Epidemiology of Endometriosis in France: A Large, Nation-Wide Study Based on Hospital Discharge Data

Epidemiology of endometriosis in Ukraine: results a multicenter study (2019-2021)

OBJECTIVE

Aim: To estimate the prevalence and incidence of endometriosis, and to evaluate risk factors associated with endometriosis in Ukraine.

PATIENTS AND METHODS

Materials and Methods: The multicenter cohort study was performed partly as a cross-sectional study to estimate occurrence of endometriosis, partly as a case-control study to look for factors associated with endometriosis. The study was carried out during the period from January 1st, 2019 to December 31st, 2021.This study included adolescent girls and adult women from 15 Ukrainian regions.

RESULTS

Results: Among 15,458 patients, 4,397 (28.4%) endometriosis were observed. Of all endometriosis cases, 48.5% were peritoneal/superf i cial endometriosis (SPE), 34.6% were ovarian endometriotic cyst/endometrioma (OMA), and 16.9% were deep inf i ltrating endometriosis (DIE). The prevalence of the three types of endometriosis was: SPE, 13.8%; OMA, 9.8%; and DIE, 4.8%. The factors associated with an increased risk for endometriosis include age 23-32 years, parity (small number of births), age of fi rst sexual intercourse <20 years, history of healthcare-associated infection after gynecological surgery (pelvic abscess or cellulitis, salpingitis and oophoritis), history of infertility, early menarche (before the age of 11), dysmenorrhea, dyspareunia, pelvic pain, intermenstrual bleeding, heavy uterine bleeding and dysmenorrhea, and heavy uterine bleeding.

CONCLUSION

Conclusions: Endometriosis is a common gynecological disease in Ukraine and the relative frequency of dif f erent types of endometriosis: the most common were ovarian and peritoneal endometriosis. Healthcare services and public health strategies need to be strengthened to ensure timely endometriosis diagnosis in adolescent girls and adult women and treatment.

Effects of a physical activity and endometriosis-based education program delivered by videoconference on endometriosis symptoms: the CRESCENDO program (inCRease physical Exercise and Sport to Combat ENDOmetriosis) protocol study

BACKGROUND

Endometriosis is a chronic disease characterized by growth of endometrial tissue outside the uterine cavity which could affect 200 million women (The term "woman" is used for convenience. Individuals gendered as man or as nonbinary can also suffer from this disease) worldwide. One of the most common symptoms of endometriosis is pelvic chronic pain associated with fatigue. This pain can cause psychological distress and interpersonal difficulties. As for several chronic diseases, adapted physical activity could help to manage the physical and psychological symptoms. The present study will investigate the effects of a videoconference-based adapted physical activity combined with endometriosis-based education program on quality of life, pain, fatigue, and other psychological symptoms and on physical activity.

METHODS

This multicentric randomized-controlled trial will propose to 200 patients with endometriosis to be part of a trial which includes a 6-month program with 45 min to more than 120 min a week of adapted physical activity and/or 12 sessions of endometriosis-based education program. Effects of the program will be compared to a control group in which patients will be placed on a waiting list. All participants will be followed up 3 and 6 months after the intervention. None of the participants will be blind to the allocated trial arm. The primary outcome measure will be quality of life. Secondary outcomes will include endometriosis-related perceived pain, fatigue, physical activity, and also self-image, stereotypes, motivational variables, perceived support, kinesiophobia, basic psychological need related to physical activity, and physical activity barriers. General linear models and multilevel models will be performed. Predictor, moderator, and mediator variables will be investigated.

DISCUSSION

This study is one of the first trials to test the effects of a combined adapted physical activity and education program for improving endometriosis symptoms and physical activity. The results will help to improve care for patients with endometriosis.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05831735 . Date of registration: April 25, 2023.

The impact of endometriosis on work ability in young Australian women

BACKGROUND

Whereas symptomatic endometriosis may affect work performance, the impact of endometriosis in the general community is not known.

AIMS

The associations between endometriosis and each of sick leave and work ability, were investigated in a large sample of non-healthcare seeking women.

MATERIALS AND METHODS

This community-based, cross-sectional study recruited 6986 women, aged 18-39 years, from three eastern states of Australia between 11 November 2016 and 21 July 2017. Women were identified as having endometriosis if they had undergone a pelvic ultrasound and reported a diagnosis of endometriosis. Working women completed the Work Ability Index.

