{"paper_id":"3e68028d-4481-4fef-b96c-d6e836a4f450","body_text":"The EuroBiotech Journal                                                                                          CASE REPORTS\n178VOLUME 4 ISSUE 4  |  OCTOBER 2020\nMedicine and Biotechnology\nAbstract\nEndometriosis is a common condition that affects reproductive-aged women and is characterized by the presence of endo -\nmetrial tissue outside the uterine cavity with nodules and lesions. The study aimed to analyze lifestyles of women affected by \nendometriosis in relation with their symptoms. In this observational study, 735 Italian women have been interviewed online \nthrough a questionnaire structured in two parts. The first part was mainly anamnestic, focused on gathering information about \nthe age, the stage of disease, comorbidities, involved organs, symptomatology, chirurgical treatment, induced menopause. The \nsecond part focused on the individual characteristics and lifestyle of the patients such as the body mass index, physical acti -\nvity, quality of sleep, and the diet. The results showed how a healthy diet and a regular physical activity reduce drastically the \nsymptoms of the patients. \nKeywords: endometriosis, diet, physical activity, body mass index, quality of sleep\nIntroduction\nEndometriosis is a worldwide common gynecological condition that affects women in re-\nproductive age. The pathology is characterized by the endometrium growth at the outside \nof its physiological localization, such as the myometrium, ovary, and peritoneum with \nconsequent inflammation, fibrosis, and formation of adhesions (1). The disease can be as-\nymptomatic or it can manifest with pelvic pain during menstrual bleeding and/or sexual \nintercourse, by influencing the quality of life (2). In addition, it represents the major cause \nof infertility (3). The exact pathogenetic mechanism has not been established but the most \naccepted hypotheses go from the retrograde menstruation and genetic or immunological-\nly linked susceptibility (4) to Müllerian rests (5) or exposition to chemical sources that \nalter the endocrine system (6). The retrograde menstruation is characterized by an out -\nflow of the endometrial lining through the fallopian tubes. This retrograde flow, together \nwith the potential hematogenous or lymphatic circulation, can result in the seeding of \nendometrial tissue into ectopic sites (7,8). Although most women have retrograde men -\nstruation, not all of them have endometriosis. The immune dysfunction in the patients \ninterferes with the elimination of the lesions themselves (9). Endometriosis is also associ-\nated with an increased risk of autoimmune diseases and endometrioid ovarian cancer as \nwell as other cancers, including lymphoma and non-Hodgkin’s melanoma (9). As above \nreported, endometriotic lesions can also result from Müllerian remains that have not un-\ndergone differentiated or failed to migrate properly during fetal development (10,11). Of \nnote, Müllerian anomalies may be the cause of the obstruction of menstrual outflow (12). \nFurthermore, also somatic mutations resulting in growth dysregulation can be considered \n1Department of Pharmaceutical Science, \nUniversity of Perugia, Perugia, Italy\n*Corresponding author: Albi, E. \n*E-Mail: elisabetta.albi@unipg.it\nDOI: 10.2478/ebtj-2020-0022\n© 2020 Authors. This work was licensed \nunder the Creative Commons Attribution-\nNonCommercial-NoDerivs 4.0 License.\nRelationship between Symptoms in Women with Endometriosis and \nLifestyles: a Qualitative Interview Study \nScavone M.1*, Gizzi C. 1, Albi E.1\n\n\n179\nThe EuroBiotech Journal\nMedicine and Biotechnology\netiological factors (9,10). Additional etiological factors may be \nprolonged exposure to endogenous estrogen such as due to \nearly menarche, late menopause or obesity (12). The treatment \ncan be pharmacological or surgical but the correct lifestyle is \nalso relevant (13). Of considerable importance are the quality \nof sleep, sports activity and diet. In fact, the low physical ac -\ntivity and the poor sleep quality are associated with the endo -\nmetriosis symptoms (14). Particular attention was payed to the \ndiet, by indicating that endometriosis is associated with a low \nintake of vegetable, fruit (15), and vitamin D (16), and with a \nhigh trans-fatty acid (17), beef and other kinds of red meat and \nalcohol (18) consumption. This is relevant thanking in account \nthat exists a relationship between lipids and vitamin D (19). \nOn the other hand, the use of omega-3 fatty acids, antioxidants \nand a combination of vitamins and minerals positively influ -\nences the endometriosis-associated symptoms (20), consid -\nering that lipids are involved in immunity and inflammatory \nprocesses (21,22). There are currently no studies that establish \na simultaneous correlation of the sleep quality, sports activi -\nty and diet with the symptoms of endometriosis. The present \nwork is a qualitative interview study aimed to highlight in the \nsame patients different aspects of endometriosis in the Italian \npopulation.