Accuracy of ultrasound signs on two-dimensional transvaginal ultrasound in prediction of adenomyosis: prospective multicenter study

OBJECTIVE

Two-dimensional (2D) transvaginal ultrasound (TVS) is an accessible and cost-effective diagnostic tool for the detection of adenomyosis. Different ultrasound features related to adenomyosis have been described, but the predictive value of each ultrasound sign and their combinations requires further investigation. We aimed to analyze the accuracy of 2D-TVS and describe possible combinations of ultrasound signs with a high predictive value in the diagnosis of adenomyosis.

METHODS

This was a prospective multicenter study of patients scheduled for laparoscopic hysterectomy who had been examined using standardized 2D-TVS at nine expert centers specializing in the diagnosis and treatment of endometriosis. 2D-TVS examination included nine typical adenomyosis ultrasound features, comprising heterogeneous myometrium, myometrial linear striations, myometrial cysts, subendometrial microcysts, asymmetrical myometrial thickening, uterine enlargement, the 'question mark sign', thickening of the junctional zone and hyperechoic myometrial spots, in order to predict or exclude the presence of adenomyosis. Ultrasound examination results were compared with histology after hysterectomy. The diagnostic reliability of the nine ultrasound signs and their combinations, and the influence of concurrent fibroids on the accuracy of the results, were analyzed.

RESULTS

A total of 202 patients were enrolled into the study. Histopathological examination revealed adenomyosis in 130 patients (64.4%). The accuracy of prediction of adenomyosis by 2D-TVS examination using all signs was 63.4% (positive predictive value, 71.5%; negative predictive value, 48.6%; sensitivity, 71.5%; specificity, 48.6%). Heterogeneous myometrium, myometrial cysts, subendometrial microcysts and hyperechoic myometrial spots showed the highest accuracy (55.7-62.1%) as individual ultrasound signs for the prediction of adenomyosis. The combination of the most accurate ultrasound signs (subendometrial microcysts, myometrial cysts and heterogeneous myometrium) improved the specificity of prediction (86.1%) when compared with that of these three single markers (35.2-81.7%). Uterine enlargement and asymmetry showed both low sensitivity (60.8% and 52.3%, respectively) and specificity (41.7% and 49.3%, respectively) as individual sonographic signs.

CONCLUSIONS

Heterogeneous myometrium, myometrial cysts, subendometrial microcysts and hyperechoic myometrial spots showed the highest accuracy for the detection of adenomyosis in this study, while uterine enlargement and asymmetry led to high false-positive and false-negative results. A combination of ultrasound features including the most accurate signs increases specificity. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

National German Guideline (S2k): Guideline for the Diagnosis and Treatment of Endometriosis: Long Version - AWMF Registry No. 015-045

In this guideline, recommendations and standards for optimum diagnosis and treatment of endometriosis are presented. They are based on the analysis of the available scientific evidence as published in prospective randomized and retrospective studies as well as in systematic reviews. The guideline working group consisted of experts from Austria, Germany, Switzerland, and the Czech Republic.

Surgical Therapy of Endometriosis: Challenges and Controversies

Endometriosis is one of the most common disorders encountered in surgical gynaecology. The laparoscopic technique, the planning of the surgical intervention, the extent of information provided to patients and the interdisciplinary coordination make it a challenging intervention. Complete resection of all visible foci of disease offers the best control of symptoms. However, the possibility of achieving this goal is limited by the difficulty of detecting all foci and the risks associated with radical surgical strategies. Thus, the excision of ovarian endometrioma can result in a significant impairment of ovarian function, while damage to nerve structures during resection of the uterosacral ligaments, the parametrium, the rectovaginal septum or the vaginal cuff to treat deep infiltrating endometriosis can lead to serious functional impairments such as voiding disorders. A detailed risk-benefit analysis is therefore necessary, and patients must be treated using an individual approach.