RESULTS

Participants were predominantly of European ancestry (73.1%) and 46.8% were overweight or had obesity. The prevalence of endometriosis was 5.4% (95%CI 4.9-6.0%) with the highest prevalence of 7.7% (95%CI 6.5 to 9.1%) for women aged 35-39 years. Among the 4618 working women, those with endometriosis had significantly more sick days from work (33.6% reported ≥10 days vs 13.5%, overall χ2 P < 0.001). Endometriosis was associated with a greater likelihood of poor to moderate work ability, after adjusting for age, body mass index, ethnicity, relationship status, student status, insecure housing, being a carer for another person, parity, ever use of assisted reproductive technologies, and depressed mood (odds ratio 1.90, 95%CI 1.40-2.58, P < 0.001).

CONCLUSIONS

This study provides new evidence that the negative impact of endometriosis on work attendance and work ability is not limited to women with prevalent symptoms and severe disease, but appears to encompass women across a broader spectrum of this condition in the community.

The risk of endometriosis by early menarche is recently increased: a meta-analysis of literature published from 2000 to 2020

PURPOSE

The relationship between menarche age and endometriosis has been studied extensively; however, the results were inconsistent due to differences in study dates, populations, and methodology. The goal of this meta-analysis was to see how different research populations, dates, and types affected the estimated risk of endometriosis in early menarche.

METHODS

The terms "endometriosis", "early menarche", and other pertinent terms were searched in PubMed, Medline, and Embase. This meta-analysis comprised 16 papers published between 2000 and 2020, with a start year ranging from 1989 to 2017. Random effects were used to examine endometriosis risks in these articles. Study start years, countries, types (case-control and cohort studies), and quality (Newcastle-Ottawa scale, NOS) were all taken into account in further stratified analysis and meta-regression analyses.

RESULTS

Early menarche (< 12 years) was associated with a significant pooled risk of endometriosis with high heterogeneity (OR = 1.34, 95% CI 1.16-1.54, I² = 72.0%). Stratified analysis showed that this risk was increased in studies started after 2000 (OR = 1.62, 95% CI 0.96-1.35, I² = 74.4%), compared to those before 2000 (OR = 1.13, 95% CI 1.16-1.54, I² = 40.7%); additionally, this risk was higher in low-income countries (OR = 2.11, 95% CI 1.55-2.87, I² = 0%) than in other countries (OR = 1.25, 95% CI 1.09-1.43, I² = 70.6%). These results were further confirmed by meta-regression analysis (both P values < 0.1). No significant differences were found between different study types and NOS scores.

CONCLUSION

Our results suggested an increasing risk of endometriosis with early menarche, which was more noticeable in low-income countries. Large-scale studies are warranted.

Endometriosis prevalence and incidence trends in a large population-based study in Catalonia (Spain) from 2009 to 2018

Objective:

Endometriosis greatly impacts women’s health and quality of life. However, research on the prevalence and incidence of endometriosis remains inconclusive. This study assesses time trends in the prevalence and incidence of endometriosis diagnoses in Catalonia (Spain) from 2009 to 2018, considering differences by age and socioeconomic status.

Methods:

Population-based cohort study using data from the Information System for Research in Primary Care (SIDIAP) database. Data were included from over 2.4 million women aged 15–55 years between 1 January 2006 and 31 December 2018.

Results:

A total of 2,337,717 women were selected as the incident population; 0.7% had an endometriosis diagnosis. Median (interquartile range) age at diagnosis was 37 (32–43) years. Most women were European (92.3%) and lived in urban areas (73.6%). Overall prevalence of endometriosis consistently increased during the 2009–2018 period, and it was 1.24% in 2018. Trends were the highest for women with less socioeconomic deprivation and for the 35–44 years age group. Median incidence rates were 94.9 (92.6–102.9) per 100,000 women-years, being the highest in women aged 35–44 years throughout the whole study period. Overall, incidence increased between 2015 and 2017, and plateaued or decreased in 2018. Incidence rates in women from the most deprived and rural areas were lower, although incidence time trends by socioeconomic status were unclear.

