Referee report. For: Holistic approaches to living well with endometriosis [version 1; peer review: 1 approved with reservations]

Endometriosis, holistic treatment for endometriosis, complementary treatment for endometriosis, chronic pelvic pain ALL Metrics - Views Downloads How to cite this article Desai J, Strong S and Ball E. Holistic approaches to living well with endometriosis [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:359 (https://doi.org/10.12688/f1000research.142586.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente Select a format first ▬ ✚ Review [version 1; peer review: 1 approved with reservations, 1 not approved] * Equal contributors PUBLISHED 23 Apr 2024 Author details Author details 1 Central and North West London NHS Foundation Trust, London, England, UK 2 Department of Obstetrics and Gynaecology, The Royal London Hospital, Barts Health NHS Trust, London, E1 1FR, UK 3 Centre for Maternal & Child Health Research, School of Health Sciences, City University of London, UK 2 Department of Obstetrics and Gynaecology, The Royal London Hospital, Barts Health NHS Trust, London, E1 1FR, UK 3 Centre for Maternal & Child Health Research, School of Health Sciences, City University of London, UK Jessica Desai Roles: Data Curation, Writing – Original Draft Preparation Roles: Data Curation, Writing – Original Draft Preparation Sophie Strong Roles: Conceptualization, Data Curation, Formal Analysis, Supervision, Writing – Original Draft Preparation Roles: Conceptualization, Data Curation, Formal Analysis, Supervision, Writing – Original Draft Preparation Elizabeth Ball Roles: Conceptualization, Methodology, Resources, Supervision, Writing – Review & Editing Roles: Conceptualization, Methodology, Resources, Supervision, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS This article is included in the Endometriosis collection. Endometriosis is a common chronic condition for which there is currently no cure. Those suffering from endometriosis-related pelvic pain (ERPP) may struggle with side effects and/or risks presented by conventional medical and surgical treatment strategies, or not get pain relief. Increasing numbers of endometriosis patients wish to explore holistic management with fewer side effects, however it is important that medical professionals maintain an evidence-based practice for recommended treatments. We present up-to-date evidence of holistic strategies used for managing ERPP including nutritional strategies, body and mind therapies, acupuncture, traditional Chinese medicine (TCM) and the use of adjunct devices such as phallus length reducers and transcutaneous electrical nerve stimulation (TENS). Nutrition: Gluten-free, low-nickel and high intake of omega-3 polyunsaturated fatty acids diets improve ERPP. Low FODMAP (fermentable oligo-, di-, monosaccharides and polyols) is helpful in those with concurrent irritable bowel syndrome. Body and mind: Cognitive behaviour therapy (CBT) is particularly beneficial in postoperative pain reduction, whilst mindfulness has been shown to reduce pain scores and dyschezia. Progressive muscle relaxation therapy and regular yoga sessions improve ERPP and Quality of life. Acupuncture: 15 randomised control trials assessing acupuncture and moxibustion show improved pain scores when compared to those receiving conventional therapies alone. Adjunct devices: TENS improves deep dyspareunia and lessens the number of days pain is experienced. Holistic management strategies for ERPP should be incorporated into routine counselling when discussing conservative, medical and or surgical treatments for endometriosis. The growing evidence presented for the use of holistic management strategies gives hope to those patients who cannot have, or don’t respond to conventional approaches and as an adjunct alongside standard treatments. Endometriosis, holistic treatment for endometriosis, complementary treatment for endometriosis, chronic pelvic pain Corresponding Author(s) Sophie Strong ([email protected]) Grant information: This study was supported by the Centre for Maternal & Child Health Research, School of Health Sciences, City University of London. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2024 Desai J et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Desai J, Strong S and Ball E. Holistic approaches to living well with endometriosis [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:359 (https://doi.org/10.12688/f1000research.142586.1) First published: 23 Apr 2024, 13:359 (https://doi.org/10.12688/f1000research.142586.1) Latest published: 08 Nov 2024, 13:359 (https://doi.org/10.12688/f1000research.142586.2) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There is a newer version of this article available. of this article available. Endometriosis, an inflammatory women’s health condition affecting about 10% of the female population,1 can cause infertility and chronic pelvic pain (CPP) with acute flares. Pain centralisation is thought to play a role for many patients.2 The mainstay of treatment has been laparoscopic excision or ablation of implants/affected organs. Hormonal or non-hormonal medical therapies can replace or complement this, along with pain relief. However, in our experience at a busy tertiary endometriosis centre in London, many women with endometriosis-related pelvic pain (ERPP) have adopted holistic approaches to manage pain and improve their quality of life (QOL). Recent developments also call us to reassess and contextualise traditional treatments, to look further afield for more comprehensive approaches, which support patient autonomy and empowerment toward living well with endometriosis. 1. A systematic review (SR) of surgical outcomes for endometriosis3 showed that 11.8% of patients reported no pain improvement. Women with isolated surface endometriosis in particular, may not benefit from surgery,4 which is currently the focus of randomised control trial (RCT) ESPriT2 (NCT04081532). 2. The coronavirus disease 2019 (COVID-19) pandemic transformed how women seek advice on endometriosis. ‘Hormonophobia’ appears to be on the rise on social media platforms, with increasing numbers of women sharing negative experiences of hormonal contraceptives, reducing the willingness to try them.5 3. Antidepressants and Gabapentin, previously prescribed as neuromodulators are not as effective as previously thought.6 In front of this backdrop and with an understanding that living with chronic conditions can be eased by holistic approaches and self-management,7 we present recent advances in this field. Numerous SRs support the role of nutrition in managing chronic pain conditions.8,9 Optimising diet quality with a high intake of anti-inflammatory nutrients reduces pain severity by modulating the body’s inflammatory response.10 Gut microbiome dysbiosis in inflammatory pain conditions such as endometriosis is hypothesised to cause incorrect immune responses resulting in pain from central sensitisation pathways. Probiotics and FODMAP diets (omitting fermentable oligo-, di-, monosaccharides and polyols), are beneficial in treating visceral pain.11 More research into dietary effects on endometriosis is recommended,12 as many studies to date have small population sizes with heterogeneity between intervention groups. A SR (one RCT and five observational studies) of low FODMAP, gluten-free and low-nickel diets as well as high intake of omega-3 polyunsaturated fatty acids (average treatment dose palmitoylethanolamide 400 mg & polydatin 40 mg twice daily for 3 months)13–15 reported that all diets, with the exception of low FODMAP reduced pain.16 Those with concurrent irritable bowel syndrome (IBS) may benefit the most from low-FODMAPs; observational data (n=160) demonstrated symptom improvement compared to patients with IBS alone (72% vs. 40%, respectively, p = 0.001).17 Compared to controls, endometriosis patients may have a higher rate of nickel allergic contact mucositis (odds ratio: 2.474; 95% confidence interval: 1.023~5.988; p = 0.044),18 causing IBS-like symptoms. Reducing nickel-rich foods e.g. tomatoes, whole wheat, and soy, resulted in significant improvement of CPP (p < 0.05) in a prospective 3-month observational study of 31 women with endometriosis and gastrointestinal symptoms.19 Krabbenborg et al.20 observed 157 women with endometriosis assessing which dietary modifications patients had already implemented improved their QOL using the EHP-30 score. The most used diets were the endometriosis diet (self-selecting nutrients to omit thought by the individual to worsen their symptoms), gluten free, low-FODMAP, low-lactose and weight loss diets. Although EHP-30 scores did not significantly alter with dietary modification, pain reduction was noted in 71.3% of patients, with gluten-free showing the greatest impact. Dietary modifications have a greater impact with longer adherence. In a placebo-controlled triple-blind RCT (n = 120), garlic extract (400 mg daily over 12 weeks) showed a significant reduction in ERPP (p < 0.05). Purported mechanisms are reduction in oxidative stresses, prostaglandin production, endometriosis cell proliferation and increased oestrogen elimination.21 Endometriosis severity may be associated with both low and high BMI.22 The association between BMI and endometriosis severity might be more complicated than a simple correlation. A confounding factor for both endometriosis and obesity may be systemic inflammation.23 It is tempting to speculate whether maintenance of a normal BMI is beneficial for symptom control, but studies designed to assess change in weight for ERPP are lacking. Body & mind therapies Poor mental health may result secondary to the multifactorial impact endometriosis has on physical, sexual, and psychological well-being.24 Strategies such as cognitive behavioural therapy (CBT), yoga and relaxation techniques can be valuable. Increasing evidence suggests psychosocial factors, such as preoperative pain catastrophising independently impact pain experience, severity of symptoms and recurrence of endometriosis.25,26 Patient awareness and self-uptake of psychological approaches for ERPP are increasingly popular, with 93.8% of women sampled in a cross-sectional survey distributed via The Endometriosis Network Canada (n = 434) utilising at least one psychological management strategy.27 CBT CBT is recognised as an effective treatment for chronic pain and associated mental health conditions, including CPP.28 Current research interest is evidenced by the publication of three RCT protocols assessing efficacy of CBT29,30 and yoga with CBT31 on QOL of patients with endometriosis. Boersen’s RCT30 aims to recruit 100 patients undergoing endometriosis surgery, assessing benefits of CBT in postoperative care. Wu et al.32 assessed the benefits of CBT plus usual care compared to usual care alone in post-surgical endometriosis patients with a case-control study (Intervention group n = 48, Control group n = 48), utilising one CBT session before and six sessions post-surgery. During a 6-month follow-up, participants provided a score on the depression, anxiety, and stress (DASS-21). Anxiety scores improved significantly (p = 0.0091). Authors suggest patient education played a large role in self-management of ERPP following CBT. Mindfulness Mindfulness is a psychological technique that draws on awareness and non-judgemental acceptance of present personal experience. The mindfulness-based stress reduction (MBSR) programme, was first developed by Kabat-Zinn33 as an adjunct to treatment for chronic pain, through relating physical and psychological conditions. Moreira et al.34 performed an RCT to assess the impact of mindfulness on CPP. They adapted the MBSR programme, forming a brief mindfulness-based intervention (bMBI, n = 31, usual care controls n = 32) which had a reduced intensity and reduced duration (4-weeks instead of 8-weeks). Formal meditation was practised around the theme of ‘reconceptualising pain.’ The intervention group showed reduced pain scores & unpleasantness and dyschezia. Hansen et al.35 found that psychological intervention, with a mindfulness focus, did not reduce perception of pain, but did improve QOL in a three-armed RCT. Participants were randomised to three groups: mindfulness and acceptance-based intervention (n = 20), non-specific psychological intervention that did not include mindfulness (relaxation and guided physical therapy) (n = 19), or a waitlist control that included usual treatment (n = 19). All participants received usual treatment which included analgesia. The ten-week programme developed (MY-ENDO), combined Kabat-Zinn’s MBSR programme and acceptance with commitment therapy. There was no statistically significant reduction in ERPP between the MY-ENDO group and non-specific intervention group (p = 0.144, d = 0.59). Psychological intervention significantly improved QOL-subscales ‘control and powerlessness’ (p = 0.019, d = 0.78), ‘emotional well-being’ (p = 0.003, d = 1.01), and ‘social support’ (p = 0.042, d = 0.66). QOL was improved through the positive effects on bowel symptoms, specifically diarrhoea (P = 0.035, d = 0.25), within the two intervention groups, thought to be due to physical activity undertaken. Further studies are needed to determine whether psychological interventions in general improves QOL or whether there is a need for a mindfulness aspect to the intervention. Yoga Yoga has a long tradition in managing chronic pain. In an AB-design pilot study of 42 women by Ravins et al.,36 participants underwent eight-weeks of conventional therapy followed by eight-weeks of 90-minute endometriosis yoga sessions, bi-weekly. EHP-30 scores and numerical pain rating scale were lower following the completion of the yoga sessions (p = 0.001). Gonçalves’ RCT37 randomly allocated 40 women; an intervention group who practised 90-minutes of yoga bi-weekly for 8 weeks (n = 28) and a control group who did not practise yoga (n = 12). Daily pain was significantly lower among the intervention group (p = 0.0007). EHP-30 domains were assessed at the time of presentation and again at 8-week follow up; pain (p = 0.0046), well-being (p = 0.0009), and image (p = 0.0087) from the central questionnaire, and work (p = 0.0027) and treatment (p = 0.0245) from the modular questionnaire were significantly different. One limitation of this study was the high loss to follow up, with only 57% of participants in the intervention group completing the full yoga-programme, highlighting the challenges faced of adhering to regular yoga practice. Similar findings were echoed by Saxena et al.38 in a randomised case-control study of 60 women with CPP. The intervention group (n = 30) who received yoga therapy with conventional therapy (non-steroidal anti-inflammatory drugs, NSAIDs) were compared with the control group (n = 30) who received NSAIDs alone. Pain scores through VAS score and QOL by the World Health Organization quality of life-BREF (WHOQOL-BREF) questionnaire were assessed at the start of the study and again at an 8-week follow up. The yoga-practising group showed a significant decrease in pain intensity (p < 0.001) and improvement in the QOL with a significant increase (p < 0.001) in physical, psychological, social, and environmental domain scores of WHOQOL-BREF. Enriched environments (consisting of enlarged space, increased physical activity and social interactions) suppresses the development of endometriosis in mice through attenuated adrenergic signalling, enhanced autophagy, and reduced leptin levels.39 Extrapolating this to humans, offering group outdoor physical activities such yoga to optimise environmental enrichment showed significantly less ERPP and perceived stress, improved mood and emotional wellbeing QOL compared with control participants in a recent RCT by Flores.40 Progressive muscle relaxation (PMR) PMR improved anxiety and depression (p < 0.05), and health-related QOL (p < 0.05) for patients with endometriosis in a study of 100 women receiving Gonadotrophin-releasing hormone (GnRH) agonist treatment. Participants were randomly assigned either to a control group or PMR group, who received 12 weeks of PMR training.41 Psychological and physical interventions positively impact on QOL in patients with ERPP. However, there remains a lack of high-powered trials in mind and body therapies. Consideration must be taken for the barriers to accessing psychological interventions. Patients should not feel their pain is less validated if a physiological approach is offered. Smart-phone applications are nowadays suggested to simplify access to Mindfulness. However, those approaches require co-development with stakeholders to be acceptable and used regularly.42 Pelvic floor muscle physiotherapy Pelvic floor muscle dysfunction (specifically levator ani hypertonia and incomplete relaxation) contributes to ERPP with deep infiltrative endometriosis (DIE).43–45 Pelvic floor physiotherapy (PFP), with 3D/4D trans-perineal ultrasound, increased levator hiatus area (LHA) which in turn improved dyspareunia and pelvic floor muscle relaxation (PFMR) reduced ERPP. Following a successful pilot study,46 Forno et al. used trans-perineal ultrasound to assess LHA before and after PFP in an RCT of 34 women.47 Participants were assigned to a no intervention group (n = 17), or the treatment group which involved five PFP sessions (n = 17). Physiotherapy sessions involved the Thiele massage, using digital pressure to elongate and relax muscles, restoring normal tone. PFMR improved on maximum Valsalva manoeuvre in the intervention group compared to the control (20.0 ± 24.8% vs –0.5 ± 3.3%, respectively; p = 0.02), and superficial dyspareunia pain scores reduced (p < 0.01). Previous studies have shown acupuncture to be a suitable tool in reducing ERPP, and is considered a safe therapy with minimal side effects.48,49 Several recent case studies have shown symptomatic improvement with acupuncture.50,51 Yan et al. published a protocol for SR and meta-analysis of RCTs on acupuncture benefits for endometriosis symptoms. ESHRE guidelines52 acknowledge that acupuncture may be a beneficial tool, however the studies that were available at that time were limited and not free from bias. Wang et al.53 recently published a systematic review of 15 RCTs (sample sizes between 10 and 54), which assessed the effectiveness of acupuncture and/or moxibustion for the treatment of endometriosis. Compared with sham acupuncture, actual acupuncture was more effective at reducing dysmenorrhoea VAS pain score (mean difference [MD] − 2.40, 95% CI [− 2.80, − 2.00]; moderate certainty evidence), pelvic pain VAS score (MD − 2.65, 95% CI [− 3.40, − 1.90]; high certainty evidence) and dyspareunia VAS scores (MD − 2.88, [− 3.83, − 1.93]), lessened the size of ovarian cyst (MD − 3.88, 95% CI [− 7.06, − 0.70]), and improved QOL. These promising results suggest that acupuncture is an effective adjunct to treating ERPP. In a multicentre, randomised, single-blind, placebo-controlled trial54 assessing the effects of acupuncture on endometriosis related symptoms (n = 106), acupuncture was delivered to the intervention group (n = 51) as 30-minute sessions once daily, three times a week, starting one week before expected onset of menstruation, for a total duration of 12-weeks. The control group (n = 53) received sham acupuncture. Lower VAS scores were seen in the intervention group at 12 weeks for dysmenorrhoea (-2.82 (-3.47, -2.18) and QOL, (EHPscore) -18.88 (-31.88, -5.87)), but not for pelvic pain and dyspareunia. At 24 weeks no statistical benefits were seen, suggesting acupuncture is a suitable immediate therapy for endometriosis related dysmenorrhoea, however the effects of acupuncture may not be sustainable over a long period of time and repeated therapy would be necessary. Phallus length reducing devices The Ohnut© device is a phallus length reducer worn over the penis or penetrating object with the intention to reduce endometriosis-associated deep dyspareunia. The effectiveness of this device is currently being assessed in a pilot RCT of 40 participants by Zhang55 who will be randomised into an intervention group or a waitlist control group. Transcutaneous electrical nerve stimulation (TENS) A TENS unit passes a current through electrodes placed on the skin for targeted pain relief via the gate control theory.56 Its use has been shown to reduce pain in primary dysmenorrhoea57 and CPP.58,59 Mira et al.60 conducted a multicentre RCT of 101 participants with DIE. The study aimed to identify whether the addition of a TENS unit to hormonal therapy (intervention group; n = 53) would provide a greater therapeutic benefit than hormonal treatment alone (control group; n = 48). The TENS device was used twice a day, 20 minutes per day, for 8 weeks. CPP improved in the intervention group (VAS decreased from 7.11 ± 2.40–4.55 ± 3.08, p < 0.001, 36% decrease), whereas it did not in the control group (VAS from 7.33 ± 2.09–7.06 ± 2.33, p = 0.554, 3.68% decrease). A greater improvement in deep dyspareunia was found in the intervention group, 32.67% reduction vs. 13.84% reduction in the control group. There was a decrease in the number of days participants experienced pain from the first week to the eighth week (from 3.27 to 2.22, p = 0.028, 32.11% decrease), which was not identified in the control group (from 4.55 to 4.07, p = 0.203, 10.54% decrease). This study was conducted over a relatively short time interval, therefore due to the chronic nature of endometriosis, further research is needed to assess whether benefits from TENS units are sustained longer-term. A cross sectional survey61 of 113 women with pelvic, perineal pain, dyspareunia or endometriosis was conducted to gather information regarding patient cannabis use. 26/113 (23%) participants reported cannabis use, of which only 5/26 obtained cannabis through a medical programme, 25 had complete data and were analysed. 15/25 (60%) used a combination of cannabidiol (CBD) and tetrahydrocannabinol (THC). There was no significant difference between the demographics of cannabis users and nonusers. Overall, 24/25 (96%) of participants reported improvement in symptoms such as pain, depression and sleep disturbance with the use of cannabis. It is important to note that participants from both groups also utilised alternative medications and therapies, and therefore reported symptom improvement cannot be confidently solely attributed to cannabis use. Traditional Chinese medicine (TCM) Zhao et al.62 performed a non-blinded RCT of 320 patients undergoing endometriosis surgery to investigate the effects of TCM (activating blood circulation and removing blood stasis treatment based on syndrome differentiation; n = 131) and Western medicine (GnRH agonist or progesterones; n = 141) on QOL postoperatively. Pre-treatment WHOQOL-BREF scores, a QOL assessment tool with four domains including physical health, psychological, social relationships and environment, showed no significant difference between the two groups (p > 0.05), however post-treatment scores in the TCM group were significantly improved (p < 0.05) and the scores of 4 items (mobility, activities of daily living, sexual activity, QOL score) were also statistically significantly better (p < 0.05). Flower et al.63 published a Cochrane review assessing the effects of Chinese herbal medicine (CHM) for endometriosis, however only 2 RCTs were included (n = 158), neither of which assessed CHM vs. placebo. The first showed no significant different in ERPP between CHM and gestrinone administration post laparoscopic treatment (95.65% vs. 93.87%; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.93 to 1.12, one RCT). Combined oral CHM and herbal enema provided better improvement in dysmenorrhoea than with danazol (RR 5.06, 95% CI 1.28 to 20.05; RR 5.63, 95% CI 1.47 to 21.54, respectively). There was no significant difference in lumbosacral pain, rectal discomfort, or vaginal nodule tenderness between CHM and danazol. Flower reports a paucity of robust studies assessing the effects of CHM and that the current studies available have been too small to apply statistical analysis. The previous cornerstones of endometriosis care have been shaken. Neuromodulators are less effective than assumed,6 a meaningful proportion do not get pain relief from surgery3 and ⅓ do not respond to progesterone. Complementary, self-management and lifestyle approaches are moving from fringe interest into mainstream endometriosis care. A historic RCT64 has shown multimodal holistic approaches yield superior outcomes to early laparoscopy in CPP. Current endometriosis centre accreditation weights bowel surgery heavily but patient education and signposting to holistic evidence-based care is left to enthusiastic HCPs, specialist nurses and patient charities, resulting in care inequities. Accreditation hinges on a multidisciplinary team of surgeons/urologists, but not with pelvic pain physiotherapists, nutritionists and psychologists. Numerous calls for more research into complementary approaches need to be answered by appropriate funding. Within a patient journey, complementary approaches could be used in the following models as a primary approach or in conjunction with routine treatment.4 1. Future women’s health hubs can identify DIE, likely to respond to surgery with specialised scanning even before referral to secondary and tertiary care. Models initiating this in the community would improve patient journeys and shorten the delay in endometriosis patients accessing care. 2. Peri-operatively in the context of pre- and rehabilitation: surgery should no longer be seen in isolation but embedded in education and self-care. Clinicians observe patients recover faster and better from endometriosis surgery if they go into surgery having practised pre-habilitation. 3. An adjunct to hormonal, surgical and pain-relieving western approaches. 4. 