Pain in Endometriosis

The role of self-management in endometriosis pain: insights from a cross-sectional survey in Germany, Austria, and Switzerland

BACKGROUND

Endometriosis has a significant negative impact on women's lives. Unfortunately, current medical treatments often fail to provide adequate pain relief and may cause intolerable side effects. Although many women experiencing primary dysmenorrhoea employ self-management strategies to help alleviate period-related symptoms, there is a paucity of knowledge about how women with endometriosis manage their symptoms through self-management.

METHODS

A cross-sectional online survey was distributed in Germany, Austria, and Switzerland, between August and December 2022, targeting women aged 18 years or older with a diagnosis of endometriosis. The survey gathered information on (pharmacological and non-pharmacological) self-management strategies employed by the respondents in the previous six months, including their frequency, reasons for non-use, self-rated effectiveness, and impact on reducing endometriosis-related medication. Furthermore, the survey collected data on demographics, medical history, current symptomatology, and medication usage. Descriptive statistical analyses were conducted.

RESULTS

Of the 912 valid responses, 75.4% reported using self-management strategies, with the most prevalent being rest (91.6%), heat (91.1%), and exercise (63.3%). The most highly rated techniques in terms of effectiveness in pain reduction were cannabis, osteopathy, heat, and alcohol, with mean effectiveness ratings of 8.0, 7.3, 7.1, and 6.8, respectively, on the Numerical Rating Scale. Interventions, such as Tai Chi/Qi Gong, yoga/Pilates, herbal medicine, stretching, and meditation/breathing, were rated as being less effective. The lack of information and costs were identified as the primary reasons for not utilising self-management approaches.

CONCLUSION

The findings of this study may provide evidence for the reimbursement of self-management techniques by health insurance companies for the treatment of endometriosis-associated pain.

Endometriosis Severity and Risk of Preeclampsia: A Combined Mendelian Randomization and Observational Study

Purpose

Endometriosis has been hypothesized to increase the risk of preeclampsia (PE) and eclampsia, although the exact mechanism of this relationship is not clear. This study aimed to further explore the potential association between endometriosis and PE/eclampsia through Mendelian randomization (MR) and confirm these findings in a retrospective cohort study.

Methods

A two-sample MR study was performed using genetic variants associated with endometriosis from the Finnish database, with outcome data for PE and eclampsia from the UK Biobank. Subgroup analyses were conducted based on endometriosis severity (American society of reproductive Medicine (ASRM) stages I-II and III-IV) and anatomical location (uterus, ovary, deep infiltrating endometriosis). Additionally, a retrospective cohort study was conducted to further assess the association, adjusting for confounding factors such as age, Body Mass Index (BMI), dysmenorrhea, history of uterine surgery, and adenomyosis. Multivariate logistic regression was used to analyze the risk of PE/eclampsia based on endometriosis severity.

Results

MR using the Inverse Variance Weighted method found a meaningful association between advanced endometriosis (ASRM stages III-IV) and PE/eclampsia (p = 0.008), while no significant associations were observed for lower stages or endometriosis in the uterus and ovary. In the retrospective cohort, the initial association between the revised American Fertility Society (r-AFS) score and PE/eclampsia (OR: 1.02, 95% CI: 1.01-1.03, p < 0.001) weakened after adjusting for confounders. Significant risk factors identified included age (OR: 1.20, 95% CI: 1.10-1.30, p < 0.001), dysmenorrhea (OR: 2.72, 95% CI: 1.31-5.76, p = 0.008) and adenomyosis showing the strongest association (OR: 9.96, 95% CI: 5.00-20.06, p < 0.001).

Conclusion

The findings suggest a potential relationship between advanced endometriosis and the risk of PE/eclampsia. However, other clinical factors such as age, dysmenorrhea, and adenomyosis appear to contribute more significantly to the risk. Further studies are needed to confirm these findings and clarify the underlying mechanisms.

The connection between endometriosis and secondary dysmenorrhea

Endometriosis (EMS) is a prevalent gynecological condition characterized by the presence of endometrial tissue outside the uterus, often leading to secondary dysmenorrhea (SD), chronic pelvic pain and infertility. This review explores the intricate connection between EMS- associated pain and SD, focusing on the pathophysiological mechanisms underlying dysmenorrhea in EMS. Key contributors to pain include inflammation, aberrant immune responses, neurogenic inflammation, peritoneal irritation, peripheral sensitization, central sensitization and cross-organ sensitization. Understanding the pain pathways in EMS highlights the complexity of symptom manifestation and underscores the necessity for a multidisciplinary approach to management. Clinical manifestations, including chronic pelvic pain, dyspareunia, infertility, gastrointestinal and bladder symptoms, fatigue and malaise, are discussed, emphasizing the diverse impact of EMS on women's health. Various treatment modalities, ranging from pharmacological interventions to surgical and complementary approaches, are outlined to provide comprehensive management strategies for EMS-related menstrual pain/SD. This review aims to enhance understanding and facilitate the effective management of EMS-associated SD, ultimately improving the quality of life for affected individuals.

Language errors in pain medicine: An umbrella review

Errors in language are common in pain medicine, but the extent of such errors has not been systematically measured. This pre-registered umbrella review explored Embase, PubMed, Medline and CINAHL and seeks to quantify the prevalence of errors in language in review articles since the last IASP definition revision. To be eligible, studies must have met the following criteria: 1) Primary aim was stated as to provide neurophysiological explanations of nociception and/or pain in humans in context of a pathology/condition; 2) Any type of review article; 3) Written in English; 4) Published in a peer-reviewed journal. Studies were excluded if they met any of the following criteria: 5) Published prior to the last revision of the IASP definition; 6) Published after May 2023; 7) Published in a predatory journal. Out of 5470 articles screened, 48 review articles met the inclusion criteria. All articles contained at least one error in language, there were no differences in the proportions of errors in language in review articles between years of publication, and various predictors were mostly not associated with a higher or lower number of errors in language counts in articles. Our findings reveal the need for heightened awareness among researchers, clinicians, journals and editorial boards regarding the prevalence and impact of these errors. Given our findings and their limitations, further research should focus on examining the contextual influence of misnomer usage and replication of these results. PERSPECTIVE: This umbrella review explored the main biomedical databases to see how many review articles contained language errors. Our findings underscore the imperative for prompt action in regulating pain medicine terminology. PRE-REGISTRATION: This umbrella review was pre-registered on OSF registries (https://doi.org/10.17605/osf.io/kau8m). ONLINE MATERIAL: https://osf.io/kdweg/.

Role of soluble neural cell adhesion molecule, soluble IL-2 receptor ɑ, and IL-2 in pelvic pain severity and their association with endometriosis in infertile women

INTRODUCTION

Pelvic pain, often associated with endometriosis, significantly affects women's quality of life. This study explored the soluble neural cell adhesion molecules (sNCAM), soluble interleukin 2 receptor α (sIL-2Rα), and IL-2 levels in the serum and peritoneal fluid of infertile women with pelvic pain.

METHODS

We enrolled 86 infertile women aged 24 to 41 years undergoing diagnostic laparoscopy: 44 women with endometriosis and 42 women who acted as controls. Pain intensity was assessed using the visual analog scale. The soluble molecules were measured using enzyme-linked immunosorbent assay.

RESULTS

Serum and peritoneal sNCAM, sIL-2Rα, and IL-2 levels were statistically significantly higher in women with pelvic pain. Both serum and peritoneal sNCAM levels correlated with visual analog scale scores, indicating a relationship between these markers and pain severity. Elevated peritoneal sIL-2Rα levels were also associated with pelvic pain. Receiver operating characteristic curve analysis showed the potential of serum sNCAM in distinguishing between mild and moderate to severe pain.

DISCUSSION

Elevated levels of sNCAM, sIL-2Rα, and IL-2 in serum and peritoneal fluid correlate with pelvic pain severity in infertile women, suggesting their involvement in disease pathogenesis and potential as objective biomarkers for pain assessment in endometriosis. Further research is needed to validate these findings for clinical use.

Shared diagnostic biomarkers and underlying mechanisms between endometriosis and recurrent implantation failure

BACKGROUND

Endometriosis (EMs) is a common condition that causes dysmenorrhea, chronic pelvic pain, and infertility, affecting millions of women worldwide. Despite the use of assisted reproductive technology, EMs patients often experience lower embryo implantation rates and recurrent implantation failure (RIF) due to impaired uterine endometrial receptivity. This study aims to identify shared diagnostic genes and underlying mechanisms between EMs and RIF using integrated transcriptomic analysis and machine learning with Gene Expression Omnibus (GEO) datasets.

METHODS

We analyzed GSE11691, GSE7305, GSE111974, and GSE103465 as training datasets for EMs and RIF, and GSE25628 and GSE92324 as validation datasets. Differentially expressed genes (DEGs) and Weighted Gene Co-Expression Network Analysis (WGCNA) identified key genes specific to and shared by EMs and RIF. Machine learning algorithms were used to determine the shared diagnostic gene, whose performance was validated in both training and validation datasets. Single-gene Gene Set Enrichment Analysis (GSEA) revealed shared biological processes in EMs and RIF, while CIBERSORT analysis highlighted similarities and differences in immune infiltration between the two conditions. Finally, endometrial samples from healthy controls, EMs, and RIF patients were collected, and qRT-PCR was performed to validate the diagnostic gene.

RESULTS

We identified 48 shared key genes between EMs and RIF. The diagnostic gene EHF was selected through machine learning algorithms, and its diagnostic performance was validated in both training and validation datasets. ROC curve analysis demonstrated excellent diagnostic accuracy of EHF for both diseases. Gene Set Enrichment Analysis (GSEA) revealed that both conditions shared biological processes, including dysregulated extracellular matrix remodeling and abnormal immune infiltration. Furthermore, we validated the expression of EHF in endometrial samples from healthy controls, EMs, and RIF patients. Additionally, we characterized the immune microenvironment in EMs and RIF, highlighting changes in immune cell components associated with EHF.

