Endometriosis in diagnostic laparoscopy in Isfahan, Iran

In 200 consecutive routine diagnostic laparoscopies, 31 cases (15.5%) of endometriosis were found. Of these 200 cases, 131 patients (65.5%) were referred for laparoscopy because of infertility. In 22 (71.0%) out of 31 patients with endometriosis infertility was the indication for laparoscopy. In the remainder of the patients laparoscopy was performed because of other indications. Half of the patients with endometriosis showed moderate or severe degrees of the disease. Seventy-one percent of the patients were below the age of 29. According to our findings, the presumption that endometriosis is a rare disease in Iran is considered to be erroneous.

Adenomyosis of the uterus: an enigma

Adenomyosis has been an entity of some interest for many years, but little is known today of its pathogenesis. There is almost universal agreement that it is associated with an accentuation of the myometrial muscle pattern, multiparity, and endometrial hyperplasia. Some authors suggest that the myometrium is vulnerable to invasion by endometrial hyperplasia. Others postulate that the myometrium is vulnerable to invasion by endometrial glands because of the absence of a basement membrane. Women in the fourth and fifth decades of life are most commonly afflicted. Preoperative diagnosis is not common.

Current concepts in endometriosis

There are no conclusive data available on the incidence or prevalence of endometriosis, yet the notion persists that the frequency of cases has dramatically risen in western societies during the past 25 years. Race, familial predisposition, reproductive history, socioeconomic status, personality type and a historical drop in age at menarche have been posited as risk factors for the complex and as-yet-unclear epidemiology of this disorder. The epidemiology of endometriosis is constrained by the difficulty of the diagnosis. Several analytic concepts from epidemiology, however, could be profitably used to further our knowledge of endometriosis. Included are the case-control study, survival and life-table analyses and correlations of psychologic traits with susceptibility to development of the disease. Though none of these techniques is original or without potential for bias, they may be underutilized in solving the conundrum of endometriosis.

Prior cesarean section. A risk factor for adenomyosis?

Four hundred eighty-five cases of histologically proven adenomyosis were reviewed to determine if that condition might have been induced by transplanted endometrium at the time of cesarean section. The rate of cesarean section in the study group was 6.4%. Evidence of the cesarean scar was noted histologically in 13 of 31 patients (42%) who had undergone cesarean section, and 2 of the 13 (15%) had evidence of glands and stroma within the scar. Both patients had other pathology that could account for their symptoms. Prior cesarean section does not appear to be a risk factor for symptomatic adenomyosis.

A clinicopathologic study on adenomyosis uteri

Clinicopathologic investigations were carried out on 51 cases that had received hysterectomy and had been diagnosed histologically as adenomyosis uteri during a 4-year period since 1977, and the following results were obtained: 1) adenomyosis uteri was found in 51 out of 418 hysterectomized patients, the incidence being 12.2%, 2) 74.5% of the cases with adenomyosis uteri were in the fifth decade, the average being 44.8 years old, 3) 94% of the cases were gravidous, 82% being parous. The incidence of sterility was low in the case of adenomyosis uteri, 4) major symptoms of the adenomyosis uteri were dysmenorrhea and hypermenorrhea, and these symptoms increased in frequency as the degree of adenomyosis uteri progressed, 5) fibroid was a complication of the adenomyosis uteri in 25 cases, while endometrial carcinoma was observed in only 1 case, 6) the ectopic endometrium also showed the same changes in secretory conditions and menstrual changes as the surface endometrium, 7) many cases showed a difference in periodicity between the menstrual cycle and endometrial cycle, and also between the menstrual cycle and the ovarian cycle, and 8) in the ovary, luteinized cysts were observed in 21, 6% of all the cases, corpus luteum persistence in 27.5%, stromal hyperplasia in 33.3%, and follicular cysts in 64.7%. Both the stromal hyperplasia and the follicular cysts were found to increase in frequency as the degree of adenomyosis uteri advanced.

