Chocolate cysts from ovarian follicles

Distribution of endometriosis phenotypes according to patients' age in adult women with surgical evaluation

STUDY QUESTION

What is the distribution of endometriosis phenotypes according to age in adult women undergoing surgery?

SUMMARY ANSWER

The phenotype of endometriosis did not significantly vary after 24 years old.

WHAT IS KNOWN ALREADY

The phenotypic evolution of endometriosis over time remains unclear. While adolescents can exhibit any type of endometriosis lesions, ovarian endometriosis (OMA) and/or deep-infiltrating endometriosis (DIE) tend to increase with age in young adults. In adulthood, understanding the evolution of lesions is crucial for disease management, but the literature on this subject is limited. This study aims to examine the distribution of endometriosis phenotypes in relation to age among adult patients requiring surgical treatment.

STUDY DESIGN, SIZE, DURATION

This observational cohort study included patients aged between ≥18 and ≤42 years, who underwent surgery for benign gynecological conditions at our institution between January 2004 and December 2022. A standardized questionnaire was completed for each patient during a face-to-face interview conducted by the surgeon in the month preceding surgery. Women with histologically proven endometriosis were included.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The distribution of endometriosis phenotypes (isolated superficial (SUP) endometriosis, OMA ± SUP, DIE ± SUP/OMA) was compared between young adults (≤24 years) and adults (>24 years) and among adults (25-28 years, 29-33 years, 34-38 years, 39 to ≤42 years) using univariate and multivariate analysis. The distribution of different subtypes of DIE (uterosacral ligament(s), vagina, bladder, intestine, and ureter), OMA size, and intensity of pain symptoms were also examined.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1311 adult women with histologically proven endometriosis were included. In women aged 24 years or younger (n = 116), the distribution of endometriosis phenotypes differed significantly from women older than 24 years (n = 1195): The frequency of the DIE ± SUP/OMA phenotype was lower (41.4% versus 56.1%, respectively), while the rate of isolated superficial lesions was higher (from 32.0% versus 25.9%) (P = 0.001). In the group of women aged >24 years, a significantly higher proportion of vaginal DIE lesions (P = 0.012) and a lower proportion of uterosacral ligament DIE lesions (P = 0.004) were found compared to women aged ≤24 years. No significant differences were observed in terms of endometrioma size. Between the ages of 25 and 42 years, there were no significant changes in the distribution of endometriosis phenotypes after univariate and multivariate analysis. The distribution of subtype of DIE lesions did not significantly change with age between 25 and 42 years. Concerning pain symptom scores, there was a significant decrease with age for dysmenorrhea and dyspareunia.

LIMITATIONS, REASONS FOR CAUTION

Inclusion of only surgical patients may have introduced a selection bias. Women referred to our center may have suffered from particularly severe clinical forms of endometriosis.

WIDER IMPLICATIONS OF THE FINDINGS

This study highlights that endometriosis presentation did not change with age in adult women. Further research on endometriosis phenotype evolution is necessary to assist practitioners in clinical decisions and treatment strategies.

STUDY FUNDING/COMPETING INTERESTS

None declared.

TRIAL REGISTRATION NUMBER

N/A.

Safety of in-vitro fertilization in women with endometriosis

Management of women with endometriosis in general is complex. It requires a multidisciplinary and tailored approach. The time of in-vitro fertilization (IVF) may be particularly complicated because women with the disease face peculiar additional risks. In particular, oocytes retrieval may be more difficult and women with endometriomas are exposed to a low but consistent risk of infection and ovarian abscess development. There are also concerns regarding progression of deep invasive peritoneal lesions and misdiagnosis of an occult early ovarian cancer. However, evidence on these latter points is more controversial. Taken together, this body evidence is generally reassuring and does not justify prophylactic surgery prior to IVF to shrink these risks. However, given the uncertainties, women with endometriosis must be informed in depth of these peculiar additional risks.

