Predictive tools are lacking for pain-related outcomes after endometriosis surgery. The objective of this study was to develop and validate a machine learning-based clinical model to predict poor pain-related quality of life after endometriosis surgery. Registry data from a prospective longitudinal cohort at a tertiary referral center (2013-2020) was used for model development and validation. Participants underwent an index endometriosis surgery, and completed the pain subscale of the Endometriosis Health Profile-30 (EHP-30) at baseline and 1-2-year follow-up. The outcome was poor pain-related quality of life defined as EHP-30 pain subscale above the 75th percentile for North America, at 1 to 2 years postsurgery. Thirty-two preoperative factors were evaluated, with final models retaining the top 10 most important predictors. Elastic net logistic regression, random forest (RF) and multilayer perceptron neural network models were developed. Internal validation was performed using 500 bootstrap samples, and a held-out test cohort. The study included 650 488 in the training cohort and 162 in a held-out test cohort. The RF model exhibited the most consistent discrimination, measured by the area under the receiver operating characteristic curve, between the training cohort (0.768; 95% CI: 0.690-0.837) and test cohort (0.766; 95% CI: 0.676-0.863, Δ = -0.002). The RF model also demonstrated the best integrated calibration index (0.029) and highest net benefit. Final preoperative predictors for the RF model included baseline EHP-30 score, surgery type (conservative fertility-sparing vs hysterectomy), anxiety scores, depression scores, pain catastrophizing scale scores, abdominal wall pain, pelvic floor myalgia, smoking status, back pain, and race/ethnicity. We present the RF model as the Endometriosis Pain Index to aid preoperative counselling for endometriosis surgery.
Yong PJ et al., 2026·Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC
To provide health care professionals with an evidence-based approach to the management of endometriosis and its associated symptoms.
Women and gender-diverse individuals affected by endometriosis.
BENEFITS, HARMS, Timely and effective management of endometriosis has the potential to reduce pain, improve fertility and quality of life, and enhance long-term health outcomes. Early intervention may also help mitigate the financial and health system burdens associated with delayed diagnosis and treatment.
Published literature was retrieved through searches of PubMed, Ovid, Medline, Embase, Scopus, and the Cochrane Library from August 2010 through December 2025, using relevant MeSH heading and keywords. Results were restricted to systematic reviews, meta-analyses, randomized controlled trials/controlled clinical trials, observational studies, and clinical practice guidelines. Results were limited to English or French language materials. Evidence was supplemented with references from the 2010 Society of Obstetricians and Gynaecologists of Canada guideline No. 244.
The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations).
Health care providers involved in the care of individuals with endometriosis.
Early identification and management of endometriosis can significantly improve patient outcomes, reduce long-term health care costs and improve their quality of life.
RECOMMENDATIONS.
Balachandran S et al., 2026·Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC
To assess the impact of the COVID-19 pandemic on reproductive outcomes in patients with recurrent pregnancy loss (RPL) and the influence of material and social deprivation on these outcomes.
This retrospective cohort study included RPL patients seen at a specialized clinic between March 1, 2018, and February 28, 2022. Patients were categorized into two groups based on care period: pre-pandemic (March 1, 2018-February 29, 2020) and pandemic (March 1, 2020-February 28, 2022). Cumulative probabilities of birth were estimated using the cumulative incidence function within a competing risk framework, treating pregnancy loss as a competing event. Fine and Gray regression models calculated sub-distribution hazard ratio (sHR) of birth.
544 patients were included in the study, with 255 in the pre-pandemic group and 289 in the pandemic group. Individuals in the pandemic group were less likely to achieve pregnancy than those in the pre-pandemic group (relative risk = 0.50, 95% confidence interval [CI] 0.39 - 0.66). Among those who conceived, the cumulative probability of live birth was 0.77 in both groups. Relative to individuals residing in high-social deprivation neighborhoods, those living in moderately deprived areas had higher sub-distribution hazards of live birth (adjusted sHR = 1.97, 95% CI 1.25 - 3.10; P = 0.003).
Within specialized RPL care and a universal maternity care system, pregnancy rates were lower during the first two years of the COVID-19 pandemic. However, among those who conceived, the probability of achieving a live birth remained similar between the pre-pandemic and pandemic periods.
Rojas HE et al., 2026·Journal of women's health (2002)
To characterize differences between individuals with and without mid-cycle pain in a registry cohort with endometriosis. Prospective analysis of data from the Endometriosis Pelvic Pain Interdisciplinary Cohort Data Registry (Clinicaltrials.gov #NCT02911090) at a tertiary referral center in Western Canada. Three hundred forty-five individuals aged 18-49 years who: (1) had at least one episode of menstrual bleeding in the last 3 months, (2) attended a baseline initial visit, and (3) subsequently had surgery with histological confirmation of endometriosis between January 2018 and December 2023. Exclusion criteria included (1) previous hysterectomy; (2) hormonal suppressive therapy use in the last 3 months; and (3) missing data on mid-cycle pain, history of hormonal therapy use, or menstrual cycle regularity. N/A. Mid-cycle pain in the last month versus No mid-cycle pain in the last month. Of the 345 participants, 67% (n = 232) reported mid-cycle pain in the last month. Mid-cycle pain in the last month was significantly associated with higher mean Central Sensitization Inventory score (48 ± 17 versus 36 ± 16, p < 0.001) and more months of prior hormonal suppressive therapy use (58 [14-120] versus 26 [0-109], p = 0.012). Abnormal anatomy at the time of surgery (e.g., endometrioma, ovarian adhesions) was not associated with mid-cycle pain in the last month. In this endometriosis cohort at a tertiary referral center, most participants reported mid-cycle pain in the last month, which was associated with central sensitization but was not clearly related to endometriosis anatomical distortion.
Bouchard TP et al., 2026·Reproductive biomedicine online·Free to read
Does formation of the corpus luteum help to identify the day of ovulation on ultrasound when follicular collapse is missed, and how reliable are sonographers versus a review panel in identifying the day of ovulation on ultrasound? Sonographers in a clinic in Canada performed serial endovaginal ultrasound scans (six to eight per cycle) to identify the day of ovulation in regularly cycling women (n = 40) who were followed for one to five cycles (n = 85). The day of ovulation was identified by: (i) identification of the dominant follicle; (ii) disappearance of the dominant follicle; and (iii) identification and dating of the corpus luteum. The main outcome measures were inter-rater reliability between two sonographers, and Bland-Altman agreement between the supervising sonographer and a panel that reviewed each scan to identify the day of ovulation. Of the 85 menstrual cycles reviewed, two cycles did not have sufficient data to date ovulation, one cycle showed an incidental dermoid cyst, and 11 cycles showed anovulatory patterns. This left a total of 71 cycles (84%) for which intra-rater reliability between two sonographers for identifying the day of ovulation was high (intraclass correlation coefficient = 0.99, P < 0.0001), and Bland-Altman agreement showed no significant difference in the estimated day of ovulation between the supervising sonographer and the panel (t = -0.28, P = 0.78). Corpus luteum criteria were necessary to help identify the day of ovulation in 14 of 71 cycles (20%). The estimated day of ovulation can be determined reliably on ultrasound by trained sonographers using collapse of the dominant follicle and formation of the corpus luteum based on six to eight scans per cycle.
Bouchard TP et al., 2026·Reproductive biomedicine online·Free to read
Do quantitative urinary hormone measurements on the Mira monitor predict and confirm ovulation accurately compared with ultrasound in women with regular menstrual cycles? Do Mira urine hormones correlate with serum hormones?
This was a prospective, single-centre, blinded diagnostic accuracy study with 52 women aged 19-44 years with regular cycles (24-38 days) who tracked 153 cycles over 18 months. Daily first-morning urine was tested with the Mira monitor for follicle stimulating hormone (FSH), oestrone-3-glucuronide (E13G), luteinizing hormone (LH) and pregnanediol glucuronide (PDG). Serial transvaginal ultrasounds (890 scans) confirmed the day of ovulation. Serum hormones were measured twice per cycle. The 121 ovulatory cycles from 49 participants with sufficient index test and reference standard data were included in the final analysis.
The Mira LH peak day strongly predicted ultrasound-confirmed ovulation (R² = 0.96, P < 0.001; intraclass correlation coefficient = 0.971), with 96% of ovulations occurring within ±1 day. The Mira PDG increase was also strongly associated with ultrasound-confirmed day of ovulation (R² = 0.87, P < 0.001). First-morning urine hormones were significantly associated with serum hormones when collected within 90 min (LH: R² = 0.92; E13G: R² = 0.73; R² = 0.61; R² = 0.75). Anovulatory cycles were identified in 11% of regularly cycling participants.
Quantitative urinary hormone monitoring with the Mira monitor provides accurate prediction and confirmation of ovulation, with strong urine-serum associations supporting reduced reliance on serial serum draws in select patients. These findings support clinical adoption of quantitative urinary fertility monitoring.
Guidelines by Issuing Body · Specialty and Consensus Panels
Kim NN et al., 2025·Sexual medicine reviews·Free to read
Sexual function is a critical issue for human health and impacts the quality of life of patients and their partners. In this ICSM report, basic science and translational perspectives have been examined from the past decade of literature since the last ICSM report, and have been integrated to produce a state of the art summary of the physiology and molecular biology of sexual function/dysfunction and development of novel nanotechnology-based vehicles and treatments to aid regeneration and clinical translation in men and women.
Examine, critically assess, and curate the most important and impactful basic and translational research findings on male and female sexual dysfunction since 2015.
Literature reviews were performed by a multidisciplinary committee of sexual medicine experts between June 2023 through May 2024. Findings were presented at the ICSM meeting in Madrid (June 2024), and comments from the consultation were incorporated to develop this consensus report.
