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The use of hormonal contraceptives in fertility treatments: a committee opinion. Fertil Steril 2024; 122:243-250. [PMID: 38483428 DOI: 10.1016/j.fertnstert.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 07/30/2024]
Abstract
The use of hormonal contraception can be considered to aid in the timing of assisted reproductive technology cycles, reduce the risk of ovarian cysts at in vitro fertilization cycle initiation, and optimize visualization before hysteroscopy.
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Agostinis C, Toffoli M, Zito G, Balduit A, Pegoraro S, Spazzapan M, Pascolo L, Romano F, Di Lorenzo G, Mangogna A, Santin A, Spedicati B, Valencic E, Girotto G, Ricci G, Kishore U, Bulla R. Proangiogenic properties of complement protein C1q can contribute to endometriosis. Front Immunol 2024; 15:1405597. [PMID: 38983846 PMCID: PMC11231091 DOI: 10.3389/fimmu.2024.1405597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/31/2024] [Indexed: 07/11/2024] Open
Abstract
Endometriosis (EM) is defined as the engraftment and proliferation of functional endometrial-like tissue outside the uterine cavity, leading to a chronic inflammatory condition. While the precise etiology of EM remains elusive, recent studies have highlighted the crucial involvement of a dysregulated immune system. The complement system is one of the predominantly altered immune pathways in EM. Owing to its involvement in the process of angiogenesis, here, we have examined the possible role of the first recognition molecule of the complement classical pathway, C1q. C1q plays seminal roles in several physiological and pathological processes independent of complement activation, including tumor growth, placentation, wound healing, and angiogenesis. Gene expression analysis using the publicly available data revealed that C1q is expressed at higher levels in EM lesions compared to their healthy counterparts. Immunohistochemical analysis confirmed the presence of C1q protein, being localized around the blood vessels in the EM lesions. CD68+ macrophages are the likely producer of C1q in the EM lesions since cultured EM cells did not produce C1q in vitro. To explore the underlying reasons for increased C1q expression in EM, we focused on its established pro-angiogenic role. Employing various angiogenesis assays on primary endothelial endometriotic cells, such as migration, proliferation, and tube formation assays, we observed a robust proangiogenic effect induced by C1q on endothelial cells in the context of EM. C1q promoted angiogenesis in endothelial cells isolated from EM lesions (as well as healthy ovary that is also rich in C1q). Interestingly, endothelial cells from EM lesions seem to overexpress the receptor for the globular heads of C1q (gC1qR), a putative C1q receptor. Experiments with siRNA to silence gC1qR resulted in diminished capacity of C1q to perform its angiogenic functions, suggesting that C1q is likely to engage gC1qR in the pathophysiology of EM. gC1qR can be a potential therapeutic target in EM patients that will disrupt C1q-mediated proangiogenic activities in EM.
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Affiliation(s)
- Chiara Agostinis
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Miriam Toffoli
- Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Gabriella Zito
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Andrea Balduit
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Silvia Pegoraro
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | | | - Lorella Pascolo
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Federico Romano
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Giovanni Di Lorenzo
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Alessandro Mangogna
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Aurora Santin
- Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Beatrice Spedicati
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Erica Valencic
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Giorgia Girotto
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Giuseppe Ricci
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Uday Kishore
- Department of Veterinary Medicine, United Arab Emirates University, Al Ain, United Arab Emirates
- Zayed Centre for Health Sciences, United Arab Emirates (UAE) University, Al Ain, United Arab Emirates
| | - Roberta Bulla
- Department of Life Sciences, University of Trieste, Trieste, Italy
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Viviano M, Benagiano G, Guo SW, Pluchino N. Why do oestrogens matter: systematic review and meta-analysis assessing GnRH antagonists, considering add-back therapy, for endometriosis-associated pain. Reprod Biomed Online 2024; 49:104321. [PMID: 39098266 DOI: 10.1016/j.rbmo.2024.104321] [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: 01/23/2024] [Revised: 05/28/2024] [Accepted: 06/05/2024] [Indexed: 08/06/2024]
Abstract
Gonadotrophin-releasing hormone (GnRH) antagonists have been demonstrated to reduce endometriosis-associated pain. Because of the hypo-oestrogenic state they induce, however, higher dosages of GnRH antagonists are not recommended for used long term. This unwanted effect may be eliminated by so-called add-back therapy (ABT). This review was conducted to assess the safety and efficacy of GnRH antagonists, with or without add-back hormonal replacement therapy. Out of the 345 studies selected through the initial search, seven randomized controlled trials were included, comparing different oral GnRH antagonists at varying dosages, from a minimum of 50 mg to a maximum of 200 mg once or twice daily. Women treated with the lowest dose of GnRH antagonists had significantly greater mean pain score reductions from baseline throughout treatment compared with those treated with placebo (odds ratio [OR] -13.12, 95% CI -17.35 to -8.89 and OR -3.08, 95% CI -4.39 to -1.76 for dysmenorrhoea and non-menstrual pelvic pain, respectively). Compatible with the dose-response effect, a positive correlation was found between response rates and adverse event rates. While GnRH antagonists offer an advantage in terms of pain reduction for endometriosis, the more recent literature suggests using GnRH antagonists with ABT, which, while mitigating the hypo-oestrogenic effects of GnRH antagonists, maintain their efficacy, while allowing their long-term use.
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Affiliation(s)
- Manuela Viviano
- Division of Gynecology, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland..
| | - Giuseppe Benagiano
- Faculty of Medicine and Dentistry, Sapienza, University of Rome, Rome, Italy
| | - Sun-Wei Guo
- Research Institute, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Nicola Pluchino
- Fertility Medicine and Gynecological Endocrinology Unit, Woman-Mother-Child Department, Lausanne University Hospital, Lausanne, Switzerland
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Donnez J, Becker C, Taylor H, Carmona Herrera F, Donnez O, Horne A, Paszkowski M, Petraglia F, Renner SP, Patel A, Boolell M, Bestel E, Dolmans MM. Linzagolix therapy versus a placebo in patients with endometriosis-associated pain: a prospective, randomized, double-blind, Phase 3 study (EDELWEISS 3). Hum Reprod 2024; 39:1208-1221. [PMID: 38648863 PMCID: PMC11144970 DOI: 10.1093/humrep/deae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/07/2024] [Indexed: 04/25/2024] Open
Abstract
STUDY QUESTION Does linzagolix administered orally once daily for up to 3 months at a dose of 75 mg alone or 200 mg in combination with add-back therapy (ABT) (1.0 mg estradiol; 0.5 mg norethindrone acetate, also known as norethisterone acetate [NETA]) demonstrate better efficacy than placebo in the management of endometriosis-related dysmenorrhea and non-menstrual pelvic pain? SUMMARY ANSWER Combining 200 mg linzagolix with ABT was found to significantly reduce dysmenorrhea and non-menstrual pelvic pain at 3 months of therapy, while a daily dose of 75 mg linzagolix yielded a significant decrease only in dysmenorrhea at 3 months. WHAT IS KNOWN ALREADY? A previously published Phase 2, dose-finding study reported that at a dose of 200 mg daily, linzagolix promotes full suppression of estradiol secretion to serum levels below 20 pg/ml and noted that the addition of ABT may be needed to manage hypoestrogenic side effects. At lower doses (75 mg and 100 mg/day), linzagolix maintains estradiol values within the target range of 20-60 pg/ml, which could be ideal to alleviate symptoms linked to endometriosis. STUDY DESIGN, SIZE, DURATION EDELWEISS 3 was a multicenter, prospective, randomized, placebo-controlled, double-blind, double-dummy Phase 3 study to evaluate the safety and efficacy of linzagolix for the treatment of moderate-to-severe endometriosis-associated pain. Treatment was administered orally once daily for up to 6 months. PARTICIPANTS/MATERIALS, SETTING, METHODS In the EDELWEISS 3 trial, 486 subjects with moderate-to-severe endometriosis-associated pain were randomized at a 1:1:1 ratio to one of the three study groups: placebo, 75 mg linzagolix alone or 200 mg linzagolix in association with ABT. Pain was measured daily on a verbal rating scale and recorded in an electronic diary. MAIN RESULTS AND THE ROLE OF CHANCE At 3 months, the daily 200 mg linzagolix dose with ABT met the primary efficacy objective, showing clinically meaningful and statistically significant reductions in dysmenorrhea and non-menstrual pelvic pain, with stable or decreased use of analgesics. The proportion of responders for dysmenorrhea in the 200 mg linzagolix with ABT group was 72.9% compared with 23.5% in the placebo group (P < 0.001), while the rates of responders for non-menstrual pelvic pain were 47.3% and 30.9% (P = 0.007), respectively. The 75 mg linzagolix daily dose demonstrated a clinically meaningful and statistically significant reduction in dysmenorrhea versus placebo at 3 months. The proportion of responders for dysmenorrhea in the 75 mg linzagolix group was 44.0% compared with 23.5% in the placebo group (P < 0.001). Although the 75 mg dose showed a trend toward reduction in non-menstrual pelvic pain at 3 months relative to the placebo, it was not statistically significant (P = 0.279). Significant improvements in dyschezia and overall pelvic pain were observed in both linzagolix groups when compared to placebo. Small improvements in dyspareunia scores were observed in both linzagolix groups but they were not significant. In both groups, hypoestrogenic effects were mild, with low rates of hot flushes and bone density loss of <1%. A daily dose of 200 mg linzagolix with ABT or 75 mg linzagolix alone was found to significantly reduce dysmenorrhea and non-menstrual pelvic pain also at 6 months of therapy. LIMITATIONS, REASONS FOR CAUTION Efficacy was compared between linzagolix groups and placebo; however, it would be useful to have results from comparative studies with estro-progestogens or progestogens. It will be important to ascertain whether gonadotropin-releasing hormone antagonists have significant benefits over traditional first-line medications. WIDER IMPLICATIONS OF THE FINDINGS Linzagolix administered orally once daily at a dose of 200 mg in combination with add-back therapy (ABT) demonstrated better efficacy and safety than placebo in the management of moderate-to-severe endometriosis-associated pain. The quality of life was improved and the risks of bone loss and vasomotor symptoms were minimized due to the ABT. The 75 mg dose alone could be suitable for chronic treatment of endometriosis-associated pain without the need for concomitant hormonal ABT, but further research is needed to confirm this. If confirmed, it would offer a viable option for women who do not want to wish to have ABT or for whom it is contraindicated. STUDY FUNDING/COMPETING INTEREST(S) Funding for the EDELWEISS 3 study was provided by ObsEva (Geneva, Switzerland). Analysis of data and manuscript writing were partially supported by ObsEva (Geneva, Switzerland), Theramex (London, UK) and Kissei (Japan) and grant 5/4/150/5 was awarded to M.-M.D. by FNRS. J.D. was a member of the scientific advisory board of ObsEva until August 2022, a member of the scientific advisory board of PregLem, and received personal fees from Gedeon Richter, ObsEva and Theramex. J.D. received consulting fees, speakers' fees, and travel support from Gedeon Richter, Obseva and Theramex, which was paid to their institution. C.B. has received fees from Theramex, Gedeon Richter, and Myovant, and travel support from Gedeon Richter-all funds went to the University of Oxford. He was a member of the data monitoring board supervising the current study, and served at an advisory board for endometriosis studies of Myovant. H.T. has received grants from Abbvie and was past president of ASRM. F.C.H. has received fees from Gedeon Richter and Theramex. O.D. received fees for lectures from Gedeon Richter and ObsEva and research grants for clinical studies from Preglem and ObsEva independent from the current study. A.H. has received grants from NIHR, UKRI, CSO, Wellbeing of Women, and Roche Diagnostics; he has received fees from Theramex. A.H.'s institution has received honoraria for consultancy from Roche Diagnostics, Gesynta, and Joii. M.P. has nothing to declare. F.P. has received fees from Theramex. S.P.R. has been a member of the scientific advisory board of Gedeon Richter and received fees from Gedeon Richter. A.P. and M.B. are employees of Theramex. E.B. was an employee of ObsEva, sponsor chair of the data monitoring board supervising the current study, and has been working as a consultant for Theramex since December 2022; she owns stock options in ObsEva. M.-M.D. has received fees and travel support from Gedeon Richter and Theramex. TRIAL REGISTRATION NUMBER NCT03992846. TRIAL REGISTRATION DATE 20 June 2019. DATE OF FIRST PATIENT’S ENROLLMENT 13 June 2019.
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Affiliation(s)
- Jacques Donnez
- Department of Gynecology, Université Catholique de Louvain, Brussels, Belgium
- Department of Gynecology, Société de Recherche pour l’Infertilité (SRI), Brussels, Belgium
| | - Christian Becker
- Nuffield Department of Women’s & Reproductive Health, Endometriosis CaRe Centre, University of Oxford, Oxford, UK
| | - Hugh Taylor
- Department of Obstetrics, Gynecology and Reproductive sciences, Yale School of Medicine, New Haven, CT, USA
| | - Francisco Carmona Herrera
- Gynaecology Department, Clinic Institute of Gynaecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Olivier Donnez
- Département de Gynécologie, Centre de l’Endométriose Complexe, Chirurgie endoscopique pelvienne, Polyclinique Urbain V (ELSAN Group), Avignon, France
| | - Andrew Horne
- Department of Gynecology, EXPPECT and MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Maciej Paszkowski
- Third Chair and Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - Felice Petraglia
- Obstetrics and Gynecology Unit, Department of Clinical Experimental and Biomedical Sciences, University of Florence, Florence, Italy
| | - Stefan P Renner
- Department of Gynecology and Obstetrics, Hospital Böblingen, Klinikverbund-Suedwest, Sindelfingen 71065, Germany
| | - Amisha Patel
- Department of Medical Affairs, Theramex UK Ltd, London, UK
| | - Mitra Boolell
- Department of Medical Affairs, Theramex UK Ltd, London, UK
| | - Elke Bestel
- Department of Medical Affairs, Theramex UK Ltd, London, UK
| | - Marie-Madeleine Dolmans
- Gynecology Research Laboratory, Institut de Recherche Expérimentale et Clinique, Department of Gynecology, Université Catholique de Louvain, Brussels, Belgium
- Gynecology Department, Cliniques Universitaires St-Luc, Brussels, Belgium
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Taylor HS, Dong L, Haikonen J, Oppelt P, Tamussino K, Wenzl R, Faustmann T, Groettrup-Wolfers E, Ren X, Seitz C. Vilaprisan for the treatment of symptomatic endometriosis: results from a terminated phase 2b randomized controlled trial. F S Rep 2024; 5:189-196. [PMID: 38983729 PMCID: PMC11228778 DOI: 10.1016/j.xfre.2024.03.002] [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: 11/07/2023] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 07/11/2024] Open
Abstract
Objective To evaluate the efficacy and safety of 2 doses of vilaprisan vs. placebo in participants with symptomatic endometriosis. Design Multicenter, randomized, double-blind, placebo-controlled, parallel-group phase 2b trial (NCT03573336). The initially planned sample size was 315 patients. Recruitment was paused to assess long-term toxicity findings in rodents; although the findings were assessed as likely to be of limited clinical relevance in humans, the study was closed by the sponsor. During the pause, enrolled patients completed 3 or 6 months of treatment per their assigned regimen. Setting University hospitals, a regional hospital, and a private clinic. Patients Premenopausal adults with confirmed endometriosis and moderate-to-severe pelvic pain (≥4/10 on a numerical rating scale) were enrolled. Inclusion required protocol adherence, including ≥24 diary entries, and an average pain score of ≥3.5. Intervention Participants were randomly assigned 1:1:1 to receive vilaprisan (2 mg), vilaprisan (4 mg), or placebo. Main Outcome Measures The primary outcome was a change in the 7-day mean "worst pain" (per the endometriosis symptom diary item 1) from baseline to month 3. All analyses were descriptive only. Results Eight participants were randomly assigned to treatment before the study pause: 6 received vilaprisan (4 mg, n = 4 and 2 mg, n = 2), and 2 received placebo. The 6 vilaprisan recipients experienced an improvement in endometriosis-associated pelvic pain, whereas the 2 placebo recipients experienced no change or increased pain; all 8 participants had decreased use of pain medication. Bleeding intensity decreased from baseline in the vilaprisan group. Conclusion The study findings suggest that vilaprisan may improve outcomes in patients with endometriosis. Further studies in larger populations would be needed to accurately assess treatment effects. Clinical Trial Registration Number NCT03573336.
