[Endometriosis : An often unrecognized pain disorder]

Scar endometriosis, a form of abdominal wall endometriosis-a neglected obstetrical complication?

BACKGROUND

Scar endometriosis (EM) is defined by the presence of endometrial-like tissue outside the uterine cavity within the scar region after abdominal or pelvic surgery. It is a form of abdominal wall EM. This systematic review addresses the question of whether women after cesarean delivery (CD) are more frequently affected by scar EM than women after other pelvic surgical procedures. The primary aim is to analyze the distribution of previous operations in patients with scar EM. Secondarily, symptoms, diagnosis, and treatment are described.

METHODS

A systematic literature search in MEDLINE (Pubmed) was performed. Twelve studies were included.

RESULTS

The terminology of scar EM is unspecific and the descriptions are, therefore, of limited comparability among authors. In 64-96%, patients with scar EM had a history of CD, followed by laparoscopy, laparotomy, and episiotomy. The main symptoms were pain, often cyclical, and the presence of local swelling. For diagnosis ultrasound, CT scan and MR imaging were used. All patients had undergone surgical resection and the diagnosis was confirmed.

CONCLUSION

Most often scar EM develops after CD. Diagnosis and treatment are often delayed. As an objective classifications system is missing, we propose a simple objective descriptive tool for abdominal wall EM.

The Incidence of Endometriosis, 2014–2022. An Analysis of Nationwide Claims Data From Physicians in Private Practice

BACKGROUND

The epidemiological characterization of endometri - osis, particularly with regard to its incidence, has been inadequate to date both in Germany and other countries. The goal of this study was to determine trends in the incidence of diagnosed endometri - osis and changes in age structure at the time of first diagnosis over the period 2014-2022.

METHODS

Nationwide claims data from physicians in private practice, obtained according to relevant German law (§ 295 SGB V), were used to identify the population at risk for a first assured diagnosis of endometriosis (ICD-10-GM: N80) during each year of the study period, consisting of women and girls aged 10-52 who were insured by the statutory health insurance system and for whom at least two years of prior observation were possible. Patients were defined as incident if they were documented as having received a first confirmed diagnosis of endometriosis, according to the case definition, during the study year. The case definition comprised multiple options for validating the diagnosis.

RESULTS

The incidence of diagnosed endometriosis rose over the period of the study from 2.8 per 1000 persons at risk in 2014 to 4.1 per 1000 in 2022, corresponding to a 44% relative increase. There was also a marked shift in agespecific incidence toward higher values at younger ages: the median age at diagnosis fell from 37 years (2014) to 34 (2022).

CONCLUSION

This is the first study providing nationwide population-based data on the incidence of endometriosis in Germany. The observed rise in newly diagnosed cases is presumably mainly due to an increased awareness of endometriosis and to the growing recognition of the disease.

Physical and psychosocial factors are crucial for maintaining physical and mental health in endometriosis: a longitudinal analysis

OBJECTIVE

To test the associations of physical and psychosocial factors with physical and mental health in individuals living with endometriosis (EM) by means of cross-sectional and longitudinal analyses.

METHODS AND MEASURES

Data were gathered via an online survey between February and August 2021. At survey date t1, sociodemographic, EM-related and psychosocial factors as well as physical and mental health of people with EM were assessed. At survey date t2 three months later, physical and mental health was reassessed. The sample consisted of n_t1 = 723 (30.60 ± 6.31 years) and n_t2 = 216 (30.56 ± 6.47 years) cis women with EM. Statistical analyses included bivariate and partial correlation analyses and hierarchical regression analyses.

RESULTS

The participants' physical health was within the average range and their mental health was below-average at t1 and t2. Cross-sectional analyses revealed that worse health was associated with longer diagnostic delay, more surgeries, greater pelvic pain and lower sense of coherence, self-efficacy, sexual satisfaction and satisfaction with the gynecological treatment. In longitudinal analyses, pelvic pain and participants' satisfaction with the gynecological treatment remained significantly associated with health.

CONCLUSION

Treatment should address both pelvic pain and psychosocial factors to improve long-term physical and mental health in EM.

[Holistic treatment of endometriosis]

BACKGROUND

The pain phenomena caused by endometriosis are manifold. In addition to nociceptive pain there is also a nociplastic reaction with central sensitization. Atypical symptoms, such as acyclic lower abdominal pain, radiating pain, nonspecific bladder and intestinal complaints or even depression increasingly occur in addition to the classical cyclic complaints, such as severe dysmenorrhea, cyclic lower abdominal pain, dyspareunia, dysuria and dyschezia. Due to the diffuse range of symptoms, affected patients often consult not just gynecologists but also specialists from other disciplines (internal medicine, gastroenterology, orthopedics, pain therapy, psychology etc.).

