All the Small Things

It’s always interesting/entertaining/amusing when an animal does something we think is typically human; a dog riding a bike, a cat playing Candy Crush, a hamster surfing, and thanks to the internet we can see all these things, what a time to be alive. But the other week I was surprised to hear of an animal that did something no-one thought it could do and the repercussions of this could have a major impact on the world of endometriosis research.

This was a report I read documenting the first ever observed occurrence of a species of mouse (the spiny mouse to be precise) having a menstrual cycle. Up until now the only animals we were familiar with that menstruate were primates like chimps, gorillas and humans. Other animals have different reproductive cycles characterised by different hormonal and physical changes in their reproductive organs. Most other mammals, including mice, undergo an estrous cycle. The estrous cycle, like the menstrual cycle, is still regulated by hormones such as estrogen and progesterone, but the way these hormones vary throughout the respective cycles and the effect they have, differs.

The diagram below shows how the different hormones that regulate the function of the reproductive organs changes over the human menstrual cycle and the rat estrous cycle. If you want to see how these hormones work in humans I've covered it here.

Image source: http://pubs.niaaa.nih.gov/publications/arh26-4/images/emanuele3.gif

As you can see, there are quite obvious differences, but also some similarities between the two. The rat proestrus stage for example, is somewhat similar to the human day 14 and the rat day 4 resembles the human day 10, but overall they are quite distinct. In terms of the actual physical changes, menstrual animals shed their endometrium after each cycle if conception doesn’t occur. This, as some of you will all too painfully know, is having a period. Estrous animals on the other hand reabsorb the endometrium if conception doesn’t occur and, although some animals like dogs might bleed at certain times of their cycle, this is not an actual period, rather it is caused by estrogen making the blood vessels in the vagina ‘leaky’.

So the discovery of a menstrual cycle in the spiny mouse is surprising to say the least, but why is this relevant to endometriosis research? In order to study the way in which endometriosis works and develop new treatments we can grow endometriosis cells in the lab and experiment on them. Unfortunately this tells us nothing of the complexity of the disease or how endometriosis behaves in a living organism. For this researchers turn to animal models of the disease. This is usually achieved by ‘inducing’ endometriosis in a lab animal (typically estrous mice). However this is far from a perfect model of the disease. Inducing the disease in mice is achieved by transplanting either pieces of whole uterus, or pieces of the normal endometrium into the pelvis of the mice. Neither of these gives a true representation of human endometriosis, but it’s the closest thing researchers have at their disposal to study endometriosis (there are much more accurate primate models of endometriosis, but there are numerous reasons, such as cost, facilities and ethics, that prohibit the use of these animals in most research centres).

Another problem is that because normally mice don’t menstruate, the disease will not behave in mice the same way it behaves in humans due to different levels of hormones in the body. Mice can be made to have hormonal cycles like humans but this involves removing the ovaries and supplementing them with hormones and even this doesn’t represent the complexity of hormonal changes during the human cycle.

By using an animal that can menstruate, our models of endometriosis would become more accurate (in fact we may not need to induce endometriosis in these spiny mice if they develop it spontaneously, much more investigation is needed to observe this though). By extension the way we understand the disease in humans and the effectiveness with which we can develop new treatments will also become more accurate. Additionally, one of the goals that researchers work towards is reducing the number of animal experiments that are required to study any given disease. By using an animal that more closely resembles the human menstrual cycle, it would eliminate the need for performing additional procedures on lab mice to induce human-like hormonal cycles.

However, there is still a lot of work to find out exactly how similar the spiny mouse menstrual cycle is to the human one. The initial research that has been done has shown the spiny mouse cycle to be 9 days long. The human cycle is, on average, 28 days long and, interestingly, the pattern of progesterone levels in the blood across the spiny mouse cycle almost exactly matches that of the human cycle.

Although there is a lot of work still to be done investigating this unusual phenomenon, it not only has impact for endometriosis research, but also into other female reproductive conditions, like infertility, pregnancy and menstrual disorders. 

What am I doing?

