Impact of Endometriomas and Deep Infiltrating Endometriosis on Pregnancy Outcomes and on First and Second Trimester Markers of Impaired Placentation

Background and objective: Previous studies did not draw a definitive conclusion about the influence of the role of deep endometriosis (DE) and ovarian endometrioma (OE) as risk factor for developing adverse perinatal outcomes in patients affected by endometriosis. This study aimed to investigate if adverse fetal and maternal outcomes, and in particular the incidence of small for gestational age (SGA) infants, are different in pregnant women with OE versus pregnant women with DE without OE. Material and methods: This study was based on a retrospective analysis of a database collected prospectively. The population included in the study was divided into three groups: patients with OE, patients with DE without concomitant OE, and patients without endometriosis (controls). The controls were matched on the basis of age and parity. Demographic data at baseline and pregnancy outcomes were recorded. Results: There was no statistically significant difference in first trimester levels of PAPP-A, first and mid-pregnancy trimester mean Uterine Artery Doppler pulsatile index, estimated fetal weight centile, and SGA fetuses' prevalence for patients with OE, and those with DE without OE in comparison to health women; moreover, there was no statistically significant difference with regard to SGA birth prevalence, prevalence of preeclampsia, and five-minute Apgar score between these three groups. Conclusions: The specific presence of OE or DE in pregnant women does not seem to be associated with an increased risk of delivering an SGA infant. These data seem to suggest that patients with endometriosis should be treated in pregnancy as the general population, thus not needing a closer monitoring.

The effects of endometrioma size and bilaterality on ovarian reserve

The aim of this study was to investigate the effects of endometrioma (OMAs) size and bilaterality on ovarian reserve. The patients with OMA were determined by ultrasonographic examination. Fifty patients with unilateral OMA (Group A), 30 patients with bilateral OMA (Group B), and 60 women without ovarian cysts (Group C) were included in this study. AMH levels were measured, and antral follicle count (AFC) was determined. The mean serum AMH levels were significantly lower in Group B than Groups C and A, and were significantly lower in Group A than Group C. There was a significant correlation between serum AMH level and OMA size in Group A (R = -.372, p = .008). OMAs per se appear to be associated with damage to the ovarian reserve. Increased OMA size is related to decreased AMH levels in patients with OMA. Bilateral OMAs have a more destructive effect on ovarian reserve.IMPACT STATEMENTWhat is already known on this subject? Previous Studies have demonstrated the effect of surgery on ovarian reserve but there have been contradictory findings reported about the effects of OMAs per se on serum AMH levels and it has not been clear what the relation between OMAs size and AMH levels is, if any.What the results of this study add? In this study, we found decreased AMH levels in patients with OMA. The results showed significant negative correlation between OMA size and AMH levels. The patients with bilateral OMAs had lower AMH levels than the unilateral ones.What the implications are of these findings for clinical practice and/or further research? Increasing OMA size might be harmful to ovarian reserve. Further studies should be done to evaluate whether increasing the size of the OMA is associated with a progressive decline in ovarian reserve and to better clarify the role of the OMAs per se or of laparoscopic surgery in the determination of damage to the ovarian reserve.

Novel diagnosis of mesenteric endometrioma: Case report

RATIONALE

Mesenteric cysts are benign gastrointestinal cystic lesions, with an incidence of <1/100 000. They usually develop in the small bowel mesentery, mesocolon (24%), retroperitoneum (14.5%), and very rarely originate from the sigmoid mesentery. Endometriomas represent a localized type of endometriosis and are usually within the ovary. Our case is unique because there are no reports in the literature of endometrial mesenteric cysts.

PATIENT CONCERNS

We present a case of a 29-year-old woman who underwent a routine gynecologic control.

DIAGNOSIS

Clinical examination and imaging identified 2 endometriomas on the left and posterior to the uterus.

INTERVENTIONS

The patient underwent exploratory laparoscopy. Unexpectedly, a 10 cm mesenteric cyst was identified; this was associated with adhesions in the left adnexal area and a left ovarian endometrioma. The classic surgical approach which was necessary identified the mesenteric cyst with cranial mesosigmoid and ileal adhesions, as well as distal adhesions which included the uterus, ileum, left ovarian endometrioma, left hydrosalpinx, left ureter, and rectum. The cyst was removed completely and a left adnexectomy was performed because of the presence of the endometrioma and adhesions.

OUTCOMES

The patient's outcome was favorable, with discharge at 72 hours after surgery. The histopathological report revealed that both the mesenteric and ovarian cysts were endometriomas.

