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Marquardt RM, Tran DN, Lessey BA, Rahman MS, Jeong JW. Epigenetic Dysregulation in Endometriosis: Implications for Pathophysiology and Therapeutics. Endocr Rev 2023; 44:1074-1095. [PMID: 37409951 PMCID: PMC10638603 DOI: 10.1210/endrev/bnad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 02/15/2023] [Accepted: 07/05/2023] [Indexed: 07/07/2023]
Abstract
Endometriosis is a prevalent gynecological condition associated with pelvic pain and infertility. Despite more than a century of research, the etiology of endometriosis still eludes scientific consensus. This lack of clarity has resulted in suboptimal prevention, diagnosis, and treatment options. Evidence of genetic contributors to endometriosis is interesting but limited; however, significant progress has been made in recent years in identifying an epigenetic role in the pathogenesis of endometriosis through clinical studies, in vitro cell culture experiments, and in vivo animal models. The predominant findings include endometriosis-related differential expression of DNA methyltransferases and demethylases, histone deacetylases, methyltransferases, and demethylases, and regulators of chromatin architecture. There is also an emerging role for miRNAs in controlling epigenetic regulators in the endometrium and endometriosis. Changes in these epigenetic regulators result in differential chromatin organization and DNA methylation, with consequences for gene expression independent of a genetic sequence. Epigenetically altered expression of genes related to steroid hormone production and signaling, immune regulation, and endometrial cell identity and function have all been identified and appear to play into the pathophysiological mechanisms of endometriosis and resulting infertility. This review summarizes and critically discusses early seminal findings, the ever-growing recent evidence of epigenetic contributions to the pathophysiology of endometriosis, and implications for proposed epigenetically targeted therapeutics.
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Affiliation(s)
- Ryan M Marquardt
- Department of Obstetrics, Gynecology & Reproductive Biology, Michigan State University, Grand Rapids, MI, USA
| | - Dinh Nam Tran
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, Columbia, MO, USA
| | - Bruce A Lessey
- Department of Obstetrics and Gynecology, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Md Saidur Rahman
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, Columbia, MO, USA
| | - Jae-Wook Jeong
- Department of Obstetrics, Gynecology and Women's Health, University of Missouri, Columbia, MO, USA
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da Costa Pinheiro DJP, Pereira AMG, Antonini M, Maria Albuquerque Salgado I, Dias AT, Lopes RGC. Tolerability of endometriosis medical treatment: a comparison between combined hormonal contraceptives and progestins. BMC Womens Health 2023; 23:510. [PMID: 37741998 PMCID: PMC10517511 DOI: 10.1186/s12905-023-02647-y] [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: 03/07/2023] [Accepted: 09/10/2023] [Indexed: 09/25/2023] Open
Abstract
Endometriosis is a chronic inflammatory disease that occurs in women of reproductive age. Much of the treatment involves hormone therapy that suppresses the proliferation of endometriosis lesions.Objective To compare discontinuation rates of pharmacological treatment with estrogen-progestins and progestins medications. The secondary objective is to evaluate the main side effects of these drugs in patients with endometriosis.Methods This retrospective study analyzed data from 330 patients who attended the Hospital of the State Public Servant of São Paulo from August 1999 to September 2020 and received pharmacological treatment for endometriosis. The data were obtained by review of the files of medical appointments with specialized staff.Results The median treatment time was 18 months, ranging from 1 to 168 months, and 177 patients interrupted the proposed treatment. The combined contraceptives with estrogens and progestins were significantly linked to treatment interruption, with a relative risk of 1,99 (p = 0,005). The most important side effects that resulted in treatment interruption were pain persistence (p = 0,043), weight gain (p = 0,017) and spotting (p < 0,001).
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Affiliation(s)
- Denise Joffily Pereira da Costa Pinheiro
- Hospital Do Servidor Público Estadual - Francisco Morato de Oliveira (HSPE-FMO), Rua Pedro de Toledo 1800, São Paulo, SP 04029000 Brazil
- CEDEP – Instituto de Assistência Médica ao Servidor Público Estadual (IAMSPE), São Paulo, Brazil
| | - Ana Maria Gomes Pereira
- Hospital Do Servidor Público Estadual - Francisco Morato de Oliveira (HSPE-FMO), Rua Pedro de Toledo 1800, São Paulo, SP 04029000 Brazil
| | - Marcelo Antonini
- Hospital Do Servidor Público Estadual - Francisco Morato de Oliveira (HSPE-FMO), Rua Pedro de Toledo 1800, São Paulo, SP 04029000 Brazil
| | - Isabella Maria Albuquerque Salgado
- Hospital Do Servidor Público Estadual - Francisco Morato de Oliveira (HSPE-FMO), Rua Pedro de Toledo 1800, São Paulo, SP 04029000 Brazil
| | - Alexandre Torchio Dias
- CEDEP – Instituto de Assistência Médica ao Servidor Público Estadual (IAMSPE), São Paulo, Brazil
| | - Reginaldo Guedes Coelho Lopes
- Hospital Do Servidor Público Estadual - Francisco Morato de Oliveira (HSPE-FMO), Rua Pedro de Toledo 1800, São Paulo, SP 04029000 Brazil
- CEDEP – Instituto de Assistência Médica ao Servidor Público Estadual (IAMSPE), São Paulo, Brazil
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3
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Clemenza S, Capezzuoli T, Eren E, Garcia Garcia JM, Vannuccini S, Petraglia F. Progesterone receptor ligands for the treatment of endometriosis. Minerva Obstet Gynecol 2023; 75:288-297. [PMID: 36255163 DOI: 10.23736/s2724-606x.22.05157-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Estrogen dependence and progesterone resistance play a crucial role in the origin and development of endometriosis. Therefore, hormonal therapies are currently the most effective treatment. Progestins are considered the first-line approach, especially for a long-term management. Progestins are synthetic compounds that mimic the effects of progesterone by binding progesterone receptors. Continuous use of progestins leads to the suppression of ovarian steroidogenesis with anovulation and low serum levels of ovarian steroids, causing endometrial pseudodecidualization. Moreover, they act by interfering on several endometriosis pathogenetic pathways, decreasing inflammation, provoking apoptosis in endometriotic cells, stimulating atrophy or regression of endometrial lesions, inhibiting angiogenesis, and decreasing expression of metalloproteinases, thus diminishing the invasiveness of endometriotic implants. Progestins are effective for pain relief and improvement of the quality of life (QoL). The side effects are limited, and the compounds are available in different formulations and routes of administration and represent, in most cases, an inexpensive treatment option. Dienogest, Medroxyprogesterone acetate and Norethisterone acetate are the labeled progestins for endometriosis, but other progestins, such as Dyhidrogesterone, Levonorgestrel and Desogestrel, have been shown to be effective in the treatment of endometriosis-associated pain. The present review aims to describe the available and emerging evidences on progestins used for the treatment of endometriosis.
