Endometriosis impacts life on many levels

Endometriosis impacts life on many levels

Research indicates that women with endometriosis are prone to physical, psychosocial, social, and sexual disturbances and obstetrical complications, according to a literature search of the impact of endometriosis on various aspects of reproductive health in the Journal of Obstetrics and Gynaecology.

Although endometriosis is not a life-threatening disease, the analysis concluded that it can significantly affect a patient’s reproductive health. “Endometriosis can be both physically and emotionally debilitating,” wrote the authors from Iran.

The authors searched four international databases for studies published in English on health issues in women with endometriosis from January 1995 to December 2019: PubMed, Science Direct, Scopus and Google scholar. A total of 46 full-text articles comprised the analysis.

Most of the papers were published in 2010 or later, reflecting a recent increase in research on the impact of endometriosis on reproductive health.

The majority of papers were also from high-income countries with developed healthcare systems: United Kingdom (n = 9), the United States (7), Brazil (5), Australia (3) Italy (3), Switzerland (2) and Japan.

The 40 quantitative studies consisted of 16 reviews, 12 cohort studies, 9 cross-sectional studies and 3 clinical trials. Conversely, the 6 qualitative studies used a range of quality-of-life instruments and assessments of variables such as symptoms, including pain; well-being; mental health; personality; and impact on work. The qualitative studies also relied on interviewing for data collection.

Study sample size varied considerably: from 16 to 116,430 women with endometriosis in quantitative studies and from 18 to 65 women with endometriosis in qualitative studies.

In addition, most of the participants had confirmed endometriosis through surgical diagnoses, for example; however, for others, diagnosis was self-reported and not clinically verified.

The physical impact from endometriosis pain can lead to complications, including chronic pelvic pain, dysmenorrhoea, dyspareunia, dyschezia and dysuria, which can decrease quality of life.

Likewise, the psychological health of women can be negatively impacted by infertility caused by endometriosis.

The social impact from endometriosis also can be exacerbated by absence from work, fewer social activities, and students missing school due to menstrual symptoms.

The disease, especially when linked to severe dyspareunia or chronic pelvic pain, can have negative effects on women’s sexual function as well, including sexual desire, orgasm, sexual satisfaction and frequency of intercourse. Fear of separation from partner can also lead to unwanted sex.

Many women with endometriosis suffer pain during sex and even have dyspareunia after intercourse.

Endometriosis also can significantly impair pregnancy by increasing the risk of miscarriage gestational diabetes, and hypertensive disorders.

The authors said it is crucial that women be informed about endometriosis and that information be easily accessible in order to improve their reproductive health. They also noted that sexuality is an integral part of one’s personality, which is adversely affected by endometriosis.

Because gynecologists are the first referral for suffering women, it is of utmost importance that they engage in a “profound conversation” with patients about their sexuality, despite the fact that sexuality is often perceived as a “shameful topic.”

Similarly, patients should engage their partners in decision-making, communicating and understanding the nature of endometriosis and its potential impact on the partner and family.

However, more research is needed to elucidate endometriosis complications, according to the authors, specifically for obstetrical outcomes.

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Improving fertility rates and symptoms for peritoneal endometriosis

Improving fertility rates and symptoms for peritoneal endometriosis

For patients suffering from symptomatic early-stage endometriosis, a consistent excision of altered peritoneum followed by adjuvant hormonal therapy and multimodal concepts improves outcomes, particularly for pregnancy and recurrence rates.

This is the major finding of a German prospective study in the Archives of Gynecology and Obstetrics.

Clinically managing endometriosis is a huge challenge,” said principal investigator Sylvia Mechsner, MD, head of the Endometriosis Centre Charité at Charité University Hospital in Berlin. “We need to find a good balance between conservative and surgical treatment.”

Mechsner has had success by starting with sufficient hormonal treatment like therapeutic amenorrhea, especially when no organ damage is suspected. “Many patients achieve good pain relief,” she said. “But when is surgery a better option?”

Ongoing pelvic pain while taking sufficient hormonal treatment is Mechsner’s No. 1 consideration for surgery. “I believe neurogenic inflammation is present in most lesion cases and can cause non-estrogen related pain,” she said. “This is acyclical pain, due to changes in the sensory and sympathetic nerve fiber composition/innervation.”

