Endometriosis and fertility: women's accounts of healthcare

Emotions of endometriosis in clinical encounters: An analysis of women's experiences of health care

BACKGROUND

A large number of illnesses that lack physical visibility are characterised by troubled clinical encounters. Endometriosis is one such condition with very real and often debilitating symptoms that remain invisible to the clinician's eye, but are experienced and lived by the patient.

METHOD

This paper probes into two first person accounts of endometriosis to find out how endometriosis patients experience health care. The Tiger and the Cage: A Memoir of a Body in Crisis (2022) by Emma Bolden and Vagina Problems: Endometriosis, Painful Sex, and Other Taboo Topics (2020) by Lara Parker are both memoirs that details on the trivialisation and delegitimization of the women's accounts of their own lived reality by a health care system that often privileges medical evidence over lived experiences of the patients. After giving a brief introduction on the condition, the paper goes on to detail on the method and conceptual frameworks chosen for analysis. This is followed by an in-depth analysis into the two texts using thematic analysis proposed by Virginia Braun and Victoria Clarke to identify shared patterns of meanings in the texts.

DISCUSSION

The identified themes take the form of emotions repeatedly narrated by the women. The findings indicate instances of disrespect, epistemic invalidation and compromised autonomy, due to which six shared categories of negative emotions are experienced by the patients: self-doubt, shame, fear, powerlessness, self-blame and anger.

CONCLUSION

The paper concludes by indicating the urgency of improved medical training, that better educates and facilitates health care professionals in dealing with conditions with complicated aetiology, difficult diagnosis and no cure.

Quality of life and symptoms of pain in patients with endometriomas compared to those with other endometriosis lesions: a cross-sectional study

BACKGROUND

Endometriomas are genetically distinct from other endometriosis lesions and could be associated with a predisposition to excessive inflammation. However, differences in clinical presentation between types of endometriosis lesions have not been fully elucidated. This study aimed to investigate the quality of life and pain scores of patients with endometriomas compared to those with other types of endometriosis lesions.

METHODS

A cross-sectional observational study was conducted between January 2020 and August 2023. Patients diagnosed with endometriosis completed the Endometriosis Health Profile 30 pain subscale questionnaire for their quality of life score and rated their endometriosis-associated pain symptoms using an 11-point numerical rating scale. The data were analyzed for comparison through multivariate linear regression models.

RESULTS

A total of 248 patients were included and divided into endometrioma (81, 33%) and nonendometrioma (167, 67%) groups. The mean age of the patients was 37.1 ± 7.5 years. Most participants were Canadian or North American (84%). One-third of the patients reported experiencing up to four concurrent pain symptoms. The most reported pain included deep dyspareunia (90%), chronic pelvic pain (84%) and lower back pain (81%). The mean quality of life score was 45.9 ± 25.9. We observed no difference in quality of life scores between patients with and without endometriomas. Patients with endometriomas had lower mean scores for deep dyspareunia (0.8; 95% CI [0 to 1.5]; p = 0.049) and higher mean scores for superficial dyspareunia (1.4; 95% CI [0.2 to 2.6]; p = 0.028). Comorbid infertility (p = 0.049) was a factor that modified superficial dyspareunia intensity in patients with endometriomas.

CONCLUSION

In patients with endometriosis, evidence was insufficient to conclude that the presence of endometriomas was not associated with a greater or lesser quality of life, but differences in specific symptoms of dyspareunia were identified.

Experiences of communication in women with endometriosis: perceived validation and invalidation in different contexts, and associations with health-related quality of life

Endometriosis, a chronic gynecological disease affecting approximately 10% of women of reproductive age, has a significant impact on physical and mental health. This cross-sectional study aimed to explore experiences of validating and invalidating communication in three contexts (with healthcare providers, employers, and family/friends), and whether this may predict health-related quality of life (HRQoL) in women with endometriosis. Data was collected through a digital survey distributed to women with self-reported endometriosis in Sweden. The survey included measures of validating and invalidating communication, depressive symptoms, anxiety, and HRQoL. A total of 427 women participated. The results indicated that women experienced varying levels of validating and invalidating communication in different contexts, with close family/friends providing the highest level of validation, and healthcare providers the lowest. Furthermore, a combined construct of high levels of validation and low levels of invalidation from healthcare providers and from close family and friends were significant predictors of HRQoL. These findings highlight the importance of supportive communication and understanding from healthcare providers and close social networks in promoting the well-being of women with endometriosis. Future research should further explore the impact of validating communication within healthcare settings and develop interventions to improve communication and support for women with endometriosis.

Patient experiences of being advised by a healthcare professional to get pregnant to manage or treat endometriosis: a cross-sectional study

BACKGROUND

There is a lack of evidence that pregnancy reduces endometriotic lesions or symptoms, however studies indicate that people with endometriosis are commonly advised to get pregnant to manage or treat endometriosis. This study sought to examine the impact of this advice on patients with endometriosis when the advice was provided by healthcare professionals.

METHODS

The Endometriosis Patient Experience Survey was a self-reported, community-based, cross-sectional online survey of people who had been medically diagnosed with endometriosis. Descriptive statistics were used to analyse the quantitative survey data and thematic analysis was undertaken for the qualitative survey data.

RESULTS

1892 participants had received the advice to get pregnant or have a baby to manage or treat their endometriosis, with 89.4% of participants receiving this advice from healthcare professionals. In exploring the qualitative data, seven themes were contextualised relating to the impact of this advice in terms of health literacy, accepting the advice, rejecting the advice, major life decisions, healthcare interactions, mental health and relationships.

CONCLUSIONS

This study demonstrates profound and often negative patient impacts of the advice from healthcare professionals to get pregnant to manage or treat endometriosis. Impacts ranged from planning for pregnancy, hastening the making of major life decisions, eroding trust with healthcare professionals, worsening mental health and straining relationships. Providing evidence-based information on the treatment and management of endometriosis is essential. Pregnancy or having a baby should not be suggested as a treatment for endometriosis and the provision of this advice by healthcare professionals can have negative impacts on those who receive it.

