An evidence-based approach to assessing surgical versus clinical diagnosis of symptomatic endometriosis.

BackgroundEndometriosis and restless leg syndrome (RLS) are both chronic conditions that can negatively affect a woman’s quality of life. A higher prevalence of RLS is seen in women and particularly in those who are pregnant, suggesting a possible ovarian hormonal influence. Endometriosis is a common (affecting 1 in 10 women) estrogen driven gynecological condition, and the prevalence of RLS in women with symptoms or a diagnosis of endometriosis is unknown.MethodsA prospective, cross-sectional, observational self-completed questionnaire study was distributed to 650 pre-menopausal women attending the gynecological department at Liverpool Women`s Hospital over a period of 4 months. 584 questionnaires were returned and 465 completed questionnaires were included in the final dataset. Data on RLS-associated (The International Restless Leg Syndrome Study Group rating scale) and endometriosis-associated (modified-British Society of Gynaecological Endoscopists pelvic pain questionnaire) symptoms were collected.ResultsWomen who reported a prior surgical diagnosis of endometriosis had a greater risk of having a prior formal diagnosis of RLS (OR 4.82, 95% CI 1.66,14.02) and suffering RLS symptoms (OR 2.13, 95% CI 1.34-3.39) compared with those without a diagnosis. When women with either a formal surgical diagnosis or symptoms associated with endometriosis were grouped together, they also have a significantly increased risk of having either a formal diagnosis or symptoms suggestive of RLS (OR 2.49, 95% CI 1.30, 3.64). In women suffering with endometriosis-associated symptoms, the cumulative endometriosis-associated symptom scores demonstrated a modest positive correlation with RLS severity scores (r=0.42 95% CI 0.25 to 0.57).ConclusionsThis is the first study highlighting an association between the symptoms relevant to the two chronic conditions RLS and endometriosis, showing that women with a reported prior surgical diagnosis or symptoms suggestive of endometriosis have a significantly higher prevalence of a prior formal diagnosis or symptoms suggestive of RLS. This data will help in facilitating the discovery of novel therapeutic targets relevant to both conditions. The simultaneous treatment of these conditions could potentially lead to improvement in the overall quality of life for these women.

Superficial Endometriosis: The Ultrasound Diagnosis

To study first birth rates according to endometriosis subtype after surgical diagnosis among nulliparous women. Retrospective population-based cohort study using Finnish national registers, linking women with first surgical diagnosis of endometriosis to fertility and sociodemographic data. The follow-up started at diagnosis and ended at first birth, sterilization/bilateral oophorectomy/hysterectomy, emigration, death, age of 50 years or December 31, 2019-whichever came first. Cohort of 9,590 nulliparous women aged 15-49 years at first surgical diagnosis of endometriosis in 1998-2012 born in 1940-1979. Women were divided into subcohorts: solely peritoneal (n = 3,146, 32.8%), ovarian (n = 3,020, 31.5%), and deep endometriosis (n = 659, 6.9%). Women with combined, rare or unspecified forms of endometriosis comprised the subcohort of combined/other endometriosis (n = 2765, 28.8%). For subanalysis, we included those with prior infertility diagnosis, i.e., presumed pregnancy wish. Surgically diagnosed endometriosis. Incidence rate of first birth. Altogether 5,184 (54.1%) of all women with endometriosis had their first birth after surgical diagnosis of endometriosis. Women with ovarian endometriosis were the oldest at surgical diagnosis (32.5 [interquartile range 28.5-37.2] years). The incidence rate of first birth per 100 person-years was 7.67 (95% confidence interval [CI]: [7.46-7.88]) among all women. We calculated the incidence rate ratio between the subcohorts, and the peritoneal subcohort presented significantly higher incidence of first birth (9.44 [9.03-9.87]) than the other subcohorts. Before surgery, 4,374 (45.6%) women had been diagnosed with infertility, of whom 2,882 (65.9%) had a first birth. Incidence rate of first birth was higher (11.5 [11.1-12.0]) among these women. The analyses of crude and adjusted restricted mean survival time difference further demonstrated that women with peritoneal endometriosis had a significantly shorter time without first birth compared with women with ovarian or combined/other endometriosis. Peritoneal endometriosis was the most favorable subtype in terms of having a first birth. In addition, women with prior diagnosis of infertility had a good prognosis. The overall chance of first birth in women with surgically verified endometriosis seems good, but the findings emphasize the impact of both age and timely diagnosis of endometriosis, in addition to treatment of infertility.

