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

Patient satisfaction with two different management modalities for erratic bleeding during continuous hormone therapy for endometriosis-associated symptoms: A before-after study

OBJECTIVE

To evaluate patient satisfaction with the management of erratic bleeding during continuous hormone therapy for endometriosis using two different strategies: an active approach (tailored cycling), which involved discontinuation of the therapy; and a passive approach, which involved waiting for spontaneous resolution of the bleeding.

METHODS

This was an observational before-after study. All patients enrolled within a previously defined time limit were instructed to adopt a passive strategy to manage erratic bleeding, while all patients enrolled after that defined time were instructed to discontinue therapy for 7 days (tailored cycling). Degree of satisfaction, characteristics of bleeding, and level of dysmenorrhoea were compared and analysed at the time of enrolment and after 6 and 12 months.

RESULTS

In total, 201 patients were included in the study. Satisfaction was 29% higher among patients in the passive strategy group compared with those in the tailored cycling group; this difference was significant. No significant differences were identified for the other outcomes.

CONCLUSION

Patients may be more satisfied with the use of a passive approach to manage irregular bleeding during continuous hormone therapy for endometriosis-associated pain. All patients should be provided with comprehensive information regarding all available management strategies for unpredictable irregular bleeding. This will enable patients to make informed decisions based on their personal experience and preferences, without external pressure, thus improving compliance, adherence and, ideally, satisfaction with treatment.

Guideline No. 345: Primary Dysmenorrhea

OBJECTIVE

This guideline reviews the investigation and treatment of primary dysmenorrhea.

TARGET POPULATION

Individuals experiencing menstrual pain for which no underlying cause has been identified.

BENEFITS, HARMS, AND COSTS

Primary dysmenorrhea is common and frequently undertreated, despite effective therapy being widely available at a minimal cost. Treatment of primary dysmenorrhea has the potential to improve quality of life and decrease time away from school or work.

EVIDENCE

Published clinical trials, randomized controlled trials, observational studies, population studies, and systematic review articles indexed in PubMed and the Cochrane database were identified using search the terms "dysmenorrhea" and "menstrual pain." This search builds on the previous review (January 2005 to March 2016), including new literature between March 2016 and December 2024.

VALIDATION METHODS

The author rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Primary care providers, pediatricians, and obstetrician/gynaecologists.

SOCIAL MEDIA ABSTRACT

Although menstrual pain is commonly experienced by women and adolescents, it is often undertreated or unfairly dismissed. If left untreated, persistent menstrual pain may develop into a chronic pain syndrome. Treatment includes non-steroidal anti-inflammatory drugs and hormonal contraceptives and can be provided without the need for pelvic examinations; treatment should not be delayed pending a definitive diagnosis. Effective treatments are available and do not require a pelvic examination or invasive procedures.

SUMMARY STATEMENTS

RECOMMENDATIONS.

A Multimodal Approach to Symptomatic Endometriosis: A Proposed Algorithm for Clinical Management

Recent research has proven that peripheral (PS) and central sensitization (CS), mental health, and myofascial dysfunction all play a role, alongside nociception, in the genesis and in the perpetuation of endometriosis' symptoms. However, such components of pain are still largely ignored in clinical practice, although not considering such contributors may entail serious consequences on women's health, including the choice of unnecessary surgery and leaving the real causes of pain untreated. At the present time, we are facing a paradox by which 25-40% of women who undergo laparoscopic surgery for pelvic pain do not have an obvious diagnosis, while the percentage of women with endometriosis who have signs of CS, of depressive or anxiety disorders, or who have an increased pelvic muscle tone ammounts to 41-55%, 15-88% and 28-73%, respectively. Moving from the widely-accepted stepwise approach suggested for endometriosis management, which consists in the initial prescription of low-dose combined oral contraceptives (COCs) or of a progestin monotherapy, followed by GnRH analogues and, ultimately, by surgery, when COCs and progestins have proven ineffective or are not tolerated or contraindicated, we propose an integration of such model which takes into account the identification and the simultaneous treatment of all pain contributors. Our objective is to encourage physicians' awareness of the need of a multidisciplinary, multimodal approach to endometriosis-related pain, and ultimately to promote a reduction in the number of unnecessary surgeries.

The long road of drug development for endometriosis - Pains, gains, and hopes

Endometriosis, defined by the growth of endometrial tissues outside of the uterine cavity, is a global health burden for ∼200 million women. Patients with endometriosis usually present with chronic pain and are often diagnosed with infertility. The pathogenesis of endometriosis is still an open question; however, tissue stemness and immunological and genetic factors have been extensively discussed in the establishment of endometriotic lesions. Current treatments for endometriosis can be categorized into pharmacological management of hormone levels and surgical removal of the lesions. Both approaches have limited efficacy, with recurrences often encountered; thus, there is no complete cure for the disease or its symptoms. We review the current knowledge of the etiology of endometriosis and summarize the advancement of pharmacological management of endometriosis. We also discuss our efforts in applying DNA-encoded chemistry technology (DEC-Tec) to identify bioactive molecules for the treatment of endometriosis, offering new avenues for developing non-hormonal treatment options for those patients who seek spontaneous pregnancies.

Progesterone receptor B over progesterone receptor A prevents recurrence in bilateral endometriomas

OBJECTIVE

Endometriosis is a disease in which stromal cells and endometrial glands extend outside of the uterine cavity. Nevertheless, treatment failure and recurrence cause difficulties in management. This study aimed to evaluate the receptor-level components of bilateral endometriomas in the recurrence state.

METHODS

Our retrospective cohort study was conducted with patients who underwent surgery for bilateral endometriomas between 2015 and 2021. In total, 113 patients were allocated. A total of 76 patients did not meet the eligibility criteria, and the data of 37 patients were evaluated. Medical treatments, recurrences, and postoperative follow-up data were collected. In archived tissue samples, measurements of progesterone receptor A and progesterone receptor B, histoscores and immunoreactivity scores, and their ratios were calculated in the group that received no postoperative medical treatment. Criteria for recurrence were a repeat operation and/or the detection of a new endometrioma>2 cm at the follow-up examination.

RESULTS

No recurrence was observed in 73.0% (n=27) of the cases, whereas recurrence was observed in 27.0% (n=10) of the participants. Patients without recurrence had significantly higher progesterone receptor B histoscore/progesterone receptor A histoscore and progesterone receptor B immunoreactivity score/progesterone receptor A immunoreactivity score results (p=0.01). Nevertheless, when the histoscores and immunoreactivity scores for both receptors were contrasted separately, there was no appreciable difference between them.

CONCLUSION

The dominance of progesterone receptor B over progesterone receptor A was inversely proportional to the recurrence status in bilateral endometriomas. Furthermore, our study revealed that assessing receptor levels alone did not result in a significant difference in recurrence.

The Role of Different Medical Therapies in the Management of Adenomyosis: A Systematic Review and Meta-Analysis

Background/Objectives: Adenomyosis is a benign condition characterized by the presence of endometrial tissue within the myometrium. Despite surgery being a valuable approach, medical options are considered as the first-line approach and have been investigated in the treatment of adenomyosis, although strong evidence in favor of these is still lacking. This study aims to gather all available data and determine the effectiveness of the aforementioned medical options in patients with associated pain and not currently seeking pregnancy, both in comparison to placebo and to one another. Methods: For this study, PubMed and EMBASE were used as data sources, searched up to January 2024. A systematic review and meta-analysis were performed in accordance to guidelines from the Cochrane Collaboration. The primary outcomes investigated were changes in dysmenorrhea, quantified by means of VAS scores, HMB in terms of number of bleeding days, and changes in uterine volume determined at ultrasound. Twelve eligible studies were selected. Results: The results highlighted that dienogest yields a reduction in dysmenorrhea that is significantly superior to that of the rest of the medical treatments investigated (p-value of <0.0002). On the other hand, GnRH agonists seem to play a more prominent role in reducing uterine volume (p-value of 0.003). While it was not possible to determine which medical treatment better decreased the number of bleeding days, it was observed that COC performed significantly worse than the other treatments studied (p-value of 0.02). Conclusions: While this meta-analysis provides valuable insights in the comparative efficacy of different treatments, the paucity of relevant studies on the topic might impact the reliability of some of the conclusions drawn.

