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Keukens A, Veth VB, Regis M, Mijatovic V, Bongers MY, Coppus SFPJ, Maas JWM. The effect of surgery or medication on pain and quality of life in women with endometrioma. A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2024; 293:95-105. [PMID: 38134610 DOI: 10.1016/j.ejogrb.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023]
Abstract
For patients with endometrioma it is unclear what treatment: surgery and/or medication, is more effective in reducing pain and improving quality of life (QoL). This systematic review and meta- analysis aimed to provide an overview of the existing evidence on the effects of surgery and/or medication (i.e. analgesics and/or hormonal medication) on pain and QoL. A search through CENTRAL, MEDLINE and Embase was conducted. The study population had to be women treated for endometrioma. Retrospective or prospective studies reporting about QoL and/or the following types of pain were reviewed: dysmenorrhea, dyspareunia, chronic pelvic pain, and pain that was not well defined in the included article (referred to as pain). We performed a meta-analysis on mean visual analogue scale (VAS) scores and proportions of patients experiencing different types of pain over time. QoL was described narratively. Out of 11.515 articles, 76 studies including 7148 patients were included for the systematic review. The meta-analysis consisted of 52 studies including 4556 patients. No studies compared medication with surgery. And there were no studies on analgesics. Meta-analysis showed that surgery and/or medication often reduced VAS scores and proportions of all types of pain over time. Surgery and medication combined seems more effective in reducing VAS scores of pain compared to surgery alone, but not to medication alone (estimated mean difference = 0.17, p < 0.0001 and -0.98, p = 0.0339). QoL improved after medication (follow up ≤ 12 months) and QoL was unchanged or worsened after surgery and medication combined (follow up ≤ 24 months). However, these were results from a total of 5 studies. Both surgery and medication reduce endometriosis-related pain in patients with endometrioma. However, there is lack of uniform, good quality data comparing surgery with medication to draw firm conclusions. For better-informed treatment decisions, further studies including a standardized core-outcome set at fixed follow-up times, are necessary.
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Affiliation(s)
- A Keukens
- Department of Gynecology, Máxima Medical Center, Veldhoven, the Netherlands; Department of Obstetrics and Gynaecology, Maastricht University Medical Center+, the Netherlands.
| | - V B Veth
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center+, the Netherlands; GROW - School for Oncology and Reproduction, Maastricht, the Netherlands
| | - M Regis
- Department of Mathematics and Computer Science, Eindhoven University of Technology, De Zaale, Eindhoven, the Netherlands
| | - V Mijatovic
- Department of Reproductive Medicine, Academic Endometriosis Center, Amsterdam University Medical Center, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - M Y Bongers
- Department of Gynecology, Máxima Medical Center, Veldhoven, the Netherlands; GROW - School for Oncology and Reproduction, Maastricht, the Netherlands
| | - S F P J Coppus
- Department of Gynecology, Máxima Medical Center, Veldhoven, the Netherlands
| | - J W M Maas
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center+, the Netherlands; GROW - School for Oncology and Reproduction, Maastricht, the Netherlands
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Eberle A, Nguyen DB, Smith JP, Mansour FW, Krishnamurthy S, Zakhari A. Medical Management of Ovarian Endometriomas: A Systematic Review and Meta-analysis. Obstet Gynecol 2024; 143:53-66. [PMID: 37944155 DOI: 10.1097/aog.0000000000005444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To estimate the effect of medical management on the size of ovarian endometriomas. DATA SOURCE Online databases were searched from inception to October 2022, including Ovid MEDLINE, Ovid EMBASE, PubMed, EBM Reviews-Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov , and Web of Science. METHODS OF STUDY SELECTION Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we included all English-language, full-text articles that reported on change in endometrioma size (either diameter or volume) after medical interventions. Studies evaluating surgical interventions or postoperative recurrence were excluded. All screening and data extraction were performed independently by two authors. Risk of bias assessment was performed with either the Cochrane Risk of Bias Tool for randomized controlled trials or a modified Newcastle-Ottawa Scale for observational studies. TABULATION, INTEGRATION, AND RESULTS After removal of duplicates, 9,332 studies were screened, with 33 full-text articles deemed eligible for inclusion. In the meta-analysis, dienogest showed significant reduction in cyst diameter (reduction 1.32 cm, 95% CI, 0.91-1.73, eight studies, n=418 cysts) and volume (mean difference of log-transformed volume 1.35, 95% CI, 0.87-1.83, seven studies, n=282 cysts). Similarly, significant reductions were seen with the oral contraceptive pill (OCP) (1.06 cm, 95% CI, 0.59-1.53, nine studies, n=455), gonadotropin-releasing hormone (GnRH) agonists (1.17 cm, 95% CI, 0.42-1.92, four studies, n=128 cysts), norethindrone acetate (0.6 cm, 95% CI, 0.27-0.94, two studies, n=88 cysts), and danazol (1.95 cm, 95% CI, 1.18-2.73, two studies, n=34 cysts). Norethindrone acetate with aromatase inhibitor was also effective in reducing endometrioma volume (mean difference of log-transformed volume 1.47, 95% CI, 0.16-2.78, two studies, n=34 cysts). CONCLUSION Medical management with dienogest, OCPs, GnRH agonists, norethindrone acetate, norethindrone acetate with aromatase inhibitor, or danazol can reduce the size of ovarian endometriomas. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD 42022363319.
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Affiliation(s)
- Alexa Eberle
- Department of Obstetrics and Gynecology, McGill University Health Centre, Montreal, Quebec, Canada
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Ferrari F, Epis M, Casarin J, Bordi G, Gisone EB, Cattelan C, Rossetti DO, Ciravolo G, Gozzini E, Conforti J, Cromi A, Laganà AS, Ghezzi F, Odicino F. Long-term therapy with dienogest or other oral cyclic estrogen-progestogen can reduce the need for ovarian endometrioma surgery. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057241252573. [PMID: 38738634 PMCID: PMC11092536 DOI: 10.1177/17455057241252573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Almost 10% of women in reproductive age are diagnosed with ovarian endometriomas and can experience symptoms and infertility disorders. Ovarian endometriomas can be treated with medical or surgical therapy. OBJECTIVE To assess whether long-term therapy with dienogest or oral cyclic estrogen-progestogens is effective in reducing the size of ovarian endometriomas, alleviating associated symptoms, and reducing the requirement for surgery. DESIGN Prospective non-interventional cohort study. METHODS We enrolled childbearing women diagnosed with ovarian endometriomas. We collected demographic, clinical, and surgical data, including the evaluation of ovarian endometrioma-associated symptoms and pain using the visual analog scale. We grouped the women according to treatment regimen into dienogest, estrogen-progestogens, and no-treatment. Patient's assessment was performed at baseline and after 12 months evaluating the largest ovarian endometrioma diameter (in millimeters) and the associated symptoms. Furthermore, we analyzed the impact of hormonal treatment in a sub-group of women fulfilling at baseline the criteria for a first-line surgical approach (ovarian endometrioma > 30 mm with visual analog scale > 8 or ovarian endometrioma > 40 mm before assisted reproductive treatments or any ovarian endometrioma(s) > 60 mm). RESULTS We enrolled 142 patients: 62, 38, and 42 in dienogest, estrogen-progestogens, and no-treatment groups, respectively. No significant differences were found regarding baseline characteristics. After 12 months, the mean largest ovarian endometrioma diameter increased in the no-treatment group (31.1 versus 33.8; p < 0.01), while a significant reduction was registered in the dienogest (35.1 versus 25.8; p < 0.01) and estrogen-progestogens (28.4 versus 16.7; p < 0.01) groups; no significant difference in ovarian endometrioma diameter reduction between these two latter groups was noted (p = 0.18). Ovarian endometrioma-associated symptoms and pain improved in dienogest and estrogen-progestogens groups, with a significantly greater effect for dienogest than for estrogen-progestogens for dysmenorrhea (74% versus 59%; p < 0.01). In the sub-group of women eligible for first-line surgery at baseline, long-term treatment with dienogest and estrogen-progestogens reduced surgical eligibility by 30%. CONCLUSIONS Decreased mean largest ovarian endometriomas'diameter after 12 months and reduction of the need for surgical treatment by 30% were observed in dienogest and estrogen-progestogens groups. Long-term treatment with dienogest had a greater effect in alleviating dysmenorrhea and pain.
