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Bandini V, Giola F, Ambruoso D, Cipriani S, Chiaffarino F, Vercellini P. The natural evolution of untreated deep endometriosis and the effect of hormonal suppression: A systematic literature review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:1722-1735. [PMID: 38867640 DOI: 10.1111/aogs.14887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/23/2024] [Accepted: 05/23/2024] [Indexed: 06/14/2024]
Abstract
INTRODUCTION Peritoneal infiltrating and fibrotic endometriosis, also known as deep endometriosis, is the most severe manifestation of the disease that can cause severe complications including bowel and ureteral stenosis. The natural history of these lesions and the possible effect of hormonal treatments on their progression are undefined. Therefore, we conducted a systematic review and meta-analysis to investigate whether and how frequently deep endometriosis progresses over time without or with ovarian suppression. This could inform management decisions in asymptomatic and mildly symptomatic patients. MATERIAL AND METHODS For this pre-registered systematic review (CRD42023463518), the PubMed and Embase databases were screened, and studies published between 2000 and 2023 that serially evaluated the size of deep endometriotic lesions without or with hormonal treatment were selected. Data on the progression, stability, or regression of deep endometriotic lesions were recorded as absolute frequencies or mean volume variations. Estimates of the overall percentage of progression and corresponding 95% confidence intervals were calculated using a random-effect model. When studies reported lesion progression as pre- and post-treatment volume means, the delta of the two-volume means was calculated and analyzed using the inverse variance method. RESULTS A total of 29 studies were identified, of which 19 studies with 285 untreated and 730 treated patients were ultimately selected for meta-analysis. The overall estimate of the percentage of lesion progression in untreated individuals was 21.4% (95% CI, 6.8-40.8%; I2 = 90.5%), whereas it was 12.4% during various hormonal treatments (95% CI, 9.0-16.1%; I2 = 0%). Based on the overall meta-analysis estimates, the odds ratio of progression in treated vs untreated patients was 0.52 (95% CI, 0.41-0.66). During hormonal suppression, the mean volume of deep endometriotic lesions decreased significantly by 0.87 cm3 (95% CI, 0.19-1.56 cm3; I2 = 0%), representing -28.5% of the baseline volume. CONCLUSIONS Untreated deep endometriotic lesions progressed in about one in five patients. Medical therapy reduced but did not eliminate this risk. Given the organ function failure potentially caused by these lesions, the decision whether to use hormonal treatments in asymptomatic or mildly symptomatic women should always be shared, carefully weighing the potential benefits and harms of the two alternatives after extensive counseling.
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Affiliation(s)
- Veronica Bandini
- Department of Clinical Sciences and Community Health, Academic Center for Research on Adenomyosis and Endometriosis, Università degli Studi, Milan, Italy
| | - Francesca Giola
- Department of Clinical Sciences and Community Health, Academic Center for Research on Adenomyosis and Endometriosis, Università degli Studi, Milan, Italy
| | - Deborah Ambruoso
- Department of Clinical Sciences and Community Health, Academic Center for Research on Adenomyosis and Endometriosis, Università degli Studi, Milan, Italy
| | - Sonia Cipriani
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Chiaffarino
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Academic Center for Research on Adenomyosis and Endometriosis, Università degli Studi, Milan, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Hélage S, Rivière L, Buy JN, Bordonné C, Préaux F, Just PA, Aflak N, Rousset P, Dion É. MRI classification of uterosacral ligament involvement in endometriosis: the Hôtel-Dieu classification. Br J Radiol 2024; 97:993-1002. [PMID: 38579251 PMCID: PMC11075982 DOI: 10.1093/bjr/tqae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/13/2023] [Accepted: 04/02/2024] [Indexed: 04/07/2024] Open
Abstract
OBJECTIVE This study aimed to establish the first-ever MRI classification of uterosacral ligament (USL) involvement in deep infiltrating endometriosis (DIE), based on reliable preoperative MRI features correlated with positive predictive values (PPVs) determined through histopathological analysis. METHODS Twenty-two women underwent surgery with histopathology due to symptoms highly suggestive of endometriosis. The 22 preoperative MRIs were analysed retrospectively, blinded to histopathology, and a classification of the preoperative aspect of USLs linked to PPVs was designed. RESULTS According to their aspects, 6 radiological types of USL were identified. The "L-category" corresponded to linear types with regular or irregular margins, including types 1, 2, 3A, and 3B. The "N-category" corresponded to haemorrhagic or nodular types, including types 4, 5A, 5B, and 6. For the L-category, PPVs ranged from 75% to 88%, depending on the USL radiological type. For the N-category, PPVs were 100% for each type. In women with endometriosis symptoms, MRI underestimated USL involvement, especially for type 1. Among the 6 uteri with lateral deviation, only one false-positive result concerning the stretched USL was induced. CONCLUSIONS In women with endometriosis symptoms, our MRI classification identified 2 USL categories, corresponding to 2 kinds of PPV; in these symptomatic patients, a normal MRI does not rule out a DIE diagnosis. ADVANCES IN KNOWLEDGE Our MRI classification of USL involvement in endometriosis may be used as a non-invasive staging of the disease, making it much clearer for clinicians and patients. Hence, we are able to propose a suitable diagnostic and therapeutic procedure for each radiological type.
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Affiliation(s)
- Siegfried Hélage
- Department of Radiology, Hôtel-Dieu de Paris (AP-HP), Paris 75004, France
| | - Lucas Rivière
- Department of Radiology, Hôtel-Dieu de Paris (AP-HP), Paris 75004, France
| | - Jean-Noël Buy
- Department of Radiology, Hôtel-Dieu de Paris (AP-HP), Paris 75004, France
| | - Corinne Bordonné
- Department of Radiology, Hôtel-Dieu de Paris (AP-HP), Paris 75004, France
| | - Frédéric Préaux
- Léonard de Vinci Medical Imaging, 43 rue Cortambert, Paris 75016, France
| | | | - Nizar Aflak
- Department of Gynecological Surgery, Hôpital Beaujon (AP-HP), Clichy 92110, France
| | - Pascal Rousset
- Department of Radiology, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre Bénite 69495, France
| | - Élisabeth Dion
- Department of Radiology, Hôtel-Dieu de Paris (AP-HP), Paris 75004, France
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Perrone U, Evangelisti G, Laganà AS, Bogliolo S, Ceccaroni M, Izzotti A, Gustavino C, Ferrero S, Barra F. A review of phase II and III drugs for the treatment and management of endometriosis. Expert Opin Emerg Drugs 2023; 28:333-351. [PMID: 38099328 DOI: 10.1080/14728214.2023.2296080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/13/2023] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Endometriosis is an estrogen-dependent disease that gives rise to pelvic pain and infertility. Although estroprogestins and progestins currently stand as the first-line treatments for this condition, demonstrating efficacy in two-thirds of patients, a significant portion of individuals experience only partial relief or symptom recurrence following the cessation of these therapies. The coexistence of superficial, deep endometriosis, and ovarian endometriomas, as three distinct phenotypes with unique pathogenetic and molecular characteristics, may elucidate the current heterogeneous biological response to available therapy. AREAS COVERED The objective of this review is to furnish the reader with a comprehensive summary pertaining to phase II-III hormonal treatments for endometriosis. EXPERT OPINION Ongoing research endeavors are directed toward the development of novel hormonal options for this benign yet debilitating disease. Among them, oral GnRH antagonists emerge as a noteworthy option, furnishing rapid therapeutic onset without an initial flare-up; these drugs facilitate partial or complete estrogen suppression, and promote prompt ovarian function recovery upon discontinuation, effectively surmounting the limitations associated with previously employed GnRH agonists. Limited evidence supports the use of selective estrogen and progesterone receptor modulators. Consequently, further extensive clinical research is imperative to garner a more profound understanding of innovative targets for novel hormonal options.
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Affiliation(s)
- Umberto Perrone
- Unit of Obstetrics and Gynecology, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | | | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | | | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore-Don Calabria" Hospital, Verona, Italy
| | - Alberto Izzotti
- Unit of Mutagenesis and Cancer Prevention, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | - Claudio Gustavino
- Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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Peitsidis P, Tsikouras P, Laganà AS, Laios A, Gkegkes ID, Iavazzo C. A Systematic Review of Systematic Reviews on the Use of Aromatase Inhibitors for the Treatment of Endometriosis: The Evidence to Date. Drug Des Devel Ther 2023; 17:1329-1346. [PMID: 37168488 PMCID: PMC10166210 DOI: 10.2147/dddt.s315726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/27/2023] [Indexed: 05/13/2023] Open
Abstract
Endometriosis is a chronic gynecologic condition that affects around 6-10% of reproductive age women. This clinical entity is characterized with pelvic pain, dysmenorrhea, dyspareunia, and infertility which are the most often presenting symptoms. Aromatase P450 is the key enzyme for ovarian estrogen biosynthesis and there is evidence that endometriotic lesions express aromatase and are able to synthesize their own estrogens. Aromatase inhibitors (AIs) are potent drugs that suppress the estrogen synthesis via suppression of aromatase. We performed a systematic review of systematic reviews and narrative reviews on the use of aromatase inhibitors in the medical management of endometriosis. We searched: PubMed (1950-2022), Google Scholar (2004-2022), Cochrane Library (2010-2022) and Researchgate (2010-2022). The search included the following medical subject headings (MeSH) or keywords: "Aromatase Inhibitors" AND "Endometriosis" AND "Systematic reviews" OR "Systematic review" AND "Reviews" OR "Reviews" AND "Endometriosis". The electronic database search yielded initially 12,106 studies from the different databases. Further assessment of the studies resulted in exclusion of (n = 12,015) studies due to duplicates and irrelevance; Finally, 24 studies were selected for inclusion, 5 were Systematic reviews and 19 were Narrative reviews. The 5 systematic reviews were assessed by AMSTAR-2 criteria and were found to have low quality. Narrative reviews were assessed with SANRA criteria and were found to have high-quality aromatase inhibitors are potent drugs that can manage the endometriosis-related symptoms in cases where initial medical management has failed to show positive results. However, their use is limited by the adverse effects that are linked with menopausal symptoms. aromatase inhibitors can be administered as an alternative treatment in patients. Future studies with randomized design are required to reach safer conclusions and further investigation. These studies should define the therapeutic dose, new add-back therapy modalities. Future directions should examine the most-appropriate way of administration and the duration of therapy.
