Consensus statement for the management of chronic pelvic pain and endometriosis: proceedings of an expert-panel consensus process

Rare case of perplexing ovarian endometriosis

OBJECTIVE

To document a rare case of coexisting endometriosis and mature cystic teratoma in the same ovary.

DESIGN

Case report.

SETTING

Gynecology unit in a tertiary training and teaching hospital in Cape Town, South Africa.

PATIENT(S)

A 30-year-old healthy nulligravida woman with a large ovarian tumor.

INTERVENTION(S)

After a basic examination, a diagnostic and management laparotomy was performed. A unilateral oophorectomy and staging laparotomy were performed.

MAIN OUTCOME MEASURE(S)

Final diagnosis of a complex ovarian tumor.

RESULT(S)

Histologic analysis confirmed endometriosis of the pelvis and concomitant compound pathology in the right ovary, which included endometriosis, mature teratoma, and mucinous cystadenoma.

CONCLUSION(S)

Co-existence of varied pathology in a single organ presents a challenge to the pathologist and the clinician. Accurate clinical (i.e., surgical) assessment and decisive histologic verification forms a critical part in this process. This case of coexisting endometriosis and teratoma in a single ovary is, to our knowledge, only the third case reported in literature.

Add-back therapy use and its impact on LA persistence in patients with endometriosis

OBJECTIVES

Persistence and compliance in women with endometriosis who are receiving gonadotropin-releasing hormone agonists (GnRH-a) may be limited by its hypoestrogenic side effects. Use of concomitant therapy with norethindrone acetate (NA), estrogen, estrogen/progestin combinations, or other progestin (i.e., 'add-back therapy' [ABT]) is recommended to alleviate these side effects. This retrospective study evaluated ABT utilization and its effect on compliance and persistence in patients with endometriosis taking the GnRH-a leuprolide acetate (LA) depot suspension.

METHODS

A retrospective analysis of a large pharmacy claims database identified patients who started LA therapy from 2002 to 2004 for the treatment of endometriosis. Patients were identified as having received ABT if they started 7 days before, or within 45 days of the last LA fill.

RESULTS

A total of 1285 women with endometriosis who began using LA were identified with 12 months of evaluable data: 211 (16.4%) used concomitant NA therapy, 116 (9.0%) used concomitant estrogen-based therapy, 28 (2.2%) used concomitant combination estrogen- and progestin-based therapies, 56 (4.4%) used concomitant progestin-based therapy, and 874 (68.0%) did not use any ABT. Mean (+/-SD) LA persistence in women receiving NA-based ABT was 5.83 +/- 2.98 months, compared with 4.25 +/- 2.62 months for those not using ABT (P < 0.0001). Average medication possession ratio was 0.43 +/- 0.20 for women receiving NA-based ABT versus 0.32 +/- 0.18 for those not receiving any ABT (P < 0.0001). Patients < 30 years of age were most likely to continue therapy longer and have greater compliance compared with the older age group cohorts (P < 0.01). Patients who used ABT continued to do so for 3.79 +/- 3.21 months.

LIMITATIONS

Limitations of this study include those associated with the use of retrospective claims databases: It does not include any information regarding the patient's pain symptoms, disease severity, or other factors, which could correlate to compliance and persistence.

CONCLUSIONS

Among women using LA therapy for endometriosis, only 32% used any type of ABT, and these patients had significantly higher persistence and compliance with LA therapy compared to no ABT user group.

Recurrence of endometriosis and its control

BACKGROUND Although surgery is currently the treatment of choice for managing endometriosis, recurrence poses a formidable challenge. To delay or to eliminate the recurrence is presently an unmet medical need in the management of endometriosis. To this end, proposals to investigate patterns of recurrence, to develop biomarkers for recurrence and to carry out biomarker-based intervention have been made. METHODS Publications pertaining to the recurrence of endometriosis and its related yet unaddressed issues were identified through MEDLINE. The reported recurrence rates, risk factors for recurrence, the effects of post-operative medication and causes of recurrence were reviewed and synthesized. In addition, several poorly explored issues such as time hazard function and mechanisms of recurrence were reviewed. Approaches to the development of biomarkers for recurrence and future intervention are discussed. RESULTS The reported recurrence rate was high, estimated as 21.5% at 2 years and 40-50% at 5 years. Few risk factors for recurrence have been consistently identified, and the evidence on the efficacy of the post-operative use of medication was scanty. The investigation on the patterns of recurrence may provide us with new insight into the possible mechanisms of recurrence and its control. The attempt to identify biomarkers for recurrence has started only very recently. CONCLUSIONS Much research is needed to better understand the patterns of recurrence and risk factors, and to develop biomarkers. One top priority is to develop biomarkers for recurrence, which may provide much needed clues to the possible mechanisms underlying recurrence and would allow the identification of patients with high recurrence risk, and permit for targeted intervention.

Chronic pelvic pain in women: etiology, pathogenesis and diagnostic approach

Chronic pelvic pain (CPP), defined as non-cyclic pain of 6 or more months, is a frequent disorder that may negatively affect health-related quality of life. In women several causes are recognised, although in a not negligible proportion of patients a definite diagnosis cannot be made. Different neurophysiological mechanisms are involved in the pathophysiology of CPP. Pain may be classified as nociceptive or non-nociceptive. In the first case the symptom originates from stimulation of a pain-sensitive structure, whereas in the second pain is considered neuropatic or psychogenic. Patients history is crucial and is generally of utmost importance for a correct diagnosis, being sometimes more indicative than several diagnostic investigations. The main contributing factors in women with CPP can still be identified by history and physical examination in most cases. Many disorders of the reproductive tract, urological organs, gastrointestinal, musculoskeletal and psycho-neurological systems may be associated with CPP. Excluding endometriosis, the most frequent causes of CPP are: post-operative adhesions, pelvic varices, interstitial cystitis and irritable bowel syndrome. CPP is a symptom, not a disease, and rarely reflects a single pathologic process. Gaining women's trust and developing a strong patient-physician relationship is of utmost importance for the long-term outcome of care.

[Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications]

The relationship between chronic pelvic pain symptoms and endometriosis is unclear because painful symptoms are frequent in women without this pathology, and because asymptomatic forms of endometriosis exist. Our comprehensive review attempts to clarify the links between the characteristics of lesions and the semiology of chronic pelvic pain symptoms. Based on randomized trials against placebo, endometriosis appears to be responsible for chronic pelvic pain symptoms in more than half of confirmed cases. A causal association between severe dysmenorrhoea and endometriosis is very probable. This association is independent of the macroscopic type of the lesions or their anatomical locations and may be related to recurrent cyclic microbleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhoea. There are histological and physiopathological arguments for the responsibility of deeply infiltrating endometriosis (DIE) in severe chronic pelvic pain symptoms. DIE-related pain may be in relation with compression or infiltration of nerves in the subperitoneal pelvic space by the implants. The painful symptoms caused by DIE present particular characteristics, being specific to involvement of precise anatomical locations (severe deep dyspareunia, painful defecation) or organs (functional urinary tract signs, bowel signs). They can thus be described as "location indicating pain". A precise semiological analysis of the chronic pelvic pain symptoms characteristics is useful for the diagnosis and therapeutic.

Treatment of pelvic pain associated with endometriosis

Pain associated with endometriosis requires careful evaluation to exclude other potential causes and may involve a number of different mechanisms. Both medical and surgical treatments for pain related to endometriosis are effective and choice of treatment must be individualized.

Endometriosis and Chronic Pelvic Pain: Unraveling the Mystery Behind this Complex Condition

Nurses often encounter patients with chronic pelvic pain associated with endometriosis, which is a puzzling and problematic gynecologic condition that has continued to plague women and baffle doctors and researchers worldwide since it was first identified by Dr. J. Sampson in the 1920s (Sampson, 1940 ). Endometriosis is defined as the growth, adhesion and progression of endometrial glands and stroma outside of the uterine cavity, with cellular activity evident in lesions, nodules, cysts or endometriomas (Audebert et al., 1992 ). Although it typically appears benign on histopathology, endometriosis has been likened to a malignant tumor since the lesions grow, infiltrate and adhere to adjacent tissues and interfere with physiologic processes (Kitawaki et al., 2002 ; Noble, Simpson, Johns, & Bulun, 1996 ). Ectopic endometriotic growths respond to cyclic changes of estrogen and proliferate and shed in a manner similar to eutopic endometrium. This cyclic ectopic activity results in internal bleeding, formation of scar tissue, inflammation and sometimes debilitating chronic pain (Kitawaki et al.).

Chronic pelvic pain in women: still a challenge

Chronic pelvic pain (CPP), a common condition particularly in reproductive-aged women, causes disability and distress, and significantly compromises quality of life and affects healthcare costs. The pathogenesis of CPP is still poorly understood and consequently poorly managed. Furthermore, the lack of a consensus on the definition of CPP greatly hinders epidemiological studies. Patients present with various associated problems, including bladder or bowel dysfunction, gynaecological pathologies or sexual dysfunction, and other systemic or constitutional symptoms. Other conditions, e.g. depression, anxiety and drug addiction, can also coexist. Effective management presupposes an integrated knowledge of all pelvic organs and other systems, including musculoskeletal, neurological and psychiatric systems. The key to treating CPP is to treat it as the complex disease it is. Treatment options range from conservative medical therapy to surgical intervention, and are primarily directed towards symptom relief. Unsatisfactory results of treatment render this condition a frustrating problem for both patients and physicians.

Physical therapy in the management of women with chronic pelvic pain

OBJECTIVES

Chronic pelvic pain (CPP) is defined as lower abdominal pain lasting for at least 6 months, which occurs continuously or intermittently and is not associated exclusively with menstruation or intercourse. CPP is a highly prevalent debilitating disease with negative impact on the quality of life and productivity of women. The dilemma regarding the management of CPP continues to frustrate the health professionals, partly because its physiopathology is poorly understood. Consequently, the treatment of this condition is often unsatisfactory and limited to temporary symptom relief. In the present review, we discuss characteristics of the clinical history and physical examination associated with musculoskeletal involvement in women with CPP and possible treatments, especially in the area of physiotherapy.

METHODS

We evaluated data available in PubMed (1984-2006) and surveyed the reference list. Three reviewers analysed the data independently, considering a study to be of high quality if it had at least three of the following characteristics: prospective design, valid measurement instruments, and adequate sample estimate and response rate. Other studies such as retrospective investigations, reviews and expert opinions were also considered, but with decreasing emphasis.

RESULTS

There are evidences of musculoskeletal system disorders in most women with CPP. These musculoskeletal disorders can be the primary cause of CPP or postural changes and pelvic muscle contractures secondary to CPP.

CONCLUSIONS

Synchronised intervention by physicians and physiotherapists is becoming increasingly more necessary both in terms of a more refined diagnosis of the clinical situation and of the institution of effective and lasting treatment.

Perceptions of surgical specialists in general surgery, orthopaedic surgery, urology and gynaecology on teaching endoscopic surgery in The Netherlands

BACKGROUND

Specific training in endoscopic skills and procedures has become a necessity for profession with embedded endoscopic techniques in their surgical palette. Previous research indicates endoscopic skills training to be inadequate, both from subjective (resident interviews) and objective (skills measurement) viewpoint. Surprisingly, possible shortcomings in endoscopic resident education have never been measured from the perspective of those individuals responsible for resident training, e.g. the program directors. Therefore, a nation-wide survey was conducted to inventory current endoscopic training initiatives and its possible shortcomings among all program directors of the surgical specialties in the Netherlands.

METHODS

Program directors for general surgery, orthopaedic surgery, gynaecology and urology were surveyed using a validated 25-item questionnaire.