Conclusion:

Healthcare services and public health strategies need to be strengthened to ensure timely endometriosis diagnosis and treatment. Special attention should be given to the most affected populations and the social inequities of health.

Temporal and regional differences in the incidence of hospital-diagnosed endometriosis: a Danish population-based study

INTRODUCTION

Due to diagnostic challenges, normalization of symptoms and an overall lack of awareness among both patients and physicians, endometriosis is an underdiagnosed disease. This can result in delayed treatment and potentially worsening of the disease. Despite initiatives, such as patients' support organizations and specialized endometriosis referral centers, differences in awareness, socioeconomic factors and lifestyle, combined with varying distances to specialized referral centers, could result in regional differences in the degree of underdiagnosing. This study aims to explore temporal and regional variations in the incidence of endometriosis based on the Danish hospital discharge register, and shed light on the degree of underdiagnosing of endometriosis in Denmark.

MATERIAL AND METHODS

This registry-based cohort study included all women aged 15-55 living in Denmark from 1990-2017. Participants were identified through the Danish Civil Registration system and endometriosis diagnoses received at a hospital were obtained from the Danish National Patient Registry. Incidence rates of diagnosed endometriosis were calculated for each year of the study period and for each municipality in Denmark. A Cox regression analysis, stratified by calendar time and adjusted for ethnic origin, household composition, highest educational level and family socioeconomic status, was performed to estimate the association between residence and likelihood of receiving a hospital-based diagnosis of endometriosis.

RESULTS

The nationwide incidence rate of hospital-diagnosed endometriosis was 7.89 (95% confidence interval [CI] 7.80-7.99) per 10 000 person-years and the prevalence in 2017 was 1.63%. The results showed an overall increase in the incidence of diagnosed endometriosis of 46.8% (95% CI 32.9-62.2) during the study period and also displayed significant regional differences. After adjustments, women living in northern Jutland had the highest probability of receiving a hospital-based diagnosis of endometriosis (hazard ratio 1.13, 95% CI 1.09-1.18), whereas women living in northern Zealand had the lowest probability (hazard ratio 0.63, 95% CI 0.60-0.67) compared with eastern Jutland. These regional differences have become more evident over time.

CONCLUSIONS

Our results reveal significant regional differences in the incidence of hospital-diagnosed endometriosis, suggesting that a significant number of women may be left behind without a diagnosis. Further studies are needed to assess the underlying reasons for the significant regional differences.

Incidence, prevalence, and trends in endometriosis diagnosis: a United States population-based study from 2006 to 2015

BACKGROUND

Accurate estimates of incidence and prevalence of endometriosis among nonselected cohorts are lacking in the United States, and earlier reports have produced varying results.

OBJECTIVE

This study aimed to define endometriosis incidence and prevalence in a US population and evaluate factors influencing these estimates over time.

STUDY DESIGN

A 10-year retrospective cohort study using Kaiser Permanente Washington electronic health records database was completed. The primary analysis included women enrollees aged 16 to 60 years, from January 2006 to December 2015, who had a uterus, were continuously enrolled for at least 2 years before cohort entry and had at least 1 healthcare utilization. Secondary analysis included all women enrollees aged 16 to 60 years during this time. Incident endometriosis was identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, diagnosis codes. Annual incidence rates were age-adjusted by direct standardization to the 2015 study population. Secular trends in incidence overall and by 5-year age group, race and ethnicity, diagnosis modality, and practitioner type were assessed using Poisson regression analyses. Prevalent cases were defined as women enrolled in 2015 and had an endometriosis diagnosis before the end of 2015. The prevalence rates of chronic pelvic pain and dysmenorrhea defined by the International Classification of Diseases, Ninth Revision and Tenth Revision, diagnosis codes in 2006-2015 were estimated.

