{"paper_id":"20ef1df1-96e0-4b08-b67b-9cac6e210297","body_text":"Vol.:(0123456789)\nDigestive Diseases and Sciences (2025) 70:885–887 \nhttps://doi.org/10.1007/s10620-025-08845-y\nINVITED COMMENTARY\n“Love Thy Neighbor” and Know Thyself: Evaluating Pelvic Pain \nand Symptoms of Endometriosis in Gastroenterology Practice\nJoy J. Liu1 · Angela Chaudhari2\nReceived: 11 December 2024 / Accepted: 2 January 2025 / Published online: 18 January 2025 \n© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2025\nAbdominopelvic pain, painful bowel movements, and con-\nstipation are commonplace symptoms in patients seen in \ngastroenterology clinics. Many patients with these symp-\ntoms have been diagnosed with irritable bowel syndrome \n(IBS). IBS can be associated with endometriosis, a condition \nin which endometrial glands or stromal tissue implant on \nareas outside the uterus, including the bowels (particularly \nthe rectum and sigmoid colon), pelvic floor ligaments and \nmuscles, and peritoneum, through retrograde menstruation. \nThese implants are thought to induce inflammation, fibro-\nsis, pelvic adhesions, and infertility. Patients with endome-\ntriosis vary in the severity of their symptoms from minimal \npain with cycles to daily, debilitating pain that interferes \nwith their activities of daily living. The European Society \nof Human Reproduction and Embryology (ESHRE) 2022 \nguidelines state that certain signs and symptoms, including \ndysmenorrhea, dyschezia, rectal bleeding, dysuria and dys-\npareunia should lead the clinician to “explore the diagnosis \nof endometriosis” with clinical evaluation and imaging [1].\nIt is estimated that 4.6% of women in the US have IBS \nand approximately 10% of women of child-bearing age have \nendometriosis. [2 ] Patients with endometriosis are more \nlikely to be diagnosed with IBS (OR: 1.6, 95% CI 1.3–1.8) \nprior to endometriosis diagnosis. [3 ] Both IBS and endo-\nmetriosis are associated with visceral hypersensitivity and \ninflammatory processes such as increased mast cell activity, \nintestinal epithelial cell permeability, and increased prosta-\nglandin activity. [4] It may be that cross-organ sensitization \nand inflammation in endometriosis leads to the bowel symp-\ntoms for which patients seek GI evaluation. There is interest \nin whether IBS treatments can be applied to endometriosis \nsymptoms. Ge et al. reported on the effects of linaclotide, \nused to treat IBS, on pelvic pain in rodents. [5] A New Zea-\nland study showed that almost three-quarters of women with \nIBS and endometriosis responded to a low FODMAP diet \nduring menstruation, and these women had 3.11 odds of \nresponding to low FODMAP diet compared to women with \nIBS without endometriosis.\nThe shared symptoms and pathophysiology lead one to \nwonder whether “IBS” in patients with endometriosis is a \ngastrointestinal (GI) complication of the disease. If this is \ntrue, gastroenterologists may improve their patients’ out-\ncomes by assessing whether patients would be well-served \nby a referral to gynecology for expert diagnosis and manage-\nment. While gastroenterologists do not routinely perform \na pelvic exam, they may be able to expedite diagnosis by \ndiscussing endometriosis and ordering non-invasive testing, \nsuch as transvaginal ultrasound or pelvic MRI.\nWhat is the current state of real-world practice regard-\ning endometriosis in gastroenterology? What are potential \nbarriers and facilitators to improving clinical diagnosis and \nappropriate treatment? In this issue of Digestive Diseases \nand Sciences, Luo et al. [6] developed an exploratory survey \nthat asks these questions. This study is a call to action to \nimprove awareness of the relationship between GI symptoms \nand endometriosis and to provide broader guidance for the \ntriage of gynecologic symptoms in gastroenterology.\nThe authors developed an electronic survey investigat-\ning provider attitudes and practices regarding evaluation \nfor endometriosis in GI clinic. There was a relatively high \nresponse rate of 40% over a short time period, indicating \ngood feasibility for a larger study. Almost 60% of respond-\nents (physicians, psychologists, and APPs in general GI, \ninflammatory bowel disease, and neurogastroenterology at \nthese academic centers) reported not screening for endo-\nmetriosis, and of these, the majority reported no/minimal \nknowledge of endometriosis diagnostic criteria, and the \nbelief that someone else (gynecology or primary care) \n * Joy J. Liu \n joy.liu@northwestern.edu\n1 Division of Gastroenterology and Hepatology, Feinberg \nSchool of Medicine, Northwestern University, Chicago, IL, \nUSA\n2 Department of Obstetrics and Gynecology, Feinberg School \nof Medicine, Northwestern University, Chicago, IL, USA\n\n886 Digestive Diseases and Sciences (2025) 70:885–887\nshould evaluate patients. After being presented with an \nin-test graphic on the relationship between endometriosis \nand GI symptoms, over 70% of respondents indicated they \nwere open to asking about endometriosis symptoms with a \nshort questionnaire. Only a minority of respondents (12.7%) \nbelieved screening was not clinically relevant or would take \ntoo much time.\nApproximately 40% of GI clinicians were comfortable \nordering imaging to evaluate for endometriosis. The survey \nstratified results by self-identified gender/sex (male/female) \nof clinicians, and interestingly, a higher proportion of male \ngastroenterology clinicians compared to female clinicians \nreported willingness to order non-invasive testing for endo-\nmetriosis. This disparity provides a rationale for obtaining \nricher qualitative data, perhaps in the form of semi-struc-\ntured interviews. Investigating the reasons for either feeling \ncomfortable or uncomfortable in pursuing additional diag-\nnostic evaluation could be evaluated in a future study.