Endometriosis

Association Between Endometriosis and Mental Disorders Including Psychiatric Disorders, Suicide, and All-Cause Mortality -A Nationwide Population-Based Cohort Study in Taiwan

Objective

A multitude of previous studies has substantiated that endometriosis correlated highly with psychiatric health. This study aims to investigate the association between endometriosis and psychiatric health.

Methods

Utilizing the National Health Insurance Research Database of Taiwan, 100,770 enrolled participants, including 20,154 patients with endometriosis and 80,616 in the control group (1:4), matched for age, and index date from Taiwan's Longitudinal Health Insurance Database between January 1, 2000, and December 31, 2015. The Cox proportional regression model was used to compare the risk of mental disorders during the 16 years of follow-up after adjusting for confounding factors.

Results

Of the study patients, 4083 (20.26%) developed mental disorders; 9225 of the 80,616 controls (11.44%) developed mental disorders. The Cox regression demonstrated that, after adjusting for age, monthly income, urbanization level, etc., people with endometriosis are more likely to suffer from mental disorders compared to those without endometriosis (hazard ratio [HR]=2.131; 95% confidence interval [CI]= 1.531-2.788; p<0.001). The result illustrated that women over 40 years old had a more significant risk.

Conclusion

Compared to people without endometriosis, this study provides evidence that patients with endometriosis are at a 2.131-fold higher risk of developing mental disorders, especially in elder women. Regular psychiatric follow-up might be needed for those patients.

Conservative Management of Uterine Adenomyosis: Medical vs. Surgical Approach

Uterine adenomyosis is a commonly encountered estrogen-dependent disease in reproductive-age women, causing heavy menstrual bleeding, intense pelvic pain, and infertility. Although adenomyosis was previously considered a disease of multiparous women, it is becoming increasingly evident that it also affects younger nulliparous women and may compromise their fertility potential. It is clear that hysterectomy, the standard approach to definitively manage the disease, is not an option for patients wishing to preserve their fertility, so there is an urgent need to develop novel conservative strategies. We searched the current literature for available methods for conservative management of adenomyosis, including both pharmacological and surgical approaches. There is no existing drug that can cure adenomyosis at present, but some off-label treatment options may be used to tackle disease symptoms and improve fertility outcomes. Adenomyosis in patients wishing to conceive can be 'treated' by conservative surgery, though these procedures require highly experienced surgeons and pose a considerable risk of uterine rupture during subsequent pregnancies. While currently available options for conservative management of adenomyosis do have some capacity for alleviating symptoms and enhancing patient fertility perspectives, more effective new options are needed, with gonadotropin-releasing hormone antagonists showing encouraging results in preliminary studies.

Uterine Adenomyosis: From Disease Pathogenesis to a New Medical Approach Using GnRH Antagonists

Uterine adenomyosis is a common chronic disorder frequently encountered in reproductive-age women, causing heavy menstrual bleeding, intense pelvic pain, and infertility. Despite its high prevalence, its etiopathogenesis is not yet fully understood, so there are currently no specific drugs to treat the disease. A number of dysregulated mechanisms are believed to contribute to adenomyosis development and symptoms, including sex steroid signaling, endometrial proliferation and invasiveness, and aberrant immune response. Abnormal sex steroid signaling, particularly hyperestrogenism and subsequent progesterone resistance, are known to play a pivotal role in its pathogenesis, which is why various antiestrogenic agents have been used to manage adenomyosis-related symptoms. Among them, gonadotropin-releasing hormone (GnRH) antagonists are swiftly gaining ground, with recent studies reporting efficient lesion regression and symptom alleviation. The aim of the present review is to compile available information on the pathogenesis of adenomyosis, explore the etiology and mechanisms of hyperestrogenism, and discuss the potential of antiestrogenic therapies for treating the disease and improving patient quality of life.

Laparoscopic anterior resection of rectum for rectal deeply infiltrating endometriosis: A short-term prospective randomized trial

