ESHRE guideline: endometriosis

Prediction of genomic biomarkers for endometriosis using the transcriptomic dataset

BACKGROUND

Endometriosis is a clinical condition characterized by the presence of endometrial glands outside the uterine cavity. While its incidence remains mostly uncertain, endometriosis impacts around 180 million women worldwide. Despite the presentation of several epidemiological and clinical explanations, the precise mechanism underlying the disease remains ambiguous. In recent years, researchers have examined the hereditary dimension of the disease. Genetic research has aimed to discover the gene or genes responsible for the disease through association or linkage studies involving candidate genes or DNA mapping techniques.

AIM

To identify genetic biomarkers linked to endometriosis by the application of machine learning (ML) approaches.

METHODS

This case-control study accounted for the open-access transcriptomic data set of endometriosis and the control group. We included data from 22 controls and 16 endometriosis patients for this purpose. We used AdaBoost, XGBoost, Stochasting Gradient Boosting, Bagged Classification and Regression Trees (CART) for classification using five-fold cross validation. We evaluated the performance of the models using the performance measures of accuracy, balanced accuracy, sensitivity, specificity, positive predictive value, negative predictive value and F1 score.

RESULTS

Bagged CART gave the best classification metrics. The metrics obtained from this model are 85.7%, 85.7%, 100%, 75%, 75%, 100% and 85.7% for accuracy, balanced accuracy, sensitivity, specificity, positive predictive value, negative predictive value and F1 score, respectively. Based on the variable importance of modeling, we can use the genes CUX2, CLMP, CEP131, EHD4, CDH24, ILRUN, LINC01709, HOTAIR, SLC30A2 and NKG7 and other transcripts with inaccessible gene names as potential biomarkers for endometriosis.

CONCLUSION

This study determined possible genomic biomarkers for endometriosis using transcriptomic data from patients with/without endometriosis. The applied ML model successfully classified endometriosis and created a highly accurate diagnostic prediction model. Future genomic studies could explain the underlying pathology of endometriosis, and a non-invasive diagnostic method could replace the invasive ones.

A systematic review and meta-analysis of advanced oxidative protein products levels (AOPP) levels in endometriosis: Association with disease stage and clinical implications

Endometriosis is a common cause of chronic pelvic pain and lacks precise pathophysiological mechanisms. Advanced oxidation protein products (AOPPs), markers of oxidative stress and inflammation, are implicated in pain-related diseases and have been suggested to play a crucial role in endometriosis pathophysiology. We aim to assess the significance of AOPP in endometriosis by analyzing their levels across serum, follicular fluid, peritoneal fluid, and ovarian endometrioma tissue, and their association with different disease stages. A systematic review of articles published up to Nov 2024 examining AOPP levels in endometriosis patients compared to controls was conducted (PROSPERO: CRD42022343714). Using the Newcastle-Ottawa Scale (NOS), the quality and risk of bias of included studies were assessed, and publication bias was evaluated using Egger's and Begg's tests. The analysis 12 studies involving 561 control patients without endometriosis and 670 patients with endometriosis. Compared to controls, elevated AOPP levels were observed in endometriosis patients' serum and peritoneal fluid. Patients with type III/IV endometriosis exhibited higher AOPP levels in serum and plasma compared to control patients, suggesting a potential association with disease severity. The study underscores the potential of AOPP levels as biomarkers for endometriosis severity and proposes them as pharmacological targets for disease management, including pelvic pain treatment.

Development of the COMPASS model of endometriosis: A COmprehensive model of pain encompassing agency, systemic factors and sense making

OBJECTIVES

Endometriosis is a chronic and progressive condition commonly associated with debilitating pain. Treatments for endometriosis pain are limited and usually invasive. Psychological interventions are a non-invasive intervention option and have proven benefits in chronic pain. Yet, psychological interventions for endometriosis pain are scant and of limited efficacy, which may be due to gaps in our understanding of endometriosis pain experiences. We sought to expand current understandings of endometriosis pain by investigating the factors that exacerbate and alleviate pain-related impact and distress, despite similar levels of pain severity.

DESIGN

A mixed-methods approach was used, comprising quantitative pain data, qualitative interviews, and qualitative analysis of open-ended survey responses.

METHODS

A total of 873 participants answered an online survey including pain outcomes. Sixteen participants were then purposively sampled for interview, in an iterative manner, in line with grounded theory until theoretical saturation was reached. Analysis of interview data resulted in a novel model of endometriosis pain. The model was cross-validated and refined using content analysis of 841 open-ended online survey responses regarding wider system priorities for endometriosis care.

RESULTS

Our COMPASS model suggested that experiences of endometriosis-related pain and associated distress and impact were shaped by a dynamic interaction between the challenges of the gendered nature of pain, invalidation, distrust in the healthcare system, agency, sense-making, and burden. These experiences were situated within broader systemic factors of difficulty accessing care, the limitations of available treatments, and a lack of financial support.

CONCLUSIONS

Our findings present a novel model of endometriosis pain. This model provides several psychosocial treatment targets that could inform future psychological and multidisciplinary interventions for endometriosis pain. Empirical validation of the model is an avenue for future research.

Bringing Endometriosis to the Road of Contemporary Pain Science

BACKGROUND

Endometriosis pain is mainly understood based on peripheral lesion characteristics and an outdated perspective equating nociception with pain. This limited view may divert understanding of interventions beyond peripheral logic, leading clinicians to see approaches targeting other processes as supplementary, limiting the effective addressing of treatment failure. Integrating critical advancements in pain and endometriosis can promote more comprehensive knowledge.

OBJECTIVES

This article provides a conceptual framework focusing on overlooked or less clearly linked areas concerning the interplay between nociception and factors influencing endometriosis pain. It explores the complexity of nociceptive processing, the association between neuromerically connected structures, and the role of the brain in pain perception. Further, it emphasizes adopting mechanism-based understanding of pain that integrates neurobiological aspects of the nociceptive apparatus and related systems, shaped by psychosocial factors contributing to a possible negative spiral in those living with endometriosis.

CONCLUSION

Aware of such a broader perspective can incentivize a balanced effort to inquire into peripheral lesion-related mechanisms and other domains potentially impacting endometriosis pain.

Eating for Optimization: Unraveling the Dietary Patterns and Nutritional Strategies in Endometriosis Management

Endometriosis is a chronic gynecological disorder affecting millions of women worldwide, causing chronic pelvic pain, dyspareunia, dysmenorrhea, and infertility, and severely impacting their quality of life. Treatment primarily involves hormonal therapies and surgical excision, but high recurrence rates and the economic burden are substantial. With these challenges, significant discussion surrounds the potential role of dietary patterns in managing endometriosis, making it necessary to bridge this critical gap. This review investigates the current scientific evidence on the dietary patterns (eg, Mediterranean, vegetarian, anti-inflammatory, low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols [low-FODMAP], and Western-style diets) associated with endometriosis and provides a concise, yet thorough, overview on the subject. In addition, antioxidants, microbiota, and artificial intelligence (AI) and their potential roles were also evaluated as future directions. An electronic-based search was performed in MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, Scopus, and Web of Science. The current data on the topic indicate that a diet based on the Mediterranean and anti-inflammatory diet pattern, rich in dietary fiber, omega-3 fatty acids, plant-based protein, and vitamins and minerals, has a positive influence on endometriosis, yielding a promising improvement in patient symptoms. Preclinical investigations and clinical trials indicate that dietary antioxidants and gut microbiota modulation present potential new approaches in managing endometriosis. Also, AI may offer a promising avenue to explore how dietary components interact with endometriosis. Ultimately, considering genetic and lifestyle factors, a healthy, balanced, personalized approach to diet may offer valuable insights on the role of diet as a means of symptom improvement, facilitating the utilization of nutrition for the management of endometriosis.

MicroRNA profiling reveals potential biomarkers for the early transformation of endometriosis towards endometriosis-correlated ovarian cancer

BACKGROUND

Endometriosis (EMS) is a chronic, gynecological condition affecting 6-10 % of reproductive-age women. While these lesions are benign, ovarian EMS presents cancer-like features, and can progress to endometriosis-correlated ovarian cancer (ECOC) through a multistep process. Given the regulatory role of miRNAs in gene expression and biological pathways, we aimed to identify miRNAs associated with the malignant transformation of ovarian EMS, which could serve as a potential diagnostic tool for the early identification of such patients.

METHODS

Global miRNA profiling was performed in 8 patients with benign ovarian EMS (EMS-b) and 29 patients with ECOC. Differential expression analysis (DEA) of miRNAs between EMS-b, EMS tissues from patients with ECOC (EMS-k) and ECOC tissues was performed. Receiver Operating Characteristic (ROC) curves were built to evaluate the binary classification performance of significant miRNAs.

RESULTS

Comparison between EMS-b and EMS-k revealed 13 significantly deregulated miRNAs. Furthermore, when comparing ECOC and EMS-b, we observed significant deregulation of 181 miRNAs. ROC analysis revealed a panel of seven upregulated miRNAs with accuracies above 0.7 in identifying EMS-k and EMS-b. Notably, four miRNAs (hsa-miR-200a-3p, hsa-miR-141-3p, hsa-miR-183-5p, hsa-miR-10a-5p) were consistently upregulated in both EMS-k and ECOC tissues, achieving accuracies above 0.77 in distinguishing between EMS-k and EMS-b. When used to distinguish between EMS-b and ECOC tissues, these miRNAs showed accuracies even higher, above 0.94. Specifically, hsa-miR-183-5p had an accuracy of 1, hsa-miR-200a-3p and hsa-miR-141-3p of 0.97, while hsa-miR-10a-5p of 0.95.

