Topical estrogens for the treatment of superficial dyspareunia related to genitourinary syndrome of menopause in women with a history of endometriosis: A clinical dilemma

Estrogen withdrawal, which occurs with the cessation of ovulation, causes genitourinary syndrome of menopause in up to 50-85% of women. Symptoms may profoundly impact quality of life and sexual function, interfering with enjoyment of sex in up to three out of four individuals. Topical estrogens have been found to provide symptom relief with minimal systemic absorption and appear to be superior to systemic therapy as what regards genitourinary symptoms. However, conclusive data on their appropriateness in postmenopausal women with a history of endometriosis is not available and the hypothesis that exogenous estrogen stimulation may reactivate endometriotic foci or even promote their malignant transformation is still open. On the other hand, endometriosis affects around 10% of premenopausal women, many of which may be exposed to an acute hypoestrogenic depletion even before spontaneous menopause occurs. This considered, excluding on principle patients with a history of endometriosis from first-line treatment for vulvovaginal atrophy would mean excluding a considerable percentage of the population from adequate care. More robust evidence is urgently needed in these regards. Meanwhile, it would appear reasonable to tailor the prescription of topical hormones in these patients, taking into account the entity of symptoms and the impact such symptoms have on patients' quality of life, as well as the form of endometriosis and the possible risks hormonal may entail. Moreover, the application of estrogens on the vulva instead of the vagina could be efficacious, while outweighing the possible biological cost of hormonal treatment in women with a history of endometriosis.

P-299 Impact of endometriosis on responsiveness to ovarian hyperstimulation and embryo development: quantitative and qualitative aspects

Study question

The present study was designed to better elucidate if endometriosis may affect follicologenesis and embryo development within a cycle of ovarian hyperstimulation for IVF (In Vitro Fertilization).

Summary answer

Endometriosis women showed fewer oocytes retrieved and a higher rate of unexpected poor response albeit number of patients without good quality embryos was similar.

What is known already

The pathogenetic mechanisms explaining the association between endometriosis and infertility are not fully explained. Pelvic adhesions and inflammation may play a role but other detrimental effects are presumably involved. They include reduced ovarian reserve, altered oocyte competence, impaired endometrial receptivity and association with other conditions affecting fertility such as adenomyosis. To note, even if in vitro fertilization is expected to overcome the pelvic detrimental milieu, the success rate of the procedure is lower in women with endometriosis.

Study design, size, duration

We designed a clinical retrospective study in order to analyse the impact of the disease on ovarian hyperstimulation and embryo development. Women were selected among those undergoing IVF cycles between January 2014 and December 2020. The primary outcome was the number of women without top quality embryos. Secondary outcomes included the rate of unexpected poor response (retrieval of ≤ 3 oocytes), cumulative clinical pregnancy rate and cumulative birth rate.

Participants/materials, setting, methods

Our study was performed at the Infertility Unit of the Fondazione IRCSS Ca’ Granda Ospedale Maggiore Policlinico of Milan. We included 496 subjects with a good ovarian reserve as demonstrated by serum Anti-mullerian hormone (AMH) > 1,1 ng/ml. Two hundreds and forty-eight women with endometriosis were identified and matched with two hundreds and forty-eight women without the disease according to age, pharmacological regimen, study period and AMH levels.

Main results and the role of chance

The number of women without good quality embryos did not differ between exposed and unexposed subjects (16% vs 16%, p = 1.00). The adjusted OR was 0.85 (95%CI: 0.51-1.44, p = 0.56). The clinical pregnancy rate and the live birth rate were also similar. We observed a lower number of oocytes retrieved and a higher rate of unexpected poor response (23% vs 13%, p = 0.005) in women with endometriosis. At subgroup analysis, the higher rate of unexpected poor responders persisted only in previously operated women (27% vs 13%, p = 0.02).

Limitations, reasons for caution

The evaluation of embryo quality was only based on morphological criteria. The histological diagnosis of endometriosis was lacking in unoperated women (128 subjects). Finally, our conclusions concern ovarian hyperstimulation and may not be extrapolated to natural reproductive processes.

Wider implications of the findings

Despite being generally reassuring, our findings do not completely exclude some mild negative effects on folliculogenesis. Effects demonstrated could be due to anatomical distortions of the pelvis causing an inefficient response of the ovarian parenchyma to hyperstimulation. We cannot exclude that the post-surgical healing process may alter local vascular supply.

Trial registration number

NA

Assessing the experience of dyspareunia in the endometriosis population: the Subjective Impact of Dyspareunia Inventory (SIDI)

STUDY QUESTION

Is the Subjective Impact of Dyspareunia Inventory (SIDI) a reliable tool to examine the experience of dyspareunia in the context of endometriosis?

SUMMARY ANSWER

In this study, the SIDI showed good structural and psychometric properties, and thus can be used as a reliable questionnaire to assess the impact of endometriosis-related dyspareunia on multiple dimensions, such as sexuality and intimate relationships.

WHAT IS KNOWN ALREADY

In the endometriosis population, dyspareunia has a tremendous negative impact on psychological health, overall sexual function and couple relationships. However, there is a paucity of tools that can be effectively used in either research or clinical practice to assess the subjective components of the dyspareunia experience, including coping strategies to deal with the pain.

