Stigma and Endometriosis: A Brief Overview and Recommendations to Improve Psychosocial Well-Being and Diagnostic Delay

Interaction mechanism of discharge readiness between discharge teaching and post-discharge outcomes in gynecological inpatients: a mediation analysis

BACKGROUND

With the rapid implementation of enhanced recovery after surgery, most gynecological patients are discharged without full recovery. Discharge planning is necessary for patients and their families to transition from hospital to home. Discharge teaching and discharge readiness are two core indicators used to evaluate the quality of discharge planning, which impacts the post-discharge outcomes. To improve post-discharge outcomes, the interaction mechanism of the three variables needs to be determined, but few studies have focused on it.

OBJECTIVES

Explore the mediating effect of discharge readiness between discharge teaching and post-discharge outcomes of gynecological inpatients.

METHODS

Discharge teaching and discharge readiness were measured by the Quality of Discharge Teaching Scale (QDTS) and Readiness for Hospital Discharge Scale (RHDS). Post-discharge outcomes on postoperative Day 7 (POF-D7) and postoperative Day 28 (POF-D28) were measured by a self-designed tool. Spearman correlations, Kruskal‒Wallis tests and Mann‒Whitney U tests were conducted to explore the correlation between post-discharge outcomes and other variables. Mediation analysis was used to explore the mediating effect of discharge readiness between discharge teaching and post-discharge outcomes.

RESULTS

QDTS and RHDS showed strong positive correlations with post-discharge outcomes. The mediation analyses verified that RHDS was a full mediator between QDTS and POF-D7, and the indirect effect accounted for 95.6% of the total direct effect. RHDS was a partial mediator between QDTS and POF-D28, and the indirect effect accounted for 50.0% of the total direct effect. RHDS was a full mediator between QDTS and total scores of post-discharge outcomes, and the indirect effect accounted for 88.9% of the total direct effect.

CONCLUSIONS

Discharge teaching can improve the post-discharge outcomes of gynecological inpatients through the intermediary role of discharge readiness. Doctors and nurses should value the quality of discharge teaching and the discharge readiness improving of gynecological inpatients. Future studies should note the interaction mechanism of the three variables to explore more efficient ways of improving post-discharge outcomes of gynecological inpatients.

Learning to cope with the reality of endometriosis: A mixed-methods analysis of psychological therapy in women with endometriosis

OBJECTIVES

Despite the need and uptake of mental health support by women with endometriosis, no research to date has explored their experience of psychological therapy. We aimed to understand the factors that predict engagement in psychological therapy by Australian women with endometriosis and to qualitative explore their experience of psychological support.

DESIGN

Mixed-methods design.

METHODS

A total of 200 women with self-reported endometriosis were recruited from the community. We explored; (1) the demographic and clinical predictors of engagement in psychological therapy, (2) the psychological approaches that seem most valuable to women in the management of endometriosis and (3) their experience engaging in psychological therapy for endometriosis.

RESULTS

Nearly half of women reported to have seen a psychologist within the past year, particularly for pain. Younger age (OR, .94; 95% CI, .886-.993), depressive symptoms (OR, 1.05; 95% CI, 1.002-1.099), and working part time compared to full time (OR, 2.17, 95% CI, 1.012-4.668), increased the likelihood of engaging in psychological therapy. Template thematic analysis identified three themes; (1) endometriosis and pain have multi-faceted psychological effects, (2) psychological support is sought to adjust and live with endometriosis and (3) there are helpful and unhelpful psychological tools for women with endometriosis.

CONCLUSIONS

Our findings support the use of psychological therapy in the management of endometriosis, and the need for psychological therapy to acknowledge the chronicity and impact of symptoms, to enlist multidisciplinary support and to consider alternative options. Further advocacy is required to educate women on the benefits of psychological therapy for endometriosis.

"I wish I knew then what I know now" - pain science education concepts important for female persistent pelvic pain: a reflexive thematic analysis

ABSTRACT

Pain science education (PSE) provides people with an understanding of "how pain works" grounded in the biopsychosocial model of pain; it has been demonstrated to improve outcomes in musculoskeletal pain conditions. Preliminary evidence suggests PSE may be effective for female individuals with persistent pelvic pain, but how the content of PSE needs to be modified for this group remains to be determined. A reflexive thematic analysis of qualitative data was performed to identify PSE concepts that female individuals with persistent pelvic pain consider important and why. Twenty individual, semistructured interviews were conducted with adult females who had engaged with PSE and had self-identified as having "improved" pelvic pain. Most participants had been diagnosed with endometriosis (n = 16). Four themes were generated capturing PSE concepts considered important by female individuals with "improved" pelvic pain: (1) "A sensitised nervous system leads to overprotective pain" validated their pelvic pain as being real; (2) "Pain does not have to mean the body is damaged (although sometimes it does)" provided reassurance that pelvic pain does not mean their condition is worsening; (3) "How I think, feel, and 'see' my pain can make it worse" enabled participants to find optimal ways to manage their pain; and (4) "I can change my pain… slowly" provided hope that pelvic pain can improve and empowered them to pursue pain improvement as a viable goal. This study generated 4 PSE learning concepts that were important to female individuals with improved pelvic pain and may be incorporated into PSE curricula for female individuals with pelvic pain.

(Re)making Scales: Communicative enfranchisement in Women's Narrative Discourses About Health Dismissal

Dismissal of women's health concerns is a discursive phenomenon with social and material consequences. A burgeoning literature documents how women experience dismissal through various forms of disenfranchising talk. Yet, women are not only subjected to disenfranchising talk; they are called to respond to it. Meaning, analyses of disenfranchisement should also examine efforts toward enfranchisement. One process by which scholars can study communicative (dis)enfranchisement is through people's scalar activity, or how they contextualize experiences at different levels of social reality. Studies of scale demonstrate that the language people use to narrate their personal experiences has meaning for how they position themselves in relation to other social actors, as well as how they make statements about what matters, how much, and to whom. Drawing on 36 interviews with women whose health issues have been dismissed, we apply scale as a theoretical lens and methodological tool to study how women use language in particular, meaningful, and patterned ways in narratives about health dismissal. Our findings suggest that women's narrative discourse is enfranchising in so much as women critique, resist, and transform the contexts of their dismissal. We document how they and others scale "realness" and "normality" across narrated and narrating events. We also note how women scale up from their own experiences to women's experiences writ large, asserting truth claims about issues borne of the broader U.S. healthcare system. Findings have implications for how critical health communication researchers study how women's health issues are constructed in talk.

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.

Inclusion of Sex and Gender to Improve the State of the Science in Women's Health

ABSTRACT

The influence of sex and gender-related factors on health and disease at all levels of scale, across all health conditions, and throughout the entire life course is increasingly clear. A series of policies instituted by the National Institutes of Health (NIH) that require researchers to include appropriate populations and to analyze the data accordingly have strengthened the evidence base around the health of women. Translating these advances to the entire research ecosystem can catalyze rigorous biomedical discovery that can improve health. We encourage journals, publishers, and funders to align their policies and expectations regarding sex and gender considerations in research with those of the NIH and other international funding agencies.