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Affiliation(s)
- Panagiotis Peitsidis
- Department of Obstetrics and Gynecology Helena Venizelou Hospital, Athens, Greece
- Correspondence: Panagiotis Peitsidis, Department of Obstetrics and Gynecology, Helena Venizelou Hospital Athens Greece, Helena Venizelou 2 Street, P.C, Athens, 11521, Greece, Tel +306972221553; +302107473793, Email
| | - Panagiotis Tsikouras
- Department of Obstetrics and Gynecology.The Democritus University of Thrace, Alexandroupolis, Greece
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology ARNAS “Civico-Di Cristina-Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Palermo, Italy
| | - Alexandros Laios
- Department of Gynecological Oncology St James Institute of Oncology, Leeds Teaching Hospitals, Leeds, Uk
| | - Ioannis D Gkegkes
- Department of Colorectal Surgery, Royal Devon and Exeter NHS Foundation, Devon, UK
| | - Christos Iavazzo
- Gynaecological Oncology Department, Metaxa Cancer Hospital, Piraeus, Greece
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Estro-Progestins and Pain Relief in Endometriosis. ENDOCRINES 2022. [DOI: 10.3390/endocrines3020028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Endometriosis is a benign, hormone-responsive chronic disease that affects women of reproductive age; long-term treatment to balance satisfactory tolerability with clinical efficacy is necessary for these patients. The first-line therapy for endometriosis is predominantly medical treatment, in order to improve symptoms or prevent post-surgical disease recurrence. Multiple factors including age and women preference, pain severity, and endometriosis stage must be considered in the choice of the most suitable therapy. Estrogen-progestogins are generally used as first-line hormone therapies among different medical options currently effective for endometriosis management. Several studies have shown that they are able to improve pain symptoms in most patients, are well tolerated, and are inexpensive. Combined hormonal contraception treatment, administered cyclically or continuously, with different types of hormones and route of administration, results in clinically noticeable decrease in dysmenorrhea, noncyclic pelvic pain, dyspareunia, and recurrence rate after surgery, and also in quality of life improvement.
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Lete I. Uso de inhibidores de la aromatasa en el tratamiento del dolor pélvico asociado a endometriosis: revisión sistemática. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2022. [DOI: 10.1016/j.gine.2021.100706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mercorio A, Giampaolino P, Romano A, Dällenbach P, Pluchino N. Is intracrinology of endometriosis relevant in clinical practice? A systematic review on estrogen metabolism. Front Endocrinol (Lausanne) 2022; 13:950866. [PMID: 36204107 PMCID: PMC9531311 DOI: 10.3389/fendo.2022.950866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED Endometriosis is a chronic, multifactorial, estrogen-dependent disease. The abnormal endocrine microenvironment of endometriosis lesions is considered a main feature and multiple enzymatic pathways leading to local increased synthesis of estrogens have been identified. However, the relevance of intracrinology in clinical practice is still lacking. Medline, Embase, Scopus database were systematically searched for studies reporting on local estrogens metabolism of endometriotic lesions. The main enzymatic pathways involved in the intracrinology of endometriosis such as aromatase (CYP19A1), 17β-hydroxysteroid dehydrogenase (HSD17B) type 1, type 2 and type 5, steroid sulfatase (STS), estrogen sulfotransferase (SULT1E1) were assessed with a critical perspective on their role in disease endocrine phenotyping, drug resistance and as therapeutic targets. Overall, studies heterogeneity and missing clinical data affect the interpretation of the clinical role of these enzymes. Although the use of some drugs such as aromatase inhibitors has been proposed in clinical practice for two decades, their potential clinical value is still under investigation as well as their modality of administration. A closer look at new, more realistic drug targets is provided and discussed. Altered expression of these key enzymes in the lesions have far reaching implication in the development of new drugs aimed at decreasing local estrogenic activity with a minimal effect on gonadal function; however, given the complexity of the evaluation of the expression of the enzymes, multiple aspects still remains to be clarified. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022311329, identifier CRD42022311329.
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Affiliation(s)
- Antonio Mercorio
- Department of Pediatrics Gynecology and Obstetrics, Division of Gynecology, Geneva University Hospitals, Geneva, Switzerland
| | - Pierluigi Giampaolino
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Andrea Romano
- Obstetrics and Gynaecology Department, GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
| | - Patrick Dällenbach
- Department of Pediatrics Gynecology and Obstetrics, Division of Gynecology, Geneva University Hospitals, Geneva, Switzerland
| | - Nicola Pluchino
- Department of Pediatrics Gynecology and Obstetrics, Division of Gynecology, Geneva University Hospitals, Geneva, Switzerland
- *Correspondence: Nicola Pluchino,
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GnRH Antagonists with or without Add-Back Therapy: A New Alternative in the Management of Endometriosis? Int J Mol Sci 2021; 22:ijms222111342. [PMID: 34768770 PMCID: PMC8583814 DOI: 10.3390/ijms222111342] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022] Open
Abstract
To evaluate the effectiveness of a new class of medical drugs, namely oral gonadotropin-releasing hormone (GnRH) antagonists, in the management of premenopausal women with endometriosis-associated pelvic pain. We reviewed the most relevant papers (n = 27) on the efficacy of new medical alternatives (oral GnRH antagonists) as therapy for endometriosis. We first briefly summarized the concept of progesterone resistance and established that oral contraceptives and progestogens work well in two-thirds of women suffering from endometriosis. Since clinical evidence shows that estrogens play a critical role in the pathogenesis of the disease, lowering their levels with oral GnRH antagonists may well prove effective, especially in women who fail to respond to progestogens. There is a need for reliable long-term oral treatment capable of managing endometriosis symptoms, taking into consideration both the main symptoms and phenotype of the disease. Published studies reviewed and discussed here confirm the efficacy of GnRH antagonists. There is a place for GnRH antagonists in the management of symptomatic endometriosis. Novel algorithms that take into account the different phenotypes are proposed.
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Newmark AL, Luciano DE, Ulrich A, Luciano AA. Medical management of endometriosis. Minerva Obstet Gynecol 2021; 73:572-587. [PMID: 34264045 DOI: 10.23736/s2724-606x.21.04776-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Endometriosis is a benign gynecologic disorder that is defined as functional endometrial tissue outside of the uterine cavity. It is an estrogen-dependent, inflammatory disease that leads to symptoms of pelvic pain, dysmenorrhea, dyspareunia, and infertility, occurring in 6-10% of reproductive aged women. The severity of the disease ranges from asymptomatic to debilitating symptoms that have a major impact on women's lives. It is a chronic, recurrent disease, frequently requiring long term management until menopause and beyond. It is considered a chronic disorder that is managed with surgery, medical treatment, and oftentimes, both. Current medical therapy for endometriosis is considered suppressive of the disease, rather than curative. Fortunately, many patients do experience improvement and control of their symptoms with medical therapy. However, long-term efficacy of the medical treatments is often limited by side effects and the cost of therapy, and symptoms do tend to recur after discontinuation of these medications. AREAS COVERED This review summarizes our understanding of the pathogenesis of endometriosis and provides more in-depth discussion of specific medical management options used to treat endometriosis, including mechanism of action and side effects. It also provides recommendations on strategy with a forward look to novel endometriosis treatments in the future. EXPERT OPINION The authors emphasize that endometriosis is a chronic disorder requiring long term medical therapy. Early diagnosis of endometriosis is key in preventing severe, debilitating symptoms and progression of disease. By utilizing our current knowledge of the pathophysiology of endometriosis and by correctly implementing currently available medical and surgical therapies we can significantly reduce the physical, psychosocial and financial burden of this chronic, recurrent and indolent disease. Current available medications are suppressive therapies, but the authors are looking forward to future therapies that can effectively cure or at least control endometriosis with minimal side effects. Future research should continue to look for the genetic trigger for endometriosis which can lead us to its underlying pathogenesis and eventually a cure or prevention.