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Affiliation(s)
- Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | | | - Johanna Haikonen
- Department of Obstetrics and Gynecology, University of Turku, Turku, Finland
- Department of Obstetrics and Gynecology, Central Hospital Satasairaala, Pori, Finland
| | - Peter Oppelt
- Department of Gynecology, Obstetrics and Gynecological Endocrinology, Kepler University Hospital, Linz, Austria
| | - Karl Tamussino
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Rene Wenzl
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | | | | | - Xiaowei Ren
- Bayer Healthcare Co. Ltd., Beijing, People's Republic of China
| | - Christian Seitz
- Bayer AG, Berlin, Germany
- Institute of Clinical Pharmacology and Toxicology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Nezhat FR, Cathcart AM, Nezhat CH, Nezhat CR. Pathophysiology and Clinical Implications of Ovarian Endometriomas. Obstet Gynecol 2024; 143:759-766. [PMID: 38626453 PMCID: PMC11090516 DOI: 10.1097/aog.0000000000005587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 04/18/2024]
Abstract
Ovarian endometriomas affect many patients with endometriosis and have significant effects on quality of life, fertility, and risk of malignancy. Endometriomas range from small (1-3 cm), densely fibrotic cysts to large (20 cm or greater) cysts with varying degrees of fibrosis. Endometriomas are hypothesized to form from endometriotic invasion or metaplasia of functional cysts or alternatively from ovarian surface endometriosis that bleeds into the ovarian cortex. Different mechanisms of endometrioma formation may help explain the phenotypic variability observed among endometriomas. Laparoscopic surgery is the preferred first-line modality of diagnosis and treatment of endometriomas. Ovarian cystectomy is preferred over cyst ablation or sclerotherapy for enabling pathologic diagnosis, improving symptoms, preventing recurrence, and optimizing fertility outcomes. Cystectomy for small, densely adherent endometriomas is made challenging by dense fibrosis of the cyst capsule obliterating the plane with normal ovarian cortex, whereas cystectomy for large endometriomas can carry unique challenges as a result of adhesions between the cyst and pelvic structures. Preoperative and postoperative hormonal suppression can improve operative outcomes and decrease the risk of endometrioma recurrence. Whether the optimal management, fertility consequences, and malignant potential of endometriomas vary on the basis of size and phenotype remains to be fully explored.
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Affiliation(s)
- Farr R Nezhat
- Weill Cornell Medical College, Cornell University, New York, and NYU Long Island School of Medicine, Mineola, New York; the Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon; the Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, Atlanta, Georgia; and the Center for Special Minimally Invasive and Robotic Surgery, and Stanford University Medical Center, Palo Alto, and the University of California, San Francisco, San Francisco, California
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Wu H, Liu JJ, Ye ST, Liu J, Li N. Efficacy and safety of dienogest in the treatment of deep infiltrating endometriosis: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2024; 297:40-49. [PMID: 38579545 DOI: 10.1016/j.ejogrb.2024.03.032] [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: 01/30/2024] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE To systematically review and conduct a meta-analysis to assess the effectiveness of dienogest (DNG) in the prolonged conservative drug management of deep infiltrating endometriosis (DIE). The findings from this study are intended to serve as a valuable reference for clinical decision-making regarding medication in the context of DIE. METHODS Following the PRISMA Statement, we searched EMBASE, PubMed, The Cochrane Library, Web of Science, and Medline databases for relevant literature published in the public domain from the date of establishment of the database until October 2023. Subsequently, all English publications on clinical studies using DNG for the treatment of DIE were included. Studies involving surgical intervention or drug therapy for postoperative recurrence were excluded. All literature included in the review underwent risk assessment of bias. Two evaluators independently screened the publications, conducted a quality assessment of each article and extracted data. We used Revman 5.4 for the meta-analysis of the included literature. RESULTS Our final analysis consisted of five clinical studies, involving a total of 256 patients. We found that there were significant improvements in the following indicators post-medication as compared to levels before taking the medication: dysmenorrhea (MD = 4.24, 95 % CI: 2.92-5.56, P < 0.00001), non-menstrual pelvic pain (MD = 3.11, 95 % CI: 2.34-3.88, P < 0.00001), dyspareunia (MD = 1.93, 95 % CI: 1.50-2.37, P < 0.00001), dyschezia (MD = 2.48, 95 % CI: 1.83-3.12, P < 0.00001), and rectosigmoid nodule size (MD = 0.32, 95 % CI: 0.18-0.46, P < 0.00001). Compared with pre-medication levels, the following indicators were significantly worse: headache (RR = 0.03, 95 % CI: 0.00-0.23, P = 0.0006), decreased libido (RR = 0.08, 95 % CI: 0.01-0.62, P = 0.02); and there was no significant improvement in dysuria (P > 0.05). CONCLUSION DNG showed efficacy in relieving pain-related symptoms and significantly reducing the size of the lesions when used in the drug conservative treatment of DIE.
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Affiliation(s)
- Han Wu
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China; Department of clinical medicine, Zunyi Medical And Pharmaceutical College, Zunyi 563000, Guizhou, China
| | - Jun-Jiang Liu
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Sheng-Tou Ye
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Jun Liu
- Department of Preventive Medicine, School of Public Health, Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Na Li
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China; Department of Obstetrics and Gynecology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China.
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8
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Oszajca K, Adamus A. Diet in Prevention and Treatment of Endometriosis: Current State of Knowledge. Curr Nutr Rep 2024; 13:49-58. [PMID: 38324218 DOI: 10.1007/s13668-024-00518-y] [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] [Accepted: 01/12/2024] [Indexed: 02/08/2024]
Abstract
PURPOSE OF REVIEW Endometriosis (EM) is a chronic gynecological disease that affects about 10% of women worldwide. It is characterized by the implantation of endometrial cells at ectopic sites. The most common symptom of EM is painful menstruation, which can often lead to chronic pelvic pain that significantly worsens the quality of life. Because some disease-related processes, such as inflammation, hormonal activity, menstrual cycle, or prostaglandin metabolism, can be modified by diet, nutrition may have a significant impact on development and treatment of EM. The purpose of this article was to overview the current knowledge regarding the dietary management of endometriosis. RECENT FINDINGS The attention of researchers has so far concentrated mainly on the role of nutrition in the risk of developing EM, while less attention has been paid to examining the use of diet in the treatment of the disease. Current studies focus primarily on various dietary components that have antiproliferative, anti-inflammatory, antioxidant, analgesic, and estrogen-lowering properties. Exploring different ways of coping with endometriosis can make a significant contribution to improving the quality of life of women at risk or diagnosed with EM.
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Affiliation(s)
- Katarzyna Oszajca
- Department of Medical Biochemistry, Medical University of Lodz, Lodz, Poland.
| | - Adrianna Adamus
- Department of Medical Biochemistry, Medical University of Lodz, Lodz, Poland
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Becker CM, Johnson NP, As-Sanie S, Arjona Ferreira JC, Abrao MS, Wilk K, Imm SJ, Mathur V, Perry JS, Wagman RB, Giudice LC. Two-year efficacy and safety of relugolix combination therapy in women with endometriosis-associated pain: SPIRIT open-label extension study. Hum Reprod 2024; 39:526-537. [PMID: 38243752 PMCID: PMC10905503 DOI: 10.1093/humrep/dead263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 11/08/2023] [Indexed: 01/21/2024] Open
Abstract
STUDY QUESTION What is the efficacy and safety of long-term treatment (up to 2 years) with relugolix combination therapy (CT) in women with moderate to severe endometriosis-associated pain? SUMMARY ANSWER For up to 2 years, treatment with relugolix CT improved menstrual and non-menstrual pain, dyspareunia, and function in women with endometriosis; after an initial decline of <1%, the mean bone mineral density (BMD) remained stable with continued treatment. WHAT IS KNOWN ALREADY Endometriosis is a chronic condition characterized by symptoms of dysmenorrhea, non-menstrual pelvic pain (NMPP), and dyspareunia, which have a substantial impact on the lives of affected women, their partners, and families. SPIRIT 1 and 2 were phase 3, randomized, double-blind, placebo-controlled studies of once-daily relugolix CT (relugolix 40 mg, oestradiol 1 mg, norethisterone acetate 0.5 mg) in premenopausal women (age 18-50 years) with endometriosis and moderate-to-severe dysmenorrhea and NMPP. These trials demonstrated a significant improvement of dysmenorrhea, NMPP, and dyspareunia in women treated with relugolix CT, with minimal decline (<1%) in BMD versus placebo at 24 weeks. STUDY DESIGN, SIZE, DURATION Patients participating in this open-label, single-arm, long-term extension (LTE) study of the 24-week SPIRIT pivotal studies (SPIRIT 1 and 2) received up to an additional 80 weeks of once-daily oral relugolix CT treatment between May 2018 and January 2023. PARTICIPANTS/MATERIALS, SETTING, METHODS Premenopausal women with confirmed endometriosis and moderate to severe dysmenorrhea and NMPP who completed the 24-week pivotal studies (SPIRIT 1 and 2 trials; Giudice et al., 2022) and who met all entry criteria were eligible to enrol. Two-year results were analysed by treatment group based on original randomization in pivotal studies: relugolix CT, delayed relugolix CT (relugolix 40 mg monotherapy for 12 weeks, followed by relugolix CT), or placebo→relugolix CT (placebo for 24 weeks followed by relugolix CT). The primary endpoints of the LTE study were the proportion of dysmenorrhea and NMPP responders at Week 52 and Week 104/end-of-treatment (EOT). A responder was a participant who achieved a predefined, clinically meaningful reduction from baseline in Numerical Rating Scale (NRS) scores (0 = no pain, 10 = worst pain imaginable) for the specific pain type with no increase in analgesic use. The predefined clinically meaningful threshold for dysmenorrhea was 2.8 points and for NMPP was 2.1 points. Secondary efficacy endpoints included change from baseline in Endometriosis Health Profile-30 (EHP-30) pain domain scores, a measure of the effects of endometriosis-associated pain on daily activities (function), NRS scores for dysmenorrhea, NMPP, dyspareunia, and overall pelvic pain, and analgesic/opioid use. Safety endpoints included adverse events and changes in BMD. MAIN RESULTS AND THE ROLE OF CHANCE Of 1261 randomized patients, 1044 completed the pivotal studies, 802 enrolled in the LTE, 681 completed 52 weeks of treatment, and 501 completed 104 weeks of treatment. Demographics and baseline characteristics of the extension population were consistent with those of the original randomized population. Among patients randomized to relugolix CT at pivotal study baseline who continued in the LTE (N = 277), sustained improvements in endometriosis-associated pain were demonstrated through 104 weeks. The proportion of responders at Week 104/EOT for dysmenorrhea and NMPP was 84.8% and 75.8%, respectively. Decreases in dyspareunia and improvement in function assessed by EHP-30 pain domain were also sustained over 2 years. At Week 104/EOT, 91% of patients were opioid-free and 75% of patients were analgesic-free. Relugolix CT over 104 weeks was well tolerated with a safety profile consistent with that observed over the first 24 weeks. After initial least squares mean BMD loss <1% at Week 24, BMD plateaued at Week 36 and was sustained for the duration of 104 weeks of treatment. Efficacy and safety results were generally consistent in women in the placebo→relugolix CT and delayed relugolix CT groups. LIMITATIONS, REASONS FOR CAUTION The study was conducted as an open-label study without a control group over the 80 weeks of the extension period. Of the 802 patients who were enrolled in this LTE study, 681 patients (84.9%) and 501 patients (62.5%) of patients completed 52 and 104 weeks of treatment, respectively. In addition, there currently are no comparative data to other hormonal medications. Finally, a third (37.4%) of the study population terminated participation early. WIDER IMPLICATIONS OF THE FINDINGS In conclusion, relugolix CT offers an additional option to help address an important unmet clinical need for effective, safe, and well-tolerated medical treatments for endometriosis that can be used longer-term, reducing the need for opioids and improving quality of life. The findings from this study may help support the care of women with endometriosis seeking longer-term effective medical management of their symptoms. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by Myovant Sciences GmbH (now Sumitomo Pharma Switzerland GmbH). C.M.B. reports fees from Myovant, grants from Bayer Healthcare, fees from ObsEva, and Chair of ESHRE Endometriosis Guideline Group (all funds went to the University of Oxford); N.P.J. reports personal fees from Myovant Sciences, during the conduct of the study, personal fees from Guerbet, personal fees from Organon, personal fees from Roche Diagnostics; S.A.-S. reports personal fees from Myovant Sciences, personal fees from Bayer, personal fees from Abbvie, personal fees from UpToDate; J.S.P., and R.B.W. are employees and shareholders of Myovant Sciences; J.C.A.F. and S.J.I. are shareholders of Myovant Sciences (but at time of publicaion are no longer employess of Myovant Sciences); M.S.A. and K.W. have no conflicts to declare; V.M. is a consultant to Myovant; L.C.G. reports personal fees from Myovant Sciences, Inc and Bayer. The authors did not receive compensation for manuscript writing, review, and revision. TRIAL REGISTRATION NUMBER NCT03654274.
