1
|
Eberle A, Nguyen DB, Smith JP, Mansour FW, Krishnamurthy S, Zakhari A. Medical Management of Ovarian Endometriomas: A Systematic Review and Meta-analysis. Obstet Gynecol 2024; 143:53-66. [PMID: 37944155 DOI: 10.1097/aog.0000000000005444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To estimate the effect of medical management on the size of ovarian endometriomas. DATA SOURCE Online databases were searched from inception to October 2022, including Ovid MEDLINE, Ovid EMBASE, PubMed, EBM Reviews-Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov , and Web of Science. METHODS OF STUDY SELECTION Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we included all English-language, full-text articles that reported on change in endometrioma size (either diameter or volume) after medical interventions. Studies evaluating surgical interventions or postoperative recurrence were excluded. All screening and data extraction were performed independently by two authors. Risk of bias assessment was performed with either the Cochrane Risk of Bias Tool for randomized controlled trials or a modified Newcastle-Ottawa Scale for observational studies. TABULATION, INTEGRATION, AND RESULTS After removal of duplicates, 9,332 studies were screened, with 33 full-text articles deemed eligible for inclusion. In the meta-analysis, dienogest showed significant reduction in cyst diameter (reduction 1.32 cm, 95% CI, 0.91-1.73, eight studies, n=418 cysts) and volume (mean difference of log-transformed volume 1.35, 95% CI, 0.87-1.83, seven studies, n=282 cysts). Similarly, significant reductions were seen with the oral contraceptive pill (OCP) (1.06 cm, 95% CI, 0.59-1.53, nine studies, n=455), gonadotropin-releasing hormone (GnRH) agonists (1.17 cm, 95% CI, 0.42-1.92, four studies, n=128 cysts), norethindrone acetate (0.6 cm, 95% CI, 0.27-0.94, two studies, n=88 cysts), and danazol (1.95 cm, 95% CI, 1.18-2.73, two studies, n=34 cysts). Norethindrone acetate with aromatase inhibitor was also effective in reducing endometrioma volume (mean difference of log-transformed volume 1.47, 95% CI, 0.16-2.78, two studies, n=34 cysts). CONCLUSION Medical management with dienogest, OCPs, GnRH agonists, norethindrone acetate, norethindrone acetate with aromatase inhibitor, or danazol can reduce the size of ovarian endometriomas. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD 42022363319.
Collapse
Affiliation(s)
- Alexa Eberle
- Department of Obstetrics and Gynecology, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | | | | | | |
Collapse
|
2
|
Bianchi P, Guo SW, Habiba M, Benagiano G. Utility of the Levonorgestrel-Releasing Intrauterine System in the Treatment of Abnormal Uterine Bleeding and Dysmenorrhea: A Narrative Review. J Clin Med 2022; 11:5836. [PMID: 36233703 PMCID: PMC9570961 DOI: 10.3390/jcm11195836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/28/2022] [Accepted: 09/28/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION We undertook a literature review of the use of levonorgestrel-releasing intrauterine devices when utilized for heavy menstrual bleeding and/or dysmenorrhea. METHODS A narrative review of articles in the Scopus and Medline databases was conducted. RESULTS A number of options exist for the management of both abnormal uterine bleeding (AUB) and dysmenorrhea, and evidence is accumulating that the insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) represents a useful option for their long-term treatment. The idea of using a progestogen released in utero was initially conceived to achieve long-term contraception, but it was quickly found that these systems could be utilized for a number of therapeutic applications. The first device to be made commercially available, Progestasert, was withdrawn from the market because, in the event of contraceptive failure, it caused a disproportionate percentage of extrauterine pregnancies. On the other hand, the LNG-IUS continues to be successfully utilized in its various variants, releasing 20, 13, or 8 μg/day. These devices have a respective duration of action of 7 (possibly 8), 5, and 3 years, and there exist versions of frameless systems affixed to the myometrium of the uterine fundus. In the present review, following a brief description of the major causes of AUB and dysmenorrhea, the molecular bases for the use of the LNG-IUS are summarized. This is followed by a compendium of its use in AUB and dysmenorrhea, concluding that the insertion of the system improves the quality of life, reduces menstrual blood loss better than other medical therapies, and decreases the extent of dysmenorrhea and pelvic pain. In addition, there is no evidence of a significant difference in these outcomes when the use of the LNG-IUS was compared with improvements offered by endometrial ablation or hysterectomy. Possibly, the most important mechanism of action of the system consists of its ability to induce amenorrhea, which effectively eliminates heavy bleeding and dysmenorrhea. However, no method is ideal for every woman, and, in the case of the LNG-IUS, younger age and severe dysmenorrhea seem to be associated with a higher risk of discontinuation. CONCLUSION The higher-dose LNG-IUS is a useful tool for HMB and dysmenorrhea in women of all ages. The low cost and ease of use make the LNG-IUS an attractive option, especially when contraception is also desired.
