Medical treatment of mild endometriosis in infertile women: analysis of a failure

Medical management of endometriosis

Current approved medical therapies for endometriosis rely on drugs that suppress ovarian steroids and induce a hypoestrogenic state, which determines the atrophy of the ectopic endometrium. Gonadotropin-releasing hormone analogs such as danazol, progestogens and estrogen-progestin combinations have all proven effective in relieving pain and reducing the extent of endometriotic implants. However, symptoms often recur after discontinuation of therapy and hypoestrogenism-related side effects limit the long-term use of most medications. Recently, knowledge of the pathogenesis of endometriosis, particularly at the molecular level, has grown substantially, providing a rational basis for the development of new drugs with precise targets that may be safely administered over the long term.

Endometriosis: preoperative and postoperative medical treatment

The quality of the evidence that supports the use of medical treatment before conservative surgery for endometriosis is manifestly poor, and no recommendations can be made based on the results of the published studies. There are practical advantages inherent to this schedule, but whether this translates into better conception rates and reduced pain recurrence rates is unproven. The effect of drug therapy after surgery can be assessed better as data from seven true randomized, controlled trials are available. The results of the current review do not support the notion that suppressing ovarian activity postoperatively increases the long-term pregnancy rate. As far as pelvic pain is concerned, more data are needed to verify the reduced symptoms recurrence rate found in four trials in women who were allocated to postoperative medical therapy, particularly in view of the different results obtained in some of the considered studies. The observed differences among various drugs used before or after surgery are limited in clinical terms and, in the absence of formal randomized comparisons, are difficult to interpret. Because of their tolerable side effects and limited cost, progestins with or without estrogens should be considered strongly as first-line postoperative medical treatment if and when suppression of ovulation after conservative surgery is deemed opportune.

Enhanced T cells interactions with extracellular matrix proteins in infertile women with endometriosis

Essential features of endometriosis involve interactions with extracellular matrix (ECM). Recent data emphasize the important role of ECM proteins in the regulation of T cell function. The aim of this study was to determine activated T cell adhesion to ECM proteins in infertile women with endometriosis. Nine women with endometriosis diagnosed by laparoscopy according to the Revised American Fertility Society classification and ten normal healthy women with a previous successful pregnancy outcome were studied. We investigated phorbol acetate myristate (PMA) or phytohemaglutinin (PHA) activated peripheral blood T cell adhesion to the following proteins of ECM: collagen IV (C-IV), elastin (E) and fibronectin (Fn). In addition, CD4, CD8, CD29, CD45RO expression on peripheral CD3(+) T cells were studied using flow cytometry. We determine that PHA-activated T cell adhesion to C-IV and Fn are significantly higher in infertile women with endometriosis when compared to normal healthy women (P<0.05). No significant differences were noted in T cell's surface antigens expression between study groups. Our data suggest the existence of disturbed T cell-ECM interactions in infertile women with endometriosis. Further studies are needed to determine the role of these abnormalities in the pathogenesis of endometriosis.

Endometriosis: an overview of the disease and its treatment

OBJECTIVE

To review endometriosis, its etiology, clinical presentation, and current management options.

DATA SOURCES

Published articles identified through MEDLINE (1966-2000) using the search term "endometriosis" and the additional terms "etiology" and "treatment." Additional articles were identified from the bibliographies of the retrieved articles.

DATA SYNTHESIS

Endometriosis, a disease that affects the physical health and emotional well-being of many women of reproductive age, is defined as the presence of endometrial tissue outside its normal location in the uterus. The disease ranges in severity from mild to severe, and patients may be asymptomatic or experience severe and potentially incapacitating symptoms, such as dysmenorrhea, dyspareunia, and infertility. The diagnosis can be confirmed only by direct visualization using laparoscopy and biopsy. The risk of endometriosis is increased in women who have an affected first-degree relative or who have shorter menstrual cycle lengths, longer duration of menstrual flow, and low parity. The etiology of endometriosis is not yet fully understand, but may involve retrograde menstruation, hereditary factors, and impaired immune function. Treatment should be individualized for each patient, taking into account the therapeutic goals, the extent of disease, symptomatology, and the woman's age and overall health. Treatment options include expectant management, hormonal therapies to suppress ovarian steroidogenesis and induce endometrial atrophy, and surgery to remove visible lesions or, as a last resort, the uterus and ovaries.