Endometriosis, Pain, and Related Psychological Disorders: Unveiling the Interplay among the Microbiome, Inflammation, and Oxidative Stress as a Common Thread

Endometriosis (EM), a chronic condition in endometrial tissue outside the uterus, affects around 10% of reproductive-age women, significantly affecting fertility. Its prevalence remains elusive due to the surgical confirmation needed for diagnosis. Manifesting with a range of symptoms, including dysmenorrhea, dyschezia, dysuria, dyspareunia, fatigue, and gastrointestinal discomfort, EM significantly impairs quality of life due to severe chronic pelvic pain (CPP). Psychological manifestations, notably depression and anxiety, frequently accompany the physical symptoms, with CPP serving as a key mediator. Pain stems from endometrial lesions, involving oxidative stress, neuroinflammation, angiogenesis, and sensitization processes. Microbial dysbiosis appears to be crucial in the inflammatory mechanisms underlying EM and associated CPP, as well as psychological symptoms. In this scenario, dietary interventions and nutritional supplements could help manage EM symptoms by targeting inflammation, oxidative stress, and the microbiome. Our manuscript starts by delving into the complex relationship between EM pain and psychological comorbidities. It subsequently addresses the emerging roles of the microbiome, inflammation, and oxidative stress as common links among these abovementioned conditions. Furthermore, the review explores how dietary and nutritional interventions may influence the composition and function of the microbiome, reduce inflammation and oxidative stress, alleviate pain, and potentially affect EM-associated psychological disorders.

Loneliness and Perceived Social Support in Endometriosis: The Roles of Body Image Disturbance and Anticipated Stigma

BACKGROUND

Research has identified that living with the chronic inflammatory disease endometriosis adversely impacts social functioning and interpersonal relationships, specifically, feelings of loneliness and a lack of perceived social support. Commonly experienced body image disturbance (BID), combined with the anticipation of endometriosis-related stigma from others, may result in further social withdrawal. This study aimed to quantitatively investigate the association between BID and social functioning (loneliness and diminished perceived social support), and the potential moderating effect of anticipated stigma on these associations.

METHOD

Participants (N = 212) with a self-reported endometriosis diagnosis completed an online questionnaire measuring social and emotional loneliness, perceived social support, BID, anticipated stigma and demographic and medical characteristics.

RESULTS

Mean scores indicated high levels of BID, emotional loneliness and diminished perceived social support. Bootstrapped multivariable regression analyses indicated that BID was significantly associated with greater emotional loneliness and lower perceived social support. BID was also associated bivariately with greater social loneliness. Anticipated stigma from healthcare workers moderated the association of BID with perceived social support, such that poorer perceived support was reported when anticipated stigma was high, despite the presence of minimal BID.

CONCLUSION

These findings highlight the psychological challenges of living with endometriosis in terms of highly prevalent BID, in the context of feeling lonely and poorly supported. The further negative impact of anticipated stigma suggests that psychosocial interventions may benefit from additionally targeting these perceptions of stigma.

Beyond physical pain: A large-scale cohort study on endometriosis trends and mental health correlates

BACKGROUND

This study investigates the increased prevalence of endometriosis in Israel and its association with psychiatric comorbidities, focusing on the timing of psychiatric diagnoses in relation to endometriosis diagnosis.

METHODS

Employing a retrospective cohort analysis, we reviewed data from 1,291,963 patients in a large scale medical database, identifying 24,259 cases (1.88%) of endometriosis. The analysis included demographic details, ICD-10 diagnoses of endometriosis and mental health conditions, and medication use patterns.

RESULTS

A marked rise in endometriosis diagnosis was observed, particularly among women born between 1973 and 1978. Those with endometriosis were more likely to have psychiatric disorders-such as mood disorders, anxiety, PTSD, and eating disorders-than the control group, with the majority of psychiatric diagnoses occurring prior to endometriosis detection, except for PTSD. The study also highlighted significant sociocultural and socioeconomic disparities in endometriosis diagnosis, suggesting barriers to healthcare access and the influence of cultural factors. Limitations include potential biases from the retrospective design and the specific context of Israel's healthcare system, which may limit generalizability.

CONCLUSIONS

The significant rise in endometriosis and its strong association with psychiatric comorbidities, predominantly preceding the diagnosis of endometriosis, underscores the necessity for integrated care approaches. The disparities in diagnosis rates call for culturally sensitive healthcare practices and early psychiatric interventions.

'Listen to women as if they were your most cherished person': Australian women's perspectives on living with the pain of endometriosis: A mixed-methods study

This mixed-methods study used an online cross-sectional survey to explore perspectives of 533 adult Australian women living with endometriosis pain, and their relationship with biopsychosocial factors. Four themes were constructed: The primary theme, 'Stigma and change' reflected women's experience of dismissal, and the wish to reverse the narrative of pain as normal. Some women emphasised self-education and self-advocacy to affect change, reflecting the theme 'self-empowerment'. Participants described the 'debilitating impact' of endometriosis and the enduring difficulty of 'inadequate healthcare', reflecting themes three and four. Analysis indicated type of social support may impact perceived outcomes for endometriosis. Hierarchical regression analyses indicated too few significant relationships between biopsychosocial factors and themes to indicate meaningful patterns without risk of common method variance. Future research should explore the influence of social support and interventions which develop participant autonomy and practitioner competence and knowledge, using disease-specific measures over time.

Circulating microRNAs as Non-Invasive Biomarkers in Endometriosis Diagnosis-A Systematic Review

The aim of this systematic review is to assess the power of circulating miRNAs as biomarkers as a diagnostic tool in endometriosis. In endometriosis-suspected women with uncertain imaging, the only way to confirm or exclude endometriosis with certainty is currently laparoscopy. This creates a need for non-invasive diagnostics. We searched the literature through the PubMed database using the Mesh terms 'endometriosis' and 'miRNAs'. Some, but limited, overlap was found between the 32 articles included, with a total of 20 miRNAs reported as dysregulated in endometriosis in two or more studies. MiR-17-5p was reported as dysregulated in six studies, followed by miR-451a and let-7b-5p in four studies and miR-20a-5p, miR-143-3p, miR-199a-5p and miR-3613-5p in three studies. Furthermore, a possible impact of the menstrual phase on miRNA expression was noted in five studies, while no influence of hormonal intake was observed in any included study. The modest reproducibility between studies may be attributable to biological variability as well as to the lack of universal protocols, resulting in pre- and analytical variability. Despite the identification of several suitable candidate biomarkers among the miRNAs, the need for high-quality studies with larger and well-defined population cohorts and the use of standardized protocols lingers.

Primary care clinicians' perspectives on interacting with patients with gynaecological conditions: a systematic review

BACKGROUND

Studies have found that women with gynaecological conditions and symptoms do not feel listened to by primary care clinicians (PCCs). Less understood is whether PCCs perceive that there are challenges around listening to and interacting with this patient group.

AIM

To understand PCCs' perspectives on the challenges of listening to and interacting with women patients with gynaecological conditions and symptoms.

DESIGN & SETTING

Systematic review of English-language studies.

