An Interdisciplinary Approach to Endometriosis-associated Persistent Pelvic Pain

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.

Standardized protocol for quantification of nerve bundle density as a biomarker for endometriosis

Introduction

We propose a standardized protocol for measurement of nerve bundle density in endometriosis as a potential biomarker, including in deep endometriosis (DE), ovarian endometriomas (OMA) and superficial peritoneal endometriosis (SUP).

Methods

This was a prospective cohort of surgically excised endometriosis samples from Dec 1st 2013 and Dec 31st 2017 at a tertiary referral center for endometriosis in Vancouver, BC, Canada. Surgical data were available from linked patient registry. Protein gene product 9.5 (PGP9.5) was used to identify nerve bundles on immunohistochemistry. PGP9.5 nerve bundles were counted visually. To calculate nerve bundle density, PGP9.5 nerve bundle count was divided by the tissue surface area (total on the slide). All samples were assessed using NHS Elements software for semi-automated measurement of the tissue surface area. For a subset of samples, high power fields (HPFs) were also counted as manual measurement of the tissue surface area. Intraclass correlation was used to assess intra observer and inter observer reliability. Generalized linear mixed model (GLMM) with random intercepts only was conducted to assess differences in PGP9.5 nerve bundle density by endometriosis type (DE, OMA, SUP).

Results

In total, 236 tissue samples out of 121 participants were available for analysis in the current study. Semi-automated surface area measurement could be performed in 94.5% of the samples and showed good correlation with manually counted HPFs (Spearman's rho = 0.781, p < 0.001). To assess intra observer reliability, 11 samples were assessed twice by the same observer; to assess inter observer reliability, 11 random samples were blindly assessed by two observers. Intra observer reliability and inter observer reliability for nerve bundle density were excellent: 0.979 and 0.985, respectively. PGP9.5 nerve bundle density varied among samples and no nerve bundles could be found in 24.6% of the samples. GLMM showed a significant difference in PGP9.5 nerve bundle density between the different endometriosis types (X2 = 87.6, P < 0.001 after adjusting for hormonal therapy, with higher density in DE and SUP in comparison to OMA).

Conclusion

A standardized protocol is presented to measure PGP9.5 nerve bundle density in endometriosis, which may serve as a biomarker reflecting local neurogenesis in the endometriosis microenvironment.

Chronic Pelvic Pain Profiles in Women Seeking Care in a Tertiary Pelvic Pain Clinic

OBJECTIVE

Female chronic pelvic pain (CPP) has multiple pain generators and significant psychosocial sequalae. Biopsychosocial-based phenotyping could help identify clinical heterogeneity that may inform tailored patient treatment. This study sought to identify distinct CPP profiles based on routinely collected clinical information and evaluate the validity of the profiles through associations with social histories and subsequent health care utilization.

METHODS

Women (18-77 years, n = 200) seeking care for CPP in a tertiary gynecological pelvic pain clinic between 2017 and 2020 were included. Baseline data of pain intensity, interference, catastrophizing, acceptance, overlapping pelvic pain syndromes, and co-occurring psychiatric disorders were subject to a partition around medoids clustering to identify patient profiles. Profiles were compared across social history and subsequent treatment modality, prescribed medications, and surgeries performed.

RESULTS

Two profiles with equal proportion were identified. Profile 1 was vulvodynia and myofascial pelvic pain-dominant characterized by lower pain burden and better psychological functioning. Profile 2 was visceral pain-dominant featuring higher pain interference and catastrophizing, lower pain acceptance, and higher psychiatric comorbidity. Patients in Profile 2 had 2-4 times higher prevalence of childhood and adulthood abuse history (all P < .001), were more likely to subsequently receive behavioral therapy (46% vs 27%, P = .005) and hormonal treatments (34% vs 21%, P = .04), and were prescribed more classes of medications for pain management (P = .045) compared to patients in Profile 1.

CONCLUSIONS

Treatment-seeking women with CPP could be separated into two groups distinguished by pain clusters, pain burden, pain distress and coping, and co-occurring mental health disorders.

AN ULTRASOUND-BASED PREDICTION MODEL TO PREDICT URETEROLYSIS AT LAPAROSCOPIC ENDOMETRIOSIS SURGERY

STUDY OBJECTIVES

To develop a model, including clinical features and ultrasound findings, to predict the need for ureterolysis (i.e. dissection of the ureter) during laparoscopy for endometriosis.

