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Canis M, Abbott J, Abrao M, Al-Jefout M, Bedaiwy M, Benagiano G, Burns KA, Canis M, Carmona F, Chapron C, Critchley HO, de Ziegler D, Falcone T, Fazleabas A, Ferrero S, Garcia-Velasco JA, Gargett C, Greaves E, Griffith LG, Guo SW, Habiba M, Harada T, Hull ML, Johnson NP, Kaufman Y, Issacson KB, Khan KN, Kim MR, Koninckx PA, Lessey BA, Martin D, Matsuzaki S, Mishra G, Osuga Y, Petraglia F, Popov A, Roman H, Romano A, Saunders P, Seckin T, Somigliana E, Taylor HS, Taylor RN, Vercellini P, Vigano P. A Call for New Theories on the Pathogenesis and Pathophysiology of Endometriosis. J Minim Invasive Gynecol 2024; 31:371-377. [PMID: 38365066 DOI: 10.1016/j.jmig.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/31/2024] [Accepted: 02/04/2024] [Indexed: 02/18/2024]
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Mijatovic V, Vercellini P. Towards comprehensive management of symptomatic endometriosis: beyond the dichotomy of medical versus surgical treatment. Hum Reprod 2024; 39:464-477. [PMID: 38199787 DOI: 10.1093/humrep/dead262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 12/06/2023] [Indexed: 01/12/2024] Open
Abstract
Except when surgery is the only option because of organ damage, the presence of suspicious lesions, or the desire to conceive, women with endometriosis-associated pain often face a choice between medical and surgical treatment. In theory, the description of the potential benefits and potential harms of the two alternatives should be standardized, unbiased, and based on strong evidence, enabling the patient to make an informed decision. However, doctor's opinion, intellectual competing interests, local availability of specific services and (mis)information obtained from social media, and online support groups can influence the type of advice given and affect patients' choices. This is compounded by the paucity of robust data from randomized controlled trials, and the anxiety of distressed women who are eager to do anything to alleviate their disabling symptoms. Vulnerable patients are more likely to accept the suggestions of their healthcare provider, which can lead to unbalanced and physician-centred decisions, whether in favour of either medical or surgical treatment. In general, treatments should be symptom-orientated rather than lesion-orientated. Medical and surgical modalities appear to be similarly effective in reducing pain symptoms, with medications generally more successful for severe dysmenorrhoea and surgery more successful for severe deep dyspareunia caused by fibrotic lesions infiltrating the posterior compartment. Oestrogen-progestogen combinations and progestogen monotherapies are generally safe and well tolerated, provided there are no major contraindications. About three-quarters of patients with superficial peritoneal and ovarian endometriosis and two-thirds of those with infiltrating fibrotic lesions are ultimately satisfied with their medical treatment although the remainder may experience side effects, which may result in non-compliance. Surgery for superficial and ovarian endometriosis is usually safe. When fibrotic infiltrating lesions are present, morbidity varies greatly depending on the skill of the individual surgeon, the need for advanced procedures, such as bowel resection and ureteral reimplantation, and the availability of expert colorectal surgeons and urologists working together in a multidisciplinary approach. The generalizability of published results is adequate for medical treatment but very limited for surgery. Moreover, on the one hand, hormonal drugs induce disease remission but do not cure endometriosis, and symptom relapse is expected when the drugs are discontinued; on the other hand, the same drugs should be used after lesion excision, which also does not cure endometriosis, to prevent an overall cumulative symptom and lesion recurrence rate of 10% per postoperative year. Therefore, the real choice may not be between medical treatment and surgery, but between medical treatment alone and surgery plus postoperative medical treatment. The experience of pain in women with endometriosis is a complex phenomenon that is not exclusively based on nociception, although the role of peripheral and central sensitization is not fully understood. In addition, trauma, and especially sexual trauma, and pelvic floor disorders can cause or contribute to symptoms in many individuals with chronic pelvic pain, and healthcare providers should never take for granted that diagnosed or suspected endometriosis is always the real, or the sole, origin of the referred complaints. Alternative treatment modalities are available that can help address most of the additional causes contributing to symptoms. Pain management in women with endometriosis may be more than a choice between medical and surgical treatment and may require comprehensive care by a multidisciplinary team including psychologists, sexologists, physiotherapists, dieticians, and pain therapists. An often missing factor in successful treatment is empathy on the part of healthcare providers. Being heard and understood, receiving simple and clear explanations and honest communication about uncertainties, being invited to share medical decisions after receiving detailed and impartial information, and being reassured that a team member will be available should a major problem arise, can greatly increase trust in doctors and transform a lonely and frustrating experience into a guided and supported journey, during which coping with this chronic disease is gradually learned and eventually accepted. Within this broader scenario, patient-centred medicine is the priority, and whether or when to resort to surgery or choose the medical option remains the prerogative of each individual woman.
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Affiliation(s)
- Velja Mijatovic
- Department of Gynaecology & Reproductive Medicine, Academic Endometriosis Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi and Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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Bailey F, Gaughran J, Mitchell S, Ovadia C, Holland TK. Diagnosis of superficial endometriosis on transvaginal ultrasound by visualization of peritoneum of pouch of Douglas. Ultrasound Obstet Gynecol 2024; 63:105-112. [PMID: 37926974 DOI: 10.1002/uog.27529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/02/2023] [Accepted: 10/28/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE Around 80% of women with endometriosis have superficial endometriosis (SE) rather than ovarian or deep endometriosis (DE). However, to date, advances in non-invasive, imaging-based diagnosis have been limited to DE or ovarian disease. The objective of this study was to determine whether we can detect SE on transvaginal ultrasound scan (TVS) by assessing the peritoneum of the pouch of Douglas (POD). METHODS This was a retrospective diagnostic test study following a change in practice to include POD peritoneum assessment for SE during TVS at a tertiary London hospital. Eligible patients underwent TVS by a single clinician trained in endometriosis scanning and a subsequent surgical procedure (laparoscopy) between April 2018 and September 2021. Participants formed a consecutive series. The TVS findings were compared with those of laparoscopy as the gold standard. Comparison of TVS findings with intraoperative findings was performed by calculating the diagnostic test performance measures (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and positive and negative likelihood ratios). RESULTS The study included a total of 100 patients. We found that 43/100 (43.0%) patients had no endometriosis, 33/100 (33.0%) had SE and 24/100 (24.0%) had DE on laparoscopy. SE was correctly detected on TVS in 17/33 patients, with a sensitivity of 51.5% (95% CI, 33.5-69.2%), specificity of 94.0% (95% CI, 85.4-98.4%), PPV of 81.0% (95% CI, 60.8-92.1%) and NPV of 79.7% (95% CI, 73.4-84.9%). DE was correctly diagnosed in 20/24 cases, including all ovarian cases, with a sensitivity of 83.3% (95% CI, 62.3-95.3%), specificity of 97.4% (95% CI, 90.8-99.7%), PPV of 90.9% (95% CI, 71.6-97.5%) and NPV of 94.9% (95% CI, 88.3-97.8%). The detection of SE on TVS was most accurate in the POD (sensitivity, 50.0%; specificity, 96.4%; PPV, 76.9%; NPV, 88.9%). CONCLUSIONS This study shows that the detection of SE in the POD is possible using routine TVS. While negative TVS does not reliably confirm the absence of disease or replace diagnostic laparoscopy, positive TVS facilitates non-invasive diagnosis for a much larger group of women than was previously possible. This should help to reduce the time from the onset of symptoms to diagnosis and enable initiation of medical treatment without the risk, cost and delay associated with a surgical diagnosis. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F Bailey
- Department of Women's Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - J Gaughran
- Department of Women's Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - S Mitchell
- Department of Women's Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - C Ovadia
- Department of Women's Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine at Guy's, School of Life Course Sciences, King's College London, London, UK
| | - T K Holland
- Department of Women's Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Bahrami F, Maheux-Lacroix S, Bougie O, Boutin A. Determinants of Perioperative Complications in Day-Surgery for Endometriosis: A Retrospective Cohort. Journal of Obstetrics and Gynaecology Canada 2024; 46:102227. [PMID: 37741619 DOI: 10.1016/j.jogc.2023.102227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVES Endometriosis is a common gynaecologic disease for which surgery is often required. Our objective was to evaluate the potential determinants of perioperative complications in day-surgeries for endometriosis. METHODS We conducted a retrospective cohort study of patients undergoing day-surgeries for endometriosis using Canadian administrative data from between 2015 and 2019. A multilevel logistic model with a random intercept at the centre level was created to assess the association between potential determinants, including age, site(s) of endometriosis lesion, centre-volume, surgical intervention, and a composite outcome of complications or specific complications. RESULTS We observed a higher risk of complications associated with greater age (40-44 vs. 20-24 years, adjusted odds ratio [aOR] 1.58; 95% CI 1.26-1.98); hysterectomies (aOR 2.29; 95% CI 1.73-3.06) compared with minor conservative surgery; lesions of the bowel or urinary tract system (aOR 1.54; 95% CI 1.16-2.06), and extra-pelvic sites of endometriosis (aOR 1.24; 95% CI 1.07-1.52) compared with endometriosis of the uterus; and with comorbidities (aOR 1.59; 95% CI 1.09-2.32). Endometriosis lesions to the bowel and urinary tract system and to extra-pelvic sites (compared with no endometriosis at the site) were associated with a greater risk of accidental damages (aOR 1.84; 95% CI 1.43-2.37) and urinary system complications (aOR 1.75; 95% CI 1.24-2.48), respectively. Among patients undergoing hysterectomies compared with those undergoing minor conservative surgery, infectious complications (aOR 8.56; 95% CI 4.70-15.59) and accidental damages (aOR 2.31; 95% CI 1.70-3.14) were more frequent. CONCLUSIONS Complications in day-surgeries for endometriosis are more frequent with older age, hysterectomy, comorbidities, and endometriosis of the bowel, urinary tract system, and extra-pelvic locations. More extensive disease is associated with more extensive surgical dissection and a higher risk of complications.
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Affiliation(s)
- Foruzan Bahrami
- Reproduction, Mother and Youth Health Unit, CHU de Québec-Université Laval Research Center, Québec City, QC
| | - Sarah Maheux-Lacroix
- Reproduction, Mother and Youth Health Unit, CHU de Québec-Université Laval Research Center, Québec City, QC; Department of Obstetrics and Gynaecology, Université Laval, Québec City, QC
| | - Olga Bougie
- Department of Obstetrics and Gynecology, Queen's University, Kingston, ON
| | - Amélie Boutin
- Reproduction, Mother and Youth Health Unit, CHU de Québec-Université Laval Research Center, Québec City, QC; Population Health and Optimal Health Practices Unit, CHU de Québec-Université Laval Research Center, Québec City, QC; Department of Pediatrics, Université Laval, Québec City, QC.
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Bahrami F, Maheux-Lacroix S, Bougie O, Boutin A. Day surgery for endometriosis in Canada: A retrospective cohort of trend and regional variation in types of surgeries and their complications. Aust N Z J Obstet Gynaecol 2023; 63:760-767. [PMID: 37264738 DOI: 10.1111/ajo.13705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/08/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND A significant proportion of patients with endometriosis require surgery for management of the disease. AIMS We aimed to assess the trend and regional variation in day surgeries for endometriosis across Canada and to identify perioperative complications associated with types of surgeries and their temporal trend and regional variation. MATERIALS AND METHODS We conducted a retrospective cohort study of women undergoing day surgeries for endometriosis between 2015 and 2019 using Canadian administrative data from the National Ambulatory Care Reporting System, which includes data from four provinces (Ontario (ON), Alberta (AB), Nova Scotia (NS) and Prince Edward Island (PEI)). Multivariate logistic regression models were used to compare perioperative complication rates, while adjusting for site(s) of endometriosis lesion, age, type of surgical intervention, and comorbidities. RESULTS During the study period, the rate of day surgeries for endometriosis remained nearly constant at 80-90 cases per 100 000 women of reproductive age (P = 0.12). The rate of day surgeries was significantly different between provinces (AB = 94, NS = 93 vs ON = 85 per 100 000 women of reproductive age: P < 0.02). The odds of complications decreased with time (2019 vs 2015; adjusted odds ratio (aOR): 0.84; 95% CI: 0.73-0.98). There was a significant regional variation in the frequency of perioperative complications (PEI vs ON aOR: 4.13, 95% CI: 2.58-6.62; and NS vs ON aOR: 1.47, 95% CI: 1.11-1.95). CONCLUSION The rates of day surgery for endometriosis remained stable and the risks of perioperative complications decreased during the five-year study period. However, there were significant regional variations in the risk of perioperative complications.