METHOD

We searched ASSIA (Applied Social Sciences Index and Abstracts), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, HMIC (Healthcare Management Information Consortium), and MEDLINE from inception to July 2023. We also conducted forward and backward citation searches of included studies. Identified records were screened independently by two reviewers. Data extraction was undertaken by one reviewer and checked by a second. Quality appraisal used the Wallace checklist. 'Best-fit' framework synthesis was used to synthesise findings around themes that explored the challenges of patient-clinician interaction.

RESULTS

We identified 25 relevant articles. Perceived challenges associated with listening to and interacting with patients with gynaecological conditions and symptoms were identified at four 'levels': individual clinician level factors; structural and organisational factors; community and external factors; and factors related to gynaecological conditions. Interpretive analysis identified specific challenges relating to sociocultural factors affecting the consultation experience; the need for further education, training, or guidance for clinicians; factors affecting referral decisions; and factors related to service structure and organisation.

CONCLUSION

PCCs acknowledge that empathy, respect, and attentive listening are important when interacting with women patients with gynaecological conditions and symptoms. However, these ideals are impeded by several factors.

Unveiling the relationship of physical literacy with muscular fitness and muscle-strengthening activities in adolescents: the EHDLA study

Objective

This study evaluated the relationship between physical literacy (PL) and muscular fitness (MF) as well as muscle-strengthening activities (MSA) in adolescents.

Methods

A secondary cross-sectional study included 823 adolescents (45.1% boys) from the Eating Healthy and Daily Life Activities Study. The Spanish Perceived Physical Literacy Instrument for Adolescents (S-PPLI) assessed the participants' perceived PL. The evaluation of MF in the young population was conducted using the Assessing the Levels of Physical Activity and Fitness (ALPHA-FIT) test battery. MSA were assessed by the following question: 'In the past week, how many days did you exercise to strengthen or tone the muscle, such as through push-ups, sit-ups or lifting weights?' To examine the associations between S-PPLI scores and handgrip strength, standing long jump and MSA days in adolescents, we employed generalised additive models.

Results

Participants with high perceived physical literacty (PPL) had the highest handgrip strength (mean=25.1; PPL had the highest handgrip strength (mean=25.1; bias-corrected and accelerated (BCa) bootstrapped 95% CI 24.2 to 26.0) and standing long jump (mean=149.7; confidence interval (CI) 24.2 to 26.0) and standing long jump (mean=149.7; 24.2 to 26.0) and standing long jump (mean=149.7; BCa bootstrapped 95% CI 145.8 to 153.5). Conversely, those adolescents with low PPL had the lowest handgrip strength (mean=23.1; BCa bootstrapped 95% CI 22.3 to 23.8) and standing long jump (mean=137.3; BCa bootstrapped 95% CI 133.9 to 140.6). For MSA, adolescents with high PPL had the highest mean of MSA days (mean=3.0; BCa bootstrapped 95% CI 2.8 to 3.3), while the lowest mean was observed for those with low PPL (mean=2.0; BCa bootstrapped 95% CI 1.8 to 2.2).

Conclusion

A high level of PL was associated with higher levels of MF and MSA among Spanish adolescents.

What Matters to Aboriginal and Torres Strait Islander Youth (WM2Y): a study protocol to develop a national youth well-being measure

INTRODUCTION

Adolescents face challenges associated with unprecedented environmental, social and technological changes. The impacts of colonisation, intergenerational trauma, racism and socioeconomic disadvantage intensify these challenges for many Aboriginal and Torres Strait Islander adolescents. However, Aboriginal and Torres Strait Islander adolescents also have cultural, spiritual, family and community capital that fosters their well-being.To date, little research has focused on understanding and appropriately measuring the well-being of Aboriginal and Torres Strait Islander adolescents, a pivotal factor in informing and guiding programmes and interventions that support them. This study will identify the domains of well-being and develop a new preference-based well-being measure based on the values and preferences of Aboriginal and Torres Strait Islander youth (aged 12-17 years).

METHODS AND ANALYSIS

This project will be conducted across three research phases: (1) qualitative exploration of well-being using PhotoYarning and yarns with adult mentors to develop candidate items; (2) Think Aloud study, quantitative survey, psychometric analysis, validity testing of candidate items and finalisation of the descriptive system; and (3) scoring development using a quantitative preference-based approach. A multinomial (conditional) logit framework will be used to analyse responses and generate a scoring algorithm for the new preference-based well-being measure.

ETHICS AND DISSEMINATION

Ethics approvals have been obtained from: the Human Research Ethics Committees for each state and territory where data are being collected, the institutions where the research is being conducted and from the relevant Departments of Education. The new well-being measure will have wide applicability and can be used in assessing the effectiveness of programmes and services. This new national measure will ensure benefit and positive impact through the ability to identify and measure the aspects of well-being important to and valued by Aboriginal and Torres Strait Islander youth. Results will be published in international peer-reviewed journals and presented at conferences, and summaries will be provided to the study partner organisations and other relevant organisations.

Mindfulness intervention effect on endometriosis-related pain dimensions and its mediator role on stress and vitality: a path analysis approach

Endometriosis-related pain is supposedly mainly responsible for generating psychological stress and deteriorating the quality of life. However, the interaction between these factors has not been investigated, considering its multidimensional nature and through the path of effects of psychosocial approaches. The present study aims to investigate the effect of a brief mindfulness-based intervention (bMBI) on pain dimensions and its mediator role on psychological stress and QoL-Vitality improvement. A secondary analysis of a pilot randomized controlled trial using a series of parallel and serial mediators was carried out. The results showed that bMBI improves the sensory (B = -6.09 [-9.81, -2.52], β = -0.42) and affective (B = -3.40 [-5.02, -1.80], β = -0.47) pain. The bMBI effect on psychological stress reduction was mediated by these changes in sensory (B = -2.81 [-6.06, -0.41], β = -0.21) and affective (B = -1.97 [-5.07, -0.17], β = -0.15) pain. Serial sensory pain and psychological stress reduction (B = 2.27 [0.11, 5.81], β = -0.09) mediated the bMBI effect on quality of life vitality. Meditation training promotes additional improvement in affective and sensory pain characteristics through which psychological stress is reduced. The sensory pain dimension must be positively impacted in combination with psychological stress for the bMBI improves women's vitality. Adding a psychosocial intervention like meditation training to the standard treatment plan may be required for some women to achieve the needed changes to restore well-being.

A thematic synthesis of qualitative studies and surveys of the psychological experience of painful endometriosis

BACKGROUND

Endometriosis is a widespread problem in women of reproductive age, causing cyclical and non-cyclical pain in the pelvis and elsewhere, and associated with fatigue, fertility problems, and other symptoms. As a chronic pain problem, psychological variables are important in adjustment and quality of life, but have not been systematically studied.

METHODS

A systematic search of multiple databases was conducted to obtain surveys and qualitative studies of women's experience of pain from endometriosis. Surveys were combined narratively; qualitative studies were combined by thematic synthesis, and the latter rated for methodological quality.