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Affiliation(s)
- Sara Clemenza
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Tommaso Capezzuoli
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Ecem Eren
- Department of Obstetrics and Gynecology, Bakırköy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Türkiye
| | - Jose M Garcia Garcia
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Silvia Vannuccini
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Felice Petraglia
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy -
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Chen LH, Lo WC, Huang HY, Wu HM. A Lifelong Impact on Endometriosis: Pathophysiology and Pharmacological Treatment. Int J Mol Sci 2023; 24:ijms24087503. [PMID: 37108664 PMCID: PMC10139092 DOI: 10.3390/ijms24087503] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/06/2023] [Accepted: 04/16/2023] [Indexed: 04/29/2023] Open
Abstract
Endometriosis is a chronic inflammatory disease associated with bothersome symptoms in premenopausal women and is complicated with long-term systemic impacts in the post-menopausal stage. It is generally defined by the presence of endometrial-like tissue outside the uterine cavity, which causes menstrual disorders, chronic pelvic pain, and infertility. Endometriotic lesions can also spread and grow in extra-pelvic sites; the chronic inflammatory status can cause systemic effects, including metabolic disorder, immune dysregulation, and cardiovascular diseases. The uncertain etiologies of endometriosis and their diverse presentations limit the treatment efficacy. High recurrence risk and intolerable side effects result in poor compliance. Current studies for endometriosis have paid attention to the advances in hormonal, neurological, and immunological approaches to the pathophysiology and their potential pharmacological intervention. Here we provide an overview of the lifelong impacts of endometriosis and summarize the updated consensus on therapeutic strategies.
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Affiliation(s)
- Liang-Hsuan Chen
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Wei-Che Lo
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Hong-Yuan Huang
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Hsien-Ming Wu
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
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Seckin KD, Kadirogullari P. Is dienogest a convenient treatment option for cesarean scar endometriosis or should it be treated surgically? Eur J Obstet Gynecol Reprod Biol 2023; 282:110-115. [PMID: 36706661 DOI: 10.1016/j.ejogrb.2023.01.025] [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: 09/12/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Endometriosis-related conditions such as subcutaneous endometriosis have been frequently seen in recent years, and dienogest or surgical excision is generally preferred as a treatment option. Our aim in this study is to determine which treatment option will be more effective in reducing the symptoms of patients with cesarean scar endometriosis. Study design This prospective study was performed with 21 patients diagnosed with cesarean scar endometriosis. The demographic features of the patients, lesion sizes before and after medical and surgical treatment, VAS scores and Ca-125 levels were recorded. VAS scores and lesion sizes were compared before-after medical treatment and before-after surgery in same group. RESULTS A total of 18 women were identified, with a mean age of 32.3 ± 5.7 years. No significant decrease in lesion size was observed in the 1st and 6th-month controls after the use of dienogest (p > 0,05), while a significant decrease in VAS scores was detected (p < 0,05). After surgery, the decrease in both lesion size and VAS scores was found statistically significant (p < 0,05). CONCLUSION Dienogest, which is frequently used in the medical treatment of pelvic and ovarian endometriosis, reduces pain minimally in cesarean scar endometriosis but does not provide a change in lesion size. Therefore, surgical treatment of cesarean scar endometriosis seems to be more effective in reducing pain and decreasing the size of the lesions.
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Affiliation(s)
- Kerem Doga Seckin
- Istinye University, Department of Obstetrics and Gynecology, Istanbul, Turkey.
| | - Pinar Kadirogullari
- Acıbadem University Atakent Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
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Capezzuoli T, Rossi M, La Torre F, Vannuccini S, Petraglia F. Hormonal drugs for the treatment of endometriosis. Curr Opin Pharmacol 2022; 67:102311. [PMID: 36279764 DOI: 10.1016/j.coph.2022.102311] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 01/25/2023]
Abstract
In the past, the primary approach for the treatment of endometriosis was represented by surgery; however, after the introduction of non-invasive diagnosis of endometriosis with the development of imaging technologies, medical treatment became the preferred approach, particularly in young patients. Hormonal drugs, by blocking menstruation, are the most effective for the treatment of endometriosis-related pain, independently of phenotype (ovarian, deep, or superficial endometriosis). Gonadotropin-releasing hormone analogs and oral antagonists act on hypothalamus-pituitary-ovary axis inducing iatrogenic menopause, thus reducing dysmenorrhea and all pain symptoms. The side effects, such as hot flushes and bone loss, may be reduced by an add-back therapy. However, the cost in terms of women's health remains high in view of a long-term treatment. Progestins are considered the first-line treatment, highly effective, and with reduced side effects. In addition to the well-known and largely used Norethisterone acetate and Medroxyprogesterone acetate, recently Dienogest has become one of the most used drugs in all endometriosis phenotypes for long-term treatment. Besides, Intrauterine levornogestrel or subcutaneous etonogestrel are valid alternative for long-term treatment.
