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Central sensitization in endometriosis-associated deep dyspareunia Orr, Natasha L 2018

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CENTRAL SENSITIZATION IN ENDOMETRIOSIS-ASSOCIATED DEEP DYSPAREUNIA by NATASHA L ORR    BSc, QUEEN’S UNIVERSITY, ON, 2016  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (REPRODUCTIVE AND DEVELOPMENTAL SCIENCES)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  April 2018 © NATASHA L ORR, 2018   ii   Abstract Endometriosis affects 10% of reproductive-aged women and is the presence of ectopic endometrial glands and stroma. It is associated with different types of pain, such as dysmenorrhea, dyschezia, and deep dyspareunia. Deep dyspareunia affects approximately 50% of women with endometriosis. Previous research has suggested that, in addition to disease-specific factors (e.g., Stage), other factors such as comorbid conditions or central sensitization may also play a role in the etiology of deep dyspareunia.  The thesis objective is to provide evidence for the role of these other factors in the etiology of deep dyspareunia in endometriosis. I propose that bladder/pelvic floor tenderness and painful bladder syndrome (PBS) are associated with an increased severity of deep dyspareunia in women with endometriosis, and that these factors may be related to central sensitization. In Aim 1, using data from a prospective registry, I found that bladder/pelvic floor tenderness (assess by physical exam) and PBS (diagnosed using established criteria) were independently associated with severity of deep dyspareunia in women with both Stage I/II endometriosis (AOR=1.94, 95% CI 1.11-3.38, p=0.019; AOR=1.99, 95% CI 1.15-3.44, p=0.013; respectively) and Stage III/IV (AOR=2.51, 95% CI 1.25-5.02, p=0.01; AOR=1.90, 95% CI 1.01-3.57, p=0.048; respectively). In Aim 2, by prospectively recruiting patients and measuring their pain-pressure thresholds (PPT), I determined that PPT at extra-pelvic sites were significantly associated with bladder/pelvic floor tenderness in women with endometriosis (t=2.9, p=0.007; t=2.3, p=0.029; respectively). In contrast, there was no association between PPT and PBS. In conclusion, I found that bladder/pelvic floor tenderness and PBS were associated with greater severity of deep dyspareunia, regardless of endometriosis stage.  I also found evidence that  iii   bladder/pelvic floor tenderness is associated with lower PPT in women with endometriosis, which may indicate the presence of central sensitization. In contrast, PBS was not associated with changes in PPT, and thus may arise in endometriosis through mechanisms other than central sensitization. My findings point to a role for central sensitization, manifesting as bladder/pelvic floor tenderness, in some women with endometriosis-associated deep dyspareunia. Further research is needed to confirm these findings, and to incorporate measures of central sensitization into the clinical management of endometriosis.      iv   Lay Summary Endometriosis affects 1 in 10 reproductive-aged females and is defined as cells that line the inside of the uterus abnormally growing outside the uterus. It can result in many types of pain but the focus of this thesis was on pain with deep sexual penetration. Currently, the cause of deep sexual pain is not fully understood so we aimed to determine if central sensitization (amplification of pain) was playing a role in this pain. We found that central sensitization was associated with bladder/pelvic floor tenderness, by measuring central sensitization with a pain-pressure threshold test, and bladder/pelvic floor tenderness was associated with deep sexual pain. The findings from this study suggests a role of central sensitization for the cause of deep dyspareunia in some women with endometriosis, who may benefit from a treatment plan different from the standard treatment of endometriosis.    v   Preface The research project presented in this thesis was originally developed in Dr. Paul Yong’s laboratory, and supported in part by the Canadian Graduate Scholarship- Master’s Award. I prepared a preliminary draft of this thesis in its entirety and then revised it based on suggestions from my supervisory committee. For Aim 1, I conducted the chart review for preliminary data and sample size estimation, and then extracted data from the prospective registry and performed the statistical analysis. For Aim 2, I participated in the study design, prepared ethics submissions, created the data collection forms, recruited all participants, performed the quantitative sensory testing, and completed the statistical analysis. All statistical analysis was done with the guidance of Drs. Paul Yong, Arianne Albert, and Sarka Lisonkova.  Chapter 3 has been submitted for publication and the results have been presented at the International Society for the Study of Women’s Sexual Health (ISSWSH).  A manuscript will be prepared for a future publication on the results from Chapter 4.  The research was approved by the BC Women’s and Children’s Hospital Research Ethics Board (REB) (certificate # H13-02563, #H16-00264, #H16-02903).  vi   Publications 1. Anglesio MS, Papadopoulos N, Ayhan A, Nazeran TM, Noë M, Horlings HM, Lum A, Jones S, Senz J, Sexkin T, Ho J, Wu R, Lac V, Ogawa H, Tessier-Cloutier B, Alhassan R, Wang A, Wang Y, Cohen J, Wong F, Hasanovic A, Orr N, Zhang M, Popoli M, McMahon W, Wood L, Mattox A, Allaire C, Segars J, Williams C, Tomasetti C, Boyd N, Kinzler K, Gilks C, Diaz L, Wang T, Vogelstein B, Yong P, Huntsman D, and Shih I. (2017). Cancer-associated mutations in endometriosis without cancer. New England Journal of Medicine, 376(19), 1835-1848. 2. Orr N, Noga H, Smith K, Williams C, Allaire C, Bedaiwy M, Lisonkova S, and Yong P. Deep dyspareunia in endometriosis:  role of the bladder and pelvic floor. (Revisions requested by J Sex Med). 3. Orr N, Noga H, Smith K, Williams C, Allaire C, Bedaiwy M, Lisonkova S, Lisonek M, and Yong P. Endometriosis-associated deep dyspareunia and central sensitization (In preparation). 4. Alotaibi F, Peng B, Klausen C, Lee A, Abdelkareem A, Orr N, Noga H, Robinson W, Bedaiwy M, and Yong P. Plasminogen activator inhibitor-1 (PAI-1) expression in endometriosis (In preparation).     vii   Table of Contents  Abstract .......................................................................................................................................... ii Lay Summary ............................................................................................................................... iv Preface ............................................................................................................................................ v Publications .................................................................................................................................. vi Table of Contents ........................................................................................................................ vii List of Tables ................................................................................................................................ xi List of Figures ............................................................................................................................. xiii List of Appendices ...................................................................................................................... xvi List of Abbreviations ................................................................................................................ xvii Acknowledgements .................................................................................................................... xix Dedication .................................................................................................................................... xx Chapter 1: Introduction ............................................................................................................... 1 1.1 Endometriosis .................................................................................................................... 1 1.1.1 Definition and Symptoms ..................................................................................... 1 1.1.2 Types of endometriosis ......................................................................................... 3 1.1.3 Theories of etiology ............................................................................................... 5 1.1.4 Pathophysiology .................................................................................................... 5 1.1.5 Staging .................................................................................................................... 9 1.1.6 Endometriosis-associated pain ........................................................................... 12 1.1.7 Diagnosis .............................................................................................................. 12 1.1.8 Treatment ............................................................................................................ 13 1.2 Deep dyspareunia ............................................................................................................ 14 1.2.1 Definition ............................................................................................................. 14 1.2.2 Causes ................................................................................................................... 14  viii   1.2.3 Treatment ............................................................................................................ 16 1.3 Bladder and pelvic floor tenderness .............................................................................. 16 1.3.1 Definition and Assessment ................................................................................. 16 1.3.2 Causes ................................................................................................................... 16 1.3.3 Treatment ............................................................................................................ 17 1.4 Psychological Factors ...................................................................................................... 17 1.4.1 Definition ............................................................................................................. 17 1.4.2 Measures .............................................................................................................. 17 1.5 Abdominal Wall Pain ..................................................................................................... 18 1.5.1 Definition and Cause ........................................................................................... 18 1.5.2 Measuring- Carnett Test .................................................................................... 18 1.5.3 Treatment ............................................................................................................ 18 1.6 Central Sensitization ....................................................................................................... 20 1.6.1 Definition ............................................................................................................. 20 1.6.2 Cross sensitization ............................................................................................... 22 1.6.3 Myofascial pain ................................................................................................... 24 1.6.4 Measuring central sensitization ......................................................................... 24 1.6.5 Treatment ............................................................................................................ 25 1.7 Objectives and Hypotheses ............................................................................................. 27 1.7.1 Aim 1: Deep dyspareunia in endometriosis: Role of bladder/pelvic floor tenderness ............................................................................................................ 27 1.7.2 Aim 2: Endometriosis-associated deep dyspareunia and central sensitization ......................................................................................................... 27 Chapter 2: Materials and Methods ........................................................................................... 28 2.1 Setting ............................................................................................................................... 28 2.2 AIM 1 - Retrospective chart review .............................................................................. 28  ix   2.3 AIM 1 AND AIM 2- Prospective data extraction ........................................................ 29 2.4 AIM 2- Recruitment of participants ............................................................................. 30 2.4.1 Case participants (women with endometriosis, with and without deep dyspareunia) ........................................................................................................ 30 2.4.2 Control participants (women without endometriosis) ..................................... 31 2.5 AIM 2 - Creating REDCap data collection forms ........................................................ 32 2.6 AIM 2 - Pain-pressure threshold measurement ........................................................... 33 2.7 Outcome Measures and Covariates ............................................................................... 36 2.7.1 AIM 1: Deep dyspareunia in endometriosis: Role of bladder/pelvic floor tenderness ............................................................................................................ 36 2.7.2 AIM 2: Endometriosis-associated deep dyspareunia and central sensitization ......................................................................................................... 37 2.7.3 AIM 1 Statistical Analysis: Deep dyspareunia in endometriosis: Role of bladder/pelvic floor tenderness .......................................................................... 37 2.7.4 AIM  2 Statistical Analysis: Endometriosis-associated deep dyspareunia and central sensitization ..................................................................................... 39 Chapter 3: Deep dyspareunia in endometriosis: Role of bladder/pelvic floor tenderness (Aim 1) ..................................................................................................................................... 40 3.1 Rationale .......................................................................................................................... 40 3.2 Study Sample ................................................................................................................... 40 3.3 Methods ............................................................................................................................ 45 3.4 Results .............................................................................................................................. 46 3.4.1 Stage I/II endometriosis ...................................................................................... 46 3.4.2 Stage III/IV endometriosis ................................................................................. 49 3.4.3 Ordinal regression .............................................................................................. 52 3.4.4 Sub-analysis: Binomial logistic regression........................................................ 54 3.5 Discussion ......................................................................................................................... 57 Chapter 4: Central sensitization in endometriosis-associated deep dyspareunia (Aim 2) ... 61  x   4.1 Rationale .......................................................................................................................... 61 4.2 Study Sample ................................................................................................................... 61 4.2.1 Case participants ................................................................................................. 61 4.2.2 Control participants ............................................................................................ 61 4.2.3 Exclusion criteria ................................................................................................ 62 4.3 Methods ............................................................................................................................ 67 4.4 Results .............................................................................................................................. 69 4.5 Discussion ......................................................................................................................... 95 Chapter 5: Conclusions and Future Directions ...................................................................... 100 References .................................................................................................................................. 107 Appendices ................................................................................................................................. 114   xi   List of Tables Table 3.1 Demographic data and clinical characteristics for prospective participants (Aim 1). .. 43 Table 3.2 Bivariate associations with the severity of deep dyspareunia (Stage I/II endometriosis). ....................................................................................................................................................... 47 Table 3.3 Bivariate associations with the severity of deep dyspareunia (Stage III/IV endometriosis). .............................................................................................................................. 50 Table 3.4 Multivariable ordinal regression models showing the association between various factors and severity of deep dyspareunia. ..................................................................................... 53 Table 3.5 Multivariable analysis of the association between bladder/pelvic floor tenderness and psychological factors among women with Stage I/II vs. Stage III/IV endometriosis (Aim 1). .... 55 Table 3.6 Multivariable analysis of the association between painful bladder syndrome and psychological factors among women with Stage I/II vs. Stage III/IV endometriosis (Aim 1). .... 56 Table 4.1 Demographics for study sample (Aim 2). ..................................................................... 64 Table 4.2 Associations between pain-pressure thresholds (PPT; newtons) and bladder/pelvic floor tenderness (BPF), in women with endometriosis. ................................................................ 70 Table 4.3 Associations between pain-pressure thresholds (PPT; newtons) and painful bladder syndrome (PBS), in women with endometriosis. .......................................................................... 71 Table 4.4 Associations between pain-pressure thresholds (PPT; newtons) and irritable bowel syndrome (IBS), in women with endometriosis. .......................................................................... 72 Table 4.5 Associations between pain-pressure thresholds (PPT; newtons) and Carnett test, in women with endometriosis. .......................................................................................................... 73 Table 4.6 Bivariate associations between pain-pressure thresholds (PPT; newtons) and severity of superficial dyspareunia (SD). ................................................................................................... 74  xii   Table 4.7 Bivariate associations between pain-pressure threshold (PPT; newtons) and depression, in women with endometriosis. ...................................................................................................... 76 Table 4.8 Bivariate associations between pain-pressure threshold (PPT; newtons) and anxiety, in women with endometriosis. .......................................................................................................... 77 Table 4.9 Bivariate associations between pain-pressure threshold (PPT; newtons) and pain catastrophizing, in women with endometriosis. ............................................................................ 78 Table 4.10 Bivariate associations with number of sexual intercourse occurrences between controls and cases. ........................................................................................................................ 94  xiii   List of Figures Figure 1.1 Possible sites of endometriosis[3]. ................................................................................ 