Symptomatic Endometriosis Research Articles

Laparoscopic Nerve Detrapment and Neurolysis of Somatic Pelvic Nerves in Deep Endometriosis: Prospective Study of 433 Patients

<h3>Study Objective</h3> To review efficacy and feasibility of laparoscopic decompression and neurolysis for cases of endometriosis involving sacral plexus and/or somatic nerves causing somatic compression and ano-genital pain on a large case series. <h3>Design</h3> Prospective case-series, single-centre, single-surgeon study on 433 patients. In a 7-year period. <h3>Setting</h3> Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona - Italy; 7-years period <h3>Patients or Participants</h3> 433 patients with deep infiltrating endometriosis complaining of recurrent sciatica and ano-genital pain in addition to "usual" endometriosis symptoms <h3>Interventions</h3> (A) medial approach for deep pelvic endometriosis with rectal and/or parametrial involvement extending to pelvic wall and somatic nerve; (B) lateral approach for isolated endometriosis of pelvic wall and somatic nerves. All the procedures were performed by a gynecologic pelvic surgeon skilled in neuro-anatomy (M.C.) <h3>Measurements and Main Results</h3> All the treated patients showed laparoscopic and pathology report evidence of compression above the somatic nervous structures, requiring decompression, whereas in 145 (33,5%) patients, there was clear infiltration of those structures, deepening to the perineural and axonal planes. Complete relief from neurologic symptoms was achieved in all patients at 6 months after surgery, post-operative neuritis was reported in 62 patients (14.3%). <h3>Conclusion</h3> Pelvic wall spread of deep infiltrating endometriosis might be more usual than thought. Laparoscopic retroperitoneal nerve-sparing approach to endometriosis extending to the pelvic wall with somatic nerve compression proved to be a feasible and safe procedure, effective in pain relief, recovery of impaired neurological functions and neuromotoric impairment motoric symptoms of the pelvis and the leg related to endometriosis. It should be limited to referral laparoscopic centres lead by surgical neuro-anatomy skilled surgeons.

8918 Relationship between Brainwave Biomarker and Endometriosis Pain Symptoms before and after Laparoscopic Surgery

Study Objective The purpose of this study was to explore the relationship between peak alpha frequency (PAF), an electroencephalogram (EEG)-based biomarker for pain sensitivity, and pain symptoms for patients undergoing laparoscopic surgery for endometriosis. Design Prospective observational pilot study. Setting Large academic hospital. Patients or Participants Patients (n=18) undergoing laparoscopic endometriosis excision surgery were invited to participate. Participants enrolled before surgery and were followed up to 6 weeks postoperatively. Interventions N/A. Measurements and Main Results Participants completed a physical exam, quantitative EEG, and symptom questionnaires before and after surgery (2-weeks and/or 6-weeks post-op). We hypothesized that PAF would increase after surgery indicating an improvement in pain symptoms. To measure PAF, EEG data was collected using a BrainBit dry electrode headset. Patient-reported outcome measures for pain and endometriosis symptoms were collected using Modified Brief Pain Inventory (BPI), Short-form McGill Pain Questionnaire 2, Endometriosis Health Profile 30, and Patient Health Questionnaire 9. Descriptive statistics and Spearman correlation coefficients were calculated for each measure before and after surgery. Overall, we observed an increase in PAF following surgery, where median values shifted from 9.88 Hz preoperatively (IQR 9.84 - 9.99 Hz) to 10.01 Hz postoperatively (IQR 9.84 - 10.06 Hz). Preliminary results suggest that preoperative PAF is moderately inversely correlated with average preoperative pain reported using BPI (rho = -0.52) but is not strongly correlated with other measures. Conclusion While the reported results are underpowered to determine statistical significance, PAF was found to increase six weeks after endometriosis surgery. Furthermore, preoperative PAF appears to be inversely correlated with preoperative pain symptoms, suggesting that PAF is a useful measure for tracking pain in patients with endometriosis. Additional investigation and follow-up is needed to determine how PAF relates to long-term surgical outcomes for patients with chronic pelvic pain. The purpose of this study was to explore the relationship between peak alpha frequency (PAF), an electroencephalogram (EEG)-based biomarker for pain sensitivity, and pain symptoms for patients undergoing laparoscopic surgery for endometriosis. Prospective observational pilot study. Large academic hospital. Patients (n=18) undergoing laparoscopic endometriosis excision surgery were invited to participate. Participants enrolled before surgery and were followed up to 6 weeks postoperatively. N/A. Participants completed a physical exam, quantitative EEG, and symptom questionnaires before and after surgery (2-weeks and/or 6-weeks post-op). We hypothesized that PAF would increase after surgery indicating an improvement in pain symptoms. To measure PAF, EEG data was collected using a BrainBit dry electrode headset. Patient-reported outcome measures for pain and endometriosis symptoms were collected using Modified Brief Pain Inventory (BPI), Short-form McGill Pain Questionnaire 2, Endometriosis Health Profile 30, and Patient Health Questionnaire 9. Descriptive statistics and Spearman correlation coefficients were calculated for each measure before and after surgery. Overall, we observed an increase in PAF following surgery, where median values shifted from 9.88 Hz preoperatively (IQR 9.84 - 9.99 Hz) to 10.01 Hz postoperatively (IQR 9.84 - 10.06 Hz). Preliminary results suggest that preoperative PAF is moderately inversely correlated with average preoperative pain reported using BPI (rho = -0.52) but is not strongly correlated with other measures. While the reported results are underpowered to determine statistical significance, PAF was found to increase six weeks after endometriosis surgery. Furthermore, preoperative PAF appears to be inversely correlated with preoperative pain symptoms, suggesting that PAF is a useful measure for tracking pain in patients with endometriosis. Additional investigation and follow-up is needed to determine how PAF relates to long-term surgical outcomes for patients with chronic pelvic pain.