Circulating CD56+ NKG2D+ NK cells and postoperative fertility in ovarian endometrioma

The current biomarkers for postoperative fertility assessment caused by ovarian endometrioma (OE) are insufficient. The present study hypothesized that the peripheral lymphocyte subpopulation can be used as a candidate biomarker of postoperative infertility in OE. The association of the number of circulating CD4/CD8 T, NK, and γδ T cells with postoperative fertility was assessed in 33 OE patients aged 20 ~ 40 years between June 2018 and January 2019. Concomitantly, 68 healthy female subjects were recruited. The changes in the baseline immune characteristics between the two groups were compared. The data demonstrated significant differences in the ratio of CD4/CD8 T cells and the number of CD56+ NKG2D+ NK cells and γδ T cells between OE patients and control subjects. The patients were followed-up till December 2019 and the number of CD56+ NKG2D+ NK cells in the cases was a significant predictor for postoperative fertility as determined by different COX regression models (crude HR = 0.220, 95% CI = 0.059–0.822; adjusted HR = 0.127, 95% CI = 0.024–0.675). A significant delay to successful pregnancy was noted in OE patients (median time, 173 vs. 99 days, log-rank P = 0.013). The present findings suggested that CD56+ NKG2D+ NK cells are a candidate biomarker of postoperative fertility in OE patients. Larger population studies are warranted.

Effect of endometrioma and its surgical excision on fertility (Review)

Endometrioma is the cystic lesion of ovaries originating from endometrial glands and stroma; it is identified in 17-44% of patients with endometriosis. Numerous existing studies have reported the association between endometrioma and infertility. However, an absolute cause-effect association requires further confirmation. Available evidence has suggested that ovarian reserve may be impaired by spatial occupation influences, local reaction or both, affecting the reproductive health of females. Given the increased focus on the pathophysiological mechanisms of endometrioma, surgical excision has commonly been considered to avoid further ovarian damage. However, the potential adverse effect of this surgery on the ovarian reserve has recently become a focal point. Whether or not surgical excision can facilitate subsequent conception in young females planning to be pregnant is controversial. As shown in the present review on the effects of endometrioma and its removal in females requiring assisted reproductive technology, prior surgery for endometrioma may not improve assisted fertility results and may further decrease the number of oocytes retrieved in the affected females. Subsequent studies are needed to ascertain the optimal management of infertility in the setting of endometriomas.

Free large sized intra-abdominal endometrioma in a postmenopausal woman: a case report

BACKGROUND

Endometriosis is an estrogen-dependent disease defined by the presence of endometrial glands and stroma out of the uterine cavity. Its prevalence is estimated to be 2-10% in reproductive aged women. Endometriosis occurrence is estimated to be 2.55% in postmenopausal patients due to the decreased levels of estrogen. Endometriosis can present in three different forms: superficial peritoneal implants, ovarian endometriomas, and deep infiltrating endometriosis. Ovarian endometriomas are the most common form of endometriosis. Even though endometriomas have been encountered in various localizations, a free abdominal endometrioma was only reported once in a premenopausal patient. Here, we are reporting the first case of a free large endometrioma in a postmenopausal patient.

CASE PRESENTATION

A 67-year-old woman presented to the emergency department at our university hospital complaining of constipation and right flank pain. She suffered from uncontrolled primary hypertension and type 2 diabetes mellitus. On presentation, she was afebrile, hypertensive, and tachycardic. An abdominal CT scan revealed a large cystic mass measuring 17 × 26 cm in the anterior-posterior and transverse diameters respectively. The cyst caused bowel obstruction and right sided hydronephrosis. The patient underwent laparotomy and during the surgical exploration a large abdominal cyst adhered to the greater omentum was found. The cyst received plenteous blood supply from the greater omentum. The uterus and both ovaries were completely normal and didn't have any connection to the cyst. An en-bloc cystectomy was performed successfully. The final histopathology report confirmed an abdominal endometrioma. The patient had an uneventful postoperative recovery.

CONCLUSIONS

Endometriomas might reach large sizes regardless of their location or the patient's age. The close relation of free abdominal endometriomas with the greater omentum suggests that these were developed from endometriotic omental implants. Endometrioma is rare in postmenopausal women. However, it should be considered as a possible differential diagnosis at any age.

