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Endometriosis and the COVID-19 pandemic: clinical advice and future considerations

Authors:

Abstract

COVID-19 has led to new obstacles in the care for women with endometriosis. With many centers around the globe temporarily ceasing outpatient appointments, diagnostic imaging for non-acute pelvic pain, surgery for endometriosis, and fertility treatments, endometriosis sufferers may feel particularly vulnerable and that resultant stress and anxiety may contribute to a worsening of symptoms. Even as societies and healthcare systems begin to emerge from lockdown, COVID-19 will leave a permanent mark, whereby care for patients with endometriosis may never be the same again. This pandemic poses several important questions for healthcare providers on how best to deliver care with current restrictions and in post-COVID-19 healthcare settings. Herein, we present clinical advice on the management of endometriosis during and after the COVID-19 pandemic.
OPINION
published: 07 July 2020
doi: 10.3389/frph.2020.00005
Frontiers in Reproductive Health | www.frontiersin.org 1July 2020 | Volume 2 | Article 5
Edited by:
Spyridon N. Karras,
Aristotle University of Thessaloniki,
Greece
Reviewed by:
Christos Venetis,
University of New South
Wales, Australia
*Correspondence:
Mathew Leonardi
mathew.leonardi@sydney.edu.au
ORCID:
Mathew Leonardi
orcid.org/0000-0001-5538-6906
Andrew W. Horne
orcid.org/0000-0002-9656-493X
Mike Armour
orcid.org/0000-0001-7539-9851
Stacey A. Missmer
orcid.org/0000-0003-3147-6768
Horace Roman
orcid.org/0000-0002-9237-0628
Luk Rombauts
orcid.org/0000-0003-2656-2792
Lone Hummelshoj
orcid.org/0000-0003-1490-7802
Arnaud Wattiez
orcid.org/0000-0002-9396-7581
George Condous
orcid.org/0000-0003-3858-3080
Specialty section:
This article was submitted to
Reproductive Epidemiology,
a section of the journal
Frontiers in Reproductive Health
Received: 07 May 2020
Accepted: 22 June 2020
Published: 07 July 2020
Citation:
Leonardi M, Horne AW, Armour M,
Missmer SA, Roman H, Rombauts L,
Hummelshoj L, Wattiez A, Condous G
and Johnson NP (2020)
Endometriosis and the Coronavirus
(COVID-19) Pandemic: Clinical Advice
and Future Considerations.
Front. Reprod. Health 2:5.
doi: 10.3389/frph.2020.00005
Endometriosis and the Coronavirus
(COVID-19) Pandemic: Clinical
Advice and Future Considerations
Mathew Leonardi 1,2,3
*, Andrew W. Horne4† , Mike Armour 5,6† , Stacey A. Missmer 7,8,9,10† ,
Horace Roman 10,11,12† , Luk Rombauts 10,13† , Lone Hummelshoj 10,14†, Arnaud Wattiez 15, 16†,
George Condous 1,2† and Neil P. Johnson 10,17,18, 19
1Acute Gynaecology, Early Pregnancy, and Advanced Endoscopy Surgery Unit, Nepean Hospital, Kingswood, NSW,
Australia, 2Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia, 3Department of Obstetrics and
Gynecology, McMaster University, Hamilton, ON, Canada, 4MRC Centre for Reproductive Health, University of Edinburgh,
Edinburgh, United Kingdom, 5NICM Health Research Institute, Western Sydney University, Penrith, NSW, Australia,
6Translational Health Research Institute (THRI), Western Sydney University, Penrith, NSW, Australia, 7Department of
Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States, 8Boston Center for Endometriosis,
Boston Children’s Hospital and Brigham & Women’s Hospital, Boston, MA, United States, 9Department of Obstetrics,
Gynecology, and Reproductive Biology College of Human Medicine, Secchia Center, Michigan State University,
Grand Rapids, MI, United States, 10 World Endometriosis Society, Vancouver, BC, Canada, 11 Endometriosis Centre, Clinic
Tivoli-Ducos, Bordeaux, France, 12 Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark,
13 Department of Obstetrics and Gynaecology, School of Medicine, Monash University, Melbourne, VIC, Australia,
14 Endometriosis.org, London, United Kingdom, 15 Latifa Hospital, Dubai, United Arab Emirates, 16 Department of Obstetrics
and Gynecology, University of Strasbourg, Strasbourg, France, 17 Robinson Research Institute, University of Adelaide,
Adelaide, SA, Australia, 18 Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand,
19 Auckland Gynaecology Group and Repromed Auckland, Auckland, New Zealand
Keywords: endometriosis, pelvic pain, infertility, COVID-19, coronavirus, recommendations, laparoscopic surgery,
assisted reproductive technology
INTRODUCTION
The COVID-19 pandemic has led to a dramatic shift in the clinical practice of women’s health
and routine care for endometriosis has been severely disrupted. Endometriosis is defined as an
inflammatory disease characterized by lesions of endometrial-like tissue outside the uterus that
is associated with pelvic pain and/or infertility (1). It affects 10% of reproductive age women
worldwide, is diagnosed by surgical visualization or by radiological imaging, and is managed with
hormone treatments or by laparoscopic removal of lesions (24).
At the time of writing, under the guidance of international gynecological organizations (57),
many centers temporarily ceased offering outpatient appointments, diagnostic imaging for non-
acute pelvic pain, surgery for endometriosis, and fertility treatments. In the absence of routine
care pathways and uncertainty about when health services will be available again, endometriosis
sufferers are likely to feel vulnerable and that resultant stress and anxiety may contribute to a
worsening of symptoms. The pandemic poses several important questions for healthcare providers
on how best to deliver care within these restrictions. Herein, we present clinical advice on
the management of endometriosis during the COVID-19 pandemic and future considerations
(Table 1).