Urine Double Trouble: A Case of Voiding Dysfunction Following Gynecologic Surgery

<h3>Study Objective</h3> We present a surgical video that demonstrates postoperative voiding dysfunction following laparoscopic excision of deeply infiltrative endometriosis with rectal involvement. This video highlights the relevant anatomy and physiology involved in postoperative voiding dysfunction. <h3>Design</h3> Surgical Educational Video. <h3>Setting</h3> Tertiary Referral Center at an Academic Residency Program. <h3>Patients or Participants</h3> 37-yo G1P1 with symptomatic deep endometriosis, presenting with a 4cm deeply infiltrative endometriotic rectal nodule. <h3>Interventions</h3> Laparoscopic excision of deeply infiltrative endometriosis and excision of rectal nodule with low anterior bowel resection. <h3>Measurements and Main Results</h3> Excision of deep infiltrating endometriosis within the pararectal fossae and parametria as well as resection of 4 cm rectal endometriotic lesion. Postoperative urinary retention led to bladder overdistension injury and subsequent chronic voiding dysfunction. <h3>Conclusion</h3> Postoperative voiding dysfunction and bladder overdistension is a common postoperative injury that can have long-term consequences. Gynecologic patients may present with multiple risk factors. Understanding the pathophysiology, surgical anatomy, signs and symptoms, and immediate treatment recommendations is important for both the generalist and specialist gynecologist.

Anatomical and Surgical Considerations for Ileocolic Endometriosis

<h3>Study Objective</h3> We aim to review the incidence, location, and management of bowel endometriosis, as well as demonstrate anatomical considerations for surgical resection of ileocolic lesions. <h3>Design</h3> This video briefly reviews the background of bowel endometriosis and indications for surgical excision. We present a case of a patient diagnosed with a symptomatic ileocolic endometriosis lesion and review the preoperative imaging. We demonstrate the steps of a medial-to-lateral surgical approach for ileocolic resection and highlight the relevant surgical anatomy. <h3>Setting</h3> This procedure was performed at a large academic institution with a multidisciplinary team of minimally invasive gynecologists and colorectal surgeons. <h3>Patients or Participants</h3> The case presented is a 44-year-old female with a known history of stage IV endometriosis. She presented with acute abdominal pain, nausea and vomiting associated with her menses, and was found to have a small bowel obstruction from a 3cm lesion thought to be an endometrioma. She failed conservative management and was thoroughly counseled about the need for surgical intervention. Pelvic MRI was performed for preoperative planning. <h3>Interventions</h3> Laparoscopic ileocolic resection is performed utilizing a medial-to-lateral approach for excision of a symptomatic 3cm ileocecal endometrioma. <h3>Measurements and Main Results</h3> Successful excision of the endometrioma with a side-to-side ileocolic anastomosis was performed with resolution of the patient's symptoms. <h3>Conclusion</h3> The bowel is the most common extragenital site for endometriosis to occur, with the highest rate of lesions located in the rectosigmoid colon. Lesions can be either superficial or deeply infiltrative and can lead to a range of symptoms. A serious sequela of bowel endometriosis includes bowel obstruction requiring surgical intervention. We present a case of a 44-year-old female with acute bowel obstruction from a 3cm ileocecal endometrioma and demonstrate a medial-to-lateral surgical technique for ileocolic resection while emphasizing the relevant anatomical structures.

