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Di Giuseppe J, Delli Carpini G, Giannella L, Terenzi T, Fichera M, Ragno F, Campanati A, Boero V, Caia C, Pesce E, Vercellini P, Gardella B, Dominoni M, Spinillo A, Sopracordevole F, Clemente N, Del Fabro A, Rossi R, Corazza M, Borghi A, Martinello R, Greco P, Rizzo G, Criscuolo AA, Mappa I, Matteini E, Botti E, Campione E, Bianchi L, Ciavattini A. A Longitudinal Multiinstitutional Study of Vulvar Lichen Sclerosus: From Childhood to Perimenopause. J Low Genit Tract Dis 2024:00128360-990000000-00110. [PMID: 38661348 DOI: 10.1097/lgt.0000000000000816] [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: 04/26/2024]
Abstract
OBJECTIVE The main outcome of this study was the evaluation of clinical characteristics, comorbidities, and therapeutic approaches in patients with vulvar lichen sclerosus (VLS) aged from childhood to perimenopause. Secondly, it was intended to compare these characteristics according to the menarchal status. METHODS Patients less than 45 years of age with a diagnosis of VLS from January 2002 to June 2022 in 10 referral centers were included in this retrospective longitudinal study. The univariate analysis compared the dependent variables according to menarchal status. RESULTS One hundred eighty-six patients met the inclusion criteria. At diagnosis, between 25% and 40% of premenarchal patients reported signs related to subepithelial hemorrhage. A significantly greater presence of bleeding (p < .005), easy bruising (p = .028), fissures (p = .008), petechiae/splinter hemorrhages (p < .001), and bleeding/blistering or open sores (p = .011) was observed in premenarchal patients with respect to the postmenarchal group. The perineum (p = .013) and the perianal region (p < .001) were significantly more involved in the premenarchal group. Topical calcineurin inhibitors were more used in the premenarchal population (p = .004), whereas vitamin E oil and moisturizers were more used in the postmenarchal population (p = .047). CONCLUSIONS Vulvar lichen sclerosus is a chronic condition that can cause vulvar changes that result in severe morbidity and affects sexual function and quality of life, even before menopause. Vulvar lichen sclerosus continues to be misdiagnosed in this population. This may lead to an average delay from symptom onset to diagnosis. Evaluating clinical manifestations of VLS in premenarchal and postmenarchal age allowed us to find different clinical characteristics between the 2 periods suggestive of the diagnosis.
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Affiliation(s)
- Jacopo Di Giuseppe
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Giovanni Delli Carpini
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Luca Giannella
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Tomas Terenzi
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Mariasole Fichera
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Federica Ragno
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Anna Campanati
- Dermatological Clinic, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Veronica Boero
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlotta Caia
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Pesce
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Barbara Gardella
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Mattia Dominoni
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Arsenio Spinillo
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Francesco Sopracordevole
- Gynecological Oncology Unit, IRCCS CRO - Centro di Riferimento Oncologico - National Cancer Institute, Aviano, Italy
| | - Nicolò Clemente
- Gynecological Oncology Unit, IRCCS CRO - Centro di Riferimento Oncologico - National Cancer Institute, Aviano, Italy
| | - Anna Del Fabro
- Gynecological Oncology Unit, IRCCS CRO - Centro di Riferimento Oncologico - National Cancer Institute, Aviano, Italy
| | - Riccardo Rossi
- Preventive Gynecological Oncology Section, European Medical Center, Florence, Italy
| | - Monica Corazza
- Section of Dermatology and Infectious Diseases, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Alessandro Borghi
- Section of Dermatology and Infectious Diseases, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Ruby Martinello
- Obstetrics and Gynaecology Clinic, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Pantaleo Greco
- Obstetrics and Gynaecology Clinic, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome Italy
| | - Anna Angela Criscuolo
- Department of Obstetrics and Gynecology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome Italy
| | - Ilenia Mappa
- Department of Obstetrics and Gynecology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome Italy
| | - Enrico Matteini
- U.O.C. Dermatology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome, Italy
| | - Elisabetta Botti
- U.O.C. Dermatology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome, Italy
| | - Elena Campione
- U.O.C. Dermatology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome, Italy
| | - Luca Bianchi
- U.O.C. Dermatology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome, Italy
| | - Andrea Ciavattini
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
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Chiaffarino F, Cipriani S, Ricci E, Esposito G, Parazzini F, Vercellini P. Correction: Histologic Subtypes in Endometriosis-Associated Ovarian Cancer and Ovarian Cancer Arising in Endometriosis: A Systematic Review and Meta-Analysis. Reprod Sci 2024:10.1007/s43032-024-01556-1. [PMID: 38649668 DOI: 10.1007/s43032-024-01556-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Affiliation(s)
- Francesca Chiaffarino
- Gynaecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, Milan, 20122, Italy
| | - Sonia Cipriani
- Gynaecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, Milan, 20122, Italy.
| | - Elena Ricci
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanna Esposito
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Fabio Parazzini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Paolo Vercellini
- Gynaecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, Milan, 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Boero V, Cetera GE, Caia C, Merli CEM, Gramegna G, Pesce E, Barbara G, Ermelinda M, Vercellini P. Beyond vulvodynia: from a correct diagnosis to a multidisciplinary care program. A referral center experience. Arch Gynecol Obstet 2024:10.1007/s00404-024-07496-0. [PMID: 38634899 DOI: 10.1007/s00404-024-07496-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 11/17/2023] [Accepted: 03/25/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Vulvodynia is a chronic pain condition without an identifiable cause. As such, it is a diagnosis of exclusion, and all other causes of vulvar pain should be excluded. Although a standard treatment for vulvodynia has not been established yet, multidisciplinary care programs appear to be effective. PUROPOSE The aim of this retrospective monocentric study was to analyze the prevalence of vulvodynia among women referred to our institution for a suspected diagnosis and to evaluate the efficacy of a multidimensional treatment plan. The primary outcome was the prevalence of vulvodynia following differential diagnosis. Secondary outcomes included: prevalence of the differential diagnoses, symptom resolution rate following treatment, and the relation between persistence of symptoms and (a) patients' age; (b) coexisting chronic overlapping pain conditions (COPCs). RESULTS After having ruled out all other causes of vulvar pain, only 40.1% of women were considered as affected by vulvodynia. The most frequent differential diagnoses included lower genital tract infections (25.3%), vulvar lichen sclerosus (17.6%) and vulvovaginal atrophy (8.2%). Following a multidisciplinary care program, resolution of symptoms was observed in 13.6% cases, improvement in 64.3% and persistence in 21.9%. We did not find a statistically significant association between persistence of symptoms and age > 38 years (OR 2.10; p = 0.30). Women with one or more COPCs other than vulvodynia had a 75% increased risk of not obtaining a resolution of symptoms (OR 1.75; p = 0.44). CONCLUSION A thorough differential diagnosis and a multidisciplinary care program may represent a first way out of the muddle in the management of these patients.
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Affiliation(s)
- Veronica Boero
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Emily Cetera
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Carlotta Caia
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | | | - Giada Gramegna
- Obstetric and Gynecological Emergency Unit and SVSeD (Service for Sexual and Domestic Violence), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Pesce
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giussy Barbara
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Monti Ermelinda
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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Abbott J, Abrao M, Al-Jefout M, Bedaiwy M, Benagiano G, Burns KA, Canis M, Carmona F, Chapron C, Critchley HOD, de Ziegler D, Falcone T, Fazleabas A, Ferrero S, Garcia-Velasco JA, Gargett C, Greaves E, Griffith LG, Guo SW, Habiba M, Harada T, Hull ML, Johnson NP, Kaufman Y, Issacson KB, Khan KN, Kim MR, Koninckx PA, Lessey BA, Martin D, Matsuzaki S, Mishra G, Osuga Y, Petraglia F, Popov A, Roman H, Romano A, Saunders P, Seckin T, Somigliana E, Taylor HS, Vercellini P, Vigano P. Answering Dr Lee about the future role of phenome. J Minim Invasive Gynecol 2024:S1553-4650(24)00168-7. [PMID: 38641049 DOI: 10.1016/j.jmig.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/21/2024]
Affiliation(s)
- Jason Abbott
- Department of Obstetrics and Gynecology, Women's and Children's Health, School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia.
| | - Mauricio Abrao
- Gynecologic Division, BP - A Beneficencia Portuguesa de Sao Paulo, BR. Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
| | - Moamar Al-Jefout
- Department of Obstetrics & Gynecology, College of Medicine & Health Sciences, United Arab Emirates University, UAE.
| | - Mohamed Bedaiwy
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada.
| | - Giuseppe Benagiano
- Faculty of Medicine and Dentistry, "Sapienza" University of Rome, 00185 Rome, Italy.
| | - Katherine A Burns
- Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A..
| | - Michel Canis
- Department of Obstetrics Gynecology and Reproductive Medicine, CHU Clermont Ferrand, Clermont Ferrand, France.
| | - Francisco Carmona
- Gynecology Department, Clinic Institute of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of Barcelona, Universitat de Barcelona, 08007 Barcelona, Spain.
| | - Charles Chapron
- Department of Gynecology, Obstetrics II, and Reproductive Medicine, Faculté de Santé, Faculté de Médecine Paris Centre, Université de Paris, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France.
| | - Hilary O D Critchley
- Centre for Reproductive Health, Institute for Regeneration and Repair, University of Edinburgh, UK.
| | | | - Tommaso Falcone
- Cleveland Clinic Department of Obstetrics and Gynecology, Women's Health Institute, 9500 Euclid Ave, Cleveland, Ohio, U.S.A..
| | - Asgerally Fazleabas
- Department of Obstetrics, Gynecology & Reproductive Biology, Michigan State University, 400 Monroe Avenue NW, Grand Rapids, Michigan, U.S.A..
| | - Simone Ferrero
- IRCCS Ospedale Policlinico San Martino, University of Genova, Italy Largo Rosanna Benzi 1, 16132 Genova, Italy.
| | - Juan A Garcia-Velasco
- IVI RMA Global Research Alliance, IVI RMA Madrid, Spain Rey Juan Carlos University, Av del Talgo 68, 28023 Madrid, Spain.
| | - Caroline Gargett
- The Ritchie Centre, Hudson Institute of Medical Research, Australia and Department of Obstetrics and Gynecology, Monash University, Melbourne, Victoria, Australia.
| | - Erin Greaves
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, U.K..
| | - Linda G Griffith
- Biological Engineering Department, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts, U.S.A..
| | - Sun-Wei Guo
- Research Institute, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China.
| | - Marwan Habiba
- Department of Health Sciences, University of Leicester, Women and Perinatal Services, Leicester Royal Infirmary, Leicester LE1 5WW, Leicestershire, UK.
| | | | - Mary Louise Hull
- Endometriosis Group, Robinson Research Institute, University of Adelaide, Women's and Children's Hospital, Adelaide and Embrace Fertility, No. 1 The Parade, Norwood, Adelaide, Australia.
| | - Neil P Johnson
- Dept. of Obstetrics & Gynecology, Flinders University, Adelaide, Robinson Research Institute, University of Adelaide, Australia; Auckland Gynecology Group and Repromed Auckland, Auckland, New Zealand; Flinders Fertility, Adelaide, Australia.
| | - Yuval Kaufman
- Department of Obstetrics & Gynecology, The Lady Davies Carmel Medical Center, Haifa, Israel.
| | - Keith B Issacson
- Minimally Invasive Gynecologic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts, U.S.A..
| | - Khaleque N Khan
- Department of Obstetrics and Gynecology, The Clinical and Translational Research Center, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Mee-Ran Kim
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Philippe A Koninckx
- Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Catholic University Leuven, 3000 Leuven, Belgium.
| | - Bruce A Lessey
- Department of Obstetrics and Gynecology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, U.S.A..
| | - Dan Martin
- University of Tennessee Health Science Center, Memphis, Tennessee, U.S.A..
| | - Sachiko Matsuzaki
- CHU Clermont-Ferrand, Chirurgie Gynécologique, Université Clermont Auvergne, Institut Pascal, UMR6602, CNRS/UCA/SIGMA, Clermont-Ferrand, France.
| | - Gita Mishra
- Australia Women and Girls' Health Research Centre, School of Public Health, University of Queensland, Brisbane, Queensland, Australia.
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
| | - Felice Petraglia
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy.
| | - Alexander Popov
- Department of operative gynecology with oncology, Moscow Regional Scientific Research Institute of Obstetrics and Gynecology, Moscow, Russian Federation.
| | - Horace Roman
- IFEMEndo, Clinique Tivoli-Ducos, Bordeaux, France.
| | - Andrea Romano
- Department of Obstetrics and Gynecology, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre, Maastricht, Netherlands.
| | - Philippa Saunders
- Centre for Inflammation Research, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh BioQuarter, Edinburgh EH16 4UU, UK.
| | - Tamer Seckin
- Department of Obstetrics and Gynecology, Lenox Hill Hospital - Northwell Health/Zucker School of Medicine, New York, New York, U.S.A..
| | - Edgardo Somigliana
- Academic Center for research on adenomyosis and endometriosis, Department of Clinical Science and Community Health, Università degli Studi and Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Hugh S Taylor
- Section of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, U.S.A.
| | - Paolo Vercellini
- Academic Center for research on adenomyosis and endometriosis, Department of Clinical Science and Community Health, Università degli Studi and Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Paola Vigano
- Infertility Unit, Fondazione IRCCS Ca' GrandaOspedale Maggiore Policlinico, 20122 Milano, Italy.
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Piccini M, Cetera GE, Nasini A, Vercellini P. Social networks and influencers as the main source of 'scientific' information on endometriosis: a medical class hara-kiri? Hum Reprod 2024; 39:856-857. [PMID: 38423532 DOI: 10.1093/humrep/deae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Affiliation(s)
- Martina Piccini
- Academic Centre for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
| | - Giulia Emily Cetera
- Academic Centre for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Anna Nasini
- Academic Centre for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
| | - Paolo Vercellini
- Academic Centre for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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Bogani G, Sopracordevole F, Ciavattini A, Ghelardi A, Vizza E, Vercellini P, Casarin J, Pinelli C, Ghezzi F, De Vincenzo R, Di Donato V, Golia D'augè T, Giannini A, Sorbi F, Petrillo M, Capobianco G, Vizzielli G, Restaino S, Cianci S, Scambia G, Raspagliesi F. HPV-related lesions after hysterectomy for high-grade cervical intraepithelial neoplasia and early-stage cervical cancer: A focus on the potential role of vaccination. Tumori 2024; 110:139-145. [PMID: 37978580 DOI: 10.1177/03008916231208344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To date, no data supports the execution of vaccination after hysterectomy for high-grade cervical intraepithelial neoplasia (CIN2+) and early-stage cervical cancer. We aim to evaluate the potential effect of vaccination after hysterectomy for high-grade cervical intraepithelial neoplasia and early-stage cervical cancer. METHODS This is a multi-center retrospective study evaluating data of women who develop lower genital tract dysplasia (including anal, vulvar and vaginal intra-epithelial neoplasia) after having hysterectomy for CIN2+ and FIGO stage IA1- IB1 cervical cancer. RESULTS Overall, charts for 77 patients who developed lower genital tract dysplasia were collected. The study population included 62 (80.5%) and 15 (19.5%) patients with CIN2+ and early-stage cervical cancer, respectively. The median (range) time between hysterectomy and diagnosis of develop lower genital tract dysplasia was 38 (range, 14-62) months. HPV types covered by the nonavalent HPV vaccination would potentially cover 94.8% of the development of lower genital tract dysplasia. Restricting the analysis to the 18 patients with available HPV data at the time of hysterectomy, the beneficial effect of nonvalent vaccination was 89%. However, considering that patients with persistent HPV types (with the same HPV types at the time of hysterectomy and who developed lower genital tract dysplasia) would not benefit from vaccination, we estimated the potential protective effect of vaccination to be 67% (12 out of 18 patients; four patients had a persistent infection for the same HPV type(s)). CONCLUSIONS Our retrospective analysis supported the adoption of HPV vaccination in patients having treatment for HPV-related disease. Even in the absence of the uterine cervix, HPV vaccination would protect against develop lower genital tract dysplasia. Further prospective studies have to confirm our preliminary research.
