Nafarelin in the management of endometriosis: quality of life assessment

Gonadotropin-releasing hormone analogues for endometriosis

BACKGROUND

Endometriosis is a common gynaecological condition affecting 6 to 11% of reproductive-age women and may cause dyspareunia, dysmenorrhoea, and infertility. One treatment strategy is medical therapy with gonadotrophin-releasing hormone analogues (GnRHas) to reduce pain due to endometriosis. One of the adverse effects of GnRHas is a decreased bone mineral density. In addition to assessing the effect on pain, quality of life, most troublesome symptom and patients' satisfaction, the current review also evaluated the effect on bone mineral density and risk of adverse effects in women with endometriosis who use GnRHas versus other treatment options.

OBJECTIVES

To assess the effectiveness and safety of GnRH analogues (GnRHas) in the treatment of painful symptoms associated with endometriosis and to determine the effects of GnRHas on bone mineral density of women with endometriosis.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO and the trial registries in May 2022 together with reference checking and contact with study authors and experts in the field to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) which compared GnRHas with other hormonal treatment options, including analgesics, danazol, intra-uterine progestogens, oral or injectable progestogens, gestrinone and also GnRHas compared with no treatment or placebo. Trials comparing GnRHas versus GnRHas in conjunction with add-back therapy (hormonal or non-hormonal) or calcium-regulation agents were also included in this review.  DATA COLLECTION AND ANALYSIS: We used standard methodology as recommended by Cochrane. Primary outcomes are relief of overall pain and the objective measurement of bone mineral density. Secondary outcomes include adverse effects, quality of life, improvement in the most troublesome symptoms and patient satisfaction.  Due to high risk of bias associated with some of the studies, primary analyses of all review outcomes were restricted to studies at low risk of selection bias. Sensitivity analysis including all studies was then performed.

MAIN RESULTS

Seventy-two studies involving 7355 patients were included. The evidence was very low to low quality: the main limitations of all studies were serious risk of bias due to poor reporting of study methods, and serious imprecision.  Trials comparing GnRHas versus no treatment  We did not identify any studies. Trials comparing GnRHas versus placebo There may be a decrease in overall pain, reported as pelvic pain scores (RR 2.14; 95% CI 1.41 to 3.24, 1 RCT, n = 87, low-certainty evidence), dysmenorrhoea scores (RR 2.25; 95% CI 1.59 to 3.16, 1 RCT, n = 85, low-certainty evidence), dyspareunia scores (RR 2.21; 95% CI 1.39 to 3.54, 1 RCT, n = 59, low-certainty evidence), and pelvic tenderness scores (RR 2.28; 95% CI 1.48 to 3.50, 1 RCT, n = 85, low-certainty evidence) after three months of treatment. We are uncertain of the effect for pelvic induration, based on the results found after three months of treatment (RR 1.07; 95% CI 0.64 to 1.79, 1 RCT, n = 81, low-certainty evidence). Besides, treatment with GnRHas may be associated with a greater incidence of hot flushes at three months of treatment (RR 3.08; 95% CI 1.89 to 5.01, 1 RCT, n = 100, low-certainty evidence). Trials comparing GnRHas versus danazol For overall pain, for women treated with either GnRHas or danazol, a subdivision was made between pelvic tenderness, partly resolved and completely resolved. We are uncertain about the effect on relief of overall pain, when a subdivision was made for overall pain (MD -0.30; 95% CI -1.66 to 1.06, 1 RCT, n = 41, very low-certainty evidence), pelvic pain (MD 0.20; 95% CI -0.26 to 0.66, 1 RCT, n = 41, very low-certainty evidence), dysmenorrhoea (MD 0.10; 95% CI -0.49 to 0.69, 1 RCT, n = 41, very low-certainty evidence), dyspareunia (MD -0.20; 95% CI -0.77 to 0.37, 1 RCT, n = 41, very low-certainty evidence), pelvic induration (MD -0.10; 95% CI -0.59 to 0.39, 1 RCT, n = 41, very low-certainty evidence), and pelvic tenderness (MD -0.20; 95% CI -0.78 to 0.38, 1 RCT, n = 41, very low-certainty evidence) after three months of treatment. For pelvic pain (MD 0.50; 95% CI 0.10 to 0.90, 1 RCT, n = 41, very low-certainty evidence) and pelvic induration (MD 0.70; 95% CI 0.21 to 1.19, 1 RCT, n = 41, very low-certainty evidence), the complaints may decrease slightly after treatment with GnRHas, compared to danazol, for six months of treatment. Trials comparing GnRHas versus analgesics  We did not identify any studies. Trials comparing GnRHas versus intra-uterine progestogens We did not identify any low risk of bias studies. Trials comparing GnRHas versus GnRHas in conjunction with calcium-regulating agents There may be a slight decrease in bone mineral density (BMD) after 12 months treatment with GnRHas, compared to GnRHas in conjunction with calcium-regulating agents for anterior-posterior spine (MD -7.00; 95% CI -7.53 to -6.47, 1 RCT, n = 41, very low-certainty evidence) and lateral spine (MD -12.40; 95% CI -13.31 to -11.49, 1 RCT, n = 41, very low-certainty evidence).  AUTHORS' CONCLUSIONS: For relief of overall pain, there may be a slight decrease in favour of treatment with GnRHas compared to placebo or oral or injectable progestogens. We are uncertain about the effect when comparing GnRHas with danazol, intra-uterine progestogens or gestrinone. For BMD, there may be a slight decrease when women are treated with GnRHas, compared to gestrinone. There was a bigger decrease of BMD in favour of GnRHas, compared to GnRHas in conjunction with calcium-regulating agents. However, there may be a slight increase in adverse effects when women are treated with GnRHas, compared to placebo or gestrinone. Due to a very low to low certainty of the evidence, a wide range of outcome measures and a wide range of outcome measurement instruments, the results should be interpreted with caution.

