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Chapron C, Marcellin L, Maitrot-Mantelet L, Bourdon M, Maignien C, Parpex G, Santulli P. Questionnaire-based screening of adolescents and young adult women can identify markers associated with endometriosis. Hum Reprod 2024:deae125. [PMID: 38901867 DOI: 10.1093/humrep/deae125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/04/2024] [Indexed: 06/22/2024] Open
Abstract
STUDY QUESTION Do adolescents and young adult women (YAW) with histologically proven endometriosis present a specific clinical history? SUMMARY ANSWER Questionnaire screening of adolescents and YAW can identify clinical markers associated with histologically proven endometriosis. WHAT IS KNOWN ALREADY Some validated questionaries can contribute to an earlier endometriosis diagnosis in adults. None of these scores, however, have been validated for adolescents or YAW. STUDY DESIGN, SIZE, DURATION This was an observational cross-sectional study using prospectively recorded data performed between January 2005 and January 2020 in a single university tertiary referral centre for endometriosis diagnosis and management. After a thorough surgical examination of the abdomino-pelvic cavity, women with histologically proven endometriosis were allocated to the endometriosis group, and symptomatic women without evidence of endometriosis were allocated to the endometriosis-free control group. The endometriotic patients were allocated into two sub-groups according to their age: adolescent (≤20 years) and YAW (21-24 years). PARTICIPANTS/MATERIALS, SETTING, METHODS Adolescents and YAW ≤24 years of age were operated for a symptomatic benign gynaecological condition with signed informed consent. A standardized questionnaire was prospectively completed in the month before the surgery and included epidemiological data, pelvic pain scores, family history of endometriosis, and symptoms experienced during adolescence. The study searched for correlations by univariate analysis to determine clinical markers of endometriosis in adolescents and YAW compared with endometriosis-free control patients. MAIN RESULTS AND THE ROLE OF CHANCE Of the 262 study participants, 77 women were adolescents (≤20 years of age) and 185 patients (70.6%) were YAW. The endometriosis group included 118 patients (45.0%) and 144 (55.0%) were assigned to the control group. A family history of endometriosis, absenteeism from school during menstruation, history of fainting spells during menstruation, and prescription of oral contraceptive pills for intense dysmenorrhea were significantly more frequently observed in the endometriotic patients. The prevalence and mean pain scores for dysmenorrhea, deep dyspareunia, non-cyclic chronic pelvic pain and gastrointestinal and lower urinary tract symptoms were significantly greater in the endometriosis group, as was experienced rectal bleeding. LIMITATIONS, REASONS FOR CAUTION The study was performed in a single referral centre that treats patients with potentially more severe disease. This questionnaire was evaluated on a population of patients with an indication for endometriosis surgery, which can also select patients with more severe disease. Women with asymptomatic endometriosis were not considered in this study. These factors can affect the external validity of this study. WIDER IMPLICATIONS OF THE FINDINGS Patient interviews are relevant to the diagnosis of endometriosis in adolescents and YAW. Combined with imaging and clinical examination, this approach will enable earlier diagnosis and treatment, while remaining non-invasive and rapid. STUDY FUNDING/COMPETING INTEREST(S) The study received no funding from external sources. There are no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Charles Chapron
- Faculté de Santé, Faculté de Médicine Paris Centre, Université Paris-Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
- Department "Development, Reproduction and Cancer", Institut Cochin, INSERM U1016, Paris, France
| | - Louis Marcellin
- Faculté de Santé, Faculté de Médicine Paris Centre, Université Paris-Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
- Department "Development, Reproduction and Cancer", Institut Cochin, INSERM U1016, Paris, France
| | - Lorraine Maitrot-Mantelet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
| | - Mathilde Bourdon
- Faculté de Santé, Faculté de Médicine Paris Centre, Université Paris-Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
- Department "Development, Reproduction and Cancer", Institut Cochin, INSERM U1016, Paris, France
| | - Chloé Maignien
- Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
| | - Guillaume Parpex
- Faculté de Santé, Faculté de Médicine Paris Centre, Université Paris-Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
- Department "Development, Reproduction and Cancer", Institut Cochin, INSERM U1016, Paris, France
| | - Pietro Santulli
- Faculté de Santé, Faculté de Médicine Paris Centre, Université Paris-Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
- Department "Development, Reproduction and Cancer", Institut Cochin, INSERM U1016, Paris, France
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Exacoustos C, Martire FG, Albanese M, Selntigia A. REPLY to Comment on Correlation between endometriosis and migraine features: Results from a prospective case-control study'': Correlation between endometriosis and migraine features is not based on a broad strokes results. Cephalalgia 2024; 44:3331024241254821. [PMID: 38863218 DOI: 10.1177/03331024241254821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Affiliation(s)
- Caterina Exacoustos
- Department of Surgical Sciences, Gynecological Unit, University of Rome Tor Vergata, Rome, Italy
| | | | - Maria Albanese
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Headache Center, Neurology Unit, Tor Vergata University Hospital, Rome, Italy