Erectile dysfunction (ED), which accompanies prostatectomy, diabetes, aging, and vascular disease in men, develops through both common and distinct mechanisms that involve neural injury, penile remodeling (smooth muscle (SM) apoptosis and increased collagen/fibrosis), dysregulated SM contractility, increased oxidative stress, immune response, and genomic instability. In women, disorders of genital pain, arousal, sexual desire, and orgasm involve multiple, overlapping neurological and endocrine mechanisms. Research on ED has been more extensive and the underlying molecular mechanisms have been better characterized than female sexual dysfunction. Future research directions should focus on pathways that underlie penile tissue remodeling and fibrosis associated with cavernous nerve injury in prostatectomy and diabetes, since this leads to irreversible ED. Particular emphasis should be placed on therapeutic targets to improve/enhance nerve regeneration, neuroprotection, "on demand" sexual function, SM contractility/relaxation, oxidative stress, immune response, and hormone function. In women, despite the existence of approved and off-label treatments for disorders of sexual desire and orgasm, the greater influence of psychosocial factors for these aspects of sexual function demands a multidisciplinary approach, along with predictive animal models. Genome-wide association studies have great potential in advancing the field but require replication and functional validation of findings from bioinformatic analyses. Progress in nanotechnology and regenerative therapies offers an exciting frontier in the targeted delivery of ameliorative/restorative treatments.
Research in sexual medicine has expanded through accelerated rates of discovery and increased breadth and diversity. However, much work remains in translating preclinical findings into biomarkers and clinical therapies that can improve patient outcomes.
Recurrent Pregnancy Loss · Immune and Thrombophilia Factors
Balachandran S et al., 2025·Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC·Free to read
To investigate the impact of the COVID-19 pandemic on the care received by patients with recurrent pregnancy loss (RPL) in British Columbia, Canada. To explore the differential impact of socioeconomic status on health care utilization outcomes during the COVID-19 pandemic for patients with RPL.
This is a retrospective cohort study of patients from an RPL clinic located within a tertiary referral centre. Patients were divided into 2 groups based on the date of their initial visit to the clinic: (1) pre-pandemic group (March 1, 2018-February 28, 2020) and (2) pandemic group (March 1, 2020-February 28, 2022). Data were sourced from the RPL Clinic Database and Population Data BC. Outcomes assessed included visit trends, immediate pandemic impact, and socioeconomic effects.
Demographic and clinical characteristics were not significantly different between study groups, except for increased referral rates to fertility clinics by the RPL clinic during the COVID-19 pandemic (4.90% vs. 9.50%). The mean number of visits per patient was comparable between pre-pandemic (3.50 ± 2.00) and during the pandemic (3.40 ± 3.40). However, monthly initial visits were lower during the pandemic (12.50 ± 3.10) compared with pre-pandemic (14.40 ± 4.83). Telehealth was rare in the pre-pandemic period and increased dramatically during the pandemic, with virtual visits reaching up to 64% of total and 94% of initial visits. The pandemic's onset caused immediate drops in total (38.80%) and initial visits (51.70%). Health care utilization was higher among those with less material deprivation, whereas contrasting effects were observed in those with less social deprivation.
The COVID-19 pandemic impacted the care received by patients with RPL within a tertiary care centre. There was a shift in how services were provided to patients, uniquely impacting specific populations within the community.
Goodwin E et al., 2025·Journal of minimally invasive gynecology·Free to read
Endometriosis is a chronic and inflammatory condition that affects approximately 10% of the reproductive-age population. During the COVID-19 pandemic, there was a shift towards virtual care for endometriosis. Our aim was to evaluate the diagnostic and treatment outcomes of virtual-only care, compared to those who had both virtual and in-person visits.
Retrospective descriptive analysis of registry data.
This study was conducted in British Columbia, Canada, at a tertiary referral center for endometriosis and pelvic pain.
In this cohort (n = 389), we examined patients who received an initial virtual assessment followed by virtual care alone (Virtual Only group, n = 203) and those who had an initial virtual assessment followed by an in-person physical exam (Physical Exam group, n = 186).
Virtual care at the center during the COVID-19 pandemic.
The Physical Exam group was more likely to have surgery compared to the Virtual Only group (45.7% vs. 16%, p <.001). At the time of surgery, the groups did not differ based on type of surgery (e.g., excision of endometriosis and/or hysterectomy), endometriosis anatomic findings (e.g., stage and anatomic subtype), surgical complexity or surgical complications. At baseline, the two groups did not differ in their pain, mental health or quality of life scores. At 1-year follow-up, the two groups did not differ in these outcome measures.
There was a lower rate of surgery, but no differences in surgical findings or complications, nor in 1-year outcomes, after virtual only care for endometriosis compared to patients that had a virtual visit and then underwent a physical exam. These results support a hybrid model, where a virtual visit is the first contact and serves as a triage tool to determine whether a patient is appropriate for virtual only care or would benefit from a physical exam. Future research could incorporate population-based administrative data or qualitative approaches to understanding patient experiences and physician perspectives on virtual care for the treatment of endometriosis.
Fayek B et al., 2025·Reproductive sciences (Thousand Oaks, Calif.)
Endometriosis contributes to 5-21% of hospital admissions for pelvic pain. While hormonal therapies are pivotal in managing endometriosis-related pain, no single hormonal treatment suits all patients. We aimed to assess the effectiveness and tolerability of hormonal therapies and factors influencing response in endometriosis-associated pain treatment. Additionally, to investigate adjuvant neuromodulatory drug usage in patients who have used hormonal therapy. This cross-sectional study examined endometriosis patients undergoing hormonal therapy for pelvic pain at a tertiary referral centre for endometriosis and chronic pelvic pain (CPP). We assessed the proportion of patients reporting ineffectiveness of hormonal therapy and rates of discontinuation attributed to side effects. We evaluated factors related to treatment ineffectiveness and discontinuation due to side effects. Lastly, we determined the rates of adjuvant neuromodulatory drug use among patients who used hormonal therapy. 1011 patients were included in the study. Most hormonal therapies' ineffectiveness was related to worse CPP (P < .05). Cul-de-sac obliteration was correlated with better response to cyclic CHCs, DNG, and GnRH agonist (OR = 0.55, 95% CI [0.36 - 0.84]; OR = 0.53, 95% CI [0.29 - 0.98]; OR = 0.26, 95% CI [0.14 - 0.91], respectively). Adjuvant neuromodulatory drugs were more frequently utilized by patients who found hormone therapy ineffective except for those who used norethisterone acetate (NETA). Endometriosis pain is associated with a high chance of failed hormonal therapy. Cul-de-sac obliteration correlated with improved hormonal therapy response, highlighting the multifactorial influence on treatment outcomes. Patients who found hormone therapy ineffective tended to use adjuvant neuromodulatory drugs more frequently.
Eckler R et al., 2025·PloS one·Free full text on PubMed Central
To investigate the impact of the COVID-19 pandemic's onset on clinical and demographic characteristics, pregnancy complications, and monthly conception rates resulting in births through spontaneous conceptions and in-vitro fertilization (IVF) in British Columbia (BC), Canada.
This retrospective population-based cohort study examined individuals who gave birth (both live births and stillbirths) in BC between June 1, 2010, and March 31, 2021, with estimated conception dates from January 1, 2010 to June 30, 2020. Data were obtained from the BC Perinatal Data Registry. Two groups were identified based on the estimated conception date: the pre-pandemic conception group (conception from January-1-2010 to February-29-2020) and the pandemic conception group (conception from March-1-2020 to June-30-2020). A time series forecasting method (ARIMA) was employed to observe trends in conception rates during the study period.
304,244 individuals with pregnancies resulting in live births or stillbirths during the study period were evaluated. A total of 429,843 such conceptions were included in the study: 417,753 (97.2%) occurring before the onset of the pandemic and 12,090 (2.8%) in the pandemic period. In June 2020, conceptions resulting in births decreased by 26.6% compared with June 2019. Trends in conceptions resulting in live births were similar, with a conception rate of 235.2 per 100,000 women of reproductive age in June 2020, compared with the expected rate of 305.0 per 100,000. In March 2020, 0.5% of conceptions that resulted in births ended in stillbirths, compared to 1.7% in March 2019. IVF conceptions ending in births declined during the pandemic, dropping to 2.5 and 2.8 per 100,000 in March and April 2020, respectively, compared with the expected 13.1 per 100,000. However, by June 2020, these rates began to recover toward the expected levels. Rates of gestational diabetes mellites (GDM), gestational hypertension (GHTN), and postpartum intensive care unit (ICU) admissions were similar before and during the COVID-19 pandemic.
During the challenging period of the COVID-19 pandemic in BC, couples may have chosen to delay conception. Rates of conceptions resulting in stillbirths remained relatively unchanged. IVF conception rates were impacted by the suspension of elective procedures. Preterm birth rates slightly exceeded expected levels but remained within normal fluctuations, and small increases in GDM and GHTN prevalence were also observed.
Tucker DR et al., 2025·Human reproduction (Oxford, England)·Free full text on PubMed Central
Is there an association between the somatic loss of PTEN (phosphatase and tensin homolog) and ARID1A (AT-rich interaction domain 1A) and endometriosis disease severity and worse clinical outcomes?
Somatic PTEN loss in endometriosis epithelium was associated with greater disease burden and subsequent surgical complexity.
Somatic cancer-driver mutations including those involving the PTEN and ARID1A genes exist in endometriosis without cancer; however, their clinical impact remains unclear.