Dysmenorrhea and Endometriosis in Transgender Adolescents

STUDY OBJECTIVE

To study the presentation of dysmenorrhea and endometriosis in transmasculine adolescents and review their treatment outcomes.

DESIGN

A retrospective review.

SETTING

Boston Children's Hospital.

PARTICIPANTS

Transmasculine persons younger than 26 years old who were diagnosed with dysmenorrhea and treated between January 1, 2000 and March 1, 2020.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

An electronic medical record review of the clinical characteristics, transition-related care, and treatment outcomes.

RESULTS

Dysmenorrhea was diagnosed in 35 transmasculine persons. Mean age was 14.9 years ± 1.9 years. Twenty-nine (82.9%) were diagnosed after social transition. Twenty-three of 35 (65.7%) were first treated with combined oral contraceptives, but 14/23 (61%) discontinued or transitioned to alternative therapy. Twelve patients with dysmenorrhea alone initiated testosterone treatment, and 4/12 (33.3%) experienced persistent symptoms. Seven of 35 patients with dysmenorrhea (20.0%) were laparoscopically evaluated for endometriosis, and it was confirmed in all seven. Six had stage I disease, and one had stage II. Three of the 7 (42.9%) were diagnosed after social transition, with one diagnosed 20 months after initiating testosterone treatment. Their endometriosis was treated with combined oral contraceptives, danazol, or progestins; four experienced suboptimal response during treatment with these therapies alone. Two of those with suboptimal response subsequently resolved their dysmenorrhea when using testosterone. Five patients with endometriosis initiated testosterone treatment, and of the 5 (40%) experienced persistent symptomatology with combined testosterone and progestin therapies.

CONCLUSION

To our knowledge, this is the first study to characterize endometriosis in transmasculine persons. Evaluation for endometriosis was underutilized in transmasculine persons with dysmenorrhea, despite those who underwent laparoscopic evaluation and had disease confirmation. Although testosterone treatment can resolve symptoms in some, others might require additional suppression. Endometriosis should be considered in transmasculine persons with symptoms even when they are using testosterone.

Adolescent Endometriosis: An Update

Endometriosis is the leading pathologic cause of dysmenorrhea and chronic pelvic pain among adolescents. The appearance of endometriosis in adolescents may be different from that in female adults, resulting in delayed recognition and intervention. This article addresses the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of endometriosis in the adolescent.

Pain Catastrophizing and Pain Health-Related Quality-of-Life in Endometriosis

OBJECTIVES

To determine if pain catastrophizing is independently associated with pain health-related quality-of-life (HRQoL) in women with endometriosis, independent of potential confounders.

