Fatigue is a common symptom of endometriosis

Fatigue is a common symptom of endometriosis

By I.Soussis MD,MSc,FRCOG, Fertility Specialist

Women with endometriosis experience debilitating fatigue more than twice as often as those who don’t have the condition, yet fatigue isn’t discussed or researched widely enough in these patients, a recent study concluded.

The international study found that high levels of fatigue experienced by women with endometriosis are independent of other factors, such as insomnia, pain, depression, occupational stress, weight, and motherhood.

The study “Fatigue – a symptom in endometriosis,” was published in the journal Human Reproduction.

Fatigue is a known symptom of endometriosis that affects the daily activities and quality of life of women living with the condition. But scientists and physicians lack large population studies investigating the frequency of fatigue in women with the disease.

Researchers designed a multicenter study that recruited 1,120 women (560 with endometriosis and 560 without it), at hospitals and private practices in Switzerland, Germany, and Austria between 2010 and 2016.

Participants responded to a questionnaire focused on several factors associating quality of life with endometriosis, as well as family and medical histories, mental disorders, and lifestyle. Fatigue and insomnia were classified at five different levels, with 1 being “never” and 5 being “very often.”

Responses showed that frequent fatigue was experienced by more than half of the women with endometriosis (50.7 percent) but by only a minority of women who didn’t have endometriosis (22.4 percent).

The study also found a link between fatigue in endometriosis and insomnia (women with endometriosis had a seven-fold increase in insomnia compared with healthy women), depression (a four-fold increase), pain (a two-fold increase), and occupational stress (nearly a 1.5-fold increase). However, no correlation was seen between the above symptoms and age, disease stage, and time since diagnosis.

Endometriosis leads to inflammation and an activation of the immune system, which may help to explain the link between endometriosis and fatigue, researchers said.

Proteins that are produced when the immune system is activated are known to be involved in fatigue symptoms. Also, chronic exposure to high stress can lead to fatigue, and researchers said this could be an additional explanation.

“These findings suggest that endometriosis has an effect on fatigue that is independent of other factors and that cannot be attributed to symptoms of the disease,” Brigitte Leeners, the study’s lead researcher and deputy head of the Department of Reproductive Endocrinology at the University Hospital Zurich, in Switzerland, said.

“We believe that in order to improve the quality of life for women with this condition, investigating and addressing fatigue should become a routine part of medical care, and doctors should investigate and address this problem when they are discussing with their patients the best ways to manage and treat the disease”. It would also help these women if steps were taken to reduce insomnia, pain, depression and occupational stress,” she added.


Read more: https://academic.oup.com/humrep/advance-article/doi/10.1093/humrep/dey115/5040620

Image credit: https://endometriosisnews.com/2018/03/16/endometriosis-causes-chronic-fatigue-more-than-feeling-tired/

Endometriosis is more severe for obese women

cramps-810x424By I.Soussis MD

Obesity is linked to an increase in endometriosis severity and a reduced frequency of minimal stage disease, according to new research from Australia.

The study was published in the Journal of Endometriosis and Pelvic Pain Disorders.

Endometriosis is a painful gynecological disease that affects approximately 6-10% of reproductive-age women. 

Due to its high negative impact on quality of life, a better understanding of its underlying mechanisms is a priority for the development of effective therapies.

Previous studies have revealed that endometriosis patients often have a lower body mass index (BMI) than healthy women. It’s not clear how body weight is related to the disease. 

In the study titled “The association of body mass index with endometriosis and disease severity in women with pain” the research team evaluated the association between obesity and endometriosis severity.

The team analyzed the clinical records of 509 pre-menopausal women who underwent laparoscopic surgery for the investigation of gynecological pain. A final diagnosis of endometriosis was achieved in 357 of the 509 women.

In line with previous studies, researchers found that women with endometriosis had a lower mean BMI than healthy women.

They found an inverse correlation between BMI and endometriosis, with a higher incidence of the disease in underweight women and significantly reduced endometriosis frequency in overweight women.

Interestingly, women with obesity who had endometriosis were found to be less likely to have minimal (stage 1) disease. Indeed, 40% of the patients with obesity had moderate-severe endometriosis (stage 3-4) compared to 24-26% of the normal and pre-obesity patients.

In general, obese patients had significantly higher disease severity scores compared to women who were slightly overweight  as well as those with normal BMIs.

