Psychotherapy with somatosensory stimulation as a complementary treatment for women with endometriosis-associated pain - a qualitative study

OBJECTIVE

This qualitative study aimed to explore patients' experiences with a novel treatment approach for endometriosis-associated pain, termed 'sinosomatics'. Specifically, it sought to understand women's experiences of the treatment and its components, the effects of the treatment on biological, psychological, and social levels, and how the women interpreted the changes they experienced.

METHODS

We conducted ten semi-structured interviews with patients, who had undergone the complementary treatment for endometriosis-associated pain. These interview sessions were audio-recorded, transcribed, and analyzed using Mayring's content analysis method with the aid of MAXQDA software.

RESULTS

Three key categories emerged: 'treatment experience,' 'treatment effects,' and 'explanation for effects'. The treatment was described as a "turning point" in patients' lives, offering new insights into the involvement of psychosocial factors in endometriosis-associated pain and paving the way for overcoming adverse life events. The therapy strengthened women's empowerment, inspired hope, fostered coping strategies, and promoted personal growth. Both the holistic view of body and mind and the psychological approach to treatment led to a change in the way how women perceived the disease.

CONCLUSIONS

Patients recognized the innovative combination of psychotherapy and acupuncture point stimulation as a significant advancement in managing their disease. The treatment has helped them to acquire a more holistic understanding of their bodily complaints and to cope more effectively with their symptoms. The findings highlight the importance of a patient-centered and empathetic treatment approach that empowers women to take an active role in managing their condition.

Natural compounds for endometriosis and related chronic pelvic pain: A review

Endometriosis is a chronic gynecological disorder characterized by significant chronic pelvic pain (CPP) and infertility, adversely affecting the quality of life for many women worldwide. This review aims to synthesize recent findings on natural bioactive compounds derived from various plant sources that exhibit beneficial effects in the management of endometriosis and related CPP. A thorough search of databases, including PubMed, Scopus, and Google Scholar, was conducted to identify studies evaluating the efficacy of natural compounds on endometriosis and related CPP. In alphabetical order, curcumins, ginsenosides, polyphenols and other secondary metabolites showed promising effects on oxidative stress, inflammation, and pain modulation associated with endometriosis acting on multiple pathways. Most of the selected articles were in vitro and in vivo studies in animal models, with a limited number of clinical trials. The reported natural compounds according to the highlighted multiple bioactivities, might be valuable complementary alternatives as supplements, nutraceuticals, or in advanced personalized nutrition. Further clinical investigations are needed to comprehensively evaluate their therapeutic potential, safety, efficacy and to establish effective treatment protocols.

Childhood adversity and risk of endometriosis, fibroids, and polycystic ovary syndrome: a systematic review

IMPORTANCE

Although childhood adversity has been extensively studied in relation to various health outcomes, investigation of its association with gynecological conditions remains limited.

OBJECTIVE

To systematically review studies examining the effect of childhood adversity on the prevalence of three gynecological conditions: endometriosis; fibroids; and polycystic ovary syndrome (PCOS) in the population.

EVIDENCE REVIEW

Six databases were searched from inception to March 12, 2024. Observational studies of women with exposure to adversity before the age of 18 and an outcome of endometriosis, fibroids, and/or PCOS were eligible for inclusion. Studies were summarized through a qualitative synthesis. We evaluated the risk of bias using the Newcastle-Ottawa Scale.

FINDINGS

Seven studies that reported on the association between a form of childhood adversity and endometriosis, fibroids, and or PCOS were selected for review. All seven studies received a moderate risk of bias score. Cumulative exposure to childhood adversity was associated with an increased risk of endometriosis and fibroids. Childhood exposure to sexual abuse was associated with an increased risk of endometriosis and fibroids. Exposure to physical abuse in childhood was associated with a greater risk of fibroids.

CONCLUSION AND RELEVANCE

A small number of studies have shown an association between childhood adversity and the development of endometriosis and fibroids in later life. These initial findings warrant further investigation in larger studies using standardized measures.

Intriguing connection between diminished ovarian reserve and childhood traumatic experiences, a prospective case-control study

INTRODUCTION

Diminished ovarian reserve (DOR) presents a complex challenge in the field of infertility, with factors like age and genetics traditionally under scrutiny. However, the potential influence of adverse childhood experiences on ovarian reserve remains a relatively unexplored area. This research aims to contribute novel insights to the understanding of diminished ovarian reserve etiology, shedding light on previously unexplored risk factors and their potential implications.