MATERIALS AND METHODS

Analysis of cross-sectional baseline data from a prospective database at a tertiary referral center for endometriosis/pelvic pain. Referrals to the center were recruited between December 2013 to April 2015, with data collected from online patient questionnaires, physical examination, and review of medical records. The primary outcome was HRQoL as measured by the 11-item pain subscale of the Endometriosis Health Profile-30 questionnaire. The Pain Catastrophizing Scale was the independent variable of interest. Other independent variables (potential confounders) included other psychological measures, pain severity, comorbid pain conditions, and social-behavioral and demographic variables. Multivariable linear regression was used to control for these potential confounders and assess independent associations with the primary outcome.

RESULTS

In total, 236 women were included (87% consent rate). The mean age was 35.0±7.3 years, and 98 (42%) had stage I to II endometriosis, 110 (47%) had stage III to IV endometriosis, and 28 (11%) were of unknown stage after review of operative records. Regression analysis demonstrated that higher pain catastrophizing (P<0.001), more severe chronic pelvic pain (P<0.001), more severe dysmenorrhea (P<0.001), and abdominal wall pain (positive Carnett test) (P=0.033) were independently associated with worse pain HRQoL.

DISCUSSION

Higher pain catastrophizing was associated with a reduced pain HRQoL in women with endometriosis at a tertiary referral center, independent of pain severity and other potential confounders.

Systematic review of quality of life measures in patients with endometriosis

OBJECTIVES

Endometriosis and quality of life has been the subject of much research, however, there is little consensus on how best to evaluate quality of life in endometriosis, resulting in many and diverse scales being used. In our study, we aim to identify quality of life scales used in endometriosis, to review their strengths and weaknesses and to establish what would define an ideal scale in the evaluation of endometriosis-related quality of life.

MATERIALS AND METHODS

A search of the MEDLINE and EMBASE databases was carried out for publications in English and French for the period from 1980 to February 2017, using the words 'endometriosis' and 'quality of life'. Publications were selected if they reported on quality of life in patients with endometriosis and specified use of a quality of life scale. A quantitative and a qualitative analysis of each scale was performed in order to establish the strengths and weaknesses for each scale (systematic registration number: PROSPERO 2014: CRD42014014210).

RESULTS

A total of 1538 articles publications were initially identified. After exclusion of duplicates and application of inclusion criteria, 201 studies were selected for analysis. The SF-36, a generic HRQoL measure, was found to be the most frequently used scale, followed by the EHP-30, a measure specific to endometriosis. Both perform well, when compared with other scales, with scale weaknesses offset by strengths. EHP-5 and EQ-5D also showed to be of good quality. All four were the only scales to report on MCID studied in endometriosis patients.

CONCLUSION

For clinical practice, routine evaluation of HRQOL in women with endometriosis is essential both for health-care providers and patients. Both SF-36 and EHP-30 perform better overall with regard to their strengths and weaknesses when compared to other scales.

Validation of the SF-36 in patients with endometriosis

Objectives

Endometriosis presents with significant pain as the most common symptom. Generic health measures can allow comparisons across diseases or populations. However, the Medical Outcomes Study Short Form 36 (SF-36) has not been validated for this disease. The goal of this study was to validate the SF-36 (version 2) for endometriosis.

Methods

Using data from two clinical trials (N = 252 and 198) of treatment for endometriosis, a full complement of psychometric analyses was performed. Additional instruments included a pain visual analog scale (VAS); a physician-completed questionnaire based on patient interview (modified Biberoglu and Behrman—B&B); clinical global impression of change (CGI-C); and patient satisfaction with treatment.

Results

Bodily pain (BP) and the Physical Component Summary Score (PCS) were correlated with the pain VAS at baseline and over time and the B&B at baseline and end of study. In addition, those who had the greatest change in BP and PCS also reported the greatest change on CGI-C and patient satisfaction with treatment. Other subscales showed smaller, but significant, correlations with change in the pain VAS, CGI-C, and patient satisfaction with treatment.

Conclusions

The SF-36—particularly BP and the PCS—appears to be a valid and responsive measure for endometriosis and its treatment.

