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Kesic V, Carcopino X, Preti M, Vieira-Baptista P, Bevilacqua F, Bornstein J, Chargari C, Cruickshank M, Erzeneoglu E, Gallio N, Gultekin M, Heller D, Joura E, Kyrgiou M, Madić T, Planchamp F, Regauer S, Reich O, Esat Temiz B, Woelber L, Zodzika J, Stockdale C. The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) Consensus Statement on the Management of Vaginal Intraepithelial Neoplasia. J Low Genit Tract Dis 2023; 27:131-145. [PMID: 36951985 PMCID: PMC10026974 DOI: 10.1097/lgt.0000000000000732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
ABSTRACT The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vaginal intraepithelial neoplasia (VaIN). The management of VaIN varies according to the grade of the lesion: VaIN 1 (low grade vaginal squamous intraepithelial lesions (SIL)) can be subjected to follow-up, while VaIN 2-3 (high-grade vaginal SIL) should be treated. Treatment needs individualization according to the patient's characteristics, disease extension and previous therapeutic procedures. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Total vaginectomy is used only in highly selected cases of extensive and persistent disease. Carbon dioxide (CO2) laser may be used as both an ablation method and an excisional one. Reported cure rates after laser excision and laser ablation are similar. Topical agents are useful for persistent, multifocal lesions or for patients who cannot undergo surgical treatment. Imiquimod was associated with the lowest recurrence rate, highest human papillomavirus (HPV) clearance, and can be considered the best topical approach. Trichloroacetic acid and 5-fluorouracil are historical options and should be discouraged. For VaIN after hysterectomy for cervical intraepithelial neoplasia (CIN) 3, laser vaporization and topical agents are not the best options, since they cannot reach epithelium buried in the vaginal scar. In these cases surgical options are preferable. Brachytherapy has a high overall success rate but due to late side effects should be reserved for poor surgical candidates, having multifocal disease, and with failed prior treatments. VaIN tends to recur and ensuring patient adherence to close follow-up visits is of the utmost importance. The first evaluation should be performed at 6 months with cytology and an HPV test during 2 years and annually thereafter. The implementation of vaccination against HPV infection is expected to contribute to the prevention of VaIN and thus cancer of the vagina. The effects of treatment can have an impact on quality of life and result in psychological and psychosexual issues which should be addressed. Patients with VaIN need clear and up-to-date information on a range of treatment options including risks and benefits, as well as the need for follow-up and the risk of recurrence.
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Affiliation(s)
- Vesna Kesic
- Medical Faculty, University of Belgrade, Clinic of Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Xavier Carcopino
- Department of Obstetrics and Gynaecology, Hôpital Nord, APHM, Aix-Marseille University (AMU), Univ Avignon, CNRS, IRD, IMBE UMR 7263, 13397, Marseille, France
| | - Mario Preti
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Pedro Vieira-Baptista
- Lower Genital Tract Unit Centro Hospitalar de São João, Porto, Portugal
- Hospital Lusiadas, Porto, Portugal
| | | | - Jacob Bornstein
- Galilee Medical Center and Azrieli Faculty of Medicine, Bar-Ilan, Israel
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Maggie Cruickshank
- Aberdeen Centre for Women’s Health Research, University of Aberdeen, Aberdeen, United Kingdom
| | - Emre Erzeneoglu
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Niccolò Gallio
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Elmar Joura
- Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Maria Kyrgiou
- Surgery and Cancer - West London Gynecological Cancer Center, IRDB, Department of Gut, Metabolism & Reproduction-Surgery & Cancer, Imperial College London, London, United Kingdom
- Imperial Healthcare NHS Trust, Queen Charlotte's & Chelsea Hospital West London Gynaecological Cancer Centre, London, United Kingdom
| | - Tatjana Madić
- Clinic for Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Sigrid Regauer
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Olaf Reich
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Bilal Esat Temiz
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
| | - Linn Woelber
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
- Dysplasia Center Hamburg; Jerusalem Hospital Hamburg, Hamburg, Germany
| | - Jana Zodzika
- Department of Obstetrics and Gynaecology Rīga Stradiņ,š University, Riga, Latvia
| | - Colleen Stockdale
- Department of Obstetrics & Gynecology, University of Iowa, Iowa City, IA
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Kesic V, Carcopino X, Preti M, Vieira-Baptista P, Bevilacqua F, Bornstein J, Chargari C, Cruickshank M, Erzeneoglu E, Gallio N, Gultekin M, Heller D, Joura E, Kyrgiou M, Madić T, Planchamp F, Regauer S, Reich O, Esat Temiz B, Woelber L, Zodzika J, Stockdale C. The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) consensus statement on the management of vaginal intraepithelial neoplasia. Int J Gynecol Cancer 2023; 33:446-461. [PMID: 36958755 PMCID: PMC10086489 DOI: 10.1136/ijgc-2022-004213] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vaginal intraepithelial neoplasia (VaIN). The management of VaIN varies according to the grade of the lesion: VaIN 1 (low grade vaginal squamous intraepithelial lesions (SIL)) can be subjected to follow-up, while VaIN 2-3 (high-grade vaginal SIL) should be treated. Treatment needs individualization according to the patient's characteristics, disease extension and previous therapeutic procedures. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Total vaginectomy is used only in highly selected cases of extensive and persistent disease. Carbon dioxide (CO2) laser may be used as both an ablation method and an excisional one. Reported cure rates after laser excision and laser ablation are similar. Topical agents are useful for persistent, multifocal lesions or for patients who cannot undergo surgical treatment. Imiquimod was associated with the lowest recurrence rate, highest human papillomavirus (HPV) clearance, and can be considered the best topical approach. Trichloroacetic acid and 5-fluorouracil are historical options and should be discouraged. For VaIN after hysterectomy for cervical intraepithelial neoplasia (CIN) 3, laser vaporization and topical agents are not the best options, since they cannot reach epithelium buried in the vaginal scar. In these cases surgical options are preferable. Brachytherapy has a high overall success rate but due to late side effects should be reserved for poor surgical candidates, having multifocal disease, and with failed prior treatments. VaIN tends to recur and ensuring patient adherence to close follow-up visits is of the utmost importance. The first evaluation should be performed at 6 months with cytology and an HPV test during 2 years and annually thereafter. The implementation of vaccination against HPV infection is expected to contribute to the prevention of VaIN and thus cancer of the vagina. The effects of treatment can have an impact on quality of life and result in psychological and psychosexual issues which should be addressed. Patients with VaIN need clear and up-to-date information on a range of treatment options including risks and benefits, as well as the need for follow-up and the risk of recurrence.
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Affiliation(s)
- Vesna Kesic
- Medical Faculty, University of Belgrade, Clinic of Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Xavier Carcopino
- Department of Obstetrics and Gynaecology, Hôpital Nord, APHM, Aix-Marseille University (AMU), Univ Avignon, CNRS, IRD, IMBE UMR 7263, 13397, Marseille, France
| | - Mario Preti
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Pedro Vieira-Baptista
- Lower Genital Tract Unit Centro Hospitalar de São João, Porto, Portugal
- Hospital Lusiadas, Porto, Portugal
| | | | - Jacob Bornstein
- Galilee Medical Center and Azrieli Faculty of Medicine, Bar-Ilan, Israel
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Maggie Cruickshank
- Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - Emre Erzeneoglu
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Niccolò Gallio
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Debra Heller
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Elmar Joura
- Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Maria Kyrgiou
- Surgery and Cancer - West London Gynecological Cancer Center, IRDB, Department of Gut, Metabolism & Reproduction-Surgery & Cancer, Imperial College London, London, UK
- Imperial Healthcare NHS Trust, Queen Charlotte's & Chelsea Hospital West London Gynaecological Cancer Centre, London, UK
| | - Tatjana Madić
- Clinic for Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Sigrid Regauer
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Olaf Reich
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Bilal Esat Temiz
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Linn Woelber
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
- Dysplasia Center Hamburg; Jerusalem Hospital Hamburg, Hamburg, Germany
| | - Jana Zodzika
- Department of Obstetrics and Gynaecology Rīga Stradiņš University, Riga, Latvia
| | - Colleen Stockdale
- Department of Obstetrics & Gynecology, University of Iowa, Iowa City, Iowa, USA
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Preti M, Joura E, Vieira-Baptista P, Van Beurden M, Bevilacqua F, Bleeker MCG, Bornstein J, Carcopino X, Chargari C, Cruickshank ME, Erzeneoglu BE, Gallio N, Heller D, Kesic V, Reich O, Stockdale CK, Esat Temiz B, Woelber L, Planchamp F, Zodzika J, Querleu D, Gultekin M. The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD) and the European Federation for Colposcopy (EFC) consensus statements on pre-invasive vulvar lesions. Int J Gynecol Cancer 2022; 32:830-845. [PMID: 35728950 PMCID: PMC9279839 DOI: 10.1136/ijgc-2021-003262] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/16/2022] Open
Abstract
The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vulvar squamous intraepithelial neoplasia, vulvar Paget disease in situ, and melanoma in situ. For differentiated vulvar intraepithelial neoplasia (dVIN), an excisional procedure must always be adopted. For vulvar high-grade squamous intraepithelial lesion (VHSIL), both excisional procedures and ablative ones can be used. The latter can be considered for anatomy and function preservation and must be preceded by several representative biopsies to exclude malignancy. Medical treatment (imiquimod or cidofovir) can be considered for VHSIL. Recent studies favor an approach of using imiquimod in vulvar Paget's disease. Surgery must take into consideration that the extension of the disease is usually wider than what is evident in the skin. A 2 cm margin is usually considered necessary. A wide local excision with 1 cm free surgical margins is recommended for melanoma in situ. Following treatment of pre-invasive vulvar lesions, women should be seen on a regular basis for careful clinical assessment, including biopsy of any suspicious area. Follow-up should be modulated according to the risk of recurrence (type of lesion, patient age and immunological conditions, other associated lower genital tract lesions).
