Endometrioma: From Pathogenesis to Clinical Management

An endometrioma (OMA) is the localization of endometriosis in ovary, and it most often develops as a cyst. The pathogenesis of OMA is still an open question and controversial; a cystic hemorrhagic corpus luteum may be a prerequisite, occurring as a transition to an endometriotic cyst. Inversion and progressive invagination of the ovarian cortex after the accumulation of menstrual debris derived from bleeding of superficial endometriotic implants, located on the ovarian surface and adherent to the peritoneum, is another hypothesis. Gene studies show that WNT4 and FN1 are predisposing genes for OMA development. A role of environmental toxicants in the development of OMA is also under investigation; dioxins and dioxin-like compounds (DLCs), interacting with steroid receptors, are possible factors. Even if women with endometriosis have a 1.5 times greater lifetime risk to develop an ovarian carcinoma, an OMA is not to be considered a preneoplastic lesion.

The clinical management of OMAs is complex and should be individualized. Ultrasounds and magnetic resonance imaging (MRI) are sensitive but not specific for diagnosis. Treatment is influenced by patient age, desire for pregnancy, pain severity, cyst dimensions and characteristics (unilateral/bilateral), coexistence of deep endometriosis, previous gynecological or obstetrical history and previous surgery. Laparoscopic surgery is considered the treatment of choice in cases of infertile patients with a large OMA or pain, and in patients not responding to medical therapy. It should be performed with proper techniques by trained surgeons to decrease the damage to the remaining ovarian tissue, and to maintain the ovarian reserve after surgery. A medical hormonal and nonhormonal treatment is used for asymptomatic and/or pain-associated OMA (progestins, estroprogestins and antiinflammatory drugs). Considering the relative high recurrence rate after surgery, a medical treatment should be offered.

An update on the pharmacological management of endometriosis

INTRODUCTION

Endometriosis is a common disease that causes pain symptoms and/or infertility in women in their reproductive years. The disease is characterised by the presence of endometrium-like tissue - glands and stroma - outside the uterine cavity. Different treatment options exist for endometriosis including medical and surgical treatments or a combination of the two approaches. The most commonly used medications are non-steroidal anti-inflammatory drugs, GnRH agonists, androgen derivatives such as danazol, combined oral contraceptive pills, progestogens and more recently the levonorgestrel intrauterine system.

AREAS COVERED

The authors review current medical treatments used for symptomatic endometriosis and also discuss new treatment approaches. The authors conducted a literature search for randomised controlled trials related to medical treatments of endometriosis in humans, searched the Cochrane library for reviews and also searched for registered trials that have not yet been published on ClinicalTrials.gov.

EXPERT OPINION

The medical treatment of endometriosis is effective at treating pain and preventing recurrence of disease after surgery. Remarkably, the oral contraceptive pill taken continuously is as effective as GnRH-a, while causing far less side-effects. Conversely, no treatment currently exists for enhancing fecundity in women whose infertility is associated with endometriosis. As all existing therapies of endometriosis are contraceptive, great efforts should be targeted at researching novel products that reduce the disease expression without shuttering ovulation.

Interleukin-19 and interleukin-22 serum levels are decreased in patients with ovarian endometrioma

OBJECTIVE

To determine the serum levels of interleukin (IL)-10 family ILs in women with ovarian endometriosis and investigate the correlation of these levels with disease activity.

DESIGN

A case-control laboratory study.

SETTING

Tertiary-care university hospital.

PATIENT(S)

Two hundred nineteen women, with (n = 112) and without (n = 107) endometriosis.

INTERVENTION(S)

Complete surgical excision with pathological analysis.

MAIN OUTCOME MEASURE(S)

Blood samples were obtained during surgical procedures. IL-10, -19, -20, and -22 were assayed by ELISA in sera, and the concentrations correlated with the extent and the severity of the disease.

RESULT(S)

IL-19 was detectable in 18.3% and IL-22 in 47.9% of sera samples from all 219 women studied. Serum IL-19 was lower in women with endometriosis (median, 292.7 pg/mL; range, 32.2-1,339.3) than in endometriosis-free women (median, 1,035.8 pg/mL; range, 32.2-2,000.0). In addition, serum IL-22 levels were decreased in women affected by endometriosis (median, 352.0 pg/mL; range, 31.2-1,392.2) as compared with endometriosis-free women (median, 709.2 pg/mL; range, 73.3-2,012.0). We found significant correlations between serum IL-22 concentrations and intensity of deep dyspareunia (r = -0.303) and noncyclic chronic pelvic pain (r = -0.212). IL-19 was correlated with the intensity of deep dyspareunia (r = -0.749).

CONCLUSION(S)

Serum IL-19 and IL-22 are decreased in women with ovarian endometrioma. IL-10 family ILs may be involved in the pathogenesis of endometriosis.

Medication and transference in psychoanalytically oriented psychotherapy of the borderline patient

The regressive potential of the borderline patient has been recognized ever since the term was first introduced by Adolph Stern in 1938. He believed these patients were "too ill for classical psychoanalysis," and indeed almost all who have written on this subject have supported Stern's view, recognizing the severe regressive potential of a borderline patient in unmodified psychoanalysis. Taking medication is not generally considered to be a particularly regressive experience. It should be remembered, however, that for many patients and especially for patients with borderline personality disorder, medication can be both an overvalued hope and a terrifying assault. Thus, although the pharmacologic action of the medication may help to integrate the patient's ego functioning, the very taking of the medication may at the same time initiate subtle and unanticipated regressive drives. Two forces are then set in motion with potentially different effects. In a treatment where the same physician is prescribing medication and doing psychotherapy, the common pathway of these forces is transference. Thus, pharmacologic action may modify transference. And more importantly, because it is less easily recognized, transference issues may affect the patient's subjective experience of the action of the medication. For this reason, it is particularly important that not only diagnostic issues but also transference issues be understood before medication is prescribed.(ABSTRACT TRUNCATED AT 250 WORDS)