Laparoscopically Confirmed Endometriosis and Risk of Incident Stroke: A Prospective Cohort Study

Aspirin does not modify cardiovascular event risk in endometriosis in the California Teachers Study

Aims

Endometriosis frequently affects reproductive aged females and is associated with increased cardiovascular disease risk. The aims of this study were (i) to confirm the relationship between cardiovascular disease and endometriosis and (ii) to test whether aspirin modified the effect of endometriosis on cardiovascular disease risk.

Methods and results

A longitudinal cohort study was conducted using data from the California Teachers Study from enrolment (1995-1996) through the current administrative end follow-up (31 December 2020). Primary outcome was any incident major adverse cardiovascular event (MACE) defined using validated ICD-9/ICD-10 codes for stroke, myocardial infarction, and coronary heart disease. Inverse probability (IP) weights were used to estimate the causal effect of self-reported endometriosis on cardiovascular events. Of the included 120 435 participants, 13 754 (11.4%) reported history of endometriosis. There were 2159 admissions for MACE in the endometriosis group vs. 16 632 in the non-endometriosis group. After controlling for demographics and vascular comorbidities, risk of MACE was higher in the endometriosis group than in the non-endometriosis group [IP-weighted hazard ratio (HR) 1.10, confidence interval (CI) 1.04-1.15], particularly in participants < 40 years of age (IP-weighted HR 1.48, CI 1.08-2.02). Aspirin use did not modify the effect of endometriosis on MACE (P interaction = 0.467). Among participants taking aspirin, the adjusted HR for endometriosis was 1.07 (95% CI, 0.96-1.19) whereas among participants not taking aspirin, adjusted HR was 1.10 (95% CI, 1.04-1.17).

Conclusion

In a large American cohort, endometriosis was associated with increased risk of adverse cardiovascular events, especially in younger participants. Aspirin did not modify this risk. Research to determine how to best reduce cardiovascular risk in endometriosis is warranted.

Endometriosis as a Risk Factor for Ischemic and Hemorrhagic Stroke: A Population-Based Cohort Study

We completed a retrospective population-based cohort study using administrative data from Ontario female patients from 1993 to 2015 to examine the association between a diagnosis of endometriosis and stroke. We identified 166 853 female patients with a diagnosis of endometriosis and 333 706 unexposed female patients. Although the absolute risk of stroke was low, during the study period, 680 patients had ischemic stroke in the endometriosis group (28.2 cases per 100 000 person-years; 95% CI 26.1-30.4) and 1119 in the unexposed group (23.8 cases per 100 000 person-years; 95% CI 22.5-25.3)-adjusted hazard ratio 1.13 (95% CI 1.03-1.24). Confirmation of this association and consideration for clinical implications is warranted.

Non-malignant gynaecological disease and risk of cardiovascular or cerebrovascular disease: a systematic review and meta-analysis

BACKGROUND

Cardiovascular disease is the leading cause of death globally. Non-malignant gynaecological diseases (NMGD) significantly affect patient health and well-being and may be associated with cardiovascular or cerebrovascular disease (C/CVD).

METHODS

Seven databases were searched for relevant studies up to 21 April 2024. Observational studies reporting risk estimates and 95% CIs for the association between NMGD and C/CVD were included. Data were extracted by two independent reviewers. Random effects models were used to calculate summary relative risk (SRR) with 95% CI. Composite C/CVD outcome was defined as a combination of ischaemic heart disease, cerebrovascular disease, heart failure, and peripheral vascular disease. The ROBINS-I tool defined study quality and risk of bias.

RESULTS

We screened 6639 studies, of which 59 were eligible for full-text review and 28 were included in our analysis, comprising a total of 3 271 242 individuals. The majority (53.5%) of the studies were scored as having a 'serious'/'critical' risk of bias. Overall, individuals with an NMGD had a significantly greater risk of composite C/CVD with low heterogeneity among contributing studies (SRR 1.28, 95% CI 1.20 to 1.37; n=16 studies, I2=65.3%), ischaemic heart disease (SRR 1.41, 95% CI 1.31 to 1.51; n=21 studies, I2=73.7%), and cerebrovascular disease (SRR 1.33, 95% CI 1.18 to 1.51; n=16 studies, I2=91.5%). In NMGD-specific analyses, the risk of C/CVD and its components was greater among those with a history of endometriosis or polycystic ovary syndrome.

CONCLUSIONS

We found an overall association between NMGD and C/CVD across all studies. However, estimates from individual studies varied substantially.

Laparoscopically confirmed endometriosis and the risk of incident NAFLD: a prospective cohort study

BACKGROUND

To investigate whether endometriosis is associated with the risk of incident nonalcoholic fatty liver disease (NAFLD).

METHODS

Data were retrieved from Nurses' Health Study II with participants followed up from 1995 to 2017. A total of 61,649 participants were included in this prospective cohort study. The exposure of this study was laparoscopically confirmed endometriosis. We performed Cox proportional hazard regression analyses to estimate the hazard ratio (HR) and 95% confidence interval (95% CI) of the association between endometriosis and NAFLD.