STUDY DESIGN, SIZE, This prospective longitudinal study involved endometriosis tissue and clinical data from 126 participants who underwent surgery at a tertiary center for endometriosis (2013-2017), with a follow-up period of 5-9 years.
PARTICIPANTS/MATERIALS, SETTING, PTEN and ARID1A loss was assessed using established immunohistochemistry (IHC) methods as proxies for somatic loss by two independent raters. PTEN and ARID1A status for each participant was defined as loss (loss in at least one sample for a participant) or retained (no loss in all samples for a participant). Primary analyses examined associations between PTEN and ARID1A loss and disease burden based on anatomic subtype (superficial peritoneal endometriosis (SUP), deep endometriosis (DE), ovarian endometrioma (OMA)) and rASRM stage (I-IV). Secondary analyses explored associations of PTEN and ARID1A loss with demographics, surgical difficulty, and pain scores (baseline and follow-up). Additionally, using previously published data on KRAS codon 12 mutations for this cohort, we investigated associations between variables in the primary and secondary analyses and acquiring two or more somatic events (PTEN loss, ARID1A loss, or KRAS mutation) in this cohort. The risk of reoperation over the 5-9 years was also examined.
MAIN PTEN loss (68.3%; 86 participants) exceeded ARID1A loss (24.6%; 31 participants). Inter-rater reliability was substantial for PTEN (k = 0.69; 95% CI: 0.62-0.77) and ARID1A (k = 0.64; 95% CI: 0.51-0.77). PTEN loss was significantly associated with more severe anatomic subtypes (P < 0.001; participants with SUP only = 46.4%; participants with DE only or OMA only = 72.7%; participants with mixed subtypes = 85.1%), and higher stages (P = 0.024; Stage I = 47.8%; Stage II = 73.7%; Stage III = 80.8%; Stage IV = 81.0%). Results were similar for ARID1A loss, albeit with smaller sample size limiting power. PTEN loss was further associated with non-White ethnicities (P = 0.017) and greater surgical difficulty (more frequent need for ureterolysis) (P = 0.02). There were no differences in pain scores (baseline or follow-up) based on PTEN or ARID1A status. Reoperation was uncommon (13.5% of the cohort), and patterns in reoperation rates based on the presence of somatic alterations did not reach statistical significance.
LIMITATIONS, Sequencing was not performed to determine the type of PTEN and ARID1A somatic mutations resulting in loss of expression.
These results demonstrate a link between PTEN somatic loss and greater endometriosis disease burden. These findings underscore the potential relevance of PTEN loss and other somatic driver mutations in a future molecular classification of endometriosis.
STUDY FUNDING/COMPETING INTEREST(S): This study was funded by Canadian Institutes of Health Research (CIHR) project grant (MOP-142273 and PJT-156084). P.J.Y. was supported by a Health Professional Investigator award from Michael Smith Health Research BC, Canada, and a Canada Research Chair (Tier 2) in Endometriosis and Pelvic Pain. M.S.A. was supported by a Michael Smith Health Research BC Scholar award, and CIHR project grants (369990, 462997, and 456767). The sponsors did not play any role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to [truncated]
Measurement and Statistics · Instrument Development and Validation
Bouchard TP et al., 2025·Womens Health Rep (New Rochelle)·Free full text on PubMed Central
Measuring quantitative menstrual cycle hormones at home may help women better understand their postpartum and perimenopause fertility transitions, but these quantitative fertility monitors require validation. This study included 16 North American women, aged 28-51, during either the postpartum (n = 8, cycles = 18) or perimenopause (n = 8, cycles = 35) fertility transitions testing daily first-morning urine testing with both the Mira Monitor and ClearBlue Fertility Monitor (CBFM) along with menstrual cycle parameter tracking. The main outcome measures were a rise in estrone-3-glucuronide (E13G) and luteinizing hormone (LH) urine hormone values from the Mira monitor correlated to low, high, or peak values on the CBFM. Both in the postpartum and perimenopause transitions, the identification of the day of ovulation based on the LH surge on the Mira and CBFM monitors was highly correlated (R = 0.94 and 0.83, p < 0.001). The E13G levels on the Mira monitor were significantly higher for a CBFM reading of "High" compared with "Low" for both the postpartum and perimenopausal cycles (all p < 0.001). Similarly, the LH levels on the Mira monitor were significantly higher for a CBFM reading of "Peak" (LH surge) compared with "High" for both the postpartum and perimenopausal cycles (all p < 0.001). The LH surge and levels of E13G in urine identified on the quantitative Mira fertility monitor strongly correlate to the LH surge and the shift from low to high on the CBFM during the postpartum and perimenopause transitions.
Allaire C et al., 2024·Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC
To provide evidence-based recommendations for the management of chronic pelvic pain in females.
This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain.
BENEFITS, HARMS, The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability.
Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included.
The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).
Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals.
Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments.
RECOMMENDATIONS.
Guidelines by Clinical Area · Gynecologic Guidelines
Singh SS et al., 2024·Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC
To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada.
Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis.
The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging.
There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment.
BENEFITS, HARMS, Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments.
Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text.
The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations).
This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them.
Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers.
RECOMMENDATIONS.
Gentles A et al., 2024·Journal of clinical medicine·Free full text on PubMed Central
Endometriosis is an inflammatory chronic condition associated with nociceptive, neuropathic, and nociplastic pain. Central sensitization (CS) is the primary nociplastic pain mechanism. However, there are currently no standardized methods for detecting CS or nociplastic pain. This review aims to identify available tools for characterizing CS/nociplastic pain in endometriosis-related chronic pelvic pain. Following the PRISMA-P protocol, MEDLINE, Embase, Scopus, and PsychINFO databases were searched on 23 April 2024, for the terms "endometriosis", "central sensitization", "nociplastic pain", "widespread pain", and "assessment tools". Publications were selected if they mentioned tool(s) for detecting nociplastic pain or CS in endometriosis patients. Information was extracted on study demographics, assessment types, and the tools used for detection. Of the 379 citations retrieved, 30 papers met the inclusion criteria. When working to identify CS and nociplastic pain, fourteen studies exclusively used patient-reported questionnaires, six used quantitative sensory testing (QST), two used clinical assessments, and eight used multiple approaches combining patient-reported questionnaires and clinical assessment. This review illustrates the diversity of tools currently used to identify CS and nociplastic pain in endometriosis patients. Further research is needed to evaluate their validity and to standardize methods in order to improve the accuracy of nociplastic pain identification and guide treatment.
Wahl K et al., 2024·Sexual medicine·Free full text on PubMed Central
Deep dyspareunia affects 50% of people with endometriosis. The Ohnut is a set of interlocking rings that fit over the penis/insertive object. One or more rings can be used to limit insertion depth and reduce deep dyspareunia.
We conducted a pilot, parallel, open-label randomized controlled trial (RCT) to investigate the feasibility of the study design and the acceptability and preliminary efficacy of the Ohnut.
Participants were recruited from a tertiary center for endometriosis. Eligibility criteria were surgically confirmed endometriosis, age 19-49 years, monogamous sexual relationship with a partner willing to participate in the study, and no comorbid superficial dyspareunia, anxiety, or depression. Couples were randomized into an intervention group or a waitlist control group using a 1:1 allocation ratio. All couples had sex as normal during weeks 1 to 4 (baseline period), and couples in the intervention group used the Ohnut with sex during weeks 5 to 10 (intervention period) while controls had sex as normal. Patient participants used daily diaries to record sexual activity and deep dyspareunia score (0-10) for the 10-week study. Intervention group participants completed an acceptability questionnaire at the end of the study.
The primary outcomes were feasibility of the study and acceptability of the Ohnut. We also assessed differences in deep dyspareunia scores in the participants who used the Ohnut compared to the control participants who did not.
We recruited approximately 5 couples per month of active recruitment. Of 864 potentially eligible participants, we successfully contacted 44.7% (n = 386), of whom 8.0% (n = 31) consented, 64.8% (n = 250) were ineligible, and 27.2% (n = 105) declined. Thirty-one couples were randomly assigned to the intervention or control group, and 17 couples completed the study. Intervention group couples used the Ohnut for an average of 72.4% (32.7%) of sexual encounters during the intervention period. The mean acceptability index score for the Ohnut was 0.83 (0.078) among patients and 0.83 (0.049) among partners (index between 0 and 1). After controlling for baseline deep dyspareunia, there was a significant difference in the intervention period mean deep dyspareunia scores between the control and intervention group (4.69 (2.44) vs 2.46 (1.82), P = .012).
We identified preliminary evidence for the acceptability and efficacy of the Ohnut among both patients and partners, suggesting that the Ohnut may be a useful stand-alone or adjuvant management tool for endometriosis-associated deep dyspareunia.
Strengths of this study were the "real-world" use of the Ohnut and data collection from both patients and partners. Limitations of the study design included the strict eligibility criteria that affected feasibility and generalizability.
This pilot RCT indicated that the Ohnut may be an acceptable and effective intervention to reduce endometriosis-associated deep dyspareunia. We identified opportunities to improve design for a larger RCT.
This clinical trial was registered with clinicaltrials.gov (#NCT04370444).
Lee CE et al., 2024·Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC
To prospectively evaluate pain-related quality-of-life (Endometriosis Health Profile-30 [EHP-30] pain subscale) after surgery at an interdisciplinary centre of expertise for endometriosis and pelvic pain.
A prospective cohort study was completed of persons undergoing surgical management for pelvic pain between December 2013 and July 2016 at an interdisciplinary tertiary referral centre for pelvic pain and endometriosis. We compared the change in EHP-30 scores for the following scenarios: (1) type of surgery (conservative surgery vs. hysterectomy), (2) stage of endometriosis (stage I/II vs. III/IV), and (3) age (age <40 vs. age ≥40 years). We used mixed-effects models to evaluate changes in pain during follow-up after surgery.
