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Perrone U, Ferrero S, Gazzo I, Izzotti A, Leone Roberti Maggiore U, Gustavino C, Ceccaroni M, Bogliolo S, Barra F. Endometrioma surgery: Hit with your best shot (But know when to stop). Best Pract Res Clin Obstet Gynaecol 2024:102528. [PMID: 38977389 DOI: 10.1016/j.bpobgyn.2024.102528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/08/2024] [Accepted: 06/25/2024] [Indexed: 07/10/2024]
Abstract
Ovarian endometriomas (OEs) are commonly detected by ultrasound in individuals affected by endometriosis. Although surgery was widely regarded in the past as the gold standard for treating OEs, especially in the case of large cysts, the surgical management of OEs remains debated. Firstly, OEs often represent the "tip of the iceberg" of underlying deep endometriosis, and this should be considered when treating OEs to ameliorate patients' pain for focusing on the surgical objectives and providing better patient counseling. In the context of fertility care, OEs may have a detrimental effect on ovarian reserve through structural alterations, inflammatory responses, and oocyte reserve depletion. Conversely, the surgical approach may exacerbate the decline within the same ovarian reserve. While evidence suggests no improvement in in-vitro fertilization (IVF) outcomes following OE surgery, further studies are needed to understand the impact of OE surgery on spontaneous fertility. Therefore, optimal management of OEs is based on individual patient and fertility characteristics such as the woman's age, length of infertility, results of ovarian reserve tests, and surgical background. Among the available surgical approaches, cystectomy appears advantageous in terms of reduced recurrence rates, and traditionally, bipolar coagulation has been used to achieve hemostasis following this approach. Driven by concerns about the negative impact on ovarian reserve, alternative methods to obtain hemostasis include suturing the cyst bed, and novel methodologies such as CO2 laser and plasma energy have emerged as viable surgical options for OEs. In instances where sonographic OE features are non-reassuring, surgery should be contemplated to obtain tissue for histological diagnosis and rule out eventual ovarian malignancy.
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Affiliation(s)
- Umberto Perrone
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Via Gio Batta Ghio 9, 16043, Chiavari, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy; Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy.
| | - Irene Gazzo
- Department of Reproductive Medicine, Ospedale Evangelico Internazionale, Genoa, 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, Largo R. Benzi 10, 16132, Genoa, 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, Negrar di Valpolicella, Verona, Italy
| | - Stefano Bogliolo
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Via Gio Batta Ghio 9, 16043, Chiavari, Genoa, Italy
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Via Gio Batta Ghio 9, 16043, Chiavari, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy
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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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Alasia I, Agostini A, Faust C, Berbis J, Pivano A. Effect of hormonal treatment on evolution of endometriomas: An observational study. J Gynecol Obstet Hum Reprod 2023; 52:102637. [PMID: 37527765 DOI: 10.1016/j.jogoh.2023.102637] [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: 12/13/2022] [Revised: 05/03/2023] [Accepted: 07/26/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVE To evaluate the evolution of endometriomas with or without medical treatment. METHODS This retrospective observational study was performed at the Gynaecological Center, Hôpital La Conception (Assistance Publique Hopitaux de Marseille). We reviewed clinical data of patients with at least one endometrioma diagnosed by magnetic resonance imaging (MRI) and at least one other MRI exam after more than three months. Patients were divided into groups receiving medical treatment and without medical treatment (high-dose progestins, low-dose progestins or combined contraceptives). The primary objective was to evaluate the evolution of endometriomas with or without hormonal treatment. The primary evaluation criterion was the diameter of the endometriomas, and the secondary evaluation criterion was the number of endometriomas for each patient observed. The secondary objective was to evaluate whether different categories of hormonal treatment have different efficacity in the evolution of endometriomas. RESULTS We included 68 patients, 39 (57,4%) with hormonal treatment and 29 (42,6%) without hormonal treatment. There were 105 total endometriomas identified at the first MRI, 52 in patients with hormonal treatment and 53 in patients without treatment. The mean diameter of the endometriomas in patients with hormonal treatment was 31,48 ± 18,1 mm at the first MRI and 23,60 ± 15,3 mm at the second MRI. The mean diameter of the endometriomas in patients without treatment was 33,57 ± 19,7 mm at the first MRI and 40,11 ± 25,7 mm at the second MRI (statistically significant difference, p = 0.01). The mean number of endometriomas in patients with treatment was 1,79 ± 1,1 at the first MRI and 1,18 ± 0,9 at the second MRI, while the mean number of endometriomas in patients without hormonal treatment was 1,38 ± 0,6 at the first MRI and 1,97 ± 1,5 at the second MRI (difference not statistically significant, p = 0.38). The subgroup analysis differentiated by category of hormonal treatment did not show statistically significant results. CONCLUSIONS The present study shows that there is a positive effect of hormonal treatment on reducing the diameter of endometriomas and also a significative increase in endometrioma size in the absence of treatment. There is no evidence of an advantage of a single category of hormonal treatment on this effect on endometriomas. Thus, any medical treatment could be proposed as a first-line therapy for endometriomas that would reduce the size of the endometrioma and thereby help to avoid surgical intervention.
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Affiliation(s)
- Ilaria Alasia
- Department of Obstetrics and Gynecology, Hôpital La Conception, Aix-Marseille University, 107 avenue de Montredon, Marseille 13008, France
| | - Aubert Agostini
- Department of Obstetrics and Gynecology, Hôpital La Conception, Aix-Marseille University, 107 avenue de Montredon, Marseille 13008, France.
| | - Cindy Faust
- CEReSS - Health Services and Quality of Life Research, Department of Epidemiology, Aix-Marseille University, Marseille, France.
| | - Julie Berbis
- CEReSS - Health Services and Quality of Life Research, Department of Epidemiology, Aix-Marseille University, Marseille, France.
| | - Audrey Pivano
- Department of Obstetrics and Gynecology, Hôpital La Conception, Aix-Marseille University, 107 avenue de Montredon, Marseille 13008, France.
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Daniilidis A, Grigoriadis G, Kalaitzopoulos DR, Angioni S, Kalkan Ü, Crestani A, Merlot B, Roman H. Surgical Management of Ovarian Endometrioma: Impact on Ovarian Reserve Parameters and Reproductive Outcomes. J Clin Med 2023; 12:5324. [PMID: 37629367 PMCID: PMC10455819 DOI: 10.3390/jcm12165324] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/08/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Ovarian endometriomas have a negative impact on a patient's reproductive potential and are likely to cause a reduction in ovarian reserve. The most commonly employed ovarian reserve parameters are anti-Müllerian hormone (AMH) and antral follicular count (AFC). Surgical management options of endometrioma include cystectomy, ablative methods, ethanol sclerotherapy and combined techniques. The optimal surgical approach remains a matter of debate. Our review aimed to summarize the literature on the impact of surgical management of endometrioma on AMH, AFC and fertility outcomes. Cystectomy may reduce recurrence rates and increase chances of spontaneous conception. However, a postoperative reduction in AMH is to be anticipated, despite there being evidence of recovery during follow-up. The reduction in ovarian reserve is likely multi-factorial. Cystectomy does not appear to significantly reduce, and may even increase, AFC. Ablative methods achieve an ovarian-tissue-sparing effect, and improved ovarian reserve, compared to cystectomy, has been demonstrated. A single study reported on AMH and AFC post sclerotherapy, and both were significantly reduced. AMH levels may be useful in predicting the chances of conception postoperatively. None of the aforementioned approaches has a clearly demonstrated superiority in terms of overall chances of conception. Surgical management of endometrioma may, overall, improve the probability of pregnancy. Evidence on its value before medically assisted reproduction (MAR) is conflicting; however, a combination of surgery followed by MAR may achieve the optimal fertility outcome. In view of the complexity of available evidence, individualization of care, combined with optimal surgical technique, is highly recommended.
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Affiliation(s)
- Angelos Daniilidis
- 1st Department in Obstetrics and Gynaecology, Papageorgiou General Hospital, School of Medicine, Aristotle University of Thessaloniki, 54643 Thessaloniki, Greece;
| | - Georgios Grigoriadis
- 2nd Department in Obstetrics and Gynecology, Hippokratio General Hospital, School of Medicine, Aristotle University of Thessaloniki, 56429 Thessaloniki, Greece;
| | | | - Stefano Angioni
- Department of Obstetrics and Gynecology, University of Cagliari, Monserrato, 09042 Cagliari, Italy;
| | - Üzeyir Kalkan
- Department of Obstetrics and Gynecology, Koç University, 34010 Istanbul, Turkey;
| | - Adrien Crestani
- Institut Franco-Europeen Multidisciplinaire d’Endometriose (IFEMEndo), Endometriosis Centre, Clinique Tivoli-Ducos, 33000 Bordeaux, France; (A.C.); (B.M.)
| | - Benjamin Merlot
- Institut Franco-Europeen Multidisciplinaire d’Endometriose (IFEMEndo), Endometriosis Centre, Clinique Tivoli-Ducos, 33000 Bordeaux, France; (A.C.); (B.M.)
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Middle East Clinic, Burjeel Medical City, Abu Dhabi 7400, United Arab Emirates
| | - Horace Roman
- Institut Franco-Europeen Multidisciplinaire d’Endometriose (IFEMEndo), Endometriosis Centre, Clinique Tivoli-Ducos, 33000 Bordeaux, France; (A.C.); (B.M.)
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Middle East Clinic, Burjeel Medical City, Abu Dhabi 7400, United Arab Emirates
- Aarhus University, 8000 Aarhus, Denmark
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Choi SH, Kim SE, Lim HH, Lee DY, Choi D. Efficacy of Post-Operative Medication to Prevent Recurrence of Endometrioma: Cyclic Oral Contraceptive (OC) After Gonadotropin-Releasing Hormone (GnRH) Agonist Versus Dienogest. J Korean Med Sci 2022; 37:e207. [PMID: 35790209 PMCID: PMC9259244 DOI: 10.3346/jkms.2022.37.e207] [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: 02/08/2022] [Accepted: 05/30/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There are several medical treatment options for endometrioma. Progestin, especially dienogest, is an effective drug for preventing recurrence of endometrioma after surgery. Additionally, oral contraceptive (OC) use after conservative surgery has been reported to reduce significantly the risk of endometrioma recurrence. The aim of this study was to compare the long-term effects of gonadotropin-releasing hormone (GnRH) agonist followed by OC to those of dienogest alone to prevent recurrence of endometrioma after laparoscopic surgery. METHODS A retrospective cohort study was performed on patients who underwent conservative laparoscopic surgery for endometrioma between January 2000 and December 2020, in the Endometriosis Clinic, Department of Gynecology, Samsung Medical Center. A total of 624 patients who received medical treatment at least six months after laparoscopic conservative surgery for endometrioma was included. Among them, 372 patients used OC after GnRH agonist therapy, and 252 patients used dienogest. Within the OC group, 148 used a 21/7 regiment and 224 used a 24/4 regimen. A cumulative endometrioma recurrence curve was presented using the Kaplan-Meier method to compare the recurrence of those groups. RESULTS The cumulative recurrence rate of endometrioma for 60 months was 2.08% (n = 4) in the OC after GnRH agonist group and 0.40% (n = 1) in the dienogest group. There was no statistical difference in cumulative recurrence of endometrioma between the two groups. In subgroup analysis, the cumulative recurrence rate of endometrioma over 60 months was 4.21% (n = 2) in the 21/7 OC group and 1.09% (n = 2) in the 24/4 OC group and showed no significant difference. CONCLUSION Long-term use of OC after GnRH agonist as well as that of dienogest treatment are effective postoperative medical therapies for preventing endometrioma recurrence. Thus, the choice of regimen can be individualized or used interchangeably depending on patient condition, need for contraception, and compliance with drug therapy.
