Recurrent endometriosis: incidence, management, and prognosis

Outcomes of laparoscopic management of chronic pelvic pain and endometriosis

This study was designed to determine the rates of reoperation following laparoscopic management of endometriosis, with additional aims to examine long-term fertility and quality of life outcomes. This is a retrospective study and a prospective questionnaire of subjects who underwent laparoscopic surgery for pelvic pain and/or endometriosis from 2010 to 2015. The rate of reoperation was 8.60%. Following surgery, 83.3% of previously infertile subjects with endometriosis attempted to conceive with an 80.0% success rate. Subjects had significant improvement in each quality of life measurement and most sexual function indices analysed.Impact StatementWhat is already known on this subject? Endometriosis is estimated to affect around 35-50% of women experiencing chronic pelvic pain and/or infertility. Surgical management of endometriosis is recommended for patients who desire fertility, are afflicted by a more severe form of endometriosis, or have had persistent or recurrent pain in spite of medical management.What the results of this study add? The overall rate of reoperation for subjects was low at 8.6%. The majority of infertile patients were able to conceive following surgery.What the implications are of these findings for clinical practice and/or further research? Laparoscopic management of endometriosis is an effective management tool with low rates of reoperation and high efficacy in treating infertility caused by endometriosis.

The role of gut and genital microbiota and the estrobolome in endometriosis, infertility and chronic pelvic pain

BACKGROUND

Endometriosis is a chronic, burdensome condition that is historically understudied. Consequently, there is a lack of understanding of the etiology of the disease and its associated symptoms, including infertility and chronic pelvic pain (CPP). Endometriosis development is influenced by estrogen metabolism and inflammation, which are modulated by several factors including the microbiome and the estrobolome (the collection of genes encoding estrogen-metabolizing enzymes in the gut microbiome). Therefore, there is increasing interest in understanding the role of microbiota in endometriosis etiology.

OBJECTIVE AND RATIONALE

To date, there is no cure for endometriosis and treatment options often are ineffective. This manuscript will review the potential relationship between the microbiome and endometriosis, infertility and CPP and highlight the available data on the microbiome in relation to endometriosis and its related symptoms. The overarching goal of this manuscript is to inform future microbiome research that will lead to a deeper understanding of the etiology of the disease and possible diagnostic modalities and treatments. The potential impact of the microbiome on estrogen regulation modulated by the estrobolome, as well as inflammation and other endometriosis-promoting mechanisms within the genital tract, will be reviewed. The methodological limitations of microbiome-related studies will be critically assessed to provide improved guidelines for future microbiome and clinical studies.

SEARCH METHODS

PubMed databases were searched using the following keywords: endometriosis AND microbiome, infertility AND microbiome, pelvic pain AND microbiome, IVF (in-vitro fertilization) AND microbiome, endometriosis AND infertility. Clinical and preclinical animal trials that were eligible for review, and related to microbiome and endometriosis, infertility or CPP were included. All available manuscripts were published in 2002-2021.

OUTCOMES

In total, 28 clinical and 6 animal studies were included in the review. In both human and animal studies, bacteria were enriched in endometriosis groups, although there was no clear consensus on specific microbiota compositions that were associated with endometriosis, and no studies included infertility or CPP with endometriosis. However, bacterial vaginosis-associated bacteria and Lactobacillus depletion in the cervicovaginal microbiome were associated with endometriosis and infertility in the majority (23/28) of studies. Interpretation of endometrial studies is limited owing to a variety of methodological factors, discussed in this review. In addition, metadata outlining antibiotic usage, age, race/ethnicity, menopausal status and timing of sample collection in relation to diagnosis of endometriosis was not consistently reported. Animal studies (6/6) support a bidirectional relationship between the gut microbiota and endometriosis onset and progression.

WIDER IMPLICATIONS

There is evidence that a dysbiotic gut or genital microbiota is associated with multiple gynecologic conditions, with mounting data supporting an association between the microbiome and endometriosis and infertility. These microbiomes likely play a role in the gut-brain axis, which further supports a putative association with the spectrum of symptoms associated with endometriosis, including infertility and CPP. Collectively, this review highlights the demand for more rigorous and transparent methodology and controls, consistency across the field, and inclusion of key demographic and clinical characteristics of disease and comparison participants. Rigorous study designs will allow for a better understanding of the potential role of the microbiome in endometriosis etiology and the relationship to other disorders of the female reproductive tract.

Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis

BACKGROUND

Although surgery for endometriosis can improve pain and fertility, the risk of disease recurrence is high. There is little consensus regarding the benefit of medical therapy in preventing recurrence of endometriosis following surgery.

OBJECTIVE AND RATIONALE

We performed a review of prospective observational studies and randomised controlled trials (RCTs) to evaluate the risk of endometriosis recurrence in patients undergoing post-operative hormonal suppression, compared to placebo/expectant management.

SEARCH METHODS

The following databases were searched from inception to March 2020 for RCTs and prospective observational cohort studies: MEDLINE, Embase, Cochrane CENTRAL and Web of Science. We included English language full-text articles of pre-menopausal women undergoing conservative surgery (conserving at least one ovary) and initiating hormonal suppression within 6 weeks post-operatively with either combined hormonal contraceptives (CHC), progestins, androgens, levonorgesterel-releasing intra-uterine system (LNG-IUS) or GnRH agonist or antagonist. We excluded from the final analysis studies with <12 months of follow-up, interventions of diagnostic laparoscopy, experimental/non-hormonal treatments or combined hormonal therapy. Risk of bias was assessed using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale (NOS) for observational studies.

OUTCOMES

We included 17 studies (13 RCTs and 4 cohort studies), with 2137 patients (1189 receiving post-operative suppression and 948 controls), which evaluated various agents: CHC (6 studies, n = 869), progestin (3 studies, n = 183), LNG-IUS (2 studies, n = 94) and GnRH agonist (9 studies, n = 1237). The primary outcome was post-operative endometriosis recurrence, determined by imaging or recurrence of symptoms, at least 12 months post-operatively. The secondary outcome was change in endometriosis-related pain. Mean follow up of included studies ranged from 12 to 36 months, and outcomes were assessed at a median of 18 months. There was a significantly decreased risk of endometriosis recurrence in patients receiving post-operative hormonal suppression compared to expectant management/placebo (relative risk (RR) 0.41, 95% CI: 0.26 to 0.65), 14 studies, 1766 patients, I² = 68%, random effects model). Subgroup analysis on patients treated with CHC and LNG-IUS as well as sensitivity analyses limited to RCTs and high-quality studies showed a consistent decreased risk of endometriosis recurrence. Additionally, the patients receiving post-operative hormonal suppression had significantly lower pain scores compared to controls (SMD −0.49, 95% CI: −0.91 to −0.07, 7 studies, 652 patients, I² = 68%).