Laparoscopic-Assisted Transanal Total Mesorectal Excision for a Patient with Bowel Endometriosis

<h3>Study Objective</h3> To explore a less-invasive surgical route for patient with bowel endometriosis to undergo segmental colorectal resection. <h3>Design</h3> A case report. <h3>Setting</h3> A university-based tertiary hospital. <h3>Patients or Participants</h3> A 34-year-old female was readmitted two years post-conservative surgery for endometriosis due to consistent digestive dysfunction symptoms. A 3-cm nodule within the muscle layer of lower rectal wall was identified by pelvic MRI. <h3>Interventions</h3> A laparoscopic-assisted transanal total mesorectal excion (TaTME) was performed (a 4-minute video clip included). <h3>Measurements and Main Results</h3> The patient was placed in a Trendelenburg position. For the laparoscopic step, the rectovaginal space was dissected. Lateral, posterior and anterior experitoneal rectal and left sigmoid dissection was performed adequately. Pay attention to protect the ureter and hypogastric nerve. An articulated endoscopic cutter was used to transect the distal rectal segment. For the trans-anal step, the rectal lumen was irrigated, the distal end of rectum was grasped out through anus. A safe margin down to the endometriotic lesion was chosen, 3-0 suture was placed followed by reloaded staplers to close the distal rectal lumen. TME was performed utilizing a "bottom up" approach. An avil was placed inside of proximal sigmoid. Rectosigmoid anastomosis completed successfully by using a circular stapler. No protective ileostomy was adopted. The surgery was uncomplicated with minimal blood loss. Significant improvement of bowel symptoms was reported within the first month postoperatively. During 3-year follow-up period no recurrence of endometriosis or digestive dysfunction symptoms was observed. <h3>Conclusion</h3> As a novel technique, laparoscopic-assisted TaTME shows advantage over laparoscopic surgery, such as better visualization of the distal resection margin while avoiding a bigger abdominal scar. Young women with colorectal endometriosis can benefit for more radical but less invasive surgical outcome. An experienced multidisciplinary team making comprehensive evaluation and discussion before surgery will ensure this technically highly demanding operation feasible and safe.

Maintenance Dienogest Therapy Following Adjuvant GnRH Agonist Treatment after Uterus-Sparing Surgery in Adenomyosis

<h3>Study Objective</h3> To investigate the safety and efficacy of combined adjuvant gonadotropin-releasing hormone agonist (GnRH-a) treatment followed by maintenance Dienogest (DNG) therapy after uterus-sparing surgery. <h3>Design</h3> A retrospective single-center observational study (Canadian Task Force classification II-2). <h3>Setting</h3> An academic tertiary hospital. <h3>Patients or Participants</h3> A total of 190 patients with severe symptomatic adenomyosis underwent uterus-sparing surgery between January 2010 and June 2020. Of these patients, 90 were eligible for this retrospective cohort study. <h3>Interventions</h3> Forty-six patients (reference group) received adjuvant 6-month GnRH-a therapy alone after uterus-sparing surgery, and 44 patients (maintenance group) received postoperative 6-month GnRH-a treatment followed by maintenance DNG therapy (2 mg per day orally). The median follow-up period was 18 months. The study was analyzed with the use of generalized estimating equations (GEE). <h3>Measurements and Main Results</h3> At baseline, the characteristics of patients in each group were comparable. Compared to the reference group, the maintenance group had a statistically significant improvement in the visual analog scale score of dysmenorrhea, hemoglobin level, and uterine volume from baseline to 18 months after uterus-sparing surgery. The symptom recurrence rate was statistically significantly lower in the maintenance group than in the reference group (4.6% vs. 37.0%, <i>P</i><0.001). <h3>Conclusion</h3> The findings of this study suggest that combined adjuvant GnRH-a treatment and maintenance DNG therapy provided a safe and an effective short-term therapy after uterus-sparing surgery for adenomyosis.

