ACOG Committee on Practice Bulletins--Gynecology. ACOG practice bulletin. Medical management of endometriosis. Number 11, December 1999 (replaces Technical Bulletin Number 184, September 1993). Clinical management guidelines for obstetrician-gynecologists

Enhancing endometrioma management: Diagnostic biomarkers and predictive outcomes in Ruptured vs. Non-Ruptured cases

OBJECTIVE

To compare the outcomes between patients undergoing surgery for ruptured endometrioma versus non-ruptured endometrioma.

STUDY DESIGN

The study was conducted at Health Sciences University, Etlik Zübeyde Hanım Training and Research Hospital Infertility Clinic. All patients who had a histopathology report of endometrioma between January 2014 and December 2020 were recruited. Patient files, surgery notes and laboratory values were extracted from the electronic recording system and patients with ruptured endometriomas (RE) or non-ruptured endometriomas (NRE) were compared.

RESULTS

Overall, 181 patients were recruited to the study. No rupture was detected in 146 (80.7 %) patients while 35 patients (19.3 %) underwent surgery for RE. Pre-operative CRP, CA 125, CA 19-9, CA 15-3, CEA and mean platelet volume (MPV) values and postoperative MPV and neutrophil/lymphocyte ratio (NLR) values were statistically significantly higher (p < 0.01) in the RE group compared to the NRE group. Post-operative lymphocyte (p = 0.029) and eosinophyl (p = 0.015) values were significantly lower in the RE group compared to the NRE group. Among the preoperative biomarkers that are evaluated for prediction of rupture; MPV, CA 19-9 and CA-15.3 had a high specifity (>75 %) but a rather low sensitivity (<60 %), meanwhile CRP, CA-125 and CEA had high sensitivity but a low specifity.

CONCLUSION

RE patients had significantly higher preoperative CRP, CA 125, CA 19-9, CA 15-3, CEA, and MPV values and postoperative MPV and NLR values while postoperative, lymphocyte and eosinophyl values were significantly lower compared with the NRE patients. Prospective studies with larger sample sizes are needed to determine biomarkers and parameters that can be used for non-invasive diagnosis of endometriosis and predict the possibility of endometrioma rupture.

Endometriosis and physical activity: A narrative review

Endometriosis is a painful gynecological disorder that affects many women. Constant treatments and contraception changes affect women looking for solutions to treat and limit the problems caused by endometriosis. The current narrative review discusses the effects of physical activity on the management, pain, and quality of life in patients with endometriosis. Findings suggest that body awareness practices such as Hatha yoga, the Jacobson method, and progressive muscle relaxation reduce pain and stress and improve the quality of life associated with endometriosis. It also highlights the current knowledge gap on available evidence and future research. Moreover, care must be taken when considering patients' physical abilities and goals and avoiding intense physical activities. The forms of endometriosis and its symptoms vary from one woman to another, so it is important to perform studies with various nonmedicinal or surgical techniques. It is important to continue randomized controlled trials to obtain more data on the benefits of physical activity in women with endometriosis and also to identify what types of activities could be beneficial to combat pain symptoms and improve the daily lives of women with endometriosis.

The 10 "Cardinal Sins" in the Clinical Diagnosis and Treatment of Endometriosis: A Bayesian Approach

Evidence-based data for endometriosis management are limited. Experiments are excluded without adequate animal models. Data are limited to symptomatic women and occasional observations. Hormonal medical therapy cannot be blinded if recognised by the patient. Randomised controlled trials are not realistic for surgery, since endometriosis is a variable disease with low numbers. Each diagnosis and treatment is an experiment with an outcome, and experience is the means by which Bayesian updating, according to the past, takes place. If the experiences of many are similar, this holds more value than an opinion. The combined experience of a group of endometriosis surgeons was used to discuss problems in managing endometriosis. Considering endometriosis as several genetically/epigenetically different diseases is important for medical therapy. Imaging cannot exclude endometriosis, and diagnostic accuracy is limited for superficial lesions, deep lesions, and cystic corpora lutea. Surgery should not be avoided for emotional reasons. Shifting infertility treatment to IVF without considering fertility surgery is questionable. The concept of complete excision should be reconsidered. Surgeons should introduce quality control, and teaching should move to explain why this occurs. The perception of information has a personal bias. These are the major problems involved in managing endometriosis, as identified by the combined experience of the authors, who are endometriosis surgeons.

