The Aggravating Endometrioma

What are endometriomas anyway? Endometriosis is classified into three main types: superficial peritoneal endometriosis, deep infiltrating endometriosis, and endometriomas (see more about that here).  Endometriomas are ovarian cysts lined by endometriotic tissue and can be filled with blood (why they are at times called “chocolate cysts”). Like the other types of endometriosis, no one knows for sure how they form. It has been theorized that endometriosis tissue on the surface of the ovary invades and forms a cyst like formation or they start as a functional ovarian cyst with gradual infiltration of endometriotic tissue. Endometriomas have been found in up to 44% of those with endometriosis and are associated with deep infiltrating endometriosis (Cranney, Condous, & Reid, 2017).

Endometriomas can be suspected with ultrasound or MRI, but as with other types of endometriosis, surgery is gold standard for diagnosis (Gałczyński et al., 2019). Endometrioma treatment can often be focused on the effect on fertility, so it is important to consider your goals when looking at treatment options. While medications are used to manage endometriomas, “endometriomas do not respond to medical therapy alone, thus usually surgical treatment is necessary” (Gałczyński et al., 2019). Many may be hesitant to perform surgery for fear of loss of healthy ovarian function and may put off surgery until the endometrioma reaches a certain size. However, Gałczyński et al. (2019) reports that treating “early-stage endometrioma provides less damage to the ovary by a less invasive surgical procedure which decreases the risk of iatrogenic premature ovarian failure” and that “long-term ovarian endometriosis leads to persistent inflammation” that can lead to loss of ovarian function. Skill of the surgeon is important in this aspect.

Gałczyński et al. (2019) reports that “the level of expertise in endometriotic surgery is inversely correlated with inadvertent removal of healthy ovarian tissue along with the endometrioma capsule”. There are multiple surgical techniques that can be used to treat endometriomas and there is no consensus on the best method, although ovarian cystectomy (removal of the ovarian cyst) is the preferred method based on studies (Pais et al., 2021). One recently published study cites “excisional surgery allows for pain resolution, a high rate of spontaneous pregnancies and a lower recurrence rate of ovarian cysts when compared to drainage and ablation techniques” (Angioni et al., 2021).

The aggravating thing about endometriomas is the likelihood of recurrence. It can hard to tell true recurrence rates from studies because “recurrence is variously defined in the literature as the relapse of pain, clinical or instrumental detection of an endometriotic lesion, repeat rise in CA 125 levels, or evidence of recurrence found during repeat surgery,” which results in the wide range of reported recurrence in studies (Ceccaroni et al., 2019). In addition, the method of surgical treatment has a bearing on recurrence rate (excision versus draining etc.). One study reported recurrence rates to be “24.2% for patients aged 20–30 years, 17.7% for 31–40 years, and 7.9% for 41–45 years” (Li et al., 2019). Other studies have echoed that younger age was linked to increased recurrence (Gałczyński et al., 2019). While younger age seems to have a direct correlation with recurrence, other factors not as much. For instance, Gałczyński et al. (2019) reports that the “diameter of the tumor, stage of endometriosis, coexistence of deep-infiltrating endometriosis, or uni- or bi-lateral involvement of ovaries were all not associated with the risk of recurrence” and that the “median time to recurrence was 53 months”.

There is also controversy about the use of hormonal suppression to prevent recurrence. Some studies and a meta-analysis report that there is not enough evidence for the use of medications to help prevent recurrence, while others indicate that it may delay but will not prevent recurrence (Gałczyński et al., 2019; Li et al., 2019; Wattanayingcharoenchai et al., 2021). Confusing? Others agree that it is- with one commentary stating that “so what are we to believe and what should we advise women affected by endometriosis to do?” (Saridogan, 2020). In the end, we each have to do our research, look at our individual goals, and decide what is best for our unique situation.

