Surgery and Endometriosis

A Podcast on Patient and Physician Perspectives on the Management of Endometriosis and Relugolix Combination Therapy

Endometriosis is a common disease, affecting approximately 5-10% of reproductively aged women. Symptoms, such as painful periods, negatively impact an individual's quality of life; however, these symptoms are often normalized, leading to delays in diagnosis and treatment, and worsening of the disease. In this podcast, a reproductive endocrinologist (Dr Sanjay K Agarwal) and patient advocate (Tara Mangum) provide their perspectives on the diagnosis and management of endometriosis. They also discuss Relugolix combination therapy as a treatment option for patients with endometriosis.Podcast available for this article.

Use of transanal irrigation (TAI) in the treatment of persistent bowel disorders in patients with endometriosis: A retrospective study

PURPOSE

Endometriosis has a strong impact on women's quality of life (QoL). Pain is the main symptom of the disease, but bowel dysfunctions such as fecal incontinence, constipation and voiding difficulties are also reported. Patients could suffer from a Low Anterior Resection Syndrome (LARS)-like syndrome. Transanal irrigation (TAI), known to alleviate LARS-related symptoms, has been suggested to aid bowel dysfunction in endometriosis patients, potentially facilitating pelvic floor rehabilitation.

METHODS

We retrospectively collected data from 60 patients with endometriosis and bowel dysfunction who had been prescribed with the Peristeen® Plus TAI system. Patient satisfaction, pain, QoL and LARS score were evaluated before (baseline) and after TAI treatment (follow-up of approximately 12 months).

RESULTS

Of the 60 patients meeting the inclusion criteria, 12 patients did not complete the questionnaires at follow-up and 16 patients discontinued treatment. Data analysis performed on 32 patients showed a mean increase of 3.6 points in patient satisfaction after TAI treatment and a mean pain reduction of 1.8 points (both, p-value < 0.001). LARS score decreased from a mean of 21.9 at baseline to a mean of 12.7 (p-value < 0.001). Accordingly, there was a notable improvement in patients' QoL.

CONCLUSION

TAI is a useful treatment for bowel dysfunctions in patients with endometriosis. When offered to these patients, TAI seems to represent a valuable strategy to reduce pelvic floor stress. This study confirms that TAI was associated to a significantly higher patients' satisfaction, as well as to a reduction of pain and LARS-like symptoms.

Connecting the dots: Exploring appendiceal endometriosis in women with diaphragmatic endometriosis

OBJECTIVES

This study aims to ascertain the prevalence of appendiceal endometriosis (AppE) in patients diagnosed with diaphragmatic endometriosis (DiaE), compare it with the prevalence in patients without DiaE, and delineate the anatomical distribution of endometriotic lesions within these cohorts.

STUDY DESIGN

Comparison of the characteristics of patients with AppE and DiaE with the characteristics of patients with abdominal endometriosis without diaphragmatic involvement, in a prospective cohort study.

SETTING

Tertiary referral center; endometriosis center.

PATIENTS

A cohort of 1765 patients with histologically confirmed endometriosis INTERVENTIONS: Evaluation of correlations between demographic, clinical, and surgical variables of AppE patients with DiaE and without DiaE. We performed appendectomies selectively, in the presence of gross abnormalities of the appendix, such as endometriotic implants, edema, tortuosity, and discoloration of the organ.

MEASUREMENTS

Patients' characteristics were evaluated using basic descriptive statistics (chi-square test or Fisher's exact test). A logistic regression analysis was performed to evaluate the relationship (hazard ratio) between patient characteristics and the presence of DiaE and AppE.

MAIN RESULTS

Within a cohort of 1765 patients with histologically confirmed endometriosis, 31 were identified with AppE (1.8 %), and 83 with DiaE (4.7 %). The prevalence of DiaE was significantly elevated at 30.1 % (25/83), among patients with AppE compared to those without AppE, who showed a DiaE prevalence of 7.2 % (6/83). The calculated odds ratio for DiaE given the presence of AppE was 5.5, 95 % CI 2.1-14.4, p = 0.0004, and risk ratio was 4.2, 95 % CI 1.8-9.6, p = 0.0008, indicating a profound association. Surgical interventions did not lead to significant perioperative or postoperative complications. In the group with DiaE, the left ovary was affected in 96 % of cases (24/25), p < 0.05, the right ureter in 80 % of cases (20/25), p < 0.01 (in 19/25 only the serosa was affected, due to external compression of an endometriotic nodule of the parametrium). Concurrent AppE and right diaphragm was found in 92 % of cases (23/25 patients), p < 0.001. The concurrent presence of DiaE and AppE was often associated with severe endometriosis, rASRM IV 72 % OR = 3, 95 % CI (1.216-7.872).

CONCLUSION

The investigation delineates a marked association between AppE and DiaE, with an odds ratio of 5.5 and risk ratio of 4.2, suggesting a markedly increased likelihood of DiaE in patients with AppE. These statistics significantly substantiate the notion that AppE can serve as a predictive marker for DiaE, underscoring the necessity for a meticulous intraoperative assessment of diaphragmatic regions in patients diagnosed with AppE. The absence of a significant correlation between the depth of DiaE infiltration and the presence of AppE implies that the detection of AppE should prompt a thorough search for DiaE, regardless of the perceived severity of the endometriosis or preoperative results of diaphragmatic MRI.