Fragmentation von Intrauterinpessaren als Komplikation bei der Extraktion

Three cases are reported in which the lateral arm of the intra-uterine contraceptive device had broken off. The fragmentation of the intrauterine contraceptive device was observed during spontaneous expulsion and during extraction. The broken off portions of the intra-uterine devices were not located by sonography, radiography or computer tomography. In two of three cases the diagnosis was not made by hysteroscopy. In one case the remaining parts of the intra-uterine device were removed by curettage. The problems from partial perforation and embedding of the fragments are discussed and the management described. A hysteroscopic diagnosis and extraction the fragments is recommended.

ENZIAN-Score, eine Klassifikation der tief infiltrierenden Endometriose

The ENZIAN-Score is presented as a new instrument to classify the deep infiltrating endometriosis. Especially the retroperitoneal part of the severe endometriosis is focussed on. In analogy to an oncological staging four different stages are pronounced. The localisation and the expansion of the endometriosis nodule was indicated to different subgroups. The still used rAFS-score is of no clinical evidence, as we pointed out in a retrospective study of our patients with severe intestinal endometriosis.

Leitlinien für den Einsatz der GnRH-Agonisten zur Behandlung der Endometriose

Today GnRH-Analogues are the most effective substances for the regression of endometriosis and endometriosis related complaints. In combination with add-back medication the treatment is effective with only few tolerable side effects. The different types of GnRH-Analogues are equally effective, but depot preparation have the best compliance. The tailored application of GnRH-Analogues preoperatively, postoperatively or instead of surgery is dependent on the individual situation of the patient and dependent on the proliferative activity, localisation, type and stage of the disease.

Current place of progestins in the treatment of endometriosis-related complaints

Oral progestins have been used for the treatment of endometriosis and endometriosis-associated complaints for more than 40 years. The mechanism of action on the menstrual cycle is well understood; however, the mechanism of action on endometriosis is still a matter of debate. The different progestins are able to stop proliferation in endometriotic implants and to induce regressive change to certain degrees; they are not able to heal endometriosis because endometriosis is a chronic and recurrent disease. For this reason, no medical treatment can heal endometriosis and repeat medication is necessary in the medical management of this disease. Progestins--especially non-androgenic progestins--are well tolerated and have only few side-effects; they can be used repeatedly or continuously over a long period of time.

Diagnostic errors in interactive telepathology

Telepathology (TP) as a service in pathology at a distance is now widely used. It is integrated in the daily workflow of numerous pathologists. Meanwhile, in Germany 15 departments of pathology are using the telepathology technique for frozen section service; however, a common recognised quality standard in diagnostic accuracy is still missing. In a first step, the working group Aurich uses a TP system for frozen section service in order to analyse the frequency and sources of errors in TP frozen section diagnoses for evaluating the quality of frozen section slides, the important components of image quality and their influences an diagnostic accuracy. The authors point to the necessity of an optimal training program for all participants in this service in order to reduce the risk of diagnostic errors. In addition, there is need for optimal cooperation of all partners involved in TP service.

Recommendations for estrogen and progestin replacement in the climacteric and postmenopause. European Progestin Club

The diversity of function that sex steroids have proven to have in the female body, gives them a position of central importance in gynaecology. Scientific research demonstrates not only the well known genital functions of sexual steroids, furthermore, various extragenital organs are influenced and modulated by ovarian hormones. Therefore, the general benefit of HRT for the female organism becomes clearer and the clinical management of menopause is developing to a broad new discipline, the gender specific medicine. In clinical practise, phytosteroids are claimed by the patient and therefore, also of high interest for the scientific research. Also, tissue specificity of the endocrine treatment and the biological relevance of different steroid receptors of HRT are discussed, leading to the development of new HrT preparations. Individualisation, the tailoring of HRT, according to the patients needs, and low dose steroids management, will also become an important aspect in the recommendations for estrogen and progestin replacement therapy.

Progestins and uterine leiomyoma

Myomas are the most frequent benign gynecological tumors and are responsible for several symptoms and complaints. Their etiology is unknown and their pathology and proliferation is poorly understood. Besides the importance of estrogens for development and growth of the myoma, progesterone seems to play an important role in the modulation of mitotic activity, local growth factors and growth factor receptors, as well as other paracrine mechanisms.