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Affiliation(s)
| | | | - Hyun Hye Lim
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Yun Lee
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - DooSeok Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Gu Z, Li X, Shi J, Wu Y, Zhang J, Zhang C, Yan H, Leng J. The Development of Predictive Nomogram of Recurrence for Patients With Endometrioma After Cystectomy Who Were Younger Than 45 Years Old and Received Postoperative Therapy. Front Med (Lausanne) 2022; 9:872481. [PMID: 35755050 PMCID: PMC9218256 DOI: 10.3389/fmed.2022.872481] [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: 02/09/2022] [Accepted: 05/06/2022] [Indexed: 11/29/2022] Open
Abstract
Objective: This study aimed to establish an effective prognostic nomogram for the postoperative recurrence of endometrioma or endometriosis-related pain for patients with endometrioma after long-term follow-up, who were younger than 45 years old and received postoperative therapy. Methods The predictive nomogram was based on 323 patients who underwent cystectomy for endometrioma at Perking Union Medical College Hospital from January 2009 to April 2013, and the last follow-up occurred in September 2018. We collected information on all included patients, including preoperative data, intraoperative data, and long-term follow-up data after surgery. The Cox proportional hazards regression model was used to evaluate the prognostic effects of multiple clinical parameters on recurrence. The survival curve was depicted based on Kaplan-Meier method and compared by log-rank method. The Index of concordance (C-index) and calibration curves were used to access the discrimination ability and predictive accuracy of the nomogram respectively, and the results were further validated via bootstrap resampling. In addition, calculating the area under the curve (AUC) via risk scores of patients aimed to further access the prediction ability of the model. Results On multivariate analysis of derivation cohort, independent factors for recurrence such as dysmenorrhea degree, sum of both cyst diameters, presence of adenomyosis, and other essential factors for recurrence such as age at surgery, presence of uterine fibroids were all selected into the nomogram. The C-index of the nomogram for predicting recurrence was 0.683 (95% CI, 0.610- 0.755). The calibration curve for probability of recurrence for 7 years and 9 years showed great agreement between prediction by nomogram and actual observation. Furthermore, the AUCs of risk score for 7-year and 9-year were 0.680 and 0.790 respectively. Conclusion This research tried to develop the predictive nomogram of recurrence for patients with endometrioma after cystectomy. The C-index and calibration curve of nomogram, as well as the AUC of the nomogram was potential to predict the recurrence probability. In addition, this predictive nomogram needs external data sets to further validate its prognostic accuracy in the future.
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Affiliation(s)
- Zhiyue Gu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Xiaoyan Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Jinghua Shi
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Yushi Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Jing Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Chenyu Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Hailan Yan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Jinhua Leng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
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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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Endometriosis in studies based on nationwide databases. Fertil Steril 2021; 117:454-455. [PMID: 34980430 DOI: 10.1016/j.fertnstert.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 11/23/2022]
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Arena A, Orsini B, Degli Esposti E, Raimondo D, Lenzi J, Verrelli L, Iodice R, Casadio P, Seracchioli R. Effects of the SARS-CoV-2 pandemic on women affected by endometriosis: a large cross-sectional online survey. Ann Med 2021; 53:1924-1934. [PMID: 34714186 PMCID: PMC8567944 DOI: 10.1080/07853890.2021.1991589] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/04/2021] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION The SARS-CoV-2 pandemic has forced healthcare providers to reorganize their activities to protect the population from infection, postponing or suspending many medical procedures. Patients affected by chronic conditions were among the most affected. In the case of catastrophes, women have a higher lifetime prevalence of post-traumatic stress disorder (PTSD), and those with endometriosis have higher anxiety levels, making them fragile in such circumstances. MATERIALS AND METHODS In this cross-sectional study, conducted in May 2020, we considered all women aged ≥18 years, followed up at our referral centre for endometriosis. Patients were sent an anonymous 6-section questionnaire via email, containing different validated tools for the evaluation of anxiety levels and the risk of PTSD. A multivariable linear regression was performed to assess the impact of patients' characteristics on the distress caused by the SARS-COV-2 pandemic. RESULTS Among the 468 women recruited, 68.8% were quite-to-extremely worried about not being able to access gynaecologic care, with almost one-third of them scoring ≥33 on the IES-R. Older age and increased levels of anxiety were associated with higher risks of PTSD (age: b = 0.28, 95% CI = 0.12 - 0.44; GAD-7: b = 1.71, 95% CI = 1.38 - 2.05), with up to 71.8% of patients with severe anxiety (GAD-7 > 15) having an IES-R score ≥33 suggestive for PTSD. Women who could leave home to work showed lower levels of PTSD (b = -4.79, 95% CI = -8.44 to - 1.15, ref. unemployed women). The implementation of telemedicine in routine clinical practice was favourably viewed by 75.6% of women. DISCUSSION Women with endometriosis are particularly exposed to the risk of PTSD during the SARS-CoV-2 pandemic, especially if they are older or have higher levels of anxiety. Gynaecologists should resort to additional strategies, and telemedicine could represent a feasible tool to help patients cope with this situation.KEY MESSAGESThe COVID-19 pandemic significantly impacted the lives of women with endometriosis, who appeared to have a considerable risk of PTSD.Older age, higher anxiety levels and unemployment were independently associated with the risk of developing PTSD.Clinicians should develop successful alternative strategies to help patients cope with this situation, and telemedicine might represent an applicable and acceptable solution.
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Affiliation(s)
- Alessandro Arena
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Via Massarenti, 13, IRCCS, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Benedetta Orsini
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Via Massarenti, 13, IRCCS, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Eugenia Degli Esposti
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Via Massarenti, 13, IRCCS, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Diego Raimondo
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Via Massarenti, 13, IRCCS, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Jacopo Lenzi
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), IRCCS Azienda Ospedaliero-Universitaria di Bologna a, Bologna, Italy
| | - Ludovica Verrelli
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Via Massarenti, 13, IRCCS, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Raffaella Iodice
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Via Massarenti, 13, IRCCS, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Paolo Casadio
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Via Massarenti, 13, IRCCS, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Renato Seracchioli
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Via Massarenti, 13, IRCCS, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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10
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Horan M, Glover L, Wingfield M. Managing endometrioma to optimize future fertility. Int J Gynaecol Obstet 2021; 158:512-519. [PMID: 34767627 DOI: 10.1002/ijgo.14020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/01/2021] [Accepted: 11/10/2021] [Indexed: 11/11/2022]
Abstract
The management of endometriomas in women wishing to preserve their fertility is complex. While surgery can help to achieve pregnancy in some, it may also have a detrimental effect on a woman's ovarian reserve. The present article reviews the impact of endometriomas on fertility and the different management approaches that should be considered in women who wish to preserve their fertility. This study also reviews the role of assisted reproduction in the setting of endometriomas, and the evolving role of oocyte cryopreservation for this benign but progressive disease. Using evidence from the latest guidelines and major publications, we emphasize the need to consider the woman's future fertility when navigating the diverse range of management strategies available, and outline an evidence-based framework to help facilitate fertility-friendly discussion, counseling and management of this complex disease.
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Affiliation(s)
- Maebh Horan
- Merrion Fertility Clinic, Dublin 2, Ireland.,Department of Obstetrics and Gynecology, National Maternity Hospital, Dublin 2, Ireland.,School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Louise Glover
- Merrion Fertility Clinic, Dublin 2, Ireland.,School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Mary Wingfield
- Merrion Fertility Clinic, Dublin 2, Ireland.,Department of Obstetrics and Gynecology, National Maternity Hospital, Dublin 2, Ireland.,School of Medicine, University College Dublin, Dublin 4, Ireland
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Management of Ovarian Endometrioma in Asymptomatic Reproductive Age Women. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2021. [DOI: 10.1007/s13669-021-00311-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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12
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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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Preoperative and perioperative intervention reduces the risk of recurrence of endometriosis in mice caused by either incomplete excision or spillage and dissemination. Reprod Biomed Online 2021; 43:379-393. [PMID: 34330642 DOI: 10.1016/j.rbmo.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/15/2021] [Accepted: 04/20/2021] [Indexed: 11/23/2022]
Abstract
RESEARCH QUESTION Can preoperative or perioperative intervention reduce the risk of recurrence of endometriosis caused by either incomplete excision or spillage and dissemination? DESIGN A mouse model of endometriosis recurrence caused by spillage and dissemination was first established using 24 female Balb/c mice. The spillage and dissemination model was used to test the efficacy of preoperative use of ketorolac, perioperative use of aprepitant and combined use of propranolol and andrographolide in a prospective, randomized mouse experiment involving 75 mice. The efficacy of these preoperative and perioperative interventions in a mouse recurrence model caused by incomplete excision was also tested using 72 mice. In all experiments, the baseline body weight and hotplate latency of all mice were measured and recorded before the induction of endometriosis, before the primary surgery and before sacrifice. In addition, all lesions were excised, weighed and processed for quantification and immunohistochemistry analysis of E-cadherin, α-SMA, VEGF, ADRB2 and putative markers of recurrence PR-B, p-p65, as well as Masson trichrome staining. RESULTS All interventions substantially and significantly suppressed the outgrowth of endometriotic lesions and reduced the risk of recurrence caused by either spillage and dissemination or incomplete excision (P = 0.0007 to 0.042). These interventions also significantly attenuated the generalized hyperalgesia, inhibited the staining of α-SMA, p-p65, VEGF and ADRB2 but increased staining of E-cadherin and PR-B, resulting in reduced fibrosis. CONCLUSION Given the excellent safety profiles of these drugs, these data strongly suggest that preoperative and perioperative intervention may potentially reduce the risk of endometriosis recurrence effectively.
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Del Forno S, Cofano M, Degli Esposti E, Manzara F, Lenzi J, Raimondo D, Arena A, Paradisi R, Casadio P, Seracchioli R. Long-Term Medical Therapy after Laparoscopic Excision of Ovarian Endometriomas: Can We Reduce and Predict the Risk of Recurrence? Gynecol Obstet Invest 2021; 86:170-176. [PMID: 33849018 DOI: 10.1159/000514310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/04/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Up to 32% of women experience anatomic recurrence after conservative surgery for endometriomas, while pain recurs in 10-40% of cases. Long-term postoperative hormonal therapy is recommended to prevent disease recurrence. We evaluated the efficacy of long-term therapy with estroprogestins (EPs) or progestins (Ps) in preventing endometrioma recurrence, as identifiable cysts and subjective symptoms, after laparoscopic excision. DESIGN This retrospective cohort study included 375 women submitted to laparoscopic endometrioma excision. Women were followed up at 6 and 12 months and then yearly after surgery. Based on postoperative medical therapy, women were divided into 4 groups: nonusers, cyclic EP users, continuous EP users, and progestogen users. Materials, Setting, Methods: Anamnestic and anthropometric characteristics were collected as well as clinical and surgical data. Gynecological examination, and transvaginal and transabdominal ultrasound scans were performed. Pain (numerical rating score >5) and endometrioma recurrence at ultrasound (ovarian cyst with typical sonographic features ≥10 mm in mean diameter) were recorded at each examination. The reoperation rate in women with recurrence was investigated. RESULTS The median follow-up was 3.7 years with a maximum of 16.7 years. Most patients used EPs (119 cyclic and 61 continuous users), 95 used P, and 100 were nonusers. In 135 women (36%), endometriotic cyst recurrence was diagnosed, with a mean diameter of 18.7 ± 10.8 mm (range 10-55 mm). The median recurrent cyst-free time was 7.9 years (95% CI 5.8-10.8). Dysmenorrhea was the first symptom to reappear, affecting 162 patients (43.2%). Upon multivariable regression analysis, continuous users had a lower risk of relapse (OR 0.56, 95% CI 0.32-0.99), in terms of both cysts and symptom recurrence, than patients who received no medications. The reoperation rate was 16.2%. LIMITATIONS The main limitation of this study is its retrospective design. Also, women switching therapies throughout the follow-up period were sorted into one of the study groups based on the longest treatment taken, without considering the discontinuation rates. CONCLUSIONS Long-term EPs, administered in a continuous regimen and starting immediately after conservative surgery for endometriomas, seem to reduce the disease recurrence risk.
