Endometriosis education in schools: A New Zealand model examining the impact of an education program in schools on early recognition of symptoms suggesting endometriosis

Adolescent dysmenorrhoea in general practice: tensions and uncertainties

This Perspectives article reflects on findings from our systematic review about adolescent dysmenorrhoea Q, drawing on sociology of diagnosis theory. We consider tensions and uncertainties between presentation with symptoms of dysmenorrhoea and processes of symptom categorisation and diagnosis in adolescents, tracing these through research and clinical guidance, considering possible implications for clinical practice. We argue that challenges in distinguishing between primary and secondary dysmenorrhoea in research translate into challenges in differentiation in clinical practice. We argue that framing this distinction as clear cut and straightforward belies the well-documented challenges in diagnosis of endometriosis, and that not recognising uncertainty and complexity inherent in this task may benefit neither clinicians nor patients.

Does Menstrual Health and Endometriosis Education Affect Knowledge Among Middle and Secondary School Students? A Cluster-Randomised Controlled Trial

OBJECTIVES

To evaluate whether endometriosis and menstrual health education improves knowledge and attitudes among adolescents and is acceptable.

METHODS

We conducted a cluster-randomised controlled trial in a Canadian school district. Eligible classes were grades 8-12, co-educational, and English. Classes were randomly assigned either to a 60-minute virtual menstrual health and endometriosis education program before (intervention) or after (waitlist control) primary data collection. The primary outcome was change in endometriosis knowledge from baseline to follow-up (∼4 weeks later, 6-item questionnaire). Secondary outcomes were changes in confidence in endometriosis knowledge, prioritisation of menstrual health knowledge, and comfort in discussing menstrual health, as well as intervention acceptability. The sexual health educator and statistician were masked.

RESULTS

In April and May 2021, 2 intervention classes and 2 control classes completed the study. In total, 71 students enrolled, and 48 were present on both baseline and follow-up days. Mean age was 15.7 ± 1.6 years, 55% identified as non-White ethnicities, and 53% were female. The knowledge score increased by 1.86 points in the intervention classes compared with 0.30 points in the control classes, with an estimated mean difference of 1.56 (95% CI 1.12-2.00). The intervention classes showed increased confidence in endometriosis knowledge, prioritisation of menstrual health knowledge, and comfort in discussing menstrual health, compared to the control classes. The mean acceptability index was 80 (SD = 10) in the intervention classes and 70 (SD = 20) in the control classes.

CONCLUSIONS

A brief menstrual health and endometriosis education program improved knowledge and attitudes among adolescents, who considered the program acceptable.

Pelvic pain education - A short review on pelvic pain and endometriosis educational programs for adolescents

Persistent pelvic pain is a significant healthcare concern among adolescents; however adolescents often have poor health literacy regarding their pain. Current school curricula fail to specifically address pelvic pain and management strategies. This review aims to summarise current pelvic pain education programs in Australian and New Zealand schools. These programs have successfully strengthened the understanding of the psychosocial impact of periods and pelvic pain, instilled greater confidence in managing persistent pain and have allowed for prompt detection and treatment of pelvic pain in adolescents. An outcomes-driven, collaborative, and coordinated approach is needed to improve pelvic health educational interventions for adolescents.

Are women with endometriosis more likely to experience reduced physical performance compared to women without the condition?

Background

Endometriosis is a condition of the female reproductive system associated with pelvic pain. Chronic pain can affect physical performance by limiting the functional activities, thus, it is hypothesized that women with endometriosis may also present decreased functional capacity, decreased strength, and mobility. The objective of this study is to compare physical performance in women with and without endometriosis.

Methods

This is a cross-sectional study composed of 115 women equally divided into two groups: the endometriosis group (EG), composed of women with a confirmed diagnosis of the disease by magnetic resonance imaging, and the comparator group (CG), consisting of women without suspicion of the disease. Physical performance (dependent variable) was assessed using hand dynamometry, the 6-min walk test (6MWT), gait speed, and the chair stands test. CG participants performed the tests during the luteal phase of the menstrual cycle. Descriptive statistics, unpaired t-tests, and chi-square tests were used to describe and compare the groups. Multiple linear regression tested the associations adjusted for covariates (age, income, education, age at menarche, and body mass index).

Results

The EG had worse gait speed (mean difference: -0.11; 95% CI: [-0.18 to -0.04]), weaker grip strength (mean difference: -3.32; 95% CI: [-5.30 to -1.33]), shorter distance covered in the 6MWT (mean difference: -83.46; 95% CI: [-121.38 to -45.53]), and a lower number of repetitions in the chair stands test (mean difference: -8.44; 95% CI: [-10.64 to -6.25]) than the CG, even after adjusting for covariates.

Conclusion

Grip strength, lower limb strength, mobility, and functional capacity were worse in women diagnosed with endometriosis. Women with endometriosis should be encouraged to engage in physical exercise, adopt healthy lifestyle habits, and participate in rehabilitation activities to control pain, with the aim of reducing functional impairments.

Living With Endometriosis: A Reflexive Thematic Analysis Examining Women's Experiences With the Irish Healthcare Services

Endometriosis is an incurable chronic condition associated with debilitating pain and subfertility, affecting 1 in 10 women. The current study aims to explore the perceptions and experiences of women with endometriosis regarding the diagnosis, support and treatment options available in Ireland. It will further determine whether additional supports or improvements are needed to care well and effectively for women with this disease in the Irish healthcare system. A qualitative study design was deemed most suitable. Twenty participants, women aged 18 and over with a diagnosis of endometriosis and experience of the Irish healthcare system, were recruited through purposeful sampling to complete semi-structured, one-to-one online interviews. Data was analysed using reflexive thematic analysis, and five themes were identified: 'dismissive attitudes normalising severe pain', 'inadequate health system', 'the impact of delayed diagnoses', 'lack of education and awareness' and 'navigating ignorance, taboo and societal views'. Insights into the experiences and needs of women diagnosed with endometriosis in Ireland were gained, and we discuss the implications of our findings for Irish healthcare services with reference to feminist health equity and recent national action plans. We propose a series of recommendations for patient-centred care models including increased access to training and education, as well as support for longer-term chronic pain management.