Follicular Fluid Metabolomics: Tool for Predicting IVF Outcomes of Different Infertility Causes

Infertility affects approximately 15% of couples at child-bearing ages and assisted reproductive technologies (ART), especially in vitro fertilization and embryo transfer (IVF-ET), provided infertile patients with an effective solution. The current paradox is that multiple embryo transfer that may leads to severe obstetric and perinatal complications seems to be the most valid measure to secure high success rate in the majority of clinic centers. Therefore, to avoid multiple transfer of embryos, it is urgent to explore biomarkers for IVF prognosis to select high-quality oocytes and embryos. Follicular fluid (FF), a typical biofluid constituted of the plasma effusion and granulosa-cell secretion, provides essential intracellular substances for oocytes maturation and its variation in composition reflects oocyte developmental competence and embryo viability. With the advances in metabolomics methodology, metabolomics, as an accurate and sensitive analyzing method, has been utilized to explore predictors in FF for ART success. Although FF metabolomics has provided a great possibility for screening markers with diagnostic and predictive value, its effectiveness is still doubted by some researchers. This may be resulted from the ignorance of the impact of sterility causes on the FF metabolomic profiles and thus its predictive ability might not be rightly illustrated. Therefore, in this review, we categorically demonstrate the study of FF metabolomics according to specific infertility causes, expecting to reveal the predicting value of metabolomics for IVF outcomes.

The Known, the Unknown and the Future of the Pathophysiology of Endometriosis

Endometriosis is one of the most common causes of chronic pelvic pain and infertility, affecting 10% of women of reproductive age. A delay of up to 9 years is estimated between the onset of symptoms and the diagnosis of endometriosis. Endometriosis is currently defined as the presence of endometrial epithelial and stromal cells at ectopic sites; however, advances in research on endometriosis have some authors believing that endometriosis should be re-defined as "a fibrotic condition in which endometrial stroma and epithelium can be identified". There are several theories on the etiology of the disease, but the origin of endometriosis remains unclear. This review addresses the role of microRNAs (miRNAs), which are naturally occurring post-transcriptional regulatory molecules, in endometriotic lesion development, the inflammatory environment within the peritoneal cavity, including the role that cytokines play during the development of the disease, and how animal models have helped in our understanding of the pathology of this enigmatic disease.

Postmenopausal endometriosis: a challenging condition beyond menopause

IMPORTANCE AND OBJECTIVE

Postmenopausal endometriosis is a complex condition that challenges the conventional belief that endometriosis resolves with menopause. Despite the cessation of menstruation, a subset of women continues to experience or develop endometriosis-related symptoms during the postmenopausal period. Thus, this review aimed to shed light on postmenopausal endometriosis, exploring its clinical features, diagnostic considerations, management approaches, and the potential impact on women's health.

METHODS

PubMed/Medline, Scopus, and Web of Science databases were used for the research, with only articles in English language, using the following terms: "postmenopausal endometriosis," "menopause," "management," "treatment," and "quality of life," from inception to 2023.

DISCUSSION AND CONCLUSION

The clinical features of postmenopausal endometriosis include persistent or recurrent pelvic pain, dyspareunia, bowel, or urinary symptoms and, occasionally, abnormal vaginal bleeding. The absence of menstrual cycles presents a diagnostic challenge, as the traditional diagnostic criteria for endometriosis rely on menstrual patterns. Visual cues may be less evident, and the symptoms often overlap with other gynecological conditions, necessitating a thorough evaluation to differentiate postmenopausal endometriosis from other potential causes. Management approaches for postmenopausal endometriosis encompass surgical intervention, hormonal therapies, pain management, and individualized care. Postmenopausal endometriosis significantly impacts the quality of life, sexual health, and long-term well-being of women. Understanding the clinical features, diagnostic challenges, and management approaches of postmenopausal endometriosis is crucial for healthcare professionals to provide effective care and to improve the quality of life of women affected by this condition.

First-line surgery versus first-line assisted reproductive technology for women with deep infiltrating endometriosis: a systematic review and meta-analysis

Background

The efficiency of different first-line treatments, such as first-line surgery and assisted reproductive technology (ART), in women with deep infiltrating endometriosis (DIE) is still unclear due to a lack of direct comparative trials. This systematic review and meta-analysis aim to elucidate and compare the efficacies of first-line treatments in patients with DIE, with an emphasis on fertility outcomes.

Methods

An exhaustive search of PubMed Central, SCOPUS, EMBASE, MEDLINE, Cochrane trial registry, Google Scholar, and Clinicaltrials.gov databases was done to identify studies directly comparing first-line surgery and assisted reproductive technology (ART) for DIE, and reporting fertility-related outcomes. Pooled estimates for each of the binary outcomes were reported as odds ratios (ORs) with 95% confidence intervals (CIs). The results were pooled using a random-effects model with the Mantel-Haenszel technique.

