The outcomes of repeat surgery for recurrent symptomatic endometriosis

Retrospective review of endometriosis surgery at Te Whatu Ora - Capital and Coast

INTRODUCTION

Endometriosis is an under-researched disease, with Aotearoa-specific data severely lacking. Current estimates of parameters such as rates of endometriosis diagnosis, indication for surgery and sites of disease are based on international data. There is currently no published data on endometriosis surgeries in Aotearoa New Zealand.

AIMS

We aimed to describe the laparoscopic surgeries conducted for suspected endometriosis at Te Whatu Ora - Capital and Coast, including the prevalence of endometriosis in this cohort, indication for surgery, symptoms experienced, endometriosis stage and sites involved, number of repeat laparoscopies, and prevalence of endometriosis at repeat surgery.

MATERIALS AND METHODS

To conduct this retrospective cross-sectional study, data were extracted from Te Whatu Ora - Capital and Coast systems to identify all records indicating surgery for suspected endometriosis during 2018 and 2019. Variables investigated included age, ethnicity, endometriosis diagnosis (International Classification of Diseases-10 Clinical Modification coding), stage of endometriosis, histological report and endometriosis symptoms (pain and/or fertility).

RESULTS

There were 436 surgeries for suspected endometriosis performed during 2018 and 2019, and endometriosis was diagnosed in 68.3% of these surgeries. Pacific and Asian people were under-represented in the study cohort compared to the demographics of the hospital catchment area (Pacific: 3.0% vs 8.4%, Asian: 9.9% vs 12.9%). The most common indication for surgery was pain. There were 76 surgeries performed for suspected recurrence of endometriosis, and endometriosis was identified in 55.6% of these.

CONCLUSIONS

Endometriosis surgeries in this hospital in Aotearoa show similar presentations and surgical findings to international data. Our findings highlight areas requiring more research in an Aotearoa-specific context.

The Expression of Kisspeptins and Matrix Metalloproteinases in Extragenital Endometriosis

Endometriosis is characterized by a condition where endometrial tissue grows outside the uterine cavity. The mechanisms of endometrium growth during endometriosis might be similar to the development of a tumor. The kisspeptin (KISS1) gene was initially discovered as a suppressor of metastasis. Matrix metalloproteinases (MMPs) and their inhibitors are described as factors in the early stages of endometriosis and tumor growth progression. We applied the quantitative polymerase chain reaction and the immunofluorescence method to investigate KISS1, its receptor (KISS1R), MMP-2, and MMP-9 in the eutopic and ectopic endometrium in women with and without endometriosis. We presume that the dysregulation of KISS1 and MMPs might contribute to endometriosis pathogenesis. Samples for the immunofluorescence study were collected from patients with a confirmed diagnosis of endometriosis in stages I-IV, aged 23 to 38 years old (n = 40). The cell line was derived from the endometrium of patients with extragenital endometriosis (n = 7). KISS1 and KISS1R expression are present in the ectopic endometrium of patients with extragenital endometriosis, as opposed to the control group where these proteins were not expressed. There is a decrease in KISS1 and KISS1R values at all stages of endometriosis. MMP-2 and MMP-9 genes express statistically significant increases in stages II, III, and IV of extragenital endometriosis. MMP synthesis increased in the last stages of endometriosis. We suppose that the KISS1/KISS1R system can be used in the future as a suppressive complex to reduce MMP-2 and MMP-9 expression and prevent endometrial cells from invading.

The gut microbiota and endometriosis: From pathogenesis to diagnosis and treatment

Endometriosis is a common gynecological disease, that often leads to pain and infertility. At present, the specific pathogenesis of endometriosis has not been clarified, but it may be closely related to an imbalance of sex hormones in the body, ectopic hyperplasia stimulated by immune inflammation, and invasion and escape based on tumor characteristics. Gut microbiota is associated with many inflammatory diseases. With the further study of the gut microbiota, people are paying increasing attention to its relationship with endometriosis. Studies have shown that there is an association between the gut microbiota and endometriosis. The specific ways and mechanisms by which the gut microbiota participates in endometriosis may involve estrogen, immune inflammation, and tumor characteristics, among others. Therefore, in the future, regulating gut microbiota disorders in various ways can help in the treatment of endometriosis patients. This study reviewed the research on the gut microbiota and endometriosis in order to provide ideas for clinical diagnosis and treatment.

Progesterone Receptor Status of Epithelial Cells as a Predictive Marker for Postoperative Recurrence of Endometriosis

CONTEXT

Progesterone resistance including progesterone receptor (PR) deficiency contributes to the pathophysiology of endometriosis; however, whether the PR expression levels in ovarian endometrioma (OE) correlate with the postoperative recurrence of endometriosis remains unclear.

OBJECTIVE

This study aimed to investigate the association between PR expression levels in OE and the recurrence of endometriosis.

METHODS

OE specimens were obtained from 132 patients who underwent conservative surgery for endometriosis. The PR expression levels were evaluated using the H score after immunohistochemical staining.

