Evaluation of the Role of Laser Treatment for the Treatment of Pain in Endometriosis

Endometriosis impairs bone marrow-derived stem cell recruitment to the uterus whereas bazedoxifene treatment leads to endometriosis regression and improved uterine stem cell engraftment

Endometriosis is a disease defined by the ectopic growth of uterine endometrium. Stem cells contribute to the generation of endometriosis as well as to repair and regeneration of normal endometrium. Here we demonstrate that the selective estrogen receptor modulator bazedoxifene (BZA), administered with conjugated estrogens (CEs), leads to regression of endometriosis lesions as well as reduction in stem cell recruitment to the lesions. Female mice underwent transplantation of male bone marrow. Endometrium was transplanted in the peritoneal cavity of half to create experimental endometriosis. Mice with or without experimental endometriosis were randomized to BZA/CE or vehicle treatment. Endometriosis lesions, bone marrow-derived mesenchymal stem cell engraftment of the lesions, and eutopic endometrium as well as ovarian stimulation were assessed. BZA treatment significantly reduced lesion size, gland number, and expression of proliferation marker proliferating cell nuclear antigen. Ovarian weight was not affected. Stem cells were recruited to the endometriosis lesions, and this recruitment was dramatically reduced by BZA/CE treatment. Stem cell engraftment was reduced in the uterus of animals with endometriosis; however the number of stem cells engrafting the uterus was completely restored by treatment with BZA/CE. Competition between endometriosis and the eutopic endometrium for a limited supply of stem cells and depletion of normal stem cells flux to the uterus is a novel mechanism by which endometriosis interferes with endometrial function and fertility. BZA/CE not only treats lesions of endometriosis, it also dramatically reduces stem cell recruitment to the lesions and restores stem cell engraftment of the uterine endometrium.

Future of endometriosis research

In women of reproductive age, health economic costs are estimated to be considerably higher for endometriosis than for conditions such as Crohn's disease, migraine and hypertension, and similar to the cost of diabetes. However, more awareness of endometriosis among patients and politicians is needed to create a better climate for research funding in the area of endometriosis in particular, and women's health in general. Recent collaboration between patients, physicians and politicians in the EU has shown that such efforts can be successful. Many arguments exist to organize the clinical care for women with advanced endometriosis in centers of excellence, but continuing education of primary-care physicians also remains a priority. New molecular techniques are resulting in new hormonal and nonhormonal targets for the noninvasive diagnosis and treatment of endometriosis. A future diagnostic serum assay might contain various elements from inflammatory serum markers to genetic/microarray/proteomics markers, owing to the multifactorial features of endometriosis.

[Intestinal endometriosis. Current status]

Endometriosis affects a wide spectrum of premenopausal women. Intestinal involvement, affecting mainly the large bowel and sometimes the small bowel, is much less frequent. Diagnosis is relatively straightforward in women with long standing pelvic endometriosis but is difficult in acute intestinal obstruction, since a diagnosis of endometriosis is not often considered in this entity. We performed an exhaustive review of the medical literature, including the option of medical treatment, which is rarely effective in intestinal endometriosis. In most patients with intestinal symptoms, the disease is so severe that surgical treatment is required. Recent studies indicate that the most effective approach is laparoscopic. We analyze the most important classical and recent series of patients and discuss treatment results.

Subcutaneous injection of depot medroxyprogesterone acetate compared with leuprolide acetate in the treatment of endometriosis-associated pain

OBJECTIVE

To compare the efficacy and safety of SC depot medroxyprogesterone acetate (DMPA-SC 104) with that of leuprolide acetate in treatment of endometriosis.

DESIGN

Phase 3, multicenter, randomized, evaluator-blinded, comparator-controlled trial.

SETTING

Clinical trial sites in Canada and United States.

PATIENT(S)

Two hundred seventy-four women with surgically diagnosed endometriosis.

INTERVENTION(S)

Intramuscular injections of DMPA-SC (104 mg) or leuprolide acetate (11.25 mg), given every 3 months for 6 months, with 12 months of posttreatment follow-up.

MAIN OUTCOME MEASURE(S)

Reduction in five endometriosis symptoms or signs (dysmenorrhea, dyspareunia, pelvic pain, pelvic tenderness, pelvic induration); change in bone mineral density (BMD), hypoestrogenic symptoms, bleeding, and weight.

RESULT(S)

The depot medroxyprogesterone acetate given SC was statistically equivalent to leuprolide in reducing four of five endometriosis symptoms or signs at the end of treatment (month 6) and in reducing all five symptoms after 12 months' follow-up (month 18). Patients in the DMPA-SC 104 group showed significantly less BMD loss than did leuprolide patients at month 6, with scores returning to baseline at 12 months' follow-up. No statistically significant differences in median weight changes were observed between groups. Compared with leuprolide, DMPA-SC 104 was associated with fewer hypoestrogenic symptoms but more irregular bleeding.

