Les médecins traitants devant le défi du dépistage et de la prise en charge de l’endométriose : résultats d’une enquête

Vitamin D and Endometriosis: Is There a Mechanistic Link?

Endometriosis is a prevalent chronic gynaecological disorder, but its cause is still unclear, and both genetic and environmental factors may contribute disease aetiology. Prominent amongst the latter is vitamin D which can be obtained either by the action of sunlight on skin or from dietary sources. Serum levels of the main circulating form of vitamin D, 25-hydroxvitamin D (25(OH)D), have been reported to be inversely correlated with endometriosis, suggesting that vitamin D-deficiency may be a risk factor for the disease. Crucially, the active form of vitamin D, 1,25-dihydroxyvitamin D (1,25(OH)2D) is known to exert many functions beyond its established role in the endocrinology of mineral homoeostasis and prevention of rickets. Several of these extra-skeletal effects of 1,25(OH)2D may impact the risk and progression of endometriosis. The following review details the studies that have assessed associations between vitamin D status/supplementation and endometriosis severity and disease progression, but also describes the mechanistic targets for 1,25(OH)2D in endometriosis with specific reference to immunomodulatory responses and effects on angiogenesis. Endometriosis is an under-reported health issue with poor non-invasive options for diagnosis. Given that vitamin D-deficiency may trigger or exacerbate key pathophysiological responses linked to endometriosis, analysis of vitamin D status in women may provide an alternative risk marker for endometriosis. Treatment options for endometriosis are also limited and the review will also consider whether vitamin D supplementation has a role in the management of endometriosis, either in prevention or treatment.

Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline

OBJECTIVE

To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada.

TARGET POPULATION

Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis.

OPTIONS

The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging.

OUTCOMES

There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment.

BENEFITS, HARMS, AND COSTS

Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments.

EVIDENCE

Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text.

VALIDATION METHODS

The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them.

TWEETABLE ABSTRACT

Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Laying the Groundwork: A Pilot Study Exploring Improved Endometriosis Management Strategies in Primary Healthcare

Objective

To evaluate if a brief educational intervention for primary health care staff regarding endometriosis gives sustainable knowledge of endometriosis symptoms and if a brief questionnaire for women seeking care for common symptoms is feasible in the Swedish primary care context.

Design

Pilot study.

Setting

3 primary care centres (PCCs) in Sweden. Exploring knowledge among staff about endometriosis at baseline and 3 months after an information workshop. Evaluation of feasibility of a brief questionnaire for women seeking care for common symptoms For PCC personnel: knowledge about endometriosis at baseline and after 3 months. For patient questionnaire: whether adequate, understandable, acceptable, and feasible.

Participants

Females in primary care centre waiting room, and staff members at participating PCCs.

Results

The knowledge level of endometriosis was improved or sustained after 3 months compared to baseline among staff at PCCs. Over 90% of the patients stated that the questionnaire was adequate, understandable, acceptable, and feasible.

Conclusion

We found that an educational programme improved the staff's knowledge about endometriosis. The programme together with the patient questionnaire could be a way to enhance knowledge about endometriosis among PCCs. This combined effort might facilitate earlier detection and treatment of women with endometriosis.

A COM-B and Theoretical Domains Framework Mapping of the Barriers and Facilitators to Effective Communication and Help-Seeking Among People With, or Seeking a Diagnosis Of, Endometriosis

Endometriosis is a chronic condition in which tissue resembling the endometrium grows outside the womb, causing severe chronic pain. People with endometriosis report difficulty in help-seeking and communicating with healthcare professionals, contributing to diagnosis delays and ineffective management. The present study aimed to identify barriers and facilitators to effective communication using the Theoretical Domains Framework (TDF) and COM-B model to inform behavior change intervention development. This study was a qualitative semi-structured interview and open-ended survey design. Thematic Analysis was utilized to identify barriers and facilitators to effective communication which were mapped to the TDF and COM-B model. Four women aged 25 to 44 with a formal diagnosis of endometriosis participated in interviews. Thirty-three participants, aged 20-48 years, participated in the online survey, 21 of whom had a diagnosis of endometriosis (12 were currently seeking diagnosis). Five COM-B domains were identified: reflective motivation, social and physical opportunity, physical and psychological capability. Ten TDF domains were reflected in concerns surrounding dismissal, disempowerment, social norms, beliefs about consequences, cognitive resources, reinforcement, and environmental context and resources, among others. This is the first study to identify barriers and facilitators of effective communication and help-seeking in light of established behavioral change theory and frameworks for comprehensive intervention design. This provides a comprehensive explanation of challenges in help-seeking for endometriosis and represents the first step in the development of complex interventions to improve help-seeking and communication for people with endometriosis. Interventions targeting salient barriers will have greater potential to change behavior and improve outcomes.

