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Rosenberger DC, Mennicken E, Schmieg I, Medkour T, Pechard M, Sachau J, Fuchtmann F, Birch J, Schnabel K, Vincent K, Baron R, Bouhassira D, Pogatzki-Zahn EM. A systematic literature review on patient-reported outcome domains and measures in nonsurgical efficacy trials related to chronic pain associated with endometriosis: an urgent call to action. Pain 2024; 165:2419-2444. [PMID: 38968394 PMCID: PMC11474936 DOI: 10.1097/j.pain.0000000000003290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 04/09/2024] [Accepted: 04/12/2024] [Indexed: 07/07/2024]
Abstract
ABSTRACT Endometriosis, a common cause for chronic pelvic pain, significantly affects quality of life, fertility, and overall productivity of those affected. Therapeutic options remain limited, and collating evidence on treatment efficacy is complicated. One reason could be the heterogeneity of assessed outcomes in nonsurgical clinical trials, impeding meaningful result comparisons. This systematic literature review examines outcome domains and patient-reported outcome measures (PROMs) used in clinical trials. Through comprehensive search of Embase, MEDLINE, and CENTRAL up until July 2022, we screened 1286 records, of which 191 were included in our analyses. Methodological quality (GRADE criteria), information about publication, patient population, and intervention were assessed, and domains as well as PROMs were extracted and analyzed. In accordance with IMMPACT domain framework, the domain pain was assessed in almost all studies (98.4%), followed by adverse events (73.8%). By contrast, assessment of physical functioning (29.8%), improvement and satisfaction (14.1%), and emotional functioning (6.8%) occurred less frequently. Studies of a better methodological quality tended to use more different domains. Nevertheless, combinations of more than 2 domains were rare, failing to comprehensively capture the bio-psycho-social aspects of endometriosis-associated pain. The PROMs used showed an even broader heterogeneity across all studies. Our findings underscore the large heterogeneity of assessed domains and PROMs in clinical pain-related endometriosis trials. This highlights the urgent need for a standardized approach to both, assessed domains and high-quality PROMs ideally realized through development and implementation of a core outcome set, encompassing the most pivotal domains and PROMs for both, stakeholders and patients.
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Affiliation(s)
| | - Emilia Mennicken
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Iris Schmieg
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Terkia Medkour
- INSERM U987, UVSQ-Paris-Saclay University, Ambroise Paré Hospital, Boulogne-Billancourt, France
| | - Marie Pechard
- INSERM U987, UVSQ-Paris-Saclay University, Ambroise Paré Hospital, Boulogne-Billancourt, France
| | - Juliane Sachau
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Fabian Fuchtmann
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Judy Birch
- Pelvic Pain Support Network, Poole, United Kingdom
| | - Kathrin Schnabel
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Katy Vincent
- Nuffield Department of Women's and Reproductive Health, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, United Kingdom
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Didier Bouhassira
- INSERM U987, UVSQ-Paris-Saclay University, Ambroise Paré Hospital, Boulogne-Billancourt, France
| | - Esther Miriam Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
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Shirafkan H, Moher D, Mirabi P. The reporting quality and spin of randomized controlled trials of endometriosis pain: Methodological study based on CONSORT extension on abstracts. PLoS One 2024; 19:e0302108. [PMID: 38696383 PMCID: PMC11065215 DOI: 10.1371/journal.pone.0302108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 03/27/2024] [Indexed: 05/04/2024] Open
Abstract