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Affiliation(s)
- Foruzan Bahrami
- Reproduction, Mother and Youth Health Unit, CHU de Québec-Université Laval Research Center, Quebec City, Quebec, Canada
| | - Sarah Maheux-Lacroix
- Department of Obstetrics and Gynaecology, Université Laval, and Reproduction, Mother and Youth Health Unit, CHU de Québec-Université Laval Research Center, Quebec City, Quebec, Canada
| | - Olga Bougie
- Department of Obstetrics and Gynecology, Queen's University, Kingston, Ontario, Canada
| | - Amélie Boutin
- Department of Pediatrics, Université Laval, and Reproduction, Mother and Youth Health & Population Health and Optimal Health Practices Units, CHU de Québec-Université Laval Research Center, Quebec City, Quebec, Canada
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Conte de Oliveira MD, Fernandes HDS, Vasconcelos AL, Russo FADP, Malheiro DT, Colombo G, Pelegrini P, Berwanger O, Teich V, Marra A, Menezes FGD, Cendoroglo Neto M, Klajner S. Impact of a quality programme on overindication of surgeries for endometriosis and cholecystectomies. BMJ Open Qual 2023; 12:e002178. [PMID: 37963671 PMCID: PMC10649569 DOI: 10.1136/bmjoq-2022-002178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 10/01/2023] [Indexed: 11/16/2023] Open
Abstract
Approximately 45% of patients receive medical services with minimal or no benefit (low-value care). In addition to the increasing costs to the health system, performing invasive procedures without an indication poses a potentially preventable risk to patient safety. This study aimed to determine whether a managed quality improvement programme could prevent cholecystectomy and surgery for endometriosis treatment with minimal or no benefit to patients.This before-and-after study was conducted at a private hospital in São Paulo, Brazil, which has a main medical remuneration model of fee for service. All patients who underwent cholecystectomy or surgery for endometriosis between 1 August 2020 and 31 May 2021 were evaluated.The intervention consisted of allowing the performance of procedures that met previously defined criteria or for which the indications were validated by a board of experts.A total of 430 patients were included in this analysis. The programme prevented the unnecessary performance of 13% of cholecystectomies (p=0.0001) and 22.2% (p=0.0006) of surgeries for the treatment of endometriosis. This resulted in an estimated annual cost reduction to the health system of US$466 094.93.In a hospital with a private practice and fee-for-service medical remuneration, the definition of clear criteria for indicating surgery and the analysis of cases that did not meet these criteria by a board of reputable experts at the institution resulted in a statistically significant reduction in low-value cholecystectomies and endometriosis surgeries.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Vanessa Teich
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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McGrath IM, Montgomery GW, Mortlock S. Genomic characterisation of the overlap of endometriosis with 76 comorbidities identifies pleiotropic and causal mechanisms underlying disease risk. Hum Genet 2023; 142:1345-1360. [PMID: 37410157 PMCID: PMC10449967 DOI: 10.1007/s00439-023-02582-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/23/2023] [Indexed: 07/07/2023]
Abstract
Comorbid conditions can be driven by underlying pleiotropic and causal mechanisms that can provide insights into shared molecular and biological processes contributing to disease risk. Endometriosis is a chronic condition affecting one in nine women of reproductive age and poses many challenges including lengthy diagnostic delays and limited treatment efficacy owing to poor understanding of disease aetiology. To shed light on the underlying biological mechanisms and to identify potential risk factors, we examine the epidemiological and genomic relationship between endometriosis and its comorbidities. In the UK Biobank 292 ICD10 codes were epidemiologically correlated with endometriosis diagnosis, including gynaecological, immune, infection, pain, psychiatric, cancer, gastrointestinal, urinary, bone and cardiovascular traits. A subset of the identified comorbidities (n = 76) underwent follow-up genetic analysis. Whilst Mendelian randomisation suggested causality was not responsible for most comorbid relationships, 22 traits were genetically correlated with endometriosis, including pain, gynaecological and gastrointestinal traits, suggestive of a shared genetic background. Pleiotropic genetic variants and genes were identified using gene-based and colocalisation analysis. Shared genetic risk factors and potential target genes suggest a diverse collection of biological systems are involved in these comorbid relationships including coagulation factors, development of the female reproductive tract and cell proliferation. These findings highlight the diversity of traits with epidemiological and genomic overlap with endometriosis and implicate a key role for pleiotropy in the comorbid relationships.
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Affiliation(s)
- Isabelle M McGrath
- The Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Grant W Montgomery
- The Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Sally Mortlock
- The Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, 4072, Australia.
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Canis M, Guo SW. In the thicket of fears, doubts, and murky facts: some reflections on treatment modalities for endometriosis-associated pain. Hum Reprod 2023; 38:1245-1252. [PMID: 37023473 DOI: 10.1093/humrep/dead061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/15/2023] [Indexed: 04/08/2023] Open
Abstract
Endometriosis-associated pain can be managed by either surgery or hormonal therapy. The final decision as to which treatment modality to take is based on efficacy and possible complications of different treatment modalities, risk of recurrence, and the patient's wishes and preferences. But in the thicket of fears, doubts, and murky facts, the choice may ultimately be the trade-off between irrational fears and ignorance versus scientific evidence. We elaborate some pros and cons of the two treatment modalities and highlight some notable downsides of hormonal therapy, in particular the possible yet unquantified risk of long-term hormonal therapy for malignant transformation, perhaps with the only exception of combined oral contraceptives. Thus, when discussing with patients, we advocate the approach of discussing the advantages and disadvantages of all treatment options in detail, accounting for the known pros and cons with a full understanding of the predictive irrationality of human beings. For endometriosis-associated pain, surgery is definitely not a failure of medicine but, rather, a viable option, especially given the recently surfaced undercurrent of wariness and dissatisfaction with the current hormonal drugs among patients with endometriosis. Above all, there is a pressing need to fill the knowledge gap of perioperative interventions intended to reduce the risk of recurrence and to fulfill the demand for the development of safe and efficacious non-hormonal therapeutics.
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Affiliation(s)
- Michel Canis
- Department of Obstetrics Gynecology and Reproductive Medicine, CHU Clermont Ferrand, Clermont Ferrand, France
| | - Sun-Wei Guo
- Research Institute, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
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Krämer B, Andress J, Neis F, Hoffmann S, Brucker S, Kommoss S, Höller A. Improvement in Fertility and Pain after Endometriosis Resection and Adhesion Prevention with 4DryField ® PH: Follow-up of a Randomized Controlled Clinical Trial. J Clin Med 2023; 12:jcm12103597. [PMID: 37240703 DOI: 10.3390/jcm12103597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/06/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Adhesions after endometriosis resection are frequent and the most common causes for chronic pain and secondary infertility. Primary results of our randomized controlled trial (RCT) on adhesion prevention after deep infiltrating endometriosis (DIE) resection using the gel barrier 4DryField® PH showed 85% adhesion reduction in second-look surgeries. Secondary endpoint data on fertility and pain development were collected during 12-month follow-ups. METHODS This RCT comprised 50 patients. Preoperatively and after 1, 6 and 12 months, pain scores for cycle-independent pelvic pain, dysmenorrhea, dyspareunia, dyschezia, and dysuria, as well as the number of pregnancies, were recorded,. RESULTS The pregnancy rate in the intervention group was significantly higher (p < 0.05). Pain development was also improved: after 12 months, all 5 subscores were lower in the intervention group and improvements were more pronounced, most prominently concerning cycle-independent pelvic pain and dysmenorrhea, the two subcategories with the highest preoperative scores and, therefore, the highest relevance for the patients. Cycle-independent pelvic pain even recurred in the control group, while barrier application prevented this. CONCLUSIONS Considering the known causal link between adhesions and pain, it is apparent that the favourable outcomes in the intervention group are linked to effective adhesion prevention. The significant increase in pregnancies is remarkable.
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Affiliation(s)
- Bernhard Krämer
- Department for Women's Health, University Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
| | - Jürgen Andress
- Department for Women's Health, University Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
| | - Felix Neis
- Department for Women's Health, University Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
| | - Sascha Hoffmann
- Department for Women's Health, University Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
| | - Sara Brucker
- Department for Women's Health, University Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
| | - Stefan Kommoss
- Department for Women's Health, University Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
| | - Alice Höller
- Department for Women's Health, University Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
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Abstract
Endometriosis affects approximately 190 million women and people assigned female at birth worldwide. It is a chronic, inflammatory, gynecologic disease marked by the presence of endometrial-like tissue outside the uterus, which in many patients is associated with debilitating painful symptoms. Patients with endometriosis are also at greater risk of infertility, emergence of fatigue, multisite pain, and other comorbidities. Thus, endometriosis is best understood as a condition with variable presentation and effects at multiple life stages. A long diagnostic delay after symptom onset is common, and persistence and recurrence of symptoms despite treatment is common. This review discusses the potential genetic, hormonal, and immunologic factors that lead to endometriosis, with a focus on current diagnostic and management strategies for gynecologists, general practitioners, and clinicians specializing in conditions for which patients with endometriosis are at higher risk. It examines evidence supporting the different surgical, pharmacologic, and non-pharmacologic approaches to treating patients with endometriosis and presents an easy to adopt step-by-step management strategy. As endometriosis is a multisystem disease, patients with the condition should ideally be offered a personalized, multimodal, interdisciplinary treatment approach. A priority for future discovery is determining clinically informative sub-classifications of endometriosis that predict prognosis and enhance treatment prioritization.
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Affiliation(s)
- Andrew W Horne
- EXPPECT Edinburgh and MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Stacey A Missmer
- Michigan State University, Grand Rapids, MI, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Marschall H, Forman A, Lunde SJ, Kesmodel US, Hansen KE, Vase L. Is laparoscopic excision for superficial peritoneal endometriosis helpful or harmful? Protocol for a double-blinded, randomised, placebo-controlled, three-armed surgical trial. BMJ Open 2022; 12:e062808. [PMID: 36328387 PMCID: PMC9639085 DOI: 10.1136/bmjopen-2022-062808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Placebo-controlled surgical designs are recommended to ascertain treatment effects for elective surgeries when there is genuine doubt about the effectiveness of the surgery. Some elective surgeries for pain have been unable to show an effect beyond sham surgery, suggesting contributions from contextual factors. However, the nature of contextual factors in elective surgery is largely unexplored. Further, methodological difficulties in placebo-controlled surgical trials impact the ability to estimate the effectiveness of a surgical procedure. These include an overall lack of testing the success of blinding, absence of comparison to a no-surgery control group and dearth of test for neuropathic pain.For women with peritoneal endometriosis, there is uncertainty regarding the pain-relieving effect of surgery. Surgery may put patients at risk of complications such as postsurgical neuropathic pain, without guarantees of sufficient pelvic pain relief. The planned placebo-controlled trial aims to examine the effect of surgery on pelvic pain, widespread pain and neuropathic pain symptoms in women with peritoneal endometriosis, and to test the contribution of contextual factors to pain relief. METHODS AND ANALYSIS One hundred women with peritoneal endometriosis will be randomised to either diagnostic laparoscopy with excision of endometrial tissue (active surgery), purely diagnostic laparoscopy (sham surgery) or delayed surgery (no-surgery control group). Outcomes include pelvic pain relief, widespread pain, neuropathic pain symptoms and quality of life. Contextual factors are also assessed. Assessments will be obtained at baseline and 1, 3 and 6 months postrandomisation. Mixed linear models will be used to compare groups over time on all outcome variables. ETHICS AND DISSEMINATION The trial is approved by the Regional Ethics Committee in the Central Denmark Region (1-10-72-152-20). The trial is funded by a PhD scholarship from Aarhus University, and supported by a grant from 'Helsefonden' (20-B-0448). Findings will be published in international peer-reviewed journals and disseminated at international conferences. TRIAL REGISTRATION NUMBER NCT05162794.
