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Masciullo L, Viscardi MF, Piacenti I, Scaramuzzino S, Cavalli A, Piccioni MG, Porpora MG. A deep insight into pelvic pain and endometriosis: a review of the literature from pathophysiology to clinical expressions. Minerva Obstet Gynecol 2021; 73:511-522. [PMID: 33904687 DOI: 10.23736/s2724-606x.21.04779-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endometriosis is a chronic inflammatory disease that affects approximately 10% of women of reproductive age. Its clinical manifestations are highly heterogeneous, but pelvic pain is the most frequent, causing functional disability. Cyclic or acyclic chronic pelvic pain (CPP), dysmenorrhea and dyspareunia are frequent symptoms which often compromise all aspects of the women's quality of life (QoL). The pathophysiology of endometriosis-related pain is extremely complex and not always clear. The aim of this literature review is to focus on recent updates on the clinical presentation, the pathophysiology and the most important mechanisms involved in the pathogenesis of pelvic pain in endometriosis. A literature search in the Cochrane library, PubMed, Scopus and web of Science databases has been performed, identifying articles from January 1995 to November 2020. Several processes seem to be involved in the pathogenesis of pain, but many aspects are still unclear. Scientific evidence has shown that a correlation between pain severity and stage of endometriosis rarely occurs, whereas there is a significant correlation between pain and the presence of deep endometriosis. Onset and intensity of pain may be due to a complex process involving central sensitization and peripheral activation of nociceptive pathways as well as dysfunction of the immune system and of the hypothalamic-pituitary-adrenal (HPA) axis. A deeper understanding of these different pathogenetic mechanisms may improve future treatments in women with painful endometriosis.
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Affiliation(s)
- Luisa Masciullo
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Maria F Viscardi
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Ilaria Piacenti
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Sara Scaramuzzino
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Alessandra Cavalli
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Maria G Piccioni
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Maria G Porpora
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy -
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2
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Agely A, Bolan C, Metcalfe A, VanBuren W, Menias C. Genitourinary manifestations of endometriosis with emphasis on the urinary tract. Abdom Radiol (NY) 2020; 45:1711-1722. [PMID: 31919646 DOI: 10.1007/s00261-019-02383-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Endometriosis is a common benign condition affecting women. The disease has a broad spectrum of presentations from incidental lesions in asymptomatic women to causing significant and debilitating morbidity in others. Ectopic endometrial glands are located in predictable locations throughout the pelvis, including implantation on the ovaries and in the rectouterine cul-de-sac. Less commonly, the urinary tract may be involved. As genitourinary manifestations may remain symptomatically occult or masquerade as other diagnoses, it is essential for the radiologist to be aware of the imaging features, consider this diagnosis, and potentially save the patient from delayed treatment.
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Affiliation(s)
- A Agely
- Department of Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - C Bolan
- Department of Radiology, Mayo Clinic Florida, Jacksonville, FL, USA.
| | - A Metcalfe
- Department of Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - W VanBuren
- Department of Radiology, Mayo Clinic Rochester, Rochester, MN, USA
| | - C Menias
- Department of Radiology, Mayo Clinic Arizona, Scottsdale, AZ, USA
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3
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Davie S, Hamilton Y, Webb L, Amoako AA. Sleep quality and endometriosis: A group comparison study. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2020. [DOI: 10.1177/2284026520909979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Endometriosis affects around 10% of women of reproductive age with symptoms of pelvic pain, dysmenorrhoea, dyspareunia, dyschezia, and infertility. Current research highlights a possible relationship between endometriosis and poor sleep quality. The aim of this study was to assess the relationship between sleep quality and endometriosis. Outcomes measured included sleep quality and quality of life and pain score. Methods: Thirty women with a histological diagnosis of endometriosis and 30 control patients completed an online questionnaire that assessed sleep quality (Pittsburgh Sleep Quality Index) and quality of life (WHO-QOL-BREF). Pain scores within the endometriosis group were evaluated using a visual analogue scale. Results: Women with endometriosis had significantly poorer sleep quality (80% vs 50%, p = 0.015) and lower quality of life scores when compared to the control group. Within the endometriosis group, there were trends between poor sleep, a reduced quality of life, and higher pain scores; however, these did not reach statistical significance. Discussion: Sleep quality and quality of life were significantly reduced in women with endometriosis when compared to controls.
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Affiliation(s)
- Stacey Davie
- Department of Obstetrics and Gynecology, Gold Coast University Hospital, Southport, QLD, Australia
- Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
| | - Yasu Hamilton
- Department of Obstetrics and Gynecology, Gold Coast University Hospital, Southport, QLD, Australia
| | - Lachlan Webb
- QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Akwasi A Amoako
- Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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Yilmaz BD, Bulun SE. Endometriosis and nuclear receptors. Hum Reprod Update 2020; 25:473-485. [PMID: 30809650 DOI: 10.1093/humupd/dmz005] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 12/03/2018] [Accepted: 02/22/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Endometriosis is recognized as a steroid-dependent disorder; however, the precise roles of nuclear receptors (NRs) in steroid responsiveness and other signaling pathways are not well understood. OBJECTIVE AND RATIONALE Over the past several years, a number of paradigm-shifting breakthroughs have occurred in the area of NRs in endometriosis. We review and clarify new information regarding the mechanisms responsible for: (i) excessive estrogen biosynthesis, (ii) estrogen-dependent inflammation, (iii) defective differentiation due to progesterone resistance and (iv) enhanced survival due to deficient retinoid production and action in endometriosis. We emphasize the roles of the relevant NRs critical for these pathological processes in endometriosis. SEARCH METHODS We conducted a comprehensive search using PubMed for human, animal and cellular studies published until 2018 in the following areas: endometriosis; the steroid and orphan NRs, estrogen receptors alpha (ESR1) and beta (ESR2), progesterone receptor (PGR), steroidogenic factor-1 (NR5A1) and chicken ovalbumin upstream promoter-transcription factor II (NR2F2); and retinoids. OUTCOMES Four distinct abnormalities in the intracavitary endometrium and extra-uterine endometriotic tissue underlie endometriosis progression: dysregulated differentiation of endometrial mesenchymal cells, abnormal epigenetic marks, inflammation activated by excess estrogen and the development of progesterone resistance. Endometriotic stromal cells compose the bulk of the lesions and demonstrate widespread epigenetic abnormalities. Endometriotic stromal cells also display a wide range of abnormal NR expression. The orphan NRs NR5A1 and NR2F2 compete to regulate steroid-synthesizing genes in endometriotic stromal cells; NR5A1 dominance gives rise to excessive estrogen formation. Endometriotic stromal cells show an abnormally low ESR1:ESR2 ratio due to excessive levels of ESR2, which mediates an estrogen-driven inflammatory process and prostaglandin formation. These cells are also deficient in PGR, leading to progesterone resistance and defective retinoid synthesis. The pattern of NR expression, involving low ESR1 and PGR and high ESR2, is reminiscent of uterine leiomyoma stem cells. This led us to speculate that endometriotic stromal cells may display stem cell characteristics found in other uterine tissues. The biologic consequences of these abnormalities in endometriotic tissue include intense inflammation, defective differentiation and enhanced survival. WIDER IMPLICATIONS Steroid- and other NR-related abnormalities exert genome-wide biologic effects via interaction with defective epigenetic programming and enhance inflammation in endometriotic stromal cells. New synthetic ligands, targeting PGR, retinoic acid receptors and ESR2, may offer novel treatment options.