RESULTS

Over 2000 records were screened on title and abstract, and provided 22 surveys and 33 qualitative studies from which accounts could be extracted of the psychological components of pain in endometriosis. Surveys mostly addressed quality of life in endometriosis, with poorer quality of life associated with higher levels of pain and of distress, but few referred to coherent psychological models. Qualitative studies focused rather on women's experience of living with endometriosis, including trajectories of diagnosis and treatment, with a few addressing meaning and identity. Thematic synthesis provided 10 themes, under the groupings of internal experience of endometriosis (impact on body, emotions, and life); interface with the external world (through self-regulation and social regulation); effects on interpersonal and social life, and encounters with medical care.

CONCLUSIONS

The psychological components of pain from endometriosis only partly corresponded with standard psychological models of pain, derived from musculoskeletal pain studies, with fewer fears about physical integrity and more about difficulties of managing pain and other symptoms in social settings, including work. Better understanding of the particular psychological threats of endometriosis, and integration of this understanding into medical care with opportunities for psychologically-based pain management, would substantially improve the experience and quality of life of women with painful endometriosis.

The Prevalence of Endometriosis in Patients with Unexplained Infertility

Endometriosis, a systemic ailment, profoundly affects various aspects of life, often eluding detection for over a decade. This leads to enduring issues such as chronic pain, infertility, emotional strain, and potential organ dysfunction. The prolonged absence of diagnosis can contribute to unexplained obstetric challenges and fertility issues, necessitating costly and emotionally taxing treatments. While biopsy remains the gold standard for diagnosis, emerging noninvasive screening methods are gaining prominence. These tests can indicate endometriosis in cases of unexplained infertility, offering valuable insights to patients and physicians managing both obstetric and non-obstetric conditions. In a retrospective cross-sectional study involving 215 patients aged 25 to 45 with unexplained infertility, diagnostic laparoscopy was performed after unsuccessful reproductive technology attempts. Pathology results revealed tissue abnormalities in 98.6% of patients, with 90.7% showing endometriosis, confirmed by the presence of endometrial-like glands and stroma. The study underscores the potential role of endometriosis in unexplained infertility cases. Although the study acknowledges selection bias, a higher than previously reported prevalence suggests evaluating endometriosis in patients who have not responded to previous reproductive interventions may be justified. Early detection holds significance due to associations with ovarian cancer, prolonged fertility drug use, pregnancy complications, and elevated post-delivery stroke risk.

Guideline No. 445: Management of Chronic Pelvic Pain

OBJECTIVE

To provide evidence-based recommendations for the management of chronic pelvic pain in females.

TARGET POPULATION

This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain.

BENEFITS, HARMS, AND COSTS

The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability.

EVIDENCE

Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals.

TWEETABLE ABSTRACT

Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Patient experiences of endometriosis diagnosis: A mixed methods approach

OBJECTIVE

To examine patient-described experiences of endometriosis diagnosis.

DESIGN

Mixed-methods study.

SETTING

Online patient-led endometriosis support groups.

POPULATION OR SAMPLE

People with endometriosis aged over 18.

METHODS

A survey with qualitative and quantitative questions was distributed through online patient-led endometriosis support groups. Descriptive statistics were used to analyse quantitative data, and thematic analysis was used for qualitative responses. Quantitative and qualitative data were triangulated to examine patient experiences of endometriosis diagnosis across age groups.

MAIN OUTCOME MEASURES

Experiences of endometriosis diagnosis among people with endometriosis.

RESULTS

A total of 2017 people with endometriosis from 63 countries responded to the questionnaire. Patients experienced an average delay of 3.7 years between symptom onset and first presentation of symptoms to a physician (the care-seeking delay) and an average delay of 5.8 years between first presentation of symptoms to a physician and diagnosis of endometriosis (the healthcare-related delay). Patients experienced an average total diagnostic delay of 9.6 years. Participants aged over 35 at the time of the study reported significantly longer times to receive an endometriosis diagnosis (mean 10.7, 95% confidence interval [CI] 10.2-11.2) compared with participants age 18-24 (6.8, 95% CI 6.1-7.5 years). The qualitative analysis identified the following themes: physicians normalised endometriosis symptoms, patients felt their symptoms were ignored by physicians because they were considered unreliable, and participant character attributes (e.g. age, appearance, weight or physical ability) led to clinician dismissal.

CONCLUSIONS

People with endometriosis of all age groups reported pervasive negative healthcare experiences during their adolescence. Patients experience delays in seeking care and in receiving a diagnosis once presenting for care.

Breaking the endometriosis silence: a social norm approach to reducing menstrual stigma and policy resistance among young adults

OBJECTIVE

Endometriosis is a menstrual disorder that affects one in ten women. Diagnosis often takes several years due to low awareness and menstrual stigma. In this study, we employed a social norm approach (SNA) to investigate the effects of an educational leaflet on endometriosis knowledge, menstrual stigma, and acceptance of paid menstrual leave among women and men.

METHODS

The 3 × 2 online experiment tested the influence of either descriptive norm messages or both descriptive and injunctive norm messages (compared to a control group, factor 1) in an educational leaflet by taking the role of addressee's sex into account (quasi-experimental factor 2). The study included 796 German participants aged 16-35.

RESULTS

Men exhibited significantly poorer knowledge, stronger menstrual stigma, and weaker policy acceptance compared to women. No significant main effect of the social norm messages on menstrual stigma was found. In contrast, the combined norm messages seem to be beneficial when addressing policy acceptance. Moreover, compared to the control group, the intervention material indirectly influenced stigma and policy acceptance through increased knowledge.

CONCLUSIONS

Providing information about social norms appears to be an effective strategy for educating not only women but especially men about menstrual disorders like endometriosis.

Cognitive-affective changes mediate the mindfulness-based intervention effect on endometriosis-related pain and mental health: A path analysis approach

BACKGROUND

There is poor knowledge about the therapeutic mechanisms of the conservative interventions for endometriosis. We hypothesized that the effects of a brief mindfulness-based intervention (bMBI) on pelvic pain intensity (PPI), pain unpleasantness (PU) and quality of life mental health (QoL-MH) are mediated by direct and indirect paths of changes in pain catastrophizing (PC), positive affect (PA) and negative affect (NA).

METHODS

A secondary analysis of a pilot randomized controlled trial of women with endometriosis, assigned to standard medical treatment (n = 32) and standard medical treatment plus bMBI (n = 31). We tested a series of parallel and serial mediators (PC, PA and NA) of the relationship between bMBI and outcomes (PPI, PU and QoL-MH).

RESULTS

The bMBI group demonstrated improvement in PA (Cohen's f2  = 0.12 [0.01, 0.36]), decreases in NA (Cohen's f2  = 0.06 [0.00, 0.24]) and PC (Cohen's f2  = 0.16 [0.02, 0.42]). The PC reduction mediated the effect of the bMBI on PPI and PU directly; however, the PC effect through PA increase mediated the PU marginally but not PPI changes. bMBI effect on Qol-MH was mediated directly by PA and NA. The PC improved Qol-MH through PA increase and Pain decrease but not via NA.