Health-related quality of life in women with endometriosis: a systematic review

Endometriosis has critical implications for women's quality of life. However, an overview of the current knowledge of this issue is limited. The objective of this systematic review was to determine the extent of endometriosis and its treatment upon women's health-related quality of life (HRQoL). PubMed, Embase, PsycoINFO, CINAHL and the Cochrane Clinical Trials were searched up to May 2012, and only studies using standardized instruments to evaluate HRQoL in women with endometriosis were selected. Our electronic searches identified 591 citations, of which 39 studies satisfied the inclusion criteria including nine qualitative studies and 30 treatment-related studies. Findings showed that endometriosis impaired women's HRQoL. Pain was strongly related to a poor HRQoL, and medical or surgical treatment could partially restore this impairment. No conclusive evidence was available on whether endometriosis imposed an additional impairment in HRQoL per se, apart from the decrease caused by chronic pelvic pain, or on the superiority of various hormonal suppression agents. The impacts of disease extent, duration and fertility status upon HRQoL were inconsistent. In summary, HRQoL was impaired in women with endometriosis, and medical or surgical treatment to alleviate pain could partially restore this impairment.

Gonadotrophin-releasing hormone analogues for pain associated with endometriosis

EDITORIAL NOTE

See https://pubmed.ncbi.nlm.nih.gov/37341141/ for a more recent review that covers this topic and has superseded this review.

BACKGROUND

Endometriosis is a common gynaecological condition, characterised by the presence of endometrial tissue in sites other than the uterine cavity (excluding adenomyosis) that frequently presents with pain. The gonadotrophin-releasing hormone analogues (GnRHas) comprise one intervention that has been offered for pain relief in pre-menopausal women. GnRHas can be administered intranasally, by subcutaneous, or intramuscular injection. They are thought to result in down regulation of the pituitary and induce a hypogonadotrophic hypogonadal state.

OBJECTIVES

To determine the effectiveness and safety of GnRHas in the treatment of the painful symptoms associated with endometriosis.

SEARCH STRATEGY

Electronic searches of the Cochrane Menstrual Disorders and Subfertility Group specialist register, CENTRAL, MEDLINE, EMBASE, PSYCInfo and CINAHL were conducted in April 2010 to identify relevant randomised controlled trials (RCTs).

SELECTION CRITERIA

RCTs of GnRHas as treatment for pain associated with endometriosis versus no treatment, placebo, danazol, intra-uterine progestagens, or other GnRHas were included. Trials using add-back therapy, oral contraceptives, surgical intervention, GnRH antagonists or complementary therapies were excluded.

DATA COLLECTION AND ANALYSIS

Quality assessment and data extraction were performed independently by two reviewers. The primary outcome was pain relief. Relative risk was used as the measure of effect for dichotomous data. For continuous data, mean differences or standardised mean differences were used.

MAIN RESULTS

Forty one trials (n=4935 women) were included. The evidence suggested that GnRHas were more effective at symptom relief than no treatment/placebo. There was no statistically significant difference between GnRHas and danazol for dysmenorrhoea RR 0.98 (95%CI 0.92 to 1.04; P = 0.53). This equates to 3 fewer women per 1000 (95%CI 12 to 6) with symptomatic pain relief in the GnRHa group. More adverse events were reported in the GnRHa group. There was a benefit in overall resolution for GnRHas RR1.10 (95%CI 1.01 to 1.21, P=0.03) compared with danazol. There was no statistically significant difference in overall pain between GnRHas and levonorgestrel SMD -0.25 (95%CI -0.60 to 0.10, P=0.46). Evidence was limited on optimal dosage or duration of treatment for GnRHas. No route of administration appeared superior to another.

AUTHORS' CONCLUSIONS

GnRHas appear to be more effective at relieving pain associated with endometriosis than no treatment/placebo. There was no evidence of a difference in pain relief between GnRHas and danazol although more adverse events reported in the GnRHa groups. There was no evidence of a difference in pain relief between GnRHas and levonorgestrel and no studies compared GnRHas with analgesics.

Quality of life instruments in studies of chronic pelvic pain: a systematic review

The use of quality of life (QoL) instruments in chronic pelvic pain (CPP) will allow a more objective assessment of patient-centred clinical outcomes. However, there is concern that not enough emphasis is placed on clinical face validity (i.e. issues which are of importance to patients and reflect their experiences and concerns). To explore this issue, we performed a systematic review of published research. Relevant papers were identified through electronic scanning of six electronic databases and by manual searching of bibliographies of known primary and review articles. Studies were selected if they assessed women with CPP for life quality, either developing QoL instruments or applying them as an outcome measure. Selected studies were assessed for the quality of their QoL instruments using a 17-item checklist, including 10 items for clinical face validity and seven items for measurement (psychometric) properties. A total of 19 articles were eligible for inclusion in the review. The generic Short Form 36 Health Survey Questionnaire (SF-36) was used most frequently, being employed in 10/19 (53%) of the studies. Three studies developed disease-specific QoL instruments for CPP complying with 59 - 77% of the quality criteria. Overall, quality assessment showed that only 4/18 (22.2%) studies complied with more than half the criteria for face validity, whereas 12/18 (66.6%) studies complied with more than half of the criteria for measurement properties (P = 0.0001). Among existing QoL instruments, compliance with the quality criteria for measurement properties is higher than for clinical face validity. There is a need to develop disease specific QoL instruments for CPP with face validity in addition to sound measurement properties.

