Non-invasive methods of diagnosis of endometriosis

A Case of Rectal Endometriosis Misdiagnosed as Rectal Malignancy on Three Colonoscopies and Biopsies Sharing a Combined Literature Review

Background

Endometriosis involves the intestine, and its clinical manifestations are nonspecific and lack of etiological manifestations. The diagnosis is difficult, which often leads to misdiagnosis. We report a case of endometriosis which was misdiagnosed as intestinal malignant tumor after colonoscopy and three biopsies.

Case Presentation

We reported a 42-year-old woman who went to see a doctor because of anal distension. She was examined by three gastrointestinal endoscopists at different levels in different hospitals and underwent biopsy at the same time. Combined with clinical manifestations, imaging examination, endoscopic examination and pathological examination, she was misdiagnosed as intestinal malignant tumor, and partial intestinal resection was performed according to the surgical principle of malignant tumor.

Conclusion

Although there are advanced gastrointestinal endoscopy and imaging techniques, intestinal endometriosis is still easy to be misdiagnosed. As our case report shows, after three colonoscopy and biopsy, it is still misdiagnosed as intestinal malignant tumor. Further research is needed to improve the ability of preoperative diagnosis, which deserves the attention of gastroenterologists and obstetricians and gynecologists.

Identification of miR-34-3p as a candidate follicular phase serum marker for endometriosis: a pilot study

OBJECTIVE

To identify early follicular phase microribonucleic acids (miRNAs) that are altered in serum of women with endometriosis.

DESIGN

Case-control study.

SETTING

Large university-affiliated in vitro fertilization center.

PATIENT(S)

Women with (n = 21) and without (n = 24) endometriosis.

INTERVENTION(S)

Serum samples were obtained from laparoscopy-confirmed patients with endometriosis.

MAIN OUTCOME MEASURE(S)

The differential expression of serum miRNAs relative to controls was measured using the NanoString nCounter technology and validated by quantitative real-time polymerase chain reaction in an independent cohort of 27 patients with endometriosis and controls (n = 24). Microribonucleic acid target signaling pathways and genes were analyzed bioinformatically. A chemically modified stable miR-34-3p oligonucleotide was used to examine the effect on proliferation of VK2E6/E7 endometrial cells in vitro.

RESULT(S)

Eighteen miRNAs were significantly up-regulated, and 1 miRNA (hsa-miR-34c-3p) was significantly down-regulated in the follicular phase of patients with endometriosis. The analysis of target signaling pathways using TargetScan predicted regulation of the mitogen-activated protein kinase, phosphoinositide 3-kinase/protein kinase B, Hippo, adenosine monophosphate-activated protein kinase, transforming growth factor beta, and endometrial cancer pathways, which have been implicated in the pathogenesis of endometriosis, by these miRNAs. The analysis of sequence complementarity identified prostaglandin E2 receptor 4, interleukin 6 signal transducer, and polo-like kinase 4 genes as possible direct targets of hsa-miR-34-3p. DSDI-1, a chemically modified stable miR-34-3p oligonucleotide, reduced cell proliferation in VK2E6/E7 endometrial cells in vitro.

CONCLUSION(S)

The follicular phase miRNA levels are altered in serum of women with endometriosis and may be useful as reproducible detection biomarkers for early diagnosis of endometriosis. hsa-miR-34-3p is significantly down-regulated in endometriosis, targets endometriosis genes, and reduces endometrial cell proliferation in vitro. These results support hsa-miR-34-3p as a potential therapeutic target in endometriosis.

Impact of endometriosis on women's life decisions and goal attainment: a cross-sectional survey of members of an online patient community

OBJECTIVES

To examine women's perceptions of endometriosis-associated disease burden and its impact on life decisions and goal attainment.

DESIGN

An anonymous online survey was distributed in October 2018 through the social media network MyEndometriosisTeam.com.

PARTICIPANTS

Women aged 19 years and older living in several English-speaking countries who self-identified as having endometriosis.

OUTCOME MEASURES

Patients' perspectives on how endometriosis has affected their work, education, relationships, overall life decisions and attainment of goals. Subanalyses were performed for women who identified as 'less positive about the future' (LPAF) or had 'not reached their full potential' (NRFP) due to endometriosis.

RESULTS

743 women completed the survey. Women reported high levels of pain when pain was at its worst (mean score, 8.9 on severity scale of 0 (no pain) to 10 (worst imaginable pain)) and most (56%, n=415) experienced pain daily. Women reported other negative experiences attributed to endometriosis, including emergency department visits (66%, n=485), multiple surgeries (55%, n=406) and prescription treatments for symptoms of endometriosis (72%, n=529). Women indicated that they believed endometriosis had a negative impact on their educational and professional achievements, social lives/relationships and overall physical health. Most women 'somewhat agreed'/'strongly agreed' that endometriosis caused them to lose time in life (81%, n=601), feel LPAF (80%, n=589) and feel they had NRFP (75%, n=556). Women who identified as LPAF or NRFP generally reported more negative experiences than those who were non-LPAF or non-NRFP.

CONCLUSIONS

Women who completed this survey reported pain and negative experiences related to endometriosis that were perceived to negatively impact major life-course decisions and attainment of goals. Greater practitioner awareness of the impact that endometriosis has on a woman's life course and the importance of meaningful dialogue with patients may be important for improving long-term management of the disease and help identify women who are most vulnerable.

Urinary Biomarkers for Detection of Clinical Endometriosis or Adenomyosis

Endometriosis or adenomyosis can be clinically diagnosed by ultrasound, symptoms, physical examination, and serum CA125. The urinary markers need to be investigated. The aim of our study was to investigate the urinary markers of clinical endometriosis/adenomyosis, and the correlation of serum CA125 was also studied. From the literature, alpha-1 antitrypsin (A1AT), enolase-1, vitamin D binding protein (VDBP), and CA125 in urine and serum were used in our study and measured by enzyme-linked immunosorbent assays (ELISA). Further clinical correlation and detection performance were evaluated. We enrolled 19 normal controls and 33 patients clinically diagnosed with endometriosis/adenomyosis. There were significant differences between studied patients and normal controls, as follows: serum CA125 (130.91 vs. 19.75 U/mL, p = 0.004); urinary CA125-creatinine ratio (5.591 vs. 0.254 ng/mg, p = 0.028); and urinary VDBP-creatinine ratio (28.028 vs. 7.301 ng/mg, p = 0.018). For diagnostic performances, serum CA125 provided the best results, with an area under curve (AUC) of 0.888 (p = 0.001) and accuracy of 86.5%. Other excellent results were also found using urinary VDBP (AUC 0.841, p = 0.001) and A1AT (AUC 0.722, p = 0.011) creatinine ratio. Using three combined biomarkers, serum CA125, urinary VDBP, and A1AT creatinine ratio, provided good detection power (AUC 0.913, p = 0.001, sensitivity 90.9%, specificity 76.5%). Double urine markers used in combination with VDBP and A1AT creatinine ratio also provided good diagnostic performance (AUC 0.809, p = 0.001, sensitivity 81.8%, specificity 76.5%, accuracy 80%). Further development of non-invasive point-of-care tests using these biomarkers could be a fruitful future endeavor.