Deep Infiltrating Endometriosis in Adolescence: Early Diagnosis and Possible Prevention of Disease Progression

Endometriosis has a prevalence of 10% worldwide in premenopausal women. Probably, endometriosis begins early in the life of young girls, and it is commonly diagnosed later in life. The prevalence of deep infiltrating endometriosis (DIE) in adolescence is currently unknown due to diagnostic limits and underestimation of clinical symptoms. Dysmenorrhea is a common symptom in adolescents affected by DIE, often accompanied by dyspareunia and chronic acyclic pelvic pain. Ultrasonography-either performed transabdominal, transvaginal or transrectal-should be considered the first-line imaging technique despite the potential for missed diagnosis due to early-stage disease. Magnetic resonance imaging should be preferred in the case of virgo patients or when ultrasonographic exam is not accepted. Diagnostic laparoscopy is deemed acceptable in the case of suspected DIE not responding to conventional hormonal therapy. An early medical and/or surgical treatment may reduce disease progression with an immediate improvement in quality of life and fertility, but at the same time, painful symptoms may persist or even recur due to the surgery itself. The aim of this narrative review is to report the prevalence of DIE in adolescents, describe the pathogenetic theories and discuss the management in adolescent women, including the challenging road to diagnosis and the treatment alternatives.

Improving the diagnosis of endometriosis in Asia-Pacific: Consensus from the Asia-Pacific Endometriosis Expert Panel for Endometriosis

Endometriosis should be diagnosed as early as possible in the continuum of care; but substantial delays of approximately 6-8 years between symptom onset and endometriosis diagnosis have been widely reported. With the purpose of improving the prompt diagnosis of endometriosis, the Asia-Pacific Endometriosis Expert Panel (APEX) sought to address the reasons for diagnostic delays across the region, and formulate a multi-pronged approach to overcoming these challenges. In the first instance, clinical diagnosis is preferable to surgical diagnosis, in order to facilitate earlier empirical treatment and minimize the negative sequelae of undiagnosed/untreated disease. There should be a high clinical index of suspicion in women presenting with cyclical symptoms, including those involving extrapelvic organs. Diagnostic delays in Asia-Pacific countries are attributable to a variety of patient, physician, and healthcare factors, including poor awareness, normalization/trivialization of pain, individual/cultural attitudes toward menstruation, default use of symptom-suppressing treatments, misdiagnosis, and a lack of diagnostic resourcing or adequate referral pathways in some areas. Suggested initiatives to reduce diagnostic delays are geared toward improving public awareness, improving clinical diagnostic skills, streamlining multidisciplinary care pathways for timely referral, updating and implementing diagnostic guidelines, lobbying policymakers and insurance companies for endometriosis support, and increasing efforts to bridge data gaps and perform further research in this field. Formulating specific action plans and gathering traction are the responsibility of individual countries within local parameters. The APEX group advocates for any initiatives and policies that support the unmet needs of women with endometriosis, to improve patient experience and outcomes.

Patient experiences of being advised by a healthcare professional to get pregnant to manage or treat endometriosis: a cross-sectional study

BACKGROUND

There is a lack of evidence that pregnancy reduces endometriotic lesions or symptoms, however studies indicate that people with endometriosis are commonly advised to get pregnant to manage or treat endometriosis. This study sought to examine the impact of this advice on patients with endometriosis when the advice was provided by healthcare professionals.

METHODS

The Endometriosis Patient Experience Survey was a self-reported, community-based, cross-sectional online survey of people who had been medically diagnosed with endometriosis. Descriptive statistics were used to analyse the quantitative survey data and thematic analysis was undertaken for the qualitative survey data.

RESULTS

1892 participants had received the advice to get pregnant or have a baby to manage or treat their endometriosis, with 89.4% of participants receiving this advice from healthcare professionals. In exploring the qualitative data, seven themes were contextualised relating to the impact of this advice in terms of health literacy, accepting the advice, rejecting the advice, major life decisions, healthcare interactions, mental health and relationships.

CONCLUSIONS

This study demonstrates profound and often negative patient impacts of the advice from healthcare professionals to get pregnant to manage or treat endometriosis. Impacts ranged from planning for pregnancy, hastening the making of major life decisions, eroding trust with healthcare professionals, worsening mental health and straining relationships. Providing evidence-based information on the treatment and management of endometriosis is essential. Pregnancy or having a baby should not be suggested as a treatment for endometriosis and the provision of this advice by healthcare professionals can have negative impacts on those who receive it.

Validation of an adolescent ovulatory menstrual health literacy questionnaire

This study aimed to face validate an adolescent ovulatory menstrual (OM) health literacy questionnaire and to measure reliability by test-retest. Draft questions from an earlier content validation were adjusted following face validity assessment with 28 adolescents. Test-retest reliability was assessed by 89 adolescents aged 14-18 years over a two-week period across four school sites. The mean levels of agreement recorded from the critical, interactive and functional health literacy domains were 83%, 74% and 68%, respectively. There were 44 out of 74 items with Kappa statistics >0.40. The questionnaire has confirmed face validity and adequate test-retest reliability for assessing adolescent OM health literacy.

Dismissal informs the priorities of endometriosis patients in New Zealand

Introduction

Endometriosis is a common condition with average delays to diagnosis in New Zealand of almost 9 years.

Methods

In total, 50 endometriosis patients participated in anonymous, asynchronous, online group discussions about their priorities, and their experiences with the development of symptoms, seeking a diagnosis, and receiving appropriate treatment.