OBJECTIVE To assess the reporting quality of published RCT abstracts regarding patients with endometriosis pelvic pain and investigate the prevalence and characteristics of spin in these abstracts. METHODS PubMed and Scopus were searched for RCT abstracts addressing endometriosis pelvic pain published from January 1st, 2010 to December 1st, 2023.The reporting quality of RCT abstracts was assessed using the CONSORT statement for abstracts. Additionally, spin was evaluated in the results and conclusions section of the abstracts, defined as the misleading reporting of study findings to emphasize the perceived benefits of an intervention or to confound readers from statistically non-significant results. Assessing factors affecting the reporting quality and spin existence, linear and logistic regression was used, respectively. RESULTS A total of 47 RCT abstracts were included. Out of 16 checklist items, only three items including objective, intervention and conclusions were sufficiently reported in the most abstracts (more than 95%), and none of the abstracts presented precise data as required by the CONSORT-A guidelines. In the reporting quality of material and method section, trial design, type of randomization, the generation of random allocation sequences, the allocation concealment and blinding were most items identified that were suboptimal. The total score for the quality varied between 5 and 15 (mean: 9.59, SD: 3.03, median: 9, IQR: 5). Word count (beta = 0.015, p-value = 0.005) and publishing in open-accessed journals (beta = 2.023, p-value = 0.023) were the significant factors that affecting the reporting quality. Evaluating spin within each included paper, we found that 18 (51.43%) papers had statistically non-significant results. From these studies, 12 (66.66%) had spin in both results and conclusion sections. Furthermore, the spin intensity increased during 2010-2023 and 38.29% of abstracts had spin in both results and conclusion sections. CONCLUSION Overall poor adherence to CONSORT-A was observed, with spin detected in several RCTs featuring non-significant primary endpoints in obstetrics and gynecology literature.
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Affiliation(s)
- Hoda Shirafkan
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - David Moher
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Parvaneh Mirabi
- Infertility and Reproductive Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
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Bianchi P, Guo SW, Habiba M, Benagiano G. Utility of the Levonorgestrel-Releasing Intrauterine System in the Treatment of Abnormal Uterine Bleeding and Dysmenorrhea: A Narrative Review. J Clin Med 2022; 11:5836. [PMID: 36233703 PMCID: PMC9570961 DOI: 10.3390/jcm11195836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/28/2022] [Accepted: 09/28/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION We undertook a literature review of the use of levonorgestrel-releasing intrauterine devices when utilized for heavy menstrual bleeding and/or dysmenorrhea. METHODS A narrative review of articles in the Scopus and Medline databases was conducted. RESULTS A number of options exist for the management of both abnormal uterine bleeding (AUB) and dysmenorrhea, and evidence is accumulating that the insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) represents a useful option for their long-term treatment. The idea of using a progestogen released in utero was initially conceived to achieve long-term contraception, but it was quickly found that these systems could be utilized for a number of therapeutic applications. The first device to be made commercially available, Progestasert, was withdrawn from the market because, in the event of contraceptive failure, it caused a disproportionate percentage of extrauterine pregnancies. On the other hand, the LNG-IUS continues to be successfully utilized in its various variants, releasing 20, 13, or 8 μg/day. These devices have a respective duration of action of 7 (possibly 8), 5, and 3 years, and there exist versions of frameless systems affixed to the myometrium of the uterine fundus. In the present review, following a brief description of the major causes of AUB and dysmenorrhea, the molecular bases for the use of the LNG-IUS are summarized. This is followed by a compendium of its use in AUB and dysmenorrhea, concluding that the insertion of the system improves the quality of life, reduces menstrual blood loss better than other medical therapies, and decreases the extent of dysmenorrhea and pelvic pain. In addition, there is no evidence of a significant difference in these outcomes when the use of the LNG-IUS was compared with improvements offered by endometrial ablation or hysterectomy. Possibly, the most important mechanism of action of the system consists of its ability to induce amenorrhea, which effectively eliminates heavy bleeding and dysmenorrhea. However, no method is ideal for every woman, and, in the case of the LNG-IUS, younger age and severe dysmenorrhea seem to be associated with a higher risk of discontinuation. CONCLUSION The higher-dose LNG-IUS is a useful tool for HMB and dysmenorrhea in women of all ages. The low cost and ease of use make the LNG-IUS an attractive option, especially when contraception is also desired.