The efficiency of susceptibility-weighted MRI in the differentiation of endometriomas from haemorrhagic ovarian cysts

OBJECTIVES

The aim of the study was to investigate the efficiency of susceptibility-weighted magnetic resonance (MR) imaging (SWIs) in differentiating endometriomas from haemorrhagic ovarian cysts.

MATERIALS AND METHODS

Between July 2017 and January 2019, 89 ovarian cystic lesions (57 endometriomas and 32 haemorrhagic cysts) that were identified as complicated cystic lesions on ultrasonography (US) and underwent lower abdominal MRI with susceptibility weighting were retrospectively evaluated. Final diagnoses were obtained with surgical pathological correlation and radiological-clinical follow-up. Two radiologists blinded to the final diagnoses retrospectively reviewed the images in consensus. The signal intensity on T1- and T2-weighted images and curved linear or punctate signal void areas on SWI were noted for the presence of lesions.

RESULTS

Forty of the 57 endometriomas demonstrated the defined MRI criteria, including a cystic hyperintensity on T1-weighted images and hypointensity on T2-weighted images. The remaining 17 lesions did not demonstrate these criteria on conventional MR images. SWI showed punctate or curved linear signal void areas in 53 of 57 endometriomas (92.9%) and none of the haemorrhagic cysts. The sensitivity, specificity and accuracy of SWI in differentiating endometrioma from haemorrhagic cyst were 92.9%, 100.0%, and 95.5%, respectively.

CONCLUSIONS

The addition of the SWI sequence to conventional MRI can help distinguish endometriomas from haemorrhagic ovarian cysts.

Brief Review of Endometriosis and the Role of Trace Elements

Endometriosis is a chronic, estrogen-dependent, inflammatory condition that is defined as the presence of endometrial glands and stroma outside the uterine cavity. Despite the progress in research into the mechanisms leading to the development of endometriosis, its cause has not yet been established. It seems to be possible that the formation of oxidative stress may be one of the main causes of the development of endometriosis. There is much research that studies the potential role of trace elements in the appearance of endometrial-like lesions. Most studies focus on assessing the content of selected trace elements in the blood, urine, or peritoneal fluid in women with endometriosis. Meanwhile, little is known about the content of these elements in endometrial-like implants, which may be helpful in developing the theory of endometriosis. Investigations that are more comprehensive are needed to confirm a hypothesis that some trace elements play a role in the pathomechanism of endometriosis.

Abdominal wall endometriosis versus desmoid tumor - a challenging differential diagnosis

Aim: Abdominal wall endometriosis (AWE) in young women, with previous gynecological abdominal surgery, is the first condition considered by many practitioners when a tumor in the region of the scar appears. AWE seems to be caused by an iatrogenic transfer of endometrial cells at the level of the scar. The onset of the disease may be late in many cases. Despite the fact that the disease could be totally asymptomatic, there are certain risk factors that can be identified during the anamnesis, such as: heredity, menarche at the age of >14 years, menstrual cycle <27 days, delayed menopause, excessive alcohol and caffeine consumption. Suggestive signs include cyclic or continuous abdominal pain caused by a palpable abdominal wall mass with a maximum tenderness in the region of the surgical scar. The differential diagnosis is complex and rare entities like desmoid tumors (DTs) must be taken into consideration. Desmoid tumor, or the so-called aggressive fibromatosis (AF), is a rare fibroblastic proliferation. This tumor can develop in any muscular aponeurotic structure of the body and is considered benign but with a high recurrence rate. DTs can cause local infiltration, subsequently producing certain levels of deformity and potential obstruction of vital structures and organs. The differential diagnosis is challenging in this situations, the imagery exams are useful, especially in detecting the precise location of the tumor. The histological examination of the tumor can state the final and precise diagnosis.

Differentiation of Endometriomas from Hemorrhagic Cysts at Magnetic Resonance: The Role of Quantitative Signal Intensity Measurements

BACKGROUND

Endometriomas and functional hemorrhagic cysts (FHCs) are a common gynecological encounter.

OBJECTIVE

This study aimed to assess the diagnostic efficiency of magnetic resonance imaging (MRI) using signal intensity measurements in differentiating endometriomas from FHCs.

METHODS

Forty-six patients who underwent pelvic MRI examinations (endometriomas, n=28; FHCs, n=18) were retrospectively included. The "T2 shading" sign was evaluated subjectively and quantitatively by measuring the T1-T2 signal intensity difference and calculating the percentage of signal decrease between T1 and T2-weighted sequences. The resulted values, along with the measurement of the Apparent Diffusion Coefficient (ADC) and the signal intensity on three diffusion- weighted sequences (DWI) (b⁵⁰, b⁴⁰⁰, and b⁸⁰⁰), were compared between groups by using the Mann-Whitney U test. Also, the receiver operating characteristic analysis was performed for the statistically significant results (P<0.016), and the area under the curve (AUC) was also calculated.

RESULTS

The two quantitative assessment methods showed similar efficiency in detecting endometriomas (P<0.001; sensitivity, 100%; specificity, 81.82%; AUC>0.86), outperforming the classic subjective evaluation of the "T2 shading" sign (sensitivity, 92.86%; specificity, 66.67%). ADC (P=0.52) and DWI measurements (P=0.49, P=0.74, and P=0.78) failed to distinguish between the two entities.

CONCLUSION

The quantitative analysis and interpretation of the "T2 shading" sign can significantly improve the differential diagnosis between endometriomas and FHCs.