Endometriosis after a hysterectomy or menopause

References

Angioni, S., Scicchitano, F., Sigilli, M., Succu, A. G., Saponara, S., & D’Alterio, M. N. (2021). Impact of Endometrioma Surgery on Ovarian Reserve. In Endometriosis Pathogenesis, Clinical Impact and Management (pp. 73-81). Springer, Cham. Retrieved from https://link.springer.com/chapter/10.1007/978-3-030-57866-4_8

Ceccaroni, M., Bounous, V. E., Clarizia, R., Mautone, D., & Mabrouk, M. (2019). Recurrent endometriosis: a battle against an unknown enemy. The European Journal of Contraception & Reproductive Health Care, 24(6), 464-474.  Retrieved from https://www.tandfonline.com/doi/abs/10.1080/13625187.2019.1662391

Cranney, R., Condous, G., & Reid, S. (2017). An update on the diagnosis, surgical management, and fertility outcomes for women with endometrioma. Acta obstetricia et gynecologica Scandinavica, 96(6), 633-643. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/aogs.13114

Gałczyński, K., Jóźwik, M., Lewkowicz, D., Semczuk-Sikora, A., & Semczuk, A. (2019). Ovarian endometrioma–a possible finding in adolescent girls and young women: a mini-review. Journal of ovarian research, 12(1), 1-8. Retrieved from https://ovarianresearch.biomedcentral.com/articles/10.1186/s13048-019-0582-5

Li, X. Y., Chao, X. P., Leng, J. H., Zhang, W., Zhang, J. J., Dai, Y., … & Wu, Y. S. (2019). Risk factors for postoperative recurrence of ovarian endometriosis: long-term follow-up of 358 women. Journal of ovarian research, 12(1), 1-10. Retrieved from https://link.springer.com/article/10.1186/s13048-019-0552-y

Pais, A. S., Flagothier, C., Tebache, L., Almeida Santos, T., & Nisolle, M. (2021). Impact of Surgical Management of Endometrioma on AMH Levels and Pregnancy Rates: A Review of Recent Literature. Journal of Clinical Medicine, 10(3), 414. Retrieved from https://www.mdpi.com/2077-0383/10/3/414

Saridogan, E. (2020). Postoperative medical therapies for the prevention of endometrioma recurrence–do we now have the final answer?(Mini-commentary on BJOG-19-1705. R2). Authorea Preprints. Retrieved from https://d197for5662m48.cloudfront.net/documents/publicationstatus/41937/preprint_pdf/d4903f81caf3e8838e672d7631e6b8bd.pdf

Wattanayingcharoenchai, R., Rattanasiri, S., Charakorn, C., Attia, J., & Thakkinstian, A. (2021). Postoperative hormonal treatment for prevention of endometrioma recurrence after ovarian cystectomy: a systematic review and network meta‐analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 128(1), 25-35. Retrieved from https://pubmed.ncbi.nlm.nih.gov/32558987/

4 years ago Endometriosis , Endometriosis Education

Celiac Disease and Endometriosis

Much like thyroid disease and endometriosis, there are not many studies looking at an association between celiac disease and endometriosis. One study found the “risk of endometriosis in patients with [celiac disease] was 112/100 000 person” (Stephansson et el., 2011). Another noted that celiac disease “is common in this population group [women with endometriosis and infertility] (2.5%) and may be clinically relevant” (Aguiar et al., 2009). Another study noted a slightly increased risk of celiac disease in those with endometriosis (“Celiac disease was diagnosed in 5 of 223 women with endometriosis and in 2 of 246 controls (2.2% versus 0.8%)”) (Seracchiolo et al., 2014). Some have had positive results on endometriosis symptoms from following a gluten free diet (Marziali et al., 2012).

On the flip side, celiac disease can present with symptoms similar to endometriosis. “Celiac disease has also been associated with chronic pelvic pain, including dysmenorrhea and deep dyspareunia” and “patients with atypical pelvic pain, particularly with GI components, may also benefit from screening” (Ory & Christie, 2013). This points out the importance of looking beyond the diagnosis of endometriosis with recurring symptoms in order to rule out other health issues that can mimic endometriosis symptoms.

References

Aguiar, F. M., Melo, S. B., Galvao, L. C., Rosa-e-Silva, J. C., dos Reis, R. M., & Ferriani, R. A. (2009). Serological testing for celiac disease in women with endometriosis. A pilot study. Clinical and experimental obstetrics & gynecology, 36(1), 23-25. Retrieved from https://pubmed.ncbi.nlm.nih.gov/19400413/

Marziali, M., Venza, M., Lazzaro, S., Lazzaro, A., Micossi, C., & Stolfi, V. M. (2012). Gluten-free diet: a new strategy for management of painful endometriosis related symptoms. Minerva Chir, 67(6), 499-504. Retrieved from https://www.minervamedica.it/en/journals/minerva-surgery/article.php?cod=R06Y2012N06A0499