Current Medical Therapy for Adenomyosis: From Bench to Bedside

Adenomyosis, characterized by the growth of endometrial tissue within the uterine wall, poses significant challenges in treatment. The literature primarily focuses on managing abnormal uterine bleeding (AUB) and dysmenorrhea, the main symptoms of adenomyosis. Nonsteroidal anti-inflammatory drugs (NSAIDs) and tranexamic acid provide limited support for mild symptoms or symptom re-exacerbation during hormone therapy. The levonorgestrel-releasing intrauterine system (LNG-IUS) is commonly employed in adenomyosis management, showing promise in symptom improvement and reducing uterine size, despite the lack of standardized guidelines. Dienogest (DNG) also exhibits potential benefits, but limited evidence hinders treatment recommendations. Danazol, while effective, is limited by androgenic side effects. Combined oral contraceptives (COCs) may be less effective than progestins but can be considered for contraception in young patients. Gonadotropin-releasing hormone (GnRH) agonists effectively manage symptoms but induce menopausal symptoms with prolonged use. GnRH antagonists are a recent option requiring further investigation. Aromatase inhibitors (AIs) show promise in alleviating AUB and pelvic pain, but their safety necessitates exploration and limited use within trials for refractory patients. This review highlights the complexity of diagnosing adenomyosis, its coexistence with endometriosis and uterine leiomyomas, and its impact on fertility and quality of life, complicating treatment decisions. It emphasizes the need for research on guidelines for medical management, fertility outcomes, long-term effects of therapies, and exploration of new investigational targets. Future research should optimize therapeutic strategies, expand our understanding of adenomyosis and its management, and establish evidence-based guidelines to improve patient outcomes and quality of life.

Insight into Dysmenorrhea Research from 1992 to 2022: A Bibliometric Analysis

Dysmenorrhea, classified as primary dysmenorrhea and secondary dysmenorrhea, is a common gynecological symptom that seriously affects female daily life. At present, studies on dysmenorrhea are numerous and complex. To better reflect the trend and innovative progress of dysmenorrhea-related research, this study screened papers on the Web of Science from January 1, 1992, to December 31, 2022. A total of 1012 papers were selected and analyzed for their affiliated countries, institutions, authors, keywords, etc. China is the country with the most academic output, Beijing University of Traditional Chinese Medicine is the most influential institution, and Yang Jie, from Chengdu University of Traditional Chinese Medicine, China, is the scholar with the most papers. We consider that the current research focus is on pathogenesis, treatment, epidemiology, and self-management. With increasing research on functional connectivity between dysmenorrhea and various brain regions, functional connectivity has gradually become the forefront of research. We hope our study can promote the further study of dysmenorrhea.

Structural Gynecological Disease: Fibroids, Endometriosis, Ovarian Cysts

Fibroids, endometriosis, and ovarian cysts are common conditions. Fibroids can be asymptomatic or present with heavy menstrual bleeding, pelvic pressure, and pain. Endometriosis is a common cause of cyclical pelvic pain. Ovarian cysts are generally diagnosed incidentally. Transvaginal ultrasound is the performed imaging modality for all structural gynecological disease. Symptomatic management is recommended for each condition. Fibroids can be managed medically or surgically depending on the patient's symptoms and desire for future fertility. Nonsteroidal anti-inflammatory drugs are the first-line therapy for endometriosis followed by oral contraceptives and surgical management. Ovarian cysts can be managed expectantly.

[Continuous/extended/flexible use of combined hormonal contraceptives: Prescribing habits of practitioners in Centre Val deLoire region]

OBJECTIVES

To date, oral contraceptives remain the most frequently prescribed contraceptive method. New combined oral contraceptive (COC) regimens (continued, extended or flexible) were developed to try and space out or avoid withdrawal bleedings in order to meet women's expectations and improve their quality of life. However, there is no recommendation published regarding the management of the prescription. The purpose of our study was to describe provider's prescription habits when it comes to new COC regimens.

METHODS

This is a descriptive observational study. A questionnaire was sent to gynecologists, general practitioners and midwives employed or in training in the Centre Valde Loire region. Prescription habits and knowledge about new oral contraceptive regimens were evaluated.

RESULTS

83% of health professionals frequently prescribed new COC regimens. Most frequent indications were endometriosis, severe menstruation-associated symptoms, patient's desire for amenorrhea or patient's request. The extended regimen (hormone-free interval not every month) was the most frequently used. Provider's knowledge about indications and benefits of those new regimens were satisfactory. However, scientific societies guidelines were poorly acquired.

CONCLUSIONS

New COC regimens are frequently proposed by health care professionals with large variability in terms of prescription model. Along with reinforcement of COC prescription guidelines for healthcare professionals, further researches are needed to better understand differences in tolerability and acceptability in terms of quality of life of the several potential regimens.

Randomized study on the effectiveness of nomegestrol acetate plus 17β-estradiol oral contraceptive versus dienogest oral pill in women with suspected endometriosis‑associated chronic pelvic pain

BACKGROUND

To evaluate the effects of a combined oral contraceptive containing 1.5 mg 17b-estradiol (E2) and 2.5 mg nomegestrol acetate (NOMAC) or 2 mg/daily dienogest (DNG) oral progestin on endometriosis-associated chronic pelvic pain (CPP) and on the quality of life (QoL) and sexual function, by a randomized study design.

METHODS

The E2/NOMAC group and DNG group included 99 and 98 women, respectively. The levels of CPP were measured by the visual analogic scale (VAS). The QoL scores were investigated by the Short Form-36 questionnaire (SF-36). Finally, sexual function was studied using the Female Sexual Function Index (FSFI), while sexual distress was studied by the Female Sexual Distress Scale (FSDS). The study had 3, 6 and 12-month follow-ups.

RESULTS

The intra-group analysis showed an improvement of the VAS score from baseline to the 12-month follow-up in the women of both groups (p < 0.001). The inter-group comparison showed a similar improvement of CPP (p = 0.06). Women on DNG had better SF-36 somatic (p < 0.01) and FSFI scores (p < 0.006) than women on E2/NOMAC at the 6- and 12-month follow-ups.

CONCLUSIONS

The results support the efficacy of both hormonal treatments, even if DNG was more effective than E2/NOMAC in a limited intergroup comparison.

Endometriosis, psychiatric comorbidities and neuroimaging: Estimating the odds of an endometriosis brain

Endometriosis is a chronic pain disorder that affects young women, impairing their physical, mental and social well-being. Apart from personal suffering, it imposes a significant economic burden on the healthcare system. We analyzed studies reporting comorbid mental disorders in endometriosis based on the ICD/DSM criteria, discussing them in the context of available neuroimaging studies. We postulate that at least one-third of endometriosis patients suffer from mental disorders (mostly depression or anxiety) and require psychiatric or psychotherapeutic support. According to three neuroimaging studies involving patients with endometriosis, brain regions related not only to pain processing but also to emotion, cognition, self-regulation and reward likely constitute the so-called "endometriosis brain". It is not clear, however, whether the neurobiological changes seen in these patients are caused by chronic pain, mental comorbidities or endometriosis itself. Given the paucity of high-quality data on mental comorbidities and neurobiological correlates in endometriosis, further research is needed.