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Affiliation(s)
- Henrik Marschall
- School of Business and Social Sciences, Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Axel Forman
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Sigrid Juhl Lunde
- School of Business and Social Sciences, Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Ulrik Schiøler Kesmodel
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Lene Vase
- School of Business and Social Sciences, Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
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Harada T, Taniguchi F, Kitajima M, Kitawaki J, Koga K, Momoeda M, Mori T, Murakami T, Narahara H, Osuga Y, Yamaguchi K. Clinical practice guidelines for endometriosis in Japan (The 3rd edition). J Obstet Gynaecol Res 2022; 48:2993-3044. [PMID: 36164759 PMCID: PMC10087749 DOI: 10.1111/jog.15416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/11/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Tasuku Harada
- Department Obstetrics and Gynecology, Tottori University
| | | | | | - Jo Kitawaki
- Department Obstetrics and Gynecology, Kyoto Prefectural University of Medicine
| | - Kaori Koga
- Department Obstetrics and Gynecology, The University of Tokyo
| | - Mikio Momoeda
- Department Obstetrics and Gynecology, Aiiku Hospital
| | - Taisuke Mori
- Department Obstetrics and Gynecology, Kyoto Prefectural University of Medicine
| | - Takashi Murakami
- Department Obstetrics and Gynecology, Shiga University of Medical Science
| | | | - Yutaka Osuga
- Department Obstetrics and Gynecology, The University of Tokyo
| | - Ken Yamaguchi
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine
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13
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Pascoal E, Wessels JM, Aas-Eng MK, Abrao MS, Condous G, Jurkovic D, Espada M, Exacoustos C, Ferrero S, Guerriero S, Hudelist G, Malzoni M, Reid S, Tang S, Tomassetti C, Singh SS, Van den Bosch T, Leonardi M. Strengths and limitations of diagnostic tools for endometriosis and relevance in diagnostic test accuracy research. Ultrasound Obstet Gynecol 2022; 60:309-327. [PMID: 35229963 DOI: 10.1002/uog.24892] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/20/2022] [Accepted: 02/22/2022] [Indexed: 06/14/2023]
Abstract
Endometriosis is a chronic systemic disease that can cause pain, infertility and reduced quality of life. Diagnosing endometriosis remains challenging, which yields diagnostic delays for patients. Research on diagnostic test accuracy in endometriosis can be difficult due to verification bias, as not all patients with endometriosis undergo definitive diagnostic testing. The purpose of this State-of-the-Art Review is to provide a comprehensive update on the strengths and limitations of the diagnostic modalities used in endometriosis and discuss the relevance of diagnostic test accuracy research pertaining to each. We performed a comprehensive literature review of the following methods: clinical assessment including history and physical examination, biomarkers, diagnostic imaging, surgical diagnosis and histopathology. Our review suggests that, although non-invasive diagnostic methods, such as clinical assessment, ultrasound and magnetic resonance imaging, do not yet qualify formally as replacement tests for surgery in diagnosing all subtypes of endometriosis, they are likely to be appropriate for advanced stages of endometriosis. We also demonstrate in our review that all methods have strengths and limitations, leading to our conclusion that there should not be a single gold-standard diagnostic method for endometriosis, but rather, multiple accepted diagnostic methods appropriate for different circumstances. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E Pascoal
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
| | - J M Wessels
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
- AIMA Laboratories Inc., Hamilton, Canada
| | - M K Aas-Eng
- Department of Gynecology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - M S Abrao
- Gynecologic Division, BP-A Beneficencia Portuguesa de São Paulo, São Paulo, Brazil
- Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - G Condous
- Acute Gynecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School, Nepean Hospital, Sydney, Australia
| | - D Jurkovic
- Institute for Women's Health, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Espada
- Department of Obstetrics and Gynaecology, Blue Mountains ANZAC Memorial Hospital, Katoomba, Australia
- Sydney Medical School, Sydney, Australia
| | - C Exacoustos
- Department of Surgical Sciences, Obstetrics and Gynecological Clinic, University of Rome 'Tor Vergata', Rome, Italy
| | - S Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - S Guerriero
- Centro Integrato di Procreazione Medicalmente Assistita (PMA) e Diagnostica Ostetrico-Ginecologica, Azienda Ospedaliero Universitaria-Policlinico Duilio Casula, Cagliari, Italy
| | - G Hudelist
- Department of Gynecology, Center for Endometriosis, St John of God Hospital, Vienna, Austria
- Scientific Endometriosis Foundation (SEF), Westerstede, Germany
| | - M Malzoni
- Endoscopica Malzoni, Center for Advanced Endoscopic Gynecologic Surgery, Avellino, Italy
| | - S Reid
- Department of Obstetrics and Gynaecology, Western Sydney University, Sydney, Australia
| | - S Tang
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - C Tomassetti
- Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven University Fertility Centre, Leuven, Belgium
| | - S S Singh
- Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, Canada
| | - T Van den Bosch
- Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven, Belgium
| | - M Leonardi
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
- Sydney Medical School, Sydney, Australia
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
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Maddern J, Grundy L, Harrington A, Schober G, Castro J, Brierley SM. A syngeneic inoculation mouse model of endometriosis that develops multiple comorbid visceral and cutaneous pain like behaviours. Pain 2022; 163:1622-1635. [PMID: 35050959 DOI: 10.1097/j.pain.0000000000002552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/29/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Endometriosis is a chronic and debilitating condition, commonly characterised by chronic pelvic pain (CPP) and infertility. Chronic pelvic pain can be experienced across multiple pelvic organs, with comorbidities commonly effecting the bowel, bladder, and vagina. Despite research efforts into endometriosis pathophysiology, little is known about how endometriosis induces CPP, and as such, therapeutic interventions are lacking. The aim of this study was to characterise a syngeneic mouse model of endometriosis that mimics naturally occurring retrograde menstruation, thought to precede endometriosis development in patients, and determine whether these mice exhibit signs of CPP and altered behaviour. We characterised the development of endometriosis over 10 weeks following uterine tissue inoculation, measured in vivo and ex vivo hypersensitivity to mechanical stimuli across multiple visceral organs, and assessed alterations in animal spontaneous behaviour. We confirmed that inoculated uterine horn tissue formed into endometriosis lesions throughout the peritoneal cavity, with significant growth by 8 to 10 weeks post inoculation. Additionally, we found that mice with fully developed endometriosis displayed hypersensitivity evoked by (1) vaginal distension, (2) colorectal distension, (3) bladder distension, and (4) cutaneous thermal stimulation, compared to their sham counterparts. Moreover, endometriosis mice displayed alterations in spontaneous behaviour indicative of (5) altered bladder function and (6) anxiety. This model creates a foundation for mechanistical studies into the diffuse CPP associated with endometriosis and the development of targeted therapeutic interventions to improve the quality of life of women with endometriosis.
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Affiliation(s)
- Jessica Maddern
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, South Australia, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Luke Grundy
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, South Australia, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Andrea Harrington
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, South Australia, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Gudrun Schober
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, South Australia, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Joel Castro
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, South Australia, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Stuart M Brierley
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, South Australia, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Mak J, Leonardi M, Condous G. 'Seeing is believing': arguing for diagnostic laparoscopy as a diagnostic test for endometriosis. Reprod Fertil 2022; 3:C23-C28. [PMID: 35794928 PMCID: PMC9254269 DOI: 10.1530/raf-21-0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/10/2022] [Indexed: 11/08/2022] Open
Abstract
Endometriosis is a benign disease that can cause pain and infertility in women. Debate exists over how endometriosis should best be diagnosed. On one hand, endometriosis can be diagnosed by directly examining pelvic anatomy via a surgical procedure known as diagnostic laparoscopy. On the other hand, the disease can be diagnosed via non-surgical means such as using medical imaging, the symptoms described by the patient and whether the patient responds to non-surgical therapies such as medication. In this debate article, we argue in favour of diagnostic laparoscopy. We review the safety of the procedure, compare the ability of diagnostic laparoscopy vs medical imaging to detect endometriosis and consider the benefits of formally diagnosing or ruling out the condition.
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Affiliation(s)
- Jason Mak
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, New South Wales, Australia
| | - Mathew Leonardi
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - George Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, New South Wales, Australia
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Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N. ESHRE guideline: endometriosis. Hum Reprod Open 2022; 2022:hoac009. [PMID: 35350465 PMCID: PMC8951218 DOI: 10.1093/hropen/hoac009] [Citation(s) in RCA: 332] [Impact Index Per Article: 166.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION How should endometriosis be diagnosed and managed based on the best available evidence from published literature? SUMMARY ANSWER The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer. WHAT IS KNOWN ALREADY Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility. STUDY DESIGN SIZE DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review. PARTICIPANTS/MATERIALS SETTING METHODS Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected. LIMITATIONS REASONS FOR CAUTION The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis. STUDY FUNDING/COMPETING INTERESTS The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare. DISCLAIMER This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).
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Affiliation(s)
- Christian M Becker
- Nuffield Department of Women’s and Reproductive Health, Endometriosis CaRe
Centre, University of Oxford, Oxford, UK
| | - Attila Bokor
- Department of Obstetrics and Gynecology, Semmelweis University,
Budapest, Hungary
| | - Oskari Heikinheimo
- Department of Obstetrics & Gynecology, University of Helsinki and Helsinki
University Hospital, Helsinki, Finland
| | - Andrew Horne
- EXPPECT Centre for Endometriosis and Pelvic Pain, MRC Centre for Reproductive
Health, University of Edinburgh, Edinburgh, UK
| | - Femke Jansen
- EndoHome—Endometriosis Association Belgium, Belgium
| | - Ludwig Kiesel
- Department of Gynecology and Obstetrics, University Hospital
Muenster, Muenster, Germany
| | | | - Marina Kvaskoff
- Paris-Saclay University, UVSQ, Univ. Paris-Sud, Inserm, Gustave Roussy,
“Exposome and Heredity” Team, CESP, Villejuif, France
| | - Annemiek Nap
- Department of Gynaecology and Obstetrics, Radboudumc, Nijmegen,
The Netherlands
| | | | - Ertan Saridogan
- Department of Obstetrics and Gynaecology, University College London
Hospital, London, UK
- Elizabeth Garrett Anderson Institute for Women’s Health, University College
London, London, UK
| | - Carla Tomassetti
- Department of Obstetrics and Gynaecology, Leuven University Fertility Center,
University Hospitals Leuven, Leuven, Belgium
- Faculty of Medicine, Department of Development and Regeneration, LEERM (Lab of
Endometrium, Endometriosis and Reproductive Medicine), KU Leuven, Leuven,
Belgium
| | - Nehalennia van Hanegem
- Department of Reproductive Medicine and Gynecology, University Medical Center
Utrecht, Utrecht, The Netherlands
| | - Nicolas Vulliemoz
- Department of Woman Mother Child, Fertility Medicine and Gynaecological
Endocrinology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nathalie Vermeulen
- European Society of Human Reproduction and Embryology,
Strombeek-Bever, Belgium
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Ball E, Karavadra B, Kremer-Yeatman BJ, Mustard C, Lee KM, Bhogal S, Dodds J, Horne AW, Allotey J, Rivas C. Systematic review of patient-specific pre-operative predictors of pain improvement to endometriosis surgery. Reprod Fertil 2022; 2:69-80. [PMID: 35128434 PMCID: PMC8812445 DOI: 10.1530/raf-20-0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/16/2021] [Indexed: 11/13/2022] Open
Abstract
Background Up to 28% of endometriosis patients do not get pain relief from therapeutic laparoscopy but this subgroup is not defined. Objectives To identify any prognostic patient-specific factors (such as but not limited to patients’ type or location of endometriosis, sociodemographics and lifestyle) associated with a clinically meaningful reduction in post-surgical pain response to operative laparoscopic surgery for endometriosis. Search strategy PubMed, Cochrane and Embase databases were searched from inception to 19 May 2020 without language restrictions. Backward and forward citation tracking was used. Selection criteria, data collection and analysis: Cohort studies reporting prognostic factors, along with scores for domains of pain associated with endometriosis before and after surgery, were included. Studies that compared surgeries, or laboratory tests, or outcomes without stratification were excluded. Results were synthesised but variation in study designs and inconsistency of outcome reporting precluded us from doing a meta-analysis. Main results Five studies were included. Quality assessment using the Newcastle–Ottawa scale graded three studies as high, one as moderate and one as having a low risk of bias. Four of five included studies separately reported that a relationship exists between more severe endometriosis and stronger pain relief from laparoscopic surgery. Conclusion Currently, there are few studies of appropriate quality to answer the research question. We recommend future studies report core outcome sets to enable meta-analysis. Lay summary Endometriosis is a painful condition caused by displaced cells from the lining of the womb, causing inflammation and scarring inside the body. It affects 6–10% of women and there is no permanent cure. Medical and laparoscopic surgical treatments are available, but about 28% of patients do not get the hoped-for pain relief after surgery. Currently, there is no way of predicting who gets better and who does not. We systematically searched the world literature to establish who may get better, in order to improve counselling when women choose treatment options. We identified five studies of variable quality showing: More complex disease (in specialist hands) responds better to surgery than less, but more studies needed.
