Diet in Prevention and Treatment of Endometriosis: Current State of Knowledge

PURPOSE OF REVIEW

Endometriosis (EM) is a chronic gynecological disease that affects about 10% of women worldwide. It is characterized by the implantation of endometrial cells at ectopic sites. The most common symptom of EM is painful menstruation, which can often lead to chronic pelvic pain that significantly worsens the quality of life. Because some disease-related processes, such as inflammation, hormonal activity, menstrual cycle, or prostaglandin metabolism, can be modified by diet, nutrition may have a significant impact on development and treatment of EM. The purpose of this article was to overview the current knowledge regarding the dietary management of endometriosis.

RECENT FINDINGS

The attention of researchers has so far concentrated mainly on the role of nutrition in the risk of developing EM, while less attention has been paid to examining the use of diet in the treatment of the disease. Current studies focus primarily on various dietary components that have antiproliferative, anti-inflammatory, antioxidant, analgesic, and estrogen-lowering properties. Exploring different ways of coping with endometriosis can make a significant contribution to improving the quality of life of women at risk or diagnosed with EM.

Atorvastatin exerts dual effects of lesion regression and ovarian protection in the prevention and treatment of endometriosis

Endometriosis is a frequent, chronic, estrogen-dependent and inflammatory gynecological disease leading to pain and infertility. Clinical and metabolic studies reveal that patients with endometriosis are susceptible to hyperlipemia and lipid dysfunction, putting them at ascending risk of cardiovascular diseases. Statins constitute a group of cholesterol-lowering drugs with pleiotropic effects. A plethora of researches have proved their ability to inhibit the growth of ectopic lesions in endometriosis. However, concerns exist about their possible adverse effects on ovarian function. This study aimed to investigate the possible effect of atorvastatin on the ovarian endocrine function and fertility capacity in the prevention and treatment of endometriosis. Here, 5 mg/kg atorvastatin was intraperitoneally injected to the endometriosis mice once a day for consecutive fourteen days during and after the development of endometriotic implants. The results indicated that atorvastatin not only led to regression of the ectopic lesions, but also caused no discernible harm to the ovary for both the preventive and the therapeutic models. In addition, it elicited a protective effect on the ovarian reserve and fertility possibly by reducing inflammation in the ovary. Hence, atorvastatin could be a promising drug for endometriosis prevention and treatment.

Proposal for targeted, neo-evolutionary-oriented secondary prevention of early-onset endometriosis and adenomyosis. Part II: medical interventions

According to consistent epidemiological data, the slope of the incidence curve of endometriosis rises rapidly and sharply around the age of 25 years. The delay in diagnosis is generally reported to be between 5 and 8 years in adult women, but it appears to be over 10 years in adolescents. If this is true, the actual onset of endometriosis in many young women would be chronologically placed in the early postmenarchal years. Ovulation and menstruation are inflammatory events that, when occurring repeatedly for years, may theoretically favour the early development of endometriosis and adenomyosis. Moreover, repeated acute dysmenorrhoea episodes after menarche may not only be an indicator of ensuing endometriosis or adenomyosis, but may also promote the transition from acute to chronic pelvic pain through central sensitization mechanisms, as well as the onset of chronic overlapping pain conditions. Therefore, secondary prevention aimed at reducing suffering, limiting lesion progression, and preserving future reproductive potential should be focused on the age group that could benefit most from the intervention, i.e. severely symptomatic adolescents. Early-onset endometriosis and adenomyosis should be promptly suspected even when physical and ultrasound findings are negative, and long-term ovulatory suppression may be established until conception seeking. As nowadays this could mean using hormonal therapies for several years, drug safety evaluation is crucial. In adolescents without recognized major contraindications to oestrogens, the use of very low-dose combined oral contraceptives is associated with a marginal increase in the individual absolute risk of thromboembolic events. Oral contraceptives containing oestradiol instead of ethinyl oestradiol may further limit such risk. Oral, subcutaneous, and intramuscular progestogens do not increase the thromboembolic risk, but may interfere with attainment of peak bone mass in young women. Levonorgestrel-releasing intra-uterine devices may be a safe alternative for adolescents, as amenorrhoea is frequently induced without suppression of the ovarian activity. With regard to oncological risk, the net effect of long-term oestrogen-progestogen combinations use is a small reduction in overall cancer risk. Whether surgery should be considered the first-line approach in young women with chronic pelvic pain symptoms seems questionable. Especially when large endometriomas or infiltrating lesions are not detected at pelvic imaging, laparoscopy should be reserved to adolescents who refuse hormonal treatments or in whom first-line medications are not effective, not tolerated, or contraindicated. Diagnostic and therapeutic algorithms, including self-reported outcome measures, for young individuals with a clinical suspicion of early-onset endometriosis or adenomyosis are proposed.

Proposal for targeted, neo-evolutionary-oriented, secondary prevention of early-onset endometriosis and adenomyosis. Part I: pathogenic aspects

The potential for repeated ovulation and menstruation is thought to have provided a Darwinian advantage during the Palaeolithic. Reproductive conditions remained relatively stable until the pre-industrial era, characterized by late menarche, very young age at first birth, multiple pregnancies, and prolonged periods of lactational amenorrhoea. For hundreds of thousands of years, menstruators experienced few ovulatory cycles, even though they were genetically adapted to ovulate and menstruate every month. In the post-industrial era, the age at menarche gradually declined, the age at first birth progressively increased, and breastfeeding became optional and often of short duration. This created a mismatch between genetic adaptation and socio-environmental evolution, so that what was initially a probable reproductive advantage subsequently contributed to increased susceptibility to diseases associated with lifetime oestrogen exposure, such as ovarian, endometrial and breast cancer and, hypothetically, also those associated with the number of ovulatory menstruations, such as endometriosis and adenomyosis. The incidence of endometriosis shows a steep and progressive increase around the age of 25 years, but given the consistently reported delay in diagnosis, the actual incidence curve should be shifted to the left, supporting the possibility that the disease has its roots in adolescence. This raises the question of whether, from an evolutionary point of view, anovulation and amenorrhoea should not still be considered the physiological state, especially in the postmenarchal period. However, an increase in the frequency of endometriosis in recent decades has not been demonstrated, although this deserves further epidemiological investigation. In addition, as endometriosis occurs in a minority of individuals exposed to retrograde menstruation, other important pathogenic factors should be scrutinised. Research should be resumed to explore in more detail the transtubal reflux of not only blood, but also endometrial cells, and whether they are systematically present in the peritoneal fluid after menstruation. If repetitive ovulatory menstruation during the early reproductive years is shown to increase the risk of endometriosis and adenomyosis development and progression in susceptible individuals, hormonal interventions could be used as secondary prevention in symptomatic adolescents.

Efficacy of Post-Operative Medication to Prevent Recurrence of Endometrioma: Cyclic Oral Contraceptive (OC) After Gonadotropin-Releasing Hormone (GnRH) Agonist Versus Dienogest

BACKGROUND

There are several medical treatment options for endometrioma. Progestin, especially dienogest, is an effective drug for preventing recurrence of endometrioma after surgery. Additionally, oral contraceptive (OC) use after conservative surgery has been reported to reduce significantly the risk of endometrioma recurrence. The aim of this study was to compare the long-term effects of gonadotropin-releasing hormone (GnRH) agonist followed by OC to those of dienogest alone to prevent recurrence of endometrioma after laparoscopic surgery.

METHODS

A retrospective cohort study was performed on patients who underwent conservative laparoscopic surgery for endometrioma between January 2000 and December 2020, in the Endometriosis Clinic, Department of Gynecology, Samsung Medical Center. A total of 624 patients who received medical treatment at least six months after laparoscopic conservative surgery for endometrioma was included. Among them, 372 patients used OC after GnRH agonist therapy, and 252 patients used dienogest. Within the OC group, 148 used a 21/7 regiment and 224 used a 24/4 regimen. A cumulative endometrioma recurrence curve was presented using the Kaplan-Meier method to compare the recurrence of those groups.

RESULTS

The cumulative recurrence rate of endometrioma for 60 months was 2.08% (n = 4) in the OC after GnRH agonist group and 0.40% (n = 1) in the dienogest group. There was no statistical difference in cumulative recurrence of endometrioma between the two groups. In subgroup analysis, the cumulative recurrence rate of endometrioma over 60 months was 4.21% (n = 2) in the 21/7 OC group and 1.09% (n = 2) in the 24/4 OC group and showed no significant difference.

CONCLUSION

Long-term use of OC after GnRH agonist as well as that of dienogest treatment are effective postoperative medical therapies for preventing endometrioma recurrence. Thus, the choice of regimen can be individualized or used interchangeably depending on patient condition, need for contraception, and compliance with drug therapy.

SCM-198 Prevents Endometriosis by Reversing Low Autophagy of Endometrial Stromal Cell via Balancing ERα and PR Signals

BACKGROUND

Endometriosis (EMS), an endocrine-related inflammatory disease, is characterized by estrogen and progesterone imbalance in ectopic lesions. However, its pathogenic mechanism has not been fully elucidated. While SCM-198 is the synthetic form of leonurine and has multiple pharmacological activities such as antioxidation and anti-inflammation, it remains unknown whether it could inhibit the progress of EMS by regulating estrogen signaling and inflammation.