STUDY DESIGN, SIZE, DURATION

In this cross-sectional study, the validity of the SIDI was examined by considering the responses provided by 638 participants with endometriosis and dyspareunia, who participated in an online survey conducted between 8 November and 21 December 2021. Participants were recruited using snowball sampling that involved posting the invitation to participate in the study on the social media of a patient association.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were women aged ≥18 with clinical or surgical diagnosis of endometriosis. The SIDI measures the subjective impact of dyspareunia and is composed of 16 items focused on the frequency of dyspareunia-related experiences in the last 6 months, rated on a 5-point Likert scale. Sexuality was assessed using the Female Sexual Function Index. Psychological health was measured using the Hospital Anxiety and Depression Scale and the Rosenberg Self-Esteem Scale. Sociodemographic and endometriosis-related information was collected using a researcher-made questionnaire. Statistical significance was set at P < 0.05.

MAIN RESULTS AND THE ROLE OF CHANCE

Factor analysis revealed that the SIDI has a four-factor structure and allows for examining the impact of dyspareunia in terms of Sexual Concerns (Factor 1), Relationship Concerns (Factor 2), Partner Support (Factor 3) and Endurance of Pain (Factor 4). The SIDI showed good structural and psychometric properties (including internal consistency), was associated with sexual function and psychological health and was able to discriminate between participants with and without sexual dysfunction.

LIMITATIONS, REASONS FOR CAUTION

Reasons for caution are related to the risk of self-selection bias depending on the study population and recruitment strategy. Moreover, all the information provided by the participants was self-reported, which may have affected the accuracy of the data collected, especially with regards to endometriosis-specific information.

WIDER IMPLICATIONS OF THE FINDINGS

This study may provide a new brief tool that can be used by clinicians and researchers to assess the impact of dyspareunia from a multidimensional perspective and to consider subjective aspects that can be usefully integrated with information about pain severity, timing and localization.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding for this study. A.F. is the President of APE-Odv (Associazione Progetto Endometriosi-Organizzazione di volontariato (Endometriosis Project Association-Volunteer Organization)), the largest nonprofit endometriosis patient association in Italy. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Conservative treatment of Herlyn-Werner-Wunderlich syndrome: Analysis and long-term follow-up of 51 cases

OBJECTIVE

The purpose of this study is to analyze the precise anatomical characteristics of a large group of patients with Herlyn-Werner-Wunderlich syndrome together with the long-term follow-up and the reproductive performance.

STUDY DESIGN

Retrospective analysis of prospectively collected data. In two tertiary medical centers, from 2008 to 2021, 51 patients with HWWS underwent surgery via the same technique. Presenting symptoms, preoperative investigations, operative management, and long-term follow-up with obstetric outcome were assessed.

RESULTS

The surgical procedure was successful in all cases with no major complications recorded. Postoperative course was uneventful. The median follow-up was 6,5 years, with a range from 6 months to 13 years. After surgery, among 14 patients who sought pregnancies, 12 (85,71%) were successful. Of these 11 patients had a total of 22 pregnancies, resulting in spontaneous miscarriage in 27% (6/22), premature birth (<37 weeks) in 36% (8/22) and full-term birth in 36% (8/22). Overall the pregnancies demonstrated had a good course.

CONCLUSIONS

Early diagnosis is essential in establishing prompt and correct surgical treatment.

Impact of endometriosis on obstetric outcome after natural conception: a multicenter Italian study

Purpose

To evaluate obstetric outcome in women with endometriosis who conceive naturally and receive standard obstetric care in Italy.

Methods

Cases were consecutive women with endometriosis managed in eleven Italian referral centers. Controls were women in whom endometriosis was excluded. All women filled in a questionnaire addressing previous natural pregnancies. Marginal logistic regression models were fitted to evaluate the impact of endometriosis on obstetric outcome. A post hoc analysis was performed within the endometriosis group comparing women with severe adenomyosis versus women with absent or mild adenomyosis.

Results

Three hundred and fifty-five pregnancies in endometriosis group and 741 pregnancies in control group were included. Women with endometriosis had a higher risk of preterm delivery < 34 weeks (6.4% vs 2.8%, OR 2.42, 95% CI 1.22–4.82), preterm delivery < 37 weeks (17.8% vs 9.7%, OR 1.98, 95% CI 1.23–3.19), and neonatal admission to Intensive Care Unit (14.1% vs 7.0%, OR 2.04, 95% CI 1.23–3.36). At post hoc analysis, women with endometriosis and severe adenomyosis had an increased risk of placenta previa (23.1% vs 1.8%, OR 16.68, 95% CI 3.49–79.71), cesarean delivery (84.6% vs 38.9%, OR 8.03, 95% CI 1.69–38.25) and preterm delivery < 34 weeks (23.1% vs 5.7%, OR 5.52, 95% CI 1.38–22.09).

Conclusion

Women with endometriosis who conceive naturally have increased risk of preterm delivery and neonatal admission to intensive care unit. When severe adenomyosis is coexistent with endometriosis, women may be at increased risk of placenta previa and cesarean delivery.

Trial registration

Clinical trial registration number: NCT03354793.

