National German Guideline (S2k): Guideline for the Diagnosis and Treatment of Endometriosis: Long Version - AWMF Registry No. 015-045

Recommendations for patient education in the management of persistent pelvic pain: a systematic review of clinical practice guidelines

ABSTRACT

Patient education has a critical role in the management of pain. There is considerable heterogeneity in patient education for females with persistent pelvic pain (PPP), and it remains unclear what is considered best clinical practice. Therefore, this systematic review identified and summarised recommendations for patient education in the management of benign gynaecological and urological conditions associated with PPP, as endorsed by international guidelines. Academic and relevant guideline databases were searched from inception to May 2022. Included guidelines were those for the management of benign gynaecological and urological conditions associated with PPP in adult females published in English, of any publication date, and endorsed by a professional organisation or society. Two independent reviewers screened 3097 records; 17 guidelines were included in the review. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Recommendations were pooled using descriptive synthesis. Persistent pelvic pain guideline quality was generally poor. Three guidelines were classified as "excellent" (The NICE, RANZCOG, and ESHRE endometriosis guidelines) and therefore recommended for use. Eleven guidelines (64.7%) recommended patient education for females with PPP. Recommendations for education content were variable, however most frequently covered treatment strategies and pelvic pain diagnoses. For education delivery, the most frequent recommendations were for support groups and written/printed materials. Further research into tailored education interventions is needed for females with PPP.

Correlation between pain and depressive symptoms in patients with confirmed endometriosis during COVID-19 pandemic

BACKGROUND

Endometriosis is a chronic, estrogen-dependent, inflammatory condition which affects women of reproductive age physically and psychologically in their everyday life. The most common symptom is chronic lower abdominal pain. Apart from physical pain, endometriosis often also leads to an unfulfilled desire to give birth. In general, these two main aspects alone lead to emotional stress for patients and often initiate depressive symptoms. To what extent endometriosis patients are additionally affected by the COVID pandemic and its effects is to be determined in this study.

METHODS

Patients who presented at our endometriosis center and met the study criteria were offered participation in the study. A link to an online questionnaire (SoSci-Survey) was sent by email. The online questionnaire evaluated depressive symptoms before and during the pandemic as well as the pain perception and perceived support during the pandemic. The data of 167 fully completed questionnaires were evaluated and analyzed using SPSS.

RESULTS

The analysis of the questionnaires revealed a significant association between pain levels and depressive symptomatology in endometriosis patients during the pandemic. Patients with more severe pain showed significantly higher depressive symptoms than patients with little or no pain. During the pandemic, patients showed higher depressive symptoms than before. In addition, it was found that those endometriosis patients who felt left alone with their pain due to the consequences of the COVID pandemic, or who felt they had to endure the pain alone, also had higher depressive symptoms.

CONCLUSION

In summary, it can be observed that endometriosis patients with a high pain burden had significantly higher depressive symptoms during the COVID pandemic. The consequences of the pandemic often led to the feeling of having to cope with the symptoms alone or having to endure pain alone, which in turn increased the depressive symptoms. As treating physicians, we should be aware of these connections and try to counteract them with targeted offers and support.

Minimally invasive surgery for deep endometriosis

Deep endometriosis (DE) is endometriotic tissue that invades the peritoneum by >5 mm. Surgery is the treatment of choice for symptomatic DE, and laparoscopic surgery is preferred over laparotomy due to better vision and postoperative pain. In this review, we aimed to collect and summarize recent literature on DE surgery and share laparoscopic procedures for rectovaginal and bowel endometriosis.

Probiotics and NLRP3 mRNA inflammasome levels in women with endometriosis-related infertility undergoing assisted reproductive technologies

This research was conducted at Bukovinian State Medical University and the Centre of Reproductive Medicine and included a total of 30 infertile women. The control group consisted of 10 women with tubal infertility resulting from a prior history of inflammation, who, following a comprehensive clinical and laboratory assessment, exhibited no other underlying health conditions and could be regarded as essentially healthy individuals. Participants in the control group ranged from 21 to 42 years, with an average age of 29.75 years. The control group did not receive the probiotic Femina Probiz. The main group, on the other hand, included 20 women diagnosed with external genital endometriosis who were undergoing assisted reproductive technologies. These patients were administered the probiotic Femina Probiz manufactured by Unic Biotech Ltd in India. They were instructed to take one tablet containing 10×10^9 Lactobacillus organisms twice daily for one month as part of their preparatory treatment before proceeding with assisted reproductive technologies. The levels of NLRP3 inflammasome were measured before and after this preparatory phase. The incidence of primary infertility was significantly higher in patients belonging to the main group.