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Affiliation(s)
- Simona Del Forno
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maria Cofano
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Eugenia Degli Esposti
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federica Manzara
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Jacopo Lenzi
- Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Diego Raimondo
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandro Arena
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Roberto Paradisi
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paolo Casadio
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Renato Seracchioli
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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15
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Chen J, Huang D, Zhang J, Shi L, Li J, Zhang S. The effect of laparoscopic excisional and ablative surgery on ovarian reserve in patients with endometriomas: A retrospective study. Medicine (Baltimore) 2021; 100:e24362. [PMID: 33607770 PMCID: PMC7899828 DOI: 10.1097/md.0000000000024362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/21/2020] [Indexed: 01/05/2023] Open
Abstract
This study investigates the effect of 2 laparoscopic methods on ovarian reserve in patients of reproductive age with endometriomas.This was a retrospective study performed at a tertiary medical center from Jan 1st to Dec 31st, 2016. Laparoscopic cystectomy (group 1, 46 patients) and laparoscopic ovarian drainage and ablation with bipolar coagulation at low power (group 2, 30 patients) were performed to treat endometriomas larger than 3 cm. Anti-Müllerian hormone was used to assess ovarian reserve before and after surgery.There were no statistically significant differences in patients' baseline clinical characteristics, endometriotic stage, operative time, and follow-up time between the groups. The mean serum anti-Müllerian hormone concentration decreased significantly from 4.25 ng/ml to 3.40 ng/ml in group 1 compared with 4.47 ng/ml to 3.95 ng/ml in group 2 (P = .04). Pregnancy rates were 71.05% in group 1 and 73.08% in group 2, with a mean follow-up of 30.40 months and 32.35 months (P > .99), respectively. Although there was no statistical significance, the recurrence rate in group 1 was lower than that in group 2 (4.35% vs 16.67%, respectively; P = .11). The mean diameter of recurrent cysts was 1.75 cm in group 1 and 1.54 cm in group 2 (P = .13).Appropriate laparoscopic electrocautery of the endometrioma wall with a bipolar instrument may be a valid alternative to traditional laparoscopic cystectomy, with less effects on ovarian reserve.
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16
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Klebanoff JS, Inaty D, Rahman S, Habib N, Bendifallah S, Ayoubi JM, Moawad GN. Appropriate surgical management of ovarian endometrioma: excision or drainage? Horm Mol Biol Clin Investig 2021; 43:127-135. [PMID: 33600671 DOI: 10.1515/hmbci-2020-0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/03/2021] [Indexed: 11/15/2022]
Abstract
Endometriosis negatively impacts the lives of countless women around the world. When medical management fails to improve quality of life often women are left making a decision whether or not to proceed with surgery. With endometriomas, patient's surgical options include complete surgical removal or drainage via laparoscopy. Here, we review the literature to discuss both techniques, excision and drainage of endometriomas, and what the research supports for endometrioma management.
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Affiliation(s)
- Jordan S Klebanoff
- Department of Obstetrics and Gynecology, Main Line Health, Wynewood, PA, USA
| | - Dana Inaty
- University of Balamand School of Medicine, Balamand, Lebanon
| | - Sara Rahman
- Department of Obstetrics and Gynecology, The George Washington University Hospital, Washington, DC, USA
| | - Nassir Habib
- Department of Obstetrics and Gynecology, Francois Quesnay Hospital, Mantes-la-Jolie, France
| | - Sofiane Bendifallah
- Department of Gynaecology and Obstetrics, University of Balamand School of Medicine, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Sorbonne, France.,UMRS-938, Sorbonne University, Sorbonne, France.,Groupe de Recherche Clinique 6 (GRC6-Sorbonne Université): Centre Expert En Endométriose (C3E), Sorbonne, France
| | - Jean Marc Ayoubi
- Department of Obstetrics and Gyncology and Reproductive Medicine, Hopital Foch, Faculté de Médecine Paris Ouest (UVSQ), Suresnes, France
| | - Gaby N Moawad
- Department of Obstetrics and Gynecology, The George Washington University Hospital, Washington, DC, USA
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17
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Chen I, Mallick R, Allaire C, Bajzak KI, Belland LM, Bougie O, Cassell KA, Choudhry AJ, Cundiff GW, Kroft J, Leyland NA, Maheux-Lacroix S, Rajakumar C, Randle E, Robertson D, Thiel JA, Tulandi T, Yong PJ, Laberge PY. Technicity in Canada: A Nationwide Whole-Population Analysis of Temporal Trends and Variation in Minimally Invasive Hysterectomies. J Minim Invasive Gynecol 2021; 28:1041-1050. [PMID: 33476750 DOI: 10.1016/j.jmig.2021.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/04/2021] [Accepted: 01/10/2021] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVE The objective of our study was to provide a contemporary description of hysterectomy practice and temporal trends in Canada. DESIGN A national whole-population retrospective analysis of data from the Canadian Institute for Health Information. SETTING Canada. PATIENTS All women who underwent hysterectomy for benign indication from April 1, 2007, to March 31, 2017, in Canada. INTERVENTIONS Hysterectomy. MEASUREMENTS AND MAIN RESULTS A total of 369 520 hysterectomies were performed in Canada during the 10-year period, during which the hysterectomy rate decreased from 313 to 243 per 100 000 women. The proportion of abdominal hysterectomies decreased (59.5% to 36.9%), laparoscopic hysterectomies increased (10.8% to 38.6%), and vaginal hysterectomies decreased (29.7% to 24.5%), whereas the national technicity index increased from 40.5% to 63.1% (p <.001, all trends). The median length of stay decreased from 3 (interquartile range 2-4) days to 2 (interquartile range 1-3), and the proportion of patients discharged within 24 hours increased from 2.1% to 7.2%. In year 2016-17, women aged 40 to 49 years had significantly increased risk of abdominal hysterectomy compared with women undergoing hysterectomy in other age categories (p <.001). Comparing women with menstrual bleeding disorders, women undergoing hysterectomy for endometriosis (adjusted relative risk [aRR] 1.36; 95% confidence interval [CI], 1.28-1.44) and myomas (aRR 2.01; 95% CI, 1.94-2.08) were at increased risk of abdominal hysterectomy, whereas women undergoing hysterectomy for pelvic organ prolapse and pelvic pain (aRR 1.47; 95% CI, 1.41-1.53) were at decreased risk. Using Ontario as the comparator, Nova Scotia (aRR 1.35; 95% CI, 1.27-1.43), New Brunswick (aRR 1.25; 95% CI, 1.18-1.32]), Manitoba (aRR 1.35; 95% CI, 1.28-1.43), and Newfoundland and Labrador (aRR 1.18; 95% CI, 1.10-1.27) had significantly higher risks of abdominal hysterectomy. In contrast, Saskatchewan (aRR 0.75; 95% CI, 0.74-0.77) and British Columbia (aRR 0.86; 95% CI, 0.85-0.88) had significantly lower risks, whereas Prince Edward Island, Quebec, and Alberta were not significantly different. CONCLUSION The proportion of minimally invasive hysterectomies for benign indication has increased significantly in Canada. The declining use of vaginal approaches and the variation among provinces are of concern and necessitate further study.
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Affiliation(s)
- Innie Chen
- Department of Obstetrics and Gynecology, University of Ottawa (Drs. Chen); Ottawa Hospital Research Institute, Ottawa, Ontario (Drs. Chen, Mallick, and Choudhry).
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, Ottawa, Ontario (Drs. Chen, Mallick, and Choudhry)
| | - Catherine Allaire
- Obstetrics & Gynecology, University of British Columbia, Vancouver, British Columbia (Drs. Allaire and Yong)
| | - Krisztina I Bajzak
- Obstetrics and Gynecology, Memorial University, St. John's, Newfoundland and Labrador (Dr. Bajzak)
| | - Liane M Belland
- Obstetrics and Gynecology, Peter Lougheed Centre, University of Calgary, Calgary, Alberta (Dr. Belland)
| | - Olga Bougie
- Obstetrics and Gynecology, Queen's University, Kingston, Ontario (Dr. Bougie)
| | - Krista A Cassell
- Obstetrics and Gynecology, Queen Elizabeth Hospital, Charlottetown, Prince Edward Island (Dr. Cassell)
| | - Abdul J Choudhry
- Ottawa Hospital Research Institute, Ottawa, Ontario (Drs. Chen, Mallick, and Choudhry)
| | - Geoffrey W Cundiff
- Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia (Dr. Cundiff)
| | - Jamie Kroft
- Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (Dr. Kroft)
| | - Nicholas A Leyland
- Obstetrics and Gynecology, McMaster University, Hamilton, Ontario (Dr. Leyland)
| | - Sarah Maheux-Lacroix
- Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec (Dr. Maheux-Lacroix and Laberge)
| | - Chandrew Rajakumar
- Obstetrics and Gynecology, University of Calgary, Calgary, Alberta (Dr. Rajakumar)
| | - Elizabeth Randle
- Obstetrics and Gynecology, Dalhousie University, Halifax, Nova Scotia (Dr. Randle)
| | - Deborah Robertson
- Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Ontario (Dr. Roberston)
| | - John A Thiel
- Obstetrics and Gynecology, University of Saskatchewan, Regina, Saskatchewan (Dr. Thiel)
| | - Togas Tulandi
- Obstetrics and Gynecology, McGill University, Montreal, Quebec (Dr. Tulandi), Canada
| | - Paul J Yong
- Obstetrics & Gynecology, University of British Columbia, Vancouver, British Columbia (Drs. Allaire and Yong)
| | - Philippe Y Laberge
- Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec (Dr. Maheux-Lacroix and Laberge)
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Wattanayingcharoenchai R, Rattanasiri S, Charakorn C, Attia J, Thakkinstian A. Postoperative hormonal treatment for prevention of endometrioma recurrence after ovarian cystectomy: a systematic review and network meta-analysis. BJOG 2021; 128:25-35. [PMID: 32558987 PMCID: PMC7754428 DOI: 10.1111/1471-0528.16366] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND The efficacy of hormonal regimens for the prevention of endometrioma recurrence in women who have undergone conservative surgery is still controversial. OBJECTIVE To compare the efficacy of different hormonal regimens in this context and to rank them. SEARCH STRATEGY MEDLINE and Scopus databases were searched through January 2020. SELECTION CRITERIA Randomised controlled trials (RCTs) or cohorts, comparing the effect of any pair of interventions (i.e. cyclic oral contraceptives [OC], continuous OC, gonadotropin-releasing hormone agonist [GnRHa], dienogest [DNG], levonorgestrel-releasing intrauterine system [LNG-IUS] and expectant management) on endometrioma recurrence were selected. DATA COLLECTION AND ANALYSIS Data were independently extracted by two reviewers. Relative treatment effects were estimated using network meta-analysis (NMA) and ranked in descending order. MAIN RESULTS Six RCTs (675 patients) and 16 cohorts (3089 patients) were included. NMA of the RCTs involving expectant management, cyclic OC, continuous OC, GnRHa and GnRHa + LNG-IUS, showed that all hormonal regimens had a nonsignificant lower risk of endometrioma recurrence compared with expectant management. NMA of the cohorts involving expectant, cyclic OC, continuous OC, GnRHa, DNG, LNG-IUS, GnRHa + OC, and GnRHa + LNG-IUS indicated that LNG-IUS, DNG, continuous OC, GnRHa + OC and cyclic OC had a significantly lower risk of endometrioma recurrence than expectant management. LNG-IUS was ranked highest, followed by DNG and GnRHa + LNG-IUS. Long-term use of hormonal treatment either OC or progestin had a significantly lower risk of endometrioma recurrence than expectant treatment. CONCLUSION In the NMA of RCTs, there was no evidence supporting hormonal treatment for postoperative prevention of endometrioma recurrence. This was at odds with the cohort evidence, which found the protective effect of OC and progestin regimens, especially long-term treatment. Large-scale RCTs of these agents are still required. TWEETABLE ABSTRACT Hormonal regimens given as long-term treatment tend to reduce risk of endometrioma recurrence after conservative surgery.
