Recurrence of endometriosis refers to the reappearance of endometrial-like tissue after it has been completely surgically removed. This can manifest as new lesions or the regrowth of previously excised disease. True recurrence differs from persistence, which results when endometriosis is left behind and not actually fully excised. Recurrence may be clinically suspected based on symptoms and can be confirmed through imaging or surgical findings.

Apart from surgery, are there any other risk factors that can lead to recurrence?

Apart from incomplete surgery, some factors can contribute to the recurrence of endometriosis, including but not limited to the presence of other gynepathologies, such as adenomyosis and/or concomitant adhesion; higher stages of disease; lesion subtype such as the presence of bowel lesions; and whether pharmacological therapy is used postoperatively or not. It is critical to note that the recurrence or persistence of pain is not always synonymous with the presence of endometriosis; secondary pain generators may often be present.

How does hormone medication work as a method of prevention for recurrence?

Hormonal medication aims to suppress the stimulation of endometrial-like tissue and inhibit its growth during therapy. It is intended to treat endometriosis-associated pain and theoretically can suppress recurrence while used. Drugs to treat endometriosis‐related pain include synthetic progestins, combined hormonal contraceptives, GnRH analogs, aromatase inhibitors, danazol, SERMs and SPRMs. While more recent publications indicate reduced reoperation rates for endometriosis in those who are treated with hormones in association with their surgery, a 2020 Cochrane Review exploring the effectiveness of hormonal suppression before, after or both before and after surgery for endometriosis determined that “the data was inconclusive.” Still, there is evidence that hormone suppression may help prevent postoperative recurrence, particularly endometriomas.

What is the rate of recurrence in endometriosis after excision and for what period of time?

Recurrence rates after endometriosis surgery vary widely and are operator-dependent. Rates are heavily influenced by factors such as extent of disease and completeness of surgical excision. Rates have been previously reported between 20%-40% within 5 years; however, more current data published by dedicated centers of expertise indicates overall rates of recurrence of less than 10%.

Is endometriosis a disease that can be cured?

There is no universal, definitive cure for endometriosis. Multidisciplinary treatments is directed at symptom management and meticulous removal of disease to reduce recurrence and persistence, with goals directed at alleviating symptoms and improving quality of life.

Is the presence of an endometrioma after surgery a sign of recurrence?

Endometriomas have a high recurrence/persistence rate, and their presence after surgery can indicate both persistence or true recurrence of the disease.

Why is the rate of recurrence higher in women under 25 years old or a bit older?

While risk predictors remain under debate, younger patients may have higher recurrence rates due to increased hormonal activity, i.e., higher plasma estrogen levels, more aggressive disease and disease subtype may be associated with endometriosis recurrence. In contrast, still other data indicates that those in the 35 + age group are positively associated with recurrence when compared to non-endometriosis controls, driving home the importance of patient-centric care adapted to the individual in order to apply tailored therapies for every patient.

What is the recurrence rate for bowel endometriosis based on the procedure done?

While the recurrence rate after colorectal surgery for endometriosis may be as high as up to 50% at 5 years, as with all forms of the disease this may vary based on the skill of the surgeon and type of surgical intervention. For example, current data implies that that the risk of recurrence is lower when segmental resection or disc excision is performed than when rectal shaving is performed.

What are the signs of endometriosis returning?

Clinical signs of endometriosis recurrence may be the same as or include those experienced at primary onset, i.e., pain (for example, persistent or new pelvic pain), changes in menstrual patterns, such as increased pain or heavy bleeding, recurrence of pain during or after sex, GI or urinary dysfunction/pain, bloating, fatigue and more. As with initial onset, timely diagnosis and effective intervention are key towards isolating and treating the diagnosis.

Can some of these symptoms be caused by adhesions?

Yes, symptoms such as pelvic pain and discomfort during intercourse can also be caused by adhesions, which are scar tissues that can form after surgery or due to chronic inflammation. Adhesions can cause similar symptoms to endometriosis and complicate the diagnosis and management, as can a number of other conditions including but not limited to adenomyosis, for example.

References

Nirgianakis K, Ma L, McKinnon B, Mueller MD. Recurrence Patterns after Surgery in Patients with Different Endometriosis Subtypes: A Long-Term Hospital-Based Cohort Study. J Clin Med. 2020 Feb 11;9(2):496. 

Magnani, L., Marchi, N., & Alvino, M. (2021). Genetic and epigenetic factors in endometriosis. Reproductive Biology and Endocrinology, 19(1), 92.

Schippert C, Witte Y, Bartels J, Garcia-Rocha GJ, Jentschke M, Hillemanns P, Kundu S. Reproductive capacity and recurrence of disease after surgery for moderate and severe endometriosis – a retrospective single center analysis. BMC Womens Health. 2020 Jul 13;20(1):144. Giudice LC, Oskotsky TT, Falako S, Opoku-Anane J, Sirota M. Endometriosis in the era of precision medicine and impact on sexual and reproductive health across the lifespan and in diverse populations. FASEB J. 2023 Sep;37(9):e23130.

Holdsworth-Carson SJ, Chung J, Machalek DA, Li R, Jun BK, Griffiths MJ, Churchill M, McCaughey T, Nisbet D, Dior U, Donoghue JF, Montgomery GW, Reddington C, Girling JE, Healey M, Rogers PAW. Predicting disease recurrence in patients with endometriosis: an observational study. BMC Med. 2024 Aug 7;22(1):320.

Chiu CC, Hsu TF, Jiang LY, Chan IS, Shih YC, Chang YH, Wang PH, Chen YJ. Maintenance Therapy for Preventing Endometrioma Recurrence after Endometriosis Resection Surgery – A Systematic Review and Network Meta-analysis. J Minim Invasive Gynecol. 2022 May;29(5):602-612.

Vercellini P, Bandini V, Viganò P, Di Stefano G, Merli CEM, Somigliana E. Proposal for targeted, neo-evolutionary-oriented, secondary prevention of early-onset endometriosis and adenomyosis. Part I: pathogenic aspects. Hum Reprod. 2024 Jan 5;39(1):1-17. 

Zakhari A, Delpero E, McKeown S, Tomlinson G, Bougie O, Murji A. Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis. Hum Reprod Update. 2021 Jan 4;27(1):96-107

Vercellini P, Somigliana E, Viganò P, De Matteis S, Barbara G, Fedele L. Post-operative endometriosis recurrence: a plea for prevention based on pathogenetic, epidemiological and clinical evidence. Reprod Biomed Online. 2010 Aug;21(2):259-65.

Ceccaroni M, Clarizia R, Mussi EA, Stepniewska AK, De Mitri P, Ceccarello M, Ruffo G, Bruni F, Rettore L, Surico D. “The Sword in the Stone”: radical excision of deep infiltrating endometriosis with bowel shaving-a single-centre experience on 703 consecutive patients. Surg Endosc. 2022 May;36(5):3418-3431.

Lv H, Liu B, Dai Y, Li F, Bellone S, Zhou Y, Mamillapalli R, Zhao D, Venkatachalapathy M, Hu Y, Carmichael GG, Li D, Taylor HS, Huang Y. TET3-overexpressing macrophages promote endometriosis. J Clin Invest. 2024 Aug 14:e181839.

Fallon L, Lau AYS, Ciccia D, Duckworth TJ, Pereira C, Kopp E, Perica V, Sherman KA. Perceived challenges in treatment decision-making for endometriosis: healthcare professional perspectives. Health Psychol Behav Med. 2024 Aug 1;12(1):2383469.