Cannabis and Endometriosis: The Roles of the Gut Microbiota and the Endocannabinoid System

Endometriosis, a chronic condition affecting around 10-14% of women, is challenging to manage, due to its complex pathogenesis and limited treatment options. Research has suggested a potential role of the gut microbiota and the endocannabinoid system in the development and progression of endometriosis. This narrative review aims to explore the role of, and any potential interactions between, the endocannabinoid system (ECS) and the gut microbiota in endometriosis. This review found that both the ECS and microbiota influence endometriosis, with the former regulating inflammation and pain perception and the latter influencing immune responses and hormonal balance. There is evidence that a dysregulation of the endocannabinoid system and the gut microbiota influence endometriosis symptoms and progression via changes in CB1 receptor expression and increased circulating levels of endocannabinoids. Microbial imbalances in the gut, such as increases in Prevotella, have been directly correlated to increased bloating, a common endometriosis symptom, while increases in E. coli have supported the bacterial contamination hypothesis as a potential pathway for endometriosis pathogenesis. These microbial imbalances have been correlated with increases in inflammatory markers such as TNF-α and IL-6, both often raised in those with endometriosis. Protective effects of the ECS on the gut were observed by increases in endocannabinoids, including 2-AG, resulting in decreased inflammation and improved gut permeability. Given these findings, both the ECS and the gut microbiota may be targets for therapeutic interventions for endometriosis; however, clinical studies are required to determine effectiveness.

Women's lived experience of endometriosis-related fertility issues

OBJECTIVE

The aim of the present study is to conduct a qualitative investigation to provide a deeper understanding of women's views about endometriosis, fertility and their perception of reproductive options.

METHODS

Semi-structured interviews were conducted by two female psychiatrists, specialized in gynecology and obstetrical consultation-liaison psychiatry, trained in qualitative procedures, with experience in qualitative studies and in psychological support of women attending infertility consultations. No prior relationship with respondents was established before data collection. Interviews were tape-recorded and transcribed. Interviews lasted 45-75 minutes. The transcripts were then analysed using thematic content analysis.

RESULTS

Twenty-nine women were contacted. Twelve agreed to an interview at the hospital's infertility clinic. Eleven women with diverse sociodemographic characteristics were included. The key findings of thematic content analysis can be grouped into four topics: (1) Diagnostic announcement and initial delay; (2) Negative perceptions of initial care: pre-diagnosis phase; (3) Struggle with endometriosis and its treatment; (4) Issues related to health problems, fertility and reproductive options.

CONCLUSION

Our analysis of the interviews corroborates the distressing impact of the trivialization of pain and the uncertainty of or the long quest for diagnosis. The findings also stress various associated issues, from the diagnostic delay to the low success rates of fertility treatments. This qualitative analysis contributes to better understand the accumulation of negative emotions within the illness trajectory and the poor dyadic adjustment within the couple.

Endometriosis research priorities in Australia

In Australia, endometriosis affects one in nine women and those assigned female at birth. Although endometriosis is more common than conditions such as diabetes, research funding for endometriosis research has historically been low in comparison. The National Action Plan for Endometriosis is an Australian Federal Government initiative designed to redress this imbalance, with a focus on research funding. Identification of research priorities, and subsequent funding allocation that is determined by consumer input is vital. An online survey focusing on Australia and New Zealand found that the highest general priorities were the treatment and management of endometriosis and its cause(s).

Demographic and clinical characteristics determining patient-centeredness in endometriosis care

PURPOSE

The primary aim of this study was to assess patient-centeredness of endometriosis care in a national sample of Swedish women with endometriosis. The secondary aims were to assess the importance of different dimensions of endometriosis care and to analyze demographic and clinical determinants associated with the experience of patient-centeredness.

METHODS

This cross-sectional study included 476 women with confirmed endometriosis. An invitation to participate was sent to 1000 randomly selected women aged ≥ 18 years having any endometriosis diagnosis and who had visited a gynecological clinic due to endometriosis problems any time during the past five years. Participants were recruited from ten different-sized gynecology clinics all over Sweden. The invitation letter had a link to the digital survey, which consisted of demographic and clinical questions, and the ENDOCARE questionnaire (ECQ). ECQ measures experiences, importance and patient-centeredness of ten dimensions of endometriosis care. Univariate and multiple regression analyses were used to analyze which patient-specific demographic and clinical determinants were associated with the experience of patient-centeredness.

RESULTS

The response rate was 48%. The results indicate that Swedish women with endometriosis experience low patient-centeredness and rate relational aspects with healthcare professionals as the most important aspects of care. Having a gynecologist with patient responsibility was an independent predictor for high patient-centeredness.

CONCLUSION

Women with endometriosis in Sweden experience low patient-centeredness, reflecting the urgent need for improvement. More effort should be given to develop the relational aspects of care. Women with endometriosis should have a responsible gynecologist to care for treatment and follow-up.

Naturopathic knowledge and approaches to managing endometriosis: a cross-sectional survey of naturopaths with experience in endometriosis care

OBJECTIVES

Endometriosis is a chronic gynaecological disease with varying symptomatology and negative health outcomes. To ensure the best care for women with endometriosis, women require a multidisciplinary team approach. While some women consult with naturopaths for endometriosis, there has been little research on naturopathic knowledge and the naturopathic approach to endometriosis care.

METHODS

This cross-sectional survey recruited naturopaths with experience in menstrual disorders from the Practitioner Research and Collaboration Initiative (PRACI) a Practice-Based Research Network (PBRN). Data collection was conducted via an online self-administrated 62-item questionnaire.

RESULTS

Invitations were sent to 109 naturopaths who self-reported having experience in menstrual disorders, of whom 29 completed the survey (26.6% response rate). Naturopaths perceived endometriosis to be caused by inflammation (n=28, 96.5%) and risk factors associated with familial history (n=26, 89.6%). Many naturopaths aimed at reducing inflammation (n=27, 93.1%) and supporting gastrointestinal function (n=25, 86.2%) in their prescriptions. Naturopaths reported using various healthcare referrals to support women with endometriosis, primarily general practitioners (n=12, 41.3%), acupuncturists/Traditional Chinese Medicine practitioners (n=11, 37.9%), and gynaecologists (n=9, 31%). Naturopaths reported receiving referrals from general practitioners (n=8, 27.5%) and psychologists (n=6, 20.6%).