Results

Our results show that pregnancy rate per patient (OR, 1.47; 95% CI, 0.59 to 3.63), pregnancy rate per cycle (OR, 1.16; 95% CI, 0.45 to 2.99), and live births per patient (OR, 1.66; 95% CI, 0.56 to 4.91) were comparable in DIE patients, treated with surgery or ART as a first line of treatment. When both complete and incomplete surgical DIE excision procedures were taken into account, surgery was associated with a significant enhancement in the pregnancy rate per patient (OR, 1.63; 95% CI, 1.11 to 2.40).

Conclusion

The available evidence suggests that both first-line surgery and ART can be effective DIE treatments with similar fertility outcomes. However, further analysis reveals that excluding studies involving endometriomas significantly alters the understanding of treatment efficacy between surgery and ART for DIE-associated infertility.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=426061, identifier CRD42023426061.

Diagnostic and therapeutic approaches for endometriosis: a patent landscape

OBJECTIVE

The aim of this review is to analyze the patent filings and to systematize the main technological trends in patent protection for the diagnosis and therapeutics for endometriosis. Patent literature has also been explored to identify active inventors and applicants in this field.

METHODOLOGY

Patent search was carried out in the freely accessible patent search databases namely, patentscope using various combinations of the keywords "Endometriosis OR Adenomyosis" AND "Diagnostic OR Therapeutics" were used along with wildcard search queries in the "Title", "Abstract" and "Descriptions" fields.

RESULTS

A patent search revealed 144 patents describing inventions for diagnostic and therapeutic purposes of endometriosis. These patents include 26 patent applications in the diagnostic utility and 116 patent applications under the therapeutic approaches. Out of these 116 patent applications, 43 describe traditional medicines for endometriosis. Two patent applications describe inventions that can fall into both categories.

CONCLUSION

Efforts are being made to improve current diagnostic instruments. Hormonal alteration methods is the most common field of invention, followed by surgical interventions for therapeutics. A general trend of increase in patent application filings has been observed with a slight decrease in recent years.

First experience with the Hugo™ robot-assisted surgery system for endometriosis: A descriptive study

INTRODUCTION

The Medtronic Hugo™ Robot-assisted Surgery (RAS) system was recently approved for clinical use. We explored the safety and feasibility of this system for endometriosis surgery. The primary outcome was safe case completion without major surgical complications (Clavien-Dindo grade ≤2) and no conversion to open surgery or laparoscopy.

MATERIAL AND METHODS

Surgeries for endometriosis performed at the Department of Gynecology, Rigshospitalet, on the Medtronic Hugo™ RAS system were included. Two experienced robotic surgeons performed all surgeries with their usual robotic team. The variables included were patient demographics, peri- and postoperative data, complications and 30-day readmission rate. We used the IDEAL framework 1/2a for surgical innovation in this descriptive study.

RESULTS

The first 12 patients were included. All cases were completed without intraoperative complications or conversion. Four patients experienced Clavien-Dindo grade 1 postoperative complications. No patients were re-admitted within 30 days. Median docking time (17 minutes), console time (87.5 minutes), blood loss (40 mL) and length of hospital stay (1 day) were acceptable compared with previous literature.

CONCLUSIONS

In this pilot study, we found the Medtronic Hugo™ RAS system safe and feasible for robot-assisted surgery for endometriosis. The advent of new robotic systems is welcomed to accelerate the development of technology that will advance surgical care for patients across the globe.

A Case of Rectal Endometriosis Misdiagnosed as Rectal Malignancy on Three Colonoscopies and Biopsies Sharing a Combined Literature Review

Background

Endometriosis involves the intestine, and its clinical manifestations are nonspecific and lack of etiological manifestations. The diagnosis is difficult, which often leads to misdiagnosis. We report a case of endometriosis which was misdiagnosed as intestinal malignant tumor after colonoscopy and three biopsies.

Case Presentation

We reported a 42-year-old woman who went to see a doctor because of anal distension. She was examined by three gastrointestinal endoscopists at different levels in different hospitals and underwent biopsy at the same time. Combined with clinical manifestations, imaging examination, endoscopic examination and pathological examination, she was misdiagnosed as intestinal malignant tumor, and partial intestinal resection was performed according to the surgical principle of malignant tumor.

Conclusion

Although there are advanced gastrointestinal endoscopy and imaging techniques, intestinal endometriosis is still easy to be misdiagnosed. As our case report shows, after three colonoscopy and biopsy, it is still misdiagnosed as intestinal malignant tumor. Further research is needed to improve the ability of preoperative diagnosis, which deserves the attention of gastroenterologists and obstetricians and gynecologists.

Endometriosis: Classification, pathophysiology, and treatment options

The human endometrium is a complex hormone-target tissue consisting of two layers: the lower basalis, and the upper functionalis. The latter of the two goes through a cycle of thickening and shedding without residual scarring or loss of function. This cycle, known as the menstrual cycle, occurs on a monthly basis in most of healthy reproductive-age women. It is, however, associated with a number of reproductive diseases, endometriosis being one of them. Endometriosis is defined as the presence of endometrium at ectopic sites within the peritoneum or, more rarely, other locations outside the abdominal area. It affects around 6-10% of reproductive-age women in the world and causes debilitating pain, heavy menstrual bleeding, pain during penetrative sex, and infertility. The etiology of the disease is not yet fully understood but the generally accepted theory is that the endometriotic lesions originate from viable eutopic endometrial cells that flow back into the peritoneum through the process of retrograde menstruation. Endometriosis is usually classified into four stages: minimal, mild, moderate, and severe, though it is important to note that the presentation of symptoms does not necessarily correspond to the disease progression. The immune system plays an important role in supporting the viability and growth of ectopic endometriotic tissue, all the while promoting chronic inflammation at the lesion sites, which causes prolonged pain. There is no definitive cure for endometriosis, but there are several options for symptom management, including laparoscopy, hormonal therapy, the use of NSAIDs, dietary changes, exercise, and, in cases when all conservative treatments fail, hysterectomy.