LESSONS

Our case is unusual in that a mesenteric cyst was identified in a patient with no clinical symptoms. Furthermore, the histopathological examination revealed the endometriotic origin of the mesenteric cyst which has not previously been reported in the literature.

Endometrial Flushing Tumor Necrosis Factor Alpha and Interleukin 2 Levels in Women with Polycystic Ovary Syndrome, Leiomyoma and Endometrioma: Comparison with Healthy Controls

Introduction An important open question in the literature is whether endometrial receptivity marker levels are different in infertility related diseases than healthy women. The aim of the study is to compare the levels of interleukin two (IL-2) and tumor necrosis factor alpha (TNF-α) during the implantation window in the endometrial flushing fluid of polycystic ovary syndrome (PCOS), endometrioma, leiomyoma patients with healthy controls. Material and Methods In this case control study, after obtaining endometrial flushing fluids at mid-luteal phase of ovulatory women with PCOS (n = 20), endometrioma (n = 19), leiomyoma (n = 20) and healthy controls (n = 20), IL-2 and TNF-α levels were measured using ELISA kits in BioTek ELISA devices. Results Mean TNF-α levels (ng/mL) were similar for the PCOS (305.6, p = 0.220) and the leiomyoma group (246.3, p = 0.502) compared to healthy patients (261.1). However, the levels were higher in the endometrioma group (338.2, p = 0,004) than the control group (261.1) in a statistically significant way. Mean IL-2 levels (ng/mL) were significantly lower in the PCOS (290.9, p = 0.0005), the leiomyoma (282.9, p = 0.0002) and the endometrioma patients (229.5, p = 0.0009) than the control group (416.0). Conclusion Relative to the control group, endometrial flushing fluid TNF-α levels were significantly higher in endometrioma patients and IL-2 levels were significantly lower in PCOS, leiomyoma and endometrioma patients. In benign gynecological diseases, endometrial markers related to infertility seem to show differences in endometrial flushing fluid. Future studies might identify the reference values for these markers, and endometrial markers can be used to diagnose gynecologic disorders causing infertility.

Retrospective evaluation of pathological results among women with ovarian endometriomas versus teratomas

The coexistence of endometrioma with dermoid cyst of the ovaries is an unusual entity, although they are both common and benign gynecological tumors. The present study aimed to investigate the association between ovarian dermoid cyst (teratoma) and endometrioma. We retrospectively, included 315 women with endometrioma and 172 with ovarian teratoma. Data were collected from medical and pathological reports from two different areas between 1995 and 2018. The mean age of cases with endometrioma was similar (35.8±7.2 years) to patients with ovarian teratoma (34.2±6.8 years). Considering the types of dermoid cysts, the observed proportion of mature type was 168/172 (98%), the immature type was 4/172 (2%) and struma ovarii was14/172 (8.1%) respectively. Endometrioma was significantly more frequent in the left ovary [174/266 (65.4%)] than in the right ovary [92/266 (34.6%)], P<0.001. By contrast, ovarian teratoma were predominant in the right ovary, 98/172 (60.6%), compared to the left side, 56/172 (32.5%), P<0.001. Regarding the size of the masses, we detected an inverse distribution between the two groups. Thirteen women were detected with ovarian teratoma and endometriosis, with 6 cases being in the same ovary. Our results indicate a left lateral predispostion of endometrioma and a right of ovarian teratoma and suggest that the pathogenesis between these conditions is different. The coexistence of endometriosis with dermoid cyst of the ovary, presents a challenge to the physicians and the investigators. Further research is required to establish the relationship between endometriosis and ovarian teratoma.

Comprehensive Serum Glycopeptide Spectra Analysis (CSGSA): A Potential New Tool for Early Detection of Ovarian Cancer

Objectives: To conduct a comprehensive glycopeptide spectra analysis of serum between cancer and non-cancer patients to identify early biomarkers of epithelial ovarian cancer (EOC). Methods: Approximately 30,000 glycopeptide peaks were detected from the digested serum glycoproteins of 39 EOC patients (23 early-stage, 16 advanced-stage) and 45 non-cancer patients (27 leiomyoma and ovarian cyst cases, 18 endometrioma cases) by liquid chromatography mass spectrometry (LC–MS). The differential glycopeptide peak spectra were analyzed to distinguish between cancer and non-cancer groups by employing multivariate analysis including principal component analysis (PCA), orthogonal partial least squares discriminant analysis (OPLS-DA) and heat maps. Results: Examined spectral peaks were filtered down to 2281 serum quantitative glycopeptide signatures for differentiation between ovarian cancer and controls using multivariate analysis. The OPLS-DA model using cross-validation parameters R2 and Q2 and score plots of the serum samples significantly differentiated the EOC group from the non-cancer control group. In addition, women with early-stage clear cell carcinoma and endometriomas were clearly distinguished from each other by OPLS-DA as well as by PCA and heat maps. Conclusions: Our study demonstrates the potential of comprehensive serum glycoprotein analysis as a useful tool for ovarian cancer detection.

