Crossroad decisions in deep endometriosis treatment options: a qualitative study among patients

Patient preference for treatment of an endometrioma, a qualitative study

OBJECTIVE

The aim of this qualitative study was to identify considerations, objections, and preferences of women with symptomatic ovarian endometrioma in the shared decision-making process.

DESIGN

This study was conducted as a qualitative study, including twenty patients facing or faced therapeutic treatment options for an ovarian endometrioma.

SETTING

Four focus groups were held between February 2020 and June 2021 in the Netherlands. Two of them were held online due to COVID-19 pandemic.

POPULATION

A qualitative study was performed using semi-structured in-depth focus group methodology. All women, aged 27-44 years, suffered from pain.

METHODS

The focus groups were audio recorded and fully transcribed using ATLAS-ti. Grounded theory methodology was applied for data analysis.

MAIN OUTCOME MEASURES

Outcome measure includes the most important aspects during decision-making process for patients facing or faced therapeutic treatment options for an ovarian endometrioma.

RESULTS

A total of twenty Dutch women with an ovarian endometrioma were included. Participants named "relief of pain", "fertility", "adverse effects or surgical complications", "recurrence of pain and lesions", and "time untill treatment effect occurs" as most important aspects during their decision-making process. In addition, women often felt "unheard", so more attention should be paid to symptoms of endometriosis.

CONCLUSION

Participants named "relief of pain", "fertility", "adverse effects or complications", "recurrence of pain and lesions", and "time untill treatment effect occurs" as most important aspects during their decision-making process.

Health-related decision-making experiences of people with endometriosis: a qualitative analysis

Objective: Endometriosis is an incurable inflammatory condition, characterised by chronic pelvic pain, among other symptoms. Optimal symptom management is dependent on an individual's preferences, underscoring the need for person-centred care and shared decision-making. Yet research on decisional support needs of people with endometriosis (PWE) is sparse. This qualitative study aimed to explore decisional processes and decision support needs among PWE regarding endometriosis management. Methods and Measures: Australian adults (N = 41) diagnosed with endometriosis were recruited from support communities to participate in focus groups. Open-ended questions prompted discussion about perceived challenges and facilitators of treatment decision-making. Multiple coders thematically analysed the transcribed qualitative data using the template approach. Results: Four themes were identified: (1) Challenges of accessing pertinent, quality information (sub-themes 1a: Inadequate information from healthcare professionals and 1b: Navigating external information sources); (2) Feeling empowered to self-advocate; (3) Balancing costs and benefits (sub-themes 3a: Financial considerations; and 3b: Balancing family needs); and, (4) Emotional toll of decision-making. Novel findings included emphasis by PWE on family needs when making decisions, and reports that decision-making eroded their resilience. Conclusion: Findings highlight difficulties experienced by PWE regarding endometriosis management, indicating a comprehensive decision support resource, such as a patient decision aid, is warranted.

Pelvic pain & endometriosis: the development of a patient-centred e-health resource for those affected by endometriosis-associated dyspareunia

BACKGROUND

We recognized a paucity of accessible, evidence-based, empowering patient-centred resources for those with endometriosis-associated dyspareunia. Affecting more than 50% of people with endometriosis, dyspareunia can significantly impact relationships, chronic pain and the ability to have a family. We aimed to develop a patient-centred educational website for those affected by endometriosis-associated dyspareunia.

METHODS

To develop a functional and meaningful website for endometriosis-associated dyspareunia, we utilized a Knowledge to Action framework, supplemented with a patient-centred research design and technology-enabled knowledge translation. Our patient partners influenced the direction and scope of the project, provided critical feedback throughout the development process, and approved website revisions prior to launch. The website was developed in five phases; (1) needs assessment interviews and focus groups with key stakeholders, (2) landscape analysis of pre-existing websites, (3) development, (4) usability testing and qualitative interviews, and (5) revisions and launch.

