International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
Violence in Adolescence: Sexual Abuse, Incest, and Their Possible Role in Symptoms Suggestive of Endometriosis - Michel Canis, MD, PhD
So good morning everyone. I'm Michel Canis from CLA firm of France, and I want to say that I want to thank you very much for the invitation. I'm very honored to be able to participate in this exciting meeting. I have three conflict of interest. I'm a surgeon. I am convinced that we should change our view about this disease and I want optimistic perspective for our patients. I am online because I wish to decrease my carbon footprint to try to preserve the planet of my children. I'm presenting on behalf of our team in and I'm very honored to be able to discuss violent sexual abuse, incest, and there are possible roles in symptoms suggestive of endometriosis. I think this is an essential topic nowadays. The first question I want to try to ask is violence, a comment or a rare event. And I have to confess that anytime I look at this data, I'm so surprised, so shocked by the results.
And this is one of the last study of the nurse health study about the coalition between trauma during childhood and premature mortality, more women. And in this study you have the incidences of physical abuse and of sexual abuse. And you see that the results was 53, 5 0.5% for physical abuse and 34% for sexual abuse. This number are huge. The first question about sexual abuse is it under declared. And as a matter of fact, if you look at this study from Australia, you see that it's very common for children who have been abused sexually to never disclose this event. And you see that up to 40% of women never disclose this demo, disclose this event during their life. So the frequency appeared to be very high and it could very well be underestimated. A good example is what happened in France over the last years in France.
Nowadays incidents of incest is supposed to be around 10%. It was about estimated to be 5%. 10 years ago the society did not change. The only thing with change is that children are speaking more easily and are much more likely to be taken in account nowadays. Judges recently changed their management assuming that the child has no reason to invent what he's talking about, whereas the adult has obvious reason to lie. So yes, this is a very common event. Unfortunately French are not worse than the others. Similar results were reported from the uk. Is this phenomena decreasing? Some recent review about this estimation suggests that yes, it could be decreasing in the modern society, but I think this has to be confirmed. Indeed, the society is becoming more and more violent and sexuality is stopped to adolescent using porn industry and porn. The content of porn industry is almost always violent so that I'm afraid that this phenomena will not disappear and will not decrease.
These are only number of childhood and adolescence. But if you look at numbers of younger adults, which are provided by studies performed during university and high schools, you see that the incidence of rape among French students was 5% and the incidence of sexual assault was 10%. A very important number year is at 24% of the victims were under the influence of alcohol. So women should be careful when they are drinking. Unfortunately, again, these results are not specific to France. And these are results published in a prospective randomized trial trying to teach women coming to the university to avoid rape. And you see that in the control group, the incidence of rape was 9% and in the resistance groups it was 5.2 0.2%. Similar results are observed among all universities all around the world. And this is the same for instance in this study from a South African university who also raised the importance of alcohol, which increased the risk for women.
And this was again the same in Kenya. So this is the same in among all students all around the world. So again, this is not where at all. If you look at this WHU study, the incidence of being the risk for a woman of being victim of sexual violence during her life is estimated to be 33%. One woman out of three has been victim of sexual violence during her life. This was confirmed about intimate partner violence in the Lancet study in the study performed in 2018 and published in 2022. And again, this is not specific to any country this see that the incidence is almost the same all around the world and this cost a lot of money. Are this violence related to endometriosis? This is the second question and first answer about intimate partner violence. And this is a study coming out from Australia.
And yes, women who have endometriosis at higher risk, women who had intimate partner, I'm sorry, have an increased risk of endometriosis. So this is related to the disease childhood maltreatment. Yes. Also, several studies have demonstrated that women with endometriosis are more likely to have been victim of sexual abuse, emotional abuse, and emotional neglect. Another study, again coming from the NL study, clearly confirmed that the hazard ratio of refi endometriosis is higher in women who were previously victim of child violence. And the more they were victim, the more chronic was the violence. The higher is the risk of endometriosis. So more severe trauma and more longer trauma are associated with endometriosis with an increased risk. So there is a clear relationship between these two eno. And this was again in this other study which also suggested that women who were previously raped or previously aggressed as victim of assault while they were children, are clearly at risk of risky sexual behavior, which increased the risk of rape and or sexual violence.
A very interesting recent study in JAMA Pediatric clearly also confirm this data and confirm also that traumatic experience are related to endometriosis with no link to genetic analysis. This is the conclusion of the study. Our findings highlight the potential association between contact trauma and endometriosis, which appears to be independent of the disease genetic predisposition. So in the future, sociology could be more important than immunology or genetic to understand endometriosis. May we understand why this trauma could be related to endometriosis? This is another question I proposed a few years ago that to start the disease, we need an event and that this event could be a trauma. Why I proposed that? Because looking at so many phenotypes, I thought, well, so many different disease, so many different anatomical appearances could not be related to only one cause. So we need somewhat another explanation. So I proposed trauma because we know that c-section induced abdominal wall endometriosis, and this also happened in epitomy and cone biopsy.
And I also proposed trauma because of this picture, which shows active bleeding induced by clinical examination of a patient, which during the laparoscopy and this clinical examination was performed to assess the limit of the nodule and this induced a severe bleeding. So I think that trauma to the posterial sac is a very important event in the development of endometriosis. What was our proposal? Very simple. We propose that the extent of the surgical phenotype of the disease may be related to the initial anatomic localization type severity and duration of the trauma. So that to explain the phenotype, please look at the possible cause. Look at the possible trauma. And this was recently confirmed in some way by this study published by the group of Kovic who in fact published two papers clearly showing that patients who were seen in emergency room with an hemoperitoneum and we follow up at ultrasound during few weeks, we're likely to have appearance of a deep nodule in the SE shoulder.
