Dr Irem leads Medtech and Femtech research at NuroKor. She brings over 15 years of international experience in research and clinical treatments, including real world experience in use of electrical stimulation for pain and wound management. 
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Q1. What is endometriosis and what causes it?

Endometriosis is a chronic condition defined as the growth or presence of  endometrial-like tissue outside the uterus.  

Endometriosis impacts approximately 10% of the women in their reproductive years, with 21-47% suffering from subfertility, while 71-87%  experiencing chronic pelvic pain.(2)

The endometrial tissues  are typically present in the pelvis - on ovaries, bladder and the ureter. Sometimes, these tissues may occur outside the pelvis, in areas such as the bowel and diaphragm. 

Although the origin of endometriosis is still unclear, research suggests that there are several immunological and inflammatory factors that lead to the development of this  condition. 

There are several theories related to the cause of endometriosis. The most common one is retrograde menstruation. The other factors that contribute are genetics, immune system disorders and differentiation of stem cells outside the uterus.
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Q2. What are the common symptoms of endometriosis and how is it diagnosed?

The typical symptoms of endometriosis are:  

• Severe period pain that occurs before or during menstruation
• Persistent or recurrent pain before, during or after intercourse
• Feeling of discomfort, burning sensation or pain during urination
• Bleeding from implants
• Persistent chronic pelvic pain impacting daily activities
• Infertility

Occasionally, some women experience pelvic pain even when they are not having their periods. Early studies have demonstrated serious gastrointestinal symptoms, including constipation, diarrhoea, nausea, vomiting, acute abdominal pain and gastrointestinal dysfunction. 
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It's often not straightforward to diagnose endometriosis as the diagnosis requires an understanding of the detailed medical history of the patient, pelvic examination, ultrasound, gynaecological diagnostics & consultation. In some scenarios when the examination findings are normal, it gets all the more difficult to diagnose endometriosis.  On average, it takes 8 years for endometriosis to be diagnosed in some patients. In most cases, this conclusion is reached after surgery. 

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Q3. Why does endometriosis cause pain for some women?

Endometriosis is a hormone-facilitated, neuro-vascular disorder. The existence of endometrial tissue stimulates an oestrogen-dependent chronic inflammatory reaction. Pain originates from increased prostaglandins, compression, and infiltration of the nerves. The increased density of nerve fibres, angiogenesis and changes in innervation of the uterus also contribute to the pain. 

Initially, the main indicator of endometriosis is painful menstruation and cyclic lower abdominal pain which leads to pelvic floor dysfunction. This can result in painful urination, intercourse and chronic pelvic pain. Shifts in the inflammatory processes can also cause inflammation in the nerves triggering hormone-independent, acyclic lower abdominal pain.

As mentioned before, pain may not be limited to the uterus but can be sciatic, rectal or can also take place during bowel movements. As the endometrial tissue grows outside the uterus, the tissue thickens and the pain with endometriosis develops. Endometrial tissue could grow in different areas in the pelvic area, including the cervix, fallopian tubes and ovaries and block organ function causing inflammation and pain.

Another reason for pain is inadequate and inconsistent treatments which worsen the situation. Damage to pelvic nerves during surgery may result in long term neuropathic pain.

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Q4. What are some of the misconceptions about endometriosis?

• Myth 1: Endometriosis means infertility-  But that’s not the case. Even though there is an association with fertility problems where the effect is not determined, endometriosis does not necessarily cause infertility. Even with severe endometriosis, 60-70% of women can get pregnant. 

• Myth 2: It is relatively easy to diagnose endometriosis- However, in reality, it might take years to diagnose it and a conclusion might only be reached after surgery. 

• Myth 3: It is easy to prevent endometriosis and provide a cure - Currently, there is no known way to prevent endometriosis. Enhanced awareness, paired with early diagnosis may slow the natural progression and decrease the long-term impacts of the symptoms.

• Myth 4: Endometriosis can’t be treated - In reality, treatment can be with medication and/or surgery depending on symptoms and lesions. Contraceptive steroids, non-steroidal anti-inflammatory medications and painkillers are common medications with potential side effects, unfortunately.

•  Myth 5: It is normal for periods to be extremely painful - This is not true and if the pain cannot be relieved by medication, the reason might be endometriosis which should be discussed with your GP. 

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Q5. What are the solutions to tackle endometriosis?

Many different treatment modalities are being studied to treat endometriosis. They include pharmacological, non-pharmacological and surgical treatments. The treatment protocols might change depending on a woman’s preference and priorities. Some women might decide to have children during the course of the treatment and accordingly the direction of the treatment might change. Endometriosis is a chronic condition affecting women throughout their reproductive lives and sometimes beyond. That’s why the pain management strategies need to be dynamic, and the patients need regular and thorough medical attention. 

• Non-steroidal anti-inflammatory drugs (NSAID): Are recommended by WHO and can be used prior to the expected onset of the menstrual period. First-line pain therapy includes NSAIDs like ibuprofen, naproxen and metamizol. Paracetamol is also preferred by some women which do not have anti-inflammatory effects but have less gastrointestinal side effects compared to NSAID. It is reported that many women, especially the ones who don’t go for hormonal treatment and have cyclical pain, use more painkillers because they suffer from therapy-resistant pain. Over-the-counter pain medication can be extremely harmful. The pain sufferer should keep a pain diary so her pain levels, impairment in daily functions and the amount of pain medication usage can be recorded and evaluated by her doctors. 