CONCLUSION(S)

Efficacy of DMPA-SC 104 was equivalent to that of leuprolide for reducing endometriosis-associated pain, with less impact on BMD and fewer hypoestrogenic side effects but more bleeding.

Advances in the management of endometriosis: an update for clinicians

Endometriosis is a chronic and recurrent disease characterized by the presence and proliferation of endometrial tissue outside the uterine cavity, which occurs in approximately 10% of women of reproductive age. In this estrogen-dependent disorder, lesions become inactive and gradually undergo regression during states of ovarian down-regulation, such as amenorrhoea or menopause. The impact of endometriosis includes impaired fertility potential, as well as symptoms of dysmenorrhoea, dyspareunia and chronic non-menstrual pain, all of which adversely affect quality of life. Management of endometriosis focuses on pain relief and includes medical and surgical treatment. Pharmacologic therapies currently in use include combination oral contraceptives (COCs), danazol, GnRH analogues and progestins. Although some agents show efficacy in relieving pain, all differ in their side effects, making it difficult to achieve a balance between efficacy and safety. Efficacy has been demonstrated with danazol or GnRH analogues; however, treatment is limited to 6 months because of significant metabolic side effects. Alternatives for longer-term management of symptoms include add-back therapy with GnRH analogues, COCs or progestins. Newer options for treatment of endometriosis include depot medroxyprogesterone acetate subcutaneous injection, as well as several agents under investigation that may prove to have therapeutic potential.

Subcutaneous depot medroxyprogesterone acetate versus leuprolide acetate in the treatment of endometriosis-associated pain

BACKGROUND

A clinical study compared efficacy and safety of depot medroxyprogesterone acetate (DMPA) with leuprolide for endometriosis-associated pain.

METHODS

This multicentre, 18 month, evaluator-blinded, comparator-controlled trial randomized 300 women with laparoscopically diagnosed endometriosis to 6 month treatment with subcutaneous injection of 104 mg/0.65 ml DMPA (DMPA-SC 104) every 3 months or leuprolide (3.75 mg monthly or 11.25 mg every 3 months), with 12 months post-treatment follow-up. Endpoints included patient response to treatment in five signs/symptoms (dysmenorrhoea, dyspareunia, pelvic pain, pelvic tenderness, induration) and changes in bone mineral density (BMD) and productivity at 6 and 18 months.

RESULTS

DMPA-SC 104 and leuprolide produced equivalent (P < 0.02) reductions in at least four pain categories and significant (P < 0.001) improvements in composite score at months 6 and 18. At month 6, reductions in total hip and lumbar spine BMD were significantly less (P < 0.001) with DMPA-SC 104 versus leuprolide. BMD returned to pre-treatment levels 12 months post-treatment in the DMPA-SC 104 but not the leuprolide group. Total productivity also significantly (P < or = 0.05) improved in both groups at 6 and 18 months.

CONCLUSIONS

DMPA-SC 104 reduces endometriosis-associated pain as effectively as leuprolide and improves productivity with significantly less BMD decline.

Vaginal Apex Resection: A Treatment Option for Vaginal Apex Pain

OBJECTIVE

Vaginal apex pain is a subset of chronic pelvic pain commonly treated with surgical excision of the vaginal apex. Our objective was to estimate long-term postoperative pain levels, recovery time, and return to sexual function in women who have undergone vaginal apex repair for chronic vaginal apex pain.

METHODS

Since 1995, 45 women have undergone vaginal apex repair at our institution. All were asked to complete a questionnaire describing pain levels, sexual function, daily activities, ability to work, and medical therapy before and after surgical repair of the vaginal apex. Demographic background, previous medical history, and surgical history were abstracted from the medical records. Fisher exact and Wilcoxon rank sum tests were used to determine associations among baseline characteristics and various outcomes. McNemar chi(2) testing was use to compare before and after pain levels.

RESULTS

Twenty-seven women constituted the study sample and were available for evaluation before and after vaginal apex repair. Sixty-seven percent of respondents experienced resolution of pelvic pain after vaginal apex repair for a median of 20 months. The number of women experiencing pain with daily activities decreased from 92% before vaginal apex repair to 41% after vaginal apex repair, and 30% reported sexual activity without dyspareunia after vaginal apex repair (P = .004). Sixty-one percent of women returned to work after vaginal apex repair. Most patients required continued medical therapy after vaginal apex repair.

CONCLUSION

Vaginal apex repair improves general levels of pelvic pain in some patients diagnosed with vaginal apex pain. Pain relief after vaginal apex repair is temporary, and women are likely to need continued medical therapy.