2 Figure 1.2 Types of endometriosis[16, 17]. .................................................................................... 4 Figure 1.3 Estrogen-inflammation feedback loop in endometriotic lesions[20]. ........................... 8 Figure 1.4 American Society for Reproductive Medicine (ASRM) classification scale for endometriosis[21]. ........................................................................................................................ 10 Figure 1.5 American Society for Reproductive Medicine (ASRM) classification examples for endometriosis[21]. ........................................................................................................................ 11 Figure 1.6 Carnett test[55]. ........................................................................................................... 19 Figure 1.7 Normal sensation versus central sensitization[62]. ..................................................... 21 Figure 1.8 Mechanisms of cross-sensitization[63]. ...................................................................... 23 Figure 1.9 Electronic Thimble Algometer. ................................................................................... 26 Figure 2.1 Quantitative Sensory Testing (QST) sites. Star indicates test site. ............................. 35 Figure 3.1 Study population flowchart for prospective database (Aim 1). ................................... 42 Figure 4.1 Flowchart for study criteria of case participants (Aim 2). ........................................... 63 Figure 4.2 Flowchart for recruitment and study process for case participants. ............................ 67 Figure 4.3 Flowchart for recruitment and study process for control participants. ........................ 68 Figure 4.4 Mean left first dorsal interosseous muscle pain-pressure threshold between groups, using deep dyspareunia scores from the test day. Confidence intervals indicated with error bars. Pain=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=1.971, p=0.133; η2=0.123......................................................................................................................... 80  xiv   Figure 4.5 Mean right first dorsal interosseous muscle pain-pressure threshold between groups, using deep dyspareunia scores from the test day. Confidence intervals indicated with error bars. Pain=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=1.124, p=0.350; η2=0.074......................................................................................................................... 81 Figure 4.6 Mean average first dorsal interosseous muscle pain-pressure threshold between groups, using deep dyspareunia scores from the test day. Confidence intervals indicated with error bars. Pain=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=1.605, p=0.202; η2=0.103. ..................................................................................................... 82 Figure 4.7 Mean left deltoid muscle pain-pressure threshold between groups, using deep dyspareunia scores from the test day. Confidence intervals indicated with error bars. Pain=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=1.153, p=0.339; η2=0.076. ....................................................................................................................................... 83 Figure 4.8 Mean right deltoid muscle pain-pressure threshold between groups, using deep dyspareunia scores from the test day. Confidence intervals indicated with error bars. Pain=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=0.761, p=0.522; η2=0.052. ....................................................................................................................................... 84 Figure 4.9 Mean average deltoid muscle pain-pressure threshold between groups, using deep dyspareunia scores from the test day. Confidence intervals indicated with error bars. Pain=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=0.989, p=0.407; η2=0.066. ....................................................................................................................................... 85 Figure 4.10 Mean left first dorsal interosseous muscle pain-pressure threshold between groups, using deep dyspareunia scores from the registry. Confidence intervals indicated with error bars. dd=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=1.089, p=0.364; η2=0.072......................................................................................................................... 87 Figure 4.11 Mean right first dorsal interosseous muscle pain-pressure threshold between groups, using deep dyspareunia scores from the registry. Confidence intervals indicated with error bars. dd=deep dyspareunia; BPFT=bladder/pelvic floor tenderness. Welch ANOVA F(3, 14.580)=0.571, p=0.643; η2=0.031. .............................................................................................. 88  xv   Figure 4.12 Mean average first dorsal interosseous muscle pain-pressure threshold between groups, using deep dyspareunia scores from the registry. Confidence intervals indicated with error bars. dd=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=0.757, p=0.524; η2=0.051. ..................................................................................................... 89 Figure 4.13 Mean left deltoid muscle pain-pressure threshold between groups, using deep dyspareunia scores from the registry. Confidence intervals indicated with error bars. dd=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  Welch ANOVA F(3, 17.844)=4.546, p=0.015; η2=0.032......................................................................................................................... 90 Figure 4.14 Mean right deltoid muscle pain-pressure threshold between groups, using deep dyspareunia scores from the registry. Confidence intervals indicated with error bars. dd=deep dyspareunia; BPFT=bladder/pelvic floor tenderness. ANOVA F(3, 42)=0.616, p=0.609; η2=0.042. ....................................................................................................................................... 91 Figure 4.15 Mean average deltoid muscle pain-pressure threshold between groups, using deep dyspareunia scores from the registry. Confidence intervals indicated with error bars. dd=deep dyspareunia; BPFT=bladder/pelvic floor tenderness. Welch ANOVA F(3, 18.187)=4.361, p=0.018; η2=0.037. Post-hoc Games-Howell pair-wise tests p=0.043; * indicates a significant difference. ..................................................................................................................................... 92 Figure 4.16 Flowchart of treatment for deep dyspareunia based on etiology. .............................. 99   xvi   List of Appendices  Appendix A: Cancer associated mutations in non-cancerous endometriosis ............................. 114 A1. Rationale .............................................................................................................................. 114 A2. Study Sample ....................................................................................................................... 114 A3. Results .................................................................................................................................. 114 A4. Discussion ............................................................................................................................ 114 Appendix B: Data collection forms (questionnaires) for Aim 2 ................................................. 115 B1. Pre-test control questionnaire ............................................................................................... 115 B2. Test-day questionnaire control participants ......................................................................... 118 B3. Test day questionnaire case participants .............................................................................. 121 B4. Post-test day questionnaire case participants ....................................................................... 125 Appendix C: Other descriptive variables (Aim 1) ...................................................................... 126   xvii   List of Abbreviations ASRM  American society for reproductive medicine BCCHRI BC Children’s Hospital Research Institute BMI  Body mass index cAMP  cyclic AMP COX-2 Cyclooxygenase- 2  CYP19A1 Aromatase gene DIE  Deep infiltrating endometriosis DTI  Diffusion tensor imaging  EPHect Endometriosis phenome and biobanking harmonization project EPPIC  Endometriosis and pelvic pain interdisciplinary cohort FDI  First dorsal interosseous  fMRI  Functional magnetic resonance imaging FSFI  Female sexual function index FSR  Force sensing resistor GAD-7 Generalized anxiety disorder GnRH  Gonadotropic releasing hormone HSD17B2 17β-hydroxysteroid dehydrogenase- 2 IBS  Irritable bowel syndrome IL-1β  Interleukin 1 beta  xviii   IUD  Intrauterine device KT  Knowledge translation MMPs  Matrix metalloproteinases  N  Newton NGF  Nerve growth factor PAG  Periaqueductal gray PBS  Painful bladder syndrome PCS  Pain catastrophizing scale PGE2  Prostaglandin E2 PGP9.5 Protein gene product 9.5 PHQ-9  Patient health questionnaire PPT  Pain-pressure threshold PSI  Public scholars initiative QST  Quantitative sensory testing REDCap Research electronic data capture SF1  Steroidogenic factor STAR  Steroidogenic acute regulatory protein TRPV1 Transient receptor protein vanilloid-receptor 1 VEGF  Vascular endothelial growth factor   xix   Acknowledgements I would like to sincerely thank my thesis supervisor and mentor, Dr. Paul Yong, for his plentiful support and encouragement. I am very grateful for his patience, guidance, and the incredible opportunities he has provided.  I would like to thank Drs. Kelly Smith, Christina Williams, and K.S Joseph (Chair), who are my thesis committee members, for their insightful comments and enthusiastic encouragement. This research could not have been done without the physicians at the BC Women’s Centre, Drs. Paul Yong, Christina Williams, Mohamed Bedaiwy, and Catherine Allaire, as well as the clinical and administrative staff at the Centre.  I would like to thank all the members of Dr. Yong’s and Dr. Bedaiwy’s laboratory for their incredible support and friendship, especially Heather Noga. Also, I would like to thank Mrs. Roshni Nair for all her help within the department. I am so grateful to have wonderful parents, Chris and Elvie Orr, who have inspired and guided me, emotionally and financially supported me, and without whom I would not have been able to achieve my goals.  My brother, Hunter Orr, has been essential in my well-being and determination throughout my education by his constant reminder to: “Do. Or do not. There is no try.”-Yoda.  Lastly, I would like to acknowledge my boyfriend, John Cameron, for his support and encouragement during long hours and stressful times in my education, as well as his constant motivation to follow my dreams.   xx   Dedication       This is dedicated to the women and their partners who suffer from endometriosis and sexual pain.   1  Chapter 1: Introduction 1.1 Endometriosis 1.1.1 Definition and Symptoms Endometriosis affects approximately 10% of reproductive-aged females and is a common cause of infertility and pelvic pain[1, 2]. It is the presence of ectopic endometrial glands and stroma which become attached to the pelvic peritoneum, reproductive organs (e.g., ovaries, fallopian tubes), or to other visceral organs in the abdominopelvic cavity (see Figure 1.1 for potential sites of endometriosis) [3, 4]. Symptoms of endometriosis include various types of pain [5] and infertility [6], which result in decreased quality of life[5]. Pain symptoms may include dysmenorrhea, dyschezia, dyspareunia and chronic pelvic pain[5]. A previous study showed that women with endometriosis and pelvic pain had a worse quality of life (measured by the Short Form-12), in comparison to women with endometriosis but without pelvic pain [7]. Another study reported that increased number of symptoms and symptom severity further decreased health-related quality of life (measured with the Endometriosis-Health Profile-30) in women with endometriosis[8]. In addition to pain, women with endometriosis have also shown an affected quality of life due to uncertainty of the future, long-term medical therapy, infertility, and other concerns[9].       2   Figure 1.1 Possible sites of endometriosis[3].        3  1.1.2 Types of endometriosis The three anatomic subtypes of endometriosis are: superficial peritoneal, ovarian endometrioma and deep infiltrating endometriosis (DIE) (Figure 1.2)[10-12]. Superficial peritoneal endometriosis refers to lesions of endometriosis on the peritoneum or other pelvic organs, infiltrating less than 5mm into the peritoneum[12]. Ovarian endometriomas are dense, cyst-like structures of endometriosis on the ovaries[12]. DIE, also called adenomyosis externa, is defined as endometrial tissue infiltrating to a depth of 5mm or greater into the peritoneum involving visceral organs such as the bowel and bladder[13, 14]. DIE is often present in Stage III/IV endometriosis, and Stage IV endometriosis is often characterized by complete cul-de-sac (pouch of Douglas) obliteration where the posterior space between the uterus and rectum has been eliminated due to a DIE nodule[12].  The presence of DIE is thought to be associated with deep dyspareunia[15].       4     Figure 1.2 Types of endometriosis[16, 17]. A=superficial endometriosis[16]. B=endometrioma[16]. C=deep infiltrating endometriosis[17]. Arrows depict the areas of endometriosis lesions. A B C  5  1.1.3 Theories of etiology The etiology of endometriosis is not fully understood; however, there are four theories of the origin of endometriosis which include retrograde menstruation, immunological factors, lymphatic/hematologic and coelomic metaplasia[2]. Retrograde menstruation refers to the reflux of the menstrual blood through the fallopian tubes and into the peritoneal cavity, rather than exiting the body via the cervix and vagina[18]. Studies have shown that most women experience retrograde menstruation, but normally their immune systems are able to destroy the refluxed endometrial cells before they implant and proliferate[2]. However, in some women, the endometrial cells from the basalis layer of the refluxed endometrium are not destroyed and may attach and proliferate causing endometriosis, suggesting an immunological etiology of endometriosis[2]. Another theory is the transport of endometrial cells through the lymphatic and vascular systems, which would explain the presence of endometriosis in atypical locations such as the pericardium[2]. Coelomic metaplasia is when the normal cells of the primitive parietal peritoneum transform into endometrial cells; this explains how women who do not experience menstruation can get endometriosis[2].   1.1.4 Pathophysiology Endometriosis is an estrogen-dependent disease, meaning that estrogen induces the growth of endometriotic tissue[19]. There are many ways that endometriotic lesions increase estradiol production, such as by: expressing aromatase (an enzyme that converts androgens to estrogens) and producing estradiol directly[20]. Also, an increased production of prostaglandins (e.g., prostaglandin E2 (PGE2)) and cytokines have been found in the lesions[19, 20]. Inflammation, increased estrogen, and progesterone resistance leads to the maintenance of endometriosis[20].    6  The implantation of endometriotic tissue into the peritoneum elicits an inflammatory response, that results in pain[19]. The lesions and inflammatory response result in proinflammatory cytokines (such as interleukin 1 beta (IL-1β)) to be released, as well as increasing the secretion of nerve growth factor (NGF), tissue remodeling enzymes (matrix metalloproteinases [MMPs]), and vascular endothelial growth factor (VEGF)[19]. Locally produced estradiol also results in an increased secretion of PGE2 that can enhance production of NGF and promote nociceptor fiber formation to result in persistent inflammatory pain[19]. There is also an increased inflammatory response in women with endometriosis that promotes the survival of the endometriotic lesions[19].  In women with endometriosis, estrogen is produced by: 1) the ovaries, and enters the blood stream and travels to the endometriotic lesions; 2) aromatase in adipose tissue; and 3) endometriotic lesions directly since they express steroidogenic genes[20]. A feedback cycle exists between estrogen production and inflammation (Figure 1.3)[20]. PGE2 is a hormone involved in inflammation and directly induces pain in women with endometriosis[20]. Cyclooxygenase-2 (COX-2) converts arachidonic acid to PGE2 and thus plays a role in inflammation[20]. There is an increased level of COX-2 in endometriotic stromal cells, compared to uterine endometrial stromal cells[20]. Factors that have been found to play a role in inducing COX-2 include: the cytokine IL-1β, PGE2, VEGF, or estradiol[20].  Activation of the PGE2 receptor subtype EP2 receptor increases cyclic AMP (cAMP) levels, which then increases the expression of steroidogenic acute regulatory protein (STAR; important for the initial steps in the production of estrogen) and CYP19A1 (the aromatase gene), thus increasing estradiol production[20]. The nuclear receptor steroidogenic factor 1 (SF1) facilitates the expression, dependent on PGE2 and cAMP, of STAR and CYP19A1[20]. Since the CpG (cytosine-phosphate-guanine) island is unmethylated in endometriotic stromal cells, there is overexpression of SF1, essentially leading to an increased level of activated estrogen[20].  7  Unlike women without endometriosis, women with endometriosis lesions produce local aromatase which facilitates the increase of estradiol levels in these women, leading to increased survival of the lesions and increased pain[19, 20]. Aromatase inhibitors have been shown to be beneficial as they block estrogen formation and reduce endometriosis lesions[19, 20]. Furthermore, in the endometrium, progesterone increases the production of retinoic acid, which then induces 17β-hydroxysteroid dehydrogenase 2 (HSD17B2) in endometrial epithelial cells, thus facilitating the conversion of potent estradiol to less potent estrone[20]. However, endometriotic stromal cells do not respond to progesterone and cannot produce retinoic acid, therefore there is a reduced amount of HSD17B2 and an increased amount of potent estradiol[20].        8   Figure 1.3 Estrogen-inflammation feedback loop in endometriotic lesions[20].           9  1.1.5 Staging The American Society for Reproductive Medicine (ASRM) classification system for endometriosis (Stage I-IV) is based on anatomical severity, including amount of each anatomic subtype of endometriosis (Figure 1.4 and 1.5)[21]. The various types of endometriosis (with consideration of the size and location) are given numeric values that are totaled; and depending on the final sum the range of values are put into one of the four groups. Stage I endometriosis is the result of a summed numeric value between 1-5, Stage II is between 6-15, Stage III is between 16-40 and Stage IV is greater than 40[21]. Complete posterior cul-de-sac obliteration automatically results in Stage IV endometriosis[21].     10   Figure 1.4 American Society for Reproductive Medicine (ASRM) classification scale for endometriosis[21].   11   Figure 1.5 American Society for Reproductive Medicine (ASRM) classification examples for endometriosis[21].      12  1.1.6 Endometriosis-associated pain Endometriosis is associated with different types of pelvic pain, including dysmenorrhea, chronic pelvic pain, dyschezia, and deep dyspareunia[22]. Dysmenorrhea is pelvic pain with menstrual bleeding[22]. Chronic pelvic pain consists of other pelvic pain that is problematic for more than 6 months[22]. Dyschezia is painful bowel movements[22]. Dyspareunia is sexual pain, and deep dyspareunia refers specifically to pelvic pain with deep vaginal penetration during sexual intercourse[22].  The etiology of endometriosis-associated pain may be due, in part, to the depth of infiltration into the peritoneum, the cytokines released by the lesions into the peritoneum[23] and distance of the lesions to highly innervated areas[24, 25]. Also, elevated levels of aromatase in eutopic endometrium[26] and prostaglandins in the endometriotic lesions[27] may result in increased pain symptoms. A previous study determined that increased nerve fibre density around endometriosis (possibly induced by the endometriosis epithelium/stroma) in the cul-de-sac or uterosacral region may be a potential etiology for deep dyspareunia in women with endometriosis. As well, contact with a DIE nodule during vaginal penetration may result in increased pain[28]. In contrast, to these endometriosis-specific factors, there may be myofascial or nervous system mechanisms – not directly related to the endometriosis lesions – that have implications in endometriosis-associated pain.  1.1.7 Diagnosis The gold standard diagnosis of endometriosis is done by surgical visualization and excision followed by histopathological confirmation[2]. However, certain clinical features may cause a physician to suspect endometriosis such as: endometrioma or negative sliding sign on transvaginal ultrasound,  13  palpable nodule or tenderness on pelvic exam, and history of pelvic pain or other pelvic symptoms especially if worse at menstruation[2, 4, 29]. 