Environmental and host-associated risk factors in endometriosis and deep endometriotic nodules: a matched case-control study

Peritoneal endometriosis (PE) and deep endometriotic nodules (DEN) are gynecological diseases recently shown to be associated with elevated serum concentrations of organochlorines. The objective of the present study was to compare risk factors associated with both forms of the disease, with a particular attention to potential sources of organochlorine exposure. This matched case-control study with prospective recruitment included 88 triads (PE-DEN-control). All women were face-to-face interviewed with a standardized questionnaire, and serum dioxin and polychlorinated biphenyl measurements were available for 58 of them. Alcohol consumption (odds ratio (OR): 5.82 [confidence interval at 95% (95%CI) 1.20-28.3]) in DEN and low physical activity at work for DEN (OR: 4.58 [95%CI 1.80-11.62]) and PE (OR: 5.61 [95%CI 1.90-16.60]) were traced as significant risk factors. Organochlorine-related factors (use of tampons, occupational or environmental exposure) were not related to the disease. The current consumption of foodstuffs that were more likely to contribute to organochlorine body burden did not differ among the groups. Only some of these fatty foodstuffs (marine fish, pig meat) were traced by multiple regression analysis as significant determinants of organochlorine body burden, explaining only a small fraction (20%) of the interindividual variation of organochlorine body burden. We conclude that PE and DEN share similar patterns of risk or protective factors.

Endometriosis and the development of malignant tumours of the pelvis. A review of literature

For several decades, endometriosis has been suspected of playing a role in the aetiology of ovarian cancer. The literature concerning a possible histogenesis of ovarian cancer from benign endometriosis is reviewed in this chapter. Epidemiological evidence from large-cohort studies confirms endometriosis as an independent risk factor for ovarian cancer. Further circumstantial evidence for this link was found in the common risk factors for ovarian cancer and endometriosis. These risk factors influence retrograde menstruation and endometriosis in the same positive or negative way. Based on data in the literature, the prevalence of endometriosis in epithelial ovarian cancer has been calculated to be 4.5, 1.4, 35.9, and 19.0% for serous, mucinous, clear-cell and endometrioid ovarian carcinoma, respectively. The risk of malignant transformation in ovarian endometriosis was calculated at 2.5% but this might be an underestimate. In addition, some authors described atypical endometriosis in a spatial and chronological association with ovarian cancer. Finally, molecular studies have detected common alterations in endometriosis and ovarian cancer. These data suggest that some tumours, especially endometrioid and clear-cell carcinomas, can arise from endometriosis. Moreover, endometriosis-associated ovarian cancer represents a distinct clinical entity, with a more favourable biological behaviour, given a lower stage distribution and better survival than non-endometriosis-associated ovarian cancer.

Endometriosis: epidemiology and aetiological factors

Estimates of the frequency of endometriosis vary widely. Based on the few reliable data, the prevalence of the condition can reasonably be assumed to be around 10%. Although no consistent information is available on the incidence of the disease, temporal trends suggest an increase among women of reproductive age. This could be explained-at least in part-by changing reproductive habits. Numerous epidemiological studies have indicated that nulliparous women and women reporting short and heavy menstrual cycles are at increased risk of developing endometriosis; data on other risk factors are less consistent. These epidemiological findings strongly support the menstrual reflux hypothesis. Additional evidence in favour of this theory includes the demonstration of viable endometrial cells in the menstrual effluent and peritoneal fluid, experimental implantation and growth of endometrium within the peritoneal cavity, observation of some degree of retrograde menstruation in most women undergoing laparoscopy during menses, and an association between obstructed menstrual outflow and endometriosis.

Delayed diagnosis of endometriosis

When following current pelvic pain management algorithms, appropriate counseling may lessen emotional and social issues associated with endometriosis-associated pelvic pain.

The tangled web of reasons for the delay in diagnosis of endometriosis in women with chronic pelvic pain: will the suffering end?

Understanding the woman's experience with chronic pelvic pain and endometriosis is critical to decreasing her suffering. Further investigation must continue to determine the relation between endometriosis and pain, despite empirical treatment with GnRH agonists becoming routine in the United States.

Endometriosis of the urinary tract in women of reproductive age

AIM

We present our experience with diagnosing and treating 22 cases of urinary tract endometriosis in women of reproductive age.