Dysmenorrhea

Pain during the menstrual period is of two types: primary, in which the pelvic organs are normal and secondary, in which pathologic lesions are found on pelvic examination or laparoscopic examination of the pelvic organs. Since the incidence varies between 31-92% of the population it has serious implications for our society. It is important to distinguish dysmenorrhea from the premenstrual tension syndrome. Currently primary dysmenorrhea is thought to be due to increased contractility of the myometrium or decreased uterine blood flow from the excessive contractions of increased sensitization of pain fibers to mechanical and chemical stimuli. These three mechanisms of pain production are due to the release of certain prostaglandins from the endometrium during menses which then go directly into the myometrium producing these effects. Situational or psychological factors may accentuate or decrease the pain. Treatment is with antiprostaglandin drugs. There are several causes of secondary dysmenorrhea both congenital and acquired. Laparoscopy is frequently needed along with D&C to make the diagnosis. After diagnosis is made appropriate treatment can be undertaken to relieve the pain.

Noncontraceptive estrogen use and the occurrence of ovarian cancer

Female residents of six counties in Washington and Utah in whom ovarian cancer was diagnosed during 1975-79 were interviewed concerning prior use of noncontraceptive estrogens. Interviews with a random sample of women drawn from these counties were obtained for comparison. Taken as a whole, women with epithelial ovarian tumors reported estrogen use for 1 year or more somewhat more often than did controls [relative risk (RR) = 1.3, 95% confidence interval (CL) = 0.9-1.8]. The proportion of women who had used estrogens varied according to the histology of their tumor; notably, of 17 women with endometrioid tumors, 12 had used estrogens (RR = 3.1, 95% CL = 1.0-9.8). The excess risk of endometrioid carcinoma related to estrogen use was not further increased when these hormones were taken for long durations, in high doses, or proximate to the time of diagnosis. Neither was there any evidence of increased risk from estrogen use in the small group of women with clear cell tumors, a histologic tumor type believed to be closely related to endometrioid carcinoma. Thus the observed association between menopausal estrogen use and the occurrence of ovarian endometrioid tumors should be interpreted cautiously until the results of additional studies are available.

Adenomyosis: study in a Jewish female population

In a series of 920 hysterectomies, performed during a three-year period at the Gynecological Clinic of Hasharon Hospital, adenomyosis weas found in 89 cases, an incidence of 9.06%. Although this result is in accordance with that reported by other authors, we found a marked difference between the incidence of adenomyosis in the two Jewish female groups under study: the Ashkenazic women (natives of European countries or U.S.A.), and the Sephardic women (natives of Near East countries, Yemen or North Africa); 69.66% of the adenomyosis cases were in the former group as against only 30.34% in the latter. A preoperative diagnosis of adenomyosis was made in 19.10% of the cases. This comparatively high percentage appears to be due to the routine examination of the serum activity of cystine aminopeptidase (CAP) and leucine aminopeptidase (LAP), performed in all patients before operation. Increased values of these enzymes indicate the presence of uterine or ovarian tumoral processes. It is suggested that the diagnosis of adenomyosis must be considered in cases of uterine bleeding, dysmenorrhea and increased CAP and LAP values discovered in multiparous women of around 50 years of age, even when the bimanual examination does not reveal any other pathologic condition.

Trends in the incidence of endometrioid and clear cell cancers of the ovary in the United States

An increase in reported incidence of endometrioid and clear cell cancers of the ovary occurred in the United States during the 1970s, while no change occurred in the overall incidence of ovarian cancer. The authors can not rule out that this was due to a shift in the criteria for histologic classification or improved coding, although these seem unlikely to account entirely for the change. In the four areas where the trend for endometrioid and clear cell cancers of the ovary was examined, the per cent increases in their occurrence were correlated with the per cent increases in the occurrence of carcinoma of the uterine corpus. The concomitant trends and the biologic similarities between these histologic types of ovarian cancer and the uterine cancers suggest that common etiologic factors may be involved. The role of postmenopausal estrogen use in the etiology of ovarian cancer must be clarified by further epidemiologic studies, but such studies should take tumor histology into consideration.