RESULTS

Phase 1 and 2 emphasized a need for comprehensive yet plain language explanations of pain mechanisms and strategies for pain management. Rigorous consultation with key stakeholders informed the creation of the preliminary website in phase 3. Usability testing in phase 4 identified five main categories of usability problems, most of which were considered minor. Phase 4 qualitative interviews identified users' overall impressions of the preliminary website, including that the website could help people understand their pain and describe their pain to partners and healthcare providers, as well as feel empowered to seek healthcare and validated in their experiences. User suggestions, combined with usability testing, informed revisions in phase 5.

CONCLUSION

We developed an educational website for endometriosis-associated painful sex where people can find evidence-based etiologies for pain, pain management options, and actionable resources. Based on the data collected through qualitative interviews with patients, this website can potentially empower people to seek health care. The strength of the website development approach used was the inclusion of qualitative user insights in addition to the commonly completed user tests. The patient interviews provided insights into the potential impact of the website and, thus, ensured that we not only created a functional website that meets end users' needs, but a website that is also meaningful to those affected by this condition.

Experiences of pain communication in endometriosis: A meta-synthesis

INTRODUCTION

Endometriosis is the leading cause of chronic pelvic pain among women. The pain associated with endometriosis significantly impacts various aspects of patients' quality of life. A notable void in the literature is the absence of a systematic review exploring pain communication between patients with endometriosis and healthcare professionals. Hence, the aim of this qualitative systematic review was to synthesize findings on how patients with endometriosis experience communicating with healthcare professionals about pain and how healthcare professionals experience these interactions.

MATERIAL AND METHODS

A systematic literature search was conducted related to patients with endometriosis and pain communication in CINAHL PLUS with full text and MEDLINE (via EBSCO host) on May 12, 2023, and updated January 26, 2024. Searches were supplemented by backward searching reference lists and forward searching citations of included reports in Scopus and Google Scholar. The review was guided by the four-step meta-synthesis methodology by Sandelowski and Barosso. Critical appraisal of included studies was conducted using Critical Appraisal Skill Program (CASP). Findings were analyzed thematically, using the approach described by Thomas and Harden. The meta-synthesis was based on a registered protocol in PROSPERO (CRD 42023425430), and the study is reported adhering to the PRISMA 2020 checklist.

RESULTS

Overall, 37 reports published from 2003 until 2023 contributed to the review, including 4842 participants. Through thematic analysis, we developed the following themes: "Navigating the double burden," "Lack of mutual understanding," and "The complexities of conveying pain."

CONCLUSIONS

The communication of pain between patients with endometriosis and healthcare professionals is complex, encompassing patterns of disbelief, normalization, and psychological attribution. Engaging in discussions about pain presents diverse challenges stemming from insufficient communication skills and assessment tools. Further research is warranted to comprehensively explore the perspectives of both patients and healthcare professionals, aiming to devise strategies that enhance communication and patient care.

Supportive Care Needs of Young Adults With Endometriosis: An Open-Ended Online Survey and Exploration of Unmet Needs

OBJECTIVE

The aim of this study is to identify and explore the unmet needs of adolescents and young adults living with endometriosis.

DESIGN

An open-ended online survey was conducted, with questions derived from prior research looking at areas of unmet need in healthcare, career and work, financial, information, psychological, social and cultural domains.

SETTING AND POPULATION

Self-selecting 18-25 year olds with surgically diagnosed endometriosis (self-reported) currently living in Australia were included as participants.

METHODS

Invitation to participate in an open-ended online survey was shared through the social media of Australian endometriosis organisations and the Royal Women's Hospital, Melbourne. Surveys were analysed qualitatively through template analysis.

MAIN OUTCOME MEASURES

Recording of the unmet supportive care needs of this population was carried out.

RESULTS

One hundred and thirty-one respondents fit the eligibility criteria of being aged 18-25 years (median age 23 years). Most were born in Australia (94%), university-educated (54%) and lived in a metropolitan setting (69%). There was a range of unmet needs that were presented across education, work, healthcare and relationships. Group-specific challenges were identified: doctors either over- or underemphasising future fertility; disrupted sexual and romantic life due to painful sex; managing pain in the classroom and workplace where periods are taboo; and being gender-queer in gynaecological medical spaces.

