An evaluation of sexual function and health-related quality of life following laparoscopic surgery in individuals living with endometriosis.

STUDY QUESTION: What is the relationship between sexual function, health-related quality of life (HRQoL), and laparoscopic surgery in individuals living with endometriosis? SUMMARY ANSWER: A higher number of laparoscopic surgeries is significantly associated with poorer HRQoL and greater levels of sexual dysfunction in individuals with endometriosis. WHAT IS KNOWN ALREADY: Prior research indicates that endometriosis is associated with lowered HRQoL and sexual function and that these outcomes are influenced by endometriosis-related symptom profiles, medical, and surgical management. A limited number of studies have examined changes in sexual function in individuals with endometriosis following laparoscopic surgery or following repeated surgeries. STUDY DESIGN, SIZE, DURATION: A cross-sectional community-based online survey was used to examine the relationships between sexual function, HRQoL, and laparoscopic surgery (n = 210). PARTICIPANTS/MATERIALS, SETTING, METHODS: Individuals with a self-reported diagnosis of endometriosis were recruited via online advertising through social media and gynaecology clinics. Endometriosis-specific data (e.g. diagnostic delay, symptom experience) was collected in addition to engagement with laparoscopic surgery, level of HRQoL (EuroQol-5 Dimension: EQ-5D-5L), and sexual function (Female Sexual Function Index: FSFI). Bivariate correlational analyses and hierarchical multiple regression were used to determine the associations between the variables of interest. MAIN RESULTS AND THE ROLE OF CHANCE: Individuals with endometriosis have substantially poorer HRQoL in comparison to Australian normative samples, with greater levels of endometriosis-related symptom burden, distress, and pain significantly associated with lower levels of HRQoL. The mean FSFI score was suggestive of clinically significant female sexual dysfunction, with the lowest level of function noted in the domain of sexual pain and the highest level of function noted in the sexual satisfaction domain. A greater number of laparoscopic surgeries was significantly associated with poorer overall HRQoL and greater levels of sexual dysfunction. LIMITATIONS, REASONS FOR CAUTION: The cross-sectional nature of the data precludes direct findings of causality and further longitudinal research is recommended. The information pertaining to engagement in laparoscopic surgery was self-report in nature and was not medically verified. WIDER IMPLICATIONS OF THE FINDINGS: The study's findings highlight the pervasive impact of endometriosis on all domains of living, emphasizing the need to extend treatment planning beyond that of physical pain management alone. Early referral for assessment and management of sexual wellbeing is recommended prior to, and post-surgical intervention, with a focus on maintaining post-surgical changes, potentially reducing the need for multiple surgeries. STUDY FUNDING, COMPETING INTEREST(S): The study was not associated with research funding. Author CN reports grant funding from the Australian Government and Medical Research Future Fund (MRFF) and was a previous employee of CSL Vifor (formerly Vifor Pharma Pty Ltd). TRIAL REGISTRATION NUMBER: N/A.

Endometriosis and mental health: a population-based cohort study.

BACKGROUND: Endometriosis is a chronic gynecologic disorder that leads to considerable pain and a reduced quality of life. Although its physiological manifestations have been explored, its impact on mental health is less well defined. Existing studies of endometriosis and mental health were conducted within diverse healthcare landscapes with varying access to care and with a primary focus on surgically diagnosed endometriosis. A single-payer healthcare system offers a unique environment to investigate this association with fewer barriers to access care while considering the mode of endometriosis diagnosis. OBJECTIVE: Our objective was to assess the association between endometriosis and the risk for mental health conditions and to evaluate differences between patients diagnosed medically and those diagnosed surgically. STUDY DESIGN: A matched, population-based retrospective cohort study was conducted in Ontario and included patients aged 18 to 50 years with a first-time endometriosis diagnosis between January 1, 2010, and July 1, 2020. Endometriosis exposure was determined through either medical or surgical diagnostic criteria. A medical diagnosis was defined by the use of the corresponding International Classification of Disease diagnostic codes from outpatient and in-hospital visits, whereas a surgical diagnosis was identified through inpatient or same-day surgeries. Individuals with endometriosis were matched 1:2 on age, sex, and geography to unexposed individuals without a history of endometriosis. The primary outcome was the first occurrence of any mental health condition after an endometriosis diagnosis. Individuals with a mental health diagnosis in the 2 years before study entry were excluded. Cox regression models were used to generate hazard ratios with adjustment for hysterectomy, salpingo-oophorectomy, infertility, pregnancy history, qualifying surgery for study inclusion, immigration status, history of asthma, abnormal uterine bleeding, diabetes, fibroids, hypertension, irritable bowel disorder, migraines, and nulliparity. RESULTS: A total of 107,832 individuals were included, 35,944 with a diagnosis of endometriosis (29.5% medically diagnosed, 60.5% surgically diagnosed, and 10.0% medically diagnosed with surgical confirmation) and 71,888 unexposed individuals. Over the study period, the incidence rate was 105.3 mental health events per 1000 person-years in the endometriosis group and 66.5 mental health events per 1000 person-year among unexposed individuals. Relative to the unexposed individuals, the adjusted hazard ratio for a mental health diagnosis was 1.28 (95% confidence interval, 1.24-1.33) among patients with medically diagnosed endometriosis, 1.33 (95% confidence interval, 1.16-1.52) among surgically diagnosed patients, and 1.36 (95% confidence interval, 1.2-1.6) among those diagnosed medically with subsequent surgical confirmation. The risk for receiving a mental health diagnosis was highest in the first year after an endometriosis diagnosis and declined in subsequent years. The cumulative incidence of a severe mental health condition requiring hospital visits was 7.0% among patients with endometriosis and 4.6% among unexposed individuals (hazard ratio, 1.56; 95% confidence interval, 1.53-1.59). CONCLUSION: Endometriosis, regardless of mode of diagnosis, is associated with a marginally increased risk for mental health conditions. The elevated risk, particularly evident in the years immediately following the diagnosis, underscores the need for proactive mental health screening among those newly diagnosed with endometriosis. Future research should investigate the potential benefits of mental health interventions for people with endometriosis with the aim of enhancing their overall quality of life.