Leonardi et al. Endometriosis and the COVID-19 Pandemic
ARE ENDOMETRIOSIS PATIENTS A
HIGH-RISK POPULATION OF BECOMING
INFECTED WITH SARS-CoV-2 OR
DEVELOPING MORE SEVERE COVID-19
DISEASE SYMPTOMS?
To date, there is no evidence that those with endometriosis
are at increased risk of becoming infected with SARS-CoV-2
or developing COVID-19 disease1. A rare subgroup of those
with endometriosis have thoracic endometriosis (lesions within
the pleural cavity or on the diaphragm). The exact prevalence
is unknown but some case series suggest that up to 12% of
those with endometriosis have extra-pelvic endometriosis, with
the thorax being the most common site (8). In general, there is
a paucity of literature labeling this form of endometriosis as a
risk factor for respiratory or systemic illness beyond catamenial
pneumothorax (9). As such, it is challenging to know whether
this group is at increased risk of becoming infected with SARS-
CoV-2 or developing COVID-19. Similarly, there is no evidence
that COVID-19 will hasten the progression/development of
endometriosis. Nonetheless, the pandemic will likely contribute
to a reduction in quality of life secondary to a delay in
diagnosis and/or the management of endometriosis owing
to the temporary closure of outpatient services, (including
complementary therapies), postponement of planned surgical
or fertility treatments, and an eventual increase in the waitlist
for services once they resume. The extent of the impact will
depend on the duration of service postponement and regional
resource variations (e.g., access to operating theater time when
surgeries resume).
MANAGEMENT OPTIONS AVAILABLE
DURING THE COVID-19 PANDEMIC
We encourage individuals in need of help to seek a clinical
assessment with their general practitioners (GP), gynecologists,
physiotherapists, and/or complementary medical providers
through telehealth avenues or in-person when services resume
exercising caution to follow local risk-reduction practices.
Referral to a gynecologist with expertise in endometriosis may
also be appropriate to offset the new diagnostic and therapeutic
challenges faced during this time. Those with an established
diagnosis who are seeking help, regardless of their intentions to
pursue surgical management, should discuss with their clinician
the potential to modify their current medication regimen. Some
with suspected endometriosis may accept a clinical diagnosis in
the absence of imaging or laparoscopy and empirical medical
therapy can be initiated (2). In those given a clinical diagnosis,
and who don’t respond to medical therapy, non-invasive imaging
could be the first investigation arranged when it is safe to do so to
evaluate for features that can reliably be identified such as deep
endometriosis, ovarian endometriomas, and pouch of Douglas
1People Who Are at Higher Risk for Severe Illness | Coronavirus | COVID-19
| CDC. Available online at: https://www.cdc.gov/coronavirus/2019-ncov/need-
extra-precautions/groups- at-higher-risk.html (accessed April 18, 2020).
TABLE 1 | Advice summary for endometriosis care during the COVID-19
pandemic and future considerations.
Be aware of the risks of the COVID-19 pandemic on endometriosis
patients
Reduction in quality of life secondary to
Delayed diagnosis and treatment due to
the closure of outpatient clinical services (consultations, diagnostic
imaging, allied health appointments) and
the eventual increase in the waitlist for services once they resume.
The high degree of uncertainty of surgical or fertility interventions
Treatment options for patients with endometriosis
• Postponement of elective surgery and fertility therapy should be guided by
medical colleges and societies and made by governing bodies
Continue current management if symptoms are stable or contact a healthcare
provider for changes to medication if symptoms are not well-managed
Patients should seek telehealth appointments over in-person visits
Patients with pain due to endometriosis may still consider the use of NSAIDs or
other over-the-counter analgesic medications
• Empirical medical therapy with hormonal medications is appropriate in the
absence of an imaging or surgical diagnosis
• Patients should consider the numerous complementary and alternative pain
management strategies available via telehealth services
Use of the emergency department
Patients should use telehealth services as much as possible before resorting to
visiting the emergency department
Future considerations for endometriosis management
• Resumption of surgery and fertility therapy should be guided by medical
colleges and societies and made by governing bodies
When surgery resumes, serious consideration should be given to:
Screening for COVID-19 pre-operatively
Adopting appropriate PPE behaviors
Mitigating release of aerosolized gas by modifying surgical techniques
Telehealth services should be considered as a viable method of assessment
once routine outpatient services resume
• Self-management strategies should continue to be highly encouraged as
adjuncts to traditional management
Preoperative triaging tools including advanced clinical algorithms and imaging
strategies should be implemented to avoid diagnostic laparoscopy and
multiple/repeated surgical procedures.
obliteration; whilst recognizing that at present superficial
peritoneal endometriosis is not reliably detected using imaging
(10,11). Non-endometriosis pathologies may also be diagnosed.
Knowledge of these entities has the potential to change clinical
management, so awareness of them is important. However, if
a patient is responding well to empiric treatment and does not
intend to alter management, it may be reasonable to proceed
without imaging. Laparoscopy as a diagnostic tool should be
avoided unless the intention is to simultaneously surgically treat
any endometriosis that is found (12). This could be considered
in those who are experiencing failed medical management, have
endometriosis-related infertility seeking to avoid or unable to
access assisted reproductive technologies, or simply prefer to
undergo surgery instead of using medical management.
