Quality of life in women with endometriosis: a narrative overview

Informational support for women with endometriosis: a scoping review

BACKGROUND

Ten per cent of women of reproductive age suffer from endometriosis, a painful and incurable disease that leaves women with severe implications for their health and overall well-being. Due to the absence of a cure and the limited effectiveness of available treatments, acquiring accurate information is paramount for women to successfully navigate both their daily lives and the complexities of the healthcare system. This scoping review aimed to map the current literature on women with endometriosis information needs, their information seeking behaviour, and the format and scope of current information resources available.

METHODS

The scoping review was conducted using the JBI methodology for scoping reviews and reported according to the PRISMA-ScR statement. The final search was conducted in August 2024, through the databases Medline, Cinahl, Embase, Scopus, and WebofScience. Studies on information resources on endometriosis and information seeking behaviour as well as information needs of women with endometriosis were eligible for inclusion.

RESULTS

The majority of the 25 included studies focused on information resources, specifically webpages and social media sites. While few studies analysed information seeking behaviour and information needs, the evidence shows women's high interest in a broad spectrum of information topics. Across all studies, the internet was the most important access point for information.

CONCLUSION

Addressing the absence of systematic analyses on the information seeking behaviour and needs of women with endometriosis is crucial for future research. This step is essential for the development of customised information resources that cater specifically to the diverse needs of women affected by endometriosis.

Magnetic Resonance Imaging of Endometriosis: The Role of Advanced Techniques

Endometriosis is a chronic inflammatory disease that affects about 10% of women, and it is characterized by the presence of endometrial tissue outside the uterine cavity. Associated symptoms are dyspareunia, chronic pelvic pain, and infertility. The diagnosis of endometriosis can be challenging due to various clinical and imaging presentations. Laparoscopy is the gold standard for the diagnosis, but it is an invasive procedure. The literature has increasingly promoted a switch to less invasive imaging techniques, such as ultrasound and magnetic resonance imaging (MRI). The latter, also in relation to the latest technological advances, allows a comprehensive and accurate assessment of the pelvis and it can also identify sites of endometriosis that escape laparoscopic evaluation. Furthermore, MRI has been found to be more accurate than other imaging techniques in relation to its improved sensitivity and specificity in identifying disease sites, also due to the role of new emerging sequences. This article aims to review the current role of advanced MRI applications in the assessment of endometriosis.

A thematic synthesis of qualitative studies and surveys of the psychological experience of painful endometriosis

BACKGROUND

Endometriosis is a widespread problem in women of reproductive age, causing cyclical and non-cyclical pain in the pelvis and elsewhere, and associated with fatigue, fertility problems, and other symptoms. As a chronic pain problem, psychological variables are important in adjustment and quality of life, but have not been systematically studied.

METHODS

A systematic search of multiple databases was conducted to obtain surveys and qualitative studies of women's experience of pain from endometriosis. Surveys were combined narratively; qualitative studies were combined by thematic synthesis, and the latter rated for methodological quality.

RESULTS

Over 2000 records were screened on title and abstract, and provided 22 surveys and 33 qualitative studies from which accounts could be extracted of the psychological components of pain in endometriosis. Surveys mostly addressed quality of life in endometriosis, with poorer quality of life associated with higher levels of pain and of distress, but few referred to coherent psychological models. Qualitative studies focused rather on women's experience of living with endometriosis, including trajectories of diagnosis and treatment, with a few addressing meaning and identity. Thematic synthesis provided 10 themes, under the groupings of internal experience of endometriosis (impact on body, emotions, and life); interface with the external world (through self-regulation and social regulation); effects on interpersonal and social life, and encounters with medical care.

CONCLUSIONS

The psychological components of pain from endometriosis only partly corresponded with standard psychological models of pain, derived from musculoskeletal pain studies, with fewer fears about physical integrity and more about difficulties of managing pain and other symptoms in social settings, including work. Better understanding of the particular psychological threats of endometriosis, and integration of this understanding into medical care with opportunities for psychologically-based pain management, would substantially improve the experience and quality of life of women with painful endometriosis.

A review of phase II and III drugs for the treatment and management of endometriosis

INTRODUCTION

Endometriosis is an estrogen-dependent disease that gives rise to pelvic pain and infertility. Although estroprogestins and progestins currently stand as the first-line treatments for this condition, demonstrating efficacy in two-thirds of patients, a significant portion of individuals experience only partial relief or symptom recurrence following the cessation of these therapies. The coexistence of superficial, deep endometriosis, and ovarian endometriomas, as three distinct phenotypes with unique pathogenetic and molecular characteristics, may elucidate the current heterogeneous biological response to available therapy.

AREAS COVERED

The objective of this review is to furnish the reader with a comprehensive summary pertaining to phase II-III hormonal treatments for endometriosis.

EXPERT OPINION

Ongoing research endeavors are directed toward the development of novel hormonal options for this benign yet debilitating disease. Among them, oral GnRH antagonists emerge as a noteworthy option, furnishing rapid therapeutic onset without an initial flare-up; these drugs facilitate partial or complete estrogen suppression, and promote prompt ovarian function recovery upon discontinuation, effectively surmounting the limitations associated with previously employed GnRH agonists. Limited evidence supports the use of selective estrogen and progesterone receptor modulators. Consequently, further extensive clinical research is imperative to garner a more profound understanding of innovative targets for novel hormonal options.

Endometriosis in the era of precision medicine and impact on sexual and reproductive health across the lifespan and in diverse populations

Endometriosis is a common estrogen-dependent disorder wherein uterine lining tissue (endometrium) is found mainly in the pelvis where it causes inflammation, chronic pelvic pain, pain with intercourse and menses, and infertility. Recent evidence also supports a systemic inflammatory component that underlies associated co-morbidities, e.g., migraines and cardiovascular and autoimmune diseases. Genetics and environment contribute significantly to disease risk, and with the explosion of omics technologies, underlying mechanisms of symptoms are increasingly being elucidated, although novel and effective therapeutics for pain and infertility have lagged behind these advances. Moreover, there are stark disparities in diagnosis, access to care, and treatment among persons of color and transgender/nonbinary identity, socioeconomically disadvantaged populations, and adolescents, and a disturbing low awareness among health care providers, policymakers, and the lay public about endometriosis, which, if left undiagnosed and under-treated can lead to significant fibrosis, infertility, depression, and markedly diminished quality of life. This review summarizes endometriosis epidemiology, compelling evidence for its pathogenesis, mechanisms underlying its pathophysiology in the age of precision medicine, recent biomarker discovery, novel therapeutic approaches, and issues around reproductive justice for marginalized populations with this disorder spanning the past 100 years. As we enter the next revolution in health care and biomedical research, with rich molecular and clinical datasets, single-cell omics, and population-level data, endometriosis is well positioned to benefit from data-driven research leveraging computational and artificial intelligence approaches integrating data and predicting disease risk, diagnosis, response to medical and surgical therapies, and prognosis for recurrence.