DESIGN

This case-control study was conducted at an Assisted Reproductive Technology (ART) Center of a university hospital. Infertile patients admitted to the ART center were enrolled in the study. The case group consisted of 102 infertile women diagnosed with diminished ovarian reserve, and the control group consisted of 103 healthy women with male factor infertility. An interview lasting approximately 30 min was held in a separate room with those who volunteered to participate in the study. Due to the sensitivity of the research subject, the data was collected anonymously. The Childhood Trauma Questionnaire was used to measure adverse childhood experiences, and the Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression in the study. The results were compared between the case and the control groups.

RESULTS

Overall, the total score of the Childhood Trauma Questionnaire and all subscale scores were higher in the case group (38.28 ± 9.86) than in the control group (35.10 ± 9.52). According to HADS, the total score was 15.92 ± 7.98 in the case group and 14.22 ± 6.87 in the control group.

CONCLUSIONS

Our pioneering study is designed to investigate a previously unexplored risk factor in low ovarian reserve. Considering our data and other studies in the literature examining childhood traumas as a risk, it makes us think that the issue is worth examining.

Partnership and relationship happiness in endometriosis related chronic pelvic pain: a multicenter case-control study

Introduction

Partnership is an important resource in dealing with endometriosis related chronic pain. Hence, our objective was to assess partnership in the context of endometriosis and its symptoms, considering the perspectives of both individuals involved.

Methods

The study was designed as a multi-center matched case-control study in Switzerland, Germany and Austria. Altogether 381 women with surgically/histologically confirmed endometriosis and 381 control women, 250 male partners of endometriosis-affected women and 229 of control women were evaluated. Partnership quality, partnership happiness, separation thoughts, and areas of conflict were evaluated through the Partnership Questionnaire and a validated list of conflict areas.

Results

Quality of partnership was rated as high by 60.1% of the women with endometriosis and 66.7% of the control women, as well as by 45.8 and 50.2% of their respective partners. Women with endometriosis mentioned separation thoughts, mostly related to sexual satisfaction, more often (34.9%/28.3%) and experienced more partnership-related conflicts than control women. Chronic pain, dyspareunia, dissatisfaction with sexuality, fatigue, and infertility were significantly associated with partnership conflicts. Fatigue and infertility but not pain experiences were related to lower partnership quality. Male partners in both groups reported separation thoughts equally often. In men, a high intensity of pain experienced by their partner was associated with reduced partnership happiness.

Conclusion

Given the significance of partnership in dealing with chronic diseases and the connection between symptoms of endometriosis and a decrease in partnership quality, it is essential to incorporate strategies that alleviate the negative impacts on relationships for both partners into medical support.

Clinical trial registration

identifier NCT02511626.

The vicious cycle of chronic endometriosis and depression-an immunological and physiological perspective

Endometriosis is a chronic, estrogen-dependent, proinflammatory disease that can cause various dysfunctions. The main clinical manifestations of endometriosis include chronic pelvic pain and impaired fertility. The disease is characterized by a spectrum of dysfunctions spanning hormonal signaling, inflammation, immune dysregulation, angiogenesis, neurogenic inflammation, epigenetic alterations, and tissue remodeling. Dysregulated hormonal signaling, particularly involving estrogen and progesterone, drives abnormal growth and survival of endometrial-like tissue outside the uterus. Chronic inflammation, marked by immune cell infiltration and inflammatory mediator secretion, perpetuates tissue damage and pain. Altered immune function, impaired ectopic tissue clearance, and dysregulated cytokine production contribute to immune dysregulation. Enhanced angiogenesis promotes lesion growth and survival. Epigenetic modifications influence gene expression patterns, e.g., HSD11B1 gene, affecting disease pathogenesis. Endometriosis related changes and infertility lead to depression in diagnosed women. Depression changes lifestyle and induces physiological and immunological changes. A higher rate of depression and anxiety has been reported in women diagnosed with endometriosis, unleashing physiological, clinical and immune imbalances which further accelerate chronic endometriosis or vice versa. Thus, both endometriosis and depression are concomitantly part of a vicious cycle that enhance disease complications. A multidimensional treatment strategy is needed which can cater for both endometrial disease and depression and anxiety disorders.

Prevalence of neuropathic pain in patients with symptomatic endometriosis: Assessment using the DN4 score

