Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline.

OBJECTIVE: To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada. TARGET POPULATION: Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis. OPTIONS: The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging. OUTCOMES: There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment. BENEFITS, HARMS, AND COSTS: Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments. EVIDENCE: Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text. VALIDATION METHODS: The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations). INTENDED AUDIENCE: This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them. TWEETABLE ABSTRACT: Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers.

Directive clinique no 449 : Directive canadienne sur le diagnostic et les impacts de l'endométriose.

OBJECTIF: Fournir une approche contemporaine pour comprendre les impacts de l'endométriose et les méthodes de diagnostic au Canada. POPULATION CIBLE: Les personnes, familles, communautés, prestataires de soins et administrateurs de services de santé qui sont concernés par l'endométriose, qui soignent des patientes atteintes d'endométriose ou qui gèrent la prestation de services relatifs à l'endométriose. OPTIONS: Le diagnostic de l'endométriose se fait par une anamnèse détaillée, un examen physique et des examens d'imagerie effectués par des prestataires expérimentés dans le traitement de l'endométriose. L'évaluation chirurgicale avec analyse anatomopathologique confirme le diagnostic d'endométriose; toutefois, elle n'est pas nécessaire pour les personnes ayant un diagnostic confirmé par imagerie. RéSULTATS: Il est nécessaire de détecter l'endométriose le plus tôt possible afin de favoriser l'accès rapide aux soins et au soutien. L'éducation du public, des personnes atteintes et de leur famille, des prestataires de soins et des administrateurs de services de santé est essentielle pour éviter de retarder le diagnostic et le traitement. BéNéFICES, RISQUES ET COûTS: La sensibilisation et l'éducation sur les impacts et l'approche du diagnostic peuvent améliorer la rapidité d'accès aux soins pour les personnes atteintes d'endométriose et leur famille. Des soins précoces et appropriés peuvent contribuer à réduire le fardeau pour le système de santé; toutefois, l'amélioration de l'évaluation clinique peut nécessiter des investissements initiaux. DONNéES PROBANTES: Chaque section a été examinée au moyen d'une stratégie de recherche unique représentant les données disponibles dans la littérature spécifique au domaine concerné. Les recherches pour chaque section de la directive sont énumérées à l'annexe A et comprennent l'information de revues systématiques publiées décrites dans le texte. MéTHODES DE VALIDATION: Les recommandations ont été élaborées à la suite de deux cycles analyse par un groupe d'experts nationaux dans le cadre d'un processus de consensus itératif de deux ans. Le processus est décrit plus en détail à l'annexe B. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe C (tableau C1 pour les définitions et tableau C2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Cette directive vise à aider les prestataires de soins et les décideurs politiques impliqués dans les soins aux personnes touchées par l'endométriose et dans les ressources nécessaires pour les soutenir. RéSUMé POUR TWITTER: Directive mise à jour sur le diagnostic et les impacts de l'endométriose à l'intention des prestataires de soins et décideurs politiques canadiens.

Prevalence of Use and Perceived Effectiveness of Medical, Surgical, and Alternative Therapies for Endometriosis Pain in Canadians.

OBJECTIVES: To describe the use and perceived effectiveness of medical, surgical, and alternative therapies (e.g., diet, exercise, heat, cannabis, etc.) in managing endometriosis-associated pain in Canadians. METHODS: A cross-sectional online survey was distributed via The Endometriosis Network Canada (TENC) from February to March 2021. Canadians aged 18-50 years with diagnosed or suspected endometriosis were eligible to participate. RESULTS: A total of 434 survey responses were included, and 93.8% of respondents reported that they used at least 1 alternative therapy in the past 6 months for endometriosis-associated pain. Respondents used an array of medical (2.3/6 months), surgical (1.7/lifetime), and alternative therapies (6.9/6 months) to manage their pain, yet 61.9% of respondents did not feel it was adequately managed. The most common alternative therapies were heat, meditation/mindfulness/rest, and diet. CONCLUSION: Alternative therapies were commonly used by Canadians living with endometriosis to manage pain. Cannabis and heat were perceived as the most effective alternative therapies. Here, we gain a better understanding of alternative therapies that can provide an additional therapeutic avenue that clinicians and people living with endometriosis may wish to discuss and explore.

Case Report: Extrapelvic Endometriosis in the Medial Thigh.

