Comment Article to “quality of Life in Women with Endometriosis: a Systematic Review and Meta-analysis” More Attention to Subtle Symptoms, Environmental Causes Prevention and Better Infertility Treatment Can Improve Qol of Endometriosis Patients

In their systematic review and meta-analysis articles, Chaman-ara at al (1) confirm that endometriosis negatively affects all aspects of women’s quality of life (QoL), and it can cause a variety of symptoms: chronic pelvic pain, dysmenorrhea, dyspareunia, dysuria, lower abdominal pain, heavy and/or irregular periods, and infertility. Also, authors state that endometriosis could cause, or contribute to, diarrhea or constipation, chronic fatigue, nausea and vomiting, headaches and hypoglycemia-menstrual pain. These nonspecific symptoms are infrequently considered related to this disease and lately, or under, treated. We underline that clinicians dealing with this disease should pay more attention to this subtle symptom in order to earlier and better treat them. In this review (1), authors claim that “so far no treatment has been found for endometriosis”. Endocrine suppressive therapy, like progestogens or combined hormonal contraceptives, not only could relieve symptoms, but at the same time helps to prevent some subtypes of ovarian cancer, like endometriotic and clear cells (2). Chaman-ara et al (1) recognize that endometriosis has a multifactorial etiology and, among causes, they appropriately mention environmental factors. Also, limitation to exposure to the potential pollution causes of endometriosis could at least theoretically improve fertility, QoL and maybe prevents some female cancers, even though research on this field is difficult (3). Pollutants like dioxins can induce a progesterone resistance that indirectly can promote estrogen related diseases like endometriosis (4). This subject of primary prevention is still neglected even though we know different pathogenetic mechanism that can explain how endocrine disruptors and pollution can contribute to endometriosis, infertility and female cancers (5). Information about environmental causes of endometriosis must be evidence based, not alarming, but focused to give practical advices to prevent o limit exposure (6). Chamanara et al (1) also state that ”the prevalence of the infertility in women affected by endometriosis is 20 times more than those without this condition” and they demonstrate that “infertility due to endometriosis shows the most negative effect on the QoL”. Endometriosis-associated pelvic pain and subfertility can be mostly managed medically, but also during available treatment fertility in suppressed. This is a problem in older women or for those with a reduced ovarian reserve. However, in the near future promising molecules for the treatment of endometriosis will help to improve QoL and include elagolix, mifepristone, TAK385, KLH-2109, ASP1707 and cabergoline (7). Surgical treatment of endometriosis has the risk of reducing ovarian reserve and it should be properly performed in selected cases; ovarian cystectomy does not improve reproductive outcomes for women with endometrioma undergoing assisted reproductive technology (ART). Laparoscopic excision is more indicated in patients who cannot or do not wish to take: medical therapies; acute surgical or pain events; deep endometriosis; during concomitant management of other gynecologic disorders; patients seeking fertility with pain; hydrosalpinges undergoing ART or as an alternative to ART, refused by the patient (8). Authors of the meta-analysis (1) conclude that “early diagnosis and developing the effective treatment protocols are very important as they could prevent the re-