Advances in the management of endometriosis in the adolescent

Medical Management of Endometriosis in Adolescent and Young Adult Women: A Review of 91 Cases of Biopsy-Confirmed Endometriosis

OBJECTIVES

To characterise contemporary trends in the hormonal management of endometriosis in adolescent and young adult patients with biopsy-proven endometriosis.

METHODS

Retrospective chart review of women aged 14-25 years who underwent laparoscopy for pelvic pain with biopsy-proven endometriosis between January 2011 and September 2020 at an academic tertiary hospital system. The final sample included 91 patients with biopsy-confirmed endometriosis.

RESULTS

Combined oral contraceptives (COCs) were the most common initial treatment (64% of patients). Progestin-only formulations (low- and high-dose norethindrone acetate) were offered to younger patients (age 15.9 ± 2.7 years) than those offered COCs (19.9 ± 3.3 years) and levonorgestrel intrauterine devices (LNG-IUDs) (21.9 ± 1.7 years). Current treatments varied widely and included COCs (32%), LNG-IUDs (18%), oral progestins (low- and high-dose norethindrone, medroxyprogesterone) (14%), elagolix (9%), and leuprolide (8%). Oral adjuncts to LNG-IUD were common: usually low- or high-dose norethindrone (37% of patients with an LNG-IUD), but also included progesterone, COCs, and elagolix.

CONCLUSIONS

Oral progestins, LNG-IUDs, and COCs were the mainstay of initial treatment. Subsequent treatments varied widely and included COCs, LNG-IUDs, oral progestins, elagolix, leuprolide, and combinations of these agents. We observed that most young women switched between therapies, suggesting that a personalised approach is often used to determine treatment plans among the wide range of options currently available. This study helps define the spectrum of treatment regimens for endometriosis in adolescent females.

Appendiceal Endometriosis: A Comprehensive Review of the Literature

Objective: the purpose of this review was to evaluate the prevalence of appendiceal endometriosis and the safety of concomitant appendectomy in women with endometriosis or pelvic pain. Materials and Methods: We searched the electronic databases Medline (PubMed), Scopus, Embase, and Web of Science (WOS). The search was not subject to any limitation in terms of time or method. The primary research question was: what is the prevalence of appendiceal endometriosis? The secondary research question was: is it safe to perform appendectomy during surgery for endometriosis? Publications that reported data about appendiceal endometriosis or appendectomy in women with endometriosis were reviewed regarding the inclusion criteria. Results: We found 1418 records. After review and screening, we included 75 studies published between 1975 and 2021. With regard to the first question of the review, we found 65 eligible studies and divided these into the following two categories: (a) endometriosis of the appendix presenting as acute appendicitis, and (b) endometriosis of the appendix as an incidental finding in gynecological surgery. Forty-four case reports described appendiceal endometriosis in women who were admitted for the treatment of pain in the right-sided lower abdomen. Endometriosis of the appendix was observed in 2.67% (range, 0.36-23%) of women who were admitted due to acute appendicitis. In addition, appendiceal endometriosis was an incidental finding during gynecological surgery in 7.23% of cases (range, 1-44.3%). With regard to the second question of the review, which was the safety of appendectomy in women with endometriosis or pelvic pain, we found 11 eligible studies. Reviewed cases had no significant intraoperative or follow-up complications during the 12 weeks. Conclusion: Based on the reviewed studies, coincidental appendectomy appears reasonably safe and was associated with no complications in the cases reviewed for the present report.

Improvement in Fertility and Pain after Endometriosis Resection and Adhesion Prevention with 4DryField® PH: Follow-up of a Randomized Controlled Clinical Trial

BACKGROUND

Adhesions after endometriosis resection are frequent and the most common causes for chronic pain and secondary infertility. Primary results of our randomized controlled trial (RCT) on adhesion prevention after deep infiltrating endometriosis (DIE) resection using the gel barrier 4DryField^® PH showed 85% adhesion reduction in second-look surgeries. Secondary endpoint data on fertility and pain development were collected during 12-month follow-ups.

METHODS

This RCT comprised 50 patients. Preoperatively and after 1, 6 and 12 months, pain scores for cycle-independent pelvic pain, dysmenorrhea, dyspareunia, dyschezia, and dysuria, as well as the number of pregnancies, were recorded,.