Impact of maternal body build characteristics on newborn size in two different European populations

The association patterns between maternal anthropometric characteristics (stature, prepregnancy weight, prepregnancy body mass index, pregnancy weight gain) and newborn size (birth weight, length, head circumference) were tested with 10,240 single births taking place between 1985 and 1995 in Vienna, Austria, and 3,452 single births taking place between 1989 and 1995 in Westerstede-Ammerland (Friesland), northern Germany. Maternal size and newborn size differed highly significantly (p < 0.001) between the two genetically and socioeconomically different population groups. Furthermore, the incidence of macrosomia among newborns (birth weight greater than 4000 g) was extraordinarily high (17.9%) in the Frisian group from northern Germany. In both populations taller and heavier women with a higher weight gain during pregnancy gave birth to heavier offspring. Nevertheless, the pregnancy weight gain, which indicates environmental conditions of the mother, had only a minor impact on newborn size compared with stature and prepregnancy weight, which reflect the maternal genetic potential to a higher degree.

Aspects of progestin activity on the breast. European Progestin Club

On 9-11 May 1997, the second Meeting of the European Progestin Club was held in Turin, Italy. Aspects of progestin use on the breast were discussed, based on the currently available scientific data. The paper covers topics addressed at the meeting and summarizes the recommendations which could be agreed on by the participants.

[The significance of gestagens in treatment of mastopathy]

The term "mastopathy" has yet to receive a common accepted definition. 70% of all mastopathies do not demonstrate, morphologically speaking, a proliferation, where as less than 10% show an atypical proliferation that suggests an increased risk for cancer development. The indication for the treatment of a mastopathy without proliferative processes is the existence of pain. The concurrent development of Hyperprolactinemia, Hyperandrogenemia, or Hypothyreosis and the resulting metabolic disorders that accompany such should be treated in a causal manner. Progestins have proved to be effective in cases where a progesterone deficit and/or a relative hyperestrogenism exist. An evaluation of progestins as a prophylaxis for breast carcinoma development in women with an atypical proliferation, however, can first be completed when a deeper knowledge of the local hormone situation in the breast tissue exists. Suitable in this case, are the 17-Hydroxyprogesterone derivatives, because the 19-Nortestosterone derivatives produce a negative influence on the Lipid metabolism due to their partial androgenic effect and in addition, antagonise the hepatocellular estrogen effect (IGF1-reduction and SHBG-increase), which may indirectly offer protection for the breast.

[Significance of progestins in treatment of endometriosis]

Endometriosis is a chronic benign proliferative disease with high risk of recurrences, despite of medical and/or surgical treatment. The variation and severity of symptoms reduce the quality of life, the ability of working and the sexual behaviour. Medical cure of symptoms is a central concept in the therapeutic strategy. Low dose progestins have shown to be effective in the clinical routine since several decades although scientific data are rare and insufficient about the mechanism of action of these substances. Subjective and biochemical side effects are important for the choice of a specific progestin. The dosage is dependent of the biological activity of the drug, especially the effect on the endometrium. On the endometriotic implants and cysts high dose therapy with progestins induces the same regressive changes as complete estrogen deprivation by reversible "medical castration".

Should add-back therapy for endometriosis be deferred for optimal results?

Add-back hormone replacement therapy has been shown to alleviate some of the hypo-oestrogenic side effects associated with gonadotrophin-releasing hormone agonists, including demineralisation of bone. Studies on patients with uterine fibroids have shown that concomitant add-back therapy reduced the efficacy of these agents, but that deferred administration was less detrimental. This trial set out to investigate if deferred add-back therapy could offer any advantages to patients with endometriosis compared with immediate therapy. Zoladex [goserelin acetate (3.6 mg every 4 weeks)] was given for 24 weeks either with placebo, with medrogestone (10 mg/day) for 24 weeks (immediate add-back therapy), or with placebo for 12 weeks followed by medrogestone (10 mg/day) for 12 weeks (deferred add-back therapy) to 123 patients. The number of responders measured using the Revised American Fertility Society score (decrease in this score of > or = 50%) was greatest in the immediate add-back therapy group, although there were no significant differences between groups. All three treatment groups showed significant decreases in bone mineral density compared with baseline but smaller losses were generally observed in the add-back groups. A significantly smaller number of patients in the immediate add-back group reported hot flushes during the first 12 weeks of treatment compared with the deferred add-back group. In conclusion, it appears that there is no extra advantage to patients with endometriosis being treated with goserelin in delaying the start of add-back therapy.

