Rethinking mechanisms, diagnosis and management of endometriosis

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.

Bowel surgery as a fertility-enhancing procedure in patients with colorectal endometriosis: methodological, pathogenic and ethical issues

Bowel surgery for colorectal endometriosis is being promoted to infertile women without severe sub-occlusive symptoms, with the objective of improving the likelihood of conception. Contrary to rectal shaving, bowel surgery involving full-thickness disk excision and segmental resection entails opening of the intestinal lumen thus increasing the risk of postoperative infectious complications. About 1 in 10 patients undergoing colorectal resection for intestinal endometriosis will experience severe sequelae, including anastomotic dehiscence, rectovaginal fistula formation, and bladder and bowel denervation. Similar to other surgical procedures aiming at enhancing fertility in women with endometriosis, bowel surgery has been introduced into clinical practice without adequate evaluation through randomized controlled trials. According to systematic literature reviews based mainly on case series, the incremental gain of adding bowel procedures to standard surgery appears uncertain in terms of pregnancy rate after both natural attempts and IVF. Considering the methodological drawbacks and the high risk of bias in the available observational studies, it is not possible to exclude the suggestion that the benefit of colorectal surgery has been overestimated. Given the risk of harms to women's health and the important ethical implications, less emphasis should be put on strict statistical significance and more emphasis should be placed on the magnitude of the effect size. In this regard, the published data may not be generalizable, as the surgeons publishing their results may not be representative of all surgeons. Until the results of adequately designed and conducted RCTs are available, colorectal surgery with the sole intent of improving the reproductive performance of infertile patients with intestinal endometriosis should be performed exclusively within research settings and by highly experienced surgeons. Women should be informed about the uncertainties regarding the harms and benefits of bowel surgery in different clinical conditions, and preoperative counselling must be conducted impartially with the objective of achieving a truly shared medical decision.

Biological differences between intrinsic and extrinsic adenomyosis with coexisting deep infiltrating endometriosis

RESEARCH QUESTION

Is there a biological difference between intrinsic and extrinsic adenomyosis with coexisting deep infiltrating endometriosis (DIE)?

DESIGN

In this prospective controlled study, biopsy specimens were collected after surgery from 23 women with intrinsic adenomyosis and 10 women with extrinsic adenomyosis with coexisting DIE lesions. Histological evaluation was carried out by immunoreaction to Ber-EP4 (epithelial cell marker) and CD10 (stromal cell marker). Tissue expression of oestrogen and progesterone receptors was analysed by immunohistochemistry. Tissue fibrosis was examined by Masson's trichrome staining with computer-based image analysis of fibrosis in respective samples.

RESULTS

The detection rate of coexistent DIE was significantly higher in women with extrinsic adenomyosis (9/10 [90.0%]) than in women with intrinsic adenomyosis (3/23 [13.0%]; P < 0.001). The pattern of Ber-EP4-stained glands and CD10-stained stromal cells of extrinsic adenomyosis was similar to that of coexistent DIE lesions. In contrast, the pattern of gland and stromal cells was similar to the endometrium in the cases with intrinsic adenomyosis. Unlike extrinsic adenomyosis, progesterone receptor expression was significantly decreased in both gland cells (P < 0.05) and stromal cells (P < 0.05) of intrinsic adenomyosis. Although relatively more fibrosis was seen in biopsy samples of extrinsic adenomyosis and coexistent DIE than in intrinsic adenomyosis and their coexistent DIE, no significant difference was found.

CONCLUSIONS

Extrinsic adenomyosis may be considered as adenomyosis externa based on a close histological and biological relationship between extrinsic adenomyosis and coexistent DIE. Our findings may contribute to the understanding of a possible biological origin of two newly classified intrinsic and extrinsic adenomyosis.

Recent advances in understanding and managing adenomyosis

Adenomyosis is a benign uterine disorder in which endometrial glands and stroma are pathologically demonstrated in the uterine myometrium and it is considered a specific entity in the PALM-COEIN FIGO (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified - International Federation of Gynecology and Obstetrics) classification of causes of abnormal uterine bleeding (AUB). Although it has always been considered the classic condition of multiparous women over 40 years old who have pain and heavy menstrual bleeding, diagnosed at hysterectomy, the epidemiological scenario has completely changed. Adenomyosis is increasingly identified in young women with pain, AUB, infertility, or no symptoms by using imaging techniques such as transvaginal ultrasound and magnetic resonance. However, there is no agreement on the definition and classification of adenomyotic lesions from both the histopathology and the imaging point of view, and the diagnosis remains difficult and unclear. A uniform and shared reporting system needs to be implemented in order to improve our understanding on imaging features, their relationship with pathogenic theories, and their importance in terms of clinical symptoms and response to treatment. In fact, adenomyosis pathogenesis remains elusive and not a single theory can explain all of the different phenotypes of the disease. Furthermore, adenomyosis often coexists with other gynecological conditions, such as endometriosis and uterine fibroids, increasing the heterogeneity of available data. Treatment requires a lifelong management plan as the disease has a negative impact on quality of life in terms of menstrual symptoms, fertility, and pregnancy outcome and has a high risk of miscarriage and obstetric complications.