In the thicket of fears, doubts, and murky facts: some reflections on treatment modalities for endometriosis-associated pain.

Endometriosis-associated pain can be managed by either surgery or hormonal therapy. The final decision as to which treatment modality to take is based on efficacy and possible complications of different treatment modalities, risk of recurrence, and the patient's wishes and preferences. But in the thicket of fears, doubts, and murky facts, the choice may ultimately be the trade-off between irrational fears and ignorance versus scientific evidence. We elaborate some pros and cons of the two treatment modalities and highlight some notable downsides of hormonal therapy, in particular the possible yet unquantified risk of long-term hormonal therapy for malignant transformation, perhaps with the only exception of combined oral contraceptives. Thus, when discussing with patients, we advocate the approach of discussing the advantages and disadvantages of all treatment options in detail, accounting for the known pros and cons with a full understanding of the predictive irrationality of human beings. For endometriosis-associated pain, surgery is definitely not a failure of medicine but, rather, a viable option, especially given the recently surfaced undercurrent of wariness and dissatisfaction with the current hormonal drugs among patients with endometriosis. Above all, there is a pressing need to fill the knowledge gap of perioperative interventions intended to reduce the risk of recurrence and to fulfill the demand for the development of safe and efficacious non-hormonal therapeutics.

Cognitive Behavioral Therapy in Endometriosis, Psychological Based Intervention: A Systematic Review / Intervenção psicológica baseada na terapia cognitivocomportamental na endometriose: Uma revisão sistemática

Abstract Introduction Endometriosis is an inflammatory disease that affects women of reproductive age, causing pain and the possibility of infertility. Endometriosis was associated to low life quality and research shows the impact of endometriosis in several areas of life, justifying how these patients are more likely to develop depression, anxiety, and stress. Objective The aim of the present systematic review was to explore the field of psychology in endometriosis, identifying studies that used the cognitive behavioral therapy technique as a treatment for endometriosis and chronic pelvic pain. Methods The keywords used were Endometriosis and Behavioral Therapy; Behavioral Disciplines and Activities; Cognitive Behavioral Therapy; Mental Health; Psychological Techniques; Psychology; Psychotherapy; Mental Health Services; and the search was performed in the following databases: PubMed/Medline, Scielo, Lilacs, and Capes. The study followed the PRISMA guidelines and all studies whose intervention strategy used was related to cognitive-behavioral therapy were considered. Results Of the 129 articles found, only 5 were selected, and it was possible to identify that the psychological intervention whose approach brought cognitive-behavioral therapy techniques promoted a decrease in the sensation of pain, improvements in the scores of depression and stress, and significant changes in aspects of quality of life such as vitality, physical and social functioning, emotional well-being, control, and autonomy. Conclusion Cognitive-behavioral therapy can be very promising to take care of the emotional side of those who have endometriosis However, the present systematic review highlights the need to develop more structured studies with consistent, clear and replicablemethods to reach a psychological intervention protocol for patients who live with this gynecological-physical-emotional condition.