Results

Higher subsidy of care was the top change endometriosis patients wanted, followed by more research funding. When asked to choose whether research should be focused on improving diagnosis or improving treatment methods, the results were evenly split. Within this cohort, patients highlighted that they did not know the difference between normal menstrual discomfort and pathological endometriotic pain. If, upon seeking help, medical practitioners classified their symptoms as "normal," these dismissals could instill doubt in patients, which made it more difficult for them to continue to seek a diagnosis and effective treatments. Patients who did not express dismissal had a significantly shorter delay from symptom onset to diagnosis of 4.6 ± 3.4 years vs. 9.0 ± 5.2 years.

Conclusion

Doubt is a frequent experience for endometriosis patients in New Zealand, which was reinforced by some medical practitioners who were dismissive of their pain and thus prolonged the patient's delay to diagnosis.

Mixed Method Evaluation of My Vital Cycles®: A Holistic School-Based Ovulatory Menstrual Health Literacy Program

There is a high prevalence of ovulatory menstrual (OM) dysfunctions among adolescents, and their menstrual health literacy is poor. The OM cycle can be used as a personal health monitor provided that the skills to understand it are correctly taught. My Vital Cycles®, a holistic school-based OM health literacy program, was trialed with a Grade 9 cohort in one single-sex school in Western Australia using the Health Promoting School framework. A validated OM health literacy questionnaire was administered pre- and post-program with 94 participants. Functional OM health literacy improved overall, with 15 out of 20 items showing improvement post-program (p < 0.05). In addition, 19 out of 53 items for interactive OM health literacy, and 18 out of 25 items for critical OM health literacy improved (p < 0.05). The improvement in mood concerns (p = 0.002) was unexpected. Thematic analysis of three focus groups of 18 girls revealed four themes of increasing comfort levels; finding the program informative; inclusion of non-teaching support such as healthcare professionals; and suggestions for future refinements. Overall, this Western Australian PhD project which developed and trialed My Vital Cycles® improved OM health literacy and was positively received. Future research possibilities include understanding the program's impact on mental health and further trials in co-educational settings; amongst different populations; and with extended post-program testing.

Disease Burden of Dysmenorrhea: Impact on Life Course Potential

Dysmenorrhea is the most common gynecologic condition among the female population and has a significant impact on life course potential. It has a widespread impact on a female's mental and physical well-being, with longstanding impairments on quality of life, personal relationships, and education and career attainment. Furthermore, untreated dysmenorrhea can lead to hyperalgesic priming, which predisposes to chronic pelvic pain. Primary dysmenorrhea is pain in the lower abdomen that occurs before or during menses and in the absence of pelvic pathology. One possible mechanism is endometrial inflammation and increased prostaglandin release, resulting in painful uterine contractions. Dysmenorrhea may also occur secondary to pelvic pathology, such as endometriosis, adenomyosis or due to cyclic exacerbation of non-gynecologic pain conditions. A thorough patient evaluation is essential to differentiate between potential causes and guide management. Treatment must be tailored to individual patient symptoms. Pharmacologic management with non-steroidal anti-inflammatory medications and/or combined hormonal contraceptives is most common. Heat therapy, exercise, vitamins and dietary supplements have limited evidence and can be offered for patients seeking non-pharmacologic adjunctive or alternative options. Greater awareness for both health-care providers and patients allows for early intervention to reduce impact on quality of life and life course potential.

Living with Endometriosis: A Narrative Analysis of the Experiences of Kenyan Women

Despite the high global prevalence of endometriosis, little is known about the experiences of women living with the disease in low- and middle-income contexts, including in Kenya and other countries across sub-Saharan Africa. This study captures the perspectives and recommendations of Kenyan women living with endometriosis through written narratives about the impact of the disease on their daily lives and their journeys through diagnosis and treatment. Thirty-seven women between the ages of 22 and 48 were recruited from an endometriosis support group in Nairobi and Kiambu, Kenya (February-March of 2022) in partnership with the Endo Sisters East Africa Foundation. Narrative data (written anonymous stories submitted through Qualtrics) were analyzed using a deductive thematic analysis methodology. Their stories revealed three themes related to their shared experiences with endometriosis: (1) stigma and disruption to quality of life, (2) barriers to acceptable healthcare, and (3) reliance on self-efficacy and social support to cope with the disease. These findings demonstrate a clear need for improved social awareness of endometriosis in Kenya and the establishment of clear, effective, and supportive pathways, with trained, geographically and financially accessible health care providers, for endometriosis diagnosis and treatment.

Evaluation of a web-based resource to improve menstrual health literacy and self-management in young women

OBJECTIVE

Menstrual cycle-related conditions, such as dysmenorrhea and heavy bleeding, are common amongst those under 25 years. Despite having significant impact on work, education, and social activities, most do not seek medical advice, preferring to self-manage their symptoms. We aimed to determine if access to a web-based resource was a feasible and acceptable method for improving menstrual health literacy and encouraging health seeking behavior.

METHODS

People were eligible to participate if they were currently living in Australia, aged 14-25 years, and had menstruated for at least 12 months. Access to the resource, comprising evidence-based information on the menstrual cycle, the Period ImPact and Pain Assessment (PIPPA) tool, and guidance on self-management options, was provided for three menstrual cycles.

RESULTS

Seventy-five participants with a mean age of 20.4 years were enrolled with 56 (75%) providing pre and post measures. Recruitment rate and retention rates met pre-specified criteria for feasibility. Eighty five percent of the participants reported the web-based resource was easy to use, and 90% reported they found the information provided 'very helpful'. Just under half (48%) reported the resource changed what they thought was a 'normal' period. Forty-three percent visited their doctor regarding their menstrual symptoms during the study period, with 84% indicating that they made the appointment due to the resource; over half (56%) who visited their doctor received a referral to a gynecologist.

CONCLUSION

Access to a web-based resource on menstrual health literacy was found to be acceptable and feasible to young people and may encourage health-seeking behavior.