Initially, caution in the use of non-steroidal anti-inflammatory
drugs (NSAIDs), commonly used for endometriosis-related
pain, was being advised (13). At present, the World Health
Organization states that there is no evidence of severe adverse
events, acute health care utilization, decreased long-term
survival, or diminished quality of life in patients with
COVID-19, as a result of the use of NSAIDs (14). As such,
Frontiers in Reproductive Health | www.frontiersin.org 2July 2020 | Volume 2 | Article 5
Leonardi et al. Endometriosis and the COVID-19 Pandemic
those with endometriosis-related pain who use NSAIDs can
continue to do so as needed, ensuring appropriate dosing
according to medication labels and/or healthcare providers,
bearing in mind that long-term use of NSAIDs come with
its own set of side-effects including peptic ulceration and
adverse impact on ovulation (2). Beyond traditional medical
therapies, problem-focused interventions such as education,
modifying work/school/social life, taking advantage of virtual
and telephone support provided by national endometriosis
organizations, improving sleep hygiene, low-intensity
physical activity (including pelvic exercises, yoga), dietary
changes, application of heat, and medical cannabis should
be considered, either with the assistance of a healthcare
provider via telehealth or independently by patients themselves
(15). Similarly, emotion-focused strategies, which include
relaxation/mindfulness, acceptance of chronic illness (e.g.,
via Acceptance and Commitment Therapy with the help
of a clinical psychologist through telehealth), reducing
catastrophizing, and improving a balance toward positive
attitude can be considered (15). These strategies are not
unique to the COVID-19 pandemic and are recognized as
an integral part of the usual multidisciplinary management
of endometriosis.
Patients should be aware that, if they experience acute
exacerbations of their chronic pain, they may warrant urgent
medical assessment, as such cases, especially those with suspected
endometrioma or severe acute recalcitrant exacerbation of pain,
may require urgent surgery. However, most pain exacerbations
are not life- or organ-threatening and with appropriate
counseling and support, a face-to-face consultation in the
emergency department may be avoided. Some GPs may find it
challenging to confidently reassure patients that they are safe
to avoid an emergency department visit, so urgent telehealth
consultation with a gynecologist or pain specialist may be
helpful. That said, we do not advocate for the avoidance of the
emergency department out of fear, so patients and providers
should continue to judiciously and safely use this service
when warranted.
ADVICE ON RESUMING PRE-PANDEMIC
“REGULAR” CARE FOR ENDOMETRIOSIS
As restrictions begin to lift, healthcare services, including
surgery for endometriosis, will resume. The decision about
when clinical care should resume will be determined by medical
colleges and societies, in compliance with governing bodies
informed by emerging viral disease pandemic experts. The
provision of appropriate medical and surgical care should
resume with an emphasis on safety for patients, healthcare
staff, and society. The American College of Surgeons (16), the
Royal College of Obstetricians and Gynaecologists (17), and
a collaborative effort by nine women’s health care societies
(18) outline important guidance for resuming surgical practice
and reintroducing these procedures. Though endometriosis is
a non-malignant disease, we believe it must be treated with
high priority due to the major impact it has on quality of
life (19). That said, facilities should employ a prioritization
policy committee, including a gynecologist with expertise in
managing the various facets of endometriosis (surgery, pain
management, fertility treatment), to ensure an appropriate
strategy is developed across all specialties. Amongst several
strategies (16), previously canceled and postponed endometriosis
surgeries should be prioritized. An objective priority scoring
tool could also be implemented [e.g., MeNTS instrument (20)].
Based on the procedure, disease type, and patient factors
that go into this scoring tool, endometriosis surgery would
be relatively low risk. Objectively judging the impact of a 2-
or 6-week delay on disease outcome is challenging as timing
surgical management (e.g., immediate vs. delayed) has never
been evaluated (21). It is unlikely for there to be a change
in the surgical difficulty/risk with a 2- or 6-week delay (22).
For urgent/emergency surgeries that have continued through
the COVID-19 pandemic, there has been discussion about the
safety of surgery based on theoretical evidence that aerosolization
of the virus can occur with ultrasonic/electrosurgery (23).
During this time, a minimally invasive surgical approach is
being recommended (24) and felt to be lower risk (20).
This COVID-19 specific recommendation aligns with the
typical approach to endometriosis preceding the pandemic.
Benefits include improved visibility of subtle endometriosis
lesions (and therefore targeted treatment), decreased blood
loss, reduced post-operative pain levels, and shorter in-hospital
stay post-operatively. We support the joint statement by
several gynecologic surgical societies, where expert opinion
recommendations on intraoperative precautions have been put
forward (25).
Adequate preoperative screening and diagnosis of SARS-CoV-
2 will be an important consideration for the resumption of
endometriosis surgery (26). Though most patients undergoing
surgery for endometriosis are relatively young and healthy,
we must be cognizant of the increased risk in those with
perioperative SARS-CoV-2 infection. It has recently been noted
that post-operative pulmonary complications occur in half of
the patients with perioperative SARS-CoV-2 infection and are
associated with high mortality (27).
At this time, we do not believe that the COVID-19 pandemic
warrants a sustained change in the overall medical approach
to the management of endometriosis (e.g., avoid surgery
and favor medical management). Regardless of a pandemic,
we encourage healthcare providers to comprehensively
counsel patients on the therapeutic options available for
each individual with endometriosis. The possible risks
and realistic scheduling obstacles secondary to COVID-19
must be part of this conversation, but patients should still
retain their autonomy to choose the option that is best
for them.
FUTURE CONSIDERATIONS
We believe that the COVID-19 pandemic can lead to sustained
improvements in the care for those with endometriosis. Firstly,
there may be an ongoing openness to telehealth (28). This
Frontiers in Reproductive Health | www.frontiersin.org 3July 2020 | Volume 2 | Article 5
Leonardi et al. Endometriosis and the COVID-19 Pandemic
could dramatically minimize the geographic barriers to care
that many women experience, and facilitate the development
of endometriosis networks of expertise, which is recommended
by the World Endometriosis Society (2). Telehealth may also
be an appropriate alternative for patients with pain that limits
their ability to travel to their healthcare provider in some
settings. Secondly, there may be increased awareness to self-
management strategies that have always existed, yet were
under-utilized (e.g., mindfulness, physical exercise, and diet)
until COVID-19 resulted in them becoming valuable tools for
patients (15). Finally, the current situation mandates a more
discerning approach to surgery now and in the future, so that
we “operate sparingly and operate well.” This approach can be
guided by preoperative triaging tools including advanced clinical
algorithms and imaging strategies (29) to avoid multiple repeated
surgical procedures.