DISCUSSION

The diagnostic gene EHF identified in this study may serve as a key link between EMs and RIF. The shared pathological processes in both conditions involve alterations in the extracellular matrix and subsequent changes in the immune microenvironment. These findings provide novel insights into potential therapeutic strategies for improving infertility treatment in patients with EMs.

Randomized, controlled, proof-of-concept trial of gefapixant for endometriosis-related pain

OBJECTIVE

To evaluate the P2X3 receptor antagonist, gefapixant, for treating moderate-to-severe endometriosis-related pain.

DESIGN

Randomized, double-blind, phase 2, and proof-of-concept trial.

SUBJECTS

Premenopausal women age 18-49 years with moderate-to-severe endometriosis-related pain who were not using hormonal treatment.

INTERVENTION(S)

Gefapixant (45-mg twice daily) or placebo over two menstrual cycles.

MAIN OUTCOME MEASURE(S)

Participants rated peak pelvic pain severity daily on a 0 (no pain) - 10 (extremely severe pain) scale. The primary endpoint was change from baseline in average daily peak pelvic pain severity during treatment cycle 2.

RESULT(S)

All 187 participants randomized (gefapixant, N = 94; placebo, N = 93) took ≥1 dose of investigational treatment and all but six in each treatment group completed the trial. The model-based least-squares mean reduction from baseline in average daily peak pelvic pain severity during treatment cycle 2 was -2.2 for gefapixant and -1.7 for placebo (difference, -0.5; 95% confidence interval, -1.01 to 0.03). In secondary analyses, the difference between gefapixant and placebo in peak pelvic pain severity reduction from baseline on menstrual days was -0.6 (95% confidence interval, -1.18 to -0.06) and -0.5 (95% confidence interval, -1.04 to 0.03) on nonmenstrual days. Taste-related adverse events were reported in 31.9% of participants for gefapixant vs. 4.3% for placebo. Pharmacokinetic assessments at months 1 and 2 clinic visits indicated that of the 94 participants in the gefapixant group, 39 had detectable levels of gefapixant in the blood for both assessments although 38 had no detectable levels for ≥1 assessment.

CONCLUSION(S)

Gefapixant (45-mg twice daily) was not shown to be superior to placebo in reducing endometriosis-related pain, although the results directionally favored gefapixant. This trial result should be considered inconclusive given possible issues with treatment compliance.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03654326.

Multiple lesion inductions intensify central sensitization driven by neuroinflammation in a mouse model of endometriosis

Introduction

Endometriosis is an inflammatory disease associated with chronic pelvic pain (CPP). Growing evidence indicates that endometriotic lesions are not the sole source of pain. Instead, central nervous system (CNS) dysfunction created by prolonged peripheral and central sensitization plays a role in developing endometriosis-associated CPP. This study investigated how CPP is established using a multiple lesion induction mouse model of endometriosis, as repeated retrograde menstruation is considered underlying endometriosis pathogenesis.

Methods

We generated endometriosis-like lesions by injecting endometrial tissue fragments into the peritoneal cavity in mice. The mice received a single (1x) or multiple inductions (6x) to simulate recurrent retrograde menstruation. Lesion development, hyperalgesia by behavioral testing, signs of peripheral sensitization, chronic inflammation, and neuroinflammation were examined with lesions, peritoneal fluids, dorsal root ganglia (DRG), spinal codes, and brain.

Results

Multiple lesion inductions increased lesion numbers and elevated abdominal and hind paw hypersensitivity compared to single induction mice. Elevated persistent glial cell activation across several brain regions and/or spinal cords was found in the multiple induction mice. Specifically, IBA1+ microglial soma size was increased in the hippocampus and thalamus. IBA1+ cells were abundant in the cortex, hippocampus, thalamus, and hypothalamus of the multiple induction mice. GFAP+ astrocytes were mainly elevated in the hippocampus. Elevated TRPV1, SP, and CGRP expressions in the DRG were persistent in the multiple induction mice. Furthermore, multiple inductions induced the severe disappearance of TIM4hi MHCIIlo residential macrophages and the influx of increased proinflammatory TIM4lo MHCIIhi macrophages in the peritoneal cavity. The single and multiple inductions elevated secreted TNFα, IL-1β, and IL-6 levels in the peritoneal cavity at 2 weeks. Elevated cytokine levels returned to the pre-induction levels in the single induction mice at 6 weeks; however, they remained elevated in the multiple induction mice.

Conclusions

Our results indicate that the repeatedly occurring lesion inductions (=mimic retrograde menstruation) can be a peripheral stimulus that induces nociceptive pain and creates composite chronic inflammatory stimuli to cause neuroinflammation and sensitize the CNS. The circuits of neuroplasticity and stimulation of peripheral organs via a feedback loop of neuroinflammation may mediate widespread endometriosis-associated CPP.

Cognitive Functioning in Females with Endometriosis-Associated Chronic Pelvic Pain: A Literature Review

OBJECTIVE

Cognitive complaints are commonplace among women living with endometriosis-associated chronic pelvic pain (CPP); yet, surprisingly few studies have assessed their cognitive functioning. As an initial step to address the resulting knowledge gap, this review aimed to synthesize the current literature reporting on cognition in females with endometriosis-associated CPP, and due to the poverty of endometriosis studies, to draw on data from female cohorts with other chronic pain conditions to gain potentially relevant insights.

METHODS

Three database searches were conducted (Scopus, PubMed, and PsycINFO). Eighteen studies met the inclusion criteria (n = 8 regarding endometriosis, n = 10 regarding other chronic pain conditions).

RESULTS

Six of the seven studies employing objective cognitive measures in females with other chronic pain reported significant cognitive deficits. Associated changes in neural circuitry thought to underpin these deficits align with neural patterns reported in females with endometriosis-associated CPP. While two studies reported a high prevalence (≥60%) of self-reported cognitive impairment in endometriosis-associated CPP, objective performance deficits have not been reported. Nonetheless, self-reported accounts of cognitive impairment suggest females with endometriosis-associated CPP may experience difficulties with inhibition, attention, and memory. Most studies did not control for potential moderating factors and comorbidities that prevail among endometriosis populations.

CONCLUSION

The field is in desperate need of research assessing cognitive performance in females with endometriosis-associated CPP, to objectively determine any cognitive difficulties. Attention should be paid to likely moderators, pain-related mechanisms, and whether findings extend to endometriosis without CPP.

Prolactin-induced sensitization of trigeminal nociceptors promotes migraine co-morbidity in endometriosis

BACKGROUND

Women with endometriosis are more likely to have migraine. The mechanisms underlying this co-morbidity are unknown. Prolactin, a neurohormone secreted and released into circulation from the anterior pituitary, can sensitize sensory neurons from female, but not male, rodents, monkeys and human donors.

METHODS

We used a syngeneic model of endometriosis to determine whether elevated prolactin levels can sensitize trigeminal ganglion neurons and increase vulnerability to migraine pain.

RESULTS

Mice with endometriotic lesions showed increased serum prolactin levels and developed persistent abdominal, but not cephalic, allodynia. However, inhalation of a transient receptor potential ankyrin 1 agonist, umbellulone, a known environmental trigger of headache in some patients, elicited cephalic allodynia in mice with endometriosis but not sham controls, suggesting that endometriosis can promote sensitization of trigeminal neurons and migraine attacks. Endometriosis dysregulated the expression of prolactin receptor isoforms in trigeminal neurons and increased their excitability measured by in vitro patch clamp electrophysiology. Inhibition of pituitary prolactin following a 2-week treatment with a dopamine receptor agonist, cabergoline, prevented cephalic allodynia elicited by activation of trigeminal afferents with umbellulone. Cabergoline treatment also normalized the expression of prolactin receptor isoforms in trigeminal ganglia and the hyperexcitability of trigeminal neurons.

CONCLUSIONS

These data demonstrate that circulating prolactin in endometriosis promotes vulnerability to migraine through sensitization of trigeminal afferents. Clinically available dopamine receptor agonists or novel monoclonal antibodies targeting prolactin signaling may be effective for migraine prevention in women with endometriosis.

Implication of the enteric glia in the IBS-like colonic inflammation associated with endometriosis

BACKGROUND

Endometriosis is a complex gynecological disorder characterized by the ectopic growth of endometrial tissue. Symptoms of endometriosis are known to impair the quality of life of patients, and among these are found dysmenorrhea, chronic pelvic pain, and gastrointestinal (GI) issues. GI issues such as painful bowel movements, bloating and constipation or diarrhea, are one of the common reasons for misdiagnosis with irritable bowel syndrome (IBS). Enteric glial cells (EGC) are known to play a role in pain associated with IBS, and reactive gliosis has been reported in patients with IBS, but the role of EGC in endometriosis has yet to be elucidated. We hypothesized that endometriosis will induce reactive gliosis, with increased expression of the glial fibrillary acidic protein (GFAP) and S100B, in the myenteric plexus of colonic sections in an animal model of endometriosis.

METHODS

In the present study animal experiments were employed to explore the impact of endometriosis on the gastrointestinal tract. Using a surgically induced endometriosis rat model, we collected ileal and colonic segments for analysis. We used H&E to assess microscopic damage in colon and ileum, immunofluorescence to measure GFAP and S100B expression in the colon, and toluidine blue staining to measure mast cell infiltration in colon and ileum. Immunofluorescence images were captured using confocal microscope and analyzed using ImageJ software.

