Measuring quality of life in women with endometriosis: tests of data quality, score reliability, response rate and scaling assumptions of the Endometriosis Health Profile Questionnaire

The Venus score for the assessment of the quality and trustworthiness of biomedical datasets

Biomedical datasets are the mainstays of computational biology and health informatics projects, and can be found on multiple data platforms online or obtained from wet-lab biologists and physicians. The quality and the trustworthiness of these datasets, however, can sometimes be poor, producing bad results in turn, which can harm patients and data subjects. To address this problem, policy-makers, researchers, and consortia have proposed diverse regulations, guidelines, and scores to assess the quality and increase the reliability of datasets. Although generally useful, however, they are often incomplete and impractical. The guidelines of Datasheets for Datasets, in particular, are too numerous; the requirements of the Kaggle Dataset Usability Score focus on non-scientific requisites (for example, including a cover image); and the European Union Artificial Intelligence Act (EU AI Act) sets forth sparse and general data governance requirements, which we tailored to datasets for biomedical AI. Against this backdrop, we introduce our new Venus score to assess the data quality and trustworthiness of biomedical datasets. Our score ranges from 0 to 10 and consists of ten questions that anyone developing a bioinformatics, medical informatics, or cheminformatics dataset should answer before the release. In this study, we first describe the EU AI Act, Datasheets for Datasets, and the Kaggle Dataset Usability Score, presenting their requirements and their drawbacks. To do so, we reverse-engineer the weights of the influential Kaggle Score for the first time and report them in this study. We distill the most important data governance requirements into ten questions tailored to the biomedical domain, comprising the Venus score. We apply the Venus score to twelve datasets from multiple subdomains, including electronic health records, medical imaging, microarray and bulk RNA-seq gene expression, cheminformatics, physiologic electrogram signals, and medical text. Analyzing the results, we surface fine-grained strengths and weaknesses of popular datasets, as well as aggregate trends. Most notably, we find a widespread tendency to gloss over sources of data inaccuracy and noise, which may hinder the reliable exploitation of data and, consequently, research results. Overall, our results confirm the applicability and utility of the Venus score to assess the trustworthiness of biomedical data.

The Multifactorial Burden of Endometriosis: Predictors of Quality of Life

Background/Objectives: Endometriosis is a chronic gynecological disorder characterized by ectopic endometrial-like tissue. The symptoms of this disease negatively affect the patient's quality of life, both physically and mentally. This study aims to identify key factors impacting health-related quality of life in endometriosis patients. Methods: A total of 175 patients from the Endometriosis Centre of the RWTH Aachen University Hospital were assessed using the German version of the EHP-30. The EHP is a patient self-report tool used to measure the wide range of impacts that endometriosis can have on women's lives (affecting pain levels, leading to feelings of powerlessness and a loss of control, and affecting their emotional well-being, social support, and self-image). Multivariate linear regression and random forest analyses were performed to evaluate predictors of health-related quality of life, focusing on demographic characteristics, pain severity, endometriosis symptoms and planned procedures. Results: Key factors that have a significant negative impact on QoL include higher pain scores, dysuria, and persistent endometriosis. Higher pain scores negatively affect the EHP-30 pain (p < 0.0001), control and powerlessness (p < 0.0001) and emotional well-being (p < 0.01) scores. Dysuria has a negative effect on pain (p < 0.001), control and powerlessness (p < 0.001), emotional well-being (p < 0.05), and social support (p < 0.05). Persistent endometriosis was negatively associated with pain (p < 0.01), control and powerlessness (p < 0.01), and social support. Previous endometriosis surgery has a positive effect on the EHP-30 scores for pain, control and powerlessness, emotional well-being, and self-image (p < 0.05). Conclusions: Our study highlights the multifactorial impact of endometriosis on health-related QoL. Personalized treatments focusing on pain management, emotional support and social interventions are crucial to improve patient outcomes.

Cost-effectiveness of long-acting progestogens versus the combined oral contraceptives pill for preventing recurrence of endometriosis-related pain following surgery: an economic evaluation alongside the PRE-EMPT trial

OBJECTIVES

To evaluate the cost-effectiveness of long-acting progestogens (LAP), including levonorgestrel-releasing intrauterine system (LNG-IUS) and depot-medroxyprogesterone acetate (DMPA), compared with the combined oral contraceptives pill (COCP) in preventing recurrence of endometriosis-related pain postsurgery.

DESIGN

Within-trial economic evaluation alongside a multicentre, pragmatic, parallel-group, open-label, randomised controlled trial (Preventing Recurrence of Endometriosis by means of Long-Acting Progestogen Therapy trial).

SETTING

Thirty-four UK hospitals recruiting participants from November 2015 to March 2019.

PATIENTS

Four hundred and five women aged 16-45 years undergoing conservative endometriosis surgery.

INTERVENTIONS

The ratio of 1:1 randomisation to receive LAPs (LNG-IUS or DMPA) or COCP.

MAIN OUTCOME MEASURES

The primary evaluation was a cost-utility analysis based on cost per quality-adjusted life-year (QALY) gained at 3 years. We adopted a UK National Health Service perspective. Secondary analyses in the form of cost-effectiveness analysis based on a range of outcomes were also undertaken.

RESULTS

For the primary analysis, the COCP group incurred an additional cost of £533 (95% CI £52 to £983) per woman compared with LAPs. Treatment with COCP generated additional QALYs of 0.031 (95% CI -0.079 to 0.139) compared with the LAP group over 36-month follow-up. The incremental cost-effectiveness ratio for COCP compared with LAPs is therefore approximately £17 193 per QALY. The probabilistic sensitivity analysis suggested that there was a 54.7% probability that COCP would be cost-effective at the £20 000/QALY threshold. The secondary analyses revealed results more in favour of LAPs.

CONCLUSION

Although the COCP has a slightly higher probability of being cost-effective at £20 000/QALY threshold, there remains considerable uncertainty, with only marginal differences in outcomes between the two treatments. The lower rates of further surgery and second-line medical treatment for women allocated to LAPs may make this option preferable for some women.

TRIAL REGISTRATION NUMBER

ISRCTN 97865475.

Psychometric Properties of the Stellenbosch Endometriosis Quality of Life (SEQOL) Among Endometriosis Patients in the United Kingdom

Background and Purpose: We aimed to determine the reliability and validity of the Stellenbosch Endometriosis Quality of Life (SEQOL) among patients with endometriosis in the United Kingdom. Methods: We used a cross-sectional research design that featured online data collection. We administered several measures to 596 participants. Data analysis included confirmatory factor analysis, exploratory factor analysis, reliability analysis, and correlations. Results: The data did not fit the original eight-factor structure, but rather a six-factor structure. Six items were removed. The measure produced strong internal consistency reliabilities. The SEQOL also demonstrated promising validity, producing strong correlations with another health-related quality of life (HRQOL) measure. Conclusion: In summary, we conclude that the United Kingdom version of the SEQOL is a viable measure of HRQOL.

Impact of relugolix combination therapy on functioning and quality of life in women with endometriosis-associated pain

OBJECTIVE

To evaluate the effect of relugolix combination therapy (relugolix CT; 40 mg relugolix, 1 mg estradiol, and 0.5 mg norethisterone acetate) for up to 2 years in the SPIRIT long-term extension study on functioning and health-related quality of life (QoL), using the Endometriosis Health Profile (EHP)-30 questionnaire, and assess how changes in QoL domains correlated with improvements in dysmenorrhea as well as nonmenstrual pelvic pain (NMPP).

DESIGN

Long-term extension study of the SPIRIT phase 3 trials.

SETTING

Clinics and University Hospitals.

PATIENT(S)

Premenopausal women with moderate-to-severe endometriosis pain who previously completed the randomized SPIRIT trials were eligible to enroll in an 80-week long-term extension where all women received relugolix CT.

INTERVENTION(S)

Relugolix CT (relugolix 40 mg, estradiol 1 mg, and norethindrone acetate 0.5 mg).

MAIN OUTCOME MEASURE(S)

Least squares (LS) mean changes in the EHP-30 domain and total scores from baseline (pivotal) were analyzed using a mixed-effects model. Results up to 104 weeks are reported by a pivotal trial treatment group with a focus on the relugolix CT group (i.e., relugolix CT or placebo for 24 weeks, or delayed relugolix CT [relugolix 40 mg monotherapy for 12 weeks, followed by relugolix CT for 12 weeks]). In addition, the relationships between changes in dysmenorrhea and NMPP as well as changes in EHP-30 scores were assessed.

RESULT(S)

In the 277 women treated with relugolix CT, LS mean EHP-30 pain domain scores improved by 57.8% (LS mean change: -32.8; 95% CI: -35.5, -30.1), 66.4% (LS mean change: -37.7; 95% CI: -40.3, -35.0), and 72.2% (LS mean change: -41.3; 95% CI: -43.9, -38.7) at weeks 24, 52, and 104, respectively. The proportions of women with clinically meaningful improvement in the EHP-30 pain domain were 75.9%, 83.6%, and 88.6% at weeks 24, 52, and 104, respectively. Non-pain EHP-30 domain and total scores likewise improved. A positive correlation between changes in dysmenorrhea/NMPP and all EHP-30 domain scores was observed. Results were similar for the delayed relugolix CT and placebo → relugolix CT groups.

CONCLUSION(S)

Sustained reduction of endometriosis-associated pain with relugolix CT observed up to 104 weeks was accompanied by improvements in functioning and health-related QoL. These findings complement the results of the pivotal SPIRIT trials, which showed that relugolix combination therapy significantly reduced dysmenorrhea, NMPP, and dyspareunia vs. placebo in premenopausal women with endometriosis-associated pain.

CLINICAL TRIAL REGISTRATION NUMBER

Registration/clinicaltrials.gov identifier: SPIRIT Extension Study (NCT03654274).