Laparoscopic anterior resection of rectum (AR) is one of surgical approaches for deeply infiltrating endometriosis (DIE). Up to date, no clinical trials have clearly analyzed the short-term and long-term complications post-surgically, indications or feasibilities for surgical procedure, or post-operative recovery. The aims of this trial were to evaluate the indications for laparoscopic AR, the short-term and long-term complications post-surgically, post-operative recovery.We conducted a prospective study of 29 patients. They were divided into 2 groups. The period of follow-up was 12 months post-surgery. In our study, we recruited patents with laparoscopic AR experiencing failure of medical treatment (3 months) or associated infertility (>2cycles). The operative data and short term and long term complications were recorded. The outcomes of laparoscopic AR group were assessed by questionnaires, such as NRS (numeric rating scale), KESS (Knowles-Eccersley-Scott Symptom Questionnaire), VAS (visual analogue scale), WCS (Wexner constipation score) and ABS (Abdominal Bloating Score), which were compared with the outcomes of medicine group at set time points of baseline, 3 months, 6 months, 9 months and 12 months. The overall outcomes of the two groups were assessed with 5-point Likert Scale.Patients in surgery group were recovery rapidly without serious short term or long term complications. All of NRS, KESS, VAS, WCS, and ABS in surgery group were getting better greatly than that in medicine group (3.04 ± 1.91 vs 5.41 ± 3.01, 5.64 ± 1.54 vs 7.01 ± 1.03, 0.50 ± 0.38 vs 3.58 ± 2.01, 4.43 ± 1.02 vs 8.92 ± 2.45, and 0.61 ± 0.34 vs 1.42 ± 0.71) at 3 months post-operation. However, the advantage of surgery group was almost vanished at 12 months (4.02 ± 2.53 vs 5.99 ± 2.31, 7.42 ± 3.17 vs 10.98 ± 2.53, 1.59 ± 1.3 vs 2.23 ± 1.59, 6.01 ± 2.53 vs 7.90 ± 3.25, and 1.31 ± 1.05 vs 1.39 ± 1.02). Furthermore, we compared the overall outcomes between the 2 groups with 5-point Likert Scale, with confirmation of the advantage at 3 months post-surgically. Additionally, we compared these questionnaires, with the finding that VAS and 5-point Likert Scale of surgery group had the same changes. Finally, a table of indications for laparoscopic AR were tabulated according our clinical experience.Patients can receive benefit from both medicine and laparoscopic AR. However, laparoscopic AR has obvious advantage of rapid symptom relief. Further studies and clinical data collections are required for indications and feasibility of combined therapy.

Cyclooxygenase-2 in Endometriosis

Endometriosis (EMS) is the most common gynecological disease in women of reproductive age, and it is associated with chronic pelvic pain, dyspareunia and infertility. As a consequence of genetic, immune and environmental factors, endometriotic lesions have high cyclooxygenase (COX)-2 and COX-2-derived prostaglandin E₂ (PGE₂) biosynthesis compared with the normal endometrium. The transcription of the PTGS2 gene for COX-2 is associated with multiple intracellular signals, which converge to cause the activation of mitogen-activated protein kinases (MAPKs). COX-2 expression can be regulated by several factors, such as estrogen, hypoxia, proinflammatory cytokines, environmental pollutants, metabolites and metabolic enzymes, and platelets. High concentrations of COX-2 lead to high cell proliferation, a low level of apoptosis, high invasion, angiogenesis, EMS-related pain and infertility. COX-2-derived PGE₂ performs a crucial function in EMS development by binding to EP2 and EP4 receptors. These basic findings have contributed to COX-2-targeted treatment in EMS, including COX-2 inhibitors, hormone drugs and glycyrrhizin. In this review, we summarize the most recent basic research in detail and provide a short summary of COX-2-targeted treatment.

Identification of LINC01279 as a cell cycle‑associated long non‑coding RNA in endometriosis with GBA analysis

Endometriosis affects 6‑10% of women of reproductive age. Though a significant amount of research has explored the pathogenesis of endometriosis, little is clear. Elucidating the mechanisms is urgently required for improving the therapeutic efficiency of endometriosis treatment. Long non‑coding RNAs (lncRNAs) have recently acquired extensive attention as regulatory components in a variety of biological processes and diseases. However, the functions of many lncRNAs in endometriosis are poorly understood. Therefore, the exploration of the dysregulated genes in endometriosis, particularly lncRNAs, is of importance. In the present study, datasets for endometriosis, including GSE7305, GSE7846, GSE29981 and E‑MTAB‑694, were downloaded from Gene Expression Omnibus and ArrayExpress. Then, the limma and Affy packages were used to analyze the CEL file. The RankProd method was used to conduct meta‑analysis. Long intergenic non‑protein coding RNA 1279 (LINC01279) was significantly upregulated in the three datasets, and was the most upregulated lncRNA as determined by the RankProd method. Gene set enrichment and Gene Ontology analyses were conducted, which revealed that LINC01279 is likely to function as a cell cycle mediator in endometriosis. Finally, it was identified that LINC01279 is strongly associated with certain previously identified key factors in the development of endometriosis, including cyclin‑dependent kinase 14 and C‑X‑C motif chemokine ligand 12. Thus, it was demonstrated that LINC01279 may be associated with the pathogenesis of endometriosis. This may potentially represent a target in the therapy of endometriosis.