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Affiliation(s)
- Paola Bianchi
- Department of Medico-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza, University of Rome, 00161 Rome, Italy
| | - Sun-Wei Guo
- Shanghai OB/GYN Hospital, Fudan University, Shanghai 200011, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai 200011, China
| | - Marwan Habiba
- Department of Health Sciences, University Hospitals of Leicester, University of Leicester, Leicester LE1 7RH, UK
| | - Giuseppe Benagiano
- Faculty of Medicine and Dentistry, Sapienza, University of Rome, 00161 Rome, Italy
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Margatho D, Makuch MY, Bahamondes L. Experiences of male partners of women with endometriosis-associated pelvic pain: a qualitative study. EUR J CONTRACEP REPR 2022; 27:454-460. [PMID: 35867527 DOI: 10.1080/13625187.2022.2097658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The purpose of the study was to assess the experiences of male partners of women with endometriosis-associated pain after medical treatment in their everyday lives. METHODS We conducted a phenomenological study based on semi-structured interviews with 11 male partners of women with endometriosis-associated pelvic pain at the Department of Obstetrics and Gynaecology, University of Campinas Medical School, Brazil. A thematic analysis of manifest content was performed, a coding frame was drafted, and the main analysis categories were elaborated. RESULTS The interviewed men had been in stable relationships for a median length of 14 years. They reported that they did not have information about endometriosis before their partners' diagnosis and that the endometriosis-associated pelvic pain suffered by their partners affected their personal everyday life, marital relationship, sexual relationship, and intimacy. CONCLUSION Male partners of women with endometriosis-associated pain reported that the disease has both a profound impact on their lives and on their relationship. Our study contributed to an increased understanding of the life experience of men living with women with endometriosis-associated pelvic pain and may contribute to encourage healthcare professionals to incorporate strategies for guidance of the couple during treatment.
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Affiliation(s)
- Deborah Margatho
- Department of Obstetrics and Gynaecology, University of Campinas Faculty of Medical Sciences, Campinas, Brazil
| | - Maria Y Makuch
- Department of Obstetrics and Gynaecology, University of Campinas Faculty of Medical Sciences, Campinas, Brazil
| | - Luis Bahamondes
- Department of Obstetrics and Gynaecology, University of Campinas Faculty of Medical Sciences, Campinas, Brazil
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Gibbons T, Georgiou EX, Cheong YC, Wise MR. Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery. Cochrane Database Syst Rev 2021; 12:CD005072. [PMID: 34928503 PMCID: PMC8686684 DOI: 10.1002/14651858.cd005072.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Endometriosis is a condition characterised by the presence of ectopic deposits of endometrial-like tissue outside the uterus, usually in the pelvis. The impact of laparoscopic treatment on overall pain is uncertain and a significant proportion of women will require further surgery. Therefore, adjuvant medical therapies following surgery, such as the levonorgestrel-releasing intrauterine device (LNG-IUD), have been considered to reduce recurrence of symptoms. OBJECTIVES: To determine the effectiveness and safety of post-operative LNG-IUD in women with symptomatic endometriosis. SEARCH METHODS We searched the following databases from inception to January 2021: The Specialised Register of the Cochrane Gynaecology and Fertility Group, CENTRAL (which now includes records from two trial registries), MEDLINE, Embase, PsycINFO, LILACS and Epistemonikos. We handsearched citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies. We contacted experts in the field for information about any additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing women undergoing surgical treatment of endometriosis with uterine preservation who were assigned to LNG-IUD insertion, versus control conditions including expectant management, post-operative insertion of placebo (inert intrauterine device), or other medical treatment such as gonadotrophin-releasing hormone agonist (GnRH-a) drugs. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, and extracted data to allow for an intention-to-treat analysis. For dichotomous data, we calculated the risk ratio (RR) and 95% confidence interval (CI) using the Mantel-Haenszel fixed-effect method. For continuous data, we calculated the mean difference (MD) and 95% CI using the inverse variance fixed-effect method. MAIN RESULTS Four RCTs were included, with a total of 157 women. Two studies are ongoing. The GRADE certainty of evidence was very low to low. The certainty of evidence was graded down primarily for serious risk of bias and imprecision. LNG-IUD versus expectant management Overall pain: No studies reported on the primary outcome of overall pain. Dysmenorrhoea: We are uncertain whether LNG-IUD improves dysmenorrhoea at 12 months. Data on this outcome were reported on by two RCTs; meta-analysis was not possible (RCT 1: delta of median visual analogue scale (VAS) 81 versus 50, P = 0.006, n = 55; RCT 2: fall in VAS by 50 (35 to 65) versus 30 (25 to 40), P = 0.021, n = 40; low-certainty evidence). Quality of life: We are uncertain whether LNG-IUD improves quality of life at 12 months. One trial demonstrated a change in total quality of life score with postoperative LNG-IUD from baseline (mean 61.2 (standard deviation (SD) 14.8) to 12 months (mean 70.3 (SD 16.2) compared to expectant management (baseline 55.1 (SD 17.0) to 57.0 (SD 33.2) at 12 months) (n = 55, P = 0.014, very low-certainty evidence). Patient satisfaction: Two studies found higher rates of satisfaction with LNG-IUD compared to expectant management; however, combining the studies in meta-analysis was not possible (n = 95, very low-certainty evidence). One study found 75% (15/20) of those given post-operative LNG-IUD were "satisfied" or "very satisfied", compared to 50% (10/20) of those in the expectant management group (RR 1.5, 95% CI 0.90-2.49, 1 RCT, n=40, very low-certainty evidence). The second study found that fewer were "very satisfied" in the expectant management group when compared to LNG, but there were no data to include in a meta-analysis. Adverse events: One study found a significantly higher proportion of women reporting melasma (n = 55, P = 0.015, very low-certainty evidence) and bloating (n = 55, P = 0.021, very low-certainty evidence) following post-operative LNG-IUD. There were no differences in other reported adverse events, such as weight gain, acne, and headaches. LNG-IUD versus GnRH-a Overall pain: No studies reported on the primary outcome of overall pain. Chronic pelvic pain: We are uncertain whether LNG-IUD improves chronic pelvic pain at 12 months when compared to GnRH-a (VAS pain scale) (MD -2.0, 95% CI -20.2 to 16.2, 1 RCT, n = 40, very low-certainty evidence). Dysmenorrhoea: We are uncertain whether LNG-IUD improves dysmenorrhoea at six months when compared to GnRH-a (measured as a reduction in VAS pain score) (MD 1.70, 95%.CI -0.14 to 3.54, 1 RCT, n = 18, very low-certainty evidence). Adverse events: One study suggested that vasomotor symptoms were the most common adverse events reported with patients receiving GnRH-a, and irregular bleeding in those receiving LNG-IUD (n = 40, very low-certainty evidence) AUTHORS' CONCLUSIONS: Post-operative LNG-IUD is widely used to reduce endometriosis-related pain and to improve operative outcomes. This review demonstrates that there is no high-quality evidence to support this practice. This review highlights the need for further studies with large sample sizes to assess the effectiveness of post-operative adjuvant hormonal IUD on the core endometriosis outcomes (overall pain, most troublesome symptom, and quality of life).
