Environmental Exposure to Persistent Organic Pollutants and Its Association with Endometriosis Risk: Implications in the Epithelial-Mesenchymal Transition Process

We aimed to explore the relationship of adipose tissue concentrations of some persistent organic pollutants (POPs) with the risk of endometriosis and the endometriotic tissue expression profile of genes related to the endometriosis-related epithelial-mesenchymal transition (EMT) process. This case-control study enrolled 109 women (34 cases and 75 controls) between January 2018 and March 2020. Adipose tissue samples and endometriotic tissues were intraoperatively collected to determine concentrations of nine POPs and the gene expression profiles of 36 EMT-related genes, respectively. Associations of POPs with endometriosis risk were explored with multivariate logistic regression, while the relationship between exposure and gene expression profiles was assessed through Spearman correlation or Mann-Whitney U tests. After adjustment, increased endometriosis risk was associated with p,p'-DDT, PCB-180, and ΣPCBs. POP exposure was also associated with reduced gene expression levels of the CLDN7 epithelial marker and increased levels of the ITGB2 mesenchymal marker and a variety of EMT promoters (HMGA1, HOXA10, FOXM1, DKK1, CCR1, TNFRSF1B, RRM2, ANG, ANGPT1, and ESR1). Our findings indicate that exposure to POPs may increase the risk of endometriosis and might have a role in the endometriosis-related EMT development, contributing to the disease onset and progression. Further studies are warranted to corroborate these findings.

Anti-SARS-CoV-2-specific antibodies in human breast milk following SARS-CoV-2 infection during pregnancy: a prospective cohort study

BACKGROUND

While the presence of SARS-CoV-2 in human breast milk is contentious, anti-SARS-CoV-2 antibodies have been consistently detected in human breast milk. However, it is uncertain when and how long the antibodies are present.

METHODS

This was a prospective cohort study including all consecutive pregnant women with confirmed SARS-CoV-2 infection during pregnancy, recruited at six maternity units in Spain and Hong Kong from March 2020 to March 2021. Colostrum (day of birth until day 4 postpartum) and mature milk (day 7 postpartum until 6 weeks postpartum) were prospectively collected, and paired maternal blood samples were also collected. Colostrum samples were tested with rRT-PCR-SARS-CoV-2, and skimmed acellular milk and maternal sera were tested against SARS-CoV-2 specific immunoglobulin M, A, and G reactive to receptor binding domain of SARS-CoV-2 spike protein 1 to determine the presence of immunoglobulins. Then, we examined how each immunoglobulin type in the colostrum was related to the time of infection by logistic regression analysis, the concordance between these immunoglobulins in the colostrum, maternal serum, and mature milk by Cohen's kappa statistic, and the relationship between immunoglobulin levels in mature milk and colostrum with McNemar.

RESULTS

One hundred eighty-seven pregnant women with confirmed SARS-CoV-2 infection during pregnancy or childbirth were recruited and donated the milk and blood samples. No SARS-CoV-2 was found in the human breast milk. Immunoglobulin A, G, and M were present in 129/162 (79·6%), 5/163 (3·1%), and 15/76 (19·7%) colostrum samples and in 17/62 (27·42%), 2/62 (3·23%) and 2/62 (3·23%) mature milk samples, respectively. Immunoglobulin A was the predominant immunoglobulin found in breast milk, and its levels were significantly higher in the colostrum than in the mature milk (p-value < 0.001). We did not find that the presence of immunoglobulins in the colostrum was associated with their presence in maternal, the severity of the disease, or the time when the infection had occurred.

CONCLUSIONS

Since anti-SARS-CoV-2 antibodies are found in the colostrum irrespective of the time of infection during pregnancy, but the virus itself is not detected in human breast milk, our study found no indications to withhold breastfeeding, taking contact precautions when there is active disease.

Expression Profiles of Genes Related to Development and Progression of Endometriosis and Their Association with Paraben and Benzophenone Exposure

Increasing evidence has been published over recent years on the implication of endocrine-disrupting chemicals (EDCs), including parabens and benzophenones in the pathogenesis and pathophysiology of endometriosis. However, to the best of our knowledge, no study has been published on the ways in which exposure to EDCs might affect cell-signaling pathways related to endometriosis. We aimed to describe the endometriotic tissue expression profile of a panel of 23 genes related to crucial cell-signaling pathways for the development and progression of endometriosis (cell adhesion, invasion/migration, inflammation, angiogenesis, and cell proliferation/hormone stimulation) and explore its relationship with the exposure of patients to parabens (PBs) and benzophenones (BPs). This cross-sectional study included a subsample of 33 women with endometriosis from the EndEA study, measuring their endometriotic tissue expressions of 23 genes, while urinary concentrations of methyl-, ethyl-, propyl-, butyl-paraben, benzophenone-1, benzophenone-3, and 4-hydroxybenzophenone were determined in 22 women. Spearman's correlations test and linear and logistic regression analyses were performed. The expression of 52.2% of studied genes was observed in >75% of endometriotic tissue samples and the expression of 17.4% (n = 4) of them in 50-75%. Exposure to certain PB and BP congeners was positively associated with the expression of key genes for the development and proliferation of endometriosis. Genes related to the development and progression of endometriosis were expressed in most endometriotic tissue samples studied, suggesting that exposure of women to PBs and BPs may be associated with the altered expression profile of genes related to cellular pathways involved in the development of endometriosis.