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Affiliation(s)
- Elizabeth Ball
- Department of Obstetrics and Gynaecology, The Royal London Hospital, Barts Health NHS Trust, London, UK.,Women's Health Research Unit, Queen Mary University of London, London, UK
| | - Babu Karavadra
- Department of Gynecology, Norfolk & Norwich University Hospital, Norwich, UK
| | | | - Connor Mustard
- Barts and the London Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Kim May Lee
- Barts and the London Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Sharandeep Bhogal
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Julie Dodds
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, UK
| | - John Allotey
- Institute of Metabolism and Systems Research and Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Carol Rivas
- UCL Social Research Institute, University College London, London, UK
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Abstract
BACKGROUND Endometriosis is a condition characterised by the presence of ectopic deposits of endometrial-like tissue outside the uterus, usually in the pelvis. The impact of laparoscopic treatment on overall pain is uncertain and a significant proportion of women will require further surgery. Therefore, adjuvant medical therapies following surgery, such as the levonorgestrel-releasing intrauterine device (LNG-IUD), have been considered to reduce recurrence of symptoms. OBJECTIVES: To determine the effectiveness and safety of post-operative LNG-IUD in women with symptomatic endometriosis. SEARCH METHODS We searched the following databases from inception to January 2021: The Specialised Register of the Cochrane Gynaecology and Fertility Group, CENTRAL (which now includes records from two trial registries), MEDLINE, Embase, PsycINFO, LILACS and Epistemonikos. We handsearched citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies. We contacted experts in the field for information about any additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing women undergoing surgical treatment of endometriosis with uterine preservation who were assigned to LNG-IUD insertion, versus control conditions including expectant management, post-operative insertion of placebo (inert intrauterine device), or other medical treatment such as gonadotrophin-releasing hormone agonist (GnRH-a) drugs. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, and extracted data to allow for an intention-to-treat analysis. For dichotomous data, we calculated the risk ratio (RR) and 95% confidence interval (CI) using the Mantel-Haenszel fixed-effect method. For continuous data, we calculated the mean difference (MD) and 95% CI using the inverse variance fixed-effect method. MAIN RESULTS Four RCTs were included, with a total of 157 women. Two studies are ongoing. The GRADE certainty of evidence was very low to low. The certainty of evidence was graded down primarily for serious risk of bias and imprecision. LNG-IUD versus expectant management Overall pain: No studies reported on the primary outcome of overall pain. Dysmenorrhoea: We are uncertain whether LNG-IUD improves dysmenorrhoea at 12 months. Data on this outcome were reported on by two RCTs; meta-analysis was not possible (RCT 1: delta of median visual analogue scale (VAS) 81 versus 50, P = 0.006, n = 55; RCT 2: fall in VAS by 50 (35 to 65) versus 30 (25 to 40), P = 0.021, n = 40; low-certainty evidence). Quality of life: We are uncertain whether LNG-IUD improves quality of life at 12 months. One trial demonstrated a change in total quality of life score with postoperative LNG-IUD from baseline (mean 61.2 (standard deviation (SD) 14.8) to 12 months (mean 70.3 (SD 16.2) compared to expectant management (baseline 55.1 (SD 17.0) to 57.0 (SD 33.2) at 12 months) (n = 55, P = 0.014, very low-certainty evidence). Patient satisfaction: Two studies found higher rates of satisfaction with LNG-IUD compared to expectant management; however, combining the studies in meta-analysis was not possible (n = 95, very low-certainty evidence). One study found 75% (15/20) of those given post-operative LNG-IUD were "satisfied" or "very satisfied", compared to 50% (10/20) of those in the expectant management group (RR 1.5, 95% CI 0.90-2.49, 1 RCT, n=40, very low-certainty evidence). The second study found that fewer were "very satisfied" in the expectant management group when compared to LNG, but there were no data to include in a meta-analysis. Adverse events: One study found a significantly higher proportion of women reporting melasma (n = 55, P = 0.015, very low-certainty evidence) and bloating (n = 55, P = 0.021, very low-certainty evidence) following post-operative LNG-IUD. There were no differences in other reported adverse events, such as weight gain, acne, and headaches. LNG-IUD versus GnRH-a Overall pain: No studies reported on the primary outcome of overall pain. Chronic pelvic pain: We are uncertain whether LNG-IUD improves chronic pelvic pain at 12 months when compared to GnRH-a (VAS pain scale) (MD -2.0, 95% CI -20.2 to 16.2, 1 RCT, n = 40, very low-certainty evidence). Dysmenorrhoea: We are uncertain whether LNG-IUD improves dysmenorrhoea at six months when compared to GnRH-a (measured as a reduction in VAS pain score) (MD 1.70, 95%.CI -0.14 to 3.54, 1 RCT, n = 18, very low-certainty evidence). Adverse events: One study suggested that vasomotor symptoms were the most common adverse events reported with patients receiving GnRH-a, and irregular bleeding in those receiving LNG-IUD (n = 40, very low-certainty evidence) AUTHORS' CONCLUSIONS: Post-operative LNG-IUD is widely used to reduce endometriosis-related pain and to improve operative outcomes. This review demonstrates that there is no high-quality evidence to support this practice. This review highlights the need for further studies with large sample sizes to assess the effectiveness of post-operative adjuvant hormonal IUD on the core endometriosis outcomes (overall pain, most troublesome symptom, and quality of life).
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Affiliation(s)
- Tatjana Gibbons
- Nuffield Department of Women's & Reproductive Health, Oxford University, Oxford , UK
| | | | - Ying C Cheong
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michelle R Wise
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
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McNamara HC, Frawley HC, Donoghue JF, Readman E, Healey M, Ellett L, Reddington C, Hicks LJ, Harlow K, Rogers PAW, Cheng C. Peripheral, Central, and Cross Sensitization in Endometriosis-Associated Pain and Comorbid Pain Syndromes. Front Reprod Health 2021; 3:729642. [PMID: 36303969 PMCID: PMC9580702 DOI: 10.3389/frph.2021.729642] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Helen C. McNamara
- Royal Women's Hospital, Melbourne, VIC, Australia
- *Correspondence: Helen C. McNamara
| | - Helena C. Frawley
- Royal Women's Hospital, Melbourne, VIC, Australia
- School of Health Sciences, University of Melbourne, Parkville, VIC, Australia
- Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Jacqueline F. Donoghue
- Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Emma Readman
- Mercy Hospital for Women, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Martin Healey
- Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Lenore Ellett
- Mercy Hospital for Women, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Charlotte Reddington
- Royal Women's Hospital, Melbourne, VIC, Australia
- Mercy Hospital for Women, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | | | - Keryn Harlow
- Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Peter A. W. Rogers
- Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Claudia Cheng
- Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
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20
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Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, Buchbinder R, Pinkney T, Bishop FL, Pugh J, Cousins S, Harris I, Lohmander LS, Blencowe N, Gillies K, Probst P, Brennan C, Cook A, Farrar-Hockley D, Savulescu J, Huxtable R, Rangan A, Tracey I, Brocklehurst P, Ferreira ML, Nicholl J, Reeves BC, Hamdy F, Rowley SC, Lee N, Cook JA. Placebo comparator group selection and use in surgical trials: the ASPIRE project including expert workshop. Health Technol Assess 2021; 25:1-52. [PMID: 34505829 PMCID: PMC8450778 DOI: 10.3310/hta25530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The use of placebo comparisons for randomised trials assessing the efficacy of surgical interventions is increasingly being considered. However, a placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges. OBJECTIVES To provide a summary of knowledge on placebo controls in surgical trials and to summarise any recommendations for designers, evaluators and funders of placebo-controlled surgical trials. DESIGN To carry out a state-of-the-art workshop and produce a corresponding report involving key stakeholders throughout. SETTING A workshop to discuss and summarise the existing knowledge and to develop the new guidelines. RESULTS To assess what a placebo control entails and to assess the understanding of this tool in the context of surgery is considered, along with when placebo controls in surgery are acceptable (and when they are desirable). We have considered ethics arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be carried out and interpreted. The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with a high risk of bias, particularly because of the placebo effect. CONCLUSIONS The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. An outline for best practice was produced in the form of the Applying Surgical Placebo in Randomised Evaluations (ASPIRE) guidelines for those considering the use of a placebo control in a surgical randomised controlled trial. LIMITATIONS Although the workshop participants involved international members, the majority of participants were from the UK. Therefore, although every attempt was made to make the recommendations applicable to all health systems, the guidelines may, unconsciously, be particularly applicable to clinical practice in the UK NHS. FUTURE WORK Future work should evaluate the use of the ASPIRE guidelines in making decisions about the use of a placebo-controlled surgical trial. In addition, further work is required on the appropriate nomenclature to adopt in this space. FUNDING Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council-National Institute for Health Research Methodology Research programme.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Jane M Blazeby
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Charles Weijer
- Departments of Medicine, Epidemiology and Biostatistics, and Philosophy, Western University, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Thomas Pinkney
- Academic Department of Surgery, University of Birmingham, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Felicity L Bishop
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Sian Cousins
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ian Harris
- Faculty of Medicine, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - Natalie Blencowe
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Andrew Cook
- Wessex Institute, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Richard Huxtable
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Health Sciences, University of York, York, UK
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Institute of Bone and Joint Research, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Barnaby C Reeves
- Clinical Trials Evaluation Unit Bristol Medical School, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Freddie Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Naomi Lee
- Editorial Department, The Lancet, London, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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21
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Ouazana M, Kerbage Y, Chauvet P, Collinet P, Bouet PE, Touboul C, Legendre G, Golfier F, Ploteau S, Santulli P. Prophylactic procedures associated with gynecological surgery for the management of superficial endometriosis and adhesions. Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF) ✰. J Gynecol Obstet Hum Reprod 2021; 50:102206. [PMID: 34391952 DOI: 10.1016/j.jogoh.2021.102206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/09/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide guidelines from the French College of Obstetricians and Gynecologists (CNGOF), based on the best currently available evidence, for the prophylactic procedures associated with gynecological surgery for benign disease such as superficial endometriosis lesions and adhesions. METHODS The CNGOF has decided to adopt the AGREE II and GRADE systems for grading scientific evidence. Each recommendation for practice was allocated a grade that reflects the quality of evidence (QE) (clinical practice guidelines). RESULTS Endometriosis and pelvic pain Superficial endometriosis can be entirely asymptomatic. Surgical treatment of asymptomatic superficial peritoneal endometriosis is not recommended in women of childbearing age for the prevention of pelvic pain, especially in case of proximity to noble organs (e.g., the ureters, rectum and sigmoid, and ovaries in nulligravida) as there is no evidence that the disease will progress to become symptomatic (low level of evidence). In case of accidental discovery of superficial endometriosis in women of childbearing age with pelvic pain, it is recommended that the lesions are excised, if surgically accessible. Removal of superficial endometriosis lesions in patients with painful symptoms improves quality of life and pain (low level of evidence). Endometriosis and infertility It appears that women with isolated superficial endometriosis diagnosed by laparoscopy with histological confirmation have a significantly higher incidence of primary infertility than patients without endometriosis. However, there is no data regarding the impact of treatment of these lesions on the fertility in these women or on the natural course of their disease (low level of evidence). It is recommended that excision is performed rather than monopolar coagulation of superficial endometriosis lesions in infertile women, as this results in a higher spontaneous pregnancy rate (low level of evidence). Adhesions and pelvic pain There is limited data in the literature regarding the benefit of performing systematic adhesiolysis during laparoscopy to prevent pelvic pain when incidental pelvic adhesions are discovered. For patients with pelvic pain, it is probably better not to perform adhesiolysis to prevent pelvic pain, although this can be decided on a case-by-case basis depending on the extent of the adhesions, the topography, and the type of surgery considered (low level of evidence). For asymptomatic patients, it is recommended not to perform adhesiolysis to prevent pelvic pain due to the lack of clear efficacy both short- or long-term and due to the increased risk of surgical injuries (low level of evidence). Adhesions and infertility There is limited data in the literature regarding the potential benefit of performing systematic adhesiolysis when there is an incidental discovery of pelvic adhesions during laparoscopy to prevent infertility. For infertile women, in the event of fortuitous discovery of adhesions at laparoscopy, it is probably better not to perform complex adhesiolysis. Only adhesiolysis of tubo-ovarian adhesions that are minimal or slight in terms of their extension and/or their nature may be useful to improve the chances of spontaneous pregnancy. However, it remains to be decided on a case-by-case basis depending on other potential causes of infertility (low level of evidence). For women without known infertility issues, it is probably better not to perform systematic adhesiolysis in order to improve their pregnancy chances, considering the balance between the unknown benefit and the risks of complications inherent to surgery (low level of evidence). CONCLUSION Further investigations are needed in order to increase the quality of management regarding associated interventions such as the treatment of superficial endometriosis or adhesions performed during a gynecologic surgical procedure and, thereby, bolster these recommendations.
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Affiliation(s)
- Marion Ouazana
- Université de Paris, Faculté de Santé, Faculté de Médecine Paris Centre, Paris, France; Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, AP-HP, Centre Hospitalier Universitaire (CHU) Cochin, 75014, Paris, France
| | - Yohan Kerbage
- CHU Lille, Service de chirurgie gynécologique F-59000 Lille, France; University Lille, CHU Lille, F-59000 Lille, France
| | - Pauline Chauvet
- Department of Gynecological Surgery, Clermont-Ferrand University Hospital Estaing, Clermont-Ferrand, France; EnCoV, IP, UMR 6602 CNRS, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Pierre Collinet
- CHU Lille, Service de chirurgie gynécologique F-59000 Lille, France; University Lille, CHU Lille, F-59000 Lille, France
| | - Pierre Emmanuel Bouet
- Department of Reproductive Medicine, Angers University Hospital, Angers 49000, France
| | - Cyril Touboul
- APHP, GHU East, Tenon Hospital, Department of Obstetrics and Gynaecology, 4 rue de la Chine, F-75020, Paris, France
| | - Guillaume Legendre
- CHU Angers, Department of Obstetrics and Gynaecology, F-49000, Angers, France
| | - Francois Golfier
- CHU Lyon, Department of Obstetrics and Gynaecology, F-69000, Lyon, France
| | - Stéphane Ploteau
- Department of Gynecology and Obstetrics, Nantes University Hospital, Nantes, France
| | - Pietro Santulli
- Université de Paris, Faculté de Santé, Faculté de Médecine Paris Centre, Paris, France; Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, AP-HP, Centre Hospitalier Universitaire (CHU) Cochin, 75014, Paris, France; Université de Paris, Department "Infection, Immunity, Inflammation", INSERM U1016, Institut Cochin, Paris, France.
