CPP with endometriosis. However, bacterial vaginosis-associated bacteria and Lactobacillus depletion in the cervicovaginal microbiome were associated with endometriosis and infertility in the majority (23/28) of studies. Interpretation of endometrial studies is limited owing to a variety of methodological factors, discussed in this review. In addition, metadata outlining antibiotic usage, age, race/ethnicity, menopausal status and timing of sample collection in relation to diagnosis of endometriosis was not consistently reported. Animal studies (6/6) support a bidirectional relationship between the gut microbiota and endometriosis onset and progression.

WIDER IMPLICATIONS

There is evidence that a dysbiotic gut or genital microbiota is associated with multiple gynecologic conditions, with mounting data supporting an association between the microbiome and endometriosis and infertility. These microbiomes likely play a role in the gut-brain axis, which further supports a putative association with the spectrum of symptoms associated with endometriosis, including infertility and CPP. Collectively, this review highlights the demand for more rigorous and transparent methodology and controls, consistency across the field, and inclusion of key demographic and clinical characteristics of disease and comparison participants. Rigorous study designs will allow for a better understanding of the potential role of the microbiome in endometriosis etiology and the relationship to other disorders of the female reproductive tract.

AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score

STUDY OBJECTIVE

To develop a new endometriosis classification system for scoring intraoperative surgical complexity and to examine its correlation with patient-reported pain and infertility.

DESIGN

Multicenter study of patients treated at 3 recognized endometriosis centers.

SETTING

Three specialized endometriosis surgical centers in São Paulo, Brazil and Barcelona, Spain.

PATIENTS

Patients aged 15 to 45 years with histologically proven endometriosis and no history of pelvic malignancy underwent laparoscopic treatment of endometriosis.

INTERVENTIONS

Demographic data and clinical history, including dysmenorrhea, noncyclic pelvic pain, dyspareunia, dysuria and dyschezia, were prospectively recorded. All patients were staged surgically according to the new 2021 American Association of Gynecologic Laparoscopists (AAGL) and revised American Society of Reproductive Medicine (ASRM) classification systems. The staging for each system was compared against a 4-level surgical complexity scale defined by the most complex procedure performed.

MEASUREMENTS AND MAIN RESULTS

A total of 1224 patients undergoing surgery met inclusion criteria. The AAGL score discriminated between 4 stages of surgical complexity with high reproducibility (κ = 0.621), whereas the ASRM score discriminated between the complexity stages with poor reproducibility (κ = 0.317). The AAGL staging system correlated with dysmenorrhea, dyspareunia, dyschezia, total pain score, and infertility comparably with the ASRM staging system.

CONCLUSION

The AAGL 2021 Endometriosis Classification allows for identifying objective intraoperative findings that reliably discriminate surgical complexity levels better than the ASRM staging system. The AAGL severity stage correlates comparably with pain and infertility symptoms with the ASRM stage.

Accuracy of Transvaginal Ultrasound Compared to Cystoscopy in the Diagnosis of Bladder Endometriosis Nodules

OBJECTIVES

To evaluate the accuracy of transvaginal ultrasound (TVUS) in predicting detrusor infiltration and ureteral meatus involvement in patients with bladder endometriosis (BE) to select which cystoscopic procedures could be avoided and, secondarily, to assess the relationship between symptoms and the characteristics of nodules and the association of BE with other forms of endometriosis.

METHODS

Patients with BE diagnosed by TVUS were classified according to detrusor infiltration: BE with partial involvement of the muscular layer (group 1) and total muscular layer involvement with bladder protrusion (group 2). We analyzed the accuracy of TVUS compared with subsequently performed cystoscopy, the correlation with symptoms, and the association with other forms of endometriosis.

RESULTS

Among the 22 patients included, TVUS showed 9 patients with BE nodules partially affecting the detrusor (group 1) with normal cystoscopic findings (TVUS negative predictive value, 100%). Transvaginal ultrasound detected 13 nodules with total involvement, all visible by cystoscopy (TVUS positive predictive value, 100%). Transvaginal ultrasound also identified ureteral orifices that were free of involvement at greater than 10 mm from the BE nodule in 21 of 22 women (TVUS sensitivity, 95%). Ultrasound criteria for adenomyosis and endometriosis in other locations were present in 20 of 22 patients.

CONCLUSIONS

Transvaginal ultrasound can identify the infiltration of BE nodules in the bladder wall and predict cystoscopic findings with great accuracy. Nodules that partially affect the muscular layer have normal cystoscopic findings, thereby obviating the need for this procedure. Bladder endometriosis nodules are commonly associated with other forms of endometriosis and do not usually affect the ureteral meatus.