[Relevance of quality of life questionnaires in women with endometriosis]

High recurrence rates have been reported in women treated for endometriosis despite advances in medical and surgical treatments improving both fertility and symptoms. It should therefore be considered a chronic disorder. In this particular setting, the main objectives for practitioners are to limit disease progression, recurrence and to improve quality of life (QOL). Previous studies have demonstrated a relation between an increase in pain intensity and a decrease in QOL. However, visual analogue scales to measure general well-being are insufficient to quantify the impact of endometriosis on QOL. Several generic questionnaires, mainly the SF-36, are available in various languages but are not specific of women with endometriosis. Some specific questionnaires are available but have been validated in English population for the most part rending comparison between countries difficult. Despite these limits, QOL should be systematically monitored over time by a validated questionnaire for this chronic disorder and could be a criterion for therapeutic strategy.

Measuring quality of life in women with endometriosis: tests of data quality, score reliability, response rate and scaling assumptions of the Endometriosis Health Profile Questionnaire

BACKGROUND

To test the data quality, scaling assumptions and scoring algorithms underlying the Endometriosis Health Profile-30 (EHP-30) questionnaire: a questionnaire developed to measure the health-related quality of life (HRQoL) of women with endometriosis.

METHODS

A cross-sectional postal survey to 727 women with surgically confirmed endometriosis recruited from an existing genetic linkage study (OXEGENE), The National Endometriosis Society (NES), UK and the outpatient gynaecology clinics of the Women's Centre, John Radcliffe Hospital, Oxford. Tests of data quality included secondary factor analysis, internal reliability consistency, descriptive statistics of the data, missing data levels, floor and ceiling effects and corrected item to total correlation scores.

RESULTS

Six hundred and ten women (83.9%) returned the questionnaire. Secondary factor analysis verified the domain structure of the EHP-30. All 11 dimensions were internally reliable with Cronbach's alpha scores ranging from 0.80 to 0.96. Missing response rates ranged from 0.2 to 1.3%, and all items were found to be most highly correlated with their own (corrected) scale.

CONCLUSIONS

Results confirmed the factor structure, scoring and scaling assumptions of the questionnaire. The high rate of data completeness indicated that the EHP-30 was acceptable and understandable to the respondents, thereby verifying its suitability for measuring the HRQoL of women with endometriosis.

A randomized, parallel, comparative study of the efficacy and safety of nafarelin versus danazol in the treatment of endometriosis in Taiwan

BACKGROUND

The purpose of this study was to evaluate the efficacy and safety of nafarelin, a gonadotropin-releasing hormone (GnRH) analogue, versus danazol in the treatment of women with endometriosis in Taiwan.

METHODS

Fifty-nine women with laparoscopically and pathologically confirmed endometriosis were randomized to receive nafarelin or danazol for 180 days. Efficacy was assessed from mean changes in laparoscopy score (LS) and total symptom severity score (TSSS). Adverse events (AEs) and laboratory parameters, including hematology, hepatic function, blood pressure, and lipid levels, were monitored for safety evaluations.

RESULTS

All demographic and baseline factors, except body weight, were comparable between the 2 treatment groups. Both nafarelin and danazol satisfactorily resolved pelvic tenderness, induration, pelvic pain, dysmenorrhea and dyspareunia. No significant differences were noted in efficacy endpoints between nafarelin and danazol regarding LS and TSSS at 90 and 180 days of treatment. No significant difference was observed between the 2 groups regarding the overall incidence of AEs, except for laboratory-related AEs. However, nafarelin tended to have less impact than danazol on aspartate transaminase and alanine transaminase, and nafarelin was better tolerated than danazol regarding changes in lipid profiles. Both treatments had little or no effect on hematologic parameters.

