Conservative treatment of endometriosis externa: the effects of danazol therapy**Presented at the Annual Meeting of the District IV American College of Obstetricians and Gynecologists, October 29, 1981, Cerromar Beach, Puerto Rico

Characteristics of uterine contractility during menses in women with mild to moderate endometriosis

OBJECTIVE

To establish the role of uterine contractions in retrograde menstruation with subsequent abdominal implantation of endometrial tissue.

DESIGN

Controlled prospective study.

SETTING

University hospital-based study.

PATIENT(S)

Infertile women with (n = 22) and without (n = 22) endometriosis.

MAIN OUTCOME MEASURE(S)

Frequency, amplitude, and basal pressure tone of uterine contractions; correlation of contractions with retrograde bleeding and presence of viable endometrial cells; and dysmenorrhea before and 3 and 24 months after surgery.

RESULT(S)

Compared with controls, patients with endometriosis had uterine contractions with higher frequency (22.73 +/- 5.66 osc/10 min vs. 11.09 +/- 3.26 osc/10 min), amplitude (20.83 +/- 3.94 mm Hg vs. 6.77 +/- 2.83 mm Hg), and basal pressure tone (50.14 +/- 16.30 mm Hg vs. 24.68 +/- 6.14 mm Hg). Dysmenorrhea was scored as 4.09 +/- 1.44 in patients with endometriosis and 0.86 +/- 1.42 in controls. Retrograde bleeding was found in 73% of patients with endometriosis vs. 9% of controls, and only 45% of patients with endometriosis had viable endometrial cells in the cul-de-sac.

CONCLUSION(S)

Endometriosis may result from abnormal myometrial contractility through tubal transportation, dissemination, and implantation of endometrial viable cells into the abdomen.

Endometriosis: absence of recurrence in patients after endometrial ablation

BACKGROUND

The present study was undertaken to evaluate differences between patients with and without eutopic endometrium in the recurrence of ectopic endometriotic implants.

METHODS

Endometrial ablation (EA) was carried out in 14 women out of 28 laparoscopically treated for endometriosis and recurrence of the disease was evaluated 24 months later. Data were compared using paired Student's t-test and chi2 test.

RESULTS

Patients undergoing EA procedures did not exhibit recurrence of endometriosis while nine patients without that procedure had recurrence of the disease (P < 0.001). The endometrial cells found in the debris of the cul de sac of eight patients who did not undergo EA were both stromal and epithelial cells. No blood or blood cells were found in the cul de sac of patients undergoing EA.

CONCLUSIONS

The present study supports a role of eutopic endometrium in the recurrence of endometriosis through tubal dissemination of endometrial debris and implantation of endometrial cells into the abdomen.

The efficacy of drugs in the management of endometriosis

STUDY OBJECTIVE

To establish the crude effects of danazol and gonadotropin-releasing hormone (GnRH) analogs in the management of endometriosis.

DESIGN

Prospective case-control study.

SETTING

Unit of the Pathophysiology of Reproduction outpatient department.

PATIENTS

Two groups of 110 women each with endometriosis (American Fertility Society score 1-3) who received danazol and GnRH analogs, and a control group who did not receive any drugs.

INTERVENTIONS

Women in the treatment groups received danazol 200 mg every 8 hours for 6 months, or a different GnRH agonist at standard dosages for 6 months. Laparoscopy was performed twice, at the time of diagnosis and just before the end of treatment (or no therapy for controls). Surgical treatment of the implants was performed at the second laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Samples of both eutopic and ectopic endometrium were collected during both laparoscopies. Both danazol and GnRH agonists were useful in reducing the AFS scores to inactive endometriotic implants, and there were no significant differences between the effects (p <0.001). Fibrosis was found after 6 months of observation in the implants in one control woman (0.9%), in 20 patients (18.2%) treated with danazol (p <0.001 vs controls), and in 4 patients (3.6%) treated with GnRH agonists (NS vs controls). A correlation between a clinical diagnosis of AFS score zero and histologic features of fibrosis in the ectopic specimens after therapies was observed in 28% of women, with poor agreement (k = 0.07).