Collapse
Affiliation(s)
- Paola Bianchi
- Department of Medico-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza, University of Rome, 00161 Rome, Italy
| | - Sun-Wei Guo
- Shanghai OB/GYN Hospital, Fudan University, Shanghai 200011, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai 200011, China
| | - Marwan Habiba
- Department of Health Sciences, University Hospitals of Leicester, University of Leicester, Leicester LE1 7RH, UK
| | - Giuseppe Benagiano
- Faculty of Medicine and Dentistry, Sapienza, University of Rome, 00161 Rome, Italy
| |
Collapse
|
3
|
Harada T, Taniguchi F, Kitajima M, Kitawaki J, Koga K, Momoeda M, Mori T, Murakami T, Narahara H, Osuga Y, Yamaguchi K. Clinical practice guidelines for endometriosis in Japan (The 3rd edition). J Obstet Gynaecol Res 2022; 48:2993-3044. [PMID: 36164759 PMCID: PMC10087749 DOI: 10.1111/jog.15416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/11/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Tasuku Harada
- Department Obstetrics and Gynecology, Tottori University
| | | | | | - Jo Kitawaki
- Department Obstetrics and Gynecology, Kyoto Prefectural University of Medicine
| | - Kaori Koga
- Department Obstetrics and Gynecology, The University of Tokyo
| | - Mikio Momoeda
- Department Obstetrics and Gynecology, Aiiku Hospital
| | - Taisuke Mori
- Department Obstetrics and Gynecology, Kyoto Prefectural University of Medicine
| | - Takashi Murakami
- Department Obstetrics and Gynecology, Shiga University of Medical Science
| | | | - Yutaka Osuga
- Department Obstetrics and Gynecology, The University of Tokyo
| | - Ken Yamaguchi
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine
| |
Collapse
|
4
|
Vannuccini S, Clemenza S, Rossi M, Petraglia F. Hormonal treatments for endometriosis: The endocrine background. Rev Endocr Metab Disord 2022; 23:333-355. [PMID: 34405378 PMCID: PMC9156507 DOI: 10.1007/s11154-021-09666-w] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 12/25/2022]
Abstract
Endometriosis is a benign uterine disorder characterized by menstrual pain and infertility, deeply affecting women's health. It is a chronic disease and requires a long term management. Hormonal drugs are currently the most used for the medical treatment and are based on the endocrine pathogenetic aspects. Estrogen-dependency and progesterone-resistance are the key events which cause the ectopic implantation of endometrial cells, decreasing apoptosis and increasing oxidative stress, inflammation and neuroangiogenesis. Endometriotic cells express AMH, TGF-related growth factors (inhibin, activin, follistatin) CRH and stress related peptides. Endocrine and inflammatory changes explain pain and infertility, and the systemic comorbidities described in these patients, such as autoimmune (thyroiditis, arthritis, allergies), inflammatory (gastrointestinal/urinary diseases) and mental health disorders.The hormonal treatment of endometriosis aims to block of menstruation through an inhibition of hypothalamus-pituitary-ovary axis or by causing a pseudodecidualization with consequent amenorrhea, impairing the progression of endometriotic implants. GnRH agonists and antagonists are effective on endometriosis by acting on pituitary-ovarian function. Progestins are mostly used for long term treatments (dienogest, NETA, MPA) and act on multiple sites of action. Combined oral contraceptives are also used for reducing endometriosis symptoms by inhibiting ovarian function. Clinical trials are currently going on selective progesterone receptor modulators, selective estrogen receptor modulators and aromatase inhibitors. Nowadays, all these hormonal drugs are considered the first-line treatment for women with endometriosis to improve their symptoms, to postpone surgery or to prevent post-surgical disease recurrence. This review aims to provide a comprehensive state-of-the-art on the current and future hormonal treatments for endometriosis, exploring the endocrine background of the disease.
Collapse
Affiliation(s)
- Silvia Vannuccini
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Sara Clemenza
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Margherita Rossi
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Felice Petraglia
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy.
| |
Collapse
|
5
|
Troìa L, Luisi S. Sexual function and quality of life in women with endometriosis. Minerva Obstet Gynecol 2022; 74:203-221. [PMID: 35420289 DOI: 10.23736/s2724-606x.22.05033-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endometriosis may exert a profound negative influence on the lives of individuals with the disorder, adversely affecting quality of life, participation in daily and social activities, physical and sexual functioning, relationships, educational and work productivity, mental health, and well-being. Symptoms of endometriosis represent a great source of stress and cause a substantial negative impact on the psychological parameters, on the daily life and on the physical functioning of patients. The impact of endometriosis on work attendance has very significant economic consequences, as lost productivity has an associated cost, as do career changes resulting from a decline in education due to symptoms. Endometriosis is a pathology that affects all aspects of women's lives and that thus, it must be treated with a multidisciplinary vision that includes not only a medical approach but also psychological, work, and economic support. In this specific long-term vision of patient-centered endometriosis care, aspects of quality of life and sexual health play a key role and should always be evaluated with any patient as part of a multidisciplinary management.
