Intricate Connections between the Microbiota and Endometriosis

Imbalances in gut and reproductive tract microbiota composition, known as dysbiosis, disrupt normal immune function, leading to the elevation of proinflammatory cytokines, compromised immunosurveillance and altered immune cell profiles, all of which may contribute to the pathogenesis of endometriosis. Over time, this immune dysregulation can progress into a chronic state of inflammation, creating an environment conducive to increased adhesion and angiogenesis, which may drive the vicious cycle of endometriosis onset and progression. Recent studies have demonstrated both the ability of endometriosis to induce microbiota changes, and the ability of antibiotics to treat endometriosis. Endometriotic microbiotas have been consistently associated with diminished Lactobacillus dominance, as well as the elevated abundance of bacterial vaginosis-related bacteria and other opportunistic pathogens. Possible explanations for the implications of dysbiosis in endometriosis include the Bacterial Contamination Theory and immune activation, cytokine-impaired gut function, altered estrogen metabolism and signaling, and aberrant progenitor and stem-cell homeostasis. Although preliminary, antibiotic and probiotic treatments have demonstrated efficacy in treating endometriosis, and female reproductive tract (FRT) microbiota sampling has successfully predicted disease risk and stage. Future research should aim to characterize the “core” upper FRT microbiota and elucidate mechanisms behind the relationship between the microbiota and endometriosis.Medicine, Faculty ofEndocrinology, Division ofMedicine, Department ofObstetrics and Gynaecology, Department ofReviewedFacultyResearche

IL-1β and PA system in endometriosis

Objective To study the role of Interleukin-1β and plasminogen activating system members in endometriosis migration/invasion. Design Primary cultures of endometriotic stromal cells. Subjects Patients with surgically excised endometriosis. Interventions Interleukin-1β stimulation of primary cultures of endometriotic stromal cells, and knockdown of plasminogen activating system members urokinase plasminogen activator, urokinase plasminogen activator receptor, and plasminogen activator inhibitor-1. Main outcome measures Invasion/migration assays Results In primary cultures, Interleukin-1β stimulated endometriotic stromal cell production of the plasminogen activating system members urokinase plasminogen activator, urokinase plasminogen activator receptor, and plasminogen activator inhibitor-1. Interleukin-1β also enhanced endometriotic stromal cell migration and invasion, and these effects were inhibited by the Interleukin-1R1 antagonist Anakinra. Knockdown of each of the three plasminogen activating system members also inhibited endometriotic stromal cell migration and invasion. Knockdown of these plasminogen activating system members further attenuated the impact of Interleukin-1β on migration and invasion, suggesting that they mediated the pro-migration and pro-invasion effects of Interleukin-1β. To supplement the cell culture work, immunohistochemistry was carried out on tissue sections of endometriosis epithelium/stroma: urokinase plasminogen activator, plasminogen activator inhibitor-1, and Interleukin-1β H-scores were not found to be correlated with each other. Conclusion In primary cultures of endometriosis stromal cells, Interleukin-1β induces migration and invasion, which is mediated by plasminogen activating system members, and inhibited by the drug Anakinra. However, immunohistochemistry expression of Interleukin-1β, urokinase plasminogen inhibitor-1 and plasminogen activator inhibitor-1 were not correlated, suggesting other regulatory mechanisms for plasminogen activating system members. Inhibition of Interleukin-1β (e.g. with Anakinra) may have potential as a novel treatment approach for the migration/invasion of endometriosis.Medicine, Faculty ofObstetrics and Gynaecology, Department ofReviewedFacultyGraduat

Elevated Nerve Growth Factor and its Receptor Levels in Endometriotic Tissues are Associated with Deep Dyspareunia