RESULTS

Among 332,056 eligible women who contributed 1,176,329 person-years during the 10-year study period, 2863 incident endometriosis cases were identified for an average incidence of 24.3 cases per 10,000 person-years. In our primary analysis, incidence rates declined over the study interval from a high of 30.2 per 10,000 person-years in 2006 to 17.4 per 10,000 person-years in 2015 and were highest among women aged 36 to 45 years in most years. Incidence rates were similar across race and ethnicity groups. The distribution of the 2863 incident cases by the diagnosis modality was as follows: 45.5% surgical, 5.7% imaging, and 48.8% clinical. Endometriosis incidence rates per 10,000 person-years were similar in women who were surgically and clinically diagnosed and decreased significantly from 2006 to 2015 (surgically diagnosed endometriosis dropped from 13.4 to 7.4 and clinically diagnosed endometriosis dropped from 16.1 to 8.9; P value of <.001 for linear trend over time for each). Incident case distribution by diagnosing provider was as follows: 73.6% obstetrician and gynecologist, 15.7% primary care provider, and 10.7% "other." Incidence of endometriosis diagnosed by an obstetrician and gynecologist and primary care provider decreased over the study interval (P<.001 for linear trend over time for each). Method of diagnosis and provider type did not differ by race and ethnicity. Among 135,162 women who contributed person-time in 2015, 2521 women were diagnosed with endometriosis, a prevalence rate of 1.9%. In our secondary analysis, the frequency of chronic pelvic pain diagnosis increased over the study interval from 3.0% in 2006 to 5.6% in 2015.

CONCLUSION

The incidence rates of endometriosis declined over the 10-year study interval and did so uniformly across age groups, races and ethnicities, and the main diagnosing modalities and providers. Declining rates may reflect a shift in practice patterns in the United States away from the diagnosis of endometriosis both clinically and surgically, rather than favoring more general diagnoses of chronic pelvic pain. The prevalence of endometriosis in 2015 in the United States is in keeping with data from recent studies outside the United States using health record data.

Novel diagnostic options for endometriosis - Based on the glycome and microbiome

Background

Endometriosis is a chronic gynaecological disease whose aetiology is still unknown. Despite its prevalence among women of reproductive age, the pathology of the disease has not yet been elucidated and only symptomatic treatment is available. Endometriosis has high latency and diagnostic methods are both limited and invasive.

Aim of review

The aim of this review is to summarise minimally invasive or non-invasive diagnostic methods for endometriosis and their diagnostic efficiencies. Furthermore, we discuss the identification and diagnostic potential of novel disease biomarkers of microbial or glycan origin.

Key scientific concepts of review

Great efforts have been made to develop minimally invasive or non-invasive diagnostic methods in endometriosis. The problem with most potential biomarker candidates is that they have high accuracy only in cases of severe disease. Therefore, it is necessary to examine other potential biomarkers more closely. Associations between gastrointestinal and genital tract microbial health and endometriosis have been identified. For instance, irritable bowel syndrome is more common in women with endometriosis, and hormonal imbalance has a negative impact on the microbiome of both the genital tract and the gastrointestinal system. Further interrogation of these associations may have potential diagnostic significance and may identify novel therapeutic avenues. Glycomics may also be a potent source of biomarkers of endometriosis, with a number of glyco-biomarkers already approved by the FDA. Endometriosis-associated microbial and glycomic profiles may represent viable targets for development of innovative diagnostics in this debilitating disease.

Epidemiology of Endometriosis in Spain and Its Autonomous Communities: A Large, Nationwide Study

A retrospective population-based study aimed to assess the incidence of endometriosis in the general population in Spain and in each of its autonomous communities. The authors used the incidence of diagnosed endometriosis in the minimum basic dataset at discharge in the national hospital discharge registry of Spain. This analysis was carried out with hospital data with a diagnosis of endometriosis (International Classification of Diseases (ICD)-9 code 617.xx and ICD-10 code N80.xx) and covered the period from 1 January 2014 to 31 December 2017 and a population of 12,775,911 women of reproductive age (15–54 years). The data were then analyzed at the national level and separately for each autonomous community. This nationwide Spanish study estimated the overall incidence of endometriosis among autonomous communities in Spain to be 16.1 per 10,000 women (range, 6.8 to 24). The mean age of the 20,547 women diagnosed with endometriosis during the study period was 36.8 ± 5.4 years. The types (proportions) of endometriosis were uterine (28.4%), tubo-ovarian (35.2%), peritoneal (8.1%), vesical (6.8%) and intestinal (3.2%) endometriosis. Further studies are needed to assess the reasons for the decrease in the observed incidence and for the significant differences in the regional incidence rates of this disease.