CONCLUSIONS

Naturopathic knowledge and management of endometriosis targets known problematic areas of endometriosis that can have debilitating effects on women's quality of life. Naturopathic care has the potential to align with important health outcomes for women with endometriosis however, further attention is needed to assess the effectiveness and continue to establish a multidisciplinary approach involving naturopathic care.

Exploring Medical Egg Freezing as a Disease Management Strategy

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

Evaluation of a web-based resource to improve menstrual health literacy and self-management in young women

OBJECTIVE

Menstrual cycle-related conditions, such as dysmenorrhea and heavy bleeding, are common amongst those under 25 years. Despite having significant impact on work, education, and social activities, most do not seek medical advice, preferring to self-manage their symptoms. We aimed to determine if access to a web-based resource was a feasible and acceptable method for improving menstrual health literacy and encouraging health seeking behavior.

METHODS

People were eligible to participate if they were currently living in Australia, aged 14-25 years, and had menstruated for at least 12 months. Access to the resource, comprising evidence-based information on the menstrual cycle, the Period ImPact and Pain Assessment (PIPPA) tool, and guidance on self-management options, was provided for three menstrual cycles.

RESULTS

Seventy-five participants with a mean age of 20.4 years were enrolled with 56 (75%) providing pre and post measures. Recruitment rate and retention rates met pre-specified criteria for feasibility. Eighty five percent of the participants reported the web-based resource was easy to use, and 90% reported they found the information provided 'very helpful'. Just under half (48%) reported the resource changed what they thought was a 'normal' period. Forty-three percent visited their doctor regarding their menstrual symptoms during the study period, with 84% indicating that they made the appointment due to the resource; over half (56%) who visited their doctor received a referral to a gynecologist.

CONCLUSION

Access to a web-based resource on menstrual health literacy was found to be acceptable and feasible to young people and may encourage health-seeking behavior.

Psychosocial correlates of symptoms of depression among patients with endometriosis in the United Kingdom

A recent study found high levels (43%) of moderate to severe symptoms of depression among patients diagnosed with endometriosis in South Africa (SA) and identified several psychosocial predictors of these symptoms of depression. However, there is limited research on predictors of symptoms of depression in other settings. Considering the contextual differences between SA and the United Kingdom (UK) and their vastly different healthcare settings, we conducted a replication study in the UK and improved on the methodology by adding an established measure of sexual dysfunction to the model and obtaining a larger sample. The study comprised of a secondary analysis of cross-sectional data collected among patients with endometriosis. Study particulars were advertised by a national endometriosis association and data were collected online using Qualtrics. The sample consisted of 598 adults with self-reported endometriosis who completed measures assessing symptoms of depression, physical functioning, menstrual characteristics, sexual functioning, feelings about the medical profession, feelings about infertility, and sexual relationships. Seventy-one percent of participants reported moderate to severe levels of symptoms of depression. In addition, physical functioning, concerns about menstrual characteristics, sexual dysfunction, feelings about infertility and feelings about the medical profession were identified as significant predictors of symptoms of depression. It is important that healthcare professionals recognize that patients with endometriosis may be at risk of depression and that psychological referral should be considered.

Lessons from implementing the Australian National Action Plan for Endometriosis

Abstract

Endometriosis is a common yet under-recognised chronic disease with one in nine (more than 830,000) women and those assigned female at birth diagnosed with endometriosis by the age of 44 years in Australia. In 2018, Australia was the first country to develop a roadmap and blueprint to tackle endometriosis in a nationwide, coordinated manner. This blueprint is outlined in the National Action Plan for Endometriosis (NAPE), created from a partnership between government, endometriosis experts and advocacy groups. The NAPE aims to improve patient outcomes in the areas of awareness and education, clinical management and care and research. As researchers and clinicians are working to improve the lives of those with endometriosis, we discuss our experiences since the launch of the plan to highlight areas of consideration by other countries when developing research priorities and clinical plans. Historically, major barriers for those with endometriosis have been twofold; first, obtaining a diagnosis and secondly, effective symptom management post-diagnosis. In recent years, there have been calls to move away from the historically accepted 'gold-standard' surgical diagnosis and single-provider specialist care. As there are currently no reliable biomarkers for endometriosis diagnosis, specialist endometriosis scans and MRI incorporating artificial intelligence offer a novel method of visualisation and promising affordable non-invasive diagnostic tool incorporating well-established technologies. The recognised challenges of ongoing pain and symptom management, a holistic interdisciplinary care approach and access to a chronic disease management plan, could lead to improved patient outcomes while reducing healthcare costs.

Lay summary

Endometriosis is a chronic disease where tissue like the lining of the uterus is found in other locations around the body. For the 830,000 people living with endometriosis in Australia, this often results in an immense burden on all aspects of daily life. In 2018, Australia was the first country to introduce a roadmap and blueprint to tackle endometriosis in a nationwide coordinated manner with the National Action Plan for Endometriosis. This plan was created as a partnership between government, endometriosis experts and advocacy groups. There are several other countries who are now considering similar plans to address the burden of endometriosis. As researchers and clinicians are working to improve the lives of those with endometriosis, we share our experiences and discuss areas that should be considered when developing these national plans, including diagnostic pathways without the need for surgery, and building new centres of expertise in Endometriosis and Pelvic Pain.

Self-management factors associated with quality of life among women with endometriosis: a cross-sectional Australian survey

STUDY QUESTION

What self-management factors are associated with quality of life among women with endometriosis?

SUMMARY ANSWER

Greater self-efficacy was associated with improved physical and mental quality of life.

WHAT IS KNOWN ALREADY

Women with endometriosis have an impaired quality of life compared to the general female population. However, most studies have investigated quality of life in a hospital or clinic setting rather than a community setting and the association between self-management factors and quality of life have not, to date, been investigated.