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Affiliation(s)
- Mario Preti
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Elmar Joura
- Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Pedro Vieira-Baptista
- Hospital Lusiadas Porto, Porto, Portugal
- Lower Genital Tract Unit, Centro Hospitalar de São João, Porto, Portugal
| | - Marc Van Beurden
- Centre for Gynecological Oncology Amsterdam, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Maaike C G Bleeker
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Jacob Bornstein
- Galilee Medical Center and Azrieli Faculty of Medicine, Bar-Ilan, Israel
| | - Xavier Carcopino
- Department of Obstetrics and Gynaecology, Hôpital Nord, APHM, Aix-Marseille University (AMU), Univ Avignon, CNRS, IRD, IMBE UMR 7263, 13397, Marseille, France
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Paris, France
| | | | - Bilal Emre Erzeneoglu
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Niccolò Gallio
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Debra Heller
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Vesna Kesic
- Department of Obstetrics and Gynecology, University of Belgrade, Belgrade, Serbia
| | - Olaf Reich
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Colleen K Stockdale
- Department of Obstetrics & Gynecology, University of Iowa, Iowa City, Iowa, USA
| | - Bilal Esat Temiz
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Linn Woelber
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
- Dysplasia Center Hamburg, Jerusalem Hospital, Hamburg, Germany
| | | | - Jana Zodzika
- Department of Obstetrics and Gynaecology Rīga Stradiņš university, Riga, Latvia
| | - Denis Querleu
- Department of Obstetrics and Gynecologic Oncology, University Hospital, Strasbourg, France
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Preti M, Joura E, Vieira-Baptista P, Van Beurden M, Bevilacqua F, Bleeker MCG, Bornstein J, Carcopino X, Chargari C, Cruickshank ME, Erzeneoglu BE, Gallio N, Heller D, Kesic V, Reich O, Stockdale CK, Temiz BE, Woelber L, Planchamp F, Zodzika J, Querleu D, Gultekin M. The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD) and the European Federation for Colposcopy (EFC) Consensus Statements on Pre-invasive Vulvar Lesions. J Low Genit Tract Dis 2022; 26:229-244. [PMID: 35763611 PMCID: PMC9232287 DOI: 10.1097/lgt.0000000000000683] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vulvar squamous intraepithelial neoplasia, vulvar Paget disease in situ, and melanoma in situ. For differentiated vulvar intraepithelial neoplasia (dVIN), an excisional procedure must always be adopted. For vulvar high-grade squamous intraepithelial lesion (VHSIL), both excisional procedures and ablative ones can be used. The latter can be considered for anatomy and function preservation and must be preceded by several representative biopsies to exclude malignancy. Medical treatment (imiquimod or cidofovir) can be considered for VHSIL. Recent studies favor an approach of using imiquimod in vulvar Paget's disease. Surgery must take into consideration that the extension of the disease is usually wider than what is evident in the skin. A 2 cm margin is usually considered necessary. A wide local excision with 1 cm free surgical margins is recommended for melanoma in situ. Following treatment of pre-invasive vulvar lesions, women should be seen on a regular basis for careful clinical assessment, including biopsy of any suspicious area. Follow-up should be modulated according to the risk of recurrence (type of lesion, patient age and immunological conditions, other associated lower genital tract lesions).