[Diagnosis and management of endometriosis by general practitioners in the south of France]

OBJECTIVE

Assessment of the practices and knowledge of general practitioners in the south of France regarding the diagnosis and management of endometriosis.

METHOD

A descriptive cross-sectional study was conducted among general practitioners in the south of France from November 14, 2021 to February 14, 2022. A questionnaire was developed in consultation with and validated by two university endometriosis reference services of the AP-HM and was sent to general practitioners practicing in the south of France. It was distributed via professional emails, care networks and the south of France's medical order. The questionnaire was divided into three parts: the first simply collected demographic and epidemiological data, the second assessed knowledge of the disease, and the last assessed individual practices. The primary endpoint was the percentage of practitioners with>75% correct responses.

RESULTS

133 general practitioners responded to the questionnaire (133/407, 32.1%). 60.2% performed more than one gynecological consultation per week. 61.7% obtained a rate of correct answers>75%. The general practitioners with the best response rates were more aware of the latest HAS guidelines (P=0.027) and performed gynecological consultations more regularly in the office (P=0.025). Intense dysmenorrhea, chronic pelvic pain and deep dyspareunia were considered as evocative by 98.1%, 95.5% and 95.5% of respondents respectively. On the other hand, uro-digestive disorders were not often mentioned. In case of suspicion of endometriosis on questioning, 54.9% of general practitioners performed a clinical gynaecological examination. 76.7% prescribed an imaging test and 32.3% introduced hormonal treatment during the consultation. Referral of patients to specialists was made by the general practitioner as soon as clinical suspicion arose for 36.8%.

CONCLUSION

The results of our study suggest that the knowledge and practices of general practitioners, performing gynecology consultations in the south of France, is perfectible. In the context of the announcement of a regional reorganization of endometriosis-related care, other similar studies should be conducted regularly in order to assess the evolution of general practitioner's practices.

Examining the Influence on Perceptions of Endometriosis via Analysis of Social Media Posts: Cross-sectional Study

Background

Social media platforms, such as Facebook and Instagram, are increasingly being used to share health-related information by “influencers,” regular users, and institutions alike. While patients may benefit in various ways from these interactions, little is known about the types of endometriosis-related information published on social media. As digital opinion leaders influence the perceptions of their followers, physicians need to be aware about ideas and beliefs that are available online, in order to address possible misconceptions and provide optimal patient care.

Objective

The aim of this study was to identify and analyze frequent endometriosis-related discussion topics on social media in order to offer caregivers insight into commonly discussed subject matter and aspects.

Methods

We performed a systematic search using predefined parameters. Using the term “endometriosis” in Facebook’s search function and a social media search engine, a list of Facebook pages was generated. A list of Instagram accounts was generated using the terms “endometriosis” and “endo” in Instagram’s search function. Pages and accounts in English with 5000 or more followers or likes were included. Nonpublic, unrelated, or inactive pages and accounts were excluded. For each account, the most recent 10 posts were identified and categorized by two independent examiners using qualitative content analysis. User engagement was calculated using the numbers of interactions (ie, shares, likes, and comments) for each post, stratified by the number of followers.