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Affiliation(s)
- Giorgio Bogani
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milano, Italy
| | - Francesco Sopracordevole
- Gynecologic Oncology Unit, Centro di Riferimento Oncologico - National Cancer Institute, Aviano, Italy
| | - Andrea Ciavattini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona, Italy
| | - Alessandro Ghelardi
- Azienda Usl Toscana Nord-Ovest, UOC Ostetricia e Ginecologia, Ospedale Apuane, Massa, Italy
| | - Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Paolo Vercellini
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Ospedale di circolo Fondazione Macchi, Varese, Italy
| | - Ciro Pinelli
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Ospedale di circolo Fondazione Macchi, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Ospedale di circolo Fondazione Macchi, Varese, Italy
| | - Rosa De Vincenzo
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Violante Di Donato
- Department of Gynecological, Obstetrical and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Tullio Golia D'augè
- Department of Gynecological, Obstetrical and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Giannini
- Department of Gynecological, Obstetrical and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Flavia Sorbi
- Department of Obstetrics and Gynecology. University of Florence, Florence, Italy
| | - Marco Petrillo
- Department of Obstetrics and Gynecology. University of Sassari, Sassari, Italy
| | | | - Giuseppe Vizzielli
- Gynecologic Oncology Unit, Centro di Riferimento Oncologico - National Cancer Institute, Aviano, Italy
| | - Stefano Restaino
- Department of Medical Area (DAME), Clinic of Obstretics and Gynecology Santa Maria della Misericordia, University Hospital Azienda Sanitaria Universitaria Friuli Centrale, University of Udine, Udine, Italy
| | - Stefano Cianci
- Department of Human Pathology of Adult and Childhood, G. Barresi Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Francesco Raspagliesi
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milano, Italy
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Boero V, Cetera GE, Caia C, Villa S, Montemurro T, Brambilla M, Monti E, Iorio M, Somigliana E, Vercellini P, Prati D. Is there a role for platelet rich plasma injection in vulvar lichen sclerosus? A self-controlled pilot study. Arch Gynecol Obstet 2024:10.1007/s00404-024-07424-2. [PMID: 38523203 DOI: 10.1007/s00404-024-07424-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 10/25/2023] [Accepted: 02/09/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Owing to the evidence that as many as 30-40% of patients with vulvar lichen sclerosus (VLS) fail to report a remission of symptoms with first-line corticosteroid treatment (TCS), especially as what regards dyspareunia, we aimed to analyze patients' satisfaction following vulvar injection of autologous platelet-rich plasma (PRP). This is intended as an adjunctive treatment, to be used following TCS, and appears to promote tissue repair. It may also possibly have immunomodulatory proprieties. MATERIALS AND METHODS Patients with VLS were considered eligible for this pilot study if, despite having been treated with a 3-month TCS regimen, they reported a persistence of symptoms. PRP was produced in a referral center using a manual method and a standardized protocol. Each patient received three treatments 4 to 6 weeks apart. RESULTS A total of 50 patients with a median age of 53 years [IQR 38-59 years] were included in the study. 6 months after the last injection of PRP all patients were either satisfied or very satisfied with the treatment (100%; 95% CI 93-100%). Median NRS scores for itching, burning, dyspareunia and dysuria were significantly reduced (p < 0.05) and FSFI, HADS and SF-12 questionnaires revealed a significant improvement in sexual function, psychological wellbeing and quality of life (p < 0.05). The number of patients reporting the need for maintenance TCS treatment was reduced by 42% (p < 0.001) and an improvement in vulvar elasticity and color was reported in all patients. CONCLUSION Following standard medical therapy, PRP may be effective not only in improving symptoms, but also in restoring function.
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Affiliation(s)
- Veronica Boero
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Emily Cetera
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Gynecology Unit, Fondazione IRCCS Ca' GrandaOspedale Maggiore Policlinico, Milan, Italy
| | - Carlotta Caia
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefania Villa
- Department of Transfusion Medicine and Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tiziana Montemurro
- Department of Transfusion Medicine and Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimiliano Brambilla
- Plastic Surgery Service, Foundation IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Ermelinda Monti
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Iorio
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edgardo Somigliana
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Gynecology Unit, Fondazione IRCCS Ca' GrandaOspedale Maggiore Policlinico, Milan, Italy
| | - Daniele Prati
- Department of Transfusion Medicine and Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Chiaffarino F, Cipriani S, Ricci E, Esposito G, Parazzini F, Vercellini P. Histologic Subtypes in Endometriosis-Associated Ovarian Cancer and Ovarian Cancer Arising in Endometriosis: A Systematic Review and Meta-Analysis. Reprod Sci 2024:10.1007/s43032-024-01489-9. [PMID: 38438776 DOI: 10.1007/s43032-024-01489-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 07/19/2023] [Accepted: 02/07/2024] [Indexed: 03/06/2024]
Abstract
The definition of the association between ovarian cancer and endometriosis was first reported by Sampson in 1925. He identified the following criteria: (a) clear evidence of endometriosis in proximity to the tumour, (b) exclusion of a metastatic tumour to the ovary, (c) presence of tissue resembling endometrial stroma surrounding epithelial glands. The naming of these cancers is "endometriosis-associated ovarian cancer" (EAOC). Scott proposed an additional stringent criterion: evidence of histological transition from endometriosis to cancer is to define "ovarian cancer arising in endometriosis" (OCAE). The aim of this systematic review is to analyse the distribution of different ovarian cancer histotypes in EAOC and OCAE to understand their similarities and differences. A total of 31 studies were included. Four studies added data for both EAOC and OCAE. Twenty-three studies were selected for EAOC, with a total of 800 patients, and 12 studies were selected for OCAE, with a total of 375 patients. The results show no significant differences in the distribution of histotypes in the two populations analysed. Clear cell carcinoma (CCC) and endometrioid carcinoma (EC) were the most common subtypes and were less frequent in EAOC compared to OCAE; the odd ratios were 0.58 (0.26-1.29) and 0.65 (0.33-1.26) respectively, although the difference was not statistically significant. The other histotypes were present in small proportions. This analysis shows that the histological profiles of EAOC and OCAE are similar, suggesting a similar aetiopathological mechanism, which requires further research to investigate whether EAOC and OCAE may be in the same way but at different points of the process to malignancy or have different pathways of progression to malignancy.
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Affiliation(s)
- Francesca Chiaffarino
- Gynaecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122, Milan, Italy
| | - Sonia Cipriani
- Gynaecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122, Milan, Italy.
| | - Elena Ricci
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanna Esposito
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Fabio Parazzini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Paolo Vercellini
- Gynaecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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9
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Merli CEM, Cetera GE, Caia C, Facchin F, Vercellini P. "The sound of silence" Giving voice to endometriosis-related positional dyspareunia. Arch Gynecol Obstet 2024; 309:887-893. [PMID: 37689593 DOI: 10.1007/s00404-023-07205-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/23/2023] [Indexed: 09/11/2023]
Abstract
Deep dyspareunia is one of the main symptoms of endometriosis. It appears to be submerged by a two-way disconnection between patients and their physicians. The aim of our review is to provide clear, ready-to-use advice on how to manage deep dyspareunia overcoming the gap in communication. Sexual history should always be taken as part of routine health care in these regards, using a patient-centered approach. An educational pelvic examination, which actively includes patients in the identification of painful areas, may prove useful to improve patients' understanding of their condition. Correlating painful pelvic areas with sexual positions and inviting patients to adopt alternative positions may represent a simple but extremely effective coping strategy to mitigate pain. Revealing and explaining to partners the nature of the pain is essential to allow them to take part in shared research of coping mechanisms, empowering the couple to make choices and changes. Couples who do not feel comfortable talking about intimacy by themselves may find that including a psychotherapist or a sexual therapist, may be a good way to start communication. Investigating and managing dyspareunia during medical encounters is a medical and ethical duty all healthcare practitioners should pursue.
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Affiliation(s)
- Camilla Erminia Maria Merli
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122, Milan, Italy.
| | - Giulia Emily Cetera
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122, Milan, Italy
| | - Carlotta Caia
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Federica Facchin
- Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy
| | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Cetera GE, Merli CEM, Barbara G, Caia C, Vercellini P. Questionnaires for the Assessment of Central Sensitization in Endometriosis: What Is the Available Evidence? A Systematic Review with a Narrative Synthesis. Reprod Sci 2024; 31:633-644. [PMID: 37751146 PMCID: PMC10912156 DOI: 10.1007/s43032-023-01343-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/28/2023] [Indexed: 09/27/2023]
Abstract
It has been suggested that central sensitization (CS) may be involved in the failure of standard medical and surgical treatment to relieve endometriosis-related pain. However, there is no gold standard for the diagnosis of CS, and self-reported questionnaires are used as diagnostic surrogates. The main objective of this review was to identify all CS questionnaires used in clinical endometriosis studies. The secondary objective was to qualitatively analyze strengths and weaknesses of each questionnaire. A PubMed and EMBASE systematic literature search conducted in April 2023 using the terms "endometriosis; central pain; central sensitization; questionnaire; patient-reported outcome measure; screening tool" identified 122 publications: six articles were included in the review. The Central Sensitization Inventory (CSI) is the most frequently used questionnaire for the detection of CS in patients with endometriosis. It has been validated in patients with endometriosis, in whom it appears to have good psychometric proprieties. The Fibromyalgia Survey Questionnaire (FSQ) has also been used, although it has not been specifically validated in endometriosis patients. The debate regarding these questionnaires' construct validity is still open and will be so until a gold standard diagnostic tool for CS is found. In fact, some authors argue these questionnaires are measuring psychological vulnerability and a hypervigilant state that is associated with pain, rather than CS itself. However, their use should not be discouraged as they are able to identify chronic pain patients which warrant further attention and who may benefit from broader treatment strategies.
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Affiliation(s)
- Giulia Emily Cetera
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Giussy Barbara
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
- Obstetric and Gynecological Emergency Unit and SVSeD (Service for Sexual and Domestic Violence), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Carlotta Caia
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Mijatovic V, Vercellini P. Towards comprehensive management of symptomatic endometriosis: beyond the dichotomy of medical versus surgical treatment. Hum Reprod 2024; 39:464-477. [PMID: 38199787 DOI: 10.1093/humrep/dead262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 12/06/2023] [Indexed: 01/12/2024] Open
Abstract
Except when surgery is the only option because of organ damage, the presence of suspicious lesions, or the desire to conceive, women with endometriosis-associated pain often face a choice between medical and surgical treatment. In theory, the description of the potential benefits and potential harms of the two alternatives should be standardized, unbiased, and based on strong evidence, enabling the patient to make an informed decision. However, doctor's opinion, intellectual competing interests, local availability of specific services and (mis)information obtained from social media, and online support groups can influence the type of advice given and affect patients' choices. This is compounded by the paucity of robust data from randomized controlled trials, and the anxiety of distressed women who are eager to do anything to alleviate their disabling symptoms. Vulnerable patients are more likely to accept the suggestions of their healthcare provider, which can lead to unbalanced and physician-centred decisions, whether in favour of either medical or surgical treatment. In general, treatments should be symptom-orientated rather than lesion-orientated. Medical and surgical modalities appear to be similarly effective in reducing pain symptoms, with medications generally more successful for severe dysmenorrhoea and surgery more successful for severe deep dyspareunia caused by fibrotic lesions infiltrating the posterior compartment. Oestrogen-progestogen combinations and progestogen monotherapies are generally safe and well tolerated, provided there are no major contraindications. About three-quarters of patients with superficial peritoneal and ovarian endometriosis and two-thirds of those with infiltrating fibrotic lesions are ultimately satisfied with their medical treatment although the remainder may experience side effects, which may result in non-compliance. Surgery for superficial and ovarian endometriosis is usually safe. When fibrotic infiltrating lesions are present, morbidity varies greatly depending on the skill of the individual surgeon, the need for advanced procedures, such as bowel resection and ureteral reimplantation, and the availability of expert colorectal surgeons and urologists working together in a multidisciplinary approach. The generalizability of published results is adequate for medical treatment but very limited for surgery. Moreover, on the one hand, hormonal drugs induce disease remission but do not cure endometriosis, and symptom relapse is expected when the drugs are discontinued; on the other hand, the same drugs should be used after lesion excision, which also does not cure endometriosis, to prevent an overall cumulative symptom and lesion recurrence rate of 10% per postoperative year. Therefore, the real choice may not be between medical treatment and surgery, but between medical treatment alone and surgery plus postoperative medical treatment. The experience of pain in women with endometriosis is a complex phenomenon that is not exclusively based on nociception, although the role of peripheral and central sensitization is not fully understood. In addition, trauma, and especially sexual trauma, and pelvic floor disorders can cause or contribute to symptoms in many individuals with chronic pelvic pain, and healthcare providers should never take for granted that diagnosed or suspected endometriosis is always the real, or the sole, origin of the referred complaints. Alternative treatment modalities are available that can help address most of the additional causes contributing to symptoms. Pain management in women with endometriosis may be more than a choice between medical and surgical treatment and may require comprehensive care by a multidisciplinary team including psychologists, sexologists, physiotherapists, dieticians, and pain therapists. An often missing factor in successful treatment is empathy on the part of healthcare providers. Being heard and understood, receiving simple and clear explanations and honest communication about uncertainties, being invited to share medical decisions after receiving detailed and impartial information, and being reassured that a team member will be available should a major problem arise, can greatly increase trust in doctors and transform a lonely and frustrating experience into a guided and supported journey, during which coping with this chronic disease is gradually learned and eventually accepted. Within this broader scenario, patient-centred medicine is the priority, and whether or when to resort to surgery or choose the medical option remains the prerogative of each individual woman.
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Affiliation(s)
- Velja Mijatovic
- Department of Gynaecology & Reproductive Medicine, Academic Endometriosis Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi and Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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12
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Somigliana E, Viganò P, Bandini V, Buggio L, Berlanda N, Vercellini P. Reply of the Authors: Adenomyosis and endometriosis in infertility-how do we optimize the house and the garden? Fertil Steril 2024; 121:549. [PMID: 38237654 DOI: 10.1016/j.fertnstert.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/06/2024] [Accepted: 01/09/2024] [Indexed: 01/27/2024]
Affiliation(s)
- Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy; Department of Women's and Children's Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Paola Viganò
- Department of Women's and Children's Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Veronica Bandini
- Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
| | - Laura Buggio
- Department of Women's and Children's Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Nicola Berlanda
- Department of Women's and Children's Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy; Department of Women's and Children's Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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13
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Cetera GE, Facchin F, Viganò P, Merli CEM, Frassineti A, Fiorini J, Somigliana E, Vercellini P. "SO FAR AWAY" How Doctors Can Contribute to Making Endometriosis Hell on Earth. A Call for Humanistic Medicine and Empathetic Practice for Genuine Person-Centered Care. A Narrative Review. Int J Womens Health 2024; 16:273-287. [PMID: 38405184 PMCID: PMC10894706 DOI: 10.2147/ijwh.s440542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 12/13/2023] [Indexed: 02/27/2024] Open
Abstract
"SO FAR AWAY" * How Doctors Can Contribute to Making Endometriosis Hell on Earth [* by Knopfler M. In Dire Straits. Brothers in Arms. Vertigo Records, U.K., 1985]. Abstract The distance physicians may create within the relationship with their patients by not having a humanistic approach to their practice may strongly influence clinical outcomes. The purpose of this paper is to convey the well-known narrative of patient dissatisfaction into pro-action by discussing the aspects of dehumanization, which may occur in the relationship between physicians and women with endometriosis. Eight dimensions of dehumanization are examined and related to everyday scenarios occurring in endometriosis care settings and the possible downstream consequences on patients' clinical outcomes are described. Objectification, which may come across as minimization of pain, may not only increase patients' perception of pain but also lead to undertreatment of unrecognized forms of endometriosis, especially among adolescents. Passivity, that is not favoring shared decision-making nor self-management, may compromise adherence to treatment, reducing patients' trust in physicians and quality of life. The same consequences may result from homogenization, that is giving for granted that all patients have the same access to care. Both isolation, ie not practicing therapeutic empathy, and loss of meaning, ie not supporting patients in the re-definition of their life plans, may affect women's psychological wellbeing and further increase pain perception. Ignoring women's personal journey by not providing clear information on the consequences endometriosis may have on their lives may favor women's self-silencing. Not promoting an un-biased communication and not setting aside scientific polarization are the main features of dislocation, which may jeopardize patient empowerment. Lastly, having a reductionist approach to the body may contribute to chronicization of pain, thus compromising quality of life. This considered, taking time to listen to women with endometriosis and tailoring decisions on the basis of their individual needs should be fostered as a moral duty. Physicians should always keep in mind that they are not only deliverers of treatment; they are a form of treatment themselves.