Visualisation of microvascular flow in benign uterine disorders: a pilot study of a new diagnostic technique

BACKGROUND

Uterine disorders have clear overlapping symptoms and ultrasound discrimination is not always easy. Accurately measuring vascularity is of diagnostic and prognostic value. Power Doppler is limited to imaging only the larger vessels. Assessment of the microvasculature requires advanced machine settings.

OBJECTIVES

In this pilot study, we aimed to test the feasibility of microvascular flow imaging of benign uterine disorders.

MATERIAL AND METHODS

Two experienced gynaecologists (JH, RL) randomly applied power Doppler and MV-flowTM mode during a single day, in ten patients each visiting the outpatient clinic. Images of eight patients were labelled with a diagnosis by the attending physicians and collected as coded data.

MAIN OUTCOME MEASURES

Microvascular flow images of normal uterine architecture including the fallopian tube, and of benign disorders such as fibroids, adenomyosis, endometriosis and uterine niches were collected. For both Doppler techniques, qualitative descriptive evaluation of the vascular architecture and a quantitative vascular index of fibroids were provided. Finally, we evaluated the effect of the cardiac cycle.

RESULTS

All microvascular flow images showed more distinctive vascular structures than visible on power Doppler. Calculating a vascular index for fibroids on 2D MV-flowTM images was easily performed on-site. During the cardiac cycle a higher vascular index (VI 75.2) is obtained in systole as compared with diastole (VI 44.0).

CONCLUSION

Microvascular flow imaging allowed detailed visualisation of the uterine vascular architecture and is easy to use.

WHAT IS NEW?

Microvascular flow imaging may be of added value for diagnosing uterine disorders, as well as for pre- and post-operative assessment of suited surgical techniques. Yet, validation with histology and clinical outcomes is required.

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.

A Lifelong Impact on Endometriosis: Pathophysiology and Pharmacological Treatment

Endometriosis is a chronic inflammatory disease associated with bothersome symptoms in premenopausal women and is complicated with long-term systemic impacts in the post-menopausal stage. It is generally defined by the presence of endometrial-like tissue outside the uterine cavity, which causes menstrual disorders, chronic pelvic pain, and infertility. Endometriotic lesions can also spread and grow in extra-pelvic sites; the chronic inflammatory status can cause systemic effects, including metabolic disorder, immune dysregulation, and cardiovascular diseases. The uncertain etiologies of endometriosis and their diverse presentations limit the treatment efficacy. High recurrence risk and intolerable side effects result in poor compliance. Current studies for endometriosis have paid attention to the advances in hormonal, neurological, and immunological approaches to the pathophysiology and their potential pharmacological intervention. Here we provide an overview of the lifelong impacts of endometriosis and summarize the updated consensus on therapeutic strategies.

Dienogest May Reduce Estradiol- and Inflammatory Cytokine-Induced Cell Viability and Proliferation and Inhibit the Pathogenesis of Endometriosis: A Cell Culture- and Mouse Model-Based Study

Dienogest (DNG) is a therapeutic medication used in endometriosis treatment. Limited data are available regarding its mechanism of action on endometrial cells. Using in vivo and in vitro models, we investigated whether DNG treatment causes significant biological changes in human endometrial stromal cells (ESCs). The markers related to the pathogenesis of endometriosis in ESCs were evaluated using estradiol, tumor necrosis factor alpha (TNF-α), interleukin 1β (IL-1β), and IL-32, administered alone or in combination with DNG. Implanted endometrial tissues were compared between C57BL/6 mice that did or did not receive DNG treatment by using size measurements and immunohistochemistry. A significant decrease in cell viability, protein kinase B (AKT) phosphorylation, and the expression of p21-activated kinase 4 and vascular endothelial growth factor were observed in ESCs treated with estradiol plus DNG. Cell viability, AKT phosphorylation, and proliferating cell nuclear antigen (PCNA) expression also decreased significantly after TNF-α plus DNG treatment. Treatment with IL-1β or IL-32 plus DNG significantly decreased cell viability or PCNA expression, respectively. The size of the implanted endometrial tissue significantly decreased in mice treated with DNG, accompanied by decreased PCNA expression. Thus, DNG may reduce cell viability and proliferation induced by estradiol, TNF-α, IL-1β, and IL-32, and inhibit the endometriosis pathogenesis by decreasing PCNA expression.

Efficacy of Post-Operative Medication to Prevent Recurrence of Endometrioma: Cyclic Oral Contraceptive (OC) After Gonadotropin-Releasing Hormone (GnRH) Agonist Versus Dienogest

BACKGROUND

There are several medical treatment options for endometrioma. Progestin, especially dienogest, is an effective drug for preventing recurrence of endometrioma after surgery. Additionally, oral contraceptive (OC) use after conservative surgery has been reported to reduce significantly the risk of endometrioma recurrence. The aim of this study was to compare the long-term effects of gonadotropin-releasing hormone (GnRH) agonist followed by OC to those of dienogest alone to prevent recurrence of endometrioma after laparoscopic surgery.