RESULTS

The pregnancy rate in the intervention group was significantly higher (p < 0.05). Pain development was also improved: after 12 months, all 5 subscores were lower in the intervention group and improvements were more pronounced, most prominently concerning cycle-independent pelvic pain and dysmenorrhea, the two subcategories with the highest preoperative scores and, therefore, the highest relevance for the patients. Cycle-independent pelvic pain even recurred in the control group, while barrier application prevented this.

CONCLUSIONS

Considering the known causal link between adhesions and pain, it is apparent that the favourable outcomes in the intervention group are linked to effective adhesion prevention. The significant increase in pregnancies is remarkable.

Does Quality of Care (QoC) Perception Influence the Quality of Life (QoL) in Women with Endometriosis? Results from an Italian Nationwide Survey during Covid Pandemic

(1) Background: Endometriosis is a chronic and progressive illness that generates a slew of issues, lowering the quality of life of women. The purpose of this study was to look at the quality of life in women with endometriosis and how it relates to the quality of care. (2) Methods: This study is an online survey performed in Italy during the COVID pandemic using the Italian version of the Health Questionnaire SF-36 and a questionnaire for assessing the quality of care received. (3) Results: 1052 women with a self-reported diagnosis of endometriosis participated in the survey. The mean levels of Physical Component Summary (PCS) and Mental Component Summary (MCS) were 38.89 ± 10.55 and 34.59 ± 11.17, respectively. A total of 77% of women judged the services they received positively, and 51% considered the coordination between healthcare professionals to be satisfactory. The satisfaction index mean was 23.11 ± 4.80. PCS was positively related to Occupation, high educational level, physical activity, and health care satisfaction. MCS was positively related to higher age, physical activity, and health care satisfaction. (4) Conclusions: The study indicated that satisfaction with health care was a significant predictor of QoL in women with endometriosis, for both physical and mental health.

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

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.

Identification of potential differentially methylated gene-related biomarkers in endometriosis

Aim: To identify epigenetic alterations of differentially expressed genes and screen out targeted therapeutic drugs in endometriosis. Methods: Based on the Gene Expression Omnibus database and a series of biological information analysis tools, supplemented by validation of clinical samples, aberrant DNA methylation-driven genes and their functions were explored, as well as possible targeted drugs. Results: This study screened out a range of DNA methylation-driven genes that were associated with powerful properties and corresponding pathways. Among them, BDNF and CCL2 were key genes in the development of endometriosis. Four chemical agents have been flagged as potential treatments for endometriosis. Conclusion: These candidate genes and small-molecule agents may be further explored as potential targets and drugs for endometriosis diagnosis and therapy, respectively.

Surgically confirmed endometriosis in adolescents in Finland-A register-based cross-sectional cohort study

INTRODUCTION

Increasing awareness of endometriosis in adolescents requires data on the nature of the disease and its management. Our objective was to investigate the subtypes of surgically confirmed endometriosis in adolescents (aged <20 years) and trends in the incidence rates and endometriosis-related procedures during the study period, 1987-2012.

MATERIAL AND METHODS

In this register-based cohort study, we identified 526 adolescents receiving their initial surgical diagnosis of endometriosis between 1987 and 2012 from the Finnish Hospital Discharge Register. The age-specific incidence rate of surgically confirmed endometriosis was calculated by dividing the number of adolescents during specific periods by person-years. We calculated the relative differences in incidence rates between the periods using crude incidence ratios.

RESULTS

Adolescents were divided into three age groups, <17, 17-18, and 19 years, which comprised 8.2% (43/526), 39.7% (209/526), and 52.1% (274/526) of the study cohort, respectively. Peritoneal endometriosis and ovarian endometriosis were the most common types (379/526 [72%] and 119/526 [23%], respectively). The incidence rate of surgically confirmed endometriosis per 100 000 person-years varied from 5.63 (95% confidence interval [CI] 4.24-7.33) to 11.42 (95% CI 9.64-13.44). The incidence rate in 2001-2005 was significantly higher and was 1.6- to 2.0-fold that of the periods 1987-1990 and 2006-2012, respectively. Comparing the periods in which International Classification of Diseases, Ninth Revision (ICD-9; 1987-1995) and Tenth Revision (ICD-10; 1996-2012) codes were used, the use of laparoscopy (78.2% vs 88.9%), day surgery (10.3% vs 31.6%), and procedures for ovarian (18.8% vs 34.1%) and deep (0.6% vs 10.8%) endometriosis increased. The types of endometriosis and procedures did not differ between the age groups.