Malignancies of the uterine body among Ibo women in Nigeria

Out of the 85 malignancies of the uterus seen at the University of Nigeria Teaching Hospital, Enugu, in the past seven years, only seven were malignancies of the uterine body. Compared with reports by other authors, the incidence is low and suggests the influence of racial and geographical factors. With the exception of one patient, the majority presented in the 50-70 year age group. More than one half of the patients were of high parity; menorrhagia was a common presenting symptom. In the absence of facilities for radiotherapy, surgery alone produces a reasonably good result for the early stages of this disease. Abnormal uterine bleeding in women over 30 years of age should be fully investigated.

Results in the operative treatment of pelvic endometriosis

Two hundred and eight patients treated surgically for endometriosis were reviewed one to four years later. The incidence of endometriosis in this survey was 17 per cent of all gynecological laparotomies. After operation, 30 per cent of the patients were symptomless, 60 per cent estimated the alleviation as good or moderate, and only 10 per cent had no benefit from the operation. In the 32 cases where infertility was the main indication for operation and other factors affecting fertility were excluded, 20 pregnancies of 19 women were achieved after operation.

Investigation of a family suspected of being at high risk for cancer

The investigation of the family of a patient with bilateral breast cancer is described. By means of interviews and the checking of hospital records and death certificates, information was obtained on 199 family members over five generations, 19 of whom had cancer. Comparison with expected numbers of cases showed an excess in only one generation. The interpretation of these findings and the advice given to family members are discussed.

Endometriosis among the Hausa/Fulani population of Nigeria

In three and half years at the Ahmadu Bello University Hospital, Zaria, Nigeria, endometriosis was found in 27 Nigerians (all negroid) and one Caucasian. Age and parity distribution were similar to what has been found in patients elsewhere. In other respects, there were striking differences. The frequency (8.2 percent) is one of the highest reported in the negro. Two fifths were menopausal, majority had associated pelvic inflammatory disease, and nearly all were in women of the lowest socio-economic status. The lesions were rare in the pouch of Douglas and were totally absent from the rectovaginal septum and in the extra peritoneal space.

The pathology of hysterectomy specimens

Six hundred and twenty-one hysterectomies were performed at National Women's Hospital, Auckland, during 1975. Abnormal vaginal bleeding was the clinical indication in 50.72% of the cases. Fibroids, pelvic mass, prolapse, stress incontinence and cervical neoplasia were the indication for 45.88% of the cases. Total hysterectomy was performed in 618 (99.5%) patients whilst sub-total hysterectomy was done in only three cases. Histopathological studies revealed that 567 (91.30%) specimens were pathological and there was multiple pathology in 55.87% of the specimens. Leiomyomas were present in 278 cases (44.76%); microleiomyomatosis in 178 specimens (22.66%); endometrial hyperplasia in 139 specimens (22.33%) adenomyosis in 87 cases (14.00%); malignant diseases in 76 cases (12.23%); and endometriosis in 40 specimens (6.44%). There were no histological abnormalities in 54 specimens, 8.69% of this series.

A reexamination of endometriosis after pregnancy

Endometriosis retards the process of conception, but conception does not retard the progression of this disease. When a series of patients with endometriosis after pregnancy were examined, sites of endometriotic involvement and presenting symptoms appeared unchanged. It seems that the effect of pregnancy on this disease is only temporary.

Endometriosis in 1,000 consecutive celiotomies: incidence and management

A prospective study of the incidence of endometriosis encountered in consecutive pelvic explorations was carried out. When study cards were filled out immediately after operation, it was found that one half of the patients had endometriosis. The symptoms, indications for operation, and pelvic findings in patients with endometriosis were compared with those in patients not having endometriosis but with similar operative procedures. The location of the condition and the results of the operation were evaluated. Further comparisons were made as to subsequent symptoms, pregnancy, operations, and hormone requirements, and conclusions were drawn as to risks and benefits referable to the type of operation performed.

Large endometrioma occurring in an adolescent

The occurrence of endometriosis and endometriomas in adolescent women is unusual. A large endometrioma of the ovary, occurring in a 19-year-old woman, with minimal symptomatology, is reported. The occurrence, etiology, and treatment are discussed.

