Adult physical activity and endometriosis risk

Impact of lifestyle and dietary modifications for endometriosis development and symptom management

PURPOSE OF REVIEW

Management of endometriosis is often complex and poorly studied. Patients with endometriosis have interest in how their lifestyle may affect their diagnosis. Self-management and lifestyle changes are often used as adjunct therapy, but best practices are not concrete in treatment guidelines.

RECENT FINDINGS

Lifestyle impact on endometriosis and possible self-management treatment therapies are reviewed. Overall, there is a need for future studies in all topics. Data suggest a link between endocrine-disrupting chemicals (EDCs), particularly persistent EDCs, and endometriosis. More work is needed to isolate and quantify exposures and explore their connection to endometriosis in order to provide guidance for clinical practice recommendations. There is insufficient evidence to support a superior diet for management of endometriosis; however, the Mediterranean diet may have the most benefit without nutrition concerns. Exercise may be another tool to improve endometriosis symptoms, but once again data are limited and best type and frequency is not well studied. Best evidence supports body-mind practices such as yoga, although new evidence suggests benefit from a holistic combination of several types of exercises.

SUMMARY

Overall, data on lifestyle effects and associated therapies are limited. Future high-quality studies are needed to guide practice.

Voluntary Wheel Running Reduces Vesicle Development in an Endometriosis Animal Model Through Modulation of Immune Parameters

Introduction

Endometriosis is a chronic gynecological disorder characterized by the growth of endometrial glands and stroma outside the endometrial cavity producing inflammation and pain. Previously we demonstrated that modulation of the hypothalamic pituitary adrenal (HPA) axis exacerbates the development and severity of this condition. A physically active lifestyle has been shown to confer health benefits in many chronic conditions by potentially acting as a stress buffer, thus we hypothesized that voluntary physical exercise can “realign/reset” the HPA axis resulting in reduced endometriosis symptoms in an animal model.

Methods

Endometriosis was induced in female Sprague Dawley rats by implanting uterine tissue next to the intestinal mesentery on day 0. Sham controls received sutures only. One group of endometriosis animals had access to a running wheel for 2 weeks prior to endometriosis induction until time of sacrifice at day 60. Sham and endometriosis controls received no exercise. All animals were examined for developed vesicles which were collected and measured. Uterine tissue was analyzed for cellular infiltration. Brain, liver, spleen, adrenal glands, leg muscles, and fat were collected, along with peritoneal fluid and blood.

Results

Endometriosis animals developed vesicles in 86.96% of the implants with significantly increased mesenteric fat compared to sham (p < 0.05). Exposure to exercise significantly decreased the size (p < 0.01) and number (p < 0.05) of vesicles that developed, as well as the mesenteric fat (p < 0.01). Exercised animals had higher levels of lactoferrin in peritoneal fluid, and decreased serum fractalkine and leptin. Exercise significantly increased estrogen alpha receptor expression levels (p < 0.01), while significantly decreasing estrogen receptor beta expression (p < 0.01) and macrophage infiltration (p < 0.05) in vesicles compared to non- exercised animals.

Conclusions

Our results suggest that voluntary physical activity might protect against endometriosis and alleviate the associated inflammation via immune modulation of the HPA axis. This offers the potential for further exploration of exercise as a complementary therapy in endometriosis patients.

Strength Exercise Has Different Effects on Pressure Pain Thresholds in Women with Endometriosis-Related Symptoms and Healthy Controls: A Quasi-experimental Study

OBJECTIVE

To evaluate the influence of strength exercises on remote pain sensitivity in women with endometriosis-related symptoms.

DESIGN

A quasi-experimental study.

SETTING

University Hospital, a tertiary health unit.

SUBJECTS

Twenty-one women with endometriosis-related symptoms and 21 healthy women provided written informed consent.

METHODS

The participants performed weekly exercise sessions on an extensor chair for four consecutive weeks. An electronic algometer was used to measure the pressure pain thresholds on the nondominant forearm. Heart rate and blood pressure were measured using a digital device. All measurements were taken before, immediately after, and 10 and 20 minutes after the exercise series.