CONCLUSIONS

Our study identified a panel of miRNA biomarkers that may serve as potential candidates for the early detection of ECOC in patients previously diagnosed with ovarian EMS.

Meeting proceedings: International Society for Fertility Preservation Tokyo, 15-17 November, 2024

The 8 th International Congress of the ISFP was held in Tokyo, Japan, from November 15 to 17, 2024. The theme of this year's Congress was "Rethinking Personalized Fertility Preservation and Cancer Survivors-Opening a New Frontier". The congress featured special lectures, keynote addresses, and 25 sessions-including a dedicated session on nursing and oral presentations by young doctors and researchers-making it one of the largest and most comprehensive events in the ISFP's history. Additionally, the program incorporated sessions featuring the Japanese, Korean, and Chinese Societies for Fertility Preservation, providing a convenient platform for international participants from across the globe to showcase their work and discuss the unique characteristics and challenges of these areas within Asia. Participants also had the opportunity to attend workshops on ovarian tissue cryopreservation and oocyte cryopreservation, conducted by leaders in their respective fields exploring the latest technological and clinical advances and translational prospects for the future.

Identification and validation of a novel machine learning model for predicting severe pelvic endometriosis: A retrospective study

This study aimed to explore potential risk factors for severe endometriosis and to develop a model to predict the risk of severe endometriosis. A total of 308 patients with endometriosis were analyzed. Least absolute shrinkage and selection operator (LASSO) was performed to identify the potential risk factors for severe endometriosis. Then, we used seven machine learning (ML) algorithms to construct the predictive models. Finally, SHapley Additive exPlanations (SHAP) interpretation was performed to evaluate the contributions of each factor to risk prediction. About 59.2% (183/308) of patients were diagnosed with severe endometriosis. The random forest (RF) model performed best in discriminative ability among the seven ML models, achieving an area under the curve (AUC) of 0.744. After reducing features according to feature importance rank, an explainable final RF model was established with six features. From the SHAP map, we found that the negative sliding sign had the greatest impact on the diagnostic performance of the RF model. This study provided a personalized risk assessment for the development of severe endometriosis, which may enable early identification of high-risk patients, facilitating timely intervention and optimized treatment strategies.

Advancing endometriosis detection in daily practice: a deep learning-enhanced multi-sequence MRI analytical model

BACKGROUND AND PURPOSE

Endometriosis affects 5-10% of women of reproductive age. Despite its prevalence, diagnosing endometriosis through imaging remains challenging. Advances in deep learning (DL) are revolutionizing the diagnosis and management of complex medical conditions. This study aims to evaluate DL tools in enhancing the accuracy of multi-sequence MRI-based detection of endometriosis.

METHOD

We gathered a patient cohort from our institutional database, composed of patients with pathologically confirmed endometriosis from 2015 to 2024. We created an age-matched control group that underwent a similar MR protocol without an endometriosis diagnosis. We used sagittal fat-saturated T1-weighted (T1W FS) pre- and post-contrast and T2-weighted (T2W) MRIs. Our dataset was split at the patient level, allocating 12.5% for testing and conducting seven-fold cross-validation on the remainder. Seven abdominal radiologists with experience in endometriosis MRI and complex surgical planning and one women's imaging fellow with specific training in endometriosis MRI reviewed a random selection of images and documented their endometriosis detection.

RESULTS

395 and 356 patients were included in the case and control groups respectively. The final 3D-DenseNet-121 classifier model demonstrated robust performance. Our findings indicated the most accurate predictions were obtained using T2W, T1W FS pre-, and post-contrast images. Using an ensemble technique on the test set resulted in an F1 Score of 0.881, AUROCC of 0.911, sensitivity of 0.976, and specificity of 0.720. Radiologists achieved 84.48% and 87.93% sensitivity without and with AI assistance in detecting endometriosis. The agreement among radiologists in predicting labels for endometriosis was measured as a Fleiss' kappa of 0.5718 without AI assistance and 0.6839 with AI assistance.

CONCLUSION

This study introduced the first DL model to use multi-sequence MRI on a large cohort, showing results equivalent to human detection by trained readers in identifying endometriosis.

Efficacy of hormone pre-treatment before ART to improve reproductive outcomes in infertile women with endometriosis: Network meta-analysis of randomized controlled trials

BACKGROUND

Hormone pre-treatment is still used before assisted reproductive technique (ART) in endometriotic women, but evidence supporting this recommendation is conflicting.

OBJECTIVES

To evaluate whether hormone pre-treatment with gonadotropin-releasing hormone (GnRH) agonists or progestogens could improve fertility in women with endometriosis undergoing ART.

SEARCH STRATEGY

MEDLINE, LILACS, EMBASE, Scielo.br, PROSPERO, Cochrane at the CENTRAL Register of Controlled Trials, conference abstracts, and international controlled trials registries were searched without temporal, geographic, and language limitations.

SELECTION CRITERIA

Randomized controlled trials that enrolled infertile women with endometriosis undergoing in vitro fertilization/intracytoplasmic sperm injection after the application of a stimulation protocol with hormone pre-treatment were selected and included.

DATA COLLECTION AND ANALYSIS

We conducted a network meta-analysis based on the random-effects model for mixed multiple treatment comparisons to rank the available hormone pre-treatment by the surface under the cumulative ranking curve area (SUCRA) following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension statement for network meta-analyses. Quality assessment was carried out using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Egger test and funnel plot analysis were used for publication bias assessment. The primary outcome was clinical pregnancy rate (CPR). Secondary outcomes were live birth rate (LBR), pregnancy loss rate (PLR), and implantation rate (IR).

MAIN RESULTS

Nine studies with 2087 women were included. Ultralong (3 months GnRH agonist) (SUCRA 24.5%) and long protocols (1 month GnRH agonist) (SUCRA 24.9%) as well as progestins (SUCRA 28.8%) showed similar results to no treatment (SUCRA 21.8%) in terms of post-ART CPR. Regarding the LBR, no treatment (SUCRA 50.0%) showed highest rates relative to progestins (SUCRA 7.0%), and long (SUCRA 36.6%) and ultralong (SUCRA 6.4%) protocols. For PLR, no treatment (SUCRA 57.9%), followed by long protocol (SUCRA 18.4%), ultralong protocol (SUCRA 12.3%), and progestins (SUCRA 11.4%) showed the greatest degree of reduction. The long (SUCRA 45.0%) and ultralong (SUCRA 39.5%) protocols seemed more effective in increasing IR than did than progestins (SUCRA 15.5%).

CONCLUSIONS

The increased number of implanted pregnancies using a GnRH agonist protocol does not lead to higher clinical pregnancies or live births. Currently, there is no indication for hormone pre-treatment before ART in women with endometriosis as it does not increase fertility chances.

Effects of a low-FODMAP diet on patients with endometriosis, a prospective cohort study

BACKGROUND

Patients with endometriosis often experience bowel symptoms such as changing stool, abdominal pain and bloating similar to those associated with irritable bowel syndrome. These symptoms reduce quality of life (QoL). Visceral hypersensitivity seems to be a shared pathogenic factor. The low-FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) diet is a known visceral hypersensitivity targeted therapy with significant reduction in bowel symptoms. The aim of this study was to evaluate the effect of low-FODMAP diet on bowel symptoms such as constipation and bloating, pain and QoL in patients with endometriosis.

METHODS

The diet involved four weeks of FODMAP elimination, followed by a reintroduction-period of at least ten weeks, varying by patient. Questionnaires were sent at baseline and after these periods. The primary outcome was constipation change after the reintroduction period compared to baseline, assessed by Groningen-DeFeC-questionnaire (0-30 scale) with paired-T-test or Wilcoxon-signed-rank-test. Secondary outcomes included changes in bloating, QoL and abdominal pain, assessed by Endometriosis Health Profile-30 (EHP-30). P-value < 0,05 indicated statistical significance.

RESULTS

Forty-seven patients were included; thirteen withdrew before starting the diet, mostly due to lack of motivation. Of the remaining 34, 24 (71%) completed the diet (i.e. following the prescribed periods) Constipation scores improved significantly after low-FODMAP diet compared to baseline from 7.0 to 5.0 (p = 0.023). There was no significant difference observed in bloating, however 53% of patients that completed the diet mentioned a decrease. The following domains of the EHP-30 improved significantly: pain (from 47.8 to 29.2 (p = 0.002)), control and powerlessness (from 69.4 to 36.7 (p = 0.000)), emotional well-being (from 45.2 to 29.2 (p = 0.001)), social support (from 46.4 to 31.3 (p = 0.0017)), self-image (from 51.2 to 40.5 (p = 0.035)), work-life (from 35.0 to 21.7 (p = 0.003)) and sexual intercourse (from 61.6 to 45.7 (p = 0.023)). 65% of patients that completed the diet mentioned a decrease in pain, especially chronic pelvic pain.

CONCLUSIONS

This study suggests the low-FODMAP diet may improve bowel symptoms and QoL in endometriosis patients motivated to follow the diet, highlighting its potential in endometriosis care. However, further research in larger populations is needed to explore factors like endometriosis type, pain intensity and dropout rates to confirm these findings.