Effect of a Multimodal Supervised Therapeutic Exercise Program on Quality of Life, Pain, and Lumbopelvic Impairments in Women With Endometriosis Unresponsive to Conventional Therapy: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effectiveness of "Physio-EndEA", a multimodal nine-week supervised exercise intervention, on quality of life, pain, and lumbopelvic impairments in women with endometriosis unresponsive to conventional therapy.

DESIGN

Parallel-group randomized controlled trial. Outcomes were measured at baseline, post-intervention, and at 1 year.

SETTING

Two Public University Hospitals.

PARTICIPANTS

This trial included 31 women with endometriosis (N=31) randomly allocated to "Physio-EndEA" group (n=16) or control group (n=15). Four participants dropped out of the study for causes unrelated to the intervention.

INTERVENTIONS

The "Physio-EndEA" program consisted of a 1-week lumbopelvic stabilization learning phase followed by an 8-week phase of stretching, aerobic, and resistance exercises focused on the lumbopelvic area. It was sequentially instructed and supervised by a trained physiotherapist (with volume and intensity progression) and adapted daily to the potential of each participant. Control group received the usual treatment stipulated by their gynecologist.

MAIN OUTCOME MEASURES

The primary outcome was quality of life. Secondary outcomes were pain intensity, pressure pain thresholds, pain-related catastrophic thoughts, abdominal and back strength, lumbopelvic stability, and muscle architecture.

RESULTS

Adherence rate was 90.6% and mean (±standard deviation) satisfaction was 9.44±0.73 out of 10. No remarkable health problems were reported during the trial. In comparison with controls, the quality of life was improved post-intervention and at 1 year in the Physio-EndEA group with large effect sizes (d>0.80). This group also evidenced: a reduced intensity of dyspareunia, catastrophic thoughts; an increase in pelvic, lumbar, and distal pressure pain thresholds; increases in abdominal and back strength and lumbopelvic stability; and increased thickness of transversus abdominis (right side) and width of lumbar multifidus (left side).

CONCLUSION

A 9-week program of multimodal supervised therapeutic exercise is a feasible and effective intervention to improve QoL in women with endometriosis. This program also offers benefits in terms of pain/sensitization and lumbopelvic impairments.

Cell cycle, apoptosis, cell differentiation, and lipid metabolism gene expression in endometriotic tissue and exposure to parabens and benzophenones

AIM

To describe the expression profile in endometriotic tissue of genes involved in four signaling pathways related to the development and progression of endometriosis (cell cycle, apoptosis, cell differentiation and lipid metabolism) and to explore its relationship with the women exposure to chemicals with hormonal activity released from cosmetics and personal care products (PCPs).

METHODS

This cross-sectional study, encompassed within the EndEA study, comprised a subsample of 33 women with endometriosis. Expression levels of 13 genes (BMI1, CCNB1, CDK1, BAX, BCL2L1, FOXO3, SPP1, HOXA10, PDGFRA, SOX2, APOE, PLCG1 and PLCG2) in endometriotic tissue and urinary concentrations of 4 paraben (PB) and 3 benzophenone (BP) congeners were quantified. Bivariate linear and logistic regression analyses were performed to explore the associations between exposure and gene expression levels.

RESULTS

A total of 8 out 13 genes (61.5 %) were expressed in >75 % of the samples. Exposure to congeners of PBs and/or BPs was associated with the overexpression of CDK1 gene (whose protein drives cells through G2 phase and mitosis), HOXA10 and PDGFRA genes (whose proteins favor pluripotent cell differentiation to endometrial cells), and APOE (whose protein regulates the transport and metabolism of cholesterol, triglycerides and phospholipids in multiple tissues) and PLCG2 genes (whose protein creates 1D-myo-inositol 1,4,5-trisphosphate and diacylglycerol, two important second messengers).

CONCLUSIONS

Our findings suggest that women exposure to cosmetic and PCP-released chemicals might be associated with the promotion of cell cycle and cell differentiation as well as with lipid metabolism disruption in endometriotic tissue, three crucial signaling pathways in the development and progression of endometriosis. However, further studies should be accomplished to confirm these preliminary data.

Assessment of physical fitness during pregnancy: validity and reliability of fitness tests, and relationship with maternal and neonatal health - a systematic review

Objectives

To systematically review studies evaluating one or more components of physical fitness (PF) in pregnant women, to answer two research questions: (1) What tests have been employed to assess PF in pregnant women? and (2) What is the validity and reliability of these tests and their relationship with maternal and neonatal health?

Design

A systematic review.

Data sources

PubMed and Web of Science.

Eligibility criteria

Original English or Spanish full-text articles in a group of healthy pregnant women which at least one component of PF was assessed (field based or laboratory tests).

Results

A total of 149 articles containing a sum of 191 fitness tests were included. Among the 191 fitness tests, 99 (ie, 52%) assessed cardiorespiratory fitness through 75 different protocols, 28 (15%) assessed muscular fitness through 16 different protocols, 14 (7%) assessed flexibility through 13 different protocols, 45 (24%) assessed balance through 40 different protocols, 2 assessed speed with the same protocol and 3 were multidimensional tests using one protocol. A total of 19 articles with 23 tests (13%) assessed either validity (n=4), reliability (n=6) or the relationship of PF with maternal and neonatal health (n=16).

Conclusion

Physical fitness has been assessed through a wide variety of protocols, mostly lacking validity and reliability data, and no consensus exists on the most suitable fitness tests to be performed during pregnancy.

PROSPERO registration number

CRD42018117554.

Premenstrual and menstrual changes reported after COVID-19 vaccination: The EVA project

BACKGROUND

Menstrual disorders were not reported as a possible secondary effect in any of the clinical trials for the SARS-CoV-2 vaccines.