CONCLUSION

Nafarelin and danazol demonstrated similar clinical efficacy, but nafarelin was associated with fewer laboratory changes and a stable lipid profile, relative to danazol. Moreover, intranasally administered nafarelin is noninvasive, and may be a more comfortable and safer alternative to slow-release injectable GnRH agonists. Based on this study, we suggest that nafarelin, like other GnRH analogues, may be a treatment of choice for Taiwanese women with endometriosis. However, direct comparative studies of nafarelin with slow-release injectable GnRH agonists are now required.

Adolescent endometriosis: diagnosis and treatment approaches

OBJECTIVES

To review the etiologies, diagnosis, and treatment options of adolescent endometriosis.

METHODS

Review of publications relating to adolescent endometriosis.

RESULTS

Endometriosis occurs in adolescents as young as 8 years of age; furthermore, there have been documented cases of endometriosis occurring prior to menarche. Adolescents presenting with pelvic pain are treated with cyclic combination oral contraceptive pills and nonsteroidal anti-inflammatory agents. If the pain does not respond to these therapies, then in adolescents as in adults, an operative laparoscopy is recommended for the diagnosis and surgical management of endometriosis. The operating gynecologist should be familiar with the appearance of the complete spectrum of various morphologies of endometriosis, as adolescents tend to have clear, red, white, and/or yellow-brown lesions more frequently than black or blue lesions. Subtle clear lesions of endometriosis may be better visualized by filling the pelvis with irrigation fluid so that the clear lesions can be appreciated in a three-dimensional appearance. Young women who are found to have endometriosis by laparoscopy may present with acyclic, cyclic, and constant pelvic pain. Adolescents with pelvic pain not responding to conventional medical therapy have approximately a 70% prevalence of endometriosis. It is known that endometriosis is a progressive disease and since there is no cure, adolescents with endometriosis require long-term medical management until the time in their lives when they have completed childbearing. Psychosocial support is extremely important for this population of young women with endometriosis.

CONCLUSIONS

Endometriosis occurs in adolescents, and presenting symptoms may vary from those seen in adult women with the disease. All health care providers must be aware of the existence of adolescent endometriosis. They should also be aware of the presenting symptoms so that the adolescent can be appropriately referred to a gynecologist comfortable with medical and surgical treatment options in this patient population. If laparoscopy is to be undertaken, the gynecologist must be prepared not only to diagnose but to surgically manage endometriosis. In addition, the subtle laparoscopic findings of endometriosis in adolescents must be recognized for an appropriate diagnosis. Long-term medical therapy will hopefully decrease pain and the progression of the disease, thus decreasing the risk of advanced-stage disease and infertility.

Health-related quality of life measurement in women with common benign gynecologic conditions: a systematic review

Endometriosis, menorrhagia, chronic pelvic pain, and polycystic ovary syndrome are major sources of psychologic morbidity and can negatively affect quality of life. Although comparative studies have been published on the measurement of health-related quality of life for gynecologic malignancies, a similar review for these benign gynecologic conditions has not been conducted. Consequently, we searched the literature systematically to identify the impact of symptoms and treatments for these conditions on health status and to report on the types and psychometric properties of the instruments used. Papers were retrieved by systematically searching 6 electronic databases and hand-searching relevant reference lists and bibliographies. Forty-six studies used a questionnaire to measure health status: 34 studies (74%) used standardized instruments; of these, 23 studies (68%) used generic tools. Although a meta analysis was not possible, it appears that women with chronic pelvic pain and conditions that are associated with pelvic pain (such as endometriosis) report worse health-related quality of life. Despite the development of disease-specific questionnaires, only 2 questionnaires were generated from interviews of patients with the condition of interest, and few questionnaires are being used to evaluate the outcomes of treatment on subjective health status.

The effect of endometriosis and its radical laparoscopic excision on quality of life indicators

OBJECTIVE

To assess the effect of endometriosis and radical laparoscopic excision on the quality of life of women with this condition.

DESIGN

A prospective study.

SETTING

The Northern Endometriosis Centre at South Cleveland Hospital, Middlesbrough and St. James's University Hospital, Leeds.

POPULATION

Fifty-seven consecutive patients undergoing laparoscopic excision of invasive endometriosis.

METHODS

Questionnaires, both pre-operatively and four-month post-operatively, for a number of different symptoms associated with endometriosis were completed by patients. Details of fertility, previous treatments and quality of life as measured by SF12 and EuroQOL (EQ-5D) and sexual activity questionnaire, as well as linear pain scores for several symptoms, were recorded. Details of intra-operative findings was also collected.