\nMaterials and Methods\nPatients \n735 women affected by endometriosis we included in the study \nrealized between February 4th to March 4th 2020. The exclu -\nsion criteria were obesity and cancer. The patients were recruit-\ned online on the Facebook page of National Association Endo-\nmetriosis Project (APE-ODV) and participated to the study on \na voluntary basis by giving their informed consent. \nInterview\nA specific questionnaire was prepared and administered on -\nline. The questionnaire was structured in two parts. The first \npart was mainly anamnestic, focused on gathering information \nabout the age, the stage of disease, comorbidities, involved or -\ngans, symptomatology, chirurgical treatment, induced meno -\npause. The second part focused on the individual characteris -\ntics and lifestyle of the patients such as the body mass index, \nphysical activity, quality of sleep, and the diet.\nResults\nPopulation characteristics\nThe analysis of the interview indicated that the average age \nof the 735 women who agreed to participate in the study was \n36.5+17.5 years. In particular, 5% aged 18-25, 37% aged 26-35, \n48% aged 36-45, and 10% over the age of 46. From the results \nwas evident that 85% aged 26-45. Interestingly, the mean age at \nthe time of diagnosis was 28+4 years. It is important to high -\nlight that 84% of patients had received the diagnosis more than \n1 year after the onset of symptoms and only 2% within 1 year, \nby indicating that often the endometriosis diagnosis is tardive. \nThe remaining 14% refers to women that have been diagnosed \nin few months. This result justifies the stage of the disease at \nthe time of diagnosis, reported by the patients. In fact, 47% of \nwomen examined were already at IV stage of the disease, 12% at \nIII stage, 6% at II stage, 6% at I stage, and 29% of patients didn’t \nremember the stage they belonged to. Only 18% of patients \ndid not present comorbidities. Figure 1 shows the percentage \nof different pathologies of 72% of women with comorbidity. A \ndata that caught particularly the attention is the high percent -\nage of women with autoimmune pathologies which covers 6% \nof the examined women of whom 62% were affected by celiac \ndisease (Fig.1). \nThe presence of comorbidities is another factor that sometimes \nmakes early diagnosis difficult.\nClinical picture \nFrom the interview it was clearly evident that several organs \nwere involved in the endometriosis, many of these were simul-\ntaneously present in the same patient.  In figure 2, the percent-\nage of involved organs. \nAs a consequence, the symptomatology linked to endome -\ntriosis is wide and complex. The main reported symptom at the \nmoment of the diagnosis was the dysmenorrhea (Fig.3). \n\n\n180  |  VOLUME 4 ISSUE 4  |  OCTOBER 2020   \nUnfortunately, the symptom that leads to the diagnosis of \nendometriosis is not strictly related to this symptom. In fact, \nalmost half of women had a chronic pelvic pain (47%), dys -\npaurenia (44%) and heavy menstrual flow (40%). These are \nsymptoms until today underestimated, that caracterises the \nmajoruty of women affected by endometriosis. A discrete \npercentage of women affected by this disease showed reptile \ndiscomfort (36%), interpreted as false sensation of needing to \ndefecate, rectal pain, discomfort to stay normally seated, sense \nof posterior heaviness. In addition, chronic tiredness is often \nneglected, even though it is a frequent symptom; 36% of wom-\nen examined showed this symptom. Moreover, 26% of patients \npresented constipation, 21% diarrhea, 21% meteorism and flat-\nulence phenomenon. Only 6% of patients were asymptomatic.\nVery relevant were the symptomatology in relation with \nmenstrual cycle and in the fertility. 56% of women indicat -\ned symptoms away from the menstrual cycle, 31% symptoms \nduring the menstrual cycle and right before it and, 13% symp-\ntoms only during the menstrual cycle. Often women find out \nto be affected by endometriosis only after a few failed attempts \nto conceive, followed by further investigations and studies that \nconfirmed the incapability to conceive.  