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22
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Castro J, Maddern J, Grundy L, Manavis J, Harrington AM, Schober G, Brierley SM. A mouse model of endometriosis that displays vaginal, colon, cutaneous, and bladder sensory comorbidities. FASEB J 2021; 35:e21430. [PMID: 33749885 DOI: 10.1096/fj.202002441r] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/19/2021] [Accepted: 01/25/2021] [Indexed: 01/15/2023]
Abstract
Endometriosis is a painful inflammatory disorder affecting ~10% of women of reproductive age. Although chronic pelvic pain (CPP) remains the main symptom of endometriosis patients, adequate treatments for CPP are lacking. Animal models that recapitulate the features and symptoms experienced by women with endometriosis are essential for investigating the etiology of endometriosis, as well as developing new treatments. In this study, we used an autologous mouse model of endometriosis to examine a combination of disease features and symptoms including: a 10 week time course of endometriotic lesion development; the chronic inflammatory environment and development of neuroangiogenesis within lesions; sensory hypersensitivity and altered pain responses to vaginal, colon, bladder, and skin stimulation in conscious animals; and spontaneous animal behavior. We found significant increases in lesion size from week 6 posttransplant. Lesions displayed endometrial glands, stroma, and underwent neuroangiogenesis. Additionally, peritoneal fluid of mice with endometriosis contained known inflammatory mediators and angiogenic factors. Compared to Sham, mice with endometriosis displayed: enhanced sensitivity to pain evoked by (i) vaginal and (ii) colorectal distension, (iii) altered bladder function and increased sensitivity to cutaneous (iv) thermal and (v) mechanical stimuli. The development of endometriosis had no effect on spontaneous behavior. This study describes a comprehensive characterization of a mouse model of endometriosis, recapitulating the clinical features and symptoms experienced by women with endometriosis. Moreover, it delivers the groundwork to investigate the etiology of endometriosis and provides a platform for the development of therapeutical interventions to manage endometriosis-associated CPP.
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Affiliation(s)
- Joel Castro
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, SA, Australia.,Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Jessica Maddern
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, SA, Australia.,Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Luke Grundy
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, SA, Australia.,Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Jim Manavis
- School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Andrea M Harrington
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, SA, Australia.,Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Gudrun Schober
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, SA, Australia.,Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Stuart M Brierley
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, SA, Australia.,Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
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23
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Abstract
Assuming we know the perfect management for endometriosis or pelvic pain is folly, but we should be celebrating our successes, not abandoning everything that we currently know.
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Affiliation(s)
- Jason A Abbott
- School of Women's and Children's Health, UNSW Sydney, Sydney, New South Wales, Australia
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24
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Koninckx PR, Ussia A, Porpora MG, Malzoni M, Adamyan L, Wattiez A. Surgical management of endometriosis-associated pain. Minerva Obstet Gynecol 2021; 73:588-605. [PMID: 33978353 DOI: 10.23736/s2724-606x.21.04864-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endometriosis and pelvic pain are associated. However, only half of the subtle and typical, and not all cystic and deep lesions are painful. The mechanism of the pain is explained by cyclical trauma and repair, an inflammatory reaction, activation of nociceptors up to 2.7 cm distance, painful adhesions and neural infiltration. The relationship between the severity of lesions and pain is variable. Diagnosis of the many causes requires laparoscopy and expertise. Imaging cannot exclude endometriosis. Surgical removal is the treatment of choice. Medical therapy without a diagnosis risks missing pathology and chronification of pain if not 100% effective. Indications and techniques of surgery are described as expert opinion since randomised controlled trials were not performed for ethical reasons, since not suited for multimorbidity while a control group is poorly accepted. Subtle endometriosis needs destruction since some cause pain or progress to more severe disease. Typical lesions need excision or vaporisation since depth can be misjudged by inspection. Painful cystic ovarian endometriosis needs adhesiolysis and either destruction of the lining or excision of the cyst wall, taking care to avoid ovarian damage. Cysts larger than 6cm need a 2 step technique or an ovariectomy. Excision of deep endometriosis is difficult and complication prone surgery involving bladder, ureter, and bowel surgery varying from excision and suturing, disc excision with a circular stapler and resection anastomosis. Completeness of excision, prevention of postoperative adhesions and recurrences of endometriosis, and the indication to explore large somatic nerves will be discussed.
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Affiliation(s)
- Philippe R Koninckx
- Latifa Hospital, Dubai, Unated Arab Emirates - .,Obstetrics and Gynecology, KULeuven, Leuven, Belgium -
| | - Anastasia Ussia
- Università Cattolica del Sacro Cuore, Rome, Italy.,Gruppo Italo Belga, Villa Del Rosario, Rome, Italy
| | - Maria G Porpora
- Department of Maternal and Child Health and Urology, Sapienza University of Rome, Rome, Italy
| | - Mario Malzoni
- Endoscopica Malzoni, Center for Advanced Pelvic Surgery, Avellino, Italy
| | - Leila Adamyan
- Department of Operative Gynecology, FSBI National Medical Research Center For Obstetrics, Gynecology And Perinatology Named After Academician V.I.Kulakov, Ministry of Healthcare of The Russian Federation, Moscow, Russia.,Department of Reproductive Medicine and Surgery, Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Arnaud Wattiez
- Latifa Hospital, Dubai, Unated Arab Emirates.,Department of Obstetrics and Gynaecology, University of Strasbourg, Strasbourg, France
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25
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Koninckx PR, Ussia A, Keckstein J, Adamyan L, Wattiez A, Martin DC. Prevalence of Endometriosis and Peritoneal Pockets in Women with Infertility and/or Pelvic Pain. J Obstet Gynaecol Can 2021; 43:935-942. [PMID: 33984522 DOI: 10.1016/j.jogc.2021.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the prevalence of endometriosis and peritoneal pockets and to analyze whether these pockets are associated with pain. METHODS Analysis of prospectively registered data of all women undergoing laparoscopy for infertility or pelvic pain between 1988 and 2011 at KU Leuven University Hospital. RESULTS Of 4497 women, 191 had 238 pockets, with a prevalence of 4.7% in women with infertility only, 4.9% in women with infertility and pelvic pain, and 3.5% in women with pelvic pain only (P = 0.045 for all infertility vs. pelvic pain only). Prevalence did not vary by age. Pockets were associated with endometriosis (P < 0.0001), which was found in 77% of women with pockets. Among women with infertility only, the prevalence of endometriosis was higher in women with pockets (P = 0.0001) than in women without. The prevalence of endometriosis was similar in women with infertility and pelvic pain or pelvic pain only. Pelvic pain as an indication for surgery was associated simultaneously (through logistic regression) with endometriosis (P < 0.0001) and pockets (P = 0.040). Pelvic pain severity was associated simultaneously with pockets (P = 0.0026) and the severity of subtle (P = 0.001), typical (P = 0.030), cystic ovarian (P = 0.051), and deep endometriosis (P < 0.0001). Pelvic pain severity was not associated with endometriosis in the pockets or the diameter or location of pockets. CONCLUSIONS The prevalence of pockets was low, at between 3.5% and 5%. Women with infertility only and pockets had more endometriosis than women without. Severe pelvic pain and pelvic pain as an indication for surgery were associated with the presence of pockets as well as the presence and severity of endometriosis.
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Affiliation(s)
- Philippe R Koninckx
- Latifa Hospital, Dubai, United Arab Emirates; Obstetrics and Gynecology KU Leuven, Bierbeek, Belgium; University of Oxford, United Kingdom; Universita Cattolica, Rome, Italy; Moscow State University, Russia; Gruppo Italo Belga, Rome, Italy.
| | - Anastasia Ussia
- Universita Cattolica, Rome, Italy; Gruppo Italo Belga, Rome, Italy
| | - Jörg Keckstein
- Endometriosis Centre, County Hospital Villach, Austria; University Ulm, Ulm, Germany
| | - Leila Adamyan
- Department of Operative Gynecology, Federal State Budget Institution V. I. Kulakov Research Centre for Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia; Department of Reproductive Medicine and Surgery, Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Arnaud Wattiez
- Latifa Hospital, Dubai, United Arab Emirates; Department of Obstetrics and Gynaecology, University of Strasbourg, France
| | - Dan C Martin
- University of Tennessee Health Science Centre, Memphis, TN; Institutional Review Board, Virginia Commonwealth University, Richmond, VA
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26
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Marlin N, Rivas C, Allotey J, Dodds J, Horne A, Ball E. Development and Validation of Clinical Prediction Models for Surgical Success in Patients With Endometriosis: Protocol for a Mixed Methods Study. JMIR Res Protoc 2021; 10:e20986. [PMID: 33818394 PMCID: PMC8056291 DOI: 10.2196/20986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/18/2020] [Accepted: 11/24/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Endometriosis is a chronic inflammatory condition affecting 6%-10% of women of reproductive age and is defined by the presence of endometrial-like tissue outside the uterus (lesions), commonly affecting the pelvis and ovaries. It is associated with debilitating pelvic pain, infertility, and fatigue and often has devastating effects on the quality of life (QoL). Although it is as common as back pain, it is poorly understood, and treatment and diagnosis are often delayed, leading to unnecessary suffering. Endometriosis has no cure. Surgery is one of several management options. Quantifying the probability of successful surgery is important for guiding clinical decisions and treatment strategies. Factors predicting success through pain reduction after endometriosis surgery have not yet been adequately identified. OBJECTIVE This study aims to determine which women with confirmed endometriosis benefit from surgical improvement in pain and QoL and whether these women could be identified from clinical symptoms measured before laparoscopy. METHODS First, we will carry out a systematic search and review and, if appropriate, meta-analysis of observational cohort and case-control studies reporting one or more risk factors for endometriosis and postsurgical treatment success. We will search PubMed, Embase, and Cochrane databases from inception without language restrictions and supplement the reference lists by manual searches. Second, we will develop separate clinical prediction models for women with confirmed and suspected diagnoses of endometriosis. A total of three suitable databases have been identified for development and external validation (the MEDAL [ISRCTN13028601] and LUNA [ISRCTN41196151] studies, and the BSGE database), and access has been guaranteed. The models will be developed using a linear regression approach that links candidate factors to outcomes. Third, we will hold 2 stakeholder co-design workshops involving eight clinicians and eight women with endometriosis separately and then bring all 16 participants together. Participants will discuss the implementation, delivery, usefulness, and sustainability of the prediction models. Clinicians will also focus on the ease of use and access to clinical prediction tools. RESULTS This project was funded in March 2018 and approved by the Institutional Research Ethics Board in December 2019. At the time of writing, this study was in the data analysis phase, and the results are expected to be available in April 2021. CONCLUSIONS This study is the first to aim to predict who will benefit most from laparoscopic surgery through the reduction of pain or increased QoL. The models will provide clinicians with robustly developed and externally validated support tools, improving decision making in the diagnosis and treatment of women. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/20986.
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Affiliation(s)
- Nadine Marlin
- Pragmatic Clinical Trials Unit, Centre for Primary Care and Public Health, Queen Mary University of London, London, United Kingdom
| | - Carol Rivas
- UCL Social Research Institute, University College London, London, United Kingdom
| | - John Allotey
- Women's Health Research Unit, Centre for Primary Care and Public Health, Queen Mary University of London, London, United Kingdom
| | - Julie Dodds
- Women's Health Research Unit, Centre for Primary Care and Public Health, Queen Mary University of London, London, United Kingdom
| | - Andrew Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Elizabeth Ball
- Women's Health Research Unit, Centre for Primary Care and Public Health, Queen Mary University of London, London, United Kingdom
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Dückelmann AM, Taube E, Abesadze E, Chiantera V, Sehouli J, Mechsner S. When and how should peritoneal endometriosis be operated on in order to improve fertility rates and symptoms? The experience and outcomes of nearly 100 cases. Arch Gynecol Obstet 2021; 304:143-155. [PMID: 33537880 PMCID: PMC8164581 DOI: 10.1007/s00404-021-05971-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/12/2021] [Indexed: 12/18/2022]
Abstract
Purpose To analyze the follow-up results of patients suffering from symptomatic early-stage endometriosis after a consistent laparoscopic peritoneal stripping of the altered peritoneum (peritoneal endometriosis and surrounding inflamed tissue) was performed. This type of endometriosis is resistant to medical therapy and/or impairs fertility. Methods Using our prospectively maintained database, we were able to identify all symptomatic women with the suspicion of only peritoneal endometriosis who underwent laparoscopy at our endometriosis center over a period of 5 years. All procedures were carried out in a standardized fashion by one single surgeon, who is highly experienced in minimal invasive surgery, and included a suspended hormonal pretreatment for 2 months. Postoperative outcomes including complications, fertility and recurrence rates were analysed. Results Laparoscopic peritonectomy was performed on 94 women. Follow-up data were available in 87% of these cases. At the time of surgery, almost all patients tested showed signs of stage I or II endometriosis (44.7 and 48.9%, respectively). More than three-quarters of the women reported pain relief, inter alia, due to the post-surgical hormonal therapy. About one-third of the patients wanted to have children after the procedure. 62% of them became pregnant and the majority did so without the need for assisted reproductive therapy. In seven women a re-operation was performed. Conclusion According to our data, a consistent excision of altered peritoneum followed by adjuvant hormonal therapy and multimodal concepts results in better outcomes for the patient, particularly in regards to pregnancy and recurrence rates.