STUDY DESIGN, SIZE, DURATION

A cross-sectional, population-based online survey was performed, which was advertised through women's, community and endometriosis-specific groups.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 620 women completed the survey for this study. Mental and physical quality of life was assessed using the standardized SF36v2 questionnaire. Self-management factors included self-efficacy, partners in health (active involvement in managing the condition) and performance of self-care activities. Treatment approaches included the use of hormonal treatment, pain medications and complementary therapies and whether the participant had a chronic disease management plan. Hierarchical regression analyses were used to examine whether self-management and treatment factors were associated with quality of life.

MAIN RESULTS AND THE ROLE OF CHANCE

Both physical and mental quality of life were significantly lower among women with endometriosis compared to the mean scores of the general Australian female population (P < 0.001). Physical quality of life was positively associated with income sufficiency (P < 0.001) and greater self-efficacy (P < 0.001), but negatively associated with age (P < 0.001), pain severity (P < 0.001), use of prescription medications (P < 0.001), having a chronic disease management plan (P < 0.05) and number of self-care activities (P < 0.05). Mental quality of life was positively associated with being older (P < 0.001), partnered (P < 0.001), having a university education (P < 0.05), increasing self-efficacy (P < 0.001) and higher partners in health scores (P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

Results are derived from a cross-sectional study and can only be interpreted as associations not as causal relationships. The sample was more educated, more likely to speak English and be born in Australia than the general Australian female population of the same age, which may influence the generalizability of these results.

WIDER IMPLICATIONS OF THE FINDINGS

This study investigated a knowledge gap by investigating quality of life of women with endometriosis in a large community sample. Self-efficacy was significantly associated with both physical and mental quality of life. Supporting women with endometriosis to improve self-efficacy through a structured chronic disease management programme may lead to improvements in this aspect of wellbeing.

STUDY FUNDING/COMPETING INTEREST(S)

R.O. undertook this research as part of her PhD at Monash University, which was supported by an Australian Government Research Training Program Stipend. J.F. is the Finkel Professor of Global Public Health, which was supported by the Finkel Family Foundation. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

NA.

Prognosis in fertilisation rate and outcome in IVF cycles in patients with and without endometriosis: a population-based comparative cohort study with controls

Background:

Subfertility occurs in 30-40% of endometriosis patients. Regarding the fertilisation rate with in vitro fertilisation (IVF) and endometriosis, conflicting data has been published. This study aimed to compare endometriosis patients to non-endometriosis cycles assessing fertilisation rates in IVF.

Methods:

A population-based cohort study was conducted at the Leiden University Medical Center. IVF cycles of endometriosis patients and controls (unexplained infertility and tubal pathology) were analysed. The main outcome measurement was fertilisation rate.

Results:

503 IVF cycles in total, 191 in the endometriosis group and 312 in the control. The mean fertilisation rate after IVF did not differ between both groups, 64.1%±25.5 versus 63.9%±24.8 (p=0.95) respectively, independent of age and r-ASRM classification. The median number of retrieved oocytes was lower in the endometriosis group (7.0 versus 8.0 respectively, p=0.19) and showed a significant difference when corrected for age (p=0.02). When divided into age groups, the statistical effect was only seen in the group of ≤ 35 years (p=0.04). In the age group ≤35, the endometriosis group also showed significantly more surgery on the internal reproductive organs compared to the control group (p<0.001). All other outcomes did not show significant differences.

Conclusion:

Similar fertilisation rates were found in endometriosis IVF cycles compared to controls. The oocyte retrieval was lower in the endometriosis group, however this effect was only significant in the age group ≤ 35 years. All other secondary outcomes did not show significant differences. In general, endometriosis patients with an IVF indication can be counselled positively regarding the chances of becoming pregnant, and do not need a different IVF approach.

Polycystic Ovary Syndrome and Endometriosis as Reasons for Women's Admission to Outpatient Specialist Care in Poland-A Retrospective Analysis

This study aimed at presenting selected aspects of outpatient specialist care for women diagnosed with polycystic ovary syndrome (PCOS) or endometriosis. The study was carried out using a retrospective analysis of the services provided under Outpatient Specialist Care (AOS) for women, based on data from the National Health Fund (NFZ). The study included data on women with PCOS or endometriosis based on the International Statistical Classification of Diseases and Related Health Problems (ICD-10) in Poland from 2016 to 2018. The average age of women in the study group with PCOS was 25.31 (±7.02) years and, for those with endometriosis, 38.21 (±10.79). AOS patients with diagnosed PCOS most often made 2–3 visits (34.60%) to a specialist doctor, and those with diagnosed endometriosis most often made one visit (39.95%). Significant differences between patients with PCOS and endometriosis using AOS were found concerning the women’s age, the year, season, place of treatment, type of clinic, mode of admission, number of visits, and their place of residence or macroregion. With increasing age, women with PCOS made more visits to AOS, and women with endometriosis made fewer visits to the AOS specialist.

Exploring the impact of endometriosis on women's lives: A qualitative study in Iran

Aim

Considering the wide impact of endometriosis on various aspects of health, this study aimed to explore the impact of endometriosis on Iranian women's lives.

Design

The present study used a qualitative approach and conventional content analysis.

Methods

Twenty patients suffering from endometriosis referring to Imam Khomeini Hospital in Tehran took part in this study. The sampling was done purposefully until data saturation. After deep semi‐structured interviews, the content analysis of the interviews was done according to the steps proposed by Zhang and Wildemuth.

Results

The mean age of the participants was 34.53 (SD: 5.81) years (range: 23–43) with duration of illness of 6.30 ± 5.86 years. Their educational level varied from high school to university, and most of them were employed. Analysis of the data from participants' experiences led to the formation of 5 categories under the titles "Physical suffering, instability of marital life, mental disorder, disruption in social life and self‐care" and 11 subcategories.

Conclusion

The findings of the present study showed that endometriosis can adversely affect women's lives including physical, sexual, psychological and social problems. Although in some cases patients adopt different strategies for self‐care, the need for more support is felt.