RESULTS

A total of 113 program directors responded (79%). The respective response percentages were 73.6% for general surgeons, 75% for orthopaedic surgeon, 90.9% for urologists and 68.2% for gynaecologists. According to the findings, 35% of general surgeons were concerned about whether residents are properly skilled endoscopically upon completion of training. Among the respondents, 34.6% were unaware of endoscopic training initiatives. The general and orthopaedic surgeons who were aware of these initiatives estimated the number of training hours to be satisfactory, whereas the urologists and gynaecologists estimated training time to be unsatisfactory. Type and duration of endoscopic skill training appears to be heterogeneous, both within and between the specialties. Program directors all perceive virtual reality simulation to be a highly effective training method, and a multimodality training approach to be key. Respondents agree that endoscopic skills education should ideally be coordinated according to national consensus and guidelines.

CONCLUSIONS

A delicate balance exists between training hours and clinical working hours during residency. Primarily, a re-allocation of available training hours, aimed at core-endoscopic basic and advanced procedures, tailored to the needs of the resident and his or her phase of training is in place. The professions need to define which basic and advanced endoscopic procedures are to be trained, by whom, and by what outcome standards. According to the majority of program directors, virtual reality (VR) training needs to be integrated in procedural endoscopic training courses.

Endometriosis: cost estimates and methodological perspective

This article aims to provide a systematic review of estimates and methodology of studies quantifying the costs of endometriosis. Included studies were cost-of-illness analyses quantifying the economic impact of endometriosis and cost analyses calculating diagnostic and treatment costs of endometriosis. Annual healthcare costs and costs of productivity loss associated with endometriosis have been estimated at $2801 and $1023 per patient, respectively. Extrapolating these findings to the US population, this study calculated that annual costs of endometriosis attained $22 billion in 2002 assuming a 10% prevalence rate among women of reproductive age. These costs are considerably higher than those related to Crohn's disease or to migraine. To date, it is not possible to determine whether a medical approach is less expensive than a surgical approach to treating endometriosis in patients presenting with chronic pelvic pain. Evidence of endometriosis costs in infertile patients is largely lacking. Cost estimates were biased due to the absence of a control group of patients without endometriosis, inadequate consideration of endometriosis recurrence and restricted scope of costs. There is a need for more and better-designed studies that carry out longitudinal analyses of patients until the cessation of their symptoms or that model the chronic nature of endometriosis.

Evolution of medical treatment for endometriosis: back to the roots?

Experimental evidence is accumulating to suggest that medicinal botanicals have anti-inflammatory and pain-alleviating properties and hold promise for treatment of endometriosis. Herein, we present a systematic review of clinical and experimental data on the use of medicinal herbs in the treatment of endometriosis. Although there is a general lack of evidence from clinical studies on the potential efficacy of medicinal herbs for the treatment of endometriosis-associated symptoms, our review highlights the anti-inflammatory and pain-alleviating mechanisms of action of herbal remedies. Medicinal herbs and their active components exhibit cytokine-suppressive, COX-2-inhibiting, antioxidant, sedative and pain-alleviating properties. Each of these mechanisms of action would be predicted to have salutary effects in endometriosis. Better understanding of the mechanisms of action, toxicity and herb-herb and herb-drug interactions permits the optimization of design and execution of complementary alternative medicine trials for endometriosis-associated pain. A potential benefit of herbal therapy is the likelihood of synergistic interactions within individual or combinations of plants. In this sense, phytotherapies may be analogous to nutraceuticals or whole food nutrition. We encourage the development of herbal analogues and establishment of special, simplified registration procedures for certain medicinal products, particularly herbal derivates with a long tradition of safe use.

Efficacy of vaginal danazol treatment in women with recurrent deeply infiltrating endometriosis

OBJECTIVE

To describe a safe long-term medical treatment for deeply infiltrating endometriosis, a critical condition characterized by multiple painful symptoms and a high recurrence rate after surgical treatment.

DESIGN

Prospective study.

SETTING

University of Siena.

PATIENT(S)

Twenty-one women with deeply infiltrating endometriosis.

INTERVENTION(S)

In a nonrandomized prospective study a low dose of vaginal danazol (200 mg/d) was self-administered for 12 months. After a previous laparoscopic surgery, these patients had reported recurrent severe dyspareunia, dysmenorrhea, and pelvic pain (in five cases also painful defecation).

MAIN OUTCOME MEASURE(S)

Before and every 3 months during the treatment a visual analogue pain scale was used. Transvaginal and transrectal ultrasound examinations were performed before and after 6 and 12 months of treatment. Adverse effects were registered, and serum concentration of cholesterol, triglycerides, aspartate aminotransferase, alanine aminotransferase, glycemia, protein S, protein C, antithrombin III, and homocysteine was evaluated before and after 12 months.

RESULT(S)

Dysmenorrhea, dyspareunia, and pelvic pain significantly decreased within 3 months and disappeared after 6 months of treatment, with a persistent effect during the 12 months of treatment. A relief of painful defecation was also shown. Ultrasound examination showed a reduction of the nodularity in the rectovaginal septum within 6 months. The medical treatment did not affect metabolic or thrombophilic parameters; few local vaginal adverse effects were reported.

CONCLUSION(S)

Vaginal danazol resulted in effective medical treatment for the various painful symptoms in women with recurrent deeply infiltrating endometriosis, and because of the lack of significant adverse effects it may be proposed as an alternative to repeated surgery.

Chronic Pelvic Pain: How Many Surgeries Are Enough?

The key to treatment of chronic pelvic pain is to treat it as the complex disease it is. Evidence is reviewed showing that identifying one aspect of the disease such as endometriosis or adhesions then treating only that component is not likely to be successful. Given our understanding of the neuropathology of chronic pelvic pain this failure of traditional therapy is to be expected. This evidence is reviewed and supports that an integrated treatment approach holds the most promise for a successful outcome. The goal of chronic pelvic pain management is for the clinician to identify every pain generator and treat each one.

