Managing endometriosis. Strategies to minimize pain and damage

Endometriosis-Associated Angiogenesis and Anti-angiogenic Therapy for Endometriosis

Endometriosis is a known estrogen-dependent inflammatory disease affecting reproductive-aged women. Common symptoms include pelvic pain, dysmenorrhea, dyspareunia, heavy menstrual bleeding, and infertility. The exact etiology of endometriosis is largely unknown, and, thus, the diagnosis and treatment of endometriosis are challenging. A complex interplay of many molecular mechanisms is thought to aid in the progression of endometriosis, most notably angiogenesis. This mini-review examines our current knowledge of the molecular etiology of endometriosis-associated angiogenesis and discusses anti-angiogenic therapy, in the blockade of endometriosis-associated angiogenesis, as potential non-hormonal therapy for the treatment of endometriosis.

Prospects and Challenges of the Drug Delivery Systems in Endometriosis Pain Management: Experimental and Theoretical Aspects

Endometriosis is considered a serious public health issue because of the large number of females affected by this illness. Chronic pain management in patients with endometriosis demands new strategies to increase the life quality of these patients. The development of drug delivery systems represents a new approach in pain treatment among endometriosis patients. Diclofenac sodium, one of the most utilized nonsteroidal anti-inflammatory drugs (NSAID), has its own limitations when being used in formulas such as oral, parental, or local applications. In this paper, a series of four drug release formulations based on chitosan, 2-hydroxy-5-nitrobenzaldehyde, and diclofenac sodium salt were prepared in view of the investigation of the drug release ability. The formulations were analyzed from a morphological and supramolecular point of view by scanning electron microscopy and polarized light microscopy. The in vitro drug release ability was investigated by mimicking a physiologic environment. A mathematical model, using the fractal paradigm of motion, is utilized to explain the behaviors of the drug delivery system presented in this paper. These results suggest a great potential of the proposed drug delivery system, based on chitosan and 2-hydroxy-5-nitrobenzaldehyde to improve the diclofenac sodium salt bioavailability, and it may represent a future treatment formula for endometriosis pain.

Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis

BACKGROUND

Endometriosis is a common gynaecological condition that affects women and can lead to painful symptoms and infertility. It greatly affects women's quality of life, impacting their careers, everyday activities, sexual and nonsexual relationships and fertility. Nonsteroidal anti-inflammatory drugs (NSAIDs) are most commonly used as first-line treatment for women with pain associated with endometriosis.

OBJECTIVES

To assess effects of NSAIDs used for management of pain in women with endometriosis compared with placebo, other NSAIDs, other pain management drugs or no treatment.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials (October 2016), published in the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, as well as MEDLINE (January 2008 to October 2016), Embase (date limited from 1 January 2016 to 19 October 2016, as all earlier references are included in CENTRAL output as a result of the Embase project), registers of ongoing trials and the reference lists of relevant publications. We identified no new randomised controlled trials. Unless we identify new evidence in the future, we will not update this review.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) describing use of NSAIDs for management of pain associated with endometriosis in women of all ages.

DATA COLLECTION AND ANALYSIS

In the 2009 update of this review, two review authors (CA and SH) independently read and extracted data from each of the included studies. We analysed cross-over trials using the inverse variance method of RevMan to calculate odds ratios for binary outcomes.

MAIN RESULTS

We identified no new trials for the 2016 update. This review includes two trials, but we included only one trial, with 24 women, in the analysis.The overall risk of bias was unclear owing to lack of methodological detail. Using the GRADE method, we judged the quality of the evidence to be very low. We downgraded evidence for risk of bias and for imprecision (wide confidence intervals and evidence based on a single small trial).Comparison of NSAIDs (naproxen) versus placebo revealed no evidence of a positive effect on pain relief (odds ratio (OR) 3.27, 95% confidence interval (CI) 0.61 to 17.69; one trial, 24 women; very low-quality evidence) in women with endometriosis. Evidence indicating whether women taking NSAIDs (naproxen) were less likely to require additional analgesia (OR 0.12, 95% CI 0.01 to 1.29; one trial, 24 women; very low-quality evidence) or to experience side effects (OR 0.46, 95% CI 0.09 to 2.47; one trial, 24 women; very low-quality evidence) when compared with placebo was inconclusive.Studies provided no data on quality of life, effects on daily activities, absence from work or school, need for more invasive treatment or participant satisfaction with treatment.