Collapse
Affiliation(s)
- Libera Troìa
- Obstetrics and Gynecology Department, San Donato Hospital, Arezzo, Italy
| | - Stefano Luisi
- Gynecology Unit, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy -
| |
Collapse
|
6
|
Gibbons T, Georgiou EX, Cheong YC, Wise MR. Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery. Cochrane Database Syst Rev 2021; 12:CD005072. [PMID: 34928503 PMCID: PMC8686684 DOI: 10.1002/14651858.cd005072.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Endometriosis is a condition characterised by the presence of ectopic deposits of endometrial-like tissue outside the uterus, usually in the pelvis. The impact of laparoscopic treatment on overall pain is uncertain and a significant proportion of women will require further surgery. Therefore, adjuvant medical therapies following surgery, such as the levonorgestrel-releasing intrauterine device (LNG-IUD), have been considered to reduce recurrence of symptoms. OBJECTIVES: To determine the effectiveness and safety of post-operative LNG-IUD in women with symptomatic endometriosis. SEARCH METHODS We searched the following databases from inception to January 2021: The Specialised Register of the Cochrane Gynaecology and Fertility Group, CENTRAL (which now includes records from two trial registries), MEDLINE, Embase, PsycINFO, LILACS and Epistemonikos. We handsearched citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies. We contacted experts in the field for information about any additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing women undergoing surgical treatment of endometriosis with uterine preservation who were assigned to LNG-IUD insertion, versus control conditions including expectant management, post-operative insertion of placebo (inert intrauterine device), or other medical treatment such as gonadotrophin-releasing hormone agonist (GnRH-a) drugs. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, and extracted data to allow for an intention-to-treat analysis. For dichotomous data, we calculated the risk ratio (RR) and 95% confidence interval (CI) using the Mantel-Haenszel fixed-effect method. For continuous data, we calculated the mean difference (MD) and 95% CI using the inverse variance fixed-effect method. MAIN RESULTS Four RCTs were included, with a total of 157 women. Two studies are ongoing. The GRADE certainty of evidence was very low to low. The certainty of evidence was graded down primarily for serious risk of bias and imprecision. LNG-IUD versus expectant management Overall pain: No studies reported on the primary outcome of overall pain. Dysmenorrhoea: We are uncertain whether LNG-IUD improves dysmenorrhoea at 12 months. Data on this outcome were reported on by two RCTs; meta-analysis was not possible (RCT 1: delta of median visual analogue scale (VAS) 81 versus 50, P = 0.006, n = 55; RCT 2: fall in VAS by 50 (35 to 65) versus 30 (25 to 40), P = 0.021, n = 40; low-certainty evidence). Quality of life: We are uncertain whether LNG-IUD improves quality of life at 12 months. One trial demonstrated a change in total quality of life score with postoperative LNG-IUD from baseline (mean 61.2 (standard deviation (SD) 14.8) to 12 months (mean 70.3 (SD 16.2) compared to expectant management (baseline 55.1 (SD 17.0) to 57.0 (SD 33.2) at 12 months) (n = 55, P = 0.014, very low-certainty evidence). Patient satisfaction: Two studies found higher rates of satisfaction with LNG-IUD compared to expectant management; however, combining the studies in meta-analysis was not possible (n = 95, very low-certainty evidence). One study found 75% (15/20) of those given post-operative LNG-IUD were "satisfied" or "very satisfied", compared to 50% (10/20) of those in the expectant management group (RR 1.5, 95% CI 0.90-2.49, 1 RCT, n=40, very low-certainty evidence). The second study found that fewer were "very satisfied" in the expectant management group when compared to LNG, but there were no data to include in a meta-analysis. Adverse events: One study found a significantly higher proportion of women reporting melasma (n = 55, P = 0.015, very low-certainty evidence) and bloating (n = 55, P = 0.021, very low-certainty evidence) following post-operative LNG-IUD. There were no differences in other reported adverse events, such as weight gain, acne, and headaches. LNG-IUD versus GnRH-a Overall pain: No studies reported on the primary outcome of overall pain. Chronic pelvic pain: We are uncertain whether LNG-IUD improves chronic pelvic pain at 12 months when compared to GnRH-a (VAS pain scale) (MD -2.0, 95% CI -20.2 to 16.2, 1 RCT, n = 40, very low-certainty evidence). Dysmenorrhoea: We are uncertain whether LNG-IUD improves dysmenorrhoea at six months when compared to GnRH-a (measured as a reduction in VAS pain score) (MD 1.70, 95%.CI -0.14 to 3.54, 1 RCT, n = 18, very low-certainty evidence). Adverse events: One study suggested that vasomotor symptoms were the most common adverse events reported with patients receiving GnRH-a, and irregular bleeding in those receiving LNG-IUD (n = 40, very low-certainty evidence) AUTHORS' CONCLUSIONS: Post-operative LNG-IUD is widely used to reduce endometriosis-related pain and to improve operative outcomes. This review demonstrates that there is no high-quality evidence to support this practice. This review highlights the need for further studies with large sample sizes to assess the effectiveness of post-operative adjuvant hormonal IUD on the core endometriosis outcomes (overall pain, most troublesome symptom, and quality of life).