CONCLUSIONS

Fibrosis, which represent the absence of endometrial cells within the specimens of endometriotic lesions or eutopic endometrium, did not appear in eutopic endometria but it was found in some endometriotic implants. Danazol and GnRH agonists reduced the clinical AFS scores of endometriosis, but their histologic effects in completely and permanently eliminating endometriotic implants were unacceptable.

Recurrent endometriosis: a review of biological and clinical aspects

The recurrence of pelvic endometriosis some time after the initial treatment is a common finding in clinical practice. When symptoms of endometriosis reappear several months after treatment, it is difficult to distinguish between recurrence and persistence of the disease. In this review, the current hypotheses about the biological basis of endometriosis recurrence/persistence are discussed. The results of several clinical trials estimating the recurrence rate of endometriosis after medical, surgical, and combined treatments are presented. In addition, a critical analysis of the tools available for the diagnosis of recurrent endometriosis is made, and some therapeutic options to treat recurrent endometriosis are discussed with recommendations for their use.

Menstrual symptoms in women with pelvic endometriosis

OBJECTIVE

To investigate menstrual symptoms in relation to pelvic pathology.

DESIGN

A prospective questionnaire-based study.

SETTING

Aberdeen Royal Infirmary, Scotland.

SUBJECTS

1250 questionnaires were sent out prior to planned admission and 1200 women (96%) brought the completed questionnaires. They comprised 598 women undergoing laparoscopic sterilization, 312 having laparoscopy because of infertility, 156 having laparoscopy because of chronic pelvic pain and 134 women undergoing abdominal hysterectomy for dysfunctional uterine bleeding.

MAIN OUTCOME MEASURES

The occurrence of dysmenorrhoea, menorrhagia, menstrual regularity, premenstrual spotting, deep dyspareunia and pelvic pain in women with either endometriosis and post infective pelvic adhesions or a normal pelvis.

RESULTS

Menorrhagia, menstrual irregularity and premenstrual spotting occurred with equal frequency in all groups. Deep dyspareunia, pain after intercourse and recurrent pain unrelated to menstruation or coitus was more common in women with endometriosis and those with post infective pelvic adhesions than in those with a normal pelvis. Dysmenorrhoea appears to be more prevalent among women having endometriosis.

CONCLUSIONS

Menstrual symptoms, while raising a high index of suspicion for endometriosis, are not entirely reliable as indicators of disease. Dysmenorrhoea is the most common reported symptom in endometriosis sufferers. Diagnostic laparoscopy should be considered before institution of treatment in women complaining of pelvic pain and menstrual symptoms.

Nafarelin acetate: a gonadotropin-releasing hormone agonist for the treatment of endometriosis

Nafarelin acetate is a gonadotropin-releasing hormone (GnRH) agonist proven as effective as danazol in treating endometriosis. Its proposed mechanism of action is the desensitization of pituitary GnRH receptors leading to a decrease in gonadotropin release, and ovarian hormone serum concentrations similar to those achieved in postmenopausal women. Nafarelin decreases or ablates the physical symptoms associated with endometriosis, and pregnancy rates following therapy with this drug are comparable to rates observed after danazol therapy. Nafarelin is administered by nasal inhalation and has been generally well tolerated. It is associated with a high incidence of adverse effects but they are rarely severe enough to cause withdrawal from treatment, and those occurring most frequently--hot flashes, vaginal dryness, and decreased libido--are a consequence of the hypoestrogenemia induced by the drug. Increased bone turnover occurs in women on nafarelin but biochemical parameters return to pretreatment concentrations by six months after termination of treatment. This agent's place in the therapy of endometriosis will be determined as clinical experience accumulates.