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Affiliation(s)
- Bahar D Yilmaz
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 250 E. Superior Street, Chicago, IL, USA
| | - Serdar E Bulun
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 250 E. Superior Street, Chicago, IL, USA
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Marinho MC, Magalhaes TF, Fernandes LFC, Augusto KL, Brilhante AV, Bezerra LR. Quality of Life in Women with Endometriosis: An Integrative Review. J Womens Health (Larchmt) 2018; 27:399-408. [DOI: 10.1089/jwh.2017.6397] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Manuela C.P. Marinho
- Department of Surgery and Maternidade Escola Assis Chateaubriand of Federal University of Ceará (UFC), Fortaleza, Brazil
| | - Thais F. Magalhaes
- Department of Surgery and Maternidade Escola Assis Chateaubriand of Federal University of Ceará (UFC), Fortaleza, Brazil
| | | | - Kathiane L. Augusto
- Department of Surgery and Maternidade Escola Assis Chateaubriand of Federal University of Ceará (UFC), Fortaleza, Brazil
- Medicine Course of University of Fortaleza (UNIFOR), Fortaleza, Brazil
| | - Aline V.M. Brilhante
- Post-Graduate Program in Public Health, University of Fortaleza (UNIFOR), Fortaleza, Brazil
- Medicine Course of University of Fortaleza (UNIFOR), Fortaleza, Brazil
| | - Leonardo R.P.S. Bezerra
- Department of Surgery and Maternidade Escola Assis Chateaubriand of Federal University of Ceará (UFC), Fortaleza, Brazil
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Ashrafi M, Sadatmahalleh SJ, Akhoond MR, Talebi M. Evaluation of Risk Factors Associated with Endometriosis in Infertile Women. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2016; 10:11-21. [PMID: 27123195 PMCID: PMC4845520 DOI: 10.22074/ijfs.2016.4763] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 06/07/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endometriosis affects women's physical and mental wellbeing. Symptoms include dyspareunia, dysmenorrhea, pelvic pain, and infertility. The purpose of this study is to assess the correlation between some relevant factors and symptoms and risk of an endometriosis diagnosis in infertile women. MATERIALS AND METHODS A retrospective study of 1282 surgical patients in an infertility Institute, Iran between 2011 and 2013 were evaluated by laparoscopy. Of these, there were 341 infertile women with endometriosis (cases) and 332 infertile women with a normal pelvis (comparison group). Chi-square and t tests were used to compare these two groups. Logistic regression was done to build a prediction model for an endometriosis diagnosis. RESULTS Gravidity [odds ratio (OR): 0.8, confidence interval (CI): 0.6-0.9, P=0.01], parity (OR: 0.7, CI: 0.6-0.9, P=0.01), family history of endometriosis (OR: 4.9, CI: 2.1-11.3, P<0.001), history of galactorrhea (OR: 2.3, CI: 1.5-3.5, P=0.01), history of pelvic surgery (OR: 1.9, CI: 1.3-2.7, P<0.001), and shorter menstrual cycle length (OR: 0.9, CI: 0.9-0.9, P=0.04) were associated with endometriosis. Duration of natural menstruation and age of menarche were not correlated with subsequent risk of endometriosis (P>0.05). Fatigue, diarrhea, constipation, dysmenorrhea, dyspareunia, pelvic pain and premenstrual spotting were more significant among late-stage endometriosis patients than in those with early-stage endometriosis and more prevalent among patients with endometriosis than that of the comparison group. In the logistic regression model, gravidity, family history of endometriosis, history of galactorrhea, history of pelvic surgery, dysmenorrhoea, pelvic pain, dysparaunia, premenstrual spotting, fatigue, and diarrhea were significantly associated with endometriosis. However, the number of pregnancies was negatively related to endometriosis. CONCLUSION Endometriosis is a considerable public health issue because it affects many women and is associated with the significant morbidity. In this study, we built a prediction model which can be used to predict the risk of endometriosis in infertile women.
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Affiliation(s)
- Mahnaz Ashrafi
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran; Department of Obstetrics and Gynecology, Faculty of Medicine, Iran University of Medical Science, Tehran, Iran
| | - Shahideh Jahanian Sadatmahalleh
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran; Department of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Mohammad Reza Akhoond
- Department of Statistics, Mathematical Science and Computer Faculty, Shahid Chamran University, Ahwaz, Iran
| | - Mehrak Talebi
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
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7
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Radhika AG, Chawla S, Nanda P, Yadav G, Radhakrishnan G. A Multivariate Analysis of Correlation between Severity and Duration of Symptoms, Patient Profile and Stage of Endometriosis. ACTA ACUST UNITED AC 2016. [DOI: 10.4236/ojog.2016.610077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sapkota Y, Attia J, Gordon SD, Henders AK, Holliday EG, Rahmioglu N, MacGregor S, Martin NG, McEvoy M, Morris AP, Scott RJ, Zondervan KT, Montgomery GW, Nyholt DR. Genetic burden associated with varying degrees of disease severity in endometriosis. Mol Hum Reprod 2015; 21:594-602. [PMID: 25882541 DOI: 10.1093/molehr/gav021] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 04/10/2015] [Indexed: 11/13/2022] Open
Abstract
Endometriosis is primarily characterized by the presence of tissue resembling endometrium outside the uterine cavity and is usually diagnosed by laparoscopy. The most commonly used classification of disease, the revised American Fertility Society (rAFS) system to grade endometriosis into different stages based on disease severity (I to IV), has been questioned as it does not correlate well with underlying symptoms, posing issues in diagnosis and choice of treatment. Using two independent European genome-wide association (GWA) datasets and top-level classification of the endometriosis cases based on rAFS [minimal or mild (Stage A) and moderate-to-severe (Stage B) disease], we previously showed that Stage B endometriosis has greater contribution of common genetic variation to its aetiology than Stage A disease. Herein, we extend our previous analysis to four endometriosis stages [minimal (Stage I), mild (Stage II), moderate (Stage III) and severe (Stage IV) disease] based on the rAFS classification system and compared the genetic burden across stages. Our results indicate that genetic burden increases from minimal to severe endometriosis. For the minimal disease, genetic factors may contribute to a lesser extent than other disease categories. Mild and moderate endometriosis appeared genetically similar, making it difficult to tease them apart. Consistent with our previous reports, moderate and severe endometriosis showed greater genetic burden than minimal or mild disease. Overall, our results provide new insights into the genetic architecture of endometriosis and further investigation in larger samples may help to understand better the aetiology of varying degrees of endometriosis, enabling improved diagnostic and treatment modalities.
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Affiliation(s)
- Yadav Sapkota
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - John Attia
- Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia Public Health Research Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Scott D Gordon
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Anjali K Henders
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Elizabeth G Holliday
- Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia Public Health Research Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Nilufer Rahmioglu
- Genetic and Genomic Epidemiology Unit, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Stuart MacGregor
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Nicholas G Martin
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Mark McEvoy
- Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia Public Health Research Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Andrew P Morris
- Genetic and Genomic Epidemiology Unit, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Rodney J Scott
- Public Health Research Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, New South Wales, Australia Division of Genetics, Hunter Area Pathology Service, Newcastle, New South Wales, Australia
| | - Krina T Zondervan
- Genetic and Genomic Epidemiology Unit, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK Nuffield Department of Obstetrics and Gynaecology, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Grant W Montgomery
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Dale R Nyholt
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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Wu CH, Yang JG, Chang YJ, Hsu CC, Kuo PL. Screening of a panel of steroid-related genes showed polymorphisms of aromatase genes confer susceptibility to advanced stage endometriosis in the Taiwanese Han population. Taiwan J Obstet Gynecol 2014; 52:485-92. [PMID: 24411031 DOI: 10.1016/j.tjog.2013.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 05/15/2012] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To establish a multilocus model for studying the effect of steroid-related genes on advanced stage endometriosis. MATERIALS AND METHODS A total of 121 patients with advanced stage endometriosis and 171 control women were included. Eighteen single-nucleotide polymorphisms (SNPs) from nine genes (HSD17B1, HSD17B2, HSD17B5, HSD17B6, CYP17, CYP19, ERα, ERβ, and PGR) were genotyped using the TaqMan assays. Logistic regression models were used to evaluate the genetic effects, with adjustment for other covariates. RESULTS Only the presence of the mutant CYP19 (aromatase gene) was associated with a significantly increased risk of endometriosis after adjusting for age, BMI, and parity (p = 0.002, OR = 2.69; 95% CI = 1.44-5.02). No association was ascertained between the other investigated SNPs and endometriosis. CONCLUSION Polymorphisms of the aromatase gene confer susceptibility to advanced stage endometriosis in the Taiwanese Han population.