RESULTS

All endometriosis animals developed vesicles. These animals had a significant increase in the colonic macroscopic damage compared to Sham and Naïve controls. Colonic and ileal sections didn't show statistical differences in microscopic damage between groups, yet endometriosis ileum had significantly increased mast cell infiltration compared to Naïve. GFAP immunostaining showed significantly increased integrated density in endometriosis when compared to Sham or Naïve, while no statistical difference was found in S100B integrated density between groups.

CONCLUSIONS

We conclude that endometriosis can alter GI homeostasis by inducing colon inflammation, reactive gliosis, and ileal mast cell infiltration. Taken together this suggests endometriosis can mimic IBS histopathology beyond the symptomatology, reinforcing this disease's complexity and the need to treat it beyond the gynecological setting.

Unveiling the fibrotic puzzle of endometriosis: An overlooked concern calling for prompt action

Endometriosis is a benign, estrogen-dependent, persistent chronic inflammatory heterogeneous condition that features fibrotic adhesions caused by periodic bleeding. The characteristic ectopic lesions are marked by a widely spread dense fibrotic interstitium comprising of fibroblasts, myofibroblasts, collagen fibers, extracellular proteins, inflammatory cells, and active angiogenesis. Fibrosis is now recognized as a critical component of endometriosis because of which current treatments, such as hormonal therapy and surgical excision of lesions are largely ineffective with severe side effects, high recurrence rates, and significant morbidity. The symptoms include dysmenorrhea (cyclic or noncyclic), dyspareunia, abdominal discomfort, and infertility. The significant lack of knowledge regarding the underlying root causes, etiology, and complex pathogenesis of this debilitating condition, hinders early diagnosis and implement effective therapeutic approaches with minimal side effects presenting substantial hurdles in endometriosis management. Emerging research offer a close relationship between endometriosis and fibrosis, which is believed to be tightly linked to pain, a primary contributor to the deterioration of the patient's quality of life. However, the underlying pathophysiological cellular and molecular signaling pathways behind endometriosis-associated fibrosis are poorly addressed. The available experimental disease models have tremendous challenges in reproducing the human characteristics of the disease limiting the treatment effectiveness. Future translational research on the topic has been hindered by the lack of an adequate fibrotic model of endometriosis emphasizing the necessity of etiological exploration. This review article focuses on recent developments in the field and highlight the necessity for novel fibrotic models for early diagnosis, a better understanding the disease's etiology and develop effective anti-fibrotic treatments. By addressing these knowledge gaps, we want to open fresh avenues for a thorough investigation and extended research in the field of endometriosis.

Management of Endometriosis-Related Pain: Comparing the Effectiveness of Hormonal Therapy, Surgical Interventions, and Complementary Therapies

Endometriosis is a chronic, inflammatory disease characterized by the presence of endometrial-like tissue outside the uterus, affecting women of reproductive age. It is linked with debilitating pain, infertility, and a notable impact on the patient's quality of life. This review aims to highlight the effectiveness of hormonal therapy, surgical procedures, and complementary therapies in managing endometriosis-related pain, providing a comprehensive overview of current treatment options and their implications for clinical practice. The literature reveals that hormonal therapies, including combined oral contraceptives, progestins, and gonadotropin-releasing hormone (GnRH) agonists, are frequently used to manage endometriosis-related pain by suppressing ovarian function and reducing menstrual flow. Surgical interventions, such as laparoscopy and hysterectomy, offer pain relief by removing endometrial lesions but carry risks of recurrence and complications. Complementary therapies, including acupuncture, dietary modifications, and physical therapy, are increasingly recognized for their potential to minimize pain and improve patients' quality of life, though evidence of their effectiveness varies. The review highlights the need for personalized treatment plans that consider patient preferences, symptom severity, and reproductive goals. Future research should concentrate on the long-term outcomes of different therapies, the advancement of non-invasive diagnostic methods, and the identification of biomarkers for tailored treatment approaches. Clinicians are encouraged to adopt an interdisciplinary approach to endometriosis management, integrating medical, surgical, and complementary therapies to optimize patient outcomes.

Endometriosis: cannabidiol therapy for symptom relief

Endometriosis is a common, chronic, incurable condition the hallmark of which is the presence of lesions (tissue resembling endometrium) in sites outside the womb, with symptoms including chronic debilitating pain and fatigue. However, current therapeutic options are limited. Recent advances in our understanding of the mechanisms that contribute to the development of lesions and pain experience in endometriosis as well as surveys of patients have increased interest in testing recently approved formulations containing cannabidiol (CBD) in this patient group. In this review, we summarise data from patient samples and animals models focussed on the pathophysiology of endometriosis, including pathways where CBD has activity. We consider the available formulations of CBD-containing products, their pharmacokinetics (PK), and their use in ongoing clinical trials in endometriosis and other pain conditions.

Effect of Dietary Interventions on Endometriosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This study aimed to systematically review existing randomized clinical trials on the effect of dietary interventions on endometriosis. A search was performed on the Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Clinical Trials, EMBASE, PubMed, Lilacs, and Cielo databases. The search terms were used: "endometriosis", "endometrioma", "diet", "supplements" and "nutrition". Electronic literature searches through databases yielded 866 publications. Two authors performed The study selection independently (and blinded), and disagreements were discussed. Eleven RCTs were included in the systematic review, with 716 women randomized. Most studies reported a positive effect on endometriosis pain scores; however, they were characterized by moderate or high-risk bias. Of these, six RCTs, including 457 women with endometriosis, were included in the meta-analysis. Compared with Placebo, antioxidant use was associated with a reduction in dysmenorrhea (mean difference - 1.95 [CI 95%, -3.78 to -0.13]. Supplementation was not significant for reducing chronic pelvic pain (mean difference - 2.22 [95% CI, -4.99 to 0.55] and dyspareunia (MD - 2.56 [95% CI, - 5. 22 to 0.10]. Both analyses showed a high degree of heterogeneity. Moreover, studies with low risk of bias did not show significant results compared to those on Placebo. The effects of nutrient compounds seem to have the potential to reduce pain in women with endometriosis, mainly to reduce dysmenorrhea. However, the available studies present high heterogeneity and moderate/high risk of bias. More randomized clinical trials are needed to accurately determine dietary interventions' short- and long-term efficacy and safety in managing endometriosis pain.

Peripheral and central neuroplasticity in a mouse model of endometriosis

Chronic pelvic pain (CPP) is the most debilitating symptom of gynaecological disorders such as endometriosis. However, it remains unclear how sensory neurons from pelvic organs affected by endometriosis, such as the female reproductive tract, detect and transmit nociceptive events and how these signals are processed within the central nervous system (CNS). Using a previously characterized mouse model of endometriosis, we investigated whether the increased pain sensitivity occurring in endometriosis could be attributed to (i) changes in mechanosensory properties of sensory afferents innervating the reproductive tract, (ii) alterations in sensory input from reproductive organs to the spinal cord or (iii) neuroinflammation and sensitization of spinal neural circuits. Mechanosensitivity of vagina-innervating primary afferents was examined using an ex vivo single-unit extracellular recording preparation. Nociceptive signalling from the vagina to the spinal cord was quantified by phosphorylated MAP kinase ERK1/2 immunoreactivity. Immunohistochemistry was used to determine glial and neuronal circuit alterations within the spinal cord. We found that sensory afferents innervating the rostral, but not caudal portions of the mouse vagina, developed mechanical hypersensitivity in endometriosis. Nociceptive signalling from the vagina to the spinal cord was significantly enhanced in mice with endometriosis. Moreover, mice with endometriosis developed microgliosis, astrogliosis and enhanced substance P neurokinin-1 receptor immunoreactivity within the spinal cord, suggesting the development of neuroinflammation and sensitization of spinal circuitry in endometriosis. These results demonstrate endometriosis-induced neuroplasticity occurring at both peripheral and central sites of sensory afferent pathways. These findings may help to explain the altered sensitivity to pain in endometriosis and provide a novel platform for targeted pain relief treatments for this debilitating disorder.

The voltage-gated sodium channel NaV1.7 underlies endometriosis-associated chronic pelvic pain

Chronic pelvic pain (CPP) is the primary symptom of endometriosis patients, but adequate treatments are lacking. Modulation of ion channels expressed by sensory nerves innervating the viscera has shown promise for the treatment of irritable bowel syndrome and overactive bladder. However, similar approaches for endometriosis-associated CPP remain underdeveloped. Here, we examined the role of the voltage-gated sodium (NaV) channel NaV1.7 in (i) the sensitivity of vagina-innervating sensory afferents and investigated whether (ii) NaV1.7 inhibition reduces nociceptive signals from the vagina and (iii) ameliorates endometriosis-associated CPP. The mechanical responsiveness of vagina-innervating sensory afferents was assessed with ex vivo single-unit recording preparations. Pain evoked by vaginal distension (VD) was quantified by the visceromotor response (VMR) in vivo. In control mice, pharmacological activation of NaV1.7 with OD1 sensitised vagina-innervating pelvic afferents to mechanical stimuli. Using a syngeneic mouse model of endometriosis, we established that endometriosis sensitised vagina-innervating pelvic afferents to mechanical stimuli. The highly selective NaV1.7 inhibitor Tsp1a revealed that this afferent hypersensitivity occurred in a NaV1.7-dependent manner. Moreover, in vivo intra-vaginal treatment with Tsp1a reduced the exaggerated VMRs to VD which is characteristic of mice with endometriosis. Conversely, Tsp1a did not alter ex vivo afferent mechanosensitivity nor in vivo VMRs to VD in Sham control mice. Collectively, these findings suggest that NaV1.7 plays a crucial role in endometriosis-induced vaginal hyperalgesia. Importantly, NaV1.7 inhibition selectively alleviated endometriosis-associated CPP without the loss of normal sensation, suggesting that selective targeting of NaV1.7 could improve the quality of life of women with endometriosis.