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Affiliation(s)
- Tommaso Capezzuoli
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Margherita Rossi
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Francesco La Torre
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Silvia Vannuccini
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Felice Petraglia
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy.
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Buggio L, Dridi D, Barbara G, Merli CEE, Cetera GE, Vercellini P. Novel pharmacological therapies for the treatment of endometriosis. Expert Rev Clin Pharmacol 2022; 15:1039-1052. [PMID: 36000243 DOI: 10.1080/17512433.2022.2117155] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Endometriosis is a chronic, estrogen-dependent, inflammatory disease associated with pelvic pain, infertility, impaired sexual function, and psychological suffering. Therefore, tailored patient management appears of primary importance to address specific issues and identify the appropriate treatment for each woman. Over the years, abundant research has been carried out with the objective to find new therapeutic approaches for this multifaceted disease. AREAS COVERED This narrative review aims to present the latest advances in the pharmacological management of endometriosis. In particular, the potential role of GnRH antagonists, selective progesterone receptor modulators (SPRMs), and selective estrogen receptors modulators (SERMs) will be discussed. We performed a literature search in PubMed and Embase, and selected the best quality evidence, giving preference to the most recent and definitive original articles and reviews. EXPERT OPINION Medical therapy represents the cornerstone of endometriosis management, although few advances have been made in the last decade. Most studies have focused on the evaluation of the efficacy and safety of GnRH antagonists (plus add-back therapy in cases of prolonged treatment), which should be used as second-line treatment options in selected cases (i.e. non-responders to first-line treatments). Further studies are needed to identify the ideal treatment for women with endometriosis.
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Affiliation(s)
- Laura Buggio
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy
| | - Dhouha Dridi
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy
| | - Giussy Barbara
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy
| | - C E E Merli
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy
| | - Giulia Emily Cetera
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy
| | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy
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Zhao H, Wu L, Yang B, Shang H. Midgut malrotation presenting with hyperemesis gravidarum: A case report. Medicine (Baltimore) 2022; 101:e29670. [PMID: 35905251 PMCID: PMC9333550 DOI: 10.1097/md.0000000000029670] [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] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Midgut malrotation is a rare congenital abnormality resulting from failure of complete intestinal rotation and subsequent fixation during early fetal development. There appeared to be no obvious symptoms in most patients, and a few patients may exhibit symptoms similar to hyperemesis gravidarum, such as nausea and vomiting. Here, we present a case of midgut malrotation presenting as hyperemesis gravidarum. PATIENT CONCERNS A 27-year-old woman with an intrauterine pregnancy of 27 + 6 weeks complained of severe nausea and vomiting for 2 weeks. DIAGNOSIS Magnetic resonance imaging showed obvious dilatation in the proximal part of the duodenum and gastric cavity and the absence of a duodenal path dorsal to the superior mesenteric artery, which was diagnosed as midgut malrotation. INTERVENTIONS Considering that the patient's vital signs were stable, without manifestation of peritonitis or the risks of surgery to the fetus, conservative treatment was adopted. Unfortunately, the fetus developed severe hydrocephalus at 32 weeks. The patient and her family decided to abandon the fetus, and a mid-trimester-induced abortion was performed. OUTCOMES The related symptoms completely disappeared after delivery, and the relevant examination after discharge also confirmed the presence of midgut malrotation without gastrointestinal discomfort within 1 year after delivery. LESSONS Midgut malrotation can be considered as a differential diagnosis of hyperemesis gravidarum. Conservative treatment under close monitoring is desirable in pregnant women diagnosed with midgut malrotation.
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Affiliation(s)
- Hongjiang Zhao
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
- Department of Gynecology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Linzhen Wu
- Department of Obstetrics, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bin Yang
- Department of Radiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongkai Shang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
- Department of Gynecology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Hongkai Shang, Department of Gynecology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China. (e-mail: )
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Ambacher K, Secter M, Sanders AP. The use of progestin subdermal implants in the management of endometriosis-related pain symptoms and quality of life: a systematic review. Curr Med Res Opin 2022; 38:479-486. [PMID: 35048754 DOI: 10.1080/03007995.2022.2031144] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The purpose of this systematic review is to evaluate the evidence for the use of progestin subdermal implants for the treatment of endometriosis-related pain symptoms and quality of life. METHODS A literature search of PubMed, Ovid (MEDLINE and EMBASE), and Web of Science was performed from inception to December 2020. In addition, a targeted search of cited references was also performed. Our search identified 330 articles of which 17 were deemed eligible for full-text review. Eligible studies included randomized control trials, observational studies, and case series with at least 5 cases, investigating the effect of progestin subdermal implants on endometriosis-related pain scores in women of reproductive age with a clinical, radiologic, or surgical diagnosis of endometriosis. Six articles were excluded after the full-text screen. RESULTS Eleven articles describing a total of 335 patients were eligible for inclusion. Across all studies, etonogestrel- and segesterone-releasing progestin subdermal implants improved VAS pain scores for cyclic pelvic pain/dysmenorrhea (VAS at baseline ranged from 6.1 to 7.5 cm and after treatment from 1.7 to 4.9 cm, n = 121), non-cyclic pelvic pain (baseline VAS 7.2-7.6 cm and after treatment 2.0-3.7 cm, n = 96) and dyspareunia (baseline VAS 1.61-8.3 cm and after treatment 1.0-7.1 cm, n = 87). Symptom improvement with the progestin subdermal implant was equivalent to treatment with depot medroxyprogesterone acetate (DMPA; average baseline VAS 6.5 and after DMPA treatment 3.0, compared to 2.0 after treatment with the implant) or the 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS; baseline cyclic and non-cyclic pain scores 7.3 and 7.4 respectively decreased to 1.9 and 1.9 after LNG-IUS treatment). Improvements were also demonstrated in quality-of-life scores (average improvement of 36% in all domains of the Endometriosis Health Profile-30 and significant improvements in social functioning, general health, bodily pain, vitality and mental health domains on the Short Form-36 questionnaire) and sexual function (total sexual function score improved from 24 to 25.35 and 26.25 at 6 and 12 months). CONCLUSION Etonogestrel- and segesterone-releasing progestin subdermal implants appear to improve endometriosis-related pain symptoms and quality of life and may provide an additional component in the management of endometriosis. However, this systematic review is limited by the small sample size and heterogeneity in the data. As such, larger prospective randomized trials are needed to guide further management. PROSPERO REGISTRATION CRD42021225665.
