Endometriosis: medical therapy

Endometriosis: Necessary and Sequential Therapeutic Procedures and Guidelines

Objectives

TO define the actual guidelines about the therapy of endometriosis. Methods. A brief review of the literature for the correct diagnosis of endometriosis and the medical and surgical approach.

Results

It is well accepted that the gold standard of endometriosis diagnosis is the direct vision of the disease with laparoscopy or the presence of endometriosis implants in vagina or cervix. Staging must be performed along with the distribution, and depth and bowel involvement must be noted. Symptoms intensity is not related to the degree of endometriosis. Therapy, medical or surgical, should be chosen in relation to symptoms and the disease degree, keeping in mind that surgery is the approach that may offer better results.

Conclusions

The direct vision of the disease is the only method to obtain the correct diagnosis and an accurate staging. However, ultrasound can be helpful in cases of pelvic localization and in the follow-up of the disease. Moreover, MRI can be employed, especially in cases with particular endometriosis implant, e.g. gluteus muscle. Surgery offers the best results but some medical therapy, especially hormonal therapy, is often employed for the relief of pains.

Does gestrinone antagonize the effects of estrogen on endometrial implants upon the peritoneum of rats?

OBJECTIVE

To evaluate the effects of estrogen treatment in combination with gestrinone on an experimental rat model of endometriosis.

METHODS

Uterine transplants were attached to the peritoneum of female Wistar rats via a surgical autotransplantation technique. The implanted area was measured during the proestrus phase and after hormonal treatment. We performed morphometric analysis and examined the macroscopic and morphometric alterations of endometrial implants after hormonal treatment in ovariectomized rats.

RESULTS

The high dose of estrogen caused macroscopic increases in the endometrial implant group compared with other groups, which were similar to increases in the proestrus phase. The low dose showed morphometric development of implants, such as an increase in number of endometrial glands, leukocyte infiltration and mitosis. Gestrinone antagonized both doses of estrogen.

CONCLUSION

Our findings suggest that gestrinone antagonizes estrogen's effects on rat peritoneal endometrial implants.

Endométriose et adolescente

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.

Combined transurethral and laparoscopic partial cystectomy and robot-assisted bladder repair for the treatment of bladder endometrioma

A 40-year-old nulliparous woman with a 7-year history of progressive abdominal discomfort and lower urinary tract symptoms was diagnosed with a deeply infiltrating 4-cm bladder endometrioma. After failing conservative therapy, she was treated with simultaneous transurethral and laparoscopic partial cystectomy and robot-assisted bladder reconstruction. She remained symptom free at last follow-up.

Equivalence of the 3-month and 28-day formulations of triptorelin with regard to achievement and maintenance of medical castration in women with endometriosis

OBJECTIVE

The present study aims at demonstrating the equivalence of the 28-day and 3-month formulations of triptorelin SR (sustained release) in terms of percentage of patients achieving castration levels of estradiol (<==50 pg/mL) 84 days after treatment initiation.

DESIGN

A phase II, prospective, randomized, multicenter, open study was conducted in two parallel groups of women with endometriosis.

SETTING

Academic hospitals.

PATIENT(S)

Seventy-two women with endometriosis. were treated with a single intramuscular injection of 3-month triptorelin SR, and 74 patients were treated with one intramuscular injection of 28-day triptorelin SR every 28 days for 3 months.

INTERVENTION(S)

As part of two parallel treatment groups, 72 women were given a single intramuscular injection of 3-month triptorelin SR, and 74 women were given one intramuscular injection of 28-day triptorelin SR every 28 days for 3 months.

MAIN OUTCOME MEASURE(S)

Percentage of patients achieving castration levels of estradiol at the end of the treatment period.

RESULT(S)

Patients participated in the study until resumption of menses. Ninety-seven percent of patients given the 3-month formulation and 94% of those given the 28-day formulation were in a state of medical castration on day 84. The mean time to achieve castration was shorter for the 3-month formulation, and the duration of castration was significantly longer. The FSH and LH parameters were comparable, though not always identical.

CONCLUSION(S)

The pharmacodynamic effects of the Decapeptyl SR 3-month formulation are equivalent to those of the 28-day formulation. The 3-month formulation provides the added advantage of a longer maintenance of medical castration in women who have endometriosis.