CONCLUSION

Although the precise etiology of endometriosis remains a mystery, treatment options have improved considerably in recent years. Pharmacists are well positioned to identify women with unexplained pelvic pain or infertility that may be indicative of endometriosis and refer them to their physicians for further evaluation. Pharmacists also can play an important role in counseling patients about the safe and effective use of the various treatments for this disease and strategies to recognize and reduce adverse effects.

A gonadotrophin-releasing hormone agonist compared with expectant management after conservative surgery for symptomatic endometriosis

OBJECTIVE

To ascertain whether the frequency of pelvic pain recurrence is reduced and time to symptoms recurrence is prolonged in women with symptomatic endometriosis undergoing conservative surgery and post-operative hormonal therapy compared with women treated with surgery only. Pregnancy rates and time to conception in women wanting children were also evaluated.

DESIGN

A multicentre, prospective, randomised controlled study.

SETTING

Nineteen Italian academic departments and teaching hospitals specialising in reparative and reconstructive surgery.

POPULATION

A total of 269 women undergoing conservative surgery for mild to severe symptomatic endometriosis.

METHODS

After surgery the women were assigned to treatment with subcutaneous goserelin depot injections for six months or to expectant management. Dysmenorrhoea, deep dyspareunia, nonmenstrual pain and general discomfort were graded according to a verbal rating scale from 0 (absent) to 3 (severe) and the scores summed to give a total symptoms score. Only patients with at least one preoperative moderate or severe symptom were enrolled. The women were evaluated regularly for two years.

MAIN OUTCOME MEASURES

Post-operative pain recurrences (total symptoms scores > or = 5), time to recurrence, pregnancy rates and time to conception in the two study groups.

RESULTS

At one- and two-year follow up visits, 14/107 (13.1%) and 19/81 (23.5%) patients had moderate or severe symptoms recurrence in the goserelin group compared with, respectively, 22/103 (21.4%) and 27/74 (36.5%) in the expectant management group (P = 0.143 at 1 year and 0.082 at 2 years). Time to symptoms recurrence was significantly longer in the goserelin group according to survival analysis (Wilcoxon test, P = 0.041). Among women wanting children, few conceptions occurred in both the goserelin (8/69, 11.6%) and the expectant management group (14/76, 18.4%). There was no significant difference at survival analysis (Wilcoxon test, P = 0.427).

CONCLUSION

Post-operative treatment with goserelin significantly prolonged the pain-free interval after conservative surgery for symptomatic endometriosis and did not influence reproductive prognosis.

Progestins for symptomatic endometriosis: a critical analysis of the evidence

OBJECTIVE

To obtain estimates of the effects of progestin treatment for pelvic pain associated with endometriosis.

DATA IDENTIFICATION

Information from studies published in the English-language literature between 1966 and 1996 was pooled. Articles were identified through hand and computerized searches using MEDLINE.

STUDY SELECTION

A total of 27 trials that were published in peer-reviewed journals were identified, and 13 of these were excluded from the analysis because of methodologic limitations. Nine of the remaining 14 studies were noncomparative (8 prospective and 1 retrospective), 1 was quasi-randomized, and 4 were true randomized controlled trials.

DATA EXTRACTION AND SYNTHESIS

The sample size was generally limited; the mean number of patients included was 26 in the noncomparative trials and 29 in the randomized controlled trials. The mean duration of treatment was 6 months. A total of 355 women had pain at entry. Considering all noncomparative studies, the pooled frequency of nonresponders at the end of treatment was 9% (18/203; 95% confidence interval [CI], 5.3% to 13.6%). The common odds ratio from the four randomized controlled trials comparing progestins with danazol or a GnRH agonist was 1.1 (95% CI, 0.4 to 3.1), suggesting equivalence in treatment effect. In the only double-blind, placebo-controlled trial, the frequency of nonresponders was not significantly different in the two arms. Only four studies assessed pain after drug withdrawal. The pooled frequency of pelvic pain at the end of follow-up was 50% (35/70; 95% CI, 37.8% to 62.2%). The overall crude conception rate after therapy among women who desired pregnancy was 44% (86/194; 95% CI, 37.2% to 51.6%). Side effects of limited clinical relevance were observed frequently.

