Acute Health Problem – Endometriosis
Endometriosis is a chronic gynecological condition that involves the growth of a tissue like the endometrium outside the uterus and majorly within the pelvic cavity (World Health Organization, 2023). The causal factors, the prevention, and the actual cure for endometriosis remain unknown. This makes it a complex condition of concern with a significant impact on patients and healthcare professionals. This paper provides a comprehensive review of endometriosis with the aim of improving the understanding of the condition for effective patient care. It covers the rationale for focusing on endometriosis, an evaluation of key concepts related to endometriosis, and a review of various practice guidelines viewpoints. The paper further assesses the quality of research evidence on endometriosis, evaluates the current EBM guidelines, and how evidence from research influences practices in endometriosis care.
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Endometriosis: Review and Rationale
Endometriosis is a complex gynecological condition I have encountered during my clinical experience. Endometriosis is a chronic inflammatory condition characterized by the endometrial tissue growing outside the uterus (Chapron et al., 2019). Endometriosis affects women at their reproductive ages and has been noted to be a risk factor for chronic pelvic pain and infertility in women (Cleveland Clinic, 2022). Endometriosis is commonly manifested by severe pelvic pain, which can become chronic with time. The pain is mostly experienced during monthly menstruation, during sex, or even during defecation (World Health Organization, 2023). Other symptoms include heavy period flow, depression, anxiety, chronic nausea, and fatigue (World Health Organization, 2023).
There are a number of reasons that make endometriosis a topic of research interest. Firstly, there is an urgent need to develop sufficient evidence, review the available approaches for the treatment of the condition, and support decision-making for patient treatment. Secondly, endometriosis has a high prevalence rate among women of reproductive age. The World Health Organization (2023) reports that endometriosis affects an estimated 10 percent or roughly 190 million reproductive-age women and girls globally. The third rationale for focusing on endometriosis is its impact on women’s physical and mental health and quality of life. The major symptoms associated with endometriosis, such as severe chronic pelvic pain and the risk for infertility, are risk factors for anxiety and depression. Endometriosis-associated depression is a mental health condition majorly associated with a reduced quality of life as well as reduced quality of life.
Besides reducing the quality of life of patients, endometriosis leads to high care costs that create a financial burden for the individual and care systems (Saunders & Horne, 2021). Based on practice experience and encounters with the client, it is notable that endometriosis creates a burden on the family’s financial resources due to the high costs associated with consultation, diagnosis, and treatment. This makes endometriosis a condition of a wider healthcare concern as it impacts not only the patients but also their families and the society around them.
Regardless of the high prevalence and impact of endometriosis on women and society, the natural causes and history of the condition are unknown. There are significant gaps in research and available knowledge on the pathobiological processes of the development of the condition, evidence on applicable approaches of treatment, and the management of the condition. The lack of sufficient research and evidence is the reason for the common misdiagnoses (Taylor et al., 2021). The lack of evidence is also the reason for the long-delayed diagnosis of the condition since the onset of symptoms and the delays in treatment (Saunders & Horne, 2021). Therefore, focusing on endometriosis will improve the understanding of the condition’s etiology and pathobiology, potentially improving the quality of diagnostic methods and developing evidence-based prevention and treatment strategies for the condition. Top of Form
Endometriosis: Evaluation of Key Concepts
Key concepts of endometriosis, such as disease etiology, pathogenesis, prevention, and cure, are poorly understood and explained. The etiopathogenesis of endometriosis is a multifactorial process resulting in a heterogeneous disease that complicates the understanding of the condition and its care (Laganà et al., 2019). Available evidence notes that women’s hormonal, neurological, and immunological factors contribute to the pathobiological mechanisms of the development of the manifested symptoms (Saunders & Horne, 2021). A majority of these interconnected underlying factors are either acquired or inherited. According to Laganà et al. (2019), complex genetic factors control the major etiopathogenesis processes of the development of endometriosis, such as hormonal and immunological dysfunction, immunohistochemical, histological, and biological processes leading to various types of endometrioses such as utopic and ectopic endometriosis. Evidence from a metanalysis of 60,674 cases and 701,926 controls of European and East Asian descent backs the argument of genetic predisposition, development, and variance in the condition. In the study, Rahmioglu et al. (2023) note that 5.01% of the noted disease variance was linked to the regulated expression or methylation of genes in endometrium and blood. In addition, genes were also linked to the manifestations of the conditions, such as pain perception and response to disease management.