RESULTS

Of the 132 patients, 36 (27.3%) experienced recurrence and 96 (72.7%) did not. No differences were observed in the patient characteristics between the recurrence and nonrecurrence groups except for follow-up period. PR immunoreactivity in the epithelial cells (ECs) was statistically significantly lower in the recurrent group than in the nonrecurrent group (P < .01); however, this change was not observed in the stromal cells. Moreover, multivariable logistic regression analysis revealed that the H score of PR in ECs was an independent factor and was statistically significantly associated with the recurrence of endometriosis (P = .01). Furthermore, we divided the patients into PR-negative or PR-positive groups. The cumulative recurrence rate in the negative PR group was statistically significantly higher than that in the positive PR group (P = .046).

CONCLUSION

Low PR expression levels in OE-ECs may predict the recurrence of endometriosis. The PR status in OE-ECs is associated with the pathophysiology of the recurrence of endometriosis, and optimized postoperative management for endometriosis may be provided by referring to the PR status.

Treatment recommendations for the management of persistent pelvic pain: A systematic review of international clinical practice guidelines

BACKGROUND

Females with persistent pelvic pain (PPP) report great variability in treatments they are recommended despite the availability of clinical practice guidelines (CPGs) that aim to standardise care. A clear consensus for the best practice care for PPP is required.

OBJECTIVE

Identify and summarise treatment recommendations across CPGs for the management of PPP, and appraise their quality.

SEARCH STRATEGY

MEDLINE, CENTRAL, EMBASE, EmCare, SCOPUS, the Cochrane Database of Systematic Reviews, Web of Science Core Collection, and relevant guideline databases were searched from their inception to June 2021.

SELECTION CRITERIA

Included CPGs were those for the management of urogynaecological conditions in adult females published in English, of any publication date, and endorsed by a professional organisation or society.

DATA COLLECTION AND ANALYSIS

We screened 1,379 records and included 20 CPGs. CPG quality was assessed using The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Descriptive synthesis compiled treatment recommendations across CPGs.

MAIN RESULTS

CPGs for seven conditions provided 281 individual recommendations. On quality appraisal, guidelines on average scored 'excellent' for the domains 'scope and purpose' (80.6%, SD=13.3) and 'clarity and presentation' (74.4%, SD=12.0); for other domains, average scores were satisfactory or poor. Four guidelines (Endometriosis, NICE, RANZCOG, ESHRE; PCOS, Teede et al. 2018) were deemed recommended for use. Recommendations were most frequent for pharmaceutical and surgical interventions. Recommendations were variable for psychological, physiotherapy, and other conservative interventions.

CONCLUSIONS

The quality of CPGs for PPP is generally poor. Several CPGs endorse the consideration of biopsychosocial elements of PPP. Yet most recommend pharmaceutical, surgical, and other biomedical interventions.

Transvaginal Photobiomodulation for the Treatment of Chronic Pelvic Pain: A Pilot Study

Background: Chronic pelvic pain (CPP) is a common and debilitating condition that affects millions of U.S. women. Most treatments are ineffective and innovative new therapies are desperately needed. Large, controlled studies show that photobiomodulation (PBM) can reduce pain in patients with other chronic pain conditions, such as low back pain, neck pain, and fibromyalgia. The objective of this pilot study was to determine if transvaginal PBM (TV-PBM) can reduce pain in women with CPP. Methods: We conducted a before and after, observational, pilot study. Patients completed the Short Form-McGill Pain Questionnaire (SF-MPQ) at baseline, 1 week, 3 months, and 6 months after nine treatments of TV-PBM. Clinicians completed the Clinical Global Impression Scale (CGI) assessing patient illness severity at the same time. Wilcoxon rank-sum t-tests and effect size using Cohen's d coefficient (low effect size if d < 0.2, medium if 0.2 < d > 8, and high if d > 0.8) was used to measure degree of pain improvement, which was also considered clinically significant if pain reduction was >30%. Results: Thirteen women completed 9 treatments, and 10 women were successfully followed to 6 months. At baseline, the mean SF-MPQ score was 19.7 (standard deviation [SD] ± 5.9). Compared with baseline, 60% improved; the mean SF-MPQ score decreased to 10.0 (SD ±7.5, p = 0.004, d = 1.6) at 1 week after treatment, to 9.7 (SD ±7.9, p = 0.005, d = 1.7) at 3 months, and 8.2 (SD ±8.1, p = 0.002, d = 1.9) at 6 months. Conclusion: Transvaginal PBM provided significant and sustained pain relief to women with CPP up to 6 months. Further controlled studies are needed to confirm these findings, however, in this initial pilot, TV-PBM shows promise.

Endometriosis and other causes of pelvic pain in perspective

Assuming we know the perfect management for endometriosis or pelvic pain is folly, but we should be celebrating our successes, not abandoning everything that we currently know.

Endometriosis and spontaneous hemoperitoneum in pregnancy: evaluation of the magnitude of the risk in women becoming pregnant via in vitro fertilization

OBJECTIVE

To estimate the frequency of spontaneous hemoperitoneum in pregnancy (SHiP) in women with endometriosis achieving pregnancy with in vitro fertilization (IVF).

DESIGN

Retrospective case series.

SETTING

Referral academic assisted reproductive technology (ART) center.