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Affiliation(s)
- Mario Preti
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Elmar Joura
- Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer; Center, Medical University of Vienna, Vienna, Austria
| | - Pedro Vieira-Baptista
- Hospital Lusiadas Porto, Porto, Portugal; Lower Genital Tract Unit, Centro Hospitalar de São João, Porto, Portugal
| | - Marc Van Beurden
- Centre for Gynecological Oncology Amsterdam, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Maaike C. G. Bleeker
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jacob Bornstein
- Galilee Medical Center and Azrieli Faculty of Medicine, Bar-Ilan, Israel
| | - Xavier Carcopino
- Department of Obstetrics and Gynaecology, Hôpital Nord, APHM, Aix-Marseille University (AMU), Univ Avignon, CNRS, IRD, IMBE UMR 7263, 13397, Marseille, France
| | - Cyrus Chargari
- Radiation Therapy, Gustave Roussy Cancer Campus, Paris, France
| | - Margaret E. Cruickshank
- Aberdeen Centre for Women’s Health Research, University of Aberdeen, Aberdeen, United Kingdom
| | - Bilal Emre Erzeneoglu
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Niccolò Gallio
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | | | - Vesna Kesic
- Department of Obstetrics and Gynecology, University of Belgrade, Belgrade, Serbia
| | - Olaf Reich
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | | | - Bilal Esat Temiz
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Linn Woelber
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Dysplasia Center Hamburg, Jerusalem Hospital, Hamburg, Germany
| | | | - Jana Zodzika
- Department of Obstetrics and Gynaecology Rīga Stradiņš university, Riga, Latvia
| | - Denis Querleu
- Department of Obstetrics and Gynecologic Oncology, University Hospital, Strasbourg, France; Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Karataş E, Temiz BE, Mumusoglu S, Yarali H, Bozdag G. P–328 Dienogest significantly decreases the size of the cyst and alters Anti-Müllerian Hormone concentration in patients with endometrioma. Hum Reprod 2021. [DOI: 10.1093/humrep/deab130.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study question
Does utilization of dienogest make any impact on the size of cyst and Anti-Müllerian Hormone (AMH) concentration in patients with endometrioma throughout 12-months?
Summary answer
Although dienogest makes a gradual reduction in the size of endometrioma cyst throughout 12-months, a significant drop in AMH serum concentration was also noticed.
What is known already
According to recent studies, pre-operative serum AMH levels might be illusively increased with parallel to the size of endometrioma which will be a misleading factor while deciding to operate the patient via cystectomy. Although dienogest is one of the medical options that might be commenced in patients with endometrioma cyst, there is limited data about its effect on the size of the endometrioma and hence serum AMH concentration throughout 12 months of follow up.
Study design, size, duration
The current observational cohort study was conducted among patients with endometrioma those treated with dienogest from January 2017 to January 2020. The primary outcome was alteration in diameter of endometrioma cyst at 6th and 12th months of treatment. Secondary outcome was alteration in serum AMH concentration in the same period. Of 104 patients treated with dienogest, 44 patients were excluded due to being treated with any type of surgical intervention during follow up period.
Participants/materials, setting, methods
A total of 60 patients were recruited for the final analysis. Of them, primary symptom was dysmenorrhea, chronic pelvic pain and menstrual irregularity in 16 (26.7%), 25 (41.7%) and 8 (13.3%) patients, respectively. Eighteen patients (30%) were asymptomatic. As 21 patients had bi-lateral endometrioma, size of the leading cyst was considered to be analyzed for the primary outcome measure. Paired-t test was used for comparison of numerical values and p ≤ 0.05 was taken as statistical significance.
Main results and the role of chance
The mean age was 31.5±8.0 years. In the time point when dienogest was started, the mean size of the endometrioma was 46.3±17.4 mm. The mean serum AMH concentration was 3.6±2.4 ng/ml. After 6 months of treatment, the mean size of the endometrioma decreased to 38.6±14.0 mm which corresponds to a mean difference of 7.8 mm (95% CI: 3.0 to 12.6; p: 0.003). The respective figure for AMH was 3.3±2.7 ng/ml which corresponds to a mean difference of 0.3 ng/ml (95% CI: –0.2 to 0.8; p: 0.23) at 6 months. After 12 months of treatment, the mean size of the endometrioma was 37.5±15.7 mm which corresponds to a mean difference of 8.9 mm (95% CI: 2.9 to 14.9; p: 0.005) at the end of 12 months. The respective figure for AMH was 2.7±1.9 ng/ml which corresponds to a mean difference of 0.9 ng/ml (95% CI: 0.1 to 1.7; p: 0.045) at the end of 12 months. The mean diameter of endometrioma and AMH concentration did not differ throughout the time period between 6th and 12th months of the treatment.
Limitations, reasons for caution
Although herein we present the largest data that depicts the alteration of endometrioma cyst and AMH concentration with the application of dienogest, the lack of control group is a limitation that avoids to perform any comparison.
Wider implications of the findings: A shrinkage after commencement of treatment suggest that dienogest might present improvement in patients with endometrioma with respect to radiological findings, but further studies are required whether a decline in AMH concentration after 12 months refers to a genuine decrease in ovarian reserve or resolution of misleading high pre-treatment levels.
Trial registration number
not available
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Affiliation(s)
- E Karataş
- Hacettepe University, Obstetrics and Gynecology, Ankara, Turkey
| | - B E Temiz
- Hacettepe University, Obstetrics and Gynecology, Ankara, Turkey
| | - S Mumusoglu
- Hacettepe University, Obstetrics and Gynecology, Ankara, Turkey
| | - H Yarali
- Hacettepe University, Obstetrics and Gynecology, Ankara, Turkey
| | - G Bozdag
- Hacettepe University, Obstetrics and Gynecology, Ankara, Turkey
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