Progestins for symptomatic endometriosis: a critical analysis of the evidence

Use of norethindrone acetate alone for postoperative suppression of endometriosis symptoms

STUDY OBJECTIVE

To evaluate the efficacy and tolerability of norethindrone acetate (NA) as single-agent hormonal therapy for suppression of endometriosis symptoms in adolescents and young adults.

DESIGN

Retrospective study.

SETTING

Two academic medical centers.

PARTICIPANTS

A keyword search using the query 'NA' was applied to the electronic medical records of all women treated by one gynecologist (M.R.L.) from 1992 to 2010. IRB-approved chart review was then conducted on the index records.

INTERVENTIONS

Continuous treatment with NA (5-15 mg daily).

MAIN OUTCOME MEASURES

Postoperative bleeding and pain scores; adverse effects.

RESULTS

One hundred and ninety-four patients with surgically diagnosed endometriosis initiated NA postoperatively during the study period. Median patient age was 18.9 years. 92.2% of patients had stage 1 or 2 disease, and distribution was similar among those excluded. Median pain scores decreased from 5 at NA initiation to 0 at follow-up (P = .0001) and bleeding scores from 2 to 0, respectively (P = .001) for all stages of endometriosis. Post-NA bleeding scores were improved regardless of prior hormonal regimen, and post-NA pain scores improved in all patients except for those previously prescribed GnRH-agonist plus add-back. Most patients (55.2%) did not report any side effects. The most common adverse effect was weight gain (16.1%), with a mean increase in BMI of 1.2 ± 1.6 kg/m(2) at 12 months.

CONCLUSION

NA alone is a well-tolerated, effective option to manage pain and bleeding for all stages of endometriosis. Among those on prior hormonal therapy, symptoms improved after NA initiation.

Effects of progressive muscular relaxation training on anxiety, depression and quality of life of endometriosis patients under gonadotrophin-releasing hormone agonist therapy

OBJECTIVES

To explore the effects of progressive muscle relaxation (PMR) training on anxiety, depression and quality of life (QOL) of endometriosis patients under gonadotrophin-releasing hormone (GnRH) agonist therapy.

STUDY DESIGN

This was a controlled, randomized, open-label study. One hundred consecutive Han Chinese endometriosis patients, aged 18-48 years, were randomly assigned to a PMR group (n=50) and a control group (n=50). In a study of 12 weeks' duration, both groups received one dose of depot leuprolide, 11.25mg IM. In addition to the GnRH agonist therapy, the PMR group received 12 weeks of PMR training. Anxiety level was measured using the state-trait anxiety inventory (STAI). Depression was assessed using subscale D of the hospital anxiety and depression scale (HADS-D). Health-related QOL was measured with SF-36 instrument. The patients were evaluated with STAI, HADS-D and SF-36 before and after the PMR intervention.

RESULTS

The control group and the PMR group were comparable at baseline. After 12 weeks of intervention, both groups showed significant improvement in overall QOL (P<0.05). The PMR group, but not the control group, showed significant improvement in state anxiety, trait anxiety and depression after intervention (P<0.05). Moreover, the PMR group showed significant improvement in all QOL domains after intervention; by contrast, the control group showed significant improvement in all physical health domains and only two mental health domains after intervention. Between-group comparisons of the improvement in scores after intervention showed that the PMR group had significantly better improvement in the scores of anxiety, depression and overall/domain QOL than the control group (P<0.05). Repeated measures ANOVA revealed that both PMR intervention and time had significant individual as well as interactive effects on state anxiety, trait anxiety depression and overall QOL (P<0.05).

CONCLUSIONS

This study suggests that PMR training is effective in improving anxiety, depression and QOL of endometriosis patients under GnRH agonist therapy. This is the first study to explore the effects of psychosomatic therapy on emotional status and QOL of endometriosis patients, and may serve as an important reference for future psychosomatic interventions on endometriosis.

Valproic acid and progestin inhibit lesion growth and reduce hyperalgesia in experimentally induced endometriosis in rats

Accumulating evidence suggests that endometriosis is an epigenetic disease. This study was designed to evaluate the effect of valproic acid (VPA) and progesterone (P4) in a rat model of endometriosis on serum tumor necrosis factor-α (TNF-α) levels, hot plate and tail-flick latencies, lesion size, and body weight. We used 77 adult female rats, and endometriosis was induced by autotransplanting pieces of uterus (ENDO) or fat (SHAM) to the pelvic cavity. The BLANK group received no surgery. After 2 weeks, the ENDO group was further divided, randomly, into 5 groups, receiving, respectively, treatment with low- and high-dose VPA, P4 alone, VPA + P4, and no treatment. The SHAM rats received no treatment. The BLANK rats were further divided into 2 groups, one received VPA treatment and the other, no treatment. After 4 weeks, all rats were sacrificed. Response latency in hot plate and tail-flick tests, body weight, and serum TNF-α levels were measured before the surgery, before and after the treatment, along with lesion size. We found that induced endometriosis reduced response latency. ENDO rats receiving VPA and/or P4 treatment had significantly reduced lesion size as compared with untreated ones, and had significantly improved response to noxious thermal stimuli. They also had significantly increased weight gain. Serum TNF-α levels increased following surgery but eventually decreased regardless of treatment or not. In conclusion, VPA is well tolerated. Treatment with VPA significantly reduces lesion growth and improves sensitivity to nocifensive stimuli. The improvement is specific to endometriosis-induced hyperalgesia. Thus, histone deacetylase inhibitors may be a promising therapeutics for treating endometriosis.