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Affiliation(s)
- Alexis L Newmark
- Department of Obstetrics and Gynecology, University of Connecticut, Farmington, CT, USA -
| | - Danielle E Luciano
- Department of Obstetrics and Gynecology, University of Connecticut, Farmington, CT, USA
| | - Amanda Ulrich
- Department of Obstetrics and Gynecology, University of Connecticut, Farmington, CT, USA
| | - Anthony A Luciano
- Department of Obstetrics and Gynecology, University of Connecticut, Farmington, CT, USA
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Barra F, Alessandri F, Scala C, Ferrero S. Ultrasonographic 3D Evaluation in the Diagnosis of Bladder Endometriosis: A Prospective Comparative Diagnostic Accuracy Study. Gynecol Obstet Invest 2021; 86:299-306. [PMID: 34157713 DOI: 10.1159/000516634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/19/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The use of three-dimensional (3D) transvaginal ultrasonography (TVS) has been investigated for the diagnosis of deep endometriosis (DE). This study aimed to evaluate if 3D reconstructions improve the performance of TVS) in assessing the presence and characteristics of bladder endometriosis (BE). DESIGN This was a single-center comparative diagnostic accuracy study. Participants/Materials, Setting, Methods: Patients referred to our institution (Piazza della Vittoria 14 Srl, Genova, Italy) with clinical suspicion of DE were included. In case of surgery, women underwent systematic preoperative ultrasonographic imaging; an experienced sonographer performed a conventional TVS; another experienced sonographer, blinded to results of the previous exam, performed TVS, with the addition of 3D modality. The presence and characteristics of BE nodules were described in accord with International DE Analysis group consensus. Ultrasound data were compared with surgical and histological results. RESULTS Overall, BE was intraoperatively found in 34 out of 194 women who underwent surgery for DE (17.5%; 95% confidence interval: 12.8-23.5%). TVS without and with 3D reconstructions were able to detect endometriotic BE in 82.2% (n = 28/34) and 85.3% (n = 29/34) of the cases (p = 0.125). Both the exams similarly estimated the largest diameter of BE (p = 0.652) and the distance between the endometriotic nodule and the closest ureteral meatus (p = 0.341). However, TVS with 3D reconstructions was more precise in estimating the volume of BE (p = 0.031). In one case (2.9%), TVS without and with 3D reconstructions detected the infiltration of the intramural ureter, which was confirmed at surgery and required laparoscopic ureterovesical reimplantation. LIMITATIONS The extensive experience of the gynecologists performing the ultrasonographic scans, the lack of prestudy power analysis, and the population selected, which may have been influenced by the position of the institution as a referral center specialized in the treatment of severe endometriosis, are limitations of the current study. CONCLUSION Our results demonstrated the high accuracy of ultrasound for diagnosing BE. The addition of 3D reconstructions does not improve the performance of TVS in diagnosing the presence and characteristics of BE. However, the volume of BE may be more precisely assessed by 3D ultrasound.
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Affiliation(s)
- Fabio Barra
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy.,Academic Unit of Obstetrics and Gynecology, IRRCS Ospedale Policlinico San Martino, Genova, Italy.,Piazza della Vittoria 14 SRL, Genova, Italy
| | - Franco Alessandri
- Unit of Obstetrics and Gynecology, IRRCS Ospedale Policlinico San Martino, Genova, Italy
| | - Carolina Scala
- Piazza della Vittoria 14 SRL, Genova, Italy.,Unit of Obstetrics and Gynecology, Gaslini Institute, Genova, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy.,Academic Unit of Obstetrics and Gynecology, IRRCS Ospedale Policlinico San Martino, Genova, Italy.,Piazza della Vittoria 14 SRL, Genova, Italy
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Endometriosis and Medical Therapy: From Progestogens to Progesterone Resistance to GnRH Antagonists: A Review. J Clin Med 2021; 10:jcm10051085. [PMID: 33807739 PMCID: PMC7961981 DOI: 10.3390/jcm10051085] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/20/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023] Open
Abstract
Background: The first objective of this review was to present, based on recent literature, the most frequently applied medical options (oral contraceptive pills (OCPs) and progestogens) for the management of symptomatic endometriosis, and evaluate their effectiveness in treating premenopausal women with endometriosis-associated pelvic pain, dysmenorrhea, non-menstrual pelvic pain and dyspareunia. The second objective was to review the concept of progesterone resistance and newly available treatment options. Methods: We reviewed the most relevant papers (n = 73) on the efficacy of OCPs and progestogens as medical therapy for endometriosis, as well as those on progesterone resistance and new medical alternatives (oral gonadotropin-releasing hormone (GnRH) antagonist). Eleven papers, essentially reviews, were selected and scrutinized from among 94 papers discussing the concept of progesterone resistance. Results: Having reviewed the most significant papers, we can confirm that OCPs and progestogens are effective in two-thirds of women suffering from endometriosis, but that other options are required in case of failure (in one-third of women due to progesterone resistance) or intolerance to these compounds. It is clear that there is a need for effective long-term oral treatment capable of managing endometriosis symptoms, while mitigating the impact of side effects. Biochemical, histological and clinical evidence show that estrogens play a critical role in the pathogenesis of endometriosis, so lowering levels of circulating estrogens should be considered an effective medical approach. The efficacy of three oral GnRH antagonists is discussed on the basis of published studies. Conclusion: There is a place for GnRH antagonists in the management of symptomatic endometriosis and clinical trials should be conducted, taking into account the different phenotypes in order to propose novel algorithms.
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Barra F, Mikhail E, Villegas-Echeverri JD, Ferrero S. Infertility in patients with bowel endometriosis. Best Pract Res Clin Obstet Gynaecol 2021; 71:161-171. [DOI: 10.1016/j.bpobgyn.2020.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022]
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Hirata T, Koga K, Kai K, Katabuchi H, Kitade M, Kitawaki J, Kurihara M, Takazawa N, Tanaka T, Taniguchi F, Nakajima J, Narahara H, Harada T, Horie S, Honda R, Murono K, Yoshimura K, Osuga Y. Clinical practice guidelines for the treatment of extragenital endometriosis in Japan, 2018. J Obstet Gynaecol Res 2020; 46:2474-2487. [PMID: 33078482 PMCID: PMC7756675 DOI: 10.1111/jog.14522] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/28/2020] [Indexed: 01/31/2023]
Abstract
The aim of this publication is to disseminate the clinical practice guidelines for the treatment of intestinal, bladder/ureteral, thoracic and umbilical endometriosis, already published in Japanese, to non-Japanese speakers. For developing the original Japanese guidelines, the clinical practice guideline committee was formed by the research team for extragenital endometriosis, which is part of the research program of intractable disease of the Japanese Ministry of Health, Labor and Welfare. The clinical practice guideline committee formulated eight clinical questions for the treatment of extragenital endometriosis, which were intestinal, bladder/ureteral, thoracic and umbilical endometriosis. The committee performed a systematic review of the literature to provide responses to clinical questions and developed clinical guidelines for extragenital endometriosis, according to the process proposed by the Medical Information Network Distribution Service. The recommendation level was determined using modified Delphi methods. The clinical practice guidelines were officially approved by the Japan Society of Obstetrics and Gynecology and the Japan Society of Endometriosis. This English version was translated from the Japanese version.
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Affiliation(s)
- Tetsuya Hirata
- Department of Obstetrics and GynecologyDoai Kinen HospitalTokyoJapan
- Department of Obstetrics and GynecologyUniversity of TokyoTokyoJapan
| | - Kaori Koga
- Department of Obstetrics and GynecologyUniversity of TokyoTokyoJapan
| | - Kentaro Kai
- Department of Obstetrics and GynecologyOita UniversityOitaJapan
| | | | - Mari Kitade
- Department of Obstetrics and GynecologyJuntendo UniversityTokyoJapan
| | - Jo Kitawaki
- Department of Obstetrics and GynecologyKyoto Prefectural UniversityKyotoJapan
| | - Masatoshi Kurihara
- Pneumothorax Research Center and Division of Thoracic SurgeryNissan Tamagawa HospitalTokyoJapan
| | | | - Toshiaki Tanaka
- Department of Surgical OncologyUniversity of TokyoTokyoJapan
- Department of SurgeryInternational Catholic HospitalTokyoJapan
| | | | - Jun Nakajima
- Department of Thoracic SurgeryUniversity of TokyoTokyoJapan
| | | | - Tasuku Harada
- Department of Obstetrics and GynecologyTottori UniversityTottoriJapan
| | - Shigeo Horie
- Department of UrologyJuntendo UniversityTokyoJapan
| | - Ritsuo Honda
- Department of Obstetrics and GynecologyKumamoto UniversityKumamotoJapan
| | - Koji Murono
- Department of Surgical OncologyUniversity of TokyoTokyoJapan
| | - Kotaro Yoshimura
- Department of Plastic SurgeryJichi Medical UniversityShimotsukeJapan
| | - Yutaka Osuga
- Department of Obstetrics and GynecologyUniversity of TokyoTokyoJapan
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14
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Garzon S, Laganà AS, Barra F, Casarin J, Cromi A, Raffaelli R, Uccella S, Franchi M, Ghezzi F, Ferrero S. Aromatase inhibitors for the treatment of endometriosis: a systematic review about efficacy, safety and early clinical development. Expert Opin Investig Drugs 2020; 29:1377-1388. [PMID: 33096011 DOI: 10.1080/13543784.2020.1842356] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Pharmacotherapy has a key role in endometriosis treatment and management, however, a significant proportion of patients have only intermittent or limited benefits with current treatment options. Therefore, novel therapeutic approaches are necessary. AREAS COVERED This systematic review provides an overview of the efficacy and safety of aromatase inhibitors (AIs) as monotherapies and combination therapies for endometriosis. A systematic literature search was performed from January 1990 to April 2020 in the electronic database MEDLINE, EMBASE, The Cochrane Library, and Web of Science. EXPERT OPINION Based on the critical role of estrogens and the rate-limiting step in the production of the estrogens represented by the aromatase enzyme, AIs are a potential therapeutic option for women affected by endometriosis. Nevertheless, further research is needed to clarify the efficacy of AIs in this setting. Adverse effects need to be investigated to clarify the preventive role of add-back therapy. On that basis, AIs should be adopted only as second-line therapy in patients who are refractory to standard treatments in the setting of scientific research. Further studies should define best dosages, appropriate add-back therapies, administration routes, treatment length, and which patients may benefit more from AIs.