“What am I doing?” A question I usually ask myself in a moment of crushing self-realisation after drinking a not insignificant amount of a famous brand of bourbon and embarrassing myself in front of my peers on a night out.  

But in this instance, the question ‘what am I doing?’ refers to the subject matter of my research. I’ve been doing my PhD for just over a year now and have only recently found my stride with it. Scientific research can be a perplexing venture; I’ve changed focus more times than I care to count. Of course a big part of that is my own tendency to pursue new avenues of interest like a dog being thrown a bucket of tennis balls. My main interest has and always will be endometriosis and working at this university has given me lots of opportunities (too many opportunities actually, not that that’s a bad thing) to investigate endo in different ways. Every new idea I have, there are the facilities here to investigate it, like being a kid in a candy store, but instead of candy store it’s a vast scientific research institute.

But anyway, enough of that rambling, I was talking about being focussed. My research is examining the role that fatty acids play in regulating inflammation in endometriosis. ‘Fatty acids’ is a bit of a vague term so I’ll clarify that first. You’ve probably heard of Omega-6 and Omega-3 polyunsaturated fatty acids; different foodstuffs like to advertise that they are ‘rich in Omega-3s’ or something along those lines. These include essential fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which fall under the Omega-3 category. Then there is arachidonic acid and linoleic acid which fall under the Omega-6 category.

We get a lot of these fatty acids from our food, but it’s what our body does with them that’s important.  When our body takes in these fatty acids, they are incorporated into the outer layer of our cells (the cell membrane) which acts as a storage space for them. The stored fatty acids can then be release from the membrane and converted into a whole plethora of different products by different enzymes, which can serve a whole manner of different functions (below is a diagram that summarises the process). In one sense this is why maintaining a healthy diet is important, it means you get the right balance of these fatty acids. From the other perspective, it may not matter how good your diet is, because your body (or certain parts of it) may not process the fatty acids correctly due to the presence/absence of certain enzymes or receptors for these fatty acids.

One function regulated by the products of omega-6 and omega-3 fatty acids is inflammation, which is very important when talking about endometriosis. Your body treats endometriosis very much like a wound, but a wound it can’t heal, so it releases a number of chemicals which ramp up the inflammatory response near the disease. Some of the products of fatty acid metabolism are key players in regulating this inflammatory response. In addition, this rogue inflammation is thought to contribute to the severe pain symptoms with which so many women with endo suffer.

You’ll notice that one of the products of Omega-6 fatty acids, the 2 series prostaglandins, are highlighted in red. This is because they are the only group of fatty acid products that we know the function of in the reproductive system in any great detail. There are numerous members of the series 2 prostaglandin family, but I’ve selected prostaglandin E2 (PGE2) and F2 alpha (PGF2a) as they are known to produce a strong inflammatory response. All of the others (don’t worry what the acronyms stand for, we’ll be drowning in syllables if I put the full names in) we don’t have any idea what roles they play, if any, in the normal function of the female reproductive system and what the consequences would be if they went awry.  

So the first part of my research is to investigate which of these fatty acid products are present in the endometrium. This is actually pretty exciting because it means making genuine discoveries. As I mentioned above we don’t know which of these fatty acid products are present in the endometrium, so discovering that will be something no-one has ever done before, exactly the type of thing us science geeks get excited about.

The second part will be to find out what differences there are, if any, in the fatty acid products from the endometrium of women with and women without endometriosis. Hopefully, finding fatty acids that are either much higher or much lower amounts in endometriosis patients will give some indication as to which of them are important. Because we don’t really know what these fatty acid products do in the uterus there’s no telling how important they may be; they might control inflammation, they might be important for hormone regulation, they may even be involved in fertility, or they may just be inconsequential. No matter what the outcome that is pretty much what I’m doing and hopefully it will lead to discoveries that will help us better understand (and better treat) the symptoms of endometriosis.  