AUTHOR’S NOTE
This manuscript has been released as a pre-print in
Authorea (30).
AUTHOR CONTRIBUTIONS
All authors meet justification criteria of authorship as per
ICMJE: substantial contributions to conception and design
or acquisition of data or analysis and interpretation of data,
drafting the article or revising it critically for important
intellectual content, final approval of the version to be published,
and agreement to be accountable for all aspects of the
work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigated
and resolved.
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Disclaimer: This viewpoint article is endorsed by the World Endometriosis Society
(WES) and the International Federation of Fertility Societies (IFFS).
Conflict of Interest: ML reports grants from Australian Women and Children’s
Research Foundation, outside the submitted work. AH reports grants from Chief
Scientist Office, NIHR EME, MRC, Wellbeing of Women, Ferring, and Roche
Diagnostics during the conduct of the study; and honoraria for consultancy for
Ferring, Roche, and AbbVie, outside the submitted work. MA reports grants
from Metagenics and Spectrum outside the submitted work. SM reports a grant
and consulting fees from Abbvie, and consulting fees from Roche outside the
submitted work. LR reports personal fees from Monash IVF Group, grants from
Ferring Australia, personal fees from Ferring Australia, non-financial support
from Merck Serono, non-financial support from MSD, non-financial support
from Guerbet, outside the submitted work; and Minority shareholder and Group
Medical Director for Monash IVF Group and the President-Elect of the World
Endometriosis Society. HR reports personal fees from Olympus, personal fees
from Ethicon, personal fees from Nordic Pharma, personal fees from Plasma
Surgical Ltd., outside the submitted work. LH reports personal fees from AbbVie,
is the chief executive of the World Endometriosis Society, and the owner of
Endometriosis.org., outside the submitted work. GC reports personal fees from
Roche, personal fees from GE Healthcare, grants from Australian Women and
Children’s Research Foundation, outside the submitted work. NJ reports personal
fees from Guerbet, personal fees from Vifor Pharma, grants and personal fees
from Myovant Sciences, grants from AbbVie, personal fees from Roche, outside
the submitted work.
The remaining author declares that the research was conducted in the absence of
any commercial or financial relationships that could be construed as a potential
conflict of interest.
Copyright © 2020 Leonardi, Horne, Armour, Missmer, Roman, Rombauts,
Hummelshoj, Wattiez, Condous and Johnson. This is an open-access article
distributed under the terms of the Creative Commons Attribution License (CC BY).
The use, distribution or reproduction in other forums is permitted, provided the
original author(s) and the copyright owner(s) are credited and that the original
publication in this journal is cited, in accordance with accepted academic practice.
No use, distribution or reproduction is permitted which does not comply with these
terms.
Frontiers in Reproductive Health | www.frontiersin.org 5July 2020 | Volume 2 | Article 5
... However, although not confirmed, women with thoracic endometriosis (in the lungs and/or diaphragm) may be at increased risk [189]. The manifestation of COVID-19 may be altered in endometriosis with a slightly decreased frequency of asymptomatic infection and fever and an increased frequency of rare symptoms (i.e., sore throat, nasal congestion, cough, shortness of breath, headache, weakness, and muscle pain, reduced sense of smell and/or taste, and ocular problems) [190]. Further studies involving a larger group of patients are needed. ...
... On the other hand, exacerbations in pelvic pain may be experienced due to high levels of inflammatory/pain mediators as well as pauses in medical or allied health treatment or postponement of surgical treatments. Evidence that COVID-19 by itself accelerates the progression/ development of endometriosis is not available [190]. ...
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Coronavirus disease 2019 (COVID-19), a pandemic disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, can affect almost all systems and organs of the human body, including those responsible for reproductive function in women. The multisystem inflammatory response in COVID-19 shows many analogies with mast cell activation syndrome (MCAS), and MCAS may be an important component in the course of COVID-19. Of note, the female sex hormones estradiol (E2) and progesterone (P4) significantly influence mast cell (MC) behavior. This review presents the importance of MCs and the mediators from their granules in the female reproductive system, including pregnancy, and discusses the mechanism of potential disorders related to MCAS. Then, the available data on COVID-19 in the context of hormonal disorders, the course of endometriosis, female fertility, and the course of pregnancy were compiled to verify intuitively predicted threats. Surprisingly, although COVID-19 hyperinflammation and post-COVID-19 illness may be rooted in MCAS, the available clinical data do not provide grounds for treating this mechanism as significantly increasing the risk of abnormal female reproductive function, including pregnancy. Further studies in the context of post COVID-19 condition (long COVID), where inflammation and a procoagulative state resemble many aspects of MCAS, are needed.
... 21,27 The impediment to accessing normal health care has limited endometriosis patients' ability to obtain their usual treatments, including those for pain relief. [27][28][29] While telehealth appointments did allow ongoing care of current patients there may have been issues in access for new patients due to lack of access to diagnostic procedures, and in the early pandemic period (May-June 2020), one in five people with endometriosis worldwide reported issues with access to their normal endometriosis medications, over a third cancelled or postponed procedures, and half cancelled or postponed gynecological appointments. 30 Pre-pandemic, there was already evidence supporting a worldwide increased adoption of self-management measures for control of endometriosis symptoms. ...
