2020 has been…different (to say the least!). Despite the pandemic, multiple research articles on endometriosis have emerged that validate the patient experience and offer glimpses into endometriosis that may help better patient care in the future. Most research studies conclude that more research is needed. Here’s a look at just a few research articles that were published in 2020:
- Impact from Covid-19 pandemic:
The pandemic has affected healthcare on every level and continues to today. The impact of the pandemic on endometriosis care was studied May through June of 2020 by Demetriou et al. (2020) and in their commentary, they report that “the impact on planned care was much greater: 50.0% of responders reported cancelled/postponed appointments with gynaecologists and 14.7% described cancelled/postponed primary care appointments; 37.2% had procedures cancelled/postponed (surgery: 27.0%; fertility: 12.0%). These proportions were similar around the world.”
The authors also addressed the question that many have on whether endometriosis makes them more vulnerable to Covid-19. The short answer is no. The authors state that the question might arise “because the known link to altered immunological responses has been misinterpreted as endometriosis being an autoimmune condition, with additional concerns for those with thoracic endometriosis”. Likewise, Leonardi et al. (2020) states that “there is no evidence that those with endometriosis are at increased risk of becoming infected with SARS-CoV-2 or developing COVID-19 disease…. At this time, we do not believe that the COVID-19 pandemic warrants a sustained change in the overall medical approach to the management of endometriosis (e.g., avoid surgery and favor medical management).”
Leonardi et al. (2020) has a hope that good can come from the pandemic on healthcare. They conclude that out of the pandemic, they hope that “there may be an ongoing openness to telehealth” that could “dramatically minimize the geographic barriers to care that many women experience, and facilitate the development of endometriosis networks of expertise”, that “there may be increased awareness to self-management strategies that have always existed, yet were under-utilized (e.g., mindfulness, physical exercise, and diet)”, and that a “discerning approach to surgery now and in the future, so that we ‘operate sparingly and operate well.’” (Leonardi et al., 2020)
2. Quality of Life:
In an aptly named article “The Burden of Endometriosis on Women’s Lifespan” by Della Corte et al. (2020), the authors demonstrate how endometriosis affects every aspect of a person’s life. This does not surprise those of us with endometriosis, but it does validate what we experience. Della Corte et al. (2020) assert that “endometriosis has not only physical but also psychological effects, causing depression, anxiety, and compromising social relationships. Furthermore, endometriosis negatively impacts sexual life and social relationships. At last, the economic burden of endometriosis should not be underestimated, both individually and for the community, as this pathology leads to a loss of productivity at work and large use of health resources. Thus, endometriosis-related symptoms control women’s lives compromising the quality of life in all aspects.”
- Social Impact: Those with endometriosis demonstrated “a negative impact on relationships, in particular for the lack of understanding and support from others [36]. In addition, previous studies have shown that women feel ashamed of their condition and as a result feel unable to discuss their health with their employer, colleagues, friends, and family [74]. This can lead to the fact that the women felt isolated and alone with endometriosis, as shown in a narrative review on the social and psychological impact of living with endometriosis [34]. It was also highlighted that sometimes the consideration of the effect of the disease on the quality of life is not taken into consideration even by clinicians with consequent compromise in the patient’s medical relationship. In a qualitative study, it has been reported that women highlighted negative experiences with health care clinicians, not receiving support from them….The major and most frequent negative effect of endometriosis is on intimate relationships. Dyspareunia harms sex and intimacy for couples….However, a cross-sectional qualitative study, the ENDOPART study, demonstrated that also general fatigue, a reduction in sex drive due to drugs, a weak mood, bleeding during and/or after sex, and problems in attempts pregnancy have an impact on the relationship.”
- Depression and Anxiety: “The study showed that women with endometriosis had an increased risk of developing major depression…and any depressive disorder… and anxiety disorders…compared to those without endometriosis [80]. Overall, most of the literature agrees to consider depression, anxiety, and emotional distress more frequently in women with endometriosis than in a healthy population [34]. There is still no agreement on the origin of this evident correlation. Some authors showed that depression and anxiety may be the result of the experience of pelvic pain itself rather than of endometriosis since the rate of these psychological disorders was not different between women with endometriosis-related pelvic pain and those with pelvic pain of another nature [81,82].”
- Economic impact: “The annual economic burden of endometriosis, including direct health care costs and indirect productivity loss, was estimated to be $22 billion in 2002 and $69.4 billion in a 2009 follow-up study, a substantial apparent increase in costs attributed to endometriosis over time [91]….in the five years before an endometriosis diagnosis, costs were $7028 higher among patients with endometriosis compared with matched controls without endometriosis [92]. …The same authors of the above-mentioned review have also shown that, in employed women with endometriosis, as a consequence of productivity loss of 6.3 h per week, the total loss per person is approximately $10,177.54 per year [49].”
3. Treatment:
- When looking at surgery, skill and expertise is important for outcomes. While surgery “has been shown to significantly improve endometriosis-associated symptoms”, its success “is directly correlated with factors such as surgical experience, the complexity of each case and anatomical locations of the disease” (Working group of ESGE et al., 2020). The Working Group of ESGE et al. (2020) published their recommendations for deep infiltrating endometriosis (DIE) of “how different types of surgery should be performed, taking potential risks into consideration, and stresses that careful planning and involving different surgeons specialising in bowel or bladder is essential to ensure the best outcomes”. You can read more about that here.