AIM

To describe the prevalence of perceived premenstrual and menstrual changes after COVID-19 vaccine administration.

DESIGN

Cross-sectional study.

METHODS

A total of 14,153 women (mean age 31.5 ± 9.3 years old) who had received the full course of vaccination at least three months earlier were included in this cross-sectional study. Data including the type of vaccine administered, perceived changes in the amount and duration of menstrual bleeding, presence of clots, cycle length, and premenstrual symptoms were collected through a retrospective online survey from June to September 2021.

RESULTS

Of the women who participated in this study, 3136 reported no menstrual changes and 11,017 (78% of the study sample) reported experiencing menstrual cycle changes after vaccination. In summary, women who reported menstrual changes after vaccination were older (overall p < 0.001) and slightly more smokers (p = 0.05) than women who did not report any changes. The most prevalent changes in relation to premenstrual symptoms were increased fatigue (43%), abdominal bloating (37%), irritability (29%), sadness (28%), and headaches (28%). The most predominant menstrual changes were more menstrual bleeding (43%), more menstrual pain (41%), delayed menstruation (38%), fewer days of menstrual bleeding (34.5%), and shorter cycle length (32%).

CONCLUSION

Women vaccinated against COVID-19 usually perceive mild menstrual and premenstrual changes. Future studies are warranted to clarify the physiological mechanisms behind these widely reported changes.

'Physio-EndEA' Study: A Randomized, Parallel-Group Controlled Trial to Evaluate the Effect of a Supervised and Adapted Therapeutic Exercise Program to Improve Quality of Life in Symptomatic Women Diagnosed with Endometriosis

Aim: The ‘Physio-EndEA’ study aims to explore the potential benefits of a therapeutic exercise program (focused on lumbopelvic stabilization and tolerance to exertion) on the health-related quality of life (HRQoL) of symptomatic endometriosis women. Design: The present study will use a parallel-group randomized controlled trial design. Methods: A total of 22 symptomatic endometriosis women will be randomized 1:1 to the Physio-EndEA or usual care groups. The ‘Physio-EndEA’ program will consist of a one-week lumbopelvic stabilization learning phase followed by an eight-week phase of stretching, aerobic and resistance exercises focused on the lumbopelvic area that will be sequentially instructed and supervised by a trained physiotherapist (with volume and intensity progression) and adapted daily to the potential of each participant. The primary outcome measure is HRQoL. The secondary outcome measures included clinician-reported outcomes (pressure pain thresholds, muscle thickness and strength, flexibility, body balance and cardiorespiratory fitness) and patient-reported outcomes (pain intensity, physical fitness, chronic fatigue, sexual function, gastrointestinal function and sleep quality). Discussion: Findings of this study will help to identify cost-effective non-pharmacological options (such as this exercise-based intervention) that may contribute to the improvement of HRQoL in symptomatic endometriosis women.

Limitations in Activities of Daily Living Among Spanish Women Diagnosed With Endometriosis

IMPORTANCE

Understanding the impact of endometriosis symptoms on patients' activities of daily living (ADLs) is a priority to establish effective and personalized intervention programs.

OBJECTIVE

To explore limitations in ADLs and instrumental ADLs (IADLs) and their association with pelvic pain (PP), chronic fatigue, and pain-catastrophizing thoughts among women with endometriosis.

DESIGN

Cross-sectional study.

SETTING

Spain.

PARTICIPANTS

Two hundred thirty women with endometriosis. Outcomes and Measures: Information regarding performance of ADLs (Barthel Index) and IADLs (Lawton-Brody questionnaire), PP intensity (Numeric Rating Scale), chronic fatigue (Piper Fatigue Scale), and pain-catastrophizing thoughts (Pain Catastrophizing Scale) was gathered. Multivariate regression analyses were created, and mediating effects of fatigue and pain-catastrophizing thoughts on the association between PP and ADL and IADL limitations were assessed.

RESULTS

The prevalence of limitations in at least one ADL and one IADL was 22.6% (95% confidence interval [CI] [17.2, 28.1]) and 39.1% (95% CI [32.8, 45.5]), respectively. Limitations in bowel continence, housework, shopping, and meal preparation were reported most frequently. Women reporting severe PP showed higher risk for ADL (odds ratio [OR] = 3.33, 95% CI [1.10, 10.10]) and IADL (OR = 7.99, 95% CI [2.86, 22.34]) limitations. Chronic fatigue and pain-catastrophizing thoughts were also positively related to ADL-IADL limitations, showing a mediating effect on the association between PP and ADL-IADL limitations.

CONCLUSIONS AND RELEVANCE

This study reveals the widespread presence of difficulties in ADL-IADL performance among women with endometriosis, with some symptoms underlying these difficulties in occupational performance. This study points to the need for cost-effective occupational therapy interventions for affected women. What This Article Adds: This research shows that the occupational performance of women with endometriosis is frequently impaired; therefore, the effectiveness of occupational therapy interventions should be addressed in the near future.