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Affiliation(s)
- Cheng-Hsuan Wu
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan
| | - Jyuer-Ger Yang
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-Jun Chang
- Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chao-Chin Hsu
- Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan.
| | - Pao-Lin Kuo
- Department of Obstetrics and Gynecology, Cheng Kung University Hospital, Tainan, Taiwan.
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10
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Nunes F, Ferreira J, Bahamondes L. Pain threshold and sleep quality in women with endometriosis. Eur J Pain 2014; 19:15-20. [DOI: 10.1002/ejp.514] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2014] [Indexed: 11/06/2022]
Affiliation(s)
- F.R. Nunes
- Human Reproduction Unit; Department of Obstetrics and Gynaecology; School of Medical Sciences; University of Campinas (UNICAMP) and the National Institute of Hormones and Women's Health; Brazil
| | - J.M. Ferreira
- Human Reproduction Unit; Department of Obstetrics and Gynaecology; School of Medical Sciences; University of Campinas (UNICAMP) and the National Institute of Hormones and Women's Health; Brazil
| | - L. Bahamondes
- Human Reproduction Unit; Department of Obstetrics and Gynaecology; School of Medical Sciences; University of Campinas (UNICAMP) and the National Institute of Hormones and Women's Health; Brazil
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11
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Kim JJ, Kurita T, Bulun SE. Progesterone action in endometrial cancer, endometriosis, uterine fibroids, and breast cancer. Endocr Rev 2013; 34:130-62. [PMID: 23303565 PMCID: PMC3565104 DOI: 10.1210/er.2012-1043] [Citation(s) in RCA: 312] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 09/17/2012] [Indexed: 12/19/2022]
Abstract
Progesterone receptor (PR) mediates the actions of the ovarian steroid progesterone, which together with estradiol regulates gonadotropin secretion, prepares the endometrium for implantation, maintains pregnancy, and differentiates breast tissue. Separation of estrogen and progesterone actions in hormone-responsive tissues remains a challenge. Pathologies of the uterus and breast, including endometrial cancer, endometriosis, uterine fibroids, and breast cancer, are highly associated with estrogen, considered to be the mitogenic factor. Emerging evidence supports distinct roles of progesterone and its influence on the pathogenesis of these diseases. Progesterone antagonizes estrogen-driven growth in the endometrium, and insufficient progesterone action strikingly increases the risk of endometrial cancer. In endometriosis, eutopic and ectopic tissues do not respond sufficiently to progesterone and are considered to be progesterone-resistant, which contributes to proliferation and survival. In uterine fibroids, progesterone promotes growth by increasing proliferation, cellular hypertrophy, and deposition of extracellular matrix. In normal mammary tissue and breast cancer, progesterone is pro-proliferative and carcinogenic. A key difference between these tissues that could explain the diverse effects of progesterone is the paracrine interactions of PR-expressing stroma and epithelium. Normal endometrium is a mucosa containing large quantities of distinct stromal cells with abundant PR, which influences epithelial cell proliferation and differentiation and protects against carcinogenic transformation. In contrast, the primary target cells of progesterone in the breast and fibroids are the mammary epithelial cells and the leiomyoma cells, which lack specifically organized stromal components with significant PR expression. This review provides a unifying perspective for the diverse effects of progesterone across human tissues and diseases.
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Affiliation(s)
- J Julie Kim
- Division of Reproductive Biology Research, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
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12
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Endométriose et douleurs pelvipérinéales chroniques. Prog Urol 2010; 20:1010-8. [DOI: 10.1016/j.purol.2010.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 08/16/2010] [Indexed: 11/21/2022]
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13
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A comparison of the effect of short-term aromatase inhibitor (letrozole) and GnRH agonist (triptorelin) versus case control on pregnancy rate and symptom and sign recurrence after laparoscopic treatment of endometriosis. Arch Gynecol Obstet 2010; 284:105-10. [DOI: 10.1007/s00404-010-1599-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 07/11/2010] [Indexed: 10/19/2022]
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14
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Uzan C, Darai E, Valent A, Graesslin O, Cortez A, Rouzier R, Vielh P. Status of HER1 and HER2 in peritoneal, ovarian and colorectal endometriosis and ovarian endometrioid adenocarcinoma. Virchows Arch 2009; 454:525-9. [PMID: 19294416 DOI: 10.1007/s00428-009-0755-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Revised: 02/24/2009] [Accepted: 02/27/2009] [Indexed: 11/26/2022]
Abstract
A role for the EGF system, in particular HER1 and 2, in growth of the endometrium has been suggested but HER1 and 2 have not been studied in all locations of endometriosis and in ovarian endometrioid adenocarcinoma (OEC) which is a rare form of malignant transformation of endometriosis. Immunohistochemistry (IHC) was used for studying HER1 and HER2 in ovarian (n = 10), peritoneal (n = 10), colorectal endometriosis (n = 20) and OEC (n = 10). Fluorescent in situ hybridisation (FISH) was used for analysing the status of HER2 gene in colorectal endometriosis and OEC. All samples were negative for HER2 in both glandular and stromal cells and in glandular cells for HER1 by IHC. In 15 out of 20 colorectal endometriosis, there was a weak expression in stromal cells. Following FISH, two colorectal samples had a partial 17 aneusomy and three OEC, a 17 polysomy. The other samples were 17 disomic without HER2 amplification; HER1 and 2 do not seem to have a role in endometriosis physiopathology.
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Affiliation(s)
- C Uzan
- Research Translational Laboratory, Histocytopathology Unit, Institute Gustave Roussy, 39, rue Camille Desmoulins, 94805, Villejuif, France.
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15
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Affiliation(s)
- Serdar E Bulun
- Division of Reproductive Biology Research, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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16
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Psychological aspects of endometriosis: Differences between patients with or without pain on four psychological variables. Eur J Obstet Gynecol Reprod Biol 2008; 139:100-5. [DOI: 10.1016/j.ejogrb.2007.10.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2007] [Revised: 10/01/2007] [Accepted: 10/03/2007] [Indexed: 11/23/2022]
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17
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Abstract
Endometriosis diagnosis and treatment planning are guided primarily by retrospective pain recall, despite the facts that (1) there is only a tenuous relationship between pain reports and physical pathology, and (2) the accuracy of pain recall has never been assessed in this population. The current study investigated the accuracy of endometriotic pain recall for pain experienced over a 30-day period, as well as potential psychological mediators of pain recall accuracy, including psychological wellbeing, distress specific to infertility, passive and active coping, and pain present at time of recall in 100 women with endometriosis. Findings indicated that women were relatively accurate in their recall of pain. Only passive coping and pain present at recall were predictive of accuracy, with greater passive coping and lower pain at recall predictive of overestimation of past pain. Study implications are discussed, including: (1) report of pain over a 30-day duration appears credible for the majority of patients with endometriosis and (2) women exhibiting greater passive coping may benefit from psychological treatment in addition to medical intervention.