• Hormonal Therapy Because endometriosis is an oestrogen dependent condition, most pharmacological therapies are aimed at ovarian function suppression like progestin containing oral contraceptives, and if oral contraceptives are not effective gonadotropin-releasing hormone (GnRH) agonists which can reduce the oestrogen levels to a post menopausal levels. There can be some side-effects like progestins may cause bleeding, weight gain, and mood changes, and resistance to  progesterone can be a problem. resistance. Androgenic drugs can cause  acne, hirsutism, and changes in lipid profiles. Most hormonal treatments aim at reducing chronic pelvic pain, but these treatments can be unsuitable in situations if women want to have children.

• Surgery: Another very important treatment in the management of endometriosis is surgery. Endometriotic lesions can be surgically cleaned from the body by excisional surgery or can be destroyed. The recent surgery methods are mostly excisional and laparoscopic but challenging because of the nature of recurrence of the endometriotic tissues. The patient may be required to continue medical treatment after the surgery.
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Q6. How can NuroKor help to cope with endometriosis? 

Women who are diagnosed with endometriosis suffer from pain symptoms, commonly dysmenorrhea, chronic pelvic pain, and dyspareunia. It affects an estimated 176 million women of reproductive age worldwide. Pharmacological options as the first line treatments help relieve symptoms in 50–80 % of the cases (4–7). Though a lot of women are hesitant to use medical treatments because of the side effects and also prolonged usage of the medication. Additionally, for some women, the pain medication dosages are not enough to relieve symptoms.(8) Subsequently, 20% of women who get the standard treatment still suffer from pain. (1) This is where NuroKor can help.

Through our development of unique bioelectronic technology and treatments, our objective is to support women around the world with alternative and effective pain management options to tackle endometriotic pain. Moreover, due to the non-invasive nature of our technology, they don’t have to worry about the side effects or the reliance on medication, they get the power to self-manage their pain. Daily usage of the NuroKor technology may also be able to help with the reduction of chronic pelvic pain. Research continues in this area. 

Though seeking medical consultation and undergoing proper examination is always advisable before the application of any home based treatments to exclude any other ongoing medical problems. 

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This Q&A is not aimed to be medical advice or an alternative to medical advice. It could help the reader review and understand potential treatment options. This text does not contain all knowledge about disorders, treatments, adverse effects, or risks that may be appropriate for a particular patient, and it does not recommend any treatments for a specific patient. Patients must seek help from a health professional for complete information about their queries and treatment options, including any risks or benefits. 

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References

1. Endometriosis and adenomyosis. In: Stenchever MA, Droegemueller W, Herbst AL, Mischell DR, eds. Comprehensive Gynaecology. Philadelphia, PA: Mosby, 2001: 531–64.
2. Sorrentino F, DE Padova M, Falagario M, D'AlteriO MN, DI Spiezio Sardo A, Pacheco LA, Carugno JT, Nappi L. Endometriosis and adverse pregnancy outcome. Minerva Obstet Gynecol. 2022 Feb;74(1):31-44. doi: 10.23736/S2724-606X.20.04718-8. Epub 2021 Jun 7. PMID: 34096691
3. https://www.who.int/news-room/fact-sheets/detail/endometriosis
4. Stratton P, Berkley KJ. Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications. Hum Reprod Update. 2011 May-Jun;17(3):327-46. doi: 10.1093/humupd/dmq050. Epub 2010 Nov 23. PMID: 21106492; PMCID: PMC3072022.
5. Youngster M, Laufer MR, Divasta AD. Endometriosis for the primary care physician. Curr Opin Pediatr 2013;25:454-462.
6. Mechsner S. Endometriosis, an Ongoing Pain-Step-by-Step Treatment. J Clin Med. 2022 Jan 17;11(2):467. doi: 10.3390/jcm11020467. PMID: 35054161; PMCID: PMC8780646.
7. Henzl, M.R.; Buttram, V.; Segre, E.J.; Bessler, S. The treatment of dysmenorrhea with naproxen sodium: A report on two independent double-blind trials. Am. J. Obstet. Gynecol. 1977, 127, 818–823. [CrossRef]
8.  Hoffman, D. Central and peripheral pain generators in women with chronic pelvic pain: Patient centred assessment and treatment. Curr. Rheumatol. Rev. 2015, 11, 146–166. [CrossRef] [PubMed]
9. Brown J, Farquhar C. Endometriosis: an overview of Cochran Reviews. Cochrane Database Syst Rev 2014:CD009590.In endometriosis, there is no clear evidence of a benefit for relief of symptoms compared to placebo

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About NuroKor:

Founded in 2018, NuroKor is a company committed to the development of bioelectronic technologies. NuroKor develops and formulates programmable bioelectronic software for clinical and therapeutic applications, in a range of easy to use, wearable devices. It provides the highest-quality products, delivering personalised pain relief and recovery support and rehabilitation to patients.

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