Managing endometriosis: a cross-sectional survey of women in Australia

PURPOSE

Endometriosis is a chronic, inflammatory condition. The aim was to describe the self-reported disease characteristics and factors associated with the use of different treatment modalities among women with surgically diagnosed endometriosis.

METHOD

A cross-sectional online survey featuring 58 fixed-response items measuring disease characteristics, self-efficacy, health service usage, and treatment approaches was conducted. Logistic regression was used to explore the factors associated with different treatment modalities.

RESULTS

Complete data were available from 620 respondents. Average delay to diagnosis was 6.4 years. Despite medical and surgical intervention, 65.8% reported dysmenorrhea and 61.1% reported dyspareunia, and 82.7% reported chronic pelvic pain in the last 3 months. Respondents had consulted an average of three different health practitioner specialties in the previous 12 months for their endometriosis.

DISCUSSION

A chronic disease management plan (CDMP) may be a useful mechanism to coordinate multidisciplinary care among women who experience ongoing symptoms.

An Aotearoa New Zealand survey of the impact and diagnostic delay for endometriosis and chronic pelvic pain

Chronic pelvic pain (CPP) causes important negative effects on quality of life. Endometriosis is the most common cause of CPP in females, and diagnostic delay is over six years internationally. Data remain scarce for CPP impact or diagnostic delay in Aotearoa New Zealand. This study used an online survey to explore the impact of CPP on various life domains for those aged over 18. Additionally, for those with an endometriosis diagnosis, diagnostic delay and factors affecting this over time were explored. There were 800 respondent (620 with self-reported endometriosis). CPP symptoms, irrespective of final diagnosis, started prior to age 20 and negatively impacted multiple life domains including employment, education, and relationships. Mean diagnostic delay for those with endometriosis was 8.7 years, including 2.9 years between symptom onset and first presentation and 5.8 years between first presentation and diagnosis. Five doctors on average were seen prior to diagnosis. However, there was a reduction in the interval between first presentation and diagnosis over time, from 8.4 years for those presenting before 2005, to two years for those presenting after 2012. While diagnostic delay is decreasing, CPP, irrespective of aetiology, continues to have a significant negative impact on the lives of those affected.

Burden of Endometriosis: Infertility, Comorbidities, and Healthcare Resource Utilization

The goal of our study was to evaluate the burden of endometriosis in the community by comparing healthcare resource utilization, total direct medical costs, infertility, and comorbidity rates of women with and without a diagnosis of endometriosis. A retrospective case–control study was performed using the databases of a 2.1 million-member nationwide healthcare plan. The study population included women aged 15–55 years enrolled in the healthcare plan. Women with a diagnosis (ICD-9) of endometriosis were compared to controls without diagnosed endometriosis. Women were individually matched (1:4) on age and residence area. Patient characteristics were described, including infertility, comorbidities, and annual healthcare resource utilization. Total direct medical costs were analyzed in a generalized linear model adjusting for age. Women with endometriosis (n = 6146, mean age ± SD: 40.4 ± 8.0 y) were significantly more likely than controls (n = 24,572) to have a lower BMI and a higher socioeconomic status. After adjusting for BMI and socioeconomic status, endometriosis was significantly associated with infertility (OR = 3.3; 95% CI 3.1–3.5), chronic comorbidities, higher utilization of healthcare services (hospitalization: OR = 2.3; 95% CI 2.1–2.5), pain medications, and antidepressants. Women aged 15–19 y with endometriosis had substantially higher utilization of primary care visits (57.7% vs. 14.4%) and oral contraceptive use (76.9% vs. 9.6%). Direct medical costs associated with endometriosis were higher than those for controls (OR = 1.75; 95% CI 1.69–1.85). Endometriosis is associated with a high burden of comorbidities, increased healthcare resource utilization, and excess costs, particularly for younger patients whose healthcare needs may differ widely from the older population.

Teachers' Perceptions and Experiences of Menstrual Cycle Education and Support in UK Schools

The purpose of this study was 2-fold, to (1) explore current education provision in UK schools including barriers to menstrual cycle education and (2) assess the perceived support teachers received to deliver menstrual cycle education. Seven hundred eighty-nine teachers (91% female) from all stages of school education in England (48%), Scotland (24%), Wales (22%) and Northern Ireland (6%) completed an online survey. The survey captured information on menstrual education in schools, teacher's knowledge and confidence of the menstrual cycle, support provided to teachers, provision of menstrual products in school and perceived impact of the menstrual cycle on young people in school. Four hundred ninety-eight teachers reported lessons were provided on the menstrual cycle (63%), predominantly delivered within personal, social, health and economic or science subjects, with over half of the lessons focusing on the biology (56%) or provision of menstrual products (40%) rather than lived experiences (14%). Teachers perceived the menstrual cycle affected participation in PE (88%), pupil confidence (88%), school attendance (82%) and attitude and behavior (82%). Overall, 80% of teachers felt receiving training would be beneficial to improve menstrual education. The results highlight education is scientifically focused, with less education on management of symptoms or lived experiences. Teachers also perceive the menstrual cycle to influence multiple aspects of school attendance and personal performance. There is a need to address menstrual education provided in schools across the UK to help empower girls to manage their menstrual cycle, preventing a negative impact on health and school performance.

The Menstrual Disorder of Teenagers (MDOT) Study No. 2: Period ImPact and Pain Assessment (PIPPA) Tool Validation in a Large Population-Based Cross-Sectional Study of Australian Teenagers

STUDY OBJECTIVE

To validate the Period ImPact and Pain Assessment (PIPPA) self-screening tool for menstrual disturbance in teenagers.

DESIGN

Cross-sectional study.

SETTING

Three senior high schools in the Australian Capital Territory (ACT), Australia.

PARTICIPANTS

A total of 1066 girls between 15 and 19 years of age.