Once Daily Oral Relugolix Combination Therapy Versus Placebo in Patients With Endometriosis-Associated Pain: Two Replicate Phase 3, Randomised, Double-Blind, Studies (SPIRIT 1 and 2)

The author describes the results of a study to examine the effect of three treatment regimens on pain associated with endometriosis.

The causal role of gastroesophageal reflux disease in endometriosis: a bidirectional Mendelian randomization study

Observational studies have reported an association between gastroesophageal reflux disease (GERD) and endometriosis. We conducted a two-sample and bidirectional Mendelian randomization analysis to determine whether those associations are causal. Two-sample and bidirectional MR analyses were performed using summary statistics from the European Individual Genome-Wide Association Study (GWAS). The inverse variance weighting (IVW) method is used as the main analysis method to evaluate causality. Sensitivity analyses were performed to assess heterogeneity, horizontal versatility, and stability. The results showed no significant causal association between GERD in women with endometriosis in the UK Bank database [ratio (OR) ≈ 0, 95% adjusted interval (CI) 1.0007∼1.0044, P = 0.006] and Finn databases [ratio (OR) = 1.29, 95% adjusted interval (CI) 0.99∼1.67, P = 0.06]. However, when studying the Finn database only for endometriosis, which is confined to the uterus, a significant increase in GERD was limited to the risk of endometriosis in the uterus [ratio (OR) = 1.47, 95% adjusted interval (CI) 1.00∼2.17, P = 0.05]. Sensitivity analysis showed that the results were robust and did not detect multi efficacy or heterogeneity. Meanwhile, reverse MR analysis showed that endometriosis did not increase the risk of GERD. This MR study supports a causal relationship between GERD and an increased risk of endometriosis confined to the uterus. Therefore, patients with gastric esophageal reflux should be treated with gynecological examination to avoid and prevent the development of endometriosis.

Current developments in endometriosis-associated pain

Endometriosis-associated pain is burdensome to both the individual and wider society. However, current treatment leaves many with persisting pain. Here, we highlight how recent work considering endometriosis in the context of chronic pain has altered our understanding and how this has the potential to improve clinical care.

Pain after laparoscopic endometriosis-specific vs. hysterectomy surgeries: A retrospective cohort analysis

OBJECTIVES

To evaluate pain perception and analgesic use between patients who underwent endometriosis-specific laparoscopic surgery compared to laparoscopic hysterectomy.

MATERIAL AND METHODS

This retrospective cohort study included women diagnosed with endometriosis who underwent laparoscopic surgery from 1/2019 to 11/2022. The control group consisted of premenopausal women who underwent laparoscopic hysterectomy, which was considered a similarly extensive surgery. Demographics, preoperative and post-operative data were compared between groups. Post-operative pain scores on a visual analogue scale (VAS) between 0 (no pain) and 10 (worst pain) were compared between groups for each post-operative day (POD). Standard pain relief analgesia on POD 0-1 included fixed intravenous treatment with paracetamol and intramuscular diclofenac. The need for additional analgesics (morphine or dipyrone) beyond the standard pain relief protocol was compared between groups.

RESULTS

Among 200 patients who underwent laparoscopic surgery, 100 (50%) were in the endometriosis group and 100 (50%) in the hysterectomy group. The endometriosis group was characterized by younger age and lower parity (both, p<0.001). There was no significant difference between the groups in mean VAS scores for each post-operative day. However, among patients who needed additional analgesics beyond the standard protocol on POD 1, a higher percentage of women in the endometriosis group used opioids rather than milder analgesics, as compared to controls (1% vs. 0.2%, respectively, p = 0.03).

CONCLUSION

Increased post-operative morphine use was observed in patients with endometriosis following laparoscopic surgery, despite no significant difference in mean VAS scores during the post-operative days. These findings suggest that personalized pain relief protocols should be adjusted for women with endometriosis.

Is Complete Excision Always Enough? A Quality of Sexual Life Assessment in Patients with Deep Endometriosis

Background and Objectives: The aim of this study was to find the factors associated with the severe impairment of QoSL and the factors associated with a better score in QoSL, as well as the evaluation of pain symptoms and QoSL after the complete and incomplete excision of rectovaginal nodules. Materials and methods: The present prospective study was conducted in a single tertiary center for endometriosis where 116 patients underwent laparoscopic surgery for deep endometriosis during a 3-year period. The goal of the intervention was to excise all endometriotic implants while conserving the rectum. Intraoperative findings were recorded after the intervention, and the patients were classified according to the ENZIAN classification and rASRM scores. QoSL was assessed using the EHP-30 Module C (QoSL Score). Results: When comparing the mean scores before and 2 years after the surgery, a highly significant improvement was found for QoSL and dysmenorrhea (p < 0.0001). The complete excision of rectovaginal nodules led to a significantly better QoSL and lower dyspareunia (p < 0.0001) than incomplete resection (p < 0.02). Conclusions: This prospective study proves that the complete laparoscopic excision of all endometriotic implants improved the QoSL and decreased the pain score of dyspareunia. Incomplete rectovaginal nodule excision was correlated with a poorer QoSL and a lower improvement of dysmenorrhea, dyspareunia, and chronic pelvic pain scores than complete excision.

Understanding the impact of endometriosis on women's life: an integrative review of systematic reviews

BACKGROUND

Endometriosis is a challenging chronic condition with a significant impact on women's well-being. This systematic review of systematic reviews aims to assess the evidence investigating the intricate interplay between endometriosis and quality of life (QoL).

METHODS

A systematic review was performed for English-language studies up to January 2022 to identify systematic reviews with and without meta-analysis analyzing quantitative or qualitative data The following databases were searched: Scopus, PubMed, Embase, Web of Science and Cochrane Central Register of Controlled Trials. Participants/population were women with endometriosis, and the outcomes included were all reported outcomes evaluating the impact of endometriosis on women's QoL (PROSPERO 2021 CRD42021289347).

RESULTS

15 systematic reviews were identified. 8 included meta-analysis: 4 explored the prevalence of mental health problems, and 1 analyzed, respectively, the overall impact of endometriosis, headache migraine, and sexual function. 7 articles reported on the mental consequences, and three sexual functioning. One was a qualitative review. The impact of the relationships with the healthcare system was analyzed in 3 reviews. Pain is a hallmark of endometriosis. Infertility and sexual problems are also frequent. Depression, anxiety, and stress represent significant contributors to lessening women's QoL. Women have frustrating relationships with the healthcare system: the complex and long diagnostic process, lack of treatment effectiveness, and persistence of symptoms contribute to emotional challenges. Negative cognitive patterns developed by women with emotional distress, such as catastrophizing and fear-avoidance behaviors, amplify the experience of pain.

CONCLUSION

The limitations of this review are the high degree of heterogeneity of papers that include many factors, including comorbidities, and use of medical care that may impact QoL, and that most of them were cross-sectional. Endometriosis is a chronic disease that significantly impacts all domains of women's lifes. Pain, infertility, and stress linked with depression, and anxiety significantly influence QoL. Women are dissatisfied with the care they receive.

Bladder Endometriosis: What do we know and what is left to find out? A narrative review

Bladder endometriosis accounts for 70-85% of urinary tract endometriosis cases. Urinary tract endometriosis occurs in approximately 1% of those living with endometriosis. Underlying aetiology and pathogenesis are not fully understood, but there are several plausible theories. As well as the typical pain symptoms, those with bladder endometriosis can experience several urinary tract symptoms. The manifestation of these symptoms can have complex pathways and processes. Imaging is accurate in the diagnosis of bladder endometriosis and clinicians should be mindful of the risk of silent kidney loss. Management should be guided by symptoms; both medical and surgical options are feasible. Surgical management offers potentially definitive treatment. Excisional surgery via bladder shave or partial cystectomy offers good improvement in symptoms with relatively low rates of serious complications and recurrence.

Pain from Internal Organs and Headache: The Challenge of Comorbidity

Headache and visceral pain are common clinical painful conditions, which often co-exist in the same patients. Numbers relative to their co-occurrence suggest possible common pathophysiological mechanisms. The aim of the present narrative review is to describe the most frequent headache and visceral pain associations and to discuss the possible underlying mechanisms of the associations and their diagnostic and therapeutic implications based on the most recent evidence from the international literature. The conditions addressed are as follows: visceral pain from the cardiovascular, gastrointestinal, and urogenital areas and primary headache conditions such as migraine and tension-type headache. The most frequent comorbidities involve the following: cardiac ischemic pain and migraine (possible shared mechanism of endothelial dysfunction, oxidative stress, and genetic and hormonal factors), functional gastrointestinal disorders, particularly IBS and both migraine and tension-type headache, primary or secondary dysmenorrhea and migraine, and painful bladder syndrome and headache (possible shared mechanisms of peripheral and central sensitization processes). The data also show that the various visceral pain-headache associations are characterized by more than a simple sum of symptoms from each condition but often involve complex interactions with the frequent enhancement of symptoms from both, which is crucial for diagnostic and treatment purposes.