Holdsworth-Carson SJ, Chung J, Machalek DA, Li R, Jun BK, Griffiths MJ, Churchill M, McCaughey T, Nisbet D, Dior U, Donoghue JF, Montgomery GW, Reddington C, Girling JE, Healey M, Rogers PAW. Predicting disease recurrence in patients with endometriosis: an observational study. BMC Med. 2024 Aug 7;22(1):320. 

Kikuchi I, Takeuchi H, Kitade M, Shimanuki H, Kumakiri J, Kinoshita K. Recurrence rate of endometriomas following a laparoscopic cystectomy. Acta Obstet Gynecol Scand. 2006;85(9):1120-4.

Guo SW. Recurrence of endometriosis and its control. Hum Reprod Update. 2009 Jul-Aug;15(4):441-61.

Holdsworth-Carson SJ, Chung J, Machalek DA, Li R, Jun BK, Griffiths MJ, Churchill M, McCaughey T, Nisbet D, Dior U, Donoghue JF, Montgomery GW, Reddington C, Girling JE, Healey M, Rogers PAW. Predicting disease recurrence in patients with endometriosis: an observational study. BMC Med. 2024 Aug 7;22(1):320.

Martire FG, Piccione E, Exacoustos C, Zupi E. Endometriosis and Adolescence: The Impact of Dysmenorrhea. J Clin Med. 2023 Aug 29;12(17):5624. 

Bendifallah S, Vesale E, Daraï E, Thomassin-Naggara I, Bazot M, Tuech JJ, Abo C, Roman H. Recurrence after Surgery for Colorectal Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol. 2020 Feb;27(2):441-451.e2.

Alborzi S, Roman H, Askary E, Poordast T, Shahraki MH, Alborzi S, Hesam Abadi AK, Najar Kolaii EH. Colorectal endometriosis: Diagnosis, surgical strategies and post-operative complications. Front Surg. 2022 Oct 4;9:978326.

The post Dr Jose Eugenio Colon-Recurrence in endometriosis appeared first on Endo Daily News.

Excision clearly means the complete removal of endometriosis. Ablation depends very much on the surgeon as well as the condition of the implant or tumor. In many cases small parts of endometriosis might be left behind so that a recurrence has to be taken into consideration.

Because endometriosis can involve various structures, with varying degrees of infiltration, surgery is considered as one of the most challenging surgeries in gynaecology. It is one that not many surgeons are doing. With this in mind, what is the purpose of surgery in endometriosis?

Unfortunately, medical therapy for endometriosis including endometriosis associated pain is only symptomatic and does not remove the endometriosis implants. Therefore, surgery is still in many cases the only way to help stop the suffering of affected women.

One of the biggest controversies is ablations vs excision. Some doctors claim that both procedures are pretty much the same. From a surgical point of view, what is ablation and what is excision?

Excision clearly means the complete removal of endometriosis. Ablation depends very much on the surgeon as well as the condition of the implant or tumor. In many cases small parts of endometriosis might be left behind so that a recurrence has to be taken in consideration.

We know that excision is used in cancer, whereby a piece of tissue with margins is removed in order to fully remove the disease. In endometriosis, how is excision executed? Do we have a margin as well?

Since fortunately endometriosis is not a malignant disease it is not necessary to have a safety margin. However, in a lot of cases endometriosis has no clear circumference and might even infiltrate the surrounding healthy tissue so that a wide excision is advised

What is the youngest and the oldest patient that you have operated on?

The youngest patient was a young girl of 16 years with a family history of endometriosis where her mother knew from the beginning of hearing her daughter complain of severe menstrual pain that this could be endometriosis.

The oldest patient was clearly postmenopausal perhaps in her late 50ies or early 60ies. She had endometriosis before which was not completely removed and as she knew the symptoms came for final surgery.

Gateway Clinics GmbH, Amelia-Mary-Earhart Straße 17, Frankfurt am Main, Germany
Photo source: courtesy of NSSU

Studies and patients’ experience show excision to be the best method for improving symptoms on a long term. However, this depends on if all visible or palpable diseases have been excised. In some cases, results may not be permanent, and endometriosis may return. So, what is the principle of excision? Is it to avoid organ damages, or to save reproductive organs? Is it to remove the source of the pain?

Probably the most important reasons or indications for endometriosis surgery is to remove the source of pain as this is sometimes debilitating for the women affected. Also, vital structures in the pelvis need to be protected from being damaged by endometriosis as for instance endometriosis can strangulate the ureter and thereby cause severe kidney problems including insufficiency of the kidney. Of course, in those women that had not completed their family planning surgery might involve a compromise as maintenance of reproductive organs is of utmost importance.

In endometriosis some say there is no cure, others say excision is the cure. When surgery is done and all the disease is removed, is that person cured, even if it might be temporary? Or only if they have no more symptoms?

As menstruation is in most cases the reason for endometriosis a woman in her reproductive age that wants to become pregnant and therefore menstruates regularly might have a stimulus for recurrence of endometriosis with every menstruation even though the excision has been complete. So in principle, the disease was cured but due to a normal condition (i.e. menstruation) it was reignited.

In some cases, despite surgery being executed correctly, patients have little or no improvements. What can be the cause, or what explanation do we have in this case?

This is the most difficult question as it might be that the initial diagnosis was not correct, and the pain should be linked to other reasons than endometriosis. There are many differential diagnoses including psychological causes like post-traumatic disorders. Therefore, pre-surgical diagnosis must be executed very carefully as it is not easy.

Given your experience, in patients that had 10 or more surgeries, and they are still in pain, will another surgery help them, or it won’t bring them much improvement?

This very much depends! Unfortunately, we see patients that had multiple incompetent surgeries where the disease was only removed superficially. In those cases, a thorough diagnosis with excellent imaging and precise pain mapping following the description of the patient is absolutely mandatory in order to decide whether the patient will benefit from another surgery.

Despite having surgery done correctly, or in some cases, by the same doctor, results are different. Some patients have a higher symptom improvement, and others far less. What can be the reason?

First of all: pain is quite subjective which might already explain the differences. In addition, especially in case of several previous surgeries side effects of these operations might be the reason for continuous pain or discomfort.

We know that excision is a procedure that requires high knowledge of pelvic anatomy and high level of surgical skills in order to remove the disease in a safe and efficient way. From this point of view is ablation easier and why is it inefficient in endometriosis?

Endometriosis is a disease that involves several disciplines in addition to gynaecology. Particularly in deep-infiltrating-endometriosis it is best if the surgeon is experienced in gynecology, bowel surgery as well as in urology. If the surgeon shies away from operating in a different disciplines area than his or her own than incomplete removal of the diseased tissue is very common as we see in many cases of ablation.

The pelvis has anatomical danger zones where there is a risk of damaging underlying structures. When it comes to ablation, they say that it can be used in said zones due to damaging organs, hence why excision is better. What are the basic surgical principles employed in excision in order to fully remove the disease and avoid damage to these organs?

As mentioned above excision means the complete removal of the disease. Even if endometriosis is close or involving important and vital structures or organs excision needs to be performed in order to prevent further destruction of that particular region. This might involve that e.g. autonomous nerves can be destroyed causing bladder dysfunction. In ideal cases the pre-operative diagnosis is so precise that this instance can be suspected and needs to be discussed with the patient. Then it will be her decision whether the unhealthy tissue should be completely removed, or parts should be left behind possibly causing recurrence of the disease already after a short interval. I think it is only fair to the patient to explain not only the procedure but also the limitations of surgery.

Do we have limitations in excision? Meaning are any types of cases where excision can’t be used?

If family planning is a vital issue removal of endometriosis of any reproductive organ has to be performed extremely carefully meaning that sometimes endometriotic tissue has to be left behind. For example, ovarian endometriosis has to obey the ovarian reserve so that production of oocytes is still possible. Another example might be brain endometriosis (which fortunately is quite rare) where the surrounding tissue needs to be protected from radical surgery. In bladder endometriosis implants close to the trigon (i.e. where the ureters end in the bladder) must carefully be respected as otherwise innervation of the bladder might be compromised or even the function of the ureter could be impaired.