PATIENT(S)

Three hundred and forty-eight women with a history of surgery for endometriosis and women with ovarian endometriomas or deep endometriotic nodules detected at basal transvaginal ultrasound performed before IVF cycle.

INTERVENTION(S)

Information obtained from patients' charts on basal characteristics, IVF cycle, and pregnancy outcomes, and binomial distribution model created to determine the 95% confidence interval (CI) of the proportion of SHiP.

MAIN OUTCOME MEASURE(S)

Rate of SHiP.

RESULT(S)

Overall, 362 pregnancies were included, among which 238 (66%) had a history of previous surgery for endometriosis and 231 (64%) had endometriosis detected at ultrasound (107 women, 30%, had both). Pregnancies were achieved after fresh and frozen cycles in 244 (67%) and 118 (33%) women, respectively. One case of SHiP was recorded, corresponding to a rate of 0.3%.

CONCLUSION(S)

In the general population of women with endometriosis undergoing IVF, SHiP is uncommon. Future studies should better identify the risk factors for SHiP to disentangle the subgroups of women at higher risk.

Pregnancy and delivery outcomes in women with rectovaginal endometriosis treated either conservatively or operatively

OBJECTIVE

To study reproductive outcomes, and pregnancy and delivery complications after conservative or operative treatment of rectovaginal endometriosis during long-term follow-up.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

PATIENT(S)

Women with rectovaginal endometriosis referred to hospital due to any indication from 2004 to 2013 (N = 543) who were treated initially either conservatively (group CONS, n = 183), or operatively (OPER, n = 360) either with resection of rectovaginal nodule (RVR, n = 192) or with concomitant bowel resection (BR, n = 132).

INTERVENTION(S)

Conservative or operative management.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate, live-birth rate, and assessment of the complications during pregnancy and delivery.

RESULTS(S)

Between women in the CONS group or OPER group, no differences were found in either clinical pregnancy rate (56%, n = 102 vs. 50%, n = 181) or live-birth rate (48%, n = 87 vs. 42%, n = 153). Of the pregnancies, 64% (n = 65) and 49% (n = 89), respectively, started after medically assisted reproduction. No differences emerge in the subanalysis of women <40 years-old who wished to conceive. The most common pregnancy complication was preterm birth: 15% (n = 13) in the CONS group and 20% (n = 30) in the OPER group. The cesarean delivery rate also was high (46%, n = 40 vs. 49%, n = 76). Complications emerged in 21% (n = 10) versus 29% (n = 23) of vaginal deliveries and 45% (n = 18) versus 53% (n = 40) of cesarean deliveries. The most common delivery complication was excessive bleeding. The follow-up period was 4.9 years in the CONS group and 5.6 years in the OPER group.

CONCLUSION(S)

Women with rectovaginal endometriosis have comparable and good reproductive prognosis regardless of the treatment method.

Endometriosis Pain Management: a Review

PURPOSE OF REVIEW

The purpose of this review is to summarize the up-to-date pain management options and recommendations for the challenging disease, endometriosis.

RECENT FINDINGS

The mainstays of endometriosis advances of both surgical and medical management continue to evolve. Experimental pharmaceuticals include Gestirone, and aromatase inhibitors have shown promise but are still under scrutiny. Surgical techniques include laparoscopic uterosacral nerve ablation/resection and presacral neurectomy. No studies have directly compared medical versus surgical management, and as such, no one treatment modality can be recommend as superior to the other. Patients may initially be given a medical diagnosis and treated with nonsteroidal anti-inflammatory drugs, neurolepitcs, OCP, GNRH agonists/antagonists, and Danazol. Assessing the success of these regimens has proved difficult. Surgical management relies on various methods including excision/ablation of the lesions, nerve ablation, neurectomy, hysterectomy, and oophorectomy.

Endometriosis-It is not just benign

Endometriosis is a common disease, not uncommonly debilitating with severe negative impact on all domains of life for women. The long-standing approach is that endometriosis is one of many gynecological benign conditions. Nevertheless, there is a growing body of evidence linking endometriosis and invasiveness. The aim of this commentary is to address the topic of the attitude toward endometriosis as a benign disease while summarizing the current literature regarding the debate that surrounds this topic.

The role of pharmacotherapy in the treatment of endometriosis across the lifespan

INTRODUCTION

Endometriosis is estimated to affect 10% of reproductive-aged women. The gold standard for treatment is surgery; however, surgery carries a significant morbidity and cost burden. There is an ongoing need for safe, effective medical therapies for endometriosis patients, both in conjunction with and independent of surgical interventions. Most conventional therapies for endometriosis work by a similar mechanism, and efficacy is variable. In recent years, there has been increased interest in the development and testing of novel pharmacotherapies for endometriosis.

AREAS COVERED

This review discusses both conventional and emerging treatments for endometriosis. The authors present the application of these drugs in different presentations of endometriosis across the lifespan and discuss how emerging therapies might fit into future medical management of endometriosis. Conventional therapies include nonsteroidal anti-inflammatory drugs, combined oral contraceptives, progestins, GnRH agonists/antagonists, and aromatase inhibitors. Emerging therapies are focused on disease-specific targets such as endothelial growth factor receptors.

