The Pain and Daily Consequences of Living with Endometriosis: A Qualitative Online Survey of Women in China, France and Russia

Transgender and non-binary people's experience of endometriosis

There is a lack of research on gender diverse people's experiences with endometriosis. We explored the experience of 11 transgender and non-binary people with endometriosis using phenomenology. We collected data through multiple interviews and diaries and constructed two themes using hermeneutic analysis: (1) Unhomelikeness of Living with Endometriosis and being Gender Diverse, and (2) Towards a Homelikeness of Living with Endometriosis as a Gender Diverse Individual, which we discussed in relation to Svenaeus Phenomenology of Medicine. Unhomelikeness is an experience of disconnection with our bodies and being-in-the-world as a result of living with a chronic disease. We show how gender diverse people with endometriosis may have additional layers of unhomelikeness due to further diagnostic delays, endometriosis symptoms that may trigger gender dysphoria and experiences with treatment that are not inclusive of their gender identity. We advocate for additional support and awareness for gender diverse people with endometriosis.

Clinical characteristics and surgical management of endometriosis-associated infertility: A multicenter prospective cohort study

OBJECTIVE

To study clinical, surgical characteristics and the relationship between endometriosis lesion types and conception rate after surgery in infertile women with endometriosis.

METHODS

A prospective, multicenter cohort of 204 women (age 20-35 years) with endometriosis was followed up post-surgery between November 2017 and February 2020 at three tertiary-care hospitals.

RESULTS

Based on the severity of endometriosis lesion type, deep infiltrating endometriosis (DIE) (81/204, 39.7%) was the most common lesion; followed by ovarian endometriosis (OMA) (64/204, 31.4%), and superficial peritoneal endometriosis (SUP) (59/204, 28.9%). Endometriosis patients had a single lesion type (94/204, 46.1%), two lesion types (77/204, 37.7%), or three lesion types (33/204, 16.2%) with significant differences between regions (P < 0.001). Around 40% (37/95) of obese women had SUP (P = 0.003) whereas 78% (14/18) of underweight women had DIE (P < 0.001). Significant differences in mean Endometriosis Fertility Index scores between endometriosis lesion types and patients with one, two, and three types of lesions were observed (P < 0.001). The majority (22/32, 68.8%) of the women conceived naturally after the surgery. Half (16/32; 50%) of the women with a single lesion type conceived after the surgery; of which most (13/16, 81.2%) had SUP, followed by OMA (2/16, 12.5%), and DIE (1/16, 6.3%).

CONCLUSION

Women with SUP and only one type of endometriotic lesion were more likely to conceive post-surgery.

Analysis of the influence of endometriosis on quality of life

Abstract Introduction: Endometriosis is a disorder that can significantly affect quality of life (QOL) and interfere in biological, psychological, social, marital and family aspects. Objective: To analyze the influence of endometriosis on the QOL of women diagnosed with the disease. Methods: The study was carried out from March to April 2018, with 10 volunteers from the Santa Casa de Misericórdia do Pará Foundation, with a clinical diagnosis of endometriosis. The Portuguese version of the endometriosis health profile questionnaire (EHP-30) was applied in order to assess QOL in women with this pathology. Results: The sociodemographic results revealed a predominance of women aged between 29 and 55 years, most of whom were married (6) and high school graduates (5). Seven of the ten volunteers had previous pregnancies. Of the aspects evaluated in the EHP-30, 79% of the items associated with pelvic pain in the core questionnaire were present in the participants. In other questionnaires, sexual life (82%) was the most affected index, followed by professional life (70%) and infertility (58.82%). Conclusion: The aspects of QOL most impacted by pelvic pain associated with endometriosis in the women evaluated were sexuality and professional life, leading to biopsychosocial trauma.

The Endometriosis Impact Questionnaire (EIQ): a tool to measure the long-term impact of endometriosis on different aspects of women's lives

BACKGROUND

Endometriosis is a chronic disease impacting on many aspects of a woman's life. Because of the chronic and recurring nature, many of the impacts of endometriosis could be missed using existing questionnaires which focus on recent events. Therefore, a questionnaire with a long-term perspective is necessary. This study aimed to develop and evaluate a questionnaire to measure the long-term impact of endometriosis on different aspects of women's lives.

METHODS

Through a methodological design, phase 1 was qualitative and phase 2 was a cross-sectional study. The original 100 EIQ items were developed based on results from an earlier qualitative study and literature review. Through a process of assessing face and content validity this was reduced to 66 items. The psychometric properties of the final 63 item EIQ were evaluated through a web-based survey with data from 423 responders with a self-reported surgically-diagnosed endometriosis.