Autoreactive epitopes within the human alpha-enolase and their recognition by sera from patients with endometriosis

Patients with endometriosis significantly develop autoantibodies directed against endometrial proteins, which may be involved in the aetiology of this gynaecological disease. Based on standard Western blot analysis, a 48 kDa protein was localized in the soluble protein extract of endometrial adenocarcinoma cells using sera from patients with clinically staged endometriosis and identified as the glycolytic enzyme alpha-enolase. The corresponding cDNA coding for the human alpha-enolase was isolated from a human endometrial cDNA library and cloned into the vector pH6EX3, allowing the efficient expression of recombinant human alpha-enolase with an N-terminal histidine-hexapeptide as affinity ligand in Escherichia coli. The purified recombinant human alpha-enolase was evaluated as a specific antigenic tool for the diagnostic measurement of antiendometrial antibodies in sera from patients with endometriosis. With selected endometriosis sera, two linear autoreactive epitopes were localized within the recombinant human alpha-enolase using epitope mapping techniques, and they were characterized.

[Treatment of endometriosis with the GnRH agonist buserelin (Suprecur): a multicenter study]

A phase III multicentre study was carried out with the GnRH agonist buserelin (Suprecur) at five university institutions (Dept. of Obstetrics and Gynaecology of Essen, Kiel, Tübingen, Münster and Erlangen) to evaluate the effect of Buserelin (3 x 300 micrograms daily intranasal) on endometriosis for a period of 6 months. Endometriosis was verified by light microscopy in all cases. The data of 430 patients could be evaluated. The extent of the endometriotic lesions was studied before the start and at the end of therapy. The mean age of the patients was 30 +/- 5 years. For 300 patients (66.4%) sterility was a main problem. Previous treatment for endometriosis consisted of operation in 20.5%, treatment with danazol in 16.8% and treatment with gestagens in 11.6% of the patients. Under treatment FSH changed from 11.0 +/- 31.4 mIU/ml to 7.0 +/- 5.6 mIU/ml at the end of therapy; LH from 11.1 +/- 12.9 mIU/ml to 7.4 +/- 7.3 mIU/ml; estradiol from 113.9 +/- 89.0 to 35.9 +/- 60.3 pg/ml and progesterone from 7.2 +/- 11.2 ng/ml to 0.8 +/- 1.4 ng/ml. The effect on endometriosis was judged according to the revised American Fertility Society score (rAFS 1985). The changes of the rAFS-score stages were as follows (before/after therapy): Stage 0: 0%/42.8%; stage I: 43.5%/38.5%; stage II: 31.1%/11.2%; stage III: 18.1%/2.2%; stage IV: 6.3%/0.2%. The total mean AFS-stage changed from 1.9 to 0.7. The frequency of clinical symptoms improved (before/after therapy): dysmenorrhoea 65.0%/11.2%; pelvic pain 48.2%/14.1%; pain at the time of gynaelogical examination 40.0%/9.7%.(ABSTRACT TRUNCATED AT 250 WORDS)

Goserelin (Zoladex) depot in the treatment of endometriosis. Zoladex Endometriosis Study Group

STUDY OBJECTIVE

To evaluate the safety and efficacy of Goserelin (Zoladex depot; ICI Pharmaceuticals, Macclesfield, Cheshire, United Kingdom) in the treatment of endometriosis.

DESIGN

Open study.

SETTING

Eleven centers in Germany and 1 center in Austria.

PATIENTS

One hundred forty-six patients with pelvic endometriosis.