Genetic variation in the sex hormone metabolic pathway and endometriosis risk: an evaluation of candidate genes

OBJECTIVE

To evaluate the relationship between common genetic variation in genes involved in the biosynthesis and signaling of estrogen and progesterone and endometriosis risk.

DESIGN

Genetic polymorphism analysis.

SETTING

Population-based case-control study conducted in Group Health Cooperative enrollees in western Washington.

PATIENT(S)

Women with newly diagnosed, surgically confirmed endometriosis between 1996 and 2001 (n = 256) and age- and reference year-matched female control subjects without a history of endometriosis (n = 567).

INTERVENTIONS(S)

None.

MAIN OUTCOME MEASURE(S)

We evaluated the relationship between common genetic variation and endometriosis risk, using gene-based tests and single-variant analysis of genetic polymorphisms in ESR1, ESR2, PGR, CYP17A1, CYP19A1, HSD17B1, HSD17B2, CYP1A1, CYP1A2, COMT, and GSTM1.

RESULT(S)

The most consistent gene-based association with endometriosis risk was for CYP19A1. We did not find evidence for consistent significant associations between previously reported candidate SNPs in sex hormone-related genes and endometriosis risk.

CONCLUSION(S)

In summary, we report increased endometriosis risk with CYP19A1 gene-based tests; replication of the association between endometriosis and this gene or gene region is necessary in a larger study population.

Use of aromatase inhibitors to treat endometriosis-related pain symptoms: a systematic review

This systematic review aims to assess the efficacy of aromatase inhibitors (AIs) in treating pain symptoms caused by endometriosis. A comprehensive literature search was conducted to identify all the published studies evaluating the efficacy of type II nonsteroidal aromatase inhibitors (anastrozole and letrozole) in treating endometriosis-related pain symptoms. The MEDLINE, EMBASE, PubMed, and SCOPUS databases and the Cochrane System Reviews were searched up to October 2010. This review comprises of the results of 10 publications fitting the inclusion criteria; these studies included a total of 251 women. Five studies were prospective non-comparative, four were randomized controlled trials (RCTs) and one was a prospective patient preference trial. Seven studies examined the efficacy of AIs in improving endometriosis-related pain symptoms, whilst three RCTs investigated the use of AIs as post-operative therapy in preventing the recurrence of pain symptoms after surgery for endometriosis. All the observational studies demonstrated that AIs combined with either progestogens or oral contraceptive pill reduce the severity of pain symptoms and improve quality of life. One patient preference study demonstrated that letrozole combined with norethisterone acetate is more effective in reducing pain and deep dyspareunia than norethisterone acetate alone. However, letrozole causes a higher incidence of adverse effects and does not improve patients' satisfaction or influence recurrence of symptoms after discontinuation of treatment. A RCT showed that combining letrozole with norethisterone acetate causes a lower incidence of adverse effects and lower discontinuation rate than combining letrozole with triptorelin. Two RCTs demonstrated that, after surgical treatment of endometriosis, the administration of AIs combined with gonadotropin releasing hormone analogue for 6 months reduces the risk of endometriosis recurrence when compared with gonadotropin releasing hormone analogue alone. In conclusion, AIs effectively reduce the severity of endometriosis-related pain symptoms. Since endometriosis is a chronic disease, future investigations should clarify whether the long-term administration of AIs is superior to currently available endocrine therapies in terms of improvement of pain, adverse effects and patient satisfaction.

The effects of hospitals' governance on optimal contracts: bargaining vs. contracting

We propose a two-stage model to study the impact of different hospitals' governance frameworks on the optimal contracts designed by third-party payers when patients' disease severity is the private information of the hospital. In the second stage, doctors and managers interact within either a bargaining or a contracting scenario. In the contracting scenario, managers offer a contract that determines the payment to doctors, and doctors decide how many patients to treat. In the bargaining scenario, doctors and managers strategically negotiate on both the payment to doctors and the number of patients to treat. We derive the equilibrium doctors' payments and number of treated patients under both scenarios. We then derive the optimal contract offered by the government to the hospital in the first stage. Results show that when the cost of capital is sufficiently low, the informational rent is lower, and the social welfare is higher, in the contracting scenario.