TRIAL REGISTRATION

ICTRP: NL-OMON28996: Feasibility study: The effect of the low FODMAP diet on women suffering from endometriosis ( https://trialsearch.who.int/Trial2.aspx?TrialID=NL-OMON28996 ) on September 13th 2019.

D-chiro-inositol effectively counteracts endometriosis in a mouse model

BACKGROUND

Endometriosis, a common condition affecting 5-10% of women of reproductive age, is the growth of endometrial-like tissue outside the uterus, leading to pain and infertility. Current treatments, such as surgery and hormonal therapy, offer limited long-term benefits. This study investigated the potential of D-chiro inositol (DCI), a natural compound that influences ovarian steroidogenesis, to treat endometriosis and compared its efficacy with a progestin drug such as Dienogest (DG).

METHODS

We established a non-surgical mouse model of endometriosis in CD1 mice. Uterine horns were removed from donor mice, cut into fragments and inoculated in recipient mice by intraperitoneal injection. Endometriosis progression was assessed at 15, 21 and 28 days after transplantation, with the 28-day window being the most effective. The mice were then randomly assigned to four experimental groups, which received for 28 days: water (EMS); DCI 0.4 mg/die (DCI); DCI 0.2 mg/die and Dienogest 0.33 ng/die (DCI + DG); DG 0.67 ng/die (DG). At the end of the treatments, endometriotic lesions, ovaries and circulating estradiol levels were analyzed.

RESULTS

The results showed that treatment with DCI, both alone and in combination with DG, significantly reduced the number, size and vascularization of endometriotic lesions compared to the EMS control group. Histological analysis confirmed a decrease in endometriotic foci across all treatment groups, with the most pronounced effects in the DCI group. To investigate the underlying molecular mechanisms, we found that DCI led to a significant reduction in the expression of Sirt1 and an increase in E-Cadherin, indicating a reduction in EMT transition relevant for lesion development. In addition, DCI decreased cell proliferation and,blood vessel formation, as evaluated by PCNA and CD34, respectively. Futhermore, in the ovary, DCI treatment downregulated the expression of aromatase (Cyp19a1), the enzyme critical for estrogen biosynthesis, and increased the number of primordial to antral follicles, suggesting a beneficial effect on ovarian folliculogenesis.

CONCLUSIONS

By modulating proliferation, EMT transition and aromatase activity, DCI emerges as a promising compound for endometriosis treatment.

Pilot Clinical and Radiomic Analysis of Deep Infiltrating Endometriosis of the Parametrium Using Shannon Entropy: A Retrospective Cohort Study

OBJECTIVE

Ultrasound techniques for diagnosing deep infiltrating endometriosis (DIE) currently lack a quantitative method to assess microstructural heterogeneity in relation to diagnosis and clinical symptoms. This study evaluates Shannon entropy-based radiomics for differentiating DIE lesions from adjacent tissue and correlating these features with pain severity.

METHODS

In this retrospective cohort study (2020-2024), fertile women with histologically confirmed parametrial endometriosis and high-quality ultrasound images were evaluated. Pain was measured using a 10-cm visual analog scale. Two 25 mm² regions of interest (ROIs) were defined: one within the DIE nodule and one in the adjacent perilesional tissue. Each ROI was analyzed with the Shannon entropy algorithm to assess tissue heterogeneity.

RESULTS

In this study, 148/663 women (22.3%) were diagnosed with parametrial DIE, of whom 52 underwent surgery and were included in the study. DIE was localized in 92.3% in the posterior, in 5.8% in both posterior and anterior, and in 2% in the anterior parametrium. Primary symptoms were menstrual pain (88%) and pain at intercourse (63%). ROI entropy of DIE lesion was lower than that of the perilesional ROI (p = 0.05). The area-under-the-curve (AUC) of Shannon entropy for endometriotic vs. adjacent tissue was 91.36% (95% CI: 84.5%-98.21%). The ROI entropy of the DIE lesion exhibited an inverse correlation with menstrual pain (rho -0.46, CI 95% -0.74/-0.12, p = 0.025), and that of perilesional tissue with chronic pelvic pain (rho -0.41, 95% CI -0.73/- 0.04; p = 0.072).

CONCLUSION

Entropy analysis distinguishes DIE lesion from perilesional tissue and significantly correlates with menstrual pain.

Imaging of endometriosis-related infertility

Endometriosis is a common cause of subfertility and infertility through myriad mechanisms. Imaging of endometriosis is critical for its diagnosis, characterization, and treatment. Understanding its imaging appearance, surgical management, and implications for assisted reproductive therapy is essential to providing the most clinically relevant and impactful reports in endometriosis patients. This manuscript will review imaging techniques used to diagnose and characterize endometriosis-related infertility. We will describe relevant imaging findings by anatomic site and review the impact of surgery and ART on its appearance.

Management of women with endometriosis in the 21st century

PURPOSE OF REVIEW

Endometriosis is a chronic inflammatory condition that significantly affects women's quality of life and fertility. Despite advancements in treatment, many areas of uncertainty persist in clinical management. This review provides a symptom-focused, patient-centered update, addressing cases from asymptomatic to those complicated by pain and infertility.

RECENT FINDINGS

Advancement in imaging technology has increased incidental diagnoses of asymptomatic endometriosis, raising the debate between immediate treatment and watchful waiting. Medical therapy primarily aims to suppress symptoms, with oral gonadotropin-releasing hormone antagonists and add-back therapy offering promising long-term pain control. Research into local neurogenesis and central sensitization supports complementary approaches, though high-quality evidence is still limited. For pain refractory to medical therapy, conservative surgical strategies can minimize postoperative complications without significantly increasing recurrence rates. In infertility, assisted reproductive technology (ART) provides effective options, although the optimal endometrial preparation and the necessity of pre-ART surgery remain to be fully elucidated.

SUMMARY

The optimal management of endometriosis requires a personalized, multidisciplinary approach within specialized centers. Long-term suppressive medical therapy remains the cornerstone of pain management while emerging targeted agents hold promise for better symptom control with fewer side effects. Surgical intervention should be performed by experienced surgeons as a single definitive procedure when possible. Tailored ART protocols can address infertility challenges. Standardized classification systems and robust randomized trials are crucial to refining treatment pathways, optimizing fertility outcomes, and enhancing quality of life.

Primary umbilical endometriosis in a nulliparous woman: A rare case report

INTRODUCTION AND IMPORTANCE

Endometriosis describes the presence of endometrial tissue outside the uterine cavity. These patients often experience cyclic pain, dysmenorrhea, dyspareunia and infertility. Extra-pelvic endometriosis, particularly at the umbilicus, is rare. The exact incidence of endometriosis is unknown; definitive diagnosis requires surgical exploration and histopathological confirmation. Conservative, medical and surgical approaches are used in treatment. A combined approach is most useful in cases where pain is a prominent symptom. There is limited discussion of umbilical endometriosis in the literature, most information is derived from case reports.

CASE PRESENTATION

Herein we present the case of a 35-year-old nulliparous woman in Northern Tanzania with a 10-year history of infertility. On presentation this patient reported a three-year history of a cyclical aching pain associated with an umbilical mass. An abdominal MRI revealed an ill-defined, enhancing mass measuring 3 × 4 × 6 cm located along the right anterior abdominal wall. The mass was connected to a sinus tract extending inferiorly to the suprapubic region but showed no communication with the peritoneal cavity, suggestive of endometriosis. Furthermore, bilateral adnexal lesions demonstrated hyperintense signals with focal hypointense areas and variable restrictions, consistent with bilateral ovarian endometriomas. The patient underwent excision of the umbilical mass, and histopathological examination confirmed the diagnosis of primary umbilical endometriosis. Despite her stable condition following management, she did not conceive over the course of the following year.

CLINICAL DISCUSSION

This case describes a case of primary umbilical endometriosis and bilateral ovarian endometriomas in a 35-year-old nulliparous woman. Surgical excision and histopathological analysis confirmed endometriosis. However, following intervention the patient was still unable to conceive. Whilst this is perhaps not unsurprising given the patient's age it is important for us to consider all possible explanations for her infertility. Critically, this case emphasizes the need for early intervention and comprehensive management of endometriosis-related fertility challenges.

CONCLUSION

We aim to provide a detailed description of this case in order to support clinicians who may encounter similar cases in the future especially in resource poor settings. We are providing data to support the theory that primary umbilical endometriosis can occur spontaneously in patients without a surgical history. Enhancing clinician awareness of this condition and fostering interdisciplinary collaboration is fundamental in providing timely support in relation to fertility challenges and symptom relief.

'Ovariostasis' as the main preventive and therapeutic strategy for gynecological pathologies in women of reproductive age

Ovariostasis is a reversible and temporary suspension of the cyclic ovarian activity, characterized by anovulation and hypogonadotropinemia (low serum concentrations of FSH and LH), which can be observed in case of pregnancy or hypothalamic amenorrhea or medically obtained through the administration of combined hormonal contraceptives, progestin-only pills, or GnRH analogues. Ovariostasis effectively prevents undesired pregnancies, ovarian torsion, and hemorrhagic corpus luteum. Moreover, ovariostasis can be useful for the treatment of primary dysmenorrhea, polycystic ovary syndrome, endometriosis, adenomyosis, uterine fibroids, and abnormal uterine bleeding. Ovariostasis also offers long-term benefits; for example, a significant risk reduction for ovarian, colorectal, and endometrial cancer, despite a slightly increased breast cancer risk. According to limited data, ovariostasis may have an influence on the age of onset of natural menopause. Experimental studies on mice hypothesize positive effects of ovariostasis on the ovarian reserve, thereby contributing to preservation of fertility. Ovariostasis can be considered as a practical, effective tool to prevent and treat gynecological pathologies in women of reproductive age and needs further studies on humans to evaluate its influence on the reproductive lifespan and ovarian reserve.