... This can be attributed to a shift in health care resource allocation during the pandemic, affecting the management of endometriosis patients worldwide. 22,29,49 Reduced access to regular health care and indefinitely delayed surgical treatment resulted in emotional distress and inconsistent endometriosis treatments, leading to increased numbers of women turning to self-management as a coping strategy. 34,41 Despite increases in cannabis consumption during the pandemic, cannabis-related expenditure did not increase to the same extent. ...
Article
Introduction: Endometriosis affects 1 in 10 women worldwide, with most experiencing difficulties achieving adequate symptom control. These difficulties have been compounded by the onset of the COVID-19 pandemic due to worldwide shifts in health care resource allocation. As cannabis is a relatively common form of self-management in endometriosis, this study aims to explore the impact of the COVID-19 pandemic on cannabis consumption in those with endometriosis. Methods: An anonymous, cross-sectional online international survey was developed and promoted by endometriosis advocacy/support organizations worldwide. Respondents needed to have a diagnosis of endometriosis and be aged between 18 and 55. Results: A total of 1634 responses were received from 46 different countries. The average age of respondents was 30, with a mean diagnosis age of 25. Eight hundred forty-six respondents (51%) reported consuming cannabis in the past 3 months, with 55% of these reporting use for symptom management only. One in five respondents (20%) reported having consumed cannabis previously, the most common reason for discontinuation (65%) was access difficulties during COVID. Those who had legal access were more likely to consume cannabis than those without (p<0.0001) and were more likely to disclose usage to health care professionals (p<0.0001). The most common reasons for consuming cannabis during COVID was increased stress/anxiety (59%) and lack of access to normal medical care (48%). Pre-pandemic, cannabis was mostly consumed at least once a day (61%) and in inhaled forms (51.6%). Consumption increased for most people (57%) during the pandemic. During the pandemic just under a quarter (23%) of respondents changed their mode of consumption, with a reduction in inhaled forms (39.5%) and an increase in consumption of edibles (40%) or oil (25.2%). Conclusions: Cannabis consumption, especially for symptom relief, was relatively common among those with endometriosis, with some people starting their consumption of cannabis due to health care restrictions that occurred due to the COVID-19 pandemic. Difficulties accessing cannabis and unpleasant/unwanted side effects were the most common reasons for lack of current cannabis consumption in those who had previously consumed it. Cannabis consumption may form an important part of endometriosis management especially when access to routine medical care is restricted.
... However, to the best of our knowledge, no studies have explored the impact of telehealth-delivered exercise on pelvic pain experienced by women with endometriosis. It has also recently been suggested that telehealth may be a suitable alternative for women with endometriosis experiencing pain that limits their ability to travel to a healthcare provider [13]. Virtual reality (VR) has also been successfully employed for the self-management of various pain conditions [14], specifically in the management of pelvic pain associated with endometriosis [15]. ...
Article
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Background: Endometriosis is a debilitating chronic condition that is commonly associated with chronic pelvic pain, affecting approximately 10% of women of reproductive age worldwide. The general principle of pain management in this population involves both pharmacological and surgical interventions. There is also increasing interest in the use of exercise as an alternative non-pharmacological analgesic, but adherence and accessibility to face-to-face exercise-delivery modalities are poor. This study aims to determine the immediate impact of a single session of ‘supervised’ telehealth-delivered exercise compared to ‘self-managed’ virtual reality (VR)-delivered exercise on pelvic pain associated with endometriosis. Methods: Twenty-two women experiencing pelvic pain due to endometriosis were included and randomized into three groups: (i) VR-delivered exercise group (n = 8); (ii) telehealth-delivered exercise group (n = 8); and (iii) control group (n = 6). The visual analogue scale (VAS) was used to assess the severity of pelvic pain. Results: There was no statistically significant between-group difference (p = 0.45) in the participants’ pain score following a single session of the study interventions (VR or telehealth) or the control. However, a ‘medium-to-large’ group x time interaction effect (η2 = 0.10) was detected, indicating a more favorable pain score change following a single session of telehealth- (pre-post ∆: +10 ± 12 mm) and VR-delivered exercise (pre-post ∆: +9 ± 24 mm) compared to the control group (pre-post ∆: +16 ± 12 mm). Conclusions: Our study suggests that a single bout of a ‘self-managed’ VR-delivered exercise may be as efficacious as a single session of ‘supervised’ telehealth-delivered exercise in providing immediate relief from pelvic pain associated with endometriosis.
... A study by Miguel-Gomez et al. involving a cohort of 24 women with COVID-19 (n = 14) and without COVID-19 (n = 10), showed that even though SARS-CoV-2 was absent from the endometrial tissue in COVID-19 patients, there was alteration in gene expression for receptors in the endometrial tissue despite the absence of SARS-CoV-2 RNA [45]. In addition, from a clinical perspective, it remains unclear whether patients with thoracic endometriosis may have a higher risk of pulmonary disease or SARS-CoV-2 infection [46]. However, evidence from recent studies has shown an increased risk of SARS-CoV-2 infection in other common gynecological conditions such as endometrial hyperplasia and cancer [47], polycystic ovary syndrome [48], and breast cancer [49]. ...
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Endometriosis is defined as ectopic endometrial tissues dispersed outside the endometrium. This can cause disruption in hormonal and immunological processes, which may increase susceptibility to SARS-CoV-2 infection. Worsening of endometriosis symptoms may occur as a result of this infection. The aim of our review was to estimate the pooled prevalence of SARS-CoV-2 infection and the health impacts of the COVID-19 pandemic in endometriosis patients. We conducted a systematic review and meta-analysis. MEDLINE, Science Direct, Scopus, and Google Scholar databases were searched, using the keywords: (endometriosis) AND (COVID-19 OR SARS-CoV-2). Forest plots and pooled estimates were created using the Open Meta Analyst software. After screening 474 articles, 19 studies met the eligibility criteria for the systematic review, and 15 studies were included in the meta-analyses. A total of 17,799 patients were analyzed. The pooled prevalence of SARS-CoV-2 infection in endometriosis patients was 7.5%. Pooled estimates for the health impacts were 47.2% for decreased access to medical care, 49.3% increase in dysmenorrhea, 75% increase in anxiety, 59.4% increase in depression, and 68.9% increase in fatigue. Endometriosis patients were undeniably impacted by the COVID-19 pandemic, which caused the worsening of symptoms such as dysmenorrhea, pelvic pain, anxiety, depression, and fatigue.