8942 Development of a Novel Physical Exam for Patients Undergoing Laparoscopic Excision of Endometriosis

Study Objective To create and validate a standardized physical exam for patients undergoing laparoscopic excision of endometriosis surgery. Design Prospective observational feasibility study. Setting Large academic hospital. Patients or Participants Patients (n = 17) undergoing operative laparoscopy for management of endometriosis were consented and enrolled before surgery and followed up to 6 weeks postoperatively. This is an ongoing study with plan to enroll 30 participants. Interventions N/A. Measurements and Main Results We developed a physical exam that included numerical pain ratings from regions typically affected by endometriosis. The complete exam was conducted at the preoperative visit and a modified version was performed at 2-week and 6-week postoperative visits for patient comfort. Composite pain scores were calculated from the modified physical exam to quantify physical symptom severity. These scores were compared to a validated patient-reported outcome measure for pain, Brief Pain Inventory (BPI). The composite physical exam pain scores improved progressively following surgery, decreasing from a median of 22.5 (IQR 14-34.29) preoperatively to 11.5 (IQR 5.26-16) at 6-weeks postoperative (p=0.072 using Wilcoxon signed-rank test). This was consistent with a decrease in average pain reported using BPI (p= 0.063). Spearman correlation coefficients showed a moderate correlation between preoperative physical exam scores and BPI (rho = 0.5419). Conclusion Currently, there is no consensus physical exam to describe symptom severity for patients with chronic pelvic pain. We report a novel standard physical exam to describe endometriosis symptom severity. Even though our results were not statistically significant, we observed a reduction in physical exam pain scores reported before and after surgery, which correlated with pain scores collected using a validated pain questionnaire. This proposed exam could be used to objectively follow up success of endometriosis excision. Our study is currently underpowered and anticipate achieving statistical significance after completing recruitment. To create and validate a standardized physical exam for patients undergoing laparoscopic excision of endometriosis surgery. Prospective observational feasibility study. Large academic hospital. Patients (n = 17) undergoing operative laparoscopy for management of endometriosis were consented and enrolled before surgery and followed up to 6 weeks postoperatively. This is an ongoing study with plan to enroll 30 participants. N/A. We developed a physical exam that included numerical pain ratings from regions typically affected by endometriosis. The complete exam was conducted at the preoperative visit and a modified version was performed at 2-week and 6-week postoperative visits for patient comfort. Composite pain scores were calculated from the modified physical exam to quantify physical symptom severity. These scores were compared to a validated patient-reported outcome measure for pain, Brief Pain Inventory (BPI). The composite physical exam pain scores improved progressively following surgery, decreasing from a median of 22.5 (IQR 14-34.29) preoperatively to 11.5 (IQR 5.26-16) at 6-weeks postoperative (p=0.072 using Wilcoxon signed-rank test). This was consistent with a decrease in average pain reported using BPI (p= 0.063). Spearman correlation coefficients showed a moderate correlation between preoperative physical exam scores and BPI (rho = 0.5419). Currently, there is no consensus physical exam to describe symptom severity for patients with chronic pelvic pain. We report a novel standard physical exam to describe endometriosis symptom severity. Even though our results were not statistically significant, we observed a reduction in physical exam pain scores reported before and after surgery, which correlated with pain scores collected using a validated pain questionnaire. This proposed exam could be used to objectively follow up success of endometriosis excision. Our study is currently underpowered and anticipate achieving statistical significance after completing recruitment.

Establishment and validation of a rodent model of endometriosis to evaluate the effect of new therapeutic strategies