Overall, 595 individuals met our inclusion criteria; the follow-up rate was 65.9% (392/595). In total, 436 (73.3%) underwent conservative surgery, while 159 (26.7%) underwent hysterectomy. Improvements in pain-related quality-of-life were seen for both conservative surgery and hysterectomy but greater improvements were seen with hysterectomy (P < 0.001). For conservative surgery, similar improvements in quality-of-life were observed regardless of endometriosis stage (I/II vs. III/IV) (P = 0.84) or age (<40 or ≥40 years old) (P = 0.87). We also observed similar improvements in quality-of-life regardless of stage (P = 0.24) or age (P = 0.71) after hysterectomy.
At an interdisciplinary centre of expertise, there were significant improvements in quality-of-life after endometriosis surgery. These improvements were seen for both conservative surgery and hysterectomy (although greater improvement with the latter), for early and advanced stage disease, and younger and older patients.
Ding A et al., 2024·The journal of sexual medicine·Free full text on PubMed Central
Pelvic pain worsened by orgasm is a poorly understood symptom in patients with endometriosis.
To assess the prevalence of pelvic pain worsened by orgasm in patients with endometriosis and explore its association with potential etiologic factors, including pelvic floor myalgia, uterine tenderness and adenomyosis, and central nervous system sensitization.
An analysis was done of a prospective data registry based at a tertiary referral center for endometriosis. Eligible participants were patients aged 18 to 50 years who were referred between January 1, 2018, and December 31, 2019, diagnosed with endometriosis, and subsequently underwent surgery at the center. Clinical features were compared between participants reporting worsening pelvic pain with orgasm and those without worsening pain with orgasm, including patient-reported variables, physical examination findings, and anatomic phenotyping at the time of surgery. Pelvic floor myalgia and uterine tenderness were assessed by palpation on pelvic examination, adenomyosis by ultrasound, and central nervous system sensitization via the Central Sensitization Inventory (range, 0-100).
Outcomes included pelvic or lower abdominal pain in the last 3 months that worsened with orgasm (yes/no).
Among 358 participants with endometriosis, 14% (49/358) reported pain worsened by orgasm while 86% (309/358) did not. Pain with orgasm was significantly associated with pelvic floor myalgia (55% [27/49] vs 35% [109/309]; Cohen's h = 0.40, P = .01) and higher scores on the Central Sensitization Inventory (mean ± SD, 53.3 ± 17.0 vs 42.7 ± 18.2; Cohen's d = 0.60, P < .001) but not with uterine tenderness or adenomyosis. Other clinical features associated with pain with orgasm were poorer sexual health (higher scores: deep dyspareunia, Cohen's h = 0.60; superficial dyspareunia, Cohen's h = 0.34; and Female Sexual Distress Scale-Revised, Cohen's d = 0.68; all P < .05) and poorer mental health (higher scores: Patient Health Questionnaire-9, 12.9 ± 6.7 vs 9.1 ± 6.3, Cohen's d = 0.59, P < .001; Generalized Anxiety Disorder-7, 9.4 ± 5.6 vs 6.8 ± 5.5, Cohen's d = 0.48, P = .002). Anatomic findings at the time of surgery did not significantly differ between the groups.
Interventions targeting pelvic floor myalgia and central nervous system sensitization may help alleviate pain worsened by orgasm in patients with endometriosis.
A strength is that pain worsened by orgasm was differentiated from dyspareunia. However, pain with orgasm was assessed by only a binary question (yes/no). Also, the study is limited to a single center, and there were limited data on sexual function.
Pelvic pain exacerbated by orgasm in people with endometriosis may be related to concurrent pelvic floor myalgia and central sensitization.
Measurement and Statistics · Instrument Development and Validation
Lin T et al., 2024·Fertility and sterility·Free to read
The World Endometriosis Research Foundation established the Endometriosis Phenome and Biobanking Harmonisation Project (EPHect) to create standardized documentation tools (with common data elements) to facilitate the comparison and combination of data across different research sites and studies. In 2014, 4 data research standards were published: clinician-reported surgical data, patient-reported clinical data, and fluid and tissue biospecimen collection. Our current objective is to create an EPHect standard for the clinician-reported physical examination (EPHect-PE) for research studies.
An international consortium involving 26 clinical and academic experts and patient partners from 11 countries representing 25 institutions and organizations. Two virtual workshops, followed by the development of the physical examination standards underwent multiple rounds of iterations and revisions.
N/A MAIN OUTCOME MEASURE(S): N/A RESULT(S): The EPHect-PE tool provides standardized assessment of physical examination characteristics and pain phenotyping. Data elements involve examination of back and pelvic girdle; abdomen including allodynia and trigger points; vulva including provoked vestibulodynia; pelvic floor muscle tone and tenderness; tenderness on unidigital pelvic examination; presence of pelvic nodularity; uterine size and mobility; presence of adnexal masses; presence of incisional masses; speculum examination; tenderness and allodynia at an extra-pelvic site (e.g., forearm); and recording of anthropometrics.
CONCLUSION(S): The EPHect-PE standards will facilitate the standardized documentation of the physical examination, including the assessment and documentation of examination phenotyping of endometriosis-associated pelvic pain.
Orr NL et al., 2023·JAMA network open·Free full text on PubMed Central
A subset of people who undergo surgery for endometriosis have persistent pain, suggesting that other factors besides the endometriosis, such as central sensitization, may play a role in this pain. The Central Sensitization Inventory, a validated self-reported questionnaire of central sensitization symptoms, may identify individuals with endometriosis who have more pain after surgery due to pain sensitization.
To examine whether greater baseline Central Sensitization Inventory scores are associated with postsurgical pain outcomes.
DESIGN, SETTING, This prospective, longitudinal cohort study performed at a tertiary center for endometriosis and pelvic pain in British Columbia, Canada, included all patients aged 18 to 50 years with diagnosed or suspected endometriosis and a baseline visit between January 1, 2018, and December 31, 2019, who underwent surgery after the baseline visit. Individuals who were menopausal, had a prior hysterectomy, or were missing data for outcomes or measures were excluded. Data analysis was performed from July 2021 to June 2022.
The primary outcome was chronic pelvic pain at follow-up measured on a scale of 0 to 10, with 0 to 3 indicating no pain or mild pain, 4 to 6 indicating moderate pain, and 7 to 10 indicating severe pain. Secondary outcomes were deep dyspareunia, dysmenorrhea, dyschezia, and back pain at follow-up. The main variable of interest was baseline Central Sensitization Inventory score (measured from 0 to 100, consisting of 25 self-reported questions rated from 0 to 4 [never, rarely, sometimes, often, and always, respectively]).
A total of 239 patients (mean [SD] age, 34 [7] years; 189 [79.1%] White [11 (5.8%) identified as White mixed with another ethnicity], 1 [0.4%] Black or African American, 29 [12.1%] Asian, 2 [0.8%] Native Hawaiian or Pacific Islander, 16 [6.7%] other, and 2 [0.8%] mixed race or ethnicity) with follow-up data at more than 4 months after surgery were included in this study (71.0% follow-up rate). The mean (SD) baseline Central Sensitization Inventory score was 43.8 (18.2), and the mean (SD) follow-up was 16.1 (6.1) months. Higher baseline Central Sensitization Inventory scores were significantly associated with higher chronic pelvic pain (odds ratio [OR], 1.02; 95% CI, 1.00-1.03; P = .02), deep dyspareunia (OR, 1.03; 95% CI, 1.01-1.04; P = .004), dyschezia (OR, 1.03; 95% CI, 1.01-1.04; P < .001), and back pain (OR, 1.02; 95% CI, 1.00-1.03; P = .02) at follow-up, when controlling for baseline pain scores. The Central Sensitization Inventory scores themselves decreased slightly from baseline to follow-up (mean [SD] score, 43.8 [18.2] vs 41.7 [18.9]; P = .05); however, individuals with high baseline Central Sensitization Inventory scores still had high scores at follow-up.
In this cohort study of 239 patients with endometriosis, higher Central Sensitization Inventory scores at baseline were associated with worse pain outcomes after endometriosis surgery, when controlling for baseline pain scores. The Central Sensitization Inventory could be used to counsel patients with endometriosis on their expected outcomes after surgery.
Allaire C et al., 2023·CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne·Free full text on PubMed Central
[For a first-person account of endometriosis, see www.cmaj.ca/lookup/doi/10.1503/cmaj.230215][1] KEY POINTS Endometriosis is a chronic condition defined by the presence of endometrial-like tissue outside of the uterus, which can lead to estrogen-driven inflammation. The extent of disease can be
MacGregor B et al., 2023·International journal of women's health·Free full text on PubMed Central
Dysmenorrhea is the most common gynecologic condition among the female population and has a significant impact on life course potential. It has a widespread impact on a female's mental and physical well-being, with longstanding impairments on quality of life, personal relationships, and education and career attainment. Furthermore, untreated dysmenorrhea can lead to hyperalgesic priming, which predisposes to chronic pelvic pain. Primary dysmenorrhea is pain in the lower abdomen that occurs before or during menses and in the absence of pelvic pathology. One possible mechanism is endometrial inflammation and increased prostaglandin release, resulting in painful uterine contractions. Dysmenorrhea may also occur secondary to pelvic pathology, such as endometriosis, adenomyosis or due to cyclic exacerbation of non-gynecologic pain conditions. A thorough patient evaluation is essential to differentiate between potential causes and guide management. Treatment must be tailored to individual patient symptoms. Pharmacologic management with non-steroidal anti-inflammatory medications and/or combined hormonal contraceptives is most common. Heat therapy, exercise, vitamins and dietary supplements have limited evidence and can be offered for patients seeking non-pharmacologic adjunctive or alternative options. Greater awareness for both health-care providers and patients allows for early intervention to reduce impact on quality of life and life course potential.