| | - Aikaterini Selntigia
- Department of Surgical Sciences, Gynecological Unit, University of Rome Tor Vergata, Rome, Italy
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Sokteang S, Tran C, Ou P, Ouk C, Pirtea P, de Ziegler D. Clinical Management of Infertility Associated with Endometriosis. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102409. [PMID: 38340984 DOI: 10.1016/j.jogc.2024.102409] [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: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE This study aimed to review recent data that affected the clinical management of infertility associated with endometriosis. DATA SOURCES We completed a PubMed review of all articles that included the following keywords: endometriosis, infertility, IVF, and ART. STUDY SELECTION A study was selected based on the pertinence of the topic addressed in relation to the study's set objectives. DATA EXTRACTION AND SYNTHESIS All identified articles were first assessed based on a review of the abstract. Pertinent articles were reviewed in depth. CONCLUSION Endometriosis interferes with natural conception primarily by altering the quality of gametes-oocytes and sperm-and early-stage embryos. On the contrary, recent data indicate that gametes and early-stage embryos are not altered in the case of ART. Surgery-a classical approach in yesteryears-does appear to improve ART outcomes and may affect ovarian reserve and the number of oocytes retrieved in ART. Surgery is thus more rarely opted for today and only when necessary; proceeding to fertility preservation prior to surgery is recommended. When ART is performed in women with endometriosis, it is recommended to use an antagonist or progesterone-primed ovarian stimulation approach followed by deferred embryo transfer. In this case, GnRH (gonadotropin releasing hormone) agonist is preferred for triggering ovulation, as it limits the risk of cyst formation as well as ovarian hyperstimulation syndrome. Frozen embryo transfers are best performed in E2 (estradiol) and progesterone replacement cycle.
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Affiliation(s)
- Sean Sokteang
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Kingdom of Cambodia
| | - Chloe Tran
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Kingdom of Cambodia
| | - Pichetra Ou
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Kingdom of Cambodia
| | - Chanpisey Ouk
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Kingdom of Cambodia
| | - Paul Pirtea
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Kingdom of Cambodia; Department of Ob-Gyn, Hopital Foch, Paris, France
| | - Dominique de Ziegler
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Kingdom of Cambodia; Department of Ob-Gyn, Hopital Foch, Paris, France.
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Raimondo D, Ianieri MM, Raffone A, Ferla S, Raspollini A, Virgilio A, Govoni F, Pavone M, Neola D, Guida M, Del Governatore M, Scambia G, Seracchioli R. Feasibility of Intraoperative Proctosigmoidoscopy after Discoid Bowel Resection for Deep Infiltrating Endometriosis: A Pilot Multicenter Study. J Minim Invasive Gynecol 2024:S1553-4650(24)00208-5. [PMID: 38761918 DOI: 10.1016/j.jmig.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 05/20/2024]
Abstract
STUDY OBJECTIVE Although surgery is the gold standard treatment for pain refractory to medical management or partial occlusion owing to rectosigmoid endometriosis, surgical resection can be associated with major perioperative complications. From general surgery experience, intraoperative proctosigmoidoscopy has shown encouraging results as a feasible, safe, and effective technique in reducing the risk of complications related to intestinal anastomosis after segmental resection. Unfortunately, there are no studies evaluating its role after discoid resection for rectosigmoid endometriosis. DESIGN A pilot, multicentric, observational, prospective, cohort study. SETTING Two academic hospitals, from March 1 to December 31, 2022. PATIENTS We enrolled all consecutive fertile-age patients affected by symptomatic endometriosis scheduled for laparoscopic discoid bowel resection. Inclusion criteria were (1) age between 18 and 50 years, (2) diagnosis of rectosigmoid endometriosis performed by transvaginal ultrasound and/or magnetic resonance imaging, and (3) women scheduled for laparoscopic discoid bowel resection of endometriosis at low risk of segmental resection. INTERVENTIONS During data analysis, enrolled patients were divided into 2 study groups for comparisons based on whether or not the intraoperative proctosigmoidoscopy was performed upon surgeons' discretion after discoid resection for treating endometriosis, in addition to standard integrity tests. Primary outcome was the rate of intraoperative proctosigmoidoscopy success. Secondary study outcomes were the differences between the intraoperative proctosigmoidoscopy group and the nonintraoperative proctosigmoidoscopy group in (1) mean of total operative time and (2) rate of perioperative complications. MEASUREMENTS AND MAIN RESULTS A total of 28 patients were enrolled and equally distributed in the 2 groups. The rate of intraoperative proctosigmoidoscopy success was 86%. No significant difference was reported between the 2 groups in terms of total operative time (p = .1) and intraoperative and postoperative complications (p = .5 and p = 1, respectively), with no surgical complication related to intraoperative proctosigmoidoscopy. CONCLUSION Intraoperative proctosigmoidoscopy seems as a feasible and non-time-consuming intraoperative procedure in women undergone discoid resection for rectosigmoid endometriosis. Larger studies with longer follow-up period are necessary to confirm our findings and assess clinical benefits over standard procedure.