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Affiliation(s)
- Giulia Emily Cetera
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Federica Facchin
- Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy
| | - Paola Viganò
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Infertility Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Annalisa Frassineti
- Associazione Progetto Endometriosi Organizzazione di Volontariato, Reggio Emilia, Italy
| | - Jessica Fiorini
- Associazione Progetto Endometriosi Organizzazione di Volontariato, Reggio Emilia, Italy
| | - Edgardo Somigliana
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Infertility Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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Canis M, Abbott J, Abrao M, Al-Jefout M, Bedaiwy M, Benagiano G, Burns KA, Canis M, Carmona F, Chapron C, Critchley HO, de Ziegler D, Falcone T, Fazleabas A, Ferrero S, Garcia-Velasco JA, Gargett C, Greaves E, Griffith LG, Guo SW, Habiba M, Harada T, Hull ML, Johnson NP, Kaufman Y, Issacson KB, Khan KN, Kim MR, Koninckx PA, Lessey BA, Martin D, Matsuzaki S, Mishra G, Osuga Y, Petraglia F, Popov A, Roman H, Romano A, Saunders P, Seckin T, Somigliana E, Taylor HS, Taylor RN, Vercellini P, Vigano P. A Call for New Theories on the Pathogenesis and Pathophysiology of Endometriosis. J Minim Invasive Gynecol 2024:S1553-4650(24)00073-6. [PMID: 38365066 DOI: 10.1016/j.jmig.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/31/2024] [Accepted: 02/04/2024] [Indexed: 02/18/2024]
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Vercellini P, Bandini V, Viganò P, Ambruoso D, Cetera GE, Somigliana E. Proposal for targeted, neo-evolutionary-oriented secondary prevention of early-onset endometriosis and adenomyosis. Part II: medical interventions. Hum Reprod 2024; 39:18-34. [PMID: 37951241 DOI: 10.1093/humrep/dead206] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/07/2024] [Indexed: 11/13/2023] Open
Abstract
According to consistent epidemiological data, the slope of the incidence curve of endometriosis rises rapidly and sharply around the age of 25 years. The delay in diagnosis is generally reported to be between 5 and 8 years in adult women, but it appears to be over 10 years in adolescents. If this is true, the actual onset of endometriosis in many young women would be chronologically placed in the early postmenarchal years. Ovulation and menstruation are inflammatory events that, when occurring repeatedly for years, may theoretically favour the early development of endometriosis and adenomyosis. Moreover, repeated acute dysmenorrhoea episodes after menarche may not only be an indicator of ensuing endometriosis or adenomyosis, but may also promote the transition from acute to chronic pelvic pain through central sensitization mechanisms, as well as the onset of chronic overlapping pain conditions. Therefore, secondary prevention aimed at reducing suffering, limiting lesion progression, and preserving future reproductive potential should be focused on the age group that could benefit most from the intervention, i.e. severely symptomatic adolescents. Early-onset endometriosis and adenomyosis should be promptly suspected even when physical and ultrasound findings are negative, and long-term ovulatory suppression may be established until conception seeking. As nowadays this could mean using hormonal therapies for several years, drug safety evaluation is crucial. In adolescents without recognized major contraindications to oestrogens, the use of very low-dose combined oral contraceptives is associated with a marginal increase in the individual absolute risk of thromboembolic events. Oral contraceptives containing oestradiol instead of ethinyl oestradiol may further limit such risk. Oral, subcutaneous, and intramuscular progestogens do not increase the thromboembolic risk, but may interfere with attainment of peak bone mass in young women. Levonorgestrel-releasing intra-uterine devices may be a safe alternative for adolescents, as amenorrhoea is frequently induced without suppression of the ovarian activity. With regard to oncological risk, the net effect of long-term oestrogen-progestogen combinations use is a small reduction in overall cancer risk. Whether surgery should be considered the first-line approach in young women with chronic pelvic pain symptoms seems questionable. Especially when large endometriomas or infiltrating lesions are not detected at pelvic imaging, laparoscopy should be reserved to adolescents who refuse hormonal treatments or in whom first-line medications are not effective, not tolerated, or contraindicated. Diagnostic and therapeutic algorithms, including self-reported outcome measures, for young individuals with a clinical suspicion of early-onset endometriosis or adenomyosis are proposed.
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Affiliation(s)
- Paolo Vercellini
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Veronica Bandini
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
| | - Paola Viganò
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Deborah Ambruoso
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
| | - Giulia Emily Cetera
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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16
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Vercellini P, Bandini V, Viganò P, Di Stefano G, Merli CEM, Somigliana E. Proposal for targeted, neo-evolutionary-oriented, secondary prevention of early-onset endometriosis and adenomyosis. Part I: pathogenic aspects. Hum Reprod 2024; 39:1-17. [PMID: 37951243 PMCID: PMC10876119 DOI: 10.1093/humrep/dead229] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/17/2023] [Indexed: 11/13/2023] Open
Abstract
The potential for repeated ovulation and menstruation is thought to have provided a Darwinian advantage during the Palaeolithic. Reproductive conditions remained relatively stable until the pre-industrial era, characterized by late menarche, very young age at first birth, multiple pregnancies, and prolonged periods of lactational amenorrhoea. For hundreds of thousands of years, menstruators experienced few ovulatory cycles, even though they were genetically adapted to ovulate and menstruate every month. In the post-industrial era, the age at menarche gradually declined, the age at first birth progressively increased, and breastfeeding became optional and often of short duration. This created a mismatch between genetic adaptation and socio-environmental evolution, so that what was initially a probable reproductive advantage subsequently contributed to increased susceptibility to diseases associated with lifetime oestrogen exposure, such as ovarian, endometrial and breast cancer and, hypothetically, also those associated with the number of ovulatory menstruations, such as endometriosis and adenomyosis. The incidence of endometriosis shows a steep and progressive increase around the age of 25 years, but given the consistently reported delay in diagnosis, the actual incidence curve should be shifted to the left, supporting the possibility that the disease has its roots in adolescence. This raises the question of whether, from an evolutionary point of view, anovulation and amenorrhoea should not still be considered the physiological state, especially in the postmenarchal period. However, an increase in the frequency of endometriosis in recent decades has not been demonstrated, although this deserves further epidemiological investigation. In addition, as endometriosis occurs in a minority of individuals exposed to retrograde menstruation, other important pathogenic factors should be scrutinised. Research should be resumed to explore in more detail the transtubal reflux of not only blood, but also endometrial cells, and whether they are systematically present in the peritoneal fluid after menstruation. If repetitive ovulatory menstruation during the early reproductive years is shown to increase the risk of endometriosis and adenomyosis development and progression in susceptible individuals, hormonal interventions could be used as secondary prevention in symptomatic adolescents.
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Affiliation(s)
- Paolo Vercellini
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Veronica Bandini
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
| | - Paola Viganò
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Giorgia Di Stefano
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
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Nicolas‐Boluda A, Le Roux E, Tavenet A, Bouaziz J, Vercellini P, Stratton P, Fauconnier A. Developing a set of patient-centered outcomes for routine use in endometriosis: An international Delphi study. Acta Obstet Gynecol Scand 2024; 103:138-152. [PMID: 37905359 PMCID: PMC10755132 DOI: 10.1111/aogs.14694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/28/2023] [Accepted: 09/30/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION There is large variation in individual patient care for endometriosis. A uniform approach to measure outcomes could be incorporated into routine clinical practice to personalize and monitor treatments and potentially improve the quality of care. The aim of this study is to identify a group of patient-centered outcomes for use in routine endometriosis care which are relevant to all patient profiles. MATERIAL AND METHODS By means of a modified two-round Delphi study with international representation including healthcare professionals, researchers and patient representatives (51 participants, 16 countries) we developed a set of patient-centered measurements. The participants evaluated 47 Patient Reported Outcome Measures (PROMs) and 30 Clinician Reported Outcome Measures (CROMs) regarding their feasibility and relevance for their use in routine endometriosis care. After the two rounds of quotation, meetings of the experts were convened to participate in a final discussion to finalize the consensus of the final set of included measures. RESULTS The final set of patient-centered outcomes includes six PROMs (measuring symptomatic impact, pain, work productivity and quality of life) and 10 CROMs (measuring clinical, imaging and surgical indicators). A supplementary list of outcomes was added to include important dimensions that were considered essential by the expert panel but are not relevant to all patients. In addition the need for development of specific tools (PROMs) measuring the psychological impact and the impact in sexual activity of endometriosis was highlighted. CONCLUSIONS We have developed a set of patient-centered outcomes measures in endometriosis care. The selected outcomes comprise the common features for all patients suffering from endometriosis. adapted for use in routine practice. The list of outcomes has been adapted for use in routine practice from which clinicians can chose, depending on their needs.
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Affiliation(s)
- Alba Nicolas‐Boluda
- One ClinicParisFrance
- European Association of Value‐Based Health CareBrusselsBelgium
| | - Enora Le Roux
- Clinical Epidemiology Unit, Hôpital Universitaire Robert DebréAP‐HP Nord‐Université de Paris, Inserm, CIC 1426ParisFrance
- ECEVE UMR 1123Université de Paris, InsermParisFrance
| | | | | | - Paolo Vercellini
- Gynecology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
- Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
| | - Pamela Stratton
- Office of the Clinical Director, National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Arnaud Fauconnier
- Research Unit 7285 Clinical Risks and Safety in Women's Health and Perinatal Health (RISCQ), UVSQUniversité Paris‐SaclayMontigny‐le‐BretonneuxFrance
- Gynecology and Obstetrics DepartmentCentre Hospitalier Intercommunal de Poissy‐Saint‐Germain‐en‐LayePoissyFrance
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Casalechi M, Reschini M, Palermo MC, Stefano GD, Vercellini P, Benaglia L, Somigliana E, Viganò P. Is endometrial receptivity affected in women with endometriosis? Results from a matched pair case-control study of assisted reproductive technology treatments. Reprod Biomed Online 2023; 47:103414. [PMID: 37879123 DOI: 10.1016/j.rbmo.2023.103414] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 09/12/2023] [Accepted: 09/12/2023] [Indexed: 10/27/2023]
Abstract
RESEARCH QUESTION Is endometriosis detrimental to embryo implantation? DESIGN A retrospective matched case-control study of women with a surgical or ultrasound diagnosis of endometriosis at Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico di Milano between 2015 and 2021. Women with endometriosis who underwent a 'freeze-all' cycle during an IVF treatment were eligible to be included. They were matched to patients without the disease, who also underwent cryopreserved blastocyst transfer cycles, in a 1:1 ratio by age (±1 year), and number (=) and quality (±1 top versus low) of cryopreserved blastocysts. All women underwent single frozen embryo transfer, and assisted reproductive technology outcomes suggested by the Core Outcome Measure for Infertility Trials initiative were evaluated. The main outcome was the cumulative live birth rate per cycle. RESULTS One hundred and one women with endometriosis and 101 matched unaffected women were included. Cumulative live birth rate per cycle did not vary between women with and without endometriosis (50% versus 58%, respectively; P = 0.32). On the basis of the Kaplan-Meier analysis, the predicted success rates over four embryos transferred were also similar (74% versus 82%, respectively; P = 0.67). CONCLUSION In women with moderate or severe endometriosis, these retrospective results seem to indicate no or a limited effect of the disease on endometrial receptivity.
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Affiliation(s)
- Maíra Casalechi
- Division of Human Reproduction, Hospital das Clínicas - Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Marco Reschini
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Carla Palermo
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgia Di Stefano
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Laura Benaglia
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edgardo Somigliana
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Paola Viganò
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Cetera GE, Merli CEM, Boero V, Caia C, Facchin F, Barbara G, Monti E, Vercellini P. Central Sensitization in Vulvodynia and Endometriosis: What Have We Been Overlooking So Far? Obstet Gynecol Surv 2023; 78:745-758. [PMID: 38134340 DOI: 10.1097/ogx.0000000000001183] [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: 12/24/2023]
Abstract
Importance Women experience more frequent and greater pain than men, although they receive less adequate treatment and are perceived as more anxious than males. Recent clinical research has lead to hypothesize a common etiology for overlapping chronic pain conditions and mood disorders, namely, central sensitization, which originates from an alteration of pain processing pathways in the central nervous system. Objective The aim of this review was to collect all available evidence regarding the potential role of central sensitization in vulvodynia and endometriosis. Evidence Acquisition A systematic literature search was performed between July and August 2022 using the electronic database PubMed. The extracted data were summarized using a narrative approach. Results Ten articles were chosen for the review. Participants' mean age was 39.2 years (SD = 5.1). Among serum markers of central sensitization, nitric oxide levels were greater in women with endometriosis than in controls, whereas brain-derived neurotrophic factor and S100B levels differed among pain conditions with structural anomalies and those without. Functional magnetic resonance imaging showed different resting state networks between patients with endometriosis and controls. In neurophysiology studies, cases had reduced pain thresholds, compared with healthy controls. Lastly, self-reported questionnaires suggested a central component of pain in women with endometriosis-related dyspareunia and associated bladder/pelvic floor tenderness. Conclusions and Relevance The management of vulvodynia and endometriosis may benefit from a new perspective, which considers their possible central etiology. It is compelling that treatment of pain starts to be considered a therapeutic goal in its own right.
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Affiliation(s)
- Giulia Emily Cetera
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | | | - Veronica Boero
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlotta Caia
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Federica Facchin
- Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy
| | - Giussy Barbara
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Ermelinda Monti
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Somigliana E, Piani LL, Paffoni A, Salmeri N, Orsi M, Benaglia L, Vercellini P, Vigano' P. Endometriosis and IVF treatment outcomes: unpacking the process. Reprod Biol Endocrinol 2023; 21:107. [PMID: 37936154 PMCID: PMC10629090 DOI: 10.1186/s12958-023-01157-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023] Open
Abstract
Advanced endometriosis is associated with a reduction of IVF success. Surgical damage to the ovarian reserve following the excision of endometriomas has been claimed as a critical factor in the explanation of this detrimental effect. However, it is generally inferred that other mechanisms might also hamper IVF success in affected women. They include diminished responsiveness to ovarian stimulation, altered steroidogenesis, a decline in oocyte quality, reduced fertilization and embryo development, and impaired implantation. To navigate these limitations, we scrutinized available literature for studies specifically designed to address distinct phases of the IVF process. Utmost consideration was given to intra-patient ovarian response comparisons in women with unilateral endometriomas and to studies applying a meticulous matching to control confounders. The following observations have been drawn: 1) endometriosis has a negligible impact on ovarian response. A slight reduction in stimulation response can only be observed for endometriomas larger than 4 cm. Follicular steroidogenesis is unaffected; 2) oocyte quality is not hampered. Fertilization rates are similar, and intracytoplasmic sperm injection (ICSI) is not justified. Embryonic development is uncompromised, with no increase in aneuploidy rate; 3) endometrial receptivity is either unaffected or only slightly impacted. In conclusion, our study suggests that, aside from the well-known negative effect on ovarian reserve from excisional endometrioma surgeries, endometriosis does not significantly affect IVF outcomes.
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Affiliation(s)
- Edgardo Somigliana
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Letizia Li Piani
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | | | - Noemi Salmeri
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Michele Orsi
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Benaglia
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Vigano'
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Bogani G, Sopracordevole F, Ciavattini A, Vizza E, Vercellini P, Giannini A, Ghezzi F, Scambia G, Raspagliesi F, Di Donato V. Duration of human papillomavirus persistence and its relationship with recurrent cervical dysplasia. Eur J Cancer Prev 2023; 32:525-532. [PMID: 37401466 DOI: 10.1097/cej.0000000000000822] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [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: 07/05/2023]
Abstract
OBJECTIVE To evaluate how the duration of human papillomavirus (HPV) persistence influences the risk of developing recurrent high-grade cervical dysplasia (CIN2+). METHODS Data of patients with persistent HPV infection (at least at 6 months) after primary conization were extracted from a multi-institutional Italian database, retrospectively. Kaplan-Meier and Cox proportional hazards models were used to evaluate associations between duration of HPV persistence with the 5-year risk of developing recurrent CIN2+. RESULTS Overall, 545 patients met the inclusion criteria. Positive margins were detected in 160 (29.3%) patients. Overall, 247 (45.3%) and 123 (22.6%) patients had a documented infection from HPV16/18, and other high-risk HPV types. 187 (34.3%), 73 (13.4%), and 40 (7.3%) were diagnosed with persistent HPV infection at 12, 18, and 24 months, respectively. Patients with HPV persistence at 6 months experienced a risk of recurrence of 7.46%. Twelve-month HPV persistence strongly correlates with the risk of developing the recurrent disease (risk of recurrence: 13.1%). While, having HPV persistence >12 months did not correlate with an increased risk of recurrence (hazard ratio: 1.34 (95% confidence interval: 0.78-2.32); P = 0.336, log-rank test). CONCLUSION HPV persistence is one of the most important factors predicting the risk of CIN2+ recurrence. The risk of CIN2+ recurrence increased with the increase of HPV persistence for up to 1 year. The persistence of HPV after the first year does not appear as a risk factor.