Role of estrogen receptor-β in endometriosis

Endometriosis is an estrogen-dependent disease. The biologically active estrogen, estradiol, aggravates the pathological processes (e.g., inflammation and growth) and the symptoms (e.g., pain) associated with endometriosis. Abundant quantities of estradiol are available for endometriotic tissue via several mechanisms including local aromatase expression. The question remains, then, what mediates estradiol action. Because estrogen receptor (ER)β levels in endometriosis are >100 times higher than those in endometrial tissue, this review focuses on this nuclear receptor. Deficient methylation of the ERβ promoter results in pathological overexpression of ERβ in endometriotic stromal cells. High levels of ERβ suppress ERα expression. A severely high ERβ-to-ERα ratio in endometriotic stromal cells is associated with suppressed progesterone receptor and increased cyclo-oxygenase-2 levels contributing to progesterone resistance and inflammation. ERβ-selective estradiol antagonists may serve as novel therapeutics of endometriosis in the future.

Aromatase inhibition for refractory endometriosis-related chronic pelvic pain

OBJECTIVE

To evaluate the use of an aromatase inhibitor for the treatment of endometriosis-related chronic pelvic pain.

DESIGN

Retrospective analysis.

SETTING

Academic medical center outpatient reproductive endocrinology clinic.

PATIENT(S)

Sixteen patients with endometriosis and chronic pelvic pain who previously failed conventional medical and/or surgical therapy.

INTERVENTION(S)

Treatment with the aromatase inhibitor letrozole (2.5 mg/d) plus a gonadotropin suppressor (norethindrone acetate, 2.5 mg/d, or a combination oral contraceptive [OC]) for an average of 6 months.

MAIN OUTCOME MEASURE(S)

Pain scores were reported at each visit using a visual analogue scale from 0 to 10 (0: no pain, 10: maximum pain).

RESULT(S)

Sixteen patients were treated with an aromatase inhibitor for 180 ± 31 days. The median pain score at the start of therapy was 7, and at the end of therapy it was 1.5. In the nine patients who were evaluated after discontinuing therapy, pain scores returned to pretreatment levels. We did not find any correlation between the length of treatment and the overall improvement in pain score.

CONCLUSION(S)

Letrozole plus a gonadotropin suppressor substantially improved pain symptoms in patients with endometriosis refractory to conventional therapies; however, pain recurred after treatment was completed.

Aberrant DNA methylation status of endometriosis: epigenetics as the pathogenesis, biomarker and therapeutic target

Endometriosis, a common, benign, estrogen-dependent disease affecting 3-10% of women of reproductive age, is characterized by the ectopic growth of endometrial tissue that is found primarily in the peritoneum, ovaries and rectovaginal septum. Recently, endometriosis has been alternatively described as an immune disease, a genetic disease and a disease caused by exposure to environmental factors, in addition to its usual description as a hormonal disease. In addition, accumulating evidence suggests that various epigenetic aberrations play definite roles in the pathogenesis of endometriosis. Epigenetic alterations reported to date in endometriosis include the genomic DNA methylation of progesterone receptor-B, E-cadherin, homeobox A10, estrogen receptor-β, steroidogenic factor-1 and aromatase. Aberrant expression of DNA methyltransferases, which attach a methyl group to the 5-carbon position of cytosine bases in the CpG island of the promoter region and silence the corresponding gene expression, has also been demonstrated in endometriosis. This review summarizes the recent studies on the aberrant DNA methylation status and aberrant expression of DNA methyltransferases, which regulate DNA methylation, in endometriosis. We also discuss the recent information on the diagnostic and therapeutic implications of epigenetic alterations occurring in endometriosis.

The steroidogenic factor-1 protein is not expressed in various forms of endometriosis but is strongly present in ovarian cortical or medullary mesenchymatous cells adjacent to endometriotic foci

Steroidogenic factor-1 (SF-1) protein expression was not observed in any form of endometriosis (peritoneal, ovarian, or deep infiltrating endometriosis), which suggests that SF-1 locally produced by endometrial or stromal cells may not play a major role in the development of endometriosis. However, the strong expression of SF-1 in cortical and medullary ovarian mesenchymatous cells may be capable of creating a favorable steroidogenic environment and the development of the disease.

Surgical procedures and their cost estimates among women with newly diagnosed endometriosis: a US database study

OBJECTIVE

This descriptive study assessed the rate and costs of surgical procedures among newly diagnosed endometriosis patients.

METHODS

Utilizing the Medstat MarketScan database, commercially insured women aged 18-45 with endometriosis newly diagnosed during 2006-2007 were identified. Each endometriosis patient was matched to four women without endometriosis (population controls) based on age and region of residence. Surgical procedures received during the 12 months post-diagnosis were assessed. Costs of surgical procedures were the amount paid by the insurance companies.

RESULTS

This study identified 15,891 women with newly diagnosed endometriosis and 63,564 population controls. More than 65% of endometriosis patients received an endometriosis-related surgical procedure within 1 year of the initial diagnosis. The most common procedure was therapeutic laparoscopy (31.6%), followed by abdominal hysterectomy (22.1%) and vaginal hysterectomy (6.8%). Prevalence and type of surgery performed varied by patient age, including a hysterectomy rate of approximately 16% in patients younger than 35 and 37% among patients aged 35-45 years. Average costs ranged from $4,289 (standard deviation [SD]: $3,313) for diagnostic laparoscopy to $11,397 (SD: $8,749) for abdominal hysterectomy.

LIMITATIONS

Diagnosis of endometriosis cannot be validated against medical records, and information on the severity of endometriosis-related symptoms is not available in administrative claims data.

CONCLUSIONS

Over 65% of patients had endometriosis-related surgical procedures, including hysterectomy, within 1 year of being diagnosed with endometriosis. The cost of surgical procedures related to endometriosis places a significant financial burden on the healthcare system.

Different progestins in the treatment of endometriosis - are there relevant differences?

Oral progestins without an estrogen component have been described to be effective in the treatment of endometriosis. Several different substances have been tested, which are on the one hand derivatives of the natural progesterone or of the C-17-OH-progesteron, or on the other hand derivatives of C-19-nortestosteron. Their common characteristic is the secretory transformation of estrogen primed uterine endometrium for which different dosages are necessary because of their different biological activities. They are different with regard to their profile and potency of action on hypothalamicpituitary axis, metabolic processes, breast tissue and genital organs. They are effectively similar with regard to endometriosis related complaints if sufficient doses are administered. No effects are noted on reduced fertility in endometriotic patients and the data are inconsistent concerning direct effects on the endometriotic cells.

Oral contraceptives and risk of endometriosis: a systematic review and meta-analysis

BACKGROUND

Combined oral contraceptives (OCs) inhibit ovulation, substantially reduce the volume of menstrual flow and may hypothetically interfere with implantation of refluxed endometrial cells. The aim of this review is to establish if OC use influences the risk of endometriosis.

METHODS

We performed a MEDLINE search to identify all studies published in the last four decades (January 1970 to January 2010) in the English language on the relationship between OC exposure and risk of endometriosis. Two authors abstracted data on standardized forms.

RESULTS

We identified 608 potentially relevant studies and 18 studies (6 cross-sectional, 7 case-control and 5 cohort) were selected. Pooling of the results derived from all the included reports independently from study design, yielded a common relative risk of 0.63 [95% confidence interval (CI), 0.47-0.85] for current OC users, 1.21 (95% CI, 0.94-1.56) for past users and 1.19 (95% CI, 0.89-1.60) for ever users. Methodological drawbacks, such as uncertain temporal relationship between exposure and outcome in cross-sectional studies and suboptimal selection of controls in case-control studies, limit the quality of the available evidence.

CONCLUSIONS

The risk of endometriosis appears reduced during OC use. However, it is not possible to exclude the possibility that the apparent protective effect of OC against endometriosis is the result of postponement of surgical evaluation due to temporary suppression of pain symptoms. Confounding by selection and indication biases may explain the trend towards an increase in risk of endometriosis observed after discontinuation, but further clarification is needed. To date, the hypothesis of recommending OCs for primary prevention of endometriosis does not seem sufficiently substantiated.

Optimal management of chronic cyclical pelvic pain: an evidence-based and pragmatic approach

This article reviews the literature on management of chronic cyclical pelvic pain (CCPP). Electronic resources including Medline, PubMed, CINAHL, The Cochrane Library, Current Contents, and EMBASE were searched using MeSH terms including all subheadings and keywords: "cyclical pelvic pain", "chronic pain", "dysmenorrheal", "nonmenstrual pelvic pain", and "endometriosis". There is a dearth of high-quality evidence for this common problem. Chronic pelvic pain affects 4%-25% of women of reproductive age. Dysmenorrhea of varying degree affects 60% of women. Endometriosis is the commonest pathologic cause of CCPP. Other gynecological causes are adenomyosis, uterine fibroids, and pelvic floor myalgia, although other systems disease such as irritable bowel syndrome or interstitial cystitis may be responsible. Management options range from simple to invasive, where simple medical treatment such as the combined oral contraceptive pill may be used as a first-line treatment prior to invasive management. This review outlines an approach to patients with CCPP through history, physical examination, and investigation to identify the cause(s) of the pain and its optimal management.

Clinical practice. Endometriosis

A healthy 25-year-old woman presents with worsening dysmenorrhea, pain of recent onset in the left lower quadrant, and dyspareunia. She has regular menstrual cycles, and her last menstrual period was 3 weeks before presentation. How should this patient be evaluated and treated?

17Beta-hydroxysteroid dehydrogenase-2 deficiency and progesterone resistance in endometriosis

Estradiol (E2) stimulates the growth and inflammation in the ectopic endometriotic tissue that commonly resides on the pelvic organs. Several clinical and laboratory-based observations are indicative of resistance to progesterone action in endometriosis. The molecular basis of progesterone resistance in endometriosis may be related to an overall reduction in the levels of progesterone receptor (PR). In normal endometrium, progesterone acts via PR on stromal cells to induce secretion of paracrine factor(s) that in turn stimulate neighboring epithelial cells to express the enzyme 17beta-hydroxysteroid dehydrogenase type 2 (HSD17B2). HSD17B2 is an extremely efficient enzyme and rapidly metabolizes the biologically potent estrogen E2 to weakly estrogenic estrone. In endometriotic tissue, progesterone is incapable of inducing epithelial HSD17B2 expression due to a defect in stromal cells. The inability of endometriotic stromal cells to produce progesterone-induced paracrine factors that stimulate HSD17B2 may be due to the very low levels of PR observed in vivo in endometriotic tissue. The end result is deficient metabolism of E2 in endometriosis giving rise to high local concentrations of this mitogen. The molecular details of this physiological paracrine interaction between the stroma and epithelium in normal endometrium and its lack thereof in endometriosis are discussed.

