"Love Thy Neighbor" and Know Thyself: Evaluating Pelvic Pain and Symptoms of Endometriosis in Gastroenterology Practice

Vol.:(0123456789) Digestive Diseases and Sciences (2025) 70:885–887 https://doi.org/10.1007/s10620-025-08845-y INVITED COMMENTARY “Love Thy Neighbor” and Know Thyself: Evaluating Pelvic Pain and Symptoms of Endometriosis in Gastroenterology Practice Joy J. Liu1 · Angela Chaudhari2 Received: 11 December 2024 / Accepted: 2 January 2025 / Published online: 18 January 2025 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2025 Abdominopelvic pain, painful bowel movements, and con- stipation are commonplace symptoms in patients seen in gastroenterology clinics. Many patients with these symp- toms have been diagnosed with irritable bowel syndrome (IBS). IBS can be associated with endometriosis, a condition in which endometrial glands or stromal tissue implant on areas outside the uterus, including the bowels (particularly the rectum and sigmoid colon), pelvic floor ligaments and muscles, and peritoneum, through retrograde menstruation. These implants are thought to induce inflammation, fibro- sis, pelvic adhesions, and infertility. Patients with endome- triosis vary in the severity of their symptoms from minimal pain with cycles to daily, debilitating pain that interferes with their activities of daily living. The European Society of Human Reproduction and Embryology (ESHRE) 2022 guidelines state that certain signs and symptoms, including dysmenorrhea, dyschezia, rectal bleeding, dysuria and dys- pareunia should lead the clinician to “explore the diagnosis of endometriosis” with clinical evaluation and imaging [1]. It is estimated that 4.6% of women in the US have IBS and approximately 10% of women of child-bearing age have endometriosis. [2 ] Patients with endometriosis are more likely to be diagnosed with IBS (OR: 1.6, 95% CI 1.3–1.8) prior to endometriosis diagnosis. [3 ] Both IBS and endo- metriosis are associated with visceral hypersensitivity and inflammatory processes such as increased mast cell activity, intestinal epithelial cell permeability, and increased prosta- glandin activity. [4] It may be that cross-organ sensitization and inflammation in endometriosis leads to the bowel symp- toms for which patients seek GI evaluation. There is interest in whether IBS treatments can be applied to endometriosis symptoms. Ge et al. reported on the effects of linaclotide, used to treat IBS, on pelvic pain in rodents. [5] A New Zea- land study showed that almost three-quarters of women with IBS and endometriosis responded to a low FODMAP diet during menstruation, and these women had 3.11 odds of responding to low FODMAP diet compared to women with IBS without endometriosis. The shared symptoms and pathophysiology lead one to wonder whether “IBS” in patients with endometriosis is a gastrointestinal (GI) complication of the disease. If this is true, gastroenterologists may improve their patients’ out- comes by assessing whether patients would be well-served by a referral to gynecology for expert diagnosis and manage- ment. While gastroenterologists do not routinely perform a pelvic exam, they may be able to expedite diagnosis by discussing endometriosis and ordering non-invasive testing, such as transvaginal ultrasound or pelvic MRI. What is the current state of real-world practice regard- ing endometriosis in gastroenterology? What are potential barriers and facilitators to improving clinical diagnosis and appropriate treatment? In this issue of Digestive Diseases and Sciences, Luo et al. [6] developed an exploratory survey that asks these questions. This study is a call to action to improve awareness of the relationship between GI symptoms and endometriosis and to provide broader guidance for the triage of gynecologic symptoms in gastroenterology. The authors developed an electronic survey investigat- ing provider attitudes and practices regarding evaluation for endometriosis in GI clinic. There was a relatively high response rate of 40% over a short time period, indicating good feasibility for a larger study. Almost 60% of respond- ents (physicians, psychologists, and APPs in general GI, inflammatory bowel disease, and neurogastroenterology at these academic centers) reported not screening for endo- metriosis, and of these, the majority reported no/minimal knowledge of endometriosis diagnostic criteria, and the belief that someone else (gynecology or primary care) * Joy J. Liu [email protected] 1 Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA 2 Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA 886 Digestive Diseases and Sciences (2025) 70:885–887 should evaluate patients. After being presented with an in-test graphic on the relationship between endometriosis and GI symptoms, over 70% of respondents indicated they were open to asking about endometriosis symptoms with a short questionnaire. Only a minority of respondents (12.7%) believed screening was not clinically relevant or would take too much time. Approximately 40% of GI clinicians were comfortable ordering imaging to evaluate for endometriosis. The survey stratified results by self-identified gender/sex (male/female) of clinicians, and interestingly, a higher proportion of male gastroenterology clinicians compared to female clinicians reported willingness to order non-invasive testing for endo- metriosis. This disparity provides a rationale for obtaining richer qualitative data, perhaps in the form of semi-struc- tured interviews. Investigating the reasons for either feeling comfortable or uncomfortable in pursuing