A gonadotropin-releasing hormone agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis**This work was conducted within the framework of the Italian National Research Council Applied Project “Prevention and Control of Disease Factors,” subproject 5 (Fertility Control), grant no. 91.00131.PF41.115.05532, Milan, Italy.††Presented at the 48th Annual Meeting of The American Fertility Society, New Orleans, Louisiana, November 2 to 5, 1992

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.

Maintenance therapy involving a tapering dose of danazol or mid/low doses of oral contraceptive after gonadotropin-releasing hormone agonist treatment for endometriosis-associated pelvic pain

Pelvic pain associated with endometriosis was treated by the long-term administration of a tapering dose of danazol or mid/low doses of oral contraceptives after the end of therapy involving a GnRH agonist (GnRH-a). Results demonstrated that each of these three therapies is a practical and efficient treatment regimen to maintain the relief of pelvic pain achieved by GnRH-a therapy, at least for a period of 12 months.

Hormonal suppression treatment or dietary therapy versus placebo in the control of painful symptoms after conservative surgery for endometriosis stage III–IV. A randomized comparative trial

OBJECTIVE

To evaluate the effectiveness for the outcomes of endometriosis-related pain and quality of life of conservative surgery plus placebo compared with conservative surgery plus hormonal suppression treatment or dietary therapy.

DESIGN

Randomized comparative trial.

SETTING

University hospital.

PATIENT(S)

Two hundred twenty-two consecutive women who underwent conservative pelvic surgery for symptomatic endometriosis stage III-IV (r-AFS).

INTERVENTION(S)

Six months of placebo (n = 110) versus GnRH-a (tryptorelin or leuprorelin, 3.75 mg every 28 days) (n = 39) or continuous estroprogestin (ethynilestradiol, 0.03 mg plus gestoden, 0.75 mg) (n = 38) versus dietary therapy (vitamins, minerals salts, lactic ferments, fish oil) (n = 35).

MAIN OUTCOME MEASURE(S)

Painful symptoms (visual analogue scale score) and quality-of-life endometriosis-related symptoms (SF-36 score) at 12 months' follow-up.

RESULT(S)

Patients treated with postoperative hormonal suppression therapy showed less visual analogue scale scores for dysmenorrhoea than patients of the other groups. Hormonal suppression therapy and dietary supplementation were equally effective in reducing nonmenstrual pelvic pain. Surgery plus placebo showed significative decrease in dyspareunia scores. Postoperative medical and dietary therapy allowed a better quality of life than placebo.

CONCLUSION(S)

Postoperative hormonal suppression treatment or dietary therapy are more effective than surgery plus placebo to obtain relief of pain associated with endometriosis stage III-IV and improvement of quality of life.

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.

Gonadotropin hormone releasing hormone agonists alter prefrontal function during verbal encoding in young women

Gonadotropin hormone releasing hormone agonists (GnRHa) are commonly used in clinical practice to suppress gonadal hormone production in the management of various gynaecological conditions and as a treatment for advanced breast and prostate cancer. Animal and human behavioural studies suggest that GnRHa may also have significant effects on memory. However, despite the widespread use of GnRHa, the underlying brain networks and/or stages of memory processing that might be modulated by GnRHa remain poorly understood. We used event-related functional magnetic resonance imaging to examine the effect of GnRHa on verbal encoding and retrieval. Neuroimaging outcomes from 15 premenopausal healthy women were assessed at baseline and 8 weeks after Gonadotrophin Releasing Hormone analogue (GnRHa) treatment. Fifteen matched wait-listed volunteers served as the control group and were assessed at similar intervals during the late follicular phase of the menstrual cycle. GnRHa was associated with changes in brain response during memory encoding but not retrieval. Specifically, GnRHa administration led to a change in the typical pattern of prefrontal activation during successful encoding, with decreased activation in left prefrontal cortex, anterior cingulate, and medial frontal gyrus. Our study suggests that the memory difficulties reported by some women following GnRHa, and possibly at other times of acute ovarian hormone withdrawal (e.g. following surgical menopause and postpartum), may have a clear neurobiological basis; one that manifest during encoding of words and that is evident in decreased activation in prefrontal regions known to sub-serve deep processing of to-be-learned words.

WITHDRAWN: Gonadotrophin-releasing hormone analogues for pain associated with endometriosis

BACKGROUND

Endometriosis is a common gynaecological condition that frequently presents with the symptom of pain. The precise pathogenesis (mode of development) of endometriosis is unclear but it is evident that endometriosis arises by the dissemination of endometrium to ectopic sites and the subsequent establishment of deposits of ectopic endometrium. The observation that endometriosis is rarely seen in the hypo-oestrogenic (low levels of oestrogen) post-menopausal woman led to the concept of medical treatment by induction of a pseudo-menopause using Gonadotrophin Releasing Hormone Analogues (GnRHas). When administered in a non-pulsatile manner (the pituitary is normally stimulated by pulses of natural GnRH and all analogues act on the pituitary at a constant level) their use results in down regulation (switching off) of the pituitary and a hypogonadotrophic hypogonadal state (low levels of female hormones due to non stimulation of the ovary).