When more is not better: 10 'don'ts' in endometriosis management. An ETIC * position statement

A network of endometriosis experts from 16 Italian academic departments and teaching hospitals distributed all over the country made a critical appraisal of the available evidence and definition of 10 suggestions regarding measures to be de-implemented. Strong suggestions were made only when high-quality evidence was available. The aim was to select 10 low-value medical interventions, characterized by an unfavorable balance between potential benefits, potential harms, and costs, which should be discouraged in women with endometriosis. The following suggestions were agreed by all experts: do not suggest laparoscopy to detect and treat superficial peritoneal endometriosis in infertile women without pelvic pain symptoms; do not recommend controlled ovarian stimulation and IUI in infertile women with endometriosis at any stage; do not remove small ovarian endometriomas (diameter <4 cm) with the sole objective of improving the likelihood of conception in infertile patients scheduled for IVF; do not remove uncomplicated deep endometriotic lesions in asymptomatic women, and also in symptomatic women not seeking conception when medical treatment is effective and well tolerated; do not systematically request second-level diagnostic investigations in women with known or suspected non-subocclusive colorectal endometriosis or with symptoms responding to medical treatment; do not recommend repeated follow-up serum CA-125 (or other currently available biomarkers) measurements in women successfully using medical treatments for uncomplicated endometriosis in the absence of suspicious ovarian cysts; do not leave women undergoing surgery for ovarian endometriomas and not seeking immediate conception without post-operative long-term treatment with estrogen-progestins or progestins; do not perform laparoscopy in adolescent women (<20 years) with moderate-severe dysmenorrhea and clinically suspected early endometriosis without prior attempting to relieve symptoms with estrogen-progestins or progestins; do not prescribe drugs that cannot be used for prolonged periods of time because of safety or cost issues as first-line medical treatment, unless estrogen-progestins or progestins have been proven ineffective, not tolerated, or contraindicated; do not use robotic-assisted laparoscopic surgery for endometriosis outside research settings. Our proposal is to better address medical and surgical approaches to endometriosis de-implementing low-value interventions, with the aim to prevent unnecessary morbidity, limit psychological distress, and reduce the burden of treatment avoiding medical overuse and allowing a more equitable distribution of healthcare resources.

The distinguishing cellular and molecular features of the endometriotic ovarian cyst: from pathophysiology to the potential endometrioma-mediated damage to the ovary

BACKGROUND

Clinical data suggest that the presence of an ovarian endometrioma may cause per se damage to the surrounding otherwise healthy ovarian tissue. However, the basic research has so far done a limited job in trying to understand the potential detrimental effect of an endometrioma presence in the context of the ovarian physiology. We have reviewed the literature with the aim of characterizing the pathophysiology of the endometrioma focusing mostly on factors and mechanisms potentially affecting the surrounding, otherwise normal, ovarian tissue.

METHODS

Comprehensive searches of PUBMED were conducted to identify human studies published from 1991 to 2013 in the English language on the cellular and molecular characterization of the various endometrioma components.

RESULTS

An endometrioma contains free iron, reactive oxygen species (ROS), proteolytic enzymes and inflammatory molecules in concentrations from tens to hundreds of times higher than those present in peripheral blood or in other types of benign cysts. The cyst fluid causes substantial changes in the endometriotic cells that it baths from gene expression modifications to genetic mutations The physical barrier between the cyst contents and the normal ovarian tissue is a thin wall composed of the ovarian cortex itself or fibroreactive tissue. ROS potentially permeating the surrounding tissues and proteolytic substances degrading the adjacent areas are likely to cause the substitution of normal ovarian cortical tissue with fibrous tissue in which the cortex-specific stroma is reduced. The fibrosis is associated with smooth muscle metaplasia and followed by follicular loss and intraovarian vascular injury. Follicular density in tissue surrounding the endometriotic cyst was consistently shown to be significantly lower than in healthy ovaries but this pathological change does not appear to be caused by the stretching of surrounding tissues owing to the presence of a cyst.

CONCLUSIONS

There is sufficient molecular, histological and morphological evidence, in part deriving from knowledge of the pathophysiology, to support a deleterious effect of the endometrioma on the adjacent ovarian cortical tissue, independent of the mere mechanical stretching owing to its size.

Pregnancy outcome in women with peritoneal, ovarian and rectovaginal endometriosis: a retrospective cohort study

We retrospectively assessed pregnancy outcome in 419 women who achieved a first spontaneous singleton pregnancy after surgery for endometriosis. A miscarriage was observed in 87 of 419 women (20.8%) and an ectopic pregnancy in eight (1.9%). Among the remaining 324 women, 14 (4.3%) experienced gestational hypertension/pre-eclampsia, 38 (11.7%) had a preterm delivery, five (1.5%) had placental abruption and 12 (3.7%) had placenta praevia. The incidence of placenta praevia was 7.6% in 150 women with rectovaginal lesions, 2.1% in 69 with ovarian endometriomas plus peritoneal implants, and 2.4% in 100 women with peritoneal implants only, whereas no case was observed in 100 women with ovarian endometriomas only.

Individual patient data meta-analysis of randomized evidence to assess the effectiveness of laparoscopic uterosacral nerve ablation in chronic pelvic pain

BACKGROUND

There have been conflicting results in randomized trials of the effects of laparoscopic uterosacral nerve ablation (LUNA) in chronic pelvic pain. Our objective was to perform a meta-analysis using individual patient data (IPD) to provide the most comprehensive and reliable assessment of the effectiveness of LUNA.