Hysterosalpingography in the assessment of proximal tubal pathology: a review of congenital and acquired abnormalities

Tubal and peritoneal disease are the main causes of infertility. Tubal pathology can be either congenital malformation or acquired, proximal or distal, unilateral or bilateral and transient or permanent. Several imaging methods such as laparoscopy, fluoroscopy, saline infusion sonography, and hysterosalpingography (HSG) have been used in the assessment of tubal and peritoneal pathology. Although laparoscopy is the modality of choice for investigating tubal patency and pelvic structure in many infertility centers, HSG is usually the initial diagnostic method for infertility workup because of its ease of performance, accuracy, and minimal risk of complications. This method provides useful information about size, contour, and anatomy of the inner surface of the fallopian tubes and is the gold standard for evaluation of tubal lumen. Tubal and peritubal pathology show various imaging manifestations on HSG. This review illustrates the radiographic features of congenital and acquired structural abnormalities of the proximal tubal pathology and along with etiology of proximal obstruction or occlusion will be described.

The Importance of a Multi-Disciplinary Approach to the Endometriotic Patients: The Relationship between Endometriosis and Psychic Vulnerability

Endometriosis is a chronic inflammatory condition, which is distinguished by the presence of the endometrial-like glands and stroma outside the uterine cavity. Pain and infertility are the most commonly expressed symptoms, occurring in 60% and 40% of cases, respectively. Women with endometriosis, especially those with pelvic pain, also have a greater vulnerability to several psychiatric disorders. There is, in particular, a tendency to contract affective or anxiety disorders as well as panic-agoraphobic and substance use disorders. Endometriosis with pelvic pain, infertility and psychic vulnerability usually leads to disability and a markedly lower quality of life for women of reproductive age. Thus, the burden of endometriosis is not limited to the symptoms and dysfunctions of the disease; it extends to the social, working and emotional spheres, leading to a severe impairment of global functioning. An analysis of scientific literature revealed a close relationship between specific temperamental traits, the expression of several psychiatric symptoms, chronicity of pain, risk of substance use and lower probability of a positive outcome. Endometriosis symptoms and the impact of related psychological consequences, increased vulnerability and the possible onset of psychiatric symptoms may influence coping strategies and weaken resilience, so triggering a vicious cycle leading to a marked deterioration in the quality of life. A multidisciplinary approach consisting of a medical team composed of gynecologists, psychologists, psychiatrists, experts in Dual Disorder, algologists and sexologists, would guarantee the setting of a target and taking the best decision on a personalized treatment plan. That approach would allow the prompt detection of any psychopathological symptoms and improve the endometriosis-related physical symptoms, bringing a healthier quality of life and a greater likelihood of a positive outcome.

Endometriosis MRI lexicon: consensus statement from the society of abdominal radiology endometriosis disease-focused panel

Endometriosis is a common gynecologic disorder characterized by the presence of ectopic endometrial tissue outside the endometrial cavity. Magnetic Resonance Imaging (MRI) has become a mainstay for diagnosis and staging of this disease. In the literature, significant heterogeneity exists in the descriptions of imaging findings and anatomic sites of involvement. The Society of Abdominal Radiology's Endometriosis Disease-Focused Panel presents this consensus document to establish an MRI lexicon for endometriosis MRI evaluation and anatomic localization.

Endometriosis in pregnancy

Endometriosis constitutes the presence of ectopic endometrial glands and stroma outside the uterine endometrium, which is hormonally responsive and responds to pregnancy hormones as well. Decidualization is a physiologic process, where the normal endometrium readies itself for optimal accommodation of a pregnancy. A similar hormonal response can be seen with ectopic endometrium as well. As such, ovarian endometriomas and deep endometriosis implants can undergo decidualization. Overall, the progestational state of pregnancy favors an improvement in endometriosis, however, decidualization can lead to findings that can lead to increased size of endometriomas and deep infiltrative endometriosis implants, changes in imaging appearance and even complications, such as spontaneous hemoperitoneum in pregnancy. Awareness of this process can help prevent misdiagnosis of decidualized endometriomas as ovarian malignancy and recognize common imaging manifestations of hormonal effects of pregnancy on endometriosis.

Endometrial biopsy and density of nerve fibers in eutopic endometrium. Looking for easier ways to diagnose endometriosis

The purpose of study was to evaluate if there is any difference between nerve fibers density in eutopic endometrium in women with and without endometriosis. The prospective case - control study conducted between October 2013 and December 2015. The study included 60 reproductive age women undergoing laparoscopy for suspected endometriosis, pelvic pain, or infertility and not currently receiving hormonal treatment for at least 3 months prior to laparoscopy. Immunohistochemical nerve fiber detection in endometrial curetting using anti-gene product 9.5 was compared with surgical diagnosis. The nerve fibers were detected in eutopic endometrium in women with and without endometriosis. PGP9.5 positive nerve fibers were found in 26 (43%) cases: 16 (50%) in women with endometriosis and 10 (36%) in women without endometriosis. The mean nerve fiber density was higher in the group with endometriosis (0.53 per mm² ± 0.68) than without endometriosis (0.48 per mm² ± 0.89), but no statistically significant difference was observed (p > .05). Test specificity was 64.3%, sensitivity 50%, positive predictive value - 61.5%, negative predictive value - 52.9%, and overall accuracy 56.7%. The detection of PGP9.5 positive nerve fibers in eutopic endometrium cannot be used as a reliable diagnostic test of diagnosing endometriosis.

Quality of the Clinical Diagnosis of Endometriosis

Background

Endometriosis is a benign but chronic disease, often associated with chronic pelvic pain and sterility in reproductive age women. Definite diagnosis of endometriosis requires surgical intervention. In our study we determined the sensitivity and specificity of the routine non-invasive diagnosis of endometriosis.

Methods

543 women underwent laparoscopy or laparotomy for benign gynecological reasons; of these, 156 women presented with endometriosis and 387 women presented without endometriosis. Charts were examined for preoperative prediction and diagnosis of endometriosis by gynecologists in private practice and by clinicians. Charts were also examined for the diagnosis after surgical and histological confirmation.

Results

Out of 101 cases, where first time endometriosis was diagnosed, in 43 patients (42.6%) the diagnosis of endometriosis was accurately predicted preoperatively by clinicians. Gynecologists in private practice suspected endometriosis in 29.7% of the cases. In the group of at least one recurrence of endometriosis (n=55), 89.1% clinic and 74.5% private practice suspected the correct diagnosis before surgery. The sensitivity for clinical diagnosis of endometriosis was calculated to be 59.0% in the clinic and 54.5% in private practice. The specificity was calculated to be 95.6% in the clinic and 96.9% in private practice.