Endometriosis and the menopause: why the question merits our full attention

As an estrogen-dependent disease, endometriosis was thought to become less active or regress with the onset of the menopause. However, based on some new data, we are discovering that this pathology can emerge or reappear at this period of life. Clinicians must consider it as a possible cause for cases of pelvic pain, and heavy bleeding. Authors have described a possibility of transformation of the intraperitoneal proliferation into a malignant type with ovarian, bowel and even lung metastasis. The risk of transformation into an ovarian cancer is around 2 or 3%. The role of menopausal hormonal therapy will be discussed as in recurrence in the case of residue existence, especially after incomplete surgery. Is it possible to prescribe hormonal therapy to a menopausal women suffering climacteric symptoms as it could trigger a recurrence of endometriosis and even an increased risk of malignant degeneration? This remains unclear. It is an unresolved therapeutic dilemma; the choice between surgery or medical treatment?

Antimüllerian hormone is reduced in the presence of ovarian endometriomas: a systematic review and meta-analysis

OBJECTIVE

To evaluate if the presence of endometriomas impacts on the ovarian reserve as evaluated with antimüllerian hormone (AMH).

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Patients with unoperated endometriomas versus controls without endometriomas.

INTERVENTION(S)

Electronic databases searched up to June 2017 to identify articles evaluating AMH levels in patients with unoperated endometriomas versus controls without endometriomas.

MAIN OUTCOME MEASURE(S)

The primary analysis was aimed at evaluation of AMH levels (mean and SD) in patients with and without endometriomas. Secondary analyses were aimed at evaluating AMH levels in patients with ovarian endometriomas compared to patients with either non-endometriosis benign ovarian cysts or healthy ovaries.

RESULT(S)

Of the 39 studies evaluated in detail, 17 were included, for a total of 968 patients with endometriomas and 1874 without endometriomas. AMH was significantly lower in patients with unoperated endometriomas compared to patients with no endometriomas (mean difference -0.84, with 95% confidence interval [CI] -1.16 to -0.52). At secondary analyses, AMH in patients with endometriomas was significantly lower both versus non-endometriosis benign ovarian cysts (mean difference -0.85, 95% CI -1.37 to -0.32, and versus women with healthy ovaries (mean difference -0.61, 95% CI -0.99 to -0.24).

CONCLUSION(S)

Ovarian reserve evaluated with AMH is reduced in patients with ovarian endometriomas compared both to patients with other benign ovarian cysts, and to patients with healthy ovaries.

Treatment of ovarian endometrial cysts in the context of recurrence and fertility

An approach to ovarian endometrial cysts has changed considerably during recent years, especially in regard to treatment of recurrent endometriosis, fertility sparing and infertility management. Surgical treatment is the primary therapeutic option. The most efficient types of treatment are radical procedures involving adhesiolysis, removal of the cyst along with its capsule and any remaining endometriotic foci. However, small asymptomatic cysts should not be treated surgically, especially in patients older than 35 years. Surgical treatment can be considered in infertile women and those who failed to get pregnant despite 1-1.5 years of trials, as well as in cases in which in vitro fertilization is not an option. Also large cysts, with more than 4 cm in diameter, should be treated surgically due to the risk of their rupture or torsion. The most efficient preventive measure for recurrent ovarian endometriosis is unilateral oophorectomy with sparing the contralateral ovary. Such a procedure should be considered in women who are no longer interested in childbearing or present with another endometriotic cyst in the same ovary. The role of pharmacotherapy is fairly limited; it should be considered in patients in whom diffuse endometriosis is associated with pain. Therapeutic agents from the following groups can be used: estrogen-progestin preparation, gestagens, including progesteronereleasing intrauterine systems and gonadotropin-releasing hormone agonists. Women with infertility should get pregnant as soon as possible, and in patients who failed to get pregnant and/or are older than 35 years, in vitro fertilization should be the treatment of choice.

Risk factors related to the recurrence of endometrioma in patients with long-term postoperative medical therapy

OBJECTIVES

The purpose of this study was to identify clinical risk factors for the recurrence of ovarian endometrioma after ovarian cystectomy in Korean women with long-term postoperative medical therapy.