\nThis survey underwent development and pilot testing with \nthe guidance of a methodologic expert. It shows promise for \ndeployment on a broader (national) scale to capture more \ngeneralizable data. Most respondents felt that they lacked \nknowledge regarding diagnostic criteria for endometriosis \nand how it relates to GI symptoms but were also interested \nin evaluating patients after receiving education on the topic. \nTherefore, developing and disseminating educational materi-\nals related to endometriosis and other pelvic conditions for \ngastroenterologists should be a future aim.\nRaising the possibility of endometriosis may lead some \npatients to leap to premature conclusions about a chronic \ndisease that has long-term reproductive and health out-\ncomes. Patients should be counseled that their symptoms \nwarrant further evaluation by a gynecologist who can make \nthe diagnosis and provide appropriate, patient-centered treat-\nment. Best practices for screening should be developed in \ncollaboration with gynecologic experts to diminish this gap \nin care. There are a multitude of short-form questionnaires \nthat have been developed and studied for endometriosis, and \nfuture work could utilize one that incorporates intestinal and \npelvic symptoms.\nOne limitation to the study’s proposal of having gas-\ntroenterologists evaluate for endometriosis-based only on \npatient-reported symptoms is the inherent complexity in \ndiagnosing endometriosis, even for those with experience \ntaking gynecologic histories. The differential for symptoms \nof endometriosis is vast and may include pelvic congestion \nsyndrome, myofascial pain, central sensitization, pelvic \nadhesions, infection, urologic conditions, and IBS. Screen-\ning for symptoms does not constitute a diagnosis of endome-\ntriosis; the diagnostic gold-standard is pathologic diagnosis \nat the time of surgery. Even among gynecologists, there is \nno single gold-standard screening tool for endometriosis: \nClinical suspicion based on the menstrual and pain history is \nkey. Pelvic exam may elucidate pain but is never diagnostic \nfor endometriosis. Transvaginal ultrasound and pelvic MRI \nmay be useful in identifying deep invasive lesions of endo-\nmetriosis but do not negate the possibility of endometriosis \nif negative. These complexities in diagnosis may decrease \ngastroenterologists’ confidence in evaluation.\nThis survey does not ask about comfort with treating \nendometriosis. Likely, gastroenterology clinicians would \nagree that the treatment of endometriosis should be man-\naged by a gynecologic expert. However, as Luo et al. point \nout, access to gynecologists is expected to decrease. Will \nthe gastroenterologist who clinically suspects endometriosis \nbut does not have a gynecologist to refer to have a duty to \nprovide treatment? This is a rhetorical question that hints at \nthe medicolegal implications of the appropriate “scope of \npractice” that may discourage gastroenterology clinicians \nfrom even asking about pelvic symptoms. However, as many \nof us know, one’s scope of practice often expands to accom-\nmodate the community’s needs. Should IBD specialists defer \nmanagement of iron deficiency anemia to hematologists? \nShould general gastroenterologists defer hemorrhoid band-\ning to colorectal surgeons? All of us should heed the pro-\nscription to “know thyself”—what we are willing and able \nto accommodate, what we are not, what the boundaries of \nour individual practice are, and how these may change with \neducation, experience, and new technology.\nIn summary, this survey-based study shows that, cur -\nrently, many gastroenterologists do not deliberately ask \nabout endometriosis symptoms in patients with chronic GI \nconditions despite the known association between endome-\ntriosis and IBS. Many respondents indicated they would be \nwilling to learn and implement screening tools. Future stud-\nies should involve collaboration with gynecology experts to \nensure that educational materials and recommendations are \nsupported by the best evidence and practices.\nAuthor’s Contribution JJL wrote the main manuscript text. AC pro-\nvided critical revisions. All authors reviewed the manuscript.\nData Availability No datasets were generated or analysed during the \ncurrent study.\nDeclarations \nConflict of interest Ironwood (speaker) and Johnson and Johnson \n(consultant); Richard Wolf Medical (consultant).\nReferences\n 1. Becker CM, Bokor A, Heikinheimo O et al. ESHRE guideline \nendometriosis. Human reproduction Open. 2022;2022:hoac009.\n\n887Digestive Diseases and Sciences (2025) 70:885–887 \n 2. Sperber AD, Dumitrascu D, Fukudo S et al. The global preva -\nlence of IBS in adults remains elusive due to the heterogeneity of \nstudies: a Rome foundation working team literature review. Gut.  \n2017;66:1075–1082.\n 3. Saidi K, Sharma S, Ohlsson B. A systematic review and meta-\nanalysis of the associations between endometriosis and irri-\ntable bowel syndrome. Eur J Obstet Gynecol Reprod Biol.  \n2020;246:99–105.\n 4. Viganò D, Zara F, Usai P. Irritable bowel syndrome and \nendometriosis: New insights for old diseases. Dig Liver Dis.  \n2018;50:213–219.\n 5. Ge P, Ren J, Harrington AM et  al. Linaclotide treatment \nreduces endometriosis-associated vaginal hyperalgesia and \nmechanical allodynia through viscerovisceral cross-talk. Pain.  \n2019;160:2566–2579.\n 6. Luo Y, Wang XJ, Keefer LA et al. Love thy neighbor? Exploring \ngastroenterology attitudes toward endometriosis screening. Dig \nDis Sci. (2024). https:// doi. org/ 10. 1007/ s10620- 024- 08740-y.\nPublisher's Note Springer Nature remains neutral with regard to \njurisdictional claims in published maps and institutional affiliations.","source_license":"public-domain-us","license_restricted":false}