Collapse
Affiliation(s)
- Tatjana Gibbons
- Nuffield Department of Women's & Reproductive Health, Oxford University, Oxford , UK
| | | | - Ying C Cheong
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michelle R Wise
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| |
Collapse
|
7
|
Association of levonorgestrel intrauterine devices with stress reactivity, mental health, quality of life and sexual functioning: A systematic review. Front Neuroendocrinol 2021; 63:100943. [PMID: 34425187 DOI: 10.1016/j.yfrne.2021.100943] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/03/2021] [Accepted: 08/18/2021] [Indexed: 11/24/2022]
Abstract
Levonorgestrel-intrauterine-devices (LNG-IUD) are one of the most used contraceptive methods worldwide. While several reviews exist on how LNG-IUDs impact physiology and gynaecological functions, this systematic review focuses on stress, mental health, quality of life, sexual functioning, and effects on brain architecture. While data on stress is scarce, results on mental health are ambiguous. More consistently, LNG-IUD use seems to improve quality of life and sexual functioning. No studies highlighting the consequences of LNG-IUD use on the brain were found. The reviewed studies are characterized by a substantial variation in approaches, participant groups, and study quality. More high-quality research assessing the effects of LNG-IUD on mental health, including response to stressors and brain function and structure, is needed to identify women vulnerable to adverse effects of LNG-IUD, also in comparison to oral contraceptives, and to empower women to make more informed choices concerning hormonal contraception.
Collapse
|
8
|
Acién P, Velasco I, Acién M. Anastrozole and levonorgrestrel-releasing intrauterine device in the treatment of endometriosis: a randomized clinical trial. BMC WOMENS HEALTH 2021; 21:211. [PMID: 34016111 PMCID: PMC8138989 DOI: 10.1186/s12905-021-01347-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 05/06/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND To study the effectiveness of an aromatase inhibitor (Anastrozole) associated with levonorgestrel-releasing intrauterine device (LNG-IUD, Mirena®) in the treatment of endometriosis. METHODS Prospective, randomized clinical trial. SETTING University Hospital (single center). Elegibility criteria: Endometriomas > 3 × 4 cm, CA-125 > 35 U/mL and endometriosis symptoms. PATIENTS Thirty-one women randomized to anastrozole + Mirena® + Conservative Surgery(CS) (n = 8), anastrozole + Mirena® + transvaginal ultrasound-guided puncture-aspiration (TUGPA) (n = 7), Mirena® + CS (n = 9), or Mirena® + TUGPA (n = 7). INTERVENTIONS Anastrozole 1 mg/day and/or only Mirena® for 6 months; CS (ovarian and fertility-sparing) or TUGPA of endometriomas one month after starting medical treatment. MAIN OUTCOME MEASURES Visual analogic scale for symptoms, CA-125 levels, ultrasound findings of endometriomas and recurrences. RESULTS A significant improvement in symptoms during the treatment (difference of 43%, 95% CI 29.9-56.2) occurred, which was maintained at 1 and 2 years. It was more significant in patients including anastrozole in their treatment (51%, 95% CI 33.3-68.7). For CA-125, the most significant decrease was observed in patients not taking anastrozole (73.8%, 95% CI 64.2-83.4 vs. 53.8%, 95% CI 25.7-81.6 under Mirena® + anastrozole). After CS for endometriosis, a reduction of ultrasound findings of endometriomas and long-term recurrence occurred, with or without anastrozole. At 4.2 ± 1.7 years (95% CI 3.57-4.85), 88% of the patients who underwent CS were asymptomatic, without medication or reoperation, compared to only 21% if TUGPA was performed, with or without anastrozole (p = 0.019). CONCLUSIONS Dosing anastrozole for 6 months, starting one month before CS of endometriosis, reduces significantly the painful symptoms and delays recurrence, but has no other significant advantages over the single insertion of LNG-IUD (Mirena®) during the same time. Anastrozole and/or only Mirena® associated with TUGPA are not effective. TRIAL REGISTRATION Eudra CT System of the European Medicines Agency (London, 29-Sept-2008) Nº EudraCT: 2008-005744-17 (07/11/2008). Date of enrolment of first patient: 15/01/2009.
Collapse
Affiliation(s)
- Pedro Acién
- Department/Division of Gynecology, Miguel Hernández University, San Juan Campus, 03550, San Juan, Alicante, Spain. .,Obstetrics and Gynecology Service, San Juan University Hospital, 03550, San Juan, Alicante, Spain. .,Departamento/Area de Ginecología, Facultad de Medicina de La Universidad "Miguel Hernández", Campus de San Juan, 03550, Alicante, Spain.