Supported by these results, the researchers suggested that there’s too much “scrutiny over a low BMI in association with endometriosis,” and research emphasis should shift to “understanding the impact of obesity on endometriosis, and in particular, the difference observed in disease severity.”

“It remains unclear what role body mass index has in the cause or effect of endometriosis,” researchers wrote. “We propose that BMI may be a useful candidate for assisting in improved endometriosis disease sub-classification,” they added, which could have implications for management and treatment decisions.

Sources: https://www.theguardian.com/society/2018/jun/12/endometriosis-is-more-painful-for-obese-women-study-finds



Endomarch Greece 2018. Great Success!

endomarch ΣΟΥΣΗΣ
It was an honor to participate in Endomarch Greece 2018 along thousands of others. My speech on “Assisted Reproduction and Endometriosis” was greatly received by the public. The good news is the excellent success rate of IVF in women with endometriosis. Timely diagnosis and personalised treatment lead to best results. Wasting time is the enemy of fertility!

Endometriosis and migraines

Endometriosis and migraines

By I.Soussis. MD,MSc, FRCOG

A new study of 391 adolescent girls in the Boston area revealed that those with a surgically diagnosed

endometriosis were more likely to suffer from migraines. The study was published in Fertility and Sterility.

Endometriosis is a chronic condition in which the endometrium grows outside the uterus, typically in the abdominal cavity or on internal organs. Patients often experience significant pain and discomfort during their period or intercourse. Endometriosis may also lead to infertility or hysterectomy.

Current diagnostic methods that rely on laparoscopy, which often patients try to avoid, are delaying the diagnosis typically five to 10 years from the onset of symptoms.

Τhe presence of migraine may be a useful clue to better early detection.

Researchers compared the self-reported frequency and pain of migraine among two populations: adolescent girls with surgically-diagnosed endometriosis and girls of a similar demographic with no such diagnosis.

After adjusting for differences in population, researchers found that those with endometriosis were 5 times more likely to suffer from migraine than the comparable group.

Researchers have also seen a close linear relationship between the severity of migraine pain and the odds of endometriosis. The more painful the migraine was, the more likely it was that a subject had endometriosis. In a scale of zero to ten, for each one point increase in pain the odds of endometriosis increased by 22%.

A serious limitation of this study is that girls who have confirmed endometriosis were more likely to have taken hormonal medications, which could increase the risk of migraines.

The results of this study seem to corroborate a rapidly growing body of evidence from other researchers who have drawn the same conclusion in adult women and it presents a useful signal to help us diagnose women more accurately and at a younger age.


Read more:

Botox injection reduces chronic pelvic pain in endometriosis

Botox injection reduces chronic pelvic pain in endometriosis

By I. Soussis MD, MSc, FRCOG

Consultant Obstetrician- Gynaecologist, Fertility Specialist

An injection of botulinum toxin, commonly known as Botox, helped relieve chronic pelvic pain in women with endometriosis for up to 11 months, according to researchers.

The results of their study were presented at the 2018 Annual Meeting of the American Academy of Neurology in a presentation titled, “Botulinum Toxin Treatment of Chronic Pelvic Pain in Women with Endometriosis.”

Pelvic pain often persists despite optimal surgical/hormonal management in women with endometriosis, often associated with pelvic floor spasm.

Researchers offered women suffering from endometriosis-associated chronic pelvic pain an open injection of the botulinum toxin, called onabotulinumtoxinA, or onaBoNTA. Patients were participating in an ongoing placebo-controlled trial with the toxin.

Ten out of 13 women participating in the study requested the onaBoNTA injection, which was injected into the pelvic floor muscle in 100-unit doses (25 units/cc).

Patients were followed for at least three months after the injection and researchers assessed the injection effects by measuring the changes in spasm, pain, and disability.

At the beginning of the study (before their injection), eight of the 10 women who decided to get the injection had spasms in their pelvic muscles, accompanied by intense pain.

One month after the onaBoNTA injection, spasm rates were significantly reduced or completely absent from all patients. Most of the patients (8 out of 10) reported only mild or even an absence of pain. Their median score on a scale for measuring pain intensity, called  the visual analogue scale, or VAS, was 1.5.

The VAS scale goes from “no pain” (score of 0) and “pain as bad as it could be” or “worst imaginable pain” (the scale can be as high as 100). As a result, half of the women reduced their need for pain medication.

The disability was also improved in three of five women who showed a moderate disability prior to injection.

The effects of the onaBoNTA injection faded in three women six to 11 months after the injection. The three requested a new shot of onaBoNTA. Adverse events were mild and transient.