Efficacy of Low-Dose Estrogen-Progestins and Progestins in Japanese Women with Dysmenorrhea: A Systematic Review and Network Meta-analysis

INTRODUCTION

Although several studies suggest beneficial effects of low-dose estrogen-progestins (LEPs) and progestins on dysmenorrhea in Japanese women, the difference in efficacy between drugs remains unknown.

METHODS

We identified studies by searching the MEDLINE, Cochrane Library, and ICHUSHI databases and included randomized controlled trials (RCTs) that used total dysmenorrhea score and visual analogue scale (VAS) as outcome measures to evaluate LEPs and progestins for primary and secondary dysmenorrhea. We analyzed results by meta-analysis and network meta-analysis (NMA).

RESULTS

We identified 10 articles on eight RCTs and included seven drugs (six LEPs and one progestin, i.e., dienogest) and placebo in the analysis. Meta-analysis showed improvements in total dysmenorrhea score and VAS for almost all drugs compared with placebo. In NMA, VAS in secondary dysmenorrhea improved more with dienogest than with norethisterone/ethinylestradiol (mean difference - 25.84 [95% CrI - 44.46 to - 7.15]). In the comparison of administration regimens, VAS improved more with progestin-continuous than LEP-cyclic and the surface under the cumulative ranking (SUCRA) of LEP-extended and progestin-continuous appeared to be higher than that of LEP-cyclic.

CONCLUSIONS

We confirmed that LEPs and dienogest are effective for primary and secondary dysmenorrhea and suggest that continuous regimens may be more effective than cyclic regimens in improving outcomes.

Observational Study for Adverse Effects and Discontinuation with Long-Term Post-Operative Hormonal Treatment for Endometriosis in Real-World Practice

Objectives: To evaluate the side effects and causes of discontinuation of either combined oral contraceptives or dienogest (DNG) used to prevent recurrence in patients with surgically confirmed endometriosis.Methods: We retrospectively analyzed the medical records of 213 women with endometriosis who had been treated with combined oral contraceptives (ethinyl estradiol 0.02 mg/drospirenone 3 mg [EE/DRSP]) or DNG 2 mg for 12 months or more. The side effects reported by the patients, laboratory parameters, causes of discontinuation of medication, and recurrence rates were evaluated one, two, three, four, and five years after starting medication (Y1, Y2, Y3, Y4, and Y5).Results: EE/DRSP were administered to 59 patients, while DNG was administered to 154 patients. The mean durations of postoperative use of EE/DRSP and DNG were 44.5 ± 22.6 months and 23.6 ± 13.5 months, respectively. The prevalence of side effects was 27.1%, 19.0%, 10.0%, 10.5%, and 7.4% in the EE/DRSP group and 29.2%, 15.7%, 14.0%, 23.1%, and 0.0% in the DNG group at Y1, Y2, Y3, Y4, and Y5, respectively. The discontinuation rates were 1.7%, 1.7%, 4.0%, 0.0%, and 7.4% at Y1, Y2, Y3, Y4, and Y5, respectively, in the EE/DRSP group and 10.4%, 3.3%, 4.0%, 3.8%, and 0.0% at the same times in the DNG group. The recurrence rates were less than 4% in both the groups.Conclusions: The side effects of commonly prescribed postoperative hormone treatments were relatively mild, and the occurrence of side effects decreased with continuous administration. Further, the long-term use of postoperative hormone treatments is likely to prevent recurrence of endometriosis after surgery.

Hormonal Contraception: Systemic Estrogen and Progestin Preparations

Combined hormonal contraception (CHC) are short-acting, reversible methods containing both estrogen and progestin. Available CHC methods include combined oral contraceptives, transdermal patches, and vaginal rings. The combined oral contraceptive remains the most commonly used contraceptive method in the United States. The general principles of CHC will be reviewed, including mechanism of action and effectiveness. Unless otherwise stated, these principles apply to all CHCs. When discussing clinical studies and specific considerations related only to pills, patches, or rings, the method(s) will be specified. Words that specify sex are used when discussing studies in which sex was specified.

Efficacy of dienogest vs combined oral contraceptive on pain associated with endometriosis: Randomized clinical trial

OBJECTIVE

To compare the efficacy of dienogest with the combined oral contraceptive pill (COC) Yasmin for the control of endometriosis-associated pelvic pain.

STUDY DESIGN

Seventy women with endometriosis-associated chronic pelvic pain, dysmenorrhoea or both for >6 months were randomized to either dienogest (Visanne) 2 mg/day or monophasic COC (Yasmin, 0.03 mg ethinyl estradiol and 3 mg drospirenone) for 24 weeks. The primary efficacy variable was change in non-cyclic pelvic pain and dysmenorrhoea from baseline to end of treatment, assessed using a visual analogue scale (VAS). The secondary efficacy variable was change in the Biberoglu and Behrman (B&B) scale scores for chronic pelvic pain, dysmenorrhoea and dyspareunia. Health-related quality of life (HRQoL) was evaluated using the Endometriosis Health Profile-30 (EHP-30) questionnaire at baseline and 24 weeks. Safety variables included incidence of side-effects, bleeding pattern and treatment tolerability.

RESULTS

Both treatments improved the mean VAS score for endometriosis-associated pelvic pain significantly: mean difference 6.0 [95% confidence interval (CI) 4.9-7.1; p < 0.0001] in the dienogest group and 4.54 (95% CI 3.1-5.9; p < 0.0001) in the COC group; the difference between them was not significant (p = 0.111). Similarly, both dienogest and COC improved HRQoL in various core and modular segments of the EHP-30 questionnaire with comparable requirements for supplemental pain medication (p = 0.782 and 0.258 at 12 and 24 weeks, respectively), and redistribution of the B&B severity profile for chronic pelvic pain (p = 0.052 and 0.526 at 12 and 24 weeks, respectively), dysmenorrhoea (p = 0.521 and 1 at 12 and 24 weeks, respectively) and dyspareunia (p = 0.376 and 0.835, respectively). Nevertheless, dienogest was associated with fewer side-effects, and hence had a better safety and tolerability profile than COC.

CONCLUSIONS

Dienogest (2 mg/day) is comparable to the COC Yasmin for the relief of endometriosis-associated pelvic pain and improvement in HRQoL.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov under number NCT04256200; date of registration 15/1/2020 (registered retrospectively).

Medical Treatment for Endometriosis: Tolerability, Quality of Life and Adherence

Endometriosis is associated with painful symptoms, infertility, sexological difficulties, and psychological suffering. All these symptoms have a negative impact on the overall quality of life of women with the disease, with significant personal, social and economic costs. Several medical options are available to manage symptomatic endometriosis. The pharmacological treatment for endometriosis-related pain may be necessary for decades, or at least until there is a desire for pregnancy or physiologic menopause occurs. In this perspective, clinicians should consider not only the efficacy, but also side effects, tolerability, and costs, along with women's preferences toward different treatments. In this mini-review, we analyzed the pros and cons of the available drugs for the medical therapy of endometriosis, such as estrogen-progestins, progestins, GnRH agonist and GnRH antagonists.