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Affiliation(s)
- A M Dückelmann
- Department of Gynecology, Charité-Universitätsmedizin BerlinVirchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - E Taube
- Department of Pathology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - E Abesadze
- Department of Gynecology, Vivantes Clinic Berlin Hellersdorf, Myslowitzerstr. 45, 12621, Berlin, Germany
| | - V Chiantera
- Department of Gynecologic Oncology, University of Palermo, Piazza Marina, 61, 90133, Palermo, Italy
| | - J Sehouli
- Department of Gynecology, Charité-Universitätsmedizin BerlinVirchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - S Mechsner
- Department of Gynecology, Charité-Universitätsmedizin BerlinVirchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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Mooney SS, Grover SR. The persistent pelvic pain study: Factors that influence outcomes in women referred to a public hospital with chronic pelvic pain - A study protocol. Aust N Z J Obstet Gynaecol 2021; 61:E6-E11. [PMID: 33386748 DOI: 10.1111/ajo.13289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 11/24/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Persistent pelvic pain affects between 10-20% of women with a significant impact on their physical and mental health, sexual relationships, families and society. Estimates of the cost to women and the community is over $9 billion/annum. Although endometriosis is considered a leading cause of pelvic pain, no symptoms reliably allow the identification of those with and without endometriosis. Furthermore, the significance of mild endometriosis is now debated. The optimal clinical approach for pelvic pain and endometriosis remains unclear, with increasing evidence of other contributing factors such as central sensitisation. Studies to date have significant limitations due to their sample size, relatively short follow-up, and inclusion of only women with laparoscopically identified endometriosis. AIMS To undertake a real-world study of women referred with pain to gynaecology outpatients of a women's hospital and explore factors influencing three-year outcomes. MATERIALS AND METHODS Five hundred women will be randomised to one of two gynaecology units. The units will provide routine clinical care but their approaches to management of women with pelvic pain and endometriosis differ: one with skilled endoscopic gynaecologists has greater emphasis on surgery, the other, gynaecologists have more medical expertise in managing pain and menstrual problems. Participants will complete six-monthly questionnaires regarding pain and quality of life for three years. This information will not be available to clinicians. Their medical care will be followed from their medical records. The cost of outpatient care and admissions will be calculated. Data will be analysed using STATA software with appropriate post hoc tests. Australian and New Zealand Clinical Trials Registry (ANZCTR:ACTRN12616000150448).
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Affiliation(s)
- Samantha S Mooney
- Endosurgery Department, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Sonia R Grover
- Plenty Gynaecology Unit, Mercy Hospital for Women, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
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Abdul Karim AK, Abd Aziz NH, Md Zin RR, Mohd Mokhtar N, Shafiee MN. The Effect of Surgical Intervention of Endometriosis to CA-125 and Pain. Malays J Med Sci 2020; 27:7-14. [PMID: 33447130 PMCID: PMC7785265 DOI: 10.21315/mjms2020.27.6.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/21/2020] [Indexed: 11/22/2022] Open
Abstract
Endometriosis is an inflammatory condition characterised by the presence of endometrial growth beyond the uterine cavity. It is a debilitating disease requiring multiple modalities of treatment. In considering surgery as the option of treatment, the benefits should outweigh the risk. Besides direct surgical risk, intervention may lead to a reduction of ovarian reserve, in addition to premature menopause and low fecundity. To date, there is an inconclusive evidence to support any specific parameters in monitoring disease progression following surgical intervention. Serum cancer antigen (CA)-125 is expressed by coelomic epithelium and has been extensively studied as a biomarker for endometriosis. Elevated expression of CA-125 has been shown in endometrial tissues and the marker increased indirectly from peritoneal irritation that accompanies an extensive form of endometriosis. Additionally, the visual analogue scale (VAS) scores have been used as an objective measurement for measuring pain, especially in a complex disease such as endometriosis. This review aims to consolidate a series of clinical trials that utilised CA-125 level and VAS score as tools for monitoring patients undergoing surgery for endometriosis.
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Affiliation(s)
- Abdul Kadir Abdul Karim
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia.,Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Nor Haslinda Abd Aziz
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Reena Rahayu Md Zin
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Norfilza Mohd Mokhtar
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Mohamad Nasir Shafiee
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
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Burks C, Lee M, DeSarno M, Findley J, Flyckt R. Excision versus Ablation for Management of Minimal to Mild Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2020; 28:587-597. [PMID: 33310168 DOI: 10.1016/j.jmig.2020.11.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/12/2020] [Accepted: 11/14/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis was to perform an updated analysis of the literature in regard to the surgical management of minimal to mild endometriosis. This study evaluated women of reproductive age with superficial endometriosis to determine if the results of surgical excision compared with those of ablation in improved pain scores postoperatively. DATA SOURCES The following databases were searched from inception to May 2020 for relevant studies: Cochrane Central Register of Controlled Trials, PubMed (MEDLINE), Ovid (MEDLINE), Scopus, and Web of Science. METHODS OF STUDY SELECTION From our literature search, a total of 2633 articles were identified and screened. Ultimately, 4 randomized controlled trials were selected and included in our systematic review. The combined total number of subjects was 346 from these 4 studies, with sample sizes ranging from 24 to 170 participants. Data from 3 of the included studies were able to be compared and analyzed for a meta-analysis. The primary outcome was reduction in the visual analog scale (VAS) score for endometriosis-associated pain (dysmenorrhea, dyschezia, and dyspareunia), with follow-up time ranging from 6 to 60 months postoperatively. TABULATION, INTEGRATION, AND RESULTS Data extracted from each study included the mean reduction in the VAS score from baseline. A random-effects model was used owing to significant heterogeneity across the studies. Statistical analyses were performed using Review Manager 5.3 software (Cochrane Collaboration, London, United Kingdom). The meta-analyses showed no significant differences between the excision and ablation groups in the mean reduction in VAS scores from baseline to 12 months postoperatively for dysmenorrhea (mean difference [MD] -0.03; 95% confidence interval [CI], -1.27 to 1.22; p = .97), dyschezia (MD 0.46; 95% CI, -1.09 to 2.02; p = .56), and dyspareunia (MD 0.10; 95% CI, -2.36 to 2.56; p = .94). In addition, there were no significant differences between the excision and ablation groups in mean VAS scores at the 12-month follow-up and beyond for dysmenorrhea (MD -0.11; 95% CI, -2.14 to 1.93; p = .92), dyschezia (MD 0.01; 95% CI, -0.70 to 0.72; p = .99), and dyspareunia (MD 0.34; 95% CI, -1.61 to 2.30; p = .73). CONCLUSION On the basis of the data from our systematic review and pooled meta-analysis, no significant difference between laparoscopic excision and ablation was noted in regard to improving pain from minimal to mild endometriosis. However, to make definitive conclusions on this topic, larger randomized controlled trials are needed with longer follow-up.
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Affiliation(s)
- Channing Burks
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Drs. Burks, Lee, and Flyckt).
| | - Mabel Lee
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Drs. Burks, Lee, and Flyckt)
| | - Michael DeSarno
- Department of Obstetrics and Gynecology, University of Vermont Medical Center, Burlington, Vermont (Mr. DeSarno and Dr. Findley)
| | - Joseph Findley
- Department of Obstetrics and Gynecology, University of Vermont Medical Center, Burlington, Vermont (Mr. DeSarno and Dr. Findley)
| | - Rebecca Flyckt
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Drs. Burks, Lee, and Flyckt)
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Abstract
BACKGROUND Endometriosis is associated with pain and infertility. Surgical interventions aim to remove visible areas of endometriosis and restore the anatomy. OBJECTIVES To assess the effectiveness and safety of laparoscopic surgery in the treatment of pain and infertility associated with endometriosis. SEARCH METHODS This review has drawn on the search strategy developed by the Cochrane Gynaecology and Fertility Group including searching the Cochrane Gynaecology and Fertility Group's specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, reference lists for relevant trials, and trial registries from inception to April 2020. SELECTION CRITERIA We selected randomised controlled trials (RCTs) that compared the effectiveness and safety of laparoscopic surgery with any other laparoscopic or robotic intervention, holistic or medical treatment, or diagnostic laparoscopy only. DATA COLLECTION AND ANALYSIS Two review authors independently performed selection of studies, assessment of trial quality and extraction of relevant data with disagreements resolved by a third review author. We collected data for the core outcome set for endometriosis. Primary outcomes included overall pain and live birth. We evaluated the quality of evidence using GRADE methods. MAIN RESULTS We included 14 RCTs. The studies randomised 1563 women with endometriosis. Four RCTs compared laparoscopic ablation or excision with diagnostic laparoscopy only. Two RCTs compared laparoscopic excision with diagnostic laparoscopy only. One RCT compared laparoscopic ablation or excision with laparoscopic ablation or excision and uterine suspension. Two RCTs compared laparoscopic ablation and uterine nerve transection with diagnostic laparoscopy only. One RCT compared laparoscopic ablation with diagnostic laparoscopy and gonadotropin-releasing hormone (GnRH) analogues. Two RCTs compared laparoscopic ablation with laparoscopic excision. One RCT compared laparoscopic ablation or excision with helium thermal coagulator with laparoscopic ablation or excision with electrodiathermy. One RCT compared conservative laparoscopic surgery with laparoscopic colorectal resection of deep endometriosis infiltrating the rectum. Common limitations in the primary studies included lack of clearly described blinding, failure to fully describe methods of randomisation and allocation concealment, and poor reporting of outcome data. Laparoscopic treatment versus diagnostic laparoscopy We are uncertain of the effect of laparoscopic treatment on overall pain scores compared to diagnostic laparoscopy only at six months (mean difference (MD) 0.90, 95% confidence interval (CI) 0.31 to 1.49; 1 RCT, 16 participants; very low quality evidence) and at 12 months (MD 1.65, 95% CI 1.11 to 2.19; 1 RCT, 16 participants; very low quality evidence), where a positive value means pain relief (the higher the score, the more pain relief) and a negative value reflects pain increase (the lower the score, the worse the increase in pain). No studies looked at live birth. We are uncertain of the effect of laparoscopic treatment on quality of life compared to diagnostic laparoscopy only: EuroQol-5D index summary at six months (MD 0.03, 95% CI -0.12 to 0.18; 1 RCT, 39 participants; low quality evidence), 12-item Short Form (SF-12) mental health component (MD 2.30, 95% CI -4.50 to 9.10; 1 RCT, 39 participants; low quality evidence) and SF-12 physical health component (MD 2.70, 95% CI -2.90 to 8.30; 1 RCT, 39 participants; low quality evidence). Laparoscopic treatment probably improves viable intrauterine pregnancy rate compared to diagnostic laparoscopy only (odds ratio (OR) 1.89, 95% CI 1.25 to 2.86; 3 RCTs, 528 participants; I2 = 0%; moderate quality evidence). We are uncertain of the effect of laparoscopic treatment compared to diagnostic laparoscopy only on ectopic pregnancy (MD 1.18, 95% CI 0.10 to 13.48; 1 RCT, 100 participants; low quality evidence) and miscarriage (MD 0.94, 95% CI 0.35 to 2.54; 2 RCTs, 112 participants; low quality evidence). There was limited reporting of adverse events. No conversions to laparotomy were reported in both groups (1 RCT, 341 participants). Laparoscopic ablation and uterine nerve transection versus diagnostic laparoscopy We are uncertain of the effect of laparoscopic ablation and uterine nerve transection on adverse events (more specifically vascular injury) compared to diagnostic laparoscopy only (OR 0.33, 95% CI 0.01 to 8.32; 1 RCT, 141 participants; low quality evidence). No studies looked at overall pain scores (at six and 12 months), live birth, quality of life, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy and miscarriage. Laparoscopic ablation versus laparoscopic excision There was insufficient evidence to determine whether there was a difference in overall pain, measured at 12 months, for laparoscopic ablation compared with laparoscopic excision (MD 0.00, 95% CI -1.22 to 1.22; 1 RCT, 103 participants; very low quality evidence). No studies looked at overall pain scores at six months, live birth, quality of life, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy, miscarriage and adverse events. Helium thermal coagulator versus electrodiathermy We are uncertain whether helium thermal coagulator compared to electrodiathermy improves quality of life using the 30-item Endometriosis Health Profile (EHP-30) at nine months, when considering the components: pain (MD 6.68, 95% CI -3.07 to 16.43; 1 RCT, 119 participants; very low quality evidence), control and powerlessness (MD 4.79, 95% CI -6.92 to 16.50; 1 RCT, 119 participants; very low quality evidence), emotional well-being (MD 6.17, 95% CI -3.95 to 16.29; 1 RCT, 119 participants; very low quality evidence) and social support (MD 5.62, 95% CI -6.21 to 17.45; 1 RCT, 119 participants; very low quality evidence). Adverse events were not estimable. No studies looked at overall pain scores (at six and 12 months), live birth, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy and miscarriage. AUTHORS' CONCLUSIONS Compared to diagnostic laparoscopy only, it is uncertain whether laparoscopic surgery reduces overall pain associated with minimal to severe endometriosis. No data were reported on live birth. There is moderate quality evidence that laparoscopic surgery increases viable intrauterine pregnancy rates confirmed by ultrasound compared to diagnostic laparoscopy only. No studies were found that looked at live birth for any of the comparisons. Further research is needed considering the management of different subtypes of endometriosis and comparing laparoscopic interventions with lifestyle and medical interventions. There was insufficient evidence on adverse events to allow any conclusions to be drawn regarding safety.
