Endometriosis: ACOG technical bulletin number 184 - September 1993 (replaces no. 85, March 1985)

What Are Patients Reading? Quality Assessment of Endometriosis Information on the Internet

OBJECTIVE

Evaluate the quality of information reported online about endometriosis and period pain.

METHODS

An online search identified the top 20 websites for 4 search engines (Google, Ask, Bing, Yahoo). Videos, duplicates, and websites not containing information related to endometriosis and period pain were excluded. Three independent authors screened websites and systematically extracted data on website characteristics and on diagnosis and treatment mentions. Website accuracy and completeness were rated for a score out of 15. The Flesch readability ease score (FRES) was used to assess readability.

RESULTS

Of 34 websites included, most were news related (44.1%) and health care affiliated (26.5%). Websites with affiliations had significantly higher accuracy scores than those without. Those with references had significantly higher completeness than those without. Non-news-related websites had significantly higher accuracy and completeness than news-related websites. The most commonly reported symptoms were dysmenorrhea (97.1% of websites), infertility (88.2%), and dyspareunia (82.4%). Cancer was mentioned on 41.1% of websites. Diagnostic laparoscopy (91.0%) and ultrasound (88.3%) were the most commonly mentioned diagnostic tools. Commonly reported therapeutics included the oral contraceptive pill (79.4%), laparoscopy (70.6%), non-steroidal anti-inflammatory drugs (NSAIDs; 67.6%), and gonadotropin-releasing hormone (GnRH) agonists (64.7%). Hysterectomy (59.0%) was mentioned more than progestins (53.0%). Overall, 18 of 34 websites (53%) contained 1 or more inaccurate or misleading statements.

CONCLUSION

While most websites contained accurate statements, commonly reported misconceptions included an emphasized risk of cancer, lack of use/benefit of ultrasound for diagnosis, and a bias for surgical over medical management, where laparoscopy was mentioned more than first-line medications. This study highlights the importance of directing patients to evidence-based resources.

The role of ovarian fossa evaluation in patients with ovarian endometriosis

PURPOSE

The aim of this study is to evaluate prospectively the presence of endometriosis in the peritoneum of the ovarian fossa of patients affected by endometriomas and its correlation with the adhesion between this peritoneum and endometrioma.

METHODS

Patients presenting ovarian endometriomas and candidate to laparoscopy were considered for inclusion in the study. Patients underwent laparoscopic excision of endometriomas. The presence of adherence of the ovarian fossa to endometrioma was investigated. In all patients, the removal of a peritoneum fragment from the ovarian fossa of the affected ovary was carried out.

RESULTS

68 patients were enrolled in the study. 48 patients presented adhesions to the ovarian fossa. Histopathologic examination of the peritoneum of the ovarian fossa revealed the presence of endometriosis in 87 % of patients presenting adhesions of the endometriomas with ovarian fossa; surprisingly it was present only in 15 % of patients not presenting this condition (p < 0.0001). Pain symptoms were more frequent in patients with endometriomas adhesion to the ovarian fossa. CA125 levels were not statistically significantly different between groups. At 12-month follow-up, four patients presented endometrioma recurrence. All of them presented adhesion of the ovarian fossa to the endometrioma in the first operation.

CONCLUSIONS

There is a strong association between adhesion of the endometriomas to the ovarian fossa and the presence of endometriosis on the peritoneal surface of the fossa. This condition significantly correlates with pain symptoms and may predict endometrioma recurrence. The removal of this peritoneum in case of adherent endometrioma may potentially reduce the incidence of recurrence.

Is a positive family history of endometriosis a risk factor for endometrioma recurrence after laparoscopic surgery?

A total of 148 patients were followed up for an average of 30.1 ± 17 months following to laparoscopic excision of ovarian endometriomas by a single surgical team. Bivariate and multivariate analyses were used to investigate the association between endometrioma recurrence and several factors, age, body mass index, family history, cyst diameter, number and location, adhesions or peritoneal implants, occurrence of spillage, postoperative treatment with gonadotropin-releasing hormone agonist, or pregnancies. The overall recurrence rate of the endometriomas was 18.2%. At bivariate analysis, recurrence rate was significantly higher in patients with a positive family history of endometriosis (40% vs 14.8%). Recurrence was also more frequent, albeit nonsignificantly, in patients with a history of dysmenorrhea, intraoperative spillage, and postoperative hormonal suppression. At multivariate analysis with logistic regression, a positive family history of endometriosis was the only variable independently associated with endometrioma recurrence following laparoscopic removal (odds ratio 3.245; 95% confidence interval: 1.090-9.661).