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Takahashi N, Yang DJ, Kurihara H, Borne A, Kohanim S, Oh CS, Mawlawi O, Kim EE. Functional imaging of estrogen receptors with radiolabeled-GAP-EDL in rabbit endometriosis model. Acad Radiol 2007; 14:1050-7. [PMID: 17707312 DOI: 10.1016/j.acra.2007.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Revised: 05/29/2007] [Accepted: 05/30/2007] [Indexed: 10/22/2022]
Abstract
RATIONALE AND OBJECTIVES Endometriosis is a common women's health problem. Animal models provide an invaluable tool to study the natural history of endometriosis. We previously have reported that (99m)Tc-labeled glutamate peptide-estradiol ((99m)Tc-GAP-EDL) is a useful agent for imaging functional estrogen receptor (ER) via an ER-mediated process. This study was to evaluate the feasibility of using radiolabeled GAP-EDL to image ER-positive (ER +) endometriosis in nonprimate animal models. MATERIALS AND METHODS 3-Aminoethyl estradiol (EDL) was conjugated to glutamate peptide (GAP) to yield GAP-EDL. In vitro cellular uptake studies of (99m)Tc and (68)Ga-GAP-EDL inhibition with cold estrone were conducted in 13,762 rat mammary tumor cells. To create a rabbit model with endometriosis, part of uterine tissue was dissected and grafted in the peritoneal wall. Eight weeks after surgery, scintigraphic images were obtained after intravenous injection of (99m)Tc-GAP-EDL (1 mCi/rabbit, intravenous) at 0.5-2.0 hours, and (68)Ga-GAP-EDL at 45 minutes. We also performed (68)Ga-GAP-EDL blocking study in rabbit model by using tamoxifen. The rabbits were sacrificed and the grafts were excised for histologic examination. RESULTS In vitro uptake study of (99m)Tc- and (68)Ga-GAP-EDL in 13,762 rat breast cancer cells showed gradually increasing uptake of both tracers. Accumulation of (68)Ga-GAP-EDL in 13,762 cells was inhibited with cold estrone in a dose-dependent manner. In the endometriosis model, the grafted uterine tissue could be visualized by (99m)Tc-GAP-EDL. Necropsy was performed at 2.5 hours after injection time. Four follicular endometrial lesions in eight implanted endometrial tissues were detected, and all lesions could be detected by (99m)Tc-GAP-EDL. Planar scintigraphy of uterus, ovary and implants of necropsy specimen revealed an increased uptake of (99m)Tc-GAP-EDL in comparison with surrounding abdominal wall tissue. Microscopic examinations support that (99m)Tc-GAP-EDL was accumulated in the microinvasive endometrial tissue. After blocking with tamoxifen, (68)Ga-GAP-EDL accumulation in the endometrial grafts could not be visualized, and endometrial tissue-to-normal tissue count ratios were statistically higher in a nonblocked image than that in the blocked image. CONCLUSIONS Endometriosis uptake of radiolabeled GAP-EDL was via an estrogen receptor-mediated process. Radiolabeled-GAP-EDLs are useful agents for imaging endometriosis.
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Affiliation(s)
- Nobukazu Takahashi
- Division of Diagnostic Imaging, Box 57, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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19
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Abstract
OBJECTIVES To establish guidelines for the medical and surgical management of painful endometriosis. MATERIAL AND METHODS An exhaustive review on Medline and Cochrane Database between 1980 and 2006 was performed. RESULTS GnRH agonists, progestins, continuous monophasic oral contraceptives and danazol have a suppressive effect on dysmenorrhoea, nonmenstrual pain and dyspareunia (grade A). Surgical treatment is effective in painful endometriosis (grade B). Complete surgical excision of deep endometriotic lesions with conservation of uterus and ovaries has a limited term efficacy on pain relief (grade C). A multidisciplinary approach is recommended (grade C). The use of the psychotherapy improves the management of chronic pain (grade A). There is a lack of information concerning the therapeutic strategy able to prevent recurrences. Whether endometriosis recurrences occur, medical treatment should be the first line approach (expert opinion). A hysterectomy with salpingo-oophorectomy and complete excision of the lesions is efficient in women with pain recurrence who no longer desire pregnancy (grade C). CONCLUSION Medical and surgical treatments have a limited term efficacy on painful endometriosis (grade A). The benefit/risk relationship, depending on secondary effect therapy, should be assessed on a case to case basis.
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Affiliation(s)
- H Roman
- Clinique Gynécologique et Obstétricale, CHU Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France.
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Bourdel N, Matsusakï S, Roman H, Lenglet Y, Botchorischvili R, Mage G, Canis M. Endométriose et adolescente. ACTA ACUST UNITED AC 2006; 34:727-34. [PMID: 16950643 DOI: 10.1016/j.gyobfe.2006.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Accepted: 07/05/2006] [Indexed: 11/23/2022]
Abstract
Endometriosis has long been considered as a disease of women over 30 years old. However, recent data from the literature demonstrated its high incidence in teenagers. Endometriosis in teenagers is generally associated with chronic pelvic pains and cyclical signs are less common than in adults. The persistence of the pain despite an estroprogestative contraception associated with non-steroidal anti-inflammatory drugs is a strong argument for the diagnosis and justifies a laparoscopic exploration. During this laparoscopy, the search for atypical lesions, which are much more common than typical ones, is essential. Biopsies of these lesions is mandatory in every patient to rule out false positives and false negatives which are common in atypical lesions. The aim of the treatment is to improve the pain. The first line of medical treatment is based on the estroprogestative contraception and non-steroidal anti-inflammatory drugs. The prescription of GnRH should be the ultimate solution because the bone reserve increases until the age of 18 to 20. The laparoscopic treatment, when required, should be as complete as possible. Early diagnosis and medical management may prevent the development of the disease. However, further studies in the teenager are essential to improve the current empirical management.
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Affiliation(s)
- N Bourdel
- Service de gynécologie-obstétrique, polyclinique Hôtel-Dieu, CHU de Clermont-Ferrand, boulevard Léon-Malfreyt, 63003 Clermont-Ferrand, France
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21
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Vercellini P, Fedele L, Aimi G, Pietropaolo G, Consonni D, Crosignani PG. Association between endometriosis stage, lesion type, patient characteristics and severity of pelvic pain symptoms: a multivariate analysis of over 1000 patients. Hum Reprod 2006; 22:266-71. [PMID: 16936305 DOI: 10.1093/humrep/del339] [Citation(s) in RCA: 318] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The association between lesion type, disease stage and severity of pain was studied in a large group of women with endometriosis to verify whether endometrial implants at different sites determine specific complaints and to evaluate the validity of the current classification system in women with symptomatic disease. METHODS A total of 1054 consecutive women with endometriosis undergoing first-line conservative or definitive surgery were included. Data on age at surgery, disease stage according to the revised American Fertility Society (AFS) classification, anatomical characteristics of endometriotic lesions, and type and severity of pain symptoms were collected and analysed by multiple logistic regression. RESULTS Minimal endometriosis was present in 319 patients, mild in 139, moderate in 292 and severe in 304. A significant inverse relationship was demonstrated between age at surgery and moderate-to-severe dysmenorrhoea, dyspareunia and non-menstrual pain. A strong association was found between posterior cul-de-sac lesions and pain at intercourse [Wald chi (2) = 17.00, P = 0.0001; odds ratio (OR) = 2.64, 95% confidence interval (CI) = 1.68-4.24]. A correlation between endometriosis stage and severity of symptoms was observed only for dysmenorrhoea (Wald chi (2) = 5.14, P = 0.02) and non-menstrual pain (Wald chi (2) = 5.63, P = 0.018). However, the point estimates of ORs were very close to unity (respectively, 1.33, 95% CI = 1.04-1.71, and 1.01, 95% CI = 1.00-1.03). CONCLUSIONS The association between endometriosis stage and severity of pelvic symptoms was marginal and inconsistent and could be demonstrated only with a major increase in study power.
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Affiliation(s)
- P Vercellini
- First Department of Obstetrics and Gynaecology, University of Milano, Italy.