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Affiliation(s)
- Christian M Becker
- Nuffield Department of Women’s & Reproductive Health, Endometriosis CaRe Centre, University of Oxford, Oxford, UK
| | - Neil P Johnson
- Robinson Research Institute, University of Adelaide, Adelaide, Australia
| | - Sawsan As-Sanie
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | | | - Mauricio S Abrao
- Gynecologic Division, A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil
- Obstetrics and Gynecology Department, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Krzysztof Wilk
- Obstetrics and Gynecology Department, Boni Fratres Hospital, Katowice, Poland
| | | | | | | | | | - Linda C Giudice
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
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Othman ER, Al-Hendy A, Mostafa R, Lambalk CB, Mijatovic V. Oral GnRH Antagonists in Combination with Estradiol and Norethindrone Acetate for Pain Relief Associated with Endometriosis: A Review of Evidence of a Novel Class of Hormonal Agents. Int J Womens Health 2024; 16:309-321. [PMID: 38435758 PMCID: PMC10908275 DOI: 10.2147/ijwh.s442357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/22/2024] [Indexed: 03/05/2024] Open
Abstract
Current medical treatment options for endometriosis associated pains are inadequate. Evidence on effects of nonsteroidal anti-inflammatory drugs is scarce. Around one third of patients are not responsive to oral contraceptives or progestins due to progesterone resistance. Gonadotropin-releasing hormone (GnRH) agonists can only be used for a short duration because of associated side effects. Oral GnRH antagonists, including elagolix, relugolix, and linzagolix allow oral administration, induce dose dependent reduction of estradiol levels, do not cause initial flare up of endometriosis symptoms, and allow the fast return of ovarian function and menstruation after discontinuation. Elagolix at a low dose of 150 mg once daily, or the higher dose of 200 mg twice daily, significantly increased the proportion of women achieving clinically meaningful decline of dysmenorrhea, noncyclic pelvic pain, and dyspareunia. Relugolix at an oral dose of 40 mg/day results in improvement in different forms of endometriosis related pelvic pain, with an efficacy and side effect profile similar to that of GnRH agonists. Adding 1 mg of estradiol and 0.5 mg of norethindrone to 40 mg of relugolix (relugolix combination therapy) allows extension of treatment to 24 weeks with maintained efficacy and an improved side effect profile. Linzagolix, in a dose of 75 mg/day, can be used alone to treat endometriosis associated pain. For severe pelvic pain and dyspareunia, linzagolix can be used in a high dose of 200 mg/day with hormonal add-back therapy to preserve bone health.
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Affiliation(s)
- Essam R Othman
- OB-GYN Department, Assiut University, Assiut, 71515, Egypt
- Academic Endometriosis Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, 60637, USA
| | - Radwa Mostafa
- OB-GYN Department, Assiut University, Assiut, 71515, Egypt
| | - Cornelis B Lambalk
- Academic Endometriosis Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Velja Mijatovic
- Academic Endometriosis Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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11
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Mumusoglu S, Hsueh AJW. Is endometriosis due to evolutionary maladaptation? Reprod Biomed Online 2024; 48:103695. [PMID: 38177037 DOI: 10.1016/j.rbmo.2023.103695] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 09/24/2023] [Accepted: 10/12/2023] [Indexed: 01/06/2024]
Abstract
Similar to diabetes and unlike many pathogen-induced diseases, endometriosis is likely a result of maladaptation to the evolutionary heritage of humans. The objective of this article is to review the literature and improve understanding of the evolutionary factors behind endometriosis, leading to more effective prevention and treatment approaches. In primates, spontaneous decidualization of the endometrium evolved to ensure optimal implantation of a limited number of early embryos, unlike many non-primates which depend on early embryos to induce decidualization and subsequent pregnancy. Spontaneous decidualization results in menstrual bleeding when embryo implantation does not occur, and endometriosis is commonly believed to be caused by retrograde menstruation. Although direct evidence is lacking, it is likely that hunter-gatherer women experienced fewer menstrual periods due to pregnancy shortly after menarche, followed by repeated pregnancies and lactation. However, the mismatch between the evolved uterine physiology and rapid societal changes has led to modern women delaying pregnancy and experiencing numerous menstrual periods, potentially increasing the incidence of endometriosis. The symptoms of endometriosis are often managed by suppressing menstruation through systemic hormonal treatments, but these may have side effects. For patients with a family history of endometriosis or in the early stages of the disease, intrauterine devices releasing progesterone locally could prevent uterine bleeding and the development of endometriosis while preserving fertility and minimizing side effects.
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Affiliation(s)
- Sezcan Mumusoglu
- Department of Obstetrics and Gynaecology, Hacettepe University School of Medicine, Sihhiye, Ankara, Turkey
| | - Aaron J W Hsueh
- Department of Obstetrics and Gynaecology, Stanford University School of Medicine, Stanford, CA, USA.
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12
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Maiorana A, Maranto M, Restivo V, Gerfo DL, Minneci G, Mercurio A, Incandela D. Evaluation of long-term efficacy and safety of dienogest in patients with chronic cyclic pelvic pain associated with endometriosis. Arch Gynecol Obstet 2024; 309:589-597. [PMID: 38019280 PMCID: PMC10808538 DOI: 10.1007/s00404-023-07271-7] [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: 06/13/2023] [Accepted: 10/15/2023] [Indexed: 11/30/2023]
Abstract
PURPOSE To evaluate the efficacy and long-term safety (up to 108 months) of treatment with Dienogest in patients with endometriosis. METHODS Patients with chronic pelvic pain endometriosis-related were enrolled in this observational study from June 2012 to July 2021. The patients enrolled took Dienogest 2 mg as a single daily administration. Group B of long-term therapy patients (over 15 months) were compared with group A of short-term therapy patients (0-15 months). The effects of the drug on pain variation were assessed using the VAS scale and endometriomas dimensions through ultrasonographic evaluation. Furthermore, has been valuated the appearance of side effects and the effect of the drug on bone metabolism by performing MOC every 24 months in group B. RESULTS 157 patients were enrolled. The mean size of the major endometrioma progressively decreased from 33.2 mm (29.4-36.9) at T0 to 7 mm (0-15.8) after 108 months of treatment. We found a significant improvement in dysmenorrhea, dyspareunia, dyschezia and non-cyclic pelvic pain. As for the side effects, both groups complained menstrual alterations present in 22.9%. In 27.6% of group B, osteopenia was found. Group B had a higher percentage statistically significant of side effects such as headaches, weight gain and libido reduction compared to group A. 2 CONCLUSION: Long-term therapy with Dienogest has proven effective in controlling the symptoms of the disease and reducing the size of endometriomas, with an increase in the positive effects related to the duration of the intake and in the absence of serious adverse events. Study approved by the "Palermo 2" Ethics Committee on July 2, 2012 No. 16.
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Affiliation(s)
- Antonio Maiorana
- HCU Obstetrics and Gynecology, ARNAS Civico Di Cristina-Benfratelli Hospital, Palermo, Italy
| | - Marianna Maranto
- HCU Obstetrics and Gynecology, ARNAS Civico Di Cristina-Benfratelli Hospital, Palermo, Italy
| | | | | | - Gabriella Minneci
- HCU Obstetrics and Gynecology, ARNAS Civico Di Cristina-Benfratelli Hospital, Palermo, Italy
| | - Antonella Mercurio
- HCU Obstetrics and Gynecology, ARNAS Civico Di Cristina-Benfratelli Hospital, Palermo, Italy
| | - Domenico Incandela
- HCU Obstetrics and Gynecology, ARNAS Civico Di Cristina-Benfratelli Hospital, Palermo, Italy
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Xholli A, Londero AP, Cavalli E, Scovazzi U, Ferraro MF, Vacca I, Schiaffino MG, Oppedisano F, Sirito G, Molinari F, Cagnacci A. The Benefit of Transvaginal Elastography in Detecting Deep Endometriosis: A Feasibility Study. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024; 45:69-76. [PMID: 36746396 DOI: 10.1055/a-2028-8214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
OBJECTIVES This study aimed to evaluate elastography features of deep infiltrating endometriosis (DIE), and to define whether this technique may discriminate lesions from surrounding non-endometriotic tissue. METHODS This was an exploratory observational study on women affected by DIE treated in a third-level academic hospital gynaecology outpatient facility between 2020 and 2021. Strain elastography (SE) was conducted via transvaginal probe. Tissue deformation of DIE and surrounding tissue was expressed as percentage tissue deformation or as subjective colour score (CS; from blue=stiff to red=soft, assigned numerical values from 0 to 3). Ratios of normal tissue/DIE were compared to ratio of normal tissue/stiffer normal tissue area. RESULTS Evaluations were performed on 46 DIE nodules and surrounding tissue of the uterosacral ligaments (n=21), parametrium (n=7), rectum (n=14), and recto-vaginal septum (n =4). Irrespective of location, DIE strain ratio (3.09, IQR 2.38-4.14 vs. 1.25, IQR 1.11-1.48; p<0.001) and CS ratio (4.62, IQR 3.83-6.94 vs. 1.13, IQR 1.06-1.29; p<0.001) was significantly higher than that of normal tissue. ROC AUC of CS ratio was higher than ROC AUC of strain ratio (99.76%, CI.95 99.26-100% vs. 91.35%, CI.95 85.23-97.47%; p=0.007), and best ROC threshold for CS ratio was 1.82, with a sensitivity of 97.83% (CI.95 93.48-100%) and a specificity of 100% (CI.95 100-100%). CONCLUSIONS Both strain and CS ratios accurately distinguish DIE nodules at various locations. Applications of elastography in improving the diagnosis DIE, in distinguishing different DIE lesions and in monitoring DIE evolution can be envisioned and are worthy of further evaluation.
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Affiliation(s)
- Anjeza Xholli
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Elena Cavalli
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Umberto Scovazzi
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Mattia Francesco Ferraro
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Ilaria Vacca
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Maria Giulia Schiaffino
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesca Oppedisano
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giorgio Sirito
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Filippo Molinari
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Angelo Cagnacci
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- DINOGMI, University of Genoa, Genova, Italy
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Agnihotri T, Ghosh A, Lamba A, Ray CE. Endometriosis: An Overview. Semin Intervent Radiol 2023; 40:544-548. [PMID: 38274215 PMCID: PMC10807967 DOI: 10.1055/s-0043-1777748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Affiliation(s)
- Tanvir Agnihotri
- Department of Radiology, New York University School of Medicine, New York, New York
| | - Abheek Ghosh
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Ashley Lamba
- Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Charles E. Ray
- Department of Radiology, University of Illinois College of Medicine, Chicago, Illinois
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Wang EB, Chang S, Bossa D, Rosero EB, Kho KA. Association between Endometriosis and Surgical Complications among Benign Hysterectomies. J Minim Invasive Gynecol 2023; 30:990-998. [PMID: 37709129 DOI: 10.1016/j.jmig.2023.09.003] [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: 03/18/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023]
Abstract
STUDY OBJECTIVE To investigate the effect of endometriosis on perioperative outcomes in patients undergoing hysterectomy for benign disease. DESIGN A retrospective cohort study. SETTING The American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS A total of 127 556 hysterectomies performed for benign gynecologic indications INTERVENTIONS: Differences in the primary outcomes were compared between patients with and without endometriosis after adjustment for group differences in covariates using inverse probability of treatment weighting approach. MEASURES AND MAIN RESULTS Of the 127 556 hysterectomies identified, 19 618 (15.4%) had a diagnosis of endometriosis. Patients with endometriosis were younger with a lower prevalence of chronic comorbidities but had higher rates of concurrent pelvic inflammatory disease and previous abdominal operations. The incidence of postoperative complications was higher in patients with endometriosis (9.9% vs 8.1%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.17-1.34). The incidence of 30-day mortality (0.1% vs 0.03%; OR, 1.98; 95% CI, 0.69-5.65) and reoperations (1.50% vs 1.36%; OR, 1.18; 95% CI, 0.98-1.42) were not different in patients with and without endometriosis. CONCLUSION Postoperative complications are more likely in hysterectomies involving endometriosis than those without endometriosis, likely owing to anatomic distortion incurring increased surgical complexity. Patients and surgeons should be aware of the increased risk of complications and plan for mitigating these increased risks before and during surgery for suspected endometriosis.
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Affiliation(s)
- Emily B Wang
- Department of Obstetrics and Gynecology (Drs. Wang, Chang, Bossa, and Kho)
| | - Stephanie Chang
- Department of Obstetrics and Gynecology (Drs. Wang, Chang, Bossa, and Kho).
| | - Deina Bossa
- Department of Obstetrics and Gynecology (Drs. Wang, Chang, Bossa, and Kho)
| | - Eric B Rosero
- Department of Anesthesiology and Pain Management (Dr. Rosero), University of Texas Southwestern Medical Center, Dallas, TX
| | - Kimberly A Kho
- Department of Obstetrics and Gynecology (Drs. Wang, Chang, Bossa, and Kho)
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Giese N, Kwon KK, Armour M. Acupuncture for endometriosis: A systematic review and meta-analysis. Integr Med Res 2023; 12:101003. [PMID: 38033648 PMCID: PMC10682677 DOI: 10.1016/j.imr.2023.101003] [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: 07/11/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/02/2023] Open
Abstract
Background Current endometriosis treatments do not always provide symptom relief, with many using complementary approaches. This study examined the effectiveness of acupuncture on pain and quality of life in people with endometriosis. Methods Searches were conducted on Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Allied and Complementary Medicine Database (AMED) and Embase (Ovid), Epistemonikos, and Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCOhost) on 20 March 2023. Trials were included if they used penetrating acupuncture. Risk of bias was assessed with Cochrane RoB2 and GRADE for overall evidence certainty. Random-effects meta-analyses were undertaken, using Hedges' g or mean difference (MD) both with 95 % confidence intervals (CI). Results Six studies involving a total of 331 participants were included. Evidence for benefit was found for acupuncture compared to non-specific acupuncture on overall pelvic pain (g = 1.54, 95 % CI 0.92 to 2.16, 3 RCTs, n = 231, low certainty evidence, p<0.001), menstrual pain (g = 1.67, 95 % CI 1.23 to 2.12, 1 RCT, n = 106, moderate certainty evidence, p<0.001), and non-specified pelvic pain (MD -2.77, 95 % CI 2.15 to 3.38, 2 RCTs, n = 125, low certainty evidence, p<0.001), and compared to usual care on menstrual pain (g = 0.9, 95 % CI 0.15 to 1.64, 1 RCT, n = 19, very low certainty evidence, p = 0.02). Most studies reported low rates of adverse events. Conclusion Acupuncture treatment for endometriosis demonstrated clinically relevant improvements in pelvic pain and should be considered as a potential treatment intervention. Study registration PROSPERO ID: CRD42023408700.