MAIN OUTCOME MEASURES

Effect of laparoscopic excision on pain scores and quality of life, operative findings, type of surgery, length of surgery and incidence of intra- and post-operative complications.

RESULTS

Patients with endometriosis were severely ill with significant pain and impairment of quality of life and sexual activity. Four months after radical laparoscopic excision for deep endometriosis there was significant improvement in all the parameters measured including their quality of life based on EuroQOL evaluation: EQ-5D (0 x 595:0 x 729, P = 0 x 002) and EQ thermometer (68 x 9:77 x 7, P = 0 x 008); SF12 physical score (44 x 8:51 x 9, P = 0 x 015); sexual activity (habit P = 0 x 002, pleasure P = 0 x 002 and discomfort P < or = 0 x 001). Only the mental health score of SF12 failed to show any statistical improvement (47 x 1:48 x 4, P = 0 x 84). Symptomatically, there was a significant reduction in dysmenorrhoea (median 8 x 0:4 x 0, P < or = 0 x 001), pelvic pain (median 7 x 0:2 x 0, P < or = 0 x 001), dyspareunia (median 6 x 0:0 x 0, P < 0 x 001) and rectal pain scores (median 4 x 0:0 x 0, P < 0 x 001). Complications were noted, but were deemed to be acceptable for the extent of the surgery.

CONCLUSIONS

This is an early analysis of the first 57 cases studied, but structured evaluation suggests that meaningful improvements in clinical symptoms and quality of life can be obtained with this approach with acceptable levels of operative morbidity. Further follow up of this series is required, but early evidence would suggest that the technique should be further evaluated as part of a randomised trial.

Pre or post-operative medical treatment with nafarelin in stage III-IV endometriosis: a French multicenter study

OBJECTIVES

To determine the effectiveness of a 6-month course of nafarelin in the treatment of stage III-IV endometriosis and to determine if pre-operative use of nafarelin facilitates surgery.

DESIGN

Prospective, multicenter, clinical trial.

SETTING

Eight university hospitals and two private practice institutions in France.

PATIENTS

Fifty-five patients with stage III and IV endometriosis. Two were excluded.

INTERVENTIONS

The severity of endometriosis was assessed at the time of laparoscopy and patients were randomized to have either laparosopic surgery at that time following 6 months of nafarelin therapy (n=28), or laparoscopic surgery following 6 months of nafarelin therapy (n=25). All had 200 microg intranasal nafarelin twice a day for 6 months and a second look laparoscopy.

MAIN OUTCOME MEASURE

Clinical efficacy, tolerance to the treatment.

RESULTS

Efficacy and tolerance to the treatment were the same in both groups. AFS scores compared on both laparoscopies were significantly better if nafarelin was given prior to surgery (P=0.007).

CONCLUSIONS

This preliminary study shows that in cases of combined medico-surgical treatment for stage III-IV endometriosis, preoperative medical treatment with GnRH-a gives a better AFS score improvement, but no conclusion was possible whether preoperative treatment facilitates surgery.

Effects of triptorelin versus placebo on the symptoms of endometriosis

OBJECTIVE

To compare the effect of a GnRH-agonist, triptorelin, versus placebo on the symptoms of endometriosis.

DESIGN

A prospective, randomized, double-blind study of 6 months of treatment followed by 12 months of follow-up.

SETTING

Departments of Obstetrics and Gynecology at two universities and one general hospital.

PATIENT(S)

Forty-nine women with symptoms of laparoscopically verified endometriosis.

INTERVENTION(S)

Triptorelin depot or placebo was given every 4 weeks. Clinical evaluation, including the Duration Intensity Behavior Scale and Visual Analogue Scale for pain, was performed before the injections and up to 12 months after treatment. A control laparoscopy was performed 4-6 weeks after the last injection.

MAIN OUTCOME MEASURE(S)

Quantitation of pain.

RESULT(S)

Twenty-four patients had active treatment and 25 received placebo. Pain symptoms according to both scales were significantly more reduced after 2 months of triptorelin treatment compared to placebo. The extent of endometriotic lesions was reduced 50% during triptorelin treatment and increased 17% during placebo. The average area of endometriotic lesions was reduced 45% during triptorelin treatment but was unchanged during placebo. Side effects, mainly hot flushes, were experienced by 80% of the actively treated group but also by 33% of patients in the placebo group. Because of recurrent symptoms, only five patients could be observed for 12 months after completion of treatment.