Eckler R et al., 2023·European journal of obstetrics, gynecology, and reproductive biology
To evaluate the odds of developing adverse maternal and perinatal outcomes in primiparous singleton pregnancies conceived with assisted reproductive technology (ART) compared with pregnancies conceived without ART.
A retrospective population-based cohort study using data from the British Columbia Perinatal Data Registry. The population included primiparous women with singleton live or stillbirths delivering at or after 20 weeks' gestation between April 1st 2008-March 31st, 2021. Women who conceived with ART were compared with those who conceived without ART. The main outcome measures were gestational diabetes, hypertensive disorders of pregnancy, preterm birth, low birth weight, neonatal intensive care unit admission, stillbirth, and 5-minute Apgar score. Adjusted odds ratios were calculated.
The study population included 191,059 primiparous women: 183,819 conceived without ART, 7,240 conceived using ART. After controlling for age, body mass index, pre-gestational diabetes, and smoking status, singleton pregnancies conceived by ART had significantly higher odds of gestational diabetes (OR 1.18, 95 % confidence interval [CI] 1.10-1.26) and hypertensive disorders of pregnancy (OR 1.39, 95 % CI 1.29-1.51). There were also significantly increased odds of preterm birth (OR 1.35, 95 % CI 1.25-1.46), low birth weight (OR 1.35, 95 % CI 1.23-1.49), and neonatal intensive care unit admission (OR 1.21, 95 % CI 1.11-1.32). There was not a statistically significant difference in the odds of stillbirth (OR 1.06, 95 % CI 0.72-1.57) or 5-minute Apgar score < 7 (OR 1.10, 95 % CI 0.97-1.26).
There is an increased odds of developing several adverse maternal or neonatal outcomes in primiparous singleton pregnancies conceived by ART including gestational diabetes, hypertensive disorders of pregnancy, preterm birth, low birth weight, and increased incidence of neonatal intensive care unit admissions.
Zhang SXJ et al., 2023·JMIR research protocols·Free full text on PubMed Central
Endometriosis-associated deep dyspareunia is associated with reduced sexual quality of life, lower self-esteem, and impaired sexual function.
The primary objective is to assess the acceptability of a phallus length reducer (brand name: Ohnut [OhnutCo]), which is a buffer worn over the penis or a penetrating object to reduce endometriosis-associated deep dyspareunia, and the feasibility of a definitive randomized controlled trial (RCT). The secondary objective is to obtain estimates of the effectiveness of the buffer. An embedded substudy will explore the acceptability and the preliminary validity and reliability of a vaginal insert for the self-assessment of deep dyspareunia.
Ours is an investigator-initiated, 2-arm RCT. We will recruit 40 patient participants with diagnosed endometriosis between the ages of 19 and 49 years, as well as their sexual partners. The participating couples will be randomized in a 1:1 ratio into the experimental arm or the waitlist control arm. The length of the study period will be 10 weeks, during which time all participants will record deep dyspareunia severity following each episode of sexual intercourse. In weeks 1 to 4, all patient participants will record deep dyspareunia severity at each sexual encounter. In weeks 5 to 10, participants in the experimental arm will use the buffer during vaginal penetration; participants in the waitlist control arm will continue engaging in vaginal penetration as usual. Participants will complete questionnaires for assessing measures of anxiety, depression, and sexual function at baseline, at 4 weeks, and at 10 weeks. In the substudy, patient participants will self-assess dyspareunia by using a vaginal insert on 2 occasions, at least 1 week apart. The primary outcomes-the acceptability and feasibility of the buffer-will be assessed with descriptive statistics, and the secondary outcome-phallus length reducer effectiveness-will be assessed by using an analysis of covariance-based approach. For the vaginal insert, we will assess acceptability, test-retest reliability, and convergent validity via correlation analyses comparing the use of the insert to clinical examination in terms of dyspareunia assessment outcomes.
Our pilot will provide initial data on the acceptability and effectiveness of the buffer and the feasibility of the study methodology. The results from our study are expected to be submitted for publication by the spring of 2023. As of September 2021, we have consented 31 couples into the study.
Our study will provide preliminary evidence for the self-assessment and management of endometriosis-associated deep dyspareunia. The findings will inform the decision to proceed to a definitive RCT.
ClinicalTrials.gov NCT04370444; https://clinicaltrials.gov/ct2/show/NCT04370444.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39834.
Tucker DR et al., 2023·American journal of obstetrics and gynecology
After endometriosis surgery, pain can persist or recur in a subset of patients. A possible reason for persistent pain after surgery is central nervous system sensitization and associated pelvic pain comorbidities. Surgery addresses the peripheral component of endometriosis pain pathophysiology (by lesion removal) but may not treat this centralized pain. Therefore, endometriosis patients with pelvic pain comorbidities related to central sensitization may experience worse pain-related outcomes after surgery, such as lower pain-related quality of life.
This study aimed to determine whether baseline (preoperative) pelvic pain comorbidities are associated with pain-related quality of life at follow-up after endometriosis surgery.
This study used longitudinal prospective registry data from the Endometriosis Pelvic Pain Interdisciplinary Cohort at the BC Women's Centre for Pelvic Pain and Endometriosis. Participants were aged ≤50 years with confirmed or clinically suspected endometriosis, and underwent surgery (fertility-sparing or hysterectomy) for endometriosis pain. Participants completed the pain subscale of the Endometriosis Health Profile-30 quality of life questionnaire preoperatively and at follow-up (1-2 years). Linear regression was performed to measure the individual relationships between 7 pelvic pain comorbidities at baseline and follow-up Endometriosis Health Profile-30 score, controlling for baseline Endometriosis Health Profile-30 and type of surgery received. These baseline (preoperative) pelvic pain comorbidities included abdominal wall pain, pelvic floor myalgia, painful bladder syndrome, irritable bowel syndrome, Patient Health Questionnaire 9 depression score, Generalized Anxiety Disorder 7 score, and Pain Catastrophizing Scale score. Least absolute shrinkage and selection operator regression was then performed to select the most important variables associated with follow-up Endometriosis Health Profile-30 from 17 covariates (including the 7 pelvic pain comorbidities, baseline Endometriosis Health Profile-30 score, type of surgery, and other endometriosis-related factors such as stage and histologic confirmation of endometriosis). Using 1000 bootstrap samples, we estimated the coefficients and confidence intervals of the selected variables and generated a covariate importance rank.
The study included 444 participants. The median follow-up time was 18 months. Pain-related quality of life (Endometriosis Health Profile-30) of the study population significantly improved at follow-up after surgery (P<.001). The following pelvic pain comorbidities were associated with lower quality of life (higher Endometriosis Health Profile-30 score) after surgery, controlling for baseline Endometriosis Health Profile-30 score and type of surgery (fertility-sparing vs hysterectomy): abdominal wall pain (P=.013), pelvic floor myalgia (P=.036), painful bladder syndrome (P=.022), Patient Health Questionnaire 9 score (P<.001), Generalized Anxiety Disorder 7 score (P<.001), and Pain Catastrophizing Scale score (P=.007). Irritable bowel syndrome was not significant (P=.70). Of the 17 covariates included for least absolute shrinkage and selection operator regression, 6 remained in the final model (lambda=3.136). These included 3 pelvic pain comorbidities that were associated with higher follow-up Endometriosis Health Profile-30 scores or worse quality of life: abdominal wall pain (β=3.19), pelvic floor myalgia (β=2.44), and Patient Health Questionnaire 9 depression score (β=0.49). The other 3 variables in the final model were baseline Endometriosis Health Profile-30 score, type of surgery, and histologic confirmation of endometriosis.
Pelvic pain comorbidities present at baseline before surgery, which may reflect underlying central nervous system sensitization, are associated with lower pain-related quality of life after endometriosis surgery. Particularly important were depression and musculoskeletal/myofascial pain (abdominal wall pain and pelvic floor myalgia). Therefore, these pelvic pain comorbidities should be candidates for a formal prediction model of pain outcomes after endometriosis surgery.
Long AJ et al., 2023·American journal of obstetrics and gynecology
More research is needed that compares the outcomes between those who underwent a hysterectomy for endometriosis with conservation of one or both ovaries and those who underwent a hysterectomy with bilateral salpingo-oophorectomy.
This study aimed to compare the rate and types of reoperations (primary outcome) and use of other pain-related health services (secondary outcomes) among people who underwent a hysterectomy with conservation of both ovaries, those who underwent a hysterectomy with unilateral salpingo-oophorectomy, and those who underwent a hysterectomy with bilateral salpingo-oophorectomy.
This was a population-based, retrospective cohort study of 4489 patients aged 19 to 50 years in British Columbia, Canada, who underwent a hysterectomy for endometriosis between 2001 and 2016. Index surgeries were classified as hysterectomy alone (conservation of both ovaries), hysterectomy with unilateral salpingo-oophorectomy, or hysterectomy with bilateral salpingo-oophorectomy. Reoperation rate was the primary outcome. Secondary outcomes (measured at 3-12 months and 1-5 years after hysterectomy) included physician visits for endometriosis and pelvic pain, prescriptions filled for opioids, and use of hormonal suppression medications and hormone replacement therapy.