Preventing recurrence of endometriosis-related pain by means of long-acting progestogen therapy: the PRE-EMPT RCT

Background

Endometriosis affects 1 in 10 women, many of whom have surgery for persistent pain. Recurrence of symptoms following an operation is common. Although hormonal treatment can reduce this risk, there is uncertainty about the best option.

Objectives

To evaluate the clinical and cost-effectiveness of long-acting progestogen therapy compared with the combined oral contraceptive pill in preventing recurrence of endometriosis-related pain and quality of life.

Design

A multicentre, open, randomised trial with parallel economic evaluation. The final design was informed by a pilot study, qualitative exploration of women's lived experience of endometriosis and a pretrial economic model.

Setting

Thirty-four United Kingdom hospitals.

Participants

Women of reproductive age undergoing conservative surgery for endometriosis.

Interventions

Long-acting progestogen reversible contraceptive (either 150 mg depot medroxyprogesterone acetate or 52 mg levonorgestrel-releasing intrauterine system) or combined oral contraceptive pill (30 µg ethinylestradiol, 150 µg levonorgestrel).

Main outcome measures

The primary outcome was the pain domain of the Endometriosis Health Profile-30 questionnaire at 36 months post randomisation. The economic evaluation estimated the cost per quality-adjusted life-years gained.

Results

Four hundred and five women were randomised to receive either long-acting reversible contraceptive (N = 205) or combined oral contraceptive pill (N = 200). Pain scores improved in both groups (24 and 23 points on average) compared with preoperative values but there was no difference between the two (adjusted mean difference: -0.8, 95% confidence interval -5.7 to 4.2; p = 0.76). The long-acting reversible contraceptive group underwent fewer surgical procedures or second-line treatments compared with the combined oral contraceptive group (73 vs. 97; hazard ratio 0.67, 95% confidence interval 0.44 to 1.00). The mean adjusted quality-adjusted life-year difference between two arms was 0.043 (95% confidence interval -0.069 to 0.152) in favour of the combined oral contraceptive pill, although this cost an additional £533 (95% confidence interval 52 to 983) per woman.

Limitations

Limitations include the absence of a no-treatment group and the fact that many women changed treatments over the 3 years of follow-up. Use of telephone follow-up to collect primary outcome data in those who failed to return questionnaires resulted in missing data for secondary outcomes. The COVID pandemic may have affected rates of further surgical treatment.

Conclusions

At 36 months, women allocated to either intervention had comparable levels of pain, with both groups showing around a 40% improvement from presurgical levels. Although the combined oral contraceptive was cost-effective at a threshold of £20,000 per quality-adjusted life-year, the difference between the two was marginal and lower rates of repeat surgery might make long-acting reversible contraceptives preferable to some women.

Future work

Future research needs to focus on evaluating newer hormonal preparations, a more holistic approach to symptom suppression and identification of biomarkers to diagnose endometriosis and its recurrence.

Trial registration

This trial is registered as ISRCTN97865475. https://doi.org/10.1186/ISRCTN97865475.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 11/114/01) and is published in full in Health Technology Assessment; Vol. 28, No. 55. See the NIHR Funding and Awards website for further award information. The NIHR recognises that people have diverse gender identities, and in this report, the word 'woman' is used to describe patients or individuals whose sex assigned at birth was female, whether they identify as female, male or non-binary.

Influence of App-Based Self-Management on the Quality of Life of Women With Endometriosis

INTRODUCTION

Endometriosis can significantly impair the quality of life of those affected. Multimodal self-help measures are recommended but are often difficult to access. Smartphone apps have been shown to improve the quality of life for other conditions with chronic pain. The aim of this study was to examine the impact of the Endo-App (Endo Health GmbH, Chemnitz, Germany) on both disease-related quality of life and symptoms of endometriosis affecting it.

METHODS

In the present randomized, controlled pilot study, the impact of utilizing the Endo-App on the quality of life among a sample of 122 women affected by endometriosis is assessed. To measure the changes over a 12-week period, the study incorporates the validated Endometriosis Health Profile (EHP-5 and EHP-30) questionnaire from Oxford University, among other assessment tools.

RESULTS

The use of the Endo-App leads to significant changes in the following areas after 12 weeks compared to the control group: pain disability, pain self-efficacy, fatigue, depressive symptoms, and Endometriosis Health Profile scores. The EHP-5 score from T0 to T12 is reduced by -16.76 (p-value of the Mann-Whitney U test (pU) = 0.008), and the EHP-30 score by -15.48 (pU = 0.004). The results remain significant in sensitivity analyses. The effect size of Cohen's d was in the medium range.

CONCLUSION

In summary, the Endo-App improves both physical and psychological symptoms and the patient's self-efficacy. The Endo-App contributes to improving endometriosis care in Germany and enables women suffering from endometriosis to significantly increase their quality of life.

Measurement of changes to the menstrual cycle: A transdisciplinary systematic review evaluating measure quality and utility for clinical trials

Despite the importance of menstruation and the menstrual cycle to health, human rights, and sociocultural and economic wellbeing, the study of menstrual health suffers from a lack of funding, and research remains fractured across many disciplines. We sought to systematically review validated approaches to measure four aspects of changes to the menstrual cycle-bleeding, blood, pain, and perceptions-caused by any source and used within any field. We then evaluated the measure quality and utility for clinical trials of the identified instruments. We searched MEDLINE, Embase, and four instrument databases and included peer-reviewed articles published between 2006 and 2023 that reported on the development or validation of instruments assessing menstrual changes using quantitative or mixed-methods methodology. From a total of 8,490 articles, 8,316 were excluded, yielding 174 articles reporting on 94 instruments. Almost half of articles were from the United States or United Kingdom and over half of instruments were only in English, Spanish, French, or Portuguese. Most instruments measured bleeding parameters, uterine pain, or perceptions, but few assessed characteristics of blood. Nearly 60% of instruments were developed for populations with menstrual or gynecologic disorders or symptoms. Most instruments had fair or good measure quality or clinical trial utility; however, most instruments lacked evidence on responsiveness, question sensitivity and/or transferability, and only three instruments had good scores of both quality and utility. Although we took a novel, transdisciplinary approach, our systematic review found important gaps in the literature and instrument landscape, pointing towards a need to examine the menstrual cycle in a more comprehensive, inclusive, and standardized way. Our findings can inform the development of new or modified instruments, which-if used across the many fields that study menstrual health and within clinical trials-can contribute to a more systemic and holistic understanding of menstruation and the menstrual cycle.

Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline

OBJECTIVE

To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada.

TARGET POPULATION

Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis.

OPTIONS

The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging.

OUTCOMES

There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment.

BENEFITS, HARMS, AND COSTS

Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments.

EVIDENCE

Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text.

VALIDATION METHODS

The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them.

TWEETABLE ABSTRACT

Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Long-term effects of surgically corrected menstrual outflow obstruction: A case-control study

OBJECTIVE

To enhance evidence-based knowledge on long-term sequalae in patients with surgically corrected obstructing Müllerian anomalies.

METHODS

This long-term case-control study included patients with menstrual outflow obstruction due to congenital anomalies of the uterus or vagina, who were at least 18 years old, and for whom 2 years had elapsed since the first surgery at the start of this study. The control group consisted of women without current gynecological problems. Patients underwent a surgical correction at the Radboud University Medical Center Nijmegen between 1980 and 2013. Of 78 patients approached, 38 (49%) were included in this study. The control group consisted of 54 females. The main outcome measures were pain and health state. The following questionnaires were used: Visual Analogue Scale pain scores, European Quality of Life-5 Dimensions questionnaire (EQ-5D-3L) and the adapted Endometriosis Health Profile questionnaire (EHP-30).

RESULTS

Patients had higher actual and maximum abdominal pain scores compared with controls (11 vs 0 [P = 0.007] and 48 vs 21 [P = 0.035], respectively). Based on the EQ-5D-3L scores, patients had more pain and discomfort (P = 0.005), more mood problems (P = 0.023), and a poorer subjective health state (P = 0.002) and self-rated health state (P = 0.031). Based on the EHP-30, patients had a significant poorer self-rated health state on four out of five subscales.

CONCLUSION

In this study, following surgically corrected menstrual obstruction, patients had statistically significant higher abdominal pain scores and a poorer self-rated health state compared with controls.

A systematic review to determine use of the Endometriosis Health Profiles to measure quality of life outcomes in women with endometriosis

BACKGROUND

The Endometriosis Health Profiles (EHPs), the EHP-30 and EHP-5, are patient-reported outcome measures that were developed to measure the health-related quality of life (HRQoL) of women living with endometriosis. Prior to their development, a systematic review was undertaken which identified that the HRQoL of women living with endometriosis was poorly understood, with only three medical and one surgical study identified.

OBJECTIVE AND RATIONALE

The 20-year anniversary of the EHP-30 provided a timely opportunity to assess how the tools have been used and explore what the findings tell us about the impact of endometriosis and its associated treatments upon women's QoL. Applying robust systematic review methodology, following PRISMA guidelines, we sought to answer: How many studies have used the EHP and for what purpose?; What are the demographic characteristics and international context of the studies?; What is the methodological nature and quality of the studies?; Which interventions have been assessed and what are the reported EHP outcomes?; and Can the EHP outcomes of these interventions be analysed using a meta-analysis and, if so, what do the results show?

SEARCH METHODS

The electronic databases MEDLINE, CINAHL, PsycINFO, PubMed, and Google Scholar were searched from the year the EHP was first published, in 2001 to 26 February 2020 using the search terms 'EHP30', 'EHP5', 'EHP-30', 'EHP-5', 'endometriosis health profile 30', and 'endometriosis health profile 5'. We updated the searches on 9 April 2021. All included studies were quality assessed using the Mixed Methods Appraisal Tool (MMAT).