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As of yesterday another endometriosis warrior is advocating for endometriosis changes in heaven. A well-known Kenyan endometriosis patient and a radio host, Jahmby Koikai has died after a long battle with endometriosis. Although the cause of her death is not known, one can only wonder if the damages done by endometriosis have contributed to her short lived life.

A heavily underdiagnosed and mistreated condition, it took Fayah Mama 17 years until she received her diagnosis. And that was only the starter of her journey. 

She had 21 surgeries for a disease that is considered harmless 

Millions of people around the world are suffering, struggling to get timely diagnosis and treatment that so much is needed. Ignored by doctors, being told that painful periods are part of being a woman, being sent home from hospitals as nothing can be seen on scans, endometriosis sufferers are left with little to no choices. Endometriosis might not kill you directly, but it can make one’s life a living hell. 

Amongst these millions there are some really brave sufferers that voice their experiences hoping for a change. Using social media as a platform, they provide help and guidance for fellow sufferers and  to reduce the impact of this neglected disease. 

Fayah Mama battled thoracic endometriosis and she spent a year in the USA after the condition took a toll on her. She had prior to that dozens of incomplete surgeries that left her battered and with more damage than before. 

In a recent social media post, she was urging Kenyan politicians to address the issue of  endometriosis and to learn from esteemed endometriosis specialists and personalities from the USA on how to manage endometriosis. From a hospital bed, Fayah never stopped to advocate for her fellow endometriosis warriors. With incredible strength and resilience, she was a beacon of light in our global communities.  Her relentless advocacy for high-quality treatment and awareness has left an indelible mark on our hearts. 

Despite her wounds, Fayah fought for changes until her last breath. Her work and fight will without any doubt be continued by other brave endometriosis warriors. For the generations to come, changes in how endometriosis is diagnosed and treated are imperative.

Photo source: Jahmby Koikai Facebook.

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What is adenomyosis and what are its symptoms?

Adenomyosis is a condition in which tissue similar to the endometrium, the lining that lines the inside of the uterus, grows in the thick muscle of the uterus, called the myometrium.

The exact causes of adenomyosis are not fully understood, but there are several theories and factors that may contribute to the development of this condition:

Invasion theory: According to this theory, endometrial tissue migrates into the uterine muscle through tears in the uterine wall, such as scars from previous surgeries (such as cesarean section) or injuries due to inflammation.

Metaplasia theory: This theory suggests that uterine muscle (myometrium) cells transform into endometrial-like cells under the influence of hormonal or other factors.

Hormonal factors: Hormones, especially estrogen, appear to play an important role in the development of adenomyosis. High levels of estrogen in the uterus of certain women favor the growth and proliferation of endometrial tissue.

Inflammatory factors: Chronic inflammation of the uterus or other pelvic organs can contribute to adenomyosis. This can be caused by repeated infections or other pelvic inflammatory conditions.

Genetic factors: There is some evidence to suggest that genetic predisposition may play a role in the development of adenomyosis, but this aspect is still being researched and understood.

Factors related to age and parity: Adenomyosis is more common in middle-aged women and those who have had several children. This could be related to hormonal changes and the impact of pregnancy on the uterus over time.

It is important to note that these causes can interact with each other and vary from person to person. Adenomyosis is a complex condition and research continues to better understand its developmental mechanisms.

Symptoms of adenomyosis can include chronic and intense pelvic pain, severe menstrual cramps, heavy and prolonged menstrual bleeding, pain during intercourse, bloating, and sometimes infertility through deformation of the uterine cavity and decreased implantation rate or abortion.

What are the types of adenomyosis and how can it be diagnosed?

There are two main types of adenomyosis: focal and diffuse. Focal adenomyosis refers to the localized presence of endometrial tissue within the uterine muscle, while diffuse adenomyosis involves a wider spread of this tissue.

The diagnosis can be established by a combination of a detailed history, clinical examination and imaging examinations. These patients must be listened to and believed. We perform a complete clinical history, gynecological examination, but the diagnosis is made by transvaginal ultrasound. Complementary – adenomyosis can also be seen at hysteroscopy or nuclear magnetic resonance.

Unlike endometriosis, in adenomyosis the only surgical option to cure the disease is hysterectomy. When can hysterectomy be performed, especially in young patients?

The choice of the type of treatment for adenomyosis must be personalized and individualized and depends on a number of factors:

Severity of symptoms: If the symptoms of adenomyosis are moderate to severe and affect the patient’s quality of life, more radical treatment may be necessary

Desire for fertility: For women who wish to become pregnant in the future, treatments that preserve the uterus and fertility may be preferred. In this case, hormone therapies or surgery that preserves the uterus will be considered.

Medical history: The patient’s medical history, including previous surgeries or other medical conditions, may influence treatment options and associated risks.

Reaction to previous treatments: If the patient has previously tried certain treatments and they were not effective or were associated with unwanted side effects, this may influence the decision to try other therapeutic options.

Patient preferences: It is important to consider the patient’s preferences and values in the decision-making process. Some women may prefer conservative treatment that preserves the uterus, while others may be more willing to opt for hysterectomy to relieve symptoms. Also, many women are against hormonal treatments, either because they are real contraindications or because they are misinformed or out of fear. We always respect the patient’s opinion.

Age of the patient: The age of the patient can influence the treatment decision. For older women who no longer wish to become pregnant, options including hysterectomy may be considered earlier.

Hysterectomy is considered by many to be the only curative option for adenomyosis, because it completely removes the uterus – the organ where the problem is. However, in young patients who wish to preserve fertility, hysterectomy may be reserved for severe cases or those where other treatment options have failed to provide relief.

In general, in young patients, hysterectomy is the last option, when all others have been exhausted. We take into account the severity of the symptoms and the completion of family planning. If all these factors are aligned – we reach the decision of hysterectomy, of course with the preservation of the ovaries – in order not to induce an early menopause.

Hormonal treatment is a recommended therapeutic option for many women who suffer from adenomyosis. What are these treatments and what are their benefits and risks?

Hormonal treatment – is used in the management of adenomyosis symptoms. It has no curative role. This includes oral contraceptives, either combined or progestogen-only, hormone-releasing intrauterine devices (such as Mirena), hormone injections, hormone patches or implants.

They work by changing the hormonal balance of the body and by controlling the menstrual cycle, namely:

Ovulation suppression: Hormonal contraceptives suppress the release of eggs from the ovaries, thereby reducing the production of estrogen during the menstrual cycle. Because high estrogen levels are associated with the development and growth of endometrial tissue, suppressing ovulation may help reduce the abnormal growth of endometrial tissue in the uterine muscle in adenomyosis.

Thinning of the endometrium: All hormonal preparations can cause thinning of the endometrium. This can reduce heavy menstrual bleeding and pain associated with adenomyosis.

Preventing the formation and growth of endometrial lesions: By suppressing the menstrual cycle and thinning the endometrium, hormone therapy can reduce the formation and growth of new adenomyosis lesions in the uterine muscle.

Control of symptoms: Finally, as I said – Hormonal treatment has a fine goal – control of symptoms associated with adenomyosis, such as chronic pelvic pain and severe menstrual cramps, pain on contact, prolonged or even intermenstrual bleeding. However, they have no effect on infertility.

And although we have listed multiple benefits, there may also be risks associated with the use of these therapies, such as: changes in body weight, changes in mood, libido, increased risk of blood clots. Perhaps the biggest risk of hormone therapy is – futility. It does not work for all patients.