PATIENTS AND METHODS

From January 2001 to January 2003, 22 women of reproductive age (mean age 34.8 years) were diagnosed suffering from endometriosis of the urinary tract. We used the Endoscopic Endometriosis Classification (EEC) for assessing the stage of endometriosis.

RESULTS

Endometriosis was present in the bladder, the lower third of the ureter, and in a postnephrectomy ureteral stump in 15 (68.1%), six (27.2%) and one (4.5%) cases, respectively. The EEC classification revealed stages I, II, III and IV in four (18.1%), one (4.5%), one (4.5%), and 16 (72.7%) patients, respectively. Urinary symptoms were present in 14 (63.6%) patients. For the treatment of bladder endometriosis, 10 patients underwent partial cystectomy, while the remaining five patients were treated with transurethral resection. In four patients ureterolysis was performed, by laparoscopy in two cases and by open surgery in the other two cases. Ureterectomy and re-implantation with bladder psoas hitching took place in six patients. In the case of endometriosis of the ureteral stump, open surgical excision took place. During the mean follow-up period of 20 months (range 16-40) no long-term complication or relapse was diagnosed.

CONCLUSIONS

Bladder and ureteral endometriosis should be considered in women of reproductive age with non-specific urinary tract or abdominal symptoms, and surgical treatment is recommended.

Lateral distribution of endometriomas as a function of age

The lateral asymmetry of ovarian endometriomas, with a left-sided predilection, seems to disappear with advancing age. This asymmetry does not seem to persist in women >35 years of age.

Diagnosis of endometriosis and pelvic pain

Both the American and the Royal Colleges of Obstetricians and Gynecologists have produced guidelines that recommend patients with chronic pelvic pain, including those suspected of having endometriosis, should receive empirical medical therapy without a preliminary diagnostic laparoscopy. This paper reviews the implications of this approach.

Should a diagnosis of endometriosis be sought in all symptomatic women?

A tool is needed to enable clinicians to determine whether women wish to seek a pathology-based explanation for chronic pelvic pain or whether they just want symptom relief. Such an approach might reduce the number of unnecessary laparoscopies without adversely affecting outcomes.

Too soon, too late, too often, too seldom?

Many variables determine the appropriate timing of diagnostic laparoscopy for suspected endometriosis. When initial treatments fail to relieve pain attributed to endometriosis, more detailed assessment is often indicated rather than escalation of treatment.

What's the delay? A qualitative study of women's experiences of reaching a diagnosis of endometriosis

OBJECTIVE

To investigate the reasons women experience delays in the diagnosis of endometriosis and the impact of this.

DESIGN

A qualitative interview-based study of 32 women, 28 of whom were subsequently diagnosed with endometriosis.

SETTING

Southeast England.

PATIENT(S)

Women attending a pelvic pain clinic.

INTERVENTION(S)

Semistructured interviews.

MAIN OUTCOME MEASURE(S)

Women's reported experiences of being diagnosed with endometriosis.

RESULT(S)

Delays in the diagnosis of endometriosis occur at an individual patient level and a medical level, as both women and family doctors normalize symptoms, symptoms are suppressed through hormones, and nondiscriminatory investigations are relied upon. Women benefited from a diagnosis, because it provided a language in which to discuss their condition, offered possible management strategies to control symptoms, and provided reassurance that symptoms were not due to cancer. Diagnosis also sanctioned women's access to social support and legitimized absences from social and work obligations.

CONCLUSION(S)

Although recent guidelines for the management of chronic pelvic pain suggest that diagnostic laparoscopy may be considered a secondary investigation after the failure of therapeutic interventions, the present study highlights the importance of an early diagnosis for women who suffer at physical, emotional, and social levels when they remain undiagnosed.

Chronic pelvic pain and endometriosis in adolescents

PURPOSE OF REVIEW

This review will provide a detailed account of chronic pelvic pain and endometriosis, two conditions that frequently occur in adolescents. Current approaches used to evaluate and treat these patients will be addressed.

RECENT FINDINGS

Although previous investigations have established relative rates of disease and basic treatment algorithms for endometriosis in adolescents, its pathogenesis is yet to be explained. Recent scientific works have focused on the interplay of specific genes and the role of host immune response. Despite such progress, we have not yet learned how to apply this knowledge to clinical use. Most innovative treatment strategies are based on algorithms generated primarily for adults, with only a small percentage focusing on adolescents.