MATERIAL AND METHODS

A total of 134 patients who were surgically treated for endometriotic cysts at Pusan National University Hospital were included in this retrospective study. All patients received long-term postoperative medical treatment for at least 12 months after the first-line conservative surgery. Several epidemiologic variables were analyzed as possible risk factors for recurrence. Endometrioma recurrence was considered when a cystic mass was observed on transvaginal or transrectal sonography. Statistical analysis was performed using independent t-tests for parametric continuous variables.

RESULTS

The mean follow-up period for the 134 patients was 56.5 ± 14.3 months (range, 36-120 months) and the mean duration of the medical therapy was 17.9 ± 17.3 months (range, 12-120 months). The overall recurrence rate was 35/134 (26.12%). Our univariate analysis showed statistically significant differences between the recurrent and non-recurrent groups in terms of weight (P = 0.013), body mass index (P = 0.007), age at the time of surgery (P = 0.013), the diameter of the largest cyst (P = 0.001), the presence of dysmenorrhea (P < 0.0001), and postoperative pregnancy (P = 0.016). Multivariate analysis showed that body mass index (OR 1.153, 95% CI 1.003-1.326, P = 0.046), age at the time of surgery (OR 0.924, 95% CI 0.860-0.992, P = 0.029), and presence of dysmenorrhea (OR 12.226, 95% CI 3.543-42.188, P < 0.0001) were significantly correlated with the recurrence of endometrioma.

CONCLUSIONS

We found that patients with dysmenorrhea after surgery, and a younger age of the patient at the time of surgery were the highest risk factors associated with the recurrence of endometrioma, despite long-term postoperative medication.

Abdominal Wall Endometriosis: A Case Report

Abdominal wall endometriosis is a rare condition that occurs after a cesarean section or pelvic surgery and it has an incidence of 0.03%-1.5% in women with previous cesarean delivery. The predominant clinical picture is cyclic pain. We report two cases of abdominal wall endometriosis. The first was a 36-year-old female patient who presented for recurrent cyclic abdominal pain and was found to have endometriosis near the cesarean scar. The second was a 40-year-old female who had the same clinical presentation and was found to have endometriosis away from the scar. These cases highlight the need to have a high index of suspicion when treating women with recurrent cyclic abdominal pain.

Does the anti-Müllerian hormone truly reflect ovarian response in women with endometrioma?

In this study, our aim was to determine which factor is more correlated with the number of oocytes retrieved in patients with endometrioma compared with controls undergoing in vitro fertilisation-intracytoplasmic sperm injection (IVF-ICSI) cycles: antral follicle count (AFC) or anti-Müllerian hormone (AMH). A total of 60 women with endometrioma and a control population of 60 women without endometrioma in the same period were randomly selected underwent the injection IVF-ICSI treatment. No significant differences were found between the groups in terms of age (28.78 ± 3.49 vs. 29.52 ± 2.47, p = .187), body mass index (23.62 ± 2.05 vs. 23.91 ± 2.11, p = .449), duration of infertility [(3 (2-4) vs. 3 (2-3), p = .139)], AMH level (1.52 ± 0.51 vs. 1.32 ± 0.92, p = .133), duration of stimulation [(9 (9-10) vs. 10 (9-10), p = .135)], total gonadotropin dose [(2750 (2262.5-3337.5) vs. 2770 (2680-3562.5), p = .125)], endometrial thickness [(10 (10-11) vs. 10 (9-11), p = .463)], fertilisation rates (67.20 ± 18.04 vs. 62.28 ± 17.13, p = .123), grade I embryo (43.3% vs. 30%, p = .185), clinical pregnancy rates (40% vs. 26.7%, p = .123), and the perinatal outcomes between the groups. The AFC was higher in the controls than in those with endometrioma (9.20 ± 1.80 vs. 6.32 ± 2.04, p < .001). The number of oocytes retrieved was also higher in the controls than in those with endometrioma [(7 (6-8) vs. 4 (4-5.75), p < .001)]. We found that women with endometrioma had a significantly lower number of oocytes retrieved than the controls despite the same AMH levels in both groups. AFC is a better marker of ovarian response than AMH in women with endometrioma undergoing IVF-ICSI. Impact statement What is already known on this subject? Utilising the ovarian reserve is important in the success of ovarian stimulation and in evaluating the success of assisted reproductive technologies. The anti-Müllerian hormone (AMH) level and the antral follicle count (AFC) are widely used in the prediction of ovarian functional reserve and response. However, no perfect marker exists in the evaluation of ovarian reserve and ovarian response. What do the results of this study add? Our study demonstrated that women with endometrioma have a significantly lower number of oocytes retrieved than the controls, despite the same AMH levels in both groups; which strongly suggests that AFC is a better reflection of ovarian response than AMH in women with endometrioma undergoing an in vitro fertilisation-intracytoplasmic sperm injection (IVF-ICSI). What are the implications of these findings for clinical practice and/or further research? This important issue has been reviewed and discussed for years, however, the conclusions are still controversial. Additional research is needed to understand which ovarian reserve test could better predict ovarian response outcome?