The mechanisms underlying pain in cases of endometriosis or chronic pelvic pain are complex, often involving various types of pain; mainly nociceptive pain, central sensitization, and neuropathic pain. Our main objective was to examine the prevalence of neuropathic pain in women with symptomatic endometriosis, and secondary, to explore the factors associated with this type of pain and to assess the prevalence of a positive PPSC score and a history of sexual violence within this population. This study is a retrospective, comparative, single-center cohort study conducted from September 2019 to January 2023. The presence of neuropathic pain was confirmed by a positive DN4 score, defined as greater than or equal to 4. The association with the following variables was studied: age, BMI, marital status, smoking, alcohol and drugs consumption, age at menarche, gestity, parity, duration of exposure to endometriosis, MRI locations, laparoscopy for endometriosis and post-laparoscopy r-ASRM classification, hormone treatment, associated symptoms, VAS, associated pathologies, infertility consultation, Pain Center consultation, EPH-5 score, positive PPSC score (≥5), and history of sexual violence. The prevalence of neuropathic pain was 44.1%. Younger age, being in a relationship, having a high EPH-5 score and undergoing laparoscopy for endometriosis are associated with neuropathic pain independently of other variables. Our study underscores the persistent high prevalence of neuropathic pain in endometriosis cases, emphasizing the importance of actively screening for it. Identifying neuropathic pain could prompt referrals to pain specialists, integrating it into a comprehensive multidisciplinary approach.

Towards comprehensive management of symptomatic endometriosis: beyond the dichotomy of medical versus surgical treatment

Except when surgery is the only option because of organ damage, the presence of suspicious lesions, or the desire to conceive, women with endometriosis-associated pain often face a choice between medical and surgical treatment. In theory, the description of the potential benefits and potential harms of the two alternatives should be standardized, unbiased, and based on strong evidence, enabling the patient to make an informed decision. However, doctor's opinion, intellectual competing interests, local availability of specific services and (mis)information obtained from social media, and online support groups can influence the type of advice given and affect patients' choices. This is compounded by the paucity of robust data from randomized controlled trials, and the anxiety of distressed women who are eager to do anything to alleviate their disabling symptoms. Vulnerable patients are more likely to accept the suggestions of their healthcare provider, which can lead to unbalanced and physician-centred decisions, whether in favour of either medical or surgical treatment. In general, treatments should be symptom-orientated rather than lesion-orientated. Medical and surgical modalities appear to be similarly effective in reducing pain symptoms, with medications generally more successful for severe dysmenorrhoea and surgery more successful for severe deep dyspareunia caused by fibrotic lesions infiltrating the posterior compartment. Oestrogen-progestogen combinations and progestogen monotherapies are generally safe and well tolerated, provided there are no major contraindications. About three-quarters of patients with superficial peritoneal and ovarian endometriosis and two-thirds of those with infiltrating fibrotic lesions are ultimately satisfied with their medical treatment although the remainder may experience side effects, which may result in non-compliance. Surgery for superficial and ovarian endometriosis is usually safe. When fibrotic infiltrating lesions are present, morbidity varies greatly depending on the skill of the individual surgeon, the need for advanced procedures, such as bowel resection and ureteral reimplantation, and the availability of expert colorectal surgeons and urologists working together in a multidisciplinary approach. The generalizability of published results is adequate for medical treatment but very limited for surgery. Moreover, on the one hand, hormonal drugs induce disease remission but do not cure endometriosis, and symptom relapse is expected when the drugs are discontinued; on the other hand, the same drugs should be used after lesion excision, which also does not cure endometriosis, to prevent an overall cumulative symptom and lesion recurrence rate of 10% per postoperative year. Therefore, the real choice may not be between medical treatment and surgery, but between medical treatment alone and surgery plus postoperative medical treatment. The experience of pain in women with endometriosis is a complex phenomenon that is not exclusively based on nociception, although the role of peripheral and central sensitization is not fully understood. In addition, trauma, and especially sexual trauma, and pelvic floor disorders can cause or contribute to symptoms in many individuals with chronic pelvic pain, and healthcare providers should never take for granted that diagnosed or suspected endometriosis is always the real, or the sole, origin of the referred complaints. Alternative treatment modalities are available that can help address most of the additional causes contributing to symptoms. Pain management in women with endometriosis may be more than a choice between medical and surgical treatment and may require comprehensive care by a multidisciplinary team including psychologists, sexologists, physiotherapists, dieticians, and pain therapists. An often missing factor in successful treatment is empathy on the part of healthcare providers. Being heard and understood, receiving simple and clear explanations and honest communication about uncertainties, being invited to share medical decisions after receiving detailed and impartial information, and being reassured that a team member will be available should a major problem arise, can greatly increase trust in doctors and transform a lonely and frustrating experience into a guided and supported journey, during which coping with this chronic disease is gradually learned and eventually accepted. Within this broader scenario, patient-centred medicine is the priority, and whether or when to resort to surgery or choose the medical option remains the prerogative of each individual woman.

Endometriosis: patient-doctor communication and psychological counselling

The fact that endometriosis is one of the most frequent gynaecological disorders in women and girls is gradually attracting greater public and political attention. There is also substantial awareness of the disorder among German gynaecologists, albeit without sufficient "equipment" for discussing the condition with patients and providing psychological counselling. This article offers hands-on proposals for medical counselling and the discussion of relevant issues, as well as other practical tips and suggested verbalisations for use by women suffering from endometriosis (and their partners). These practical recommendations will certainly help to improve the doctor-patient relationship in the case of endometriosis. The resources mentioned below (guidebooks, websites) focus on German-language offerings only.