SUMMARY

Treating pain associated with endometriosis may be facilitated by early intervention. Future study should focus on identifying adolescents with progressive disease and introducing less invasive therapies that could reverse inflammatory pathways and minimize subsequent morbidity.

KRAS variation and risk of endometriosis

Endometriosis is a common gynaecological disease with symptoms of pelvic pain and infertility which affects 7-10% of women in their reproductive years. Activation of an oncogenic allele of Kirsten rat sarcoma viral oncogene homologue (KRAS) in the reproductive tract of mice resulted in the development of endometriosis. We hypothesized that variation in KRAS may influence risk of endometriosis in humans. Thirty tagSNPs spanning a region of 60.7 kb across the KRAS locus were genotyped using iPLEX chemistry on a MALDI-TOF MassARRAY platform in 959 endometriosis cases and 959 unrelated controls, and data were analysed for association with endometriosis. Genotypes were obtained for most individuals with a mean completion rate of 99.1%. We identified six haplotype blocks across the KRAS locus in our sample. There were no significant differences between cases and controls in the frequencies of individual single-nucleotide polymorphisms (SNPs) or haplotypes. We also developed a rapid method to screen for 11 common KRAS and BRAF mutations on the Sequenom MassARRAY system. The assay detected all mutations previously identified by direct sequencing in a panel of positive controls. No germline variants for KRAS or BRAF were detected. Our results demonstrate that any risk of endometriosis in women because of common variation in KRAS must be very small.

Relationship between delay of surgical diagnosis and severity of disease in patients with symptomatic deep infiltrating endometriosis

We investigated relationships between delay of surgical diagnosis and severity of disease in 95 patients with symptomatic deep infiltrating endometriosis. The delay before surgical diagnosis of deep infiltrating endometriosis was significantly longer for patients with advanced stage IV (revised American Society for Reproductive Medicine [ASRM] score >70) disease than for those with stage I, II, III, or IV (revised ASRM score <or=70) disease.

Endométriose et adolescente

Endometriosis has long been considered as a disease of women over 30 years old. However, recent data from the literature demonstrated its high incidence in teenagers. Endometriosis in teenagers is generally associated with chronic pelvic pains and cyclical signs are less common than in adults. The persistence of the pain despite an estroprogestative contraception associated with non-steroidal anti-inflammatory drugs is a strong argument for the diagnosis and justifies a laparoscopic exploration. During this laparoscopy, the search for atypical lesions, which are much more common than typical ones, is essential. Biopsies of these lesions is mandatory in every patient to rule out false positives and false negatives which are common in atypical lesions. The aim of the treatment is to improve the pain. The first line of medical treatment is based on the estroprogestative contraception and non-steroidal anti-inflammatory drugs. The prescription of GnRH should be the ultimate solution because the bone reserve increases until the age of 18 to 20. The laparoscopic treatment, when required, should be as complete as possible. Early diagnosis and medical management may prevent the development of the disease. However, further studies in the teenager are essential to improve the current empirical management.

No difference in cycle pregnancy rate and in cumulative live-birth rate between women with surgically treated minimal to mild endometriosis and women with unexplained infertility after controlled ovarian hyperstimulation and intrauterine insemination

OBJECTIVE

The association between infertility and minimal to mild endometriosis is controversial and poorly understood. The clinical pregnancy rate (PR) per cycle after controlled ovarian hyperstimulation (COH) with or without intrauterine insemination (IUI) is reportedly lower in women with surgically untreated minimal to mild endometriosis than in women with unexplained infertility. It is possible that prior laparoscopic removal of endometriosis has a positive effect on the clinical PR after COH and IUI. Therefore, we tested the hypothesis that after COH and IUI the PR per cycle and the cumulative live-birth rate (CLBR) are equal or higher in women with recently surgically treated minimal to mild endometriosis when compared with women with unexplained infertility.

DESIGN

A retrospective, controlled cohort study.

SETTING

Leuven University Fertility Centre, a tertiary academic referral center.