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Affiliation(s)
- Diego Raimondo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Ferla, Raspollini, Virgilio, Govoni, and Seracchioli), Bologna, Italy
| | - Manuel Maria Ianieri
- Division of Gynecologic Oncology, Department of Women's and Children's Health, Fondazione Policlinico Universitario A. Gemelli IRCCS (Drs. Ianieri, Pavone, Scambia, and Seracchioli), Rome, Italy
| | - Antonio Raffone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II (Drs. Raffone, Neola, and Guida), Naples, Italy; Department of Medical and Surgical Sciences (DIMEC), University of Bologna (Drs. Raffone, Ferla, Raspollini, and Virgilio), Bologna, Italy.
| | - Stefano Ferla
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Ferla, Raspollini, Virgilio, Govoni, and Seracchioli), Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC), University of Bologna (Drs. Raffone, Ferla, Raspollini, and Virgilio), Bologna, Italy
| | - Arianna Raspollini
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Ferla, Raspollini, Virgilio, Govoni, and Seracchioli), Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC), University of Bologna (Drs. Raffone, Ferla, Raspollini, and Virgilio), Bologna, Italy
| | - Agnese Virgilio
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Ferla, Raspollini, Virgilio, Govoni, and Seracchioli), Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC), University of Bologna (Drs. Raffone, Ferla, Raspollini, and Virgilio), Bologna, Italy
| | - Francesca Govoni
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Ferla, Raspollini, Virgilio, Govoni, and Seracchioli), Bologna, Italy
| | - Matteo Pavone
- Division of Gynecologic Oncology, Department of Women's and Children's Health, Fondazione Policlinico Universitario A. Gemelli IRCCS (Drs. Ianieri, Pavone, Scambia, and Seracchioli), Rome, Italy
| | - Daniele Neola
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II (Drs. Raffone, Neola, and Guida), Naples, Italy
| | - Maurizio Guida
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II (Drs. Raffone, Neola, and Guida), Naples, Italy
| | - Marco Del Governatore
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Dr. del Governatore), Bologna, Italy
| | - Giovanni Scambia
- Division of Gynecologic Oncology, Department of Women's and Children's Health, Fondazione Policlinico Universitario A. Gemelli IRCCS (Drs. Ianieri, Pavone, Scambia, and Seracchioli), Rome, Italy
| | - Renato Seracchioli
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna (Drs. Raimondo, Ferla, Raspollini, Virgilio, Govoni, and Seracchioli), Bologna, Italy; Division of Gynecologic Oncology, Department of Women's and Children's Health, Fondazione Policlinico Universitario A. Gemelli IRCCS (Drs. Ianieri, Pavone, Scambia, and Seracchioli), Rome, Italy
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Orlov S, Sladkevicius P, Jokubkiene L. Evaluating the development of endometriosis and adenomyosis lesions over time: An ultrasound study of symptomatic women. Acta Obstet Gynecol Scand 2024. [PMID: 38687177 DOI: 10.1111/aogs.14865] [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: 01/18/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION There is a gap in knowledge regarding development of endometriosis and adenomyosis lesions visible at transvaginal ultrasound. The objectives were to evaluate if women with symptoms suggestive of endometriosis or adenomyosis but normal ultrasound examination develop endometriosis or adenomyosis lesions visible at ultrasound over time and if alterations of symptoms over time are associated with ultrasound findings at follow-up. MATERIAL AND METHODS This was a prospective cohort study of 100 symptomatic women with normal initial ultrasound examination during 2014-2017 who underwent follow-up ultrasound examination in 2022. Symptoms suggestive of endometriosis were assessed using visual analog scale at both examinations and minimal clinically important difference of 10 mm was considered as a significant alteration. An examiner with expertise in advanced ultrasound examination of endometriosis performed transvaginal ultrasound examinations in accordance with the consensus protocol by the International Deep Endometriosis Analysis group. RESULTS At follow-up ultrasound examination of 100 women, 13 (13% [95% CI 7.1-21.2]) had visible endometriosis or adenomyosis lesions, 8 (8% [95% CI 3.5-15.2]) had endometriosis lesions, and 6 (6% [95% CI 2.2-12.6]) had adenomyosis. At follow-up, women with endometriosis or adenomyosis lesions reported lower intensity of dysmenorrhea and chronic pelvic pain compared to women without lesions (48 mm [IQR 16-79] vs. 73 mm [IQR 46-85] and 45 mm [IQR 26-57] vs. 57 mm [IQR 36-75], p = 0.087 and p = 0.026, respectively). None of the women with endometriosis or adenomyosis lesions reported increased intensity of dysmenorrhea at follow-up, compared to 32/86 women (37%) without lesions (p = 0.008). Increased intensity of chronic pelvic pain tended to be less common in women with lesions compared to those without (3/13 [23%] vs. 35/86 [41%], p = 0.223). CONCLUSIONS Our findings suggest that in symptomatic women, endometriosis and adenomyosis lesions visible at ultrasound may develop over time. However, majority of women remain having normal ultrasound examinations despite symptoms. Exacerbation of dysmenorrhea or chronic pelvic pain during follow-up was not associated with the development of endometriosis or adenomyosis lesions visible at ultrasound, suggesting that even women with less severe symptoms might benefit from a follow-up ultrasound when indicated.