Comparison of a new modified laparoscopic presacral neurectomy and conventional laparoscopic presacral neurectomy in the treatment of midline dysmenorrhea

OBJECTIVE

To describe a newly modified laparoscopic presacral neurectomy procedure and to evaluate the long-term benefits of the surgery as a treatment for midline dysmenorrhea.

METHOD

Eighty-eight reproductive female patients with midline dysmenorrhea were enrolled in the non-randomized prospective study. There were fifty-five patients in the modified laparoscopic presacral neurectomy (MLPSN) group and thirty-three patients in the conventional laparoscopic presacral neurectomy (LPSN) group. All patients received post-surgery follow-up of more than eight years for evaluation with respect to pain relief, recurrence, and complications.

RESULTS

Upon receipt of surgery, the MLPSN and the LPSN groups both demonstrated a significant decrease (P<0.001) in the mean pain score when compared to the pre-surgery mean pain scores. However, the probability of recurrence during the eight years of follow-up was 81.8% (27 patients) in the LPSN group, compared to 43.6% (24 patients) in the MLPSN group, resulting in a significantly lower long-term recurrence rate in the MLPSN group, compared to the LPSN group (P<0.05). No patients in the MLPSN group had long-term complications and one patient had constipation after surgery in the LPSN group.

CONCLUSION

The modified laparoscopic presacral neurectomy procedure provides an alternative for those patients who suffer intractable midline dysmenorrhea. This surgery is relatively simple and safe and could result in a satisfactory long-term outcome in the intervention of midline dysmenorrhea.

Treatment of pelvic pain associated with endometriosis

Pain associated with endometriosis requires careful evaluation to exclude other potential causes and may involve a number of different mechanisms. Both medical and surgical treatments for pain related to endometriosis are effective and choice of treatment must be individualized.

Use of the levonorgestrel-releasing intrauterine system in women with endometriosis, chronic pelvic pain and dysmenorrhea

OBJECTIVES

This report is a review of the medical literature on the use of the levonorgestrel-releasing intrauterine system (LNG-IUS) in women with endometriosis, adenomyosis, cyclic pelvic pain and dysmenorrhea.

MATERIAL AND METHODS

A review was carried out using the MEDLINE and EMBASE databases to evaluate the use of LNG-IUS in women with endometriosis and adenomyosis.

RESULTS

Nine studies were identified, only two of which were randomized clinical trials. One compared the insertion of LNG-IUS after surgery with expectant conduct and the other compared the use of the device with a GnRH analogue (GnRH-a). All studies reported an improvement in pelvic pain and dysmenorrhea, and a reduction in menstrual bleeding. One study found an improvement in the staging of the disease at 6 months of use, and the studies that evaluated the use of LNG-IUS in women with adenomyosis reported a reduction in uterine volume. Furthermore, the only study in which women were followed up for 3 years after insertion found improvement in pelvic pain at 12 months of use. However, there was no improvement after that period.

CONCLUSIONS

The use of LNG-IUS is an alternative for the medical treatment of women suffering from endometriosis, adenomyosis, chronic pelvic pain or dysmenorrhea, but experience is limited and long-term studies are necessary to reach definitive conclusions. However, for women who do not wish to become pregnant, this device offers the possibility of at least 5 years of treatment following one single intervention.

Presacral neurectomy for surgical management of pelvic pain associated with endometriosis: a descriptive review

Pelvic pain associated with endometriosis is a common clinical problem. In approximately 20% of cases endometriosis-related pelvic pain is either minimally or not responsive to medical treatment; thus surgical treatment seems to be a valid option. The aim of this review is to describe presacral neurectomy surgical techniques, data regarding safety and efficacy of this procedure, its indications, and future research on its applications in clinical practice.

Diagnosis of endometriosis and pelvic pain

Both the American and the Royal Colleges of Obstetricians and Gynecologists have produced guidelines that recommend patients with chronic pelvic pain, including those suspected of having endometriosis, should receive empirical medical therapy without a preliminary diagnostic laparoscopy. This paper reviews the implications of this approach.

Should a diagnosis of endometriosis be sought in all symptomatic women?

A tool is needed to enable clinicians to determine whether women wish to seek a pathology-based explanation for chronic pelvic pain or whether they just want symptom relief. Such an approach might reduce the number of unnecessary laparoscopies without adversely affecting outcomes.

Hysterectomy for treatment of pain associated with endometriosis

The literature was searched for endometriosis and hysterectomy on PubMed and the individual search engines of the Journal of Minimally Invasive Surgery, Fertility and Sterility, BJOG, Obstetrics and Gynecology, the American Journal of Obstetrics and Gynecology, and Human Reproduction. Eighty references of interest were identified and included in this review. Analysis of hysterectomy for pain associated with endometriosis is difficult for many reasons. These include a lack of differentiation of various forms of cyclic pain from other forms of non-cyclic pain, the retrospective nature of much of the literature, and a low specificity for identifying pain. Hysterectomy for chronic non-specified pelvic pain associated with endometriosis is a successful approach in many women. It can not be determined whether this is due to intermingling of patients with and without cyclic pain or if both of these respond equally well. Focused prospective research is needed to determine whether symptoms, signs, or laboratory findings might be useful in determining more specific response patterns.

Health-related quality of life burden of women with endometriosis: a literature review

PURPOSE

The purpose of this study was to conduct a comprehensive and systematic literature review of the health-related quality of life (HRQL) burden of endometriosis in adults and adolescents.

METHODS

We conducted a systematic search and review of studies published between January 1999 and January 2006 using MEDLINE and relevant online resources. Search terms used included endometriosis, quality of life, burden of illness, psychology, and adolescent. We assessed: (1) the HRQL impact of endometriosis and related key symptoms; (2) the impact of specific pharmacologic and surgical treatments of endometriosis on HRQL; and (3) the presence and impact of endometriosis in adolescents.