Endometriosis from thelarche to midteens: pathogenesis and prognosis, prevention and pedagogy

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.

A pilot study of the use of low dose human menopausal gonadotropin in ovulation induction

OBJECTIVE

To evaluate the clinical efficacy of a combined regimen of follicle stimulating hormone (FSH) and low dose human menopausal gonadotropin (hMG) following GnRH agonist ultralong protocol in controlled ovarian hyperstimulation (COH) for in vitro fertilization and embryo transfer (IVF-ET).

STUDY DESIGN

IVF-ET was performed on 45 patients who had uterine or peritoneal factors, such as moderate to severe endometriosis, adenomyosis, or uterine myoma. The patients were randomized into two groups after the administration of long-acting GnRH agonist 2-4 times within a 4-week interval; highly purified FSH (FSH-HP) and hMG (Group A, n=26), FSH-HP only (Group B, n=19). hMG was administered at a fixed-dose of 75IU per day and the dose of FSH-HP was adjusted according to the patient's individual response. The results of COH and IVF-ET were assessed and compared between the two groups.

RESULTS

Serum estradiol (E2) level on hCG day was significantly higher in Group A (1418.2+/-920.2 pg/ml, mean+/-S.D.) than in Group B (678.4+/-457.8 pg/ml) (P<0.05). The clinical pregnancy rate and implantation rate tended to be higher in Group A than in Group B; 23.1% (6/26) versus 10.5% (2/19), 11.0% (9/82) versus 4.6% (3/65).

CONCLUSION

In COH for IVF-ET using GnRH agonist ultralong protocol, the combined treatment of FSH-HP and low dose hMG showed a higher serum E2 level when compared with treatment with FSH-HP alone.

Effect of endometriosis on in vitro fertilization

OBJECTIVE

To investigate the IVF outcome for patients with endometriosis.

DESIGN

Meta-analysis.

SETTING

Academic research center.

PATIENT(S)

A MEDLINE search and review of the literature were performed. Patients were classified by level of endometriosis, and controls were classified according to the indication for IVF.

INTERVENTION(S)

Bivariate analysis and multivariate logistic regression was used to estimate overall effect and control for confounding.

MAIN OUTCOME MEASURE(S)

Pregnancy rates, fertilization rate, implantation rates, and numbers of oocytes retrieved.

RESULT(S)

Twenty-two published studies were included in the overall analysis. The chance of achieving pregnancy was significantly lower for endometriosis patients (odds ratio, 0.56; 95% confidence interval, 0.44-0.70) when compared with tubal factor controls. Multivariate analysis also demonstrated a decrease in fertilization and implantation rates, and a significant decrease in the number of oocytes retrieved for endometriosis patients. Pregnancy rates for women with severe endometriosis were significantly lower than for women with mild disease (odds ratio, 0.60; 95% confidence interval, 0.42-0.87).

CONCLUSION(S)

Patients with endometriosis-associated infertility undergoing IVF respond with significantly decreased levels of all markers of reproductive process, resulting in a pregnancy rate that is almost one half that of women with other indications for IVF. These data suggest that the effect of endometriosis is not exclusively on the receptivity of the endometrium but also on the development of the oocyte and embryo.

Medroxyprogesterone acetate and dexamethasone are competitive inhibitors of different human steroidogenic enzymes