Utility of sexually transmitted infection screening in diagnosing clinical gynaecological conditions using endometrial specimens

Sexually transmitted infections are associated with gynaecological conditions, yet screening algorithms are lacking. The aim was determining the utility of endometrial specimens for chronic gynaecological diagnosis. In a retrospective cohort study of 91 patients (42.8 % CD138-positive), only 5.5 % tested were positive for Ureaplasma parvum. Endometrial STI screening was not useful in a population of low STI prevalence (<10 %), suggesting its value depends on STI prevalence.

Limitations and perspectives of the novel salivary test for endometriosis: an open web-based survey study of German gynecologic healthcare providers

INTRODUCTION

The description of a salivary miRNA signature for endometriosis has led to the development of a non-invasive diagnostic test. Current healthcare provider practices regarding the test remain uncaptured. The application of this test in practice was examined in a web-based survey, with the aim to provide their opinions on it.

METHODS

We conducted an open web-based survey study between November 2023 and January 2024. Members of the German society of gynecologic endoscopy (Arbeitsgemeinschaft gynäkologische Endoskopie, AGE), society of endometriosis (Arbeitsgemeinschaft Endometriose, AGEM), and the endometriosis research foundation (Stiftung Endometriose Forschung, SEF) were contacted per e-mail twice. Participants' data were anonymized. Differences in responses based on self-reported expertise in the field (basic knowledge, specialized knowledge, expert) were assessed using the χ2-test or Fisher's exact test. Statistical significance was set as p < 0.05.

RESULTS

In total 141 of 190 respondents completely responded to the survey (> 75% of the questions of the survey). Twenty-one physicians reported having experience with the test, while most participants had at least specialized knowledge on the field (112/141). In terms of specific questions, more than 90% found the costs high; almost 85% did not believe that the test replaces standard diagnostic tools (histology, clinical examination, and sonography). Eighty-six providers supported the use of the test in adolescents. Gynecologists with basic knowledge had a more positive attitude compared with more experienced ones in terms of usefulness (Fisher's exact test, p < 0.001). Significant differences were demonstrated between expertise groups regarding (not only) applicability in adolescents (Fisher's exact test, p = 0.004), and using the test for screening purposes (χ2-test, p = 0.002).

DISCUSSION

Despite the promising benefits of a salivary test for endometriosis, German healthcare providers would not change current practices. Nevertheless, less experienced colleagues were more positive towards the test.

Overexpression of FOS enhances the malignant potential of eutopic endometrial stromal cells in patients with endometriosis‑associated ovarian cancer

Endometrial cysts of the ovary (EMC) may develop into endometriosis (EM)‑associated ovarian cancer over time (EAOC), but the pathogenesis of this disease has not been determined. In the present study, RNA sequencing was used to identify a feasible biomarker, and the molecular function of this biomarker in eutopic endometrial cells from EAOC and EMC patients was evaluated to explore the potential mechanism related to EAOC and orthotopic endometrial tissue. RNA sequencing was performed on 5 EAOC and 4 EMC tissue samples, and differential expression analysis was performed. To identify biomarkers, differentially expressed genes were subjected to protein‑protein interaction network design, Gene Ontology pathway enrichment, and Gene Set Enrichment Analysis pathway enrichment. The expression of FOS in the endometrium was detected via immunohistochemical staining. Lv‑FOS was utilized to upregulate FOS in human endometrial stromal cells (hEnSCs), and Cell Counting Kit‑8, colony formation and scratch assays were performed to assess cell viability, proliferation and migration, respectively. Western blotting was used to determine protein expression. In total, 249 genes, including FOS, were differentially expressed. Pathway enrichment analysis demonstrated that the MAPK, AP‑1, ERK and other signaling pathways were involved in the EMC‑to‑EAOC conversion. FOS upregulation in hEnSCs increased cell viability, proliferation and migration. Western blot results revealed that after FOS expression was inhibited, P21 expression was upregulated, and CDK4, Cyclin D1, p‑Stat3, MMP2 and MMP9 expression was downregulated. In conclusion, mitosis and the cell cycle were found to affect the progression of EMC to EAOC. The expression of FOS, a novel biomarker, was identified to enhance the malignant potential of eutopic endometrial stromal cells in patients with EM‑associated ovarian cancer.

Bowel Endometriosis: Systematic Approach to Diagnosis with US and MRI

Endometriosis involving the bowel is a severe form of the disease, and the bowel is the most common site of extragenital endometriosis. Surface lesions of the bowel are considered peritoneal disease. Bowel endometriosis (BE) is defined as endometriotic tissue infiltrating the muscularis propria layer of the bowel wall. BE is estimated to affect up to 37% of patients with known deep endometriosis, highlighting its coexistence with genital endometriosis. The rectosigmoid colon is the most common segment of the bowel involved, followed by the distal small bowel. US and MRI are the most common imaging modalities used to detect BE. Depending on which bowel segment is imaged, endometriosis protocols for transvaginal US after bowel preparation with a transabdominal component and MRI and MR enterography are most commonly used. The authors provide a systematic approach to the diagnosis of BE using these imaging modalities. Imaging protocols and techniques for optimization of visualization of the bowel are discussed, the normal bowel wall anatomy with both imaging modalities is described, and the varying degrees of bowel wall involvement in endometriosis are illustrated. The imaging features of infiltration of endometriosis in the bowel muscularis propria are described in detail, along with key imaging findings to be conveyed to surgical colleagues to optimize surgical treatment and decrease complications, thereby improving overall patient outcomes. ©RSNA, 2025 Supplemental material is available for this article.

Childhood adversity and risk of endometriosis, fibroids, and polycystic ovary syndrome: a systematic review

IMPORTANCE

Although childhood adversity has been extensively studied in relation to various health outcomes, investigation of its association with gynecological conditions remains limited.

OBJECTIVE

To systematically review studies examining the effect of childhood adversity on the prevalence of three gynecological conditions: endometriosis; fibroids; and polycystic ovary syndrome (PCOS) in the population.

EVIDENCE REVIEW

Six databases were searched from inception to March 12, 2024. Observational studies of women with exposure to adversity before the age of 18 and an outcome of endometriosis, fibroids, and/or PCOS were eligible for inclusion. Studies were summarized through a qualitative synthesis. We evaluated the risk of bias using the Newcastle-Ottawa Scale.

FINDINGS

Seven studies that reported on the association between a form of childhood adversity and endometriosis, fibroids, and or PCOS were selected for review. All seven studies received a moderate risk of bias score. Cumulative exposure to childhood adversity was associated with an increased risk of endometriosis and fibroids. Childhood exposure to sexual abuse was associated with an increased risk of endometriosis and fibroids. Exposure to physical abuse in childhood was associated with a greater risk of fibroids.

CONCLUSION AND RELEVANCE

A small number of studies have shown an association between childhood adversity and the development of endometriosis and fibroids in later life. These initial findings warrant further investigation in larger studies using standardized measures.

Endometriosis and adenomyosis unveiled through single-cell glasses

Single-cell technologies are expanding our understanding of endometriosis and adenomyosis, which are sister disorders of the uterine endometrium that contain similar complements of lesion cell types but in different locations-outside and inside the uterus, respectively. Both diseases cause significant morbidity and impaired quality of life among those affected, and current therapies mitigate most of the symptoms although with highly variable efficacy, duration of effect, and frequent intolerable side effects. Thus, there is a pressing need for transformative approaches and to develop individualized therapies for the variety of presentations of endometriosis and adenomyosis symptoms and the heterogeneity of lesion types, both histologically and architecturally. Single-cell technologies are transforming the understanding of human physiology and pathophysiology in the reproductive system and beyond. This manuscript reviews the clinical characteristics of endometriosis and adenomyosis and the recent studies focused on eutopic endometrium and ectopic lesions at single-cell resolution, the myriad of cell types and subtypes, cell-cell communications, signaling pathways, applications for novel drug discovery and therapeutic approaches, and challenges and opportunities that accompany this type of research. Key take-home messages from the studies reviewed herein include the following: We conclude the review with an eye to the future-what Alice might see beyond the single-cell looking glass that connects endometrium and endometrial disorders with the trillions of cells of other tissues and organs in health and disease throughout the human body and the opportunities for novel diagnostic modalities and drug discovery for endometriosis, adenomyosis, and related uterine and inflammatory conditions.

Precision surgery for endometriosis: preventing chronic pelvic pain in patients with higher pre-operative pain scores and in patients of advanced age

OBJECTIVE

Symptom relief can be achieved for many patients with endometriosis by tailored individual treatment. However, therapy resistance is observed in some patients. This study surveyed patient-reported long-term outcomes after laparoscopic endometriosis surgery and evaluated potential pre-operative predictors for insufficient symptom control.

METHODS

This retrospective study included patients with complete surgical endometriosis resection treated between 2013-2016 at the Department of Gynaecology and Reproductive Medicine, Jena University Hospital. Our 2020 survey gathered socio-demographic, reproductive, symptom-related, and subjective general condition data from 122 patients. Overall pain intensity was assessed using a numeric rating scale (NRS) from zero (no pain) to 100 (highest imaginable pain). Clinical records provided additional information.