OBJECTIVES

To determine the effectiveness of Gonadotrophin Releasing Hormone analogues (GnRHas) in the treatment of the painful symptoms of endometriosis by comparing them with no treatment, placebo, other recognised medical treatments, and surgical interventions.

SEARCH STRATEGY

The search strategy of the Menstrual Disorders and Subfertility review group (please see Review Group details) was used to identify all randomised trials of the use of GnRHas for the treatment of the painful symptoms of endometriosis.

SELECTION CRITERIA

Trials were included if they were randomised, and considered the effectiveness of GnRHas in the treatment of the painful symptoms of endometriosis.

DATA COLLECTION AND ANALYSIS

Twenty-six studies had data appropriate for inclusion in the review. The largest group (15 studies) compared GnRHas with danazol. There are five studies comparing GnRHas with GnRHas plus add-back therapy, three comparing GnRHa with GnRHa in a different form or dose, one compares them with gestrinone, one with the combined oral contraceptive pill, and one with placebo. Data was extracted independently by two reviewers. The authors of eleven studies have been contacted to clarify missing or unclear data. Only four have replied to date. Data on relief of pain, change in revised American Fertility Society (rAFS) scores, and side effects was collected.

MAIN RESULTS

No difference was found between GnRHas and any of the other active comparators with respect to pain relief or reduction in endometriotic deposits. The side effect profiles of the different treatments were different, with danazol and gestrinone having more androgenic side effects, while GnRHas tend to produce more hypo-oestrogenic symptoms.

AUTHORS' CONCLUSIONS

There is little or no difference in the effectiveness of GnRHas in comparison with other medical treatments for endometriosis. GnRHas do appear to be an effective treatment. Differences that do exist relate to side effect profiles. Side effects of GnRHas can be ameliorated by the addition of addback therapy.

Oral contraceptives for pain associated with endometriosis

BACKGROUND

Endometriosis is a common gynaecological condition which affects many women of reproductive age worldwide and is a major cause of pain and infertility. The modern oral contraceptive pill is widely used to treat pain occurring as a result of endometriosis, although the evidence for its efficacy is limited.

OBJECTIVES

To assess the effects of the oral contraceptive pill (OCP) in comparison to other treatments for painful symptoms of endometriosis in women of reproductive age.

SEARCH STRATEGY

We searched the Menstrual Disorders and Subfertility Group Specialised Register of controlled trials; Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2006); MEDLINE (January 1966 to September 2006); EMBASE (1980 to September 2006); National Research Register; and reference lists of articles.

SELECTION CRITERIA

All truly randomised controlled trials of the use of oral contraceptive pills in the treatment of women of reproductive age with symptoms ascribed to the diagnosis of endometriosis and made visually at surgical procedure were included.

DATA COLLECTION AND ANALYSIS

Study quality assessment and data extraction were carried out independently by two review authors. One of the assessors was an expert in the content matter. We contacted study authors for additional information.

MAIN RESULTS

Only one study met the inclusion criteria, in which a total of 57 women were allocated to two groups to compare an OCP to a GnRH analogue. Methods of randomisation and allocation concealment were unclear and the study was acknowledged by its authors to be underpowered. Women in the GnRH analogue group became amenorrhoeic during the treatment period of six months, whilst women in the OCP group reported a decrease in dysmenorrhoea. No evidence of a significant difference between the two groups was observed in terms of dysmenorrhoea at six months follow up after stopping treatment (OR 0.48; 95% CI 0.08 to 2.90). Some evidence for a decrease in dyspareunia was found at the end of treatment in women in the GnRH analogue group, although no evidence of a significant difference in dyspareunia was observed at the end of the six months follow up (OR 4.87; 95% CI 0.96 to 24.65).

AUTHORS' CONCLUSIONS

The limited data we found available suggests that this is no evidence of a difference in outcomes between the the oral contraceptive pill (OCP) studied and GnRH analogue was as effective as a GnRH analogue in treating for endometriosis-associated painful symptoms of endometriosis. However, the lack of studies with larger sample sizes, or focusing on other comparable treatments is concerning and further research is needed to fully evaluate fully the role of OCPs oral contraceptive pills in managing symptoms associated with ement of endometriosis.

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.

Noninvasive assessment of ectopic uterine tissue development in rats using magnetic resonance imaging

OBJECTIVE

To non-invasively characterize ectopic uterine tissue (EUT) development in a modified autologous rat surgical model of endometriosis using magnetic resonance imaging (MRI).

DESIGN

Investigational MRI study.

SETTING

A pharmaceutical company.

ANIMAL(S)

Female Sprague Dawley rats.

INTERVENTION(S)

Uterine tissue was autotransplanted on the right peritoneal wall of rats. Rats were serially imaged after surgery and after endogenous hormone suppression, hormone supplementation, or ovariectomy. In addition, an MRI contrast agent was administered to examine EUT perfusion characteristics.

MAIN OUTCOME MEASURE(S)

Changes in transplanted EUT volume and perfusion were monitored using MRI.