Assisted reproduction in endometriosis

Endometriosis - a disease causing pain and infertility - is encountered in nearly 50% of infertile women. While medical treatment is effective on pain and recurrence of symptoms after surgical excision, it is of no help for treating infertility for which the only options considered are surgery and ART. Surgery enhances the chances of conceiving naturally during the 12-18 ensuing months irrespective of the stage of the disease. Surgery however is of no help when ART is considered, as it does not improve outcome and can only harm the ovarian response to stimulation. Today therefore, ART is commonly the primary option to be considered in women whose infertility is associated with endometriosis and whose ovarian reserve is compromised and/or who are over 35 years of age. When, ART is envisioned it is best to opt for a segmented ART approach with agonist trigger, freeze all and deferred embryo transfer.

Endometriosis in pregnancy - diagnostics and management

OBJECTIVE

Endometriosis in pregnancy predominantly tends to regress or to stay stable but small part of endometriomas and nodules of deep infiltrating endometriosis may undergo the process of decidualization. Therefore, the foci of endometriosis enlarge their volume and change their structure due to cellular hypertrophy and stromal edema associated with higher vascularization caused by the hormonal changes in pregnant women. Consequently, these totally benign lesions may resemble malignant tumors in ultrasound examination.

DESIGN

Review article.

SETTING

Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague.

METHODS

A literature review of published data on decidualization of endometriosis.

RESULTS

Majority of decidualized ovarian endometriomas is asymptomatic so it is mostly accidentally found during the routine ultrasound check-ups within the frame of perinatologic screening. The rounded, smooth, highly vascularized solid papillary projections in internal wall of endometroid cysts are the most specific characteristics of decidualization. If ultrasound simple rules are not applicable or show probable malignancy, the pregnant patient should be referred to a tertiary center for expert ultrasound assessment. Magnetic resonance is indicated in cases of uncertain ultrasound findings, because it can clarify the diagnostics due to its high accuracy in detection of products of blood degradation and ability of diffusion-weighted imaging to recognize lower tissue cellularity of benign decidualized endometriomas in comparison to malignant ovarian tumors.

CONCLUSION

If the imaging methods confirm supposed decidualized endometriosis, watch and wait management based on regular ultrasound examinations during the whole pregnancy and after childbed is recommended. The regression of the tumor size and disappearance of the solid portions within endometriomas is expected after delivery. Decidualized endometriosis is rarely a source of gestational or obstetrical complications demanding acute surgical intervention. Elective surgical procedures in pregnant women are indicated only if expert ultrasound or magnetic resonance imaging assess the masses as border-line or invasive tumors (carcinomas) and in cases of suspicious changes of the originally presumed benign cysts during the surveillance.

Parietal Endometriosis: A Challenge for the General Surgeon

Background: Parietal endometriosis (PE) is a rare pathology, which usually develops in fertile women, after surgical or gynecological procedures. Its quasi-pathognomonic symptomatology consists in catamenial pain with or without palpable mass. The diagnosis can be challenging because it may be confused with stitch granuloma, hematoma, hernia or even cancer. Patients and methods: Between January 2007 and December 2017, 10 female patients with PE were referred for diagnosis and surgery to our clinic. Results: The mean age of the patients was 35.8 years. The primary symptom was pain (9/10 patients) and a palpable mass was present in all patients. Five cases were correctly preoperatively diagnosed as PE and five were misdiagnosed as tumors (4 patients) and stitch granuloma (1 patient). Eight patients had a history of gynecological procedure (cesarean section, episiotomy) and two had no previous surgical interventions. The size of the mass varied from 1 cm to 14 cm. Resection of PE required parietal reconstruction with mesh in five patients but for the rest of the patients no mesh was needed. Conclusions: Our study confirms PE as a rare surgical entity and indicates the necessity of thorough history and physical examination, as well as imaging exams, for making the correct diagnosis in order to choose the appropriate surgical procedure.