Extrapelvic endometriosis, although rare, can present in the musculoskeletal system of reproductive-age women and cause significant pain and morbidity. The pathophysiology of this disease is not well understood. In this study, we described the case of a 39-year-old women with an inner-thigh mass causing catamenial pain. Core-biopsy of the mass confirmed endometriosis and she was referred to minimally-invasive gynecology for management. Surgical excision was performed by a multidisciplinary team and she remains pain-free postoperatively on hormonal therapy. Unique to this case, the patient had a history of pelvic fracture. Through this case report, we discuss possible pathophysiologic mechanisms of extrapelvic musculoskeletal endometriosis including the stem/progenitor cell theory and the role that musculoskeletal trauma may have in the development of this condition. Gynecologists play an important role in the recognition, diagnosis, and management of musculoskeletal endometriosis.

A Call-to-Action for Clinicians to Implement Evidence-Based Best Practices When Caring for Women with Uterine Fibroids.

Uterine fibroids are common benign tumors that occur in up to 80% of women. Approximately half of the women affected experience considerable physical, psychological, and economic burdens and impact on quality of life due to symptoms such as heavy menstrual bleeding, pelvic pain, and infertility. Several medical and surgical options are available to treat uterine fibroids; however, healthcare providers may benefit from practical guidance in the development of individualized treatment plans based on a personalized approach. Medical treatments and minimally invasive procedures are generally preferred by most patients before considering more invasive, higher risk surgical interventions. In general, patient-centered, uterine-preserving procedures may be prioritized based on the patient's goals and the clinical scenario. Occasionally, hysterectomy may be the preferred treatment option for some patients who require definitive treatment. This call-to-action highlights recent challenges to patient care, including radical shifts in physician-patient interactions due to the COVID-19 pandemic and recent changes to evidence-based, clinically approved therapies. This report also reviews contemporary recommendations for women's health providers in the diagnosis and medical and surgical management of uterine fibroids. This call-to-action aims to empower healthcare providers to optimize the quality of care for women with uterine fibroids utilizing the best available evidence and best practices.

Ovarian Torsion Occurring Nine Days after Ipsilateral Dermoid Cystectomy.

Ovarian torsion (OT) is a gynecological emergency that requires prompt treatment and management. It is associated with risk factors such as ovarian cysts and prior pelvic surgery. Diagnosis and treatment require surgery to examine the adnexa, correct the torsion, and determine if cystectomy or oophorectomy are required. We reported the case of a 34-year-old woman who presented 9 days after a dermoid cystectomy with sudden onset abdominal pain. An ultrasound showed abnormal blood flow to the ovary. She then underwent a repeat laparoscopy revealing a necrotic and twisted ovary on the same side that had a cystectomy. The surgeons proceeded with a right oophorectomy. Following surgery, the patient reported no concerns with no ongoing bleeding or pain. OT can present in the short-term postoperatively to an ovarian cystectomy, likely as a result of mechanical forces secondary to structural changes of the ovary. The role for prophylaxis against OT is unclear in those with significant risk factors for torsion.

Informing the Spectrum of Approaches: Institutional Review of Placenta Accreta Spectrum Disorders Management.

OBJECTIVE: Placenta accreta spectrum (PAS) is a condition defined by abnormal adherence of the placenta. Cesarean hysterectomy is the preferred management, but practice patterns vary based on local resources and expertise. We retrospectively reviewed the clinical course of patients diagnosed antenatally with PAS who underwent surgical management in our centre. METHODS: We conducted a retrospective records review involving patients with an antenatal diagnosis of PAS between 2014 and 2019. The primary outcome was a composite score of maternal morbidity, and secondary outcomes were total estimated blood loss and composite neonatal morbidity. Patients were stratified based on the presence or absence of PAS on final pathology. Antenatal diagnosis by ultrasound and magnetic resonance imaging (MRI) was compared with final histologic diagnosis. RESULTS: A total of 34 patients were diagnosed with PAS antenatally and managed at our institution. Final histology confirmed PAS in 29 patients. The overall composite morbidity rate was 44%, with no significant difference between patients with and without PAS on pathology (P = 0.355). Intraoperative blood loss was similar between the 2 groups (2374 ± 2212 mL vs. 1080 ± 852 mL; P = 0.232). The rate of composite neonatal morbidity was 47%. Ultrasound achieved a high positive predictive value in the diagnosis of PAS (96%) and more accurately predicted pathology than MRI. CONCLUSIONS: PAS is associated with high rates of morbidity. Dissemination of our local experience serves to inform best practices in the management of this complex condition.

Endometrial microbiota is more diverse in people with endometriosis than symptomatic controls.