METHODS

The therapeutic effects of SCM-198 on EMS and its potential mechanism were analyzed by establishing EMS mouse models and performing an RNA sequencing (RNA-seq) assay. ELISA was performed to detect estrogen and tumor necrosis factor (TNF) -α concentrations in normal endometrial stromal cells (nESCs) and ectopic endometrial stromal cells (eESCs) with or without SCM-198 treatment. Western blotting, RNA silencing, and plasmid overexpression were used to analyze the relationship between inflammation, endocrine factors, and autophagy and the regulatory activity of SCM-198 on the inflammation-endocrine-autophagy axis.

RESULTS

Increased estrogen-estrogen receptor (ER) α signaling and decreased progesterone receptor isoform B (PRB) expression synergistically led to a hypo-autophagy state in eESCs, which further inhibited the apoptosis of eESCs. The high expression of TNF-α in eESCs enhanced the antiapoptotic effect mediated by low autophagy through the activation of the aromatase-estrogen-ERα signaling pathway. SCM-198 inhibited the growth of ectopic lesions in EMS mice and promoted the apoptosis of eESCs both in vivo and in vitro. The apoptotic effect of SCM-198 on eESCs was attained by upregulating the autophagy level via the inhibition of the TNF-α-activated aromatase-estrogen-ERα signal and the increase in PRB expression.

CONCLUSION

Inflammation facilitated the progress of EMS by disrupting the estrogen regulatory axis. SCM-198 inhibited EMS progression by regulating the inflammation-endocrine-autophagy axis.

Chinese herbal medicine for previous cesarean scar defect: A protocol for systematic review and meta-analysis

BACKGROUND

Previous cesarean scar defect (PCSD) is a gynecological disease that can cause bleeding after intercourse, prolonging menstrual period, intermenstrual bleeding, dysmenorrhea, and even lead to infertility. Chinese herbal medicine plays an important role in the treatment of gynecological diseases in China and East Asia. This study aims to assess the efficacy and safety of Chinese herbal medicine for PCSD.

METHODS

We search the following databases: PubMed, the Cochrane Library, Chinese Biomedical Literature Database (CB), Chinese Science and Technique Journals Database (VIP), EMBASE, Chinese National Knowledge Infrastructure Database (CNKI), and the Wanfang Database. Other sources will also be searched like Google Scholar and gray literature. All databases mentioned above are searched from the start date to the latest version. Randomized controlled trials will be included which recruiting PCSD participants to assess the efficacy and safety of Chinese herbal medicines against controls (placebo or other therapeutic agents). Primary outcomes will include the size of PCSD, menstrual cycle, menstrual phase, menstrual volume, duration of disease, security index. Two authors will independently scan the searched articles, extract the data from attached articles, and import them into Endnote X8 and use Microsoft Excel 2013 to manage data and information. We will assess the risk of bias by Cochrane tool of risk of bias. Disagreements will be resolved by consensus or the participation of a third party. All analysis will be performed based on the Cochrane Handbook for Systematic Reviews of Interventions. The meta-analysis in this review will use RevMan 5.3 software.

RESULTS

The study aims to evaluate the efficacy and safety of the treatment that Chinese herbal medicine for PCSD.

CONCLUSION

This study of the meta-analysis could provide evidence for clinicians and help patients to make a better choice.

INPLASY REGISTRATION NUMBER

INPLASY202090080.

Experiences of health after dietary changes in endometriosis: a qualitative interview study

OBJECTIVES

Endometriosis is a chronic disease with no known cure. Persons affected by this disease often use complementary therapies such as dietary changes to reduce their symptoms, and so it is important to investigate whether and how these therapies affect endometriosis symptoms. The aim of this study was to explore how persons with endometriosis experienced their health after dietary changes.

DESIGN

Semi-structured qualitative interviews were conducted with 12 persons with endometriosis who had made individual dietary changes aimed at decreasing their endometriosis symptoms. The interviews were recorded and transcribed verbatim, and analysed using thematic analysis.

SETTING

Region Västra Götaland and the estern part of Central Sweden, Sweden.

PARTICIPANTS

Twelve persons with endometriosis aged 28 to 44 were recruited from two Swedish endometriosis support forums on the Internet.

RESULTS

Participants experienced an increase in well-being and a decrease in symptoms following their dietary and lifestyle changes. They also felt that the dietary changes led to increased energy levels and a deeper understanding of how they could affect their health by listening to their body's reactions. The participants understood that they could influence their symptoms through lifestyle changes. Support from family and friends was important in implementing and sustaining the dietary changes. However, the participants stressed the lack of support from healthcare professionals.

CONCLUSIONS

This study contributes to filling the knowledge gap about dietary strategies in endometriosis and lifestyle change as a method of alleviating suffering and increasing well-being. An important finding is that the participants experienced decreased symptoms and increased well-being after adopting an individually-adapted diet. Healthcare professionals should take their patients' knowledge and experience into consideration, and allow patients to participate in their own care. Further research is necessary to give evidenced-based dietary advices in endometriosis.

Epigenetic Therapy: Novel Translational Implications for Arrest of Environmental Dioxin-Induced Disease in Females

Increased toxicant exposure and resultant environmentally induced diseases are a tradeoff of industrial productivity. Dioxin [2,3,7,8 tetrachlorodibenzo-p-dioxin (TCDD)], a ubiquitous byproduct, is associated with a spectrum of diseases including endometriosis, a common, chronic disease in women. TCDD activates cytochrome (CYP) p450 metabolic enzymes that alter organ function to cause disease. In contrast, the transcription factor, Krüppel-like factor (KLF) 11, represses these enzymes via epigenetic mechanisms. In this study, we characterized these opposing mechanisms in vitro and in vivo as well as determining potential translational implications of epigenetic inhibitor therapy. KLF11 antagonized TCDD-mediated activation of CYP3A4 gene expression and function in endometrial cells. The repression was pharmacologically replicated by selective use of an epigenetic histone acetyltransferase inhibitor (HATI). We further showed phenotypic relevance of this mechanism using an animal model for endometriosis. Fibrotic extent in TCDD-exposed wild-type animals was similar to that previously observed in Klf11-/- animals. When TCDD-exposed animals were treated with a HATI, Cyp3 messenger RNA levels and protein expression decreased along with disease progression. Fibrotic progression is ubiquitous in environmentally induced chronic, untreatable diseases; this report shows that relentless disease progression can be arrested through targeted epigenetic modulation of protective mechanisms.

Shedding new light on female fertility: The role of vitamin D

In the last decades several studies suggested that vitamin D is involved in the modulation of the reproductive process in women due to the expression of VDR and 1α-hydroxylase in reproductive tissues such as ovary, uterus, placenta, pituitary and hypothalamus. Vitamin D has also a role in the regulation of sex hormone steroidogenesis. Increasing evidence suggests that vitamin D might have a regulatory role in polycystic ovary syndrome (PCOS)-associated symptoms, including ovulatory dysfunction, insulin resistance and hyperandrogenism. Vitamin D deficiency also has been reported to contribute to the pathogenesis of endometriosis due to its immunomodulatory and anti-inflammatory properties. Although most of the studies supported a role of vitamin D in the onset of these diseases, randomized controlled trials to assess the efficacy of vitamin D supplementation have never been performed. In this review we critically discuss the role of vitamin D in female fertility, starting from in vitro and in vivo studies, focusing our attention on the two most frequent causes of female infertility: PCOS and endometriosis.

Disulfiram, as a candidate NF-κB and proteasome inhibitor, prevents endometriotic implant growing in a rat model of endometriosis

OBJECTIVE

Disulfiram (DSF) exerts its therapeutic effects through oxidative, proteasome, and nuclear factor kappa beta (NF-κB) pathways. The study was planned to test the impact of DSF on growing of endometriotic implants in rats with experimentally induced endometriosis.

PATIENTS AND METHODS

Thirty rats were labeled as the control (n = 8), sham (n = 6), GnRH-agonist (n = 8) and the DSF (n = 8) groups. The rats in the group 3 exposed to single dose leuprolide acetate. The rats in group 4 were treated with DSF for 21 days. The serum activity of oxidant and antioxidant markers, total oxidant status (TOS), total antioxidant status (TAS), interleukin-1β, and tumor necrosis factor-α (TNF-α) were determined. Implants were processed for NF-κB, PCNA, and CD34 immunostaining.

RESULTS

The serum concentration of malondialdehyde in the DSF group was significantly higher than those in other groups. The concentration of TAS, TNF-α, and interleukin-1β in the DSF group considerably decreased compared to control group. Following treatment with DSF while the percentage of Grade 1 and 2 implants increased the percentage of Grade 3 and 4 implants decreased. The implants disappeared totally in two cases in the DSF group and one case in the GnRH-agonist group. The mean H-Scores of implant NF-κB and PCNA in DSF treated animals were found to significantly lower than those of the control group.

CONCLUSIONS

By decreasing NF-κB expression, angiogenesis, and cell proliferation DSF prevents the growth of endometriotic implants.