Adenomyosis is a disease of the uterus. One of the therapeutic methods is Mirena. What is this device and how does it work?

The Mirena IUD is an intrauterine device that we insert into the uterus and that releases a hormone called levonorgestrel, a derivative of progesterone.

It works by thinning the uterine lining and reducing menstrual bleeding and pain associated with adenomyosis. In addition, the expression of aromatase and COX2 decreases – 2 absolutely important enzymes in the formation of local estrogen – the main hormone in adenomyosis.

When can the placement procedure be carried out? Is a certain preparation necessary? Is it only done on certain days of the cycle?

The IUD placement procedure can be performed routinely during a gynecological office visit. Although it can be fitted at any time during the menstrual cycle – we prefer the placement to be performed during menstruation, when the cervix is more open – the fitting being easier both for us as gynecologists and for the patients. I repeat it is not mandatory. No special preparation is needed before the procedure, but the doctor may recommend taking a pain reliever before the placement.

Is it painful to insert and how do you know when it’s still in place?

Insertion of the IUD may be slightly uncomfortable and associated with mild cramping, but is usually not painful and does not require general anesthesia, although local anesthesia should be performed. There is a little discomfort during installation – but that’s about it. The doctor will use an instrument called a speculum to see the cervix and then insert the IUD through the cervical canal into the uterine cavity. However, insertion can be difficult in patients with severe adenomyosis – the uterine cavity being very deformed. After placement, the doctor will check the position of the IUD with transvaginal ultrasound, maybe even with 3D reconstruction.

What are the complications that can occur?

Complications associated with having a Mirena inserted can include:

rejection – being a foreign body – in some patients the uterus cannot bear it – this is manifested by menometrorrhagia (small bleeding) corns and uterine cramps. The first 3 months are decisive.

uterine perforation during insertion

the involuntary expulsion of the device – the risk being higher in the first 6 months after installation, but also in people with many births and large uteruses

pelvic infections;

increased risk of ectopic pregnancy – progesterone affecting tubal motility – slowing the movement of cilia in the tubes and increasing the risk of ectopic pregnancy;

weight gain – mainly due to water retention

How effective is it and for how long? 

The efficiency of the Mirena IUD in the treatment of adenomyosis is considered good – if we talk about the painful symptoms. Studies have shown a significant reduction in dysmenorrhea and dyspareunia. In terms of bleeding, the efficiency is very good – many of the patients even reach the absence of menstrual bleeding – altogether. However, there are also many patients – for whom MIRENA does not work, the adenomyosis progresses and the symptoms get worse with the IUD. The cause is being studied. It may have to do with the different etiology of some forms of adenomyosis – let’s not forget that Mirena is a symptomatic treatment – it does not affect the cause. The studies missed that although it has an effect on the symptoms – the Mirena IUD has no effect on the changes inside the uterus.

Until recently – its duration of action was considered to be 5 years – more recent studies have shown that even after 10 years the IUD releases a smaller amount of hormone. Mirena can be removed at any time.

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From a young age as women we are taught that period pain is normal. Many of us have been told that nothing can be done, and in some homes/cultures speaking about periods is a taboo. how would you explain to a 9-10 year old what a period is?

I think the first thing to remember is that it really IS important to talk about periods in the first place. As you said, too many people still don’t, because they think it’s embarrassing, or something to hide, or even in some cases, “dirty” – none of which are true, of course, but these assumptions can even be generational and persist in many settings today. Everyone should feel comfortable talking about their bodies and understanding what’s happening to them. 

Also, talking about periods helps everyone understand and reduces societal taboos attached to menstruation. It’s key to have the conversation in a way that meets individuals where they are, though – you want to frame the discussion in a way that’s factual, informative and invites questions, but which is also age-appropriate in terms of health literacy, simplistic, and of course culturally sensitive. 

The critical messaging is that periods are not anything to be ashamed of and everyone should be able to manage theirs comfortably and with dignity. And the REALLY vital part of the conversation is helping an adolescent to understand what’s normal and what’s not. If period pain – which is such a hallmark symptom of endometriosis for so many, even though it’s not a ‘menstrual disease’ per se – is keeping you home from school, out of sports, interrupting your social life, that’s not normal, but you don’t have to suffer silently.

”Periods are not anything to be ashamed of and everyone should be able to manage theirs comfortably and with dignity”

Is there anything to be ashamed of when you have your period?

Absolutely not. I recognize the persistent stigmas which continue to surround menstruation, however, which are so unfortunate because they perpetuate a lack of body literacy and an unnecessary legacy of shame associated with periods. It can also have real implications for health, by reducing care-seeking, for example, which leads to sustained diagnostic delays and treatments where diseases like endometriosis are concerned. In fact, the concept of menstruation being considered the “fifth vital sign” has become the norm over the past two decades, emphasizing the importance of menstrual health as a key indicator of overall well-being similar to other vital signs like temperature, blood pressure, heart rate, and respiratory rate.

Given the high number of people affected by endometriosis, should endometriosis be part of their curriculum as a way of preventing endometriosis complications?

Without a doubt. Some of the reasons we have pushed for formal legislation that includes endometriosis education and why we support programs like EndoWhat’s School Nurse & Practitioner Kit is because early intervention is critical for management of this disease. All students should be made aware of endometriosis and its symptoms, so that it helps lead towards earlier diagnosis and treatment. 

Through education also comes empowerment. And again, although it’s not just a ‘painful period,’ the association of endometriosis with menstruation is common for many; however, the association also promotes misinformation and stigmas about the disease. Including it in curricula helps bring endometriosis out in the open, reducing taboos and promoting open – accurate – conversation.  Talking about the disease in the academic setting also improves body and health literacy, which is important for self-advocacy and supporting initiatives aimed at reducing diagnostic delays and choosing the best treatment for oneself.

What will be the most important thing that young people should know about endometriosis? 

If I can only choose ONE key element, I would say it’s imperative that adolescents are taught to recognize the symptoms of endometriosis, including and especially those which are not what society typically recognizes (e.g., painful menses) – it’s so much more than just so-called killer cramps, with symptoms that can include severe abdominopelvic pain, pain during or after sex, painful bowel movements, painful urination, even collapsed lung in some cases and a whole host of systemic effects. Knowing the signs can help individuals seek care earlier and get proper treatment.

Should young people be taught that painful periods might be endometriosis? 

I know I dwell endlessly on the fact that endometriosis isn’t just a ‘painful period’ and that it’s a whole-body disease which can affect those who menstruate as easily as those who don’t, but I do think it’s really imperative that individuals learn from an early age that while periods can be uncomfortable for some, they shouldn’t interrupt your life. The misconception that severe menstrual pain is normal and is just something someone has to endure contributes to delays in diagnosing and treating endometriosis. If you’re missing school or work or sports or social functions because of pain and symptoms, it’s a sign that something is WRONG. 

The whole reason we continue to see an average of a decade-long delay in diagnosis with this disease is because society – medical professionals to patients, parents to children, peers to each other – is so entrenched in this mistaken belief that periods are supposed to be debilitating. This misconception is so deeply rooted in norms and cultural beliefs! It’s so far past time to promote open conversations and break the silence surrounding menstrual health, so we can empower every individual to advocate for themselves and seek appropriate care when needed. 

Endometriosis is considered a disease that affects mainly fertile women. How is it in reality? 

It’s really important to continue to debunk stereotypes surrounding endometriosis. First, the disease occurs at various ages, including adolescents and postmenopausal individuals. There are also reports in the scientific literature of the disease being found in fetuses (and a few men, while we’re at it). So while it may become more symptomatic during reproductive years (and more importantly, that’s when a patient frequently receives a diagnosis after being dismissed for a decade or longer), it’s definitely possible for endometriosis to be painful earlier or later in life. 