How Women with Endometriosis Experience Health Care Encounters

Objective: The aim of this meta-synthesis was to synthesize and interpret the available qualitative studies to increase our understanding and extend knowledge about how women with endometriosis experience health care encounters. Methods: The literature review was carried out using CINAHL, Psychinfo, Academic Search Premier, PubMed, and Scopus, from 2000 to 2018, and was limited to articles in English. Articles were only included if they reported original relevant research on endometriosis and women experiences. Results: The meta-synthesis was based on 14 relevant studies. They included 370 women with diagnosed endometriosis, 16-78 years of age. Three fusions were identified and interpreted in this meta-synthesis. The first was: Insufficiency knowledge, where the physicians could judge the symptoms to be normal menstruation without examining whether there were other underlying causes. The second fusion was Trivializing-just a women's issue, where the physicians thought that the symptoms were part of being a woman, and women's' discomfort was trivialized or completely disregarded. The third fusion was Competency promotes health, where the insufficiency of knowledge became a minor concern if women had a supportive relationship with their physician and the physician showed interest in their problems. Conclusions: Women with endometriosis experience that they are treated with ignorance regarding endometriosis in nonspecialized care. They experience delays in both their diagnosis and treatment and feel that health care professionals do not take their problems seriously. In addition, it appears that increased expertise and improved attitudes among health care professionals could improve the life situation of women with endometriosis.

Beyond the numbers-understanding women's experiences of accessing care for abnormal uterine bleeding (AUB): a qualitative study

OBJECTIVE

To gain a deeper understanding of women's experiences of accessing care for abnormal uterine bleeding (AUB) in order to inform future strategies to improve care pathways, including the early detection of endometrial cancer.

DESIGN

We conducted semistructured interviews with 15 women who attended their first gynaecological specialist consultation for AUB at Wellington Regional Hospital between October and December 2019. Inductive thematic analysis was used to explore experiences and barriers to seeking care.

RESULTS

The median age of the participant cohort was 45 years, with women self-identifying as New Zealand European (9/15), Māori (2/15) and Pasifika (4/15). All women had sought investigation for their AUB in primary care, for some women this was over a timeframe of many years. For all women, AUB had a significant and traumatic impact on their quality of life including their relationships and their work or education. Women described how they felt they often received inadequate care for AUB, and reported negative experiences with their general practitioner. Timely access was further compounded by feelings of embarrassment and that AUB was a taboo subject, and being able to discuss it with family, friends and their general practitioners was difficult.

CONCLUSION

Women in our cohort experienced a multitude of compounding influences that acted as barriers to them having access to appropriate and timely care. Information campaigns that create awareness around 'abnormal periods' alongside better health provider practice guidelines for AUB investigation need to be a priority.

“The most lonely condition I can imagine”: Psychosocial impacts of endometriosis on women’s identity

Endometriosis is a condition which affects around 1–2% of women worldwide and has profound effects on their everyday lives. Previous research has tended to focus on physical symptoms (such as chronic pain); how women manage changes to their identity and relationships as a result of endometriosis has received less attention. This paper discusses qualitative data examining how women negotiate changes to identity while living with endometriosis, in a social context where women are expected to minimise their symptoms and conform to feminine role expectations. We conducted thematic analysis of 34 replies to an online survey seeking qualitative text responses. The women identified disruptions to personal identity as a result of living with endometriosis. They talked about not feeling like themselves (Theme 1) and about reactions from medical and social connections prompting feelings that they were going “mad” (Theme 2). Participants also expressed feeling as though they were a burden to loved ones (Theme 3), which often resulted in self-silencing (Theme 4). Findings are discussed in the context of Western expectations of women’s roles in social relationships and suggest that professionals who support women with endometriosis should be aware of strategies such as self-silencing which may reduce effective self-care.

A web-based survey of reproductive awareness and choices in women with endometriosis

OBJECTIVE

Our aim was to study fertility issues, attitudes towards reproductive techniques and fertility preservation options in women of reproductive age with endometriosis.

STUDY DESIGN

In 2018 we conducted a web-based survey on fertility issues in women aged 18-40 years with endometriosis. Participants were recruited via advertisements on social media and local endometriosis support groups. Participants completed a self-developed online questionnaire evaluating the following dimensions: sociodemographic, medical data, parental project, knowledge and attitudes toward endometriosis and fertility, means used to access information, and reproductive choices.

RESULTS

The majority of women (96 %) worried about the impact of endometriosis on their fertility. Approximately half of them (52 %) reported having received sufficient information concerning the effect of endometriosis on fertility from their doctor, whereas 31 % had discussed fertility issues with their doctor but desired further information. In contrast, only a minority (27 %) of women considered themselves well-informed on fertility preservation options. Information given by specialists on endometriosis and reproduction was considered most useful. Information mediated through patient support groups was also highly rated, whereas information given by the general gynecologist was less highly rated. The majority of women would consider assisted reproductive techniques (74 %) or adoption (70 %) in case of infertility. Interestingly, 72 % of women would undergo oocyte vitrification for fertility preservation, whereas only 37 % would resort to oocyte donation.

CONCLUSION

This is the first survey to address the topic of fertility issues from the patient's perspective in women with endometriosis. The vast majority of women attach great importance to a discussion about fertility possibilities and only a minority of women consider themselves well-informed. Our results highlight the importance of addressing the issue of fertility in women with endometriosis. Special attention should be given to information and counselling about fertility preservation options since most women consider their knowledge on the topic insufficient. Knowledge and attitudes to counsel endometriosis patients on fertility issues and fertility preservation options should be included in the training curricula of gynecologists. Adequate information on reproductive aging, risk factors for infertility, and reproductive choices, including oocyte vitrification, should be incorporated into follow-up visits for endometriosis patients.

Fertility Outcomes After Laparoscopic Cystectomy in Infertile Patients with Stage III-IV Endometriosis: a Cohort with 6-10 years of Follow-up

INTRODUCTION

Ovarian endometriosis is the most common type of endometriosis (EM), affecting more than 40% of women with EM. Currently, surgical intervention is still controversial in infertile patients with ovarian endometriosis, especially in those with stage III-IV EM. Very few studies have been done to analyze long-term pregnancy results in patients with endometrioma more than 5 years after surgery. Therefore, the aim of this study was to explore the pregnancy outcomes and the related factors in patients with endometrioma and stage III-IV endometriosis during a long-term follow-up postoperatively.

