Pelvic pain: What are the symptoms and predictors for surgery, endometriosis and endometriosis severity

Levonorgestrel-Releasing Intrauterine Device: An Effective Treatment for Symptoms of Persistent Pelvic Pain

BACKGROUND

Persistent pelvic pain (PPP) affects 5%-27% of women of reproductive age. The calls for earlier and improved access to surgery to diagnose endometriosis do not address the requirement for symptom management and exclude the 50% of women who undergo a laparoscopy for identical pain symptoms but do not have endometriosis identified. Moreover, current evidence for the management of pelvic pain almost exclusively focuses on patients diagnosed with endometriosis.

AIMS

To investigate the pain scores and overall satisfaction with symptom control in participants with PPP who utilised the levonorgestrel-intrauterine device 52 mg (LNG-IUD), to explore the association between time since last menstrual period (LMP) and other potential factors, including the impact of surgery and surgical findings, on pain outcomes.

MATERIALS AND METHODS

This prospective cohort study recruited participants between February 2015 and December 2017 following outpatient clinic referral for pelvic pain symptoms (dysmenorrhea, non-cyclic pelvic pain, dysuria, dyspareunia or dyschezia). Over 18 months, 72 participants had an LNG-IUD (52 mg) inserted, with 51 completing a follow-up questionnaire 6-18 months after insertion to assess pain outcomes.

RESULTS

Dysmenorrhoea (coefficient = -0.142, p < 0.001) and overall satisfaction with symptom control (coefficient = 0.079, p = 0.020) scores improved linearly with increased months since LMP in LNG-IUD users. In multivariate analysis, the age of onset of symptoms, laparoscopies prior to study entry or during the study period, and a histological diagnosis of endometriosis did not have a significant relationship with pain outcome or overall satisfaction with symptom control.

CONCLUSIONS

This study demonstrates that menstrual suppression with the LNG-IUD, regardless of a diagnosis of endometriosis, significantly improves a woman's overall satisfaction with PPP management. The LNG-IUD is an effective first-line medical management option for patients presenting with PPP.

Mitochondrial dynamics: Molecular mechanism and implications in endometriosis

Endometriosis affects about 10 % of women of reproductive age, leading to a disabling gynecologic condition. Chronic pain, inflammation, and oxidative stress have been identified as the molecular pathways involved in the progression of this disease, although its precise etiology remains uncertain. Although mitochondria are considered crucial organelles for cellular activity, their dysfunction has been linked to the development of this disease. The purpose of this review is to examine the functioning of the mitochondrion in endometriosis: in particular, we focused on the mitochondrial dynamics of biogenesis, fusion, and fission. Since excessive mitochondrial activity is reported to affect cell proliferation, we also considered mitophagy as a mechanism involved in limiting disease development. To better understand mitochondrial activity, we also considered alterations in circadian rhythms, the gut microbiome, and estrogen receptors: indeed, these mechanisms are also involved in the development of endometriosis. In addition, we focused on recent research about the impact of numerous substances on mitochondrial activity; some of them may offer a future breakthrough in endometriosis treatment by acting on mitochondria and inhibiting cell proliferation.

Seeking help for menstrual pain during adolescence: A mixed-methods retrospective survey of treatment experiences and preferences

BACKGROUND

Menstrual pain can significantly impact adolescents' well-being and functioning. Despite the prevalence of adolescent menstrual pain, information about adolescents' experiences seeking treatment is limited.

OBJECTIVES

We examined retrospective reports of help-seeking in adolescence among menstruators to better understand perceptions and experiences of interacting with the healthcare system due to menstrual pain.

DESIGN

This study used an embedded mixed-methods design in which the qualitative and quantitative data were collected concurrently.

METHODS

Young adults aged 18-25 who experienced menstrual pain in adolescence completed an online, mixed-methods survey of help-seeking experiences. Responses were analyzed using descriptive statistics and reflexive thematic analysis.