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Affiliation(s)
- Celine Bafort
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Yusuf Beebeejaun
- King's Fertility, King's College Hospital NHS Foundation Trust, London, UK
| | - Carla Tomassetti
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Jan Bosteels
- Academic Centre for General Practice, Cochrane Belgium, Leuven, Belgium
| | - James Mn Duffy
- Institute for Women's Health, University College London, London, UK
- King's Fertility, Fetal Medicine Research Institute, London, UK
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Abstract
Endometriosis is a chronic and debilitating condition affecting ∼10% of women. Endometriosis is characterized by infertility and chronic pelvic pain, yet treatment options remain limited. In many respects this is related to an underlying lack of knowledge of the etiology and mechanisms contributing to endometriosis-induced pain. Whilst many studies focus on retrograde menstruation, and the formation and development of lesions in the pathogenesis of endometriosis, the mechanisms underlying the associated pain remain poorly described. Here we review the recent clinical and experimental evidence of the mechanisms contributing to chronic pain in endometriosis. This includes the roles of inflammation, neurogenic inflammation, neuroangiogenesis, peripheral sensitization and central sensitization. As endometriosis patients are also known to have co-morbidities such as irritable bowel syndrome and overactive bladder syndrome, we highlight how common nerve pathways innervating the colon, bladder and female reproductive tract can contribute to co-morbidity via cross-organ sensitization.
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Affiliation(s)
- Jessica Maddern
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Luke Grundy
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Joel Castro
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Stuart M. Brierley
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Discipline of Medicine, University of Adelaide, North Terrace Campus, Adelaide, SA, Australia
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the up-to-date pain management options and recommendations for the challenging disease, endometriosis. RECENT FINDINGS The mainstays of endometriosis advances of both surgical and medical management continue to evolve. Experimental pharmaceuticals include Gestirone, and aromatase inhibitors have shown promise but are still under scrutiny. Surgical techniques include laparoscopic uterosacral nerve ablation/resection and presacral neurectomy. No studies have directly compared medical versus surgical management, and as such, no one treatment modality can be recommend as superior to the other. Patients may initially be given a medical diagnosis and treated with nonsteroidal anti-inflammatory drugs, neurolepitcs, OCP, GNRH agonists/antagonists, and Danazol. Assessing the success of these regimens has proved difficult. Surgical management relies on various methods including excision/ablation of the lesions, nerve ablation, neurectomy, hysterectomy, and oophorectomy.
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Affiliation(s)
- Daniel Carlyle
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3, P.O. Box 208051, New Haven, CT, 06510, USA.
| | - Tarek Khader
- Department of Obstetrics and Gynecology, Yale University School of Medicine, 333 Cedar Street, TMP 3, P.O. Box 208051, New Haven, CT, 06510, USA
| | - David Lam
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3, P.O. Box 208051, New Haven, CT, 06510, USA
| | - Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3, P.O. Box 208051, New Haven, CT, 06510, USA
| | - Devina Shiwlochan
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3, P.O. Box 208051, New Haven, CT, 06510, USA
| | - Cho Yonghee
- Department of Obstetrics and Gynecology, Yale University School of Medicine, 333 Cedar Street, TMP 3, P.O. Box 208051, New Haven, CT, 06510, USA
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Jonas WB, Crawford C, Colloca L, Kriston L, Linde K, Moseley B, Meissner K. Are Invasive Procedures Effective for Chronic Pain? A Systematic Review. Pain Med 2020; 20:1281-1293. [PMID: 30204920 PMCID: PMC6611529 DOI: 10.1093/pm/pny154] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objective To assess the evidence for the safety and efficacy of invasive procedures for reducing chronic pain and improving function and health-related quality of life compared with sham (placebo) procedures. Design Systematic review with meta-analysis. Methods Studies were identified by searching multiple electronic databases, examining reference lists, and communicating with experts. Randomized controlled trials comparing invasive procedures with identical but otherwise sham procedures for chronic pain conditions were selected. Three authors independently extracted and described study characteristics and assessed Cochrane risk of bias. Two subsets of data on back and knee pain, respectively, were pooled using random-effects meta-analysis. Overall quality of the literature was assessed through Grading of Recommendations, Assessment, Development, and Evaluation. Results Twenty-five trials (2,000 participants) were included in the review assessing the effect of invasive procedures over sham. Conditions included low back (N = 7 trials), arthritis (4), angina (4), abdominal pain (3), endometriosis (3), biliary colic (2), and migraine (2). Thirteen trials (52%) reported an adequate concealment of allocation. Fourteen studies (56%) reported on adverse events. Of these, the risk of any adverse event was significantly higher for invasive procedures (12%) than sham procedures (4%; risk difference = 0.05, 95% confidence interval [CI] = 0.01 to 0.09, P = 0.01, I2 = 65%). In the two meta-analysis subsets, the standardized mean difference for reduction of low back pain in seven studies (N = 445) was 0.18 (95% CI = –0.14 to 0.51, P = 0.26, I2 = 62%), and for knee pain in three studies (N = 496) it was 0.04 (95% CI = –0.11 to 0.19, P = 0.63, I2 = 36%). The relative contribution of within-group improvement in sham treatments accounted for 87% of the effect compared with active treatment across all conditions. Conclusions There is little evidence for the specific efficacy beyond sham for invasive procedures in chronic pain. A moderate amount of evidence does not support the use of invasive procedures as compared with sham procedures for patients with chronic back or knee pain. Given their high cost and safety concerns, more rigorous studies are required before invasive procedures are routinely used for patients with chronic pain.
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Affiliation(s)
- Wayne B Jonas
- Integrative Health Programs, H&S Ventures, Alexandria, Virginia
| | | | - Luana Colloca
- University of Maryland School of Nursing and Medicine, Baltimore, Maryland, USA
| | - Levente Kriston
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klaus Linde
- Institute of General Practice, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Bruce Moseley
- Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Karin Meissner
- Division Health Promotion, University of Applied Sciences Coburg, Coburg, Germany.,Institute of Medical Psychology, LMU Munich, Munich, Germany
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Harris A, McCaughey T, Tsaltas J, Davies-Tuck M, Ratner R, Najjar H, Barel O. Endometriosis-related pelvic pain following laparoscopic surgical treatment. Journal of Endometriosis and Pelvic Pain Disorders 2020. [DOI: 10.1177/2284026520926038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Endometriosis is a common, often-debilitating disease, affecting women of reproductive age. Pain is a common symptom of the disease and is commonly treated by surgery, medical therapy, or a combination of the two. This study aimed to evaluate the rates of ongoing pain post laparoscopic excision and the risk factors for ongoing pain symptoms. Methods: This retrospective cohort study analyzed the medical records of all patients who underwent laparoscopic surgery for endometriosis in a large tertiary healthcare service in Australia between January 2009 and September 2016. Results were analyzed using SPSS statistics version 11. Results: A total of 972 patients met the inclusion criteria; of these, 398 had follow-up at our hospital network and were included in the final analysis. The median age was 34.5 years, 69.6% were of Caucasian ethnicity, and the median body mass index was 25.9; 70.6% of our patients reported decreased pain after surgery. Patients who suffered from chronic pain were twice as likely to experience ongoing pain, while patients with stage 3–4 endometriosis were found to have 65% reduced odds of pain at follow-up (95% confidence interval = 0.22–0.61, p < 0.001). In univariate analysis of non-Caucasian patients, those who had a specialist endometriosis surgeon perform the surgery had significantly higher incidence of symptom improvement (58% reduced odds of recurrent pain and 40% reduced odds, p < 0.05, accordingly). Conclusion: The prevalence and severity of pain associated with endometriosis mandates a thorough understanding of the effectiveness of current management. Our article highlights the utility of laparoscopic surgery in treating endometriosis-associated pain.
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Affiliation(s)
- Amani Harris
- Gynaecological Endoscopy and Endometriosis Surgery Unit, Monash Health and Monash University, Melbourne, VIC, Australia
| | - Tristan McCaughey
- Gynaecological Endoscopy and Endometriosis Surgery Unit, Monash Health and Monash University, Melbourne, VIC, Australia
- The Royal Women’s Hospital, Melbourne, VIC, Australia
| | - Jim Tsaltas
- Gynaecological Endoscopy and Endometriosis Surgery Unit, Monash Health and Monash University, Melbourne, VIC, Australia
- Melbourne IVF, Melbourne, VIC, Australia
| | - Miranda Davies-Tuck
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Roni Ratner
- Gynaecological Endoscopy and Endometriosis Surgery Unit, Monash Health and Monash University, Melbourne, VIC, Australia
| | - Haider Najjar
- Gynaecological Endoscopy and Endometriosis Surgery Unit, Monash Health and Monash University, Melbourne, VIC, Australia
- Melbourne IVF, Melbourne, VIC, Australia
| | - Oshri Barel
- Obstetrics and Gynecology, Assuta Medical Center, Ben-Gurion University of the Negev, Ashdod, Israel
- Assuta Ashdod University Hospital, Ashdod, Israel
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36
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Abstract
Endometriosis is the leading pathologic cause of dysmenorrhea and chronic pelvic pain among adolescents. The appearance of endometriosis in adolescents may be different from that in female adults, resulting in delayed recognition and intervention. This article addresses the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of endometriosis in the adolescent.
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Affiliation(s)
- Jessica Y Shim
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Marc R Laufer
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts; Center for Infertility and Reproductive Surgery, Brigham & Women's Hospital, Boston, Massachusetts; Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts; Boston Center for Endometriosis, Boston, Massachusetts.
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Cousins S, Blencowe NS, Tsang C, Lorenc A, Chalmers K, Carr AJ, Campbell MK, Cook JA, Beard DJ, Blazeby JM. Reporting of key methodological issues in placebo-controlled trials of surgery needs improvement: a systematic review. J Clin Epidemiol 2020; 119:109-116. [PMID: 31786153 PMCID: PMC7066579 DOI: 10.1016/j.jclinepi.2019.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/12/2019] [Accepted: 11/24/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To examine key methodological considerations for using a placebo intervention in randomized controlled trials (RCTs) evaluating invasive procedures, including surgery. STUDY DESIGN AND SETTING RCTs comparing an invasive procedure with a placebo were included in this systematic review. Articles published from database inception to December 31, 2017, were retrieved from Ovid MEDLINE, Ovid EMBASE and CENTRAL electronic databases, by handsearching references and expert knowledge. Data on trial characteristics (clinical area, nature of invasive procedure, number of patients and centers) and key methodological (rationale for using placebos, minimization of risk, information provision, offering the treatment intervention to patients randomized to placebo, delivery of cointerventions, and intervention standardization and fidelity) were extracted and summarized descriptively. RESULTS One hundred thirteen articles reporting 96 RCTs were identified. Most were conducted in gastrointestinal surgery (n = 40, 42%) and evaluated minimally invasive procedures (n = 44, 46%). Over two-thirds randomized fewer than 100 patients (n = 65, 68%) and a third were single center (n = 31, 32%). A third (n = 33, 34%) did not report a rationale for using a placebo. Most common strategies to minimize patient risk were operator skill (n = 22, 23%) and independent data monitoring (n = 28, 29%). Provision of patient information regarding placebo use was infrequently reported (n = 11, 11%). Treatment interventions were offered to patients randomized to placebo in 43 trials (45%). Cointerventions were inconsistently reported, but 64 trials (67%) stated that anesthesia was matched between groups. Attempts to standardize interventions and monitor their delivery were reported in n = 7, (7%) and n = 4, (4%) trials, respectively. CONCLUSION Most placebo-controlled trials in surgery evaluate minor surgical procedures and currently there is inconsistent reporting of key trial methods. There is a need for guidance to optimize the transparency of trial reporting in this area.