From November 1998 to June 1999 a previously healthy 38-year-old woman experienced seven episodes of recurrent spontaneous right-sided pneumothorax associated with the period of menstruation. The intervals of menstruation were regular and she described neither gynecologic complaints nor pelvic pain. Her obstetric history was three vaginal deliveries and apart from these no hospitalization. There was no history of thoracic disease, and she was a nonsmoker. The woman was each time admitted to hospital because of right-sided chest pain and dyspnoea. Physical and radiological examination confirmed each diagnosis of pneumothorax. Twice she was treated with chest drainage. Thorascopy diagnosed an area apically of different sized blebs/bullae located on the surface of the parietal pleura (subpleural) and thin adhesions from the lung to the parietal pleura. The pulmonary parenchyma appeared normal and in particular no bullae were seen. Pleural abrasion was performed eliminating the pleural blebs. With her next menstruation the woman presented with a pneumothorax located at the basal part of her right lung indicating sufficient efficacy of the apical pleurodesis. Computed tomography revealed no further pathology apart from the pneumothorax and pneumomediastinum. Chemical pleurodesis with administration of tetracycline was done to prevent recurrent basal pneumothorax. The symptoms of catamenial pneumothorax were now commanding and suspecting thoracic endometriosis a laparoscopy was performed and tubal occlusion planned. At laparoscopy the left ovary had several purplish-red nodules owing to endometriosis of the ovary and along the sacrouterine ligaments tiny bullae and minor chronic inflammation of the peritoneum were noted consistent with the diagnosis of pelvic endometriosis. The diaphragmatic surface was normal with no abnormalities or fenestrations to be seen. The histological evaluation revealed hemorrhagic foci but no exact diagnosis of endometriosis could be stated. Cytological examination of the pleural fluid offered no diagnosis either. Tubal occlusion using Filshie clips was carried out. The woman has had no recurrent pneumothorax. Endometriosis is a common gynecologic disease probably affecting 6–25% of fertile women. The knowledge of the epidemiology is limited owing to some women being asymptomatic and to different prevalence among the various groups of symptomatic women (infertility, chronic pelvic pain, sterilization) (1). Extra-pelvic endometriosis occurs in the presence or absence of pelvic disease, and thoracic endometriosis occurs in more than half of these cases (2, 3). Catamenial (Katamenios, Greek meaning menses/monthly) pneumothorax, i.e. spontaneous recurrent pneumothorax associated with the menstrual period mainly right-sided (93%), represents 2.8–5.6% of spontaneous pneumothoraces in women (3, 7). Spontaneous recurrent pneumothorax related to menstruation was first described in 1958 (4) and named Catamenial pneumothorax in 1972 (5). Since then approximately 100 cases have been reported. The age at onset of symptoms is mid-thirties. The diagnosis is clinical and the mean time before diagnosis is 8 months because of delay until attention is brought to the relationship to menstruation. Histological verification is dependant on an invasive procedure, and cytology is seldom helpful (3). The etiology and pathogenesis remain controversial. It has been hypothesized that diaphragmatic fenestrations of various sizes allow air from the peritoneal cavity to enter the pleural space and cause Catamenial pneumothorax. The air presumably gains access to the peritoneal cavity via the genital tract with the onset of menstruation. Widely accepted also is the theory of dissemination of endometrial tissue by microembolization through vascular or lymphatic channels. Swelling in response to hormonal changes may cause bronchial obstruction leading to increased intra-alveolar pressure and pleural rupture. Diaphragmatic fenestrations are found in some cases. Pleural or diaphragmatic endometrial implants are demonstrated in less than 50% of cases (4–7). Traditional therapy has involved surgical procedures as first-line treatment. Hormonal treatment suppresses ovulation and Catamenial pneumothorax is thereby prevented; however, a certain risk of recurrence is possible when treatment is stopped. Ultimately hysterectomy and bilateral oophorectomy have been performed (5–7). A less invasive procedure is tubal occlusion at laparoscopy only described once in the literature by Eckford and Westgate in 1996 (7). Theoretically the procedure hinders the air leakage through the genital tract. We describe a case where a woman suffered Catamenial pneumothorax with each menstruation and has not had any recurrence after tubal occlusion with Filshie chips. Address for correspondence: Lone Laursen Department of Gynecology and Obstetrics Odense University Hospital DK-5000 Odense C Denmark e-mail: [email protected]