Overall, these findings show that “injection of onaBoNTA reduced pain, spasm, and disability for up to 11 months,” researchers wrote.

“Utility of botulinum toxin for endo-CPP (endometriosis-associated chronic pelvic pain) merits evaluation in controlled clinical trials,” the study concluded.


Read more: http://n.neurology.org/content/90/15_Supplement/P2.098

Source: https://endometriosisnews.com/2018/05/02/aan2018-botulinum-toxin-may-help-reduce-pelvic-pain-endometriosis/

Discovery promises early diagnosis of endometriosis

Discovery promises early diagnosis of endometriosis

By I.Soussis, MD, MSc, FRCOG, Fertility Specialist


Scientists from the Feinstein Institute for Medical Research announced an experimental, rapid and non-invasive way to diagnose endometriosis, which may lead to earlier and more effective treatments for this disorder that affects approximately 176 million women globally.

The scientists found that a particular feature of cells found in menstrual blood suggests that a patient has endometriosis, according to findings published in Molecular Medicine.

The simple test uses menstrual blood and takes only a few days to report. This is a dramatic improvement over current diagnostic methods that rely on laparoscopy, which patients try to avoid, delaying diagnosis typically five to 10 years from the onset of symptoms.

Endometriosis is a chronic condition in which the endometrium grows outside the uterus, typically in the abdominal cavity or on internal organs. Patients often experience significant pain and discomfort during their period or intercourse.  Endometriosis may also lead to infertility or hysterectomy.

Researchers at the Feinstein Institute established the Research Out-Smarts Endometriosis (ROSE) program to study the genetic basis of endometriosis and what is occurring at the cellular level in this disease. As part of ROSE, healthy women and others with endometriosis, provide peripheral and menstrual blood samples which are stored in a biobank so that they can be analysed in current and future research studies.

The recently-published study focused on the role of stromal fibroblasts, a type of stem cell found in menstrual blood, and the immune system. Professors Christine N.Metz, PhD and Peter K.Gregersen, MD, along with Laura A. Warren, an MD-PhD student at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell have led this research effort.

“The cause of endometriosis is not known. One theory is retrograde menstruation, which is where menstrual blood containing uterine tissue is transported into the abdominal cavity instead of out of the body. Almost all women experience retrograde menstruation, but we’re unsure why in some women this endometrial tissue latches on to the abdominal wall and internal organs and grows causing endometriosis,” said Dr. Metz. “In this study, we found that the stem cells in the menstrual blood of women with endometriosis are very different from those of healthy women and we are learning from these differences to develop a novel non-invasive diagnostic test.”

Metz and her colleagues observed that the menstrual blood of endometriosis patients contained a significantly smaller number of uterine natural killer (uNK) cells compared with healthy participants. In addition to this decrease, they observed that endometriosis patients’ stem cells showed impaired decidualization, a process that prepares the uterus for embryo implantation.

“Instead of having to undergo surgery to accurately diagnose endometriosis, these findings will enable us to develop a rapid test for endometriosis based on menstrual blood, which can be easily collected. This will allow medical professionals to know if someone is at risk of developing endometriosis and start treatment sooner, and it will help them monitor patients’ responses to treatment,” said Dr. Gregersen. “Endometriosis is a chronic, complex condition and improved understanding of this disease through studying menstrual blood is likely to drive personalization of new therapies.”


You can read the data published in Molecular Medicine, here:


Source: https://www.feinsteininstitute.org/2018/03/feinstein-institute-discovery-promises-improved-diagnosis-understanding-endometriosis/

Image credit: http://healthizmo.com/endometriosis-what-you-need-to-know

Women with endometriosis and diffuse adenomyosis at higher risk for smaller babies, study suggests

Women with endometriosis and diffuse adenomyosis at higher risk for smaller babies, study suggests

By I.Soussis, MD, MSc,FRCOG

Fertility Specialist

Researchers have found that pregnant women with both endometriosis and diffuse adenomyosis have a nearly four times greater risk of carrying a baby that is small for its gestational age.

The study from Italy, was published in the journal Ultrasound in Obstetrics and Gynecology.

In the last decade, many studies have reported an association between endometriosis and major pregnancy-related complications, including spontaneous late miscarriage, preterm labor, fetuses small for gestational age (SGA), hypertension, pre-eclampsia, and other issues. But other studies have not reached similar conclusions.