QS ENDO Pilot - A Study by the Stiftung Endometrioseforschung (SEF) on the Quality of Care Provided to Patients with Endometriosis in Certified Endometriosis Centers in the DACH Region

Introduction Endometriosis significantly reduces patients' quality of life and is additionally a burden on healthcare and social security systems. There are currently no quality indicators for the treatment of endometriosis. The care of patients with endometriosis must be considered inadequate. QS ENDO aims to record the quality of care available in the DACH region and to introduce quality indicators for the diagnosis and treatment of endometriosis as part of providing quality assurance in endometriosis care. The first phase, QS ENDO Real, recorded the reality of current care using a questionnaire. The second phase, QS ENDO Pilot, investigated the treatment of 435 patients who underwent surgical treatment within a defined one month period in certified endometriosis centers. Material and Methods An online tool was used to gather information about 9 points which covered both prior patient history and the process of clinical diagnosis. Surgery reports were reviewed to obtain information about the surgical approach, the investigated sites, findings of any histological examinations, the use of classification systems, and information about resection status. Results 85.3% of patients were asked all 4 questions about their prior medical history. All 5 diagnostic steps were carried out in 34.5% of patients. The 3 areas needed to describe potential sites of disease were recorded in 67.1% of patients. Samples for histological examination were taken in 84.1% of patients. The endometriosis stage was classified in 94.7% of surgeries. A combination of the rASRM and the ENZIAN classifications, which is needed for complex cases, was used in 46.1% of patients. Complete resection was achieved in 81.6% of surgical procedures. Conclusion For the first time, the quality of care in certified endometriosis centers has been recorded using QS ENDO Pilot. Despite the high certification standards, a substantial number of required indicators were omitted.

A NEW APPROACH TO ASSISTED REPRODUCTIVE TECHNOLOGIES PREPARATION IN WOMEN WITH ENDOMETRIOSIS ASSOCIATED INFERTILITY USING PROBIOTICS

OBJECTIVE

Aim: To examine the expression Nlrp3-inflammasome in the blood of women with endometriosis-associated infertility using assisted reproductive technologies with included probiotic and estimate a new approach with included probiotic for preparation to assisted reproductive technologies.

PATIENTS AND METHODS

Materials and methods: For the purpose of the research we examined 30 infertile women. Control group consisted of 10 women with tubal infertility due to an inflammatory process in the anamnesis, in whom, as a result of a complex clinical and laboratory examination, no other diseases were detected and in terms of their health they could be equated with practically healthy women (age from 21 to 42 years, the average age was 29.75 years) and who did not take probiotic. The main group consists from 20 women with external genital endometriosis were included in assisted reproductive technologies. Patients from main group took probiotic produced by Unic Biotech Ltd, India. 1 tablet twice a day with 10×109 Lactobacillus during 1 month in complex preparation (treatment) before assisted reproductive technologies. The indices of Nlrp3 - Inflammasome determined before and after preparation. The study was performer in Bukovinian State Medical University and Centre of Reproductive Medicine. To analyze the expression of the NLPP3-inflammasome gene and determine the relative normalized expression of NLPP3 mRNA, we used the polymerase chain reaction with reverse transcription in real time (RT-PCR). The object for molecular genetic studies by the RT-PCR method was the fraction of mononuclear cells isolated from the whole blood of patients with endometriosis. The value of p (authenticity difference) was determined by Student's table-Fischer. Differences between contrasting averages were considered significant at p <0.05.

RESULTS

Results: Analized the results of our research stated that in main group expression of Nlrp-3 inflammasome was 24,43, which is significantly higher than after preparation (0,70 accordingly). In control group expression of Nlrp3-inflammasome was 0,54. Expression of Nlrp-3 inflammasome increased in patients before preparation more than 34 times compare with patients after preparation accordingly.

CONCLUSION

Conclusions: consequently, after using probiotic, the increased level of Nlrp3-inflammasome sharply decreases, indicating the effectiveness and the possibility of use in the programme for assisted reproductive technologies preparation.

Clinical Diagnosis and Early Medical Management for Endometriosis: Consensus from Asian Expert Group

This work provides consensus guidance regarding clinical diagnosis and early medical management of endometriosis within Asia. Clinicians with expertise in endometriosis critically evaluated available evidence on clinical diagnosis and early medical management and their applicability to current clinical practices. Clinical diagnosis should focus on symptom recognition, which can be presumed to be endometriosis without laparoscopic confirmation. Transvaginal sonography can be appropriate for diagnosing pelvic endometriosis in select patients. For early empiric treatment, management of women with clinical presentation suggestive of endometriosis should be individualized and consider presentation and therapeutic need. Medical treatment is recommended to reduce endometriosis-associated pelvic pain for patients with no immediate pregnancy desires. Hormonal treatment can be considered for pelvic pain with a clinical endometriosis diagnosis; progestins are a first-line management option for early medical treatment, with oral progestin-based therapies generally a better option compared with combined oral contraceptives because of their safety profile. Dienogest can be used long-term if needed and a larger evidence base supports dienogest use compared with gonadotropin-releasing hormone agonists (GnRHa) as first-line medical therapy. GnRHa may be considered for first-line therapy in some specific situations or as short-term therapy before dienogest and non-steroidal anti-inflammatory drugs as add-on therapy for endometriosis-associated pelvic pain.