A novel mifepristone-loaded implant for long-term treatment of endometriosis: in vitro and in vivo studies

The objective of this study was to prepare a novel mifepristone-loaded PCL/Pluronic F68 implant to achieve long-term treatment of endometriosis. PCL/Pluronic F68 compound (90/10, w/w) with viscosity average molecular weight of 65,000 was successfully synthesized. The end-capped Pluronic F68 was incorporated in PCL matrixes as molecular dispersion without forming a copolymer. The mifepristone-loaded implant made of PCL/Pluronic F68 compound was a cylindrical capsule with an outer diameter of 2.5mm and an inner diameter of 2.2mm. The surface of PCL/Pluronic F68 compound appears porous because Pluronic F68 which is water soluble could leach out due to the water phase. Drug loading of 0.75-, 1.5- and 3.0-cm length implants was 3.05+/-0.18, 6.06+/-0.41 and 11.87+/-0.39mg, respectively. A sustained mifepristone release rate without obvious initial burst and later decline over a period of 180d was observed. The cumulative drug release showed a linear relationship with time, indicating that mifepristone release from the implants followed zero-order kinetics (R(2)>0.99). The data showed that the C(max) and AUC(0-inf) were proportional to imlant length and dose, and all groups reached plasma C(max) at about the same time (approximately 7d) and had similar T(1/2) (approximately 150d) and MRT (approximately 220d). There were obvious inhibitory effects on the growth of endometrial explants in Wister rats in a dose-dependent manner after administration of mifepristone-loaded implants with implant length from 1.5 to 9.0cm for 1-3 months. However, mifepristone-loaded implants with implant length of 12.0cm had no better inhibitory effects on the growth of endometrium when compared with the implants with implant length of 9.0cm (P>0.05). In conclusion, subcutaneous implantation of mifepristone-loaded PCL/Pluronic F68 capsules was proven an effective means for long-term treatment of chronic endometriosis.

Estrogen receptor-beta, estrogen receptor-alpha, and progesterone resistance in endometriosis

Loss of progesterone signaling in the endometrium may be a causal factor in the development of endometriosis, and progesterone resistance is commonly observed in women with this disease. In endometriotic stromal cells, the levels of progesterone receptor (PR), particularly the PR-B isoform, are significantly decreased, leading to a loss of paracrine signaling. PR deficiency likely underlies the development of progesterone resistance in women with endometriosis who no longer respond to progestin therapy. Here we review the complex epigenetic and transcriptional mechanisms leading to PR deficiency. The initial event may involve deficient methylation of the estrogen receptor (ER)beta promoter resulting in pathologic overexpression of ERbeta in endometriotic stromal cells. We speculate that alterations in the relative levels of ERbeta and ERalpha in endometrial tissue dictate E2-regulated PR expression, such that a decreased ERalpha-tauomicron-ERbeta ratio may result in suppression of PR. In this review, we propose a molecular model that may be responsible for changes in ERbeta and ERalpha leading to PR loss and progesterone resistance in endometriosis.

Progestins and medical treatment of endometriosis - physiology, history and society

The transitory effect of hormonal treatment is the alleged main reason to criticize progestins (PGS) and combined pills (OP) in the managment of endometriosis. To the contrary their poor efficacy in the long run is often underlined. As a result, medical treatment is too seldom advised in endometriosis. In this article, we shall focus on the analysis of the reasons of the paucity of the medical interest given to progestins, reasons, which are not of a scientific or objective nature. The ultimate aim of this analysis is to develop arguments in favour of continuous administration of hormones as to obtain not simply an anovulation but a state of prolonged amenorrhea much more efficacious than the simple suppression of ovulation too often advised. And, with an emphasis on the fundamental role of surgery in the treatment of endometriosis, to give the greatest consideration to the specific nature of this disease, which is a chronic disease, justifying the long duration of hormonal administration.

[Ovarian gonadotropic inhibition and endometriosis. About fighting false dogmas...]

Ovarian gonadotropic inhibition is today an efficacious tool in the treatment of endometriosis mainly when associated with surgery and sometimes by itself. However, to be useful, this inhibition must be stable - without any cyclical looseness - of long duration, sometimes during years and sufficiently powerful. Depending on the severity of symptoms and that of the disease, the choice will be among GnRH agonists, gestagens and combined OCs. The recent development of continuous oral contraception with protracted amenorrhoea makes treatment by continuous hormonal administration easier for the patients with endometriosis.

