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Kiser AC, Schliep KC, Hernandez EJ, Peterson CM, Yandell M, Eilbeck K. An artificial intelligence approach for investigating multifactorial pain-related features of endometriosis. PLoS One 2024; 19:e0297998. [PMID: 38381710 PMCID: PMC10881015 DOI: 10.1371/journal.pone.0297998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/16/2024] [Indexed: 02/23/2024] Open
Abstract
Endometriosis is a debilitating, chronic disease that is estimated to affect 11% of reproductive-age women. Diagnosis of endometriosis is difficult with diagnostic delays of up to 12 years reported. These delays can negatively impact health and quality of life. Vague, nonspecific symptoms, like pain, with multiple differential diagnoses contribute to the difficulty of diagnosis. By investigating previously imprecise symptoms of pain, we sought to clarify distinct pain symptoms indicative of endometriosis, using an artificial intelligence-based approach. We used data from 473 women undergoing laparoscopy or laparotomy for a variety of surgical indications. Multiple anatomical pain locations were clustered based on the associations across samples to increase the power in the probability calculations. A Bayesian network was developed using pain-related features, subfertility, and diagnoses. Univariable and multivariable analyses were performed by querying the network for the relative risk of a postoperative diagnosis, given the presence of different symptoms. Performance and sensitivity analyses demonstrated the advantages of Bayesian network analysis over traditional statistical techniques. Clustering grouped the 155 anatomical sites of pain into 15 pain locations. After pruning, the final Bayesian network included 18 nodes. The presence of any pain-related feature increased the relative risk of endometriosis (p-value < 0.001). The constellation of chronic pelvic pain, subfertility, and dyspareunia resulted in the greatest increase in the relative risk of endometriosis. The performance and sensitivity analyses demonstrated that the Bayesian network could identify and analyze more significant associations with endometriosis than traditional statistical techniques. Pelvic pain, frequently associated with endometriosis, is a common and vague symptom. Our Bayesian network for the study of pain-related features of endometriosis revealed specific pain locations and pain types that potentially forecast the diagnosis of endometriosis.
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Affiliation(s)
- Amber C. Kiser
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States of America
| | - Karen C. Schliep
- Department of Family and Preventative Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Edgar Javier Hernandez
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States of America
- Department of Human Genetics, Utah Center for Genetic Discovery, University of Utah, Salt Lake City, Utah, United States of America
| | - C. Matthew Peterson
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Utah, Salt Lake City, Utah, United States of America
| | - Mark Yandell
- Department of Human Genetics, Utah Center for Genetic Discovery, University of Utah, Salt Lake City, Utah, United States of America
| | - Karen Eilbeck
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States of America
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Moiño D, Sarkar P, Al Jumaily M, Malak S, Tanner JP, Mikhail E. Association between pathological positivity rate of endometriosis, demographics, and concomitant gynecological conditions. Ther Adv Reprod Health 2024; 18:26334941241242351. [PMID: 38618559 PMCID: PMC11015736 DOI: 10.1177/26334941241242351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 03/11/2024] [Indexed: 04/16/2024] Open
Abstract
Background To date, there remains a paucity of present-day literature on the topic of demographics and the biopsy-proven pathological positivity rate of endometriosis. Objective The goal of this study was to explore the association between patients' demographics and other concomitant gynecological conditions or procedures and the pathological positivity rate of excision of endometriosis. Design Retrospective cohort study. Methods All women >18 years old who underwent laparoscopic surgery for endometriosis at a tertiary care hospital from October 2011 to October 2020. Women were classified into two groups: (1) Study group: women with >80% pathological positivity rate of endometriosis and (2) Control group: women with <80% pathological positivity rate. Results A total of 401 women were included in the analysis. No difference was noted in the 80% pathological positivity rate based on body mass index [BMI; 68.7% in normal BMI versus 80% in underweight, versus 74.5% in overweight, and 74.1% in obese patients (p = 0.72)]. The percentage of patients reaching 80% pathological positivity of endometriosis was lower in women who had undergone previous laparoscopy for endometriosis compared to surgery naïve women (66.5% versus 76.5%, p = 0.03). In addition, a higher percentage of women who underwent concomitant hysterectomy (83.5% versus 68.8% for non-hysterectomy, p = 0.005) or bilateral oophorectomy (92.7% versus 70.0% for non-oophorectomy, p = 0.002) reached 80% pathological positivity. Women with an associated diagnosis of fibroids (79.7% versus 70.5%) or adenomyosis (76.4% versus 71.7%) were more likely to reach 80% pathological positivity compared to women without any other coexisting pathology; however, the observed differences were not statistically significant. After applying a log-binomial regression model, compared to White non-Hispanics, Hispanic patients were 30% less likely to reach 80% positivity (RR: 0.70, 95% CI: 0.49-1.02), although not statistically significant. Conclusion No significant racial difference was found when comparing the rates of 80% pathological positivity of suspected endometriosis lesions among groups. Endometriosis pathological positivity rate was unaffected by patients' BMI and the presence of concomitant pathologies. In addition, prior laparoscopic surgery for endometriosis might cause tissue changes that result in a decrease in the observed pathological positivity rate of endometriosis lesions during subsequent surgeries.
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Affiliation(s)
- Daniela Moiño
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Papri Sarkar
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL, USA
| | - Maha Al Jumaily
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL, USA
| | | | - Jean Paul Tanner
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Emad Mikhail
- Division of Gynecologic Subspecialities, Department of Obstetrics and Gynecology, University of South Florida, 2 Tampa General Circle, STC, 6th Floor, Tampa, FL 33606, USA
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Sasamoto N, Ngo L, Vitonis AF, Dillon ST, Sieberg CB, Missmer SA, Libermann TA, Terry KL. Plasma proteomic profiles of pain subtypes in adolescents and young adults with endometriosis. Hum Reprod 2023; 38:1509-1519. [PMID: 37196326 PMCID: PMC10391309 DOI: 10.1093/humrep/dead099] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/12/2023] [Indexed: 05/19/2023] Open
Abstract
STUDY QUESTION What are the similarities and differences in the systemic proteomic profiles by endometriosis-associated pain subtypes among adolescents and young adults with endometriosis? SUMMARY ANSWER Endometriosis-associated pain subtypes exhibited distinct plasma proteomic profiles. WHAT IS KNOWN ALREADY Endometriosis patients, especially those diagnosed in adolescents and young adults, are often plagued by various pain symptoms. However, it is not clear what biological processes underlie this heterogeneity. STUDY DESIGN, SIZE, DURATION We conducted a cross-sectional analysis using data and plasma samples from 142 adolescent or young adult participants of the Women's Health Study: From Adolescence to Adulthood cohort with laparoscopically confirmed endometriosis. PARTICIPANTS/MATERIALS, SETTING, METHODS We measured 1305 plasma protein levels by SomaScan. We classified self-reported endometriosis-associated pain into subtypes of dysmenorrhea, acyclic pelvic pain, life impacting pelvic pain, bladder pain, bowel pain, and widespread pain phenotype. We used logistic regression to calculate the odds ratios and 95% confidence intervals for differentially expressed proteins, adjusting for age, BMI, fasting status, and hormone use at blood draw. Ingenuity Pathway Analysis identified enriched biological pathways. MAIN RESULTS AND THE ROLE OF CHANCE Our study population consisted mainly of adolescents and young adults (mean age at blood draw = 18 years), with nearly all (97%) scored as rASRM stage I/II at laparoscopic diagnosis of endometriosis, which is a common clinical presentation of endometriosis diagnosed at a younger age. Pain subtypes exhibited distinct plasma proteomic profiles. Multiple cell movement pathways were downregulated in cases with severe dysmenorrhea and life impacting pelvic pain compared to those without (P < 7.5×10-15). Endometriosis cases with acyclic pelvic pain had upregulation of immune cell adhesion pathways (P < 9.0×10-9), while those with bladder pain had upregulation of immune cell migration (P < 3.7×10-8) and those with bowel pain had downregulation (P < 6.5×10-7) of the immune cell migration pathways compared to those without. Having a wide-spread pain phenotype involved downregulation of multiple immune pathways (P < 8.0×10-10). LIMITATIONS, REASONS FOR CAUTION Our study was limited by the lack of an independent validation cohort. We were also only able to explore any presence of a pain subtype and could not evaluate multiple combinations by pain subtypes. Further mechanistic studies are warranted to elucidate the differences in pathophysiology by endometriosis-pain subtype. WIDER IMPLICATIONS OF THE FINDINGS The observed variation in plasma protein profiles by pain subtypes suggests different underlying molecular mechanisms, highlighting the need for potential consideration of pain subtypes for effectively treating endometriosis patients presenting with various pain symptoms. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by the Department of Defense W81XWH1910318 and the 2017 Boston Center for Endometriosis Trainee Award. Financial support for establishment of and data collection within the A2A cohort were provided by the J. Willard and Alice S. Marriott Foundation. N.S., A.F.V., S.A.M., and K.L.T. have received funding from the Marriott Family Foundation. C.B.S. is funded by an R35 MIRA Award from NIGMS (5R35GM142676). S.A.M. and K.L.T. are supported by NICHD R01HD094842. S.A.M. reports serving as an advisory board member for AbbVie and Roche, Field Chief Editor for Frontiers in Reproductive Health, personal fees from Abbott for roundtable participation; none of these are related to this study. Other authors report no conflict of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Naoko Sasamoto
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Boston Center for Endometriosis, Boston Children’s Hospital and Brigham and Women’s Hospital, Boston, MA, USA
| | - Long Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Allison F Vitonis
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Boston Center for Endometriosis, Boston Children’s Hospital and Brigham and Women’s Hospital, Boston, MA, USA
| | - Simon T Dillon
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Genomics, Proteomics, Bioinformatics and Systems Biology Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Christine B Sieberg
- Biobehavioral Pain Innovations Lab, Department of Psychiatry & Behavioral Sciences, Boston Children’s Hospital, Boston, MA, USA
- Pain & Affective Neuroscience Center, Department of Anesthesiology, Critical Care, & Pain Medicine, Boston Children’s Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Stacey A Missmer
- Boston Center for Endometriosis, Boston Children’s Hospital and Brigham and Women’s Hospital, Boston, MA, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University, Grand Rapids, MI, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Towia A Libermann
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Genomics, Proteomics, Bioinformatics and Systems Biology Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kathryn L Terry
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Boston Center for Endometriosis, Boston Children’s Hospital and Brigham and Women’s Hospital, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Mansfield C, Lenobel D, McCracken K, Hewitt G, Appiah LC. Impact of Pelvic Floor Physical Therapy on Function in Adolescents and Young Adults with Biopsy-Confirmed Endometriosis at a Tertiary Children's Hospital: A Case Series. J Pediatr Adolesc Gynecol 2022; 35:722-727. [PMID: 35830927 DOI: 10.1016/j.jpag.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 06/17/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
STUDY OBJECTIVE The purpose of this case series is to describe the change in capability to perform self-selected activities in adolescent and young adult patients with chronic pelvic pain and surgically proven endometriosis following pelvic floor physical therapy as part of multidisciplinary treatment. DESIGN Retrospective case series SETTING: Tertiary care pediatric hospital PARTICIPANTS: Twenty patients with ages ranging from 14 to 22 years and a median age of 16.5 years with biopsy-confirmed endometriosis INTERVENTION: Pelvic floor physical therapy MAIN OUTCOME MEASURE(S): Patient-Specific Functional Scale (PSFS) outcome measure RESULTS: Patients had a clinically significant functional improvement (median score of 6.0 points on the PSFS outcome measure; interquartile range, 3.8-13.5) over the course of care (median number of 12 visits; range 4-48 visits) (P < .001). CONCLUSIONS Patients with chronic pelvic pain and surgically proven endometriosis experienced significant functional improvement after physical therapy treatment. The results of this case series suggest that physical therapy is a viable additional intervention for adolescents and young adults with chronic pelvic pain and endometriosis and warrants further research.
