Laparoscopic management of patients with endometriosis and chronic pelvic pain

Expression of ZEB1 in different forms of endometriosis: A pilot study

OBJECTIVES

Epithelial-Mesenchymal Transition (EMT), a cellular process in which epithelial cells lose epithelial characteristics while acquire mesenchymal features, is believed to contribute to migration and invasion abilities of the endometriotic cells. Studies on gene expression of the transcription factor ZEB1, a crucial transcription factor of EMT, show that there is probably a modified expression in the endometriotic lesions. The aim of the study was to compare the expression levels of ZEB1 in types of endometriotic lesions with different biological behavior such as endometriomas and deep infiltrating endometriotic nodules.

STUDY DESIGN

We have studied 19 patients with endometriosis and 8 patients with benign gynecological lesions without endometriosis. The endometriosis patient group included 9 women with only endometriotic cysts without deep infiltrating endometriotic lesion (DIE) and 10 women with DIE who had developed concurrent endometriotic cysts. The technique applied to investigate ZEB1 expression levels is Real-Time PCR. The results of the reaction were normalized by simultaneously investigating the expression of the house-keeping gene G6PD.

RESULTS

Analysis of the samples showed underexpression of ZEB1 in the eutopic endometrium of women with only endometriotic cysts when compared to normal endometrium. A tendency of higher ZEB1 expression, without reaching significant difference, was found between the endometriotic cysts and their paired eutopic endometrium. In women with DIE, no significant difference was found between their eutopic and normal endometrium. No significant difference was found between the endometriomas and DIE lesions. ZEB1 shows different expression profile in the endometriotic cysts of women with and without DIE when the cyst is compared to their paired eutopic endometrium.

CONCLUSIONS

It therefore appears that ZEB1 expression differs between different types of endometriosis. The expression levels of ZEB1 in the eutopic endometrium could affect the development of infiltrating lesions or not. However, the most important observation is the different ZEB1 expression profile of endometriomas between women with and without DIE. Although, they both share the same histologic characteristics, they show different ZEB1 expression indicating different pathogenetic mechanisms of endometriomas in cases with and without DIE. Therefore, future research on endometriosis should consider DIE and ovarian endometriosis as different diseases.

Neurogenic Inflammation in the Context of Endometriosis-What Do We Know?

Endometriosis (EM) is an estrogen-dependent disease characterized by the presence of epithelial, stromal, and smooth muscle cells outside the uterine cavity. It is a chronic and debilitating condition affecting ~10% of women. EM is characterized by infertility and pain, such as dysmenorrhea, chronic pelvic pain, dyspareunia, dysuria, and dyschezia. Although EM was first described in 1860, its aetiology and pathogenesis remain uncertain. Recent evidence demonstrates that the peripheral nervous system plays an important role in the pathophysiology of this disease. Sensory nerves, which surround and innervate endometriotic lesions, not only drive the chronic and debilitating pain associated with EM but also contribute to a growth phenotype by secreting neurotrophic factors and interacting with surrounding immune cells. Here we review the role that peripheral nerves play in driving and maintaining endometriotic lesions. A better understanding of the role of this system, as well as its interactions with immune cells, will unearth novel disease-relevant pathways and targets, providing new therapeutics and better-tailored treatment options.

Endometriosis and nuclear receptors

BACKGROUND

Endometriosis is recognized as a steroid-dependent disorder; however, the precise roles of nuclear receptors (NRs) in steroid responsiveness and other signaling pathways are not well understood.

OBJECTIVE AND RATIONALE

Over the past several years, a number of paradigm-shifting breakthroughs have occurred in the area of NRs in endometriosis. We review and clarify new information regarding the mechanisms responsible for: (i) excessive estrogen biosynthesis, (ii) estrogen-dependent inflammation, (iii) defective differentiation due to progesterone resistance and (iv) enhanced survival due to deficient retinoid production and action in endometriosis. We emphasize the roles of the relevant NRs critical for these pathological processes in endometriosis.

SEARCH METHODS

We conducted a comprehensive search using PubMed for human, animal and cellular studies published until 2018 in the following areas: endometriosis; the steroid and orphan NRs, estrogen receptors alpha (ESR1) and beta (ESR2), progesterone receptor (PGR), steroidogenic factor-1 (NR5A1) and chicken ovalbumin upstream promoter-transcription factor II (NR2F2); and retinoids.

OUTCOMES

Four distinct abnormalities in the intracavitary endometrium and extra-uterine endometriotic tissue underlie endometriosis progression: dysregulated differentiation of endometrial mesenchymal cells, abnormal epigenetic marks, inflammation activated by excess estrogen and the development of progesterone resistance. Endometriotic stromal cells compose the bulk of the lesions and demonstrate widespread epigenetic abnormalities. Endometriotic stromal cells also display a wide range of abnormal NR expression. The orphan NRs NR5A1 and NR2F2 compete to regulate steroid-synthesizing genes in endometriotic stromal cells; NR5A1 dominance gives rise to excessive estrogen formation. Endometriotic stromal cells show an abnormally low ESR1:ESR2 ratio due to excessive levels of ESR2, which mediates an estrogen-driven inflammatory process and prostaglandin formation. These cells are also deficient in PGR, leading to progesterone resistance and defective retinoid synthesis. The pattern of NR expression, involving low ESR1 and PGR and high ESR2, is reminiscent of uterine leiomyoma stem cells. This led us to speculate that endometriotic stromal cells may display stem cell characteristics found in other uterine tissues. The biologic consequences of these abnormalities in endometriotic tissue include intense inflammation, defective differentiation and enhanced survival.

WIDER IMPLICATIONS

Steroid- and other NR-related abnormalities exert genome-wide biologic effects via interaction with defective epigenetic programming and enhance inflammation in endometriotic stromal cells. New synthetic ligands, targeting PGR, retinoic acid receptors and ESR2, may offer novel treatment options.

Novel Drug Targets with Traditional Herbal Medicines for Overcoming Endometriosis

Endometriosis is a disease in which the lining of the endometrium is found outside of the uterus. Recent medical treatments for endometriosis have adverse effects, limiting their long-term use. Furthermore, the recurrence of the disease after the cessation of therapy is quite common, and most patients need to continue treatment to maintain a hypoestrogenic environment till conception. Notwithstanding recent advances in computational and chemical practices, traditional medicines are considered the most consistent sources for the discovery of new drugs. Numerous medicinal plants and plantderived compounds have been tested against gynecological disorders, mainly endometriosis. This review aimed to describe the pharmacological activity profile of the medicinal plants and their active ingredients and draw attention to the discovery of multitargeted drug molecules for rational therapy.

Management of women affected by endometriosis: Are we stepping forward?

Endometriosis is an estrogen-dependent chronic disease defined by the presence of endometrial-like tissue, glands and stroma in ectopic areas. Among all the pathogenic theories proposed to explain the origin of the disease, a pivotal role for immune, hormonal, and epigenetic disbalances have been hypothesized. Endometriosis affects up to 10%–15% of women in reproductive age and represents one of the most common gynecological causes of severe pelvic pain. The main symptoms reported by patients are dysmenorrhea and deep dyspareunia. Although the histological confirmation has been commonly considered mandatory, to date the possibility offered by the improvement in imagining techniques allows to make a proper diagnosis of the disease in most of the cases. Medical therapy represents only a symptomatic treatment and not the definitive solution. The aim of the hormonal therapy is to abolish the menstrual flow using progestin, oral contraceptives, and gonadotropin-releasing hormone agonists to reduce pelvic pain. Surgical treatment consisting of laparoscopy has the goal of abolishing pain and may be conservative or radical in nature depending on the patients’ desire of spontaneous conception in the future. Radical surgery seems to be associated with a higher percentage of pain relief as well as higher recurrence rates. Due to the worldwide acceptance and the ongoing evolution of minimally invasive surgery to treat both benign and malignant diseases, future investigations may be conducted to consider this approach to save the function of all the organs involved by the disease and to reduce post-operative discomfort and psychological impact.

Follicular fluid alterations in endometriosis: label-free proteomics by MS(E) as a functional tool for endometriosis

Endometriosis is a chronic gynecological condition that affects 10-32% of women of reproductive age and may lead to infertility. The study of protein profiles in follicular fluid may assist in elucidating possible biomarkers related to this disease. For this, follicular fluid samples were obtained from women with tubal factor or minimal male factor infertility who had pregnancy outcomes after in vitro fertilization (IVF) treatment (control group, n = 10), women with endometriosis (endometriosis group, n = 10), along with the endometrioma from these same patients were included (endometrioma group, n = 10). For proteomic analysis, samples were pooled according to their respective groups and normalized to protein content. Proteins were analyzed by in tandem mass spectrometry (MS(E)) Spectra processing and the ProteinLynx Global Server v.2.5. was used for database searching. Data was submitted to the biological network analysis using Cytoscape 2.8.2 with ClueGO plugin. As a result, 535 proteins were identified among all groups. The control group differentially or uniquely expressed 33 (6%) proteins and equal expression of 98 (18%) proteins was observed in the control and endometriosis groups of which 41 (7%) proteins were further identified and/or quantified. Six (1%) proteins were observed in both the endometriosis and endometrioma groups, but 212 (39%) proteins were exclusively identified and/or quantified in the endometrioma group. There were 9 (1%) proteins observed in both the control and endometrioma groups and there were 139 (25%) proteins common among all three groups. Distinct differences among the protein profiles in the follicular fluid of patients included in this study were found, identifying proteins related to the disease progression and IVF success. Thus, some pathways related to endometriosis are associated with the presence of specific proteins, as well as the absence of others. This study provides a first step to the development of more sensitive diagnostic tests and treatment.

Systematic review of endometriosis pain assessment: how to choose a scale?

BACKGROUND

Numerous studies concerning endometriosis and pain have been reported. However, there is no consensus on the best method to evaluate pain in endometriosis and many scales have been used. Moreover, there are only a few descriptions of minimal clinically important differences after treatment (MCID) to evaluate variations in pain. In our study, we aim to identify pain scales used in endometriosis pain treatment, to address their strong and weak points and to define which would be the ideal scale to help clinicians and researchers to evaluate endometriosis-related pain.

METHODS

A search of the MEDLINE and EMBASE databases was carried out for publications in English, French or Portuguese from 1980 to December 2012, for the words: endometriosis, treatment, pain. Studies were selected if they studied an endometriosis treatment and a pain scale was specified. A quantitative and a qualitative analysis of each scale was performed to define strong and weak points of each scale (systematic registration number: CRD42013005336).

RESULTS

A total of 736 publications were identified. After excluding duplications and applying inclusion criteria 258 studies remained. We found that the visual analog scale (VAS) is the most frequently used scale. Both VAS and the numerical rating scale (NRS) show a good balance between strong and weak points in comparison with others such as the Biberoglu and Behrman scale. Concerning MCID, only VAS, NRS and Brief Pain Inventory scales have reported MCID and, among these, only VAS MCID has been studied in endometriosis patients (VAS MCID = 10 mm). Adding the Clinical Global Impression score (CGI) to the pain scale allows calculation of the MCID.

CONCLUSIONS

When using pain scales their strengths and weaknesses must be known and included in the analysis. VAS is the most frequently used pain scale and, together with NRS, seems the best adapted for endometriosis pain measurement. The use of VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep dyspareunia and non-menstrual chronic pelvic pain), combined with the CGI and a quality-of-life scale will provide both clinicians and researchers with tools to evaluate treatment response.

The peritoneum--an important factor for pathogenesis and pain generation in endometriosis

Endometriosis (EM) is an oestrogen-dependent disease affecting 10-15 % of women during reproductive age. It is characterised by the presence of endometrial glands, stromal- and smooth muscle-like cells outside of the uterine cavity. Fifty to sixty per cent of women and teenage girls with pelvic pain suffer from EM. EM causes disability and compromises the quality of life in women and young girls significantly. Pain generation in EM is an intricate interplay of several factors such as the endometriotic lesions themselves and the pain-mediating substances, nerve fibres and cytokine-releasing immune cells such as macrophages. These interactions seem to induce a neurogenic inflammatory process. Recently published data demonstrated an increased peptidergic and decreased noradrenergic nerve fibre density in peritoneal lesions. These data could be substantiated by in vitro analyses demonstrating that the peritoneal fluids of patients suffering from EM induced an enhanced sprouting of sensory neurites from chicken dorsal root ganglia and decreased neurite outgrowth from sympathetic ganglia. These findings might be directly involved in the perpetuation of inflammation and pain. Furthermore, the evidence of EM-associated smooth muscle-like cells seems another important factor in pain generation. The peritoneal endometriotic lesion leads to reactions in the surrounding tissue and, therefore, is larger than generally believed. The identification of EM-associated nerve fibres and smooth muscle-like cells fuel discussions on the mechanisms of pain generation in EM, and may present new targets for innovative treatments.

Combination of non-invasive and semi-invasive tests for diagnosis of minimal to mild endometriosis

OBJECTIVES

Non-surgical diagnostic approach for endometriosis would be of great gain to both physicians and patients. The aim of this study was to evaluate the diagnostic value of serum measurement of IL-6 combined with the presence of nerve fibres in the functional layer of endometrium for diagnosis of minimal-mild endometriosis.

METHODS

In this prospective study 114 women who underwent laparoscopy for infertility and/or pelvic pain were divided into two groups: control cases (40 cases) with no pathologic findings; and endometriosis patients (74 cases) [subdivided into stages 1-2 or minimal-mild (MM) and stages 3-4 or moderate-severe cases]. Blood was drawn one day before laparoscopy and stored for subsequent analysis of IL-6. Endometrial biopsy was obtained prior to laparoscopy and Immunohistochemistry was performed using the pan-neuronal marker protein gene product 9.5(PGP9.5). Then laparoscopic diagnosis of endometriosis confirmed by histopathology was done.

RESULTS

Serum IL-6 with a threshold of 15.4 pg/ml was found to be able to diagnose MM endometriosis with 89.5 % sensitivity and 82.5 % specificity, but sensitivity and specificity of presence of nerve fibres in the functional layer of endometrium were 92 % and 80 % respectively. When two diagnostic modalities were combined the sensitivity and specificity were raised to 100 and 92.5 % respectively.

CONCLUSIONS

Combination of both serum IL-6 and presence of nerve fibres in the endometrium is more reliable method for diagnosis of MM endometriosis than in single test.

Chronic pelvic pain in endometriosis: an overview

Chronic pelvic pain (CPP) could be considered nowadays a deep health problem that challenges physicians all over the world. This because its aetiology is still unclear, the course of the disease could vary a lot among different patients and through time in the same patient, and the response to treatments is not every time successful. Among women who underwent laparoscopy for CPP, endometriosis is found in about 1/3 of the cases, while only 25% of women with histological confirmed endometriosis are asymptomatic. A wide range of variables may exert their influence on the resulting pain syndrome in endometriosis; for example, score according to American society for reproductive medicine (rASRM), size of the sub-peritoneal and pelvic wall implants, Douglas obliteration, previous surgery. It is widely accepted nowadays that central nervous system (CNS) and peripheral nervous system (PNS) seems to influence each other and this interconnection play a key role in pain modulation. Moreover, the phenomena induced by endometriosis in the pelvis, including the breakdown of peritoneal homeostasis and the induction of the production of proinflammatory and proangiogenic cytokines, are responsible of altered innervations and modulation of pain pathways in these patients. There are many proposed medical and surgical approach to treat this painful syndrome, although there is necessity of more efforts to create new non-invasive strategies that set a more accurate diagnosis of the causes of endometriotic-related CPP, and therefore facilitate its eradication.

Baboon model for the study of endometriosis

Endometriosis is a benign, estrogen-dependent disease and is now recognized as an enigmatic disease owing to its various clinical manifestations and locations. The lack of a reliable and specific method for the early detection of endometriosis often results in delayed diagnosis. So far, research has born inadequate findings regarding understanding the basic etiology or pathophysiology of endometriosis. Animal models that accurately represent the cellular and molecular changes associated with the initiation and progression of human endometriosis have significant potential to facilitate the development of better methods for the early detection and treatment of endometriosis. A number of animal model systems have been developed for the study of this disease. These models replicate many of the known salient features of human endometriosis. This review provides an insight into the use of the baboon model for studies focused on understanding human endometriosis.

New trends for the medical treatment of endometriosis

INTRODUCTION

Endometriosis is a benign sex hormone-dependent gynecological disease, characterized by the presence and growth of endometrial tissue outside the uterus; it affects 10% of women of reproductive age and is associated with infertility and pain. Treatment of endometriosis involves conservative or radical surgery, or medical therapies. The goals for endometriosis treatment may be the relief of pain and/or a successful pregnancy achievement in infertile patients. Treatment must be individualized with a multidisciplinary approach. The classical treatments carry adverse side effects and in some cases a negative impact on quality of life. New agents promise a distinct perspective in endometriosis treatment.

AREAS COVERED

The aim of this paper is to systematically review the literature evidence of new medical treatments for endometriosis, defined as pharmacological treatments not yet commonly available and currently under investigation.

EXPERT OPINION

These new medical therapies would be used associated with surgical treatment and, in the future, will render possible the association of hormone therapy with non-hormonal treatment for endometriosis.

Combined oral contraceptive therapy in women with posterior deep infiltrating endometriosis

STUDY OBJECTIVE

To estimate the effect of combined oral contraceptives (COCs) in women with deep infiltrating endometriosis.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

Tertiary care university hospital.

PATIENTS

One hundred six women with uncomplicated posterior deep infiltrating endometriosis scheduled to undergo laparoscopic surgery between November 2004 and November 2009.

INTERVENTIONS

During the waiting-list time, between surgical scheduling and laparoscopic intervention (preoperative period), 75 patients received cyclic COCs (users), and 31 received no hormone therapy (COC nonusers).

MEASUREMENTS AND MAIN RESULTS

Patients had undergone 2 clinical examinations, at surgical scheduling and immediately before surgery. Presence and intensity of dysmenorrhea, dyspareunia, chronic pelvic pain, and dyschezia were evaluated using a 10-point visual analog scale (VAS) (primary outcome). In both examinations, patients underwent transvaginal ultrasonography to evaluate localization and mean diameter of endometriotic nodules. Quality of life was evaluated using the Short Form-36 (SF-36) score. Mean (SD) nodule diameter at the beginning and end of the preoperative period in COC users was, respectively, 24.81 (15.13) mm and 26.66 (15.5) mm (p = .09), and in the nonuser group was, respectively, 23.09 (11.11) mm and 30.89 (19.1) mm (p = .007). In COC users, VAS scores for dysmenorrhea, dyspareunia, chronic pelvic pain, and dyschezia did not vary significantly during the preoperative period (p = .90, p = .55, p = .15, and p = .17, respectively). In nonusers, VAS scores for dysmenorrhea and dyspareunia were significantly higher at the second examination than at the first examination (p = .002 and p = .005, respectively), whereas scores for chronic pelvic pain and dyschezia did not vary during the preoperative period (p = .88 and p = .16, respectively). The Short Form-36 total score did not vary significantly during the preoperative period in either the COC user group (p = .82) or the nonusers group (p = .76).

CONCLUSIONS

Combined oral contraceptive therapy can have a role in restraining the progression of dysmenorrhea and dyspareunia and the growth of deep endometriotic nodules.

Post-operative use of oral contraceptive pills for prevention of anatomical relapse or symptom-recurrence after conservative surgery for endometriosis

BACKGROUND

Endometriosis recurrence after conservative surgery is not infrequent. Variable regimens of hormonal therapy have been proposed as adjuvant post-operative measures for prophylaxis against recurrence. Among these, the combined oral contraceptive pills (OCP), represents a valuable option in terms of safety and tolerability for long-term use. The objective of this review is to evaluate the effect of post-operative use of OCP in preventing symptom recurrence, and/or anatomical relapse of endometriosis.

METHODS

A systematic search of Medline identified seven studies evaluating post-operative OCP treatment on prevention of endometriosis recurrence.

RESULTS

A reduction in anatomical relapse rate was observed when oral contraceptive therapy was administered for more than 1 year after conservative surgery. Post-operative use of OCP was associated with a reduction in frequency and intensity of dysmenorrhoea recurrence. No association was found between OCP therapy and dyspareunia prevention, although the effect of OCP on chronic pelvic pain was conflicting.

CONCLUSION

Long-term OCP therapy can be a reliable adjuvant post-operative measure to prevent or reduce frequency/severity of recurrent dysmenorrhoea and anatomical relapse of endometriosis. Since both continuous and cyclic OCP administration regimens seem to have comparable effects, the choice of regimen can be modulated according to patient preferences. The protective effect seems to be related to the duration of treatment.

Safety of the Helica Thermal Coagulator in treatment of early stage endometriosis

The objective of this prospective study was to assess the safety and short-term outcome of the Helica Thermal Coagulator in the laparoscopic treatment of early stage endometriosis. Two hundred and fifty consecutive women with chronic pelvic pain and stage I and II endometriosis (r-AFS classification) were treated laparoscopically with the Helica Thermal Coagulator. No bladder, ureteric or bowel injuries occurred. None of the procedures was converted to laparotomy and there were no major peri-operative complications. The only complication was a vaginal perforation during dissection of the cul-de-sac in a patient with a vaginal vault endometriotic nodule. We conclude that the Helica Thermal Coagulator is a safe alternative for the treatment of mild to moderate endometriosis. Long-term efficacy studies are required to better assess the role of the device in laparoscopic management of endometriosis.

Long-term oral contraceptive pills and postoperative pain management after laparoscopic excision of ovarian endometrioma: a randomized controlled trial

OBJECTIVE

To evaluate postoperative long-term cyclic and continuous administration of combined oral contraceptive (OC) pills in preventing endometriosis-related pain recurrence.

DESIGN

Prospective, randomized, controlled trial.

SETTING

Tertiary care university hospital.

PATIENT(S)

Three hundred eleven women who underwent laparoscopic excision for symptomatic ovarian endometrioma.

INTERVENTION(S)

Patients were randomly divided into three groups: nonuser group receiving no therapy, and cyclic user group and continuous user group receiving low-dose, monophasic OC pills for 24 months in either cyclic or continuous administration.

MAIN OUTCOME MEASURE(S)

Presence and intensity of dysmenorrhea, dyspareunia, and chronic pelvic pain were assessed by a 10-point visual analogue scale (VAS) at 6, 12, 18, and 24 months postoperatively.

RESULT(S)

A significant reduction in recurrence rate and VAS scores for dysmenorrhea was evident in the continuous users versus the other groups at 6 months, and in cyclic users versus nonusers at 18 months postoperatively. No significant differences in recurrence rate and VAS scores for dyspareunia and chronic pelvic pain were demonstrated among the groups. The increase of VAS scores from 6-24 months during the study period for dysmenorrhea, dyspareunia, and chronic pelvic pain was significantly higher in nonusers than in the other groups.

CONCLUSION(S)

Long-term postoperative use of OC pills can reduce the frequency and the severity of recurrent endometriosis-related dysmenorrhea.

Natural history and therapeutic implications of patients with catamenial hemoptysis

Evidence as to whether clinician has to give specific treatment in all patients of catamenial hemoptysis is unclear. We considered that the current treatment such as long-term usage of hormonal agent or surgery might be excessive for the catamenial hemoptysis. Therefore, we developed prospective observation study with observation strategy and follow-up for the patients. In sequential four patients of catamenial hemoptysis between December 2000 and November 2001, physical examination, chest X-ray, pelvic ultrasonogram and chest CT scan were taken at both the diagnosis and last follow-up. All patients were only observed without specific treatment within the limit of the possibility and followed for average 58 months. Mean age of patients was 23.5years (range, 22-25years). All patients have a history of undertaking one or two dilatations and curettages before diagnosis. The chest CT scans of all patients presented with ground-glass opacities of peripheral location that were disappeared without any residual lesion at last follow-up. Hemoptysis of two patients was spontaneously disappeared after 6 months. In the other two patients, it was greatly lessened in amount and frequency, then clinically insignificant in one. It was disappeared after subsequent 2 months and then relapsed two times in the late of follow-up of another patient. This study suggests that observation only may be an alternative option in the treatment of catamenial hemoptysis.

Over one thousand patients with early stage endometriosis treated with the Helica Thermal Coagulator (HELICA): safety aspects

STUDY OBJECTIVE

To assess the safety of the Helica Thermal Coagulator in the laparoscopic treatment of early stage endometriosis.

DESIGN

Retrospective, observational.

SETTINGS

The Princess Royal University Hospital, The Sloane and Chelsfield Park Hospitals, Kent, UK.

PATIENTS

One thousand and sixty patients with early stage endometriosis.

RESULTS

All patients were treated laparoscopically with the Helica Thermal Coagulator; a new laparoscopic device that combines electrical energy with helium for the treatment of endometriosis. No major bladder, ureteric or bowel injuries occurred. The only complication was a perforated vagina from the cutting probe during dissection of the cul-de-sac in a patient with a vaginal endometriotic nodule.

CONCLUSION

The Helica Thermal Coagulator is a safe device for the laparoscopic treatment of endometriosis.

Laparoscopic evaluation of infertile patients with chronic pelvic pain

In this study over a 10-year period, 1584 patients complaining of infertility of more than 1 year duration were evaluated for their laparoscopic findings in relation to the presence or not of chronic pelvic pain (CPP). Infertility was the only complaint in 1215 cases (group 1), whereas 369 patients complained of infertility and CPP (group 2). All cases underwent routine infertility investigation and pelvic ultrasonography, followed by diagnostic laparoscopy, with infertility-only cases acting as a control group. At laparoscopy 76.7% of patients with CPP were found with pelvic pathology, compared with only 42.6% of cases without CPP (P < or = 0.0001). Omental-abdominal wall adhesions, advanced endometriosis, endometriomas with adhesions, pelvic venous congestion, and hydrosalpinges with pelvic adhesions were significantly more frequent in cases with CPP. Dysmenorrhoea was the most frequent type of CPP. Cases with CPP and a negative laparoscopy were further investigated using a multidisciplinary approach. In conclusion, chronic pelvic pain can be the result of several pelvic pathologies. Infertile patients with CPP are much more frequently found with an abnormal pelvis in comparison with cases without CPP. Laparoscopy is an invaluable diagnostic tool especially for symptomatic patients and should be used early in their diagnostic infertility work-up.

Advances in the management of endometriosis: an update for clinicians

Endometriosis is a chronic and recurrent disease characterized by the presence and proliferation of endometrial tissue outside the uterine cavity, which occurs in approximately 10% of women of reproductive age. In this estrogen-dependent disorder, lesions become inactive and gradually undergo regression during states of ovarian down-regulation, such as amenorrhoea or menopause. The impact of endometriosis includes impaired fertility potential, as well as symptoms of dysmenorrhoea, dyspareunia and chronic non-menstrual pain, all of which adversely affect quality of life. Management of endometriosis focuses on pain relief and includes medical and surgical treatment. Pharmacologic therapies currently in use include combination oral contraceptives (COCs), danazol, GnRH analogues and progestins. Although some agents show efficacy in relieving pain, all differ in their side effects, making it difficult to achieve a balance between efficacy and safety. Efficacy has been demonstrated with danazol or GnRH analogues; however, treatment is limited to 6 months because of significant metabolic side effects. Alternatives for longer-term management of symptoms include add-back therapy with GnRH analogues, COCs or progestins. Newer options for treatment of endometriosis include depot medroxyprogesterone acetate subcutaneous injection, as well as several agents under investigation that may prove to have therapeutic potential.

Laparoscopic appendectomy in patients with endometriosis

STUDY OBJECTIVE

To report the frequency and spectrum of histologically proved diseases of the appendix in patients undergoing laparoscopic surgery for chronic pelvic pain in conjunction with endometriosis in a tertiary referral center.

DESIGN

Patient database with retrospective chart review (Canadian Task Force classification II-3).

SETTING

University ambulatory endoscopic surgery center-tertiary referral center.

PATIENTS

Two hundred thirty-one women.

INTERVENTIONS

Appendectomy during laparoscopic surgery for endometriosis.

MEASUREMENTS AND MAIN RESULTS

We reviewed the medical records of 231 patients who underwent appendectomy during laparoscopic treatment of endometriosis performed from January 1994 through July 2004. Of the 231 patients with pelvic endometriosis, concomitant appendiceal pathology was present in 115.

CONCLUSION

The appendix may be involved and may contribute to pelvic pain in patients with endometriosis.

Successful laparoscopic treatment of ileocecal-appendicular endometriosis

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