Neuropelveology for Endometriosis Management: A Systematic Review and Multilevel Meta-Analysis

Background: Despite the availability of treatments such as surgery and hormonal therapy, women with endometriosis often endure chronic problems. This review aims to evaluate the effectiveness and safety of neuropelveology. Methods: In a systematic review with a meta-analysis, we searched three electronic databases: MEDLINE (PubMed), Scopus, Embase, and Web of Science (WOS). The search was conducted in January 2024 with no date or language restrictions using a carefully curated set of keywords. We conducted a comprehensive review, including all observational and clinical trials reporting data on neuropelveology approaches in the management of endometriosis, irrespective of geographical location. The studies included in our review were required to be published in peer-reviewed journals and be available in any language, with at least an abstract in English. The data of all included studies were summarized in excel (version 19) and were analyzed by Comprehensive Meta-analysis v3.3 (Biostat) and STATA (version 17). A multilevel meta-analysis was performed on studies with two arms (intervention and control) to evaluate the efficacy of neuropelveology in managing women with endometriosis. Results: After screening 476 records, 30 studies, published from 1952 to 2021, were included in this review, each employing various methodologies. The studies were divided into the following three categories: (a) efficacy of neurectomy or nerve resection (n = 20), (b) efficacy of neurolysis (nerve blocks) (n = 4), and (c) efficacy of neuromodulation (n = 6) in the management of endometriosis. Among the studies evaluating the efficacy of neurectomy or nerve resection, 10 studies (with 18 group comparisons) were included in the random-effects meta-analysis. Treatment success (not occurrence of pain) was higher with neurectomy vs. controls (RR = 0.497, 95% CI = 0.236 to 1.04, p = 0.06 (for experimental studies) and RR = 0.248, 95% CI = 0.14 to 0.43, p < 0.001 (for observational studies)), representing a 50% and 75.2% risk reduction in the recurrence of pain in experimental and observational studies, respectively. Similarly, neurolysis, particularly superior hypogastric plexus blocks and uterine nerve ethanol neurolysis, demonstrated encouraging outcomes in pain reduction and an improved quality of life for women with endometriosis. The efficacy of neuromodulation in managing endometriosis symptoms appears promising but requires further investigation. Conclusions: In conclusion, neuropelveology approaches, such as neurectomy, neurolysis, and neuromodulation, offer significant potential for pain reduction in endometriosis patients, albeit with risks of complications and high recurrence rates, necessitating careful patient selection and long-term monitoring.

The Burden of Pelvic Pain Associated With Endometriosis Among Women in Selected European Countries and the United States: A Restricted Systematic Review

OBJECTIVE

To evaluate the burden of endometriosis-associated pelvic pain (EAPP) on health-related quality of life (HRQoL) among women living in similar socio-economic conditions.

DATA SOURCES

Searches were performed in PubMed and Embase on September 26, 2022. The review was performed in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol (PRISMA-P) and was registered on PROSPERO (ID: CRD42023370363).

METHODS OF STUDY SELECTION

Due to the high volume of eligible publications following initial review, inclusion criteria were restricted to studies undertaken in France, Germany, Italy, Spain, the United Kingdom, and the United States. This restriction was applied before screening as these countries have broad social and economic similarities, and previous studies in the literature suggest pain reporting and experience are influenced by numerous socio-cultural factors. Eligible studies were those published between 2013 and 2022 and include a sample size of ≥50 participants. The search strategy identified all relevant publications relating to the burden of illness due to EAPP. A variety of terms are used in the literature to describe pain associated with endometriosis, and this was considered in the design of the search strategy and screening procedure.

TABULATION, INTEGRATION, AND RESULTS

The database searches resulted in a total of 6139 records. After removal of duplicates, 3855 records were assessed further. A total of 27 publications were identified as eligible. Fourteen (52%) were from Italy, 5 (19%) were multinational studies, 4 (15%) were from the United States, 3 (11%) were from Spain, and 1 (4%) was from Germany. Most studies were cross-sectional (n = 15; 56%); 7 (26%) were case-control studies; 3 (11%) were cohort studies; and 2 (7%) were longitudinal studies. These publications collectively highlighted an association between EAPP and reduced HRQoL. Several studies showed that EAPP was associated with lower HRQoL when compared with endometriosis without pain and potentially with chronic pelvic pain caused by other conditions, although the evidence is limited in this case. Moreover, the studies reported detrimental effects on general HRQoL, mental health functioning, and sexual functioning, culminating in reduced work productivity and difficulties in performing everyday activities. The associations were generally similar across study populations, including adolescents, as well as younger and older women. Results were consistent across the range of different patient-reported outcome tools used to assess HRQoL.

CONCLUSION

The existing literature suggests that, among women in selected European countries and the United States, EAPP is associated with reduced HRQoL, including impaired mental and sexual functioning, as well as reduced work performance and productivity; each of which may contribute to the societal burden of endometriosis.

Study on the Mechanisms of Glrα3 in Pain Sensitization of Endometriosis

Endometriosis, often associated with chronic pelvic pain, can lead to anxiety and depression. This study investigates the role and mechanism of Glycine receptor alpha 3 (Glrα3) in the central sensitization of pain in endometriosis, aiming to identify new therapeutic targets. Using a Glrα3 knockout mouse model of endometriosis, we employed behavioral tests, qPCR, immunofluorescence, Nissl staining, MRI, and Western blot to assess the involvement of Glrα3 in central pain sensitization. Our results indicate that endometriosis-induced hyperalgesia and anxiety-depressive-like behaviors are linked to increased Glrα3 expression. Chronic pain in endometriosis leads to gray matter changes in the sensory and insular cortices, with Glrα3 playing a significant role. The inhibition of Glrα3 alleviates pain, reduces neuronal abnormalities, and decreases glial cell activation. The absence of Glrα3 effectively regulates the central sensitization of pain in endometriosis by inhibiting glial cell activation and maintaining neuronal stability. This study offers new therapeutic avenues for the clinical treatment of endometriosis-related pain.

Satellite Glial Cells Bridge Sensory Neuron Crosstalk in Visceral Pain and Cross-Organ Sensitization

Following colonic inflammation, the uninjured bladder afferent neurons are also activated. The mechanisms and pathways underlying this sensory neuron cross-activation (from injured neurons to uninjured neurons) are not fully understood. Colonic and bladder afferent neurons reside in the same spinal segments and are separated by satellite glial cells (SGCs) and extracellular matrix in dorsal root ganglia (DRG). SGCs communicate with sensory neurons in a bidirectional fashion. This review summarizes the differentially regulated genes/proteins in the injured and uninjured DRG neurons and explores the role of SGCs in regulation of sensory neuron crosstalk in visceral cross-organ sensitization. The review also highlights the paracrine pathways in mediating neuron-SGC and SGC-neuron coupling with an emphasis on the neurotrophins and purinergic systems. Finally, I discuss the results from recent RNAseq profiling of SGCs to reveal useful molecular markers for characterization, functional study, and therapeutic targets of SGCs. SIGNIFICANCE STATEMENT: Satellite glial cells (SGCs) are the largest glial subtypes in sensory ganglia and play a critical role in mediating sensory neuron crosstalk, an underlying mechanism in colon-bladder cross-sensitization. Identification of novel and unique molecular markers of SGCs can advance the discovery of therapeutic targets in treatment of chronic pain including visceral pain comorbidity.

Pathogenesis of Endometriosis and Endometriosis-Associated Cancers

Endometriosis is a hormone-dependent, chronic inflammatory condition that affects 5-10% of reproductive-aged women. It is a complex disorder characterized by the growth of endometrial-like tissue outside the uterus, which can cause chronic pelvic pain and infertility. Despite its prevalence, the underlying molecular mechanisms of this disease remain poorly understood. Current treatment options are limited and focus mainly on suppressing lesion activity rather than eliminating it entirely. Although endometriosis is generally considered a benign condition, substantial evidence suggests that it increases the risk of developing specific subtypes of ovarian cancer. The discovery of cancer driver mutations in endometriotic lesions indicates that endometriosis may share molecular pathways with cancer. Moreover, the application of single-cell and spatial genomics, along with the development of organoid models, has started to illuminate the molecular mechanisms underlying disease etiology. This review aims to summarize the key genetic mutations and alterations that drive the development and progression of endometriosis to malignancy. We also review the significant recent advances in the understanding of the molecular basis of the disorder, as well as novel approaches and in vitro models that offer new avenues for improving our understanding of disease pathology and for developing new targeted therapies.

Vaginal and rectal microbiome contribute to genital inflammation in chronic pelvic pain

BACKGROUND

Chronic pelvic pain (CPP) is a multifactorial syndrome that can substantially affect a patient's quality of life. Endometriosis is one cause of CPP, and alterations of the immune and microbiome profiles have been observed in patients with endometriosis. The objective of this pilot study was to investigate differences in the vaginal and gastrointestinal microbiomes and cervicovaginal immune microenvironment in patients with CPP and endometriosis diagnosis compared to those with CPP without endometriosis and no CPP.

METHODS

Vaginal swabs, rectal swabs, and cervicovaginal lavages (CVL) were collected among individuals undergoing gynecologic laparoscopy. Participants were grouped based on patients seeking care for chronic pain and/or pathology results: CPP and endometriosis (CPP-Endo) (n = 35), CPP without endometriosis (n = 23), or patients without CPP or endometriosis (controls) (n = 15). Sensitivity analyses were performed on CPP with endometriosis location, stage, and co-occurring gynecologic conditions (abnormal uterine bleeding, fibroids). 16S rRNA sequencing was performed to profile the microbiome, and a panel of soluble immune mediators was quantified using a multiplex assay. Statistical analysis was conducted with SAS, R, MicrobiomeAnalyst, MetaboAnalyst, and QIIME 2.

RESULTS

Significant differences were observed between participants with CPP alone, CPP-Endo, and surgical controls for body mass index, ethnicity, diagnosis of ovarian cysts, and diagnosis of fibroids. In rectal microbiome analysis, both CPP alone and CPP-Endo exhibited lower alpha diversity than controls, and both CPP groups revealed enrichment of irritable bowel syndrome-associated bacteria. CPP-Endo exhibited an increased abundance of vaginal Streptococcus anginosus and rectal Ruminococcus. Patients with CPP and endometrioma (s) demonstrated increased vaginal Streptococcus, Lactobacillus, and Prevotella compared to other endometriosis sites. Further, abnormal uterine bleeding was associated with an increased abundance of bacterial vaginosis-associated bacteria. Immunoproteomic profiles were distinctly clustered by CPP alone and CPP-Endo compared to controls. CPP-Endo was enriched in TNF⍺, MDC, and IL-1⍺.