RESULTS

A total of 4,774 incident NAFLD cases were recorded during a 1,313,067 person-years of follow-up. In the multivariable adjusted model, laparoscopically confirmed endometriosis was positively associated with the risk of NAFLD (HR: 1.17, 95% CI: 1.07 - 1.29). The results of the mediation analyses revealed that the association was partly attributable to hysterectomy/oophorectomy (31.6% mediated, 95% CI: 18.8-47.9%), hypercholesterolemia, hypertension and infertility. Further analysis revealed that the interaction effect of age was significant for the association between endometriosis and NAFLD (P = 0.01).

CONCLUSIONS

Laparoscopically confirmed endometriosis was positively associated with the risk of incident NAFLD. Awareness of the potential NAFLD risk should be raised for clinicians and patients during the regular follow-up of endometriosis.

Examining the interplay between endometriosis and later-life cerebro-cardiovascular diseases: A systematic review, meta-analysis, and trial sequential analysis

Beyond gynecological issues, women with endometriosis have a significant risk of cardiac outcomes. Despite this evidence, the extent and mechanisms of the association remain unclear. The aim of this study was to evaluate the association between endometriosis and the incidence of cerebro-cardiovascular disorders. Using preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines, seven databases were searched as of October 14, 2024, for observational studies assessing the association between endometriosis and cerebro-cardiovascular disorders. The main outcome was major adverse cardiovascular and cerebrovascular event (MACCE) while the secondary outcomes included all-cause mortality, cerebrovascular accident (CVA), ischemic heart disease (IHD), myocardial infarction (MI), arrhythmia, and heart failure (HF). Bias was assessed with the risk of bias in non-randomized studies of exposures (ROBINS-E) tool. Odds ratios with 95% confidence interval (CI) were calculated using random-effects meta- analysis. Evidence certainty was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Robustness was assessed via sensitivity analyses and trial sequential analysis (TSA). Out of 3,141 studies, nine cohort studies encompassing 1,670,589 women (follow-up 7-28 years) were included. Endometriosis was associated with 24% higher odds of MACCE incidence (95%CI: 1.18-1.31, moderate certainty). In addition, having endometriosis increased the odds of CVA by 49% (95%CI: 1.20-1.85, high certainty), IHD by 64% (95%CI: 1.31-2.05, low certainty), MI by 53% (95%CI: 1.18-1.98, high certainty), arrhythmias by 24% (95%CI: 1.12-1.37, high certainty), and HF by 13% (95%CI: 1.03-1.25, high certainty). Endometriosis did not significantly associate with all-cause mortality. Sensitivity analyses and TSA reinforced all of these findings. In conclusion, endometriosis was significantly associated with increased odds of cerebro-cardiovascular disorders. Future research should clarify the underlying mechanisms and develop targeted prevention strategies.

Unravelling the Causal Relationship between Endometriosis and the Risk for Developing Venous Thromboembolism: A Pooled Analysis

To investigate the effect of endometriosis on venous thromboembolism (VTE) in oral contraceptive (OC) users. Pooled analysis on a harmonized dataset compromising international patient-centric cohort studies: INAS-VIPOS, INAS-SCORE, and INAS-FOCUS. Eleven European countries, the United States, and Canada. Individuals being newly prescribed an OC with or without an endometriosis and no VTE history.Detailed information was captured using self-administered questionnaires at baseline and every 6 to 12 months thereafter. Self-reported VTEs were medically validated and reviewed by an independent adjudication committee. Incidence rates (IRs) were calculated per 10,000 woman-years. The association of endometriosis on VTE was determined in a time-to-event analysis, calculating crude and adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) using stabilized inverse probability of treatment weighting (IPTW).A total of 22,072 women had an endometriosis diagnosis, and 91,056 women did not. Women with endometriosis contributed 78,751 woman-years during which 41 VTE events occurred (IR: 5.2/10,000, 95% CI: 3.7-7.1) compared to 127 VTEs during 310,501 woman-years in women without endometriosis (IR: 4.1/10,000, 95% CI: 3.4-4.9). The hazard ratio of VTE in women with endometriosis was 1.79 (95% CI: 1.24-2.57) using stabilized IPTW controlling for age, body mass index, smoking, education, age at menarche, and family history of VTE. Subgroup and sensitivity analyses showed similar results.These results highlight the importance of considering endometriosis as a potential factor contributing to VTE in women using OC; however, further research on the relationship between endometriosis and VTE is warranted.

Disease Burden, Temporal Trends, and Cross-Country Inequality Associated with Sociodemographic Indicators in Alzheimer's Disease and Other Dementias

INTRODUCTION

The purpose of this article is to describe the global burden and temporal trends of Alzheimer's disease and other dementias from 1990 to 2021 and explore cross-country inequality associated with sociodemographic development-related factors.

METHODS

The disability-adjusted life years of Alzheimer's disease and other dementias and sociodemographic index were extracted from the Global Burden of Disease 2021 study, and other sociodemographic development-related factors, including government expenditure on education (% of GDP), net national income per capita, health expenditure per capita, and fertility rate, were sourced from World Bank Data. Disability-adjusted life years of Alzheimer's disease and other dementias across 204 countries/territories and global age-sex distribution in 2021 were illustrated. The Joinpoint regression model was used to analyze the temporal trends of disease burden, and the slope index of inequality and concentration index were calculated to quantify cross-country inequalities. Analyses were conducted in 2024.