Conclusions

According to the results of this study, the sensitivity of the clinical diagnosis for patients with newly detected endometriosis is very low, whereas it increases significantly for patients with recurrent disease. We recommend more investigations using non-invasive diagnostic tools. It should thereupon be possible to detect endometriosis earlier than the current delay of around nine years between the onset of symptoms and the final diagnosis.

Diffusion-weighted magnetic resonance imaging in the differentiation of endometriomas from hemorrhagic cysts in the ovary

BACKGROUND

The classic magnetic resonance imaging (MRI) feature of endometriomas is the shading sign, which is characterized by T2-shortening in ovarian cystic lesions that are hyperintense on T1-weighted images. The shading sign is infrequently observed in hemorrhagic ovarian cysts.

PURPOSE

To investigate the value of MRI with diffusion-weighted imaging (DWI) for distinguishing endometriomas from hemorrhagic cysts in the ovary.

MATERIAL AND METHODS

This retrospective study included 91 patients with 98 ovarian endometriomas and 21 hemorrhagic ovarian cysts that were confirmed pathologically, who had undergone MRI with DWI. Two radiologists compared MRI features, including size, bilaterality, multilocularity, the shading sign, the ovarian lesion/muscle signal intensity ratio at T2-weighted images, and T2 dark spots, between endometriomas and hemorrhagic cysts. We also compared the mean ADC value between endometriomas and hemorrhagic cysts, and determined the optimal cutoff ADC value for differentiating endometriomas from hemorrhagic cysts.

RESULTS

The size and mean ADC values were significantly different between endometriomas and hemorrhagic cysts. The mean ADC values of endometriomas and hemorrhagic cysts were 1.06 ± 0.38 × 10 (-3) mm(2)/s and 0.73 ± 0.29 × 10(-3) mm(2)/s, respectively (P < 0.002). The optimal cutoff ADC value for differentiating endometriomas from hemorrhagic cysts was 0.849 × 10(-3) mm(2)/s (sensitivity, 77.6%; specificity, 76.2%).

CONCLUSION

The addition of DWI could help in differentiating endometriomas from hemorrhagic cysts in the ovary, when conventional MRI is challenging.

Expect the unexpected: Endometriosis mimicking a rectal carcinoma in a post-menopausal lady

Altered bowels habits along with rectal mass in an elderly would point toward a rectal cancer. We report an unusual case of a post-menopausal lady who presented with these complaints. We had difficulties in establishing a pre-operative diagnosis. With a tentative diagnosis of a rectal cancer/gastrointestinal stromal tumor, she underwent a laparoscopic anterior resection. On histopathology, this turned out to be endometriosis. Bowel endometriosis is an uncommon occurrence. That it occurred in a post-menopausal lady was a very unusual finding. We discuss the case, its management, and the relevant literature.

Genome-wide Long Non-coding RNA Analysis Identified Circulating LncRNAs as Novel Non-invasive Diagnostic Biomarkers for Gynecological Disease

Increasing evidence indicates that long non-coding RNAs (lncRNAs) play important roles in human diseases. This study aimed to investigate the tissue and serum lncRNAs that are differentially expressed between patients with endometriosis, a gynecological disease, to evaluate the potential of these lncRNAs as non-invasive markers for the disease. The differentially expressed lncRNAs as competing endogenous RNAs (ceRNAs) were also analyzed to predict their functions in disease development. Genome-wide profiling of lncRNA expression patterns revealed that many lncRNAs were abnormally expressed between sera and tissuesof the patient samples. A set of aberrant differentially expressed lncRNAs were further validated in a validation cohort of 110 serum and 24 tissue samples. Functional analysis predicted that differentially expressed lncRNAs may participate in disease development through crosstalk between the ceRNAs of miRNAs and may be involved in a range of cellular pathways including steroid or hormone responses. We also found a unique set of lncRNAs that were associated with disease severity and progression, and their diagnostic values were also investigated. Our study demonstrated that lncRNAs could potentially serve as non-invasive biomarkers for the diagnosis of endometriosis and as important regulators in the progression of this disease.

Performance of Circulating Placental Growth Factor as A Screening Marker for Diagnosis of Ovarian Endometriosis: A Pilot Study

Background

The aim of this study is to compare the circulating placental growth factor (PlGF) concentration in women with and without endometrioma to verify the performance of this marker to diagnose the disease.

Materials and Methods

In this case-control study, thirteen women with histological diagnosis of ovarian endometriosis were compared with women without endometriosis disease. PlGF plasma levels of endometriotic patients and controls were investigated using a fluorescence immunoassay technique.

Results

PlGF showed a direct correlation with body mass index (BMI) only in the control group (P=0.013). After adjustment for BMI values, PlGF median value in endometriosis group (14.7 pg/mL) resulted higher than in control group (13.8 pg/ mL, P=0.004).

Conclusion

PlGF is a promising peripheral blood marker that can discriminate between patients with and without ovarian endometriosis.

Endometriosis presenting as carcinoma colon in a perimenopausal woman

Endometriosis is a common benign disease of reproductive age women, and can involve the intestinal tract. Inconsistent clinical presentation, similar features on radiological imaging and colonoscopy with other inflammatory and malignant lesions of the bowel makes the preoperative diagnosis of bowel endometriosis difficult. We present a case of a 42-year-old perimenopausal female clinically presented, investigated and managed in the lines of carcinoma of sigmoid colon. She underwent terminal ileac resection with end to end anastomoses, Hartmann's procedure and total hysterectomy with bilateral salpingoophorectomy. The histopathological report revealed endometriosis of small intestine, large intestine, mesentery, right ovary and adenomyoma of uterus. Thus, bowel endometriosis should also be considered as differential diagnosis in reproductive age women with gastrointestinal symptoms or intestinal mass of uncertain diagnosis.

Asymmetric dimethylarginine (ADMA), nitric oxide metabolite, and estradiol levels in serum and peritoneal fluid in women with endometriosis

BACKGROUND

Increase in nitric oxide (NO) concentration accompanied by alteration in peritoneal immune defense reactions is involved in the pathogenesis of endometriosis. Asymmetric dimethylarginine is an endogenous competitive inhibitor of NO synthase. This study was designed to compare NO metabolite (nitrite), asymmetric dimethylarginine, and estradiol concentrations in serum and peritoneal fluid (PF) of patients with and without endometriosis.