METHODS

Electronic searches were conducted in the Medline, Embase, PsycInfo and Cochrane Library databases from database inception to August 2009. The reference lists of known relevant papers were searched for any further articles. Randomized trials comparing LUNA with no additional intervention were selected and authors contacted for IPD. Raw data were available from 862 women randomized into five trials. Pain scores were calibrated to a 10-point scale and were analysed using a multilevel model allowing for repeated measures.

RESULTS

There was no significant difference between LUNA and No LUNA for the worst pain recorded over a 12 month time period (mean difference 0.25 points in favour of No LUNA on a 0-10 point scale, 95% confidence interval: -0.08 to 0.58; P = 0.1).

CONCLUSIONS

LUNA does not result in improved chronic pelvic pain.

Gynecological endoscopy for symptomatic endometriosis

The best available evidence on surgery for endometriosis-associated pain has been reviewed in order to define the benefit of various interventions in the most frequently encountered clinical conditions, and discuss the robustness of the reported data in light of the quality of the relevant study design. Methodological drawbacks limit the validity of observational, non-comparative studies on the effect of laparoscopy for stage I to IV disease. The results of three randomized, controlled trials, indicate that the absolute benefit increase of destruction of lesions compared with sham operation in terms of proportion of women reporting pain relief was between 30% and 40% after short follow-up periods. The effect size decreased with time and the reoperation rate, based on long-term follow-up studies, was as high as 50%. In most case series on excisional surgery for rectovaginal endometriosis, substantial short-term pain relief was experienced by about 70-80% of the subjects who continued the study. However, at one-year follow-up approximately 50% of the women needed medical treatments. Major complications were observed in 3-10% of the patients. Medium-term recurrence of lesions was observed in about 20% of the cases, and around 25% of the women underwent repetitive surgery. Routine complementary performance of denervating procedures cannot be recommended based on the quality of the available information, as only a few symptomatic patients complain of exclusively midline, hypogastric pain. Pain recurrence and reoperation rates after conservative surgery for symptomatic endometriosis are high and probably underestimated. Clinicians and patients should be aware that the expected benefit is operator-dependent and, especially in complex conditions, acceptable results can be assured in referral centers.

'Blood On The Tracks' from corpora lutea to endometriomas

OBJECTIVE

To detect a direct transition from a haemorrhagic corpus luteum to an endometriotic cyst by serial transvaginal ultrasonographic scans.

DESIGN

Prospective observational study.

SETTING

An academic tertiary care and referral centre for women with endometriosis.

POPULATION

One hundred and nine women younger than 40 years, with regular menstrual cycles, undergoing first-line surgery for endometriomas, and not wanting postoperative oral contraception.

METHODS

Three-monthly transvaginal ultrasonography during the luteal phase for 2 years after surgery.

MAIN OUTCOME MEASURE

Sonographic identification of progression from a haemorrhagic corpus luteum to a recurrent endometriotic cyst.

RESULTS

A haemorrhagic corpus luteum was identified in 13 women. Serial ultrasonographic scans demonstrated transition to an endometriotic cyst in 11 (85%) instances and resorption in two. A unilateral endometriotic cyst without previous detection of a cystic corpus luteum was observed in 14 women.

CONCLUSIONS

Bleeding from a corpus luteum appears to be a critical event in the development of endometriomas.

The effect of surgery for symptomatic endometriosis: the other side of the story

BACKGROUND

Surgery is often considered the best treatment option in women with symptomatic endometriosis. However, extent and duration of the therapeutic benefit are still poorly defined.

METHODS

The best available evidence on surgery for endometriosis-associated pain has been reviewed to estimate the effect size of interventions in the most frequently encountered clinical conditions.

RESULTS

Methodological drawbacks limit considerably the validity of observational, non-comparative studies on the effect of laparoscopy for stage I-IV disease. As indicated by the results of three RCTs, the absolute benefit increase of destruction of lesions compared with diagnostic only operation in terms of proportion of women reporting pain relief was between 30% and 40% after short follow-up periods. The effect size tended to decrease with time and the re-operation rate, based on long-term follow-up studies, was as high as 50%. In most case series on excisional surgery for rectovaginal endometriosis, substantial short-term pain relief was experienced by approximately 70-80% of the subjects who continued the study. However, at 1 year follow-up, approximately 50% of the women needed analgesics or hormonal treatments. Major complications were observed in 3-10% of the patients. Medium-term recurrence of lesions was observed in approximately 20% of the cases, and around 25% of the women underwent repetitive surgery.

CONCLUSIONS

Pain recurrence and re-operation rates after conservative surgery for symptomatic endometriosis are high and probably underestimated. Clinicians and patients should be aware that the expected benefit is operator-dependent.

Asymmetry in distribution of diaphragmatic endometriotic lesions: evidence in favour of the menstrual reflux theory

BACKGROUND

If the menstrual reflux or implantation theory of endometriosis is true, refluxed endometrial cells could reach the right hypochondrium transported by the clockwise peritoneal fluid current and would implant more easily on the right diaphragmatic leaf as they are stuck there by the falciform ligament.