OBJECTIVE

The complexity of endometriosis is presented. The resulting approaches to multimodal interdisciplinary holistic treatment are described.

RESULTS

Interdisciplinary concepts should be involved in the optimal treatment of endometriosis patients along with hormonal and surgical treatment, mostly under the supervision of a gynecologist and pain management, dietary changes, psychological support and physiotherapeutic management should also be included. This article provides an overview of possible treatment strategies for chronic symptomatic endometriosis.

CONCLUSION

Based on multimodal treatment strategies and regarding the complex pathophysiological alterations of this disease, the complex complaints that significantly impair the quality of life of endometriosis patients can be greatly improved.

Mechanisms of peripheral sensitization in endometriosis patients with peritoneal lesions and acyclical pain

PURPOSE

Endometriosis (EM) is one of the most frequent differential diagnoses concerning chronic pelvic pain. Women under hormonal therapy (HT) often benefit from it but sometimes suffer a setback and develop acyclical pelvic pain. Due to the assumption that mechanisms of neurogenic inflammation are involved in the generation of chronic pelvic pain, we aimed to investigate the expression of sensory nerve markers in EM-associated nerve fibers of patients with/without HT.

METHODS

Laparoscopically excised peritoneal samples from 45 EM and 10 control women were immunohistochemically stained for: PGP9.5, Substance P (SP), NK1R, NGFp75, TRPV-1, and TrkA. Demographics and severity of pain were documented.

RESULTS

EM patients showed a higher nerve fiber density (PGP9.5 and SP) and increased expression of NGFp75, TRPV1, TrkA, and NK1R in blood vessels and immune cells compared with controls. Patients with HT have cycle-dependent pelvic pain but suffer from acyclical pelvic pain. Interestingly, reducing NK1R expression in blood vessels under HT was observed. A correlation between dyspareunia severity and nerve fibers density and between NGFRp75 expression in blood vessels and cycle-dependent pelvic pain severity was observed.

CONCLUSION

Patients under HT have no ovulation and no (menstrual) bleeding, which correlate with inflammation and cyclical pain. However, acyclical pain seems to be due to peripheral sensitization once it is present under treatment. Neurotransmitters, like SP and their receptors, are involved in mechanisms of neurogenic inflammation, which are relevant for pain initiation. These findings indicate that in both groups (EM with/without HT), neurogenic inflammation is present and responsible for acyclical pain.

Exploring regional healthcare utilisation and quality of care for endometriosis in rural areas in Hesse, Germany: a mixed methods study protocol

INTRODUCTION

The need of a regional healthcare monitoring in order to evaluate quality and utilisation of health services in smaller scale is internationally and in Germany well established. Little is known about variation in healthcare in rural German areas, especially for women's health. In particular, endometriosis is highly prevalent and known to be unsatisfactorily treated. Thus, this study aims to investigate utilisation and quality of care, the influence of structural determinants on quality and the patient's experiences on endometriosis healthcare in rural Hesse.

METHODS AND ANALYSIS

We will use a mixed methods approach to ensure reliable mapping of the care situation for endometriosis patients in seven counties in Central and Eastern Hesse. First, retrospective secondary utilisation data and quality indicators will be used to describe possible regional variation in the treatment of endometriosis in the outpatient and inpatient sector. Second, we compare structural determinants of regions with quality of care. Third, we conduct qualitative, semistructured interviews with endometriosis patients on their perspective and experiences in those chosen rural regions. Data will then be analysed using descriptive statistics, small area variation analyses and multifactorial analyses of variance (ANOVAs). The interview will be interpreted using the experience-focused phenomenological approach.

ETHICS AND DISSEMINATION

The study has been approved by the ethics committee of Philipps-University Marburg. Utilisation data and structural determinants are anonymised and partly aggregated. The interview will use tokens for pseudonymisation to prevent the collected data from being assigned to an individual person. Also, informed consent will be obtained from patients.The results of this study will be reported to the scientific community in peer-reviewed journals and at conferences. A summary of the key findings will be provided to the interviewed patients and the Endometriosis Association Germany.

Effects of Progestin on Modulation of the Expression of Biomarkers in Endometriosis

BACKGROUND

Our study aimed to examine the osteopontin (OPN) serum levels and tissue expression of CD44 and OPN in endometriosis-affected women both undergoing and not undergoing progestin treatment, and also to determine their involvement in the pathogenesis of endometriosis.