- Some studies have looked into ways to enhance the visibility during surgery as “the identification of endometriotic tissue during laparoscopy is not always clear which may partly contribute to the high rates of recurrence reported after surgical treatment (40–50% at 5 years) [3]” (Lier et al., 2020). Lier et al. (2020) note that “enhanced laparoscopic imaging with 3D white light, combined with NBI, improves the detection rate of peritoneal endometriosis when compared to conventional 2D white-light imaging. The use of these imaging techniques may potentially result in a more complete laparoscopic resection of endometriosis”.
4. Diagnosis:
- Endometriosis has a long delay in diagnosis, which can leave those with it suffering for a long time and without adequate treatment. A definitive diagnosis is achieved through surgery, preferably with pathology confirming it. Research into an easier way to achieve diagnosis, such as through a blood test, is being studied; unfortunately, no biomarkers or blood tests have proven reliability to use for diagnosis yet. Anastasiu et al. (2020) did a review of the research to date and report that “the majority of studies focused on a panel of biomarkers, rather than a single biomarker and were unable to identify a single biomolecule or a panel of biomarkers with sufficient specificity and sensitivity in endometriosis.” They conclude that at this time “noninvasive biomarkers, proteomics, genomics, and miRNA microarray may aid the diagnosis, but further research on larger datasets along with a better understanding of the pathophysiologic mechanisms are needed” (Anastasiu et al., 2020). The end goal of a way to diagnose earlier is so “that no women with endometriosis or other significant pelvic pathology are missed who might benefit from surgery for endometriosis-associated pain and/or infertility [17–19]” (Fassbender et al., 2015).
Let us hope for a bright future for endometriosis care in 2021. Happy new year to you all!
References
Anastasiu, C. V., Moga, M. A., Elena Neculau, A., Bălan, A., Scârneciu, I., Dragomir, R. M., … & Chicea, L. M. (2020). Biomarkers for the Noninvasive Diagnosis of Endometriosis: State of the Art and Future Perspectives. International Journal of Molecular Sciences, 21(5), 1750. Retrieved from https://www.mdpi.com/1422-0067/21/5/1750
Carlyle, D., Khader, T., Lam, D., Vadivelu, N., Shiwlochan, D., & Yonghee, C. (2020). Endometriosis Pain Management: a Review. Current Pain and Headache Reports, 24(9), 1-9. Retrieved from https://link.springer.com/article/10.1007/s11916-020-00884-6
Della Corte, L., Di Filippo, C., Gabrielli, O., Reppuccia, S., La Rosa, V. L., Ragusa, R., … & Giampaolino, P. (2020). The burden of endometriosis on women’s lifespan: a narrative overview on quality of life and psychosocial wellbeing. International Journal of Environmental Research and Public Health, 17(13), 4683. Retrieved from https://www.mdpi.com/1660-4601/17/13/4683/htm
Demetriou, L., Cox, E., Lunde, C., Becker, C., Invitti, A., Martínez-Burgo, B., … & Zondervan, K. (2020). A commentary on the need for support with mental as well as physical health for people with endometriosis during the COVID-19 pandemic and beyond. Authorea Preprints. Retrieved from https://d197for5662m48.cloudfront.net/documents/publicationstatus/54168/preprint_pdf/921ccb14a9dcae7291958ce34ba67304.pdf
Fassbender, A., Burney, R. O., F O, D., D’Hooghe, T., & Giudice, L. (2015). Update on biomarkers for the detection of endometriosis. BioMed research international, 2015. Retrieved from https://www.hindawi.com/journals/bmri/2015/130854/
Leonardi, M., Horne, A. W., Armour, M., Missmer, S. A., Roman, H., Rombauts, L., … & Johnson, N. P. (2020). Endometriosis and the Coronavirus (COVID-19) Pandemic: Clinical Advice and Future Considerations. Frontiers in Reproductive Health, 2, 5. Retrieved from https://www.frontiersin.org/articles/10.3389/frph.2020.00005/full?fbclid=IwAR2FwiMuHuKb4UW6PVVBz2WuktOK7InbdzMD8DAQ0Df3JD-dPmgEYiOPs3E
Lier, M. C., Vlek, S. L., Ankersmit, M., van de Ven, P. M., Dekker, J. J., Bleeker, M. C., … & Tuynman, J. B. (2020). Comparison of enhanced laparoscopic imaging techniques in endometriosis surgery: a diagnostic accuracy study. Surgical Endoscopy, 34(1), 96-104. Retrieved from https://link.springer.com/article/10.1007/s00464-019-06736-8
Working group of ESGE, ESHRE, and WES, Keckstein, J., Becker, C. M., Canis, M., Feki, A., Grimbizis, G. F., … & Tanos, V. (2020). Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. Human Reproduction Open, 2020(1), hoaa002. Retrieved from https://academic.oup.com/hropen/article/2020/1/hoaa002/5733057?login=true