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Affiliation(s)
- Giorgio Bogani
- Department of Gynecological, Obstetrical and Urological Sciences, 'Sapienza' University of Rome
| | - Francesco Sopracordevole
- Gynecological Oncology Unit, Centro di Riferimento Oncologico - National Cancer Institute, Aviano
| | - Andrea Ciavattini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona
| | - Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS 'Regina Elena' National Cancer Institute, Rome
| | - Paolo Vercellini
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
| | - Andrea Giannini
- Department of Gynecological, Obstetrical and Urological Sciences, 'Sapienza' University of Rome
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria; Ospedale di circolo Fondazione Macchi, Varese
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma and
| | - Francesco Raspagliesi
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milano, Italy
| | - Violante Di Donato
- Department of Gynecological, Obstetrical and Urological Sciences, 'Sapienza' University of Rome
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Mensi L, Riccaboni A, Alagna F, Filippi F, Benaglia L, Reschini M, Somigliana E, Vercellini P. Prevalence and clinical effect of caesarean scar defects in women undergoing IVF. Reprod Biomed Online 2023; 47:103240. [PMID: 37542845 DOI: 10.1016/j.rbmo.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/19/2023] [Accepted: 05/27/2023] [Indexed: 08/07/2023]
Abstract
RESEARCH QUESTION How common are caesarean scar defects (isthmocele) among patients who have had previous caesarean delivery undergoing IVF for secondary infertility? Does the presence of isthmocele affect the chances of success of IVF? DESIGN In this cohort study, women referred to an Italian public assisted reproduction centre between January 2016 and April 2021 were retrospectively reviewed. Women with a history of caesarean delivery and an indication for IVF were selected. On the basis of the local policy, all patients with a history of caesarean section underwent saline contrast sonography (SCS). Sonographic evaluation was standardized. RESULTS One hundred and forty-four women were eligible, of whom 22 declined SCS and eight decided to delay pregnancy seeking. Overall, 114 women were available for data analysis. Seventy-six women were diagnosed with caesarean scar defects, corresponding to a prevalence of 67% (95% CI 58 to 75%). Baseline characteristics of women with and without isthmocele were similar. Conversely, the clinical pregnancy rate (adjusted OR 0.31, 95% CI 0.13 to 0.72) and live birth rate (adjusted OR 038, 95% CI 0.17 to 0.86) were significantly lower among affected women. No associations between specific sonographic defect characteristics and IVF outcome could be identified. CONCLUSIONS Caesarean scar defects are common among women with a history of caesarean section requiring IVF. The presence of these lesions may reduce the chance of success of the procedure.
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Affiliation(s)
- Laura Mensi
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Alessandra Riccaboni
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Alagna
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Filippi
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Benaglia
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Reschini
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edgardo Somigliana
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Paolo Vercellini
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy; Gynecological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Bogani G, Sopracordevole F, Ciavattini A, Vizza E, Vercellini P, Ghezzi F, Scambia G, Di Donato V, Giannini A, Raspagliesi F. HPV persistence after cervical surgical excision of high-grade cervical lesions. Cancer Cytopathol 2023. [PMID: 37747763 DOI: 10.1002/cncy.22760] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 09/26/2023]
Abstract
Human papillomavirus (HPV) is the primary cause of cervical dysplasia and cervical cancer. Attempts are needed to better categorize patients with HPV in order to provide useful information for prognosticating and appropriately tailoring surveillance.
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Affiliation(s)
- Giorgio Bogani
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Francesco Sopracordevole
- Gynecological Oncology Unit, Centro di Riferimento Oncologico-National Cancer Institute, Aviano, Italy
| | - Andrea Ciavattini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona, Italy
| | - Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Paolo Vercellini
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
- Ospedale di Circolo Fondazione Macchi, Varese, Italy
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Violante Di Donato
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Andrea Giannini
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Francesco Raspagliesi
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
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Cetera GE, Merli CEM, Boero V, Caia C, Vercellini P. Topical estrogens for the treatment of superficial dyspareunia related to genitourinary syndrome of menopause in women with a history of endometriosis: A clinical dilemma. Eur J Obstet Gynecol Reprod Biol 2023; 288:12-17. [PMID: 37421742 DOI: 10.1016/j.ejogrb.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/10/2023]
Abstract
Estrogen withdrawal, which occurs with the cessation of ovulation, causes genitourinary syndrome of menopause in up to 50-85% of women. Symptoms may profoundly impact quality of life and sexual function, interfering with enjoyment of sex in up to three out of four individuals. Topical estrogens have been found to provide symptom relief with minimal systemic absorption and appear to be superior to systemic therapy as what regards genitourinary symptoms. However, conclusive data on their appropriateness in postmenopausal women with a history of endometriosis is not available and the hypothesis that exogenous estrogen stimulation may reactivate endometriotic foci or even promote their malignant transformation is still open. On the other hand, endometriosis affects around 10% of premenopausal women, many of which may be exposed to an acute hypoestrogenic depletion even before spontaneous menopause occurs. This considered, excluding on principle patients with a history of endometriosis from first-line treatment for vulvovaginal atrophy would mean excluding a considerable percentage of the population from adequate care. More robust evidence is urgently needed in these regards. Meanwhile, it would appear reasonable to tailor the prescription of topical hormones in these patients, taking into account the entity of symptoms and the impact such symptoms have on patients' quality of life, as well as the form of endometriosis and the possible risks hormonal may entail. Moreover, the application of estrogens on the vulva instead of the vagina could be efficacious, while outweighing the possible biological cost of hormonal treatment in women with a history of endometriosis.
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Affiliation(s)
- G E Cetera
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - C E M Merli
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - V Boero
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - C Caia
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - P Vercellini
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Fedele F, Parazzini F, Vercellini P, Bergamini V, Candiani M. Rokitansky Syndrome or Cervicovaginal Atresia? J Minim Invasive Gynecol 2023; 30:742-747. [PMID: 37172890 DOI: 10.1016/j.jmig.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/07/2023] [Accepted: 05/08/2023] [Indexed: 05/15/2023]
Abstract
STUDY OBJECTIVE To investigate the possibility of conservative management of rudimentary uterine horns associated with vaginal agenesis. DESIGN Observational study on cohort of consecutive cases treated with the same criteria from 2008 to 2021. SETTING Two academic institutions and teaching hospitals in Milan, Italy. PATIENTS Eight patients with vaginal agenesis associated with rudimentary cavitated uterine horns treated by the same team and postoperatively followed. INTERVENTIONS All the subjects underwent the same standardized surgical procedure: laparoscopy, intraoperative ultrasound, and horn-vestibular direct anastomosis. Postoperatively vaginoscopy was performed every 6 months. MEASUREMENTS AND MAIN RESULTS The postoperative course was generally uneventful and the mean hospital stay was 4.3 ± 2.5 (SD) days. All the patients began to menstruate a few months after the operation. Menstrual flows were light but regular. All patients had a neovaginal length > 4 cm at 1 year postoperatively, reaching approximately 6 cm at 2 years. During the follow-up period, 5 patients were sexually active without dyspareunia. In all cases, surgery restored the continuity of the neovagina and uterine horn through the creation of a "vaginal-horn fistula tract." CONCLUSION In patients with vaginal agenesis associated with the presence of a uterine cavitary horn, it is possible to recover not only sexual activity but also menstrual function. The horn-vestibular anastomosis may be considered a valid, safe, and effective therapeutic option but requires accurate preoperative and intraoperative evaluation of rudimentary uterine structures.
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Affiliation(s)
- Francesco Fedele
- Department of Obstetrics and Gynecology (Drs. Fedele, Parazzini, and Vercellini), Fondazione "Policlinico-Mangiagalli-Regina Elena" University of Milan, Italy.
| | - Fabio Parazzini
- Department of Obstetrics and Gynecology (Drs. Fedele, Parazzini, and Vercellini), Fondazione "Policlinico-Mangiagalli-Regina Elena" University of Milan, Italy
| | - Paolo Vercellini
- Department of Obstetrics and Gynecology (Drs. Fedele, Parazzini, and Vercellini), Fondazione "Policlinico-Mangiagalli-Regina Elena" University of Milan, Italy
| | - Valentino Bergamini
- Obstetrics and Gynecology Division B (Dr. Bergamini), University of Verona, Verona, Italy
| | - Massimo Candiani
- Obstetrics and Gynecology Department (Dr. Candiani), IRCCS San Raffaele Scientific Institute, University School of Medicine, Milan, Italy
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Bogani G, Ghelardi A, Sopracordevole F, Annoni M, Ciavattini A, Giannella L, De Vincenzo R, Cattani P, Barbero M, Vercellini P, Raspagliesi F, Bonanni P, Scambia G. Human papillomavirus (HPV) vaccination: a call for action in Italy. Int J Gynecol Cancer 2023; 33:1132-1139. [PMID: 36918227 DOI: 10.1136/ijgc-2023-004275] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Human papillomavirus (HPV) is the most common sexually transmitted infection. The implementation of primary prevention aims to reduce the burden of HPV infection and HPV-related disease. However, HPV-related diseases are still a concern, even in high-income countries. Approximately 570 000 new cervical cancer cases are diagnosed in Italy every year. Prophylactic HPV vaccines have been developed to minimize the spread of HPV. Growing evidence supports the administration of HPV vaccines (even just one dose) in reducing the prevalence of HPV infection and HPV-related disease including cancers. HPV vaccines are characterized by a high level of efficacy (>95%) in women who are naïve to HPV; however, they do not increase clearance in patients with ongoing HPV infection. With more than 200 million doses administered to date, HPV vaccines are considered to be safe and effective at preventing HPV-related infections and cancers. In this review we aim to review the current evidence regarding HPV vaccination and to describe trends in HPV vaccination coverage in Italy. In Italy, vaccination against HPV has been included in the National Immunization Plan (NIP) since 2007-2008. Using data abstracted from the Italian Ministry of Health, we analyzed changes in HPV vaccination coverage. We observed that HPV vaccines are underutilized and coverage rates are decreasing. Looking at the target population (females and males aged 11-12 years) in Italy, a decrease in coverage rates was observed. A call for action, improved HPV awareness, and education are the key elements to enhance the widespread adoption of HPV vaccination.
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Affiliation(s)
- Giorgio Bogani
- Department of Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Francesco Sopracordevole
- Gynecological Oncology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Marco Annoni
- National Research Council of Italy, Roma, Italy
- Fondazione Umberto Veronesi, Milano, Italy
| | - Andrea Ciavattini
- Woman's Health Sciences Department, Polytechnic University of Marche, Ancona, Italy
| | - Luca Giannella
- Woman's Health Sciences Department, Polytechnic University of Marche, Ancona, Italy
| | - Rosa De Vincenzo
- Gynecologic Oncology, Catholic University of the Sacred Heart, Roma, Italy
| | - Paolo Cattani
- Italian Society of Colposcopy and Cervico-Vaginal Pathology, Roma, Italy
| | - Maggiorino Barbero
- Department of Obstetrics and Gynecology, Azienda Sanitaria Locale di Asti, Asti, Italy
| | - Paolo Vercellini
- Department of Obstetrics and Gynecology, Policlinico of Milan Mangiagalli Center, Milano, Italy
| | | | - Paolo Bonanni
- Department of Obstetrics and Gynecology, Università degli Studi di Firenze, Firenze, Italy
| | - Giovanni Scambia
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
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Vercellini P, Esposito G, Santucci C, Parazzini F, La Vecchia C. Nomegestrol acetate for symptomatic endometriosis and meningioma risk: understandable statistics for decision-making. Eur J Obstet Gynecol Reprod Biol 2023; 286:149-150. [PMID: 37183159 DOI: 10.1016/j.ejogrb.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/26/2023] [Accepted: 05/04/2023] [Indexed: 05/16/2023]
Affiliation(s)
- Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy
| | - Giovanna Esposito
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Italy.
| | - Claudia Santucci
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Italy
| | - Fabio Parazzini
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Italy
| | - Carlo La Vecchia
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Italy
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Cetera GE, Merli CEM, Facchin F, Viganò P, Pesce E, Caprara F, Vercellini P. Non-response to first-line hormonal treatment for symptomatic endometriosis: overcoming tunnel vision. A narrative review. BMC Womens Health 2023; 23:347. [PMID: 37391793 PMCID: PMC10311799 DOI: 10.1186/s12905-023-02490-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/18/2023] [Indexed: 07/02/2023] Open
Abstract
One-fourth to one-third of women with endometriosis receiving first-line hormonal treatment lacks an adequate response in terms of resolution of painful symptoms. This phenomenon has been ascribed to "progesterone resistance", an entity that was theorized to explain the gap between the ubiquity of retrograde menstruation and the 10% prevalence of endometriosis among women of reproductive age.Nevertheless, the hypothesis of progesterone resistance is not free of controversies. As our understanding of endometriosis is increasing, authors are starting to set aside the traditionally accepted tunnel vision of endometriosis as a strictly pelvic disease, opening to a more comprehensive perspective of the condition. The question is: are patients not responding to first-line treatment because they have an altered signaling pathway for such treatment, or have we been overlooking a series of other pain contributors which may not be resolved by hormonal therapy?Finding an answer to this question is evermore impelling, for two reasons mainly. Firstly, because not recognizing the presence of further pain contributors adds a delay in treatment to the already existing delay in diagnosis of endometriosis. This may lead to chronicity of the untreated pain contributors as well as causing adverse consequences on quality of life and psychological health. Secondly, misinterpreting the consequences of untreated pain contributors as a non-response to standard first-line treatment may imply the adoption of second-line medical therapies or of surgery, which may entail non-negligible side effects and may not be free of physical, psychological and socioeconomic repercussions.The current narrative review aims at providing an overview of all the possible pain contributors in endometriosis, ranging from those strictly organic to those with a greater neuro-psychological component. Including these aspects in a broader psychobiological approach may provide useful suggestions for treating those patients who report persistent pain symptoms despite receiving first-line hormonal medical treatment.
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Affiliation(s)
- Giulia Emily Cetera
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Federica Facchin
- Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy
| | - Paola Viganò
- Infertility Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Pesce
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Francesca Caprara
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Giannella L, Delli Carpini G, Di Giuseppe J, Bogani G, Sopracordevole F, Clemente N, Giorda G, De Vincenzo RP, Evangelista MT, Gardella B, Dominoni M, Monti E, Alessi C, Alessandrini L, Pagan A, Caretto M, Ghelardi A, Amadori A, Origoni M, Barbero M, Raspagliesi F, Simoncini T, Vercellini P, Scambia G, Ciavattini A. In Situ/Microinvasive Adenocarcinoma of the Uterine Cervix and HPV-Type Impact: Pathologic Features, Treatment Options, and Follow-Up Outcomes-Cervical Adenocarcinoma Study Group (CAS-Group). Cancers (Basel) 2023; 15:cancers15112876. [PMID: 37296839 DOI: 10.3390/cancers15112876] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 04/11/2023] [Revised: 05/09/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
It is unknown whether human papillomavirus (HPV) status impacts the prognosis of early stage cervical glandular lesions. This study assessed the recurrence and survival rates of in situ/microinvasive adenocarcinomas (AC) according to HPV status during a 5-year follow-up. The data were retrospectively analyzed in women with available HPV testing before treatment. One hundred and forty-eight consecutive women were analyzed. The number of HPV-negative cases was 24 (16.2%). The survival rate was 100% in all participants. The recurrence rate was 7.4% (11 cases, including four invasive lesions (2.7%)). Cox proportional hazards regression showed no difference in recurrence rate between HPV-positive and HPV-negative cases (p = 0.148). HPV genotyping, available for 76 women and including 9/11 recurrences, showed a higher relapse rate for HPV-18 than HPV-45 and HPV-16 (28.5%, 16.6%, and 9.52%, p = 0.046). In addition, 60% and 75% of in situ and invasive recurrences, respectively, were HPV-18 related. The present study showed that most ACs were positive for high-risk HPV, and the recurrence rate was unaffected by HPV status. More extensive studies could help evaluate whether HPV genotyping may be considered for recurrence risk stratification in HPV-positive cases.
