Self-management strategies amongst Australian women with endometriosis: a national online survey

An Integrative Approach for Endometriosis-Related Pain

BACKGROUND

Pain is a common, severe symptom related to endometriosis. Despite this prominent feature, there is limited literature regarding its description and use of integrative treatment methods.

OBJECTIVE

We aimed to describe endometriosis-related pain characteristics, severity, and association with an integrative approach encompassing pharmacological and non-pharmacological methods.

METHODS

A cross-sectional descriptive correlational study was conducted using convenience sampling of adult women with endometriosis-related pain. Three questionnaires were utilized: a demographic and general health questionnaire, a visual analog pain scale (VAS), and the short-form McGill pain questionnaire (SF-MPQ).

RESULTS

Participants included 93 women with a mean general pain level of 6.2/10 (SD = 2.7) on the VAS. The total mean pain score on the SF-MPQ was 26.25/45 (SD = 10.1). Sixty-four women (68.8%) reported experiencing pain at the time of completion of the questionnaire (mean: 1.6/4, SD = 1.3). All participants utilized analgesia; those who used opioids reported a higher overall mean pain score of 2.3 (SD = 1.3) than patients who did not use opioids reported a mean of 1.4 (SD = 1.2; z = 9.59; P < .001). Present pain intensity was significantly higher for women using opioids than those not using opioids. In all, 77 women (82.8%) used integrative methods to alleviate the pain symptoms. Women who utilized nutritional therapy as part of the non-pharmacological method experienced lower mean (SD) overall pain (4.4 [2.5]) compared with patients who did not utilize nutritional therapy (6.75 [2.5]; P < .01).

CONCLUSIONS

More studies are needed to find evidence-based treatment options for women for integrative pain relief for endometriosis-related pain.

I am in Charge, But Not Always in Control: A Qualitative Exploration of Female's Beliefs and Knowledge About Their Pelvic Pain

OBJECTIVES

Beliefs and knowledge about pain can influence how an individual approaches pain management. At present, there have been no investigations into the beliefs and knowledge that females hold about their pelvic pain; therefore, pain intervention approaches may not be targeted at current patient understandings. Exploring beliefs and knowledge may help inform and subsequently improve pain intervention outcomes for pelvic pain by allowing more tailored content to be delivered. This study aimed to identify beliefs and knowledge that females hold about their pelvic pain.

MATERIALS AND METHODS

Semistructured interviews (n = 12) were conducted. Based on the common sense model, interview questions investigated participants' beliefs and knowledge related to the identity (diagnostic labels), cause, consequence, control, and timeline of their pelvic pain. Transcribed interviews were analyzed using an Interpretive Description Framework.

RESULTS

Participants reported holding biopsychosocial understandings of pain; however, many described their own pain experience in a way that was more aligned with the biomedical model of pain, suggesting incongruence in pain understanding. Participants valued their ability to take charge of their pain management, highlighting bodily autonomy and being proactive in pain management approaches. This approach to management did not provide total control over participants' pelvic pain. Pelvic pain was perceived as disruptive of life, both at present and into the future, with the predictability of pain varying over time.

CONCLUSION

This study provides insight into the perspectives of females with pelvic pain. Recommendations for clinicians are provided with a focus on delivering targeted education and equipping patients with helpful representations of their pain.

Cannabis use in endometriosis: the patients have their say-an online survey for German-speaking countries

PURPOSE

Endometriosis is a chronic inflammatory disease that can cause various pain symptoms. Current therapy options do not always provide sufficient pain relief and often cause unpleasant side effects. Recent studies have shown that the endocannabinoid system is involved in the endometriosis pathophysiology, and using Cannabinoids may be a potential therapeutic option. We aimed to determine for the first time, the Cannabis use prevalence, self-rated effectiveness, and the possible reduction in medication in German-speaking countries.

METHODS

A cross-sectional online survey was distributed through endometriosis support and advocacy groups on social media. German-speaking endometriosis patients aged ≤ 18, residing in Germany, Austria, and Switzerland were eligible to participate.

RESULTS

Out of 912 participants who provided valid answers, 114 reported using cannabis for self-management. Cannabis was rated as the most effective self-management strategy to reduce symptom intensity (self-rated efficacy 7.6 out of 10). Additionally, ~ 90% of the participants were able to decrease their pain medication intake. The greatest improvement was observed in sleep (91%), menstrual pain (90%), and non-cyclic pain (80%). Apart from increased fatigue (17%), side effects were infrequent (≤ 5%).

CONCLUSION

At the time of the study, Cannabis consumption was still illegal in Germany, Austria, and Switzerland, with medical cannabis being rarely prescribed due to complex requirements. Results suggest that Cannabis has become a popular self-management method for treating endometriosis-related symptoms, leading to substantial symptom improvement. Further studies are needed to investigate the best administration methods, dosage, THC/CBD ratio, potential side effects, and long-term effects to provide official recommendations to patients and healthcare providers.

Holistic Approaches in Endometriosis - as an Effective Method of Supporting Traditional Treatment: A Systematic Search and Narrative Review

Endometriosis is one of the gynecological diseases where women suffer from pain, quality of life decreased. The aim of this review was to describe the most common non-medical methods used in the treatment of symptoms associated with endometriosis and to determine their effectiveness. The review was performed in PubMed, Embase and Web of Science databases. Randomized controlled trials, case studies, observational studies, retrospective studies, prospective studies, pilot studies, trails, publications in English or Polish were searched based on the Participant-Intervention-Comparator-Outcomes-Study design (PICOS) format. The criteria used to select studies were: women with endometriosis, no cancer, included any physiotherapeutic or non-medical intervention. 3706 articles were found, however only 26 met the inclusion criteria and were included in the review. Quality of the studies was assessed by Risk of Bias 2 tool and ROBINS-1 tool. The most holistic approach used in the treatment of symptoms of endometriosis include physical therapy, manual therapy, electrophysical agents acupuncture, diet and psychological interventions. Most research has focused on relieving pain and increasing quality of life. Non-medical methods showed reduction of symptoms of endometriosis. Physical activity, manual therapy, electrophysical agents, acupuncture, diet and cognitive behavioral therapy showed no negative side effects and reduced pain, what improved the quality of life and reduced the perceived stress.

Effects of Illness Perception and Coping Style on Self-Management in Peritoneal Dialysis Patients: A Cross-Sectional Study

Aim

Chronic disease self-management is critical to disease prognosis and patient quality of life. Several psychological factors influence this process of self-management. In this background, the present study investigated the impact of illness perceptions and coping style on self-management in people with peritoneal dialysis (PD).

Methods

The study is a cross-sectional study. From May 2022 to January 2023, a convenience sampling method was used to recruit 246 peritoneal dialysis patients. General information questionnaire, brief illness perception questionnaire, medical coping style modes questionnaire and the self-management scale for peritoneal dialysis patients were used in this study. We used SPSS 24.0 to analyze the data, and the statistical methods included descriptive analysis, single factor analysis, Pearson correlation analysis and multiple linear regression analysis.

Results

A total of 246 patients were included in this study (93.89% response rate). Cognitive representations and emotional representations were 30.40, 14.18, respectively. However, illness comprehensibility was 2.87. Illness perceptions were negative significantly correlated with self-management. With regard to coping style, our patients were more likely to adopt avoidance and resignation coping style. Confrontation and avoidance were positively related to self-management, while acceptance-resignation was negatively related.

Conclusion

Self-management of peritoneal dialysis patients needs to be improved. Age, female sex, monthly income, illness perceptions and coping style were independently associated with self-management.

Impact

These findings suggest that interventions that improve illness perceptions and coping style should be explored to ultimately improve their self-management. For example, patients can be provided with psychological counseling so that they can face the disease correctly, and we should pay attention to the positive role of social support.

Exercise and endometriosis-is there a promising future? A narrative review

BACKGROUND

Endometriosis is the leading cause of chronic pelvic pain in women of reproductive age with debilitating effects on quality of life, yet no cure exists. Exercise yields the potential in providing women with a non-invasive, non-pharmacological method of symptom control.

AIM(S)

Present up-to-date knowledge regarding how exercise may contribute to the management of endometriosis-related symptoms.

OBJECTIVE(S)

Discuss: 1. The pathophysiology surrounding exercise and endometriosis. 2. The role of exercise in endometriosis symptom control.

RATIONALE

Scientific literature has alluded to exercise being a favourable factor in the management of endometriosis-related symptoms. Moreover, current clinical guidelines for endometriosis fail to reflect the aforementioned benefits of exercise.

SEARCH STRATEGY

A search strategy using the terms 'endometriosis', 'endometriomas', 'exercise', and 'physical activity' was devised. Pubmed, Medline, Cochrane reviews, and Embase were reviewed.

INCLUSION CRITERIA

Interventional studies, within-subjects studies, randomised-control trials, systematic reviews, meta-analysis, cohort studies, publication since 2000.

EXCLUSION CRITERIA

Non-English publications, non-human studies.

RESULTS

Numerous studies have suggested positive effects for endometriosis patients who performed exercise exclusively or in conjunction with other therapies. Improvements in pain levels, quality of life, anxiety, and depression were noted.