Endometriosis is a chronic, estrogen-dependent gynecological condition affecting approximately 10% of reproductive age women. The most widely accepted theory of its etiology includes retrograde menstruation. Recent reports suggest the uterus is not sterile. Thus, the refluxed menstrual effluent may carry bacteria, and contribute to inflammation, the establishment and growth of endometriotic lesions. Here, we compared and contrasted uterine bacteria (endometrial microbiota) in people with surgically confirmed presence (N = 12) or absence of endometriosis (N = 9) using next-generation 16S rRNA gene sequencing. We obtained an average of > 9000 sequence reads per endometrial biopsy, and found the endometrial microbiota of people with endometriosis was more diverse (greater Shannon Diversity Index and proportion of 'Other' taxa) than symptomatic controls (with pelvic pain, surgically confirmed absence of endometriosis; diagnosed with other benign gynecological conditions). The relative abundance of bacterial taxa enriched in the endometrial microbiota of people with endometriosis belonged to the Actinobacteria phylum (Gram-positive), Oxalobacteraceae (Gram-negative) and Streptococcaceae (Gram-positive) families, and Tepidimonas (Gram-negative) genus, while those enriched in the symptomatic controls belonged to the Burkholderiaceae (Gram-negative) family, and Ralstonia (Gram-negative) genus. Taken together, results suggest the endometrial microbiota is perturbed in people with endometriosis.

Guideline No. 417: prevention of venous thromboembolic disease in gynaecological surgery [Pré-print] / Prévention de la maladie thromboembolique veineuse en chirurgie gynécologique [Pré-print]

The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the use of thromboprophylaxis in gynaecological surgery. All patients undergoing gynaecological surgery for benign or malignant indications. The implementation of this guideline will benefit patients undergoing gynaecological surgery and provide physicians with a standard algorithm for the use of perioperative thromboprophylaxis. The following search terms were entered into MEDLINE, Google Scholar, and Cochrane in 2017 and 2018: VTE, PE, DVT, thromboprophylaxis, gynaecological surgery, heparin, graduated compression stocking, intermittent pneumatic stocking, obesity, pediatrics, minimally invasive surgery, heparin induced thrombocytopenia, regional anesthesia). Articles included were randomized controlled trials, meta-analyses, systematic reviews, and observational studies. Additional publications were identified from the reference lists of these articles. There were no date limits, but search results were limited to English language articles only. Searches were updated and incorporated into the guideline up to September 2018. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Gynaecologists and other members of the surgical team.

Guideline No. 417: Prevention of Venous Thromboembolic Disease in Gynaecological Surgery.

OBJECTIVE: The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the use of thromboprophylaxis in gynaecological surgery. TARGET POPULATION: All patients undergoing gynaecological surgery for benign or malignant indications. BENEFITS, HARMS, AND COSTS: The implementation of this guideline will benefit patients undergoing gynaecological surgery and provide physicians with a standard algorithm for the use of perioperative thromboprophylaxis. EVIDENCE: The following search terms were entered into MEDLINE, Google Scholar, and Cochrane in 2017 and 2018: VTE, PE, DVT, thromboprophylaxis, gynaecological surgery, heparin, graduated compression stocking, intermittent pneumatic stocking, obesity, pediatrics, minimally invasive surgery, heparin induced thrombocytopenia, regional anesthesia). Articles included were randomized controlled trials, meta-analyses, systematic reviews, and observational studies. Additional publications were identified from the reference lists of these articles. There were no date limits, but search results were limited to English language articles only. Searches were updated and incorporated into the guideline up to September 2018. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED USERS: Gynaecologists and other members of the surgical team. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Water Vapor Endometrial Ablation for Heavy Menstrual Bleeding: 36-Month Follow-Up of a Prospective, Multicenter Pivotal Clinical Trial.

STUDY OBJECTIVE: To report 36-month follow-up of a pivotal trial that evaluated the safety and effectiveness of the AEGEA Water Vapor System for the treatment of heavy menstrual bleeding (HMB) secondary to Abnormal Uterine Bleeding due to Endometrial disorders or Leiomyomata (AUB-E and AUB-L). METHODS: A prospective, multicenter, single-arm clinical trial at 14 sites in the US, Canada, Mexico, and the Netherlands. Inclusion criteria included a Pictorial Blood Loss Assessment (PBLAC, Higham) score ≥150 and allowed treatment of subjects with leiomyomata classified by the International Federation of Gynecology and Obstetrics (FIGO) Types 2-6 up to 4 cm in diameter, a uterine cavity up to 12 cm in length (uterine sound), Essure® contraceptive inserts and/or prior cesarean section. Follow-up assessments were conducted annually up to 36 months after endometrial ablation. The following outcomes were evaluated for 125/155 women: gynecological adverse events, qualitative assessment of menstrual flow, quality of life using the Menorrhagia Impact Questionnaire (MIQ), patient satisfaction, and medical or surgical reintervention for AUB. RESULTS: One hundred and fifty-five premenopausal women aged 30 to 50 years were enrolled from September 2014 through May 2015. Water vapor endometrial ablation was performed under varying anesthesia/sedation regimens in offices, surgical centers and operating rooms. There were 6 procedure-related adverse events that occurred between 12- and 36-month follow-up, 1 of which was deemed serious (hematometra managed successfully hysteroscopically). Seventy-two percent reported amenorrhea or light menstrual flow. The mean quality of life (MIQ) score improved from 14.7 at baseline to 6.4. Ninety-three percent reported "Satisfied" or "Very Satisfied." Post-ablation hysterectomy for any indication was performed in 6.5% of patients, and the total rate of re-intervention for bleeding was 7.1%. CONCLUSION: Outcomes 36-months after water vapor endometrial ablation for HMB are consistent with 12- and 24-month follow-up results in all subgroups evaluated. The AEGEA Water Vapor System increases the population of patients amenable to efficacious and acceptable treatment of Heavy Menstrual Bleeding (HMB) due to Abnormal Uterine Bleeding (AUB-E,-L). CinicalTrials.gov NCT01979861 registered November 8, 2013.