METHODS

To investigate if a lateral asymmetry exists in diaphragmatic endometriotic lesion distribution, all articles on diaphragmatic endometriosis identified by MEDLINE, EMBASE and PUBMED database searches were retrieved, and additional reports were collected by systematically reviewing all references. The number of women and the side of the lesion with respect to the falciform ligament of the liver were obtained from individual studies, and the combined frequency of right- and left-side diaphragmatic endometriosis was computed. In addition, seven personal cases were described.

RESULTS

There were 16 reports including 47 subjects selected. Diaphragmatic endometriosis was on the right side in 31 (66%) patients, on the left in 3 (6%) and bilateral in 13 (27%). In the personal series, lesions were on the right side in five cases, on the left in one and bilateral in one. Considering only unilateral lesions, the observed proportion of right-sided endometriotic implants (36/40) was 90% (95% CI 76-97%; chi(2)(1) 32.6, P < 0.0001).

CONCLUSIONS

The observed major asymmetry in diaphragmatic endometriotic lesion distribution in favour of the right leaf supports the menstrual reflux theory.

Fibroids and female reproduction: a critical analysis of the evidence

Observational epidemiological studies aimed at elucidating the relationship between fibroids and infertility are inconclusive due to methodological limitations. However, two main pieces of clinical evidence support the opinion that the fibroids interfere with fertility. First, in IVF cycles, the delivery rate is reduced in patients with fibroids but is not affected in patients who have undergone myomectomy. Second, even if randomized studies are lacking, surgical treatment appears to increase the pregnancy rate: approximately 50% women who undergo myomectomy for infertility, subsequently conceive. Available evidence also suggests that submucosal, intramural and subserosal fibroids interfere with fertility in decreasing order of importance. Although more limited, some data supports an impact of the number and dimension of the lesions. Drawing clear guidelines for the management of fibroids in infertile women is difficult due to the lack of large randomized trials aimed at elucidating which patients may benefit from surgery. At present, physicians should pursue a comprehensive and personalized approach clearly exposing the pros and cons of myomectomy to the patient, including the risks associated with fibroids during pregnancy on one hand, and those associated with surgery on the other hand.

[Progestogens and estroprogestins in the treatment of pelvic pain associated with endometriosis]

We performed a MEDLINE and EMBASE search to identify all studies published in the English language literature on the use of progestogens for the treatment of endometriosis. The aim of our review was to clarify the biological rationale for treatment and define the drugs that can be used. It has been demonstrated that progestogens may prevent implantation and growth of regurgitated endometrium by inhibiting the expression of matrix metalloproteinases and angiogenesis, and they have several anti-inflammatory in vitro and in vivo effects that may reduce the inflammatory state generated by the metabolic activity of the ectopic endometrium. Oral contraceptives increase the abnormally low apoptotic activity of the endometrium of patients with endometriosis. Moreover, anovulation, decidualization, amenorrhoea and the establishment of a steady estrogen-progestogen milieu contribute to disease quiescence. Progestogens are able to control pain symptoms in approximately three out of four women with endometriosi. Different compounds can be administered by the oral, intramuscular, subcutaneous, intravaginal or intrauterine route, each with specific advantages or disadvantages. Medical treatment plays a role in the therapeutic strategy only if administered over a prolonged period of time. Given their good tolerability, minor metabolic effects and low cost, progestogens must therefore be considered drugs of choice and are currently the only safe and economic alternative to surgery. However, their contraceptive effectiveness limits their use to women who do not wish to have children in the short-term.

Association between endometriosis stage, lesion type, patient characteristics and severity of pelvic pain symptoms: a multivariate analysis of over 1000 patients

BACKGROUND

The association between lesion type, disease stage and severity of pain was studied in a large group of women with endometriosis to verify whether endometrial implants at different sites determine specific complaints and to evaluate the validity of the current classification system in women with symptomatic disease.

METHODS

A total of 1054 consecutive women with endometriosis undergoing first-line conservative or definitive surgery were included. Data on age at surgery, disease stage according to the revised American Fertility Society (AFS) classification, anatomical characteristics of endometriotic lesions, and type and severity of pain symptoms were collected and analysed by multiple logistic regression.

RESULTS

Minimal endometriosis was present in 319 patients, mild in 139, moderate in 292 and severe in 304. A significant inverse relationship was demonstrated between age at surgery and moderate-to-severe dysmenorrhoea, dyspareunia and non-menstrual pain. A strong association was found between posterior cul-de-sac lesions and pain at intercourse [Wald chi (2) = 17.00, P = 0.0001; odds ratio (OR) = 2.64, 95% confidence interval (CI) = 1.68-4.24]. A correlation between endometriosis stage and severity of symptoms was observed only for dysmenorrhoea (Wald chi (2) = 5.14, P = 0.02) and non-menstrual pain (Wald chi (2) = 5.63, P = 0.018). However, the point estimates of ORs were very close to unity (respectively, 1.33, 95% CI = 1.04-1.71, and 1.01, 95% CI = 1.00-1.03).

CONCLUSIONS

The association between endometriosis stage and severity of pelvic symptoms was marginal and inconsistent and could be demonstrated only with a major increase in study power.

Uterine leiomyoma and menstrual cycle characteristics in a population-based cohort study

BACKGROUND

We examined the association of uterine leiomyoma with menstrual cycle characteristics in a population of non-care-seeking women.