Use of intraperitoneal interferon alpha-2b therapy after conservative surgery for endometriosis and postoperative medical treatment with depot gonadotropin-releasing hormone analog: a randomized clinical trial

OBJECTIVE

To evaluate the possible therapeutic effects of interferon alpha-2b left in the peritoneum after surgery, followed by or not followed by treatment with GnRH analogs.

DESIGN

A prospective, randomized clinical trial.

SETTING

University hospital.

PATIENT(S)

Fifty-two infertile patients with moderate or severe endometriosis.

INTERVENTION(S)

Laparotomic conservative surgery and either interferon alpha-2b or saline alone left in the pouch of Douglas followed by administration of either GnRH analogs depot or oral indomethacin with transvaginal echography and analysis of CA-125, immunoglobulins, and lymphocyte populations.

MAIN OUTCOME MEASURE(S)

Recurrence of endometriosis was considered clinically, echographically, and laparoscopically.

RESULT(S)

Recurrence of endometriosis in four cases without interferon (15.4%) versus 11 patients (42.3%) with interferon alpha-2b. Life table analysis showed significant differences between the groups with and without interferon 21 months after conservative surgery. There were no differences in the recurrence between the groups with or without GnRH analogs. Likewise, there were no significant changes in immunoglobulins and lymphocyte populations among patients with and without recurrence of endometriosis. The patients that received GnRH analogs depot showed a decrease in the number of CD16 and an increase of CD11b cells after treatment.

CONCLUSION(S)

The use of interferon alpha-2b within the peritoneal cavity after conservative surgery may be inappropriate because it increased later recurrence of endometriosis. The postoperative treatment with GnRH analogs did not significantly reduce the recurrence rate. Immunoglobulins and lymphocyte populations did not change in relation to the recurrence of endometriosis.

Postoperative administration of monophasic combined oral contraceptives after laparoscopic treatment of ovarian endometriomas: a prospective, randomized trial

OBJECTIVE

We sought to evaluate the efficacy of postoperative administration of monophasic, combined, low-dose oral contraceptives on endometrioma recurrence and on persistence-recurrence of associated pain symptoms after laparoscopic treatment of moderate-to-severe endometriosis.

STUDY DESIGN

In a prospective, randomized trial 70 patients who were not attempting to conceive, aged 20 to 35 years, underwent laparoscopic excision of ovarian endometriomas, followed by either postoperative administration of low-dose cyclic oral contraceptives for 6 months or no treatment on the basis of a computer-generated sequence. At 3 and 6 months after surgery and then at 6-month intervals, both groups underwent ultrasonographic examination for possible evidence of endometrioma recurrence and for evaluation of the absence, persistence, or recurrence of pain symptoms.

RESULTS

Two patients in the oral contraceptive group did not complete the study. After a mean follow-up of 22 months (range, 12-48 months), there were 2 (6.1%) endometrioma recurrences in the 33 patients who received postoperative oral contraceptives versus 1 (2.9%) recurrence in the 35 patients in the control group (not significant). The moderate-to-severe pain recurrence rate was 9.1% in the oral contraceptive group versus 17.1% in the control group (not significant). The mean time to recurrence of either symptoms or endometriomas was 18.2 months in the oral contraceptive group versus 12.7 months in the control group. The 12-month cumulative recurrence rate at life-table analysis was significantly lower for patients receiving oral contraceptives versus control subjects, whereas no significant difference was evident at 24 and 36 months.

CONCLUSION

Postoperative administration of low-dose cyclic oral contraceptives does not significantly affect the long-term recurrence rate of endometriosis after surgical treatment. A delay in recurrence is evident at life-table analysis.

Identification of rhesus macaques with spontaneous endometriosis

Rhesus macaques (Macaca mulatta) with endometriosis were identified using reproductive histories, serum levels CA-125, pelvic ultrasonography, laparoscopy, and histopathology. All animals were evaluated from a large breeding colony and had a history of infertility and/ or spontaneous abortions. Laparoscopy and ultrasonography were performed on 40 macaques: 27 macaques from the breeding colony with elevated CA-125 levels, ten macaques from the breeding colony with normal or low serum CA-125 levels, and three macaques from another facility with previously diagnosed spontaneous endometriosis. Clinical endometriosis was diagnosed by laparoscopy in 16/37 (43%) macaques from the breeding colony and was confirmed by histologic examination in all animals biopsied. The disease was classified as minimal (40%), mild (25%), moderate (10%), or severe (25%). The most common sites of endometriosis were the serosal surface of the uterus (75%) and the posterior cul-de-sac (75%). In this study, CA-125 levels were useful in identifying animals from the breeding colony with endometriosis. The rhesus macaque provides a valuable animal model to study endometriosis and potentially to assess efficacy of therapeutic agents for this disease condition.