Ory, S. J., & Christie, D. R. (2013). Reproductive effects of celiac disease. Contemporary OB/GYN, 58(4), 34. Retrieved from https://www.contemporaryobgyn.net/view/reproductive-effects-celiac-disease

Seracchioli, R., Montanari, G., Mabrouk, M., & Nassif, J. (2014). Endometriosis: novel models, diagnosis, and treatment. Retrieved from https://doi.org/10.1155/2014/236821

Stephansson, O., Falconer, H., & Ludvigsson, J. F. (2011). Risk of endometriosis in 11 000 women with celiac disease. Human reproduction, 26(10), 2896-2901. Retrieved from https://doi.org/10.1093/humrep/der263

4 years ago Endometriosis , Endometriosis Education

Keep Endometriosis Awareness Going

As we come to the end of endometriosis awareness month, those of us with endometriosis knows it doesn’t end in March. Raising awareness and fighting against misinformation is a constant effort. Please feel free to share links from the webpage. The more we share, the more awareness and up-to-date information is out there for others. It can be discouraging to see so much of the same old misinformation perpetuated that can cause others to suffer as we have. Let’s spread hope!

We have collected all the infographs shared on Nancy’s Nook Facebook page and have sprinkled them throughout the website so that you can share the infograph and the link to more information. All the infographs are also collected here.

Endometriosis Quick Facts to Share is also another good resource to share. One of my favorites to reference to is the Myths and Misinformation page. Keep the awareness going, because endometriosis doesn’t stop in March.

4 years ago Endometriosis , Endometriosis Education

The Personal Burden of Endometriosis

Last week we looked at the direct financial burden of endometriosis, including the loss of education, loss of productivity at work and home, and loss of income. Today we look at the personal burden of endometriosis- the altered relationships with family and friends, the pain and suffering, the ill effects on mental health, and the loss of who we feel we are as a person because of it.

Pain and fatigue can limit our ability to function and the quality of our life experience (Missmer et al., 2021). Our ability to maintain relationships can be difficult, especially when others do not understand the impact that endometriosis has on us. Much research has shown the effect on intimate partner relationships due to the interference with sexual health (Missmer et al., 2021). Not as many studies have been done on the effects of parenting with endometriosis; however, in our Facebook group Nancy’s Nook, many of you have shared the significant effect endometriosis has had on the ability to function as a parent. These limitations imposed from our illness can affect our mental health as well.

In studies, people with endometriosis express “feelings of worthlessness, guilt, and frustration connected with disease-related limitations on participation in daily activities, social functioning, independence, and interpersonal relationships” as well as frustration “from a woman’s inability to manage or predict her pain and the feeling that endometriosis/endometriosis-associated pain controls her life” (Missmer et al., 2021). Add to this the burden of the “perception that others (even healthcare professionals) consider what they are experiencing to be ‘all in their heads’” (Missmer et al., 2021). The struggle is real. And it is no wonder that many feel a loss of who they are as a person because of it.

On a positive note, a systematic review and meta-analysis, as well as other studies, reveal that surgery for endometriosis does improve quality of life (Arcoverde et al., 2019; Parra et al., 2021). Another study reports that “laparoscopic surgery is associated with improved quality of life and emotional well-being compared to medical therapies” and cautions that “although the GnRH agonists are effective in reducing endometriosis symptoms, they are often associated with anxiety and depression during treatment” (Laganà et al., 2017). To help manage symptoms, one study that surveyed people with endometriosis found that “heat (70%), rest (68%), and meditation or breathing exercises (47%)” helped and to a lesser degree “yoga/Pilates, stretching, and exercise” (Armour et al., 2019). Changes in diet, individualized to your specific needs, can help with symptom management for some (Karlsson, Patel, & Premberg, 2020). Other things such as acupuncture have been helpful to some as well. Mental healthcare is important to our well-being and should not be neglected either.

The impact endometriosis has on our lives is significant. Know that you are not alone.