It’s also imperative to recognize that even though the disease can and does affect individuals regardless of fertility status or gender identity (i.e., transgender men/non-binary/gender-diverse individuals) due to vast healthcare disparities and inherent biases, too often the emphasis is still being placed on procreative potential vs. quality of life or pain – so sometimes it’s not until the patient is unsuccessful at conceiving that they are even able to obtain a diagnosis in the first place. So again, while endometriosis is often discussed in the context of its impact on fertility and reproductive health, it’s actually a far more complex disease than just simply a ‘menstrual issue’ or ‘fertility disorder.’

Due to being a disease that not many speak about, some young people might believe that they are the only one that is weak. Is being in pain a sign of weakness? 

No! Pain is a common human experience that occurs for assorted reasons – injury, illness, etc. Experiencing pain – and showing it – is not a reflection on a person’s strength and we’ve got to do better as a society at rewarding pain silencing. Telling people to ‘fight through it’ or otherwise minimizing their pain, teaching them to hide their pain, all of this is so HUGELY problematic. It contributes to a culture where people feel pressured to suppress pain rather than seek appropriate help and support. This has profound consequences for both physical and mental health and serves only to perpetuate harmful beliefs about suffering. To be clear – pain is real. 

It’s a complex phenomenon that involves physical, emotional, and psychological components, which our bodies alert us to as a way of saying something is wrong. And this notion that the higher one’s pain tolerance, the better a person they are is SO damaging – in fact, we should be recognizing that pain tolerance varies from person to person and is influenced by so many factors…just because someone experiences pain differently or finds it challenging to cope with doesn’t mean they are weak. It actually takes a lot of strength to seek care and support! 

Acknowledging and addressing our pain, making steps towards getting help to healing, reaching out for support and advocating for oneself – those things actually take a lot of courage, resilience and strength. Those are not signs of weakness! It’s far past time we started validating and supporting individuals experiencing pain, and showing empathy in how we respond – for both others as well as ourselves. There are no badges of honor being given out for ignoring pain – especially someone else’s. 

It is well known that endometriosis can cause severe issues. Can these issues be prevented through education? 

I’m not sure it’s fair to say education can prevent complications of the disease or progression of symptoms, but I do think it’s abundantly clear that education=empowerment and can change how and when a person advocates for themselves in terms of care seeking, demanding intervention and obtaining the care they deserve towards disease management. 

There are many myths about endometriosis, from pregnancy is a cure to removing organs. Why are none of these a cure for endometriosis?

Where to begin? First, there is no cure for endometriosis. We’re still not even certain what causes the disease and every theory is just that – a theory. And all of them are the subject of heated debate. Probably the fairest thing we can say is that it’s a combination of factors as to why the disease happens in the first place. It’s also really imperative that we acknowledge there isn’t a one-size-fits-all approach to the disease; what works for one may not work for another, and even more importantly, it’s likely a comprehensive, interdisciplinary, multidisciplinary, integrative approach is best. While it’s true a hysterectomy or oophorectomy may bring relief for some, neither are curative. 

The disease has to be treated in all the other areas it impacts as well. Leaving disease behind to persist is most likely going to continue to cause symptoms. So that’s not a cure. Nor is pregnancy, which is rooted in the antediluvian idea that because some folks in the early endometriosis literature indicated they felt better temporarily during pregnancy (i.e., due to changes in hormone levels, menstrual cessation, etc.), this meant the disease was eradicated. 

Pregnancy doesn’t cure endometriosis and is not a ‘treatment’ for the disease at all. We need healthcare providers to stop prescribing pregnancy…it’s 2024, not 1920, and its high time this myth be put to bed for good. 

“Is all in your head”. Most doctors who do not know endometriosis often tell their patients that their pain is not real. if there is a dangerous phrase this one is for sure. How can one know who is a specialist in endometriosis? 

This is the one that gets me the most upset, I think. By invalidating and dismissing someone’s very real pain, which often impacts their entire life on every level and in every domain, is so dangerous. Really egregious conduct on the part of a practitioner who swore an oath to First, Do No Harm, actually.  

When healthcare providers dismiss endometriosis pain as psychosomatic, it leads to delays in diagnosis and treatment, makes an individual less likely to seek medical help, further impacts their emotional and physical health, isolates them and makes them doubt their own bodies – on which they are the ONLY experts, by the way, undermines their trust in the healthcare system and so much more. Importantly, it can also lead to untreated or poorly managed endometriosis that results in complications (infertility, adhesions, chronic pain, etc.). 

Finding someone who validates you, treats you as a partner in your care, has a compassionate bedside manner, admits they don’t have all the answers, is willing to refer to interdisciplinary specialists, and/or who themselves possess the vast skills needed to treat the disease effectively on a patient-centric basis is a little bit like finding a needle in the proverbial haystack of this community, as anyone can call themselves an endo specialist when in fact no such accreditation exists – but thankfully there are practitioners out there who CAN help. 

Ask for peer referrals to start – patients know best who is successful at treating the disease. Find out about their annual volume – do they have a dedicated practice that is primarily directed at treating the disease? Or do they ‘dabble’ in endometriosis along with obstetrics and general obgyn practice? It’s ok to ask. Do they collaborate with a team to treat the disease fully i.e., a colorectal surgeon for bowel disease, physical therapists for adjunct care, so forth. Check into their reviews. No one is perfect, for sure, but are the majority of reviews good? 

Why is it important for young people to know about endometriosis? 

All people should know about endometriosis. It is an incredibly complex, systemic inflammatory disease (characterized by the presence of endometrial-LIKE tissue located elsewhere in the body) that affects nearly 200 million women and girls and unmeasured amounts of gender diverse individuals around the world. It’s a really insidious disease that can have far-reaching consequences, which for many can be catastrophic and disruptive – including one’s work life and earning potential, something which is often left out of the conversations on the disease. 

It’s a public health crisis that imposes annual direct and indirect costs in just the USA alone of nearly 70 billion annually. It’s time everyone knows about endometriosis – young people included and maybe even especially, so that we can help promote early recognition, timely intervention, and more compassionate care at the first signs of the disease…not 10, 12 or 20 years into the person’s painful journey. It’s also imperative to correct as much of the widespread misinformation we continue to see, whether it is an article in the media or yet another celebrity’s story about endometriosis that contains absurdly incorrect details. 

Misinformation has real consequences and contributes to the ongoing barriers to quality care, keeps the disease positioned as just painful periods or a menstrual condition only of women of reproductive age, and much more. Real, substantive, intersectional issues that have to be confronted and addressed – because lives depend on it. Knowledge is power: it allows individuals to prioritize their health, seek appropriate support, and advocate for themselves and actively participate in their own healthcare decisions. No one should be suffering in silence with endometriosis – or as is too often unfortunately still the case, screaming to be heard.

The post Heather Guidone: Why Is It Important For Young People To Know About Endometriosis? appeared first on Endo Daily News.

The hysteroscope is a medical instrument used to visualise the inside of the uterus. It involves the insertion of a telescope with a camera, which can be of varying sizes depending on the purpose of the hysteroscopy – thinner, just visualisation, then it is called diagnostic hysteroscopy, or to treat a condition, in this case the instrument has a larger diameter and is called operative hysteroscopy.

What conditions can it be used for?