Objective: To examine the laparoscopic findings in patients with suspicion of endometriosis. Study Design: Retrospective study. Setting: Department of Obstetrics and Gynecology, University of Oulu, Finland. Sample: First-time laparoscopy, without any known surgical diagnosis, was made in 53 consecutive patients between January 2006 and November 2011. Main Outcome Measures: The laparoscopic findings, staging of endometriosis, the percentages of different symptoms linked with endometriosis. Results: Laparoscopy revealed endometriosis in 40% of cases. Most frequent symptoms were dysmenorrhea (86%) and dyspareunia (81%) followed with vibration pain (71%), urinary symptoms (29%) and lowered fertility (24%). Only 5% of patients with endometriosis complained of bowel symptoms, which were significantly more common in patients without endometriosis (28%) (p = 0.034). The median interval between the onset of symptoms and laparoscopic diagnosis was 1.9 years (SD 3.2, range 0.6 - 11). Conclusions: The interval between the onset of symptoms and laparoscopic diagnosis is short reflecting the prompt availability of the necessary facilities in specialist health care. Finally laparoscopy seems to be safe in cases of endometriosis suspicion.

Getting Ready for Wound Certification: Assessing and Managing Lower Extremity Venous Disease.

None of the biomarkers evaluated in this review could be evaluated in a meaningful way and there was insufficient or poor-quality evidence. Laparoscopy remains the gold standard for the diagnosis of endometriosis and using any non-invasive tests should only be undertaken in a research setting.

The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the diagnosis and treatment of patients with known or suspected cardiovascular disease. Coronary artery disease (CAD) is the leading cause of death in the United States. Unstable angina (UA) and the closely related condition non–ST-segment elevation myocardial infarction (NSTEMI) are very common manifestations of this disease. These life-threatening disorders are a major cause of emergency medical care and hospitalizations in the United States. In 1996, the National Center for Health Statistics reported 1 433 000 hospitalizations for UA or NSTEMI. In recognition of the importance of the management of this common entity and of the rapid advances in the management of this condition, the need to revise guidelines published by the Agency for Health Care Policy and Research (AHCPR) and the National Heart, Lung and Blood Institute in 1994 was evident. This Task Force therefore formed the current committee to develop guidelines for the management of UA and NSTEMI. The present guidelines supersede the 1994 guidelines. The customary ACC/AHA classifications I, II, and III summarize both the evidence and expert opinion and provide final recommendations for both patient evaluation and therapy: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective . Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. The weight of the evidence was ranked highest (A) if the data …

Use of the endometriosis fertility index in daily practice: A prospective evaluation

To evaluate the clinical value of magnetic resonance imaging (MRI) of the uterus and the pelvis in infertile female with symptomatic endometriosis for the assessment of uterine morphology and function. Forty-one infertile women (mean age: 33.2 years) with symptomatic endometriosis documented by laparoscopy were evaluated with high-field MRI (Sonata, Siemens) using T2- and T1-weighted sequences. In addition, the patients underwent hysterosalpingoscintigraphy (HSSG) for evaluation of the uterotubal transport capacity. Pathologic findings of the uterine junction zone were correlated with the laparoscopic results, clinical symptoms and uterotubal transport capacity. Adenomyosis was diagnosed on T2-weigthed MR-images in 35 (85.4 %) patients (focal adenomatosis in 26 patients and diffuse adenomatosis in 9). Patients showing signs of adenomyosis tended to be older than patients without adenomyosis (mean age 34.1 years vs. 30.1 years) and showed a longer history of symptomatic endometriosis. A positive transport capacity in HSSG was observed in 73.1 % (19/26) of the patients with focal adenomyosis and in only 22.2 % (2/9) of patients with diffuse adenomyosis. In 83.3 % (5/6) of the patients without signs of adenomyosis, a positive uterotubal transport was documented. MRI of the uterus is a helpful diagnostic tool for the diagnosis of adenomyosis and for planning further therapies. Patients with the diagnosis of adenomyosis showed a reduced uterotubal transport capacity that depended on the severity of adenomyotic changes and might be a possible cause of infertility.

Background: Endometriosis affects around 10% of women worldwide. Many women with endometriosis struggle with finding adequate pain management, and data from other countries suggest that women use cannabis, either legal or illicit, to help manage their endometriosis symptoms. The aim of this study was to determine use of cannabis where endometriosis was self-identified as a condition that was being treated with cannabis, as well as the impact of cannabis use on the usage on other pharmaceuticals. Materials and Methods: A cross-sectional online survey of those using cannabis for health-related conditions run between May and July 2019. This article reports on the subset of this larger data set for those reporting they had a diagnosis of endometriosis and/or polycystic ovary syndrome. Data were collected on demographics, modes of cannabis administration, symptoms treated, changes in pharmaceutical usage, and adverse events. Results: Two hundred thirteen valid responses were analyzed. Mean age of respondents was 32 years and 79.8% were current cannabis users. The most common outcomes that cannabis was used for were to improve pain relief (95.5%) and to improve sleep (95.5%). Respondents reported that their symptom was "much better" for pain (81%), sleep (79%), and nausea or vomiting (61%). Over three-quarters (81.4%) indicated cannabis had reduced their normal medication usage. Over half (59%) were able to completely stop a medication, most commonly (66%) analgesics. Opioids (40%) were the most common class of analgesic stopped. Conclusions: Cannabis is reported as an effective intervention for pain and other endometriosis symptoms with potential substitution effects on opioid usage.