AUTHORS' CONCLUSIONS

Owing to lack of high-quality evidence and lack of reporting of outcomes of interest for this review, we can make no judgement as to whether NSAIDs (naproxen) are effective in managing pain caused by endometriosis. No evidence shows whether any individual NSAID is more effective than another. As shown in other Cochrane reviews, women taking NSAIDs must be aware that these drugs may cause unintended effects.

Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis

BACKGROUND

Endometriosis is a common gynaecological condition that affects women and can lead to painful symptoms and infertility. It greatly affects women's quality of life, impacting on their careers, everyday activities, sexual and non-sexual relationships, and fertility. Non-steroidal anti-inflammatory drugs (NSAIDs) are the most commonly used first-line treatment for endometriosis.

OBJECTIVES

To assess the effects of NSAIDs used for the management of pain in women with endometriosis compared to placebo, other NSAIDs, other pain management drugs, or no treatment.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (April 2008) published in the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (1966 to April 2008), EMBASE (1980 to April 2008), and the reference lists from relevant publications. Experts in the field were also contacted for information about possible studies.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) describing the use of NSAIDs in the treatment of endometriosis in women of all ages.

DATA COLLECTION AND ANALYSIS

Two review authors (CA and SH) independently read and extracted data from each of the included studies. Crossover trials were analysed using the inverse variance method in RevMan to calculate the odds ratio for binary outcomes.

MAIN RESULTS

Two trials were identified but only one trial, with 24 women, was included in the analysis. Comparing NSAIDs (naproxen) to placebo, there was no evidence of a positive effect on pain relief (odds ratio (OR) 3.27, 95% CI 0.61 to 17.69) in women with endometriosis. There was also inconclusive evidence to indicate whether women taking NSAIDs (naproxen) were less likely to require additional analgesia (OR 0.12, 95% CI 0.01 to 1.29) or to experience side effects (OR 0.46, 95% CI 0.09 to 2.47) when compared to placebo.

AUTHORS' CONCLUSIONS

There is inconclusive evidence to show whether or not NSAIDs (naproxen) are effective in managing pain caused by endometriosis. There is no evidence on whether any individual NSAID is more effective than another. As shown in other Cochrane reviews, women using NSAIDs need to be aware of the possibility that these drugs may cause unintended effects.

A Rare Case of Precoccygeal Endometriosis

BACKGROUND

Endometriosis is commonly identified in the abdomen, specifically the ovaries, adnexa, and fallopian tubes, and sometimes in more distant areas; precoccygeal endometriosis is an extremely rare phenomenon.

CASE

We present a case involving a 44-year-old woman diagnosed and treated for precoccygeal endometriosis. She underwent laparotomy, extensive lysis of pelvic adhesions, and resection of a 2.5-cm midline precoccygeal mass. After surgical excision of the precoccygeal endometriosis, the patient recovered without incident.

CONCLUSION

Precoccygeal endometriosis is a very rare diagnosis.

Non-steroidal anti-inflammatory drugs for pain in women with endometriosis

BACKGROUND

Endometriosis is a common gynaecological condition that affects women and can lead to painful symptoms and infertility. It affects women's quality of life greatly, impacting on their careers, everyday activities, sexual and non-sexual relationships, and fertility. Non-steroidal anti-inflammatory drugs (NSAIDs) are the most commonly used first-line treatment for endometriosis.

OBJECTIVES

To assess the effects of NSAIDs for the management of pain in women with endometriosis compared to placebo, other NSAIDs, other pain management drugs, or no treatment.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Trials Register (May 2005) published in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to May 2005), EMBASE (1980 to May 2005) and the reference lists from relevant publications. Experts in the field were also contacted for information about possible studies.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) describing the use of NSAIDs in the treatment of endometriosis in women of all ages.

DATA COLLECTION AND ANALYSIS

Two review authors (CA and SH) independently read and extracted data from each of the included studies. Crossover trials were analysed using the inverse variance method in RevMan to calculate the odds ratio for binary outcomes.

MAIN RESULTS

Two trials were identified but only one trial, with 24 women, was included in the analysis. Comparing NSAIDs (naproxen) to placebo, there was no evidence of a positive effect on pain relief (odds ratio (OR) 3.27, 95% CI 0.61 to 17.69) in women with endometriosis. There was also inconclusive evidence to indicate whether women taking NSAIDs (naproxen) were less likely to require additional analgesia (OR 0.12, 95% CI 0.01 to 1.29) or experience side effects (OR 0.46, 95% CI 0.09 to 2.47) when compared to placebo.

AUTHORS' CONCLUSIONS

There is inconclusive evidence to show whether NSAIDs (naproxen) are effective in managing pain caused by endometriosis. There is no evidence to show whether any individual NSAID is more effective than another. As shown in other Cochrane reviews, women using NSAIDs need to be aware of the possibility that these drugs may cause unintended effects.

A life shaped by pain: women and endometriosis

AIMS AND OBJECTIVES

The research aim was to explore women's perceptions of living with endometriosis, its effects on their lives and the strategies used to manage their disease.

BACKGROUND

Symptomatic endometriosis significantly affects women's quality of life. Characteristically the condition causes severe pain and has a negative impact on the ability to work, on family relationships and self-esteem. There has been little discussion about women's experience of endometriosis in nursing literature.

DESIGN

A qualitative research design informed by feminist research principles was chosen for this project.

METHODS

Eighteen women agreed to take part in the research. The individual, audio taped interviews were semi-structured and interactive. The interviews were analysed using a thematic analysis approach.

RESULTS

The dominant feature of data from the interviews was the experience of severe and chronic pain impacting on all aspects of life. Analysis related to pain resulted in four themes: manifestations of pain, the pain trajectory, intractable pain and controlling pain.

CONCLUSION

The diagnostic process typically took 5-10 years indicating that primary health care practitioners need higher levels of 'suspicion' for this condition. Case studies and problem-based scenarios focusing on endometriosis in health professional education programmes would enhance diagnostic skills and knowledge development. No formal pain management follow up after diagnosis and treatment meant women actively sought information from other sources as they made major lifestyle changes in the areas of activity and nutrition. Pain management services specifically for women with endometriosis would provide much needed support with this neglected aspect of the disease.

RELEVANCE TO CLINICAL PRACTICE

This is a fertile area for the development of the Nurse Practitioner role which, also drawing on the considerable collective expertise of women with endometriosis, could provide significant information and support for women as they manage this highly complex condition.

Endometriosis--a missed malady

Endometriosis is a disease that affects approximately 5.5 million girls and women in their reproductive years in the United States and Canada. During the menstrual cycle, the endometrial lining of the uterus thickens in preparation to receive a fertilized egg. If fertilization does not occur, this lining sloughs off during menstruation. Endometrial tissue can migrate out of the fallopian tubes and grow outside of the uterus as endometrial implants. This can result in severe pain. Endometriosis is very difficult to detect because most women become accustomed to painful menstrual cycles at an early age. The disease often will go undiagnosed because even with extensive endometriosis it is possible to have minimal symptoms or none at all. Physicians have few diagnostic tools to detect the scars and growths of endometriosis. The only way to confirm the diagnosis and stage of endometriosis is by laparoscopy. Treatment options include hormone therapy and surgery. In the past, the most successful treatment was open laparotomy with excision of the endometrial implants. This article discusses the use of the ultrasonic scalpel to resect endometrial implants through the laparoscope. The patient's perioperative course also is discussed.