Endometriosis is the disease that the endometrium, the tissue lining the uterus is located outside the uterus. Often is accompanied by adenomyosis, which refers to a condition where the tissue lining the uterus grows into the muscular wall of the uterus.

The reported prevalence of adenomyosis in patients with endometriosis ranges from 20% to 50%. Previous studies have shown that adenomyosis can lead to an increased risk of adverse events in pregnancy, but few studies have paid close attention to the correlation between adenomyosis and pregnancy outcomes in patients with concurrent endometriosis.

Researchers set out to determine whether the maternal and fetal outcomes were different in women with endometriosis alone compared to endometriosis with either diffuse or focal adenomyosis.

Focal adenomyosis occurs in one particular site of the uterus, while diffuse adenomyosis is when the condition is spread throughout the uterus.

Researchers conducted a retrospective analysis of 206 pregnant women with endometriosis, of which 71.8% had endometriosis alone, 18.4% had endometriosis with focal adenomyosis (EFA) and 9.7% had endometriosis with diffuse adenomyosis (EDA).

Conventional risk factors associated with placental insufficiency such as BMI, PAPP-A levels, and mean uterine artery pulsatility index (UtA PI) in the first and the second trimester were found to be significantly associated with EDA, compared to patients with endometriosis alone. There were no statistically significant differences found in EFA patients.

 Interestingly, an analysis showed that EDA was the only independent risk factor for babies who were small for gestational age (SGA), with an overall higher risk of 3.74 in women with EDA compared to those with endometriosis alone.

SGA is a term used to describe a fetus that is smaller than average for the number of weeks of pregnancy.

One explanation for this result is that women with adenomyosis have imbalanced blood flow, with higher blood flow to the uterine adenomyosis area and lower blood flow to the placenta, which could lead to the reduced growth of the fetus.

“The current study shows that diffuse adenomyosis in pregnant women with endometriosis is strongly associated with SGA infants,” the study’s authors concluded.

They added that women with EDA should be treated as high-risk patients for placental dysfunction and should be more closely monitored.

Source: https://endometriosisnews.com/2018/01/03/women-endometriosis-diffuse-adenomyosis-higher-risk-smaller-babies/

Image credit:https://www.healthline.com/health/pregnancy/getting-pregnant-with-endometriosis

Breast feeding linked to lower risk of endometriosis

Breast feeding linked to lower risk of endometriosis




A new study, which followed more than 72 thousand women for more than 20 years, has found that breast feeding is linked to a lower risk of being diagnosed with endometriosis.

Researchers found that among the 72,394 women who had one or more pregnancies (that lasted at least 6 months) there were 3,296 laparoscopically confirmed cases of endometriosis. Compared with women who nursed for less than a month per pregnancy, those who nursed for a year or more had a 32% reduced risk of endometriosis. For each additional three months of breast feeding, the risk was reduced by 8%.

The association between the risk reduction and breast feeding may be mediated at least in part by amenorrhea, according to the researchers who analyzed data from Nurses’ Health Study II (NHS II).

The study, led by Brigham and Women’s Hospital (BWH) in Boston, MA, and published in the British Medical Journal. It is the largest study to date on the link between breast feeding and the risk of endometriosis.

A 40% reduced risk of endometriosis was seen in women who breastfed for ≥ 36 months during their reproductive lives versus women who never breastfed.

Incidence of endometriosis was 453 per 100,000 person-years in the women who breastfed for less than a month versus 184 per 100,000 person-years for those who reported a lifetime total ≥ 36 months. Every additional 3 months of total breastfeeding per pregnancy was associated with an 8% lower risk of endometriosis. A 14% lower risk of endometriosis was seen for every additional 3 months of exclusive breastfeeding.

The protective association with breast feeding was strongest among women who had given birth within the last 5 years. Postpartum amenorrhea partially influenced the association with breastfeeding (34% total breast feeding and endometriosis and 57% for exclusive breast feeding and endometriosis).

Endometriosis is a chronic, incurable gynecologic disorder that affects girls and women. The disorder arises when tissue that is similar to the lining of the uterus (endometrium) is found attached to other areas in the body, generally in the pelvic cavity. As a result, most women with endometriosis experience “chronic pelvic pain, painful periods, and pain during intercourse.


A new non-invasive diagnostic test for endometriosis

A new non-invasive diagnostic test for endometriosis

A revolutionary new diagnostic test for endometriosis will shortly be released by an American company. The test developed by the San Francisco based company uses the patient’s saliva to look for particular biomarkers found to be elevated in endometriosis patients.