... Additionally, the International Society of Ultrasound in Obstetrics and Gynecology has recommended postponing ultrasound evaluation of non-acute pelvic pain (Bourne et al., 2020). Furthermore, patients with endometriosis have reported their concerns with seeking medical help because of the fear of becoming infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, in medical centres (Leonardi et al., 2020a). Consequently, the quality of life of these patients has been drastically impaired by pain, subfertility, frustration about disease recurrence and uncertainty regarding the therapeutic options available to them (Ammar et al., 2020;Pfefferbaum and North, 2020). ...
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STUDY QUESTION What was the effect of the coronavirus disease 2019 (COVID-19) pandemic on healthcare and quality of life in those suffering from endometriosis? SUMMARY ANSWER Our study reveals a clear correlation between the deterioration of the reported physical and mental state, and impaired medical care for patients suffering from endometriosis during the COVID-19 pandemic. WHAT IS KNOWN ALREADY The quality of life of patients suffering from endometriosis is compromised in a variety of aspects. In response to the ongoing COVID-19 pandemic, self-isolation practices aimed at curbing the spread of COVID-19 have severely complicated the availability of proper medical care worldwide. STUDY DESIGN, SIZE, DURATION The study involved a cross-sectional international self-reported online survey. Responses were accepted between November 2020 and January 2021. The survey was prepared by the department of obstetrics and gynecology in a medical university setting. The survey contained 17 questions and was placed online. Cooperation with different endometriosis organizations around the world enabled distribution of the survey through their social media platforms. PARTICIPANTS/MATERIALS, SETTING, METHODS The study participants (n = 3024 replies) originated from 59 countries. The questionnaire was created after a literature review and is partially based on validated quality of life questionnaires, adjusted to the study question. The survey was then translated to 15 other languages following World Health Organization recommendations as closely as possible. Chi-square tests for independence were carried out for the analysis of the two variables: suspension of health services, and the patients mental and physical well-being. MAIN RESULTS AND THE ROLE OF CHANCE Out of 3024 participants from 59 countries who submitted the questionnaire between November 2020 and January 2021, 2964 (98.01%) provided information that enabled a full analysis. For the 1174 participants who had their medical appointments cancelled, 43.7% (n = 513) reported that their symptoms had been aggravated, and 49.3% (n = 579) reported that their mental state had worsened. In comparison, of the 1180 participants who kept their appointments, only 29.4% (n = 347) stated that their symptoms had been aggravated, and 27.5% (n = 325) stated their mental health had worsened. The results showed that there was a significant link between reported deterioration of mental and physical wellbeing and impaired medical care (cancellation) (P ≪ 0.001). A total of 610 participants did not have medical appointments scheduled, and these participants followed a similar pattern as the participants who kept their appointments, with 29.0% (n = 177) reporting aggravation of symptoms and 28.2% (n = 172) reporting that their mental state had worsened. LIMITATIONS, REASONS FOR CAUTION Cultural differences among international participants are to be expected and this may have affected how participants from different countries interpreted and answered the questionnaire. Translating the questionnaire into 15 different languages, even though incorporating backwards translation, could possibly lead to different interpretations of given questions, simply based on different wording in the languages. The majority of respondents (around 90%) were from Europe and South America and therefore the findings may not be generalizable to other locations. WIDER IMPLICATIONS OF THE FINDINGS Further research is needed to assess the true impact and long-term consequences of the COVID-19 pandemic for patients living with endometriosis. STUDY FUNDING/COMPETING INTEREST(S) This study received no funding and the authors declare they have no relevant conflicts of interest. TRIAL REGISTRATION NUMBER N/A
... From the clinical perspective, it is not yet clear whether patients with thoracic endometriosis have a higher risk of pulmonary disease or COVID-19 infection [25]. An expert opinion has suggested specific treatment guidelines, in order to reduce the susceptibility of endometriosis patients to COVID-19 infection [26]. ...
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Background In today’s world, coronavirus disease 2019 (COVID-19) is the most critical health problem and research is continued on studying the associated factors. But it is not clear whether endometriosis increases the risk of COVID-19. Methods Women who referred to the gynecology clinic were evaluated and 507 women with endometriosis (case group) were compared with 520 women without endometriosis (control group). COVID-19 infection, symptoms, exposure, hospitalization, isolation, H1N1 infection and vaccination, and past medical history of the participants were recorded and compared between the groups using IBM SPSS Statistics for Windows version 21. Results Comparison between the groups represent COVID-19 infection in 3.2% of the case group and 3% of the control group ( P = 0.942). The control group had a higher frequency of asymptomatic infection (95.7% vs. 94.5%; P < 0.001) and fever (1.6% vs. 0%; P = 0.004), while the frequency of rare symptoms was more common in the case group ( P < 0.001). The average disease period was 14 days in both groups ( P = 0.694). COVID-19 infection was correlated with close contact (r = 0.331; P < 0.001 in the case group and r = 0.244; P < 0.001 in the control group), but not with the history of thyroid disorders, H1N1 vaccination, traveling to high-risk areas, and social isolation ( P > 0.05). Conclusion Endometriosis does not increase the susceptibility to COVID-19 infections, but alters the manifestation of the disease. The prevalence of the disease may depend on the interaction between the virus and the individual’s immune system but further studies are required in this regard.