DISCUSSION

Current research outlines promise regarding the potential benefit of exercise prescribing in patients with endometriosis as well as a synergy between exercise and hormonal therapies for the management of endometriosis-related symptoms. However, the current paucity of high-quality robust studies investigating these aspects of endometriosis management is an apparent obstacle to progression in this area.

CONCLUSION

For clinicians to incorporate exercise in managing endometriosis, clear recommendations regarding advice and benefits are needed.

Can general exercise training and pelvic floor muscle training be used as an empowering tool among women with endometriosis? Experiences among women with endometriosis participating in the intervention group of a randomized controlled trial

BACKGROUND

The potential benefit of exercise in alleviating symptoms of endometriosis is unclear. Still, exercise may be used to empower women and manage disease symptoms. The purpose of this study was to explore how regular supervised group- and individual exercise training, including pelvic floor muscle training (PFMT), is experienced among women with endometriosis after participating in a randomized controlled trial (RCT).

METHODS

Among 41 women randomized to exercise training for four months, ten women were interviewed about their experiences with exercise training after participation in the trial. The weekly group training was led by women's health physiotherapists and included individualized and progressive muscular strength training of large muscle groups and the pelvic floor muscles, in addition to endurance-, flexibility, and relaxation training. An individual training program followed the same principles as the group training and was to be performed 3-5 times per week, depending on the level of intensity. PFMT was recommended daily. The women also received a group pain management course emphasizing exercise training as self-management. Using inductive reflexive thematic analysis, responses to the question "Did participation in the study change your view of exercise as part of the treatment for endometriosis?" were analyzed.

RESULTS

The women brought forward the importance of knowledge about the benefits of exercise to make informed decisions in disease management. Further, the women described how exercise training was perceived as less frightening and manageable when exposed to various intensities, dosages, and types of exercises in a safe and supportive environment. PFMT was especially brought forward as something new and appreciated, and for some of the women, to be performed on days when their bodies could not handle the general exercise training. They also expressed that the supervised exercise brought an extra dimension of belonging through group participation.

CONCLUSIONS

Individualization and regular supervision seem important to empower women with knowledge about exercise training as self-management and to experience exercise training as safe and non-threatening. Further, creating a sense of belonging through group training may improve social support and build active coping strategies that are essential for disease management of endometriosis.

TRIAL REGISTRATION

NCT05091268 (registered 23.09.2021).

Eating for Optimization: Unraveling the Dietary Patterns and Nutritional Strategies in Endometriosis Management

Endometriosis is a chronic gynecological disorder affecting millions of women worldwide, causing chronic pelvic pain, dyspareunia, dysmenorrhea, and infertility, and severely impacting their quality of life. Treatment primarily involves hormonal therapies and surgical excision, but high recurrence rates and the economic burden are substantial. With these challenges, significant discussion surrounds the potential role of dietary patterns in managing endometriosis, making it necessary to bridge this critical gap. This review investigates the current scientific evidence on the dietary patterns (eg, Mediterranean, vegetarian, anti-inflammatory, low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols [low-FODMAP], and Western-style diets) associated with endometriosis and provides a concise, yet thorough, overview on the subject. In addition, antioxidants, microbiota, and artificial intelligence (AI) and their potential roles were also evaluated as future directions. An electronic-based search was performed in MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, Scopus, and Web of Science. The current data on the topic indicate that a diet based on the Mediterranean and anti-inflammatory diet pattern, rich in dietary fiber, omega-3 fatty acids, plant-based protein, and vitamins and minerals, has a positive influence on endometriosis, yielding a promising improvement in patient symptoms. Preclinical investigations and clinical trials indicate that dietary antioxidants and gut microbiota modulation present potential new approaches in managing endometriosis. Also, AI may offer a promising avenue to explore how dietary components interact with endometriosis. Ultimately, considering genetic and lifestyle factors, a healthy, balanced, personalized approach to diet may offer valuable insights on the role of diet as a means of symptom improvement, facilitating the utilization of nutrition for the management of endometriosis.

Laparoscopic nerve lysis for deep endometriosis improves quality of life and chronic pain levels: A pilot study

OBJECTIVES

To assess the benefit of surgical management of patients with endometriosis infiltrating pelvic nerves in terms of pain, analgesic consumption, and quality of life (QOL).

METHODS

We conducted a retrospective cohort study In an Endometriosis referral center at a tertiary care university affiliated medical center. Patients diagnosed with endometriosis that underwent laparoscopic neurolysis for chronic pain were included. Patients rated their pain before and after surgery and differentiated between chronic pain and acute crises. Patients were requested to maintain a record of analgesic consumption and to evaluate their quality-of-life (QOL).

RESULTS

Of the 21 patients in our study 15 (71.5 %) had obturator nerve involvement, 2 (9.5 %) had pudendal nerve involvement and 4 (19 %) had other pelvic nerve involvement. Median postoperative follow - up was of 8 months. All but 2 patients (9.6 %) had significant chronic pain improvement with a mean decrease of VAS of 3.05 (±2.5). Analgesic habits changed postoperatively with a significant decrease of 66 % of patients' daily consumption of any analgesics. Surgery improved QOL in 12 cases (57.1 %) and two patients (9.6 %) completely recovered with a high QOL.

CONCLUSION

Neurolysis and excision of endometriosis of pelvic nerves could results in significant improvement of quality of life.

Evaluating the Current Evidence for the Efficacy of Cannabis in Symptom Management of Endometriosis-Associated Pain

Introduction

Endometriosis is a chronic condition that affects millions of women in the United States. Chronic pain can be debilitating and complex to manage. Despite common approaches like hormonal treatments and surgery, many women continue to endure pain. Managing the chronic and multifaceted nature of endometriotic pain necessitates a comprehensive strategy.

Methods

This study explores the potential of cannabis in alleviating endometriosis-related pain through an extensive literature search. Cohort studies, case-control studies, cross-sectional surveys, and systematic reviews from January 1996 to August 2022 were eligible for inclusion. Articles were then assessed and included for further analysis if they met the following criteria: (1) Population was women with endometriosis; (2) Discussed the therapeutic use of medical cannabis for endometriosis-related pain.

Results

The literature search revealed 522 articles, with eight articles meeting criteria for analysis: four cross-sectional surveys, two systematic reviews, one retrospective cohort study, and one literature review. Cannabis consumption for symptom relief was common among women with endometriosis, and some even reported that the use of cannabis reduced their use of analgesics.

Discussion

The use of cannabis for endometriosis-related pain holds significant promise for addressing the often-debilitating comfort experienced by those with this condition. By interacting with the endocannabinoid system, cannabis may provide relief by modulating pain perception, reducing inflammation, relaxing muscles, and alleviating neuropathic discomfort.

Women's Self-Management of Dyspareunia Associated With Endometriosis: A Qualitative Study

Given the limitations of medical treatment for endometriosis, self-management is a critical component of symptom management, and providing patients with information and education is a necessary complement to medical interventions. Though 50 to 70% of people with endometriosis experience dyspareunia (painful sex), there is limited knowledge of self-management specific to painful sex. A comprehensive understanding of the self-management strategies used is foundational to developing supportive care interventions that help ease pain and related psychosocial sequelae. The objective was to describe people's experiences of navigating endometriosis-associated painful sex and developing self-management strategies. We analyzed interview data from 20 women using constant comparative and thematic analysis techniques, guided by qualitative interpretive description methodology. Participants (age range 18-44 years) all identified as women and were predominately Caucasian (90%) and heterosexual (80%). Throughout their lives, the women appeared to gradually develop self-management strategies while navigating painful sexual experiences. This complex journey encompassed four phases: 1) viewing painful sex as normal, 2) experiencing evolving thoughts and emotions, 3) coming to understand painful sex and seeking help, and 4) learning strategies to navigate painful sex, these include preparing mentally and physically for sex and communicating with intimate partner(s). Women in this study developed self-management strategies over time through engagement with others who understood their challenges. Future research is warranted regarding initiatives to counter the normalization of painful sex, develop and disseminate patient-facing information, provide education specific to dyspareunia, improve access to multidisciplinary care, facilitate social connections and support, and enhance communication with intimate partners. PERSPECTIVE: In this paper, we report on the experiences of women with endometriosis-associated painful sex and their self-management strategies. Clinicians may be interested in a qualitative exploration of endometriosis-associated painful sex as they seek to further understand their patient's experiences and what strategies can be implemented to alleviate dyspareunia. DATA AVAILABILITY: The data sets generated during and/or analyzed during the current study are not publicly available as participants did not consent to making their data publicly available but are available from the corresponding author on reasonable request.