Two- and three-dimensional transvaginal ultrasonography for diagnosis of adenomyosis of the inner myometrium

RESEARCH QUESTION

How diagnostically accurate is two-dimensional (2D-TVS) compared with three-dimensional transvaginal ultrasonography (3D-TVS) in diagnosing adenomyosis of the inner myometrium. What is the most accurate combination of ultrasonographic features?

DESIGN

Premenopausal women (n = 110) scheduled for hysterectomy or transcervical resection of the endomyometrium owing to abnormal uterine bleeding were consecutively enrolled. All participants had real-time 2D-TVS and, later, blinded off-line 3D-TVS to diagnose adenomyosis. Results were compared with a detailed histopathological examination of the inner myometrium as gold standard.

RESULTS

Prevalence of adenomyosis of the inner myometrium was 29%. For 2D-TVS and 3D-TVS, respectively, the diagnostic accuracy was sensitivity 72% (95% CI 53 to 86) and 69% (95% CI 50 to 84); specificity 76% (95% CI 65 to 85) and 86% (95% CI 76-93); and area under the curve (AUC) 0.74 (95% CI 0.7 to 0.8) and 0.77 (95% CI 0.7 to 0.9). Specificity of 3D-TVS was not statistically significantly better than 2D-TVS; the difference between them almost reached statistical significance (P = 0.06). The most accurate three-dimensional feature was junctional zone irregularity (JZ_max-JZ_min ≥5mm) (AUC: 0.78). A combination of two or more two-dimensional and two or more three-dimensional features was highly accurate (AUC: 0.77).

CONCLUSIONS

For diagnosing adenomyosis of the inner myometrium, 3D-TVS offers a high accuracy similar to 2D-TVS. Identification of junctional zone irregularity with 3D-TVS may be beneficial to diagnosis. Two or more two-dimensional features and two or more three-dimensional features combined may give a more objective diagnosis, and may be useful for clinical practice and future research.

Role of medical therapy in the management of uterine adenomyosis

Adenomyosis is a benign uterine condition affecting women at various ages with different symptoms. The management of these patients is still controversial. Few clinical studies focusing on medical or surgical treatment for adenomyosis have been performed. No drug is currently labelled for adenomyosis and there are no specific guidelines to follow for the best management. Anyhow, medical treatments are effective in improving symptoms (pain, abnormal uterine bleeding and infertility). The rationale for using medical treatment is based on the pathogenetic mechanisms of adenomyosis: sex steroid hormones aberrations, impaired apoptosis, and increased inflammation. Several nonhormonal (i.e., nonsteroidal anti-inflammatory drugs) and hormonal treatments (i.e., progestins, oral contraceptives, gonadotropin-releasing hormone analogues) are currently used off-label to control pain symptoms and abnormal uterine bleeding in adenomyosis. Gonadotropin-releasing hormone analogues are indicated before fertility treatments to improve the chances of pregnancy in infertile women with adenomyosis. An antiproliferative and anti-inflammatory effect of progestins, such as dienogest, danazol and norethindrone acetate, suggests their use in medical management of adenomyosis mainly to control pain symptoms. On the other hand, the intrauterine device releasing levonorgestrel resulted is extremely effective in resolving abnormal uterine bleeding and reducing uterine volume in a long-term management plan. Based on new findings on pathogenetic mechanisms, new drugs are under development for the treatment of adenomyosis, such as selective progesterone receptor modulators, aromatase inhibitors, valproic acid, and anti-platelets therapy.

Symptoms and classification of uterine adenomyosis, including the place of hysteroscopy in diagnosis

Where histology used the presence of glands and/or stroma in the myometrium as pathognomonic for adenomyosis, imaging uses the appearance of the myometrium, the presence of striations, related to the presence of endometrial tissue within the myometrium, the presence of intramyometrial cystic structures and the size and asymmetry of the uterus to identify adenomyosis. Preliminary reports show a good correlation between the features detected by imaging and the histological findings. Symptoms associated with adenomyosis are abnormal uterine bleeding, pelvic pain (dysmenorrhea, chronic pelvic pain, dyspareunia), and impaired reproduction. However a high incidence of existing comorbidity like fibroids and endometriosis makes it difficult to attribute a specific pathognomonic symptom to adenomyosis. Heterogeneity in the reported pregnancy rates after assisted reproduction is due to the use of different ovarian stimulation protocols and absence of a correct description of the adenomyotic pathology. Current efforts to classify the disease contributed a lot in elucidated the potential characteristics that a classification system should be relied on. The need for a comprehensive, user friendly, and clear categorization of adenomyosis including the pattern, location, histological variants, and the myometrial zone seems to be an urgent need. With the uterus as a possible unifying link between adenomyosis and endometriosis, exploration of the uterus should not only be restricted to the hysteroscopic exploration of the uterine cavity but in a fusion with ultrasound.