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Affiliation(s)
- Federico Ferrari
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- S.C. Ginecologia e Ostetricia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Matteo Epis
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Giulia Bordi
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Emanuele Baldo Gisone
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Chiara Cattelan
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | | | - Giuseppe Ciravolo
- S.C. Ginecologia e Ostetricia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Elisa Gozzini
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- S.C. Ginecologia e Ostetricia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Jacopo Conforti
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- S.C. Ginecologia e Ostetricia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Antonella Cromi
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, Palermo, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Franco Odicino
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- S.C. Ginecologia e Ostetricia, ASST Spedali Civili di Brescia, Brescia, Italy
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Pitner I, Mikuš M, Šprem Goldštajn M, Laganà AS, Chiantera V, Ferrari F, Shah M, D'Alterio MN, Vitale SG, Angioni S. Effects of different progesterone levels on reproductive outcomes in assisted reproductive technologies: from molecular basis to treatment strategies. Gynecol Endocrinol 2023; 39:2190806. [PMID: 36963420 DOI: 10.1080/09513590.2023.2190806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
PURPOSE The aim of this narrative review is to offer an overview about the role of progesterone levels on pregnancy outcome in patients undergoing assisted reproductive technologies (ARTs). METHODS A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science) to determine the importance of elevated progesterone levels at different stages of the cycle for pregnancy rates in the in vitro fertilization (IVF) cycle. Our review also provides information on the differences between elevated progesterone levels and their interpretation in normal and in poorly responding women. RESULTS After careful evaluation, our search strategy yielded a total of 15 included articles, showing the possible factors that may have had an impact on the increased progesterone level before human chorionic gonadotropin (HCG) injection and the different thresholds above which the pregnancy rate was lower. Furthermore, increased progesterone on cycle day 2 or 3 could serve as a marker for increased progesterone in the late follicular phase, which is associated with a lower pregnancy rate. CONCLUSION Despite the literature data that support the negative effect of elevated progesterone on fresh cycles, due to lack of randomized controlled trials, the value of measuring progesterone in daily practice is questionable. Available evidence supports the detrimental effect of elevated progesterone in different subgroups of women, although there is still the need for defining different thresholds and durations of high progesterone exposure. The need for various thresholds for different cohorts of women, the inter-assay variability is making this decision harder.
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Affiliation(s)
- Iva Pitner
- Department of Gynecology and Obstetrics, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Mislav Mikuš
- Department of Obstetrics and Gynecology, Clinical Hospital Center Zagreb, Zagreb, Croatia
| | - Marina Šprem Goldštajn
- Department of Obstetrics and Gynecology, Clinical Hospital Center Zagreb, Zagreb, Croatia
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS "Civico - Di Cristina - Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Vito Chiantera
- Unit of Gynecologic Oncology, ARNAS "Civico - Di Cristina - Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Federico Ferrari
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Mohsin Shah
- Department of Physiology, Khyber Medical University, Peshawar, Pakistan
| | - Maurizio Nicola D'Alterio
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Salvatore Giovanni Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Stefano Angioni
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
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Fernandez H, Agostini A, Baffet H, Chabbert-Buffet N, Descamps P, Estrade JP, Giraudet G, Hocke C, Salle B, Tremollieres F, Chapron C. Update on the management of endometriosis-associated pain in France. J Gynecol Obstet Hum Reprod 2023; 52:102664. [PMID: 37669732 DOI: 10.1016/j.jogoh.2023.102664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/02/2023] [Indexed: 09/07/2023]
Abstract
The French National College of Obstetricians and Gynecologists (CNGOF) published guidelines for managing endometriosis-associated pain in 2018. Given the development of new pharmacological therapies and a review that was published in 2021, most national and international guidelines now suggest a new therapeutic approach. In addition, a novel validated screening method based on patient questionnaires and analysis of 109-miRNA saliva signatures, which combines biomarkers and artificial intelligence, opens up new avenues for overcoming diagnostic challenges in patients with pelvic pain and for avoiding laparoscopic surgery when sonography and MRI are not conclusive. Dienogest (DNG) 2 mg has been a reimbursable healthcare expense in France since 2020, and, according to recent studies, it is at least as effective as combined hormonal contraception (CHC) and can be used as an alternative to CHC for first-line treatment of endometriosis-associated pain. Since 2018, the literature concerning the use of DNG has grown considerably, and the French guidelines should be modified accordingly. The levonorgestrel intrauterine system (LNG IUS) and other available progestins per os, including DNG, or the subcutaneous implant, can be offered as first-line therapy, gonadotropin-releasing hormone (GnRH) agonists with add-back therapy (ABT) as second-line therapy. Oral GnRH antagonists are promising new medical treatments for women with endometriosis-associated pain. They competitively bind to GnRH receptors in the anterior pituitary, preventing native GnRH from binding to GnRH receptors and from stimulating the secretion of luteinizing hormone and follicle-stimulating hormone. Consequently, estradiol and progesterone production is reduced. Oral GnRH antagonists will soon be on the market in France. Given their mode of action, their efficacy is comparable to that of GnRH agonists, with the advantage of oral administration and rapid action with no flare-up effect. Combination therapy with ABT is likely to allow long-term treatment with minimal impact on bone mass. GnRH antagonists with ABT may thus be offered as second-line treatment as an alternative to GnRH agonists with ABT. This article presents an update on the management of endometriosis-associated pain in women who do not have an immediate desire for pregnancy.
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Affiliation(s)
- Hervé Fernandez
- AP-HP, Gynecology and Obstetrics Department, Bicetre Hospital, GHU Sud, 78 avenue du Général Leclerc, Le Kremlin Bicetre F-94276, France; Paris Saclay University, 63 rue Gabriel Péri, Le Kremlin Bicetre F-94276, France; Centre of research in epidemiology and population health (CESP), UMR1018, Inserm, Paris Saclay University, Hôpital Paul Brousse, 16 avenue Paul Vaillant Couturier, Villejuif F-94816, France.
| | - Aubert Agostini
- A Agostini, Service de Gynécologie Obstétrique, AP-HM, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Hortense Baffet
- H Baffet, Service de Gynécologie Médicale, Orthogénie et Sexologie, CHU de Lille, université de Lille, Lille, France
| | - Nathalie Chabbert-Buffet
- N Chabbert-Buffet, Service de Gynécologie Obstétrique Médecine de la Reproduction, Centre expert en Endométriose C3E, Hôpital Tenon APHP Sorbonne Université, Paris, France
| | - Philippe Descamps
- P Descamps, Service de Gynécologie Obstétrique et Médecine de la Reproduction, CHU Angers, Centre expert en Endométriose Pays de Loire, Angers, France
| | | | | | - Claude Hocke
- C Hocké, Service de Chirurgie Gynécologique et Médecine de la Reproduction, Centre expert régional Nouvelle Aquitaine, Centre Aliénor d'Aquitaine, Université Bordeaux, Bordeaux, France
| | - Bruno Salle
- B Salle, Service de Médecine de la Reproduction, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Université Claude-Bernard Lyon 1, Bron, France
| | - Florence Tremollieres
- F Trémollieres, Centre de Ménopause, Hôpital Paule de Viguier, CHU Toulouse, Université Toulouse III, Toulouse, France
| | - Charles Chapron
- C Chapron, Service de Chirurgie Gynécologique II et Médecine de la Reproduction, AP-HP, Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Université Paris-Cité, Faculté de Médecine Paris-Centre, Paris, France
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Canis M, Guo SW. In the thicket of fears, doubts, and murky facts: some reflections on treatment modalities for endometriosis-associated pain. Hum Reprod 2023; 38:1245-1252. [PMID: 37023473 DOI: 10.1093/humrep/dead061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/15/2023] [Indexed: 04/08/2023] Open
Abstract
Endometriosis-associated pain can be managed by either surgery or hormonal therapy. The final decision as to which treatment modality to take is based on efficacy and possible complications of different treatment modalities, risk of recurrence, and the patient's wishes and preferences. But in the thicket of fears, doubts, and murky facts, the choice may ultimately be the trade-off between irrational fears and ignorance versus scientific evidence. We elaborate some pros and cons of the two treatment modalities and highlight some notable downsides of hormonal therapy, in particular the possible yet unquantified risk of long-term hormonal therapy for malignant transformation, perhaps with the only exception of combined oral contraceptives. Thus, when discussing with patients, we advocate the approach of discussing the advantages and disadvantages of all treatment options in detail, accounting for the known pros and cons with a full understanding of the predictive irrationality of human beings. For endometriosis-associated pain, surgery is definitely not a failure of medicine but, rather, a viable option, especially given the recently surfaced undercurrent of wariness and dissatisfaction with the current hormonal drugs among patients with endometriosis. Above all, there is a pressing need to fill the knowledge gap of perioperative interventions intended to reduce the risk of recurrence and to fulfill the demand for the development of safe and efficacious non-hormonal therapeutics.
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Affiliation(s)
- Michel Canis
- Department of Obstetrics Gynecology and Reproductive Medicine, CHU Clermont Ferrand, Clermont Ferrand, France
| | - Sun-Wei Guo
- Research Institute, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
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Lin SC, Li WN, Lin SC, Hou HT, Tsai YC, Lin TC, Wu MH, Tsai SJ. Targeting YAP1 ameliorates progesterone resistance in endometriosis. Hum Reprod 2023:7128246. [PMID: 37071897 DOI: 10.1093/humrep/dead071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/21/2023] [Indexed: 04/20/2023] Open
Abstract
STUDY QUESTION Does YAP1 inhibition alleviate progesterone resistance in endometriosis? SUMMARY ANSWER YAP1 inhibition reduces progesterone resistance in vitro and in vivo. WHAT IS KNOWN ALREADY Progesterone resistance not only causes treatment failure for endometriosis but also inhibits eutopic endometrial cell proliferation, dysregulates decidualization, and reduces the success rates of pregnancy. Hippo/yes-associated protein 1 (YAP1) signaling pathway plays an important role in the pathogenesis of endometriosis. STUDY DESIGN, SIZE, DURATION Paraffin-embedded tissues containing paired endometriotic and endometrial specimens (n = 42) and serum samples isolated from normal controls (n = 15) or endometriotic patients with (n = 25) or without (n = 21) prior dienogest treatment were analyzed. A mouse model of endometriosis was also used to evaluate the effects of YAP1 inhibition on progesterone resistance. PARTICIPANTS/MATERIALS, SETTING, METHODS Primary endometriotic and endometrial stromal cells treated with YAP1 inhibitor or miR-21 mimic/inhibitor were used for the in vitro studies including decidualization induction, chromatin immunoprecipitation (ChIP), and RNA immunoprecipitation. Tissue specimens and serum from human and mouse were used for immunohistochemistry staining, exosome isolation, and microRNA (miRNA) quantification, respectively. MAIN RESULTS AND THE ROLE OF CHANCE Herein, we report, by using ChIP-PCR and RNA-IP, that YAP1 inhibits progesterone receptor (PGR) expression through upregulation of miR-21-5p. Upregulation of miR-21-5p not only reduces PGR expression but also inhibits endometrial stromal cell decidualization. Indeed, levels of YAP1 and miR-21-5p are inversely correlated with the level of PGR in human endometrial samples. In contrast, knockdown of YAP1 or treatment with verteporfin (VP), a YAP1 inhibitor, reduces miR-21-5p expression, thus leading to an increase in PGR expression in ectopic endometriotic stromal cells. In the mouse model of endometriosis, treatment with VP increases PGR expression and enhances decidualization. More importantly, VP synergistically increases the treatment effect of progestin in causing the regression of endometriotic lesions and improves the decidualization capability of the endometrium. Interestingly, treatment with dienogest, a synthetic progestin, reduces YAP1 and miR-21-5p expression in human cells and in the mouse model of endometriosis. Patients who received dienogest treatment for 6 months show a significant decrease in serum extracellular vesicle-associated miR-21-5p level. LARGE SCALE DATA A public dataset (GSE51981) containing a large cohort of endometriotic tissues is available from the Gene Expression Omnibus (GEO). LIMITATIONS, REASONS FOR CAUTION A large cohort of clinical samples is needed to verify the current diagnostic value of miR-21-5p in future studies. WIDER IMPLICATIONS OF THE FINDINGS The reciprocal regulation of YAP1 and PGR suggests that combined YAP1 inhibitor and progestin may be a better therapeutic approach for treating endometriosis. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by the Ministry of Science and Technology, Taiwan (MOST-111-2636-B-006-012, MOST-111-2314-B-006-075-MY3, and MOST-106-2320-B-006-072-MY3). The authors have no conflict of interest to disclose.
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Affiliation(s)
- Shih-Chieh Lin
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wan-Ning Li
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shin-Chih Lin
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Haun-Tzu Hou
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya-Chuan Tsai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tin-Chien Lin
- Department of Obstetrics and Gynecology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Meng-Hsing Wu
- Department of Obstetrics and Gynecology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shaw-Jenq Tsai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physiology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Tayade S, Rai S, Pai H, Patel M, Makhija N. Efficacy of Dienogest in Adolescent Endometriosis: A Narrative Review. Cureus 2023; 15:e36729. [PMID: 37123753 PMCID: PMC10139672 DOI: 10.7759/cureus.36729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/20/2023] [Indexed: 03/29/2023] Open
Abstract
Teenage endometriosis is seen as a chronic condition that can worsen if untreated. Treatment objectives include relief of symptoms, prevention of disease development, and preservation of future fertility. In many regions, dienogest (DNG), an oral progestin, has emerged as a key treatment in suppressing endometriosis. The usage of DNG for endometriosis in adolescents was researched in papers published between 2015 and 2022 using PubMed and Google Scholar. A thorough search of all identified studies' reference lists and previously published literature reviews was carried out. The study's nature and geographic scope were not restricted. After reviewing these publications, the authors decided on which ones were the most pertinent in light of their personal experiences. The final study consisted of 14 studies that satisfied inclusion requirements. The trials showed that taking DNG 2 mg daily efficiently lowers endometriotic lesions, eases painful endometriosis symptoms, and improves quality-of-life indicators. In most of these investigations, DNG was shown to be safe and tolerated, with predictable and moderate side effects, good patient compliance rates, and low withdrawal rates. Although endometrioma did not enlarge while receiving treatment, significant regression was not typical. Overall, the studies found that DNG is safe and effective in reducing symptoms of endometriosis in adolescents.
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Choi SH, Kim S, Lee SW, Won S, Shim SH, Lee N, Kim MK, Jung YW, Seong SJ, Kim ML. Recurrence, Reoperation, Pregnancy Rates, and Risk Factors for Recurrence after Ovarian Endometrioma Surgery: Long-Term Follow-Up of 756 Women. Yonsei Med J 2023; 64:204-212. [PMID: 36825347 PMCID: PMC9971436 DOI: 10.3349/ymj.2022.0278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/27/2022] [Accepted: 01/11/2023] [Indexed: 02/25/2023] Open
Abstract
PURPOSE The aims of this study were to evaluate the cumulative recurrence, reoperation, and pregnancy rates after ovarian endometrioma surgery at a single institution for more than a 5-year follow-up period. MATERIALS AND METHODS This study was conducted as a retrospective chart review of patients with ovarian endometrioma who underwent surgery between January 2008 and March 2016. Study subjects included premenopausal women with at least 5 years of follow-up. Exclusion criteria were patients with stage I or II ovarian endometrioma, those who underwent hysterectomy or bilateral oophorectomy, and presence of residual ovarian lesions on the first postoperative ultrasonography at 3-6 months. Recurrence was defined as a cystic mass by ultrasonography. RESULTS A total of 756 patients were recruited. The median follow-up duration was 85.5 months (interquartile range, 71-107 months). Recurrent endometrioma was detected in 27.9% patients, and reoperation was performed in 8.3% patients. Cumulative rates at 24, 36, 60, and 120 months were 5.8%, 8.7%, 15.5% and 37.6%, respectively, for recurrence and 0.1%, 0.5%, 2.9%, and 15.1%, respectively, for reoperation. After multivariable analysis, age ≤31 years [hazard ratio (HR)=2.108; 95% confidence interval (CI)=1.522-2.921; p<0.001], no subsequent pregnancy (HR=1.851; 95% CI=1.309-2.617; p<0.001), and postoperative hormonal treatment ≤15 months (HR=2.869; 95% CI=2.088-3.941; p<0.001) were significant risk factors for recurrent endometrioma. Among 315 patients who desired pregnancy, 54.0% were able to have a successful pregnancy and delivery. CONCLUSION Considering that longer postoperative hormonal treatment is the sole modifiable factor for recurrent endometrioma, we recommend long-term hormonal treatment until subsequent pregnancy, especially in younger women.
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Affiliation(s)
- Su Hyeon Choi
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Sujin Kim
- Department of Obstetrics and Gynecology, Dong-A University Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Si Won Lee
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Seyeon Won
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - So Hyun Shim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Nara Lee
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Mi Kyoung Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Yong Wook Jung
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Mi-La Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea.
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Muzii L, Galati G, Mattei G, Chinè A, Perniola G, Di Donato V, Di Tucci C, Palaia I. Expectant, Medical, and Surgical Management of Ovarian Endometriomas. J Clin Med 2023; 12:1858. [PMID: 36902645 PMCID: PMC10003094 DOI: 10.3390/jcm12051858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/02/2023] Open
Abstract
Management options for ovarian endometriomas include expectant management, medical treatment, surgical treatment, in vitro fertilization (IVF), or a combination of the above. The choice of management depends on many clinical parameters that should be taken into consideration, the first of which is the main presenting symptom. Most patients are today referred to medical therapy as a first option in the case of associated pain, and to IVF in the case of associated infertility. When both symptoms are present, usually surgery is the preferred approach. Recently, however, surgical excision of an ovarian endometrioma has been associated with a postoperative reduction in the ovarian reserve, and recent guidelines suggest that the clinician should caution the patient as to the possible damage to the ovarian reserve in the case of surgery. However, evidence has been published as to a possible detrimental effect of the ovarian endometrioma on the ovarian reserve even if expectant management is followed. In this review, the current evidence on the conservative management of ovarian endometriomas, with particular focus on the issue of the ovarian reserve, is evaluated, and the different surgical techniques for the treatment of ovarian endometriomas are discussed.
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Affiliation(s)
- Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Giulia Galati
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Giulia Mattei
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Alessandra Chinè
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Giorgia Perniola
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Violante Di Donato
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Chiara Di Tucci
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Innocenza Palaia
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
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11
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Carrillo Torres P, Martínez-Zamora MÁ, Ros C, Rius M, Mensión E, Gracia M, Carmona F. Clinical and sonographic impact of oral contraception in patients with deep endometriosis and adenomyosis at 2 years of follow-up. Sci Rep 2023; 13:2066. [PMID: 36739298 PMCID: PMC9899265 DOI: 10.1038/s41598-023-29227-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/31/2023] [Indexed: 02/06/2023] Open
Abstract
Nowadays, combined oral contraceptives (COCs) are successfully employed for the treatment of endometriosis (END) and adenomyosis (AD) in a large proportion of patients. However, literature focusing on the clinical and sonographic response to treatment in the long-term follow-up of patients with deep endometriosis (DE) and AD is scarce. The aim of this study was to evaluate the changes in the symptoms and the sonographic exams at 12 and 24 months of follow-up in patients who had received a flexible extended COC regimen containing 2 mg of dienogest/30 μg ethinyl estradiol. This prospective, longitudinal, observational study included women diagnosed with DE and AD presenting no surgical indication and were candidates to treatment with COCs. The presence and severity of dysmenorrhea, non-menstrual pelvic pain, deep dyspareunia, dyschezia and dysuria were evaluated using the Numerical Rating Scale (NRS) at baseline, and at 12 and 24 months of treatment. Transvaginal ultrasound was also performed at these check points searching for criteria of AD and reporting the size of the DE nodules and ovarian endometriomas (OE). Sixty-four patients were included. A significant decrease in the number of patients with severe dysmenorrhea and non-menstrual pelvic pain was reported during follow-up. The mean NRS score for dysmenorrhea, non-menstrual pelvic pain, deep dyspareunia, dyschezia and dysuria was also significantly lower at follow-up. There was a significant reduction in the sonographic number and type of AD criteria during follow-up after treatment. Similarly, a significant decrease in the size of OE and uterosacral ligament involvement in DE was observed at the 12-month follow-up, with a further, albeit not statistically significant, decrease in the 12- to 24-month follow-up. Additionally, torus and rectosigmoid DE decreased in size, although the reduction was not statistically significant at any study point. This prospective study suggests a clinical and sonographic improvement after a flexible extended COC regimen in DE and AD patients, which was significant at 12 months of follow-up. The improvement was more evident in AD and OEs compared with DE. Further research with a longer follow-up, larger sample size and comparison with other treatments is needed.