CONCLUSION(S)

The available data suggest that the efficacy of progestins for temporary relief of endometriosis-associated pelvic pain is good and comparable to that of other, less safe treatments.

Depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol for long-term treatment of pelvic pain associated with endometriosis

OBJECTIVE

Our purpose was to evaluate the efficacy and safety of depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol in the long-term treatment of pelvic pain in women with endometriosis.

STUDY DESIGN

Eighty patients with endometriosis and moderate or severe pelvic pain were randomized to treatment for 1 year with intramuscular depot medroxyprogesterone acetate 150 mg every 3 months or a cyclic monophasic oral contraceptive (ethinyl estradiol 0.02 mg, desogestrel 0.15 mg) combined with oral danazol 50 mg a day for 21 days of each 28-day cycle. The women were asked to grade the degree of their satisfaction at the end of therapy. Variations in severity of symptoms during treatment were determined by a 10 cm visual analog and a 0- to 3-point verbal rating scale.

RESULTS

Twenty nine of 40 subjects (72.5%) in the depot medroxyprogesterone acetate group were satisfied after 1 year of therapy compared with 23 of 40 (57.5%) in the oral contraceptive plus danazol group (chi 2(1) = 1.37, p = 0.24, odds ratio 1.95, 95% confidence interval 0.76 to 4.97). A significant decrease was observed in all symptom scores in both study groups. At 1-year assessment dysmenorrhea was significantly greater in women allocated to oral contraceptive plus danazol.

CONCLUSION

Depot medroxyprogesterone acetate seems to be an effective, safe, and convenient low-cost treatment for pelvic pain associated with endometriosis. However, women should be carefully counseled regarding menstrual changes and the potential prolonged delay in the return of ovulation.

Postsurgical medical treatment of advanced endometriosis: results of a randomized clinical trial

OBJECTIVE

Our purpose was to investigate the efficacy of postsurgical treatment with nafarelin in women with advanced endometriosis.

STUDY DESIGN

Eligible for trial were women < or = 38 years old with unexplained infertility with or without chronic pelvic pain and stage III or IV endometriosis according to the American Fertility Society, revised, classification who underwent laparotomy as first surgical treatment for debulking or radical surgery of endometriotic lesions. Patients were assigned according to a randomization list to nasal nafarelin, 400 micrograms/day (36 subjects) or placebo nasal spray (39 subjects) for 3 months. Pelvic pain was assessed before first surgery and at the 12-month follow-up visit in women with pelvic pain by means of a multidimensional score system and a 10-point linear pain scale.

RESULTS

No marked differences in pain scores emerged among women allocated to different treatments. The mean reduction of the multidimensional score was 3.6 and 4.0, respectively, in women allocated to nafarelin and placebo and of the 10-point linear scale scores was 7.0 and 6.9. These differences were not statistically significant. Within 1 year from randomization, of the 36 women allocated to nafarelin and the 39 allocated to placebo, seven (19%) and seven (18%), respectively, became pregnant.

CONCLUSION

This study suggests that medical treatment with nafarelin does not markedly improve pelvic pain and short-term reproductive prognosis in women with stages III and IV endometriosis.

Endometriosis-associated infertility

Despite intense clinical interest and increasingly sophisticated diagnostic techniques, we know surprisingly little of the relationship between endometriosis and infertility or the mechanism of infertility in these couples. No therapy specifically directed toward the ectopic endometrial implants, medical or surgical, has been demonstrated to improve the likelihood of pregnancy for couples with endometriosis-associated infertility. This is consistent with the observation that, in the absence of mechanical distortion of the pelvic viscera, no therapy directed against the implants improves the likelihood of pregnancy in these couples. The reason for this lack of progress is most probably that the mechanism of infertility in these couples remains to be determined. At present, it would be more accurate to say that these couples have unexplained infertility. The most promising therapeutic approach is to treat women with endometriosis-associated infertility with a non-specific cycle fecundity enhancing technique. Typically this is one of the newer assisted reproductive technologies such as controlled ovarian hyperstimulation with intrauterine insemination of capacitated sperm. Since the fecundity of many of the women with endometriosis in the later reproductive years is rapidly declining, this may represent their most cost-effective option for establishing a pregnancy. Only with further effort directed towards determining the mechanisms of infertility in these couples will a more effective therapy be forthcoming.