RESULTS

Across participants (N = 590, Mage = 21.78 years), 41% sought treatment for menstrual pain in adolescence and of these 43% found the treatments they were offered ineffective. Three themes were generated related to why treatment was perceived as unsuitable: "Side effects and risks of pharmacological treatment," "treatment not tailored to the individual," and "treatment seen as a band-aid solution." Participants perceived the treatment options as limited and likely not addressing the underlying cause of their pain. Four themes were generated related to perceived improvements to treatment seeking. Participants recommended that healthcare providers: "Go beyond contraceptives," "share and demonstrate expertise," "investigate menstrual pain," and "listen and do not dismiss." Participants reported that having more information, feeling validated, and understanding treatment recommendations would improve their experience.

CONCLUSION

Participants perceived that their menstrual pain-related treatment needs were unmet in adolescence, despite being offered treatments that align with treatment guidelines for adolescent menstrual pain. Findings suggest that improving explanations about treatment provided to youth, along with improving communication and menstrual education, may lead to more optimal help-seeking experiences among adolescents.

A systematic literature review on patient-reported outcome domains and measures in nonsurgical efficacy trials related to chronic pain associated with endometriosis: an urgent call to action

ABSTRACT

Endometriosis, a common cause for chronic pelvic pain, significantly affects quality of life, fertility, and overall productivity of those affected. Therapeutic options remain limited, and collating evidence on treatment efficacy is complicated. One reason could be the heterogeneity of assessed outcomes in nonsurgical clinical trials, impeding meaningful result comparisons. This systematic literature review examines outcome domains and patient-reported outcome measures (PROMs) used in clinical trials. Through comprehensive search of Embase, MEDLINE, and CENTRAL up until July 2022, we screened 1286 records, of which 191 were included in our analyses. Methodological quality (GRADE criteria), information about publication, patient population, and intervention were assessed, and domains as well as PROMs were extracted and analyzed. In accordance with IMMPACT domain framework, the domain pain was assessed in almost all studies (98.4%), followed by adverse events (73.8%). By contrast, assessment of physical functioning (29.8%), improvement and satisfaction (14.1%), and emotional functioning (6.8%) occurred less frequently. Studies of a better methodological quality tended to use more different domains. Nevertheless, combinations of more than 2 domains were rare, failing to comprehensively capture the bio-psycho-social aspects of endometriosis-associated pain. The PROMs used showed an even broader heterogeneity across all studies. Our findings underscore the large heterogeneity of assessed domains and PROMs in clinical pain-related endometriosis trials. This highlights the urgent need for a standardized approach to both, assessed domains and high-quality PROMs ideally realized through development and implementation of a core outcome set, encompassing the most pivotal domains and PROMs for both, stakeholders and patients.

An artificial intelligence approach for investigating multifactorial pain-related features of endometriosis

Endometriosis is a debilitating, chronic disease that is estimated to affect 11% of reproductive-age women. Diagnosis of endometriosis is difficult with diagnostic delays of up to 12 years reported. These delays can negatively impact health and quality of life. Vague, nonspecific symptoms, like pain, with multiple differential diagnoses contribute to the difficulty of diagnosis. By investigating previously imprecise symptoms of pain, we sought to clarify distinct pain symptoms indicative of endometriosis, using an artificial intelligence-based approach. We used data from 473 women undergoing laparoscopy or laparotomy for a variety of surgical indications. Multiple anatomical pain locations were clustered based on the associations across samples to increase the power in the probability calculations. A Bayesian network was developed using pain-related features, subfertility, and diagnoses. Univariable and multivariable analyses were performed by querying the network for the relative risk of a postoperative diagnosis, given the presence of different symptoms. Performance and sensitivity analyses demonstrated the advantages of Bayesian network analysis over traditional statistical techniques. Clustering grouped the 155 anatomical sites of pain into 15 pain locations. After pruning, the final Bayesian network included 18 nodes. The presence of any pain-related feature increased the relative risk of endometriosis (p-value < 0.001). The constellation of chronic pelvic pain, subfertility, and dyspareunia resulted in the greatest increase in the relative risk of endometriosis. The performance and sensitivity analyses demonstrated that the Bayesian network could identify and analyze more significant associations with endometriosis than traditional statistical techniques. Pelvic pain, frequently associated with endometriosis, is a common and vague symptom. Our Bayesian network for the study of pain-related features of endometriosis revealed specific pain locations and pain types that potentially forecast the diagnosis of endometriosis.