Endometriosis is a chronic condition where the tissue that lines the womb (called endometrium) grows outside of the womb. This ectopic tissue then bleeds at the same time as a normal period and causes pain. 

Endometriosis is extremely difficult to diagnose due to overlapping symptoms with other gynaecological conditions and usually, there is a long delay from the first appearance of symptoms to a definitive diagnosis.

Currently, the only way to diagnose endometriosis is through laparoscopy, so the availability of such a simple non-invasive test would be welcomed by patients and clinicians alike. 

American company Dotlab announced it will mail a saliva test kit to the patient’s home. The patient then will mail the saliva sample back to them and later get their results through a secure online dashboard.

There is no data available as yet about the reliability of the saliva-based test but the company claims it has been tested on thousands of patients to date. 

The development of the test seems to have stemmed from much research the company has carried out into the levels of molecules called microRNAs present in the blood. 

The levels of these molecules could be used to accurately predict a surgically achieved diagnosis of endometriosis in those suspected of having the condition. 

Dr. Hugh Taylor, Chair of Obstetrics, Gynecology, and Reproductive Sciences at the Yale School of Medicine, Chief Medical Officer and co-founder of Dotlab said: “Diagnostic biomarkers for endometriosis have the potential to dramatically reduce the time from the onset of symptoms to effective diagnosis and management.” Dr. Taylor also said that once diagnosed, the test could be used for ongoing monitoring of the disease, “These biomarkers could be used to not only identify patients requiring medical or surgical treatment but also to monitor treatment response and recurrence of the disease.”

At present, there is only an early access program allowing some clinicians to get their hands on the kit. The company has not announced a general release date or if the test will be available throughout the world.


Obstetric complications in women with endometriosis

Image courtesy of imagerymajestic at FreeDigitalPhotos.net

Image courtesy of imagerymajestic at FreeDigitalPhotos.net

Obstetric complications in women with endometriosis

By I.Soussis MD

Women with endometriosis present an increased chance of complications during pregnancy, compared to those without.

A large Swedish study comprised of 8.922 women with endometriosis, who gave birth to 13.090 children (single pregnancies) was compared to 1.4 million births of children obtained from the National Birth Records Office.

When women without endometriosis were compared to women with endometriosis, it was found that the latter were at increased risk regarding:

Premature labour.  The risk is increased 1.24 times in women that got pregnant with IVF and 1.37 times in those with spontaneous conception.

Preeclampsia.  Increased risk by 1.13 times.

Placental abruption- haemorrhage.   Increased risk 1.76 times

Caesarian section.  Increased risk by 1.47 times

This study found no relation between endometriosis and underweight babies or intrauterine death.

Professor P.Barri from the University of Barcelona, presented his results at the 6th National Conference IVI in Alicante 2015.

The complications of pregnancy of 118 women, who had gotten pregnant with IVF due to endometriosis, were compared to 118 women who got pregnant with IVF due to male factors and 10.633 spontaneous pregnancies.

The percentage of gestational diabetes mellitus, fetal macrosomia and Caesarian section rates, showed no significant differences in the three groups.

It remains to be seen, if the increased risks that were mentioned are due to endometriosis itself, infertility or IVF.

Sebutal et al. carried out a systematic retrospective review of  studies, regarding complications of pregnancy in women with deep infiltrating endometriosis. They found 12 articles describing the spread of deep infiltrating endometriosis during pregnancy and one article describing six cases of bowel obstruction during IVF.

Despite the fact that traditionally, pregnancy was regarded as a treatment for endometriosis, this is not the case in some women.

The mentioned complications are severe, but rare. Although the chance of their occurrence can not be ruled out.

Fertil Steril. 2014 Feb;101(2):442-6. doi: 10.1016/j.fertnstert.2013.11.001. Epub 2013 Dec 18. Bowel complications of deep endometriosis during pregnancy or in vitro fertilization. Setúbal A1, Sidiropoulou Z2, Torgal M3, Casal E3, Lourenço C4, Koninckx P5.

Hum Reprod. 2009 Sep;24(9):2341-7. doi: 10.1093/humrep/dep186. Epub 2009 May 12. Endometriosis, assisted reproduction technology, and risk of adverse pregnancy outcome. Stephansson O1, Kieler H, Granath F, Falconer H.

BARRI.P, 6th International Congress IVI Alicante Spain 23-25 April,2015 Reproductive Medicine and beyond

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