DESIGN

A retrospective observational study of patients who had transvaginal ultrasound (TVS) according to the International Deep Endometriosis Analysis (IDEA) consensus and subsequent laparoscopy +/- excision of endometriosis between January 2017 and February 2021 was conducted.

SETTING

Sydney Medical School Nepean, University of Sydney, Nepean Hospital and Blue Mountains Hospital, New South Wales, Australia INTERVENTION: The demographic, clinical, TVS and intra-operative data were extracted through electronic clinical records.

MEASUREMENTS

Multi-categorical decision-tree and baseline models were built to choose the variables most correlated to the outcome under study. Receiver operating characteristic (ROC) analysis was performed on the binary classification. Based on our results, we selected the variables performing with significant statistical differences (p-value < .05).

MAIN RESULTS

During the study period, 177 consecutive patients were recruited and divided into two subgroups, ureterolysis (51.4%) and and non-ureterolysis (48.6%). Ureterolysis was noted in 87.5% of patients in which the left ovary was immobile (p-value< .001), and in 82.5% in which the right ovary was fixed (p-value<.001). For patients with right uterosacral ligament (USL) deep endometriosis (DE), ureterolysis was performed on 96.2% (p-value< .001), and 64.6% (p-value= .043) for left USL DE. Among patients with bowel DE, the proportion of patients undergoing ureterolysis was 95.5% (p-value < .001). The prognostic variables utilized in the final model to predict ureterolysis included dyschezia, absence of ovarian mobility, presence of right or left USL DE and presence of bowel DE on TVS. According to the developed model, the baseline risk for performing ureterolysis is 20% in our sample. The overall model performance demonstrated an area under the ROC curve 0.82.

CONCLUSION

Our study demonstrates that it is possible to predict the need for ureterolysis with clinical and sonographic data. Furthermore, patients presenting with the combination of the variables of our model (dyschezia, ovarian immobility, USL and bowel DE lesions) have a high risk of ureterolysis. On the other hand, patients without these features have a low risk (approximately 20%) of needing ureterolysis.

Peripheral, Central, and Cross Sensitization in Endometriosis-Associated Pain and Comorbid Pain Syndromes

Endometriosis-associated pain and the mechanisms responsible for its initiation and persistence are complex and difficult to treat. Endometriosis-associated pain is experienced as dysmenorrhea, cyclical pain related to organ function including dysuria, dyschezia and dyspareunia, and persistent pelvic pain. Pain symptomatology correlates poorly with the extent of macroscopic disease. In addition to the local effects of disease, endometriosis-associated pain develops as a product of peripheral sensitization, central sensitization and cross sensitization. Endometriosis-associated pain is further contributed to by comorbid pain conditions, such as bladder pain syndrome, irritable bowel syndrome, abdomino-pelvic myalgia and vulvodynia. This article will review endometriosis-associated pain, its mechanisms, and its comorbid pain syndromes with a view to aiding the clinician in navigating the literature and terminology of pain and pain syndromes. Limitations of our current understanding of endometriosis-associated pain will be acknowledged. Where possible, commonalities in pain mechanisms between endometriosis-associated pain and comorbid pain syndromes will be highlighted.

Evaluation of clinical practice guidelines (CPG) on the management of female chronic pelvic pain (CPP) using the AGREE II instrument

Introduction and hypothesis

Variations in guidelines may result in differences in treatments and potentially poorer health-related outcomes. We aimed to systematically review and evaluate the quality of national and international guidelines and create an inventory of CPG recommendations on CPP.

Methods

We searched EMBASE and MEDLINE databases from inception till August 2020 as well as websites of professional organizations and societies. We selected national and international CPGs reporting on the diagnosis and management of female CPP. We included six CPGs. Five researchers independently assessed the quality of included guidelines using the AGREE II tool and extracted recommendations.