Objectives: Endometriosis is a common disease that affects about 10% - 15% of women in their reproductive years worldwide with no curative treatment. The most common symptom of endometriosis is debilitating pelvic/abdominal pain. Current therapeutic options have limited insight into the disease mechanism and include drugs and/or surgery, which may be ineffective over the long term with unwanted side effects. We aimed at establishing a translational rodent endometriosis model that can be used to identify novel therapies. The validity of the model was confirmed by investigating the effect of the clinically-used GnRH agonist, leuprolide. Methods: Endometriosis was induced by a surgical procedure in adult non-pregnant female Sprague Dawley rats in the diestrus or estrus stage (cycle determination by vaginal smear). One group of rats received a subcutaneous injection of leuprolide at 1mg/kg, every 4 weeks. Following the treatment period, we performed a direct assessment of the endometriosis-induced abdominal pain using the Von-Frey method and spontaneous pain using the abdominal licking test. Then, the lesions were excised and measured. Results: Abdominal pain threshold was decreased by more than 2 fold in rats with surgically-induced endometriosis compared to sham rats. Leuprolide treatment significantly increased the threshold force required to elicit a behavioral withdrawal response in rats suffering from endometriosis. The observed pelvic floor mechanical hyperalgesia has not been correlated to the growth of endometriosis lesions. The hormonal cycle at the surgery induction influenced the endometriosis lesions growth. Leuprolide significantly inhibited the growth of endometriosis-like lesions. Conclusions: we have established, based on previously reported rodent models, a model of endometriosis-associated pain that responds to clinically active drugs and can, therefore, be used to identify novel therapies and investigate some of the pathophysiological mechanisms involved in endometriosis.

“Better late than never but never late is better”, especially in young women. A multicenter Italian study on diagnostic delay for symptomatic endometriosis

Purpose The aim of the study was to assess the length of diagnostic delay of symptomatic endometriosis in Italy and analyse the presence of correlations between the socio-demographic status of patients and the clinical characteristics/type of diagnosis. Materials and methods This multicenter cross-sectional questionnaire-based study was conducted in 10 tertiary Italian referral centres for diagnosis and treatment endometriosis. A total of 689 respondents with histologically proven endometriosis and onset of the disease with pain symptoms completed an on-line self-reported questionnaire written in their own language (World Endometriosis Research Foundation-Endometriosis Phenome and Biobanking Harmonisation Project-Endometriosis Patient Questionnaire–Minimum) evaluating endometriosis related symptoms, family history of endometriosis and chronic pelvic pain, demographic data, as well as medical, reproductive, and obstetric history. Results The mean diagnostic delay found was of 11.4 years. The mean time (14.8 years) from symptoms onset to diagnosis was significantly longer among patients aged 9–19 vs patients aged 20–30 (mean 6.9 years, p < 0.001) and patients aged 31–45 (mean 2.9, p < 0.001). No significant association were found between a delayed diagnosis and any of the clinically relevant factors such as the number or severity of the reported symptoms, familiarity, hormonal therapy intake or methodology of diagnosis. Conclusions The mean diagnostic delay of endometriosis in Italy is about 11 years. The delay can be up to 4 years longer in patients with pain symptoms onset under 20 years. Educating clinicians and patients on pathologic nature of endometriosis related pelvic pain is advisable to reduce waiting time to diagnosis, especially for young women.

Endometriosis and COVID-19: A Systematic Review and Meta-Analysis.

Endometriosis is defined as ectopic endometrial tissues dispersed outside the endometrium. This can cause disruption in hormonal and immunological processes, which may increase susceptibility to SARS-CoV-2 infection. Worsening of endometriosis symptoms may occur as a result of this infection. The aim of our review was to estimate the pooled prevalence of SARS-CoV-2 infection and the health impacts of the COVID-19 pandemic in endometriosis patients. We conducted a systematic review and meta-analysis. MEDLINE, Science Direct, Scopus, and Google Scholar databases were searched, using the keywords: (endometriosis) AND (COVID-19 OR SARS-CoV-2). Forest plots and pooled estimates were created using the Open Meta Analyst software. After screening 474 articles, 19 studies met the eligibility criteria for the systematic review, and 15 studies were included in the meta-analyses. A total of 17,799 patients were analyzed. The pooled prevalence of SARS-CoV-2 infection in endometriosis patients was 7.5%. Pooled estimates for the health impacts were 47.2% for decreased access to medical care, 49.3% increase in dysmenorrhea, 75% increase in anxiety, 59.4% increase in depression, and 68.9% increase in fatigue. Endometriosis patients were undeniably impacted by the COVID-19 pandemic, which caused the worsening of symptoms such as dysmenorrhea, pelvic pain, anxiety, depression, and fatigue.

You Can Change a Girl's Life Today: The Truth About Periods and Endometriosis.

While endometriosis, a condition where tissue growing outside the uterus causes pain and infertility, is generally widespread among teenage girls and women, it is often misdiagnosed leading to a delay in treatment while the symptoms and damage from the disease increase. This article uses a case study to illustrate the signs and symptoms of endometriosis in a teenage girl, while also discussing many factors surrounding the issue such as the incidence, disease burden, medical research and women, reasons for diagnostic delay, and the current recommended treatments. School nurses are in the unique position to identify young girls and adolescents who are presenting with painful periods or other symptoms possibly associated with endometriosis and can become advocates for the next generation of patients.