Endometriosis of the Small Bowel: A Diagnostic Enigma

Endometriosis refers to the implantation and proliferation of endometrial tissue outside the uterus. Small bowel endometriosis is an uncommon location for endometrial deposits and when present, it can pose diagnostic difficulty. Here, we present a case of a 50-year-old female with small bowel endometriosis who suffered from recurrent attacks of colicky abdominal pain for few months. Her cross-sectional investigations remained largely inconclusive. Ultimately, she underwent diagnostic laparoscopy which was diagnostic and therapeutic.

Adolescent Endometriosis

Importance

Endometriosis is a major health concern in the adolescent population and significantly impacts daily physical and psychosocial functioning. Endometriosis can have differing presentations in this population, and the diagnosis often involves long delays and multiple visits to specialists.

Objective

The aim of this review is to discuss adolescent endometriosis, factors specific to this population, accurate diagnosis, and evidence-based surgical and medical management.

Evidence Acquisition

Computerized searches on the topic of endometriosis and adolescent endometriosis were completed. References from identified sources were then searched manually to allow for a thorough review. Data from relevant sources were synthesized to create the review.

Results

The literature supports endometriosis as a frequent cause of secondary dysmenorrhea. The characteristics of adolescents with endometriosis are shown to differ from those of adults. Initial medical therapy includes nonsteroidal anti-inflammatory drugs and combined hormonal contraceptives, but laparoscopy does have a role in the adolescent population, particularly those who have inadequate response to these treatments. Adolescent endometriosis may have a different appearance and be of all stages. Medical therapies are similar to that of the adult population; however, the benefits of medical and surgical management must be tailored to the adolescent patient.

Conclusions and Relevance

Adolescent endometriosis is likely a more prevalent cause of dysmenorrhea than currently appreciated. A high index of suspicion combined with recognition of risk factors and history-based markers of endometriosis may help identify adolescent endometriosis earlier and avoid delays in diagnosis. Expert opinion supports earlier laparoscopic evaluation in patients with symptoms unresponsive to oral medications, those who have failed initial medical therapy, or those who have evidence of deeply invasive disease, such as an endometrioma. Surgeons should be familiar with the unique appearance of lesions in the adolescent and understand the evidence as it relates to surgical therapy. Postoperative medical management is generally advocated by many, although the efficacy remains unclear at present.

Surgical management of diaphragmatic and thoracic endometriosis': A French multicentric descriptive study

INTRODUCTION

Surgical management of Diaphragmatic and thoracic endometriosis (DTE) is still controversial, a thoracic or an abdominal approach can be proposed.

METHODS

We conducted a multicentric retrospective study in 8 thoracic, gynecology or digestive surgery units in 5 French university hospitals. The main objective was to review the current management of DTE.

RESULTS

50 patients operated for DTE from 2010 to 2017 were included: 26 with a thoracic approach and 24 with an abdominal approach. Preoperative pelvic endometriosis (PE) concerned 25 patients. In 38 patients, DTE diagnosis was made on clinical symptoms (pneumothorax (n = 19), chronic or catamenial chest pain (n = 18) or hemopneumothorax (n = 1)). Median time from onset of symptoms to diagnosis was 47 months (0-212). PE surgery concurrently occurred in 22 patients. We report diaphragmatic nodules, pleuropulmonary nodules and diaphragmatic perforations in 42, 5 and 22 women respectively. Lesions were right-sided in 45 patients. Nodules were destructed in 12 cases and resected in 38 cases. When a diaphragmatic reconstruction was needed (n = 31), a simple suture was performed in 26 patients, while 5 patients needed a mesh repair. Pleural symphysis was performed for all patients who received a thoracic approach. DTE resection was considered complete in 46 patients. Three patients had severe 30-days complications of DTE surgery. Median follow-up was 20 months (range 1-69). Recurrence occurred in 10 patients.

CONCLUSION

The results emphasize the importance of systematically looking for chest pain in patients suffering from PE and underline the lack of a standardized procedure and treatment in DTE.

Long-Term Medical Therapy after Laparoscopic Excision of Ovarian Endometriomas: Can We Reduce and Predict the Risk of Recurrence?

OBJECTIVES

Up to 32% of women experience anatomic recurrence after conservative surgery for endometriomas, while pain recurs in 10-40% of cases. Long-term postoperative hormonal therapy is recommended to prevent disease recurrence. We evaluated the efficacy of long-term therapy with estroprogestins (EPs) or progestins (Ps) in preventing endometrioma recurrence, as identifiable cysts and subjective symptoms, after laparoscopic excision.

DESIGN

This retrospective cohort study included 375 women submitted to laparoscopic endometrioma excision. Women were followed up at 6 and 12 months and then yearly after surgery. Based on postoperative medical therapy, women were divided into 4 groups: nonusers, cyclic EP users, continuous EP users, and progestogen users. Materials, Setting, Methods: Anamnestic and anthropometric characteristics were collected as well as clinical and surgical data. Gynecological examination, and transvaginal and transabdominal ultrasound scans were performed. Pain (numerical rating score >5) and endometrioma recurrence at ultrasound (ovarian cyst with typical sonographic features ≥10 mm in mean diameter) were recorded at each examination. The reoperation rate in women with recurrence was investigated.

RESULTS

The median follow-up was 3.7 years with a maximum of 16.7 years. Most patients used EPs (119 cyclic and 61 continuous users), 95 used P, and 100 were nonusers. In 135 women (36%), endometriotic cyst recurrence was diagnosed, with a mean diameter of 18.7 ± 10.8 mm (range 10-55 mm). The median recurrent cyst-free time was 7.9 years (95% CI 5.8-10.8). Dysmenorrhea was the first symptom to reappear, affecting 162 patients (43.2%). Upon multivariable regression analysis, continuous users had a lower risk of relapse (OR 0.56, 95% CI 0.32-0.99), in terms of both cysts and symptom recurrence, than patients who received no medications. The reoperation rate was 16.2%.

LIMITATIONS

The main limitation of this study is its retrospective design. Also, women switching therapies throughout the follow-up period were sorted into one of the study groups based on the longest treatment taken, without considering the discontinuation rates.

CONCLUSIONS

Long-term EPs, administered in a continuous regimen and starting immediately after conservative surgery for endometriomas, seem to reduce the disease recurrence risk.

Efficacy of cyclic and extended regimens of ethinylestradiol 0.02 mg -levonorgestrel 0.09 mg for dysmenorrhea: A placebo-controlled, double-blind, randomized trial

PURPOSE

We aimed to evaluate the efficacy and safety of 28-day Cyclic and 84-day Extended regimens of NPC-16 (ethinylestradiol 0.02 mg plus levonorgestrel 0.09 mg) in patients with dysmenorrhea.

METHODS

This was a placebo-controlled, double-blind, randomized trial conducted in Japan. A total of 251 primary and secondary dysmenorrhea patients were randomly assigned to the NPC-16-Cyclic group, NPC-16-Extended group, or the Placebo group. The primary end point was a comparison of the efficacy and safety of the Cyclic and Extended NPC-16 regimen for the treatment of dysmenorrhea relative to the Placebo.

MAIN FINDINGS

Significantly greater reductions in total dysmenorrhea score and visual analog scale score were observed in the Cyclic and Extended groups compared with the Placebo group. Compared with the Cyclic regimen as a secondary end point, the Extended regimen exhibited greater efficacy in the treatment of dysmenorrhea over the course of the study period, particularly in patients with severe dysmenorrhea. The incidence of adverse drug reactions (ADRs) was significantly higher in the Cyclic and Extended groups than in the Placebo group.