Reoperation rates were low across all groups, with 89.5% of all patients remaining reoperation free by the end of follow-up (median of 10 years; interquartile range, 6.1-14.3 years). Patients who underwent a hysterectomy alone were more likely to undergo at least 1 reoperation when compared with those who underwent a hysterectomy with bilateral salpingo-oophorectomy (13% vs 5%; P<.0001), most commonly an oophorectomy or adhesiolysis. When oophorectomy as reoperation was removed in a sensitivity analysis, this difference was partially attenuated (6% of hysterectomy alone group vs 3% of hysterectomy with bilateral salpingo-oophorectomy group undergoing at least 1 reoperation). All groups were very similar in terms of rates of physician visits for endometriosis or pelvic pain and the number of days of opioid prescriptions filled. Furthermore, the rate of hormonal suppression medication use was similar among the groups, whereas the rate of prescriptions filled for hormone replacement therapy after hysterectomy with bilateral salpingo-oophorectomy was 60.6% of patients who filled at least 1 prescription at 3 to 12 months after index surgery.
Patients who underwent a hysterectomy with bilateral salpingo-oophorectomy had a lower reoperation rate than those who underwent a hysterectomy with conservation of one or both ovaries. However, there was little difference between the groups for the secondary outcomes measured, including physician visits for endometriosis and pelvic pain, opioid use, and use of hormonal suppression medications, suggesting that persistent pelvic pain after hysterectomy for endometriosis may not differ substantively based on ovarian conservation status. One limitation was the inability to stratify patients by stage of endometriosis or to determine the impact of endometriosis stage or the presence of adnexal disease or deep endometriosis on the outcomes. Moreover, hormone replacement therapy prescriptions was not filled by about 40% of patients after hysterectomy with bilateral salpingo-oophorectomy, which may have significant health consequences for these individuals undergoing premature surgical menopause. Therefore, strong consideration should be given to ovarian conservation at the time of hysterectomy for endometriosis.
Although racial and ethnic disparities in adverse birth outcomes have been well documented, it is unknown whether such disparities diminish in women who use medically assisted reproduction (MAR). We examined differences in the association between maternal race and ethnicity and adverse birth outcomes among women who conceived spontaneously and those who used MAR, including assisted reproduction technology (ART), eg, in-vitro fertilization, and also non-ART MAR, eg, fertility drugs.
We conducted a population-based retrospective cohort study using data on all singleton births (N = 7 545 805) in the United States from 2016 to 2017. The outcomes included neonatal and fetal death, preterm birth, and serious neonatal morbidity, among others. Modified Poisson regression was used to estimate adjusted rate ratios (aRR) and 95% confidence intervals (CI) and to assess the interactions between race and ethnicity and mode of conception.
Overall, 93 469 (1.3%) singletons were conceived by MAR. Neonatal mortality was twofold higher among infants of non-Hispanic Black versus non-Hispanic White women in the spontaneous-conception group (aRR = 1.9, 95% CI: 1.8-1.9), whereas in the ART-conception group, neonatal mortality was more than fourfold higher in infants of non-Hispanic Black women (aRR = 4.1, 95% CI: 2.9-5.9). Racial and ethnic disparities between Hispanic versus non-Hispanic White women were also significantly larger among women who conceived using MAR with regard to preterm birth (<34 weeks) and perinatal mortality.
Compared to women who conceived spontaneously, racial and ethnic disparities in adverse perinatal outcomes were larger in women who used MAR. More research is needed to identify preventive measures for reducing risks among vulnerable women who use medically assisted reproduction.
Wahl KJ et al., 2021·Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC
Endometriosis is an enigmatic, painful, complex disease that affects approximately 1 million people in Canada. The disease can involve multiple organ systems, often resulting in debilitating chronic pain and infertility. Social, medical, geographic, and other factors are implicated in years-long diagnostic delays and may limit access to care. An integrated approach from bench to bedside to community is urgently required. A pan-Canadian collaboration among patients, clinicians and researchers will improve endometriosis awareness, provide best practices, and link research across Canada.
Yong PJ et al., 2020·Human reproduction open·Free full text on PubMed Central
What are the use patterns and factors associated with combined hormonal contraception (CHC) ineffectiveness or discontinuation due to side-effects in patients with endometriosis and pelvic pain?
Worse chronic pelvic pain (CPP) severity and pelvic floor myalgia were associated with continuous CHC ineffectiveness, while poorer quality-of-life was associated with continuous CHC discontinuation due to side-effects.
CHC is a first line of therapy for endometriosis-associated pelvic pain in women. However, some patients state that CHC is ineffective for their pain, while others have to discontinue CHC due to side-effects.
Analysis of a prospective patient database from a tertiary care referral center for patients with endometriosis and pelvic pain between December 2013 and April 2015 was carried out.
PARTICIPANTS/MATERIALS A total of 373 patients of reproductive age with endometriosis from the database were included in the study. Data included patient self-reported questionnaires, physical examination findings and validated instruments. There were four variables of interest: history of cyclical CHC ineffectiveness (yes/no), history of cyclical CHC discontinuation due to side-effects (yes/no), history of continuous CHC ineffectiveness (yes/no) and history of continuous CHC discontinuation due to side-effects (yes/no). The primary outcome was CPP severity for the past 3 months (score of 0-10), and secondary outcomes were other pelvic pain scores, quality-of-life on the Endometriosis Health Profile 30 (EHP-30) and underlying conditions including irritable bowel syndrome, painful bladder syndrome, abdominal wall pain, pelvic floor myalgia and depression, anxiety and pain catastrophizing.
MAIN Among the 373 cases in the dataset, prior cyclical CHC use was reported by 228 (61.1%) women, of which 103 (27.6%) stated it was ineffective for their pain and 94 (25.2%) stated they discontinued CHC due to side-effects. Previous continuous CHC use was reported by 175 (46.9%) women, of which 67 (18.0%) stated it was ineffective and 59 (15.8%) stated they discontinued due to side-effects. Worse CPP severity in the last 3 months was associated with a history of continuous CHC ineffectiveness (P < 0.001). Poorer quality-of-life was present in women who reported a history of continuous CHC discontinuation due to side-effects (P = 0.005). Among the underlying conditions, pelvic floor tenderness (as a marker of pelvic floor myalgia) was associated with CHC ineffectiveness.
LIMITATIONS This study involved patient recall and no longitudinal follow-up. Also, we do not have data on the type of side-effect that led to discontinuation. Medication ineffectiveness was reported subjectively by the patient rather than using standardized criteria. Finally, the diagnosis of endometriosis was based on previous surgery or a current nodule or endometrioma on examination/ultrasound; without prospective surgical data on all the patients, it was not possible to do a sub-analysis by current surgical features (e.g. stage).
In women with endometriosis, CHC ineffectiveness was associated with worse CPP and pelvic floor myalgia, which suggests myofascial or nervous system contributors to CPP that does not respond to hormonal suppression. A tender pelvic floor, as a sign of pelvic floor myalgia, may be a clinical marker of patients with endometriosis who are less likely to have an optimal response to hormonal suppression. For women who discontinue CHC due to side-effects, research is needed to help alleviate these side-effects as these patients report worse quality-of-life.
This work was supported by a Canadian Institutes of Health Research (CIHR) Transitional Open Operating Grant (MOP-142273) as well as BC Women's Hospital and the Women's Health Research Institute. PY is also supported by a Health Professional Investigator Award from the Michael Smith Foundation for Health Research. MB/CA has financial affiliations with Abbvie and Allergan; the other authors have no conflicts of interest.
Fertility and Outcomes · Conception After Excision
Yong PJ et al., 2020·Journal of minimally invasive gynecology
To systematically review and perform a meta-analysis of the risk of ectopic pregnancy in endometriosis.
MEDLINE (OVID), Embase (OVID), CINAHL (EBSCO), and Cochrane Library to April 1, 2019. Inclusion criteria were cohort or case-control studies from 1990 onward. Exclusion criteria were cohort studies without controls, case reports or series, or no English full-text.
A total of 1361 titles/abstracts were screened after removal of duplicates, 39 full-texts were requested, and, after 24 studies were excluded, there were 15 studies in the meta-analysis.
TABULATION, INTEGRATION, Data were extracted using standardized spreadsheets with 2 independent reviewers, and conflicts were resolved by a third reviewer. We performed random effects calculation of weighted estimated average odds ratio (OR). Heterogeneity and publication bias were assessed with the I2 metric and funnel plots/Egger's test, respectively. The Ottawa-Newcastle Quality Assessment Scale was used with a cutoff of ≥7 for higher quality. There were 10 case-control studies (17 972 ectopic pregnancy cases and 485 266 nonectopic pregnancy controls) and 5 cohort studies (30 609 women with endometriosis and 107 321 women without endometriosis). For case-control studies, endometriosis was associated with increased risk of ectopic pregnancy with an OR of 2.66 (95% confidence interval [CI] = 1.14-6.21, p = .02). For cohort studies, the OR was 0.95 (95% CI = 0.29-3.11, p = .94), but after post hoc analysis of the studies with a Ottawa-Newcastle score ≥7, the OR was 2.16 (95% CI = 1.67-2.79, p <.001). For both case-control and cohort studies, there was high heterogeneity among studies (I2 = 93.9% and I2 = 96.6%, Q test p <.001) but no obvious evidence of systematic bias in the funnel plot, and Egger's test results were not significant (p = .35, p = .70), suggesting no strong publication bias. There were insufficient data to make any conclusions with respect to anatomic characteristics of endometriosis (e.g., stage) or mode of conception (e.g., assisted reproductive technology vs spontaneous).
Possible evidence of an association between endometriosis and ectopic pregnancy was observed (OR = 2.16-2.66). However, these results should be considered with caution, owing to high heterogeneity among studies. Continued research is needed to delineate the pregnancy implications of endometriosis.