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Affiliation(s)
- Simone Garzon
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria , Varese, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria , Varese, Italy
| | - Fabio Barra
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova , Genova, Italy.,Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino , Genova, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria , Varese, Italy
| | - Antonella Cromi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria , Varese, Italy
| | - Ricciarda Raffaelli
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona , Verona, Italy
| | - Stefano Uccella
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona , Verona, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona , Verona, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria , Varese, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova , Genova, Italy.,Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino , Genova, Italy
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15
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Magnetic Resonance Rectal Enema Versus Computed Tomographic Colonography in the Diagnosis of Rectosigmoid Endometriosis. J Comput Assist Tomogr 2020; 44:501-510. [PMID: 32558775 DOI: 10.1097/rct.0000000000001031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Rectosigmoid involvement by endometriosis causes intestinal symptoms such as constipation, diarrhea, and dyschezia. A precise diagnosis about the presence, location, and extent of bowel implants is required to plan the most appropriate treatment. The aim of the study was to compare the accuracy of magnetic resonance with distension of the rectosigmoid (MR-e) with computed colonography (CTC) for diagnosing rectosigmoid endometriosis. METHODS This study was based on the retrospective analysis of a prospectively collected database of patients with suspicion of rectosigmoid endometriosis who underwent both MR-e and CTC, and subsequently were treated by laparoscopy. The findings of imaging techniques were compared with surgical and histological results. RESULTS Of 90 women included in the study, 44 (48.9%) had rectosigmoid nodules and underwent bowel surgery. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for the diagnosis of rectosigmoid endometriosis were 88.6%, 93.5%, 92.9%, 89.6%, and 91.1% for CTC, and 93.2%, 97.9%, 97.6%, 93.8%, and 95.6% for MR-e. There was no significant difference in the accuracy of both radiologic examinations for diagnosing rectosigmoid endometriosis (P = 0.344). However, MR-e was more accurate than CTC in estimating the largest diameter of the main rectosigmoid nodule (P < 0.001). The pain perceived by the patients was significantly lower during MR-e than during CTC (P < 0.001). CONCLUSIONS MR-e and CTC have similar diagnostic performance for the diagnosis of rectosigmoid involvement of endometriosis. However, MR-e is more accurate in the estimation of the largest diameter of main rectosigmoid nodule and more tolerated than CTC.
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Vercellini P, Sergenti G, Buggio L, Frattaruolo MP, Dridi D, Berlanda N. Advances in the medical management of bowel endometriosis. Best Pract Res Clin Obstet Gynaecol 2020; 71:78-99. [PMID: 32680785 DOI: 10.1016/j.bpobgyn.2020.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 12/29/2022]
Abstract
Endometriosis infiltrating the bowel can be treated medically in accurately selected women not seeking conception and without overt obstructive symptomatology. When the rectosigmoid junction is involved, the probabilities of intestinal symptoms relief, undergoing surgery after treatment failure, and developing bowel obstruction during hormonal treatment are around 70%, 10%, and 1-2%, respectively. When the lesion infiltrates exclusively the mid-rectum, thus in cases of true rectovaginal endometriosis, the probabilities of intestinal symptoms relief and undergoing surgery are about 80% and 3%, respectively. Endometriotic obstructions of the rectal ampulla have not been reported. A rectosigmoidoscopy or colonoscopy should be performed systematically before starting medical therapies, also to rule out malignant tumours arising from the intestinal mucosa. Progestogens are safe, generally effective, well-tolerated, inexpensive, and should be considered as first-line medications for bowel endometriosis. Independently of symptom relief, intestinal lesions should be checked periodically to exclude nodule progression during hormonal treatment.
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Affiliation(s)
- Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi, Via Commenda, Milan, Italy; Fondazione Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12-20122, Milan, Italy.
| | - Greta Sergenti
- Department of Clinical Sciences and Community Health, Università degli Studi, Via Commenda, Milan, Italy
| | - Laura Buggio
- Fondazione Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12-20122, Milan, Italy
| | - Maria Pina Frattaruolo
- Fondazione Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12-20122, Milan, Italy
| | - Dhouha Dridi
- Department of Clinical Sciences and Community Health, Università degli Studi, Via Commenda, Milan, Italy; Fondazione Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12-20122, Milan, Italy
| | - Nicola Berlanda
- Fondazione Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12-20122, Milan, Italy
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Ferrero S, Stabilini C, Barra F, Clarizia R, Roviglione G, Ceccaroni M. Bowel resection for intestinal endometriosis. Best Pract Res Clin Obstet Gynaecol 2020; 71:114-128. [PMID: 32665125 DOI: 10.1016/j.bpobgyn.2020.05.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 01/12/2023]
Abstract
Over the last twenty years, segmental resection (SR) has been the technique most frequently used to treat bowel endometriosis. Nowadays, it is most commonly performed by laparoscopy; however, there is evidence that it can be safely performed by robotic-assisted laparoscopic surgery. Rectovaginal fistula and anastomotic leakage are the two major complications of SR; other complications include pelvic abscess, postoperative bleeding, ureteral damage, and anastomotic stricture. Several studies showed that SR causes improvement in pain and intestinal symptoms; nerve-sparing SR may improve the functional outcomes. The rates of postoperative recurrence of bowel endometriosis vary across the studies, possibly because of the different definitions of recurrence.
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Affiliation(s)
- Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, Genoa, 16132, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy
| | - Cesare Stabilini
- Department of Surgical Science, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, Genoa, 16132, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, Genoa, 16132, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy.
| | - Roberto Clarizia
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Via Don A. Sempreboni 5, Negrar, 37024, Verona, Italy
| | - Giovanni Roviglione
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Via Don A. Sempreboni 5, Negrar, 37024, Verona, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Via Don A. Sempreboni 5, Negrar, 37024, Verona, Italy
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18
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Reis FM, Coutinho LM, Vannuccini S, Batteux F, Chapron C, Petraglia F. Progesterone receptor ligands for the treatment of endometriosis: the mechanisms behind therapeutic success and failure. Hum Reprod Update 2020; 26:565-585. [PMID: 32412587 PMCID: PMC7317284 DOI: 10.1093/humupd/dmaa009] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 12/04/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Despite intense research, it remains intriguing why hormonal therapies in general and progestins in particular sometimes fail in endometriosis. OBJECTIVE AND RATIONALE We review here the action mechanisms of progesterone receptor ligands in endometriosis, identify critical differences between the effects of progestins on normal endometrium and endometriosis and envisage pathways to escape drug resistance and improve the therapeutic response of endometriotic lesions to such treatments. SEARCH METHODS We performed a systematic Pubmed search covering articles published since 1958 about the use of progestins, estro-progestins and selective progesterone receptor modulators, to treat endometriosis and its related symptoms. Two reviewers screened the titles and abstracts to select articles for full-text assessment. OUTCOMES Progesterone receptor signalling leads to down-regulation of estrogen receptors and restrains local estradiol production through interference with aromatase and 17 beta-hydroxysteroid dehydrogenase type 1. Progestins inhibit cell proliferation, inflammation, neovascularisation and neurogenesis in endometriosis. However, progesterone receptor expression is reduced and disrupted in endometriotic lesions, with predominance of the less active isoform (PRA) over the full-length, active isoform (PRB), due to epigenetic abnormalities affecting the PGR gene transcription. Oxidative stress is another mechanism involved in progesterone resistance in endometriosis. Among the molecular targets of progesterone in the normal endometrium that resist progestin action in endometriotic cells are the nuclear transcription factor FOXO1, matrix metalloproteinases, the transmembrane gap junction protein connexin 43 and paracrine regulators of estradiol metabolism. Compared to other phenotypes, deep endometriosis appears to be more resistant to size regression upon medical treatments. Individual genetic characteristics can affect the bioavailability and pharmacodynamics of hormonal drugs used to treat endometriosis and, hence, explain part of the variability in the therapeutic response. WIDER IMPLICATIONS Medical treatment of endometriosis needs urgent innovation, which should start by deeper understanding of the disease core features and diverse phenotypes and idiosyncrasies, while moving from pure hormonal treatments to drug combinations or novel molecules capable of restoring the various homeostatic mechanisms disrupted by endometriotic lesions.