CONCLUSION

The Cyclic and Extended regimens of NPC-16 significantly reduced dysmenorrhea severity compared to placebo. The Extended regimen was superior to cyclic regimen in reducing the dysmenorrhea.

Endometriosis presenting as vaginal polyps: outpatient vaginoscopic treatment

OBJECTIVE

To demonstrate an outpatient vaginoscopic technique for treating multiple vaginal polyps.

DESIGN

Demonstration of surgical technique using slides, pictures, and video.

SETTING

Private hospital.

PATIENT(S)

Thirty-two-year-old nulligravid woman presenting to the gynecology clinic with one episode of intermenstrual bleeding, regular menstrual cycles with normal flow, and no history of dysmenorrhoea or dyspareunia. The genital local examination was normal, and speculum examination showed multiple vaginal lesions like polyps in the proximal posterior two-thirds and right lateral vaginal walls. Her transvaginal ultrasound read a normal uterus with a right ovarian simple cyst.

INTERVENTION(S)

The surgeon performed an outpatient operative vaginoscopy using a 5-mm continuous flow office hysteroscope with a 2.9-mm rod lens optical system and a 5F working channel. Distension of the vagina was achieved with a normal saline solution, and an intrauterine pressure of 50 to 60 mm Hg was maintained by an irrigation and aspiration electronic pump. An inspection of the vaginal walls, fornices, and the external cervical os (Fig. 1) revealed 10 vaginal lesions like polyps in the proximal two-thirds of the posterior and right lateral vaginal wall. The vaginal lesions (Fig. 2) varied in size from 0.5 cm to 4 cm. An excisional biopsy was performed and the sample sent for histopathologic evaluation. The vaginal lesions <2 cm in length were excised by cutting the base with scissors or using a bipolar vaporization electrode, which was connected to an electrocautery unit by a bipolar high-frequency cord. Vaginal lesions >2 cm were excised with the TruClear 5C Hysteroscopic Tissue Removal System (HTRS) with a zero-degree scope using the 2.9-mm incisor with a 5-mm cutting window at one end attached to a reusable handpiece with two connectors-one to the motor unit and second to the suction bottle with a collection bag. The overall diameter of TruClear 5C is 5.7 mm, and the optic size is 0.8 mm. The same irrigation pump is compatible with HTRS, and the pressure was increased to 150 mm Hg to maintain vaginal distension. Three factors influenced our decision to use the HTRS intraoperatively: the number and size of the vaginal lesions and the surgical time in the outpatient setting. A mechanical system that works on the principle of excising and aspirating tissue, the HTRS incisor has a rotatory action with the excising window placed against the most distal part of the vaginal lesions. The cutting action is controlled via a foot pedal attached to a motor control with 800 rotations per minute. The handpiece remains stationary while the polyp is excised and aspirated through the window into the collection bag. Minimal bleeding occurred and stopped spontaneously. The institutional ethics committee exempted this case report from review, and we obtained informed written consent from the patient.

MAIN OUTCOME MEASURE(S)

All vaginal lesions excised in an outpatient setting via vaginoscopy technique without anesthesia.

RESULT(S)

The operative time with the Bettocchi hysteroscope was 14 minutes, and HTRS was 6 minutes. The patient did not complain of pain but did describe minimal discomfort, rated on the visual analog scale as 2 (where ≥5 is severe pain). She was discharged 1 hour later. The histopathology was reported as vaginal endometriosis (ectopic presentation of endometriosis is rare, accounting for 0.02% of cases). After surgery, she was started on cyclical oral contraceptive pills (OCP) in the combination of 30 mg of ethinyl estradiol + 2 mg of dienogest because she desired to delay pregnancy by 1 year. She remained asymptomatic for 6 months. These contraceptive hormones are available in the form of oral pills, vaginal rings, and transdermal patches, and a physician can provide OCP continuously or cyclically. Continuous OCP is more efficacious for control of dysmenorrhoea, but cyclical OCP is preferred because it is affordable, tolerable, effective, produces no unpredictable bleeding, and slows the progression of the disease. (A cohort study found the contraceptive vaginal ring to be more effective for symptom-control in rectovaginal endometriosis with higher patient satisfaction than the transdermal patch; vaginal rings or transdermal patches are not available in some countries.) CONCLUSION(S): Vaginoscopy allows a more in-depth visualization of the vagina with complete inspection and removal of all polyps. Vaginoscopy is feasible in the outpatient setting and allows a comfortable, ergonomic position for the surgeon. Vaginoscopy or no-touch technique avoids the use of a speculum or tenaculum and results in minimal pain during the outpatient procedure.

Comparison of dienogest versus combined oral contraceptive pills in the treatment of women with adenomyosis: A randomized clinical trial

OBJECTIVE

To compare the efficacy and safety of dienogest with combined oral contraceptives (COCs) for treating adenomyosis-associated symptoms.

METHODS

This was a randomized clinical trial including women with symptomatic adenomyosis conducted from March 1, 2019 to August 1, 2020 at Assiut Woman's Health Hospital, Egypt. Participants were randomly assigned to the dienogest group or COCs group. The primary outcome was the level of adenomyosis-associated pain from before to 6 months after treatment measured by a visual analog scale (VAS). Changes in the uterine bleeding pattern, uterine volume, and uterine artery blood flow were also reported.

RESULTS

The VAS score of pain was significantly decreased in both groups; however, the decreased rate was more pronounced in the dienogest group (3.21 ± 1.18) in comparison with the COCs group (4.92 ± 1.22). Bleeding pattern was improved greatly; uterine volume and uterine artery blood flow decreased significantly in the dienogest group. However, women in the dienogest group reported a higher rate of side effects.

CONCLUSION

Dienogest and COCs are effective in treating adenomyosis-associated symptoms after 6 months of use but dienogest is more effective. The decrease in uterine volume and uterine artery blood flow may be the cause of the treatment effect. Dienogest carries a higher risk of side effects.

CLINICAL TRIAL

gov: NCT03890042.

Adherence to the oral contraceptive pill: the roles of health literacy and knowledge

OBJECTIVE

The oral contraceptive pill is the most widely used method of contraception and when adhered to perfectly is 99% effective at preventing pregnancy. However, adherence to the pill is relatively low. Knowledge has shown to be important in continuation of the pill, and previous research shows the importance of health literacy in adhering to medication in chronic illnesses, but its role has yet to be explored in this behavior.

METHODS

This cross-sectional study examined the associations between health literacy, knowledge of the pill and adherence, as well as the predictive ability of these two variables and their interaction, in predicting adherence. Recruited through CloudResearch, 193 women (M age = 32.63 years, SD = 5.98) residing in the United States completed the Health Literacy Skills Instrument - Short Form, a previously validated measure of oral contraceptive pill knowledge and the Medication Adherence Report Scale.

RESULTS

Results showed a strong positive correlation between health literacy and adherence (r = .76) and moderate associations between health literacy and knowledge (r = .42), and knowledge and adherence (r = .42). The final model of the hierarchical multiple regression accounted for 59.8% of variance in adherence, with health literacy (β = .69) and length of time taking the pill (β = .13) the only significant predictors of adherence.

CONCLUSION

Family planning clinics should consider assessing the patient's health literacy skills before prescribing the pill to ensure patients fully understand the requirements.

Does Nomegestrol Acetate Plus 17β-Estradiol Oral Contraceptive Improve Endometriosis-Associated Chronic Pelvic Pain in Women?