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Affiliation(s)
- Nora Giese
- Praxis für Chinesische Medizin, Bonn, Germany
| | - Ki Kyung Kwon
- NICM Health Research Institute, Western Sydney University, Penrith, Australia
| | - Mike Armour
- NICM Health Research Institute, Western Sydney University, Penrith, Australia
- Translational Health Research Institute (THRI), Western Sydney University, Penrith, Australia
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
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Cervantes GV, Ribeiro PAAG, Tomasi MC, Farah D, Ribeiro HSAA. Sexual Function of Patients with Deep Endometriosis after Surgical Treatment: A Systematic Review. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:e729-e744. [PMID: 38029775 PMCID: PMC10686762 DOI: 10.1055/s-0043-1772596] [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: 01/11/2023] [Accepted: 05/11/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE To review the current state of knowledge on the impact of the surgical treatment on the sexual function and dyspareunia of deep endometriosis patients. DATA SOURCE A systematic review was conducted in accordance with the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We conducted systematic searches in the PubMed, EMBASE, LILACS, and Web of Science databases from inception until December 2022. The eligibility criteria were studies including: preoperative and postoperative comparative analyses; patients with a diagnosis of deep endometriosis; and questionnaires to measure sexual quality of life. STUDY SELECTION Two reviewers screened and reviewed 1,100 full-text articles to analyze sexual function after the surgical treatment for deep endometriosis. The risk of bias was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Collaboration's tool for randomized controlled trials. The present study was registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration CRD42021289742). DATA COLLECTION General variables about the studies, the surgical technique, complementary treatments, and questionnaires were inserted in an Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, United States) spreadsheet. SYNTHESIS OF DATA We included 20 studies in which the videolaparoscopy technique was used for the excision of deep infiltrating endometriosis. A meta-analysis could not be performed due to the substantial heterogeneity among the studies. Classes III and IV of the revised American Fertility Society classification were predominant and multiple surgical techniques for the treatment of endometriosis were performed. Standardized and validated questionnaires were applied to evaluate sexual function. CONCLUSION Laparoscopic surgery is a complex procedure that involves multiple organs, and it has been proved to be effective in improving sexual function and dyspareunia in women with deep infiltrating endometriosis.
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Affiliation(s)
- Graziele Vidoto Cervantes
- Department of Gynecology, Endometriosis and Laparoscopic Surgery Center, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
| | - Paulo Augusto Ayroza Galvão Ribeiro
- Department of Gynecology, Endometriosis and Laparoscopic Surgery Center, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
| | - Mariana Carpenedo Tomasi
- Department of Gynecology, Endometriosis and Laparoscopic Surgery Center, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
| | - Daniela Farah
- Department of Gynecology, Women's Health Technology Assessment Center, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Conte de Oliveira MD, Fernandes HDS, Vasconcelos AL, Russo FADP, Malheiro DT, Colombo G, Pelegrini P, Berwanger O, Teich V, Marra A, Menezes FGD, Cendoroglo Neto M, Klajner S. Impact of a quality programme on overindication of surgeries for endometriosis and cholecystectomies. BMJ Open Qual 2023; 12:e002178. [PMID: 37963671 PMCID: PMC10649569 DOI: 10.1136/bmjoq-2022-002178] [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: 11/03/2022] [Accepted: 10/01/2023] [Indexed: 11/16/2023] Open
Abstract
Approximately 45% of patients receive medical services with minimal or no benefit (low-value care). In addition to the increasing costs to the health system, performing invasive procedures without an indication poses a potentially preventable risk to patient safety. This study aimed to determine whether a managed quality improvement programme could prevent cholecystectomy and surgery for endometriosis treatment with minimal or no benefit to patients.This before-and-after study was conducted at a private hospital in São Paulo, Brazil, which has a main medical remuneration model of fee for service. All patients who underwent cholecystectomy or surgery for endometriosis between 1 August 2020 and 31 May 2021 were evaluated.The intervention consisted of allowing the performance of procedures that met previously defined criteria or for which the indications were validated by a board of experts.A total of 430 patients were included in this analysis. The programme prevented the unnecessary performance of 13% of cholecystectomies (p=0.0001) and 22.2% (p=0.0006) of surgeries for the treatment of endometriosis. This resulted in an estimated annual cost reduction to the health system of US$466 094.93.In a hospital with a private practice and fee-for-service medical remuneration, the definition of clear criteria for indicating surgery and the analysis of cases that did not meet these criteria by a board of reputable experts at the institution resulted in a statistically significant reduction in low-value cholecystectomies and endometriosis surgeries.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Vanessa Teich
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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19
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Deng T, Lin Y, Chen L, Jiang JY. Comparison of Dydrogesterone and GnRH-a Effects After Laparoscopic Surgery in Patients with Stage III and IV Endometriosis. Int J Gen Med 2023; 16:4357-4364. [PMID: 37786803 PMCID: PMC10541528 DOI: 10.2147/ijgm.s429953] [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: 07/11/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023] Open
Abstract
Objective To compare the spontaneous pregnancy rates between dydrogesterone and Gonadotropin-releasing hormone agonist (GnRH-a) treatments in patients with endometriosis stage III and IV after laparoscopy. Methods The clinical data of patients with endometriosis stage III and IV administered laparoscopic surgery in our hospital from January 2018 to March 2020 were retrospectively analyzed. Totally 151 cases were divided into two groups according to postoperative medication, including the study (70 cases) and control (81 cases) groups treated with dydrogesterone and GnRH-a, respectively. The spontaneous pregnancy and subsequent pregnancy outcomes were assessed within 12 months. Results Totally 49 patients had spontaneous pregnancy. Among them, there were 31 cases in the dydrogesterone group (spontaneous pregnancy rate of 44.3%, 31/70), including 25 live birth cases (35.7%, 25/70), 4 miscarriage cases, and 2 ectopic pregnancy cases. The time to conception was 1-10 months (median value of 5 months). Totally 18 cases in the GnRH-a group had spontaneous pregnancy (22.2%, 18/81), including 16 live birth cases (19.8%, 16/81). 81) and 2 miscarriage cases; the time to conception was 3-11 months (median value of 6 months). There were significant differences in spontaneous pregnancy rate and cumulative spontaneous pregnancy rate between the two groups (P = 0.005 and 0.003, respectively). Conclusion Dydrogesterone after laparoscopic surgery in patients with endometriosis stage III and IV improved the natural pregnancy rate.
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Affiliation(s)
- Ting Deng
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, People’s Republic of China
| | - Yin Lin
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, People’s Republic of China
| | - Li Chen
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, People’s Republic of China
| | - Jun-Ying Jiang
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, People’s Republic of China
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20
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Zhang L, Mohankumar K, Martin G, Mariyam F, Park Y, Han SJ, Safe S. Flavonoids Quercetin and Kaempferol Are NR4A1 Antagonists and Suppress Endometriosis in Female Mice. Endocrinology 2023; 164:bqad133. [PMID: 37652054 PMCID: PMC10502789 DOI: 10.1210/endocr/bqad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/02/2023]
Abstract
Nuclear receptor 4A1 (NR4A1) plays an important role in endometriosis progression; levels of NR4A1 in endometriotic lesions are higher than in normal endometrium, and substituted bis-indole analogs (NR4A1) antagonists suppress endometriosis progression in mice with endometriosis. In addition, the flavonoids kaempferol and quercetin are natural products that directly bind NR4A1 and significantly repress the intrinsic NR4A1-dependent transcriptional activity in human endometriotic epithelial and stromal cells and Ishikawa endometrial cancer cells. NR4A1 knockdown and inhibition of NR4A1 by kaempferol and quercetin suppressed proliferation of human endometriotic epithelial cells and Ishikawa cells by inhibiting epidermal growth factor receptor/c-Myc/survivin-mediated growth-promoting and survival pathways, The mammalian target of rapamycin (mTOR) signaling and αSMA/CTGF/COL1A1/FN-mediated fibrosis signaling but increasing Thioredoxin domain Containing 5/SESN2-mediated oxidative/estrogen receptors stress signaling. In human endometriotic stromal cells, NR4A1 knockdown and inhibition of NR4A1 by kaempferol and quercetin primarily inhibited mTOR signaling by suppressing proliferation of human endometrial stromal cells. In addition, kaempferol and quercetin treatment also effectively suppressed the growth of endometriotic lesions in mice with endometriosis compared with the vehicle without any body weight changes. Therefore, kaempferol and quercetin are NR4A1 antagonists with potential as nutritional therapy for endometriosis.
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Affiliation(s)
- Lei Zhang
- Department of Veterinary Physiology and Pharmacology, Texas A&M University, College Station, TX 77843, USA
| | - Kumaravel Mohankumar
- Department of Veterinary Physiology and Pharmacology, Texas A&M University, College Station, TX 77843, USA
| | - Gregory Martin
- Department of Veterinary Physiology and Pharmacology, Texas A&M University, College Station, TX 77843, USA
| | - Fuada Mariyam
- Department of Veterinary Physiology and Pharmacology, Texas A&M University, College Station, TX 77843, USA
| | - Yuri Park
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Sang Jun Han
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Stephen Safe
- Department of Veterinary Physiology and Pharmacology, Texas A&M University, College Station, TX 77843, USA
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21
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Koninckx PR, Ussia A, Gordts S, Keckstein J, Saridogan E, Malzoni M, Stepanian A, Setubal A, Adamyan L, Wattiez A. The 10 "Cardinal Sins" in the Clinical Diagnosis and Treatment of Endometriosis: A Bayesian Approach. J Clin Med 2023; 12:4547. [PMID: 37445589 DOI: 10.3390/jcm12134547] [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: 06/06/2023] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 07/15/2023] Open
Abstract
Evidence-based data for endometriosis management are limited. Experiments are excluded without adequate animal models. Data are limited to symptomatic women and occasional observations. Hormonal medical therapy cannot be blinded if recognised by the patient. Randomised controlled trials are not realistic for surgery, since endometriosis is a variable disease with low numbers. Each diagnosis and treatment is an experiment with an outcome, and experience is the means by which Bayesian updating, according to the past, takes place. If the experiences of many are similar, this holds more value than an opinion. The combined experience of a group of endometriosis surgeons was used to discuss problems in managing endometriosis. Considering endometriosis as several genetically/epigenetically different diseases is important for medical therapy. Imaging cannot exclude endometriosis, and diagnostic accuracy is limited for superficial lesions, deep lesions, and cystic corpora lutea. Surgery should not be avoided for emotional reasons. Shifting infertility treatment to IVF without considering fertility surgery is questionable. The concept of complete excision should be reconsidered. Surgeons should introduce quality control, and teaching should move to explain why this occurs. The perception of information has a personal bias. These are the major problems involved in managing endometriosis, as identified by the combined experience of the authors, who are endometriosis surgeons.
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Affiliation(s)
- Philippe R Koninckx
- Department of OBGYN, Faculty of Medicine, Katholieke University Leuven, 3000 Leuven, Belgium
- Department of OBGYN, Faculty of Medicine, University of Oxford, Oxford OX1 2JD, UK
- Department of OBGYN, Faculty of Medicine, University Cattolica, del Sacro Cuore, 00168 Rome, Italy
- Department of OBGYN, Faculty of Medicine, Moscow State University, 119991 Moscow, Russia
- Latifa Hospital, Dubai 9115, United Arab Emirates
| | - Anastasia Ussia
- Department of OBGYN, Gemelli Hospitals, Università Cattolica, 00168 Rome, Italy
| | | | - Jörg Keckstein
- Endometriosis Centre, Dres. Keckstein, 9500 Villach, Austria
- Faculty of Medicine, University Ulm, 89081 Ulm, Germany
| | - Ertan Saridogan
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London SW7 2BX, UK
| | | | - Assia Stepanian
- Academia of Women's Health and Endoscopic Surgery, Atlanta, GA 30328, USA
| | - Antonio Setubal
- Department of Ob/Gyn and MIGS, Hospital da Luz Lisbon, 1500-650 Lisboa, Portugal
| | - Leila Adamyan
- Department of Operative Gynecology, Federal State Budget Institution V. I. Kulakov, Research Centre for Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, 117198 Moscow, Russia
- Department of Reproductive Medicine and Surgery, Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia
| | - Arnaud Wattiez
- Latifa Hospital, Dubai 9115, United Arab Emirates
- Department of Obstetrics and Gynaecology, University of Strasbourg, 67081 Strasbourg, France
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22
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Canis M, Guo SW. In the thicket of fears, doubts, and murky facts: some reflections on treatment modalities for endometriosis-associated pain. Hum Reprod 2023; 38:1245-1252. [PMID: 37023473 DOI: 10.1093/humrep/dead061] [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: 11/15/2022] [Revised: 03/15/2023] [Indexed: 04/08/2023] Open
Abstract
Endometriosis-associated pain can be managed by either surgery or hormonal therapy. The final decision as to which treatment modality to take is based on efficacy and possible complications of different treatment modalities, risk of recurrence, and the patient's wishes and preferences. But in the thicket of fears, doubts, and murky facts, the choice may ultimately be the trade-off between irrational fears and ignorance versus scientific evidence. We elaborate some pros and cons of the two treatment modalities and highlight some notable downsides of hormonal therapy, in particular the possible yet unquantified risk of long-term hormonal therapy for malignant transformation, perhaps with the only exception of combined oral contraceptives. Thus, when discussing with patients, we advocate the approach of discussing the advantages and disadvantages of all treatment options in detail, accounting for the known pros and cons with a full understanding of the predictive irrationality of human beings. For endometriosis-associated pain, surgery is definitely not a failure of medicine but, rather, a viable option, especially given the recently surfaced undercurrent of wariness and dissatisfaction with the current hormonal drugs among patients with endometriosis. Above all, there is a pressing need to fill the knowledge gap of perioperative interventions intended to reduce the risk of recurrence and to fulfill the demand for the development of safe and efficacious non-hormonal therapeutics.