METHODS

We collected 347 patients with ovarian endometriosis, which included 59 infertile patients with stage III-IV endometriosis who had a minimum of 5 years of postoperative follow-up after undergoing laparoscopic excision of ovarian endometriomas performed by a single doctor at the Peking Union Medical College Hospital from January 2009 to April 2013.

RESULTS

A total of 59 infertile patients were recruited. The mean age was 31.8 ± 3.6 years. The mean size of the endometriomas was 6.8 ± 3.3 cm. Before surgery, dysmenorrhea was present in 88.1% (52/59) of the cases, while chronic pelvic pain was reported in nine cases (15.3%). A total of 20.3% (12/59) of cases were concurrent with leiomyoma, 52.5% (31/59) with deep infiltrating endometriosis (DIE), and 39.0% (23/59) with adenomyosis. During laparoscopy, 21 cases were diagnosed as stage III (35.6%) and 38 as stage IV (64.4%) EM according to the revised American Fertility Society (AFS) classification. After laparoscopic cystectomy, 38 (64.4%) patients became successfully pregnant by the 5th year. All the patients were divided into two groups according to the postoperative pregnancy outcomes. In univariate analysis, the higher mean age and concurrent diagnosis of adenomyosis were seen to be related to poor postoperative pregnancy outcomes (p < 0.05). In multivariate analysis, however, the mean age, chronic pelvic pain (CPP), and adenomyosis were independent risk factors of pregnancy outcomes between the two groups (p < 0.05). With a minimum follow-up of 6 years, 23.7% (14/59) of recurrence was observed in the entire study cohort.

CONCLUSION

Infertile patients with endometrioma and stage III-IV EM may have lower pregnancy rates after laparoscopic cystectomy if they are older and present with CPP and adenomyosis. Our data showed a lower rate of recurrence but a higher rate of pregnancy after surgery.

Path to diagnosis and women’s perspectives on the impact of endometriosis pain

Introduction:

Endometriosis is a burdensome chronic disease that can be difficult to diagnose, yet few studies examine experiences along the continuum of disease state. We sought to explore women’s journeys to an endometriosis diagnosis, experience with endometriosis pain, and interactions with healthcare practitioners.

Methods:

An anonymous 23-question online survey was distributed to women (aged >19 years) who self-identified as having a surgical or nonsurgical diagnosis of endometriosis and living in seven English-speaking countries through the social media network MyEndometriosisTeam.com .

Results:

From January through April 2018, 317 women in the United States and 134 women outside the United States completed the survey. More than 50% of the women waited 6 or more years for a diagnosis of endometriosis. Overall, 54.3% experienced endometriosis-related pain daily. Respondents (US/non-US) reported a significant impairment in quality of life that interfered with their family (45.7%/45.5%) and social life (40.1%/44.0%), education/career (42.9%/46.3%), and sexual function (68.1%/70.1%). Women reported their disease led to other conditions, including fatigue (93.6%), gastrointestinal issues (91.8%), and difficulty sleeping (87.4%). Many women were not satisfied with their practitioner’s ability to listen to concerns and felt that their practitioner’s treatment recommendations lacked consistency with their own goals/needs.

Conclusion:

Women still experience long delays and difficult journeys to an endometriosis diagnosis. Disease-associated pain is pervasive and has direct and indirect impacts on quality of life. Women are frequently not satisfied with disease-management options presented to them by their practitioners. These results suggest a need for improved medical education on disease state for both patients and practitioners.

Deep Dyspareunia, Superficial Dyspareunia, and Infertility Concerns Among Women With Endometriosis: A Cross-Sectional Study

Introduction

Deep dyspareunia is a cardinal symptom of endometriosis, and as many as 40% of people with this condition experience comorbid superficial dyspareunia.

Aim

To evaluate the relationship between sexual pain and infertility concerns among women with endometriosis.

Methods

This is a cross-sectional study conducted at a university-based tertiary center for endometriosis. 300 reproductive-aged participants in the prospective Endometriosis Pelvic Pain Interdisciplinary Cohort (ClinicalTrials.gov Identifier: NCT02911090) with histologically confirmed endometriosis were included (2013–2017).

Main Outcome Measure

The total score on the infertility concerns module of the Endometriosis Health Profile-30 categorized into 5 groups (0, 1–4, 5–8, 9–12, 13–16).

Results

The odds of infertility concerns did not increase with severity of deep dyspareunia (odds ratio = 1.02, 95% CI: 0.95–1.09, P = .58). However, the odds of infertility concerns increased with severity of superficial dyspareunia (odds ratio = 1.09, 95% CI: 1.02–1.16, P = .011); this relationship persisted after adjusting for endometriosis-specific factors, infertility risk factors, reproductive history, and demographic characteristics (adjusted odds ratio [AOR] = 1.14, 95% CI: 1.06–1.24, P < .001). Other factors in the model independently associated with increased infertility concerns were previous difficulty conceiving (AOR = 2.09, 95% CI 1.04–4.19, P = .038), currently trying to conceive (AOR = 5.23, 95% CI 2.77–9.98, P < .001), nulliparity (AOR = 3.21, 95% CI 1.63–6.41, P < .001), and younger age (AOR = 0.94, 95% CI: 0.89–0.98, P = .005).

Conclusion

Severity of superficial dyspareunia, but not deep dyspareunia, was associated with increased odds of infertility concerns among women with endometriosis. Strengths of the study included the use of a validated measure of infertility concerns and disaggregation of sexual pain into deep and superficial dyspareunia. Limitations included the setting of a tertiary center for pelvic pain, which affects generalizability to fertility clinic and primary care settings. Women experiencing introital dyspareunia, who can have difficulties with achieving penetrative intercourse, may be concerned about their future fertility and should be counselled appropriately.

Wahl KJ, Orr NL, Lisonek M, et al. Deep Dyspareunia, Superficial Dyspareunia, and Infertility Concerns Among Women With Endometriosis: A Cross-Sectional Study. Sex Med 2020;8:274–281.