Diary of an Endometriosis Researcher – The beginning

As regular readers may know, after waiting for a long, long, long time I finally have the opportunity to study for a PhD in endometriosis research. Engaging in said PhD has been keeping me fairly busy of late, hence the lack of regular updates on this blog. So I thought it might be worth keeping an online journal of my progress as an endometriosis researcher, as I’m sure that is something not many people have read before (though there may be a good reason for that). It would also remind me to keep updating this blog and hopefully give better insight into the whole process of endometriosis research from beginning to end. It will also give you a behind-the-scenes glance at the seedy underworld of scientific research and all the scandalous activities us students get up to. Ok, when I say ‘seedy underworld’ and ‘scandalous activities’ what I actually mean is ‘sterile laboratory environments’ and ‘staring at a lot of graphs’ but that didn’t sound as good.   

Anyway, on with the journal, yes I’m a full-time student, again, with ‘31 years old’ bearing down on me like an oversized ACME anvil on Wile-E-Coyote, my ever increasing age made shockingly evident by all the youthful students wandering around campus looking like they’ve only recently been severed from the umbilical cord. But still, my disgust at the younger generation and their nauseatingly trendy haircuts aside, I am definitely where I want to be – researching endometriosis. I know the term ‘researching endometriosis’ is annoyingly vague but there are a couple of reasons I can’t go into a huge amount of detail yet 1) There are certain confidentially protocols I must abide by, lest I get offered up as a blood sacrifice to the gods of research ethics and 2) Academic research is like a big high school exam and there is always some cheating little shit trying to copy your answers. So as much as I’d like to scream my experimental results from the rafters like some madman in a labcoat, I’ll have to be patient until I’ve finished, which is only four years away.

Nevertheless, it’s not all cloak and dagger, there are some things I can tell you, otherwise this would be a very short and boring journal (as opposed to the long and boring one it will inevitably become). For starters I am going to be investigating the effect of some novel drugs on endometriosis, hopefully non-hormonal drugs, thus lessening the notorious list of side effects associated with today’s medical therapy. If given the opportunity I also have some ideas for a diagnostic blood test for endometriosis, but we’ll have to wait and see about that.

During the intervening time between when I started and now I’ve been doing a lot of paperwork (oh how I could lament the Sisyphean task of completing paperwork), reading and writing. Every PhD student, at the beginning of their study, has to write a ‘literature report’, a summarisation of the current research into the subject they will be studying. I do enjoy writing about endometriosis, as this blog attests to, so was overjoyed to be able to write about it and get paid for it! Several drafts and bleary eyed days spent trying to pick out the relevant sentence in a 2000 page book later and my literature review is finally finished. Huzzah! Now what I call the ‘proper science’ can begin.

To begin the ‘proper science’ I’m going to have to learn several of the basic techniques I’ll need throughout my PhD, fortunately in my group there is another student who has already been here for a year and can train myself and the other students (luckily he has the patience of a saint, which will come in handy for all concerned). If I am to do any experiments, I’ll need something to experiment on and given the nature of my research, endometrial cells are a good place to start.

Growing endometrial cells in the lab is then the first thing I will have to master and in order to do that I have to get some endometrial cells from somewhere. It probably would be considered very impolite of me to walk up to women on the street with a speculum and a swab and ask if they could spare me some endometrium. So instead we have an arrangement with a surgeon at the local hospital to provide samples of endometrium from consenting patients undergoing laparoscopy for various reasons. The other week we had a consignment of several samples, which resembled nothing more than a few chunks of bloody tissue, but after a 12hour stint carefully processing them we had endometrial cells growing happily in little plastic flasks. Although it took us ages to get the cells into their flasks, this was by no means the hard part. No, the hard part is keeping the cells alive, which is called ‘culturing’ cells. If I had to liken cell culture to something I would say it is like gardening, you have to feed your cells, make sure they are grown in the right conditions, transfer them into bigger containers when they get too big and sing to them (ok that last one is optional). Some cells, like some plants, are easy to grow and don’t require much effort. Some cells, on the other hand, are like those extremely rare plants that only grow in a very specific two square foot of tropical rainforest and die if you so much as express a strong opinion in front of them – guess which category human endometrial cells fall into?