... The association of immune system disturbances with the incidence of endometriosis has been discovered previously (16). It has been suggested that intratracheal endometriosis may induce and/or worsen pulmonary symptoms of COVID-19 infection (17). An expert opinion has suggested speci c treatment guidelines, in order to reduce the susceptibility of endometriosis patients to COVID-19 infection (18). ...
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Background In today’s world, coronavirus disease 2019 (COVID–19) is the most critical health problem and research is continued on studying the associated factors. But it is not clear whether endometriosis increases the risk of COVID–19. Methods Women who referred to the gynecology clinic were evaluated and 507 women with endometriosis (case group) were compared with 520 women without endometriosis (control group). COVID–19 infection, symptoms, exposure, hospitalization, isolation, H1N1 infection and vaccination, and past medical history of the participants were recorded and compared between the groups using IBM SPSS Statistics for Windows version 21. Results Comparison between the groups represent COVID–19 infection in 3.2% of the case group and 3% of the control group (P = .942). The control group had a higher frequency of asymptomatic infection (95.7% vs. 94.5%; P < .001) and fever (1.6% vs. 0%; P = .004), while the frequency of rare symptoms was more common in the case group (P < .001). The average disease period was 14 days in both groups (P = .694). COVID–19 infection was correlated with close contact (r = .331; P < .001 in the case group and r = .244; P < .001 in the control group), but not with the history of thyroid disorders, H1N1 vaccination, traveling to high-risk areas, and social isolation (P > .05). Conclusion Endometriosis does not increase the susceptibility to COVID–19 infections, but alters the manifestation of the disease. The prevalence of the disease may depend on the interaction between the virus and the individual’s immune system but further studies are required in this regard.
Article
Aim To identify and review the success of non-pharmaceutical, non-surgical biopsychosocial interventions in individuals with endometriosis, in managing pain and improving body image. Methods Cochrane, EBSCO, IBSS, NICE, Open Grey, OVID, Proquest, Scopus and Science Direct were searched in April 2021, using inclusion and exclusion criteria. Data collection and analysis Five randomised control trials, and one controlled clinical trial resulted from the search. Study quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool. Studies were synthesised by intervention type, into physical only, and physical and psychological. Results Across the six papers, 323 participants were recruited, through medical records or self-referral, and treatments largely administered by specialist practitioners. From the EPHPP quality assessment,2 weak quality papers, and four moderate quality papers found improvements to pain, with large effect sizes in four papers. No studies used established body image measures to examine intervention effects on body image, and all lacked health psychology theoretical basis. There were common issues in selection bias, confounders and blinding. Conclusion Without gold-standard methodology, evidence of effectiveness cannot be concluded. However, there is promising rationale if these issues are addressed.
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Objectives: To examine women's perceptions of endometriosis-associated disease burden and its impact on life decisions and goal attainment. Design: An anonymous online survey was distributed in October 2018 through the social media network MyEndometriosisTeam.com. Participants: Women aged 19 years and older living in several English-speaking countries who self-identified as having endometriosis. Outcome measures: Patients' perspectives on how endometriosis has affected their work, education, relationships, overall life decisions and attainment of goals. Subanalyses were performed for women who identified as 'less positive about the future' (LPAF) or had 'not reached their full potential' (NRFP) due to endometriosis. Results: 743 women completed the survey. Women reported high levels of pain when pain was at its worst (mean score, 8.9 on severity scale of 0 (no pain) to 10 (worst imaginable pain)) and most (56%, n=415) experienced pain daily. Women reported other negative experiences attributed to endometriosis, including emergency department visits (66%, n=485), multiple surgeries (55%, n=406) and prescription treatments for symptoms of endometriosis (72%, n=529). Women indicated that they believed endometriosis had a negative impact on their educational and professional achievements, social lives/relationships and overall physical health. Most women 'somewhat agreed'/'strongly agreed' that endometriosis caused them to lose time in life (81%, n=601), feel LPAF (80%, n=589) and feel they had NRFP (75%, n=556). Women who identified as LPAF or NRFP generally reported more negative experiences than those who were non-LPAF or non-NRFP. Conclusions: Women who completed this survey reported pain and negative experiences related to endometriosis that were perceived to negatively impact major life-course decisions and attainment of goals. Greater practitioner awareness of the impact that endometriosis has on a woman's life course and the importance of meaningful dialogue with patients may be important for improving long-term management of the disease and help identify women who are most vulnerable.
Article
The world is still grappling with the threat due to the emergence of the coronavirus disease-2019 (COVID-19) caused by a new variant of coronavirus. The high transmission of the virus among humans has led to a pandemic and there is also emergence of mutant strain of virus (severe acute respiratory syndrome coronaviruses 2 Variant VOC 202012/01) within communities. With the uncertainties in the development, efficacy and reach of an effective vaccine among the masses, it has become a mammoth task for human beings to carry on with the dayto-day task and lifestyle. This has severely impacted the health-care services including the fertility treatments. The assisted reproductive technology (ART) services have accordingly molded itself to cater to patients. There are various guidelines and regulations introduced to provide fertility services on the basis of priority of the patients seeking treatments, keeping in compliance to the safety measures for the healthcare staffs and patients. On the other hand, couples wish to pursue their way to parenthood even in the testing times. Melatonin, a neurohormone, is a multipotent molecule associated with male and female reproduction and is being protectively involved in the various reproductive processes. It maintains the circadian rhythmicity of various hormones and has potentials in treating COVID-19 patients. Its use in IVF procedures can be protective and effective measure to deal with the uncertainties of time. Its immune enhancing role can be utilized in fulfilling the patients’ health and achieving fertility goals contributing to the success of ART.