The Relation between Patient-Centered Care and Quality of Life in Women with Endometriosis

OBJECTIVE

The objective of this study was to examine the hypothesis that experiences with patient-centered endometriosis care are related to the endometriosis-specific quality of life dimensions "emotional well-being" and "social support."

DESIGN

A secondary regression analysis of two cross-sectional studies was conducted. Participants/Materials: In total, data from 300 women were eligible for analysis. The participating women all had surgically proven endometriosis.

SETTING

The study was conducted in one secondary and two tertiary endometriosis clinics in the Netherlands. Questionnaires were disseminated between 2011 and 2016.

METHODS

Both included studies investigated patient-centeredness of endometriosis care and endometriosis-specific quality of life using, respectively, the ENDOCARE questionnaire (ECQ) and the Endometriosis Health Profile 30 (EHP-30). To increase power, the regression analysis focused on the previously found relation between the ten dimensions of the ECQ and the EHP-30 domains "emotional well-being" and "social support" rather than all five EHP-30 domains. After the Bonferroni correction to limit type 1 errors, the adjusted p value was 0.003 (0.05/20).

RESULTS

The participating women had a mean age of 35.7 years and had predominantly been diagnosed with moderate to severe endometriosis. None of the relations between patient-centered endometriosis care and the EHP-30 domain "emotional well-being" were significant. Three dimensions of patient-centered endometriosis care proved to be significantly related to the EHP-30 domain "social support": "information, communication, and education" (p < 0.001, beta = 0.436), "coordination and integration of care" (p = 0.001, beta = 0.307), and "emotional support and alleviation of fear and anxiety" (p = 0.002, beta = 0.259).

LIMITATIONS

This cross-sectional study identified relations rather than proving causality between experiencing less patient-centeredness of care and having lower quality of life. Nevertheless, it is very tangible that some causality exists, either directly or indirectly (e.g., through empowerment) and that by improving patient-centeredness, quality of life might be improved as well.

CONCLUSION

"Information, communication, and education"; "coordination and integration of care"; and "emotional support and alleviation of fear and anxiety" as dimensions of patient-centered endometriosis care are related to the quality of life domain "social support" of women with endometriosis. Improving the patient-centeredness of endometriosis care was already considered an important goal, but even more so given its relation with women's quality of life, which is increasingly considered the ultimate measure of health care quality. Quality improvement projects focusing on "information, communication, and education" are expected to impact women's quality of life the most.

Effects of STAT Inhibitors in Mouse Models of Endometriosis

The signal transducer and activator of transcription (STAT) pathway, which regulates cell proliferation and immunity, has been implicated in chronic inflammatory diseases such as rheumatoid arthritis. However, few reports have described the effects of STAT inhibitors on endometriosis, another chronic inflammatory disease. Here, we investigated the intraperitoneal microenvironment and the effects of a STAT inhibitor in a mouse model of endometriosis. In the treatment group, a STAT3 inhibitor (Stattic®, 80 mg/kg) was orally administered three times per week; control animals received orally dosed phosphate-buffered saline. Endometriosis-like lesions and peritoneal lavage fluid were collected before and 1, 2, and 3 weeks after STAT3 inhibitor administration was initiated. The lesion area was significantly increased in both groups after the first week. However, in the treatment group, the lesion areas were significantly reduced at weeks 2 and 3 compared with week 1. Transforming growth factor (TGF)-β messenger RNA (mRNA) levels in ascites cells were significantly lower at weeks 1 and 2 than at week 0. Interleukin (IL)-6 mRNA levels were significantly higher at week 1 than at week 0 but were significantly lower at weeks 2 and 3 than at week 1. Thus, STAT inhibitors appeared to reduce the extent of endometriosis in this mouse model, and may also inhibit the IL-6 signaling pathway and reduce TGF-β levels. This study suggests that STAT inhibitors warrant further exploration for use in the treatment of endometriosis.

Analysis of preoperative and postoperative quality of life, sexual function, and sleep in patients with endometriosis: a prospective cohort study

PURPOSE

Endometriosis affects the quality of life, sleep, and sexual life of patients due to pain. This study compared the scores of endometriosis patients in these three areas before and after surgery.

METHODS

Patients between the ages of 18 and 60 with a prediagnosis of endometriosis were enrolled. Postoperative histopathological diagnosis of endometriosis was confirmed in all patients. This study included 56 patients who completed pre- and postoperative (three months) evaluation of quality scale questionnaires: a visual analog scale for pelvic pain, the Pittsburgh Sleep Quality Index, Morningness-Eveningness Questionnaire, Endometriosis Health Profile-30 Questionnaire, and Female Sexual Function Index were administered prior to and 3 months after each patient's surgery.

RESULTS

Among the 56 female patients included in this study, statistically significant improvement was observed in pain scores, quality of life, sexual function, and sleep of all patients regardless of endometriosis stage.

CONCLUSION

Endometriosis is a disease that progresses, with increasing pain scores; it has negative effects on the quality of life, sexual function, and sleep of patients. Surgical or medical treatment can be performed considering the complaints and fertility status of the patients.

Co-design and Development of EndoSMS, a Supportive Text Message Intervention for Individuals Living With Endometriosis: Mixed Methods Study

BACKGROUND

Endometriosis, which affects 1 in 10 people assigned female at birth, is a chronic systemic inflammatory disease with a high symptom burden and adverse socioemotional impacts. There is a need for an accessible, cost-effective, and low-burden intervention to support individuals in managing their endometriosis condition.

OBJECTIVE

This study aimed to co-design and evaluate the acceptability, readability, and quality of a bank of supportive SMS text messages (EndoSMS) for individuals with endometriosis.

