It’s Endometriosis Awareness Month, which aims to raise awareness of ‘the invisible disease’, which affects around 176 million girls and women worldwide. It can have a huge impact on the lives of these women. Along with other symptoms, it can cause severe pain and fertility problems. With no available cure, treatment is directed at managing symptoms and trying to limit the effects of the disease. Treatments for pain include medical approaches, such as hormone treatments, with or without surgery. For women with fertility problems associated with endometriosis, drug treatments, surgery and assisted reproductive technologies (ART) may all be considered.
Overviews can really help if you are making decisions about treatments, as they bring together in one place the best evidence we have, summarising systematic reviews which can be looked at together to give us a clearer picture of what is known about how effective treatments are and if there are any associated harms.
This overview from the Cochrane Menstrual Disorders and Subfertility Group brings together evidence from Cochrane systematic reviews on treatment options for women with pain or subfertility associated with endometriosis. The seventeen reviews are all of high quality, but the The certainty (or quality) of evidence is the extent to which we can be confident that what the research tells us about a particular treatment effect is likely to be accurate. Concerns about factors such as bias can reduce the certainty of the evidence. Evidence may be of high certainty; moderate certainty; low certainty or very-low certainty. Cochrane has adopted the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) for assessing certainty (or quality) of evidence. Find out more here: https://training.cochrane.org/grade-approach More in the studies they include varies from low to moderate.
Here’s what they found:
- There was moderate quality evidence that laparascopic surgery reduced pain, as did suppression of menstrual cycles with levonorgestrel-releasing intrauterine system LNG-IUD
- Gonadotrophin-releasing (GnRH) analogues and danazol helped pain symptoms but the evidence is low quality
- Progestogen, with or without oestrogen, and anti-tumour necrosis factor-a (anti-TNF-α) drugs, were no better than placebo (sugar pill), and there was no benefit seen from medical treatments after surgery, but this was also low quality evidence
- One review found a benefit for auricular acupuncture compared with Chinese herbal medicine and another found Chinese herbal medicine to be comparable to danazol, but the evidence for both is low quality
- It’s unclear whether non-steroidal anti-inflammatory drugs help with pain
- There was moderate quality evidence of a benefit from laparoscopic surgery compared to diagnostic laparoscopy, with higher live birth and pregnancy rates. Miscarriage rates were comparable
- The evidence on medical treatments to improve fertility was of poor quality and not encouraging, though there was low quality evidence that three months treatment with a GnRH agonist may increase the likelihood of pregnancy in women undergoinging ART
- There is not enough evidence to draw conclusions about surgical treatment of endometriosis in women undergoing ART
- Most of the studies failed to report live birth rates
We need better evidence
It’s really disappointing, and very important to know, that the evidence is mostly very poor. Often evidence came from just one small trial and there were problems with the ways the studies were done and reported.
The reviews themselves were high quality but only eight included searches for new studies within the past three years, so it’s possible that when these reviews are updated there will be new evidence to add. Let’s hope so, and that there are much better trials. The authors note that head-to-head comparisons of medical and surgical treatments for endometriosis pain would be useful, as well as further trials exploring the role of surgery for women undergoing ART.
This review follows the publication last year of an overview of Cochrane reviews on ART. At least some of the evidence was high quality. Of the 30 included reviews, 21 support with clear conclusions how to perform some of the steps in the IVF/ICSI procedures, while more reveal gaps in knowledge and provide useful direction for future research. You can read a really helpful editorial about this overview here.
Support for women with endometriosis
A search for #endometriosis on Twitter immediate reveals a vibrant community of women with endometriosis, or #endosisters, who share knowledge and offer support, along with charities such as Endometriosis UK, as we see of course in many areas of health on social media platforms. There’s a really thoughtful article about the benefits of people who share a health condition coming together on social networks, and why health professionals should embrace this, here. In it, authors Anne Cooper and Partha Kar talk about people with diabetes, but the same principles apply to people living with any chronic condition.
So if you are a woman with endometriosis, I hope you are tapping into these sources of support and information and I hope it is helpful to know what evidence we have on some of the treatments you may be considering. As for researchers in this field, they have much still to do.
Brown J, Farquhar C. Endometriosis: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD009590. DOI: 10.1002/14651858.CD009590.pub2.
Farquhar C, Rishworth JR, Brown J, Nelen WLDM, Marjoribanks J. Assisted reproductive technology: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD010537. DOI: 10.1002/14651858.CD010537.pub2
Strandell A. Comprehensive evidence on assisted reproductive technologies [editorial]. Cochrane Database of Systematic Reviews2014;(1):ED000077.