Deep Endometriosis: the Involvement of Multiple Pelvic Compartments Is Associated with More Severe Pain Symptoms and Infertility

Burden of somatic morbidity associated with a surgically verified diagnosis of endometriosis at a young age: a register-based follow-up cohort study in Finland

STUDY QUESTION

How does the burden of somatic disorders compare between women with surgically verified endometriosis diagnosed in adolescence or early adulthood, and matched women without a history of endometriosis?

SUMMARY ANSWER

Women with endometriosis diagnosed at a young age had a higher incidence of several somatic disorders and a higher number of hospital visits compared to women without endometriosis.

WHAT IS KNOWN ALREADY

Endometriosis is associated with an increased risk of several somatic disorders, including autoimmune, inflammatory, and pain-related disorders with higher utility of health care resources. There may be differences in the experience of pain relating to the subtypes of endometriosis. Depression and anxiety are linked to endometriosis and increase overall somatic comorbidity.

STUDY DESIGN, SIZE, DURATION

Longitudinal retrospective register-based cohort study utilizing episode data from specialized care; 2680 women under 25 years with a surgical of diagnosis endometriosis in 1998-2012, and 5338 reference women of the same age and municipality followed up from the index day to the end of 2019, emigration, death or the outcome of interest.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We analysed incidence rates, cumulative incidence rates, and crude hazard rate ratios (HR) with 95% CIs across 15 groups of somatic disorders. Subgroup analyses were conducted among women with endometriosis, by (i) type of endometriosis-ovarian only (n = 601) versus combined types (n = 2079), and (ii) pre-existing diagnosis of depression or anxiety (n = 270) versus those without such diagnoses (n = 2410).

MAIN RESULTS AND THE ROLE OF CHANCE

Women reached a median age of 38 (IQR 34-42) years after a median follow-up of almost 16 (12, 19) years. Compared to the reference cohort, women with endometriosis had a higher incidence of several somatic disorders during the follow-up. By the age of 40 years, 38% of women with endometriosis and 9% of the reference cohort had diagnoses of infertility (HR 5.88 [95% CI 5.24-6.61]). The corresponding figures for genital tract infections were 24% and 6% (4.64 [4.03-5.36]), symptoms and signs of pain 62% and 28% (3.27 [3.04-3.51]), migraine 15% and 6.4% (2.49 [2.13-2.92]), and chronic pain conditions 33% and 19% (2.01 [1.83-2.22]), respectively. In women with endometriosis, a higher incidence was seen also for dyspareunia, uterine myomas, celiac disease, asthma, anaemia, high blood pressure, hypercholesterolemia or cardiovascular diseases; autoimmune diseases, and disorders of the thyroid gland. For women with ovarian endometriosis only, we observed a lower HR of high blood pressure, hypercholesterolemia or cardiovascular diseases, asthma, migraine, and pain-related disorders compared to those with other or combined types of endometriosis. Within the endometriosis cohort, women with pre-existing diagnoses of depression or anxiety had higher HRs of several somatic disorders compared to those without such diagnoses. The number of hospital visits after the index day was higher in women with endometriosis when compared to the reference cohort (40 vs 18).

LIMITATIONS, REASONS FOR CAUTION

Confounding bias may arise from the reliance on registry-based hospital diagnoses, as women undergoing surgery are already engaged with health care, and, subsequently, more likely to receive new diagnoses. Furthermore, the homogenous population of Finland limits the generalizability of these findings.

WIDER IMPLICATIONS OF THE FINDINGS

Surgical diagnosis of endometriosis at a young age is associated with a burden of somatic disorders, emphasizing importance of comprehensive approach to management of endometriosis and endometriosis-related conditions. Further studies are needed to clarify the varying reasons behind these associations. However, the results of this study suggest that pain and mental health may play a key role in the development of subsequent somatic disorders. Therefore, careful management of primary dysmenorrhea and mental health in young women is essential.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was received from the Hospital District of Helsinki and Uusimaa, and from Finska Läkaresällskapet. E.R. acknowledges financial support from The Finnish Society of Research for Obstetrics and Gynaecology and The Finnish Medical Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. O.H. serves occasionally on advisory boards for Bayer AG, Gedeon Richter, and Roche, has received travel support from Gedeon Richter, has received consulting fees from Orion Pharma and Nordic Pharma, and has helped to organize and lecture at educational events for Bayer AG and Gedeon Richter. The other authors report no conflict of interest concerning the present work.

TRIAL REGISTRATION NUMBER

N/A.

Lesion size and location in deep infiltrating bowel endometriosis: Correlation with gastrointestinal dysfunction and pain

INTRODUCTION

Presence of deep infiltrating bowel endometriosis (DE) is associated with occurrence of dyschezia and gastrointestinal symptoms. The degree of the disease, the lesion length, and the location, that is, lesion-to-anal-verge distance (LAVD) of DE, as well as the severity of the symptoms appear to be correlated. Nevertheless, it is not yet known to what extent the size and LAVD of bowel DE influence the severity of gastrointestinal symptoms. The present study aims to evaluate a possible correlation of lesion location (LAVD) and size (according to the #Enzian classification) with preoperative symptoms.