RESULTS

Significant disparities were observed in the numbers, rates, and age-standardized rates of disability-adjusted life years across 204 countries/territories. Females demonstrated higher disability-adjusted life year numbers (rates) for all age groups. Age-standardized disability-adjusted life year rate increased worldwide and was high in high-middle and middle sociodemographic index regions but increased faster in low (average annual percentage change=0.227%) and low-middle (average annual percentage change=0.244%) sociodemographic index regions. Cross-country inequality analyses indicated that disability-adjusted life years of Alzheimer's disease and other dementias were skewed and higher in countries with higher sociodemographic development, and the inequality increased with time except for education expenditure-related inequality.

CONCLUSIONS

The burden of Alzheimer's disease and other dementias has risen globally over the past 3 decades, accompanied by increasing cross-country inequalities, which disproportionately affects countries with high sociodemographic development. Boosting expenditure on education may narrow this inequality.

Salsalate negatively impacts microvascular function in women with endometriosis

Women with endometriosis, an inflammatory disease, are at increased risk of cardiovascular disease and demonstrate impaired microvascular endothelial function, characterized by reduced nitric oxide (NO)-mediated vasodilation. In some clinical cohorts, nuclear factor-kappa B (NFκB) inhibition with salsalate improves endothelial function. We hypothesized that salsalate would improve cutaneous microvascular endothelial function in women with endometriosis. Following placebo or salsalate (3,000 mg·day-1 for 5 days), four intradermal microdialysis probes were placed in 11 women (33 ± 7 yr) with endometriosis. Local heating units (set to 33°C) and laser-Doppler flowmetry (red blood cell flux) probes were placed over the probes. Increasing doses of acetylcholine (ACh; dissolved in lactated Ringer's solution) were perfused, alone (control) or coperfused with: NG-nitro-l-arginine methyl ester (l-NAME), atorvastatin (statin), or l-NAME + statin (combo). Maximal vasodilation was then induced (local heat at 43°C + sodium nitroprusside perfusion). Data were normalized as percentage of maximal cutaneous vascular conductance (CVC%max red blood cell flux/mean arterial pressure). To measure macrovascular endothelial function, flow-mediated dilation (FMD) was additionally performed. During placebo, coperfusion with statin did not impact the CVC%max ACh dose-response (P = 0.93). Oral salsalate attenuated the CVC%max response to ACh perfusion alone (P < 0.01) but did not impact the l-NAME site (P = 0.09). Salsalate significantly augmented the CVC%max response of the statin site (P < 0.01) but did not affect the combo site response (P = 1.00). FMD was not different between treatments (P = 0.79). Salsalate treatment impairs vasodilation in the cutaneous microcirculation in women with endometriosis through non-NO-dependent mechanisms.NEW & NOTEWORTHY Our results show that oral salsalate treatment negatively impacts microvascular function but does not alter macrovascular function. In contrast to the majority of other clinical populations with endothelial dysfunction, salsalate treatment reduces microcirculatory function through non-NO-dependent mechanisms in women with endometriosis.

Are Noncancerous Gynecologic Conditions or Pregnancy Risk Factors for Ischemic Stroke in Cervical Artery Dissection?

OBJECTIVE

Cervical artery dissection (CeAD) was previously thought to be more common in men, but recent epidemiology studies show a disproportionate increase in the incidence of CeAD in women. In addition to sex-based differences in clinical presentation, there are unique biological risk factors for CeAD in women. Identifying risk factors for ischemic stroke in CeAD is crucial in individualizing treatment options. Herein, we utilized an inpatient cohort to investigate whether noncancerous gynecologic conditions or pregnancy are risk factors for ischemic stroke in CeAD.

METHODS

The National Inpatient Sample was queried from 2016 to 2020 for patients diagnosed with CeAD using the International Classification of Diseases, 10th edition, correction of the mean codes. Diagnoses of pregnancy/puerperium and noncancerous gynecologic conditions were identified. Among CeAD admissions, acute ischemic stroke (AIS) was also identified. Hierarchical, multivariable regression, adjusted for patient demographics and medical comorbidities, was conducted to assess factors associated with AIS.

RESULTS

A total of 34,925 women with CeAD were identified. Of these women, 2.1% were pregnant or up to six weeks postpartum, 1.3% had a noncancerous gynecologic condition, and 0.09% had both active pregnancy/puerperium and a noncancerous gynecologic condition. Noncancerous gynecologic conditions (odds ratio = 1.86, P = 0.012) were found to be an independent risk factor for AIS in CeAD but not active pregnancy/puerperium (odds ratio = 0.84, P = 0.34).

CONCLUSION

In this national inpatient sample of female patients with CeAD, the presence of noncancerous gynecologic conditions is associated with an increased risk of AIS. Further studies are needed to validate this observation and help guide the best antithrombotic treatment decisions in this patient population.

Menstruation: An Important Indicator for Assessing Stroke Risk and Its Outcomes

In recent years, stroke incidence in older adults has declined strikingly, but stroke in younger women has become more common. Abnormalities of menstruation, the shedding of the uterine lining at the beginning of each menstrual cycle, may offer clues about stroke risk in young and midlife women. Endometrial and structural uterine abnormalities are associated with anemia and may be associated with hypercoagulability, possibly increasing stroke risk. Patient factors that influence both menstruation and stroke risk include coagulopathies, polycystic ovarian syndrome, endometriosis, migraine, and other systemic disorders, in addition to menopause. Environmental and iatrogenic factors that influence both menstruation and stroke risk include hormonal contraceptives, nicotine, xenoestrogens, phytoestrogens, oophorectomy, and hysterectomy. Importantly, secondary stroke prevention can affect menstruation. Our current review presents literature supporting the idea that abnormal menstruation may indicate elevated stroke risk in premenopausal women.