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Affiliation(s)
- Sofie Orlov
- Obstetric, Gynecological and Prenatal Ultrasound Research, Department of Clinical Sciences Malmo, Lund University, Malmo, Sweden
- Department of Obstetrics and Gynecology, Skane University Hospital, Malmo, Sweden
- Department of Obstetrics and Gynecology, Ystad Hospital, Ystad, Sweden
| | - Povilas Sladkevicius
- Obstetric, Gynecological and Prenatal Ultrasound Research, Department of Clinical Sciences Malmo, Lund University, Malmo, Sweden
- Department of Obstetrics and Gynecology, Skane University Hospital, Malmo, Sweden
| | - Ligita Jokubkiene
- Obstetric, Gynecological and Prenatal Ultrasound Research, Department of Clinical Sciences Malmo, Lund University, Malmo, Sweden
- Department of Obstetrics and Gynecology, Skane University Hospital, Malmo, Sweden
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Burla L, Sartoretti E, Mannil M, Seidel S, Sartoretti T, Krentel H, De Wilde RL, Imesch P. MRI-Based Radiomics as a Promising Noninvasive Diagnostic Technique for Adenomyosis. J Clin Med 2024; 13:2344. [PMID: 38673617 PMCID: PMC11051471 DOI: 10.3390/jcm13082344] [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: 03/10/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Background: MRI diagnostics are important for adenomyosis, especially in cases with inconclusive ultrasound. This study assessed the potential of MRI-based radiomics as a novel tool for differentiating between uteri with and without adenomyosis. Methods: This retrospective proof-of-principle single-center study included nine patients with and six patients without adenomyosis. All patients had preoperative T2w MR images and histological findings served as the reference standard. The uterus of each patient was segmented in 3D using dedicated software, and 884 radiomics features were extracted. After dimension reduction and feature selection, the diagnostic yield of individual and combined features implemented in the machine learning models were assessed by means of receiver operating characteristics analyses. Results: Eleven relevant radiomics features were identified. The diagnostic performance of individual features in differentiating adenomyosis from the control group was high, with areas under the curve (AUCs) ranging from 0.78 to 0.98. The performance of ML models incorporating several features was excellent, with AUC scores of 1 and an area under the precision-recall curve of 0.4. Conclusions: The set of radiomics features derived from routine T2w MRI enabled accurate differentiation of uteri with adenomyosis. Radiomics could enhance diagnosis and furthermore serve as an imaging biomarker to aid in personalizing therapies and monitoring treatment responses.
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Affiliation(s)
- Laurin Burla
- Department of Gynecology, University Hospital Zurich, 8091 Zurich, Switzerland; (L.B.)
- Department of Gynecology and Obstetrics, Hospital of Schaffhausen, 8208 Schaffhausen, Switzerland
| | | | - Manoj Mannil
- Clinic for Radiology, Muenster University Hospital, 48149 Muenster, Germany
| | - Stefan Seidel
- Institute for Radiology and Nuclear Medicine, Hospital of Schaffhausen, 8208 Schaffhausen, Switzerland
| | | | - Harald Krentel
- Department of Gynecology, Obstetrics and Gynecological Oncology, Bethesda Hospital Duisburg, 47053 Duisburg, Germany
| | - Rudy Leon De Wilde
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, 26121 Oldenburg, Germany
| | - Patrick Imesch
- Department of Gynecology, University Hospital Zurich, 8091 Zurich, Switzerland; (L.B.)
- Clinic for Gynecology, Bethanien Clinic, 8044 Zurich, Switzerland
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Centini G, Schettini G, Pieri E, Giorgi M, Lazzeri L, Martire FG, Mancini V, Raimondo D, Seracchioli R, Habib N, Fedele F, Zupi E. Endometriosis-Related Ovarian Cancer: Where Are We Now? A Narrative Review towards a Pragmatic Approach. J Clin Med 2024; 13:1933. [PMID: 38610698 PMCID: PMC11012952 DOI: 10.3390/jcm13071933] [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: 03/06/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Endometriosis affects more than 10% of reproductive-aged women, causing pelvic pain and infertility. Despite the benign nature of endometriosis, ovarian endometriomas carry a higher risk of developing endometrioid carcinomas (EnOCs) and clear cell ovarian carcinomas (CCCs). Atypical endometriosis, defined as cytological atypia resembling intraepithelial cancer, is considered the precursor of endometriosis-associated ovarian cancer (EAOC). This narrative review aims to provide an overview of EAOC, proposing a practical approach to clinical and therapeutic decision making. METHODS An electronic literature search was conducted from inception up to January 2023, using the MEDLINE database via PubMed to evaluate the existing literature on EAOC, including its pathogenesis, the diagnostic process, and the therapeutic possibilities, with articles not relevant to the topic or lacking scientific merit being excluded. RESULTS Eighty-one articles were included in the review to present the current state of the art regarding EAOC. A pragmatic clinical flowchart is proposed to guide therapeutic decisions and improve patient outcomes. CONCLUSIONS Endometriosis patients may have an increased risk of developing EAOC (either EnOC or CCC). Despite not being fully accepted, the concept of AE may reshape the endometriosis-ovarian cancer relationship. Further research is needed to understand the unaddressed issues.