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Hansen KE, Brandsborg B, Kesmodel US, et al.: Psychological interventions improve quality of life despite persistent pain in endometriosis: results of a 3-armed randomized controlled trial. Qual. Life Res. 2023; 32(6): 1727–1744. PubMed Abstract | Publisher Full Text | Free Full Text - 36. Ravins I, Joseph G, Tene L: The Effect of Practicing “Endometriosis Yoga” on Stress and Quality of Life for Women with Endometriosis: AB Design Pilot Study. Altern. Ther. Health Med. 2023; 29(3): 8–14. - 37. Gonçalves AV, Barros NF, Bahamondes L: The Practice of Hatha Yoga for the Treatment of Pain Associated with Endometriosis. J. Altern. Complement. Med. 2017; 23(1): 45–52. PubMed Abstract | Publisher Full Text - 38. Saxena R, Gupta M, Shankar N, et al.: Effects of yogic intervention on pain scores and quality of life in females with chronic pelvic pain. Int. J. Yoga. 2017; 10(1): 9–15. Publisher Full Text - 39. Yin B, Jiang H, Liu X, et al.: Enriched Environment Decelerates the Development of Endometriosis in Mouse. Reprod. Sci. 2020; 27(7): 1423–1435. PubMed Abstract | Publisher Full Text - 40. I F, B B-C, G DH, D R-S, V L-R, C N-V et al.: Impact of Environmental Enrichment on Pain, Perceived Stress, Mental Health and Quality of Life of Women with Endometriosis The World Congress on Endometriosis; Edinburgh, UK.2023. - 41. Zhao L, Wu H, Zhou X, et al.: Effects of progressive muscular relaxation training on anxiety, depression and quality of life of endometriosis patients under gonadotrophin-releasing hormone agonist therapy. Eur. J. Obstet. Gynecol. Reprod. Biol. 2012; 162(2): 211–215. PubMed Abstract | Publisher Full Text - 42. Ball E, Rivas C: Health Apps Require Co-development to Be Acceptable and Effective. Front. Psychol. 2021; 12: 714453. PubMed Abstract | Publisher Full Text | Free Full Text - 43. Fraga MV, Oliveira Brito LG, Yela DA, et al.: Pelvic floor muscle dysfunctions in women with deep infiltrative endometriosis: An underestimated association. Int. J. Clin. Pract. 2021; 75(8): e14350. PubMed Abstract | Publisher Full Text - 44. da Silva JP , de Almeida BM , Ferreira RS, et al.: Sensory and muscular functions of the pelvic floor in women with endometriosis - cross-sectional study. Arch. Gynecol. Obstet. 2023; 308(1): 163–170. Publisher Full Text - 45. Arena A, Degli Esposti E, Cocchi L, et al.: Three-Dimensional Ultrasound Evaluation of Pelvic Floor Muscle Contraction in Women Affected by Deep Infiltrating Endometriosis: Application of a Quick Contraction Scale. J. Ultrasound Med. 2022; 41(12): 2973–2979. PubMed Abstract | Publisher Full Text - 46. Del Forno S, Arena A, Alessandrini M, et al.: Transperineal Ultrasound Visual Feedback Assisted Pelvic Floor Muscle Physiotherapy in Women With Deep Infiltrating Endometriosis and Dyspareunia: A Pilot Study. J. Sex Marital Ther. 2020; 46(7): 603–611. Publisher Full Text - 47. Del Forno S, Arena A, Pellizzone V, et al.: Assessment of levator hiatal area using 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: randomized controlled trial. Ultrasound Obstet. Gynecol. 2021; 57(5): 726–732. PubMed Abstract | Publisher Full Text - 48. Mira TAA, Buen MM, Borges MG, et al.: Systematic review and meta-analysis of complementary treatments for women with symptomatic endometriosis. Int. J. Gynaecol. Obstet. 2018; 143(1): 2–9. PubMed Abstract | Publisher Full Text - 49. Payne JA: Acupuncture for Endometriosis: A Case Study. Med Acupunct. 31. United States: Copyright 2019, Mary Ann Liebert, Inc., Publishers; 2019; pp. 392–394. - 50. Martin BR: Multimodal Care for Headaches, Lumbopelvic Pain, and Dysmenorrhea in a Woman With Endometriosis: A Case Report. J. Chiropr. Med. 2021; 20: 148–157. 20. United States: © 2022 by National University of Health Sciences. Publisher Full Text - 51. Yan Q, Li J, Zeng J: The role of acupuncture in the treatment of women with pain in endometriosis: A protocol for systematic review and meta-analysis. Medicine (Baltimore). 2021; 100(49): e27582. Publisher Full Text - 52. Becker CM, Bokor A, Heikinheimo O, et al.: ESHRE guideline: endometriosis. Hum. Reprod. Open. 2022; 2022(2): hoac009. Publisher Full Text - 53. Wang Y, Coyle ME, Hong M, et al.: Acupuncture and moxibustion for endometriosis: A systematic review and analysis. Complement. Ther. Med. 2023; 76: 102963. Publisher Full Text - 54. Li PS, Peng XM, Niu XX, et al.: Efficacy of acupuncture for endometriosis-associated pain: a multicenter randomized single-blind placebo-controlled trial. Fertil. Steril. 2023; 119(5): 815–823. PubMed Abstract | Publisher Full Text - 55. Zhang SXJ, MacLeod RGK, Parmar G, et al.: Ohnut Versus a Waitlist Control for the Self-management of Endometriosis-Associated Deep Dyspareunia: Protocol for a Pilot Randomized Controlled Trial. JMIR Res. Protoc. 2023; 12: e39834. PubMed Abstract | Publisher Full Text | Free Full Text - 56. Teoli D, An J: Transcutaneous Electrical Nerve Stimulation. StatPearls. Treasure Island (FL): StatPearls Publishing. Copyright © 2023, StatPearls Publishing LLC; 2023. - 57. Arik MI, Kiloatar H, Aslan B, et al.: The effect of TENS for pain relief in women with primary dysmenorrhea: A systematic review and meta-analysis. Explore (N.Y.). 2022; 18(1): 108–113. PubMed Abstract | Publisher Full Text - 58. Bridger C, Prabhala T, Dawson R, et al.: Neuromodulation for Chronic Pelvic Pain: A Single-Institution Experience With a Collaborative Team. Neurosurgery. 2021; 88(4): 819–827. Publisher Full Text - 59. Guy M, Foucher C, Juhel C, et al.: Transcutaneous electrical neurostimulation relieves primary dysmenorrhea: A randomized, double-blind clinical study versus placebo. Prog. Urol. 2022; 32(7): 487–497. PubMed Abstract | Publisher Full Text - 60. Mira TAA, Yela DA, Podgaec S, et al.: Hormonal treatment isolated versus hormonal treatment associated with electrotherapy for pelvic pain control in deep endometriosis: Randomized clinical trial. Eur. J. Obstet. Gynecol. Reprod. Biol. 2020; 255: 134–141. Publisher Full Text - 61. Carrubba AR, Ebbert JO, Spaulding AC, et al.: Use of Cannabis for Self-Management of Chronic Pelvic Pain. J. Womens Health (Larchmt). 2021; 30(9): 1344–1351. PubMed Abstract | Publisher Full Text - 62. Zhao RH, Liu Y, Tan Y, et al.: Chinese medicine improves postoperative quality of life in endometriosis patients: a randomized controlled trial. Chin. J. Integr. Med. 2013; 19(1): 15–21. PubMed Abstract | Publisher Full Text - 63. Flower A, Liu JP, Lewith G, et al.: Chinese herbal medicine for endometriosis. Cochrane Database Syst. Rev. 2012; 2012(5): CD006568. Publisher Full Text - 64. Peters AA, van Dorst E , Jellis B, et al.: A randomized clinical trial to compare two different approaches in women with chronic pelvic pain. Obstet. Gynecol. 1991; 77(5): 740–744. PubMed Abstract - 65. Zheng Q, Mao H, Xu Y, et al.: Can postoperative GnRH agonist treatment prevent endometriosis recurrence? A meta-analysis. Arch. Gynecol. Obstet. 2016; 294(1): 201–207. PubMed Abstract | Publisher Full Text Author details Author details 1 Central and North West London NHS Foundation Trust, London, England, UK 2 Department of Obstetrics and Gynaecology, The Royal London Hospital, Barts Health NHS Trust, London, E1 1FR, UK 3 Centre for Maternal & Child Health Research, School of Health Sciences, City University of London, UK 2 Department of Obstetrics and Gynaecology, The Royal London Hospital, Barts Health NHS Trust, London, E1 1FR, UK 3 Centre for Maternal & Child Health Research, School of Health Sciences, City University of London, UK Jessica Desai Roles: Data Curation, Writing – Original Draft Preparation Roles: Data Curation, Writing – Original Draft Preparation Sophie Strong Roles: Conceptualization, Data Curation, Formal Analysis, Supervision, Writing – Original Draft Preparation Roles: Conceptualization, Data Curation, Formal Analysis, Supervision, Writing – Original Draft Preparation Elizabeth Ball Roles: Conceptualization, Methodology, Resources, Supervision, Writing – Review & Editing Roles: Conceptualization, Methodology, Resources, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This study was supported by the Centre for Maternal & Child Health Research, School of Health Sciences, City University of London. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) Copyright © 2024 Desai J et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. metrics | Views | Downloads | | |---|---|---| | F1000Research | - | - | | PubMed Central Data from PMC are received and updated monthly. | - | - | Citations CITE how to cite this article Desai J, Strong S and Ball E. Holistic approaches to living well with endometriosis [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:359 (https://doi.org/10.12688/f1000research.142586.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. track receive updates on this article Track an article to receive email alerts on any updates to this article. Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 23 Apr 2024 Views 0 How to cite this report: Saunders PT. Reviewer Report For: Holistic approaches to living well with endometriosis [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:359 (https://doi.org/10.5256/f1000research.156153.r292395) The direct URL for this report is: https://f1000research.com/articles/13-359/v1#referee-response-292395 https://f1000research.com/articles/13-359/v1#referee-response-292395 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 22 Jul 2024 Not Approved VIEWS 0 Endometriosis is an incurable disorder and as the authors correctly state patients are often keen to try non-medical approaches to manage symptoms including chronic pain, bloating and fatigue. Some approaches including physiotherapy are often included in multidisciplinary care and information ... Continue reading 2. Horne AW, Vincent K, Hewitt CA, Middleton LJ, et al.: Gabapentin for chronic pelvic pain in women (GaPP2): a multicentre, randomised, double-blind, placebo-controlled trial.Lancet. 2020; 396 (10255): 909-917 PubMed Abstract | Publisher Full Text 3. Velho RV, Werner F, Mechsner S: Endo Belly: What Is It and Why Does It Happen?-A Narrative Review.J Clin Med. 2023; 12 (22). PubMed Abstract | Publisher Full Text 4. Karp BI, Stratton P: Applications of botulinum toxin to the female pelvic floor: Botulinum toxin for genito-pelvic pain penetration disorder and chronic pelvic pain in women.Toxicon. 2023; 230: 107162 PubMed Abstract | Publisher Full Text 5. Genovese T, Cordaro M, Siracusa R, Impellizzeri D, et al.: Molecular and Biochemical Mechanism of Cannabidiol in the Management of the Inflammatory and Oxidative Processes Associated with Endometriosis.Int J Mol Sci. 2022; 23 (10). PubMed Abstract | Publisher Full Text 6. Liang AL, Gingher EL, Coleman JS: Medical Cannabis for Gynecologic Pain Conditions: A Systematic Review.Obstet Gynecol. 2022; 139 (2): 287-296 PubMed Abstract | Publisher Full Text 7. Armour M, Sinclair J, Chalmers KJ, Smith CA: Self-management strategies amongst Australian women with endometriosis: a national online survey.BMC Complement Altern Med. 2019; 19 (1): 17 PubMed Abstract | Publisher Full Text I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close Endometriosis is an incurable disorder and as the authors correctly state patients are often keen to try non-medical approaches to manage symptoms including chronic pain, bloating and fatigue. Some approaches including physiotherapy are often included in multidisciplinary care and information on patient websites includes a wide range of complementary therapies some of which are discussed in this review [https://www.endometriosis-uk.org/]. The authors are to be commended on bringing together information about a very wide range of potential interventions and their assessment that many individuals with symptomatic endometriosis are keen to explore self management and alternative therapies as part of their care plan is something increasingly reported by health care professionals. The section entitled ‘Recent findings’ makes some dogmatic statements and it was not clear they were backed up by the latest data – this was particularly true of nutrition which is a fast moving field. Given the importance of the topic it is of concern that there appears to be an overall lack of ‘balance’ in the paper with a lot of emphasis in the first section placed on a systematic reviews – REFs 1-5, 8,9,12. In some parts of the text it is hard to know if the results discussed relate to individuals with CPP or those with CPP/Endo so careful re-reading and clarification of is advised (examples include yoga, TENS, mindfulness). [table of mind and body therapies?] It is recommended that the authors assemble information from relevant high quality original information from trials in tables – this would be more useful to the reader than simple text. Authors are referred to a number of recent reviews related to the impact of diet, inflammation and the gut brain axis as sources of information. Additional References Esprit2 trial has a published protocol [Ref -1].