INTERVENTION

Goserelin (Zoladex depot) therapy, one depot (3.6 mg) subcutaneously every 4 weeks for 6 months.

RESULTS

Total subjective score and total pelvic symptom score showed a reduction by 86% and 93%, respectively, at the end of the treatment and did not exceed one fifth of the pretreatment value throughout the follow-up period of 48 weeks. One hundred seven women underwent a second laparoscopy at the end of the therapy for determination of objective efficacy: 54% of the patients showed a reduction of implants and adhesions by at least 50% or more, and 31.5% had a complete resolution of visible deposits. The mean reduction of implants and adhesions was 50%, and the mean reduction of implants 72%. Twenty of 64 (31.3%) previously infertile patients successfully conceived within 12 months after discontinuation of the therapy. Goserelin led to a down regulation of the pituitary ovarian axis and as a pharmacological effect of this hypoestrogenism most patients had hot flushes and vaginal dryness.

CONCLUSIONS

Zoladex depot therapy proved to be safe and effective in the medical treatment of endometriosis.

[Ovarian suppression by the GnRH analog buserelin in the treatment of endometriosis. Clinical, biochemical and pelviscopic studies]

To evaluate the efficacy, safety and tolerance of the GnRH-analogue Buserelin in the treatment of endometriosis, we started a non-comparative study of 52 patients with various stages of endometriosis. The dosage of 900 mcg/d was administered 3 times daily intranasally for 6 months. The degree of the disease was evaluated before and at the end of treatment by pelviscopy and biopsy. A regression of the implant score was found in 88% of patients. The mean AFS score was reduced from 17.4 +/- 1.9 before medication to 7.2 +/- 8.2 after therapy. Endometriosis related complaints were significantly improved during treatment. After 6 months 75% of the patients were without lower abdominal pain, 98% without dysmenorrhoea, and 85% without dyspareunia. As a result of the induced low level of oestrogen, 60% of the patients claimed hot flushes, 12% sweating, reduced libido, and dry vagina. Bleeding (spotting, break-through bleeding, menstruation) occurred in 40% during the first month, and was continuously reduced during the following period. Before, during and after therapy, venous blood samples were drawn to check laboratory tests for blood count, clotting parameters, clinical chemistry, serum electrolytes, as well as liver and lipid metabolism. All values stayed within the normal range without significant changes. In the follow-up period of at least 12 months, we achieved an uncorrected pregnancy rate of 41% in the group of 34 women with primary or secondary infertility.

[Residual endometriosis following LHRH analog therapy]

LHRH analogue therapy has proved effective in the treatment of endometriosis. Although in the majority of patients a marked reduction in AFS implant score is observed, in some cases residual endometriotic foci are macroscopically suspected and can be confirmed by histological examination during a second check operation at the end of treatment. In the study presented, 34 patients from 69 showed residual endometriosis after a 6 months' treatment with the LHRH analogue buserelin (900 mcg/d intranasally). According to light microscopical criteria regressive changes were seen in 52% of the implanted patients, nevertheless 29% presented with proliferative elements of the disease. In 19% proliferation and regression were seen in the same biopsy or even in the same gland. Histology did not relate to either the degree of ovarian suppression by LHRH analogue therapy, or to the location of the residual endometriotic foci. These results add another piece of evidence to the fact, that endometriosis presents itself as a heterogenic disorder. In addition, susceptibility to a hormonal ablative therapy rather depends on the degree of dysontogenetic differentiation, than on the completeness of induced ovarian suppression.