Objective: Determine the accuracy of deep endometriosis (DE) and ovarian endometrioma (OE) diagnosis on pelvic MRI in non-specialized tertiary healthcare, taking surgical diagnosis as the reference test. Additionally, we aimed to evaluate symptom severity and the presence and size of endometriomas as predictors of DE detection during surgery.Methods: This retrospective cross-sectional study assessed endometriosis patients presenting to a tertiary healthcare center over one year (2018-2019). Pelvic MRI data, obtained within six months of surgery, were extracted from radiologic reports. A symptom severity score (SSS) was used to estimate symptom severity.Results: Pelvic MRI exhibited low sensitivity (75.6%) and high specificity (100%) for DE (n=96). Conversely, OE was diagnosed with high sensitivity (100%) and specificity (93.9%; n=122). Three-way contingency analysis showed that, irrespective of the presence and size of endometrioma, there was a correlation between symptom severity and detection of DE during surgery (OR=6.6, p-value≤0.001; n=287). In a multivariable logistic regression analysis model controlling for endometrioma size, a higher SSS was significantly associated with a higher risk of DE detection during surgery (SSS=1: OR=4.65, p≤0.001; SSS=2: OR=10.66, p≤0.001; n=287). However, when controlling for symptom severity, there was no significant association between the presence and size of endometrioma and surgical detection of DE (endometrioma ≥5 cm: OR=1.57, p>0.05; n=287).Conclusion: While pelvic MRI effectively identifies DE in this population, caution is advised regarding negative DE MRI results in non-specialized settings. Based on our findings, a high suspicion for DE should be maintained in patients with severe symptoms.

PURPOSE: To review the accuracy of the history and physical examination, clinical assessment, and noninvasive diagnostic tests for the diagnosis of deep vein thrombosis (DVT). BACKGROUND: Each year, over 250,000 patients are hospitalized in the United States for the treatment of acute DVT, and many more are diagnosed while hospitalized for surgical procedures or medical illness or while residing in long-term care facilities. Prompt diagnosis and treatment are essential to prevent the short-term sequelae of pulmonary embolism and death and the long-term complications of recurrent venous thromboembolism and the postthrombotic syndrome.1 Knowledge of the accuracy of elements of the history and physical examination helps clinicians assess the probability of DVT before ordering confirmatory diagnostic studies or instituting therapy. Several studies have found that the incidence of venous thrombosis increases with age.2, 3 The important contribution of age was demonstrated in a study of Swedish men that found the cumulative probability for venous thromboembolism to be relatively low (0.5%) by the age of 50 but substantial (10.7%) by the age of 80.4 The case-fatality rate also increases with age; mortality increases exponentially beginning at the age of 40.3 Given the advancing age of the population of the United States, clinicians can expect to be assessing patients, and particularly older patients, for suspected DVT with increasing frequency. The authors have reviewed the literature to describe the accuracy of various elements of the history and physical examination, the combination of these findings, and noninvasive tests in the diagnosis of DVT. DATA SOURCES: A structured Medline search was performed (limited to English-language studies from 1966 to 1997) to identify studies examining the clinical assessment of patients with suspected DVT. Bibliographies of the retrieved articles were reviewed for additional relevant studies. STUDY SELECTION CRITERIA: Studies examining the accuracy of the physical examination, clinical assessment, or diagnostic tests for the diagnosis of DVT were selected for complete review. DATA EXTRACTION: Of 115 articles retrieved, 68 were considered relevant for analysis and were completely reviewed. The selected studies were graded based on the quality of their methods using a scoring system described by Sackett et al.5 Data for individual trials are presented separately. Meta-analyses were not performed. The prevalences of symptoms and signs of DVT are reported for patients with and without DVT. Data are presented as odds ratios (ORs) for risk factors and as sensitivity, specificity, and likelihood ratios (LRs) for the clinical assessment of DVT. The derivation and validation of a clinical decision rule is described in detail. The results for the clinical decision rule are reported as positive predictive values and LRs. ORs, LRs, sensitivities, and specificities are reported with 95% confidence intervals (CIs).