6 is to a protocol – the trial has been completed and the correct reference is [Ref -2] In section on nutrition it would be useful to mention GWAS and other data that support patient experience of IBS-like symptoms in association with endometriosis (includes abdominal bloating [Ref-3], diarrhoea etc). Recent paper [Ref-3] No mention of botox for treatment of pelvic floor pain although there are reports it is effective · [Ref -4] The section on cannabinoids is very brief which seems at odds with the widespread use of CBD in management of chronic pain, in some countries they are prescribed and there are several trials for endometriosis CPP underway – add more references. [Ref 5-7] Add more details from Ref 64 – this paper is from 1991 – any follow up papers? The authors are to be commended on bringing together information about a very wide range of potential interventions and their assessment that many individuals with symptomatic endometriosis are keen to explore self management and alternative therapies as part of their care plan is something increasingly reported by health care professionals. The section entitled ‘Recent findings’ makes some dogmatic statements and it was not clear they were backed up by the latest data – this was particularly true of nutrition which is a fast moving field. Given the importance of the topic it is of concern that there appears to be an overall lack of ‘balance’ in the paper with a lot of emphasis in the first section placed on a systematic reviews – REFs 1-5, 8,9,12. In some parts of the text it is hard to know if the results discussed relate to individuals with CPP or those with CPP/Endo so careful re-reading and clarification of is advised (examples include yoga, TENS, mindfulness). [table of mind and body therapies?] It is recommended that the authors assemble information from relevant high quality original information from trials in tables – this would be more useful to the reader than simple text. Authors are referred to a number of recent reviews related to the impact of diet, inflammation and the gut brain axis as sources of information. Additional References Esprit2 trial has a published protocol [Ref -1].

6 is to a protocol – the trial has been completed and the correct reference is [Ref -2] In section on nutrition it would be useful to mention GWAS and other data that support patient experience of IBS-like symptoms in association with endometriosis (includes abdominal bloating [Ref-3], diarrhoea etc). Recent paper [Ref-3] No mention of botox for treatment of pelvic floor pain although there are reports it is effective · [Ref -4] The section on cannabinoids is very brief which seems at odds with the widespread use of CBD in management of chronic pain, in some countries they are prescribed and there are several trials for endometriosis CPP underway – add more references. [Ref 5-7] Add more details from Ref 64 – this paper is from 1991 – any follow up papers? - Is the topic of the review discussed comprehensively in the context of the current literature? No - Are all factual statements correct and adequately supported by citations? No - Is the review written in accessible language? Yes - Are the conclusions drawn appropriate in the context of the current research literature? No

1. Mackenzie SC, Stephen J, Williams L, Daniels J, et al.: Effectiveness of laparoscopic removal of isolated superficial peritoneal endometriosis for the management of chronic pelvic pain in women (ESPriT2): protocol for a multi-centre randomised controlled trial.Trials. 2023; 24 (1): 425 PubMed Abstract | Publisher Full Text2. Horne AW, Vincent K, Hewitt CA, Middleton LJ, et al.: Gabapentin for chronic pelvic pain in women (GaPP2): a multicentre, randomised, double-blind, placebo-controlled trial.Lancet. 2020; 396 (10255): 909-917 PubMed Abstract | Publisher Full Text 3. Velho RV, Werner F, Mechsner S: Endo Belly: What Is It and Why Does It Happen?-A Narrative Review.J Clin Med. 2023; 12 (22). PubMed Abstract | Publisher Full Text 4. Karp BI, Stratton P: Applications of botulinum toxin to the female pelvic floor: Botulinum toxin for genito-pelvic pain penetration disorder and chronic pelvic pain in women.Toxicon. 2023; 230: 107162 PubMed Abstract | Publisher Full Text 5. Genovese T, Cordaro M, Siracusa R, Impellizzeri D, et al.: Molecular and Biochemical Mechanism of Cannabidiol in the Management of the Inflammatory and Oxidative Processes Associated with Endometriosis.Int J Mol Sci. 2022; 23 (10). PubMed Abstract | Publisher Full Text 6. Liang AL, Gingher EL, Coleman JS: Medical Cannabis for Gynecologic Pain Conditions: A Systematic Review.Obstet Gynecol. 2022; 139 (2): 287-296 PubMed Abstract | Publisher Full Text 7. Armour M, Sinclair J, Chalmers KJ, Smith CA: Self-management strategies amongst Australian women with endometriosis: a national online survey.BMC Complement Altern Med. 2019; 19 (1): 17 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Reproductive biologist, specialising in women's health conditions including endometriosis. Translational research focused on improving range of treatments for chronic pelvic pain including self management strategies. CITE HOW TO CITE THIS REPORT Saunders PT. Reviewer Report For: Holistic approaches to living well with endometriosis [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:359 (https://doi.org/10.5256/f1000research.156153.r292395) The direct URL for this report is: https://f1000research.com/articles/13-359/v1#referee-response-292395 https://f1000research.com/articles/13-359/v1#referee-response-292395 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. - Author Response 08 Nov 2024Jessica Desai, Central and North West London NHS Foundation Trust, London, UK08 Nov 2024Author ResponseWe thank you for the suggestions and have made the following adjustments: In some parts of the text it is hard to know if the results discussed relate to ... Continue reading We thank you for the suggestions and have made the following adjustments: In some parts of the text it is hard to know if the results discussed relate to individuals with CPP or those with CPP/Endo so careful re-reading and clarification of is advised (examples include yoga, TENS, mindfulness). [table of mind and body therapies?] - Clarification has been made on relation to CPP/endometriosis throughout the text It is recommended that the authors assemble information from relevant high quality original information from trials in tables – this would be more useful to the reader than simple text. - Please see Table 1 Esprit2 trial has a published protocol [Ref -1]. - Espirit2 trial protocol has now been referenced, please see reference 5