RESULT(S)

The EUT growth could be readily monitored non-invasively by MRI. Although EUT growth was rapid during the initial 4 days after surgery, volume stabilized by the third week and maintained for at least 9 weeks after transplantation. The EUT volumes varied with the estrous cycle and were hormonally sensitive to ovariectomy, to Antide (GnRH antagonist), and to Antide followed by 17beta-E(2) supplementation. The use of an MRI contrast agent facilitated visualization of EUT wall perfusion.

CONCLUSION(S)

MRI allows for noninvasive, dynamic evaluation of transplanted EUT growth in the rat. This reproducible model will allow for performing quantifiable pharmacologic studies in pre-clinical drug discovery for therapies targeting endometriosis.

Management of the pain associated with endometriosis: an update of the painful problems

Endometriosis is a condition characterized by ectopic endometrial tissues located outside of the uterus, most commonly found on the pelvic peritoneum or ovary. Endometriosis, which occurs in 7-10% of women in the general population and 71-87% of women with chronic pelvic pain, is associated with dysmenorrhea, chronic pelvic pain, and infertility. There is considerable debate about the effectiveness of various interventions for endometriosis. This review discusses the benefits and drawbacks of pharmacologic and surgical treatments for the pain associated with endometriosis. Laparoscopic surgery has been demonstrated to relieve the pain associated with endometriosis. Hormonal therapies, such as gonadotropin-releasing hormone (GnRH) analogues or the weak androgen danazol, have also been effective at relieving the pain associated with endometriosis. Oral contraceptives appear to be as effective as GnRH analogues for pain relief. Although both surgical and pharmacologic treatments have been effective for relief of the pain associated with endometriosis, the recurrence rate remains significant. The management of pain associated with endometriosis has thus not been satisfied. Larger unified clinical trials are needed to evaluate the effectiveness of new treatments in managing the pain associated with endometriosis.

Aromatase inhibitors: the next generation of therapeutics for endometriosis?

OBJECTIVE AND DESIGN

To review the role of aromatase inhibitors (AIs) in the treatment of endometriosis.

CONCLUSION(S)

Endometriosis is a common estrogen-dependent disorder that can result in substantial morbidity, including pelvic pain, multiple operations, and infertility. Approximately only half of women with endometriosis get pain relief from existing medical or surgical treatments. Medical treatments usually are directed at inhibiting estrogen action or its production from the ovaries and do not address local estrogen biosynthesis by the aromatase enzyme in endometriotic lesions. A single gene encodes aromatase, which is the final enzyme in the estrogen biosynthesis pathway, and its inhibition effectively eliminates estrogen production. The recently introduced highly specific AIs have successfully treated pelvic pain and significantly reduced the lesion size. In premenopausal women, an AI alone may induce ovarian folliculogenesis, and thus AIs are combined with a progestin, a combination oral contraceptive, or a GnRH analogue. The side-effect profile of AIs administered in combination with an oral contraceptive or a progestin is remarkably benign. We review herein the published clinical evidence for the use of AIs in the treatment of endometriosis.

Medical management of endometriosis

Current approved medical therapies for endometriosis rely on drugs that suppress ovarian steroids and induce a hypoestrogenic state, which determines the atrophy of the ectopic endometrium. Gonadotropin-releasing hormone analogs such as danazol, progestogens and estrogen-progestin combinations have all proven effective in relieving pain and reducing the extent of endometriotic implants. However, symptoms often recur after discontinuation of therapy and hypoestrogenism-related side effects limit the long-term use of most medications. Recently, knowledge of the pathogenesis of endometriosis, particularly at the molecular level, has grown substantially, providing a rational basis for the development of new drugs with precise targets that may be safely administered over the long term.

High-dose pilot study with the novel progestogen dienogestin patients with endometriosis

High-dose dienogest (20 mg/day) was used for the treatment of endometriosis in women aged 18-52 years after laparoscopic and histological diagnosis of endometriosis and staging according to the revised American Fertility Society criteria. Treatment efficacy was analyzed objectively by second-look laparoscopy, and serum hormone measurements and evaluation of endometriosis-related symptoms were performed done and side-effects recorded. Compared with other high-dose progestin therapies, treatment with dienogest was shown to be effective even in stage IV endometriosis. The side-effect profile of the high-dose dienogest treatment appears to be highly favorable compared with other treatments. Neither the menopausal symptoms caused by therapy with gonadotropin-releasing hormone agonists nor the adverse androgen-related effects induced by danazol were observed. Therefore, long-term high-dose dienogest therapy can be recommended particularly for women with progressive endometriosis.

Effect on insulin sensitivity of Implanon vs. GnRH agonist in women with endometriosis

OBJECTIVES

To evaluate the influence of two medical treatments for endometriosis on insulin sensitivity.

STUDY DESIGN

After surgery, 26 women with endometriosis were randomly allocated to a 6-month treatment with a GnRH agonist (Leuprorelin 3.75 mg/28 days) or a subdermal progestin implant (etonogestrel 68 mg). Insulin sensitivity (SI) and glucose utilization independent of insulin (Sg) were investigated at baseline and after 6 months by a frequently sampled intravenous glucose tolerance test (FSIGT) associated with the minimal model method.

RESULTS

Both therapies tended to decrease SI, but the effect did not reach statistical significance in the GnRH agonist group (5.43+/-1.29 vs. 3.99+/-0.8) and was significant in the etonogestrel group (5.74+/-1.12 vs. 3.95+/-0,78; p=.046). Sg, fasting glucose, insulin, C-peptide and C-peptide/insulin were not modified by either treatment.