CONCLUSIONS

Vaginal and rectal microbiomes were observed to differ between patients with CPP alone and CPP with endometriosis, which may be useful in personalized treatment for individuals with CPP and endometriosis from those with other causes of CPP. Further investigation is warranted in patients with additional co-occurring conditions, such as AUB/fibroids, which add additional complexity to these conditions and reveal the enrichment of distinct pathogenic bacteria in both mucosal sites. This study provides foundational microbiome-immunoproteomic knowledge related to chronic pelvic pain, endometriosis, and co-occurring gynecologic conditions that can help improve the treatment of patients seeking care for pain.

Endometriosis, Pain, and Related Psychological Disorders: Unveiling the Interplay among the Microbiome, Inflammation, and Oxidative Stress as a Common Thread

Endometriosis (EM), a chronic condition in endometrial tissue outside the uterus, affects around 10% of reproductive-age women, significantly affecting fertility. Its prevalence remains elusive due to the surgical confirmation needed for diagnosis. Manifesting with a range of symptoms, including dysmenorrhea, dyschezia, dysuria, dyspareunia, fatigue, and gastrointestinal discomfort, EM significantly impairs quality of life due to severe chronic pelvic pain (CPP). Psychological manifestations, notably depression and anxiety, frequently accompany the physical symptoms, with CPP serving as a key mediator. Pain stems from endometrial lesions, involving oxidative stress, neuroinflammation, angiogenesis, and sensitization processes. Microbial dysbiosis appears to be crucial in the inflammatory mechanisms underlying EM and associated CPP, as well as psychological symptoms. In this scenario, dietary interventions and nutritional supplements could help manage EM symptoms by targeting inflammation, oxidative stress, and the microbiome. Our manuscript starts by delving into the complex relationship between EM pain and psychological comorbidities. It subsequently addresses the emerging roles of the microbiome, inflammation, and oxidative stress as common links among these abovementioned conditions. Furthermore, the review explores how dietary and nutritional interventions may influence the composition and function of the microbiome, reduce inflammation and oxidative stress, alleviate pain, and potentially affect EM-associated psychological disorders.

Connecting the dots: the role of fatigue in female infertility

Fatigue, an increasingly acknowledged symptom in various chronic diseases, has garnered heightened attention, during the medical era of bio-psycho-social model. Its persistence not only significantly compromises an individual's quality of life but also correlates with chronic organ damage. Surprisingly, the intricate relationship between fatigue and female reproductive health, specifically infertility, remains largely unexplored. Our exploration into the existing body of evidence establishes a compelling link between fatigue with uterine and ovarian diseases, as well as conditions associated with infertility, such as rheumatism. This observation suggests a potentially pivotal role of fatigue in influencing overall female fertility. Furthermore, we propose a hypothetical mechanism elucidating the impact of fatigue on infertility from multiple perspectives, postulating that neuroendocrine, neurotransmitter, inflammatory immune, and mitochondrial dysfunction resulting from fatigue and its co-factors may further contribute to endocrine disorders, menstrual irregularities, and sexual dysfunction, ultimately leading to infertility. In addition to providing this comprehensive theoretical framework, we summarize anti-fatigue strategies and accentuate current knowledge gaps. By doing so, our aim is to offer novel insights, stimulate further research, and advance our understanding of the crucial interplay between fatigue and female reproductive health.

Evidence for the role of multidisciplinary team care in people with pelvic pain and endometriosis: A systematic review

BACKGROUND

Endometriosis is a chronic, inflammatory condition characterised by the presence of endometrial-like tissue outside the uterine cavity. Given the multi-system nature of the disease and the potential for significant negative impact on quality of life, there has been a long-standing recognition of the need for multidisciplinary care for people with endometriosis. However, there is paucity to the data supporting this approach, and much of the evidence is anecdotal.

AIM

This systematic review aims to describe recent evidence-based models and patient-centred perspectives of multidisciplinary care for endometriosis, to improve understanding of the role of an integrated, multidisciplinary team in effectively addressing patients' care needs.

MATERIALS AND METHODS

PubMed, Medline, Embase and Web of Science were searched for relevant articles published between 1 January 2010 to 7 July 2022.

RESULTS

Nineteen studies met the inclusion and exclusion criteria and pinpointed a multidisciplinary team consisting of gynaecologists, pain specialists, nurses, physiotherapists, psychologists, sex therapists, nutritionists, complementary medicine practitioners, and social workers to be most commonly utilised in holistically managing people with pelvic pain and endometriosis. Furthermore, patient perspectives on care highlighted the need for reliable information, respect and validation of experiences or preferences, discussion of long-term treatment plans and social and emotional supports.

CONCLUSION

The trend for multidisciplinary team care for people with endometriosis is growing. Further consumer-driven clinical studies and outcome evaluations need to be conducted to determine the effect of multidisciplinary care on improvements to quality of life for people living with endometriosis and or pelvic pain.

Acceptability of using the Raising Awareness Tool for Endometriosis (RATE) in general practice: a mixed methods pilot study

AIMS

The Raising Awareness Tool for Endometriosis (RATE) was developed to facilitate discussions with health providers regarding endometriosis-associated symptoms. We aim to evaluate the acceptability of the RATE by general practitioners (GP), including determining the prevalence of symptoms of women presenting to general practice and immediate management of symptoms.

METHODS

A mixed-methods study was undertaken using a combination of quantitative and qualitative data in Western Australian General Practices from 2021 to 2022. A purposive sample of 12 GPs were included, who recruited women (18-50 years) on attendance for consultation over a one- to two-week period, followed by qualitative interviews exploring GPs' experiences with the tool. The quantitative and qualitative components were integrated during analysis of results.

RESULTS

A total of 111 women completed the RATE (mean: 33, standard deviation: 8.6 years) prior to routine consultation. The tool was considered to be acceptable for use in general practice and aided discussions on symptoms and management. Overall, 68.5% of patients experienced pelvic pain or discomfort, with 22.4% rating that this interfered with quality of life. Of those with pelvic pain, 75% had associated chronic pain conditions, and 42.1% reported allodynia. The chronic pain questions provoked GP uncertainty. After symptoms were identified, GPs arranged individualised investigations and follow-up.

CONCLUSIONS

The RATE was considered to be acceptable for use in the general practice setting. It identified symptoms and initiated discussions on possible diagnosis as well as management of endometriosis. Further GP education on identifying those women at most risk of developing chronic pain syndromes is needed.

Vitamin C and E antioxidant supplementation may significantly reduce pain symptoms in endometriosis: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The primary challenge encountered by individuals diagnosed with endometriosis is the experience of pain. Emerging research indicates that oxidative stress is implicated in the initiation of pain associated with endometriosis. Vitamins C and E are known for their antioxidative properties. The primary objective of this study is to assess the efficacy of antioxidant supplementation, consisting of these vitamins, in the management of pain associated with endometriosis.

METHODS

A comprehensive search was conducted on the ClinicalTrials.gov, Scopus, Europe PMC, and Medline databases up until August 23rd, 2023, utilizing a combination of relevant keywords. This review incorporates literature that examines the relationship between antioxidant supplementation and pain in endometriosis. We employed fixed-effect models to analyze the risk ratio (RR) and present the outcomes together with their corresponding 95% confidence intervals (CI).

RESULTS

A total of five RCTs were incorporated. The results of our meta-analysis indicated that antioxidant supplementation with vitamin C and E combination was associated with higher proportion of endometriosis patients reporting reduced chronic pelvic pain (RR 7.30; 95%CI: 3.27-16.31, p<0.00001, I2 = 0%), alleviations of dysmenorrhea (RR 1.96; 95%CI: 1.25-3.07, p = 0.003, I2 = 39%), and dyspareunia (RR 5.08; 95%CI: 2.10-12.26, p = 0.0003, I2 = 0%) than patients only receiving placebo.

CONCLUSIONS

This study suggests the potential ability of vitamin C and E in alleviating pain symptoms experienced by individuals with endometriosis.

Postmenopausal endometriosis: a challenging condition beyond menopause

IMPORTANCE AND OBJECTIVE

Postmenopausal endometriosis is a complex condition that challenges the conventional belief that endometriosis resolves with menopause. Despite the cessation of menstruation, a subset of women continues to experience or develop endometriosis-related symptoms during the postmenopausal period. Thus, this review aimed to shed light on postmenopausal endometriosis, exploring its clinical features, diagnostic considerations, management approaches, and the potential impact on women's health.

METHODS

PubMed/Medline, Scopus, and Web of Science databases were used for the research, with only articles in English language, using the following terms: "postmenopausal endometriosis," "menopause," "management," "treatment," and "quality of life," from inception to 2023.

DISCUSSION AND CONCLUSION

The clinical features of postmenopausal endometriosis include persistent or recurrent pelvic pain, dyspareunia, bowel, or urinary symptoms and, occasionally, abnormal vaginal bleeding. The absence of menstrual cycles presents a diagnostic challenge, as the traditional diagnostic criteria for endometriosis rely on menstrual patterns. Visual cues may be less evident, and the symptoms often overlap with other gynecological conditions, necessitating a thorough evaluation to differentiate postmenopausal endometriosis from other potential causes. Management approaches for postmenopausal endometriosis encompass surgical intervention, hormonal therapies, pain management, and individualized care. Postmenopausal endometriosis significantly impacts the quality of life, sexual health, and long-term well-being of women. Understanding the clinical features, diagnostic challenges, and management approaches of postmenopausal endometriosis is crucial for healthcare professionals to provide effective care and to improve the quality of life of women affected by this condition.