Urinary Biomarkers for Detection of Clinical Endometriosis or Adenomyosis

Endometriosis or adenomyosis can be clinically diagnosed by ultrasound, symptoms, physical examination, and serum CA125. The urinary markers need to be investigated. The aim of our study was to investigate the urinary markers of clinical endometriosis/adenomyosis, and the correlation of serum CA125 was also studied. From the literature, alpha-1 antitrypsin (A1AT), enolase-1, vitamin D binding protein (VDBP), and CA125 in urine and serum were used in our study and measured by enzyme-linked immunosorbent assays (ELISA). Further clinical correlation and detection performance were evaluated. We enrolled 19 normal controls and 33 patients clinically diagnosed with endometriosis/adenomyosis. There were significant differences between studied patients and normal controls, as follows: serum CA125 (130.91 vs. 19.75 U/mL, p = 0.004); urinary CA125-creatinine ratio (5.591 vs. 0.254 ng/mg, p = 0.028); and urinary VDBP-creatinine ratio (28.028 vs. 7.301 ng/mg, p = 0.018). For diagnostic performances, serum CA125 provided the best results, with an area under curve (AUC) of 0.888 (p = 0.001) and accuracy of 86.5%. Other excellent results were also found using urinary VDBP (AUC 0.841, p = 0.001) and A1AT (AUC 0.722, p = 0.011) creatinine ratio. Using three combined biomarkers, serum CA125, urinary VDBP, and A1AT creatinine ratio, provided good detection power (AUC 0.913, p = 0.001, sensitivity 90.9%, specificity 76.5%). Double urine markers used in combination with VDBP and A1AT creatinine ratio also provided good diagnostic performance (AUC 0.809, p = 0.001, sensitivity 81.8%, specificity 76.5%, accuracy 80%). Further development of non-invasive point-of-care tests using these biomarkers could be a fruitful future endeavor.

Gross Ascites Secondary to Endometriosis: A Rare Presentation in Pre-Menopausal Women

Ascites caused by endometriosis is an unusual phenomenon with approximately 60 cases described since it was first reported in 1954. Moreover, such a case has rarely been reported in the Caribbean literature. Ascites is frequently treated with surgical options that do not preserve fertility. This is due to the association of ascites with gynaecological malignancies in women with elevated serum cancer antigen (CA-125). We describe three cases of severe endometriosis associated with massive ascites, successfully treated with hormonal therapy while preserving fertility.

Endometriosis Pain Management: a Review

PURPOSE OF REVIEW

The purpose of this review is to summarize the up-to-date pain management options and recommendations for the challenging disease, endometriosis.

RECENT FINDINGS

The mainstays of endometriosis advances of both surgical and medical management continue to evolve. Experimental pharmaceuticals include Gestirone, and aromatase inhibitors have shown promise but are still under scrutiny. Surgical techniques include laparoscopic uterosacral nerve ablation/resection and presacral neurectomy. No studies have directly compared medical versus surgical management, and as such, no one treatment modality can be recommend as superior to the other. Patients may initially be given a medical diagnosis and treated with nonsteroidal anti-inflammatory drugs, neurolepitcs, OCP, GNRH agonists/antagonists, and Danazol. Assessing the success of these regimens has proved difficult. Surgical management relies on various methods including excision/ablation of the lesions, nerve ablation, neurectomy, hysterectomy, and oophorectomy.

Scar Endometriosis Presenting as a Painful Abdominal Mass

Abdominal wall scar endometriosis occurs in 1%–2% of women following a cesarean section delivery. We report a case of a 36-year-old woman with scar endometriosis, presenting with an acute, painful abdominal wall mass. She underwent a cesarean section 8 years before presentation. She was admitted to the emergency room for physical examination of the abdomen, which revealed a palpable mass. Abdominal computed tomography (CT) revealed an ill-defined soft-tissue lesion over the left rectus abdominis muscle (abdominal scar). Surgical removal of the abdominal wall mass was performed with adequate clearance margins with a preoperative diagnosis of postcesarean scar endometriosis. Postcesarean scar endometriosis is a rare cause of an abdominal mass; however, when this condition presents acutely, it can be difficult to diagnose. In this case, careful analysis of the patient's history, CT images, and histopathological results together confirmed the diagnosis. Surgical excision was performed under general anesthesia while maintaining adequate clearance margins.

Disparities in healthcare services in women with endometriosis with public vs private health insurance

BACKGROUND

The goals of health disparities research are to identify facilitators and barriers to healthcare use to help eliminate health inequalities. There are few studies on disparities in healthcare access and use trends for patients with endometriosis that may lead to differences in appropriate care based on socioeconomic status.

OBJECTIVE

This retrospective, cross-sectional study was conducted to compare health services use patterns and prevalence of co-morbidities of women with endometriosis with public (government-based) vs private (purchased or provided by employer) health insurance.