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Affiliation(s)
- Christine Mansfield
- Sports and Orthopedic Therapies, Nationwide Children's Hospital, Columbus, OH, United States
| | - Dana Lenobel
- Pediatric and Adolescent Gynecology, Outpatient Care Center, Nationwide Children's Hospital, 555 S 18th St #5, Columbus, OH 43205, United States.
| | - Kate McCracken
- Pediatric and Adolescent Gynecology, Outpatient Care Center, Nationwide Children's Hospital, 555 S 18th St #5, Columbus, OH 43205, United States
| | - Geri Hewitt
- Pediatric and Adolescent Gynecology, Outpatient Care Center, Nationwide Children's Hospital, 555 S 18th St #5, Columbus, OH 43205, United States
| | - Leslie C Appiah
- Obsetrics and Gynecology, University of Colorado Hospital, Aurora, CO, United States
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Cho HH, Yoon YS. Development of an endometriosis self-assessment tool for patient. Obstet Gynecol Sci 2022; 65:256-265. [PMID: 35381626 PMCID: PMC9119729 DOI: 10.5468/ogs.21252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/21/2021] [Accepted: 03/15/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This study aimed to develop and verify an endometriosis self-assessment tool (ESAT). METHODS A non-experimental, descriptive, correlational study design was used. Candidate items were developed based on a conceptual framework constructed using the results of in-depth interviews and an integrative literature review. The construct validity of the developed tool was also examined. One-hundred and forty-two participants (117 patients with endometriosis and 25 patients without endometriosis) were included in the validity and reliability tests. The data were collected between August and December 2018. Nomological validity was verified based on significant correlations between the ESAT and the quality-of-life scores. RESULTS A 21-item ESAT was developed, and its construct validity was supported. Exploratory factor analysis indicated that the tool consisted of four components (gastrointestinal symptoms, dysmenorrhea, usual symptoms, and the amount and characteristics of menstrual bleeding) with a variance of 61.6%. The variance in quality-of-life scores, as explained by the ESAT scores, was relatively high. Receiver operator characteristics curve analysis indicated that ESAT scores significantly differentiated endometriosis from non-endometriosis with fair discriminatory power at a cut-off score of 50 (sensitivity, 0.76; specificity, 0.72; area under the curve, >0.75; P<0.001). This means that patients with ESAT scores >50 points were more likely to have endometriosis. Thus, the reliability of the ESAT was confirmed. CONCLUSION The devised tool appears valid and reliable. This tool may allow women to determine their risk of endometriosis by distinguishing between normal and pathological menstruation-related symptoms.
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Affiliation(s)
- Hyun-Hee Cho
- Department of Obstetrics & Gynecology, Catholic University College of Medicine, Seoul,
Korea
| | - Young-Sub Yoon
- Department of Nursing, Incheon Catholic University College of Nursing, Incheon,
Korea
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Leuenberger J, Kohl Schwartz A, Geraedts K, Haeberlin F, Eberhard M, von Orelli S, Imesch P, Leeners B. Living with endometriosis: Comorbid pain disorders, characteristics of pain, and relevance for daily life. Eur J Pain 2022; 26:1021-1038. [PMID: 35184363 PMCID: PMC9306988 DOI: 10.1002/ejp.1926] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background Methods Results Conclusions Significance
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Affiliation(s)
- J. Leuenberger
- University Hospital Zurich Department of Reproductive Endocrinology Frauenklinik‐strasse 10 8910 Zurich Switzerland
| | - A.S. Kohl Schwartz
- University Hospital Zurich Department of Reproductive Endocrinology Frauenklinik‐strasse 10 8910 Zurich Switzerland
| | - K. Geraedts
- University Hospital Zurich Department of Reproductive Endocrinology Frauenklinik‐strasse 10 8910 Zurich Switzerland
| | - F. Haeberlin
- Cantonal Hospital St Gallen, Department of Gynecology and Obstetrics, St. Gallen, Rorschacherstrasse 501 9007 St. Gallen Switzerland
| | - M. Eberhard
- Cantonal Hospital Schaffhausen Department of Gynecology and Obstetrics Geissbergstrasse 81 8208 Schaffhausen Switzerland
| | - S. von Orelli
- Triemli Hospital Department of Gynecology and Obstetrics Birmensdorferstrasse 497 8063 Zürich Switzerland
| | - P. Imesch
- University Hospital Zurich Department of Gynecology Frauenklinikstrasse 10 8910 Zurich Switzerland
| | - B. Leeners
- University Hospital Zurich Department of Reproductive Endocrinology Frauenklinik‐strasse 10 8910 Zurich Switzerland
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Yong PJ. Deep dyspareunia: a narrative review of impact on sexual function and quality-of-life. Minerva Obstet Gynecol 2022; 74:222-233. [PMID: 35107234 DOI: 10.23736/s2724-606x.22.04974-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Deep dyspareunia refers to pain with deep penetration or insertion into the vagina, which affects quality-of-life. The aim of this narrative review is to examine how the underlying conditions that give rise to deep dyspareunia, and the symptoms of these conditions, can affect sexual function and quality-of-life beyond the deep dyspareunia itself. For example, deep dyspareunia may be associated with gynaecological pathologies that cause cyclical pain symptoms (e.g dysmenorrhea, dyschezia/dysuria), resulting in quality-of-life changes related to menstrual cycle events such as ovulation or menstruation. Recurrent dysmenorrhea can cause hyperalgesic priming that sensitizes the nervous system, leading to chronic pelvic pain that can be exacerbated with sexual activity. The co-existence of functional bowel or bladder disorders can result in urgency and frequency that affect the sexual response cycle. Myofascial/musculoskeletal origins of deep dyspareunia may affect body positioning during sexual activity. Central nervous system sensitization can underlie these different factors, and also be associated with mental health conditions, which together can cause symptomatology across body systems that can affect all aspects of one's sexual life. Recognition and management of the far-reaching impacts of deep dyspareunia and its associated comorbidities may be important in clinical care to meaningfully improve quality-of-life. Future research should include a comprehensive empirical validation of the hypotheses and potential mechanisms in this review.
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Affiliation(s)
- Paul J Yong
- Divisions of Gynaecologic Specialities & Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada -
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de França Moreira M, Gamboa OL, Pinho Oliveira MA. Association between severity of pain, perceived stress and vagally-mediated heart rate variability in women with endometriosis. Women Health 2021; 61:937-946. [PMID: 34719338 DOI: 10.1080/03630242.2021.1993423] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chronic pelvic pain is the main symptom in women with endometriosis. Evidence suggests that psychological stress and autonomic regulation contribute to symptoms and pathophysiological modulation. We investigated the relationship between endometriosis-related pain severity, perceived stress, and autonomic balance in a sample of 81 women suffering chronic pelvic pain with deep endometriosis. Perceived stress and pelvic pain symptoms were assessed using the 10-item version of the Perceived Stress Scale (PSS-10) and the Numeric Pain Rating Scale (NPRS), respectively. Autonomic nervous system regulation was evaluated using vagally mediated components of the heart rate variability (vmHRV). Our results showed that pain unpleasantness and perceived stress were positively correlated, and women with mood disorders had higher perceived stress. The women with low resting vmHRV experience more intense pelvic pain, pain unpleasantness, and a higher number of severe endometriosis-related pain descriptors. The positive association between perceived stress, mood disorder, and pain unpleasantness demonstrates the additive effect between these aversive experiences. The inverse association between parasympathetic tone and pain suggests contributions of the Descending Inhibitory Pain pathway efficiency to symptom severity in women with endometriosis.
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Affiliation(s)
| | - Olga Lucia Gamboa
- EQness, Sydney, New South Wales, Australia.,School of Psychology, University of Sydney, Camperdown, New South Wales, Australia
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Yoon D, Fast AM, Cipriano P, Shen B, Castillo JB, McCurdy CR, Mari Aparici C, Lum D, Biswal S. Sigma-1 Receptor Changes Observed in Chronic Pelvic Pain Patients: A Pilot PET/MRI Study. FRONTIERS IN PAIN RESEARCH 2021; 2:711748. [PMID: 35295458 PMCID: PMC8915714 DOI: 10.3389/fpain.2021.711748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/24/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: Chronic pelvic pain is a highly prevalent pain condition among women, but identifying the exact cause of pelvic pain remains a significant diagnostic challenge. In this study, we explored a new diagnostic approach with PET/MRI of the sigma-1 receptor, a chaperone protein modulating ion channels for activating nociceptive processes. Methods: Our approach is implemented by a simultaneous PET/MRI scan with a novel radioligand [18F]FTC-146, which is highly specific to the sigma-1 receptor. We recruited 5 chronic pelvic pain patients and 5 healthy volunteers and compared our PET/MRI findings between these two groups. Results: All five patients showed abnormally increased radioligand uptake on PET compared to healthy controls at various organs, including the uterus, vagina, pelvic bowel, gluteus maximus muscle, and liver. However, on MRI, only 2 patients showed abnormalities that could be potentially associated with the pain symptoms. For a subset of patients, the association of pain and the abnormally increased radioligand uptake was further validated by successful pain relief outcomes following surgery or trigger point injections to the identified abnormalities. Conclusion: In this preliminary study, sigma-1 receptor PET/MRI demonstrated potential for identifying abnormalities associated with chronic pelvic pain. Future studies will need to correlate samples with imaging findings to further validate the correlation between S1R distribution and pathologies of chronic pelvic pain. Trial Registration: The clinical trial registration date is June 2, 2018, and the registration number of the study is NCT03195270 (https://clinicaltrials.gov/ct2/show/NCT03556137).