Transcriptomic changes in eutopic endometrium and ectopic lesions during endometriosis progression in a mouse model

OBJECTIVE

To identify the transcriptomic changes of ectopic lesions and eutopic endometrial tissues during the progression of endometriosis, we performed transcriptomic analysis in the eutopic endometrium and ectopic lesions.

DESIGN

Laboratory study.

SETTING

Academic medical center.

ANIMALS

Four fertile and 4 subfertile Pgrcre/+Rosa26mTmG/+ mice with endometriosis, and 4 sham mice for each group of endometriosis mice as control. These mice underwent either surgery to induce endometriosis or sham surgery. Fertile sham and mice with endometriosis were used 1 month after surgery, whereas subfertile ones were used 3 months after surgery.

INTERVENTIONS

Early and chronic effects of endometriosis on transcriptomics of ectopic lesions and eutopic endometrium.

MAIN OUTCOME MEASURES

RNA-sequencing analysis and identification of differentially expressed genes and pathways in the ectopic lesions and eutopic uteri from mice with endometriosis and sham mice at day 3.5 of pregnancy.

RESULTS

Our mouse model recapitulates the transcriptomic changes of ectopic lesions in humans. RNA-sequencing analysis was performed in ectopic lesions and eutopic uteri from mice with or without endometriosis during the progression of the disease. Estrogen activity, inflammation, angiogenesis, and fibrosis pathways were consistently elevated in all the ectopic lesions compared with eutopic endometrium. Cholesterol/glucose synthesis and stem cell pluripotency pathways were more enhanced in ectopic lesions from subfertile mice compared with their eutopic endometrium. Dysregulation of infiltration of macrophage, dendritic, T and B cells was validated with the use of immunohistochemistry in ectopic lesions. Multiple ligand-receptor pairs between the ectopic and eutopic endometrium were altered compared with the sham endometrium. Suppressed WNT and EGF pathways were only found in the eutopic endometrium from subfertile not fertile mice compared with sham.

CONCLUSIONS

Our mouse endometriosis model recapitulates the transcriptomics of ectopic lesions in humans. Our transcriptomic analysis during endometriosis progression in our mouse model will help us understand the pathophysiology of endometriosis.

Chronic postsurgical pain: A European survey

BACKGROUND

Chronic postsurgical pain (CPSP) is a clinical problem, and large prospective studies are needed to determine its incidence, characteristics, and risk factors.

OBJECTIVE

To find predictive factors for CPSP in an international survey.

DESIGN

Observational study.

SETTING

Multicentre European prospective observational trial.

PATIENTS

Patients undergoing breast cancer surgery, sternotomy, endometriosis surgery, or total knee arthroplasty (TKA).

METHOD

Standardised questionnaires were completed by the patients at 1, 3, and 7 days, and at 1, 3, and 6 months after surgery, with follow-up via E-mail, telephone, or interview.

MAIN OUTCOME MEASURE

The primary goal of NIT-1 was to propose a scoring system to predict those patient likely to have CPSP at 6 months after surgery.

RESULTS

A total of 3297 patients were included from 18 hospitals across Europe and 2494 patients were followed-up for 6 months. The mean incidence of CPSP at 6 months was 10.5%, with variations depending on the type of surgery: sternotomy 6.9%, breast surgery 7.4%, TKA 12.9%, endometriosis 16.2%. At 6 months, neuropathic characteristics were frequent for all types of surgery: sternotomy 33.3%, breast surgery 67.6%, TKA 42.4%, endometriosis 41.4%. One-third of patients experienced CPSP at both 3 and 6 months. Pre-operative pain was frequent for TKA (leg pain) and endometriosis (abdomen) and its frequency and intensity were reduced after surgery. Severe CPSP and a neuropathic pain component decreased psychological and functional wellbeing as well as quality of life. No overarching CPSP risk factors were identified.

CONCLUSION

Unfortunately, our findings do not offer a new CPSP predictive score. However, we present reliable new data on the incidence, characteristics, and consequences of CPSP from a large European survey. Interesting new data on the time course of CPSP, its neuropathic pain component, and CPSP after endometriosis surgery generate new hypotheses but need to be confirmed by further research.

TRIAL REGISTRATION

clinicaltrials.gov ID: NCT03834922.

The role of peroxisome proliferator-activated receptors in endometriosis

Endometriosis constitutes the most common cause of chronic pelvic pain in female patients and is associated with infertility. Although there is no known cause for the disease, it is a heritable condition that is determined by numerous genetic, epigenetic, and environmental aspects. Peroxisome proliferator-activated receptors (PPARs) represent nuclear receptor proteins that control gene expression. By using the MEDLINE and LIVIVO databases we conducted a literature review in order to look into the role of PPARs in the endometriosis pathophysiology and succeeded in revealing 36 pertinent publications between 2001 and 2022. In regards to PPAR expression in endometriosis, PPARγ seems to represent the most studied PPAR isoform in endometriosis and to influence various pathways involved in the disease onset and progression. It's interesting to note that diverse treatment agents targeting the PPAR system have been identified as innovative, effective therapeutic alternatives in the context of endometriosis treatment. In conclusion, PPARs appear to contribute an important role in both endometriosis pathophysiology and therapy.

Pyroptotic T cell-derived active IL-16 has a driving function in ovarian endometriosis development

Endometriosis, affecting 6%-10% of women, often leads to pain and infertility and its underlying inflammatory mechanisms are poorly understood. We established endometriosis models in wild-type and IL16KO mice, revealing the driver function of IL-16 in initiating endometriosis-related inflammation. Using an in vitro system, we confirmed iron overload-induced GSDME-mediated pyroptosis as a key trigger for IL-16 activation and release. In addition, our research led to the development of Z30702029, a compound inhibiting GSDME-NTD-mediated pyroptosis, which shows promise as a therapeutic intervention for endometriosis. Importantly, our findings extend beyond endometriosis, highlighting GSDME-mediated pyroptosis as a broader pathway for IL-16 release and offering insights into potential treatments for various inflammatory conditions.

Role of the gut microbiota in the pathogenesis of endometriosis: a review

Endometriosis is classically defined as a chronic inflammatory heterogeneous disorder occurring in any part of the body, characterized by estrogen-driven periodic bleeding, proliferation, and fibrosis of ectopic endometrial glands and stroma outside the uterus. Endometriosis can take overwhelmingly serious damage to the structure and function of multi-organ, even impair whole-body systems, resulting in severe dysmenorrhea, chronic pelvic pain, infertility, fatigue and depression in 5-10% women of reproductive age. Precisely because of a huge deficiency of cognition about underlying etiology and complex pathogenesis of the debilitating disease, early diagnosis and treatment modalities with relatively minor side effects become bottlenecks in endometriosis. Thus, endometriosis warrants deeper exploration and expanded investigation in pathogenesis. The gut microbiota plays a significant role in chronic diseases in humans by acting as an important participant and regulator in the metabolism and immunity of the body. Increasingly, studies have shown that the gut microbiota is closely related to inflammation, estrogen metabolism, and immunity resulting in the development and progression of endometriosis. In this review, we discuss the diverse mechanisms of endometriosis closely related to the gut microbiota in order to provide new approaches for deeper exploration and expanded investigation for endometriosis on prevention, early diagnosis and treatment.

Developing a Predictive Model for Minimal or Mild Endometriosis as a Clinical Screening Tool in Infertile Women: Uterosacral Tenderness as a Key Predictor

STUDY OBJECTIVE

To develop a noninvasive predictive model based on patients with infertility for identifying minimal or mild endometriosis.

DESIGN

A retrospective cohort study.

SETTING

This study was conducted at a tertiary referral center.

PATIENTS

A total of consecutive 1365 patients with infertility who underwent laparoscopy between January 2013 and August 2020 were divided into a training set (n = 910) for developing the predictive model and a validation set (n = 455) to confirm the model's prediction efficiency. The patients were randomly assigned in a 2:1 ratio.

INTERVENTIONS

Sensitivities, specificities, area under the curve, the Hosmer-Lemeshow goodness of fit test, Net Reclassification Improvement index, and Integrated Discrimination Improvement index were evaluated in the training set to select the optimum model. In the validation set, the model's discriminations, calibrations, and clinical use were tested for validation.

MEASUREMENTS AND MAIN RESULTS

In the training set, there were 587 patients with minimal or mild endometriosis and 323 patients without endometriosis. The combination of clinical parameters in the model was evaluated for both statistical and clinical significance. The best-performing model ultimately included body mass index, dysmenorrhea, dyspareunia, uterosacral tenderness, and serum cancer antigen 125 (CA-125). The nomogram based on this model demonstrated sensitivities of 87.7% and 93.3%, specificities of 68.6% and 66.4%, and area under the curve of 0.84 (95% confidence interval 0.81-0.87) and 0.85 (95% confidence interval 0.80-0.89) for the training and validation sets, respectively. Calibration curves and decision curve analyses also indicated that the model had good calibration and clinical value. Uterosacral tenderness emerged as the most valuable predictor.

CONCLUSION

This study successfully developed a predictive model with high accuracy in identifying infertile women with minimal or mild endometriosis based on clinical characteristics, signs, and cost-effective blood tests. This model would assist clinicians in screening infertile women for minimal or mild endometriosis, thereby facilitating early diagnosis and treatment.

Pain perception and analgesic use after cesarean delivery among women with endometriosis

BACKGROUND

Patients with endometriosis are known to have altered pain perceptions. Cesarean delivery (CD) is one of the most prevalent surgeries performed worldwide. Appropriate pain control following CD is clinically important to the recovery and relief of patients. This study assessed pain perception and analgesic use after CD among women with or without endometriosis.