Selenium Plays a Protective Role in Staphylococcus aureus-Induced Endometritis in the Uterine Tissue of Rats

The essential trace element selenium (Se) modulates the functions of many regulatory proteins in signal transduction, conferring benefits in inflammatory diseases. Endometritis is a reproductive obstacle disease both in humans and animals. Staphylococcus aureus is the major pathogen that causes endometritis. The present study analyzes the protection and mechanism of Se-methylselenocysteine (MSC) and methylseleninic acid (MSA) on S. aureus-induced endometritis. An atomic fluorescence spectrophotometry study showed that the uterine Se content increased with the addition of MSC and MSA. Histopathology observation and TUNEL detection showed that Se supplementation displayed a greater defense against uterine inflammatory damage. The quantitative PCR (qPCR) and ELISA analyses showed that the expressions of tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6) increased with S. aureus infection and decreased with the addition of MSC and MSA. The Toll-like receptor 2 (TLR2) expression showed the same status as the inflammatory cytokines. The Western blot results showed that the increased phosphorylation of IκBα and NF-κB p65 was also reduced by the addition of MSC and MSA. The qPCR and Western blot results also showed that the transcription expressions and the protein dissociation of caspase-9, caspase-3, caspase-7, caspase-6, and poly(ADP-ribose) polymerase (PARP), which were increased by S. aureus infection, were inhibited by Se supplementation. All of the results displayed that the protection conferred by MSC was stronger than MSA. The present study indicated the Se supplementation might be a potential prevention and control measure for S. aureus-induced endometritis.

Postoperative administration of dienogest for suppressing recurrence of disease and relieving pain in subjects with ovarian endometriomas

To assess the effect of dienogest on recurrence of ovarian endometriomas and severity of pain after laparoscopic surgery, a retrospective study of 81 patients was performed at three institutions in Osaka, Japan. Patients had a six-month minimum follow-up after laparoscopic surgery for ovarian endometriomas performed between June 2012 and August 2014. Patients who chose to receive 2 mg dienogest daily and those who were managed expectantly postoperatively were included. Recurrence was defined as the presence of endometriomas of more than 2 cm. A visual analog scale (VAS) was used to score the intensity of pelvic pain. The cumulative recurrence rate and absolute VAS score changes between the baseline and at 6, 12, 18 and 24 months after the start of administration were evaluated in both groups. The recurrence rate was 16.5% and 24.0% in the expectant management group at 12 and 24 months, respectively. No recurrences occurred in the dienogest treatment group. The rate of VAS score reduction was significantly higher in the dienogest than in the expectant management group. Dienogest is effective on the recurrence of ovarian endometrioma and relieving pelvic pain after laparoscopic surgery.

Pharmaceutical treatments to prevent recurrence of endometriosis following surgery: a model-based economic evaluation

OBJECTIVE

Conduct an economic evaluation based on best currently available evidence comparing alternative treatments levonorgestrel-releasing intrauterine system, depot-medroxyprogesterone acetate, combined oral contraceptive pill (COCP) and 'no treatment' to prevent recurrence of endometriosis after conservative surgery in primary care, and to inform the design of a planned trial-based economic evaluation.

METHODS

We developed a state transition (Markov) model with a 36-month follow-up. The model structure was informed by a pragmatic review and clinical experts. The economic evaluation adopted a UK National Health Service perspective and was based on an outcome of incremental cost per quality-adjusted life year (QALY). As available data were limited, intentionally wide distributions were assigned around model inputs, and the average costs and outcome of the probabilistic sensitivity analyses were reported.

RESULTS

On average, all strategies were more expensive and generated fewer QALYs compared to no treatment. However, uncertainty attributing to the transition probabilities affected the results. Inputs relating to effectiveness, changes in treatment and the time at which the change is made were the main causes of uncertainty, illustrating areas where robust and specific data collection is required.

CONCLUSIONS

There is currently no evidence to support any treatment being recommended to prevent the recurrence of endometriosis following conservative surgery. The study highlights the importance of developing decision models at the outset of a trial to identify data requirements to conduct a robust post-trial analysis.

[POST-CAESAREAN ABDOMINAL WALL ENDOMETRIOSIS PREVENTION]

Abdominal wall endometriosis (AWE) is a rare type of endometriosis. Its pathophysiological pathways are still unknown. It generally occurs after surgical, mainly gynecological or obstetrical, interventions. The incidence of AWE after a caesarean section is around 0.03 to 0.04%. The symptoms are various, but the classical triad includes the presence of a mass, generally painful, associated with a cyclic variation of the symptomatology. The recommended treatment currently remains complete surgical resection of the mass. This article describes three cases of AWE. Each patient had a caesarean section. Their symptoms, however, occurred after various lengths of time and in different circumstances. We will more specifically discuss AWE secondary to cesarean sections, the diagnostic tools, treatment and prevention strategies.

[Clinical effect evaluation of acupuncture combined with medication for prevention of endometriosis recurrence after surgery]

OBJECTIVE

To evaluate the effect and safety of acupuncture combined with Jiawei Mojie tablet for the prevention of endometriosis recurrence after surgery.

METHODS

One hundred and six patients after the conservative surgery against endometriosis were randomly divided into a western medication group and an acupuncture and medication group(a combination group), 53 cases in each one. In the western medication group, gestrinone was applied orally. In the combination group, acupuncture and Jiawei Mojie tablet with oral administration were adopted. Xuehai (SP 10), Sanyinjiao (SP 6) and Guanyuan (CV 4) were mainly used, and acupoints based on syndrome differentiation were combined. After the surgery and when the menstruation was end, 3 to 5 days later the preventive treatment was used successively for 6 months. Patients were followed up after treatment and in 3 months, 6 months, and 18 months (two years after surgery) after treatment. The recurrence [Abdominal/perineal ultrasonic examination, serum cancer antigen 125 (CA125) test], menstruation score, endometriosis health profile-5 (EHP-5) and the safety index of serum alanine aminotransferase (ALT) were compared between the two groups.

RESULTS

Eight patients (five cases in the western medication group and three cases in the combination group) were rejected because of dropping, and six ones (two cases in the western medication group and four cases in the combination group) discontinued. When patients were followed up in 18 months after treatment, the suspected recurrence rate through ultrasonic examination was 2.0% (1/50), and the unusual rate of serum CA125 text was 4.0% (2/50) in the combination group, which were apparently lower than 18.8% (9/48) and 25.0% (12/48) in the western medication group (both P < 0.01). After treatment and 3-month, 6-month, and 18-month following up, the menstruation scores of the combination group were obviously lower than those of the western medication group (P < 0.01, P < 0.05). After 18 months, the positive rate of EHP-5 in the combination group was 0 (0/50), which was markedly lower than 18.8% (9/48) in the western medication group (P < 0.01). After treatment and 3-month, 6-month, and 18-month following up, the unusual rates of serum ALT text in the combination group were lower than those in the western medication group (P < 0.01, P < 0.05). After treatment, the unusual rate of serum ALT text was not significantly different in the combination group compared with that before treatment (P > 0.05), and after treatment and 3-month, 6-month following up, the unusual rates of serum ALT text in the western medication group were remarkablely higher than those before treatment (P < 0.01, P < 0.05). After 18-month following up, the unusual rate of serum ALT text in the western medication group was not statistically significant compared with that before treatment (P > 0.05).

CONCLUSION

Acupuncture combined with Jiawei Mojie tablet can effectively prevent endometriosis recurrence after surgery, and improve menstruation condition and life quality, which are less injurious for liver than gestrinone.

Adenosine Triphosphate Regresses Endometrial Explants in a Rat Model of Endometriosis

The aim of this study was to determine the effects of adenosine triphosphate (ATP) in a rat endometriosis model. After surgical induction of endometriosis, 3 rats were killed, and explants were measured in the remaining 19 rats, which were then randomly assigned to 4 groups. Group 1 (n = 4) received normal saline (2 mL/d intragastric [IG]), group 2 (n = 4) gestrinone (0.5 mg/kg/d IG), group 3 (n = 5) ATP (3.4 mg/kg/d IG), and group 4 (n = 6) ATP (1.0 mg/kg/d; intramuscularly), respectively. Four weeks after medication, they were euthanized to evaluate histological features of explants and eutopic uterine tissues. To test the effect of ATP on the growth of eutopic endometrium stromal cells, proliferation rates of hEM15A cells at 24, 48, and 72 hours after treatment with different concentrations of ATP and vehicle control were detected with the Cell Counting Kit-8 (CCK-8) method. There was a significant difference between pretreatment and posttreatment volumes within group 2 (positive control; P = .048) and group 4 (P = .044). On condition that pretreatment implant size was similar in both groups (P = .516), regression of explants in group 4 was significantly higher than that in group 1 (negative control; P = .035). Epithelial cells were significantly better preserved in group 1 than in group 3 (P = .008) and group 4 (P = .037). The CCK-8 assay showed no significant difference in proliferation among hEM15A cells treated with ATP and controls. These results suggest that ATP regresses endometriotic tissues in a rat endometriosis model but has no impact on the growth of eutopic endometrium stromal cells.

[Lentiviral vector-mediated short hairpin RNA targeting survivin inhibits abdominal growth of human endometrium xenograft in nude mice]

OBJEVTIVE

To investigate the inhibitory effect of lentiviral vector-mediated short hairpin RNA targeting survivin (LV-survivin shRNA) on the growth of human endometrium xenograft in the abdominal cavity of nude mice.

METHODS

The endometrium xenografts from 8 women with endometriosis were injected into the peritoneal cavities of 45 nude mice. The mice were then randomly assigned to receive intraperitoneal injection of LV-survivin shRNA, pGCL-NC-GFP (negative control) or PBS (blank control). Two weeks later, the number and morphometry of endometriotic lesions were quantified and the expression of survivin protein were detected by immunohistochemistry.

RESULTS

The formation of endometriotic lesions was significantly suppressed in mice receiving LV-survivin shRNA injection as compared with those in the two control groups (P/0.001). The mice in LV-survivin-shRNA group showed significantly down-regulated expression levels of survivin protein compared with those in the negative and blank control groups, presenting also necrosis in the endometriosis-like lesions in microscopic observation.