Association of Self-Reported Physical Fitness during Late Pregnancy with Birth Outcomes and Oxytocin Administration during Labour-The GESTAFIT Project

We explored (a) the associations between self-reported maternal physical fitness and birth outcomes; (b) whether self-reported maternal physical fitness (PF) is related to the administration of oxytocin to induce or stimulate labour. Pregnant women from the GESTAFIT project randomized controlled trial (n = 117) participated in this prospective longitudinal study. Maternal physical fitness was assessed through the International Fitness Scale at the 34th gestational week. Maternal and neonatal birth outcomes and oxytocin administration were collected from the obstetric medical records. Umbilical arterial and venous cord blood gas were analysed immediately after birth. Self-reported overall fitness, cardiorespiratory fitness, muscular strength and flexibility were not related to any maternal and neonatal birth outcomes (all p > 0.05). Greater speed-agility was associated with a more alkaline arterial (p = 0.04) and venous (p = 0.02) pH in the umbilical cord blood. Women who were administered oxytocin to induce or stimulate labour reported lower cardiorespiratory fitness (p = 0.013, Cohen's d = 0.55; 95% confidence interval (CI): 0.14, 0.93) and flexibility (p = 0.040, Cohen´s d = 0.51; 95% CI: 0.09, 0.89) compared to women who were not administered oxytocin. Greater maternal physical fitness during pregnancy could be associated with better neonatal birth outcomes and lower risk of needing oxytocin administration.

Cosmetic and personal care product use, urinary levels of parabens and benzophenones, and risk of endometriosis: results from the EndEA study

AIM

To explore the relationship of urinary concentrations of different congeners of benzophenones and parabens with the utilization of cosmetics and personal care products (PCPs) and their impact on the risk of endometriosis, and to evaluate the influence of oxidative stress on associations found.

METHODS

This case-control study comprised a subsample of 124 women (35 cases; 89 controls). Endometriosis was confirmed (cases) or ruled out (controls) by laparoscopy, with visual inspection of the pelvis and biopsy of suspected lesions (histological diagnosis). Urinary concentrations of benzophenone-1 (BP-1), benzophenone-3 (BP-3), 4-hydroxibenzophenone (4-OH-BP), methyl- (MeP), ethyl- (EtP), propyl- (PrP), and butyl-paraben (BuP), and biomarkers of oxidative stress [lipid peroxidation (TBARS) and total antioxidant power (TAP)] were quantified. Information was gathered on the frequency of use of cosmetics and PCPs. Associations between the frequency of cosmetics/PCP use, urinary concentrations of benzophenones and parabens, oxidative stress, and endometriosis risk were explored in logistic and linear multivariable regression analyses.

RESULTS

The frequency of utilization of certain cosmetics and PCPs was significantly associated with urinary concentrations of benzophenones and parabens. After adjustment for potential confounders, the risk of endometriosis was increased in women in the second versus first terciles of MeP (OR = 5.63; p-value<0.001), BP-1 (OR = 5.12; p-value = 0.011), BP-3 (OR = 4.98; p-value = 0.008), and ƩBPs (OR = 3.34; p-value = 0.032). A close-to-significant relationship was observed between TBARS concentrations and increased endometriosis risk (OR = 1.60, p-value = 0.070) and an inverse association between TAP concentrations and this risk (OR = 0.15; p-value = 0.048). Oxidative stress results did not modify associations observed between benzophenone/paraben exposure and endometriosis risk.

CONCLUSIONS

Our findings indicate that the frequency of cosmetics and PCP utilization is a strong predictor of exposure to certain benzophenone and paraben congeners. These compounds may increase the risk of endometriosis in an oxidative stress-independent manner. Further studies are warranted to corroborate these findings.

Impact of symptom burden on work performance status in Spanish women diagnosed with endometriosis

OBJECTIVE

To explore work performance status in Spanish women with endometriosis and to identify those endometriosis-related symptoms that potentially contribute to the reduced work performance.

DESIGN

Cross-sectional study.

SETTING

Spain.

POPULATION

Women with endometriosis working at enrolment (n = 148).

METHODS

Work performance status was assessed through the Work Role Functioning Questionnaire (WRFQ). Endometriosis-related symptoms (pelvic pain, catastrophizing thoughts related to pain, chronic fatigue, sleep quality, mood status, gastrointestinal discomfort and social support) were also evaluated through validated scales. Statistical analyses were performed through multivariate linear regression analyses.

MAIN OUTCOME MEASURES

Work performance status.

RESULTS

Median WRFQ score was 72.0, with the lowest scores found in demands related to worker's needs to manage the workday from beginning to end and those dynamic and static physical loads required in the conduct of work duties. Severe pelvic pain, depressive mood and poorer sleep quality was inversely related to work performance status (p-values <0.020). Finally, self-perceived social support was borderline associated with better work performance (p = 0.057). Considered together, these four psychosocial factors were responsible to explain the 37.9 % of the limitations on work performance observed in our study sample.

CONCLUSIONS

Spanish women with endometriosis reported lower WRQF scores (predominantly in work scheduling and physical demands) in comparison with previous studies on Spanish healthy adults. Psychosocial factors, including pelvic pain, sleep quality and depressive mood are related with work performance status. Thus, the effectiveness of physical and psychological rehabilitation programs in work productivity in women with endometriosis should be evaluated in the close future.

Association of Self-Reported Physical Fitness with Pregnancy Related Symptoms the GESTAFIT Project

We explored the association of physical fitness (PF) with pregnancy-related symptoms, at the 16th and 34th gestational weeks (g.w.). The International Fitness Scale and the Pregnancy Symptoms Inventory were employed to assess self-reported PF and pregnancy-related symptoms, respectively. At the 16th g.w. greater self-reported overall PF was associated with lower incidence of urinary frequency (p = 0.020); greater overall PF, cardiorespiratory fitness (CRF), muscular strength and speed-agility were associated with lower incidence of tiredness-fatigue (all, p < 0.05); greater overall PF and speed-agility were associated with lower incidence of poor sleep (both, p < 0.05); greater CRF and flexibility were associated with lower limitations by tiredness-fatigue (both, p < 0.05); and greater flexibility was associated with lower limitations by poor sleep (p = 0.021). At the 34th g.w. greater self-reported overall PF, CRF and muscular strength were associated with lower incidence of tiredness-fatigue (all, p < 0.05); greater CRF was associated with lower incidence of poor sleep (p = 0.019); and, greater flexibility was associated with lower incidence of increased vaginal discharge (p = 0.023). Adequate levels of PF, especially CRF, may help women to cope with the most endorsed pregnancy-related symptoms and its limitations, especially tiredness-fatigue and poor sleep.