Endometriosis: current therapies and new pharmacological developments

Endometriosis is a chronic inflammatory condition that is responsive to management with steroids. The establishment of a steady hormonal environment and inhibition of ovulation can temporarily suppress ectopic implants and reduce inflammation as well as associated pain symptoms. In terms of pharmacological management, the currently available agents are not curative, and treatment often needs to be continued for years or until pregnancy is desired. Similar efficacy has been observed from the various therapies that have been investigated for endometriosis. Accordingly, combined oral contraceptives and progestins, based on their favourable safety profile, tolerability and cost, should be considered as first-line options, as an alternative to surgery and for post-operative adjuvant use. In situations where progestins and oral contraceptives prove ineffective, are poorly tolerated or are contraindicated, gonadotrophin-releasing hormone analogues, danazol or gestrinone may be used. Future therapeutic options for managing endometriosis must compare favourably against existing agents before they can be considered for inclusion into current practice. Finally, as reproductive prognosis is not ameliorated by medical treatment, it is not indicated for women seeking conception.

The non-human primate model of endometriosis: research and implications for fecundity

The development of an animal model of endometriosis is crucial for the investigation of disease pathogenesis and therapeutic intervention. These models will enhance our ability to evaluate the causes for the subfertility associated with disease and provide a first-line validation of treatment modulators. Currently rodents and non-human primate models have been developed, but each model has their limitations. The aim of this manuscript is to summarize the current findings and theories on the development of endometriosis and disease progression and the effectiveness of therapeutic targets using the experimental induced model of endometriosis in the baboon (Papio anubis).

Medical treatment for rectovaginal endometriosis: what is the evidence?

BACKGROUND

Rectovaginal endometriosis usually causes distressing pain. Surgical treatment may be effective but is associated with a high risk of morbidity and major complications. Information on the effect of medical alternatives for pain relief in this condition is scarce.

METHODS

A comprehensive literature search was conducted to identify all the English language published observational and randomized studies evaluating the efficacy of medical treatments on pain associated with rectovaginal endometriosis. A combination of keywords was used to identify relevant citations in PubMed, MEDLINE and EMBASE.

RESULTS

A total of 217 cases of medically treated rectovaginal endometriosis were found; 68 in five observational, non-comparative studies, 59 in one patient preference cohort study, and 90 in a randomized controlled trial. An aromatase inhibitor was used in two of the non-comparative studies, vaginal danazol in one, a GnRH agonist in one, and an intrauterine progestin in one. Two estrogen-progestin combinations used transvaginally or transdermally were evaluated in the patient preference study, whereas an oral progestin and an estrogen-progestin combination were compared in the randomized controlled trial. With the exception of an aromatase inhibitor used alone, the antalgic effect of the considered medical therapies was high for the entire treatment period (from 6 to 12 months), with 60-90% of patients reporting considerable reduction or complete relief from pain symptoms.

CONCLUSIONS

Despite problems in interpretation of data, the effect of medical treatment in terms of pain relief in women with rectovaginal endometriosis appear substantial.

Recurrence of endometriosis and its control

BACKGROUND Although surgery is currently the treatment of choice for managing endometriosis, recurrence poses a formidable challenge. To delay or to eliminate the recurrence is presently an unmet medical need in the management of endometriosis. To this end, proposals to investigate patterns of recurrence, to develop biomarkers for recurrence and to carry out biomarker-based intervention have been made. METHODS Publications pertaining to the recurrence of endometriosis and its related yet unaddressed issues were identified through MEDLINE. The reported recurrence rates, risk factors for recurrence, the effects of post-operative medication and causes of recurrence were reviewed and synthesized. In addition, several poorly explored issues such as time hazard function and mechanisms of recurrence were reviewed. Approaches to the development of biomarkers for recurrence and future intervention are discussed. RESULTS The reported recurrence rate was high, estimated as 21.5% at 2 years and 40-50% at 5 years. Few risk factors for recurrence have been consistently identified, and the evidence on the efficacy of the post-operative use of medication was scanty. The investigation on the patterns of recurrence may provide us with new insight into the possible mechanisms of recurrence and its control. The attempt to identify biomarkers for recurrence has started only very recently. CONCLUSIONS Much research is needed to better understand the patterns of recurrence and risk factors, and to develop biomarkers. One top priority is to develop biomarkers for recurrence, which may provide much needed clues to the possible mechanisms underlying recurrence and would allow the identification of patients with high recurrence risk, and permit for targeted intervention.

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.

[Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications]

The relationship between chronic pelvic pain symptoms and endometriosis is unclear because painful symptoms are frequent in women without this pathology, and because asymptomatic forms of endometriosis exist. Our comprehensive review attempts to clarify the links between the characteristics of lesions and the semiology of chronic pelvic pain symptoms. Based on randomized trials against placebo, endometriosis appears to be responsible for chronic pelvic pain symptoms in more than half of confirmed cases. A causal association between severe dysmenorrhoea and endometriosis is very probable. This association is independent of the macroscopic type of the lesions or their anatomical locations and may be related to recurrent cyclic microbleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhoea. There are histological and physiopathological arguments for the responsibility of deeply infiltrating endometriosis (DIE) in severe chronic pelvic pain symptoms. DIE-related pain may be in relation with compression or infiltration of nerves in the subperitoneal pelvic space by the implants. The painful symptoms caused by DIE present particular characteristics, being specific to involvement of precise anatomical locations (severe deep dyspareunia, painful defecation) or organs (functional urinary tract signs, bowel signs). They can thus be described as "location indicating pain". A precise semiological analysis of the chronic pelvic pain symptoms characteristics is useful for the diagnosis and therapeutic.

Treatment of pelvic pain associated with endometriosis

Pain associated with endometriosis requires careful evaluation to exclude other potential causes and may involve a number of different mechanisms. Both medical and surgical treatments for pain related to endometriosis are effective and choice of treatment must be individualized.