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Affiliation(s)
- Pilar Carrillo Torres
- Gynaecology Department Institute Clinic of Gynaecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - M Ángeles Martínez-Zamora
- Gynaecology Department Institute Clinic of Gynaecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Universitat de Barcelona, Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), C/ Villarroel 170, 08036, Barcelona, Spain.
| | - Cristina Ros
- Gynaecology Department Institute Clinic of Gynaecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Mariona Rius
- Gynaecology Department Institute Clinic of Gynaecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Eduard Mensión
- Gynaecology Department Institute Clinic of Gynaecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Meritxell Gracia
- Gynaecology Department Institute Clinic of Gynaecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Francisco Carmona
- Gynaecology Department Institute Clinic of Gynaecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Universitat de Barcelona, Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), C/ Villarroel 170, 08036, Barcelona, Spain
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12
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Muacevic A, Adler JR, Aydın A, Yalcin Bahat P, Akça A. Effects of Dienogest Therapy on Endometriosis-Related Dysmenorrhea, Dyspareunia, and Endometrioma Size. Cureus 2023; 15:e34162. [PMID: 36843832 PMCID: PMC9949989 DOI: 10.7759/cureus.34162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Endometriosis is an estrogen-dependent chronic inflammatory disease that is defined by the presence of endometrial-like tissue outside of the uterus. The most common localization is the ovaries, and endometriosis in this location is then called an endometrioma. According to the European Society of Human Reproduction and Embryology (ESHRE) (2022) guidelines, the most commonly prescribed treatments for endometriosis include drugs that alter the hormonal milieu. Dienogest is a new generation of progestin used in the treatment of endometriosis. The aim of this study was to assess the effect of Dienogest treatment on endometrioma size and endometriosis-related pain symptoms over a six-month follow-up period. METHODS This prospective observational study was conducted at a tertiary clinic in Turkey between March 2020 and March 2021. Here, 64 patients aged 17-49 years with unilateral or bilateral endometriomas without any hormone-dependent cancers and any medical conditions contraindicating the onset of hormonal treatment, such as active venous thromboembolism, previous or current cardiovascular disease, diabetes with cardiovascular complications, current severe liver disease, and not being pregnant, were included. Endometrioma sizes were determined by transvaginal ultrasonography (TVUS). Dysmenorrhea and dyspareunia symptoms were evaluated using the visual analogue scale (VAS). Patients received Dienogest 2 mg/day continuously for six months. At the three- and six-month follow-ups, the patients were re-evaluated. RESULTS The mean endometrioma size decreased significantly from an initial measurement of 44.0 ± 13 mm to 39.5 ± 15 mm at three months and to 34.4 ± 18 mm at the six-month follow-up. The mean dysmenorrhea VAS scores before treatment, at the three-month follow-up, and at the six-month follow-up were 6.9 ± 2.6, 4.3 ± 2.8, and 3.8 ± 2.7, respectively. Dysmenorrhea VAS scores decreased significantly over the first three months (p<0.01). Similarly, the mean VAS score for dyspareunia decreased at three and six months compared with the pretreatment value (p<0.01). CONCLUSION This study shows that dienogest treatment reduced the symptoms of dysmenorrhea and dyspareunia and the size of endometriomas. However, the main significant decrease in dysmenorrhea and dyspareunia symptoms was noted in the first three months, making it a good treatment option, especially in young patients with a fertility wish.
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13
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Daniilidis A, Angioni S, Di Michele S, Dinas K, Gkrozou F, D’Alterio MN. Deep Endometriosis and Infertility: What Is the Impact of Surgery? J Clin Med 2022; 11:jcm11226727. [PMID: 36431203 PMCID: PMC9693611 DOI: 10.3390/jcm11226727] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/26/2022] [Accepted: 11/05/2022] [Indexed: 11/16/2022] Open
Abstract
In women with deep endometriosis, the spontaneous fertility rate might range from 2 to 10%. The optimal management of these women is still an area of debate. Therefore, this review aims to explore the literature on the impact of deep endometriosis surgery on reproductive outcomes and pregnancy rates in women with and without prior infertility. A total of 392 articles were identified through database searching. Twenty-three studies were eligible to be included in the review. A total of 1548 women were identified, 814 of whom became pregnant, with a mean pregnancy rate of 52.6% (95% CI 49.7-63%). Our review suggests that surgery may improve fertility outcomes. Due to the variability in the studies, it is impossible to stratify fertility outcomes of surgery by the localization of deep endometriosis. More investigations are needed to determine whether surgical management should be first-intention or limited to the failure of medically assisted reproduction treatment.
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Affiliation(s)
- Angelos Daniilidis
- Department of Obstetrics and Gynecology, Hippokratio Hospital, Aristotle University of Thessaloniki, 546 42 Thessaloniki, Greece
- Correspondence: (A.D.); (M.N.D.); Tel.: +39-07051093399 (M.N.D.)
| | - Stefano Angioni
- Department of Surgical Science, University of Cagliari, Cittadella Universitaria Blocco I, Asse Didattico Medicna P2, Monserrato, 09042 Cagliari, Italy
| | - Stefano Di Michele
- Department of Surgical Science, University of Cagliari, Cittadella Universitaria Blocco I, Asse Didattico Medicna P2, Monserrato, 09042 Cagliari, Italy
| | - Konstantinos Dinas
- Department of Obstetrics and Gynecology, Hippokratio Hospital, Aristotle University of Thessaloniki, 546 42 Thessaloniki, Greece
| | - Fani Gkrozou
- University Clinic in Obstetrics and Gynecology, University of Ioannina, 451 10 Ioannina, Greece
| | - Maurizio Nicola D’Alterio
- Department of Surgical Science, University of Cagliari, Cittadella Universitaria Blocco I, Asse Didattico Medicna P2, Monserrato, 09042 Cagliari, Italy
- Correspondence: (A.D.); (M.N.D.); Tel.: +39-07051093399 (M.N.D.)