Guidelines by Clinical Area · Gynecologic Guidelines
Auclair MH et al., 2019·Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC
The aim of this guideline is to aid primary care physicians and gynaecologists in the initial evaluation of women with suspected endometrial hyperplasia, to recommend the use of the 2014 World Health Organization classification for endometrial hyperplasia by all health care providers, and to guide the optimal treatment of women diagnosed with endometrial hyperplasia.
Physicians, including gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; medical trainees, including medical students, residents, and fellows; and all other health care providers.
Adult women (18 years and older) presenting with suspected or confirmed endometrial hyperplasia.
The discussion relates to the medical therapy as well as surgical treatment options for women with and without atypical endometrial hyperplasia.
For this guideline, relevant studies were searched in PubMed, Cochrane Wiley, and the Cochrane Systematic Reviews using the following terms, either alone or in combination, with the search limited to English language materials, human subjects, and published since 2000: (endometrial hyperplasia, endometrial intraepithelial neoplasia, endometrial sampling, endometrial curettage, diagnosis) AND (treatment, progestin therapy, surgery, LNG-IUS, aromatase inhibitors, metformin ), AND (obesity). The search was performed in April 2018. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional significant articles were identified through cross-referencing the identified reviews. The total number of studies identified was 2152, and 82 studies were included in this review.
The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework. The interpretation of strong and weak recommendations was also included. The Summary of Findings is available upon request.
BENEFITS, HARMS, It is expected that this guideline will benefit women with endometrial hyperplasia. This should guide patient informed consent before both medical and surgical management of this condition.
Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.
RECOMMENDATIONS.
Arion K et al., 2019·Journal of minimally invasive gynecology
To evaluate the point-of-care preoperative transvaginal ultrasound (TVUS) sliding sign in comparison with palpation of a nodule on digital pelvic examination for the prediction of pouch of Douglas (POD) obliteration.
Analysis of data from a prospective data registry (Canadian Task Force classification II-2).
A tertiary referral center.
Women with suspected endometriosis who had preoperative pelvic examination and point-of-care TVUS followed by laparoscopic surgery between August 2015 and December 2016.
Women were preoperatively assessed for the prediction of POD obliteration with pelvic examination for a nodule and point-of-care TVUS uterine/cervix sliding sign.
The study included 269 women, 15.2% (41/269) of whom had POD obliteration at the time of surgery. A preoperative negative sliding sign had a sensitivity of 73.2% (95% confidence interval, 57.1%-85.8%) and a specificity of 93.9% (95% CI, 89.9%-96.6%) in the prediction of POD obliteration compared with preoperative palpation of a nodule on pelvic examination, which had a sensitivity of 24.4% (95% CI, 12.4%-40.3%) and a specificity of 93.4% (95% CI, 89.4%-96.3%). The difference in sensitivity was statistically significant (McNemar test, p <.001). A negative sliding sign was also associated with longer operating times and more difficult surgery including the need for ureterolysis.
The point-of-care TVUS sliding sign showed significantly improved sensitivity compared with palpation of a nodule on pelvic examination for the prediction of POD obliteration. Therefore, the point-of-care TVUS sliding sign improves the preoperative assessment of POD disease and thus may lead to more optimal surgical planning in women with suspected endometriosis.
Lisonkova S et al., 2019·BMJ open·Free full text on PubMed Central
To examine temporal trend in maternal mortality/severe morbidity associated with hospitalisation due to ectopic pregnancy.
A population-based observational study.
All women hospitalised for ectopic pregnancy in Washington State, USA, 1987-2014 (n=20 418). The main composite outcome of severe morbidity/mortality included death, sepsis, need for transfusion, hysterectomy and systemic or organ failure, identified by diagnostic and procedure codes from hospitalisation files. Severe morbidity/mortality due to ectopic pregnancy were expressed as incidence ratios among women of reproductive age (15-64 years) and among women hospitalised for ectopic pregnancy. Comparisons were made between 1987-1991 (reference) and 2010-2014 using ratios of incidence ratios (RR) and ratio differences (RD). The Cochran-Armitage test for trend assessed statistical significance; logistic regression was used to obtain adjusted OR (AOR) and 95% CI, adjusted for demographic factors and comorbidity.
Hospitalisation for ectopic pregnancy declined from 0.89 to 0.16 per 1000 reproductive age women between 1987-1991 and 2010-2014 (p<0.001). Among reproductive age women, ectopic pregnancy mortality remained stable (0.03 per 100 000); and mortality/severe morbidity increased among women aged 25-34 years (p=0.022). Among women hospitalised for ectopic pregnancy, mortality increased from 0.29 to 1.65 per 1000 between 1987-1991 and 2010-2015 (p=0.06); severe morbidity/mortality increased from 3.85% to 19.63% (RR=5.10, 95% CI 4.36 to 5.98; RD=15.78 per 100 women, 95% CI 13.90 to 17.66; AOR for 1-year change was 1.08, 95% CI 1.07 to 1.08).
Hospitalisation for ectopic pregnancy declined in Washington State, USA, between 1987 and 2014; however, mortality/severe morbidity associated with ectopic pregnancy increased in female population aged 25-34 years.
Allaire C et al., 2018·American journal of obstetrics and gynecology
Chronic pelvic pain affects ∼15% of women, and presents a challenging problem for gynecologists due to its complex etiology involving multiple comorbidities. Thus, an interdisciplinary approach has been proposed for chronic pelvic pain, where these multifactorial comorbidities can be addressed by different interventions at a single integrated center. Moreover, while cross-sectional studies can provide some insight into the association between these comorbidities and chronic pelvic pain severity, prospective longitudinal cohorts can identify comorbidities associated with changes in chronic pelvic pain severity over time.
We sought to describe trends and factors associated with chronic pelvic pain severity over a 1-year prospective cohort at an interdisciplinary center, with a focus on the role of comorbidities and controlling for baseline pain, demographic factors, and treatment effects.
This was a prospective 1-year cohort study at an interdisciplinary tertiary referral center for pelvic pain and endometriosis, which provides minimally invasive surgery, medical management, pain education, physiotherapy, and psychological therapies. Exclusion criteria included menopause or age >50 years. Sample size was 296 (57% response rate at 1 year; 296/525). Primary outcome was chronic pelvic pain severity at 1 year on an 11-point numeric rating scale (0-10), which was categorized for ordinal regression (none-mild 0-3, moderate 4-6, severe 7-10). Secondary outcomes included functional quality of life and health utilization. Baseline comorbidities were endometriosis, irritable bowel syndrome, painful bladder syndrome, abdominal wall pain, pelvic floor myalgia, and validated questionnaires for depression, anxiety, and catastrophizing. Multivariable ordinal regression was used to identify baseline comorbidities associated with the primary outcome at 1 year.
Chronic pelvic pain severity decreased by a median 2 points from baseline to 1 year (6/10-4/10, P < .001). There was also an improvement in functional quality of life (42-29% on the pain subscale of the Endometriosis Health Profile-30, P < .001), and a reduction in subjects requiring a physician visit (73-36%, P < .001) or emergency visit (24-11%, P < .001) in the last 3 months. On multivariable ordinal regression for the primary outcome, chronic pelvic pain severity at 1 year was independently associated with a higher score on the Pain Catastrophizing Scale at baseline (odds ratio, 1.10; 95% confidence interval, 1.00-1.21, P = .04), controlling for baseline pain, treatment effects (surgery), age, and referral status.
Improvements in chronic pelvic pain severity, quality of life, and health care utilization were observed in a 1-year cohort in an interdisciplinary setting. Higher pain catastrophizing at baseline was associated with greater chronic pelvic pain severity at 1 year. Consideration should be given to stratifying pelvic pain patients by catastrophizing level (rumination, magnification, helplessness) in research studies and in clinical practice.
Shum LK et al., 2018·Sexual medicine·Free full text on PubMed Central
Deep dyspareunia occurs in half of women with endometriosis, a condition present in 10% of reproductive-age women and associated with negative effects on sexual quality of life (SQoL). However, women with endometriosis can have other clinical factors (eg, superficial dyspareunia, other pelvic pains, and psychological or pain conditions) possibly affecting SQoL. To determine whether deep dyspareunia is associated with SQoL in women with endometriosis, independent of potential confounders. This study involved a prospective patient registry of women at a tertiary-level referral center for endometriosis and pelvic pain. Inclusion criteria were (i) referrals to the center recruited into the registry from January 2014 through December 2016 and (ii) subsequent surgery at the center with histologic confirmation of endometriosis. Exclusion criteria included menopausal status, age at least 50 years, never sexually active, or did not answer dyspareunia or SQoL questions. Bi-variable tests and multiple linear regression analysis were performed. SQoL measured by the 5-item sexual intercourse subscale of the Endometriosis Health Profile-30 (EHP-30) modular questionnaire (0-100%, with higher scores indicating worse SQoL). Consent rate for the prospective registry was 87%; 277 women met the study criteria (mean age = 34.2 ± 7.1 years). Most women had stage I to II endometriosis at time of surgery (64%), with the remaining having stage III to IV endometriosis. Through regression analysis, worse SQoL (higher EHP-30 sexual intercourse subscale score) was independently associated with: more severe deep dyspareunia (P < .0001), more severe superficial dyspareunia (P < .0001), increased depression (P < .001), higher pain catastrophizing (P = .04), bladder pain syndrome (P = .02), heterosexual orientation (P < .001), and new referral status (P = .02). In women with endometriosis at a tertiary referral center, more severe deep dyspareunia was associated with worse SQoL, independent of superficial dyspareunia, psychological comorbidities, and other potential confounders. Shum LK, Bedaiwy MA, Allaire C, et al. Deep Dyspareunia and Sexual Quality of Life in Women With Endometriosis. Sex Med 2018;6:224-233.
