Argon laser laparoscopy for treatment of pelvic endometriosis associated with infertility and pelvic pain

Argon laser laparoscopy was used for treatment of 46 patients with pelvic endometriosis. Infertility was the primary diagnosis in 31 patients, and pelvic pain was the primary diagnosis in 21 patients. A 600 mum laser fiber was used through the operative channel of the laparoscope, and the tip of the fiber was kept at a distance of 2-3 mm from the lesions. The power density used varied between 1604 and 1069 W/cm 2 at the tissue level. The pregnancy rate following treatment of the infertile group was 42%. Eighty-four percent of these pregnancies occurred within the first 8 months of treatment. In the group with pelvic pain, 8 patients experienced complete pain relief, and 13 patients experienced partial pain relief. Difficulties with the use of the fiber included breakage in 3 patients and melting of the fiber tip in 1 patient.     

Progestogens and estroprogestins in the treatment of pelvic pain associated with endometriosis

We performed a MEDLINE and EMBASE search to identify all studies published in the English language literature on the use of progestogens for the treatment of endometriosis. The aim of our review was to clarify the biological rationale for treatment and define the drugs that can be used. It has been demonstrated that progestogens may prevent implantation and growth of regurgitated endometrium by inhibiting the expression of matrix metalloproteinases and angiogenesis, and they have several anti-inflammatory in vitro and in vivo effects that may reduce the inflammatory state generated by the metabolic activity of the ectopic endometrium. Oral contraceptives increase the abnormally low apoptotic activity of the endometrium of patients with endometriosis. Moreover, anovulation, decidualization, amenorrhoea and the establishment of a steady estrogen-progestogen milieu contribute to disease quiescence. Progestogens are able to control pain symptoms in approximately three out of four women with endometriosi. Different compounds can be administered by the oral, intramuscular, subcutaneous, intravaginal or intrauterine route, each with specific advantages or disadvantages. Medical treatment plays a role in the therapeutic strategy only if administered over a prolonged period of time. Given their good tolerability, minor metabolic effects and low cost, progestogens must therefore be considered drugs of choice and are currently the only safe and economic alternative to surgery. However, their contraceptive effectiveness limits their use to women who do not wish to have children in the short-term.     

Presacral neurectomy for the treatment of pelvic pain associated with endometriosis: a controlled study.

OBJECTIVE: Our objective was to evaluate the efficacy of presacral neurectomy combined with conservative surgery for the treatment of pelvic pain associated with endometriosis. STUDY DESIGN: In a randomized, controlled study performed in a tertiary institution 71 patients with moderate or severe endometriosis and midline dysmenorrhea were randomly assigned to conservative surgery alone (n = 36) or conservative surgery and presacral neurectomy (n = 35). Main outcome measures were relief of dysmenorrhea, pelvic pain, and deep dyspareunia after surgery according to a multidimensional and an analog pain scale. RESULTS: Presacral neurectomy markedly reduced the midline component of menstrual pain, but no statistically significant differences were observed between the two groups in the frequency and severity of dysmenorrhea, pelvic pain, and dyspareunia in the long-term follow-up. After presacral neurectomy, constipation developed or worsened in 13 patients and urinary urgency occurred in three and a painless first stage of labor in two. CONCLUSION: Presacral neurectomy should be combined with conservative surgery for endometriosis only in selected cases.     

Videolaseroscopy for the treatment of endometriosis associated with infertility

Recent advances in laparoscopic surgery have enabled the gynecologic surgeon to treat an increased number of diseases of the reproductive organs by using the laser through the laparoscope. This article reviews the results of 243 patients with infertility associated with endometriosis ranging in severity from mild to extensive who were treated by the same surgeon using CO2 laser laparoscopically with videocamera augmentation and control. Of the 243 infertility patients, 168 (69.1%) achieved pregnancy. The pregnancy rates were 71.8% in 39 patients with stage I disease, 69.8% in 86 patients with stage II disease, 67.2% of 67 patients with stage III disease, and 68.6% in 51 patients with stage IV disease. The life table and two-parameter exponential model were used to calculate monthly fecundity, "cure," and "probability of pregnancy" rates. The results indicate that videolaseroscopic treatment of endometriosis associated with infertility, in surgically experienced hands, is at least as efficacious as other forms of therapy for mild and moderate cases of disease, but appears to be more successful than laparotomy for the more severe and extensive stages of disease.     