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Affiliation(s)
- Tatjana Gibbons
- Nuffield Department of Women's & Reproductive Health, Oxford University, Oxford , UK
| | | | - Ying C Cheong
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michelle R Wise
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
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Rocca ML, Palumbo AR, Visconti F, Di Carlo C. Safety and Benefits of Contraceptives Implants: A Systematic Review. Pharmaceuticals (Basel) 2021; 14:548. [PMID: 34201123 PMCID: PMC8229462 DOI: 10.3390/ph14060548] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 12/11/2022] Open
Abstract
Progestin-only contraceptive implants provide long-acting, highly effective reversible contraception. We searched the medical publications in PubMed, CENTRAL, and EMBASE for relevant articles on hormonal implants published in English between 1990 and 2021. Levonorgestrel (LNG) 6-capsule subdermal implants represented the first effective system approved for reversible contraception. The etonogestrel (ENG) single rod dispositive has been widely employed in clinical practice, since it is a highly effective and safe contraceptive method. Abnormal menstrual bleeding is a common ENG side effect, representing the main reason for its premature discontinuation. Emerging evidence demonstrated that it is possible to extend the use of the ENG implant beyond the three-year period for which it is approved. The ENG implant could be an effective and discrete alternative to the IUD in young girls, such as post-partum/post-abortion. Implants should be inserted by trained skilled clinicians who previously provide adequate counselling about their contraceptive effect, benefits, and any possible adverse events. More studies are needed to validate the extended use of the ENG implant for up to 5 years.
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Affiliation(s)
- Morena Luigia Rocca
- Operative Unit of Obstetric and Gynaecology, Pugliese-Ciaccio Hospital, 88100 Catanzaro, Italy
| | - Anna Rita Palumbo
- Department of Obstetrics and Gynaecology, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.R.P.); (F.V.); (C.D.C.)
| | - Federica Visconti
- Department of Obstetrics and Gynaecology, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.R.P.); (F.V.); (C.D.C.)
| | - Costantino Di Carlo
- Department of Obstetrics and Gynaecology, “Magna Graecia” University, 88100 Catanzaro, Italy; (A.R.P.); (F.V.); (C.D.C.)
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Margatho D, Carvalho NM, Bahamondes L. Endometriosis-associated pain scores and biomarkers in users of the etonogestrel-releasing subdermal implant or the 52-mg levonorgestrel-releasing intrauterine system for up to 24 months. EUR J CONTRACEP REPR 2020; 25:133-140. [PMID: 32069126 DOI: 10.1080/13625187.2020.1725461] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: The aims of the study were to correlate endometriosis-associated pain, evaluated by visual analogue scale (VAS) scores, with serum levels of etonogestrel (ENG), levonorgestrel (LNG), CA-125 and soluble CD23 in users of the ENG implant or the 52-mg LNG-releasing intrauterine system (52 mg LNG-IUS) for up to 2 years after device placement.Methods: A randomised trial was conducted at the University of Campinas Medical School, Brazil. All participants (n = 103) had had endometriosis-associated chronic pelvic pain or dysmenorrhoea, or both, for more than 6 months. Participants were randomly assigned to use an ENG implant (experimental treatment) or a 52-mg LNG-IUS (active comparator). Follow-up was conducted 6 monthly for up to 24 months after device placement. Dysmenorrhoea and chronic pelvic pain were evaluated using a VAS and the scores were correlated with serum levels of ENG, LNG, CA-125 and soluble CD23.Results: Both progestin-only contraceptives significantly reduced VAS scores for dysmenorrhoea and chronic pelvic pain and reduced serum levels of soluble CD23 (p < 0.001). Serum levels of CA-125 decreased only in the ENG implant group after 24 months' use of the device (p < 0.001). No correlation was found between pain scores and ENG or LNG serum levels over time (p > 0.005).Conclusion: Both contraceptives improved dysmenorrhoea and chronic pelvic pain scores in women with endometriosis-associated pain and they reduced serum levels of soluble CD23; however, serum levels of CA-125 were reduced only in ENG implant users over the 24-month study period.
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Affiliation(s)
- Deborah Margatho
- Department of Obstetrics and Gynaecology, University of Campinas Medical School, Campinas, São Paulo, Brazil
| | - Nelsilene Mota Carvalho
- Department of Obstetrics and Gynaecology, University of Campinas Medical School, Campinas, São Paulo, Brazil
| | - Luis Bahamondes
- Department of Obstetrics and Gynaecology, University of Campinas Medical School, Campinas, São Paulo, Brazil
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