There is a clinical need to improve the diagnosis of endometriosis, as well as expand its treatment armamentarium and upgrade overall disease management, according to recent medical literature on the subject. 

While some patients are diagnosed and treated sufficiently, some are unrecognized or even undertreated. Estimates place the global burden of endometriosis at 10% of women, and a similar percentage of nonbinary and transgender people—meaning hundreds of millions may suffer from chronic pelvic pain, dysmenorrhea, deep dyspareunia or dysuria, along with infertility and other health conditions.

Clinicians rely on invasive laparoscopic procedures for endometriosis diagnosis, and treatments that often have poor side effect profiles. However, researchers from across the globe are investigating different avenues for both diagnosis and treatment, bringing hope of better identification and interdisciplinary management, and therefore, better patient outcomes and improved quality of life.

“This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden,” wrote researchers in Nature Reviews Endocrinology (2019;15[11]:666-682). “Rethinking the diagnosis and management of endometriosis is warranted.”

Nonsurgical Diagnosis

While laparoscopy has long been considered the “gold standard” for endometriosis diagnosis, it may not always be needed to begin treatment, according to the Nature researchers. There is support in the literature that diagnosis can be based on patient interviews, examination and imaging, the investigators wrote, and pain should be treated immediately “to avoid central sensitization, as this can be become autonomous, occurring independently of the peripheral stimulus, and can explain coexisting chronic pain syndromes.”

As noted, imaging could bring patients a less invasive option for understanding their symptoms. MRI and transvaginal ultrasound are increasingly being used for endometriosis. Along with being less invasive, diagnostic imaging can be cheaper, specifically for transvaginal ultrasound (BJOG 2019;126[12]:1499-1506).

Biomarkers may one day be another noninvasive alternative for endometriosis diagnosis. Current research has found microRNAs, which modulate gene expression, hold promise (Int J Mol Sci 2018;19[2]:599).

Novel Treatments

MicroRNAs may not only act as biomarkers; current research has seen new microRNA treatments for various chronic conditions and cancers. Yale researchers found through in vivo studies that administering microRNA Let-7b reduced endometriosis lesion size, possibly by suppressing gene expression of certain genes that promote growth (J Cell Mol Med 2018;22[11]:5346-5353).

As hormonal treatments have remained a large part of endometriosis treatment, nuclear receptors—proteins within cells responsible for sensing certain hormones—also could be a medical target. According to several in vivo and in vitro studies, targeting progesterone receptors, estrogen receptor beta and retinoic acid receptors could lower inflammation of endometriotic stromal cells, among other effects (Hum Reprod Update 2019;25[4]:473-485).

Other hormone modulators, such as aromatase inhibitors, along with tumor necrosis factor inhibitors often a treatment for rheumatoid disorders, are already being used for some patients, although more research is needed to endorse widespread efficacy (J Turk Ger Gynecol Assoc 2018;19[3]:158-164).

There has even been movement within surgical procedures for endometriosis treatment. High-intensity focused ultrasound is being touted as a noninvasive alternative to remove lesions (Int J Hyperthermia 2015;31[3]:280-284), and a clinical trial of percutaneous radiofrequency ablation will soon be recruiting patients in Europe (ClinicalTrials.gov Identifier: NCT04333017).

And it’s not just pharmacologic and surgical interventions under investigation. Barbara Karp, MD, and Pamela Stratton, MD, researchers with the National Institutes of Health, spoke to Pain Medicine News about their investigations of botulinum toxin as an adjunct to endometriosis-related chronic pelvic pain. Complementary and alternative medicine adjuncts abound, including dietary supplements such as curcuma (ClinicalTrials.gov Identifier: NCT04150406), acupuncture (ClinicalTrials.gov Identifier: NCT03125304) and psychological interventions of support (ClinicalTrials.gov Identifier: NCT03828591). 

This variety of new treatment avenues reflects a modern movement within pain management to more personalized medicine. 

“Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach,” wrote the researchers in Nature Reviews Endocrinology. “Endometriosis management should be individualized according to the patient’s intentions and priorities; management strategies can vary from country to country as pain perception and health care systems differ around the world.”

—Meaghan Lee Callaghan

Music: “Don’t Creep Me Out” and “Furnace” by Silicon Transmitter

A Q&A with Drs. Karp and Stratton also appeared in the June issue of Pain Medicine News. New episodes of ON PAIN appear at PainMedicineNews.com/Multimedia.