For the study, patients stopped hormonal treatment 2 months prior to surgery, consisting of a resection not only of the visible lesions, but of the inflamed altered surrounding tissue as well.

Of course, infertility or seeking pregnancy are also indications for the surgery,” Mechsner told Contemporary OB/GYN. “We wanted to prove this concept and analyze the extension of inflammation in the excised tissue and the pain relief and fertility rate.”

The prospectively maintained database at the Endometriosis Centre Charité identified all symptomatic women with the suspicion of only peritoneal endometriosis who underwent laparoscopy from January 2014 to June 2019.

Laparoscopic peritonectomy was performed on 94 women, all by Mechsner. Follow-up data were available for 87% of the cases.

At the time of surgery, nearly all patients showed signs of stage I or II endometriosis: 44.7% and 48.9%, respectively.

Roughly 75% of the women reported pain relief due to the post-surgical hormonal therapy, with 25% completely pain free.

It was unexpected, but made me happy, to see so many women achieve some pain relief,” Mechsner said. “However, in many of these cases, we found severe adenomyosis. And in cases of organ-sparing surgery, it is logical that uterus-associated pain could be persistent.

Some patients also suffer from severe chronic pelvic pain syndrome with central sensitization, thus needing ongoing multimodal treatment like hormonal treatment, osteopathy, manual therapy, pelvic floor relaxing exercises, transcutaneous electrical nerve stimulation (TENS), pain management and psychological support.

The study found that 33% of women wanted to have children after the procedure, of whom 63% became pregnant, with the majority not requiring assisted reproductive therapy (ART).

Seven of the women had a reoperation.

According to the findings, “a consistent excision of altered peritoneum followed by adjuvant hormonal therapy and multimodal concepts results in better outcomes for the patient, particularly in regards to pregnancy and recurrence rates”.

Two limitations of the study are no control group and limited to a single center.

I believe it is good to know that endometriosis-related pain should be treated conservatively, especially in cases when no organ damage is suspected,” Mechsner said. “It is also reassuring to know that there is no need to schedule surgery for diagnosis only because the study’s protocol confirmed the peritoneal lesions in 100% of women.”

But in cases of ongoing acyclical pelvic pain, “it appears that peritoneal lesions are the cause of the pain, for which surgery with destruction/excision is recommended,” she said.

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Impact of opioids in women with endometriosis

Impact of opioids in women with endometriosis

The risk of opioid use after endometriosis diagnosis is significantly greater in patients who used opioids before diagnosis, according to a retrospective analysis of data from a large health database.

The analysis in the Journal of Comparative Effectiveness Research also found that the risk of prolonged opioid use was significantly greater if comorbidities existed before diagnosis.

Senior author Georgine Lamvu, MN, MPH, a professor of ob/gyn at the University of Central Florida College of Medicine in Orlando, was prompted to undertake the analysis after a colleague remarked to her that he did not believe that women with endometriosis used opioids.

In my practice, I had seen many women with endometriosis who reported using opioids, so I was curious to find out the actual numbers,” Lamvu told Contemporary OB/GYN.

Medical and pharmacy claims information on 79,947 women with endometriosis from July 2015 to June 2018 were analyzed from the Symphony Health database.

The date of the first endometriosis diagnosis was deemed the index date and the 1-year period preceding the index data was considered the baseline period.

Women were aged 18 to 49 at the index date and had continuous pharmacy and medical enrollment for at least 1 year before and after their endometriosis diagnosis; in other words, at least one pharmacy claim every 3 months during the study period.

Women with endometriosis who used opioids at baseline were 61% more likely to receive opioids post-diagnosis.

The risk of prolonged opioid supply post-diagnosis was highest among women with a prolonged supply at baseline: relative risk (RR) 21.14, which significantly decreased to 1.32 for patients without a prolonged supply but with at least one comorbidity, 1.37 for pain comorbidities and 1.07 for psychiatric co-morbidities.

I was surprised to find out how many women with endometriosis actually used opioids beyond 90 days,” Lamvu said. “All the other findings were expected.”