CONCLUSIONS

Our findings showed that bMBI impacts pain through changes in pain-related cognitive-affective factors. bMBI can improve QoL-MH by multiple pathways, including but not limited to pain reduction, highlighting the independent potential of improvement in affect to restore mental health in endometriosis.

SIGNIFICANCE

Brief mindfulness-based intervention improves endometriosis pain through pain-related cognitive-affective factors and quality of life mental health via pain and affect changes unrelated to pain.

Effects of social norms and message framing on reducing the stigma of gynecological diseases: A cognitive-affective-behavioral model

This paper presents an experiment exploring message strategies to reduce the stigma of gynecological diseases and promote women's sexual and reproductive health. Drawing on the cognitive-affective-behavioral model of stigma, we propose that social norms and message framing as two message strategies, respectively, address the cognitive and affective components of the stigma of gynecological diseases, which lead to desired changes in the help-seeking intention as the behavioral component. We conducted a 3 (no norm vs. descriptive norm vs. descriptive plus injunctive norms) by 2 (gain-framed vs. loss-framed) between-subject experiment (N = 202). The results reveal that messages with the combination of descriptive and injunctive norms reduce the greatest cognitive components of stigma. Gain-framed messages induced fewer affective components than loss-framed ones. The results suggest that changes in the cognitive and affective components of stigma may sequentially lead to favorable changes in the behavioral component. This study contributes to public understanding of the stigma of gynecological diseases by disentangling the various components and identifying the specific message strategies for stigma reduction.

Associations between endometriosis and common symptoms: findings from the Australian Longitudinal Study on Women's Health

BACKGROUND

Endometriosis has been linked to higher rates of a variety of symptoms; however, the findings from longitudinal studies are scarce and inconsistent.

OBJECTIVE

This study aimed to examine the association between endometriosis and common symptoms in a prospective cohort study.

STUDY DESIGN

This study included 7606 women born from 1973 to 1978 using data from the Australian Longitudinal Study on Women's Health that were collected every 3 years from 2009 to 2018. We identified women with endometriosis based on self-reported incidence from each survey and linked administrative health data. At each survey, women also completed a checklist on the presence of 24 symptoms. Generalized estimating equations for multinomial responses were used for analyses.

RESULTS

Women with endometriosis had significantly more menstrual symptoms than those without endometriosis with an adjusted odds ratio (95% confidence interval) of 3.61 (3.11-4.19) for severe period pain, 2.40 (2.10-2.74) for heavy menstrual bleeding, 1.76 (1.52-2.03) for irregular bleeding, and 1.52 (1.32-1.76) for premenstrual tension. They also had higher odds of mental health problems with adjusted odds ratios of 1.67 (1.39-2.01) for depression and 1.59 (1.24-2.03) for anxiety and higher odds of allergies and nonspecific symptoms with adjusted odds of 1.62 (1.40-1.89) for allergies or hay fever or sinusitis, 1.79 (1.56-2.05) for severe tiredness, 1.56 (1.35-1.81) for sleep difficulty, and 1.77 (1.37-2.18) for palpitations. There was also a strong association with other forms of pain with an adjusted odds ratio of 1.76 (1.53-2.04) for backpain, 1.50 (1.29-1.74) for headaches or migraines, and 1.65 (1.41-1.93) for stiff or painful joints. Women with endometriosis also had increased odds of developing bowel and urinary symptoms with an adjusted odds ratio (95% confidence interval) of 1.67 (1.35-2.08) for constipation, 1.46 (1.12-1.90) for hemorrhoids or piles, 1.25 (1.03-1.52) for indigestion or heartburn, 2.80 (1.71-4.58) for urine burn or stings, and 1.37 (1.03-1.82) for vaginal discharge or irritation. The association between each symptom and endometriosis was similar whether endometriosis was surgically confirmed or clinically suspected. No association was found between endometriosis and the risk for skin problems, leaking urine, or breathing difficulty.

CONCLUSION

This study suggests that women with endometriosis are more likely to report not only menstrual symptoms but are also at an increased risk for mental health problems, other pain symptoms, bowel and urinary symptoms, and nonspecific symptoms, such as severe tiredness and difficulty sleeping.

The Perception of the Quality of Professional Healthcare Assistance for the Management of Endometriosis: Findings from a National Survey in Italy

(1) Background: endometriosis is included in the list of chronic and disabling pathologies. This study aimed to examine patients' points of view about the quality of care for endometriosis during the COVID-19 pandemic; (2) Methods: we conducted a survey on knowledge about endometriosis, management of endometriosis, perceived mental and physical well-being, and perceived changes in the quality of care during the pandemic; (3) Results: out of 1065 participants, 875 were included in the analysis, with an average age of 34. Overall, patients had positive perceptions of care accessibility and cleanliness (95%), but less satisfaction with visit hours (86%). Those with better physical and psychological health were more satisfied with service hours, while those treated at specialised centres were more content with cleanliness. Satisfaction with clarity was linked to specialist treatment, and perceived availability to listen correlated with age, complications, and overall health status; (4) Conclusions: patients' perspectives are crucial for patient education and advocate for specialised interdisciplinary networks to support endometriosis management and patients' well-being. These findings highlight the importance of considering patient viewpoints, particularly in the context of the COVID-19 pandemic's impact on healthcare systems and suggest a need for further research from the patient's perspective.

Stigma and mental health in endometriosis

This review provides an overview of patient experiences of endometriosis, endometriosis-related types and sources of stigma pertaining to menstruation, chronic pain, and infertility, and their impact on patients' mental health with particular implications for patient care. Because endometriosis is a complex disease with multifactorial etiology, complicated pathophysiology, and a spectrum of clinical features, diagnosis of endometriosis is typically a lengthy process, and many patients experience initial misdiagnosis. A hallmark symptom is severe menstrual pain with other symptoms including chronic pelvic pain, dysmenorrhea, and infertility. Prior research documents that the diagnostic odyssey, complex management, disabling and unpredictable nature of the disease, and painful symptom profile affect multiple life domains of patients, resulting in poor physical, social, and psychological functioning and clinically-significant rates of anxiety and depression for many. More recently, stigma has been recognized as a potent contributor to poor mental health in endometriosis patients, but existing research is limited and largely atheoretical. We identify major sources of stigma related to endometriosis, including menstrual stigma, chronic pain stigma, and infertility stigma, and their likely impact on patients and health care provision. An integrative theoretical approach is described to facilitate research on the prevalence and effects of endometriosis stigma and their explanatory mechanisms, highlighting specific well-validated psychological instruments to assess stigma. Implications for patient care are emphasized. Better understanding of stigma and mental health in people with endometriosis will enhance the standard of care for this patient population.