Spatial Patterns of Endometriosis Incidence. A Study in Friuli Venezia Giulia (Italy) in the Period 2004-2017

Background: Diagnosis of endometriosis and evaluation of incidence data are complex tasks because the disease is identified laparoscopically and confirmed histologically. Incidence estimates reported in literature are widely inconsistent, presumably reflecting geographical variability of risk and the difficulty of obtaining reliable data. Methods: We retrieved incident cases of endometriosis in women aged 15–50 years using hospital discharge records and pathology databases of the Friuli Venezia Giulia region in the calendar period 2004–2017. We studied the spatial pattern of endometriosis incidence applying Bayesian approaches to Disease Mapping, and profiled municipalities at higher risk controlling for multiple comparisons using both q-values and a fully Bayesian approach. Results: 4125 new cases of endometriosis were identified in the age range 15 to 50 years in the period 2004–2017. The incidence rate (x100 000) is 111 (95% CI 110–112), with a maximum of 160 in the age group 31–35 years. The geographical distribution of endometriosis incidence showed a very strong north-south spatial gradient. We consistently identified a group of five neighboring municipalities at higher risk (RR 1.31 95% CI 1.13; 1.52), even accounting for ascertainment bias. Conclusions: The cluster of 5 municipalities in the industrialized and polluted south-east part of the region is suggestive. However, due to the ecologic nature of the present study, information on the patients’ characteristics and exposure histories are limited. Individual studies, including biomonitoring, and life-course studies are necessary to better evaluate our findings.

The Effect of Combined Vitamin C and Vitamin E Supplementation on Oxidative Stress Markers in Women with Endometriosis: A Randomized, Triple-Blind Placebo-Controlled Clinical Trial

Background

Endometriosis is a chronic and estrogen-dependent pelvic inflammatory disease, which may have various causes, such as oxidative stress. Dysmenorrhea, dyspareunia, and pelvic pain are well-known symptoms of endometriosis. The present clinical trial assessed the role of supplementation with antioxidant vitamins on the indices of oxidative stress as well as the severity of pain in women with endometriosis.

Materials and Methods

We enrolled 60 reproductive-aged (15–45 years) women with pelvic pain in this triple-blind clinical trial. They had 1–3 stages of laparoscopic-proven endometriosis. The participants were randomized to group A (n = 30), given vitamin C (1000 mg/day, 2 tablets of 500 mg each) and vitamin E (800 IU/day, 2 tablets of 400 IU each) combination, or group B (n = 30), given placebo pills daily for 8 weeks.

Results

Following treatment with vitamin C and vitamin E, we found a significant reduction in MDA and ROS compared with the placebo group. There was no significant decline in total antioxidant capacity after treatment. However, the severity of pelvic pain (p value <0.001), dysmenorrhea (p value <0.001), and dyspareunia (p value <0.001) significantly decreased in the treatment group after 8 weeks of supplementation.

Conclusions

The present findings support the potential role of antioxidants in the management of endometriosis. The intake of vitamin C and vitamin E supplements effectively reduced dysmenorrhea severity and improved dyspareunia and severity of pelvic pain.

Systematic Review and Meta-Analysis of Incidence and Prevalence of Endometriosis

There is still much controversy regarding the epidemiology of endometriosis. The objective of this work is to conduct a systematic review, and if possible, proceed with a meta-analysis of studies that have analyzed the incidence and prevalence of this condition among women in the general population. The inclusion criteria were papers published after 1997 that had reported data of the incidence or prevalence of endometriosis. The PubMed search engine was used to identify papers meeting the inclusion criteria from 1997 to 2019, with an additional manual search for the identification of potentially eligible studies. The search was limited to papers published in English. The risk of bias was assessed according to the Joanna Briggs Institute Critical Appraisal Checklist. As a result, 27 papers, which included a total of 28,660,652 women, were classified according to the type of design and sources of information in five subgroups. Pooled estimates of prevalence for studies with self-reported data were 0.05 (95% CI: 0.03; 0.06), 0.01 for population-based integrated information systems (95% CI: 0.01; 0.02), and 0.04 (95% CI 0.04; 0.05) in studies using other designs. The pooled incidence rate of endometriosis was: 1.36 per 1000 person-years (PY) (95% CI: 1.09; 1.63) for studies based on hospital discharges, 3.53 per 1000 PY (95% CI: 2.06; 4.99) for cohort studies, and 1.89 per 1000 PY (95% CI: 1.42; 2.37) for population-based integrated information systems. Meta-analysis indicated high heterogeneity based on I-squared statistics. This significant variability may not only be due to methodological issues and the specific limitations of the different designs and data analyzed, including case definitions and subject selection strategies, but also to the inherent heterogeneity of endometriosis. Epidemiological studies with appropriate study designs remain necessary to provide a valid estimation of the population burden of endometriosis.

