Endometriosis: a life cycle approach?

To improve the still fragmented understanding of endometriosis, a life cycle approach was adopted that revealed unexpected aspects of the natural history of the disease throughout a woman's life. Three age-related stages of endometriosis are distinguished. In premenarcheal and adolescent endometriosis, 2 types can be distinguished: a classic form that can occur before menarche, and a congenital obstructive form that is caused by uterine anomaly and outflow obstruction. The lesions include superficial peritoneal implants, but adhesions and endometrioma can also occur. It is suggested that premenarcheal and possibly adolescent endometriosis develop by activation of resting stem cells shed at the time of neonatal retrograde uterine bleeding. In the adult, endometriosis can be related to uterine preconditioning by cyclic menstruations acting as a priming mechanism for deep placentation. In adult life, the typical lesions are peritoneal, ovarian, and deep or adenomyotic endometriosis. More recently, endometriosis has been associated with endometrial dysfunction and myometrial junctional zone hyperplasia. These uterine changes can be linked with some major obstetrical syndromes. In postmenopause, endometriosis can develop or be reactivated both in the presence or absence of exogenous estrogens and can spread to a variety of organs and structures causing constrictive lesions.

Endometriosis in adolescents is a hidden, progressive and severe disease that deserves attention, not just compassion

Endometriosis in the adolescent has, in recent years, been discovered to be a challenging problem in gynaecology. Although the pain may start at a young age, even before the onset of menstruation, the diagnosis by laparoscopy is almost always postponed for several years, by which time destructive lesions have affected the tubo-ovarian structures and severely compromised fecundability. Several factors may play a role, but one important reason for this disease progression is likely to be the delay in diagnosis. Therefore, transvaginal ultrasounds and transvaginal access with a less invasive needle endoscopy are recommended for exploration of the pelvis, diagnosis of endometriosis and treatment at an early stage before severe lesions develop.

"After birth" abortion: a biomedical and conceptual nonsense

Recently, two authors suggested that killing a healthy newborn might be morally permissible, subsuming it under the heading of 'after birth abortion'. Their proposed new definition implies that infanticide should be permitted whenever II trimester abortion for social reasons is. The suggestion stirred public outcry; nonetheless it needs to be analyzed since some 20% of countries allow II trimester abortion for social reasons and 5% do this on demand. A proper delimitation of the definition of "abortion" is thus very important to ensure careful application; for this reason we have attempted a critical analysis of their arguments. In the area of pregnancy termination different moral standards are apparently applied in different countries, but many reasons exist why the equation between II trimester abortion for social reasons and the killing of healthy neonates is to be morally rejected in all cases. The "inversed reification" of the concept of infanticide as a more abstract, euphemistic 'after birth abortion' blurs the fundamental difference between a non-viable fetus and a viable neonate. The best-known and most widely utilized (although illegal) "social reason" for "late abortion" and "infanticide" is a pregnancy with a female fetus or neonate. If infanticide for neonates were to be considered morally permissible, specifically it is this practice that would be applied. And this should be rejected on two levels: conceptual, through a critique of the exclusive use of one specific notion of personhood, and pragmatic through refusal of gender-discriminatory forms of infanticide (the killing of female neonates). In conclusion, having investigated the new concept we have concluded that the term "after birth abortion" is biologically and conceptually nonsensical.

Early stage management of ovarian endometrioma to prevent infertility

There are now convincing data showing that cystectomy of the endometrioma is not only no cure of infertility, but may harm follicle reserve. The question arises why is cystectomy for an endometrioma, in contrast with other -benign cysts, a risk for follicle reserve and how can ovarian damage be prevented. Surgical specimens of ovaries with endometrioma in situ show in the majority of cases manifestly a combined -extra-ovarian and intra-ovarian pathology with the cortex invaginated to form a pseudocyst. The extra-ovarian pathology includes endometrial lining of the cortex, bleeding and adhesions with surrounding tissues. The intra-ovarian pathology is characterized by microscopic stromal implants, fibrosis, smooth muscle metaplasia and -arteriosclerosis, all affecting follicle reserve in the endometrioma bed. Clinically, ovarioscopy allows differential diagnosis (e.g. luteal cyst) and evaluation of the degree of fibrosis and darkening of the cortical wall. Transvaginal colour Doppler sonography can demonstrate the presence and extent of devascularisation in the endometrioma bed. Given this reality, surgery should be based on evaluation of the pathology of the endometrioma bed, but not on the mere size of the chocolate cyst. The main clinical problem is indeed the delayed diagnosis and consequently advanced irreversible cortical damage. Therefore, the sooner endometriomas are diagnosed, the better, because it increases the chances that vascularisation of the endometrioma bed is preserved. Finally, ablation, but not excision is the treatment of choice. The diagnosis of endometriosis is traditionally based on laparoscopy, but in a sexually active adolescent transvaginal endoscopy can be proposed.

The Endometrium in Adenomyosis

Eutopic and ectopic endometria of women with adenomyosis show a series of metabolic and molecular abnormalities that increase angiogenesis and proliferation, decrease apoptosis, allow local production of estrogens, create progesterone resistance, and impair cytokine expression. These changes enhance the ability of the endometrium to infiltrate the junctional zone myometrium and the growth of ectopic tissue. In addition, in these subjects several immunological abnormalities have been observed, together with an increased production of ‘free radicals’ leading to excessive growth of endometrial stromal cells that may facilitate the establishment of adenomyosis. A limiting factor is that these studies have been performed on hysterectomy specimens representing final stages of the disease. This increased knowledge has created new therapeutic options, including the block of local aromatase production through the use of selective estrogen receptor modulators, estrogen-progestin combinations and gonadotropin-releasing hormone super agonists. Also promising are investigations into the mechanism of dysmenorrhea and abnormal uterine bleeding.