additional diag- nostic evaluation could be evaluated in a future study. This survey underwent development and pilot testing with the guidance of a methodologic expert. It shows promise for deployment on a broader (national) scale to capture more generalizable data. Most respondents felt that they lacked knowledge regarding diagnostic criteria for endometriosis and how it relates to GI symptoms but were also interested in evaluating patients after receiving education on the topic. Therefore, developing and disseminating educational materi- als related to endometriosis and other pelvic conditions for gastroenterologists should be a future aim. Raising the possibility of endometriosis may lead some patients to leap to premature conclusions about a chronic disease that has long-term reproductive and health out- comes. Patients should be counseled that their symptoms warrant further evaluation by a gynecologist who can make the diagnosis and provide appropriate, patient-centered treat- ment. Best practices for screening should be developed in collaboration with gynecologic experts to diminish this gap in care. There are a multitude of short-form questionnaires that have been developed and studied for endometriosis, and future work could utilize one that incorporates intestinal and pelvic symptoms. One limitation to the study’s proposal of having gas- troenterologists evaluate for endometriosis-based only on patient-reported symptoms is the inherent complexity in diagnosing endometriosis, even for those with experience taking gynecologic histories. The differential for symptoms of endometriosis is vast and may include pelvic congestion syndrome, myofascial pain, central sensitization, pelvic adhesions, infection, urologic conditions, and IBS. Screen- ing for symptoms does not constitute a diagnosis of endome- triosis; the diagnostic gold-standard is pathologic diagnosis at the time of surgery. Even among gynecologists, there is no single gold-standard screening tool for endometriosis: Clinical suspicion based on the menstrual and pain history is key. Pelvic exam may elucidate pain but is never diagnostic for endometriosis. Transvaginal ultrasound and pelvic MRI may be useful in identifying deep invasive lesions of endo- metriosis but do not negate the possibility of endometriosis if negative. These complexities in diagnosis may decrease gastroenterologists’ confidence in evaluation. This survey does not ask about comfort with treating endometriosis. Likely, gastroenterology clinicians would agree that the treatment of endometriosis should be man- aged by a gynecologic expert. However, as Luo et al. point out, access to gynecologists is expected to decrease. Will the gastroenterologist who clinically suspects endometriosis but does not have a gynecologist to refer to have a duty to provide treatment? This is a rhetorical question that hints at the medicolegal implications of the appropriate “scope of practice” that may discourage gastroenterology clinicians from even asking about pelvic symptoms. However, as many of us know, one’s scope of practice often expands to accom- modate the community’s needs. Should IBD specialists defer management of iron deficiency anemia to hematologists? Should general gastroenterologists defer hemorrhoid band- ing to colorectal surgeons? All of us should heed the pro- scription to “know thyself”—what we are willing and able to accommodate, what we are not, what the boundaries of our individual practice are, and how these may change with education, experience, and new technology. In summary, this survey-based study shows that, cur - rently, many gastroenterologists do not deliberately ask about endometriosis symptoms in patients with chronic GI conditions despite the known association between endome- triosis and IBS. Many respondents indicated they would be willing to learn and implement screening tools. Future stud- ies should involve collaboration with gynecology experts to ensure that educational materials and recommendations are supported by the best evidence and practices. Author’s Contribution JJL wrote the main manuscript text. AC pro- vided critical revisions. All authors reviewed the manuscript. Data Availability No datasets were generated or analysed during the current study. Declarations Conflict of interest Ironwood (speaker) and Johnson and Johnson (consultant); Richard Wolf Medical (consultant). References 1. Becker CM, Bokor A, Heikinheimo O et al. ESHRE guideline endometriosis. Human reproduction Open. 2022;2022:hoac009. 887Digestive Diseases and Sciences (2025) 70:885–887 2. Sperber AD, Dumitrascu D, Fukudo S et al. The global preva - lence of IBS in adults remains elusive due to the heterogeneity of studies: a Rome foundation working team literature review. Gut. 2017;66:1075–1082. 3. Saidi K, Sharma S, Ohlsson B. A systematic review and meta- analysis of the associations between endometriosis and irri- table bowel syndrome. Eur J Obstet Gynecol Reprod Biol. 2020;246:99–105. 4. Viganò D, Zara F, Usai P. Irritable bowel syndrome and endometriosis: New insights for old diseases. Dig Liver Dis. 2018;50:213–219. 5. Ge P, Ren J, Harrington AM et  al. Linaclotide treatment reduces endometriosis-associated vaginal hyperalgesia and mechanical allodynia through viscerovisceral cross-talk. Pain. 2019;160:2566–2579. 6. Luo Y, Wang XJ, Keefer LA et al. Love thy neighbor? Exploring gastroenterology attitudes toward endometriosis screening. Dig Dis Sci. (2024). https:// doi. org/ 10. 1007/ s10620- 024- 08740-y. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.