Fertility performance and the predictive value of the endometriosis fertility index staging system in women with recurrent endometriosis: A retrospective study

This study presents the postoperative pregnancy rate of women with recurrent endometriosis and evaluates the predictive value of the endometriosis fertility index (EFI) for the pregnancy.A total of 107 women who wished to conceive after surgery for recurrent endometriosis from January 2007 to December 2016 were included. The EFI score was calculated postoperatively. The receiver operator characteristic (ROC) curve was plotted to determine the most promising contributor to predicting pregnancy, and Kaplan-Meier (K-M) analysis was used to estimate the cumulative pregnancy rate (CPR).A total of 61 pregnancies were registered in 58 women and the remaining 49 patients failed to become pregnant. The EFI score was strongly associated with the postoperative fertility prognosis. The CPRs during the first 2 and 3 years postoperatively were 51.86% and 66.38%, respectively, and increased to 71.98% within the first 5 years postoperatively in patients with EFI scores ≥5. However, the CPR was 26.00% during the first 2 years after surgery in individuals with EFI scores <5, and there was no increase in the CRP thereafter.Women suffering from recurrent endometriosis still experienced a probability of natural pregnancy, especially patients with EFI scores ≥5. The EFI score had good predictive power for postoperative pregnancy in these patients.

Medical conditions, pregnancy perspectives and contraceptive decision-making among young people: an exploratory, qualitative analysis

OBJECTIVE

To explore perspectives on family planning among young people who perceive they are infertile or will have difficulty carrying a pregnancy to term owing to medical conditions or procedures.

METHODS

This exploratory analysis examined pregnancy plans and contraceptive behavior among 12 young adults with a diagnosed medical condition or who had undergone a medical procedure associated with impaired fertility, and who had discussed fertility with a healthcare provider. We utilized data from a larger study investigating prospective pregnancy intentions and plans among 50 young (ages 18-24) women and their male partners (n=100).

RESULTS

Medical conditions included endometriosis, polycystic ovary syndrome, and lupus. For some, medical conditions/procedures led to use of no or less effective contraception; perceived risk for pregnancy was low, though seven participants had previously experienced pregnancies. Participants also described how medical conditions altered their timelines for pregnancy and overall desire for children; for example, one participant described continuing an unplanned pregnancy because she feared it would be her only chance to parent.

CONCLUSION

This exploratory analysis suggests that among young people, medical issues perceived to affect fertility and pregnancy may influence pregnancy planning and contraceptive behavior. Young people may lack knowledge about fertility and the impact of a medical condition; thus it is critical that providers clarify the difference between anticipated difficulty conceiving and complete infertility. Tailored contraceptive care is needed for young adults with medical conditions that may affect fertility to ensure they have the necessary information to make informed family planning decisions.

IMPLICATIONS

Medical conditions known to affect fertility may influence young people's family planning desires and behaviors. Understanding how young adults process information about medical conditions' impact on their fertility and change or make plans in response is important in order to best meet their family planning needs.

Biopsychosocial predictors of symptoms of depression in a sample of South African women diagnosed with endometriosis

We examined biopsychosocial predictors of symptoms of depression in women with endometriosis. The sample consisted of 202 women with endometriosis who completed a battery of measures including a demographic questionnaire, Beck Depression Inventory, Stellenbosch Endometriosis Quality of life Menstrual characteristics subscale, Short form health survey Physical functioning subscale, and three modular components of the Endometriosis Health Profile 30, namely the Sexual Relationships, Feelings about the Medical Profession, and Feelings about Infertility modules. About 43.1% of the sample reported moderate to severe symptoms of depression. Physical functioning, feelings about the medical profession and sexual relationships were significant predictors of symptoms of depression. The identification of these predictors may enable researchers and practitioners to identify patients to be screened for depression, e.g., patients who report sub-optimal physical functioning, negative feelings about the medical profession and difficult sexual relationships.

Self-management in condition-specific health: a systematic review of the evidence among women diagnosed with endometriosis

Background

Endometriosis is a chronic condition, requiring long-term care as there is no cure. Self-management is the active participation of a person in managing their chronic condition and has been associated with improved knowledge, self-efficacy, performance of self-management tasks and some aspects of health status in interventions for other chronic diseases. The aim was to review the available evidence about the impact of self-management on condition-specific health among women with endometriosis.

Methods

The Medline, PsycINFO, CinahlPlus, Web of Science and Scopus databases were searched and PRISMA guidelines were followed. Search terms were entered both as keywords and mapped to individual database subject headings. Inclusion criteria were: papers that reported investigations of any approach to self-management; among women (at least 18 years) diagnosed with endometriosis and published in English in a peer-reviewed journal. All study designs using quantitative or qualitative methods were eligible for inclusion. Two reviewers independently examined the quality of studies using standard criteria. The systematic review was registered with Prospero (CRD42016042028).

Results

A total of 1164 records were identified (after duplicates were removed), and 27 papers, reporting 19 studies met inclusion criteria. Two papers reported findings from RCTs of complementary therapies, seven reported survey data and 18 qualitative studies. No study had investigated all elements of self-management. Women with endometriosis utilise a range of self-care activities and complementary therapies to assist them to manage their symptoms. Women reported both positive and negative experiences with health care providers.

Conclusions

There is some evidence that self-care activities, complementary therapies and positive patient–healthcare provider relationships are important components of self-management for endometriosis. Self-management among women with endometriosis is an emerging field of research and no investigations of all elements of self-management, informed by a comprehensive definition and theoretical framework are available. Health and wellbeing outcomes and barriers and facilitators to self-management for women with endometriosis require further investigation.

Electronic supplementary material

The online version of this article (10.1186/s12905-019-0774-6) contains supplementary material, which is available to authorized users.