Medroxyprogesterone acetate (MPA), a widely used progestin, can suppress the hypothalamic-pituitary-gonadal axis but can also directly inhibit gonadal steroidogenesis; the success of MPA as a treatment for gonadotropin-independent sexual precocity derives from its direct action on steroidogenic tissues. Dexamethasone, a widely used glucocorticoid, can suppress the hypothalamic-pituitary-adrenal axis, but its potential effect directly on the adrenal is unclear. Previous reports suggested that these two drugs may act on the initial steps in the rodent steroidogenic pathway; therefore, we investigated their abilities to inhibit the first three human enzymes in steroidogenesis: the cholesterol side-chain cleavage enzyme (P450scc), the 17alpha-hydroxylase/17,20-lyase (P450c17), and type II 3beta-hydroxysteroid dehydrogenase/isomerase (3betaHSDII). We found no effect of either drug on P450scc in intact human choriocarcinoma JEG-3 cells. Using microsomes from yeast expressing human P450c17 or microsomes from human adrenals, we found that dexamethasone inhibited P450c17 with a Ki of 87 micromol/L, which is about 1000 times higher than typical therapeutic concentrations, but that MPA has no detectable action on P450c17. Using microsomes from yeast expressing human 3betaHSDII, we found that this enzyme has indistinguishable apparent Km values of 5.2-5.5 micromol/L and similar maximum velocities of 0.34-0.56 pmol steroid/min x microg microsomal protein for the three principal endogenous substrates, pregnenolone, 17-hydroxypregnenolone, and dehydroepiandrosterone. In this system, MPA inhibited 3betaHSDII with a Ki of 3.0 micromol/L, which is near concentrations achieved by high therapeutic doses of 5-20 mg MPA/kg x day. These data establish the mechanism of action of MPA as an inhibitor of human steroidogenesis, and are in contrast with the results of earlier studies indicating that MPA inhibited both P450c17 and 3betaHSD in rat Leydig cells. These studies establish the "humanized yeast" system as a model for studying the actions of drugs on human steroidogenic enzymes and suggest that 3betaHSDII may be an appropriate target for pharmacological interventions in human disorders characterized by androgen excess or sex steroid dependency.

Operative management of deep endometriosis infiltrating the uterosacral ligaments

STUDY OBJECTIVE

To describe and assess the efficacy of laparoscopic surgical treatment for patients with pain and deep endometriosis located on the uterosacral ligaments.

DESIGN

Retrospective analysis (Canadian Task Force classification II-2).

SETTING

University-affiliated hospital.

PATIENTS

One hundred ten consecutive women with deep endometriosis infiltrating uterosacral ligaments.

INTERVENTION

Operative laparoscopic management of endometriosis.

MEASUREMENTS AND MAIN RESULTS

Improvement was reported in 82.3% (70/85) of patients with severe dysmenorrhea and was considered satisfactory in 82.8% (58/70). Improvement also occurred in 88.2% (75/85) of women with deep dyspareunia, and was considered satisfactory in 88.0% (66/75).

CONCLUSION

Provided the surgeon is highly skilled in laparoscopy, operative laparoscopy is efficient for the treatment of painful symptoms related to deep endometriosis infiltrating uterosacral ligaments. (J Am Assoc Gynecol Laparosc 6(1):31-37, 1999)

Fertility after laparoscopic management of deep endometriosis infiltrating the uterosacral ligaments

The aim of this study was to evaluate fertility outcome after laparoscopic management of deep endometriosis infiltrating the uterosacral ligaments (USL). From January 1993 to December 1996, 30 patients who presented with no other infertility factors were treated using laparoscopic surgery. The overall rate of intrauterine pregnancy (IUP) was 50.0% (15 patients). Only one of these 15 pregnancies was obtained using in-vitro fertilization techniques (IVF). The cumulative IUP rate for the 14 pregnancies which occurred spontaneously was 48.5% at 12 months (95% confidence interval 28.3-68.7). The rate of spontaneous pregnancies was not significantly correlated with the revised American Fertility Society (rAFS) classification. The rate of IUP was 47.0% (eight cases) for patients with stage I or II endometriosis and 46.1% (six cases) for the patients presenting stage III or IV endometriosis (not significant). These encouraging preliminary results show that in a context of infertility it is reasonable to associate classic treatment for endometriosis (e.g. lysis, i.p. cystectomy, biopolar coagulation of superficial peritoneal endometriotic lesions) with resection of deep endometriotic lesions infiltrating the USL. Apart from the benefit with respect to the pain symptoms from which these patients suffer, it is possible to use laparoscopic surgery with substantial retroperitoneal dissection and enable half of the patients to become pregnant. These results also raise the question of the influence of deep endometriotic lesions on infertility.

Fertility-disrupting potential of synthetic peptides derived from the beta-subunit of follicle-stimulating hormone

PROBLEM

Hormone immunoneutralization is hampered by immunologic cross-reactivity caused by close-sequence homology between related molecules. One solution is to use smaller fragments to induce antibodies of greater specificity.