CONCLUSIONS

The increasingly young age at which patients are receiving an endometriosis diagnosis precipitates a shift in patient care. The treatment decisions that are being made must be reflective of the unique needs of the adolescents who carry the burden of the disease. Clinicians are advised to be aware of and discuss needs with their patients.

PATIENT OR PUBLIC CONTRIBUTION

The nine open-ended questions in this survey were developed from data from a preliminary series of interviews with endometriosis patients in a tertiary women's healthcare centre. In asking these data-informed questions to the online endometriosis community, patients across broader sociocultural demographics and disease states (including less symptomatic endometriosis) have provided a broader understanding of their supportive care needs.

Perceived challenges in treatment decision-making for endometriosis: healthcare professional perspectives

Background

Endometriosis, a systemic chronic inflammatory condition which has no cure, has a high symptom burden that can negatively impact every facet of life. Given the absence of a gold-standard treatment, the best symptom management regimen in endometriosis is heavily reliant on a patient's values and preferences, making shared decision-making (SDM) vital. However, a comprehensive patient decision aid (PtDA) intervention that could facilitate patient decision-making and promote SDM is lacking in endometriosis, and there is little research on the decisional support needs of individuals with this condition. This qualitative study aimed to explore healthcare professional (HP) perspectives of their clients' decisional support needs when choosing treatments to manage endometriosis symptoms, with a view to evaluating the need for a PtDA.

Methods

Australian HPs identified as specialising in endometriosis care (N = 13) were invited to participate in a short interview over the Internet by phone. Questions focussed on perceived facilitators and challenges of decision-making when choosing treatments for endometriosis. Transcribed qualitative data were thematically analysed and verified by multiple coders, using the template approach.

Results

Four themes were identified: (1) Identifying and setting priorities; (2) HPs' lack of time and perceived lack of knowledge; (3) Patient-centred care and SDM, including patient capacity; and (4) Decision-making blinded by hope. This is the first known study to explore HPs' perspectives on patient decision-making challenges in endometriosis.

Discussion

Findings draw attention to the difficulties people with endometriosis experience when assessing and choosing treatments, highlighting the need for a comprehensive PtDA intervention to support this decision-making.

Postmenopausal endometriosis: a challenging condition beyond menopause

IMPORTANCE AND OBJECTIVE

Postmenopausal endometriosis is a complex condition that challenges the conventional belief that endometriosis resolves with menopause. Despite the cessation of menstruation, a subset of women continues to experience or develop endometriosis-related symptoms during the postmenopausal period. Thus, this review aimed to shed light on postmenopausal endometriosis, exploring its clinical features, diagnostic considerations, management approaches, and the potential impact on women's health.

METHODS

PubMed/Medline, Scopus, and Web of Science databases were used for the research, with only articles in English language, using the following terms: "postmenopausal endometriosis," "menopause," "management," "treatment," and "quality of life," from inception to 2023.

DISCUSSION AND CONCLUSION

The clinical features of postmenopausal endometriosis include persistent or recurrent pelvic pain, dyspareunia, bowel, or urinary symptoms and, occasionally, abnormal vaginal bleeding. The absence of menstrual cycles presents a diagnostic challenge, as the traditional diagnostic criteria for endometriosis rely on menstrual patterns. Visual cues may be less evident, and the symptoms often overlap with other gynecological conditions, necessitating a thorough evaluation to differentiate postmenopausal endometriosis from other potential causes. Management approaches for postmenopausal endometriosis encompass surgical intervention, hormonal therapies, pain management, and individualized care. Postmenopausal endometriosis significantly impacts the quality of life, sexual health, and long-term well-being of women. Understanding the clinical features, diagnostic challenges, and management approaches of postmenopausal endometriosis is crucial for healthcare professionals to provide effective care and to improve the quality of life of women affected by this condition.