6 is to a protocol – the trial has been completed and the correct reference is [Ref -2] - Reference amended In section on nutrition it would be useful to mention GWAS and other data that support patient experience of IBS-like symptoms in association with endometriosis (includes abdominal bloating [Ref-3], diarrhoea etc). Recent paper [Ref-3] - Please see use of reference 23 in our paper No mention of botox for treatment of pelvic floor pain although there are reports it is effective · [Ref -4] - Section on botulinum toxin added to paper The section on cannabinoids is very brief which seems at odds with the widespread use of CBD in management of chronic pain, in some countries they are prescribed and there are several trials for endometriosis CPP underway – add more references. [Ref 5-7] - CBD section has been expanded, please see references 69, 70 Add more details from Ref 64 – this paper is from 1991 – any follow up papers? - Section expanded, please refer to reference 76We thank you for the suggestions and have made the following adjustments:Competing Interests: No competing interests were disclosed. Close In some parts of the text it is hard to know if the results discussed relate to individuals with CPP or those with CPP/Endo so careful re-reading and clarification of is advised (examples include yoga, TENS, mindfulness). [table of mind and body therapies?] - Clarification has been made on relation to CPP/endometriosis throughout the text It is recommended that the authors assemble information from relevant high quality original information from trials in tables – this would be more useful to the reader than simple text. - Please see Table 1 Esprit2 trial has a published protocol [Ref -1]. - Espirit2 trial protocol has now been referenced, please see reference 5

6 is to a protocol – the trial has been completed and the correct reference is [Ref -2] - Reference amended In section on nutrition it would be useful to mention GWAS and other data that support patient experience of IBS-like symptoms in association with endometriosis (includes abdominal bloating [Ref-3], diarrhoea etc). Recent paper [Ref-3] - Please see use of reference 23 in our paper No mention of botox for treatment of pelvic floor pain although there are reports it is effective · [Ref -4] - Section on botulinum toxin added to paper The section on cannabinoids is very brief which seems at odds with the widespread use of CBD in management of chronic pain, in some countries they are prescribed and there are several trials for endometriosis CPP underway – add more references. [Ref 5-7] - CBD section has been expanded, please see references 69, 70 Add more details from Ref 64 – this paper is from 1991 – any follow up papers? - Section expanded, please refer to reference 76 COMMENTS ON THIS REPORT - Author Response 08 Nov 2024Jessica Desai, Central and North West London NHS Foundation Trust, London, UK08 Nov 2024Author ResponseWe thank you for the suggestions and have made the following adjustments: In some parts of the text it is hard to know if the results discussed relate to ... Continue reading We thank you for the suggestions and have made the following adjustments: In some parts of the text it is hard to know if the results discussed relate to individuals with CPP or those with CPP/Endo so careful re-reading and clarification of is advised (examples include yoga, TENS, mindfulness). [table of mind and body therapies?] - Clarification has been made on relation to CPP/endometriosis throughout the text It is recommended that the authors assemble information from relevant high quality original information from trials in tables – this would be more useful to the reader than simple text. - Please see Table 1 Esprit2 trial has a published protocol [Ref -1]. - Espirit2 trial protocol has now been referenced, please see reference 5