METHODS

This cross-sectional study uses data from the Seveso Women's Health Study (SWHS), a population-based cohort in Italy. Participants included 341 premenopausal women, 30-60 years old, who had an intact uterus and were not pregnant, lactating, or using oral contraception or intra-uterine devices. We examined the presence of any ultrasound-detected uterine leiomyoma in relation to self-reported menstrual cycle length, flow length and heaviness of flow. The association of leiomyoma number, volume, tissue layer location and axial position with menstrual cycle characteristics was also examined.

RESULTS

Uterine leiomyomata were detected in 73 women (21.4%). After adjustment for covariates, the presence of a leiomyoma was not significantly related to menstrual cycle length, flow length or heaviness of flow [odds ratio (OR) for scanty flow =1.9, 95% confidence interval (CI) 0.8-4.3; OR for heavy flow =1.3, 95% CI 0.7-2.5; relative to moderate flow]. Number, volume, tissue layer location (subserosal or intramural) and axial position (anterior or posterior) of the leiomyoma were also not related to menstrual cycle characteristics.

CONCLUSION

In this Italian population of women not seeking gynaecological care, menstrual characteristics are not related to leiomyoma.

Growth and rupture of an ovarian endometrioma in pregnancy

Pregnancy has long been considered to have beneficial effects on endometriosis. We describe a patient who underwent emergency exploratory laparotomy at gestation week 35 for rupture of an ovarian endometrioma.

Validation study of nonsurgical diagnosis of endometriosis

OBJECTIVE

To determine whether the surgical diagnosis of endometriosis can be predicted using symptoms, signs, and ultrasound findings.

DESIGN

Prospective study (study sample); retrospective record review (test sample).

SETTING

Hospital of Desio (study sample) and Mangiagalli Hospital (test sample), Italy.

PATIENT(S)

Ninety women scheduled to undergo laparoscopy or laparotomy (study sample); 120 women who underwent laparoscopy (test sample).

INTERVENTION

The study sample group was interviewed before surgery about infertility and dysmenorrhea, dyspareunia, and noncyclic pelvic pain and each member had a pelvic examination and a transvaginal ultrasound. At surgery, endometriosis was noted. For the test sample, the same information was abstracted from medical records after laparoscopy.

MAIN OUTCOME MEASURE(S)

The ability of symptoms, signs, and ultrasound to predict endometriosis at surgery. A classification tree was developed with the study sample and evaluated with the test sample.

RESULT(S)

Ovarian endometriosis, but not nonovarian endometriosis, could be reliably predicted with noninvasive tools. Ultrasound and examination best predicted ovarian endometriosis, correctly classifying 100% of cases with no false positive diagnoses in the study sample. Similar results were found in the test sample.

CONCLUSION(S)

Noninvasive tools may be used to identify women with ovarian, but not nonovarian endometriosis, with excellent agreement with surgical diagnosis.

Site of origin of epithelial ovarian cancer: the endometriosis connection

To investigate the left- and right-sided distribution of ovarian malignant surface epithelial tumours, data were collected on 209 women undergoing first-line surgery for Stage I and II disease. Considering the unilateral cancers, the observed proportion of left-sided lesions was 35/54 (65%) in the endometrioid, 20/45 (44%) in the serous, 19/35 (54%) in the clear cell, 13/29 (45%) in the mucinous, 2/8 (25%) in the mixed, and 2/5 (40%) in the undifferentiated histological type group. The proportion of left-sided unilateral endometrioid cancers was significantly different from the expected 50% (chi2(1), 4.74, P = 0.03) and very similar to that previously observed for benign endometriotic cysts, constituting further evidence in favour of a possible development of endometrioid cancers from the latter lesions.

Surgical management of endometriosis

A systematic literature review of the last two decades was performed to evaluate the effect of pelvic denervations in addition to conservative surgery on dysmenorrhoea and deep dyspareunia associated with endometriosis. Chronic pelvic pain relief after hysterectomy or adhesiolysis was also assessed. In the five non-comparative studies on the effect of pre-sacral neurectomy, the frequency of dysmenorrhoea recurrence or persistence after treatment ranged from 4 to 40%. The pooled frequency of non-responders at the end of follow-up was 23% (95% confidence interval (CI), 19 to 27%). Only two of the three comparative, non-randomized trials demonstrated a significant treatment benefit of pre-sacral neurectomy, and the results of the two identified randomized controlled trials are discordant. Significant quantitative heterogeneity among studies prevented pooling of data on dysmenorrhoea. The common odds ratio of deep dyspareunia persistence was 0.69 (95% CI, 0.31 to 1.54). In the 10 non-comparative studies on the effect of uterosacral ligament resection, the frequency of dysmenorrhoea and deep dyspareunia persistence after treatment ranged, respectively, from 0 to 50% and from 6 to 42%. The pooled frequency of non-responders at the end of follow-up was 23% (95% CI, 20 to 27%) and 13% (95% CI, 8 to 18%), respectively. Routine performance of complementary denervating procedures cannot be recommended based on the quality of the evidence available. The results of the five studies on the effect of hysterectomy on chronic pelvic pain of presumed uterine origin consistently demonstrated that 83-97% of operated women reported pain relief or improvement 1 year after surgery. There is no consensus on the outcome of adhesiolysis in patients with chronic pain, and the role of pelvic adhesions in causing symptoms is under scrutiny.