Background: To evaluate the effects of a 24/4 regimen combined oral contraceptive (COC) containing 1.5 mg 17β-estradiol (E2) and 2.5 mg nomegestrol acetate (NOMAC) compared to on-demand nonsteroidal anti-inflammatory drugs (NSAIDs) on women affected by endometriosis-associated chronic pelvic pain (the primary end point) and their quality of life (QoL) and sexual function (the secondary end points).

Materials and Methods: Ninety-nine women on E2/NOMAC constituted the study group; and 63 women on NSAIDs constituted the control group. The visual analogic scale was used to measure the levels of pelvic pain, dysmenorrhea, and dyspareunia. To assess their QoL, sexual function, and sexual distress, the Short Form-36 (SF-36), the Female Sexual Function Index (FSFI), and the Female Sexual Distress Scale (FSDS) were used, respectively. The study included two follow-ups at 3 and 6 months.

Results: Improvement in chronic pelvic pain was observed in the study group at both the 3- and 6-month follow-ups (p < 0.001). SF-36, FSFI, and FSDS had a similar trend at the 3- and 6-month follow-ups (p < 0.001). Women on NSAIDs did not report any reduction in pain symptoms or improvement in QoL (p ≤ 0.4). However, they had a limited improvement of their FSFI and FSDS (p < 0.001). The improvement of the pain symptoms, QoL, FSFI, and FSDS, was more evident in women on E2/NOMAC than in those on NSAIDs, when the study group and control group values were compared at the 3- and 6-month follow-ups (p < 0.001).

Conclusions: Women on E2/NOMAC COC showed a better reduction of endometriosis-associated chronic pelvic pain and an improvement of their QoL and sexual activity than those of the women on NSAIDs.

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.

CHC for pelvic pain in women with endometriosis: ineffectiveness or discontinuation due to side-effects

STUDY QUESTION

What are the use patterns and factors associated with combined hormonal contraception (CHC) ineffectiveness or discontinuation due to side-effects in patients with endometriosis and pelvic pain?

SUMMARY ANSWER

Worse chronic pelvic pain (CPP) severity and pelvic floor myalgia were associated with continuous CHC ineffectiveness, while poorer quality-of-life was associated with continuous CHC discontinuation due to side-effects.

WHAT IS KNOWN ALREADY

CHC is a first line of therapy for endometriosis-associated pelvic pain in women. However, some patients state that CHC is ineffective for their pain, while others have to discontinue CHC due to side-effects.

STUDY DESIGN, SIZE, DURATION

Analysis of a prospective patient database from a tertiary care referral center for patients with endometriosis and pelvic pain between December 2013 and April 2015 was carried out.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

A total of 373 patients of reproductive age with endometriosis from the database were included in the study. Data included patient self-reported questionnaires, physical examination findings and validated instruments. There were four variables of interest: history of cyclical CHC ineffectiveness (yes/no), history of cyclical CHC discontinuation due to side-effects (yes/no), history of continuous CHC ineffectiveness (yes/no) and history of continuous CHC discontinuation due to side-effects (yes/no). The primary outcome was CPP severity for the past 3 months (score of 0–10), and secondary outcomes were other pelvic pain scores, quality-of-life on the Endometriosis Health Profile 30 (EHP-30) and underlying conditions including irritable bowel syndrome, painful bladder syndrome, abdominal wall pain, pelvic floor myalgia and depression, anxiety and pain catastrophizing.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 373 cases in the dataset, prior cyclical CHC use was reported by 228 (61.1%) women, of which 103 (27.6%) stated it was ineffective for their pain and 94 (25.2%) stated they discontinued CHC due to side-effects. Previous continuous CHC use was reported by 175 (46.9%) women, of which 67 (18.0%) stated it was ineffective and 59 (15.8%) stated they discontinued due to side-effects. Worse CPP severity in the last 3 months was associated with a history of continuous CHC ineffectiveness (P < 0.001). Poorer quality-of-life was present in women who reported a history of continuous CHC discontinuation due to side-effects (P = 0.005). Among the underlying conditions, pelvic floor tenderness (as a marker of pelvic floor myalgia) was associated with CHC ineffectiveness.

LIMITATIONS AND REASONS FOR CAUTION

This study involved patient recall and no longitudinal follow-up. Also, we do not have data on the type of side-effect that led to discontinuation. Medication ineffectiveness was reported subjectively by the patient rather than using standardized criteria. Finally, the diagnosis of endometriosis was based on previous surgery or a current nodule or endometrioma on examination/ultrasound; without prospective surgical data on all the patients, it was not possible to do a sub-analysis by current surgical features (e.g. stage).

WIDER IMPLICATIONS OF THE FINDINGS

In women with endometriosis, CHC ineffectiveness was associated with worse CPP and pelvic floor myalgia, which suggests myofascial or nervous system contributors to CPP that does not respond to hormonal suppression. A tender pelvic floor, as a sign of pelvic floor myalgia, may be a clinical marker of patients with endometriosis who are less likely to have an optimal response to hormonal suppression. For women who discontinue CHC due to side-effects, research is needed to help alleviate these side-effects as these patients report worse quality-of-life.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a Canadian Institutes of Health Research (CIHR) Transitional Open Operating Grant (MOP-142273) as well as BC Women’s Hospital and the Women’s Health Research Institute. PY is also supported by a Health Professional Investigator Award from the Michael Smith Foundation for Health Research. MB/CA has financial affiliations with Abbvie and Allergan; the other authors have no conflicts of interest.

No. 345-Primary Dysmenorrhea Consensus Guideline

OBJECTIVE

This guideline reviews the investigation and treatment of primary dysmenorrhea.

INTENDED USERS

Health care providers.

TARGET POPULATION

Women and adolescents experiencing menstrual pain for which no underlying cause has been identified.

EVIDENCE

Published clinical trials, population studies, and review articles cited in PubMed or the Cochrane database from January 2005 to March 2016.

VALIDATION METHODS

Seven clinical questions were generated by the authors and reviewed by the SOGC Clinical Practice-Gynaecology Committee. The available literature was searched. Guideline No. 169 was reviewed and rewritten in order to incorporate current evidence. Recommendations addressing the identified clinical questions were formulated and evaluated using the ranking of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Primary dysmenorrhea is common and frequently undertreated. Effective therapy is widely available at minimal cost. Treatment has the potential to improve quality of life and to decrease time lost from school or work.

GUIDELINE UPDATE

This guideline is a revision and update of No. 169, December 2005.

SPONSORS

SOGC.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Gynaecology problems in puberty

With the onset of puberty a range of problems may be encountered by the young girl. Some of these include a range of gynaecological issues relating to delayed onset of puberty, delayed menarche, atypical pubertal changes and the identification of anomalies of the genital tract. The distinction between physiological events and pathological problems is important to avoid unnecessary distress and anxiety. The onset of cyclic hormonal changes also provokes a number of "non-gynaecological" problems - where the link to cyclic hormonal events is often overlooked and an important opportunity to potentially intervene and assist is missed. From a global perspective there are a range of problems that are particularly encountered with the onset of puberty including the risks of sexual violence, which in the setting of having achieved the age of reproductive potential result in unplanned pregnancies, unsafe abortions and adolescent pregnancy all of which pose life threatening risks. Sex education in its broadest sense is important for all young people. Access to contraception for adolescents is vital, such that clinicians across all streams of health care who are involved in the care of young people should take the opportunity to educate and provide this care.

Continuous vs. cyclic combined hormonal contraceptives for treatment of dysmenorrhea: a systematic review

Objective

This systematic review aims to evaluate the benefits of oral continuous combined hormonal contraceptives (CHCs) in managing dysmenorrhea by comparing randomized controlled trials (RCTs) evaluating the efficacy of continuous vs. cyclic CHC use for the following outcomes: (a) reducing dysmenorrhea duration and frequency, (b) severity, (c) recurrence and (d) interference with daily activity.