Widespread Pain Hypersensitivity and Lumbopelvic Impairments in Women Diagnosed with Endometriosis

OBJECTIVE

To explore hypersensitivity to pain and musculoskeletal impairments in the lumbopelvic area in women with and without endometriosis.

METHODS

This cross-sectional study included 66 women (41 women with endometriosis and 25 healthy women). Pain and related catastrophizing thoughts were assessed through a numeric rating scale, pressure pain thresholds (PPTs), the slump test, and the Pain Catastrophizing Scale. Lumbopelvic muscles were evaluated through ultrasound imaging, flexor/extensor resistance tests, and the lumbopelvic stability test.

RESULTS

Women with endometriosis showed increased self-reported intensity of current pelvic pain (CuPP), reduced local PPTs (42.8-64.7% in the affected area, P-value <.001) and higher prevalence of lumbar nerve root impingement/irritation pain and catastrophizing thoughts (P-value ≤.002). Moreover, affected women showed decreased thickness of transversus abdominis, reduced resistance of flexor and extensor trunk muscles and lower lumbopelvic stability (P-values <.030). Endometriosis stage and severity of CuPP were related to worse results in these parameters.

CONCLUSIONS

The presence of pain sensitization signs and lumbopelvic impairments, more pronounced in patients with stage IV endometriosis and moderate/severe CuPP, warrants the development of rehabilitation interventions targeting pain and lumbopelvic impairments in women with endometriosis.

Objectively measured sedentary time and physical activity levels in Spanish pregnant women. Factors affecting the compliance with physical activity guidelines

The aims of this cross-sectional study were to describe objectively measured sedentary time (ST) and physical activity (PA) levels in Spanish pregnant women, to analyze the degree of compliance with PA guidelines during the early second trimester of pregnancy and to explore sociodemographic and clinical factors associated with meeting these PA guidelines. One hundred and thirty-four Caucasian pregnant women were recruited between October 2015 and October 2017 to participate in this study. Triaxial accelerometers were used to analyze ST andPA levels for seven consecutive valid days. Womenspent512 ± 92.1 minutes daily in sedentary behaviors, and 85 ± 108.2 minutes in moderate-to-vigorous physical activity (MVPA) in bouts of at least 10 minutes. They walked on average 7436 ± 2410steps per day. Only 22% of the study sample complied with the PA guidelines. Having an University degree was related with threefold higher odds of compliance with the PA guidelines (95% confidence interval: 0.096-0.913, p < .05). Binary logistic regressions showed that being primiparous was associated with fivefold higher odds of compliance with the PA guidelines (95% confidence interval 1.658-18.039, respectively, p < .01). Maternal age, BMI, marital status, working status, and previous miscarriages were not associated with compliance with PA guidelines. Pregnant women spent more than a third of the day in sedentary behaviors and the compliance with PA guidelines was less than desirable. Finally, not having an university degree or having children could be factors related to lower odds of compliance with these guidelines, and therefore require special attention from healthcare professionals.

Contribution of Chronic Fatigue to Psychosocial Status and Quality of Life in Spanish Women Diagnosed with Endometriosis

AIM

To analyze the levels of chronic fatigue in Spanish women with endometriosis and its relationship with their psychosocial status and quality of life (QoL).

METHODS

A total of 230 Spanish women with a clinical diagnosis of endometriosis were recruited. Chronic fatigue (Piper Fatigue Scale) and pelvic pain (Numeric Rating Scale) were evaluated. An on-line battery of validated scales was used to assess psychosocial status [Hospital Anxiety and Depression Scale, Scale for Mood Assessment, Pain Catastrophizing Scale, Pittsburgh Sleep Quality Index, Gastrointestinal Quality of Life Index, Female Sexual Function Index and Medical Outcomes Study-Social Support Survey] and QoL [Endometriosis-Health Profile questionnaire-30]. Associations between fatigue and both psychosocial and QoL outcomes were explored through multivariate regression models.

RESULTS

One-third and one-half of women showed moderate and severe fatigue, respectively. Fatigue was associated with higher anxiety and depression, poorer sleep quality, poorer sexual functioning, worse gastrointestinal health, higher catastrophizing thoughts, higher anger/hostility scores and lower QoL (p-values < 0.050). Moreover, fatigue and catastrophizing thoughts showed a mediating effect on the association between pelvic pain and QoL.

CONCLUSION

This work reveals the important role of fatigue in the association between pain, psychosocial status, and QoL of Spanish women with endometriosis.

Chronic Fatigue, Physical Impairments and Quality of Life in Women with Endometriosis: A Case-Control Study

AIM

To explore endometriosis-related fatigue (ERF), health-related fitness, sleep quality, and health-related quality of life (HRQoL) in women with endometriosis in comparison with matched controls.