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Affiliation(s)
- Luca Giannella
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Giovanni Delli Carpini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Jacopo Di Giuseppe
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
| | - Giorgio Bogani
- Gynecological Oncology Unit, Fondazione IRCCS-Istituto Nazionale Tumori, 20133 Milan, Italy
| | - Francesco Sopracordevole
- Gynecologic Oncology Unit, IRCCS-Centro di Riferimento Oncologico di Aviano, 33081 Aviano, Italy
| | - Nicolò Clemente
- Gynecologic Oncology Unit, IRCCS-Centro di Riferimento Oncologico di Aviano, 33081 Aviano, Italy
| | - Giorgio Giorda
- Gynecologic Oncology Unit, IRCCS-Centro di Riferimento Oncologico di Aviano, 33081 Aviano, Italy
| | - Rosa Pasqualina De Vincenzo
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Scienze della Vita e Sanita Pubblica, Università Cattolica Del Sacro Cuore, 00168 Rome, Italy
| | - Maria Teresa Evangelista
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Barbara Gardella
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, 27100 Pavia, Italy
| | - Mattia Dominoni
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, 27100 Pavia, Italy
| | - Ermelinda Monti
- Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Chiara Alessi
- UOC Ostetricia Ginecologia, Dipartimento per la Salute della Donna e del Bambino, Azienda Ospedaliera-Università di Padova, 35128 Padova, Italy
| | - Lara Alessandrini
- Pathological Anatomy Unit, Department of Medicine DIMED, University of Padova, 35128 Padova, Italy
| | | | - Marta Caretto
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Alessandro Ghelardi
- Azienda Usl Toscana Nord-Ovest, UOC Ostetricia e Ginecologia, Ospedale Apuane, 54100 Massa, Italy
| | | | - Massimo Origoni
- Department of Gynecology & Obstetrics, Vita Salute San Raffaele University School of Medicine, 20132 Milan, Italy
| | - Maggiorino Barbero
- Department of Obstetrics and Gynecology, Asti Community Hospital, 14100 Asti, Italy
| | - Francesco Raspagliesi
- Gynecological Oncology Unit, Fondazione IRCCS-Istituto Nazionale Tumori, 20133 Milan, Italy
| | - Tommaso Simoncini
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giovanni Scambia
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Scienze della Vita e Sanita Pubblica, Università Cattolica Del Sacro Cuore, 00168 Rome, Italy
| | - Andrea Ciavattini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60123 Ancona, Italy
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Viganò P, Casalechi M, Vercellini P, Somigliana E. “Shadow of a Doubt”—The Pathogenic Role of Endometrial Defects in Endometriosis Development and Endometriosis-Associated Infertility: Robust Demonstration of Clinical Relevance Is Still Urgently Needed. Biomolecules 2023; 13:biom13040651. [PMID: 37189399 DOI: 10.3390/biom13040651] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023] Open
Abstract
Endometriosis is an estrogen-dependent chronic inflammatory disease characterized by the presence of endometrial glands and stroma associated with fibrosis outside the uterine cavity [...]
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Affiliation(s)
- Paola Viganò
- Infertility Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20122 Milan, Italy
| | - Maíra Casalechi
- Division of Human Reproduction, Hospital das Clínicas-Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Brazil
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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Giannella L, Delli Carpini G, Di Giuseppe J, Gardella B, Bogani G, Monti E, Liverani CA, Roncella E, Raspagliesi F, Spinillo A, Vercellini P, Ciavattini A. Should attention be paid to the cone depth in the fully visible transformation zone? Retrospective analysis of 517 patients with cervical intraepithelial neoplasia grade 3. Int J Gynaecol Obstet 2023; 161:137-143. [PMID: 36263898 DOI: 10.1002/ijgo.14520] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 08/06/2022] [Revised: 10/13/2022] [Accepted: 10/13/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The predictors of positive endocervical margin (EM) and a cone-depth cutoff value are not established in the fully visible transformation zone (TZ). The present study aimed to assess the independent variables associated with positive EM in women with high-grade cervical intraepithelial neoplasia (CIN) and fully visible TZ. METHODS The current investigation was a retrospective study including women with fully visible TZ and CIN 3 cone histology between 2014 and 2019. The sample was divided into women with positive versus those with negative EM. Univariate and multivariate analyses were performed. Finally, receiver operating characteristic curve analysis was also used. RESULTS A total of 123 of 517 women (23.8%) showed positive EM at conization. Multivariate analysis found a positive association with type 2 TZ (odds ratio [OR], 2.17 [95% confidence interval (CI), 1.19-3.94]) and lesion extension ≥2 cervical quadrants (OR, 35.57 [95% CI, 17.96-70.45]). Cone depth was inversely related to positive EM (OR, 0.71 [95% CI, 0.63-0.80]). In women with type 2 TZ and lesion extension ≥2 cervical quadrants, the cutoff value was achieved at 8-mm cone depth (area under the curve, 0.79 [95% CI, 0.67-0.90]). CONCLUSION In women with high-grade CIN and fully visible TZ undergoing conization, the lesion extension and the TZ subtype (1 or 2) should be considered. A no less than 9-mm cone depth provided a fair predictive value in achieving free EM.
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Affiliation(s)
- Luca Giannella
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona, Italy
| | - Giovanni Delli Carpini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona, Italy
| | - Jacopo Di Giuseppe
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona, Italy
| | - Barbara Gardella
- Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Giorgio Bogani
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Ermelinda Monti
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlo Antonio Liverani
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Roncella
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Arsenio Spinillo
- Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia, Pavia, Italy
| | - Paolo Vercellini
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Ciavattini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona, Italy
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Boero V, Cavalli R, Caia C, Berrettini A, Cetera GE, Monti E, Barbara G, Albertini GC, Restelli E, Libutti G, Motta T, Lazzari C, Vercellini P. Pediatric vulvar lichen sclerosus: Does it resolve or does it persist after menarche? Pediatr Dermatol 2023; 40:472-475. [PMID: 36998082 DOI: 10.1111/pde.15308] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/14/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Although data regarding the rates of remission and progression of the disease are still scarce, it is generally now acknowledged that pediatric vulvar lichen sclerosus (pVLS) can persist beyond puberty. Recent studies reveal that this condition may persist in as many as 75% of cases. The present study aims to answer the following query: how does pVLS evolve after menarche? METHODS This observational retrospective study conducted on premenarchal girls diagnosed with pVLS in our institution between 1990 and 2011 describes 31 patients who returned for multidisciplinary clinical evaluation following menarche. RESULTS The mean follow-up time was 14 years. At the post-menarche clinical examination, patients were classified as follows: 58% were still affected by VLS, 16% presented with a complete remission of disease, and 26% were completely asymptomatic although with persistent clinical signs of VLS. CONCLUSIONS In our series, pVLS persists following menarche in the majority of patients. These findings suggest the importance of a long-term follow-up even among patients who report resolution of symptoms following menarche.
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Affiliation(s)
- Veronica Boero
- Gynecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Cavalli
- Pediatric Dermatology Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlotta Caia
- Gynecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Alfredo Berrettini
- Pediatric Urology Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Emily Cetera
- Gynecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Ermelinda Monti
- Gynecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giussy Barbara
- Gynecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giorgia Carlotta Albertini
- Gynecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Elisa Restelli
- Gynecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giada Libutti
- Gynecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tiziano Motta
- Gynecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Caterina Lazzari
- Gynecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Paolo Vercellini
- Gynecology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Vercellini P, Viganò P, Bandini V, Buggio L, Berlanda N, Somigliana E. ASSOCIATION OF ENDOMETRIOSIS AND ADENOMYOSIS WITH PREGNANCY AND INFERTILITY. Fertil Steril 2023; 119:727-740. [PMID: 36948440 DOI: 10.1016/j.fertnstert.2023.03.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/24/2023]
Abstract
We performed a comprehensive narrative synthesis of systematic reviews with meta-analysis published in the last five years on the association of endometriosis and adenomyosis with reproductive and obstetric outcomes. The aim was defining the information on which to base preconceptional counselling and clarifying whether and in which cases pregnant women with endometriosis and adenomyosis should be referred to tertiary care centers and followed as high-risk obstetric patients. Reduced pregnancy and live birth rates, and an increased miscarriage rate were observed in women with endometriosis and adenomyosis. The effect was larger in women with adenomyosis than in those with endometriosis. Women with superficial peritoneal and ovarian endometriosis do not appear to be at considerably increased risk of major obstetric and neonatal complications, whereas women with severe endometriosis, whether operated or not, are at several fold increased risk of placenta previa. Moreover, deep infiltrating endometriosis is a risk factor for spontaneous hemoperitoneum in pregnancy and is associated with surgical complications at cesarean section. Overall, women with adenomyosis are at increased risk for various adverse obstetric outcomes, including pre-eclampsia, preterm delivery, fetal malpresentation, postpartum hemorrhage, low birth weight, and small for gestational age. Most studies included in the considered systematic reviews are characterized by substantial qualitative and quantitative heterogeneity. This makes a reliable assessment of the available evidence difficult, and caution should be exercised when trying to derive clinical indications. Nevertheless, women with deep infiltrating endometriosis and severe adenomyosis should be considered at high obstetric risk and could benefit from referral to tertiary care centers where they can be safely followed through pregnancy and delivery. Whether the same should apply also to pregnant women with minimal endometriosis and adenomyosis forms is currently uncertain. Emerging evidence suggests that some adverse reproductive and obstetric outcomes observed in women with endometriosis may in fact be associated with coexisting adenomyosis.
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Affiliation(s)
- Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi, Via Commenda 19, 20122 Milano, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milano, Italy.
| | - Paola Viganò
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milano, Italy.
| | - Veronica Bandini
- Department of Clinical Sciences and Community Health, Università degli Studi, Via Commenda 19, 20122 Milano, Italy.
| | - Laura Buggio
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milano, Italy.
| | - Nicola Berlanda
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milano, Italy.
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università degli Studi, Via Commenda 19, 20122 Milano, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milano, Italy.
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Giannini A, Di Donato V, Sopracordevole F, Ciavattini A, Ghelardi A, Vizza E, D'Oria O, Simoncini T, Plotti F, Casarin J, Golia D'Augè T, Cuccu I, Serati M, Pinelli C, Bergamini A, Gardella B, Dell'Acqua A, Monti E, Vercellini P, D'Ippolito G, Aguzzoli L, Dario Mandato V, Giannella L, Scaffa C, Ditto A, Falcone F, Borghi C, Malzoni M, Di Giovanni A, Salerno MG, Liberale V, Contino B, Donfrancesco C, Desiato M, Perrone AM, De Iaco P, Ferrero S, Sarpietro G, Matarazzo MG, Cianci A, Cianci S, Bosio S, Ruisi S, Mosca L, Tinelli R, De Vincenzo R, Zannoni GF, Ferrandina G, Petrillo M, Capobianco G, Carlea A, Zullo F, Muschiato B, Palomba S, Greggi S, Spinillo A, Ghezzi F, Colacurci N, Angioli R, Benedetti Panici P, Muzii L, Scambia G, Raspagliesi F, Bogani G. Outcomes of High-Grade Cervical Dysplasia with Positive Margins and HPV Persistence after Cervical Conization. Vaccines (Basel) 2023; 11:vaccines11030698. [PMID: 36992282 DOI: 10.3390/vaccines11030698] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 03/31/2023] Open
Abstract
The objective of this work is to assess the 5-year outcomes of patients undergoing conization for high-grade cervical lesions that simultaneously present as risk factors in the persistence of HPV infection and the positivity of surgical resection margins. This is a retrospective study evaluating patients undergoing conization for high-grade cervical lesions. All patients included had both positive surgical margins and experienced HPV persistence at 6 months. Associations were evaluated with Cox proportional hazard regression and summarized using hazard ratio (HR). The charts of 2966 patients undergoing conization were reviewed. Among the whole population, 163 (5.5%) patients met the inclusion criteria, being at high risk due to the presence of positive surgical margins and experiencing HPV persistence. Of 163 patients included, 17 (10.4%) patients developed a CIN2+ recurrence during the 5-year follow-up. Via univariate analyses, diagnosis of CIN3 instead of CIN2 (HR: 4.88 (95%CI: 1.10, 12.41); p = 0.035) and positive endocervical instead of ectocervical margins (HR: 6.44 (95%CI: 2.80, 9.65); p < 0.001) were associated with increased risk of persistence/recurrence. Via multivariate analyses, only positive endocervical instead of ectocervical margins (HR: 4.56 (95%CI: 1.23, 7.95); p = 0.021) were associated with worse outcomes. In this high-risk group, positive endocervical margins is the main risk factor predicting 5-year recurrence.