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Affiliation(s)
- Fernando M Reis
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Department of Gynecology Obstetrics II and Reproductive Medicine, Faculté de Médecine, Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Institut Cochin, INSERM U1016, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Larissa M Coutinho
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, Careggi University Hospital University of Florence, Florence, Italy
| | - Silvia Vannuccini
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, Careggi University Hospital University of Florence, Florence, Italy
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
- Department of Gynecology Obstetrics II and Reproductive Medicine, Faculté de Médecine, Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Frédéric Batteux
- Institut Cochin, INSERM U1016, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Charles Chapron
- Department of Gynecology Obstetrics II and Reproductive Medicine, Faculté de Médecine, Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Institut Cochin, INSERM U1016, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Felice Petraglia
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, Careggi University Hospital University of Florence, Florence, Italy
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19
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Ferrero S, Scala C, Ciccarelli S, Vellone VG, Barra F. Treatment of rectovaginal endometriosis with the etonogestrel-releasing contraceptive implant. Gynecol Endocrinol 2020; 36:540-544. [PMID: 31711348 DOI: 10.1080/09513590.2019.1689552] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This study aimed to investigate the efficacy of the etonogestrel (ENG)-releasing implant in treating patients with rectovaginal endometriosis. The study was based on the retrospective analysis of a prospectively collected database, including symptomatic women who had ultrasonographic diagnosis of rectovaginal endometriosis. Patients were follow-up at 6, 12 and 24 months from the insertion of the ENG-releasing implant. The intensity of pain symptoms was evaluated using a visual analog scale. The volume of the nodules was estimated by virtual organ computer-aided analysis. The Endometriosis Health Profile (EHP-30) was used to evaluate quality of life. Overall, 43 women were included in the study. The 2-year continuation rate for the ENG-releasing implant was 93.0%. The treatment quickly improved the intensity of non-menstrual pelvic pain, deep dyspareunia, dysmenorrhea, and dyschezia. At 6-month follow-up, there were improvements in all domains of the EHP-30 compared with baseline. Further improvements in the EHP-30 results were observed only in pain sub score at 12-month follow-up and in emotional well-being sub score at 24-month follow-up. At 6-month follow-up the volume of the rectovaginal nodules was significantly lower compared with baseline; a further decrease was observed at 12- and 24-month follow-up. The treatment was well tolerated.
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Affiliation(s)
- Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy
- Piazza Della Vittoria 14 Srl, Genova, Italy
| | - Carolina Scala
- Unit of Obstetrics and Gynecology, Gaslini Institute, Genova, Italy
| | | | - Valerio Gaetano Vellone
- Department of Surgical and Diagnostic Sciences (DISC), Ospedale Policlinico San Martino, Genova, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy
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20
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Schwartz K, Llarena NC, Rehmer JM, Richards EG, Falcone T. The role of pharmacotherapy in the treatment of endometriosis across the lifespan. Expert Opin Pharmacother 2020; 21:893-903. [PMID: 32164462 DOI: 10.1080/14656566.2020.1738386] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Endometriosis is estimated to affect 10% of reproductive-aged women. The gold standard for treatment is surgery; however, surgery carries a significant morbidity and cost burden. There is an ongoing need for safe, effective medical therapies for endometriosis patients, both in conjunction with and independent of surgical interventions. Most conventional therapies for endometriosis work by a similar mechanism, and efficacy is variable. In recent years, there has been increased interest in the development and testing of novel pharmacotherapies for endometriosis. AREAS COVERED This review discusses both conventional and emerging treatments for endometriosis. The authors present the application of these drugs in different presentations of endometriosis across the lifespan and discuss how emerging therapies might fit into future medical management of endometriosis. Conventional therapies include nonsteroidal anti-inflammatory drugs, combined oral contraceptives, progestins, GnRH agonists/antagonists, and aromatase inhibitors. Emerging therapies are focused on disease-specific targets such as endothelial growth factor receptors. EXPERT OPINION The field of endometriosis therapy is moving toward modifying the immune and inflammatory milieu surrounding endometrial implants. If these drugs show efficacy in clinical trials, combining them with current medical treatment is expected to result in a profound impact on symptom and disease burden for patients who suffer from endometriosis worldwide.
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Affiliation(s)
- Kaia Schwartz
- Women's Health Institute, Cleveland Clinic Foundation , Cleveland, OH, United States
| | - Natalia C Llarena
- Women's Health Institute, Cleveland Clinic Foundation , Cleveland, OH, United States
| | - Jenna M Rehmer
- Women's Health Institute, Cleveland Clinic Foundation , Cleveland, OH, United States
| | - Elliott G Richards
- Women's Health Institute, Cleveland Clinic Foundation , Cleveland, OH, United States
| | - Tommaso Falcone
- Women's Health Institute, Division of Reproductive Endocrinology and Infertility, Cleveland Clinic Foundation , Cleveland, OH, United States
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21
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Barra F, Scala C, Leone Roberti Maggiore U, Ferrero S. Long-Term Administration of Dienogest for the Treatment of Pain and Intestinal Symptoms in Patients with Rectosigmoid Endometriosis. J Clin Med 2020; 9:jcm9010154. [PMID: 31935969 PMCID: PMC7019573 DOI: 10.3390/jcm9010154] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 12/28/2019] [Accepted: 01/05/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Rectosigmoid endometriosis is a severe form of deep endometriosis, which may be responsible for pain symptoms and a wide range of intestinal complains such as diarrhea, constipation, and abdominal cramping. The primary objective of this study was to evaluate the efficacy of long-term therapy with dienogest (DNG), a fourth-generation progestin, for ameliorating quality of life, pain, and intestinal symptoms of patients affected by rectosigmoid endometriosis. Methods: A retrospective analysis of a prospectively collected database was done on patients with endometriotic nodules infiltrating at least the muscular layer of the rectosigmoid wall with an estimated colorectal stenosis <60%. The diagnosis of rectosigmoid endometriosis was based on transvaginal ultrasonography. Patients accepting to participate in the study received continuous oral treatment with DNG at the dose of 2 mg/day. Results: At the end of the first year of treatment, a significant decrease in dysmenorrhea (P < 0.001), chronic pelvic pain (P < 0.001), dyspareunia (P < 0.001), dyschezia (P < 0.001), and in intestinal symptoms (P < 0.001) was observed. A progressive increase of the Endometriosis Health Profile-30 (EHP-30) and Gastrointestinal Quality of Life Index (GIQLI) scores was observed in the first two years of therapy (P < 0.001 and P < 0.001, respectively). Improvements of patients’ symptoms and quality of life were maintained until the end of the study. The regimen was well tolerated, and the frequency and amount of irregular bleeding decreased as treatment progressed. Conclusion: The current study confirms the efficacy of long-term therapy with DNG for treating symptoms caused by rectosigmoid endometriosis.
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Affiliation(s)
- Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132 Genoa, Italy;
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, 16132 Genoa, Italy
| | - Carolina Scala
- Unit of Obstetrics and Gynecology, Gaslini Institute, 16147 Genova, Italy;
| | | | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132 Genoa, Italy;
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, 16132 Genoa, Italy
- Piazza della Vittoria 14 S.r.l., 16121 Genova, Italy
- Correspondence: ; Tel.: +39-11-3477211682
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Barra F, Grandi G, Tantari M, Scala C, Facchinetti F, Ferrero S. A comprehensive review of hormonal and biological therapies for endometriosis: latest developments. Expert Opin Biol Ther 2019; 19:343-360. [DOI: 10.1080/14712598.2019.1581761] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Fabio Barra
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Giovanni Grandi
- Department of Obstetrics, Gynecology and Pediatrics, Obstetrics and Gynecology Unit, Azienda Ospedaliero-Universitaria Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - Matteo Tantari
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Carolina Scala
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Fabio Facchinetti
- Department of Obstetrics, Gynecology and Pediatrics, Obstetrics and Gynecology Unit, Azienda Ospedaliero-Universitaria Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
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Ferrero S, Evangelisti G, Barra F. Current and emerging treatment options for endometriosis. Expert Opin Pharmacother 2018; 19:1109-1125. [DOI: 10.1080/14656566.2018.1494154] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Giulio Evangelisti
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
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Barra F, Scala C, Mais V, Guerriero S, Ferrero S. Investigational drugs for the treatment of endometriosis, an update on recent developments. Expert Opin Investig Drugs 2018; 27:445-458. [PMID: 29708812 DOI: 10.1080/13543784.2018.1471135] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Endometriosis is a hormone-dependent benign chronic disease that requires a chronic medical therapy. Although currently available drugs are efficacious in treating endometriosis-related pain, some women experience partial or no improvement. Moreover, the recurrence of symptoms is expected after discontinuation of the therapies. Currently, new drugs are under intense clinical investigation for the treatment of endometriosis. AREAS COVERED This review aims to offer the reader a complete and updated overview on new investigational drugs and early molecular targets for the treatment of endometriosis. The authors describe the pre-clinical and clinical development of these agents. EXPERT OPINION Among the drugs under investigation, late clinical trials on gonadotropin-releasing hormone antagonists (GnRH-ant) showed the most promising results for the treatment of endometriosis. Aromatase inhibitors (AIs) are efficacious in treating endometriosis related pain symptoms but they cause significant adverse effects that limit their long-term use. New targets have been identified to produce drugs for the treatment of endometriosis, but the majority of these new compounds have only been investigated in laboratory studies or early clinical trials. Thus, further clinical research is required in order to elucidate their efficacy and safety in human.