RESULTS

Median time between surgery and interview was 6 years. Postoperatively, the proportion of patients reporting symptoms was considerably reduced (menstrual pain 32.0% vs. 85.2%, chronic pelvic pain [CPP] 40.2% vs. 67.2%, dyspareunia 34.4% vs. 59.8%, hypermenorrhea 17.2% vs. 49.2%; p < 0.001). The majority of respondents (70%) reported improved subjective general condition. Mean NRS Score significantly decreased from 77.2 to 26.6 (p < 0.001). Among pre-operatively infertile women, 45.2% reported successful pregnancies. However, 20-30% of patients did not respond to therapy in one of the analyzed domains. Multivariate logistic regression identified CPP as a strong predictor for failure in permanent pain reduction (OR 5.544, 95% CI 1.338-22.965, p = 0.018) and risk for reoperation (OR 5.191, 95% CI 1.100-24.501, p = 0.038). Higher pre-operative NRS scores and increasing age were associated with better long-term pain relief.

CONCLUSION

Patients with higher pre-operative pain scores and patients of advanced age benefit significantly from precision surgery, experiencing sustained symptom relief and improved subjective general condition. However, younger patients with CPP and moderate pre-operative pain intensity showed a higher risk for therapy resistance and require multimodal treatment strategies.

Subdermal implants vs. levonorgestrel intrauterine devices outcomes in reproductive-aged women: a systematic review and meta-analysis

PURPOSE

We aimed to conduct a systematic review and meta-analysis comparing the outcomes of subdermal implants and levonorgestrel intrauterine system (LNG-IUS) in reproductive-aged women.

METHODS

In April 2024, we searched Pubmed, Embase and Cochrane trials using the search terms: "etonogestrel", "levonorgestrel" and "randomized controlled trials". We identified 2862 results comparing the LNG-IUS to subdermal implants. Randomized controlled trials (RCTs) were selected with no restrictions on language or year of publication.

RESULTS

We include six RCTs comprising 1503 patients. R Studio was used for statistical analysis. Subdermal implants were associated with a higher risk of dissatisfaction (OR 2.42; 95% CI 1.47-3.98), acne (OR 2.21; 95% CI 1.21-4.04), weight gain (OR 4.63; 95% CI 1.96-10.63), and device removal due to side effects (OR 2.02; 95% CI 1.20-3.41) compared to the LNG-IUS group. Subgroup analysis indicated that irregular bleeding may be influenced by gynecological conditions, and the risk of new ovarian cyst detection was lower in healthy women using subdermal implants. Norplant-2 was associated with an increased risk of irregular bleeding and a decreased risk of amenorrhea or infrequent bleeding. The leave-one-out analysis and heterogeneity were well distributed among studies for all evaluated outcomes.

CONCLUSIONS

Reproductive-aged women in use of subdermal implants experienced a higher rate of acne, weight gain, device removal due to side effects and dissatisfaction compared to those in use of LNG-IUS.

TRIAL REGISTRATION

PROSPERO ID: CRD42024516472.

The clinical characteristics and prognosis of surgically treated ovarian endometrioma in pregnant women

PURPOSE

To investigate the clinical characteristics and prognosis of surgically treated ovarian endometrioma (OMA) in pregnant women.

METHODS

This retrospective cohort study analyzed 30 patients with pathologically confirmed ovarian endometrioma during pregnancy and delivery. Clinical characteristics and follow-up data were summarized.

RESULTS

Among the 30 patients, 21 underwent laparoscopic surgery during pregnancy. A total of 24 OMAs were identified in 21 patients and exhibited various changes during pregnancy: 13 did not show significant changes, 10 increased in size and 1 decreased in size. The indications for surgery included suspicion of malignancy (16/21), large and progressive growth (3/21), and ovarian cyst torsion (2/21). The postoperative pathology results showed that decidualization occurred in 7 cases, while only 1 case was diagnosed with malignancy, and there appears to be a lack of specific clinical characteristics to distinguish between malignant cysts and de ci du a l I zed cysts. Of the 21 patients, 19 underwent successful follow-up. Among them, 2 cases were preterm births, 1 experienced recurrence, and 2 developed adenomyosis during long-term follow-up. Besides, 9 patients underwent cystectomy during the cesarean section. All the ultrasound findings showed regular and smooth-walled unilocular cysts, with diameters smaller than 6 cm and no apparent growth during pregnancy. Postoperative pathology revealed decidualization in 3 cases, and 1 case experienced recurrence during follow-up.

CONCLUSIONS

OMA presents various changes during pregnancy and caution should also be taken for recurrence after delivery. Surgical intervention is prompted mainly by suspected malignancies which is difficult to distinguish with decidualization, and laparoscopic surgery is relatively safe during mid-pregnancy.

Diagnosing diagnostic error of endometriosis: a secondary analysis of patient experiences from a mixed-methods survey

OBJECTIVE

To analyse endometriosis diagnostic errors made by clinicians as reported by patients with endometriosis.

METHODS

This study deductively analysed qualitative data as part of a larger mixed-methods research study examining 'invalidating communication' by clinicians concerning patients' symptoms. Data analysed were responses to an open-ended prompt asking participants to describe an interaction with a clinician prior to their diagnosis in which they felt their symptoms were dismissed. We used three validated taxonomies for diagnosing diagnostic error (Diagnosis Error Evaluation and Research (DEER), Reliable Diagnosis Challenges (RDC) and generic diagnostic pitfalls taxonomies).

RESULTS

A total of 476 relevant interactions with clinicians were identified from 444 patients to the open-ended prompt, which identified 692 codable units using the DEER taxonomy, 286 codable units using the RDC taxonomy and 602 codable diagnostic pitfalls. Most prevalent subcategories among these three taxonomies were inaccurate/misinterpreted/overlooked critical piece of history data (from DEER Taxonomy; n=291), no specific diagnosis was ever made (from diagnostic pitfalls taxonomy; n=271), and unfamiliar with endometriosis (from RDC Taxonomy; n=144).

CONCLUSION

Examining a series of patient-described diagnostic errors reported by patients with surgically confirmed endometriosis using three validated taxonomies demonstrates numerous areas for improvement. These findings can help patients, clinicians and healthcare organisations better anticipate errors in endometriosis diagnosis and design and implement education efforts and safety to prevent or mitigate such errors.

Patient satisfaction with two different management modalities for erratic bleeding during continuous hormone therapy for endometriosis-associated symptoms: A before-after study

OBJECTIVE

To evaluate patient satisfaction with the management of erratic bleeding during continuous hormone therapy for endometriosis using two different strategies: an active approach (tailored cycling), which involved discontinuation of the therapy; and a passive approach, which involved waiting for spontaneous resolution of the bleeding.

METHODS

This was an observational before-after study. All patients enrolled within a previously defined time limit were instructed to adopt a passive strategy to manage erratic bleeding, while all patients enrolled after that defined time were instructed to discontinue therapy for 7 days (tailored cycling). Degree of satisfaction, characteristics of bleeding, and level of dysmenorrhoea were compared and analysed at the time of enrolment and after 6 and 12 months.

RESULTS

In total, 201 patients were included in the study. Satisfaction was 29% higher among patients in the passive strategy group compared with those in the tailored cycling group; this difference was significant. No significant differences were identified for the other outcomes.

CONCLUSION

Patients may be more satisfied with the use of a passive approach to manage irregular bleeding during continuous hormone therapy for endometriosis-associated pain. All patients should be provided with comprehensive information regarding all available management strategies for unpredictable irregular bleeding. This will enable patients to make informed decisions based on their personal experience and preferences, without external pressure, thus improving compliance, adherence and, ideally, satisfaction with treatment.

Endometriosis Severity and Risk of Preeclampsia: A Combined Mendelian Randomization and Observational Study

Purpose

Endometriosis has been hypothesized to increase the risk of preeclampsia (PE) and eclampsia, although the exact mechanism of this relationship is not clear. This study aimed to further explore the potential association between endometriosis and PE/eclampsia through Mendelian randomization (MR) and confirm these findings in a retrospective cohort study.

Methods

A two-sample MR study was performed using genetic variants associated with endometriosis from the Finnish database, with outcome data for PE and eclampsia from the UK Biobank. Subgroup analyses were conducted based on endometriosis severity (American society of reproductive Medicine (ASRM) stages I-II and III-IV) and anatomical location (uterus, ovary, deep infiltrating endometriosis). Additionally, a retrospective cohort study was conducted to further assess the association, adjusting for confounding factors such as age, Body Mass Index (BMI), dysmenorrhea, history of uterine surgery, and adenomyosis. Multivariate logistic regression was used to analyze the risk of PE/eclampsia based on endometriosis severity.

Results

MR using the Inverse Variance Weighted method found a meaningful association between advanced endometriosis (ASRM stages III-IV) and PE/eclampsia (p = 0.008), while no significant associations were observed for lower stages or endometriosis in the uterus and ovary. In the retrospective cohort, the initial association between the revised American Fertility Society (r-AFS) score and PE/eclampsia (OR: 1.02, 95% CI: 1.01-1.03, p < 0.001) weakened after adjusting for confounders. Significant risk factors identified included age (OR: 1.20, 95% CI: 1.10-1.30, p < 0.001), dysmenorrhea (OR: 2.72, 95% CI: 1.31-5.76, p = 0.008) and adenomyosis showing the strongest association (OR: 9.96, 95% CI: 5.00-20.06, p < 0.001).