CONCLUSION

Lentiviral vector-mediated shRNA can effectively inhibit the expression of survivin in human endometrium xengrafts and suppress the formation and growth of endometriotic lesions in the abdominal cavities of nude mice.

Tobacco smoking and risk of endometriosis: a systematic review and meta-analysis

OBJECTIVE

Since conflicting results have been published on the role of tobacco smoking on the risk of endometriosis, we provide an up-to-date summary quantification of this potential association.

DESIGN

We performed a PubMed/MEDLINE search of the relevant publications up to September 2014, considering studies on humans published in English. We searched the reference list of the identified papers to find other relevant publications. Case-control as well as cohort studies have been included reporting risk estimates on the association between tobacco smoking and endometriosis. 38 of the 1758 screened papers met the inclusion criteria. The selected studies included a total of 13,129 women diagnosed with endometriosis.

SETTING

Academic hospitals.

MAIN OUTCOME MEASURE

Risk of endometriosis in tobacco smokers.

RESULTS

We obtained the summary estimates of the relative risk (RR) using the random effect model, and assessed the heterogeneity among studies using the χ(2) test and quantified it using the I(2) statistic. As compared to never-smokers, the summary RR were 0.96 (95% CI 0.86 to 1.08) for ever smokers, 0.95 (95% CI 0.81 to 1.11) for former smokers, 0.92 (95% CI 0.82 to 1.04) for current smokers, 0.87 (95% CI 0.70 to 1.07) for moderate smokers and 0.93 (95% CI 0.69 to 1.26) for heavy smokers.

CONCLUSIONS

The present meta-analysis provided no evidence for an association between tobacco smoking and the risk of endometriosis. The results were consistent considering ever, former, current, moderate and heavy smokers, and across type of endometriosis and study design.

Leisure and occupational physical activity at different ages and risk of endometriosis

OBJECTIVE

Cohort and case-control studies have suggested that adult physical activity (PA) may lower endometriosis risk and improve symptoms, but evidence is still controversial. To add information on leisure and occupational PA impact, if any, on endometriosis risk, we have analyzed data from a small case-control study conducted in Milan (Italy).

STUDY DESIGN

Ninety cases and 90 controls (median age 35 years, range 18-76) were compared. Endometriosis was laparoscopically diagnosed within the year before interview. Information on demographic variables, menstrual and reproductive history, occupational and recreational physical activity was collected.

RESULTS

A consistent protective effect emerged between leisure PA and endometriosis risk. For <2-4 and ≥5h/week (reference no PA), the estimated odds ratios (ORs) were, respectively: 0.36 (95% CI 0.18-0.74) and 0.83 (95% CI 0.27-2.53) as regards PA in early adolescence; 0.31 (95% CI 0.15-0.63) and 0.78 (95% CI 0.25-2.38) as regards PA in teenage years; 0.34 (95% CI 0.12-0.94) and 0.33 (95% CI 0.08-1.28) for PA in adulthood. However, no significant trend was seen according to hours spent in leisure PA. Occupational PA did not show statistical significant differences among different types or across age classes.

CONCLUSIONS

These results suggest that leisure PA in early adolescence, teenage years and adulthood may, to some extent, decrease the risk of endometriosis. In the interpretation of these results, however, the role of potential biases cannot be totally ruled out.

Effects of long-term postoperative oral contraceptive use for the prevention of endometrioma recurrence on bone mineral density in young women

Concerns for negative effects of oral contraceptives (OCs) on bone mineral density (BMD) in long-term users have been raised, since OCs suppress the hypothalamic-pituitary-ovarian axis. However, there have been still limited data regarding the effects of long-term OC use on BMD in young women in the twenties. We investigated the effects of long-term OC use for the prevention of endometrioma recurrence on BMD in young women. Ninety-two women aged 20-30 years who underwent conservative surgery for endometrioma and used postoperative OC for at least 12 months to prevent the recurrence were included for this cross-sectional study, and BMDs after OC use were analyzed. The mean age at starting OC and duration of OC use was 25.6 ± 2.9 years and 40.7 ± 28.5 months, respectively. No correlation was found between BMDs and age at starting OC at all sites. In addition, BMDs were also not correlated with the duration of OC use, and were comparable according to the dose of OC (20 versus 30 μg). In conclusion, long-term use of OCs has no adverse effect on BMD in post-adolescent young women.

Activated AKT pathway promotes establishment of endometriosis

The pathogenesis of endometriosis remains unclear, and relatively little is known about the mechanisms that promote establishment and survival of the disease. Previously, we demonstrated that v-akt murine thymoma viral oncogene homolog (AKT) activity was increased in endometriosis tissues and cells from ovarian endometriomas and that this increase promoted cell survival as well as decreased levels of progesterone receptor. The objective of this study was to demonstrate a role for AKT in the establishment of ectopic lesions. First, a dose-dependent inhibition of AKT in stromal cells from human ovarian endometriomas (OSIS) as well as endometrial stromal cells from disease-free patients (ESC) with the allosteric AKT inhibitor MK-2206 was demonstrated by decreased levels of phosphorylated (p)(Ser473)-AKT. Levels of the AKT target protein, p(Ser256)-forkhead box O1 were increased in OSIS cells, which decreased with MK-2206 treatment, whereas levels of p(Ser9)-glycogen synthase kinase 3β did not change in response to MK-2206. Although MK-2206 decreased viability of both OSIS and ESC in a dose-dependent manner, proliferation of OSIS cells was differentially decreased significantly compared with ESC. Next, the role of hyperactive AKT in the establishment of ectopic lesions was studied using the bigenic, PR(cre/+)Pten(f/+) heterozygous mouse. Autologous implantation of uterine tissues was performed in these mice. After 4 weeks, an average of 4 ± 0.33 lesions per Pten(f/+) mouse and 7.5 ± 0.43 lesions in the PR(cre/+)Pten(f/+) mouse were found. Histological examination of the lesions showed endometrial tissue-like morphology, which was similar in both the Pten(f/+) and PR(cre/+)Pten(f/+) mice. Treatment of mice with MK-2206 resulted in a significantly decreased number of lesions established. Immunohistochemical staining of ectopic lesions revealed decreased p(Ser473)-AKT and the proliferation marker Ki67 from MK-2206-treated mice compared with vehicle-treated mice. Furthermore, levels of FOXO1 and progesterone receptor increased in lesions of mice receiving MK-2206. These results demonstrate that heightened AKT activity plays an active role in the establishment of ectopic endometrial tissues.

Lipoxin A₄ prevents the progression of de novo and established endometriosis in a mouse model by attenuating prostaglandin E₂ production and estrogen signaling

Endometriosis, a leading cause of pelvic pain and infertility, is characterized by ectopic growth of endometrial-like tissue and affects approximately 176 million women worldwide. The pathophysiology involves inflammatory and angiogenic mediators as well as estrogen-mediated signaling and novel, improved therapeutics targeting these pathways are necessary. The aim of this study was to investigate mechanisms leading to the establishment and progression of endometriosis as well as the effect of local treatment with Lipoxin A₄ (LXA₄), an anti-inflammatory and pro-resolving lipid mediator that we have recently characterized as an estrogen receptor agonist. LXA₄ treatment significantly reduced endometriotic lesion size and downregulated the pro-inflammatory cytokines IL-1β and IL-6, as well as the angiogenic factor VEGF. LXA₄ also inhibited COX-2 expression in both endometriotic lesions and peritoneal fluid cells, resulting in attenuated peritoneal fluid Prostaglandin E₂ (PGE₂) levels_. Besides its anti-inflammatory effects, LXA₄ differentially regulated the expression and activity of the matrix remodeling enzyme matrix metalloproteinase (MMP)-9 as well as modulating transforming growth factor (TGF)-β isoform expression within endometriotic lesions and in peritoneal fluid cells. We also report for first time that LXA₄ attenuated aromatase expression, estrogen signaling and estrogen-regulated genes implicated in cellular proliferation in a mouse model of disease. These effects were observed both when LXA₄ was administered prior to disease induction and during established disease. Collectively, our findings highlight potential targets for the treatment of endometriosis and suggest a pleotropic effect of LXA₄ on disease progression, by attenuating pro-inflammatory and angiogenic mediators, matrix remodeling enzymes, estrogen metabolism and signaling, as well as downstream proliferative pathways.

[Efficacy observation on the combination of acupuncture and Chinese medication in prevention of the recurrence of endometriosis after laparoscopic surgery]

OBJECTIVE

To evaluate the efficacy and safety of acupuncture-moxibustion combined with modified Mojie tablet (see text) in the prevention of the recurrence of endometriosis (EMS) after laparoscopic surgery.

METHODS

After laparoscopic surgery, 120 cases of EMS were randomized into an acupuncture-moxibustion group, a western medication group, a Chinese medication group and a combined therapy of acupuncture-moxibustion and Chinese medication group (combined therapy group), 30 cases in each one. In the acupuncture-moxibustion group, acupuncture was applied at Xuehai (SP 10), Sanyinjiao (SP 6) and Guanyuan (CV 4); the isolated moxibustion with ginger was used at Guanyuan (CV 4), once a day, twice a week. In the western medication group, gestrinone was prescribed for oral administration, 2.5 mg, once a day, twice a week. In the Chinese medication group, the self-prepared Mojie tablet were prescribed for oral administration. In the combined therapy group, acupuncture, moxibustion and modified Mojie tablet for oral administration were used in combination. The therapeutic methods were same as the acupuncture-moxibustion group and the Chinese medication group. Totally, the treatment of 3 months was required. Separately, before treatment, after treatment, in 3 months after treatment and in 6 months after treatment, EHP-5 score (endometriosis health profile-5), the abdominal/vaginal ultrasound examination, serum CA125 detection and safety index (ALT detection) were compared in patients among 4 groups.