A combination of environmental factors and genetics are also noted to contribute to the growth of the endometrial tissue outside of the uterus. Exposure to harsh environments, including exposure to chemicals and toxins in the environment, increase the risk of endometriosis. Besides these, environmental factors can influence epigenetic modifications with an impact on gene expression, which further influence biological, hormonal, and immunological processes that contribute to the development and progression of endometriosis (Laganà et al., 2019).
Practice Guidelines Viewpoints
The lack of sufficient evidence of the etiopathogenesis of endometriosis makes the disease complex. Hence, there are multiple inconclusive and unclear multiple practice guidelines on the management of the condition. The currently used guidelines for the management of endometriosis include the College National des Gynecologues et Obstetriciens Francais, the National German Guideline (S2k), the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians (ACOG), the American Society for Reproductive Medicine (ASRM), the National Institute for Health and Care (NICE), and the guidelines provided by the World Endometriosis Society and the European Society of Human Reproduction and Embryology. Due to the inconsistency of evidence related to endometriosis and the complexities of the condition, the recommended approaches to practice may vary across the available guidelines based on jurisdiction and other factors. However, the guidelines hold almost similar viewpoints towards endometriosis and provide largely agreeable recommendations for the management of the condition across diverse conditions and settings.
For instance, all guidelines agree that the effective management of endometriosis requires early recognition of presented symptoms and diagnosis of the condition (Kalaitzopoulos et al., 2021). Accordingly, the early recognition and diagnosis of endometriosis make it possible to design effective interventions to manage the progression of the conditions and related complications such as chronic pelvic pain, infertility, and depression.
Another common viewpoint across all of the available practice guidelines is the need for a collaborative multidisciplinary approach toward the management of endometriosis. Endometriosis is a complex heterogeneous condition (Laganà et al., 2019), with multiple presentations and varied impacts on the physical, mental, emotional, economic, and reproductive well-being of a patient and their families. Therefore, the available guidelines view the need for a collaborative approach to the management of patients with endometriosis across various disciplines and specializations, including input from gynecologists, pain management experts, female fertility specialists, physical and mental health healthcare professionals, and the patients and their families.
The impact of endometriosis varies across individuals and their care settings. All guidelines agree on the need for care approaches that are tailored to the needs of the patients and the level of progression of the condition. The recommendations for individualized patient care argue that care providers need to consider the severity of the presented symptoms, the age of the patient, and a consideration of their future fertility, available resources, and how the condition has impacted the patient’s life (Becker et al., 2022). A common recommendation across all practice guidelines is the need to focus on pain management for endometriosis-related pain to reduce its impact on the quality of life of the patients with the condition. Additionally, all guidelines identify the need for follow-up care for the patients in the long term to avoid instances of complications due to treatment approaches adopted and the resurgence of the disease.
A controversial viewpoint across all practice guidelines is the recommendation for surgery for the treatment of endometriosis. Although laparoscopic surgery is majorly recommended for definitive diagnosis and for the removal of endometriotic lesions, other types of surgery, such as hysterectomy, are recommended. The complications of surgery include the need for further management, adding to the costs of care. Surgeries such as hysterectomy lead to loss of fertility, which can negatively impact the mental and physical health of women with future desires to bear children.
The Merit of Evidence on Endometriosis
A literature search based on the client’s condition encountered during the practice experience was conducted, focusing on randomized controlled trials on various approaches applied in the management of endometriosis. A few RCT papers are available on the management of endometriosis. Two RCT articles were selected from the literature search; the article by Merlot et al. (2022) focuses on the use of digital therapeutic tools in managing endometriosis-related pelvic pain, and the article by Osuga et al. (2021) focuses on the use of pharmacological approaches in endometriosis-associated pain management.
In the randomized controlled trial (RCT), Merlot et al. (2022) aimed to measure the effect of a single-use 20-minute DTx (Endocare), an immersive digital therapeutic tool, on the management of pelvic pain in women who had been diagnosed and living with endometriosis. The digital therapeutics (DTx) tool provides an alternative non-pharmacological approach to the management of pain associated with endometriosis. From a population of 45 women living with endometriosis, the RCT study compared the analgesic effect of a single-use immersive virtual reality DTx Endocare on 23 women with the outcomes of using a 2D digital tool among 22 women as the control group. The RCT study results showed that the use of the Endocare tool had a significant reduction in pelvic pain as compared to the 2D digital control group. Using the Endocare tool had extended effects on pain perception posttreatment across various time points from 15 minutes to 4 hours. The RCT study concludes that DTx (virtual reality immersive) tools such as Endocare can be an effective non-pharmacological alternative for treating pelvic pain associated with endometriosis.