Hysteroscopy is a commonly used investigation in the Department of Assisted Human Reproduction and In Vitro Fertilisation for patients with infertility. It plays an essential role in the treatment of synechiae, septations, conformation abnormalities of the uterine cavity, excision of intracavitary formations such as polyps or fibroids, but it is also extremely useful in oncology for endometrial biopsies or endometrial ablations. Young breast cancer patients with estrogen receptors present will undergo hormonal treatment for 5 to 10 years. Tamoxifen has as an adverse reaction the thickening of the endometrium, the formation of endouterine polyps and later endometrial cancer may even occur. Patients on Tamoxifen require close ultrasound monitoring of the endometrium, even every 3-4 months to detect in time when a change occurs. Hysteroscopy is essential in these cases, because it differentiates between endometrial thickening, or the presence of a polyp and also resolves the problem with a minimally invasive procedure after which the patient goes home the same day.

When can it be performed under sedation?

Only diagnostic procedures are usually performed without sedation, for operative procedures sedation is required because of discomfort for the patient. If a long hysteroscopy follows it can even be performed under spinal anaesthesia.

How is it performed?

Depending on the diameter of the hysteroscope it may or may not be necessary to dilate the cervix anteriorly. It is penetrated through the cervical canal (through the cervix) into the uterine cavity, the cavity is emptied with fluid (the choice of fluid depends on the type of hysteroscopy, whether it requires the use of electrosurgery or not) and with the help of various instruments, under permanent visual control, we perform the surgery.

What are its complications?

Complications can occur at different stages:

 -cervical dilatation – creation of a false pathway and perforation

-during the hysteroscopy itself: when excising large fibroids that reach close to the uterine surface, perforation may occur or if the operation lasts a long time, complications may arise from the intravasation of the fluid used. The uterine synechiae can be very difficult and in general perforation remains the most common complication.

Complications are however very rare, rarer than in the case of uterine curettage, due to the fact that everything takes place under visual control, but if they occur, they are usually treated conservatively.

How do we prepare for hysteroscopy and how long does it take?

Preparation may require medication beforehand to facilitate dilation of the cervix, but on the day of surgery it is recommended that the patient does not consume fluids or food if sedation is required.

You are a specialist in gynecological oncology and are part of the Medicover Endometriosis Centre team. In the literature we find cases of endometriosis undergoing malignant transformation. What can you tell us about this?

Endometriosis is a fairly common disease, but fortunately there are rare cases where endometriosis is associated with malignancy and this is the case with endometriotic ovarian cysts. I have encountered two cases so far, and the confirmation came after histopathological results on paraffin. All tissues that are removed during surgery should be sent to pathology for microscopic examination. The good part, if there is such a thing in oncology, was related to the good prognosis of both cases.

How do you see endometriosis as a woman, but also as a doctor who participates in endometriosis operations? 

I find it dreadful as a disease and extremely difficult in terms of complexity of surgery. It affects young women of childbearing age who have extremely painful menstrual periods, or heavy menstrual flow, pain during sexual intercourse, problems with defecation or urination and the list goes on. These symptoms can be debilitating, so that patients with endometriosis can become unable to carry out normal activities. Surgical interventions are laborious and must necessarily be performed by surgeons with experience in endometriosis, because an incomplete intervention guarantees a quick relapse. 

What should a young woman who has severe menstrual pain know? 

Some women have significant menstrual pain all their lives, without necessarily being related to endometriosis, but if it worsens or is associated with other symptoms, they should seek a gynaecological consultation with a doctor specialising in diagnosing endometriosis.

However, all women should have an annual gynaecological and breast check-up, because screening saves lives in oncology.

The post Dr Mihaela Radu: Hysteroscopy and its role   appeared first on Endo Daily News.

The pathophysiology of postoperative adhesions involves a cascade of events regulated by various cellular and humoral factors, including insufficient peritoneal fibrinolytic capacity (Hellebrekers & Kooistra, 2011). The formation of postoperative adhesions is a natural consequence of surgical tissue trauma and healing (“Control and prevention of peritoneal adhesions in gynecologic surgery”, 2006). Animal studies have shown that administration of TGF-␤ to the postoperative abdomen enhances the formation of adhesions, while blockade of TGF-␤1 via inhibitory antibody treatment decreases the formation of adhesions (Boland & Weigel, 2006). 

Furthermore, it has been suggested that insufficient peritoneal fibrinolytic capacity is the main factor in determining postoperative adhesion formation (Hellebrekers & Kooistra, 2011). Despite meticulous surgical techniques, postoperative adhesions develop in the majority of patients undergoing abdominopelvic surgery (Diamond, 2016). 

To prevent the formation of postoperative adhesions, various strategies have been proposed, including the use of bioabsorbable materials (Hamaji et al., 2015), ovarian suspension in patients undergoing laparoscopic surgery for endometriosis (Giampaolino et al., 2019), and pharmacologic agents such as anti-inflammatories, antiestrogens, and antioxidants (Öner & Ulug, 2015). Additionally, the use of neurokinin-1 receptor antagonists (Reed et al., 2008), naproxen nanoparticle-loaded thermosensitive chitosan hydrogel (Wang et al., 2019), and traditional Japanese medicine Tokita et al. (2011) have also been investigated for their potential in preventing postoperative adhesions. 

Moreover, the effectiveness of sodium hyaluronate, sesame oil, and liquid paraffin in preventing postoperative surgical adhesion formation has been evaluated (Khorshidi et al., 2017; Kataria & Singh, 2016). Other studies have examined the use of bioresorbable hyaluronate-carboxymethylcellulose membranes (Mueller et al., 2000), interferon γ, and plasminogen activator inhibitor 1 Ohashi et al. (2014) as potential preventive measures. 

In conclusion, the prevention of postoperative adhesions is a complex and multifaceted issue, and various approaches have been explored to address this challenge. Further research, including pre-clinical and clinical studies, is necessary to evaluate the effectiveness of these prevention strategies and to develop comprehensive guidelines for their implementation. 

The post Dr Ramiro Cabrera: Postoperative adhesions  appeared first on Endo Daily News.

Endometriosis is a benign, chronic pathology that patients face throughout their lives, therefore early diagnosis and correct management are essential.

Endometriosis is a common disease among young women, but it can affect women of any age. It is estimated that 1 in 10 women suffer from endometriosis, with approximately 176 million women in the world with this diagnosis.

Can endometriosis affect fertility?

Current data show that between 25% and 50% of infertile women have endometriosis and that 30-50% of patients with endometriosis are infertile.

A couple without fertility problems has a 15-20% chance of getting pregnant within a month, but in patients with endometriosis these chances are reduced to 2-10%.

Current medicine has not been able to fully explain the relationship between endometriosis and infertility, however several mechanisms have been described.

-Endometriosis is responsible for the appearance of adhesions on the ovaries and fallopian tubes that can mechanically prevent ovulation, the capture of the ovum by the fallopian tube and its transport to the uterine cavity. Patients with severe stages (III-IV) require surgical intervention that can restore normal anatomy and sometimes restore fertility.

-Analysis of pelvic fluid reinforced the idea that endometriosis is an inflammatory disease, as higher concentrations of pro-inflammatory cells were identified in women with endometriosis compared to healthy women. This inflammation has negative effects on the egg, sperm, fallopian tubes and embryo.

Patients with endometriosis may more frequently have anovulatory cycles, i.e. cycles in which ovulation did not occur.

– Several studies evaluated the quality of oocytes and embryos of patients with endometriosis and concluded that oocytes may have a poorer quality and embryos a slower evolution.

If a couple who wants a child cannot conceive, what should they do?

The monthly pregnancy rate for a couple with normal fertility is 15-20% compared to 2-10% for a couple with a partner suffering from endometriosis. Thus, the expectant attitude is sometimes against the patient.

For patients with endometriosis, who are under 35 years old and have unprotected sexual contact for more than 12 months and for those over 35 years old and have unprotected sexual contact for more than 6 months, an active attitude is recommended in order to obtain a pregnancy.