Comparison of cyproterone acetate and danazol in the treatment of pelvic pain associated with endometriosis

Twenty-three patients with laparoscopically diagnosed endometriosis and pelvic pain were allocated randomly to treatment with cyproterone acetate 27 mg plus ethinyl estradiol 0.035 mg/day (11 patients) or danazol 600 mg/day (12 patients). All women received treatment for 6 months, except for one in the cyproterone group who suspended treatment for nonmedical reasons and was excluded from analysis of the results. The clinical condition and pain symptoms were monitored in all patients for 1 year after treatment suspension. The intensity of pelvic pain at diagnosis, during treatment, and at follow-up was evaluated by a multidimensional verbal score and an analogue scale. At the end of treatment, a repeat laparoscopy was performed in those patients who agreed (four in the cyproterone group, five in the danazol group); the results showed a partial regression of endometriotic lesions in both groups, with no significant differences between them. Dysmenorrhea disappeared in all patients during treatment. At 6 months after suspension, dysmenorrhea recurred in 66% of the cyproterone group and 58% of the danazol group, and at 1 year in 89 and 92%, respectively. Intermenstrual pelvic pain improved markedly during treatment in both groups; 6 months after treatment withdrawal it was present in four cyproterone subjects and four danazol group patients, whereas after 1 year, only one woman in the danazol group did not have this symptom. Deep dyspareunia was less affected by treatment, and 6 months later had recurred in all the women.(ABSTRACT TRUNCATED AT 250 WORDS)     

Gamete intrafallopian transfer as treatment for infertility associated with endometriosis

Forty-six patients with endometriosis-associated infertility underwent 59 GIFT cycles. The pregnancy rate per cycle was 30.5%. The presence of endometriomas in 11 patients did not affect this rate adversely. We conclude that, provided at least one fallopian tube is patent, GIFT compensates effectively for the possible causes of infertility in these patients.     

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

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

Laparoscopic treatment of pelvic pain associated with minimal and mild endometriosis with use of the Helica Thermal Coagulator

OBJECTIVE: To investigate the clinical efficacy and safety of Helica Thermal Coagulator (TC) in the treatment of pelvic pain associated with minimal (stage I) and mild (stage II) endometriosis. DESIGN: A clinical observational study. SETTING: A referral center for laparoscopic treatment of endometriosis. PATIENT(S): Eighty-one women with pelvic pain symptoms associated with minimal and mild endometriosis diagnosed at laparoscopy. INTERVENTION(S): Helica TC to treat endometriotic lesions. The revised American Fertility Society (rAFS) classification was used to stage endometriosis. Pain symptoms and patient satisfaction were assessed subjectively at 3 and 6 months follow-up. MAIN OUTCOME MEASURE(S): Improvement or relief of pelvic pain symptoms, and intra- or postoperative complications. RESULT(S): A total of 79 women completed the study to 6 months follow-up. At 3 months, 59 (74.7%) women reported resolution and satisfactory improvement of symptoms, whereas 20 (25.3%) women continued to experience painful symptoms. At 6 months, 69 (87.4%) women reported resolution and satisfactory improvement of symptoms, whereas 9 (11.4%) women reported no changes and 1 (1.2%) woman experienced worsening symptoms. No significant differences were found between minimal and mild disease. No side effects or surgical complications occurred. CONCLUSION(S): Meaningful improvements and relief in clinical symptoms can be obtained with conservative laparoscopic surgery. Helica TC is a simple, effective, and safe device for the treatment of pelvic pain in women with stages I and II endometriosis. This approach requires further evaluation as part of randomized controlled trials.     

Methyltestosterone treatment of infertility associated with pelvic endometriosis.

Sixty-four patients who had infertility associated only with endometriosis were treated with methyltestosterone, 5 mg/day, continuously for a period of 6 months. The patients continued to ovulate while receiving medication and 12 patients became pregnant, on an average, 6 months after the initiation of therapy. A computer analysis indicated that approximately 30% of the patients could expect pregnancy within 2 years after the testosterone treatment was begun. The side effects of the low-dose methyltestosterone therapy were acne in 6% of the patients, mild hirsutism in 3%, and an occasional delay in ovulation.     

Presacral neurectomy for surgical management of pelvic pain associated with endometriosis: a descriptive review

Pelvic pain associated with endometriosis is a common clinical problem. In approximately 20% of cases endometriosis-related pelvic pain is either minimally or not responsive to medical treatment; thus surgical treatment seems to be a valid option. The aim of this review is to describe presacral neurectomy surgical techniques, data regarding safety and efficacy of this procedure, its indications, and future research on its applications in clinical practice.     