Although conclusive, the article by Merlot et al. (2022) presents evidence using the Endocare tool as an effective non-pharmacological option in reducing pain perception in women living with endometriosis is of low quality for various reasons. Firstly, the evidence is drawn from a very small population, and the perception of pain was self-reported. Only 45 women participated in the RCT study, of which only 23 used the immersive virtual reality therapeutic tool. Additionally, the experience and perception of pain were self-reported, which subjects the reporting to bias. The small participant population and self-reporting make it hard to validate the evidence and draw conclusive assumptions that the Endocare tool effectively manages endometriosis-associated pain. Additionally, the authors note that they are the first to identify the extended effect of Endocare on pelvic pain reduction (Merlot et al., 2022). The lack of other sources to back the evidence makes the findings inconclusive and the evidence quality very low.
The other RCT by Osuga et al. (2021) aimed to compare the efficacy and safety of 3-dose levels of relugolix with placebo and leuprorelin doses in women living with pelvic pain associated with endometriosis. Relugolix is a nonpeptide, a gonadotropin-releasing hormone receptor antagonist (GnRH receptor antagonist) that has been noted to be effective in the management of pain in multiple related studies. In the current RCT study, the authors conducted a 4 to 12-week double-dummy (placebo) pretreatment followed by a 12-week treatment and a 4-week post-week follow-up. In the treatment period, 103, 100, and 103 patients received relugolix 10, 20, and 40 mg orally daily, respectively, while 97 patients received placebo orally daily, and 80 received leuprorelin 3.75 mg as a subcutaneous monthly treatment. The authors identify the perception of pelvic pain 28 days before the end of treatment as the main measure of the RCT outcomes. The results of the RCT study note that orally administered relugolix was effective in alleviating endometriosis-associated pain. Relugolix is also well tolerated as compared to other treatment options. Additionally, the efficacy and safety of relugolix improved with dosage as the 40 mg dose showed better outcomes on efficacy and safety than smaller dosages compared to subcutaneously-administered leuprorelin.
Despite the use of a smaller patient population, the quality of evidence on the efficiency and safety of relugolix provided by this RCT study is of high quality. Firstly, the RCT compares different dosage regimens for relugolix and compares them to other known treatment options, such as leuprorelin. Secondly, the study utilized a multicenter, randomized, double-blind, parallel-group, placebo-controlled study design, eliminating the high risk of bias associated with RCTs. The observations on pain reduction and perception across the patient groups participating in the RCT study are objective. This further eliminates subjective bias from self-reported levels of pain perception. The study’s methodological quality is also high as it clearly describes the population selected, the participant selection processes, and the statistical analyses applied to the collected data. Additionally, the findings of the RCT study are consistent with other findings from multiple studies focused on the efficacy and safety of relugolix in the management of endometriosis-associated pain, such as studies by Giudice et al. (2022) (Harada et al., 2022) and Saraswat & Bhattacharya (2022). This gives the evidence a significant level of expert consensus, meaning it is of high quality.Top of Form
Evaluation of Current EBM Guidelines
The majorly used guidelines in the United States for the management of endometriosis are provided by the American College of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM). Both guidelines provide recommendations based on the available information and evidence on endometriosis to support evidence-based management of the condition. As with other guidelines discussed above, the ACOG and ASRM guidelines provide similar recommendations for early symptom recognition and diagnosis, collaborative care, focus on pain management, considerations on fertility in the choice of treatment, use of pharmacological and non-pharmacological approaches of care, and follow-up care. Top of Form
Diversity, Cultural, Spiritual, and Socioeconomic Considerations
The effective management of endometriosis requires the adoption of individualized and patient-centered care. This means the adoption of a diagnosis and management plan that considers the patient’s culture, spirituality, and social economic background. Providing patient-centered care from a general perspective improves operational efficiency throughout the continuum of care as well as improves patient experiences (Ko et al., 2019). Culture and spiritual beliefs are critical social determinants of health. A patient’s culture can influence their willingness and openness when discussing and treating endometriosis. Considering the patient’s spiritual beliefs can also influence their views and perceptions of the seriousness of the disease. These viewpoints impact the patient’s capacity to cope with the condition as well as their choice of strategies to manage endometriosis and other associated conditions such as pain, infertility, and depression. Additionally, it is important to consider the patient’s social and economic background during the management process of endometriosis. The patient’s socioeconomic factors determine the patient’s ability to access factors of endometriosis care, such as quality diagnosis and medications, as well as other treatment alternatives. Other factors, such as their level of education, influence their understanding of the condition and essential elements of care, such as self-management.