Yong PJ et al., 2018·The journal of sexual medicine
Deep dyspareunia is a common symptom in women, including in half of women with endometriosis, but little is known about its response to treatment and predictors of persistent deep dyspareunia over time.
To follow up deep dyspareunia severity over a 1-year prospective cohort at an interdisciplinary center, and to identify baseline predictors of more persistent deep dyspareunia at 1 year.
Prospective 1-year cohort study at a tertiary referral center for pelvic pain and endometriosis, where a range of interdisciplinary treatments are provided at a single center (surgical, hormonal, physical, and psychological therapies). Exclusion criteria were menopause, age >50 years, and never previously sexually active. Primary outcome (deep dyspareunia severity) and secondary outcome (sexual quality of life) were followed up over 1 year. Ordinal logistic regression was performed, controlling for baseline severity of deep dyspareunia, to identify baseline predictors of deep dyspareunia severity at 1 year.
Primary outcome was severity of deep dyspareunia on an 11-point numeric rating scale (0-10), categorized into absent-mild (0-3), moderate (4-6), and severe (7-10); secondary outcome was sexual quality of life measured by the Endometriosis Health Profile-30.
1-year follow-up was obtained for 278 subjects (56% response rate at 1 year; 278/497). Severity of deep dyspareunia improved over the 1 year (McNemar test, P < .0001): the proportion of patients in the severe category decreased from 55.0% to 30.4%, the moderate category remained similar from 17.7% to 25.0%, and the absent-mild category increased from 27.3% to 44.6%. Sexual quality of life also improved (56% to 43% on the sex subscale of the Endometriosis Health Profile-30) (Welch t test, P < .001). On ordinal regression, severity of deep dyspareunia at 1 year was independently associated with younger age (OR = 0.94, 95% CI = 0.91-0.97, P = .008), and with a higher baseline depression score on the Patient Health Questionnaire-9 (OR = 1.07, 95% CI = 1.03-1.11, P = .01).
Clinicians should consider employing an interdisciplinary approach for deep dyspareunia, and screening for and treating depression symptoms in these women.
Strengths of the study include its prospective nature, and assessment of deep dyspareunia specifically (as opposed to superficial dyspareunia). Limitations include non-randomized design, and the patients lost to follow-up over the 1 year.
Over 1 year in an interdisciplinary setting, improvements were observed in deep dyspareunia and sexual quality of life, but younger women and those with more severe depression at baseline had more persistent deep dyspareunia at 1 year. Yong PJ, Williams C, Bodmer-Roy S, et al. Prospective Cohort of Deep Dyspareunia in an Interdisciplinary Setting. J Sex Med 2018;15:1765-1775.
Anglesio MS et al., 2017·N Engl J Med·Free full text on PubMed Central
Endometriosis, defined as the presence of ectopic endometrial stroma and epithelium, affects approximately 10% of reproductive-age women and can cause pelvic pain and infertility. Endometriotic lesions are considered to be benign inflammatory lesions but have cancerlike features such as local invasion and resistance to apoptosis. We analyzed deeply infiltrating endometriotic lesions from 27 patients by means of exomewide sequencing (24 patients) or cancer-driver targeted sequencing (3 patients). Mutations were validated with the use of digital genomic methods in microdissected epithelium and stroma. Epithelial and stromal components of lesions from an additional 12 patients were analyzed by means of a droplet digital polymerase-chain-reaction (PCR) assay for recurrent activating KRAS mutations. Exome sequencing revealed somatic mutations in 19 of 24 patients (79%). Five patients harbored known cancer driver mutations in ARID1A, PIK3CA, KRAS, or PPP2R1A, which were validated by Safe-Sequencing System or immunohistochemical analysis. The likelihood of driver genes being affected at this rate in the absence of selection was estimated at P=0.001 (binomial test). Targeted sequencing and a droplet digital PCR assay identified KRAS mutations in 2 of 3 patients and 3 of 12 patients, respectively, with mutations in the epithelium but not the stroma. One patient harbored two different KRAS mutations, c.35G→T and c.35G→C, and another carried identical KRAS c.35G→A mutations in three distinct lesions. We found that lesions in deep infiltrating endometriosis, which are associated with virtually no risk of malignant transformation, harbor somatic cancer driver mutations. Ten of 39 deep infiltrating lesions (26%) carried driver mutations; all the tested somatic mutations appeared to be confined to the epithelial compartment of endometriotic lesions.
Yong PJ et al., 2015·The journal of sexual medicine
Little is known about women with concurrent diagnoses of deep dyspareunia and superficial dyspareunia.
The aim of this study was to determine the prevalence, associations, and outcome of women with concurrent deep-superficial dyspareunia.
This is a prospective study of a multidisciplinary vulvodynia program (n = 150; mean age 28.7 ± 6.4 years). Women with superficial dyspareunia due to provoked vestibulodynia were divided into two groups: those also having deep dyspareunia (i.e., concurrent deep-superficial dyspareunia) and those with only superficial dyspareunia due to provoked vestibulodynia. Demographics, dyspareunia-related factors, other pain conditions, and psychological variables at pretreatment were tested for an association with concurrent deep-superficial dyspareunia. Outcome in both groups was assessed to 6 months posttreatment.
Level of dyspareunia pain (0-10) and Female Sexual Distress Scale were the main outcome measures.
The prevalence of concurrent deep-superficial dyspareunia was 44% (66/150) among women with superficial dyspareunia due to provoked vestibulodynia. At pretreatment, on multiple logistic regression, concurrent deep-superficial dyspareunia was independently associated with a higher level of dyspareunia pain (odds ratio [OR] = 1.19 [1.01-1.39], P = 0.030), diagnosis of endometriosis (OR = 4.30 [1.16-15.90], P = 0.022), history of bladder problems (OR = 3.84 [1.37-10.76], P = 0.008), and more depression symptoms (OR = 1.07 [1.02-1.12], P = 0.007), with no difference in the Female Sexual Distress Scale. At 6 months posttreatment, women with concurrent deep-superficial dyspareunia improved in the level of dyspareunia pain and in the Female Sexual Distress Scale to the same degree as women with only superficial dyspareunia due to provoked vestibulodynia.
Concurrent deep-superficial dyspareunia is reported by almost half of women in a multidisciplinary vulvodynia program. In women with provoked vestibulodynia, concurrent deep-superficial dyspareunia may be related to endometriosis or interstitial cystitis, and is associated with depression and more severe dyspareunia symptoms. Standardized multidisciplinary care is effective for women with concurrent dyspareunia.
Yong PJ et al., 2013·JSLS : Journal of the Society of Laparoendoscopic Surgeons·Free full text on PubMed Central
Chronic pelvic pain affects 15% of women. Our objective was to evaluate empiric laparoscopic inguinal exploration and mesh placement in this population.
Retrospective cohort with follow-up questionnaire of women with lateralizing chronic pelvic pain (right or left), ipsilateral inguinal tenderness on pelvic examination, no clinical hernia on abdominal examination, and ipsilateral empiric laparoscopic inguinal exploration with mesh placement (2003-2009). Primary outcome was pain level at the last postoperative visit. Secondary outcomes were pain level and SF-36 scores from the follow-up questionnaire.
Forty-eight cases met the study criteria. Surgery was done empirically for all patients, with only 7 patients (15%) found to have an ipsilateral patent processus vaginalis (shallow peritoneal dimple or a deeper defect (occult hernia)). Of 43 cases informative for the primary outcome, there was pain improvement in 15 patients (35%); pain improvement then return of the pain in 18 patients (42%); and pain unchanged in 9 patients (21%) and worse in 1 patient (2%). Improvement in pain was associated with a positive Carnett's test in the ipsilateral abdominal lower quadrant (P = .024). Thirteen patients returned the questionnaire (27%), and the pain was now described as improved in 9 patients (69%), unchanged in 4 patients (31%), and worse in none. Three SF-36 subscales showed improvement (physical functioning, social functioning, and pain).
In select women with chronic pelvic pain, empiric laparoscopic inguinal exploration and mesh placement results in moderate improvement in outcome. A positive Carnett's test in the ipsilateral abdominal lower quadrant is a predictor of better outcome.
Prenatally diagnosed trisomy 16 mosaicism is associated with the increased risk of poor pregnancy outcome including intrauterine growth restriction, intrauterine death and fetal malformation. While maternal preeclampsia has also been reported in some cases, this has not been systematically evaluated.
To better define the risk of preeclampsia and the clinical course of preeclampsia in these pregnancies and to identify associated clinical variables, we reviewed 25 cases of prenatally diagnosed trisomy 16 mosaicism for which molecular studies were undertaken and sufficient obstetrical data were present to include/exclude the diagnosis of preeclampsia.
Six of 25 (24%) mosaic trisomy 16 cases exhibited preeclampsia as compared to 3 of 44 (7%) matched controls. There were no differences between those mosaic trisomy 16 cases presenting with preeclampsia and those that did not, in terms of the presence/absence of UPD, IUGR, malformation, or trisomy on amniocentesis. Four of the 6 (67%) preeclampsia-associated fetuses were male, compared with only 4 of 19 (21%) (p = 0.06) nonpreeclampsia case fetuses, and three of these also had hypospadias. The levels of trisomy tended to be high in placentas associated with preeclampsia; however very high levels of placental trisomy were also often seen in the absence of preeclampsia.
As it is impossible to predict which subset of cases is at highest risk, all women receiving a prenatal diagnosis of trisomy 16 mosaicism should be closely monitored for signs of preeclampsia.