A preoperative predictive model for stage IV endometriosis

This was a retrospective study that evaluated a total of 280 patients who underwent surgery for complete removal of endometriosis to develop and validate the predictive model for stage IV endometriosis. The differences between stage I-III and stage IV endometriosis were performed by logistic regression. A model for the prediction of stage IV endometriosis was constructed, which was subsequently validated. The independent variables were visual analogue scale (VAS)≥4 [3.855, 95% confidence interval (CI): 1.675-8.871, p = 0.002], painful nodularity on uterosacral ligaments (13.954, 95% CI: 1.658-117.423, p = 0.015), and bilateral endometriosis (5.933, 95% CI: 1.931-18.225, p = 0.002). The AUC of the model was 0.777, with a sensitivity of 71.9% and specificity of 76.3% for stage IV endometriosis. Therefore, a complete collection of patient information prior to surgery, asking about pain and VAS scores, careful completion of pelvic examinations, and application of imaging techniques are conducive to better diagnosis and prediction of advanced endometriosis.IMPACT STATEMENTWhat is already known on this subject? Endometriosis, a chronic disease causing pain and infertility, is characterised by endometrial-like tissue outside the uterine cavity, which is often treated via surgery at present. Considering the risks of surgery, it is necessary to identify patients with stage IV endometriosis through non-invasive predictive models for adequate preparation for surgery. However, there is no reliable non-invasive predictive model now, despite utilisation of patient medical history, symptoms especially pain-related ones, pelvic examinations, laboratory examinations, and images in the preoperative diagnosis of endometriosis in the clinic.What do the results of this study add? A model developed based on three simple, accessible and non-invasive indicators displays good performance in predicting stage IV endometriosis.What are the implications of these findings for clinical practice and/or further research? It is conducive to diagnosing and predicting advanced endometriosis before surgery, so as to reduce the difficulty and improve the safety of surgery.

Short review on Adverse Childhood Experiences, Pelvic Pain and Endometriosis

The exposure to adverse childhood experiences has been associated with the subsequent development of several chronic health conditions, including pelvic pain. Endometriosis is a chronic disease characterized by the growth of endometrial-like tissue outside of the uterus, and is considered a common cause of chronic pelvic pain and infertility in reproductive-age women. However, the topic of pelvic pain and endometriosis is fraught with many challenges. This applies not just to clinical practice but also to research where many inconsistencies relating to pelvic pain and endometriosis definitions are encountered. A review was carried out for articles exploring the association of adverse childhood experiences and endometriosis. Studies addressing self-reported endometriosis suggested a relationship with childhood adversity, whilst papers relying on surgically diagnosed lesions of endometriosis irrespective of clinical presentation did not. This highlights the potential bias associated with the inconsistent use of the expression "endometriosis" in research.

The Association between Childhood Adversity and Risk of Dysmenorrhea, Pelvic Pain, and Dyspareunia in Adolescents and Young Adults: A Systematic Review

PURPOSE

Exposure to adverse childhood experiences (ACEs) has been associated with poor health outcomes, including chronic pain. However, little is known about the potential impact on the development of pelvic pain in adolescents and young adults. This systematic review was conducted to explore the association between ACEs and dysmenorrhea, pelvic pain, and dyspareunia in adolescents and young adults.

METHODS

Medline, Embase, and PsycNET were searched, using keywords related to childhood adversity, dysmenorrhea, pelvic pain, and dyspareunia.

RESULTS

Of the 566 articles identified, 19 studies were included. There was an association between the number and severity of ACEs and the risk of dysmenorrhea. Sexual abuse and posttraumatic stress disorder appeared to be associated with dysmenorrhea, pelvic pain, and dyspareunia, but it was unclear whether this relationship was mediated by poorer mental health. No association was found for immigration and bullying, and findings were inconsistent regarding female genital mutilation, parental separation, and parental death.

CONCLUSIONS

Future research should include longitudinal follow-up and use validated tools to assess childhood adversity. A greater understanding of the risk of ACEs among adolescents and young adults with dysmenorrhea, chronic pelvic pain, and dyspareunia could provide insight into the development of these conditions.