EXPERT OPINION

The field of endometriosis therapy is moving toward modifying the immune and inflammatory milieu surrounding endometrial implants. If these drugs show efficacy in clinical trials, combining them with current medical treatment is expected to result in a profound impact on symptom and disease burden for patients who suffer from endometriosis worldwide.

Curcumin-loaded nanofibers for targeting endometriosis in the peritoneum of a mouse model

Endometriosis is a common, chronic gynecological disorder associated with ongoing pelvic pain, infertility, and adhesions in reproductive age women. Current therapeutic strategies are not effective and the recurrent nature of endometriosis makes it difficult to treat. In this study, we have designed a drug delivery system to control sustained and prolonged release of curcumin in the peritoneum and pelvic cavity of a mouse model of endometriosis. Poly ε-Caprolactone (PCL) and poly ethylene glycol (PEG) polymers were used to synthesize curcumin loaded nanofibers. After scanning electron microscopy (SEM) observation of the nanofiber's morphology, we evaluated the drug release profile and in vitro degradation rate of the curcumin-loaded nanofibers. Next, we tested these nanofibers in vivo in the peritoneum of an endometriosis mouse model to determine their anti-endometriosis effects. Histological evaluations were also performed. Curcumin loaded nanofibers were successfully synthesized in the 8 and 10 wt% polymers. The release test of the curcumin-loaded nanofibers showed that approximately 23% of the loaded curcumin was released during 30 min, 35% at 24 h, and 50% at 30 days. Endometriosis was successfully induced in Balb/c mice, as noted by the observed characteristics of endometriosis in all of the mice and confirmation of endometriosis by hematoxylin and eosin (H&E) staining. In vivo experiments showed the ability of these implanted curcumin loaded nanofibers to mitigate endometriosis. We observed a considerable reduction in the endometrial glands and stroma, along with significant reduction in infiltration of inflammatory cells. Implantable curcumin loaded nanofibers successfully mitigated intraperitoneal endometriosis.

Surgical treatment of endometriosis: prognostic factors for better quality of life

The present study investigated the effect of surgical treatment of endometriosis on physical and mental health. We undertook a prospective survey including 153 premenopausal women with histological diagnosis of endometriosis. The Short Form 12 (SF-12) questionnaire comprising physical and mental component scales was used. Two groups of patients were distinguished: Group A (n = 42) with SF-12 scores above the median in both physical and mental scales; Group B (n = 111) with SF-12 scores below the median in either physical or mental scale. Group A was diagnosed and operated for endometriosis for the first time at an older age (30 vs. 26 years), had undergone more frequently a single surgical intervention (64% vs. 46%), was less affected by symptom or lesion recurrence and had reported less intense current pain symptoms than Group B. Having the first endometriosis surgery at a later age was an independent predictor of better health status (adjusted odds ratio 1.146 per year, 95% confidence interval 1.058-1.242) after accounting for the potential confounding effects of reoperation, pelvic pain and time elapsed since the first surgery. In conclusion, patients with endometriosis who had a single surgery at an older age have good symptom control and better quality of life (QoL).

Negative laparoscopy unveiled

Introduction:

Studies indicate a variable proportion of laparoscopies done for the management of non-acute pelvic pain that do not identify visible pathology and are called negative laparoscopies. Possible explanations have included undetected endometriosis, observer error, and/or neural tissues in the endometrium acting as nociceptive input. The goal was to compare demographic and pain testing measures between women with negative laparoscopies and confirmed endometriosis in a cohort of women presenting with chronic pelvic pain.

Methods:

Women with chronic pelvic pain (n = 255) provided written consent for the study prior to entry. Data were collected at the time of clinic visit and entered contemporaneously into SPSS. Pain sensitization was identified as the presence of cutaneous allodynia. Clinical, pain, and pain sensitization variables were compared using Student’s t-test.

Results:

The frequency of negative laparoscopy was 13.7% (35 cases) and that of confirmed endometriosis was 27.1% (69 cases). There were no differences between women with a negative laparoscopy and women with confirmed endometriosis in clinical, dysmenorrhea, or pain testing measurements.

Conclusion:

The data suggest in the absence of endometriotic tissue in the pelvis, chronic visceral pain may result from a uterine origin and result in a generalized pattern of pain and pain sensitization.

Treatment Patterns, Complications, and Health Care Utilization Among Endometriosis Patients Undergoing a Laparoscopy or a Hysterectomy: A Retrospective Claims Analysis

INTRODUCTION

Hysterectomy and laparoscopy are common surgical procedures used for the treatment of endometriosis. This study compares outcomes for women who received either procedure within the first year post initial surgery.

METHODS

The study used data from the Truven Health MarketScan claims databases from 2004 to 2013 to identify women aged 18-49 years who received an endometriosis-related laparoscopy or hysterectomy. Patients were excluded if they did not have continuous insurance coverage from 1 year before through 1 year after their endometriosis-related procedure, if they were diagnosed with uterine fibroids prior to or on the date of surgery (i.e., index date), or if they had a hysterectomy prior to the index date. The descriptive analyses examined differences between patients with an endometriosis-related laparoscopy or hysterectomy in regard to medications prescribed, complications, and hospitalizations during the immediate year post procedure.