The impact of the localisation of endometriosis lesions on ovarian reserve and assisted reproduction techniques outcomes

This case-control study was designed to evaluate the impact of endometriosis and the presence of endometrioma (OMA) per se on the serum anti-Müllerian hormone (AMH) level and also to compare the in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) outcomes after therapeutic surgery in endometriosis patients, according to the localisation of endometriosis lesions. One hundred and fifty two infertile women ≤40 years with suspicious symptoms were surgically evaluated to detect the aetiology of infertility at the Royan Institute during this study and, in parallel, 131 patients with a male factor infertility diagnosis were considered as the control group. The serum AMH level and IVF/ICSI outcomes were compared according to the nature and extension degree of endometriosis lesions. The results demonstrated that the existence of a deep infiltrating endometriosis (DIE) with and without OMA was associated with a significant decrease in AMH level, antral follicle count and ovarian sensitivity index (OSI) (p < .001 and p = .007, respectively). The multivariable logistic regression analysis adjusted for confounding factors indicated that the OSI and the existence of DIE with and without OMA were a significant predictive variable for clinical pregnancy and for live birth. On the basis of our results, the severity of endometriosis and the location of its lesions could affect an ovarian reserve and the ovarian stimulation outcomes. Impact Statement What is already known on this subject? Previous studies have evaluated the impact of endometrioma (OMA) on ovarian reserve and the assisted reproduction technology (ART) outcomes and controversial results have been reported; therefore, it seems that this topic still needs further research. What the results of this study add? In the present study, the effect of endometriosis lesions' localisation on ovarian reserve and the success rate of the in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) cycle after therapeutic surgery were compared with that of the control group. It was found that the existence of a deep infiltrating endometriosis (DIE) with and without OMA was associated with a significant decrease in the anti-Müllerian hormone (AMH) level, antral follicle count, ovarian sensitivity index (OSI), clinical pregnancy and live birth rates. What the implications are of these findings for clinical practice and/or further research? The results of this study has a practical value in the decision making process for the ovarian stimulation protocol in patients with the different severity of endometriosis and the counselling regarding the success rate of IVF or ICSI/embryo transfer cycles.

Usefulness of hematological parameters for differential diagnosis of endometriomas in adolescents/young adults and older women

BACKGROUND

Inflammatory processes have been considered to be involved in the pathogenesis of endometriosis. However, the predictive role of inflammatory hematological parameters in endometriosis is not clear. The aim of this study was to analyze the clinical value of hematologic markers in the differential diagnosis of endometriomas in younger and older reproductive age women.

MATERIALS AND METHODS

A retrospective chart review was done for 502 patients who underwent surgery: 267 with endometriomas (endometrioma group) and 235 with other benign adnexal cysts (control group). Patients were placed into subgroups as younger (adolescents/young adults, aged <25 years) and older (aged ≥25 years) women. Total and differential white blood cell count, neutrophil-to-lymphocyte ratio, platelet indices and platelet-to-lymphocyte ratio (PLR) were evaluated with receiver operating characteristic curve analysis for differential diagnosis of endometriomas.

RESULTS

The mean serum levels of PLR, plateletcrit (PCT), platelet count and CA-125 (reference range below 35 IU/mL) were significantly higher in the endometrioma group (p < 0.001). The area under the curve (AUC) for CA-125 was 0.85 [95% confidence interval (CI), 0.82-0.88] (p < 0.001) for the entire group. However, platelet count, PLR, and PCT showed poor discriminative ability for detecting endometriomas with AUC values of 0.59 (95% CI, 0.55-0.65, p < 0.001), 0.58 (95% CI, 0.53-0.63, p = 0.002) and 0.61 (95% CI, 0.56-0.66, p < 0.001), respectively. In age-stratified analysis, these platelet indices had also low diagnostic performance in both age groups.

CONCLUSIONS

Hematologic markers do not adequately differentiate ovarian endometriomas from other benign cysts in neither adolescents/young adults nor older women.

Intestinal obstruction secondary to cecal endometriosis

Endometriosis of the gastrointestinal tract is rare and occurs in <1% of all patients undergoing major gynecological surgeries. Bowel involvement has been reported in 3%-37% of all women of childbearing age with endometriosis. Total obstruction of the gastrointestinal tract occurs in <1% of cases of endometriosis with bowel obstruction. This case report is that of a 42-year-old female who presented with a 6-month history of change in bowel habits in favor of increasing constipation. This was associated with cyclical lower abdominal pains, abdominal swelling, and weight loss. Examination revealed hyperactive bowel sounds with scant fecal matter on rectal examination. An impression of intestinal obstruction was made and she had an emergency laparotomy. Dilated ileum and a hard, constricting cecal mass were found intraoperatively. She had a right hemicolectomy and ileo-transverse anastomosis, with progressive improvement postoperatively. Histology of the resected bowel segment confirmed cecal endometriosis. In conclusion, cecal endometriosis is a rare cause of intestinal obstruction. A high index of suspicion is required for diagnosis, especially if the woman is premenopausal with a history of abdominal pain that worsens with menstrual periods. Outcome is good with appropriate surgical intervention.