Seveso Women's Health Study: a study of the effects of 2,3,7,8-tetrachlorodibenzo-p-dioxin on reproductive health

Although reproductive effects of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) exposure have been reported in numerous investigations of animals, studies of this association in humans are limited. In 1976, an explosion in Seveso, Italy exposed the surrounding population to among the highest levels of TCDD recorded in humans. The relatively pure exposure to TCDD and the ability to quantify individual level TCDD exposure from sera collected in 1976 for the Seveso cohort affords a unique opportunity to evaluate the potential dose-response relationship between TCDD exposure and a spectrum of reproductive endpoints. The Seveso Women's Health Study (SWHS) is the first comprehensive study of the reproductive health of a human population exposed to TCDD. The primary objectives of the study are to investigate the relationship of TCDD and the following endpoints: (1) endometriosis; (2) menstrual cycle characteristics; (3) age at menarche; (4) birth outcomes of pregnancies conceived after 1976; (5) time to conception and clinical infertility; and (6) age at menopause. Included in the SWHS cohort are women who were 0-40 yr old in 1976, who have adequate stored sera collected between 1976 and 1980, and who resided in Zones A or B at the time of the accident. All women were interviewed extensively about their reproductive and pregnancy history and had a blood draw. For an eligible subset of women, a pelvic exam and transvaginal ultrasound were conducted and a menstrual diary was completed. More than 95% of the women were located 20 yr after the accident and roughly 80% of the cohort agreed to participate. Data collection was completed in July 1998, serum TCDD analysis of samples for analysis of endometriosis as a nested case-control study was completed in October 1998, and statistical analysis of these data should be completed in early 1999. Serum samples are now being analyzed in order to relate TCDD levels with the remaining reproductive outcomes.

Deep endometriosis conundrum: evidence in favor of a peritoneal origin

OBJECTIVE

To determine whether the depth and volume of the pouch of Douglas differs in patients with endometriosis with and without deep lesions and to compare them with subjects with a healthy pelvis or with diseases other than endometriosis.

DESIGN

Prospective, comparative study.

SETTING

Tertiary care and referral center for patients with endometriosis.

PATIENT(S)

Women undergoing laparoscopy for infertility, pelvic pain, or adnexal anomalies (deep endometriotic rectovaginal lesions in 16 cases, endometriosis without deep lesions in 127 cases, miscellaneous anomalies in 35 cases, and normal pelvis in 26 cases).

INTERVENTION(S)

Douglas pouch depth measurement from the upper border of uterosacral ligaments to its base with a calibrated probe and volume assessment by a fluid-filling technique.

MAIN OUTCOME MEASURE(S)

Douglas pouch depth and volume.

RESULT(S)

Mean (+/-SD) Douglas pouch depth and volume measurements were 3.6 +/- 1.6 cm and 41.6 +/- 19.3 mL in women with deep endometriosis, 5.3 +/- 0.8 cm and 67.2 +/- 18.1 mL in those with peritoneal and ovarian lesions only, 5.2 +/- 0.9 cm and 67.6 +/- 12.6 mL in those with miscellaneous conditions, and 5.5 +/- 0.8 cm and 65.8 +/- 10.9 mL in those with normal pelvis.

CONCLUSION(S)

Reduced Douglas pouch depth and volume in women with deep endometriosis suggest that such lesions develop not in the rectovaginal septum but intraperitoneally and that burial by anterior rectal wall adhesions creates a false bottom, giving an erroneous impression of extraperitoneal origin.

Lateral distribution of nonendometriotic benign ovarian cysts

To investigate the left- and right-sided distribution of nonendometriotic benign ovarian cysts, data were collected on 406 women undergoing first-line surgery for tumours with various histotypes. Considering the unilateral cysts, the observed proportion of left lesions was 65/129 (50.4%) in the serous, 38/79 (48.1%) in the mucinous, 59/134 (44.0%) in the dermoid, 11/21 (52.4%) in the parovarian, and 3/7 (42.9%) in the miscellaneous cysts group, without significant differences from the expected 50%. This contrasts with the finding of a significantly more frequent development of endometriomas on the left ovary, and suggests that the pathogenesis of endometriotic and nonendometriotic cysts is different.

Is ureteral endometriosis an asymmetric disease?

Six cases of endometriosis obstructing the left ureter were observed among 1,054 consecutive patients undergoing surgery in an eight-year period. In addition, 125 women with ureteral endometriosis (left-sided, n = 66; right-sided, n = 40; bilateral, n = 19) were described in 62 articles identified in a systematic review of the English language literature between 1980 and 1998. Considering only the patients with unilateral ureteral endometriosis and combining the published figures with those of our surgical series, the observed proportion of left lesions (72/112, 64%; 95% CI 55% to 73%) was significantly different from the expected proportion of 50% (chi2(1), 9.14, P = 0.002). The lateral asymmetry found in the location of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomical differences of the left and right hemipelvis.

Randomized comparison of vaporizing electrode and cutting loop for endometrial ablation

OBJECTIVE

To compare endometrial ablation using a vaporizing electrode with resection using a standard cutting loop, evaluating distension fluid absorption, operating time, and ease of procedure.