MATERIAL AND METHODS

In this prospective study, premenopausal patients with histologically confirmed DE undergoing modified limited nerve-vessel sparing rectal segmental bowel resection or full-thickness discoid resection were evaluated. Extent of endometriosis was defined according to the #Enzian classification during surgery. The primary outcome measure was the correlation between lesion size and location with the GI function impairment reflected by presurgical lower anterior resection syndrome (LARS) scores; the secondary outcome was differences in presurgical numeric rating scale pain scores of dyschezia, dyspareunia, and dysmenorrhea as well as the impact of concomitant DE of other locations on symptom intensity.

RESULTS

Of 162 consecutive patients, 151 were included in the final analysis. No significant correlation was observed between lesion size (#Enzian compartments C1/C2/C3) or LAVD and GI dysfunction reflected by LARS-like symptoms (p = 0.314 and p = 0.185, respectively) or pain symptoms (dyschezia, p = 0.440; dyspareunia, p = 0.136; and dysmenorrhea p = 0.221). Furthermore, no significant correlation was observed between lesion size and GI dysfunction when merging two severity grades (#Enzian compartments C1 plus C2 vs. C3; p = 0.611). In addition, LAVD did not affect the degree of dyschezia (p = 0.892), dyspareunia (p = 0.395), or dysmenorrhea (p = 0.705). Finally, the presence of concomitant DE lesions infiltrating the vagina/rectovaginal space (#Enzian compartment A) and/or sacrouterine ligaments/parametrium (#Enzian compartment B) did not alter the severity of preoperative dyschezia (p = 0.493) or dysmenorrhea (p = 0.128) but showed a trend toward affecting gastrointestinal function (p = 0.078) and was significantly associated with dyspareunia (p = 0.035).

CONCLUSIONS

In present study, we could not find a correlation between colorectal DE lesion size and location (LAVD) and gastrointestinal function impairment or intensity of dyschezia and dysmenorrhea. Additional involvement of vagina/rectovaginal space (#Enzian compartment A) and/or sacrouterine ligaments/parametrium (#Enzian compartment B) exerts a significant impact on the degree of dyspareunia in women with colorectal DE.

Psychiatric disorders and mortality due to external causes following diagnosis of endometriosis at a young age: a longitudinal register-based cohort study in Finland

BACKGROUND

Endometriosis diagnosed in adults is associated with increased risk of various psychiatric disorders. However, little is known concerning psychiatric comorbidity and mortality due to external causes associated with endometriosis diagnosed at a young age.

OBJECTIVE

This longitudinal cohort study aimed to investigate the link between surgical diagnosis of endometriosis at a young age and subsequent psychiatric disorders and mortality due to external causes. In addition, we compared the occurrence of the most common psychiatric disorders between different sites of surgically confirmed endometriosis (ovarian vs other) because of possible differences in pain manifestations.

STUDY DESIGN

We conducted a retrospective register-based cohort study. Altogether 4532 women with surgically confirmed diagnosis of endometriosis before the age of 25 years from 1987 to 2012 were identified from the Finnish Hospital Discharge Register. They were matched with women without surgically diagnosed endometriosis for age and municipality on the index day (n=9014). Women were followed up from the index day until the end of 2019 for the outcomes of interest, which included 9 groups of psychiatric disorders (inpatient episodes since 1987, outpatient episodes since 1998) and death due to external causes, including deaths due to accidents, suicides, and violence (Finnish Register of Causes of Death). Cox proportional hazard models were applied to assess the crude and parity-adjusted hazard ratios and 95% confidence intervals.

RESULTS

The cohort's median age was 22.9 years (interquartile range, 21.3-24.1) at the beginning and 42.5 years (36.7-48.3) after a median follow-up time of 20.0 years (14.5-25.7). We observed a higher hazard of depressive, anxiety, and bipolar disorders in women with endometriosis compared with the reference cohort, with depressive and anxiety disorders being the two most common psychiatric disorders. These differences appeared early and remained the same during the entire follow-up, irrespective of whether assessed from the data on inpatient episodes only or the data on both in- and outpatient episodes. The corresponding adjusted hazard ratios were 2.57 (95% confidence interval, 2.11-3.14) and 1.87 (1.65-2.12) for depressive disorders, 2.40 (1.81-3.17) and 2.09 (1.84-2.37) for anxiety disorders, and 1.71 (1.30-2.26) and 1.66 (1.28-2.15) for bipolar disorders, respectively. A higher hazard was observed for nonorganic sleeping disorders for the first 10 years only (3.83; 2.01-7.30) when assessed using the data on both in- and outpatient episodes. When based on inpatient records, a higher hazard for alcohol/drug dependence after 15 years of follow-up (2.07; 1.21-3.54) was observed. The difference in hazard for personality disorders tended to increase during follow-up (<10 years, 2.12 [1.28-3.52]; ≥10 years, 3.08 [1.44-6.57]). Depressive and anxiety disorders occurred more frequently in women with types of endometriosis other than ovarian endometriosis. No difference in deaths due to external causes was observed between the endometriosis and reference cohorts.

CONCLUSION

Surgical diagnosis of endometriosis at a young age was associated with increased incidence of several psychiatric disorders. Moreover, within the endometriosis population, psychiatric comorbidity was more common in women with types of endometriosis other than ovarian endometriosis. We speculate that chronic pain is essential in the development of these psychiatric disorders, and that early and effective pain management is important in reducing the risk of psychiatric morbidity in young women. More research concerning the associations and management of endometriosis and associated psychiatric disorders is warranted.