Exploring Medical Egg Freezing as a Disease Management Strategy

Medical egg freezing (MEF) allows women with fertility-threatening diseases to have their oocytes cryopreserved and stored for later use. Endometriosis is a common gynecological disease that might cause infertility. Qualitative research on endometriosis patients' experiences with MEF is minimal. I report on in-depth interviews among French endometriosis patients undertaking MEF. Their experiences are profoundly shaped by endometriosis-related pain. Egg freezing was described as a disease management strategy to cope with potential future infertility integral to their commitment to motherhood. Singlehood was a determining element for agreeing to undertake a physically and psychologically costly "additional" medical intervention.

Treatment preferences for medication or surgery in patients with deep endometriosis and bowel involvement - a discrete choice experiment

Objective

To study the preferences of women with deep endometriosis (DE) with bowel involvement when they have to choose between conservative (medication) or surgical treatment.

Design

Labelled discrete choice experiment (DCE).

Setting

Dutch academic and non‐academic hospitals and online recruitment.

Population or Sample

A total of 169 women diagnosed with DE of the bowel.

Methods

Baseline characteristics and the fear of surgery were collected. Women were asked to rank attributes and choose between hypothetical conservative or surgical treatment in different choice sets (scenarios). Each choice set offered different levels of all treatment attributes. Data were analysed by using multinomial logistic regression.

Main Outcome Measures

The following attributes – effect on/risk of pain, fatigue, pregnancy, endometriosis lesions, mood swings, osteoporosis, temporary stoma and permanent intestinal symptoms – were used in this DCE.

Results

In the ranking, osteoporosis was ranked with low importance, whereas in the DCE, a lower chance of osteoporosis was one of the most important drivers when choosing a conservative treatment. Women with previous surgery showed less fear of surgery compared with women without surgery. Low anterior resection syndrome was almost equally important for patients as the chance of pain reduction. Pain reduction had higher importance than improving fertility chances, even in women with desire for a future child.

Conclusions

The risk of developing low anterior resection syndrome as a result of treatment is almost equally important as the reduction of pain symptoms. Women with previous surgery experience less fear of surgery compared with women without a surgical history.

Tweetable Abstract

First discrete choice experiment in patients with deep endometriosis.

First discrete choice experiment in patients with deep endometriosis.

SMURF1-mediated ubiquitylation of SHP-1 promotes cell proliferation and invasion of endometrial stromal cells in endometriosis

Background

Endometriosis is a widespread benign gynecological disorder. The signal transducer and activator of transcription 3 (STAT3) signaling pathway plays an important role in the pathogenesis of endometriosis through regulating proliferation and invasion of endometrial stromal cells. Furthermore, the protein tyrosine phosphatase (PTP), SH2 domain-containing phosphatase 1 (SHP-1), negatively regulates STAT3 activation. However, regulation of the SHP-1-STAT3 pathway in the pathogenesis of endometriosis remains unclear.

Methods

Cell proliferation and invasion were assessed by Cell Counting Kit-8 (CCK-8) assay and Transwell analysis, respectively, to investigate the role and regulation of the SHP-1-STAT3 pathway in the proliferation and invasion of endometrial stromal cells. Expression of Smad ubiquitin regulatory factor 1 (SMURF1), SHP-1, matrix metalloproteinase 2 (MMP2), MMP9, STAT3, and phospho-STAT3 (p-STAT3) level in patients with endometriosis were measured by Western blotting and/or immunohistochemical staining. The interaction between SMURF1 and SHP-1 was investigated by co-immunoprecipitation and ubiquitylation analysis.

Results

The present study demonstrated that downregulation of SHP-1 expression in patients with endometriosis was negatively correlated with SMURF1 expression. SMURF1, an E3 ubiquitin ligase, activated the STAT3 pathway via ubiquitylation and degradation of SHP-1. Furthermore, SMURF1 promoted cell proliferation and invasion of endometrial stromal cells by activating STAT3 signaling and expression of its downstream targets, MMP2 and MMP9, whereas SHP-1 demonstrated an inverse effect. Additionally, SHP-1 inhibited SMURF1-mediated cell invasion and proliferation of endometrial stromal cells.

Conclusions

Our findings indicate that SMURF1-mediated ubiquitylation of SHP-1 regulates endometrial stromal cell proliferation and invasion during endometriosis.