RESULTS

The final sample consisted of 24,915 women who underwent a hysterectomy and 37,308 who underwent a laparoscopy. Results revealed significant differences between the cohorts, with women who received a laparoscopy more likely to be prescribed a GnRH agonist, progestin, danazol, or an opioid analgesic in the immediate year post procedure compared to women who underwent a hysterectomy. In contrast, women who underwent a hysterectomy generally had higher complication rates. Index hospitalization rates and length of stay (LOS) were higher for women who had a hysterectomy, while post-index hospitalization rates and LOS were higher for women who had a laparoscopy. For both cohorts, post-procedure complications were associated with significantly higher hospitalization rates and longer LOS.

CONCLUSION

This study indicated significantly different 1-year post-surgical outcomes for patients who underwent an endometriosis-related hysterectomy relative to a laparoscopy. Furthermore, the endometriosis patients in this analysis had a considerable risk of surgical complications, subsequent surgeries, and hospital admissions, both during and after their initial therapeutic laparoscopy or hysterectomy.

FUNDING

AbbVie.

An Interdisciplinary Approach to Endometriosis-associated Persistent Pelvic Pain

Endometriosis-associated pelvic pain is a common and often challenging problem. For certain patients, pain persists or recurs despite adequate medical or surgical therapy targeted to endometriosis. In this patient population, there is often the presence of coexisting pain conditions such as irritable bowel syndrome, painful bladder syndrome and myofascial pain as well central sensitisation. An interdisciplinary approach where both peripheral pain triggers and central sensitization are addressed is likely to lead to improved pain and quality of life. The approach to the evaluation and treatment of the patients with persistent/chronic pelvic pain and endometriosis is outlined in this article.

Surgery for endometriosis: beyond medical therapies

Endometriosis-associated pelvic pain and subfertility may be managed medically in many cases; however, the surgical management of this insidious disease remains a necessary part of the treatment algorithm. Laparoscopy for diagnosis alone is rarely indicated with the advancements in preoperative imaging. When surgery is performed, the ideal goal would be a therapeutic and effective surgical intervention based on the preoperative evaluation. Surgery for women with pain due to endometriosis may be indicated in patients who cannot or do not wish to take medical therapies; acute surgical or pain events; deep endometriosis; during concomitant management of other gynecologic disorders; and patients seeking fertility with pain. The role of surgery for endometriosis-related subfertility may be considered in those with hydrosalpinges undergoing IVF; management of ovarian endometriomas in specific circumstances; and when a patient requests surgery as an alternative to assisted reproductive technology (ART). Surgery for ovarian endometriomas requires special attention due to the risk of potential harm on future fertility. Finally, a combined approach of surgery followed by postoperative medical therapy offers the best long-term outcomes for recurrence of disease and symptoms. A patient-centered approach and a goal-oriented approach are essential when determining the options for care in this population.

Deep infiltrating endometriosis affecting the urinary tract-surgical treatment and fertility outcomes in 2004-2013

Urinary tract endometriosis (UTE) is a rare form of deep infiltrating endometriosis. We studied the operative treatment of UTE and evaluated postoperative recurrences and fertility outcomes. This is a retrospective cohort study of 53 women who underwent operative treatment for UTE in 2004–2013 at Helsinki University Hospital, and were followed-up until the end of 2014. The data were gathered from the hospital’s electronic database. The main outcome measures were complications, reoperations, postoperative pregnancies, and deliveries. Preoperative diagnosis was accurate in 72 % with bladder endometriosis and in 93 % with ureteral disease. Thirty-one (58 %) of the 53 operations were performed via laparoscopy. Postoperative complications requiring re-intervention occurred in five cases (9 %). Five reoperations were performed in four cases due to endometriosis recurrence, only two due to recurrence of UTE (4 %). Twenty-eight women wished for pregnancy; 18 (64 %) of them conceived. Infertility treatment was needed in 20 (71 %) cases. Twelve (75 %) women delivered via cesarean section; intraoperative difficulties occurred in ten (83 %). The complication rate with UTE operations is acceptable and recurrences are rare. Infertility is common, but 57 % of those who wished for a child succeeded. A majority of the deliveries involved unplanned and complicated cesarean section.

Neuromodulation for the Treatment of Endometriosis-Related Symptoms

Sacral and pudendal neuromodulation have been advocated for the treatment of refractory pelvic pain, urinary urgency and retention, as well as fecal incontinence or constipation, all of which are commonly related to endometriosis and/or its surgical treatment.

In this review, the mechanisms of action and different routes of neuromodulation will be detailed, as well as all the studied applications of neuromodulation on ameliorating symptoms related to endometriosis and/or its treatment.