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14
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Krakhotkin DV, Silkina MN, Chernylovskyi VA, Gayvoronskaya SA. The dienogest-related cystitis in women with endometriosis: a prospective, controlled, comparative study. J OBSTET GYNAECOL 2022; 42:2492-2497. [PMID: 35653789 DOI: 10.1080/01443615.2022.2081492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The aim of the study was to examine the severity of clinical symptoms of acute cystitis and the level bacteriuria in female patients who underwent to laparoscopic surgery followed by a postoperative administration of dienogest 2 mg and combined oral contraceptives pills (COCP). One hundred and forty five women who had a laparoscopic surgery prospectively were enrolled. Criteria inclusions were the age from 30 to 45 years old; body mass index (BMI) absence of previous hormonal therapy at least 6 month and recent performed a laparoscopy surgery for endometriosis. The women (n = 35) who had uterine myoma, abnormal coagulation profile; concomitant neoplastic diseases; chronic pelvic inflammatory disease and chronic recurrent cystitis were excluded from study. The female patients were assigned into both groups treatment: group I (n = 54) and group II (control, n = 56) who received dienogest 2 mg once daily and COCP, respectively. During follow-up three female patients of group I were withdrawn due to prolonged genital bleedings. The final analysis included 105 women. The patients of both groups had a low level of bacteriuria <103 CFU/ml without clinical symptoms of acute cystitis before treatment. The level of bacteriuria in-group I significantly increased from 102 to 106 CFU/ml whereas in-group II did not exceed 102 CFU/ml during 4 weeks of hormonal treatment. The differences of values of acute cystitis symptom score (ACSS) for differential, typical, quality of life domains were statistically significant after 4, 8 and 12 weeks of therapy in-group I compared with group II. During 3 months of hormonal treatment with dienogest 2 mg in group I, the acute cystitis developed in 10 (18.5%), in 19 (38%) and in 34 (68%) women at 4, 8 and 12 weeks of follow-up, respectively. All cases of acute cystitis in-group I were successfully treated with fosfomycin trometamol 3 g single dose or nitrofurantoin 50 mg four times a day during 5 days. We concluded that the dienogest might increase the level bacteriuria and severity of clinical symptoms of acute cystitis during a postoperative prophylaxis of endometriosis.Impact statementWhat is already known on this subject? Dienogest is a 19-nortestosterone derivative progestogen that is highly selective for progesterone receptors with high efficacy for reducing endometriosis-related pelvic pain syndrome. The administration of dienogest is a standard treatment option after laparoscopic excision of endometrial heterotopic tissue with prophylactic purpose. However, there are some adverse events, which are a cause for discontinuation.What do the results of this study add? Despite the low incidence of urinary tract infection (1-5.4%) reported in different studies this study has shown that there was a significant increase of level bacteriuria and severity of clinical symptoms of cystitis in the dienogest group.What are the implications of these findings for clinical practice and/or further research? The implications of these findings are that the administration of dienogest may lead to enhancing of clinical symptoms of cystitis and increasing bacteriuria in some women after operative treatment of endometriosis.
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Affiliation(s)
| | - Maria N Silkina
- Department of Gynecology, Emergency City Hospital, Rostov-on-Don, Russia
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15
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Vannuccini S, Clemenza S, Rossi M, Petraglia F. Hormonal treatments for endometriosis: The endocrine background. Rev Endocr Metab Disord 2022; 23:333-355. [PMID: 34405378 PMCID: PMC9156507 DOI: 10.1007/s11154-021-09666-w] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 12/25/2022]
Abstract
Endometriosis is a benign uterine disorder characterized by menstrual pain and infertility, deeply affecting women's health. It is a chronic disease and requires a long term management. Hormonal drugs are currently the most used for the medical treatment and are based on the endocrine pathogenetic aspects. Estrogen-dependency and progesterone-resistance are the key events which cause the ectopic implantation of endometrial cells, decreasing apoptosis and increasing oxidative stress, inflammation and neuroangiogenesis. Endometriotic cells express AMH, TGF-related growth factors (inhibin, activin, follistatin) CRH and stress related peptides. Endocrine and inflammatory changes explain pain and infertility, and the systemic comorbidities described in these patients, such as autoimmune (thyroiditis, arthritis, allergies), inflammatory (gastrointestinal/urinary diseases) and mental health disorders.The hormonal treatment of endometriosis aims to block of menstruation through an inhibition of hypothalamus-pituitary-ovary axis or by causing a pseudodecidualization with consequent amenorrhea, impairing the progression of endometriotic implants. GnRH agonists and antagonists are effective on endometriosis by acting on pituitary-ovarian function. Progestins are mostly used for long term treatments (dienogest, NETA, MPA) and act on multiple sites of action. Combined oral contraceptives are also used for reducing endometriosis symptoms by inhibiting ovarian function. Clinical trials are currently going on selective progesterone receptor modulators, selective estrogen receptor modulators and aromatase inhibitors. Nowadays, all these hormonal drugs are considered the first-line treatment for women with endometriosis to improve their symptoms, to postpone surgery or to prevent post-surgical disease recurrence. This review aims to provide a comprehensive state-of-the-art on the current and future hormonal treatments for endometriosis, exploring the endocrine background of the disease.
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Affiliation(s)
- Silvia Vannuccini
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Sara Clemenza
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Margherita Rossi
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Felice Petraglia
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy.
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16
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The role of dynamic thiol/disulfide homeostasis for the evaluation of oxidative stress in endometriosis patients. MARMARA MEDICAL JOURNAL 2022. [DOI: 10.5472/marumj.1120611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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17
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Caruso S, Cianci A, Iraci Sareri M, Panella M, Caruso G, Cianci S. Randomized study on the effectiveness of nomegestrol acetate plus 17β-estradiol oral contraceptive versus dienogest oral pill in women with suspected endometriosis‑associated chronic pelvic pain. BMC Womens Health 2022; 22:146. [PMID: 35538479 PMCID: PMC9092804 DOI: 10.1186/s12905-022-01737-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/14/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To evaluate the effects of a combined oral contraceptive containing 1.5 mg 17b-estradiol (E2) and 2.5 mg nomegestrol acetate (NOMAC) or 2 mg/daily dienogest (DNG) oral progestin on endometriosis-associated chronic pelvic pain (CPP) and on the quality of life (QoL) and sexual function, by a randomized study design. METHODS The E2/NOMAC group and DNG group included 99 and 98 women, respectively. The levels of CPP were measured by the visual analogic scale (VAS). The QoL scores were investigated by the Short Form-36 questionnaire (SF-36). Finally, sexual function was studied using the Female Sexual Function Index (FSFI), while sexual distress was studied by the Female Sexual Distress Scale (FSDS). The study had 3, 6 and 12-month follow-ups. RESULTS The intra-group analysis showed an improvement of the VAS score from baseline to the 12-month follow-up in the women of both groups (p < 0.001). The inter-group comparison showed a similar improvement of CPP (p = 0.06). Women on DNG had better SF-36 somatic (p < 0.01) and FSFI scores (p < 0.006) than women on E2/NOMAC at the 6- and 12-month follow-ups. CONCLUSIONS The results support the efficacy of both hormonal treatments, even if DNG was more effective than E2/NOMAC in a limited intergroup comparison.