METHODS

In phase 1 of this mixed method design, 17 consumer representatives (individuals with endometriosis) participated across three 3-hour web-based (Zoom, Zoom Video Communications, Inc) focus groups. The transcripts were encoded and analyzed thematically. In phase 2, consumer representatives (n=14) and health care professionals (n=9) quantitatively rated the acceptability, readability, and appropriateness of the developed text messages in a web-based survey. All the participants initially completed a background survey assessing sociodemographic and medical factors.

RESULTS

Consumer representatives demonstrated diverse sociodemographic characteristics (Mage=33.29), varying in location (metropolitan vs rural or regional), employment, and relationship and educational statuses. Participants reached a consensus regarding the delivery of 4 SMS text messages per week, delivered randomly throughout the week and in one direction (ie, no reply), with customization for the time of day and use of personal names. Seven main areas of unmet need for which participants required assistance were identified, which subsequently became the topic areas for the developed SMS text messages: emotional health, social support, looking after and caring for your body, patient empowerment, interpersonal issues, general endometriosis information, and physical health. Through a web-based survey, 371 co-designed SMS text messages were highly rated by consumers and health care professionals as clear, useful, and appropriate for individuals with endometriosis. Readability indices (Flesch-Kincaid scale) indicated that the SMS text messages were accessible to individuals with a minimum of 7th grade high school education.

CONCLUSIONS

On the basis of the needs and preferences of a diverse consumer representative group, we co-designed EndoSMS, a supportive SMS text message program for individuals with endometriosis. The initial evaluation of the SMS text messages by consumer representatives and health professionals suggested the high acceptability and suitability of the developed SMS text messages. Future studies should further evaluate the acceptability and effectiveness of EndoSMS in a broader population of individuals with endometriosis.

Endometriosis and Sexual Functioning: How Much Do Cognitive and Psycho-Emotional Factors Matter?

Women with endometriosis often suffer from genito-pelvic pain. The objective of the present study was to analyze the relationship between cognitive and psycho-emotional factors and sexual functioning of women with endometriosis, comparing women with and without endometriosis. A total of 87 women with endometriosis (EG) and 100 women without endometriosis (CG) completed a socio-demographic questionnaire; the short-form of McGill Pain Questionnaire (SF-MPQ); the Female Sexual Functioning Index (FSFI); the Sexual Distress Scale (SDS); the Symptoms Checklist (SCL-90-R); the Toronto Alexithymia Scale (TAS-20); the Positive and Negative Affects Scale (PANAS); the Sexual Dysfunctional Belief Questionnaire (SDBQ); the Sexual Modes Questionnaire (SMQ); and the Questionnaire of Cognitive Schema Activation in Sexual Context (QCSASC). EG obtained worse scores than CG in SF-MPQ, Pain subscale of FSFI, and SDS. EG reached higher scores than CG on almost all scales of SCL-90-R and lower scores in the “Identifying Feelings” scale of TAS-20. Furthermore, EG reported more negative emotions toward sexuality than CG (PANAS) higher scores on the “Affection Primacy” scale of SDBQ and the “Helpless” sexual cognitive schema of QCSASC than CG. No significant differences were found in SMQ. Sexual health professionals should address psychological, emotional, and cognitive factors since they seem involved in patients’ sexual experiences.

The State of Health and the Quality of Life in Women Suffering from Endometriosis

Quality of life is related to good health, family relations, feeling of self-esteem, and ability to cope with difficult situations. Endometriosis is a chronic condition which affects different areas of life. The lack of satisfaction in everyday life is mainly due to constant pain. The process of adjusting to a life with illness is associated with negative emotions. The aim of the article is to review the current state of knowledge concerning the impact of social and medical factors on a population of women affected by endometriosis. Women with endometriosis have an impaired quality of life compared to the general female population. Psychological consequences of endometriosis include: depression, anxiety, powerlessness, guilt, self-directed violence, and deterioration of interpersonal relations. It may contribute to lower productivity at work and less satisfying intimate life. A multi-disciplinary, evidence-based care is needed. The disease can take away the ability to be physically active, obtain an education, work continuously, and interact with friends. Social support and cognitive-behavioral therapy are extremely important for healing.

Concerns on ranibizumab and zoledronic acid safety for experimentally treating women with endometriosis

Correspondence to the original research entitled "Effects of ranibizumab and zoledronic acid on endometriosis in a rat model" published by Ozdemir et al.

Measuring Resilience in Women with Endometriosis

Endometriosis is a multifactorial disease with pathophysiological factors not yet well known; it also presents a wide symptomatic range that makes us think about the need for multidisciplinary management. It is a chronic disease in which there is no definitive treatment, and is associated in a large majority of cases with psychological pathology. Connecting comorbidities and multimorbidities on a neurobiological, neuropsychological, and pathophysiological level could significantly contribute to their more successful prevention and treatment. In our study, resilience is analyzed as an adjunctive measure in the management of endometriosis. Methods: A multi-centre, cross-sectional study was performed to analyse resilience levels in a sample of Spanish women suffering from endometriosis. CDRIS-25, CDRIS-10, BDI, the STAI, and the SF-36 Health Questionnaire were used for assessments. A representative group of 202 women with endometriosis was recruited by consecutive sampling. Exploratory and confirmatory factor analyses were performed for both resilience scales. Results: Mean CDRIS-25 and CDRIS-10 scores were 69.58 (SD 15.1) and 29.37 (SD 7.2), respectively. Women with adenomyosis and without signs of deep endometriosis showed the lowest scores. The best predictive model included women’s age, years of endometriosis evolution, number of pregnancies, and history of fertility problems as the best predictive factors. Conclusions: Women build resilience as the number of years of evolution of the disease increases. Symptoms such as dyspareunia and continued abdominal pain were more prevalent among less resilient women.

Improving Patient-Centredness in Endometriosis Care: A Study Protocol for a Prospective Study with a Mixed-Methods Approach

OBJECTIVE

Endometriosis is a chronic gynaecologic disease, causing pain and infertility. As there is no definitive cure, patients are subjected to long-term care. This study aimed to improve patient-centred endometriosis care. Patient-centredness of endometriosis care can be evaluated using the validated ENDOCARE questionnaire (ECQ), resulting in centre-specific targets for improvement. To understand how to tackle the targets for improvement as found by the ECQ, focus groups can be organized.