RESULTS

Twenty relevant studies were identified and reviewed. Generic instruments most commonly used to assess HRQL in patients with endometriosis included the SF-36 and the SF-12. The EQ-5D was used to measure utilities. The Endometriosis Health Profile-30 (EHP-30) and its subset, the EHP-5, have been recently developed for use in endometriosis studies. Endometriosis was associated with significant impairments in pain, psychological functioning, and social functioning. Pharmacological and surgical treatments for endometriosis improved patients physical functioning, psychological functioning, vitality, pain level, and general health. Few studies used disease specific instruments to characterize the HRQL burden of endometriosis, addressed the HRQL impact of endometriosis-related infertility, and examined endometriosis in adolescents. Instruments specifically validated to measure HRQL in adolescents were not identified.

CONCLUSIONS

Endometriosis impairs HRQL, especially in the domains of pain, psychological and social functioning. Therapies have been shown to alleviate symptoms and improve HRQL. Further research is warranted to evaluate the impact of endometriosis on HRQL in adolescents and the impact of infertility due to endometriosis on HRQL.

Endométriose et adolescente

Endometriosis has long been considered as a disease of women over 30 years old. However, recent data from the literature demonstrated its high incidence in teenagers. Endometriosis in teenagers is generally associated with chronic pelvic pains and cyclical signs are less common than in adults. The persistence of the pain despite an estroprogestative contraception associated with non-steroidal anti-inflammatory drugs is a strong argument for the diagnosis and justifies a laparoscopic exploration. During this laparoscopy, the search for atypical lesions, which are much more common than typical ones, is essential. Biopsies of these lesions is mandatory in every patient to rule out false positives and false negatives which are common in atypical lesions. The aim of the treatment is to improve the pain. The first line of medical treatment is based on the estroprogestative contraception and non-steroidal anti-inflammatory drugs. The prescription of GnRH should be the ultimate solution because the bone reserve increases until the age of 18 to 20. The laparoscopic treatment, when required, should be as complete as possible. Early diagnosis and medical management may prevent the development of the disease. However, further studies in the teenager are essential to improve the current empirical management.

Recurrence of endometriomas after laparoscopic removal: sonographic and clinical follow-up and indication for second surgery

STUDY OBJECTIVE

This study involved patients who, after laparoscopic surgery, had recurrence of endometriomas detected by sonography. The aim of this study was to evaluate the role of transvaginal sonography (TVS) in the management of recurrent endometriomas and to establish ultrasonographic criteria that would direct the therapy toward additional surgery versus medical or expectant management.

DESIGN

Retrospective analysis of 62 reproductive-age women who showed recurrence of endometriomas on TVS after laparoscopic removal of an ovarian endometrioma by the stripping technique (Canadian Task Force classification II-1).

SETTING

Obstetrics and Gynecology Department, University of Rome Tor Vergata.

PATIENTS

Sixty-two patients with recurrent endometriomas after first-line treatment with laparoscopy.

INTERVENTIONS

Ultrasonographic follow-up and/or second surgery.

MEASUREMENTS AND MAIN RESULTS

Recurrence of an ovarian endometrioma was defined as the presence of ovarian cysts with the typical sonographic criteria of endometriomas and a diameter of more than 10 mm. The clinical and sonographic postoperative follow-up period lasted from 6 to 97 months (median 24.6) after the first procedure. Of 62 patients with recurrent endometriomas, 50 had recurrence on the treated ovary, 7 on the contralateral untreated ovary, and 5 on both the treated and untreated ovaries. Recurrence of endometriomas was associated with symptoms (pain or infertility) in 47 patients (76%), while the remaining 15 (24%) were asymptomatic. Of the 47 symptomatic patients with recurrence detected by TVS, a second procedure was performed in 15. Second surgery in these patients was indicated by the larger size of the recurrent cysts, a poor response to medical treatment, the presence on TVS of pelvic adhesions and nodules of deep endometriosis, and overall progression of the disease. Symptomatic patients who did not undergo a second procedure (32) had smaller recurrent endometriomas. However of the 31 symptomatic patients with large recurrent endometriomas (>3 cm), only 45% had repeat surgery.

CONCLUSION

Recurrent endometriomas, as detected by TVS, can remain asymptomatic and do not necessarily progress in size with or without medical treatment. The decision to reoperate depends less on the endometrioma's size than on symptoms, in particular severe pain, and failure of medical treatment. However such patients are also more likely to have signs of deep nodules and adnexal/bowel adhesions and larger endometriomas on TVS scan, thus predisposing them to require a second procedure.

Guidelines for the management of pelvic pain associated with endometriosis: a systematic appraisal of their quality

BACKGROUND

Guidelines exist for the management of endometriosis. Validated and reliable appraisal tools exist to assess the quality of guidelines.

OBJECTIVES

To systematically appraise the quality of guidelines for the management of pelvic pain associated with endometriosis.

SEARCH STRATEGY

Guidelines were identified using a prospective protocol through a systematic search of MEDLINE (1951-2005), EMBASE (1974-2005), the Cochrane Library (2005, issue 2), known guideline websites and the World Wide Web.

SELECTION CRITERIA

Type of document: guideline, consensus statement, care protocol or healthcare technology assessment produced by national or international professional organisations and societies or governmental agencies; subject: management of pelvic pain associated with endometriosis.

DATA COLLECTION AND ANALYSIS

Two validated appraisal tools, Cluzeau and The Appraisal of Guidelines and Research and Evaluation (AGREE), were used to quantitatively assess the quality of guidelines. Areas evaluated included 'rigour of development', 'context and content' and 'application.'

MAIN RESULTS

Eight of 596 potentially relevant citations identified met our inclusion criteria. The Cluzeau instrument quality score were the following: rigour of development, 53% (range 5-65%); context and content, 69% (range 29-79%) and application 20% (range 0-20%). The application dimension achieved significantly lower quality scores (P = 0.026 versus rigour of development and P = 0.017 versus context and content). The AGREE instrument quality scores were the following: scope and purpose, 68% (range 17-89%); stakeholder involvement, 33% (range 13-63%); rigour of development, 49% (range 10-81%); clarity of presentation, 55% (range 42-67%); applicability, 14% (range 0-28%) and editorial independence, 28% (range 8-67%). The applicability domain achieved significantly lower quality scores (P = 0.001 versus scope and purpose and P = 0.009 versus rigour of development).