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Affiliation(s)
- Salvatore Caruso
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy.
- Research Group for Sexology, University of Catania, Catania, Italy.
| | - Antonio Cianci
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy
- Research Group for Sexology, University of Catania, Catania, Italy
| | - Marco Iraci Sareri
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy
| | - Marco Panella
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy
| | | | - Stefano Cianci
- Department of Obstetrics and Gynecology, University of Messina, Messina, Italy
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18
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Kizilkaya Y, Ibanoglu MC, Kıykac Altinbas S, Engin-Ustun Y. A prospective study examining the effect of dienogest treatment on endometrioma size and symptoms. Gynecol Endocrinol 2022; 38:403-406. [PMID: 35319333 DOI: 10.1080/09513590.2022.2053956] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE We aimed to determine the effect of dienogest on cyst volume, symptoms, and quality of life in patients with endometrioma. METHOD This prospective cohort study included 37 patients diagnosed with endometrioma and planned for medical treatment. Subjects were treated with a 3-month oral dose of dienogest 2 mg/day. Pre-treatment and post-treatment endometriosis measurements were assessed via 3D ultrasonography, pain symptoms via 100-mm visual analog scale (VAS), and quality of life via Short Form-36. RESULTS The mean age of the patients was 36.0 ± 6.6 years. The mean endometrioma volume was significantly reduced by 31% after treatment (26.7 ± 19.7 mm3) compared to the pre-treatment volume (17.4 ± 11.2 mm3, p < .001). Post-treatment VAS scores of dysmenorrhea, dyspareunia, and chronic pelvic pain VAS values were significantly decreased by 35.5% (p < .001), 37.5% (p < .001), and 38.5% (p < .001), respectively. The mean physical function score and mental health score significantly increased by 15% (p = .009) and 28% (p < .001), respectively. CONCLUSION Our findings showed dienogest treatment at oral doses of 2 mg/day for 3 months significantly reducing the size of endometrioma, reducing pain level, and increasing quality of life in women with endometriosis.
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Affiliation(s)
- Yasemin Kizilkaya
- Department of Gynecology, Ankara Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
| | - Mujde Can Ibanoglu
- Department of Gynecology, Ankara Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
| | - Sadiman Kıykac Altinbas
- Department of Gynecology, Ankara Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
| | - Yaprak Engin-Ustun
- Department of Gynecology, Ankara Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
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19
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Management of Ovarian Endometrioma in Asymptomatic Reproductive Age Women. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2021. [DOI: 10.1007/s13669-021-00311-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Yalçın Bahat P, Yücel B, Yuksel Ozgor B, Kadiroğulları P, Topbas Selçuki NF, Çakmak K, Üreyen Özdemir E. The effect of dydrogesterone on sexual function in endometriosis. J OBSTET GYNAECOL 2021; 42:1276-1279. [PMID: 34581254 DOI: 10.1080/01443615.2021.1958765] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Endometriosis is an oestrogen-dependent chronic disease, which is commonly regarded as a disease of reproductive-aged women. We aimed to evaluate the sexual function with Female Sexual Function Index (FSFI) in women with endometriosis who received dydrogesterone for 6 months. A total of 79 women with endometriomas were recruited in the study group and received 10 mg dydrogesterone tablets orally for 6 months. FSFI and visual analog scale (VAS) scores for each patient before and after treatment were recorded. When before treatment VAS scores and after treatment VAS scores (5.7 ± 1.27, 3.97 ± 1.01, respectively) were compared, a significant decrease was observed (p = .001). A significant increase in mean orgasm scores (3.23 ± 0.6 vs. 3.57 ± 0.65, p = .01) and means satisfaction scores (3.85 ± 0.48 vs. 4.10 ± 0.38, p < .001) were observed. In addition, means desire scores were also significantly higher following treatment (p = .01). In conclusion, this study showed that FSFI scores were increased after 6 months of dydrogesterone treatment in patients with endometriosis. Desire, satisfaction, orgasm and pain scores improved significantly, and sexual dysfunction decreased after treatment.Impact statementWhat is already known on this subject? Endometriosis is a chronic inflammatory disease associated with severe dysmenorrhoea, pelvic pain, dyspareunia, painful gastrointestinal symptoms and sub-fertility are among the symptoms. These symptoms can be responsible for a significant decrease in the quality of life scores of the patients. Dydrogesterone is a synthetic progesterone derivative, which suppresses oestrogen levels and ovulation. Dydrogesterone's effect on pain relief in endometriosis patients has already been shown, but it's role on the sexual dysfunction observed in women with endometriosis has not yet been questioned.What do the results of this study add? To the best of our knowledge this is the first study showing the effects of dydrogesterone on sexual function in patients with endometriosis.What are the implications of these findings for clinical practice and/or further research? Dydrogesterone can safely be used in medical treatment of endometriosis not only for pain relief but also patients with additional complaints such as sexual dysfunction can benefit from this treatment. Future studies with larger cohorts and long-term follow-ups are needed to validate our results.
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Affiliation(s)
- Pınar Yalçın Bahat
- Department of Obstetrics and Gynecology, Istanbul Kanuni Sultan Suleyman Research and Training Hospital, Health Sciences University, İstanbul, Turkey
| | - Burak Yücel
- Department of Obstetrics and Gynecology, Istanbul Kanuni Sultan Suleyman Research and Training Hospital, Health Sciences University, İstanbul, Turkey
| | - Bahar Yuksel Ozgor
- Department of Obstetrics and Gynecology, Esenler Maternity and Children's Hospital, Istanbul, Turkey
| | - Pınar Kadiroğulları
- Department of Obstetrics and Gynecology, Acıbadem University Atakent Hospital, Istanbul, Turkey
| | - Nura Fitnat Topbas Selçuki
- Department of Obstetrics and Gynecology, Health Sciences University, Istanbul Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Kübra Çakmak
- Department of Obstetrics and Gynecology, Esenler Maternity and Children's Hospital, Istanbul, Turkey
| | - Eda Üreyen Özdemir
- Department of Obstetrics and Gynecology, Çubuk Halil Şıvgın Hospital, Ankara, Turkey
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21
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Mariani LL, Novara L, Mancarella M, Fuso L, Casula E, Biglia N. Estradiol/nomegestrol acetate as a first-line and rescue therapy for the treatment of ovarian and deep infiltrating endometriosis. Gynecol Endocrinol 2021; 37:646-649. [PMID: 33749482 DOI: 10.1080/09513590.2021.1903420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Estradiol valerate/nomegestrol acetate (E2V/NOMAC) is a new combined oral contraceptive with a good tolerability profile and low drop-out rates, which was shown to improve menstrual-related symptoms. This study aims to evaluate its effectiveness in the control of symptoms and progression of disease in women with ovarian endomestriomas and deep infiltrating endometriosis (DIE). METHODS This was a retrospective cohort study on 39 women with pelvic endometriosis treated with E2V/NOMAC. We assessed for each patient, at the beginning of treatment and after 6 months, the painful symptoms, through a global VAS (Visual Analogue Scale) index and the size of the greatest ovarian and/or deep infiltrating endometriotic lesions. RESULTS After 6 months of treatment, a significant reduction was observed for the global VAS score for pain symptoms and for the mean size of ovarian endometriomas, whereas DIE lesions did not present significant changes in mean size. CONCLUSIONS E2/NOMAC was effective in reducing pain symptoms associated with pelvic endometriosis and the size of ovarian endometriomas, whereas DIE lesions remained stable. This therapy could provide good results in the control of symptoms and disease progression in women with pelvic endometriosis.