METHODS

A retrospective cohort study was performed on patients who underwent conservative laparoscopic surgery for endometrioma between January 2000 and December 2020, in the Endometriosis Clinic, Department of Gynecology, Samsung Medical Center. A total of 624 patients who received medical treatment at least six months after laparoscopic conservative surgery for endometrioma was included. Among them, 372 patients used OC after GnRH agonist therapy, and 252 patients used dienogest. Within the OC group, 148 used a 21/7 regiment and 224 used a 24/4 regimen. A cumulative endometrioma recurrence curve was presented using the Kaplan-Meier method to compare the recurrence of those groups.

RESULTS

The cumulative recurrence rate of endometrioma for 60 months was 2.08% (n = 4) in the OC after GnRH agonist group and 0.40% (n = 1) in the dienogest group. There was no statistical difference in cumulative recurrence of endometrioma between the two groups. In subgroup analysis, the cumulative recurrence rate of endometrioma over 60 months was 4.21% (n = 2) in the 21/7 OC group and 1.09% (n = 2) in the 24/4 OC group and showed no significant difference.

CONCLUSION

Long-term use of OC after GnRH agonist as well as that of dienogest treatment are effective postoperative medical therapies for preventing endometrioma recurrence. Thus, the choice of regimen can be individualized or used interchangeably depending on patient condition, need for contraception, and compliance with drug therapy.

Is there a role for small molecule metabolite biomarkers in the development of a diagnostic test for endometriosis?

Endometriosis is a disease defined by the presence of benign lesions of endometrial-like glands and stroma outside the endometrial cavity. Affecting an estimated 11.4% of Australian women, symptoms include chronic pelvic pain, dysmenorrhea and infertility. The current gold standard of diagnosis requires an expensive and invasive laparoscopic surgery, resulting in delayed time to treatment. The identification of a non-invasive endometriosis biomarker - a measurable factor correlating with disease presence or activity - has therefore become a priority in endometriosis research, although no biomarker has yet been validated. As small molecule metabolites and lipids have emerged as a potential focus, this review with systematic approach, aims to summarize studies examining metabolomic biomarkers of endometriosis in order to guide future research. EMBASE, PubMed and Web of Science were searched using keywords: lipidomics OR metabolomics OR metabolome AND diagnostic tests OR biomarkers AND endometriosis, and only studies written in English from August 2000 to August 2020 were included. Twenty-nine studies met inclusion and exclusion criteria and were included. These studies identified potential biomarkers in serum, ectopic tissue, eutopic endometrium, peritoneal fluid, follicular fluid, urine, cervical swabs and endometrial fluid. Glycerophospholipids were identified as potential biomarkers in all specimens, except urine and cervical swab specimens. However, no individual molecule or metabolite combination has reached clinical diagnostic utility. Further research using large study populations with robust patient phenotype and specimen characterisation is required if we are to make progress in identifying and validating a non-invasive diagnostic test for endometriosis.

Systematic review of patient-specific pre-operative predictors of pain improvement to endometriosis surgery

Background

Up to 28% of endometriosis patients do not get pain relief from therapeutic laparoscopy but this subgroup is not defined.

Objectives

To identify any prognostic patient-specific factors (such as but not limited to patients’ type or location of endometriosis, sociodemographics and lifestyle) associated with a clinically meaningful reduction in post-surgical pain response to operative laparoscopic surgery for endometriosis.

Search strategy

PubMed, Cochrane and Embase databases were searched from inception to 19 May 2020 without language restrictions. Backward and forward citation tracking was used.

Selection criteria, data collection and analysis:

Cohort studies reporting prognostic factors, along with scores for domains of pain associated with endometriosis before and after surgery, were included. Studies that compared surgeries, or laboratory tests, or outcomes without stratification were excluded. Results were synthesised but variation in study designs and inconsistency of outcome reporting precluded us from doing a meta-analysis.

Main results

Five studies were included. Quality assessment using the Newcastle–Ottawa scale graded three studies as high, one as moderate and one as having a low risk of bias. Four of five included studies separately reported that a relationship exists between more severe endometriosis and stronger pain relief from laparoscopic surgery.

Conclusion

Currently, there are few studies of appropriate quality to answer the research question. We recommend future studies report core outcome sets to enable meta-analysis.

Lay summary

Endometriosis is a painful condition caused by displaced cells from the lining of the womb, causing inflammation and scarring inside the body. It affects 6–10% of women and there is no permanent cure. Medical and laparoscopic surgical treatments are available, but about 28% of patients do not get the hoped-for pain relief after surgery. Currently, there is no way of predicting who gets better and who does not. We systematically searched the world literature to establish who may get better, in order to improve counselling when women choose treatment options. We identified five studies of variable quality showing: More complex disease (in specialist hands) responds better to surgery than less, but more studies needed.