CONCLUSIONS

The modifications of glucose-insulin metabolism induced by the GnRH agonist are of no relevance for the short-term use of this molecule. Even if the modification induced by the etonogestrel implant is subtle and of no major impact, it should be taken into consideration for the long-term treatment of individuals with abnormalities of glucose-insulin metabolism.

Advances in the management of endometriosis: an update for clinicians

Endometriosis is a chronic and recurrent disease characterized by the presence and proliferation of endometrial tissue outside the uterine cavity, which occurs in approximately 10% of women of reproductive age. In this estrogen-dependent disorder, lesions become inactive and gradually undergo regression during states of ovarian down-regulation, such as amenorrhoea or menopause. The impact of endometriosis includes impaired fertility potential, as well as symptoms of dysmenorrhoea, dyspareunia and chronic non-menstrual pain, all of which adversely affect quality of life. Management of endometriosis focuses on pain relief and includes medical and surgical treatment. Pharmacologic therapies currently in use include combination oral contraceptives (COCs), danazol, GnRH analogues and progestins. Although some agents show efficacy in relieving pain, all differ in their side effects, making it difficult to achieve a balance between efficacy and safety. Efficacy has been demonstrated with danazol or GnRH analogues; however, treatment is limited to 6 months because of significant metabolic side effects. Alternatives for longer-term management of symptoms include add-back therapy with GnRH analogues, COCs or progestins. Newer options for treatment of endometriosis include depot medroxyprogesterone acetate subcutaneous injection, as well as several agents under investigation that may prove to have therapeutic potential.

Optimizing gonadotropin-releasing hormone agonist therapy in women with endometriosis

Endometriosis is a highly prevalent disease among women of reproductive age. While many treatments are available, one of the most widely utilized is treatment with gonadotropin-releasing hormone (GnRH) agonists. These agents work by producing a profound suppression of gonadotropin secretion by the pituitary, resulting in a hypoestrogenic state and subsequent diminution of endometriosis lesions. The GnRH agonists on the market have been shown to work quite well in reducing all pain symptoms associated with endometriosis, including dysmenorrhea, dyspareunia, and noncyclic pelvic pain. However, there is no evidence to suggest that this treatment is of value in endometriosis-associated infertility. Conflicting data exist regarding the role of GnRH agonists in the treatment of endometriomas, but the bulk of the evidence suggests a low degree of efficacy. GnRH agonists are often initiated with the onset of menses, but a more rapid response is observed with mid-luteal administration. A limit of 6 months per treatment course is required due to loss of bone mineral density during therapy, but this can be extended via the addition of 'add-back' therapy. Such adjunctive regimens demonstrated to maintain efficacy and reduce adverse effects include progestogen alone or a low-dose combination of estrogen and progestogen. Retreatment with these drugs is supported by limited data. The use of GnRH agonists as surgical adjuncts has been studied by several investigators. Their use preoperatively has not been shown to be of value. Similarly, 3 months of postoperative administration has failed to enhance treatment. However, 6 months of postoperative GnRH agonists appear to improve the duration of relief of pain symptoms. Future studies will need to focus on the role of these agents when used for repeated courses, in young women, and in conjunction with assisted reproduction.

Peroxisome proliferator-activated receptor-gamma induces regression of endometrial explants in a rat model of endometriosis

OBJECTIVE

To determine the effects of a thiazolidinedione, ciglitazone, in a rat model of endometriosis.

DESIGN

Prospective, randomized, placebo-controlled study.

SETTING

Experimental surgery laboratory in a university department.

ANIMAL(S)

Twenty female Sprague-Dawley rats given endometriotic lesions by transplanting autologous uterine tissue to ectopic sites on the peritoneum.

INTERVENTION(S)

Four weeks after surgery, 20 rats were randomly divided into two groups and treated with IP injections of vehicle every other day (control; n = 10) or ciglitazone (1 mg per rat; n = 10) and euthanized 4 weeks from the start of treatment.

MAIN OUTCOME MEASURE(S)

At the end of treatment, laparotomy was performed to photograph each explant and then they were measured and weighed. Histologic analysis was performed on the uterine allograft, ovary, and eutopic uterine tissue.

RESULT(S)

By histologic assessment, both groups maintained folliculogenesis and normal eutopic endometrial architecture. Treatment with ciglitazone significantly decreased the size of ectopic uterine tissues and the mean explant wet weight. The ciglitazone-treated group showed marked epithelial regression compared with the control group.

CONCLUSION(S)

We conclude that a PPAR-gamma ligand, ciglitazone, reduced the size of experimental endometriosis in the rat model of endometriosis. This animal model suggests that a thiazolidinedione drug may be helpful in women with endometriosis.

Current practice for the laparoscopic diagnosis and treatment of endometriosis: a national questionnaire survey of consultant gynaecologists in UK

OBJECTIVE

To determine current practice regarding laparoscopic diagnosis and treatment of endometriosis.

DESIGN

A prospective questionnaire survey.

SETTING

The United Kingdom.