References

Arcoverde, F. V. L., de Paula Andres, M., Borrelli, G. M., de Almeida Barbosa, P., Abrão, M. S., & Kho, R. M. (2019). Surgery for endometriosis improves major domains of quality of life: a systematic review and meta-analysis. Journal of minimally invasive gynecology, 26(2), 266-278. Retrieved from https://doi.org/10.1016/j.jmig.2018.09.774

Armour, M., Sinclair, J., Chalmers, K. J., & Smith, C. A. (2019). Self-management strategies amongst Australian women with endometriosis: a national online survey. BMC complementary and alternative medicine, 19(1), 1-8. Retrieved from https://link.springer.com/article/10.1186/s12906-019-2431-x

Karlsson, J. V., Patel, H., & Premberg, A. (2020). Experiences of health after dietary changes in endometriosis: a qualitative interview study. BMJ open, 10(2), e032321. Retrieved from https://bmjopen.bmj.com/content/10/2/e032321.abstract

Laganà, A. S., La Rosa, V. L., Rapisarda, A. M. C., Valenti, G., Sapia, F., Chiofalo, B., … & Vitale, S. G. (2017). Anxiety and depression in patients with endometriosis: impact and management challenges. International journal of women’s health, 9, 323. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5440042/

Missmer, S. A., Tu, F. F., Agarwal, S. K., Chapron, C., Soliman, A. M., Chiuve, S., … & As-Sanie, S. (2021). Impact of Endometriosis on Life-Course Potential: A Narrative Review. International Journal of General Medicine, 14, 9. doi: 10.2147/IJGM.S261139

Parra, R. S., Feitosa, M. R., Camargo, H. P. D., Valério, F. P., Zanardi, J. V. C., Rocha, J. J. R. D., & Féres, O. (2021). The impact of laparoscopic surgery on the symptoms and wellbeing of patients with deep infiltrating endometriosis and bowel involvement. Journal of Psychosomatic Obstetrics & Gynecology, 42(1), 75-80. Retrieved from https://doi.org/10.1080/0167482X.2020.1773785

4 years ago Endometriosis , Endometriosis Education

The Costly Burden of Endometriosis

Endometriosis has a powerful cost in terms of quality of life. However, there are financial costs as well. Financial loss can come from direct healthcare costs as well as loss of productivity. The estimated annual cost between those two in 2009 was $69.4 billion (Della Corte et al., 2020).

Della Corte et al. (2020) notes that “in employed women with endometriosis, as a consequence of productivity loss of 6.3 h per week, the total loss per person is approximately $10,177.54 per year.” Chronic pain is a significant factor in the loss of productivity and Armour et al. (2019) concludes that “priority should be given to improving pain control in women with pelvic pain.” Similarly, Facchin et al. (2019) notes that those with greater severity of symptoms were less likely to be employed and state that “endometriosis symptoms may significantly affect women’s professional life, with important socioeconomic, legal, and political implications.” The loss of productivity doesn’t only affect the workplace. Soliman et al. (2017) found that there was loss of household productivity as well.

The loss of productivity can start with symptom onset, starting in adolescence. Missmer et al. (2021) state that “endometriosis (and its associated symptoms) has been shown to hamper educational attainment, hinder work productivity, alter career choices and success, impair social life and activities, affect family choices, induce strain in personal relationships, negatively influence mental and emotional health, and adversely affect [quality of life]. These multiple and pervasive effects are anticipated to materially alter the life-course trajectory of women with endometriosis.”

So how can we help this? Earlier diagnosis and successful treatment are key. Surrey et al. (2020) notes that “patients with endometriosis who had longer diagnostic delays had more pre-diagnosis endometriosis-related symptoms and higher pre-diagnosis healthcare utilization and costs compared with patients who were diagnosed earlier after symptom onset, providing evidence in support of earlier diagnosis.” On the same note, Missmer et al. (2021) state that “unfortunately, current practice models too often result in a prolonged delay between symptom onset, diagnosis, and treatment of endometriosis, thereby increasing the impact on the life course.” This is why we advocate and share evidence-based information- so that the next person doesn’t have their life so significantly altered by endometriosis.