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Affiliation(s)
- R Wattanayingcharoenchai
- Department of Clinical Epidemiology and BiostatisticsFaculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand,Department of Obstetrics and GynaecologyFaculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - S Rattanasiri
- Department of Clinical Epidemiology and BiostatisticsFaculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - C Charakorn
- Department of Clinical Epidemiology and BiostatisticsFaculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand,Department of Obstetrics and GynaecologyFaculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - J Attia
- Centre for Clinical Epidemiology and BiostatisticsSchool of Medicine and Public HealthFaculty of Health and MedicineUniversity of NewcastleNew LambtonAustralia
| | - A Thakkinstian
- Department of Clinical Epidemiology and BiostatisticsFaculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
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Abdominal Wall Endometriosis: Two Case Reports and Literature Review. ACTA ACUST UNITED AC 2020; 56:medicina56120727. [PMID: 33371515 PMCID: PMC7767517 DOI: 10.3390/medicina56120727] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 12/20/2022]
Abstract
Background and objectives: Abdominal wall endometriosis, also known as scar endometriosis, is a rare condition that is becoming increasingly common. The recent rise in incidence is attributed primarily to the surge of cesarean births, figures that could be influenced in a positive manner considering the improvements brought towards the ultrasound diagnostic methods that have been made in recent years. Materials and Methods: Here we report the cases of two Caucasian women of 38- (G2P2) and 36-years old (G1P1), both subjected to an ultrasound examination due to a specific symptomatic panel reported during anamnesis. Independently of the current status, in the first patient, there were no reported symptom-specific associations with endometriosis, but she had a known history of mild hereditary thrombophilia; the second woman suffered from two conditions positively associated with endometriosis. Results: In both cases, abnormal structures were revealed, with the diagnostic(s) of endometriosis being histologically confirmed based on a set of features observed during the investigation. Conclusions: This paper aims to highlight the importance of reducing cesarean births and to consider the diagnosis of scar endometriosis in women with a history of obstetric or gynaecological surgeries who present with cyclic, recurrent abdominal pain.
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Chen I, Veth VB, Choudhry AJ, Murji A, Zakhari A, Black AY, Agarpao C, Maas JW. Pre- and postsurgical medical therapy for endometriosis surgery. Cochrane Database Syst Rev 2020; 11:CD003678. [PMID: 33206374 PMCID: PMC8127059 DOI: 10.1002/14651858.cd003678.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endometriosis is a common gynaecological condition affecting 10% to 15% of reproductive-age women and may cause dyspareunia, dysmenorrhoea, and infertility. One treatment strategy is combining surgery and medical therapy to reduce the recurrence of endometriosis. Though the combination of surgery and medical therapy appears to be beneficial, there is a lack of clarity about the appropriate timing of when medical therapy should be used in relation with surgery, that is, before, after, or both before and after surgery, to maximize treatment response. OBJECTIVES To determine the effectiveness of medical therapies for hormonal suppression before, after, or both before and after surgery for endometriosis for improving painful symptoms, reducing disease recurrence, and increasing pregnancy rates. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and two trials registers in November 2019 together with reference checking and contact with study authors and experts in the field to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) which compared medical therapies for hormonal suppression before, after, or before and after, therapeutic surgery for endometriosis. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. Where possible, we combined data using risk ratio (RR), standardized mean difference or mean difference (MD) and 95% confidence intervals (CI). Primary outcomes were: painful symptoms of endometriosis as measured by a visual analogue scale (VAS) of pain, other validated scales or dichotomous outcomes; and recurrence of disease as evidenced by EEC (Endoscopic Endometriosis Classification), rAFS (revised American Fertility Society), or rASRM (revised American Society for Reproductive Medicine) scores at second-look laparoscopy. MAIN RESULTS We included 26 trials with 3457 women with endometriosis. We used the term "surgery alone" to refer to placebo or no medical therapy. Presurgical medical therapy compared with placebo or no medical therapy Compared to surgery alone, we are uncertain if presurgical medical hormonal suppression reduces pain recurrence at 12 months or less (dichotomous) (RR 1.10, 95% CI 0.72 to 1.66; 1 RCT, n = 262; very low-quality evidence) or whether it reduces disease recurrence at 12 months - total (AFS score) (MD -9.6, 95% CI -11.42 to -7.78; 1 RCT, n = 80; very low-quality evidence). We are uncertain if presurgical medical hormonal suppression decreases disease recurrence at 12 months or less (EEC stage) compared to surgery alone (RR 0.88, 95% CI 0.78 to 1.00; 1 RCT, n = 262; very low-quality evidence). We are uncertain if presurgical medical hormonal suppression improves pregnancy rates compared to surgery alone (RR 1.16, 95% CI 0.99 to 1.36; 1 RCT, n = 262; very low-quality evidence). No trials reported pelvic pain at 12 months or less (continuous) or disease recurrence at 12 months or less. Postsurgical medical therapy compared with placebo or no medical therapy We are uncertain about the improvement observed in pelvic pain at 12 months or less (continuous) between postsurgical medical hormonal suppression and surgery alone (MD -0.48, 95% CI -0.64 to -0.31; 4 RCTs, n = 419; I2 = 94%; very low-quality evidence). We are uncertain if there is a difference in pain recurrence at 12 months or less (dichotomous) between postsurgical medical hormonal suppression and surgery alone (RR 0.85, 95% CI 0.65 to 1.12; 5 RCTs, n = 634; I2 = 20%; low-quality evidence). We are uncertain if postsurgical medical hormonal suppression improves disease recurrence at 12 months - total (AFS score) compared to surgery alone (MD -2.29, 95% CI -4.01 to -0.57; 1 RCT, n = 51; very low-quality evidence). Disease recurrence at 12 months or less may be reduced with postsurgical medical hormonal suppression compared to surgery alone (RR 0.30, 95% CI 0.17 to 0.54; 4 RCTs, n = 433; I2 = 58%; low-quality evidence). We are uncertain about the reduction observed in disease recurrence at 12 months or less (EEC stage) between postsurgical medical hormonal suppression and surgery alone (RR 0.80, 95% CI 0.70 to 0.91; 1 RCT, n = 285; very low-quality evidence). Pregnancy rate is probably increased with postsurgical medical hormonal suppression compared to surgery alone (RR 1.22, 95% CI 1.06 to 1.39; 11 RCTs, n = 932; I2 = 24%; moderate-quality evidence). Pre- and postsurgical medical therapy compared with surgery alone or surgery and placebo There were no trials identified in the search for this comparison. Presurgical medical therapy compared with postsurgical medical therapy We are uncertain about the difference in pain recurrence at 12 months or less (dichotomous) between postsurgical and presurgical medical hormonal suppression therapy (RR 1.40, 95% CI 0.95 to 2.07; 2 RCTs, n = 326; I2 = 2%; low-quality evidence). We are uncertain about the difference in disease recurrence at 12 months or less (EEC stage) between postsurgical and presurgical medical hormonal suppression therapy (RR 1.10, 95% CI 0.95 to 1.28; 1 RCT, n = 273; very low-quality evidence). We are uncertain about the difference in pregnancy rate between postsurgical and presurgical medical hormonal suppression therapy (RR 1.05, 95% CI 0.91 to 1.21; 1 RCT, n = 273; very low-quality evidence). No trials reported pelvic pain at 12 months or less (continuous), disease recurrence at 12 months - total (AFS score) or disease recurrence at 12 months or less (dichotomous). Postsurgical medical therapy compared with pre- and postsurgical medical therapy There were no trials identified in the search for this comparison. Serious adverse effects for medical therapies reviewed There was insufficient evidence to reach a conclusion regarding serious adverse effects, as no studies reported data suitable for analysis. AUTHORS' CONCLUSIONS Our results indicate that the data about the efficacy of medical therapy for endometriosis are inconclusive, related to the timing of hormonal suppression therapy relative to surgery for endometriosis. In our various comparisons of the timing of hormonal suppression therapy, women who receive postsurgical medical therapy compared with no medical therapy or placebo may experience benefit in terms of disease recurrence and pregnancy. There is insufficient evidence regarding hormonal suppression therapy at other time points in relation to surgery for women with endometriosis.
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Affiliation(s)
- Innie Chen
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Veerle B Veth
- Department of Obstetrics & Gynecology, Máxima Medical Center, Veldhoven, Netherlands
| | | | - Ally Murji
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Andrew Zakhari
- Royal Victoria Hospital MUHC Glen Site, McGill University, Toronto, Canada
| | - Amanda Y Black
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Jacques Wm Maas
- Department of Obstetrics & Gynecology, Máxima Medical Center, Veldhoven, Netherlands
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21
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Zakhari A, Delpero E, McKeown S, Tomlinson G, Bougie O, Murji A. Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis. Hum Reprod Update 2020; 27:96-107. [PMID: 33020832 PMCID: PMC7781224 DOI: 10.1093/humupd/dmaa033] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/16/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew Zakhari
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada.,Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada
| | - Emily Delpero
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada.,Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada
| | - Sandra McKeown
- Bracken Health Sciences Library, Queen's University, Kingston, ON K7L 3N6, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network (UHN), Toronto, ON M5G 2C4, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
| | - Olga Bougie
- Department of Obstetrics and Gynecology, Kingston General Hospital Victory 4, Queen's University, Kingston, ON K7L 2V7, Canada
| | - Ally Murji
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada.,Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada.,700 University Avenue, 3rd Floor, Toronto, ON M5G 1Z5, Canada
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22
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Guo SW, Martin DC. Reply: Perioperative intervention vs. postoperative menstruation suppression in preventing recurrence of endometriosis. Hum Reprod 2020; 35:1247-1248. [PMID: 32400876 DOI: 10.1093/humrep/deaa054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Sun-Wei Guo
- Shanghai OB/GYN Hospital, Fudan University, Shanghai 200011, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China
| | - Dan C Martin
- School of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Institutional Review Board, Virginia Commonwealth University, Richmond, VA, USA
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23
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Roman H, Chanavaz-Lacheray I, Forestier D, Magne E, Celhay O, Pasticier G, Susperregui J, Merlot B. [Early postoperative complications in a multidisciplinary surgical center exclusively dedicated to endometriosis: A 491-patients series]. ACTA ACUST UNITED AC 2020; 48:484-490. [PMID: 32173597 DOI: 10.1016/j.gofs.2020.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The objective of our study is to present the activity volume and postoperative complications in a center exclusively destined to endometriosis surgery. METHODS Retrospective mono-centric study analyzing data collected prospectively in patients surgically managed for endometriosis from September 2018 to August 2019. RESULTS Four hundred and ninety-one patients underwent surgery for endometriosis during 12 consecutive months: 268 for colorectal localizations (54.6%), 51 for endometriosis of the urinary tract (10.4%), 17 for nodules of ileum and right colon (3.5%), 43 for nodules of parametriums (8.8%), 12 for nodules of sacral roots and sciatic nerves (2.4%), 7 for diaphragmatic localizations (1.4%). Among 268 patients with colorectal endometrioses, of which 48.1% concerned the low and mid rectum, shaving was performed in 102 cases, disc excision in 96 cases and colorectal resection in 100 cases. Stoma was performed in 13.1% of the cases. Patients could have 2 different procedures for multiple colorectal nodules. One hundred and ninety-nine ovarian endometriomas were managed by plasma energy ablation in 64.8%, sclerotherapy in 11.1%, cystectomy in 13.1%, oophorectomy in 11.1%. Major postoperative complications included 12 rectovaginal fistulas, while 18 other surgical procedures were carried out for various complications. In all, 38.1% of procedures involved a general surgeon and 5.3% an urologist. CONCLUSION The creation of centers exclusively destined to endometriosis surgery allows the multidisciplinary management of a high number of patients, with an over-representation of severe forms and rare locations of the disease, followed by satisfactory complication rates.