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

STUDY QUESTION

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

SUMMARY ANSWER

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

WHAT IS KNOWN ALREADY

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

STUDY DESIGN, SIZE, DURATION

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

PARTICIPANTS/MATERIALS, SETTING, METHODS

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

MAIN RESULTS AND THE ROLE OF CHANCE

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

LIMITATIONS, REASONS FOR CAUTION

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

WIDER IMPLICATIONS OF THE FINDINGS

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

STUDY FUNDING/COMPETING INTEREST(S)

No funding or competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Understanding Psychological Symptoms of Endometriosis from a Research Domain Criteria Perspective

Endometriosis is currently the second most common gynecological disease and is associated with severe pain, vegetative impairment, and infertility. In association, there are considerable psychological symptoms that limit the quality of life of those affected. In this narrative review, the Research Domain Criteria (RDoC) framework was utilized to display the different transdiagnostic processes involved in disease progression and maintenance in regard to psychosocial functioning. Using the RDoC framework, it becomes clear that immune/endocrinological dysregulation is interlocked with (pelvic) pain chronification processes and psychological symptoms such as depressive mood, loss of control, higher vigilance toward the onset or worsening of symptoms, social isolation, and catastrophizing. This paper will discuss and identify promising treatment approaches, in addition to medical care, as well as further research implications. Endometriosis can come with substantial psychosomatic and social burden, requiring more research to understand the interdependence of different factors involved in its chronic development pathway. However, it is already clear that standard care should be extended with multifaceted treatments addressing pain, as well as the psychological and social burden, in order to halt the cycle of aggravation of symptoms and to improve quality of life for patients.

What is the association between childhood adversity and subsequent chronic pain in adulthood? A systematic review

Background

Adverse childhood experiences and chronic pain are complex problems affecting millions of people worldwide, and result in significant healthcare utilisation. Our review aimed to determine known associations between adversity in childhood and chronic pain in adulthood.

Methods

We performed a prospectively registered systematic review (PROSPERO ID: 135625). Six electronic databases (Pubmed, Medline, Cochrane, Scopus, APA PsycNet, Web of Science) were searched from January 1, 2009 until May 30, 2022. Titles and abstracts were screened, and all original research studies examining associations between adverse childhood experiences and chronic pain in adulthood were considered for inclusion. Full texts were reviewed, and a narrative synthesis was used to identify themes from extracted data. Ten percent of studies were dual reviewed to assess inter-rater reliability. Quality assessment of study methodology was undertaken using recognised tools.

Results

Sixty-eight eligible studies describing 196 130 participants were included. Studies covered 15 different types of childhood adversity and 10 different chronic pain diagnoses. Dual reviewed papers had a Cohen's kappa reliability rating of 0.71. Most studies were of retrospective nature and of good quality. There were consistent associations between adverse childhood experiences and chronic pain in adulthood, with a 'dose'-dependent relationship. Poor mental health was found to mediate the detrimental connection between adverse childhood experiences and chronic pain.

Conclusion

A strong association was found between adverse childhood experiences and chronic pain in adulthood. Adverse childhood experiences should be considered in patient assessment, and early intervention to prevent adverse childhood experiences may help reduce the genesis of chronic pain. Further research into assessment and interventions to address adverse childhood experiences is needed.

Short review on Adverse Childhood Experiences, Pelvic Pain and Endometriosis

The exposure to adverse childhood experiences has been associated with the subsequent development of several chronic health conditions, including pelvic pain. Endometriosis is a chronic disease characterized by the growth of endometrial-like tissue outside of the uterus, and is considered a common cause of chronic pelvic pain and infertility in reproductive-age women. However, the topic of pelvic pain and endometriosis is fraught with many challenges. This applies not just to clinical practice but also to research where many inconsistencies relating to pelvic pain and endometriosis definitions are encountered. A review was carried out for articles exploring the association of adverse childhood experiences and endometriosis. Studies addressing self-reported endometriosis suggested a relationship with childhood adversity, whilst papers relying on surgically diagnosed lesions of endometriosis irrespective of clinical presentation did not. This highlights the potential bias associated with the inconsistent use of the expression "endometriosis" in research.

Physiotherapy Management in Endometriosis

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

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

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

Chronic Pelvic Pain in Endometriosis: Cross-Sectional Associations with Mental Disorders, Sexual Dysfunctions and Childhood Maltreatment

The aim of this cross-sectional study was to compare the rates of mental disorders, sexual dysfunctions and childhood maltreatment (CM) in women with endometriosis with either chronic pelvic pain (CPP) or minimal to no pelvic pain. Additionally, two models to predict a current mental disorder were tested, including pelvic-pain-related or psychosocial predictor variables. We examined 100 women with confirmed endometriosis (group CPP, n = 50; group NOPAIN, n = 50). Participants responded to a comprehensive questionnaire and the Childhood Trauma Questionnaire. The Diagnostic Interview for Mental Disorders was used to assess mental disorders according to DSM-5 and to screen for sexual dysfunctions. The mean age was 28.8 ± 5.6 (CPP)/2.7 ± 6.3 (NOPAIN). Participants with CPP had higher rates of current mental disorders (p = 0.019), lifetime mental disorders (p = 0.006) and sexual dysfunctions (p < 0.001), but not CM (p = 0.074). In two binary-logistic regression analyses, a greater need for pain relief (aOR = 4.08, p = 0.026) and a sexual dysfunction (aOR = 2.69, p = 0.031) were significant predictors for a current mental disorder. Our findings confirmed the crucial role of pelvic pain for mental and sexual well-being in endometriosis. They highlight the need for pain relief and interdisciplinary care in the treatment of endometriosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SIGNIFICANCE

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

Endometriosis, psychiatric comorbidities and neuroimaging: Estimating the odds of an endometriosis brain

Endometriosis is a chronic pain disorder that affects young women, impairing their physical, mental and social well-being. Apart from personal suffering, it imposes a significant economic burden on the healthcare system. We analyzed studies reporting comorbid mental disorders in endometriosis based on the ICD/DSM criteria, discussing them in the context of available neuroimaging studies. We postulate that at least one-third of endometriosis patients suffer from mental disorders (mostly depression or anxiety) and require psychiatric or psychotherapeutic support. According to three neuroimaging studies involving patients with endometriosis, brain regions related not only to pain processing but also to emotion, cognition, self-regulation and reward likely constitute the so-called "endometriosis brain". It is not clear, however, whether the neurobiological changes seen in these patients are caused by chronic pain, mental comorbidities or endometriosis itself. Given the paucity of high-quality data on mental comorbidities and neurobiological correlates in endometriosis, further research is needed.

Using Microbiome-Based Approaches to Deprogram Chronic Disorders and Extend the Healthspan following Adverse Childhood Experiences

Adverse childhood experiences (ACEs), which can include child trafficking, are known to program children for disrupted biological cycles, premature aging, microbiome dysbiosis, immune-inflammatory misregulation, and chronic disease multimorbidity. To date, the microbiome has not been a major focus of deprogramming efforts despite its emerging role in every aspect of ACE-related dysbiosis and dysfunction. This article examines: (1) the utility of incorporating microorganism-based, anti-aging approaches to combat ACE-programmed chronic diseases (also known as noncommunicable diseases and conditions, NCDs) and (2) microbiome regulation of core systems biology cycles that affect NCD comorbid risk. In this review, microbiota influence over three key cyclic rhythms (circadian cycles, the sleep cycle, and the lifespan/longevity cycle) as well as tissue inflammation and oxidative stress are discussed as an opportunity to deprogram ACE-driven chronic disorders. Microbiota, particularly those in the gut, have been shown to affect host–microbe interactions regulating the circadian clock, sleep quality, as well as immune function/senescence, and regulation of tissue inflammation. The microimmunosome is one of several systems biology targets of gut microbiota regulation. Furthermore, correcting misregulated inflammation and increased oxidative stress is key to protecting telomere length and lifespan/longevity and extending what has become known as the healthspan. This review article concludes that to reverse the tragedy of ACE-programmed NCDs and premature aging, managing the human holobiont microbiome should become a routine part of healthcare and preventative medicine across the life course.

Depression Partially Mediates the Association of Adverse Childhood Experiences with Pain Intensity in Patients with Chronic Pelvic Pain Syndrome: Results from a Cross-Sectional Patient Survey

OBJECTIVE

Adverse childhood experiences (ACEs), such as emotional and physical maltreatment, are linked to chronic pelvic pain syndrome (CPPS) in adults. Psychological factors are important in understanding CPPS. We aimed to determine the nature and frequency of ACEs in male and female patients with CPPS and to investigate whether somatic symptoms and psychological comorbidities mediate the relationship of ACE severity with pain intensity.

DESIGN

Cross-sectional study.

SETTING

Interdisciplinary outpatient clinic for CPPS in Hamburg, Germany.

SUBJECTS

Individuals with CPPS (n = 234) who were 18 to 84 years of age.

METHODS

Using a self-administered questionnaire, we assessed the history of ACEs (ACE Scale), pain intensity (McGill Pain Questionnaire), somatic symptoms (Patient Health Questionnaire-15]), depression (Patient Health Questionnaire-9), and anxiety (Generalized Anxiety Disorder Scale). Parallel mediation analysis was conducted to examine whether the association of ACE severity with pain intensity is mediated by somatic symptoms, depression, and anxiety.

RESULTS

Emotional abuse and neglect were reported more than twice as often as physical abuse and neglect (37.2% vs 17.1%). Depression partially mediated the association of ACE severity with pain intensity in the whole study population. In sex-stratified analyses, different patterns of associations were observed, but somatic symptoms predicted pain intensity in both sexes.

CONCLUSIONS

Emotional maltreatment was highly prevalent, supporting an increased consideration of psychological factors in CPPS and indicating the need to screen for ACEs in patients with CPPS. Findings further suggest that depression and somatic symptoms may be important targets for therapeutic interventions in patients with CPPS who have a history of childhood adversity.

The Importance of a Multi-Disciplinary Approach to the Endometriotic Patients: The Relationship between Endometriosis and Psychic Vulnerability

Endometriosis is a chronic inflammatory condition, which is distinguished by the presence of the endometrial-like glands and stroma outside the uterine cavity. Pain and infertility are the most commonly expressed symptoms, occurring in 60% and 40% of cases, respectively. Women with endometriosis, especially those with pelvic pain, also have a greater vulnerability to several psychiatric disorders. There is, in particular, a tendency to contract affective or anxiety disorders as well as panic-agoraphobic and substance use disorders. Endometriosis with pelvic pain, infertility and psychic vulnerability usually leads to disability and a markedly lower quality of life for women of reproductive age. Thus, the burden of endometriosis is not limited to the symptoms and dysfunctions of the disease; it extends to the social, working and emotional spheres, leading to a severe impairment of global functioning. An analysis of scientific literature revealed a close relationship between specific temperamental traits, the expression of several psychiatric symptoms, chronicity of pain, risk of substance use and lower probability of a positive outcome. Endometriosis symptoms and the impact of related psychological consequences, increased vulnerability and the possible onset of psychiatric symptoms may influence coping strategies and weaken resilience, so triggering a vicious cycle leading to a marked deterioration in the quality of life. A multidisciplinary approach consisting of a medical team composed of gynecologists, psychologists, psychiatrists, experts in Dual Disorder, algologists and sexologists, would guarantee the setting of a target and taking the best decision on a personalized treatment plan. That approach would allow the prompt detection of any psychopathological symptoms and improve the endometriosis-related physical symptoms, bringing a healthier quality of life and a greater likelihood of a positive outcome.

The association between adverse childhood experiences and quality of partnership in adult women

BACKGROUND

Adverse childhood experiences (ACE) have a significant effect on psychological and physical child development and represent a risk factor for interpersonal difficulties.

OBJECTIVE

This study aims to investigate the association between ACE, in particular physical, sexual, emotional abuse and neglect, and partnership quality during adulthood in women.

PARTICIPANTS AND SETTING

This study is a secondary analysis of a retrospective multi-center study evaluating risk factors and quality of life in women with and without endometriosis, a chronic, disabling gynecological disease. The investigation includes 533 consenting adult women (159 with ACE and 374 women without) recruited from various hospitals in Switzerland, Austria and Germany.

METHODS

To evaluate the association between ACE and partnership, a questionnaire including the Childhood Trauma Questionnaire and a validated partnership questionnaire were used.

RESULTS

Altogether, 29.8 % (N = 159) women experienced maltreatment in childhood, 9.7 % (N = 52) of them more than one type. Women who went through ACE showed a lower level of happiness (P = 0.013) and of quality of partnership (P = 0.001) as well as a higher number of conflict areas (P < 0.001). Emotional (P = 0.03; 95 % CI=-1.27,-0.070) and sexual abuse (P = 0.01; 95 % CI=-1.765,-0.197) had the strongest association with reduced partnership quality.

CONCLUSION

Our study showed a significant association between ACE, in particular sexual and emotional abuse, and reduced partnership quality. As the quality of partnership is a key factor in the quality of life, improvement in social support with a special focus on intimate relationships should be part of the strategy to address the consequences of ACE already during childhood/adolescence.

Is Stress a Cause or a Consequence of Endometriosis?