Standardized Procedure for Endometriosis
As earlier noted, diagnosing endometriosis faces a major challenge due to the lack of clear evidence on the etiopathogenesis of the condition and the variability of symptoms. However, a standardized procedure for the diagnosis of endometriosis would consider the patient’s history, including the history of the clinical manifestations of the disease, the severity of the symptoms, and any fertility and familial history of endometriosis. The diagnosis procedures should also consider physical examination, including pelvic examination for pain in the pelvic cavity, the pelvic tissue for lesions, and any palpable masses on the pelvic region. Other considerations for objective testing and confirmation of the presence or absence of endometriosis include the use of imaging modalities such as transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI). Surgical procedures such as laparoscopic surgery provide a more conclusive diagnosis of endometriosis (Bafort et al., 2020).
Evidence Impacting Clinical Practices
A review of available evidence from the literature has brought new insights into the understanding of endometriosis. From the encounter with the patient, I held an unclear view of the condition. I thought it was never serious or could be easily managed with over-the-counter medications. I have learned that due to the variability of the symptoms and heterogeneity of endometriosis, all disease diagnoses and treatment procedures need to be individualized to the patient. It is hard and unprofessional to generalize the diagnosis and management of endometriosis. Therefore, I have learned that I need to consider the specific symptoms an individual patient is experiencing. Additionally, I have learned that one can easily make the wrong diagnoses and overlook the presence of endometriosis due to the lack of specific symptoms of the condition. Notably, a majority of endometriosis diagnoses are a matter of chance (Becker et al., 2022). This means that it is easy to miss a diagnosis if care is not taken. Additionally, I thought I could easily manage patients due to the view that the condition can be easily managed with OTC treatments. However, a review of evidence has helped me understand that endometriosis management requires collaboration across interdisciplinary and multidisciplinary care teams that include the services of gynecologists, radiologists, mental healthcare professionals, and social workers, among other care teams.
Conclusion
Endometriosis is a poorly understood gynecological condition with extreme social, mental, physical, and economic impacts on the patient and society. It is worth noting that the factors responsible for the development of endometriosis are not mutually exclusive and combine with other factors to contribute to the etiology and pathophysiology of endometriosis, the clinical manifestation, and the choice of treatment and response to that treatment. Most of the available literature and guidelines provide inconclusive procedures for managing endometriosis. The emphasis of current evidence is on the management of endometriosis-related conditions such as pain and infertility. Regardless, there is an evidence gap from randomized controlled trials (RCTs) for the management of advanced forms of endometriosis and related outcomes (Bafort et al., 2020). In conclusion, there is a need to improve research on endometriosis with a focus on understanding the etiopathogenesis processes of the condition to improve the efficiency and effectiveness of diagnosis and management for better patient and disease outcomes.
References
Bafort, C., Beebeejaun, Y., Tomassetti, C., Bosteels, J., & Duffy, J. M. N. (2020). Laparoscopic surgery for endometriosis. Cochrane Database of Systematic Reviews, 2020(10). https://doi.org/10.1002/14651858.CD011031.PUB3/MEDIA/CDSR/CD011031/IMAGE_N/NCD011031-CMP-004.02.SVG
Becker, C. M., Bokor, A., Heikinheimo, O., Horne, A., Jansen, F., Kiesel, L., King, K., Kvaskoff, M., Nap, A., Petersen, K., Saridogan, E., Tomassetti, C., van Hanegem, N., Vulliemoz, N., Vermeulen, N., Group, E. E. G., Altmäe, S., Ata, B., Ball, E., … Yazbeck, C. (2022). ESHRE guideline: endometriosis. Human Reproduction Open, 2022(2), 1–26. https://doi.org/10.1093/HROPEN/HOAC009
Chapron, C., Marcellin, L., Borghese, B., & Santulli, P. (2019). Rethinking mechanisms, diagnosis and management of endometriosis. Nature Reviews Endocrinology 2019 15:11, 15(11), 666–682. https://doi.org/10.1038/s41574-019-0245-z
Cleveland Clinic. (2022). Endometriosis: Causes, Symptoms, Diagnosis & Treatment. https://my.clevelandclinic.org/health/diseases/10857-endometriosis