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Affiliation(s)
- H Roman
- Centre d'endométriose, clinique Tivoli-Ducos, 220, rue Mandron, 33000 Bordeaux, France; Département de chirurgie gynécologique et neuropelvéologie, Hôpital Universitaire d'Aarhu, Aarhus, Danemark.
| | - I Chanavaz-Lacheray
- Centre d'endométriose, clinique Tivoli-Ducos, 220, rue Mandron, 33000 Bordeaux, France
| | - D Forestier
- Centre d'endométriose, clinique Tivoli-Ducos, 220, rue Mandron, 33000 Bordeaux, France
| | - E Magne
- Centre d'endométriose, clinique Tivoli-Ducos, 220, rue Mandron, 33000 Bordeaux, France
| | - O Celhay
- Centre d'endométriose, clinique Tivoli-Ducos, 220, rue Mandron, 33000 Bordeaux, France
| | - G Pasticier
- Centre d'endométriose, clinique Tivoli-Ducos, 220, rue Mandron, 33000 Bordeaux, France
| | - J Susperregui
- Centre d'endométriose, clinique Tivoli-Ducos, 220, rue Mandron, 33000 Bordeaux, France
| | - B Merlot
- Centre d'endométriose, clinique Tivoli-Ducos, 220, rue Mandron, 33000 Bordeaux, France
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24
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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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25
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Yong PJ, Alsowayan N, Noga H, Williams C, Allaire C, Lisonkova S, Bedaiwy MA. CHC for pelvic pain in women with endometriosis: ineffectiveness or discontinuation due to side-effects. Hum Reprod Open 2020; 2020:hoz040. [PMID: 32128454 PMCID: PMC7048681 DOI: 10.1093/hropen/hoz040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 11/16/2019] [Indexed: 01/20/2023] Open
Abstract
STUDY QUESTION What are the use patterns and factors associated with combined hormonal contraception (CHC) ineffectiveness or discontinuation due to side-effects in patients with endometriosis and pelvic pain? SUMMARY ANSWER Worse chronic pelvic pain (CPP) severity and pelvic floor myalgia were associated with continuous CHC ineffectiveness, while poorer quality-of-life was associated with continuous CHC discontinuation due to side-effects. WHAT IS KNOWN ALREADY CHC is a first line of therapy for endometriosis-associated pelvic pain in women. However, some patients state that CHC is ineffective for their pain, while others have to discontinue CHC due to side-effects. STUDY DESIGN, SIZE, DURATION Analysis of a prospective patient database from a tertiary care referral center for patients with endometriosis and pelvic pain between December 2013 and April 2015 was carried out. PARTICIPANTS/MATERIALS, SETTING AND METHODS A total of 373 patients of reproductive age with endometriosis from the database were included in the study. Data included patient self-reported questionnaires, physical examination findings and validated instruments. There were four variables of interest: history of cyclical CHC ineffectiveness (yes/no), history of cyclical CHC discontinuation due to side-effects (yes/no), history of continuous CHC ineffectiveness (yes/no) and history of continuous CHC discontinuation due to side-effects (yes/no). The primary outcome was CPP severity for the past 3 months (score of 0–10), and secondary outcomes were other pelvic pain scores, quality-of-life on the Endometriosis Health Profile 30 (EHP-30) and underlying conditions including irritable bowel syndrome, painful bladder syndrome, abdominal wall pain, pelvic floor myalgia and depression, anxiety and pain catastrophizing. MAIN RESULTS AND THE ROLE OF CHANCE Among the 373 cases in the dataset, prior cyclical CHC use was reported by 228 (61.1%) women, of which 103 (27.6%) stated it was ineffective for their pain and 94 (25.2%) stated they discontinued CHC due to side-effects. Previous continuous CHC use was reported by 175 (46.9%) women, of which 67 (18.0%) stated it was ineffective and 59 (15.8%) stated they discontinued due to side-effects. Worse CPP severity in the last 3 months was associated with a history of continuous CHC ineffectiveness (P < 0.001). Poorer quality-of-life was present in women who reported a history of continuous CHC discontinuation due to side-effects (P = 0.005). Among the underlying conditions, pelvic floor tenderness (as a marker of pelvic floor myalgia) was associated with CHC ineffectiveness. LIMITATIONS AND REASONS FOR CAUTION This study involved patient recall and no longitudinal follow-up. Also, we do not have data on the type of side-effect that led to discontinuation. Medication ineffectiveness was reported subjectively by the patient rather than using standardized criteria. Finally, the diagnosis of endometriosis was based on previous surgery or a current nodule or endometrioma on examination/ultrasound; without prospective surgical data on all the patients, it was not possible to do a sub-analysis by current surgical features (e.g. stage). WIDER IMPLICATIONS OF THE FINDINGS In women with endometriosis, CHC ineffectiveness was associated with worse CPP and pelvic floor myalgia, which suggests myofascial or nervous system contributors to CPP that does not respond to hormonal suppression. A tender pelvic floor, as a sign of pelvic floor myalgia, may be a clinical marker of patients with endometriosis who are less likely to have an optimal response to hormonal suppression. For women who discontinue CHC due to side-effects, research is needed to help alleviate these side-effects as these patients report worse quality-of-life. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by a Canadian Institutes of Health Research (CIHR) Transitional Open Operating Grant (MOP-142273) as well as BC Women’s Hospital and the Women’s Health Research Institute. PY is also supported by a Health Professional Investigator Award from the Michael Smith Foundation for Health Research. MB/CA has financial affiliations with Abbvie and Allergan; the other authors have no conflicts of interest.
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Affiliation(s)
- Paul J Yong
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver V6H3N1, Canada.,BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver V6H3N1, Canada.,Women's Health Research Institute, Vancouver V6H3N1, Canada
| | - Najla Alsowayan
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver V6H3N1, Canada
| | - Heather Noga
- BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver V6H3N1, Canada.,Women's Health Research Institute, Vancouver V6H3N1, Canada
| | - Christina Williams
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver V6H3N1, Canada.,BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver V6H3N1, Canada
| | - Catherine Allaire
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver V6H3N1, Canada.,BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver V6H3N1, Canada.,Women's Health Research Institute, Vancouver V6H3N1, Canada
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver V6H3N1, Canada.,Women's Health Research Institute, Vancouver V6H3N1, Canada
| | - Mohamed A Bedaiwy
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver V6H3N1, Canada.,BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver V6H3N1, Canada.,Women's Health Research Institute, Vancouver V6H3N1, Canada
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26
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Recurrence Patterns after Surgery in Patients with Different Endometriosis Subtypes: A Long-Term Hospital-Based Cohort Study. J Clin Med 2020; 9:jcm9020496. [PMID: 32054117 PMCID: PMC7073694 DOI: 10.3390/jcm9020496] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 12/14/2022] Open
Abstract
Recurrence of endometriosis after surgery constitutes a serious challenge. Whether there is an evolution of lesion subtypes with each recurrence and whether certain lesions subtypes tend to recur faster than others is not adequately addressed. Medical records of all patients who underwent surgery for endometriosis between 1997 and 2018 in the Department of Gynecology and Obstetrics, University of Bern, were reviewed. Inclusion criteria was surgically confirmed endometriosis recurrence, defined as a subsequent surgery for endometriosis after a previous complete surgical excision of endometriosis lesions. Three subtypes of endometriosis were defined: superficial peritoneal endometriosis (SUP), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). Time to recurrence and variation in endometriosis subtype between the first and recurrent surgeries were the primary outcome measures. Out of the 322 patients with recurrent surgery that were identified, for 234 of them, the endometriosis subtype at first surgery was confirmed and classified (SUP = 56, OMA = 124, DIE = 54). No statistically significant difference was found for time to recurrence between lesion subtypes. SUP compared to the other groups had a higher possibility of presenting with SUP at recurrence (Odds Ratio (OR): 3.65, 95% confidence interval (CI): 1.74–7.51) and OMA compared to the other groups had a higher possibility of presenting with OMA at recurrence (OR: 3.72, 95% CI: 2.04–6.74). Nevertheless, a large number of SUP patients subsequently presented with OMA (10/56: 17.9%) or DIE (27/56: 48.2%) lesions at recurrence. Similarly, a large number of OMA patients subsequently presented with DIE (49/124: 39.5%) lesions at recurrence. In conclusion, although SUP and OMA patients compared to the others are more likely to present with the same subtype at recurrence, increasing lesion subtype severity occurs in a substantial proportion of patients. Time to recurrence is independent from the lesion subtype at first surgery.
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27
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Habib N, Centini G, Lazzeri L, Amoruso N, El Khoury L, Zupi E, Afors K. Bowel Endometriosis: Current Perspectives on Diagnosis and Treatment. Int J Womens Health 2020; 12:35-47. [PMID: 32099483 PMCID: PMC6996110 DOI: 10.2147/ijwh.s190326] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/29/2019] [Indexed: 12/13/2022] Open
Abstract
Endometriosis is a chronic condition primarily affecting young women of reproductive age. Although some women with bowel endometriosis may be asymptomatic patients typically report a myriad of symptoms such as alteration in bowel habits (constipation/diarrhoea) dyschezia, dysmenorrhoea and dyspareunia in addition to infertility. To date, there are no clear guidelines on the evaluation of patients with suspected bowel endometriosis. Several techniques have been proposed including transvaginal and/or transrectal ultrasonography, magnetic resonance imaging, and double-contrast barium enema. These different imaging modalities provide greater information regarding presence, location and extent of endometriosis ensuring patients are adequately informed whilst also optimizing preoperative planning. In cases where surgical management is indicated, surgery should be performed by experienced surgeons, in centres with access to multidisciplinary care. Treatment should be tailored according to patient symptoms and wishes with a view to excising as much disease as possible, whilst at the same time preserving organ function. In this review article current perspectives on diagnosis and management of bowel endometriosis are discussed.
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Affiliation(s)
- Nassir Habib
- Department of Obstetrics and Gynaecology, Beaujon Hospital-University of Paris, Clichy Cedex 92110, France
| | - Gabriele Centini
- Department of Molecular and Developmental Medicine, University of Siena, Ospedale Santa Maria alle Scotte, Siena 53100, Italy
| | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, University of Siena, Ospedale Santa Maria alle Scotte, Siena 53100, Italy
| | - Nicola Amoruso
- Department of Molecular and Developmental Medicine, University of Siena, Ospedale Santa Maria alle Scotte, Siena 53100, Italy
| | - Lionel El Khoury
- Department of Colorectal Surgery-Delafontaine Hospital, Saint Denis 93200, France
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, University of Siena, Ospedale Santa Maria alle Scotte, Siena 53100, Italy
| | - Karolina Afors
- Department of Obstetrics and Gynaecology, Whittington Hospital, London, UK
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28
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Triantafyllidou O, Kolovos G, Voros C, Vlachos A, Vakas P, Vlahos N. Time to full effect, following treatment with combined oral contraceptives (cyclic versus continuous administration) in patients with endometriosis after laparoscopic surgery: a prospective cohort study. HUM FERTIL 2020; 25:72-79. [DOI: 10.1080/14647273.2019.1704451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
| | - Georgios Kolovos
- 2nd Department of Obstetrics and Gynecology, “Aretaieion” University Hospital, Athens, Greece
| | - Charalambos Voros
- 1st Department of Obstetrics and Gynecology, “Alexandra” University Hospital, Athens, Greece
| | - Athanasios Vlachos
- Department of Gynecological Oncology, “Iaso” Maternity Hospital, Athens, Greece
| | - Panagiotis Vakas
- 2nd Department of Obstetrics and Gynecology, “Aretaieion” University Hospital, Athens, Greece
| | - Nikos Vlahos
- 2nd Department of Obstetrics and Gynecology, “Aretaieion” University Hospital, Athens, Greece
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29
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Medical treatment of endometriosis: is it a choice of the physician? GINECOLOGIA.RO 2020. [DOI: 10.26416/gine.27.1.2020.2885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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30
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Angioni S, Pontis A, Malune ME, Cela V, Luisi S, Litta P, Vignali M, Nappi L. Is dienogest the best medical treatment for ovarian endometriomas? Results of a multicentric case control study. Gynecol Endocrinol 2020; 36:84-86. [PMID: 31311360 DOI: 10.1080/09513590.2019.1640674] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Ovarian endometriomas are common manifestations of endometriosis. Surgical excision has been shown to potentially decrease ovarian reserves. In this prospective study, we included 81 patients with ovarian endometriosis. 40 were treated with 2 mg of dienogest daily (DNG) and 41 were treated with cyclic oral estro-progestins (ethinyl estradiol 30 mcg [EE] plus dienogest 2 mg) (DNG + EE). Aim of the study was the effect of the treatment on the size of the endometriotic cysts. Further, in the symptomatic patients, follow-up included an evaluation of chronic pain before and during treatment. Both treatments were able to significantly decrease the pain in symptomatic patients with no statistical differences. The mean visual analog scale score at enrollment was 65 ± 14 and 70 ± 18, and there was significant improvement (19 ± 15, p < .001, DNG; 18 ± 12, p < .001, DNG + EE). The size of the endometrioma cysts were significantly reduced in the DNG group. The mean cyst diameter was 52 ± 22 mm at baseline and 32 ± 12 mm after six months of treatment (p < .001), yielding a 75% volume reduction in DNG group. The decrease in the size of endometrioma cysts observed in the women treated with only progestin could be noteworthy, as it may reduce the negative impacts on the affected ovary and avoid surgery.