WIDER IMPLICATIONS

Hormonal suppression should be considered for patients not seeking pregnancy immediately after endometriosis surgery in order to reduce disease recurrence and pain. Various hormonal agents have been shown to be effective, and the exact treatment choice should be individualised according to each woman’s needs.

No. 109-Hysterectomy

OBJECTIVE

To identify the indications for hysterectomy, preoperative assessment, and available alternatives required prior to hysterectomy. Patient self-reported outcomes of hysterectomy have revealed high levels of patient satisfaction. These may be maximized by careful preoperative assessment and discussion of other treatment choices. In most cases hysterectomy is performed to relieve symptoms and improve quality of life. The patient's preference regarding treatment alternatives must be considered carefully.

OPTIONS

The areas of clinical practice considered in formulating this guideline are preoperative assessment including alternative treatments, choice of method for hysterectomy, and evaluation of risks and benefits. The risk-to-benefit ratio must be examined individually by the woman and her health practitioners.

OUTCOMES

Optimizing the decision-making process of women and their caregivers in proceeding with a hysterectomy having considered the disease process, and available alternative treatments and options, and having reviewed the risks and anticipated benefits.

EVIDENCE

Using Medline, PubMed, and the Cochrane Database, English language articles were reviewed from 1996 to 2001 as well as the review published in the 1996 SOGC guidelines. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination.

BENEFITS, HARMS, AND COSTS

Hysterectomy is the treatment of choice for certain gynaecologic conditions. The predicted advantages must be carefully weighed against the possible risks of the surgery and other treatment alternatives. In the properly selected patient, the result from the surgery should be an improvement in the quality of life. The cost of the surgery to the health care system and to the patient must be interpreted in the context of the cost of untreated conditions. The approach selected for the hysterectomy will impact on the cost of the surgery.

RECOMMENDATIONS

Benign Disease Preinvasive Disease Invasive Disease Acute Conditions Other Indications Surgical Approach VALIDATION: Medline searches were performed in preparing this guideline with input from experts in their field across Canada. The guideline was reviewed and accepted by SOGC Council and Executive.

SPONSOR

The Society of Obstetricians and Gynaecologists of Canada.

[Effect of GnRHa therapy following conservative laparoscopic surgery for endometriosis on clinical pregnant rate in patients with endometriosis-associated infertility]

OBJECTIVE

To investigate the impact of conservative laparoscopic surgery for endometriosis with postoperative gonadotropin-releasing hormone agonist (GnRHa) therapy on the pregnancy outcomes in patients with endometriosis-associated infertility.

METHODS

The clinical data were collected from the patients with endometriosis-associated infertility undergoing conservative laparoscopic surgery in our department between January, 2011 and December, 2016. The patients were divided into laparoscopic surgery only group (without any other treatments) and postoperative GnRha therapy group, and the pregnancy outcomes were compared between the two groups at different time points during the follow-up.

RESULTS

In cases with moderate or severe endometriosis, laparoscopic surgery with postoperative GnRha therapy was associated with a significantly higher clinical pregnancy rate than laparoscopic surgery alone (P<0.05). In patients receiving postoperative GnRha therapy, the accumulative pregnancy rates at 6, 12, 24 and 36 months after discontinuation of GnRha therapy were significantly higher than those in patients receiving laparoscopic surgery alone. The pregnancy rate following IVF-ET cycles was significantly higher than the spontaneous pregnancy rate in patients receiving conservative laparoscopic surgery alone (P<0.05), while such a difference was not found in patients with postoperative GnRHa therapy (P>0.05).

CONCLUSIONS

GnRHa therapy after conservative laparoscopic surgery can significantly increase the clinical pregnancy rate in infertile 6 months women with moderate or severe endometriosis but not in mild cases. Within 6 months following laparoscopic surgery or following discontinuation of GnRHa therapy is the optimal time window for pregnancy, and a longer time from therapy discontinuation is associated with a lower possibility of spontaneous pregnancy.

Surgical outcomes of laparoscopic endometriosis surgery: a 6 year experience

OBJECTIVES

The aim of the present study was to review 6 year experience on the surgical outcomes of laparoscopic endometriosis surgery.

METHODS

A cohort study was performed in Shiraz University of Medical Sciences using data from medical records of 1315 cases of patients with endometriosis undergoing laparoscopic surgery with follow-up of 6 to 72 months.

RESULTS

This study concerned a cohort of 1315 patients diagnosed with endometriosis operated between April 2010 and April 2016, 1086 (82.5%) of whom were in stage III and IV; 968 (73.61%) had endometrioma (regardless of having deep infiltrative endometriosis [DIE] or peritoneal involvement) and 347 (26.39%) of patients had either DIE or peritoneal involvement without endometrioma. Regarding the patients, unilateral endometrioma was statistically significant in the left ovary (p = .002). One hundred and thirty-three (10.7%) rectal wall, 7 (0.32%) sigmoid colon, 4 (0.18%) vagina, 125 (5.6%) ureter and 33 (1.52) bladder involvements were detected. Prior to operation, the pain VAS score was 8.23 ± 2.03, which decreased to 4.46 ± 2.47 in 93.07% of patients. Fifty-three patients (6.56%) needed reoperation. Sixty-six (33.1%) infertile women had spontaneous pregnancy and 15 (25%) became pregnant using intrauterine insemination (IUI) or assisted reproductive technique (ART) post-operatively.

CONCLUSION

Surgical treatment of endometriosis seems to be an effective treatment. DIE can be present in the absence of endometrioma. The rate of left endometrioma is higher due to the pressure effect of the sigmoid colon. Nonetheless, if an expert surgeon performs this procedure, not only the rate of post-operative complications, but also the possibility of recurrence would decrease.

A randomized study comparing the side effects and hormonal status of triptorelin and leuprorelin following conservative laparoscopic surgery for ovarian endometriosis in Chinese women

OBJECTIVES

Different gonadotropin-releasing-hormone agonist (GnRH-a) formulations with different potency and associated side effects, therefore, different compliance and persistence of therapy. This study was to evaluate the difference of hormonal profile and side effects due to hypoestrogenic status after treatment of leuprorelin and triptorelin in Chinese women with ovarian endometrioma after conservative surgical treatment.

STUDY DESIGN

A total of 302 women underwent laparoscopic excision of ovarian endometriomas with rASRM III and IV were enrolled in the study.Subjects were randomized into two groups with use of a random table. Twenty two patients dropped out during the study. Thus 142 patients had three doses of i.m. leuprorelin (group A) and 138 patients had three doses of i.m. triptorelin(group B) at 4 weeks intervals after surgical treatment. Menopausal symptoms were evalutaed using a questionnaire and serum sex hormonal levels were also measured during the follow-up.