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Affiliation(s)
- Gabriele Centini
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (G.C.); (G.S.); (E.P.); (L.L.); (F.G.M.)
| | - Giorgia Schettini
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (G.C.); (G.S.); (E.P.); (L.L.); (F.G.M.)
| | - Emilio Pieri
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (G.C.); (G.S.); (E.P.); (L.L.); (F.G.M.)
| | - Matteo Giorgi
- Department of Surgical Sciences, Gynecological Unit, Valdarno Hospital, 52025 Montevarchi, Italy
| | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (G.C.); (G.S.); (E.P.); (L.L.); (F.G.M.)
| | - Francesco Giuseppe Martire
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (G.C.); (G.S.); (E.P.); (L.L.); (F.G.M.)
- Department of Surgical Sciences, Gynecological Unit, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Virginia Mancini
- Department of Medical Biotechnology, Section of Pathology, University of Siena, 53100 Siena, Italy;
| | - Diego Raimondo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (D.R.); (R.S.)
| | - Renato Seracchioli
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (D.R.); (R.S.)
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Nassir Habib
- Department of Obstetrics and Gynecology, Francois Quesnay Hospital, 78201 Mantes-la-Jolie, France;
| | - Francesco Fedele
- Department of Obstetrics and Gynecology, Fondazione “Policlinico-Mangiagalli-Regina Elena” University of Milan, 20122 Milan, Italy;
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (G.C.); (G.S.); (E.P.); (L.L.); (F.G.M.)
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Russo C, Lazzeri L, Siciliano T, Selntigia A, Farsetti D, Chiaramonte C, Martire FG, Zupi E, Exacoustos C. Reproducibility of #Enzian classification by transvaginal ultrasound and its correlation with symptoms. Facts Views Vis Obgyn 2024; 16:47-58. [PMID: 38551474 PMCID: PMC11198882 DOI: 10.52054/fvvo.16.1.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024] Open
Abstract
Background The #Enzian classification represents a system to describe endometriotic lesions during surgery. Its use is well established in correlating ultrasound and surgical findings. Objectives To describe interobserver reproducibility of ultrasound use and symptom correlation with compartments involved using #Enzian classification. Materials and Methods Two experienced operators performed transvaginal sonography (TVS) in 52 patients affected by pelvic endometriosis. A rate agreement was determined. A further 200 women with endometriotic TVS signs, with no previous surgery and not taking any hormonal therapy, were staged by one of three different operators according to the #Enzian (compartments A, B, C, O, T, FA, FB, FI, FU, FO). Statistical analysis compared all the compartments, as single or associated, with single or combined symptoms (dysmenorrhea, dyspareunia, heavy menstrual bleeding - HMB, bowel symptoms). Main outcome measures Evaluation of the reproducibility of #Enzian classification in assessing pelvic endometriosis among different operators using TVS, and of possible associations between symptoms and specific #Enzian compartments. Results Excellent agreement between the two operators in evaluating almost all the compartments (k >0.8) was observed. Dysmenorrhea did not correlate with any specific compartment. We observed a significant association between dyspareunia and B compartment (p=0.02). HMB is associated with FA (p=0.02). Bowel symptoms were associated with B (p=0.02). Combining more symptoms, we observed more significant associations with different compartments. Conclusions #ENZIAN classification is reproducible in the evaluation of pelvic endometriosis. Some symptoms are correlated to specific ultrasound signs of the disease. What is new? An accurate evaluation of symptoms could guide TVS examination to detect specific endometriotic lesions and establish the best management for the patients.
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Martire FG, Giorgi M, D’Abate C, Colombi I, Ginetti A, Cannoni A, Fedele F, Exacoustos C, Centini G, Zupi E, Lazzeri L. Deep Infiltrating Endometriosis in Adolescence: Early Diagnosis and Possible Prevention of Disease Progression. J Clin Med 2024; 13:550. [PMID: 38256683 PMCID: PMC10816815 DOI: 10.3390/jcm13020550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024] Open
Abstract
Endometriosis has a prevalence of 10% worldwide in premenopausal women. Probably, endometriosis begins early in the life of young girls, and it is commonly diagnosed later in life. The prevalence of deep infiltrating endometriosis (DIE) in adolescence is currently unknown due to diagnostic limits and underestimation of clinical symptoms. Dysmenorrhea is a common symptom in adolescents affected by DIE, often accompanied by dyspareunia and chronic acyclic pelvic pain. Ultrasonography-either performed transabdominal, transvaginal or transrectal-should be considered the first-line imaging technique despite the potential for missed diagnosis due to early-stage disease. Magnetic resonance imaging should be preferred in the case of virgo patients or when ultrasonographic exam is not accepted. Diagnostic laparoscopy is deemed acceptable in the case of suspected DIE not responding to conventional hormonal therapy. An early medical and/or surgical treatment may reduce disease progression with an immediate improvement in quality of life and fertility, but at the same time, painful symptoms may persist or even recur due to the surgery itself. The aim of this narrative review is to report the prevalence of DIE in adolescents, describe the pathogenetic theories and discuss the management in adolescent women, including the challenging road to diagnosis and the treatment alternatives.