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Vercellini P, Fedele L, Aimi G, De Giorgi O, Consonni D, Crosignani PG. Reproductive performance, pain recurrence and disease relapse after conservative surgical treatment for endometriosis: the predictive value of the current classification system. Hum Reprod 2006; 21:2679-85. [PMID: 16790608 DOI: 10.1093/humrep/del230] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To assess the predictive value of the current classification of endometriosis in terms of response to surgical treatment, we studied to what extent disease stage, lesion type and lesion site were associated with post-operative pregnancy rate, symptom recurrence and disease relapse. METHODS A total of 729 women with endometriosis undergoing first-line conservative laparoscopic surgery were included. Data on age at surgery, disease stage according to the revised American Fertility Society (AFS) classification, anatomical characteristics of endometriotic lesions, fertility status and types and severity of pain symptoms were collected. RESULTS Minimal endometriosis was present in 222 patients, mild in 106, moderate in 197 and severe in 204. The cumulative probability of pregnancy at 3 years from surgery in 537 infertile women was 47% (51% at stage I, 45% at stage II, 46% at stage III and 44% at stage IV; log-rank test, chi(2)3=1.50, P=0.68). The cumulative probability of moderate or severe dysmenorrhoea recurrence in 425 symptomatic subjects was 24% (32% at stage I, 24% at stage II, 21% at stage III and 19% at stage IV; log-rank test, chi2(3)=6.39, P=0.094). The cumulative probability of disease relapse was 12% (3% at stage I, 11% at stage II, 11% at stage III and 23% at stage IV; log-rank test, chi(2)3=24.95, P=0.0001). Using Cox's multivariate proportional hazards regression analysis, no association was observed between endometriosis stage or lesion type and lesion site and any of the considered study outcomes. CONCLUSIONS The current classification of endometriosis has an inadequate predictive value with regard to the major clinical outcomes.
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Affiliation(s)
- Paolo Vercellini
- First Department of Obstetrics and Gynaecology, University of Milano, Italy.
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Milingos S, Protopapas A, Kallipolitis G, Drakakis P, Loutradis D, Liapi A, Antsaklis A. Endometriosis in patients with chronic pelvic pain: is staging predictive of the efficacy of laparoscopic surgery in pain relief? Gynecol Obstet Invest 2006; 62:48-54. [PMID: 16543749 DOI: 10.1159/000092023] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2005] [Accepted: 01/13/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Endometriosis is considered an important cause of chronic pelvic pain. Despite its high prevalence, controversy still exists regarding the true association between the extent of endometriosis and the severity of symptoms. We conducted this prospective study to investigate the association between the stage of endometriosis and type and severity of pain, and to evaluate the efficacy of laparoscopic surgery in pain relief. METHODS Ninety-five patients complaining of chronic pain were diagnosed with endometriosis and were treated with laparoscopic surgery. The severity of pain was assessed in patients with an endometriosis AFS (American Fertility Society) score less than 16 (group 1) and those with an AFS score greater than or equal to 16 (group 2), preoperatively and 6 months after surgery, using a visual pain scale. Any reduction in pain scores by 2 points or more was considered to be an improvement. RESULTS Dysmenorrhea and deep dyspareunia, were significantly more frequent in patients of group 2. Preoperative pain scores were significantly higher for dysmenorrhea (p = 0.0022) and deep dyspareunia (p < 0.0001) but not for non-menstrual pain in group 2. Deep dyspareunia was correlated with the presence of dense pelvic adhesions. After surgery, dysmenorrhea improved in 43% of cases in group 1, vs. 66% of cases in group 2 (p = 0.0037). For deep dyspareunia, improvement was reported by 33% in group 1, vs. 67% in group 2 (p = 0.074). Improvement in non-menstrual pain was not significantly different between the two groups (67% vs. 56%). CONCLUSIONS Advanced endometriosis is more frequently related to dysmenorrhea and deep dypareunia in comparison to early disease. Laparoscopic surgery may offer relief or improvement in the majority of patients with endometriosis and chronic pelvic pain. Cases with advanced disease seem to benefit the most.
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Affiliation(s)
- Spyros Milingos
- First Department of Obstetrics and Gynecology, University of Athens, Alexandra Maternity Hospital, Athens, Greece
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24
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Milingos S, Protopapas A, Kallipolitis G, Drakakis P, Makrigiannakis A, Liapi A, Milingos D, Antsaklis A, Michalas S. Laparoscopic evaluation of infertile patients with chronic pelvic pain. Reprod Biomed Online 2006; 12:347-53. [PMID: 16569325 DOI: 10.1016/s1472-6483(10)61008-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In this study over a 10-year period, 1584 patients complaining of infertility of more than 1 year duration were evaluated for their laparoscopic findings in relation to the presence or not of chronic pelvic pain (CPP). Infertility was the only complaint in 1215 cases (group 1), whereas 369 patients complained of infertility and CPP (group 2). All cases underwent routine infertility investigation and pelvic ultrasonography, followed by diagnostic laparoscopy, with infertility-only cases acting as a control group. At laparoscopy 76.7% of patients with CPP were found with pelvic pathology, compared with only 42.6% of cases without CPP (P < or = 0.0001). Omental-abdominal wall adhesions, advanced endometriosis, endometriomas with adhesions, pelvic venous congestion, and hydrosalpinges with pelvic adhesions were significantly more frequent in cases with CPP. Dysmenorrhoea was the most frequent type of CPP. Cases with CPP and a negative laparoscopy were further investigated using a multidisciplinary approach. In conclusion, chronic pelvic pain can be the result of several pelvic pathologies. Infertile patients with CPP are much more frequently found with an abnormal pelvis in comparison with cases without CPP. Laparoscopy is an invaluable diagnostic tool especially for symptomatic patients and should be used early in their diagnostic infertility work-up.
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Affiliation(s)
- Spyros Milingos
- 1st Department of Obstetrics and Gynecology, University of Athens, Alexandra Hospital, Athens, Greece
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Dufournet C, Uzan C, Fauvet R, Cortez A, Siffroi JP, Daraï E. Expression of apoptosis-related proteins in peritoneal, ovarian and colorectal endometriosis. J Reprod Immunol 2005; 70:151-62. [PMID: 16378643 DOI: 10.1016/j.jri.2005.11.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2005] [Revised: 08/30/2005] [Accepted: 11/18/2005] [Indexed: 10/25/2022]
Abstract
Endometriosis is defined as the presence of endometrial glands and stroma outside the uterus. Apoptosis, a physiological process by which multicellular organisms eliminate superfluous cells, is altered in tumor tissue. Here we studied the expression of the apoptosis-related proteins p53, bcl-2, bax, p21 and fas in proliferative (n=9) and secretory (n=9) endometrium, and in peritoneal (n=11), ovarian (n=20) and colorectal (n=20) endometriosis, by qualitative and semi-quantitative immunohistochemical methods using the percentage of positive cells and HSCORE analysis. In endometrium, p53, p21 and fas expression was low, whereas bax and bcl-2 expression was elevated. Using HSCORE analysis, only bcl-2 expression varied during the menstrual cycle (48.9+/-34.2% in the proliferative phase, 11.5+/-24.7% in the secretory phase, p=0.01). Using HSCORE analysis, p53 expression was higher in ovarian endometriosis than in peritoneal (p<0.0001) and colorectal endometriosis (p=0.03). P21 expression was higher in ovarian endometriosis than in peritoneal (p=0.01) and colorectal endometriosis (p=0.01). Bcl-2 expression was lower in ovarian endometriosis than in peritoneal (p=0.0002) and colorectal endometriosis (p<0.0001). Fas expression was higher in peritoneal endometriosis than in ovarian (p=0.02) and colorectal endometriosis (p=0.008). In conclusion, these results confirm the involvement of apoptosis in the pathogenesis of endometriosis. Moreover, expression of apoptosis-related proteins varies according to the location of endometriosis suggesting the involvement of different apoptotic pathways.