Is adenomyosis the neglected phenotype of an endomyometrial dysfunction syndrome?

Since the dissociation between adenomyoma and endometriosis in the 1920s and the laparoscopic progress in the diagnosis and surgery of endometriosis, the literature has been greatly focused on the disease endometriosis. The study of adenomyosis, on the other hand, has been neglected as the diagnosis remained based on hysterectomy specimens. However, since the introduction of magnetic resonance and sonographic imaging techniques in the 1980s, the myometrial junctional zone has been identified as a third uterine zone and interest in adenomyosis was renewed. This has also been the start for the interest in the role of the myometrial junctional zone dysfunction and adenomyosis in reproductive and obstetrical disorders.

Endometriosis, a modern syndrome

The identification of endometriosis has been a subject of intense debate over the last decade. There is, however, no doubt that Thomas Cullen was the first to describe endometriosis and adenomyosis as one disease characterized by the presence of endometrium-like tissue outside the uterine cavity. With the introduction of laparoscopy in the early 1960s three different clinical presentations of endometriosis were distinguished: peritoneal, deep adenomyotic and cystic ovarian. As soon as synthetic steroids became available, pioneer clinicians started utilizing these in an attempt to replace radical surgery by a medical treatment. While medical therapy may resort in relief, in most cases the current approach consists of a combination of medical and surgical therapy. While the pathogenesis of endometriosis is still enigmatic and complex, there is increasing evidence that endometriosis is part of a uterine reproductive dysfunction syndrome. For prevention of complications, it is very important that diagnosis is made as early as possible in a woman's life.

The "Great Obstetrical Syndromes" are associated with disorders of deep placentation

Defective deep placentation has been associated with a spectrum of complications of pregnancy including preeclampsia, intrauterine growth restriction, preterm labor, preterm premature rupture of membranes, late spontaneous abortion, and abruptio placentae. The disease of the placental vascular bed that underpins these complications is commonly investigated with targeted biopsies. In this review, we critically evaluate the biopsy technique to summarize the salient types of defective deep placentation, and propose criteria for the classification of defective deep placentation into 3 types based on the degree of restriction of remodeling and the presence of obstructive lesions in the myometrial segment of the spiral arteries.

Condoms, HIV and the Roman Catholic Church

For decades, the Roman Catholic Church opposed use of condoms to prevent spread of sexually transmitted infections (STI) because of their contraceptive effect. In 2009, Pope Benedict XVI said that widespread use of condoms could worsen the situation, a position rejected as 'unscientific'. Recently, however the Pontiff stated that because the Church considers acts of prostitution and homosexuality to be gravely immoral and disordered, in such specific cases use of a condom might become an initial step in the direction of a moralization leading to an assumption of responsibility and a new awareness of the meaning of sexuality. In doing so, he reaffirmed his belief that condoms cannot solve the problem of STI spread, stressing the Church's position that modern societies no longer see sexuality as an 'expression of love, but only as a sort of drug that people administer to themselves'. The new Papal position has been widely applauded, but made conservative Catholics unhappy. A dialogue with the Church now seems possible: Does concentrating on condoms hinder the effectiveness of other strategies? What are the respective roles of condoms and other approaches to prevent infection spread? Does a special situation exist in Africa requiring specific and focused interventions?

Deep placentation

Deep placentation in human pregnancy is realised by deep invasion of the placental bed by the extravillous trophoblast, involving the decidua and the inner (junctional zone) myometrium. Interstitial invasion of the stroma and endovascular trophoblast invasion of the spiral arteries both occur. Deep endovascular trophoblast invasion into the myometrial segments of spiral arteries is important for proper placental functioning. Before this extended vascular invasion begins, decidua-associated vascular remodelling, which includes swelling and disorganisation of the vascular smooth muscle, occurs during a period of rising placental oxygen. This early remodelling step may accommodate the progressively increasing maternal blood flow to the developing placenta. The subsequent trophoblast-associated remodelling step enhances and stabilises the widening of the vessels, whereas the vascular smooth muscle and elastic lamina are replaced by a fibrinoid matrix with embedded trophoblast. Defective deep remodelling contributes to placental malfunctioning in complications of pregnancy.

Endovascular trophoblast and preeclampsia: A reassessment

Since the earliest report on impaired spiral artery remodelling in preeclamptic human pregnancies, numerous studies have been devoted to possible mechanisms of impaired trophoblast invasion. A better knowledge of early uteroplacental blood flow has provided a physiological context for the processes of spiral artery invasion and associated remodelling, revealing a closely timed relationship between increasing flow and early steps in vascular remodelling. Concerning the impaired trophoblast invasion in preeclampsia, it has also to be considered that impaired invasion not only concerns invasion depth per se, but also the extension of this deep invasion from the central towards the more lateral spiral arteries of the placental bed. Since also in preeclampsia the very central spiral arteries may be normally invaded, the existence of such spatial gradient provides a further dimension to the problem. A practical consequence is that frequently used rodent models, which show invasion of two or three spiral arteries only, may be less useful for studying this particular aspect of the disease. Amongst non-human primates, baboons and rhesus monkeys are 'shallow invaders', and only in some of the great apes deep trophoblast invasion and associated spiral artery remodelling occurs. A better knowledge of the evolutionary history of deep invasion and its possible selective benefit might ultimately improve our understanding of failed deep invasion and impaired spiral artery remodelling in preeclampsia.