Rethinking mechanisms, diagnosis and management of endometriosis

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.

Ultrasound Imaging in Endometriosis

Ultrasound examination is an indisputable imaging method in the diagnosis of endometriosis, as the first step in the detection, as the fundamental tool in planning the management, and as the best diagnostic instrument during surveillance of affected women. The aim of this article is to provide an update on the role of ultrasound in the detection, in the planning of medical and surgical treatment, and in the surveillance of patients with endometriosis.

Endometriosis

Pelvic endometriosis is a complex syndrome characterized by an estrogen-dependent chronic inflammatory process that affects primarily pelvic tissues, including the ovaries. It is caused when shed endometrial tissue travels retrograde into the lower abdominal cavity. Endometriosis is the most common cause of chronic pelvic pain in women and is associated with infertility. The underlying pathologic mechanisms in the intracavitary endometrium and extrauterine endometriotic tissue involve defectively programmed endometrial mesenchymal progenitor/stem cells. Although endometriotic stromal cells, which compose the bulk of endometriotic lesions, do not carry somatic mutations, they demonstrate specific epigenetic abnormalities that alter expression of key transcription factors. For example, GATA-binding factor-6 overexpression transforms an endometrial stromal cell to an endometriotic phenotype, and steroidogenic factor-1 overexpression causes excessive production of estrogen, which drives inflammation via pathologically high levels of estrogen receptor-β. Progesterone receptor deficiency causes progesterone resistance. Populations of endometrial and endometriotic epithelial cells also harbor multiple cancer driver mutations, such as KRAS, which may be associated with the establishment of pelvic endometriosis or ovarian cancer. It is not known how interactions between epigenomically defective stromal cells and the mutated genes in epithelial cells contribute to the pathogenesis of endometriosis. Endometriosis-associated pelvic pain is managed by suppression of ovulatory menses and estrogen production, cyclooxygenase inhibitors, and surgical removal of pelvic lesions, and in vitro fertilization is frequently used to overcome infertility. Although novel targeted treatments are becoming available, as endometriosis pathophysiology is better understood, preventive approaches such as long-term ovulation suppression may play a critical role in the future.

Molecular and Cellular Pathogenesis of Endometriosis

BACKGROUND

A substantial body of studies supports the view that molecular and cellular features of endometriotic lesions differ from those of eutopic endometrium. Apart from that, evidence exists that the eutopic endometrium from pa-tients with endometriosis differs from that of females without endometriosis.

OBJECTIVE

Aberrant expression profiles include a number of non-steroid signaling pathways that exert their putative influ-ence on the pathogenesis of endometriosis at least in part via crosstalk(s) with estrogen-mediated mechanisms. A rational to focus research on non-steroid signal pathways is that they might be remunerative targets for the development and selection of novel therapeutics to treat endometriosis possibly without affecting estrogen levels.

RESULTS AND CONCLUSION

In this article, we describe molecular and cellular features of endometriotic lesions and focus on the canonical WNT/β-signaling pathway, a key regulatory system in biology (including stem cell homeostasis) and often in pathophysiological conditions such as endometriosis. Recently emerged novel biological concepts in signal transduction and gene regulation like exosomes and microRNAs are discussed in their putative role in the pathogenesis of endometriosis.

[Definition, description, clinicopathological features, pathogenesis and natural history of endometriosis: CNGOF-HAS Endometriosis Guidelines]