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Affiliation(s)
- Fabio Barra
- a Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | - Carolina Scala
- a Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | - Valerio Mais
- c Department of Obstetrics and Gynecology , University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato , Cagliari , Italy
| | - Stefano Guerriero
- c Department of Obstetrics and Gynecology , University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato , Cagliari , Italy
| | - Simone Ferrero
- a Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
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Egekvist AG, Forman A, Riiskjaer M, Kesmodel US, Mathiasen M, Seyer-Hansen M. Intra- and interobserver variability in nodule size of rectosigmoid endometriosis measured by two- and three-dimensional transvaginal sonography. Acta Obstet Gynecol Scand 2018. [DOI: 10.1111/aogs.13343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Anne G. Egekvist
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
- Department of Obstetrics and Gynecology; Aarhus University Hospital; Aarhus Denmark
| | - Axel Forman
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
- Department of Obstetrics and Gynecology; Aarhus University Hospital; Aarhus Denmark
| | - Mads Riiskjaer
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
- Department of Obstetrics and Gynecology; Aarhus University Hospital; Aarhus Denmark
| | - Ulrik S. Kesmodel
- Department of Obstetrics and Gynecology; Herlev and Gentofte University Hospital; Herlev Denmark
- Institute for Clinical Medicine; University of Copenhagen; Copenhagen Denmark
| | - Mie Mathiasen
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
- Department of Obstetrics and Gynecology; Aarhus University Hospital; Aarhus Denmark
| | - Mikkel Seyer-Hansen
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
- Department of Obstetrics and Gynecology; Aarhus University Hospital; Aarhus Denmark
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Abstract
The management of chronic pelvic pain poses a significant challenge to both physicians and patients. Patients should be evaluated for both gynecologic and nongynecologic conditions, and >1 source may be identified. Treatment involves medical as well as surgical options, and it is important to set realistic goals with patients. Treatment may not be curative, but should improve the patient's quality of life.
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Geoffron S, Cohen J, Sauvan M, Legendre G, Wattier JM, Daraï E, Fernandez H, Chabbert-Buffet N. [Endometriosis medical treatment: Hormonal treatment for the management of pain and endometriotic lesions recurrence. CNGOF-HAS Endometriosis Guidelines]. ACTA ACUST UNITED AC 2018. [PMID: 29530557 DOI: 10.1016/j.gofs.2018.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The available literature, from 2006 to 2017, on hormonal treatment has been analysed as a contribution to the HAS-CNGOF task force for the treatment of endometriosis. Available data are heterogeneous and the general level of evidence is moderate. Hormonal treatment is usually offered as the primary option to women suffering from endometriosis. It cannot be used in women willing to conceive. In women who have not been operated, the first line of hormonal treatment includes combined oral contraceptives (COC) and the levonorgestrel-releasing intra uterine system (52mg LNG-IUS). As a second line, desogestrel progestin only pills, etonogestrel implants, GnRH analogs (GnRHa) with add back therapy and dienogest can be offered. Add back therapy should include estrogens to prevent bone loss and improve quality of life, it can be introduced before the third month of treatment to prevent side effects. The literature does not support preoperative hormonal treatment for the sole purpose of reducing complications or recurrence, or facilitating surgical procedures. After surgical treatment, hormonal treatment is recommended to prevent pain recurrence and improve quality of life. COCs or LNG IUS are recommended as a first line. To prevent recurrence of endometriomas COC is advised and maintained as long as tolerance is good in the absence of pregnancy plans. In case of dysmenorrhea, postoperative COC should be used in a continuous scheme. GnRHa are not recommended in the sole purpose of reducing endometrioma recurrence risk.
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Affiliation(s)
- S Geoffron
- Service de gynecologie-obstetrique et medecine de la reproduction, CHU de Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - J Cohen
- Service de gynecologie-obstetrique et medecine de la reproduction, CHU de Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France; GRC-6 Centre expert en endométriose (C3E), UMR-S938 Inserm, Sorbonne université, 75012 Paris, France
| | - M Sauvan
- Service de gynecologie-obstetrique, CHU de Bicêtre, AP-HP, 78, avenue du Général-de-Gaulle, 94275 Le Kremlin-Bicêtre, France
| | - G Legendre
- Service de gynecologie-obstétrique, CHU d'Angers, 4, rue Larrey, 49033 Angers cedex 01, France; CESP-INSERM, U1018, équipe 7, genre, sante sexuelle et reproductive, université Paris Sud, 94276 Le Kremlin-Bicêtre cedex, France
| | - J M Wattier
- Centre d'étude et traitement de la douleur, hôpital Claude-Huriez, CHRU de Lille, rue Michel-Polonowski, 59000 Lille, France
| | - E Daraï
- Service de gynecologie-obstetrique et medecine de la reproduction, CHU de Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France; GRC-6 Centre expert en endométriose (C3E), UMR-S938 Inserm, Sorbonne université, 75012 Paris, France
| | - H Fernandez
- Service de gynecologie-obstetrique, CHU de Bicêtre, AP-HP, 78, avenue du Général-de-Gaulle, 94275 Le Kremlin-Bicêtre, France; CESP-INSERM, U1018, équipe épidémiologie et évaluation des stratégies de prise en charge : VIH, reproduction, pédiatrie, université Paris Sud, 94800 Villejuif, France
| | - N Chabbert-Buffet
- Service de gynecologie-obstetrique et medecine de la reproduction, CHU de Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France; GRC-6 Centre expert en endométriose (C3E), UMR-S938 Inserm, Sorbonne université, 75012 Paris, France.
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Scala C, Leone Roberti Maggiore U, Barra F, Venturini P, Ferrero S. Norethindrone acetate versus extended-cycle oral contraceptive (Seasonique ® ) in the treatment of endometriosis symptoms: A prospective open-label comparative study. Eur J Obstet Gynecol Reprod Biol 2018; 222:89-94. [DOI: 10.1016/j.ejogrb.2018.01.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 12/29/2017] [Accepted: 01/16/2018] [Indexed: 12/01/2022]
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Role of medical therapy in the management of deep rectovaginal endometriosis. Fertil Steril 2017; 108:913-930. [DOI: 10.1016/j.fertnstert.2017.08.038] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/29/2017] [Accepted: 08/30/2017] [Indexed: 12/17/2022]
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Geoffron S, Legendre G, Daraï E, Chabbert-Buffet N. [Medical treatment of endometriosis: Hormonal treatment of pain, impact on evolution and future perspectives]. Presse Med 2017; 46:1199-1211. [PMID: 29133081 DOI: 10.1016/j.lpm.2017.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 10/03/2017] [Accepted: 10/03/2017] [Indexed: 11/30/2022] Open
Abstract
CONTEXT Endometriosis is a chronic painful disease, for which hormone therapy is usually offered as a first line option to women not willing to conceive. OBJECTIVES To analyse and synthesize the literature, from 2006 onwards, on pain control, and disease evolution in oemn using combined hormonal contraceptives, progestins and GnRH analogs. Data on other current and future treatment perspectives is included as well. SOURCES Medline (Pubmed), the Cochrane Library, and endometriosis treatment recommendations published by European Society of Human Reproduction and Embryology (ESHRE), National Institute for health and Care Excellence (NICE), American College of Obstetricians and Gynecologists (ACOG), Royal College of Obstetricians and Gynaecologists (RCOG) and Société des Obstétriciens et Gynécologues du Canada (SOGC). STUDY SELECTION Meta-analysis and clinical trials are included. RESULTS Study quality is heterogeneous in general. Hormone therapy inconstantly allows pain relief and prevention of endometrioma and rectovaginal wall nodules recurrence. Available molecules and routes of administration as well as risk benefit balance are evaluated. Data on future perspectives are limited to date and do not allow use in routine. CONCLUSION Hormonal treatment of endometriosis relies on combined hormonal contraceptives (using different routes of administration), progestins and particularly the levonorgestrel-releasing IUS, and GnRH analogs as a last option, in combination with an add-back therapy. Promising alternatives are currently under preclinical and clinical evaluation.