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The care of patients with endometriosis has been complicated by the coronavirus disease 2019 (COVID-19) pandemic. Medical and allied healthcare appointments and surgeries are being temporarily postponed. Mandatory self-isolation has created new obstacles for individuals with endometriosis seeking pain relief and improvement in their quality of life. Anxieties may be heightened by concerns over whether endometriosis may be an underlying condition that could predispose to severe COVID-19 infection and what constitutes an appropriate indication for presentation for urgent treatment in the epidemic. Furthermore, the restrictions imposed due to COVID-19 can impose negative psychological effects, which patients with endometriosis may be more prone to already. In combination with medical therapies, or as an alternative, we encourage patients to consider self-management strategies to combat endometriosis symptoms during the COVID-19 pandemic. These self-management strategies are divided into problem-focused and emotion-focused strategies, with the former aiming to change the environment to alleviate pain, and the latter address the psychology of living with endometriosis. We put forward this guidance, which is based on evidence and expert opinion, for healthcare providers to utilize during their consultations with patients via telephone or video. Patients may also independently use this article as an educational resource. The strategies discussed are not exclusively restricted to consideration during the COVID-19 pandemic. Most have been researched before this period of time and all will continue to be a part of the biopsychological approach to endometriosis long after COVID-19 restrictions are lifted.
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Background The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 82·6% (219 of 265) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p<0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
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The coronavirus disease (COVID-19) pandemic has certainly been an unprecedented time. We have had to halt and modify our lives on a local, national, and international level and cooperate in fighting with this “invisible enemy” in every sector (medical, governmental, industrial, eco- nomic, educational, and social). Our immediate action in American Association of Gynecologic Laparoscopists has been to organize weekly webinars on subjects related to the pandemic and unite with 8 other professional women’s healthcare societies to provide joint statements that guide our membership and others to expand their knowledge and optimize patient care during the COVID-19 crisis. This international and multidisciplinary collaboration with sur- geons and medical specialists at the leading edge of the pandemic course has been an invaluable resource for global healthcare providers who are at earlier points on the COVID-19 curve. COVID-19 preparedness has required flexibility because of a lack of diagnostic tools to accurately detect all viral carriers and the absence of effective viral ther- apy. Most gynecologists have halted most of the “non- essential” office and surgical procedures to protect and mitigate risk for all patients and caregivers, preserve personal protective equipment (PPE), and maintain facility capacity for a surge in COVID-19 cases. Joint statements from the American College of Surgeons and the consortium of 9 women’s healthcare societies have provided guidance for resuming surgical practice and reintroducing elective procedures [1,2]. This special article provides further detailed information necessary for successful surgical and clinical reactivation for elective procedures during the COVID-19 Era, while severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains a viable threat.
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The roadmap to elective surgery resumption after this COVID-19 pandemic should be progressive and cautious. The aim of this paper was to give recommendations and guidelines for resuming elective orthopedic surgery in the safest environment possible. Elective surgery should be performed in COVID-free facilities and hospital stay should be as short as possible. For matters of safety, patients considered first for surgery should be carefully selected according to COVID infection status/exposure, age, ASA physical status classification system / risk factors, socio-professional situation and surgical indication. A strategy for resuming elective surgery in four phases is proposed. Preoperative testing for COVID-19 infection is highly recommended. In any cases, COVID symptoms including fever and increased temperature should be constantly monitored until the day of surgery. Elective surgery should be postponed at the slightest suspicion of a COVID-19 infection. In case of surgery, adapted personal protective equipment in terms of gowns, gloves, masks and eye protection is highly recommended and described.
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The COVID-19 pandemic poses several important questions for healthcare providers on how best to deliver endometriosis care with these restrictions. Herein, we present clinical guidance on the management of endometriosis during the COVID-19 pandemic. This Commentary is endorsed by the World Endometriosis Society (WES) and the International Federation of Fertility Societies (IFFS)
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The unprecedented pandemic of COVID-19 has impacted many lives and affects the whole healthcare systems globally. In addition to the considerable workload challenges, surgeons are faced with a number of uncertainties regarding their own safety, practice, and overall patient care. This guide has been drafted at short notice to advise on specific issues related to surgical service provision and the safety of minimally invasive surgery during the COVID-19 pandemic. Although laparoscopy can theoretically lead to aerosolization of blood borne viruses, there is no evidence available to confirm this is the case with COVID-19. The ultimate decision on the approach should be made after considering the proven benefits of laparoscopic techniques versus the potential theoretical risks of aerosolization. Nevertheless, erring on the side of safety would warrant treating the coronavirus as exhibiting similar aerosolization properties and all members of the OR staff should use personal protective equipment (PPE) in all surgical procedures during the pandemic regardless of known or suspected COVID status. Pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction, or conversion to open. All emergent endoscopic procedures performed during the pandemic should be considered as high risk and PPE must be used by all endoscopy staff.
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Hospitals have severely curtailed the performance of non-urgent surgical procedures in anticipation of the need to redeploy healthcare resources to meet the projected massive medical needs of patients with Coronavirus Disease 2019 (COVID-19). Surgical treatment of non-COVID-19 related disease during this period, however, still remains necessary. The decision to proceed with Medically-Necessary, Time-Sensitive (MeNTS) procedures in the setting of the COVID-19 pandemic requires incorporation of factors (resource limitations, COVID-19 transmission risk to providers and patients) heretofore not overtly considered by surgeons in the already complicated processes of clinical judgment and shared decision-making. We describe a scoring system that systematically integrates these factors to facilitate decision-making and triage for MeNTS procedures and appropriately weighs individual patient risks with the ethical necessity of optimizing public health concerns. This approach is applicable across a broad range of hospital settings (academic and community, urban and rural) in the midst of the pandemic and may be able to inform case triage as OR capacity resumes once the acute phase of the pandemic subsides.