Long-term follow-up on the treatment of endometriosis with the GnRH-agonist buserelinacetate. Long-term follow-up data (up to 98 months) of 42 patients with endometriosis who were treated with GnRH-agonist buserelinacetate (Suprecur), were evaluated in respect of recurrence of pain symptoms and pregnancy outcome

Clinical studies investigating the use of leuprorelin in Asian women with endometriosis: a review

We aimed to examine how leuprorelin has been studied for the treatment of women with endometriosis in Asia. We conducted a literature search of PubMed, the Cochrane Library and ClinicalTrials.gov. This review includes randomised trials of women with endometriosis treated with leuprorelin in Asia. Phase I-IV clinical trials published between January 1 2000 and December 31 2016 and written in English were included. Four studies were identified, showing that leuprorelin significantly improves pain and quality of life. The oestrone and oestradiol levels are decreased by leuprorelin but can be increased using an 'add-back' therapy with conjugated equine oestrogen and methoxyprogesterone. Menopause is more common in women treated with leuprorelin. The bone mineral density is reduced in women treated with leuprorelin. There are limited studies investigating the use of leuprorelin for the treatment of endometriosis in Asian populations. However, the research that has been conducted supports the use of leuprorelin in an Asian population.

Systematic review of quality of life measures in patients with endometriosis

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Long-Term Effects of Gonadotropin-Releasing Hormone Agonists and Add-Back in Adolescent Endometriosis

STUDY OBJECTIVE

To explore the potential occurrence of long-term side effects and tolerability of gonadotropin-releasing hormone agonist (GnRHa) plus 2 different add-back regimens in adolescent patients with endometriosis.

DESIGN

Follow-up questionnaire sent in 2016 to patients who participated in a drug trial between 2008 and 2012.

SETTING

Tertiary care center in Boston, Massachusetts.

PARTICIPANTS

Female adolescents with surgically confirmed endometriosis (n = 51) who enrolled in a GnRHa plus add-back trial as adolescents.

INTERVENTIONS

Leuprolide depot 11.25 mg intramuscular injection every 3 months, plus oral norethindrone acetate 5 mg daily or oral norethindrone acetate 5 mg daily and oral conjugated equine estrogens 0.625 mg daily.

MAIN OUTCOME MEASURES

Side effects during and after treatment, irreversible side effects, changes in pain, overall satisfaction.

RESULTS

The response rate was 61% (25 of 41; 10 subjects could not be located). Almost all (24 of 25) reported side effects during treatment; 80% (16 of 21) reported side effects lasting longer than 6 months after stopping treatment. Almost half (9 of 20) reported side effects they considered irreversible, including memory loss, insomnia, and hot flashes. Despite side effects, participants rated GnRHa plus add-back as the most effective hormonal medication for treating endometriosis pain; two-thirds (16 of 25) would recommend it to others. More participants who received a modified 2-drug add-back regimen vs standard 1-drug add-back would recommend GnRHa and believed it was the most effective hormonal medication.

CONCLUSION

Subjects believed that GnRHa used with add-back was effective and would recommend it to others, despite significant side effects. Those who received 2-drug add-back reported more success than those who received standard add-back. A subset of patients reported side effects they consider to be irreversible.

Systematic review of endometriosis pain assessment: how to choose a scale?

BACKGROUND

Numerous studies concerning endometriosis and pain have been reported. However, there is no consensus on the best method to evaluate pain in endometriosis and many scales have been used. Moreover, there are only a few descriptions of minimal clinically important differences after treatment (MCID) to evaluate variations in pain. In our study, we aim to identify pain scales used in endometriosis pain treatment, to address their strong and weak points and to define which would be the ideal scale to help clinicians and researchers to evaluate endometriosis-related pain.

METHODS

A search of the MEDLINE and EMBASE databases was carried out for publications in English, French or Portuguese from 1980 to December 2012, for the words: endometriosis, treatment, pain. Studies were selected if they studied an endometriosis treatment and a pain scale was specified. A quantitative and a qualitative analysis of each scale was performed to define strong and weak points of each scale (systematic registration number: CRD42013005336).

RESULTS

A total of 736 publications were identified. After excluding duplications and applying inclusion criteria 258 studies remained. We found that the visual analog scale (VAS) is the most frequently used scale. Both VAS and the numerical rating scale (NRS) show a good balance between strong and weak points in comparison with others such as the Biberoglu and Behrman scale. Concerning MCID, only VAS, NRS and Brief Pain Inventory scales have reported MCID and, among these, only VAS MCID has been studied in endometriosis patients (VAS MCID = 10 mm). Adding the Clinical Global Impression score (CGI) to the pain scale allows calculation of the MCID.

CONCLUSIONS

When using pain scales their strengths and weaknesses must be known and included in the analysis. VAS is the most frequently used pain scale and, together with NRS, seems the best adapted for endometriosis pain measurement. The use of VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep dyspareunia and non-menstrual chronic pelvic pain), combined with the CGI and a quality-of-life scale will provide both clinicians and researchers with tools to evaluate treatment response.

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

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

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

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

Buserelin acetate microparticle dispersion effects drug release and plasma E(1) levels

We investigated the effect of different dispersion methods on release behavior and efficacy onset following microparticle administration of buserelin acetate (BA) sustained-release injection. In this in vitro release study, the initial dispersion of BA increased with increased stirring speed (p<0.01). Stability of BA was studied over 7 days after BA release. The initial BA release rate was higher (p<0.01) after a 1-min vibration dispersion method (VDM) using a test tube mixer (2000 rpm) compared with the standard dispersion method (SDM) by hand. Without shaking, powder aggregation was observed, and BA release was lower than in either the SDM or VDM methods. In this study using 4-week-old Sprague-Dawley female rats, the initial plasma estrone (E(1)) concentrations were lower (p<0.05) in the VDM method than in the SDM method. Observations by optical microscope and scanning microscope showed no change in microparticle shape or distribution of size induced by SDM, VDM or the ultrasonication dispersion method. These results suggest that different dispersion methods do not change the shape and distribution of microparticle size, but clearly change the BA release rate and the transition in plasma E(1) concentrations that can affect drug efficacy.

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

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

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

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

A comparative study of the acceptability and effect of goserelin and nafarelin on endometriosis

The effects of goserelin and nafarelin were compared in a prospective, randomized, open, parallel study of 6 months' treatment of 252 women with symptomatic, laparoscopically proven endometriosis. Twenty-eight departments of obstetrics and gynecology in Sweden, Norway, Denmark and Finland were included. Evaluations were made every 3 months for quantification of pain, bleeding and adverse events and convenience of treatment, and at 3 months after the end of treatment, when a control laparoscopy was performed for evaluation of changes in endometriotic lesion size, color and location. Thirty-nine patients withdrew and 113 women given goserelin and 100 women given nafarelin completed the study. There were no statistically significant differences between the groups, either in adverse events or in bleeding. There were no correlations between location, lesion size or type of lesion, and symptom score in either group, or between treatments with regard to change in endometriosis score. In both groups, the percentage of red and black lesions was reduced while the proportion of white lesions increased. The pain score was significantly reduced in both groups. Local irritation in the nasal mucosa was reported in both groups, mostly in the nafarelin-treated group. The goserelin-treated group also reported local symptoms at the injection site. We conclude that there is no statistically significant difference in treatment results or side-effects between goserelin and nafarelin when used for the treatment of endometriosis.

Current and potential application of GnRH agonists in gynecologic practice

The development of GnRH-a (analogues or agonists) is a major leap forward in the treatment of various hormone-dependent diseases in medicine. Their introduction in reproductive endocrinology, in in vitro fertilization/embryo transfer (IVF/ET) and other assisted reproduction techniques had a revolutionary impact. They have been effective in other gynecologic conditions including fibroids, endometriosis, anovulatory disorders, precocious puberty, dysfunctional uterine bleeding, and operative hysteroscopy. Medical castration induced by GnRH-a has become first-line therapy in metastatic breast cancer. Their long-term use, though, has been associated with a variety of adverse effects such as bone loss and decreased cardioprotection. "Steroid add-back" therapy in these cases apparently is an effective alternative. It may allow their safe long-term application beyond 6 months, averting unpleasant side-effects and maintaining bone mass and cardioprotection.

Rates of endometriosis recurrence and pregnancy 1 year after treatment with intranasal buserelin acetate (Suprecur) (a prospective study)

OBJECTIVES

This multicenter prospective study of buserelin acetate (Suprecur) therapy for endometriosis was performed in order to examine pregnancy rates and the recurrence of endometriosis 1 year after the end of intranasal administration.

METHODS

This study was conducted at 349 institutions, including university hospitals and major hospitals in Japan, and 1,284 patients were recruited as participants. Recurrence of symptoms was followed for 1 year after the end of administration of buserelin acetate in patients whose condition as a whole was evaluated as "improved" or better at the end of administration. Furthermore, the pregnancy rate was similarly followed in patients who complained of sterility at the commencement of the administration. Recurrence was defined as either a case in which all of the main symptoms observed before administration returned to the pretreatment state, or a case in which at least one symptom deteriorated compared to the pretreatment state. Kaplan-Meier's method was used for statistical analysis.

RESULTS

Among 459 patients who could be evaluated for recurrence of symptoms, the cumulative recurrence rate was 17.8% 1 year after the end of administration. Among 156 patients who could be evaluated for pregnancy, the pregnancy rate was 23.3% 1 year after the end of administration.

CONCLUSION

Intranasal buserelin acetate therapy exhibited not only transient clinical effects during administration or immediately after the end of administration, but also exhibited specific continuing effects after the end of administration.