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Koninckx PR, Ussia A, Adamyan L, Gomel V, Martin DC. Peritoneal fluid progesterone and progesterone resistance in superficial endometriosis lesions. Hum Reprod 2021; 37:203-211. [PMID: 34849906 DOI: 10.1093/humrep/deab258] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/22/2021] [Indexed: 12/22/2022] Open
Abstract
Peritoneal fluid in ovulatory women is an ovarian exudate with higher estrogen and progesterone concentrations than in plasma. In the follicular phase, progesterone concentrations are as high as plasma concentrations in the luteal phase. After ovulation, estrogen and progesterone concentrations in the peritoneal fluid are 5-10 times higher than in plasma, both in women with and without endometriosis. The histologically proliferative aspect without secretory changes of most superficial subtle lesions is not compatible with the progesterone concentrations in the peritoneal fluid. Therefore, we have to postulate a strong progesterone resistance in these lesions. The mechanism is unclear and might be a peritoneal fluid effect in women with predisposing defects in the endometrium, or isolated endometrial glands with progesterone resistance, or subtle lesions originating from the basal endometrium: the latter hypothesis is attractive since in basal endometrium progesterone does not induce secretory changes while progesterone withdrawal, not occurring in peritoneal fluid, is required to resume mitotic activity and proliferation. Hormone concentrations in the peritoneal fluid are an important factor in understanding the medical therapy of endometriosis. The effect of oestro-progestin therapy on superficial endometriosis lesions seems to be a consequence of the decreased estrogen concentrations rather than a direct progestin effect. In conclusion, the peritoneal fluid, being a secretion product of the ovarian follicule, deserves more attention in the pathophysiology and treatment of endometriosis.
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Affiliation(s)
- Philippe R Koninckx
- Obstetrics and Gynecology, Latifa Hospital, Dubai, United Arab Emirates.,Prof Emeritus OBGYN, KULeuven, Leuven, Belgium.,University of Oxford-Hon Consultant, Obstetrics and Gynaecology, Oxford, UK.,Gemelli hospitals, Obstetrics and Gynecology, University Cattolica, Roma, Italy.,Moscow State University, Obstetrics and gynecology, Moscow, Russia.,Gruppo Italo Belga, Obstetrics and Gynecology, Villa Del Rosario Rome, Rome, Italy
| | - Anastasia Ussia
- Gemelli hospitals, Obstetrics and Gynecology, University Cattolica, Roma, Italy.,Gruppo Italo Belga, Obstetrics and Gynecology, Villa Del Rosario Rome, Rome, Italy
| | - Leila Adamyan
- Department of Operative Gynecology, Federal State Budget Institution V. I. Kulakov Research Centre for Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia; Department of Reproductive Medicine and Surgery, Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Victor Gomel
- Department of Obstetrics and Gynecology, University of British Columbia, Women's Hospital, Vancouver, British Columbia, Canada
| | - Dan C Martin
- Professor Emeritus, University of Tennessee Health Science Centre, Memphis, TN, USA.,Institutional Review Board, Virginia Commonwealth University, Richmond, VA, USA
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Cryopreservation of human oocytes, zygotes, embryos and blastocysts: A comparison study between slow freezing and ultra rapid (vitrification) methods. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2013. [DOI: 10.1016/j.mefs.2012.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Nezhat C, Hajhosseini B, King LP. Laparoscopic management of bowel endometriosis: predictors of severe disease and recurrence. JSLS 2012; 15:431-8. [PMID: 22643495 PMCID: PMC3340949 DOI: 10.4293/108680811x13176785203752] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This study suggests that laparoscopic management of bowel endometriosis can be safe and effective. Two statistically significant predictors of higher stage disease were identified that showed the need for careful surgical planning. Background and Objectives: The identification of high-stage and recurrent cases of bowel endometriosis is critical, because these cases require careful surgical planning. We aim to describe the clinical characteristics of women with bowel endometriosis, our principles in laparoscopic management of this pathology, and to identify predictors of severe disease and recurrence. Methods: This was a retrospective study of 193 patients with pathologically confirmed bowel endometriosis. Results: Predictors of higher-stage endometriosis include a history of previous laparoscopic surgery (P=.04) and a presenting complaint of abnormal uterine bleeding (P=.01). The higher the stage of endometriosis, the more likely there would be coexistent urinary tract endometriosis (P=.02), a need for enterolysis (P=.002), ovarian cystectomy (P<.001), and bowel resection (P=.01) performed during laparoscopy. Patients with higher body mass index (BMI) had significantly higher recurrence rates of endometriosis compared to those with lower BMI (P=.002). Within our cohort, 87% of our patients achieved amelioration of symptoms by the end of the first postoperative month. Conclusions: Our study confirms that laparoscopic management of bowel endometriosis is safe and effective. We found 2 statistically significant predictors of higher-stage disease that should prompt careful surgical planning. Obesity is associated with a higher rate of recurrence of endometriosis.