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Affiliation(s)
- Kristin Ambacher
- Department of Obstetrics and Gynecology, University of Calgary, Alberta, AB, Canada
| | - Michael Secter
- Department of Obstetrics and Gynecology, University of Calgary, Alberta, AB, Canada
| | - Ari P Sanders
- Department of Obstetrics and Gynecology, University of Calgary, Alberta, AB, Canada
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10
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Siqueira-Campos VM, de Deus MSC, Poli-Neto OB, Rosa-E-Silva JC, de Deus JM, Conde DM. Current Challenges in the Management of Chronic Pelvic Pain in Women: From Bench to Bedside. Int J Womens Health 2022; 14:225-244. [PMID: 35210869 PMCID: PMC8863341 DOI: 10.2147/ijwh.s224891] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/04/2022] [Indexed: 12/11/2022] Open
Abstract
Chronic pelvic pain (CPP) affects a significant proportion of women worldwide And has a negative impact on several aspects of these women’s lives including mental health, work, relationships and sexual function, among others. This set of factors ultimately reflects negatively on quality Of life. The physiopathology of CPP is complex and remains to be fully clarified; however, recent advances have increased understanding of the mechanisms involved in chronic pain in general, and more specifically, CPP. Nonetheless, even when a detailed clinical history is obtained, meticulous physical examination is performed and imaging resources are appropriately used, the organic cause of the pain may still fail to be identified in a substantial number of women with CPP. Management of CPP may therefore be challenging. This narrative review was aimed at adding to the available literature on the subject, presenting and discussing the principal characteristics of CPP in women. The paper highlights gaps in the literature while providing the most up-to-date evidence associated with the physiopathology and classification of pain, its diagnosis and treatment. In addition, current challenges in the management of women with CPP are discussed.
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Affiliation(s)
- Vânia Meira Siqueira-Campos
- Department of Obstetrics and Gynecology, School of Medicine, Federal University of Goiás, Goiânia, Goiás, Brazil
| | | | - Omero Benedicto Poli-Neto
- Laboratory for Translational Data Science, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Julio Cesar Rosa-E-Silva
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - José Miguel de Deus
- Department of Obstetrics and Gynecology, School of Medicine, Federal University of Goiás, Goiânia, Goiás, Brazil
| | - Délio Marques Conde
- Department of Obstetrics and Gynecology, School of Medicine, Federal University of Goiás, Goiânia, Goiás, Brazil
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11
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Kalaitzopoulos DR, Samartzis N, Kolovos GN, Mareti E, Samartzis EP, Eberhard M, Dinas K, Daniilidis A. Treatment of endometriosis: a review with comparison of 8 guidelines. BMC Womens Health 2021; 21:397. [PMID: 34844587 PMCID: PMC8628449 DOI: 10.1186/s12905-021-01545-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/18/2021] [Indexed: 02/07/2023] Open
Abstract
Background Endometriosis, the presence of endometrial-like tissue outside the uterus, is a common clinical entity between women of reproductive age, with a prevalence of about 10%. Due to the variety of endometriosis-associated symptoms, a great variety of treatments have been implemented. The aim of this review is to give an overview on therapeutical approaches of eight national and international widely used guidelines.
Methods Six national (College National des Gynecologues et Obstetriciens Francais, National German Guideline (S2k), Society of Obstetricians and Gynaecologists of Canada, American College of Obstetricians (ACOG) and Gynecologists, American Society for Reproductive Medicine (ASRM) and National Institute for Health and Care (NICE) and two international (World Endometriosis Society, European Society of Human Reproduction and Embryology) guidelines are included in this review. Conclusion All the above-mentioned guidelines agree that the combined oral contraceptive pill, progestogens are therapies recommended for endometriosis associated pain. Concerning infertility, there is no clear consensus about surgical treatment. Discrepancies are also found on recommendation of the second- and third-line treatments.