There is limited evidence to indicate that long-term opioid therapy is effective in treating other chronic pain conditions and no research to validate that opioids are efficacious for endometriosis-related pain.

Nonetheless, the risk of opioid-related adverse events correlates with the dose and duration of opioid use,” Lamvu said. “This can lead to opioid-induced hyperalgesia, which counterproductively amplifies pain.”

In addition, high daily doses and prolonged use of opioids for chronic non-cancer pain can increase the risk of opioid abuse. More definitive is that comorbid psychiatric disorders in patients with chronic pain conditions like low back pain are linked to opioid misuse.

The high prevalence of psychiatric comorbidities in patients with endometriosis suggests that this population may be vulnerable to opioid misuse,” Lamvu said.

Optimal endometriosis treatment should encompass a patient-centric strategy, according to Lamvu, integrating pharmacologic and surgical options to manage symptoms, in conjunction with therapies to improve health-related quality of life.

Multi-disciplinary care with adequate management of comorbidities could optimize endometriosis treatment and reduce inappropriate or excessive treatment with opioids,” Lamvu said.

The analysis identifies a group of women who need specific counseling on the risks of long-term opioid use. “However, because we have no research that shows that opioids are effective for endometriosis-related pain, we need more research on this topic,” Lamvu said. “Also, because many women with endometriosis have surgery, post-op opioid use needs to be discussed with caution.”

Acupuncture found to be effective adjunctive treatment for endometriosis-related pain

Acupuncture found to be effective adjunctive treatment for endometriosis-related pain

By I.Soussis MD, Fertility Specialist

Endometriosis, Pain Management Meta-analysis of 3 studies of acupuncture for relief of endometriosis-related pain found positive results for reduction in pain intensity, according to research published in the Journal of Pain Research. This alternative and complementary therapy has been proven to be safe, with a low side-effect profile.

Swedish researchers performed a literature search for clinical trials, case reports, and observational studies with abstracts written in English using the keywords “acupuncture and endometriosis.” 

They retrieved 3 articles involving a total of 99 women with diagnosed endometriosis (stages I-IV) aged 13 to 40. All of the studies entailed acupuncture sessions during which 7 to 12 needles were inserted per subject and left in for 15 to 25 minutes. 

The needles were placed in the lower back,/pelvic area, lower abdominal area, feet, and/or hands. Depth of stimulation with the needles ranged from intracutaneous to subcutaneous to intramuscular, and the stimulation was primarily manual in nature. 

The number of treatments varied from 9 to 16 and occurred once or twice a week, and treatments were given in a hospital, acupuncturist’s office, or patient’s home. All of the studies reported a decrease in rated pain intensity, but differed in terms of research design, needle stimulation techniques, and the instruments used to evaluate the outcomes.

Two of the studies were prospective, randomized, single-blind, placebo/sham trials and the other was a retrospective observational case series study (n=2). The Visual Analog Scale, Numeric Rating Scale, and Verbal Rating Scale were used to measure patient-rated pain intensity. Subjects were permitted to continue using their standard analgesic in 2 studies.

The results indicated that no matter the specific technique used, acupuncture effectively and safely reduced pain intensity compared to baseline. One study found that acupuncture also reduced pain-related disability, and 2 studies found reduced analgesic intake and perceived stress. Likewise, 2 studies found that the therapy improved health-related quality of life, and social activity and attendance in school were increased after acupuncture treatment in the observational study.


Although acupuncture has been used for many years to relieve pain and has been noted to have few serious side effects, its use remains controversial due to a lack of understanding of its mechanism of action. 

The authors reported that “the pain-alleviating effects induced by acupuncture have been attributed to different physiological and psychological processes such as activation of endogenous descending pain inhibitory systems, deactivation of brain areas transmitting sensations of pain-related unpleasantness, interaction between nocioceptive impulses and somato-visceral reflexes, and as a method that induces the expectation of symptom relief.” 

They noted that currently available therapies for pain management in endometriosis patients are often ineffective or accompanied by adverse effects, and there is need for nonpharmacological interventions such as acupuncture. 



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.


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