Endometriosis and adenomyosis are histologically defined. The frequency of endometriosis cannot be precisely estimated in the general population. Endometriosis is considered a disease when it causes pain and/or infertility. Endometriosis is a heterogeneous disease with three well-recognized subtypes that are often associated with each other: superficial endometriosis (SUP), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). DIE is frequently multifocal and mainly affects the following structures: the uterosacral ligaments, the posterior vaginal cul-de-sac, the bladder, the ureters, and the digestive tract (rectum, recto-sigmoid junction, appendix). The role of menstrual reflux in the pathophysiology of endometriosis is major and explains the asymmetric distribution of lesions, which predominate in the posterior compartment of the pelvis and on the left (NP3). All factors favoring menstrual reflux increase the risk of endometriosis (early menarche, short cycles, AUB, etc.). Inflammation and biosteroid hormones synthesis are the main mechanisms favoring the implantation and the growth of the lesions. Pain associated with endometriosis can be explained by nociception, hyperalgia, and central sensitization, associated to varying degrees in a single patient. Typology of pain (dysmenorrhea, deep dyspareunia, digestive or urinary symptoms) is correlated with the location of the lesions. Infertility associated with endometriosis can be explained by several non-exclusive mechanisms: a pelvic factor (inflammation), disrupting natural fertilization; an ovarian factor, related to oocyte quality and/or quantity; a uterine factor disrupting implantation. The pelvic factor can be fixed by surgical excision of the lesions that improves the chance of natural conception (NP2). The uterine factor can be corrected by an ovulation-blocking treatment that improves the chances of getting pregnant by in vitro fertilization (NP2). The impact of endometrioma exeresis on the ovarian reserve (NP2) should be considered when a surgery is scheduled. Endometriosis is a multifactorial disease, resulting from combined action of genetic and environmental factors. The risk of developing endometriosis for a first-degree relative is five times higher than in the general population (NP2). Identification of genetic variants involved in the disease has no implication for clinical practice for the moment. The role of environmental factors, particularly endocrine disrupters, is plausible but not demonstrated. Literature review does not support the progression of endometriosis over time, either in terms of the volume or the number of the lesions (NP3). The risk of acute digestive occlusion or functional loss of a kidney in patients followed for endometriosis seems exceptional. These complications were revealing the disease in the majority of cases. IVF does not increase the intensity of pain associated with endometriosis (NP2). There is few data on the influence of pregnancy on the lesions, except the possibility of a decidualization of the lesions that may give them a suspicious aspect on imaging. The impact of endometriosis on pregnancy is debated. There is an epidemiological association between endometriosis and rare subtypes of ovarian cancer (endometrioid and clear cell carcinomas) (NP2). However, the relative risk is moderate (around 1.3) (NP2) and the causal relationship between endometriosis and ovarian cancer is not demonstrated so far. Considering the low incidence of endometriosis-associated ovarian cancer, there is no argument to propose a screening or a risk reducing strategy for the patients.

Progestins for the Treatment of Endometriosis: An Update

Endometriosis is a gynecological condition that affects approximately 10% of women of reproductive age, including 25–40% of infertile women. Dysmenorrhea, dyspareunia and chronic pelvic pain are the most common symptoms. Currently available medical therapies for endometriosis do not cure the disease, but are directed at symptom relief, typically utilizing the hormone responsiveness of endometriotic tissue to induce lesion atrophy. Unfortunately, pain relapse after treatment suspension is a common event. Treatment with pharmacological therapies for endometriosis should be conceived in terms of years, thus agents that must be withdrawn after a few months due to poor tolerability or severe metabolic side effects do not greatly benefit women with symptomatic endometriosis. The characteristics of progestins render this class an ideal pharmacological choice for administration over extended periods. The present paper will review the rationale for using progestins and their mechanism of action in endometriosis. Thereafter, the results obtained by various progestins in the treatment of endometriosis will be evaluated (danazol, gestrinone, norethisterone acetate, desogestrel, cyproterone acetate, megestrol acetate, medroxyprogesterone acetate, and levonorgestrel). A progestin called dienogest, recently introduced for the treatment of endometriosis, will be given special focus, describing its mechanism of action and clinical results.

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.

[Management of endometrioma]

Preoperative evaluation: clinical examination, and research for associated lesions. Laparoscopic approach. Cystectomy: gold standard, conformed to the endometrioma pathophysiology (3 zones). Laser CO₂ Plasmajet^® vaporisation: important data lead to legitimate utilisation. Haemostasis: be patient! Use of bipolar energy sparingly. Look for other endometriotic lesions, and systematic treatment. Preoperative medical treatment not always useful. Postoperative treatment: decrease recurrence. Especially for patients with no immediate pregnancy desire.