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Affiliation(s)
- Camran Nezhat
- Department of Obstetrics and Gynecology, Stanford University Medical Center, Palo Alto, CA, USA.
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Al-Jefout M. Brief update on endometriosis treatment. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2011. [DOI: 10.1016/j.mefs.2011.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Coagulation versus excision of primary superficial endometriosis: a 2-year follow-up. Eur J Obstet Gynecol Reprod Biol 2010; 150:195-8. [PMID: 20303642 DOI: 10.1016/j.ejogrb.2010.02.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 12/04/2009] [Accepted: 02/05/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Even the common mild forms of endometriosis can strongly affect quality of life due to dysmenorrhea, dyspareunia, dyschezia, or subfertility. We compared the effectiveness of the two laparoscopic methods, coagulation versus excision, for intraperitoneal superficial endometriosis with regard to recurrence and symptom control. STUDY DESIGN In a retrospective analysis we evaluated the postoperative follow-up of 79 patients, aged 16-42, with superficial manifestation of endometriosis (median rASRM score 9.2) operated on in the Department of Gynecology and Obstetrics at the Jena University Hospital. Forty-three patients were treated by electrocoagulation and 36 underwent sharp excision. Therapy success was evaluated by using a questionnaire after a mean follow-up of 29 months. Patients were interviewed about pain associated with endometriosis such as dysmenorrhea, dyspareunia, dyschezia and possible medical treatment after surgery. We evaluated the number of surgically proven relapses and questionnaire results using a pain score on an ordinal scale (1-5) for the three categories dysmenorrhea, dyspareunia, and dyschezia. RESULTS Both treatment methods resulted in a low number of endometriosis-related symptoms after surgical intervention and in recurrences of 2.8% in the coagulation group and 18.6% in the excision group. The recurrence rate in the coagulation group was lower (p=0.001). The coagulation group was also presented with a significantly lower postoperative pain score at our long-term follow-up (p=0.0067). CONCLUSION In cases of superficial endometriosis, laparoscopic surgery achieved low recurrence rates and good symptom control. Compared to sharp excision the use of bipolar electrocoagulation might result in fewer endometriosis-related symptoms as well as fewer relapses with need for surgical re-intervention after a more than 2-year interval. Due to the retrospective, non-randomized character of this study the results should be interpreted carefully. Further prospective studies are needed to assess the value of both surgical approaches in the treatment of endometriosis.
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Fauconnier A, Fritel X, Chapron C. [Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications]. ACTA ACUST UNITED AC 2009; 37:57-69. [PMID: 19128998 DOI: 10.1016/j.gyobfe.2008.08.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Accepted: 08/27/2008] [Indexed: 01/04/2023]
Abstract
The relationship between chronic pelvic pain symptoms and endometriosis is unclear because painful symptoms are frequent in women without this pathology, and because asymptomatic forms of endometriosis exist. Our comprehensive review attempts to clarify the links between the characteristics of lesions and the semiology of chronic pelvic pain symptoms. Based on randomized trials against placebo, endometriosis appears to be responsible for chronic pelvic pain symptoms in more than half of confirmed cases. A causal association between severe dysmenorrhoea and endometriosis is very probable. This association is independent of the macroscopic type of the lesions or their anatomical locations and may be related to recurrent cyclic microbleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhoea. There are histological and physiopathological arguments for the responsibility of deeply infiltrating endometriosis (DIE) in severe chronic pelvic pain symptoms. DIE-related pain may be in relation with compression or infiltration of nerves in the subperitoneal pelvic space by the implants. The painful symptoms caused by DIE present particular characteristics, being specific to involvement of precise anatomical locations (severe deep dyspareunia, painful defecation) or organs (functional urinary tract signs, bowel signs). They can thus be described as "location indicating pain". A precise semiological analysis of the chronic pelvic pain symptoms characteristics is useful for the diagnosis and therapeutic.
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Affiliation(s)
- A Fauconnier
- Unité 149 recherches épidémiologiques en santé périnatale et santé des femmes, Inserm, Paris, France.
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Gidoni Y, Holzer H, Tulandi T, Tan SL. Fertility preservation in patients with non-oncological conditions. Reprod Biomed Online 2008; 16:792-800. [PMID: 18549688 DOI: 10.1016/s1472-6483(10)60144-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In addition to cancers, many non-oncological conditions, including chromosomal abnormalities and autoimmune disorders, are currently treated with gonadotoxic agents that can lead to premature ovarian failure. Because of the young age of some of the women affected by these conditions, attempts to preserve fertility and ovarian function are recommended. To date, retrieval of immature oocytes followed by in-vitro maturation and vitrification has been found to be especially useful for women who cannot undergo ovarian stimulation, or when there is a contraindication.