METHODS

Using an ELISA kit, we evaluated the OPN serum levels of healthy and endometriosis-affected women both undergoing and not undergoing progestin treatment. Immunohistochemical (IHC) analyses were used to assess the endometriotic tissue expressions of CD44 and OPN.

RESULTS

There were statistically significant higher OPN serum levels in the healthy control group compared to the women with endometriosis. Furthermore, there were higher OPN serum levels in the endometriosis-affected women undergoing the progestin treatment, but the difference did not reach statistical significance. In comparison to OPN, CD44 expression was significantly higher in all the endometriotic tissue glands and stroma, regardless of the patient's treatment status. Compared to the group receiving therapy, the OPN levels were higher in the endometriosis group not receiving therapy. OPN's robust cytoplasmic expression seemed to be associated with the non-treatment group.

CONCLUSION

Endometriosis, CD44, and OPN appear to be closely related. This study suggests that endometriosis that has not been treated has an immunological profile distinct to endometriosis that has received treatment.

Understanding Psychological Symptoms of Endometriosis from a Research Domain Criteria Perspective

Endometriosis is currently the second most common gynecological disease and is associated with severe pain, vegetative impairment, and infertility. In association, there are considerable psychological symptoms that limit the quality of life of those affected. In this narrative review, the Research Domain Criteria (RDoC) framework was utilized to display the different transdiagnostic processes involved in disease progression and maintenance in regard to psychosocial functioning. Using the RDoC framework, it becomes clear that immune/endocrinological dysregulation is interlocked with (pelvic) pain chronification processes and psychological symptoms such as depressive mood, loss of control, higher vigilance toward the onset or worsening of symptoms, social isolation, and catastrophizing. This paper will discuss and identify promising treatment approaches, in addition to medical care, as well as further research implications. Endometriosis can come with substantial psychosomatic and social burden, requiring more research to understand the interdependence of different factors involved in its chronic development pathway. However, it is already clear that standard care should be extended with multifaceted treatments addressing pain, as well as the psychological and social burden, in order to halt the cycle of aggravation of symptoms and to improve quality of life for patients.

Anxiety-related behaviors without observation of generalized pain in a mouse model of endometriosis

Endometriosis is a chronic, hormone-dependent, inflammatory disease, characterized by the presence and growth of endometrial tissue outside the uterine cavity. It is associated with moderate to severe pelvic and abdominal pain symptoms, subfertility and a marked reduction in health-related quality of life. Furthermore, relevant co-morbidities with affective disorders like depression or anxiety have been described. These conditions have a worsening effect on pain perception in patients and might explain the negative impact on quality of life observed in those suffering from endometriosis-associated pain. Whereas several studies using rodent models of endometriosis focused on biological and histopathological similarities with the human situation, the behavioral characterization of these models was never performed. This study investigated the anxiety-related behaviors in a syngeneic model of endometriosis. Using elevated plus maze and the novel environment induced feeding suppression assays we observed the presence of anxiety-related behaviors in endometriosis-induced mice. In contrast, locomotion or generalized pain did not differ between groups. These results indicate that the presence of endometriosis lesions in the abdominal cavity could, similarly to patients, induce profound psychopathological changes/impairments in mice. These readouts might provide additional tools for preclinical identification of mechanisms relevant for development of endometriosis-related symptoms.

Chronic Pelvic Pain: A Comprehensive Review

Chronic pelvic pain (CPP) is explained as a complaint of cyclic or non-cyclic pelvic pain lasting for at least six months with or without dysmenorrhea, dyspareunia, dysuria, and dyschezia. The etiology of symptoms can be categorized according to organ system involvement. Gynecological causes typically involve endometriosis-related pain, pelvic congestion syndrome, pelvic inflammatory disease, adenomyosis, hydrosalpinx, etc. Endometriosis-related pain is seldom non-cyclic and may present due to recurrent bleeding in endometriotic implants. Engorgement of veins leads to inadequate venous washout and presents chronic pelvic pain in pelvic congestion syndrome. The pressure effect of benign lesions of the uterus and cervix may lead to cyclic pain, as in uterine fibroids. Often presentation of diseases like hydrosalpinx may not present until it has overdistended or may at times present as acute pelvic pain if it undergoes torsion. Long-standing untreated pelvic inflammatory diseases in sexually active females is another cause of pelvic pain. The complaint of CPP is also shared due to the involvement of the gastrointestinal system in conditions like irritable bowel syndrome, inflammatory bowel diseases, long-standing abdominal hernias, colorectal cancer, etc. Alteration of the gut biome and dysregulated brain-gut associations lead to typical manifestations of chronic lower back pain and pelvic pain in irritable bowel syndrome. Colorectal tumors, when in the advanced stage, may spread to nearby tissues creating fistulas and affecting nearby nerves, causing pelvic, perineal, and sacral pain. Abdominal hernias with small bowel prolapse are always related to pelvic pain symptoms. Infections in the urinary tract like urethral syndrome, chronic prostatitis, and chronic recurrent cystitis present with CPP and voiding problems. Musculoskeletal etiologies, though varying in degrees, are responsible for isolated complaints of CPP. Examples include pelvic girdle pain, levator syndrome, coccygodynia, and pelvic floor prolapse.