OUTCOMES

The review included 139 papers. In clinical intervention studies, the EHPs were deployed most frequently to measure the outcomes of medical (n = 35) and surgical (n = 21) treatment. The EHPs were also used in 13 other intervention studies, 29 non-interventional studies, 32 psychometric/cross cultural validation studies; six diagnostic studies, and in three other studies to measure outcomes in related conditions. They were mainly deployed in studies undertaken in Europe and North America. Overall, regardless of the nature of the intervention, most women reported improvements in HRQoL after treatment. Surgical interventions generally resulted in significant improvements for the longest amount of time. There was also evidence that when participants stopped taking medication their EHP scores worsened, perhaps reinforcing the temporary impact of medical treatment. Younger patients reported more negative impact upon their HRQoL. Further evidence using classical test theory to support the EHPs' robust psychometric properties, including acceptability, dimensionality, reliability, validity (including cross-cultural), and responsiveness, was demonstrated, particularly for the EHP-30. Strikingly, using anchor-based methods, EHP-30 responsiveness studies demonstrate the largest mean changes in the 'control and powerlessness' domain post-intervention, followed by 'pain'. MMAT outcomes indicated the quality of the papers was good, with the exception of five studies. A meta-analysis was not undertaken owing to the heterogeneity of the interventions and papers included in this review.

WIDER IMPLICATIONS

Women with endometriosis face a lifetime of surgical and/or medical interventions to keep the condition under control. Less invasive treatments that can lead to improved longer term physical and psycho-social outcomes are needed. The EHPs are reliable, valid, acceptable, and responsive tools, but more assessment of EHP outcomes using modern psychometric methods and in the context of women from ethnically diverse backgrounds and in routine clinical care would be beneficial. Given the brevity of the EHP-5, it may be the most appropriate version to use in routine clinical practice, whereas the longer EHP-30, which provides more granularity, is more appropriate for research.

IVF stimulation protocols and outcomes in women with endometriosis

Endometriosis is a complex medical condition with a high prevalence in women of reproductive age. Fertility is compromised in patients with endometriosis, and success in IVF treatments has been a challenge leading to evaluation of different stimulation protocols. The long-standing debate between GnRH agonist long protocols and short GnRH antagonist protocols is being resolved in favor of the latter, since in addition to presenting equivalent results with respect to the traditional option, they have the additional benefit of safety. The good results derived from vitrification techniques have led to the development of new stimulation strategies, such as progestin-primed ovarian stimulation (PPOS), with a greater degree of approval among patients. None of the stimulation protocols currently applied in women with endometriosis has been shown to be superior, so early intervention with an Assisted Reproduction treatment, regardless of the chosen protocol, can provide these women with good chances of motherhood. Women with endometrioma should be counseled for fertility preservation before planned ovarian endometrioma excision. The number of cryopreserved oocytes or embryos can be increased by repeated cycles.

Clinical factors associated with quality of life among women with endometriosis: a cross-sectional study

BACKGROUND

Endometriosis often leads to a decrease in Quality of Life (QoL), due to its impact on various aspects of women's lives, such as social life, mental health, sex life, and working capacity. Although previous studies have assessed QoL in women with endometriosis, few studies have explored the impact of different clinical variables on QoL. The aim of this study was to investigate how women with endometriosis perceive their QoL, and to analyze which clinical factors are associated with QoL.

METHODS

The Endometriosis Health Profile-30 and the ENDOCARE Questionnaire were distributed to 1000 women diagnosed with endometriosis from 10 different clinics across Sweden. The responses from 476 women were included in univariate and multivariable regression analyses, where the clinical factors were correlated with overall QoL and QoL dimensions.

RESULTS

The women participating in this study reported a low QoL. The clinical factors that showed a significant correlation with overall QoL were age at first onset of endometriosis symptoms (β= -0.64, p < 0.001), having more than 10 visits to general practitioners before referral to a gynecologist (β = 5.58, p = 0.036), current or previous mental health issues (β = 7.98, p < 0.001) patient-centeredness (β= -2.59, p < 0.001) and use of opioids (β = 7.14, p = 0.002).

CONCLUSIONS

This study shows that opioid use and mental health issues were associated with a worse QoL, whereas a higher degree of patient-centeredness was associated with a better QoL. The association between opioid use and a worse QoL might not entirely be caused by the opioid use itself but also by symptom severity and mental health issues. An improved patient-centeredness and more focus on taking care of mental health issues would reasonably result in a better QoL for women with endometriosis.

Gonadotropin-Releasing Hormone Antagonists-A New Hope in Endometriosis Treatment?

Endometriosis is a chronic disease, in which endometrial-like tissue is found outside the uterine cavity. Lesions are typically located in the true pelvis but can be found, in addition to extragenital endometriosis, in the respiratory system, the diaphragm, the pleura or the pericardium. As the extrauterine endometrial lesions undergo the menstrual cycle, they cause many symptoms, including pain, and besides infertility, they all mostly affect the quality of the patient's life. Pharmacological management of endometriosis significantly increases in importance either as a first-line treatment or as a complementary therapy after surgery. Yet, current research on antagonists of the gonadotropin-releasing hormone (GnRH) has revealed their potential benefits in endometriosis treatment. Their mechanism of action is to down-regulate the hypothalamic-pituitary-gonadal axis and therefore induce a hypoestrogenic state. The resulting reduction of estrogen levels prevents disease progression and diminishes the recurrence rate after surgical removal of endometriosis. The present review summarizes recent reports of the role oral GnRH antagonists have as a significant treatment option for pain reduction in endometriosis patients.

Evaluation of quality of life in endometriosis patients before and after surgical treatment using the EHP30 questionnaire

BACKROUND

Endometriosis is one of the most common gynecological illnesses causing extensive psychological, physical and social impact on patient's life and exerts negative effects on health-related quality of Life (HRQoL). However, the effects of surgery on the postoperative HRQoL in the different endometriosis subgroups have not been fully evaluated.

METHODS

We performed a comparative retrospective study between 2014 and 2018 at the Medical University of Vienna, including all patients with surgically confirmed endometriosis who had completed the standardized Endometriosis Health Profile-30 (EHP-30) questionnaire 1 day after surgery (the questions refer to the 4 weeks preoperatively) and 6-10 weeks postoperatively.

RESULTS

Compared to preoperative values, we found significant benefits, regarding postoperative conditions, in our study group (n = 115) in all five categories, "pain" (HR 0.78, p < 0.001); "self-determination" (HR 0.92, p < 0.001); "emotional health" (HR 0.83, p < 0.001);" social environment" (HR 0.67, p < 0.001); and "self-image" (HR 0.47, p < 0.001). Patients with only peritoneal endometriosis had the lowest preoperative clinical symptoms and there were no significant changes in any of the categories. In the subgroups deep infiltrating endometriosis (DIE) and DIE + ovarian endometrioma, surgical intervention results in a significantly greater improvement in all categories of EHP 30 compared to ovarian endometrioma without DIE or peritoneal endometriosis.

CONCLUSION

Our study shows, that especially women with DIE-with or without ovarian endometrioma-demonstrate a more pronounced benefit from surgical therapy compared to patients with peritoneal endometriosis or endometrioma without DIE.

Health-related quality of life in endometriosis: The influence of endometriosis-related symptom presence and distress

This international cross-sectional study examined the relationships between endometriosis-related symptom experience and health-related quality of life (HRQoL) in 318 women with endometriosis. Measures of symptom burden and distress, pain, psychological wellbeing, and HRQoL were collected via an online survey. Age, symptom duration, burden, and distress were associated with lower psychological wellbeing and HRQoL, with small to medium effect sizes. Somatic concern, depression, pain, dysmenorrhea, clitoral pain, dyspareunia, and bloating were found to be significant correlates of HRQoL. The findings highlight the importance of considering a broader range of endometriosis-related symptoms than pain alone and the ongoing need to reduce diagnostic delay in endometriosis.

Body image and depression in endometriosis: Examining self-esteem and rumination as mediators

Endometriosis is a chronic systemic disease affecting 1 in 10 people assigned female at birth, that can result in appearance-based and functional bodily changes which can negatively impact body image. Empirical evidence supports the body dissatisfaction-driven hypothesis that negative body image leads to greater depressive symptoms; but potential underlying mechanisms are under-researched. This prospective study investigated the mediating role of two theoretically-derived intervening factors, self-esteem and rumination, in individuals living with endometriosis who typically report high rates of body image concerns and depressive symptoms. Initially, 996 participants completed the first online survey (T0) assessing demographic, medical and psychological factors. Of these, 451 completed surveys at 1-month (T1) and 2-months (T2) follow-up assessing self-esteem, rumination and depression. Bootstrapped analyses with full-information maximum likelihood estimation indicated that poor body image (T0) predicted greater depressive symptoms over time (T2). Self-esteem (T1), but not rumination (T1), mediated the body image-depression relationship. These results provide support for the body dissatisfaction-driven hypothesis and further identify that self-esteem is a key meditating factor. This highlights the importance of addressing self-esteem in body image focused interventions.

Psychosocial correlates of symptoms of depression among patients with endometriosis in the United Kingdom

A recent study found high levels (43%) of moderate to severe symptoms of depression among patients diagnosed with endometriosis in South Africa (SA) and identified several psychosocial predictors of these symptoms of depression. However, there is limited research on predictors of symptoms of depression in other settings. Considering the contextual differences between SA and the United Kingdom (UK) and their vastly different healthcare settings, we conducted a replication study in the UK and improved on the methodology by adding an established measure of sexual dysfunction to the model and obtaining a larger sample. The study comprised of a secondary analysis of cross-sectional data collected among patients with endometriosis. Study particulars were advertised by a national endometriosis association and data were collected online using Qualtrics. The sample consisted of 598 adults with self-reported endometriosis who completed measures assessing symptoms of depression, physical functioning, menstrual characteristics, sexual functioning, feelings about the medical profession, feelings about infertility, and sexual relationships. Seventy-one percent of participants reported moderate to severe levels of symptoms of depression. In addition, physical functioning, concerns about menstrual characteristics, sexual dysfunction, feelings about infertility and feelings about the medical profession were identified as significant predictors of symptoms of depression. It is important that healthcare professionals recognize that patients with endometriosis may be at risk of depression and that psychological referral should be considered.