RESULTS

Participants were aged 16-58 years. Exploratory factor analysis of a 66-item EIQ was established with 423 responders. The final 63-item EIQ contained six dimensions including: 33-item physical-psychosocial; 3-item fertility; 7-item sexual; 11-item employment; 6-item educational; and 3-item lifestyle. Cronbach's alpha of 0.99 for the whole 63-item EIQ, and 0.84 to 0.98 for the dimensions suggests a very good reliability. High positive correlations between the EIQ and the EHP-5 (altered recall period) indicated good evidence of concurrent validity. High intra-class correlations indicated very good test-retest reliability.

CONCLUSIONS

The EIQ, as a disease-specific questionnaire, could be used to provide a better understanding of the impact of endometriosis on different aspects of life, to better meet the needs of women. We recommend additional studies to establish validity evidence for the EIQ, including studies in other countries and languages.

Systematic review of quality of life measures in patients with endometriosis

OBJECTIVES

Endometriosis and quality of life has been the subject of much research, however, there is little consensus on how best to evaluate quality of life in endometriosis, resulting in many and diverse scales being used. In our study, we aim to identify quality of life scales used in endometriosis, to review their strengths and weaknesses and to establish what would define an ideal scale in the evaluation of endometriosis-related quality of life.

MATERIALS AND METHODS

A search of the MEDLINE and EMBASE databases was carried out for publications in English and French for the period from 1980 to February 2017, using the words 'endometriosis' and 'quality of life'. Publications were selected if they reported on quality of life in patients with endometriosis and specified use of a quality of life scale. A quantitative and a qualitative analysis of each scale was performed in order to establish the strengths and weaknesses for each scale (systematic registration number: PROSPERO 2014: CRD42014014210).

RESULTS

A total of 1538 articles publications were initially identified. After exclusion of duplicates and application of inclusion criteria, 201 studies were selected for analysis. The SF-36, a generic HRQoL measure, was found to be the most frequently used scale, followed by the EHP-30, a measure specific to endometriosis. Both perform well, when compared with other scales, with scale weaknesses offset by strengths. EHP-5 and EQ-5D also showed to be of good quality. All four were the only scales to report on MCID studied in endometriosis patients.

CONCLUSION

For clinical practice, routine evaluation of HRQOL in women with endometriosis is essential both for health-care providers and patients. Both SF-36 and EHP-30 perform better overall with regard to their strengths and weaknesses when compared to other scales.

Plasma urocortin-1 as a preoperative marker of endometriosis in symptomatic women

Accurate noninvasive diagnostic tests for endometriosis are still missing. This study evaluated the predictive value of the neuropeptide urocortin 1 (Ucn1) to detect pelvic endometriosis in symptomatic women. We enrolled prospectively 97 consecutive women submitted to gynecologic laparoscopy for chronic or acute pelvic pain, infertility or adnexal mass. Preoperative blood samples were assayed for Ucn1 using enzyme immunoassay. Patients with endometriosis had higher plasma Ucn1 levels compared to patients with no lesions (median 59 vs. 34 pg/ml, p < .01, Dunn's test). Elevated plasma Ucn1 levels were found among all endometriosis phenotypes (superficial peritoneal lesions, ovarian endometrioma, and deep infiltrating endometriosis, p < .05 vs. no lesions). Receiver operating characteristics curve analysis identified plasma Ucn1 > 46 pg/mL as the best cutoff point to detect endometriosis vs. no lesions, with 76% sensitivity and 88% specificity (area under the curve [AUC] 0.827, 95% confidence interval [CI] 0.695 - 0.959), but no cutoff could accurately distinguish endometriosis from other pathological conditions (AUC 0.593 [95% CI 0.474 - 0.711]). In women with chronic pelvic pain, infertility, or both symptoms, the probability of endometriosis (positive predictive value) increased consistently with the increase of plasma Ucn1 levels. The present findings suggest that high plasma Ucn1 levels increase the likelihood of endometriosis in symptomatic women.

Tumor Necrosis Factor and its Soluble Receptors as Potential Diagnostic Markers of Endometriosis

Introduction

Tumor necrosis factor (TNF) is a proinflammatory and angiogenic factor produced by activated macrophages. TNF acts through the cell membrane receptors TNFR1 and TNFR2, whose soluble forms play an important role in regulating TNF activity through competition with its receptors. The aim of this study was to evaluate whether TNF and/or its soluble receptors are useful to detect endometriosis in women undergoing laparoscopy for gynecological complains.