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Affiliation(s)
- Daehyun Yoon
- Department of Radiology, School of Medicine, Stanford University, Stanford, CA, United States
| | - Angela M. Fast
- Diagnostic, Molecular and Interventional Radiology, The Mount Sinai Hospital, New York, NY, United States
| | - Peter Cipriano
- Department of Radiology, School of Medicine, Stanford University, Stanford, CA, United States
| | - Bin Shen
- Department of Radiology, School of Medicine, Stanford University, Stanford, CA, United States
| | - Jessa B. Castillo
- Department of Radiology, School of Medicine, Stanford University, Stanford, CA, United States
| | - Christopher R. McCurdy
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Carina Mari Aparici
- Department of Radiology, School of Medicine, Stanford University, Stanford, CA, United States
| | - Deirdre Lum
- Department of Obstetrics and Gynecology, School of Medicine, Stanford University, Stanford, CA, United States
- *Correspondence: Sandip Biswal
| | - Sandip Biswal
- Department of Radiology, School of Medicine, Stanford University, Stanford, CA, United States
- Deirdre Lum
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10
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Godin SK, Wagner J, Huang P, Bree D. The role of peripheral nerve signaling in endometriosis. FASEB Bioadv 2021; 3:802-813. [PMID: 34632315 PMCID: PMC8493968 DOI: 10.1096/fba.2021-00063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/14/2021] [Accepted: 07/20/2021] [Indexed: 12/27/2022] Open
Abstract
A hallmark of endometriosis - a chronic debilitating condition whose causes are poorly understood - is neuronal innervation of lesions. Recent evidence demonstrates that the peripheral nervous system plays an important role in the pathophysiology of this disease. Sensory nerves, which surround and innervate endometriotic lesions, not only drive the chronic and debilitating pain associated with endometriosis but also contribute to a pro-growth phenotype by secreting neurotrophic factors and interacting with surrounding immune cells. The diverse array of contributions that neurons play in endometriosis indicate that it should be considered as a nerve-centric disease. This review is focused on the emerging field of exoneural biology and how it applies to the field of endometriosis, in particular the role that peripheral nerves play in driving and maintaining endometriotic lesions. A better understanding of the mechanisms of neuronal contribution to endometriosis, as well as their interactions with accompanying stromal and immune cells, will unearth novel disease-relevant pathways and targets, providing additional, more selective therapeutic horizons.
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Dückelmann AM, Taube E, Abesadze E, Chiantera V, Sehouli J, Mechsner S. When and how should peritoneal endometriosis be operated on in order to improve fertility rates and symptoms? The experience and outcomes of nearly 100 cases. Arch Gynecol Obstet 2021; 304:143-155. [PMID: 33537880 PMCID: PMC8164581 DOI: 10.1007/s00404-021-05971-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/12/2021] [Indexed: 12/18/2022]
Abstract
Purpose To analyze the follow-up results of patients suffering from symptomatic early-stage endometriosis after a consistent laparoscopic peritoneal stripping of the altered peritoneum (peritoneal endometriosis and surrounding inflamed tissue) was performed. This type of endometriosis is resistant to medical therapy and/or impairs fertility. Methods Using our prospectively maintained database, we were able to identify all symptomatic women with the suspicion of only peritoneal endometriosis who underwent laparoscopy at our endometriosis center over a period of 5 years. All procedures were carried out in a standardized fashion by one single surgeon, who is highly experienced in minimal invasive surgery, and included a suspended hormonal pretreatment for 2 months. Postoperative outcomes including complications, fertility and recurrence rates were analysed. Results Laparoscopic peritonectomy was performed on 94 women. Follow-up data were available in 87% of these cases. At the time of surgery, almost all patients tested showed signs of stage I or II endometriosis (44.7 and 48.9%, respectively). More than three-quarters of the women reported pain relief, inter alia, due to the post-surgical hormonal therapy. About one-third of the patients wanted to have children after the procedure. 62% of them became pregnant and the majority did so without the need for assisted reproductive therapy. In seven women a re-operation was performed. Conclusion According to our data, a consistent excision of altered peritoneum followed by adjuvant hormonal therapy and multimodal concepts results in better outcomes for the patient, particularly in regards to pregnancy and recurrence rates.
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Affiliation(s)
- A M Dückelmann
- Department of Gynecology, Charité-Universitätsmedizin BerlinVirchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - E Taube
- Department of Pathology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - E Abesadze
- Department of Gynecology, Vivantes Clinic Berlin Hellersdorf, Myslowitzerstr. 45, 12621, Berlin, Germany
| | - V Chiantera
- Department of Gynecologic Oncology, University of Palermo, Piazza Marina, 61, 90133, Palermo, Italy
| | - J Sehouli
- Department of Gynecology, Charité-Universitätsmedizin BerlinVirchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - S Mechsner
- Department of Gynecology, Charité-Universitätsmedizin BerlinVirchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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Maddern J, Grundy L, Castro J, Brierley SM. Pain in Endometriosis. Front Cell Neurosci 2020; 14:590823. [PMID: 33132854 PMCID: PMC7573391 DOI: 10.3389/fncel.2020.590823] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/15/2020] [Indexed: 12/15/2022] Open
Abstract
Endometriosis is a chronic and debilitating condition affecting ∼10% of women. Endometriosis is characterized by infertility and chronic pelvic pain, yet treatment options remain limited. In many respects this is related to an underlying lack of knowledge of the etiology and mechanisms contributing to endometriosis-induced pain. Whilst many studies focus on retrograde menstruation, and the formation and development of lesions in the pathogenesis of endometriosis, the mechanisms underlying the associated pain remain poorly described. Here we review the recent clinical and experimental evidence of the mechanisms contributing to chronic pain in endometriosis. This includes the roles of inflammation, neurogenic inflammation, neuroangiogenesis, peripheral sensitization and central sensitization. As endometriosis patients are also known to have co-morbidities such as irritable bowel syndrome and overactive bladder syndrome, we highlight how common nerve pathways innervating the colon, bladder and female reproductive tract can contribute to co-morbidity via cross-organ sensitization.
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Affiliation(s)
- Jessica Maddern
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Luke Grundy
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Joel Castro
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Stuart M. Brierley
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Discipline of Medicine, University of Adelaide, North Terrace Campus, Adelaide, SA, Australia
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Cai CW, Sisler KE, Gavard JA, Eugenio-Colon JD, Yeung PP. Abnormal pathology seen on appendectomy in patients with predominant right-sided pelvic pain. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2020. [DOI: 10.1177/2284026520924904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Previous studies have linked chronic pelvic pain (CPP) to appendix pathologies. However, few studies have investigated appendix pathology specifically in the context of CPP that is right-side predominant (R-CPP). We hypothesized that women with R-CPP have higher rates of appendix pathology compared with women with CPP that is not right-side predominant (N-CPP). Methods: We conducted a retrospective case–control study of 220 women who underwent diagnostic laparoscopy and planned or incidental appendectomy for CPP and suspected endometriosis between January 2015 and December 2018 at a tertiary care center in Saint Louis, MO. Results: No significant difference in abnormal appendix pathology was found between women with R-CPP and women with N-CPP (30.9% vs 34.5%, p = 0.74, odds ratio = 0.85, 95% CI: (0.44, 1.62)). Gross abnormalities of the appendix were documented in 40 of 220 patients (18.2%), with the most common abnormal gross findings being adhesions (8.2%), followed by abnormal lesions (7.3%). Conclusion: In this study, the presence of abnormal pathology within the appendix did not correlate with R-CPP, indicating triage based on predominant pain location cannot help identify patients with underlying appendix pathology. However, consistent with previous studies, we identified a high rate of abnormal appendix pathology overall, supporting the practice of many surgeons to perform routine appendectomy in women with CPP.
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Affiliation(s)
- Catherine W Cai
- Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, Saint Louis University, St. Louis, MO, USA
| | - Katelin E Sisler
- Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, Saint Louis University, St. Louis, MO, USA
| | - Jeffrey A Gavard
- Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, Saint Louis University, St. Louis, MO, USA
| | - Jose D Eugenio-Colon
- Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, Saint Louis University, St. Louis, MO, USA
| | - Patrick P Yeung
- Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, Saint Louis University, St. Louis, MO, USA
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Recommendations for the surgical treatment of endometriosis Part 2: deep endometriosis †‡¶. Facts Views Vis Obgyn 2020; 11:269-297. [PMID: 32322824 PMCID: PMC7162667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
STUDY QUESTION How should surgery for endometriosis be performed? SUMMARY ANSWER This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age. WHAT IS KNOWN ALREADY Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe. STUDY DESIGN SIZE DURATION A working group of the European Society for Gynaecological Endoscopy (ESGE), European Society of Human Reproduction and Embryology (ESHRE) and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis. PARTICIPANTS MATERIALS SETTING METHODS This document focused on surgery for deep endometriosis, and is complementary to a previous document in this series focusing on endometrioma surgery. MAIN RESULTS AND THE ROLE OF CHANCE The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis. LIMITATIONS REASONS FOR CAUTION Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added. WIDER IMPLICATIONS OF THE FINDINGS These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma. STUDY FUNDING - COMPETING INTERESTS The meetings of the working group were funded by ESGE, ESHRE and WES.Dr. Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS, and NORDIC PHARMA, outside the submitted work; Dr. Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences, and Roche Diagnostics Inc, and other relationships or activities from AbbVie Inc, and Myriad Inc, during the conduct of the study; Dr. Tomassetti reports non-financial support from ESHRE, during the conduct of the study; non-financial support and other from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals, and Merck SA, outside the submitted work. The other authors had nothing to disclose.
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Keckstein J, Becker CM, Canis M, Feki A, Grimbizis GF, Hummelshoj L, Nisolle M, Roman H, Saridogan E, Tanos V, Tomassetti C, Ulrich UA, Vermeulen N, De Wilde RL. Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. Hum Reprod Open 2020; 2020:hoaa002. [PMID: 32064361 PMCID: PMC7013143 DOI: 10.1093/hropen/hoaa002] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 11/27/2019] [Indexed: 12/25/2022] Open
Abstract
STUDY QUESTION How should surgery for endometriosis be performed? SUMMARY ANSWER This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age. WHAT IS KNOWN ALREADY Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions, it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe. STUDY DESIGN SIZE DURATION A working group of the European Society for Gynaecological Endoscopy (ESGE), ESHRE and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis. PARTICIPANTS/MATERIALS SETTING METHODS This document focused on surgery for deep endometriosis and is complementary to a previous document in this series focusing on endometrioma surgery. MAIN RESULTS AND THE ROLE OF CHANCE The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis. LIMITATIONS REASONS FOR CAUTION Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added. WIDER IMPLICATIONS OF THE FINDINGS These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma. STUDY FUNDING/COMPETING INTERESTS The meetings of the working group were funded by ESGE, ESHRE and WES. Dr Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS and NORDIC PHARMA, outside the submitted work; Dr Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences and Roche Diagnostics Inc. and other relationships or activities from AbbVie Inc., and Myriad Inc, during the conduct of the study; Dr Tomassetti reports non-financial support from ESHRE, during the conduct of the study; and non-financial support and other were from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals and Merck SA, outside the submitted work. The other authors had nothing to disclose. TRIAL REGISTRATION NUMBER na.