MATERIALS AND METHODS

Subjects were assigned to two groups based on their laparoscopic results. The groups consisted of women with and without endometriosis (90 and 89 participants, respectively). The serum and peritoneal levels of nitrite (stable NO metabolite), asymmetric dimethylarginine, and estradiol were measured using enzyme-linked immunosorbent assay (ELISA) kits. These parameters were analyzed and compared between the groups statistically using SPSS software version 16.

RESULTS

Both nitrite and asymmetric dimethylarginine levels were significantly higher in the serum of the participants from both groups than those in the PF group (P < 0.05). However, no significant difference in the asymmetric dimethylarginine level was detected between the two groups. In addition, the PF level of nitrite increased significantly in patients with endometriosis when compared with non-endometriosis subjects (P < 0.05). The PF levels of estradiol in both groups were significantly higher than the serum levels of estradiol (P < 0.05).

CONCLUSIONS

The NO metabolite level of PF implies the possible role of NO in the pathogenesis of endometriosis.

Potential role of cervicovaginal extracellular particles in diagnosis of endometriosis

Background

Macaques are an excellent model for many human diseases, including reproductive diseases such as endometriosis. A long-recognized need for early biomarkers of endometriosis has not yet resulted in consensus. While biomarker studies have examined many bodily fluids and targets, cervicovaginal secretions have been relatively under-investigated. Extracellular vesicles (EVs, including exosomes and microvesicles) are found in every biofluid examined, carry cargo including proteins and RNA, and may participate in intercellular signaling. Little is known about EVs in the cervicovaginal compartment, including the effects of reproductive tract disease on quantity and quality of EVs.

Case presentation

In September 2014, a 9-year-old rhesus macaque was diagnosed with endometriosis at The Johns Hopkins University School of Medicine. Ultrasound-guided fine needle aspiration of a cyst and subsequent laparotomy confirmed diagnosis. The animal was sent to necropsy following euthanasia for humane reasons. Perimortem vaginal swabs and cervicovaginal lavages were obtained. Using a combination of methods, including ultracentrifugation and NanoSight visualization technology, approximate numbers of EVs from each sample were calculated and compared to populations of EVs from other, reproductively normal macaques. Fewer EVs were recovered from the endometriosis samples as compared with those from reproductively healthy individuals.

Conclusion

To our knowledge, this is the first examination of EVs in primate cervicovaginal secretions, including those of a macaque with endometriosis. This case study suggests that additional research is justified to determine whether quantification of EVs—or their molecular cargo—in cervicovaginal lavage and vaginal swabs may provide a novel, relatively non-invasive diagnostic for primate endometrial disease or other reproductive tract diseases.

Diagnostic value of serum CA125, CA19-9 and CA15-3 in endometriosis: A meta-analysis

Aim

To evaluate the diagnostic value of serum cancer antigen (CA)125, CA19-9 and CA15-3 concentrations in endometriosis.

Methods

Case–control studies evaluating CA125, CA19-9 and CA15-3 and endometriosis, published between January 2000 and November 2014 were retrieved from PubMed® and Google Scholar. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated. Subgroup analyses were carried out by ethnicity and disease stage (early, stage I/II; advanced, stage III/IV).

Results

The analysis included 12 case–control studies (963 cases, 855 controls). CA125 was associated with endometriosis in the overall population (SMD 0.82, 95% CI 0.72, 0.92), Caucasian subgroup (SMD 1.08, 95% CI 0.96, 1.19), and early (SMD 1.20, 95% CI 0.93, 1.48) or advanced disease (SMD 1.29, 95% CI 1.04, 1.55). CA19-9 was associated with endometriosis in the overall population (SMD 0.48, 95% CI 0.24, 0.72), Caucasian subgroup (SMD 0.31, 95% CI 0.07, 0.55), Asian subgroup (SMD 9.65, 95% CI 7.88, 11.42) and advanced disease (SMD 0.60, 95% CI 0.34, 0.87). CA15-3 was significantly associated with advanced disease (SMD 0.47, 95% CI 0.09, 0.84).

Conclusions

Serum CA125 and CA19-9 may represent useful biomarkers for the noninvasive diagnosis of endometriosis.

Circulating Micro-RNAs as Diagnostic Biomarkers for Endometriosis: Privation and Promise

Endometriosis represents a major medical concern in women of reproductive age. One of the remaining major hurdles for successful treatment of endometriosis is the limitation of the process of timely disease diagnosis. A simple blood test for endometriosis-specific biomarkers would offer a more timely accurate diagnosis for the disease, thus allowing for earlier treatment intervention. Although there have been considerable efforts to identify such biomarkers, no clear choice for such noninvasive diagnostic tools has been identified. Micro-RNAs are small noncoding RNAs that have been evaluated intensively as biomarkers for several diseases, and they may hold promise for a diagnosis of endometriosis. In this review, we highlight the need for noninvasive testing for endometriosis, discuss the potential use of micro-RNAs as diagnostic tools for this disease, and consider potential limitations in the use of these small RNA molecules as diagnostic markers for endometriosis.

Peripheral biomarkers of endometriosis: a systematic review

BACKGROUND

Endometriosis is estimated to affect 1 in 10 women during the reproductive years. There is often delay in making the diagnosis, mainly due to the non-specific nature of the associated symptoms and the need to verify the disease surgically. A biomarker that is simple to measure could help clinicians to diagnose (or at least exclude) endometriosis; it might also allow the effects of treatment to be monitored. If effective, such a marker or panel of markers could prevent unnecessary diagnostic procedures and/or recognize treatment failure at an early stage.

METHODS

We used QUADAS (Quality Assessment of Diagnostic Accuracy Studies) criteria to perform a systematic review of the literature over the last 25 years to assess critically the clinical value of all proposed biomarkers for endometriosis in serum, plasma and urine.

RESULTS

We identified over 100 putative biomarkers in publications that met the selection criteria. We were unable to identify a single biomarker or panel of biomarkers that have unequivocally been shown to be clinically useful.

CONCLUSIONS

Peripheral biomarkers show promise as diagnostic aids, but further research is necessary before they can be recommended in routine clinical care. Panels of markers may allow increased sensitivity and specificity of any diagnostic test.

Diagnosis and management of endometriosis: the role of the advanced practice nurse in primary care

PURPOSE

To discuss the etiology, clinical presentation, diagnosis, and management of endometriosis for the advanced practice nurse (APN) in primary care.

DATA SOURCES

Selected research, clinical studies, clinical practice guidelines, and review articles.