Should I trust you? Investigating trustworthiness judgements of painful facial expressions

Past research indicates that patients' reports of pain are often met with skepticism and that observers tend to underestimate patients' pain. The mechanisms behind these biases are not yet fully understood. One relevant domain of inquiry is the interaction between the emotional valence of a stranger's expression and the onlooker's trustworthiness judgment. The emotion overgeneralization hypothesis posits that when facial cues of valence are clear, individuals displaying negative expressions (e.g., disgust) are perceived as less trustworthy than those showing positive facial expressions (e.g., happiness). Accordingly, we hypothesized that facial expressions of pain (like disgust) would be judged more untrustworthy than facial expressions of happiness. In two separate studies, we measured trustworthiness judgments of four different facial expressions (i.e., neutral, happiness, pain, and disgust), displayed by both computer-generated and real faces, via both explicit self-reported ratings (Study 1) and implicit motor trajectories in a trustworthiness categorization task (Study 2). Ratings and categorization findings partly support our hypotheses. Our results reveal for the first time that when judging strangers' facial expressions, both negative expressions were perceived as more untrustworthy than happy expressions. They also indicate that facial expressions of pain are perceived as untrustworthy as disgust expressions, at least for computer-generated faces. These findings are relevant to the clinical setting because they highlight how overgeneralization of emotional facial expressions may subtend an early perceptual bias exerted by the patient's emotional facial cues onto the clinician's cognitive appraisal process.

Female reproductive health impacts of Long COVID and associated illnesses including ME/CFS, POTS, and connective tissue disorders: a literature review

Long COVID disproportionately affects premenopausal women, but relatively few studies have examined Long COVID's impact on female reproductive health. We conduct a review of the literature documenting the female reproductive health impacts of Long COVID which may include disruptions to the menstrual cycle, gonadal function, ovarian sufficiency, menopause, and fertility, as well as symptom exacerbation around menstruation. Given limited research, we also review the reproductive health impacts of overlapping and associated illnesses including myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), postural orthostatic tachycardia syndrome (POTS), connective tissue disorders like Ehlers-Danlos syndrome (EDS), and endometriosis, as these illnesses may help to elucidate reproductive health conditions in Long COVID. These associated illnesses, whose patients are 70%-80% women, have increased rates of dysmenorrhea, amenorrhea, oligomenorrhea, dyspareunia, endometriosis, infertility, vulvodynia, intermenstrual bleeding, ovarian cysts, uterine fibroids and bleeding, pelvic congestion syndrome, gynecological surgeries, and adverse pregnancy complications such as preeclampsia, maternal mortality, and premature birth. Additionally, in Long COVID and associated illnesses, symptoms can be impacted by the menstrual cycle, pregnancy, and menopause. We propose priorities for future research and reproductive healthcare in Long COVID based on a review of the literature. These include screening Long COVID patients for comorbid and associated conditions; studying the impacts of the menstrual cycle, pregnancy, and menopause on symptoms and illness progression; uncovering the role of sex differences and sex hormones in Long COVID and associated illnesses; and addressing historical research and healthcare inequities that have contributed to detrimental knowledge gaps for this patient population.

Endometriosis and the Temporomandibular Joint-Preliminary Observations

(1) Background: The complete picture of the disease is not fully recognized and extends far beyond the pelvis. The disease's impacts lead to systemic inflammation, in turn resulting in sensitization to pain. The aim of this study was to check whether statistical correlations exist in women with endometriosis with regard to their experience of pain: headache, pelvic pain, temporomandibular joint pain, along with teeth clenching and the treatment of the disease. We constructed contingency tables, followed by Pearson's chi-square test and Cramer's V coefficient values. (2) Methods: A survey was conducted among 128 women aged 33.43 ± 5.79 with a diagnosis of endometriosis (disease duration 6.40 ± 5.88 years). (3) Results: There was a correlation between the occurrence of pain on the right and left sides of the pelvis and pain on the right and left sides of the temporomandibular joint, p-value = 0.0397, V = 0.2350, and between the presence of pelvic pain and the treatment of endometriosis, p-value = 0.0104, V = 0.3709, and between the presence of pain outside the pelvis and the treatment of endometriosis, p-value = 0.0311, V = 0.4549. There was a highly significant correlation between teeth clenching and temporomandibular joint pain, p-value = 0.0005, V = 0.3695. (4) Conclusions: The study revealed a correlation between pelvic endometriosis symptoms and symptoms in the temporomandibular joint.

Epidemiology of Endometriosis Awareness in Turkey

INTRODUCTION

Endometriosis is a chronic painful disease that affects the daily quality of life of individuals. Estimated rates show one in 10 women has endometriosis, although the actual prevalence is unknown. In this study, the impact of endometriosis prevalence and symptoms on women's lives in Turkey was questioned through a web-based questionnaire.

METHODS

We utilized a version of the World Endometriosis Research Foundation (WERF) EndoCost tool, which was sent to applicants via social media. Data from women aged 18-50 years were analyzed.

RESULTS

The results of 15,673 participants have been analyzed, and 2880 (18.3%) participants had endometriosis. Respondents with endometriosis reported urinary, neurological, and gastrointestinal disorders at statistically higher rates when compared to individuals without endometriosis diagnosis (54.2%, 84.5%, and 89.9% vs. 37.2%, 75.5%, and 81.1%, respectively; p = 0.001). Most respondents with endometriosis (80.1%) reported persistent fatigue and 21.2% of endometriosis participants reported feeling socially isolated related to their condition (p = 0.001). Of the participants with endometriosis, 63.2% mentioned that people did not believe their pain or symptoms and 77.9% experienced financial difficulties due to the cost of therapy. Of the participants with endometriosis, 46.0% reported that they had problems in their personal relationships, 28.3% had difficulties at work/school, and 7.4% were unable to attend class/work due to endometriosis-related symptoms.

CONCLUSION

Endometriosis is a chronic, underestimated disease that affects 18% of Turkish women of reproductive age. There is a need for guidelines to inform healthcare providers, population professionals, and patients. Societies and governmental health authorities must work together to resolve this public health issue.

Web-Based Digital Storytelling for Endometriosis and Pain: Qualitative Pilot Study

BACKGROUND

Endometriosis is a complex chronic disease characterized by pain, including painful sex, that can contribute to considerable sexual function, self-esteem, and relationship challenges. Digital storytelling is an arts-based, participatory methodology wherein individuals create and share their illness experiences in detailing their lived experiences.

OBJECTIVE

The study objective was to pilot-test a web-based digital storytelling workshop focused on endometriosis to understand storytellers' experiences of workshop participation. We assessed the feasibility of story cocreation and sharing, including the emotional impact of workshop participation, the acceptability of the workshop for the subject matter, and the storytellers' willingness to share their stories with broader audiences as a method for knowledge translation.

METHODS

This study used a community-based participatory methodology supplemented with patient-oriented research and integrated knowledge translation. Study participants, referred to as storytellers, cocreated 3- to 5-minute individual digital stories about their lived experiences of endometriosis during a web-based workshop (comprising five 2-hour sessions over 6 weeks) facilitated by The Center for Digital Storytelling. Data were collected through participant observations at the workshop, storyteller weekly reflective journals, and an end-of-workshop focus group interview with storytellers. These data were analyzed using a qualitative interpretive description approach.

RESULTS

A total of 5 women and 1 nonbinary storyteller aged 19 to 39 years who had experienced endometriosis for 4 to 22 years participated in the study. We characterized storytelling workshop participation and the acceptability of story cocreation by describing participants' experiences of opportunity, commitment, and connection; complex emotions that were healing; and a desire to share. Feasibility was demonstrated through 100% engagement in the workshops. All 6 storytellers reported feeling empowered by publicly sharing their cocreated digital stories through social media and the Sex, Pain & Endometriosis website.