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Affiliation(s)
- Michel Canis
- Department of Obstetrics Gynecology and Reproductive Medicine, CHU Clermont Ferrand, Clermont Ferrand, France
| | - Sun-Wei Guo
- Research Institute, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
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23
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Weng SS, Wang YL, Chuang FC, Sun FJ. Effect of dienogest on serum anti-Mullerian hormone level after laparoscopic cystectomy of ovarian endometrioma. Taiwan J Obstet Gynecol 2023; 62:521-524. [PMID: 37407187 DOI: 10.1016/j.tjog.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVE This comparative study aimed to evaluate the effect of postoperative dienogest treatment on serum anti-Mullerian hormone (AMH) levels in patients undergoing laparoscopic cystectomy of ovarian endometriomas. MATERIALS AND METHODS A total of 71 patients with ovarian endometriomas treated at our department were enrolled. After surgery, 54 patients received oral dienogest 2 mg daily continuously for 6 months (dienogest group). The other 17 patients did not receive postoperative medical treatment (control group). Serum AMH levels were measured before surgery, at 3-month period after surgery, and at the end of 6-month follow-up period. Serial changes of AMH levels were compared between the two groups. RESULTS The age, endometrioma size, and serum AMH level before surgery were comparable between the dienogest group and the control group. The AMH levels decreased significantly at 3-month period after surgery in the dienogest group (a decrease of 65.5%; p < 0.001) and the control group (a decrease of 64.8%; p = 0.018). The AMH levels increased gradually from the nadir at 3-month period after surgery and recovered partially at the end of 6-month follow-up period in both groups. There were no statistically significant differences in the rate of reduction of serum AMH levels between the two groups (p = 0.707). CONCLUSION Laparoscopic cystectomy of ovarian endometrioma causes a significant decrease in serum AMH levels. The rates of reduction of AMH levels are similar regardless of dienogest treatment. Postoperative dienogest treatment for 6 months has no rescue effect on serum AMH levels in these patients.
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Affiliation(s)
- Shih-Shien Weng
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan.
| | - Yeou-Lih Wang
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Fu-Ching Chuang
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Fang-Ju Sun
- Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
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24
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Kim HK, Kim ES, Park KS, Lee YJ, Ha IH. Current treatments for endometriosis in South Korea: an analysis of nationwide data from 2010 to 2019. Sci Rep 2023; 13:9573. [PMID: 37311821 DOI: 10.1038/s41598-023-36291-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/31/2023] [Indexed: 06/15/2023] Open
Abstract
While a wide range of treatments, including medical therapies and surgery, are used to manage endometriosis, the characteristics and treatment status of patients who received these treatments have not been investigated in Korea. This study analyzed the Korean Health Insurance Review & Assessment Service-National Patient Sample (HIRA-NPS) data from 2010 to 2019 with 7530 patients diagnosed with endometriosis. Annual trends in the types of visit and surgery, medication prescriptions and associated costs were investigated. The analysis showed that surgery slightly decreased among the types of utilized healthcare services (2010: 16.3, 2019: 12.7), dienogest prescription rapidly increased due to national health insurance coverage from 2013 (2013: 12.1, 2019: 36.0), and the use of gonadotrophin-releasing hormone analogues decreased (2010: 33.6, 2019: 16.4). There was no significant change in total and outpatient costs per person over time. Regarding endometriosis treatment, conservative treatment mainly based on prescribed medications has been gradually replacing surgery. Particularly, the listing of dienogest for national health insurance coverage might have affected the trend. However, there were no significant changes in terms of total and medication costs per person.
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Affiliation(s)
- Han Kyul Kim
- Jaseng Hospital of Korean Medicine, Gangnam-Daero, Gangnam-Gu, Seoul, Republic of Korea
| | - Eun-San Kim
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Gangnam-Daero, Gangnam-Gu, Seoul, Republic of Korea
| | - Kyoung Sun Park
- Jaseng Hospital of Korean Medicine, Gangnam-Daero, Gangnam-Gu, Seoul, Republic of Korea
| | - Yoon Jae Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Gangnam-Daero, Gangnam-Gu, Seoul, Republic of Korea
| | - In-Hyuk Ha
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Gangnam-Daero, Gangnam-Gu, Seoul, Republic of Korea.
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25
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Clemenza S, Capezzuoli T, Eren E, Garcia Garcia JM, Vannuccini S, Petraglia F. Progesterone receptor ligands for the treatment of endometriosis. Minerva Obstet Gynecol 2023; 75:288-297. [PMID: 36255163 DOI: 10.23736/s2724-606x.22.05157-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Estrogen dependence and progesterone resistance play a crucial role in the origin and development of endometriosis. Therefore, hormonal therapies are currently the most effective treatment. Progestins are considered the first-line approach, especially for a long-term management. Progestins are synthetic compounds that mimic the effects of progesterone by binding progesterone receptors. Continuous use of progestins leads to the suppression of ovarian steroidogenesis with anovulation and low serum levels of ovarian steroids, causing endometrial pseudodecidualization. Moreover, they act by interfering on several endometriosis pathogenetic pathways, decreasing inflammation, provoking apoptosis in endometriotic cells, stimulating atrophy or regression of endometrial lesions, inhibiting angiogenesis, and decreasing expression of metalloproteinases, thus diminishing the invasiveness of endometriotic implants. Progestins are effective for pain relief and improvement of the quality of life (QoL). The side effects are limited, and the compounds are available in different formulations and routes of administration and represent, in most cases, an inexpensive treatment option. Dienogest, Medroxyprogesterone acetate and Norethisterone acetate are the labeled progestins for endometriosis, but other progestins, such as Dyhidrogesterone, Levonorgestrel and Desogestrel, have been shown to be effective in the treatment of endometriosis-associated pain. The present review aims to describe the available and emerging evidences on progestins used for the treatment of endometriosis.
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Affiliation(s)
- Sara Clemenza
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Tommaso Capezzuoli
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Ecem Eren
- Department of Obstetrics and Gynecology, Bakırköy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Türkiye
| | - Jose M Garcia Garcia
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Silvia Vannuccini
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Felice Petraglia
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy -
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26
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Caruana A, Savona-Ventura C, Calleja-Agius J. COX Isozymes and Non-Uniform Neoangiogenesis: What is their role in Endometriosis? Prostaglandins Other Lipid Mediat 2023; 167:106734. [PMID: 37028470 DOI: 10.1016/j.prostaglandins.2023.106734] [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: 03/07/2023] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 04/09/2023]
Abstract
This literature review compared the efficacy in of NSAIDs with a placebo in pain relief and disease regression of endometriosis. Despite the poor evidence found, the results showed that NSAIDs were more effective in pain relief with regressive effects on the endometriotic lesions compared to placebo. We postulate herein that COX-2 is chiefly responsible for pain whilst COX-1 is responsible mainly for the establishment of endometriotic lesions. Hence, there must be a temporal difference in the activation of the two isozymes. We differentiated between two pathways in the conversion of arachidonic acid to prostaglandins by the COX isozymes referred to as 'direct' and indirect', supporting our initial theory. Finally, we postulate that there are two stages of neoangiogenesis in the formation of endometriotic lesions; 'founding' that first establishes blood supply and 'maintenance' that upkeeps it This is fertile ground for further research in a niche that needs more literature. Its aspects may be diversely explored. The theories we propose offer information for a more targeted treatment of endometriosis.
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Affiliation(s)
- Andrea Caruana
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta.
| | - Charles Savona-Ventura
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Surgery, University of Malta
| | - Jean Calleja-Agius
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta
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27
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Vahid-Dastjerdi M, Hosseini R, Rodi H, Rastad H, Hosseini L. Comparison of the effectiveness of Dienogest with medroxyprogesterone acetate in the treatment of pelvic pain and recurrence of endometriosis after laparoscopic surgery. Arch Gynecol Obstet 2023; 308:149-155. [PMID: 36995381 DOI: 10.1007/s00404-022-06898-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/17/2022] [Indexed: 03/31/2023]
Abstract
PURPOSE The aim of this study was to compare the effects of Dienogest and medroxyprogesterone acetate (MPA) on the recurrence of endometriosis lesions and clinical symptoms in women undergoing laparoscopic surgery. METHODS This single center clinical trial was conducted among 106 women with endometriosis undergoing laparoscopic surgery who candidate receiving post-surgery hormone therapy. Participants were allocated to two groups. The first group received Dienogest pills (2 mg) daily for the first three months and then cyclic for three months afterward. The second group received MPA pills twice daily (10 mg) for three months and then cyclic for the next three months. Six months after the intervention, the rate of endometriosis recurrence, the size of endometriosis lesions and pelvic pain were assess and compared between two groups. RESULTS Finally, data were evaluated based on 48 and 53 women in the Dienogest and MPA groups, respectively. After 6 months follow-up assessments the pelvic pain score was significantly lower in Dienogest group than MPA group (P < 0.001). There was not statistically difference between two groups in terms of recurrence rate of endometriosis (P = 0.4). Although the size of endometriosis cyst recurrence was smaller in Dienogest group compared to MPA group (P = 0.02). CONCLUSIONS The findings showed that Dienogest treatment has better effect in reducing pelvic pain and the mean size of the recurrent endometriosis lesions after endometriosis laparoscopic surgery when compared to MPA treatment. Although the recurrent rate of endometriosis was similar between these treatments.
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Affiliation(s)
- Marzieh Vahid-Dastjerdi
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Baghdarnia St., Farjam St., Tehran, 1653915911, Iran
| | - Reihaneh Hosseini
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Baghdarnia St., Farjam St., Tehran, 1653915911, Iran
| | - Hanieh Rodi
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Baghdarnia St., Farjam St., Tehran, 1653915911, Iran.
| | - Hadith Rastad
- Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Ladan Hosseini
- Research Development Center, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
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28
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Bergsten TM, Li K, Lantvit DD, Murphy BT, Burdette JE. Kaempferol, a Phytoprogestin, Induces a Subset of Progesterone-Regulated Genes in the Uterus. Nutrients 2023; 15:1407. [PMID: 36986136 PMCID: PMC10051346 DOI: 10.3390/nu15061407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/27/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023] Open
Abstract
Progesterone functions as a steroid hormone involved in female reproductive physiology. While some reproductive disorders manifest with symptoms that can be treated by progesterone or synthetic progestins, recent data suggest that women also seek botanical supplements to alleviate these symptoms. However, botanical supplements are not regulated by the U.S. Food and Drug Administration and therefore it is important to characterize and quantify the inherent active compounds and biological targets of supplements within cellular and animal systems. In this study, we analyzed the effect of two natural products, the flavonoids, apigenin and kaempferol, to determine their relationship to progesterone treatment in vivo. According to immunohistochemical analysis of uterine tissue, kaempferol and apigenin have some progestogenic activity, but do not act in exactly the same manner as progesterone. More specifically, kaempferol treatment did not induce HAND2, did not change proliferation, and induced ZBTB16 expression. Additionally, while apigenin treatment did not appear to dramatically affect transcripts, kaempferol treatment altered some transcripts (44%) in a similar manner to progesterone treatment but had some unique effects as well. Kaempferol regulated primarily unfolded protein response, androgen response, and interferon-related transcripts in a similar manner to progesterone. However, the effects of progesterone were more significant in regulating thousands of transcripts making kaempferol a selective modifier of signaling in the mouse uterus. In summary, the phytoprogestins, apigenin and kaempferol, have progestogenic activity in vivo but also act uniquely.
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Affiliation(s)
| | | | | | | | - Joanna E. Burdette
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Illinois Chicago, Chicago, IL 60607, USA
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29
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Giese N, Heirs MK. Development of Provisional Acupuncture Guidelines for Pelvic Pain in Endometriosis Using an e-Delphi Consensus Process. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2023; 29:169-180. [PMID: 36454211 PMCID: PMC10039271 DOI: 10.1089/jicm.2022.0659] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Introduction: Growing evidence suggests that acupuncture can improve pelvic pain in women with endometriosis. The treatments used in research vary considerably. It remains unclear which treatment could be recommended for clinical practice. This research project aimed at clarifying how acupuncture could be used when treating this condition. Methods: This research comprised two phases: a systematized literature review to extract acupuncture treatment details from published research, and an e-Delphi study to gain knowledge about details as used by expert acupuncturists. Review: Four databases were searched using predefined eligibility criteria. Data were extracted based on the STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) criteria. e-Delphi: Purposeful sampling from colleagues and international experts. An open first round gathered qualitative data, analyzed with the Framework method. In rounds 2 and 3, experts rated statements to build group consensus, defined as a rating of ≥5 on a 7-point Likert scale by ≥70% of the experts. The strength of agreement was graded using the median score and interquartile range. Results from the literature review and the e-Delphi were compared using the STRICTA items. Results: The literature review (n = 29 unique studies) found a wide range of treatment details with little agreement. The e-Delphi of international experts (n = 20) resulted in agreement on 94 statements (such as key factors for effectiveness); disagreement on a further 29 (such as acupressure); and absence of consensus on 55 statements (such as the number of needle insertions). A comparison of the review and e-Delphi results found little agreement. Conclusions: Details of acupuncture treatment for endometriosis-related pelvic pain were presented. In the absence of acupuncture guidelines for this condition, the researchers of this e-Delphi recommend using the treatment details on which experts agreed as guidance for good practice. The effectiveness of these guidelines should be evaluated in future research. Study registration: Deutsches Register Klinischer Studien, DRKS00022215, June 30, 2020, retrospectively registered.