CONCLUSIONS

Commonly encountered by the APN in primary care, endometriosis is a chronic, progressive inflammatory disease characterized by endometrial lesions, cysts, fibrosis, or adhesions in the pelvic cavity, causing chronic pelvic pain and infertility in women of reproductive age. Because of its frequently normal physical examination findings, variable clinical presentations, and nonspecific, overlapping symptoms with other conditions, endometriosis can be difficult to diagnose. As there currently are no accurate noninvasive diagnostic tests specific for endometriosis, it is imperative for the APN to become knowledgeable about the etiology, clinical presentation, diagnosis, and current treatment options of this disease.

IMPLICATIONS FOR PRACTICE

The APN in primary care plays an essential role in health promotion through disease management and infertility prevention by providing support and much needed information to the patient with endometriosis. APNs can also facilitate quality of care and manage treatments effectively to improve quality of life, reduce pain, and prevent further progression of disease. Practice recommendations include timely diagnosis, pain management, infertility counseling, patient education, and support for quality of life issues.

Magnetic resonance neurography for the diagnosis of extrapelvic sciatic endometriosis

OBJECTIVE

To illustrate magnetic resonance neurography findings of severe sciatic injury and muscle denervation related to deep gluteal endometriosis at the sciatic notch.

DESIGN

Case report.

SETTING

Academic teaching hospital.

PATIENT(S)

A 39-year-old woman with a 4-year history of sciatica related to the menstrual cycle.

INTERVENTION(S)

Surgical exploration of the sciatic notch for diagnostic confirmation, external neurolysis of the sciatic nerve, and eventual pharmacologic treatment.

MAIN OUTCOME MEASURE(S)

Magnetic resonance neurography imaging revealed severe neuropathic injury and muscle denervation related to a deep infiltrative endometriotic focus at the sciatic notch, which was confirmed histologically on surgical exploration. Detailed electrodiagnostic and clinical neurologic examinations at initial presentation and during follow-up were obtained for further assessment of nerve degeneration, muscle denervation, and clinical recovery.

RESULT(S)

Initial gynecologic and eventual laparoscopic evaluation on persisting complaints were without pathological findings. When a progressive weakness of the leg was noted, magnetic resonance neurography revealed a severe axonal damage to the sciatic nerve and denervation of distal target muscles related to a diffuse infiltrative lesion at the sciatic notch. On surgical exploration, extragenital endometriosis was confirmed histologically. Considerable improvement in pain and strength occurred after pharmacologic therapy with a GnRH analogue.

CONCLUSION(S)

This is the first report to describe imaging findings of magnetic resonance neurography in severe neuropathic injury of the sciatic nerve and subsequent muscle denervation related to a deep infiltrative gluteal endometriotic focus.

Endometriosis at several sites, cyclic bowel symptoms, and the likelihood of the appendix being affected

In patients with endometriosis of the appendix, other sites are use to be affected by the disease, mainly bladder, rectosigmoid and retrocervical endometriosis. When these characteristics are present or if patients have more than three sites affected by endometriosis, the surgeon should evaluate the appendix carefully.

Diagnostic accuracy and potential limitations of transvaginal sonography for bladder endometriosis

OBJECTIVES

To evaluate the accuracy and the potential limitations of transvaginal sonography (TVS) in the preoperative evaluation of women with clinically suspected bladder endometriosis and to describe the sonographic features of the pathological condition in cases in which it was confirmed.

METHODS

In the period between 2001 and 2006, we operated on 490 patients with clinically/sonographically suspected endometriosis. In 41 cases, bladder endometriosis was diagnosed at surgery and confirmed at histopathological examination. All patients underwent TVS in a standardized manner not more than 1 month before surgery. Findings at preoperative TVS were described and compared with those at laparoscopy in order to evaluate the sensitivity, specificity, and positive and negative predictive values of TVS.

RESULTS

Bladder endometriosis was correctly identified at TVS in 18/41 cases (43.9%) while 23/41 (56.1%) patients had a negative preoperative sonogram. The sensitivity, specificity and positive and negative predictive values of TVS for bladder endometriosis were 44% (18/41), 100% (449/449), 100% (18/18) and 95% (449/472), respectively, and the total accuracy was 95% (467/490). The detection rate was strongly related to mean lesion diameter as measured by the pathologist (mean +/- SD, 42.5 +/- 22.1 mm in the nodules detected vs. 28.9 +/- 14.8 mm in the nodules missed; P = 0.029) and to a history of previous surgery for endometriosis (70.6% vs. 25.0%; P = 0.005). At TVS, the nodule was hypoechogenic, its morphology was either elongated ('comma-shaped': 12/18, 66.7%) or spherical (6/18, 33.3%), and the site involved was the dome (11/18, 61.1%) or the base (7/18, 38.9%) of the bladder. Small anechogenic cystic areas within the nodule were seen in five of the 18 patients (27.8%) and a bright hyperechogenic rim was seen in 10 (55.6%).

CONCLUSIONS

The detection rate of bladder endometriosis by TVS depends on the size of the endometriotic nodules, with detected nodules being larger than those that were missed. A history of previous surgery for endometriosis increases the likelihood of bladder endometriosis being detected on ultrasound examination.

Intestinal endometriosis mimicking carcinoma of rectum and sigmoid colon: a report of five cases

Among women with intestinal endometriosis, the sigmoid colon and rectum are the most commonly involved areas. Sometimes, the differential diagnosis of colorectal endometriosis from carcinoma of the colon and rectum is difficult due to similar colonoscopic and radiologic findings. From October 2002 to September 2007, we performed five operations with curative intent for rectal and sigmoid colon cancer that revealed intestinal endometriosis. Colonoscopic and radiologic findings were suggestive of carcinoma of rectum and sigmoid colon, such as rectal cancer, sigmoid colon cancer and gastrointestinal stromal tumor (GIST). Anterior resection was performed in two patients, low anterior resection was performed in one patient and laparoscopic low anterior resection was done in two patients. We suggest to consider also intestinal endometriosis in reproductive women presenting with gastrointestinal symptoms and an intestinal mass of unknown origin.