DESIGN

This protocol presents a prospective study with a mixed-methods approach to improve patient-centredness of endometriosis care. The study consists of 5 steps: (1) evaluating current patient-centredness of endometriosis care by using the ECQ, (2) understanding targets for improvement, (3) drafting an improvement plan, (4) implementing improvements, and (5) evaluating the improved patient-centredness of endometriosis care. The final evaluation will be performed 1.5 years after implementing the improvement plan.

METHODS

Patient-centredness will be evaluated using the ECQ by inviting women with endometriosis to participate (steps 1 and 5). To investigate step 2, focus groups will be organized. For these focus groups, women with endometriosis are asked to participate until data saturation is achieved. During focus groups, participants are motivated to discuss the found targets for improvement and stimulated to find ways to improve them. The drafting and implementing of the improvement plan (steps 3 and 4) will be organized with the help of health-care providers in close collaboration with the patient organization. To assess whether the implementation of the improvement plan was successful in improving endometriosis care, the results from the ECQ in step 5 will be compared to the results from the ECQ in step 1. Ethical approval was granted by the local Institutional Review Board (Ref 2018.438).

SETTING

The study was conducted in the university hospital in the Netherlands.

LIMITATIONS

Both patients and health-care providers will be involved in drafting the improvement plan. By making the health-care providers responsible for improving care, the chance of succeeding is optimized. Whether this improvement strategy is successful will be investigated after the implementation of the improvement plan. The improvement plan is clinic specific and can possibly not be extrapolated to other endometriosis clinics. In order to aim to improve patient-centred endometriosis care elsewhere, the complete study protocol should be performed.

CONCLUSIONS

This study protocol aimed to investigate focus groups as a strategy to identify possible interventions to improve patient-centred endometriosis care by investigating the underlying causes for poor performance on patient-centred care. This study protocol could be used in more endometriosis care centres in the future and might also be useful for improving patient-centredness in other chronic diseases.

Fertility-Sparing Approach in Women Affected by Stage I and Low-Grade Endometrial Carcinoma: An Updated Overview

Endometrial cancer (EC) is a deleterious condition which strongly affects a woman's quality of life. Although aggressive interventions should be considered to treat high-grade EC, a conservative approach should be taken into consideration for women wishing to conceive. In this scenario, we present an overview about the EC fertility-sparing approach state of art. Type I EC at low stage is the only histological type which can be addressed with a fertility-sparing approach. Moreover, no myometrium and/or adnexal invasion should be seen, and lymph-vascular space should not be involved. Regarding the pharmaceutical target, progestins, in particular medroxyprogesterone acetate (MPA) or megestrol acetate (MA), are the most employed agent in conservative treatment of early-stage EC. The metformin usage and hysteroscopic assessment is still under debate, despite promising results. Particularly strict and imperious attention should be given to the follow-up and psychological wellbeing of women, especially because of the double detrimental impairment: both EC and EC-related infertility consequences.

Uterine leiomyoma is associated with the risk of developing endometriosis: A nationwide cohort study involving 156,195 women

Objective

Evidence for an association between uterine leiomyoma and increased risk of endometriosis is limited by small sample sizes and short follow-up periods. We assessed this association in a large nationwide sample with 14 years of data.

Design

Data were sourced from Taiwan’s Longitudinal Health Insurance Database 2000 (LHID2000).

Materials and methods

We identified 31,239 women aged ≥20 years diagnosed with uterine leiomyoma (International Classification of Disease, Ninth Revision, Clinical Modification [ICD-9-CM] code 218) between Jan 1, 2000 and Dec 31, 2012, who were matched with 124,956 controls (1:4) by 5-year age groups and year of diagnosis. Follow-up was from the date of LHID2000 entry to the first occurrence of endometriosis, loss to follow-up, insurance termination, or until December 31, 2013, whichever was earlier.

Results

In Cox regression analysis, the adjusted hazard ratio (aHR) for endometriosis in women with uterine leiomyoma was 6.44 (95% CI, 6.18, 6.72) compared with controls. The risk of endometriosis was significantly increased in women with uterine leiomyoma and comorbidities of tube-ovarian infection (aHR 2.86; 95% CI, 1.28, 6.36), endometritis (1.14; 1.06, 1.24), infertility (1.26; 1.16, 1.37), or allergic diseases (1.11; 1.05, 1.17). Having both uterine leiomyoma and endometritis significantly increased the risk of endometriosis (aHR 6.73; 95% CI, 6.07, 7.45) versus having only uterine leiomyoma (6.61; 6.33, 6.91) or endometritis (1.49; 1.31, 1.69). Similarly, having both uterine leiomyoma and infertility significantly increased the risk of endometriosis (aHR 6.95; 95% CI, 6.21, 7.78) versus having only uterine leiomyoma (6.66; 6.38, 6.96) or infertility (1.78; 1.57, 2.02).

Conclusions

A diagnosis of uterine leiomyoma appears to increase the risk of endometriosis. Patients presenting with uterine fibroids should be encouraged to give informed consent for possible simultaneous surgical treatment of endometriosis.

Endometriosis-A Multifaceted Problem of a Modern Woman

Endometriosis is a chronic disease of unclear aetiology that affects millions of women around the world. It causes chronic pain, dysmenorrhea, and infertility, which significantly reduces the quality of daily life. The aim of the following study was a multivariate analysis of the functioning of women diagnosed with endometriosis, and the identification of the relationship between the level of physical activity and sexual functioning, ability to cope with stress, and the degree of anxiety and mood disorders. The prospective survey was conducted of 957 women. The research was carried out using standardised IPAQ, FSFI, HADS, and Mini-Cope questionnaires. The study showed that patients with endometriosis exhibit a higher level of depression and anxiety disorders (p = 0.01) and a lower level of sexual functions (p < 0.001). The influence of physical activity on the functioning of patients with endometriosis was demonstrated. Depending on the clinical stage of endometriosis, the influence of physical activity on individual aspects of life differed. Physical activity was shown, inter alia, to reduce anxiety (p = 0.015), and influence stress-coping strategies. Endometriosis affects the mental and physical health of women. Physical activity can reduce the severity of endometriosis symptoms and improve the daily functioning of patients.

A Standardized Evaluation Method for Assessing Patients With Genital Dyschromia

Objective

The population's ever-growing concern with genital aesthetic dysfunctions reflects an increasing demand in the field of intimate aesthetics. For this reason, as well as the lack of a standardized evaluation, this paper aims to develop a form that facilitates the initial investigation of aesthetic genital dysfunctions. 