Giudice, L. C., As-Sanie, S., Arjona Ferreira, J. C., Becker, C. M., Abrao, M. S., Lessey, B. A., Brown, E., Dynowski, K., Wilk, K., Li, Y., Mathur, V., Warsi, Q. A., Wagman, R. B., & Johnson, N. P. (2022). Once daily oral relugolix combination therapy versus placebo in patients with endometriosis-associated pain: two replicate phase 3, randomized, double-blind, studies (SPIRIT 1 and 2). The Lancet, 399(10343), 2267–2279. https://doi.org/10.1016/S0140-6736(22)00622-5
Harada, T., Osuga, Y., Suzuki, Y., Fujisawa, M., Fukui, M., & Kitawaki, J. (2022). Relugolix, an oral gonadotropin-releasing hormone receptor antagonist, reduces endometriosis-associated pain compared with leuprorelin in Japanese women: a phase 3, randomized, double-blind, noninferiority study. Fertility and Sterility, 117(3), 583–592. https://doi.org/10.1016/J.FERTNSTERT.2021.11.013
Kalaitzopoulos, D. R., Samartzis, N., Kolovos, G. N., Mareti, E., Samartzis, E. P., Eberhard, M., Dinas, K., & Daniilidis, A. (2021). Treatment of endometriosis: a review with comparison of 8 guidelines. BMC Women’s Health, 21(1), 1–9. https://doi.org/10.1186/S12905-021-01545-5/TABLES/2
Ko, D. G., Mai, F., Shan, Z., & Zhang, D. (2019). Operational efficiency and patient-centered health care: A view from online physician reviews. Journal of Operations Management, 65(4), 353–379. https://doi.org/10.1002/JOOM.1028
Laganà, A. S., Garzon, S., Götte, M., Viganò, P., Franchi, M., Ghezzi, F., & Martin, D. C. (2019). The Pathogenesis of Endometriosis: Molecular and Cell Biology Insights. International Journal of Molecular Sciences 2019, Vol. 20, Page 5615, 20(22), 5615. https://doi.org/10.3390/IJMS20225615
Merlot, B., Dispersyn, G., Husson, Z., Chanavaz-Lacheray, I., Dennis, T., Greco-Vuilloud, J., Fougère, M., Potvin, S., Cotty-Eslous, M., Roman, H., & Marchand, S. (2022). Pain Reduction With an Immersive Digital Therapeutic Tool in Women Living With Endometriosis-Related Pelvic Pain: Randomized Controlled Trial. Journal of Medical Internet Research, 24(9). https://doi.org/10.2196/39531
Osuga, Y., Seki, Y., Tanimoto, M., Kusumoto, T., Kudou, K., & Terakawa, N. (2021). Relugolix, an oral gonadotropin-releasing hormone receptor antagonist, reduces endometriosis-associated pain in a dose-response manner: a randomized, double-blind, placebo-controlled study. Fertility and Sterility, 115(2). https://doi.org/10.1016/j.fertnstert.2020.07.055
Rahmioglu, N., Mortlock, S., Ghiasi, M., Møller, P. L., Stefansdottir, L., Galarneau, G., Turman, C., Danning, R., Law, M. H., Sapkota, Y., Christofidou, P., Skarp, S., Giri, A., Banasik, K., Krassowski, M., Lepamets, M., Marciniak, B., Nõukas, M., Perro, D., … Zondervan, K. T. (2023). The genetic basis of endometriosis and comorbidity with other pain and inflammatory conditions. Nature Genetics 2023 55:3, 55(3), 423–436. https://doi.org/10.1038/s41588-023-01323-z
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Question 
Acute Adult Illness
Select a client from your past or current FNP clinical rotations with an acute health problem (ENDOMETRIOSIS), which required at least two visits.
Based on this client’s condition, (ENDOMETRIOSIS) conducts a literature search for two research articles that discuss various approaches to the treatment of this condition. Peer-reviewed articles must address the standardized procedure or guidelines for this diagnosis. The research articles must be original research contributions (no review articles or meta-analysis) and must have been published within the last five years. Incorporate the research findings into the decision-making for this client’s treatment.
Attached is the initial visit/comprehensive SOAP note and follow-up visit /focused SOAP note as appendices. You may include SOAP notes that have already been submitted in your clinical courses. The discussion on relating research to practice should be approximately 5-10 pages and the total paper should be no longer than 10 pages, excluding references and appendices.
Cover the criteria listed below:
Review the topic and explain the rationale for topic selection in the context of client care.
-Evaluates key concepts related to the topic.
-Describes multiple viewpoints on whether this is a controversial issue or one for which there are no clear guidelines.
-Assess the merit of evidence found on this topic i.e. soundness of research
-Evaluate current guidelines, if available. Or, recommends what these guidelines should be based on available research.
– Discuss the Standardized Procedure for this diagnosis.
-Discuss how the evidence impacted/would impact practice. —
-What should have been done differently based on the knowledge gained?
-Consider cultural, spiritual, and socioeconomic issues as applicable.