Postoperative desogestrel for pelvic endometriosis-related pain: a randomized controlled trial

OBJECTIVE

To determine the effectiveness of desogestrel for relieving endometriosis-related pain.

METHODS

A double-blinded randomized placebo-controlled trial was conducted in 40 patients who had endometriosis with moderate-to-severe dysmenorrhea or chronic pelvic pain undergoing laparoscopic conservative surgery. After surgery, patients were randomized to desogestrel or placebo group. Outcomes included changes in visual analog scale (VAS) of dysmenorrhea, pelvic pain and dyspareunia, patient satisfaction, and adverse effects.

RESULTS

Forty patients were randomized to desogestrel group (n = 20) and placebo group (n = 20). At month 6, the desogestrel group had significantly lower median VAS of overall pelvic pain, dysmenorrhea and noncyclic pelvic pain. Comparing with the placebo group, the desogestrel group had greater reduction in VAS of overall pain, dysmenorrhea and pelvic pain, but comparable reduction in VAS of dyspareunia. No patient in the desogestrel group but 4 patients in the placebo group still had moderate-to-severe pelvic pain at 6 months postoperatively. The proportion of patients who rated the treatment as very satisfied was higher in the desogestrel group than in the placebo group. There was no serious adverse event during the study period.

CONCLUSIONS

Desogestrel is effective and acceptable for postoperative therapy for patients with moderate-to-severe pain related to endometriosis.

The age-related recurrence of endometrioma after conservative surgery

OBJECTIVE

As endometrioma frequently recurs after conservative surgery, long-term postoperative medical treatment for the prevention of recurrence is necessary. However, it has not been elucidated whether long-term postoperative medical treatment is crucial to all patients until menopause. Thereupon, this study was conducted to evaluate the age-related recurrence patterns after conservative surgery for endometrioma.

STUDY DESIGN

A retrospective cohort study was performed on a total of 420 reproductive-aged women who underwent conservative surgery for endometrioma between January 2000 and December 2010. Ultrasonography was used during the follow-up period to detect endometrioma recurrence. Patients were classified into two groups according to the use of postoperative medications. The first group was observation only, while the second received gonadotropin releasing hormone agonists followed by cyclic oral contraceptives. The cumulative recurrence rate of endometrioma was compared according to the age at surgery (20-29 years, 30-39 years, 40-45 years) within each group. Subgroup analysis was performed according to the age between the two groups.

RESULTS

The median follow-up duration after surgery was 29.0 months (range 6-159 months) for all patients. After adjusting for parity, size and bilaterality of cyst, and stage with American Society for Reproductive Medicine classification of endometriosis which was statistically different, within the group of no treatment, the cumulative recurrence rate in 40-45 years (10.2%) was significantly lower compared with those in 20-29 years (43.3%; hazard ratio (HR)=0.04; 95% confidence interval (CI)=0.01-0.52) and 30-39 years (22.5%; HR=0.19; 95% CI=0.04-0.92). However, there were no differences within the group of postoperative medical treatment. When we compared between the two groups, the cumulative recurrence rate was significantly different in 20-29 years (8.1 vs 43.3%; p<0.001) and 30-39 years (5.4 vs 22.5%; p=0.007), but there was no difference in 40-45 years (4.5 vs 10.2%; p=0.901).

CONCLUSIONS

Our preliminary results demonstrate that the risk of endometrioma recurrence decreases with age. After the age of forty, the recurrence rate does not differ according to the use of postoperative medication. Based on our results, postoperative medical treatment may be individualized according to the patient's age at the time of surgery. Further studies are needed to identify patients who may benefit from postoperative medication.