6 is to a protocol – the trial has been completed and the correct reference is [Ref -2] - Reference amended In section on nutrition it would be useful to mention GWAS and other data that support patient experience of IBS-like symptoms in association with endometriosis (includes abdominal bloating [Ref-3], diarrhoea etc). Recent paper [Ref-3] - Please see use of reference 23 in our paper No mention of botox for treatment of pelvic floor pain although there are reports it is effective · [Ref -4] - Section on botulinum toxin added to paper The section on cannabinoids is very brief which seems at odds with the widespread use of CBD in management of chronic pain, in some countries they are prescribed and there are several trials for endometriosis CPP underway – add more references. [Ref 5-7] - CBD section has been expanded, please see references 69, 70 Add more details from Ref 64 – this paper is from 1991 – any follow up papers? - Section expanded, please refer to reference 76We thank you for the suggestions and have made the following adjustments:Competing Interests: No competing interests were disclosed. Close In some parts of the text it is hard to know if the results discussed relate to individuals with CPP or those with CPP/Endo so careful re-reading and clarification of is advised (examples include yoga, TENS, mindfulness). [table of mind and body therapies?] - Clarification has been made on relation to CPP/endometriosis throughout the text It is recommended that the authors assemble information from relevant high quality original information from trials in tables – this would be more useful to the reader than simple text. - Please see Table 1 Esprit2 trial has a published protocol [Ref -1]. - Espirit2 trial protocol has now been referenced, please see reference 5

6 is to a protocol – the trial has been completed and the correct reference is [Ref -2] - Reference amended In section on nutrition it would be useful to mention GWAS and other data that support patient experience of IBS-like symptoms in association with endometriosis (includes abdominal bloating [Ref-3], diarrhoea etc). Recent paper [Ref-3] - Please see use of reference 23 in our paper No mention of botox for treatment of pelvic floor pain although there are reports it is effective · [Ref -4] - Section on botulinum toxin added to paper The section on cannabinoids is very brief which seems at odds with the widespread use of CBD in management of chronic pain, in some countries they are prescribed and there are several trials for endometriosis CPP underway – add more references. [Ref 5-7] - CBD section has been expanded, please see references 69, 70 Add more details from Ref 64 – this paper is from 1991 – any follow up papers? - Section expanded, please refer to reference 76 Views 0 How to cite this report: Raimondo D. Reviewer Report For: Holistic approaches to living well with endometriosis [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:359 (https://doi.org/10.5256/f1000research.156153.r271069) The direct URL for this report is: https://f1000research.com/articles/13-359/v1#referee-response-271069 https://f1000research.com/articles/13-359/v1#referee-response-271069 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 02 Jul 2024 Diego Raimondo, Division of Gynaecology and Human Reproduction Physiopathology, IRCCS AOUBO, Bologna, Italy Approved with Reservations VIEWS 0

The abstract is well-structured and provides a clear overview of the topic. However, it could benefit from a concluding sentence that highlights the clinical significance of the findings to enhance reader understanding.

The ... Continue reading 2. Ianieri MM, De Cicco Nardone A, Benvenga G, Greco P, et al.: Vascular- and nerve-sparing bowel resection for deep endometriosis: A retrospective single-center study.Int J Gynaecol Obstet. 2024; 164 (1): 277-285 PubMed Abstract | Publisher Full Text I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close The abstract is well-structured and provides a clear overview of the topic. However, it could benefit from a concluding sentence that highlights the clinical significance of the findings to enhance reader understanding.

The ... Continue reading

The abstract is well-structured and provides a clear overview of the topic. However, it could benefit from a concluding sentence that highlights the clinical significance of the findings to enhance reader understanding.

The introduction is comprehensive and provides adequate context on endometriosis and the challenges associated with its treatment. However, it could benefit from emphasizing more recent research, particularly from the last two to three years. Please discuss on the iatrogenic risk of endometriosis surgery and not only on the risk of recurrence (i.e. Ref [1,2])

The methodology section is detailed and rigorous but could use some clarifications. Inclusion and Exclusion Criteria: Provide more details on the criteria used to include or exclude specific studies. Search Methodology: Describe the databases used and the search terms applied more specifically. Quality Assessment: Describe the metrics or tools used to evaluate the quality of the included studies.

The results are well-presented and supported by a solid evidence base. However, some sections could benefit from more synthesis to improve readability. Nutrition: The information is detailed and pertinent, but a summary table could help visualize the effects of different dietary interventions better. Acupuncture: The acupuncture section is thorough but could benefit from a discussion on the limitations of the cited studies.

The conclusions effectively summarize the key points of the article. However, reinforcing the message on the importance of integrating holistic strategies into clinical practice could enhance the impact. Graphs and Tables: Including more graphs and tables to visualize key data could improve the manuscript's comprehensibility and visual appeal.. The abstract is well-structured and provides a clear overview of the topic. However, it could benefit from a concluding sentence that highlights the clinical significance of the findings to enhance reader understanding.

The introduction is comprehensive and provides adequate context on endometriosis and the challenges associated with its treatment. However, it could benefit from emphasizing more recent research, particularly from the last two to three years. Please discuss on the iatrogenic risk of endometriosis surgery and not only on the risk of recurrence (i.e. Ref [1,2])

The methodology section is detailed and rigorous but could use some clarifications. Inclusion and Exclusion Criteria: Provide more details on the criteria used to include or exclude specific studies. Search Methodology: Describe the databases used and the search terms applied more specifically. Quality Assessment: Describe the metrics or tools used to evaluate the quality of the included studies.

The results are well-presented and supported by a solid evidence base. However, some sections could benefit from more synthesis to improve readability. Nutrition: The information is detailed and pertinent, but a summary table could help visualize the effects of different dietary interventions better. Acupuncture: The acupuncture section is thorough but could benefit from a discussion on the limitations of the cited studies.

The conclusions effectively summarize the key points of the article. However, reinforcing the message on the importance of integrating holistic strategies into clinical practice could enhance the impact. Graphs and Tables: Including more graphs and tables to visualize key data could improve the manuscript's comprehensibility and visual appeal.. - Is the topic of the review discussed comprehensively in the context of the current literature? Yes - Are all factual statements correct and adequately supported by citations? Yes - Is the review written in accessible language? Yes - Are the conclusions drawn appropriate in the context of the current research literature? Yes

1. Seracchioli R, Ferrini G, Montanari G, Raimondo D, et al.: Does laparoscopic shaving for deep infiltrating endometriosis alter intestinal function? A prospective study.Aust N Z J Obstet Gynaecol. 2015; 55 (4): 357-62 PubMed Abstract | Publisher Full Text2. Ianieri MM, De Cicco Nardone A, Benvenga G, Greco P, et al.: Vascular- and nerve-sparing bowel resection for deep endometriosis: A retrospective single-center study.Int J Gynaecol Obstet. 2024; 164 (1): 277-285 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: endometriosis CITE HOW TO CITE THIS REPORT Raimondo D. Reviewer Report For: Holistic approaches to living well with endometriosis [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:359 (https://doi.org/10.5256/f1000research.156153.r271069) The direct URL for this report is: https://f1000research.com/articles/13-359/v1#referee-response-271069 https://f1000research.com/articles/13-359/v1#referee-response-271069 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. - Author Response 08 Nov 2024Jessica Desai, Central and North West London NHS Foundation Trust, London, UK08 Nov 2024Author ResponseWe thank you for the suggestions and have made the following adjustments to our paper:

The abstract is well-structured and provides a clear overview of the topic. However, ... Continue reading We thank you for the suggestions and have made the following adjustments to our paper:

The abstract is well-structured and provides a clear overview of the topic. However, it could benefit from a concluding sentence that highlights the clinical significance of the findings to enhance reader understanding. - Abstract concluding sentence adjusted

The introduction is comprehensive and provides adequate context on endometriosis and the challenges associated with its treatment. However, it could benefit from emphasizing more recent research, particularly from the last two to three years. Please discuss on the iatrogenic risk of endometriosis surgery and not only on the risk of recurrence (i.e. Ref [1,2]) - Please refer to reference 6 and 7 cited in the amended submission