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Affiliation(s)
- Nora Giese
- Department of Advanced Oriental Medicine, Northern College of Acupuncture, York, United Kingdom
- Praxis für Chinesische Medizin, Bonn, Germany
| | - Morag K Heirs
- Department of Advanced Oriental Medicine, Northern College of Acupuncture, York, United Kingdom
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30
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Quality of life and clinical factors in women with endometriosis, the role of dienogest vs EE/dienogest over time: a single-center study. Arch Gynecol Obstet 2023; 307:1503-1512. [PMID: 36738318 PMCID: PMC10110631 DOI: 10.1007/s00404-023-06942-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/18/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE The aims of this observational study were: to assess the relationship between psychological variables, pain, Duration Untreated Endometriosis (DUE) in a sample of women with Endometriosis; and to assess the effect of dienogest 2 mg/daily (DNG) and dienogest/ethinylestradiol 0.03 mg/daily (EE/DNG) on Symptoms, QoL, HRQoL, pain and sexual satisfaction, over time. METHODS 64 women constituted the study group; (56%) took DNG and (44%) took EE/DNG. VAS, SF-36, EHP-30 and ISS were used to assess endometriosis-associated pelvic pain, QoL, HRQoL and sexual satisfaction, respectively. The study included one follow-up at 18 months. RESULTS At T0, a longer period of DUE was related both to worst HRQoL and Physical QoL. At T1, a correlation was found between longer DUE and worst HRQoL. At T0, a negative correlation was found between VAS and PCS and between VAS and EHP-30. At T1, the same above correlation was found between VAS and PCS/MCS and VAS and EHP-30 scale. There was a correlation between ISS and VAS. ANOVA showed a reduction in dysmenorrhea, in general pain level and an improvement in emotional wellbeing, relationship with medical profession, and PCS over time, regardless to type of treatment. Moreover, a significant time × treatment group interaction for dysmenorrhea was found. CONCLUSION DUE and pain are important variables related to psychological aspects of women with endometriosis. Treatment with both DNG and EE/DNG may have positive effects on the QoL, HRQoL and symptoms. Moreover, DNG seems to have a greater effect than EE/DNG on dyspareunia reduction over time.
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Kim J, Boo Y, Lee CU, Ko KJ, Chung JH, Sung HH, Baek M, Jeon SS, Han DH. Effects of hormone therapy on the clinical outcomes of endoscopic intervention in patients with endometriosis-related ureteral obstruction. Investig Clin Urol 2023; 64:13-19. [PMID: 36629061 PMCID: PMC9834571 DOI: 10.4111/icu.20220224] [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: 07/01/2022] [Revised: 08/23/2022] [Accepted: 10/13/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE We investigated whether endoscopic interventions, including laser endoureterotomy and balloon dilatation following hormone therapy, are a good choice to treat ureteral obstruction due to ureteral endometriosis instead of laparoscopic or open surgery. MATERIALS AND METHODS Patients with ureteral obstruction due to endometriosis who underwent endoscopic intervention between 2004 and 2021 were reviewed. Patients with other causes of ureteral obstruction or previous ureteral surgery were excluded from the study. The primary endpoint was the 3-month success rate of endoscopic intervention with or without hormone therapy. Secondary endpoints were the success rate of endoscopic intervention between the hormone-treated and hormone-untreated groups at 6 months and the success rate according to the hormone therapy response of endometriosis at 3 and 6 months. RESULTS Eighteen patients with 19 ureter units were evaluated in this study, including 12 patients receiving hormone therapy and six patients not receiving hormone therapy. Among patients receiving hormone therapy, one patient had bilateral ureteral obstruction. The success rate of endoscopic intervention was higher in patients who received hormone therapy than in those who did not receive hormone therapy three months after endoscopic intervention (76.9% vs. 0.0%, p=0.003). The same result was also found 6 months after endoscopic intervention (75.0% vs. 0.0%, p=0.005). In addition, the success rates were higher in the hormone-responsive group than in the non-responsive group (100.0% vs. 57.1%), although the difference was not statistically significant (p=0.122). CONCLUSIONS Ureteral obstruction caused by endometriosis can be effectively treated by endoscopic intervention with hormone therapy in select patients.
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Affiliation(s)
- Jungyu Kim
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Youngjun Boo
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chung Un Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Jin Ko
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hoon Chung
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Hwan Sung
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Minki Baek
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Soo Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Deok Hyun Han
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Guo B, Chen JH, Zhang JH, Fang Y, Liu XJ, Zhang J, Zhu HQ, Zhan L. Pattern-recognition receptors in endometriosis: A narrative review. Front Immunol 2023; 14:1161606. [PMID: 37033937 PMCID: PMC10076794 DOI: 10.3389/fimmu.2023.1161606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/02/2023] [Indexed: 04/11/2023] Open
Abstract
Endometriosis is closely associated with ectopic focal inflammation and immunosuppressive microenvironment. Multiple types of pattern recognition receptors (PRRs) are present in the innate immune system, which are able to detect pathogen-associated molecular patterns (PAMPs) and danger-associated molecular patterns (DAMPs) in both intracellular and external environments. However, the exact role of PRRs in endometriosis and the underlying molecular mechanism are unclear. PRRs are necessary for the innate immune system to identify and destroy invasive foreign infectious agents. Mammals mainly have two types of microbial recognition systems. The first one consists of the membrane-bound receptors, such as toll-like receptors (TLRs), which recognize extracellular microorganisms and activate intracellular signals to stimulate immune responses. The second one consists of the intracellular PRRs, including nod-like receptors (NLRs) and antiviral proteins retinoic acid-inducible gene I (RIG-I) and melanoma differentiation-associated gene 5 (MDA-5) with helix enzyme domain. In this review, we mainly focus on the key role of PRRs in the pathological processes associated with endometriosis. PRRs recognize PAMPs and can distinguish pathogenic microorganisms from self, triggering receptor ligand reaction followed by the stimulation of host immune response. Activated immune response promotes the transmission of microbial infection signals to the cells. As endometriosis is characterized by dysregulated inflammation and immune response, PRRs may potentially be involved in the activation of endometriosis-associated inflammation and immune disorders. Toll-like receptor 2 (TLR2), toll-like receptor 3 (TLR3), toll-like receptor 4 (TLR4), nod-like receptor family caspase activation and recruitment domain (CARD) domain containing 5 (NLRC5), nod-like receptor family pyrin domain containing 3 (NLRP3), and c-type lectin receptors (CLRs) play essential roles in endometriosis development by regulating immune and inflammatory responses. Absent in melanoma 2 (AIM2)-like receptors (ALRs) and retinoic acid-inducible gene I-like receptors (RLRs) may be involved in the activation of endometriosis-associated immune and inflammation disorders. PRRs, especially TLRs, may serve as potential therapeutic targets for alleviating pain in endometriosis patients. PRRs and their ligands interact with the innate immune system to enhance inflammation in the stromal cells during endometriosis. Thus, targeting PRRs and their new synthetic ligands may provide new therapeutic options for treating endometriosis.
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Affiliation(s)
- Bao Guo
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jia hua Chen
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jun hui Zhang
- First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yuan Fang
- First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xiao jing Liu
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jing Zhang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Hai qing Zhu
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Lei Zhan
- Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- *Correspondence: Lei Zhan,
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Carneiro MM. Deciding on the appropriate pharmacotherapy for the treatment of endometriosis. Expert Opin Pharmacother 2023; 24:1-5. [PMID: 35973977 DOI: 10.1080/14656566.2022.2113383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Márcia Mendonça Carneiro
- Obstetrics and Gynecology Department, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
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Uehara M, Wada-Hiraike O, Koga K, Yamamoto N, Hirano M, Harada M, Hirota Y, Osuga Y. Prediction of the final menstrual period in women taking Dienogest using estradiol and follicle-stimulating hormone values: a case-control study. Endocr J 2022; 69:1437-1445. [PMID: 36070964 DOI: 10.1507/endocrj.ej22-0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Dienogest (DNG) is widely used to treat dysmenorrhea associated with estrogen-dependent diseases such as endometriosis and adenomyosis. DNG becomes unnecessary after menopause when estrogen secretion declines drastically. However, there are no clear criteria for when to halt DNG in perimenopausal patients. Menstruation and dysmenorrhea often resume after discontinuation due to approaching menopause. This case-control study used serum estradiol and follicle-stimulating hormone (FSH) levels to predict whether menstruation would resume in perimenopausal women after discontinuation of DNG. The study enrolled patients aged ≥40 years with endometriosis and/or adenomyosis and who had either completed oral DNG therapy (DNG group) or had spontaneous menopause without hormone therapy (control group). We assessed estradiol and FSH values before DNG termination or the final menstrual period. DNG group members that resumed menstruation after DNG termination (D (+) group, n = 17) had significantly higher estradiol and lower FSH levels than those who did not (D (-) group, n = 22) up to four months before DNG termination but not from four to 12 months. Estradiol and FSH levels were not significantly different between the D (-) and control groups. Receiver operating characteristic curves created from the estradiol and FSH values indicated that menstruation resumed when levels were ≥17 pg/mL and <100 mIU/mL, respectively. In contrast, menstruation did not resume in cases of estradiol ≤20 pg/mL and FSH >80 mIU/mL. The study results provide useful criteria for deciding when to terminate DNG in perimenopausal patients that consider their tolerance for resuming menstruation. Applications to menopause-inducing therapy for uterine fibroids and other conditions are anticipated. Further large-scale studies are needed.
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Affiliation(s)
- Mari Uehara
- Department of Obstetrics and Gynecology, University of Tokyo, Tokyo 113-8655, Japan
| | - Osamu Wada-Hiraike
- Department of Obstetrics and Gynecology, University of Tokyo, Tokyo 113-8655, Japan
| | - Kaori Koga
- Department of Obstetrics and Gynecology, University of Tokyo, Tokyo 113-8655, Japan
| | - Naoko Yamamoto
- Department of Obstetrics and Gynecology, University of Tokyo, Tokyo 113-8655, Japan
| | - Mana Hirano
- Department of Obstetrics and Gynecology, University of Tokyo, Tokyo 113-8655, Japan
| | - Miyuki Harada
- Department of Obstetrics and Gynecology, University of Tokyo, Tokyo 113-8655, Japan
| | - Yasushi Hirota
- Department of Obstetrics and Gynecology, University of Tokyo, Tokyo 113-8655, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, University of Tokyo, Tokyo 113-8655, Japan
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Clinical Diagnosis and Early Medical Management for Endometriosis: Consensus from Asian Expert Group. Healthcare (Basel) 2022; 10:healthcare10122515. [PMID: 36554040 PMCID: PMC9777951 DOI: 10.3390/healthcare10122515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/22/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
This work provides consensus guidance regarding clinical diagnosis and early medical management of endometriosis within Asia. Clinicians with expertise in endometriosis critically evaluated available evidence on clinical diagnosis and early medical management and their applicability to current clinical practices. Clinical diagnosis should focus on symptom recognition, which can be presumed to be endometriosis without laparoscopic confirmation. Transvaginal sonography can be appropriate for diagnosing pelvic endometriosis in select patients. For early empiric treatment, management of women with clinical presentation suggestive of endometriosis should be individualized and consider presentation and therapeutic need. Medical treatment is recommended to reduce endometriosis-associated pelvic pain for patients with no immediate pregnancy desires. Hormonal treatment can be considered for pelvic pain with a clinical endometriosis diagnosis; progestins are a first-line management option for early medical treatment, with oral progestin-based therapies generally a better option compared with combined oral contraceptives because of their safety profile. Dienogest can be used long-term if needed and a larger evidence base supports dienogest use compared with gonadotropin-releasing hormone agonists (GnRHa) as first-line medical therapy. GnRHa may be considered for first-line therapy in some specific situations or as short-term therapy before dienogest and non-steroidal anti-inflammatory drugs as add-on therapy for endometriosis-associated pelvic pain.
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Yan H, Shi J, Li X, Dai Y, Wu Y, Zhang J, Gu Z, Zhang C, Leng J. Oral gonadotropin-releasing hormone antagonists for treating endometriosis-associated pain: a systematic review and network meta-analysis. Fertil Steril 2022; 118:1102-1116. [PMID: 36283862 DOI: 10.1016/j.fertnstert.2022.08.856] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To review the use of oral gonadotropin-releasing hormone (GnRH) antagonists and synthesize their efficacy and safety parameters for the treatment of endometriosis-associated pain. DESIGN Systematic review and network meta-analysis. SETTING Not applicable. PATIENT(S) Premenopausal women with endometriosis who had experienced moderate or severe pain. INTERVENTION(S) The Web of Science, Embase, Scopus, and MEDLINE were searched until April 10, 2022. Only randomized controlled trials were included. The risk of bias in the included studies was assessed using the Cochrane Risk of Bias tool 2. A Bayesian random-effects network meta-analysis was used to perform indirect comparisons. I2 was used to assess the global heterogeneity. Relative treatment estimates were performed. Treatment ranking was performed through the surface under the cumulative ranking curve. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation framework. MAIN OUTCOME MEASURE(S) Endometriosis-associated pain, dysmenorrhea, dyspareunia, and noncyclic pelvic pain reduction. RESULT (s): Five studies and 6 randomized controlled trials, including a total of 2,796 women and 10 different doses of oral GnRH antagonist treatments, were eligible for inclusion. All studies were considered to have a low risk of bias. Almost all efficacy- and safety-related outcomes showed a dose-response relationship. Regarding endometriosis-associated pain, the top 3 treatments were elagolix 400 mg, linzagolix 75 mg, and linzagolix 200 mg, with mean differences of -1.26 (95% credible interval [CrI], -1.70 to -0.79), -0.98 (95% CrI, -1.84 to -0.15), and -0.98 (95% CrI, -1.90 to -0.064), respectively. The top 3 treatments to decrease dysmenorrhea were relugolix 40 mg, elagolix 400 mg, and relugolix 20 mg, with mean differences of -1.60 (95% CrI, -2.07 to -1.14), -1.25 (95% CrI, -1.56 to -0.95), and -1.10 (95% CrI, -1.59 to -0.62), respectively. However, only high-dose treatments were significantly associated with most quality of life- and adverse effect-related outcomes. Relugolix 40 and 20 mg and elagolix 400 mg, with odds ratios of 6.88 (95% CrI, 2.18-24.58), 1.60 (95% CrI, 0.62-4.13), and 1.85 (95% CrI, 1.05-3.30), had a significantly increased incidence of adverse events. CONCLUSION (s): Oral GnRH antagonists are effective for endometriosis-associated pain and dysmenorrhea and the patient global impression. The incidence of ovarian hypoestrogenic effects in a short-term duration was significant in a dose-effect response, particularly the highest dose. CLINICAL TRIAL REGISTRATION NUMBER International Prospective Register of Systematic Reviews registration number CRD42022332904.
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Affiliation(s)
- Hailan Yan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, People's Republic of China
| | - Jinghua Shi
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, People's Republic of China
| | - Xiaoyan Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, People's Republic of China
| | - Yi Dai
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, People's Republic of China
| | - Yushi Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, People's Republic of China
| | - Jing Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, People's Republic of China
| | - Zhiyue Gu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, People's Republic of China
| | - Chenyu Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, People's Republic of China
| | - Jinhua Leng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, People's Republic of China.