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Affiliation(s)
- Andrea Giannini
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Violante Di Donato
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Francesco Sopracordevole
- Gynecological Oncology Unit, Centro di Riferimento Oncologico-National Cancer Institute, 33081 Aviano, Italy
| | - Andrea Ciavattini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60126 Ancona, Italy
| | - Alessandro Ghelardi
- Azienda Usl Toscana Nord-Ovest, UOC Ostetricia e Ginecologia, Ospedale Apuane, 54100 Massa, Italy
| | - Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS "Regina Elena" National Cancer Institute, 00144 Rome, Italy
| | - Ottavia D'Oria
- Department of Woman's and Child's Health, Obstetrics and Gynecological Unit, San Camillo-Forlanini Hospital, 00152 Rome, Italy
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Francesco Plotti
- Department of Obstetrics and Gynecology, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, 21100 Varese, Italy
| | - Tullio Golia D'Augè
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Ilaria Cuccu
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Maurizio Serati
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, 21100 Varese, Italy
| | - Ciro Pinelli
- Ospedale di Circolo Fondazione Macchi, 21100 Varese, Italy
| | - Alice Bergamini
- Department of Obstetrics and Gynecology, IRCCS Ospedale San Raffaele, 20100 Milano, Italy
| | - Barbara Gardella
- IRCCS S. Matteo Foundation, Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Andrea Dell'Acqua
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Ermelinda Monti
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Paolo Vercellini
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giovanni D'Ippolito
- Division of Obstetrics and Gynecology, Cesare Magati Hospital, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42019 Scandiano, Italy
| | - Lorenzo Aguzzoli
- Division of Obstetrics and Gynecology, Cesare Magati Hospital, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42019 Scandiano, Italy
| | - Vincenzo Dario Mandato
- Division of Obstetrics and Gynecology, Cesare Magati Hospital, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42019 Scandiano, Italy
| | - Luca Giannella
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60126 Ancona, Italy
| | - Cono Scaffa
- Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", 80131 Naples, Italy
| | - Antonino Ditto
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, 20133 Milan, Italy
| | - Francesca Falcone
- Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", 80131 Naples, Italy
| | - Chiara Borghi
- Department of Obstetrics and Gynecology, S. Anna University Hospital, 44121 Ferrara, Italy
| | - Mario Malzoni
- Endoscopica Malzoni, Center for Advanced Endoscopic Gynecological Surgery, 83100 Avellino, Italy
| | - Alessandra Di Giovanni
- Endoscopica Malzoni, Center for Advanced Endoscopic Gynecological Surgery, 83100 Avellino, Italy
| | - Maria Giovanna Salerno
- Department of Woman's and Child's Health, Obstetrics and Gynecological Unit, San Camillo-Forlanini Hospital, 00152 Rome, Italy
| | - Viola Liberale
- Department of Obstetrics and Gynecology, Ospedale Maria Vittoria, 10144 Torino, Italy
| | - Biagio Contino
- Department of Obstetrics and Gynecology, Ospedale Maria Vittoria, 10144 Torino, Italy
| | - Cristina Donfrancesco
- Department of Obstetrics and Gynecology, Azienda ASL Frosinone, Ospedale S Trinità di Sora, 03039 Sora, Italy
| | - Michele Desiato
- Department of Obstetrics and Gynecology, Azienda ASL Frosinone, Ospedale S Trinità di Sora, 03039 Sora, Italy
| | - Anna Myriam Perrone
- Gynecologic Oncology Unit, Sant'Orsola-Malpighi Hospital, 40138 Bologna, Italy
| | - Pierandrea De Iaco
- Gynecologic Oncology Unit, Sant'Orsola-Malpighi Hospital, 40138 Bologna, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, 16132 Genova, Italy
| | - Giuseppe Sarpietro
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy
| | - Maria G Matarazzo
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy
| | - Antonio Cianci
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy
| | - Stefano Cianci
- Department of Gynecologic Oncology, Università degli Studi di Messina, Policlinico G. Martino, 98122 Messina, Italy
| | - Sara Bosio
- San Paolo Hospital, Università degli Studi di Milano, 20142 Milan, Italy
| | - Simona Ruisi
- San Paolo Hospital, Università degli Studi di Milano, 20142 Milan, Italy
| | - Lavinia Mosca
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Raffaele Tinelli
- Department of Obstetrics and Gynecology, "Valle d'Itria" Hospital, Martina Franca, Via San Francesco da Paola, 74015 Taranto, Italy
| | - Rosa De Vincenzo
- UOC Ginecologia Oncologica, Dipartimento per la Salute Della Donna e del Bambino e Della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Gian Franco Zannoni
- UOC Ginecologia Oncologica, Dipartimento per la Salute Della Donna e del Bambino e Della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Gabriella Ferrandina
- UOC Ginecologia Oncologica, Dipartimento per la Salute Della Donna e del Bambino e Della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Marco Petrillo
- Gynecologic and Obstetric Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
| | - Giampiero Capobianco
- Gynecologic and Obstetric Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
| | - Annunziata Carlea
- Department of Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy
| | | | - Stefano Palomba
- Unit of Obstetrics and Gynecology, GOM of Reggio Calabria & University 'Magna Graecia' of Catanzaro, 88100 Catanzaro, Italy
| | - Stefano Greggi
- Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", 80131 Naples, Italy
| | - Arsenio Spinillo
- IRCCS S. Matteo Foundation, Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, 21100 Varese, Italy
- Ospedale di Circolo Fondazione Macchi, 21100 Varese, Italy
| | - Nicola Colacurci
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Roberto Angioli
- Department of Obstetrics and Gynecology, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Pierluigi Benedetti Panici
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Ludovico Muzii
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento per la Salute Della Donna e del Bambino e Della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Francesco Raspagliesi
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, 20133 Milan, Italy
| | - Giorgio Bogani
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, 20133 Milan, Italy
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Viganò P, Reschini M, Ciaffaglione M, Cucè V, Casalechi M, Benaglia L, Vercellini P, Somigliana E. Conventional IVF performs similarly in women with and without endometriosis. J Assist Reprod Genet 2023; 40:599-607. [PMID: 36637584 PMCID: PMC10033814 DOI: 10.1007/s10815-022-02700-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/17/2022] [Indexed: 01/14/2023] Open
Abstract
PURPOSE A reduced oocyte competence has been claimed as one of the factors underlying infertility in women with endometriosis. This idea has justified the hypothesis that intracytoplasmic sperm injection (ICSI), rather than conventional IVF (c-IVF), may overcome oocyte impairment and ensure better assisted reproduction technology (ART) outcomes; however, data from the literature are controversial. Thus, the aim of this study was to compare ART success rates following (c-IVF) between women with and without endometriosis in the presence of normozoospermic partners. METHODS This is a retrospective, matched case-control study of 314 patients who underwent c-IVF cycles between January 2014 and December 2020. Women with endometriosis were matched in a 1:1 ratio with patients undergoing ART for other indications, considering age (± 6 months), number of oocytes retrieved (± 1), and study period. The main outcome measures included total fertilization failure, fertilization rate, embryo quality, cumulative clinical pregnancy, and live birth rates. RESULTS The fertilization rate and the proportion of women with total fertilization failure did not differ between women with and without endometriosis. Similarly, all other embryological variables did not also differ, except for the number of top-quality cleavage stage embryos which was higher in the endometriosis group. Cumulative clinical pregnancy and live birth rates were similar between women with and without endometriosis. CONCLUSION A diagnosis of endometriosis does not negatively affect the performance of c-IVF; thus, c-IVF can be efficiently used in women affected, unless a male factor is also involved. This issue holds clinical relevance to help operators on their insemination technique decision-making.
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Affiliation(s)
- Paola Viganò
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20122, Milan, Italy.
| | - Marco Reschini
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20122, Milan, Italy
| | - Marta Ciaffaglione
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20122, Milan, Italy
| | - Veronica Cucè
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20122, Milan, Italy
| | - Maíra Casalechi
- Division of Human Reproduction, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Laura Benaglia
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20122, Milan, Italy
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edgardo Somigliana
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 28, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
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Candiani M, Vercellini P, Fedele F, Parma M, Salvatore S, Fedele L. Long-Term Follow-Up after Laparoscopic Uterovestibular Anastomosis in Patients with Cervical Atresia and Complete Absence of the Vagina. J Pediatr Adolesc Gynecol 2023; 36:72-78. [PMID: 35489472 DOI: 10.1016/j.jpag.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 04/14/2022] [Accepted: 04/20/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The surgical treatment of girls with cervical atresia and complete absence of the vagina remains a problem because of the rarity of cases and the controversial study results. OBJECTIVE To describe the surgical technique and long-term results of laparoscopically assisted uterovestibular anastomosis in patients with cervical atresia and complete absence of the vagina STUDY DESIGN: Sixteen consecutive patients with cervical atresia and complete absence of the vagina were conservatively treated with laparoscopically assisted uterovestibular anastomosis in 2 tertiary care referral centers. The follow-up assessments included clinical examination, determination of the presence and quality of sexual intercourse, and vaginoscopy. RESULTS All patients underwent laparoscopically assisted uterovestibular anastomosis. No perioperative complications occurred. The mean follow-up period was 8 ± 3.2 years. In all patients, the length of the neovagina was greater than 4 cm at 1 year after the surgery and approximately 6 cm after 2 years. After the start of sexual intercourse, the neovagina exceeded 7 cm in length in 2 of the 11 sexually active patients. At 12 months after the surgery, iodine-positive epithelium was present in all patients and was maintained over time. The continuity of the neovagina, neocervix, and uterine body was maintained without further interventions in 15 of the 16 patients. During the follow-up, 11 patients were sexually active, 5 were married, 4 were seeking conception, and 2 had spontaneous pregnancy. CONCLUSIONS Laparoscopically assisted uterovestibular anastomosis seems to be a safe and effective treatment for patients with cervical atresia and complete absence of the vagina, at least in terms of the recovery of menstrual function and sexual activity.
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Affiliation(s)
- Massimo Candiani
- Obstetrics and Gynaecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Vercellini
- Department of Obstetrics and Gynecology, Fondazione "Policlinico-Mangiagalli-Regina Elena" University of Milan, Italy
| | - Francesco Fedele
- Obstetrics and Gynaecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marta Parma
- Obstetrics and Gynaecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Salvatore
- Obstetrics and Gynaecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Fedele
- Department of Obstetrics and Gynecology, Fondazione "Policlinico-Mangiagalli-Regina Elena" University of Milan, Italy.
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Pino I, Belloni GM, Barbera V, Solima E, Radice D, Angioni S, Arena S, Bergamini V, Candiani M, Maiorana A, Mattei A, Muzii L, Pagliardini L, Porpora MG, Remorgida V, Seracchioli R, Vercellini P, Zullo F, Zupi E, Vignali M, Nicola DM, Cecilia B, Alessio P, Paola V, Ludovica B, Jessica O, Matteo S, Domenico I, Walter A, Federica P, Ilaria P, Sara S, Claudia M, Simona DF, Nicola B, Edgardo S, Agnese D, Gabriele C, Lucia L, Luca LB, Caterina E, Giuseppe S, Roberta V. "Better late than never but never late is better", especially in young women. A multicenter Italian study on diagnostic delay for symptomatic endometriosis. EUR J CONTRACEP REPR 2023; 28:10-16. [PMID: 36287190 DOI: 10.1080/13625187.2022.2128644] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 02/07/2023]
Abstract
PURPOSE The aim of the study was to assess the length of diagnostic delay of symptomatic endometriosis in Italy and analyse the presence of correlations between the socio-demographic status of patients and the clinical characteristics/type of diagnosis. MATERIALS AND METHODS This multicenter cross-sectional questionnaire-based study was conducted in 10 tertiary Italian referral centres for diagnosis and treatment endometriosis. A total of 689 respondents with histologically proven endometriosis and onset of the disease with pain symptoms completed an on-line self-reported questionnaire written in their own language (World Endometriosis Research Foundation-Endometriosis Phenome and Biobanking Harmonisation Project-Endometriosis Patient Questionnaire-Minimum) evaluating endometriosis related symptoms, family history of endometriosis and chronic pelvic pain, demographic data, as well as medical, reproductive, and obstetric history. RESULTS The mean diagnostic delay found was of 11.4 years. The mean time (14.8 years) from symptoms onset to diagnosis was significantly longer among patients aged 9-19 vs patients aged 20-30 (mean 6.9 years, p < 0.001) and patients aged 31-45 (mean 2.9, p < 0.001). No significant association were found between a delayed diagnosis and any of the clinically relevant factors such as the number or severity of the reported symptoms, familiarity, hormonal therapy intake or methodology of diagnosis. CONCLUSIONS The mean diagnostic delay of endometriosis in Italy is about 11 years. The delay can be up to 4 years longer in patients with pain symptoms onset under 20 years. Educating clinicians and patients on pathologic nature of endometriosis related pelvic pain is advisable to reduce waiting time to diagnosis, especially for young women.
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Affiliation(s)
- Ida Pino
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, Milan, Italy
| | - Gaia Maria Belloni
- Department of Obstetrics and Gynecology, Macedonio Melloni Hospital and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Valeria Barbera
- Department of Obstetrics and Gynecology, Macedonio Melloni Hospital and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Eugenio Solima
- Department of Obstetrics and Gynecology, Macedonio Melloni Hospital and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Davide Radice
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Stefano Angioni
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Saverio Arena
- Department of Obstetrics and Gynecology, Azienda Ospedaliera of Perugia, Perugia, Italy
| | - Valentino Bergamini
- Department of Obstetrics and Gynecology Verona, University of Verona, Verona, Italy
| | - Massimo Candiani
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Maiorana
- Department of Obstetrics and Gynecology, Civico Hospital, Palermo, Italy
| | - Alberto Mattei
- Division of Gynaecology and Obstetrics, Santa Maria Annunziata Hospital, USL Toscana Centro, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urology, University of Rome "Sapienza", Policlinico "Umberto I", Roma, Italy
| | - Luca Pagliardini
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Grazia Porpora
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valentino Remorgida
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino and Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Renato Seracchioli
- Gynaecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences, DIMEC, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano and Fondazione Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Errico Zupi
- Gynecology Department, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Michele Vignali
- Department of Obstetrics and Gynecology, Macedonio Melloni Hospital and Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | | | | | - Bonin Cecilia
- Department of Obstetrics and Gynecology, Azienda Ospedaliera of Perugia, Perugia, Italy
| | - Perandini Alessio
- Department of Obstetrics and Gynecology, Azienda Ospedaliera of Perugia, Perugia, Italy
| | - Viganò Paola
- Department of Obstetrics and Gynecology Verona, University of Verona, Verona, Italy
| | - Bartiromo Ludovica
- Department of Obstetrics and Gynecology Verona, University of Verona, Verona, Italy
| | - Ottolina Jessica
- Department of Obstetrics and Gynecology Verona, University of Verona, Verona, Italy
| | - Schimberni Matteo
- Department of Obstetrics and Gynecology Verona, University of Verona, Verona, Italy
| | - Incandela Domenico
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alio Walter
- Gynecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Perelli Federica
- Department of Obstetrics and Gynecology, Civico Hospital, Palermo, Italy
| | - Piacenti Ilaria
- Division of Gynaecology and Obstetrics, Santa Maria Annunziata Hospital, USL Toscana Centro, Florence, Italy
| | - Scaramuzzino Sara
- Division of Gynaecology and Obstetrics, Santa Maria Annunziata Hospital, USL Toscana Centro, Florence, Italy
| | - Massarotti Claudia
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Del Forno Simona
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino and Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Berlanda Nicola
- Gynaecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences, DIMEC, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Somigliana Edgardo
- Gynaecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences, DIMEC, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Donati Agnese
- Gynaecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences, DIMEC, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Centini Gabriele
- Gynecology Department, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Lazzeri Lucia
- Gynecology Department, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - La Banca Luca
- Gynecology Department, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Exacoustos Caterina
- Department of Biomedicine and Prevention, Obstetrics and Gynecological Unit, University of “Tor Vergata”,, Rome, Italy
| | - Sorrenti Giuseppe
- Department of Gynecology and Obstetric Unit, Hospital Casilino, Rome, Italy
| | - Venturella Roberta
- Department of Clinical and Experimental Medicine – Magna Graecia University of Catanzaro, Italy
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Vercellini P, Bandini V, Buggio L, Barbara G, Berlanda N, Dridi D, Frattaruolo MP, Somigliana E. Mitigating the economic burden of GnRH agonist therapy for progestogen-resistant endometriosis: why not? Hum Reprod Open 2023; 2023:hoad008. [PMID: 37016694 PMCID: PMC10067151 DOI: 10.1093/hropen/hoad008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 02/24/2023] [Indexed: 04/06/2023] Open
Abstract
STUDY QUESTION Is it possible to reduce the cost of GnRH agonist treatment for endometriosis by using non-standard dosing regimens? SUMMARY ANSWER An extended-interval dosing regimen of a 3.75 mg depot formulation of triptorelin injected every 6 weeks instead of every 4 weeks reduces the cost by one-third without compromising the effect on pain relief. WHAT IS KNOWN ALREADY Cost constitutes a limit to prolonged GnRH agonists use. Alternative modalities to reduce the economic burden of GnRH agonist treatment have been anecdotally attempted. STUDY DESIGN SIZE DURATION A systematic review was conducted to evaluate and compare the effect of three alternative modalities for GnRH use in women with endometriosis, i.e. intermittent oestrogen deprivation therapy, reduced drug dosage, and extended-interval dosing regimens of depot formulations. A PubMed and Embase search was initially conducted in October 2022 and updated in January 2023 using the following search strings: (endometriosis OR adenomyosis) AND (GnRH-agonists OR gonadotropin-releasing hormone agonists OR triptorelin OR leuprorelin OR goserelin OR buserelin OR nafarelin). Full-length articles published in English in peer-reviewed journals since 1 January 1980, and reporting original data on GnRH agonist treatment of pain symptoms associated with endometriosis were selected. PARTICIPANTS/MATERIALS SETTING METHODS Information was extracted on study design, GnRH-agonist used, dosage, total duration of therapy, side effects, treatment adherence, and pelvic pain relief. Reviews, commentaries, conference proceedings, case reports, and letters to the editor were excluded. MAIN RESULTS AND THE ROLE OF CHANCE Of the 1664 records screened, 14 studies regarding clinical outcomes associated with the 3 considered alternative modalities for GnRH agonist use were eventually included (intermittent oestrogen deprivation therapy, n = 2; low-dose or 'draw-back' therapy, n = 8; extended-interval dosing regimen, n = 4). Six studies were randomized controlled trials (RCTs) (double blind, n = 2) and eight adopted a prospective cohort design (non-comparative, n = 6; comparative, n = 2). A total of 776 women with endometriosis were recruited in the above studies (intermittent oestrogen deprivation therapy, n = 77; low-dose or 'draw-back' therapy, n = 528; extended-interval dosing regimen, n = 171). Robust data demonstrating cost saving without detrimental clinical consequences were available for the extended-interval dosing regimen only. In particular, the 3.75 mg triptorelin depot preparation inhibits ovarian function for a longer period compared with the 3.75 mg leuprorelin depot preparation, allowing injections every 6 instead of 4 weeks. Based on the cost indicated by the Italian Medicine Agency for the 3.75 mg triptorelin depot preparation, this would translate in a yearly saving of €744.60 (€2230.15-€1485.55; -33.4%). LIMITATIONS REASONS FOR CAUTION The quality of the evidence reported in the selected articles was not formally evaluated and a quantitative synthesis could not be performed. Some studies were old and the tested therapeutic approaches were apparently obsolete. Only cost containment associated with GnRH analogue use, and not cost-effectiveness, has been addressed. WIDER IMPLICATIONS OF THE FINDINGS Consuming less resources without negatively impacting on health outcomes carries ethical and practical implications for individuals and the community, as this approach may result in overall increased healthcare access. STUDY FUNDING/COMPETING INTERESTS This study was supported by the Italian Ministry of Health (Ricerca Corrente 2023, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano). E.S. discloses payments from Ferring for research grants and honoraria from Merck-Serono for lectures. All other authors declare they have no conflict of interest. REGISTRATION NUMBER N/A.