Resumo Introdução A endometriose é uma doença inflamatória que afeta mulheres em idade reprodutiva, causando dor e possibilidade de infertilidade. A endometriose foi associada a baixa qualidade de vida e pesquisas mostram o impacto da endometriose emdiversas áreas da vida, justificando como tais pacientes têmmaior probabilidade de desenvolver depressão, ansiedade e estresse. Objetivo O objetivo da presente revisão sistemática foi explorar o campo da psicologia na endometriose, identificando estudos que usaram a técnica da terapia cognitiva comportamental como tratamento da endometriose e da dor pélvica crônica. Métodos As palavras chaves utilizadas foram Endometriose AND Terapia comportamental; Disciplinas e atividades comportamentais; Terapia cognitiva comportamental; Saúde mental; Técnicas psicológicas; Psicologia; Psicoterapia; Serviços de saúde mental, e a busca foi realizada nos bancos de dados PubMed / Medline, SCIELO, LILACS e CAPES. O estudo seguiu as diretrizes dos Principais Itens para Relatar Revisões Sistemáticas e Metanálises (PRISMA, na sigla em inglês) e foram considerados todos os estudos cuja estratégia de intervenção utilizada estava relacionada à terapia cognitivocomportamental. Resultados Dos 129 artigos encontrados, somente 5 foram selecionados, e foi possível identificar que a intervenção psicológica cuja abordagem trouxe técnicas da terapia cognitivo-comportamental promoveu diminuição na sensação de dor, melhora nos escores de depressão e estresse e mudanças significativas em aspectos da qualidade de vida como vitalidade, funcionalidade física e social, bem-estar emocional, controle e autonomia. Conclusão A terapia cognitivo-comportamental pode ser muito promissora para o tratamento psicológico/emocional de quem tem endometriose. No entanto, a presente revisão sistemática destaca a necessidade de desenvolver estudos mais estruturados com métodos consistentes, claros e replicáveis para se chegar a um protocolo de intervenção psicológica para pacientes que convivem com esse quadro ginecológico-físico-emocional.

Seeking adaptation from uncertainty: Coping strategies of South Korean women with endometriosis.

Women with endometriosis may experience uncertainty owing to the characteristics of the disease, including vague symptom patterns, delayed diagnosis, and long-term management with no cure. However, women use various coping strategies to adapt to the uncertainty caused by their endometriosis. This descriptive qualitative study explored the coping experiences of women with endometriosis to reduce their uncertainty about the disease and to achieve successful adaptation to their lives with endometriosis. By using convenience and purposive sampling methods, qualitative data were collected from 14 women in South Korea (mean age = 37.7 years, age range = 27-54 years), who were diagnosed with endometriosis through laparoscopy or open surgery. All interview data were thematically analyzed. Four themes were identified as adaptive coping experiences: (1) gaining self-control over the ambiguous disease; (2) regaining the daily routines destroyed by the disease; (3) being emotionally supported and expressing oneself when feeling unsupported by society; and (4) taking an active role in one's treatment plan by being self-directed. Patients' sense of self-control and self-directedness regarding the disease and the treatment process were important to adapt to life with endometriosis. In addition, regaining stable daily routines as well as being emotionally supported were critical for decreasing their uncertainty. This paper has widespread implications, including the need for training or a continuing education program for health professionals to enhance their competencies when caring for women with endometriosis and the need for social efforts to increase awareness of the disease.

Effect of psychosocial trauma and stress on sexual dysfunction in women with endometriosis.

BACKGROUND: Endometrial tissue plays an important role in the regulation of female fertility and there is evidence that endometrial pathology (including endometriosis) is closely related to endocrine disorders. On the other hand, various neuroendocrine changes can be significantly affected by psychosocial stress. In connection with these findings, we tested the relationship between neuroendocrine changes, sexual dysfunction, psychosocial/traumatic stress, and dissociative symptoms in women with endometriosis. METHODS: A total of 65 patients with endometriosis were included in the study. Clinical examinations were focused on the biochemical analysis of neuroendocrine markers of endometriosis (cancer antigen 125 [CA 125] and cancer antigen 19-9 [CA 19-9]), estradiol, psychometric evaluation of sexual dysfunction, psychosocial/traumatic stress, and dissociative symptoms. RESULTS: The results showed significant Spearman correlations between the values of the revised range of sexual difficulties for sexual dysfunction (Revised Female Sexual Distress Scale), psychosocial/traumatic stress (Trauma Symptoms Checklist) (R = 0.31), and dissociative symptoms (Somatoform Dissociation Questionnaire) (R = 0.33). Positive correlations were also found between CA 125 and CA 19-9 (R = 0.63), and between CA 125 and the results of the values of the revised scale of sexual difficulties for sexual dysfunction (Revised Female Sexual Distress Scale) (R = 0.29). Also psychosocial/traumatic stress (Trauma Symptoms Checklist) significantly correlated with CA 125 (R = 0.38) and with CA 19-9 (R = 0.33). CONCLUSION: These results represent the first findings regarding the relationship of the neuroendocrine markers CA 125 and CA 19-9 and sexual dysfunction with trauma/stress-related symptoms and dissociative symptoms in women with endometriosis.