Increased expression of c-fos protein associated with increased matrix metalloproteinase-9 protein expression in the endometrium of endometriotic patients

OBJECTIVE

To investigate c-fos and matrix metalloproteinase-9 (MMP-9) expression in the endometrium from women with or without endometriosis throughout the menstrual cycle, and to explore the correlation of c-fos expression with MMP-9 expression and 17beta-E(2) levels in serum.

DESIGN

Molecular studies in human tissue.

SETTING

A women's hospital in China.

PATIENT(S)

Fifty-five premenopausal women (25 with endometriosis and 30 without endometriosis) undergoing laparoscopic surgery or hysterectomy.

INTERVENTION(S)

Eutopic and ectopic endometrium tissue were obtained at the time of surgery. Peripheral sera were also collected on the same day.

MAIN OUTCOME MEASURE(S)

Immunohistochemical localization of c-fos in the endometrium, c-fos and MMP-9 protein levels in the endometrium, and 17beta-E(2) levels in the serum.

RESULT(S)

c-fos protein was predominantly located in the nuclei of glandular epithelial cells and stromal cells. c-fos and MMP-9 protein levels in paired eutopic and ectopic endometria from women with endometriosis were significantly higher than those in the endometrium from women without endometriosis. No significant difference in c-fos or MMP-9 protein levels was observed between paired eutopic and ectopic endometria. c-fos protein levels in endometrium positively correlated with endometrial MMP-9 levels and serum 17beta-E(2) levels.

CONCLUSION(S)

Expression of c-fos in the human endometrium may be regulated by 17beta-E(2), and c-fos may be involved in development of endometriosis by promoting MMP-9 gene expression and subsequently the invasive potential of endometrial explants.

[Bladder endometriosis and barrenness: diagnostic and treatment strategy]

Deep infiltrating endometriosis is a well-known female disease responsible for chronic pelvic pain, urinary dysfunction, infertility, and altered quality of life. Endometriosis and infertility are complex entities and the optimal choice of management of both of them remains obscure. Mechanism of development of the disease has to be understood to optimize patients care. The link between barrenness and endometriosis is well known, but there is no direct link between bladder lesion and infertility. Bladder endometriosis is a deeply infiltrating endometriosis lesion. Its management is first diagnostic and then remedial. In case of ineffectiveness of medical strategy, surgical treatment is indicated. However, for patient suffering from symptomatic isolated bladder endometriosis, surgical management can be offered in first intention. Isolated bladder injuries due to endometriosis are mostly treated by conservative laparoscopic surgery, after a complete evaluation of endometriosis disease and barrenness by clinical exam and imaging techniques.

Anti-TNF-alpha treatment for deep endometriosis-associated pain: a randomized placebo-controlled trial

BACKGROUND

Endometriosis is associated with an inflammatory response. Hence infliximab, an anti-TNF-alpha monoclonal antibody, might relieve pain.

METHODS

A randomized placebo-controlled trial was designed with 21 women with severe pain and a rectovaginal nodule of at least 1 cm. After 1 month of observation, three infusions of infliximab (5 mg/kg) or placebo were given. Surgery was performed 3 months later and follow-up continued for 6 months. The primary end-point was pain (dysmenorrhea, deep dyspareunia and non-menstrual pain) rated at each visit by the clinician and on a daily basis by the patient who in addition scored pain by visual analog pain scale and analgesia intake. Secondary end-points included the volume of the endometriotic nodule, pelvic tenderness and the visual appearance of endometriotic lesions at laparoscopy.

RESULTS

Pain severity decreased during the treatment by 30% in both the placebo (P < 0.001) and infliximab groups (P < 0.001). However, no effect of infliximab was observed for any of the outcome measures. After surgery, pain scores decreased in both groups to less than 20% of the initial value.

CONCLUSIONS

Infliximab appears not to affect pain associated with deep endometriosis. Treatment is associated with an important placebo effect. After surgery, pain decreases to less than 20%. Trials registration number ClinicalTrials.gov: NCT00604864.

Use of a progestogen only preparation containing desogestrel in the treatment of recurrent pelvic pain after conservative surgery for endometriosis

OBJECTIVE

To assess the effect of a new progestin progestogen only pill (desogestrel) versus an oral contraceptive in the treatment of recurrent endometriosis.

STUDY DESIGN

A randomized prospective clinical study. A group of women with endometriosis (n=40) who showed recurrent dysmenorrhea and/or pelvic pain after conservative surgery, and did not desire a pregnancy. Continuous treatment for 6 months with desogestrel (75 microg/d) (n=20) versus a combined oral contraceptive (ethinyl estradiol 20 microg plus desogestrel 150 microg) (n=20) was performed.

RESULTS

A significant improvement of both pelvic pain and dysmenorrhea was observed following each type of treatment (P<0.001). The use of desogestrel progestogen only pill was associated with a breakthrough bleeding in 20% patients, while a significant body weight increase was observed in 15% after oral contraceptive.

CONCLUSIONS

Both desogestrel and an oral estro-progestinic were effective, safe and low cost therapy of pain symptoms after endoscopic surgery for endometriosis, the former showing an impact on breakthrough bleeding, the later an incidence on body weight increase.