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Affiliation(s)
- Francesco Giuseppe Martire
- Gynecological Unit, Department of Surgical Sciences, University of Rome “Tor Vergata”, 00133 Rome, Italy; (F.G.M.); (C.E.)
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Matteo Giorgi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Claudia D’Abate
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Irene Colombi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Alessandro Ginetti
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Alberto Cannoni
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Francesco Fedele
- Department of Obstetrics and Gynecology, Fondazione “Policlinico-Mangiagalli-Regina Elena” University of Milan, 20122 Milan, Italy;
| | - Caterina Exacoustos
- Gynecological Unit, Department of Surgical Sciences, University of Rome “Tor Vergata”, 00133 Rome, Italy; (F.G.M.); (C.E.)
| | - Gabriele Centini
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
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10
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Vercellini P, Bandini V, Viganò P, Ambruoso D, Cetera GE, Somigliana E. Proposal for targeted, neo-evolutionary-oriented secondary prevention of early-onset endometriosis and adenomyosis. Part II: medical interventions. Hum Reprod 2024; 39:18-34. [PMID: 37951241 DOI: 10.1093/humrep/dead206] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/07/2024] [Indexed: 11/13/2023] Open
Abstract
According to consistent epidemiological data, the slope of the incidence curve of endometriosis rises rapidly and sharply around the age of 25 years. The delay in diagnosis is generally reported to be between 5 and 8 years in adult women, but it appears to be over 10 years in adolescents. If this is true, the actual onset of endometriosis in many young women would be chronologically placed in the early postmenarchal years. Ovulation and menstruation are inflammatory events that, when occurring repeatedly for years, may theoretically favour the early development of endometriosis and adenomyosis. Moreover, repeated acute dysmenorrhoea episodes after menarche may not only be an indicator of ensuing endometriosis or adenomyosis, but may also promote the transition from acute to chronic pelvic pain through central sensitization mechanisms, as well as the onset of chronic overlapping pain conditions. Therefore, secondary prevention aimed at reducing suffering, limiting lesion progression, and preserving future reproductive potential should be focused on the age group that could benefit most from the intervention, i.e. severely symptomatic adolescents. Early-onset endometriosis and adenomyosis should be promptly suspected even when physical and ultrasound findings are negative, and long-term ovulatory suppression may be established until conception seeking. As nowadays this could mean using hormonal therapies for several years, drug safety evaluation is crucial. In adolescents without recognized major contraindications to oestrogens, the use of very low-dose combined oral contraceptives is associated with a marginal increase in the individual absolute risk of thromboembolic events. Oral contraceptives containing oestradiol instead of ethinyl oestradiol may further limit such risk. Oral, subcutaneous, and intramuscular progestogens do not increase the thromboembolic risk, but may interfere with attainment of peak bone mass in young women. Levonorgestrel-releasing intra-uterine devices may be a safe alternative for adolescents, as amenorrhoea is frequently induced without suppression of the ovarian activity. With regard to oncological risk, the net effect of long-term oestrogen-progestogen combinations use is a small reduction in overall cancer risk. Whether surgery should be considered the first-line approach in young women with chronic pelvic pain symptoms seems questionable. Especially when large endometriomas or infiltrating lesions are not detected at pelvic imaging, laparoscopy should be reserved to adolescents who refuse hormonal treatments or in whom first-line medications are not effective, not tolerated, or contraindicated. Diagnostic and therapeutic algorithms, including self-reported outcome measures, for young individuals with a clinical suspicion of early-onset endometriosis or adenomyosis are proposed.
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Affiliation(s)
- Paolo Vercellini
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Veronica Bandini
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
| | - Paola Viganò
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Deborah Ambruoso
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
| | - Giulia Emily Cetera
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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11
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Gordts S, Grimbizis G, Tanos V, Koninckx P, Campo R. Junctional zone thickening: an endo-myometrial unit disorder. Facts Views Vis Obgyn 2023; 15:309-316. [PMID: 38128089 PMCID: PMC10832651 DOI: 10.52054/fvvo.15.4.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Adenomyosis is a disease defined by histopathology, mostly of hysterectomy specimens, and classification is challenged by the disagreement of the histologic definition. With the introduction of Magnetic Resonance Imaging (MRI) and two- and three-dimensional ultrasound, the diagnosis of adenomyosis became a clinical entity. In MRI and US, adenomyosis ranges from thickening of the inner myometrium or junctional zone to nodular, cystic, or diffuse lesions involving the entire uterine wall, up to a well-circumscribed adenomyoma or a polypoid adenomyoma. The absence of an accepted classification and the vague and inconsistent terminology hamper basic and clinical research. The sub-endometrial halo seen at US and MRI is a distinct entity, differing from the outer myometrium by its increased nuclear density and vascular structure. The endometrium and the sub-endometrial muscularis or archimetra are of Müllarian origin, while the outer myometrium is non-Mullerian mesenchymal. The junctional zone (JZ) is important for uterine contractions, conception, implantation, and placentation. Thickening of the JZ can be considered inner myometrium adenomyosis, with or without endometrial invasion. Changes in the JZ should be considered a different entity than myometrial clinically associated with impaired conception, implantation, abnormal uterine bleeding, pelvic pain and obstetrical outcome. Pathology of the basal endometrium and JZ is a separate entity and should be identified as an endo-myometrial unit disorder (EMUD).