POPULATION

All 1411 UK consultant gynaecologists identified from a Royal College of Obstetricians and Gynaecologists database.

METHODS

A postal questionnaire was sent to all consultants with reply paid envelopes. A postal reminder was sent three months following the initial questionnaire.

MAIN OUTCOME MEASURE

Current practice for the laparoscopic diagnosis and treatment of endometriosis and willingness to participate in a randomised trial.

RESULTS

The response rate was 66% (893/1411). Diagnostic laparoscopy was performed by 87% (772/893) of respondents. Seventy-six percent of these (58/772) were confident to visually diagnose endometriosis and 6% (47/772) routinely verified the diagnosis histologically. Laparoscopic surgery was routinely undertaken by 41% (318/772) of respondents. Ablative therapy was the most frequently employed technique utilised [620/653 (95%)] and electrodiathermy was the most popular energy modality (80%). Among respondents expressing a preference, excision of disease was believed to be more effective, but less safe compared with ablation. One-third of respondents (273/893) were willing to enter patients into a randomised controlled trial to compare laparoscopic treatments for pelvic pain associated with endometriosis.

CONCLUSION

Laparoscopic surgery for endometriosis associated with pelvic pain is routinely undertaken by a large number of UK consultant gynaecologists, but techniques used and beliefs about efficacy vary. In view of this division of opinion regarding the relative roles of laparoscopic treatment methods, a randomised trial comparing the efficacy and safety of these methods is urgently needed.

Pain in endometriosis: effectiveness of medical and surgical management

PURPOSE OF REVIEW

Endometriosis is a common cause of chronic pelvic pain and has a detrimental effect on the quality of life for women affected with the condition. It is also clear that early diagnosis with prompt effective management does not always occur. This review will discuss the medical and surgical treatment options and support conclusions with randomized double blind placebo-controlled studies where possible.

RECENT FINDINGS

Assessment of the pelvic pain associated with endometriosis can be categorized according to its relation to the menstrual cycle. Dysmenorrhoea and ovulatory pain occur with cyclical changes, as compared with chronic non-cyclic pain and deep dyspareunia. Dyskesia and urinary pain may have a relation to the menstrual cycle. The severity of pain symptoms, as well as the effect on the woman's quality of life, should be quantified. The preoperative symptoms can be compared with the operative findings and the stage of endometriosis according to the revised American Fertility Score.

SUMMARY

Review of the current literature demonstrates that a combined medical and conservative surgical approach is beneficial for most women with endometriosis associated pelvic pain.

Endometriosis: Treatment Strategies

Endometriosis is often a perplexing medical condition for both the physician and the patient. Accordingly, development of treatment strategies based on the needs of the individual patient is highly desirable. Although endometriosis has been part of the clinical practice for almost a century, many questions remain relating to the relationship between endometriosis and infertility as well as endometriosis and pelvic pain. Endometriosis is a disease of reproductive-age women, and it is now well recognized that a genetic susceptibility appears probable. The prevalence in the general population has never been clearly established. Factors to consider in management include the age and reproductive desires of the patient, the stage of the disease, and, most importantly, the symptoms. Therapeutic options include no treatment, medical therapy, surgery, or combination therapy. Oral contraceptives, androgenic agents, progestins, and gonadotropin releasing hormone (GnRH) analogs have all been used successfully, although at the present time, the latter preparations are the most popular medical therapy for endometriosis. Leuprolide acetate, goserelin acetate, and nafarelin acetate are all effective agents. Surgical therapy is appropriate, especially for advanced stages of the disease. Laparoscopy is an effective surgical approach with the goal of excision of visible endometriosis in a hemostatic fashion. Since endometriosis is a chronic condition, it is not uncommon for recurrences to occur. While endometriosis remains an enigmatic disease, the introduction of new pharmacologic agents, such as GnRH analogs and newer endoscopic methods of surgical treatment, have facilitated and improved the overall management of this disease.

Continuous use of an oral contraceptive for endometriosis-associated recurrent dysmenorrhea that does not respond to a cyclic pill regimen

OBJECTIVE

To ascertain whether long-term reduction of pain is obtained by continuous administration of an oral contraceptive (OC) in women with endometriosis-associated recurrent dysmenorrhea that does not respond to cyclic OC use.

DESIGN

Prospective, therapeutic, self-controlled clinical trial.

SETTING

A tertiary care and referral center for patients with endometriosis.

PATIENT(S)

Fifty women who underwent surgery for endometriosis in the previous year and experienced recurrent dysmenorrhea despite cyclic OC use.

INTERVENTION(S)

Continuous use of an OC containing ethinyl estradiol (0.02 mg) and desogestrel (0.15 mg) for 2 years.

MAIN OUTCOME MEASURE(S)

Dysmenorrhea variation during cyclic and continuous OC use, evaluated with a 100-mm visual analog scale and a 0- to 3-point verbal rating scale, and degree of satisfaction with continuous OC treatment.