| | - Irene Velasco
- Obstetrics and Gynecology Service, San Juan University Hospital, 03550, San Juan, Alicante, Spain
| | - Maribel Acién
- Department/Division of Gynecology, Miguel Hernández University, San Juan Campus, 03550, San Juan, Alicante, Spain.,Obstetrics and Gynecology Service, San Juan University Hospital, 03550, San Juan, Alicante, Spain
| |
Collapse
|
9
|
Kokot I, Piwowar A, Jędryka M, Sołkiewicz K, Kratz EM. Diagnostic Significance of Selected Serum Inflammatory Markers in Women with Advanced Endometriosis. Int J Mol Sci 2021; 22:2295. [PMID: 33669013 PMCID: PMC7956504 DOI: 10.3390/ijms22052295] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/10/2021] [Accepted: 02/22/2021] [Indexed: 12/17/2022] Open
Abstract
Endometriosis is a gynecological disease, the pathogenesis of which seems to be directly associated with inflammatory processes. Serum concentrations of IL-1β, IL-6, hs-CRP, IgG, YKL 40 and PRL, in comparison to the well-known CA 125 levels, were studied with the aim of identifying an additional noninvasive inflammatory marker or set of markers characteristic for endometriosis. The study group included 43 women with endometriosis (E), 35 women with benign gynecological disorders but without endometriosis (NE, non-endometriosis) as a comparative group, and a control group consisting of 18 healthy subjects (C). The serum concentrations of IL-1β, IL-6, hs-CRP, YKL-40, PRL and CA 125 were significantly higher in the E group (median values: 0.41 pg/mL, 2.42 pg/mL, 2.33 mg/L, 79.30 ng/mL, 21.88 ng/mL and 68.00 U/mL, respectively) than in the control group (median values: 0.21 pg/mL, 0.98 pg/mL, 0.52 mg/L, 49.77 ng/mL, 12.08 ng/mL and 12.20 U/mL respectively), with the significance of p = 0.011, p < 0.001, p = 0.028, p = 0.005, p < 0.001 and p < 0.001, respectively. The IgG concentrations were significantly lower in the endometriosis group (median value: 1061.21 mg/dL) as compared to healthy women (median value: 1210.50 mg/dL; p = 0.025). Significant differences in concentrations of IL-6 (p = 0.040), hs-CRP (p = 0.007) and CA 125 (p < 0.001) were observed in stage III vs. stage IV of endometriosis. Significantly higher concentrations of IL-6 (p = 0.010), hs-CRP (p = 0.037) and PRL (p < 0.001) were observed in the NE group vs. the control group. Only CA 125 concentrations were significantly higher in endometriosis patients as compared to the non-endometriosis group (p < 0.001). The proposed panel of inflammatory markers, especially IL-6, PRL and CA 125, may become a useful tool to identify women with advanced endometriosis who could qualify for treatment.
Collapse
Affiliation(s)
- Izabela Kokot
- Department of Laboratory Diagnostics, Division of Laboratory Diagnostics, Faculty of Pharmacy, Wroclaw Medical University, Borowska Street 211A, 50-556 Wroclaw, Poland; (K.S.); (E.M.K.)
| | - Agnieszka Piwowar
- Department of Toxicology, Faculty of Pharmacy, Wroclaw Medical University, Borowska Street 211A, 50-556 Wroclaw, Poland;
| | - Marcin Jędryka
- Department of Oncology, Gynecological Oncology Clinic, Faculty of Medicine, Wroclaw Medical University, Hirszfeld Square 12, 53-413 Wroclaw, Poland;
- Department of Oncological Gynecology, Wroclaw Comprehensive Cancer Center, Hirszfeld Square 12, 53-413 Wroclaw, Poland
| | - Katarzyna Sołkiewicz
- Department of Laboratory Diagnostics, Division of Laboratory Diagnostics, Faculty of Pharmacy, Wroclaw Medical University, Borowska Street 211A, 50-556 Wroclaw, Poland; (K.S.); (E.M.K.)
| | - Ewa Maria Kratz
- Department of Laboratory Diagnostics, Division of Laboratory Diagnostics, Faculty of Pharmacy, Wroclaw Medical University, Borowska Street 211A, 50-556 Wroclaw, Poland; (K.S.); (E.M.K.)
| |
Collapse
|
10
|
Vignali M, Solima E, Barbera V, Becherini C, Belloni GM. Approaching ovarian endometrioma with medical therapy. Minerva Obstet Gynecol 2020; 73:215-225. [PMID: 33314904 DOI: 10.23736/s2724-606x.20.04751-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endometriosis is a chronic inflammatory gynecological disorder associated with pelvic pain symptoms and infertility. Ovarian cysts (endometriomas) are the most common localization of endometriosis in the pelvis. Considering non-invasive methods, transvaginal ultrasound has high sensitivity and specificity for endometrioma diagnosis. Laparoscopic removal of endometrioma is related to a damage to the ovarian reserve and should be limited to patients with suspicious cysts or unresponsive to medical treatment. The main goal of medical therapy of symptomatic endometrioma is the control of pain symptoms, while no benefits have been demonstrated in terms of improving fertility rates of women seeking pregnancy. The aim of medical treatment is the inhibition of ovulation, stop of menstruation and achievement of a stable hypo-hormonal milieu. Estroprogestins and progestins are indicated by guidelines as first line medications for symptomatic patients. Several hormonal treatments have been proposed for the treatment of symptomatic endometriomas. In particular, dienogest, a relatively new progestin, has shown promising results. Medical treatment should be conceived as a long-term treatment. Safety, tolerability, a low percentage of side effects and an easy route of administration are essential for patient acceptance and adherence to therapy.