Economic Implications of Endometriosis: A Review

Endometriosis is a chronic inflammatory disease that can have serious physical and emotional consequences for patients in terms of pain, quality of life, and infertility. Despite affecting about 10% of women, the pathophysiology and economic impact of the disease are not fully understood. This study aimed to review and summarize research articles quantifying the direct and indirect costs of endometriosis in the context of current national and international treatment guidelines. A search including the terms 'endometriosis' AND 'costs' OR 'cost of illness' OR 'cost analysis' OR 'economic burden' was performed, focusing on studies published between January 2000 and May 2022. Total costs, costs of primary and secondary care, productivity losses, and indirect costs were reported. The medical costs of endometriosis were principally registered in secondary care settings, where surgery was the main cost driver. There was considerable variability of populations and study settings, with the overall direct medical cost range of endometriosis from US$1459 to US$20,239 (2022) per patient per year. An increasing trend has been reported in secondary care costs over time; however, not enough data were available at this time to evaluate inpatient and outpatient costs versus treatment strategies. Similarly, further research is required to evaluate the costs and potential savings associated with new therapies. Numerous studies have evaluated the indirect costs of endometriosis in recent years, finding costs between US$4572 and US$14,079 (2022). Currently, limited data are available on the economic burden of the disease at the patient level.

Pathophysiology, diagnosis, and management of endometriosis

Endometriosis affects approximately 190 million women and people assigned female at birth worldwide. It is a chronic, inflammatory, gynecologic disease marked by the presence of endometrial-like tissue outside the uterus, which in many patients is associated with debilitating painful symptoms. Patients with endometriosis are also at greater risk of infertility, emergence of fatigue, multisite pain, and other comorbidities. Thus, endometriosis is best understood as a condition with variable presentation and effects at multiple life stages. A long diagnostic delay after symptom onset is common, and persistence and recurrence of symptoms despite treatment is common. This review discusses the potential genetic, hormonal, and immunologic factors that lead to endometriosis, with a focus on current diagnostic and management strategies for gynecologists, general practitioners, and clinicians specializing in conditions for which patients with endometriosis are at higher risk. It examines evidence supporting the different surgical, pharmacologic, and non-pharmacologic approaches to treating patients with endometriosis and presents an easy to adopt step-by-step management strategy. As endometriosis is a multisystem disease, patients with the condition should ideally be offered a personalized, multimodal, interdisciplinary treatment approach. A priority for future discovery is determining clinically informative sub-classifications of endometriosis that predict prognosis and enhance treatment prioritization.

Quality evaluation of endometriosis guidelines using AGREE II

BACKGROUND

To systematically evaluate the guidelines for endometriosis published in the past decade, and to provide reference for the selection of guidelines for endometriosis through quality evaluation and comparison.

METHODS

PubMed database, Embase database, evidence-based medicine clinical practice guidelines (CPG) database and the National Institute for Health and Clinical Excellence in the United Kingdom were searched by computer from December 2012 to December 2020 to retrieve published endometriosis CPG published by professional institutions or organizations. The search languages are English and Portuguese. Two researchers evaluated the quality of included CPG according to appraisal of guidelines for research and evaluation (AGREE II). The evaluation includes 6 areas: scope and purpose, participants, rigor of formulation, clarity of expression, applicability and independence. The recommendation level of CPG is determined by the distribution of standardized scores in the above 6 areas.

RESULTS

A total of 8 articles on endometriosis CPG were included, including 5 guidelines and 3 consensuses, covering 5 countries in 2 continents; the publication year was 2013 to 2020. The average standardized scores of the scope and purpose, participants, rigor, clarity, applicability and independence of CPG were 77.1%, 52.8%, 50.5%, 86.8%, 31.3%, and 36.5%, respectively. Among the 8 CPGs, 1 was grade A (recommended), 5 were grade B (recommended after improvement), and 2 were grade C (not recommended). Seven CPG recommendations were based on expert consensus, and one was developed through detailed literature retrieval, analysis and evidence rating evaluation. There was little difference between the guidelines in terms of treatment-related recommendations.

CONCLUSIONS

The quality of endometriosis CPG released in 2013 to 2020 is quite different, and some CPGs are not ideal in terms of rigor, applicability and independence. The guidelines issued by NICE in 2017 are A-grade recommendations. The standardized scores in various fields are high, and the formation process of CPG is the most standardized, which is worth learning and reference.

Quality Requirements for gynecological ultrasound examinations of DEGUM level II - Recommendations of the Sections/Working Groups Gynecology and Obstetrics of DEGUM, ÖGUM and SGUM

Gynecological sonography is the central and most frequently used technical examination method used by gynecologists. Its focus is on the clarification of masses of the uterus and the adnexa, fertility diagnosis, clarification of bleeding disorders and chronic and acute pelvic problems, pelvic floor and incontinence diagnosis as well as the differential diagnosis of disturbed early pregnancy. The indication for diagnostic and therapeutic interventions, preoperative planning and postoperative controls are largely based on the findings of gynecological sonography. These examinations are particularly dependent on the experience of the examiner.Based on the proven multi-stage concept of obstetric diagnostics, gynecological sonography should primarily be performed by an experienced and specialized examiner in patients for whom the initial gynecological examinations have not yet led to a sufficient assessment of the findings. So that the expert status required for this has an objective basis, the Gynecology and Obstetrics Section of DEGUM in cooperation with ÖGUM and SGUM implemented the option of acquiring DEGUM Level II for gynecological sonography. The effectiveness of the care in the multi-level concept depends on the quality of the ultrasound examination at level I. Quality requirements for the basic examination and the differentiation between the basic and further examination have therefore already been defined by DEGUM/ÖGUM. The present work is intended to set out quality requirements for gynecological sonography of DEGUM level II and for the correspondingly certified gynecologists.Common pathologies from gynecological sonography and requirements for imaging and documentation are described.