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Affiliation(s)
- Charlotte Dufournet
- Service d'Anatomie Pathologie, Hôpital Tenon, AP-HP, UFR Saint Antoine, Paris VI, France
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26
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Hassa H, Tanir HM, Uray M. Symptom distribution among infertile and fertile endometriosis cases with different stages and localisations. Eur J Obstet Gynecol Reprod Biol 2005; 119:82-6. [PMID: 15734090 DOI: 10.1016/j.ejogrb.2004.07.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate endometriosis patients' symptoms and relate them to different stages and locations of endometriosis and also to fertility/infertility of the patients. STUDY DESIGN Sixty-eight patients diagnosed with endometriosis constituted the population investigated in this cross-sectional observational study, 55 and 13 of whom were diagnosed from the visual findings recorded during laparoscopy and laparotomy, respectively. All cases were categorised as early- (stages I and II) or late (stages III and IV)-stage endometriosis and as fertile or infertile endometriosis. The extent of endometriosis was further divided into peritoneal, ovarian, and ovarian and peritoneal. Symptoms of dysmenorrhoea, deep dyspareunia, dyschesia and dysuria and also depressive mood state were analysed and compared among those different groups. RESULTS Cyclic chronic pelvic pain was more relevant in late-stage endometriosis (P = 0.04). Deep dyspareunia, painful defecation, dysuria, infertility, and depressive state did not differ with stages of endometriosis or fertility status. Admission for pelvic pain of any duration was more prevalent among fertile patients with endometriosis (P = 0.008). Chronic noncyclic pelvic pain was more frequently observed in patients with fertile than in those with infertile endometriosis (P = 0.01). More cases in the fertile group experienced noncyclic pelvic pain (P = 0.04). More patients admitted with cyclic pelvic pain had ovarian or ovarian and peritoneal endometriosis than peritoneal endometriosis only (P = 0.03). Infertility was more prevalent among peritoneal endometriosis cases than among those with ovarian or peritoneal and ovarian involvement (P = 0.008). CONCLUSION Symptoms of endometriosis may predict the stage and localisation of the disease to some extent.
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Affiliation(s)
- Hikmet Hassa
- Department of Obstetrics and Gynaecology, Osmangazi University Faculty of Medicine, Meselik Kampusu, 26480 Eskisehir, Turkey
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Uzan C, Cortez A, Dufournet C, Fauvet R, Siffroi JP, Daraï E. Eutopic endometrium and peritoneal, ovarian and bowel endometriotic tissues express a different profile of matrix metalloproteinases-2, -3 and -11, and of tissue inhibitor metalloproteinases-1 and -2. Virchows Arch 2004; 445:603-9. [PMID: 15452706 DOI: 10.1007/s00428-004-1117-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2004] [Accepted: 08/05/2004] [Indexed: 10/26/2022]
Abstract
Endometriosis is subsequent to the ability of endometrial glands to invade normal tissues. Matrix metalloproteinases (MMPs)--enzymes that mediate normal tissue turnover, including endometrial breakdown during menstruation-appear to be involved in this invasive process. Here, we examined the immunohistochemical expression of MMP-2, MMP-3, MMP-11, tissue inhibitor metalloproteinase (TIMP)-1 and TIMP-2 in endometrium from women with (n=9) or without endometriosis (n=18) in comparison with peritoneal (n=20), ovarian (n=20) and colorectal endometriosis (n=20). Women with endometriosis showed decreased endometrial MMP-2 expression compared with women without endometriosis (mean+/-SD positive cells: 24.3+/-28.3% and 69.3+/-12.1%), together with loss of MMP-3 expression (0 versus 17.5%+/-20.2). MMP-11, TIMP-1 and TIMP-2 expression was similar in the two groups. Endometrial MMP-2, -3 and -11 expression and TIMP-1 and -2 expression were similar in women with endometriosis and in those with peritoneal endometriosis. MMP-2, -3 and -11 expression was higher in colorectal endometriosis than in ovarian and peritoneal endometriosis. TIMP-2 expression was lower in colorectal endometriosis (P=0.0002) and ovarian endometriotic cysts (P=0.003) than in peritoneal endometriosis. TIMP-1 expression did not vary according to the location of endometriotic lesions. These results suggest that MMP-2 and -3 and TIMP-2 may be involved in the pathogenesis of endometriosis. Interestingly, MMP-2 and -3 overexpression was related to the infiltrative nature of endometriotic lesions, with possible sequential expression from peritoneal to colorectal endometriosis.
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Affiliation(s)
- Catherine Uzan
- Service d'Anatomie Pathologie, Hôpital Tenon, AP-HP, France
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Milingos S, Protopapas A, Drakakis P, Liapi A, Loutradis D, Kallipolitis G, Milingos D, Michalas S. Laparoscopic management of patients with endometriosis and chronic pelvic pain. Ann N Y Acad Sci 2004; 997:269-73. [PMID: 14644834 DOI: 10.1196/annals.1290.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Endometriosis has been traditionally included among the most important causes of chronic pelvic pain (CPP) in women of reproductive age. The main clinical manifestations of endometriosis are dysmenorrhea, dyspareunia, and chronic nonmenstrual pain. Despite the high prevalence of endometriosis in women suffering from CPP, controversy still exists regarding the true association between the stage and extent of this peculiar disease and the severity of pain. Over the last decade, advances in endoscopic technology have enabled gynecologic surgeons to recognize many atypical appearances of the endometriotic implants not known to exist before, thus allowing their complete excision or destruction. Laparoscopic surgery may offer considerable relief in patients with endometriosis and CPP. Although cases with advanced endometriosis seem to benefit the most, we also support surgical treatment in patients with early endometriosis diagnosed using laparoscopy, as many will experience improvement in their symptoms.
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Affiliation(s)
- Spyros Milingos
- 1st Department of Obstetrics and Gynecology, University of Athens, Alexandra Maternity Hospital, 115 28 Athens, Greece
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Batt RE, Mitwally MFM. Endometriosis from thelarche to midteens: pathogenesis and prognosis, prevention and pedagogy. J Pediatr Adolesc Gynecol 2003; 16:337-47. [PMID: 14642954 DOI: 10.1016/j.jpag.2003.09.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
John Huffman, a founder of the subspecialty of pediatric and adolescent gynecology in North America, first related the diagnosis of endometriosis to thelarche. Subsequently, endometriosis was diagnosed in early puberty between thelarche and menarche. Based on solid evidence, we suggest that the theory of embryonic mullerian rests be added to currently accepted theories of pathogenesis of endometriosis. This article argues for recognition of embryonic mullerian rests as the pathogenesis of some cases of endometriosis not explained by accepted theories. Along with Huffman, we propose that thelarche be recognized as a developmental benchmark, after which endometriosis is included in the differential diagnosis of chronic pelvic pain. Thus, in an effort to refocus research and patient care to early adolescence, this review is limited to endometriosis occurring in young women from thelarche to their sixteenth birthday. Relating endometriosis to thelarche has fundamental implications for pathogenesis, early diagnosis, prognosis, treatment, education, and long-term care of adolescents.
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Affiliation(s)
- Ronald E Batt
- Department of Gynecology-Obstetrics, University at Buffalo, The State University of New York, Buffalo, New York 14086, USA.