Unfolded protein response, a link between endometrioid ovarian carcinoma and endometriosis: A pilot study

The aim of the present study was to analyze the expression profile of unfolded protein response (UPR) genes in endometrioid ovarian carcinoma and to evaluate its possible involvement in the neoplastic progression of endometriosis. An experimental retrospective pilot study was conducted on women with a diagnosis of endometrioid ovarian carcinoma at FIGO stage IA, ovarian endometriotic cysts or healthy subjects without a previous diagnosis of endometriosis. The expression profiles of UPR genes (ATF6, GRP78, CHOP and XBP1) were compared among ovaries with endometrioid ovarian cancer, endometriotic ovarian cysts, healthy contralateral ovaries and eutopic and healthy endometrial tissues. A significantly higher expression of ATF6 and GRP78 was detected in the affected ovaries in comparison with the healthy contralateral ovaries, while CHOP and XBP1 exhibited a significantly lower expression. XBP1 was overexpressed in endometrial tissues and its expression gradually decreased in endometriosis cysts and endometrioid ovarian carcinoma. These results support the hypothesis that alterations in the UPR genes CHOP and XBP1 are involved in the neoplastic progression of endometrioid ovarian cancer and are acquired following ovarian localization of ectopic endometrial cells.

Dienogest therapy during the early stages of recurrence of endometrioma might be an alternative therapeutic option to avoid repeat surgeries

AIM

We aimed to evaluate whether hormonal therapy immediately after postsurgical recurrence of ovarian endometrioma controls disease progression and can be an alternative therapeutic option to avoid multiple repeat surgeries.

METHODS

We enrolled 146 patients treated for endometrioma at the University Hospital of Kyoto Prefectural University of Medicine between 2009 and 2015. After laparoscopic cystectomy using the stripping technique, opening of cul-de-sac obliterations and complete resection of the deep infiltrating endometriosis lesions, the patients either received no treatment (n = 83), oral contraceptives (OC; n = 32) or dienogest (DNG; n = 27), depending on their medical history. Four patients were excluded because they changed their regimens during the follow-up period. All patients were followed up every 3 months. Patients who developed recurrence of endometrioma immediately received DNG, OC or gonadotropin-releasing hormone agonist.

RESULTS

Overall, 16 patients developed a recurrence of the endometrioma (12 in the nontreatment group, three in the OC group and one in the DNG group). The 11 patients with recurrence were treated with DNG immediately after the diagnosis of recurrent endometrioma. Among them, seven patients continued treatment with DNG (2 mg) for 24 months. After 24 months of treatment with DNG, complete resolution of recurrent endometrioma was achieved in four (57.1%) of seven patients. There was no improvement in the three patients who received OC and one patient who underwent secondary surgery.

CONCLUSION

DNG therapy early after recurrence of postsurgical endometrioma appears to be viable for reducing the risk of repeated surgery.

The long-term effects of endometrioma surgery on ovarian reserve: a prospective case-control study

The objective of this study was to evaluate the long-term effects of endometrioma excision on ovarian reserve. This study evaluated the long-term effects of endometrioma excision on ovarian reserve. A total of 63 women were enrolled in this prospective case-control study; 21 women had histories of endometrioma surgery (study group), 21 women had diagnoses of endometrioma, and 21 healthy age-matched women served as controls. Participants were recruited from the Department of Obstetrics and Gynecology, Inonu University Faculty of Medicine, between January 2007 and January 2016. The mean follow-up duration after endometrioma surgery was 30.4 ± 18.0 months for the study group. The mean follicle-stimulating hormone, luteinizing hormone and estradiol levels were similar among groups, but the anti-Müllerian hormone (AMH) level was significantly lower in the surgery group than in the control group (p < .001). The mean AMH level was 42% lower in the endometrioma surgery group than in the endometrioma group and 30% lower in the endometrioma group than in the control group (p = .080 and p = .160, respectively). Endometrioma has a detrimental effect on ovarian reserve, and decreased ovarian reserve compared with that in healthy fertile subjects without endometrioma is evident shortly after endometrioma excision. However, the endometrioma excision procedure does not significantly decrease the ovarian reserve in the long term.