Comorbidities and Quality of Life in Women Undergoing First Surgery for Endometriosis: Differences Between Chinese and Italian Population.

An observational cross-sectional study was conducted in a group (n = 371) of fertile age women with endometriosis, by administering a structured questionnaire, in order to evaluate the incidence of gynecological and systemic comorbidities and the impact on quality of life (QoL) in two different groups of Italian and Chinese patients affected by endometriosis. Chinese (n = 175) and Italian (n = 196) women were compared regarding systemic (inflammatory, autoimmune, and mental) and gynecological comorbidities, pain symptoms, and QoL, by using the Short Form 12 (SF-12). Italian patients resulted younger at the diagnosis and suffered more frequently from severe pain than Chinese ones. Deep infiltrating endometriosis (DIE) and mixed phenotypes were more frequent in Italian patients, whereas ovarian (OMA) and superficial endometriosis (SUP) were more common in the Chinese. The Italian group showed more systemic comorbidities, and those disorder were already present before the diagnosis of endometriosis. Furthermore, the Italian group showed lower SF-12 physical and mental scores, suggesting a worse health-related QoL in Italian endometriotic patients. A number of differences has been observed between Italian and Chinese women with endometriosis in terms of comorbidities and QoL, which may be related to the ethnicity, the different health system organization and the social and cultural background.

Patients' perspective on cognitive behavioural therapy after surgical treatment of endometriosis: a qualitative study.

RESEARCH QUESTION: Would adding cognitive behavioural therapy (CBT) to the treatment of endometriosis improve the quality of life of patients suffering from endometriosis-associated pain? The aim of this study was to identify if patients believed CBT should be added to endometriosis treatment and which form of CBT they would prefer: face-to-face individual or group, or web-based individual, sessions. DESIGN: Between November 2019 and January 2020, semi-structured focus groups were conducted using an interview guide to ensure all topics were discussed. Data collection was continued until saturation was obtained. The focus groups were transcribed word for word and openly encoded. Finally, themes were formulated. RESULTS: All participating women believed CBT should be offered to patients undergoing endometriosis surgery. They believed it could be an asset to improve quality of life. Participants preferred either in-person individual or group therapy. They stressed the importance of being offered a custom-made treatment plan, individually tailored to the different needs of different patients. CONCLUSION: This study has shown that patients with endometriosis believe that CBT should be added to the standard treatment regimen of endometriosis in either group or individual face-to-face sessions, because they expect that CBT will improve their quality of life after surgery.

The effect of new cross linked hyaluronan gel on quality of life of patients after deep infiltrating endometriosis surgery: a randomized controlled pilot study.

In this prospective randomised placebo-controlled study, we aimed to evaluate the effect of New Cross linked Hyaluronan Gel (NCH gel) on the quality of life of patients who underwent laparoscopic surgery due to Deep Infiltrating Endometriosis (DIE). The intervention group received 40 mL of NCH gel, and the control group had a 40 mL sterile saline solution instilled into the peritoneal cavity following standard laparoscopic procedures. The patients were called in the third and sixth postoperative months and requested to fill the Visual Analogue Scale (VAS), Endometriosis Health Profile (EHP-5), and Short Form for Mental and Physical Health (SF-12) questionnaires. There was a significant reduction in dysmenorrhoea, dyschezia, dyspareunia VAS scores at 3rd, and 6th-month visits in NCH gel group. The postoperative 6th-month EHP-5 scores were significantly lower (1.16 ± 1.51, p-value: .02) in NCH gel group. Besides, NCH gel group had higher SF-12 mental and SF-12 physical scores. Clinical Trials registration number: NCT04023383IMPACT STATEMENTWhat is already known on this subject? Application of solid or liquid physical barriers is believed to be a promising strategy to reduce adhesions after laparoscopic endometriosis surgery. However, comparable data regarding the effects of adhesion barriers are still lacking.What the results of this study add? We revealed that there was a significantly higher decrease in VAS and EHP-5 scores and an increase in SF-12 physical-mental ratings after surgery in NCH gel group.What are the implications of these findings for clinical practice and/or further research? Using NHC gel in addition to standard surgical procedure improves postoperative VAS scores, and provides better quality of life scores.

Crossroad decisions in deep endometriosis treatment options: a qualitative study among patients.