INTERVENTIONS AND MAIN OUTCOME MEASURES

A quantitative paper survey collected self-reports of menstrual bleeding patterns, typical and atypical symptoms, morbidities, and interference with daily activities. Multiple correspondence analysis was used to examine associations between PIPPA questions. Generalized linear models compared total score and subscores by validation criteria: pain, school absence, and body mass index (BMI). Receiver operating characteristic curves were used to evaluate the predictiveness of menstrual disturbance indicators by total PIPPA score.

RESULTS

Reports of pain, interference, and concern within the PIPPA items and between both the MDOT and PIPPA questionnaires were significantly correlated (P < .0001). The indicator "missing school" was highly associated (P < .0001) with pain and interference. Obesity (BMI ≥30) was associated with higher PIPPA scores, as was underweight (BMI≤18.4). Where 0 = no disturbance, 5 = high disturbance, aggregated PIPPA scores found 75% scoring 0-2 (out of 5) and 25% scoring 3-5 (257/1037). High scores of 4 or 5 (out of 5) were 7% (72/1037) and 3.7% (38/1037), respectively.

CONCLUSION

PIPPA is a valid screening tool for pain-related menstrual disturbance that affects functioning in young women. PIPPA subdomains of pain/interference have good validity relative to indicators of pain and interference and are responsive to age, BMI, and school absence differences.

Prevalence and Impact of Dysmenorrhea Among University Students in Ireland

OBJECTIVE

Primary dysmenorrhea (PD), or painful menstruation, is a common gynecological condition that can cause intense pain and functional disability in women of reproductive age. As a nonmalignant condition, PD is relatively understudied and poorly managed. The purpose of this study was to estimate the prevalence and impact of PD among third-level students in Ireland.

DESIGN

A cross-sectional observational design was used.

METHODS

Students (n = 892; age range = 18-45 years) completed an online survey on menstrual pain characteristics, pain management strategies, pain interference, and pain catastrophizing.

RESULTS

The prevalence of PD was 91.5% (95% confidence interval = 89.67-93.33). Nonpharmacological management strategies were most popular (95.1%); of these, heat application (79%), rest (60.4%), hot shower/bath (40.9%), and exercise (25.7%) were most common. Perceived effectiveness of these methods varied between participants. Analgesic use was also common (79.5%); of these, paracetamol was most used (60.5%) despite limited perceived effectiveness. Pain catastrophizing was a significant predictor of variance in both pain intensity and pain interference scores such that those with higher pain catastrophizing scores reported more intense pain and greater interference with daily activities and academic demands.

CONCLUSIONS

This article presents the first investigation into PD among third-level students in Ireland. Poorly managed menstrual pain may impact functional ability across several domains. Future research should focus on improving menstrual pain management education and support and promoting menstrual health literacy for women affected by PD.

An assessment of Polish women’s level of knowledge about endometriosis: a pilot study

Introduction

Insufficient knowledge about endometriosis among women is one of the causes of its delayed diagnoses. Due to the elusiveness of symptoms, the most important component of early detection is proper and exhaustive knowledge. The objective of the study was to assess Polish women's awareness of endometriosis.

Methods

The pilot studies were performed with the participation of 200 women, in an average age of 33.65 years (SD = 11.45), who completed the authors’ questionnaire related to self-assessment of the level of knowledge about the disease, its symptoms, late effects and directions of a remediation procedure. The statistical analysis was performed using the IBM SPSS Statistics 25 suite. It included a frequency analysis, a one-way analysis of variance ANOVA, a single variable regression analysis and Student’s t-test for independent samples.

Results

Almost 84% of women had heard about endometriosis, while only 1/3 of them considered their knowledge sufficient or good. Very good knowledge was declared by 4.5% of women, while 16.1% of participants had never heard about it. The level of knowledge was significantly higher (p = 0.001) among women with medical education. Polish women acquired their knowledge mainly from the Internet and the experience of other women. The reasons identified by women were the still existing ‘taboo’ related to menstruation, the absence of information in the media and education in schools, which is critical according to 92.4% of women.

Conclusions

Polish women’s level of knowledge about endometriosis is insufficient, which we should strive to improve. Higher awareness is presented by women with medical education, and the higher the level of knowledge, the larger a woman’s interest in healthy behaviour.

Strengths and weaknesses in the diagnostic process of endometriosis from the patients' perspective: a focus group study

OBJECTIVES

Endometriosis is characterized by a long interval between onset of symptoms and diagnosis. Detailed information about the patients' perspective on the diagnostic delay of endometriosis is scarce. The aim of this study was to identify strengths and weaknesses in the diagnostic process of endometriosis from the patients' perspective.

METHODS

Qualitative study with semi-structured focus groups. Participants were women between 18 and 45 years old with a recently confirmed diagnosis. The focus groups were audio recorded and fully transcribed. Grounded theory methodology was applied for data analysis.

RESULTS

Six focus groups were organized, in which 23 women participated. Mean time from start of symptoms to diagnosis was 8.5 years. Dominant themes were knowledge about normal menstruation and endometriosis, being believed and acknowledged by medical staff, and collaboration between health care providers including fast referral to a gynaecologist. Barriers to a timely referral and diagnosis were young age, normalization of symptoms and a lack of awareness in general practitioners. Facilitating factors included adequate knowledge and skills of the general practitioner, a desire for pregnancy and persisting in a request for specialist consultation by the patient.

CONCLUSIONS

The diagnostic process of endometriosis is hampered by delayed consultation, inadequate appraisal of symptoms by general practitioners and the interaction between patients and medical professionals. Efforts should be made to increase public awareness and to provide medical staff with sufficient knowledge and skills to adequately acknowledge presented symptoms.

‘My devil womb’: Patients’ perspectives on, and understanding of, endometriosis: An observational cross-sectional study

Objective:

To gain insight into patients’ understanding of endometriosis, utilised sources of information on endometriosis and perceptions of available treatment options.

Design:

Observational cross-sectional study.

Setting:

Data were collected from an outpatient specialist endometriosis clinic within a tertiary hospital.