This is a drawing and if you look at the ultrasound at zero weeks, you have an hemoperitoneum with an a corpus luteum hemorrhage. At one weeks the fluid begins to disappear and the clot is organized and the clot is traumatizing. The peritoneum, which becomes thicker eight weeks, the clot is resorb and you almost see the transition to the appearance of a deep nodule. And the deep module is clearly visible at 26 weeks. This group is a group of expert in ultrasonography. Histologic confirmation was obtained unfortunately in only one case, but they are good ultras fist and I think that their results should be very carefully considered showing that probably trauma to the compost shoulder sac could facilitate the appearance of deep endometriosis. Could this happen after a sexual trauma? When I go back to this picture and when I remember when I was working in Morocco in the university hospital in Casablanca, I'm quite convinced that severe trauma to the posterior shoulder site can damage the vagina, probably can damage the peritoneum and probably also be related to some case of deep endometriosis.
We have this evidence from the literature one paper coming from the group of virtually which has been retired, and one paper coming from the group of she in Paris. Both are suggesting that the most attractive women are more likely to develop deep endometriosis trauma to seeing women. Trauma to the posterior sac is obviously more easy to induce in seen women than in obese patients. Another idea which is in my mind very important, is that peritoneal trauma is not limited to surgical incision or surgical excision. If you look at this blue area, this area are showing damaged peritoneum. And this damage of the peritoneum was only induced by this probe. So a very traumatic instrument damage the peritoneum and load an hydrophobic surface to become hydrophilic. And this was confirmed by veterinarian studies. What are they doing? They are following and recording and monitoring ovulation in boths.
And for this they are using rectal ovarian palpation. And because this is quite traumatic to the rectum, the peritoneum of the sac is traumatized by this examination and they look at the peritoneum and indeed they demonstrated that palpation through the rectum, not inside the peritoneum, but just in their right trauma may induce peritoneal damage. And when the peritoneal trauma disrupt the peritoneal surface, it facilitates the implantation of endometrial cells. Role of violence and stress have also been suggested. This study from San White Youth Group did a very interesting study, the induced childhood maltreatment in young mice. So when they were less than 21 days, they separated them their mice, baby mice from their mother three hours a day. And when the mice were at eight weeks old, the induced endometriosis and what they show is very important and very interesting. The weight of endometriosis in mice who have been separated from their mother is significantly higher than in the control group who have not been separated from their mother.
And also there is an hyperalgesia in mice who have been separated from their mother. So childhood trauma facilitates the growth of endometrial uses in adult mice and increased risk of pain in this adult. The same group did another study and they clearly showed that if you induce stress in a mice and then if you induce endometriosis, the endometriosis will be more severe in the animal groups who were stressed just after or before and after induction of endometriosis. So stress makes endometriosis worse. So we have the mechanism to explain the relationship between endometriosis and trauma during childhood, adolescence and even adulthood. And my final idea today is that we can propose a prevention of endometriosis based on these ideas. From this paper, it appears that dyspareunia may be a warning sign suggesting an anatomical trauma to the posterior field sac, which may expose a woman to the risk of endometriosis.
So saying no to any painful sex may be proposed as a prevention rule for endometriosis and or as a prevention of an increase of an increase in the diameter of a deep nole. This is a very simple rule, very easy to apply, very good and very safe for women, and I think very acceptable for everyone. The second rule is coming from this comment, all adolescent or young adults who have severe dysuria do not have endometriosis, but many of them have a history of child violence, sexual abuse, emotional neglect, which may expose them to higher risk of endometriosis. And if you recall of these studies that I showed you already, separation from their mother in babies', mice induce more severe endometriosis in adult mice. So prevention of childhood violence could be a way to prevent endometriosis from this study of the group of shell chapon. We also know that this previous violence during childhood expose patients to more severe pelvic pain when they are adolescent or young adult.
So decreasing preventing childhood violence could decrease the incidence of severe pain. And we are further evidence of that when we look at the study from San View who showed that maternal separation induce increased the risk of IPR analgesia in adult mice. Indeed, prevention of childhood violence may prevent both endometriosis and severe pain in patients without endometriosis. Again, all adolescents who have severe dysuria don't all have endometriosis or may have endometriosis, but the stress induced by the severe pain could increase the risk of endometriosis as suggested by this study of San V, which clearly showed that if you stress the animals before, after, or before and after the induction induction of endometriosis, you have more severe disease in the animals who were stressed. So prevention of pain, acute correct treatment of pain will decrease the stress and will decrease the risk of the disease. So myoma idea raised different questions about the natural history of the disease, about possible way of prevention.
I don't know if this story is correct, at least this theory gave me different ideas, but it suggested me also that we should look for different theories which may give us new ideas to try to understand endometriosis that we are not understanding. Although we are doing extensive research for the last 40 years, our understanding is still very limited. So we need hypothesis. And I share this opinion with a lot of experts and this paper was published in GM and we open the website. If you have an hypothesis, you can send it here. You can submit your hypothesis there. We will look at it and if it's correct and respectful of everyone, it'll be published on the site. Every opinion is worth being looked at because our knowledge has not changed over 40 years or very limited change, the understanding is still very limited. So we need new ideas and I invite you to come to the World Congress Telemetry use in Sydney in May, so that we can share as many ideas as you wish about endometriosis. I thank you very much for your attention and again, I thank you very much for the invitation.