STUDY DESIGN

A total of 342 deidentified datasets (171 randomly-selected cases per study group) from women with endometriosis 14-50 years old who were members of one health insurance company that provides both public and private health insurance coverage in Puerto Rico were analyzed. Patients were defined as having at least 1 endometriosis-related medical claim (ICD-9-617.xx; International Classification of Diseases, Ninth Revision, Clinical Modification) during the 3-year study period.

RESULTS

Medical service (eg, hospital, laboratory, pathology, and radiology) use trends were 3 times lower in the public vs the private sector. Women in the public sector were 3.5 times less likely to have a laparoscopy, 2.7 times more likely to be prescribed opioid/narcotics, and were the only study subjects reporting emergency department use. Obstetrics and gynecology services were used >2-fold less by women in the public (29.5%) vs the private sector (70.5%) (P=.087).

CONCLUSIONS

We report significant differences in the use trends of endometriosis-related medical services and prescriptions, indicating differences in healthcare access based on socioeconomic parameters. Our results support the development of public health programs to promote access to healthcare for patients with endometriosis irrespective of socioeconomic status and promote health disparity research in other healthcare systems.

An Interdisciplinary Approach to Endometriosis-associated Persistent Pelvic Pain

Endometriosis-associated pelvic pain is a common and often challenging problem. For certain patients, pain persists or recurs despite adequate medical or surgical therapy targeted to endometriosis. In this patient population, there is often the presence of coexisting pain conditions such as irritable bowel syndrome, painful bladder syndrome and myofascial pain as well central sensitisation. An interdisciplinary approach where both peripheral pain triggers and central sensitization are addressed is likely to lead to improved pain and quality of life. The approach to the evaluation and treatment of the patients with persistent/chronic pelvic pain and endometriosis is outlined in this article.

Endometriosis in Adolescents: A Systematic Review

Introduction

The aim of this manuscript is to present a systematic review of characteristics and management of endometriosis in adolescents in order to gain some relevant insight into the most appropriate clinical management of the disease.

Methods

The literature review was done using electronic database PubMed focusing on the terms ‘adolescents’, ‘endometriosis’, ‘teenagers’, ‘pain’, ‘infertility’, ‘quality of life’, ‘medical’ and ‘surgical management’ from 1980 onward and was limited to articles in English. Articles were only included if they reported original relevant research.

Results

The 24 studies selected for review included 1148 adolescents with laparoscopic proven endometriosis. The diagnosis of endometriosis was histologically confirmed in 39.02% (448/1148) of cases. The results from trials have been tabulated and main results presented in a question and answer format.

Conclusions

The majority of adolescent girls with chronic pelvic pain not responding to conventional medical therapy have endometriosis (up to 80%). Laparoscopy with biopsy is the only way to diagnose endometriosis in the adolescent population, and depends on recognition of atypical manifestations of the disease. Surgical management (especially by an expert surgeon) has been shown to be beneficial in reducing pain, improving infertility, and preventing progression or recurrence of disease. Postoperative hormonal suppression helps reduce pain symptoms and recurrence of endometriomas, but it does not seem to prevent disease recurrence or progression of peritoneal endometriosis, and has not been shown to improve future fertility. Postoperative suppression until pregnancy is based on expert opinion only. There is a need for good quality properly randomized trials.

Effects of different add-back regimens on hypoestrogenic problems by postoperative gonadotropin-releasing hormone agonist treatment in endometriosis

Objective

To compare the efficacy of different add-back regimens on hypoestrogenic symptoms during postoperative gonadotropin-releasing hormone (GnRH) agonist treatment in endometriosis patients.

Methods

This prospective cohort study included reproductive-aged women who underwent conservative laparoscopic surgery for ovarian endometriosis and received add-back therapy during a 6-month course of GnRH agonist therapy after surgery. Participants received one of four different add-back regimens: 1 mg of estradiol valerate, 2.5 mg of tibolone, or a combination of 1 mg of estradiol and 2 mg of drospirenone or 0.5 mg of norethisterone acetate. Changes in quality of life, hypoestrogenic symptoms, and bone mineral density were compared according to add-back regimens.

Results

A total of 57 participants completed a 6-month course of GnRH agonist and add-back therapy. All components of quality of life did not differ across groups. However, within the same treatment group, social relationship factors decreased significantly with estradiol valerate and tibolone alone, and environmental factors decreased significantly with estradiol valerate alone. Menopausal Rating Scale score did not change significantly, but the incidence of hot flushes significantly decreased with a combination of estradiol and norethisterone acetate. Bone mineral densities at the lumbar spine declined significantly after treatment in all groups except with a combination of estradiol and norethisterone acetate.