RESULTS

Women with endometriosis-related symptoms had lower pain thresholds. Pressure pain thresholds increased immediately after exercise in healthy women, returning to baseline level 20 minutes after exercise. Women with endometriosis-related symptoms did not present significant pressure pain threshold alterations after exercise. However, they had a higher heart rate and systolic, diastolic, and average blood pressure than healthy women at all the timepoints. There were no consistent correlations between pressure pain thresholds and heart rate or blood pressure.

CONCLUSIONS

The strength exercise regimen used in this study increased pain thresholds in healthy women but not in women with endometriosis-related painful symptoms. The maintenance or even worsening of pain perception after exercise in women with persistent pain, such as those with endometriosis, may limit their adherence to a physical training program, which in turn could prevent them from experiencing the long-term beneficial effects of exercise.

Body size during adulthood, but not in childhood, associates with endometriosis, specifically in the peritoneal subtype-population-based life-course data from birth to late fertile age

INTRODUCTION

Endometriosis is a common gynecological condition causing chronic pain and infertility. Only limited data exist on body size during childhood and adolescence in affected women. A leaner body shape has been associated with endometriosis in adults. However, longitudinal follow-up data from birth to adulthood are lacking. The aim of this study was to assess the association between body size and endometriosis from birth to age 46 years. We also performed in-depth analysis of the endometriosis subtypes.

MATERIAL AND METHODS

This was a population-based study including 96% of the children born in Northern Finland in 1966. Endometriosis case identification was based on (a) the World Health Organization's International Statistical Classification of Diseases code documentation from national hospital discharge registers and (b) self-reported diagnosis. A total of 348 women with endometriosis (203 in subtype analysis) and 3487 women without endometriosis were identified. Pregnancy, birth, and growth data up to adolescence were collected from welfare clinical records. Follow-up data of the Northern Finland Birth Cohort 1966 were collected at ages 14, 31, and 46 years through postal questionnaires and clinical examinations and included height, weight, and waist and hip circumference measurements. The associations between endometriosis and body size were assessed using logistic regression models.

RESULTS

Body sizes in childhood and adolescence were comparable between women developing endometriosis and those not developing endometriosis. On average, the risk for endometriosis was 2% lower for every kilogram of weight (odds ratio [OR] 0.98, 95% CI 0.97-1.00) and 6% lower for every body mass index unit (OR 0.94, 95% CI 0.90-0.99) at age 31. By age 46, a lower risk for peritoneal endometriosis was observed with greater weight (OR 0.95, 95% CI 0.92-0.98), weight gain from age 14 to age 46 years (OR 0.97, 95% CI 0.93-1.00), body mass index (OR 0.90, 95% CI 0.82-0.98), waist circumference (OR 0.95, 95% CI 0.92-0.99), and waist-hip ratio (OR 0.41, 95% CI 0.21-0.78).

CONCLUSIONS

This study provides further evidence of the associations between endometriosis and body size and adiposity, specifically in women with peritoneal endometriosis. The associations are evident in adulthood but not in childhood or adolescence.

An Evidence-Based Review of Elagolix for the Treatment of Pain Secondary to Endometriosis

Purpose of Review

This is a review of elagolix use for pain related to endometriosis. It summarizes the background and recent data available about the pathogenesis of endometriosis and pain that is secondary to this syndrome. It then reviews the evidence to support the use of elagolix and the indications for use.

Recent Findings

Endometriosis occurs in 10% of reproductive-age women and is a common source of chronic pelvic pain, infertility, and co-morbid disorders. It usually presents with some combination of dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. Treatment options may be surgical or hormonal. Traditional treatment is divided into medical and surgical. The latter, though effective, is reserved for surgical emergencies and patients failing medical management. Medical management with NSAIDs is usually limited in efficacy. It is generally based on hormonal suppression leading to atrophy of endometrial lesions. Elagolix (Orlissa) is a GnRH antagonist that suppressed the entire hypophysis-gonadal axis. Reduced levels of estrogen and progesterone lead to involution of the endometrial lesions and improvement in symptoms. Clinical trials showed that elagolix is effective in treating dysmenorrhea and non-menstrual pain that is secondary to endometriosis. It is well tolerated and has a relatively safe usage profile. Studies up to 12 months long showed continued efficacy and reduction in dysmenorrhea of up to 75%, with 50%-60% reduction in non-menstrual pain. Elagolix was found effective when compared to both placebo and alternative treatments.