The role of gut and genital microbiota and the estrobolome in endometriosis, infertility and chronic pelvic pain

BACKGROUND

Endometriosis is a chronic, burdensome condition that is historically understudied. Consequently, there is a lack of understanding of the etiology of the disease and its associated symptoms, including infertility and chronic pelvic pain (CPP). Endometriosis development is influenced by estrogen metabolism and inflammation, which are modulated by several factors including the microbiome and the estrobolome (the collection of genes encoding estrogen-metabolizing enzymes in the gut microbiome). Therefore, there is increasing interest in understanding the role of microbiota in endometriosis etiology.

OBJECTIVE AND RATIONALE

To date, there is no cure for endometriosis and treatment options often are ineffective. This manuscript will review the potential relationship between the microbiome and endometriosis, infertility and CPP and highlight the available data on the microbiome in relation to endometriosis and its related symptoms. The overarching goal of this manuscript is to inform future microbiome research that will lead to a deeper understanding of the etiology of the disease and possible diagnostic modalities and treatments. The potential impact of the microbiome on estrogen regulation modulated by the estrobolome, as well as inflammation and other endometriosis-promoting mechanisms within the genital tract, will be reviewed. The methodological limitations of microbiome-related studies will be critically assessed to provide improved guidelines for future microbiome and clinical studies.

SEARCH METHODS

PubMed databases were searched using the following keywords: endometriosis AND microbiome, infertility AND microbiome, pelvic pain AND microbiome, IVF (in-vitro fertilization) AND microbiome, endometriosis AND infertility. Clinical and preclinical animal trials that were eligible for review, and related to microbiome and endometriosis, infertility or CPP were included. All available manuscripts were published in 2002-2021.

OUTCOMES

In total, 28 clinical and 6 animal studies were included in the review. In both human and animal studies, bacteria were enriched in endometriosis groups, although there was no clear consensus on specific microbiota compositions that were associated with endometriosis, and no studies included infertility or CPP with endometriosis. However, bacterial vaginosis-associated bacteria and Lactobacillus depletion in the cervicovaginal microbiome were associated with endometriosis and infertility in the majority (23/28) of studies. Interpretation of endometrial studies is limited owing to a variety of methodological factors, discussed in this review. In addition, metadata outlining antibiotic usage, age, race/ethnicity, menopausal status and timing of sample collection in relation to diagnosis of endometriosis was not consistently reported. Animal studies (6/6) support a bidirectional relationship between the gut microbiota and endometriosis onset and progression.

WIDER IMPLICATIONS

There is evidence that a dysbiotic gut or genital microbiota is associated with multiple gynecologic conditions, with mounting data supporting an association between the microbiome and endometriosis and infertility. These microbiomes likely play a role in the gut-brain axis, which further supports a putative association with the spectrum of symptoms associated with endometriosis, including infertility and CPP. Collectively, this review highlights the demand for more rigorous and transparent methodology and controls, consistency across the field, and inclusion of key demographic and clinical characteristics of disease and comparison participants. Rigorous study designs will allow for a better understanding of the potential role of the microbiome in endometriosis etiology and the relationship to other disorders of the female reproductive tract.

Surgical Techniques to Reduce the Diminished Ovarian Reserve Risk of Endometrial Cyst

AIM: The objective of the study was to report the endometriosis case and surgical technique to reduce the diminished ovarian reserve risk. CASE PRESENTATION: A 32-year-old woman was presented with the lower abdominal pain since 1 year ago, intermittent, and got worse during menstruation. The mobile cystic mass was palpable on the abdomen without pain during palpation. Vaginal examination showed mobile and smooth surface cystic mass was palpable, the upper pole was three fingers below the umbilicus, and lower pole was in line with pubic symphysis. Transvaginal ultrasonography (TVUS) showed uterus and right ovary enlargement; and unilocular cyst with homogenous echo pattern. There was a marked increase in CA-125. Based on International Tumor Analysis, the tumor was classified as B1 unilocular cyst and the malignancy risk index was 600. The patient was diagnosed with endometriosis and laparotomy cystectomy was performed. CONCLUSION: Patient was diagnosed with endometrial cyst and laparotomy cystectomy was performed as treatment. Ovarian cystectomy in infertile women was shown to have comparable ovarian reserve (OR), reduced pain symptoms, and increased conception among infertile patients.

A narrative review of functional outcomes following nerve-sparing surgery for deeply infiltrating endometriosis

Endometriosis negatively impacts the lives of countless women around the world. When medical management fails to improve the quality of life for women with either previously confirmed or suspected endometriosis often a decision must be made whether or not to proceed with surgery. When deeply infiltrating disease is diagnosed either clinically or by imaging studies often medical management alone will not suffice without excisional surgery. Surgery for endometriosis, especially deeply infiltrating disease, is not without risks. Aside from common risks of surgery endometriosis may also involve pelvic nerves, which can be hard to recognize to the untrained eye. Identification of pelvic nerves commonly encountered during endometriosis surgery is paramount to avoid inadvertent injury to optimize function outcomes. Injury to pelvic nerves can lead to urinary retention, constipation, sexual dysfunction, and refractory pain. However, nerve-sparing surgery for endometriosis has been proven to mitigate these complications and enhance recovery following surgery. Here we review the benefits of nerve-sparing surgery for deeply infiltrating disease.