1.1.8 Treatment  Endometriosis can be treated with medical therapy to cause pseudo-pregnancy or pseudo-menopause that suppresses endometriosis lesions[3]. Examples of hormonal therapies include: estrogen-progestin contraceptives, progestin only, gonadotropin releasing hormone (GnRH) analogs, and intrauterine devices (IUD)[3, 30, 31]. Estrogen-progestin contraceptives, such as the birth control pill, directly suppress endometriosis lesions, as well as ovulation, and induce a pseudo-pregnant state[32]. Progestin only therapies directly suppress endometriosis lesions, even reducing the size of nodules, but spotting and breakthrough bleeding are possible side effects[33]. GnRH analogs reduce the follicle-stimulating hormone and luteinizing hormone secreted, causing hypoestrogenism and thus resulting in a pseudo-menopausal state[3]. A new therapy for endometriosis, GnRH antagonists, may also reduce endometriosis-associated pain, while limiting the effects of hypoestrogenism[34, 35]. The progestin (levonorgestrel) IUD can also be used to reduce endometriosis lesions and subsequently associated pain[30, 31, 34]. Other possible treatment options that target the associated symptoms include: non-steroidal anti-inflammatory drugs, physiotherapy, nutritional or complementary therapies (e.g., Chinese medicine), and pain medication (e.g., opioids)[3, 31, 36, 37]. Medical therapy does not work for every case, and surgical removal of the endometriosis lesions, or more radical surgery by hysterectomy with or without removal of ovaries (oophorectomy) may be necessary. Laparoscopic surgery is usually done, but laparotomy may be needed if the disease is advanced and/or includes multiple organs. In women with minimum, mild, or moderate endometriosis, surgery with removal or ablation of endometriosis lesions has shown to be more effective in reducing endometriosis-associated  14  pain, compared to surgery without removal of endometriosis[38]. However, 40-50% of cases reported recurrences of endometriosis 5 years after surgical treatment[39]. Another study looking specifically at rectovaginal endometriosis showed a 34.2% cumulative endometriosis recurrence rate after 36 months[40]. Hysterectomy and bilateral oophorectomy may be done as a definitive treatment for endometriosis[31].  1.2 Deep dyspareunia 1.2.1 Definition Deep dyspareunia is defined as pelvic pain with deep vaginal penetration during intercourse and affects approximately 50% of women with endometriosis[41]. It can result in decreased sexual quality of life and negative impacts on relationships[41]. Since traditional hormonal and surgical therapy does not always lead to successful treatment of deep dyspareunia in women with endometriosis[42], a further understanding of the pathophysiology and associated factors that result in deep dyspareunia is needed to improve treatment options and outcomes[15, 41].  1.2.2 Causes Factors that may influence the etiology of deep dyspareunia include: endometriosis-specific factors (e.g., location and anatomic type of endometriosis, and local nerve fiber density around endometriosis), and other factors associated with endometriosis but not directly due to the lesions themselves (e.g., bladder pain, pelvic floor dysfunction, and psychological variables)[15, 43]. The traditional focus in the literature has been on endometriosis-specific factors. For example, it was shown that endometriosis of the cul-de-sac and uterosacral ligaments, in particular DIE, compared to other locations, was significantly associated with deep dyspareunia[15, 44].   15  In addition to cul-de-sac/uterosacral DIE, our laboratory has found other factors associated with deep dyspareunia. We found a significant increase in protein gene product 9.5 (PGP9.5) nerve bundle density in a cohort of women with tender endometriosis of the cul-de-sac/uterosacrals and deep dyspareunia, compared to women with non-tender endometriosis and no deep dyspareunia (p=0.001)[15]. Also, a significant correlation was shown between the PGP9.5 nerve bundle density and the severity of deep dyspareunia (p=0.001)[15].  This suggests that nerve bundle density around endometriosis of the cul-de-sac/uterosacrals is also important in the etiology of deep dyspareunia.  Our lab has also found that this local nerve growth may be induced by expression of NGF by endometriosis stroma and epithelium[45]. It has recently been proposed that, in addition to endometriosis-specific factors (e.g., stage, location, depth of invasion, etc.), it is important to consider other comorbid pain conditions (e.g., painful bladder syndrome (PBS) or irritable bowel syndrome (IBS)), myofascial contributors, and central sensitization of the nervous system in the pathophysiology of deep dyspareunia in endometriosis[42].  For example, bladder tenderness was associated with deep dyspareunia in a retrospective study[43]. Also, in a prospective study, tenderness of the bladder or pelvic floor (levator ani) shared common risk factors and were both associated with more severe deep dyspareunia, independent of tenderness at other anatomic sites[46].  PBS was also associated with deep dyspareunia in this study, rather than IBS[46].  However, both studies involved a mixed sample of women with and without endometriosis; and, in the women with endometriosis, endometriosis-specific features could not be assessed as detailed surgical data were not available.  16  1.2.3 Treatment  Placebo-controlled trials have not shown a clear benefit of surgery or hormonal therapy in the treatment of deep dyspareunia[42]. Due to the variability in deep dyspareunia in women with endometriosis, treatment depends on the etiology of the pain[42]. For example, deep dyspareunia resulting from DIE nodules was shown to significantly improve after surgical excision[28]. Deep dyspareunia directly due to endometriosis lesions may also benefit from hormonal management[42]. On the other hand, deep dyspareunia likely due to other pain mechanisms (e.g., comorbid pain conditions, central sensitization, myofascial pain) may benefit from a multidisciplinary treatment plan (e.g., physiotherapy, pain modulators, counselling, pain education) or specific treatment of the comorbid condition[42]. If deep dyspareunia is caused by a combination of factors, treatment plans should include medical and/or surgical management, as well as treating comorbid conditions and central or myofascial pain mechanisms[42].   1.3 Bladder and pelvic floor tenderness 1.3.1 Definition and Assessment Bladder and pelvic floor tenderness was derived from the registry. Tenderness of the bladder or pelvic floor (levator ani muscle) refers to pain verbally reported by the patient with single digit palpation during the pelvic exam by the gynecologist at the BC Women’s Centre for Pelvic Pain and Endometriosis.  1.3.2 Causes Bladder/pelvic floor tenderness may arise from several mechanisms: central sensitization, intrinsic bladder problems, or myofascial etiology[43]. We found that the association with bladder/pelvic floor tenderness was independent of PBS, suggesting that central sensitization or myofascial etiology may  17  be important[47]. I tested the hypothesis of central sensitization in bladder/pelvic floor tenderness in Aim 2.   1.3.3 Treatment Due to the sensitization etiology of bladder/pelvic floor tenderness, a multidisciplinary treatment plan, including pelvic floor physiotherapy, pain education, and counselling, may be beneficial. Previous research has shown that myofascial physical therapy can relieve symptoms due to PBS[48]. 1.4 Psychological Factors 1.4.1 Definition Depression, anxiety and pain catastrophizing are psychological factors that may also modulate sexual pain, including deep dyspareunia. Catastrophizing is defined as over appraisal of the actual or anticipated pain sensations[49]. Yong et al. found that depression was specifically associated with bladder or pelvic floor tenderness[46].  Our lab has shown an independent association between depression and the tenderness of the bladder and pelvic floor (p<0.001 and p=0.001, respectively), and between depression and concurrent deep-superficial dyspareunia (p=0.007)[46, 50]. We have also found an independent association between functional quality of life (measured by EHP-30 pain subscale) and the following: higher pain catastrophizing scale (p<0.001), and more severe chronic pelvic pain (p<0.001) and dysmenorrhea (p<0.001)[51].  1.4.2 Measures Depression was measured on the Patient Health Questionnaire (PHQ-9), anxiety on the Generalized Anxiety Disorder (GAD-7), and pain catastrophizing on the Pain Catastrophizing Scale (PCS).  For  18  this thesis, the PHQ-9 and GAD-7 were dichotomized into < 10 (mild symptoms) and =>10 (moderate-severe symptoms), while the PCS was dichotomized into <30 and =>30 (75th centile).   1.5 Abdominal Wall Pain 1.5.1 Definition and Cause Abdominal wall pain (pain from the abdominal wall layer, rather than intraperitoneal) is commonly overlooked[52]. Clinically it presents as localized pain, that may originally be sharp but then become a dull ache, usually at the lateral edge of the rectus abdominis muscle[52, 53]. Possible causes of abdominal wall pain are entrapment of a branch of the thoracic intercostal nerves, sensitization, or myofascial pain[53]. 1.5.2 Measuring- Carnett Test The physician performs the Carnett test by first laying the patient down on their back, and then telling them to do a sit up or leg raise to contract their abdominal muscles (Figure 1.6)[54]. Carnett positive (worse) is when the pain increases during the abdominal wall contraction, suggesting that the source of the pain is in the abdominal wall[54]. Carnett negative is when the pain decreases (or is unchanged) during the abdominal wall contraction, suggesting that the source of the pain is in the viscera[54].  1.5.3 Treatment Targeted injection of an anesthetic/corticosteroid to the site of pain has been shown to result in pain relief to approximately 75% of patients[53]. Nerve block, nonsteroidal anti-inflammatory drugs, analgesics or antidepressants may also be used to treat abdominal wall pain[53]. In severe cases of nerve entrapment, surgical sectioning or freezing may be done[53].   19   Figure 1.6 Carnett test[55].       20  1.6 Central Sensitization 1.6.1 Definition Central sensitization is the enhancement in the function of the neurons, especially in the dorsal horn of the spinal cord, which results in hyperalgesia (increased response to pain) and allodynia (pain with an innocuous stimulus) (Figure 1.7)[56, 57]. Central sensitization, through hyperalgesia, can result in healthy tissues becoming painful (e.g., the bladder and pelvic floor)[58].  Central sensitization may be caused by the persistent and longstanding over-firing of neurons in the spinal cord by impulses in peripheral A-beta fibers and C fibers[59]. In the process of central sensitization, A-beta fibers undergo morphological changes (e.g., substance P expression) that implicate them as pain-transmitting fibers similar to C fibers, and therefore touch or slight pressure becomes painful[59, 60]. Another result of central sensitization is that after applied noxious stimulus to one area, the dorsal horn neurons that were previously responsive to only one area begin to respond to nociception from areas that previously had not provoked a response[59].  A previous study by McAllister et al. discovered that ectopic endometriosis lesions developed their own C fiber and sympathetic nerve supply, and therefore it was suggested that the innervation of the endometriosis is the major contributor to pain[61]. Sprouting of C fibers and sympathetic fibers causes increased activity of these fibers and increased nociceptive activity, which may provoke central sensitization[61]. Central sensitization can lead to chronic pain, and can eventually become self-sustained (autonomous), such that removal of the endometriosis lesions does not alleviate pain[61]. In our lab, we hypothesized that bladder/pelvic floor tenderness and PBS may be markers of central sensitization[46].   21    Figure 1.7 Normal sensation versus central sensitization[62].  22  1.6.2 Cross sensitization An additional mechanism by which pain can occur is cross-sensitization, where crossing of neural pathways leads to a painful organ or somatic structure. The convergence is suggested to occur at three different levels of the neural system, either working together or independently: the dorsal root ganglion, spinal cord, and brain[63]. Firstly, the noxious stimulus from a pathologically painful organ/structure is transmitted to the neuronal cell bodies of the dorsal root ganglion[63]. If the dorsal root ganglion cell body has a neuronal connection with an adjacent pelvic organ/structure, an action potential may be released to this adjacent organ/structure resulting in it to become painful[63]. This phenomenon is called the “axon-reflex” (Figure 1.8)[63]. Secondly, noxious convergence at the same spinal interneuron at the dorsal horn of the spinal cord may result in a pathologically painful organ/structure to cause an adjacent organ/structure to become painful (Figure 1.8)[63]. Lastly, at the level of the brain, descending feedback in response to a pathologically painful organ/structure can result in a painful adjacent organ/structure, as well as the persistence of pain (Figure 1.8)[63]. An example of this phenomena is sensitization of the bladder through viscero-visceral convergence or sensitization of the pelvic floor through viscero-somatic convergence, from an originally painful pathological organ (e.g., the uterus, due to endometriosis), due to the convergence of noxious sensory information.  Research has suggested that cross-inhibition may be responsible for why not all organs/structures become painful from a pathologically painful organ/structure; however, further research is required[63].   23   Figure 1.8 Mechanisms of cross-sensitization[63]. 1) Convergence at the level of the dorsal root ganglion; 2) Convergence at the dorsal horn of the spinal cord; 3) Convergence in the brain. The stars represent the convergence locations[63].  24  1.6.3 Myofascial pain Myofascial pain refers to pain of musculoskeletal origin, which is often related to tender trigger points[64, 65] due to hyperactive nerve firing within the skeletal muscle reflex arc secondary to muscle fiber trauma[64]. These trigger points have been implicated in many types of chronic pain.  Stimulus of a trigger point can cause referred pain to other anatomical sites within the pathway of the nerve[48, 65]. It has been suggested that myofascial pain can induce central sensitization, since it was previously shown in animal models that central nervous system neurons can become sensitized after inputs from peripheral afferent fibers in muscles and joints have relayed to them[66, 67].  Myofascial pain may also be a consequence of central or cross-sensitization. 1.6.4 Measuring central sensitization One way of assessing central sensitization is by the clinical examination.  Tenderness at sites not directly related to the endometriosis lesions, such as bladder/pelvic floor tenderness, may suggest central sensitization.  However, clinical examination for the diagnosis of central sensitization is limited since it is not formally measured, and due to the fact that the clinical environment is not blinded or standardized. Therefore, formal measurement to confirm central sensitization is necessary. Central sensitization of the nervous system can be formally measured with quantitative sensory testing (QST)[62, 68]. QST measures pathology in sensory nerve fiber function[69]. Some examples of perception testing include: vibration, thermal, pain, and pressure[69]. In Aim 2 of my thesis, I measured pain-pressure threshold (PPT) using an Electronic Thimble Algometer, purchased from the University of North Carolina (Figure 1.9). This device has been used in a previous study by Zolnoun et al., who examined PPT in vestibular mucosal sites in a population of women with vestibulodynia (chronic vulvar pain) compared to controls[70]. This study showed that women with vestibulodynia  25  had lower PPT measurements than pain-free controls[70]. A previous study used an algometer to compare the PPT’s at an extra-pelvic site of women with endometriosis and history of menstrual pain to controls (non-endometriosis, no menstrual pain)[71]. They found that the PPT’s in women with endometriosis and pain was decreased compared to the controls, suggesting that the endometriosis lesions can result in a generalized hypersensitivity and central sensitization[71]. An association has been found between PPT and chronic pelvic pain; however, further QST studies are needed for confirmation of the association between PPT and severity of deep dyspareunia in women with endometriosis[72, 73].  1.6.5 Treatment Central sensitization can be managed with tricyclics antidepressants (e.g., duloxetine), anti-epileptics (e.g., pregabalin), neuromodulators, and anesthetics, as well as a multidisciplinary approach (physiotherapy, psychological therapy, pain education, etc.); however, further randomized control trials are needed to confirm the efficacy of these approaches[34, 62]. A recent study has looked at transient receptor protein vanilloid-receptor 1 (TRPV1) expression in an endometriosis animal model and found that TRPV1 expression was increased in the endometriosis group compared to the controls[74]. Since TRPV1 mediates the pain response and has been determined to play a role in pain sensitization, this study concluded that TRPV1 may be important in the treatment of sensitization and associated endometriosis pain[74]. Trigger point injections and ultrasound therapy, in combination with stretching, were shown to reduce pain intensity in patients with myofascial trigger points that can be associated with sensitization[75]. Also, psychosocial factors, such as stress, are important in chronic pain, and thus, psychosocial factors should be considered and managed (e.g., with cognitive behavioral therapy) in the treatment plan[75].   26   Figure 1.9 Electronic Thimble Algometer.     27  1.7 Objectives and Hypotheses 1.7.1 Aim 1: Deep dyspareunia in endometriosis: Role of bladder/pelvic floor tenderness The objective of Aim 1 is to determine if bladder/pelvic floor tenderness and PBS are significantly associated with an increased severity of deep dyspareunia in women with endometriosis, regardless of Stage.  I hypothesized that bladder/pelvic floor tenderness and PBS is significantly associated with an increased severity of deep dyspareunia in women with either Stage I/II or Stage III/IV endometriosis.      1.7.2 Aim 2: Endometriosis-associated deep dyspareunia and central sensitization  The objective of Aim 2 is to determine if there is a significant association between central sensitization (assessed by a decreased PPT), and bladder/pelvic floor tenderness, PBS, and severity of deep dyspareunia in women with endometriosis. I hypothesized that an increased central sensitization will be associated with bladder/pelvic floor tenderness, PBS, and an increased severity of deep dyspareunia.  28  Chapter 2: Materials and Methods 2.1 Setting This thesis work took place at the BC Women’s Centre for Pelvic Pain and Endometriosis at the BC Women’s Hospital and Health Centre, the Women’s Health Research Institute exam room (D406A), and UBC Division of Reproductive Endocrinology and Infertility office space (B423), in Vancouver, British Columbia.  