CONCLUSIONS

Despite the complexities of the story-building process, the workshop and the cocreation and sharing of digital stories were feasible. The storytellers found that this process allowed for emotional healing and personal empowerment by offering a unique way to talk about painful sex, which also facilitated a connection among those in the workshop. The use of digital storytelling as a knowledge translation tool shows promise, and this approach also has potential as a therapeutic intervention.

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

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

"Premature" Girls with "Illegitimate" Diseases: A Qualitative Exploration of the Stigma of Gynecological Diseases for Unmarried Young Women in China

Stigma has been a prominent barrier in women's pursuit of better sexual and reproductive health (SRH). Specifically, evidence supports the stigmatization of gynecological diseases (GDs) for unmarried young women. Drawing upon the model of social identity threats, this study explored the GD stigma and social identity threats faced by unmarried young women in China with 26 in-depth interview data. The interpersonal, socio-cultural, and intrapersonal layers of GD stigma were identified. First, participants' disclosure and concealment of GDs concerning different significant others were contrasted as an interpersonal layer and voluntary response to social identity threats. In participants' GD experiences, peers stood out for providing emotional, tangible, and informational support, while parents were most often avoided for anticipated stigma. Second, collective representations of GDs and the cultural rationale in the socio-cultural layer were probed. The traditional and modernized sexual norms centering on the legitimacy of premarital sex and SRH knowledge were unveiled. At last, the interpersonal layer was identified. Unmarried young patients suffered social identity threats regarding their independence, sexual agency, and bodily awareness. This is one of the first studies that investigated the underappreciated GD stigma in China. Theoretical and practical implications are discussed.

Endometriosis Awareness Month on Social Media: A Content Analysis of Images and Captions on Instagram

Endometriosis Awareness Month (EAM) is a global movement that seeks to increase awareness of endometriosis. There is a paucity of peer-reviewed research that explores the social media activity of EAM, making it difficult to draw conclusions about what information is being shared. To address this gap, we performed inductive thematic analysis to investigate the visual and written content of images (n = 879 images), as well as post captions of N = 600 posts. that contained the hashtag “#endometriosisawarenessmonth”. Results show that written content within the images most frequently contained features of the disease. Caption content featured general/vague knowledge about the disease and general awareness of endometriosis, such as ‘pain (general/unspecified)’. The mental health impact of the disease was underrepresented in Instagram posts. Moving forward, the #endometriosisawarenessmonth campaign could be strengthened by communicating specific diagnostic and prevalence information, and harnessing conversations about the impact of the disease on mental health.

Does Quality of Care (QoC) Perception Influence the Quality of Life (QoL) in Women with Endometriosis? Results from an Italian Nationwide Survey during Covid Pandemic

(1) Background: Endometriosis is a chronic and progressive illness that generates a slew of issues, lowering the quality of life of women. The purpose of this study was to look at the quality of life in women with endometriosis and how it relates to the quality of care. (2) Methods: This study is an online survey performed in Italy during the COVID pandemic using the Italian version of the Health Questionnaire SF-36 and a questionnaire for assessing the quality of care received. (3) Results: 1052 women with a self-reported diagnosis of endometriosis participated in the survey. The mean levels of Physical Component Summary (PCS) and Mental Component Summary (MCS) were 38.89 ± 10.55 and 34.59 ± 11.17, respectively. A total of 77% of women judged the services they received positively, and 51% considered the coordination between healthcare professionals to be satisfactory. The satisfaction index mean was 23.11 ± 4.80. PCS was positively related to Occupation, high educational level, physical activity, and health care satisfaction. MCS was positively related to higher age, physical activity, and health care satisfaction. (4) Conclusions: The study indicated that satisfaction with health care was a significant predictor of QoL in women with endometriosis, for both physical and mental health.

Cross-sectional study for derivation of a cut-off value for identification of an early versus delayed diagnosis of endometriosis based on analytical and descriptive research methods

BACKGROUND

Endometriosis is a benign, hormone-dependent, chronic inflammatory gynecological disease accompanied by cyclic and acyclic pelvic pain and other complaints. The long lists of research recommendations in the AWMF guideline (Burghaus et al., Geburtshilfe Frauenheilkd 81:422-46, 2021) and ESHRE Endometriosis Guideline (ESHRE Endometriosis Guideline Development Group, Endometriosis: Guideline of European Society of Human Reproduction and Embryology, 2022) show that there is still a great need for research in all aspects of the disease. Diagnostic delay, defined as the mean time between symptom onset and confirmed diagnosis, is a particular problem associated with endometriosis. Some quantitative and qualitative studies have investigated possible reasons for this. A range of physician-related (Dixon et al., Br J Gen Pract 71:e668-e676, 2021; van der Zanden and Nap, Reprod Biomed Online 32:527-31, 2016) and patient-related factors (Sayer-Jones and Sherman, Health Psychol Behav Med 9:456-79, 2021) as well as stigmatization of the topic of menstruation by society have been identified (Kruckenberg, Frauenarzt 59:2-5, 2018; Seear, Soc Sci Med 69:1220-7, 2009). The consequences of the disease being diagnosed late (or too late) on the course of disease, the quality of life and the costs of the disease have already been documented in studies (Sims Int J Environ Res Public Health 18(15):8210, 2021; Surrey Adv Ther 37:1087-99, 2020). However, a systematically derived cut-off value that clearly distinguishes between short and long delay is still lacking. Therefore, the aim of our study was to derive a threshold value for the definition of a target corridor for endometriosis diagnosis based on descriptive and analytical methods.

METHODS

Since our review of the rather sparse publications on diagnostic delay did not yield satisfactory results, we used descriptive statistics and location parameters to calculate a cut-off value for German population data from the EndoCost study. Statistical methods were used for correlation analysis of shortDD versus longDD (correlation analysis and logistic regression) and group membership (discriminant analysis).

RESULTS

Five years was identified as the cut-off value that significantly differentiated between shortDD and longDD based on various disease-related variables. This suggests that endometriosis should be definitively diagnosed within less than five years to minimize the risk of an unfavorable course of the disease.

CONCLUSION

Our findings confirmed that an early onset of endometriosis-related symptoms is the most important risk factor for a long diagnostic delay. Consequently, adolescent females should receive increased attention as an especially vulnerable group. Evidently, there is an urgent need to develop adequate concepts to improve the endometriosis education and care among this target group.

Pathophysiology, diagnosis, and management of endometriosis

Endometriosis affects approximately 190 million women and people assigned female at birth worldwide. It is a chronic, inflammatory, gynecologic disease marked by the presence of endometrial-like tissue outside the uterus, which in many patients is associated with debilitating painful symptoms. Patients with endometriosis are also at greater risk of infertility, emergence of fatigue, multisite pain, and other comorbidities. Thus, endometriosis is best understood as a condition with variable presentation and effects at multiple life stages. A long diagnostic delay after symptom onset is common, and persistence and recurrence of symptoms despite treatment is common. This review discusses the potential genetic, hormonal, and immunologic factors that lead to endometriosis, with a focus on current diagnostic and management strategies for gynecologists, general practitioners, and clinicians specializing in conditions for which patients with endometriosis are at higher risk. It examines evidence supporting the different surgical, pharmacologic, and non-pharmacologic approaches to treating patients with endometriosis and presents an easy to adopt step-by-step management strategy. As endometriosis is a multisystem disease, patients with the condition should ideally be offered a personalized, multimodal, interdisciplinary treatment approach. A priority for future discovery is determining clinically informative sub-classifications of endometriosis that predict prognosis and enhance treatment prioritization.