Conclusion

This preliminary study suggests that an add-back regimen containing estradiol valerate and norethisterone acetate may have better efficacy in terms of quality of life, hypoestrogenism-associated symptoms, and bone mineral density.

Serum Anti-Müllerian Hormone Levels before Surgery in Patients with Ovarian Endometriomas Compared to Other Benign Ovarian Cysts

OBJECTIVES

To evaluate preoperative anti-Müllerian hormone (AMH) levels in women with endometrioma or other benign ovarian cysts and differences of AMH changes according to various characteristics.

METHODS

Ninety-seven patients aged 20 to 39 years who underwent surgery for benign ovarian cyst were enrolled retrospectively. Of these, 65 patients were diagnosed as endometriomas, and 32 had other benign cysts. Serum AMH, mean, maximum, and total diameter of ovarian cysts were measured. The AMH levels were compared according to pathology (endometrioma vs. other benign cyst), size of ovarian cyst, age-matched AMH quartile percentile and characteristics of endometrioma.

RESULTS

Preoperative serum AMH level was significantly lower in endometrioma group than other benign cyst group (4.12 ± 2.42 ng/mL vs. 6.02 ± 2.29 ng/mL, P < 0.001). Serum AMH level was significantly lower in endometrioma group, especially in patients aged 30 to 39 years. Dividing to age-matched AMH quartile percentile, there were significantly fewer patients with AMH level ≥ 75 percentile in endometrioma group (24.6% vs. 50.0%, P = 0.035). Among 4 subgroups of endometrioma, patients with AMH level ≥ 75 percentile were significantly decreased in multiple bilateral endometrioma group. Mean and total diameter of cysts were negatively correlated with preoperative serum AMH level in other benign cyst group.

CONCLUSION

We suggest that preoperative AMH level measurement might be considered in women with endometrioma, especially in 30 to 39 years old, multiple bilateral type, or big-sized other benign ovarian cyst to assess the diminished ovarian reserve.

The case of the missing appendix: a case report of appendiceal intussusception at the site of colonic mullerianosis

Right lower quadrant pain is a symptom with an exceptionally broad differential diagnosis. Intussusception of the appendix is a very uncommon condition with many manifestations. Additionally, the pathologic finding of ectopic presence of a mixture of at least two mullerian-derived tissue components is rare. This report presents the case of a 49-year-old woman who presented twice with acute right lower abdominal pain. Diagnosis of appendiceal inversion was made surgically. Pathologic examination of the specimen identified extensive endometriosis, endosalpingiosis and endocervicosis of the colon wall. Appendiceal intussusception and colonic mullerianosis, present together, are discussed, and recommendations for the diagnosis and treatment of appendiceal intussusception are discussed.

Gonadotrophin-releasing hormone analogue or dienogest plus estradiol valerate to prevent pain recurrence after laparoscopic surgery for endometriosis: a multi-center randomized trial

OBJECTIVES

To evaluate the efficacy of dienogest + estradiol valerate (E2V) and gonadotrophin-releasing hormone analogue (GnRH-a) in reducing recurrence of pain in patients with chronic pelvic pain due to laparoscopically diagnosed and treated endometriosis.

DESIGN

Multi-center, prospective, randomized study.

SETTING

Three university departments of obstetrics and gynecology in Italy.

POPULATION

Seventy-eight women who underwent laparoscopic surgery for endometriosis combined with chronic pelvic pain.

METHODS

Post-operative administration of dienogest + E2V for 9 months (group 1) or GnRH-a monthly for 6 months (group 2).

MAIN OUTCOME MEASURES

A visual analogue scale was used to test intensity of pain before laparoscopic surgery at 3, 6 and 9 months of follow up. A questionnaire to investigate quality of life was administered before surgery and at 9 months of follow up.

RESULTS

The visual analogue scale score did not show any significant differences between the two groups (p = 0.417). The questionnaire showed an increase of scores for all women compared with pre-surgery values, demonstrating a marked improvement in quality of life and health-related satisfaction with both treatments. No significant differences were found between the groups. The rate of apparent endometriosis recurrence was 10.8% in group 1 and 13.7% in group 2 (p = 0.962).

CONCLUSION

Both therapies seemed equally efficacious in preventing endometriosis-related chronic pelvic pain recurrence in the first 9 months of follow-up.

National German Guideline (S2k): Guideline for the Diagnosis and Treatment of Endometriosis: Long Version - AWMF Registry No. 015-045

In this guideline, recommendations and standards for optimum diagnosis and treatment of endometriosis are presented. They are based on the analysis of the available scientific evidence as published in prospective randomized and retrospective studies as well as in systematic reviews. The guideline working group consisted of experts from Austria, Germany, Switzerland, and the Czech Republic.

Pregnancy rate in endometriosis patients according to the severity of the disease after using a combined approach of laparoscopy, GnRH agonist treatment and in vitro fertilization

AIM

To evaluate the effects of combined treatment approaches on endometriosis-associated infertility in different stages of endometriosis using laparoscopy, gonadotropin-releasing hormone (GnRH) agonist (GnRHa) therapy and in vitro fertilization (IVF).

METHODS

This retrospective study was carried out on 179 women with surgically confirmed endometriosis. Patients were divided into subgroups: group 1 (stage I-II, n = 121) and group 2 (stage III-IV, n = 58). Patients eligible for IVF, who were found to have adenomyosis or moderate to severe endometriosis, were also given postoperative GnRHa. Pregnancy and delivery rates were cumulatively calculated during 5 years according to the severity of the disease.

RESULTS

The overall pregnancy, delivery and miscarriage rates were 66.5, 56.4 and 15.1%, respectively, for all patients following spontaneous and assisted conception. There were no significant differences in reproductive outcomes between the study groups. The pregnancy and delivery rates were also comparable within group 1 between the patients with and without GnRHa treatment.

CONCLUSION

Pregnancy and delivery rates at different stages of endometriosis were not affected by the different approaches used for infertility treatment, with >60 and >50% of patients having conceived and delivered a baby, respectively, in both groups. The usefulness of GnRHa treatment for endometriosis patients with minimal to mild forms is questionable and deserves further studies.

Anti-Müllerian hormone trend after laparoscopic surgery in women with ovarian endometrioma

Operative laparoscopy is the gold standard in the treatment of endometriotic ovarian cysts. Excisional surgery is the best technique to prevent recurrences and improve symptoms but it may result in ovarian reserve damage due to the removal of healthy ovarian cortex. The aim of this study was to investigate the extent of the ovarian reserve damage after stripping technique of unilateral endometriomas, by dosing the Anti-Müllerian Hormone (AMH). This prospective study was conducted at the Center of Minimally Invasive Pelvic Surgery of the Department of Health of Woman and Child, University of Padua, from October 2010 to June 2012. Twenty-five women underwent excision of monolateral endometriosis ovarian cyst by stripping without accessing a bipolar coagulation and performing an intracortical suture. The AMH serum levels were estimated in the early proliferative phase of the cycle, before surgery (time 0), 24 h after surgery (time 1), the first menstrual cycle after surgery (time 2) and the third menstrual cycle after surgery (time 3). We found a nonstatistically significant decreases in serum AMH levels after surgical excision of the cysts. Our results suggest that an appropriate surgical technique, without the use of the bipolar coagulation of ovarian border, does not determine a significant reduction of ovarian reserve.

Abdominal and urogenital diseases can often be the cause of lower back pain and sciatic-like symptoms

SUMMARY The treatment of lower back pain and sciatic-type symptoms are often not related to spinal cord infringement, but are due to other factors such as urogenital irritation and piriformis syndrome. Other factors can exist and it behooves the physician to make a definitive diagnosis in order to prevent treating with medicines and treatments that often do not work. Medicines in high doses can lead to dependence or addiction. A normal MRI test is often a flag to the physician that something other than spinal problems may be the cause. A complete workup must be performed including imaging procedures, diagnostic testing and specialized physical examinations if initial diagnosis and treatments do not produce an amelioration of symptoms. There are many causes of chronic lower back pain and sciatica-type symptoms and if the problems and symptoms persist, they should be investigated.

Management of pregnancy in patients with congenital heart disease

Congenital heart diseases are the most common birth defects in humans, affecting approximately 0.8% of all live births. In the past, many of the more severe defects resulted in profound disability and death during childhood, and adult survival was exceptional. The past 4 decades have seen dramatic improvements in the survival and quality of life of patients with the more severe defects. As a result of these improvements, the challenges of caring for adults with congenital heart disease are only now being realized. Most women with congenital heart disease are now expected to reach childbearing age and maternal cardiac disease is the major cause of maternal morbidity and mortality. As such, appropriate pre-pregnancy counseling and management during pregnancy are fundamental components of the care of these patients. This article describes the circulatory changes that occur during normal pregnancy and delivery, addresses the risks posed during pregnancy by specific congenital lesions, and reviews the current data on pregnancy outcomes in patients with individual congenital defects.

Endometriosis of the appendix: A diagnostic dilemma

The incidence of endometriosis of the appendix is reported to be just <1% of the total endometriosis cases. Laparoscopic visualization and diagnostic yield are of profound significance to women in whom gynecologic diseases such as endometriosis, pelvic inflammatory disease, ruptured ovarian follicles or tubal pregnancy may be the source of pain and mimic appendicitis. Therefore, lower abdominal pain in reproductive age group female must invite the attention of the surgeon or gynecologist to entertain the possibility of endometriosis since appendiceal endometriosis, while relatively uncommon in patients with endometriosis, is rare in the general population.

Minimal endometriosis: a therapeutic dilemma?

Accidental finding of minimal endometriosis during surgery for complaints unassociated with endometriosis presents a therapeutical dilemma. Because the clinical significance of minimal endometriosis is not thoroughly defined, it is uncertain by which means, if at all, such types of peritoneal or ovarian lesions should be treated. We, therefore, compiled our clinical observations and evaluated them in relation to the results reported in the recent literature. A search on the clinical importance and the need for any treatment of minimal and mild endometriosis was conducted. Based on the available evidence, we are tempted to conclude that minimal endometriosis should be treated surgically when accidentally discovered. This approach should be exerted even in the absence of clinical symptoms. However, postoperative medical treatment is not warranted in those patients who are without clinical complaints. Because the clinical course of minimal endometriosis is not predictable, any benefit from specific medications remains uncertain. When associated with infertility, minimal endometriosis should be surgically erased, thus to allow spontaneous conceptions to occur. As there is no evidence of medical treatment modalities altering the clinical course of minimal and mild endometriosis, any specific medical treatment (i.e. GnRH analogues, danazol) is not indicated in asymptomatic patients and those desiring pregnancy.

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.

Desenvolvimento de modelo experimental de endometriose em ratas

OBJETIVO: Desenvolver um modelo de endometriose experimental em ratas. MÉTODOS: Foram utilizadas 30 ratas adultas da linhagem Wistar. A técnica cirúrgica consistiu em laparotomia mediana com identificação do útero bicorno e ressecção de um segmento de 2 cm do corno uterino direito. Um retalho de 0,25 cm² foi retirado dessa estrutura e suturado na parede abdominal com a face endometrial voltada para a cavidade peritoneal. As ratas foram divididas aleatoriamente em dois grupos de acordo com o tempo para a reoperação: grupo 1 (n=15), reoperado em 30 dias, e grupo 2 (n=15), em 60 dias. No momento da segunda laparotomia os implantes foram avaliados macroscopicamente, ressecados e encaminhados para análise microscópica com coloração hematoxilina-eosina e imunohistoquímica (HEMA, AE1 e AE2). RESULTADOS: Os implantes se desenvolveram em 83,3 % do Grupo 1 e 71,4% no Grupo 2. Não houve diferença estatisticamente significativa entre o peso dos animals dos dois grupos. Também não houve diferença estatisticamente significativa no tamanho da área das lesões induzidas: no Grupo 1 a média foi 0,37 cm² e no Grupo 2, de 0,25 cm². Segundo a classificação histológica semi-quantitativa de Keenan (de acordo com a preservação da camada epitelial de endométrio), o Grupo 1 teve média de 1,9 e o Grupo 2, de 2,4. CONCLUSÃO: A técnica utilizada para o desenvolvimento de endometriose em ratas foi satisfatória.

Recurrence of endometriosis and its control

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

Biomechanical perspective on the remineralization of dentin

The objective of this article is to critically evaluate the methods that are used to assess outcomes of remineralization of dentin. Currently, the most used assessment methods fall either into quantitative analysis of the mineral content of the remineralized structures or dry measurements of their mechanical properties. Properties obtained from the dehydrated organic dentin matrix may not reflect the true mechanical behavior of the remineralized tissue under physiological and hydrated conditions. Here we seek to clarify the biomechanical aspects of remineralization of dentin, pointing out the effects of hydration and dehydration on the mechanical properties of treated tissues. We also emphasize that a more appropriate endpoint to evaluate the effectiveness of remineralization in dentin should be associated with the recovery of the mechanical properties of the hydrated tissue, which is presumed to correlate well with its overall functionality.

A logistic model for the prediction of endometriosis

OBJECTIVE

To develop a model that uses individual and lesion characteristics to help surgeons choose lesions that have a high probability of containing histologically confirmed endometriosis.

DESIGN

Secondary analysis of prospectively collected information.

SETTING

Government research hospital in the United States.

PATIENT(S)

Healthy women 18-45 years of age, with chronic pelvic pain and possible endometriosis, who were enrolled in a clinical trial.

INTERVENTION(S)

All participants underwent laparoscopy, and information was collected on all visible lesions. Lesion data were randomly allocated to a training and test data set.

MAIN OUTCOME MEASURE(S)

Predictive logistic regression, with the outcome of interest being histologic diagnosis of endometriosis.

RESULT(S)

After validation, the model was applied to the complete data set, with a sensitivity of 88.4% and specificity of 24.6%. The positive predictive value was 69.2%, and the negative predictive value was 53.3%, equating to correct classification of a lesion of 66.5%. Mixed color; larger width; and location in the ovarian fossa, colon, or appendix were most strongly associated with the presence of endometriosis.

CONCLUSION(S)

This model identified characteristics that indicate high and low probabilities of biopsy-proven endometriosis. It is useful as a guide in choosing appropriate lesions for biopsy, but the improvement using the model is not great enough to replace histologic confirmation of endometriosis.

Post-traumatic catamenial sciatica

This article presents a unique case of posttraumatic extrapelvic endometriosis presenting as a gluteal mass causing cyclic sciatica. A 38-year-old woman presented with an enlarging right buttock mass over the previous 6 years. She also had symptoms of radicular pain referred to the right leg and foot with sitting and daily activity. Four years prior to noticing the mass, she sustained a gunshot wound through the lower abdomen while 5 months pregnant. Excisional biopsy of the gluteal mass revealed endometrioma. Sciatica is a common and painful disorder that is believed to have an incidence of 40% in the adult population. Sciatica is most often due to intraspinal pathology affecting the lumbar nerve roots. There are many recognized extraspinal etiologies for sciatica in the literature including aneurysms, sciatic hernia, abcess, neoplasm, trochanteric wire, piriformis syndrome, ischial fracture, a posteriorly flexed uterus, and even an intrauterine device following uterine perforation. Similarly, endometriosis is a gynecologic condition that represents a significant health problem for women of reproductive age as it occurs in up to 50% of premenopausal women and 71% to 87% in women with chronic pelvic pain. Although rare, endometriosis has a well known ability to migrate outside of the abdominal cavity and proliferate ectopically under the control of systemic estrogen.

Konservative Therapie der Endometriose

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

Les formes anatomocliniques de l'endométriose

The aim of this literature review is to precise definition, anatomoclinical entities and natural history of endometriosis to allow clinical guideline establishment.

DEFINITION

Endometriosis is defined as the presence of endometrial tissue (glands and stroma) outside the uterus. This histologic definition does not implicate symptoms. Macroscopic lesions supposed to be endometriosis are not always confirmed by histology. Histology is recommended to confirm endometriosis. Negative histology does not exclude endometriosis.

ANATOMOCLINICAL ENTITIES

Three endometriosis entities are described: peritoneal endometriosis, ovarian endometrial cyst, and deeply infiltrating endometriosis. There is no evidence to establish a different pathogenesis of theses entities.

ENDOMETRIOSIS NATURAL HISTORY

It is not well known. It may progress or regress with or without treatment. There is no evidence of treatment in case of asymptomatic endometriosis. There is an association between endometriosis and ovarian cancer. The risk of endometriosis malignant transformation is still a subject of controversy. There is no evidence for a specific oncologic follow-up of woman having endometriosis.

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

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

A randomized study comparing triptorelin or expectant management following conservative laparoscopic surgery for symptomatic stage III-IV endometriosis

OBJECTIVE

To investigate the role of adjuvant treatment with gonadotropin-releasing-hormone agonist (GnRHa) following conservative surgical treatment of endometriosis.

STUDY DESIGN

Sixty patients in the reproductive age (mean age 28.6 years), with symptomatic stages III and IV endometriosis following laparoscopic surgery and without previous hormonal treatment were enrolled in a prospective, randomized, controlled trial to compare the effects of 3-month treatment with triptorelin depot-3.75 i.m. (30 patients) versus expectant management using placebo injection (30 patients).

RESULTS

Six patients (one in triptorelin group and five in placebo group) were lost at follow-up, the remaining 54 were suitable for analysis. Pelvic pain persistence or recurrence, endometrioma relapses and pregnancy rate were evaluated during a 5-year follow-up. The results of 29 cases treated with triptorelin and 25 that received placebo did not show significant differences in pain recurrence (P=1, RR=0.94, 95% CI=0.57-1.55), endometrioma relapse (P=0.67, RR=1.29, 95% CI=0.66-2.50), and pregnancy rate in infertile women (P=0.80, RR=0.81, 95% CI=0.37-1.80). Curves of time of pain recurrence and pregnancy during 5-year follow-up did not show significant differences between the two groups (P=0.79 and P=0.51, respectively, using Mantel-Haenzsel logrank test).

CONCLUSION

Triptorelin treatment after operative laparoscopy for stage III/IV endometriosis does not appear to be superior to expectant management in terms of prevention of symptoms recurrence and endometrioma relapse, and has no influence on pregnancy rate in endometriosis-associated infertility.

Medicated intrauterine systems for treatment of endometriosis-associated pain

Medicated intrauterine systems (IUSs) are intrauterine devices that act by means of the local release of a medication. The levonorgestrel (LNG)-IUS is a T-shaped device that releases the progestogen LNG directly into the uterine cavity. The LNG-IUS can be used with noncontraceptive, therapeutic intent for idiopathic menorrhagia, hormonal replacement therapy in conjunction with oral or transdermal estrogens, and endometriosis or adenomyosis-associated pain. For this last indication, however, the use of the LNG-IUS is still under clinical investigation.

Guidelines for the management of pelvic pain associated with endometriosis: a systematic appraisal of their quality

BACKGROUND

Guidelines exist for the management of endometriosis. Validated and reliable appraisal tools exist to assess the quality of guidelines.

OBJECTIVES

To systematically appraise the quality of guidelines for the management of pelvic pain associated with endometriosis.

SEARCH STRATEGY

Guidelines were identified using a prospective protocol through a systematic search of MEDLINE (1951-2005), EMBASE (1974-2005), the Cochrane Library (2005, issue 2), known guideline websites and the World Wide Web.

SELECTION CRITERIA

Type of document: guideline, consensus statement, care protocol or healthcare technology assessment produced by national or international professional organisations and societies or governmental agencies; subject: management of pelvic pain associated with endometriosis.

DATA COLLECTION AND ANALYSIS

Two validated appraisal tools, Cluzeau and The Appraisal of Guidelines and Research and Evaluation (AGREE), were used to quantitatively assess the quality of guidelines. Areas evaluated included 'rigour of development', 'context and content' and 'application.'

MAIN RESULTS

Eight of 596 potentially relevant citations identified met our inclusion criteria. The Cluzeau instrument quality score were the following: rigour of development, 53% (range 5-65%); context and content, 69% (range 29-79%) and application 20% (range 0-20%). The application dimension achieved significantly lower quality scores (P = 0.026 versus rigour of development and P = 0.017 versus context and content). The AGREE instrument quality scores were the following: scope and purpose, 68% (range 17-89%); stakeholder involvement, 33% (range 13-63%); rigour of development, 49% (range 10-81%); clarity of presentation, 55% (range 42-67%); applicability, 14% (range 0-28%) and editorial independence, 28% (range 8-67%). The applicability domain achieved significantly lower quality scores (P = 0.001 versus scope and purpose and P = 0.009 versus rigour of development).

AUTHOR'S CONCLUSIONS

Guidelines for the management of pelvic pain associated with endometriosis do not comply with the recommendations for high-quality standards.

Changes in cytokine levels of patients with ovarian endometriosis after treatment with gonadotropin-releasing hormone analogue, ultrasound-guided drainage, and intracystic recombinant interleukin-2

OBJECTIVE

To determine the changes in cytokine levels from women with endometriomas who are treated with recombinant interleukin-2 after ultrasound-guided cyst aspiration, and to relate these changes to the clinical results observed in these patients.

DESIGN

A double-blind randomized controlled trial.

SETTING

University hospital.

PATIENT(S)

Twenty-four women with endometriosis-related symptoms and endometriomas.

INTERVENTION(S)

Endometriomas in women receiving GnRH analogues and undergoing transvaginal ultrasound-guided cyst aspiration were injected with dextrose that did or did not contain recombinant interleukin-2 (IL-2). Serum samples were collected before and after treatment.

MAIN OUTCOME MEASURE(S)

Serum samples were analyzed by enzyme immunoassay to determine the levels of IL-1beta, IL-2, IL-6, IL-8, IL-10, IL-12, IL-13, and IL-17.

RESULT(S)

The cytokine levels after treatment with GnRH analogues and recombinant IL-2 were similar to the initial levels. The patients receiving GnRH analogues without IL-2 had higher IL-1, IL-2, IL-8, and IL-13 levels. Good clinical results were observed in 90% of the patients in the first group but in only 30% of the second one.

CONCLUSION(S)

Administration of recombinant IL-2 intracystically decreases cytokine production in women with endometriomas. These results have important implications for the design of future therapies based on immunomodulation, such as using higher or repeated doses of recombinant IL-2 in the cysts.

The role of laparoscopy in the diagnosis and treatment of conditions associated with chronic pelvic pain

Laparoscopy is a useful tool for the diagnosis and treatment of conditions associated with chronic pelvic pain. In the evaluation of chronic pelvic pain, laparoscopic techniques vary from conservative procedures, such as pain mapping, excision, and nerve ablation, to more extensive procedures like oophorectomy and hysterectomy. Although useful for diagnosis, laparoscopy continues to have a controversial role in the treatment of chronic pelvic pain.