A More Diverse Cervical Microbiome Associates with Better Clinical Outcomes in Patients with Endometriosis: A Pilot Study

Infection-induced chronic inflammation is common in patients with endometriosis. Although microbial communities in the reproductive tracts of patients have been reported, little was known about their dynamic profiles during disease progression and complication development. Microbial communities in cervical mucus were collected by cervical swabs from 10 healthy women and 23 patients, and analyzed by 16S rRNA amplicon sequencing. The abundance, ecological relationships and functional networks of microbiota were characterized according to their prevalence, clinical stages, and clinical features including deeply infiltrating endometriosis (DIE), CA125, pain score and infertility. Cervical microbiome can be altered during endometriosis development and progression with a tendency of increased Firmicutes and decreased Actinobacteria and Bacteroidetes. Distinct from vaginal microbiome, upregulation of Lactobacillus, in combination with increased Streptococcus and decreased Dialister, was frequently associated with advanced endometriosis stages, DIE, higher CA125 levels, severe pain, and infertility. Significantly, reduced richness and diversity of cervical microbiome were detected in patients with more severe clinical symptoms. Clinical treatments against infertility can partially reverse the ecological balance of microbes through remodeling nutrition metabolism and transport and cell-cell/cell-matrix interaction. This study provides a new understanding on endometriosis development and a more diverse cervical microbiome may be beneficial for patients to have better clinical outcomes.

Surgical modalities for the treatment of recto-vaginal deep infiltrating endometriosis: systematic review and meta-analysis

Background Deeply infiltrating endometriosis is a distinct type of endometriosis that is characterized by presence of endometrial nodes that penetrates >5 mm under the peritoneal surface. Surgery is the main method for relief of its associated pain and for improvement of quality of life. Objectives To assess effectiveness and safety of different laparoscopic surgical techniques in the treatment of deeply infiltrating endometriosis. Search methods We searched CENTRAL, MEDLINE, EMBASE, other data bases, and trial registries from inception till May 2020. The search strategy was developed by the review team. Some of the studies' authors were contacted for more clarification of information but we didn't get response. Selection criteria We included only randomized controlled trials (RCTs) that compare between the effectiveness and safety of different surgical techniques used in laparoscopic surgery to improve quality of life, treat pain, and improve sexual function in patients diagnosed with deeply infiltrating endometriosis Data collection and analysis Study selection, assessment of risk of bias of the included studies, and data collection were independently done by two of the review authors (Salama, M. and Ibrahim, N.). Any disagreement was resolved by discussion with the third review author (Nabhan, A.). We contacted investigators of some studies for more clarification of information and getting the primary data but we didn't get response. The quality of evidence was evaluated using GRADE methods. Results One RCT was included in the review. The study randomized 52 patients experiencing different types of pain and digestive symptoms, bad quality of life resulting from deeply infiltrating endometriosis. It compared laparoscopic versus open surgery in colorectal resection. The main limitations were unclear statement of allocation concealment, and lack of clearly described blinding beside the small number of participants. The study reported that there is no difference between the two approaches as regards to pain and symptomatic relief besides improving quality of life, but data are represented in median and range. The method of data presentation and absence of more studies in this comparison lead to the impossibility of doing meta-analysis. As for the other three comparisons we also found no studies that compared the surgical techniques together. Authors' conclusions There was insufficient evidence to conclude which surgical technique used during laparoscopy is the best regarding the relief of different types of pain associated with deeply infiltrating endometriosis and the improvement of quality of life of patients with such condition with the least adverse events. More research is needed in this field with very thorough consideration to the ethical dimensions of such trials in helping patients to get the best possible care according to their individual cases together with good design of the trial to enable the investigators to compare between different techniques.

Comprehensive characterization of endometriosis patients and disease patterns in a large clinical cohort

Purpose In many diseases, it is possible to classify a heterogeneous group into subgroups relative to tumor biology, genetic variations, or clinical and pathological features. No such classification is available for endometriosis. In our retrospective case–case analysis we defined subgroups of endometriosis patients relative to the type and location of the endometriosis lesion and relative to basic patient characteristics. Methods From June 2013 to July 2017, a total of 1576 patients with endometriosis diagnosed at surgery were included in this study. The patients’ history and clinical data were documented using a web-based remote data entry system. To build subgroups, all possible combinations of endometriosis locations/types (peritoneal; ovarian endometriosis; deeply infiltrating endometriosis; adenomyosis) were used. Due to the variation in group sizes, they were combined into five substantial larger groups. Results Age, pregnancy rate, and live birth rate were identified as characteristics that significantly differed between the five patient groups that were defined. No significant differences were noted in relation to body mass index, length of menstrual cycle, age at menarche, reason for presentation, or educational level. Conclusion This study describes basic patient characteristics in relation to common clinical subgroups in a large clinical cohort of endometriosis patients. Epidemiological information about different clinical groups may be helpful in identifying groups with specific clinical courses, potentially suggesting novel approaches to early detection and to surgical and systemic treatment.