Suppression of IL-1β-induced COX-2 expression by trichostatin A (TSA) in human endometrial stromal cells

OBJECTIVE

Over-production of cyclooxygenase-2 (COX-2) plays an important role in the positive feedback loop that leads to proliferation and inflammation in endometriosis. Following our observation that histone deacetylase inhibitors (HDACIs) trichostatin A (TSA) and valproic acid (VPA) can suppress proliferation of endometrial stromal cells, we sought to determine whether TSA suppresses IL-1beta-induced COX-2 expression in endometrial stromal cells.

STUDY DESIGN

In vitro study using a recently established immortalized endometrial stromal cell line. The stromal cells were pretreated with TSA before stimulation with IL-1beta, and COX-2 gene and protein expression was measured by real-time quantitative RT-PCR and Western blot analysis, respectively.

RESULTS

IL-1beta stimulated COX-2 expression in a concentration-dependent manner in endometrial stromal cells. The induced COX-2 gene and protein expression were suppressed by TSA pretreatment.

CONCLUSIONS

TSA suppresses IL-1beta-induced COX-2 gene and protein expression in endometrial stromal cells. This finding, coupled with the findings that TSA and another HDACI, valproic acid, suppress proliferation and induce cell cycle arrest, suggests that HDACIs are a promising class of compound that has therapeutic potential for endometriosis.

Long-term use of progestogens--effects on endometriosis, adenomyosis and myomas

Oral progestins, without an estrogen component, have been reported to be effective in the treatment of endometriosis, but not adenomyosis or myomas. The mode of action on the target tissue is still a matter of debate. Besides the importance of estrogens for the development and growth of endometriosis and myomas, progesterone seems to play an important role in the modulation of mitotic activity, local growth factors and growth factor receptors, as well as other paracrine mechanisms. Earlier studies postulated activities via steroid receptor mechanisms, as observed in the uterine mucosa and myometrium. Recent studies, however, have raised some doubts about this hypothesis. Effective new therapies for endometriosis have been introduced during the last 30 years and progestins now have a place in the symptomatic management of pain, bleeding and other symptoms caused by endometriosis, adenomyosis or myoma, particularly when long-term medication is indicated or when repeated courses of treatment are acceptable.

La contraception des adolescentes en France en 2007

The two main objectives of adolescence contraception are the eviction of involuntary pregnancies and the prevention of sexually transmitted infections. In France, in spite of our rich contraceptive arsenal and a widely spread information, the rate of voluntary termination of pregnancy keeps growing among the teenagers population--and this, probably because the gap between theoretical effectiveness and practice of contraception is particularly wide among the young people. Every contraceptive means can be used by teenagers; the best option being, it seems, the "double DUTCH", which consists of concomitant use of condoms and hormonal contraception. Most often, the consultation for contraception is the first gynaecological consultation. That is the reason why it is usually stressful for teenagers who dread undergoing a gynaecological examination. If this examination is not necessary for most of young patients, it is essential to create a trustful relationship and to make explicit the several contraceptive methods. During this consultation it is interesting to look for common teenage troubles like addiction to smoking and eating disorders. For any prescription of hormonal contraception, it is important to explain the benefits and the possible side effects, to stress the observance and to tell the teenager about the recommendations in case of forgetting. Concerning condom - the only efficient way of preventing sexually transmitted infections--, it is useful to talk about it in concrete and straightforward terms, to show its handling and to inform about risks of tearing. With this state of mind, an emergency contraception can be prescribed straightaway in order to make its use easier. Also, without any moralizing speech, the need for maturity must be emphasized as well as taking care of one's body with the aim of avoiding a premature pregnancy or any sexually transmitted infection. This consultation must be coupled with a close follow-up, availability and mutual confidence which are the main elements vouching for a good observance and consequently an efficient contraception.

Konservative Therapie der Endometriose

Endometriosis is the second most frequent benign disease of the female of reproductive age. In spite of extensive research, the etiology of this disease is still largely enigmatic. A causal therapy has not been found yet. Several drug therapy approaches are available but none offers a permanent cure of endometriosis. In addition, the range of side effects of the particular drug therapies has to be considered individually. The treatment of patients with endometriosis cannot be standardized but has to differentiate the individual factors and life circumstances of the patients.

Evolution of medical treatment for endometriosis: back to the roots?

Experimental evidence is accumulating to suggest that medicinal botanicals have anti-inflammatory and pain-alleviating properties and hold promise for treatment of endometriosis. Herein, we present a systematic review of clinical and experimental data on the use of medicinal herbs in the treatment of endometriosis. Although there is a general lack of evidence from clinical studies on the potential efficacy of medicinal herbs for the treatment of endometriosis-associated symptoms, our review highlights the anti-inflammatory and pain-alleviating mechanisms of action of herbal remedies. Medicinal herbs and their active components exhibit cytokine-suppressive, COX-2-inhibiting, antioxidant, sedative and pain-alleviating properties. Each of these mechanisms of action would be predicted to have salutary effects in endometriosis. Better understanding of the mechanisms of action, toxicity and herb-herb and herb-drug interactions permits the optimization of design and execution of complementary alternative medicine trials for endometriosis-associated pain. A potential benefit of herbal therapy is the likelihood of synergistic interactions within individual or combinations of plants. In this sense, phytotherapies may be analogous to nutraceuticals or whole food nutrition. We encourage the development of herbal analogues and establishment of special, simplified registration procedures for certain medicinal products, particularly herbal derivates with a long tradition of safe use.