Study design

Cochrane, PUBMED and Popline databases were searched from 1934 to 2018 for all relevant studies evaluating CHC for treatment of dysmenorrhea. A study was selected if it (a) compared continuous regimen vs. cyclic regimen of oral CHC, (b) measured dysmenorrhea as a primary or secondary outcome, (c) was an RCT and (d) was published in English. Due to differences in CHC used and outcome measurement, a systematic analysis of individual study results and a limited meta-analysis were conducted.

Results

Of 780 studies that were screened by title and abstract, 8 were included in the final analysis; 6 evaluated cyclic vs. continuous CHC, and 2 evaluated cyclic vs. extended/flexible CHC use. Quality of evidence was low for all outcome measures. Overall, compared to cyclic use, flexible/extended CHC resulted in 4 fewer days of dysmenorrhea. Studies revealed conflicting results for interference with daily activity, pain severity and pain recurrence. Side effects were few in both comparison groups.

Conclusions

Continuous or extended/flexible CHC use may reduce dysmenorrhea duration compared to cyclic regimen; however, more rigorous research is needed.

Implications

This systematic review shows that continuous CHC use may reduce dysmenorrhea duration compared to cyclic regimen, although the quality of evidence is low. Future double-blinded RCTs with more rigorous study design, consistent outcome measures and comprehensive outcome reporting are needed.

Does exist a correlation between endometriosis and thrombophilic disorders? A pilot study

OBJECTIVE

At present, there is growing evidence of the existence of a genetic predisposition in both thrombophilic disorders and endometriosis. The aim of our study was to evaluate for the first time the prevalence of some thrombophilic disorders in patients with endometriosis.

MATERIALS AND METHODS

We conducted a retrospective study on 138 patients with endometriosis and 278 healthy control women. All women were subjected to a blood examination testing for thrombophilic screening and the variables examinated were: hyperhomocysteinemia, factor V Leiden and factor II prothrombin G20210A mutations in heterozygosis and homozigosis.

RESULTS

A significant reduced prevalence (p < 0.05) of factor V Leiden mutation in endometriosis patients was found, whereas no significant differences (p = NS) for factor II and hyperhomocysteinemia were observed.

CONCLUSION

Our preliminary data do not show any association between thrombophilic condition and endometriosis. Before assuming hormonal therapies, a thrombophilic plasmatic screening seems to be unnecessary in patients affected by endometriosis.

Consensus Statement on the Use of Oral Contraceptive Pills in Polycystic Ovarian Syndrome Women in India

OBJECTIVE

To provide consensus recommendations for health-care providers on the use of oral contraceptive pills (OCPs) in polycystic ovarian syndrome (PCOS) women in India.

PARTICIPANTS

Extensive deliberations, discussions, and brainstorming were done with different fraternities (specialists) being involved. These included endocrinologists, gynecologists, reproductive endocrinologists, dermatologists, public health experts, researchers, and a project manager with a team to develop the guideline.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 2003 to December 2017 using appropriate-controlled vocabulary (e.g., oral contraceptive pills, polycystic ovarian syndrome, long term outcomes, infertility). Clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies' publications and data were also reviewed to suggest the recommendations.

PROCESS

The working group for guideline committee included members from the PCOS Society (India), Indian Society for Assisted Reproduction, The Mumbai Obstetric and Gynecological Society, The Endocrine Society of India, Indian Association of Dermatologists, Venereologists and Leprologists, Cosmetic Dermatology Society (India), Academicians from Medical Colleges, National Institute for Research in Reproductive Health, and a Research Associate. The core team included five reproductive endocrinologists, five gynecologists, five dermatologists, three endocrinologists, two public health experts and one research associate.

CONCLUSIONS

This consensus statement provides the guidance/recommendations for Indian practitioners regarding the use of OCP in women with PCOS. PCOS is one of the common endocrinopathies encountered in gynecological/endocrine practice. The spectrum of this disorder may range from prepubertal girls with premature pubarche, young girls with hirsutism, acne and anovulatory cycles, married women with infertility, and elderly women. Although obesity is a common feature for most PCOS patients, 'lean PCOS' also exists. For several years, OCPs have played an important role in the symptom management of PCOS women. This is due to the fact that OCPs decrease the luteinizing hormone, reduce androgen production, and increase sex hormone-binding globulin, which binds androgens. Several new formulations of OCPs have been developed to decrease the side effects. This includes use of less androgenic progestins and lower doses of ethinyl estradiol. These consensus recommendations help the health provider to choose the right type of OCPs, which will alleviate the symptoms with least side effects. It also gives insight into the indications, contraindications, and concerns regarding its short, intermediate and long-term use.

Management of Chronic Pelvic Pain

The management of chronic pelvic pain poses a significant challenge to both physicians and patients. Patients should be evaluated for both gynecologic and nongynecologic conditions, and >1 source may be identified. Treatment involves medical as well as surgical options, and it is important to set realistic goals with patients. Treatment may not be curative, but should improve the patient's quality of life.

The Investigation and Management of Adenomyosis in Women Who Wish to Improve or Preserve Fertility

The management of adenomyosis remains a great challenge to practicing gynaecologists. Until recently, hysterectomy has been the only definitive treatment in women who have completed child bearing. A number of nonsurgical and minimally invasive, fertility-sparing surgical treatment options have recently been developed. This review focuses on three aspects of management, namely, (1) newly introduced nonsurgical treatments; (2) management strategies of reproductive failures associated with adenomyosis; and (3) surgical approaches to the management of cystic adenomyoma.

[Endometriosis medical treatment: Hormonal treatment for the management of pain and endometriotic lesions recurrence. CNGOF-HAS Endometriosis Guidelines]

The available literature, from 2006 to 2017, on hormonal treatment has been analysed as a contribution to the HAS-CNGOF task force for the treatment of endometriosis. Available data are heterogeneous and the general level of evidence is moderate. Hormonal treatment is usually offered as the primary option to women suffering from endometriosis. It cannot be used in women willing to conceive. In women who have not been operated, the first line of hormonal treatment includes combined oral contraceptives (COC) and the levonorgestrel-releasing intra uterine system (52mg LNG-IUS). As a second line, desogestrel progestin only pills, etonogestrel implants, GnRH analogs (GnRHa) with add back therapy and dienogest can be offered. Add back therapy should include estrogens to prevent bone loss and improve quality of life, it can be introduced before the third month of treatment to prevent side effects. The literature does not support preoperative hormonal treatment for the sole purpose of reducing complications or recurrence, or facilitating surgical procedures. After surgical treatment, hormonal treatment is recommended to prevent pain recurrence and improve quality of life. COCs or LNG IUS are recommended as a first line. To prevent recurrence of endometriomas COC is advised and maintained as long as tolerance is good in the absence of pregnancy plans. In case of dysmenorrhea, postoperative COC should be used in a continuous scheme. GnRHa are not recommended in the sole purpose of reducing endometrioma recurrence risk.