Vaginal patterns during danazol and buserelin acetate therapy for endometriosis: structural and ultrastructural study

OBJECTIVE

To evaluate histologic and ultrastructural changes of the vaginal mucosa in patients given buserelin acetate or danazol treatment for endometriosis.

DESIGN

Controlled clinical study.

SETTING

Infertility clinic of an academic unit.

PATIENTS

Infertile women with endometriosis randomized to receive buserelin acetate or danazol and undergoing vaginal biopsies during treatment were selected.

INTERVENTIONS

Buserelin acetate was administered IN 400 micrograms three times per day and danazol orally 600 mg/d. Vaginal biopsies were performed baseline and at 3 and 6 months of treatment, and specimens were examined by light microscopy and scanning electron microscopy. 17 beta-Estradiol and P levels were determined in each patient at the time of each biopsy.

MAIN OUTCOME MEASURE

Structural and ultrastructural patterns of vaginal mucosa after 3 and 6 months of treatment.

RESULTS

Buserelin acetate treatment induced early, marked hypotrophy of the vaginal mucosa with aspects typical of the menopause. The modifications caused by danazol occurred mainly in the intermediate layer, which was weakly hypotrophic only at the end of the treatment.

CONCLUSION

Vaginal mucosa undergoes constant and well-defined modifications during both buserelin acetate and danazol treatment for endometriosis. The modifications are compatible with the biological effects of the drugs.

Buserelin acetate versus expectant management in the treatment of infertility associated with minimal or mild endometriosis: a randomized clinical trial

OBJECTIVE

We performed a randomized clinical trial to evaluate the efficacy of intranasal 400 micrograms buserelin three times daily for 6 months versus expectant management in the treatment of infertile women with pelvic endometriosis stage I or II of the revised American Fertility Society classification.

STUDY DESIGN

Seventy-one consecutive patients (mean age 32 years) were studied at the First Department of Obstetrics and Gynecology, University of Milan, and the Department of Obstetrics and Gynecology, Ospedali Riuniti, Bergamo, between February 1988 and June 1989. Thirty-five women were randomly allocated to buserelin treatment and 36 to expectant management. The baseline distribution of subjects for age, disease stage, and reproductive history was similar in the two groups. All patients were followed regularly; median follow-up was 17 months in the buserelin group and 18 months in the women given expectant management. If pregnancy did not occur within 12 months of randomization, cycles were monitored by ultrasonography and hormone measurements, and when abnormalities were detected clomiphene citrate and human chorionic gonadotropin were administered.

RESULTS

A total of 17 pregnancies were observed both in the buserelin-treated patients and in the expectant management group. The 1- and 2-year actuarial overall pregnancy rates were similar in the two groups, 30% and 61% in the former and 37% and 61% in the latter group, respectively. Spontaneous abortion occurred in five of the 17 pregnancies in the women treated with buserelin and in one of the 17 in those managed expectantly; this difference was, however, not statistically significant (chi 1(2) adjusted for disease stage and use of clomiphene citrate and human chorionic gonadotropin treatment = 3.01, p = 0.08). No fetal death or stillbirth was observed.

CONCLUSIONS

Our findings suggest that treatment with gonadotropin-releasing hormone agonists is unlikely to have a marked influence on the reproductive outcome of infertile women with minimal or mild endometriosis.

Pelvic denervation for chronic pain associated with endometriosis: fact or fancy?

The efficacy of presacral neurectomy and amputation of the uterosacral ligaments in the treatment of chronic pelvic pain has been debated for decades. These procedures used to be done mainly in women with normal pelves, but more recently they have been performed during conservative surgery for treatment of endometriosis. In the 1980s the rapid spread of laparoscopic surgery has led to an increasing number of endoscopic denervations in patients with chronic pelvic pain associated with endometriosis. However, an analysis of literature data has failed to prove that presacral neurectomy and amputation of the uterosacral ligaments are effective and did not demonstrate better results with the use of lasers rather than electrocoagulation. Moreover, no valid comparison has yet been made between laparotomy and laparoscopic methods.