Collapse
Affiliation(s)
- Michele Vignali
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy -
| | - Eugenio Solima
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| | - Valeria Barbera
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| | - Chiara Becherini
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| | - Gaia M Belloni
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| |
Collapse
|
11
|
Zhu SY, Wu YS, Gu ZY, Zhang J, Jia SZ, Shi JH, Dai Y, Leng JH, Li XY. Preventive therapeutic options for postoperative recurrence of ovarian endometrioma: gonadotropin-releasing hormone agonist with or without levonorgestrel intrauterine system insertion. Arch Gynecol Obstet 2020; 303:533-539. [PMID: 33104866 DOI: 10.1007/s00404-020-05843-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Here, we compared endometrioma recurrence rates in patients who have undergone a laparoscopic cystectomy and treated with a gonadotropin-releasing hormone agonist (GnRHa) alone or a GnRHa combined with a levonogestrel intrauterine system (LND-IUS). METHODS We enrolled endometrioma patients who underwent laparoscopic cyst enucleation and divided them into two groups according to postoperative management: GnRHa alone and GnRHa in combination with LND-IUS. We compared preoperative history, perioperative parameters, postoperative endometrioma recurrence, and symptoms between these two groups. RESULTS A total of 320 patients were included in the final analysis. With a median 84.6 months of follow-up, we detected significant differences between the two groups with respect to age at surgery (31.6 ± 4.8 vs. 37.6 ± 4.2 years, χ2 = 1.978, p < 0.001), gravida (0 vs. 2, χ2 = 4.391, p < 0.001), parity (0 vs. 1, χ2 = 0.035, p < 0.001), body mass index (21.0 ± 2.5 vs. 21.9 ± 2.4, χ2 = 0.0096, p = 0.009), r-AFS score (48 vs. 64, χ2 = 4.888, p = 0.001), and operation time (60 vs. 75 min, χ2 = 9.119, p = 0.003). Patients treated with both GnRHa and LND-IUS achieved significantly less endometrioma recurrence (23.6 vs. 11.5%, χ2 = 5.202, p = 0.023) and higher rates of pain remission (92.1 vs. 100%, χ2 = 6.511, p = 0.011), while those with GnRHa alone suffered more recurrent and painful symptoms (χ2 = 9.280, p = 0.026). Multivariate analysis using a Cox regression demonstrated that combined GnRHa and LNG-IUS treatment correlated with a decreased endometrioma recurrence rate after laparoscopic cystectomy (RR 0.369, 95% CI 0.182-0.749, p = 0.006). CONCLUSIONS Combination treatment of GnRHa and LNG-IUS exhibited superior pain relief and recurrence prevention among endometrioma patients after fertility-sparing surgery. Thus, combination treatment is a preferable long-term option for patients without intent for pregnancy in the near future.
Collapse
Affiliation(s)
- Shi-Yang Zhu
- Department of Obstetrics and Gynecology, Dongcheng District, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Shuaifuyuan No. 1, Beijing, China
| | - Yu-Shi Wu
- Department of Obstetrics and Gynecology, Dongcheng District, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Shuaifuyuan No. 1, Beijing, China
| | - Zhi-Yue Gu
- Department of Obstetrics and Gynecology, Dongcheng District, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Shuaifuyuan No. 1, Beijing, China
| | - Jing Zhang
- Department of Obstetrics and Gynecology, Dongcheng District, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Shuaifuyuan No. 1, Beijing, China
| | - Shuang-Zheng Jia
- Department of Obstetrics and Gynecology, Dongcheng District, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Shuaifuyuan No. 1, Beijing, China
| | - Jing-Hua Shi
- Department of Obstetrics and Gynecology, Dongcheng District, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Shuaifuyuan No. 1, Beijing, China
| | - Yi Dai
- Department of Obstetrics and Gynecology, Dongcheng District, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Shuaifuyuan No. 1, Beijing, China
| | - Jin-Hua Leng
- Department of Obstetrics and Gynecology, Dongcheng District, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Shuaifuyuan No. 1, Beijing, China
| | - Xiao-Yan Li
- Department of Obstetrics and Gynecology, Dongcheng District, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Shuaifuyuan No. 1, Beijing, China.
| |
Collapse
|
12
|
Caruso S, Cianci A, Iraci M, Fava V, Di Pasqua S, Cianci S. Does Nomegestrol Acetate Plus 17β-Estradiol Oral Contraceptive Improve Endometriosis-Associated Chronic Pelvic Pain in Women? J Womens Health (Larchmt) 2020; 29:1184-1191. [PMID: 32678691 PMCID: PMC7520912 DOI: 10.1089/jwh.2020.8291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: To evaluate the effects of a 24/4 regimen combined oral contraceptive (COC) containing 1.5 mg 17β-estradiol (E2) and 2.5 mg nomegestrol acetate (NOMAC) compared to on-demand nonsteroidal anti-inflammatory drugs (NSAIDs) on women affected by endometriosis-associated chronic pelvic pain (the primary end point) and their quality of life (QoL) and sexual function (the secondary end points). Materials and Methods: Ninety-nine women on E2/NOMAC constituted the study group; and 63 women on NSAIDs constituted the control group. The visual analogic scale was used to measure the levels of pelvic pain, dysmenorrhea, and dyspareunia. To assess their QoL, sexual function, and sexual distress, the Short Form-36 (SF-36), the Female Sexual Function Index (FSFI), and the Female Sexual Distress Scale (FSDS) were used, respectively. The study included two follow-ups at 3 and 6 months. Results: Improvement in chronic pelvic pain was observed in the study group at both the 3- and 6-month follow-ups (p < 0.001). SF-36, FSFI, and FSDS had a similar trend at the 3- and 6-month follow-ups (p < 0.001). Women on NSAIDs did not report any reduction in pain symptoms or improvement in QoL (p ≤ 0.4). However, they had a limited improvement of their FSFI and FSDS (p < 0.001). The improvement of the pain symptoms, QoL, FSFI, and FSDS, was more evident in women on E2/NOMAC than in those on NSAIDs, when the study group and control group values were compared at the 3- and 6-month follow-ups (p < 0.001). Conclusions: Women on E2/NOMAC COC showed a better reduction of endometriosis-associated chronic pelvic pain and an improvement of their QoL and sexual activity than those of the women on NSAIDs.