A gluten-free diet for endometriosis patients lacks evidence to recommend it

Endometriosis is an estrogen-dependent chronic disease characterized by the presence of endometriumlike tissue outside the uterus and is often associated with symptoms, such as dysmenorrhea, dysuria, dyschezia, chronic pelvic pain, and infertility. Moreover, women diagnosed with endometriosis can report gastrointestinal symptoms, including bloating, constipation or diarrhea, and abdominal cramping, which can be associated with irritable bowel syndrome and can result in the misdiagnosis of endometriosis as irritable bowel syndrome at first. Treatment usually involves hormonal therapy, pain management, surgery, and/or assisted reproductive techniques in case of infertility. Nonetheless, these treatment methods can be insufficient for alleviating symptoms or can have unacceptable side effects, leading to noncompliance. Therefore, women often apply self-management strategies, including dietary interventions. One of the diets frequently suggested as a tool to manage endometriosis-related symptoms on social media and patient forums is a gluten-free diet. Although a gluten-free diet has been proven effective in managing nonceliac wheat sensitivity or celiac disease, its effectiveness in endometriosis remains uncertain. The Nurses' Health Study II found it unlikely that gluten intake was a strong factor in endometriosis etiology and symptomatology. To the best of our knowledge, the most frequently cited and sole published intervention study on the efficacy of a gluten-free diet for endometriosis has several important limiting factors, including the absence of a control group. In addition, gluten consumption is highly susceptible to a placebo effect and a nocebo effect, where women might experience symptom relief after eliminating gluten and return of symptoms after they consume gluten again, solely because they believe that gluten is bad for them. Despite the inverse association between body mass index and endometriosis and between a gluten-free diet and increased body mass index, this is an association, and no causality was proven. In addition, other factors should be taken into consideration. Of note, a gluten-free diet is expensive, has limited availability, and has a significant effect on quality of life. Moreover, without proper dietary guidance, it may adversely affect the gastrointestinal microbiome. Therefore, scientifically substantiated advice regarding the use of a gluten-free diet for endometriosis-related symptoms is currently not available, and a gluten-free diet should be discouraged unless there is an additional diagnosis of nonceliac wheat sensitivity or celiac disease.

Holistic approach to care for patients with endometriosis

PURPOSE OF REVIEW

Endometriosis is a chronic, often debilitating, disease which is typically managed with surgery and hormonal medications. However, many patients feel they lack agency when managing endometriosis symptoms. The purpose of this review is to discuss the mental and physical management strategies, the long-term health consequences, and the role of a multidisciplinary team in the treatment of endometriosis.

RECENT FINDINGS

Evidence is becoming more robust regarding the role of complementary care and physical activity in the management of endometriosis. Health risks such as infertility are well known and newer evidence is evolving regarding perinatal and cardiovascular health risks. There are also trends towards multiple specialist involvement in the care of endometriosis and the benefit of interdisciplinary collaboration.

SUMMARY

Endometriosis is a frequently recurrent condition requiring not only meticulous medical and surgical care, but also coordinated longitudinal disease management and impact mitigation. Gynecologists should be aware of the short-term and long-term implications of the disease to empower patients on the management of their overall health.

Impact of lifestyle and dietary modifications for endometriosis development and symptom management

PURPOSE OF REVIEW

Management of endometriosis is often complex and poorly studied. Patients with endometriosis have interest in how their lifestyle may affect their diagnosis. Self-management and lifestyle changes are often used as adjunct therapy, but best practices are not concrete in treatment guidelines.

RECENT FINDINGS

Lifestyle impact on endometriosis and possible self-management treatment therapies are reviewed. Overall, there is a need for future studies in all topics. Data suggest a link between endocrine-disrupting chemicals (EDCs), particularly persistent EDCs, and endometriosis. More work is needed to isolate and quantify exposures and explore their connection to endometriosis in order to provide guidance for clinical practice recommendations. There is insufficient evidence to support a superior diet for management of endometriosis; however, the Mediterranean diet may have the most benefit without nutrition concerns. Exercise may be another tool to improve endometriosis symptoms, but once again data are limited and best type and frequency is not well studied. Best evidence supports body-mind practices such as yoga, although new evidence suggests benefit from a holistic combination of several types of exercises.

SUMMARY

Overall, data on lifestyle effects and associated therapies are limited. Future high-quality studies are needed to guide practice.

Endometriosis: A Comprehensive Analysis of the Pathophysiology, Treatment, and Nutritional Aspects, and Its Repercussions on the Quality of Life of Patients

Endometriosis is a chronic proinflammatory pathology characterized by the growth of tissue similar to the endometrium outside the uterus, affecting approximately 5 to 15% of women worldwide. Suffering from endometriosis entails a complex pathophysiological process, significantly impacting the quality of life and reproductive function of affected women; therefore, it must be addressed in a personalized and comprehensive manner, as its management requires a multidisciplinary approach. This article aims to conduct a comprehensive literature review of endometriosis, not only as a pathophysiological condition but also as a significant factor impacting the social, nutritional, and mental well-being of those who experience it. Emphasis is placed on the importance of understanding and assessing the impact of the pathology to provide a better and more comprehensive approach, integrating various alternatives and strategic treatments for the factors involved in its development. The aim is to provide a complete overview of endometriosis, from its pathophysiology to its impact on the quality of life of patients, as well as a review of current treatment options, both pharmacological and alternative, in order to broaden the perspective on the pathology to improve the care of patients with this disease.

Self-management of primary dysmenorrhea-related pain: cross-sectional study on non-pharmacological interventions

Aim: Different nonpharmacological strategies are adopted to decrease primary dysmenorrhea (PD)-related pain. The present study aimed to verify women's use of nonpharmacological methods for pain and compare them with evidence from the literature.Materials & methods: A two-step study was conducted, comprising an online survey with 9144 women to assess nonpharmacological strategies for relieving PD-related pain, and a literature review on PubMed of verify the evidence of nonpharmacological methods.Results: Many women reported using heat therapy (61.5%), tea (42.4%) and massage (30.9%) to alleviate menstrual pain. However, the literature on these methods is limited.Conclusion: Several nonpharmacological methods are used by women to relieve PD-related pain and studies with low bias risk are needed to prove their effectiveness.

The accessibility of pelvic health physiotherapy for adolescents with persistent pelvic pain: a qualitative framework analysis

BACKGROUND

Physiotherapy, with a specific focus on pelvic health, is one service used in the multidisciplinary management of adolescent persistent pelvic pain (PPP). However, there has been little investigations into the accessibility of physiotherapy for adolescents with PPP.

OBJECTIVE

This qualitative study aimed to detail the experiences of adolescents with PPP accessing a tertiary hospital physiotherapy service.

METHODS

Two focus groups included six adolescent females diagnosed with PPP that had either a) been referred and attended the physiotherapy clinic (n = 5), or b) been referred to physiotherapy but yet to attend their appointment (n = 1 plus one support person). Focus group transcripts were deductively thematically analyzed according to four domains from the patient-centered healthcare accessibility framework.

RESULTS

The domain of 'Approachability and ability to perceive' was impacted by limited information and poor patient health literacy. 'Acceptability and ability to seek' was hindered by adolescent mental health struggles and failures of previous PPP management. 'Availability and accommodation, and ability to reach' was influenced by lengthy referral processes, and reliance on familial support for transport. 'Acceptability and ability to engage' was facilitated by engaging clinicians and group environments, however, adolescents became dependent on physiotherapy for pain management.

CONCLUSION

Physical, social, and environmental factors influence the accessibility of physiotherapy for adolescents with PPP. Healthcare services should consider the specific needs of adolescents with PPP for optimizing accessibility.

Factors influencing health-related quality of life in women with endometriosis: A cross-sectional study

This study aimed to assess the health-related quality of life and identify its associated factors in women with endometriosis. A cross-sectional correlation study design and convenience sampling were conducted in the gynecological outpatient clinic of a teaching hospital in northern Taiwan. A total of 216 women with endometriosis were recruited. The data were collected using structured questionnaires and analyzed using descriptive and inferential statistics. Participants reported a moderate level of health-related quality of life. The most significant impact of endometriosis on health-related quality of life was emotional well-being, followed by feeling of control or powerless, pain, social support, and self-image. Educational attainment, menstrual cycle, period length, perceived menstrual flow, symptom distress, and self-management strategies explained 66% of the variance in health-related quality of life. Factors influencing health-related quality of life in women with endometriosis play a key role in promoting women's well-being. Interventions based on these related factors should be developed and taken into practice to effectively manage the disease-related symptoms for women with endometriosis and thereby improve their overall health-related quality of life.