Participants:

New patients referred with symptoms suggestive of endometriosis.

Methods:

A paper based questionnaire was completed by new patients on their first presentation to the clinic.

Main outcome measures:

Patient understanding of symptoms and causes of endometriosis, types and expectations of treatment, and sources of information utilised by patients in researching endometriosis.

Results:

Approximately half of all included patients were unsure of the aetiology of endometriosis. Patients who relied on information from specialist gynaecologists were more optimistic about the outcome of surgical treatment, while those who relied on general practitioners were more optimistic about the outcome of medical treatment, when compared to those who sought information from online sources.

Conclusions:

Endometriosis is a chronic and debilitating condition, yet there is limited data available regarding both the sources of information that patients’ access, and their perceptions of the disease. Given the high proportion of patients in our study who lacked knowledge of endometriosis, and the negative correlation between the use of social media for information and perception of treatment, there is a clear need for improved access to evidence-based resources for patient education.

Combating Diagnostic Delay of Endometriosis in Adolescents via Educational Awareness: A Systematic Review

Endometriosis occurs in approximately 10% of adult women worldwide; however, it is commonly under- or misdiagnosed in adolescents. The purpose of this study was to analyze existing scientific literature for reasons for diagnostic delay of endometriosis and to determine how education regarding endometriosis could be improved. An integrative review was conducted based on articles published between December 1980 and December 2020. Suitable articles were identified from the MEDLINE/PubMed databases, using relevant terms. Eligible studies included discussion on potential causes of diagnostic delay of endometriosis in the adolescent population. Data were extracted from eligible publications and qualitative synthesis was used. The 27 articles included in the study revealed several primary reasons for the delay, such as a physician and/or patient knowledge gap, normalization by physician and patient, lack of research, and physician resistance. Strategies to lessen diagnostic delay of endometriosis in adolescents must include integrated actions by educators and healthcare providers to improve health literacy and awareness of common causes of pelvic pain in this age group.

Menstrual Health Literacy and Management Strategies in Young Women in Australia: A National Online Survey of Young Women Aged 13-25 Years

STUDY OBJECTIVE

To explore key aspects of menstrual health literacy and menstrual management in young women at school or in tertiary education.

DESIGN

Cross-sectional online survey.

SETTING

Australia-wide.

PARTICIPANTS

A total of 4202 adolescent and young women (13-25 years of age; median age 17 years), having reached menarche, living in Australia and currently attending school (n = 2421) or tertiary education (n = 1781).

INTERVENTIONS

Online survey hosted by Qualtrics between November 2017 and January 2018. Data were collected on contraceptive use, management strategies, sources of information, and knowledge of menstruation.

MAIN OUTCOME MEASURES

Information on prevalence and effectiveness of different management strategies, health-seeking behavior, knowledge about menstruation, and common menstrual disorders such as endometriosis.

RESULTS

The majority of young women did not seek medical advice for their menstrual symptoms, but used information from the Internet (50%) and engaged in self-management, most commonly with over-the-counter medications such as paracetamol (51%) or ibuprofen (52%). Oral contraceptive use was relatively common (35%), and mostly for reduction of menstrual pain (58%). Despite having significant dysmenorrhea, approximately one-half of the participants (51%) thought that their period was normal. Women with higher pain scores were more likely to rate their period as "abnormal" (P < .0001) but not more likely to consult a doctor (P = .13). Only 53% of those at school had heard of endometriosis.

CONCLUSION

Self-management of menstrual symptoms is common, but a significant minority of women are underdosing or choosing ineffective methods. Most women do not seek medical advice even when symptoms are severe, and cannot identify symptoms suggestive of secondary dysmenorrhea. Improved education on menstruation is vital.

Impact of endometriosis on reproductive health: an integrative review

Endometriosis is a debilitating chronic disease that affects 10% of the general female population, with a frequency of 38% in infertile women. This review aims to provide an overview of the impact of endometriosis on different aspects of reproductive health. A literature search was performed in four international databases, including PubMed, Science Direct, Scopus, and Google scholar, from January 1995 to December 2019 to identify the potentially relevant articles. We included all relevant articles published in English and identified 46 studies on health issues in women with endometriosis. The research suggests that women with endometriosis are at risk for physical, psychosocial, social, and sexual disturbances and obstetrical complications. More research is needed to clarify better understanding of endometriosis complications specifically obstetrical consequences.

Adolescent Menstrual Health Literacy in Low, Middle and High-Income Countries: A Narrative Review

Background: Poor menstrual health literacy impacts adolescents’ quality of life and health outcomes across the world. The aim of this systematic review was to identify concerns about menstrual health literacy in low/middle-income countries (LMICs) and high-income countries (HICs). Methods: Relevant social science and medical databases were searched for peer-reviewed papers published from January 2008 to January 2020, leading to the identification of 61 relevant studies. Results: A thematic analysis of the data revealed that LMICs report detrimental impacts on adolescents in relation to menstrual hygiene and cultural issues, while in HICs, issues related to pain management and long-term health outcomes were reported more frequently. Conclusions: In order to improve overall menstrual health literacy in LMICs and HICs, appropriate policies need to be developed, drawing on input from multiple stakeholders to ensure evidence-based and cost-effective practical interventions.

The Prevalence of Endometriosis in Adolescents with Pelvic Pain: A Systematic Review

STUDY OBJECTIVE

Endometriosis is a recognized cause of pelvic pain in adolescents with menstrual symptoms that significantly affect education, activity, and social interactions. We aim to provide an updated systematic review of the prevalence of endometriosis in adolescents with pelvic pain presenting for gynecological investigation.

DATA SOURCES

We searched Medline, Embase, and Cinahl from 2011 to July 2019.

METHODS OF STUDY SELECTION

We included cohort studies of adolescents with pelvic pain undergoing gynecological investigation. Two authors independently selected studies and extracted study characteristics and prevalence data. Methodological quality was assessed using the Critical Appraisal Skills Program for cohort studies.