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Affiliation(s)
- Luca Liban Mariani
- Obstetrics and Gynecology University Department, Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Italy
| | - Lorenzo Novara
- Obstetrics and Gynecology University Department, Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Italy
| | - Matteo Mancarella
- Obstetrics and Gynecology University Department, Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Italy
| | - Luca Fuso
- Obstetrics and Gynecology University Department, Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Italy
| | - Elisa Casula
- Obstetrics and Gynecology University Department, Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Italy
| | - Nicoletta Biglia
- Obstetrics and Gynecology University Department, Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Italy
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D'Alterio MN, Saponara S, D'Ancona G, Russo M, Laganà AS, Sorrentino F, Nappi L, Angioni S. Role of surgical treatment in endometriosis. Minerva Obstet Gynecol 2021; 73:317-332. [PMID: 34008386 DOI: 10.23736/s2724-606x.21.04737-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Endometriosis can take one of three forms depending on its clinical presentation and management: endometriotic ovarian cyst (ovarian endometrioma), superficial or peritoneal endometriosis and deep infiltrating endometriosis (DIE).1Among them, DIE is considered the most aggressive, and the patient is often affected by more than one type together. The therapeutic methodology should not be influenced by a combination of different types of endometriotic lesion. According to the clinical context and the patient's needs, the treatment of this pathology can be medical or surgical. Although medical therapy could improve endometriosis-associated symptoms, it never offers a definite treatment for symptomatic patients, who often require surgical treatment. The rationale behind endometriosis surgical treatment is to achieve the complete removal of all lesions through a one-step surgical procedure; to obtain promising long-term results for pelvic pain, recurrence rate, and fertility; and to protect the functionality of the involved organs. Achieving these results depends on the total removal of the pathology from the pelvis, in an attempt to preserve, as much as possible, the healthy tissues surrounding the site of the disease. The choice of a surgical approach rather than medical therapy is subject to the patient's expectations, such as pregnancy desire, the effectiveness of treatment compared to possible complications, the type of pain and its intensity, and the location and severity of the disease. In this context, surgical management using a multidisciplinary endometriosis team is an important factor for achieving good outcomes.
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Affiliation(s)
- Maurizio N D'Alterio
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy -
| | - Stefania Saponara
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Gianmarco D'Ancona
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Margherita Russo
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Antonio S Laganà
- Department of Obstetrics and Gynecology, Filippo del Ponte Hospital, University of Insubria, Varese, Italy
| | - Felice Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Stefano Angioni
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
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23
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D'Alterio MN, Giuliani C, Scicchitano F, Laganà AS, Oltolina NM, Sorrentino F, Nappi L, Orrù G, Angioni S. Possible role of microbiome in the pathogenesis of endometriosis. Minerva Obstet Gynecol 2021; 73:193-214. [PMID: 33851803 DOI: 10.23736/s2724-606x.21.04788-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION There is an urgent necessity to explore the complex pathophysiological nature of endometriosis, which may enable the rationale for new diagnostic and therapeutic strategies to be discovered. This systematic review aimed to clarify the bidirectional relationship between endometriosis and the microbiome and evaluate if the microbiome may be involved in endometriosis's pathogenesis, establishing a potential connection between the different studies. EVIDENCE ACQUISITION Studies were identified through a systematic literature search of papers that evaluated the microbiomes of human or other animal species with endometriosis and of those without in the electronic database PubMed/Medline, and Embase without a date restriction. We included all cohort studies focusing on the interaction between endometriosis and the microbiomes of humans or other mammals, evaluating if the microbiome may be involved in endometriosis's pathogenesis. EVIDENCE SYNTHESIS Endometriosis appears to be associated with elevated levels of different microorganisms across various microbiome sites. An ineffective immune response seems to play a key role in endometriosis pathogenesis, and there is some scientific proof to state that the immune response may be modulated by the microbiome. Interestingly, nine studies of our review detected species belonging to the phyla Proteobacteria, Bacteroidetes, and Negativicutes characterized by Gram-negative staining, that were significantly increased in endometriosis cohorts. CONCLUSIONS Laboratory and clinical investigations indicate that hosts' microbiome profiles with and without endometriosis can be significantly different. To further our understanding of the relationships between endometriosis and the host microbiome, more studies are necessary.
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Affiliation(s)
- Maurizio N D'Alterio
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy -
| | - Carlotta Giuliani
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Francesco Scicchitano
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Antonio S Laganà
- Department of Obstetrics and Gynecology, Filippo del Ponte Hospital, University of Insubria, Varese, Italy
| | - Noemi M Oltolina
- Department of Obstetrics and Gynecology, Filippo del Ponte Hospital, University of Insubria, Varese, Italy
| | - Felice Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Germano Orrù
- Molecular Biology Service Lab, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Stefano Angioni
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
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24
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Vignali M, Solima E, Barbera V, Becherini C, Belloni GM. Approaching ovarian endometrioma with medical therapy. Minerva Obstet Gynecol 2020; 73:215-225. [PMID: 33314904 DOI: 10.23736/s2724-606x.20.04751-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endometriosis is a chronic inflammatory gynecological disorder associated with pelvic pain symptoms and infertility. Ovarian cysts (endometriomas) are the most common localization of endometriosis in the pelvis. Considering non-invasive methods, transvaginal ultrasound has high sensitivity and specificity for endometrioma diagnosis. Laparoscopic removal of endometrioma is related to a damage to the ovarian reserve and should be limited to patients with suspicious cysts or unresponsive to medical treatment. The main goal of medical therapy of symptomatic endometrioma is the control of pain symptoms, while no benefits have been demonstrated in terms of improving fertility rates of women seeking pregnancy. The aim of medical treatment is the inhibition of ovulation, stop of menstruation and achievement of a stable hypo-hormonal milieu. Estroprogestins and progestins are indicated by guidelines as first line medications for symptomatic patients. Several hormonal treatments have been proposed for the treatment of symptomatic endometriomas. In particular, dienogest, a relatively new progestin, has shown promising results. Medical treatment should be conceived as a long-term treatment. Safety, tolerability, a low percentage of side effects and an easy route of administration are essential for patient acceptance and adherence to therapy.
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Affiliation(s)
- Michele Vignali
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy -
| | - Eugenio Solima
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| | - Valeria Barbera
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| | - Chiara Becherini
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| | - Gaia M Belloni
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
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