METHODS

This retrospective case control study included women diagnosed with endometriosis, based on clinical or surgical findings, who underwent CD from 2014 to 2022. Controls were matched to the study group by maternal age, BMI (kg/m2), parity, number of previous CDs and by CD indication, in a 2:1 ratio. Post-operative visual analogue scale (VAS) pain scores, on each post-operative day (POD) were compared between groups. Pain intensity was measured and compared using the VAS, range 0 (no pain) to 10 (worst pain). The standard pain relief analgesia protocol in our department includes fixed oral treatment with paracetamol and diclofenac, with the addition of morphine sulphate on POD 0. Analgesic dosages used and the percentage of patients not using the full standard analgesic protocol were compared between groups.

RESULTS

As compared to controls (n = 142), the endometriosis group (n = 71) was characterized by higher rates of in-vitro fertilization (IVF) pregnancies and previous abdominal surgeries other than CD (p < .001 for both). Other maternal characteristics between groups did not differ. On POD 0, mean morphine dosage was significantly higher in the endometriosis group compared to the control group (24 mg vs. 22.8 mg, respectively; p = .044). More patients in the endometriosis group used the full standard analgesia protocol or more, as compared to controls. VAS scores were not significantly different between groups.

CONCLUSIONS

Increased use of analgesics after CD was more common among women with endometriosis. These findings imply that pain relief protocols should be personalized for women with endometriosis.

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

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

Association of endometriosis with Sjögren's syndrome: Genetic insights (Review)

Patients with a history of endometriosis have an increased risk of developing various autoimmune diseases such as rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, multiple sclerosis and celiac disease. There is a potential association between endometriosis and an increased susceptibility for Sjögren's syndrome (SS). SS is a common chronic, inflammatory, systemic, autoimmune, multifactorial disease of complex pathology, with genetic, epigenetic and environmental factors contributing to the development of this condition. It occurs in 0.5‑1% of the population, is characterized by the presence of ocular dryness, lymphocytic infiltrations and contributes to neurological, gastrointestinal, vascular and dermatological manifestations. Endometriosis is an inflammatory, estrogen‑dependent, multifactorial, heterogeneous gynecological disease, affecting ≤10% of reproductive‑age women. It is characterized by the occurrence of endometrial tissue outside the uterine cavity, mainly in the pelvic cavity, and is associated with pelvic pain, dysmenorrhea, deep dyspareunia and either subfertility or infertility. It is still unclear whether SS appears as a secondary response to endometriosis, or it is developed due to any potential shared mechanisms of these conditions. The aim of the present review was to explore further the biological basis only of the co‑occurrence of these disorders but not their association at clinical basis, focusing on the analysis of the partially shared genetic background between endometriosis and SS, and the clarification of the possible similarities in the underlying pathogenetic mechanisms and the relevant molecular pathways.

Efficacy and safety of a novel pain management device, AT-04, for endometriosis-related pain: study protocol for a phase III randomized controlled trial

BACKGROUND

Endometriosis-related pain encompassing dysmenorrhea, dyspareunia, and chronic pelvic pain, reduces the quality of life in premenopausal women. Although treatment options for endometriosis alleviate this pain, approximately one-third of women still experience pain even after receiving treatment, indicating the need for novel approaches to pain relief in those women. The Angel Touch device (AT-04) is a portable magnetic fields irradiation device that incorporates a combination of mixed alternative magnetic fields at 2 kHz and 83.3 MHz. A phase III trial confirmed the efficacy and safety of AT-02, a prototype of AT-04, for pain relief in patients with fibromyalgia.

METHODS

This is a phase III, multicenter, prospective, randomized, sham device-controlled, double-blind, parallel study. The participants will be premenopausal women aged > 18 years who have endometriosis-related pain with at least moderate severity. Considering dropouts, 50 participants have been deemed appropriate. Eligible women will be centrally registered, and the data center will randomly allocate them in a 1:1 ratio to the intervention and control groups. Women in the intervention group will receive electromagnetic wave irradiation generated by AT-04 and those who in the control group will wear a sham device for 16 weeks, and both groups will wear AT-04 for another 4 weeks. The primary outcome measure is the change in the Numeric Rating Scale score at 16 weeks compared with the baseline. Secondary outcome measures are efficacy for pelvic pain including dysmenorrhea and non-menstrual pain, and chronic pelvic pain not related to menstruation, dysmenorrhea, and dyspareunia, and improvement of quality of life during the study period. Safety will be evaluated by device defects and the frequency of adverse events. The study protocol has been approved by the Clinical Study Review Board of Chiba University Hospital, Chiba, Japan, and will be conducted in accordance with the principles of the Declaration of Helsinki and the Japanese Clinical Trials Act and relevant notifications.

DISCUSSION

This study aims to develop a novel method of managing endometriosis-related pain. The AT-04 is an ultralow-invasive device that can be used without inhibiting ovulation, suggesting potential benefits to women of reproductive-age. Trial registration number Japan Registry of Clinical Trials (jRCTs032230278).

Pingchong Jiangni recipe through nerve growth factor/transient receptor potential vanilloid 1 signaling pathway to relieve pain in endometriosis model rats

ETHNOPHARMACOLOGICAL RELEVANCE

Pingchong Jiangni recipe (PJR) is often used in the treatment of endometriosis (EM). This formula has been clinically validated by the State Administration of Traditional Chinese Medicine Key Specialties Collaborative Group for its therapeutic efficacy. Recently, our research team also confirmed that PJR has a shrinking effect on ovarian chocolate cysts. Additionally, PJR was also found to have a shrinking effect on EM lesions; however, the mechanism by which this effect occurs remains unclear.

AIM OF THE STUDY

To explore the mechanisms by which PJR relieves pain in patients with EM.

MATERIALS AND METHODS

A rat model of EM was established by autologous transplantation. PJR (3.78 g/kg, 7.56 g/kg, and 15.12 g/kg) was orally administered for 21 days. The rat grimace scale (RGS) score and paw withdrawal threshold (PWT) were measured at a fixed time during the experiment. Hematoxylin and eosin staining was performed to observe histopathological changes in EM rats after administration, enzyme-linked immunosorbent assay to evaluate the plasma expression of tumor necrosis factor-α (TNF-α) and nerve growth factor (NGF), and immunohistochemistry and western blotting to identify differences in the expression of pain-related factors in EM rats.

RESULTS

The medium-dose group of PJR (7.56 g/kg) had the best effect on relieving pain in EM rats by reducing RGS, increasing PWT, reducing the ectopic endometrium, improving the cellular structure of the lesion, and reducing TNF-α and NGF levels. However, PJR significantly decreased the expression of transient receptor potential vanilloid 1 (TRPV1), phosphorylated TRPV1 (p-TRPV1), protein kinase C (PKC), and NGF.

CONCLUSION

The mechanism by which PJR relieves EM pain may be through the downregulation of NGF, PKC, and TRPV1 expression.

Associations between psychological flexibility and daily functioning in endometriosis-related pain

OBJECTIVES

Processes of psychological flexibility (PF) are positively associated with health and wellbeing in several chronic pain disorders. However, these processes have not been investigated in endometriosis, a chronic pain disorder affecting 5-10 % of women worldwide. This study is a preliminary investigation of the associations between PF or psychological inflexibility (PI) and daily functioning in people with a primary diagnosis of endometriosis.

METHODS

This study is based on a secondary analysis of survey data from Swedish-speaking adult participants with chronic pain recruited online. The current study included only those reporting a diagnosis of endometriosis and significant long-term pain. All participants completed the Multidimensional Psychological Flexibility Inventory (MPFI), a measure of PF and PI, as well as other measures of PF, and measures of pain and daily functioning. Correlation and multiple regression analyses were performed to examine relations of PF and PI with measures of pain and daily functioning.

RESULTS

In general, PF facet scores from the MPFI did not correlate with pain interference but did correlate with depression, with the exception of acceptance. The overall facets of PI appeared to perform better as correlates and in regression. Established measures of PF performed in correlation and regression analyses generally as has been observed in other chronic pain populations, with significant positive associations.

CONCLUSIONS

In this preliminary analysis of PF and PI in participants with endometriosis-related pain, these processes appear relevant, especially in understanding depression, but results varied along with the measures used. Specifically, when employing the MPFI, the PI facets emerged as stronger correlates. The findings underscore the potential benefit of incorporating assessments of PF and PI as process variables in endometriosis-research, but also that careful consideration should be given when selecting instruments.

Assessing the Utility of artificial intelligence in endometriosis: Promises and pitfalls

Endometriosis, a chronic condition characterized by the growth of endometrial-like tissue outside of the uterus, poses substantial challenges in terms of diagnosis and treatment. Artificial intelligence (AI) has emerged as a promising tool in the field of medicine, offering opportunities to address the complexities of endometriosis. This review explores the current landscape of endometriosis diagnosis and treatment, highlighting the potential of AI to alleviate some of the associated burdens and underscoring common pitfalls and challenges when employing AI algorithms in this context. Women's health research in endometriosis has suffered from underfunding, leading to limitations in diagnosis, classification, and treatment approaches. The heterogeneity of symptoms in patients with endometriosis has further complicated efforts to address this condition. New, powerful methods of analysis have the potential to uncover previously unidentified patterns in data relating to endometriosis. AI, a collection of algorithms replicating human decision-making in data analysis, has been increasingly adopted in medical research, including endometriosis studies. While AI offers the ability to identify novel patterns in data and analyze large datasets, its effectiveness hinges on data quality and quantity and the expertise of those implementing the algorithms. Current applications of AI in endometriosis range from diagnostic tools for ultrasound imaging to predicting treatment success. These applications show promise in reducing diagnostic delays, healthcare costs, and providing patients with more treatment options, improving their quality of life. AI holds significant potential in advancing the diagnosis and treatment of endometriosis, but it must be applied carefully and transparently to avoid pitfalls and ensure reproducibility. This review calls for increased scrutiny and accountability in AI research. Addressing these challenges can lead to more effective AI-driven solutions for endometriosis and other complex medical conditions.