RESULTS

This updated systematic review evaluated a total of 19 studies including 1243 symptomatic adolescents. In all, 648 of 1011 (64%) adolescents undergoing laparoscopy were found to have endometriosis. The prevalence ranged from 25% to 100%, with a mean prevalence of 64%. Thirteen studies including 381 participants categorized disease severity using the revised American Society of Reproductive Medicine classification. Among these, 53% of participants (201/381) had stage I, 28% (105/381) had stage II, 20% (76/381) had stage III, and 13% (49/381) had stage IV disease.

CONCLUSIONS

The prevalence of endometriosis among adolescents with pelvic pain symptoms is high. Endometriosis is treatable, and prompt recognition will help to ensure that adolescents are signposted earlier to appropriate specialists. The management of adolescents with suspected endometriosis should be consistent with best practice guidance. Despite recommendations to increase the awareness and knowledge of endometriosis in adolescence, minimal research has followed.

Endometriosis and chronic pelvic pain have similar impact on women, but time to diagnosis is decreasing: an Australian survey

Chronic pelvic pain (CPP) affects a significant number of women worldwide. Internationally, people with endometriosis report significant negative impact across many areas of their life. We aimed to use an online survey using the EndoCost tool to determine if there was any difference in the impact of CPP in those with vs. those without a confirmed diagnosis of endometriosis, and if there was any change in diagnostic delay since the introduction of clinical guidelines in 2005. 409 responses were received; 340 with a diagnosis of endometriosis and 69 with no diagnosis. People with CPP, regardless of diagnosis, reported moderate to severe dysmenorrhea and non-cyclical pelvic pain. Dyspareunia was also common. Significant negative impact was reported for social, academic, and sexual/romantic relationships in both cohorts. In the endometriosis cohort there was a mean diagnostic delay of eight years, however there was a reduction in both the diagnostic delay (p < 0.001) and number of doctors seen before diagnosis (p < 0.001) in those presenting more recently. Both endometriosis and CPP have significant negative impact. Whilst there is a decrease in the time to diagnosis, there is an urgent need for improved treatment options and support for women with the disease once the diagnosis is made.

Exploring the Unmet Needs of Parents of Adolescent Girls with Heavy Menstrual Bleeding and Dysmenorrhea: A Qualitative Study

STUDY OBJECTIVE

To provide insight into the unmet needs of parents of adolescents with heavy menstrual bleeding or dysmenorrhea, in the context of their daughters' menstrual concerns.

DESIGN

Qualitative interview study using semi-structured interviews.

SETTING

Gynecology outpatient clinic at The Royal Children's Hospital, Melbourne, Australia.

PARTICIPANTS

Parents of adolescent girls with heavy menstrual bleeding or dysmenorrhea recruited from an adolescent gynecology clinic between May and August 2018.

INTERVENTIONS

In depth, semi-structured interviews with 24 parents whose daughters had heavy menstrual bleeding or dysmenorrhea. Data were analyzed using a grounded theory approach.

MAIN OUTCOME MEASURES

Themes derived from interview transcripts about the supportive care needs of parents.

RESULTS

Thirteen themes emerged in the interviews across 4 areas of need: (1) experiences with healthcare, (2) informational needs, (3) support and acceptance, and (4) financial impacts. Across the interviews, parents identified a need for greater awareness and education among parents and daughters, health professionals, and the broader community.

CONCLUSION

This research confirmed that parents play a significant role in daughters' menstrual health care and have a series of unmet needs. Strategies and interventions specifically targeting these parents may be warranted.

Self-management strategies to consider to combat endometriosis symptoms during the COVID-19 pandemic

The care of patients with endometriosis has been complicated by the coronavirus disease 2019 (COVID-19) pandemic. Medical and allied healthcare appointments and surgeries are being temporarily postponed. Mandatory self-isolation has created new obstacles for individuals with endometriosis seeking pain relief and improvement in their quality of life. Anxieties may be heightened by concerns over whether endometriosis may be an underlying condition that could predispose to severe COVID-19 infection and what constitutes an appropriate indication for presentation for urgent treatment in the epidemic. Furthermore, the restrictions imposed due to COVID-19 can impose negative psychological effects, which patients with endometriosis may be more prone to already. In combination with medical therapies, or as an alternative, we encourage patients to consider self-management strategies to combat endometriosis symptoms during the COVID-19 pandemic. These self-management strategies are divided into problem-focused and emotion-focused strategies, with the former aiming to change the environment to alleviate pain, and the latter address the psychology of living with endometriosis. We put forward this guidance, which is based on evidence and expert opinion, for healthcare providers to utilize during their consultations with patients via telephone or video. Patients may also independently use this article as an educational resource. The strategies discussed are not exclusively restricted to consideration during the COVID-19 pandemic. Most have been researched before this period of time and all will continue to be a part of the biopsychological approach to endometriosis long after COVID-19 restrictions are lifted.

Unmet Needs and Experiences of Adolescent Girls with Heavy Menstrual Bleeding and Dysmenorrhea: A Qualitative Study

STUDY OBJECTIVE

To identify and examine the key areas of need and explore the experiences of adolescent girls with heavy menstrual bleeding and/or dysmenorrhea.

DESIGN AND SETTING

Qualitative interview study using semi-structured interviews. Gynaecology outpatient clinic at The Royal Children's Hospital, Melbourne, Australia.

PARTICIPANTS

Adolescent girls (12-18 years; mean age, 14.8 ± 1.5 years) presenting with heavy menstrual bleeding and/or dysmenorrhea at the clinic (N = 30).

INTERVENTIONS AND MAIN OUTCOME MEASURES

In-depth semi-structured interviews were conducted between May and August 2018. Interview data were thematically analyzed using a grounded theory approach. Themes covered experiences and unmet needs of adolescent girls with heavy menstrual bleeding and/or dysmenorrhea.