Treatment recommendations for the management of persistent pelvic pain: A systematic review of international clinical practice guidelines

BACKGROUND

Females with persistent pelvic pain (PPP) report great variability in treatments they are recommended despite the availability of clinical practice guidelines (CPGs) that aim to standardise care. A clear consensus for the best practice care for PPP is required.

OBJECTIVE

Identify and summarise treatment recommendations across CPGs for the management of PPP, and appraise their quality.

SEARCH STRATEGY

MEDLINE, CENTRAL, EMBASE, EmCare, SCOPUS, the Cochrane Database of Systematic Reviews, Web of Science Core Collection, and relevant guideline databases were searched from their inception to June 2021.

SELECTION CRITERIA

Included CPGs were those for the management of urogynaecological conditions in adult females published in English, of any publication date, and endorsed by a professional organisation or society.

DATA COLLECTION AND ANALYSIS

We screened 1,379 records and included 20 CPGs. CPG quality was assessed using The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Descriptive synthesis compiled treatment recommendations across CPGs.

MAIN RESULTS

CPGs for seven conditions provided 281 individual recommendations. On quality appraisal, guidelines on average scored 'excellent' for the domains 'scope and purpose' (80.6%, SD=13.3) and 'clarity and presentation' (74.4%, SD=12.0); for other domains, average scores were satisfactory or poor. Four guidelines (Endometriosis, NICE, RANZCOG, ESHRE; PCOS, Teede et al. 2018) were deemed recommended for use. Recommendations were most frequent for pharmaceutical and surgical interventions. Recommendations were variable for psychological, physiotherapy, and other conservative interventions.

CONCLUSIONS

The quality of CPGs for PPP is generally poor. Several CPGs endorse the consideration of biopsychosocial elements of PPP. Yet most recommend pharmaceutical, surgical, and other biomedical interventions.

Perioperative considerations in the treatment of endometriosis

Endometriosis is one of the most common benign diseases in women of reproductive age. Nearly all gynecological offices and clinics will contain patients with endometriosis; the frequency and severity of the disease will vary from one setting to another. Adjoining specialties, such as internal medicine, general medicine, surgery, urology, orthopedics, neurology and psychosomatic medicine, will be challenged directly or indirectly by various forms of endometriosis and its sequelae. The disease is characterized by pelvic pain, dysmenorrhea, dyspareunia and sterility. Even now, several years may elapse between the onset of the disease and its diagnosis. The diagnosis of endometriosis is complicated by the diversity of the symptoms. A precise documentation of the patient’s medical history and thorough diagnostic procedures are essential to establish a robust diagnosis. This article will discuss the perioperative considerations, diagnosis and treatment of endometriosis.

What to choose and why to use - a critical review on the clinical relevance of rASRM, EFI and Enzian classifications of endometriosis

Background

Endometriosis is a common benign gynaecological disease that affects pelvic structures and causes adhesions. Endometriosis outside the pelvis exists but is rarer. Deep endometriosis may affect organs such as the urinary bladder, ureters, bowel and sacral roots. Adenomyosis (growth of endometrium in the myometrium, sometimes explained by disruption of the uterine junctional zone) frequently co-exists with deep endometriosis. Over the past decades, multiple attempts have been made to describe the anatomical extent of endometriosis. Out of approximately 20 classification systems suggested and published so far, three have gained widespread acceptance. These are the rASRM (American Society of Reproductive Medicine) classification, the Endometriosis Fertility Index (EFI) and the Enzian classification. Ideally, a classification system should be useful both for describing disease extent based on surgical findings and results of imaging methods (ultrasound, magnetic resonance imaging).

Objectives

To highlight the advantages and disadvantages of the three classification systems.

Methods

This is a narrative review based on selected publications and experience of the authors. We discuss the current literature on the use of the rASRM, EFI and Enzian classification systems for describing disease extent with imaging methods and for prediction of fertility, surgical complexity, and risk of surgical complications. We underline the need for one universally acceptable terminology to describe the extent of endometriosis.

Conclusions

A useful classification system for endometriosis should describe the sites and extent of the disease, be related to surgical complexity and to disease-associated symptoms, including subfertility and should satisfy needs of both, imaging specialists for pre-operative classification and surgeons. The need for such a system is obvious and is provided by the #Enzian classification. Future research is necessary to test its validity.

Treatment of endometriosis: a review with comparison of 8 guidelines

Background

Endometriosis, the presence of endometrial-like tissue outside the uterus, is a common clinical entity between women of reproductive age, with a prevalence of about 10%. Due to the variety of endometriosis-associated symptoms, a great variety of treatments have been implemented. The aim of this review is to give an overview on therapeutical approaches of eight national and international widely used guidelines.

Methods

Six national (College National des Gynecologues et Obstetriciens Francais, National German Guideline (S2k), Society of Obstetricians and Gynaecologists of Canada, American College of Obstetricians (ACOG) and Gynecologists, American Society for Reproductive Medicine (ASRM) and National Institute for Health and Care (NICE) and two international (World Endometriosis Society, European Society of Human Reproduction and Embryology) guidelines are included in this review.

Conclusion

All the above-mentioned guidelines agree that the combined oral contraceptive pill, progestogens are therapies recommended for endometriosis associated pain. Concerning infertility, there is no clear consensus about surgical treatment. Discrepancies are also found on recommendation of the second- and third-line treatments.