CONCLUSIONS

Peritoneal endometriosis was the most common type of endometriosis overall and by age group. During the 26-year period, the incidence rate of initial surgical diagnosis of endometriosis peaked in 2001-2005 and decreased thereafter. The proportion of procedures performed for ovarian and deep endometriosis increased, as did the use of laparoscopy and day surgery.

Effects of miR-363 on the Biological Activities of Eutopic Endometrial Stromal Cells in Endometriosis

EMs is a kind of benign disease with certain malignant behaviors. The adhesion, invasive growth, and angiogenesis of ectopic endometrial cells are the pathological basis of EMs occurrence, but its etiology and pathogenesis have not been completely illustrated yet. In our research, we aim to investigate the role of miR-363 in the pathogenesis of endometriosis. Real-time quantitative PCR was used to detect the expression of miR-363 before and after ESC/NSC transfection. CCK-8, flow cytometry, and transwell assay were used to detect the effect of the miR-363 expression on cell proliferation, apoptosis, and invasion. The effects of the miR-363 expression on the contents of Fas/APO-1 and ICAM-1 in cell culture supernatant were detected by ELISA. qRT-PCR and WB assay were used to detect the effects of the miR-363 expression on the mRNA and protein expression levels of ICAM-1, MMP-7, and VEGF in ESC. The increased expression of miR-363 could inhibit the proliferation and invasion of ESC, promote apoptosis, and inhibit the secretion of FAS/APO-1 and ICAM-1. The knockdown expression of miR-363 promoted proliferation and invasion of NSC, inhibited apoptosis, and promoted secretion of FAS/APO-1 and ICAM-1. VCAM-1, VEGF, and MMP-7 were detected in ESCs before transfection. The protein expression level was higher than that of NSCs. Compared with pretransfection, the protein levels of VCAM-1, VEGF, and MMP-7 in the M-363 group were significantly downregulated. The downregulated expression of miR-363 was associated with a stronger cell proliferation ability, a lower cell apoptosis rate, and a stronger ESC. Migration is associated with invasiveness, proliferation, angiogenesis, and immune escape. The low expression of miR-363 promotes endogenesis through posttranscriptional regulation of target genes VCAM-1, MMP-7, and VEGF. The differential expression of miR-363 between ESC and NSC may be an important factor in the many biological differences between ESC and NSC.

Age-dependent phenotypes of ovarian endometriomas

Purpose

To analyze the characteristics of the ovarian endometrioma (OE) across the life span of a woman. In the past, the OE has traditionally been viewed as a single, monolithic disease. Today, there are emerging data indicating that OE phenotypes differ according to the age of the woman.

Method

A narrative review of original articles on OE indexed by PubMed.

Results

When appearing in infancy and early adolescence, OE may be the consequence of endometrial cells retrogradely shed with neonatal uterine bleeding. The post-menarcheal variant, manifesting itself during full adolescence, is singularly frequent in the presence of vaginal or uterine outflow obstructive anomalies. The typical and most frequent adult phenotype is characterized by increasing fibrosis and a tendency to progress; its mere presence exerts a detrimental effect on the surrounding healthy ovarian tissue. In postmenopause, an old lesion may be reactivated in the presence of exogenous or endogenous estrogens, or even be produced ex novo; rarely, it can spread to a variety of organs and structures and even degenerate causing malignancies.

Conclusions

Given the existence of these variants, it is important to agree on management guidelines that take into consideration these different phenotypes.