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Affiliation(s)
- Sophie Geoffron
- AP-HP, université Pierre-et-Marie-Curie Paris 6, hôpital Tenon, service de gynécologie-obstétrique, médecine de la reproduction, 75020 Paris, France
| | - Guillaume Legendre
- CHU d'Angers, service de gynécologie-obstétrique, 49000 Angers, France; Université Paris Sud, CESP-Inserm, U1018, équipe 7, genre, santé sexuelle et reproductive, 75000 Paris, France
| | - Emile Daraï
- AP-HP, université Pierre-et-Marie-Curie Paris 6, hôpital Tenon, service de gynécologie-obstétrique, médecine de la reproduction, 75020 Paris, France; AP-HP, hôpital Tenon, centre expert en endométriose (C3E), 75020 Paris, France; UPMC, groupe de recherche clinique GRC-6, 75020 Paris, France
| | - Nathalie Chabbert-Buffet
- AP-HP, université Pierre-et-Marie-Curie Paris 6, hôpital Tenon, service de gynécologie-obstétrique, médecine de la reproduction, 75020 Paris, France; AP-HP, hôpital Tenon, centre expert en endométriose (C3E), 75020 Paris, France; UPMC, groupe de recherche clinique GRC-6, 75020 Paris, France.
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Efficacy and acceptability of long-term norethindrone acetate for the treatment of rectovaginal endometriosis. Eur J Obstet Gynecol Reprod Biol 2017; 213:4-10. [DOI: 10.1016/j.ejogrb.2017.03.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/05/2017] [Accepted: 03/25/2017] [Indexed: 01/01/2023]
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Leone Roberti Maggiore U, Ferrero S, Candiani M, Somigliana E, Viganò P, Vercellini P. Bladder Endometriosis: A Systematic Review of Pathogenesis, Diagnosis, Treatment, Impact on Fertility, and Risk of Malignant Transformation. Eur Urol 2016; 71:790-807. [PMID: 28040358 DOI: 10.1016/j.eururo.2016.12.015] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/15/2016] [Indexed: 02/03/2023]
Abstract
CONTEXT The bladder is the most common site affected in urinary tract endometriosis. There is controversy regarding the pathogenesis, clinical management (diagnosis and treatment), impact on fertility, and risk of malignant transformation of bladder endometriosis (BE). OBJECTIVE To systematically evaluate evidence regarding the pathogenesis, diagnosis, medical and surgical treatment, impact on female fertility, and risk of malignant transformation of BE. EVIDENCE ACQUISITION A systematic review of PubMed/Medline from inception until October 2016 was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and was registered in the PROSPERO registry (www.crd.york.ac.uk/prospero; CRD42016039281). Eighty-seven articles were selected for inclusion in this analysis. EVIDENCE SYNTHESIS BE is defined as the presence of endometrial glands and stroma in the detrusor muscle. Ultrasonography is the first-line technique for assessment of BE owing to its accuracy, safety, and cost. Clinical management can be conservative, using hormonal therapies, or surgical. When conservative treatment is preferred, estrogen-progestogen combinations and progestogens should be chosen because of their favorable profile that allows long-term therapy. Surgery should guarantee complete removal of the bladder nodule to minimize recurrence, so transurethral surgery alone should be avoided in favor of segmental bladder resection. There is not a strong rationale for hypothesizing a detrimental impact of BE per se on fertility. Furthermore, current evidence does not support the removal of bladder endometriotic lesions because of the potential risk of malignant transformation since this phenomenon is exceedingly rare. CONCLUSIONS BE is a challenging condition, and the common coexistence of other types of endometriosis means that clinical management of BE should involve collaboration between gynecologists and urologists. PATIENT SUMMARY In this article we review available knowledge on bladder endometriosis. The review provides a useful tool to guide physicians in the management of this complex condition.
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Affiliation(s)
- Umberto Leone Roberti Maggiore
- Academic Unit of Obstetrics and Gynecology, IRCCS AOU San Martino, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS AOU San Martino, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.
| | - Massimo Candiani
- Department of Obstetrics and Gynecology, Vita Salute San Raffaele University School of Medicine, IRCCS, Ospedale San Raffaele, Milan, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano and Department of Obstet-Gynecol, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Viganò
- Reproductive Sciences Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano and Department of Obstet-Gynecol, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Estrogen-progestins and progestins for the management of endometriosis. Fertil Steril 2016; 106:1552-1571.e2. [DOI: 10.1016/j.fertnstert.2016.10.022] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/10/2016] [Accepted: 10/12/2016] [Indexed: 02/08/2023]
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Ferrero S, Alessandri F, Racca A, Leone Roberti Maggiore U. Treatment of pain associated with deep endometriosis: alternatives and evidence. Fertil Steril 2015; 104:771-792. [DOI: 10.1016/j.fertnstert.2015.08.031] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 08/24/2015] [Accepted: 08/25/2015] [Indexed: 02/07/2023]
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Tafi E, Leone Roberti Maggiore U, Alessandri F, Bogliolo S, Gardella B, Vellone VG, Grillo F, Mastracci L, Ferrero S. Advances in pharmacotherapy for treating endometriosis. Expert Opin Pharmacother 2015; 16:2465-83. [PMID: 26569155 DOI: 10.1517/14656566.2015.1085510] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Leone Roberti Maggiore U, Salvatore S, Candiani M, Ferrero S. Evaluation of Symptoms and Methodology of the Urodynamic Study Matter. J Minim Invasive Gynecol 2015; 22:701-2. [DOI: 10.1016/j.jmig.2015.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 02/04/2015] [Indexed: 11/17/2022]
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Alabiso G, Alio L, Arena S, di Prun AB, Bergamini V, Berlanda N, Busacca M, Candiani M, Centini G, Di Cello A, Exacoustos C, Fedele L, Gabbi L, Geraci E, Lavarini E, Incandela D, Lazzeri L, Luisi S, Maiorana A, Maneschi F, Mattei A, Muzii L, Pagliardini L, Perandini A, Perelli F, Pinzauti S, Remorgida V, Sanchez AM, Seracchioli R, Somigliana E, Tosti C, Venturella R, Vercellini P, Viganò P, Vignali M, Zullo F, Zupi E. How to Manage Bowel Endometriosis: The ETIC Approach. J Minim Invasive Gynecol 2015; 22:517-29. [PMID: 25678420 DOI: 10.1016/j.jmig.2015.01.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/07/2015] [Accepted: 01/08/2015] [Indexed: 01/07/2023]
Abstract
A panel of experts in the field of endometriosis expressed their opinions on management options in a 35-year-old patient desiring pregnancy with a history of previous surgery for endometrioma and bowel obstruction symptoms. Many questions that this paradigmatic patient may pose to the clinician are addressed, and various clinical scenarios are discussed. A decision algorithm derived from this discussion is proposed as well.
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Affiliation(s)
- Giulia Alabiso
- Department of Obstetrics and Gynecology, Macedonio Melloni Hospital, University of Milan, Milan, Italy
| | - Luigi Alio
- Department of Obstetrics and Gynecology, Civico Hospital, Palermo, Italy
| | - Saverio Arena
- Department of Obstetrics and Gynecology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | | | - Valentino Bergamini
- Department of Obstetrics and Gynecology, University of Verona, Verona, Italy
| | - Nicola Berlanda
- Department of Obstetrics and Gynecology, Isituto Luigi Mangiagalli, University of Milan, Milan, Italy
| | - Mauro Busacca
- Department of Obstetrics and Gynecology, Macedonio Melloni Hospital, University of Milan, Milan, Italy
| | - Massimo Candiani
- Department of Obstetrics and Gynecology, San Raffaele Hospital, University of Milan, Milan, Italy
| | - Gabriele Centini
- Department of Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Annalisa Di Cello
- Department of Obstetrics and Gynecology, University of Magna Graecia, Catanzaro, Italy
| | | | - Luigi Fedele
- Department of Obstetrics and Gynecology, Isituto Luigi Mangiagalli, University of Milan, Milan, Italy
| | - Laura Gabbi
- Department of Obstetrics and Gynecology, University of Genova, Genova, Italy
| | - Elisa Geraci
- Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy
| | - Elena Lavarini
- Department of Obstetrics and Gynecology, University of Verona, Verona, Italy
| | - Domenico Incandela
- Department of Obstetrics and Gynecology, Civico Hospital, Palermo, Italy
| | - Lucia Lazzeri
- Department of Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Stefano Luisi
- Department of Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Antonio Maiorana
- Department of Obstetrics and Gynecology, Civico Hospital, Palermo, Italy
| | - Francesco Maneschi
- Department of Obstetrics and Gynecology, Santa Maria Goretti Hospital, Latina, Italy
| | - Alberto Mattei
- Department of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | - Ludovico Muzii
- Department of Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy
| | - Luca Pagliardini
- Department of Obstetrics and Gynecology, San Raffaele Hospital, University of Milan, Milan, Italy
| | - Alessio Perandini
- Department of Obstetrics and Gynecology, University of Verona, Verona, Italy
| | - Federica Perelli
- Department of Obstetrics and Gynecology, University of Florence, Florence, Italy
| | - Serena Pinzauti
- Department of Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Valentino Remorgida
- Department of Obstetrics and Gynecology, University of Genova, Genova, Italy
| | - Ana Maria Sanchez
- Department of Obstetrics and Gynecology, San Raffaele Hospital, University of Milan, Milan, Italy
| | - Renato Seracchioli
- Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy
| | - Edgardo Somigliana
- Infertility Unit, Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudia Tosti
- Department of Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Roberta Venturella
- Department of Obstetrics and Gynecology, University of Magna Graecia, Catanzaro, Italy
| | - Paolo Vercellini
- Department of Obstetrics and Gynecology, Isituto Luigi Mangiagalli, University of Milan, Milan, Italy
| | - Paola Viganò
- Department of Obstetrics and Gynecology, San Raffaele Hospital, University of Milan, Milan, Italy
| | - Michele Vignali
- Department of Obstetrics and Gynecology, Macedonio Melloni Hospital, University of Milan, Milan, Italy
| | - Fulvio Zullo
- Department of Obstetrics and Gynecology, University of Magna Graecia, Catanzaro, Italy
| | - Errico Zupi
- Department of Obstetrics and Gynecology, University of Siena, Siena, Italy.