Contribution of CD4+ cells in the emotional alterations induced by endometriosis in mice.

Endometriosis is a disease defined by the presence of endometrial tissue in extrauterine locations. This chronic condition is frequently associated with pain and emotional disorders and has been related with altered immune function. However, the specific involvement of immune cells in pain and behavioral symptoms of endometriosis has not been yet elucidated. Here, we implement a mouse model of non-surgical endometriosis in which immunocompetent mice develop abdomino-pelvic hypersensitivity, cognitive deficits, anxiety and depressive-like behaviors. This behavioral phenotype correlates with expression of inflammatory markers in the brain, including the immune cell marker CD4. Depletion of CD4 + cells decreases the anxiety-like behavior of mice subjected to the endometriosis model, whereas abdomino-pelvic hypersensitivity, depressive-like behavior and cognitive deficits remain unaltered. The present data reveal the involvement of the immune response characterized by CD4 + white blood cells in the anxiety-like behavior induced by endometriosis in mice. This model, which recapitulates the symptoms of human endometriosis, may be a useful tool to study the immune mechanisms involved in pain and behavioral alterations associated to endometriosis.

Stressful experiences impact clinical symptoms in people with endometriosis

Endometriosis is a chronic condition that affects ~10% of women globally. Its symptoms include chronic pelvic pain, heavy periods and tiredness/fatigue, which have been associated with poorer quality of life and mental health. We aim to explore the impact of the COVID-19 pandemic on pain and fatigue symptoms and their interactions with the impact on mental health in people with endometriosis. This global cross-sectional online survey study collected data from 4717 adults with self-reported surgical/radiological diagnosis of endometriosis between May and June 2020. The survey included questions on the current status and changes of endometriosis symptoms (pelvic pain, tiredness/fatigue, and bleeding patterns), mental health, pain catastrophising, and the impact of the COVID-19 pandemic on the respondents’ lives. Compared to 6 months earlier, Respondents reported a marked worsening of their endometriosis symptoms (endometriosis-associated pain (39.3%; 95% CI: 37.7, 40.5), tiredness/fatigue (49.9%; 95% CI: 48.4, 51.2) and bleeding patterns (39.6%; 95% CI: 38.2, 41)) and mental health (38.6%; 95% CI: 37.2, 39.9). Those with a pre-existing mental health diagnosis (38.8%) were more likely to report their symptoms worsening. Worsening of pain and tiredness/fatigue was significantly correlated with worsening of mental health (P &lt; 0.001). The relationship between changes in mental health and (a) change in pain and (b) change in fatigue was found to be weakly mediated by pain catastrophising scores (pain: B = 0.071, lower limit of confidence interval (LLCI) = 0.060, upper limit of confidence interval (ULCI) = 0.082, tiredness/fatigue: B = 0.050, LLCI = 0.040, ULCI = 0.060). This study demonstrates that stressful experiences impact the physical and mental health of people with endometriosis. The findings highlight the need to consider psychological approaches in the holistic management of people with endometriosis. Lay summary Endometriosis is a chronic condition in which tissue similar to that of the lining of the womb grows outside it. It affects around 10% of women globally, and the symptoms often include persistent pelvic pain, heavy periods and tiredness/fatigue. These symptoms are associated with impaired mental health and life quality. This study used an online questionnaire to assess the experiences of people with endometriosis during the first months of the pandemic. Results from 4717 adults revealed that pelvic pain, tiredness/fatigue and bleeding worsened in more than 39% of the participants. Poor mental health was also exacerbated and associated with worsening in tiredness/fatigue. Further analysis revealed that this relationship could be partially explained by ‘pain catastrophising’, which measures how participants think about their pain. Our results suggest that stressful experiences like the pandemic negatively impact the already burdened mental health of people with endometriosis, who could benefit from psychological interventions.