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Endometriosis and uterine fibroids and risk of premature mortality: prospective cohort study

OBJECTIVE

To prospectively assess the effect of endometriosis and uterine fibroids on the long term risk of premature mortality (younger than 70 years).

DESIGN

Prospective cohort study SETTING: The Nurses' Health Study II, United States (1989-2019).

PARTICIPANTS

110 091 women aged 25-42 years in 1989 without a history of hysterectomy before endometriosis or fibroids diagnosis, cardiovascular diseases, or cancer.

MAIN OUTCOME MEASURES

Hazard ratios (estimated by Cox proportional hazards models) for total and cause specific premature mortality according to laparoscopically confirmed endometriosis or ultrasound or hysterectomy confirmed uterine fibroids reported in biennial questionnaires.

RESULTS

4356 premature deaths were recorded during 2 994 354 person years of follow-up (27.2 years per person), including 1459 from cancer, 304 from cardiovascular diseases, and 90 from respiratory diseases. The crude incidence of all cause premature mortality for women with and without laparoscopically confirmed endometriosis was 2.01 and 1.40 per 1000 person years, respectively. In age adjusted models, laparoscopically confirmed endometriosis was associated with a hazard ratio of 1.19 (95% confidence interval 1.09 to 1.30) for premature death; these models were strengthened after also adjusting for potential confounders including behavioral factors (1.31, 1.20 to 1.44). Cause specific mortality analyses showed that the association was largely driven by mortality from senility and ill-defined diseases (1.80, 1.19 to 2.73), non-malignant respiratory diseases (1.95, 1.11 to 3.41), diseases of the nervous system and sense organs (2.50, 1.40 to 4.44), and malignant neoplasm of gynecological organs (2.76, 1.79 to 4.26). Ultrasound or hysterectomy confirmed uterine fibroids were not associated with all cause premature mortality (1.03, 0.95 to 1.11), but were associated with a greater risk of mortality from malignant neoplasm of gynecological organs (2.32, 1.59 to 3.40) in cause specific mortality analyses. The risk of mortality caused by cardiovascular and respiratory diseases varied according to joint categories of endometriosis and uterine fibroids, with an increased risk of all cause premature mortality among women reporting both endometriosis and uterine fibroids.

CONCLUSION

Women with a history of endometriosis and uterine fibroids might have an increased long term risk of premature mortality extending beyond their reproductive lifespan. These conditions were also associated with an increased risk of death due to gynecological cancers. Endometriosis was associated with a greater risk of non-cancer mortality. These findings highlight the importance for primary care providers to consider these gynecological disorders in their assessment of women's health.

Endometriosis, Anxiety, and Atherosclerosis: A Study of Eight Million Young Hospitalized Women in the USA

OBJECTIVE

In recent years, several studies have proposed an association between endometriosis and various cardiovascular diseases. Our study evaluated the association between endometriosis and atherosclerosis in patients under 35 years of age using a large population database.

DESIGN

This was a cross-sectional retrospective population-based study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We used the data of more than eight million hospitalized women under 35 years of age who were registered in one of the hospitals participating in the Healthcare Cost and Utilization Project - National Inpatient Sample (HCUP NIS) during the study period of 2007-2014. The prevalence of endometriosis, atherosclerosis, and related conditions was estimated, and logistic regression model was used to examine the association.

RESULTS

In the period of study of 8,061,754 patients, we noted an upward pattern for the prevalence of atherosclerosis and a downward trend for endometriosis. Adjusting the analysis for sociodemographic characteristics and comorbidities, the probability of being diagnosed with atherosclerosis was 42% higher in patients with endometriosis (odds ratio [OR] = 1.421; 95% confidence interval [CI]: 1.058-1.910); 35% higher in patients with anxiety (OR = 1.352; 95% CI: 1.249-1.464); and three times higher in women with both endometriosis and anxiety (OR = 3.075; 95% CI: 1.969-4.803) compared to women without those conditions.

LIMITATIONS

In HCUP NIS databases, some information such as the severity of disease, laboratory findings, or medical treatment is not available.

CONCLUSION

The strong association between endometriosis and atherosclerosis suggests that they may share a similar mechanism possibly endothelial dysfunction related to chronic inflammation. Further studies on the potential role of psychological conditions, such as anxiety, on systemic inflammatory diseases are also deemed timely and important.

Cardio-Metabolic Risk Profile of Women With Endometriosis: A Population-Based Study

AIMS

Endometriosis (EM) and metabolic disorders are frequent health problems among reproductive-aged women worldwide. Cardio-metabolic risk profile of women with EM is not well understood. We aimed to investigate the cardio-metabolic risk profile of Iranian reproductive-aged women with EM.

METHODS

This study included 976 female participants aged 20-45 years of Tehran Lipid and Glucose Study. Endometriosis was diagnosed based on the participants' self-reported previous diagnosis of EM, which was confirmed by reviewing the relevant medical documentation. All biochemical measures (low-density lipoprotein cholesterol [LDL], high-density lipoprotein cholesterol [HDL], triglycerides [TG], and fasting blood glucose concentrations [FBG]) and measurement of systolic blood pressure (SBP) and diastolic blood pressure (DBP) and anthropometric parameters were performed according to the standard protocol of TLGS. Logistic regression analysis was performed to estimate the odds ratio of cardio-metabolic disease.