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Leone Roberti Maggiore U, Scala C, Remorgida V, Venturini PL, Del Deo F, Torella M, Colacurci N, Salvatore S, Ferrari S, Papaleo E, Candiani M, Ferrero S. Triptorelin for the treatment of endometriosis. Expert Opin Pharmacother 2014; 15:1153-79. [PMID: 24832495 DOI: 10.1517/14656566.2014.916279] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Over the past 30 years, gonadotropin-releasing hormone agonists (GnRH-a) have been used to induce a hypoestrogenic status in women with endometriosis with the aim to cause an improvement in pain symptoms similar to that observed after menopause. Triptorelin is one of the most commonly used GnRH-a. AREAS COVERED This review offers an explanation of the mechanism of action, of the pharmacokinetics and pharmacodynamics of triptorelin and gives the readers a complete overview of the studies on the clinical efficacy, tolerability and safety of this agent in patients with endometriosis. EXPERT OPINION The studies reviewed in the current manuscript demonstrate the efficacy of triptorelin in improving pain symptoms caused by endometriosis. Further, this effect is confirmed by the reduction in the volume of the endometriotic nodules during treatment. Future research should evaluate whether the pre-operative administration of triptorelin prior to surgical excision of endometriomas may be useful in preserving the ovarian reserve.
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Affiliation(s)
- Umberto Leone Roberti Maggiore
- IRRCS San Raffaele Hospital and Vita-Salute San Raffaele University, Department of Obstetrics and Gynaecology , Via Olgettina 58-60, 20132, Milan , Italy
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Bizzarri N, Remorgida V, Leone Roberti Maggiore U, Scala C, Tafi E, Ghirardi V, Salvatore S, Candiani M, Venturini PL, Ferrero S. Dienogest in the treatment of endometriosis. Expert Opin Pharmacother 2014; 15:1889-902. [DOI: 10.1517/14656566.2014.943734] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ferrero S, Remorgida V, Maganza C, Venturini PL, Salvatore S, Papaleo E, Candiani M, Leone Roberti Maggiore U. Aromatase and endometriosis: estrogens play a role. Ann N Y Acad Sci 2014; 1317:17-23. [DOI: 10.1111/nyas.12411] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Simone Ferrero
- Department of Obstetrics and Gynecology; San Martino Hospital and National Institute for Cancer Research; University of Genoa; Genoa Italy
| | - Valentino Remorgida
- Department of Obstetrics and Gynecology; San Martino Hospital and National Institute for Cancer Research; University of Genoa; Genoa Italy
| | - Carlo Maganza
- Department of Obstetrics and Gynecology; San Martino Hospital and National Institute for Cancer Research; University of Genoa; Genoa Italy
| | - Pier Luigi Venturini
- Department of Obstetrics and Gynecology; San Martino Hospital and National Institute for Cancer Research; University of Genoa; Genoa Italy
| | - Stefano Salvatore
- IRCCS San Raffaele Hospital and Vita-Salute; San Raffaele University Hospital; Department of Obstetrics and Gynecology; Milan Italy
| | - Enrico Papaleo
- IRCCS San Raffaele Hospital and Vita-Salute; San Raffaele University Hospital; Department of Obstetrics and Gynecology; Milan Italy
| | - Massimo Candiani
- IRCCS San Raffaele Hospital and Vita-Salute; San Raffaele University Hospital; Department of Obstetrics and Gynecology; Milan Italy
| | - Umberto Leone Roberti Maggiore
- IRCCS San Raffaele Hospital and Vita-Salute; San Raffaele University Hospital; Department of Obstetrics and Gynecology; Milan Italy
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Ferrero S, Remorgida V, Venturini PL, Leone Roberti Maggiore U. Norethisterone acetate versus norethisterone acetate combined with letrozole for the treatment of ovarian endometriotic cysts: a patient preference study. Eur J Obstet Gynecol Reprod Biol 2014; 174:117-22. [DOI: 10.1016/j.ejogrb.2013.11.030] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 11/12/2013] [Accepted: 11/30/2013] [Indexed: 11/28/2022]
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Leone Roberti Maggiore U, Remorgida V, Scala C, Tafi E, Venturini PL, Ferrero S. Desogestrel-only contraceptive pill versus sequential contraceptive vaginal ring in the treatment of rectovaginal endometriosis infiltrating the rectum: a prospective open-label comparative study. Acta Obstet Gynecol Scand 2014; 93:239-47. [DOI: 10.1111/aogs.12326] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 12/19/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Umberto Leone Roberti Maggiore
- Department of Obstetrics and Gynecology; San Martino Hospital and National Institute for Cancer Research; University of Genoa; Genoa Italy
| | - Valentino Remorgida
- Department of Obstetrics and Gynecology; San Martino Hospital and National Institute for Cancer Research; University of Genoa; Genoa Italy
| | - Carolina Scala
- Department of Obstetrics and Gynecology; San Martino Hospital and National Institute for Cancer Research; University of Genoa; Genoa Italy
| | - Emanuela Tafi
- Department of Obstetrics and Gynecology; San Martino Hospital and National Institute for Cancer Research; University of Genoa; Genoa Italy
| | - Pier L. Venturini
- Department of Obstetrics and Gynecology; San Martino Hospital and National Institute for Cancer Research; University of Genoa; Genoa Italy
| | - Simone Ferrero
- Department of Obstetrics and Gynecology; San Martino Hospital and National Institute for Cancer Research; University of Genoa; Genoa Italy
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Ferrero S, Venturini PL, Gillott DJ, Remorgida V. Letrozole and norethisterone acetate versus letrozole and triptorelin in the treatment of endometriosis related pain symptoms: a randomized controlled trial. Reprod Biol Endocrinol 2011; 9:88. [PMID: 21693037 PMCID: PMC3141645 DOI: 10.1186/1477-7827-9-88] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2010] [Accepted: 06/21/2011] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND When aromatase inhibitors are used to treat premenopausal women with endometriosis, additional drugs should be used to effectively down-regulate gonadal estrogen biosynthesis. This randomized prospective open-label study compared the efficacy in treating pain symptoms and the tolerability of letrozole combined with either norethisterone acetate or triptorelin. METHODS Women with pain symptoms caused by rectovaginal endometriosis were treated with letrozole (2.5 mg/day) and were randomized to also receive either oral norethisterone acetate (2.5 mg/day; group N) or intramuscular injection of triptorelin (11.25 mg every 3 months; group T). The scheduled length of treatment was 6 months. A visual analogue scale and a multidimensional categorical rating scale were used to assess the severity of pain symptoms. The volume of the endometriotic nodules was estimated by ultrasonography using virtual organ computer-aided analysis. Adverse effects of treatment were recorded. RESULTS A total of 35 women were randomized between the two treatment protocols. Significantly more patients in group N rated their treatment as satisfactory or very satisfactory (64.7%) as compared to group T (22.2%; p=0.028). The intensity of both non-menstrual pelvic pain and deep dyspareunia significantly decreased during treatment in both study groups, though no statistically meaningful difference between the two groups was apparent. Reduction in the volume of endometriotic nodules was significantly greater in group T than in group N. Interruption of treatment due to adverse effects significantly differed between the groups, with 8 women in group T (44.4%) and 1 woman in group N (5.9%) interrupting treatment (p=0.018). Similarly, 14 women included in group T (77.8%) and 6 women included in group N (35.3%) experienced adverse effects of treatment (p=0.018). During treatment, mineral bone density significantly decreased in group T but not in group N. CONCLUSIONS Aromatase inhibitors reduce the intensity of endometriosis-related pain symptoms. Combining letrozole with oral norethisterone acetate was associated with a lower incidence of adverse effects and a lower discontinuation rate than combining letrozole with triptorelin.
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Affiliation(s)
- Simone Ferrero
- Department of Obstetrics and Gynaecology, San Martino Hospital and University of Genoa, Italy
- St. Bartholomew's School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Pier L Venturini
- Department of Obstetrics and Gynaecology, San Martino Hospital and University of Genoa, Italy
| | - David J Gillott
- St. Bartholomew's School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Valentino Remorgida
- Department of Obstetrics and Gynaecology, San Martino Hospital and University of Genoa, Italy
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