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Affiliation(s)
| | - Joerg Keckstein
- Endometriosis Centre Dres. Keckstein, Richard-Wagner Strasse 18, 9500 Villach, Austria
| | - Christian M Becker
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, John Radcliffe Hospital Womens Centre, OX3 9DU Oxford, UK
| | - Michel Canis
- Department of Gynaecological Surgery, University Clermont Auvergne CHU, Estaing 1 Place Lucie Aubrac, 63000 Clermont-Ferrand, France
| | - Anis Feki
- Department of Obstetrics and Gynecology, HFR Fribourg Hopital cantonal, 1708 Fribourg, Switzerland
| | - Grigoris F Grimbizis
- 1st Department of Obstetrics and Gynecology, Medical School Aristotle University of Thessaloniki, Tsimiski 51 Street, 54623 Thessaloniki, Greece
| | | | - Michelle Nisolle
- Hôpital de la Citadelle, Department of Obstetrics & Gynecology, 4000 Liège, Belgium
| | - Horace Roman
- Endometriosis Centre, Clinic Tivoli-Ducos, Bordeaux, France
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - Ertan Saridogan
- Reproductive Medicine Unit, Elizabeth Garrett Anderson Wing Institute for Women’s Health, University College Hospital, NW1 2BU London, UK
| | - Vasilios Tanos
- Department of Obstetrics and Gynecology, Aretaeio Hospital, 2024 Nicosia, Cyprus
| | - Carla Tomassetti
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, 3000 Leuven, Belgium
| | - Uwe A Ulrich
- Department of Obstetrics and Gynaecology, Martin Luther Hospital, 14193 Berlin, Germany
| | | | - Rudy Leon De Wilde
- University Hospital for Gynecology, Carl von Ossietzky Universitat Oldenburg, 26129 Oldenburg, Germany
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Greaves E, Rosser M, Saunders PTK. Endometriosis-Associated Pain - Do Preclinical Rodent Models Provide a Good Platform for Translation? ADVANCES IN ANATOMY, EMBRYOLOGY, AND CELL BIOLOGY 2020; 232:25-55. [PMID: 33278006 DOI: 10.1007/978-3-030-51856-1_3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pelvic pain is a common symptom of endometriosis. Our understanding of its etiology remains incomplete and medical management is limited by poor translation from preclinical models to clinical trials. In this review, we briefly consider the evidence, or lack thereof, that different subtypes of lesion, extra-uterine bleeding, and neuropathic pathways add to the complex and heterogeneous pain experience of women with the condition. We summarize the studies in rodent models of endometriosis that have used behavioral endpoints (evoked and non-evoked) to explore mechanisms of endometriosis-associated pain. Lesion innervation, activation of nerves by pronociceptive molecules released by immune cells, and a role for estrogen in modulating hyperalgesia are key endometriosis-associated pain mechanisms replicated in preclinical rodent models. The presence of ectopic (full thickness uterus or endometrial) tissue may be associated with changes in the spinal cord and brain, which appear to model changes reported in patients. While preclinical models using rats and mice have yielded insights that appear relevant to mechanisms responsible for the development of endometriosis-associated pain, they are limited in scope. Specifically, most studies are based on models that only resulted in the formation of superficial lesions and use induced (evoked) behavioral 'pain' tests. We suggest that translation for patient benefit will be improved by new approaches including models of ovarian and deep infiltrating disease and measurement of spontaneous pain behaviors. Future studies must also capitalize on new advances in the wider field of pain medicine to identify more effective treatments for endometriosis-associated pain.
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Affiliation(s)
- Erin Greaves
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK.
| | - Matthew Rosser
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Philippa T K Saunders
- Centre for Inflammation Research, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
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Bougie O, Yap MI, Sikora L, Flaxman T, Singh S. Influence of race/ethnicity on prevalence and presentation of endometriosis: a systematic review and meta-analysis. BJOG 2019; 126:1104-1115. [PMID: 30908874 DOI: 10.1111/1471-0528.15692] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Understanding the impact of race/ethnicity on the prevalence and presentation of endometriosis may help improve patient care. OBJECTIVE To review systematically the evidence for the influence of race/ethnicity on the prevalence of endometriosis. SEARCH STRATEGY CENTRAL, MEDLINE, PubMed, Embase, LILACS, SCIELO, and CINAHL databases, as well as the grey literature, were searched from date of inception until September 2017. SELECTION CRITERIA Randomised control trials and observational studies reporting on prevalence and/or clinical presentation of endometriosis. DATA COLLECTION AND ANALYSIS Twenty studies were included in the review and 18 studies were used to calculate odds ratio (OR) with 95% confidence interval (CI) through a random effects model. Methodological quality was assessed using the Newcastle-Ottawa risk of bias scale (NOS). MAIN RESULTS Compared with White women, Black woman were less likely to be diagnosed with endometriosis (OR 0.49, 95% CI 0.29-0.83), whereas Asian women were more likely to have this diagnosis (OR 1.63, 95% CI 1.03-2.58). Compared with White women, there was a statistically significant difference in likelihood of endometriosis diagnosis in Hispanic women (OR 0.46, 95% CI 0.14-1.50). Significant heterogeneity (I2 > 50%) was present in the analysis for all racial/ethnic groups but was partially reduced in subgroup analysis by clinical presentation, particularly when endometriosis was diagnosed as self-reported, CONCLUSIONS: Prevalence of endometriosis appears to be influenced by race/ethnicity. Most notably, Black women appear less likely to be diagnosed with endometriosis compared with White women. There is scarce literature exploring the influence of race/ethnicity on symptomatology, as well as treatment access, preference, and response. TWEETABLE ABSTRACT Prevalence of endometriosis may be influenced by race/ethnicity, but there is limited quality literature exploring this topic.
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Affiliation(s)
- O Bougie
- Department of Obstetrics and Gynaecology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Ma I Yap
- Department of Obstetrics and Gynecology, St. Luke's Medical Center, Quezon City, Philippines
| | - L Sikora
- Health Sciences Library, University of Ottawa, Ottawa, ON, Canada
| | - T Flaxman
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - S Singh
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, ON, Canada
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Bougie O, Healey J, Singh SS. Behind the times: revisiting endometriosis and race. Am J Obstet Gynecol 2019; 221:35.e1-35.e5. [PMID: 30738028 DOI: 10.1016/j.ajog.2019.01.238] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 01/29/2019] [Accepted: 01/31/2019] [Indexed: 12/01/2022]
Abstract
Endometriosis is a common gynecologic condition, affecting approximately 10% of reproductive-aged women. It commonly presents with pelvic pain, painful periods, and infertility and can significantly have an impact on one's quality of life. Early exploration into the pathophysiology of this condition identified race as a risk factor for endometriosis, with the condition predominantly identified in white women. It is still unclear whether there is a biological basis for this conviction or whether it can be explained by methodological and social bias that existed in the literature at that time. Although there is more recent literature exploring the association between endometriosis and race/ethnicity, studies have continued to focus on the prevalence of disease and have not taken into account possible variation in disease presentation among women of different ethnicities. Furthermore, information on diverse populations by race/ethnicity, other than white or black, is quite limited. This paper explores the history of how the association between endometriosis and whiteness was established and whether we still ascribe to a certain stereotype of a typical endometriosis patient today. Furthermore, we discuss the potential implications of such a racial bias on patient care and suggest areas of focus to achieve a personalized and patient focused approach in endometriosis care.
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Affiliation(s)
- Olga Bougie
- Department of Obstetrics and Gynaecology, Queen's University, Kingston, Canada.
| | - Jenna Healey
- Department of Obstetrics and Gynaecology, Queen's University, Kingston, Canada; Department of History, Queen's University, Kingston, Canada
| | - Sukhbir S Singh
- Ottawa Hospital Research Institute, Ottawa, Canada; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
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Aerts L, Grangier L, Dallenbach P, Wenger JM, Streuli I, Bianchi-Demicheli F, Pluchino N. Understanding sexual pain in endometriosis. ACTA ACUST UNITED AC 2019; 71:224-234. [DOI: 10.23736/s0026-4784.19.04379-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Ghai V, Jan H, Shakir F, Kent A. Identifying Preoperative Factors Associated with Nonresponders in Women Undergoing Comprehensive Surgical Treatment for Endometriosis. J Minim Invasive Gynecol 2019; 27:141-147. [PMID: 30885782 DOI: 10.1016/j.jmig.2019.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE To examine whether existing quality of health outcome measures can be used to predict or have an association with nonresponse surgery for endometriosis. DESIGN Retrospective cohort study. SETTINGS Single endometriosis referral center. PATIENTS Women (n = 198) undergoing surgery for endometriosis. INTERVENTIONS Validated health questionnaires and visual analogue scales. MEASUREMENTS AND MAIN RESULTS Patients were given validated health questionnaires, including Endometriosis Health Profile 30, Gastrointestinal Quality of Life Index, EuroQol-5, Hospital Anxiety and Depression Scale, preoperatively and at 12 months after full surgical excision of endometriosis. Visual analogue scales were also used that measured dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain. Surgical management was dependent on severity of disease. Superficial disease was treated by laparoscopic peritoneal excision or laser ablation. Deep infiltrating disease involving the bowel was excised completely together with laparoscopic bowel surgery (shave, disc, or segmental resection) with/without concomitant total hysterectomy and bilateral salpingo-oophorectomy. Nonresponders were defined as women who failed to demonstrate an improvement in pain scores 12 months postoperatively. We examined preoperative and postoperative questionnaires, visual analogue scores, and other variables such as age at onset of symptoms, type of surgery, and the presence of postoperative complications comparing responder and nonresponder women to identify the factors associated with nonresponse. Of 102 women treated for superficial endometriosis, 25 (24.51%) were nonresponders. No factors were associated with nonresponse at 12 months. Of 96 women treated for severe endometriosis involving the bowel, 10 (10.41%) were nonresponders. Nonresponders had significantly less preoperative pain (p = .031) and feeling of control (p = .015) than responders. There was no association between nonresponders and women who underwent a hysterectomy with bilateral salpingo-oophorectomy or those with complications. Radical bowel surgery (resection) was associated with nonresponders. CONCLUSION Minimal preoperative factors are associated with nonresponse for women having surgery for endometriosis. The severity of pain experienced by women with endometriosis may be used to predict their response to surgery.
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Affiliation(s)
- Vishalli Ghai
- Department of Obstetrics and Gynaecology (Miss. Ghai and M Jan), Epsom & St. Helier's University Hospitals NHS Trust, Surrey, United Kingdom.
| | - Haider Jan
- Department of Obstetrics and Gynaecology (Miss. Ghai and M Jan), Epsom & St. Helier's University Hospitals NHS Trust, Surrey, United Kingdom
| | - Fevzi Shakir
- Department of Obstetrics and Gynaecology (Mr. Shakir), Royal Free University Hospital NHS Trust, London, United Kingdon
| | - Andrew Kent
- Department of Obstetrics and Gynaecology (Mr. Kent), Royal Surrey County University NHS Hospital Trust, Guildford, United Kingdom
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Argentino GLS, Bueloni-Dias FN, Leite NJ, Peres GF, Elias LV, Bortolani VC, Padovani CR, Spadoto-Dias D, Dias R. The role of laparoscopy in the propaedeutics of gynecological diagnosis1. Acta Cir Bras 2019; 34:e20190010000010. [PMID: 30785511 PMCID: PMC6585922 DOI: 10.1590/s0102-865020190010000010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 12/04/2018] [Indexed: 11/22/2022] Open
Abstract
Purpose To evaluate agreement between pre- and post-laparoscopy gynecological
diagnosis in order to demonstrate the rationality of this minimally invasive
technique use in gynecological propaedeutics. Methods Retrospective chart review study conducted between March 2010 and October
2016 based on a convenience sample. 315 patients undergoing surgical
laparoscopy at the Center of Gynecologic Endoscopy and Family Planning of
Botucatu Medical School/UNESP. Pre- and postoperative diagnoses were
compared by the diagnosis agreement test considering the proportions of
events. Results Laparoscopy contributed to diagnosis in 59.6% of infertility cases
(P>0.05), in 93.7% of chronic pelvic pain of undetermined origin
(P<0.01) and conclusively elucidated the diagnosis of acute abdomen and
the ruling out of tubo-ovarian abcess (P<0.05). Laparoscopy also
increased the diagnosis of pelvic-abdominal adhesions in 76.7% (P>0.05).
Conclusion The use of laparoscopy considerably contributed to diagnostic elucidation,
especially in cases of undetermined chronic pelvic pain.
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Affiliation(s)
- Gislaine Laperuta Serafim Argentino
- Assistant Physician, Gynecological Endoscopy and Family Planning Sector, Department of Gynecology and Obstetrics, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Botucatu-SP, Brazil. Conception and design of the study; acquisition, analysis and interpretation of data; technical procedures; manuscript preparation
| | - Flávia Neves Bueloni-Dias
- Clinical Assistant Professor, Department of Gynecology and Obstetrics, Botucatu Medical School, UNESP, Botucatu-SP, Brazil. Acquisition, analysis and interpretation of data; technical procedures; manuscript preparation
| | - Nilton José Leite
- Assistant Physician, Gynecological Endoscopy and Family Planning Sector, Department of Gynecology and Obstetrics, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Botucatu-SP, Brazil. Conception and design of the study; acquisition, analysis and interpretation of data; technical procedures; manuscript preparation
| | - Gustavo Filipov Peres
- Assistant Physician, Gynecological Endoscopy and Family Planning Sector, Department of Gynecology and Obstetrics, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Botucatu-SP, Brazil. Conception and design of the study; acquisition, analysis and interpretation of data; technical procedures; manuscript preparation
| | - Leonardo Vieira Elias
- Assistant Physician, Gynecological Endoscopy and Family Planning Sector, Department of Gynecology and Obstetrics, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Botucatu-SP, Brazil. Conception and design of the study; acquisition, analysis and interpretation of data; technical procedures; manuscript preparation
| | - Vitória Cristina Bortolani
- Resident, Department of Gynecology and Obstetrics, Botucatu Medical School, UNESP, Botucatu-SP, Brazil. Acquisition of data
| | - Carlos Roberto Padovani
- Full Professor, Department of Biostatistics, Botucatu Biosciences Institute, UNESP, Botucatu-SP, Brazil. Statistics analysis
| | - Daniel Spadoto-Dias
- Clinical Assistant Professor, Department of Gynecology and Obstetrics, Botucatu Medical School, UNESP, Botucatu-SP, Brazil. Acquisition, analysis and interpretation of data; technical procedures; manuscript preparation
| | - Rogério Dias
- Associate Professor III, Department of Gynecology and Obstetrics, Botucatu Medical School, UNESP, Botucatu-SP, Brazil. Conception and design of the study, manuscript preparation
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Oladosu FA, Tu FF, Hellman KM. Nonsteroidal antiinflammatory drug resistance in dysmenorrhea: epidemiology, causes, and treatment. Am J Obstet Gynecol 2018; 218:390-400. [PMID: 28888592 DOI: 10.1016/j.ajog.2017.08.108] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/14/2017] [Accepted: 08/31/2017] [Indexed: 11/25/2022]
Abstract
Although nonsteroidal antiinflammatory drugs can alleviate menstrual pain, about 18% of women with dysmenorrhea are unresponsive, leaving them and their physicians to pursue less well-studied strategies. The goal of this review is to provide a background for treating menstrual pain when first-line options fail. Research on menstrual pain and failure of similar drugs in the antiplatelet category suggested potential mechanisms underlying nonsteroidal antiinflammatory drug resistance. Based on these mechanisms, alternative options may be helpful for refractory cases. This review also identifies key pathways in need of further study to optimize menstrual pain treatment.
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Huchon C, Aubry G, Ploteau S, Fauconnier A. [Specific clinical signs suggestive of endometriosis (excluding adenomyosis) and questionnaires of symptoms, pain and quality of life: CNGOF-HAS Endometriosis Guidelines]. ACTA ACUST UNITED AC 2018. [PMID: 29530559 DOI: 10.1016/j.gofs.2018.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In case of consultation for chronic pelvic pain or suspicion of endometriosis, it is recommended to evaluate the pain (intensity, resonance) and to search out the evocative and localizing symptoms of endometriosis (Grade B). The main symptoms suggestive of endometriosis are: severe dysmenorrhea (NP2), deep dyspareunia (NP2), painful defecation during menstruation (NP2), urinary tract symptoms during menstruation (NP2) and infertility (NP2). In patients with chronic pelvic pain, it is recommended to search deep infiltrating endometriosis in patients with painful defecation during menstruation or severe deep dyspareunia (Grade B). It is recommended to search symptoms suggestive of sensitization in painful patients with endometriosis (Grade B). When suggestive symptoms of endometriosis are present, a directed gynecological examination is recommended, where possible, including examination of the posterior vaginal cul-de-sac (Grade C). In assessing pain intensity or evaluating analgesic effectiveness of a treatment, it is recommended to use a scale to measure the intensity of pain (Grade A). In the management of symptomatic endometriosis, it is recommended to evaluate the quality of life (Grade C).
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Affiliation(s)
- C Huchon
- Service de gynécologie & obstétrique, CHI Poissy-St-Germain-en-Laye, Université Versailles-Saint-Quentin en Yvelines, 10, rue du champ Gaillard, BP 3082, 78303 Poissy cedex, France.
| | - G Aubry
- Service de gynécologie-obstétrique, CHI Poissy-St-Germain, 10, rue du Champ-Gaillard, 78303 Poissy, France
| | - S Ploteau
- Service de gynécologie-obstétrique et médecine de la reproduction, hôpital Mère-Enfant, CHU de Nantes, 8, boulevard Jean-Monnet, 44093 Nantes, France
| | - A Fauconnier
- Service de gynécologie & obstétrique, CHI Poissy-St-Germain-en-Laye, Université Versailles-Saint-Quentin en Yvelines, 10, rue du champ Gaillard, BP 3082, 78303 Poissy cedex, France
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Jarrell J, Arendt-Nielsen L. Negative laparoscopy unveiled. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2018. [DOI: 10.1177/2284026517749478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction:Studies indicate a variable proportion of laparoscopies done for the management of non-acute pelvic pain that do not identify visible pathology and are called negative laparoscopies. Possible explanations have included undetected endometriosis, observer error, and/or neural tissues in the endometrium acting as nociceptive input. The goal was to compare demographic and pain testing measures between women with negative laparoscopies and confirmed endometriosis in a cohort of women presenting with chronic pelvic pain.Methods:Women with chronic pelvic pain (n = 255) provided written consent for the study prior to entry. Data were collected at the time of clinic visit and entered contemporaneously into SPSS. Pain sensitization was identified as the presence of cutaneous allodynia. Clinical, pain, and pain sensitization variables were compared using Student’s t-test.Results:The frequency of negative laparoscopy was 13.7% (35 cases) and that of confirmed endometriosis was 27.1% (69 cases). There were no differences between women with a negative laparoscopy and women with confirmed endometriosis in clinical, dysmenorrhea, or pain testing measurements.Conclusion:The data suggest in the absence of endometriotic tissue in the pelvis, chronic visceral pain may result from a uterine origin and result in a generalized pattern of pain and pain sensitization.
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Affiliation(s)
- John Jarrell
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada
| | - Lars Arendt-Nielsen
- Center for Sensory-Motor Interaction, School of Medicine, Aalborg University, Aalborg, Denmark
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Porpora MG, Vinci V, De Vito C, Migliara G, Anastasi E, Ticino A, Resta S, Catalano C, Benedetti Panici P, Manganaro L. The Role of Magnetic Resonance Imaging-Diffusion Tensor Imaging in Predicting Pain Related to Endometriosis: A Preliminary Study. J Minim Invasive Gynecol 2017; 25:661-669. [PMID: 29126882 DOI: 10.1016/j.jmig.2017.10.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/24/2017] [Accepted: 10/29/2017] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To evaluate the sacral nerve root features by the means of magnetic resonance imaging-diffusion tensor imaging (MRI-DTI) tractography in women with endometriosis and/or adenomyosis, and to analyze the correlations among DTI abnormalities, pain symptoms, and endometriotic lesions found at surgery. DESIGN A cross-sectional, observational study (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS Women (n = 76) with clinical suspicion of endometriosis. INTERVENTIONS Before surgery, dysmenorrhea, deep dyspareunia, and noncyclic pelvic pain (NCPP) were assessed using a 10-point visual analog scale. MRI enabled a 3-dimensional reconstruction of S1, S2, and S3. Fractional anisotropy was calculated for each root. Laparoscopic treatment of endometriosis was performed in 56 patients. MEASUREMENTS AND MAIN RESULTS Our findings revealed correlations among sacral root reconstruction by MRI-DTI, pain symptoms, and laparoscopic findings. DTI of sacral roots revealed a regular and homogeneous appearance in 17 patients (25.8%) and abnormalities in microstructure reconstruction, with fiber irregularities and disorganization and loss of the simple unidirectional course, in 44 patients (66.7%). At laparoscopy, ovarian endometriomas were found in 82.1% of the patients, and deeply infiltrating endometriosis (DIE) were found in 57.1%. Endometriosis was staged according to the revised American Society for Reproductive Medicine classification. Pathological DTI findings were significantly associated with the severity of dysmenorrhea and NCPP, pain duration, presence of tubo-ovarian and cul-de-sac adhesions, and DIE. CONCLUSION The presence of pathological DTI findings of the sacral nerve roots correlates with the type of pain, adhesions, and DIE. At present, DTI can be useful for providing a better understanding of pain; however, DTI could become a useful tool in therapeutic planning for patients with endometriosis.
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Affiliation(s)
- Maria Grazia Porpora
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy.
| | - Valeria Vinci
- Department of Radiological, Oncological and Pathological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Giuseppe Migliara
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Emanuela Anastasi
- Department of Molecular Medicine, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Adele Ticino
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Serena Resta
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Pathological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Pierluigi Benedetti Panici
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Lucia Manganaro
- Department of Radiological, Oncological and Pathological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
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Aredo JV, Heyrana KJ, Karp BI, Shah JP, Stratton P. Relating Chronic Pelvic Pain and Endometriosis to Signs of Sensitization and Myofascial Pain and Dysfunction. Semin Reprod Med 2017; 35:88-97. [PMID: 28049214 DOI: 10.1055/s-0036-1597123] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Chronic pelvic pain is a frustrating symptom for patients with endometriosis and is frequently refractory to hormonal and surgical management. While these therapies target ectopic endometrial lesions, they do not directly address pain due to central sensitization of the nervous system and myofascial dysfunction, which can continue to generate pain from myofascial trigger points even after traditional treatments are optimized. This article provides a background for understanding how endometriosis facilitates remodeling of neural networks, contributing to sensitization and generation of myofascial trigger points. A framework for evaluating such sensitization and myofascial trigger points in a clinical setting is presented. Treatments that specifically address myofascial pain secondary to spontaneously painful myofascial trigger points and their putative mechanisms of action are also reviewed, including physical therapy, dry needling, anesthetic injections, and botulinum toxin injections.
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Affiliation(s)
- Jacqueline V Aredo
- National Institute of Neurological Disorders and Stroke, Clinical Center, Intramural Research Program NIH, Bethesda, Maryland
| | - Katrina J Heyrana
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, New York
| | - Barbara I Karp
- National Institute of Neurological Disorders and Stroke, Clinical Center, Intramural Research Program NIH, Bethesda, Maryland
| | - Jay P Shah
- Rehabilitation Medicine Department, Clinical Center, Intramural Research Program NIH, Bethesda, Maryland
| | - Pamela Stratton
- National Institute of Neurological Disorders and Stroke, Clinical Center, Intramural Research Program NIH, Bethesda, Maryland
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Yeung PP, Logan I, Gavard JA. Deep Retraction Pockets, Endometriosis, and Quality of Life. Front Public Health 2016; 4:85. [PMID: 27242981 PMCID: PMC4861171 DOI: 10.3389/fpubh.2016.00085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 04/20/2016] [Indexed: 11/30/2022] Open
Abstract
Objective The purpose of this study was to examine if deep retraction pockets (DRPs) in the posterior cul-de-sac and uterosacral ligaments could be a manifestation of endometriosis and if excision of these pockets improves pain symptoms and quality of life. Study design Prospective cohort study Canadian Task Force Classification, II-3. Materials and methods Preoperative data, operative data, and follow-up data were collected prospectively at the Center for Endometriosis at Saint Louis University, a referral center for the surgical management of endometriosis. Results The 107 consecutive patients who presented with preoperative deep dyspareunia were included in the study, and the median postoperative follow-up was 13 months. Endometriosis was confirmed histologically in any location excised in 88/107 (82.2%) of the women, and 31 DRPs were excised from 25 women with DRPs in the posterior cul-de-sac or uterosacral ligaments, of which 15/31 (48.4%) had endometriosis. Of the 10 DRPs without visible surface lesions, 3 (30.0%) had endometriosis on histology. Pain symptoms and quality of life significantly improved after excision surgery, whether or not DRPs were present. Women who had endometriosis in their DRP also had significant improvement in deep dyspareunia and chronic pelvic pain and quality of life. Results did not differ when patients who took postoperative hormonal suppression were removed from the analyses. Conclusion Patients had significantly improved pain symptoms and quality of life after excision surgery, whether or not DRPs were present. This study demonstrated that a DRP may be a manifestation of endometriosis (even with a clear surface of the pocket), so that DRPs should be excised to achieve optimal excision of endometriosis.
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Affiliation(s)
- Patrick P Yeung
- Division of Gynecologic Surgical Subspecialties, Department of Obstetrics, Gynecology, and Women's Health, Center for Endometriosis, Saint Louis University , St. Louis, MO , USA
| | - Ian Logan
- School of Medicine, Saint Louis University , St. Louis, MO , USA
| | - Jeffrey A Gavard
- Department of Obstetrics, Gynecology, and Women's Health, Saint Louis University , St. Louis, MO , USA
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28
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Anatomical Distribution of Deep Infiltrating Endometriosis and Its Relationship to Pelvic Pain. J Gynecol Surg 2016. [DOI: 10.1089/gyn.2015.0092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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As-Sanie S, Kim J, Schmidt-Wilcke T, Sundgren PC, Clauw DJ, Napadow V, Harris RE. Functional Connectivity is Associated With Altered Brain Chemistry in Women With Endometriosis-Associated Chronic Pelvic Pain. THE JOURNAL OF PAIN 2016; 17:1-13. [PMID: 26456676 PMCID: PMC4698023 DOI: 10.1016/j.jpain.2015.09.008] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 09/09/2015] [Accepted: 09/23/2015] [Indexed: 12/29/2022]
Abstract
UNLABELLED In contrast to women with relatively asymptomatic endometriosis, women with endometriosis-associated chronic pelvic pain (CPP) exhibit nonpelvic hyperalgesia and decreased gray matter volume in key neural pain processing regions. Although these findings suggest central pain amplification in endometriosis-associated CPP, the underlying changes in brain chemistry and function associated with central pain amplification remain unknown. We performed proton spectroscopy and seed-based resting functional connectivity magnetic resonance imaging to determine whether women with endometriosis display differences in insula excitatory neurotransmitter concentrations or intrinsic brain connectivity to other pain-related brain regions. Relative to age-matched pain-free controls, women with endometriosis-associated CPP displayed increased levels of combined glutamine-glutamate (Glx) within the anterior insula and greater anterior insula connectivity to the medial prefrontal cortex (mPFC). Increased connectivity between these regions was positively correlated with anterior insula Glx concentrations (r = .87), as well as clinical anxiety (r = .61, P = .02), depression (r = .60, P = .03), and pain intensity (r = .55, P = .05). There were no significant differences in insula metabolite levels or resting-state connectivity in endometriosis patients without CPP versus controls. We conclude that enhanced anterior insula glutamatergic neurotransmission and connectivity with the mPFC, key regions of the salience and default mode networks, may play a role in the pathophysiology of CPP independent of the presence of endometriosis. PERSPECTIVE Similar to other chronic pain conditions, endometriosis-associated pelvic pain is associated with altered brain chemistry and function in pain processing regions. These findings support central pain amplification as a mechanism of chronic pelvic pain, and clinicians should consider the use of adjunctive therapies that target central pain dysfunction in these women.
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Affiliation(s)
- Sawsan As-Sanie
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan.
| | - Jieun Kim
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Tobias Schmidt-Wilcke
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan Health Center, Ann Arbor, Michigan
| | - Pia C Sundgren
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Daniel J Clauw
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan Health Center, Ann Arbor, Michigan
| | - Vitaly Napadow
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Richard E Harris
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan Health Center, Ann Arbor, Michigan
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30
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Schliep KC, Chen Z, Stanford JB, Xie Y, Mumford SL, Hammoud AO, Boiman Johnstone E, Dorais JK, Varner MW, Buck Louis GM, Peterson CM. Endometriosis diagnosis and staging by operating surgeon and expert review using multiple diagnostic tools: an inter-rater agreement study. BJOG 2015; 124:220-229. [PMID: 26435386 DOI: 10.1111/1471-0528.13711] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine agreement on endometriosis diagnosis between real-time laparoscopy and subsequent expert review of digital images, operative reports, magnetic resonance imaging (MRI), and histopathology, viewed sequentially. DESIGN Inter-rater agreement study. SETTING Five urban surgical centres. POPULATION Women, aged 18-44 years, who underwent a laparoscopy regardless of clinical indication. A random sample of 105 women with and 43 women without a postoperative endometriosis diagnosis was obtained from the ENDO study. METHODS Laparoscopies were diagnosed, digitally recorded, and reassessed. MAIN OUTCOME MEASURES Inter-observer agreement of endometriosis diagnosis and staging according to the revised American Society for Reproductive Medicine criteria. Prevalence and bias-adjusted kappa values (κ) were calculated for diagnosis, and weighted κ values were calculated for staging. RESULTS Surgeons and expert reviewers had substantial agreement on diagnosis and staging after viewing digital images (n = 148; mean κ = 0.67, range 0.61-0.69; mean κ = 0.64, range 0.53-0.78, respectively) and after additionally viewing operative reports (n = 148; mean κ = 0.88, range 0.85-0.89; mean κ = 0.85, range 0.84-0.86, respectively). Although additionally viewing MRI findings (n = 36) did not greatly impact agreement, agreement substantially decreased after viewing histological findings (n = 67), with expert reviewers changing their assessment from a positive to a negative diagnosis in up to 20% of cases. CONCLUSION Although these findings suggest that misclassification bias in the diagnosis or staging of endometriosis via visualised disease is minimal, they should alert gynaecologists who review operative images in order to make decisions on endometriosis treatment that operative reports/drawings and histopathology, but not necessarily MRI, will improve their ability to make sound judgments. TWEETABLE ABSTRACT Endometriosis diagnosis and staging agreement between expert reviewers and operating surgeons was substantial.