RESULTS

Of the 976 study participants, 161 individuals (16.5%) had a confirmed diagnosis of endometriosis. There were no significant differences in the median of metabolic parameters among women with and without endometriosis (p > 0.05). The prevalence of metabolic syndrome was significantly higher in women with EM group compared to the non-EM group (21.9% vs. 14.9%). The presence of endometriosis was associated with an increased odds of metabolic syndrome (adjusted odds ratio 1.99 [95% CI 1.20-3.30]; p = 0.007). And endometriosis significantly increased odds of low HDL by 2.07 (1.02-4.20); after adjustment, it still remained significant (p = 0.03). Endometriosis also increased odds of high waist circumstance significantly (1.58 [1.06-2.37]; p = 0.02).

CONCLUSIONS

Women with endometriosis may be at an increased risk of developing metabolic syndrome, high waist circumstance and low HDL compared to their counterparts without the condition. Given the potential cardio-metabolic implications, healthcare providers should consider assessing the metabolic profile of women diagnosed with endometriosis.

Cardiovascular risks and endothelial dysfunction in reproductive-age women with endometriosis

Endometriosis is a prevalent gynecological condition, affecting around 10% of reproductive-age women. Inflammatory processes associated with endometriosis may contribute to endothelial dysfunction. Increased skin accumulation of advanced glycation end-products (AGEs), reflecting arterial stiffness, potentially links endometriosis with elevated risk of cardiovascular events. We hypothesized that patients with endometriosis have impaired endothelial function as well as increased arterial stiffness and AGE skin accumulation, compared to healthy controls. We compared endothelial function, arterial stiffness, and levels of AGEs in patients suffering from endometriosis and in healthy controls. The study included 45 women aged 20 to 40: 21 patients with endometriosis and 24 healthy controls, matched in terms of age, BMI, and blood pressure values. Endo-PAT 2000 device was used for non-invasive assessment of (i) endothelial function, expressed as Reactive Hyperemia Index (RHI), and (ii) arterial stiffness, expressed as Augmentation Index (AI) and Augmentation Index at 75 heart beats/min (AI@75). Endothelial dysfunction was defined as an RHI value ≤ 1.67. AGE Reader device was used for non-invasive evaluation of skin AGE level accumulation. Patients with endometriosis had lower mean RHI values (1.69 ± 0.54 vs. 2.02 ± 0.48, p = 0.037) and a higher prevalence of endothelial dysfunction, (52.4% vs. 20.8%, p = 0.027) compared to healthy controls. Skin AGE level was higher in patients with endometriosis, compared to controls (2.00 ± 0.57 vs. 1.70 ± 0.24, p = 0.013). There were no significant differences in AI and AI@75 between the two groups. Patients with endometriosis have impaired endothelial function and higher AGE skin accumulation, which are well-established preclinical manifestations of increased cardiovascular risk. There is a great need for comprehensive cardiovascular risk assessments in women with endometriosis to prevent the development of potential atherosclerotic-based complications.

Association between cardiometabolic Index (CMI) and endometriosis: a cross-sectional study on NHANES

BACKGROUND

Endometriosis is intricately linked to metabolic health. The Cardiometabolic Index (CMI), a novel and readily accessible indicator, is utilized to evaluate metabolic status. This study seeks to investigate the potential correlation between CMI and endometriosis.

METHODS

Data from four consecutive survey cycles of the National Health and Nutrition Examination Survey (NHANES) conducted between 1999 and 2006 were utilized. This included adult females with self-reported diagnoses of endometriosis and complete information required for calculating the CMI. The calculation formula for CMI is Triglycerides(TG) / High-density lipoprotein cholesterol (HDL-C) × WHtR (WHtR = waist circumference / height). A multivariable logistic regression model was employed to investigate the linear association between CMI and endometriosis. Subgroup analyses were performed to explore potential influencing factors. Additionally, the linear relationship was validated using restricted cubic spline (RCS) curve plotting and threshold effect analysis.

RESULTS

This study, based on the National Health and Nutrition Examination Survey (NHANES), included a cohort of 2,224 adult women. The multivariable logistic regression analysis demonstrated that in the fully adjusted model, individuals with the highest CMI exhibited a 78% elevated likelihood of endometriosis compared to those with the lowest CMI (OR = 1.78; 95% CI, 1.02-3.11, P < 0.05). The subgroup analysis indicated that there were no significant interactions between CMI and specific subgroups (all interaction P > 0.05), except for the subgroup stratified by stroke status (P < 0.05). Additionally, the association between CMI and endometriosis was linear, with a 20% increase in the association for each unit increase in CMI when CMI > 0.67 (OR = 1.20; 95% CI, 1.05-1.37, P < 0.01).

CONCLUSION

The study found that CMI levels are closely correlated with endometriosis, with this correlation increasing when the CMI exceeds 0.67. This finding implies that by regularly monitoring CMI levels, physicians may be able to screen women at risk for endometriosis at an earlier stage, thereby enabling the implementation of early interventions to slow the progression of the disease. To further validate these findings, larger-scale cohort studies are required to support the results of this research.