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Affiliation(s)
- Sian Cousins
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK.
| | - Natalie S Blencowe
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK; Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Carmen Tsang
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Ava Lorenc
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Katy Chalmers
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Headington, Oxford, UK; National Institute of Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | | | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Headington, Oxford, UK; National Institute of Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Headington, Oxford, UK; National Institute of Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - Jane M Blazeby
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK; Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Budden A, Ravendran K, Abbott JA. Identifying the Problems of Randomized Controlled Trials for the Surgical Management of Endometriosis-associated Pelvic Pain. J Minim Invasive Gynecol 2020; 27:419-432. [DOI: 10.1016/j.jmig.2019.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/24/2019] [Accepted: 11/01/2019] [Indexed: 12/20/2022]
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Leonardi M, Gibbons T, Armour M, Wang R, Glanville E, Hodgson R, Cave AE, Ong J, Tong YYF, Jacobson TZ, Mol BW, Johnson NP, Condous G. When to Do Surgery and When Not to Do Surgery for Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2020; 27:390-407.e3. [DOI: 10.1016/j.jmig.2019.10.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 12/24/2022]
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Rezai S, Giovane RA, Mann T, Patil NM, Bardawil E, Henderson CE, Guan X. Laparoscopic Vessel Endometriosis Resection Surgery: A Case Report and Review of Literature. Case Rep Obstet Gynecol 2019; 2019:1375208. [PMID: 31915556 DOI: 10.1155/2019/1375208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/13/2019] [Accepted: 08/27/2019] [Indexed: 11/17/2022] Open
Abstract
Background Endometriosis usually occurs in the pelvis and often involves the ovaries, the uterosacral and broad ligaments, and the pelvic peritoneum. In rare instances, it can occur in the vasculature of the pelvis. Patients with endometriosis present with abnormal pain, menstrual cycle disruption and infertility. Management of endometriosis is usually surgical with excision of the tissue via laparoscopic means. Case A 42-year-old Gravida 5, Para 2-0-3-2 patient with a 22 year history of endometriosis, who had had multiple laparoscopic endometriosis resections, total abdominal hysterectomy, and an exploratory laparotomy with bilateral salpingo-oophorectomy, presented with left pelvic pain when standing, dyspareunia, and a 3.7 cm cyst on ultrasound. The patient underwent laparoscopic vessel endometriosis resection and excision of endometriotic nodules from external iliac vessels. Final pathology report showed evidence of old endometriosis in all locations. On interval follow-up, the patient reported sustained relief from pain. Conclusion Complete resection of endometriosis from large vessels can be successfully achieved laparoscopically by a well-experienced surgeon with delicate, proper techniques.
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Singh SS, Gude K, Perdeaux E, Gattrell WT, Becker CM. Surgical Outcomes in Patients With Endometriosis: A Systematic Review. J Obstet Gynaecol Can 2019; 42:881-888.e11. [PMID: 31718952 DOI: 10.1016/j.jogc.2019.08.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Among women treated surgically for endometriosis-associated pain, comprehensive data are lacking on the proportions of patients who experience little or no symptom relief, develop recurrent symptoms, or require further surgical treatment for endometriosis. The aim of this study was to assess the efficacy of surgical procedures used to treat endometriosis-associated pain. METHODS Medline and Embase were searched on October 13, 2016. Articles referring to women undergoing surgery for the treatment of endometriosis-associated pain were screened by two independent investigators. For each included treatment arm, data were extracted for the proportion of patients reporting partial or no improvement after surgery for endometriosis-associated pain, pain recurrence, or requirement for further surgery. RESULTS A total of 38 studies were included. Most studies did not report relevant outcomes to evaluate pain (71.1%) and recurrent surgery (68.4%). Of the women who underwent lesion excision, 11.8% reported no improvement in pain, and 22.6% underwent further surgery. Postoperative pain, recurrent pain, and adverse events were reported by 34.3%, 28.7%, and 14.8%, respectively, of patients who underwent excision or ablation of endometriosis combined with pelvic denervation and in 25.0%, 15.8%, and 8.1% of women who underwent lesion excision alone. Of the patients who were treated surgically for deep endometriosis affecting the bowel and/or bladder, 7.0% experienced recurrent symptoms, and 4.1% underwent further surgery. CONCLUSION This review supports the findings of previous studies and highlights the need for standardized reporting and more detailed follow-up after surgery for endometriosis-associated pain.
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Affiliation(s)
- Sukhbir S Singh
- Department of Obstetrics and Gynecology, The Ottawa Hospital & University of Ottawa, Ottawa, ON.
| | - Kerstin Gude
- Global Pharmacovigilance, Bayer AG, Berlin, Germany
| | | | - William T Gattrell
- Research Evaluation Unit, Oxford PharmaGenesis, Oxford, United Kingdom; Department of Mechanical Engineering and Mathematical Sciences, Oxford Brookes University, Oxford, United Kingdom
| | - Christian M Becker
- Endometriosis Care and Research (CaRe) Centre, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
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Jarrell JF, Vilos GA, Allaire C, Burgess S, Fortin C, Gerwin R, Lapensee L, Lea RH, Leyland NA, Martyn P, Shenassa H, Taenzer P. No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain. J Obstet Gynaecol Can 2019; 40:e747-e787. [PMID: 30473127 DOI: 10.1016/j.jogc.2018.08.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; G) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.
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No Author. Chapitre 4 : Prise en charge chirurgicale de l'endométriose. Journal of Obstetrics and Gynaecology Canada 2019; 41 Suppl 1:S140-S145. [DOI: 10.1016/j.jogc.2019.02.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Maharajaa SPK, Asally R, Markham R, Manconi F. Endometriotic lesions. Journal of Endometriosis and Pelvic Pain Disorders 2019. [DOI: 10.1177/2284026519838748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Endometriosis is a complex gynaecological condition affecting women of reproductive age. It is characterised by the presence of lesions containing endometrial glands and stroma outside the uterus. The disease is typically associated with pelvic pain (including dysmenorrhoea and dyspareunia), infertility and bowel-related symptoms. Endometriotic lesions have a highly variable presentation and most commonly occur in the abdominal cavity. These lesions are broadly classified into peritoneal, ovarian and deep infiltrating endometriosis. There have been observations of increased density of nerve fibres and neurological molecules in the endometriotic lesions compared to the uninvolved peritoneum of women without endometriosis and the presence of unmyelinated nerve fibres were higher near the glands. The lesion sites are characterised by a range of immunological alterations, and specific immune cell populations have also been known to synthesise and secrete neurogenic factors. Endometriotic lesions are capable of producing prostaglandins which are direct generators of pain and are capable of inducing inflammation. Diagnosing the disease involves direct visualisation of the lesions through a laparoscopic or laparotomy, which is followed by histopathological examination of biopsied or excised lesions. The staging of endometriosis due to its complexity is highly variable as presentation and gaps in knowledge pose a great challenge in the classification of the disease. The medical management of endometriosis aims at providing adequate analgesia and suppression of the activity of the lesion. A better understanding of endometriotic lesion relationships between innervations and specific clinical characteristics may elucidate aspects of pain mechanisms and infertility in endometriosis and facilitate the development of novel therapeutic approaches.
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Affiliation(s)
- Sri PK Maharajaa
- Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Camperdown, NSW, Australia
| | - Razan Asally
- Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Camperdown, NSW, Australia
| | - Robert Markham
- Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Camperdown, NSW, Australia
| | - Frank Manconi
- Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Camperdown, NSW, Australia
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45
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No Author. Chapitre 3 : Prise en charge médicale de la douleur associée à l'endométriose. Journal of Obstetrics and Gynaecology Canada 2019; 41:S133-S139. [DOI: 10.1016/j.jogc.2019.02.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Park KS. The Efficacy and Safety of Korean Herbal Medicine in a Patient with Endometrioma of The Ovary: A Case Report. Explore (NY) 2019; 15:142-7. [DOI: 10.1016/j.explore.2018.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 06/24/2018] [Indexed: 01/14/2023]
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Riley KA, Benton AS, Deimling TA, Kunselman AR, Harkins GJ. Surgical Excision Versus Ablation for Superficial Endometriosis-Associated Pain: A Randomized Controlled Trial. J Minim Invasive Gynecol 2019; 26:71-77. [DOI: 10.1016/j.jmig.2018.03.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/22/2018] [Accepted: 03/24/2018] [Indexed: 10/17/2022]
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Negi N, Roy KK, Kumar S, Nair VG, Vanamail P. Clinical Outcome Analysis and Correlation of Reproductive Outcome with Endometriosis Fertility Index in Laparoscopically Managed Endometriosis Patients: A Retrospective Cohort Study. J Hum Reprod Sci 2019; 12:98-103. [PMID: 31293323 PMCID: PMC6594121 DOI: 10.4103/jhrs.jhrs_157_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Laparoscopy is important for management of endometriosis patients with estimation of endometriosis fertility index (EFI) which can predict reproductive outcome. Aims: This study aims to evaluate clinical outcome in laparoscopically managed pelvic endometriosis and correlation of reproductive outcome with EFI. Setting and Design: Retrospective cohort study carried out in the Department of Obstetrics and Gynecology. Materials and Methods: Our study included 123 patients who had undergone laparoscopic management of endometriosis from January 2017 to March 2018. Case files were retrieved and meticulously analyzed. All patients were contacted and interviewed. Symptomatic relief and pregnancy in infertility patients were recorded. EFI was calculated. Statistical Analysis: Data analyses were carried out using statistical software STATA version 12.0. P < 0.05 was considered statistically significant. Results and Conclusions: A total of 123 cases were enrolled; the most common complaint was infertility 107 (86.99%); the mean age was 32.4 years. EFI was found to be (6 to 10) in 28(26.2%) patients, EFI of (4 to 5) in 49 (45.8%) and EFI of (0 to 3) in 30 (28.0%). Post surgery, dysmenorrhoea was relieved in 56 (65.88%) patients, menstrual irregularities were relieved in 45 (76.27 %) patients, dyspareunia in 32 (54.24%) and chronic pelvic pain in 24 (40.5%) patients. 8 (40%) patients with low EFI conceived, 20 (58.82%) with moderate, and 26 (96.29%) with high EFI conceived. EFI score showed statistically significant positive correlation with pregnancy outcome P = 0.001, higher the EFI score, better the reproductive outcome. Laparoscopic surgeries are important for managing patients of endometriosis. It provides significant symptomatic relief, and EFI estimation can be done, which is a good tool to predict reproductive outcome of infertility patients with endometriosis.
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Affiliation(s)
- Neha Negi
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Kallol Kumar Roy
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Sunesh Kumar
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Vinod G Nair
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - P Vanamail
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
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Jarrell JF, Vilos GA, Allaire C, Burgess S, Fortin C, Gerwin R, Lapensée L, Lea RH, Leyland NA, Martyn P, Shenassa H, Taenzer P. No 164 - Directive clinique de consensus pour la prise en charge de la douleur pelvienne chronique. Journal of Obstetrics and Gynaecology Canada 2018; 40:e788-e836. [DOI: 10.1016/j.jogc.2018.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Richards L, Healey M, Cheng C, Dior U. Laparoscopic Oophorectomy to Treat Pelvic Pain FollowingOvary-Sparing Hysterectomy: Factors Associated with Surgical Complications and Pain Persistence. J Minim Invasive Gynecol 2018; 26:1044-1049. [PMID: 30308307 DOI: 10.1016/j.jmig.2018.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/29/2018] [Accepted: 10/04/2018] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE To examine the surgical management and outcomes of patients treated laparoscopically for pelvic pain following ovary-sparing hysterectomy. DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING General gynecology unit at a tertiary university hospital. PATIENTS A total of 99 patients treated with laparoscopic oophorectomy for pelvic pain following ovary-sparing hysterectomy between January 2008 and December 2016. INTERVENTIONS Laparoscopic oophorectomy was performed in all patients. MEASUREMENTS AND MAIN RESULTS The patients undergoing surgery had a mean age of 48.9 years and a mean body mass index (BMI) of 28.1. They reported a mean of 3.0 previous abdominal surgeries. Sixty percent of patients reported previous abdominal hysterectomy, 21% had previous laparoscopic hysterectomy, and 19% had previous vaginal hysterectomy. At a 6-week follow-up, 59.5% of patients reported resolution of symptoms, 10.7% reported persistent symptoms, and 29.8% reported improved but not resolved symptoms. Younger patients and those reporting a previous history of gastrointestinal disease were more likely to report persistent pain at follow-up. Thirteen percent of patients had intraoperative (6%) or postoperative complications (7%), and there was a 2% rate of conversion to laparotomy. Patients at greater risk of intraoperative complications were those with a higher BMI, a greater number of previous open abdominal surgeries, or severe adhesions noted at the time of procedure. CONCLUSIONS Laparoscopic oophorectomy to treat pelvic pain following ovary-sparing hysterectomy is a feasible yet challenging procedure. Despite a significant rate of complications and a small proportion of patients reporting persistent symptoms, most experience symptom resolution or improvement after such surgery. Further studies are needed to assess long-term outcomes. Careful patient selection and counseling are critical before this procedure.
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Affiliation(s)
- Lucy Richards
- Gynaecology 2 Unit (Endometriosis and Pelvic Pain), Royal Women's Hospital, Melbourne, VIC, Australia.
| | - Martin Healey
- Gynaecology 2 Unit (Endometriosis and Pelvic Pain), Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Claudia Cheng
- Gynaecology 2 Unit (Endometriosis and Pelvic Pain), Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Uri Dior
- Gynaecology 2 Unit (Endometriosis and Pelvic Pain), Royal Women's Hospital, Melbourne, VIC, Australia
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