Results

A total of 39 Facebook pages and 43 Instagram accounts with approximately 1.4 million followers were identified. Hospitals and medical centers made up 15% (6/39) of the Facebook pages and 5% (2/43) of the Instagram accounts. Top accounts had up to 111,600 (Facebook) and 41,400 (Instagram) followers. A total of 820 posts were analyzed. On Facebook, most posts were categorized as “awareness” (101/390, 25.9% of posts), “education and research” (71/390, 18.2%), and “promotion” (64/390, 16.4%). On Instagram, the top categories were “inspiration and support” (120/430, 27.9% of posts), “awareness” (72/430, 16.7%), and “personal story” (72/430, 16.7%). The frequency of most categories differed significantly between platforms. User engagement was higher on Instagram than on Facebook (3.20% vs 0.97% of followers per post). On Instagram, the highest percentage of users engaged with posts categorized as “humor” (mean 4.19%, SD 4.53%), “personal story” (mean 3.02%, SD 4.95%), and “inspiration and support” (mean 2.83%, SD 3.08%). On Facebook, posts in the categories “awareness” (mean 2.05%, SD 15.56%), “humor” (mean 0.91%, SD 1.07%), and “inspiration and support” (mean 0.56%, SD 1.37%) induced the most user engagement. Posts made by hospitals and medical centers generated higher user engagement than posts by regular accounts on Facebook (mean 1.44%, SD 1.11% vs mean 0.88%, SD 2.71% of followers per post) and Instagram (mean 3.33%, SD 1.21% vs mean 3.19%, SD 2.52% of followers per post).

Conclusions

Facebook and Instagram are widely used to share endometriosis-related information among a large number of users. Most posts offer inspiration or support, spread awareness about the disease, or cover personal issues. Followers mostly engage with posts with a humoristic, supportive, and awareness-generating nature. Health care providers should be aware about the topics discussed online, as this may lead to an increased understanding of the needs and demands of digitally proficient patients with endometriosis.

Recognizing and treating endometriosis

ABSTRACT

Endometriosis, defined as endometrium-like tissue located outside the uterine cavity, is a chronic and frequently painful disease that affects about 10% of reproductive-aged women worldwide. The ectopic endometrial tissue, which is still hormonally responsive, generates a chronic inflammatory state resulting in an array of sometimes debilitating symptoms as well as subfertility. Despite its prevalence and significant effect on a woman's health and quality of life, receiving a diagnosis of endometriosis often takes years. This article reviews the epidemiology, pathophysiology, clinical presentation, and treatment options for managing endometriosis in women who do not desire pregnancy and in those who do, and includes information on the newest treatment option, the oral gonadotropin-releasing hormone (GnRH) antagonist elagolix.

Health Information in the Era of Social Media: An Analysis of the Nature and Accuracy of Posts Made by Public Facebook Pages for Patients with Endometriosis

STUDY OBJECTIVE

To analyze the nature and accuracy of social media (Facebook) content related to endometriosis.

DESIGN

Retrospective content analysis.

SETTING

Social media platform, Facebook.

PARTICIPANTS

Social media posts on Facebook endometriosis pages.

INTERVENTIONS

A search of public Facebook pages was performed using the key word "endometriosis." Posts from the month-long study period were categorized and analyzed for accuracy. Two independent researchers used thematic evaluation to place posts into the following 11 categories: educational, emotional support, advocacy, discussion, events, humor, promotional, recipes, resources, surveys, and other. Posts categorized as educational were further subcategorized and reviewed. Each posted fact was cross-referenced in peer-reviewed scientific journals to determine whether the claim made was evidence-based. Engagement in a post was calculated by taking the sum of comments, shares, and reactions.

MEASUREMENTS AND MAIN RESULTS

A total of 53 Facebook pages meeting inclusion criteria were identified and 1464 posts from the study period were evaluated. Emotional support posts comprised the largest category of posts (48%) followed by educational posts (21%). Within the educational category, the epidemiology and pathophysiology subcategory comprised the largest group (42.0%) followed by the symptom's subcategory (19.6%). Post category had an effect on the amount of post engagement (p-value <.001) with emotional posts generating 70% of the overall engagement. The subcategories of the educational posts demonstrated a similar effect on engagement (p-value <.001). Posts were more engaging if they contained epidemiology and pathophysiology information with 44% of all engagement of educational posts occurring within this subcategory. Educational posts were found to be 93.93% accurate. There was no correlation between post engagement and post information accuracy (p-value = .312).