Methods

This was a prospective, controlled, cross-sectional study including 75 consecutive women scheduled for gynecological laparoscopy due to chronic pelvic pain, infertility, or a pelvic image suggestive of endometrioma. Plasma TNF and soluble TNF receptors (sTNFR1 and sTNFR2) were measured by flow cytometry with the Cytometric Bead Array Human TH1/TH2 Kit (BD Biosciences).

Results

Women ultimately proven to have endometriosis had lower preoperative plasma levels of sTNFR1 (median 81 pg/mL vs. 121 pg/mL, p<0.05), resulting in higher TNF/sTNFR1 ratios compared to those without endometriosis (0.055 vs. 0.033, p<0.05). Using the cut-off <108 pg/mL for plasma sTNFR1 to detect endometriosis in this setting, the sensitivity was 51.6% (95% confidence interval [CI], 35%-68%), the specificity was 75.0% (95% CI, 61%-85%) and the positive likelihood ratio was 2.1 (95% CI, 1.1-3.8). The area under the ROC curve was 0.647 (SE = 0.065; 95% CI, 0.519-0.774; p = 0.031).

Conclusions

Plasma sTNFR1 levels are lower in symptomatic women with confirmed endometriosis compared to symptomatic women without endometriosis. The lower plasma sTNFR1 levels may increase the bioavailability of TNF, thereby contributing to the systemic low grade inflammation associated with endometriosis.

Alteration of Nrf2 and Glutamate Cysteine Ligase expression contribute to lesions growth and fibrogenesis in ectopic endometriosis

The redox-sensitive nuclear factor erythroid-derived 2-like 2 (NRF2) controls endogenous antioxidant enzymes' transcription and protects against oxidative damage which is triggered by inflammation and known to favor progression of endometriosis. Glutamate Cysteine Ligase (GCL), a target gene of NRF2, is the first enzyme in the synthesis cascade of glutathione, an important endogenous antioxidant. Sixty-one patients, with thorough surgical examination of the abdominopelvic cavity, were recruited for the study: 31 with histologically-proven endometriosis and 30 disease-free women taken as controls. Expressions of NRF2 and GCL were investigated by quantitative RT-PCR and immunohistochemistry in eutopic and ectopic endometria from endometriosis-affected women and in endometrium of disease-free women. Ex vivo stromal and epithelial cells were extracted and purified from endometrial and endometriotic biopsies to explore expression of NRF2 and GCL in both stromal and epithelial compartments by western blot. Finally, in order to strengthen the role of NRF2 in endometriosis pathogenesis, we evaluated the drop of NRF2 expression in a mouse model of endometriosis using NRF2 knockout (NRF2^-/-) mice. The mRNA levels of NRF2 and GCL were significantly lower in ectopic endometria of endometriosis-affected women compared to eutopic endometria of disease-free women. The immunohistochemical analysis confirmed the decreased expression of both NRF2 and GCL in ectopic endometriotic tissues compared to eutopic endometria of endometriosis-affected and disease-free women. Immunoblotting revealed a significant decreased of NRF2 and GCL expression in epithelial and stroma cells from ectopic lesions of endometriosis-affected women compared to eutopic endometria from controls. Using a murine model of endometriosis, NRF2^-/- implants were more fibrotic compared to wild-type with an increased weight and volume. These findings indicate that expression of the transcription factor NRF2 and its effector GCL are both profoundly deregulated in endometriotic lesions towards increased growth and fibrogenetic processes.

Plasma brain-derived neurotrophic factor in women with pelvic pain: a potential biomarker for endometriosis?

AIM

To test whether plasma BDNF levels are useful to predict the presence of endometriosis in women with pelvic pain.

PATIENTS & METHODS

Prospective cross-sectional study including 67 consecutive women aged 24-49 years, scheduled for laparoscopy due to chronic pelvic pain. Preoperative plasma samples were assayed for BDNF using a commercial enzyme immunoassay.

RESULTS

Women with ovarian endometrioma had higher preoperative plasma BDNF (1063 ± 157 pg/ml) compared with women with other benign ovarian tumors (537 ± 131 pg/ml, F = 2.53; p = 0.02). However, plasma BDNF levels were not helpful to indicate the presence of peritoneal or deep infiltrating endometriosis. Plasma BDNF levels were positively correlated with the severity of pelvic pain (r = 0.489; p < 0.0001).

CONCLUSION

Plasma BDNF might be a biomarker of ovarian endometrioma but not a useful diagnostic marker to detect other forms of endometriosis in women with painful symptoms.