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Affiliation(s)
- Paolo Vercellini
- Correspondence address. Department of Clinical Sciences and Community Health, Università degli Studi and Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milano, Italy. E-mail:
| | - Veronica Bandini
- Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
| | - Laura Buggio
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Giussy Barbara
- Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Nicola Berlanda
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Dhouha Dridi
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Maria Pina Frattaruolo
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
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Bonanni V, Reschini M, La Vecchia I, Castiglioni M, Muzii L, Vercellini P, Somigliana E. The impact of small and asymptomatic intramural and subserosal fibroids on female fertility: a case-control study. Hum Reprod Open 2022; 2023:hoac056. [PMID: 36579123 PMCID: PMC9782921 DOI: 10.1093/hropen/hoac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 11/02/2022] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION Do small and asymptomatic intramural and subserosal uterine fibroids affect female fertility? SUMMARY ANSWER Small and asymptomatic fibroids that do not encroach the endometrial cavity appear to not markedly affect female fertility. WHAT IS KNOWN ALREADY The available evidence on uterine fibroids and fertility is limited. Most information has been obtained in IVF settings by comparing the success in women affected and not affected by fibroids. These studies have shown a detrimental effect of submucosal and possibly intramural fibroids. However, this study design provides information only on embryo implantation, not on female fertility in general. STUDY DESIGN SIZE DURATION A retrospective observational case-control study on 200 women whose partner was diagnosed with severe male infertility and 200 women with unexplained infertility was conducted. If the null hypothesis (that fibroids do not affect fertility) is valid, one would expect a similar prevalence of fibroids in the two study groups. Conversely, if fibroids do impact fertility, one would expect a higher prevalence among women with unexplained infertility. The study was carried out at the Infertility Unit of the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico covering a 5-year period between January 2014 and June 2020. PARTICIPANTS/MATERIALS SETTING METHODS We retrospectively recruited women seeking pregnancy whose partner was repeatedly documented to have a sperm concentration below 1 million/ml and matched them by age and study period to a group of women with unexplained infertility. The latter group of women was considered as a case group (infertile subjects), while the former group of women was considered as a control group (reflecting the general female population). Women with fibroids could be included in both study groups; only those with submucosal lesions were excluded. MAIN RESULTS AND THE ROLE OF CHANCE Fibroids were diagnosed in 31 women (16%) with unexplained infertility and in 32 women (16%) with severe male factor infertility. The adjusted odds ratio of carrying fibroids in women with unexplained infertility was 0.91 (95% CI: 0.52-1.58). Subgroup analyses according to number, dimension and location of fibroids failed to highlight an increased risk of infertility in any group. LIMITATIONS REASONS FOR CAUTION This is a retrospective study and some inaccuracies in fibroids detection cannot be ruled out. Moreover, the relatively small sample size hampers robust subgroup analyses. Even though we excluded women with patent causes of infertility, some women with specific causes of infertility could have been included among controls (yet are expected to account for <10% of the group). WIDER IMPLICATIONS OF THE FINDINGS This study suggests that small fibroids that do not encroach the endometrial cavity do not markedly affect female fertility. This information is clinically relevant when counseling infertile women with small fibroids and an otherwise unremarkable diagnostic work-up. Surgery may still be considered but only in selected cases. STUDY FUNDING/COMPETING INTERESTS This study was partially funded by Italian Ministry of Health: current research IRCCS. E.S. reports grants from Ferring, grants and personal fees from Merck, and grants and personal fees from Theramex outside the submitted work. All the other authors do not have any competing interest to declare. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Valentina Bonanni
- Department of Gynecology, Obstetrics and Urology, “Sapienza” University of Rome, Rome, Italy
| | - Marco Reschini
- Correspondence address. Infertility Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via M. Fanti, 6, 20122 Milan, Italy. Tel: +39-02-55034303; Fax: +39-02-55036581; E-mail:
| | - Irene La Vecchia
- Infertility Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Castiglioni
- Infertility Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Ludovico Muzii
- Department of Gynecology, Obstetrics and Urology, “Sapienza” University of Rome, Rome, Italy
| | - Paolo Vercellini
- Infertility Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Edgardo Somigliana
- Infertility Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Ciavattini A, Di Giuseppe J, Marconi C, Giannella L, Delli Carpini G, Paolucci M, Fichera M, De Vincenzo RP, Scambia G, Evangelista MT, Bogani G, Bertolina F, Raspagliesi F, Gardella B, Spinillo A, Dominoni M, Monti E, Liverani CA, Vercellini P, Iorio M, Vitobello D, Portuesi R, Bresciani G, Origoni M, Cantatore F, Pellegri AM, Moriconi L, Serri M, Chiari A, Sopracordevole F, Barbero M, Parazzini F. Hysterectomy for cervical intraepithelial neoplasia: A retrospective observational multi-institutional study. Int J Gynaecol Obstet 2022; 159:679-688. [PMID: 35474511 PMCID: PMC9790541 DOI: 10.1002/ijgo.14233] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/04/2022] [Accepted: 04/21/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To analyze the clinical management, the outcomes, and the trend in hysterectomy rates (HR) in patients who underwent this procedure for cervical intraepithelial neoplasia (CIN). METHODS Multicentric retrospective observational study conducted on 242 patients who underwent hysterectomy for CIN between 2010 and 2020 in nine Italian institutions. Hysterectomy for invasive or micro-invasive neoplasia, sub-total hysterectomy, or trachelectomy were excluded. RESULTS A significant increase in the trend of HR for CIN was recorded (P = 0.002, r = 0.81; C.I. 95%: 0.415-0.949); HR increased from 0.46% in the year 2010 to 3.32% in 2020. The mortality rate was 0.4%, and 5% had operative complications. On definitive histopathology examination, a CIN of any grade was recorded in 71.5% of cases, and an occult invasive cancer in 1.24%. No pathology or CIN1 was found in 26.8% of cases, suggesting over treatment. During follow-up, a vaginal lesion was recorded in 5% of cases. CONCLUSION A significant increase in the number of hysterectomies performed for CIN in the last 10 years was recorded. Hysterectomy for CIN can lead to complications, risk of the onset of vaginal lesions, and risk of overtreatment, and remains, in the first instance, an unacceptable treatment, to be proposed only after adequate counseling.
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Affiliation(s)
- Andrea Ciavattini
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical SciencesUniversità Politecnica delle MarcheAnconaItaly
| | - Jacopo Di Giuseppe
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical SciencesUniversità Politecnica delle MarcheAnconaItaly
| | - Chiara Marconi
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical SciencesUniversità Politecnica delle MarcheAnconaItaly
| | - Luca Giannella
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical SciencesUniversità Politecnica delle MarcheAnconaItaly
| | - Giovanni Delli Carpini
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical SciencesUniversità Politecnica delle MarcheAnconaItaly
| | - Michela Paolucci
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical SciencesUniversità Politecnica delle MarcheAnconaItaly
| | - Mariasole Fichera
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical SciencesUniversità Politecnica delle MarcheAnconaItaly
| | - Rosa Pasqualina De Vincenzo
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public HealthFondazione Policlinico Universitario A. Gemelli, IRCCSRomeItaly
- Dipartimento di Scienze della Vita e Sanità PubblicaUniversità Cattolica del Sacro CuoreRomeItaly
| | - Giovanni Scambia
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public HealthFondazione Policlinico Universitario A. Gemelli, IRCCSRomeItaly
- Dipartimento di Scienze della Vita e Sanità PubblicaUniversità Cattolica del Sacro CuoreRomeItaly
| | - Maria Teresa Evangelista
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public HealthFondazione Policlinico Universitario A. Gemelli, IRCCSRomeItaly
| | - Giorgio Bogani
- Gynecologic Oncology UnitFondazione IRCCS Istituto Nazionale dei Tumori di MilanoMilanItaly
| | - Francesca Bertolina
- Gynecologic Oncology UnitFondazione IRCCS Istituto Nazionale dei Tumori di MilanoMilanItaly
| | - Francesco Raspagliesi
- Gynecologic Oncology UnitFondazione IRCCS Istituto Nazionale dei Tumori di MilanoMilanItaly
| | - Barbara Gardella
- Department of Obstetrics and GynecologyIstituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Foundation Policlinico San Matteo and University of PaviaPaviaItaly
| | - Arsenio Spinillo
- Department of Obstetrics and GynecologyIstituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Foundation Policlinico San Matteo and University of PaviaPaviaItaly
| | - Mattia Dominoni
- Department of Obstetrics and GynecologyIstituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Foundation Policlinico San Matteo and University of PaviaPaviaItaly
| | - Ermelinda Monti
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | | | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Maria Iorio
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | | | | | | | - Massimo Origoni
- Vita Salute San Raffaele University School of Medicine ‐ Department of Gynecology & ObstetricsMilanItaly
| | - Francesco Cantatore
- Vita Salute San Raffaele University School of Medicine ‐ Department of Gynecology & ObstetricsMilanItaly
| | - Antonio Maurizio Pellegri
- Vita Salute San Raffaele University School of Medicine ‐ Department of Gynecology & ObstetricsMilanItaly
| | - Lorenzo Moriconi
- Obstetrics and Gynecologic Unit, A.S.U.RBenedetto del Tronto (AP)Italy
| | - Matteo Serri
- Obstetrics and Gynecologic Unit, A.S.U.RBenedetto del Tronto (AP)Italy
| | - Andrea Chiari
- Obstetrics and Gynecologic Unit, A.S.U.RBenedetto del Tronto (AP)Italy
| | | | | | - Fabio Parazzini
- Department of Clinical Sciences and Community HealthUniversità degli Studi di Milano Facoltà di Medicina e ChirurgiaMilanItaly
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Buggio L, Somigliana E, Sergenti G, Ottolini F, Dridi D, Vercellini P. Anogenital Distance and Endometriosis: Results of a Case-Control Study. Reprod Sci 2022; 29:3508-3515. [PMID: 35817951 DOI: 10.1007/s43032-022-01009-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 06/12/2022] [Indexed: 12/14/2022]
Abstract
AGD is the distance measured from the anus to the genital tubercle. Recent evidence suggests that a shorter AGD, a sensitive biomarker of the prenatal hormonal environment, could be associated with higher endometriosis risk. However, studies investigating AGD in affected women are scanty. We have set up a case-control study recruiting nulliparous women (aged 18-40 years) with endometriosis between 2017 and 2018. Cases were 90 women with a surgical or with a current nonsurgical diagnosis of endometriosis (n = 45 deep infiltrating endometriosis (DIE), and n = 45 ovarian endometrioma (OMA)). Controls were 45 asymptomatic women referring for periodical gynaecological care and without a previous diagnosis of endometriosis. They were matched to cases for age and BMI. For each woman, two measures were obtained using a digital calliper: AGDAC, from the clitoral surface to the upper verge of the anus, and AGDAF, from the posterior fourchette to the upper verge of the anus. Each distance was derived from the mean of six measurements acquired from two different gynaecologists. The mean ± SD AGDAC in women with DIE, OMA and without a diagnosis of endometriosis was 76.0 ± 12.1, 76.1 ± 11.1 and 77.8 ± 11.4 mm, respectively (p = 0.55). The mean ± SD AGDAF in women with DIE, OMA and without a diagnosis of endometriosis was 22.8 ± 5.0, 21.7 ± 9.0 and 23.7 ± 7.8 mm, respectively (p = 0.38). Our study failed to find an association between AGD and the presence of endometriosis. AGD does not seem to represent a reliable indicator of the presence of endometriosis to be used in clinical practice.
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Affiliation(s)
- Laura Buggio
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12 - 20122, Milan, Italy.
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Greta Sergenti
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Federica Ottolini
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Dhouha Dridi
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12 - 20122, Milan, Italy
| | - Paolo Vercellini
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12 - 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
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Fedele F, Parazzini F, Vercellini P, Bergamini V, Fedele L. Reconstructive surgery for congenital atresia of the uterine cervix: a systematic review. Arch Gynecol Obstet 2022:10.1007/s00404-022-06825-5. [DOI: 10.1007/s00404-022-06825-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/11/2022] [Indexed: 11/02/2022]
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Monti E, Barbara G, Libutti G, Boero V, Parazzini F, Ciavattini A, Bogani G, Pignataro L, Magni B, Merli CEM, Vercellini P. A clinician’s dilemma: what should be communicated to women with oncogenic genital HPV and their partners regarding the risk of oral viral transmission? BMC Womens Health 2022; 22:379. [PMID: 36115987 PMCID: PMC9482202 DOI: 10.1186/s12905-022-01965-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/09/2022] [Indexed: 11/23/2022] Open
Abstract
Head and neck cancer, the sixth most common cancer worldwide, account for about 1 out of 20 malignant tumors. In recent years a reduction in the incidence of cervical cancer, but a concomitant major increase in the incidence of HPV-mediated oropharyngeal cancer caused by orogenital HPV transmission has been observed. Consequently, in wealthy countries oropharyngeal squamous-cell carcinomas (OPSCC) is now the most frequent HPV-related cancer, having overtaken cervical cancer. Without effective medical interventions, this incidence trend could continue for decades. As no specific precursor lesion has been consistently identified in the oral cavity and oropharynx, HPV vaccination is the logical intervention to successfully counteract also the rising incidence of OPSCCs. However, HPV vaccine uptake remains suboptimal, particularly in males, the population at higher risk of OPSCC. Alternative primary prevention measures, such as modifications in sexual behaviors, could be implemented based on knowledge of individual genital HPV status. Until recently, this information was not available at a population level, but the current gradual shift from cytology (Pap test) to primary HPV testing for cervical cancer screening is revealing the presence of oncogenic viral genotypes in millions of women. In the past, health authorities and professional organizations have not consistently recommended modifications in sexual behaviors to be adopted when a persistent high-risk HPV cervicovaginal infection was identified. However, given the above changing epidemiologic scenario and the recent availability of an immense amount of novel information on genital HPV infection, it is unclear whether patient counseling should change. The right of future partners to be informed of the risk could also be considered. However, any modification of the provided counseling should be based also on the actual likelihood of a beneficial effect on the incidence of HPV-associated oropharyngeal cancers. The risk is on one side to induce unjustified anxiety and provide ineffective instructions, on the other side to miss the opportunity to limit the spread of oral HPV infections. Thus, major health authorities and international gynecologic scientific societies should issue or update specific recommendations, also with the aim of preventing inconsistent health care professionals’ behaviors.
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Buggio L, Dridi D, Barbara G, Merli CEE, Cetera GE, Vercellini P. Novel pharmacological therapies for the treatment of endometriosis. Expert Rev Clin Pharmacol 2022; 15:1039-1052. [PMID: 36000243 DOI: 10.1080/17512433.2022.2117155] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 11/04/2022]
Abstract
INTRODUCTION Endometriosis is a chronic, estrogen-dependent, inflammatory disease associated with pelvic pain, infertility, impaired sexual function, and psychological suffering. Therefore, tailored patient management appears of primary importance to address specific issues and identify the appropriate treatment for each woman. Over the years, abundant research has been carried out with the objective to find new therapeutic approaches for this multifaceted disease. AREAS COVERED This narrative review aims to present the latest advances in the pharmacological management of endometriosis. In particular, the potential role of GnRH antagonists, selective progesterone receptor modulators (SPRMs), and selective estrogen receptors modulators (SERMs) will be discussed. We performed a literature search in PubMed and Embase, and selected the best quality evidence, giving preference to the most recent and definitive original articles and reviews. EXPERT OPINION Medical therapy represents the cornerstone of endometriosis management, although few advances have been made in the last decade. Most studies have focused on the evaluation of the efficacy and safety of GnRH antagonists (plus add-back therapy in cases of prolonged treatment), which should be used as second-line treatment options in selected cases (i.e. non-responders to first-line treatments). Further studies are needed to identify the ideal treatment for women with endometriosis.