RESULT(S)

In the study period, amenorrhea, spotting, and breakthrough bleeding were reported by 19 (38%), 18 (36%), and 13 (26%) women. The mean +/- SD number of >7-day bleeding episodes with consequent 7-day OC suspension was 5.5 +/- 2.1. The mean +/- SD dysmenorrhea visual analog scale and verbal rating scale scores were 75 +/- 13 and 2.4 +/- 0.5 at baseline and 31 +/- 17 and 0.7 +/- 0.6 at 2-year follow-up, respectively. Moderate or severe side effects were reported by 7/50 (14%) women. At final evaluation, 13 (26%) women were very satisfied, 27 (54%) were satisfied, 1 (2%) was uncertain, 8 (16%) were dissatisfied, and 1 (2%) was very dissatisfied.

CONCLUSION(S)

Long-term continuous OC use can be proposed to women with symptomatic endometriosis and menstruation-related pain symptoms.

The efficacy of non-contraceptive uses for hormonal contraceptives

In addition to providing safe and effective contraception, both the combined oral contraceptive pill (COCP) and selected long-acting progestogen-only contraceptives have significant health benefits. The COCP may reduce menstrual blood loss, dysmenorrhoea and premenstrual syndrome; unequivocally reduces the later incidence of endometrial and ovarian cancer; appears to help protect future fertility, probably by reducing the risk of acute pelvic inflammatory disease, endometriosis and uterine fibroids. The quality of evidence for individual non-contraceptive health benefits of the COCP is very variable.

Adolescent endometriosis

Endometriosis is a cause of chronic, pelvic pain in adolescents. Lack of response to NSAIDS and OCPs should prompt further investigation and subsequent treatment. The goal of therapy is to minimize pelvic pain and dysmenorrhea primarily through long-term, medical therapy. Surgical intervention is principally indicated to establish a diagnosis. The poor response to surgical therapy negates the need for repetitive or radical surgery. Much patience and care should be directed toward these patients to provide them with an understanding of their disease and to help enhance the quality of their life.

Future directions in endometriosis research

Future research in endometriosis must focus on pathogenesis studies in the baboon model, the early interactions between endometrial and peritoneal cells in the pelvic cavity at the time of menstruation, and potential differences between eutopic endometrium and myometrium in women with and without endometriosis. More integration is needed between the areas of epidemiology and genetics. Pelvic inflammation in women with endometriosis could be the target for new diagnostic and therapeutic approaches. Important questions remain regarding the relationship between endometriosis and environmental factors. Systemic and extrapelvic manifestations of endometriosis must be analyzed carefully, and better tools are needed to measure quality of life in women with chronic pain caused by endometriosis. Most current evidence supports a causal relationship between endometriosis and subfertility, and the spontaneous progressive nature of endometriosis has been demonstrated in 30% to 60% of patients. Recurrence of endometriosis after classic medical and surgical therapy is a major and underestimated problem, especially in women with advanced disease. Integrated clinical and research teams are needed that combine expert medical, surgical, and holistic care with state-of-the-art research expertise in immunology, endocrinology, and genetics to discover new diagnostic methods and medical treatments for endometriosis.

Medical management of endometriosis-associated pain

In the coming years, basic science research into the mechanisms of endometriosis development and persistence almost certainly will open new avenues for treatment. A wide armamentarium of medical therapies already exists, however. The efficacy of most of these methods in reducing endometriosis-associated pain is well established. The choice of which to use depends largely on patient preference after an appropriate discussion of risks, side effects, and cost. Typically, oral contraceptives and NSAIDs are first-line therapy because of their low cost and mild side effects (Box 6). Because of its greater potential for suppressing endometrial development, consideration should be given to prescribing a low-dose monophasic oral contraceptive continuously. If adequate relief is not obtained or if side effects prove intolerable, consideration should be given to the use of progestins (oral, intramuscular, or IUD) or a GnRH agonist with immediate add-back therapy. Progestins are less expensive, but GnRH agonists with add-back may be better tolerated. If none of these medications proves beneficial or if side effects are too pronounced, then repeat surgery is warranted. The surgery may have analgesic value and serves to reconfirm the diagnosis. Finally, if endometriosis is identified at the time of surgery, then consideration should be given to prescribing medical therapy postoperatively.

Consensus statement for the management of chronic pelvic pain and endometriosis: proceedings of an expert-panel consensus process

OBJECTIVE

To develop recommendations for the medical and surgical care of women who present with chronic pelvic pain (CPP) and are likely to have endometriosis as the underlying cause.

DESIGN

An expert panel comprised of practicing gynecologists from throughout the United States and experts in consensus guideline development was convened. After completion of a structured literature search and creation of draft algorithms by an executive committee, the expert panel of >50 practicing gynecologists met for a 2-day consensus conference during which the clinical recommendations and algorithms were reviewed, refined, and then ratified by unanimous or near-unanimous votes.

PATIENT(S)

Women presenting with CPP who are likely to have endometriosis as the underlying cause.

MAIN OUTCOME MEASURE(S)

None.