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Affiliation(s)
- Dimitrios Rafail Kalaitzopoulos
- Department of Gynecology and Obstetrics, Cantonal Hospital Schaffhausen, Geissbergstrasse 81, 8208, Schaffhausen, Switzerland. .,Department of Gynecology, University Hospital Zurich, Zurich, Switzerland.
| | - Nicolas Samartzis
- Department of Gynecology and Obstetrics, Cantonal Hospital Schaffhausen, Geissbergstrasse 81, 8208, Schaffhausen, Switzerland
| | - Georgios N Kolovos
- Department of Gynecology and Obstetrics, Cantonal Hospital Schaffhausen, Geissbergstrasse 81, 8208, Schaffhausen, Switzerland
| | - Evangelia Mareti
- Department of Obstetrics and Gynecology, Hippokratio Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Markus Eberhard
- Department of Gynecology and Obstetrics, Cantonal Hospital Schaffhausen, Geissbergstrasse 81, 8208, Schaffhausen, Switzerland
| | - Kostantinos Dinas
- Department of Obstetrics and Gynecology, Hippokratio Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Angelos Daniilidis
- Department of Obstetrics and Gynecology, Hippokratio Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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GnRH Antagonists with or without Add-Back Therapy: A New Alternative in the Management of Endometriosis? Int J Mol Sci 2021; 22:ijms222111342. [PMID: 34768770 PMCID: PMC8583814 DOI: 10.3390/ijms222111342] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022] Open
Abstract
To evaluate the effectiveness of a new class of medical drugs, namely oral gonadotropin-releasing hormone (GnRH) antagonists, in the management of premenopausal women with endometriosis-associated pelvic pain. We reviewed the most relevant papers (n = 27) on the efficacy of new medical alternatives (oral GnRH antagonists) as therapy for endometriosis. We first briefly summarized the concept of progesterone resistance and established that oral contraceptives and progestogens work well in two-thirds of women suffering from endometriosis. Since clinical evidence shows that estrogens play a critical role in the pathogenesis of the disease, lowering their levels with oral GnRH antagonists may well prove effective, especially in women who fail to respond to progestogens. There is a need for reliable long-term oral treatment capable of managing endometriosis symptoms, taking into consideration both the main symptoms and phenotype of the disease. Published studies reviewed and discussed here confirm the efficacy of GnRH antagonists. There is a place for GnRH antagonists in the management of symptomatic endometriosis. Novel algorithms that take into account the different phenotypes are proposed.
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Barbara G, Buggio L, Facchin F, Vercellini P. Medical Treatment for Endometriosis: Tolerability, Quality of Life and Adherence. Front Glob Womens Health 2021; 2:729601. [PMID: 34816243 PMCID: PMC8594049 DOI: 10.3389/fgwh.2021.729601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/01/2021] [Indexed: 11/21/2022] Open
Abstract
Endometriosis is associated with painful symptoms, infertility, sexological difficulties, and psychological suffering. All these symptoms have a negative impact on the overall quality of life of women with the disease, with significant personal, social and economic costs. Several medical options are available to manage symptomatic endometriosis. The pharmacological treatment for endometriosis-related pain may be necessary for decades, or at least until there is a desire for pregnancy or physiologic menopause occurs. In this perspective, clinicians should consider not only the efficacy, but also side effects, tolerability, and costs, along with women's preferences toward different treatments. In this mini-review, we analyzed the pros and cons of the available drugs for the medical therapy of endometriosis, such as estrogen-progestins, progestins, GnRH agonist and GnRH antagonists.
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Affiliation(s)
- Giussy Barbara
- Obstetric and Gynaecologic Emergency Department and SVSeD (Service for Sexual and Domestic Violence), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Laura Buggio
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Facchin
- Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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14
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Newmark AL, Luciano DE, Ulrich A, Luciano AA. Medical management of endometriosis. Minerva Obstet Gynecol 2021; 73:572-587. [PMID: 34264045 DOI: 10.23736/s2724-606x.21.04776-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Endometriosis is a benign gynecologic disorder that is defined as functional endometrial tissue outside of the uterine cavity. It is an estrogen-dependent, inflammatory disease that leads to symptoms of pelvic pain, dysmenorrhea, dyspareunia, and infertility, occurring in 6-10% of reproductive aged women. The severity of the disease ranges from asymptomatic to debilitating symptoms that have a major impact on women's lives. It is a chronic, recurrent disease, frequently requiring long term management until menopause and beyond. It is considered a chronic disorder that is managed with surgery, medical treatment, and oftentimes, both. Current medical therapy for endometriosis is considered suppressive of the disease, rather than curative. Fortunately, many patients do experience improvement and control of their symptoms with medical therapy. However, long-term efficacy of the medical treatments is often limited by side effects and the cost of therapy, and symptoms do tend to recur after discontinuation of these medications. AREAS COVERED This review summarizes our understanding of the pathogenesis of endometriosis and provides more in-depth discussion of specific medical management options used to treat endometriosis, including mechanism of action and side effects. It also provides recommendations on strategy with a forward look to novel endometriosis treatments in the future. EXPERT OPINION The authors emphasize that endometriosis is a chronic disorder requiring long term medical therapy. Early diagnosis of endometriosis is key in preventing severe, debilitating symptoms and progression of disease. By utilizing our current knowledge of the pathophysiology of endometriosis and by correctly implementing currently available medical and surgical therapies we can significantly reduce the physical, psychosocial and financial burden of this chronic, recurrent and indolent disease. Current available medications are suppressive therapies, but the authors are looking forward to future therapies that can effectively cure or at least control endometriosis with minimal side effects. Future research should continue to look for the genetic trigger for endometriosis which can lead us to its underlying pathogenesis and eventually a cure or prevention.