Hyaluronic Acid-Modified Nanoplatforms as a Vector for Targeted Delivery of Autophagy-Related Gene to the Endometriotic Lesions in Mice

This investigation probed endometriosis treatment using targeted nanoparticles (NPs) to modulate autophagic activity. To that end, a novel form of polymer-based NP gene delivery platform consisting of polyethyleneimine (PEI) conjugated to stearic acid (SA) and nucleotides (DNA/siRNAs) and enclosed by hyaluronic acid (HA) was prepared. CD44 is highly upregulated in cystic lesions, and HA–CD44 binding in this specific nanoplatform was used to achieve targeted drug delivery to CD44-expression endometriotic tissues. The expression of autophagy-related genes was modulated to explore the importance of this process in the development of endometriosis. By inducing autophagic activity, we were able to reduce the size of endometriotic cysts and suppress the development of ectopic endometrium. To further confirm the relationship between autophagic activity and this disease in humans and animals, numbers of autophagic vesicles and autophagic protein expression were assessed in lesion tissue samples from patients, revealing there may be consistency between animal and human data. Overall, these data revealed the ability of this (PEI–SA/DNA) HA gene delivery system to regulate autophagic activity and, thereby, aid in the treatment of endometriosis.

Chronic Pelvic Pain in Endometriosis: Cross-Sectional Associations with Mental Disorders, Sexual Dysfunctions and Childhood Maltreatment

The aim of this cross-sectional study was to compare the rates of mental disorders, sexual dysfunctions and childhood maltreatment (CM) in women with endometriosis with either chronic pelvic pain (CPP) or minimal to no pelvic pain. Additionally, two models to predict a current mental disorder were tested, including pelvic-pain-related or psychosocial predictor variables. We examined 100 women with confirmed endometriosis (group CPP, n = 50; group NOPAIN, n = 50). Participants responded to a comprehensive questionnaire and the Childhood Trauma Questionnaire. The Diagnostic Interview for Mental Disorders was used to assess mental disorders according to DSM-5 and to screen for sexual dysfunctions. The mean age was 28.8 ± 5.6 (CPP)/2.7 ± 6.3 (NOPAIN). Participants with CPP had higher rates of current mental disorders (p = 0.019), lifetime mental disorders (p = 0.006) and sexual dysfunctions (p < 0.001), but not CM (p = 0.074). In two binary-logistic regression analyses, a greater need for pain relief (aOR = 4.08, p = 0.026) and a sexual dysfunction (aOR = 2.69, p = 0.031) were significant predictors for a current mental disorder. Our findings confirmed the crucial role of pelvic pain for mental and sexual well-being in endometriosis. They highlight the need for pain relief and interdisciplinary care in the treatment of endometriosis.

Endometriosis, an Ongoing Pain—Step-by-Step Treatment

Endometriosis is a disease that is becoming more and more challenging for the medical community. The current therapeutic concepts (surgical therapy and/or hormonal therapies) often do not lead to sufficient pain control, and late diagnosis and high recurrence rates mean that women affected by the disease can suffer for decades before receiving proper treatment. Although the introduction of certified endometriosis centers has created contact points for surgical therapies performed by endometriosis experts, these centers are not sufficient to offer the affected patients the all-encompassing long-term support they need. In recent years, new findings regarding the pathogenesis and correlations of the pain phenomena caused by endometriosis have shown that conventional therapy strategies are not adequate and individual long-term concepts must be developed. Not only can endometriosis cause nociceptive pain, but it can also lead to a nociplastic reaction with central sensitization. Hence, aside from the classic cyclic complaints, patients increasingly suffer from atypical pain. Due to the high number of affected patients who are treated inadequately, it is necessary for gynecologists in private practices to become familiar with multimodal treatment concepts since they are the central point of contact of their patients. The following article will provide an overview of treatment strategies for chronic symptomatic endometriosis.