METHODS

Premenopausal menorrhagic women with normal hysteroscopic and endometrial biopsy findings were allocated randomly to endometrial vaporization (n = 47) or resection (n = 44). Distension medium deficit, operating time, and degree of difficulty of the procedure were determined at surgery. Menstrual pattern of women in both groups was also assessed after 1-year follow-up.

RESULTS

Mean +/- standard deviation (SD) distension fluid deficit was 109+/-126 mL in the vaporization and 367+/-257 mL in the resection group (mean difference 258 mL; 95% confidence interval 175, 341 mL; P < .001, unpaired t test). Mean +/- SD operating time was, respectively, 9.2+/-3.1 minutes versus 10.7+/-2.5 minutes. The surgeon classified intraoperative difficulties as none in 32, minimal in 11, moderate in four, and severe in none in the vaporization group, and 17, 14, seven, and six in the resection group. Menstrual pattern at 1 year in the former group was amenorrhea in 17 (36%) cases, hypomenorrhea or spotting in 20 (43%), normal flows in 10 (21%), and menorrhagia in none compared with, respectively, 21 (48%), 14 (32%), seven (16%), and two (5%) in the latter group.

CONCLUSION

Endometrial ablation with the vaporizing electrode limited fluid absorption compared with resection by the standard cutting loop. Long-term effects on uterine bleeding were similar.

A levonorgestrel-releasing intrauterine system for the treatment of dysmenorrhea associated with endometriosis: a pilot study

OBJECTIVE

To evaluate the efficacy and safety of an intrauterine system releasing 20 microg of levonorgestrel per 24 hours in the long-term treatment of recurrent dysmenorrhea in women already operated on conservatively for endometriosis.

DESIGN

A prospective noncomparative pilot study.

SETTING

A tertiary care and referral academic center for patients with endometriosis.

PATIENT(S)

Twenty parous women with recurrent moderate or severe dysmenorrhea after conservative surgery for endometriosis who did not want further children.

INTERVENTION(S)

A levonorgestrel-releasing intrauterine system was inserted in each woman within 7 days of the start of a menstrual cycle.

MAIN OUTCOME MEASURE(S)

Variations in severity of dysmenorrhea during treatment according to a 100-mm visual analogue scale and a 0-3-point verbal rating scale, modification of a pictorial blood-loss assessment chart devised to evaluate the amount of menstrual flow, and degree of satisfaction after 12 months of therapy.

RESULT(S)

One woman was lost to follow-up after achieving amenorrhea and expressing satisfaction, and 1 requested system removal because of weight gain and abdominal bloating. In another subject, the levonorgestrel intrauterine system was expelled 3 months after insertion. The menstrual patterns in the remaining 17 women were characterized by amenorrhea in 4 cases, hypomenorrhea or spotting in 8, and normal flow in 5. Baseline and 12-month follow-up mean +/- SD blood loss scores were 111+/-36 and 27+/-26, respectively. At the same time, mean +/- SD visual analogue and verbal rating scale scores dropped, respectively, from 76+/-12 to 34+/-23 points and from 2.5+/-0.5 to 1.2+/-0.5 points. Four women were very satisfied with treatment, 11 were satisfied, 2 were uncertain, and 3 were dissatisfied at 12-month follow-up.

CONCLUSION(S)

Because of the amenorrhea or hypomenorrhea induced in most women, a levonorgestrel intrauterine system greatly reduced menstrual pain associated with endometriosis and achieved a high degree of patient satisfaction.

Hysteroscopic myomectomy: long-term effects on menstrual pattern and fertility

OBJECTIVE

To determine the effects of hysteroscopic myomectomy on menorrhagia and infertility and the influence of intramural extension on surgical feasibility and long-term outcomes.

METHODS

We studied 108 women who had first-line hysteroscopic resection of submucous pedunculated (n = 54), sessile (n = 30), or intramural (n = 24) leiomyomas over 7 years at an academic department specializing in endoscopic surgery.

RESULTS

The mean (+/- standard deviation) operating time and distension medium deficit were 18+/-7 minutes and 204+/-276 mL in the pedunculated lesion group, 23+/-9 minutes and 278+/-269 mL in the sessile lesion group, and 32+/-8 minutes and 335+/-272 mL in the intramural lesion group, respectively. More than one procedure was required to complete myoma removal in 14 (26%) of 54, eight (26%) of 30, and 12 (50%) of 24 subjects in the pedunculated, sessile, and intramural lesion groups, respectively. After a mean follow-up of 41 months, myomas recurred in 27 subjects, with a 3-year cumulative rate of 34%. Twenty women had recurrent menorrhagia, with a 3-year cumulative probability of 30%. The 3-year cumulative probability of conception was 49% in women with pedunculated lesions, 36% in those with sessile lesions, and 33% in those with intramural lesions. The study had 80% power to detect five- and three-fold increases in menorrhagia recurrence and conception rates, respectively, in the mainly intramural myoma group compared with the completely or mainly intracavitary myoma group.

CONCLUSION

Hysteroscopic resection of submucous myomas gives satisfactory menorrhagia control and limited recurrence, but the benefit for infertility was less impressive. Myoma intramural extension did not have a substantial influence on any of the long-term outcomes but affected operating time and the number of procedures needed for complete removal.