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Affiliation(s)
- Stefano Angioni
- Department of Obstetrics and Gynecology, Azienda Ospedaliero Universitaria, Presidio Policlinico di Monserrato, University of Cagliari, Monserrato, Italy
| | - Alessandro Pontis
- Department of Obstetrics and Gynecology, San Francesco Hospital, Nuoro, Italy
| | - Maria E Malune
- Department of Obstetrics and Gynecology, Azienda Ospedaliero Universitaria, Presidio Policlinico di Monserrato, University of Cagliari, Monserrato, Italy
| | - Vito Cela
- Department of Obstetrics and Gynecology, University of Pisa, Pisa, Italy
| | - Stefano Luisi
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Pietro Litta
- Department of Gynaecological Sciences and Human Reproduction, University of Padua, Padua, Italy
| | | | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
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Chapron C, Marcellin L, Borghese B, Santulli P. Rethinking mechanisms, diagnosis and management of endometriosis. Nat Rev Endocrinol 2019; 15:666-682. [PMID: 31488888 DOI: 10.1038/s41574-019-0245-z] [Citation(s) in RCA: 426] [Impact Index Per Article: 85.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2019] [Indexed: 02/08/2023]
Abstract
Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.
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Affiliation(s)
- Charles Chapron
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France.
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France.
- Department 'Development, Reproduction and Cancer', Institut Cochin, INSERM U1016, Université Paris Descartes, Paris, France.
| | - Louis Marcellin
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
- Department 'Development, Reproduction and Cancer', Institut Cochin, INSERM U1016, Université Paris Descartes, Paris, France
| | - Bruno Borghese
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
- Department 'Development, Reproduction and Cancer', Institut Cochin, INSERM U1016, Université Paris Descartes, Paris, France
| | - Pietro Santulli
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
- Department 'Development, Reproduction and Cancer', Institut Cochin, INSERM U1016, Université Paris Descartes, Paris, France
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Ceccaroni M, Bounous VE, Clarizia R, Mautone D, Mabrouk M. Recurrent endometriosis: a battle against an unknown enemy. EUR J CONTRACEP REPR 2019; 24:464-474. [PMID: 31550940 DOI: 10.1080/13625187.2019.1662391] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Recurrence of endometriosis after conservative surgery is not an uncommon finding. There is no uniformity, however, on what the term 'recurrence' means. Recurrence is variously defined in the literature as the relapse of pain, clinical or instrumental detection of an endometriotic lesion, repeat rise in CA 125 levels, or evidence of recurrence found during repeat surgery. Consequently, the reported recurrence rate varies widely (0-89%) in the different series, depending on its definition and the type of study performed. As endometriosis recurrence seems to be an indeterminate enemy, we set out to examine exactly what we were fighting in our everyday battle. In this narrative review, we aimed to seek an answer to questions related to endometriosis recurrence, some of which are often asked by our patients.
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Affiliation(s)
- Marcello Ceccaroni
- Department of Obstetrics and Gynaecology, Gynaecological Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Valentina Elisabetta Bounous
- Department of Surgical Sciences, Unit of Gynaecology and Obstetrics, Mauriziano Umberto I Hospital, University of Turin, Turin, Italy
| | - Roberto Clarizia
- Department of Obstetrics and Gynaecology, Gynaecological Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Daniele Mautone
- Department of Obstetrics and Gynaecology, Gynaecological Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Mohamed Mabrouk
- Minimally Invasive Pelvic Surgery Unit, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
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Goldberg JM, Falcone T, Diamond MP. Current controversies in tubal disease, endometriosis, and pelvic adhesion. Fertil Steril 2019; 112:417-425. [DOI: 10.1016/j.fertnstert.2019.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/07/2019] [Accepted: 06/17/2019] [Indexed: 12/20/2022]
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Li XY, Chao XP, Leng JH, Zhang W, Zhang JJ, Dai Y, Shi JH, Jia SZ, Xu XX, Chen SK, Wu YS. Risk factors for postoperative recurrence of ovarian endometriosis: long-term follow-up of 358 women. J Ovarian Res 2019; 12:79. [PMID: 31470880 PMCID: PMC6717364 DOI: 10.1186/s13048-019-0552-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/13/2019] [Indexed: 11/19/2022] Open
Abstract
Objective To explore the risk factors for the recurrence of endometrioma and the risk factors for the recurrence of endometriosis-related pain after long-term follow-up. Methods This study retrospectively analyzed 358 women with endometriomas who had a minimum of 5-years follow up after laparoscopic endometrioma excision, which was performed at Peking Union Medical College Hospital from January 2009 to April 2013. All women were divided into recurrence group and nonrecurrence group. Analysis was performed with regard to preoperative history, laboratory analysis, findings during surgery, and symptoms during follow-up, including improvement and recurrence. Results The cumulative incidence rates of recurrence from 5 to 10 years after surgery were 15.4, 16.8, 19.3, 22.5, 22.5, and 22.5%, respectively. Significant differences were found between two groups in terms of age at surgery (RR: 0.764, 95% CI: 0.615–0.949, p = 0.015), duration of dysmenorrhea (RR: 1.120, 95% CI: 1.054–1.190, p < 0.001), presence of adenomyosis (RR: 1.629, 95% CI: 1.008–2.630, p = 0.046), CA125 level (RR: 1.856, 95% CI: 1.072–3.214, p = 0.021) and severity of dysmenorrhea. The severity of dysmenorrhea (RR: 1.711, 95% CI: 1.175–2.493, p = 0.005) and postoperative pregnancy (RR: 0.649, 95% CI: 0.460–0.914, p = 0.013) were significantly correlated with endometrioma recurrence in the multivariate analysis. No significant associations were found between the recurrence rate and gravida, parity, body mass index, infertility, leiomyoma presence, the size of ovarian endometrioma, the presence of deep infiltrating endometriosis, disease stage or postoperative medication. Conclusions The severity of dysmenorrhea and postoperative pregnancy were independent risk factors for the recurrence of ovarian endometriomas after surgery during the long-time follow up.
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Affiliation(s)
- Xiao-Yan Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Xiao-Pei Chao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Jin-Hua Leng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China.
| | - Wen Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Jun-Ji Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Yi Dai
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Jing-Hua Shi
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Shuang-Zheng Jia
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Xiao-Xuan Xu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Si-Kai Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Yu-Shi Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
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Candiani M, Ottolina J, Schimberni M, Tandoi I, Bartiromo L, Ferrari S. Recurrence Rate after "One-Step" CO 2 Fiber Laser Vaporization versus Cystectomy for Ovarian Endometrioma: A 3-Year Follow-up Study. J Minim Invasive Gynecol 2019; 27:901-908. [PMID: 31377455 DOI: 10.1016/j.jmig.2019.07.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 07/17/2019] [Accepted: 07/30/2019] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To assess postoperative recurrence rates in patients with endometriomas managed by either "one-step" CO2 fiber laser vaporization or cystectomy. DESIGN Retrospective study with prospective recording of data. SETTING University hospital. PATIENTS One hundred twenty-five patients with symptomatic endometriomas. INTERVENTIONS Patients underwent a standardized laparoscopic stripping technique (group 1) or cyst vaporization with CO2 fiber laser (group 2). After surgery, patients were incorporated in a prolonged surveillance program with periodic clinical follow-up to check for recurrence of the cyst and/or recurrence of symptoms. Endometrioma recurrence was defined as an ovarian cyst (>10 mm) with a typical aspect arising on the operated ovary identified by transvaginal ultrasound. MEASUREMENTS AND MAIN RESULTS The primary endpoint was the comparison of recurrence rates between the 2 groups. The secondary endpoint was the evaluation of endometriosis-related pain recurrence in the 2 groups. Other endpoints selected for analysis included the identification of risk factors for the recurrence of endometrioma and of endometriosis-related symptoms. The mean follow-up was 29 ± 13 months (range, 13-49). Recurrence of ovarian endometriosis was recorded in 6.3% of patients (n = 4) treated with cystectomy and in 4.9% of patients (n = 3) managed with CO2 fiber laser (p = .74). Recurrence of endometriosis-related pain was observed in 5 patients (7.8%) in group 1 and in 6 patients (9.8%) in group 2 (p = .67). Mean endometrioma diameter > 5 cm at the time of surgery was identified as the only independent poor prognostic indicator for cyst recurrence (p = .008; odds ratio [OR], 2.21; 95% confidence interval [CI], 1.19-3.32). Moreover, the presence of deep endometriosis at surgery (p = .032; OR, 4.60; 95% CI, 1.14-18.57) and discontinuation of hormonal treatment (p = .015; OR, 3.18; 95% CI, 1.25-8.06) were independent poor prognostic indicators for pain recurrence. CONCLUSION This study suggests that one-step CO2 fiber laser vaporization may be effective for endometrioma treatment because it is associated with recurrence rates comparable with those occurring after cystectomy, with the advantage of being an ovarian tissue-sparing technique.
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Affiliation(s)
- Massimo Candiani
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy (all authors)
| | - Jessica Ottolina
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy (all authors)..
| | - Matteo Schimberni
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy (all authors)
| | - Iacopo Tandoi
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy (all authors)
| | - Ludovica Bartiromo
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy (all authors)
| | - Stefano Ferrari
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy (all authors)
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Black A, Guilbert E, Costescu D, Dunn S, Fisher W, Kives S, Mirosh M, Norman WV, Pymar H, Reid R, Roy G, Varto H, Waddington A, Wagner MS, Whelan AM. No. 329-Canadian Contraception Consensus Part 4 of 4 Chapter 9: Combined Hormonal Contraception. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 39:229-268.e5. [PMID: 28413042 DOI: 10.1016/j.jogc.2016.10.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the availability of cited contraceptive methods in Canada. EVIDENCE Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1994 to December 2015 in order to update the Canadian Contraception Consensus published February-April 2004. Relevant Canadian government publications and position papers from appropriate health and family planning organizations were also reviewed. VALUES The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice are ranked according to the method described in this report. SUMMARY STATEMENTS RECOMMENDATIONS.