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Fauconnier A, Chapron C, Dubuisson JB, Vieira M, Dousset B, Bréart G. Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril 2002; 78:719-26. [PMID: 12372446 DOI: 10.1016/s0015-0282(02)03331-9] [Citation(s) in RCA: 314] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate whether specific types of pelvic pain are correlated with the anatomic locations of deeply infiltrating endometriosis (DIE). DESIGN Retrospective data analysis. SETTING University tertiary referral center. PATIENT(S) Two hundred and twenty-five women with pelvic pain symptoms and DIE. INTERVENTION(S) During surgery, we recorded the anatomic locations of DIE implants and associated endometriosis. MAIN OUTCOME MEASURE(S) We studied the incidence of pelvic pain symptoms including severe dysmenorrhea, deep dyspareunia, noncyclic chronic pelvic pain, painful defecation during menstruation, urinary tract symptoms, and gastrointestinal symptoms as related to the location of DIE. RESULT(S) The frequency of severe dysmenorrhea increased with Douglas pouch adhesions and decreased with parity. The frequency of dyspareunia increased with a uterosacral ligament DIE location and decreased when it involved the bladder. The frequency of noncyclic chronic pelvic pain was higher when it involved the bowel and was lower for women who were treated for infertility. The frequency of painful defecation during menstruation was higher when DIE involved the vagina; lower urinary tract symptoms were more frequent when DIE involved the bladder and less frequent in women with a lower body mass index. Gastrointestinal symptoms were associated with bowel or vaginal DIE locations. CONCLUSION(S) The types of pelvic pain are related to the anatomic location of DIE. Knowledge of the characteristics of pelvic pain symptoms is important in the preoperative assessment of patients with suspected DIE.
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Affiliation(s)
- Arnaud Fauconnier
- Service de Chirurgie Gynécologique, Clinique Universitaire Baudelocque, CHU Cochin, Saint Vincent de Paul, La Roche-Guyon, Paris, France
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Abstract
When approaching the patient with acute pelvic pain, it is imperative to keep in mind the subtle differences each diagnosis can present with. Narrowing down pelvic pain to a specific location in the body while maintaining a high index of suspicion for acute pelvic pain emergencies will aid in a more rapid and accurate diagnosis. Bear in mind that acute pelvic pain is a clinical challenge, and although an exact diagnosis maybe elusive, emergency treatment should always be provided first and foremost despite an exact diagnosis.
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Affiliation(s)
- P A Baines
- Department of Emergency Medicine, Wake Forest University, Baptist Medical Center, Winston-Salem, North Carolina, USA
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Kwok A, Lam A, Ford R. Deeply infiltrating endometriosis: implications, diagnosis, and management. Obstet Gynecol Surv 2001; 56:168-77. [PMID: 11254153 DOI: 10.1097/00006254-200103000-00024] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Deeply infiltrating endometriosis was described in the early part of the last century. Only recently, has there become a greater awareness and understanding of this form of endometriosis aided in part by advances in laparoscopic surgical technology in techniques. The clinical implications of the disease as well as diagnosis and current management are reviewed.
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Affiliation(s)
- A Kwok
- The Women's Institute-Endosurgery, The Mater Misericordiae Hospital, North Sydney, Australia
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Abstract
OBJECTIVE To provide a review of the humoral and cellular immunology of endometriosis and to discuss the rationale for future approaches to diagnosis and treatment. DESIGN Literature survey. RESULT(S) Defective immunosurveillance in women who are destined to develop endometriosis may allow for the survival of ectopic endometrial tissue. The evidence includes endometrial cell resistance to apoptosis, perhaps through the secretion of proteins that interfere with implant recognition and/or FasL expression by stromal cells, inducing apoptosis of Fas-bearing immune cells. Although the immune response may be defective, aspects of it clearly are enhanced in endometriosis, as is seen by the generalized polyclonal B-cell autoimmune activation and secretion of immune proteins. Several cytokines, chemokines, and growth factors (including vascular growth factors) are increased in women with endometriosis. CONCLUSION(S) A complex network of locally produced cytokines modulate the growth and inflammatory behavior of ectopic endometrial implants. Proinflammatory proteins from endometriotic lesions and associated immune cells contribute to the enhanced inflammatory reaction associated with endometriosis that subserves the survival of these lesions instead of leading to their demise.
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Affiliation(s)
- D I Lebovic
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
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35
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Abstract
This paper proposes a standard definition of endometriotic disease for epidemiologic studies and suggests subject-selection strategies to increase the validity of clinic- or population-based studies of the disease. Although endometriosis can be defined simply as the presence of ectopic endometrial tissue, emerging evidence indicates that to be pathologic, such tissue must persist and progress. The proposed disease definition incorporates the concepts of persistence and progression, and its use may increase the likelihood of observing true associations in etiologic studies. Potential threats to validity of substantial magnitude exist in both clinic- and population-based epidemiologic studies of endometriosis. In clinic-based studies, control subjects (infertility clinic patients, women delivering infants, or women undergoing tubal ligation) often are not representative of the population from which the cases arose, and bias can be considerable for behavioral and hormone-related exposures. In population-based studies, substantial case underascertainment may exist, and diagnosed cases may be a biased sample of all potential cases in the population. Although neither the ideal design nor the ideal case and control groups are likely to be achievable in epidemiologic studies of endometriosis, the subject-selection strategies suggested may improve the validity of studies that are obliged to depart from the ideal.
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Affiliation(s)
- V L Holt
- Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle 98195-8080, USA
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Bodden-Heidrich R, Hilberink M, Frommer J, Stratkötter A, Rechenberger I, Bender HG, Tress W. [Not Available]. ZEITSCHRIFT FUR PSYCHOSOMATISCHE MEDIZIN UND PSYCHOTHERAPIE 1999; 45:372-89. [PMID: 11781900 DOI: 10.13109/zptm.1999.45.4.372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Endometriosis is one of the most frequent gynecological disorders in the reproductive age. Discrepancies between clinical findings and subjective Symptoms cause the question of the determing factors for the subjective experience. In the present study an hermeneutic, sense-orientated approach was employed by using qualitative methods of research. Eleven interviews with endometriosis patients were recorded on tape and transcribed, followed by an individual-case and a comparative analysis in partly deductively and inductively defined categories. The psychosexual development has been found as negatively influenced. Endometriosis patients show conflicting concepts of their sex-specific role. A found aggression conflict manifests itself in the pain Sensation, at an intrapsychic land an interpersonnel level: it influences the relations with other persons, in particular, the doctor-patient relationship. Changes of sense in the doctor-patient-relationship and recent concepts of psychosomatic disorders are discussed.
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Affiliation(s)
- R Bodden-Heidrich
- Universitäts-Frauenklinik, Heinrich-Beine-Universität, Moorenstr. 5, 40225 Düsseldorf
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37
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Abstract
The challenge of creating a satisfactory classification of endometriosis remains to be answered. The ability of the current classification schemes to predict pregnancy outcome or to aid in the management of pelvic pain is recognized to be inadequate. Further revisions of the current classification scheme are anticipated as the understanding of how endometriosis contributes to infertility and pelvic pain evolves. In any revision of the classification system, use of empirically derived weights and breakpoints to define disease stages based on outcome data in larger clinical trials should be attempted. It is also possible that additional factors such as CA-125 level or lesion characteristics may be shown to play an important role in prognosis. If so, these will need to be accounted for in the classification scheme. Careful and consistent use of the recommendations of the American Society for Reproductive Medicine classification of endometriosis subcommittee should allow for collection of data for use in further revisions. It is quite possible that a classification scheme that is designed to predict outcome with respect to pregnancy may be totally inadequate in assessing patients who have endometriosis and pelvic pain. Factors found to be important in the assessment of pelvic pain may be different from those involved with the pathophysiology of endometriosis and infertility. The AFS form suggested for use in the management of endometriosis in the presence of pelvic pain allows for recording of variables such as depth of invasion, histology, as well as documenting adjunct investigations and preoperative physical findings. Such prospective data collection and review in large centers may provide a large clinical base from which to derive empirical point scores and breakpoints in a classification scheme.