Levonorgestrel-Releasing Intrauterine System for the Treatment of Endometriosis: Biological and Clinical Evidence

Endometriosis-associated symptomatology can be safely and effectively treated with intrauterine-released progestin, which is associated with fewer adverse effects than other therapeutic options and may be used on a long-term basis. We have herein reviewed the current literature in relation to the biological and clinical rationale for the use of an intrauterine system releasing 20 μg/day of levonorgestrel for the treatment of pelvic pain symptoms associated with endometriosis. Levonorgestrel induces endometrial glandular atrophy and decidual transformation of the stroma, reduces endometrial cell proliferation and increases apoptotic activity. After the first year of use, a 70–90% reduction in menstrual blood loss is observed. The levonorgestrel-releasing intrauterine system has proven effective in relieving pelvic pain symptoms caused by peritoneal and rectovaginal endometriosis and in reducing the risk of recurrence of dysmenorrhea after conservative surgery. Thus, the intrauterine delivery of a potent progestin may constitute an innovative, effective, safe and convenient alternative for local delivery of a potent progestin in the long-term therapy of symptomatic endometriosis.

Endometriosis: pathogenesis and treatment

Endometriosis is defined as the presence of endometrial-type mucosa outside the uterine cavity. Of the proposed pathogenic theories (retrograde menstruation, coelomic metaplasia and Müllerian remnants), none explain all the different types of endometriosis. According to the most convincing model, the retrograde menstruation hypothesis, endometrial fragments reaching the pelvis via transtubal retrograde flow, implant onto the peritoneum and abdominal organs, proliferate and cause chronic inflammation with formation of adhesions. The number and amount of menstrual flows together with genetic and environmental factors determines the degree of phenotypic expression of the disease. Endometriosis is estrogen-dependent, manifests during reproductive years and is associated with pain and infertility. Dysmenorrhoea, deep dyspareunia, dyschezia and dysuria are the most frequently reported symptoms. Standard diagnosis is carried out by direct visualization and histologic examination of lesions. Pain can be treated by excising peritoneal implants, deep nodules and ovarian cysts, or inducing lesion suppression by abolishing ovulation and menstruation through hormonal manipulation with progestins, oral contraceptives and gonadotropin-releasing hormone agonists. Medical therapy is symptomatic, not cytoreductive; surgery is associated with high recurrence rates. Although lesion eradication is considered a fertility-enhancing procedure, the benefit on reproductive performance is moderate. Assisted reproductive technologies constitute a valid alternative. Endometriosis is associated with a 50% increase in the risk of epithelial ovarian cancer, but preventive interventions are feasible.

Postoperative medical therapy after surgical treatment of endometriosis: from adjuvant therapy to tertiary prevention

The high rate of disease recurrence after surgery is critical and frustrating for women with endometriosis. Adjuvant treatments using a 3- to 6-months course of hormone therapy after surgery have been extensively investigated during the last 2 decades; however, results have been unsatisfactory, primarily because the benefits of hormone therapy rapidly vanish once treatment is discontinued. The protective effect is limited to the period of use. Accordingly, it is recognized that suppressive hormone therapy after surgery markedly prevents recurrent episodes only if given over the long term. The emerging view is that estroprogestins do not ameliorate the effects of surgery but demonstrate tertiary prevention of the disease. They prevent ovulation and reduce retrograde menstrual flow, two crucial events in the pathogenesis of endometriosis. The available literature strongly supports the benefits of prolonged administration of estroprogestins after surgery in preventing recurrence of endometriomas and dysmenorrhea. In contrast, data on dyspareunia and nonmenstrual pelvic pain remain scanty and unconvincing, and there is no information about recurrence of other forms of endometriosis such as peritoneal implants and adhesions. Overall, estroprogestin therapy after surgery to treat endometriosis should be recommended in women who do not seek to become pregnant. Further evidence is warranted to better delineate the beneficial effects of this emerging but convincing strategy.

Oral contraceptive pills for endometriosis after conservative surgery: a systematic review and meta-analysis

To assess the effects of oral contraceptive pills (OCPs) for endometriosis in women after conservative surgery, we performed a search of PubMed, Embase, ISI Web of Science, Cochrane Library, Scidirect, Chinese VIP, CNKI and WANGFANG database. Randomized controlled trials (RCTs) of OCPs in postoperative medical therapy for endometriosis were collected. Articles published as of January 2013 with no language restriction were identified using defined keywords, and 15 studies comprising 1850 patients were included. There was a significantly higher rate of total endometriosis remission [OR = 2.55, 95% CI (1.68, 3.86), p < 0.00001] and a lower rate of recurrence [OR = 0.31, 95% CI (0.22, 0.45), p < 0.00001] in the OCPs group compared with surgery alone. There appears to be no statistical difference in pregnancy rates between the OCPs group as compared with surgery alone or other hormonal drug treatments in infertility patients. As for the rate of recurrence and complete remission, there were no statistical differences among OCPs and gestrinone, mifepristone or GnRH-a groups. However, OCPs users had less side effects that were more mild as compared with patients using other hormonal treatments.