Path to diagnosis and women’s perspectives on the impact of endometriosis pain

Introduction:

Endometriosis is a burdensome chronic disease that can be difficult to diagnose, yet few studies examine experiences along the continuum of disease state. We sought to explore women’s journeys to an endometriosis diagnosis, experience with endometriosis pain, and interactions with healthcare practitioners.

Methods:

An anonymous 23-question online survey was distributed to women (aged >19 years) who self-identified as having a surgical or nonsurgical diagnosis of endometriosis and living in seven English-speaking countries through the social media network MyEndometriosisTeam.com .

Results:

From January through April 2018, 317 women in the United States and 134 women outside the United States completed the survey. More than 50% of the women waited 6 or more years for a diagnosis of endometriosis. Overall, 54.3% experienced endometriosis-related pain daily. Respondents (US/non-US) reported a significant impairment in quality of life that interfered with their family (45.7%/45.5%) and social life (40.1%/44.0%), education/career (42.9%/46.3%), and sexual function (68.1%/70.1%). Women reported their disease led to other conditions, including fatigue (93.6%), gastrointestinal issues (91.8%), and difficulty sleeping (87.4%). Many women were not satisfied with their practitioner’s ability to listen to concerns and felt that their practitioner’s treatment recommendations lacked consistency with their own goals/needs.

Conclusion:

Women still experience long delays and difficult journeys to an endometriosis diagnosis. Disease-associated pain is pervasive and has direct and indirect impacts on quality of life. Women are frequently not satisfied with disease-management options presented to them by their practitioners. These results suggest a need for improved medical education on disease state for both patients and practitioners.

Is Endometriosis More Common and More Severe Than It Was 30 Years Ago?

OBJECTIVE

Current estimates of endometriosis prevalence and incidence are highly variable, leading to uncertainty regarding true endometriosis frequency or validity of quantified changes over time. We present a comprehensive review of the prevalence, incidence, and stage of endometriosis worldwide as reported over the past 30 years.

DATA SOURCES

We conducted a systematic search of observational studies using the PubMed, Web of Science, EMBASE, and CINAHL databases to identify research papers published in English between January 1989 and June 2019. Search terminologies were limited to titles containing endometriosis and prevalence or incidence, or epidemiology, or frequency, or occurrence, or statistics.

METHODS OF STUDY SELECTION

Two independent reviewers screened abstracts for study eligibility, and data from included studies were abstracted.

TABULATION, INTEGRATION, AND RESULTS

Overall, 69 studies describing the prevalence and/or incidence of endometriosis met the inclusion criteria. Among these, 26 studies involved general population samples, 17 of which were from regional/national hospitals or insurance claims systems. The other 43 studies were conducted in single clinic or hospital settings. Prevalence estimates for endometriosis widely varied from 0.2% to 71.4% depending on the population sampled. The prevalence reported in general population studies ranged from 0.7% to 8.6%, whereas that reported in single clinic- or hospital-based studies ranged from 0.2% to 71.4%. When defined by indications for diagnosis, endometriosis prevalence ranged from 15.4% to 71.4% among women with chronic pelvic pain, 9.0% to 68.0% among women presenting with infertility, and 3.7% to 43.3% among women undergoing tubal sterilization. A meta-regression was conducted with year as the predictor of prevalence. No trend across time was observed among "general population in country/region" studies (β = 0.04, p = .12) or among "single hospital or clinic" studies (β = -0.02, p = .34); however, a decrease over time was observed among general population studies abstracted from health systems or insurance systems (β = -0.10, p = .005).

CONCLUSION

As with all human studies, population sampling and study design matter. Heterogeneity of inclusion and diagnostic criteria and selection bias overwhelmingly account for variability in endometriosis prevalence estimated across the literature. Thus, it is difficult to conclude if the lack of observed change in frequency and distribution of endometriosis over the past 30 years is valid.

Development of a prediction model to aid primary care physicians in early identification of women at high risk of developing endometriosis: cross-sectional study

OBJECTIVES

To identify predictors of disease among a few factors commonly associated with endometriosis and if successful, to combine these to develop a prediction model to aid primary care physicians in early identification of women at high risk of developing endometriosis.

DESIGN

Cross-sectional anonymous postal questionnaire study.

SETTING

Women aged 18-45 years recruited from the Norwegian Endometriosis Association and a random sample of women residing in Oslo, Norway.

PARTICIPANTS

157 women with and 156 women without endometriosis.

MAIN OUTCOME MEASURES

Logistic and least absolute shrinkage and selection operator (LASSO) regression analyses were performed with endometriosis as dependent variable. Predictors were identified and combined to develop a prediction model. The predictive ability of the model was evaluated by calculating the area under the receiver operating characteristic curve (AUC) and positive predictive values (PPVs) and negative predictive values (NPVs). To take into account the likelihood of skewed representativeness of the patient sample towards high symptom burden, we considered the hypothetical prevalences of endometriosis in the general population 0.1%, 0.5%, 1% and 2%.

RESULTS

The predictors absenteeism from school due to dysmenorrhea and family history of endometriosis demonstrated the strongest association with disease. The model based on logistic regression (AUC 0.83) included these two predictors only, while the model based on LASSO regression (AUC 0.85) included two more: severe dysmenorrhea in adolescence and use of painkillers due to dysmenorrhea in adolescence. For the prevalences 0.1%, 0.5%, 1% and 2%, both models ascertained endometriosis with PPV equal to 2.0%, 9.4%, 17.2% and 29.6%, respectively. NPV was at least 98% for all values considered.

CONCLUSIONS

External validation is needed before model implementation. Meanwhile, endometriosis should be considered a differential diagnosis in women with frequent absenteeism from school or work due to painful menstruations and positive family history of 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.

Endometriosis-Associated Ovarian Cancer: Population Characteristics and Prognosis

OBJECTIVE

The aim of this study was to analyze and compare the clinicopathologic features and prognosis of clear cell ovarian carcinoma (CCOC) and endometrioid ovarian carcinoma (EOC) associated or not with endometriosis.

METHODS

This was a reconstituted cohort study from a single-institution Brazilian cancer center approved under review board no. 68150617.7.0000.5404 with 50 patients with CCOC and EOC diagnosed between 1995 and 2016, followed up until 2017. Clinicopathologic characteristics and survival outcomes were analyzed.

RESULT(S)

There were 23 women (46%) with CCOC and 27 with EOC (54%); 80% of those women had histologic confirmation of endometriosis; 42% were nulliparous, and 42% were premenopausal; and cancer antigen 125 was elevated in both International Federation of Gynecology and Obstetrics stages I-II disease (mean, 614.7 Ui/mL; range, 3-6030 Ui/mL) or International Federation of Gynecology and Obstetrics stages III-IV disease (mean, 2361.2 Ui/mL; range, 8-12771 Ui/mL). Women with EOC were 7 years younger than those with CCOC. When associated with endometriosis, CCOCs were more likely diagnosed at earlier stages. Endometrioid ovarian carcinoma and CCOC at initial stage and EOC at advanced stage share similar good prognosis. Univariate analysis showed that CCOC not associated with endometriosis has worse overall survival (OS). However, multivariate analysis showed that only abnormally elevated levels of cancer antigen 125 and advanced stage at diagnosis were significantly associated with reduced progression-free survival. Tumor stage remains the only prognostic factor for OS.

CONCLUSIONS

The presence of coexisting endometriosis did not change the prognosis of EOC but was associated with better OS in patients with CCOC. Patients with CCOC and EOC at initial stages and EOC at advanced stages have a good prognosis; however, CCOC at advanced stages had a sooner recurrence and shorter OS.

The Endobiota Study: Comparison of Vaginal, Cervical and Gut Microbiota Between Women with Stage 3/4 Endometriosis and Healthy Controls

Dysbiosis in the genital tract or gut microbiome can be associated with endometriosis. We sampled vaginal, cervical and gut microbiota from 14 women with histology proven stage 3/4 endometriosis and 14 healthy controls. The V3 and V4 regions of the 16S rRNA gene were amplified following the 16S Metagenomic Sequencing Library Preparation. Despite overall similar vaginal, cervical and intestinal microbiota composition between stage 3/4 endometriosis group and controls, we observed differences at genus level. The complete absence of Atopobium in the vaginal and cervical microbiota of the stage 3/4 endometriosis group was noteworthy. In the cervical microbiota, Gardnerella, Streptococcus, Escherichia, Shigella, and Ureoplasma, all of which contain potentially pathogenic species, were increased in stage 3/4 endometriosis. More women in the stage 3/4 endometriosis group had Shigella/Escherichia dominant stool microbiome. Further studies can clarify whether the association is causal, and whether dysbiosis leads to endometriosis or endometriosis leads to dysbiosis.

The risk of extra-ovarian malignancies among women with endometriosis: A systematic literature review and meta-analysis

We conducted a meta-analysis of studies reporting on the risk of extra-ovarian malignancies among women with endometriosis. Summary relative risk (SRR) and 95% confidence intervals (CI) were calculated through random effect models. We explored causes of between-studies heterogeneity and assessed the presence of publication bias. We included 32 studies published between 1989 and 2018. We found an increased risk of endometrial (SRR 1.38, 95%CI 1.10-1.74) and thyroid cancer (SRR 1.38, 95%CI 1.17-1.63), and inverse association with cervical cancer (SRR 0.78, 95%CI 0.60-0.95). No association emerged for breast cancer (SRR 1.04, 95%CI 0.99-1.09) and melanoma (SRR 1.31, 95%CI 0.86-1.96). Between-study heterogeneity was large for breast and endometrial cancer and melanoma. Associations were generally stronger in case-control, cross-sectional, and cohort studies with internal control group, compared to cohort studies with external control group. No indication for publication bias was found. Our conclusions need to be confirmed in properly designed cohort studies with clinical confirmation of endometriosis.

Associations between internal exposure levels of persistent organic pollutants in adipose tissue and deep infiltrating endometriosis with or without concurrent ovarian endometrioma

Endometriosis is a gynaecological disease characterized by the presence of ectopic endometrial tissue. Histologically, it appears as different sub-types, being peritoneal endometriosis, ovarian endometrioma (OvE) and deep infiltrating endometriosis (DIE), which are of major relevance due to their varying clinical presentations. A number of persistent organic pollutants (POPs) have been associated with the onset of endometriosis, yet the overall set of existing studies remains fairly divergent. In this preliminary case-control study we aimed to assess the potential associations between the internal exposure to POPs and the presence of DIE with or without concurrent OvE. Adipose tissue and serum samples were collected from surgically confirmed cases (n=55) and controls (n=44) enrolled during 2013 and 2015 in Pays de la Loire, France. Targeted pollutants (76 historical or more emerging POPs including dioxins, polychlorobiphenyls (PCB), polybrominated diphenyl ethers (PBDEs), polybrominated biphenyls (PBBs), hexabromocyclododecanes (HBCDs) and organochlorine pesticides (OCPs) were quantified by chromatography coupled to mass spectrometry. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated from unconditional logistic regression adjusted for known confounding variables. The results showed significant associations between DIE and adipose tissue levels of 1.2.3.7.8 - PeCDD, OCDF, PCB 105, 114, 118 and 123, PBDE 183, PBB 153, and several OCPs including trans‑nonachlor, cis‑heptachlor epoxide, dieldrin, β-hexachlorocyclohexane and hexachlorobenzene. The largest associations were observed for OCDF followed by cis‑heptachlor epoxide, exhibiting adjusted ORs (95% CI) of 5.42 (2.73-12.85) and 5.36 (2.44-14.84) per 1-SD increase, respectively. The stratified analysis comparing both disease sub-types suggested that adipose tissue exposure markers may be more associated with DIE concurrent with OvE, however these results need to be confirmed in a larger population.