Clinical studies clearly indicate that endometriosis is a condition associated with high levels of chronic stress. The stress intensity correlates with pain severity and disease extension. However, it is unknown whether chronic stress represents a primary cause of endometriosis and, therefore, if avoiding or treating chronic stress may reduce the risk of developing endometriosis. Repeated, uncontrolled stress either before or after experimental endometriosis induction promotes disease mechanisms and accelerates lesion growth in rodents. Furthermore, patients with endometriosis have a heightened risk of other inflammatory and immune-related diseases, many of which have also been associated with stress. Here, we review the latest evidences regarding the relationship between chronic stress and endometriosis and discuss the potential bidirectional aspect of such association. Further research may clarify if endometriosis is a cause and/or a consequence of stress and whether stress-reducing therapies are effective to mitigate symptoms and slow down the development of endometriotic lesions.

Endometriosis and pain in the adolescent- striking early to limit suffering: A narrative review

Endometriosis, a condition in which uterine tissue grows outside the uterus, is a debilitating disease, affecting millions of women and costing the United States approximately $78 billion annually in pain- related disability. It is also the leading cause of chronic pelvic pain (CPP), which is often unresponsive to existing treatments. Adolescent women with the disease are at particular risk as there are often significant diagnostic delays, which in turn can exacerbate pain. Research and treatment guidelines for adolescents with endometriosis are largely based on studies for adult women due to the limited number of studies focusing on adolescents. The current paper critically reviews the literature as it pertains to endometriosis pathophysiology, mechanisms contributing to CPP, and treatment implications and recommendations with a focus on gaps related to adolescents.

Qualitative and quantitative aspects of sex life in the context of endometriosis: a multicentre case control study

RESEARCH QUESTION

What are the specific characteristics of sexual activity in women with endometriosis compared with women without endometriosis?

DESIGN

Multicentre case control study. Participants were recruited from university hospitals, district hospitals and doctor's offices in Germany, Switzerland and Austria. A total of 565 women with endometriosis were pair-matched to 565 control women by age and ethnic background. Diagnosis of endometriosis was confirmed by histology, and disease stage was classified according to American Society for Reproductive Medicine criteria. Data on sexuality were collected using selected questions from the Brief Index of Sexual Function and the Sexual History Form.

RESULTS

Altogether, 69.1% of women with endometriosis and 77.8% of control women engaged in sexual activity during the month before the study period (P < 0.001). Overall, 42.3% of endometriosis-affected women and 30.5% of the control women desired a higher frequency of sexual activity (P < 0.001). Petting, foreplay and vaginal sexual intercourse were reported to be practised less often by women with endometriosis. Frequencies for masturbation, reciprocal masturbation, oral and anal sex were similar in both groups. Dyspareunia was negatively associated with sexual activity (OR 2.42, 95% CI 1.26 to 4.63), whereas chronic pain showed no association with sexual activity (OR 1.35, 95% CI 0.93, 1.96).

CONCLUSIONS

Women with endometriosis have lower frequencies of petting, foreplay and vaginal sexual intercourse than control women; this difference has to be attributed, at least in part, to dyspareunia. Potentially pain-free sexual options are used to a limited degree. As endometriosis-affected women desire higher levels of sexual activity, sexual counselling should be included in medical support.

Rethinking mechanisms, diagnosis and management of endometriosis

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.

Love is a physiological motivation (like hunger, thirst, sleep or sex)

The multitude of terms associated with love has given rise to a false perception of love. In this paper, only maternal and romantic love are considered. Love is usually regarded as a feeling, motivation, addiction, passion, and, above all, an emotion. This confusion has consequences in the lives of human beings, leading not only to divorces, suicides, femicides but possibly also to a number of mental illnesses and suffering. Therefore, it is crucial to first clarify what is meant by emotion, motivation and love. This work aims to finally place love within the category of physiological motivations, such as hunger, thirst, sleep, or sex, on the basis that love is also essential for human survival, especially in childhood. Love is presented from an evolutionary perspective. Some other similarities between love and other physiological motivations are pointed out, such as its importance for appropriate human development, both its ontogeny and its permanence, and the long-lasting consequences of abuse and neglect. There are summarized reasons that account for this, such as the fact that physiological motivations are essential for survival and that love is an essential motivation for the survival of human offspring. Other reasons are that minimum changes in the quantity and quality of love alters development, that there can be a variety of neurophysiological and behavioural states within a motivation, and that motivations (also love) appear and change throughout development. Also, motivations and love sometimes may lead to an addictive behaviour. Finally, it is recognized that once physiological motivations (and love) appear, they become permanent. In a third section, some potential social, cultural, clinical and scientific consequences of the proposed consideration of love as a motivation are discussed. Accordingly, love's recognition as a motivation in the clinical field would imply a better understanding of its disorders and its inclusion in classifications manuals such as The Diagnostic and Statistical Manual of Mental Disorders (DSM), or in the International Classification of Diseases (ICD). Considering love as a motivation rather than an emotion could also impact the results of scientific research (an example is included). A comprehensive understanding of these questions could potentially allow for a new therapeutic approach in the treatment of mental illness, while offering an all-inclusive evolutionary explanation of cultural phenomena such as the origin and diffusion of both language and art. Love should be understood as a physiological motivation, like hunger, sleep or sex, and not as an emotion as it is commonly considered.