CONCLUSION(S)

Chronic pelvic pain frequently occurs secondary to nongynecologic conditions that must be considered in the evaluation of affected women. For women in whom endometriosis is the suspected cause of the pain, laparoscopic confirmation of the diagnosis is unnecessary, and a trial of medical therapy, including second-line therapies such as danazol, GnRH agonists, and progestins, is justified provided that there are no other indications for surgery such as the presence of a suspicious adnexal mass. When surgery is necessary, laparoscopic approaches seem to offer comparable clinical outcomes to those performed via laparotomy, but with reduced morbidity. The balance of evidence supports the use of adjuvant postoperative medical therapy after conservative surgery for CPP. There is some evidence that adjuvant presacral neurectomy adds benefit for midline pain, but currently, there is inadequate evidence to support the use of uterosacral nerve ablation or uterine suspension. Hysterectomy alone has undocumented value in the surgical management of women with endometriosis-associated CPP.

Diagnosis and management of chronic pelvic pain

Chronic pelvic pain is difficult to diagnose and to treat [81] because of the multiple and often overlapping causes [82]. A systematic approach aids in the thorough evaluation and appropriate therapy. At the initial visit(s), a thorough history should be taken and complete physical examination performed. Screening for co-existing conditions, such as depression, narcotic dependency, and physical, sexual, or emotional abuse is crucial so these issues may be addressed immediately while additional causes for pelvic pain are evaluated. The relative likelihood of gastrointestinal, urologic, musculoskeletal, or gynecologic etiology must be considered to guide a more thorough initial evaluation. With gynecologic chronic pelvic pain, differentiation between hormonally responsive and nonresponsive conditions is helpful for diagnosis and treatment. Therapy can then be instituted or an appropriate referral made.

Endometriosis: current concepts and therapy

Endometriosis is the growth of endometrial tissue in ectopic locations. The clinical picture is extremely pleiomorphic, which can make the diagnosis difficult. Despite 70 years of theories and experimentation, the cause is not clear, and it is likely that more than one mechanism is at work in most patients. Both medical and surgical treatments are available. In each case, the woman and her physician should formulate a comprehensive treatment plan that addresses the primary complaint as well as the patient's reproductive desires.

Oral contraceptives suppress cell proliferation and enhance apoptosis of eutopic endometrial tissue from patients with endometriosis

OBJECTIVE

To evaluate the effects of administering combination oral contraceptives (COCs) to patients with endometriosis on the regulation of cell growth in the eutopic endometrium.

DESIGN

Prospective study.

SETTING

Research institute and clinical fertility center.

PATIENT(S)

Thirteen women with untreated endometriosis and 13 controls.

INTERVENTION(S)

Biopsy specimens of the eutopic endometrium were obtained from all subjects. Apoptosis, cell proliferation, and Bcl-2 and Bax expression were examined at the epithelial and stromal levels in the eutopic endometrium from patients with endometriosis before and after 30 days of daily exposure to COCs and from controls.

MAIN OUTCOME MEASURE(S)

Apoptotic cells were detected by using the dUTP nick-end labeling assay; Ki-67, Bcl-2, and Bax expressions were assessed by using immunohistochemical techniques.

RESULT(S)

After exposure to COCs, apoptosis was significantly increased in the eutopic endometrium compared with before COC administration, both at epithelial and stromal levels. Cell proliferation was significantly lowered by COCs.

CONCLUSION(S)

COCs showed a positive effect on patients with endometriosis by down-regulating cell proliferation and enhancing apoptosis in the eutopic endometrium.

Disruptions of social relationships accentuate the association between emotional distress and menstrual pain in young women

This study examined the effects of social support on dysmenorrhea and whether social support moderates the relationship between negative emotions and painful symptoms. Women (N = 184) completed questionnaires on menstrual symptoms, depression, anxiety, and social networks. Depression and anxiety were strongly associated with menstrual pain. Women who no longer had access to their prior support providers manifested more symptoms than did women with stable social relations. In addition, this disruption in their social networks moderated the relationship between distress and menstrual pain. Results indicate that loss of social support is a significant contributor to menstrual symptoms and point to the importance of considering specific aspects of social support in studying its effect on health.

Endometriosis: aetiology, pathogenesis and treatment

Endometriosis, which may be defined as the presence and proliferation of endometrial tissue outside the uterine cavity, causes pain and infertility for millions of women worldwide. Studies suggest a prevalence of 0.5 to 5% in fertile and 25 to 40% in infertile women. The most widely accepted aetiological theory is that retrograde flow of menstrual fluid through the Fallopian tubes deposits viable endometrial tissue, which implants on the peritoneal surface. Increasingly, the aetiology of endometriosis is being studied at the immunological and genetic levels. The aim of treatment of endometriosis is to remove or diminish disease deposits. This may be attempted through medical or surgical means. It has long been recognised that endometriotic glands are hormonally sensitive. Medical therapies work by inducing a hypoestrogenic, anovulatory state to induce atrophy within the glandular tissue. Conception is generally not possible during medical therapy and has not been demonstrated to increase afterwards. Medical treatment of endometriosis should be discouraged when infertility is the primary problem. In this situation surgery or an assisted reproduction treatment such as in vitro fertilisation may be more appropriate. Medical treatment of pain caused by endometriosis is generally effective. There is little difference in efficacy between the different medications but their adverse effect profiles differ greatly. It appears that gonadotropin-releasing hormone agonists, particularly when used with add-back estrogen, may be more acceptable to women than other treatments. Laparoscopic surgical treatment of minimal and mild endometriosis has been demonstrated to increase fecundity. Surgical treatment has also been shown to decrease pain scores compared with expectant management. Ongoing and future research examining the aetiology of endometriosis at the immunological and genetic levels should usher in new treatments directed at the actual cause of the disease. More randomised trials examining the role of surgery, and comparing surgical and medical treatments, are also required and are necessary if we are to continue in our attempts to adopt an evidence-based approach to treatment.