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Affiliation(s)
- K C Schliep
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland, USA.,Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Z Chen
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland, USA
| | - J B Stanford
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Y Xie
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland, USA
| | - S L Mumford
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland, USA
| | - A O Hammoud
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - E Boiman Johnstone
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - J K Dorais
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - M W Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - G M Buck Louis
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland, USA
| | - C M Peterson
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
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Schliep KC, Mumford SL, Peterson CM, Chen Z, Johnstone EB, Sharp HT, Stanford JB, Hammoud AO, Sun L, Buck Louis GM. Pain typology and incident endometriosis. Hum Reprod 2015; 30:2427-38. [PMID: 26269529 DOI: 10.1093/humrep/dev147] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 06/01/2015] [Indexed: 12/11/2022] Open
Abstract
STUDY QUESTION What are the pain characteristics among women, with no prior endometriosis diagnosis, undergoing laparoscopy or laparotomy regardless of clinical indication? SUMMARY ANSWER Women with surgically visualized endometriosis reported the highest chronic/cyclic pain and significantly greater dyspareunia, dysmenorrhea, and dyschezia compared with women with other gynecologic pathology (including uterine fibroids, pelvic adhesions, benign ovarian cysts, neoplasms and congenital Müllerian anomalies) or a normal pelvis. WHAT IS KNOWN ALREADY Prior research has shown that various treatments for pain associated with endometriosis can be effective, making identification of specific pain characteristics in relation to endometriosis necessary for informing disease diagnosis and management. STUDY DESIGN, SIZE, DURATION The study population for these analyses includes the ENDO Study (2007-2009) operative cohort: 473 women, ages 18-44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at one of 14 surgical centers located in Salt Lake City, UT or San Francisco, CA. Women with a history of surgically confirmed endometriosis were excluded. PARTICIPANTS/MATERIALS, SETTING AND METHODS Endometriosis was defined as surgically visualized disease; staging was based on revised American Society for Reproductive Medicine (rASRM) criteria. All women completed a computer-assisted personal interview at baseline specifying 17 types of pain (rating severity via 11-point visual analog scale) and identifying any of 35 perineal and 60 full-body front and 60 full-body back sites for which they experienced pain in the last 6 months. MAIN RESULTS AND THE ROLE OF CHANCE There was a high prevalence (≥30%) of chronic and cyclic pelvic pain reported by the entire study cohort regardless of post-operative diagnosis. However, women with a post-operative endometriosis diagnosis, compared with women diagnosed with other gynecologic disorders or a normal pelvis, reported more cyclic pelvic pain (49.5% versus 31.0% and 33.1%, P < 0.001). Additionally, women with endometriosis compared with women with a normal pelvis experienced more chronic pain (44.2 versus 30.2%, P = 0.04). Deep pain with intercourse, cramping with periods, and pain with bowel elimination were much more likely reported in women with versus without endometriosis (all P < 0.002). A higher percentage of women diagnosed with endometriosis compared with women with a normal pelvis reported vaginal (22.6 versus 10.3%, P < 0.01), right labial (18.4 versus 8.1%, P < 0.05) and left labial pain (15.3 versus 3.7%, P < 0.01) along with pain in the right/left hypogastric and umbilical abdominopelvic regions (P < 0.05 for all). Among women with endometriosis, no clear and consistent patterns emerged regarding pain characteristics and endometriosis staging or anatomic location. LIMITATIONS, REASONS FOR CAUTION Interpretation of our findings requires caution given that we were limited in our assessment of pain characteristics by endometriosis staging and anatomic location due to the majority of women having minimal (stage I) disease (56%) and lesions in peritoneum-only location (51%). Significance tests for pain topology related to gynecologic pathology were not corrected for multiple comparisons. WIDER IMPLICATIONS OF THE FINDINGS Results of our research suggest that while women with endometriosis appear to have higher pelvic pain, particularly dyspareunia, dysmenorrhea, dyschezia and pain in the vaginal and abdominopelvic area than women with other gynecologic disorders or a normal pelvis, pelvic pain is commonly reported among women undergoing laparoscopy, even among women with no identified gynecologic pathology. Future research should explore causes of pelvic pain among women who seek out gynecologic care but with no apparent gynecologic pathology. Given our and other's research showing little correlation between pelvic pain and rASRM staging among women with endometriosis, further development and use of a classification system that can better predict outcomes for endometriosis patients with pelvic pain for both surgical and nonsurgical treatment is needed. STUDY FUNDING/COMPETING INTERESTS Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests.
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Affiliation(s)
- K C Schliep
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20852, USA Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - S L Mumford
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20852, USA
| | - C M Peterson
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - Z Chen
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20852, USA
| | - E B Johnstone
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - H T Sharp
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - J B Stanford
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - A O Hammoud
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - L Sun
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20852, USA
| | - G M Buck Louis
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20852, USA
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Standardizing data exchange for clinical research protocols and case report forms: An assessment of the suitability of the Clinical Data Interchange Standards Consortium (CDISC) Operational Data Model (ODM). J Biomed Inform 2015; 57:88-99. [PMID: 26188274 DOI: 10.1016/j.jbi.2015.06.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 03/27/2015] [Accepted: 06/26/2015] [Indexed: 01/27/2023]
Abstract
Efficient communication of a clinical study protocol and case report forms during all stages of a human clinical study is important for many stakeholders. An electronic and structured study representation format that can be used throughout the whole study life-span can improve such communication and potentially lower total study costs. The most relevant standard for representing clinical study data, applicable to unregulated as well as regulated studies, is the Operational Data Model (ODM) in development since 1999 by the Clinical Data Interchange Standards Consortium (CDISC). ODM's initial objective was exchange of case report forms data but it is increasingly utilized in other contexts. An ODM extension called Study Design Model, introduced in 2011, provides additional protocol representation elements. Using a case study approach, we evaluated ODM's ability to capture all necessary protocol elements during a complete clinical study lifecycle in the Intramural Research Program of the National Institutes of Health. ODM offers the advantage of a single format for institutions that deal with hundreds or thousands of concurrent clinical studies and maintain a data warehouse for these studies. For each study stage, we present a list of gaps in the ODM standard and identify necessary vendor or institutional extensions that can compensate for such gaps. The current version of ODM (1.3.2) has only partial support for study protocol and study registration data mainly because it is outside the original development goal. ODM provides comprehensive support for representation of case report forms (in both the design stage and with patient level data). Inclusion of requirements of observational, non-regulated or investigator-initiated studies (outside Food and Drug Administration (FDA) regulation) can further improve future revisions of the standard.
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Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain. Obstet Gynecol 2015; 125:719-728. [PMID: 25730237 DOI: 10.1097/aog.0000000000000663] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate sensitization, myofascial trigger points, and quality of life in women with chronic pelvic pain with and without endometriosis. METHODS A cross-sectional prospective study of women aged 18-50 years with pain suggestive of endometriosis and healthy, pain-free volunteers without a history of endometriosis. Patients underwent a physiatric neuromusculoskeletal assessment of clinical signs of sensitization and myofascial trigger points in the abdominopelvic region. Pain symptoms, psychosocial, and quality-of-life measures were also assessed. All participants with pain underwent laparoscopic excision of suspicious lesions to confirm endometriosis diagnosis by histologic evaluation. RESULTS Patients included 18 with current, biopsy-proven endometriosis, 11 with pain only, and 20 healthy volunteers. The prevalence of sensitization as measured by regional allodynia and hyperalgesia was similar in both pain groups (83 and 82%) but much lower among healthy volunteers (15%, P<.001). Nearly all women with pain had myofascial trigger points (94 and 91%). Adjusting for study group, those with high anxiety (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.004-1.099, P=.031) and depression (OR 1.06, 95% CI 1.005-1.113, P=.032) scores were more likely to have sensitization. Pain patients with any history of endometriosis had the highest proportion of sensitization compared with the others (87% compared with 67% compared with 15%; P<.001). Adjusting for any history of endometriosis, those with myofascial trigger points were most likely sensitized (OR 9.41, 95% CI 1.77-50.08, P=.009). CONCLUSION Sensitization and myofascial trigger points were common in women with pain regardless of whether they had endometriosis at surgery. Those with any history of endometriosis were most likely to have sensitization. Traditional methods of classifying endometriosis-associated pain based on disease, duration, and anatomy are inadequate and should be replaced by a mechanism-based evaluation, as our study illustrates. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT00073801. LEVEL OF EVIDENCE II.
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Menakaya U, Lu C, Infante F, Lam A, Condous G. Relating historical variables at first presentation with operative findings at laparoscopy for endometriosis. Aust N Z J Obstet Gynaecol 2015; 54:480-6. [PMID: 25287566 DOI: 10.1111/ajo.12256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 08/14/2014] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To determine the correlation between historical variables at presentation with the phenotype and location of biopsy proven endometriosis at laparoscopy. METHODS Prospective observational study. Consecutive women had laparoscopic surgery following clinical suspicion of endometriosis. Standardised history and clinical examination were taken, and the presenting complaints were evaluated within four subsets of women: (i) primary laparoscopy for endometriosis (ii) previous laparoscopically confirmed endometriosis (iii) biopsy positive for endometriosis and (iv) all biopsies negative for endometriosis. Historical pain variables within the four subsets were compared with disease location and phenotype (superficial, deep infiltrating, endometriomata) at laparoscopy. A stringent P-value of 0.01 was used as the cut-off for significance. RESULTS Overall 104 consecutive women were included: mean age 34.3 years, 66/104 (63.5%) had reoperation and 38/104 (36.5%) had primary laparoscopy. 89/104 (85.6%) were biopsy positive for endometriosis, and 11/104 (10.6%) were biopsy negative. Superficial endometriosis was most common phenotype. Site of pain did not correlate with ipsilateral location of disease. Significant correlations included as follows: dyspareunia and endometrioma (P = 0.0009) in women undergoing reoperation; dyspareunia and posterior compartment (P = 0.0086) and lateral compartment (P = 0.0004) disease in women with histology proven endometriosis; left iliac fossa pain and biopsy proven posterior compartment endometriosis (P = 0.0041). CONCLUSIONS Although a history of dyspareunia in women with previous endometriosis was significantly correlated with endometrioma, site-specific locations of pain symptoms did not correlate with ipsilateral locations of endometriosis at laparoscopy. The phenotype - combined deep and superficial endometriosis - was associated with dyspareunia among women with previous history of endometriosis.
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Affiliation(s)
- Uche Menakaya
- Acute Gynaecology and Early Pregnancy Unit, Nepean Centre for Perinatal Care, Nepean Clinical School, University of Sydney, Nepean Hospital, Sydney, New South Wales, Australia
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Development of a Symptom-Based, Screening Tool for Early-Stage Endometriosis in Patients with Chronic Pelvic Pain. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2014. [DOI: 10.5301/je.5000200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose The aim of this study was to develop a noninvasive screening tool for patients with chronic pelvic pain, for early-stage endometriosis, with a discriminatory ability of the area under the curve (AUC) for the receiver operator characteristic (ROC) curve of over 0.8. Methods Participants were women aged 13-55 years, with chronic pelvic pain (for more than 6 months despite medical therapy), seen at the Saint Louis University Center for Endometriosis, from January 2012 to June 2013, who were found to have early-stage endometriosis or not, based on histology. All patients received the same surgical approach and goal of surgery, which was excision of all visible abnormal peritoneum. Potential variables used for generating the screening tool came from the pre-operative questionnaire with standard pain symptoms and quality-of-life questions. Individual categorical variables were tested. In addition, new binary variables were created to test specific combinations of answers to 2 individual questions. A backwards-stepping multiple logistic regression model was used to develop the screening tool. Results Ninety patients found to have early-stage disease completed pre-operative surveys. Of these, 70 (77.8%) had histologically confirmed endometriosis and 20 (22.2%) were confirmed not to be affected. Combinations of 2 variables made it possible to create a predictive model for early-stage endometriosis with excellent discriminatory ability (AUC = 0.822, p<0.001). This model was generated using a multi-staged, backwards stepping logistic regression analysis with all variables that were univariately significant included in the initial model (p<0.025). The final model had 80.5% sensitivity and 57.7% specificity. The model allows for an individual probability of disease to be calculated for each patient. Conclusions A clinically useful, symptom-based screening tool was developed for early-stage endometriosis in patients with chronic pelvic pain seen at a referral center. This approach to developing a screening tool for endometriosis should be tested further.