Assessing the experience of dyspareunia in the endometriosis population: the Subjective Impact of Dyspareunia Inventory (SIDI)

STUDY QUESTION

Is the Subjective Impact of Dyspareunia Inventory (SIDI) a reliable tool to examine the experience of dyspareunia in the context of endometriosis?

SUMMARY ANSWER

In this study, the SIDI showed good structural and psychometric properties, and thus can be used as a reliable questionnaire to assess the impact of endometriosis-related dyspareunia on multiple dimensions, such as sexuality and intimate relationships.

WHAT IS KNOWN ALREADY

In the endometriosis population, dyspareunia has a tremendous negative impact on psychological health, overall sexual function and couple relationships. However, there is a paucity of tools that can be effectively used in either research or clinical practice to assess the subjective components of the dyspareunia experience, including coping strategies to deal with the pain.

STUDY DESIGN, SIZE, DURATION

In this cross-sectional study, the validity of the SIDI was examined by considering the responses provided by 638 participants with endometriosis and dyspareunia, who participated in an online survey conducted between 8 November and 21 December 2021. Participants were recruited using snowball sampling that involved posting the invitation to participate in the study on the social media of a patient association.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were women aged ≥18 with clinical or surgical diagnosis of endometriosis. The SIDI measures the subjective impact of dyspareunia and is composed of 16 items focused on the frequency of dyspareunia-related experiences in the last 6 months, rated on a 5-point Likert scale. Sexuality was assessed using the Female Sexual Function Index. Psychological health was measured using the Hospital Anxiety and Depression Scale and the Rosenberg Self-Esteem Scale. Sociodemographic and endometriosis-related information was collected using a researcher-made questionnaire. Statistical significance was set at P < 0.05.

MAIN RESULTS AND THE ROLE OF CHANCE

Factor analysis revealed that the SIDI has a four-factor structure and allows for examining the impact of dyspareunia in terms of Sexual Concerns (Factor 1), Relationship Concerns (Factor 2), Partner Support (Factor 3) and Endurance of Pain (Factor 4). The SIDI showed good structural and psychometric properties (including internal consistency), was associated with sexual function and psychological health and was able to discriminate between participants with and without sexual dysfunction.

LIMITATIONS, REASONS FOR CAUTION

Reasons for caution are related to the risk of self-selection bias depending on the study population and recruitment strategy. Moreover, all the information provided by the participants was self-reported, which may have affected the accuracy of the data collected, especially with regards to endometriosis-specific information.

WIDER IMPLICATIONS OF THE FINDINGS

This study may provide a new brief tool that can be used by clinicians and researchers to assess the impact of dyspareunia from a multidimensional perspective and to consider subjective aspects that can be usefully integrated with information about pain severity, timing and localization.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding for this study. A.F. is the President of APE-Odv (Associazione Progetto Endometriosi-Organizzazione di volontariato (Endometriosis Project Association-Volunteer Organization)), the largest nonprofit endometriosis patient association in Italy. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Impact of Long-Term Dienogest Therapy on Quality of Life in Asian Women with Endometriosis: the Prospective Non-Interventional Study ENVISIOeN

Several clinical trials in women with endometriosis demonstrated that dienogest reduces endometrial lesions and improves health-related quality of life (HRQoL). To assess HRQoL in dienogest-treated patients in real-world setting, we conducted a prospective, non-interventional study in 6 Asian countries. Women aged ≥18 years with clinical or surgical diagnosis of endometriosis, presence of endometriosis-associated pelvic pain (EAPP) and initiating dienogest therapy were enrolled. The primary objective was to evaluate HRQoL using the Endometriosis Health Profile-30 (EHP-30) questionnaire. The secondary objectives included analysis of EAPP, satisfaction with dienogest, endometriosis symptoms and bleeding patterns. 887 patients started dienogest therapy. Scores for all EHP-30 scales improved with the largest mean changes at month 6 and 24 in scale pain (−28.9 ± 27.5 and − 34 ± 28.4) and control and powerlessness (−23.7 ± 28.2 and − 28.5 ± 26.2). Mean EAPP score change was −4.6 ± 3.0 for both month 6 and 24 assessments. EAPP decrease was similar in surgically and only clinically diagnosed patients. From baseline to month 24, rates of normal bleeding decreased (from 85.8% to 17.5%) while rates of amenorrhea increased (from 3.5% to 70.8%). Majority of patients and physicians were satisfied with dienogest. Over 80% of patients reported symptoms improvement. 39.9% of patients had drug-related treatment-emergent adverse events, including vaginal hemorrhage (10.4%), metrorrhagia (7.3%) and amenorrhea (6.4%). In conclusion, dienogest improves HRQoL and EAPP in the real-world setting in women with either clinical or surgical diagnosis of endometriosis. Dienogest might be a promising first-line treatment option for the long-term management of debilitating endometriosis-associated symptoms.

NCT02425462, 24 April 2015.

Effectiveness of intracavitary monopolar dielectric radiofrequency in women with endometriosis-associated pain: A case series

BACKGROUND

and Purpose: Endometriosis-associated pain is the main cause of chronic pelvic pain in women. Endometriosis has a significant negative impact across different domains of patients' quality of life. This study aimed to evaluate the efficacy of an intracavitary application of monopolar dielectric radiofrequency in women with endometriosis-associated pain.

PATIENT PRESENTATION

Five women with endometriosis received 25 sessions of an intracavitary application of monopolar dielectric radiofrequency within three months. Outcomes, including quality of life, sex interference (Endometriosis Health Profile [EHP]-30 + section C), myofascial pain syndrome (myofascial trigger points), pain intensity (Visual Analogue Scale), frequency and referral pattern, pressure pain thresholds, allodynia and neuropathic pain (modified DN4), were examined both during and outside menses, after intervention and six months later.

RESULTS

Clinically meaningful improvements were achieved by most participants regarding pelvic pain intensity, abdominal sensitivity, and myofascial pain of the pelvic floor.

CONCLUSION

This study lays the foundation for future in-depth research, suggesting that monopolar dielectric radiofrequency could be helpful in improving the symptomatology and quality of life of women with endometriosis, also in patients who are unresponsive to medical and/or surgical treatments, or who cannot undergo them in the short term.

Health-related quality of life in women with endometriosis: psychometric validation of the Endometriosis Health Profile 30 questionnaire using confirmatory factor analysis

STUDY QUESTION

Which of the competing models of the Endometriosis Health Profile 30 Questionnaire (EHP-30) factor structure is best supported by confirmatory factor analysis (CFA)?

SUMMARY ANSWER

Findings support a five-factor first-order model of the EHP-30, thereby lending support to the model originally suggested by the questionnaire developers.

WHAT IS KNOWN ALREADY

Endometriosis has a negative impact on quality of life, and measures specifically developed to address this impact, such as the EHP-30, are vital in research and disease management. Previous studies have found different models of the EHP-30 factor structure, and generated uncertainty regarding how to use the questionnaire. CFA can be applied to compare competing factor models and determine the underlying structure of a questionnaire.

STUDY DESIGN SIZE DURATION

This cross-sectional multicenter study included 304 women with endometriosis recruited from three different public health service endometriosis clinics (referral centers for treatment of severe endometriosis) and the Danish Endometriosis Patients Association from 2014 to 2015.

PARTICIPANTS/MATERIALS SETTING METHODS

Diagnosis of endometriosis was confirmed in medical records for 84.2% and by histology for 66.8% of participants. Questionnaires (the licensed Danish version of the EHP-30) were sent by post two times with a 6- to 12-week interval. CFA was used to examine construct validity and Bland-Altman plots to examine test-retest reliability and the convergent validity with the Short Form 36 version 2.

MAIN RESULTS AND THE ROLE OF CHANCE

Response rate was high (87.6%). CFA supported the original first-order five-factor structure of the EHP-30, and thereby, the use of five separate scale-scores in clinical and research practice. Visual inspection of Bland-Altman plots suggested excellent test-retest reliability of the EHP-30 and supported the use of a disease specific quality of life instrument for women with endometriosis.

LIMITATIONS REASONS FOR CAUTION

Diagnosis could not be confirmed through histology data in 33.2% of participants. However, subgroup analyses based on women with confirmed histology only, yielded similar results. Data related to menstrual cycle stage and the use of hormonal and pain medication during questionnaire completion were not collected. A larger study, including data from different countries on different continents, would be better designed to exclude potential population bias.

WIDER IMPLICATIONS OF THE FINDINGS

EHP-30, with its original five-factor structure, appears to be a valid, stable, and specific quality of life measure for women with endometriosis. It seems easy to understand, quick to administer, and importantly, scoring might be unaffected by cyclical/menstrual pain symptoms related to endometriosis. The finding of a five-factor model from different studies across several countries supports the crosscultural validity of the EHP-30.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by the Danish Endometriosis Association, which is a nongovernmental organization run by women with endometriosis and by a scholarship from the Health Research Fund of Central Denmark Region. The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

The Danish Data Protection Agency (J.nr: 2013-41-2264).

Relugolix, an oral gonadotropin-releasing hormone (GnRH) receptor antagonist, in women with endometriosis-associated pain: phase 2 safety and efficacy 24-week results

Background

Relugolix is a once-daily, oral, nonpeptide, gonadotropin-releasing hormone receptor antagonist. The aim of this study was to evaluate safety of relugolix over 24 weeks in women with endometriosis-associated pain.