PATIENT(S)

One hundred seven women treated during 259 cycles with COH and IUI including patients with endometriosis (n = 58, 137 cycles) and unexplained infertility (n = 49, 122 cycles). All patients with endometriosis had minimal (n = 41, 100 cycles) or mild (n = 17, 37 cycles) disease that had been laparoscopically removed within 7 months before the onset of treatment with COH and IUI.

INTERVENTION(S)

Controlled ovarian hyperstimulation using clomiphene citrate (23 cycles) or gonadotrophins (236 cycles) in combination with IUI.

MAIN OUTCOME MEASURE(S)

Clinical PR per cycle and CLBR within four cycles of treatment with COH and IUI.

RESULT(S)

The clinical PR per cycle was comparable in women with minimal or mild endometriosis (21% or 18.9%, respectively) and in women with unexplained infertility (20.5%). The CLBR within four cycles of COH and IUI was also comparable in women with minimal endometriosis, mild endometriosis, and unexplained infertility (70.2%, 68.2 %, 66.5%, respectively).

CONCLUSION(S)

The data from our study suggest that COH and IUI shortly after laparoscopic excision of endometriosis is as effective as COH and IUI in patients with unexplained subfertility.

Recurrence of endometriomas after laparoscopic removal: sonographic and clinical follow-up and indication for second surgery

STUDY OBJECTIVE

This study involved patients who, after laparoscopic surgery, had recurrence of endometriomas detected by sonography. The aim of this study was to evaluate the role of transvaginal sonography (TVS) in the management of recurrent endometriomas and to establish ultrasonographic criteria that would direct the therapy toward additional surgery versus medical or expectant management.

DESIGN

Retrospective analysis of 62 reproductive-age women who showed recurrence of endometriomas on TVS after laparoscopic removal of an ovarian endometrioma by the stripping technique (Canadian Task Force classification II-1).

SETTING

Obstetrics and Gynecology Department, University of Rome Tor Vergata.

PATIENTS

Sixty-two patients with recurrent endometriomas after first-line treatment with laparoscopy.

INTERVENTIONS

Ultrasonographic follow-up and/or second surgery.

MEASUREMENTS AND MAIN RESULTS

Recurrence of an ovarian endometrioma was defined as the presence of ovarian cysts with the typical sonographic criteria of endometriomas and a diameter of more than 10 mm. The clinical and sonographic postoperative follow-up period lasted from 6 to 97 months (median 24.6) after the first procedure. Of 62 patients with recurrent endometriomas, 50 had recurrence on the treated ovary, 7 on the contralateral untreated ovary, and 5 on both the treated and untreated ovaries. Recurrence of endometriomas was associated with symptoms (pain or infertility) in 47 patients (76%), while the remaining 15 (24%) were asymptomatic. Of the 47 symptomatic patients with recurrence detected by TVS, a second procedure was performed in 15. Second surgery in these patients was indicated by the larger size of the recurrent cysts, a poor response to medical treatment, the presence on TVS of pelvic adhesions and nodules of deep endometriosis, and overall progression of the disease. Symptomatic patients who did not undergo a second procedure (32) had smaller recurrent endometriomas. However of the 31 symptomatic patients with large recurrent endometriomas (>3 cm), only 45% had repeat surgery.

CONCLUSION

Recurrent endometriomas, as detected by TVS, can remain asymptomatic and do not necessarily progress in size with or without medical treatment. The decision to reoperate depends less on the endometrioma's size than on symptoms, in particular severe pain, and failure of medical treatment. However such patients are also more likely to have signs of deep nodules and adnexal/bowel adhesions and larger endometriomas on TVS scan, thus predisposing them to require a second procedure.

Diagnosis and management of endometriosis

Signs and symptoms of endometriosis are nonspecific, and an acceptably accurate noninvasive diagnostic test has yet to be reported. Serum markers do not provide adequate diagnostic accuracy. The preferred method for diagnosis of endometriosis is surgical visual inspection of pelvic organs with histologic confirmation. Such diagnosis requires an experienced surgeon because the varied appearance of the disease allows less-obvious lesions to be overlooked. Empiric use of nonsteroidal anti-inflammatory drugs or acetaminophen is a reasonable symptomatic treatment, but the effectiveness of these agents has not been well-studied. Oral contraceptive pills, medroxyprogesterone acetate, and intrauterine levonorgestrel are relatively effective for pain relief. Danazol and various gonadotropin-releasing hormone analogues also are effective but may have significant side effects. There is limited evidence that surgical ablation of endometriotic deposits may decrease pain and increase fertility rates in women with endometriosis. Presacral neurectomy is particularly beneficial in women with midline pelvic pain. Hysterectomy and bilateral salpingo-oophorectomy definitively treat pain from endometriosis at 10 years in 90 percent of patients.