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

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

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

Structured report for dynamic ultrasonography in patients with suspected or known endometriosis: Recommendations of the International Society for Gynecologic Endoscopy (ISGE)

OBJECTIVE

The International Society for Gynecologic Endoscopy (ISGE) developed this project to establish the recommendations for structured reporting of dynamic ultrasound findings, promoting on this manner the practice of standardized, comprehensive and systematic evaluation and reporting of endometriosis in pelvic structures, in correlation with the #Enzian classification.

STUDY DESIGN

A non-systematic review was done through a search on the following databases: MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database and Web of Science, using the medical subject heading (MeSH) term "endometriosis" (MeSH Unique ID: D004715) in combination with "diagnostic imaging" (MeSH Unique ID Q000000981) and "consensus" (MeSH Unique ID D032921). The information extracted from the articles of interest, written in English and published from inception of the above-mentioned databases until May 2021, was graded by the level of evidence using the American College of Chest Physicians (ACCP) classification system. The recommendations for a structured reporting of ultrasound findings were developed through multiple cycles of literature analysis and expert discussion following the Delphi method.

RESULTS

The ISGE recommends the adoption of the terms, definitions and methods proposed by the International Deep Endometriosis Analysis (IDEA) Group for ultrasound assessment of patients with suspected or known endometriosis (grade 1C), since this is the most comprehensive and systematic concept currently available. This paper provides the ISGE structured reporting template for presenting quantitative and qualitative information upon the IDEA consensus-based sonographic assessment of the uterus, adnexa, anterior and posterior compartment. The #Enzian classification is recommended to summarize the findings in a standard fashion (grade 1B).

CONCLUSION

Mapping of pelvic endometriosis by ultrasound is accurate when trained sonographers perform the technique. Structured reporting of the lesions may improve patient counseling and treatment planning, including the organization of multidisciplinary teams and the selection of the most appropriate medical or surgical therapeutic strategy.

Complementary and alternative medicine (CAM) in women with endometriosis

OBJECTIVE

This study aimed to provide an overview of the extent to which women with endometriosis are informed about, interested in, and make use of CAM, and to evaluate which of the methods are most often applied.

STUDY DESIGN

A retrospective, two-center cohort study was conducted using a validated questionnaire among women with laparoscopically confirmed endometriosis at two urban teaching hospitals, certified as endometriosis centres.

RESULTS

A total of 592 patients were included in the study and received the questionnaire; 114 (19.3 %) were included in the data analysis. Most of the women were not receiving hormone therapy at the time of the study (n = 60, 52.6 %). Most (n = 75, 65.8 %) were interested in CAM, but only a minority (n = 12, 10.5 %) had detailed knowledge about it. A total of 81 patients (71.1 %) had used at least one CAM method for disease management; the five most frequently used CAM methods were exercise (n = 55, 48.2 %), vitamins (n = 40, 35.1 %), yoga (n = 38, 33.3 %), homeopathy (n = 32, 28.1 %), and trace elements (n = 27, 23.7 %).

CONCLUSIONS

In our study population, women with endometriosis are strongly interested in using CAM, but have only limited information about it. Nevertheless, a majority of the patients had used at least one CAM method to relieve symptoms associated with the disease and the most often used was exercise.

Reproductive capacity and recurrence of disease after surgery for moderate and severe endometriosis - a retrospective single center analysis

BACKGROUND

Endometriosis can be associated with considerable pain and sterility. After surgical excision of moderate or severe endometriosis lesions, the rate of recurrence reaches up to 67%. The objective of this retrospective study was to establish the recurrence and pregnancy rates following surgical resection of stage III/IV endometriosis lesions. Indications for operation were endometriosis symptoms, sonographic findings and/or infertility.

METHODS

A total of 456 patients who underwent stage III/IV endometriosis surgery between 2004 and 2014 were sent a questionnaire relating to their postoperative medical treatment, pregnancies, relief of symptoms and recurrence. Responses of 206 patients (45.2%) and their clinical data were analysed for this study.

RESULTS

A total of 66.5% (N = 137) of patients had stage III disease, and 33.5% (N = 69) had stage IV disease. The average age was 37 years (17-59). A total of 63.1% (N = 130) of surgeries were performed by laparoscopy, 21.8% (N = 45) were performed by laparotomy and 15% (N = 31) were performed by conversion. Complete resection of endometriosis lesions was achieved in 90.8% of patients (N = 187). After surgery, 48.5% (N = 100) of the women did not receive hormonal treatment; the main reason was the desire for children in 53%. Complete or partial relief in complaints was achieved in 93.2% (N = 192). The rate of recurrence was 21.8% (N = 45). The statistically significant factors that was associated with a higher risk to develop recurrence was an age < 35 (p < 0.005). After surgery, 65.8% (79/120) of patients who wished to have children became pregnant. There was a statistically significant association among a higher postoperative pregnancy rate and age < 35 (p < 0.003) in multivariate logistic regression analysis and laparoscopic surgical access in univariate logistic regression analysis (p < 0.01).

CONCLUSION

We assessed the high percentage of complete or partial relief of symptoms of 93.2%, the high postoperative pregnancy rate of 65.8% and the low rate of recurrence of 21.8% compared to international literature to be very encouraging for women suffering from moderate and severe endometriosis. Though laparoscopy is considered the 'gold standard'of endometriosis surgery, laparotomy still may be indicated in patients with extensive endometriosis especially to preserve reproductive function.

Recommendations for the surgical treatment of endometriosis Part 2: deep endometriosis †‡¶

STUDY QUESTION

How should surgery for endometriosis be performed?

SUMMARY ANSWER

This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age.

WHAT IS KNOWN ALREADY

Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe.

STUDY DESIGN SIZE DURATION

A working group of the European Society for Gynaecological Endoscopy (ESGE), European Society of Human Reproduction and Embryology (ESHRE) and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis.

PARTICIPANTS MATERIALS SETTING METHODS

This document focused on surgery for deep endometriosis, and is complementary to a previous document in this series focusing on endometrioma surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis.

LIMITATIONS REASONS FOR CAUTION

Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma.

STUDY FUNDING - COMPETING INTERESTS

The meetings of the working group were funded by ESGE, ESHRE and WES.Dr. Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS, and NORDIC PHARMA, outside the submitted work; Dr. Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences, and Roche Diagnostics Inc, and other relationships or activities from AbbVie Inc, and Myriad Inc, during the conduct of the study; Dr. Tomassetti reports non-financial support from ESHRE, during the conduct of the study; non-financial support and other from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals, and Merck SA, outside the submitted work. The other authors had nothing to disclose.

Endometriosis in Menopause-Renewed Attention on a Controversial Disease

Endometriosis, an estrogen-dependent inflammatory disease characterized by the ectopic presence of endometrial tissue, has been the topic of renewed research and debate in recent years. The paradigm shift from the belief that endometriosis only affects women of reproductive age has drawn attention to endometriosis in both premenarchal and postmenopausal patients. There is still scarce information in literature regarding postmenopausal endometriosis, the mostly studied and reported being the prevalence in postmenopausal women. Yet, other important issues also need to be addressed concerning diagnosis, pathophysiology, and management. We aimed at summarizing the currently available data in literature in order to provide a concise and precise update regarding information available on postmenopausal endometriosis.

QS ENDO Real - A Study by the German Endometriosis Research Foundation (SEF) on the Reality of Care for Patients with Endometriosis in Germany, Austria and Switzerland

Endometriosis affects a significant number of young premenopausal women. Quite apart from the medical challenges, endometriosis is a relevant burden for healthcare and social security systems. Standardized quality indicators for the treatment of endometriosis have not previously been systematically verified. The three-stage study QS ENDO was initiated to record and improve the reality and quality of care. One of its aims is to create quality indicators for the diagnosis and treatment of endometriosis. For the first stage of QS ENDO Real, letters were sent to all 1014 gynecological departments in the German-speaking area of Europe (the DACH region) which included a questionnaire as a means of surveying the current state of care. A total of 296 (29.2%) of the centers which received the questionnaire participated in the survey. The subsequent evaluation of the completed questionnaires showed that the majority of patients with endometriosis (around 60%, based on estimates from the data) are not treated in hospitals which have been certified by the SEF. The guidelines recommend the use of specific classification systems (rASRM, ENZIAN) but, depending on the level of care offered by the hospital, only around 44.4 to 66.4% of departments used the rASRM score and only 27% of hospitals used the ENZIAN classification system to describe deep-infiltrating endometriosis. When taking patientsʼ medical history, some centers (6.6 – 17.9%) considered questions about leading symptoms such as dyschezia, dysuria and dyspareunia to be unimportant. QS ENDO Real has made it possible, for the first time, to get an overview of the reality of care provided to patients with endometriosis in the German-speaking areas of Europe. The findings indicate that several of the measures recommended in international guidelines as the gold standard of care are only used to treat some of the patients. In this respect, more efforts will be needed to provide more advanced training. The approach used for treatment must be guideline-based, also in not-certified centers, to improve the quality of care in the treatment of patients with endometriosis.

Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis

STUDY QUESTION

How should surgery for endometriosis be performed?

SUMMARY ANSWER

This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age.

WHAT IS KNOWN ALREADY

Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions, it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe.

STUDY DESIGN SIZE DURATION

A working group of the European Society for Gynaecological Endoscopy (ESGE), ESHRE and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis.

PARTICIPANTS/MATERIALS SETTING METHODS

This document focused on surgery for deep endometriosis and is complementary to a previous document in this series focusing on endometrioma surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis.

LIMITATIONS REASONS FOR CAUTION

Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma.

STUDY FUNDING/COMPETING INTERESTS

The meetings of the working group were funded by ESGE, ESHRE and WES. Dr Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS and NORDIC PHARMA, outside the submitted work; Dr Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences and Roche Diagnostics Inc. and other relationships or activities from AbbVie Inc., and Myriad Inc, during the conduct of the study; Dr Tomassetti reports non-financial support from ESHRE, during the conduct of the study; and non-financial support and other were from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals and Merck SA, outside the submitted work. The other authors had nothing to disclose.

TRIAL REGISTRATION NUMBER

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Standards Used by a Clinical and Scientific Endometriosis Center for the Diagnosis and Therapy of Patients with Endometriosis

Endometriosis is one of the most common benign gynecological diseases. The extremely heterogeneous complex of symptoms complicates the diagnosis and treatment of this disease. In most patients, there is a latency period of several years between the first occurrence of symptoms and the definitive diagnosis. This paper aims (1) to evaluate standards for the diagnosis and treatment of patients with (symptoms suspicious for) endometriosis in terms of feasibility, and (2) to assess the potential use of data collected by a certified clinical and scientific endometriosis center to answer scientific questions. Standards for outpatient consultations were developed for a special endometriosis outpatient clinic. Between January 2014 and December 2017, a total of 1715 outpatients with a suspicion of endometriosis presented to this special endometriosis outpatient clinic; the diagnosis and treatment of patients was carried out in accordance with the developed standards. Data of this patient cohort obtained from patient records created during outpatient consultations and from a questionnaire recorded in an Oracle-based database was analyzed. The patient cohort was also compared with another patient cohort who had attended different outpatient clinics and had been diagnosed intraoperatively with endometriosis. 41.8% of patients examined during special outpatient consultations had surgery for suspicion or recurrence of endometriosis. Endometriosis was confirmed in 81.5% of cases. Pain symptoms were the main indication for surgery in 70.1% of cases compared to 45.1% of cases in the comparison group. The structured approach used in the special endometriosis outpatient clinic is a key aspect of the care provided by the certified clinical and scientific endometriosis center. It ensures that patients are diagnosed and treated in accordance with guideline recommendations, that diagnosis and treatment comply with certification requirements, and that the collected data can be used to answer scientific questions.

The cost-effective, but forgotten, medical endometriosis therapy: a prospective, quasi-randomized study on progestin therapy

Endometriosis represents nowadays a real burden for the patients as well as for the physicians, as it requires surgical and/or medical treatment, often long - termed and repeated. Moreover, the high costs necessary to diagnose and treat endometriosis represent a real economic burden, being comparable to other chronic diseases like diabetes or rheumatoid arthritis. Therefore, the physicians dealing with this disease should take into account not only the efficacy of the treatment, but also the economic aspects and patients compliance. The present paper analyses the efficiency of progestins (lynestrenol and medrogestone) in endometriosis as a cost - effective, but forgotten medical therapy of the disease. Our study underlines the good tolerability of progestins, as they have limited side effects, the compliance of patients being high. They are also low-cost medications, which could represent an effective alternative method in the endometriosis treatment, especially in less - developed countries that cannot afford the higher therapeutic costs.

Major and minor complications after resection without bowel resection for deeply infiltrating endometriosis

PURPOSE

To analyze major and minor complications following surgery for deeply infiltrating endometriosis including long-term impairment of intestinal, bladder, and sexual function.

METHODS

Patients who had undergone resection for deeply infiltrating endometriosis without anterior rectal resection between 2001 and 2011 were included (n = 134). Clinical and surgical data, as well as minor and major complications, were recorded. A questionnaire was sent to the patients and to a healthy control group (n = 100).

RESULTS

Major complications occurred in 3.7% and minor complications in 12.7% of the patients. Surgical revision was necessary in five cases. The questionnaire response rate was 66.4%, with a mean follow-up period of 75.6 months. Weak urinary flow was reported by 26.4% of the patients; a feeling of residual urine by 16.1%; constipation by 13.5%; more than one bowel movement/day by 16.9%; insufficient lubrication during intercourse by 30.3%. The findings for weak urinary flow, feeling of residual urine, and insufficient lubrication differed significantly from the control group. Subgroup analysis did not identify any statistical associations between questionnaire responses and dyspareunia or dysmenorrhea as reasons for surgery, or previous endometriosis surgery in the patient's history.

CONCLUSIONS

The major and minor complication rates were consistent with or lower than the literature data. Few studies have investigated complication rates associated with treatment for endometriosis in the sacrouterine ligaments and/or the rectovaginal septum. The high rates of impaired bladder function and sexual function after endometriosis surgery, as well as inadequate data, make further prospective studies on this topic necessary.

Daily Vaginal Application of Dienogest (Visanne©) for 3 Months in Symptomatic Deeply Infiltrating Rectovaginal Endometriosis: A Possible New Treatment Approach?

A 27-year-old patient suffering from deeply infiltrating rectovaginal endometriosis was treated with 2 mg/day dienogest vaginally for 3 months. The therapy was tolerated very well. The patient reported less side effects compared to the oral use of dienogest. After 3 months of dienogest treatment, the rectovaginal gynecological examination identified the visible vaginal part of endometriosis in remission. The firm endometriosis node approximately 3 cm in size and approximately 10 cm ab ano was still palpable, but it was much less painful. The laboratory values for luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were unremarkable, with an LH/FSH quotient of 0.7 during dienogest treatment, while 17-β estradiol and progesterone were suppressed. At palpation and vaginal ultrasonography, there was no change in the findings before and after 3 months of dienogest treatment, but the patient was now de facto asymptomatic. To the best of our knowledge, this is the first report of a vaginal dienogest treatment in symptomatic deeply infiltrating rectovaginal endometriosis. Vaginal administration of dienogest should receive further investigation in pharmacokinetic and clinical studies.

Recommendations for the surgical treatment of endometriosis-part 1: ovarian endometrioma

Study question

What does this document on the surgical treatment of endometriosis jointly prepared by the European Society for Gynaecological Endoscopy (ESGE), ESHRE, and the World Endometriosis Society (WES) provide?

Summary answer

This document provides recommendations covering technical aspects of different methods of surgery for endometriomas in women of reproductive age.

What is already known

Endometriomas (ovarian endometriotic cysts) are a commonly diagnosed form of endometriosis, owing to the relative ease and accuracy of ultrasound diagnosis. They frequently present a clinical dilemma as to whether and how to treat them when found during imaging or incidentally during surgery. Previously published guidelines have provided recommendations based on the best available evidence, but without technical details on the management of endometriosis.

Study design size and duration

A working group of ESGE, ESHRE and WES collaborated on writing recommendations on the practical aspects of endometrioma surgery.

Participants/materials setting and methods

This document focused on endometrioma surgery. Further documents in this series will provide recommendations for surgery of deep and peritoneal endometriosis.

Main results and the role of chance

The document presents general recommendations for surgery of endometrioma and specific recommendations for cystectomy, ablation by laser or by plasma energy, electrocoagulation and a combination of these techniques applied together or with an interval between them.

Limitations and reasons for caution

Owing to the limited evidence available, recommendations are mostly based on clinical expertise.

Wider implications of the findings

These recommendations complement previous guidelines on the management of endometriosis.

Study funding/competing interests

The meetings of the working group were funded by ESGE, ESHRE and WES. CB declares to be a member of the independent data monitoring committee for a clinical study by ObsEva and receiving research grants from Bayer, Roche Diagnostics, MDNA Life Sciences and Volition. ES received honoraria for provision of training to healthcare professionals from Ethicon, Olympus and Gedeon Richter. The other authors declare that they have no conflict of interest.

Recommendations for the Surgical Treatment of Endometriosis. Part 1: Ovarian Endometrioma

STUDY QUESTION

What does this document on the surgical treatment of endometriosis jointly prepared by the European Society for Gynaecological Endoscopy (ESGE), ESHRE, and the World Endometriosis Society (WES) provide?

SUMMARY ANSWER

This document provides recommendations covering technical aspects of different methods of surgery for endometriomas in women of reproductive age.

WHAT IS ALREADY KNOWN

Endometriomas (ovarian endometriotic cysts) are a commonly diagnosed form of endometriosis, owing to the relative ease and accuracy of ultrasound diagnosis. They frequently present a clinical dilemma as to whether and how to treat them when found during imaging or incidentally during surgery. Previously published guidelines have provided recommendations based on the best available evidence, but without technical details on the management of endometriosis.

STUDY DESIGN SIZE DURATION

A working group of ESGE, ESHRE and WES collaborated on writing recommendations on the practical aspects of endometrioma surgery.

PARTICIPANTS/MATERIALS SETTING METHODS

This document focused on endometrioma surgery. Further documents in this series will provide recommendations for surgery of deep and peritoneal endometriosis.

MAIN RESULTS AND THE ROLE OF CHANCE

The document presents general recommendations for surgery of endometrioma, and specific recommendations for cystectomy, ablation by laser or by plasma energy, electrocoagulation and a combination of these techniques applied together or with an interval between them.

LIMITATIONS REASONS FOR CAUTION

Owing to the limited evidence available, recommendations are mostly based on clinical expertise.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations complement previous guidelines on the management of endometriosis.

STUDY FUNDING/COMPETING INTERESTS

The meetings of the working group were funded by ESGE, ESHRE and WES. C.B. declares to be a member of the independent data monitoring committee for a clinical study by ObsEva, and receiving research grants from Bayer, Roche Diagnostics, MDNA Life Sciences, and Volition. E.S. received honoraria for provision of training to healthcare professionals from Ethicon, Olympus and Gedeon Richter. The other authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

NA.

The International Endometriosis Evaluation Program (IEEP Study) - A Systematic Study for Physicians, Researchers and Patients

INTRODUCTION

Endometriosis is a heterogeneous disease characterized by a range of different presentations. It is usually diagnosed when patients present with pain and/or infertility, but it has also been diagnosed in asymptomatic patients. Because of the different diagnostic approaches and diverse therapies, time to diagnosis can vary considerably and the definitive diagnosis may be delayed, with some cases not being diagnosed for several years. Endometriosis patients have many unmet needs. A systematic registration and follow-up of endometriosis patients could be useful to obtain an insight into the course of the disease. The validation of biomarkers could contribute to the development of diagnostic and predictive tests which could help select patients for surgical assessment earlier and offer better predictions about patients who might benefit from medical, surgical or other interventions. The aim is also to obtain a better understanding of the etiology, pathogenesis and progression of the disease.

MATERIAL AND METHODS

To do this, an online multicenter documentation system was introduced to facilitate the establishment of a prospective multicenter case-control study, the IEEP (International Endometriosis Evaluation Program) study. We report here on the first 696 patients with endometriosis included in the program between June 2013 and June 2015.

RESULTS

A documentation system was created, and the structure and course of the study were mapped out with regard to data collection and the collection of biomaterials.

CONCLUSION

The documentation system permits the history and clinical data of patients with endometriosis to be recorded. The IEEP combines this information with biomaterials and uses it for scientific studies. The recorded data can also be used to evaluate clinical quality control measures such as the certification parameters used by the EEL (European Endometriosis League) to assess certified endometriosis centers.