LH-RH agonist (buserelin): treatment of endometriosis. Clinical, laparoscopic, endocrine and metabolic evaluation

To investigate the effects of the LH-RH agonist Buserelin [D-Ser (But)6 des-Gly10-LHRH ethylamide] on endometriosis, 64 patients were treated with 900 micrograms/d Buserelin intranasally over 6 months after histological verification of the disease. As shown by the follow-up operation at the end of treatment, 73% of cases showed regression of implants, whereas adhesions seemed to be unaffected. The uncorrected pregnancy rate of the 45 patients with a history of infertility was 40%, while the overall recurrence rate--confirmed by histological examination--was 9.4%. The endocrine parameters demonstrated a highly significant suppression of estradiol (E2) and a sharp decline of progesterone (Prog), indicating anovulatory cycles. Follicle-stimulating hormone (FSH) was unchanged, while luteinizing hormone (LH) and prolactin (Prl) decreased significantly. The androgenic parameters testosterone (T), dehydroepiandrosterone sulfate (DHEA-S), and sex-hormone-binding globulin (SHBG) revealed no relevant changes. Influence on bone metabolism could not be detected by measuring calcitonin and parathyroid hormone fragments (PTH-C and PTH-MM). Negative metabolic effects were absent in terms of hematology, clotting system, liver enzymes, renal parameters and lipid metabolism. Remarkable was a significant increase of high-density-lipoprotein cholesterol (HDL). Subjective complaints were mostly attributed to the therapy-induced hypoestrogenism. We consider Buserelin to be an effective drug in the treatment of endometriosis, with a low incidence of relevant side effects.

Mild endometriosis and ovulatory dysfunction: effect of danazol treatment on success of ovulation induction

The effectiveness of ovulation induction with clomiphene citrate or human menopausal gonadotropins was evaluated in 52 infertile women with stage I or stage II endometriosis and ovulatory dysfunction: anovulation or luteinized unruptured follicle (LUF) syndrome before (group I) and after (group II) danazol treatment. The incidence of anovulation and LUF in the endometriosis population was 9% and 34%, respectively. In group I, 10 of 36 patients (27.8%) conceived, with an average of 17.6 induction cycles per pregnancy. In group II, 21 of 30 patients (70%) conceived, with an average of 4.5 cycles per pregnancy (difference significant at P less than 0.001). There was no difference in the average number of ovulation induction cycles per patient between groups I and II (4.9 and 3.1, respectively). Of 14 patients who did not conceive in group I and crossed over to group II, 9 (64.3%) conceived (not different from group II). Spontaneous abortion rates were 20% in group I and 14% in group II. These results indicate that mild endometriosis may interfere with conception through mechanisms other than ovulatory dysfunction and that treatment with danazol appears to more than double the fertility rate.

Surgical treatment of endometriosis via laser laparoscopy

The carbon dioxide laser has been used laparoscopically for the removal of endometriotic implants, excision of endometrioma capsules, and lysis of adnexal adhesions in 102 patients. These patients were followed for a period ranging from 12 to 18 months, during which time there were 62 pregnancies, including 9 spontaneous abortions and 1 elective termination. The rates of conception after surgery were as follows: 75% for patients with mild endometriosis, 62% for patients with moderate endometriosis, 42.1% for patients with severe endometriosis, and 50% for patients with extensive endometriosis. Of 102 patients presenting with infertility attributed to endometriosis, 60.7% conceived within 24 months after laser laparoscopy. In this patient group, no immediate or subsequent laparotomy was required before conception was achieved, nor was hormonal therapy enacted during the study period after surgery.

Endometriosis: a reappraisal of pathogenesis and treatment

The enigmatic disease of endometriosis continues to baffle both the scientist and the clinician. An encompassing theory of pathogenesis has failed to emerge from contemporary understanding of the immunologic manifestations, the hormonal aberrations, or the evasive infertility associated with endometriosis. Similarly unsettling is the failure of medical or conservative surgical maneuvers to eradicate endometriosis in a manner commensurate with castration. It is hoped that further insight into these areas of research will resolve both of these dilemmas.