子宫内膜异位症疼痛发病机制及目前治疗问题探讨

摘要：子宫内膜异位症（内异症）疼痛的机制可能是病灶内周期性出血、腹腔内慢性炎症以及病灶神经出芽生长导致外周与中枢神经敏化诱发痛觉过敏。虽然手术彻底切除内异症病灶是内异症疼痛治疗的先决条件,但术后药物长期治疗也是必须的。选择兼顾炎症性、伤害性及神经病理性作用的药物是获得有效治疗内异症疼痛的关键。     

Systematic review of the effects of aromatase inhibitors on pain associated with endometriosis

Objective  To assess the effects of aromatase inhibitors in women symptomatic of pain with endometriosis.
Design  A systematic review of published literature.
Material and methods  We conducted a comprehensive literature search to identify all the published observational and randomised studies evaluating the efficacy of aromatase inhibitors on pain associated with endometriosis. A combination of keywords was used to identify the maximum number of relevant citations in MEDLINE, EMBASE, CINAHL and the Cochrane Database.
Outcome  Pain relief, lesion size and quality of life.
Results  There were eight studies (137 women) evaluating outcomes of aromatase inhibitors. In case series/reports (seven studies, 40 women), aromatase inhibitors combined with progestogens or oral contraceptive pill or gonadotrophin-releasing hormone (GnRH) analogues reduced mean pain scores and lesion size and improved quality of life. An RCT (97 women) demonstrated that aromatase inhibitors in combination with GnRH analogues significantly improved pain ( P < 0.0001) compared with GnRH analogues alone together with significant improvement in multidimensional patient scores ( P < 0.0001). There was no significant reduction in spine or hip-bone densities.
Conclusion  Aromatase inhibitors appear to have a promising effect on pain associated with endometriosis, but the strength of this inference is limited due to a dearth of the evidence available.     

微腹腔镜与常规腹腔镜手术治疗轻度子宫内膜异位症相关慢性盆腔痛临床研究

目的 评价微腹腔镜和常规腹腔镜手术治疗轻度子宫内膜异位症的疗效.方法 前瞻性队列分析2004年8月至2006年9月首都医科大学附属北京朝阳医院妇产科住院实施保守性手术的子宫内膜异位症相关慢性盆腔痛患者43例,经腹腔镜诊断或病理证实为子宫内膜异位症,符合r-AFS分期为轻度的Ⅰ～Ⅱ期,分为微腹腔镜（20例）和常规腹腔镜（23例）两组行保守性手术.结果 微腹腔镜组与常规腹腔镜组比较术后胃肠功能恢复时间短,术后住院天数少,住院费用少,差异有显著性意义.比较手术时间、术中出血量、手术费用、手术效果,两组差异无显著性意义.两组均无围手术期并发症发生.结论 微腹腔镜手术治疗轻度子宫内膜异位症可以与常规腹腔镜一样安全和有效,并且在术后胃肠功能恢复、术后住院时间和总的住院费用等方面具有一定的优势.     

子宫内膜异位症疼痛的研究现状及方向

子宫内膜异位症(内异症)是育龄期妇女的常见病,疼痛是内异症最主要的症状,严重影响其健康和生活质量.疼痛机制的复杂和对其认识的不足、疼痛评估方法的不完善、内异症进展的缓慢和治疗后的高复发率,以及深部浸润型内异症(DIE)累及盆腔其他器官造成的症状和体征的多样性,使得内异症疼痛成为国际相关研究的热点和临床治疗的难点.     

子宫内膜异位症疼痛的研究现状及方向

子宫内膜异位症(内异症)是育龄期妇女的常见病,疼痛是内异症最主要的症状,严重影响其健康和生活质量.疼痛机制的复杂和对其认识的不足、疼痛评估方法的不完善、内异症进展的缓慢和治疗后的高复发率,以及深部浸润型内异症(DIE)累及盆腔其他器官造成的症状和体征的多样性,使得内异症疼痛成为国际相关研究的热点和临床治疗的难点.     

子宫内膜异位症疼痛的研究现状及方向

子宫内膜异位症(内异症)是育龄期妇女的常见病,疼痛是内异症最主要的症状,严重影响其健康和生活质量.疼痛机制的复杂和对其认识的不足、疼痛评估方法的不完善、内异症进展的缓慢和治疗后的高复发率,以及深部浸润型内异症(DIE)累及盆腔其他器官造成的症状和体征的多样性,使得内异症疼痛成为国际相关研究的热点和临床治疗的难点.     

子宫内膜异位症疼痛的研究现状及方向

子宫内膜异位症(内异症)是育龄期妇女的常见病,疼痛是内异症最主要的症状,严重影响其健康和生活质量.疼痛机制的复杂和对其认识的不足、疼痛评估方法的不完善、内异症进展的缓慢和治疗后的高复发率,以及深部浸润型内异症(DIE)累及盆腔其他器官造成的症状和体征的多样性,使得内异症疼痛成为国际相关研究的热点和临床治疗的难点.     

子宫内膜异位症疼痛的研究现状及方向

子宫内膜异位症(内异症)是育龄期妇女的常见病,疼痛是内异症最主要的症状,严重影响其健康和生活质量.疼痛机制的复杂和对其认识的不足、疼痛评估方法的不完善、内异症进展的缓慢和治疗后的高复发率,以及深部浸润型内异症(DIE)累及盆腔其他器官造成的症状和体征的多样性,使得内异症疼痛成为国际相关研究的热点和临床治疗的难点.