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12
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Martire FG, Piccione E, Exacoustos C, Zupi E. Endometriosis and Adolescence: The Impact of Dysmenorrhea. J Clin Med 2023; 12:5624. [PMID: 37685691 PMCID: PMC10488856 DOI: 10.3390/jcm12175624] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/24/2023] [Accepted: 08/27/2023] [Indexed: 09/10/2023] Open
Abstract
Endometriosis affects approximately 10% of premenopausal women worldwide. Despite its impact on quality of life, the delay in diagnosing this chronic disease is well known. Many patients with endometriosis report having suffered from dysmenorrhea and chronic pelvic pain in adolescence or at a young age. However, this painful symptom is often highly underestimated and considered a normal and transient symptom in young women. The real prevalence of endometriosis in adolescence remains uncertain. Some authors recently described at least one ultrasound feature of endometriosis in 13.3% of a general population of adolescent girls, which increased to 35.3% in young girls with severe dysmenorrhea. Dysmenorrhea is classified as primary dysmenorrhea or secondary dysmenorrhea. Primary dysmenorrhea is defined as a menstrual pain without organic disease, while secondary dysmenorrhea is defined as a menstrual pain associated with organic pelvic pathology. Since endometriosis represents the main cause of secondary dysmenorrhea in adolescents and young women, it is important to determine whether the patient has primary dysmenorrhea or additional suggestive symptoms related to endometriosis. Endometriosis in adolescent patients is a challenging problem with clinical and pathological differences compared with its presentation in premenopausal women. Adolescents and young women with dysmenorrhea and painful symptoms that suggest endometriosis should be referred to dedicated endometriosis centers for an early diagnosis and appropriate medical and surgical management. This paper aims to describe the role of dysmenorrhea in adolescents and the management of these young patients to confirm or exclude endometriosis.
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Affiliation(s)
- Francesco G. Martire
- Department of Biomedicine and Prevention, Section of Gynecology and Obstetrics, University of Rome “Tor Vergata”, 00133 Rome, Italy;
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy;
| | - Emilio Piccione
- Department of Surgical Sciences, Catholic University “Our Lady of Good Counsel”, 1000 Tirane, Albania
| | - Caterina Exacoustos
- Department of Surgical Sciences, Section of Gynecology and Obstetrics, University of Rome “Tor Vergata”, 00133 Rome, Italy;
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy;
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13
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Lazzeri L, Andersson KL, Angioni S, Arena A, Arena S, Bartiromo L, Berlanda N, Bonin C, Candiani M, Centini G, Forno SD, Donati A, Exacoustos C, Fuggetta E, Labanca L, Maiorana A, Maneschi F, Mattei A, Muzii L, Ottolina J, Perandini A, Perelli F, Pino I, Porpora MG, Remorgida V, Scaramuzzino S, Schimberni M, Seracchioli R, Solima E, Vignali M, Zupi E, Martire FG. How to Manage Endometriosis in Adolescence: The Endometriosis Treatment Italian Club Approach. J Minim Invasive Gynecol 2023; 30:616-626. [PMID: 37001691 DOI: 10.1016/j.jmig.2023.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 04/03/2023]
Abstract
The evaluation of endometriosis in an adolescent girl is a challenging topic. The initial stage of the disease and the limited diagnostic instrument appropriate for the youth age and for its typical features can reduce the ability of the gynecologist. At the same time, missing a prompt diagnosis can delay the beginning of specific and punctual management of endometriosis, which could avoid a postponed diagnosis from 6 to 12 years, typical of adolescent girls complaining of dysmenorrhea. This article aimed to answer all the potential questions around the diagnosis and management of endometriosis in adolescents starting from a clinical case looking at the possible solution that is easily reproducible in the clinical practice.