It is good to address this aspect with the attending gynaecologist and later to contact an assisted human reproduction centre. When establishing a therapeutic strategy, we must take into account a number of factors: the age of the patient, the duration of infertility, the symptoms and the stage of endometriosis.

 For patients with very low ovarian reserve (AMH < 0.5 ng/dl), the IVF procedure will be urgent, surgical intervention on the ovaries will be avoided due to the risk of reducing the ovarian reserve, which could require the subsequent call for donated oocytes.

The IVF procedure should be considered in patients with endometriosis and infertility when:

• artificial insemination procedures have failed for 6 months
• an endometriosis in stages III-IV
• impairment of tubal function
• the association of male infertility
• other treatments to get pregnant have failed

Assisted human reproduction procedures have increased the chances of endometriosis patients to achieve a pregnancy and are a solution, sometimes the only solution for those patients with severe disease, where the rate of achieving a spontaneous pregnancy is extremely low.

What are the stages of endometriosis that have the greatest impact on getting pregnant?

We could say that endometriosis is a strange disease because when it comes to the intensity of the pain, studies say that it does not correlate with the severity of the disease, but instead when we analyse infertility we know that it correlates with the stage of the disease, so we expect that patients with severe stages III-IV more frequently associate infertility.

Although endometriosis affects fertility at multiple levels, more so in stages III and IV, the distortion of pelvic anatomy can be a primary cause of infertility. Thus, the restoration of the pelvic anatomy through a correctly performed surgical intervention could represent the main benefit in order to obtain a pregnancy.

A study conducted at the Royal Hospital for Women, Sydney in patients with severe stage III-IV endometriosis who underwent ovarian surgery and deep endometriosis lesions recorded an increased pregnancy rate of 73%. Of these, 63% got pregnant spontaneously and 37% through assisted human reproduction procedures.

H. Roman also reports a high pregnancy rate after surgery even in patients with severe forms of colorectal endometriosis. The probability of getting pregnant at 12 months was 33.4%, at 24 months 60.6%, at 36 months 77% and 86.8% at 48 months.

Publications such as the one led by H. Lee reported a low percentage of pregnancies achieved postoperatively for stage IV patients, 20% compared to stage III, 53.3%.

A research conducted in Beijing, China, published differences in obtaining a pregnancy after surgery according to the severity of the disease: grade I- 53.6%; grade II- 32.0%; grade III- 48.3% and grade IV- 33.3%. The lowest level is found in the group of patients with grade IV.

​

Once a pregnancy is obtained, how will it proceed?

Patients who also suffer from endometriosis should know that during the 9 months of pregnancy they will not have to perform additional tests compared to the usual ones.

The results of the studies that evaluated the rate of pregnancy complications in patients with endometriosis are contradictory, some of them attest to a higher rate for spontaneous abortion, placenta praevia, preeclampsia, bleeding during pregnancy and premature birth, while other numerous studies have demonstrated that there is no association between endometriosis and a high-risk pregnancy.

Most of the time, the pregnancy will proceed without complications, however, pregnant women with endometriosis may have some risks. The exact mechanism responsible for the slightly higher rate of complications during pregnancy in patients with endometriosis is not known. It is considered that the more intense inflammation, the contractility of the uterus and the presence of endometrial tissue outside the endometrium could be responsible for the occurrence of complications.

What is the period of pregnancy with the greatest risk?

Regarding the evolution of the pregnancy, the first and last trimester are the periods with the greatest risk. In the first trimester there is a higher risk of spontaneous abortion, and in the third trimester complications such as bleeding, preeclampsia, foetal growth restriction may occur, sometimes leading to premature birth.

Regarding endometriosis, the specialised literature indicates the second half of pregnancy and labour as the periods with risk of complications. Spontaneous cyst rupture or ovarian torsion may occur in patients with endometriomas. Cases of spontaneous intra-abdominal haemorrhage, uterine rupture or bowel perforation in patients with severe forms have also been described.

How do we give birth, naturally or by caesarean section?

There is no data in the literature that requires caesarean birth in patients with endometriosis. However, there is a slightly higher incidence of caesarean delivery than in the general population. The doctor will take into account all the obstetrical factors and together with the patient will decide the mode of birth. For patients with low rectal resections, caesarean birth is preferable to avoid possible complications at the anastomosis level.

What happens with endometriosis during pregnancy and breastfeeding?

Pregnancy can cure endometriosis is a myth, unfortunately. Patients should not consider pregnancy as a strategy for the management or treatment of endometriosis.

According to studies, the symptoms and evolution of endometriosis can be different from patient to patient. Women who suffered from intense pain during menstruation, during pregnancy due to the lack of menstruation can notice an improvement in the quality of life.

One of the drugs used to reduce the symptoms associated with endometriosis and to slow down the rate of development is progestin, which is a synthetic version of progesterone. During pregnancy, increased levels of progesterone are synthesized, thus explaining why the disease does not evolve most of the time during this period.

On the other hand, another hormone at maximum levels during pregnancy is estrogen, endometriosis being an estrogen-dependent disease, this phenomenon can explain why some patients still face the evolution of the disease during pregnancy.

Especially those patients who have chronic pelvic pain may feel the pain intensification due to the growth of the uterus, the traction of the ligaments that anchor it in the pelvis and additional pressure on the existing endometriosis lesions.

However, most of the time, patients with endometriosis confirm the reduction of painful symptoms during pregnancy and breastfeeding and, unfortunately, the symptoms reappear with the resumption of menstruation.

Even if sometimes the journey to the magical moment when you hold your baby in your arms can be long and difficult, don’t forget that you will succeed, and we doctors are with you.

The post Dr Raluca Enciu: Pregnancy and endometriosis  appeared first on Endo Daily News.

The development of endometriotic lesions involves various cellular and molecular processes, and their characterization demands advanced analytical tools. Bioinformatics, with its ability to analyze large-scale biological data, holds significant promise in advancing our understanding of endometriosis pathogenesis, diagnosis, and treatment. This paper explores novel bioinformatics strategies to enhance our understanding of endometriosis pathogenesis and potential precision medicine interventions, emphasizing the integration of multi-omics data and exploring novel avenues such as spatial transcriptomics and artificial intelligence to uncover novel insights. 

Genomic Profiling 

Utilizing high-throughput sequencing technologies such as whole-genome sequencing (WGS) and RNA sequencing (RNA-seq),  bioinformatics tools can analyze genomic profiles, differential gene expression, single-nucleotide polymorphisms (SNPs), and copy number variations (CNVs) to identify genetic variations  associated with endometriosis. Comparative studies between endometriotic lesions and normal endometrial tissue can provide insights into the underlying molecular mechanisms of disease development. 

Integration of genomics data can reveal novel candidate genes and pathways implicated in the pathogenesis of the disease. 

2. Epigenomic Profiling 

Investigate genetic variants, gene expression patterns, epigenetic modifications, including DNA methylation and histone modifications, in endometriotic lesions, eutopic endometrium, and peripheral blood samples from affected individuals and healthy controls to unravel the epigenomic landscape of endometriosis. Epigenome-wide association studies (EWAS) can identify differential methylation patterns associated with disease subtypes and severity. Integrating epigenomic data with other omics layers can elucidate the regulatory mechanisms governing gene expression in endometriotic lesions. Machine learning algorithms can identify epigenetic signatures unique to endometriotic lesions, shedding light on the role of epigenetics in disease progression. 

3. Proteomic Profiling 

Employ mass spectrometry-based proteomics to characterize the protein landscape in endometriotic tissues. Identify differentially expressed proteins, post-translational modifications, and protein-protein interactions. Integration of proteomic data with genomic and transcriptomic datasets can provide a comprehensive understanding of the functional consequences of molecular alterations in endometriosis. 