Exploring the Relationship between Endometriomas and Infertility

Several clinical and epidemiological studies demonstrated an association between endometriosis and infertility. A role in the genesis of infertility may be played by endometriomas, which may interfere with ovulation or damage ovarian tissue. Unlike peritoneal implants, the availability of an accurate noninvasive sonographic diagnosis facilitates the investigation of endometrioma associated infertility. The laparoscopic excision of an endometrioma relieves the ovary from the damage caused by the cyst itself, which may be progressive over time, but at the same time is associated with a detrimental effect on ovarian reserve and with high rates of postoperative endometrioma recurrence. Therefore, the management of endometrioma-related infertility should not be based upon surgery alone, but upon a combination of surgery, with a refinement of the operating technique, long-term oral contraceptive, in vitro fertilization and oocyte cryopreservation.

Clear cell thymic carcinoma: a case report

Clear cell thymic carcinoma is a rare and invasive tumor of the mediastinum for which there are no uniform treatment guidelines. The combination of carboplatin plus paclitaxel seems to be the most effective regimen for this disease. We report a case of locally advanced clear cell thymic carcinoma treated with this schedule, in which we observed a relevant and rapid tumor shrinkage.

Current strategies for endometriosis management

Endometriosis is a common gynecologic disorder that persists throughout the reproductive years. Although endometriosis is a surgical diagnosis, medical management with ovarian suppression remains the mainstay of long-term management with superimposed surgical intervention when needed. The goal of surgery should be excision or ablation of all visible disease to minimize risk of recurrence and need for repeat surgeries. When infertility is the presenting symptom, surgical therapy in addition to assisted reproductive technology can improve chances of conception; however, the treatment approach depends on stage of disease and other patient characteristics that affect fecundity.

ERβ- and prostaglandin E2-regulated pathways integrate cell proliferation via Ras-like and estrogen-regulated growth inhibitor in endometriosis

In endometriosis, stromal and epithelial cells from the endometrium form extrauterine lesions and persist in response to estrogen (E2) and prostaglandin E2 (PGE2). Stromal cells produce excessive quantities of estrogen and PGE2 in a feed-forward manner. However, it is unknown how estrogen stimulates cell proliferation and survival for the establishment and persistence of disease. Previous studies suggest that estrogen receptor-β (ERβ) is strikingly overexpressed in endometriotic stromal cells. Thus, we integrated genome-wide ERβ binding data from previously published studies in breast cells and gene expression profiles in human endometriosis and endometrial tissues (total sample number = 81) and identified Ras-like, estrogen-regulated, growth inhibitor (RERG) as an ERβ target. Estradiol potently induced RERG mRNA and protein levels in primary endometriotic stromal cells. Chromatin immunoprecipitation demonstrated E2-induced enrichment of ERβ at the RERG promoter region. PGE2 via protein kinase A phosphorylated RERG and enhanced the nuclear translocation of RERG. RERG induced the proliferation of primary endometriotic cells. Overall, we demonstrated that E2/ERβ and PGE2 integrate at RERG, leading to increased endometriotic cell proliferation and represents a novel candidate for therapeutic intervention.

Impact of surgical excision of lesions on pain in a rat model of endometriosis

BACKGROUND

Chronic pain is the most common and disabling feature of endometriosis. Surgical excision of endometriosis lesions provides relief but pain relapse is common. Studies in a preclinical model of endometriosis might help to unravel the role of the ectopic lesions as the source of pain. Thus, we evaluated the impact of lesion excision on mechanical hyperalgesia in a preclinical model of endometriosis pain.

METHODS

Endometriosis was induced by implanting autologous uterine tissue onto the gastrocnemius muscle. Surgical excision or aspiration drainage of the cystic lesion was performed at different times post-implant and mechanical nociceptive thresholds were assessed at the site of the lesion.

RESULTS

Lesions at 2, 8 and 16 weeks post-implant produced mechanical hyperalgesia of similar magnitude (n = 6/group). Excision of lesions (n = 6/group) produced a longer inhibition, with a magnitude and time course depending upon the timing of excision. Excision at 2 and 8 weeks produced a rapid onset marked attenuation of hyperalgesia, which returned to pre-excision values by post-surgical week 3. In contrast, excision of the lesion at 16 weeks produced a peak of inhibition of hyperalgesia 2 weeks post-excision, but then the inhibition was sustained. Aspiration of fluid from cysts in the lesions briefly attenuated mechanical hyperalgesia (n = 6/group).

CONCLUSIONS

In this preclinical model, we demonstrate that endometriosis pain is alleviated by surgical excision of the ectopic lesion or drainage of its cysts, providing support for the clinical observation that endometriosis pain is dependent upon the ongoing presence of the lesions.

Endometriosis: pathogenesis and treatment

Endometriosis is defined as the presence of endometrial-type mucosa outside the uterine cavity. Of the proposed pathogenic theories (retrograde menstruation, coelomic metaplasia and Müllerian remnants), none explain all the different types of endometriosis. According to the most convincing model, the retrograde menstruation hypothesis, endometrial fragments reaching the pelvis via transtubal retrograde flow, implant onto the peritoneum and abdominal organs, proliferate and cause chronic inflammation with formation of adhesions. The number and amount of menstrual flows together with genetic and environmental factors determines the degree of phenotypic expression of the disease. Endometriosis is estrogen-dependent, manifests during reproductive years and is associated with pain and infertility. Dysmenorrhoea, deep dyspareunia, dyschezia and dysuria are the most frequently reported symptoms. Standard diagnosis is carried out by direct visualization and histologic examination of lesions. Pain can be treated by excising peritoneal implants, deep nodules and ovarian cysts, or inducing lesion suppression by abolishing ovulation and menstruation through hormonal manipulation with progestins, oral contraceptives and gonadotropin-releasing hormone agonists. Medical therapy is symptomatic, not cytoreductive; surgery is associated with high recurrence rates. Although lesion eradication is considered a fertility-enhancing procedure, the benefit on reproductive performance is moderate. Assisted reproductive technologies constitute a valid alternative. Endometriosis is associated with a 50% increase in the risk of epithelial ovarian cancer, but preventive interventions are feasible.