According to this, from \nthe 735 women, only 30% managed to conceive of whom 62% \nhad a disease at the III o IV stage. As consequence, 44% of \nwomen were in menopause. Of these, 84% were on a pharma -\ncological menopause, 10% are on a surgical menopause and, \n6% are on a spontaneous menopause. Considering that 78% \nof patients had undergone surgery, either laparoscopic or with \nlaparotomy, it is evident that when patients arrived for surgery, \nmany were already in pharmacological or spontaneous meno -\npause. Among all women that had a surgical treatment, 36% \nfaced a bowel resection or rectal shaving. Among the women \nexamined, 62% followed a pharmacological therapy and of \nthese 78% suffered from collateral effects.  Many effects were \nsimultaneously present in multiple patients. Therefore, 43% \npresented abnormal vaginal discharge, 30% increase in appe -\ntite, 28% vaginal candidiasis or other fungal infections, 55% \nheadache, 44% hot flashes, 76% decreased libido, 13% hyper -\ntrichosis,  72% body weight changes, 25% nausea, 8% diarrhea, \n33% hair loss, 63% nervousness, 60% depression.  \nLifestyles\nBMI\nBMI is an important factor for the health of subject and its \nvalue is calculated considering height and weight. Generally, \nin adult, BMI between 18.50 and 24.99 is considered as nor -\nmal-weight, BMI between 16.00-18.49 as under-weight, BMI \nbetween 25.00 and 29.99 as over-weight and, BMI above 30 as \nobesity. As above reported, the patients with obesity were not \nincluded in the study. Of the 735 women, 68% were normal \nweight, 22% under-weight, and 10% over-weight. On a closer \nlook the youngest women had more adequate BMI than older \nwomen. More specifically 69% of women over 36 were over -\nweight. These data are relevant considering that the high BMI is \nstrictly related with inflammation of the adipose tissue and an \ninflammatory picture is not a positive factor for endometriosis.\nPhysical activity\nFrom this study it has been observed how the physical activity \nis beneficial on those who work out on a regular basis. How -\never, only 17% of women examined worked out and reported \npositive results on their health conditions. In details, 33% of \nwomen did not work out and another important percentage \n(30%) worked out only when had time (Fig. 4).  \nIt has been observed how women over 46 years showed \nmore interest in working out. It resulted evident that  women \nwith the age between 18 and 25 years and women over 45 did \nnot like physical activity. In fact only 7% of women over 45 and \n2% of women with the age between 18 and 25 years practiced \nphysical activity. The majority of women confirmed that used \nwalk for long distances. Among the sport most performed it \nhas been mentioned: yoga, pilates, jogging, swimming e water \ngym. It is obvious the importance of a healthy and correct life-\nstyle in order to prevent some pathologies.\nQuality of sleep\n21% had a bad quality of sleep, 46% of women reported a dis -\ncreet quality of sleep, 28% had a good quality of sleep, and only \n5% had an excellent quality of sleep. Interestingly, by compar-\n\n\n181\nThe EuroBiotech Journal\ning the chronic tiredness, as one of the symptoms in women \naffected by endometriosis, with the quality of sleep it appeared \nevident that among 36% of women that suffered from chronic \nfatigue syndrome, 76% suffered from poor- quality of sleep; in \nparticular 27% of patients suffered from a very bad quality of \nsleep, while 49% suffered from discreet quality of sleep; only \n23% had a good quality of sleep and a smaller percentage had \nan excellent quality of sleep. \nDiet\n75% of the examined women thought that nutrition plays a key \nrole on the reduction of the pain linked to the inflammation \ninduced by endometriosis. 46% followed a healthy diet and \nin particular women aged from 36 to 45 years old. There are \nseveral nutritional regimes that can be associated to different \nethical, environmental, religious choices and often influenced \nby current trends. (Fig. 5). According to this aspect, it has been \nobserved that 77% of examined women followed an omnivo -\nrous diet,  9% follows a vegetarian diet, 2% follows a vegan diet, \nabout 12% followed alternative diets (ketogenic, macrobiotic, \ndukan ect.).\nIn the study we showed how milk and milk derivatives exacer-\nbated the most painful condition (on 59% of patients) followed \nby sugar, refined flour and baked goods form it derived (on 50% \nof patients), by indicating that these nutrients might facilitate \ninflammation process (Fig. 6). Notably, 35% of patients ingest-\ned these nutrients 2-4 times a week. In the figure 6 it has been \nreported the consumption of each type of food during the week\nIt is known that additional foods that contribute to pain con-\nditions in endometriosis patients are soy and red meat. From \nthe analysis of the responses it was highlighted that women had \nbeen alerted about this. In fact, most women did not consume \nsoy and consumed red meat once a week (Fig. 7).