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Affiliation(s)
- Yariv Gidoni
- Department of Obstetrics and Gynecology, McGill University, 687 Pine Avenue West, Montreal, H3A 1A1, Quebec, Canada
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D'Cruz OJ, Uckun FM. Targeting mast cells in endometriosis with janus kinase 3 inhibitor, JANEX-1. Am J Reprod Immunol 2007; 58:75-97. [PMID: 17631002 DOI: 10.1111/j.1600-0897.2007.00502.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Endometriosis (EMS) is a chronic inflammatory disease of multifactorial etiology characterized by implantation and growth of endometrial glands and stroma outside the uterine cavity. EMS is a significant public health issue as it affects 15-20% of women in their reproductive age. Clinical symptoms may include pelvic pain, dysmenorrhea, dyspareunia, pelvic/abdominal masses, and infertility. Symptomatic treatments such as surgical resection and/or hormonal suppression of ovarian function and analgesics are not as effective as desired. Consequently, there is an enormous unmet need to develop effective medical therapy capable of preventing the occurrence and recurrence of EMS without undesirable side-effects. EMS-associated intra-abdominal bleeding episodes, local inflammation, adhesions, and i.p. immunologic dysfunction leads to pelvic nociception and pelvic pain. Increasing evidence supports the involvement of allergic-type inflammation in EMS. Invasion of mast cells, degranulation, and proliferation of interstitial component are observed in endometriotic lesions. Presence of activated and degranulating mast cells within the nerve structures can contribute to the development of pain and hyperalgesia by direct effects on primary nociceptive neurons. Therefore, treatments targeting endometrial mast cells may prove effective in preventing or alleviating EMS-associated symptoms. The Janus kinase 3 (JAK3) is abundantly expressed in mast cells and is required for the full expression of high-affinity IgE receptor-mediated mast cell inflammatory sequelae. JANEX-1/WHI-P131 is a rationally designed novel JAK3 inhibitor with potent anti-inflammatory activity in several cellular and in vivo animal models of inflammation, including mouse models of peritonitis, colitis, cellulitis, sunburn, and airway inflammation with favorable toxicity and pharmacokinetic profile. We hypothesize that JAK3 inhibitors, especially JANEX-1, may prove useful to prevent or alleviate the symptoms of EMS.
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Affiliation(s)
- Osmond J D'Cruz
- Drug Discovery Program, Paradigm Pharmaceuticals, St Paul, MN 55113, USA.
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Martin DC. Hysterectomy for treatment of pain associated with endometriosis. J Minim Invasive Gynecol 2006; 13:566-72. [PMID: 17097580 DOI: 10.1016/j.jmig.2006.06.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Revised: 06/27/2006] [Accepted: 06/28/2006] [Indexed: 01/24/2023]
Abstract
The literature was searched for endometriosis and hysterectomy on PubMed and the individual search engines of the Journal of Minimally Invasive Surgery, Fertility and Sterility, BJOG, Obstetrics and Gynecology, the American Journal of Obstetrics and Gynecology, and Human Reproduction. Eighty references of interest were identified and included in this review. Analysis of hysterectomy for pain associated with endometriosis is difficult for many reasons. These include a lack of differentiation of various forms of cyclic pain from other forms of non-cyclic pain, the retrospective nature of much of the literature, and a low specificity for identifying pain. Hysterectomy for chronic non-specified pelvic pain associated with endometriosis is a successful approach in many women. It can not be determined whether this is due to intermingling of patients with and without cyclic pain or if both of these respond equally well. Focused prospective research is needed to determine whether symptoms, signs, or laboratory findings might be useful in determining more specific response patterns.
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Affiliation(s)
- Dan C Martin
- Department of Obstetrics and Gynecology, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA.
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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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Davis CJ, McMillan L. Pain in endometriosis: effectiveness of medical and surgical management. Curr Opin Obstet Gynecol 2004; 15:507-12. [PMID: 14624218 DOI: 10.1097/00001703-200312000-00009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Endometriosis is a common cause of chronic pelvic pain and has a detrimental effect on the quality of life for women affected with the condition. It is also clear that early diagnosis with prompt effective management does not always occur. This review will discuss the medical and surgical treatment options and support conclusions with randomized double blind placebo-controlled studies where possible. RECENT FINDINGS Assessment of the pelvic pain associated with endometriosis can be categorized according to its relation to the menstrual cycle. Dysmenorrhoea and ovulatory pain occur with cyclical changes, as compared with chronic non-cyclic pain and deep dyspareunia. Dyskesia and urinary pain may have a relation to the menstrual cycle. The severity of pain symptoms, as well as the effect on the woman's quality of life, should be quantified. The preoperative symptoms can be compared with the operative findings and the stage of endometriosis according to the revised American Fertility Score. SUMMARY Review of the current literature demonstrates that a combined medical and conservative surgical approach is beneficial for most women with endometriosis associated pelvic pain.
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Affiliation(s)
- Colin J Davis
- The Fertility Centre, St Bartholomews Hospital, Barts and The London NHS Trust, London, UK.
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