Whilst human endometrium grows with happy abandon in your uterus (and for those ladies with endometriosis, outside your uterus too), growing it in the lab requires the type of care normally reserved for preterm baby pandas. Needless to say the endometrial cells are quite delicate and often die before I have the chance to kill them with drugs. One of the skills you have to learn quickly to maintain your cells is ‘sterile technique’. Whenever you’re working with cell cultures everything has to be sterile, not just the equipment, but the actual way you work. For example, you have to work in a specially designed sterile air cabinet, you have to think through every move you make with your hands like a person playing chess with a sleeping wolverine on the chess board and you have to clean your hands with alcohol so much it would make the most sanitary obsessive compulsive look like a filthy slob. Despite the requisite fussiness of it all, it is absolutely necessary; trust me when I say it is rather disheartening to carefully culture your cells for a week only to lose the whole batch to a bacterial infection. Still, its early days yet and hopefully in the coming weeks I will perfect my endometrial cell culture technique.  

Although there are obstacles to overcome, I could not be happier to be doing what I’m doing.

So that’s the beginning of my research, what has been going on in the literature? Here are a few free articles

A Case of Multisystem Endometriosis

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3888339/

Whilst endometriosis outside the pelvic cavity is considered rare, there are still cases that come up with a degree of regularity; this is a case report of a woman with endometriosis near the lungs

Extrapelvic Endometriosis: A Rare Entity or Underdiagnosed Condition?

http://www.diagnosticpathology.org/content/pdf/1746-1596-8-194.pdf

Continuing along the lines of endometriosis outside the uterus, here is a short review of different locations endometriosis

Endometriosis and Physical Exercises: A Systematic Review

http://www.rbej.com/content/pdf/1477-7827-12-4.pdf

This review summarises what little information there is on the effect of exercise on endometriosis symptoms

Research Roundup

Fresh from the success of endometriosis awareness month endometriosis research has continued apace. Unfortunately I’ve been quite busy lately so I haven’t had much time to write a detailed overview on any research this month. But, what I will do is briefly cover some of the highlights of endometriosis research that has been published over April.

To start us off is an article from South Korea looking into the effect of laparoscopic surgery for endo and its effect on the ability to conceive naturally. This study took 43 infertile women with endometriosis and followed up their conception rates 12 months after they underwent laparoscopic surgery to remove their disease. The overall result was 18 out of 43 women (41.9%) had conceived naturally after 12 months. As fertility issues are a major concern for women with endometriosis it is good to know surgical intervention can improve the likelihood of conceiving. (You can read the full article, for free, here)

Next is an encouraging piece of research looking at serious investigation into new treatments for the pain associated with endometriosis. This latest study from Brazil was a Phase II clinical trial (basically a detailed check to see if a drug works before it is put on the market) of melatonin for the treatment of endometriosis associated pain symptoms. You may have heard of melatonin before, it is produced by your body at different levels during the day and is responsible for telling your body when to wake up and go to sleep, but it also acts as an anti-inflammatory and analgesic. Results of this trial showed 10mg melatonin daily for 8 weeks reduced daily pain scores by 39.8% and dysmenorrhoea (excessively painful periods) by 38% also reducing the need for taking other pain killers by 80%. As an added bonus melatonin was also found to improve sleep quality with no severe side effects.

Next is a continuation of investigations into the relationship between environmental pollutants and endometriosis. All the conducted research thus far has failed to provide any conclusive proof of linking one type of pollutant to endometriosis. This latest study hopes to add some weight to the argument by exploring the relationship between Bisphenol A and 14 Phthalate metabolites in women undergoing laparoscopy or MRI. This study found that, in the women undergoing MRI, 6 phthalates were associated with a higher likelihood of being diagnosed with endometriosis. However, in women undergoing laparoscopy and histological confirmation (which is the superior diagnostic method) only two phthalates were found to be associated with an increased risk of being diagnosed with endometriosis. This study highlights the need for researchers to pay special attention to the way studies are conducted when looking at environmental exposures and endometriosis. From my own point of view I think it may be worth looking at younger girls when designing experiments. Every current study has been focussed on adult women with endometriosis, but if endometriosis is a condition you are born with (which the current evidence certainly suggests) then in-utero and early life exposures to pollutants will be more important.