Association between female infertility and stroke mortality: evidence from the PLCO cancer screening trial

OBJECTIVE

While infertility affects about 15% of women during their reproductive years, its long-term impact on stroke mortality after this period remains unclear. This study aims to investigate the association between infertility and stroke mortality in women using data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial.

METHODS

We analyzed data from 75,778 female participants aged 55-74 years with a median follow-up of 16.84 years. Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for stroke mortality, adjusting for potential confounders.

RESULTS

Among participants, 14.53% reported infertility. During follow-up, 1,159 women died from stroke. Compared to women without infertility, those with infertility had a higher risk of stroke mortality (HR 1.21, 95% CI 1.04-1.41, p = 0.016). This association remained statistically significant after adjusting for age, race, education level, marital status, smoking status, body mass index, history of hypertension, history of heart attack, history of diabetes mellitus, birth control pill use, hormone replacement therapy, endometriosis, first menstrual period and pregnancy history (HR 1.20, 95% CI 1.02-1.42, p = 0.029). Sensitivity and subgroup analyses yielded consistent results.

CONCLUSION

The findings of this study indicate that infertility is associated with an increased risk of stroke mortality in women. Further research is needed to confirm these findings and elucidate the underlying mechanisms.

Fostering cardio-endometriosis: a call to action for a comprehensive understanding of cardiovascular disease in endometriosis

Recently, a growing body of evidence has highlighted a concerning link between endometriosis and cardiovascular disease. Endometriosis, a chronic, inflammatory, hormone-dependent condition affecting 5-10% of reproductive-aged women worldwide, has long been associated with reproductive and gynaecological consequences. However, emerging research has suggested that it may also contribute to adverse cardiovascular outcomes. This paper aims to shed light on the importance of recognizing cardio-endometriosis as a new and developing sphere of research in the field of cardiology, thereby urging the medical community to address this pressing issue.

Growing evidence that endometriosis is a systemic disease

The pathophysiology of endometriosis remains unclear. Retrograde menstruation could be a phenomenon that initiates the process, but it may not explain the entire pathophysiology of endometriosis. Current evidence suggests that endometriosis is a type of chronic inflammatory disease. Many conditions that affect the vascular endothelium, including atherosclerosis, cardiovascular disease and pre-eclampsia, have been shown to be associated with endometriosis. Evidence to date suggests a complex interaction in endometriosis between angiogenesis, hormones and immunological changes stemming from chronic inflammation, with the inflammatory cells releasing cytokines and chemokines including tumour necrosis factor-α (TNF-α). Indeed, TNF-α is considered to be one of the possible markers of endometriosis in the blood, endometrium or menstrual blood. We emphasize the importance of pursuing research for novel and safer anti-inflammatory and immunomodulatory drugs that can be used by patients with endometriosis on a long-term basis.

Endometriosis and aspirin: a systematic review

Introduction

Endometriosis is delineated as a benign yet steroid-dependent disorder characterized by the ectopic presence of endometrial glandular and stromal cells outside the uterine cavity, affecting estimated 10%-15% of women of reproductive age, 20%-50% of all women with infertility and costing a great economic burden per-patient. Endometriosis exerts pervasive influence on multiple facets of female reproductive physiology. Given its characterization as a chronic inflammatory disorder, escalated levels of pro-inflammatory cytokines were unequivocally recognized as well-established characteristics of endometriosis, which might attribute to mechanisms like retrograde menstruation, progesterone receptor resistance, and immune dysregulation. Therapeutic utilization of non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, analgesic agent for reducing pain, inflammation, and fever, could be holding promise in augmenting reproductive outcomes of endometriosis women. Therefore, the objective of this comprehensive review is to elucidate the intricate interplay between endometriosis and aspirin, both within the context of infertility and beyond. We meticulously explore potential pharmacological agents targeting endometriosis, which may concurrently optimize the efficacy of reproductive interventions, while also delving into the underlying mechanistic pathways linking endometriosis with inflammatory processes.

Methods

We conducted a comprehensive search in the data available in PubMed and the Web of Science using the terms 'endometriosis' and 'aspirin'. Then analyzed the identified articles based on established inclusion and exclusion criteria independently by three reviewers.

Results

The survey of the chosen terms revealed 72 articles, only 10 of which were considered for review.

Discussion

Based on the research available currently, it is not substantial enough to address the conclusion that aspirin shall be an effective therapeutic choice for endometriosis, further studies are needed to elucidate the efficacy, safety profile, and optimal dosing regimens of aspirin in the context of endometriosis treatment.

Holistic approach to care for patients with endometriosis

PURPOSE OF REVIEW

Endometriosis is a chronic, often debilitating, disease which is typically managed with surgery and hormonal medications. However, many patients feel they lack agency when managing endometriosis symptoms. The purpose of this review is to discuss the mental and physical management strategies, the long-term health consequences, and the role of a multidisciplinary team in the treatment of endometriosis.

RECENT FINDINGS

Evidence is becoming more robust regarding the role of complementary care and physical activity in the management of endometriosis. Health risks such as infertility are well known and newer evidence is evolving regarding perinatal and cardiovascular health risks. There are also trends towards multiple specialist involvement in the care of endometriosis and the benefit of interdisciplinary collaboration.