“A little monster inside me that comes out now and again”: endometriosis and pain in Austria

Abstract: The topics of endometriosis and pain imply far-reaching problems for women’s health. Using a qualitative research approach, this paper addresses the subjective experience and effects of pain, the methods for dealing with these issues, and the needs of affected women in Austria. Data were collected by problem-focused interviews conducted with ten women suffering from endometriosis, which were later transcribed and subjected to qualitative content analysis. Findings are therefore described using content-related categories. Results show that negative thoughts and feelings like fear, despair, and anger are associated with endometriosis and pain. Moreover, predominantly negative impacts and changes are found in various areas of life, such as the well-being and psyche of those affected, their attitude towards life in general, partnerships, social life, leisure time and work-life balance. In dealing with endometriosis and pain, both Western biomedicine and complementary medicine treatments are used. Support from one’s inner circle of friends and exchange and interaction with others affected by the disease are seen to be invaluable. Attending physicians as well as patients themselves and their private, social, and working environment should encourage open communication about endometriosis and the related pain.

Pathogenesis of Endometriosis: The Origin of Pain and Subfertility

Endometriosis (EM) and adenomyosis (AM) are common conditions with pain and infertility as the principal symptoms. The pathophysiology of pain in EM and AM comprises sensory and somatoform pain mechanisms. Over time, these may aggravate and lead to individual complex disease patterns if not diagnosed and treated. Despite the known facts, several years often pass between the onset of symptoms and diagnosis. Chronic pain disorders with changes on a neuronal level frequently arise and are linked to depressive disorders, with the process becoming a vicious cycle. Additionally, women with EM and AM suffer from sub- and infertility. Low fecundity rates are caused by anatomical changes in combination with behavioral changes in the sexual activity of women with chronic pain as well as local proinflammatory factors that not only decrease implantation rates but also promote early abortions.

[Management of endometriosis pain : Stage-based treatment strategies and clinical experience]

BACKGROUND

Endometriosis is associated with various types of intense pain. In addition to nociceptive pain, there is also a nociplastic reaction with central sensitization. Atypical symptoms such as acyclic lower abdominal pain, radiating pain, non-specific bladder and intestinal complaints or even depression are frequent as are classic cyclical complaints such as severe dysmenorrhea, cyclical lower abdominal pain, dyspareunia, dysuria and dyschezia. In cases of a diverse range of symptoms, patients often consult not just gynecologists but specialists from other disciplines (e.g., internal medicine, gastroenterology, orthopedics, pain therapy, psychology).

AIMS

Overview about the pathophysiology and complexity of the disease and the resulting treatment options. A multimodal interdisciplinary concept might be able to take into consideration all aspects of the complex disease.

METHODS

Interdisciplinary concepts should be involved in the treatment of endometriosis patients along with hormonal and surgical therapy, which are generally under the supervision of a gynecologist. Pain management, dietary changes, psychological support, as well as physiotherapy should be included. The present article is intended to provide an overview of possible treatment strategies for chronic, symptomatic endometriosis.

CONCLUSION

The use of multimodal treatment strategies regarding the complex pathophysiological aspects of this disease might be helpful in significantly improving the quality of life of endometriosis patients.

Laparoscopic bowel resection of deep infiltrating endometriosis. Comparative outcomes of a public teaching hospital and a referral private hospital

PURPOSE

To compare the operative outcomes of laparoscopic surgical treatment for bowel endometriosis in a public teaching hospital versus in a private referral hospital.

METHODS

The indications for surgery, type and time of operation, length of hospital stay, need for a temporary stoma, rate of conversion to open surgery, and postoperative complications were evaluated.

RESULTS

One hundred eighty-one patients were included (150 patients, 82.9%, in a private hospital). In the private hospital, there were more patients with infertility [56% vs. 29%; P=0.01] as an indication for surgery) and segmental resection was more common in the private hospital (48% vs. 29%, p=0.05). The average operative time (211.9±83.4 minutes vs. 128 ± 55 minutes, p<0.001) as well as the length of hospital stay (3.97±1.7 days vs. 1.56±0.85 days, p<0.001) was higher in the public hospital; the rate of conversion to open surgery was significantly lower in the private hospital (2% vs. 32.3%, p<0.001). Operations performed at the public hospital were associated with higher rates of postoperative complications (Clavien-Dindo II and II) (38.7% x 11.3%, p=0.021; OR 3.2, CI 95% 1.2-8.0).

CONCLUSION

Laparoscopic surgery in private centers was associated with reductions in major complications, surgical times, lengths of stay and rates of conversion to open surgery compared to that in public teaching hospitals.