Summary

Endometriosis is a common syndrome that causes significant pain, morbidity, and disability, as well as financial loss. Elagolix is an effective drug in treating the symptoms of endometriosis and is a relatively safe option. Phase 4 studies will be required to evaluate the safety and efficacy of long term chronic use.

Modifiable life style factors and risk for incident endometriosis

BACKGROUND

Caffeine, alcohol, smoking and physical activity are known to alter sex steroid synthesis, which may affect hormone-dependent gynaecologic disease risk, such as endometriosis; however, few studies have assessed life style factors prior to endometriosis diagnosis.

METHODS

Four hundred and seventy three women, ages 18-44 years, underwent laparoscopy or laparotomy, regardless of clinical indication, at 14 clinic sites, 2007-2009. Women with prior surgically confirmed endometriosis were excluded. Life style factors were assessed prior to surgery. Adjusted risk ratios (RR) of endometriosis by caffeine, alcohol, smoking (serum cotinine), and physical activity were estimated, adjusting for age, marital status, education, race/ethnicity, age at menarche, gravidity, BMI, study site, and other life style factors.

RESULTS

There were no associations between women with endometriosis and alcohol consumption (RR 0.9, 95% CI 0.7, 1.3), caffeine consumption (RR 1.1, 95% CI 0.8, 1.5), or smoking (serum cotinine <10 vs ≥10 ng/mL; RR 1.0, 95% CI 0.7, 1.6). Similar null findings were found between endometriosis and weekly occurrences of physical activity and total walking, moderate, and vigorous activity; a modest trend was found between total daily sitting time and increased endometriosis risk.

CONCLUSIONS

This study, which is unique in its capture of life style exposures prior to incident endometriosis diagnosis, largely found no association between alcohol, caffeine, smoking, and physical activity and risk of endometriosis.

Risk for and consequences of endometriosis: A critical epidemiologic review

Endometriosis affects approximately 10% of women of reproductive age. Characteristics robustly associated with a greater risk for endometriosis include early age at menarche, short menstrual cycle length, and lean body size, whereas greater parity has been associated with a lower risk. Relationships with other potential characteristics including physical activity, dietary factors, and lactation have been less consistent, partially because of the need for rigorous data collection and a longitudinal study design. Critical methodologic complexities include the need for a clear case definition; valid selection of comparison/control groups; and consideration of diagnostic bias and reverse causation when exploring demographic characteristics, medical history, and lifestyle factors. Reviewers and editors must demand a detailed description of rigorous methods to facilitate comparison and replication to advance our understanding of endometriosis.

Associations among body size across the life course, adult height and endometriosis

STUDY QUESTION

Are body size across the life course and adult height associated with endometriosis?

SUMMARY ANSWER

Endometriosis is associated with lean body size during childhood, adolescence and adulthood; tall total adult height; and tall sitting height.

WHAT IS KNOWN ALREADY

The literature suggests that both adult body size and height are associated with endometriosis risk, but few studies have investigated the role of body size across the life course. Additionally, no study has investigated the relationships between components of height and endometriosis.

STUDY DESIGN, SIZE, DURATION

We used a nested case-control design within E3N (Etude Epidémiologique auprès de femmes de l'Education Nationale), a prospective cohort of French women. Data were updated every 2-3 years through self-administered questionnaires. Odds ratios (ORs) and 95% CIs were computed using logistic regression models adjusted for a priori confounding factors.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 2416 endometriosis cases were reported as surgically ascertained among the 61 208 included women.

MAIN RESULTS AND THE ROLE OF CHANCE

The odds of endometriosis were lower among women who reported having a large versus lean body size at 8 years (P for trend = 0.003), at menarche (P for trend < 0.0001) and at ages 20-25 years (P for trend < 0.0001). Women in the highest quartiles of height had statistically significantly increased odds of endometriosis compared to those in the lowest (<158 cm) (162-164 cm: OR = 1.28, 95% CI = 1.12-1.46; ≥165 cm: OR = 1.33, 95% CI = 1.18-1.49, P for trend < 0.0001). Statistically significantly increased odds were also observed among women with a taller sitting height (OR = 1.24, 95% CI = 1.05-1.47, P for trend = 0.01). Leg length was not statistically significantly associated with endometriosis.

LIMITATIONS REASONS FOR CAUTION

Endometriosis cases may be prone to misclassification; however, we restricted our case definition to surgically-confirmed cases, which showed a high validation rate. Body size is based on retrospective self-report, which may be subject to recall bias.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study suggest that endometriosis is positively associated with lean body size across the life course and total adult height. They also suggest that components of height are associated with endometriosis, which should be investigated further.

STUDY FUNDING/COMPETING INTEREST(S)

The Mutuelle Générale de l'Education Nationale (MGEN); the European Community; the French League against Cancer (LNCC); Gustave Roussy; the French Institute of Health and Medical Research (Inserm). L.V.F. was supported by a T32 grant (#HD060454) in reproductive, perinatal and pediatric epidemiology from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Cancer Institute (3R25CA057711) National Institutes of Health. M.K. was supported by a Marie Curie Fellowship within the seventh European Community Framework Programme (#PIOF-GA-2011-302078). The authors have no conflicts of interest to declare.

Beyond Body Mass Index: Using Anthropometric Measures and Body Composition Indicators to Assess Odds of an Endometriosis Diagnosis

BACKGROUND

Body mass index (BMI) and endometriosis have been inversely associated. To address gaps in this research, we examined associations among body composition, endometriosis, and physical activity.

MATERIALS AND METHODS

Women from 14 clinical sites in the Salt Lake City, Utah and San Francisco, California areas and scheduled for laparoscopy/laparotomy were recruited during 2007-2009. Participants (N = 473) underwent standardized anthropometric assessments to estimate body composition before surgery. Using a cross-sectional design, odds of an endometriosis diagnosis (adjusted odds ratio [aOR]; 95% confidence interval [CI]) were calculated for anthropometric and body composition measures (weight in kg; height in cm; mid upper arm, waist, hip, and chest circumferences in cm; subscapular, suprailiac, and triceps skinfold thicknesses in mm; arm muscle and fat areas in cm²; centripetal fat, chest-to-waist, chest-to-hip, waist-to-hip, and waist-to-height ratios; arm fat index; and BMI in kg/m²). Physical activity (metabolic equivalent of task-minutes/week) and sedentariness (average minutes sitting on a weekday) were assessed using the International Physical Activity Questionnaire-Short Form. Measures were modeled continuously and in quartiles based on sample estimates. Adjusted models were controlled for age (years, continuous), site (Utah/California), smoking history (never, former, or current smoker), and income (below, within 180%, and above of the poverty line). Findings were standardized by dividing variables by their respective standard deviations. We used adjusted models to examine whether odds of an endometriosis diagnosis were moderated by physical activity or sedentariness.

RESULTS

Inverse relationships were observed between endometriosis and standardized: weight (aOR = 0.71, 95% CI 0.57-0.88); subscapular skinfold thickness (aOR = 0.79, 95% CI 0.65-0.98); waist and hip circumferences (aOR = 0.79, 95% CI 0.64-0.98 and aOR = 0.76, 95% CI 0.61-0.94, respectively); total upper arm and upper arm muscle areas (aOR = 0.76, 95% CI 0.61-0.94 and aOR = 0.74, 95% CI 0.59-0.93, respectively); and BMI (aOR = 0.75, 95% CI 0.60-0.93), despite similar heights. Women in the highest versus lowest quartile had lower adjusted odds of an endometriosis diagnosis for: weight; mid-upper arm, hip, and waist circumferences; total upper arm and upper arm muscle areas; BMI; and centripetal fat ratio. There was no evidence of a main effect or moderation of physical activity or sedentariness.

CONCLUSION

In a surgical cohort, endometriosis was inversely associated with anthropometric measures and body composition indicators.

Physical activity and endometriosis risk in women with infertility or pain: Systematic review and meta-analysis

BACKGROUND

The potential association between endometriosis and physical activity (PA) has been suggested in several epidemiological studies.We aimed to establish whether PA influences endometriosis risk.

METHODS

MEDLINE and EMBASE were searched using "physical activity" OR "exercise" combined with "endometriosis," in Medical Subject Headings and free text. We selected original articles in English, published up to April 2016, evaluating the association between endometriosis and recent or past PA (case-control or cohort studies). References of retrieved papers were reviewed. We computed summary odds ratios (ORs) of endometriosis for recent and past PA.

RESULTS

Six case-control and 3 cohort studies included 3355 cases for recent PA and 4600 cases for past PA. The summary OR for endometriosis according to PA level, calculated by the random-effect model, was 0.85 [95% confidence interval (CI) 0.67-1.07] for any recent versus no PA. As compared to no recent PA, ORs for low and moderate/high PA were 1.00 (95% CI: 0.68-1.28) and 0.75 (95% CI: 0.53-1.07), respectively.

CONCLUSIONS

Though it suggests that PA may reduce the risk of endometriosis, this meta-analysis does not conclusively support the hypothesis. Whether our findings are really explained by the benefit of exercise at molecular and endocrine level, or related to confounding mechanisms, such as study design, choice of controls, and PA potentially improving pain, needs to be further investigated.

Impact of physical activity on pain perception in an animal model of endometriosis

BACKGROUND

Symptoms of endometriosis, such as pain and infertility, are considered significant sources of stress. In many chronic conditions, exercise can act as a stress buffer and influence pain perception. We tested the impact of swimming exercise on pain perception and pain receptors in an animal model of endometriosis.

METHODS

Endometriosis (Endo) was induced in female rats by suturing uterine horn tissue next to the intestinal mesentery. Sham rats received sutures only. Rats were exposed to swimming exercise for 7 consecutive days, while no-exercise rats were left in the home cage. Fecal pellets were counted after swimming as an index of anxiety, and serum corticosterone levels measured. Pain perception was assessed using the hot plate test for hyperalgesia and Von Frey test for allodynia. Mu-opioid receptor (MOR) and neurokinin-1 receptor expression in the spinal cord was measured by immunofluorescence.

RESULTS

Fecal pellet counts were higher in those animals that swam (p<0.05), but no significant difference in corticosterone was found. Although Endo-exercise rats had higher colonic damage (p<0.05) with more cellular infiltration, the lesions were smaller than in Endo-no exercise rats (p<0.05). Exercise did not ameliorate the hyperalgesia, whereas it improved allodynia in both groups. MOR expression was significantly higher in Endo-exercise vs. Endo-no exercise rats (p<0.01), similar to Sham-no exercise levels.

CONCLUSIONS

Our results point toward beneficial effects of swimming exercise during endometriosis progression. Physical interventions might be investigated further for their ability to reduce perceived stress and improve outcomes in endometriosis.

Coexistence of Polycystic Ovary Syndrome and Endometriosis in Women with Infertility

Purpose

The aim of this study was to investigate if there is a higher incidence of endometriosis in patients with polycystic ovary syndrome (PCOS), compared with normal fertile controls.

Material and methods

Women with PCOS according to Rotterdam criteria, with infertility and/or pelvic pain, were identified (n = 104), and together with fertile women seeking bilateral tubal ligation (n = 111), they were submitted to laparoscopy at the Greenville Hospital System or the University of North Carolina at Chapel Hill. A biopsy was performed in 40 patients with PCOS to confirm or not endometriosis.

Results

Age was similar in both groups (control: 29.7 ± 0.5 years; PCOS: 29.6 ± 0.4). The incidence of suspected endometriotic lesions in controls and PCOS patients was 12.6% (95% confidence interval [95% CI], 7.6%-20%) and 74% (95% CI, 64.8%-81.5%), respectively; with an odds ratio of 19.7 (95% CI, 9.6-40.2) of finding endometriosis in PCOS (p<0.0001). Our results were similar when endometriosis was confirmed by pathology report. Of the PCOS patients with endometriosis, 76% had endometriosis stage I or II, according to the revised American Society for Reproductive Medicine criteria.

Conclusions

In this case-control study, a significant association between endometriosis and women with PCOS with pelvic pain and/or infertility was found. The majority of endometriotic lesions (76%) were stage I or II.

Endometriosis: pathogenesis and treatment

Endometriosis is defined as the presence of endometrial-type mucosa outside the uterine cavity. Of the proposed pathogenic theories (retrograde menstruation, coelomic metaplasia and Müllerian remnants), none explain all the different types of endometriosis. According to the most convincing model, the retrograde menstruation hypothesis, endometrial fragments reaching the pelvis via transtubal retrograde flow, implant onto the peritoneum and abdominal organs, proliferate and cause chronic inflammation with formation of adhesions. The number and amount of menstrual flows together with genetic and environmental factors determines the degree of phenotypic expression of the disease. Endometriosis is estrogen-dependent, manifests during reproductive years and is associated with pain and infertility. Dysmenorrhoea, deep dyspareunia, dyschezia and dysuria are the most frequently reported symptoms. Standard diagnosis is carried out by direct visualization and histologic examination of lesions. Pain can be treated by excising peritoneal implants, deep nodules and ovarian cysts, or inducing lesion suppression by abolishing ovulation and menstruation through hormonal manipulation with progestins, oral contraceptives and gonadotropin-releasing hormone agonists. Medical therapy is symptomatic, not cytoreductive; surgery is associated with high recurrence rates. Although lesion eradication is considered a fertility-enhancing procedure, the benefit on reproductive performance is moderate. Assisted reproductive technologies constitute a valid alternative. Endometriosis is associated with a 50% increase in the risk of epithelial ovarian cancer, but preventive interventions are feasible.

ESHRE guideline: management of women with endometriosis

STUDY QUESTION

What is the optimal management of women with endometriosis based on the best available evidence in the literature?

SUMMARY ANSWER

Using the structured methodology of the Manual for ESHRE Guideline Development, 83 recommendations were formulated that answered the 22 key questions on optimal management of women with endometriosis.

WHAT IS KNOWN ALREADY

The European Society of Human Reproduction and Embryology (ESHRE) guideline for the diagnosis and treatment of endometriosis (2005) has been a reference point for best clinical care in endometriosis for years, but this guideline was in need of updating.

STUDY DESIGN, SIZE, DURATION

This guideline was produced by a group of experts in the field using the methodology of the Manual for ESHRE Guideline Development, including a thorough systematic search of the literature, quality assessment of the included papers up to January 2012 and consensus within the guideline group on all recommendations. To ensure input from women with endometriosis, a patient representative was part of the guideline development group. In addition, patient and additional clinical input was collected during the scoping and review phase of the guideline.

PARTICIPANTS/MATERIALS, SETTING, METHODS

NA.

MAIN RESULTS AND THE ROLE OF CHANCE

The guideline provides 83 recommendations on diagnosis of endometriosis and on the treatment of endometriosis-associated pain and infertility, on the management of women in whom the disease is found incidentally (without pain or infertility), on prevention of recurrence of disease and/or painful symptoms, on treatment of menopausal symptoms in patients with a history of endometriosis and on the possible association of endometriosis and malignancy.

LIMITATIONS, REASONS FOR CAUTION

We identified several areas in care of women with endometriosis for which robust evidence is lacking. These areas were addressed by formulating good practice points (GPP), based on the expert opinion of the guideline group members.

WIDER IMPLICATIONS OF THE FINDINGS

Since 32 out of the 83 recommendations for the management of women with endometriosis could not be based on high level evidence and therefore were GPP, the guideline group formulated research recommendations to guide future research with the aim of increasing the body of evidence.

STUDY FUNDING/COMPETING INTEREST(S)

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the implementation of the guideline. The guideline group members did not receive payment. All guideline group members disclosed any relevant conflicts of interest (see Conflicts of interest).

TRIAL REGISTRATION NUMBER

NA.

Endometriosis and physical exercises: a systematic review

Regular physical exercise seems to have protective effects against diseases that involve inflammatory processes since it induces an increase in the systemic levels of cytokines with anti-inflammatory and antioxidant properties and also acts by reducing estrogen levels. Evidence has suggested that the symptoms associated with endometriosis result from a local inflammatory peritoneal reaction caused by ectopic endometrial implants. Thus, the objective of the present review was to assess the relationship between physical exercise and the prevalence and/or improvement of the symptoms associated with endometriosis. To this end, data available in PubMed (1985-2012) were surveyed using the terms "endometriosis and physical exercises", "endometriosis and life style and physical exercises" in the English language literature. Only 6 of the 935 articles detected were included in the study. These studies tried establish a possible relationship between the practice of physical exercise and the prevalence of endometriosis. The data available are inconclusive regarding the benefits of physical exercise as a risk factor for the disease and no data exist about the potential impact of exercise on the course of the endometriosis. In addition, randomized studies are necessary.

Endometriosis for the primary care physician

PURPOSE OF REVIEW

This review will empower the primary care provider (PCP) to evaluate, manage, and refer as needed adolescents with dysmenorrhea and/or chronic pelvic pain (CPP) who are suspected to have endometriosis.