LH-RH agonist (buserelin): treatment of endometriosis. Clinical, laparoscopic, endocrine and metabolic evaluation

To investigate the effects of the LH-RH agonist Buserelin [D-Ser (But)6 des-Gly10-LHRH ethylamide] on endometriosis, 64 patients were treated with 900 micrograms/d Buserelin intranasally over 6 months after histological verification of the disease. As shown by the follow-up operation at the end of treatment, 73% of cases showed regression of implants, whereas adhesions seemed to be unaffected. The uncorrected pregnancy rate of the 45 patients with a history of infertility was 40%, while the overall recurrence rate--confirmed by histological examination--was 9.4%. The endocrine parameters demonstrated a highly significant suppression of estradiol (E2) and a sharp decline of progesterone (Prog), indicating anovulatory cycles. Follicle-stimulating hormone (FSH) was unchanged, while luteinizing hormone (LH) and prolactin (Prl) decreased significantly. The androgenic parameters testosterone (T), dehydroepiandrosterone sulfate (DHEA-S), and sex-hormone-binding globulin (SHBG) revealed no relevant changes. Influence on bone metabolism could not be detected by measuring calcitonin and parathyroid hormone fragments (PTH-C and PTH-MM). Negative metabolic effects were absent in terms of hematology, clotting system, liver enzymes, renal parameters and lipid metabolism. Remarkable was a significant increase of high-density-lipoprotein cholesterol (HDL). Subjective complaints were mostly attributed to the therapy-induced hypoestrogenism. We consider Buserelin to be an effective drug in the treatment of endometriosis, with a low incidence of relevant side effects.

[Effects of danazol therapy in endometriosis on the blood picture and blood coagulation]

Over a six-month period, 62 endometriosis patients were given 600 mg per day of the ethisterone derivative danazol. Blood count and coagulation status were checked before and during treatment. There was a significant increase (p less than 0.05) in hemoglobin and hematocrit. There were no changes in RBC, leukocyte count, or thrombocyte count; the mean cellular erythrocyte volume, thrombin time, thromboplastin time, and partial thromboplastin time also remained unchanged, as did factors VII, VIII, X, XII, and alpha-1-antitrypsin. Antithrombin III levels increased, while alpha-2-macroglobulin values decreased. Only the drop in fibrinogen, to pathologic values, and the increase in plasminogen reached significant levels (p less than 0.01). These in part contradictory changes suggest that hypocoagulability occurs under danazol medication; however, its clinical relevance is unclear.

[Metabolic effects and general side effects in the treatment of endometriosis with an LHRH agonist]

Between 1983 and 1986 40 patients were treated for external genital endometriosis with the LHRH agonist buserelin. Ovarian suppression was achieved for a period of six months with a dose of 900 to 1,800 mcg per day. In addition to gynecological findings, liver and kidney function and lipid metabolism were checked prior to treatment and at regular intervals during treatment. No deviations from normal ranges were found. The general side effects observed during treatment were as a rule attributable to the buserelin-induced relative estrogen deficiency. The efficacy of the medication in the treatment of endometriosis was demonstrated by control pelviscopy. Since no undesirable metabolic side effects have so far been observed with buserelin, it may be considered an effective new alternative treatment for endometriosis.

[Effects of a chlormadinone acetate-containing ovulation inhibitor on androgenization pictures and liver and lipid metabolism in young females]

Twenty-two patients, average age 22 years, were treated for androgenization phenomena with a combination preparation containing ethinyl estradiol and chlormadinone acetate (Neo-Eunomin) over a period lasting 12 cycles. Under this therapy acne, seborrhea, alopecia and hirsutism improved. The hepatic metabolism parameters checked before and during the study (alkalic phosphatase, SGPT, gamma-GT and total bilirubin) showed no pathologic changes and decreased significantly toward the end of the treatment period. SGOT remained uninfluenced. The effects on the lipoproteins checked were favorable, as the atherogenic index (LDL/HDL) dropped from 2.2 prior to therapy to 1.7 in the twelfth cycle of the treatment period. The HDL fraction increased significantly in the very first cycle, while the LDL fraction remained almost constant. There was a significant increase in cholesterol and triglycerides. The serum androgen count (testosterone and DHEA-S) was significantly lowered. There was a clear decrease in testosterone in saliva.