Conclusion

The findings suggest a potential relationship between advanced endometriosis and the risk of PE/eclampsia. However, other clinical factors such as age, dysmenorrhea, and adenomyosis appear to contribute more significantly to the risk. Further studies are needed to confirm these findings and clarify the underlying mechanisms.

Endometriosis imaging in the community setting: implementation of the SRU consensus recommendations on routine pelvic US

Endometriosis is a common gynecologic disorder with a significant burden of morbidity that is often subject to substantial diagnostic delay. While transvaginal ultrasound (TVUS) is the first-line imaging tool for symptoms like chronic pelvic pain and infertility, it has limitations in detecting deep endometriosis. In 2024, the Society of Radiologists in Ultrasound (SRU) issued recommendations to enhance detection by incorporating additional techniques into standard TVUS. This article outlines practical adaptations to improve diagnostic accuracy with minimal extra scan time in community practices. It covers patient selection, stakeholder involvement, training, and quality assurance while addressing implementation challenges. Community ultrasound practices play a key role in early detection, guiding patients toward appropriate care.

Endometriosis and autoimmunity

Endometriosis is a female-specific chronic condition that affects 1 in 10 women and other individuals with a uterus worldwide with common symptoms that include pelvic pain and infertility. Reliable and effective non-invasive biomarkers for endometriosis do not exist, and therefore currently a diagnosis of endometriosis requires direct visualization of lesions at surgery. Similarly, few safe and effective management strategies exist for endometriosis, with hormonal interventions and surgery only providing temporary symptom control. The development of endometriosis involves the implantation and proliferation of ectopic endometrial cells which triggers local and systemic inflammation and fibrosis. While multiple genetic, environmental, and lifestyle factors appear to influence the natural history of endometriosis, chronic inflammation is a hallmark feature associated with development and progression of the disease. Data further shows that endometriosis commonly co-occurs with autoimmune diseases, adding evidence that immune dysfunction likely contributes to the pathogenesis of this disorder. Specific innate and adaptive immune system drivers of endometriosis remain to be identified and additional research is needed to elucidate the mechanistic underpinnings of this debilitating disease. In this narrative review, we discuss the shared biological mechanisms and plausible immune-related connections between endometriosis and autoimmunity.

Long-term follow-up of the effect of oral dienogest and dienogest/ethinylestradiol treatment on cell-free DNA levels in patients with deep endometriosis

BACKGROUND

Endometriosis is currently considered a systemic inflammatory disease and different non-invasive inflammatory markers, such as cell-free DNA (cfDNA), have recently been evaluated. Hormonal treatments are frequently prescribed as first-line treatments to improve symptoms, reduce lesions and improve the quality of life of patients with endometriosis. The most frequently used hormonal treatments are estroprogestins and progestins due to their effectiveness and well-tolerated clinical profile. However, the impact these hormonal treatments may have on these markers has yet to be determined. The aim of this study was to assess whether cfDNA levels are modified under the two main first-line hormonal treatments in patients with deep endometriosis (DE).

METHODS

Ninety patients diagnosed with DE were analyzed in this prospective, observational study. Forty-five received daily oral treatment with dienogest 2 mg, and 45 with 2 mg dienogest/30 μg ethinylestradiol. Plasma cfDNA levels were evaluated by fluorescent assay prior to initiation of treatment and at 6 and 12 months of treatment.

RESULTS

An increase in cfDNA levels was observed during the follow-up at 6 and 12 months. However, these higher levels were only statistically significant at 12 months of treatment. The increase of cfDNA levels was similar with both treatments.

CONCLUSION

Higher cfDNA levels were observed in DE patients at 12 months of oral hormonal treatment showing similar results with dienogest or dienogest/ethinylestradiol. This increase could be explained by apoptosis of the endometriosis foci due to the treatment.

Effect of Endometriosis on Disease-Specific Quality of Life

OBJECTIVE

To evaluate disease-specific quality of life (QOL) in women with endometriosis and assess concurrent validity of the Endometriosis Impact Questionnaire (EIQ).

DESIGN

Observational, cross-sectional design.

SETTING

Online survey.

PARTICIPANTS

Women ages 18 to 49 years who self-reported a diagnosis of endometriosis.

MEASUREMENT

Disease-specific QOL was measured with the EIQ and the Endometriosis Health Profile-5 (EHP-5). Health-related QOL was measured with two WHOQOL-BREF questions.

RESULTS

There were 413 participants with complete data included in the analysis. Mean (SD) age at participation was 33.9 (7.1) years and at diagnosis was 28.9 (7.0) years. Responses to the EIQ demonstrated that endometriosis had the greatest effect on QOL through physical-psychosocial symptoms and fertility problems. Lifestyle behaviors related to alcohol and tobacco use were the least affected. Scores on the EHP-5 demonstrated similar results, with social support, self-image, and feelings of control being most impacted. Health-related QOL was also found to be impaired. Participants rated their overall QOL as neither poor nor good and their overall satisfaction with their health as dissatisfied. Concurrent validity for the EIQ was acceptable. Women who reported worse disease-specific QOL on the EIQ also had worse disease-specific QOL on the EHP-5 (p ˂ .01) and worse health-related QOL on the WHOQOL-BREF questions (p ˂ .01).

CONCLUSION

Endometriosis significantly impairs disease-specific QOL in addition to general health-related QOL. The EIQ is a valid measure of disease-specific QOL and can be used to assess the impact of endometriosis on the multiple dimensions of women's lives. It is recommended that providers use this tool to obtain a more in-depth understanding of the effect on QOL and tailor patient-specific care that targets the multidimensions of endometriosis.

Non-invasive blood tests for earlier diagnosis and treatment of endometriosis

Endometriosis is a chronic condition characterized by the presence of endometrial-like tissue outside the uterus, leading to symptoms such as dysmenorrhea and chronic pain. It affects approximately 2-10 % of women of reproductive age and up to 50 % of those experiencing infertility, significantly impacting the healthcare system. Despite its prevalence, endometriosis presents in a variety of forms and phenotypes, partly due to the absence of a non-invasive biomarker for diagnosis. Early detection of endometriosis is crucial for effective management; however, the most dependable diagnostic method currently available is laparoscopy. Many women are reluctant to undergo this surgical procedure, resulting in a substantial number remaining unaware of their condition. This review aims to explore the potential of non-invasive blood tests in developing reliable biomarkers or a combination of biomarkers for the early detection and diagnosis of endometriosis. Innovative therapies such as immunomodulation, stem cell therapy, biosensors, and nanotheranostics present promising avenues for personalized diagnosis and treatment, focusing on genetic, epigenetic, and immunological aspects. The review emphasizes the importance of various biomarkers and the necessity for further research to enhance diagnosis and improve the quality of life for women affected by endometriosis.

Symptom assessment related to the menstrual cycle to predict endometriosis and adenomyosis in university students

OBJECTIVE

To assess the prevalence of self-reported symptoms of endometriosis and adenomyosis among university students and identify potential predictors of these diseases among these symptoms.

METHODS

This cross-sectional study was conducted at a private university in northeastern Brazil. The students were asked to complete an electronic questionnaire using a Google Form link. Participants were asked about general information, the menstrual cycle, and bleeding symptoms. The electronic questionnaire results were compared between two groups: students who self-reported endometriosis/adenomyosis (ENDO/ADENO) and students who self-reported no endometriosis/adenomyosis (NO ENDO/ADENO).

RESULTS

Four (2.9%) students self-reported adenomyosis alone, 26 (18.6%) students self-reported endometriosis alone, and two (1.4%) students self-reported an associated diagnosis of endometriosis and adenomyosis. Participants were divided into two groups: ENDO/ADENO (n=32) and NO ENDO/ADENO (n=108). Participants in the ENDO/ADENO group reported more severe dysmenorrhea, worsening dysmenorrhea in the last 12 months, frequent absence from class, dyspareunia, and dysuria. Worsening dysmenorrhea was a predictor of endometriosis/adenomyosis in university female students (odds ratio = 5.73; 95% confidence interval, 1.91-17.22, p=0.002).

CONCLUSIONS

The assessment of menstrual cycle symptoms can be used as a screening tool for patients at risk of endometriosis/adenomyosis. The progressive worsening of dysmenorrhea in the last 12 months was a predictor of endometriosis/adenomyosis diagnosis.

The endometrioma paradox

Endometriosis is a chronic disease that affects around 10% of reproductive age women worldwide and a common cause of infertility. One of its manifestations is ovarian endometriomas, which are present in 17-44% of endometriosis patients. Endometriomas can impair fertility by mechanical stretching and local inflammation, promoting oxidative stress in the surrounding ovarian cortex that could lead to apoptosis and necrosis of early follicles. The removal of endometriomas may improve spontaneous pregnancy rates, as already demonstrated by some studies. To reduce endometriomas recurrence, it is advised to perform cystectomy followed by hormonal suppression. However, this approach is unfeasible in patients desiring pregnancy. At the same time, cystectomy poses a threat to ovarian reserve and, therefore, to controlled ovarian stimulation. Women who have endometriomas surgically removed are at risk to have diminished response to ovarian stimulation if in vitro fertilization is needed in the future.