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Abstract
Endometriosis affects approximately 190 million women and people assigned female at birth worldwide. It is a chronic, inflammatory, gynecologic disease marked by the presence of endometrial-like tissue outside the uterus, which in many patients is associated with debilitating painful symptoms. Patients with endometriosis are also at greater risk of infertility, emergence of fatigue, multisite pain, and other comorbidities. Thus, endometriosis is best understood as a condition with variable presentation and effects at multiple life stages. A long diagnostic delay after symptom onset is common, and persistence and recurrence of symptoms despite treatment is common. This review discusses the potential genetic, hormonal, and immunologic factors that lead to endometriosis, with a focus on current diagnostic and management strategies for gynecologists, general practitioners, and clinicians specializing in conditions for which patients with endometriosis are at higher risk. It examines evidence supporting the different surgical, pharmacologic, and non-pharmacologic approaches to treating patients with endometriosis and presents an easy to adopt step-by-step management strategy. As endometriosis is a multisystem disease, patients with the condition should ideally be offered a personalized, multimodal, interdisciplinary treatment approach. A priority for future discovery is determining clinically informative sub-classifications of endometriosis that predict prognosis and enhance treatment prioritization.
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Affiliation(s)
- Andrew W Horne
- EXPPECT Edinburgh and MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Stacey A Missmer
- Michigan State University, Grand Rapids, MI, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Clemenza S, Vannuccini S, Ruotolo A, Capezzuoli T, Petraglia F. Advances in targeting estrogen synthesis and receptors in patients with endometriosis. Expert Opin Investig Drugs 2022; 31:1227-1238. [PMID: 36529967 DOI: 10.1080/13543784.2022.2152325] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Endometriosis is an estrogen-dependent disease on the background of progesterone resistance. Increased estrogen production, low estrogen metabolization, and altered estrogen receptors (ERs) expression contribute to the hyperestrogenic milieu within endometriotic lesions. Since estrogens play a crucial role in the pathogenesis of the disease, inhibition of estrogen production is one of the main targets of available and emerging drugs. AREAS COVERED Firstly, we described the molecular alterations responsible for estrogen dependence. Secondly, we reviewed available and emerging treatments that interfere, through central (gonadotropin-releasing hormone analogs (GnRH-a), GnRH antagonists) or local mechanisms (aromatase inhibitors (AIs), inhibitors of steroid sulfatase (STS) and hydroxysteroid dehydrogenase type 1 (17β-HSD1)), with estrogen dependence. Finally, we focused on emerging treatments targeting ERs (selective estrogen receptor modulators (SERMs), estrogen receptors agonists, and antagonists). EXPERT OPINION Available treatments interfering with estrogen pathways exert a contraceptive effect, have hypoestrogenic side effects, and cannot prevent or definitively treat the disease. Preclinical and animal studies are focusing on emerging drugs targeting ERs in order to overcome limitations of available treatments. These treatments may represent a promising option, as they may produce a more specific inhibition of disease activity within endometriotic implants, avoiding prolonged hypoestrogenic status and limiting systemic side effects.
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Affiliation(s)
- Sara Clemenza
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Silvia Vannuccini
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Agostino Ruotolo
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Tommaso Capezzuoli
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Felice Petraglia
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
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Quality of Life in Women after Deep Endometriosis Surgery: Comparison with Spanish Standardized Values. J Clin Med 2022; 11:jcm11206192. [PMID: 36294513 PMCID: PMC9605478 DOI: 10.3390/jcm11206192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/26/2022] Open
Abstract
The quality of life (QoL) of women who have been surgically treated for endometriosis may be severely impaired. Therefore, QoL can be a determining factor in the recovery of these patients. The aims of this study were to evaluate if the QoL of women surgically treated for deep endometriosis differs from a healthy age-matched population from Catalonia (Spain) and to analyze the QoL of these women considering concomitant events. This is an observational cross-sectional study, where 112 women (between 18 and 48 years old), with endometriosis treated by surgery at Hospital Universitario La Paz (Madrid, Spain), were enrolled to assess the QoL using the second version of the 12-item short form (SF-12) questionnaire. The QoL in these women were tested against a reference population of healthy women using a standardized one-sample comparison method. In addition, the QoL was compared according to the pathophysiology and type of surgery. In women with endometriosis, the physical health component, but not mental health component, was positively correlated with age (r = 0.19; p-Value = 0.048). In addition, physical (20.3 ± 29.2) and social functions (29.7 ± 38.3) and the overall physical health component (37.8 ± 19.4) were significantly lower than the reference population. On the contrary, the body pain (64.1 ± 41.2), emotional role (62.5 ± 42.2), mental health (54.4 ± 26.0), vitality (59.3 ± 31.2), and the overall mental health component (59.4 ± 26.6) had significantly higher scores than the reference. The anatomical compartment of endometriosis, reintervention, bowel nodule resection, and fertility preservation did not show statistical differences in QoL. Women with deep endometriosis had worse physical and social functions, and the overall physical health, compared to the norm in Spanish women. Bodily pain, emotional role, vitality, and the overall mental health improved. These areas could be considered protective factors in this disease. Considering the importance of QoL in adjustments in mental and physical health, it would be necessary to improve these areas of QoL in women surgically treated for deep endometriosis.
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Elsherbini M, Koga K, Maki E, Kumasawa K, Satake E, Taguchi A, Makabe T, Takeuchi A, Izumi G, Takamura M, Harada M, Hirata T, Hirota Y, Wada-Hiraike O, Osuga Y. Impact of Chronic Exposure to Endometriosis on Perinatal Outcomes: Establishment of a Mouse Model. Biomedicines 2022; 10:biomedicines10102627. [PMID: 36289889 PMCID: PMC9599701 DOI: 10.3390/biomedicines10102627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/25/2022] Open
Abstract
The purpose of this study was to establish a new mouse model of endometriosis that mimics real-world women’s health problems, in which women continue to be affected by endometriosis long before they wish to become pregnant, and to evaluate the impact of “chronic exposure to endometriosis” on perinatal outcome. Endometriosis was established by the intraperitoneal injection of homologous minced mouse uteri. Vehicle was injected for the control. Mating was initiated either 1 or 43 days after disease establishment (Young or Aged studies, respectively). Mice were sacrificed on 18 dpc. The number pups and resorptions were counted and pups’ body weights (BW) were measured, and the endometriosis lesion was identified and weighted. In the Young study, the number of resorptions and BW were comparable between the groups. In the Aged study, the number of resorptions was significantly higher and BW was significantly lower in endometriosis than that in control. The total weight of endometriosis lesion per dam was significantly lower in the Aged compared to the Young endometriosis group; however, not a single mouse was found to have any lesions at all. These results suggest that in addition to the presence of endometriosis per se, “chronic exposure to endometriosis” prior to pregnancy affect perinatal outcomes.
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Affiliation(s)
- Mohammed Elsherbini
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Kaori Koga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
- Correspondence:
| | - Eiko Maki
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Keiichi Kumasawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Erina Satake
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Ayumi Taguchi
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Tomoko Makabe
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Arisa Takeuchi
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Gentaro Izumi
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Masashi Takamura
- Department of Obstetrics and Gynecology, Faculty of Medicine, Saitama Medical University, Saitama 350-0495, Japan
| | - Miyuki Harada
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Tetsuya Hirata
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
- Department of Integrated Women’s Health, St Luke’s International Hospital, Tokyo 104-8560, Japan
| | - Yasushi Hirota
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Osamu Wada-Hiraike
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
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Scheepers WFW, Maas JWM, van de Kar MMA. Bowel function and quality of life following surgery for deep endometriosis. J Psychosom Obstet Gynaecol 2022; 43:334-339. [PMID: 34309498 DOI: 10.1080/0167482x.2021.1952570] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To assess the influence of surgical approach, complications and patient characteristics and their postoperative functional outcomes on (sexual) quality of life (QoL) in patients with deep endometriosis (DE) with bowel involvement. METHODS Retrospective cohort study on patients surgically treated for DE in a Dutch tertiary referral hospital. Data are based on surgical records and questionnaires covering current postoperative bowel function and (sexual) QoL. RESULTS Postoperative functional score outcomes: constipation, fecal incontinence and Low Anterior Resection Syndrome (LARS) did not differ between patients treated with rectal shaving or segmental resection. Thirty percent of women treated with rectal shaving experienced LARS-like symptoms as well. Women who underwent segmental resection had a worse sexual QoL compared to patients managed by shaving. Patients who suffered from complications had a worse postoperative QoL. A higher postoperative constipation score was correlated with a significantly higher pain score and a lower overall and sexual QoL. LARS-score was correlated with a worsened sexual QoL. CONCLUSION Women who underwent surgery for deep endometriosis rated their overall QoL as lower when a complication occurred. Segmental resection resulted in a lower sexual QoL compared to shaving. We showed that a higher LARS-score correlates with a lower sexual QOL, and postoperative constipation with more pain and a lower overall and sexual QoL. Interestingly, after using the shaving technique one-third of the patients experienced LARS-like symptoms as well.
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Affiliation(s)
- Wessel F W Scheepers
- Máxima Medical Centre, Department of Obstetrics and Gynecology, Veldhoven, The Netherlands
| | - Jacques W M Maas
- Máxima Medical Centre, Department of Obstetrics and Gynecology, Veldhoven, The Netherlands
| | - Majorie M A van de Kar
- Máxima Medical Centre, Department of Obstetrics and Gynecology, Veldhoven, The Netherlands
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Buggio L, Dridi D, Barbara G, Merli CEE, Cetera GE, Vercellini P. Novel pharmacological therapies for the treatment of endometriosis. Expert Rev Clin Pharmacol 2022; 15:1039-1052. [PMID: 36000243 DOI: 10.1080/17512433.2022.2117155] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Endometriosis is a chronic, estrogen-dependent, inflammatory disease associated with pelvic pain, infertility, impaired sexual function, and psychological suffering. Therefore, tailored patient management appears of primary importance to address specific issues and identify the appropriate treatment for each woman. Over the years, abundant research has been carried out with the objective to find new therapeutic approaches for this multifaceted disease. AREAS COVERED This narrative review aims to present the latest advances in the pharmacological management of endometriosis. In particular, the potential role of GnRH antagonists, selective progesterone receptor modulators (SPRMs), and selective estrogen receptors modulators (SERMs) will be discussed. We performed a literature search in PubMed and Embase, and selected the best quality evidence, giving preference to the most recent and definitive original articles and reviews. EXPERT OPINION Medical therapy represents the cornerstone of endometriosis management, although few advances have been made in the last decade. Most studies have focused on the evaluation of the efficacy and safety of GnRH antagonists (plus add-back therapy in cases of prolonged treatment), which should be used as second-line treatment options in selected cases (i.e. non-responders to first-line treatments). Further studies are needed to identify the ideal treatment for women with endometriosis.
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Affiliation(s)
- Laura Buggio
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy
| | - Dhouha Dridi
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy
| | - Giussy Barbara
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy
| | - C E E Merli
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy
| | - Giulia Emily Cetera
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy
| | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy
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Xie C, Yin Z, Liu Y. Analysis of characteristic genes and ceRNA regulation mechanism of endometriosis based on full transcriptional sequencing. Front Genet 2022; 13:902329. [PMID: 35938015 PMCID: PMC9353714 DOI: 10.3389/fgene.2022.902329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/01/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Endometriosis is a common gynecological disorder that usually causes infertility, pelvic pain, and ovarian masses. This study aimed to mine the characteristic genes of endometriosis, and explore the regulatory mechanism and potential therapeutic drugs based on whole transcriptome sequencing data and resources from public databases, providing a theoretical basis for the diagnosis and treatment of endometriosis. Methods: The transcriptome data of the five eutopic (EU) and ectopic (EC) endometrium samples were obtained from Beijing Obstetrics and Gynecology Hospital, Beijing, China, and dinified as the own data set. The expression and clinical data of EC and EU samples in GSE25628 and GSE7305 datasets were obtained from the GEO database (https://www.ncbi.nlm.nih.gov/gds). Differential gene expression analysis and weighted gene co-expression network analysis (WGCNA) were used to identify the endometriosis-related differentially expressed genes. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were conducted by the “clusterProfiler” R package. Then, characteristic genes for endometriosis were identified by the least absolute shrinkage and selection operator (LASSO) and support vector machine recursive feature elimination (SVM-RFE) algorithm. The expression of characteristic genes was verified by quantitative reverse transcription polymerase chain reaction (qRT-PCR) and western-blot. The receiver operating characteristic (ROC) curve was used to evaluate the discriminatory ability of characteristic genes. We assessed the abundance of infiltrating immune cells in each sample using MCP-counter and ImmuCellAI algorithms. The competitive endogenous RNA (ceRNA) regulatory network of characteristic genes was created by Cytoscape and potential targeting drugs were obtained in the CTD database. Results: 44 endometriosis-related differentially expressed genes were obtained from GSE25628 and the own dataset. Subsequently, LASSO and SVM-RFE algorithms identified four characteristic genes, namely ACLY, PTGFR, ADH1B, and MYOM1. The results of RT-PCR and western-blot were consistent with those of sequencing. The result of ROC curves indicated that the characteristic genes had powerful abilities in distinguishing EC samples from EU samples. Infiltrating immune cells analysis suggested that there was a certain difference in immune microenvironment between EC and EU samples. The characteristic genes were significantly correlated with specific differential immune cells between EC and EU samples. Then, a ceRNA regulatory network of characteristic genes was constructed and showed a total of 7, 11, 11, and 1 miRNA associated with ACLY, ADH1B, PTGFR, and MYOM1, respectively. Finally, we constructed a gene-compound network and mined 30 drugs targeting ACLY, 33 drugs targeting ADH1B, 13 drugs targeting MYOM1, and 12 drugs targeting PTGFR. Conclusion: Comprehensive bioinformatic analysis was used to identify characteristic genes, and explore ceRNA regulatory network and potential therapeutic agents for endometriosis. Altogether, these findings provide new insights into the diagnosis and treatment of endometriosis.