2.2 AIM 1 - Retrospective chart review I first performed a retrospective chart review to provide preliminary data for sample size estimation for my subsequent analysis of a prospective data registry. Patients who underwent endometriosis-related surgery between August 2000 and October 2013 at the BC Women’s Centre for Pelvic Pain and Endometriosis were identified from the physicians’ surgical spreadsheet. Medical charts were obtained from the Centre’s health records department or from Iron Mountain (a storage facility for archived charts) and reviewed to identify if they had pathologically confirmed DIE. The patients who were confirmed to have DIE underwent complete chart review and data collection. Patient information collected included: physical examination data, questionnaire information, past medical history and operative notes. This information was transcribed into a data collection sheet that contained their unique non-identifiable research number. A password protected and encrypted master list spreadsheet was kept on a secured shared drive within the BC Women’s Hospital network, that linked the unique research number to the patient medical record number, as per standard research practice. This data was used for sample size calculation (Aim 1), as well as for a genomics side project (Appendix A).  29  2.3 AIM 1 AND AIM 2- Prospective data extraction An analysis of data from phase 1 and 2 of a prospective registry for endometriosis and pelvic pain, the Endometriosis Pelvic Pain Interdisciplinary Cohort (EPPIC) (Clinical Trials #NCT02911090), was carried out for Aim 1 and Aim 2. The EPPIC registry included a collection of clinical variables in an online database stored in Research Electronic Data Capture (REDCap) software, thus enabling easy extraction of clinical information for each participant. I was able to filter the registry participants and identify participants who met the study inclusion criteria. I then extracted certain variables from the eligible participants into an excel file which was then transferred to an SPSS file for statistical analysis. This cohort of prospectively-consented patients has been previously described in detail, and was designed for the examination of associations between multiple factors and different types of pelvic pain [76]. The registry included women who underwent a detailed preoperative examination and included a question on deep dyspareunia severity on a numeric rating scale (0-10), which was differentiated from superficial dyspareunia[76]. Other data elements from history and physical examination were prospectively entered into the registry database, including surgical data from surgeries prospectively performed at the Centre as per the recommendations of the Endometriosis Phenome and Biobanking Harmonisation Project (EPHect)[77]. Information on stage and other disease-specific factors (i.e., location, depth of disease) were obtained during the surgery performed at the Centre and were therefore reflective of the state of the disease at the time of the preoperative examination. Participants were filtered based on eligibility criteria and a subset of data was extracted for the patients eligible for each Aim.  30  2.4 AIM 2- Recruitment of participants  2.4.1 Case participants (women with endometriosis, with and without deep dyspareunia) At the end of their appointment with one of the endometriosis specialists at the BC Women’s Centre for Pelvic Pain and Endometriosis, the physician asked the patient if they were interested in learning more about this research study (if the physician deemed them acceptable to be included based on screening of inclusion and exclusion criteria). The physician provided the patient a copy of the consent form to read at home and asked the patient if a research assistant could call them in the next couple of days. Physicians emphasized that participation was optional and would not influence their health care. A poster introducing the study was also available in the clinic waiting rooms. Potential participants were encouraged, if they felt comfortable doing so, to discuss the consent form with family, friends, and/or their physician. Ms. Heather Noga (the Research Coordinator) collected the physician forms and confirmed that the interested potential case participants had consented to the data registry. Ms. Noga provided me with the contact information of the potential case participants that consented to the data registry and they were given a minimum of 24 hours to review the consent form before I contacted them. During the phone call, I asked if the potential case participant was interested in participating in the study, and explained the study and consent process. During this phone conversation, I reminded the potential case participant that they had consented to the data registry, and consent to this study would allow us access to analyze their registry data. Verbal consent was given if the potential case participant wanted to participate, and a test appointment was booked. I logged the participant into the test computer during the test day so that they could complete the test day questionnaire online. Case participants signed the consent form in-person at the beginning of the test day appointment. Participants were instructed not to take analgesics within 24 hours before the scheduled test, nor to take opioids within 2 weeks before the scheduled test, nor to consume alcohol  31  within 24 hours prior to scheduled test time. The participants were also told to wear comfortable clothing with easy access to their shoulder for the scheduled appointment. Case participants received a $10 coffee gift card for participating in this study. 2.4.2 Control participants (women without endometriosis) Recruitment of the control group was done by poster advertisement at the BC Women’s Hospital. If they were interested, potential participants were asked to contact me (contact information on poster) to learn more about the study. In addition to poster advertisement, an invitation was circulated (via email/social media) to an in-person information session open to all potential control participants who may be interested in the study. In-person information sessions/putting posters up also occurred at the BC Children’s Hospital, the BC Children’s Hospital Research Institute (BCCHRI), and the University of British Columbia. An in-person information session included a short presentation about the research study and what is required of the control participants, and contact information was left for the potential control participants if they wanted more information/wanted to participate. Recruitment of control participants was also done through institutional research newsletters. In addition, we recruited via electronic forms of communication (e.g., institutional listservs such as CRC net for the BC Children's Hospital Research Institution) and research/student groups. I mentioned to participants in the study that their friends and family were welcome to contact us if they would like to participate and provided the participant with a copy of the poster. This happened at the final interaction between the participant and the researcher, so they did not feel pressured. I provided the potential control participant with a copy of the consent form (in person or by email). Each potential control participant was advised to carefully read the consent form, and to contact me with any questions about the information contained in the consent form. Potential participants were encouraged, if they felt comfortable doing so, to discuss the consent form with family, friends, and/or their physician. The  32  interested control participants gave me their contact information in person or via email. They were given a minimum of 24 hours to review the consent form before I contacted them to ask if they would like to take part in the study. If the control participant expressed interest in the study after reading the consent form, I sent them a link to access the REDCap screening questions indicating sexual and non-sexual pain, age, and history of fibromyalgia. Each control subject was assigned a de-identified unique study ID. Eligibility criteria was assessed by screening questions. If the participants were eligible based on the screening questions (18 years or older, sexual and non-sexual pain scores less than 5/10, and no fibromyalgia) then they were asked if they would like to consent to the study (online consent). This online consent allowed access to the data from the screening questions. If they were not eligible, or did not consent to the study, their screening questions were not analyzed. Once the control participant consented online, they were asked to complete additional questions on REDCap (e.g., height, weight, etc.). I received an email from REDCap once the control participant had consented online and contacted the participant to book a test day appointment. If the control participant had not completed the pre-test questionnaire after one week, they were sent an email reminder. On the test day, the consent participants signed the same consent form in-person to consent to the testing procedures. Participants were instructed not to take analgesics within 24 hours before the scheduled test, nor to take opioids within 2 weeks before the scheduled test, nor to consume alcohol within 24 hours prior to scheduled test time. The participants were also told to wear comfortable clothing with easy access to their shoulder for the scheduled appointment. 2.5 AIM 2 - Creating REDCap data collection forms  New REDCap data collection forms were created specifically for Aim 2. Pre-test questionnaires were created to assess eligibility of control participants. Eligible control participants were contacted to book  33  a test-day appointment. Both case and control participants completed a test day questionnaire during their test day appointment. The test-day questionnaire asked about the woman’s experience of deep dyspareunia based on their last episode of intercourse. We did other analyses using the deep dyspareunia scores from the data registry which represented a global measure of deep dyspareunia and is not limited to the last episode.  QST was also performed during the test day appointment. Post-test questionnaires were sent to the case participants each day for six weeks following the test day appointment; these questionnaires indicate daily deep dyspareunia scores. The data for these post test questionnaires are not completed and therefore not presented in this thesis. Questionnaire items were modified from the Brief Pain Index and the BC Women’s Centre’s Intake questionnaire. See Appendix B for questionnaires. 2.6 AIM 2 - Pain-pressure threshold measurement In the recruited cases and controls, an Electronic Thimble Algometer was used to measure PPT at non-pelvic sites as a marker of central sensitization (a decreased PPT = greater central sensitization). The algometer consists of a calibration load cell and a force sensing resistor (FSR), as well as an amplifier which “reads” the force from the resistor and transfers the data to the connected laptop (Figure 1.8). The calibration load cell was calibrated once using 2 weights (0kg and 0.5kg) (Fisher Scientific, Cat #: S01369), as per the manufacturer’s recommendations. The device was monitored for fluctuations in measurements and was calibrated again if required. The FSR was then calibrated on the load cell before use on each participant. The calibrations ensured the accuracy and reliability of the measurements. Four test sites were measured: left deltoid muscle, right deltoid muscle, left first dorsal interosseous (FDI) muscle, and right FDI muscle (Figure 2.1). All test sites were measured twice; therefore, the PPT was measured eight times. The test sites were measured bilaterally and duplicated  34  to obtain an average value. The order of the test sites was determined randomly (randomization is intrinsic to the Electronic Thimble Algometer software).  I was blinded to participants’ symptoms and questionnaire scores, while the participants were blinded to the computer screen (where the PPT data were displayed) to ensure they were not influenced by the data during the QST. The testing room was at a temperature between 20 and 25 degrees Celsius, with no fans or open windows, and no stressful stimuli (e.g., no loud noises or blinking lights). The participants were sitting on a chair when QST occurred and before testing they were asked if they were comfortable.            35   Figure 2.1 Quantitative Sensory Testing (QST) sites. Star indicates test site.            36  2.7 Outcome Measures and Covariates 2.7.1 AIM 1: Deep dyspareunia in endometriosis: Role of bladder/pelvic floor tenderness The primary outcome was deep dyspareunia severity from the data registry, reported by patients on an 11-point numeric rating scale (0 being no pain and 10 being worst pain imaginable). The scores were then categorized into mild (0-3), moderate (4-6), and severe (7-10). The main variables of interest were: 1) tenderness of the bladder/pelvic floor (levator ani) determined on pelvic exam and grouped as a single variable[46]; and 2) PBS (using the diagnostic criteria from the American Urological Association and International Continence Society)[78-80]. Information on other factors potentially associated with deep dyspareunia were also obtained from the registry, and included the following: 1) abdominal wall pain (diagnosed by the Carnett test)[54]; 2) IBS (Rome III diagnostic criteria); 3) demographic factors  (e.g., age, parity, BMI); and 4) endometriosis-specific variables. Besides staging (Stage I/II vs Stage III/IV), the endometriosis-specific factors included endometriosis affecting the cul-de-sac (pouch of Douglas), which has been shown in previous studies to be associated with deep dyspareunia compared to endometriosis of other sites[44, 46].  For example, we included surgical diagnosis of an invasive nodule of the cul-de-sac and/or surgical diagnosis of cul-de-sac obliteration (partial or complete), which both constitute evidence of DIE. Another endometriosis-specific factor was tenderness of the cul-de-sac on pre-operative exam, in the presence of any surgically confirmed endometriosis of the cul-de-sac (“tender” endometriosis, whether invasive or not).  We also included tenderness of the cul-de-sac on pre-operative exam but without any surgically confirmed endometriosis of the cul-de-sac (which could represent referred pain); and a tender uterus/cervix on pre-operative exam, which we previously showed to also be associated with more severe deep dyspareunia[46].  37  2.7.2 AIM 2: Endometriosis-associated deep dyspareunia and central sensitization The primary outcomes were bladder/pelvic floor tenderness (yes/no) and PBS (yes/no), both derived from the registry, as well as severity of deep dyspareunia with pain associated with the last episode of intercourse reported by patients on an 11-point numeric rating scale (0 being no pain and 10 being worst pain imaginable). The main variable of interest was PPT at non-pelvic sites, deltoid muscles and FDI muscles, (as a marker central sensitization) measured by the Electronic Thimble Algometer on a continuous scale, in units of newtons (N). Given the results from Aim 1, I first tested for an association between PPT, and bladder/pelvic floor tenderness or PBS.  Information on other factors potentially associated with PPT were also obtained, and included the following: 1) abdominal wall pain (diagnosed by the Carnett test)[54]; 2) IBS (Rome III diagnostic criteria); 3) demographic factors  (e.g., age, BMI); and 4) psychological factors (depression [PHQ-9], anxiety [GAD-7], and pain catastrophizing [PCS]). I also tested for associations between PPT and deep dyspareunia severity with the last episode of intercourse self-reported on an 11-point numeric rating scale (0 being no pain and 10 being worst pain imaginable). The scores were then categorized into two categories -- low pain (0-4) and high pain (5-10), rather than the three categories in Aim 1, due to the smaller sample size in Aim 2. 2.7.3 AIM 1 Statistical Analysis: Deep dyspareunia in endometriosis: Role of bladder/pelvic floor tenderness The retrospective chart review yielded 48 women who had surgical removal of DIE between August 2010 and October 2013 and who also completed a questionnaire on deep dyspareunia severity scores.  38  Bivariate analysis indicated that deep dyspareunia severity [categorized into mild (0-3), moderate (4-6), and severe (7-10)] was significantly associated with bladder/pelvic floor tenderness (X2=6.58, p=0.037). Therefore, with power (1-β) = 0.80 and α = 0.05 two-tailed, and prevalence ratio 1.4 or higher, a sample size of 85 in the data registry was required for the prospective study to find an association between the severity of deep dyspareunia and bladder/pelvic floor tenderness (OpenEpi, Version 3).    For the analysis of the data registry, the primary outcome (deep dyspareunia severity categorized as none-mild [0-3], moderate [4-6], and severe [7-10]) was examined for the associations with bladder/pelvic floor tenderness (yes/no) and PBS (yes/no) and the other covariates using the Chi-square test (categorical variables) or Spearman correlation coefficient (continuous variables).  These associations were examined separately in two groups, Stage I/II and Stage III/IV endometriosis. Variables with significant bivariate associations (p < 0.05) were then entered into an ordinal logistic regression model with deep dyspareunia as the primary outcome categorized into three groups (0-3, 4-6, 7-10).  Two such models were fitted, one separately for the Stage I/II endometriosis group, and another for the Stage III/IV endometriosis group. Backward stepwise elimination method was used to derive the final models, with p-value criterion = 0.05. Ordinal regression was utilized because the assumptions of linear regression were not met when the raw 0-10 values were used for the primary outcome. A sub-analysis was done to look at the psychological factors associated with bladder/pelvic floor tenderness and PBS. The main variables of interest were: symptoms of depression, anxiety, and pain catastrophizing. Variables of interest were entered into a binominal logistic regression model with bladder/pelvic floor tenderness (yes/no) or PBS (yes/no) as the primary outcome. Two such models  39  were fitted for each primary outcome, one separately for the Stage I/II endometriosis group, and another for the Stage III/IV endometriosis group. Backward stepwise elimination method was used to derive the final models, with a p-value criterion of 0.05. Statistical analyses were performed using IBM SPSS Statistics 24.  Observations with missing data on any of the covariates were excluded from regression analyses.   2.7.4 AIM  2 Statistical Analysis: Endometriosis-associated deep dyspareunia and central sensitization Amongst the recruited endometriosis cases, the PPT (N) was tested for bivariate associations with bladder/pelvic floor tenderness, PBS, deep dyspareunia severity, as well as other variables (T-test).  Endometriosis cases were also compared to the healthy controls. Levene’s test for equality of variance was performed for all T-tests, and if significant (p<0.05), the Welch’s T-test was used. ANOVA was used to compare PPT between groups. Levene’s test for equality of variance was performed for all ANOVA tests, and, if significant, (p<0.05) the Welch’s ANOVA was used. Effect sizes (Cohen’s d for T-test and Eta2(η2) for ANOVA) were calculated. The association between the number of times engaged in intercourse between cases vs. controls was also examined using the Mann Whitney U test. Statistical analyses were performed using IBM SPSS Statistics 24.    40  Chapter 3: Deep dyspareunia in endometriosis: Role of bladder/pelvic floor tenderness (Aim 1) 3.1 Rationale To determine whether bladder/pelvic floor tenderness and PBS are associated with severity of deep dyspareunia, regardless of Stage of endometriosis disease (Stage I/II vs. Stage III/IV).  3.2 Study Sample Inclusion criteria for this study were new referral or re-referral patients at the BC Women’s Centre for Pelvic Pain and Endometriosis, who had a prospective surgery at the Centre with diagnosis and excision of histologically-confirmed endometriosis between January 1, 2014 and December 31, 2016.  Exclusion criteria were: indication of never being sexually active (on a questionnaire), post-menopausal status (spontaneous or surgical), missing pre-operative information on dyspareunia severity score, and absence of pre-operative pelvic exam (e.g., due to severe vaginismus) (Figure 3.1). Patients were divided into those with Stage I/II endometriosis and those with Stage III/IV endometriosis at the time of the surgery.  The goal was to determine whether bladder/pelvic floor tenderness and PBS were associated with severity of deep dyspareunia, even in women with high anatomic load of endometriosis disease (i.e., Stage III/IV). Four hundred and twenty-four patients from the registry were selected according to the study criteria (Figure 3.1, Table 3.1). In this sample, 263 women had Stage I/II endometriosis and 148 had Stage III/IV endometriosis, while 13 had missing data for Stage and were therefore excluded from analyses.  