METHODS

Twenty-five affected women and twenty-five age and height-matched women without endometriosis were included. ERF was assessed through the Piper Fatigue Scale; health-related fitness was assessed through the Schöber, flamingo, and 6-min walking tests and dynamometry; and body composition was assessed through impedanciometry. Self-perceived physical fitness, sleep quality, and HRQoL were assessed through the International Fitness Scale, the Pittsburgh Sleep Quality Index, and the 12-item Short Form Health Survey, respectively.

RESULTS

Affected women exhibited higher levels of ERF than controls, increased fat mass, and physical deconditioning (reduced back strength, lumbar flexibility, body balance, and functional capacity, p-values < 0.050). Moreover, cases also had poorer perceived physical fitness, sleep quality, and HRQoL (p-value < 0.050). Finally, we observed deteriorated health-related fitness, sleep quality, and HRQoL in those women with endometriosis with higher levels of ERF.

CONCLUSIONS

This study constitutes the first evidence that women with endometriosis describe a generalized physical deconditioning, even more pronounced in affected women with higher levels of ERF. Further studies assessing the efficacy of rehabilitation interventions to face these physical impairments in women with endometriosis are warranted.

Menstrual blood concentrations of parabens and benzophenones and related factors in a sample of Spanish women: An exploratory study

AIM

To evaluate concentrations of parabens (PBs) and benzophenones (BzPs) in menstrual blood and explore related sociodemographic/lifestyle factors, and to compare between menstrual and peripheral blood concentrations in a subset of samples.

MATERIAL AND METHODS

Concentrations of 4 PBs [methyl- (MeP), ethyl- (EtP), propyl- (PrP) and butyl-paraben (BuP)] and 6 BzPs [BzP-1, BzP-2, BzP-3, BzP-6, BzP-8 and 4-OH-BzP] were determined in menstrual blood from 57 women and in both menstrual and peripheral blood samples from 12 women, all healthy Spanish women of reproductive age. Socio-demographic characteristics and lifestyle habits [diet and use of cosmetics and personal care products (PCPs)] were gathered using an online questionnaire. Spearman correlation analysis was performed to examine the relationship between menstrual and peripheral blood concentrations, while multivariable linear regression was used to identify potential explanatory variables for menstrual PB and BzP concentrations.

RESULTS

Globally, all menstrual blood samples had detectable levels of ≥3 compounds, and 52.6% of the samples contained ≥6 compounds. MeP, PrP, and BzP-3 were the most frequently detected compounds (detection frequencies >90.0%), with median concentrations of 1.41, 0.63, and 1.70 ng/mL of menstrual blood, respectively. Age, the use of PCPs, and consumption of some food items (meat, pasta, cheese, or dairy products) were related to the menstrual blood concentrations of some PBs/BzPs. Serum:menstrual blood ratios of PBs/BzPs ranged from 1.7 to 3.6, with no inter-matrix correlations.

CONCLUSIONS

This study reveals, to our knowledge for the first time, the widespread presence of several PBs and BzPs in intimate contact with gynecological tissues, although their concentrations in menstrual blood were not correlated with those in peripheral blood from the same women. These results shed light on the information provided by the menstrual blood as a potential matrix for characterizing exposure to PBs and BzPs, whose consequences for women's reproductive health need to be addressed.

Association of objectively measured physical fitness during pregnancy with maternal and neonatal outcomes. The GESTAFIT Project

Aim

To analyse i) the association of physical fitness during early second trimester and late pregnancy with maternal and neonatal outcomes; and ii) to investigate whether physical fitness is associated with the type of birth (vaginal or caesarean section).

Methods

Pregnant women from the GESTAFIT Project (n = 159) participated in this longitudinal study. Maternal physical fitness including upper- and lower-body strength, cardiorespiratory fitness (CRF) and flexibility were measured through objective physical fitness tests at the 16^th and 34^th gestational weeks. Maternal and neonatal outcomes were collected from obstetric medical records. Umbilical arterial and venous blood gas pH and partial pressure of carbon dioxide (PCO₂) and oxygen (PO₂), were assessed.

Results

At the 16^th week, greater upper-body muscle strength was associated with greater neonatal birth weight (r = 0.191, p<0.05). Maternal flexibility was associated with a more alkaline arterial pH (r = 0.220, p<0.05), higher arterial PO₂ (r = 0.237, p<0.05) and lower arterial PCO₂ (r = -0.331, p<0.01) in umbilical cord blood. Maternal CRF at the 16^th gestational week was related to higher arterial umbilical cord PO₂ (r = 0.267, p<0.05). The women who had caesarean sections had lower CRF (p<0.001) at the 16^th gestational week and worse clustered overall physical fitness, both at the 16^th (-0.227, p = 0.003, confidence interval (CI): -0.376, -0.078) and 34^th gestational week (-0.223; p = 0.018; CI: -0.432, -0.015) compared with the women who had vaginal births.

Conclusion

Increasing physical fitness during pregnancy may promote better neonatal outcomes and is associated with a decrease in the risk of caesarean section.

This trial was registered at ClinicalTrials.gov (NCT02582567) on October 20, 2015.