Methods

An evaluation form for female and male genital dyschromia was developed between July and November 2018. Following initial development, the form was evaluated for quality and was updated by a panel of specialists (a psychologist, two pelvic dysfunction physiotherapists, and two dermato-functional physiotherapists) via email and through a content validity questionnaire. The face validity of the form was assessed by five physiotherapy and medical students who were randomly selected. The students answered a questionnaire evaluating the proposed form. The reliability of the form was established through the test-retest procedure by evaluating its reproducibility over time.

Results

The “Genital Dyschromia Evaluation Form'' (composed of identification, anamnesis, and physical examination sections) was approved by the specialist panel. They suggested questions to be added in the anamnesis (dermatological lesions or fungal and bacterial infections) and physical examination (hyperemia, edema in the perianal and internal thigh region) sections. As for the image analysis, an increase in quality, resolution, and sharpness was suggested. Lastly, for the cutaneous phototype evaluation, the DoctorSkinFototipo® digital analyzer device was chosen since it is small, portable, easily positioned on the genital area, and can be readily cleaned between patients. 

Conclusion

The “Genital Dyschromia Evaluation Form” is a questionnaire approved by specialists and could represent a suitable option for health professionals.

Sexual function in patients with endometriosis: a prospective case-control study in China

OBJECTIVE

Endometriosis is a common disease in women of childbearing age, leading to sexual dysfunction or loss of libido. We aimed to evaluated the effect of endometriosis on women's sexual function.

METHODS

We performed a prospective case-control study to determine the effect of endometriosis on women's sexual function using a self-administered questionnaire from September 2017 to August 2018. The simplified Chinese version of the Female Sexual Function Index (FSFI) was used to assess sexual function.

RESULTS

We found that sexual function of women in the endometriosis group (n=77) in all dimensions was significantly lower compared with that in the control group (n=63). The total FSFI score in patients was 25.5, which tended to be lower than that in the control group (26.7). Sexual arousal, sexual pain, and satisfaction were significantly different between the two groups. Sexual arousal and sexual pain scores were significantly lower in the endometriosis group than in the control group at the ages of 31 to 40 years.

CONCLUSION

Women with endometriosis suffer from sexual dysfunction, especially those aged 31 to 40 years. Our findings suggest that the quality of sexual life in this subpopulation needs to be improved.

Endometriosis-associated pain: a review of quality of life, sexual health and couple relationship

INTRODUCTION

Endometriosis is a chronic gynecological disease that affects women's quality of life, sexuality, and relationship. Endometriosis-associated pain plays an essential role in well-being impairment. The present review aimed to analyze literature about endometriosis-associated pain and quality of life, sexual health, and quality of the relationship, assessing the role of the biopsychosocial factors involved and the women's pain experience.

EVIDENCE ACQUISITION

Bibliographic research of relevant articles published from 2015 to 2020 in PubMed, Google Scholar, Web of Science, Scopus, EBSCO, and Cochrane Library.

EVIDENCE SYNTHESIS

Endometriosis is associated with impairing all women's quality of life domains, and pain appears to be the most influential variable. The pain mechanism is not simple and implies several biological, psychological, and social factors. Women's sexual health is also impaired, and patients report dyspareunia, sexual dysfunctions, dissatisfaction, and distress. Partners' sexual well being is compromised as well. Endometriosis negatively influences relationship quality, and the illness burden affects both couple members.

CONCLUSIONS

A multidisciplinary team using a couple-centered and a biopsychosocial approach is crucial to provide appropriate treatment for endometriosis-associated pain. A better comprehension of all bio-psycho-social aspects implicated in women's well-being and pain experience needs more research.

Impact of Endometriosis on Life-Course Potential: A Narrative Review

Endometriosis may exert a profound negative influence on the lives of individuals with the disorder, adversely affecting quality of life, participation in daily and social activities, physical and sexual functioning, relationships, educational and work productivity, mental health, and well-being. Over the course of a lifetime, these daily challenges may translate into limitations in achieving life goals such as pursuing or completing educational opportunities; making career choices or advancing in a chosen career; forming stable, fulfilling relationships; or starting a family, all of which ultimately alter one's life trajectory. The potential for endometriosis to impact the life course is considerable, as symptom onset generally occurs at a time of life (menarche through menopause, adolescence through middle age) when multiple life-changing and trajectory-defining decisions are made. Using a life-course approach, we examine how the known effects of endometriosis on life-domain satisfaction may impact health and well-being across the life course of affected individuals. We provide a quasi-systematic, narrative review of the literature as well as expert opinion on recommendations for clinical management and future research directions.

Dydrogesterone in the treatment of endometriosis: evidence mapping and meta-analysis

Purpose

Endometriosis is a common, chronic gynecological disease that affects women’s fertility potential. Dydrogesterone is an effective and safe drug that is under-utilized due to limited clinical research. The purpose of this evidence mapping is to identify, describe, and analyze the current available evidence regarding dydrogesterone for the treatment of endometriosis.

Materials and methods

We performed a search in electronic databases: Medline, The Cochrane Library, EMBASE, PubMed, CNKI, Wanfang, VIP, and CBM. We also hand-searched google for relevant studies. Our primary outcomes included changes in pain relief including pelvic pain, dysmenorrhea, and dyspareunia. Secondary outcomes included pregnancy rate, frequency of analgesic use, and other reported outcomes according to specific settings in the studies.

Results

Of 377 references screened, 19 studies were included in the data synthesis involving 1709 female participants. Nearly three-quarters were either randomized control trials or clinical control trials. Compared with gestrinone, dydrogesterone relieved dysmenorrhea, increased the pregnancy rate, and reduced the risk of certain adverse events. Compared with GnRH-a, dydrogesterone also lowered the risk of endometriosis recurrence and elevated transaminase levels. Whether there was any difference in efficacy between dydrogesterone and leuprolide acetate, letrozole or traditional Chinese medicine remains unclear due to insufficient data.

Conclusions

The amount and quality of evidence evaluating the effects of dydrogesterone for the treatment of endometriosis is generally very low. Limited evidence suggests that dydrogesterone may have some advantages over gestrinone, GnRH agonists, and other therapeutic interventions in treating endometriosis. However, this conclusion should be interpreted with caution.

