Current Research on Endometriosis: An Interview with Dr. Giorgia Elisabeth Colombo

“Prevention is the key: If we know that there’s an increased risk of cardiovascular disease in patients who have endometriosis and other gynecological non-malignant diseases, then the key thing would be to take steps to prevent the development of cardiovascular diseases. 

Teresa Götz: Welcome, Giorgia. Could you please introduce yourself?

Dr. Giorgia Elisabeth Colombo: Hello, I am Georgia. I am a doctor, trained originally in Scotland, but I am about to start my special training in gynecology in Switzerland. My research and clinical interest is in non-malignant gynecological disease, and that includes endometriosis.

Teresa Götz: How did you come to research this topic?

Dr. Giorgia Elisabeth Colombo: I spent two months in Sydney, Australia, when I was a medical student. There, I met Dr. Leonardi, who is an expert in endometriosis. He’s currently an assistant professor at McMaster University in Canada. I started working with him when we were both in Sydney, and we started doing some research projects together. Then, through his interest in endometriosis, he introduced me to research on this topic, and I just grew to love it.

About Dr. Giorgia Elisabeth Colombo

Dr. Giorgia Elisabeth Colombo is a doctor, trained originally in Scotland, and currently about to start her special training in gynecology in Switzerland. Her research and clinical interest is in non-malignant gynecological diseases, like endometriosis, and especially their connection to cardiovascular conditions. 

Teresa Götz: What would you say is your main motivation to work in this field?

Dr. Giorgia Elisabeth Colombo: It’s a condition that we still have a lot to learn about. It really affects patient’s lives, so patients with endometriosis have a big impact on their day-to-day life. I am honored to be able to provide information so that we can manage these patients appropriately and make a difference in their quality of life.

Teresa Götz: That’s true. We have a lot to learn in this field. In your opinion, what is the greatest challenge in the field of endometriosis?

Dr. Giorgia Elisabeth Colombo: My research tends to be more on epidemiology, so the bigger picture, not the pathology and the way endometriosis develops or the treatment. But more on the things that are associated with endometriosis. Coming from my own biased perspective, with my own research, the greatest challenge is that we are figuring out the impact that endometriosis has on other conditions.

Specifically, my research. One of the posters I presented at the Congress was about cardiovascular disease. For me, that’s one of my personal areas of challenge for individual patients, but there are many.

Teresa Götz: Can you summarize some of the results of your research?

Dr. Giorgia Elisabeth Colombo: The specific study that I’m talking about now is about non-malignant gynecological disease. It’s not just endometriosis but non-malignant gynecological disease in general and whether there’s an association with cardiovascular disease. We screened many studies. We ended up including 35 studies with over two million individuals included between the exposure groups and the control groups.

Obviously, it depends on what results are reported by the studies and which ones were included in specific steps of the meta-analysis. In our meta-analysis, we found that there is an association. According to our study, with cardiovascular disease, we had different outcomes.

The primary outcome was composite cardiovascular disease. That was a combination of an incidence of ischemic heart disease, cerebrovascular disease, heart failure, and peripheral vascular disease. Therefore, any outcome reported by a study that included multiple conditions, so not just a simple one.

We found that there was a 1.29 increase, so the relative risk was 1.29 in patients with non-malignant gynecological and composite CVD. That higher risk remained in the endo patients. It is 1.36 for the composite CVD, and in the subgroup of endometriosis patients and the subgroup of ischemic heart disease specifically, it was 1.41, so actually higher.

Then, in endometriosis patients and cerebrovascular disease, things like stroke and ischemic attack, there was a 1.28 increased risk. 

Teresa Götz: Regarding these results, are there recommendations for endometriosis patients?

Dr. Giorgia Elisabeth Colombo: There aren’t that many studies that have looked at this. There’s one systematic meta-analysis in endometriosis patients that’s a bit smaller than ours. There are a couple of ones that have looked at PCOS patients. What our study does is look at gynecological diseases, but because there’s not that much research, we can’t say with certainty.

Systematically, meta-analysis is very robust, but again, we need further research to confirm this association. For our study, the key message that we want to give to patients is about prevention. If we know that there’s an increased risk of cardiovascular disease in patients who have endometriosis and other gynecological non-malignant diseases, then the key thing would be to take steps to prevent the development of cardiovascular diseases.

The key components such as a healthy diet, cardiovascular exercise, maintaining weight, not smoking, and these kinds of things if you’ve already got a higher risk of cardiovascular disease. In diabetic patients, they are known to have a higher risk of cardiovascular disease. These are the recommendations that we give to them. These can be extended to patients with non-malignant gynecological diseases.

I think that there probably is a higher risk. If patient studies do confirm this association, what might happen is in practice, there might be monitoring and screening implemented for cardiovascular diseases, but also the things that patients themselves be aware that there is a higher risk so that if they do have symptoms, they should seek medical attention appropriately.

Teresa Götz: The positive message is that we can do something about cardiovascular disease. For example, diet or smoking, if someone knows he or she has a higher risk, he or she can do something about it, or the doctors are more alert to it. You also had a study about quality of life. Can you tell us about this?

Dr. Giorgia Elisabeth Colombo: The study that we conducted was on endometriosis patients only, and it was about the health-related quality of life in endometriosis patients who also have psychiatric condition, mostly anxiety or depression.

The results that we found, unfortunately, we couldn’t conduct a meta-analysis. The way they diagnose the psychiatric condition, so anxiety and depression, was with different scales. There were questionnaires that the patients filled out, and then the results of the health-related quality of life were also done with the scale.