Pathogenesis of endometriosis: the genetic/epigenetic theory

OBJECTIVE

To study the pathophysiology of endometriosis.

DESIGN

Overview of observations on endometriosis.

SETTING

Not applicable.

PATIENT(S)

None.

INTERVENTIONS(S)

None.

MAIN OUTCOME MEASURE(S)

The hypothesis is compatible with all observations.

RESULT(S)

Endometriosis, endometrium-like tissue outside the uterus, has a variable macroscopic appearance and a poorly understood natural history. It is a hereditary and heterogeneous disease with many biochemical changes in the lesions, which are clonal in origin. It is associated with pain, infertility, adenomyosis, and changes in the junctional zone, placentation, immunology, plasma, peritoneal fluid, and chronic inflammation of the peritoneal cavity. The Sampson hypothesis of implanted endometrial cells following retrograde menstruation, angiogenic spread, lymphogenic spread, or the metaplasia theory cannot explain all observations if metaplasia is defined as cells with reversible changes and an abnormal behavior/morphology due to the abnormal environment. We propose a polygenetic/polyepigenetic mechanism. The set of genetic and epigenetic incidents transmitted at birth could explain the hereditary aspects, the predisposition, and the endometriosis-associated changes in the endometrium, immunology, and placentation. To develop typical, cystic ovarian or deep endometriosis lesions, a variable series of additional transmissible genetic and epigenetic incidents are required to occur in a cell which may vary from endometrial to stem cells. Subtle lesions are viewed as endometrium in a different environment until additional incidents occur. Typical cystic ovarian or deep endometriosis lesions are heterogeneous and represent three different diseases.

CONCLUSION(S)

The genetic epigenetic theory is compatible with all observations on endometriosis. Implications for treatment and prevention are discussed.

Upregulation of Fibroblast Growth Factors Caused by Heart and Neural Crest Derivatives Expressed 2 Suppression in Endometriotic Cells: A Possible Therapeutic Target in Endometriosis

Several features exist that distinguish endometriotic cells from eutopic endometrial cells. Progesterone resistance is one of the main distinguishing features, although how progesterone resistance affects the phenotype of endometriotic cells is not fully elucidated. Heart and neural crest derivatives expressed 2 (HAND2) is a transcriptional factor that plays an important role in maintaining endometrial function in a progesterone-dependent manner. Therefore, we explored whether progesterone-dependent HAND2 is implicated in the progression of endometriosis. HAND2 was less expressed by endometriotic tissues compared to endometrial tissues. Suppression of HAND2 expression induced fibroblast growth factor 1 (FGF1), FGF2, and FGF9 in endometriotic stromal cells and consequently enhanced migration and invasion capacity. AZD4547, a FGF receptor inhibitor, diminished the migration and invasion of endometriotic cells in vitro. In the murine model of endometriosis, AZD4547 showed suppressive effects on the development of endometriotic lesions at a relatively low concentration. In conclusion, we demonstrated that FGF1, FGF2, and FGF9 are downstream effectors of HAND2 in endometriotic cells. Since HAND2-dependent FGFs play roles in enhancing invasive capacity of endometriotic cells, our results suggest that FGF receptor inhibitors, such as AZD4547, can be promising therapeutic targets for endometriosis.

[Bowel endometriosis and infertility: Do we need to operate?]

Endometriosis is a benign chronic inflammatory disease, whose pathogenesis is still unclear. Endometriosis is responsible for infertility and/or pelvic pain. One of the most important features of the disease is the heterogeneity (clinical and anatomical: superficial peritoneal, ovarian and/or deep infiltrating lesions). Bowel involvement constitutes one particularly severe form of the disease, affecting 8-12% of women with deep endometriosis. In case of associated infertility, bowel endometriosis constitutes a real therapeutic challenge for gynecologists. Indeed, while complete resection of the lesions alleviates pain and seems to improve spontaneous fertility, surgery remains technically challenging and may cause severe complications. Reverting to assisted Reproductive Technology (ART) is another valuable therapeutic option regarding pregnancy rates. Thus, the choice between surgical management or ART is still debated. Benefits and risks of these two options should be considered and discussed before planning treatment. In the present study, we aimed to answer the question: Bowel endometriosis and infertility: do we need to operate?