CONCLUSION(S)

Triptorelin reduces endometriotic lesions and pain to a significantly higher degree than placebo.

Intranasal nafarelin versus buserelin (short protocol) for controlled ovarian hyperstimulation before in vitro fertilization: a prospective clinical trial

The aim of this study was to compare the effect of nafarelin acetate with that of buserelin acetate nasal spray, when administered in a 'short' protocol, as an adjunct to human menopausal gonadotropin (hMG) for controlled ovarian hyperstimulation before in vitro fertilization (IVF). Twenty-two IVF subjects were randomly recruited. Each underwent two consecutive treatment cycles; one with buserelin (900 micrograms/day) and another with nafarelin (400 micrograms/day). The treatment protocol included transnasal gonadotropin-releasing hormone (GnRH) analog from the second cycle day and hMG from the fourth day of the cycle. The buserelin and nafarelin cycles did not differ significantly in the following parameters: baseline hormone profile, duration of GnRH analog treatment, mean hMG dose required, peak estradiol levels, number of preovulatory follicles, number of aspirated oocytes, fertilization rate and number of transferred or frozen embryos. No side-effects or cancellations of treatment were recorded. The average dose required was lower for nafarelin and, because this analog was given only twice a day, it was more convenient to administer. These findings suggest that nafarelin is as effective as buserelin (when administered in a "short' protocol) in achieving controlled ovarian hyperstimulation. It even offers advantages over buserelin with respect to the total dose required (which probably reflects its relatively high potency) and the subjects' compliance.

Effects of a gonadotropin-releasing hormone agonist on the calcium-parathyroid axis and bone turnover in women with endometriosis

OBJECTIVE

Our purpose was to investigate the effects of nafarelin on bone turnover and mass (bone mineral density, in grams per square centimeter) in women with endometriosis.

STUDY DESIGN

We monitored 22 young women with endometriosis during and 6 months after 6 months of nafarelin treatment. We compared the bone mineral density status of these women with that of healthy controls undergoing sequential bone mineral density measurement.

RESULTS

Subjects had a 2.2% loss in L2-4 bone mineral density by 6 months, increasing 3 months later to 3% and returning toward baseline by 6 months after treatment. Radius bone mineral density did not change in the treatment group. Bone mineral density did not change in controls. Serum and urinary calcium levels rose during treatment. Hydroxyproline excretion increased and remained elevated 6 months after treatment. A rise in serum osteocalcin persisted 3 months after therapy but normalized by 6 months.

CONCLUSIONS

Bone mineral density deficits with nafarelin are reversible. Increased bone turnover persists 6 months beyond treatment, demonstrating the need for careful monitoring of women receiving prolonged or repeated treatment.

Comparison between nafarelin and leuprolide acetate for in vitro fertilization: preliminary clinical study

OBJECTIVE

To evaluate the clinical effect of two different biochemical GnRH agonists (GnRH-a), nafarelin acetate and leuprolide acetate (LA), as adjunct to induction of ovulation in patients for IVF.

DESIGN

Twenty-four women were assigned randomly to either nafarelin acetate or LA during IVF cycles.

SETTING

University-affiliated clinics.

PATIENTS

Infertile women undergoing IVF cycles in an academic research environment.

INTERVENTIONS

Intranasal nafarelin at a dosage of 200 micrograms twice daily or LA at a dose of 1 mg/d SC was administered. Blood samples were collected on day 21 of previous cycle, days 2 and 8, and before hCG injection.

MAIN OUTCOME MEASURE

Patient response as indicated by follicular phase serum levels of E2, FSH, and LH.

RESULTS

Hormone profiles on cycle day 2 showed no statistical difference between both GnRH-a groups in FSH levels and a slight statistical difference for E2 levels. Patient response as demonstrated by follicular phase of E2, FSH, and LH measured on cycle day 8 and the day of hCG injection showed no statistically significant difference in both groups. Furthermore, the mean number of follicles, eggs retrieved, egg quality, fertilization rate, and number of embryos transferred and frozen were similar. The cycle cancellation rate and pregnancy rate per stimulation start were also not statistically different between the two groups.

CONCLUSION

The study shows the comparable efficacy of these two drugs in controlled ovarian hyperstimulation (COH) protocols. The easy administration of nafarelin with prompt nasal absorption and the readily achieved blood level made nafarelin an option for use in COH in assisted reproductive technology.