The methodology section is detailed and rigorous but could use some clarifications. Inclusion and Exclusion Criteria: Provide more details on the criteria used to include or exclude specific studies. Search Methodology: Describe the databases used and the search terms applied more specifically. Quality Assessment: Describe the metrics or tools used to evaluate the quality of the included studies. - Inclusion and exclusion criteria, search methodology and quality assessment sections added to paper

The results are well-presented and supported by a solid evidence base. However, some sections could benefit from more synthesis to improve readability. Nutrition: The information is detailed and pertinent, but a summary table could help visualize the effects of different dietary interventions better. Acupuncture: The acupuncture section is thorough but could benefit from a discussion on the limitations of the cited studies. - Limitations of paper reference 62 has been added

The conclusions effectively summarize the key points of the article. However, reinforcing the message on the importance of integrating holistic strategies into clinical practice could enhance the impact. - Conclusion has been amended with statement on the importance of integration into clinical practice Graphs and Tables: Including more graphs and tables to visualize key data could improve the manuscript's comprehensibility and visual appeal.. - Please refer to Table 1We thank you for the suggestions and have made the following adjustments to our paper:Competing Interests: No competing interests were disclosed. Close

The abstract is well-structured and provides a clear overview of the topic. However, it could benefit from a concluding sentence that highlights the clinical significance of the findings to enhance reader understanding. - Abstract concluding sentence adjusted

The introduction is comprehensive and provides adequate context on endometriosis and the challenges associated with its treatment. However, it could benefit from emphasizing more recent research, particularly from the last two to three years. Please discuss on the iatrogenic risk of endometriosis surgery and not only on the risk of recurrence (i.e. Ref [1,2]) - Please refer to reference 6 and 7 cited in the amended submission

The methodology section is detailed and rigorous but could use some clarifications. Inclusion and Exclusion Criteria: Provide more details on the criteria used to include or exclude specific studies. Search Methodology: Describe the databases used and the search terms applied more specifically. Quality Assessment: Describe the metrics or tools used to evaluate the quality of the included studies. - Inclusion and exclusion criteria, search methodology and quality assessment sections added to paper

The results are well-presented and supported by a solid evidence base. However, some sections could benefit from more synthesis to improve readability. Nutrition: The information is detailed and pertinent, but a summary table could help visualize the effects of different dietary interventions better. Acupuncture: The acupuncture section is thorough but could benefit from a discussion on the limitations of the cited studies. - Limitations of paper reference 62 has been added

The conclusions effectively summarize the key points of the article. However, reinforcing the message on the importance of integrating holistic strategies into clinical practice could enhance the impact. - Conclusion has been amended with statement on the importance of integration into clinical practice Graphs and Tables: Including more graphs and tables to visualize key data could improve the manuscript's comprehensibility and visual appeal.. - Please refer to Table 1 COMMENTS ON THIS REPORT - Author Response 08 Nov 2024Jessica Desai, Central and North West London NHS Foundation Trust, London, UK08 Nov 2024Author ResponseWe thank you for the suggestions and have made the following adjustments to our paper:

The abstract is well-structured and provides a clear overview of the topic. However, ... Continue reading We thank you for the suggestions and have made the following adjustments to our paper:

The abstract is well-structured and provides a clear overview of the topic. However, it could benefit from a concluding sentence that highlights the clinical significance of the findings to enhance reader understanding. - Abstract concluding sentence adjusted

The introduction is comprehensive and provides adequate context on endometriosis and the challenges associated with its treatment. However, it could benefit from emphasizing more recent research, particularly from the last two to three years. Please discuss on the iatrogenic risk of endometriosis surgery and not only on the risk of recurrence (i.e. Ref [1,2]) - Please refer to reference 6 and 7 cited in the amended submission

The methodology section is detailed and rigorous but could use some clarifications. Inclusion and Exclusion Criteria: Provide more details on the criteria used to include or exclude specific studies. Search Methodology: Describe the databases used and the search terms applied more specifically. Quality Assessment: Describe the metrics or tools used to evaluate the quality of the included studies. - Inclusion and exclusion criteria, search methodology and quality assessment sections added to paper

The results are well-presented and supported by a solid evidence base. However, some sections could benefit from more synthesis to improve readability. Nutrition: The information is detailed and pertinent, but a summary table could help visualize the effects of different dietary interventions better. Acupuncture: The acupuncture section is thorough but could benefit from a discussion on the limitations of the cited studies. - Limitations of paper reference 62 has been added

The conclusions effectively summarize the key points of the article. However, reinforcing the message on the importance of integrating holistic strategies into clinical practice could enhance the impact. - Conclusion has been amended with statement on the importance of integration into clinical practice Graphs and Tables: Including more graphs and tables to visualize key data could improve the manuscript's comprehensibility and visual appeal.. - Please refer to Table 1We thank you for the suggestions and have made the following adjustments to our paper:Competing Interests: No competing interests were disclosed. Close

The abstract is well-structured and provides a clear overview of the topic. However, it could benefit from a concluding sentence that highlights the clinical significance of the findings to enhance reader understanding. - Abstract concluding sentence adjusted

The introduction is comprehensive and provides adequate context on endometriosis and the challenges associated with its treatment. However, it could benefit from emphasizing more recent research, particularly from the last two to three years. Please discuss on the iatrogenic risk of endometriosis surgery and not only on the risk of recurrence (i.e. Ref [1,2]) - Please refer to reference 6 and 7 cited in the amended submission

The methodology section is detailed and rigorous but could use some clarifications. Inclusion and Exclusion Criteria: Provide more details on the criteria used to include or exclude specific studies. Search Methodology: Describe the databases used and the search terms applied more specifically. Quality Assessment: Describe the metrics or tools used to evaluate the quality of the included studies. - Inclusion and exclusion criteria, search methodology and quality assessment sections added to paper

The results are well-presented and supported by a solid evidence base. However, some sections could benefit from more synthesis to improve readability. Nutrition: The information is detailed and pertinent, but a summary table could help visualize the effects of different dietary interventions better. Acupuncture: The acupuncture section is thorough but could benefit from a discussion on the limitations of the cited studies. - Limitations of paper reference 62 has been added

The conclusions effectively summarize the key points of the article. However, reinforcing the message on the importance of integrating holistic strategies into clinical practice could enhance the impact. - Conclusion has been amended with statement on the importance of integration into clinical practice Graphs and Tables: Including more graphs and tables to visualize key data could improve the manuscript's comprehensibility and visual appeal.. - Please refer to Table 1 Alongside their report, reviewers assign a status to the article: - Approved - Approved with reservations - Not approved | Invited Reviewers | || |---|---|---| | 1 | 2 | | | Version 2 (revision) 08 Nov 24 | read | read | | Version 1 23 Apr 24 | read | read | Sign up for content alerts You are now signed up to receive this alert Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' - Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. - You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. - You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). - You work at the same institute as any of the authors. - You hope/expect to benefit (e.g. favour or employment) as a result of your submission. - You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' - You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. - You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. - You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Sign up for content alerts and receive a weekly or monthly email with all newly published articles Already registered? Sign in close Error Sign In If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password. Email us for further assistance. The email address should be the one you originally registered with F1000. Email address not valid, please try again You registered with F1000 via Google, so we cannot reset your password. To sign in, please click here. If you still need help with your Google account password, please click here. You registered with F1000 via Facebook, so we cannot reset your password. To sign in, please click here. If you still need help with your Facebook account password, please click here. Code not correct, please try again Server error, please try again. If your email address is registered with us, we will email you instructions to reset your password. If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance. Please wait...