RESULTS

At week 4 after the treatment, most of the patients in leuprorelin group have no obvious side effects. After 9 weeks, bone pain, hot flashes and sweating, and irregular bleeding were the main side effects and showed no difference between the groups. Anxiety, depression, vaginal dryness, headache, and acne rates were all significantly higher in triptorelin group than in leuprorelin group. A significant difference in FSH (p=0.003), LH (p=0.026) and E2 (p=0.002) levels between the groups were observed after 21 days of the GnRHa treatment. The FSH (p=0.021) and E2 (p=0.033) levels remained higher in the leuprorelin group than the triptorelin group after six weeks of treatment, but the difference of LH(p=0.917) level was no longer discernible.

CONCLUSION

Leuprorelin in down-regulating the pituitary-ovarian function was more moderate, and the hormonal levels decrease progressively and gradually, therefore, with lower rate of menopausal symptoms. Leuprorelin acetate maybe better tolerated than triptorelin.

ERβ- and prostaglandin E2-regulated pathways integrate cell proliferation via Ras-like and estrogen-regulated growth inhibitor in endometriosis

In endometriosis, stromal and epithelial cells from the endometrium form extrauterine lesions and persist in response to estrogen (E2) and prostaglandin E2 (PGE2). Stromal cells produce excessive quantities of estrogen and PGE2 in a feed-forward manner. However, it is unknown how estrogen stimulates cell proliferation and survival for the establishment and persistence of disease. Previous studies suggest that estrogen receptor-β (ERβ) is strikingly overexpressed in endometriotic stromal cells. Thus, we integrated genome-wide ERβ binding data from previously published studies in breast cells and gene expression profiles in human endometriosis and endometrial tissues (total sample number = 81) and identified Ras-like, estrogen-regulated, growth inhibitor (RERG) as an ERβ target. Estradiol potently induced RERG mRNA and protein levels in primary endometriotic stromal cells. Chromatin immunoprecipitation demonstrated E2-induced enrichment of ERβ at the RERG promoter region. PGE2 via protein kinase A phosphorylated RERG and enhanced the nuclear translocation of RERG. RERG induced the proliferation of primary endometriotic cells. Overall, we demonstrated that E2/ERβ and PGE2 integrate at RERG, leading to increased endometriotic cell proliferation and represents a novel candidate for therapeutic intervention.

Chinese herbal medicine for endometriosis

BACKGROUND

Endometriosis is characterized by the presence of tissue that is morphologically and biologically similar to normal endometrium in locations outside the uterus. Surgical and hormonal treatment of endometriosis have unpleasant side effects and high rates of relapse. In China, treatment of endometriosis using Chinese herbal medicine (CHM) is routine and considerable research into the role of CHM in alleviating pain, promoting fertility, and preventing relapse has taken place.This review is an update of a previous review published in the Cochrane Database of Systematic Reviews 2009, issue No 3.

OBJECTIVES

To review the effectiveness and safety of CHM in alleviating endometriosis-related pain and infertility.

SEARCH METHODS

We searched the Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library) and the following English language electronic databases (from their inception to 31/10/2011): MEDLINE, EMBASE, AMED, CINAHL, and NLH.We also searched Chinese language electronic databases: Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Chinese Sci & Tech Journals (VIP), Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), and Chinese Medical Current Contents (CMCC).

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving CHM versus placebo, biomedical treatment, another CHM intervention; or CHM plus biomedical treatment versus biomedical treatment were selected. Only trials with confirmed randomisation procedures and laparoscopic diagnosis of endometriosis were included.

DATA COLLECTION AND ANALYSIS

Risk of bias assessment, and data extraction and analysis were performed independently by three review authors. Data were combined for meta-analysis using relative risk (RR) for dichotomous data. A fixed-effect statistical model was used, where appropriate. Data not suitable for meta-analysis were presented as descriptive data.

MAIN RESULTS

Two Chinese RCTs involving 158 women were included in this review. Both these trials described adequate methodology. Neither trial compared CHM with placebo treatment.There was no evidence of a significant difference in rates of symptomatic relief between CHM and gestrinone administered subsequent to laparoscopic surgery (95.65% versus 93.87%; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.93 to 1.12, one RCT). The intention-to-treat analysis also showed no significant difference between the groups (RR 1.04, 95% CI 0.91 to 1.18). There was no significant difference between the CHM and gestrinone groups with regard to the total pregnancy rate (69.6% versus 59.1%; RR 1.18, 95% CI 0.87 to 1.59, one RCT).CHM administered orally and then in conjunction with a herbal enema resulted in a greater proportion of women obtaining symptomatic relief than with danazol (RR 5.06, 95% CI 1.28 to 20.05; RR 5.63, 95% CI 1.47 to 21.54, respectively). Overall, 100% of women in all the groups showed some improvement in their symptoms.Oral plus enema administration of CHM showed a greater reduction in average dysmenorrhoea pain scores than did danazol (mean difference (MD) -2.90, 95% CI -4.55 to -1.25; P < 0.01). Combined oral and enema administration of CHM also showed a greater improvement measured as the disappearance or shrinkage of adnexal masses than with danazol (RR 1.70, 95% CI 1.04 to 2.78). For lumbosacral pain, rectal discomfort, or vaginal nodules tenderness, there was no significant difference between CHM and danazol.

AUTHORS' CONCLUSIONS

Post-surgical administration of CHM may have comparable benefits to gestrinone but with fewer side effects. Oral CHM may have a better overall treatment effect than danazol; it may be more effective in relieving dysmenorrhoea and shrinking adnexal masses when used in conjunction with a CHM enema. However, more rigorous research is required to accurately assess the potential role of CHM in treating endometriosis.

Risk Factors for Endometriosis in a German Case-Control Study

Objective: The etiology of endometriosis is still a research field in which few consistent data are available. Large case-control studies or even cohort studies are rare, and most of the published data are conflicting. The aim of the present study was therefore to examine common epidemiological and endometriosis-specific risk factors in a German case-control study. Design: From 2001 to 2010, a pool of 595 laparoscopically confirmed cases and 475 controls were recruited in a hospital-based setting. After matching for age, 298 cases and 300 controls remained in the pool. Age at menarche, menstrual cycle length, duration of menstrual bleeding, number of pregnancies, live births, miscarriages, use of contraceptive pills, body mass index (BMI), and smoking status were analyzed with logistic regression models predicting endometriosis case-control status. Results: Menstrual cycle length, duration of menstrual bleeding, number of pregnancies, number of miscarriages, and smoking status, as relevant predictors for endometriosis case-control status, were identified as risk factors for endometriosis. Other factors such as age at menarche, number of live births, ever having used contraceptive pills, and BMI were not predictive. Conclusions: This hospital-based case-control study reproduced most of the familiar risk factors. Comparison of this study with others reveals a wide variety of effect sizes and directions of association with risk factors and may increase the information available about the characteristics of the patient population being treated in the relevant hospital setting.

The outcomes of repeat surgery for recurrent symptomatic endometriosis

PURPOSE OF REVIEW

To evaluate the efficacy of second-line surgery in the management of recurrent endometriosis.