Pathogenesis of endometriosis: Interaction between Endocrine and inflammatory pathways

Despite an estimated prevalence of 11% in women and plausible historical descriptions dating back to the 17th century, the etiology of endometriosis remains poorly understood. Classical theories of the histological origins of endometriosis are reviewed below. Clinical presentations are variable, and signs and symptoms do not correlate well with the extent of disease. In this summary, we have attempted to synthesize the growing evidence that hormonal and immune factors conspire to activate a local inflammatory microenvironment that encourages endometriosis to persist and elaborate mediators of its two cardinal symptoms: pain and infertility. Surprisingly, in the search for novel therapeutics for medical treatment of endometriosis, some compounds appear to have dual pharmacological functions, simultaneously modifying the endocrine and immune system facets of this complex gynecologic syndrome. We predict that these lead drugs will provide more therapeutic choices for patients in the future.

Laparoscopic surgery with urinary tract reconstruction and bowel endometriosis resection for deep infiltrating endometriosis

Deep infiltrating endometriosis (DIE) is the most severe form of endometriosis. It causes chronic pelvic pain, severe dysmenorrhea, deep dyspareunia, dyschezia, and dysuria, markedly impairing the quality of life of women of reproductive age. A number of randomized controlled trials on surgical and medical treatments to reduce the pain associated with endometriosis have been reported, but few have focused on this in DIE. DIE causes not only pain but also functional invasion to the urinary organs and bowel, such as hydronephrosis and bowel stenosis. In addition to DIE resection, surgical treatment involves adhesion separation as well as resection and reconstruction of the urinary organs and bowel; high-level skills are required. The severity of DIE should be evaluated preoperatively as accurately as possible. Using ENZIAN in conjunction with the AFS (The revised American Fertility Society classification of endometriosis) classification makes a more detailed assessment of DIE possible. The operative procedures used for laparoscopic resection of urinary DIE and reconstruction of the urinary organs are chosen based on the type of lesion (intrinsic/extrinsic) and length of stenosis. In addition to ureteroneocystostomy, the psoas bladder hitch and Boari bladder flap procedures are applied when necessary to extend the urinary tract. Bowel resection for bowel endometriosis is classified into classic segmental resection and conservative approaches (shaving/discoid). When these procedures are employed, it is advisable to work in consultation with urologists and gastroenterologists and to inform the patients of the associated risks and outcomes. Furthermore, postoperative medication is essential because it is difficult to conduct repeated surgeries.

Endometriosis: Diagnosis and Management

Objective

To improve the understanding of endometriosis and to provide evidence-based guidelines for the diagnosis and management of endometriosis.

Outcomes

Outcomes evaluated include the impact of the medical and surgical management of endometriosis on women's experience of morbidity and infertility.

Methods

Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of both location in Canada and type of practice, as well as subspecialty expertise along with general gynaecology background. The committee reviewed all available evidence in the English and French medical literature and available data from a survey of Canadian women. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC.

Results

This document provides a summary of up-to-date evidence regarding diagnosis, investigations, and medical and surgical management of endometriosis. The resulting recommendations may be adapted by individual health care workers when serving women with this condition.

Conclusions

Endometriosis is a common and sometimes debilitating condition for women of reproductive age. A multidisciplinary approach involving a combination of lifestyle modifications, medications, and allied health services should be used to limit the impact of this condition on activities of daily living and fertility. In some circumstances surgery is required to confirm the diagnosis and provide therapy to achieve the desired goal of pain relief or improved fecundity. Women who find an acceptable management strategy for this condition may have an improved quality of life or attain their goal of successful pregnancy.

Evidence

Medline and Cochrane databases were searched for articles in English and French on subjects related to endometriosis, pelvic pain, and infertility from January 1999 to October 2009 in order to prepare a Canadian consensus guideline on the management of endometriosis.

Values

The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force. See Table 1.

Benefits, harms, and costs

Implementation of the guideline recommendations will improve the care of women with pain and infertility associated with endometriosis.

Is Shifting to a Progestin Worthwhile When Estrogen-Progestins Are Inefficacious for Endometriosis-Associated Pain?

The purpose of this study was to assess the proportion of patients satisfied with their treatment after a change from a low-dose oral contraceptive (OC) to norethisterone acetate (NETA) because of inefficacy of OC on pain symptoms. To this end, prospective, self-controlled study was conducted on 153 women using OC as a treatment for endometriosis and with persistence of one or more moderate or severe pain symptoms. At baseline and during 12 months after a shift from OC to oral NETA, 2.5 mg/d, pelvic pain was measured by means of a 0- to 10-point numerical rating scale and a multidimensional categorical rating scale. Variations in health-related quality of life, psychological status, and sexual function were also evaluated with validated scales. At the end of the study period, participants indicated the degree of satisfaction with their treatment according to a 5-degree scale from very satisfied to very dissatisfied. A total of 28 women dropped out of the study, the main reason was intolerable side effects (n = 15). At 12-month assessment, 70% of participants were very satisfied or satisfied with NETA treatment (intention-to-treat analysis). Statistically significant improvements were observed in health-related quality of life, psychological status, and sexual function. At per-protocol analysis, almost half of the patients (58/125) reported suboptimal drug tolerability. However, complaints were not severe enough to cause dissatisfaction, drug discontinuation, or request for surgery. These encouraging results could be used to counsel women with symptomatic endometriosis not responding to OC and to inform their decisions on modifications of disease management.

A case of endometriosis causing acute large bowel obstruction

•

Endometriosis causing acute large bowel obstruction is extremely rare.

•

Diagnostic challenges still remain in recognising intestinal endometriosis with or without intestinal obstruction.

•

Definitive surgical management is needed for endometriosis causing acute intestinal obstruction.

Introduction

Endometriosis is a gynaecological condition which produce symptoms such as pelvic pain, abnormal menstruation and infertility. Intestinal endometriosis can occur however endometriosis causing acute large bowel obstruction is extremely rare.

Presentation of case

We present a 37-year-old lady with acute large bowel obstruction caused by endometriosis. Despite initial endoscopic decompression being unsuccessful due to severe mucosal stenosis, she underwent emergency laparoscopic wedge resection and decompression successfully.

Discussion

Diagnosing intestinal endometriosis is difficult. While different modalities of investigation help, definitive diagnosis is achieved via laparoscopy. Treatment of obstruction is decompression followed by surgical resection.

Conclusion

Diagnosing intestinal endometriosis with or without obstruction is challenging. Correct diagnosis is needed for definitive management.

[Medical treatment of endometriosis: Hormonal treatment of pain, impact on evolution and future perspectives]

CONTEXT

Endometriosis is a chronic painful disease, for which hormone therapy is usually offered as a first line option to women not willing to conceive.

OBJECTIVES

To analyse and synthesize the literature, from 2006 onwards, on pain control, and disease evolution in oemn using combined hormonal contraceptives, progestins and GnRH analogs. Data on other current and future treatment perspectives is included as well.

SOURCES

Medline (Pubmed), the Cochrane Library, and endometriosis treatment recommendations published by European Society of Human Reproduction and Embryology (ESHRE), National Institute for health and Care Excellence (NICE), American College of Obstetricians and Gynecologists (ACOG), Royal College of Obstetricians and Gynaecologists (RCOG) and Société des Obstétriciens et Gynécologues du Canada (SOGC).

STUDY SELECTION

Meta-analysis and clinical trials are included.

RESULTS

Study quality is heterogeneous in general. Hormone therapy inconstantly allows pain relief and prevention of endometrioma and rectovaginal wall nodules recurrence. Available molecules and routes of administration as well as risk benefit balance are evaluated. Data on future perspectives are limited to date and do not allow use in routine.

CONCLUSION

Hormonal treatment of endometriosis relies on combined hormonal contraceptives (using different routes of administration), progestins and particularly the levonorgestrel-releasing IUS, and GnRH analogs as a last option, in combination with an add-back therapy. Promising alternatives are currently under preclinical and clinical evaluation.