Identification of diagnostic subtypes of chronic pelvic pain and how subtypes differ in health status and trauma history

OBJECTIVE

Our primary aim was to identify subtypes of chronic pelvic pain and to compare the cases of women with the identified subtypes on health status and trauma history. We hypothesized that women with diffuse abdominal/pelvic pain would have greater health impairment and report more lifetime trauma than women with vulvovaginal pain or cyclic pain.

STUDY DESIGN

We collected questionnaire data on 289 consecutive women patients from a university chronic pelvic pain clinic. From patient records, 1 gynecologist identified chronic pelvic pain subtypes on the basis of reported symptoms and the localization of pain during examination. We used analysis of covariance with pairwise contrasts.

RESULTS

Seven diagnostic subtypes were identified. Patients with diffuse abdominal/pelvic pain had more trauma and worse mental and physical health status compared with patients with vulvovaginal pain and cyclic pain. Those patients with abdominal/pelvic pain also had poorer health than patients with neuropathic and fibroid pain. Endometriosis was unrelated to health status.

CONCLUSION

There is immense need for further research to define subtypes of chronic pelvic pain.

Is the endometriosis recurrence rate increased after ovarian hyperstimulation?

OBJECTIVE

To test the hypothesis that the cumulative endometriosis recurrence rate (CERR) after fertility surgery for endometriosis stage III or IV is increased in women exposed to very high E(2) levels during ovarian hyperstimulation (OH) for IVF when compared with women exposed to less high E(2) levels during OH for intrauterine insemination (IUI).

DESIGN

Retrospective cohort study including infertility patients with endometriosis stage III or IV.

SETTING

Leuven University Fertility Center, between 1990 and 2001.

PATIENT(S)

Patients (n = 67) with endometriosis stage III (n = 45) or IV (n = 22) who underwent pelvic reconstructive surgery and subsequently started fertility treatment with either IVF only (n = 39), both IVF and IUI in different cycles (n = 11), or IUI only (n = 17).

INTERVENTION(S)

Life table analysis was used to calculate the CERR.

MAIN OUTCOME MEASURE(S)

The CERR based on histologic or cytologic proof of disease recurrence.

RESULT(S)

At 21 months after the start of OH the overall CERR was 31% and was significantly lower in patients treated with IVF only (7%) or women treated with both IVF and IUI in different cycles (43 %) than in those treated with IUI only (70%). At 36 months after the start of OH, the overall CERR was 63%.

CONCLUSION(S)

In contrast to our hypothesis, the results from this study showed that the CERR is lower after ovarian hyperstimulation for IVF than after lower-dose ovarian stimulation for IUI, suggesting that temporary exposure to very high E(2) levels in women during OH for IVF is not a major risk factor for endometriosis recurrence in women treated with assisted reproductive technology.

Transvaginal ultrasound for diagnosis of adenomyosis: a review

The objective of this chapter is to relate the image findings of transvaginal ultrasound (TVS) to structural changes of adenomyosis; in order to clarify the present clinical diagnostic approach in the diagnosis of adenomyosis, the performance of TVS is evaluated in comparison to other diagnostic modalities. A Medline search of papers in English on the use of TVS and needle biopsy for the diagnosis of adenomyosis was carried out. It was found that TVS is highly observer-dependent, but in the hands of experienced investigators it has an adequate diagnostic accuracy in clinically suspected cases. The diagnostic accuracy of TVS is at an intermediate level but is in line with that of magnetic resonance imaging (MRI) in unselected patients without myomas undergoing surgery. TVS is a sufficiently accurate tool for diagnosis of adenomyosis in clinically suspected cases, but not in unselected premenopausal women with myomas. Resectoscopic hysteroscopic biopsy has not been sufficiently evaluated but could be a useful diagnostic tool, whereas needle biopsy is not. In conclusion, in clinically suspected adenomyosis cases TVS should be favoured as the primary diagnostic tool. Substantial experience and specific training is required for TVS to be a useful diagnostic tool in adenomyosis. MRI may be considered when TVS is inconclusive. Clinicians should above all be observant of image findings of adenomyosis in patients with no wish to preserve fertility.