In the Stage I/II cohort, 12.2% (32/263) of women had none/mild deep dyspareunia (0-3 points on the severity scale), 18.3% (48/263) had moderate deep dyspareunia (4-6 points), and 69.6% (183/263) had  41  severe deep dyspareunia (7-10 points). In the Stage III/IV cohort, 27.7% (41/148) of women had none/mild deep dyspareunia (0-3 points on the severity scale), 23% (34/148) had moderate deep dyspareunia (4-6 points), and 49.3% (73/148) had severe deep dyspareunia (7-10 points) (Table 3.1). Other descriptive variables are shown in Appendix C.                  42                        Figure 3.1 Study population flowchart for prospective database (Aim 1).  Potentially eligible cases between January 1, 2014 and December 31, 2016 who had an exam date (n=842 phase 1 + n= 1443 phase 2. N total=2285) Total research cohort (n=294 phase 1, and n=450 phase 2. N total=744) Confirmed eligible (n=728 phase 1, and n=1260 phase 2. N total=1988) Included in study and analysis (n=182 phase 1, and n=242 phase 2. N total=424) Excluded cases who declined research consent or who withdrew from study (n=114 phase 1, and n=183 phase 2. N total=297)  Exclude cases who did not have a surgery date (n=434 phase 1, and n= 810 phase 2. N total=1244)  Excluded cases if: missing deep/superficial dyspareunia scores, never sexually active, age < 18 or >49 years old, post-menopausal, cases with no pathology confirmed endometriosis, both ovaries removed, physical exam not completed. (n=112 phase 1, and n=208 phase 2. N total=320)   43   Table 3.1 Demographic data and clinical characteristics for prospective participants (Aim 1).  Stage I/II (n=263) Stage III/IV (n=148) Characteristic Mean ± SD or Percentage (frequency) Mean ± SD or Percentage (frequency) Age, years   33.2 ± 6.9 36.3 ± 6.3  BMI, kg/m2      Underweight, <18.5      Normal, 18.5-24.9      Overweight, 25.0-29.9      Obese, >=30.0      Missing  2.3% (6) 58.6% (154) 22.4% (59) 15.2% (40) 1.5% (4)  4.1% (6) 59.5% (88) 22.3% (33) 14.2% (21) 0% (0) Parity      Previous birth(s)      No previous births      Missing  39.5% (104) 59.7% (157) 0.8% (2)  33.8% (50) 65.5% (97) 0.7% (1) Hormonal Suppression      Currently taking      Not currently taking  30.8% (81) 69.2% (182)   27% (40) 73% (108) Bladder or Pelvic floor tenderness      Yes      No  45.6% (120) 54.4% (143)  33.8% (50) 66.2% (98) Cul-de-sac tenderness      Yes      No  65.8% (173) 34.2% (90)  49.3% (73) 50.7% (75) Uterus or cervix tenderness      Yes      No      Missing  33.5% (88) 66.5% (175) 0% (0)  25% (37) 73.6% (109) 1.4% (2) Irritable bowel syndrome      Yes      No  56.7% (149) 43.3% (114)  54.7% (81) 45.3% (67) Painful bladder syndrome      Yes      No  49.8% (131) 50.2% (132)  49.3% (73) 50.7% (75)  44   Stage I/II (n=263) Stage III/IV (n=148) Characteristic Mean ± SD or Percentage (frequency) Mean ± SD or Percentage (frequency) Abdominal wall pain      Carnett test positive      Carnett test negative  35.7% (94) 64.3% (169)  18.2% (27) 81.8% (121) Cul-de-sac nodule at surgery      Yes      No  11% (29) 89% (234)  25% (37) 75% (111) Cul-de-sac obliteration at surgery (partial or complete)      Yes      No   3% (8) 97% (255)   53.4% (79) 46.6% (69) Cul-de-sac tenderness on exam, and cul-de-sac endometriosis at surgery      Yes      No   62.4% (164) 37.6% (99)   38.5% (57) 61.5% (91) Cul-de-sac tenderness on exam, and no cul-de-sac endometriosis at surgery      Yes      No   9.9% (26) 90.1% (237)   13.5% (20) 86.5% (128) Deep Dyspareunia Mild (0-3) Moderate (4-6) Severe (7-10)  12.2% (32) 18.3% (48) 69.6% (183)  27.7% (41) 23% (34) 49.3% (73)        45  3.3 Methods  Data collection and analysis of a retrospective cohort of women with DIE was done to power the prospective cohort. Clinical data of women from the prospective cohort who met the study eligibility criteria was collected from the online prospective data registry and analysed. See Chapter 2 for more details.              46  3.4 Results 3.4.1 Stage I/II endometriosis  In women with Stage I/II endometriosis, severity of deep dyspareunia was associated with bladder/pelvic floor tenderness (X2=11.38, p=0.003) and PBS (X2=12.18, p=0.002), as well as cul-de-sac nodule (X2=6.99, p=0.03), and uterus and/or cervix tenderness (X2=6.54, p=0.038) (Table 3.2).  Other variables, including Carnett test, IBS, and endometriosis-specific factors, were not associated with deep dyspareunia (Table 3.2).             47    Table 3.2 Bivariate associations with the severity of deep dyspareunia (Stage I/II endometriosis). Factor N total None-Mild deep dyspareunia (0-3)  Moderate deep dyspareunia (4-6) Severe  deep dyspareunia  (7-10) Statistics  P value Categorical Variables     Chi-Squared/ Fisher’s Exact   Bladder/ Pelvic floor tenderness      Yes      No 263    5%1 (6) 18%1 (26)    18% (21) 19% (27)    77% (93) 63% (90) 11.38 0.003 Painful bladder syndrome      Yes      No 263          5% (7) 19% (25)    18% (23) 19% (25)    77% (101) 62% (82) 12.18 0.002 Cul-de-sac tenderness      Yes      No 263   10% (17) 17% (15)   16% (28) 22% (20)   74% (128) 61% (55) 4.87 0.088 Cul-de-sac nodule      Yes      No 263   21% (6) 11% (26)   31% (9) 17% (39)   48% (14) 72% (169) 7.00 0.03 Cul-de-sac obliteration (partial)      Yes      No 263    25% (2) 12% (30)    0% (0) 19% (48)    75% (6) 69% (177) 2.66 0.27 Cul-de-sac tenderness and  cul-de-sac endometriosis      Yes      No 263      12% (19) 13% (13)      18% (30) 18% (18)      70% (115) 69% (68) 0.14 0.93  48  Factor N total None-Mild deep dyspareunia (0-3)  Moderate deep dyspareunia (4-6) Severe  deep dyspareunia  (7-10) Statistics  P value Categorical Variables     Chi-Squared/ Fisher’s Exact   Cul-de-sac tenderness and  no cul-de-sac  endometriosis      Yes      No 263      4% (1) 13% (31)      11% (3) 19% (45)      85% (22) 68% (161) 3.29 0.19 Uterus/cervix tenderness      Yes      No 263   7% (6) 15% (26)   14% (12) 21% (36)   79% (70) 64% (113) 6.54 0.038 Irritable bowel syndrome      Yes      No 263    10% (15) 15% (17)    17% (26) 19% (22)    73% (108) 66% (75) 1.78 0.41 Abdominal wall pain    Carnett pos    Carnett neg 263   8% (7)       15% (25)   19% (18)       18% (30)   73% (69)    67% (114) 3.05 0.22 Parity      Yes      No 261  9% (9) 15% (23)  16% (17) 19% (30)  75% (78) 66% (104) 2.79 0.25 Current hormonal suppression      Yes      No 263    9% (7) 14% (25)    22% (18) 16% (30)    69% (56) 70% (127) 2.21 0.33 Continuous Variables     Spearman Correlation Coefficient (r)  Age  263 -- -- -- -0.038 0.54 BMI group  259 -- -- -- 0.093 0.13 1Percentages are for each row (e.g., % based on the sum for the “yes” row, and % based on the sum for the “no” row)  49  3.4.2 Stage III/IV endometriosis In women with Stage III/IV endometriosis, severity of deep dyspareunia was associated with bladder/pelvic floor tenderness (X2=10.05, p=0.007), and PBS (X2=7.24, p=0.027), as well as positive Carnett test (X2=6.17, p=0.046), younger age (r=-0.18, p=0.03) (Table 3.3).                50    Table 3.3 Bivariate associations with the severity of deep dyspareunia (Stage III/IV endometriosis). Factor N total None-Mild deep dyspareunia (0-3)  Moderate deep dyspareunia (4-6) Severe  deep dyspareunia  (7-10) Statistics P value Categorical Variables     Chi-Squared/ Fisher’s Exact  Bladder/ pelvic floor tenderness      Yes      No 148    12%1 (6) 36%1 (35)    24% (12) 22% (22)    64% (32) 42% (41) 10.05 0.007 Painful bladder syndrome      Yes      No 148    18% (13) 37% (28)    25% (18) 21% (16)    57% (42) 42% (31) 7.24 0.027 Cul-de-sac tenderness      Yes      No 148   21% (15) 35% (26)   27% (20) 19% (14)   52% (38) 46% (35) 4.12 0.13 Cul-de-sac nodule      Yes      No 148   30% (11) 27% (30)   24% (9) 23% (25)   46% (17) 50% (56) 0.23 0.89 Cul-de-sac obliteration (partial or complete)      Yes      No 148     27% (21) 29% (20)     25% (20) 20% (14)     48% (38) 51% (35) 0.53 0.77 Cul-de-sac tenderness and  cul-de-sac endometriosis      Yes      No 148            18% (10) 34% (31)      28% (16) 20% (18)      54% (31) 46% (42) 4.98 0.083  51  Factor N total None-Mild deep dyspareunia (0-3)  Moderate deep dyspareunia (4-6) Severe  deep dyspareunia  (7-10) Statistics P value Categorical Variables     Chi-Squared/ Fisher’s Exact  Cul-de-sac tenderness and no  cul-de-sac endometriosis      Yes      No 148             25% (5) 28% (36)           35% (7) 21% (27)                     40% (8) 51% (65) 1.93 0.38 Uterus/cervix tenderness      Yes      No 146   19% (7) 30% (33)   32% (12) 20% (22)   49% (18) 50% (54) 3.08 0.21 Irritable bowel syndrome      Yes      No 148    25% (20) 31% (21)    26% (21) 20% (13)    49% (40) 49% (33) 1.27 0.53 Abdominal wall pain Carnett pos Carnett neg 148       11% (3) 31% (38)   37% (10) 20% (24)   52% (14) 49% (59) 6.17 0.046 Parity      Yes      No 147  30% (15) 27% (26)  20% (10) 25% (24)  50% (25) 48% (47) 0.46 0.80 Current hormonal suppression      Yes      No 148          20% (8) 31% (33)                  18% (7) 25% (27)                      62%(25)  44% (48) 3.82 0.15 Continuous Variables     Spearman correlation coefficient (r)  Age 148 -- -- -- -0.18 0.03 BMI group 148 -- -- -- 0.033 0.69 1Percentages are for each row (e.g., % based on the sum for the “yes” row, and % based on the sum for the “no” row)  52  3.4.3 Ordinal regression In women with Stage I/II endometriosis, severity of deep dyspareunia was independently associated with bladder/pelvic floor tenderness (AOR=1.94, 95% CI 1.11-3.38, p=0.019), and PBS (AOR=1.99, 95% CI 1.15-3.44, p=0.013), in addition to cul-de-sac nodule (AOR=0.41, 95% CI 0.19-0.87, p=0.021) (Table 3.4).  In women with Stages III/IV endometriosis, severity of deep dyspareunia was independently associated with bladder/pelvic floor tenderness (AOR=2.51, 95% CI 1.25-5.02, p=0.01), and PBS (AOR=1.90, 95% CI 1.01-3.57, p=0.048) (Table 3.4).           53  Table 3.4 Multivariable ordinal regression models showing the association between various factors and severity of deep dyspareunia. Factor Stage I/II (N=263) Stage III/IV      (N=148) B AOR (95% CI) P value B AOR (95% CI) P value Bladder/ Pelvic floor tenderness 0.66 1.94 (1.11 – 3.38) 0.019 0.92 2.51 (1.25 – 5.02) 0.01 Painful Bladder Syndrome 0.69 1.99 (1.15 – 3.44) 0.013 0.64 1.90 (1.01 - 3.57) 0.048 Cul-de-sac nodule -0.89 0.41 (0.19 – 0.87)  0.021 -- -- -- B denotes the Beta coefficient, AOR denotes adjusted odds ratio.               54  3.4.4 Sub-analysis: Binomial logistic regression In women with Stage I/II endometriosis, bladder/pelvic floor tenderness was independently associated with increased severity of depression and pain catastrophizing on binary logistic regression (AOR=2.23, 95% CI 1.29-3.86, p=0.004, and AOR=2.13, 95% CI 1.17-3.88, p=0.013, respectively) (Table 3.5).  PBS was independently associated with increased severity of depression on binary logistic regression (AOR=2.73, 95% CI 1.65-4.53, p=0.000) (Table 3.6). On the other hand, in women with Stage III/IV endometriosis, bladder/pelvic floor tenderness was independently associated with increased anxiety only (AOR=3.41, 95% CI 1.62-7.18, p=0.001) (Table 3.5). PBS was independently associated with increased severity of depression on binary logistic regression (AOR=2.94, 95% CI 1.46-5.95, p=0.003) (Table 3.6).          55  Table 3.5 Multivariable analysis of the association between bladder/pelvic floor tenderness and psychological factors among women with Stage I/II vs. Stage III/IV endometriosis (Aim 1). Factor Stage I/II (N=263) Stage III/IV      (N=148) B AOR (95% CI) P value B AOR (95% CI) P value Depression 0.80 2.23 (1.29 – 3.87) 0.004 -- -- -- Pain Catastrophizing 0.76 2.13 (1.17 – 3.88) 0.013 -- -- -- Anxiety -- -- -- 1.23 3.41 (1.62 – 7.18) 0.001 B denotes the Beta coefficient, AOR denotes adjusted odds ratio.                56  Table 3.6 Multivariable analysis of the association between painful bladder syndrome and psychological factors among women with Stage I/II vs. Stage III/IV endometriosis (Aim 1). Factor Stage I/II (N=263) Stage III/IV      (N=148) B AOR (95% CI) P value B AOR (95% CI) P value Depression 1.00 2.73 (1.65 – 4.53) <0.001 1.08 2.94 (1.46 – 5.95) 0.003 B denotes the Beta coefficient, AOR denotes adjusted odds ratio.                 57  3.5 Discussion In this study of women with surgically and histologically confirmed endometriosis from a tertiary care centre, we found that bladder/pelvic floor tenderness and PBS were associated with severity of deep dyspareunia, regardless of other clinical factors, including endometriosis-specific variables.  These findings were observed in women with both minimal-mild (Stage I/II) and moderate-to-severe (Stage III/IV) endometriosis, suggesting a role for bladder/pelvic floor tenderness and PBS regardless of the anatomic load of disease. We hypothesize that one mechanism for deep dyspareunia in endometriosis may involve direct contact with the bladder or levator ani during deep penetration. Alternatively, bladder/pelvic floor tenderness on exam and meeting clinical criteria for PBS could be markers for pelvic floor dysfunction in the sexual context. The etiology of bladder/pelvic floor tenderness may include intrinsic bladder problems, nervous system sensitization, or factors with a myofascial origin[43].  Invasive endometriosis of the bladder or pelvic floor is rare and would not account for bladder/pelvic floor tenderness in most women with endometriosis.  In contrast, PBS is a common comorbid condition in women with endometriosis, and its association with severity of deep dyspareunia suggests that it can account for some cases of deep dyspareunia in women with endometriosis. We also found that bladder/pelvic floor tenderness was associated with deep dyspareunia, independent of PBS, suggesting that myofascial factors or central (or cross) sensitization may also be important in tenderness of these areas[46].  Myofascial pain could involve tender trigger points in the levator ani or anterior vaginal wall[64, 65] due to hyperactive nerve firing within the skeletal muscle reflex arc due to muscle fibre trauma[64, 66].  Sensitization could manifest as hyperalgesia and allodynia[56, 57] in normally non-tender structures (e.g., the bladder and pelvic floor); this could occur by amplification of central nervous system nociceptive  58  pathways, or by viscero-visceral convergence or viscero-somatic convergence at the spinal cord that links gynecologic pain to other visceral (e.g., bladder) or somatic (e.g., pelvic floor) structures[58].  Strengths of the study include its prospective nature and appropriately powered sample size, as well as stringent surgical phenotyping combined with detailed patient-reported and physical examination data in the registry. Limitations include the assessment of pelvic floor tenderness of only one muscle (levator ani).  Also, in future work, it would be interesting to determine whether bladder/pelvic floor tenderness or PBS predicts change in deep dyspareunia severity after surgical removal of endometriosis.  Generalizability is affected by the tertiary referral setting of the study.    In summary, in this study, we found that bladder/pelvic floor tenderness and PBS were associated with more severe deep dyspareunia in women in endometriosis, independent of Stage (anatomic load of disease) or other endometriosis-specific variables (e.g., location or invasiveness of disease).  This raises the possibility of nervous system or myofascial mechanisms in some women with endometriosis-associated deep dyspareunia, even in those with Stage III/IV endometriosis.  An association has been found between dyspareunia and decreased PPT (as a marker of central nervous system sensitization) in the chronic pelvic pain population[81].  A similar QST study should be done in the endometriosis population to further characterize the relationship between central sensitization, bladder/pelvic floor tenderness and PBS, and severity of deep dyspareunia (Aim 2).   Greater recognition of potential nervous system and myofascial origins of deep dyspareunia in endometriosis, even in women with advanced Stage endometriosis, is important as it may guide management[42].  For example, even in the patient with advanced Stage endometriosis that requires surgery, there may still be a peri-operative role for pelvic floor physiotherapy, cognitive therapies, and sexual therapy to address the nervous system and myofascial components of the deep dyspareunia.  In  59  other patients with endometriosis, their deep dyspareunia may be primarily due to the bladder/pelvic floor, rather than the endometriosis lesions, and it may be ideal to avoid surgery in this population and focus on allied health care approaches. These latter patients could be classified as having DSM-V genito-pelvic pain penetration disorder, where the deep dyspareunia is not directly due to the underlying disease (endometriosis), but to sensitization/myofascial mechanisms[42]. Further research is needed to accurately phenotype sexual pain in endometriosis, to individualize treatment based on the actual causes of deep dyspareunia in each case, and to avoid unnecessary treatments such as repetitive surgeries. We also found that in women with Stage I/II endometriosis, bladder/pelvic floor tenderness was specifically associated with increased symptoms of depression and pain catastrophizing, and PBS was independently associated with increased depressive symptoms. In contrast, in women with Stage III/IV endometriosis, bladder/pelvic floor tenderness was specifically associated with increased symptoms of anxiety, while PBS was again associated with increased depressive symptoms. This suggests that there may be different psychological etiologies or consequences of bladder/pelvic floor tenderness in women with minimal-mild disease vs. those with moderate-severe disease. Nevertheless, these results suggest that symptoms of depression are important for PBS, regardless of Stage of endometriosis.   The clinical implications of this analysis are that different psychological factors should be considered more significant in managing bladder/pelvic floor tenderness in women with Stage I/II versus Stage III/IV endometriosis. Also, clinicians should consider screening for symptoms of depression since these results indicate that depression is the psychological factor most consistently associated with bladder/pelvic floor tenderness or PBS in our cohort.  This should lead a gynecologist to a more  60  multidisciplinary treatment plan where psychological factors can be managed. However, further investigation into this is required.   61  Chapter 4: Central sensitization in endometriosis-associated deep dyspareunia (Aim 2) 4.1 Rationale In Aim 1, I found that bladder/pelvic floor tenderness and PBS were independently associated with deep dyspareunia, in both women with Stage I/II and Stage III/IV endometriosis.  In Aim 2, I sought to determine whether bladder/pelvic floor tenderness and PBS are associated with markers of central sensitization, by using QST for PPT at non-pelvic sites (lower PPT indicative of central sensitization).  Additionally, in Aim 2, I determined whether lower PPT was associated with more severe deep dyspareunia.   4.2 Study Sample 4.2.1 Case participants I prospectively recruited 29 women with endometriosis (previous surgical diagnosis, or current palpable nodule or visualized endometrioma on ultrasound) between 18-49 years old from the BC Women’s Centre for Pelvic Pain and Endometriosis (Figure 4.1 and 4.2). In this cohort, 55.2% (16/29) of women had 0 to mild deep dyspareunia scores (0-4 points on the severity scale), and 44.8% (13/29) had moderate to severe deep dyspareunia scores (5-10 points) (Table 4.1). Demographic variables are shown in Table 4.1. 4.2.2 Control participants I also recruited a control cohort of 17 women without endometriosis (suspected or diagnosed) between 18-49 years, recruited by flyer/electronic advertisement from the community (Figure 4.3). In this  62  cohort, 100% (17/17) of the women had 0 to mild deep dyspareunia scores (0-4 points on the severity scale) (Table 4.1). Demographic variables are shown in Table 4.1. 4.2.3 Exclusion criteria The exclusion criteria for both case and control participants were as follows: fibromyalgia, severe and/or enduring psychological illness affecting cognition (e.g., schizophrenia), currently pregnant and/or breastfeeding, central and/or peripheral neurological disorder, do not speak English, diabetes mellitus and/or neuropathic pain, trauma to QST test site(s) (deltoid muscle and FDI muscle). Women with fibromyalgia, central and/or peripheral neurological disorders, and diabetes mellitus and/or neuropathic pain were excluded for this study as these conditions influence QST results[82]. Severe and/or enduring psychological illness affecting cognition was an exclusion criterion to ensure that the participants fully understood the procedures of the study. Women who did not speak English were excluded from this study since we could not be sure that they would fully understand the procedures; also, we did not have the funds for a translator. Women who were currently pregnant/breastfeeding were excluded to ensure no harm came to the fetus or baby[83]. Lastly, trauma to test sites was an exclusion criterion since it may have affected the PPT results.       