Endometriosis-associated nerve fibers and pain

The assessment and diagnosis of endometriosis remain elusive targets. Patient and medical-related factors add to delays in the detection and treatment. Recently, investigators have revealed specific nerve fibers present in endometriotic tissue, with existing parallels between density and pain severity. The aim of this review is to compile a comprehensive review of existing literature on endometriosis-related nerve fiber detection, and the effects of medical therapy on these neural fibers. We performed a systematic literature-based review using Medline and PubMed of nerve fibers detected in eutopic endometrium, endometriotic lesions, and the peritoneum. Various arrangements of significant medical terms and phrases consisting of endometriosis, pelvic pain, nerve fiber detection/density in endometriosis, and diagnoses methodology, including treatment and detection were applied in the search. Subsequent references used were cross-matched with existing sources to compile all additional similar reports. Similar nerve fibers were detected within lesions, endometrium, and myometrium, though at varying degrees of density. Hormonal therapy is widely used to treat endometriosis and was shown to be related to a reduction in fiber density. A direct result of specific nerve fiber detection within eutopic endometrial layers points to the use of a minimally invasive endometrial biopsy technique in reducing delay in diagnosis and subsequent possible preservation of fertility.

Anatomic distribution of posterior deeply infiltrating endometriosis on MRI after vaginal and rectal gel opacification

OBJECTIVE

The challenges of imaging posterior deeply infiltrating endometriosis with MRI are to image a small anatomic area encompassing several thin fibromuscular anatomic structures such as uterosacral ligaments, and the vaginal and rectal walls; and to image endometriotic lesions, which are fibromuscular structures and have an MRI signal intensity very close to those of surrounding fibromuscular anatomic structures.

CONCLUSION

We show the capability and potential of MRI in diagnosing and staging of posterior deeply infiltrating endometriosis after vaginal and rectal gel opacification.

Novel noninvasive detection method for endometriosis: research and development of scintigraphic survey on endometrial implants in rats

In this experimental study on endometriosis, the majority of the implants were successfully detected with technetium-(99mTc) labeled red blood cell scintigraphy.

A logistic model for the prediction of endometriosis

OBJECTIVE

To develop a model that uses individual and lesion characteristics to help surgeons choose lesions that have a high probability of containing histologically confirmed endometriosis.

DESIGN

Secondary analysis of prospectively collected information.

SETTING

Government research hospital in the United States.

PATIENT(S)

Healthy women 18-45 years of age, with chronic pelvic pain and possible endometriosis, who were enrolled in a clinical trial.

INTERVENTION(S)

All participants underwent laparoscopy, and information was collected on all visible lesions. Lesion data were randomly allocated to a training and test data set.

MAIN OUTCOME MEASURE(S)

Predictive logistic regression, with the outcome of interest being histologic diagnosis of endometriosis.

RESULT(S)

After validation, the model was applied to the complete data set, with a sensitivity of 88.4% and specificity of 24.6%. The positive predictive value was 69.2%, and the negative predictive value was 53.3%, equating to correct classification of a lesion of 66.5%. Mixed color; larger width; and location in the ovarian fossa, colon, or appendix were most strongly associated with the presence of endometriosis.

CONCLUSION(S)

This model identified characteristics that indicate high and low probabilities of biopsy-proven endometriosis. It is useful as a guide in choosing appropriate lesions for biopsy, but the improvement using the model is not great enough to replace histologic confirmation of endometriosis.

Targeting mast cells in endometriosis with janus kinase 3 inhibitor, JANEX-1

Endometriosis (EMS) is a chronic inflammatory disease of multifactorial etiology characterized by implantation and growth of endometrial glands and stroma outside the uterine cavity. EMS is a significant public health issue as it affects 15-20% of women in their reproductive age. Clinical symptoms may include pelvic pain, dysmenorrhea, dyspareunia, pelvic/abdominal masses, and infertility. Symptomatic treatments such as surgical resection and/or hormonal suppression of ovarian function and analgesics are not as effective as desired. Consequently, there is an enormous unmet need to develop effective medical therapy capable of preventing the occurrence and recurrence of EMS without undesirable side-effects. EMS-associated intra-abdominal bleeding episodes, local inflammation, adhesions, and i.p. immunologic dysfunction leads to pelvic nociception and pelvic pain. Increasing evidence supports the involvement of allergic-type inflammation in EMS. Invasion of mast cells, degranulation, and proliferation of interstitial component are observed in endometriotic lesions. Presence of activated and degranulating mast cells within the nerve structures can contribute to the development of pain and hyperalgesia by direct effects on primary nociceptive neurons. Therefore, treatments targeting endometrial mast cells may prove effective in preventing or alleviating EMS-associated symptoms. The Janus kinase 3 (JAK3) is abundantly expressed in mast cells and is required for the full expression of high-affinity IgE receptor-mediated mast cell inflammatory sequelae. JANEX-1/WHI-P131 is a rationally designed novel JAK3 inhibitor with potent anti-inflammatory activity in several cellular and in vivo animal models of inflammation, including mouse models of peritonitis, colitis, cellulitis, sunburn, and airway inflammation with favorable toxicity and pharmacokinetic profile. We hypothesize that JAK3 inhibitors, especially JANEX-1, may prove useful to prevent or alleviate the symptoms of EMS.

Human endometriosis is associated with plasma cells and overexpression of B lymphocyte stimulator

Endometriosis affects 10-20% of women of reproductive age and is associated with pelvic pain and infertility, and its pathogenesis is not well understood. We used genomewide transcriptional profiling to characterize endometriosis and found that it exhibits a gene expression signature consistent with an underlying autoimmune mechanism. Endometriosis lesions are characterized by the presence of abundant plasma cells, many of which produce IgM, and macrophages that produce BLyS/BAFF/TNFSF13B, a member of the TNF superfamily implicated in other autoimmune diseases. B lymphocyte stimulator (BLyS) protein was found elevated in the serum of endometriosis patients. These observations suggest a model for the pathology of endometriosis where BLyS-responsive plasma cells interact with retrograde menstrual tissues to give rise to endometriosis lesions.

Serum cytokines as biomarkers for nonsurgical prediction of endometriosis

OBJECTIVE

To test the ability of a group of serum cytokines, either individually or in combination, to serve as biomarkers for the nonsurgical diagnosis of endometriosis.

STUDY DESIGN

Subjects were allocated to two groups according to their laparoscopic diagnosis. The first group consisted of patients with endometriosis and the second group was made up of infertile women with no pelvic pathology (controls). Blood samples were collected preoperatively and stored. Cytokines were measured in the serum of all participants using the Bio-Plex Protein Array System. Nonparametric statistics and the Mann-Whitney test were used to compare groups. Subjects were seen at the Gynecologic endoscopy unit.