CO-EXPRESSION OF ACTIVATING AND INHIBITORY RECEPTORS ON PERITONEAL FLUID NK CELLS DIFFERS BETWEEN DEEP ENDOMETRIOSIS AND PERITONEAL ENDOMETRIOSIS

Deep endometriosis causes severe dysmenorrhea and chronic pelvic pain. Deep endometriosis and peritoneal endometriosis are considered to have different histopathogenesis. Previously, we have reported that NKp46 expression, an active receptor for NK cells in ascites, is reduced in women with pelvic endometriosis. So, in this study, we aimed to investigate the differences in NK cell associations between deep endometriosis and peritoneal endometriosis, and the correlation between the degree of dysmenorrhea as a symptom of deep endometriosis and the expression of NK cell surface markers or intracellular cytokine production.

Time to stop the hand-wringing. 'Net zero' hysterectomy is not an appropriate goal.

Hysterectomy is an essential part of the treatment armamentarium for patients with malignant disease, severe prolapse, massive fibroids, with genetic mutations that predispose to endometrial cancer, and in selected patients with severe symptomatic endometriosis and adenomyosis. For patients with abnormal uterine bleeding unresponsive to non-surgical measures, there is high-level evidence that hysterectomy, particularly minimally invasive hysterectomy, is associated with higher rates of satisfaction and quality of life, comparable rates of serious adverse events and a lower incidence of further surgery, than endometrial resection or ablation. A 'net zero' hysterectomy is not an appropriate goal in contemporary gynaecological practice.

Clinical practice guidelines for endometriosis in Japan (The 3rd edition).

Clinical practice guidelines for endometriosis in Japan (The 3rd edition).

Ultrasound-guided microwave ablation for symptomatic abdominal wall endometriosis and treatment response evaluation with contrast-enhanced imaging: The first experience.

Abdominal wall endometriosis (AWE) is a relatively uncommon condition associated with diagnostic and therapeutic difficulties among all the extra pelvic endometriosis. The main therapies include surgery and oral contraceptive administration. Percutaneous cryoablation and high intensity focused ultrasound (HIFU) are also proven to be valid alternatives. Microwave ablation (MWA) as one of the thermal ablation methods has not been applied in the treatment of AWE yet. Herein the feasibility of ultrasound (US) -guided MWA for AWE was explored and treatment response evaluation was carried out using contrast-enhanced imaging. Three consecutive patients who underwent US-guided MWA for AWE with typical symptoms were included in this retrospective study. US, magnetic resonance imaging (MRI), laboratory tests, and US-guided core-needle biopsy were conducted for pre-treatment assessment and ruling out malignancy. The interventional procedure was carried out under local anesthesia with MWA and the output power was 60w. Post-treatment contrast-enhanced ultrasound (CEUS) was performed to evaluate the instant treatment response. The follow-up intervals were 1 month, 6 months, and 12 months after treatment. The clinical symptoms and condition of AWE lesions were recorded in each follow-up. The MWA procedure was completed in all the patients with no blood perfusion inside each lesion by instant CEUS after treatment. The mean ablation time was 687 seconds (s) for a single patient (ranged from 660s to 742s). Clinical symptoms were relieved evidently at the end of the follow-up. The pain according to the visual analogue scale (VAS) decreased from 4-6 before treatment to 0-2 after treatment. Mild to moderate complications included slightly abdominal pain and fat liquefaction occurred. In terms of technical outcomes, the volume of all six lesions reduced in different degrees at the end of follow-up (ranged: 16.6% to 100%). US-guided MWA may be a feasible and promising approach for symptomatic AWE.

The incidence of unexpected uterine malignancies in hysterectomies carried out for benign indications

PurposeThe aim of the present study was to evaluate the incidence of unexpected uterine malignancies in patients undergoing hysterectomy for benign indications and to evaluate their clinical characteristics.MethodsWe conducted a retrospective review of patients who underwent benign hysterectomy in the Department of Gynecology, the First Hospital of Shanxi Medical University from January 2015 to December 2020. The clinical data of these patients were retrieved and collected.ResultsTheir median age was 49.8 years (31–82 years). The mean parity was 1.86 ± 2.54. Their mean BMI was 27.5 ± 7.6 kg/m2. 42.90% were (2438/5683) postmenopausal. The benign indications of procedure were as follows: symptomatic uterine leiomyomas 2218/5683 (39.02%), pelvic organ prolapse 1406/5683 (24.74%), symptomatic endometriosis or adenomyosis 1132/5683 (19.91%), and 927/5683 (16.31%) to treat other benign conditions such as abnormal uterine bleeding, infection, polyps, and endometrial hyperplasia without atypia. In minimally invasive surgery subgroups, 1560/2621 (59.52%) specimens were removed by in-bag manual morcellation through vaginal cuff. The mean operative time of minimally invasive surgery with in-bag morcellation was shorter than abdominal hysterectomy (96.75 ± 35.7 vs. 140 ± 32.6, P < .001), and the estimated blood loss was also less than abdominal hysterectomy (47.35 ± 42.3 vs. 170 ± 60.4, P < .001). A total of 19/5683 (0.33%) unexpected uterine malignancies were recorded, of which 14/5683 (0.26%) were unexpected endometrial carcinomas and 5/5683 (0.08%) were unexpected uterine sarcomas.ConclusionPreoperative examination in the context of benign hysterectomy must be undertaken with care, and patients should be educated about the very slight possibility of a malignant diagnosis.