Endometrioma-related reduction in ovarian reserve (ERROR): a prospective longitudinal study

OBJECTIVE

To evaluate whether endometrioma is associated with a progressive decline in ovarian reserve, and to compare the rate of decline with natural decline in ovarian reserve.

DESIGN

Prospective, observational study.

SETTING

Tertiary university hospital, endometriosis clinic.

PATIENT(S)

Forty women with endometrioma and 40 age-matched healthy controls.

INTERVENTION(S)

Women with endometriomas who did not need hormonal/surgical treatment at the time of recruitment and were expectantly managed. Controls were age-matched, healthy women. All participants underwent serum antimüllerian hormone (AMH) testing twice, 6 months apart. Sexually active patients with endometrioma also underwent antral follicle count.

MAIN OUTCOME MEASURE(S)

Change in serum AMH levels.

RESULT(S)

Median (25th-75th percentile) serum AMH level at recruitment was 2.83 (0.70-4.96) ng/mL in the endometrioma group and 4.42 (2.26-5.57) ng/mL in the control group. The median percent decline in serum AMH level was 26.4% (11.36%-55.41%) in the endometrioma group and 7.4% (-11.98%, 29.33%) in the control groups. Twenty-two women with endometrioma who had antral follicle count (AFC) had median AFC of 10 (8-12) at recruitment and 8 (6.3-10) at 6 months.

CONCLUSION(S)

Women with endometrioma experience a progressive decline in serum AMH levels, which is faster than that in healthy women.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02438735.

Development of endometrioma after cervical conization

The association between cervical conization and subsequent development of endometriosis is uncertain. The objective of this study was to estimate the incidence rate of ovarian endometrioma after cervical conization and to determine factors associated with the development of endometrioma. One hundred forty-two patients who underwent cervical conization at the University of Tokyo Hospital between January 2006 and December 2013 were included in the study. Their medical records were retrospectively studied until April 2015. The incidence rate of postconization endometrioma was calculated. Patients' characteristics (age, parity, preoperative and postoperative diagnosis and observation period) were analyzed. Six patients developed endometrioma after the cervical conization, and the incidence rate of endometrioma among patients who underwent cervical conization was 10.8 per 1000 person-year (95%CI 3.6-20.5). Patients' age, percent of nulliparous, postoperative diagnosis and observation period were not associated with the development of postconization endometrioma. A preoperative diagnosis with invasive cancer (p < 0.05) was significantly associated with the development of postconization endometrioma. The incidence rate of endometrioma among patients who underwent cervical conization in the current study was higher than that reported population.

Elevated serum CA 19-9 with adnexal mass: is it always an ovarian malignancy?

Endometriotic cysts a common benign gynaecological disease in women of reproductive age. We report an unusual case of ruptured endometrioma associated with increased CA 19-9. A 27-year-old woman presented with an acute abdomenal adnexal mass and elevated CA 19-9. The initial diagnosis of ovarian malignancy turned out to be a ruptured endometrioma, confirmed during surgery and in the histopathological report.

EGFR-mediated matrix metalloproteinase-7 up-regulation promotes epithelial-mesenchymal transition via ERK1-AP1 axis during ovarian endometriosis progression

Endometriosis, characterized by extrauterine development of endometrial glands and stroma, is associated with increased risk of ovarian cancer development. In the present study, we investigated the role of matrix metalloproteinase-7 (MMP-7) on epithelial-mesenchymal transition (EMT) during ovarian endometriosis ( N = 40) progression. We found that the expressions of EMT markers such as vimentin, slug, and N-cadherin were significantly elevated in late stages of ovarian endometriosis compared with those found in early stages. In addition, the activity and expression of ectopic MMP-7 were significantly higher in the late stages of endometriosis. In vitro studies revealed that increased expression of MMP-7 as well as epidermal growth factor (EGF), which was significantly elevated in severe stages of ovarian endometriosis, induced EMT in endocervical epithelial cells (End1/E6E7). Silencing the MMP-7 transcripts using small interfering RNA attenuated EMT responses, whereas treatment with recombinant active MMP-7 promoted EMT by cleaving E-cadherin. In addition, EGF receptor (EGFR) inhibitor treatments regressed endometriotic lesions and decreased MMP-7 activities in a mouse model of endometriosis. Chromatin immunoprecipitation assay identified EGFR-mediated ERK1 and activator protein 1 signaling for the transcriptional activation of MMP-7 in End1/E6E7 epithelial cells.-Chatterjee, K., Jana, S., DasMahapatra, P., Swarnakar, S. EGFR-mediated matrix metalloproteinase-7 up-regulation promotes epithelial-mesenchymal transition via ERK1-AP1 axis during ovarian endometriosis progression.