Changes of plasma lipids and lipoprotein levels during danazol treatment for endometriosis

Previous data of lipid and lipoprotein level changes with the application of danazol, an isoxazol derivative of 17-alpha-ethinyl testosterone, have been conflicting. We measured cholesterol, triglycerides, low density lipoproteins and high density lipoproteins, estradiol and progesterone in 62 patients treated for endometriosis with danazol 600 mg daily. The fasting blood samples were taken before, every month during danazol medication, and 4, 12 and 24 weeks after cessation of therapy. Inconsistent changes in total cholesterol and triglyceride levels were observed. The data showed a constant, though not significant increase of the mean LDL levels. Plasma HDL decreased approximately 45% during the first two months of danazol influence and remained constantly low for the rest of the treatment. The atherogenic ratio (LDL:HDL) was doubled by-danazol. Five patients developed a reversible type IIa hyperlipoproteinemia. The plasma levels of estradiol decreased, but showed normal midfollicular values during the treatment period. In contrast, the plasma levels of progesterone fell significantly and were sometimes undetectable. These findings demonstrate an atherogenic potential of danazol, especially when long term treatment is taken into consideration.

Endocrine dependency of endometriosis: an ultrastructural study

The comparison of the ultrastructural features of endometriotic implants in 96 patients before and after suppressive therapy by danazol showed that the glands of the ectopic endometrium had a wide range of morphologic development. In about one-third of the pretreatment biopsies significantly different ultrastructural patterns were observed in the same specimen, ranging from poorly to highly differentiated endometrial glands. Adequate morphological changes during the menstrual cycle were found in implants only in 14 patients during the proliferative phase, but adequate, homogeneously performed secretory changes were completely missing during the luteal phase. Besides incomplete or delayed secretory changes the majority was proliferative rather than secretory. After 6 months of endocrine suppression laparoscopic biopsies of endometriosis were repeated, and the ultrastructural findings lead to three conclusions. 1. Poorly differentiated endometriotic foci do not respond to danazol. 2. Endometriotic implants consisting of highly differentiated epithelium with adequate cyclic variations respond well to danazol and disappear in nearly 80% of cases. 3. In endometriosis with mixed areas consisting of various degrees of glandular differentiation the hormonal suppression can eliminate endometriotic implants or arrest them at a proliferative stage. If the morphological appearance of the ectopic implants depends not simply upon the endocrine stimulus, but primarily on the degree of differentiation and maturity of the cell, then perhaps cyclic modulation is only a secondary phenomenon, and hormones play only a secondary role in therapy. If this hypothesis is correct, only complete elimination of endocrine influence can cure endometriosis. Transient or incomplete suppression may lead only to partial regression.

Ultrastructural comparison of endometriotic implants and eutopic endometrium

Ultrastructural features of endometriotic implants suggest an incomplete response to the prevalent hormonal milieu. The cyclic changes, especially in the secretory phase, appear to depend more on the morphologic differentiation of the ectopic implants than on the hormonal stimulus. The endometriotic tissue encompassed a wide range of morphologic development from poorly to highly differentiated glands. Variations occurred from gland to gland and even within the same gland. Complete proliferative development was found only in some of the patients and full secretory transformation was absent in all. The incomplete morphologic response to cyclic hormonal changes may explain the frequent failure of endocrine therapy.

[Kell antibodies in pregnancy]

The paper is concerned with a case presentation of a pregnancy complicated by Kell sensitization. A review of 14 own cases and the literature revealed that sensitization against Kell-antigens requires treatment similar to those with sensitization against D-antigens (Rh0). The diagnostic procedures include repeated amniocentesis, sonography, and titer controls of the Kell-antibodies.

[Diagnosis and treatment of intra-uterine contraceptive devices retained during pregnancy]

68 pregnancies were observed with an intrauterine device in place, and the threat no longer visible in the cervical canal. The various diagnostic and therapeutic possibilities are described. Ultra-sonography is capable of localizing the I.U.C.D. in 4/5 of the cases. In some cases a positive identification of the I.U.C.D. is only possible by radiographic methods. In order to reduce the maternal risk of infection and to increase the chances for an uncomplicated course of the pregnancy the intra-uterine device needs to be extracted even when the threat is no longer visible. The hysteroscopic localization and extraction was found to be the safest and most effective method of retrieval. Among 26 cases, removal was feasible in 25 cases, and 21 pregnancies remained undisturbed.