4. Metabolomics Profiling 

Metabolomics studies, combined with bioinformatics analyses, can uncover alterations in metabolic pathways associated with endometriosis. Liquid chromatography-mass spectrometry (LC-MS) and nuclear magnetic resonance (NMR) spectroscopy can identify metabolites that serve as potential biomarkers for disease diagnosis and progression. Integrating metabolomic data with other omics layers can enhance our understanding of the metabolic dysregulation in endometriosis. 

5. Biomarker discovery 

Leverage machine learning algorithms to identify robust biomarkers for endometriosis diagnosis, prognosis, and disease monitoring. Utilize classification models based on transcriptomic or proteomic signatures to distinguish between endometriotic lesions and normal tissues. Explore differential expression of genes, microRNAs (miRNAs), and long non-coding RNAs (lncRNAs) in endometriotic tissue samples. Explore the potential of liquid biopsy, analyzing circulating RNA, DNA, and proteins, for non-invasive detection and monitoring of endometriosis. 

Mining large-scale omics datasets can reveal molecular signatures indicative of disease progression, aiding in the development of non-invasive diagnostic tools. 

6. Transcriptomics Analysis 

Utilizing RNA-sequencing data from endometrial tissues, bioinformatics tools can identify genetic variants, isoforms, non-coding RNA molecules, alternative splicing events, differentially expressed genes and uncover dysregulated pathways. Integration with protein-protein interaction networks can highlight key nodes in the endometriosis interactome, providing potential targets for therapeutic intervention.Use bioinformatics tools to integrate multi-omics data and construct interaction networks among genes, proteins, and metabolites implicated in endometriosis pathophysiology. Also conduct transcriptomic studies to explore gene expression changes in response to hormonal fluctuations, inflammatory signals, and other environmental factors relevant to endometriosis development and progression. 

• Single-cell RNA-seq analysis 

Apply single-cell RNA sequencing (scRNA-seq) to dissect the cellular heterogeneity within endometriotic lesions at unprecedented resolution. Identify distinct and rare cell populations and their gene expression profiles. Characterize cell-to-cell communication networks and investigate the role of immune cells, stromal cells, and epithelial cells in the pathogenesis of endometriosis. 

• Functional Genomics and Transcriptomics 

Employ functional genomics approaches, such as CRISPR/Cas9-mediated gene editing and gene knockout/knockdown experiments, to investigate the functional significance of candidate genes and genetic variants associated with endometriosis. Bioinformatics tools can assist in the design and analysis of CRISPR screens, pinpointing genes essential for disease development and progression. Conduct transcriptomic studies to explore gene expression changes in response to hormonal fluctuations, inflammatory signals, and other environmental factors relevant to endometriosis development and progression. 

• Spatial Transcriptomics  

Leverage spatial transcriptomics to map the molecular landscapes within endometriotic lesions in their native spatial context. This technique provides insights into the spatial organization of cells, revealing how microenvironments influence disease progression. Investigate spatial heterogeneity in gene expression, cell-cell interactions, and immune responses to identify spatially regulated pathways and potential therapeutic targets. 

7. Microbiome Analysis 

The role of the microbiome in endometriosis is an emerging area of research. Bioinformatics tools can aid in analyzing 16S rRNA sequencing data to characterize the endometrial microbiome in women with endometriosis. However bioinformatics tools can be employed to analyze metagenomic data from endometrial and gut microbiota, unraveling potential associations between dysbiosis and disease progression. 

Explore potential links between the gut and reproductive tract microbiota and the development or exacerbation of endometriosis, paving the way for microbiome-targeted interventions.Examine host-microbe interactions and their impact on immune homeostasis and disease progression.Understanding the interplay between the host microbiome and endometrial tissue may unveil novel therapeutic targets. Assess the impact of the microbiome on immune dysregulation and inflammation in the context of endometriosis. 

8. Non-Coding RNA Analysis 

Exploration of the non-coding RNA landscape, including microRNAs (miRNAs) and long non-coding RNAs (lncRNAs), using bioinformatics tools can uncover their their regulatory roles in gene expression networks, epigenetic modifications, and post-transcriptional regulation in endometriosis pathogenesis and its development. Functional annotation and network analysis can provide insights into the regulatory roles of lncRNAs in endometrial tissue. 

9.  Machine Learning Predictive Models for Diagnosis and Prognosis 

Train machine learning algorithms on large-scale omics datasets to develop robust diagnostic biomarkers for endometriosis.  

Explore the use of supervised learning techniques – Machine learning algorithms, including support vector machines (SVM), random forests, and neural networks, can be employed to develop predictive models for endometriosis risk assessment. Integrating clinical data, genetic information, and environmental factors, these models have the potential to enhance early diagnosis and personalized treatment strategies, providing a comprehensive approach for personalized medicine. 

10.  Drug Repurposing and Therapeutic Target Identification 

Employ network pharmacology and computational drug repurposing approaches to identify potential therapeutic agents for endometriosis. Construct protein-protein interaction (PPI) networks integrating omics data from endometriotic tissues and drug-target interactions. Utilize network-based algorithms to prioritize candidate drugs based on their ability to modulate key pathways implicated in endometriosis pathophysiology. Virtual screening and molecular docking techniques can pinpoint compounds with therapeutic potential, expediting drug development processes. 

The post Poppy Stathopoulou: Innovative Bioinformatics Approaches in Understanding Endometriosis  appeared first on Endo Daily News.

There is no definite link between obesity and endometriosis, but there are studies that mention obesity as one of the risk factors for endometriosis. Among them are studies that show that women with endometriosis who are obese have a severe degree of endometriosis.

One such study was conducted in Australia on 700 women surgically diagnosed with endometriosis. The study’s findings showed that although the incidence rate of endometriosis in obese women is lower compared to those of normal weight, they have a higher risk of having severe endometriosis.

But there are also studies that suggest that for every 5 kg/m2, the risk of developing endometriosis is reduced by 33%. This is a meta-analysis, including a quantitative investigation of 11 studies, entitled “What is the link between endometriosis and obesity?”, and was conducted in Korea. The study’s authors suggest, however, that women with a high BMI are less likely to be recommended for surgery for pelvic pain, thereby reducing the chances of endometriosis being diagnosed laparoscopically.

Another study conducted in Australia, published in 2022 in Obesity Research & Clinical Practice, to see if there is a link between body mass index and endometriosis diagnosis, which analysed data from 11,794 young women, the findings show that overweight women had a lower risk of confirmed endometriosis compared to women of normal weight. On the other hand, the risk of clinically suspected endometriosis was higher among overweight women compared to those of normal weight.

Cause or effect?

Although an exact cause between obesity and endometriosis has not yet been established, certain aspects of endometriosis can lead to weight gain. Menopause-inducing hormone treatments often recommended for endometriosis can have the side effect of either weight gain or make weight loss difficult. Specifically, in menopause, estradiol, the hormone that helps regulate metabolism and body weight, decreases. Lower estradiol levels can lead to weight gain.

The risks of obesity

One of the risks of obesity for women is the impact on fertility. Being overweight leads to hormonal dysregulation but also to high levels of androgens, which combined can cause a dysfunction of the secretion of hypothalamic gonadotropin hormones, resulting in a reduction in the number of follicles, as well as the level of progesterone.

Intra and postoperative risks

Being overweight increases the risks associated with surgery often required for endometriosis. Obesity is a significant risk factor for wound infection, blood loss, and longer operative time. Recovery can be more difficult and lengthy, and hospitalisation can also be longer.

The post Dr Stefan Tuca: Obesity, cause or effect of endometriosis? appeared first on Endo Daily News.