METHOD OF STUDY

A number of peptides selected from beta-follicle-stimulating hormone (FSH) were conjugated to tetanus toxoid and were used to immunize female rats. The antisera were examined for FSH cross-reactivity by immunoassays and in an in vitro bioassay.

RESULTS

In the immunoassays, the antisera did not react with FSH but did react with their respective peptides. In the bioassay, sera from VYKDPARPC- and CDSLYTYP-immunized animals inhibited FSH-receptor interaction by 73% and 68%, respectively. These animals also showed reduced estradiol levels. Sequences were synthesized around VYKDPARPC and were tested on a FSH-receptor-bearing Chinese hamster ovary cell line. LVYKDPARPC, VYKDPARPC, YKDPARPIC, CLVYKDPARP, and LVYKDPARP inhibited FSH-receptor interaction by greater than 50%. In female mice, TRDLVYKDPARPKI and LVYKDPARP disrupted estrous cycling in all animals; LVYKDPARPC and CLVYKDPARP disrupted cycling in three of five animals, whereas VYKDPARPC disrupted cycling in one of four animals.

CONCLUSIONS

Peptides from two areas of beta-FSH (VYKDPARP and DSLYTYP) were shown to raise FSH-neutralizing antibodies, which were able to suppress estradiol levels. An additional leucine residue to VYKDPARP greatly enhanced the peptide's ability to inhibit FSH-receptor binding and caused fertility disruption in vivo.

Cost comparisons between nafarelin and leuprolide in the treatment of endometriosis

The objective of this study was to compare the cost and effectiveness of nafarelin versus leuprolide in the treatment of endometriosis. To compare the economic impact of treating endometriosis with leuprolide or nafarelin and to facilitate cost comparisons between the two, we statistically analyzed information concerning the costs of medications for the treatment of endometriosis, outpatient services, and management of adverse effects, as well as other related costs. A national claims database, MarketScan, was used to obtain data on patients with a principal diagnosis of endometriosis who were treated with either leuprolide or nafarelin. During the calendar years 1992-1994, 114 patients with endometriosis had claims for nafarelin, and 343 had claims for leuprolide. There were no significant differences between nafarelin and leuprolide recipients with respect to demographic variables, types of concomitant drug used, types of outpatient service received, or major outpatient diagnostic categorization. In 1994 dollars, the cost of using leuprolide was $326.7 greater than that of using nafarelin. The results of this study suggest that nafarelin is a less expensive alternative to leuprolide for the treatment of endometriosis.

Laser laparoscopic surgery in the treatment of ovarian endometriomas

STUDY OBJECTIVE

To assess the efficacy of laser laparoscopic photocoagulation of endometriomas (2-18 cm) in patients with pain, infertility, or a combination of the two.

DESIGN

Retrospective review of all patients with endometriomas from June 1, 1983, to December 31, 1993.

SETTING

Department of gynecology and obstetrics at a district general hospital and national training center in minimal access surgery.

PATIENTS

One hundred sixty-five women with large endometriomas present at the time of laser laparoscopy.

INTERVENTIONS

Carbon dioxide laser or potassium-titanyl-phosphate laser laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Ninety (74%) of 122 patients reported improvement or resolution of pain; and 30 of 66 achieved a pregnancy, for a cumulative conception rate of 45%.

CONCLUSION

Laser laparoscopy is a practical, safe, and effective technique for the management of large ovarian endometriomas.

Goserelin depot versus danazol in the treatment of endometriosis the Australian/New Zealand experience

A multicentre, open, randomized comparison of depot goserelin versus danazol to treat endometriosis was undertaken in 9 Australian/New Zealand centres. The study compared the effects of the 2 drugs on subjective and objective parameters in women with symptomatic and/or infertility associated endometriosis. The duration of treatment was 24 weeks with either depot goserelin acetate, 3.6 mg, subcutaneously at 4-weekly intervals or danazol, 600 mg/day. As shown in previous studies, depot goserelin and danazol were equally effective in reducing endometriosis scores and pain. Patients in our study showed considerably more intolerance of study drugs, particularly danazol, than women in American and European reports: 19 of 36 women randomized to danazol in our study failed to complete 6 months therapy, because of adverse events (9/36) or because of unwillingness to continue with therapy (8/36). Consumer satisfaction with medical treatment for endometriosis was an important issue in this study.