OBJECTIVE: To study the experiences, considerations, and motivations of patients with endometriosis in the decision-making process for deep endometriosis (DE) treatment options. DESIGN: Qualitative study using semi-structured in-depth focus group methodology. SETTING: University medical center. PATIENT(S): A total of 19 Dutch women diagnosed with DE between 27 and 47 years of age. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Focus group topics were disease impact and motives for treatment, expectations of the treatment process, and important factors in the decision process. RESULT(S): Women reported that pain, fertility, and strong fear of complications are important decisive factors in the treatment process. The goal of conceiving a child is considered important, however, sometimes doctors emphasize this topic too much. It emerged that complication counseling is frequently about surgical complications, whereas side effects of hormonal treatments are neglected. Shared decision making and information about treatment options, complications, and side effects are not always optimal, making it difficult to make a well-considered choice. Despite negative experiences encountered after surgery, the positive effect of surgery ensures that most women do not regret their choice. CONCLUSION(S): In the treatment decision process for patients with DE, pain is almost always the most important decisive factor. The wish to conceive and strong fear of complications can change this choice. Doctors should understand the importance of fertility for the majority of women, but, also, if this is not considered paramount, respect that view. To improve shared decision making, exploration of treatment goals, training of healthcare providers, and better patient information provision are desirable.

The COVID-19 pandemic and patients with endometriosis: A survey-based study conducted in Turkey.

OBJECTIVE: To apply rapid online surveying to determine the knowledge and perceptions of the COVID-19 pandemic on patients with endometriosis in Turkey. METHODS: An online survey was conducted by the Turkish Endometriosis & Adenomyosis Society and administered to patients with endometriosis who agreed to participate in the study. The survey included 25 questions prepared by an expert committee of four professionals (two gynecologists and two endometriosis specialists). RESULTS: Of the 290 questionnaires sent out, 261 (90%) were returned. A total of 213 (83.86%) patients reported that they were afraid of having endometriosis-related problems during the pandemic period. In addition, 133 (53.63%) patients thought the management of their endometriosis was affected because of the pandemic. CONCLUSION: Clinical studies clearly indicate that endometriosis is a condition associated with high levels of chronic stress. The COVID-19 pandemic has led the public to experience psychological problems such as post-traumatic stress disorder, psychological distress, depression, and anxiety. The majority of patients with endometriosis were afraid of having endometriosis-related problems during the pandemic period. The majority of elective endometriosis surgeries have not been postponed. Patients were highly aware of the pandemic and practiced social distancing and hygiene. Only 4 (1.59%) patients with endometriosis required hospitalization.

Quality of Life in Women with Deep Endometriosis: A Cross-Sectional Study.

OBJECTIVE: To describe clinical and sociodemographic characteristics of women with deep infiltrating endometriosis (DIE) and assess their quality of life (QOL) during 6 months of medical treatment. METHODS: A descriptive cross-sectional study of 60 women diagnosed with DIE either by surgery or image methods (ultrasound or magnetic resonance), who received clinical treatment for at least 6 months in the Universidade de Campinas, Campinas, state of São Paulo, Brazil. Both the SF-36 and the EHP-30 questionnaires were used to assess the quality of life. RESULTS: The mean age of the patients was 37.7 ± 6.0 years old, with 50% presenting dysmenorrhea; 57% dyspareunia; and 50% chronic pelvic pain. The SF-36 and the EHP-30 revealed impaired quality of life. In the SF-36, the worst domains were limitation due to emotional aspects (40.2 ± 43.1) and self-esteem and disposition (46.1 ± 24.8), whereas in the EHP-30 they were social well-being (50.3 ± 30.6); infertility (48.0 ± 36.3); and sexual intercourse (54.0 ± 32.1). CONCLUSION: Although clinically treated, women with deep endometriosis present impairment in different domains of quality of life regardless of the questionnaire used for evaluation.

OBJETIVO: Descrever características clínicas e sociodemográficas de mulheres com endometriose profunda infiltrativa e avaliar sua qualidade de vida dentro de 6 meses de tratamento clínico. MéTODOS: Estudo de corte transversal descritivo com 60 mulheres em seguimento ambulatorial na Universidade de Campinas, Campinas, SP, Brasil, com endometriose profunda infiltrativa diagnosticada por cirurgia ou métodos de imagem (ultrassonografia ou ressonância magnética), em tratamento clínico há pelo menos 6 meses. Para avaliar a qualidade de vida, foram utilizados os questionários SF-36 e EHP-30. RESULTADOS: A média etária das mulheres foi de 37,7 ± 6,0 anos; 50% delas apresentaram dismenorreia, 57% dispareunia e 50% dor pélvica crônica. O SF-36 e o EHP-30 mostraram comprometimento da qualidade de vida destas mulheres. No SF-36, os piores domínios foram os aspectos emocionais (40,2 ± 43,1) e a autoestima e disposição (46,1 ± 24,8), enquanto que no EHP-30 foram o bem-estar social (50,3 ± 30,6), a infertilidade (48,0 ± 36,3) e as relações sexuais (54,0 ± 32,1). CONCLUSãO: Embora tratadas clinicamente, as mulheres com endometriose profunda apresentaram comprometimento em diferentes domínios da qualidade de vida independente do questionário utilizado para avaliação.