References

Armour, M., Lawson, K., Wood, A., Smith, C. A., & Abbott, J. (2019). The cost of illness and economic burden of endometriosis and chronic pelvic pain in Australia: A national online survey. PloS one, 14(10), e0223316. Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0223316

Della Corte, L., Di Filippo, C., Gabrielli, O., Reppuccia, S., La Rosa, V. L., Ragusa, R., … & Giampaolino, P. (2020). The burden of endometriosis on women’s lifespan: a narrative overview on quality of life and psychosocial wellbeing. International Journal of Environmental Research and Public Health, 17(13), 4683. Retrieved from https://www.mdpi.com/1660-4601/17/13/4683/htm

Facchin, F., Buggio, L., Ottolini, F., Barbara, G., Saita, E., & Vercellini, P. (2019). Preliminary insights on the relation between endometriosis, pelvic pain, and employment. Gynecologic and obstetric investigation, 84(2), 190-195. Retrieved from https://doi.org/10.1159/000494254

Missmer, S. A., Tu, F. F., Agarwal, S. K., Chapron, C., Soliman, A. M., Chiuve, S., … & As-Sanie, S. (2021). Impact of Endometriosis on Life-Course Potential: A Narrative Review. International Journal of General Medicine, 14, 9. doi: 10.2147/IJGM.S261139

Soliman, A. M., Coyne, K. S., Gries, K. S., Castelli-Haley, J., Snabes, M. C., & Surrey, E. S. (2017). The effect of endometriosis symptoms on absenteeism and presenteeism in the workplace and at home. Journal of managed care & specialty pharmacy, 23(7), 745-754. Retrieved from https://doi.org/10.18553/jmcp.2017.23.7.745

Surrey, E., Soliman, A. M., Trenz, H., Blauer-Peterson, C., & Sluis, A. (2020). Impact of endometriosis diagnostic delays on healthcare resource utilization and costs. Advances in therapy, 37(3), 1087-1099. Retrieved from https://link.springer.com/article/10.1007/s12325-019-01215-x

4 years ago Endometriosis , Endometriosis Education

Endometriosis Quick Facts to Share

What is endometriosis?

Endometriosis is an inflammatory disorder where lesions similar to the lining of the uterus are located outside of the uterus. Endometriosis lesions have distinct differences from the lining of the uterus in both their form and function. The lesions release proinflammatory chemicals, can produce estrogen, can grow their own nerves and blood vessels, and can cause adhesions. It is usually located in the pelvis but has been found in other areas throughout the body. An estimated 11% of people assigned female at birth (including teenagers)have endometriosis- although it has been found in men on rare occasion.

What causes it?

No one knows. There is a genetic component, with higher rates seen in those with close relatives having endometriosis. It has been found in fetuses, suggesting it is present before birth.

What are its symptoms?

Endometriosis has many symptoms- from chronic pelvic pain to fatigue to infertility. Symptom severity does not necessarily correlate with the extent of lesions.

• Pain: chronic pelvic pain, pain with menses, pain in between menses, pain with exercise, pain with sex, pain with bowel movements, pain with urination, low back pain
• Fatigue
• Bowel symptoms similar to irritable bowel syndrome such as constipation, diarrhea, and bloating
• Infertility
• And many others

How is diagnosed?

Endometriosis is diagnosed with surgery, preferably with pathology from tissue samples. Some imaging, such as MRI’s and ultrasounds, can rule in endometriosis, but they cannot rule it out. The accuracy of diagnosis depends on the knowledge and skill of the provider.

How is it treated?

While there is no definitive cure for endometriosis, excision surgery where all lesions are removed is recommended. The skill and knowledge of the surgeon is paramount in the ability to recognize and remove all lesions. Hormonal medication might help temporarily with symptom management, but it cannot be used to diagnosis, cure (“clean up”), or prevent the progression of endometriosis. Endometriosis can persist after a hysterectomy or menopause. Endometriosis is often present with other painful conditions such as adenomyosis and interstitial cystitis.

For more information see: nancysnookendo.com

Reaching Out To Teach Another: nancysnookendo.com/support-us/

4 years ago Endometriosis , Endometriosis Education

Chronic Pelvic Pain: More Than Endometriosis Alone

If you have chronic pelvic pain, endometriosis is likely- endometriosis is diagnosed in up to 80% of patients with chronic pelvic pain (Butrick, 2007). Endometriosis is bad enough, but it is frequently accompanied by other conditions that can cause chronic pelvic pain and other symptoms similar to endometriosis. For instance:

• Adenomyosis: Adenomyosis and endometriosis have been found together anywhere from 21.8% to 79% of the time (Antero et al., 2017; Di Donato et al., 2014; Kunz et al., 2005).
• Interstitial cystitis (IC): The so-called “evil twin” of endometriosis occurs in anywhere between 33-65% of people with endometriosis (Butrick, 2007; Chung et al., 2005). One article stated that “if [endometriosis] symptoms recur within the first 12 months after surgical therapy, IC should be considered as a possible cause” or “when therapy for the symptoms of endometriosis is unsuccessful, increasing evidence suggests that IC may be an underlying cause” (Butrick, 2007).
• Endometrial/uterine polyps: Uterine polyps have been found in 48% of people with endometriosis (Zhang et al., 2018; Zheng et al., 2015). And if you have uterine polyps, you are also more likely to have adenomyosis as well (Indraccolo & Barbieri, 2011).
• Fibroids (Leiomyomas): Both endometriosis and fibroids have been found together in 12-26% of patients, although one small study found both in 86% of the patients studied (Huang et al., 2010; Nezhat et al., 2016; Uimara et al., 2011).

These can also lead to other problems such as pelvic floor dysfunction. Other conditions not necessarily associated with endometriosis can also cause chronic pelvic pain. These might include pelvic congestion syndrome, pudendal neuralgia, or occult hernias. This is why it is so important to identify other pain/symptom generators and treat those as well. If it all gets blamed on endometriosis, you may miss a key to finding relief.

References

Antero, M. F., O’Sullivan, D., Mandavilli, S., & Mullins, J. (2017). High prevalence of endometriosis in patients with histologically proven adenomyosis. Fertility and Sterility, 107(3), e46. Retrieved from https://doi.org/10.1016/j.fertnstert.2017.02.088

Butrick, C. W. (2007). Patients with chronic pelvic pain: endometriosis or interstitial cystitis/painful bladder syndrome?. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 11(2), 182. Retrieved from https://europepmc.org/article/med/17761077

Chung, M. K., Chung, R. P., & Gordon, D. (2005). Interstitial cystitis and endometriosis in patients with chronic pelvic pain: the “evil twins” syndrome. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 9(1), 25. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015562/

Di Donato, N., Montanari, G., Benfenati, A., Leonardi, D., Bertoldo, V., Monti, G., … & Seracchioli, R. (2014). Prevalence of adenomyosis in women undergoing surgery for endometriosis. European Journal of Obstetrics & Gynecology and Reproductive Biology, 181, 289-293. Retrieved from https://doi.org/10.1016/j.ejogrb.2014.08.016

Huang, J. Q., Lathi, R. B., Lemyre, M., Rodriguez, H. E., Nezhat, C. H., & Nezhat, C. (2010). Coexistence of endometriosis in women with symptomatic leiomyomas. Fertility and sterility, 94(2), 720-723. Retrieved from https://www.fertstert.org/article/S0015-0282(09)00620-7/pdf

Indraccolo, U., & Barbieri, F. (2011). Relationship between adenomyosis and uterine polyps. European Journal of Obstetrics & Gynecology and Reproductive Biology, 157(2), 185-189. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21470766/

Kunz, G., Beil, D., Huppert, P., Noe, M., Kissler, S., & Leyendecker, G. (2005). Adenomyosis in endometriosis—prevalence and impact on fertility. Evidence from magnetic resonance imaging. Human reproduction, 20(8), 2309-2316. Retrieved from https://doi.org/10.1093/humrep/dei021

Nezhat, C., Li, A., Abed, S., Balassiano, E., Soliemannjad, R., Nezhat, A., … & Nezhat, F. (2016). Strong association between endometriosis and symptomatic leiomyomas. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 20(3). doi: 10.4293/JSLS.2016.00053

Uimari, O., Järvelä, I., & Ryynänen, M. (2011). Do symptomatic endometriosis and uterine fibroids appear together?. Journal of human reproductive sciences, 4(1), 34. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136067/

Zhang, Y. N., Zhang, Y. S., Yu, Q., Guo, Z. Z., Ma, J. L., & Yan, L. (2018). Higher prevalence of endometrial polyps in infertile patients with endometriosis. Gynecologic and obstetric investigation, 83(6), 558-563. DOI:10.1159/000487946

Zheng, Q. M., Mao, H. L., Zhao, Y. J., Zhao, J., Wei, X., & Liu, P. S. (2015). Risk of endometrial polyps in women with endometriosis: a meta-analysis. Reproductive Biology and Endocrinology, 13(1), 1-9. Retrieved from https://doi.org/10.1186/s12958-015-0092-2

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