RECENT FINDINGS

Long-term probability of pain recurrence after repeat conservative surgery for recurrent endometriosis varies between 20 and 40%. The association of presacral neurectomy to the treatment of endometriosis might be effective in reducing midline pain; however, no studies have evaluated this procedure among patients with recurrent disease. The medium-term outcome of hysterectomy for endometriosis-associated pain is quite satisfactory; nevertheless, probability of pain persistence after hysterectomy is 15% and risk of pain worsening 3-5%, with a six times higher risk of further surgery in patients with ovarian preservation as compared to ovarian removal. The conception rate among women undergoing repetitive surgery for recurrent endometriosis associated with infertility is 26%, whereas the overall crude pregnancy rate after a primary procedure is 41%.

SUMMARY

Repeat conservative surgery for pelvic pain associated with recurrent endometriosis has the same efficacy and limitations as primary surgery. Conversely, after repeat conservative surgery for infertility, the pregnancy rate is almost half the rate obtained after primary surgery. More data are needed to define the best therapeutic option in women with recurrent endometriosis, in terms of pain relief, pregnancy rate and patient compliance.

Levo-tetrahydropalmatine retards the growth of ectopic endometrial implants and alleviates generalized hyperalgesia in experimentally induced endometriosis in rats

One primary goal of medical treatment of endometriosis is to alleviate pain and there is a pressing need for new therapeutics for endometriosis with better efficacy and side-effect profiles. Levo-tetrahydropalmatine (l-THP) has been used as a sedative or analgesic for chronic pains in China since 1970s. In this study, we sought to evaluate the efficacy of l-THP, with or without valproic acid (VPA), in a rat model of endometriosis. We surgically induced endometriosis in 55 adult female rats. Two weeks after, all rats were further divided into 5 groups randomly: untreated, low- and high-dose of l-THP, VPA, and l-THP + VPA. Response latency in hotplate test was measured before the surgery, before and after 3-week treatment of respective drugs. All rats were then sacrificed for analysis. The average lesion size and the immunoreactivity to N-methyl-D-asparate receptor 1 (NMDAR1), acid-sensing ion channel 3 (ASIC3), calcitonin gene-related peptide (CGRP), c-Fos, tyrosine kinase receptor A (TrkA), and histone deacetylase 2 (HDAC2) in dorsal root ganglia (DRG), to phorphorylated p65, HDAC2, TrkA, and CGRP in ectopic endometrium and to phorphorylated p65 and CGRP in eutopic endometrium were evaluated. We found that rats receiving l-THP, with or without VPA, had significantly reduced lesion size and exhibited significantly improved response to noxious thermal stimulus. The treatment also significantly lowered immunoreactivity to all mediators involved in central sensitization and to HDAC2 in DRG, to TrkA and CGRP in ectopic endometrium, and to CGRP in eutopic endometrium. In summary, l-THP reduces lesion growth and generalized hyperalgesia. Thus, l-THP may be a promising therapeutics for endometriosis.

Treatment of endometriosis with laparoscopic surgery today

Az endometriosis korszerű sebészi kezelésének célja a károsodott kismedencei anatómia helyreállításával az endometriosishoz társuló fájdalomtünetek csökkentése, illetve a teherbe esési esélyek javítása. Cikkünkben a különböző elhelyezkedésű kismedencei endometriosislaesiók eltávolításának műtéti lehetőségeit elemezzük. Az endometriosis sebészi kezelése döntően laparoszkópia útján valósul meg, míg a laparotomia alkalmazási köre egyre inkább beszűkült és csak speciális esetekre korlátozódik. A peritonealis endometriosis laesiói reszekció, elektrokoaguláció vagy lézervaporizáció segítségével kezelhetők, amelyek azonos mértékben csökkentik az endometriosishoz társuló fájdalomtüneteket, illetve javítják a teherbe esési esélyeket. Az endometrioma kezelésében hosszú éveken át kétféle műtéti megoldás terjedt el; a cisztatok eltávolítása az úgynevezett strippingtechnika segítségével, valamint a cisztatok megszüntetése az ablatiós műtéti technikával. Napjainkra egyértelműen bebizonyosodott, hogy a stripping előnyösebb az endometrioma ablatiójával szemben mind a fájdalomtünetek csökkenése, mind a reproduktív funkciók szempontjából. A mélyen infiltráló endometriosis kezelése jelenti a legnagyobb kihívást az endometriosis sebészetében. A mélyen infiltráló laesiók eltávolításában a lézertechnika alkalmazásának jut főszerep. A rectovaginalis septum endometriosisa esetén lézer segítségével a mélyen infiltráló laesio biztonsággal és maradéktalanul eltávolítható. Bélendometriosis esetén az érintett bélszakaszt szegmentális reszekcióval, discreszekcióval vagy az úgynevezett shavingtechnikával távolíthatjuk el. Leggyakrabban a szegmentális reszekciót alkalmazzuk, mivel egyedül ez esetben biztosítható a reszekciós szél biztos épsége. Az ureter endometriosisa esetén kisfokú érintettség mellett ureterolysis, míg obstruktív uropathia fennállásakor az ureter reszekciója javasolható. Az endometriosishoz társuló fájdalom hatékonyabb csökkentését célozza a praesacralis neurectomia és az uterusidegrost-ablatio. Ezen beavatkozások klinikai eredményessége azonban nem egyértelmű, az endometriosis kezelésében betöltött pontos szerepük tisztázása további vizsgálatokat igényel. Az endometriosis sebészetében a folyamatosan fejlődő műtéti technikák az endometriosislaesiók egyre teljesebb és hatékonyabb eltávolítását teszik lehetővé, amelynek köszönhetően egyre eredményesebben kezelhetők az endometriosishoz társuló klinikai tünetek és csökkenthető a betegség kiújulásának veszélye.

Endometriosis: associations with menopause, hormone replacement therapy and cancer

Endometriosis is an estrogen-dependent condition and is characterized by the presence of ectopic endometrial tissue. The pathogenesis of this condition remains an enigma. Endometriosis has well known associations with menopause both in terms of secondary outcomes from medical and surgical therapy in premenopausal women, as well as a natural occurrence/recurrence of the disease in women going through menopause naturally. This review article aims to discuss the current day modalities of management of endometriosis with their pros and cons especially in the context of menopause and cancer.

Endometrioid adenocarcinoma arising from endometriosis of the uterine cervix: a case report

Endometrioid adenocarcinoma arising from endometriosis of the uterine cervix is rare in premenopausal woman. We describe here a patient with this condition and review the clinical and pathological features of these tumors. A 48-yr-old woman complaining of severe dysmenorrhea was referred for investigation of a pelvic mass. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Histological examination revealed an endometrioid adenocarcinoma directly adjacent to the endometriosis at the uterine cervix, with a transition observed between endometriosis and endometrioid adenocarcinoma. The patient was diagnosed as having endometrioid adenocarcinoma arising from endometriosis of the uterine cervix and underwent postoperative chemotherapy. Gynecologists and pathologists should be aware of the difficulties associated with a delay in diagnosis of endometrioid adenocarcinoma arising from endometriosis when the tumor presents as a benign looking endometrioma.