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Affiliation(s)
- Laura Buggio
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy
| | - Dhouha Dridi
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy
| | - Giussy Barbara
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy
| | - C E E Merli
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy
| | - Giulia Emily Cetera
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy
| | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda, 12, 20122 Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy
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Ottolina J, Vignali M, Papaleo E, Viganò P, Somigliana E, Ferrari S, Liprandi V, Belloni G, Reschini M, Candiani M, Vercellini P, Benaglia L. Surgery versus IVF for the treatment of infertility associated to ovarian and deep endometriosis (SVIDOE: Surgery Versus IVF for Deep and Ovarian Endometriosis). Clinical protocol for a multicenter randomized controlled trial. PLoS One 2022; 17:e0271173. [PMID: 35921357 PMCID: PMC9348732 DOI: 10.1371/journal.pone.0271173] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/23/2022] [Indexed: 11/18/2022] Open
Abstract
The management of endometriosis-related infertility is still a challenging issue. Women can be managed with either surgery or in vitro fertilization (IVF). The decision is tailored to the patients considering pros and cons of both approaches. Surgery might increase the chances of natural conception and relieve symptoms. IVF may be more effective, but costs are higher and unoperated women face some peculiar additional risks during the procedure and pregnancy. The unavailability of randomized trials comparing the two strategies hampers the possibility to provide precise estimates. This Randomized Controlled Trial (RCT) aims at filling this gap. This is a multicenter, non-blinded, randomized controlled trial with parallel groups and allocation 1:1. Three Italian Academic Infertility Units will be involved. Main inclusion criteria are infertility for more than one year, age less than 40 years and a sonographic diagnosis of endometriosis (ovarian endometriomas or deep peritoneal lesions). Previous IVF and previous surgery for endometriosis are exclusion criteria. Women will be randomized to either surgery and then natural pregnancy seeking or a standard program of three IVF cycles. The primary aim is the comparison of live birth rate between the two groups (IVF versus surgery) within one year of randomization. The secondary aim is the evaluation of cost-effective profile of the two interventions. The present study can influence the clinical practice of infertility treatment in women with endometriosis. From a public health perspective, information on the more cost-effective clinical management strategy would consent a wiser allocation of resources. Trial registration:NCT04743167, registered on 8 February 2021.
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Affiliation(s)
- Jessica Ottolina
- Department of Gynecology and Obstetrics, San Raffaele Scientific Institute, Milan, Italy
- * E-mail:
| | - Michele Vignali
- Department of Biomedical Sciences for Health, Macedonio Melloni Hospital, University of Milan, Milan, Italy
| | - Enrico Papaleo
- Department of Gynecology and Obstetrics, San Raffaele Scientific Institute, Milan, Italy
| | - Paola Viganò
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Edgardo Somigliana
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Stefano Ferrari
- Department of Gynecology and Obstetrics, San Raffaele Scientific Institute, Milan, Italy
| | - Valeria Liprandi
- Department of Biomedical Sciences for Health, Macedonio Melloni Hospital, University of Milan, Milan, Italy
| | - Gaia Belloni
- Department of Biomedical Sciences for Health, Macedonio Melloni Hospital, University of Milan, Milan, Italy
| | - Marco Reschini
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Candiani
- Department of Gynecology and Obstetrics, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Vercellini
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Laura Benaglia
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
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Invernici D, Reschini M, Benaglia L, Somigliana E, Galati G, La Vecchia I, Viganò P, Vercellini P. P-299 Impact of endometriosis on responsiveness to ovarian hyperstimulation and embryo development: quantitative and qualitative aspects. Hum Reprod 2022. [DOI: 10.1093/humrep/deac107.286] [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: 11/13/2022] Open
Abstract
Abstract
Study question
The present study was designed to better elucidate if endometriosis may affect follicologenesis and embryo development within a cycle of ovarian hyperstimulation for IVF (In Vitro Fertilization).
Summary answer
Endometriosis women showed fewer oocytes retrieved and a higher rate of unexpected poor response albeit number of patients without good quality embryos was similar.
What is known already
The pathogenetic mechanisms explaining the association between endometriosis and infertility are not fully explained. Pelvic adhesions and inflammation may play a role but other detrimental effects are presumably involved. They include reduced ovarian reserve, altered oocyte competence, impaired endometrial receptivity and association with other conditions affecting fertility such as adenomyosis. To note, even if in vitro fertilization is expected to overcome the pelvic detrimental milieu, the success rate of the procedure is lower in women with endometriosis.
Study design, size, duration
We designed a clinical retrospective study in order to analyse the impact of the disease on ovarian hyperstimulation and embryo development. Women were selected among those undergoing IVF cycles between January 2014 and December 2020. The primary outcome was the number of women without top quality embryos. Secondary outcomes included the rate of unexpected poor response (retrieval of ≤ 3 oocytes), cumulative clinical pregnancy rate and cumulative birth rate.
Participants/materials, setting, methods
Our study was performed at the Infertility Unit of the Fondazione IRCSS Ca’ Granda Ospedale Maggiore Policlinico of Milan. We included 496 subjects with a good ovarian reserve as demonstrated by serum Anti-mullerian hormone (AMH) > 1,1 ng/ml. Two hundreds and forty-eight women with endometriosis were identified and matched with two hundreds and forty-eight women without the disease according to age, pharmacological regimen, study period and AMH levels.
Main results and the role of chance
The number of women without good quality embryos did not differ between exposed and unexposed subjects (16% vs 16%, p = 1.00). The adjusted OR was 0.85 (95%CI: 0.51-1.44, p = 0.56). The clinical pregnancy rate and the live birth rate were also similar. We observed a lower number of oocytes retrieved and a higher rate of unexpected poor response (23% vs 13%, p = 0.005) in women with endometriosis. At subgroup analysis, the higher rate of unexpected poor responders persisted only in previously operated women (27% vs 13%, p = 0.02).
Limitations, reasons for caution
The evaluation of embryo quality was only based on morphological criteria. The histological diagnosis of endometriosis was lacking in unoperated women (128 subjects). Finally, our conclusions concern ovarian hyperstimulation and may not be extrapolated to natural reproductive processes.
Wider implications of the findings
Despite being generally reassuring, our findings do not completely exclude some mild negative effects on folliculogenesis. Effects demonstrated could be due to anatomical distortions of the pelvis causing an inefficient response of the ovarian parenchyma to hyperstimulation. We cannot exclude that the post-surgical healing process may alter local vascular supply.
Trial registration number
NA
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Affiliation(s)
- D Invernici
- University of Milan- Fondazione Ca’ Granda- Ospedale Maggiore Policlinico, Department of Obstet-Gynecol , Milan, Italy
| | - M Reschini
- Infertility Unit- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Obstet-Gynecol , Milan, Italy
| | - L Benaglia
- Fondazione Ca’ Granda- Ospedale Maggiore Policlinico, Department of Obstet-Gynecol , Milan, Italy
| | - E Somigliana
- University of Milan- Fondazione Ca’ Granda- Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health- Department of Obstet-Gynecol , Milan, Italy
| | - G Galati
- Sapienza University, Department of Obstet-Gynecol , Rome, Italy
| | - I La Vecchia
- Fondazione Ca’ Granda- Ospedale Maggiore Policlinico, Department of Obstet-Gynecol , Milan, Italy
| | - P Viganò
- Infertility Unit- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Obstet-Gynecol , Milan, Italy
| | - P Vercellini
- University of Milan- Gynecology Unit- Fondazione Ca’ Granda- Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health- Department of Obstet-Gynecol , Milan, Italy
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Facchin F, Barbara G, Buggio L, Dridi D, Frassineti A, Vercellini P. Assessing the experience of dyspareunia in the endometriosis population: the Subjective Impact of Dyspareunia Inventory (SIDI). Hum Reprod 2022; 37:2032-2041. [PMID: 35726864 DOI: 10.1093/humrep/deac141] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/01/2022] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Is the Subjective Impact of Dyspareunia Inventory (SIDI) a reliable tool to examine the experience of dyspareunia in the context of endometriosis? SUMMARY ANSWER In this study, the SIDI showed good structural and psychometric properties, and thus can be used as a reliable questionnaire to assess the impact of endometriosis-related dyspareunia on multiple dimensions, such as sexuality and intimate relationships. WHAT IS KNOWN ALREADY In the endometriosis population, dyspareunia has a tremendous negative impact on psychological health, overall sexual function and couple relationships. However, there is a paucity of tools that can be effectively used in either research or clinical practice to assess the subjective components of the dyspareunia experience, including coping strategies to deal with the pain. STUDY DESIGN, SIZE, DURATION In this cross-sectional study, the validity of the SIDI was examined by considering the responses provided by 638 participants with endometriosis and dyspareunia, who participated in an online survey conducted between 8 November and 21 December 2021. Participants were recruited using snowball sampling that involved posting the invitation to participate in the study on the social media of a patient association. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants were women aged ≥18 with clinical or surgical diagnosis of endometriosis. The SIDI measures the subjective impact of dyspareunia and is composed of 16 items focused on the frequency of dyspareunia-related experiences in the last 6 months, rated on a 5-point Likert scale. Sexuality was assessed using the Female Sexual Function Index. Psychological health was measured using the Hospital Anxiety and Depression Scale and the Rosenberg Self-Esteem Scale. Sociodemographic and endometriosis-related information was collected using a researcher-made questionnaire. Statistical significance was set at P < 0.05. MAIN RESULTS AND THE ROLE OF CHANCE Factor analysis revealed that the SIDI has a four-factor structure and allows for examining the impact of dyspareunia in terms of Sexual Concerns (Factor 1), Relationship Concerns (Factor 2), Partner Support (Factor 3) and Endurance of Pain (Factor 4). The SIDI showed good structural and psychometric properties (including internal consistency), was associated with sexual function and psychological health and was able to discriminate between participants with and without sexual dysfunction. LIMITATIONS, REASONS FOR CAUTION Reasons for caution are related to the risk of self-selection bias depending on the study population and recruitment strategy. Moreover, all the information provided by the participants was self-reported, which may have affected the accuracy of the data collected, especially with regards to endometriosis-specific information. WIDER IMPLICATIONS OF THE FINDINGS This study may provide a new brief tool that can be used by clinicians and researchers to assess the impact of dyspareunia from a multidimensional perspective and to consider subjective aspects that can be usefully integrated with information about pain severity, timing and localization. STUDY FUNDING/COMPETING INTEREST(S) There was no funding for this study. A.F. is the President of APE-Odv (Associazione Progetto Endometriosi-Organizzazione di volontariato (Endometriosis Project Association-Volunteer Organization)), the largest nonprofit endometriosis patient association in Italy. The other authors have no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- F Facchin
- Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy
| | - G Barbara
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - L Buggio
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - D Dridi
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - A Frassineti
- Associazione Progetto Endometriosi-Organizzazione di Volontariato (APE-Odv), Reggio Emilia, Italy
| | - P Vercellini
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Candiani M, Vercellini P, Ferrero-Caroggio C, Fedele F, Salvatore S, Fedele L. Conservative treatment of Herlyn-Werner-Wunderlich syndrome: Analysis and long-term follow-up of 51 cases. Eur J Obstet Gynecol Reprod Biol 2022; 275:84-90. [PMID: 35763966 DOI: 10.1016/j.ejogrb.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 11/18/2021] [Revised: 05/04/2022] [Accepted: 06/12/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The purpose of this study is to analyze the precise anatomical characteristics of a large group of patients with Herlyn-Werner-Wunderlich syndrome together with the long-term follow-up and the reproductive performance. STUDY DESIGN Retrospective analysis of prospectively collected data. In two tertiary medical centers, from 2008 to 2021, 51 patients with HWWS underwent surgery via the same technique. Presenting symptoms, preoperative investigations, operative management, and long-term follow-up with obstetric outcome were assessed. RESULTS The surgical procedure was successful in all cases with no major complications recorded. Postoperative course was uneventful. The median follow-up was 6,5 years, with a range from 6 months to 13 years. After surgery, among 14 patients who sought pregnancies, 12 (85,71%) were successful. Of these 11 patients had a total of 22 pregnancies, resulting in spontaneous miscarriage in 27% (6/22), premature birth (<37 weeks) in 36% (8/22) and full-term birth in 36% (8/22). Overall the pregnancies demonstrated had a good course. CONCLUSIONS Early diagnosis is essential in establishing prompt and correct surgical treatment.
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Affiliation(s)
- M Candiani
- Obstetrics and Gynaecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - P Vercellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico
| | | | - F Fedele
- Obstetrics and Gynaecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - S Salvatore
- Obstetrics and Gynaecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - L Fedele
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico.
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Barbara G, Viero A, Pellizzone I, Buggio L, Facchin F, Cattaneo C, D’Amico ME, Vercellini P, Kustermann A. Intimate Partner Violence in the COVID-19 Era: A Health, Psychological, Forensic and Legal Perspective. Int J Environ Res Public Health 2022; 19:ijerph19094973. [PMID: 35564368 PMCID: PMC9104607 DOI: 10.3390/ijerph19094973] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/17/2022] [Accepted: 04/18/2022] [Indexed: 11/16/2022]
Abstract
This commentary aims to provide a multidisciplinary framework on intimate partner violence (IPV) during the COVID-19 pandemic (with a specific focus on the most predominant form of gender-based violence, i.e., male violence towards women), commenting on the multiple negative consequences of the pandemic on gender violence and providing elements of effective practice. We searched literature for reports/studies on the issue of IPV during the COVID-19 pandemic, focusing on health, psychological, forensic, and legal aspects. The combined effects of lockdowns, isolation at home with abusive partners, quarantine, and economic worries/loss of a job could significantly facilitate violence against women and, at the same time, diminish women’s chances to seek for help, with a strong negative impact on their life. The continued offer of clinical, psychological, forensic, and legal services for survivors of violence, despite the modifications to the provision of these services due to the new needs related to the COVID-19 pandemic, appears of utmost importance. All actions to support survivors of IPV are expected to be multidisciplinary, including the involvement of social and/or legal services and health systems, and woman-centred. Implementing these measures in the COVID-19 era appears challenging but is of primary importance.
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Affiliation(s)
- Giussy Barbara
- Gynaecological Unit and SVSeD, Service for Sexual and Domestic Violence, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (P.V.); (A.K.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
- Correspondence: (G.B.); (L.B.); Tel.: +39-02-5503-2917 (G.B.); Fax: +39-02-0320264 (G.B.)
| | - Alessia Viero
- Legal Medicine and Toxicology Unit, Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, 35121 Padua, Italy;
| | - Irene Pellizzone
- Department of Italian and Supranational Public Law, University of Milan, 20122 Milan, Italy; (I.P.); (M.E.D.)
| | - Laura Buggio
- Gynaecological Unit and SVSeD, Service for Sexual and Domestic Violence, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (P.V.); (A.K.)
- Correspondence: (G.B.); (L.B.); Tel.: +39-02-5503-2917 (G.B.); Fax: +39-02-0320264 (G.B.)
| | - Federica Facchin
- Department of Psychology, Catholic University of the Sacred Heart, Largo A. Gemelli 1, 20123 Milan, Italy;
| | - Cristina Cattaneo
- Department of Biomedical Sciences for Health, University of Milan, 20133 Milan, Italy;
- LABANOF—Laboratorio di Antropologia e Odontologia Forense, 20133 Milan, Italy
| | - Maria Elisa D’Amico
- Department of Italian and Supranational Public Law, University of Milan, 20122 Milan, Italy; (I.P.); (M.E.D.)
| | - Paolo Vercellini
- Gynaecological Unit and SVSeD, Service for Sexual and Domestic Violence, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (P.V.); (A.K.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Alessandra Kustermann
- Gynaecological Unit and SVSeD, Service for Sexual and Domestic Violence, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (P.V.); (A.K.)
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Berlanda N, Donati A, Fedele F, Lepri M, Vercellini P. Adenomyosis and Obstetrical Outcome: a Narrative Mini-Review of the Latest Evidence. Curr Obstet Gynecol Rep 2022. [DOI: 10.1007/s13669-021-00316-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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