63                       Figure 4.1 Flowchart for study criteria of case participants (Aim 2).    Potential case participants (n=249) Total research cohort (n=30) Confirmed eligible (n=61) Included in study and analysis (N total=29) Excluded cases who: did not want to be contacted by a researcher; did not have endometriosis; did not consent to the data registry; had fibromyalgia/currently pregnant or breastfeeding/did not speak English/psychological illness/peripheral or central neurological disorder/diabetes mellitus/neuropathic pain (n=188)  Excluded cases if: were unable to be reached via. phone call or did not consent to research or missing deep dyspareunia scores or age < 18 or >49 years old or post-menopausal or both ovaries removed or trauma to QST sites (n=31)  Excluded cases who withdrew (n=1)  64   Table 4.1 Demographics for study sample (Aim 2).  Case (n=29) Control (n=17) Characteristic Mean ± SD or Percentage (frequency) Mean ± SD or Percentage (frequency) Age, years   34.8±6.7 30.6 ± 7.5  BMI, kg/m2 Underweight, <18.5 Normal, 18.5-24.9 Overweight, 25.0-29.9 Obese, >=30.0 Missing  0% (0) 48.3% (14) 34.5% (10) 17.2% (5) 0% (0)  0% (0) 64.7% (11) 11.8% (2) 23.5% (4) 0% (0) Hormonal Suppression Currently taking Not currently taking  62.1% (18) 37.9% (11)   35.3% (6) 64.7% (11) Deep Dyspareunia (test day) None Low (1-4) High (>=5)  10.3% (3) 44.8% (13) 44.8% (13)  58.8% (10) 41.2% (7) 0% (0) Deep Dyspareunia (registry) None Low (1-4) High (>=5)  10.3% (3) 13.8% (4) 75.9% (22)  N/A Deep Dyspareunia Mild (0-3) Moderate (4-6) Severe (7-10)  44.8% (13) 27.6% (8) 27.6% (8)  100% (17) 0% (0) 0% (0) Superficial Dyspareunia Mild (0-3) Moderate (4-6) Severe (7-10)  62.1% (18) 20.7% (6) 17.2% (5)  94.1% (16) 5.9% (1) 0% (0) Superficial Dyspareunia (test day) None Low (1-4) High (>=5)  37.9% (11) 34.5% (10) 27.6% (8)  58.8% (10) 41.2% (7) 0% (0) Superficial Dyspareunia (registry) None Low (1-4) High (>=5)  31.0% (9) 37.9% (11) 31.0% (9)  N/A Worst Pelvic Pain in the last 24 hours Mild (0-3) Moderate (4-6) Severe (7-10)  72.4% (21) 10.3% (3) 17.2% (5)  100% (17) 0% (0) 0% (0)  65   Case (n=29) Control (n=17) Characteristic Mean ± SD or Percentage (frequency) Mean ± SD or Percentage (frequency) Least Pelvic Pain in the last 24 hours Mild (0-3) Moderate (4-6) Severe (7-10)  93.1% (27) 6.9% (2) 0% (0)  100% (17) 0% (0) 0% (0) Average Pelvic Pain in the last 24 hours Mild (0-3) Moderate (4-6) Severe (7-10)  86.2% (25) 13.8% (4) 0% (0)  100% (17) 0% (0) 0% (0) Pelvic Pain right now Mild (0-3) Moderate (4-6) Severe (7-10)  82.8% (24) 17.2% (5) 0% (0)  100% (17) 0% (0) 0% (0) Menstrual Pain (LMP) Mild (0-3) Moderate (4-6) Severe (7-10)  17.2% (5) 41.4% (12) 41.4% (12)  88.2% (15) 11.8% (2) 0% (0) Dysmenorrhea ever (registry) Low (<5) High (>=5) Missing (no dysmenorrhea ever)  0.0% (0) 96.6% (28) 3.4% (1)  N/A Dysmenorrhea 3 months (registry) Low (<5) High (>=5) No Bleeding  13.8% (4) 79.3% (23) 6.9% (2)  N/A Dyschezia (registry) Low (<5) High (>=5)  65.5% (19) 34.5% (10)  N/A Chronic Pelvic Pain (registry) Low (<5) High (>=5) Missing (no other pelvic pain)  24.1% (7) 69.0% (20) 6.9% (2)  N/A Back Pain (registry) Low (<5) High (>=5) Missing (no back pain)  31.0% (9) 55.2% (16) 13.8% (4)  N/A Average pain-pressure threshold of the left deltoid, newton 14.5 ± 6.8 14.9 ± 6.7 Average pain-pressure threshold of the right deltoid, newton 15.3 ± 6.5 14.6 ± 6.2 Average pain-pressure threshold of the left first dorsal interosseous, newton 14.0 ± 7.5 11.1 ± 7.2  66   Case (n=29) Control (n=17) Characteristic Mean ± SD or Percentage (frequency) Mean ± SD or Percentage (frequency) Average pain-pressure threshold of the right first dorsal interosseous, newton 14.7 ± 7.7 12.3 ± 7.7 Average pain-pressure threshold for deltoid, newton 14.9 ± 6.6 14.8 ± 6.0 Average pain-pressure threshold for first dorsal interosseous, newton 14.3 ± 7.3 11.7 ± 7.4 Parity Previous birth(s) No previous births  20.7% (6) 79.3% (23)   N/A Bladder or Pelvic floor tenderness Yes No  20.7% (6) 79.3% (23)  N/A Cul-de-sac tenderness Yes No  48.3% (14) 51.7% (15)  N/A Uterus or cervix tenderness Yes No  13.8% (4) 86.2% (25)  N/A Irritable bowel syndrome Yes No  58.6% (17) 41.4% (12)  N/A Painful bladder syndrome Yes No  51.7% (15) 48.3% (14) N/A  Abdominal wall pain Carnett test positive (worse) Carnett test negative  24.1% (7) 75.9% (22) N/A  Patient Health Questionnaire <10 >=10  62.1% (18) 37.9% (11)  N/A Generalized Anxiety Disorder <10 >=10  65.5% (19) 34.5% (10)  N/A  Pain Catastrophizing Scale <30 >=30  72.4% (21) 27.6% (8)  N/A   67  4.3 Methods Test DayData Registry QuestionnairePhysician AppointmentMet Inc/Exc Criteria?Are they interested in participating?YesEnd StudyNo NoResearcher calls only individuals who consent to data registryMD indicates  yes  on inc/exc form and gives consent formYesMinimum 24hrslaterInterested in the study?NoBook AppointmentYesOnline questionnaireQSTFeedback FormConsent in personResearcher calls – Any survey problems?1 weeklaterFix survey ProblemsComplete REDCap survey for 6 weeksTo remind study participant to send dataAutomated EmailHas data been sent in?Researcher phones to remind study participantNoData SentYesEnd StudyAppendix ANote: Researcher is Natasha Orr or her delegateYes Figure 4.2 Flowchart for recruitment and study process for case participants.  68  Test DaySee AdvertisementContact Researcher to learn more about studyAre they interested in participating?End StudyNoResearcher gives copy of consent form.REDCap email sent to request consent and complete screening questionsYesOnline questionnaireQSTFeedback FormAppendix BNote: Researcher is Natasha Orr or her delegateConsent given?NoFill out pre-visit online questionnaireYesEnd StudyResearcher calls to book test dateConsent in person Figure 4.3 Flowchart for recruitment and study process for control participants.  69  4.4 Results In our population of women with endometriosis, average PPT was 14.9±6.6 N at the deltoid muscles, and 14.3±7.3 N at the FDI muscles.  In the control population, average PPT was 14.8±6.0 N at the deltoid muscles, and 11.7±7.4 N at the FDI muscles.  In the case participants, PPT (central sensitization) at the deltoids and FDI muscles were significantly associated with bladder/pelvic floor tenderness (t=2.9, p=0.007; t=2.3, p=0.029; respectively) (Table 4.2). There was no significant association between PPT and PBS, nor with IBS or abdominal wall pain (positive Carnett test) (Tables 4.3-4.5). There was a significant association between lower left deltoid PPT and higher severity of test day superficial dyspareunia (low [0-4] vs. high [5-10]), on Welch’s T test (t=2.1, p=0.045), as shown in Table 4.6. Effect sizes (Cohen’s d) are indicated in the tables.          70  Table 4.2 Associations between pain-pressure thresholds (PPT; newtons) and bladder/pelvic floor tenderness (BPF), in women with endometriosis. Factor N total BPF no tender (n=23) BPF tender (n=6) Statistics  P value Cohen’s d Continuous Variables    T Test   Average PPT of the left deltoid 29 16.1±6.5 8.2±4.2 2.840 0.008 1.44 Average PPT of the right deltoid 29 16.9±6.2 9.3±4.2 2.810 0.009 1.44 Average PPT of the left FDI 29 15.6±7.0 7.9±6.2 2.448 0.021 1.16 Average PPT of the right FDI 29 16.0±7.7 9.4±5.4 1.965 0.060 0.99 Average PPT of the deltoid 29 16.5±6.2 8.7±4.0 2.903 0.007 1.50 Average PPT of the FDI 29 15.8±7.1 8.6±5.3 2.308 0.029 1.15             71  Table 4.3 Associations between pain-pressure thresholds (PPT; newtons) and painful bladder syndrome (PBS), in women with endometriosis. Factor N total PBS (n=15) No PBS (n=14) Statistics  P value Cohen’s d Continuous Variables    T Test   Average PPT of the left deltoid 29 15.2±7.9 13.7±5.8 -0.567 0.575 0.22 Average PPT of the right deltoid 29 15.6±7.8 15.0±5.2 -0.225 0.824 0.09 Average PPT of the left FDI 29 15.6±8.6 12.2±5.8 -1.215 0.235 0.46 Average PPT of the right FDI 29 15.4±9.1 13.9±6.1 -0.533 0.598 0.19 Average PPT of the deltoid 29 15.4±7.7 14.4±5.3 -0.408 0.687 0.15 Average PPT of the FDI 29 15.5±8.7 13.1±5.3 -0.901 0.375 0.33            72  Table 4.4 Associations between pain-pressure thresholds (PPT; newtons) and irritable bowel syndrome (IBS), in women with endometriosis. Factor N total IBS (n=17) No IBS (n=12) Statistics  P value Cohen’s d Continuous Variables    T Test   Average PPT of the left deltoid 29 15.0±7.4 13.8±6.2 -0.464 0.65 0.18 Average PPT of the right deltoid 29 15.4±7.4 15.2±5.3 -0.09 0.93 0.03 Average PPT of the left FDI 29 15.3±8.4 12.1±5.7 -1.132 0.27 0.45 Average PPT of the right FDI 29 15.4±8.5 13.6±6.7 -0.626 0.54 0.24 Average PPT of the deltoid 29 15.2±7.3 14.5±5.6 -0.287 0.78 0.11 Average PPT of the FDI 29 15.4±8.2 12.9±5.6 -0.910 0.37 0.36            73  Table 4.5 Associations between pain-pressure thresholds (PPT; newtons) and Carnett test, in women with endometriosis. Factor N total Carnett positive worse (n=7) Carnett negative (n=22) Statistics  P value Cohen’s d Continuous Variables    T Test   Average PPT of the left deltoid 29 15.5±8.8 14.2±6.3 -0.439 0.66 0.17 Average PPT of the right deltoid 29 16.6±8.1 14.9±6.1 -0.602 0.55 0.24 Average PPT of the left FDI 29 15.9±9.6 13.4±6.8 -0.787 0.44 0.30 Average PPT of the right FDI 29 15.0±10.6 14.6±6.8 -0.117 0.91 0.04 Average PPT of the deltoid 29 16.0±8.3 14.5±6.1 -0.529 0.60 0.21 Average PPT of the FDI 29 15.4±10.1 14.0±6.4 -0.463 0.65 0.17          74  Table 4.6 Bivariate associations between pain-pressure thresholds (PPT; newtons) and severity of superficial dyspareunia (SD). Factor N total Cases <5 SD (n=21) Case >=5 SD (n=8) Levene’s F; significance Statistics  P value Cohen’s d Continuous Variables     T Test   Average PPT of the left deltoid 29 15.7±7.3 11.2±4.1 4.776; 0.038 2.119 0.045 0.76 Average PPT of the right deltoid 29 16.3±7.1 12.6±3.7 -- 1.386 0.18 0.65 Average PPT of the left FDI 29 14.7±7.9 12.1±6.4 -- 0.848 0.40 0.36 Average PPT of the right FDI 29 15.1±8.6 13.6±4.7 -- 0.467 0.64 0.22 Average PPT of the deltoid 29 16.0±7.1 11.9±3.7 -- 1.557 0.13 0.72 Average PPT of the FDI 29 14.9±7.9 12.8±5.3 -- 0.681 0.50 0.31         75  Psychological variables (depression, anxiety and pain catastrophizing) were assessed for their relationship with PPT (central sensitization) in case participants, using t-tests. There were no significant associations found between any PPT sites and psychological variables (Table 4.7-4.9).                   76  Table 4.7 Bivariate associations between pain-pressure threshold (PPT; newtons) and depression, in women with endometriosis. Factor N total PHQ <10 (n=18) PHQ >=10 (n=11) Statistics  P value Cohen’s d Continuous Variables    T Test   Average PPT of the left deltoid 29 13.7±6.7 15.7±7.3 -0.752 0.46 -0.29 Average PPT of the right deltoid 29 14.3±6.6 16.9±6.3 -1.009 0.32 -0.40 Average PPT of the left FDI 29 12.9±6.5 15.7±8.9 -0.971 0.34 -0.36 Average PPT of the right FDI 29 13.8±7.0 16.0±9.0 -0.736 0.47 -0.27 Average PPT of the deltoid 29 14.0±6.5 16.3±6.6 -0.896 0.38 -0.35 Average PPT of the FDI 29 13.4±6.4 15.9±8.7 -0.888 0.38 -0.33 PHQ denotes Patient Health Questionnaire. A score of 10 or higher is clinically relevant.          77   Table 4.8 Bivariate associations between pain-pressure threshold (PPT; newtons) and anxiety, in women with endometriosis. Factor N total GAD <10 (n=19) GAD >=10 (n=10) Statistics  P value Cohen’s d Continuous Variables    T Test   Average PPT of the left deltoid 29 13.6±7.3 16.1±5.8 -0.919 0.37 -0.38 Average PPT of the right deltoid 29 15.0±6.9 15.8±6.0 -0.282 0.78 -0.12 Average PPT of the left FDI 29 14.1±7.8 13.8±7.2 0.092 0.93 0.04 Average PPT of the right FDI 29 14.6±7.7 14.8±8.1 -0.040 0.97 -0.03 Average PPT of the deltoid 29 14.3±7.0 15.9±5.8 -0.618 0.54 -0.25 Average PPT of the FDI 29 14.4±7.4 14.3±7.4 0.026 0.98 0.01 GAD denotes Generalized Anxiety Disorder. A score of 10 or higher is clinically relevant.         78   Table 4.9 Bivariate associations between pain-pressure threshold (PPT; newtons) and pain catastrophizing, in women with endometriosis. Factor N total PCS <30 (n=21) PCS >=30 (n=8) Statistics  P value Cohen’s d Continuous Variables    T Test   Average PPT of the left deltoid 29 13.6±7.1 16.9±5.9 -1.165 0.25 -0.51 Average PPT of the right deltoid 29 14.1±6.7 18.4±5.1 -1.633 0.11 -0.72 Average PPT of the left FDI 29 12.9±7.7 16.9±6.4 -1.305 0.20 -0.56 Average PPT of the right FDI 29 14.2±7.6 16.0±8.2 -0.578 0.57 -0.23 Average PPT of the deltoid 29 13.8±6.8 17.6±5.4 -1.420 0.17 -0.62 Average PPT of the FDI 29 13.5±7.3 16.4±7.2 -0.970 0.34 -0.40 PCS denotes Pain Catastrophizing Scale. A score of 30 or higher is a clinically relevant score, representing the 75th percentile of chronic pain patients.       79    Figures 4.4-4.9 shows the mean and 95% confidence intervals for the PPT’s between four groups using the deep dyspareunia scores from the test day questionnaire: 1) cases with high deep dyspareunia scores and bladder/pelvic floor tenderness (n=4); 2) cases with high deep dyspareunia scores and no bladder/pelvic floor tenderness (n=9); 3) cases with low deep dyspareunia scores (n=16); and 4) controls (n=17).   For all test sites, we observed that the cases with high deep dyspareunia and bladder/pelvic floor tenderness had lower PPT compared to the other groups (Figures 4.4-4.9).  However, the ANOVA showed that these differences were not statistically significant (Figures 4.4-4.9). Effect sizes (η2) are indicated in the figure captions.        80   Figure 4.4 Mean left first dorsal interosseous muscle pain-pressure threshold between groups, using deep dyspareunia scores from the test day. Confidence intervals indicated with error bars. Pain=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=1.971, p=0.133; η2=0.123.       81     Figure 4.5 Mean right first dorsal interosseous muscle pain-pressure threshold between groups, using deep dyspareunia scores from the test day. Confidence intervals indicated with error bars. Pain=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=1.124, p=0.350; η2=0.074.   82   Figure 4.6 Mean average first dorsal interosseous muscle pain-pressure threshold between groups, using deep dyspareunia scores from the test day. Confidence intervals indicated with error bars. Pain=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=1.605, p=0.202; η2=0.103.   83   Figure 4.7 Mean left deltoid muscle pain-pressure threshold between groups, using deep dyspareunia scores from the test day. Confidence intervals indicated with error bars. Pain=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=1.153, p=0.339; η2=0.076.   84   Figure 4.8 Mean right deltoid muscle pain-pressure threshold between groups, using deep dyspareunia scores from the test day. Confidence intervals indicated with error bars. Pain=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=0.761, p=0.522; η2=0.052.  85   Figure 4.9 Mean average deltoid muscle pain-pressure threshold between groups, using deep dyspareunia scores from the test day. Confidence intervals indicated with error bars. Pain=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=0.989, p=0.407; η2=0.066.       86  In addition, we divided the participants into four groups using the deep dyspareunia scores from the registry (not from the test day): 1) cases with high deep dyspareunia scores and bladder/pelvic floor tenderness (n=4); 2) cases with high deep dyspareunia scores and no bladder/pelvic floor tenderness (n=18); 3) cases with low deep dyspareunia scores (n=7); and 4) controls (n=17).   For the FDI test-sites, there were lower PPT in the group with high deep dyspareunia and bladder/pelvic floor tenderness, but ANOVA showed that these differences were not statistically significant (Figures 4.10-4.12). Effect sizes (η2) are indicated in the figure captions.   For the left deltoid, the mean (95% CI) for the four groups are shown in Figure 4.13 (Welch ANOVA F(3, 17.844)=4.546, p=0.015; η2=0.032); post-hoc Games-Howell pair-wise tests did not reach significance. For the right deltoid, the mean (95% CI) for the four groups are shown in Figure 4.14 (ANOVA F(3, 42)=0.616, p=0.609; η2=0.042). For average deltoid, the mean (95% CI) for the four groups are shown in Figure 4.15 (Welch ANOVA F(3, 18.187)=4.361, p=0.018; η2=0.037); post-hoc Games-Howell pair-wise tests showed that average deltoid PPT of 11.18±0.84 N in the bladder/pelvic floor tenderness and high deep dyspareunia group, was significantly lower compared to the average deltoid PPT of 15.66±6.33 N in the no bladder/pelvic floor tenderness and high deep dyspareunia group (p=0.043).   87   Figure 4.10 Mean left first dorsal interosseous muscle pain-pressure threshold between groups, using deep dyspareunia scores from the registry. Confidence intervals indicated with error bars. dd=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=1.089, p=0.364; η2=0.072.   88   Figure 4.11 Mean right first dorsal interosseous muscle pain-pressure threshold between groups, using deep dyspareunia scores from the registry. Confidence intervals indicated with error bars. dd=deep dyspareunia; BPFT=bladder/pelvic floor tenderness. Welch ANOVA F(3, 14.580)=0.571, p=0.643; η2=0.031.  89   Figure 4.12 Mean average first dorsal interosseous muscle pain-pressure threshold between groups, using deep dyspareunia scores from the registry. Confidence intervals indicated with error bars. dd=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  ANOVA F(3, 42)=0.757, p=0.524; η2=0.051.  90   Figure 4.13 Mean left deltoid muscle pain-pressure threshold between groups, using deep dyspareunia scores from the registry. Confidence intervals indicated with error bars. dd=deep dyspareunia; BPFT=bladder/pelvic floor tenderness.  Welch ANOVA F(3, 17.844)=4.546, p=0.015; η2=0.032.    91   Figure 4.14 Mean right deltoid muscle pain-pressure threshold between groups, using deep dyspareunia scores from the registry. Confidence intervals indicated with error bars. dd=deep dyspareunia; BPFT=bladder/pelvic floor tenderness. ANOVA F(3, 42)=0.616, p=0.609; η2=0.042.   92   Figure 4.15 Mean average deltoid muscle pain-pressure threshold between groups, using deep dyspareunia scores from the registry. Confidence intervals indicated with error bars. dd=deep dyspareunia; BPFT=bladder/pelvic floor tenderness. Welch ANOVA F(3, 18.187)=4.361, p=0.018; η2=0.037. Post-hoc Games-Howell pair-wise tests p=0.043; * indicates a significant difference.      *  93   There was a significant difference in the number of times the participant had had sexual intercourse within the last month between the cases and controls (U=170, p=0.049) (Table 4.10). The sample size was too small to examine intercourse frequency by subgroup of case participants (e.g., since only 4 case participants had high severity of deep dyspareunia and bladder/pelvic floor tenderness). However, this should be investigated in future studies.              94  Table 4.10 Bivariate associations with number of sexual intercourse occurrences between controls and cases. Factor N total Controls (n=17) Cases (n=29) Statistics  P value Ordinal Variables    Mann Whitney  How many times have you had sexual intercourse in the last month? 0 1-5 6-10 More than 10  46     11.8% (2) 47.0% (8) 29.4% (5) 11.8% (2)     20.7% (6) 65.5% (19) 13.8% (4) 0% (0) 170 0.049           95  4.5 Discussion In this study of women with endometriosis (previously surgically confirmed or current nodule or current endometrioma), we found that lower PPTs at non-pelvic sites were associated with bladder/pelvic floor tenderness. Also, in women with bladder/pelvic floor tenderness and high deep dyspareunia, PPTs were lower compared with women with no bladder/pelvic floor tenderness and high deep dyspareunia, women with low deep dyspareunia, and healthy controls. Statistical analysis revealed a significant difference in average deltoid PPT between the cases with high deep dyspareunia scores (registry) and bladder/pelvic floor tenderness, and the cases with high deep dyspareunia scores (registry) and no bladder/pelvic floor tenderness.  These findings suggest that central sensitization (decreased PPT) may be associated with bladder/pelvic floor tenderness. In other words, the group with bladder/pelvic floor tenderness and high severity of deep dyspareunia likely represents the women with endometriosis sexual pain that is related to central sensitization.  