Treatment of pelvic pain associated with endometriosis: a committee opinion

Pain associated with endometriosis may involve many mechanisms and requires careful evaluation to confirm the diagnosis and exclude other potential causes. Both medical and surgical treatments for pain related to endometriosis are effective, and choice of treatment must be individualized. This document replaces the document by the same name last published in 2008 (Fertil Steril 2008;90:S260-9).

Recurrence of ovarian endometrioma after second-line, conservative, laparoscopic cyst enucleation

OBJECTIVE

We sought to evaluate the cumulative recurrence rate of endometrioma after a second-line, conservative, laparoscopic endometriotic cyst enucleation and to analyze the factors that influence the recurrence of endometrioma.

STUDY DESIGN

A multicenter retrospective cohort study was performed at 3 gynecologic surgery centers from January 2000 through December 2010. Patients surgically treated by laparoscopic enucleation of endometriotic cysts on 2 previous occasions were selected. All patients were aged <40 years at the time of the primary surgery and were followed up for at least 6 months. Endometrioma recurrence was considered when transvaginal sonography indicated a cystic mass with a diameter of ≥20 mm.

RESULTS

In total, 183 patients were followed up for 33.2 ± 27.7 months (range, 6-121 months). Thirty-eight (20.8%) patients experienced recurrence after the second-line surgery and 24 (13.1%) patients underwent a third surgery. The median time to recurrence was 24 ± 3.36 months (SEM) (range, 3-72 months). The cumulative recurrence rates per patient at 12, 24, 36, and 60 months after the second-line surgery were 7.7%, 13.7%, 21.3%, and 37.5%, respectively. After multivariate analysis and analysis of covariance, the revised American Fertility Society score and stage were significantly higher in patients who experience a third recurrence of endometrioma.

CONCLUSION

The cumulative recurrence rate of ovarian endometrioma after a second-line surgery appears to be correlated to the duration of follow-up. Severe endometriosis at the second-line surgery seems to be a factor associated with a high recurrence risk. Physicians should be cautious with regard to the postoperative management of these patients.

Surgical Therapy of Endometriosis: Challenges and Controversies

Endometriosis is one of the most common disorders encountered in surgical gynaecology. The laparoscopic technique, the planning of the surgical intervention, the extent of information provided to patients and the interdisciplinary coordination make it a challenging intervention. Complete resection of all visible foci of disease offers the best control of symptoms. However, the possibility of achieving this goal is limited by the difficulty of detecting all foci and the risks associated with radical surgical strategies. Thus, the excision of ovarian endometrioma can result in a significant impairment of ovarian function, while damage to nerve structures during resection of the uterosacral ligaments, the parametrium, the rectovaginal septum or the vaginal cuff to treat deep infiltrating endometriosis can lead to serious functional impairments such as voiding disorders. A detailed risk-benefit analysis is therefore necessary, and patients must be treated using an individual approach.

The significant effect of endometriosis on physical, mental and social wellbeing: results from an international cross-sectional survey

STUDY QUESTION

To what extent do the management of endometriosis and the symptoms that remain after treatment affect the quality of life in women with the disease?

SUMMARY ANSWER

Many women with endometriosis had impaired quality of life and continued to suffer from endometriosis-associated symptoms even though their endometriosis has been managed in tertiary care centres.

WHAT IS KNOWN ALREADY

The existing literature indicates that quality of life and work productivity is reduced in women with endometriosis. However, most studies have small sample sizes, are treatment related or examine newly diagnosed patients only.

STUDY DESIGN, SIZE, DURATION

A cross-sectional questionnaire-based survey among 931 women with endometriosis treated in 12 tertiary care centres in 10 countries.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women diagnosed with endometriosis who had at least one contact related to endometriosis-associated symptoms during 2008 with a participating centre were enrolled into the study. The study investigated the effect of endometriosis on education, work and social wellbeing, endometriosis-associated symptoms and health-related quality of life, by using questions obtained from the World Endometriosis Research Foundation (WERF) GSWH instrument (designed and validated for the WERF Global Study on Women's Health) and the Short Form 36 version 2 (SF-36v2).