AUTHOR'S CONCLUSIONS

Guidelines for the management of pelvic pain associated with endometriosis do not comply with the recommendations for high-quality standards.

Aromatase inhibitors: the next generation of therapeutics for endometriosis?

OBJECTIVE AND DESIGN

To review the role of aromatase inhibitors (AIs) in the treatment of endometriosis.

CONCLUSION(S)

Endometriosis is a common estrogen-dependent disorder that can result in substantial morbidity, including pelvic pain, multiple operations, and infertility. Approximately only half of women with endometriosis get pain relief from existing medical or surgical treatments. Medical treatments usually are directed at inhibiting estrogen action or its production from the ovaries and do not address local estrogen biosynthesis by the aromatase enzyme in endometriotic lesions. A single gene encodes aromatase, which is the final enzyme in the estrogen biosynthesis pathway, and its inhibition effectively eliminates estrogen production. The recently introduced highly specific AIs have successfully treated pelvic pain and significantly reduced the lesion size. In premenopausal women, an AI alone may induce ovarian folliculogenesis, and thus AIs are combined with a progestin, a combination oral contraceptive, or a GnRH analogue. The side-effect profile of AIs administered in combination with an oral contraceptive or a progestin is remarkably benign. We review herein the published clinical evidence for the use of AIs in the treatment of endometriosis.

The use of ultrasound-based 'soft markers' for the prediction of pelvic pathology in women with chronic pelvic pain-can we reduce the need for laparoscopy?

OBJECTIVE

To assess the accuracy of new transvaginal ultrasound-scan-based markers and to compare them to conventional ultrasound methods used in the detection of common pelvic pathology in women with chronic pelvic pain (CPP).

DESIGN

A prospective observational study.

SETTING

Teaching hospital.

POPULATION

A total of 120 consecutive women with CPP undergoing transvaginal ultrasonography before either diagnostic or operative laparoscopy.

METHODS

Anatomical abnormalities, e.g. endometrioma or hydrosalpinx (hard markers), were documented. The woman was then assessed for the presence or absence of 'soft markers' (reduced ovarian mobility and site-specific pelvic tenderness).

MAIN OUTCOME MEASURE

Presence or absence of pelvic pathology noted during laparoscopy.

RESULTS

Seventy women had pelvic pathology, of whom 51 had endometriosis alone, 7 both endometriosis and pelvic adhesions, 6 pelvic adhesions, 1 hydrosalpinx with endometriosis and 5 hydrosalpinx and pelvic adhesions. The likelihood ratio for the hard markers was infinity (specificity was 100%), for the soft makers 1.9 (95% CI 1.2-3.1) and for a 'normal' ultrasound 0.18 (0.09-0.34). The pre-test probability of pelvic disease in our population of women with CPP was 58%, and this probability of disease was raised to 100% with the presence of hard markers and to 73% with the presence of soft markers. The pre-test probability of 58% fell to 20% when ultrasound finding was found to be normal.

CONCLUSION

This new approach improves the detection and exclusion of significant pathology in women with CPP and may lead to a reduction in the number of unnecessary laparoscopies carried out on women with CPP.

Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications

The relationship between chronic pelvic pain symptoms and endometriosis is unclear because painful symptoms are frequent in women without this pathology, and because asymptomatic forms of endometriosis exist. Our comprehensive review attempts to clarify the links between the characteristics of lesions and the semiology of chronic pelvic pain symptoms. Based on randomized trials against placebo, endometriosis appears to be responsible for chronic pelvic pain symptoms in more than half of confirmed cases. A causal association between severe dysmenorrhoea and endometriosis is very probable. This association is independent of the macroscopic type of the lesions or their anatomical locations and may be related to recurrent cyclic micro-bleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhoea. There are histological and physiopathological arguments for the responsibility of deeply infiltrating endometriosis (DIE) in severe chronic pelvic pain symptoms. DIE-related pain may be in relation with compression or infiltration of nerves in the sub-peritoneal pelvic space by the implants. The painful symptoms caused by DIE present particular characteristics, being specific to involvement of precise anatomical locations (severe deep dyspareunia, painful defecation) or organs (functional urinary tract signs, bowel signs). They can thus be described as location indicating pain. A precise semiological analysis of the chronic pelvic pain symptoms characteristics is useful for the diagnosis and therapeutic management of endometriosis in a context of pain.

Polyglycolic acid/chitosan glue and apoptosis of endometriotic cells

OBJECTIVE

To induce apoptosis of endometriotic cells of patients with endometriosis.

DESIGN

To demonstrate that polyglycolic acid/chitosan glue directly inhibits cell proliferation by inducing apoptosis.

SETTING

University hospital infertility center.

PATIENT(S)

Twelve women who visited the center for infertility therapy.

INTERVENTION(S)

Polyglycolic acid/chitosan glue was applied into primary endometriotic cells; the manipulated cells were collected 1-4 days after polyglycolic acid/chitosan glue treatment.

MAIN OUTCOME MEASURE(S)

Primary endometriotic cell cultures from eutopic endometriotic tissue were established. The effect of the novel biological glue, polyglycolic acid/chitosan glue A, on endometrial cells in vitro was examined. The different stages of apoptosis were analyzed using flow cytometry with fluorescein isothiocyanate conjugate (FITC)-annexin V and propidium iodide staining.

RESULT(S)

The growth inhibitory effects of polyglycolic acid/chitosan glue A on endometrial cells were found to be dose-response and time dependent. Less than 15% viability was detected in cultures containing 2,000 microg of polyglycolic acid/chitosan glue A after 4 days of treatment. Induced apoptosis and caspase activity were revealed. The caspase-3 activity increased 2.2-fold with 4 days of culture with 2,000 microg of polyglycolic acid/chitosan glue A.