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Alio L, Angioni S, Arena S, Bartiromo L, Bergamini V, Berlanda N, Bonin C, Busacca M, Candiani M, Centini G, D’Alterio MN, Di Cello A, Exacoustos C, Fedele L, Frattaruolo MP, Incandela D, Lazzeri L, Luisi S, Maiorana A, Maneschi F, Martire F, Massarotti C, Mattei A, Muzii L, Ottolina J, Perandini A, Perelli F, Pino I, Porpora MG, Raimondo D, Remorgida V, Seracchioli R, Solima E, Somigliana E, Sorrenti G, Venturella R, Vercellini P, Viganó P, Vignali M, Zullo F, Zupi E. When more is not better: 10 'don'ts' in endometriosis management. An ETIC * position statement. Hum Reprod Open 2019; 2019:hoz009. [PMID: 31206037 PMCID: PMC6560357 DOI: 10.1093/hropen/hoz009] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 12/09/2018] [Indexed: 02/07/2023] Open
Abstract
A network of endometriosis experts from 16 Italian academic departments and teaching hospitals distributed all over the country made a critical appraisal of the available evidence and definition of 10 suggestions regarding measures to be de-implemented. Strong suggestions were made only when high-quality evidence was available. The aim was to select 10 low-value medical interventions, characterized by an unfavorable balance between potential benefits, potential harms, and costs, which should be discouraged in women with endometriosis. The following suggestions were agreed by all experts: do not suggest laparoscopy to detect and treat superficial peritoneal endometriosis in infertile women without pelvic pain symptoms; do not recommend controlled ovarian stimulation and IUI in infertile women with endometriosis at any stage; do not remove small ovarian endometriomas (diameter <4 cm) with the sole objective of improving the likelihood of conception in infertile patients scheduled for IVF; do not remove uncomplicated deep endometriotic lesions in asymptomatic women, and also in symptomatic women not seeking conception when medical treatment is effective and well tolerated; do not systematically request second-level diagnostic investigations in women with known or suspected non-subocclusive colorectal endometriosis or with symptoms responding to medical treatment; do not recommend repeated follow-up serum CA-125 (or other currently available biomarkers) measurements in women successfully using medical treatments for uncomplicated endometriosis in the absence of suspicious ovarian cysts; do not leave women undergoing surgery for ovarian endometriomas and not seeking immediate conception without post-operative long-term treatment with estrogen-progestins or progestins; do not perform laparoscopy in adolescent women (<20 years) with moderate-severe dysmenorrhea and clinically suspected early endometriosis without prior attempting to relieve symptoms with estrogen-progestins or progestins; do not prescribe drugs that cannot be used for prolonged periods of time because of safety or cost issues as first-line medical treatment, unless estrogen-progestins or progestins have been proven ineffective, not tolerated, or contraindicated; do not use robotic-assisted laparoscopic surgery for endometriosis outside research settings. Our proposal is to better address medical and surgical approaches to endometriosis de-implementing low-value interventions, with the aim to prevent unnecessary morbidity, limit psychological distress, and reduce the burden of treatment avoiding medical overuse and allowing a more equitable distribution of healthcare resources.
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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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Saridogan E. Role of general gynaecologists in the prevention of infertility. Best Pract Res Clin Obstet Gynaecol 2019; 59:132-136. [PMID: 30837119 DOI: 10.1016/j.bpobgyn.2019.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/26/2019] [Accepted: 01/31/2019] [Indexed: 11/25/2022]
Abstract
Gynaecologists are frequently involved in the management of conditions that may result in reduced fertility or treatments they administer can lead to infertility. Sexually transmitted infections and pelvic inflammatory disease are the most common cause of tubal damage. Gynaecologists can play an important role in the identification and early treatment of these diseases. Pelvic surgery for conditions such as leiomyoma, ovarian cysts and endometriosis can lead to pelvic adhesions and iatrogenic infertility. By avoiding unnecessary operations by careful assessment of women with these conditions and by identifying those who can be managed without surgery, the future risk of infertility can be avoided. When surgery is clinically indicated, primary prevention of pelvic adhesions would be of paramount importance. A reliable surgical technique and the use of anti-adhesion agents may reduce the development of pelvic adhesions. Ovarian surgery for endometriomas and other benign cysts should be performed in the hands of experienced surgeons or in 'centres of clinical expertise', and maximum efforts should be made to preserve normal ovarian tissue as much as possible.
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Affiliation(s)
- Ertan Saridogan
- Consultant in Reproductive Medicine and Minimal Access Surgery, University College London Hospitals, UK.
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Grandi G, Barra F, Ferrero S, Sileo FG, Bertucci E, Napolitano A, Facchinetti F. Hormonal contraception in women with endometriosis: a systematic review. EUR J CONTRACEP REPR 2019; 24:61-70. [PMID: 30664383 DOI: 10.1080/13625187.2018.1550576] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE A systematic review was carried out of studies of women with endometriosis, to examine the evidence for efficacy of the use of hormonal contraception to improve disease-related pain and decrease postoperative risk of disease recurrence. METHODS A search of the Medline/PubMed and Embase databases was performed to identify all published English language studies on hormonal contraceptive therapies (combined hormonal contraceptives [CHCs], combined oral contraceptives [COCs], progestin-only pills [POPs] and progestin-only contraceptives [POCs]) in women with a validated endometriosis diagnosis, in comparison with placebo, comparator therapies or other hormonal therapies. Main outcome measures were endometriosis-related pain (dysmenorrhoea, pelvic pain and dyspareunia), quality of life (QoL) and postoperative rate of disease recurrence during treatment. RESULTS CHC and POC treatments were associated with clinically significant reductions in dysmenorrhoea, often accompanied by reductions in non-cyclical pelvic pain and dyspareunia and an improvement in QoL. Only two COC preparations (ethinylestradiol [EE]/norethisterone acetate [NETA] and a flexible EE/drospirenone regimen) demonstrated significantly increased efficacy compared with placebo. Only three studies found that the postoperative use of COCs (EE/NETA, EE/desogestrel and EE/gestodene) reduced the risk of disease recurrence. There was no evidence that POCs reduced the risk of disease recurrence. CONCLUSIONS CHCs and POCs are effective for the relief of endometriosis-related dysmenorrhoea, pelvic pain and dyspareunia, and improve QoL. Some COCs decreased the risk of disease recurrence after conservative surgery, but POCs did not. There is insufficient evidence, however, to reach definitive conclusions about the overall superiority of any particular hormonal contraceptive.
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Affiliation(s)
- Giovanni Grandi
- a Department of Medical and Surgical Sciences for Mothers, Children and Adults , University of Modena and Reggio Emilia, Azienda Ospedaliero Universitaria Policlinico , Modena , Italy
| | - Fabio Barra
- b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health (DINOGMI) , University of Genoa, IRCCS Ospedale Policlinico San Martino , Genoa , Italy
| | - Simone Ferrero
- b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health (DINOGMI) , University of Genoa, IRCCS Ospedale Policlinico San Martino , Genoa , Italy
| | - Filomena Giulia Sileo
- a Department of Medical and Surgical Sciences for Mothers, Children and Adults , University of Modena and Reggio Emilia, Azienda Ospedaliero Universitaria Policlinico , Modena , Italy
| | - Emma Bertucci
- a Department of Medical and Surgical Sciences for Mothers, Children and Adults , University of Modena and Reggio Emilia, Azienda Ospedaliero Universitaria Policlinico , Modena , Italy
| | - Antonella Napolitano
- a Department of Medical and Surgical Sciences for Mothers, Children and Adults , University of Modena and Reggio Emilia, Azienda Ospedaliero Universitaria Policlinico , Modena , Italy
| | - Fabio Facchinetti
- a Department of Medical and Surgical Sciences for Mothers, Children and Adults , University of Modena and Reggio Emilia, Azienda Ospedaliero Universitaria Policlinico , Modena , Italy
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Muzii L, Di Tucci C, Di Feliciantonio M, Galati G, Marchetti C, Perniola G, Pecorini F, Benedetti Panici P. Management of endometriosis from diagnosis to treatment: roadmap for the future. ACTA ACUST UNITED AC 2018; 71:54-61. [PMID: 30318872 DOI: 10.23736/s0026-4784.18.04320-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Endometriosis, in spite of decades of research on the topic, remains a mysterious and elusive disease. Both in the fields of diagnosis and treatment, many issues remain unresolved, and the scientific community strives in trying to find universal criteria for diagnosis, and algorithms of treatment that may be universally applied. Recently, there has been a shift away from the view of the need of invasive diagnosis and therapy with the universal use of laparoscopy. Today the diagnosis of endometriosis may be reliably performed with noninvasive methods, and therapy can be nonsurgical in most cases. Recent guidelines state that diagnostic laparoscopy may be better seen as a second line of investigation, whereas medical therapy with either oral estroprogestins or progestogens is the first therapeutic option in case of associated pain. A thorough discussion with the patient should address all the available treatments, so as to make a shared decision on which treatment best fits the needs of that single patient.
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Affiliation(s)
- Ludovico Muzii
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy -
| | - Chiara Di Tucci
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy
| | | | - Giulia Galati
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy
| | - Claudia Marchetti
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy
| | - Giorgia Perniola
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy
| | - Francesco Pecorini
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy
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[The Rouen Expert center in the diagnosis and multidisciplinary management of endometriosis: A French pilot experiment]. ACTA ACUST UNITED AC 2018; 46:563-569. [PMID: 29937108 DOI: 10.1016/j.gofs.2018.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To retrospectively describe the activity of the Diagnosis and Multidisciplinary Management of Endometriosis Expert Center of Rouen-Normandy, before and after official identification by French Health Authorities. METHODS Retrospective study of the main activities of an Expert Center, from January 2013 to March 2018. RESULTS The Endometriosis Expert Center of Rouen-Normandy is a regional network, organised as a pyramid with a Referral Center at the top (the Rouen University Hospital) leading a network of public and private Expertise Centers below in Normandy. Ten to 11 Multidisciplinary Team meetings per year were organised, allowing the study of 15 to 20 cases by physicians coming from up to 17different places (hospital, clinic or private practice). 2066patients diagnosed with endometriosis were hospitalised in the Referral Center, among them 615were operated for colorectal endometriosis, among which 607by laparoscopy (97%). The surgical team was multidisciplinary in 444surgeries (72.2%). 50cycles of fertility preservation (oocyte freezing) were led. Research activity allowed the publication of 76scientific articles, among which 41 (53.9 %) in a journal of rank SIGAPS A or B. Medical training was organised for active health professionals as well as students, including school nurses. CONCLUSION The Endometriosis Expert Center of Rouen-Normandy pilot project has helped improving the diagnosis and better management of the disease in Normandy. This experiment could be exported to all the other regions of France, in order to unit health professionals with the aim of a national fight program against endometriosis.
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Ata B, Mumusoglu S, Aslan K, Seyhan A, Kasapoglu I, Avci B, Urman B, Bozdag G, Uncu G. Which is worse? Comparison of ART outcome between women with primary or recurrent endometriomas. Hum Reprod 2018; 32:1427-1431. [PMID: 28498960 DOI: 10.1093/humrep/dex099] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 05/03/2017] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTİON Are live birth rates (LBR) different after ART cycles between women with primary or recurrent endometrioma? SUMMARY ANSWER Women with recurrent endometrioma have similar LBR as compared to patients with primary endometrioma. WHAT IS ALREADY KNOWN Recurrence rate can be as high as 29% after endometrioma excision. Prior studies on management of endometrioma before ART involve primary endometriomas. There is limited information regarding the prognosis of women with recurrent endometriomas. STUDY DESIGN, SIZE, DURATION A multicenter retrospective cohort study, including 76 women with primary and 82 women with recurrent endometriomas treated at the participating centers over a 6-year period. PARTICIPANTS/MATERIALS, SETTING, METHODS Women with endometrioma who underwent ART at three academic ART centers. Couples with another indication for ART were excluded. MAIN RESULTS AND THE ROLE OF CHANCE Female age, median number of prior failed ART cycles, proportion of patients with bilateral endometrioma (28 versus 28.9%), ovarian stimulation protocols, and total gonadotropin consumption were similar between the study groups. Numbers of metaphase two oocytes (5 versus 6), number of embryos transferred, and the proportion of patients undergoing blastocyst transfer were similar across the study groups. Clinical pregnancy rates (36.6 versus 34.2%, absolute difference 2.4%, 95% CI: -12.5 to 17.3%, P = 0.83) and LBR (35.4 versus 30.3%, absolute difference 5.1%, 95% CI: -9.5 to 19.7%, P = 0.51) per started cycle in recurrent and primary endometrioma were similar. Comparable success rates were also confirmed with logistic regression analysis (OR: 1.14, 95% CI: 0.78-0.57, P = 2.3). LIMITATIONS, REASONS FOR CAUTION The retrospective design has inherent limitations. Some women with severely decreased ovarian reserve after primary endometrioma excision may not have pursued further treatment. WIDER IMPLICATIONS OF THE FINDINGS The management of endometrioma prior to ART is controversial but a different management strategy is not required for recurrent endometriomas. Since recurrent endometriomas do not have a worse impact on ART outcome than primary endometriomas, and repeat surgery has a higher risk for complications, conservative management without surgery can be justified. STUDY FUNDING/COMPETING INTEREST(S) No funding or competing interests to declare. TRIAL REGISTRATION NUMBER None.