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Affiliation(s)
- Alexis L Newmark
- Department of Obstetrics and Gynecology, University of Connecticut, Farmington, CT, USA -
| | - Danielle E Luciano
- Department of Obstetrics and Gynecology, University of Connecticut, Farmington, CT, USA
| | - Amanda Ulrich
- Department of Obstetrics and Gynecology, University of Connecticut, Farmington, CT, USA
| | - Anthony A Luciano
- Department of Obstetrics and Gynecology, University of Connecticut, Farmington, CT, USA
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15
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Endometriosis and Medical Therapy: From Progestogens to Progesterone Resistance to GnRH Antagonists: A Review. J Clin Med 2021; 10:jcm10051085. [PMID: 33807739 PMCID: PMC7961981 DOI: 10.3390/jcm10051085] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/20/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023] Open
Abstract
Background: The first objective of this review was to present, based on recent literature, the most frequently applied medical options (oral contraceptive pills (OCPs) and progestogens) for the management of symptomatic endometriosis, and evaluate their effectiveness in treating premenopausal women with endometriosis-associated pelvic pain, dysmenorrhea, non-menstrual pelvic pain and dyspareunia. The second objective was to review the concept of progesterone resistance and newly available treatment options. Methods: We reviewed the most relevant papers (n = 73) on the efficacy of OCPs and progestogens as medical therapy for endometriosis, as well as those on progesterone resistance and new medical alternatives (oral gonadotropin-releasing hormone (GnRH) antagonist). Eleven papers, essentially reviews, were selected and scrutinized from among 94 papers discussing the concept of progesterone resistance. Results: Having reviewed the most significant papers, we can confirm that OCPs and progestogens are effective in two-thirds of women suffering from endometriosis, but that other options are required in case of failure (in one-third of women due to progesterone resistance) or intolerance to these compounds. It is clear that there is a need for effective long-term oral treatment capable of managing endometriosis symptoms, while mitigating the impact of side effects. Biochemical, histological and clinical evidence show that estrogens play a critical role in the pathogenesis of endometriosis, so lowering levels of circulating estrogens should be considered an effective medical approach. The efficacy of three oral GnRH antagonists is discussed on the basis of published studies. Conclusion: There is a place for GnRH antagonists in the management of symptomatic endometriosis and clinical trials should be conducted, taking into account the different phenotypes in order to propose novel algorithms.
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16
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Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic systemic disease: clinical challenges and novel innovations. Lancet 2021; 397:839-852. [PMID: 33640070 DOI: 10.1016/s0140-6736(21)00389-5] [Citation(s) in RCA: 349] [Impact Index Per Article: 116.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 08/09/2020] [Accepted: 08/14/2020] [Indexed: 12/14/2022]
Abstract
Endometriosis is a common disease affecting 5-10% of women of reproductive age globally. However, despite its prevalence, diagnosis is typically delayed by years, misdiagnosis is common, and delivery of effective therapy is prolonged. Identification and prompt treatment of endometriosis are essential and facilitated by accurate clinical diagnosis. Endometriosis is classically defined as a chronic, gynaecological disease characterised by endometrial-like tissue present outside of the uterus and is thought to arise by retrograde menstruation. However, this description is outdated and no longer reflects the true scope and manifestations of the disease. The clinical presentation is varied, the presence of pelvic lesions is heterogeneous, and the manifestations of the disease outside of the female reproductive tract remain poorly understood. Endometriosis is now considered a systemic disease rather than a disease predominantly affecting the pelvis. Endometriosis affects metabolism in liver and adipose tissue, leads to systemic inflammation, and alters gene expression in the brain that causes pain sensitisation and mood disorders. The full effect of the disease is not fully recognised and goes far beyond the pelvis. Recognition of the full scope of the disease will facilitate clinical diagnosis and allow for more comprehensive treatment than currently available. Progestins and low-dose oral contraceptives are unsuccessful in a third of symptomatic women globally, probably as a result of progesterone resistance. Oral gonadotropin-releasing hormone (GnRH) antagonists constitute an effective and tolerable therapeutic alternative when first-line medications do not work. The development of GnRH antagonists has resulted in oral drugs that have fewer side-effects than other therapies and has allowed for rapid movement between treatments to optimise and personalise endometriosis care. In this Review, we discuss the latest understanding of endometriosis as a systemic disease with multiple manifestations outside the parameters of classic gynaecological disease.
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Affiliation(s)
- Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA.
| | - Alexander M Kotlyar
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Valerie A Flores
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
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17
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Dobrokhotova JE, Kalimatova DM, Ilyina IY, Grishin II. Study of dienogest clinical efficacy in the treatment of adenomyosis. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2021. [DOI: 10.1177/2284026521993699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: A number of works provide information on the effectiveness of dienogest in uterine adenomyosis. However, information on the use of the drug at various degrees of the adenomatous nodes, is not presented in the available literature. Aim: The aim of the study was to evaluate the clinical efficacy of dienogest in the treatment of patients with adenomyosis 2nd and 3rd stage and chronic pelvic pain. Materials and methods: A comprehensive clinical survey and treatment of 46 patients with signs of adenomyosis were carried out. Patients were divided into two groups: 28 patients with stage 2 adenomyosis, 18 patients with type 3 adenomyosis were included in the 2nd group. On the first phase of the menstrual cycle all patients underwent hysteroscopy for endoscopic verification of the diagnosis using the traditional Karl Storz hysteroscopic stand with separate treatment and diagnostic curettage of the uterine cavity and cervical canal, followed by histological examination. After surgical treatment all patients received dienogest at a dose 2 mg/day for 6 months. The treatment was performed during 6 months. After 3, 6, and 12 months of the study, the patients included in the survey underwent a comprehensive examination with a clinical assessment of the manifestations of the disease. The level of pain manifestations was evaluated on a visual analog scale (VAS) with a range of 0–10 points. During pain assessment, its manifestations were differentiated—pain due to dyspareunia, dysmenorrhea, dyschezia, and chronic pelvic pain were evaluated. Results: In the group of patients with 2nd adenomyosis stage, the intake of dienogest for 6 months led to the absence of manifestations of uterine bleeding and dyschezia, a decrease in the frequency of dyspareunia—by 7.7 times. In patients with the 3rd stage of the disease, the decrease in the symptoms of adenomyosis was less pronounced, however, after taking the drug, a decrease in the frequency of uterine bleeding was found to be 6 times, dyspareunia 4 times, and dyschezia 5 times. Twelve months after the start of observation (6 months after the end of treatment), none of the patients with 2nd stage of disease showed severe pelvic pain, in the group with 3rd stage of adenomyosis there were only two of these patients (11.1%). At the same time, the vast majority of patients included in the study did not have manifestations of chronic pelvic pain—78.6% of patients with 2nd stage of adenomyosis and 55.6% of patients with 3rd stage of disease, the remaining 21.4% and 33.3% of patients of the first and second groups reported a significant decrease in the severity of pain. Conclusions: The inclusion of dienogest in the combined treatment of adenomyosis is clinically effective, contributing to the rapid and reliable relief of the main manifestations of the disease in patients with adenomyosis with grade 2 and 3 nodes. Treatment of adenomyosis with the use of dienogest is clinically effective, contributing to the rapid and reliable relief of the main manifestation of the disease.