Results

Two hundred thirty-two recommendations were recorded and grouped into six categories: diagnosis, medical treatment, surgical management, behavioural interventions, complementary/alternative therapies and education/research. Thirty-nine (17.11%) recommendations were comparable including: a comprehensive pain history, a multi-disciplinary approach, attributing muscular dysfunction as a cause of CPP and an assessment of quality of life. Two guidelines acknowledged sexual dysfunction associated with CPP and recommended treatment with pelvic floor exercises and behavioural interventions. All guidelines recommended surgical management; however, there was no consensus regarding adhesiolysis, bilateral salpingo-oophorectomy during hysterectomy, neurectomy and laparoscopic uterosacral nerve ablation. Half of recommendations (106, 46.49%) were unreferenced or made in absence of good-quality evidence or supported by expert opinion. Based on the AGREE II assessment, two guidelines were graded as high quality and recommended without modifications (EAU and RCOG). Guidelines performed poorly in the “Applicability”, “Editorial Independence” and “Stakeholder Involvement” domains.

Conclusion

Majority of guidelines were of moderate quality with significant variation in recommendations and quality of guideline development.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-021-04848-1.

Impact of a Persistent Pelvic Pain Clinic: Emergency attendances following multidisciplinary management of persistent pelvic pain

Persistent pelvic pain (PPP) is an important cause of psychological distress and productivity loss in women. In 2017, a multidisciplinary clinic was established to care for Queensland women with PPP. By analysing clinic and emergency department data, we found 19% fewer patients required any presentation to the emergency department for exacerbations of pelvic pain (P = 0.003) within 12 months of clinic attendance. There was also a reduction in number of presentations, short stay admissions and daily opiate use in regular users. The Persistent Pelvic Pain Clinic (PPPC) made a difference to these women and reduced resource burden on a busy emergency department.

Interdisciplinary Teams in Endometriosis Care

Endometriosis-associated chronic pelvic pain can at times be a complex problem that is resistant to standard medical and surgical therapies. Multiple comorbidities and central sensitization may be at play and must be recognized with the help of a thorough history and physical examination. If a complex pain problem is identified, most endometriosis expert reviews and guidelines recommend multidisciplinary care. However, there are no specific recommendations about what should be the components of this approach and how that type of team care should be delivered. There is evidence showing the effectiveness of specific interventions such as pain education, physical therapy, psychological therapies, and pharmacotherapies for the treatment of chronic pain. Interdisciplinary team models have been well studied and validated in other chronic pain conditions such as low back pain. The published evidence in support of interdisciplinary teams for endometriosis-associated chronic pain is more limited but appears promising. Based on the available evidence, a model for an interdisciplinary team approach for endometriosis care is outlined.

A systematic review on reported outcomes and outcome measures in female idiopathic chronic pelvic pain for the development of a core outcome set

BACKGROUND

A core outcome set (COS) is required to address inconsistencies in outcome reporting in chronic pelvic pain (CPP) trials.

OBJECTIVES

Evaluation of reported outcomes and selected outcome measures in CPP trials by producing a comprehensive inventory to inform a COS.

SEARCH STRATEGY

Systematic review of randomised controlled trials (RCTs) identified from Cochrane Central Register of Controlled Trials (CENTRAL), Embase and MEDLINE databases.

SELECTION CRITERIA

RCTs assessing efficacy and safety of medical, surgical and psychological interventions for women with idiopathic CPP.

DATA COLLECTION AND ANALYSIS

Two independent researchers extracted outcomes and outcome measures. Similar outcomes were grouped and classified into domains to produce a structured inventory.

MAIN RESULTS

Twenty-four trials were identified including 136 reported outcomes and outcome measures. Rates of reporting outcomes varied (4-100%) and pelvic pain was the most frequently reported outcome (100%). All trials reported the pain domain; however, only half reported quality of life, clinical effectiveness and adverse events. No differences in outcome reporting were observed in five high-quality trials (21%). Univariate analysis demonstrated an association between quality of outcome reporting and methodological quality of studies (r_s  = 0.407, P = 0.048).

CONCLUSION

There is wide variation in reported outcomes and applied outcome measures in CPP trials. While a COS is being developed and implemented, we propose the interim use of commonly reported outcomes in each domain: pain (pelvic pain, dyspareunia, dysmenorrhoea), life impact (quality of life, emotional functioning, physical functioning), clinical effectiveness (efficacy, satisfaction, cost effectiveness, return to daily activities) and adverse events (surgical, perioperative observations, nonsurgical).

TWEETABLE ABSTRACT

There is significant variation in outcome reporting in CPP trials. Our systematic review forms the basis for the development of a core outcome set.

Rethinking mechanisms, diagnosis and management of endometriosis

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.