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

'It just stops me from living': A qualitative study of losses experienced by women with self-reported endometriosis

AIMS

To understand the experience of loss in Australian women with endometriosis.

DESIGN

A total of 532 participants completed an online survey containing three open-ended questions relating to pelvic pain and activity loss due to endometriosis. Participants were Australian women aged between 18 and 50 years (M = 30.8, SD = 7.1) with a self-reported diagnosis of endometriosis. An inductive, qualitative approach, with template analysis was used to identify and organize themes. A pragmatic feminist perspective was used to interpret the findings.

RESULTS

Three main themes were identified: the loss of liberty: 'I'm trapped in the house'; the loss of bodily autonomy: 'I can barely move/breathe/talk' and loss of connection: 'It stops me from being social'. Pain emerged as the greatest concern for participants, preventing them from the physical functioning required to participate in many of life's activities.

CONCLUSIONS

The losses women with endometriosis experience are wide-reaching, restricting control and choice across multiple life domains. Losses were often unacknowledged by loved ones and healthcare providers, further impacting the physical, emotional and mental health of participants.

PATIENT OR PUBLIC CONTRIBUTION

People with endometriosis were involved in the design of the study, including identifying topics of interest.

Racial disparities in uterine fibroids and endometriosis: a systematic review and application of social, structural, and political context

IMPORTANCE

Uterine fibroids and endometriosis are 2 of the leading causes of morbidity among reproductive-aged women. There are significant racial disparities in disease prevalence, incidence, age of onset, and treatment profile in fibroids. The data on endometriosis are less clear.

OBJECTIVE

To conduct a systematic review of racial disparities in prevalence of uterine fibroids and endometriosis in the United States and summarize the literature on these 2 highly prevalent benign gynecologic conditions using a framework that explicitly incorporates and acknowledges the social, structural, and political contexts as a root cause of racial disparities between Black and White women.

EVIDENCE REVIEW

A systematic review regarding racial disparities in prevalence of fibroids and endometriosis was conducted separately. Two separate searches were conducted in PubMed to identify relevant original research manuscripts and prior systematic reviews regarding racial disparities in uterine fibroids and endometriosis using standardized search terms. In addition, we conducted a structured literature search to provide social, structural, and political context of the disparities.

FINDINGS

A systematic review of the literature indicated that the prevalence of uterine fibroids was consistently higher in Black than in White women with the magnitude of the difference varying depending on population and case definition. Prevalence of endometriosis varied considerably depending on the base population and case definition, but was the same or lower among Black vs. White women. As a result of the social, structural, and political context in the United States, Black women disproportionately experience a range of exposures across the life course that may contribute to their increased uterine fibroid incidence, prevalence, and severity of uterine fibroids. However, data suggest no racial difference in the incidence of endometriosis. Nevertheless, Black women with fibroids or endometriosis experience worse clinical and surgical outcomes than their White counterparts.

CONCLUSION AND RELEVANCE

Racial disparities in uterine fibroids and endometriosis can be linked with differential exposures to suspected etiologic agents, lack of adequate access to health care, including highly skilled gynecologic surgeons, and bias and discrimination within the health care system. Eliminating these racial disparities will require solutions that address root causes of health disparities through policy, education and programs to ensure that all patients receive culturally- and structurally-competent care.

Qualitative Research Methods in Chronic Disease: Introduction and Opportunities to Promote Health Equity

Public health research that addresses chronic disease has historically underutilized and undervalued qualitative methods. This has limited the field's ability to advance (a) a more in-depth understanding of the factors and processes that shape health behaviors, (b) contextualized explanations of interventions' impacts (e.g., why and how something did or did not work for recipients and systems), and (c) opportunities for building and testing theories. We introduce frameworks and methodological approaches common to qualitative research, discuss how and when to apply them in order to advance health equity, and highlight relevant strengths and challenges. We provide an overview of data collection, sampling, and analysis for qualitative research, and we describe research questions that can be addressed by applying qualitative methods across the continuum of chronic disease research. Finally, we offer recommendations to promote the strategic application of rigorous qualitative methods, with an emphasis on priority areas to enhance health equity across the evidence generation continuum.