Association of Urinary Levels of Bisphenols A, F, and S with Endometriosis Risk: Preliminary Results of the EndEA Study

Aim: The aim of this study was to explore associations of urinary concentrations of bisphenols A (BPA), S (BPS), and F (BPF) and of thiobarbituric acid reactive substances (TBARS) with the risk of endometriosis in women of childbearing age. Methods: This case-control study enrolled 124 women between January 2018 and July 2019: 35 women with endometriosis (cases) and 89 women without endometriosis undergoing abdominal surgery for other reasons (controls). Endometriosis was diagnosed (cases) or ruled out (controls) by laparoscopic inspection of the pelvis and the biopsy of suspected lesions (histological diagnosis). Fasting urine samples were collected before surgery to determine concentrations of BPA, BPS, BPF, and TBARS. Associations of bisphenol and TBARS concentrations with endometriosis risk were explored with multivariate logistic and linear regression analyses. Results: After adjustment for urinary creatinine, age, BMI, parity, and residence, endometriosis risk was increased with each 1 log unit of BPA [OR 1.5; 95%CI 1.0-2.3] and Σbisphenols [OR 1.5; 95%CI 0.9-2.3] but was not associated with the presence of BPS and BPF. Classification of the women by tertiles of exposure revealed statistically significant associations between endometriosis risk and the second tertile of exposure to BPA [OR 3.7; 95%CI 1.3-10.3] and Σbisphenols [OR 5.4; 95%CI 1.9-15.6]. In addition, TBARS concentrations showed a close-to-significant relationship with increased endometriosis risk [OR 1.6; 95%CI 1.0-2.8], and classification by TBARS concentration tertile revealed that the association between endometriosis risk and concentrations of BPA [OR 2.0; 95%CI 1.0-4.1] and Σbisphenols [OR 2.2; 95%CI 1.0-4.6] was only statistically significant for women in the highest TBARS tertile (>4.23 μM). Conclusion: Exposure to bisphenols may increase the risk of endometriosis, and oxidative stress may play a crucial role in this association. Further studies are warranted to verify these findings.

International Fitness Scale-IFIS: Validity and association with health-related quality of life in pregnant women

This study aimed (a) to examine the construct validity of the International Fitness Scale (IFIS) to discriminate between different objectively measured physical fitness levels in pregnant women and (b) to assess the extent to which IFIS is able to discriminate between pregnant women with different levels of health-related quality of life (HRQoL). A total of 159 pregnant women were involved in the GESTAtion and FITness project: 106 pregnant women (mean age 32.7, SD 4.4 years) were included. Self-reported physical fitness-that is, cardiorespiratory fitness, muscular strength, flexibility, and overall fitness-was assessed with the IFIS. Physical fitness was objectively measured using the Bruce test, the handgrip strength test and the back-scratch test. The HRQoL was assessed with the 36-item Short Form Health Survey (SF-36). Higher self-reported physical fitness measured with IFIS was associated with higher objectively measured physical fitness (P < .05). There was a linear association so that higher self-reported physical fitness (ie, IFIS; regardless of the fitness component) was related to greater General Health dimension scores (P < .05). Moreover, higher self-reported physical fitness (all components except muscular strength) was associated with better Physical Functioning, lower Bodily Pain and higher Vitality scores (ie, SF-36 components). This linear trend was not seen for objectively measured physical fitness. The results of this study suggest that IFIS might be a useful tool for identifying pregnant women with low or very low physical fitness and with low quality of life health-related. Further research should elucidate whether IFIS can identify women with pregnancy complications before it can be implemented in clinical practice.

Bisphenol A and adiposity measures in peripubertal boys from the INMA-Granada cohort

INTRODUCTION

Childhood obesity is one of the most serious public health challenges of our times. Although an important body of experimental evidence highlights the obesogenic potential of endocrine disruptors such as bisphenol A (BPA), the epidemiological evidence remains inconclusive and limited.

OBJECTIVE

To assess associations between urinary BPA concentrations and several adiposity measures in peripubertal boys from the Environment and Childhood (INMA) cohort in Granada, Spain.

MATERIAL AND METHODS

BPA concentrations were determined in spot urine samples from 298 boys aged 9-11, and their weight, height, waist circumference, and percentage body fat mass were measured. Overweight/obesity was defined as BMI z-score ≥85th percentile and abdominal obesity as waist-to-height ratio (WHtR) ≥0.5. Associations were assessed using multivariable linear and logistic regression models.

RESULTS

In adjusted models, each natural log-unit increase in urinary BPA concentrations was associated with higher BMI z-score (β = 0.22; 95%CI = 0.03, 0.41) and increased odds of overweight/obesity (OR = 1.46; 95%CI = 1.05, 2.05). Children with higher BPA concentrations had higher WHtR values (β = 0.007; 95%CI = -0.001, 0.015), and BPA was associated with a greater risk of abdominal obesity (OR = 1.45; 95%CI = 1.03, 2.06). No associations were found with % body fat mass.

CONCLUSIONS

BPA may exert an obesogenic effect in peripubertal boys, potentially increasing the risk of overweight/obesity, especially abdominal obesity. However, these results should be interpreted with caution given the modest sample size and the possibilities of reverse causality and residual confounding by diet and lifestyle patterns.

Association of sedentary time and physical activity during pregnancy with maternal and neonatal birth outcomes. The GESTAFIT Project

AIM

(a) To analyse the association of objectively measured sedentary time (ST) and physical activity (PA) during early second trimester of pregnancy with maternal and neonatal birth outcomes; (b) to explore if ST and PA differ between women with vaginal or caesarean section deliveries.

METHODS

Ninety-four Caucasian pregnant women (32.9 ± 4.6 years old) participated in this prospective longitudinal study. Triaxial accelerometers were used to assess ST and PA intensity levels for seven consecutive days during second trimester of pregnancy. Birth data were collected from the obstetric medical records. Umbilical cord arterial and venous blood gas (pH, partial pressure of carbon dioxide and oxygen, and oxygen saturation) were analysed after birth.