Levonorgestrel-Releasing Intrauterine System Improves Menorrhagia-Related Quality of Life in Patients with Symptomatic Adenomyosis.

Levonorgestrel-releasing intrauterine system (LNG-IUS) relieves dysmenorrhea and heavy menstrual bleeding (HMB) in adenomyosis. However, its efficacy on health-related quality of life (HR-QOL) in patients with symptomatic adenomyosis remains unclear. The menorrhagia multi-attribute scale (MMAS), which measures HR-QOL improvement through the treatment of HMB, has never been used for evaluating menorrhagia-specific HR-QOL in patients with symptomatic adenomyosis. Hence, this study aimed to investigate the efficacy of LNG-IUS in improving menorrhagia-specific HR-QOL in these patients using the MMAS. The participants were diagnosed by magnetic resonance imaging. We also assessed the relationships between menorrhagia-specific HR-QOL, blood hemoglobin levels, and the degree of dysmenorrhea before and during LNG-IUS treatment. The LNG-IUS treatment improved the menorrhagia-specific HR-QOL more effectively in incipienttype adenomyosis than in advanced type adenomyosis. The efficacy of LNG-IUS treatment on dysmenorrhea evaluated by the visual analog scale score tended to be better in the incipient type than in the advanced type. By the treatment of LNG-IUS, the blood hemoglobin level was not improved in the advanced type but in the incipient type. Furthermore, dysmenorrhea and HMB-related anemia were associated with HR-QOL impairment, and LNG-IUS treatment may improve the HR-QOL by relieving the symptoms. In conclusion, the effectiveness of LNG-IUS on HR-QOL is decreased by advanced adenomyosis. Thus, magnetic resonance imaging use should be reinforced to predict LNG-IUS efficacy in improving the HR-QOL of patients with adenomyosis.

Biomarkers of Endometriosis

Background: Endometriosis is an under-recognised and often misdiagnosed chronic disease that affects one in ten women. It occurs when cells similar to those that line a uterus grow in other parts of the body, usually around the pelvis. The current gold standard for diagnosis of endometriosis is direct visualisation by histological analysis which can only be achieved by an invasive laparoscopy. It is estimated 176 million women and girls around the world are living with endometriosis. The condition costs $7.7 billion a year in direct medical expenses and lost productivity in Australia alone. Aim: To analyse a series of plasma samples from patients with clinically diagnosed endometriosis, others with gynaecological symptoms without endometriosis and otherwise healthy controls to identify biomarkers to differentiate these groups and potentially aid in endometriosis diagnosis. Method: A standard proteomic discovery workflow was used to search for unique biomarkers of endometriosis. Initially, pooled plasma samples from three distinct groups of patients were tested. The first group had symptoms of endometriosis with a laparoscopic/histology confirmed diagnosis. The second group also had symptoms, but the laparoscopy confirmed no endometriosis or an alternate diagnosis. The third group were healthy matched controls. The pooled plasma samples were quantitatively profiled against each other with a triplicate experiment. A validation of the biomarkers identified as significant in the discovery phase, was then undertaken in a larger clinical cohort (n=902) using a targeted multiplex mass spectrometry assay using multiple reaction monitoring (MRM). Statistical analyses were caried out using Stata and logistical regression was used to evaluate associations of biomarkers with binary clinical outcomes. Results: Out of the 943 proteins identified with [Formula: see text] 2 significant peptides in the initial discovery workflow, 47 were determined as being differential biomarkers across the three clinical groups. The derived targeted MRM assay was tested on the clinical validation cohort, and a number of candidate biomarkers were significantly associated, thereby indicating their potential for use in the diagnosis of endometriosis.