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Affiliation(s)
- K M Hoeger
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine, NY 14642, USA
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Affiliation(s)
- A H Kim
- Fertility Physicians of Northern California, Palo Alto, USA
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39
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Abstract
Endometriosis generally causes pain that is cyclic and generally responds to medication and/or surgery. When endometriosis is found coincidentally, it may need no treatment because many women have endometriosis as a self-limited disease. In other women, the biologic behavior is much more unpredictable. Severe dysmenorrhea, focal pelvic tenderness, and deep dyspareunia are suggestive of endometriosis. Diagnosis at laparoscopy includes concerns about subtle appearance, endometriosis hidden within adhesions, retroperitoneal disease, and intra-ovarian lesions. Negative laparoscopy results do not mean that patients have no endometriosis. In contrast, a response to GnRH agonists can occur in patients with no endometriosis because conditions other than endometriosis are estrogen sensitive. Coexistent disease can confuse the picture at the time of surgery. Some coexistent diseases also can cause pain that is similar to that of endometriosis. Distinguishing those patients who need no treatment from those who need intermediate or extensive treatment can be very difficult. Care is needed to ensure that patients are neither overtreated or undertreated. An integrated approach involving a multidisciplinary team is needed in some. Other patients respond to primary care techniques.
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40
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Affiliation(s)
- C A Winkel
- Department of Obstetrics and Gynecology, Georgetown University School of Medicine, Washington, DC 20007, USA
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Bodden-Heidrich R, Küppers V, Beckmann MW, Rechenberger I, Bender HG. Chronic pelvic pain syndrome (CPPS) and chronic vulvar pain syndrome (CVPS): evaluation of psychosomatic aspects. J Psychosom Obstet Gynaecol 1999; 20:145-51. [PMID: 10497757 DOI: 10.3109/01674829909075588] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The purpose of our study was to examine the chronic pelvic pain syndrome (CPPS) and the chronic vulvar pain syndrome (CVPS) as two psychosomatic gynecological syndromes. Sociodemographic data were collected from 106 CPPS and 36 CVPS in-patients (under internal and external supervision). Sixty-eight CPPS and 24 CVPS patients were examined using psychological tests (Freiburg Personality Inventory (FBI) and Giessen Test (GT)) and compared with a control group of 34 healthy women. Descriptive statistics, the chi-square test, multi-variant analyses, and regression analyses were used for statistical evaluation. There was a significantly higher incidence of sexual abuse and severe psychological disturbances in the CPPS group (p < 0.03). Sexual abuse was found to be a significant predictor of the CPP syndrome. The CPPS and CVPS patients were significantly more depressed than the control group (p < 0.03). CPPS and CVPS are two distinct psychosomatic gynecological syndromes accompanied by different psychological disturbances.
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Affiliation(s)
- R Bodden-Heidrich
- Department of Obstetrics and Gynecology, Heinrich-Heine University, Düsseldorf, Germany
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42
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Brosens I, Campo R, Gordts S. Office hydrolaparoscopy for the diagnosis of endometriosis and tubal infertility. Curr Opin Obstet Gynecol 1999; 11:371-7. [PMID: 10498023 DOI: 10.1097/00001703-199908000-00003] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Transvaginal hydrolaparoscopy has been described as an office procedure that is particularly suitable for the diagnosis of endometriosis and adhesions. It is recommended as a first line procedure in patients with infertility. The procedure is performed under local anaesthesia or sedation in an office setting. The abdominal distension is achieved by transvaginal instillation of warm saline using a combined Veress needle-trocar system. The exploration under fluid allows the inspection of the tubo-ovarian structures in their natural position and the easy identification of endometriotic lesions and adhesions in the posterior pelvis. The limitation of the inspection to the posterior pelvis is not a major problem for the diagnosis of endometriosis because exclusively anterior pelvis endometriosis is rare and of doubtful significance in infertility. Transvaginal hydrolaparoscopy can be performed in the office setting in combination with minihysteroscopy, tubal patency test and salpingoscopy, offering major advantages for the diagnosis of pelvic disease in patients with infertility.
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Affiliation(s)
- I Brosens
- Leuven Institute for Fertility and Embryology, Belgium.
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43
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Abstract
Dysmenorrhea and pelvic pain are common complaints in the adolescent population. Although most cases are primary dysmenorrhea and easily treated with NSAIDs or OCPs, pathologic causes should be considered, especially in cases not responding to standard medical management. Endometriosis is the most common finding in teenagers who do not respond to this regimen, but müllerian anomalies and musculoskeletal causes must also be considered.
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Affiliation(s)
- B Schroeder
- Department of Obstetrics and Gynecology, Allegheny University, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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Zeitoun K, Takayama K, Michael MD, Bulun SE. Stimulation of aromatase P450 promoter (II) activity in endometriosis and its inhibition in endometrium are regulated by competitive binding of steroidogenic factor-1 and chicken ovalbumin upstream promoter transcription factor to the same cis-acting element. Mol Endocrinol 1999; 13:239-53. [PMID: 9973254 DOI: 10.1210/mend.13.2.0229] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In stromal cells of endometriosis, marked levels of aromatase P450 (P450arom) mRNA and activity are present and can be vigorously stimulated by (Bu)2cAMP or PGE2 to give rise to physiologically significant estrogen biosynthesis. Since eutopic endometrial tissue or stromal cells lack P450arom expression, we studied the molecular basis for differential P450arom expression in endometriosis and eutopic endometrium. First, we demonstrated by rapid amplification of cDNA 5'-ends that P450arom expression in pelvic endometriotic lesions is regulated almost exclusively via the alternative promoter II. Then, luciferase reporter plasmids containing deletion mutations of the 5'-flanking region of promoter II were transfected into endometriotic stromal cells. We identified two critical regulatory regions for cAMP induction of promoter II activity: 1) a-214/-100 bp proximal region responsible for a 3.7-fold induction, and 2) a -517/ -214 distal region responsible for potentiation of cAMP response up to 13-fold. In the -214/-100 region, we studied eutopic endometrial and endometriotic nuclear protein binding to a nuclear receptor half-site (NRHS, AGGTCA) and an imperfect cAMP response element (TGCACGTCA). Using electrophoretic mobility shift assay, cAMP response element-binding activity in nuclear proteins from both endometriotic and eutopic endometrial cells gave rise to formation of identical DNA-protein complexes. The NRHS probe, on the other hand, formed a distinct complex with nuclear proteins from endometriotic cells, which migrated at a much faster rate compared with the complex formed with nuclear proteins from eutopic endometrial cells. Employing recombinant proteins and antibodies against steroidogenic factor-1 (SF-1) and chicken ovalbumin upstream promoter transcription factor (COUP-TF), we demonstrated that COUP-TF but not SF-1 bound to NRHS in eutopic endometrial cells, whereas SF-1 was the primary NRHS-binding protein in endometriotic cells. In fact, COUP-TF transcripts were present in both eutopic endometrial (n = 12) and endometriotic tissues (n = 8), whereas SF-1 transcripts were detected in all endometriotic tissues (n = 12), but in only 3 of 15 eutopic endometrial tissues. Moreover, we demonstrated a dose-dependent direct competition between SF-1 and COUP-TF for occupancy of the NRHS, to which SF-1 bound with a higher affinity. Finally, overexpression of SF-1 in eutopic endometrial and endometriotic cells strikingly potentiated baseline and cAMP-induced activities of -517 promoter II construct, whereas overexpression of COUP-TF almost completely abolished these activities. In conclusion, COUP-TF might be one of the factors responsible for the inhibition of P450arom expression in eutopic endometrial stromal cells, which lack SF-1 expression in the majority (80%) of the samples; in contrast, aberrant SF-1 expression in endometriotic stromal cells can override this inhibition by competing for the same DNA-binding site, which is likely to account for high levels of baseline and cAMP-induced aromatase activity.
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Affiliation(s)
- K Zeitoun
- Cecil H. Ida Green Center for Reproductive Biology Sciences, Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas 75235-9051, USA
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