Methods

This phase 2, randomized, open-label, parallel-group extension study was conducted in 101 clinics in Japan. Patients (premenopausal females ≥ 20 years) who completed the preceding 12-week relugolix phase 2 study continued to receive relugolix (10 mg, 20 mg, or 40 mg), placebo, or leuprorelin (3.75 mg) for an additional 12 weeks. Relugolix was administered orally once daily, and leuprorelin subcutaneously once every 4 weeks. The primary outcome was safety, including bone mineral density (BMD) and treatment-emergent adverse events (TEAEs). Secondary endpoints included visual analog scale (VAS) scores for endometriosis-associated pain. Analysis sets were defined as all patients who were administered the study drug.

Results

Of 487 randomized patients in the preceding study, 397 enrolled in this extension study and continued to receive placebo (n = 77), relugolix 10 mg (n = 84), relugolix 20 mg (n = 78), relugolix 40 mg (n = 89), or leuprorelin (n = 69). Baseline characteristics were similar between extension study patients and patients in the preceding study. Frequency of TEAEs including metrorrhagia, menorrhagia, and hot flush was similar in the relugolix 40-mg and leuprorelin groups. Mean (SD) change in BMD from baseline at Week 24 was − 0.2 (1.99)% for placebo;  − 1.6 (2.34)%,  − 2.6 (2.94)%, and  − 4.9 (2.91)% for the relugolix 10-mg, 20-mg, and 40-mg groups, respectively; and − 4.4 (2.16)% for leuprorelin. Mean ± SD change from baseline in mean VAS score (mm) for pelvic pain at end of treatment was − 3.2 ± 12.16 for placebo; − 6.8 ± 10.56, − 9.0 ± 11.84, and − 11.9 ± 11.26 for the relugolix 10-mg, 20-mg, and 40-mg groups, respectively; and − 12.7 ± 12.57 for leuprorelin. Estradiol levels decreased with increasing relugolix dose and remained below postmenopausal levels throughout the 24-week relugolix 40-mg treatment period.

Conclusions

Treatment with relugolix for 24 weeks was generally well tolerated and demonstrated similar pain reduction to leuprorelin in women with endometriosis. The dose-dependent loss in BMD observed with relugolix treatment was expected due to an induced hypoestrogenic state. Relugolix demonstrated a similar benefit/risk profile to injectable therapy in this phase 2 study.

Trial registration NCT01452685 (ClinicalTrials.gov, registered 17/10/2011).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01393-3.

Dichloroacetate as a possible treatment for endometriosis-associated pain: a single-arm open-label exploratory clinical trial (EPiC)

BACKGROUND

Endometriosis (where endometrial-like tissue is found outside the uterus) affects ~ 176 million women worldwide and can lead to debilitating pelvic pain. There is an unmet need for new medical treatment options for endometriosis. Pelvic peritoneal mesothelial cells of women with endometriosis exhibit detrimental metabolic reprogramming that creates an environment favouring the formation and survival of endometriosis lesions. We have generated powerful preclinical proof-of-concept data to show that it is possible to correct this metabolic phenotype using dichloroacetate (DCA), a non-hormonal compound previously used to treat rare metabolic disorders in children. We plan a single-arm, open-label, single site exploratory clinical trial to inform the design of a future randomised controlled trial (RCT) to determine the efficacy of DCA for the treatment of endometriosis-associated pain.

METHODS

We will recruit 30 women with endometriosis-associated pain over a 6-month period. All participants will receive approximately 6.25 mg/kg oral DCA capsules twice daily for 6 weeks, with a dose increase to approximately 12.5 mg/kg twice daily for a further 6 weeks if their pain has not been adequately controlled on this dose regime and side-effects are acceptable. If pain is adequately controlled with minimal side-effects, the lower dose will be continued for a further 6 weeks. The primary objective is to determine whether it is possible to achieve acceptable recruitment and retention rates within the defined exclusion and inclusion criteria. Secondary objectives are to determine the acceptability of the trial to participants, including the proposed methods of recruitment, treatment, follow-up frequency and number of questionnaires. The recruitment rate will be determined by the proportion of patients recruited from the pool of eligible women. The retention rate will be determined by the proportion of participants who attended the final trial visit.

DISCUSSION

This is a feasibility study to explore effectiveness and acceptability of the proposed field methodology (recruitment, retention, study processes and compliance with treatment). The results will be used to inform the design of a future RCT.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04046081 Registered 6 August 2019.

Laparoscopic treatment of isolated superficial peritoneal endometriosis for managing chronic pelvic pain in women: study protocol for a randomised controlled feasibility trial (ESPriT1)

BACKGROUND

Endometriosis (where endometrial-like tissue is found outside the uterus) affects ~ 176 million women worldwide and can lead to debilitating pelvic pain. Three subtypes of endometriosis exist, with ~ 80% of women having superficial peritoneal endometriosis (SPE). Endometriosis is diagnosed by laparoscopy and, if SPE is found, gynaecologists usually remove it surgically. However, many women get limited pain relief from surgical removal of SPE. We plan to undertake a future large trial where women who have only SPE found at initial laparoscopy are randomly allocated to have surgical removal (excision or ablation) of SPE, or not. Ultimately, we want to determine whether surgical removal improves overall symptoms and quality of life, or whether surgery is of no benefit, exacerbates symptoms, or even causes harm. The primary objective of this feasibility study is to determine what proportion of women with suspected SPE undergoing diagnostic laparoscopy will agree to randomisation. The secondary objectives are to determine if there are differences in key prognostic parameters between eligible women that agree to be randomised and those that decline; how many women having laparoscopy for investigation of chronic pelvic pain are eligible for the trial; the range of treatment effects and variability in outcomes and the most acceptable methods of recruitment, randomisation and assessment tools.

METHODS

We will recruit up to 90 women with suspected SPE undergoing diagnostic laparoscopy over a 9-month recruitment period in four Scottish hospitals and randomise them 1:1 to either diagnostic laparoscopy alone (with a sham port to achieve blinding of the allocation) or surgical removal of endometriosis. Baseline characteristics, e.g. age, index of social deprivation, ethnicity, and intensity/duration of pain will be collected. Participants will be followed up by online questionnaires assessing pain, physical and emotional function at baseline, 3 months, 6 months and 12 months.

DISCUSSION

Recruitment to a randomised controlled trial to assess the effectiveness of surgery for endometriosis may be challenging because of preconceived ideas about treatment success amongst patients and clinicians. We have designed this study to assess feasibility of recruitment and to inform the design of our future definitive trial.

TRIAL REGISTRATION

ClincicalTrials.gov, NCT04081532 STATUS: Recruiting.

Health-Related Quality of Life Improvements in Patients With Endometriosis Treated With Elagolix

OBJECTIVE

To evaluate the effects of elagolix on clinically meaningful improvements in health-related quality of life (HRQOL) measured by the EHP-30 (Endometriosis Health Profile-30).

METHODS

Data from two phase III trials of elagolix for moderate to severe pain associated with endometriosis were pooled and analyzed as three groups: placebo, elagolix 150 mg once daily, or elagolix 200 mg twice daily. Patients were administered the EHP-30 questionnaire at baseline, and at months 1, 3, and 6 of treatment. Previously established responder definitions were applied to determine percentages of patients with clinically meaningful EHP-30 improvements. The probability of meeting EHP-30 responder definitions with elagolix compared with placebo at months 3 and 6 was determined by Poisson regression analysis, controlling for baseline scores.

RESULTS

At month 6, the probabilities of meeting EHP-30 subscale responder definitions for pain, control and powerlessness, self-image, social support, emotional well-being, and sexual intercourse were 169% (adjusted relative risk [aRR]: 2.69, 95% CI 2.26-3.21), 129% (aRR 2.29, 95% CI 1.96-2.67), 80% (aRR 1.80, 95% CI 1.54-2.11), 70% (aRR 1.70, 95% CI 1.47-1.97), 67% (aRR 1.67, 95% CI 1.45-1.92), and 62% (aRR 1.62, 95% CI 1.36-1.92) greater, respectively (all P<.001), in the 200-mg group than in the placebo group. Although lower in magnitude than the 200-mg group, the 150-mg group also had greater probabilities of meeting responder definitions than the placebo group for all subscales except sexual intercourse. The probabilities of meeting responder definitions for pain, control and powerlessness, self-image, social support, and emotional well-being were 75% (aRR 1.75, 95% CI 1.44-2.14), 50% (aRR 1.50, 95% CI 1.25-1.80), 22% (aRR 1.22, 95% CI 1.01-1.47), 30% (aRR 1.30, 95% CI 1.09-1.53), and 35% (aRR 1.35, 95% CI 1.16-1.57) greater, respectively (all P<.05), in the 150-mg group than in the placebo group.

CONCLUSION

Patients with moderate to severe pain associated with endometriosis and were treated with elagolix experienced clinically meaningful HRQOL improvements.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01620528 and NCT01931670.

FUNDING SOURCE

AbbVie Inc.

Psychometric evaluation of the Swedish version of the 30-item endometriosis health profile (EHP-30)

Background

The 30-Item Endometriosis Health Profile (EHP-30) is a specific instrument measuring quality of life among women with endometriosis. Although the Swedish version of EHP-30 is widely used in research and clinical settings, it has not yet been evaluated psychometrically. Ensuring validity and reliability is of most importance when using translated instruments. Therefore, the aim of the study was to evaluate the psychometric properties of the Swedish version of the EHP-30.

Methods

This study was conducted at a Swedish referral university hospital specializing in endometriosis. Data collection was performed in January 2013. The EHP-30 was sent to 369 randomly selected women with a laparoscopy-verified endometriosis diagnosis. The psychometric evaluation included evaluation of data completeness, score distributions, floor and ceiling effects, internal consistency, factor analysis and test-retest reliability.