I have written before about the relationship between ovarian endometriosis and ovarian cancer. Having ovarian endometriosis for a long period of time can increase your risk of ovarian cancer, but only by a very small percent. Nevertheless some women with endo may wonder what effects surgical or medical therapy may have on their ovarian cancer risk. A recent study from Sweden has done exactly that by examining medical records of women diagnosed with epithelial ovarian cancer at least one year after being diagnosed with endometriosis and calculating if surgical or medical therapies had any effect. What this study found was that women with endometriosis who had a single ovary removed, or had radical excision of all visible endometriosis, had a significant reduction in their ovarian cancer risk. This study provides further evidence that complete removal of all endometriosis should be a number one priority for all doctors dealing with the disease.

Quicker surgical intervention for endometriosis can only come from quicker diagnosis of endometriosis. This could be achieved with non-invasive tests for endometriosis before laparoscopy - identifying patients with a high likelihood of the disease in an objective way. I’ve reported previously about the current progress of non-invasive tests, but these are just stand alone tests; what if different non-invasive tests were combined? A study from Egypt has shown that combining a blood test for interleukin-6 (a substance produced in your body in response to infection or trauma) with a test for nerve fibres in the endometrium, can push the diagnostic sensitivity for minimal-mild endometriosis to 100% Clearly more research needs to be done in this area to validate these results, but in the future multiple tests from a single blood sample may be able to identify women with endometriosis.

It may seem fairly obvious to anyone who has any spent any length of time with, or near anyone with, endometriosis that the disease can severely impact the sufferers ability to work. However, just knowing its true isn’t enough, in order to convince policy makers, we need empirical evidence that endometriosis has an impact on a woman’s ability to work. What that means is we need scientific studies comparing women with and without endometriosis to show, in numbers and statistics, the true devastating effect of the disease. Fortunately there have been studies in the past conducted for this very reason and now there is another from Denmark. This study gave questionnaires to 610 women diagnosed with endometriosis and 751 reference women relating to health and work ability. Perhaps unsurprisingly this study found that endometriosis was associated with more sick days and low work ability, which in turn was associated with tiredness, daily pain and high pain levels. All obvious things you would think, but we need studies such as these to highlight the impact of endometriosis and get society and governments to take the disease more seriously.

That’s all I’ve got for this month, don’t forget to follow me on Twitter @EndoUpdateBlog for shorter, but more frequent, updates!

Research you can be part of

If you suffer from endometriosis then you are actually a goldmine of information, you are experts in the disease in your own right and there are several studies being done at the moment that would like you to share your collective wisdom about the disease with a view to improving awareness and understanding.

The first of these studies is a survey open to any woman who has been surgically diagnosed with endometriosis. Here is a summary of the research objectives:

The purpose of this research study is to understand the various ways endometriosis impacts women who are diagnosed, the pathways to obtain a diagnosis, and the effectiveness of different treatments. There are no direct benefits to you from participation. But, your willingness to participate will contribute to understanding the challenges of endometriosis sufferers and improving the quality of care for endometriosis patients.

I have taken part in endometriosis research myself and know several women who have and I can tell you it is a richly rewarded experience. Being able to tell your side of the story is almost therapeutic and the fact that this goes to helping other women with endo is a double bonus. If you think this is something you would be interested in taking part in have a look at this link https://endo-research.com:8443/EndoResearch/

The second study is one I have mentioned previously, but is still open to those able to participate. It is being conducted in the UK and is limited only to women in the UK with surgically confirmed endometriosis; the researchers are particularly interested in talking to South Asian couples. Here is a summary of this study:

                                                                                                                                                             

Endopart - Endometriosis: Improving the well-being of couples

Researchers at De Montfort University, Birmingham City University and the University of Nottingham are carrying out research into the impact of endometriosis on couples in the UK. The team will use the findings to make recommendations about how women with endometriosis and their partners can best be supported and how care can be improved. The research, led by Prof Lorraine Culley, has been funded by the UK Economic and Social Research Council and has received ethical approval.