RECENT FINDINGS

Endometriosis is a common cause of CPP in adolescents who do not respond to primary medical treatment. The presentation in adolescents is unique, causing high rates of misdiagnosis or delayed treatment. Endometriosis-related pain has a marked negative impact on social and mental health. Simple treatments that are available in the primary care setting can alleviate pain and improve quality of life for these young women if initiated in a timely fashion.

SUMMARY

Adolescents usually turn to their PCP for evaluation of dysmenorrhea and CPP. By maintaining a high index of suspicion, initiating treatment, and referring when needed, the PCP can have a tremendous effect on the patient's present and future quality of life.

Childhood and adolescent exposures and the risk of endometriosis

BACKGROUND

Because endometriosis is diagnosed predominantly in young women, exposures occurring during childhood or adolescence may have a major impact on the disease. However, potential risk factors during this time period have received little attention. Our objective was to investigate relationships between childhood and adolescent exposures and the risk of endometriosis.

METHODS

E3N is a prospective cohort of 98,995 French women aged 40-65 at enrollment in 1990. Follow-up questionnaires were sent every 2-3 years. Using a nested case-control design, we computed odds ratios (ORs) and 95% confidence intervals using unconditional logistic regression models.

RESULTS

A total of 2684 endometriosis cases were reported as surgically ascertained among the 75,918 included women. There were inverse relationships of endometriosis risk with menarcheal age (test for trend, P < 0.0001) and with menstrual cycle length before 17 years of age (test for trend, P = 0.06), whereas menstrual cycle regularity before 17 years of age was not associated with risk. There were modest associations of endometriosis risk with exposure to pet animals (OR = 1.12 [95% confidence interval =1.02-1.22]) or living in a farm for 3 or more consecutive months during childhood (1.12 [1.02-1.24]), although with no link to any specific type of farm animal. In addition, there were positive linear associations between endometriosis risk and level of indoor exposure to passive smoking during childhood (up to 1.34 [1.09-1.64] with several hours exposure a day), experiencing food deprivation during World War II (1.34 [0.94-1.91]), and walking activity at 8-15 years of age (1.17 [1.05-1.31] for 5+ hours a week).

CONCLUSIONS

This large study suggests that some exposures during childhood or adolescence may influence the risk of endometriosis. Further research is needed to confirm and better understand these relationships.

Retinoic acid suppresses growth of lesions, inhibits peritoneal cytokine secretion, and promotes macrophage differentiation in an immunocompetent mouse model of endometriosis

OBJECTIVE

To determine the effects of all-trans-retinoic acid (RA) on establishment and growth of endometrial lesions, peritoneal interleukin-6 (IL-6) and macrophage chemotactic factor-1 (MCP-1) concentrations, and CD38, CD11b, and F4/80 expression on peritoneal macrophages in an immunocompetent mouse model of endometriosis.

DESIGN

Experimental transplantation study using mice.

SETTING

Academic medical center.

ANIMAL(S)

C57BL/6 recipient mice and syngeneic green fluorescent protein transgenic (GFP+) mice.

INTERVENTION(S)

Recipient mice were inoculated with GFP+ minced uterine tissue to induce endometriosis and treated with RA (400 nmol/day) or vehicle for 17 days (3 days before to 14 days after tissue injection).

MAIN OUTCOME MEASURE(S)

Total number of GFP+ implants in recipient mice, number of implants showing visible blood vessels, total volume of established lesions per mouse, concentrations of IL-6 and MCP-1 in peritoneal fluid, and expression of CD11b, F4/80, and CD38 on peritoneal macrophages.

RESULT(S)

Retinoic acid treatment for 17 days reduced the number of implants versus controls and decreased the frequency of lesions with vessels. Peritoneal washings in RA-treated animals had lower concentrations of IL-6 and MCP-1 than controls 3 days after endometrial inoculation and lower levels of IL-6 on day 14 after inoculation. Concomitant with these effects on day 14, CD38, CD11b, and F4/80 were higher on macrophages from RA-treated mice versus controls.

CONCLUSION(S)

The development of endometriotic implants is inhibited by RA. This effect may be caused, at least in part, by reduced IL-6 and MCP-1 production and enhanced differentiation of peritoneal macrophages.