Background: Endometriosis is an under-recognised and often misdiagnosed chronic disease that affects one in ten women. It occurs when cells similar to those that line a uterus grow in other parts of the body, usually around the pelvis. The current gold standard for diagnosis of endometriosis is direct visualisation by histological analysis which can only be achieved by an invasive laparoscopy. It is estimated 176 million women and girls around the world are living with endometriosis. The condition costs $7.7 billion a year in direct medical expenses and lost productivity in Australia alone. Aim: To analyse a series of plasma samples from patients with clinically diagnosed endometriosis, others with gynaecological symptoms without endometriosis and otherwise healthy controls to identify biomarkers to differentiate these groups and potentially aid in endometriosis diagnosis. Method: A standard proteomic discovery workflow was used to search for unique biomarkers of endometriosis. Initially, pooled plasma samples from three distinct groups of patients were tested. The first group had symptoms of endometriosis with a laparoscopic/histology confirmed diagnosis. The second group also had symptoms, but the laparoscopy confirmed no endometriosis or an alternate diagnosis. The third group were healthy matched controls. The pooled plasma samples were quantitatively profiled against each other with a triplicate experiment. A validation of the biomarkers identified as significant in the discovery phase, was then undertaken in a larger clinical cohort (n=902) using a targeted multiplex mass spectrometry assay using multiple reaction monitoring (MRM). Statistical analyses were caried out using Stata and logistical regression was used to evaluate associations of biomarkers with binary clinical outcomes. Results: Out of the 943 proteins identified with [Formula: see text] 2 significant peptides in the initial discovery workflow, 47 were determined as being differential biomarkers across the three clinical groups. The derived targeted MRM assay was tested on the clinical validation cohort, and a number of candidate biomarkers were significantly associated, thereby indicating their potential for use in the diagnosis of endometriosis.

Study question Can machine learning models trained on self-reported data from the Lucy mobile health app predict endometriosis? Summary answer Machine learning models trained on self-reported data from Lucy app accurately predicted endometriosis, with XGBoost and Random Forest achieving accuracies of 89% and 84%, respectively. What is known already Endometriosis affects millions worldwide, however it is poorly recognized, underfunded, and under-researched, leading to diagnostic delays of 4 to 11 years. Mobile health tools can potentially transform chronic disease management by improving symptom tracking and assessment—offering clinical benefits and cost savings. Despite these benefits, their application in endometriosis remains limited, and research is scarce. This study aims to bridge this gap by applying machine learning (ML) classification models to analyze real-world, self-reported data from the Lucy app for early detection of endometriosis. Study design, size, duration This prospective study utilized self-reported data from the Lucy app, which allows users to log their menstrual cycles, medical records, dietary details, and pain symptoms. Women aged 18 years and older, both with and without a diagnosis of endometriosis, were included in the study. Data were collected from 4,812 users (n = 1,212 controls, n = 3,600 endometriosis cases) from eight European countries, including Hungary, Denmark, Sweden, Germany, Austria, Italy, Romania, and Poland. Participants/materials, setting, methods After filtering, 520,000 records were analyzed using correlation methods and visualization tools to identify symptom associations with endometriosis. Machine learning models (XGBoost, Random Forest) were trained on a subset of 4,812 users to predict endometriosis. To handle missing data, we applied imputation techniques, replacing missing values with statistically estimated ones to maintain data integrity and enhance model performance. Main results and the role of chance The first step was to filter the data to address issues such as unrealistic data and inconsistencies typical of real-world datasets. Strong associations between known endometriosis-associated symptoms—including pelvic pain, pelvic cramps, dysmenorrhea, and lower back pain—were shown by records from patients diagnosed with endometriosis but not yet treated. Our machine learning models effectively distinguished between endometriosis and control cases. The XGBoost model achieved an overall accuracy of 89%, with an F1-score of 0.92. The Random Forest model achieved an accuracy of 84%, with an F1-score of 0.78. These metrics were obtained as means from 5-fold cross-validation, supporting the robustness of the model. Feature importance analysis identified dysmenorrhoea and pelvic pain as the most important predictors of classification. Limitations, reasons for caution While our models demonstrated strong predictive performance, limitations include reliance on self-reported data and lack of clinical validation. When working with patient symptom data, missing values are a common challenge and may affect accuracy. Future studies should focus on external validation and clinical implementation to improve diagnostic reliability. Wider implications of the findings Our preliminary analysis showed that real-world, self-reported data are consistent with known endometriosis symptoms, highlighting that using mobile apps like Lucy for endometriosis monitoring is a promising strategy. These findings may pave the way for improving early detection and transforming endometriosis management, ultimately improving patient care. Trial registration number Yes