LINC01116 promotes proliferation and migration of endometrial stromal cells by targeting FOXP1 via sponging miR-9-5p in endometriosis

Endometriosis is a common multi-factorial gynaecological disease. Recent studies have revealed that long non-coding RNAs (lncRNAs) are involved in the pathogenesis of endometriosis. In the present study, the expression profiles of lncRNAs in 6 pairs of endometriosis ectopic endometrium (ecEM) and eutopic endometrium (euEM) tissues were analysed by RNA sequencing. From the profiles, LINC01116 was found to be up-regulated in ecEM tissues compared to euEM tissues and was verified by quantitative real-time PCR (qRT-PCR). Then, functional experiments demonstrated that LINC01116 promoted the proliferation and migration of ectopic primary endometrial stromal cells (ESCs), while miR-9-5p exerted the opposite effects. Dual-luciferase reporter assays verified that LINC01116 directly sponged miR-9-5p and relieved the suppression of its target, Forkhead box protein P1 (FOXP1). Rescue experiments further demonstrated that LINC01116 could promote proliferation and migration of ESCs by targeting FOXP1 via sponging miR-9-5p. Overall, our study illuminates that LINC01116 promotes the progression of endometriosis through the miR-9-5p/FOXP1 axis. This finding provides a novel therapeutic target for patients with endometriosis.

Brassica Bioactives Could Ameliorate the Chronic Inflammatory Condition of Endometriosis

Endometriosis is a chronic, inflammatory, hormone-dependent disease characterized by histological lesions produced by the presence of endometrial tissue outside the uterine cavity. Despite the fact that an estimated 176 million women are affected worldwide by this gynecological disorder, risk factors that cause endometriosis have not been properly defined and current treatments are not efficient. Although the interaction between diet and human health has been the focus of many studies, little information about the correlation of foods and their bioactive derivates with endometriosis is available. In this framework, Brassica crops have emerged as potential candidates for ameliorating the chronic inflammatory condition of endometriosis, due to their abundant content of health-promoting compounds such as glucosinolates and their hydrolysis products, isothiocyanates. Several inflammation-related signaling pathways have been included among the known targets of isothiocyanates, but those involving aquaporin water channels have an important role in endometriosis. Therefore, the aim of this review is to highlight the promising effects of the phytochemicals present in Brassica spp. as major candidates for inclusion in a dietary approach aiming to improve the inflammatory condition of women affected with endometriosis. This review points out the potential roles of glucosinolates and isothiocyanates from Brassicas as anti-inflammatory compounds, which might contribute to a reduction in endometriosis symptoms. In view of these promising results, further investigation of the effect of glucosinolates on chronic inflammatory diseases, either as diet coadjuvants or as therapeutic molecules, should be performed. In addition, we highlight the involvement of aquaporins in the maintenance of immune homeostasis. In brief, glucosinolates and the modulation of cellular water by aquaporins could shed light on new approaches to improve the quality of life for women with endometriosis.

How can we improve knowledge and perceptions of menstruation? A mixed-methods research study

BACKGROUND

Traditionally, menstrual education has consisted of lectures directed toward women. The objective of this study was to design an innovative menstrual education (ME) program that reflects the needs of both young women and men, and verify its effectiveness.

METHODS

A mixed-method design was used to determine the program needs and assess young adults' knowledge and perceptions of menstruation and menstrual products. Focus group interviews were conducted with 14 young adults, and 150 young adults participated in an online survey. After developing the ME program, 10 young adults participated in a study to verify its effectiveness.

RESULTS

Interview results showed young adults wanted more information about menstrual products. The online survey revealed significant differences in knowledge based on participants' general characteristics and experience; exposure to menstruation and menstrual products positively impacted knowledge and perception. In addition, the results indicated young adults wanted ME content access via mobile and in-person modalities, designed for both genders, drawing on menstrual experts' knowledge. Based on these results, a multi-experimental menstrual education (MEME) program was designed and included: hands-on exposure to 60 menstrual products, product demonstrations with a female perineal model, a YouTube video created by the researchers, a true-or-false quiz, and question-and-answer sessions with menstrual experts.

CONCLUSIONS

This study clarified the requirements of an innovative menstrual education program. It led to high satisfaction among participants, and improved knowledge and perceptions of menstruation and menstrual products. The online survey showed a correlation between the extent of received ME, and respondents' perception of menstrual products. This implied that a MEME program could change perceptions when conducted systematically; by extension it could ameliorate menstruation challenges attributed to poverty. Future research could further verify the effectiveness of the MEME program, using a larger sample, and examine its suitability for incorporation into official ME curricula at universities and companies.

TRIAL REGISTRATION

This trial was registered in a Clinical Research Information Service in Korea linked with the World Health Organization's International Clinical Trial Registry Platform (WHO's ICTRP) (no. KCT0004715 ), Registered 07 Feb 2020.

CD200 and CD200R Expression on Peripheral Blood Lymphocytes and Serum CD200 Concentration as a New Marker of Endometriosis

The causes of endometriosis (EMS) remain unknown; however, a number of immunological abnormalities contribute to the pathogenesis of the disease. The cluster of differentiation-200 (CD200) and its receptor (CD200R) maintain peripheral self-tolerance by negatively regulating immune responses. In this comparative cross-sectional study, we investigated the expression of CD200 and CD200R on T and B lymphocytes and the serum level of soluble CD200 (sCD200) using flow cytometry and ELISA, respectively. Peripheral blood samples were collected from 54 female patients and 20 healthy, age-matched controls. Results were tested for correlation with disease severity and selected clinical parameters. We demonstrated that the differences in sCD200 levels (p = 0.001), the frequencies of CD200-positive T and B lymphocytes (p < 0.001 and p = 0.004, respectively), and the frequencies of CD200R-positive T and B lymphocytes (p < 0.001 for all comparisons) in the study group correlated positively with disease severity. Receiver operating characteristic (ROC) analysis indicated that aberrant expression of CD200/CD200R might serve as a marker to distinguish between EMS cases. Finally, negative co-stimulatory factors may contribute to the induction and persistence of inflammation associated with EMS. It seems that it is essential to determine whether alteration in the CD200/CD200R pathway can be therapeutically targeted in EMS.