Endometriosis and Infertility: Gynecological Examination Practical Guide

Endometriosis, a prevalent gynecological condition affecting 10-15% of reproductive-age women, involves the growth of endometrial-like tissue outside the uterine cavity. This chronic inflammatory disease can significantly impact fertility by disrupting ovulation, tubal transport, and implantation. Clinical manifestations vary widely, ranging from asymptomatic cases to severe pelvic pain, dysmenorrhea, and dyspareunia. Accurate diagnosis remains challenging, often requiring a combination of patient history, clinical examination, and imaging studies. This paper will discuss the clinical approach to endometriosis during a first-line gynecological appointment, focusing on patient history, including detailed assessment of menstrual, pelvic, and bowel symptoms, and clinical examination; thorough gynecological examination, including abdominal and pelvic palpation, speculum examination, and bimanual examination; imaging evaluation (particularly of the role of ultrasound in identifying and characterizing endometriotic lesions, including the use of the #ENZIAN classification for deep infiltrating endometriosis and evaluation of fertility impact); and discussion of the Endometriosis Fertility Index (EFI) as a tool for assessing fertility potential. This comprehensive approach aims to guide clinicians in identifying and managing endometriosis effectively, improving patient outcomes and optimizing fertility management strategies. Methods: A literature search for suitable articles published from January 1974 to 2024 in the English language was performed using PubMed. Results: Endometriosis is associated with infertility rates ranging from 20% to 68%, with mechanisms including pelvic adhesions, chronic inflammation, and immune dysregulation. The revised American Society for Reproductive Medicine (rASRM) classification and #ENZIAN classification were identified as essential tools for staging and characterizing the disease. Transvaginal ultrasound (TVS) demonstrated high diagnostic accuracy for deep infiltrating endometriosis, with a sensitivity of up to 96% and specificity of 99%. EFI emerged as a valuable predictor of natural conception post-surgery. Additionally, the review underscores the frequent co-occurrence of adenomyosis in women with endometriosis, which may further compromise fertility. Despite advancements in imaging techniques and classification systems, the variability in symptom presentation and disease progression continues to challenge early diagnosis and effective management. Conclusions: Endometriosis is a prevalent gynecological condition affecting women of reproductive age and is associated with infertility. This paper describes the diagnostic approach to endometriosis during a first-line gynecological appointment, focusing on clinical history, physical examination, and the role of imaging, particularly ultrasound, in identifying and characterizing endometriosis lesions. The adoption of standardized classification systems such as #ENZIAN and EFI enhances disease staging and fertility prognosis, allowing for tailored treatment strategies. Despite improvements in non-invasive diagnostic methods, challenges persist in correlating symptom severity with disease extent, necessitating continued research into biomarkers and novel imaging techniques. Additionally, the frequent coexistence of adenomyosis further complicates fertility outcomes, underscoring the need for comprehensive management strategies. Further research is needed to enhance early detection strategies and optimize fertility preservation techniques for affected women.

Predictive value of homocysteine levels in embryo culture media for embryo selection in infertile patients with endometriosis

Objective

To investigate the possible ability of homocysteine (Hcy) levels in embryo culture media for estimating better invitro fertilization outcomes in endometriosis patients.

Materials and Methods

Nineteen women with endometriosis who were admitted to Cerrahpaşa Medical Faculty, Department of Obstetrics and Gynecology, Infertility Outpatient Clinic with the diagnosis of infertility were included in the study. The results of intracytoplasmic sperm injection treatments were recorded and Hcy levels in the embryo culture were evaluated. The results were compared with those of the control patients without endometriosis, who had previously been admitted to our clinic for assisted reproductive technology.

Results

Mean Hcy levels in the culture media of the endometriosis group and non-endometriosis group were 4.31±0.48 µmol/L and 4.15±1.44 µmol/L, respectively (p>0.05). Pregnancy was achieved in 3 patients in the endometriosis group, while 13 pregnancies were obtained in the non-endometriosis group (p>0.05). When all cases were evaluated, the mean value of Hcy in the culture medium was found to be 3.60±0.84 µmol/L in the patients with a pregnancy and 4.21±0.84 µmol/L in the group that failed to achieve a pregnancy, and this difference was statistically significant (p<0.05).

Conclusion

Difference between mean Hcy levels in the culture media of the endometriosis group and non-endometriosis group was statistically non-significant. Further studies with larger groups are needed for evaluating the association of Hcy with infertility in endometriosis patients. Mean Hcy levels in the group of patients who succeeded in conceiving were statistically higher than the group of patients who failed to conceive. It may be suggested that Hcy levels in the embryo culture media can predict the achievement of a pregnancy independently from some conditions which may adversely affect the embryo quality, such as endometriosis.

Evaluation of Long-COVID Syndrome in a Cohort of Patients with Endometriosis or Adenomyosis

Background: Long-COVID is characterized by the persistency of COVID-19 symptoms beyond 12 weeks, and it is probably consequent to immune dysregulation induced by SARS-CoV-2 infection. Immune dysregulation is associated with and probably involved in the pathogenesis of chronic gynecological conditions like endometriosis and adenomyosis. This study evaluated whether the presence of endometriosis or adenomyosis increases the risk of long-COVID, i.e., the persistence of COVID-19 symptoms beyond 12 weeks since infection. Methods: This retrospective observational study was performed at the outpatient service for endometriosis and chronic pelvic pain, at a university hospital. The diagnosis of endometriosis/adenomyosis was primarily based on clinical symptoms and ultrasonography assessment. Data regarding infection, vaccination, symptoms associated with SARS-CoV-2 infection, and their persistence for a minimum of 12 weeks were collected. Results: This study included 247 women, 149 controls without and 98 cases with endometriosis/adenomyosis. Among these, 194 (116 controls and 78 cases) had suffered from SARS-CoV-2 infection. Rates of infection and vaccination were similar in the two groups. The distribution of the SARS-CoV-2 vaccine was uniform across the two cohorts. COVID-19 patients with endometriosis or adenomyosis exhibited a higher prevalence (p < 0.001) of dyspnea and chest pain. The prevalence of long-COVID beyond 12 weeks was higher in cases than controls (42% vs. 12%; p < 0.001) with chest pain (p < 0.001) and ageusia (p < 0.05), forming the most representative symptoms. Conclusions: Symptoms of long-COVID are more frequent in women with than without endometriosis/adenomyosis.

A Potential Link Between Oral Microbiota and Female Reproductive Health

Oral cavity dysbiosis is associated with numerous inflammatory diseases, including diabetes, inflammatory bowel diseases, and periodontal disease. Changes in the oral microenvironment lead to bidirectional interactions between pathogens and individual host systems, which may induce systemic inflammation. There is increasing evidence linking the condition of the oral cavity with the most common causes of female infertility, such as polycystic ovary syndrome and endometriosis, as well as gestational complications, e.g., low birth weight, preterm delivery, and miscarriages. This review highlights the composition of the female oral microbiome in relation to infertility-related disorders, such as endometriosis and polycystic ovary syndrome, and provides a comprehensive overview of the current state of knowledge on the relationship between a dysbiotic oral microbiome, pregnancy, and its impact on the female reproductive tract.

Conservative endometrioma surgery: The combined technique versus CO2-laser vaporization only (BLAST: Belgium LAser STudy): Clinical protocol for a multicenter randomized controlled trial

BACKGROUND

The surgical management of endometrioma(s) remains challenging. Although laparoscopic surgery is a well-established treatment of endometrioma(s), caution is required to minimize ovarian damage. Several surgical techniques have been described to treat endometrioma(s): classical cystectomy, ablative techniques, or a combination of both. As cystectomy is strongly associated with a reduction in ovarian reserve, this randomized controlled trial (RCT) aims to determine to what extent the two other surgical procedures may affect ovarian reserve by comparing changes in serum anti-Müllerian hormone (AMH) levels concentrations after each type of surgery.

METHODS

This is a multicenter, non-blinded, RCT with parallel groups (group 1 (combined technique) versus group 2 (CO2 laser vaporization only)) and allocation 1:1. Four Belgian centers will be involved. Main inclusion criteria are symptomatic patients (pain and/or infertility), 18-40 years (both inclusive) with an endometriotic cyst (mean diameter of ≥ 2.5 cm and ≤ 8 cm) and AMH level ≥ 0.7 ng/mL. Suspicion of malignancy, a contralateral endometrioma of > 2 cm, use of gonadotrophin-releasing hormone (GnRH) analogues around timing of surgery or previous oophorectomy are exclusion criteria. The primary aim is the evaluation of the difference in serum AMH levels between baseline and 3 months postoperatively (or delta AMH). The secondary outcomes include differences in AMH levels at 6 and 12 months postoperatively, cyst recurrence rate, evolution of pain pattern and fertility outcomes.

DISCUSSION

The present study will help us to answer the question on which surgical technique for endometrioma(s) has the most favorable outcome in patients wishing to preserve their reproductive potential.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04151433. Registered on November 5th, 2019.

Pelvic peritoneal endometriosis is linked to the endometrial inflammatory profile: a prospective cohort study

BACKGROUND

Pelvic endometriosis is an estrogen-driven inflammatory syndrome of unknown origin that alters the peritoneal microenvironment and likely impairs endometrial receptivity, adversely affecting fertility. Chronic endometritis (CE) may be a potential contributing factor to reduced endometrial receptivity in endometriosis. The aim of the study was to analyze the correlation between pelvic endometriosis and CE.