SUMMARY

Endometriosis is a frequently recurrent condition requiring not only meticulous medical and surgical care, but also coordinated longitudinal disease management and impact mitigation. Gynecologists should be aware of the short-term and long-term implications of the disease to empower patients on the management of their overall health.

Ischemic stroke with concomitant clear cell carcinoma of the ovary: A case report and review of literature

BACKGROUND

Ischemic stroke is a rare event associated with an elevated risk of blood clot formation owing to an underlying malignancy. Herein, we present a case of ovarian carcinoma that led to cerebral infarction.

CASE SUMMARY

A 43-year-old woman experienced sudden onset right-sided paralysis and difficulty speaking two days after discovery of a large ovarian tumor measuring approximately 14 cm, which was suspected to be malignant. Further examination revealed left middle cerebral artery infarction. The patient had a history of hypertension and adenomyosis. Following stabilization with heparin treatment and vital signs management, the patient underwent debulking surgery, including total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and bilateral pelvic and para-aortic lymph node dissection. The final diagnosis was clear cell carcinoma of the right ovary (stage IA). Subsequently, the patient completed six rounds of adjuvant chemotherapy while simultaneously undergoing rehabilitation. Presently, the patient is able to walk independently, although she still experiences aphasia.

CONCLUSION

Prompt medical intervention and interdisciplinary care are crucial in the setting of incidental findings such as a large ovarian tumor.

Causal associations of male infertility with stroke: a two-sample Mendelian randomization study

Background

Stroke is a devastating global health issue, with high mortality and disability rates. The increasing prevalence of male infertility among reproductive-aged men has become a growing concern worldwide. However, the relationship between male infertility and stroke incidence remains uncertain. This study aimed to address this knowledge gap by employing a Mendelian randomization (MR) approach.

Method

Utilizing genetic instrumental variables derived from a genome-wide association study (GWAS) on male infertility and stroke, a two-sample MR design was implemented. Five different analysis methods, with inverse-variance weighted as the primary approach, were used to examine the genetic causal associations between male infertility and various stroke subtypes. Heterogeneity analysis, pleiotropy tests, and leave-one-out validation were conducted to assess heterogeneity, evaluate pleiotropy, and ensure the robustness of the findings.

Result

The results indicate a potential lower risk of small vessel stroke associated with male infertility (odds ratio, 95% confidence interval: 0.82, 0.68 to 0.99, p=0.044), although no significant impact on other stroke subtypes was observed. The study exhibited low heterogeneity and no apparent pleiotropy; however, the stability of the results was not optimal.

Conclusion

Male infertility might potentially confer a protective effect against small vessel stroke risk. Caution is warranted due to potential confounding factors. Additional studies are necessary to confirm these findings and provide further validation.

Endometriosis and Risk of Cardiovascular Disease: Systematic Review and Meta-Analysis

Background: Endometriosis is a common disease affecting 10% of reproductive-age women globally and is associated with chronic systemic inflammation. Some studies suggest that women with endometriosis have a higher risk of cardiovascular disease, whereas others have conflicting findings. This study aims to further investigate the association between endometriosis and cardiovascular disease. Methods: A systematic review was conducted using the EMBASE and MEDLINE databases from inception to October 2022. The search strategy comprised terms for "endometriosis" and "cardiovascular disease." Eligible studies had to include one group of patients with endometriosis and another group of individuals without endometriosis. The study must then compare the incidence or prevalence of cardiovascular disease (major adverse cardiovascular events [MACE], ischemic heart disease [IHD], cerebrovascular accident [CVA], or peripheral artery disease [PAD]). Results: A total of 5,401 articles were identified, and 9 studies were eligible for meta-analysis. Pooled analysis showed an increased prevalence of IHD (pooled odds ratio [OR]: 1.22; 95% confidence interval [95% CI]: 0.74-2.02), CVA (pooled OR: 1.28; 95% CI: 1.07-1.53), and PAD (pooled OR: 1.55; 95% CI: 1.35-1.78). Pooled analysis showed an increased incidence of MACE (pooled hazard ratio [HR]: 1.23; 95% CI: 1.14-1.33), IHD (pooled HR: 1.43; 95% CI: 1.28-1.59), and CVA (pooled HR: 1.20; 95% CI: 1.11-1.30). Conclusions: This systematic review and meta-analysis found a statistically significant association between endometriosis and increased risk of cardiovascular disease (MACE, IHD, CVA, PAD).

In the thicket of fears, doubts, and murky facts: some reflections on treatment modalities for endometriosis-associated pain

Endometriosis-associated pain can be managed by either surgery or hormonal therapy. The final decision as to which treatment modality to take is based on efficacy and possible complications of different treatment modalities, risk of recurrence, and the patient's wishes and preferences. But in the thicket of fears, doubts, and murky facts, the choice may ultimately be the trade-off between irrational fears and ignorance versus scientific evidence. We elaborate some pros and cons of the two treatment modalities and highlight some notable downsides of hormonal therapy, in particular the possible yet unquantified risk of long-term hormonal therapy for malignant transformation, perhaps with the only exception of combined oral contraceptives. Thus, when discussing with patients, we advocate the approach of discussing the advantages and disadvantages of all treatment options in detail, accounting for the known pros and cons with a full understanding of the predictive irrationality of human beings. For endometriosis-associated pain, surgery is definitely not a failure of medicine but, rather, a viable option, especially given the recently surfaced undercurrent of wariness and dissatisfaction with the current hormonal drugs among patients with endometriosis. Above all, there is a pressing need to fill the knowledge gap of perioperative interventions intended to reduce the risk of recurrence and to fulfill the demand for the development of safe and efficacious non-hormonal therapeutics.