Psychometric evaluation of the Swedish version of the 30-item endometriosis health profile (EHP-30)

Background

The 30-Item Endometriosis Health Profile (EHP-30) is a specific instrument measuring quality of life among women with endometriosis. Although the Swedish version of EHP-30 is widely used in research and clinical settings, it has not yet been evaluated psychometrically. Ensuring validity and reliability is of most importance when using translated instruments. Therefore, the aim of the study was to evaluate the psychometric properties of the Swedish version of the EHP-30.

Methods

This study was conducted at a Swedish referral university hospital specializing in endometriosis. Data collection was performed in January 2013. The EHP-30 was sent to 369 randomly selected women with a laparoscopy-verified endometriosis diagnosis. The psychometric evaluation included evaluation of data completeness, score distributions, floor and ceiling effects, internal consistency, factor analysis and test-retest reliability.

Results

Out of the 211 women with endometriosis who answered the questionnaire, 128 were native Swedish speakers who had experienced symptoms of endometriosis during the past 4 weeks, and were included in the psychometric evaluation. Data completeness was 99.5%. The highest median score was found in the Control and Powerlessness subscale, and lowest in Pain. Distributions towards ill health were found in all subscales except for the pain subscale, but there were no noteworthy floor or ceiling effects. Internal consistency was good (Cronbach’s α 0.83–0.96). Factor analysis could roughly confirm three of the five subscales. The test-rest analysis showed good reliability. Scores were systematically lower during the second measurement.

Conclusions

We conclude that the Swedish version of EHP-30 is a valid and reliable instrument to measure health-related quality of life in women with endometriosis. It is understandable, acceptable and usable and can be recommended for use in clinical daily routines and for research purposes.

Free large sized intra-abdominal endometrioma in a postmenopausal woman: a case report

BACKGROUND

Endometriosis is an estrogen-dependent disease defined by the presence of endometrial glands and stroma out of the uterine cavity. Its prevalence is estimated to be 2-10% in reproductive aged women. Endometriosis occurrence is estimated to be 2.55% in postmenopausal patients due to the decreased levels of estrogen. Endometriosis can present in three different forms: superficial peritoneal implants, ovarian endometriomas, and deep infiltrating endometriosis. Ovarian endometriomas are the most common form of endometriosis. Even though endometriomas have been encountered in various localizations, a free abdominal endometrioma was only reported once in a premenopausal patient. Here, we are reporting the first case of a free large endometrioma in a postmenopausal patient.

CASE PRESENTATION

A 67-year-old woman presented to the emergency department at our university hospital complaining of constipation and right flank pain. She suffered from uncontrolled primary hypertension and type 2 diabetes mellitus. On presentation, she was afebrile, hypertensive, and tachycardic. An abdominal CT scan revealed a large cystic mass measuring 17 × 26 cm in the anterior-posterior and transverse diameters respectively. The cyst caused bowel obstruction and right sided hydronephrosis. The patient underwent laparotomy and during the surgical exploration a large abdominal cyst adhered to the greater omentum was found. The cyst received plenteous blood supply from the greater omentum. The uterus and both ovaries were completely normal and didn't have any connection to the cyst. An en-bloc cystectomy was performed successfully. The final histopathology report confirmed an abdominal endometrioma. The patient had an uneventful postoperative recovery.

CONCLUSIONS

Endometriomas might reach large sizes regardless of their location or the patient's age. The close relation of free abdominal endometriomas with the greater omentum suggests that these were developed from endometriotic omental implants. Endometrioma is rare in postmenopausal women. However, it should be considered as a possible differential diagnosis at any age.

Psychosocial Cardiological Schedule-Revised (PCS-R) in a Cardiac Rehabilitation Unit: Reflections Upon Data Collection (2010-2017) and New Challenges

Introduction

The Psychosocial Cardiological Schedule (PCS) was developed as a screening tool for patients undergoing cardiac rehabilitation (CR) to detect clinically relevant psychosocial/cognitive problems requiring psychological assessment/intervention. Filled out by a trained nurse, it classifies patients according to their need or not for a psychological interview and intervention provided by the psychologist (PCS-Yes vs. PCS-No).

Aims

The main aim was to compare PCS data collected, respectively, in 2010 and 2017, regarding patients’ socio-demographic characteristics, clinical variables, and the inclusion criteria for psychological counseling. Subsequently, the original Italian PCS was revised and an English version of the schedule was provided [PCS-Revised (PCS-R)].

Results

28 patients (aged 53.5 + 12.6 years, M = 20) of the 87 recruited in 2010 vs. 35 (aged 64.9 + 12.7 years, M = 28) of the 83 recruited in 2017 met the criteria for PCS-Yes: age < 55 years, social problems (living alone, no social support), manifest psychological/behavioral problems, suspected neuropsychological disorders, low prescription adherence, inadequate disease awareness. Comparing the two samples (2010 vs. 2017), clinical variables were similar, and the need for a psychological interview did not differ substantially (32.2 vs. 42.2%), but age increased significantly (PCS-Yes: 53.5 ± 12.6 vs. 64.9 ± 12.7 years, p = 0.001; PCS-No: 68.3 ± 8.0 vs. 75.0 ± 7.7 years, p = 0.0001). A significant increase was observed in the recommendation for neuropsychological assessment (3.6 vs. 25.7%, p = 0.02) to confirm eventual cognitive deficits. These results, the clinical experience, and the recent evidences from literature led to the PCS-R, incorporating a psychosocial screening, a psychological/neuropsychological deeper assessment, and a recommendation for a specific intervention to be carried out either during rehabilitation or in outpatient services.

Conclusion

The data comparison highlight changes in the cardiac population, which is aging and more frequently requires neuropsychological assessment. The PCS-R could be considered in clinical practice as a useful screening tool to implement a timely coordinated interdisciplinary intervention, comprehensive of specific and tailored psychotherapeutic techniques.

Endometriosis Lowers the Cumulative Live Birth Rates in IVF by Decreasing the Number of Embryos but Not Their Quality

Endometriosis and infertility are closely linked, but the underlying mechanisms are still poorly understood. This study aimed to evaluate the impact of endometriosis on in vitro fertilization (IVF) parameters, especially on embryo quality and IVF outcomes. A total of 1124 cycles with intracytoplasmic sperm injection were retrospectively evaluated, including 155 cycles with endometriosis and 969 cycles without endometriosis. Women with endometriosis had significantly lower ovarian reserve markers (AMH and AFC), regardless of previous ovarian surgery. Despite receiving significantly higher doses of exogenous gonadotropins, they had significantly fewer oocytes, mature oocytes, embryos, and top-quality embryos than women in the control group. Multivariate analysis did not reveal any association between endometriosis and the proportion of top-quality embryo (OR = 0.87; 95% CI [0.66-1.12]; p = 0.3). The implantation rate and the live birth rate per cycle were comparable between the two groups (p = 0.05), but the cumulative live births rate was significantly lower in in the endometriosis group (32.1% versus 50.7%, p = 0.001), as a consequence of the lower number of frozen embryos. In conclusion, endometriosis lowers the cumulative live birth rates by decreasing the number of embryos available to transfer, but not their quality.