RESULTS

In 3 and 6 months after treatment, the positive rates of EHP-5 score were 0% (0/30) in the combined therapy group and 0% (0/30) in the acupuncture-moxibuston group, which were all lower significantly than 13.3% (4/30) in the western medication group (both P < 0.05). In follow-up stage of 6 months after treatment, there was no recurrence case in abdominal lviginal ultrasound examination in the combined therapy group, which was lower than 13.3% (4/30) in the western medication group (P < 0.05); the serum CA125 detection in the combined therapy group did not find any abnormal case, which was lower than 16.7% (5/30) in the western medication group (P < 0.05). At the end of treatment session and in the follow-up stage of 3 months after treatment, the abnormal rate of ALT were 20.0% (6/30) and 13.3% (4/30) in the western medication group, which were higher than those in any of the rest groups (P < 0.05). In the follow-up stage of 6 months after treatment, there were 3 abnormal cases of ALT in the western medication group, but which was not different significantly as compared with the rest groups (P > 0.05).

CONCLUSION

Acupuncture and moxibustion combined with modified Mojie tablet effectively prevent from the recurrence of EMS after laparoscopic surgery and improve the life quality of the patients. This combined therapy brings less damage on the liver as compared with the western medication of gestrinone and indicates its definite efficacy and safety.

[Influence of feeding rumen-protected choline to transition dairy cows. Part 2: Health and reproduction]

OBJECTIVE

To determine the effects of rumen-protected choline (RPC) on health and reproduction in dairy cows.

MATERIAL AND METHODS

A total of 298 primi- and multiparous German Holstein cows of a high-production dairy herd (average daily milk yield: 32 l) were assigned randomly to a control or treatment group and were hand fed with 0 or 60 g/d of RPC as ReaShure®, respectively, from 21 days before expected calving to 21 days post partum (p. p.) as a top dressing. Health data was analyzed for the incidence of fever within the first 10 days in milk (DIM) as well as the incidence of diseases and the culling rate within the first 200 DIM. Reproduction data were evaluated in terms of the calving data, uterine involution on days 10, 21 and 42 p. p., uterine cytology at day 42 p. p., progesterone concentrations during weeks 3 and 5 p. p. and certain fertility measures. In the statistical analysis, it was differentiated between the control and treatment groups and between primi- and multiparous animals, and their interactions were analyzed.

RESULTS

The treatment group had less cows with subclinical endometritis, higher sickness rates after day 100 p. p., lower numbers of stillbirths and more cyclic cows in week 5 p. p. compared to the control group (p  <  0.05). Primipara in contrast to multipara had fever more frequently, higher rates of subclinical ketosis p. p., metritis and lameness, higher numbers of sick cows in the first 30 DIM, higher rates of stillbirths and dystocia, showed impaired involution of the uterus on day 10 p. p., fewer animals were cyclic during week 5 p. p. and less animals were culled (p < 0.05). Statistically significant interactions indicated that more heifers of the treatment group were lame, more heifers of the control group developed fever and subclinical endometritis, cows of the treatment group suffered more metritis and were sick more often in the first 30 DIM, and cows of the control group had more dystocia (p < 0.05).

CONCLUSION

Overall, supplementing RPC had only minor effects on the health status and reproduction. Further research in other dairy herds should focus on this topic.

Factors associated with the laterality of recurrent endometriomas after conservative surgery

We evaluated the laterality of primary endometrioma and characteristics of patients according to the laterality of recurrent endometrioma in 140 women with recurrent endometrioma after conservative surgery. Histologically confirmed recurrent endometriomas were found on the left side in 49 patients (35.0%), the right in 44 (31.4%) and bilaterally in 47 (33.6%). The sites of primary endometrioma were not associated with those of recurrent endometrioma, and the recurrence rate in the treated ovary (59.8%) was similar to that of the intact ovary (69.0%) at the primary surgery. Proportions of stage IV endometriosis and posterior cul-de-sac obliteration were higher in patients with bilateral recurrence than in those with unilateral recurrence (p < 0.01 for all comparisons) and in patients with contralateral recurrence than in those with ipsilateral recurrence (p < 0.05 for all comparisons), but no differences were found in other characteristics of participants according to the laterality or pattern of recurrence. In conclusion, the lateral distribution of recurrent endometrioma was not associated with that of the primary lesion, and endometrioma did not recur more frequently in the treated ovary. An advanced stage and the presence of posterior cul-de-sac obliteration were factors associated with bilateral or contralateral recurrence of endometrioma.

Dairy-food, calcium, magnesium, and vitamin D intake and endometriosis: a prospective cohort study

The etiology of endometriosis is poorly understood, and few modifiable risk factors have been identified. Dairy foods and some nutrients can modulate inflammatory and immune factors, which are altered in women with endometriosis. We investigated whether intake of dairy foods, nutrients concentrated in dairy foods, and predicted plasma 25-hydroxyvitamin D (25(OH)D) levels were associated with incident laparoscopically confirmed endometriosis among 70,556 US women in Nurses' Health Study II. Diet was assessed via food frequency questionnaire. A score for predicted 25(OH)D level was calculated for each participant. During 737,712 person-years of follow-up over a 14-year period (1991-2005), 1,385 cases of incident laparoscopically confirmed endometriosis were reported. Intakes of total and low-fat dairy foods were associated with a lower risk of endometriosis. Women consuming more than 3 servings of total dairy foods per day were 18% less likely to be diagnosed with endometriosis than those reporting 2 servings per day (rate ratio = 0.82, 95% confidence interval: 0.71, 0.95; P(trend) = 0.03). In addition, predicted plasma 25(OH)D level was inversely associated with endometriosis. Women in the highest quintile of predicted vitamin D level had a 24% lower risk of endometriosis than women in the lowest quintile (rate ratio = 0.76, 95% confidence interval: 0.60, 0.97; P(trend) = 0.004). Our findings suggest that greater predicted plasma 25(OH)D levels and higher intake of dairy foods are associated with a decreased risk of endometriosis.

Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery

BACKGROUND

Various options exist for treating endometriosis, including surgical, medical, such as ovarian suppression, or a combination of these strategies. Surgical treatment of endometriosis aims to remove visible areas of endometriosis. The aim of medical therapy is to inhibit growth of endometriotic implants by induction of a hypo-estrogenic state. Treatment with a hormone-releasing intrauterine device, using levonorgestrel (LNG-IUD), has also been suggested.

OBJECTIVES

To determine whether postoperative LNG-IUD insertion in women with endometriosis improves pain and reduces recurrence of symptoms compared with no postoperative treatment, postoperative insertion of a placebo, or postoperative therapy.

SEARCH METHODS

The following databases were searched from inception to June 2012: Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, CINAHL, and the World Health Organization (WHO) International Clinical Trials Registry Platform. EMBASE was searched from 2010 to June 2012. The citation lists of relevant publications, review articles, abstracts of scientific meetings, and included studies were also searched.

SELECTION CRITERIA

Trials were included if they compared women undergoing surgical treatment for endometriosis with uterine preservation and then randomised within three months to LNG-IUD insertion versus no postoperative treatment, placebo (inert IUD), or other treatment. Diagnostic laparoscopy alone was not considered suitable treatment.

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, the risk ratio (RR) and 95% confidence interval (CI) were calculated using the Mantel-Haenszel random-effects method. For continuous data, the mean difference (MD) and 95% CI were calculated using the inverse variance random-effects method.

MAIN RESULTS

Three randomised controlled trials were included. In two trials, there was a statistically significant reduction in the recurrence of painful periods in the LNG-IUD group compared with expectant management (RR 0.22, 95% CI 0.08 to 0.60, 95 women, I(2) = 0%, moderate strength of evidence). The proportion of women who were satisfied with their treatment was also higher in the LNG-IUD group but did not reach statistical significance (RR 1.21, 95% CI 0.80 to 1.82, 95 women, I(2) = 0%). The number of women reporting a change in menstruation was significantly higher in the LNG-IUD group (RR 37.80, 95% CI 5.40 to 264.60, 95 women, I(2) = 0%) but the number of women not completing the allocated treatment did not differ between groups (RR 0.66, 95% CI 0.08 to 5.25, I(2) = 43%).In one trial, women receiving LNG-IUD noted lower pain scores compared with women receiving gonadotrophin-releasing hormone agonists (MD -0.16, 95% CI -2.02 to 1.70, 40 women) but this did not reach statistical significance.

AUTHORS' CONCLUSIONS

There is limited but consistent evidence showing that postoperative LNG-IUD use reduces the recurrence of painful periods in women with endometriosis. Further well-designed RCTs are needed to confirm these findings.

Curcumin delays endometriosis development by inhibiting MMP-2 activity

Endometriosis is a common reproductive disorder believed to be associated with matrix metalloproteinases (MMPs) activities for invasion and remodeling of endometrial tissues. Ectopic endometrium has higher capacity to produce proMMP-2 than eutopic tissues; however, the role of MMP-2 during early phase of endometriosis development is still unclear. In the present study, we investigated the role of MMP-2 in establishment and development of endometriosis in mouse model. The effect of curcumin on regression of endometriosis through protease/antiprotease balance between MMP-2 and TIMP-2 was also examined. After endometrial inoculation into peritoneum, we observed a significant elevation of proMMP-2 activity from day 2 onwards. This increased MMP-2 activity was associated with decreased expression of tissue inhibitor of MMP (TIMP)-2, while a significant up-regulation of active MMP-2 activity was observed from day 3 onwards. The activation of proMMP-2 to active MMP-2 was associated with increased expression of membrane type 1 matrix metalloproteinase (MT1MMP). Curcumin at a dose of 48 mg/kg b.w. repressed the MMP-2 activity via up-regulation of bound TIMP-2 expression, thus delayed endometriosis development. In addition, curcumin inhibited production of active MMP-2 by down-regulating MT1MMP expression. Moreover, endometriotic progression was directly linked with increased MMP-2/TIMP-2 ratio which was delayed by curcumin pretreatment. In summary, our study documents the regulation of MMP-2 activity by TIMP-2 during the early phase of endometriosis development and inhibitory action of curcumin thereon.

Macrophage migration inhibitory factor antagonist blocks the development of endometriosis in vivo

Endometriosis, a disease of reproductive age women, is a major cause of infertility, menstrual disorders and pelvic pain. Little is known about its etiopathology, but chronic pelvic inflammation is a common feature in affected women. Beside symptomatic treatment of endometriosis-associated pain, only two main suboptimal therapeutic approaches (hormonal and invasive surgery) are generally recommended to patients and no specific targeted treatment is available. Our studies led to the detection of a marked increase in the expression of macrophage migration inhibitory factor (MIF) in the eutopic endometrium, the peripheral blood and the peritoneal fluid of women with endometriosis, and in early, vascularized and active endometriotic lesions. Herein, we developed a treatment model of endometriosis, where human endometrial tissue was first allowed to implant into the peritoneal cavity of nude mice, to assess in vivo the effect of a specific antagonist of MIF (ISO-1) on the progression of endometriosis and evaluate its efficacy as a potential therapeutic tool. Administration of ISO-1 led to a significant decline of the number, size and in situ dissemination of endometriotic lesions. We further showed that ISO-1 may act by significantly inhibiting cell adhesion, tissue remodeling, angiogenesis and inflammation as well as by altering the balance of pro- and anti-apoptotic factors. Actually, mice treatment with ISO-1 significantly reduced the expression of cell adhesion receptors αv and ß3 integrins (P<0.05), matrix metalloproteinases (MMP) 2 and 9 (P<0.05), vascular endothelial cell growth factor (VEGF) (P<0.01), interleukin 8 (IL8) (P<0.05), cyclooxygenease (COX)2 (P<0.001) and the anti-apoptotic protein Bcl2 (P<0.01), but significantly induced the expression of Bax (P<0.05), a potent pro-apoptotic protein. These data provide evidence that specific inhibition of MIF alters endometriotic tissue growth and progression in vivo and may represent a promising potential therapeutic avenue.

[Medical treatment of endometriosis: an obligation rather than a mere option!]

The aim of this article is to argue the usefulness of the systematic administration of medical treatment in women managed for endometriosis, either alone or associated with the surgery. The authors dispute seven frequent objections against the medical treatment: the lack of curative effect, the lack of primary prevention and the risk of delaying the diagnostic, the contraceptive effect in women wishing to conceive, the adverse effects, the risk of occurrence of new lesions following the arrest of the treatment, the lack of proof favourable to the efficient prevention of recurrences and the cost of the treatment. The authors conclude that to date the therapeutic amenorrhea represents an indispensable tool in the management of the endometriosis, in women both benefiting or not from surgical procedures.

Activation of mutated K-ras in donor endometrial epithelium and stroma promotes lesion growth in an intact immunocompetent murine model of endometriosis

Endometriosis is a common chronic gynaecological condition, affecting 5-10% of women of child-bearing age. Its study has been hampered by lack of genetically tractable models. We transplanted steroid-manipulated, menstrual-like endometrium from K-ras(G12V/+) /Ah-Cre(+/+) /ROSA26R-LacZ(+/+) mice into gonad-intact immunocompetent wild-type mice. This led to endometriosis-like lesion development. Long-term lesion survival depended on the presence of the activated K-ras in the small proportion of the cells in the mature lesion that had undergone Cre-mediated K-ras activation. LacZ activity demonstrated Cre-mediated recombination in both endometrial epithelial cells and stromal cells, and transgenic K-ras expression was confirmed by RT-PCR. The endometriosis lesions developed without exogenous oestradiol supplementation and anti-oestrogen (fulvestrant, ICI 182780) treatment greatly suppressed their growth. Immunohistochemistry confirmed that as in human endometriosis, there was invasion and activation of fibroblasts, endothelial cells, and macrophages, with marked collagen deposition in the lesions. This model provides an opportunity to investigate endometriosis lesion establishment, growth, and regression in genetically tractable, immunocompetent, and hormonally intact mice. Furthermore, for the first time it provides a suitable model to test clinically validated driver genes in a faithful mouse model of the predisposing endometriotic lesion, thus providing the correct cellular context and microenvironment for ovarian clear cell carcinogenesis.

Peroxisome proliferator-activated receptor-(gamma) receptor ligand partially prevents the development of endometrial explants in baboons: a prospective, randomized, placebo-controlled study

A prospective, randomized, placebo-controlled study was conducted in a baboon model to determine if a thiazolidinedione agonist of peroxisome proliferator-activated receptor-gamma, pioglitazone, can impede the development of endometriosis. Endometriosis was induced using laparoscopic, intrapelvic injection of eutopic menstrual endometrium, previously incubated with placebo or pioglitazone for 30 min, in 12 female baboons with a normal pelvis that had undergone at least one menstrual cycle since the time of captivity. At this point, the 12 baboons were randomized into two groups and treated from the day of induction. They received either PBS tablets (n = 6, placebo control, placebo tablets once a day by mouth) or pioglitazone (n = 6, test drug, 7.5 mg by mouth each day). A second and final laparoscopy was performed in the baboons to record the extent of endometriotic lesions between 24 and 42 d after induction (no difference in length of treatment between the two groups, P = 0.38). A videolaparoscopy was performed to document the number and surface area of endometriotic lesions. The surface area and volume of endometriotic lesions were significantly lower in pioglitazone treated baboons than the placebo group (surface area, 48.6 vs. 159.0 mm(2), respectively, P = 0.049; vol, 23.7 vs. 131.8 mm(3), respectively, P = 0.041). The surface area (3.5 vs. 17.8 mm(2), P = 0.017, pioglizatone vs. placebo) and overall number (1.5 vs. 9.5, P = 0.007, pioglizatone vs. placebo) of red lesions were lower in the pioglitazone group. A peroxisome proliferator-activated receptor-gamma ligand, pioglitazone, effectively reduced the initiation of endometriotic disease in the baboon endometriosis model. Using this animal model, we have shown that thiazolidinedione is a promising drug for preventive treatment of endometriosis.

Adult physical activity and endometriosis risk

BACKGROUND

Regular exercise has been associated with a 40%-80% reduction in risk for endometriosis in several case-control studies. However, women experiencing symptoms prior to their diagnosis may be less likely to exercise than healthy controls, thus biasing the observed association.

METHODS

Using data collected from the Nurses' Health Study II, a prospective cohort study of premenopausal US nurses that began in 1989, we have attempted to clarify this relation. Data are updated every 2 years with follow-up for these analyses through 2001. In 1989, 1991, and 1997 women reported average amount of time per week engaging in various physical activities. A metabolic equivalent (MET) score was assigned to each activity, and these were summed to estimate total activity.

RESULTS

A total of 102,197 premenopausal women contributed 996,422 person-years of follow-up with 2703 cases of laparoscopically confirmed endometriosis. After adjusting for BMI at age 18, current BMI, smoking, parity, infertility status, oral contraceptive use, age at menarche, and menstrual cycle length and pattern in college, we observed only a slight reduction in the incidence of endometriosis, comparing the highest level of activity (>or=42 MET hours/week) to the lowest (<3 MET hours/week) (rate ratio = 0.89 [95% confidence interval = 0.77-1.03]). The association was limited to participants with no past or concurrent infertility (P = 0.002, test for heterogeneity). No associations were seen with inactivity.

CONCLUSIONS

In this first prospective assessment, we did not find evidence of the strong inverse association previously reported, although we cannot rule out a modest inverse association.

Endometriosis and the role of reproductive medicine

Endometriosis is a complex trait with significant environmental and genetic influences that are likely to affect its phenotype. Natural history of the disease varies from one individual to another. The gold standard of surgical diagnosis is limited in accuracy by visibility and recognition of lesions by the attending surgeon. Several lines of evidence suggest that pelvic endometriosis results from the reflux of viable endometrial tissue through the fallopian tubes. Endometriosis is an inflammatory disease that nuclear factor kappa B pathway may play an important role in its pathogenesis. Endometriotic lesions demonstrate increased aromatase expression in association with increased cyclo-oxygenase-2 expression, especially in red lesions which represent earlier stages of inflammation. Estrogen and progesterone receptor expressions vary according to the morphology and the inflammatory status of the endometriotic lesions. Normal endometrial tissue fragments can adhere and implant to peritoneum. Aromatase expression, a possible intrinsic survival factor for endometrial tissue, is inducible in human endometrial fragments by androstenedione at physiological concentrations found in peritoneal fluid. Inflammatory response to ectopic endometrial tissue, which may vary in each individual seems to be important in disease progression. Current therapies for endometriosis include surgical and medical approaches aimed at cytoreduction or hormonal suppression. However, the disease have tendency to recur in many symptomatic women. Although new management approaches are emerging, properly designed clinical trials are desperately needed in treatment of pain and subfertility associated with endometriosis. Future studies should also focus on identifying risk population to develop preventive strategies, since the treatment of endometriosis is costly and challenging.