Partners instead of patients: Women negotiating power and knowledge within medical encounters for endometriosis

Endometriosis is currently poorly understood by the medical sciences; contemporary healthcare has been evidenced as failing to meet the diverse needs of the women who live with the condition. This study examined women’s experiences of navigating knowledge and power within medical encounters for endometriosis. In-depth interviews were conducted with 26 women who have been diagnosed with endometriosis about their experiences of the condition and associated healthcare. Women valued both their own knowledge and their doctor’s clinical expertise; as to which they privileged was situational, but it was essential the woman dictated which it would be. Women were wary of the social status and power of doctors to reduce their wellbeing through medical labels they did not identify with or by inhibiting their access to care. They identified the need for doctors to listen to and believe them as being essential to the provision of healthcare that meets women’s needs and addresses the complexities of endometriosis. Our findings suggest that medical education needs to equip doctors with the skills to acknowledge and incorporate women’s knowledge of their bodies within the medical encounter, and to understand how their practice affects women’s social and economic participation.

“Do mad people get endo or does endo make you mad?”: Clinicians’ discursive constructions of Medicine and women with endometriosis

Endometriosis, a common disease characterised as a “gynaecological disorder” in the medical literature, has attracted the attention of feminist scholars as a metaphorical meeting point for gender, knowledge and power. Based on interviews conducted with general practitioners and gynaecologists, we examined the language clinicians use to construct Medicine and women with endometriosis. We sought to identify whether these constructions endorsed or challenged historical discourses, and any implications for women with endometriosis. Clinicians endorsed Medicine as the authoritative knowledge on women and their bodies, and constructed Medicine as being about providing answers on, and doing things to, the body. Women with endometriosis were constructed as reproductive bodies with hysterical tendencies. The historical hysteria discourse was most often endorsed when discussing “difficult” women, referring to those for whom treatment was not helpful or who held a perception of their disease alternative to their clinician. The findings of our study are consistent with previous social analyses of medical literature on endometriosis and with women’s reported experiences, suggesting these discourses to be prevalent in contemporary healthcare for endometriosis. Medical education needs to address the historical androcentric bias of medical knowledge and equip clinicians with the skills to address women’s diverse needs.

The construction and validation of the Stellenbosch Endometriosis Quality of life measure (SEQOL)

In this paper, we describe the process of construction and validation of a health-related quality of life (HRQOL) measure for patients with endometriosis. The items in the measure were initially constructed, edited and reduced using a consultative process with endometriosis experts. We then determined the test reliability, validity and factor structure of the measure by administering the measure and several other measures to 203 patients with endometriosis. The 35-item measure produced an eight-dimension factor structure. The measure and its subscales demonstrated excellent internal consistency reliability and promising validity.

Hypoxia-inhibited DUSP2 expression promotes IL-6/STAT3 signaling in endometriosis

PROBLEM

How does hypoxia-mediated downregulation of dual-specificity phosphatase-2 (DUSP2) promote the development of endometriotic lesions?

METHOD OF STUDY

The levels of IL-6 and DUSP2 were assessed in eutopic stromal cells with DUSP2 knockdown or hypoxia treatment. Bromodeoxyuridine (BrdU) incorporation was applied for evaluating cell proliferation. The protein levels of DUSP2, cleaved caspase-3, phosphorylated STAT3, and STAT3 were analyzed using immunoblot.

RESULTS

The genomewide analysis of cells with DUSP2 overexpression indicated IL-6 regulates multiple pathways related to inflammation, proliferation, and apoptosis. DUSP2 overexpression significantly suppressed IL-6 expression, while DUSP2 knockdown promoted IL-6 expression. The hypoxia-treated eutopic stromal cells expressed higher levels of IL-6, recapitulating the elevated levels of IL-6 in ectopic stromal cells. The treatment with IL-6 elicited the phosphorylation of STAT3, mimicking the elevated levels of phosphorylated STAT3 in the ectopic stromal cells. The IL-6-treated eutopic stromal cells showed more BrdU incorporation and less cleaved caspase-3, which can be reversed by STAT3 inhibitor.

CONCLUSION

Hypoxia-induced IL-6 production in endometriotic lesions is mediated via downregulation of DUSP2, which causes aberrant activation of STAT3 signaling pathway and helps the endometriotic cells survive under the ectopic environment.

Clinicians' perceptions of women's experiences of endometriosis and of psychosocial care for endometriosis

BACKGROUND

Endometriosis is a complex, chronic condition with known psychological and social implications for women. Little is known about clinicians' perceptions of the psychosocial aspects of endometriosis and associated care.

AIM

To describe clinicians' perceptions of women's experiences of living with endometriosis and of the provision of psychosocial care for endometriosis.

MATERIALS AND METHODS

A qualitative approach was taken using semi-structured interviews with eight gynaecologists and four general practitioners who provide care to women with endometriosis in Victoria, conducted by telephone and in person from June to December 2014.

RESULTS

Clinicians' perceptions of women's experiences of endometriosis were consistent with those reported by women, particularly when discussing potential infertility. However, less comprehensive descriptions of the effects of endometriosis on women's work and social life and intimate relationships were observed. Some clinicians asserted that endometriosis is caused by poor mental health. General practitioners positioned themselves as best placed to provide psychosocial care to women with endometriosis; gynaecologists suggested various potential providers but rarely themselves. Most clinicians assessed themselves as not being adequately trained to understand and provide care for the psychosocial aspects of endometriosis; half of the gynaecologists did not believe it was necessary for them to do so.

CONCLUSIONS

The findings of this research demonstrate clinicians' need for further support in the provision of psychosocial care for women with endometriosis, potentially through expanded clinical guidelines and professional development opportunities.

Salient aspects of quality of life among women diagnosed with endometriosis: A qualitative study

This study examined health-related quality of life among a sample of South African women diagnosed with endometriosis. Semistructured interviews were conducted with 25 participants in South Africa. Participants discussed the ways in which endometriosis affected their health-related quality of life. A total of 10 categories emerged from the data, namely, (1) medical factors, (2) physical functioning, (3) psychological functioning, (4) sexual functioning, (5) reproductive functioning, (6) interpersonal functioning, (7) occupational functioning, (8) information and knowledge, (9) healthcare and medical treatment and (10) financial impact and considerations. Each category was described and compared with findings from other health-related quality of life research in women with endometriosis.