Results

Out of the 211 women with endometriosis who answered the questionnaire, 128 were native Swedish speakers who had experienced symptoms of endometriosis during the past 4 weeks, and were included in the psychometric evaluation. Data completeness was 99.5%. The highest median score was found in the Control and Powerlessness subscale, and lowest in Pain. Distributions towards ill health were found in all subscales except for the pain subscale, but there were no noteworthy floor or ceiling effects. Internal consistency was good (Cronbach’s α 0.83–0.96). Factor analysis could roughly confirm three of the five subscales. The test-rest analysis showed good reliability. Scores were systematically lower during the second measurement.

Conclusions

We conclude that the Swedish version of EHP-30 is a valid and reliable instrument to measure health-related quality of life in women with endometriosis. It is understandable, acceptable and usable and can be recommended for use in clinical daily routines and for research purposes.

Relugolix, an oral gonadotropin-releasing hormone receptor antagonist, reduces endometriosis-associated pain in a dose-response manner: a randomized, double-blind, placebo-controlled study

OBJECTIVE

To evaluate the efficacy and safety of three dose levels of relugolix, a gonadotropin-releasing hormone receptor antagonist, compared with placebo and leuprorelin in women with endometriosis-associated pain.

DESIGN

Phase 2, multicenter, randomized, double-blind, placebo-controlled study.

SETTING

Hospitals and clinics.

PATIENT(S)

Adult premenopausal women with endometriosis who had dysmenorrhea and endometriosis-associated pelvic pain.

INTERVENTION(S)

During a 12-week treatment period, patients received relugolix 10 mg (n = 103), 20 mg (n = 100), or 40 mg (n = 103) as a daily oral dose; placebo (n = 97) as a daily oral dose; or leuprorelin 3.75 mg (n = 80) as a monthly subcutaneous injection.

MAIN OUTCOME MEASURE(S)

Primary endpoint was the change from baseline in mean visual analog scale score for pelvic pain during 28 days before the end of treatment.

RESULT(S)

The mean changes in mean visual analog scale score for pelvic pain were -3.8 mm in the placebo group; -6.2, -8.1, and -10.4 mm in the relugolix 10-mg, 20-mg, and 40-mg groups; respectively; and -10.6 mm in the leuprorelin group. The major adverse events with relugolix were hot flush, metrorrhagia, menorrhagia, and irregular menstruation, and bone mineral density decrease in a dose-response manner, which were also observed in the leuprorelin group with a frequency comparable with that in the relugolix 40-mg group.

CONCLUSION(S)

Oral administration of relugolix alleviated endometriosis-associated pain in a dose-response manner and was generally well tolerated. Relugolix 40 mg demonstrated efficacy and safety comparable with those of leuprorelin.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01458301.

Endometriosis and Sexual Quality of Life

Introduction

Endometriosis is a benign gynecological disease with a high disease burden and significant, multifaceted impact on health-related quality of life (HRQoL) and sexual quality of life (SQoL).

Aim

To explore which patient- and disease-specific characteristics were independently associated with SQoL.

Methods

A literature search was carried out to identify characteristics with an evidence-based or hypothesized effect on SQoL. Subsequently, data on HRQoL in women with endometriosis (n = 224), collected between 2013 and 2018 in a prospective longitudinal Dutch cohort study performed in 7 referral centers, were used to perform a cross-sectional cohort study. Data were collected using an online self-administered survey including the validated Endometriosis Health Profile-30. Inclusion criteria were recently diagnosed endometriosis patients or newly referred patients with a clinical diagnosis of endometriosis. Patients were excluded in case of incomplete answers on the SQoL questions. Univariate analyses and multiple linear regression analyses were performed.

Outcomes

SQoL, measured by the 5-item “sexual intercourse” dimension score of the modular Endometriosis Health Profile-30 questionnaire, was the primary outcome with scores ranging from 0 to 100 (0 indicating the best and 100 indicating the worst health status).

Results

Based on a literature search, 29 characteristics potentially associated with SQoL were selected from the survey and included in the analyses. In total, 192 women (mean age 36 years) met the inclusion criteria. The majority of women (86.5%) had had intercourse in the period before completing the survey and the study population showed a mean SQoL score of 47.5 ± 29.6, indicating moderate SQoL. Worse SQoL was independently associated with dyspareunia (P < .001), worse HRQoL (P = .001), severity of dysmenorrhea (P = .017), and unemployed work status (P = .022).

Conclusion

In a cohort of women with endometriosis, worse SQoL was significantly and independently associated with the presence of dyspareunia, more severe dysmenorrhea, worse HRQoL, and unemployed work status.

van Poll M, van Barneveld E, Aerts L, et al. Endometriosis and Sexual Quality of Life. Sex Med 2020;8:532–544.

Effect of hysterectomy on pain in women with endometriosis: a population-based registry study

OBJECTIVE

To assess pain symptoms before and after hysterectomy in women with endometriosis.

DESIGN

A population-based registry study.

SETTING

Sweden.

POPULATION

Women aged 18-45 years who underwent hysterectomy for endometriosis between 2010 and 2015.

METHODS

Pain symptoms before hysterectomy and 12 months after surgery were collected from the Swedish National Quality Register for Gynaecological Surgery (GynOp). Pain symptoms were also assessed by follow-up surveys after a median follow-up period of 63 months.

MAIN OUTCOME MEASURES

Pelvic or lower abdominal pain after hysterectomy.

RESULTS

The study included 137 women. The proportion of women experiencing pain of any severity decreased by 28% after hysterectomy (P < 0.001). The proportion of women with severe pain symptoms decreased by 76% after hysterectomy (P < 0.001). The majority of women (84%) were satisfied with the surgical result. Presence of severe pain symptoms after the hysterectomy was associated with less satisfaction (P < 0.001). Pain symptoms after surgery, patient satisfaction and the patient's perceived improvement were not significantly different between women whose ovarian tissue was preserved and women who underwent bilateral oophorectomy.

CONCLUSIONS

We observed a significant, long-lasting reduction in pain symptoms after hysterectomy among women with endometriosis. Hysterectomy, with the possibility of ovarian preservation, may be a valuable option for women with endometriosis who suffer from severe pain symptoms.

TWEETABLE ABSTRACT

Hysterectomy is a valuable option for women with endometriosis and severe pain symptoms.

Cross-Sectional Survey of the Impact of Endometriosis Symptoms on Health-Related Quality of Life in Canadian Women

OBJECTIVE

To characterize the health-related quality of life (HRQOL) of Canadian women with a self-reported diagnosis of endometriosis (DxE).

METHODS

Canadian women aged 18-49 years completed a survey from December 2018 through January 2019 in which HRQOL was assessed via the 12-item Short Form Health Survey (SF-12) and Endometriosis Health Profile-30 (EHP-30) questionnaire. We used t tests to compare SF-12 scores between women with and without a self-reported DxE, as well as the severity of hallmark endometriosis symptoms, including menstrual pelvic pain/cramping, non-menstrual pelvic pain/cramping, and dyspareunia, for women with a DxE (moderate/severe vs. mild/none). The effects of overall endometriosis symptom severity on HRQOL were assessed via analysis of variance.

RESULTS

In total, 26 528 women without a DxE and 2004 women with a self-reported DxE were included. SF-12 scores were significantly lower for women with versus without a DxE (Mental Component Summary: 38.6 vs. 41.2; Physical Component Summary: 47.3 vs. 52.1; both P < 0.001), indicating reduced HRQOL. Moderate/severe hallmark endometriosis symptoms were associated with low SF-12 scores (i.e., worse HRQOL), with the greatest impact from non-menstrual pelvic pain/cramping. EHP-30 scores for women with a DxE ranged from 40.6 to 46.8, with the greatest impairment in self-image. Women with severe endometriosis symptoms had EHP-30 scores 1.3- and >2-fold higher (i.e., worse) than those with moderate and mild symptoms, at 67.5-74.6 versus 51.3-56.9 and 25.6-32.9, respectively.

CONCLUSION

Canadian women with a self-reported diagnosis of endometriosis had significantly impaired health-related quality of life, which was inversely correlated with endometriosis symptom severity. This finding highlights a substantial unmet need among women with endometriosis.

Elagolix in the treatment of endometriosis: impact beyond pain symptoms

While the most common symptom associated with endometriosis is pelvic pain, the systemic manifestations of the disease and the accompanying adverse psychological, emotional, social, familial, sexual, educational and workplace effects are increasingly recognized. Elagolix is an oral gonadotropin-releasing hormone receptor antagonist that is approved for the management of moderate to severe pain associated with endometriosis. However, the benefits of elagolix extend beyond reducing pain symptoms. This article reviews the non-pain systemic manifestations associated with endometriosis and summarizes the beneficial effects of elagolix on non-pain outcomes. This includes improvements in quality of life, reductions in fatigue and improvements in workplace and household productivity. These results indicate that elagolix provides non-pain benefits in women with endometriosis and improves outcomes that are clinically meaningful to patients.

Quality of life in women with endometriosis: a narrative overview

Endometriosis is a very complex condition and has a significant impact on the quality of life, psychological wellbeing and interpersonal relationships of affected women. Endometriosis symptoms progressively impair the woman's ability to carry out some daily activities and result in a perception of worsening health status and overall well-being. The impact of these symptoms has been only partially investigated, and further studies and clinical insights are needed to fully understand the extent of this condition. It has been shown that endometriosis is associated with considerable direct and indirect costs, comparable to those of major worldwide chronic diseases such as diabetes. In addition, endometriosis-related symptoms substantially interfere with the employment of affected women, resulting in many cases in several working days missed. In this scenario, the aim of this narrative review is to provide a general overview of the psychological and social impact of this disease, as well as the effects of different therapeutic options, on quality of life and general well-being.