Technicity in Canada: A Nationwide Whole-Population Analysis of Temporal Trends and Variation in Minimally Invasive Hysterectomies.

STUDY OBJECTIVE: The objective of our study was to provide a contemporary description of hysterectomy practice and temporal trends in Canada. DESIGN: A national whole-population retrospective analysis of data from the Canadian Institute for Health Information. SETTING: Canada. PATIENTS: All women who underwent hysterectomy for benign indication from April 1, 2007, to March 31, 2017, in Canada. INTERVENTIONS: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: A total of 369 520 hysterectomies were performed in Canada during the 10-year period, during which the hysterectomy rate decreased from 313 to 243 per 100 000 women. The proportion of abdominal hysterectomies decreased (59.5% to 36.9%), laparoscopic hysterectomies increased (10.8% to 38.6%), and vaginal hysterectomies decreased (29.7% to 24.5%), whereas the national technicity index increased from 40.5% to 63.1% (p <.001, all trends). The median length of stay decreased from 3 (interquartile range 2-4) days to 2 (interquartile range 1-3), and the proportion of patients discharged within 24 hours increased from 2.1% to 7.2%. In year 2016-17, women aged 40 to 49 years had significantly increased risk of abdominal hysterectomy compared with women undergoing hysterectomy in other age categories (p <.001). Comparing women with menstrual bleeding disorders, women undergoing hysterectomy for endometriosis (adjusted relative risk [aRR] 1.36; 95% confidence interval [CI], 1.28-1.44) and myomas (aRR 2.01; 95% CI, 1.94-2.08) were at increased risk of abdominal hysterectomy, whereas women undergoing hysterectomy for pelvic organ prolapse and pelvic pain (aRR 1.47; 95% CI, 1.41-1.53) were at decreased risk. Using Ontario as the comparator, Nova Scotia (aRR 1.35; 95% CI, 1.27-1.43), New Brunswick (aRR 1.25; 95% CI, 1.18-1.32]), Manitoba (aRR 1.35; 95% CI, 1.28-1.43), and Newfoundland and Labrador (aRR 1.18; 95% CI, 1.10-1.27) had significantly higher risks of abdominal hysterectomy. In contrast, Saskatchewan (aRR 0.75; 95% CI, 0.74-0.77) and British Columbia (aRR 0.86; 95% CI, 0.85-0.88) had significantly lower risks, whereas Prince Edward Island, Quebec, and Alberta were not significantly different. CONCLUSION: The proportion of minimally invasive hysterectomies for benign indication has increased significantly in Canada. The declining use of vaginal approaches and the variation among provinces are of concern and necessitate further study.

Impact of Endometriosis on Life-Course Potential: A Narrative Review.

Endometriosis may exert a profound negative influence on the lives of individuals with the disorder, adversely affecting quality of life, participation in daily and social activities, physical and sexual functioning, relationships, educational and work productivity, mental health, and well-being. Over the course of a lifetime, these daily challenges may translate into limitations in achieving life goals such as pursuing or completing educational opportunities; making career choices or advancing in a chosen career; forming stable, fulfilling relationships; or starting a family, all of which ultimately alter one's life trajectory. The potential for endometriosis to impact the life course is considerable, as symptom onset generally occurs at a time of life (menarche through menopause, adolescence through middle age) when multiple life-changing and trajectory-defining decisions are made. Using a life-course approach, we examine how the known effects of endometriosis on life-domain satisfaction may impact health and well-being across the life course of affected individuals. We provide a quasi-systematic, narrative review of the literature as well as expert opinion on recommendations for clinical management and future research directions.