Endometriomas in adolescents and young women

STUDY OBJECTIVE

To evaluate clinical aspects of endometriomas encountered in late adolescent females and young women and to review the issues specifically related to the disease in this age group.

DESIGN

Retrospective medical chart review study.

SETTING

Adolescent gynecology and infertility clinic of a tertiary care hospital with women's health focus.

PARTICIPANTS

Sixty-three late adolescent females and young women aged ≤ 24 years with endometrioma.

INTERVENTIONS

Operative laparoscopy for endometriomas.

MAIN OUTCOME MEASURES

Baseline clinical characteristics of the patients including age, marital status, body mass index, symptoms on admission, family history of endometriosis, past medical history, CA-125 levels, presence of a müllerian anomaly, endometriosis characteristics at the time of surgery, and correlation between ASRM scores and patient characteristics.

RESULTS

The mean age and body mass index of the patients were 22 ± 2 (range 17-24) years and 20.8 ± 2.6 (range 16.6-28.5) kg/m(2) respectively. Chronic pelvic pain was the most common symptom (44%). Two patients had a diagnosis of genital malformation. Forty-one (65%) patients had endometrioma on the right ovary, and 14 (22%) patients had bilateral endometriomas. Only one patient had posterior cul-de-sac completely obliterated. Fifty-five (87%) patients had score <16 points for adnexal adhesions calculated according to the revised American Society for Reproductive Medicine classification.

CONCLUSION

Endometriomas, although rare, can be encountered in adolescents and young women. The disease in adolescent patient group offers particular importance since early intervention is essential in order to decrease pain, prevent progression of the disease and enhance future fertility.

Markers of adult endometriosis detectable in adolescence

Endometriosis, a disease of young females that is possibly a devastating ailment requiring surgery, appears to be associated with certain features encountered in adolescence. First among these symptoms is the history of severe and lasting dysmenorrhea at the time of adolescence and the need to use oral contraceptives (OCs) for alleviating dysmenorrhea that failed to respond to nonsteroidal anti-inflammatory drugs (NSAIDs). Further awareness about existing associations between certain symptoms experienced at adolescence and the later development of endometriosis is important. Indeed, the possibility of diagnosing endometriosis earlier when suggested by clinical history could lead to less extensive surgery and thus, less damage. Experimental verification of this insight, however, is needed before the concept that early diagnosis means lesser destructive surgery can be ascertained.

Recurrent endometrioma and ovarian reserve: biological connection or surgical paradox?

OBJECTIVE

Cumulative evidence supports the view that ovarian endometriomas originate from ovulatory events and that the ovarian reserve is reduced following surgery. On these bases, we have hypothesized that the risk of recurrence may be related to the residual ovarian reserve of the operated ovary.

STUDY DESIGN

We retrospectively selected 45 women scheduled for in vitro fertilization who previously underwent surgical excision of monolateral endometriomas and compared ovarian responsiveness in those who did (n = 24) and did not (n = 21) have a recurrent endometrioma.

RESULTS

In the intact ovaries, the mean ± SD number of codominant follicles in women with and without recurrences was 3.5 ± 1.7 and 3.7 ± 2.2, respectively (P = NS). In the affected ovaries, the mean ± SD number of follicles in gonads with and without recurrences was 2.5 ± 2.3 and 1.1 ± 1.5, respectively (P < .05).

CONCLUSION

Ovarian responsiveness is higher in gonads that developed recurrent endometriomas.

Endometrioma and ART: Does the Needle Work?

Aim and Objectives

The aim of this study was to see if the fertility outcome improved when IVF/ICSI was done after administration of GnRH analogs and cyst aspiration in comparison with patients in whom either only cyst aspiration or only GnRh analogs were administered.