Impact of coping strategies on quality of life of adolescents and young women with endometriosis

Purpose: Endometriosis is a hormone-dependent, inflammatory, painful condition affecting 1 in 10 women during their reproductive years. The symptoms of endometriosis-dysmenorrhea, dyspareunia, infertility-negatively impact the quality of life (QoL) of the affected women. Few studies have been conducted on mental health and QoL impact in a younger endometriosis patient population (adolescents and young women). This study quantitative, cross-sectional study was designed to address this gap by ascertaining whether coping strategies may impact the QoL of this patient population. Methods: After consent, participants (n = 24) completed a sociodemographic questionnaire, Beck Anxiety Inventory (BAI), Beck Depression Inventory II (BDI-II), Coping Strategies Inventory (CSI), Endometriosis Health Patient-5 (EHP-5) and Visual Analogue Scale (VAS). Results: Participants reported the use of both positive and maladaptive strategies to deal with the symptomatology, which were associated with QoL levels and mental health status. Associations between QoL and maladaptive coping strategies (e.g. autocriticism, social withdrawal) were uncovered. Cognitive restructuring was identified as an adaptive coping strategy that impacts QoL positively. Conclusion: These results provide additional evidence showing that endometriosis symptoms substantially affect the psychological well-being of young patients and identify opportunities for interventions (e.g. cognitive behavioral, rational/emotive therapy) to implement coping styles leading to improved QoL.

Effectiveness of dienogest in improving quality of life in Asian women with endometriosis (ENVISIOeN): interim results from a prospective cohort study under real-life clinical practice

Background

Dienogest has been shown to substantially improve endometriosis-associated symptoms such as debilitating chronic pelvic pain, and in turn, health-related quality of life (HRQoL). To date, there is no data on patient-reported outcomes reflecting the real-world practice in Asia where endometriosis is a relevant health, social and economic burden. This non-interventional, multi-center, prospective study aims to investigate the influence of dienogest on HRQoL.

Methods

Asian women received dienogest (2 mg/daily) and were followed for 24 months. The effectiveness of dienogest to improve HRQoL and endometriosis-associated pelvic pain (EAPP) was assessed by patient-reported outcomes. HRQoL, especially the “pain” domain as primary endpoint, was evaluated with the Endometriosis Health Profile-30 (EHP-30) questionnaire. The numeric rating scale served to determine changes in the severity of EAPP. Within the presented interim analysis (data cut-off: 2017-11-27), the mean changes in EHP-30 and EAPP scores from baseline to 6 months upon availability of the data were evaluated. Treatment-emergent adverse events (TEAEs) and bleeding profiles were documented.

Results

Dienogest therapy decreased EHP-30 scores in all assessed domains (score 0–100, lower scores indicate better HRQoL). Primarily, the “pain” domain was improved in 78.4% of patients. EAPP was reduced (score 0–10, lower scores reflect less pain), highlighted by a mean reduction of the pain score by − 4.5 points. Patients with a higher EAPP score at baseline had an increased response to dienogest (− 6.2 points mean change) compared to patients with low baseline EAPP severity (− 1.4 points mean change). Both surgically and clinically diagnosed patients described comparable pain reduction, as well as women with or without prior treatment.

Drug-related TEAEs were documented for 31.5% of patients, with amenorrhoea (5.9%) and metrorrhagia (5.1%) being the most common events. The bleeding pattern was changed upon dienogest, characterized by decreased normal bleeding (84.2 to 28.8%) and increased amenorrhea (3.2 to 42.9%) at 6 months.

Conclusion

The data indicate an amelioration of HRQoL and EAPP upon dienogest therapy. No new safety signals were observed. Therefore, its use as first-line therapy for long-term management of debilitating and chronic endometriosis-associated pain represents an interesting option that remains to be further investigated.

Trial registration

Name of registry: Clinical Trials Clinicaltrials.gov registration number: NCT02425462 Registration date: 2015-04-24. Registration timing: prospective.

Pain Catastrophizing and Pain Health-Related Quality-of-Life in Endometriosis

OBJECTIVES

To determine if pain catastrophizing is independently associated with pain health-related quality-of-life (HRQoL) in women with endometriosis, independent of potential confounders.

MATERIALS AND METHODS

Analysis of cross-sectional baseline data from a prospective database at a tertiary referral center for endometriosis/pelvic pain. Referrals to the center were recruited between December 2013 to April 2015, with data collected from online patient questionnaires, physical examination, and review of medical records. The primary outcome was HRQoL as measured by the 11-item pain subscale of the Endometriosis Health Profile-30 questionnaire. The Pain Catastrophizing Scale was the independent variable of interest. Other independent variables (potential confounders) included other psychological measures, pain severity, comorbid pain conditions, and social-behavioral and demographic variables. Multivariable linear regression was used to control for these potential confounders and assess independent associations with the primary outcome.

RESULTS

In total, 236 women were included (87% consent rate). The mean age was 35.0±7.3 years, and 98 (42%) had stage I to II endometriosis, 110 (47%) had stage III to IV endometriosis, and 28 (11%) were of unknown stage after review of operative records. Regression analysis demonstrated that higher pain catastrophizing (P<0.001), more severe chronic pelvic pain (P<0.001), more severe dysmenorrhea (P<0.001), and abdominal wall pain (positive Carnett test) (P=0.033) were independently associated with worse pain HRQoL.

DISCUSSION

Higher pain catastrophizing was associated with a reduced pain HRQoL in women with endometriosis at a tertiary referral center, independent of pain severity and other potential confounders.

The Impact of Female Chronic Pelvic Pain Questionnaire (IF-CPPQ): A Validation Study

OBJECTIVES

The aim of this study was to assess the validity, reliability, and factor structure of the Impact of Female Chronic Pelvic Pain Questionnaire (IF-CPPQ).

MATERIALS AND METHODS

This was a cross-sectional questionnaire study that was administered online. To be eligible to participate, women had to have experienced chronic pelvic pain for a minimum of 6 months and be at least 18 years of age. A total of 969 women (mean age: 35.4 y, SD=12.0) took part. The main outcome measure was the IF-CPPQ. Additional validated measures that assessed related constructs were also administered. Principal axis factor analysis was used to assess the factor structure of the IF-CPPQ. Internal consistency was assessed using Cronbach α. Convergent and discriminant validity was assessed using Pearson correlations between factor scores on the IF-CPPQ and measures of related constructs. The consistency and model fit of the resulting factor structure was assessed using confirmatory factor analysis.

RESULTS

The final 26-item questionnaire comprised 5 factors (Psychological Impact, Sexual Impact, Relationship Impact, Occupational Impact, and Emotional Impact). Findings suggested good convergent and discriminant validity and internal consistency.

DISCUSSION

The findings indicate that the IF-CPPQ is a reliable and valid measure of the impact of chronic pelvic pain on women. While the IF-CPPQ has the potential for multiple uses within research and clinical practice, further research is needed to determine the questionnaire's ability to detect clinically meaningful changes with treatment.

Systematic review of quality of life measures in patients with endometriosis

OBJECTIVES

Endometriosis and quality of life has been the subject of much research, however, there is little consensus on how best to evaluate quality of life in endometriosis, resulting in many and diverse scales being used. In our study, we aim to identify quality of life scales used in endometriosis, to review their strengths and weaknesses and to establish what would define an ideal scale in the evaluation of endometriosis-related quality of life.

MATERIALS AND METHODS

A search of the MEDLINE and EMBASE databases was carried out for publications in English and French for the period from 1980 to February 2017, using the words 'endometriosis' and 'quality of life'. Publications were selected if they reported on quality of life in patients with endometriosis and specified use of a quality of life scale. A quantitative and a qualitative analysis of each scale was performed in order to establish the strengths and weaknesses for each scale (systematic registration number: PROSPERO 2014: CRD42014014210).

RESULTS

A total of 1538 articles publications were initially identified. After exclusion of duplicates and application of inclusion criteria, 201 studies were selected for analysis. The SF-36, a generic HRQoL measure, was found to be the most frequently used scale, followed by the EHP-30, a measure specific to endometriosis. Both perform well, when compared with other scales, with scale weaknesses offset by strengths. EHP-5 and EQ-5D also showed to be of good quality. All four were the only scales to report on MCID studied in endometriosis patients.

CONCLUSION

For clinical practice, routine evaluation of HRQOL in women with endometriosis is essential both for health-care providers and patients. Both SF-36 and EHP-30 perform better overall with regard to their strengths and weaknesses when compared to other scales.

Are symptoms after a colorectal segmental resection in deep endometriosis really improved? The point of view of women before and after surgery

INTRODUCTION

Bowel endometriosis can cause debilitating symptoms. Surgical colorectal resection is often required for symptomatic relief. Aim of our study was to evaluate quality of life over a one-year follow-up period in patients submitted to a colorectal resection for the treatment of deep endometriosis. Change in intestinal and extra-intestinal symptoms, and reproductive outcome were also evaluated.

METHODS

A prospective observational study was conducted on a cohort of 20 women affected by intestinal endometriosis and submitted to a laparoscopic colorectal resection. The subjects completed a questionnaire about quality of life (SF-36), and they scored in a 100-point rank questionnaire gynecological, urinary and gastrointestinal symptoms, pre-operatively and one- year postoperatively.

RESULTS

Significant improvements were observed in all domains of the SF-36 throughout the study period. Dysmenorrhea, dyspareunia and not menstrual pelvic pain showed a significant decrease 1 year after surgery. There was also a decrease in abdominal pain, rectal bleeding and constipation but not of nausea, abdominal pain, defecation pain, tenesmus, diarrhea, mucorrhea. Also some urinary symptoms did not improve.

CONCLUSIONS

The radical surgical approach has a positive impact on quality of life, although it does not improve all the symptoms complained before surgery. Clear pre-surgical counseling and careful patient selection is suggested.