RESULTS

A total of 12 themes were identified, and covered the impact of symptoms, experiences, and/or unmet needs of these adolescents. Key themes highlighting experiences and unmet needs related to (1) coordination of healthcare, (2) day-to-day coping, (3) school, and (4) information surrounding menstrual issues. From these themes, 7 unmet needs emerged and were organized under 3 key areas of need: (1) treatment, management, and care, (2) improvements in the school environment, and (3) menstrual health as a gendered issue.

CONCLUSION

Menstrual concerns can have a profound physical and psychosocial impact on adolescents. Effective school-based menstrual education programs may be key in reducing stigma, fear, and shame surrounding menstruation, in teaching positive management strategies and in encouraging adolescents to seek help for their menstrual concerns.

"I Thought I Was Dying:" (Un)Supportive Communication Surrounding Early Menstruation Experiences

Menstruation is a salient, and sometimes scary, communication topic for young women. The present study reports on the early communication experiences about menstruation from 165 women using open-ended survey data. Through the framework of supportive communication, findings reveal that a discrepancy occurs between the health and practical information and needs to which young people who menstruate desire access, and their social and emotional needs. The present study indicates an inadequacy of both aspects of menstruation communication from important others in childhood and adolescence. Themes of boundary management, impersonal, silence, and accidents also characterize early communication experiences about menstruation. Our participants identified a desire for conversations that normalize menstruation as typical and acceptable, validate period pain and prescribe management tactics, and describe the existence of feminine hygiene products other than pads and tampons. Limitations and directions for future research are discussed.

Developing and trialling a school-based ovulatory-menstrual health literacy programme for adolescent girls: a quasi-experimental mixed-method protocol

INTRODUCTION

A review of international and Australian school-based resources suggests that teaching of the ovulatory-menstrual (OM) cycle is predominantly couched in biology. A whole-person framework that integrates spiritual, intellectual, social and emotional dimensions with the physical changes of the OM cycle is needed to facilitate adolescent OM health literacy. This paper describes the protocol for a study that aims to develop and trial an intervention for adolescent girls aged 13-16 years that enhances positive attitudes towards OM health coupled with developing skills to monitor and self-report OM health. These skills aim to foster acceptance of the OM cycle as a 'vital sign' and facilitate confident communication of common OM disturbances (namely, dysmenorrhoea, abnormal uterine bleeding and premenstrual syndrome), which are known to impact school and social activities.

METHODS AND ANALYSIS

Phase I will comprise a Delphi panel of women's health specialists, public health professionals and curriculum consultants and focus groups with adolescent girls, teachers and school healthcare professionals. This will inform the development of an intervention to facilitate OM health literacy. The Delphi panel will also inform the development of a valid and reliable questionnaire to evaluate OM health literacy. Phase II will trial the intervention with a convenience sample of at least 175 adolescent girls from one single-sex school. The mixed-method evaluation of the intervention will include a pre-intervention and post-intervention questionnaire. One-on-one interviews with teachers and school healthcare professionals will expand the understanding of the barriers, enablers and suitability of implementation of the intervention in a school-based setting. Finally, focus groups with purposively selected trial participants will further refine the intervention.

ETHICS AND DISSEMINATION

The study findings will be disseminated through local community seminars, conferences, peer-review articles and media channels where appropriate. The Curtin University of Human Research Ethics Committee has approved this study (approval HRE2018-0101). This project is registered with the 'Australian and New Zealand Clinical Trials Registry'.

TRIAL REGISTRATION NUMBER

ACTRN12619000031167; Pre-results.

Non-coding RNAs in endometriosis: a narrative review

BACKGROUND

Endometriosis is a benign gynaecological disorder, which affects 10% of reproductive-aged women and is characterized by endometrial cells from the lining of the uterus being found outside the uterine cavity. However, the pathophysiological mechanisms causing the development of this heterogeneous disease remain enigmatic, and a lack of effective biomarkers necessitates surgical intervention for diagnosis. There is international recognition that accurate non-invasive diagnostic tests and more effective therapies are urgently needed. Non-coding RNA (ncRNA) molecules, which are important regulators of cellular function, have been implicated in many chronic conditions. In endometriosis, transcriptome profiling of tissue samples and functional in vivo and in vitro studies demonstrate that ncRNAs are key contributors to the disease process.

OBJECTIVE AND RATIONALE

In this review, we outline the biogenesis of various ncRNAs relevant to endometriosis and then summarize the evidence indicating their roles in regulatory pathways that govern disease establishment and progression.

SEARCH METHODS

Articles from 2000 to 2016 were selected for relevance, validity and quality, from results obtained in PubMed, MEDLINE and Google Scholar using the following search terms: ncRNA and reproduction; ncRNA and endometriosis; miRNA and endometriosis; lncRNA and endometriosis; siRNA and endometriosis; endometriosis; endometrial; cervical; ovary; uterus; reproductive tract. All articles were independently screened for eligibility by the authors.

OUTCOMES

This review integrates extensive information from all relevant published studies focusing on microRNAs, long ncRNAs and short inhibitory RNAs in endometriosis. We outline the biological function and synthesis of microRNAs, long ncRNAs and short inhibitory RNAs and provide detailed findings from human research as well as functional studies carried out both in vitro and in vivo, including animal models. Although variability in findings between individual studies exists, collectively, the extant literature justifies the conclusion that dysregulated ncRNAs are a significant element of the endometriosis condition.

WIDER IMPLICATIONS

There is a compelling case that microRNAs, long non-coding RNAs and short inhibitory RNAs have the potential to influence endometriosis development and persistence through modulating inflammation, proliferation, angiogenesis and tissue remodelling. Rapid advances in ncRNA biomarker discovery and therapeutics relevant to endometriosis are emerging. Unravelling the significance of ncRNAs in endometriosis will pave the way for new diagnostic tests and identify new therapeutic targets and treatment approaches that have the potential to improve clinical options for women with this disabling condition.