Stromal cells of endometriosis fail to produce paracrine factors that induce epithelial 17beta-hydroxysteroid dehydrogenase type 2 gene and its transcriptional regulator Sp1: a mechanism for defective estradiol metabolism

OBJECTIVE

In endometrium, stromal progesterone receptors mediate production of paracrine factors, which enhance binding of the transcription factor specific protein-1 to the promoter of the gene encoding the 17beta-hydroxysteroid dehydrogenase type 2 enzyme responsible for converting biologically active estradiol to estrone in epithelium. The objective of this study is to define the cellular defect responsible for the disruption of this stromal-epithelial interaction in endometriosis.

STUDY DESIGN

We determined the effects of conditioned media generated from primary human eutopic endometrial stromal cells vs endometriotic stromal cells on Ishikawa malignant endometrial epithelial cells.

RESULTS

Conditioned media from progestin-pretreated eutopic endometrial stromal cells but not endometriotic stromal cells significantly stimulated specific protein-1 protein levels, 17beta-hydroxysteroid dehydrogenase type 2 messenger RNA levels and promoter activity, and binding activity of specific protein-1 to the 17beta-hydroxysteroid dehydrogenase type 2 promoter region in Ishikawa cells.

CONCLUSION

A stromal cell defect in endometriosis blocks formation of progesterone-dependent production of factors leading to 17beta-hydroxysteroid dehydrogenase type 2 deficiency and defective conversion of estradiol to estrone in epithelium.

Treatment of pelvic pain associated with endometriosis

Pain associated with endometriosis requires careful evaluation to exclude other potential causes and may involve a number of different mechanisms. Both medical and surgical treatments for pain related to endometriosis are effective and choice of treatment must be individualized.

Histone deacetylase inhibitors trichostatin A and valproic acid induce cell cycle arrest and p21 expression in immortalized human endometrial stromal cells

OBJECTIVE

Following our observation that histone deacetylase inhibitors (HDACIs) trichostatin A (TSA) and valproic acid (VPA) can suppress proliferation of endometrial stromal cells, we sought to determine whether TSA and VPA do so by inducing cell cycle arrest and p21 expression.

STUDY DESIGN

A recently established immortalized endometrial stromal cell line was treated with TSA, VPA, and/or all-trans retinoic acid (ATRA) and the consequent cell cycle progression was measured by flow cytometry and p21 protein expression by Western blot analysis.

RESULTS

Both TSA and VPA induced cell cycle arrest and p21 expression in a concentration-dependent manner. Treatment with ATRA alone also induced cell cycle arrest and moderate increase in p21 expression but joint treatment of ATRA and TSA/VPA did not further enhance cell cycle arrest as compared with TSA/VPA treatment alone.

CONCLUSIONS

HDACIs suppress proliferation of endometrial stromal cells through induction of cell cycle arrest and possibly also through apoptosis as well. RA also induces cell cycle arrest but it does not synergize with HDACIs in inducing cell cycle arrest. HDACIs may be promising compounds for treating endometriosis.

Induction of maternal tolerance to fetal alloantigens by RANTES production

PROBLEM

Previous studies have demonstrated a requirement for RANTES (regulated on activated normal T-cell expressed, and secreted) at immune privileged sites; we have investigated the role of RANTES in the induction of maternal-fetal tolerance.

METHOD OF STUDY

Endometrial and peripheral T lymphocytes were obtained from women with recurrent pregnancy losses (RPLs) and fertile women. RANTES modulation by progesterone or paternal alloantigens was measured by enzyme-linked immunosorbent assay or flow cytometry analysis.

RESULTS

Progesterone significantly increased intracellular RANTES expression in CD4+ and CD8+ endometrial T cells. Moreover, alloreactive lymphocytes from RPL patients produced lower RANTES levels when compared with those from fertile women. At the local level, treatment with recombinant RANTES induced a decrease in CCR5 and CXCR4 messenger RNA that correlated with an increase in T-bet expression. RPL patients and normally fertile women express RANTES similarly, but differ in their patterns of RANTES receptor expression.

CONCLUSION

RANTES may be implicated in the local induction of a Th1-type response necessary for successful implantation. Altered response to RANTES stimulation among some RPL patients may be responsible for poor pregnancy outcomes.

The role of progestins in treating the pain of endometriosis

Progestins, synthetic progestational agents, have been used in the management of symptomatic endometriosis both as primary therapy and as an adjunct to surgical resection. A variety of oral agents have been employed in this regard with investigators demonstrating differing degrees of benefit. Unfortunately, due to the lack of large-scale, appropriately controlled, randomized trials, or dose-ranging studies, no single agent can be demonstrated to be truly efficacious. The lack of a standardized instrument to evaluate painful symptoms makes comparative analysis more difficult. Injectable administration of long-acting depot medroxyprogesterone acetate preparations intramuscularly or subcutaneously has been investigated in three randomized trials. The lower dose subcutaneous injection holds promise with an apparent reduction in side effects. Issues of reversible bone mineral density loss, breakthrough bleeding, and return of menses have not been completely resolved. Selective progesterone receptor modulators represent an intriguing alternative. These orally administered agents have been shown in preliminary investigations to be not only efficacious in reducing symptoms but also associated with minimal side effects. Further investigation of these agents is clearly required.