Simvastatin protects against the development of endometriosis in a nude mouse model

CONTEXT

Endometriosis is a common condition associated with infertility and pelvic pain in women. Recent in vitro studies have shown that statins decrease proliferation of endometrial stroma (ES) and inhibit angiogenesis.

OBJECTIVE

The aim was to evaluate effects of simvastatin on development of endometriosis in a nude mouse model.

METHODS

Proliferative phase human endometrial biopsies were obtained from healthy donors and established as organ cultures or used to isolate ES cells. To establish endometriosis in the nude mouse, endometrial tissues were maintained in 1 nm estradiol (E) for 24 h and subsequently injected into ovariectomized nude mice. Mice (n = 37) were treated with E (8 mg, SILASTIC capsule implants; made in author laboratory) alone or with E plus simvastatin (5 or 25 mg/kg x d) for 10 d beginning 1 d after tissue injection (from three donors). Mice were killed and examined for disease. Effects of simvastatin on matrix metalloproteinase-3 (MMP-3) were evaluated in cultures of ES cells.

PRIMARY OUTCOME

The number and size of endometriotic implants were measured.

RESULTS

Simvastatin induced a dose-dependent decrease of the number and size of endometrial implants in mice. At the highest dose of simvastatin, the number of endometrial implants decreased by 87%, and the volume by 98%. Simvastatin also induced a concentration-dependent decrease in MMP-3 in the absence and presence of inflammatory challenge (using IL-1alpha).

CONCLUSIONS

Simvastatin exerted a potent inhibitory effect on the development of endometriosis in the nude mouse. Mechanisms of action of simvastatin may include inhibition of MMP-3. The present findings may lead to the development of novel treatments of endometriosis involving statins.

Vaginal parturition decreases recurrence of endometriosis

OBJECTIVE

To evaluate the role of parturition in the recurrence of endometriosis.

DESIGN

Retrospectively analyzed, prospectively obtained data.

SETTING

Unit of Physiopathology of Reproduction, Health Care Unit of Rimini, and University of Bologna Cervesi General Hospital, Cattolica, Italy.

PATIENT(S)

Three hundred forty-five patients with stage II-IV endometriosis, dysmenorrhea, and infertility were treated for endometriosis and divided into four groups according to parity and mode of parturition.

INTERVENTION(S)

The patients were laparoscopically treated for endometriosis upon the occurrence and recurrence of the disease. Ultrasound measurements of the uterine internal ostium (IOS) were performed at each study interval.

MAIN OUTCOME MEASURE(S)

Degree of dysmenorrhea, occurrence and recurrence of endometriosis, and uterine IOS measurements were established and related to parity and mode of parturition.

RESULT(S)

After parturition, dysmenorrhea recurrence was significantly higher in nulliparous women than in women with vaginal parturition. The endometriosis recurrence rate was higher in women who did not have vaginal parturition. The IOS significantly enlarged after vaginal delivery but not after cesarean delivery. There were significant negative correlations between IOS and the recurrence of endometriosis and dysmenorrhea. Odds ratios indicated that as the IOS enlarged, the risk of recurrence decreased.

CONCLUSION(S)

Vaginal parturition plays a protective role in the recurrence of endometriosis.

The role of iron in the pathogenesis of endometriosis

BACKGROUND

Endometriosis may cause symptoms including chronic pelvic pain and infertility, and increases susceptibility to the development of ovarian cancer. Genomic studies have started to delineate the wide array of mediators involved in the development of endometriosis. Understanding the mechanisms of endometriosis development and elucidating its pathogenesis and pathophysiology are intrinsic to prevention and the search for effective therapies.

METHOD OF STUDY

The present article reviews the English language literature for biological, pathogenetic and pathophysiological studies on endometriosis. Several recent genomic studies are discussed in the context of endometriosis biology.

RESULTS

Severe hemolysis occurring during the development of endometriosis results in high levels of free heme and iron. These compounds oxidatively modify lipids and proteins, leading to cell and DNA damage, and subsequently fibrosis development. Recent studies based on genome-wide expression analysis technology have noted specific expression of heme/iron-dependent mediators in endometriosis. The heme/iron-dependent signaling pathway of endometriosis, which is providing new insights into the regulation of inflammation, detoxification and survival, is discussed.

CONCLUSION

Several important endometriosis-specific genes overlap with those known to be regulated by iron. Other genes are involved in oxidative stress. Iron has a significant impact on endometriotic-cell gene expression. This review summarizes recent advances in the heme/iron-mediated signaling and its target genes, outlines the potential challenges to understanding of the pathogenesis and pathophysiology of endometriosis, and proposes a possible novel model.

[Preventive and therapeutic effect of E-leng capsule on post-operation recurrence of ovarian endometriotic cysts and its influence on expression of matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 in eutopic and ectopic endometrium]

OBJECTIVE

To investigate the effect and mechanism of E-leng Capsule (ELC) in preventing and treating post-operation recurrence of ovarian endometriotic cysts (OEC).

METHODS

A total of 60 patients enrolled were the inpatients, who underwent cystectomy of OEC in the Gynecological Department of Guangdong Provincial Hospital of Traditional Chinese Medicine from 2002 to 2004. They were randomly assigned to two groups, the treatment group and the control group. Patients in the treatment group were administered with ELC before operation and after operation (starting from the 7th day post-operation), each for 3 months, while patients in the control group were untreated before operation and administered with Danazol from the 7th day post-operation for 3 months. Specimens of eutopic and ectopic endometrium in all patients of both groups were taken during the operation for detecting expressions of matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1) mRNA by polymerase chain reaction (PCR), and the incidence of post-operation recurrence was observed 12 months later.

RESULTS

The 12-month follow-up showed that recurrence presented in 1 patient in the treatment group (3.3%), and 6 in the control group (20.0%), showing significant difference between them (P<0.05). The expressions of TIMP-1 mRNA in eutopic and ectopic endometrium were 0.85 +/- 0.36 and 0.76 +/- 0.57 in the treatment group, and 0.71 +/- 0.33 and 0.56 +/- 0.39 in the control group, while the expressions of MMP-9 mRNA were 0.36 +/- 0.40 and 0.35 +/- 0.35 vs 0.36 +/- 0.33 and 0.72 +/- 0.59, respectively. The expression of endometrial TIMP-1 mRNA, either eutopic or ectopic, was significantly higher, and the expression of ectopic endometrial MMP-9 mRNA was lower in the treatment group than that in the control group (P<0.01).

CONCLUSION

ELC can reduce the invasive ability of endometrium tissue probably by regulating the balance of MMP/TIMP, namely, increase the expression of eutopic and ectopic endometrial TIMP-1 and decrease the expression of ectopic endometrial MMP-9, and thus to achieve its preventive and therapeutic effect on recurrence of OEC.

Role of melatonin in regulating matrix metalloproteinase-9 via tissue inhibitors of metalloproteinase-1 during protection against endometriosis

Endometriosis is a gynecological disease of women and plausibly regulated by matrix metalloproteinases (MMPs). However, mechanisms of alterations in MMPs during endometriosis remain unclear. Human endometriotic tissues possessing varying degrees of severity were examined for expression of MMPs and tissue inhibitors of metalloproteinase (TIMP)-1. In addition, endometriosis was generated in mice and endometriotic tissues were tested for MMP-9 activity. Results show significant upregulation of secreted and synthesized proMMP-9 activity with duration and severity of endometriosis. Along with upregulation of activity, the expression of proMMP-9 was found increased while TIMP-1 expression followed an inverse trend. The effect of melatonin, a major secretory product of the pineal gland, on endometriosis was examined in preventive and therapeutic models in mice. The results show that melatonin arrested lipid peroxidation and protein oxidation and downregulated proMMP-9 activity and expression in a time and dose-dependent manner while protecting and regressing peritoneal endometriosis. Moreover, the attenuated activity and expression of proMMP-9 were associated with subsequent elevation in the expression of TIMP-1. Our study reveals for the first time the role of melatonin in arresting peritoneal endometriosis in mice and a novel marker, expression ratio of proMMP-9 versus TIMP-1, was identified for assessing severity and progression of endometriosis.

Lifting the curse

Adenomyosis is a condition most women have never heard of. Yet it can cause severe menstrual cramping and heavy bleeding.

Effects of a protein kinase C inhibitor on the initial development of ectopic implants in a syngeneic mouse model of endometriosis

OBJECTIVE

To evaluate the effect of protein kinase C inhibition on surgically induced endometriosis in mice.

DESIGN

Prospective, randomized study.

SETTING

Academic facility.

ANIMALS

Sixty adult female C57BJ6 mice.