Appropriate surgical management of ovarian endometrioma: excision or drainage?

Endometriosis negatively impacts the lives of countless women around the world. When medical management fails to improve quality of life often women are left making a decision whether or not to proceed with surgery. With endometriomas, patient's surgical options include complete surgical removal or drainage via laparoscopy. Here, we review the literature to discuss both techniques, excision and drainage of endometriomas, and what the research supports for endometrioma management.

Superior hypogastric plexus block as an effective treatment method for endometriosis-related chronic pelvic pain: an open-label pilot clinical trial

We aimed to investigate the effect of superior hypogastric plexus (SHP) block on pain relief and quality of life of patients with refractory endometriosis. Sixteen patients with refractory endometriosis underwent SHP block. The outcome measures included visual analogue scale (VAS) for chronic pelvic pain, VAS for dysmenorrhoea, and VAS for dyspareunia. The short-form endometriosis health profile (EHP-5) was used to measure quality of life. All the outcome measures were evaluated at weeks 0, 1, 4, 12 and 24. The mean baseline VAS scores significantly improved after the SHP block (p < .001 for all). The mean overall EHP-5 score also significantly improved from 54.3 ± 18.2 to 24.6 ± 13.3 (p < .001). The positive effects of SHP were not diminished over time. No serious adverse effect was noticed in any of the patients. Preliminary results suggest that SHP block could be used as an effective method in pain control and improvement of quality of life in refractory endometriosis.IMPACT STATEMENTWhat is already known on this subject? Safety and efficacy of SHP block in the treatment of CPP has been revealed in earlier investigations. However, the efficacy of SHP block for pain management in patients with refractory endometriosis has not been investigated in earlier investigations.What do the results of this study add? SHP block is an effective method for pain control and improvement of quality of life in patients with refractory endometriosis. The positive effects of this treatment did not diminish over 24-weeks follow-up of the study. No serious adverse effect was noticed in any of the patients.What are the implications of these findings for clinical practice and/or further research? Preliminary results suggest that SHP block could be used safely and effectively for controlling pain and improvement of quality of life in patients with refractory endometriosis.

Safety and Effectiveness of Dienogest (Visanne®) for Treatment of Endometriosis: A Large Prospective Cohort Study

Dienogest (DNG) is a progestin with highly selective progesterone activity and known to be effective in the treatment of endometriosis. This prospective cohort study in patients who had been treated with DNG 2 mg (Visanne^®) for endometriosis was conducted to assess the safety and effectiveness of DNG in a large Korean cohort. This study included 3356 patients with endometriosis from 73 centers in Korea. All patients were treated with DNG 2 mg daily and were followed up for at least 6 months after initial visit. Any adverse events were recorded including severity, onset/closing date, outcomes, treatments, and the causality with DNG. Effectiveness of DNG was measured by changes in visual analogue scale (VAS) from baseline at the end of follow-up. The mean age of the subjects was 34.96 years, and the mean duration of treatment was 285.44 days. Incidence of adverse drug reaction (ADR) was 13.27% (413/3113). The most frequently reported ADR were "abnormal uterine bleeding" 4.14% (129/3113), "increased weight" 2.57% (80/3113), and "headache" 1.22% (38/3113). The number of patients (%) with favorable bleeding patterns was observed to increase as the duration of treatment increases. Amenorrhea was observed in 29.63%, 41.25%, 46.26%, and 53.20% of patients at 3 months, 6 months, 12 months, and more than 12 months follow-up period, respectively. The mean (±SD) VAS change from baseline at the last follow-up visit was -28.19 ± 28.39 mm (P value < 0.0001). This large cohort study confirms, in routine clinical practice, that DNG is safe and effective for treatment of endometriosis.

Epidemiological aspects of the outcomes from the treatment of endometriosis: Experience from two different geographical areas

The purpose of the present study was two-fold: First to review the epidemiological aspects of the experience on the surgical outcomes via laparotomy or laparoscopy, as regards endometriosis from two different academic institutions and, second, to illustrate potential differences in two different geographical areas, New Haven (US) and Greece. This retrospective study included 1,200 patients (15–80 years of age) treated via laparotomy or laparoscopy, at two different institutions, for endometriosis, between 1990 and 2017. Data were collected and analyzed from medical and pathological reports. The statistical methods used included the Student's t-test and χ² test, as well as the Mann-Whitney U test. A total of 600 women from Yale University and 600 women from Greece participated in this study. Endometrioma was confirmed in 359 (29.9%) cases. Women were compatible in terms of the site of endometriomas. Left-sided cysts were observed (P<0.001) significantly more often compared with right-sided cysts in both groups. The two groups of patients had similar rates of endometriosis stages. A statistically significant positive association (P<0.001) was found for the co-existence of benign gynecological tumors (apart from endometrioma), endometriosis-associated ovarian cancer and for post-menopausal endometriosis in women with endometriosis from Greece. Moreover, similar results were observed as regards endometriosis following in utero exposure to diethylstilbestrol (DES), non-Hodgkin's lymphoma, endometriosis-associated Lyme disease, human immuno-deficiency virus (HIV), melanoma and endometriosis in adolescents, between the two groups. To conclude, the two populations exhibited similar results as regards the surgical outcomes of endometriosis laparoscopic or open surgery. Endometriosis represents a multifactorial entity that depends on complex interactions of hormonal, genetic, immunological and environmental factors. Gynecologists should be aware that there is an association between endometriosis and cancerous diseases. It is thus suggested that the presence of comorbidities in women with endometriosis.