\nAdditionally, cured and processed meats (40% of cases), al-\ncohol (35% of cases), coffee, tea and drinks with caffeine (29% \nof cases), pre-cooked and readymade goods (28% of cases), \nchocolate (26% of cases), legumes (17% of cases) increased the \npain. Only in some cases fruits (7%) and vegetables (10%) in -\ncreased the pain condition. It is important to know how cooked \nvegetables, on 58% of cases, provoked more discomfort com -\npared to raw vegetables. It is really difficult to establish exactly \nwhich food is responsible for a pain because several foods of -\nten cause pain in the same patient. Patients were well educat -\ned about the importance of water consumption. Despite this, \n40% of women consumed 1 liter or less of water per day. The \nmost relevant symptoms consequent to the consumption of \nthe above nutrients included abdominal bloating (88%), pelvic \npain (40%) and chronic tiredness (34%) (Fig. 8).\n\n\n182  |  VOLUME 4 ISSUE 4  |  OCTOBER 2020   \nSome symptoms are less frequent, but still relevant such as \ndiarrhea, constipation, migraine, dysuria, nausea, meteorism \nand dyspepsia. \nDiscussion\nConsidering how nowadays lifestyle influences the health \nof the single person, this study aims to prove the association \nbetween lifestyle of a specific group of women who share a \ncommon disease. The results obtained in the present study \nsupport the difficulty in making an early diagnosis due to the \nvariability of the tissues and organs presented and the comor -\nbidities. The symptoms of the disease are so constant, even if \nvariable, that they become part of the patient’s life. It is diffi -\ncult to determine whether lifestyle is one of the causes of pain \nor whether pain determines lifestyle. It is likely that this is a \nvicious cycle. Therefore, it is essential to know all the factors \nthat can block this cycle and a correct and continuous informa-\ntion on physical activity and nutrition is necessary. Besides the \nusual approaches, from a couple of years it has been suggested \nto follow a personalized nutrition regime in order to support \nthe individual medical treatment. These nutritional regimes \nare mainly focused on the importance of supporting the caloric \nneeds of the patient and potential preferences towards certain \nfood, avoiding the consumption of the so-called pro-inflam -\nmatory goods. A correct nutrition status is essential in order \nto reduce the symptomatology related to endometriosis. There \nare many foods identified by patients as the cause of increased \npain. Therefore, it will be important to carry out a specific food \nplan in the individual subject and also in relation to the men -\nstrual cycle. Red meat and soy are less ingested probably be -\ncause different scientific studies reported how these two partic-\nular foods might cause the endometriosis disease. It has been \ndemonstrated that a specific natural integrator based on lipoic \nacid, palmitoiletanolamide and myrrh reduces the pelvic pain \nin endometriosis (23). Moreover, very useful are omega-3 and \nomega-6 fatty acids (24) that play a role as antioxidant mole -\ncules (25). Moreover, the study has highlighted that the average \nage to conceive tends to rise. This can be related on one hand \nto socio-economical problems that affect couples nowadays, on \nthe other hand to the pathology that often requires the inter -\nvention of assisted reproduction techniques. Therefore, an ear-\nly diagnosis may be beneficial in terms of quality of life and in \nterms of fertility preservation. \nConclusions\nIn conclusion this study indicates how even for more complex \npathologies like endometriosis, a regular physical activity and a \ncorrect nutritional strategy associated to the pharmacotherapy \nand surgical-therapy, visibly can improve the pain conditions \nof the patients and her lifestyle.\nConflicts of Interest\nThe authors declare no conflict of interest.\nReferences\n1. Brown J, Crawford TJ, Datta S, Prentice A, and Cochrane \nGynaecology and Fertility Group. Cochrane Database Syst \nRev. Oral contraceptives for pain associated with endome-\ntriosis. Cochrane Database Syst Rev. 2018(5): CD001019. \ndoi: 10.1002/14651858.CD001019.pub3.\n2. Moradi M, Parker M, Sneddon A, Lopez V , Ellwood D. Im-\npact of endometriosis on women’s lives: a qualitative study. \nBMC Womens Health. 2014;14:123. doi: 10.1186/1472-\n6874-14-123\n3. 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Mole -\ncules. 2020;25(12):2910. doi: 10.3390/molecules25122910.","source_license":"CC0","license_restricted":false}