CONCLUSION(S)

This is the first study to demonstrate that polyglycolic acid/chitosan glue directly inhibits cell proliferation by inducing apoptosis, thus suggesting that this new biological glue may be useful for endometriosis therapy.

Alternative medical and surgical options to hysterectomy

The range of alternatives to hysterectomy includes 'expanded' oral medical regimens, the levonorgestrel-releasing intrauterine system (LNG-IUS), a wide range of endometrial ablative techniques, and-where fibroids are the primary pathology-myomectomy and uterine artery embolization. Since research has shown that hysterectomy is a highly effective treatment, these alternatives must be assessed against the recognized high satisfaction rates and improved quality of life reported following hysterectomy. Additional issues that would also need to be addressed include complication rates, side-effects, and cost-effectiveness. For women with prolonged abnormal uterine bleeding, recent research suggests that hysterectomy is significantly superior to an expanded medical treatment regimen for health-related quality-of-life measures. Satisfaction with treatment, and health-related quality of life and psychosocial well-being, are reportedly similar between hysterectomy and the LNG-IUS, but the latter has the advantage of reduced cost. Endometrial ablation reduces menstrual blood flow, but its benefits relative to hysterectomy lessen over time. No large-scale studies have adequately compared uterine artery embolization or myomectomy to hysterectomy. Perhaps the most telling finding from recent research with respect to the place of alternative therapies to hysterectomy is that the existence or advent of these alternatives has not reduced hysterectomy rates, but merely increased treatment options and interventions for excessive menstrual loss.

Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis

BACKGROUND

The objective of this multicentre randomized, controlled clinical trial was to compare the efficacy of a levonorgestrel-releasing intrauterine system (LNG-IUS) and a depot-GnRH-analogue in the control of endometriosis-related pain over a period of six months.

METHODS

Eighty-two women, 18 to 40 years of age (mean 30 years), with endometriosis, dysmenorrhoea and/or CPP, were randomized using a computer-generated system of sealed envelopes into either LNG-IUS (n = 39) or GnRH analogue (n = 43) treatment groups at three university centres. Daily scores of endometriosis-associated CPP were evaluated using the Visual Analogue Scale (VAS), daily bleeding score was calculated from bleeding calendars, and improvement in quality of life was evaluated using the Psychological General Well-Being Index Questionnaire (PGWBI). The pain score diary was based on the VAS in which women recorded the occurrence and intensity of pain on a daily basis. A monthly score was calculated from the result of the sum of the daily scores divided by the number of days in each observation period.

RESULTS

CPP decreased significantly from the first month throughout the six months of therapy with both forms of treatment and there was no difference between the groups (P > 0.999). In both treatment groups, women with stage III and IV endometriosis showed a more rapid improvement in the VAS pain score than women with stage I and II of the disease (P < 0.002). LNG-IUS users had a higher bleeding score than GnRH-analogue users at all time points of observation with 34% and 71% of patients in the LNG-IUS and GnRH-analogue groups, respectively, reporting no bleeding during the first treatment month, and 70% and 98% reporting no bleeding during the sixth month. No difference was observed between groups with reference to improvement in quality of life.

CONCLUSIONS

Both, the LNG-IUS and the GnRH-analogue were effective in the treatment of CPP-associated endometriosis, although no differences were observed between the two treatments. Among the additional advantages of the LNG-IUS is the fact that it does not provoke hypoestrogenism and that it requires only one medical intervention for its introduction every 5 years. This device could therefore become the treatment of choice for CPP-associated endometriosis in women who do not wish to conceive.

Uterine preservation during surgery for uterovaginal prolapse: a review

The traditional surgical treatment for uterovaginal prolapse has been vaginal hysterectomy. For many reasons, women may request uterine preservation at the time of prolapse surgery. The purpose of this paper is to review the medical literature pertaining to the role of uterine preservation during reconstructive surgery for uterovaginal prolapse. A MEDLINE search of literature in the English language (1966 to current) was carried out using the keywords 'hysterectomy', 'hysteropexy', 'uterine preservation', 'uterine suspension' and 'uterovaginal prolapse.' Fourteen articles primarily addressing the surgical repair of uterovaginal prolapse with uterine preservation were included in this review. Papers primarily addressing other forms of pelvic organ prolapse, incontinence or obliterative procedures were excluded. Existing procedures and their clinical outcomes were reviewed. The current literature suggests that uterine preservation during surgery for uterovaginal prolapse may be an option in appropriately selected women who desire it; prospective, randomized trials are needed to corroborate this.

Incidence and characterization of diagnosed endometriosis in a geographically defined population

OBJECTIVE

We examined whether widespread use of laparoscopy was accompanied by increased diagnosis of asymptomatic endometriosis, inflated rates of diagnosis, or changes in the clinical spectrum of disease.

DESIGN

Population-based cohort.

SETTING

Olmsted County, Minnesota.

PATIENT(S)

All participants were women residents, aged > or =15 years.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

We estimated the likelihood that women with a surgical procedure during which endometriosis could be visualized would receive a surgical diagnosis, as well as the proportions of all diagnoses, regardless of setting, that were [1] assigned without surgery, [2] refuted by surgery, [3] surgically confirmed, and [4] asymptomatic. The incidence of diagnosed endometriosis for 1987 to 1999 was compared with published rates for 1970 to 1979.

RESULT(S)

Of 8,229 women aged > or =15 years with > or =1 surgery during which endometriosis could be visualized, 11.5% received a surgical diagnosis of endometriosis. The incidence of diagnosed endometriosis, regardless of setting, was 1.9 per 1,000 person-years (10% were without relevant surgery, 6% had surgery but no surgical evidence, 85% had surgical evidence); 85% of surgically confirmed diagnoses had presenting symptoms. Using definitions comparable with those in the 1970 to 1979 study, the 1987 to 1999 incidence was 2.46 per 1,000 versus 2.49 per 1,000 for 1970 to 1979; 88% of symptomatic incident diagnoses were surgically confirmed versus 65% for 1970 to 1979.