The patients would fill out a questionnaire, and the health-related quality of life level was determined by that. In all the studies used, there were variations in the individual’s health profile and the short-form questionnaire, but there were different variations, different studies, and different questionnaires used to assess anxiety and depression.

Teresa Götz: Could you explain briefly to our readers what the meta-analysis is?

Dr. Giorgia Elisabeth Colombo: A meta-analysis is when you take the data from various studies. You’re not producing any data and you’re not assessing the patients yourself, but you’re taking the data that other people have collected, and you take their results and combine all the results together. A meta-analysis or a Cochrane meta-analysis is the highest level of evidence.

In general, systematic review and meta-analysis is a very robust form of data because it has a large study population, because it has many different sources, and utilizes data from various studies to confirm whether there is an association or not. In summary, you take the data from different studies and combine it.

Teresa Götz: What did you find? You said it was more of a comparison. What were your results?

Dr. Giorgia Elisabeth Colombo: For the study on endometriosis and quality of life, we found that, as you would expect, patients who have endometriosis and anxiety or depression tend to have a worse quality of life. There was one study that showed that there was no significant difference between anxiety and non-anxiety patients.

All the studies that looked at depression found that the quality of life was worse than with that. Again, these are qualitative. I’m reporting it narratively, as I’m telling you what I saw in the studies but haven’t conducted an analysis. It’s a bit difficult with this topic to determine what comes first. There’s an interaction between your quality of life, your mental health, and your endometriosis symptoms, such as pain.

We also interestingly found that patients who had chronic pelvic pain didn’t have a significant difference. Other studies have found that patients who have chronic pelvic pain but don’t have endometriosis tend to have similar effects on quality of life. It’s a bit difficult to determine whether the endometriosis itself is contributing to this or whether it’s the symptoms of the endometriosis that are causing this.

There’s an interaction between pain and mental health because if you’re in pain all the time, your quality of life decreases, and then your mental health is affected by that. Lastly, we looked at whether mental health is the one that’s driving quality of life.

Teresa Götz:  It’s not easy to distinguish between cause and consequences in research. In this field, we can’t do an experiment like inflicting pain on somebody for months, and then we look at the changes.

Dr. Giorgia Elisabeth Colombo: It’s a big challenge in research, and it’s also a similar challenge we came across in both of our studies because you can’t really conduct a randomized controlled trial in these kinds of exposure studies. You can’t assign patients randomly based on whether they have an interest or not. The studies tend to have quite a high level of bias.

For example, in the study on cardiovascular disease, we found that 51 percent of studies had a critical risk of bias, and this was mostly because of confounding. Confounding is factors that might affect the result. For example, specifically in cardiovascular diseases, this could be something like your BMI.

Patients are at a higher risk of cardiovascular disease regardless of whether they have a complication or not, and smoking is also a recognized factor. It’s important that these studies are of interest for BMI, smoking, and other factors that are confounding. That could influence the result. If they don’t, we rate them as biased.

It’s important to be aware that many studies in this field of research, specifically the study that we conducted, are at critical risk of bias.

Teresa Götz: Maybe we could talk about what your future research goals are.

Dr. Giorgia Elisabeth Colombo: As I mentioned, my interest is in non-malignant gynecological diseases. I want to continue to work on endometriosis research, and I also have an interest in PCOS. I recently contributed to the new international guideline that’s going to be published shortly. I want to continue to investigate endometriosis and epidemiological things, and I also hope to conduct some more primary research, as in interactive research with patients directly.

Now that I’m starting my training in Switzerland. I’m in Ticino/Tessin in the Italian part because I speak Italian. I’m trying to learn German. The hospital where I will be starting is in Lugano and is the only endometriosis center in Ticino/Tessin. I’ll get to treat patients with endometriosis, but hopefully, it’ll also allow me to start something like a database so we can analyze data about patients with endometriosis and determine other interactions that there may be in other outcomes that you can expect with patients with endometriosis. It’s a very broad net, but essentially, I want to continue to learn everything I can about these conditions.

Teresa Götz: I also think that now you have direct contact with the patients and the research, which sounds like a good combination. My next question is: what is your opinion on digital self-help?

Dr. Giorgia Elisabeth Colombo: It’s great. I’ve looked a little bit into the Endo-App specifically obviously when you wrote to me. It seems like a great resource for patients. Nowadays, especially our younger patients, who tend to be the ones who are more affected by these conditions, obviously use their phones a lot. You always have your phone with you, so it’s convenient.

For example, the Endo-App offers a symptom diary, you have your phone there, so you can say, “Oh, right, this symptom.” You don’t have to remember it. When you get home, write it down. It’s an excellent way and it’s the future of medicine. There’s going to be a big interaction with technology which means digital treatment.

Endo-App provides information but also places to record like a separate symptom tracker are going to be more and more common. This is a very positive thing.

Teresa Götz: Is there anything else you would like to share with those affected by endometriosis?

Dr. Giorgia Colombo: From my research point of view specifically, one thing that I think is important is just to be aware and advocate for yourself. If you know that there is an increased risk of cardiovascular diseases, being aware of that can help when you go to your doctor.

Especially there’s a big diagnostic delay in getting that initial diagnosis. Therefore, make sure that you advocate for yourself and that you’re aware of this association as well as keeping an eye out for symptoms of cardiovascular disease, mental health, and your quality of life because as we know, these are also affected by endometriosis. Therefore, not letting things slide, and making sure that you get the medical attention that you need.

Teresa Götz