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Affiliation(s)
- Lucia Lazzeri
- Department of Molecular and Developmental Medicine (Drs. Lazzeri, Centini, Martire, and Zupi), Università di Siena, Siena, Italy
| | - Karin Louise Andersson
- Department of Territory Health (Dr. Andersson, Exacoustos), Azienda Sanitaria Toscana Centro, Florence, Italy
| | - Stefano Angioni
- Department of Surgical Sciences (Dr. Angioni), Università di Cagliari, Cittadella Universitaria, Cagliari, Italy
| | - Alessandro Arena
- Department of Medical and Surgical Sciences (Drs. A. Arena, Del Forno, and Seracchioli), DIMEC, Sant'Orsola Hospital, Università di Bologna, Bologna, Italy
| | - Saverio Arena
- Department of Obstetrics and Gynecology (Arena), Santa Maria della Misericordia hospital, Perugia, Italy
| | - Ludovica Bartiromo
- Department of Obstetrics and Gynecology (Drs. Bartiromo, Candiani, Ottolina, and Schimberni), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Berlanda
- Department of Obstetrics and Gynecology (Drs. Berlanda and Donati), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Cecilia Bonin
- Azienda Ospedaliera Universitaria Integrata (Drs. Bonin and Perandini), Università di Verona, Piazzale A. Stefani 1, Verona, Italy
| | - Massimo Candiani
- Department of Obstetrics and Gynecology (Drs. Bartiromo, Candiani, Ottolina, and Schimberni), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Centini
- Department of Molecular and Developmental Medicine (Drs. Lazzeri, Centini, Martire, and Zupi), Università di Siena, Siena, Italy
| | - Simona Del Forno
- Department of Medical and Surgical Sciences (Drs. A. Arena, Del Forno, and Seracchioli), DIMEC, Sant'Orsola Hospital, Università di Bologna, Bologna, Italy
| | - Agnese Donati
- Department of Obstetrics and Gynecology (Drs. Berlanda and Donati), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Caterina Exacoustos
- Department of Territory Health (Dr. Andersson, Exacoustos), Azienda Sanitaria Toscana Centro, Florence, Italy; Department of Surgical Sciences, Gynecologic Unit (Drs. Exacoustos, and Martire), University of Rome "Tor Vergata" Rome, Italy
| | - Eliana Fuggetta
- Department of Obstetrics and Gynecology (Drs. Fuggetta and Maneschi), San Giovanni Addolorata Hospital (Drs. Labanca and Martire), Roma, Italy
| | - Luca Labanca
- Department of Surgical Sciences (Drs. Labanca), Valdarno Hospital, Azienda Toscana Sud Est, Italy
| | - Antonio Maiorana
- Department of Obstetrics and Gynecology (Dr. Maiorana), ARNAS Ospedale Civico Piazza Nicola, Palermo, Italy
| | - Francesco Maneschi
- Department of Obstetrics and Gynecology (Drs. Fuggetta and Maneschi), San Giovanni Addolorata Hospital (Drs. Labanca and Martire), Roma, Italy
| | - Alberto Mattei
- Department of Molecular and Developmental Medicine (Drs. Lazzeri, Centini, Martire, and Zupi), Università di Siena, Siena, Italy; Department of Surgical Sciences, Gynecologic Unit (Drs. Exacoustos, and Martire), University of Rome "Tor Vergata" Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urology (Drs. Muzii, Porpora, and Scaramuzzino), Università di Roma La Sapienza, Policlinico Umberto I, Rome, Italy
| | - Jessica Ottolina
- Department of Obstetrics and Gynecology (Drs. Bartiromo, Candiani, Ottolina, and Schimberni), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessio Perandini
- Azienda Ospedaliera Universitaria Integrata (Drs. Bonin and Perandini), Università di Verona, Piazzale A. Stefani 1, Verona, Italy
| | - Federica Perelli
- Division of Gynecology and Obstetrics (Drs. Mattei and Perelli), Santa Maria Annunziata Hospital, USL Toscana Centro, Florence, Italy
| | - Ida Pino
- Preventive Gynecology Unit (Dr. Pino), European Institute of Oncology IRCCS, Milan, Italy
| | - Maria Grazia Porpora
- Department of Maternal and Child Health and Urology (Drs. Muzii, Porpora, and Scaramuzzino), Università di Roma La Sapienza, Policlinico Umberto I, Rome, Italy
| | - Valentino Remorgida
- Unit of Obstetrics and Gynecology (Dr. Remorgida), University of Eastern Piedmont, Novara, Italy
| | - Sara Scaramuzzino
- Department of Maternal and Child Health and Urology (Drs. Muzii, Porpora, and Scaramuzzino), Università di Roma La Sapienza, Policlinico Umberto I, Rome, Italy
| | - Matteo Schimberni
- Department of Obstetrics and Gynecology (Drs. Bartiromo, Candiani, Ottolina, and Schimberni), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Renato Seracchioli
- Department of Medical and Surgical Sciences (Drs. A. Arena, Del Forno, and Seracchioli), DIMEC, Sant'Orsola Hospital, Università di Bologna, Bologna, Italy; Division of Gynecology and Human Reproduction Phisiopatology (Dr. Seracchioli), IRCCS, Azienda Ospedaliera Universitaria di Bologna, Bologna Italy
| | - Eugenio Solima
- Department of Obstetrics and Gynecology (Drs. Solima and Vignali), Macedonio Melloni Hospital, Milan, Italy
| | - Michele Vignali
- Department of Obstetrics and Gynecology (Drs. Solima and Vignali), Macedonio Melloni Hospital, Milan, Italy
| | - Errico Zupi
- Department of Molecular and Developmental Medicine (Drs. Lazzeri, Centini, Martire, and Zupi), Università di Siena, Siena, Italy.
| | - Francesco Giuseppe Martire
- Division of Gynecology and Obstetrics (Drs. Mattei and Perelli), Santa Maria Annunziata Hospital, USL Toscana Centro, Florence, Italy
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