The Burden of Endometriosis on Women's Lifespan: A Narrative Overview on Quality of Life and Psychosocial Wellbeing

Endometriosis is a chronic, inflammatory disease affecting more than 170 million women worldwide and up to 10% of women of reproductive age. As a consequence of inflammatory reaction and infiltration of anatomic structures, endometriosis can cause “pain symptoms” including dysmenorrhea, dyspareunia, dyschezia, dysuria, and chronic pelvic pain. In this review, we summarized the impact of endometriosis on quality of life in all its aspects including sexual life, work, and social relationships. The data research was conducted using web-based search engines and/or various electronic research databases querying for all articles related to endometriosis and quality of life from the inception of the database up to February 2020. Endometriosis has not only physical but also psychological effects, causing depression, anxiety, and compromising social relationships. Furthermore, endometriosis negatively impacts sexual life and social relationships. At last, the economic burden of endometriosis should not be underestimated, both individually and for the community, as this pathology leads to a loss of productivity at work and large use of health resources. Thus, endometriosis-related symptoms control women’s lives compromising the quality of life in all aspects. In this review, we summarized the impact of endometriosis on various aspects of women’s lives.

The Many Faces of Endometriosis-Related Neoplasms in the Same Patient: A Brief Report

INTRODUCTION

Endometriosis is a common benign gynecological condition that can be associated with a slightly increased risk of developing a wide range of malignancies.

CASE PRESENTATION

We herein report a singular case of a 62-year-old woman with a history of pelvic endometriosis, referred to our institution for chronic pelvic pain and uterine bleeding, with clinical and radiological evidence of left ovarian mass of 18 cm in largest diameter and multiple nodular mural lesions of the uterine cavity. The patient underwent exploratory laparotomy followed by hysterectomy, bilateral salpingo-oophorectomy, and omentectomy with pelvic lymph-node sampling. The histological examination of the ovarian mass revealed a clear-cell ovarian carcinoma arising from an endometriotic cyst. The microscopic examination of the uterine cavity showed multiple conventional leiomyomas, diffuse foci of adenomyosis, and a 1.5-cm yellow nodule diagnosed as low-grade endometrial stromal sarcoma associated with glandular atypical differentiation and with extension into parametrial and omental tissues. Following the diagnosis, the patient was treated with chemotherapy, radiation therapy, and hormonal therapy and after 9 months of follow-up is alive without local recurrences and distant metastases.

DISCUSSION/CONCLUSIONS

To the best of our knowledge, the present case represents the first evidence of the simultaneous occurrence of clear-cell carcinoma and low-grade endometrial stromal sarcoma arising within ovarian and uterine endometriotic foci, respectively.

Ultrasound Assessment of the Abdominal Wall Muscles in Women with and without Primary Dysmenorrhea: A Cross-Sectional Study

Background: Primary dysmenorrhea (PD) is one of the most common gynecological disorders in women of reproductive age that may affect quality of life. It is believed that the underlying cause of PD may be the excessive production of prostaglandins (PGs), however, between 20%–25% of women with PD did not respond to pharmacological treatments, showing that nociceptive mechanisms underlying PD are still not understood. The purpose of this study was to measure and compare, through the use of ultrasound imaging, the thickness at rest of the abdominal wall, as well as the interrecti distance (IRD), in women with and without PD. Methods: A cross-sectional study has been performed using ultrasound imaging (USI) to measure the resting thickness of the external oblique (EO), internal oblique (IO), transversus abdominis (TrAb), rectus abdominis (RA), as well as the IRD in a sample of 39 women, 19 with PD and 20 without PD (median ± IR age: 20 ± 4 and 22.5 ± 7 years, respectively). Results: Findings of muscular thickness did not reveal statically significant differences (p < 0.05) in EO, IO, TrAb, RA, and the IRD between the PD group and control group. Conclusions: These findings suggest that the thickness of the abdominal wall is not associated with PD.

Ion Channels in The Pathogenesis of Endometriosis: A Cutting-Edge Point of View

BACKGROUND

Ion channels play a crucial role in many physiological processes. Several subtypes are expressed in the endometrium. Endometriosis is strictly correlated to estrogens and it is evident that expression and functionality of different ion channels are estrogen-dependent, fluctuating between the menstrual phases. However, their relationship with endometriosis is still unclear.

OBJECTIVE

To summarize the available literature data about the role of ion channels in the etiopathogenesis of endometriosis.

METHODS

A search on PubMed and Medline databases was performed from inception to November 2019.

RESULTS

Cystic fibrosis transmembrane conductance regulator (CFTR), transient receptor potentials (TRPs), aquaporins (AQPs), and chloride channel (ClC)-3 expression and activity were analyzed. CFTR expression changed during the menstrual phases and was enhanced in endometriosis samples; its overexpression promoted endometrial cell proliferation, migration, and invasion throughout nuclear factor kappa-light-chain-enhancer of activated B cells-urokinase plasminogen activator receptor (NFκB-uPAR) signaling pathway. No connection between TRPs and the pathogenesis of endometriosis was found. AQP5 activity was estrogen-increased and, through phosphatidylinositol-3-kinase and protein kinase B (PI3K/AKT), helped in vivo implantation of ectopic endometrium. In vitro, AQP9 participated in extracellular signal-regulated kinases/p38 mitogen-activated protein kinase (ERK/p38 MAPK) pathway and helped migration and invasion stimulating matrix metalloproteinase (MMP)2 and MMP9. ClC-3 was also overexpressed in ectopic endometrium and upregulated MMP9.

CONCLUSION

Available evidence suggests a pivotal role of CFTR, AQPs, and ClC-3 in endometriosis etiopathogenesis. However, data obtained are not sufficient to establish a direct role of ion channels in the etiology of the disease. Further studies are needed to clarify this relationship.