A September Campus meeting organised by the SIG Nursing and Midwifery reviewed current approaches to endometriosis management but heard that care must depend on a multidisciplinary approach in which nurses and midwives are an essential part.
Now is the time, added Chapron, from Cochin University Hospital in Paris, for a new paradigm for managing endometriosis. The approach should be multi-disciplinary and include surgery, but also medical treatment, ART and radiology. The rationale behind healthcare treatment includes efficacy inside decreasing inflammation, a key aspect of pathogenesis, and the downsides of surgical treatment, such as a zero effect on retrograde menstruation, inability to eradicate pain, association with decreased ovarian reserve, and attendant risks such as neurogenic bladder.
For a woman with endometriosis yet no infertility and no immediate desire for a baby, Chapron said his personal approach was based on follow-up and long-term medical treatment. For patients wishing to get pregnant but needing surgery, he said procedures must be performed not at diagnosis but when women want in order to conceive, along with ovarian reserve a key to timing.
His own healthcare department has been exploring how in order to optimise diagnosis, to shift from medical (biopsy) to non-surgical methods. The result is the questionnaire-based system which has demonstrated 85% accuracy in identifying high risk patients for referral to specialist radiologists. (1)
The afternoon of this Campus meeting featured a very practical session covering all aspects of transvaginal ultrasound plus MRI — including how and when each should be used, illustrated with detailed case histories.
Radiologist Corinne Bordonne said ultrasound can provide answers in 90% associated with endometriosis diagnoses and equally clear results for small endometriomas (< 10 mm). Ultrasound, she said, is superior with regard to rectal and sigmoid colon endometriosis, yet MRI is superior within some instances – eg, for adolescents (the lack of a probe is an advantage) plus abnormal cysts.
New advances in imaging technology can speed up diagnosis including MRI enterography, which shows the entire digestive system (although patients need to fast beforehand), and specific MRI regarding patients who experience shoulder pain during menstruation. However, before the expert use of imaging technology, the girl added that will a medical history (eg, early menarche) and clinical examination (as advised in ESHRE guidelines) are crucial inside identifying at-risk women and within achieving treatment goals (eg, live birth).
Presentations on day two of this Campus, organised from the SIG Nursing and Midwifery, focused upon disease management from the perspective of ARTWORK, pregnancy and drug treatment.
What is the impact of endometriosis on egg quality plus quantity, asked Pietro Santulli, also from Cochin University Hospital. The effect on oocyte and embryo quality is little, according in order to data through a recent study showing that aneuploidy rates among IVF patients with endometriosis are equivalent to those associated with age-matched controls. (2) Nevertheless, in many other studies ladies with the disease were lost to follow-up because of spontaneous conception.
However , the particular picture intended for quantity will be less positive according to outcomes from the cohort study of ART outcomes in women along with endometrioma. (3) AMH levels were similar in the two groups, but higher gonadotrophin doses were needed for females with endometrioma, and prior surgery to get endometrioma was a risk factor for poor ovarian response.
Professor Santulli’s take-home message was that, even in severe cases, endometriosis is a good indication for ARTWORK based on evidence from live birth rates, although chances are reduced when endometriosis and adenomyosis occur together. For infertile women without pain, he suggested ART without surgery, because chances increase significantly after four IVF cycles.
Management is more challenging pertaining to infertile women wishing to conceive but who do experience pain, he stated. Surgery continues to be the best (and only) option for these cases, but the strategy lies in planning. One recognised approach is in order to offer individuals hormone therapy for three months prior to starting IVF, although some sufferers find oral contraception in this period unacceptable.
Nevertheless , oral contraceptives are among first and second-line hormone therapies to treat infertility and discomfort. Yet it’s a case of trial and error to find which works for each individual patient. As yet, no ideal drug meant for managing endometriosis exists: one that is usually low cost, destroys lesions, improves symptoms including pain, has limited side effects plus can be used long-term. Silvia Vannuccini from your University associated with Florence advises nurses and midwives in order to balance benefits and drawbacks, and explain to patients what to expect. In future, the hope is that will ‘we’ll develop something different from hormonal treatments’, said Vannuccini, who outlined new techniques in the pipeline such as antioxidants, monoclonal antibodies, anti-angiogenetic drugs, and cannabinoids.
Pregnancy itself has been regarded as a treatment for endometriosis symptoms. But is there any proof for this or can the particular disease actually undermine pregnancy outcomes? Data presented by Guillaume Parpex, from Bichat–Claude Bernard Medical center, suggest that lesions may decrease or even stabilise right after pregnancy. However, a systematic review showed pregnancy does not seem to result systematically in benefits for ladies with endometriosis: some skin lesions show regression mostly in the third trimester, while others remain stable or increase. (4)
Although rare, complications through pregnancy like bowel perforation are uncommon. A prospective cohort research involving 1351 women found that endometriosis is not a risk factor designed for preterm birth but will increase the chance of threatened preterm labour and small for gestational age. (5) In view of these findings, Parpex concluded that being pregnant with endometriosis should be monitored yet considered as a normal maternity.
On the final day time, a round-table discussion emphasised the need for multi-professional teams to improve diagnosis, treatment and care management for women who feel they are usually neither heard nor taken seriously. Endometriosis remains the chronic incurable condition which involves life-long therapy. Midwives plus nurses, it was agreed, must be part of a support program which focuses on quality of life and treatment, with personalised treatment and a long-term plan based upon efficiency and safety.
1 . Chapron C, Lafay-Pillet M-C, Santulli P, et al. The new validated screening method for endometriosis analysis based on patient questionnaires. Lancet (eClinical Medicine) 2022; doi. org/10. 1016/j. eclinm. 2021. 101263
2 . Juneau C, Kraus E, Werner M, ainsi que al. Patients with endometriosis have aneuploidy rates equivalent to their age-matched peers in the in vitro fertilization population. Fertil Steril 2017; 108: 284-286.
doi. org/10. 1016/j. fertnstert. 2017. 05. 038
3. Bourdon M, Raad J, Dahan Y, et al. Endometriosis plus ART: A prior history of surgical procedure for OMA is associated with a poor ovarian response to hyperstimulation. PLOS ONE 2018; https://doi.org/10.1371/journal.pone.0202399
4. Leeners B, Damaso F, Ochsenbein-Kölble N, Farquhar C. The effect associated with pregnancy about endometriosis — facts or fiction? Hum Reprod Update 2018; 24: 290–299.
doi. org/10. 1093/humupd/dmy004
5. Marcellin L, Goffinet F, Azria E, ou al. Association between endometriosis phenotype and preterm delivery in France. JAMA Network Open 2022; e2147788; doi. org/10. 1001/jamanetworkopen. 2021. 47788