Complementary and Alternative Medicine for Dysmenorrhea Caused by Endometriosis: A Review of Utilization and Mechanism

Endometriosis (EM) is a common and benign estrogen-dependent gynecological disorder among women of reproductive age, and secondary dysmenorrhea is one of the more severe symptoms. However, the mechanism behind the development of dysmenorrhea is poorly understood, and there is a lack of effective methods for diagnosing and treating EM dysmenorrhea. In this regard, complementary and alternative medicine (CAM) has recently come into widespread use due to its limited adverse reactions and high efficiency. This review updates the progress of CAM in the treatment of EM dysmenorrhea and seeks to identify the therapeutic efficacy as well as the mechanisms behind these effects based on the available clinical and experimental studies. According to the literature, CAM therapy for EM dysmenorrhea, including herbs (herbal prescriptions, extracts, and patents), acupuncture, and Chinese herbal medicine enema (CHM enema), is effective for relieving dysmenorrhea with fewer unpleasant side effects when compared to hormonal and surgical treatments. In addition, we discuss and analyze the existing gaps in the literature. We hope to provide some instructive suggestions for clinical treatment and experimental research in the future.

Ectopic endometriosis, menstruation, and acute appendicitis: A thought-provoking case

INTRODUCTION AND IMPORTANCE

Ectopic endometrium in the appendix is rare. The relationships between ectopic endometrium in the alimentary tract and digestive symptoms and between digestive symptoms due to ectopic endometriosis and periodic menstruation are controversial. We herein describe the successful treatment of acute appendicitis that we suspect was caused by ectopic endometriosis and periodic menstruation.

PRESENTATION OF CASE

A 38.9-year-old multipara with uterine didelphys developed lower abdominal pain during menstruation, and she was clinically diagnosed with acute appendicitis. She received conservative management with cephem antibiotics, and her pain disappeared uneventfully. However, the lower abdominal pain during menstruation later recurred, and she again received conservative treatment. Laparoscopic appendectomy was subsequently performed because for 4 months, her appendicitis-induced digestive symptoms had recurred in association with periodic menstruation. Ectopic endometrial gland proliferations were histopathologically observed in the proper muscular layer of the appendiceal tip. She developed no further episodes of digestive symptoms postoperatively.

CLINICAL DISCUSSION

Ectopic endometriosis of the alimentary tract may be accompanied by digestive symptoms; moreover, these symptoms may be related to periodic menstruation. However, the sensitivity of ectopic endometrium to hormones shows considerable variation among patients. We speculate that the acute appendicitis might have been triggered by ectopic endometriosis in our case because the patient developed repeated digestive symptoms in association with periodic menstruation. Ectopic endometrium may be incidentally observed in histopathological assessments of resected specimens. The therapeutic strategy should be carefully decided on a case-by-case basis.

CONCLUSION

We hope this thought-provoking case provides a timely reminder for gastrointestinal clinicians and general surgeons.

Inquiry into women's pathways to diagnosis of endometriosis: A qualitative study protocol

AIMS

This protocol describes a study aiming to: (1) describe pathways and experiences of women's symptom recognition, appraisal and management of endometriosis; and (2) identify differences in pathways and experiences among a socioeconomically and racially diverse group of women.

DESIGN

Descriptive qualitative study with stratified purposeful sampling.

METHODS

Data will be collected from a minimum of 24 women with provider-presumed or surgically confirmed diagnoses across two time points. The study will recruit across socioeconomic status (SES) and race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic/Latina) to ensure diversity of the sample. Recruitment will occur at a large public hospital in the southeastern United States (US). Participants will be interviewed using semi-structured interview guides informed by Elder and Giele's Life Course perspective approaching women as active beings in dynamic systems shaped by: 1) their location in time and space; 2) linked lives; and 3) human agency, and 4) the time of their lives. Each woman's experiences, symptoms, and contacts with health-care systems will be mapped to trace their diagnostic pathways. Coded interviews and data will undergo within- and across-case analysis to identify similarities and differences in their experiences. Institutional review board approval was obtained June 2019.

DISCUSSION

The participants' diagnostic maps will enable us to distinguish the differences in pathways and experiences between and across groups. Findings will inform the development of interventions aimed at shortening the time to diagnosis.

IMPACT

This will be the first study to compare pathways to diagnosis of endometriosis in a socioeconomically and racially diverse sample of US women using the life course perspective. The results from this research stand to inform future interventions aimed at helping women achieve more timely diagnoses.