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Affiliation(s)
- Baris Ata
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Davutpasa Caddesi No 4, Topkapi, Istanbul 34010, Turkey
| | - Sezcan Mumusoglu
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Sihhiye, Ankara 06100, Turkey
| | - Kiper Aslan
- Department of Obstetrics and Gynecology, Uludag University School of Medicine, Gorukle, Bursa 16059, Turkey
| | - Ayse Seyhan
- Women's Health and Assisted Reproduction Center of the American Hospital of Istanbul, Guzelbahce Sokak, Nisantasi, Istanbul 34365, Turkey
| | - Isil Kasapoglu
- Department of Obstetrics and Gynecology, Uludag University School of Medicine, Gorukle, Bursa 16059, Turkey
| | - Berrin Avci
- Department of Obstetrics and Gynecology, Uludag University School of Medicine, Gorukle, Bursa 16059, Turkey
| | - Bulent Urman
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Davutpasa Caddesi No 4, Topkapi, Istanbul 34010, Turkey
| | - Gurkan Bozdag
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Sihhiye, Ankara 06100, Turkey
| | - Gurkan Uncu
- Department of Obstetrics and Gynecology, Uludag University School of Medicine, Gorukle, Bursa 16059, Turkey
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Lee JH, Song JY, Yi KW, Lee SR, Lee DY, Shin JH, Cho S, Seo SK, Kim SH. Effectiveness of Dienogest for Treatment of Recurrent Endometriosis: Multicenter Data. Reprod Sci 2018; 25:1515-1522. [DOI: 10.1177/1933719118779733] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Jae Hoon Lee
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Women’s Life Medical Science, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Yen Song
- Department of Obstetrics and Gynecology, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kyong Wook Yi
- Department of Obstetrics and Gynecology, College of Medicine, Korea University, Seoul, South Korea
| | - Sa Ra Lee
- Department of Obstetrics and Gynecology, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Dong-Yun Lee
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung-Ho Shin
- Department of Obstetrics and Gynecology, College of Medicine, Korea University, Seoul, South Korea
| | - SiHyun Cho
- Institute of Women’s Life Medical Science, Yonsei University College of Medicine, Seoul, South Korea
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Seok Kyo Seo
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Women’s Life Medical Science, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Hoon Kim
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Abstract
BACKGROUND Endometriosis is a common gynaecological condition which affects many women of reproductive age worldwide and is a major cause of pain and infertility. The combined oral contraceptive pill (COCP) is widely used to treat pain occurring as a result of endometriosis, although the evidence for its efficacy is limited. OBJECTIVES To determine the effectiveness, safety and cost-effectiveness of oral contraceptive preparations in the treatment of painful symptoms ascribed to the diagnosis of laparoscopically proven endometriosis. SEARCH METHODS We searched the following from inception to 19 October 2017: the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials, the Cochrane CENTRAL Register of Studies Online (CRSO), MEDLINE, Embase, PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the trial registers ClinicalTrials.gov and the World Health Organization Clinical Trials Registry Platform (WHO ICTRP). We also handsearched reference lists of relevant trials and systematic reviews retrieved by the search. SELECTION CRITERIA We included randomised controlled trials (RCT) of the use of COCPs in the treatment of women of reproductive age with symptoms ascribed to the diagnosis of endometriosis that had been made visually at a surgical procedure. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality and extracted data. One review author was an expert in the content matter. We contacted study authors for additional information. The primary outcome was self-reported pain (dysmenorrhoea) at the end of treatment. MAIN RESULTS Five trials (612 women) met the inclusion criteria. Only three trials (404 women) provided data that were suitable for analysis.Combined oral contraceptive pill versus placeboTwo trials compared COCP with a placebo. These studies were at high risk of bias. For GRADE outcomes (self-reported pain (dysmenorrhoea) at the end of treatment), the quality of the evidence very low. Evidence was downgraded for imprecision as it was based on a single, small trial and for the visual analogue scale data there were wide confidence intervals (CIs). There appeared to have been substantial involvement of the pharmaceutical company funding the trials.Treatment with the COCP was associated with an improvement in self-reported pain at the end of treatment as evidenced by a lower score on the Dysmenorrhoea verbal rating scale (scale 0 to 3) compared with placebo (mean difference (MD) -1.30 points, 95% CI -1.84 to -0.76; 1 RCT, 96 women; very low quality evidence), a lower score on the Dysmenorrhoea visual analogue scale (no details of scale) compared with placebo (MD -23.68 points, 95% CI -28.75 to -18.62, 2 RCTs, 327 women; very low quality evidence) and a reduction in menstrual pain from baseline to the end of treatment (MD 2.10 points, 95% CI 1.38 to 2.82; 1 RCT, 169 women; very low quality evidence).Combined oral contraceptive pill versus medical therapiesOne underpowered trial compared the COCP with another medical treatment (goserelin). The study was at high risk of bias; the trial was unblinded and there was insufficient detail to judge allocation concealment and randomisation. For GRADE outcomes (self-reported pain (dysmenorrhoea) at the end of treatment), the quality of the evidence ranged from low to very low.At the end of treatment, the women in the goserelin group were amenorrhoeic and therefore no comparisons could be made between the groups for the primary outcome. At six months' follow-up, there was no clear evidence of a difference between women treated with the COCP and women treated with goserelin for measures of dysmenorrhoea on a visual analogue scale (scale 1 to 10) (MD -0.10, 95% CI -1.28 to 1.08; 1 RCT, 50 women; very low quality evidence) or a verbal rating scale (scale 0 to 3) (MD -0.10, 95% CI -0.99 to 0.79; 1 RCT, 50 women; very low quality evidence). At six months' follow-up, there was no clear evidence of a difference between the COCP and goserelin groups for reporting complete absence of pain as measured by the visual analogue scale (risk ratio (RR) 0.36, 95% CI 0.02 to 8.43; 1 RCT, 50 women; very low quality evidence) or the verbal rating scale (RR 1.00, 95% CI 0.93 to 1.08; 1 RCT, 49 women; low quality evidence). AUTHORS' CONCLUSIONS Based on the limited evidence from two trials at high risk of bias and limited data for the prespecified outcomes for this review, there is insufficient evidence to make a judgement on the effectiveness of the COCP compared with placebo and the findings cannot be generalised.Based on the limited evidence from one small trial that was at high risk of bias, there is insufficient evidence to make a judgement on the effectiveness of the COCP compared with other medical treatments. Only one comparison was possible, with the medical intervention being goserelin, and the findings cannot be generalised.Further research is needed to fully evaluate the role of COCPs in managing pain-related symptoms associated with endometriosis. There are other formulations of the combined hormonal contraception such as the transdermal patch, vaginal ring or combined injectable contraceptives which this review did not cover but should be considered in future updates.
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Affiliation(s)
- Julie Brown
- The University of AucklandDepartment of Obstetrics and GynaecologyPark RdGraftonAucklandNew Zealand1142
| | - Tineke J Crawford
- The University of AucklandLiggins Institute85 Park RoadGraftonAucklandNew Zealand1023
| | - Shree Datta
- King's College Hospital NHS Foundation TrustDenmark HillLondonSurreyUKSE9 5RS
| | - Andrew Prentice
- University of Cambridge Clinical SchoolDepartment of Obstetrics and Gynaecology, Rosie HospitalRobinson WayCambridgeUKCB2 0SW
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47
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Abstract
Colorectal surgeons often participate in the multidisciplinary management of young females with endometriosis. Complications of endometriosis as well as its management often result in infertility since they can involve all pelvic organs including the procreative organs: uterus, ovaries and fallopian tubes. Complete excision of all endometriotic lesions should not be performed at the expense of irreversible destruction of the procreative organs; definitive infertility should not be the price to pay in order to obtain an improvement of the painful symptoms caused by endometriosis. Surgery for ovarian endometriomas should be specifically adapted to the patient's desire for future conception and to her preoperative ovarian reserve. Two main techniques are used to treat ovarian endometriomas: ovarian cystectomy excises the wall of the cyst while ablation consists of destruction of the internal surface of the cyst. The use of mono polar or biolar coagulation for cyst ablation is strongly contra-indicated. Ablation using laser or plasma energy has resulted in comparable rates of post-operative pregnancy to those obtained by ovarian cystectomy. Patients who wish to delay their attempt to conceive for some period of time, should be placed on long-term oral contraception with prevention of menstruation to reduce the risk of recurrent endometriosis. When surgery for colorectal endometriosis is necessary, the laparoscopic approach increases the chances of spontaneous conception compared to laparotomy. Surgery for deep-seated endometriosis has been accompanied by a high rate of spontaneous conception and successful pregnancy and does not seem to decrease the chances for conception by in vitro fertilization.
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Affiliation(s)
- H Roman
- Clinique gynécologique et obstétricale, centre expert de diagnostic et prise en charge multidisciplinaire de l'endométriose, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France.
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48
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Mabrouk M, Paradisi R, Arena A, Del Forno S, Matteucci C, Zannoni L, Caprara G, Seracchioli R. Short-term histopathological effects of dienogest therapy on ovarian endometriomas: in vivo, nonrandomized, controlled trial. Gynecol Endocrinol 2018; 34:399-403. [PMID: 29160135 DOI: 10.1080/09513590.2017.1405932] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Ovarian endometriosis is a common gynecological disorder. To date, progestins are recommended as the first-line medical treatment for symptomatic ovarian endometriosis. The aim of this study was to evaluate the main histopathological effects of short-term dienogest therapy in patients with ovarian endometriomas scheduled for surgery. A prospective, nonrandomized controlled trial, including 70 symptomatic women with single ovarian endometriotic cyst (diameter between 30-50 mm) was conducted. Women scheduled for surgery were divided into two groups, depending on the treatment established at enrollment: 36 women received progestin therapy with dienogest (P group) and 34 women received no therapy (C group). At histopathological examination necrosis, inflammation, decidualization, glandular atrophy and angiogenesis were blindly evaluated. At tissue level, decidualization was significantly more frequent in P group compared to C group (p = .001). A nonsignificant tendency (p = .29) towards a slight decreased inflammation in P group was found. No significant differences were observed between the two groups in terms of necrosis, glandular atrophy and angiogenesis. The study suggests that high decidualization rate and the tendency to reduced inflammatory reaction in the short-term administration of dienogest might contribute to its therapeutic efficacy.
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Affiliation(s)
- Mohamed Mabrouk
- a Gynecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences , DIMEC, S. Orsola Hospital, University of Bologna , Bologna , Italy
- b Department of Obstetrics and Gynecology, Faculty of Medicine , University of Alexandria , Alexandria , Egypt
| | - Roberto Paradisi
- a Gynecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences , DIMEC, S. Orsola Hospital, University of Bologna , Bologna , Italy
| | - Alessandro Arena
- a Gynecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences , DIMEC, S. Orsola Hospital, University of Bologna , Bologna , Italy
| | - Simona Del Forno
- a Gynecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences , DIMEC, S. Orsola Hospital, University of Bologna , Bologna , Italy
| | - Carlotta Matteucci
- a Gynecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences , DIMEC, S. Orsola Hospital, University of Bologna , Bologna , Italy
| | - Letizia Zannoni
- a Gynecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences , DIMEC, S. Orsola Hospital, University of Bologna , Bologna , Italy
| | - Giacomo Caprara
- c Histopathological and Molecular Diagnostic Unit of Solid Organ and Transplant , S. Orsola Hospital, University of Bologna , Bologna , Italy
| | - Renato Seracchioli
- a Gynecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences , DIMEC, S. Orsola Hospital, University of Bologna , Bologna , Italy
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49
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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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50
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Abstract
Preoperative evaluation: clinical examination, and research for associated lesions. Laparoscopic approach. Cystectomy: gold standard, conformed to the endometrioma pathophysiology (3 zones). Laser CO2 Plasmajet® vaporisation: important data lead to legitimate utilisation. Haemostasis: be patient! Use of bipolar energy sparingly. Look for other endometriotic lesions, and systematic treatment. Preoperative medical treatment not always useful. Postoperative treatment: decrease recurrence. Especially for patients with no immediate pregnancy desire.
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