RESULTS

Three cytokines were significantly higher in the serum of subjects with endometriosis than in the control group: interleukin-6 (IL-6) [4.41 pg/ml (range: 1.47-15.01) versus 0.97 pg/ml (range: 0.29-2.98), respectively; p<0.001], monocyte chemotactic protein-1 (MCP-1) [37.91 pg/ml (range: 24.54-94.74) versus 22.13 pg/ml (range: 13.85-39.45), respectively; p<0.001], and interferon-gamma (INF-gamma) [19.01 pg/ml (range: 1.19-73.52) versus 0.30 pg/ml (range: 0.00-13.05), respectively; p<0.001]. There was no statistically significant difference between subjects with endometriosis and controls in the serum concentration of vascular endothelial growth factor (VEGF), tumor necrosis factor-alpha (TNF-alpha), or granulocyte macrophage colony stimulating factor (GM-CSF). Interleukin-2 (IL-2), interleukin-8 (IL-8), and interleukin-15 (IL-15) were undetectable in the serum of both groups. None of the measured cytokines showed significant correlation with the cycle phase or stage of endometriosis. In a multivariate analysis, serum interleukin-6 provided a sensitivity of 71% and a specificity of 66% to discriminate between endometriosis patients and controls at a cutoff point of 1.9 pg/ml. Adding monocyte chemotactic protein-1 and interferon-gamma to interleukin-6 did not increase the discriminative ability over that achieved by measuring serum interleukin-6 alone.

CONCLUSIONS

Serum of subjects with endometriosis contains significantly higher levels of interleukin-6, monocyte chemotactic protein-1, and interferon-gamma than control women. Serum interleukin-6 measurements discriminate between women with endometriosis and controls. Interleukin-6 provides a promising serum marker for the nonsurgical prediction of endometriosis.

Subhepatic retroperitoneal endometrioma: report of a case

A 38-year-old woman with a history of pelvic endometriosis was referred to our surgical department for the treatment of a cystic lesion most probably originating from the liver. At the laparotomy a solitary cyst was found in the retroperitoneum, connected to the inferior surface of the liver, and was resected. Histopathological examination of the resected specimen revealed that it was an endometriotic cyst. The occurrence of endometriotic cyst in the upper abdomen is very rare: there are no published reports of an endometriotic cyst in that anatomic location. The literature on this subject is reviewed.

Intestinal Obstruction Due to Rectal Endometriosis: A Surgical Enigma

Obstructed rectal endometriosis is an uncommon presentation. The clinical and intraoperative presentation may present as malignant obstruction. The difficulty in making the diagnosis may delay the definitive management of the patient. We report a unique case of rectal endometriosis mimicking malignant rectal mass causing intestinal obstruction and discuss the management of the case.

Uterine adenomyoma presenting as a vesico-uterine endometrioma

This is an image case report of a 5-cm uterine adenomyoma in a 38-year-old asymptomatic woman, presenting as a vesico-uterine endometrioma in both ultrasound scan and magnetic resonance imaging.

Endometriosis: What is the risk of hospital admission, readmission, and major surgical intervention?

STUDY OBJECTIVE

To describe trends in hospital utilization and surgical rates for endometriosis and to estimate the probability of hospital readmission over 4 years among women with early-stage disease.

DESIGN

Population-based, retrospective cross-sectional and longitudinal analysis of 53,385 hospital admissions for same-day surgery or inpatient treatment of endometriosis from fiscal years 1994/95 through 2001/02 (Canadian Task Force classification III).

SETTING

All hospital discharge records that listed endometriosis as the most-responsible diagnosis in the province of Ontario, Canada, from fiscal years 1994-1995 through 2001-2002.

PATIENTS

Ontario female patients 15 years of age or older admitted to the hospital for treatment of endometriosis.

INTERVENTIONS

Surgical treatments were classified as minor, intermediate, or major depending on the extent of the surgery.

MEASUREMENTS AND MAIN RESULTS

Age-standardized annual discharge rates were calculated and trends in surgical treatment described. The records of 7993 women who received minor or intermediate surgery on their index hospital visit were linked, and the likelihood and predictors of readmission were calculated using survival analysis and logistic regression. During the observation period, the standardized discharge rates fell significantly from 172.9 per 100,000 women aged 15 to 70 to 137.1 per 100,000 (p<.05). Age-specific rates were highest for women aged 15 to 39 (approximately 200 per 100,000). The proportion of hospitalizations involving minor surgeries dropped (from 27% to 17%), and the proportion involving intermediate surgeries increased (from 40% to 53%). The likelihood of hospital readmission within 4 years for additional surgical treatment was 27% and of having a hysterectomy was 12%.

CONCLUSION

Fewer women are being hospitalized for minor surgical procedures for endometriosis with hospital-based care being reserved for more extensive procedures. Nonetheless, about a quarter of women hospitalized for initial surgical treatment for endometriosis will undergo additional surgical treatment within 4 years, and one in 10 will have a hysterectomy.

Successful laparoscopic treatment of ileocecal-appendicular endometriosis

Intestinal endometriosis is an uncommon clinical entity that is rarely seen by general surgeons. It traditionally requires laparoscopy for diagnosis and an open laparotomy procedure for the treatment. Herein, we report a rare case of colonic endometriosis involving the ileocecal region and left adnexal region. The management was totally laparoscopic: an ileocecal resection of the lesions was successfully performed. Endometriosis was not suspected preoperatively; however, it became a differential diagnosis during the operation and then confirmed by the histopathologic examination. We discuss the investigation process, surgical management, and prognosis related to ectopic endometriosis.

A predictive model for endometriosis

BACKGROUND

Aromatase is the key enzyme in the process of estrogen biosynthesis from the precursor androgen. Recently, aromatase has been found to be aberrantly expressed in eutopic endometrium of patients suffering from endometriosis. This finding has prompted speculation about the contribution of this enzyme to the prediction of this disease.

METHODS

We prospectively aimed to evaluate whether endometrial biopsy, prior to laparoscopy in symptomatic women to screen for the presence of aromatase by real-time RT-PCR and immunohistochemistry, combined with select patients' characteristics, is of value to predict endometriosis.

RESULTS

Of 48 consecutive symptomatic and eligible patients, 25 (52.1%) exhibited endometriosis and 23 (47.9%) were disease-free. A multiple logistic regression model revealed that 95.5% of patients whose eutopic endometrium was found to be positive for aromatase mRNA as well as immunohistochemically detected protein and who were additionally suffering from moderate to severe dysmenorrhoea (visual analogue scale score >4/10) exhibited endometriosis at laparoscopy.

CONCLUSIONS

These findings provide direct evidence that screening for eutopic endometrial aromatase in combination with clinical data could be of discriminative value in the prediction of disease.