CONCLUSION(S)

Widespread use of laparoscopy does not appear to have contributed to dramatically increased rates of endometriosis diagnoses but rather to a smaller proportion of diagnoses being assigned without surgical confirmation.

Pain in endometriosis: effectiveness of medical and surgical management

PURPOSE OF REVIEW

Endometriosis is a common cause of chronic pelvic pain and has a detrimental effect on the quality of life for women affected with the condition. It is also clear that early diagnosis with prompt effective management does not always occur. This review will discuss the medical and surgical treatment options and support conclusions with randomized double blind placebo-controlled studies where possible.

RECENT FINDINGS

Assessment of the pelvic pain associated with endometriosis can be categorized according to its relation to the menstrual cycle. Dysmenorrhoea and ovulatory pain occur with cyclical changes, as compared with chronic non-cyclic pain and deep dyspareunia. Dyskesia and urinary pain may have a relation to the menstrual cycle. The severity of pain symptoms, as well as the effect on the woman's quality of life, should be quantified. The preoperative symptoms can be compared with the operative findings and the stage of endometriosis according to the revised American Fertility Score.

SUMMARY

Review of the current literature demonstrates that a combined medical and conservative surgical approach is beneficial for most women with endometriosis associated pelvic pain.

A danazol-loaded intrauterine device decreases dysmenorrhea, pelvic pain, and dyspareunia associated with endometriosis

A danazol-loaded intrauterine device (IUD) containing 300-400 mg of danazol was inserted for 6 months in a group of women (n = 18) (median age 36.6 years; age range: 30 to 46 years) with a histologic diagnosis of endometriosis, referred for recurrent pelvic pain. Dysmenorrhea, dyspareunia, and pelvic pain significantly decreased after the first month, with a persistent effect during the 6 months of IUD insertion. These results show that a danazol-loaded IUD is an effective conservative therapy for patients with endometriosis-related pelvic pain.

An open and randomized study comparing the efficacy of standard danazol and modified triptorelin regimens for postoperative disease management of moderate to severe endometriosis

OBJECTIVE

To compare the efficacy of danazol and triptorelin (Decapeptyl CR, Ferring, Kiel, Germany) in the management of moderate and severe endometriosis in terms of symptom control and revised American Fertility Society (AFS) score reduction, and to evaluate the hormonal profile of patients treated with triptorelin every 6 weeks.

DESIGN

Open and randomized trial.

SETTING

Kwong Wah Hospital, a large public hospital in an urban location (Hong Kong).

PATIENT(S)

Forty patients after their first conservative operation for endometriosis, with surgical confirmation of revised AFS stage III or IV endometriosis.

INTERVENTION(S)

Postoperative 6 months' therapy of danazol or triptorelin every 6 weeks, postmedical therapy second-look laparoscopy.

MAIN OUTCOME MEASURE(S)

Symptom control and patients' tolerance during medical therapy, posttherapy revised AFS score, hormonal profile during triptorelin therapy.

RESULT(S)

Pain control was similar between danazol and triptorelin therapy. There was less breakthrough bleeding with triptorelin. More patients failed to complete the whole course of danazol because of its side effects. The revised AFS score at second-look laparoscopy did not show a significant difference between the two medications. Adequate pituitary suppression was observed with injection of triptorelin every 6 weeks.

CONCLUSION(S)

Lengthening of triptorelin administration intervals from 4 weeks to 6 weeks is effective in maintaining a hypoestrogenic state. Patients were more compliant with triptorelin than danazol. Thus, triptorelin injection every 6 weeks is more cost-effective than conventional regimens.

Adolescent endometriosis: diagnosis and treatment approaches

OBJECTIVES

To review the etiologies, diagnosis, and treatment options of adolescent endometriosis.

METHODS

Review of publications relating to adolescent endometriosis.

RESULTS

Endometriosis occurs in adolescents as young as 8 years of age; furthermore, there have been documented cases of endometriosis occurring prior to menarche. Adolescents presenting with pelvic pain are treated with cyclic combination oral contraceptive pills and nonsteroidal anti-inflammatory agents. If the pain does not respond to these therapies, then in adolescents as in adults, an operative laparoscopy is recommended for the diagnosis and surgical management of endometriosis. The operating gynecologist should be familiar with the appearance of the complete spectrum of various morphologies of endometriosis, as adolescents tend to have clear, red, white, and/or yellow-brown lesions more frequently than black or blue lesions. Subtle clear lesions of endometriosis may be better visualized by filling the pelvis with irrigation fluid so that the clear lesions can be appreciated in a three-dimensional appearance. Young women who are found to have endometriosis by laparoscopy may present with acyclic, cyclic, and constant pelvic pain. Adolescents with pelvic pain not responding to conventional medical therapy have approximately a 70% prevalence of endometriosis. It is known that endometriosis is a progressive disease and since there is no cure, adolescents with endometriosis require long-term medical management until the time in their lives when they have completed childbearing. Psychosocial support is extremely important for this population of young women with endometriosis.

CONCLUSIONS

Endometriosis occurs in adolescents, and presenting symptoms may vary from those seen in adult women with the disease. All health care providers must be aware of the existence of adolescent endometriosis. They should also be aware of the presenting symptoms so that the adolescent can be appropriately referred to a gynecologist comfortable with medical and surgical treatment options in this patient population. If laparoscopy is to be undertaken, the gynecologist must be prepared not only to diagnose but to surgically manage endometriosis. In addition, the subtle laparoscopic findings of endometriosis in adolescents must be recognized for an appropriate diagnosis. Long-term medical therapy will hopefully decrease pain and the progression of the disease, thus decreasing the risk of advanced-stage disease and infertility.