METHODS

The study included women undergoing laparoscopy for suspected pelvic endometriosis, and each underwent endometrial aspiration biopsy for CE. The stage of endometriosis was assessed intraoperatively, and CE activity was evaluated histopathologically and immunohistochemically. The associations between selected clinical characteristics of the disease and the density of endometrial plasma cells, immunohistochemical status, and histopathological profile of the endometrium were analyzed.

RESULTS

Stage III endometriosis reduced the risk of the inflammatory immunohistochemical profile by 80% (OR = 0.18, p = 0.037) when compared to Stage I. Peritoneal endometriosis was associated with a 3.429-fold increase in the risk of the immunohistochemical endometrial inflammatory profile (OR = 3.429, p = 0.038). No significant associations were found between the clinical features of the disease and plasma cell density or the histopathological profile of the endometrium (all p values > 0.05). No significant differences were observed in IVF use (p = 0.67), pregnancy rates (p = 1), or live birth rates (p = 0.41) between infertile women with and without CE.

CONCLUSIONS

Should peritoneal endometriosis be diagnosed during a laparoscopy conducted for the treatment of infertility, it is advisable to obtain an endometrial biopsy for CE evaluation, as this may enhance the efficacy of the therapeutic approach. The hypothetical link between pelvic endometriosis-related inflammation, its clinical manifestations, and CE requires further investigation. The lack of a noninvasive marker for endometriosis and its grade limits the study results due to reliance on surgical cases, highlighting the need for advanced research in the field of noninvasive diagnostic tools.

TRIAL REGISTRATION

NCT05824507 (registered April 20, 2023).

Impact of deep or ovarian endometriosis on pelvic pain and quality of life: prospective cross-sectional ultrasound study

OBJECTIVE

To assess whether premenopausal women diagnosed with deep or ovarian endometriosis on transvaginal sonography (TVS) were more likely to suffer from dyspareunia and pelvic pain symptoms, and have a lower quality of life, compared to women without sonographically diagnosed deep or ovarian endometriosis.

METHODS

This was a prospective, cross-sectional study carried out between February 2019 and October 2020 at the general gynecology clinic at University College London Hospital, London, UK. All premenopausal women aged 18-50 years, who were examined consecutively by a single experienced examiner and underwent a detailed TVS scan, were eligible for inclusion. Pregnant women and those who had received a previous diagnosis of endometriosis or who had experienced a hysterectomy or unilateral/bilateral oophorectomy were excluded. Sonographic findings consistent with deep or ovarian endometriosis were noted. All women completed the British Society of Gynaecological Endoscopy pelvic pain questionnaire. The primary outcome was to determine whether women with sonographic evidence of endometriosis were more likely to experience moderate-to-severe levels of dyspareunia (score of ≥ 4 on an 11-point numerical rating scale (NRS)). Secondary outcomes included assessing moderate-to-severe levels of other pelvic pain symptoms (NRS score of ≥ 4), bowel symptoms (score of ≥ 2 on a 5-point Likert scale) and quality of life, which was measured using the EuroQol-5D-3L (EQ-5D) questionnaire. The number of women with pain scores ≥ 4 and bowel scores ≥ 2, as well as the mean EQ-5D scores, were compared between the group with and that without sonographic evidence of endometriosis using logistic regression analysis, and multivariable analysis was used to adjust for demographic and clinical variables.

RESULTS

A total of 514 women were included in the final study population, of whom 146 (28.4%) were diagnosed with deep or ovarian endometriosis on TVS. On multivariable analysis, the presence of moderate-to-severe dyspareunia was not found to be associated with endometriosis. Moderate-to-severe dyspareunia was significantly associated with lower age (odds ratio (OR), 0.70 (95% CI, 0.56-0.89); P = 0.003) and a history of migraine (OR, 3.52 (95% CI, 1.42-8.77); P = 0.007), and it occurred significantly less frequently in women with non-endometriotic ovarian cysts (OR, 0.47 (95% CI, 0.28-0.78); P = 0.003). There was also a trend towards a positive association between anxiety/depression and moderate-to-severe dyspareunia (OR, 1.94 (95% CI, 0.93-4.03); P = 0.08). Following multivariable analysis, the only symptoms that were significantly more common in women with endometriosis compared to those without were menstrual dyschezia (OR, 2.44 (95% CI, 1.59-3.78); P < 0.001) and difficulty emptying the bladder (OR, 2.56 (95% CI, 1.52-4.31); P < 0.001). Although not reaching statistical significance on multivariable analysis, dysmenorrhea (OR, 1.72 (95% CI, 0.92-3.20); P = 0.09) and lower EQ-5D score (mean ± SD, 0.67 ± 0.33 vs 0.72 ± 0.28; P = 0.06) also occurred more frequently in women with sonographic evidence of endometriosis.

CONCLUSIONS

The majority of pelvic pain symptoms did not differ significantly between women with and those without sonographic evidence of endometriosis, indicating that endometriosis may not always be the source of pelvic pain, even if present. This highlights the need to rule out other causes of pain in symptomatic endometriosis patients before considering surgical procedures, and to provide appropriate patient counseling. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Weighing up GnRH agonist therapy for endometriosis: outcomes and the treatment paradigm

INTRODUCTION

Endometriosis is a chronic inflammatory estrogen-dependent disease affecting 10% of women worldwide leading to chronic pelvic pain and infertility which may be treated clinically or surgically.

AREAS COVERED

Current literature was reviewed using the keywords 'gonadotropin releasing hormone agonists (GnRHa),' 'endometriosis,' 'infertility' and 'chronic pelvic pain.' Relevant papers prioritizing randomized controlled clinical trials (RCT), systematic reviews, meta-analyses, as well as international guidelines were evaluated.

EXPERT OPINION

Available options for relieving endometriosis-associated pain include GnRHa, progestagens, and combined oral contraceptives, all of which block menstruation to control symptoms without curing the disease. GnRHa administration decreases pain and symptom recurrence after surgical treatment, but side effects and costs limit its use. Published studies to test its effectiveness in easing endometriosis-associated pain are heterogeneous, consider different outcomes with no long-term results. Drug choice should be individualized considering the side-effect profile, tolerability, costs, risks, and benefits as one size does not fit all. As we wait for the development of an ideal pharmacological agents, GnRHa with an add-back regimen remains a second-line option to alleviate the painful symptoms in women with endometriosis. Endometriosis management should consider the systemic nature of the disease and the complexity involved in the pathogenesis of symptoms.

The Development and Validation of a Patient Questionnaire Tool for the Assessment of Patient-Reported Experiences With Endometriosis Ultrasound

OBJECTIVES

Endometriosis ultrasound is an accurate, cost-effective, and non-invasive diagnostic tool that can help improve the diagnostic delay that patients with endometriosis experience. As an emerging diagnostic method, the perspectives of patients undergoing endometriosis ultrasound remain unexplored. Therefore, the objective of this study was to develop and validate an assessment tool that evaluates patient-reported experiences with endometriosis ultrasound as a decision-making tool.

METHODS

This was a 2-part study with the first phase involving a modified Delphi consensus process including a panel of clinicians, sonologists, researchers, and a patient with lived experience of endometriosis. Pre- and post-ultrasound patient questionnaires were subsequently developed. The second phase included validating the questionnaires via a prospective cross-sectional survey study carried out at the Endometriosis Clinic at McMaster University Medical Centre in Hamilton, Canada. Data were analyzed using measures of central tendency, chi-square test, and Fisher exact test as appropriate. Statistical significance was determined by 2-sided P values less than 0.05.

RESULTS

Pre- and post-ultrasound questionnaires were developed comprising 8 and 10 questions, respectively. Of 46 respondents, there was a similar representation of patients with an abnormal endometriosis ultrasound (58.7% of patients, n = 27) and those with a normal endometriosis ultrasound (41.3 %, n = 19). Moreover, endometriosis ultrasound results helped most participants (84.8%, n = 39) with treatment decision-making.

CONCLUSIONS

This study validates a survey tool that can be used clinically to assess patient-reported experiences with endometriosis ultrasound. It also demonstrates the highly informative nature of endometriosis ultrasound, with many patients choosing to defer more invasive diagnostic methods (i.e., surgery).

The investigation and management of recurrent early pregnancy loss: a Canadian Fertility and Andrology Society clinical practice guideline

This guideline defines recurrent early pregnancy loss (REPL) as two or more losses that occur before 10 weeks gestational age and includes non-consecutive and biochemical losses. Investigations should be considered on an individual basis and may include an evaluation of genetic, anatomical, endocrinological, structural and male-associated factors. Based on the findings and available resources, options for management may include preimplantation genetic testing (PGT) for aneuploidies or PGT for chromosomal structural rearrangements, progesterone supplementation and supportive care. This guideline emphasizes a personalized approach to the problem of REPL, recognizing an overall promising prognosis for this patient population and the avoidance of treatment options that have not been shown to be of benefit.

The effect of endometriosis on oocyte quality: mechanisms, diagnosis and treatment

Endometriosis significantly impacts the physical and mental health of women of reproductive age. While some patients can achieve pregnancy through surgery or in vitro fertilization (IVF), many still struggle with IVF failure due to poor oocyte quality. This presents a major clinical challenge that requires immediate attention. The causes of oocyte quality decline in endometriosis patients are diverse and have not yet been definitively identified. Furthermore, effective diagnostic mechanisms and therapeutic strategies remain elusive. To provide possible clinical solutions to improve pregnancy rates in patients with endometriosis, this review evaluates the current literature on the impact of endometriosis on oocyte quality, the possible mechanisms and management strategies of endometriosis leading to poor oocyte quality.