The treatment of endometriosis: a review of the evidence

The treatment of endometriosis focuses upon amelioration of two symptoms: pain and infertility. The treatment of endometriosis-associated pain has been well studied and all major medical therapies appear to be superior to placebo. In addition, none seems to be drastically better than another. Surgical therapy also appears to be efficacious, albeit with a relatively high rate of recurrence of symptoms following conservative surgical intervention. There are no trials comparing the relative value of medical versus surgical therapy. Combination surgery/medical therapy has several high-quality trials for evaluation, but its value remains unclear. The treatment of endometriosis-associated infertility presents a different picture: medical therapy has not been shown to be of any value and may prove detrimental to fertility. Surgical treatment does improve fertility, probably for all stages of disease. Assisted reproduction also seems to be efficacious, with both controlled ovarian hyperstimulation and intrauterine insemination as well as in vitro fertilization shown to be of benefit. Finally, the combination of in vitro fertilization and either medical or surgical therapy may be beneficial with advanced endometriosis, but further study is required.

Conventional medical therapies for endometriosis

Endometriosis is a common gynecologic disorder that affects approximately 14% of all women and 30% to 50% of infertile women. Since the most common symptoms of endometriosis--progressive dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility--are also symptoms of multiple disorders, a diagnosis of endometriosis can be elusive and confirmed only by visualization, that is, laparoscopy. Endometriosis is often treated surgically upon diagnosis; however, the rate of recurrence is high, suggesting that a combination of therapeutic approaches might provide better outcomes than any one option alone. The most widely utilized hormonal treatments for endometriosis are GnRH agonists and oral contraceptives; agents indicated by the Food and Drug Administration include GnRH agonists and the androgen, danazol. The majority of evidence in support of medical therapy for endometriosis is largely observational, with the exception of studies of GnRH agonists, danazol, and a few progestins. Conventional treatment approaches for the medical management of endometriosis focus on suspected endometriosis, following a diagnosis of endometriosis, following surgical treatment of endometriosis, long-term management, and retreatment. Although major advances have been made in the treatment of endometriosis in recent decades, lack of randomized clinical trials evaluating the use of agents such as oral contraceptives alone or as add-back therapy for GnRH agonists, or those that examine combined medical and surgical treatments, has hampered the ability of physicians to provide the broadest range of medical therapies for this disorder. Future trials addressing these issues are warranted.

Cyproterone acetate versus a continuous monophasic oral contraceptive in the treatment of recurrent pelvic pain after conservative surgery for symptomatic endometriosis

OBJECTIVE

To evaluate the efficacy and safety of cyproterone acetate versus an oral contraceptive in the treatment of endometriosis-associated recurrent pelvic pain.

DESIGN

Randomized controlled trial.

SETTING

Academic center.

PATIENT(S)

Ninety women with recurrent moderate or severe pelvic pain after conservative surgery for symptomatic endometriosis.

INTERVENTION(S)

Six months of continuous treatment with oral cyproterone acetate, 12.5 mg/d, or an oral contraceptive containing ethinyl estradiol, 0.02 mg, and desogestrel, 0.15 mg.

MAIN OUTCOME MEASURE(S)

Degree of satisfaction with therapy.

RESULT(S)

Six patients in the cyproterone acetate arm and nine in the oral contraceptive arm withdrew because of side effects (n = 9), treatment inefficacy (n = 4), or loss to follow-up (n = 2). At 6 months, dysmenorrhea, deep dyspareunia, and nonmenstrual pelvic pain scores were substantially reduced, and significant improvements were observed in health-related quality-of-life, psychiatric profile, and sexual satisfaction; no major between-group differences were seen. Subjective and metabolic side effects were limited. According to an intention-to-treat analysis, 33 of 45 (73%) of patients in the cyproterone acetate group and 30 of 45 (67%) in the oral contraceptive group were satisfied with the treatment received.

CONCLUSIONS

Both cyproterone acetate and a continuous monophasic oral contraceptive were effective, safe, and inexpensive therapy for recurrent pain after conservative surgery for endometriosis.

Focus on primary care: chronic pelvic pain in women

Chronic pelvic pain (CPP) is a major health problem. It is the reason for 10% of all outpatient visits to gynecologist as well as being responsible for approximately 40% of laparoscopies and 10% to 15% of hysterectomies. A significant number of patients have no obvious etiology for their pain at the time of laparoscopy. The condition may not be cured in a large number of patients. This is ultimately unsatisfying for both the patient and physician. Although CPP may not be curable, it can be managed so those patients attain normal or near-normal levels of functions. To identify and review the methods used for diagnosis and treatment of chronic pelvic pain in women, a MEDLINE and Cochrane systematic review search from 1980 to 2000 was performed to collect information and evidence on diagnosis and treatment of women suffering from chronic pelvic pain.