Towards comprehensive management of symptomatic endometriosis: beyond the dichotomy of medical versus surgical treatment

Except when surgery is the only option because of organ damage, the presence of suspicious lesions, or the desire to conceive, women with endometriosis-associated pain often face a choice between medical and surgical treatment. In theory, the description of the potential benefits and potential harms of the two alternatives should be standardized, unbiased, and based on strong evidence, enabling the patient to make an informed decision. However, doctor's opinion, intellectual competing interests, local availability of specific services and (mis)information obtained from social media, and online support groups can influence the type of advice given and affect patients' choices. This is compounded by the paucity of robust data from randomized controlled trials, and the anxiety of distressed women who are eager to do anything to alleviate their disabling symptoms. Vulnerable patients are more likely to accept the suggestions of their healthcare provider, which can lead to unbalanced and physician-centred decisions, whether in favour of either medical or surgical treatment. In general, treatments should be symptom-orientated rather than lesion-orientated. Medical and surgical modalities appear to be similarly effective in reducing pain symptoms, with medications generally more successful for severe dysmenorrhoea and surgery more successful for severe deep dyspareunia caused by fibrotic lesions infiltrating the posterior compartment. Oestrogen-progestogen combinations and progestogen monotherapies are generally safe and well tolerated, provided there are no major contraindications. About three-quarters of patients with superficial peritoneal and ovarian endometriosis and two-thirds of those with infiltrating fibrotic lesions are ultimately satisfied with their medical treatment although the remainder may experience side effects, which may result in non-compliance. Surgery for superficial and ovarian endometriosis is usually safe. When fibrotic infiltrating lesions are present, morbidity varies greatly depending on the skill of the individual surgeon, the need for advanced procedures, such as bowel resection and ureteral reimplantation, and the availability of expert colorectal surgeons and urologists working together in a multidisciplinary approach. The generalizability of published results is adequate for medical treatment but very limited for surgery. Moreover, on the one hand, hormonal drugs induce disease remission but do not cure endometriosis, and symptom relapse is expected when the drugs are discontinued; on the other hand, the same drugs should be used after lesion excision, which also does not cure endometriosis, to prevent an overall cumulative symptom and lesion recurrence rate of 10% per postoperative year. Therefore, the real choice may not be between medical treatment and surgery, but between medical treatment alone and surgery plus postoperative medical treatment. The experience of pain in women with endometriosis is a complex phenomenon that is not exclusively based on nociception, although the role of peripheral and central sensitization is not fully understood. In addition, trauma, and especially sexual trauma, and pelvic floor disorders can cause or contribute to symptoms in many individuals with chronic pelvic pain, and healthcare providers should never take for granted that diagnosed or suspected endometriosis is always the real, or the sole, origin of the referred complaints. Alternative treatment modalities are available that can help address most of the additional causes contributing to symptoms. Pain management in women with endometriosis may be more than a choice between medical and surgical treatment and may require comprehensive care by a multidisciplinary team including psychologists, sexologists, physiotherapists, dieticians, and pain therapists. An often missing factor in successful treatment is empathy on the part of healthcare providers. Being heard and understood, receiving simple and clear explanations and honest communication about uncertainties, being invited to share medical decisions after receiving detailed and impartial information, and being reassured that a team member will be available should a major problem arise, can greatly increase trust in doctors and transform a lonely and frustrating experience into a guided and supported journey, during which coping with this chronic disease is gradually learned and eventually accepted. Within this broader scenario, patient-centred medicine is the priority, and whether or when to resort to surgery or choose the medical option remains the prerogative of each individual woman.

"SO FAR AWAY" How Doctors Can Contribute to Making Endometriosis Hell on Earth. A Call for Humanistic Medicine and Empathetic Practice for Genuine Person-Centered Care. A Narrative Review

"SO FAR AWAY" * How Doctors Can Contribute to Making Endometriosis Hell on Earth [* by Knopfler M. In Dire Straits. Brothers in Arms. Vertigo Records, U.K., 1985].

Abstract

The distance physicians may create within the relationship with their patients by not having a humanistic approach to their practice may strongly influence clinical outcomes. The purpose of this paper is to convey the well-known narrative of patient dissatisfaction into pro-action by discussing the aspects of dehumanization, which may occur in the relationship between physicians and women with endometriosis. Eight dimensions of dehumanization are examined and related to everyday scenarios occurring in endometriosis care settings and the possible downstream consequences on patients' clinical outcomes are described. Objectification, which may come across as minimization of pain, may not only increase patients' perception of pain but also lead to undertreatment of unrecognized forms of endometriosis, especially among adolescents. Passivity, that is not favoring shared decision-making nor self-management, may compromise adherence to treatment, reducing patients' trust in physicians and quality of life. The same consequences may result from homogenization, that is giving for granted that all patients have the same access to care. Both isolation, ie not practicing therapeutic empathy, and loss of meaning, ie not supporting patients in the re-definition of their life plans, may affect women's psychological wellbeing and further increase pain perception. Ignoring women's personal journey by not providing clear information on the consequences endometriosis may have on their lives may favor women's self-silencing. Not promoting an un-biased communication and not setting aside scientific polarization are the main features of dislocation, which may jeopardize patient empowerment. Lastly, having a reductionist approach to the body may contribute to chronicization of pain, thus compromising quality of life. This considered, taking time to listen to women with endometriosis and tailoring decisions on the basis of their individual needs should be fostered as a moral duty. Physicians should always keep in mind that they are not only deliverers of treatment; they are a form of treatment themselves.

Differences in characteristics and use of complementary and alternative methods for coping with endometriosis-associated acyclic pelvic pain across adolescence and adulthood

Introduction

Over four million women in the US alone have been diagnosed with endometriosis. For those living with this disease, surgery and hormonal treatment reduce associated pelvic pain in some, while others continue to experience life impacting pain. Therefore, identification of accessible and cost-effective methods of pain reduction to compliment current treatment is urgently needed. Our objective was to quantify the prevalence of complementary and alternative methods used to manage acyclic pelvic pain and their reported benefit among women of different age groups living with endometriosis.

Methods

We used baseline questionnaire data from laparoscopically-confirmed endometriosis cases who completed a WERF EPHect compliant questionnaire in the longitudinal cohort of The Women's Health Study: From Adolescence to Adulthood (A2A). Participants with acyclic pelvic pain were asked to indicate specific methods or activities that either helped or worsened their pelvic/lower abdominal pain. Differences among age groups [adolescent (<18 years), young adult (18-25 years), and adult (>25 years)] were assessed using Fisher's exact test.

Results

Of the 357 participants included in analysis, sleep for coping was reported more frequently among adolescents (n = 59, 57.3%) compared to young adults (n = 40, 44.0%) and adults (n = 19, 31.1%; p = 0.004). Adolescents also reported more frequent use of music (n = 29, 21.2%) than young adults (n = 10, 7.0%) and adults (n = 7, 9.1%; p = 0.001). Exercise worsened pain most commonly among adolescents (n = 82, 59.9%), followed by younger adults (n = 67, 46.9%), and adults (n = 27, 35.1%; p = 0.002).

Discussion

Our analysis of participants in the A2A cohort showed that the prevalence of complementary and alternative methods used for coping with endometriosis-associated acyclic pelvic pain varied by age group. Future studies should aim to provide information that will further inform decisions in making care plans for managing endometriosis-associated pain that is effective, accessible, and tailored to the preferences of the patient.

How Can Selected Dietary Ingredients Influence the Development and Progression of Endometriosis?

Endometriosis is a chronic, hormone-dependent disease characterized by the presence of endometrial tissue in ectopic locations. Since the treatment options for this disease are still limited, and the cure rate is unsatisfactory, the search for ways to treat symptoms and modify the course of the disease is of key importance in improving the quality of life of patients with endometriosis. So far, the literature has shown that nutrition can influence endometriosis through hormonal modification and altering the inflammatory or oxidative response. Since the importance of nutrition in this disease is still a subject of scientific research, we aimed to summarize the current knowledge on the role of dietary modifications in endometriosis. Our review showed that nutrients with anti-inflammatory and antioxidant properties, including most vitamins and several trace elements, may influence the pathogenesis of endometriosis and can be considered as the nutrients preventing the development of endometriosis. However, despite the many discoveries described in this review, further interdisciplinary research on this topic seems to be extremely important, as in the future, it may result in the development of personalized therapies supporting the treatment of endometriosis.

Comprehensive endometriosis care: a modern multimodal approach for the treatment of pelvic pain and endometriosis

Endometriosis is a prevalent gynecological disease, leading to chronic pain and inflammation, affecting 1 in 10 individuals presumed female at birth. The diagnostic journey is often arduous, marked by neglect of the right diagnosis and prolonged wait times, significantly compromising the quality of life among those affected. This review provides a nuanced exploration of endometriosis-associated pain management, encompassing medical, surgical, and holistic approaches, all guided by accurate and refined diagnostics. Our paramount goal is to empower physicians as key figures in confronting this intricate challenge with a patient-centric approach, ultimately aiming to improve treatment and quality of life. Acknowledging each patient's unique needs, we emphasize the importance of tailoring a spectrum of options informed by current literature and insights gleaned from our experience in a high-volume tertiary endometriosis center. It is imperative to recognize endometriosis as a complex and chronic disease, often occurring with co-morbid conditions and nuanced complexities, necessitating a long-term personalized multimodal approach for each case. In addition, incorporating principles such as patient autonomy, profound respect for diverse experiences, and practical education on treatment choices is pivotal in enhancing treatment outcomes and overall patient satisfaction.

The effect of dietary interventions on pain and quality of life in women diagnosed with endometriosis: a prospective study with control group

STUDY QUESTION

What is the influence of dietary interventions, namely the low fermentable oligo-, di-, mono-saccharides, and polyols (Low FODMAP) diet and endometriosis diet, on endometriosis-related pain and quality of life (QoL) compared to a control group?

SUMMARY ANSWER

After adhering to a dietary intervention for 6 months, women with endometriosis reported less pain and an improved QoL compared to baseline whereas, compared to the control group, they reported less bloating and a better QoL in 3 of 11 domains.

WHAT IS KNOWN ALREADY

Standard endometriosis treatment can be insufficient or may be accompanied by unacceptable side effects. This has resulted in an increasing interest in self-management strategies, including the appliance of the Low FODMAP diet and the endometriosis diet (an experience-based avoidance diet, developed by women with endometriosis). The Low FODMAP diet has previously been found effective in reducing endometriosis-related pain symptoms, whereas only limited studies are available on the efficacy of the endometriosis diet. A survey study recently found the endometriosis diet effective in improving QoL but currently no guidelines on use of the diet exist.

STUDY DESIGN, SIZE, DURATION

A prospective one-center pilot study was performed between April 2021 and December 2022. Participants could choose between adherence to a diet-the Low FODMAP diet or endometriosis diet-or no diet (control group). Women adhering to a diet received extensive guidance from a dietician in training. The follow-up period was 6 months for all three groups. For all outcomes, women adhering to the diets were compared to their baseline situation and to the control group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included women diagnosed with endometriosis (surgically and/or by radiologic imaging) who reported pain scores ≥3 cm on the visual analogue score (0-10 cm) for dysmenorrhea, deep dyspareunia, and/or chronic pelvic pain. The primary endpoint focused on pain reduction for all pain symptoms, including dysuria, bloating, and tiredness. Secondary endpoints, assessed via questionnaires, focused on QoL, gastro-intestinal health, and diet adherence.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 62 participants were included in the low FODMAP diet (n = 22), endometriosis diet (n = 21), and control group (n = 19). Compared to their baseline pain scores, participants adhering to a diet reported less pain in four of six symptoms (range P < 0.001 to P = 0.012) and better scores in 6 of 11 QoL domains (range P < 0.001 to P = 0.023) after 6 months. Compared to the control group, analyzed longitudinally over the 6-month follow-up period, participants applying a diet reported significant less bloating (P = 0.049), and better scores in 3 of 11 QoL domains (range P = 0.002 to P = 0.035).

LIMITATIONS, REASONS FOR CAUTION

No sample size was calculated since efficacy data were lacking in the literature. In order to optimize dietary adherence, randomization was not applied, possibly resulting in selection bias.

WIDER IMPLICATIONS OF THE FINDINGS

Our study suggests that women could benefit from adherence to a dietary intervention, since we found lower pain scores and better QoL after 6 months. However, caution is implied since this is a pilot study, no sample size was calculated, and data on long-term effects (>6 months) are lacking. The results of this pilot study underline the importance of further research and the drawing up of guidelines.

STUDY FUNDING/COMPETING INTEREST(S)

A.v.H. reports receiving a travel grant from Merck outside the scope of this study. J.W., S.V., J.T., and B.D.B. have no conflicts of interest to report. A.d.V. reports having received KP-register points for internship guidance of J.W., performing paid consultations with endometriosis patients outside the study and receiving reimbursements for educational lectures at the local hospital (Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands). A.S. reports having received expenses for travel and hotel costs as an invited speaker from ESHRE. This was outside the scope of this study. M.v.W. reports that she is a Co-Ed of Cochrane Gynecology and Fertility. V.M. reports receiving travel and speaker's fees from Guerbet and research grants from Guerbet, Merck and Ferring. The department of reproductive medicine (V.M.) of the Amsterdam UMC, location VUmc, has received several research and educational grants from Guerbet, Merck and Ferring not related to the submitted work.

TRIAL REGISTRATION NUMBER

N/A.

An Intersectional Approach to Quantifying the Impact of Geographic Remoteness and Health Disparities on Quality-Adjusted Life Expectancy: Application to Australia

OBJECTIVES

An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) is a novel method for exploring the interaction between sociodemographic characteristics that affect health outcomes. This study explores the interaction between geographic remoteness and socioeconomic status on health outcomes in Australia from an intersectional perspective.

METHODS

Data from a cross-sectional survey were matched with data from the Australian Bureau of Statistics and the Australian Institute of Health and Welfare. To explore the effect of health-related quality of life on life expectancy, quality-adjusted life expectancy (QALE) was estimated through applying utility values derived from the EQ-5D-5L to life table data from the Australian Bureau of Statistics. The effect of geographic remoteness on QALE was quantified using multivariable linear regression. An intersectional MAIHDA was performed to explore differences in mean QALE across strata formed by intersections of age, sex, and Socioeconomic Indexes for Areas score.

RESULTS

Based on multivariable linear modeling, QALE declined significantly with increasing remoteness (inner regional, -1.0 years [undiscounted]; remote/very remote, -3.3 years [undiscounted]) (P < .001). In contrast, life expectancy was only significantly different between participants in remote/very remote areas and major cities (β-coefficient, -2.4; 95% CI -4.4 to -0.4; P = .016). No intersectional interaction effects between strata on QALE were found in the MAIHDA.

CONCLUSIONS

QALE has considerable value as a metric for exploring disparities in health outcomes. Given that no intersectional interactions were identified, our findings support broad interventions that target the underlying social determinants of health appropriately reduce disparities versus interventions targeting intersectional interactions.

Endo Belly: What Is It and Why Does It Happen?-A Narrative Review

Endometriosis is a chronic inflammatory disease where endometrial-like lesions settle outside the uterus, resulting in extensive inflammatory reactions. It is a complex disease that presents with a range of symptoms, with pain and infertility being the most common. Along with severe dysmenorrhea, cyclic and acyclic lower abdominal pain, cyclic dysuria and dyschezia, dyspareunia, and infertility, there are also nonspecific complaints that can cause confusion and make endometriosis the chameleon among gynecological diseases. These symptoms include unspecific intestinal complaints, cyclic diarrhea, but also constipation, nausea, vomiting, and stomach complaints. It appears that in addition to general bowel symptoms, there are also specific symptoms related to endometriosis such as cyclic bloating of the abdomen, known as endo belly. During the second half of the menstrual cycle leading up to menstruation, the abdomen becomes increasingly bloated causing discomfort and pain due to elevated sensitivity of the intestinal wall. Patients with endometriosis exhibit a reduced stretch pain threshold of the intestinal wall. Here, we review the endo belly, for the first time, pathophysiology and the influence of other diseases (such as irritable bowel syndrome-IBS), microbiome, hormonal levels, inflammation, and diet on the presentation of this condition.

Cannabis and Endometriosis: The Roles of the Gut Microbiota and the Endocannabinoid System

Endometriosis, a chronic condition affecting around 10-14% of women, is challenging to manage, due to its complex pathogenesis and limited treatment options. Research has suggested a potential role of the gut microbiota and the endocannabinoid system in the development and progression of endometriosis. This narrative review aims to explore the role of, and any potential interactions between, the endocannabinoid system (ECS) and the gut microbiota in endometriosis. This review found that both the ECS and microbiota influence endometriosis, with the former regulating inflammation and pain perception and the latter influencing immune responses and hormonal balance. There is evidence that a dysregulation of the endocannabinoid system and the gut microbiota influence endometriosis symptoms and progression via changes in CB1 receptor expression and increased circulating levels of endocannabinoids. Microbial imbalances in the gut, such as increases in Prevotella, have been directly correlated to increased bloating, a common endometriosis symptom, while increases in E. coli have supported the bacterial contamination hypothesis as a potential pathway for endometriosis pathogenesis. These microbial imbalances have been correlated with increases in inflammatory markers such as TNF-α and IL-6, both often raised in those with endometriosis. Protective effects of the ECS on the gut were observed by increases in endocannabinoids, including 2-AG, resulting in decreased inflammation and improved gut permeability. Given these findings, both the ECS and the gut microbiota may be targets for therapeutic interventions for endometriosis; however, clinical studies are required to determine effectiveness.

The Place of Cannabinoids in the Treatment of Gynecological Pain

Cannabis sativa (L), a plant with an extensive history of medicinal usage across numerous cultures, has received increased attention over recent years for its therapeutic potential for gynecological disorders such as endometriosis, chronic pelvic pain, and primary dysmenorrhea, due at least in part to shortcomings with current management options. Despite this growing interest, cannabis inhabits an unusual position in the modern medical pharmacopoeia, being a legal medicine, legal recreational drug, and an illicit drug, depending on jurisdiction. To date, the majority of studies investigating cannabis use have found that most people are using illicit cannabis, with numerous obstacles to medical cannabis adoption having been identified, including outdated drug-driving laws, workplace drug testing policies, the cost of quality-assured medical cannabis products, a lack of cannabis education for healthcare professionals, and significant and persistent stigma. Although currently lacking robust clinical trial data, a growing evidence base of retrospective data, cohort studies, and surveys does support potential use in gynecological pain conditions, with most evidence focusing on endometriosis. Cannabis consumers report substantial reductions in pelvic pain, as well as common comorbid symptoms such as gastrointestinal disturbances, mood disorders such as anxiety and depression, and poor sleep. Substitution effects were reported, with >50% reduction or cessation in opioid and/or non-opioid analgesics being the most common. However, a substantial minority report not disclosing cannabis consumption to their health professional. Therefore, while such deprescribing trends are potentially beneficial, the importance of medical supervision during this process is paramount given the possibility for withdrawal symptoms.

"A glimmer of hope" - Perceptions, barriers, and drivers for medicinal cannabis use amongst Australian and New Zealand people with endometriosis

Previous quantitative research has shown that cannabis use, mostly illicit, is used for symptom management amongst those with endometriosis living in Australia or New Zealand, but the drivers and barriers for use of legal, medicinal cannabis in this population are currently unclear. This study sought to investigate, via online focus-groups, the perceptions, barriers, drivers, and experiences associated with cannabis use, whether legal or illicit, amongst 37 Australians and New Zealanders, aged 18-55, with a medical diagnosis of endometriosis. Previous cannabis usage was not required to participate. Discussion topics included strategies employed to manage symptoms, exploration of current medications, previous use of cannabis for pain management, and interest in using medicinal cannabis as a management strategy. Participants with moderate to severe symptoms of medically diagnosed endometriosis reported inadequacies with their current medical and self-management strategies and were inclined to try medicinal cannabis, both as part of their medical management and as part of a clinical trial. Barriers to medicinal cannabis adoption identified in this cohort included high costs of legal cannabis products, lack of clarity and fairness in current roadside drug testing laws and workplace drug testing policies, concern over the impact of stigma affecting familial, social and workplace life domains, and subsequent judgement and the lack of education/engagement from their medical providers regarding cannabis use. Given the interest in medicinal cannabis and the reported lack of effective symptom management, clinical trials are urgently required to determine the potential role that medicinal cannabis may play in reducing the symptoms of endometriosis.

The impact of endometriosis on dietary choices and activities of everyday life: a cross-sectional study

Introduction

Endometriosis is characterized by ectopic endometrial tissue and severe pain; frequently, women afflicted by this condition resort to non-medical interventions, such as dietary modifications. The aim of this study is to assess the impact of endometriosis on dietary patterns and quality of life.

Methods

An online survey was conducted among Italian women with endometriosis to gather self-reported demographic, clinical, dietary habit, and daily life data post-diagnosis.

Results

A total of 4,078 participants were included. Following an endometriosis diagnosis, 66% reported changes in eating habits, and 92% experienced a decline in daily life. Respondents chose dietary interventions: gluten-free (15%), anti-inflammatory (8%), Mediterranean (7.1%), or ketogenic (4%) diets, to improve health and reduce symptoms. The study revealed a shift in eating habits, with increased consumption of vegetables, fruits (10%), cereals, legumes (6.6%), and fish (4.5%), while reducing dairy products (18.4%), soy-containing foods (6.7%), and high saturated fats (8%). Eating habit changes correlated with endometriosis stages and worsened daily life. Educational level, endometriosis stages, years of symptoms, and eating habit changes linked to changes in daily life.

Conclusion

Our findings emphasize the importance of monitoring eating behaviors to prevent unhealthy habits and malnutrition in women with endometriosis. Further studies are needed to evaluate how different diets impact symptoms and enhance daily life for these individuals.

Diet associations in endometriosis: a critical narrative assessment with special reference to gluten

Endometriosis is characterized by the presence of endometrium-like tissue outside the uterus. The etiology remains largely unknown. Despite adequate treatment, patients can still experience symptoms or side effects resulting in therapy incompliance and in self-management strategies such as dietary measures is increasing. A gluten free diet is thought to be contributory in reducing endometriosis-related pain, thereby optimizing quality of life. However, data is conflicting and currently provides no evidence for causality. This narrative review aims to put the effect of dietary self-management strategies on endometriosis in a balanced perspective, especially the effect of gluten and a gluten free diet. Several studies have found a strong overlap in symptoms, metabolic and immune responses associated with endometriosis and those associated with celiac disease, ulcerative colitis, Crohn's disease, irritable bowel syndrome and non-celiac wheat sensitivity. However, it remains unclear whether these diseases and/or disorders are causal to an increased risk of endometriosis. Some studies have found a positive effect on the risk of endometriosis, endometriosis-related symptoms and quality of life (QoL) when women either avoided certain nutrients or foods, or applied a specific nutrient supplementation. This includes the avoidance of red meat, an increasing intake of foods rich in anti-oxidants, omega-3, micronutrients and dietary fibers (e.g., fruit, vegetables) and the appliance of a gluten free diet. However, data from the available studies were generally graded of low quality and it was noted that placebo and/or nocebo effects influenced the reported positive effects. In addition, such effects were no longer seen when adjusting for confounders such as overweight, when a translation was made from in vitro to in vivo, or when the nutrients were not supplemented as isolated sources but as part of a mixed daily diet. Finally, some studies showed that long-term adherence to a gluten free diet is often associated with an impaired diet quality and nutrient intake, leading to negative health outcomes and reduced QoL. Concluding, scientific evidence on the efficacy of dietary interventions on well-defined clinical endpoints of endometriosis is lacking and recommending a gluten free diet to women solely diagnosed with endometriosis should therefore not be advised.

Biomarkers of endometriosis

Endometriosis is one of the most severe female reproductive disorders, affecting 6-10% of women between 18 and 35. It is a gynaecological condition where endometrial tissue develops and settles outside the uterus. The aetiology of endometriosis is primarily influenced by genetic, epigenetic, and non-genetic variables, making it highly challenging to create a therapeutic therapy explicitly targeting the ectopic tissue. The delay in the treatment is due to the limitations in the diagnostic approaches, which are restricted to invasive techniques such as laparoscopy or laparotomy. This accords to 70% of the women being diagnosed at later stages. By understanding the subject, several treatment medications have been produced to lessen the disease's symptoms. Nevertheless, endometriosis cannot be permanently cured. A viable or persuasive standard screening test for endometriosis must be utilized in a clinical context. A helpful assessment method for the early identification of endometriosis could be biomarkers. A major research priority is the identification of a biomarker that is sensitive and specific enough for detecting endometriosis. The present article has reviewed studies published on the expression of biomarkers of endometriosis. It outlines various biomarkers from different sample types, such as serum/plasma and urine, in addition to tissue. This would provide a non-invasive approach to diagnosing the disease at the initial stages without any harmful repercussions. Future high-throughput advances in science and technology are anticipated to result in the creation of a potent remedy for endometriosis. To achieve successful outcomes, it is necessary to research the discussed biomarkers that demonstrate substantial results extensively.

Physical Activity in Women with Endometriosis: Less or More Compared with a Healthy Control?

BACKGROUND

Endometriosis, i.e., endometrial-like tissue outside the uterus, is a chronic inflammatory condition affecting physical functioning. However, the specific levels of physical activity (PA) in the context of endometriosis and different disease symptoms remain unclear.

METHODS

This multi-center, cross-sectional study compared PA levels and influencing factors in endometriosis patients and non-endometriosis patients. Data were collected through questionnaires. Endometriosis was surgically confirmed. A statistical analysis was performed with appropriate tests.

RESULTS

The study included 460 women with endometriosis and 460 age-matched women without this condition. The two groups did not differ significantly in terms of age, education level, or stable partnership. Women with endometriosis exhibited lower PA levels, practicing fewer hours of sports weekly and climbing fewer stairs daily compared to the control group. These differences remained significant after controlling for confounding factors. Factors such as endometriosis, current dysmenorrhea, and depression were associated with decreased PA.

CONCLUSIONS

These findings suggest that women with endometriosis engage in less PA compared to those without this condition. These results highlight the need for interventions to promote increased PA in endometriosis patients and harness the associated health benefits. Further research is warranted to explore the underlying mechanisms and develop tailored exercise therapies for this population.

Application value of self-management manual combined with case management superiority model in postoperative management of nasopharyngeal carcinoma after radiotherapy

OBJECTIVE

To explore the application value of the self-management manual combined with the case management model in postoperative management of nasopharyngeal carcinoma after radiotherapy.

METHODS

Eighty-four patients with nasopharyngeal carcinoma admitted to Yingtan People's Hospital from May 2020 to April 2022 were retrospectively included in this study. They were divided into the experimental group (receiving self-management manual combined with case management mode scheme, n=42) and the control group (receiving continuous management after conventional nasopharyngeal carcinoma radiotherapy, n=42) according to mode differences. The cancer-related fatigue [Cancer Fatigue Scale (CFS)], comfort status [General Comfort Questionnaire (GCQ)], self-management efficacy [Chinese Strategies Used by People to Promote Health (C-SUPPH)], self-care ability (self-care ability measurement), pain score [Visual analogue scale (VAS)], and quality of life [European Organization for Research and Treatment of Cancer QLQ-C30 (EORTC QLQ-C30)] were compared between the two groups after 4 weeks of radiotherapy. The adverse reactions of the two groups were recorded. Combined with periodic review and follow-up records, the prognostic factors of the two groups of patients were analyzed.

RESULTS

After treatment, the scores of physical fatigue (12.83±1.10), emotional fatigue (9.78±1.32), cognitive fatigue (5.62±1.31), and total score of CFS (28.24±2.26) in the experimental group were 12.83±1.10. The control group physical fatigue (13.90±1.25) points, emotional fatigue (10.55±1.40) points, cognitive fatigue (6.80±1.75) points, and total CFS (31.33±2.59) points in both groups were lower than before treatment. The experimental group was lower than the control group (ALL P<0.05). The physiological, psychological, spiritual, socio-cultural, and environmental scores of the experimental group were higher than those of the control group (all P<0.05). The scores of health knowledge, self-care skills, self-care responsibility, and self-concept score of patients in the experimental group were higher than the control group (all P<0.05). After intervention, the VAS score of the experimental group was lower than that of the control group (P<0.05). After intervention, the EORTC QLQ-C30 score of both groups increased significantly as compared with pre-intervention. The score in the experimental group was significantly higher than that in the control group [(80.05±10.72) vs (68.11±12.10), P<0.05]. Postoperative (various) adverse reactions in the experimental group were lower than the control group (all P<0.05). The factors influencing the prognosis of nasopharyngeal carcinoma patients were age, tumor stage, and intervention mode by Cox model analysis (all P<0.05).

CONCLUSION

The self-management manual combined with the case management mode can alleviate cancer fatigue, improve postoperative self-management ability, self-care ability, and quality of life of patients with nasopharyngeal cancer radiotherapy, reduce the occurrence of adverse reactions and improve the prognosis of patients. It is worth promoting in clinical settings.

Locked inside: Living with uncertainty in self-management for endometriosis during the COVID-19 pandemic

OBJECTIVE

A high symptom burden systemic inflammatory disorder, endometriosis typically entails both medical management and self-management strategies. The COVID-19 pandemic in Australia precipitated changes to healthcare provision, societal restrictions, and negative psychosocial outcomes particularly for those managing chronic illnesses (e.g., endometriosis). This study's objective was to address the following questions: "How have endometriosis self-management strategies changed since the outbreak of COVID-19, and what are the consequences of these changes?"

METHODS

In total, 21 respondents residing in Australia during the COVID-19 pandemic participated in a semi-structured interview following completion of an online survey advertised by Endometriosis Australia. In the survey, respondents provided demographic and clinical information, and psychological distress was assessed. Interviews were conducted online and recorded for transcribing. Transcribed data were thematically analyzed using the template method.

RESULTS

Qualitative analysis identified five themes: i) Maintaining Relationships with Health Professionals, ii) Altered Information Seeking Strategies, iii) More Autonomous Decision Making, iv) Diminished Self-Care and Behaviour Change, and v) Shifted Priorities. Respondents reported disruptions to, and uncertainties within, the healthcare system that precipitated adverse effects upon their ability to manage endometriosis and mental health.

CONCLUSIONS

These findings suggest that for many, COVID-19-related disruptions to the healthcare system and social isolation adversely impacted their endometriosis self-management. Targeted interventions are needed to address the consequences of these, including providing reliable information to support informed decision-making regarding endometriosis self-management, and assisting with mental health challenges arising from COVID-19-related social isolation.

Complementary therapy for endometriosis related pelvic pain

In the setting of a global pandemic, it is vastly important now more than ever that patients have agency and control over pain management when living with a debilitating chronic pain disease such as endometriosis. We present a review of the available literature on the most popular and easily accessible complementary pain management therapies for endometriosis including Transcutaneous Electrical Nerve stimulator (TENS) units, diets, Cannabidiol (CBD), turmeric, meditation, yoga, and acupuncture. These are worthwhile recommendations; however, the data for each is limited and more research is needed to further support each of its use.

A better quality of life could be achieved by applying the endometriosis diet: a cross-sectional study in Dutch endometriosis patients

RESEARCH QUESTION

Does the endometriosis diet positively affect quality of life (QoL) in women diagnosed with endometriosis?

DESIGN

A cross-sectional study was performed, recruiting women using the website and online peer platforms from the Dutch Endometriosis Society. In total, 211 women with a self-reported diagnosis of endometriosis were included in the study. They completed a questionnaire on the six QoL domains based on the conversation tool 'My Positive Health'. Women who adhered to the endometriosis diet were compared with women who did not. A distinction was made between strict (score ≥8 on a scale of 0-10) and less strict adherence to the diet.

RESULTS

A significantly higher score was seen in all six QoL domains in women who adhered to the endometriosis diet (n = 90) compared with women who did not (n = 121) (range P < 0.001 to P = 0.043). Furthermore, women with strict adherence (n = 48) compared to less strict adherence (n = 42) reported significantly higher scores in all six QoL domains (range P = 0.005 to 0.05). Women diagnosed with endometriosis more than 10 years ago (n = 13) adhered to the endometriosis diet significantly less often than women that were diagnosed more recently (n = 163; range P = 0.005 to 0.046).

CONCLUSION

The endometriosis diet was associated with a better QoL in Dutch women with endometriosis. Strict adherence showed higher QoL scores compared with less strict adherence. Therefore, more research is needed to clarify the mechanism of this beneficial effect and to identify facilitators and barriers to dietary adjustments in patients with endometriosis.

Psychological adaptation in women with endometriosis: current knowledge and future research perspectives

This short report aims to present current knowledge on endometriosis. The daily repercussions of endometriosis and their impact on women's psychological state, the resentment often expressed towards doctors associated with diagnosis delay, influencing both appropriation and adaptation to the disease and driving women mainly to self-manage are discussed. Directions for research and intervention include the need to devise a comprehensive strategy in collaboration with stakeholders and to examine targeted study areas more thoroughly, notably related to work environment management, dietary changes and their consequences or the social representation of endometriosis among physicians, are proposed.

The Efficacy of Self-Management Strategies for Females with Endometriosis: a Systematic Review

Self-management is critical for the care of endometriosis. Females with endometriosis frequently use self-management strategies to manage associated symptoms; however, the efficacy of such strategies is unknown. The aim of this review was to systematically appraise the evidence concerning efficacy of self-management strategies for endometriosis symptoms. Electronic databases, including Medline, Embase, Emcare, Web of Science Core Collection, Scopus, and the Cochrane Central Register of Controlled Trials, were searched from inception to March 2021. We included peer-reviewed experimental studies published in English evaluating the efficacy of self-management strategies in human females laparoscopically diagnosed with endometriosis. Studies underwent screening, data extraction, and risk of bias appraisal (randomised studies: Risk of Bias 2 tool; non-randomised studies: Risk Of Bias In Non-randomized Studies - of Interventions tool). Of the fifteen studies included, 10 evaluated dietary supplements, three evaluated dietary modifications, one evaluated over-the-counter medication, and one evaluated exercise. Most studies had a high-critical risk of bias. Many self-management strategies were not more effective at reducing endometriosis symptoms compared to placebo or hormonal therapies. Where studies suggest efficacy for self-management strategies, no recommendations can be made due to the poor quality and heterogeneity of evidence. High-quality empirical evidence is required to investigate the efficacy of self-management strategies for females with endometriosis.

Prevalence of Use and Perceived Effectiveness of Medical, Surgical, and Alternative Therapies for Endometriosis Pain in Canadians

OBJECTIVES

To describe the use and perceived effectiveness of medical, surgical, and alternative therapies (e.g., diet, exercise, heat, cannabis, etc.) in managing endometriosis-associated pain in Canadians.

METHODS

A cross-sectional online survey was distributed via The Endometriosis Network Canada (TENC) from February to March 2021. Canadians aged 18-50 years with diagnosed or suspected endometriosis were eligible to participate.

RESULTS

A total of 434 survey responses were included, and 93.8% of respondents reported that they used at least 1 alternative therapy in the past 6 months for endometriosis-associated pain. Respondents used an array of medical (2.3/6 months), surgical (1.7/lifetime), and alternative therapies (6.9/6 months) to manage their pain, yet 61.9% of respondents did not feel it was adequately managed. The most common alternative therapies were heat, meditation/mindfulness/rest, and diet.

CONCLUSION

Alternative therapies were commonly used by Canadians living with endometriosis to manage pain. Cannabis and heat were perceived as the most effective alternative therapies. Here, we gain a better understanding of alternative therapies that can provide an additional therapeutic avenue that clinicians and people living with endometriosis may wish to discuss and explore.

“It’s Just Another Unfortunate Part of Being Female”: A Qualitative Study on Dysmenorrhea Severity and Quality of Life

The present study sought to understand similarities and differences in the experiences of women with mild, moderate and severe menstrual pain. Women aged 18-50 years were recruited from the community between May and July 2019 (n = 624). Participants were asked to rate their menstrual pain severity using a Numerical Rating Scale categorised into mild (scores 1-4), moderate (scores 5-7), and severe dysmenorrhea (scores 8-10) and respond to three open-ended questions about the impact of menstrual pain. Inductive template thematic analysis was used to understand patterns of meaning and compare and contrast the experience of menstrual pain across severity. Three themes were derived, including 'Dysmenorrhea is more than menstrual pain;' 'It puts a hold on lives;' and 'Lack of health-related information.' Women across all pain severities reported disabling symptoms, disrupted physical activity and the need for education and treatment. Those experiencing mild pain reported relatively brief symptoms and minor impacts, whilst those with moderate, and especially severe pain reported debilitating symptoms and extensive impacts. Supportive care including education is needed for all menstruating people.

Unmet Needs in Endometriosis: Lessons from COVID-19

BACKGROUND

One key challenge of the COVID-19 pandemic is health care access. Government-imposed restrictions and increased health care burden have induced considerable changes to health care services and their delivery. These are likely to have substantially impacted those with chronic conditions such as endometriosis, as they require sustained management.

AIMS

Our objective was to explore the impact of the COVID-19 pandemic on the experience of people with endometriosis, and to use this information to inform health care delivery for the management of chronic conditions in a COVID-normal future.

MATERIALS AND METHODS

Invitation to participate in an open-ended online survey through social media of Australian endometriosis organizations and the Royal Women's Hospital, Melbourne. Surveys were analyzed qualitatively through template analysis.

RESULTS

Of 576 surveys returned, 329 reported COVID-19 having an impact. Fifteen areas of impact were identified and grouped under three domains: impact on access to health care services, impact on daily life, and impact of isolation. Common impacts included reduced access to health care services, improved symptom management due to decreased day-to-day travel and work-from-home arrangements, and both positive and negative views of telehealth services.

CONCLUSIONS

This study provides in-depth insight into the experiences of people with endometriosis during the COVID-19 pandemic, confirming previous studies' findings and offering insight into discrepancies between the Australian Healthcare system categorization of surgeries as "non-essential," and patient views of these procedures as "essential" to their well-being. Results may inform future adjustments to health care services and delivery to improve the lives of people with endometriosis, and by extension, other chronic conditions.

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.

Complementary medicine usage in surgery: a cross-sectional survey in Germany

Background

Complementary medicine (CM) is frequently used by patients, but little is known about the usage of CM in surgical patients. The study aimed to elucidate the relevance of CM in surgery.

Methods

This cross-sectional, multi-center survey utilized a paper-based questionnaire consisting of 21 questions to capture CM usage and interest as well as CM communication in visceral and thoracic surgical patients being hospitalized at the corresponding departments of surgery at the University Medical Centers in Freiburg, Heidelberg und Ulm, Germany.

Results

Overall, 151 patients consented to the survey. On average, current CM usage was stated by 44% of patients. Most frequently used CM approaches were physical exercise (63%), nutritional supplements (59%) and herbal medicine (56%). Strong interest in CM counselling was stated by 51% of patients. Almost 80% of patients wanted to be treated in a holistic manner and desired for reliable information about CM as well as CM informed physicians. Only 12% of patients communicated CM usage and interest with their attending physician. Review of literature revealed similar results showing an overall CM usage of 43%, preferring nutritional supplements and herbal medicine.

Conclusion

The results of our cross-sectional study indicate a high percentage of CM users and a strong interest in CM among surgical patients. Indeed, the current communication about CM between patients and surgeons is poor. With respect to safety and quality reasons, but also to pay attention to patients’ demands, physicians should be aware of patients’ CM usage in surgery.

Trial registration

German Clinical Trial register (DRKS00015445).

Nonsurgical management of adenomyosis: an overview of current evidence

PURPOSE OF REVIEW

Adenomyosis is a condition where endometrium-like tissue spreads within the myometrium. Although its prevalence in the general population is not exactly known, its clinical manifestations are well established and include pelvic pain, dysmenorrhea (painful periods), heavy menstrual bleeding and subfertility [1] . Adenomyosis often coexists with other gynaecological conditions, such as endometriosis or fibroids, and may cloud the clinical presentation [2] . The aim of this article is to review current noninterventional, nonsurgical management modalities and wherever possible offer information that allows women to make safe and informed choices regarding their treatment options.

RECENT FINDINGS

Recent studies support that medical strategies, including the Mirena coil, Dienogest and GnRH antagonists, are efficient in improving adenomyosis-associated symptoms. High-quality evidence is scarce and is needed to properly counsel women with this condition. Future research should prioritize overall pain, menstrual bleeding, quality of life and live birth as primary outcomes and assess women with different grades of adenomyosis.

SUMMARY

This review provides the most current evidence with regards to the nonsurgical management of adenomyosis. In light of the paucity and low quality of existing data, high-quality trials are needed to definitely determine the impact of conservative and medical treatment on the clinical management of adenomyosis.

Cannabis Use for Endometriosis: Clinical and Legal Challenges in Australia and New Zealand

Introduction: Endometriosis is a difficult to manage condition associated with a significant disease burden. High levels of illicit cannabis use for therapeutic purposes have been previously reported by endometriosis patients in Australia and New Zealand (NZ). Although access to legal medicinal cannabis (MC) is available through medical prescription via multiple federal schemes, significant barriers to patient access remain. Methods: An anonymous cross-sectional online survey was developed and distributed through social media via endometriosis advocacy groups worldwide. Respondents were asked about legal versus illicit cannabis usage, their understanding of access pathways and legal status, and their interactions with health care professionals. Results: Of 237 respondents who reported cannabis use with a medical diagnosis of endometriosis, 186 (72.0%) of Australian and 51 (88.2%) NZ respondents reported self-administering cannabis illicitly. Only 23.1% of Australian and 5.9% of NZ respondents accessed cannabis through a doctor's prescription, with 4.8% of Australian and no NZ respondents reporting to legally self-administer cannabis. Substantial substitution effects (>50% reduction) were observed in users of nonopioid analgesia (63.1%), opioid analgesia (66.1%), hormonal therapies (27.5%), antineuropathics (61.7%), antidepressants (28.2%) and antianxiety medications (47.9%). Of Australian respondents, 18.8% and of NZ respondents, 23.5% reported not disclosing their cannabis use to their medical doctor, citing concern over legal repercussions, societal judgment, or their doctors' reaction and presumed unwillingness to prescribe legal MC. Conclusions: Respondents self-reported positive outcomes when using cannabis for management of endometriosis, demonstrating a therapeutic potential for MC. Despite this, many are using cannabis without medical supervision. While evidence for a substantial substitution effect by cannabis was demonstrated in these data, of particular concern are the clinical consequences of using cannabis without medical supervision, particularly with regard to drug interactions and the tapering or cessation of certain medications without that supervision. Improving doctor and patient communication about MC use may improve levels of medical oversight, the preference for legal MC adoption over acquisition via illicit supply and reducing cannabis-associated stigma.

Endometriosis and Cannabis Consumption During the COVID-19 Pandemic: An International Cross-Sectional Survey

Introduction: Endometriosis affects 1 in 10 women worldwide, with most experiencing difficulties achieving adequate symptom control. These difficulties have been compounded by the onset of the COVID-19 pandemic due to worldwide shifts in health care resource allocation. As cannabis is a relatively common form of self-management in endometriosis, this study aims to explore the impact of the COVID-19 pandemic on cannabis consumption in those with endometriosis. Methods: An anonymous, cross-sectional online international survey was developed and promoted by endometriosis advocacy/support organizations worldwide. Respondents needed to have a diagnosis of endometriosis and be aged between 18 and 55. Results: A total of 1634 responses were received from 46 different countries. The average age of respondents was 30, with a mean diagnosis age of 25. Eight hundred forty-six respondents (51%) reported consuming cannabis in the past 3 months, with 55% of these reporting use for symptom management only. One in five respondents (20%) reported having consumed cannabis previously, the most common reason for discontinuation (65%) was access difficulties during COVID. Those who had legal access were more likely to consume cannabis than those without (p<0.0001) and were more likely to disclose usage to health care professionals (p<0.0001). The most common reasons for consuming cannabis during COVID was increased stress/anxiety (59%) and lack of access to normal medical care (48%). Pre-pandemic, cannabis was mostly consumed at least once a day (61%) and in inhaled forms (51.6%). Consumption increased for most people (57%) during the pandemic. During the pandemic just under a quarter (23%) of respondents changed their mode of consumption, with a reduction in inhaled forms (39.5%) and an increase in consumption of edibles (40%) or oil (25.2%). Conclusions: Cannabis consumption, especially for symptom relief, was relatively common among those with endometriosis, with some people starting their consumption of cannabis due to health care restrictions that occurred due to the COVID-19 pandemic. Difficulties accessing cannabis and unpleasant/unwanted side effects were the most common reasons for lack of current cannabis consumption in those who had previously consumed it. Cannabis consumption may form an important part of endometriosis management especially when access to routine medical care is restricted.

Associations between physical exercise patterns and pain symptoms in individuals with endometriosis: a cross-sectional mHealth-based investigation

OBJECTIVES

This study investigates the association of daily physical exercise with pain symptoms in endometriosis. We also examined whether an individual's typical weekly (ie, habitual) exercise frequency influences (ie, moderates) the relationship between their pain symptoms on a given day (day t) and previous-day (day t-1) exercise.

PARTICIPANTS

The sample included 90 382 days of data from 1009 participants (~85% non-Hispanic white) living with endometriosis across 38 countries.

STUDY DESIGN

This was an observational, retrospective study conducted using data from a research mobile app (Phendo) designed for collecting self-reported data on symptoms and self-management of endometriosis.

PRIMARY OUTCOME MEASURES

The two primary outcomes were the composite day-level pain score that includes pain intensity and location, and the change in this score from previous day (Δ-score). We applied generalised linear mixed-level models to examine the effect of previous-day exercise and habitual exercise frequency on these outcomes. We included an interaction term between the two predictors to assess the moderation effect, and adjusted for previous-day pain, menstrual status, education level and body mass index.

RESULTS

The association of previous-day (day t-1) exercise with pain symptoms on day t was moderated by habitual exercise frequency, independent of covariates (rate ratio=0.96, 95% CI=0.95 to 0.98, p=0.0007 for day-level pain score, B=-0.14, 95% CI=-0.26 to -0.016, p=0.026 for Δ-score). Those who regularly engaged in exercise at least three times per week were more likely to experience favourable pain outcomes after having a bout of exercise on the previous day.

CONCLUSIONS

Regular exercise might influence the day-level (ie, short-term) association of pain symptoms with exercise. These findings can inform exercise recommendations for endometriosis pain management, especially for those who are at greater risk of lack of regular exercise due to acute exacerbation in their pain after exercise.