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Affiliation(s)
| | | | - Yong Liu
- *Correspondence: Chengmao Xie, ; Yong Liu,
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44
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Huang KJ, Li YX, Wu CJ, Chang WC, Wei LH, Sheu BC. Sonographic features differentiating early-stage ovarian clear cell carcinoma from endometrioma with atypical features. J Ovarian Res 2022; 15:84. [PMID: 35836288 PMCID: PMC9284754 DOI: 10.1186/s13048-022-01019-8] [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: 04/22/2022] [Accepted: 07/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ovarian clear cell carcinoma (OCCC) is the most common endometriosis-associated ovarian cancer. Ovarian endometriosis may present with atypical or malignant sonographic features and interfere with clinical judgment about whether definitive surgical intervention is required. OBJECTIVE To compare the characteristics of endometrioma with atypical features and OCCC. METHODS This study enrolled patients with pathologic diagnoses of either endometrioma or OCCC. For patients with endometrioma, only those with atypical features, defined as the presence of at least one of the following sonographic characteristics: cyst diameter of 10 ± 1 cm, multi-cystic lesions, any solid component or papillary structure, and blood flow of any degree, were included. RESULTS Sixty-three patients had endometriomas with atypical features, while 57 patients had OCCC. Patients with endometriomas were younger (39.33 ± 7.04 years vs. 53.11 ± 9.28 years, P < 0.01), had smaller cysts (7.81 ± 2.81 cm vs. 12.68 ± 4.60 cm, P < 0.01), and had smaller solid components (0.93 ± 1.74 cm vs. 4.82 ± 3.53 cm, P < 0.01). In contrast, OCCCs were associated with loss of ground-glass echogenicity (6.3% vs 68.4%, P < 0.01). In multivariate analysis, advanced age (> 47.5 years), large cysts (> 11.55 cm), large solid components (size > 1.37 cm), and loss of ground-glass echogenicity were independent factors suggestive of malignancy. CONCLUSION Advanced age, larger cyst sizes, larger solid component sizes, and loss of ground-glass echogenicity are major factors differentiating endometriomas from malignancies. For women in menopausal transition who have finished childbearing who present with endometrioma with atypical features, removal of the adnexa intact could be considered.
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Affiliation(s)
- Kuan-Ju Huang
- National Taiwan University Hospital, Yunlin Branch, Yunlin county, Taiwan.,Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ying-Xuan Li
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Chung-Shan South Road, Taipei, Taiwan
| | - Chin-Jui Wu
- National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Wen-Chun Chang
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Chung-Shan South Road, Taipei, Taiwan
| | - Lin-Hung Wei
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Chung-Shan South Road, Taipei, Taiwan
| | - Bor-Ching Sheu
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan. .,Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Chung-Shan South Road, Taipei, Taiwan.
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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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Giudice LC, As-Sanie S, Arjona Ferreira JC, Becker CM, Abrao MS, Lessey BA, Brown E, Dynowski K, Wilk K, Li Y, Mathur V, Warsi QA, Wagman RB, Johnson NP. Once daily oral relugolix combination therapy versus placebo in patients with endometriosis-associated pain: two replicate phase 3, randomised, double-blind, studies (SPIRIT 1 and 2). Lancet 2022; 399:2267-2279. [PMID: 35717987 DOI: 10.1016/s0140-6736(22)00622-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/13/2022] [Accepted: 03/28/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Endometriosis is a common cause of pelvic pain in women, for which current treatment options are suboptimal. Relugolix, an oral gonadotropin-releasing hormone receptor antagonist, combined with estradiol and a progestin, was evaluated for treatment of endometriosis-associated pain. METHODS In these two replicate, phase 3, multicentre, randomised, double-blind, placebo-controlled trials at 219 community and hospital research centres in Africa, Australasia, Europe, North America, and South America, we randomly assigned women aged 18-50 years with surgically or directly visualised endometriosis with or without histological confirmation, or with histological diagnosis alone. Participants were eligible if they had moderate to severe endometriosis-associated pain and, during the 35-day run-in period, a dysmenorrhoea Numerical Rating Scale (NRS) score of 4·0 or higher on two or more days and a mean non-menstrual pelvic pain NRS score of 2·5 or higher, or a mean score of 1·25 or higher that included a score of 5 or more on 4 or more days. Women received (1:1:1) once-daily oral placebo, relugolix combination therapy (relugolix 40 mg, estradiol 1 mg, norethisterone acetate 0·5 mg), or delayed relugolix combination therapy (relugolix 40 mg monotherapy followed by relugolix combination therapy, each for 12 weeks) for 24 weeks. During the double-blind randomised treatment and follow-up period, all patients, investigators, and sponsor staff or representatives involved in the conduct of the study were masked to treatment assignment. The co-primary endpoints were responder rates at week 24 for dysmenorrhoea and non-menstrual pelvic pain, both based on NRS scores and analgesic use. Efficacy and safety were analysed in the modified intent-to-treat population (randomised patients who received ≥1 study drug dose). The studies are registered at ClinicalTrials.gov (SPIRIT 1 [NCT03204318] and SPIRIT 2 [NCT03204331]) and EudraCT (SPIRIT 1 [2017-001588-19] and SPIRIT 2 [2017-001632-19]). Eligible patients who completed the SPIRIT studies could enrol in a currently ongoing 80-week open-label extension study (SPIRIT EXTENSION [NCT03654274, EudraCT 2017-004066-10]). Database lock for the on-treatment duration has occurred, and post-treatment follow-up for safety, specificially for bone mineral density and menses recovery, is ongoing at the time of publication. FINDINGS 638 patients were enrolled into SPIRIT 1 and randomly assigned between Dec 7, 2017, and Dec 4, 2019, to receive relugolix combination therapy (212 [33%]), placebo (213 [33%]), or relugolix delayed combination therapy (213 [33%]). 623 patients were enrolled into SPIRIT 2 and were randomly assigned between Nov 1, 2017 and Oct 4, 2019, to receive relugolix combination therapy (208 [33%]), placebo (208 [33%]), or relugolix delayed combination therapy (207 [33%]). 98 (15%) patients terminated study participation early in SPIRIT 1 and 115 (18%) in SPIRIT 2. In SPIRIT 1, 158 (75%) of 212 patients in the relugolix combination therapy group met the dysmenorrhoea responder criteria compared with 57 (27%) of 212 patients in the placebo group (treatment difference 47·6% [95% CI 39·3-56·0]; p<0·0001). In SPIRIT 2, 155 (75%) of 206 patients in the relugolix combination therapy group were dysmenorrhoea responders compared with 62 (30%) of 204 patients in the placebo group (treatment difference 44·9% [95% CI 36·2-53·5]; p<0·0001). In SPIRIT 1, 124 (58%) of 212 patients in the relugolix combination therapy group met the non-menstrual pelvic pain responder criteria versus 84 (40%) patients in the placebo group (treatment difference 18·9% [9·5-28·2]; p<0·0001). In SPIRIT 2, 136 (66%) of 206 patients were non-menstrual pelvic pain responders in the relugolix combination therapy group compared with 87 (43%) of 204 patients in the placebo group (treatment difference 23·4% [95% CI 13·9-32·8]; p<0·0001). The most common adverse events were headache, nasopharyngitis, and hot flushes. There were nine reports of suicidal ideation across both studies (two in the placebo run-in, two in the placebo group, two in the relugolix combination therapy group, and three in the delayed relugolix combination therapy group). No deaths were reported. Least squares mean percentage change in lumbar spine bone mineral density in the relugolix combination therapy versus placebo groups was -0·70% versus 0·21% in SPIRIT 1 and -0·78% versus 0·02% in SPIRIT 2, and in the delayed relugolix combination group was -2·0% in SPIRIT 1 and -1·9% in SPIRIT 2. Decreases in opioid use were seen in treated patients as compared with placebo. INTERPRETATION Once-daily relugolix combination therapy significantly improved endometriosis-associated pain and was well tolerated. This oral therapy has the potential to address the unmet clinical need for long-term medical treatment for endometriosis, reducing the need for opioid use or repeated surgical treatment. FUNDING Myovant Sciences.
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Affiliation(s)
- Linda C Giudice
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA, USA.
| | - Sawsan As-Sanie
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | | | - Christian M Becker
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Mauricio S Abrao
- BP- A Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil; Departamento de Ginecologia e Obstetrícia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | | | - Eric Brown
- Gyn-Care in Atlantic Station, Atlanta, GA, USA
| | | | - Krzysztof Wilk
- Boni Fratres Hospital Obstetrics and Gynecology Department Katowice, Katowice, Poland
| | - Yulan Li
- Myovant Sciences, Brisbane, CA, USA
| | | | | | | | - Neil P Johnson
- Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
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Taylor H, Li HJ, Carson S, Flores V, Pal L, Robbins J, Santoro NF, Segars JH, Seifer D, Huang H, Young S, Zhang H. Pre-IVF treatment with a GnRH antagonist in women with endometriosis (PREGNANT): study protocol for a prospective, double-blind, placebo-controlled trial. BMJ Open 2022; 12:e052043. [PMID: 35715184 PMCID: PMC9207753 DOI: 10.1136/bmjopen-2021-052043] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Infertility is a common complication of endometriosis. While in vitro fertilisation-embryo transfer (IVF) successfully treats endometriosis-associated infertility, there is some evidence that pregnancy rates may be diminished in women seeing fertility treatment for endometriosis-associated infertility compared with other etiologies of infertility. The use of gonadotropin releasing hormone (GnRH) agonist prior to IVF has been suggested to improve success, however studies have been small and rarely reported live birth rates. Recent approval of an oral GnRH antagonist for endometriosis provides a novel option for women with endometriosis who are undergoing IVF. There have been no studies on the efficacy of GnRH antagonists for the treatment of endometriosis-related infertility. METHODS AND ANALYSIS This study is a multicentre, prospective, randomised, double-blind, placebo-controlled trial to study the efficacy of GnRH antagonist pretreatment for women with endometriosis who are undergoing IVF. A total of 814 patients with endometriosis undergoing fertility treatment will be enrolled and randomised 1:1 into two groups: elagolix 200 mg two times per day or placebo for 8 weeks, prior to undergoing IVF. All participants will then undergo IVF treatment per local protocols. The primary outcome is live birth. Secondary outcomes include oocyte number, fertilisation rate, embryo morphology and implantation rates, as well as rates of known endometriosis-related obstetrical outcomes (pregnancy-induced hypertension, antepartum haemorrhage, caesarean delivery and preterm birth). ETHICS AND DISSEMINATION The PREGnant trial was approved by the Institutional Review Board at Johns Hopkins University. Results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04173169.
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Affiliation(s)
- Hugh Taylor
- Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Howard J Li
- Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sandra Carson
- Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Valerie Flores
- Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lubna Pal
- Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jared Robbins
- Obstetrics and Gynecology, Northwestern University, Evanston, Chicago, USA
| | - Nanette F Santoro
- Obstetrics and Gynecology, University of Colorado, Denver, Colorado, USA
| | - James H Segars
- Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Seifer
- Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Hao Huang
- Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Steven Young
- Obstetrics and Gynecology, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Heping Zhang
- Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
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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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Vannuccini S, Clemenza S, Rossi M, Petraglia F. Hormonal treatments for endometriosis: The endocrine background. Rev Endocr Metab Disord 2022; 23:333-355. [PMID: 34405378 PMCID: PMC9156507 DOI: 10.1007/s11154-021-09666-w] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 12/25/2022]
Abstract
Endometriosis is a benign uterine disorder characterized by menstrual pain and infertility, deeply affecting women's health. It is a chronic disease and requires a long term management. Hormonal drugs are currently the most used for the medical treatment and are based on the endocrine pathogenetic aspects. Estrogen-dependency and progesterone-resistance are the key events which cause the ectopic implantation of endometrial cells, decreasing apoptosis and increasing oxidative stress, inflammation and neuroangiogenesis. Endometriotic cells express AMH, TGF-related growth factors (inhibin, activin, follistatin) CRH and stress related peptides. Endocrine and inflammatory changes explain pain and infertility, and the systemic comorbidities described in these patients, such as autoimmune (thyroiditis, arthritis, allergies), inflammatory (gastrointestinal/urinary diseases) and mental health disorders.The hormonal treatment of endometriosis aims to block of menstruation through an inhibition of hypothalamus-pituitary-ovary axis or by causing a pseudodecidualization with consequent amenorrhea, impairing the progression of endometriotic implants. GnRH agonists and antagonists are effective on endometriosis by acting on pituitary-ovarian function. Progestins are mostly used for long term treatments (dienogest, NETA, MPA) and act on multiple sites of action. Combined oral contraceptives are also used for reducing endometriosis symptoms by inhibiting ovarian function. Clinical trials are currently going on selective progesterone receptor modulators, selective estrogen receptor modulators and aromatase inhibitors. Nowadays, all these hormonal drugs are considered the first-line treatment for women with endometriosis to improve their symptoms, to postpone surgery or to prevent post-surgical disease recurrence. This review aims to provide a comprehensive state-of-the-art on the current and future hormonal treatments for endometriosis, exploring the endocrine background of the disease.
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Affiliation(s)
- Silvia Vannuccini
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Sara Clemenza
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Margherita Rossi
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Felice Petraglia
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy.
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The analysis of the prevalence of extragenital pathology in infertile women with external genital endometriosis. ACTA BIOMEDICA SCIENTIFICA 2022. [DOI: 10.29413/abs.2022-7.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background. External genital endometriosis (EGE) is often the cause of infertility, while coagulation of its foci leads to the restoration of fertility. Often, non-invasivepreoperative diagnosis of EGE is difficult. Today, the issue of laparoscopy in infertility and whether there is a need for additional indications for its implementation remains controversial. Identification of the relationship between certain extragenital diseases with EGE is promising in terms of both understanding the pathogenesis of EGE and predicting its development.The aim. Identification of the relationship of extragenital diseases with the presence of EGE in infertile women of reproductive age.Materials and methods. In preparation for assisted reproductive technology programs at the Vitromed Clinic, 1 132 women of reproductive age were examined from 2019 to 2021. Collection and processing of clinical and anamnestic data were carried out. The diagnosis of EGE was verified by laparoscopy with histological examination. The results were analyzed using exact test and binary logistic regression to build a model of the relationship between EGE and somatic pathology.Results. EGE was detected in 222 patients. A number of somatic diseases were found that are most common in EGE: bowel diseases; minor cardiac maldevelopments; chronic anemia; pathology of the pancreas; chronic tonsillitis; allergy. A logistic regression model was constructed to predict the presence of EGE in patients with the indicated somatic pathology with a sensitivity of 81.53 % and a specificity of 97.25 %.Conclusion. Identification of comorbid extragenital diseases associated with EGE in women with infertility can serve as a basis for expanding the scope of therapeutic and diagnostic measures, in particular for laparoscopy.
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