The team are interviewing heterosexual couples living in the UK:

. who have been living together for at least one year,

. where the woman has experienced endometriosis-related symptoms for at least one year and

. where the woman has a diagnosis of endometriosis following laparoscopy.

Each partner is interviewed separately. Findings from the study will be anonymous.

Please note, the team has closed general recruitment for couples to take part in interviews. However, they are still interested in hearing from South Asian (Indian, Bangladeshi, Pakistani) couples who may be interested in talking about their experiences.

If you and your partner would be interested in finding out more visit www.endopart.co.uk or contact Caroline Law, Research Assistant, at claw@dmu.ac.uk or on 0116 2506124.

                                                                                                                                                              

Both my wife and I have taken part in this study and I can highly recommend it to anyone who meets the criteria.

Most of the research into endometriosis is focused purely on the cold, hard scientific workings of the disease, which is great, but it’s also great to see research addressing the impact the disease has on the individual and those around them, and you can be part of it!

The Big Picture

As the Olympics have got well underway in my home country this month, I thought I would hold my own competition; but this isn’t one of sporting prowess, this is a competition to see who the best endometriosis researching country in the world is. Every time I look through the research on endometriosis I notice there is a lot of it coming from all sorts of different places. I report here about individual stories of interest but wouldn’t it be good to see all the research in a wider context, and who is the best at it?

Endometriosis is a global problem, it impacts negatively upon all the countries of the world both in terms of monetary value and in the surfeit of suffering the condition lays on all those affected. To that end then, it would be interesting to see which countries are at the forefront of tackling the problem of endometriosis, and which countries are falling behind. So over the last month I’ve been doing some research of my own to try and answer questions about the global scale of endometriosis research.

Let’s dive straight in and see how much research into endometriosis has been going on over the years. The graph below shows the number of articles published on the subject of endometriosis between 1925 and 2011. NB Click on any image for a bigger version

Research publications on endometriosis over time

As you can see it’s looking pretty good; the amount of research published on endometriosis has increased quite rapidly. In fact the research output over the last 11 years is double that of the preceding 60 years!

I suppose the next question to ask would be - where is all this research coming from? The map below shows which countries have produced the most research in endo over the years; the darker the country’s colour, the more research it has produced.

Map of endometriosis research published by country

Some surprises here. For example, did you know that Iran has published more research on endometriosis than Ireland? Or that Kenya has produced more endo research than Russia, despite the fact Russia is 30 times larger than Kenya. Unsurprisingly we can see that the vast majority of endometriosis research comes from North America, Western Europe and Japan. These countries (and continents) have always been the big hitters in the field of endo research, especially the United States, who lead the pack by quite some way. That’s an understatement really; according to the Scopus citation database the United Kingdom is the second most prolific endo research producing country in the world, with 1,659 articles published, which is pretty respectable. The UK however, looks like a dinghy compared the vast aircraft carrier of the United States contribution of 5,541 articles. With that in mind I thought it would be interesting to focus on the US and see which states are producing the most endo research. So I put together a map similar to the one above but just for the US.

Map of endometriosis research publications by US state

So it looks like New York, California and Texas are leading the pack with a pretty poor show from Idaho, Montana and Nevada.

Of course, what I’ve been showing thus far is all the research conducted to date, but how has the output of the world’s endometriosis research changed over time? To answer that the next few pictures show maps of the Top 10 endometriosis research producing countries, namely: United States, United Kingdom, Japan, Italy, Germany, France, Belgium, Spain, Canada and Australia, but I’ve also included four of the ‘up and coming’ countries of endo research, namely: China, Brazil, India and Turkey.

Each country is represented by its flag, and the size of the flag represents the proportion of its research output compared to the other countries. Let’s start with the groovy era of the 1960’s.

1960's

It’s plain to see where most of the endo research came from during these turbulent times. That said, between all the countries we are looking at, only 48 research articles were published on endometriosis during this entire decade. Let’s disco dance into the 1970’s and see how this changes.