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Yeung P. The Laparoscopic Management of Endometriosis in Patients with Pelvic Pain. Obstet Gynecol Clin North Am 2014; 41:371-83. [DOI: 10.1016/j.ogc.2014.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Bourdel N, Alves J, Pickering G, Ramilo I, Roman H, Canis M. Systematic review of endometriosis pain assessment: how to choose a scale? Hum Reprod Update 2014; 21:136-52. [PMID: 25180023 DOI: 10.1093/humupd/dmu046] [Citation(s) in RCA: 211] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Numerous studies concerning endometriosis and pain have been reported. However, there is no consensus on the best method to evaluate pain in endometriosis and many scales have been used. Moreover, there are only a few descriptions of minimal clinically important differences after treatment (MCID) to evaluate variations in pain. In our study, we aim to identify pain scales used in endometriosis pain treatment, to address their strong and weak points and to define which would be the ideal scale to help clinicians and researchers to evaluate endometriosis-related pain. METHODS A search of the MEDLINE and EMBASE databases was carried out for publications in English, French or Portuguese from 1980 to December 2012, for the words: endometriosis, treatment, pain. Studies were selected if they studied an endometriosis treatment and a pain scale was specified. A quantitative and a qualitative analysis of each scale was performed to define strong and weak points of each scale (systematic registration number: CRD42013005336). RESULTS A total of 736 publications were identified. After excluding duplications and applying inclusion criteria 258 studies remained. We found that the visual analog scale (VAS) is the most frequently used scale. Both VAS and the numerical rating scale (NRS) show a good balance between strong and weak points in comparison with others such as the Biberoglu and Behrman scale. Concerning MCID, only VAS, NRS and Brief Pain Inventory scales have reported MCID and, among these, only VAS MCID has been studied in endometriosis patients (VAS MCID = 10 mm). Adding the Clinical Global Impression score (CGI) to the pain scale allows calculation of the MCID. CONCLUSIONS When using pain scales their strengths and weaknesses must be known and included in the analysis. VAS is the most frequently used pain scale and, together with NRS, seems the best adapted for endometriosis pain measurement. The use of VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep dyspareunia and non-menstrual chronic pelvic pain), combined with the CGI and a quality-of-life scale will provide both clinicians and researchers with tools to evaluate treatment response.
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Affiliation(s)
- Nicolas Bourdel
- Department of Gynecologic Surgery, CHU Estaing Clermont Ferrand, 63058 Clermont Ferrand Cedex 1, France Faculté de medicine, ISIT - Université d'Auvergne, Place Henri Dunant, 63000 Clermont-Ferrand, France
| | - João Alves
- Department of Gynecologic Surgery, CHU Estaing Clermont Ferrand, 63058 Clermont Ferrand Cedex 1, France
| | - Gisele Pickering
- Centre de Pharmacologie Clinique, CHU Clermont Ferrand, Inserm CIC 501, Inserm, U1107 Neuro-Dol, F-63003 Clermont-Ferrand, France
| | - Irina Ramilo
- Department of Gynecologic Surgery, CHU Estaing Clermont Ferrand, 63058 Clermont Ferrand Cedex 1, France
| | - Horace Roman
- Department of Gynecology and Obstetrics, Rouen University Hospital-Charles Nicolle, 1 rue de Germont, 76031 Rouen, France
| | - Michel Canis
- Department of Gynecologic Surgery, CHU Estaing Clermont Ferrand, 63058 Clermont Ferrand Cedex 1, France Faculté de medicine, ISIT - Université d'Auvergne, Place Henri Dunant, 63000 Clermont-Ferrand, France
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Posadzka E, Jach R, Pityński K, Jablonski MJ. Treatment efficacy for pain complaints in women with endometriosis of the lesser pelvis after laparoscopic electroablation vs. CO2 laser ablation. Lasers Med Sci 2014; 30:147-52. [PMID: 25053520 PMCID: PMC4289154 DOI: 10.1007/s10103-014-1630-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/03/2014] [Indexed: 01/02/2023]
Abstract
Endometriosis is a chronic disease affecting mainly women of the reproductive age. Its most common manifestations include impaired fecundity, pelvic pain, and dyschezia. Laparoscopic removal of endometriotic foci remains to be the gold standard for the treatment of endometriosis. More effective techniques of endoscopic approach—among others, laser application—are continually being developed. The aim of the study was to evaluate the efficacy of laparoscopic treatment with the use of CO2 laser ablation vs. electroablation with regard to pain complaints in the affected patients. The study included 48 women (aged 22–42) with varying degrees of endometriosis of the lesser pelvis. The Numeric Rating Scale (NRS) was used to evaluate pain intensity before the surgery in all patients, followed by either laser ablation or electroablation of the endometriotic foci. The results of the laparoscopic treatment were monitored after 3 and 6 months postoperatively. p value of 0.05 was considered to be statistically significant. Patients from both groups reported less intensive pain before/during menstruation (dysmenorrhea) 6 months postoperatively, with more distinct tendency in the electroablation group (p = 0.004) as compared to the laser ablation group (p = 0.025). Despite the initial improvement reported at the 3-month checkup (p = 0.008), 6 months postoperatively, a statistically significant increase in pain intensity was noted in both groups (p = 0.016 and p = 0.032 for CO2 laser ablation and electroablation, respectively). Both surgical methods seem to be effective only in the treatment of endometriosis-related dysmenorrhea, whereas the intensity of other pain complaints (dyspareunia, dysuria, dyschezia, pelvic pain syndrome (PPS)) has remained on the same level.
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Affiliation(s)
- Ewa Posadzka
- Departament of Gynecology and Obstetrics, Jagiellonian University Medical College, 23 Kopernika str, 31-501, Krakow, Poland
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[Urinary functional disorders bound to deep endometriosis and to its treatment: review of the literature]. ACTA ACUST UNITED AC 2014; 43:431-42. [PMID: 24831568 DOI: 10.1016/j.jgyn.2014.03.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 03/10/2014] [Accepted: 03/24/2014] [Indexed: 11/22/2022]
Abstract
Lower urinary tract disorders in case of deep endometriosis are common (up to 50% of patients), although often masked by pelvic pain. They result from damage to the pelvic autonomic nervous system by direct infiltration of these structures by endometriotic lesions or surgical trauma (especially in resection of the uterosacral ligaments, rectum or vagina). These are mainly sensory disturbances and bladder voiding dysfunction. They impact quality of life and could be responsible for long-term complications (recurrent urinary tract infections on a persistent residual urine or pelvic floor disorders due to chronic thrusting). It is therefore important to diagnose and treat early these troubles by well-conducted interviews or standardized questionnaires. Different drug treatments have been proposed, such as cholinergics or prokinetics, but their effectiveness has not been demonstrated yet. Neuromodulation of the superior hypogastric plexus for treatment of refractory atonic bladder with persistent urinary retention after surgery seems promising but should be confirmed by further studies. To date, standard treatment of urinary retention after surgery remains self-catheterization. In terms of prevention, surgical nerve sparing techniques have been developed in order to minimize intraoperative injury of pelvic nerve plexus and reduce postoperative morbidity.
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Abstract
OBJECTIVE To determine whether women with chronic pelvic pain and variable degrees of endometriosis demonstrate altered pain sensitivity relative to pain-free healthy women in a control group and whether such differences are related to the presence or severity of endometriosis or comorbid pain syndromes. METHODS Four patient subgroups (endometriosis with chronic pelvic pain [n=42], endometriosis with dysmenorrhea [n=15], pain-free endometriosis [n=35], and chronic pelvic pain without endometriosis [n=22]) were each compared with 30 healthy women in a control group in this cross-sectional study. All patients completed validated questionnaires regarding pain symptoms and underwent screening for comorbid pain disorders. Pain sensitivity was assessed by applying discrete pressure stimuli to the thumbnail using a previously validated protocol. RESULTS While adjusting for age and education, pain thresholds were lower in all subgroups of women with pelvic pain relative to healthy women in the control group (all P values <.01). There was no difference in pain thresholds when comparing patients with endometriosis without pelvic pain with healthy women in the control group (mean difference 0.02 kg/m2, 95% confidence interval -0.43 to 0.47). The presence and severity of endometriosis and number of comorbid pain syndromes were not associated with a difference in pain thresholds. CONCLUSION Women with chronic pelvic pain demonstrate increased pain sensitivity at a nonpelvic site compared with healthy women in a control group, which is independent of the presence or severity of endometriosis or comorbid pain syndromes. These findings support the notion that central pain amplification may play a role in the development of pelvic pain and may explain why some women with pelvic pain do not respond to therapies aimed at eliminating endometriosis lesions. LEVEL OF EVIDENCE II.
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Is a Picture Worth a Thousand Biopsies? Challenges in the Diagnosis of Endometriosis. J Minim Invasive Gynecol 2013; 20:733-4. [DOI: 10.1016/j.jmig.2013.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 09/12/2013] [Indexed: 11/19/2022]
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Fauconnier A, Staraci S, Huchon C, Roman H, Panel P, Descamps P. Comparison of patient- and physician-based descriptions of symptoms of endometriosis: a qualitative study. Hum Reprod 2013; 28:2686-94. [DOI: 10.1093/humrep/det310] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Dun EC, Wieser FA, Nezhat CH. Pelvic and Extragenital Endometriosis: A Review of the Surgical Management of Deeply Infiltrating Lesions. J Gynecol Surg 2013. [DOI: 10.1089/gyn.2012.0119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Erica C. Dun
- Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, Atlanta, GA
| | - Friedrich A. Wieser
- Department of Gynecology & Obstetrics, Emory University School of Medicine, Atlanta, GA
| | - Ceana H. Nezhat
- Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, Atlanta, GA
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Jarrell J, Arendt-Nielsen L. Quantitative Sensory Testing in Gynaecology: Improving Preoperative and Postoperative Pain Diagnosis. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2013; 35:531-535. [DOI: 10.1016/s1701-2163(15)30911-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Zhai A, Axt J, Hamilton EC, Koehler E, Lovvorn HN. Assessing gonadal function after childhood ovarian surgery. J Pediatr Surg 2012; 47:1272-9. [PMID: 22703805 PMCID: PMC4148072 DOI: 10.1016/j.jpedsurg.2012.03.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE We aimed to assess the late effects of ovarian salvage or oophorectomy on gonadal function and fertility as measured by menstrual regularity. METHODS We performed a 10-year retrospective review of females aged 20 years or younger who required surgery to treat an ovarian disorder. A mail survey was distributed to these patients to evaluate the effects of ovarian surgery on menarche, menstrual regularity, and pregnancy. RESULTS A total of 180 females had surgery to treat an ovarian disorder. Eighty-six of these underwent unilateral oophorectomy (48%), whereas 94 (52%) had an ovary sparing procedure. Eighty-one patients (45%) returned completed surveys. Of the respondents, 44 had oophorectomy, and 37 had ovarian salvage. Ages of menarche were similar between surgical groups. Symptoms of menstrual irregularity differed most significantly according to painful menses (oophorectomy, 27.3%; salvage, 59.5%; P < .04). Interestingly, continuation of regular menses after surgery was higher in the oophorectomy group (oophorectomy, 70%; salvage, 15%; P = .013). CONCLUSIONS Unilateral oophorectomy does not appear to impair late gonadal function when compared with ovarian salvage. Surprisingly, oophorectomy appears to maintain more normal ovarian activity as estimated by menstrual regularity. Oophorectomy may be performed without apparent adverse effect on gonadal activity.
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Affiliation(s)
| | | | | | | | - Harold N. Lovvorn
- Corresponding author. Vanderbilt University Children's Hospital, Nashville, TN 37232-9780. Tel.: +1 615 936 1050; fax: +1 615 936 1046. (H.N. Lovvorn)
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