Incidence of endometriosis among Japanese women

Clinical experience based on gynecologic practice in Hawaii indicated a high incidence of endometriosis among Oriental women. To investigate this impression, a statistical analysis of gynecologic admissions and of diagnoses of endometriosis was performed on the basis of race at three hospitals, two in Hawaii and one in Japan. The result supports the impression that the Japanese female population has a high incidence of endometriosis. Approximately 10% of their gynecologic admissions were for endometriosis. The order of incidence in other racial groups was non-Japanese Oriental, white, and black.

Endometriosis in the black woman

Endometriosis has heretofore been considered rare in black women. Laparoscopy in 190 black women, in many of whom pelvic inflammatory disease was previously diagnosed clinically and treated, revealed endometriosis to be present in 21 per cent. The importance of this finding for clinical practice is discussed.

Dietary iodine and risk of breast, endometrial, and ovarian cancer

Geographic differences in the rates of breast, endometrial, and ovarian cancer appear to be inversely correlated with dietary iodine intake. Endocrinological considerations suggest that a low dietary iodine intake may produce a state of increased effective gonadotrophin stimulation, which in turn may produce a hyperoestrogenic state characterised by relatively high production of oestrone and oestradiol and a relatively low oestriol to oestrone plus oestradiol ratio. This altered endocrine state may increase the risk of breast, endometrial, and ovarian cancer. Increasing dietary iodine intake may reduce the risk of these cancers.

Ovarian tumors in pregnancy. An ovarian tumor registry review

Among the 2300 cases accumulated in the Emil Novak Tumor Registry between the years 1942 and 1972, there were 100 examples of ovarian neoplasia associated with gestation. Lutein cysts or luteomas were excluded since such lesions usually represent physiologic responses of the gonad to increased levels of chorionic gonadotropin. Only 10 cases of dermoids (benign cystic teratomas) were reviewed. We believe this to be the largest series reported in conjunction with pregnancy. There was a total 5-year salvage rate of 76%, which is obviously much greater than with ovarian tumors in general, although there are certain patients alive with a late recurrence. This excellent survival rate seemingly reflects the low-grade malignant potential of many of the neoplasms encountered during pregnancy. However, certain cases of extremely aggressive and advanced ovarian tumors as noted at operation seemed to do surprisingly well following termination of pregnancy, and one must speculate whether gestation impairs antibody response with an apparent immunologic rebound postpartum.

The role of surgery in the management of endometriosis

Surgery has a specific and realistic place in the management of endometriosis. In the presence of an ovarian mass, diagnosis to rule out neoplasm is mandatory. Therapeutic surgery is carried out for the relief of pain when there is known symptomatic endometriosis or to provide improved chances of a successful gestation when there is infertility. The use of hormones preoperatively has not been routine but seems to be logical when there is extensive and significant scarring. It would seem appropriate to attempt to preserve childbearing function in those patients who are young and desirous of this. In older patients or those in whom the childbearing is complete, it seems unwise to leave behind diseased tissue that can require a subsequent operation. Conservative surgical treatment for infertility related to endometriosis has about a 40 percent chance of successful pregnancy; such conservative treatment carries a 10 to 12 percent risk of subsequent reoperation. The rate of malignancy in endometriosis is low. Intestinal tract endometriosis is uncommon. Bowel preparation is recommended if bowel surgery is anticipated because of the endometriosis. Urinary tract endometriosis is even more uncommon with the exception of the extrinsic pressure and scarring secondary to extensive pelvic endometriosis. tsurgical treatment seems to be of more value than hormone therapy when other organs are involved.

Endometriosis of the appendix. Report of twelve cases and review of the literature

Twelve cases of endometriosis of the vermiform appendix are discribed and reviewed. The incidence of 0.80 per cent is higher than has been previously reported. None of the patients displayed symptoms of acute appendicitis, however, five (42 per cent) patients had symptoms suggestive of chronic or cyclic appendicitis. Laboratory tests were nondiagnostic of this lesion. There did not appear to be a correlation between the histologic location of the endometriosis and the symptoms of chronic or cyclic appendicitis. All cases of endometriosis of the appendix were discovered as a result of incidental appendectomy.