Risk Factors for Endometriosis in a German Case-Control Study

Objective: The etiology of endometriosis is still a research field in which few consistent data are available. Large case-control studies or even cohort studies are rare, and most of the published data are conflicting. The aim of the present study was therefore to examine common epidemiological and endometriosis-specific risk factors in a German case-control study. Design: From 2001 to 2010, a pool of 595 laparoscopically confirmed cases and 475 controls were recruited in a hospital-based setting. After matching for age, 298 cases and 300 controls remained in the pool. Age at menarche, menstrual cycle length, duration of menstrual bleeding, number of pregnancies, live births, miscarriages, use of contraceptive pills, body mass index (BMI), and smoking status were analyzed with logistic regression models predicting endometriosis case-control status. Results: Menstrual cycle length, duration of menstrual bleeding, number of pregnancies, number of miscarriages, and smoking status, as relevant predictors for endometriosis case-control status, were identified as risk factors for endometriosis. Other factors such as age at menarche, number of live births, ever having used contraceptive pills, and BMI were not predictive. Conclusions: This hospital-based case-control study reproduced most of the familiar risk factors. Comparison of this study with others reveals a wide variety of effect sizes and directions of association with risk factors and may increase the information available about the characteristics of the patient population being treated in the relevant hospital setting.

Bilateral oophorectomy in relation to risk of postmenopausal breast cancer: confounding by nonmalignant indications for surgery?

Bilateral oophorectomy is often performed during hysterectomy for benign conditions and can reduce breast cancer risk by 20%-50% when performed at younger ages. Accuracy of estimating the decrease in breast cancer risk associated with bilateral oophorectomy could be affected by common conditions that lead to surgery, such as uterine fibroids or endometriosis. The authors examined the potential for confounding by nonmalignant indications for surgery on breast cancer risk estimates in a population-based case-control study of invasive breast cancer newly diagnosed in 1992-1995. Breast cancer cases (N = 4,935) aged 50-79 years were identified from Wisconsin, Massachusetts, and New Hampshire tumor registries; similarly aged controls (N = 5,111) were selected from driver's license and Medicare lists. Reproductive and medical history was obtained from structured telephone interviews. Odds ratios and 95% confidence intervals were estimated with multivariate logistic regression. Women who underwent bilateral oophorectomy with hysterectomy at age ≤ 40 years had significantly reduced odds of breast cancer (odds ratio = 0.74, 95% confidence interval: 0.60, 0.90) compared with women with intact ovaries and uterus. Effect estimates were virtually unchanged after adjustment for uterine fibroids or endometriosis history. Results indicate that breast cancer risk reductions conferred by bilateral oophorectomy are not strongly confounded by failure to account for nonmalignant indications for surgery.

Adolescent physical activity and endometriosis risk

BACKGROUND

In the one study examining the relationship, adolescent physical activity was not associated with risk for endometriosis. Case-control studies have shown 40-80% reductions in risk for adult activity, while only an 11% reduction in endometriosis risk was observed in a recent prospective analysis.

METHODS

Using data collected from the Nurses' Health Study II, a prospective cohort study of premenopausal US nurses that began in 1989, we have attempted to clarify this relation. Data are updated every 2 yrs with follow-up for these analyses through to 2001. Women reported the average amount of time per week spent in moderate and strenuous recreational activity during three age periods: ages 12-13, ages 14-17, and ages 18-22. A metabolic equivalent (MET) score was assigned to each activity and these were summed to estimate total activity.

RESULTS

During 637,747 person-years of follow-up, 1,481 cases of laparoscopically confirmed endometriosis were reported among women with no past infertility. After adjusting for age, calendar time, birth weight, age at menarche, parity, oral contraceptive use, and body mass index (BMI), we observed a 16% increase in the risk for endometriosis comparing the greatest amount of activity (≥80 MET-h/wk) with the least (<20 MET-h/wk) during ages 12-13 (RR=1.16, 95% CI=0.98-1.37, p-value test for trend=0.02), and no associations for ages 14-17 or ages 18-22. In analyses of the individual activity types within each time period, only strenuous activity during ages 12-13 was associated with endometriosis.

CONCLUSIONS

We did not find evidence of a beneficial association between adolescent physical activity and laparoscopically confirmed endometriosis, but in fact found a small increase in risk.