A Quantitative Analysis of Sleep Quality in Women with Endometriosis.

Background: Endometriosis is a complex condition that can negatively affect a woman's quality of life, including her sleep. This study aims to assess the multifactorial variables associated with poorer quality of sleep in women with endometriosis. Materials and Methods: Data from the Endometriosis Pelvic Pain Interdisciplinary Cohort (EPPIC) data registry were analyzed for women who underwent surgery at the BC Women's Center for Pelvic Pain and Endometriosis with histopathological confirmation of endometriosis (June 2015 to June 2017). The primary outcome was quality of sleep preoperatively, from the Chronic Pain Sleep Inventory (0-100 VAS). Bivariate analysis and multivariable linear regression were done to determine any significant associations between preoperative patient variables and overall quality of sleep, based on p-value of 0.05. Results: Two hundred and seventy-five women met the study criteria. Poorer overall quality of sleep was independently associated with poorer functional quality of life (EHP-30) (b = -0.18, p = 0.0026), more depressive symptoms (PHQ-9) (b = -1.62, p < 0.001), and painful bladder syndrome (PBS) (b = -5.82, p = 0.035). This indicates that a 1 point increase in the EHP-30 (worsening quality of life), a 1 point increase in the PHQ-9 (worsening depression), and the presence of PBS increased the primary outcome (i.e., toward poorer quality of sleep) by 0.18, 1.62, and 5.82 points. Conclusions: Poorer quality of sleep in women with endometriosis is associated with poorer quality of life, more depressive symptoms, and bladder pain. Research into interventions that improve sleep is warranted as part of the management of some women with endometriosis.

Clinicians' Perceptions of Norwegian Women's Experiences of Infertility Diseases.

BACKGROUND: Norway has one of the best health systems in the world. However, it has a low birth rate, which decreased by 21.2% between 2009 and 2018, and one of the highest rates of infertility prevalence. The aim of this study is to understand how Norwegian doctors perceive female infertility diseases, namely those that are more difficult to diagnose and to treat, and that are more common in their practice. METHOD: Descriptive qualitative study was conducted with gynecologists and general practitioners. The sample resulted from the establishment of five criteria and on the doctors' acceptance to participate in this study. Our sample comprised thirteen highly qualified and experienced doctors. Qualitative content analysis was the method chosen to analyze the collected data. RESULTS: Clinical diseases (polycystic ovary syndrome, endometriosis and vulvodynia) and consequences of these diseases were the pinpointed themes. These led to a set of sub-themes: the main symptoms and the treatment of the diseases, from the perspective of both women and doctors (stigmatization, disturbances in women's daily life, diagnostic delay, and governmental support). CONCLUSIONS: The three most relevant disorders mentioned were polycystic ovary syndrome, endometriosis and vulvodynia. These diseases cause several impacts on the lives of women, because they feel stigmatized and limited in their daily life and sexuality, and the diagnosis of these diseases takes too much time. Governments should better redistribute the financing of women's health and allocate resources to specialized centers.

Quality of life in women with deep endometriosis: A cross-sectional study / Qualidade de vida de mulheres com endometriose profunda: Estudo de corte transversal

Abstract Objective To describe clinical and sociodemographic characteristics of women with deep infiltrating endometriosis (DIE) and assess their quality of life (QOL) during 6 months of medical treatment. Methods A descriptive cross-sectional study of 60 women diagnosed with DIE either by surgery or image methods (ultrasound or magnetic resonance), who received clinical treatment for at least 6 months in the Universidade de Campinas, Campinas, state of São Paulo, Brazil. Both the SF-36 and the EHP-30 questionnaires were used to assess the quality of life. Results The mean age of the patients was 37.7 ± 6.0 years old, with 50% presenting dysmenorrhea; 57% dyspareunia; and 50% chronic pelvic pain. The SF-36 and the EHP-30 revealed impaired quality of life. In the SF-36, the worst domains were limitation due to emotional aspects (40.2 ± 43.1) and self-esteem and disposition (46.1 ± 24.8), whereas in the EHP-30 they were social well-being (50.3 ± 30.6); infertility (48.0 ± 36.3); and sexual intercourse (54.0 ± 32.1). Conclusion Although clinically treated, women with deep endometriosis present impairment in different domains of quality of life regardless of the questionnaire used for evaluation.