Determinants of long-term clinically detected recurrence rates of deep, ovarian, and pelvic endometriosis

OBJECTIVE

This study was undertaken to analyze the frequency and the determinants of long-term clinically detectable recurrence rate of deep, ovarian, and pelvic endometriosis.

STUDY DESIGN

The clinical data of 1106 women with first diagnosis of endometriosis observed between 1979 and 2001 were collected.

RESULTS

The 4-year recurrence rate was 24.6%, 17.8%, 30.6% and 23.7%, respectively, for cases of ovarian, pelvic, deep, and ovarian and pelvic endometriosis (P < .05). The recurrence rates decreased in all groups (with the exception of ovarian endometriosis) in the class age 34 years or older, these findings were significant (P < .05). Radicality was associated with lower recurrence rates in all the groups. A pregnancy after diagnosis was associated with a reduced risk of recurrence.

CONCLUSION

The study shows that the recurrence rates of endometriosis were higher in case of deep endometriosis and that the risk factors for recurrence were similar among women with endometriosis at different sites.

Endometriosis and the appendix: a case series and comprehensive review of the literature

OBJECTIVE

To report the prevalence of appendiceal disease in women with chronic pelvic pain undergoing laparoscopy for possible endometriosis, summarize the literature, and more accurately estimate the prevalence of endometriosis of the appendix.

DESIGN

Prospective case series and literature review.

SETTING

Academic research institute.

PATIENT(S)

One hundred thirty-three patients with chronic pelvic pain and possible endometriosis undergoing laparoscopy.

INTERVENTION(S)

History, physical exam, and abdominopelvic laparoscopy. Endometriosis and adhesions were excised using selective Nd:YAG contact laser trabeculoplasty and pathologically evaluated. Only patients with visible abnormalities involving the appendix were treated via concurrent laparoscopic appendectomy.

MAIN OUTCOME MEASURE(S)

Appendiceal abnormalities at laparoscopy.

RESULT(S)

Of 133 patients, 13 had a previous appendectomy with unknown pathology. Of the remaining 120 patients, 109 reported right lower quadrant pain. Of this subgroup, six patients had appendiceal pathology: four with pathology-confirmed endometriosis, one with Crohn's disease suspected at laparoscopy, and one with chronic appendicitis. The prevalence of appendiceal endometriosis in patients with biopsy-proven endometriosis (n = 97) or with right lower quadrant pain (n = 109) was 4.1% and 3.7%, respectively. This rate was similar to the 2.8% prevalence confirmed by literature review in patients with endometriosis but was much higher than that reported in all patients (0.4%).

CONCLUSION(S)

Appendiceal endometriosis, while relatively uncommon in patients with endometriosis, is rare in the general population. In patients with right lower quadrant or pelvic pain, the appendix should be inspected for endometriosis and evidence of nongynecologic disease.

The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins

OBJECTIVE

To clarify whether the presence of ovarian endometriomas is associated with a reduced responsiveness to ovarian hyperstimulation.

DESIGN

Observational study.

SETTING

University teaching hospital.

PATIENT(S)

Women selected for in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) cycles who were found to have unilateral ovarian endometriomas and who did not undergo previous ovarian surgery.

INTERVENTION(S)

Ovarian hyperstimulation using gonadotropins.

MAIN OUTCOME MEASURE(S)

Number of codominant follicles (mean diameter >15 mm) in the affected and in the contralateral intact gonads.

RESULT(S)

Thirty-six patients were enrolled. They underwent 56 IVF-ICSI cycles. The number of codominant follicles in the intact and affected ovaries were 4.0 +/- 2.2 and 3.0 +/- 1.7, respectively (P=.01). This difference corresponded to a mean reduction (95% confidence interval [CI]) of 25% (6%-44%). This deleterious effect was more evident in women with larger cysts, in those with more than one cyst, and in those who were more responsive to ovarian hyperstimulation.

CONCLUSION(S)

The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins.