Does deep endometriosis infiltrating the uterosacral ligaments present an asymmetric lateral distribution?

Laterality and asymmetry of endometriotic lesions

OBJECTIVE

To identify possible sources of heterogeneities in the estimation of the proportion of bilateral cases and of left-sided cases of endometriotic lesions.

DESIGN

We included 20 studies that reported estimated proportions, and examined the effect of sample size and the anatomic location of lesions on the heterogeneity using a mixed-effect logit regression model.

SETTING

Academic.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

None.

RESULT(S)

The sample size of these studies ranged from 64 to 1,407, with a median of 227 and a total sample size of 7,236 cases. There is substantial heterogeneity in the estimated proportion of both bilateral and left-sided cases. The estimated proportion of bilateral cases is positively associated with the sample size of the study, whereas that of left-sided cases is negatively associated with the sample size, irrespective of the anatomic locations of endometriotic lesions.

CONCLUSION(S)

There is an identifiable source of heterogeneity in proportion estimates, with the sample size being an apparent source. Although the precise causes for the sample size dependency are unclear, it is possible that the invasive nature of endometriotic lesions may eventually render most cases bilateral. Moreover, there are both promoting as well as mitigating or negating factors that contributing to the asymmetry of endometriotic lesions.

Lateral distribution of endometriomas as a function of age

The lateral asymmetry of ovarian endometriomas, with a left-sided predilection, seems to disappear with advancing age. This asymmetry does not seem to persist in women >35 years of age.

Association between endometriosis and cancer: a comprehensive review and a critical analysis of clinical and epidemiological evidence

OBJECTIVE

This review was aimed to critically evaluate observational, cohort, and case-control studies performed so far in order to assess the association between endometriosis and malignant diseases. Based on the observations herein presented, clinical indications that might avoid physicians' mismanaging of affected patients are proposed.

METHODS

Search strategies included online searching of the MEDLINE database and hand searching of relevant publications and reviews. Additional reports were collected by systematically reviewing all references from retrieved papers.

RESULTS

Endometriosis is not associated with an increased risk of cancer in general. Data from large cohort and case-control studies indicate an increased risk of ovarian cancers in women with endometriosis. The observed effect sizes are modest varying between 1.3 and 1.9. Evidence from clinical series consistently demonstrates that the association is confined to the endometrioid/clear-cell histotypes. Available studies are characterized by several limitations, some of which potentially bias results towards the null hypothesis whereas others leading to overestimate the association. Evidence for an association with melanoma and non-Hodgkin's lymphoma is increasing but still to be verified whereas an increased risk for other gynecological cancer types is not supported.

CONCLUSIONS

Epidemiological findings on the association between endometriosis and cancer are still elusive. At present, endometriosis should not be considered a medical condition associated with a clinically relevant risk of any specific cancer. On the basis of the present findings, modifications of the standard treatment options for the disease are not justifiable.

Deep Endometriosis: Definition, Pathogenesis, and Clinical Management

"Deep endometriosis" includes rectovaginal lesions as well as infiltrative forms that involve vital structures such as bowel, ureters, and bladder. The available evidence suggests the same pathogenesis for deep infiltrating vesical and rectovaginal endometriosis (i.e., intraperitoneal seeding of regurgitated endometrial cells, which collect and implant in the most dependent portions of the peritoneal cavity and the anterior and posterior cul-de-sac, and trigger an inflammatory process leading to adhesion of contiguous organs with creation of false peritoneal bottoms). According to anatomic, surgical, and pathologic findings, deep endometriotic lesions seem to originate intraperitoneally rather than extraperitoneally. Also the lateral asymmetry in the occurrence of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomic differences of the left and right hemipelvis. Peritoneal, ovarian, and deep endometriosis may be diverse manifestations of a disease with a single origin (i.e., regurgitated endometrium). Based on different pathogenetic hypotheses, several schemes have been proposed to classify deep endometriosis, but further data are needed to demonstrate their validity and reliability. Drugs induce temporary quiescence of active deep lesions and may be useful in selected circumstances. Progestins should be considered as first-line medical treatment for temporary pain relief. However, in most cases of severely infiltrating disease, surgery is the final solution. Great importance must be given to complete and balanced counseling, as awareness of the real possibilities of different treatments will enhance the patient's collaboration.

Endometriosis: the consequence of neurological dysfunction?

Endometriosis describes endometrium found outside the uterine cavity and is frequently associated with clinical presentations of chronic pelvic pain, dysmenorrhoea, dyspareunia and subfertility. It was originally attributed to retrograde menstruation with endometrium passing in a reverse direction along the Fallopian tubes into the peritoneal cavity though this theory does not account for the spectrum of intrapelvic findings. Denervation followed by reinnervation in the uterine isthmus is proposed as the primary source of clinical symptoms, and, retrograde menstruation with adhesion of endometrium to injured tissue surfaces the variable laparoscopic findings. Primary sources of denervation are difficult intrapartum episodes (parous women) and persistent straining to achieve defaecation (nulliparous women). Progressive reinnervation including stromal nerve fibre proliferation, microneuroma formation and periarterial nerve fibre proliferation, takes place over five to ten years. Damage to uterine innervation interrupts normal patterns of uterine contractility, causing loss of fundocervical polarity which promotes retrograde menstruation. Ectopic endometrium may be a marker for prior tissue damage and does not contribute to the clinical symptoms--the disease may have been largely defined by an epiphenomenon.