Hello Mathew,

Very useful discussion!

First of all, I think that is very important to advise our patients to avoid NSAID medication because data shows us that is detrimental for infection evolution.

If we keep in mind that endometriosis is a chronic inflammatory disease and the new data suggest that COVID infection induce a procoagulant state, maybe is better to avoid COC pills and go to more use of dienogest. Why i shoudnt recomend the use of GnRH analogue? Because they induce some negative impact on quality of life (sleeplessness, low mood or anxiety ) or even some simptoms that cand create a false impresion of COVID infection (hot flushes, night sweats, headaches).

So for my patiens I recomend as medication: Dienogest, for pain paracetamol or tramadol in combination with paracetamol.

For patient with DIE: a good hydration, a diet with fibers and avoid meat, and food with phytoestrogens, sugar, chocolate.

Fizical activity in the house better.

To avoid any trigger for pain as much as possible: i.e. intercourse

Hey Matthew,

Very neat topic!!

In regards to alternative/complementary at-home interventions, two came to mind:

1) There has been growing evidence suggesting that moderate cannabis use could help mitigate pain in endo through several MOA. Several cross-sec studies have shown that cannabis is one of the most frequently used non-pharmaceutical interventions amongst patients with endo. Cannabinoid receptors (CB1) have been found at the somatic fibres adjacent to the lesion site. Several murine studies have shown the potential of cannabinoids in drastically reducing pain scores and even reducing the lesion.

In general, especially in areas such as Canada or America, cannabis is widely accessible. Although the caveat remains, as there is not enough literature to fully support the clause due to variation in cannabis and route of administration.

2) I've noticed that the most frequently suggested intervention by women with endo over social media is changing diet. This could be a great way to reduce inflammation at home and improve overall health in some cases.

Hello Dr. Mathew,

As NSAIDs are contraindicated for patients with COVID-19, I would rather suggest the use of Norethisterone acetate. Some studies have shown that it's a good alternative for surgery in reducing endometriosis pain. Additionally, it's relatively safe and doesn't induce bothering side effects like GnRH agonists do.

Hi Antoine Naem thanks for responding!

Norethisterone is a good option. What do you think about non-hormonal options like exercise, diet, heat, cannabis, etc? Things that patients can do with little/no guidance from healthcare providers?

Shay Freger is there any literature you can share with us on cannabis or diet? Both are very interesting concepts, especially cannabis in the context of legal acquisition and use. Thanks!

Thank you for asking Dr. Mathew. In my opinion, cannabis shouldn't be recommended to patients unless the pain is severe and all other treatment strategies have failed in resolving or reducing it. During the lock-down, patients might experience depression due to self-isolation and endometriosis pain could even worsen their psychological condition, which might encourage patients to overuse cannabis and become addicts at the end of the day. I think the combination between physical exercise and hot water sacs are good treatment alternatives in these situations. Physical activity is known to reduce estrogen levels that tend to "fuel" endometriosis on the one hand, and it can ameliorate the patients' mood and reduce depression on the other hand. Hot water sacs can be applied when acute pain episodes occur, like dysmenorrhea for example. Additionally, I would suggest music as an additional way to reduce pain even though its effects aren't studied in this category of patients. However, one meta-analysis has shown that music can have analgesic effect in patient suffering from chronic pain.

Mathew Leonardi I've attached the articles on cannabis below, although there are a few more on PubMed

• Armour, M., Sinclair, J., Chalmers, K. J., & Smith, C. A. (2019). Self-management strategies amongst Australian women with endometriosis: a national online survey. BMC complementary and alternative medicine, 19(1), 17.
• Dmitrieva, N., Nagabukuro, H., Resuehr, D., Zhang, G., McAllister, S. L., McGinty, K. A., ... & Berkley, K. J. (2010). Endocannabinoid involvement in endometriosis. PAIN®, 151(3), 703-710.
• Escudero-Lara, A., Argerich, J., Cabañero, D., & Maldonado, R. (2020). Disease-modifying effects of natural Δ9-tetrahydrocannabinol in endometriosis-associated pain. eLife, 9.

I believe Antoine Naem has an interesting point regarding psychological conditions. THC and other psychoactive components may exacerbate any anxiety (depending on the individuals experiences and even the type of cannabis). It may be that cannabis could pose as a valid option for individuals who already have experience with it rather than offering it as a novel therapeutic.

It should also be noted that cannabis has a plethora of non-psychoactive components such as CBD, which are well known to mitigate chronic pain disorders, without altering the CNS. Edibles, strains, or oils with high CBD and low THC content may be a good option in that case.

Some co-authors and I have written this article on self-management strategies. It has been reviewed and endorsed by the World Endometriosis Society and International Federation of Fertility Societies. It is in submission though not yet formally peer-reviewed or published.

Preprint Self-management strategies to consider to combat endometrios...

Happy to discuss any element of this piece!

- M

I'm surprised that no-one has mentioned meditation and mindfulness, particularly in chronic pain conditions, as being helpful.

Pain can be very distressful can we employ the use of etoricoxib

what of Mirena which has the added advantage of having local progesterone effect within the pelvis

I think that there is need to evaluate the pain score threshold which should be individualized, followed by evaluation of the pain management therapies the individual has previously been on and related response; address the psycho- social well - being of the patient as they may be attributing pain to endometriosis but can be PTS with COVID 19 social mitigation

There are a host of pharmacological and non pharmacological methods which should also look at diet ,exercise, meditation,

Amongst the pharmacological commonly employed are GnRHa needs to be given 3-6 months with considered add back therapy; use of coxib therapy and Mirena

Interesting topic research should be undertaken

Good question,

SKY technique can be learnt online . Self management of pain management with this special technique is very much needed

Look www.artoflivingresearch.org