MAIN RESULTS AND THE ROLE OF CHANCE

Of 3216 women invited to participate in the study, 1450 (45%) provided informed consent and out of these, 931 (931/3216 = 29%) returned the questionnaires. Endometriosis had affected work in 51% of the women and affected relationships in 50% of the women at some time during their life. Dysmenorrhoea was reported by 59%, dyspareunia by 56% and chronic pelvic pain by 60% of women. Quality of life was decreased in all eight dimensions of the SF-36v2 compared with norm-based scores from a general US population (all P < 0.01). Multivariate regression analysis showed that number of co-morbidities, chronic pain and dyspareunia had an independent negative effect on both the physical and mental component of the SF-36v2.

LIMITATIONS, REASONS FOR CAUTION

The fact that women were enrolled in tertiary care centres could lead to a possible over-representation of women with moderate-to-severe endometriosis, because the participating centres typically treat more complex and referred cases of endometriosis. The response rate was relatively low. Since there was no Institute Review Board approval to do a non-responder investigation on basic characteristics, some uncertainty remains regarding the representativeness of the investigated population.

WIDER IMPLICATIONS OF THE FINDINGS

This international multicentre survey represents a large group of women with endometriosis, in all phases of the disease, which increases the generalizability of the data. Women still suffer from frequent symptoms, despite tertiary care management, in particular chronic pain and dyspareunia. As a result their quality of life is significantly decreased. A patient-centred approach with extensive collaboration across disciplines, such as pain specialists, psychologists, sexologists and social workers, may be a valuable strategy to improve the long-term care of women with endometriosis.

STUDY FUNDING/COMPETING INTEREST(S)

The WERF EndoCost study is funded by the World Endometriosis Research Foundation (WERF) through grants received from Bayer Schering Pharma AG, Takeda Italia Farmaceutici SpA, Pfizer Ltd and the European Society of Human Reproduction and Embryology. The sponsors did not have a role in the design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript. L.H. is the chief executive and T.D. was a board member of WERF at the time of funding. T.D. holds the Merck-Serono Chair in Reproductive Medicine and Surgery, and the Ferring Chair in Reproductive Medicine at the Katholieke Universiteit Leuven in Belgium and has served as consultant/research collaborator for Merck-Serono, Schering-Plough, Astellas and Arresto.

Intraoperative detection of subtle endometriosis: a novel paradigm for detection and treatment of pelvic pain associated with the loss of peritoneal integrity

Endometriosis is a common disease affecting 40 to 70% of reproductive-aged women with chronic pelvic pain (CPP) and/or infertility. The purpose of this study was to demonstrate the use of a blue dye (methylene blue) to stain peritoneal surfaces during laparoscopy (L/S) to detect the loss of peritoneal integrity in patients with pelvic pain and suspected endometriosis. Forty women with CPP and 5 women without pain were evaluated in this pilot study. During L/S, concentrated dye was sprayed onto peritoneal surfaces, then aspirated and rinsed with Lactated Ringers solution. Areas of localized dye uptake were evaluated for the presence of visible endometriotic lesions. Areas of intense peritoneal staining were resected and some fixed in 2.5% buffered gluteraldehyde and examined by scanning (SEM) electron microscopy. Blue dye uptake was more common in women with endometriosis and chronic pelvic pain than controls (85% vs. 40%). Resection of the blue stained areas revealed endometriosis by SEM and loss of peritoneal cell-cell contact compared to normal, non-staining peritoneum. Affected peritoneum was associated with visible endometriotic implants in most but not all patients. Subjective pain relief was reported in 80% of subjects. Based on scanning electron microscopy, we conclude that endometrial cells extend well beyond visible implants of endometriosis and appear to disrupt the underlying mesothelium. Subtle lesions of endometriosis could therefore cause pelvic pain by disruption of peritoneal integrity, allowing menstrual or ovulatory blood and associated pain factors access to underlying sensory nerves. Complete resection of affected peritoneum may provide a better long-term treatment for endometriosis and CPP. This simple technique appears to improve detection of subtle or near invisible endometriosis in women with CPP and minimal visual findings at L/S and may serve to elevate diagnostic accuracy for endometriosis at laparoscopy.

Aromatase inhibitors in post-menopausal endometriosis

Postmenopausal endometriosis is a rare clinical condition. The diagnosis and treatment of an endometriotic lesion in postmenopausal women is complicated. First line treatment choice should be surgical, given that there is a potential risk of malignancy. Medical treatment may be considered as second line or as an alternate first line treatment whenever surgery is contradicted and aims to alter the hormonal pathway leading to endometriosis progress. Different hormonal regimens have been administered to these patients, with conflicting however results. Aromatase inhibitors (AIs) represent one of the most recently used drugs for postmenopausal endometriosis. Clinical data for the use of (AIs) in postmenopausal patients is scarce. Up to date only 5 case reports are available regarding the use of these agents in postmenopausal women. Although definite conclusions may be premature, AIs appear to considerably improve patients' symptoms and reduce endometriotic lesions size. Nonetheless the subsequent induced reduction in estrogen production, leads to certain short-term and long-term adverse effects. Despite the limited available data, AIs appear to represent a new promising method which may improve symptoms and treat these patients, either as first line treatment, when surgery is contraindicated or as a second line for recurrences following surgical treatment. However, careful monitoring of patients' risk profile and further research regarding long-term effects and side-effects of these agents is essential prior implementing them in everyday clinical practice.