Leveraging electronic health record data for endometriosis research

Endometriosis is a chronic, complex disease for which there are vast disparities in diagnosis and treatment between sociodemographic groups. Clinical presentation of endometriosis can vary from asymptomatic disease-often identified during (in)fertility consultations-to dysmenorrhea and debilitating pelvic pain. Because of this complexity, delayed diagnosis (mean time to diagnosis is 1.7-3.6 years) and misdiagnosis is common. Early and accurate diagnosis of endometriosis remains a research priority for patient advocates and healthcare providers. Electronic health records (EHRs) have been widely adopted as a data source in biomedical research. However, they remain a largely untapped source of data for endometriosis research. EHRs capture diverse, real-world patient populations and care trajectories and can be used to learn patterns of underlying risk factors for endometriosis which, in turn, can be used to inform screening guidelines to help clinicians efficiently and effectively recognize and diagnose the disease in all patient populations reducing inequities in care. Here, we provide an overview of the advantages and limitations of using EHR data to study endometriosis. We describe the prevalence of endometriosis observed in diverse populations from multiple healthcare institutions, examples of variables that can be extracted from EHRs to enhance the accuracy of endometriosis prediction, and opportunities to leverage longitudinal EHR data to improve our understanding of long-term health consequences for all patients.

Infertility and Risk of Cardiovascular Disease: A Prospective Cohort Study

Background Certain symptoms associated with infertility are associated with cardiovascular disease, including menstrual cycle irregularity, early menopause, and obesity; however, few studies have investigated the association between infertility and cardiovascular disease risk. Methods and Results Participants in the NHSII (Nurses' Health Study II) who reported infertility (12 months of trying to conceive without success, including women who subsequently conceived) or who were gravid, with no infertility were followed from 1989 until 2017 for development of incident, physician-diagnosed coronary heart disease (CHD) (myocardial infarction, coronary artery bypass grafting, angioplasty, stent) and stroke. Time-varying Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% CIs and were adjusted a priori for potential confounding variables. Among 103 729 participants, 27.6% reported having ever experienced infertility. Compared with gravid women who had not reported infertility, women with a history of infertility had greater risk of CHD (HR, 1.13 [95% CI, 1.01-1.26]) but not stroke (HR, 0.91 [95% CI, 0.77-1.07]). The association between history of infertility and CHD was strongest among women who reported infertility at an earlier age (HR for infertility first reported at ≤25 years, 1.26 [95% CI, 1.09-1.46]; HR at 26-30 years, 1.08 [95% CI, 0.93-1.25]; HR at >30 years, 0.91 [95% CI, 0.70-1.19]). When we investigated specific infertility diagnoses, elevated risk of CHD was observed among women whose infertility was attributed to an ovulatory disorder (HR, 1.28 [95% CI, 1.05-1.55]) or endometriosis (HR, 1.42 [95% CI, 1.09-1.85]). Conclusions Women with infertility may be at an increased risk of CHD. Risk differed by age at first infertility diagnosis and was restricted to ovulatory- and endometriosis-related infertility.

Stroke in Women and Unique Risk Factors

There has been a plethora of studies focused on female-specific risk factors and sex differences in stroke published in the past year. This article summarizes several of those novel studies which provide new knowledge about the field of stroke in women. The Nurses' Health Study II provides new data on the association between laparoscopically proven endometriosis and future stroke, accounting for the mediation effects of hysterectomy and oophorectomy. In a cohort of women from China, the relationship between hysterectomy, oophorectomy, and stroke is further clarified, accounting for the age at which the procedure is performed. The UK Biobank study provides new information on the relationship between oral contraceptive and hormone replacement therapy and stroke, with analytical techniques that focus on the timing of events related to duration of exposure. Finally, 2 new meta-analyses address the question of whether sex differences exist in the presentation of stroke symptoms.

Pathophysiology, diagnosis, and management of endometriosis

Endometriosis affects approximately 190 million women and people assigned female at birth worldwide. It is a chronic, inflammatory, gynecologic disease marked by the presence of endometrial-like tissue outside the uterus, which in many patients is associated with debilitating painful symptoms. Patients with endometriosis are also at greater risk of infertility, emergence of fatigue, multisite pain, and other comorbidities. Thus, endometriosis is best understood as a condition with variable presentation and effects at multiple life stages. A long diagnostic delay after symptom onset is common, and persistence and recurrence of symptoms despite treatment is common. This review discusses the potential genetic, hormonal, and immunologic factors that lead to endometriosis, with a focus on current diagnostic and management strategies for gynecologists, general practitioners, and clinicians specializing in conditions for which patients with endometriosis are at higher risk. It examines evidence supporting the different surgical, pharmacologic, and non-pharmacologic approaches to treating patients with endometriosis and presents an easy to adopt step-by-step management strategy. As endometriosis is a multisystem disease, patients with the condition should ideally be offered a personalized, multimodal, interdisciplinary treatment approach. A priority for future discovery is determining clinically informative sub-classifications of endometriosis that predict prognosis and enhance treatment prioritization.