INTERVENTION(S)

On day -7, oral gavage of a vehicle alone or of a protein kinase C inhibitor (100 mg/kg/day, once a day) was started and continued for 1 week in donor groups A and B, respectively. On day 0, uterine fragments from donor group A were implanted into recipient mice. Recipient mice were divided randomly into two groups: group 1 (vehicle) and group 2 (protein kinase C inhibitor). Uterine fragments from donor group B were implanted into recipient mice, and they were divided randomly into two groups: group 3 (vehicle) and group 4 (protein kinase C inhibitor). Oral gavage of a protein kinase C inhibitor (100 mg/kg/day, once a day) or vehicle was continued for 1 week.

MAIN OUTCOME MEASURE(S)

Presence and number of ectopic implants.

RESULT(S)

The number of mice that developed ectopic implants was significantly lower in groups 3 (40%) and 4 (30%) than in group 1 (100%). The number of ectopic implants was significantly lower in groups 2, 3, and 4 than in group 1.

CONCLUSION(S)

Protein kinase C inhibitor use partially prevented the development of ectopic implants in a mouse model of endometriosis.

Genistein causes regression of endometriotic implants in the rat model

OBJECTIVE

To determine the effects of raloxifene and genistein on experimentally induced endometriosis in a rat model.

DESIGN

Prospective, randomized animal study.

SETTING

Animal surgery laboratory in a university hospital.

ANIMAL(S)

Thirty-three adult, mature female Wistar-Albino rats in which endometriotic implants were induced by transplanting autologous uterine tissue to ectopic sites on the peritoneum.

INTERVENTION(S)

After the endometriotic implants were formed surgically, the 33 rats were randomly divided into three groups. Group 1 (genistein group, 10 rats) were given 500 mg/kg per day of oral genistein. Group 2 (raloxifene group, 10 rats) were given 10 mg/kg per day of oral raloxifene. Group 3 were given no medication and served as controls (13 rats). All the rats continued to receive treatment for 21 days, and then were killed to assess the implants' size and for histologic examination.

MAIN OUTCOME MEASURE(S)

The surface area of the endometriotic implants and the score of histologic analysis.

RESULT(S)

At the beginning of the medical treatment, the mean surface areas of the endometriotic implants were comparable in all three groups. At the end of the medical treatment, the mean surface area of implants in groups 1 and 2 was smaller than that of implants in the control group. The decrease in the surface area of the endometriotic implants was greater in group 1 and group 2 than found in the control group. The histologic assessment revealed that the mean of the histopathologic score of the implants at the end of the treatment was lower in groups 1 and 2 when compared with the control group.

CONCLUSION(S)

Genistein caused a statistically significant regression of endometriotic implants.

PPAR-gamma receptor ligand induces regression of endometrial explants in baboons: a prospective, randomized, placebo- and drug-controlled study

OBJECTIVE

To determine the effects of a thiazolidinedione (TZD) agonist of peroxisome proliferator-activated receptor (PPAR)-gamma, rosiglitazone, in a baboon model of established endometriosis.

DESIGN

Prospective, randomized, placebo-controlled study.

SETTING

Experimental surgery laboratory at the Institute of Primate Research in Nairobi, Kenya.

ANIMAL(S)

Endometriosis was induced using intrapelvic injection of eutopic menstrual endometrium in 12 female baboons with a normal pelvis that had undergone at least one menstrual cycle since the time of captivity.

INTERVENTION(S)

Induction of endometriosis by laparoscopy was performed in 12 baboons with a normal pelvis. Endometrial tissue was extracted from each baboon by curettage, and a standard amount of endometrium was then seeded onto several peritoneal sites. About 34-68 days after the induction of laparoscopy, a pretreatment laparoscopy (baseline disease assessment) was performed in the baboons to record the extent of endometriotic lesions. The 12 baboons were randomized into three groups and treated from the day after the staging laparoscopy for a total duration of 30 days. They received phosphate-buffered saline tablets (n = 4, placebo control; placebo tablets once a day by mouth for 30 days), GnRH-antagonists (n = 4, active control; ganirelix acetate 125 microg/day for 30 days), or rosiglitazone (n = 4, test drug, 2 mg by mouth each day for 30 days). A third and final laparoscopy on day 30 after the start of treatment was performed to record the extent of endometriosis. The type of lesion (typical, red, white, or suspicious) was recorded. Biopsies were obtained to confirm the histological presence of endometriosis.

MAIN OUTCOME MEASURE(S)

A videolaparoscopy was performed 30 days after treatment to document the number and surface area of endometriotic lesions as well as to calculate the revised American Society for Reproductive Medicine score and stage.

RESULT(S)

The surface area of endometriotic lesions was statistically significantly lower in rosiglitazone-treated baboons when compared with the placebo group. Baboons treated with rosiglitazone or ganirelix had a greater negative relative change in surface area of peritoneal endometriotic lesions than controls. The overall weighted appearance of the lesion types suggests that rosiglitazone may deter the development of newer endometriotic lesions.

CONCLUSION(S)

A PPAR-gamma ligand, rosiglitazone, effectively diminishes the burden of endometriosis disease in a baboon endometriosis model. This animal model holds promise that a TZD drug may be helpful in women with endometriosis.

Effect of soy isoflavones on endometriosis: interaction with estrogen receptor 2 gene polymorphism

BACKGROUND

Progression of endometriosis is considered estrogen-dependent. Dietary soy isoflavones may affect the risk of endometriosis, and polymorphisms in estrogen receptor genes may modify this association. We examined associations among soy isoflavone intake, estrogen receptor 2 (ESR2) gene polymorphisms and risk of endometriosis.

METHODS

We recruited women age 20-45 years old who had consulted a university hospital for infertility in Tokyo, Japan in 1999 or 2000. A total of 138 eligible women were diagnosed laparoscopically and classified into 3 subgroups: control (no endometriosis), early endometriosis (stage I-II) and advanced endometriosis (stage III-IV). We measured urinary levels of genistein and daidzein as markers for dietary intake of soy isoflavones, and genotyped ESR2 gene RsaI polymorphisms.

RESULTS

Higher levels of urinary genistein and daidzein were associated with decreased risk of advanced endometriosis (P for trend = 0.01 and 0.06, respectively) but not early endometriosis. For advanced endometriosis, the adjusted odds ratio for the highest quartile group was 0.21 (95% confidence interval = 0.06-0.76) for genistein and 0.29 (0.08-1.03) for daidzein, when compared with the lowest group. Inverse associations were also noted between urinary isoflavones and the severity of endometriosis (P for trend = 0.01 for genistein and 0.07 for daidzein). For advanced endometriosis, ESR2 gene RsaI polymorphism appeared to modify the effects of genistein (P for interaction = 0.03).

CONCLUSIONS

Dietary isoflavones may reduce the risk of endometriosis among Japanese women.

Effect of the immunomodulator leflunomide on the induction of endometriosis in an experimental rat model

The effect of immunomodulator leflunomide on the development of an experimental endometriosis model was assessed by surgically transplanting autologous fragments of endometrial tissue onto the inner surface of the abdominal wall and arterial cascades of the small intestines. Leflunomide was found to affect the development of endometriosis negatively and seemed to interfere with the growth and maintenance of the uterine explant in this experimental rat model.

Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery

BACKGROUND

Various options exist for treating endometriosis, including ovarian suppression therapy, surgical treatment or a combination of these strategies. Surgical treatment of endometriosis sets out to remove visible areas of endometriosis and restore anatomy by division of adhesions. The aim of medical therapy is to inhibit growth of endometriotic implants by suppression of ovarian steroids and induction of a hypo-estrogenic state. Postoperative treatment with a hormone-releasing intrauterine system, using levonorgestrel (LNG-IUS), has been suggested.

OBJECTIVES

To determine if postoperative use of an LNG-IUS in women with endometriosis improves pain symptoms associated with menstruation and reduces recurrence compared with treatment with surgery only, placebo or systemic hormones.

SEARCH STRATEGY

The following databases were searched: (1) Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials; (2) Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 1); (3) MEDLINE (1966 to January 2006) and EMBASE (1980 to January 2006); (4) National Research Register (NRR). (5) The citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies were also searched.

SELECTION CRITERIA

Trials were included if they compared women undergoing any type of surgical treatment for endometriosis with uterine preservation then randomized to LNG-IUS insertion within two to three months versus no treatment, placebo (inert IUD) or systemic treatment. Diagnostic laparoscopy alone was excluded.

DATA COLLECTION AND ANALYSIS

Two review authors (AM Abou-Setta and HG Al-Inany) independently selected studies for inclusion and extracted data. Statistical analysis was performed in accordance with the statistical guidelines developed by the Cochrane Menstrual Disorders and Subfertility Group. Data extracted from the trials was analyzed on an intention-to-treat basis. For binary data, the overall common odds ratio (OR) (that is, the odds of having clinical symptoms) and the risk difference with 95% confidence interval (CI) were calculated using the Mantel-Haenszel fixed-effect method.

MAIN RESULTS

In one small randomized controlled trial (RCT) there was a statistically significant reduction in the recurrence of painful periods in the LNG-IUS group compared with the control group receiving a gonadotrophin-releasing hormone (GnRH) agonist (OR 0.14, 95% CI = 0.02 to 0.75). The proportion of women who were satisfied with their treatment was higher in the LNG-IUS group than in the control group but this difference did not reach statistical difference (OR 3.00, 0.79 to 11.44).

AUTHORS' CONCLUSIONS

One small study has shown that postoperative use of the LNG-IUS reduces the recurrence of painful periods in women who have had surgery for endometriosis. There is a need for further well-designed RCTs of this approach.