RESULTS

After adjusting for potential confounders, greater ST was associated with higher arterial and venous cord blood partial pressure of carbon dioxide and more acidic arterial and venous pH (all, P < 0.01). Moderate PA, moderate-to-vigorous PA (MVPA), total PA and steps per day were positively associated with arterial cord blood oxygen saturation (all P < 0.05). Steps per day were inversely associated with gestational age at birth (P < 0.01), and duration of first stage of labor (P < 0.05). Total and light PA were associated with a more alkaline pH in umbilical vein (all, P < 0.01). Vigorous PA was inversely associated with the Apgar score (P < 0.01). No significant differences were observed in ST and PA levels between women with vaginal and women with caesarean section deliveries (all, P > 0.10).

CONCLUSION

Increasing PA and decreasing ST during pregnancy might promote better maternal and neonatal birth markers.

Anogenital distance and reproductive outcomes in 9- to 11-year-old boys: the INMA-Granada cohort study

BACKGROUND

Studies examining the association of anogenital distance (AGD), a biomarker of prenatal androgen exposure, with sexual development in children are lacking.

OBJECTIVE

To assess the association between AGD measures and reproductive outcomes, including puberty onset, testicular volume, reproductive hormone levels, and urogenital malformations in boys aged 9-11 years.

MATERIALS AND METHODS

A cross-sectional study was conducted among children belonging to the Spanish Environment and Childhood (INMA) Project, a population-based birth cohort study. The present sample included 279 boys for whom data were available on AGD, pubertal stage, testicular volume, and relevant covariates. Out of the boys with AGD data, 187 provided a blood sample for hormone analysis. AGD was measured from the center of the anus to the base of the scrotum. Pubertal development was assessed according to Tanner stage of genital development (G1-G5), and testicular volume was measured with an orchidometer.

RESULTS

After adjusting for potential confounders, logistic regression analysis showed that AGD was positively associated with testicular volume but not with Tanner stage (>G1 vs. G1), serum hormone levels, or undescended testis. Regardless of their age, body mass index, and Tanner stage (G1 or >G1), boys with longer AGD showed increased odds of a testicular volume >3 mL (OR = 1.06, 95%CI = 1.00-1.19 per 10% increment in AGD; and OR = 3.14, 95%CI = 0.99-9.94 for AGD >42 mm vs. <33 mm).

DISCUSSION

Longer AGD was associated with testicular growth, an indicator of gonadarche, but not with other reproductive outcomes.

CONCLUSIONS

Although AGD was positively associated with testicular volume, it remains unclear whether AGD predicts testis size at puberty or is related to puberty onset.

Thyroid status and its association with cognitive functioning in healthy boys at 10 years of age

OBJECTIVE

Thyroid hormones (THs) are crucial for the correct maturation of the CNS and the neurodevelopment of the child. We aimed to investigate the association of TSH and free thyroxine (FT4) levels with cognitive functioning in children from the INMA-Granada cohort studied during their follow-up at the age of 9-11 years.

DESIGN

We evaluated 300 children from the original cohort, which comprised 668 eligible mother-son pairs recruited at birth from 2000 to 2002 in Granada (Spain).

METHODS

FT4 and TSH concentrations were measured, and cognitive development was assessed using neuropsychological tests (n=187). Children with chronic disease related to thyroid function and/or cognitive development were excluded.

RESULTS

Median TSH and FT4 levels were 3.1 μIU/ml and 1.2 ng/dl respectively. In multivariable regression analyses adjusted for maternal and child characteristics, children with TSH levels in the top tertile had worse verbal comprehension and immediate and long-term recall. Children with FT4 levels in the top tertile had better attention and lower impulsivity and were at a lower risk of scoring below the 20th percentile in intelligence quotient (OR=0.24; 95% CI=0.08-0.74; P=0.013) and in abstract reasoning ability (OR=0.28; 95% CI=0.09-0.88; P=0.029).

CONCLUSION

Our findings indicate that circulating THs and TSH may in the top tertile have an impact on cognitive functions; thus, higher TSH slightly but significantly increased the risk of a lower score in certain neuropsychological tests.

Characterization of indoor extremely low frequency and low frequency electromagnetic fields in the INMA-Granada cohort

OBJECTIVE

To characterize the exposure to electric fields and magnetic fields of non-ionizing radiation in the electromagnetic spectrum (15 Hz to 100 kHz) in the dwellings of children from the Spanish Environment and Childhood-"INMA" population-based birth cohort.

METHODOLOGY

The study sample was drawn from the INMA-Granada cohort. Out of 300 boys participating in the 9-10 year follow-up, 123 families agreed to the exposure assessment at home and completed a specific ad hoc questionnaire gathering information on sources of non-ionizing radiation electric and magnetic fields inside the homes and on patterns of use. Long-term indoor measurements were carried out in the living room and bedroom.

RESULTS

Survey data showed a low exposure in the children's homes according to reference levels of the International Commission on Non-Ionizing Radiation Protection but with large differences among homes in mean and maximum values. Daytime electrostatic and magnetic fields were below the quantification limit in 78.6% (92 dwellings) and 92.3% (108 dwellings) of houses, with an arithmetic mean value (± standard deviation) of 7.31±9.32 V/m and 162.30±91.16 nT, respectively. Mean magnetic field values were 1.6 lower during the night than the day. Nocturnal electrostatic values were not measured. Exposure levels were influenced by the area of residence (higher values in urban/semi-urban versus rural areas), type of dwelling, age of dwelling, floor of the dwelling, and season.

CONCLUSION

Given the greater sensitivity to extremely low-frequency electromagnetic fields of children and following the precautionary principle, preventive measures are warranted to reduce their exposure.