My results also showed that there was a significant difference between the number of times the participants had sexual intercourse between women with endometriosis and controls. This finding suggests that women with endometriosis are engaging in less sexual intercourse possibly as a consequence of their endometriosis. This issue should be investigated in future work.  Strengths of this study include its prospective recruitment of participants and a group of control participants. Also, the BC Women’s Centre has a large prospective database of clinical variables including: history, self-reported pain scores, surgical and pathology data, etc. Prospective daily pain scores were collected for case participants, which is the gold standard for collecting such information;  96  however, we are still waiting for a few participants to complete the six weeks of daily pain scores, so the data has not been added to this thesis yet. Limitations of this study include that the case participants are from a tertiary care centre; thus, the study findings may not generalizable to the overall population. This study was also limited by its small sample size; particularly its small group of women with endometriosis and bladder/pelvic floor tenderness (N = 6).  I plan on recruiting more cases as I continue this research as part of my PhD. With additional case collection, if there continues to be an association between lower PPT (i.e., central sensitization) and bladder/pelvic floor tenderness, then the latter may be a clinical marker for central sensitization. That is, bladder/pelvic floor tenderness may identify the centrally sensitized patient with endometriosis, who may benefit from a multidisciplinary treatment plan including physiotherapy and cognitive approaches, rather than hormonal/surgical treatments targeted to the endometriosis itself. On the other hand, the population with endometriosis and high deep dyspareunia but no bladder/pelvic floor tenderness may represent cases where the deep dyspareunia is due to endometriosis-specific factors, myofascial/musculoskeletal pain mechanisms, or nervous system pathways other than central sensitization (e.g., cross-sensitization).  It has been assumed in the literature that PBS is a marker of central sensitization[84], but I found no association between PPT and PBS. Similarly, a worse Carnett finding has also been assumed to be a marker of central sensitization[85]. However, in this study Carnett status was not significantly associated with PPT. Thus, these results suggest that PBS and worse Carnett findings are due to cross sensitization (or musculoskeletal factors), rather than central sensitization. Further studies are needed to investigate this hypothesis.  97  Furthermore, there were no associations found between psychological variables and PPT (at any sites). It has been assumed that psychological symptoms are increased and are a marker of central sensitization (lower PPT)[68, 86]. However, this assumption was not the case with our cohort. In our future research, we will have the control participants complete the validated psychological questionnaires so we can compare the psychological symptoms between cases and controls. Stratton et al. measured sensitization using neuromusculoskeletal assessment, where the presence of regional allodynia or regional hyperalgesia was defined as sensitization[73]. In our study, the PPT was used to measure sensitization. Similar to our findings, Stratton et al. found that the group with endometriosis and pelvic pain had greater clinical evidence of central sensitization[73]. They found that those with myofascial pain were more likely to have central sensitization, which is in contrast to our findings that there was no significant association between myofascial pain  and central sensitization (PPT)[73]. In addition, Stratton et al. found that women with higher levels of anxiety and depressive symptoms were more likely to have sensitization, as opposed to our finding that there was no significant association between psychological factors and central sensitization[73]. Perhaps these differences are due to the different methods of measuring central sensitization, as well as the difference in determining myofascial pain. Our group uses the Carnett test to measure abdominal wall that may be due to myofascial pain, but the research by Stratton et al. assessed myofascial pain from multiple muscle sites, in addition to the abdominal muscles. Our sample did not all undergo surgery, in contrast to the study by Stratton et al.; therefore, we do not know how many women have histopathologically confirmed endometriosis. For my PhD, I plan to increase sample size, and to also measure PPT before and after treatments to assess outcomes and see which treatment (if any) increases PPT (reduces central sensitization). For example, I will measure PPT before and after surgery, before and after beginning a new hormonal  98  therapy, and before and after physiotherapy, etc. The results from this future study may demonstrate which treatment modalities can reduce central sensitization.  Ultimately, my goal is to phenotype deep dyspareunia in endometriosis, to allow for more individualized treatment (Figure 4.16).  The next chapter contains more details about my future experimental plans.                99      Figure 4.16 Flowchart of treatment for deep dyspareunia based on etiology. Deep dyspareuniaia Bladder/pelvic floor tenderness Co-morbid conditions (PBS) Endometriosis lesions     Surgery and/or medical therapy Treat co-morbid condition Multidisciplinary treatment plan  100  Chapter 5: Conclusions and Future Directions Endometriosis is a common gynecologic disease that costs approximately $1.8 billion per year[87]. This thesis focused on sexual pain etiology in women with endometriosis. In Aim 1 of this study, I showed that bladder/pelvic floor tenderness and PBS are associated with severity of deep dyspareunia, even in women with Stage III/IV endometriosis. These results indicate that nervous system or myofascial mechanisms may be important in deep dyspareunia, independent of endometriosis-specific factors such as location, amount, or invasiveness of disease. Following up on this, in Aim 2 the results from our QST show that only bladder/pelvic floor tenderness was associated with a marker of central sensitization (PPT).  Therefore, there may be an alternative etiology for PBS, which could be the co-existence of two independent conditions, or perhaps cross sensitization.  My findings suggest that bladder/pelvic floor tenderness may be a clinical marker for central sensitization in women with endometriosis. Thus, bladder/pelvic floor tenderness could be used to help phenotype these women, leading to a more personalized treatment approach. These results were limited due to the small sample size of women with deep dyspareunia suspected to be due to central sensitization; therefore, my first future PhD study will be recruiting more women with bladder/pelvic floor tenderness and endometriosis to increase the power of these analyses. If my results support what I have previously found, then clinicians should consider that women with endometriosis and bladder/pelvic floor tenderness may be truly sensitized, which should be considered in the treatment plan (e.g., surgical, medical, or interdisciplinary).   I also found a significant association with the number of times that a participant engaged in sexual intercourse between case and control participants. This finding suggests that women with endometriosis may be engaging in less sexual activity; however, this needs to be further researched with more detailed questions in our data registry.   101  Ultimately, my goal is to phenotype patients based on the etiology of their sexual pain in women with endometriosis and to treat accordingly. In a recent review  my supervisor proposed a framework the treatment of deep dyspareunia based on etiology[42]. I plan to validate these treatment options in women with endometriosis and deep dyspareunia and then implement this into clinical practice. Doing so may change clinical practice to limit any unnecessary treatments (e.g., repeated surgeries). For example, a future study could involve the use of the Electronic Thimble Algometer, in addition to history, physical exam, and co-morbidities associated with endometriosis (e.g., PBS), to “type” patients into one of four groups: deep dyspareunia due to 1) endometriosis; 2) co-morbid conditions; 3) central sensitization; 4) combination of 1-3, based off the proposed framework[42].  Treatment should be tailored to each group (Figure 4.16), and outcomes assessed. Targeting specific treatments depending on the true etiology of the deep sexual pain may reduce unnecessary treatments[42].  In women who have cul-de-sac tenderness and/or cul-de-sac obliteration, the deep dyspareunia may be most likely due to cul-de-sac endometriosis[42]. Treatment for this patient should include surgical removal of the endometriosis and hormonal therapy (Type 1); however, if this patient’s deep dyspareunia does not improve after these treatments or if no endometriosis lesions are found during surgery then the pain may be due to central sensitization and they should be treated with a multidisciplinary plan (pelvic floor physiotherapy, counselling, pain education/management) (Type 3)[42]. The women who have complications of endometriosis, such as PBS, should be treated for their co-morbidity[42]. Treatment may include physiotherapy, bladder instillations, and pain medication (Type 2)[42]. Psychological factors may increase the severity of deep dyspareunia, so they should also be considered in the treatment plan (Type 2)[42]. The results of our studies suggest that women with bladder/pelvic floor tenderness and high severity of deep dyspareunia may have central sensitization, thus they should be treated with a multidisciplinary treatment plan (Type 3)[42]. Women who have  102  tenderness throughout their pelvic cavity, and even at extra-pelvic sites, may also have central sensitization[42]. Since central sensitization can lead to pain that is self-sustained, surgical removal of the endometriosis lesions may not result in any relief. Therefore, surgery may be avoided for such patients. In women whose pain may be due to central sensitization, as well as endometriosis lesions, the sensitization should be managed with a multidisciplinary treatment plan[42]. Once the central sensitization is reduced and if the patient is still having deep dyspareunia, then surgery or hormonal therapy may be used to treat the endometriosis lesions (Type 4)[42]. Sexual therapy should be considered in the treatment of all women with deep dyspareunia[42].  Ultimately, future studies will be needed to validate the personalized treatment plans for these women depending on the etiology of their deep dyspareunia. Once confirmed the findings can be disseminating to clinicians and translated to patient populations.  Implementing of new clinical guidelines for the treatment approach to deep dyspareunia in this population will facilitate such knowledge translation. In addition to phenotyping patients based on etiology of deep dyspareunia, I plan to measure central sensitization longitudinally (using the Electronic Thimble Algometer) before and after each treatment (e.g., surgery, starting hormonal therapy, etc.) to assess whether each specific treatment can reduce the level of sensitization (increasing PPT). Of particular interest is the change in PPT after standard surgical or hormonal therapies of the endometriosis lesions. While these treatments would not be expected to directly reduce central sensitization, it is possible that some central changes may be observed by treatment of the peripheral triggers of pain (lesions).  I am also interested in functional magnetic resonance imaging (fMRI) studies to further study the role of the central nervous system in endometriosis-associated deep dyspareunia. The BC Children’s Hospital has an MRI facility that offers researchers the opportunity to use the machine for their  103  research study participants. The MRI can take T1 and T2, fMRI, multiband, and diffusion tensor images (DTI). The facility also offers an MRI compatible temperature-pain threshold device that can be used on the patient during the MRI.  A recent review summarized key findings in brain structure and function in women with endometriosis[86]. Women with endometriosis-associated pain were found to have an increased resting connectivity of the anterior insula to other brain regions, and well as increased levels of excitatory neurotransmitters in the anterior insula, compared with women who have  endometriosis and no pain, and also controls without endometriosis[86, 88]. In addition, women with endometriosis-associated pelvic pain and women with pelvic pain without endometriosis were found to have a decreased grey matter volume in areas associated with pain perception[86, 89]. Also, women with endometriosis and no pain were found to have an increased periaqueductal gray (PAG) volume, which is an important region for descending pain inhibition pathways[86, 89].  In my future research, I would like to use MRI to look at these changes in our population of women with endometriosis, specifically with deep dyspareunia, compared with endometriosis/no deep dyspareunia and healthy controls. I would also like to study MRIs of women with endometriosis-associated deep dyspareunia before and after treatments (in addition to our PPT test), to assess if there are any changes after treatment. Our previous findings suggest that women with endometriosis, high severity of deep dyspareunia, and bladder/pelvic floor tenderness are the women with central sensitization. In the future, I can look at the difference in temperature-pain threshold and functional brain changes between four groups: 1) women with endometriosis, high severity of deep dyspareunia, and bladder/pelvic floor tenderness (central sensitization); 2) women with endometriosis, high severity of deep dyspareunia, and no bladder/pelvic floor tenderness; 3) women with endometriosis and low severity of deep dyspareunia; and 4) healthy controls.   104  In another avenue of research, I will investigate implementing additional questions or changing questions asked in the EPPIC registry questionnaires to provide a more comprehensive assessment of sexual pain and function in endometriosis.   During arousal, there is increased blood flow and swelling to the genitals, increased lubrication, and the vagina expands and lengthens. These changes may affect the degree of pain associated during sexual intercourse. In the future, I may consider adding the Female Sexual Function Index (FSFI) questionnaire to better account for arousal and sexual functioning in our research. My future research into deep dyspareunia could control for size of the penis/sex toy used for deep vaginal penetration, which may influence the severity of deep dyspareunia. This could potentially be asked during the initial appointment with the physician. A variety of dilators could be presented, and the physician could ask which size represents their partners erect penis/sex toy.  The most recent version of the EPPIC database (Phase III, start Jan 2018) has now implemented more questions associated with pain during sexual intercourse. In addition to these questions, a question on the number of times a woman has engaged in sexual intercourse in the last month may provide more necessary details to the physician and researchers. In addition to this, clarifying our deep and superficial sexual pain questions to ensure that they imply the same meaning to the entire population would be beneficial. For instance, I have received feedback that our deep dyspareunia question is confusing or exclusive to women with a female partner. Therefore, providing a preamble to the question to better explain what is meant by “sexual activity” and specification that deep or superficial penetration can be with a penis or sex toy or digit would clarify the intent of the subsequent questions. In addition, further research will be done to better differentiate between deep and superficial dyspareunia. As an example, the physicians may use a Q-tip to palpate certain areas (e.g., superficial vulvar region and deep in the vagina) while the patient uses a mirror to visualize what the physician  105  sees, to better help the patient identify where their pain is; thus, helping them better differentiate between deep and superficial dyspareunia. Additionally, validated questionnaires may be used to better differentiate between these two types of dyspareunia. Future research on deep dyspareunia in women with endometriosis should account for provoked vestibulodynia, since central sensitization may play a role in this vestibular pain, as well as vaginismus which may cause or exacerbate the deep dyspareunia.    I am also interested in pursuing knowledge translation in this area. I will be applying to the Public Scholars Initiative (PSI) which provides support for PhD students creating knowledge translation (KT) projects as a component of their thesis.  I plan to create educational videos that display an animated view of endometriosis. This video will start with the different theories of endometriosis and the pathways that endometrial cells may take. The videos will also include animations of the different types of endometriosis, and how endometriosis lesions may be treated (e.g., surgical removal). This animated video will be targeted to patients to relieve anxiety associated with their disease or treatments, and to act as a teaching tool when physicians are explaining the process to patients. I would also like to create a video on sensitization of the nervous system which will show the pathway of normal pain sensation, as well as central and cross sensitization. This video will also be targeted towards patients to better explain how their central nervous system may be playing a role in their pain.  These videos will be used for educational purposes within our clinic and research team and may be posted online in the future. Many women with sexual pain may suffer in silence. Qualitative interviews may shed some light on the effect of sexual pain on a women’s life. Since physicians may be less inclined to read an article than to watch a short video, I would like to create short (approx. 3 minutes) narratives on the effect  106  that sexual pain in women with endometriosis have on their lives. These videos will incorporate images that relate to the feelings that these women experience and may include them speaking themselves. A book called ‘Thorns & Roses’ is a memoir written by a patient about her life with sexual pain, which provided support for women who were going through the same experiences. Such videos will help the population of women with sexual pain, and will inform physicians of the effect sexual pain on their quality of life. I also hope to organize a sexual pain workshop with patients and primary care physicians being the target audience. This could include clinical and research presentations, as well as booths for patent-oriented resources (e.g., for the O-nut, which is a silicon device that is placed on the penis during sexual intercourse and limits the depth of penetration, which was created by a woman with deep dyspareunia). This workshop will be free and could be funded by the PSI and our future grants. My hope is that this workshop will provide women with a better understanding of central sensitization and their deep dyspareunia. It will also provide physicians the opportunity to see the decision-making process undertaken by endometriosis specialists and to consider other factors (in addition to the endometriosis lesions) underlying the etiology of their deep dyspareunia.    To conclude, my findings suggest that bladder/pelvic floor tenderness is a clinical marker of central sensitization in women with endometriosis. Women with endometriosis, bladder/pelvic floor tenderness, and high severity of deep dyspareunia, represent those whose sexual pain is due to central sensitization. In my future PhD studies, I plan on using a multifactorial approach to further work in this area, including increasing the sample size of women with QST testing, performing QST before and after different treatments, exploring fMRI, validating a framework for phenotyping women with endometriosis-associated sexual pain, and developing knowledge translation plans to share with women and clinicians.    107  References [1] Macer ML, Taylor HS. Endometriosis and infertility: a review of the pathogenesis and treatment of endometriosis-associated infertility. Obstet Gynecol Clin North Am. 2012;39:535-549. Epub 2012/11/28. doi: 10.1016/j.ogc.2012.10.002. PubMed PMID: 23182559; PubMed Central PMCID: PMCPMC3538128. [2] Gupta S, Harlev A, Agarwal A. Endometriosis: a comprehensive update: Springer; 2015. [3] Olive DL, Pritts EA. Treatment of endometriosis. N Engl J Med. 2001;345:266-275. [4] Johnston JL, Reid H, Hunter D. Diagnosing endometriosis in primary care: clinical update. Br J Gen Pract. 