Adverse effects of endometriosis on pregnancy: a case-control study

BACKGROUND

Endometriosis is a common disease occurring in 1-2% of all women of reproductive age. Although there is increasing evidence on the association between endometriosis and adverse perinatal outcomes, little is known about the effect of pre-pregnancy treatments for endometriosis on subsequent perinatal outcomes. Thus, this study aimed to evaluate maternal and neonatal outcomes in pregnant women with endometriosis and to investigate whether pre-pregnancy surgical treatment would affect these outcomes.

METHODS

This case-control study included 2769 patients who gave birth at Nagoya University Hospital located in Japan between 2010 and 2017. Maternal and neonatal outcomes were compared between the endometriosis group (n = 80) and the control group (n = 2689). The endometriosis group was further divided into two groups: patients with a history of surgical treatment such as cystectomy for ovarian endometriosis, ablation or excision of endometriotic implants, or adhesiolysis (surgical treatment group, n = 49) and those treated with only medications or without any treatment (non-surgical treatment group, n = 31).

RESULTS

In the univariate analysis, placenta previa and postpartum hemorrhage were significantly increased in the endometriosis group compared to the control group (12.5% vs. 4.1%, p <  0.01 and 27.5% vs. 18.2%, p = 0.04, respectively). In the multivariate analysis, endometriosis significantly increased the odds ratio (OR) for placenta previa (adjusted OR, 3.19; 95% confidence interval [CI], 1.56-6.50, p <  0.01) but not for postpartum hemorrhage (adjusted OR, 1.14; 95% CI, 0.66-1.98, p = 0.64). Other maternal and neonatal outcomes were similar between the two groups. In patients with endometriosis, patients in the surgical treatment group were significantly associated with an increased risk of placenta previa (OR. 4.62; 95% CI, 2.11-10.10, p <  0.01); however, patients in the non-surgical treatment group were not associated with a high risk (OR, 1.63; 95% CI, 0.19-6.59, p = 0.36). Additionally, other maternal and neonatal outcomes were similar between the two groups.

CONCLUSION

Women who have had surgical treatment for their endometriosis appear to have a higher risk for placenta previa. This may be due to the more severe stage of endometriosis often found in these patients. However, clinicians should be alert to this potential increased risk and manage these patients accordingly.

Retrospective evaluation of pathological results among women with ovarian endometriomas versus teratomas

The coexistence of endometrioma with dermoid cyst of the ovaries is an unusual entity, although they are both common and benign gynecological tumors. The present study aimed to investigate the association between ovarian dermoid cyst (teratoma) and endometrioma. We retrospectively, included 315 women with endometrioma and 172 with ovarian teratoma. Data were collected from medical and pathological reports from two different areas between 1995 and 2018. The mean age of cases with endometrioma was similar (35.8±7.2 years) to patients with ovarian teratoma (34.2±6.8 years). Considering the types of dermoid cysts, the observed proportion of mature type was 168/172 (98%), the immature type was 4/172 (2%) and struma ovarii was14/172 (8.1%) respectively. Endometrioma was significantly more frequent in the left ovary [174/266 (65.4%)] than in the right ovary [92/266 (34.6%)], P<0.001. By contrast, ovarian teratoma were predominant in the right ovary, 98/172 (60.6%), compared to the left side, 56/172 (32.5%), P<0.001. Regarding the size of the masses, we detected an inverse distribution between the two groups. Thirteen women were detected with ovarian teratoma and endometriosis, with 6 cases being in the same ovary. Our results indicate a left lateral predispostion of endometrioma and a right of ovarian teratoma and suggest that the pathogenesis between these conditions is different. The coexistence of endometriosis with dermoid cyst of the ovary, presents a challenge to the physicians and the investigators. Further research is required to establish the relationship between endometriosis and ovarian teratoma.

Endometriosis

Endometriosis is a common inflammatory disease characterized by the presence of tissue outside the uterus that resembles endometrium, mainly on pelvic organs and tissues. It affects ~5-10% of women in their reproductive years - translating to 176 million women worldwide - and is associated with pelvic pain and infertility. Diagnosis is reliably established only through surgical visualization with histological verification, although ovarian endometrioma and deep nodular forms of disease can be detected through ultrasonography and MRI. Retrograde menstruation is regarded as an important origin of the endometrial deposits, but other factors are involved, including a favourable endocrine and metabolic environment, epithelial-mesenchymal transition and altered immunity and inflammatory responses in genetically susceptible women. Current treatments are dictated by the primary indication (infertility or pelvic pain) and are limited to surgery and hormonal treatments and analgesics with many adverse effects that rarely provide long-term relief. Endometriosis substantially affects the quality of life of women and their families and imposes costs on society similar to those of other chronic conditions such as type 2 diabetes mellitus, Crohn's disease and rheumatoid arthritis. Future research must focus on understanding the pathogenesis, identifying disease subtypes, developing non-invasive diagnostic methods and targeting non-hormonal treatments that are acceptable to women who wish to conceive.