Resumo Objetivo Descrever características clínicas e sociodemográficas de mulheres com endometriose profunda infiltrativa e avaliar sua qualidade de vida dentro de 6 meses de tratamento clínico. Métodos Estudo de corte transversal descritivo com 60 mulheres em seguimento ambulatorial na Universidade de Campinas, Campinas, SP, Brasil, com endometriose profunda infiltrativa diagnosticada por cirurgia ou métodos de imagem (ultrassonografia ou ressonância magnética), em tratamento clínico há pelo menos 6 meses. Para avaliar a qualidade de vida, foram utilizados os questionários SF-36 e EHP-30. Resultados A média etária das mulheres foi de 37,7 ± 6,0 anos; 50% delas apresentaram dismenorreia, 57% dispareunia e 50% dor pélvica crônica. O SF-36 e o EHP-30 mostraram comprometimento da qualidade de vida destas mulheres. No SF-36, os piores domínios foram os aspectos emocionais (40,2 ± 43,1) e a autoestima e disposição (46,1 ± 24,8), enquanto que no EHP-30 foram o bem-estar social (50,3 ± 30,6), a infertilidade (48,0 ± 36,3) e as relações sexuais (54,0 ± 32,1). Conclusão Embora tratadas clinicamente, as mulheres com endometriose profunda apresentaram comprometimento em diferentes domínios da qualidade de vida independente do questionário utilizado para avaliação.

Rethinking mechanisms, diagnosis and management of endometriosis.

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.

Surgical treatment of endometriosis: prognostic factors for better quality of life.

The present study investigated the effect of surgical treatment of endometriosis on physical and mental health. We undertook a prospective survey including 153 premenopausal women with histological diagnosis of endometriosis. The Short Form 12 (SF-12) questionnaire comprising physical and mental component scales was used. Two groups of patients were distinguished: Group A (n = 42) with SF-12 scores above the median in both physical and mental scales; Group B (n = 111) with SF-12 scores below the median in either physical or mental scale. Group A was diagnosed and operated for endometriosis for the first time at an older age (30 vs. 26 years), had undergone more frequently a single surgical intervention (64% vs. 46%), was less affected by symptom or lesion recurrence and had reported less intense current pain symptoms than Group B. Having the first endometriosis surgery at a later age was an independent predictor of better health status (adjusted odds ratio 1.146 per year, 95% confidence interval 1.058-1.242) after accounting for the potential confounding effects of reoperation, pelvic pain and time elapsed since the first surgery. In conclusion, patients with endometriosis who had a single surgery at an older age have good symptom control and better quality of life (QoL).

Validation of the Sexual Activity Questionnaire in women with endometriosis.

STUDY QUESTION: Is the Sexual Activity Questionnaire (SAQ) a valid tool for patients treated for symptomatic endometriosis? SUMMARY ANSWER: For women having surgical treatment for endometriosis, we determined that the SAQ is a valid and responsive tool. WHAT IS KNOWN ALREADY: Endometriosis adversely affects sexual quality of life. Suitable validated sexual quality of life instruments for endometriosis are lacking both in clinical practice and for research. STUDY, DESIGN, SIZE, DURATION: A total of 367 women with proven endometriosis undergoing medical or surgical treatment were included in an observational study conducted between 1 January 2012 and 31 December 2014 in two French tertiary care centers. Both hospitals are reference centers for endometriosis treatment. Of these 367 women, 267 were sexually active and constituted the baseline population. PARTICPANTS/MATERIALS, SETTINGS, METHODS: Women >18 years old with histological or radiological proven endometriosis, consulting for painful symptoms of at least 3 months duration, infertility, or other symptoms (bleeding, cysts) were invited to complete self-administered questionnaires before (T0) and 12 months after treatment (T1). Tests of data quality included descriptive statistics of the data, missing data levels, floor and ceiling effects, structural validity and internal consistency.The construct validity was obtained by testing presupposed relationships between previously established SAQ scores and prespecified characteristics of the patients by comparing different subgroups of patients at T0. Sensitivity to change was subsequently calculated by comparing the SAQ score between T1 and T0 overall and for different subgroups of treatment. Effect sizes (to T1) were calculated according to Cohen's method. The minimally important difference was estimated by a step-wise triangulation approach (including anchor-based method). MAIN RESULTS AND THE ROLE OF CHANCE: In total, 267 sexually active patients (204 surgical and 63 medical treatment) completed the SAQ at T0 and 136 (50.9%) at T1. The SAQ score ranged from 2.0 to 28.0 (mean ± SD: 16.8 ± 5.7).The SAQ score was one-dimensional according to the scree plot with good internal consistency (Cronbach alpha = 0.78, 95% CI 0.74-0.81) and had good discriminative ability according to pain descriptors and quality of life in endometriosis. The SAQ was responsive in patients treated by surgery but the effect size was low (0.3, 95% CI (0.0-0.6), P = 0.01). The minimally important difference was determined at 2.2. LIMITATIONS, REASONS FOR CAUTION: The effect size for medical treatment was non-significant. Other effect sizes were low but statistically significant. This could be explained by lower libido due to progestin intake, which was used for both surgically and medically treated patients. WIDER IMPLICATIONS OF THE FINDINGS: The SAQ is easy to use, valid and effective in assessing sexual quality of life in patients with endometriosis. This patient-reported score could be used as a primary outcome for future clinical studies. The minimally important difference estimation will be useful for future research. We recommend using 2.2 for the minimally important difference of the SAQ. STUDY FUNDING/COMPETING INTEREST(S): This work was funded by the 'Direction à la Recherche Clinique et à l'Innovation' of Versailles, France and the 'Institut de Recherche en Santé de la Femme' (IRSF). The authors have no conflicts of interest to declare.