2015;65:101-102. Epub 2015/01/28. doi: 10.3399/bjgp15X683665. PubMed PMID: 25624305; PubMed Central PMCID: PMCPMC4325443. [5] Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nature Reviews Endocrinology. 2014;10:261-275. [6] Bulletti C, Coccia ME, Battistoni S, Borini A. Endometriosis and infertility. Journal of assisted reproduction and genetics. 2010;27:441-447. [7] Facchin F, Barbara G, Saita E, Mosconi P, Roberto A, Fedele L, Vercellini P. Impact of endometriosis on quality of life and mental health: pelvic pain makes the difference. Journal of Psychosomatic Obstetrics & Gynecology. 2015;36:135-141. [8] Soliman AM, Coyne KS, Zaiser E, Castelli-Haley J, Fuldeore MJ. The burden of endometriosis symptoms on health-related quality of life in women in the United States: a cross-sectional study. Journal of Psychosomatic Obstetrics & Gynecology. 2017:1-11. [9] Moradi M, Parker M, Sneddon A, Lopez V, Ellwood D. Impact of endometriosis on women’s lives: a qualitative study. BMC women's health. 2014;14:123. [10] Anaf V, Simon P, El Nakadi I, Fayt I, Buxant F, Simonart T, Peny M-O, Noel J-C. Relationship between endometriotic foci and nerves in rectovaginal endometriotic nodules. Hum Reprod. 2000;15:1744-1750. [11] Vercellini P, Frontino G, Pietropaolo G, Gattei U, Daguati R, Crosignani PG. Deep endometriosis: definition, pathogenesis, and clinical management. J Am Assoc Gynecol Laparosc. 2004;11:153-161. PubMed PMID: 15200766. [12] Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril. 1997;68:585-596. [13] Mendiola J, Sanchez-Ferrer ML, Jimenez-Velazquez R, Canovas-Lopez L, Hernandez-Penalver AI, Corbalan-Biyang S, Carmona-Barnosi A, Prieto-Sanchez MT, Nieto A, Torres-Cantero AM. Endometriomas and deep infiltrating endometriosis in adulthood are strongly associated with anogenital distance, a biomarker for prenatal hormonal environment. Hum Reprod. 2016;31:2377- 108  2383. Epub 2016/07/01. doi: 10.1093/humrep/dew163. PubMed PMID: 27357299; PubMed Central PMCID: PMCPMC5027925. [14] Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J. Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril. 2012;98:564-571. doi: 10.1016/j.fertnstert.2012.07.1061. PubMed PMID: 22938769. [15] Williams C, Hoang L, Yosef A, Alotaibi F, Allaire C, Brotto L, Fraser IS, Bedaiwy MA, Ng TL, Lee AF, Yong PJ. Nerve Bundles and Deep Dyspareunia in Endometriosis. Reprod Sci. 2016;23:892-901. doi: 10.1177/1933719115623644. PubMed PMID: 26711313. [16] Santulli P, Marcellin L, Tosti C, Chouzenoux S, Cerles O, Borghese B, Batteux F, Chapron C. MAP kinases and the inflammatory signaling cascade as targets for the treatment of endometriosis? Expert opinion on therapeutic targets. 2015;19:1465-1483. [17] Schipper E, Nezhat C. Video-assisted laparoscopy for the detection and diagnosis of endometriosis: safety, reliability, and invasiveness. International journal of women's health. 2012;4:383. [18] Burney RO, Giudice LC. Pathogenesis and pathophysiology of endometriosis. Fertil Steril. 2012;98:511-519. doi: 10.1016/j.fertnstert.2012.06.029. PubMed PMID: 22819144; PubMed Central PMCID: PMCPMC3836682. [19] Giudice LC. Endometriosis. New England Journal of Medicine. 2010;362:2389-2398. [20] Bulun SE. Endometriosis. N Engl J Med. 2009;360:268-279. [21] Canis M, Donnez JG, Guzick DS, Halme JK, Rock JA, Schenken RS, Vernon MW. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril. 1997;67:817-821. PubMed PMID: 9130884. [22] Howard FM. Endometriosis and mechanisms of pelvic pain. J Minim Invasive Gynecol. 2009;16:540-550. doi: 10.1016/j.jmig.2009.06.017. PubMed PMID: 19835795. [23] Berkley KJ, Rapkin AJ, Papka RE. The Pains of Endometriosis. Science. 2005;308:1587-1589. doi: 10.1126/science.1111445. [24] Anaf V, Simon P, El Nakadi I, Fayt I, Simonart T, Buxant F, Noël JC. Hyperalgesia, nerve infiltration and nerve growth factor expression in deep adenomyotic nodules, peritoneal and ovarian endometriosis. Human Reproduction. 2002;17:1895-1900. [25] Tulandi T, Felemban A, Chen MF. Nerve fibers and histopathology of endometriosis-harboring peritoneum. The Journal of the American Association of Gynecologic Laparoscopists. 2001;8:95-98. [26] Maia Jr H, Haddad C, Casoy J. Correlation between aromatase expression in the eutopic endometrium of symptomatic patients and the presence of endometriosis. International journal of women's health. 2012;4:61.  109  [27] Jabbour HN, Sales KJ, Smith OPM, Battersby S, Boddy SC. Prostaglandin receptors are mediators of vascular function in endometrial pathologies. Molecular and cellular endocrinology. 2006;252:191-200. [28] Ferrero S, Ragni N, Remorgida V. Deep dyspareunia: causes, treatments, and results. Curr Opin Obstet Gynecol. 2008;20:394-399. doi: 10.1097/GCO.0b013e328305b9ca. [29] Aksoy T, Allaire C, Noga H, Bedaiwy M, Williams C, Yong P. O-GYN-MD-038 Sliding Sign in the Prediction of Posterior Cul-de-sac Obliteration in Women with Suspected Endometriosis. Journal of Obstetrics and Gynaecology Canada. 2017;39:382. [30] Dlugi AM, Miller JD, Knittle J, Group LS. Lupron depot (leuprolide acetate for depot suspension) in the treatment of endometriosis: a randomized, placebo-controlled, double-blind study. Fertility and sterility. 1990;54:419-427. [31] Medicine TPCotASfR. Treatment of pelvic pain associated with endometriosis: a committee opinion. Fertil Steril. 2014;101:927-935. [32] Vercellini P, Trespidi L, Colombo A, Vendola N, Marchini M, Crosignani PG. A gonadotropin-releasing hormone agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis. Fertility and sterility. 1993;60:75-79. [33] Valle RF, Sciarra JJ. Endometriosis: Treatment Strategies. Ann N Y Acad Sci. 2003;997:229-239. doi: 10.1196/annals.1290.026. [34] Bedaiwy MA, Alfaraj S, Yong P, Casper R. New developments in the medical treatment of endometriosis. Fertility and sterility. 2017. [35] Küpker W, Felberbaum R, Krapp M, Schill T, Malik E, Diedrich K. Use of GnRH antagonists in the treatment of endometriosis. Reproductive biomedicine online. 2002;5:12-16. [36] Kauppila A, RÖnnberg L. Naproxen sodium in dysmenorrhea secondary to endometriosis. Obstetrics & Gynecology. 1985;65:379-383. [37] Kennedy S, Bergqvist A, Chapron C, D'Hooghe T, Dunselman G, Greb R, Hummelshoj L, Prentice A, Saridogan E. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod. 2005;20:2698-2704. [38] Sutton CJ, Ewen SP, Whitelaw N, Haines P. Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertility and sterility. 1994;62:696-700. [39] Wheeler JM, Malinak LR. Recurrent endometriosis: incidence, management, and prognosis. American journal of obstetrics and gynecology. 1983;146:247-253. [40] Fedele L, Bianchi S, Zanconato G, Bettoni G, Gotsch F. Long-term follow-up after conservative surgery for rectovaginal endometriosis. American journal of obstetrics and gynecology. 2004;190:1020-1024.  110  [41] Ferrero S, Esposito F, Abbamonte LH, Anserini P, Remorgida V, Ragni N. Quality of sex life in women with endometriosis and deep dyspareunia. Fertil Steril. 2005;83:573-579. doi: 10.1016/j.fertnstert.2004.07.973. PubMed PMID: 15749483. [42] Yong PJ. Deep Dyspareunia in Endometriosis: A Proposed Framework Based on Pain Mechanisms and Genito-Pelvic Pain Penetration Disorder. Sex Med Rev. 2017. doi: 10.1016/j.sxmr.2017.06.005. PubMed PMID: 28778699. [43] Nourmoussavi M, Bodmer-Roy S, Mui J, Mawji N, Williams C, Allaire C, Yong PJ. Bladder base tenderness in the etiology of deep dyspareunia. J Sex Med. 2014;11:3078-3084. doi: 10.1111/jsm.12708. PubMed PMID: 25244182. [44] Vercellini P, Fedele L, Aimi G, Pietropaolo G, Consonni D, Crosignani PG. Association between endometriosis stage, lesion type, patient characteristics and severity of pelvic pain symptoms: a multivariate analysis of over 1000 patients. Hum Reprod. 2007;22:266-271. Epub 2006/08/29. doi: 10.1093/humrep/del339. PubMed PMID: 16936305. [45] Peng B, Zhan H, Alotaibi F, Alkusayer GM, Bedaiwy MA, Yong PJ. Nerve Growth Factor Is Associated With Sexual Pain in Women With Endometriosis. Reproductive Sciences. 2017:1933719117716778. [46] Yong PJ, Williams C, Yosef A, Wong F, Bedaiwy MA, Lisonkova S, Allaire C. Anatomic sites and associated clinical factors for deep dyspareunia. Sex Med. 2017. doi: 10.1016/j.esxm.2017.07.001. PubMed PMID: 28778678. [47] Yong PJ, Williams C, Yosef A, Wong F, Bedaiwy M, Lisonekova S, Allaire C. Etiology of deep dyspareunia in women with endometriosis and pelvic pain. Hum Reprod. 2016. [48] FitzGerald MP, Payne CK, Lukacz ES, Yang CC, Peters KM, Chai TC, Nickel JC, Hanno PM, Kreder KJ, Burks DA, Mayer R, Kotarinos R, Fortman C, Allen TM, Fraser L, Mason-Cover M, Furey C, Odabachian L, Sanfield A, Chu J, Huestis K, Tata GE, Dugan N, Sheth H, Bewyer K, Anaeme A, Newton K, Featherstone W, Halle-Podell R, Cen L, Landis JR, Propert KJ, Foster HE, Jr., Kusek JW, Nyberg LM, Interstitial Cystitis Collaborative Research N. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol. 2012;187:2113-2118. Epub 2012/04/17. doi: 10.1016/j.juro.2012.01.123. PubMed PMID: 22503015; PubMed Central PMCID: PMCPMC3351550. [49] Sullivan MJ, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess. 1995;7:524. [50] Yong PJ, Sadownik L, Brotto LA. Concurrent deep-superficial dyspareunia: prevalence, associations, and outcomes in a multidisciplinary vulvodynia program. J Sex Med. 2015;12:219-227. doi: 10.1111/jsm.12729. PubMed PMID: 25345552. [51] Mcpeak AE, Allaire C, Williams C, Albert A, Lisonkova S, Yong PJ. Pain Catastrophizing and Pain Health-related Quality-of-life in Endometriosis. The Clinical journal of pain. 2017.  111  [52] Koop H, Koprdova S, Schürmann C. Chronic Abdominal Wall Pain: A Poorly Recognized Clinical Problem. Deutsches Ärzteblatt International. 2016;113:51. [53] Srinivasan R, Greenbaum DS. Chronic abdominal wall pain: a frequently overlooked problem. The American journal of gastroenterology. 2002;97:824-830. [54] Montenegro M, Vasconcelos E, Candido dos Reis F, Nogueira A, Poli‐Neto O. Physical therapy in the management of women with chronic pelvic pain. Int J Clin Pract. 2008;62:263-269. [55] van Assen T, de Jager-Kievit JW, Scheltinga MR, Roumen RM. Chronic abdominal wall pain misdiagnosed as functional abdominal pain. The Journal of the American Board of Family Medicine. 2013;26:738-744. [56] Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain. 2009;10:895-926. Epub 2009/08/29. doi: 10.1016/j.jpain.2009.06.012. PubMed PMID: 19712899; PubMed Central PMCID: PMCPMC2750819. [57] Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in pain. Science. 2000;288:1765-1769. PubMed PMID: 10846153. [58] Brawn J, Morotti M, Zondervan KT, Becker CM, Vincent K. Central changes associated with chronic pelvic pain and endometriosis. Hum Reprod Update. 2014;20:737-747. [59] Nielsen LA, Henriksson KG. Pathophysiological mechanisms in chronic musculoskeletal pain (fibromyalgia): the role of central and peripheral sensitization and pain disinhibition. Best Pract Res Clin Rheumatol. 2007;21:465-480. [60] Neumann S, Doubell TP, Leslie T, Woolf CJ. Inflammatory pain hypersensitivity mediated by phenotypic switch in myelinated primary sensory neurons. Nature. 1996;384:360. [61] McAllister SL, Dmitrieva N, Berkley KJ. Sprouted innervation into uterine transplants contributes to the development of hyperalgesia in a rat model of endometriosis. PloS one. 2012;7:e31758. [62] Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152:S2-S15. [63] Malykhina A. Neural mechanisms of pelvic organ cross-sensitization. Neuroscience. 2007;149:660-672. [64] Chennamsetty A, Ehlert MJ, Peters KM, Killinger KA. Advances in diagnosis and treatment of interstitial cystitis/painful bladder syndrome. Curr Infect Dis Rep. 2015;17:454. Epub 2014/11/25. doi: 10.1007/s11908-014-0454-5. PubMed PMID: 25416849. [65] de las Peñas CF, Sohrbeck Campo M, Fernández Carnero J, Miangolarra Page JC. Manual therapies in myofascial trigger point treatment: a systematic review. J Bodyw Mov Ther. 2005;9:27-34. doi: 10.1016/j.jbmt.2003.11.001.  112  [66] Butrick CW. Pathophysiology of pelvic floor hypertonic disorders. Obstet Gynecol Clin North Am. 2009;36:699-705. Epub 2009/11/26. doi: 10.1016/j.ogc.2009.08.006. PubMed PMID: 19932422. [67] Jensen R. Pathophysiological mechanisms of tension‐type headache: a review of epidemiological and experimental studies. Cephalalgia. 1999;19:602-621. [68] Kaya S, Hermans L, Willems T, Roussel N, Meeus M. Central sensitization in urogynecological chronic pelvic pain: a systematic literature review. Pain Physician. 2013;16:291-308. [69] Siao P, Cros DP. Quantitative sensory testing. Physical Medicine and Rehabilitation Clinics. 2003;14:261-286. [70] Zolnoun D, Bair E, Essick G, Gracely R, Goyal V, Maixner W. Reliability and reproducibility of novel methodology for assessment of pressure pain sensitivity in pelvis. The Journal of Pain. 2012;13:910-920. [71] Bajaj P, Bajaj P, Madsen H, Arendt-Nielsen L. Endometriosis is associated with central sensitization: a psychophysical controlled study. The Journal of Pain. 2003;4:372-380. [72] Tu FF, Fitzgerald CM, Kuiken T, Farrell T, Norman HR. Comparative measurement of pelvic floor pain sensitivity in chronic pelvic pain. Obstet Gynecol. 2007;110:1244-1248. [73] Stratton P, Khachikyan I, Sinaii N, Ortiz R, Shah J. Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain. Obstet Gynecol. 2015;125:719-728. Epub 2015/03/03. doi: 10.1097/aog.0000000000000663. PubMed PMID: 25730237; PubMed Central PMCID: PMCPMC4347996. [74] Lian YL, Cheng MJ, Zhang XX, Wang L. Elevated expression of transient receptor potential vanilloid type 1 in dorsal root ganglia of rats with endometriosis. Molecular medicine reports. 2017;16:1920-1926. [75] Esenyel M, Caglar N, Aldemir T. Treatment of myofascial pain. American journal of physical medicine & rehabilitation. 2000;79:48-52. [76] Yosef A, Allaire C, Williams C, Ahmed AG, Al-Hussaini T, Abdellah MS, Wong F, Lisonkova S, Yong PJ. Multifactorial contributors to the severity of chronic pelvic pain in women. Am J Obstet Gynaecol. 2016;215:760. e761-760. e714. [77] Becker CM, Laufer MR, Stratton P, Hummelshoj L, Missmer SA, Zondervan KT, Adamson GD, Group WEW. World endometriosis research foundation endometriosis phenome and biobanking harmonisation project: I. Surgical phenotype data collection in endometriosis research. Fertil Steril. 2014;102:1213-1222. [78] Hanno P, Lin A, Nordling J, Nyberg L, van Ophoven A, Ueda T, Wein A. Bladder pain syndrome international consultation on incontinence. Neurourology and urodynamics. 2010;29:191-198.  113  [79] Hanno PM, Erickson D, Moldwin R, Faraday MM. Diagnosis and treatment of interstitial cystitis/bladder pain syndrome: AUA guideline amendment. The Journal of urology. 2015;193:1545-1553. [80] Warren JW, Meyer WA, Greenberg P, Horne L, Diggs C, Tracy JK. Using the International Continence Society’s definition of painful bladder syndrome. Urology. 2006;67:1138-1142. [81] Alappattu MJ, George SZ, Robinson ME, Fillingim RB, Moawad N, LeBrun EW, Bishop MD. Painful intercourse is significantly associated with evoked pain perception and cognitive aspects of pain in women with pelvic pain. J Sex Med. 2015;3:14-23. [82] Pavlaković G, Petzke F. The role of quantitative sensory testing in the evaluation of musculoskeletal pain conditions. Current rheumatology reports. 2010;12:455-461. [83] Reed BD, Sen A, Harlow SD, Haefner HK, Gracely RH. Multimodal Vulvar and Peripheral Sensitivity Among Women With Vulvodynia: A Case-Control Study. Journal of lower genital tract disease. 2017;21:78-84. [84] Lai HH, Gardner V, Ness TJ, Gereau RW. Segmental hyperalgesia to mechanical stimulus in interstitial cystitis/bladder pain syndrome: evidence of central sensitization. J Urol. 2014;191:1294-1299. [85] Yong PJ, Mui J, Allaire C, Williams C. Pelvic floor tenderness in the etiology of superficial dyspareunia. Journal of Obstetrics and Gynaecology Canada. 2014;36:1002-1009. [86] Coxon L, Horne AW, Vincent K. Pathophysiology of endometriosis-associated pain: a review of pelvic and central nervous system mechanisms. Best Practice & Research Clinical Obstetrics & Gynaecology. 2018. [87] Levy AR, Osenenko KM, Lozano-Ortega G, Sambrook R, Jeddi M, Bélisle S, Reid RL. Economic burden of surgically confirmed endometriosis in Canada. Journal of Obstetrics and Gynaecology Canada. 2011;33:830-837. [88] As-Sanie S, Kim J, Schmidt-Wilcke T, Sundgren PC, Clauw DJ, Napadow V, Harris RE. Functional connectivity is associated with altered brain chemistry in women with endometriosis-associated chronic pelvic pain. The Journal of Pain. 2016;17:1-13. [89] As-Sanie S, Harris RE, Napadow V, Kim J, Neshewat G, Kairys A, Williams D, Clauw DJ, Schmidt-Wilcke T. Changes in regional gray matter volume in women with chronic pelvic pain: a voxel-based morphometry study. Pain. 2012;153:1006-1014. Epub 2012/03/06. doi: 10.1016/j.pain.2012.01.032. PubMed PMID: 22387096; PubMed Central PMCID: PMCPMC3613137.    114  Appendices Appendix A: Cancer associated mutations in non-cancerous endometriosis A1. Rationale Endometriosis has cancer-like features (e.g., invasion), thus this study looked to determine if benign endometriosis lesions have somatic mutations in cancer driver genes (such as KRAS). Mutations were identified using exomewide sequencing (n=24), targeted amplicon sequencing (n=3), or droplet digital polymerase-chain-reaction (PCR) assay for recurrent activating KRAS mutations (n=12). Genomic methods to determine somatic mutations in the endometriosis tissue. A2. Study Sample Using retrospective data, 39 women with histopathologically confirmed DIE were identified. This sample had a mean age of 37 years.  A3. Results Twenty six percent (10/39) of participants had somatic cancer driver mutations. A4. Discussion Somatic cancer driver mutations were found in the glandular epithelium of non-cancerous DIE lesions in some but not all cases, suggesting that these mutations do not cause endometriosis. Further studies are needed to look at the genomic differences between mutation-associated endometriosis and nonmutation endometriosis.    115  Appendix B:         Data collection forms (questionnaires) for Aim 2 B1. Pre-test control questionnaire    116    117         118   B2. Test-day questionnaire control participants   119    120           121  B3. Test day questionnaire case participants   122    123    124        125   B4. Post-test day questionnaire case participants   126   Appendix C: Other descriptive variables (Aim 1)   Stage I/II (n=263) Stage III/IV (n=148) Clinical characteristic Percentage (frequency) Percentage (frequency) Superficial Dyspareunia Mild (0-3) Moderate (4-6) Severe (7-10)  49.8% (131) 22.1% (58) 28.1% (74)  55.4% (82) 20.9% (31) 23.6% (35) Dysmenorrhea Mild (0-3) Moderate (4-6) Severe (7-10)  4.6% (12) 8.7% (23) 86.7% (228)  5.4% (8) 7.4% (11) 87.2% (129) Dyschezia Mild (0-3) Moderate (4-6) Severe (7-10)  41.8% (110) 27% (71) 31.2% (82)  44.6% (66) 21.6% (32) 33.8% (50) Chronic Pelvic Pain Mild (0-3) Moderate (4-6) Severe (7-10)  17.1% (45) 22.1% (58) 60.8% (160)  23% (34) 27.7% (41) 49.3% (73) Back Pain Mild (0-3) Moderate (4-6) Severe (7-10)  21.7% (57) 34.2% (90) 44.1% (116)  25% (37) 33.1% (49) 41.9% (62) Marital status      Married      Other      Missing  48.7% (128) 50.6% (133) 0.8% (2)  58.8% (87) 40.5% (60) 0.7% (1) Highest level of education      Some high school      Graduated high school or earned GED      Some college      Graduated 2 years college      Graduated 4 years college      Post-grad degree      Other      Missing  3.4% (9) 11.4% (30) 27.4% (72) 13.7% (36) 24% (63) 17.5% (46) 1.9% (5) 0.8% (2)  3.4% (5) 4.7% (7) 20.3% (30) 12.8% (19) 30.4% (45) 21.6% (32) 6.1% (9) 0.7% (1)  127   Stage I/II (n=263) Stage III/IV (n=148) Clinical characteristic Percentage (frequency) Percentage (frequency) Sexual Orientation      Heterosexual      Other      Missing  95.4% (251) 4.2% (11) 0.4% (1)  89.2% (132) 10.8% (16) 0% (0) Annual socio-economic status      Less than $20,000      $20,000 to $39,999      $40,000 to $59,999      $60,000 to $79,999      $80,000 to $99,999      $100,000 or more      Missing  11.8% (31) 13.3% (35) 14.4% (38) 17.5% (46) 14.4% (38) 27.8% (73) 0.8% (2)  11.5% (17) 18.2% (27) 10.8% (16) 22.3% (33) 13.5% (20) 23% (34) 0.7% (1) Smoking      Yes      No      Missing  13.7% (36) 85.6% (225) 0.8% (2)  12.8% (19) 86.5% (128) 0.7% (1) Alcohol      Yes      No      Missing  66.2% (174) 33.1% (87) 0.8% (2)  57.4% (85) 41.9% (62) 0.7% (1) Ethnicity      Caucasian      Non-Caucasian      Missing  81.7% (215) 17.9% (47) 0.4% (1)  49.3% (73) 50.7% (75) 0% (0)      

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