CONCLUSION

Facebook pages offer emotional support and education to people with endometriosis. Most information found in these Facebook pages is evidence-based. Clinicians should consider discussing the use of Facebook pages with their patients diagnosed with endometriosis.

No gynecologist in town: the gynecological care of women in rural Taiwan

BACKGROUND

A shortage of gynecologists exists in many countries. Even within an affluent country, gynecological clinics might not be evenly distributed. The purpose of the study was to investigate the disparity in gynecological care between adult women living in towns with and without gynecologists in Taiwan.

METHODS

Data sources were the cohort datasets of the National Health Insurance Research Database, with claims data of 1 million beneficiaries in 2010. A woman's residency was operationally inferred from the locations where she had most frequently visited physicians' clinics or local community hospitals within the year.

RESULTS

In Taiwan, 145 (39.4%) of 368 towns had no practicing gynecologist. Of 382,167 women with health care use in the datasets, 21,794 (5.7%) lived in towns without a gynecologist. The overwhelming majority of these towns lay in sparsely populated, rural areas. During the year, 132,702 women (34.7%) had sought medical help for gynecological diseases and 113,698 (29.8%) had visited gynecologists for gynecological diseases. Women in towns without a gynecologist were less likely to consult for gynecological diseases (23.8% versus 35.4%; P<0.001) and visit gynecologists (18.7% versus 30.4%; P<0.001) than women in towns with a gynecologist. The disparity existed in each age group. Among 5,189 adult women living in towns without a gynecologist and having gynecological diseases, 78.5% (number [n]=4,074) visited gynecologists out of town, especially for infertility, benign disorders of the uterus and ovaries, gynecological examinations, and contraceptive problems, and by contrast 23.3% (n=1,209) visited nongynecologists in town, most commonly for menopausal disorders, endometriosis and pelvic pain, menstrual disorders and hormonal dysfunction, and genital dysplasia.

CONCLUSION

Gynecological care of rural women was adversely affected by the shortage of gynecologists. The consequences of accessibility in underserved areas deserve further investigation.

Dysmenorrhea, absenteeism from school, and symptoms suspicious for endometriosis in adolescents

STUDY OBJECTIVE

To quantify in adolescents the prevalence of dysmenorrhea and other symptoms found to be suggestive of future diagnosis of endometriosis, in particular their impact on monthly absenteeism from school/work, activity impairment, and sexual life and to quantify the awareness of endometriosis in adolescents.

DESIGN

Cross-sectional study.

SETTING

Academic institution.

PATIENTS

Adolescents (n = 250) aged 14-20 years referring to 3 family Counseling services.

INTERVENTIONS

Participants completed an anonymous questionnaire.

MAIN OUTCOME MEASURES

Prevalence of dysmenorrhea and absenteeism from school/work during menses. Other outcomes were impairment of daily activities, dyspareunia, and awareness of endometriosis as a pathologic condition.

RESULTS

68% (170/250) of the participants complain of dysmenorrhea, 12% (30/250) lose days of school/work monthly because of dysmenorrhea, 13% (33/250) complain of intermenstrual pain which limits daily activities, 27% (56/208) of the adolescents who are sexually active complain of dyspareunia, 82% (203/250) have never heard about endometriosis and 80% (200/250) would like to know more about it. A significant association was found between severe dysmenorrhea, absenteeism from school/work, and basic level of education. Absence from school/work during menses showed an adjusted odds ratio for severe dysmenorrhea about 28 times greater than those who did not declare absenteeism (95%CI 7.898-98.920, P<.000).

CONCLUSIONS

The rates of dysmenorrhea and school absenteeism caused by dysmenorrhea are high. According to recent studies these patients are at higher risk of further development of endometriosis, whereas the knowledge of the disease is low among the adolescents investigated, so those involved with adolescents both in the health profession and particularly in schools and Family Counseling Services should be educated about endometriosis and its symptoms to reduce the significant lag time between symptoms and diagnosis.