Effect of danefukang on symptoms and biomarkers in women with endometriosis.

OBJECTIVE: The purpose of this study was to observe the efficacy of Danefukang (DEFK) soft extract for the treatment of symptoms associated with endometriosis, and its effect on quality of life, the Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS) scores, and on levels of carbohydrate antigen (CA)-125, tumor necrosis factor (TNF)-α, and interleukin (IL)-6. MATERIALS AND METHODS: A total of 174 patients with endometriosis treated from January 2010 to December 2013 were randomly divided into a control group treated with mifepristone (n = 87) or DEFK (n = 87). Both groups were treated for 3 months. Symptoms, quality of life, SAS, SD scores, and levels of CA-125, TNF-α, and IL-6 were evaluated before and after treatment. RESULTS: The effectiveness rate was 93.10% in the DEFK group and 81.61% in the mifepristone control group (χ2 = 4.215, P < 0.05). Treatment with DEFK resulted in a greater improvement in quality of life, SDS, and SAS scores compared with mifepristone (all, P < 0.05). DEFK treatment also resulted in a greater decrease of CA-125, TNF-α, and IL-6 levels compared with mifepristone (all, P < 0.05). CONCLUSION: Based on the current results - improved symptoms, attenuated depression and anxiety, and reduced the levels of pro-inflammatory cytokines and CA-125 -treatment with DEFK is a meaningful option for patients with endometriosis. DEFK fills an unmet need in the pharmacologic treatment of endometriosis.

Pain-related behavior and brain activation in cynomolgus macaques with naturally occurring endometriosis.

STUDY QUESTION: Can pain be objectively assessed in macaques with naturally occurring endometriosis? SUMMARY ANSWER: Behavioral, pharmacological and in vivo brain imaging findings indicate that pain can be quantified in macaques with endometriosis. WHAT IS KNOWN ALREADY: Endometriosis is characterized by abdominopelvic hypersensitity. The mechanism by which endometriosis evokes pain is largely unknown, as currently available analgesics offer limited pain relief. Thus, there is a need for both greater understanding of the in vivo mechanism of endometriosis-associated pain and better methods of testing novel therapeutics. STUDY DESIGN, SIZE, DURATION: Pain-related behavior and brain activation were assessed in five cynomolgus macaques with endometriosis. Three healthy female macaques served as controls. PARTICIPANTS/MATERIALS, SETTING, METHODS: Abdominopelvic sensitivity to force was assessed with an algometer. Activation of brain areas using block design force stimulation and the effects of a single dose of the analgesic drug morphine and 2-month treatment with the progestin dienogest on brain activation were observed via functional magnetic resonance imaging. MAIN RESULTS AND THE ROLE OF CHANCE: Pain response thresholds in macaques with endometriosis were significantly less than that of healthy macaques (P = 0.0003). In addition, non-noxious force activated the insula and thalamus, which was reduced with morphine and 2-month dienogest treatment. LIMITATIONS, REASONS FOR CAUTION: The specific role of cysts, such as peritoneal cysts, in endometriosis pain was not explored. While non-noxious stimulation activated the insula and thalamus, macaques were sedated during fMRI scans. Current findings need further confirmation in a larger cohort. WIDER IMPLICATIONS OF THE FINDINGS: The current study demonstrated central sensitization and related pain behavior in macaques with naturally occurring endometriosis. Altered functioning of the central nervous system could be the focus of future mechanistic studies and for the development of novel therapeutics. STUDY FUNDING/COMPETING INTEREST(S): Supported by a grant from the Shizuoka Industrial Foundation. All authors are employees of Hamamatsu Pharma Research, Inc.