CONTEXT; Deep dyspareunia (pelvic pain with sexual intercourse) affects half of women with endometriosis, but the underlying mechanisms are unclear. OBJECTIVE: To investigate whether nerve growth factor (NGF) and its receptor (TrkA/p75NTR) levels in endometriotic tissues are elevated in women with deep dyspareunia. DESIGN: In vitro study. SETTING: University hospital affiliated research laboratories. PATIENTS: 34 women with endometriosis in the posterior pelvic compartment (cul-de-sac/uterosacrals) were included, either with (n=18) or without (n=16) deep dyspareunia symptoms which was confirmed by endovaginal ultrasound-assisted palpation on examination. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Utilizing surgically excised cul-de-sac/uterosacral endometriosis, expression of NGF/TrkA/p75NTR was examined by immunohistochemistry and Histoscore. Cultured endometriotic stromal cells (ESCs, n=3) were incubated with/without NGF and/or Trk inhibitor K252a. Prostaglandin-endoperoxide synthase-2 (PGST-2/COX-2) mRNA and protein levels were examined by RT-qPCR and Western blot, respectively. Prostaglandin E2 (PGE2) secretion were examined by ELISA. RESULTS: NGF/TrkA/p75NTR were expressed in the epithelium and stroma of the cul-de- sac/uterosacral endometriosis, and were significantly elevated in women with deep dyspareunia compared to women without deep dyspareunia. NGF immunoreactivity in the stroma was also significantly associated with deep dyspareunia severity and with nerve bundle density. In cultured ESCs, NGF significantly increased PTGS-2/COX-2 mRNA and protein levels as well as PGE2 secretion, and these effects could be abolished by pretreatment of K252a. CONCLUSIONS: Elevated NGF/TrkA/p75NTR levels may be associated with sexual pain (deep dyspareunia) in women with cul-de-sac/uterosacral endometriosis. This association may be mediated by an increase in nerve bundle density and by COX-2 and PGE2 stimulation via Trk receptor.Medicine, Faculty ofOther UBCObstetrics and Gynaecology, Department ofUnreviewedFacult

Ethnicity and Severe Endometriosis

Study objective: To investigate ethnic differences for moderate-to-severe endometriosis. Design: Analysis of a prospective registry (Canadian Task Force classification II-2). Setting: Tertiary referral center. Patients: A total of 1594 women with pelvic pain and/or endometriosis. Interventions: None MEASUREMENTS AND MAIN RESULTS: On logistic regression, adjusting for potential confounders, East/South East Asians were 8.3 times more likely than whites to have a previous diagnosis of stage III/IV endometriosis before referral (adjusted odds ratio [aOR], 8.33; 95% confidence interval [CI], 3.74-18.57), 2.7 times more likely to have a palpable nodule (aOR, 2.66; 95% CI, 1.57-4.52), 4.1 times more likely to have an endometrioma on ultrasound (aOR, 4.10; 95% CI, 2.68-6.26), and 10.9 times more likely to have stage III/IV endometriosis at the time of surgery at our center (aOR, 10.87; 95% CI, 4.34-27.21). Conclusion: Moderate-to-severe endometriosis was more common in women with East or South East Asian ethnicity in our tertiary referral center. This could be explained by East/South East Asians with minimal to mild disease being less likely to seek care or genetic/environmental differences that increase the risk of more severe disease among East/South East Asians. (ClinicalTrials.gov, NCT02911090.).Medicine, Faculty ofNon UBCObstetrics and Gynaecology, Department ofReviewedFacultyResearcherPostdoctora

Prediction of Pouch of Douglas obliteration : Point-of-care ultrasound vs. pelvic examination

Study Objective: To evaluate point-of-care pre-operative transvaginal ultrasound (TVUS) sliding sign, in comparison to palpation of a nodule on digital pelvic examination, for the prediction of pouch of Douglas (POD) obliteration. Design: Analysis of data from a prospective data registry (Canadian Task Force Classification II-2). Setting: Tertiary referral center. Patients: Women with suspected endometriosis who had pre-operative pelvic examination and point-of-care TVUS, followed by laparoscopic surgery between August 2015 and December 2016. Intervention: Women were pre-operatively assessed for prediction of POD obliteration with pelvic examination for a nodule and point-of-care TVUS uterine-cervix sliding sign. Measurements and Main Results: The study included 269 women, of which 15.2% (41/269) had POD obliteration at the time of surgery. A pre-operative negative sliding sign had a sensitivity of 73.2% (95% CI: 57.1-85.8%) and specificity of 93.9% (95% CI: 89.9-96.6%) in prediction of POD obliteration, compared to pre-operative palpation of a nodule on pelvic examination which had a sensitivity of 24.4% (95% CI: 12.4-40.3%) and specificity of 93.4% (95% CI: 89.4-96.3%). The difference in sensitivity was statistically significant (McNemar test, p < .001). A negative sliding sign was also associated with longer operating times and more difficult surgery including need for ureterolysis. Conclusion: Point-of-care TVUS sliding sign demonstrated significantly improved sensitivity compared to palpation of a nodule on pelvic examination for prediction of POD obliteration. Therefore, point-of-care TVUS sliding sign improves the pre-operative assessment of POD disease, and thus may lead to more optimal surgical planning in women with suspected endometriosisMedicine, Faculty ofNon UBCObstetrics and Gynaecology, Department ofReviewedFacultyResearche

Deep dyspareunia in endometriosis : Role of the bladder and pelvic floor

Background. The etiology of endometriosis-associated deep dyspareunia may include direct endometriosis-specific factors (e.g., Stage or invasiveness of disease) and/or indirect contributors such as bladder/pelvic floor dysfunction (e.g., related to myofascial mechanisms or nervous system sensitization). Aim. This study aimed to determine whether bladder/pelvic floor tenderness and painful bladder syndrome were associated with severity of deep dyspareunia in women with endometriosis, regardless of Stage (I/II vs. III/IV) or other endometriosis-specific factors. Methods. Observational study from a prospective patient registry (January 2014 – December 2016) at a tertiary centre for endometriosis. Included were women aged 18-49 years who had surgical removal and histopathological confirmation of endometriosis at the centre. Cases with Stage I/II vs. Stage III/IV endometriosis were analyzed separately. Bivariate associations with the primary outcome (severity of deep dyspareunia) were tested for bladder/pelvic floor tenderness, painful bladder syndrome, as well as endometriosis-specific factors identified at the time of laparoscopic surgery (e.g., deep infiltrating endometriosis) and demographic factors (e.g., age). Multivariable ordinal logistic regression was carried out to adjust for factors associated with the primary outcome. Main Outcome Measure. Primary outcome was severity of deep dyspareunia on an 11-point numeric rating scale, categorized as none/mild (0-3), moderate (4-6), and severe (7-10), from a pre-operative self-reported questionnaire. Results. Overall, 411 women had surgically confirmed endometriosis: 263 had Stage I/II and 148 had Stage III/IV endometriosis. Among women with Stage I/II endometriosis, severity of deep dyspareunia was associated with both bladder/pelvic floor tenderness and painful bladder syndrome (AOR=1.99, 95% CI: 1.15-3.44, p=0.013 and AOR=1.94, 95% CI: 1.11–3.38, 66 p=0.019, respectively), independent of endometriosis-specific factors or other factors associated with deep dyspareunia severity. Similar associations were found in women with Stage III/IV endometriosis (bladder/pelvic floor tenderness AOR=1.90, 95% CI: 1.01 – 3.57, p=0.048, painful bladder syndrome: AOR=2.51, 95% CI: 1.25 – 5.02, p=0.01). Clinical Implications. Myofascial or nervous system mechanisms may be important for deep dyspareunia in women with endometriosis, even in those with moderate-to-severe disease (Stage III/IV). Strengths & Limitations. Strengths include the prospective registry, and histological confirmation of endometriosis and staging by experienced endometriosis surgeons. Limitations include assessment of only one pelvic floor muscle (levator ani). Conclusion. In women with Stage I/II or Stage III/IV endometriosis, severity of deep dyspareunia was strongly associated with bladder/pelvic floor tenderness and painful bladder syndrome, independent of endometriosis-specific factors, which suggests the role of myofascial or sensitization pain mechanisms in deep dyspareunia.Medicine, Faculty ofNon UBCObstetrics and Gynaecology, Department ofReviewedFacultyPostdoctoralGraduateUndergraduat

A quantitative analysis of sleep quality in women with endometriosis

Background: Endometriosis is a complex condition that can negatively affect a woman’s quality of life, including her sleep. This study aims to assess the multifactorial variables associated with poorer quality of sleep in women with endometriosis. Methods: Data from the Endometriosis Pelvic Pain Interdisciplinary Cohort (EPPIC) data registry were analyzed for women who underwent surgery at the BC Women’s Center for Pelvic Pain and Endometriosis with histopathological confirmation of endometriosis (June 2015 to June 2017). The primary outcome was quality of sleep pre-operatively, from the Chronic Pain Sleep Inventory. Bivariate analysis and multivariable linear regression were done to determine any significant associations between pre-operative patient variables and overall quality of sleep, based on p-value of 0.05. Results: Two hundred and seventy-five women met the study criteria. Poorer overall quality of sleep was independently associated with poorer functional quality-of-life (EHP- 30)(b = -.18, p = .0026), more depressive symptoms (PHQ-9) (b = -1.62, p < .001), and painful bladder syndrome (b = -5.82, p = .035). This indicates that a 1 point increase in the EHP-30 (worsening quality-of-life), a 1 point increase in the PHQ-9 (worsening depression) and the presence of painful bladder syndrome, increased the primary outcome (i.e. towards poorer quality of sleep) by 0.18, 1.62, and 5.82 points. Conclusion: Poorer quality of sleep in women with endometriosis is associated with poorer quality-of-life, more depressive symptoms, and bladder pain. Research into interventions that improve sleep is warranted as part of the management of some women with endometriosis.Medicine, Faculty ofNon UBCObstetrics and Gynaecology, Department ofReviewedFacultyResearche

Endometriosis and negative perception of the medical profession

Objective: This study sought to identify factors independently associated with a negative impression of the medical profession in patients with endometriosis who were presenting to a tertiary referral centre. Methods: A cross-sectional analysis was conducted on a prospective data registry between December 2013 and June 2017 at a tertiary referral centre for pelvic pain and endometriosis. The main outcome variable, negative impression about the medical profession, was measured with the four-item subscale of the Endometriosis Health Profile-30 and divided into three groups: no (0), some (1-8), and many (9-16) negative impressions. Patients with a surgical and histological diagnosis of endometriosis were included. Postmenopausal women were excluded. Bivariate analyses determined significant associations (P < 0.05) between variables from the registry and the main outcome. Variables with a significant association were put into ordinal logistic regression with sequential backwards elimination.Results: Negative impression of the medical profession was independently associated with previous surgery that did not help symptoms (adjusted odds ratio [aOR] 1.77; 95% confidence interval [CI] 1.09-2.87; P = 0.021), presentation to an emergency room in the past 3 months (aOR 1.90; 95% CI 1.17-3.07; P = 0.009), and previous visits to a complementary health care provider (aOR 2.16; 95% CI 1.42-3.29; P < 0.0005), while controlling for an endometriosis pain-related morbidity composite variable.Conclusion: Negative perception of the medical profession in women with endometriosis was associated with surgical treatment failure, emergency room use, and accessing complementary health care. Each identified factor offers an opportunity for intervention to improve the perception of the medical profession among women with endometriosis.Medicine, Faculty ofNon UBCObstetrics and Gynaecology, Department ofReviewedFacultyResearcherGraduat

Phenotyping sexual pain in endometriosis using the Central Sensitization Inventory

Background. Deep dyspareunia, a common symptom in endometriosis, has previously been associated with bladder or pelvic floor tenderness (BPFT), which suggests a role for central nervous system sensitization. The Central Sensitization Inventory (CSI, 0-100) is a validated self-reported scale for patients with central sensitization. The objective of this study was to phenotype deep dyspareunia using BPFT and the CSI.Medicine, Faculty ofNon UBCObstetrics and Gynaecology, Department ofReviewedFacultyResearcherGraduat

Central Sensitization Inventory in endometriosis

A key clinical problem is identifying the endometriosis patient whose pain is complicated by central nervous system sensitization, where conventional gynecologic treatment (e.g. hormonal therapy or surgery) may not completely alleviate the pain. The Central Sensitization Inventory (CSI) is a questionnaire previously validated in the chronic pain population. The objective of this study was an exploratory proof-of-concept to identify a CSI cut-off in the endometriosis population to discriminate between individuals with significant central contributors (identified by central sensitivity syndromes (CSS)) to their pain compared to those without. We analyzed a prospective data registry at a tertiary referral center for endometriosis, and included subjects aged 18-50 years with endometriosis who were newly or re-referred to the center in 2018. The study sample consisted of 335 subjects with a mean age of 36.0±7.0 years. An increasing number of CSS was significantly correlated with dysmenorrhea, deep dyspareunia, dyschezia, and chronic pelvic pain scores (p’s<.001) and with the CSI score (0-100) (r=.731, p<.001). ROC analysis indicated that a CSI cut-off of 40 had sensitivity 78% (95% CI: 72.7% - 84.6%) and specificity 80% (95% CI: 70.3% - 84.5%) for identifying an endometriosis patient with ≥ 3 CSS. In the group with CSI≥40, 18% retrospectively self-reported pain non-responsive to hormonal therapy and 40% self-reported daily pain, compared to 6% and 20% in the CSI<40 group (p=.003 and .002, respectively). In conclusion, a CSI ≥ 40 may be a practical tool to help identify endometriosis patients with pain contributors related to central nervous system sensitization.Medicine, Faculty ofNon UBCObstetrics and Gynaecology, Department ofReviewedFacultyResearcherPostdoctora