Does endometriosis affect professional life? A matched case-control study in Switzerland, Germany and Austria

OBJECTIVES

Endometriosis is a gynaecological disease most commonly causing severe and chronic pelvic pain as well as an impaired quality of life. The aim of this study was to investigate if and how endometriosis affects choices regarding professional life as well as the quality of daily working life.

DESIGN, SETTING AND PARTICIPANTS

In the context of a multicentre case-control study, we collected data from 505 women with surgically/histologically confirmed diagnosis of endometriosis and 505 matched controls. Study participants were recruited prospectively in hospitals and doctors' practices in Switzerland, Germany and Austria. Using a detailed questionnaire, the study investigated work-life and career choices of study participants.

MAIN OUTCOME MEASURES

Associations between endometriosis/disease symptoms and limitations in career development as well as ability to work.

RESULTS

Women with endometriosis were less often able to work in their desired profession than women from the control group (adjusted OR=1.84, 95% CI: 1.15 to 2.94, R²=0.029, p=0.001) and they had to take health-related limitations into consideration in their career decisions to a significantly higher degree than women in the control group (OR=4.79, 95% CI: 2.30 to 9.96, R²=0.063, p<0.001). Among women with endometriosis, chronic pain was significantly associated with increased sick leave (OR=3.52, 95% CI: 2.02 to 6.13, R²=0.072, p<0.001) as well as with loss of productivity at work (OR=3.08, 95% CI: 2.11 to 4.50, R²=0.087, p<0.001).

CONCLUSIONS

Endometriosis is associated with impairment of professional life, in particular with regard to career choices. Further research to develop strategies to support endometriosis-affected women in realising professional opportunities is recommended.

TRIAL REGISTRATION NUMBER

NCT02511626; Pre-results.

The use of home remedies and complementary health approaches in endometriosis

RESEARCH QUESTION

Conventional treatments are often associated with adverse effects and endometriosis pain symptoms may reoccur despite treatment. Consequently, many women use complementary health approaches (CHA) and home remedies (HR) to relieve their pain. The aim of this study was to examine the frequency and the subjectively perceived efficacy of CHA/HR use by women affected by endometriosis.

DESIGN

Retrospective evaluation using medical charts and a questionnaire. Women recruited in hospitals and in self-help groups were asked about the use of 'topical heat', 'repose/relaxation', 'movement/massages', 'homeopathy/phytotherapy', 'acupuncture/traditional Chinese medicine (TCM)' and 'kinesiology/physiotherapy'.

RESULTS

From a total of 574 women with a confirmed diagnosis of endometriosis, 359 (62.5%) applied some form of CHA/HR. Women suffering from fatiguing disease symptoms more often selected alternative therapies (odds ratio [OR] 3.14, 95% confidence interval [CI] 1.39-7.11, P = 0.006) compared with women without these characteristics. Furthermore, women dissatisfied with healthcare provided by their treating physician, more frequently (OR 2.30, 95% CI 1.19-4.45, P = 0.013) chose the aforementioned alternative strategies.

CONCLUSION

As conventional therapies may not be sufficiently effective, women's needs should be closely examined, and individual treatment options should be discussed and initiated by clinicians to provide the best comprehensive treatment possible for endometriosis.

Satisfaction with medical support in women with endometriosis

Endometriosis affects various aspects of women's lives. We searched for predictors for patient satisfaction with medical support (PSwMS) in women with endometriosis. The study was designed as a multi-centre retrospective cohort study. We approached women with histologically confirmed endometriosis from 2010 until 2016, comparing women satisfied to women dissatisfied with medical support. We analysed data on characteristics of endometriosis, PSwMS and the influence of disease characteristics on PSwMS. Information on satisfaction with medical support was collected through a standardized questionnaire. After exclusion of 73 women because of inchoately filled in questionnaires, data from 498 women was evaluated. Altogether, it was observed that 54.6% (n = 272) of the study participants were satisfied with medical support and 45.4% (n = 226) were not. Feeling adequately informed by the time of diagnosis (p < 0.001), taking women's mental troubles seriously (p < 0.001) and supporting women in handling their pain (p < 0.001) were significantly associated with satisfaction. We found adequate information to be the most distinctive indicator for PSwMS. Further, acknowledging psychological distress and supporting women in handling their symptoms rather than to alleviate them, positively affect PSwMS. To achieve PSwMS, healthcare providers have to give adequate information on endometriosis and its management.