Variation among human populations in endometriosis and PCOS A test of the inverse comorbidity model

Evidence linking endometriosis to low prenatal testosterone, and evidence that risk of polycystic ovary syndrome (PCOS) is associated with high prenatal testosterone, have motivated the hypothesis that endometriosis and PCOS exhibit inverse comorbidity. The inverse comorbidity hypothesis predicts that populations exhibiting higher prevalence of one disorder should show lower prevalence of the other. To test this prediction, data were compiled from the literature on the prevalence of endometriosis and PCOS, levels of serum testosterone in women during pregnancy and digit ratios as indicators of prenatal testosterone, in relation to variation in inferred or observed population ancestries. Published studies indicate that rates of endometriosis are highest in women from Asian populations, intermediate in women from European populations and lowest in women from African populations (i.e. with inferred or observed African ancestry); by contrast, rates of PCOS show evidence of being lowest in Asian women, intermediate in Europeans and highest in individuals from African populations. Women from African populations also show higher serum testosterone during pregnancy (which may increase PCOS risk, and decrease endometriosis risk, in daughters), and higher prenatal testosterone (as indicated by digit ratios), than European women. These results are subject to caveats involving ascertainment biases, socioeconomic, cultural and historical effects on diagnoses, data quality, uncertainties regarding the genetic and environmental bases of population differences and population variation in the causes and symptoms of PCOS and endometriosis. Despite such reservations, the findings provide convergent, preliminary support for the inverse comorbidity model, and they should motivate further tests of its predictions.

Lay Summary: Given that endometriosis risk and risk of polycystic ovary syndrome show evidence of having genetically, developmentally, and physiologically opposite causes, they should also show opposite patterns of prevalence within populations: where one is more common, the other should be more rare. This hypothesis is supported by data from studies of variation among populations in rates of endometriosis and PCOS and studies of variation among populations in levels of prenatal testosterone, which mediaterisks of both conditions.

Circular RNA circZFPM2 promotes epithelial-mesenchymal transition in endometriosis by regulating miR-205-5p/ZEB1 signalling pathway

Endometriosis is a debilitating gynecological disease affecting millions of women worldwide, but its exact pathogenesis remains unclear. Circular RNAs (circRNAs) have been demonstrated to be important regulators in multiple diseases. Nonetheless, the potential regulatory mechanism of aberrant circRNA expression in endometriosis has been elusive. The up-regulated circZFPM2 in ectopic endometrial tissues was previously screened by circRNA high-throughput sequencing and was furtherly validated by quantitative real time reverse transcriptase polymerase chain reaction (RT-qPCR). Overexpression of circZFPM2 promoted the proliferation, migration, invasion, and epithelial-mesenchymal transition (EMT) in Ishikawa and End1/E6E7 cells, whereas silencing circZFPM2 produced the opposite effect. Luciferase reporter assays validated that circZFPM2 could directly target miR-205-5p and miR-205-5p target ZEB1. RT-qPCR results showed that miR-205-5p was underexpressed while ZEB1 was overexpressed in ectopic endometrial tissues compared with their expression in eutopic endometria and non-endometriosis control endometria. The expression level of miR-205-5p was inversely proportional and that of ZEB1 was directly proportional with the proliferative, migrative, and invasive ability of endometrial cells. Further in vitro investigation indicated that miR-205-5p could inhibit EMT by targeting ZEB1. Subsequent rescue experiments confirmed that circZFPM2 could induce EMT and promote cell proliferation, migration, and invasion cascades through the miR-205-5p /ZEB1 signaling pathway. Conclusively, circZFPM2 may present a promising biomarker in the diagnosis and treatment of endometriosis.