Chinese herbal medicine for endometriosis

BACKGROUND

Endometriosis is characterized by the presence of tissue that is morphologically and biologically similar to normal endometrium in locations outside the uterus. Surgical and hormonal treatment of endometriosis have unpleasant side effects and high rates of relapse. In China, treatment of endometriosis using Chinese herbal medicine (CHM) is routine and considerable research into the role of CHM in alleviating pain, promoting fertility, and preventing relapse has taken place.

OBJECTIVES

To review the effectiveness and safety of CHM in alleviating endometriosis-related pain and infertility.

SEARCH STRATEGY

We searched the Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library) and the following English language electronic databases (from their inception to the present): MEDLINE, EMBASE, AMED, CINAHL, NLH on the 30/04/09.We also searched Chinese language electronic databases: Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Chinese Sci & Tech Journals (VIP), Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), and Chinese Medical Current Contents (CMCC).

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving CHM versus placebo, biomedical treatment, another CHM intervention, or CHM plus biomedical treatment versus biomedical treatment were selected. Only trials with confirmed randomisation procedures and laparoscopic diagnosis of endometriosis were included.

DATA COLLECTION AND ANALYSIS

Risk of bias assessment, and data extraction and analysis were performed independently by three review authors. Data were combined for meta-analysis using relative risk (RR) for dichotomous data. A fixed-effect statistical model was used, where appropriate. Data not suitable for meta-analysis are presented as descriptive data.

MAIN RESULTS

Two Chinese RCTs involving 158 women were included in this review. Both these trials described adequate methodology. Neither trial compared CHM with placebo treatment.There was no evidence of a significant difference in rates of symptomatic relief between CHM and gestrinone administered subsequent to laparoscopic surgery (95.65% versus 93.87%; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.93 to 1.12, one RCT). The intention-to-treat analysis also showed no significant difference between the groups (RR 1.04, 95% CI 0.91 to 1.18). There was no significant difference between the CHM and gestrinone groups with regard to the total pregnancy rate (69.6% versus 59.1%; RR 1.18, 95% CI 0.87 to 1.59, one RCT).CHM administered orally and then in conjunction with a herbal enema resulted in a greater proportion of women obtaining symptomatic relief than with danazol (RR 5.06, 95% CI 1.28 to 20.05; RR 5.63, 95% CI 1.47 to 21.54, respectively).Overall, 100% of women in all the groups showed some improvement in their symptoms.Oral plus enema administration of CHM showed a greater reduction in average dysmenorrhoea pain scores than did danazol (mean difference (MD) -2.90, 95% CI -4.55 to -1.25; P < 0.01).Combined oral and enema administration of CHM showed a greater improvement, measured as the disappearance or shrinkage of adnexal masses, than with danazol (RR 1.70, 95% CI 1.04 to 2.78). For lumbosacral pain, rectal discomfort, or vaginal nodules tenderness, there was no significant difference either between CHM and danazol.

AUTHORS' CONCLUSIONS

Post-surgical administration of CHM may have comparable benefits to gestrinone but with fewer side effects. Oral CHM may have a better overall treatment effect than danazol; it may be more effective in relieving dysmenorrhea and shrinking adnexal masses when used in conjunction with a CHM enema. However, more rigorous research is required to accurately assess the potential role of CHM in treating endometriosis.

Recurrence of endometriosis and its control

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

A call for more transparency of registered clinical trials on endometriosis

In response to the pressing need for more efficacious and safer therapeutics for endometriosis, there have been numerous reports in the last decade of positive results from animal and in vitro studies of various compounds as potential therapeutics for endometriosis. A handful of these have undergone phase II/III clinical trials. Since the announcement of the International Committee of Medical Journal Editors that mandated registration as a prerequisite for publication, 57 endometriosis-related clinical trials have been registered at ClinicalTrials.gov, an Internet-based public depository for information on drug studies. Among them, 25 are listed as completed, and 2 as suspended. There are 15 completed phase II/III trials, which evaluated the efficacy of various promising compounds. Yet only three of the 15 trials (20%) have published their results. The remaining 12 (80%) studies so far have not published their findings. We argue that this apparent lack of transparency will actually not benefit the trial sponsors or the public, and will ultimately prove detrimental to research efforts attempting to develop more efficacious and safer therapeutics for endometriosis. Thus we call for more transparency of clinical trials on endometriosis.

Treatment of pelvic pain associated with endometriosis

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

Peroxisome proliferator-activated receptor-gamma and retinoid X receptor agonists synergistically suppress proliferation of immortalized endometrial stromal cells

OBJECTIVE

To examine whether trichostatin A (TSA), a histone deacetylase inhibitor (HDACI), can induce up-regulation of peroxisome proliferator-activating receptor gamma (PPAR gamma) and to see whether LG100268, a retinoid X receptor (RXR) ligand, can inhibit proliferation of endometriotic cells alone or in synergy with ciglitazone, a PPAR gamma agonist.

DESIGN

One endometrial stromal cell line and two endometriotic cell lines used as a model system: Western blot analysis to determine whether TSA can up-regulate PPAR gamma expression, and MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) proliferation assay to see whether ciglitazone and LG100268 have any antiproliferative effects individually or jointly.

SETTING

Academic.

PATIENT(S)

None.

INTERVENTION(S)

Culture of immortalized endometrial and endometriotic cell lines with TSA, or ciglitazone or LG100268.

MAIN OUTCOME MEASURE(S)

PPAR gamma protein expression levels in cells treated with or without TSA, and number of viable cells treated with or without ciglitazone, LG100268, or both.

RESULT(S)

The TSA treatment resulted in up-regulation of PPAR gamma expression in all cell lines in a dose-dependent fashion. Both ciglitazone and LG100268 inhibited proliferation in a dose-dependent manner, and the antiproliferative effects appeared to be synergistic. In addition, endometriotic cells were more sensitive than endometrial stromal cells to LG100268 treatment.

CONCLUSION(S)

The up-regulation of PPAR gamma induced by TSA indicates that the action of HDACIs also includes the PPAR gamma signaling pathway, suggesting that the activation of PPAR gamma is a desirable way to contain endometriosis phenotypes. The higher sensitivity of endometriotic cells than their endometrial counterpart to LG100268 treatment suggests that the sensitivity differential could be exploited effectively to eradicate unwanted ectopic endometrial tissues while minimizing the collateral damage to the normal endometrial tissues.

Impact of GnRH agonist treatment on recurrence of ovarian endometriomas after conservative laparoscopic surgery

OBJECTIVE

To analyze the influence of postoperative GnRH agonist treatment on disease recurrence after conservative laparoscopic surgery for ovarian endometriomas according to duration of the treatment.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

PATIENT(S)

One hundred nine consecutive premenopausal women who underwent conservative laparoscopic surgery for ovarian endometriomas (endometriosis stage III/IV) were enrolled in the study. The patients were divided into four treatment groups: expectant management (n = 37) and GnRH agonist therapy for 3 (n = 28), 4 (n = 21), and 6 months (n = 23).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

An ultrasound confirmed recurrence of ovarian endometriomas.

RESULT(S)

The overall crude recurrence rate was 16.5% after follow-up for an average of 20.1 months. The crude recurrence and the cumulative probabilities of disease recurrence at 24/36 months tended to be lower in patients who received a GnRH agonist for 6 months (4.3%, 5.3%/5.3%) compared with those who received it for 3 months (17.9%, 12.5%/25.0%) and 4 months (28.6%, 18.9%/39.2%) and patients with expectant management (16.2%, 22.4%/37.9%). However, the differences did not reach statistical significance.

CONCLUSION(S)

Treatment with GnRH agonist for six months had a beneficial impact on the recurrence rate after conservative laparoscopic surgery for ovarian endometriomas.

Chronic Pelvic Pain: How Many Surgeries Are Enough?

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

Treatment of pelvic pain associated with endometriosis

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

Two Unsuccessful Clinical Trials on Endometriosis and a Few Lessons Learned

In 1999, a phase II clinical trial on the use of fulvestrant to treat endometriosis was launched; yet after 7 years there is still no report on its outcome. In 2005, another trial on the use of raloxifene to treat endometriosis was terminated early due to unfavorable outcome. The two apparently unsuccessful clinical trials on endometriosis have taught us a few important lessons. First, we need to understand endometriosis through more basic research. We have also been reminded that human endometriosis trials differ from animal studies; anatomy and physiology are often divergent, and outcome measures are certainly different. Ectopic endometrium can differ significantly from eutopic tissue, and this issue needs to be more thoroughly explored. We believe human cell lines will prove to be an inexpensive and valuable tool for future preliminary evaluation of medical therapies as well as discerning pathophysiologic processes of the disease. Based on our current understanding of endometriosis, some concrete benchmarks can be established for testing or screening potential compounds in vitro. Finally, estrogen receptor modulators are often tissue-, cell-, and context-specific in their actions; they should not be simplistically grouped together nor should extrapolations from one compound to another be undertaken in a cavalier manner.

A randomized study comparing triptorelin or expectant management following conservative laparoscopic surgery for symptomatic stage III-IV endometriosis

OBJECTIVE

To investigate the role of adjuvant treatment with gonadotropin-releasing-hormone agonist (GnRHa) following conservative surgical treatment of endometriosis.

STUDY DESIGN

Sixty patients in the reproductive age (mean age 28.6 years), with symptomatic stages III and IV endometriosis following laparoscopic surgery and without previous hormonal treatment were enrolled in a prospective, randomized, controlled trial to compare the effects of 3-month treatment with triptorelin depot-3.75 i.m. (30 patients) versus expectant management using placebo injection (30 patients).

RESULTS

Six patients (one in triptorelin group and five in placebo group) were lost at follow-up, the remaining 54 were suitable for analysis. Pelvic pain persistence or recurrence, endometrioma relapses and pregnancy rate were evaluated during a 5-year follow-up. The results of 29 cases treated with triptorelin and 25 that received placebo did not show significant differences in pain recurrence (P=1, RR=0.94, 95% CI=0.57-1.55), endometrioma relapse (P=0.67, RR=1.29, 95% CI=0.66-2.50), and pregnancy rate in infertile women (P=0.80, RR=0.81, 95% CI=0.37-1.80). Curves of time of pain recurrence and pregnancy during 5-year follow-up did not show significant differences between the two groups (P=0.79 and P=0.51, respectively, using Mantel-Haenzsel logrank test).

CONCLUSION

Triptorelin treatment after operative laparoscopy for stage III/IV endometriosis does not appear to be superior to expectant management in terms of prevention of symptoms recurrence and endometrioma relapse, and has no influence on pregnancy rate in endometriosis-associated infertility.

Is the endometriosis recurrence rate increased after ovarian hyperstimulation?

OBJECTIVE

To test the hypothesis that the cumulative endometriosis recurrence rate (CERR) after fertility surgery for endometriosis stage III or IV is increased in women exposed to very high E(2) levels during ovarian hyperstimulation (OH) for IVF when compared with women exposed to less high E(2) levels during OH for intrauterine insemination (IUI).

DESIGN

Retrospective cohort study including infertility patients with endometriosis stage III or IV.

SETTING

Leuven University Fertility Center, between 1990 and 2001.

PATIENT(S)

Patients (n = 67) with endometriosis stage III (n = 45) or IV (n = 22) who underwent pelvic reconstructive surgery and subsequently started fertility treatment with either IVF only (n = 39), both IVF and IUI in different cycles (n = 11), or IUI only (n = 17).

INTERVENTION(S)

Life table analysis was used to calculate the CERR.

MAIN OUTCOME MEASURE(S)

The CERR based on histologic or cytologic proof of disease recurrence.

RESULT(S)

At 21 months after the start of OH the overall CERR was 31% and was significantly lower in patients treated with IVF only (7%) or women treated with both IVF and IUI in different cycles (43 %) than in those treated with IUI only (70%). At 36 months after the start of OH, the overall CERR was 63%.

CONCLUSION(S)

In contrast to our hypothesis, the results from this study showed that the CERR is lower after ovarian hyperstimulation for IVF than after lower-dose ovarian stimulation for IUI, suggesting that temporary exposure to very high E(2) levels in women during OH for IVF is not a major risk factor for endometriosis recurrence in women treated with assisted reproductive technology.

Laparoscopic excision of recurrent endometriomas: long-term outcome and comparison with primary surgery

OBJECTIVE

To compare the laparoscopic excision of primary versus recurrent ovarian endometriomas.

DESIGN

Descriptive study.

SETTING

Tertiary referral center for the treatment of endometriosis.

PATIENT(S)

Between 1993 and 2002, 359 consecutive patients: 305 primary surgeries (group A) and 54 reoperations for a recurrent endometrioma in the same ovary of the primary cyst (group B).

INTERVENTION(S)

Laparoscopic stripping of the cyst wall. Follow-up evaluations every 6 months, including clinical and ultrasonographic evaluations and a questionnaire for pain symptoms (mean follow-up time, +/- standard deviation: 35.4 +/- 27.6 months).

MAIN OUTCOME MEASURE(S)

Recurrence of pain symptoms, sonographic recurrence of endometriomas, need for a new medical or surgical treatment, and reproductive outcome.

RESULT(S)

In groups A and B, respectively, the 5-year cumulative rates were not statistically significantly different: pain recurrence 20.5% versus 17.4%; ultrasonographic recurrence 18.9% versus 15.1%; retreatment requirement 19.4% versus 17.3%; and pregnancy 40.8% versus 32.4%. Although the difference was not statistically significant, compared with patients of group A, the women of group B underwent assisted reproduction techniques more frequently (50% vs. 32.2%) and had more irregular menstrual cycles associated with follicle-stimulating hormone levels > or = 14 IU/mL in the early follicular phase (5.5% vs. 1.3%).

CONCLUSION(S)

After laparoscopic excision of recurrent ovarian endometriomas, the recurrence of pain and the reproductive outcome are comparable with those found after primary surgery.

Reduced progesterone action during endometrial maturation: a potential risk factor for the development of endometriosis

OBJECTIVE

To discuss the role that reduced endometrial responsiveness to progesterone (P) might play in the pathophysiology of endometriosis.

DESIGN

A review of experimental evidence regarding the failure of P to regulate the expression of matrix metalloproteinases (MMPs) in the endometrium of patients with endometriosis.

CONCLUSION(S)

Progesterone and locally produced differentiation factors act cooperatively to reduce MMP expression by maternal endometrial cells within the pro-inflammatory micro-environment of early pregnancy. Our in vitro studies with normal human endometrium demonstrate that prior P exposure not only down-regulates MMP expression, but also limits the ability of locally produced proinflammatory cytokines to stimulate expression of these enzymes. In contrast, endometrial tissues from women with endometriosis demonstrate an altered response to P, allowing a continuous expression of MMPs throughout the secretory phase. Although the factors that influence the loss of P sensitivity in the endometrium of patients with endometriosis have not yet been defined, alterations in cell-cell communication seem to contribute to dysregulated MMP expression. Specifically, proinflammatory cytokines produced by epithelial cells oppose stromal cell responses to P, inhibiting production of key differentiation factors necessary for cell-specific MMP regulation. The resulting loss in normal MMP regulation enhances the invasive capacity of endometrial tissue, promoting ectopic establishment in an experimental model.

Endometriosis: Treatment Strategies

Endometriosis is often a perplexing medical condition for both the physician and the patient. Accordingly, development of treatment strategies based on the needs of the individual patient is highly desirable. Although endometriosis has been part of the clinical practice for almost a century, many questions remain relating to the relationship between endometriosis and infertility as well as endometriosis and pelvic pain. Endometriosis is a disease of reproductive-age women, and it is now well recognized that a genetic susceptibility appears probable. The prevalence in the general population has never been clearly established. Factors to consider in management include the age and reproductive desires of the patient, the stage of the disease, and, most importantly, the symptoms. Therapeutic options include no treatment, medical therapy, surgery, or combination therapy. Oral contraceptives, androgenic agents, progestins, and gonadotropin releasing hormone (GnRH) analogs have all been used successfully, although at the present time, the latter preparations are the most popular medical therapy for endometriosis. Leuprolide acetate, goserelin acetate, and nafarelin acetate are all effective agents. Surgical therapy is appropriate, especially for advanced stages of the disease. Laparoscopy is an effective surgical approach with the goal of excision of visible endometriosis in a hemostatic fashion. Since endometriosis is a chronic condition, it is not uncommon for recurrences to occur. While endometriosis remains an enigmatic disease, the introduction of new pharmacologic agents, such as GnRH analogs and newer endoscopic methods of surgical treatment, have facilitated and improved the overall management of this disease.

Adolescent endometriosis

Endometriosis is a cause of chronic, pelvic pain in adolescents. Lack of response to NSAIDS and OCPs should prompt further investigation and subsequent treatment. The goal of therapy is to minimize pelvic pain and dysmenorrhea primarily through long-term, medical therapy. Surgical intervention is principally indicated to establish a diagnosis. The poor response to surgical therapy negates the need for repetitive or radical surgery. Much patience and care should be directed toward these patients to provide them with an understanding of their disease and to help enhance the quality of their life.

Diagnosis and treatment of endometriosis

Endometriosis is a chronic and progressive disease that affects approximately 10% of women of reproductive age. Its aetiology remains unknown, however, factors such as retrograde menstruation, heredity, impaired immune function and environmental toxins have been implicated. Laparoscopy is still considered the mainstay for diagnosis, however non-invasive diagnostic methods such as transvaginal ultrasound and MRI may also be complementary. Treatment should be individualised and current treatment options include medical treatment and surgery, however, disease recurrence is common following treatment. Hormonal therapy induces atrophy of endometriotic lesions. Conservative surgery may be successful in removing visible lesions, however in cases of severe or incapacitating illness, removal of the uterus and ovaries may be necessary. In such cases, extreme care must be taken to remove all traces of disease. Experimental treatments for endometriosis show promising preliminary results and include GnRH antagonists, aromatase inhibitors, selective oestrogen receptor modulators and mifepristone.

Endometrial adenocarcinoma arising from endometriosis of the rectosigmoid colon

BACKGROUND

Only 21.3% of cases of malignant transformation of endometriosis occur at extragonadal pelvic sites. Forty cases of endometriosis-associated intestinal tumors are reported in the literature. Of these, 17 cases are primary adenocarcinomas arising in the rectosigmoid colon. In 8 of the 17 case reports the patients were using unopposed estrogen replacement therapy.

CASE

The patient had previously undergone a total abdominal hysterectomy and bilateral salpingo-oophorectomy for deeply infiltrating rectovaginal endometriosis, and was using estrogen replacement therapy. She presented with rectal bleeding 12 years later, and a polyp was detected arising from the sigmoid colon. A biopsy detected malignant transformation of endometriosis to adenocarcinoma.

CONCLUSION

This is the ninth case of a patient with this condition reported in the literature.

Effect of endometriosis on in vitro fertilization

OBJECTIVE

To investigate the IVF outcome for patients with endometriosis.

DESIGN

Meta-analysis.

SETTING

Academic research center.

PATIENT(S)

A MEDLINE search and review of the literature were performed. Patients were classified by level of endometriosis, and controls were classified according to the indication for IVF.

INTERVENTION(S)

Bivariate analysis and multivariate logistic regression was used to estimate overall effect and control for confounding.

MAIN OUTCOME MEASURE(S)

Pregnancy rates, fertilization rate, implantation rates, and numbers of oocytes retrieved.

RESULT(S)

Twenty-two published studies were included in the overall analysis. The chance of achieving pregnancy was significantly lower for endometriosis patients (odds ratio, 0.56; 95% confidence interval, 0.44-0.70) when compared with tubal factor controls. Multivariate analysis also demonstrated a decrease in fertilization and implantation rates, and a significant decrease in the number of oocytes retrieved for endometriosis patients. Pregnancy rates for women with severe endometriosis were significantly lower than for women with mild disease (odds ratio, 0.60; 95% confidence interval, 0.42-0.87).

CONCLUSION(S)

Patients with endometriosis-associated infertility undergoing IVF respond with significantly decreased levels of all markers of reproductive process, resulting in a pregnancy rate that is almost one half that of women with other indications for IVF. These data suggest that the effect of endometriosis is not exclusively on the receptivity of the endometrium but also on the development of the oocyte and embryo.

[Treatment of a case of ovarian cysts in a patient known to have endometriosis]

Endometrioma is one of the most frequent localisations of endometriosis. The diagnosis is based mainly on the intravaginal ultrasonography which has a good predictive value, even if there are a lot of atypical echographic aspects. Endoscopic surgery remains the standard treatment for endometriosis, the goal being the complete removal of the lesions. Three surgical options are possible: intraperitoneal cystectomy, the three-phase "Donnez technique" in three time, and ovariectomy. Treatment of recurrences of endometriosis must be based on a precise diagnosis, and also on the type of patient being treated: patient wishing to be pregnant, patient under medically-assisted reproductive programs, and patients close to menopause. The ultrasound-guided puncture could be an interesting option for multioperated patients or patients under assisted reproductive programs, yet these patients should be informed of the high risk of further episodes of endometriosis after such a puncture.

Recurrence of endometriosis in women with bilateral adnexectomy (with or without total hysterectomy) who received hormone replacement therapy

OBJECTIVE

To estimate the risk of recurrence after administration of hormone replacement therapy (HRT) among women who have had endometriosis and who underwent bilateral salpingo-oophorectomy (BSO).

DESIGN

Prospective randomized trial (115 women receiving HRT and 57 not receiving HRT). SETTING; Public university hospital.

PATIENT(S)

Women with a histologic diagnosis of endometriosis in whom BSO was performed; 91.8% had a total hysterectomy.

INTERVENTION(S)

Periodical clinical examination, vaginal ultrasound, and CA-125 levels; surgical evaluation and histologic study.

MAIN OUTCOME MEASURE(S)

Recurrence rate, prognostic factors, and a mean follow-up time of 45 months.

RESULT(S)

There was no recurrence among women who did not receive HRT, versus a 3.5% rate (4 out of 115), or 0.9% per year, in women who received HRT. Two recurrences required abdominal surgery. There was one additional patient who required surgery, but the relationship to the endometriosis recurrence was controversial. Among women receiving HRT, the following risk factors were detected: peritoneal involvement > 3 cm (2.4% recurrence per year vs. 0.3%) and incomplete surgery (22.2% per patient vs. 1.9%).

CONCLUSION(S)

Patients with a history of endometriosis in whom total hysterectomy and bilateral salpingo-oophorectomy have been performed have a low risk of recurrence when HRT is administered. In those patients, HRT is a reasonable option. However, in cases with peritoneal involvement > 3 cm, the recurrence rate makes HRT a controversial option; if HRT is indicated, it should be monitored closely.

Post-operative GnRH analogue treatment after conservative surgery for symptomatic endometriosis stage III-IV: a randomized controlled trial

BACKGROUND

In order to decrease endometriosis recurrence after surgical therapy, it has been proposed to use a post-surgical oestrogen-lowering medical treatment. Results from previous trials on this topic are contradictory.

METHODS

A total of 89 women were randomized, by computer-generated list, after laparoscopic conservative surgery for symptomatic endometriosis stage III-IV to receive monthly i.m. injections of gonadotrophin-releasing hormone (GnRH) analogue, leuprolide acetate depot (3.75 mg) for 3 months (n = 44) or to an expectant management (n = 45). All patients were followed up every 6 months for evaluation of pain symptoms, fertility and objective disease recurrence.

RESULTS

During the follow-up, which ranged from 6-36 months, five (33%) of the 15 women who wanted children and who were allocated the GnRH analogue and six (40%) of the 15 given no treatment became pregnant (not significant). Moderate/severe pelvic pain recurred during the follow-up in 10 (23%) of the women allocated the GnRH analogue and 11 (24%) of those allocated no treatment; the cumulative pain recurrence rates at 18 months were 23 and 29% respectively (not significant). Four women (9%) treated with GnRH analogue and four women (9%) who received no treatment had objective disease recurrence as demonstrated by gynaecological examination and/or pelvic ultrasonography.

CONCLUSIONS

This study does not support the routine post-operative use of a 3 month course of GnRH analogue in women with symptomatic endometriosis stage III-IV.

Endometriosis: an overview of the disease and its treatment

OBJECTIVE

To review endometriosis, its etiology, clinical presentation, and current management options.

DATA SOURCES

Published articles identified through MEDLINE (1966-2000) using the search term "endometriosis" and the additional terms "etiology" and "treatment." Additional articles were identified from the bibliographies of the retrieved articles.

DATA SYNTHESIS

Endometriosis, a disease that affects the physical health and emotional well-being of many women of reproductive age, is defined as the presence of endometrial tissue outside its normal location in the uterus. The disease ranges in severity from mild to severe, and patients may be asymptomatic or experience severe and potentially incapacitating symptoms, such as dysmenorrhea, dyspareunia, and infertility. The diagnosis can be confirmed only by direct visualization using laparoscopy and biopsy. The risk of endometriosis is increased in women who have an affected first-degree relative or who have shorter menstrual cycle lengths, longer duration of menstrual flow, and low parity. The etiology of endometriosis is not yet fully understand, but may involve retrograde menstruation, hereditary factors, and impaired immune function. Treatment should be individualized for each patient, taking into account the therapeutic goals, the extent of disease, symptomatology, and the woman's age and overall health. Treatment options include expectant management, hormonal therapies to suppress ovarian steroidogenesis and induce endometrial atrophy, and surgery to remove visible lesions or, as a last resort, the uterus and ovaries.

CONCLUSION

Although the precise etiology of endometriosis remains a mystery, treatment options have improved considerably in recent years. Pharmacists are well positioned to identify women with unexplained pelvic pain or infertility that may be indicative of endometriosis and refer them to their physicians for further evaluation. Pharmacists also can play an important role in counseling patients about the safe and effective use of the various treatments for this disease and strategies to recognize and reduce adverse effects.

Managing endometriosis. Strategies to minimize pain and damage

Endometriosis is a common condition affecting a significant number of women of childbearing age. The diagnosis is clinical and thus can be difficult to make. History taking is generally most helpful, and diagnostic tests have a limited role. Diagnostic laparoscopy remains the "gold standard" for diagnosis of endometriosis. Treatment is geared toward improving fertility and controlling pain and is often not curative. However, both medical and surgical therapies are of value in controlling the disease. Attention to the psychosocial needs of the patient are also critical. Future therapies will be based on a further understanding of the pathogenesis of endometriosis and the effect of hormones on the disease. For the primary care physician who may not be comfortable prescribing GnRH analogs or other medical therapies, referral to a gynecologist or endocrinologist should be considered.

Selected hormonal agents in gynecology

Hormonal agents are used to treat many conditions, including endometriosis, amenorrhea, fibroids, and dysfunctional uterine bleeding. Because women visit their care provider for various gynecologic problems more than any other reason, application of therapeutic uses in this rapidly expanding field is essential for nurses working in endocrine gynecology. Strategies for hormone use are discussed in light of the goals of patient education and treatment in the areas of pain relief, fertility, and cycle regulation.