A narrative review of functional outcomes following nerve-sparing surgery for deeply infiltrating endometriosis

Endometriosis negatively impacts the lives of countless women around the world. When medical management fails to improve the quality of life for women with either previously confirmed or suspected endometriosis often a decision must be made whether or not to proceed with surgery. When deeply infiltrating disease is diagnosed either clinically or by imaging studies often medical management alone will not suffice without excisional surgery. Surgery for endometriosis, especially deeply infiltrating disease, is not without risks. Aside from common risks of surgery endometriosis may also involve pelvic nerves, which can be hard to recognize to the untrained eye. Identification of pelvic nerves commonly encountered during endometriosis surgery is paramount to avoid inadvertent injury to optimize function outcomes. Injury to pelvic nerves can lead to urinary retention, constipation, sexual dysfunction, and refractory pain. However, nerve-sparing surgery for endometriosis has been proven to mitigate these complications and enhance recovery following surgery. Here we review the benefits of nerve-sparing surgery for deeply infiltrating disease.

MRI for the diagnosis and staging of deeply infiltrating endometriosis: a national survey of BSGE accredited endometriosis centres and review of the literature

Objectives: Our objective was to establish the primary mode of imaging and MR protocols utilised in the preoperative staging of deeply infiltrating endometriosis in centres accredited by the British Society of Gynaecological Endoscopy (BSGE). Methods: The lead consultant radiologist in each centre was invited to complete an online survey detailing their protocols. Results Out of 49 centres, 32 (65%) responded to the survey. Two centres performed transvaginal ultrasound as the primary method for preoperative staging of deeply infiltrating endometriosis and the remainder performed MRI. 21/25 centres did not recommend a period of fasting prior to MRI and 22/25 administered hyoscine butylbromide. None of the centres routinely offered bowel preparation or recommended a specific pre-procedure diet. 21/25 centres did not time imaging according to the woman’s menstrual cycle, and instructions regarding bladder filling were varied. Rectal and vaginal opacification methods were infrequently utilised. All centres preferentially performed MRI in the supine position – six used an abdominal strap and four could facilitate prone imaging. Just under half of centres used pelvic-phased array coils and three centres used gadolinium contrast agents routinely. All centres performed T1W with fat-suppression and T2W without fat-suppression sequences. There was significant variation relating to other MR sequences depending on the unit. Conclusions: There was significant inconsistency between centres in terms of MR protocols, patient preparation and the sequences performed. Many practices were out of line with current published evidence. Advances in knowledge: Our survey demonstrates a need for evidence-based standardisation of imaging in BSGE accredited endometriosis centres.

Medical management of deeply infiltrating endometriosis - 7 year experience in a tertiary endometriosis centre in London

Background Deeply infiltrating endometriosis has an estimated prevalence of 1% in women of reproductive age. Ninety percent have rectovaginal lesions but disease may also include the bowel, bladder and ureters. Current practice often favours minimally invasive surgical excision; however, there is increasing evidence that medical management can be as effective as long as obstructive uropathy and bowel stenosis are excluded. Our objective was to establish the proportion of women with deeply infiltrating endometriosis successfully managed with hormonal therapies within our tertiary endometriosis centre in West London. Secondary analysis was performed on anonymised data from the Trust’s endometriosis database. Results One hundred fifty-two women with deeply infiltrating endometriosis were discussed at our endometriosis multidisciplinary meeting between January 2010 and December 2016. Seventy-five percent of women underwent a trial of medical management. Of these, 44.7% did not require any surgical intervention during the study period, and 7.9% were symptomatically content but required interventions to optimise their fertility prospects. Another 7.0% were successfully medically managed for at least 12 months, but ultimately required surgery as their symptoms deteriorated. 26.5% took combined oral contraceptives, 14.7% oral progestogens, 1.5% progestogen implant, 13.2% levonorgestrel intrauterine device, 22.1% gonadotrophin-releasing hormone analogues, and 22.1% had analogues for 3–6 months then stepped down to another hormonal contraceptive. All women who underwent serial imaging demonstrated improvement or stable disease on MRI or ultrasound. Conclusions Medical treatments are generally safe, well tolerated and inexpensive. More than half (52.6%) of women were successfully managed with medical therapy to control their symptoms. This study supports the growing evidence supporting hormonal therapies in the management of deeply infiltrating endometriosis. The findings may be used to counsel women on the likely success rate of medical management.