Lack of cross-cultural validity of the Endometriosis Health Profile-30

Introduction:

The Endometriosis Health Profile-30 is a disease-specific patient-reported outcome measure of health-related quality of life. Cross-cultural validation of the Endometriosis Health Profile-30 has been performed for several translated versions. The aim of this study was to evaluate the measurement properties of a Norwegian version Endometriosis Health Profile-30.

Methods:

This study was designed as a cross-sectional anonymous postal questionnaire study. A total of 157 women with endometriosis were included during a period from 2012 to 2013. Women aged 18–45 years were recruited from the Norwegian Endometriosis Association. Principal components analysis with varimax rotation was used to assess construct validity. Short Form-36 was used to determine convergent validity. Cronbach’s alpha was used to measure internal consistency. Intraclass correlation coefficients and paired t-tests were used to evaluate test–retest reliability. Floor and ceiling effects were estimated.

Results:

Factor analysis resulted in a three and five-factor model for the core and modular questionnaire, respectively. Factor analysis could not support construct validity of the scales self-image and treatment. The Norwegian version Endometriosis Health Profile-30 demonstrated acceptable internal consistency and test–retest reliability, except for the scale relationship with children. Floor effects were observed for the scales self-image (20.1%), work life (33.9%), relationship with children (34.2%), and medical profession (20.5%).

Conclusion:

The construct self-image does not seem to be measured appropriately by the Norwegian version Endometriosis Health Profile-30, suggesting a lack of cross-cultural validity of the Endometriosis Health Profile-30. With multinational studies increasing, adequate translation, cross-cultural adaptation, and cross-cultural validation of instruments are essential to ensure equivalence in languages and cultures other than the original.

Health-related quality of life in women with endometriosis, compared with the general population and women with rheumatoid arthritis

INTRODUCTION

Women with endometriosis have reduced health-related quality of life (HRQoL). However, comparisons to the general population and other patient groups are lacking.

MATERIAL AND METHODS

The present cross-sectional questionnaire study included 157 women with endometriosis, 156 women from the general population, and 837 women with rheumatoid arthritis (RA). During a period from 2012 to 2013, women aged 18-45 years were recruited from the Norwegian Endometriosis Association and from a random sample of women residing in Oslo, Norway. HRQoL data from women with RA were included from a survey conducted in 2009 among patients of the Oslo Rheumatoid Arthritis Register. The Short Form-36 (SF-36) questionnaire was used to measure HRQoL.

RESULTS

Compared with the control group, the endometriosis group had significantly reduced mean scores for all SF-36 scales. The difference was largest for the scale bodily pain with a mean score of 47.6 in the endometriosis group vs 81.5 in the control group. Compared with the RA group, the endometriosis group had significantly reduced mean scores for the three SF-36 scales vitality, social functioning, and mental health. The mean scores of these scales in the endometriosis group were 33.4, 62.7, and 66.3, respectively, vs 42.7, 68.8, and 72.6 in the RA group.

CONCLUSIONS

Women with moderate to severe endometriosis seem to have overall impaired HRQoL compared with women from the general population, and poorer mental HRQoL compared with women with RA.

Patterns of missing data in the use of the endometriosis symptom diary

BACKGROUND

Endometriosis is a common, chronic condition in women of reproductive age that is characterized by the presence of functional endometriotic lesions outside the uterus. The Endometriosis Symptom Diary (ESD) is an electronic patient-reported outcome (ePRO) instrument that assesses women's experience of endometriosis symptoms, with pain scored using a 0-10 numeric rating scale. This study investigated patterns of data missing from the ESD in the VALEPRO study.

METHODS

Post hoc analyses of missing data were conducted.

RESULTS

Of 272 participants using the ESD, 26.5% had no missing diary entries, 46.7% had > 0-5% of entries missing, 13.2% had > 5-10% of entries missing and 13.6% had > 10% of entries missing over the entire study period. The duration of missing episodes (defined as ≥1 consecutive days with missing diary entries) was generally short; most (81.4%) were 1 day. The difference in mean worst pain scores between missing and complete episodes per participant was - 0.1, suggesting that missing episodes were not related to severity of pain. Entries were significantly more likely to be missing on Fridays (18.5%) and Saturdays (22.9%) compared with other days of the week (p < 0.0001). Participants in the USA had significantly more long missing episodes than those in Germany (proportions of missing episodes longer than 1 day, 22.6 and 10.5%, respectively; p < 0.0001). The proportions of women with ≥1 missing entry were 50.0, 70.2 and 79.8% for women with elementary education, secondary education, and a college or university education, respectively. The proportions of women with ≥1 missing entry were similar for those with and without children (72.2 and 74.3%, respectively).

CONCLUSIONS

Most participants were highly compliant with entering data in the ESD and the amount of missing data was low. Entries were significantly more likely to be missing on Fridays and Saturdays compared with other days of the week, and participants in the USA had significantly more long missing episodes than participants in Germany.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01643122 , registered 4 July 2012.

Deep Dyspareunia and Sexual Quality of Life in Women With Endometriosis

Introduction

Deep dyspareunia occurs in half of women with endometriosis, a condition present in 10% of reproductive-age women and associated with negative effects on sexual quality of life (SQoL). However, women with endometriosis can have other clinical factors (eg, superficial dyspareunia, other pelvic pains, and psychological or pain conditions) possibly affecting SQoL.

Aims

To determine whether deep dyspareunia is associated with SQoL in women with endometriosis, independent of potential confounders.

Methods

This study involved a prospective patient registry of women at a tertiary-level referral center for endometriosis and pelvic pain. Inclusion criteria were (i) referrals to the center recruited into the registry from January 2014 through December 2016 and (ii) subsequent surgery at the center with histologic confirmation of endometriosis. Exclusion criteria included menopausal status, age at least 50 years, never sexually active, or did not answer dyspareunia or SQoL questions. Bi-variable tests and multiple linear regression analysis were performed.

Main Outcome Measures

SQoL measured by the 5-item sexual intercourse subscale of the Endometriosis Health Profile-30 (EHP-30) modular questionnaire (0–100%, with higher scores indicating worse SQoL).

Results

Consent rate for the prospective registry was 87%; 277 women met the study criteria (mean age = 34.2 ± 7.1 years). Most women had stage I to II endometriosis at time of surgery (64%), with the remaining having stage III to IV endometriosis. Through regression analysis, worse SQoL (higher EHP-30 sexual intercourse subscale score) was independently associated with: more severe deep dyspareunia (P < .0001), more severe superficial dyspareunia (P < .0001), increased depression (P < .001), higher pain catastrophizing (P = .04), bladder pain syndrome (P = .02), heterosexual orientation (P < .001), and new referral status (P = .02).

Conclusion

In women with endometriosis at a tertiary referral center, more severe deep dyspareunia was associated with worse SQoL, independent of superficial dyspareunia, psychological comorbidities, and other potential confounders.

Shum LK, Bedaiwy MA, Allaire C, et al. Deep Dyspareunia and Sexual Quality of Life in Women With Endometriosis. Sex Med 2018;6:224–233.

Evaluation, validation and refinement of noninvasive diagnostic biomarkers for endometriosis (ENDOmarker): A protocol to phenotype bio-specimens for discovery and validation

OBJECTIVE

Endometriosis is a chronic, estrogen dependent condition that affects 5-10% of reproductive aged women and is associated with pelvic pain and infertility. As the approach to therapy shifts from surgical ablation to pharmacological control, a non-surgical mode of diagnosis would be desirable. The ENDOmarker study was designed by the NICHD Reproductive Medicine Network (RMN) to obtain well characterized and phenotyped bio specimens in a standardized fashion from women with and without endometriosis.

DESIGN

Development of a diagnostic test.

SETTING

Academic medical centers.

PATIENTS

This study will enroll up to 500 participants, and follow them for up to 5 months. Included subjects are aged 18-44, scheduled to undergo gynecologic surgery (laparoscopy/laparotomy) for clinical reasons.

INTERVENTIONS

Presence and stage of endometriosis (or its absence) is characterized by visual examination at the time of surgery. Subjects will undergo extensive clinical evaluation pre-operatively and at visits one and four months postoperatively. Endometrial biopsy, blood, urine and disease specific questionnaires will be collected at each visit.

MAIN OUTCOME

Samples will be placed in a bio-repository to be used to validate and optimize the clinical use of genomic classifiers of the endometrium alone or in combination with serum cytokines as a non-surgical composite marker of endometriosis.

CONCLUSION

This protocol can serve as a reference for objective collection of high quality bio specimens for discovery or validation of potential nonsurgical diagnosis of presence or severity of disease.

Hair cortisol and the relationship with chronic pain and quality of life in endometriosis patients

Endometriosis is a chronic estrogen-dependent disease in which pelvic pain is the dominant symptom. The negative effects of endometriosis on the life of women with this disease can be a cause of stress. Stress levels can be measured in different ways, mostly reflecting acute stress responses. Hair cortisol measurements are a reflection of long-term systematic cortisol levels. In this study a first attempt is made to measure cortisol levels in hair of endometriosis patients in comparison with healthy controls. Moreover, it is explored whether chronic pain symptoms as well as different aspects of Health Related Quality of Life (HRQoL) are associated with hair cortisol levels in women with endometriosis. Results show that the mean hair cortisol level is significantly higher in women with endometriosis compared to healthy controls (p = 0.018). There is a positive correlation between hair cortisol level and HRQoL in patients but not in controls (Rho 0.426). The level of hair cortisol does not correlate with the reported pain intensity in patients (Rho -0.082). These results are indicative of an altered HPA-axis function in endometriosis patients, possibly caused by higher chronic stress level in these patients. Moreover, a potential explanation for the positive correlation of cortisol with the HRQoL in these patients is that patients with a high HRQoL have an adequate stress response by increasing their cortisol levels as a response to physical and emotional stress induced by the endometriosis.