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Affiliation(s)
- Julia E Dobrokhotova
- Department of Obstetrics and Gynecology, N.I.Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Donna M Kalimatova
- Department of Obstetrics and Gynecology, N.I.Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Irina Yu Ilyina
- Department of Obstetrics and Gynecology, N.I.Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Igor I Grishin
- Department of Obstetrics and Gynecology, N.I.Pirogov Russian National Research Medical University, Moscow, Russian Federation
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Upson K, Harmon QE, Heffron R, Hall JE, Wise LA, Wegienka G, Tokar EJ, Baird DD. Depot Medroxyprogesterone Acetate Use and Blood Lead Levels in a Cohort of Young Women. ENVIRONMENTAL HEALTH PERSPECTIVES 2020; 128:117004. [PMID: 33206002 PMCID: PMC7673223 DOI: 10.1289/ehp7017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 09/28/2020] [Accepted: 10/23/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Injectable contraceptive use is common, with 74 million users worldwide. Use of the injectable contraceptive depot medroxyprogesterone acetate (DMPA) is associated with bone mineral density loss. We hypothesize that increased bone resorption with DMPA use allows for mobilization of the toxic metal lead stored in bone to blood, presenting users with increased systemic exposure to lead. OBJECTIVE The objective of our study was to investigate the association between current DMPA use and blood lead concentrations. METHODS We conducted a cross-sectional analysis using enrollment data from the Study of Environment, Lifestyle & Fibroids (SELF), a cohort of 1,693 African-American women who were 23-35 years of age. Data on DMPA use were collected by computer-assisted telephone interview. Blood lead concentrations were measured in whole blood samples among 1,548 participants (91% of cohort). We estimated the adjusted percent difference in blood lead concentrations and 95% confidence intervals (CI) between current DMPA users and nonusers using multivariable linear regression. RESULTS Geometric mean blood lead concentration was 0.69 μ g / dL (95% CI: 0.67, 0.71). After adjustment, current DMPA users (7% of cohort) had blood lead concentrations that were 18% higher than those of nonusers (95% CI: 8%, 29%). Similar associations were observed with additional analyses to assess for potential bias from smoking, DMPA-induced amenorrhea, use of estrogen-containing contraceptives, having given birth in the prior year, and history of medical conditions or current medication use associated with bone loss. DISCUSSION Our results indicate that current DMPA use is associated with increased blood lead concentrations. Further research, particularly in populations highly exposed to lead, is warranted to consider tradeoffs between the adverse effects of lead on human health and the importance of DMPA as a contraceptive option to prevent unintended pregnancy. https://doi.org/10.1289/EHP7017.
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Affiliation(s)
- Kristen Upson
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Quaker E. Harmon
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Janet E. Hall
- Clinical Research Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Lauren A. Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Ganesa Wegienka
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Erik J. Tokar
- Stem Cells Toxicology Group, National Toxicology Program Laboratory, Division of the National Toxicology Program, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Donna D. Baird
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
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19
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Garzon S, Laganà AS, Barra F, Casarin J, Cromi A, Raffaelli R, Uccella S, Franchi M, Ghezzi F, Ferrero S. Novel drug delivery methods for improving efficacy of endometriosis treatments. Expert Opin Drug Deliv 2020; 18:355-367. [PMID: 32981374 DOI: 10.1080/17425247.2021.1829589] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Pharmacotherapy has a key role in the management of endometriosis. However, a significant proportion of patients gains only intermittent or limited benefits. In this regard, alternative and novel drug delivery methods are of paramount importance to improve efficacy and compliance of available treatments and develop alternative medical approaches. AREAS COVERED This review aims to provide the reader with a complete overview of available evidence about alternative and novel drug delivery methods for endometriosis pharmacotherapy and highlight new research lines. EXPERT OPINION Progestins and estroprogestins, which represent the first-line therapy, are already available in different formulations, being employed for contraception. Nevertheless, evidence on their adoption is still limited for some drug delivery methods, such as vaginal rings, patches, and subcutaneous implants. Further research is needed to define better their clinical utility in patients with endometriosis. Nanotechnologies have been investigated as novel drug delivery methods able to target the drug at the disease level. However, data are very limited and preliminary, and further research is needed to consider a possible clinical application in endometriosis.
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Affiliation(s)
- Simone Garzon
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Fabio Barra
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova, Genova, Italy.,Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Antonella Cromi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Ricciarda Raffaelli
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Stefano Uccella
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova, Genova, Italy.,Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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20
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Della Corte L, Barra F, Mercorio A, Evangelisti G, Rapisarda AMC, Ferrero S, Bifulco G, Giampaolino P. Tolerability considerations for gonadotropin-releasing hormone analogues for endometriosis. Expert Opin Drug Metab Toxicol 2020; 16:759-768. [DOI: 10.1080/17425255.2020.1789591] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples “Federico II”, Naples, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genoa, Italy
| | - Antonio Mercorio
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples “Federico II”, Naples, Italy
| | - Giulio Evangelisti
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genoa, Italy
| | | | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genoa, Italy
| | - Giuseppe Bifulco
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples “Federico II”, Naples, Italy
| | - Pierluigi Giampaolino
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
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Pokrzywinski R, Soliman AM, Chen J, Snabes MC, Taylor HS, Coyne KS. Responsiveness Evaluation and Recommendation for Responder Thresholds for Endometriosis Health Profile-30: Analysis of Two Phase III Clinical Trials. J Womens Health (Larchmt) 2019; 29:253-261. [PMID: 31855102 DOI: 10.1089/jwh.2019.7788] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective: To evaluate the responsiveness of the Endometriosis Health Profile-30 (EHP-30) and ascertain score changes that are indicative of response to treatment. A post hoc analysis of two Phase III, double-blind, placebo-controlled, randomized clinical trials among women with moderate-to-severe endometriosis-associated pain (Elaris Endometriosis I and II [EM-I and EM-II]). Materials and Methods: EHP-30 core items and sexual relationship module were administered at day 1, month 3 (M3), and month 6 (M6) to monitor patient-reported impacts of endometriosis-related pain. A seven-response level Patient Global Impression of Change (PGIC) was administered at M3 and M6. Dysmenorrhea (DYS), nonmenstrual pelvic pain (NMPP), and dyspareunia (DYSP) were collected using a daily diary. Three psychometric approaches, "triangulation," were used to suggest responder thresholds for the EHP-30 domains. The three approaches were anchor- and distribution-based analyses and use of clinically relevant indicators (DYS, NMPP, DYSP). Results: EM-I and EM-II enrolled 871 and 815 women, respectively. All EHP-30 domains improved during the trials (M3, M6). Differences (p < 0.001) for all EHP-30 domains were found among the PGIC responses at M3 and M6, indicating greater change was associated with greater EHP-30 improvements. Large effect sizes were noted for all EHP-30 domains (EM-I range -0.59 to -1.80; EM-II range -0.52 to -1.59). EHP-30 thresholds of meaningful change ranged from -20 to -35, with greater changes indicating greater improvement in health status. Conclusion: Responder thresholds by EHP-30 domain are recommended to evaluate treatment efficacy. Clinicians can individualize goals of treatment by EHP-30 domain and track changes using the EHP-30.
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Affiliation(s)
| | | | - Jun Chen
- Evidera, Patient-Centered Research, Bethesda, Maryland
| | | | | | - Karin S Coyne
- Evidera, Patient-Centered Research, Bethesda, Maryland
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22
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Gheorghisan-Galateanu AA, Gheorghiu ML. HORMONAL THERAPY IN WOMEN OF REPRODUCTIVE AGE WITH ENDOMETRIOSIS: AN UPDATE. ACTA ENDOCRINOLOGICA-BUCHAREST 2019; 15:276-281. [PMID: 31508191 DOI: 10.4183/aeb.2019.276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Medical therapy of endometriosis is under continuous reevaluation. Hereby we updated the drugs currently available or under investigation for the hormonal treatment of endometriosis.
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Affiliation(s)
- A A Gheorghisan-Galateanu
- "Carol Davila" University of Medicine and Pharmacy - Dept. of Cellular and Molecular Biology and Histology, Bucharest, Romania.,"C.I. Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - M L Gheorghiu
- "Carol Davila" University of Medicine and Pharmacy - Dept. of Endocrinology, Bucharest, Romania.,"C.I. Parhon" National Institute of Endocrinology, Bucharest, Romania
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23
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Ciavattini A, Delli Carpini G, Serri M, Tozzi A, Leoni F, Di Loreto E, Saccucci F. Unfolded protein response, a link between endometrioid ovarian carcinoma and endometriosis: A pilot study. Oncol Lett 2018; 16:5449-5454. [PMID: 30250617 DOI: 10.3892/ol.2018.9256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 06/28/2018] [Indexed: 12/25/2022] Open
Abstract
The aim of the present study was to analyze the expression profile of unfolded protein response (UPR) genes in endometrioid ovarian carcinoma and to evaluate its possible involvement in the neoplastic progression of endometriosis. An experimental retrospective pilot study was conducted on women with a diagnosis of endometrioid ovarian carcinoma at FIGO stage IA, ovarian endometriotic cysts or healthy subjects without a previous diagnosis of endometriosis. The expression profiles of UPR genes (ATF6, GRP78, CHOP and XBP1) were compared among ovaries with endometrioid ovarian cancer, endometriotic ovarian cysts, healthy contralateral ovaries and eutopic and healthy endometrial tissues. A significantly higher expression of ATF6 and GRP78 was detected in the affected ovaries in comparison with the healthy contralateral ovaries, while CHOP and XBP1 exhibited a significantly lower expression. XBP1 was overexpressed in endometrial tissues and its expression gradually decreased in endometriosis cysts and endometrioid ovarian carcinoma. These results support the hypothesis that alterations in the UPR genes CHOP and XBP1 are involved in the neoplastic progression of endometrioid ovarian cancer and are acquired following ovarian localization of ectopic endometrial cells.
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Affiliation(s)
- Andrea Ciavattini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona I-60123, Italy
| | - Giovanni Delli Carpini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona I-60123, Italy
| | - Matteo Serri
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona I-60123, Italy
| | - Alessandra Tozzi
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona I-60123, Italy
| | - Francesca Leoni
- Department of Biochemistry, Biology and Genetics, Polytechnic University of Marche, Ancona I-60121, Italy
| | - Eugenia Di Loreto
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona I-60123, Italy
| | - Franca Saccucci
- Department of Biochemistry, Biology and Genetics, Polytechnic University of Marche, Ancona I-60121, Italy
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