1970's

Well the US still retains its dominance, but an important point is that out of the 14 countries we’re looking at, only 6 were doing any endo research in the 1960’s. By the end of the 1970’s, 13 out of our 14 countries were now doing some endo research. Also the amount of endo research published has increased by nearly 1500%, which is the highest increase in endo research in the entire history of the world! Let’s see how the mullet clad scientists of the 1980’s faired.

1980's

The 1980’s was known for many things, and most of these things involved unforgivable crimes against fashion. But in terms of endo research there were a few changes during the 80’s. Certainly research output from Western Europe and Japan increased. Japan in particular secured its place as the rising run of endo research by overtaking the European powerhouses of Germany, France, Italy and Britain.  Let’s see if this continues into the 1990’s

1990's

Whilst the fashion wasn’t much better in the 90’s, the global scale of endometriosis research was changing for the better. Japan and the UK grew in their output, as did Spain and Italy. France and Germany, whilst still generating a respectable amount of research, actually shrank a tiny amount. Belgium, despite being only a little country, showed it could hold its own against bigger countries like Canada and Australia. Also we see the sudden emergence of Turkey, a country that only produced two articles during between 1960 and 1989 suddenly, during the 90’s produces forty articles in one decade. Moving on to more recent times now, and the period between 2000 and 2011.

2000-2011

Well there’s a change; every country grows apart from the US (don’t worry American readers, it only shrinks relative to the other countries, the US still produces well over half the total endo research). The UK and Italy overtakes Japan; Belgium, Australia and Canada also make some decent growth. But by far the biggest surprise is China, Brazil, India and Turkey who explode onto the research scene, no doubt due to the economic surge in these countries. These four countries put together only produced less than 3% of the total endo research in the 1980’s, but produced 13% of the total output during the last 11 years. China in particular has, in the 2011-2012 period, overtaken most European countries except for The UK and Italy. Brazil and Turkey are both in hot pursuit. If the current trends continue, in the next ten to twenty years, these up and comers will be the dominant forces in the field of endometriosis research; but can anyone challenge the top spot of the mighty US? That remains to be seen. 

So far we’ve looked at certain countries and their research output, but what about the centres of endometriosis research within these countries, who can boast begin the best? Below is a leader board of the top ten endometriosis research producing institutions and their associated countries.

No surprise the see the US well represented here again. It’s also a rather excellent achievement for the University of Sao Paulo, ranking 5^th in the world is no mean feat, especially as they have only relatively recently started putting serious effort into endo research. But the gold medal goes to the University of Milan, felicitazioni! to you my friends.

To finish though, I think we need to acknowledge the individuals who contribute most to taking the monster of endometriosis by the horns and trying to beat it into submission. Below is a list of the Individuals who have contributed most to the field of endometriosis research by way of peer reviewed publications.

The world owes a great debt of gratitude to these people who work so tirelessly to better understand endometriosis and, if one day, I could make it onto that list, I would go to my grave a happy man. Of course it doesn’t end here, there are many, many people out there deserving of our praise; from doctors to awareness raisers, advocates, scientists and women who refuse to be defeated by endometriosis. There are too many of you to name, but you know who you are and you are all an inspiration.

If our collective was a living being and each of us represented a different part of that being, the excellent doctors who understand a woman’s struggle would be the healing hands; the researchers and scientists would be the enquiring mind, always thinking ahead; and the women who suffer this disease? You who face it every day, yet in facing it do not allow it to overcome you? You would be the heart and soul, you are the driving force without which the world’s interest in endometriosis would wane and grind to a halt. When the cure for endometriosis arrives, it will be because of someone like you.

All information on published works were retrieved from the Scopus database, where the title/abstract/keyword contains the word ‘endometriosis’ published up to the end of 2011 unless otherwise stated. Additionally, countries that no longer exist (such as the Soviet Union or Czechoslovakia) were not included in the search.

Only articles using the Greek/Latin term endometriosis were included in the search, therefore some articles which use language specific variations of endometriosis would have been omitted.

For the US map, a search was conducted for articles where the state affiliated with the article was given; therefore some publications will have been missed.

For the top ten lists only articles which contained the word ‘endometriosis’ in the title were considered. For the institutional and individual lists, research output was quantified by total number of publications over all years.