Psychosocial factors associated with pain and health-related quality of life in Endometriosis: A systematic review

BACKGROUND AND OBJECTIVE

Endometriosis is associated with pain and impaired health-related quality of life (HRQoL). Psychosocial factors have been associated with pain and HRQoL in other conditions, suggesting their potential relevance in Endometriosis. However, the role of psychosocial factors in this population has not been systematically explored yet. This systematic review aims to explore the association of psychosocial factors with pain intensity/severity and HRQoL in women with Endometriosis.

DATABASES AND DATA TREATMENT

Observational and experimental studies that explored the association of psychosocial factors with pain and HRQoL in women with Endometriosis were eligible. The following databases were searched: Medline, Embase, Cochrane library, Web of Science, PsychInfo and Cumulative index of nursing and allied health literature. The methodological quality was assessed, and findings were synthesized using narrative synthesis.

RESULTS

Twenty-seven studies were eligible for inclusion, which included 5419 women with Endometriosis. Catastrophising and anxiety were the factors most consistently associated with greater pain, whilst depression, anxiety and stress were related to worse HRQoL. Findings regarding depression and pain were mixed, and research on social factors was limited.

CONCLUSIONS

This systematic review highlights the role of psychosocial factors in Endometriosis. Anxiety, depression and catastrophising are suggested as potential treatment targets. The review also indicates the lack of research on other potentially important psychosocial factors, such as avoidance, perceived injustice and social support.

SIGNIFICANCE

This systematic review explored the role of psychosocial factors in Endometriosis, suggesting that these are associated with pain and health-related quality of life (HRQoL). Among the psychosocial factors included, anxiety, depression and catastrophising were the factors most often associated with pain and HRQoL in Endometriosis. These findings highlight the need to target psychological factors in the treatment of women with Endometriosis.

Internet-based cognitive behavioral therapy for improving health-related quality of life in patients with endometriosis: study protocol for a randomized controlled trial

BACKGROUND

The trial investigates the efficacy of internet-based cognitive behavioral therapy (iCBT) in improving health-related QoL in patients with endometriosis, which is a chronic gynecological condition affecting up to 15% of people with female-assigned reproductive organs. Endometriosis is stress-related and comes with various physical symptoms such as pelvic pain and infertility. It has a substantial impact on health-related quality of life (QoL), and mind-body interventions seem promising in reducing the psychological burden.

METHODS

This is a monocentric randomized-controlled trial recruiting 120 patients with endometriosis. The intervention consists of eight iCBT modules focusing on psychoeducation, cognitive restructuring, pacing, and emotion regulation. Participants will receive written feedback from a trained therapist weekly. The comparator is a waitlist control group. All participants will be followed up 3 months after the intervention, and the intervention group will additionally be followed up 12 months after the intervention. Trial participants will not be blinded to the allocated trial arm. Primary outcome measures are endometriosis-related QoL, pain, and pain-related disability. Secondary outcomes include coping, illness representations, and psychological flexibility. Statistical analyses will be performed following intention-to-treat principles.

DISCUSSION

This randomized-controlled trial is the first trial to test the efficacy of iCBT for improving endometriosis-related QoL. Potential predictor variables and key mechanisms in treatment will be investigated to enable further progression in medical and psychological care for patients with endometriosis.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT05098444 Registered on October 28, 2021.

Portrayals of narcolepsy from 1980 to 2020: a descriptive analysis of stigmatizing content in newspaper articles

STUDY OBJECTIVES

The media are the primary source of information about health for the public. The media portrayal of narcolepsy might contribute to the stigmatization of people affected by this condition. This study aimed to describe how narcolepsy is portrayed in newspapers.

METHODS

We collected 257 newspaper articles from the digital archive of "La Stampa" published between 1980 and 2020 that mentioned key search terms. The content was assessed using an ad-hoc coding schema developed to evaluate the presence of sensationalistic title, negative language, stigmatizing content, stereotypical description, disclosure of a person diagnosed with narcolepsy, person with narcolepsy described as dangerous, presence of an accurate diagnosis, identifiable symptoms, indications about diagnostic and treatment services. The Chi-squared analysis was performed to identify changes over time in the type of content.

RESULTS

In 10.9% of the articles, there was a sensationalistic title; inappropriate, negative, and outdated language appeared in 10.5% of the articles. Stigmatizing and stereotypical content were reported in 19.5% and 14.8% of the articles, respectively. In 62.3% of the articles, it was disclosed that a person has narcolepsy, and in 5.1% of the articles patients with narcolepsy are described as dangerous. 30.4% of the articles referred to the presence of an accurate diagnosis, while 16.7% described identifiable symptoms. Services for diagnosis and treatment were mentioned in 24.1% of the articles. Changes over time in the content of articles are discussed.

CONCLUSIONS

Our findings highlight areas for improvement in the media portrayal of narcolepsy and could help guide the development of new targeted antistigma campaigns.

A Single-blind, randomized, pilot study of a brief Mindfulness-Based Intervention for the endometriosis-related pain management

BACKGROUND

Women with endometriosis suffer from frequent symptoms despite multiple treatments in tertiary care. Although there is a need for a biopsychosocial perspective on endometriosis treatment, few conservative treatments have been investigated. We aimed to investigate the effects of a brief Mindfulness-Based Intervention (bMBI) in women with deep endometriosis who remain symptomatic despite undergoing conventional medical treatment.

METHODS

A randomized controlled trial was performed with 2 groups: a standard medical treatment plus bMBI program and only standard medical treatment as a control. A total of 63 eligible participants were randomized to bMBI and control group. The primary outcome was endometriosis-related pain, and secondary outcomes were quality of life and stress perception posttreatment. Analyses were carried out using multiple regression models.

RESULTS

The results show that bMBI significantly improved pain unpleasantness (Cohen's f2 = 0.67, NNT = 3.2), pelvic pain (Cohen's f2 = 0.16, NNT = 5.3), and dyschezia (Cohen's f2 = 0.23, NNT = 2.9) immediately posttreatment and decreased all endometriosis-related pain (Cohen's f2 ranging from 0.20 to 0.60 and NNT ranging from 5 to -9) after the follow-up. We found an extensive positive effect of bMBI on the mental health dimension in the two time-point measures (Cohen's f2 = 0.34 and 0.25, NNT = 3.5 and 2.3) and vitality (Cohen's f2 = 0.22, NNT = 2.1) after the follow-up.

CONCLUSIONS

Our study suggests that bMBI is useful for managing endometriosis-related pain and restoring women's psychological well-being.