Materials and methods

This was a prospective study done in a tertiary level ART center which included 30 patients over a span of 5 years from 2004 to 2009. All of them had endometriomas and underwent assisted reproductive techniques (ART) either after cyst aspiration with or without GnRH analog pretreatment or only GnRH analog pretreatment.

Depending on the pretreatment received, they were classified into three groups:

• Group B: Both GnRH analog and cyst aspiration

• Group C: Only cyst aspiration

• Group G: Only GnRH analog.

The patients were not randomized.

The number of days required for stimulation, total dose of stimulation required, number of oocytes obtained, quality of embryos, and the pregnancy rates for each group were tabulated for comparison.

Statistical analysis

The significance of the difference in ART outcome after the different modalities of pretreatment, which was estimated in terms of pregnancy rates was evaluated by calculating the p-value.

Observations and results

Significant difference was observed between the pregnancy rates in the three groups, with the maximum pregnancy rate in group B, followed by the group G and then the group C. The p-value showed a trend, though not statistically significant, indicating the need for larger prospective studies with greater number of subjects.

Conclusion

Pretreating endometriomas by aspirating the cysts and administering three doses of GnRH analog depot preparation prior to IVF/ICSI seems to be better than administering GnRH analog depot preparation alone or aspirating the cysts alone in terms of the number of days required for stimulation, the number of oocytes obtained, and the clinical pregnancy rates.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Post-operative endometriosis recurrence: a plea for prevention based on pathogenetic, epidemiological and clinical evidence

Prevention of the recurrence of post-operative endometriosis is crucial for future fertility. The incidence of disease relapse can be influenced by major demographic changes and by the use of long-term adjuvant medical treatment. Decrease in age at menarche, number of pregnancies and duration of breastfeeding and increase in age at first birth all lead to an increase in the overall number of ovulations and menstruations a woman has within a reproductive lifespan. These changes impact during the decade at highest risk for endometriosis, i.e. between 25 and 35 years of age, and may substantially expand the hiatus between first-line surgical treatment and conception attempt. Several lines of evidence suggest that ovulation inhibition reduces the risk of endometriosis recurrence. After pooling the results of a cohort and a randomized controlled trial on long-term post-operative oral contraceptive use, a recurrent endometrioma developed in 26/250 regular users (10%; 95% CI 7-15%) compared with 46/115 never users (40%; 95% CI 31-50%), with a common OR of 0.16 (95% CI 0.04-0.65). After first-line surgery for endometriosis, women should be invited to seek conception as soon as possible. Alternatively, oral contraceptive use until pregnancy is desired should be considered.

The impact of IVF procedures on endometriosis recurrence

OBJECTIVE

In infertile women with endometriosis requiring an in vitro fertilization (IVF) procedure, the potential risk of an IVF-related progression of the disease remains a matter of debate. Thus, since available data on this issue are scanty and controversial, an observational study has been herein conducted in order to clarify this issue.

STUDY DESIGN

We recruited 233 women with endometriosis who underwent IVF cycles in our unit. Patients were contacted to assess whether they experienced recurrences of the disease after IVF. The main outcome was to evaluate the impact of the number of IVF cycles and the responsiveness to ovarian hyperstimulation on the likelihood of recurrence. Clinical characteristics of women who did and did not have a recurrence were compared.

RESULTS

One hundred and eighty-nine women were included, 41 of whom (22%) had a diagnosis of endometriosis recurrence. The 36 months cumulative recurrence rate was 20%. The number of IVF cycles and the responsiveness to ovarian hyperstimulation were not associated with the risk of disease recurrence. The adjusted OR for recurrences according to the number of started cycles was 0.92 (95% CI: 0.77-1.10) per cycle (p=0.35). The adjusted OR for recurrences in women with intact versus compromised ovarian reserve was 0.80 (95% CI: 0.40-1.58) (p=0.52).

CONCLUSIONS

IVF procedures do not seem to influence the likelihood of endometriosis recurrence.

Endometriosis: current therapies and new pharmacological developments

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