Collapse
Affiliation(s)
- Salvatore Caruso
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.,Research Group for Sexology, University of Catania, Catania, Italy
| | - Antonio Cianci
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.,Research Group for Sexology, University of Catania, Catania, Italy
| | - Marco Iraci
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Valentina Fava
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.,Research Group for Sexology, University of Catania, Catania, Italy
| | - Salvatore Di Pasqua
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Stefano Cianci
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy
| |
Collapse
|
13
|
Margatho D, Carvalho NM, Bahamondes L. Endometriosis-associated pain scores and biomarkers in users of the etonogestrel-releasing subdermal implant or the 52-mg levonorgestrel-releasing intrauterine system for up to 24 months. EUR J CONTRACEP REPR 2020; 25:133-140. [PMID: 32069126 DOI: 10.1080/13625187.2020.1725461] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: The aims of the study were to correlate endometriosis-associated pain, evaluated by visual analogue scale (VAS) scores, with serum levels of etonogestrel (ENG), levonorgestrel (LNG), CA-125 and soluble CD23 in users of the ENG implant or the 52-mg LNG-releasing intrauterine system (52 mg LNG-IUS) for up to 2 years after device placement.Methods: A randomised trial was conducted at the University of Campinas Medical School, Brazil. All participants (n = 103) had had endometriosis-associated chronic pelvic pain or dysmenorrhoea, or both, for more than 6 months. Participants were randomly assigned to use an ENG implant (experimental treatment) or a 52-mg LNG-IUS (active comparator). Follow-up was conducted 6 monthly for up to 24 months after device placement. Dysmenorrhoea and chronic pelvic pain were evaluated using a VAS and the scores were correlated with serum levels of ENG, LNG, CA-125 and soluble CD23.Results: Both progestin-only contraceptives significantly reduced VAS scores for dysmenorrhoea and chronic pelvic pain and reduced serum levels of soluble CD23 (p < 0.001). Serum levels of CA-125 decreased only in the ENG implant group after 24 months' use of the device (p < 0.001). No correlation was found between pain scores and ENG or LNG serum levels over time (p > 0.005).Conclusion: Both contraceptives improved dysmenorrhoea and chronic pelvic pain scores in women with endometriosis-associated pain and they reduced serum levels of soluble CD23; however, serum levels of CA-125 were reduced only in ENG implant users over the 24-month study period.
Collapse
Affiliation(s)
- Deborah Margatho
- Department of Obstetrics and Gynaecology, University of Campinas Medical School, Campinas, São Paulo, Brazil
| | - Nelsilene Mota Carvalho
- Department of Obstetrics and Gynaecology, University of Campinas Medical School, Campinas, São Paulo, Brazil
| | - Luis Bahamondes
- Department of Obstetrics and Gynaecology, University of Campinas Medical School, Campinas, São Paulo, Brazil
| |
Collapse
|
14
|
Lee D, Kim SK. A comprehensive review and the pharmacologic management of primary dysmenorrhea. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.3.171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Dayong Lee
- Department of Obstetrics and Gynecology, Kyungpook National University Hospital, Daegu, Korea
| | - Seul Ki Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| |
Collapse
|
15
|
di Spiezio Sardo A, Mastantuoni E, De Angelis MC, Zizolfi B. Contraception with the new intrauterine systems: a winning choice if shared! MINERVA GINECOLOGICA 2019; 71:377-384. [PMID: 31698892 DOI: 10.23736/s0026-4784.19.04463-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Today the rate of unexpected pregnancy is still unacceptably high; long-acting reversible contraceptives, (LARC) seem to be an effective and modern solution. Intrauterine contraception (IUC) is the main exponent of the LARC and it is living a new exponential spread in the last years. Today IUC is the most widely used reversible contraceptive method and it is recommended by the major scientific gynecological societies. This review of the literature aims to retrace the history of intrauterine contraception and to focus attention on intrauterine systems (IUS), its last and most modern form. The three systems (LNG-IUS 52 mg; LNG-IUS 13.5 mg; LNG-IUS 19.5 mg) base their extraordinary effectiveness on the same mechanism of action, however they present some important differences that can be used to enhance and customize the treatment, not just contraceptive, based on the woman's needs.
