This article reviews patient reported self-management strategies for dealing with endometriosis symptoms.
Alternative treatments for endometriosis are becoming increasingly more popular as the treatment failure rates for conventional therapies are high. Further investigating from the patient’s perspective what they are using to manage their symptoms allows for further elucidation of methods that patients are commonly using and find helpful. Cannabis in particular ranked by patients as the most effective but not most commonly used. This could allow for further research into cannabis, hemp and CBD oils. Areas for improvement include: 1. In the discussion section, deciding either to discuss the most commonly used methods or the most effective methods for the discussion points. The methods that were discussed did not seem to follow a clear and consistent reasoning for their selection. For instance, breathing and mediation were used more commonly than dietary changes, but yet not discussed. Or acupressure was more effective than rest or exercise but also not discussed. 2. Acknowledgement that acupuncture was not used in this study and is currently a tool reported in the literature as highly effective for management of endometriosis symptoms. Acupressure is not at the same level of effectiveness and not having acupuncture as a question on the survey is a limitation of the study. 3. In the results section, percentages are used, but an improvement in the data could be noting where treatments were statistically significant especially in light of the numbers using heat versus using cannabis. Cannabis ranks higher in pain management, but the number of individuals using this therapy (48) was much lower than those using heat (259). Is cannabis statistically more effective than heat? 4. Making table S1 a part of the study itself instead of a supplement. Being able to use the data from reduction in medications is helpful and may be used to further bolster the ranking of pain management therapies. This also allows for actionable, clinically relevant data that can be used in the clinical setting. Minor areas for improvement: 1. Background paragraph 3 line 1 “safety” could be replaced with adverse effects as referenced in the results section for what was actually measured.

Comments on abstract, title, references

The title and abstract provide a clear understanding to the reader as to what is being studied and why and is well referenced. Taking into account the patient perspective in research is both innovative and important to finding better solutions for this complex disease process.

Comments on introduction/background

The research question is clearly outlined, but safety seems to be outside the scope of this study since it is a survey oriented research project based on patient perspective. A better choice of words may be adverse events or side effects from the treatment protocol. The background review is thorough and brings up that patients are already using alternative treatment modalities based on previous studies. Currently there is limited research in the area of cannabis and if patients are using for self management, further research projects could be geared in this arena.

Comments on methodology

The choice of subjects is clear and the methodology is repeatable. Due to social media being the recruitment tool there is potential for selection bias and endometriosis status is based on patient report, not surgical report. However, using patient focus groups to help design the study allowed for a more patient centered approach The selection of acupressure and not acupuncture leaves a gap in self-care strategies. Originally I wondered if that was because of the "self" in the management strategies, but in the survey questionnaire Tai Chi/Qi Gong was listed as a possible beginners class, which would require another person's help. I am concerned that by not comparing acupuncture cannabis may not have been the highest rated pain relief strategy found later in the results section.

Comments on data and results

The tables are well organized and complete in their details and titles. I am however unclear what results are statistically significant. There is one comment about statistically significance between diets but no other mention of significance. The additional Table S1 would have been nice to be further broken down and summarized in the full article itself. That allows more practically meaningful results since ideally reducing pain medications is a practical end point.

Comments on discussion and conclusions

The organization of the discussion left out the categories of acupressure and massage which were self reported to have a higher improvement in pain relief than rest or exercise which were included in the discussion. This felt a little disjointed. CBD and hemp oil were also missing from the discussion on cannabis section. While they may be considered another category, discussion on them seems appropriate based on their ranking in pain relief. Options for future research seem, from the author's perspective, to be limited to cannabis. While the aims of the study were met, the overall discussion section felt slanted toward future research on cannabis instead of looking at other modalities, especially since things like pilates and yoga were grouped together instead of separated and exercise was not clearly defined by authors in the survey (which the authors do mention).