Collapse
Affiliation(s)
| | - Enrica Mastantuoni
- Department of Neurologic, Reproductive, and Odontostomatologic Sciences, Federico II University, Naples, Italy -
| | - Maria Chiara De Angelis
- Department of Neurologic, Reproductive, and Odontostomatologic Sciences, Federico II University, Naples, Italy
| | - Brunella Zizolfi
- Department of Neurologic, Reproductive, and Odontostomatologic Sciences, Federico II University, Naples, Italy
| |
Collapse
|
16
|
Caruso S, Iraci M, Cianci S, Vitale SG, Fava V, Cianci A. Effects of long-term treatment with Dienogest on the quality of life and sexual function of women affected by endometriosis-associated pelvic pain. J Pain Res 2019; 12:2371-2378. [PMID: 31536046 PMCID: PMC6681157 DOI: 10.2147/jpr.s207599] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/06/2019] [Indexed: 12/22/2022] Open
Abstract
Purpose The aim of this prospective study was to evaluate quality of life (QoL) and sexual function of women affected by endometriosis pain treated with Dienogest (DNG) for 24 months. Patients and methods Fifty-four women constituted the study group and were given DNG 2 mg/daily; 38 women were given non-steroidal anti-inflammatory drugs (NSAIDs) and constituted the control group. To define endometriosis-associated pelvic pain, dysmenorrhea and dyspareunia the Visual Analogic Scale (VAS) was used. The Short Form-36 (SF-36), the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) were used to assess the QoL, sexual function and the sexual distress, respectively. The study included five follow-ups at 3, 6, 12, 18 and 24 months. Results Slight improvements in chronic pelvic pain, dysmenorrhea and dyspareunia were observed in the study group at 3 months (p<0.05) and improved more from 6 to 24 months of DNG treatment (p<0.001). QoL improved with a similar trend: at 3 months the improvement was significant in several categories (p<0.05), and from 6 to 24 months in all categories (p<0.001). The FSFI score did not change at the 3 month follow-up (p=not significant [NS]) but it improved from 6 to 24 months (p<0.001). A similar trend was observed for the FSDS score (p<0.001). No change was observed in the control group (p=NS). Conclusion Long-term treatment with DNG 2 mg once-daily in women with endometriosis-associated pelvic pain may have positive effects on the QoL and sexual life, confirming the observations of the previous study on the first 6 months of treatment.
Collapse
Affiliation(s)
- Salvatore Caruso
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.,Research Group for Sexology, University of Catania, Catania, Italy
| | - Marco Iraci
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Stefano Cianci
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Salvatore Giovanni Vitale
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Valentina Fava
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.,Research Group for Sexology, University of Catania, Catania, Italy
| | - Antonio Cianci
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.,Research Group for Sexology, University of Catania, Catania, Italy
| |
Collapse
|
17
|
|
18
|
Margatho D, Mota Carvalho N, Eloy L, Bahamondes L. Assessment of biomarkers in women with endometriosis-associated pain using the ENG contraceptive implant or the 52 mg LNG-IUS: a non-inferiority randomised clinical trial. EUR J CONTRACEP REPR 2018; 23:344-350. [PMID: 30372645 DOI: 10.1080/13625187.2018.1531117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of the study was to assess the serum levels of the following biomarkers in women with endometriosis-associated pelvic pain before and after six months of using the etonogestrel (ENG) contraceptive implant or the 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS): cancer antigen (CA)-125, cluster of differentiation (CD) 23 and endometrial nerve fibre density. METHODS The study was conducted at the Department of Obstetrics and Gynaecology, University of Campinas Medical School, Brazil. A total of 103 women with endometriosis-associated pain diagnosed by surgery, transvaginal ultrasound and/or magnetic resonance imaging were included. Endometrial nerve fibre density and serum levels of CA-125 and soluble CD23 were assessed before and after six months of using the allocated method and were correlated to 10 cm visual analogue scale (VAS) scores for non-cyclical pelvic pain and dysmenorrhoea. RESULTS Both contraceptive methods significantly reduced concentrations of serum soluble CD23 and endometrial nerve fibre density (p < .001); however, CA-125 was significantly reduced only among users of the ENG implant (p < .05). No correlation was observed between reduction of biomarkers and improvement of VAS pain and dysmenorrhoea scores. No differences were observed between the ENG implant and the LNG-IUS. CONCLUSION Both progestin-only contraceptives significantly reduced two out of the three biomarkers evaluated. These two biomarkers could, therefore, be used as surrogate markers to follow up medical treatment of endometriosis-associated pain.
Collapse
Affiliation(s)
- Deborah Margatho
- a Department of Obstetrics and Gynaecology , University of Campinas Medical School , Campinas , Brazil
| | - Nelsilene Mota Carvalho
- a Department of Obstetrics and Gynaecology , University of Campinas Medical School , Campinas , Brazil
| | - Larissa Eloy
- b Department of Pathology , University of Campinas Medical School , Campinas , Brazil
| | - Luis Bahamondes
- a Department of Obstetrics and Gynaecology , University of Campinas Medical School , Campinas , Brazil
| |
Collapse
|